Modern Concepts of Frontal Sinus Surgery - semicomedia.be

1 The LaryngoscopeLippincott Williams & Wilkins, Inc., Philadelphia 2001 The American Laryngological,Rhinological and Otological Society, Concepts of Frontal Sinus SurgeryRainer Weber, MD; Wolfgang Draf, MD, FRCS Ed; Barbara Kratzsch, MD; Werner Hosemann, MD;Steven D. Schaefer, MD, FACSO bjectives/Hypothesis:To validate the endonasalsurgical approach to Frontal Sinus in inflammatorysinus disease, trauma, and selective tumor Surgery ,and to define the role of external approaches to thefrontal Sinus . Endonasal Frontal sinusotomy canrange from endoscopic removal of obstructing frontalrecess cells or uncinate process to the more complexunilateral or bilateral removal of the Frontal sinusfloor as described in the Draf II III drainage proce-dures.

2 In contrast, the osteoplastic Frontal sinusot-omy remains the gold standard for external ap-proaches to Frontal Sinus :Aretrospective review of 1286 patients undergoing ei-ther endonasal or external Frontal sinusotomy by theauthors at four university teaching programs from1977. Prior author reports were updated and previ-ously unreported patient series were :Six hundred thirty-five patients underwenttype I Frontal sinusotomy, 312 type II sinusotomy, and156 type III sinusotomy. A successful result was seenin these groups, to , 79% to , to 95%, respectively.

3 External Frontal sinusot-omy or osteoplastic Frontal sinusotomy was success-fully performed in 187 of 194 patients. Clinical symp-toms, endoscopic findings, computed tomography,and magnetic resonance image scanning, and reop-eration rate measured postoperative :A stepwise approach to the surgical treatmentof Frontal sinusitis, trauma, and selective benigntumors yields successful results as defined by spe-cific criteria which vary from 79% to The de-tails of specific techniques are discussed, essentialpoints emphasized, and author variations.

4 Frontal Sinus Surgery , osteoplastic Frontal si-nus Surgery , endonasal Frontal sinusotomy, type Idrainage, type II drainage, type III ,111:137 146, 2001 INTRODUCTIONIn principle, Surgery of the Frontal Sinus can be per-formed endonasally or through an external approach. Theendonasal approach for surgical treatment of Frontal si-nusitis has become increasingly established in the last 14 This follows developments in knowledge of si-nus pathophysiology,15,16optical aids,2,3,17 20and moderninstrumentation (Table I).21,22 With increasing surgicalexperience, selective tumor and trauma cases are man-aged successfully with the endonasal ,23,24A wide spectrum of defined endonasal surgical pro-cedures of the Frontal Sinus has been developed.

5 These arebased on the drainage or sinusotomy classification ,4,13 May and Schaitkin developed a similar classi-fication based on the Draf system (Table II; Figs. 1 3).10 Draf Type I Frontal SinusotomyDraf type I Frontal sinusotomy consists of removal ofobstructing disease inferior to the Frontal ostium. Theterm ostium is used to simplify the description of thesurgical procedures. It means the drainage area betweenthe Frontal infundibulum from above and the Frontal re-cess from below. The anterosuperior ethmoidal cells ob-structing the frontonasal outflow tract are removed with-out altering the Frontal Sinus ostium.

6 This least invasivetechnique serves to expose the Frontal ostium (Draf type I,NF 1).Draf Type II Frontal SinusotomyDraf type II Frontal sinusotomy consists of enlarge-ment of the Frontal Sinus drainage or outflow tract. Draftype IIA is removal of ethmoidal cells protruding into thefrontal Sinus (similar to the so-called uncapping the egg as described by Kuhn et Stammberger26). Thisresults in a larger opening of the Frontal Sinus floor be-tween the lamina papyracea and the middle type IIB drainage (NF 3) is resection of the frontalsinus floor between the lamina papyracea and the nasalseptum to provide a maximal opening on one Type III Frontal SinusotomyDraf type III Frontal sinusotomy consists of contigu-ous bilateral enlargement of Frontal Sinus drainage.

7 Max-imum access is provided by a median drainage procedurewith removal of the Frontal Sinus floor on both sides andremoval of adjacent parts of the intrafrontal and nasalseptum (Draf type III, NF 4).From the Department of Otorhinolaryngology, Head and Neck Sur-gery, Facial Plastic Surgery , and Communication Disorders ( , , ), Fulda Hospital, Academic Teaching Hospital of the University ofMarburg, Fulda, Germany; the Department of Otorhinolaryngology ( ),Otto-von-Guericke-University Magdeburg, Magdeburg, Germany; the De-partment of Otorhinolaryngology ( ), Regensburg University Hospital,Regensburg, Germany.

8 And the Department of Otolaryngology and Com-municative Sciences ( ), New York Eye & Ear Infirmary/New YorkMedical College, New York, s Note: This Manuscript was accepted for publication October19, Correspondence to Rainer Weber, MD, Department of Otorhi-nolaryngology, Otto-von-Guericke-University Magdeburg, Leipziger , D-39120 Magdeburg, Germany. E-mail: 111: January 2001 Weber et al.: Frontal Sinus Surgery137 Despite the recent enthusiasm for endonasal ap-proaches to the sinuses, external or open Frontal sinusot-omy remains an important procedure in the care of se-lected patients.

9 Of the various open techniques, theosteoplastic flap procedure with fat obliteration has beenhailed as the gold standard of definitive Frontal 29As disease or trauma extends intracrani-ally, the osteoplastic approach to the Frontal Sinus may bemodified to include removal of the posterior wall of thesinus or marsupialization of the Sinus into the ,31 Because the success of Frontal Sinus Surgery must bejudged over time and in sufficient numbers of patients, theauthors report their combined experience over a period of24 years with endonasal and open approaches to frontalsinusotomy.

10 This reports seeks to: 1) offer specific indica-tions for the various endonasal and open Frontal sinusot-omy techniques, 2) describe highlights of surgical proce-dures and note technical variations between authors, and3) validate the patient selection and techniques throughexamination of retrospective review of patients treated at the De-partments of Otolaryngology at Fulda Hospital (AcademicTeaching Hospital of the University of Marburg), Otto-von-Guericke-University Magdeburg, Regensburg Univer-sity Hospital, and the New York Eye & Ear Infirmary(New York Medical College) over a period of up to 24 years(range, 18 24 y) was conducted.