The Frontal Sinus and Frontal Recess: Anatomical, Radiological and Surgical Concepts

Abstract Introduction The frontal sinus (FS) is the most complex of the paranasal sinuses due to its location, anatomical variations and multiple clinical presentations. The surgical management of the FS and of the frontal recess (FR) is technically challenging, and a complete understanding of its anatomy, radiology, main diseases and surgical techniques is crucial to achieve therapeutic success. Objectives To review the FS and FR anatomy, radiology, and surgical techniques. Data Synthesis The FS features a variety of anatomical, volumetric and dimensional characteristics. From the endoscopic point of view, the FR is the point of greatest narrowing and, to have access to this region, one must know the anatomical limits and the ethmoid cells that are located around the FR and very often block the sinus drainage. Benign diseases such as chronic rhinosinusitis (CRS), mucocele and osteomas are the main pathologies found in the FS; however, there is a wide variety of malignant tumors that can also affect this region and represent a major technical challenge to the surgeon. With the advances in the endoscopic technique, the vast majority of diseases that affect the FS can be treated according to Wolfgang Draf, who systemized the approaches into four types (I, IIa, IIb, III). Conclusion Both benign and malignant diseases that affect the FS and FR can be successfully managed if one has a thorough understanding of the FS and FR anatomy, an individualized approach of the best surgical technique in each case, and the appropriate tools to operate in this region.

Aplasia of Frontal Sinus: CT Study.

Aim: The paranasal sinuses are subject to large variety of lesions. Congenital malformations and normal anatomic variations are important in this region To find out prevalence of frontal sinus aplasia in normal healthy population and to discuss its clinical importance. Materials and Methods: A cross-sectional analysis is performed on CT scans of head & neck region of patients visiting Radio-diagnosis Department of Era’s Lucknow Medical College. Results: Frontal sinus aplasia was observed in 6.6% of target population. Conclusion: It is important for surgeons to be aware of variations in sinuses that may predispose patients to increased risk of intraoperative complications and help avoid possible complications and improve success of management strategies.

Endoscopic Frontal Sinus Surgery / 대한이비인후과학회지

Surgery on the frontal sinus or frontal recess remains a challenge for rhinologist because of its variability and complex anatomy. Its location, relatively complex and narrow frontal recess also make visualization difficult and predispose it to stenosis. Significantly, serious complications are possible due to the anterior ethmoidal artery, orbit and anterior cranial fossa. An understanding of frontal sinus and frontal recess anatomy is essential to perform endoscopic frontal sinus surgery. This paper examines frontal sinus anatomy and then variable procedures of endoscopic frontal sinus surgery. The selection of less invasive procedure as possible after assessment of the patient's history, diagnostic endoscopy, and the CT scan makes successful endoscopic treatment of frontal sinus diseases.

Effects of Frontal Recess Cells on the Development of Frontal Sinusitis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Frontal recess anatomy can be very complex, with accessory cells extending to the frontal sinus and possibly contributing to the obstruction of the frontal sinus. However, there is still controversy on the effect of the frontal recess cells. We designed this study to assess the effect of frontal recess cells on frontal sinusitis. SUBJECTS AND METHOD: We retrospectively reviewed chart and collected data of those who visited the outpatient clinic between January and June, 2011. Parnasal sinus CT was taken with Brillance 64-slice computed tomography scanners. The image was reviewed by two or more otolaryngologists to identify the frontal recess cells. The nasofrontal isthmus diameter and the area of nasofrontal isthmus was reconstructed and measured with workstation. Then, we compared the radiological results of frontal recess cells with the frequency of frontal sinusitis. RESULTS: The presence of anterior group of frontal recess cells showed no influence on the frontal recess anatomy. The presence of frontal bullar cell was significantly associated with the development of frontal sinusitis by simple (p=0.001) and multiple (p=0.038) logistic regression models. It was shown that the narrower the area of frontal isthmus the more developed were the frontal sinusitis, showing statistically significance in the simple (p=0.013) and multiple (p=0.017) logistic regression models. CONCLUSION: Our results also showed that similar results compared to previous Asianreport. The narrowness of nasofrontal isthmus could be the cause of frontal sinusitis. The frontal bullar cell could be the cause of frontal sinusitis encroaching on the frontal recess and affect the nasofrontal pathway.

Biometría etmoidal, del complejo osteomeatal y sus variantes anatómicas: estudio en cadáveres / Ethmoidal and osteomeatal complex biometry and its anatomical variations: cadavers study

La anatomía del etmoides y del complejo osteomeatal ha sido la base fundamental de muchos avancescientíficos especialmente en el campo de la cirugía endoscópica. Por ello el objetivo del presente trabajo es describir la anatomía etmoidal, del complejo osteomeatal y sus variantes anatómicas en los cadáveres del anfiteatro de la Universidad del Rosario, un estudio observacional descriptivo tiposerie de casos donde se tomaron 20 cabezas, se hicieron disecciones y mediciones en ellas. Se evaluó la concordancia interobservador e intraobservador en las variables numéricas con el paquete SPSSversión 11.5, se halló el coeficiente de correlación intraclase (CCI), el intervalo de confianza (IC) tomando significativo CCI > 0.6; y para las variables categóricas el test de concordancia Kappa, a un nivel de significancia de cinco por ciento (0.05). De los resultados finales, se encontraron promedios para la apófisis Crista Galli de longitud ancho yprofundidad. Para la lamela lateral se encontró mayor frecuencia el Keros II en 45% seguida de Keros I (42,5%) y en menor frecuencia Keros III en 12,5%. Se halló el promedio de la longitud antero-posterior y supero-inferior de los cornetes superior, medio y supremo. Se describieron seis variantes anatómicas de la forma del cornete superior y se encontraron cinco variantes anatómicas de la forma del cornete medio. El cornete supremo se encontró en el 15% de los especímenes y se encontraron dosformas del mismo. Fueron observadas 10 variantes anatómicas de la inserción superior de la apófisis unciforme y ocho tipos de inserción inferior del mismo. Se creó una clasificación de la inserción inferior de la apófisis unciforme con respecto al ostium del seno maxilar...

Ethmoidal and osteomeatal complex anatomy had been fundamental base of several scientific advances, especially in endoscopic sinus surgery. The objective of this study is to describe ethmoidal anatomy, osteomeatal complex and its anatomical variations in corpse´s anphitheater of the Rosario University; in an observational descriptive studytype case series. Twenty heads (20) were evaluated with interobserver and intraobserver measures in numercial variables with SPSS version 11.5, it was obtained the intraclass correlation coefficient (ICC), the confidence interval (CI) with significance ICC>0,6 and categorical Kappa variable test with levelof significance of five percent (0.05).Of the final outcomes, Crista galli process wide and depth length was obtained. Lateral lamella was more frequent Keros type II (45%) than type I (42,5%) and type III (12,5%). For the superior, supreme and middle turbinates was found its length and incidence. Six anatomical variations of the superior attachment of the uncinate process and five anatomical variations of the form of middle turbinate weredescribed. The supreme turbinate was found in 15% of the specimens and there were two forms of it. Ten anatomical variations of the superior attachment of the unciform process and eight types of its inferior attachment were found. It was created a new classification of inferior attachment of uncinate process with relation to the maxillary ostia...

Manejo de trauma frontal: revisión de literatura y reporte de casos / Management of frontal trauma: review literature and report of cases / Abordagem de trauma frontal: revisão da literatura e relato de casos

Desde la época de Reidel (1898) han sido considerables los avances en el manejo del trauma frontal; sin embargo, el tratamiento para este trauma sigue siendo controvertido y si por alguna circunstancia el manejo no es el adecuado, se pueden presentar serias complicaciones. En este articulo se reportan siete casos manejados por el servicio de Cirugía Oral y Maxilofacial del Hospital Militar Central (HMC) de Bogotá, Colombia, y se hace una revisión de la literatura sobre manejo de fracturas de seno frontal y las diferentes técnicas utilizadas, especialmente en la obliteración del receso frontal con los materiales autógenos o aloplásticos disponibles y las complicaciones más frecuentes...

Since the work of Reidel (1898), there have been considerable advances in the management of frontal trauma. However, the treatment for this trauma is still controversial, so if given the case of inappropriate management, it can imply serious complications. In this article seven cases handled by the service of Oral Surgery and Maxilofacial of the Central Military Hospital (HMC) of Bogotá-Colombia are reported. A literature review was prepared on managing fracture of frontal sinus and the different technologies used, especially in the frontal recess obliteration with available autogenous or alloplastic materials and the most frequent complications...

Desde o tempo de Reidel (1898) tem havido avanços consideráveis na abordagem de trauma frontal; porem, o tratamento para o trauma ainda é controverso e se por algum motivo, a abordagem não é adequada, complicações graves podem ocorrer. Neste trabalho nós relatamos sete casos tratados pelo Serviço de Cirurgia Bucomaxilofacial do Hospital Militar Central (HMC) de Bogotá, Colômbia, e uma revisão da literatura sobre abordagem de fraturas do seio frontal e as diferentes técnicas utilizadas, especialmente na obliteração do recesso frontal com materiais autógenos ou aloplásticos disponíveis e as complicações mais freqüentes...

Anatomic Variations of the Frontal Recess and Frontal Sinusitis: Computed Tomographic Analysis

BACKGROUND AND OBJECTIVES: The frontal recess (FR) cells, including the frontal cell (FC), agger nasi cell (ANC), supraorbital ethmoid cell (SOC) and inter-frontal sinus septal cell (IFSSC), can interfere with the drainage system of the frontal sinus. We evaluated the relationship between the FR cells and the frontal sinusitis. SUBJECTS AND METHODS: All paranasal sinus CT scans performed from July 2004 through June 2005 were reviewed. Of the 675 scans reviewed, 317 patients (634 sides) were selected for data collection. Exclusion criteria included a clinical history of neoplasms, bony deformities, and extensive disease responsible for obscuring the bony anatomy. Similarly, CT scans with severe artifacts were also excluded. RESULT: FCs were present in 21.9% of the patients. According to the Bent's classification, the prevalence of each FC type was as follows; type 1 FC (13.6%), type 2 FC (3.2%), type 3 FC (1.9%) and type 4 FC (3.1%). Of the four types of FR cells, type 4 had a significant association with frontal sinusitis. The incidence of hyperpneumatized frontal sinus, ANC, SOC, IFSSC were significantly higher among patients with the FC than those without the FC (p<0.05). Patients without the ANC or with type 1 uncinate process, according to Stammberger's classification, displayed a higher frequency of frontal sinusitis (p<0.05). There was a statistically significant decrease in the frequency of frontal sinusitis among patients with hypopneumatized frontal sinus (p<0.05). CONCLUSION: In our series, the frontal sinusitis was influenced by each types of FC, attachment sites of uncinate process and the degree of frontal sinus pneumatization. Therefore, these anatomic variations in the frontal recess should be appropriately addressed during the surgical management of the frontal sinusitis.

Prevalence of Frontal Recess Cells in Koreans / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: This research aimed to evaluate the prevalence of specific frontal recess cells in Koreans using the classification developed by Lee, et al. SUBJECTS AND METHOD: Frontal recess was studied using high resolution CT scans of normal 60 Koreans. RESULTS: Three volunteers were found to have sinusitis around frontal recess in CT and therefore were excluded from this study. Agger nasi cells were observed in 107 sides (94.0%), frontal cell type 1 in 26 sides (22.8%), type 2 in 16 sides (14,0%), type 3 in 9 sides (7.9%) and type 4 in 0 side (0.0%). Frontal bullar cells were observed in 16 sides (14.0%), suprabullar cells in 45 sides (39.5%) and supraorbital ethmoid cells in 3 sides (2.6%). Intersinus septal cells were observed in 10 sides (8.8%) and terminal recess in 76 sides (66.7%). CONCLUSION: This is the first study conducted about the Korean prevalence of frontal recess cells using the new classification.

The distributional characteristics of frontal recess cells during image navigation assisted endoscopic sinus surgery / 中国耳鼻咽喉头颈外科

OBJECTIVE To recognize the frontal recess cells and analyze their distributional characteristics during image navigation assisted endoscopic sinus surgery. METHODS 20 cases(39 sides)of chronic sinusitis with nasal polyps were observed in this study. The fontal recess cells and frontal sinus were opened under the endoscope and the distributional characteristics were observed and recorded, and then confirmed by the image navigation system. RESULTS Centred on frontal sinus ostium, frontal recess cells were divided into three areas: the agger nasi cell(ANC)and frontal cells(FC)are located in front of frontal sinus ostium(FS); frontal septum cells(IFSSC)and terminal cells(RT)are located at the same plane of FS; supra-ethmoidal bulla recess(SBR), frontal bulla cell(FBC)and super-obital cells(SOEC)are in the posterior area. The coincidence of identification for ANC, FCI and II, SBR, FBC and IFSSC under endoscope and image navigation is 100%, the coincidence of identification for FS is 89.7%, SOEC 80%, RT 71.4% and FC III and IV 60%. CONCLUSION The distribution of the frontal recess cells around the frontal ostium showed a fixed pattern.It would well benefit the orientation of frontal ostium and the opening of frontal sinus. Furthermore, it is significant for the orientation and opening of the frontal recess cells.

Advances in the image anatomy of the frontal recess / 医学研究生学报

Frontal recess locates at the anterosuperior part of the ethmoidal labyrinth,the anatomical structure of which is most complicated. The acknowledgement of this area is fundamental for the endoscopic frontal sinus surgery. With the development of technology,images of the computed tomography can display more delicate micro structure of the anatomy. So we can study the frontal recess anatomy in detail with the technique. This study reviewed the current research on the image anatomy of the frontal recess.

Imaging Study by Sagittal Reconstruction of Paranasal Computed Tomography / 대한이비인후과학회지

BACKGROUND: It is very difficult to evaluate the anatomy of several tiny structures of paranasal sinus(PNS), especially frontal recess area. Until now, plain X-ray, coronal and axial computed tomogram(CT) and MRI have been used as the radiologic study of PNS. However, there is a lack of full understanding with these 2 dimensional images. Routine coronal and axial CT helps us understand the structure of PNS approximately. But they have limitations in understanding the A-P directional anatomy and difficulties especially in establishing the 3 dimensional concept with frontal recess, which has the various structure as the degree of developing of agger nasi and surrounding structure of frontal recess. OBJECTIVES: We studied to resolve these difficulties and limitations in understanding the A-P directional anatomy and 3 dimensional concept of complicated structures of PNS. MATERIALS AND METHODS: We checked PNS CT in 20 patients who have been suspected to have paranasal problems, and we reconstructed each CT scan into axial and sagittal images from the thin cutted axial PNS CT by using 3 dimensional reconstruction software, SIENET magic view 1,000. RESULTS: With comparing each reconstructed images this problem, we got clear understanding of the structures of A-P direction of nasal cavity and PNS, especially frontal recess area. CONCLUSION: Three dimensional reconstructed views provides clear images in complicated anatomy of nose and paranasal sinus, so it is considered to helpful in planning of surgery.

Significance of Uncinate Process and Paranasal Sinus Computed Tomography in Endoscopic Frontal Recess Approach / 대한이비인후과학회지

OBJECTIVES: To determine the value of uncinate process variations in paranasal sinus(PNS) coronal computed tomography(CT) scan, and to recommend the accurate frontal recess approach technique by uncinate process variations. METHOD: We initiated a prospective, randomized study in fifty patients(100 cases) of frontal sinusitis. Cases were classified as three groups depending on the PNS CT scan findings according to the Stammberger's classification. And then, we could identify the ostium of the frontal sinus by manipulating the terminal recess in group A. It was also shown at the lateral side of uncinate process by approaching anterosuperiorly from below the uncinate process with a bent spoon in group B. Finally, we could find the ostium of the frontal sinus by fracturing the bony septa with a bent spoon in group C. RESULTS: In the evaluation of the uncinate process variations by PNS CT scan, 45(98%) of 46 cases(Group A), 24(100%) of 24cases(Group B), 18(86%) of 21cases(Group C) were in accord with operative finding, and 9cases could not be determined by PNS CT scan. We could identify easily the frontal sinus opening with this technique, and there were no serious post-operative complications. CONCLUSIONS: PNS coronal CT scan is useful in the evaluation of the uncinate process variations, and this frontal recess approach technique is safe and easy to identify the frontal sinus opening.