[History of frontal sinus surgery and current view of the problem. Part 2]. / Istoriya khirurgii lobnoi pazukhi i sovremennyi vzglyad na problemu. Chast' 2.

Surgical treatment of inflammatory diseases of the frontal sinus is one of the biggest challenges of modern otorhinolaryngology. Close proximity of the frontal sinus and frontal sinus drainage pathways to the skull base, the orbit and the anterior ethmoid artery, great limitations with its visualization and instrumentation, and high risk of the frontal recess scarring cause difficulties in either endoscopic or external approaches to the frontal sinus. At the same time endoscopic approach to the frontal sinus is considered as preferred method of frontal sinusitis surgical treatment by majority of peers nowadays. The introduction of extended approaches to the frontal sinus pathology treatment with frontal sinus floor and interfrontal sinus septum drill-out as well as superior septectomy with common drainage pathway formation gave an opportunity to greatly decrease a rate of indications for external frontal sinus procedures. In this paper historical backgrounds of endonasal approaches to frontal sinuses are presented, current controversies in proper selection of extent and methods of the frontal sinus surgery are analyzed and endoscopic as well as external approaches to frontal sinuses are summarized.

Pott's Puffy: First Shot is the Best Shot.

OBJECTIVE: Low incidence of Pott's Puffy tumor (PPT) has caused studying risk factors and recurrences of the disease to be difficult. We used the comparatively increased incidence at our institution to evaluate potential risk factors for the disease process itself and prognostic factors for recurrence of the disease. METHODS: Single institutional retrospective chart review identified 31 patients from 2010 to 2022 with PPT compared with a control group of 20 patients with either chronic rhinosinusitis or recurrent sinusitis. Patient mean age of PPT was 42 (range of 5 to 90) with the majority of the patient population as male (74%) and Caucasian (68%) in the setting of rural West Texas. Patient mean age of the control group was 50.7 (range of 30-78) with majority of patient population as male (55%) and Caucasian (70%). Interventions studied were functional endoscopic sinus surgery (FESS), FESS with trephination, and cranialization with or without FESS to compare prognostic factors for recurrence rates of PPT. These patients' prognostic risk factors for recurrence and risk factors to develop PPT were analyzed using Analysis of Variance (ANOVA) χ 2 statistical analysis with Fischer exact testing. RESULTS: Mean age was 42 years (range of 5-90) with the majority of the PPT patient population as male (74%) and Caucasian (68%) with an overall incidence of about 1 in 300,000. Pott's Puffy tumor patients were significantly favored in the younger and male population compared with the control patients. Risk factors of no prior allergy diagnosis, previous trauma, medication allergy to penicillin class or cephalosporin class, and lower body mass index were significant in the PPT population compared with the control group. Significant prognostic factors for recurrence of PPT were prior history of sinus surgery and operative treatment choice. Fifty percent (3/6) of patients with prior sinus surgery had recurrence of PPT. Of our 4 treatment options (FESS, FESS with trephination, FESS with cranialization, or cranialization alone), ;FESS had a recurrence of PPT of 0% (0/13), FESS with trephination had a recurrence of PPT of 50% (3/6), FESS with cranialization had a recurrence of PPT of 11% (1/9), and cranizalization alone had a recurrence of PPT of 0% (0/3). Of note, postop chronic rhinosinusitis was seen in 46% (6/13) of FESS alone, 17% (1/6) with FESS with trephination, 0% (0/9) with FESS with cranialization, and 33% (1/3) with just cranialization alone. CONCLUSIONS: Pott's Puffy tumor patients were younger and predominately male when compared to the control patients. No prior allergy diagnosis, previous trauma history, medication allergy to penicillin class or cephalosporin class, and lower body mass index are risk factors for PPT. There are 2 prognostic factors that predict recurrence of PPT: first operative treatment choice and prior sinus surgery. History of prior sinus surgery tends to increase the recurrence of PPT. The first operative treatment plan is the best shot at definitively treating PPT. Correct management surgically can prevent recurrence of PPT as well as long-term recurrence of chronic rhinosinusitis. With early diagnosis and mild disease, FESS is sufficient to prevent recurrence of PPT but chronic sinusitis may continue to occur if frontal sinus outflow track is not well opened. If considering trephination, a definitive cranialization may be more suited for more advanced disease since our study showed 50% of recurrence of PPT with trephination and FESS along with 17% chronic sinusitis long term. More advanced diseases with higher WBCs and intracranial extension do better with more aggressive surgical management with a cranialization with or without FESS which shows to reduce rates of PPT recurrence significantly.

Frontal sinus obliteration with beta-tricalcium phosphate putty: case series with long-term radiological follow up.

OBJECTIVES: Frontal sinus obliteration is often performed using fat, autologous bone or a range of synthetic materials. This paper reports the long-term clinical and radiological outcomes of frontal sinus obliteration using beta-tricalcium phosphate putty. METHODS: A retrospective audit was performed of patients who underwent frontal sinus obliteration with beta-tricalcium phosphate putty. Patient-, disease- and procedure-related data were collected. Pre- and post-operative computed tomography scans were reviewed to assess bone integration. RESULTS: Four patients underwent frontal sinus obliteration using beta-tricalcium phosphate putty for treatment of a cerebrospinal leak, mucocele and recalcitrant frontal sinusitis. All patients had disease resolution, with no intra- or post-operative complications reported in the 16.5-month follow up. Post-operative computed tomography scans confirmed native bone obliteration of the frontonasal ducts in all patients. CONCLUSION: Beta-tricalcium phosphate putty is a safe and effective option for bone obliteration of the frontal sinus in a range of pathologies, including cerebrospinal fluid leak.

Orbital abscess as a complication of Pott's puffy tumour in an adolescent male.

Pott's puffy tumour (PPT) is a known complication of frontal sinusitis. It is defined as subperiosteal abscess formation due to osteomyelitis of the frontal bone presenting as a forehead swelling. It is a life-threatening condition that can lead to intracranial and intraorbital complications. Gadolinium-enhanced MRI and contrast CT scan are the best modalities to localise and define the collection, in addition to confirming disease extension. Once confirmed by imaging and depending on disease extension, management of PPT requires a multidisciplinary team approach and depends on the local provision of surgical care. Following surgical drainage of the abscess cavity, a prolonged course of antibiotics is required postoperatively to treat the underlying osteomyelitis.

Imaging of complicated frontal sinusitis.

Complications occur in 3% of the cases of frontal sinusitis. These are mainly oculo-orbital, intracranial and osteomyelitis. Our aim is to describe the contribution of different imaging modalities in the diagnosis of these complications and their post-treatment monitoring. within a 15 years period (2000-2014), 10 patients with complicated frontal sinusitis were included into this retrospective study. 10 patients (9 males) aged 9 to 70 year old (mean 28). Two of these patients (20%) had a history of craniofacial trauma. Frontal headache was present in all cases (100%), frontal swelling in 8 cases (80%) and unilateral palpebral edema in 3 cases (30%). A CT scan of the face and brain was performed in all cases and revealed frontal osteomyelitis in 6 cases (60%), extradural empyema in 3 cases (33%), intracranial frontal abscess in 2 cases (20%) and occulo-orbital complications in 3 cases (30%). Magnetic resonance imaging was performed in one patient and demonstrated thrombosis of the upper longitudinal sinus. 40% of our patients associated 2 complications. Cross-sectional imaging is important in early and accurate diagnosis of complicated frontal sinusitis.

IL-5 and IL-6 are increased in the frontal recess of eosinophilic chronic rhinosinusitis patients.

BACKGROUND: Eosinophilic chronic frontal sinusitis is difficult to treat compared with non-eosinophilic sinusitis because of recurring inflammation and polyp formation in the frontal recess after the post-operative follow-up period. Studying inflammatory mediators in the frontal recess of eosinophilic chronic rhinosinusitis (ECRS) patients and non-eosinophilic chronic rhinosinusitis (non-ECRS) patients may lead to a better understanding of the pathogenesis of chronic frontal sinusitis. METHODS: Homogenates of sinonasal mucosa from 20 non-ECRS patients and 36 ECRS patients were measured for levels of transforming growth factor (TGF)-ß, interleukin (IL)-5, IL-6, and inducible nitric oxide synthase (iNOS) using real-time RT-PCR and TaqMan gene expression assays. Sinonasal mucosal specimens were obtained from the frontal recess, ethmoid sinus, and nasal polyp separately. RESULTS: The expression of IL-5 was significantly elevated in all sinonasal regions tested in the ECRS group, but absent in non-ECRS patients. Furthermore, the ECRS patients showed significantly increased levels of IL-5 in the frontal recess mucosa compared with ethmoid sinus mucosa. IL-6 was also significantly increased in the frontal recess mucosa compared with ethmoid sinus mucosa and nasal polyps in these patients. There were no significant differences in the levels of TGF-ß or iNOS between the ECRS and non-ECRS groups in any sinonasal region tested. CONCLUSIONS: This study is the first to characterize the cytokine milieu in the frontal recess of ECRS patients. We should keep these cytokine profiles in mind when we treat ECRS patients with frontal sinusitis.

Correlation between the extent of pneumatization of Agger agger Nasi nasi cells and the anterior-to-posterior length of the frontal recess: A a computer-assisted anatomical study.

OBJECTIVES: To explore the correlation between the volume of the aAgger nNasi (AN) cell bulge and the A-P length of the frontal recess (FR). SUBJECTS AND METHODS: In total, 120 patients, who underwent septoplasty, were included. All patients underwent preoperative paranasal sinus computed tomography of the paranasal sinuses (PNS CT) imaging. In total, CT data on of all 120 PNSs patients were analyzed in terms of thewith respect to the extent of pneumatization of the AN cell bulge and the A-P dimensions of the FR. Each side was analyzed separately. RESULTS: We included 120 patients,: 78 (65.0%) females and 42 (35.0 %) males. Their average age was 33.7 ± 11.6 years (range: 18-65 years). The mean volume of the AN cell bulge was 0.26 ± 0.4 mm3 on both the right and left sides. The A-P length of the FR was 7.7 ± 2.2 mm. No significant between-side difference in the mean volume of the AN cell bulge was apparent observed (p=0.906). This volume did not differ significantly by age or sex (p=0.844 and p=0.971, respectively). We found no correlation between the volume of the AN cell bulge and the A-P length of the FR (r = 0.098, p=0.192). CONCLUSION: In the present study, no correlation between AN cell volume and the A-P length of the FR was found. When studying the anatomical complexity of the FR, it is essential to consider the AN cell volume. We suggest that preoperative CT imaging is critical when endoscopic sinus surgery is planned. However, further studies with larger numbers of patients are needed to explore the relationship between AN cell pneumatization and the anatomy of the FR.

Influence of opacification in the frontal recess on frontal sinusitis.

OBJECTIVES: This study aimed to radiologically evaluate the influence of inflammatory changes in frontal recess cells on frontal sinusitis. METHODS: A total of 93 patients (186 sides) who underwent primary sinonasal surgery at Hyogo College of Medicine were enrolled in 2015 and 2016. Opacification of agger nasi, fronto-ethmoidal, ethmoid bulla, suprabullar and frontal bulla cells was determined by pre-operative computed tomography and its influence on frontal sinusitis was investigated. RESULTS: In all, 42 per cent of 186 sides were affected by frontal sinusitis. Agger nasi, ethmoid bulla, fronto-ethmoidal, suprabullar and frontal bulla cells were identified in 99 per cent, 100 per cent, 38 per cent, 69 per cent, and 16 per cent of sides, respectively. The presence of frontal recess cells and frontal ostium size did not significantly influence frontal sinusitis development. However, opacification of agger nasi, type 1 fronto-ethmoidal and suprabullar cells significantly influenced frontal sinusitis development. CONCLUSION: Frontal sinusitis is caused by inflammatory changes in frontal recess cells.

Extended applications of the endoscopic modified Lothrop procedure.

OBJECTIVE: The endoscopic modified Lothrop procedure is mainly used for refractory frontal sinusitis. However, we have used it as an access procedure to facilitate treatment for an extended range of additional frontal sinus pathologies. METHODS: A retrospective review of patients who underwent the endoscopic modified Lothrop procedure for 'alternative' frontal sinus pathologies was conducted. Patient data were reviewed. The main outcome parameter measured was signs of recurrence. RESULTS: Twelve patients (6 males, 6 females) from a 7-year study period, with a mean age of 45.2 years (range, 16-78 years), were analysed. The surgical indications included frontoethmoidal mucoceles, cerebrospinal fluid leaks within the frontal sinus, cystic fibrosis, frontal sinus osteoma, frontal sinus ossifying fibroma and frontal silent sinus syndrome. The mean follow-up period was 33.3 months. There were no known recurrences. CONCLUSION: We have used the endoscopic modified Lothrop procedure for a range of frontal sinus pathologies, safely and effectively, with no peri-operative complications.

A comparison of radiographic evidence of frontal sinusitis in middle-turbinate sacrificing versus middle-turbinate sparing approaches to the sella.

BACKGROUND: Initial descriptions of endoscopic approaches to the sella and pituitary involved resecting the middle turbinate (MT) to help improve access and visualization. Modifications of these procedures to preserve the MT have since been described, one rationale being to reduce the incidence of frontal sinusitis. The objective of this study was to establish the incidence of postoperative frontal sinusitis in MT sparing (MTsp) and MT sacrificing (MTsc) approaches to the sella. OBJECTIVE: A retrospective cohort study that compared radiographic evidence of frontal rhinosinusitis or frontal recess obstruction after skull base surgery in patients who underwent MTsc and MTsp endonasal approaches to the sella. METHODS: Consecutive retrospective review of pre- and postoperative magnetic resonance imaging from two institutions in geographic proximity but with different approaches to the sella. Mucosal thickening in the frontal sinus was measured and graded by a radiologist blinded to patient cohorts. RESULTS: Seventy-five patients, based on sample size calculations, were included at each site. Baseline demographics and indications for surgery were not significantly different between the groups. No difference was seen between the groups in the overall grade of radiographic frontal sinusitis seen on postoperative imaging. A total of 8 patients (10%) in the MTsc group had measured mucosal thickening, which was increased from their preoperative scan versus 15 in the MTsp group (20%) (p = 0.10). New mucosal thickening of >1 mm was found in three patients in the MTsc group and eight patients in the MTsp group (p = 0.21); the only patient with postoperative complete frontal sinus opacification was in the MTsp group. CONCLUSIONS: The choice of MTsc versus MTsp in endonasal endoscopic approach to the sella does not seem to make a difference in the incidence of postoperative radiographic frontal sinusitis.

Rare giant frontal sinus osteoma mimicking fibrous dysplasia.

OBJECTIVE: To present the first report of a giant frontal sinus osteoma treated by excision and single-stage reconstruction with custom-made titanium cranioplasty and left orbital roof prostheses. CASE REPORT: A 31-year-old man with a history of chronic frontal sinusitis presented with a deforming, painless, midline forehead swelling of 11 years' duration, which had been treated unsuccessfully in Nigeria. Differential diagnosis included both benign and malignant bony tumours. Computerised tomography revealed a giant bony frontal sinus tumour extending beyond the sinus roof and breaching the left orbit, consistent with fibrous dysplasia. Given the extent of the tumour, open craniectomy was performed for surgical extirpation. Histological analysis identified multiple osteomas. This surgical approach achieved excellent cosmesis, with no evidence of recurrence at 12-month follow up. CONCLUSION: Forehead swelling may pose diagnostic and management dilemmas for the ENT surgeon; however, effective management is facilitated by a multidisciplinary approach.

The association of frontal recess anatomy and mucosal disease on the presence of chronic frontal sinusitis: a computed tomographic analysis.

OBJECTIVES: The frontal sinus has the most complex and variable drainage routes of all paranasal sinus regions. The goal of this study was to identify these anatomical factors and inflammation areas relating to chronic frontal sinusitis by comparing radiological presentations in patients with and without frontal sinusitis. METHODS: All adult patients with chronic rhinosinusitis who had received computed tomography (CT) scans of the nasal cavities and paranasal sinuses between October 2010 and September 2011. Logistic regression analysis was used to compare the distribution of various frontal recess cells and surrounding inflammatory conditions in patients with and without frontal sinusitis. RESULTS: Analysis of 240 sides of CT scans was performed with 66 sides excluded. The opacification of the frontal recess and sinus lateralis demonstrated a strong association with an increased presence of frontal sinusitis by multiple logistic regression models. CONCLUSION: Opacification of the frontal recess and sinus lateralis was found to be associated with a significantly increased risk of frontal sinusitis and developing severe blockage of drainage pathways. It provides evidence that mucosal inflammation disease in these two areas is a very important factor leading to chronic frontal sinusitis.

Concha bullosa mucocele with orbital invasion and secondary frontal sinusitis: a case report.

BACKGROUND: Although concha bullosa (CB) is the most common variants of the middle turbinate, mucocele of CB is uncommon. Furthermore, CB mucocele with orbital invasion and secondary frontal sinusitis has not been reported previously. CASE PRESENTATION: A 42-year-old Korean male presented with gradually progressive proptosis of right eye and right-sided frontal headache. He had previously undergone endoscopic sinus surgery (ESS) 15 and 9 years ago. The endoscopic examination showed an expansive, large middle turbinate with normal mucosa filled the majority of right nasal cavity and displaced the septum to the left. A computed tomography and magnetic resonance imaging showed a well demarcated cystic huge mass at right nasal cavity extending to ethmoid sinus and orbit. The mass caused a bony defect on the lamina papyracea and displaced medial rectus muscle and orbit laterally. Moreover, the right frontal and ethmoid sinus was totally opacified. This article reports orbital invasion and frontal sinusitis complicating a CB mucocele, which was successfully treated by endoscopic resection of the lateral wall of CB and frontal sinusotomy. CONCLUSIONS: This case illustrates that CB mucocele could develop to such a massive extent that it leads to orbital complication and secondary frontal sinusitis. Therefore, we consider this entity in the differential diagnosis of orbital complications and secondary sinusitis caused by intranasal mass.

Isolated primary frontal sinus aspergillosis: role of endonasal endoscopic approach.

BACKGROUND: Frontal sinus involvement in aspergillosis associated with the nose and paranasal sinuses is a common occurrence, but the incidence of primary frontal sinus aspergillosis is rare, and there are few reports in the English literature. OBJECTIVE: This study aimed to evaluate the role of the endonasal endoscopic surgical approach for isolated primary frontal sinus aspergillosis. METHOD: This paper describes a retrospective study of 16 cases of primary frontal sinus aspergillosis. The patients had presented to the out-patient services of the Department of Otolaryngology and Head and Neck Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India, between January 1999 and July 2011. RESULTS: The overall success rate of the endonasal endoscopic approach was 82.25 per cent. The disease recurred in three patients and was subsequently managed using the modified Lothrop procedure. CONCLUSION: Minimally invasive endonasal endoscopic sinus surgery was found to be an effective and a safe approach for managing primary frontal sinus aspergilloma, even in cases with larger bony defects involving the posterior table of the frontal sinus.

Radiographic density profiles link frontal and anterior ethmoid sinuses behavior in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) may occur through heterogeneous disease processes. It is possible that more than 1 inflammatory process underlies CRS in any given patient. If so, heterogeneity in processes may be a function of the spatial organization of the paranasal sinuses. Density characteristics of sinus opacities on computed tomography (CT) scans offer insight into the nature of sinus opacities and disease, in general, and may thus be used to detect spatial heterogeneity of sinus disease within a given patient. METHODS: The study was a retrospective chart review of CRS patients with available sinus CT scans. Radiographic density profiles of sinus opacities were assessed by raw measures of densities (in Hounsfield units [HU]). Radiographic density profiles of the different affected sinuses were compared to each other, checked for correlation, and finally, checked for evidence of clustering using a principal component analysis. RESULTS: Frontal sinus opacities appear to be more heterogeneous, with both higher and lower density components than other sinuses. There was strong correlation between the radiographic density profiles of opacities in the frontal, anterior ethmoid, and sphenoid sinuses (p < 0.001). However, on principal component analysis the radiographic density characteristics of the opacities of the frontal and anterior ethmoid sinuses appeared to cluster together more than the other sinuses. CONCLUSION: Radiographic properties of sinus opacities suggest the nature of sinus opacities are related not only to some common underlying pathology but also to factors related to the specific sinus as well as other spatially close affected sinuses. This suggests an anatomic orientation for sinus pathophysiology in CRS.

A sheep model to investigate the role of fungal biofilms in sinusitis: fungal and bacterial synergy.

BACKGROUND: The role of fungi in the spectrum of chronic rhinosinusitis (CRS) is poorly understood. Fungal biofilms have recently been discovered in CRS patients. We have developed an animal model for the investigation of sinonasal fungal biofilms. The role of type I hypersensitivity and pathogenic bacteria is presented. METHODS: Thirty sheep were sensitized with fungal antigens-Aspergillus fumigatus and Alternaria alternata, or control. Endoscopic surgery was performed to expose both frontal sinus ostia-1 was occluded. Fungi with or without Staphylococcus aureus were inoculated into the sinus. Skin-prick tests assessed for fungal allergy. Fungal and S. aureus biofilms, histology, and culture rates were assessed. RESULTS: Forty-five percent of experimental sheep were sensitized to fungal antigen. Only 1 sinus inoculated with fungus developed minimal fungal biofilm. Eighty percent developed fungal biofilm when S. aureus was co-inoculated. The presence of hypersensitivity to fungus was not related to fungal biofilm development. CONCLUSION: Significant fungal biofilm only occurred when S. aureus was the co-inoculum. Hypersensitivity was not requisite. The relationship of S. aureus to fungal biofilms is of great clinical interest. Fungi may be opportunistic pathogens that simply require inflamed mucosa with weakened innate defenses; alternatively, a cross-kingdom synergy could be contributing to fungal proliferation.