Babak Saedi
Associate Professor of Department of Otolaryngology
Tehran University of Medical
Sciences http://www.dr.babaksaedi.com/De sktopDefault.aspx?tabindex=14&t abid=115&lang=fa-IR

 Uncinate process
 Agger Nasi http://www.dr.babaksaedi.com/DesktopDef ault.aspx?tabindex=14&tabid=115&lang=f a-IR

 Cribriform Plate
 Lamina papyracea
 Fovea ethmoidalis

Wormald PJ 2008

A common reason for ESS failure is inadequate removal of cells obstructing the outflow of the frontal sinus

Single Agger Nasi Cell Without Frontal Cells
Wormald PJ 2008

Single Agger Nasi Cell Without Frontal Cells
Wormald PJ 2008

Single Agger Nasi Cell Without Frontal Cells
Wormald PJ 2008

Transition From Frontal Sinus To Frontal Recess
Wormald PJ 2008

Kuhn FA 1994

 Type I - Single cell above the agger nasi
 Type II - Two or more cells above the agger cell
 Type III - Single cell extending from the agger cell into the frontal sinus
 Type IV - Isolated cell within the frontal sinus

 Chronic sinusitis unresolved with maximal medical therapy;
 Polyps and allergic fungal sinusitis
 Intracranial complications of sinusitis
 Mucoceles or mucopyoceles
 Benign neoplasms such as osteomas, inverting papillomas, or fibrous dysplasia.

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

Understand the patient’s frontal recess anatomy
Ascertain the anatomical reason for frontal recess/frontal sinus obstruction
Determine the best surgical approach to the problem

 Dissection should be performed from posterior to anterior and from medial to lateral
 Preserve all frontal recess mucus membrane
 The frontal ostium can be stented or left alone!!!!
Kuhn FA 2006

http://www.dr.babaksaedi.com/DesktopDef ault.aspx?tabindex=14&tabid=115&lang=f a-IR

 Anterior ethmoid cells
 Uncinate process
 Obstructing frontal cells

 Floor of the frontal sinus
 Lamina papyracea to Septum
 Anterior face of Frontal

 Modified Lothrop
 Interfrontal septum
 Nasal septum
 Frontal sinus floor

Surgical Outcomes Following the
Endoscopic
Modified Lothrop Procedure
 Conclusion: EMLP is a safe and
effective surgical alternative to OPF for patients with recalcitrant frontal sinus disease. Major complications are rare. A large percentage of patients may require revision surgery
Laryngoscope, 117:765–769, 2007

 Finding the frontal recess
 Mucoceles
 Isolated Type IV frontal cells
 With endoscopic techniques to assist with Draf II and III

 The least invasive procedure
 It can be used as a stand-alone procedure or with ethmoidectomy
 It pushes the medial agger nasi cell wall laterally and the ethmoid bulla lamella posteriorly
 K
Kuhn FA 2006

Frontal Recess & Frontal Beak
Wormald PJ 2008

 Narrow Nasal Airway
 Small Frontal Sinus
 Deep Nasion
 Floor of sinus < 1.5 cm
 Heavy thick nasofrontal beak
 Proliferative osteitis, complicated chronic infection
 Favor Draf III for mucoceles

The frontal osteoplastic flap: does it still have a place in rhinological surgery
 The frontal osteoplastic flap still has a role in frontal sinus surgery.
The Journal of Laryngology & Otology (2011), 125, 162–168.

 May be modified to fit the patient

 Osteoplastic and endoscopic (above and below approach)
 Frontal sinus obliteration
Wynn R, et al 2007

 Osteomyelitis of the anterior wall of the frontal sinus
 Failure of frontal sinus obliteration
 Some tumors of the frontal sinus

Pearl #1 Carefully Examine the Anatomy in more than one CT plane
 Size of the frontal recess
 Size of the frontal sinus
 Bony thickening or neo-osteogenesis
 Identify the frontal sinus drainage pathway
 Note the position of the anterior ethmoidal artery

Pearl # 2 Identify the Anterior
Ethmoidal Artery
 Superior extension of anterior wall of bulla
 Nipple on the medial orbital wall
 14 mm’s below skull base
 Typically posterior to supraorbital ethmoid cells

Pearl #3: Plan the least invasive approach possible
 Ethmoidectomy with Middle Meatal
Antrostomy without frontal recess surgery
 Frontal recess surgery
 Endoscopic frontal sinusotomy
 Frontal sinus trephination
 Unilateral extend frontal sinus surgery
(Draf II)
 Endoscopic Modified Lothrop (Draf III)
 Osteoplastic flap with or without obliteration

Pearl #4 Positively Identify the Skull
Base Posteriorly
 Skeletonize from posterior to anterior
 Open cells immediately posterior to the middle turbinate
 Identify the sinus with a seeker

Pearl #5 Positively identify the frontal sinus with a probe
 Need a relatively dry field
 45 degree telescopes are helpful
 Identify medial orbital wall and stay close to it dissecting superiorly
 Opening to frontal sinus typically medial
 Identify opening with a probe

 Consider leaving polyps if sinus is open
 Remove osteitic intersinus septae carefully
 Do not traumatize unless sinus can be opened widely
 Standard frontal sinusotomy
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
Draf Type II
Works well if you can:
○ Preserve mucosa
○ Remove bony partitions
○ Create an ostium >4-5 mm

Pearl #7 Keep the Sinus Open
Postoperatively
 Remove fibrin and blood from frontal recess and frontal sinus
 Remove residual bone
 Antibiotics, topical steroids?
 Oral Steroids?

 Very little evidence based medicine
 Do the least invasive procedures first
 Be aware of various surgical options
 Image guidance a valuable tool
 First do no harm