Endoscopic trans-septal frontal sinusotomy

Abstract

The successful surgical management of chronic frontal sinus disease remains a significant challenge for otolaryngologists. From an anatomic standpoint, the drainage pathway of the frontal sinus is hidden from direct view by a complex and variable pneumatization pattern of anterior ethmoid and frontal cells. The close proximity to critical structures, including the lamina papyracea, anterior cranial fossa, and anterior ethmoid artery, adds to the dilemma of effective surgical treatment of these patients. The recent advances in endoscopic sinus surgery and image guidance have afforded direct visualization and easier access to the frontal recess and have made surgery feasible for chronic frontal sinusitis [4, 9, 14, 16, 18, 20]. Despite these advances, frontal sinus disease remains refractory in a subset of patients. This is typically related to neo-osteogenesis resulting in complete or near-complete stenosis of the nasofrontal pathway.A common contributing factor to the frontal recess stenosis is resection of the middle turbinate [19]. The destabilized middle turbinate remnant with excoriated mucosa on its lateral surface lateralizes across the floor of the frontal sinus and compromises the frontal recess patency (Fig. 27.1) [19]. Standard endoscopic techniques are generally inadequate for treatment of chronic frontal disease in these patients. In the past, they required external approaches such as frontal sinus obliteration or cranialization. These open techniques have the potential for significant morbidity. In 250 consecutive osteoplastic procedures, Hardy and Montgomery reported an operative complication rate of 19% and intraoperative cerebrospinal fluid (CSF) leak rate of 2.8% [7]. These difficult patients can now be successfully treated with extended endoscopic approaches to the frontal sinus. The novel technique of endoscopic trans-septal frontal sinusotomy (TSFS) augments management of refractory frontal sinus disease in this setting.TSFS is a unique endoscopic surgical approach that utilizes the relationship of the nasal septum to the midline floor of the frontal sinus. Like the Draf III or modified Lothrop procedure, the trans-septal approach provides good access to the midline floor of the frontal sinus and permits but does not require intersinus septum removal [5, 6]. TSFS can be utilized even in circumstances where the severity of the stenosis prohibits cannulation of the frontal recess as a primary landmark. Translocation of the nasal septum, especially in cases of a narrow nasal vault, allows for: Improved visualization Improved instrumentation Minimizing the size of the planned septal perforation In addition, TSFS also has several theoretical advantages over frontal sinus obliteration including: Decreased morbidity Improved cosmesis Ease of endoscopic and radiographic surveillance postoperatively. © Springer-Verlag Berlin Heidelberg 2005.