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Clinical Consultation: Answers to readers’ questions on: Endoscopic frontal sinus obliteration
Although most patients with frontal rhinosinusitis improve with medical therapy, those with persistent symptoms resulting from anatomic obstruction of the frontal sinus drainage pathways may be candidates for surgery. Over the past decade, traditional external approaches to the frontal sinus have been largely replaced by endoscopic procedures.1 These are performed with a small-diameter rigid endoscope that is passed through the nostril, avoiding the need for facial incisions. Instruments passed alongside the endoscope are used to remove obstructing tissue and drain the infected sinus.
What is the role ofendoscopic frontalsinus obliteration?What are the indications for endoscopicfrontal sinus obliteration?
Although most patients with frontal rhinosinusitis improve with medical therapy, those with persistent symptoms resulting from anatomic obstruction of the frontal sinus drainage pathways may be candidates for surgery. Over the past decade, traditional external approaches to the frontal sinus have been largely replaced by endoscopic procedures.1 These are performed with a small-diameter rigid endoscope that is passed through the nostril, avoiding the need for facial incisions. Instruments passed alongside the endoscope are used to remove obstructing tissue and drain the infected sinus.
Although endoscopic sinus surgery is generally successful, failure rates of 10% to 30% have been reported.2-4 Failures are commonly the result of the formation of scar tissue or recurrent polyps with re-obstruction of the frontal ostium.5 In this scenario, obliteration of the frontal sinus is considered.
Conventional obliteration of the frontal sinus requires a large external incision across the hair-bearing scalp or through a forehead crease to gain access to the sinus. The flap of bone forming the anterior table of the frontal sinus is elevated to expose the sinus interior. The mucosa lining the sinus is then removed using a drill.
To permanently isolate the frontal sinus from the nasal cavity, the drainage ostium is plugged and the sinus is filled with graft material, usually autogenous fat harvested from the abdomen. Patients are typically hospitalized for 2 to 3 days after such surgery. Success rates range from 80% to 97%.1,6
We have used a new, less invasive approach to obliterate the frontal sinus. This procedure is performed with an endoscope passed through a small incision in the eyebrow. An opening is made through the bony floor of the frontal sinus through which endoscopic instruments, including a drill, are passed to remove diseased tissue within the sinus, similar to conventional obliteration. The sinus is then filled with autogenous fat. Endoscopic obliteration is ideally suited for patients with small to medium-sized frontal sinuses, in whom the depths of the sinus cavity can be easily reached with endoscopic instrumentation. It is also well suited to patients with unilateral disease, in whom a single, small incision can be easily disguised. Conventional obliteration is technically easier in patients with large frontal sinuses and in those with bilateral disease. The complementary nature of these 2 approaches for patients with refractory frontal rhinosinusitis is reflected in the Figure.
Unlike conventional external obliteration, which has been performed for more than 40 years, experience with endoscopic obliteration is limited to less than 5 years. Preliminary results suggest an efficacy comparable to that of conventional techniques, with reduced patient morbidity, including decreased intraoperative blood loss, shorter hospital stay, and reduced time of anesthesia.7 Nevertheless, the long-term results of endoscopic frontal sinus obliteration remain unknown.
References:
REFERENCES
1. Montgomery WW. State-of-the-art for osteoplastic frontal sinus operation. Otolaryngol Clin North Am.2001;34:167-177.
2. Metson R, Sindwani R. Endoscopic surgery for frontal sinusitis--a graduated approach.
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3. Weber R, Draf W, Kratzsch B, et al. Modern concepts of frontal sinus surgery.
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4. Samaha M, Cosenza MJ, Metson R. Endoscopic frontal sinus drillout in 100 patients.
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5. Chandra RK, Palmer JN, Tangsujarittham T, Kennedy DW. Factors associated with failure of frontal sinusotomy in the early follow-up period.
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2004;131:514-518.
6. Correa AJ, Duncavage JA, Fortune DS, Reinisch L. Osteoplastic flap for obliteration of the frontal sinus: five years' experience.
Otolaryngol Head Neck Surg.
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7. Ung F, Sindwani R, Metson R. Endoscopic frontal sinus obliteration: a new technique for the treatment of chronic frontal sinusitis.
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2005;133:551-555.
