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Frontal Sinus Surgery

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Frontal Sinus Surgery

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    1. Frontal Sinus Surgery Jacques Peltier, MD Matthew Ryan, MD Department of Otolaryngology University of Texas Medical Branch Galveston, TX October 11, 2006

    2. Anatomy Uncinate process Agger Nasi

    4. Anatomy Hiatus Semilunaris Ethmoid infundibulum

    6. Frontal Sinus Drainage Pathway Frontal Sinus Ostium Anatomy

    7. Anatomy Cribriform Plate Lamina papyracea Fovea ethmoidalis

    9. Anatomic Variations

    11. Anatomy Anterior Terminal Recess Posterior Terminal Recess

    13. Finding The Frontal Recess

    14. Finding The Frontal Recess

    16. Frontal Cells 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

    17. Frontal Cells

    18. Frontal Cells

    19. Frontal Cells

    20. Anatomic Variations

    21. Surgical Indications 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.

    27. Draf Procedures

    28. Draf I Anterior ethmoid cells Uncinate process Obstructing frontal cells

    29. Draf II Floor of the frontal sinus Lamina papyracea to Septum Anterior face of Frontal

    30. Draf III Modified Lothrop Interfrontal septum Nasal septum Frontal sinus floor

    31. Frontal Sinus Trephination Finding the frontal recess Mucoceles Isolated Type IV frontal cells With endoscopic techniques to assist with Draf II and III

    32. Frontal Sinus Trephination

    33. Frontal Sinus Trephination

    34. Frontal Sinus Trephination

    35. Frontal Sinus Trephination

    36. Combined Approaches

    37. Combined Approaches

    38. Combined Approaches

    40. Modified Lothrop

    43. Modified Lothrop Take down the septum first

    52. Osteoplastic Flap Vs. Draf III 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

    53. Osteoplastic Flap Vs. Draf III

    56. Osteoplastic Flap May be modified to fit the patient

    57. Osteoplastic Flap Small bony flap Care to preserve supratrochlear bundle

    61. Osteoplastic Flap 6 foot Caldwell Image guidance Wire probe

    62. Osteoplastic Flaps

    63. Osteoplastic Flaps

    64. Osteoplastic Flap

    65. Osteoplastic Flap

    66. Osteoplastic Flap

    67. Pearls to Operating in the frontal recess Taken from a lecture by David Kennedy MD at the academy meeting this year Pearl look for lectures at academy that will assist your grand rounds

    68. 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

    69. Pearl # 2 Identify the Anterior Ethmoidal Artery Superior extension of anterior wall of bulla Nipple on the medial orbital wall 1-4 mms below skull base Typically posterior to supraorbital ethmoid cells

    70. 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

    71. 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

    72. 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

    73. Pearl # 6 Preserve the Mucosa Consider leaving polyps if sinus is open Remove osteitic intersinus septae carefully Do not traumatize unless sinus can be opened widely Standard frontal sinusotomy Draf Type II Works well if you can: Preserve mucosa Remove bony partitions Create an ostium >4-5 mm

    74. 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?

    75. Pearl #8 Avoid obliteration in tumors and allergic fungal sinusitis Combine osteoplastic approach with Draf 3 if possible in these situations Avoids imaging difficulties after surgery

    77. Pearl #9 Always avoid complications in FESS. Most operations are for benign disease

    78. Conclusion 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

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