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Endoscopic treatment of acute frontal sinusitis: Indications and limitations
Endoscopic treatment of acute frontal sinusitis: Indications and limitations HASSAN H. RAMADAN, MD, FACS, Morgantown, West Virginia
I , J u r i n g t h e last d e c a d e , e n d o s c o p i c sinus s u r g e r y ( E S S ) has b e c o m e t h e p r o c e d u r e o f choice for t h e t r e a t m e n t o f c h r o n i c sinusitis. R e c e n t r e p o r t s have shown t h a t E S S is very effective for t r e a t i n g c h r o n i c f r o n t a l s i n u s i t i s J O n l y a few r e p o r t s a r e available a b o u t t h e u s e of E S S in t h e t r e a t m e n t o f a c u t e f r o n t a l sinusitis. 2 A c u t e f r o n t a l sinusitis, an u n c o m m o n c o n d i t i o n , usually r e s p o n d s to m e d i c a l t r e a t m e n t . Occasionally, cases o f a c u t e f r o n t a l sinusitis m a y c a u s e c o m p l i c a t i o n s t h a t n e e d to b e a d d r e s s e d surgically. Also, cases o f a c u t e f r o n t a l sinusitis m a y b e e n c o u n t e r e d t h a t d o n o t r e s p o n d to m e d i c a l t r e a t m e n t , T h e t r e a t m e n t o f choice has b e e n an e x t e r n a l p r o c e d u r e . L y n c h in 1921 said t h a t " i n a c u t e f u l m i n a t i o n states, t h e e x t e r n a l o p e r a t i o n is t h e m e t h o d o f choice. ''3 T r e p h i n a t i o n o r d r a i n a g e t h r o u g h a n e x t e r n a l p r o c e d u r e has b e e n t h e p r o c e d u r e o f choice. E S S has a l l o w e d access to t h e f r o n t a l recess a r e a a n d t h e ability to o p e r a t e to r e s t o r e d r a i n a g e to t h e f r o n t a l sinus. In this r e p o r t f o u r cases of i s o l a t e d a c u t e f r o n t a l sinusitis t h a t u n d e r w e n t ESS a r e p r e s e n t e d , a n d t h e i n d i c a t i o n s a n d l i m i t a t i o n s of t h e p r o c e d u r e a r e discussed. CASE REPORTS Case I. A 29-year-old woman was admitted for intra-
venous antibiotic therapy for isolated acute frontal sinusitis. One week before admission she was seen in the emergency department with a 1-week history of left forehead headache. On examination she looked toxic and had a temperature of 101 ° F. She was tender on the left forehead. Nasal examination revealed erythema and swelling of the turbinates but no purulence. Plain x-ray From the Department of Otolaryngology-Head and Neck Surgery, West Virginia University. Presented at the American Rhinologic Society; West Palm Beach, Fla., May 7-9, 1994. Received for publication Aug. 25, 1994; accepted Jan. 20, 1995. Reprint requests: Hassan H. Ramadan, MD, Department of Otolaryngology-Head and Neck Surgery, West Virginia University, 2222 Robert C. Byrd Health Sciences South, P.O. Box 9200, Morgantown, WV 26506-9200. OTOLAaYNGOLHEADNECKSUaO 1995;113:295-300. Copyright © 1995 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/95/$3.00 + 0 23/4/63532
Fig. t. Plain x-ray film of paranasal sinuses showing opacification of left frontal sinus.
films showed opacification of the left frontal sinus (Fig. 1). Treatment with oral antibiotics was not successful. On admission, she was given intravenous antibiotics, but 72 hours later she was still symptomatic. A computed tomography (CT) scan revealed complete opacification of the left frontal sinus (Fig. 2). Four days after admission she underwent a septoplasty with endoscopic anterior ethmoidectomy and opening of the frontal recess as described previously.~.2 Purulence was encountered, and culture grew Propionibacterium acnes andPeptostreptococcus. The ethmoid area was packed with Merocel for 24 hours. Stents were not used. Twenty-four hours later, she was afebrile, and her pain and tenderness were remarkably decreased. She was discharged on the second postoperative day and was prescribed oral antibiotics. The patient remains symptom free 15 months after surgery. Case 2. A 33-year-old man was referred after two courses of oral antibiotics for the treatment of acute right frontal sinusitis failed. He had an external ethmoidectomy performed for drainage of his frontal sinus, but his forehead pain persisted. On examination he had severe tenderness above the right eye. Plain x-ray film revealed 295
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Otolaryngology Head and Neck Surgery September ~995
Fig. 2. Coronal CT i m a g e of the paranasal sinuses showing opacification of the left frontal sinus.
Fig. 3. Plain x-ray film of sinuses after insertion of catheter revealing continued opacification of right frontal sinus.
opacification of his right frontal sinus. Intravenous antibiotics for 72 hours did not improve his symptoms. CT scan revealed complete opacification of the right frontal sinus. An endoscopic anterior ethmoidectomy and opening of the nasofrontal duct area were performed. Purulence was recovered from the nasofrontal duct, and his culture grew StaphylococcuX aureus. He had marked improvement of his symptoms 24 hours after the procedure and was discharged while still taking oral antibiotics. He remains symptom free 9 months after surgery.
Case 3. A 23-year-old man was referred because of right forehead pain of 4 weeks' duration. He began receiving intravenous antibiotics initially; however, because of lack of response, he had two trephination procedures performed with insertion of a catheter for irrigation and drainage but without any improvement (Fig. 3). An attempt at flexible endoscopy of the nose for irrigation failed. Despite the trephination he still reported severe pain over the right forehead area. His past medical history was positive for acute sinusitis a year before that had
Otolaryngology H e a d a n d N e c k Surgery
Volume 113
Number 3
Fig. 4. Endoscopic view of right nasal cavity with a 0-degree telescope revealing a lateralized middle turbinate.
necessitated an intranasal procedure. His examination revealed tenderness over the right forehead and the scar of the previous trephination. He had a 3 x 2 cm swelling above the right eye. Nasal endoscopy revealed a lateralized middle turbinate, and the osteomeatal area was not adequately visualized (Fig. 4). A C T scan revealed complete opacification of the right frontal sinus (Fig. 5). Endoscopic partial middle turbinectomy on the right side was performed along with an anterior ethmoidectomy and opening of the nasofrontal duct. Purulence was recovered, and culture grew Staphylococcus epidermidis. He remains symptom free 19 months after surgery. Caae 4. A 60-year-old man was transferred to us from another hospital because of a right frontal lobe abscess and right frontal sinusitis that were not responsive to 6 weeks of intravenous antibiotics. He initially had grand mal seizures with reports of headache, cough, and postnasal drainage. A C T scan and magnetic resonance image (MRI) showed right frontal sinusitis complicated by a frontal lobe abscess (Figs. 6 and 7). Endoscopic examination on the right side was not possible because of marked septal deviation. His examination on the left revealed a markedly enlarged middle turbinate. Follow-up CT scan did not show any improvement in his right frontal sinusitis. The scan also showed a concha bullosa on the left with marked septal deviation. A septoplasty, a partial middle turbinectomy on the left, and a right anterior ethmoidectomy and opening of the nasofrontal duct area on the right were performe& During the procedure and after identification of the nasofrontal duct, we were not able to see well into the frontal sinus. The procedure was complicated by periorbital emphysema. A stent was inserted; however, the patient pulled it out hours after the procedure. The patient did well after surgery and was discharged. The neurosurgeons did not believe that his
RAMADAN 29'1
Fig. 5. Coronal CT image of paranasal sinuses revealing opacification of right frontal sinus.
Fig. 6. Axial CT image of paranasal sinuses showing opacification of right frontal sinus.
frontal lobe abscess needed to be drained. Two months after surgery the patient again reported right forehead pain and headache despite another 6-week course of antibiotics after surgery, A repeat CT scan showed persistence of the opacification of the right frontal sinus (Fig. 8). Because of that he underwent an osteoplastic flap with fat obliteration. During the procedure, the right frontal sinus was noted to have two chambers that were opened, and then the sinus was obliterated with fat. After surgery he did extremely well, and he is symptom
298
Otolaryngology Head and Neck Surgery September 1995
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Fig. 7. MRI of the brain showing brain abscess in right frontal lobe.
Fig. 8. CT image of paranasal sinuses showing persistent opacification of right frontal sinus.
free 13 months after surgery. A repeat MRI showed the frontal lobe abscess to be improving. DISCUSSION
Nasal endoscopy and improved imaging techniques have resulted in a more accurate assessment of sinus disease. Obstruction of the nasofrontal duct area can be better visualized. Drainage of the frontal sinus through the external route has been the preferred method of choice for cases with persistent
symptoms, despite adequate medical therapy including intravenous antibiotics. Our preliminary results of treating four cases of acute frontal sinusitis that were refractory to medical treatment with ESS are encouraging. Three patients had complete resolution of their symptoms after medical and in some instances surgical treatment had failed. Endoscopic treatment failed in one case (case 4), and the patient needed frontal sinus obliteration. Case 1 represents an isolated acute frontal sinusitis that was not responsive to medical therapy. Instead of a trephination procedure, an endoscopic procedure was performed for drainage of the sinuses, and at the same time cultures were obtained. The patient had resolution of her symptoms in 24 hours. No external incisions were used, and the patient was discharged from the hospital on oral antibiotics in 48 hours. Follow-up at 15 months revealed that the patient had not reported symptoms of sinus disease. Initial medical therapy, for which a Lynch procedure was performed with some improvement initially, failed in case 2. However, symptoms recurred. Endoscopic drainage of the sinus resulted in resolution of symptoms. The patient remains symptom free after 9 months of follow-up. Medical treatment failed in case 3, and subsequently the patient had two trephination procedures performed in an effort to relieve the symptoms; however, to no avail. In this particular case, nasal endoscopy allowed us to visualize the pathology behind the failure of the external procedure. A
Otolaryngology Head and Neck Surgery Volume t t 3 Number 3
RAMADAN
1
3
4
5
299
2
6
7
8
9
10
Fig. 9. Transverse section through frontal sinus from a b o v e showing a frontal bulla (2). f, Large frontal sinus on the left side; 2, anterosuperior ethmoid cell in the orbital roof (a frontal bulia by our criteria); 3, temporal muscle; 4, temporal lobe pole; 5, meningo-orbital ramus; 6, anterior petroclinoid fold a n d oculomotor nerve; 7, gyrus rectus, optic nerve, and section of the anterior lobe of the pituitary gland; 8, infundibulum and section of the posterior lobe of the pituitary gland; 9, falx cerebri, olfactory tract, and section of internal carotid artery; 10, frontal sinus on the right with a millimeter strip. (Reprinted with permission from Lang J. Clinical a n a t o m y of the nose, nasal cavity and paranasal sinuses, p. 64, Copyright 1989 by Thieme Medical Publishers, Inc., New York.]
lateralized middle turbinate was seen that was adherent to the lateral nasal wall blocking the outflow tract of the frontal sinus (Fig. 4). Nasal endoscopy enabled us to identify the problem, after partial middle turbinectomy and opening of the nasofrontal duct. The patient has been free of symptoms for 19 months. Case 4 represents a complication of acute frontal sinusitis that did not respond to medical therapy. The cause of the frontal sinusitis was a deviated nasal septum caused by a concha bullosa on the contralateral side. The deviated septum resulted in lateralization of the middle turbinate and blockage of the outflow tract of the sinus. This case also represents a limitation of endoscopic frontal sinus drainage. During the procedure, we were not able to drain the lateral part of the frontal sinus. It was not until we were performing the osteoplastic flap that we identified the anatomic cause of failure of ESS. A frontal bulla was noted in the frontal sinus, which m a d e it extremely difficult to drain the sinus. After review of the literature, we learned that a frontal bulla has been described by several authors (Fig. 9). Boege in 19034 found two frontal sinuses on one side
in 1.5% of his cases. Grfinwald (1925) 5 had similar findings in 3% of his cases. This extra sinus lay in the medial third of the orbital roof. It was present in 17% of the cases reviewed by Lang. 6 The only complication encountered was orbital emphysema in case 4 that resolved spontaneously in 72 hours. All cases were done with patients under general anesthesia. Long-term follow-up of any new surgical procedure is needed before conclusions can be drawn about its success. Kennedy et a l / drained eight frontal sinus mucoceles endoscopically with no recurrences after up to 16 months of follow-up. Schaefer and Close I reported on 34 patients, mainly with chronic frontal sinusitis, of whom 21 had complete resolution of symptoms after 9 months of follow-up. Metson 2 operated on six cases of acute and subacute frontal sinusitis endoscopically, and all patients did well after surgery. In all of our cases only drainage of the involved sinus was performed. No stenting was used, except in one patient who pulled it out after surgery. Correction of the anatomic deformities was also performed. The endoscopic approach preserves the anatomy
Head
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of the sinus and allows its drainage functionally. Unlike the trephination or Lynch procedures, the bony framework of the nasofrontal recess is preserved. A n external skin incision and a scar are avoided. The procedure, however, may have some limitations, as we have seen in case 4, and may not be the procedure of choice in every patient. Meticulous endoscopic techniques and intimate knowledge of the anatomy are needed to obtain the best results. As more experience is gained with the procedure, proper indications and contraindications will be acquired. CONCLUSION
Trephination, external drainage, or the osteoplastic flap have been recommended for the treatment of refractory or complicated acute frontal sinusitis. Functional ESS provides a more functional conservative approach for the treatment of acute frontal sinusitis. The morbidity of the procedure seems to be less than with the more traditional approaches. More cases and longer follow-up will be required before the success of the procedure can be evalu-
Otolaryngology and Neck Surgery S e p t e m b e r 1995
ated. Functional endoscopic surgery appears to be an alternative for the treatment of selected cases of acute frontal sinusitis. Thanks to Kimberly ReVeal for preparation of this manuscript. REFERENCES 1. Schaefer SD, Close LG. Endoscopic management of frontal
sinus disease. Laryngoscope1990;100:155-60. 2. Metson R. Endoscopictreatment of frontal sinusitis. Laryngoscope 1992;102:712-6. 3. LynchRC. The technique of a radical frontal sinus operation which has givenme the best results. Laryngoscope1921;31:1-5. 4. BoegeK. Zur anatomie der stirnh6hlen (sinus frontalis). Diss., K6nigsberg i. Pr.; Jber. Fortschr. Anat. Entw.-Gesch. 1903; 8(111):22. 5. Griinwald L. Deskriptive und topographische anatomie der nase und ihrer nebenh6hlen. In: Denker A, Kahler O. Die krankheiten der luftwege und der mundh6hle. Berlin: Springer, 1925:$1-95. 6. Lang J. Clinical anatomy of the nose, nasal cavity and paranasal sinuses. New York: Thieme Medical Publishers, Inc., 1989:62-4. 7. Kennedy DW, Josephson JS, Zinreich SJ, et al. Endoscopic sinus surgeryfor mucoceles:a viable alternative. Laryngoscope 1989;99:885-95.
I , J u r i n g t h e last d e c a d e , e n d o s c o p i c sinus s u r g e r y ( E S S ) has b e c o m e t h e p r o c e d u r e o f choice for t h e t r e a t m e n t o f c h r o n i c sinusitis. R e c e n t r e p o r t s have shown t h a t E S S is very effective for t r e a t i n g c h r o n i c f r o n t a l s i n u s i t i s J O n l y a few r e p o r t s a r e available a b o u t t h e u s e of E S S in t h e t r e a t m e n t o f a c u t e f r o n t a l sinusitis. 2 A c u t e f r o n t a l sinusitis, an u n c o m m o n c o n d i t i o n , usually r e s p o n d s to m e d i c a l t r e a t m e n t . Occasionally, cases o f a c u t e f r o n t a l sinusitis m a y c a u s e c o m p l i c a t i o n s t h a t n e e d to b e a d d r e s s e d surgically. Also, cases o f a c u t e f r o n t a l sinusitis m a y b e e n c o u n t e r e d t h a t d o n o t r e s p o n d to m e d i c a l t r e a t m e n t , T h e t r e a t m e n t o f choice has b e e n an e x t e r n a l p r o c e d u r e . L y n c h in 1921 said t h a t " i n a c u t e f u l m i n a t i o n states, t h e e x t e r n a l o p e r a t i o n is t h e m e t h o d o f choice. ''3 T r e p h i n a t i o n o r d r a i n a g e t h r o u g h a n e x t e r n a l p r o c e d u r e has b e e n t h e p r o c e d u r e o f choice. E S S has a l l o w e d access to t h e f r o n t a l recess a r e a a n d t h e ability to o p e r a t e to r e s t o r e d r a i n a g e to t h e f r o n t a l sinus. In this r e p o r t f o u r cases of i s o l a t e d a c u t e f r o n t a l sinusitis t h a t u n d e r w e n t ESS a r e p r e s e n t e d , a n d t h e i n d i c a t i o n s a n d l i m i t a t i o n s of t h e p r o c e d u r e a r e discussed. CASE REPORTS Case I. A 29-year-old woman was admitted for intra-
venous antibiotic therapy for isolated acute frontal sinusitis. One week before admission she was seen in the emergency department with a 1-week history of left forehead headache. On examination she looked toxic and had a temperature of 101 ° F. She was tender on the left forehead. Nasal examination revealed erythema and swelling of the turbinates but no purulence. Plain x-ray From the Department of Otolaryngology-Head and Neck Surgery, West Virginia University. Presented at the American Rhinologic Society; West Palm Beach, Fla., May 7-9, 1994. Received for publication Aug. 25, 1994; accepted Jan. 20, 1995. Reprint requests: Hassan H. Ramadan, MD, Department of Otolaryngology-Head and Neck Surgery, West Virginia University, 2222 Robert C. Byrd Health Sciences South, P.O. Box 9200, Morgantown, WV 26506-9200. OTOLAaYNGOLHEADNECKSUaO 1995;113:295-300. Copyright © 1995 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/95/$3.00 + 0 23/4/63532
Fig. t. Plain x-ray film of paranasal sinuses showing opacification of left frontal sinus.
films showed opacification of the left frontal sinus (Fig. 1). Treatment with oral antibiotics was not successful. On admission, she was given intravenous antibiotics, but 72 hours later she was still symptomatic. A computed tomography (CT) scan revealed complete opacification of the left frontal sinus (Fig. 2). Four days after admission she underwent a septoplasty with endoscopic anterior ethmoidectomy and opening of the frontal recess as described previously.~.2 Purulence was encountered, and culture grew Propionibacterium acnes andPeptostreptococcus. The ethmoid area was packed with Merocel for 24 hours. Stents were not used. Twenty-four hours later, she was afebrile, and her pain and tenderness were remarkably decreased. She was discharged on the second postoperative day and was prescribed oral antibiotics. The patient remains symptom free 15 months after surgery. Case 2. A 33-year-old man was referred after two courses of oral antibiotics for the treatment of acute right frontal sinusitis failed. He had an external ethmoidectomy performed for drainage of his frontal sinus, but his forehead pain persisted. On examination he had severe tenderness above the right eye. Plain x-ray film revealed 295
296
RAMADAN
Otolaryngology Head and Neck Surgery September ~995
Fig. 2. Coronal CT i m a g e of the paranasal sinuses showing opacification of the left frontal sinus.
Fig. 3. Plain x-ray film of sinuses after insertion of catheter revealing continued opacification of right frontal sinus.
opacification of his right frontal sinus. Intravenous antibiotics for 72 hours did not improve his symptoms. CT scan revealed complete opacification of the right frontal sinus. An endoscopic anterior ethmoidectomy and opening of the nasofrontal duct area were performed. Purulence was recovered from the nasofrontal duct, and his culture grew StaphylococcuX aureus. He had marked improvement of his symptoms 24 hours after the procedure and was discharged while still taking oral antibiotics. He remains symptom free 9 months after surgery.
Case 3. A 23-year-old man was referred because of right forehead pain of 4 weeks' duration. He began receiving intravenous antibiotics initially; however, because of lack of response, he had two trephination procedures performed with insertion of a catheter for irrigation and drainage but without any improvement (Fig. 3). An attempt at flexible endoscopy of the nose for irrigation failed. Despite the trephination he still reported severe pain over the right forehead area. His past medical history was positive for acute sinusitis a year before that had
Otolaryngology H e a d a n d N e c k Surgery
Volume 113
Number 3
Fig. 4. Endoscopic view of right nasal cavity with a 0-degree telescope revealing a lateralized middle turbinate.
necessitated an intranasal procedure. His examination revealed tenderness over the right forehead and the scar of the previous trephination. He had a 3 x 2 cm swelling above the right eye. Nasal endoscopy revealed a lateralized middle turbinate, and the osteomeatal area was not adequately visualized (Fig. 4). A C T scan revealed complete opacification of the right frontal sinus (Fig. 5). Endoscopic partial middle turbinectomy on the right side was performed along with an anterior ethmoidectomy and opening of the nasofrontal duct. Purulence was recovered, and culture grew Staphylococcus epidermidis. He remains symptom free 19 months after surgery. Caae 4. A 60-year-old man was transferred to us from another hospital because of a right frontal lobe abscess and right frontal sinusitis that were not responsive to 6 weeks of intravenous antibiotics. He initially had grand mal seizures with reports of headache, cough, and postnasal drainage. A C T scan and magnetic resonance image (MRI) showed right frontal sinusitis complicated by a frontal lobe abscess (Figs. 6 and 7). Endoscopic examination on the right side was not possible because of marked septal deviation. His examination on the left revealed a markedly enlarged middle turbinate. Follow-up CT scan did not show any improvement in his right frontal sinusitis. The scan also showed a concha bullosa on the left with marked septal deviation. A septoplasty, a partial middle turbinectomy on the left, and a right anterior ethmoidectomy and opening of the nasofrontal duct area on the right were performe& During the procedure and after identification of the nasofrontal duct, we were not able to see well into the frontal sinus. The procedure was complicated by periorbital emphysema. A stent was inserted; however, the patient pulled it out hours after the procedure. The patient did well after surgery and was discharged. The neurosurgeons did not believe that his
RAMADAN 29'1
Fig. 5. Coronal CT image of paranasal sinuses revealing opacification of right frontal sinus.
Fig. 6. Axial CT image of paranasal sinuses showing opacification of right frontal sinus.
frontal lobe abscess needed to be drained. Two months after surgery the patient again reported right forehead pain and headache despite another 6-week course of antibiotics after surgery, A repeat CT scan showed persistence of the opacification of the right frontal sinus (Fig. 8). Because of that he underwent an osteoplastic flap with fat obliteration. During the procedure, the right frontal sinus was noted to have two chambers that were opened, and then the sinus was obliterated with fat. After surgery he did extremely well, and he is symptom
298
Otolaryngology Head and Neck Surgery September 1995
RAMADAN
Fig. 7. MRI of the brain showing brain abscess in right frontal lobe.
Fig. 8. CT image of paranasal sinuses showing persistent opacification of right frontal sinus.
free 13 months after surgery. A repeat MRI showed the frontal lobe abscess to be improving. DISCUSSION
Nasal endoscopy and improved imaging techniques have resulted in a more accurate assessment of sinus disease. Obstruction of the nasofrontal duct area can be better visualized. Drainage of the frontal sinus through the external route has been the preferred method of choice for cases with persistent
symptoms, despite adequate medical therapy including intravenous antibiotics. Our preliminary results of treating four cases of acute frontal sinusitis that were refractory to medical treatment with ESS are encouraging. Three patients had complete resolution of their symptoms after medical and in some instances surgical treatment had failed. Endoscopic treatment failed in one case (case 4), and the patient needed frontal sinus obliteration. Case 1 represents an isolated acute frontal sinusitis that was not responsive to medical therapy. Instead of a trephination procedure, an endoscopic procedure was performed for drainage of the sinuses, and at the same time cultures were obtained. The patient had resolution of her symptoms in 24 hours. No external incisions were used, and the patient was discharged from the hospital on oral antibiotics in 48 hours. Follow-up at 15 months revealed that the patient had not reported symptoms of sinus disease. Initial medical therapy, for which a Lynch procedure was performed with some improvement initially, failed in case 2. However, symptoms recurred. Endoscopic drainage of the sinus resulted in resolution of symptoms. The patient remains symptom free after 9 months of follow-up. Medical treatment failed in case 3, and subsequently the patient had two trephination procedures performed in an effort to relieve the symptoms; however, to no avail. In this particular case, nasal endoscopy allowed us to visualize the pathology behind the failure of the external procedure. A
Otolaryngology Head and Neck Surgery Volume t t 3 Number 3
RAMADAN
1
3
4
5
299
2
6
7
8
9
10
Fig. 9. Transverse section through frontal sinus from a b o v e showing a frontal bulla (2). f, Large frontal sinus on the left side; 2, anterosuperior ethmoid cell in the orbital roof (a frontal bulia by our criteria); 3, temporal muscle; 4, temporal lobe pole; 5, meningo-orbital ramus; 6, anterior petroclinoid fold a n d oculomotor nerve; 7, gyrus rectus, optic nerve, and section of the anterior lobe of the pituitary gland; 8, infundibulum and section of the posterior lobe of the pituitary gland; 9, falx cerebri, olfactory tract, and section of internal carotid artery; 10, frontal sinus on the right with a millimeter strip. (Reprinted with permission from Lang J. Clinical a n a t o m y of the nose, nasal cavity and paranasal sinuses, p. 64, Copyright 1989 by Thieme Medical Publishers, Inc., New York.]
lateralized middle turbinate was seen that was adherent to the lateral nasal wall blocking the outflow tract of the frontal sinus (Fig. 4). Nasal endoscopy enabled us to identify the problem, after partial middle turbinectomy and opening of the nasofrontal duct. The patient has been free of symptoms for 19 months. Case 4 represents a complication of acute frontal sinusitis that did not respond to medical therapy. The cause of the frontal sinusitis was a deviated nasal septum caused by a concha bullosa on the contralateral side. The deviated septum resulted in lateralization of the middle turbinate and blockage of the outflow tract of the sinus. This case also represents a limitation of endoscopic frontal sinus drainage. During the procedure, we were not able to drain the lateral part of the frontal sinus. It was not until we were performing the osteoplastic flap that we identified the anatomic cause of failure of ESS. A frontal bulla was noted in the frontal sinus, which m a d e it extremely difficult to drain the sinus. After review of the literature, we learned that a frontal bulla has been described by several authors (Fig. 9). Boege in 19034 found two frontal sinuses on one side
in 1.5% of his cases. Grfinwald (1925) 5 had similar findings in 3% of his cases. This extra sinus lay in the medial third of the orbital roof. It was present in 17% of the cases reviewed by Lang. 6 The only complication encountered was orbital emphysema in case 4 that resolved spontaneously in 72 hours. All cases were done with patients under general anesthesia. Long-term follow-up of any new surgical procedure is needed before conclusions can be drawn about its success. Kennedy et a l / drained eight frontal sinus mucoceles endoscopically with no recurrences after up to 16 months of follow-up. Schaefer and Close I reported on 34 patients, mainly with chronic frontal sinusitis, of whom 21 had complete resolution of symptoms after 9 months of follow-up. Metson 2 operated on six cases of acute and subacute frontal sinusitis endoscopically, and all patients did well after surgery. In all of our cases only drainage of the involved sinus was performed. No stenting was used, except in one patient who pulled it out after surgery. Correction of the anatomic deformities was also performed. The endoscopic approach preserves the anatomy
Head
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RAMADAN
of the sinus and allows its drainage functionally. Unlike the trephination or Lynch procedures, the bony framework of the nasofrontal recess is preserved. A n external skin incision and a scar are avoided. The procedure, however, may have some limitations, as we have seen in case 4, and may not be the procedure of choice in every patient. Meticulous endoscopic techniques and intimate knowledge of the anatomy are needed to obtain the best results. As more experience is gained with the procedure, proper indications and contraindications will be acquired. CONCLUSION
Trephination, external drainage, or the osteoplastic flap have been recommended for the treatment of refractory or complicated acute frontal sinusitis. Functional ESS provides a more functional conservative approach for the treatment of acute frontal sinusitis. The morbidity of the procedure seems to be less than with the more traditional approaches. More cases and longer follow-up will be required before the success of the procedure can be evalu-
Otolaryngology and Neck Surgery S e p t e m b e r 1995
ated. Functional endoscopic surgery appears to be an alternative for the treatment of selected cases of acute frontal sinusitis. Thanks to Kimberly ReVeal for preparation of this manuscript. REFERENCES 1. Schaefer SD, Close LG. Endoscopic management of frontal
sinus disease. Laryngoscope1990;100:155-60. 2. Metson R. Endoscopictreatment of frontal sinusitis. Laryngoscope 1992;102:712-6. 3. LynchRC. The technique of a radical frontal sinus operation which has givenme the best results. Laryngoscope1921;31:1-5. 4. BoegeK. Zur anatomie der stirnh6hlen (sinus frontalis). Diss., K6nigsberg i. Pr.; Jber. Fortschr. Anat. Entw.-Gesch. 1903; 8(111):22. 5. Griinwald L. Deskriptive und topographische anatomie der nase und ihrer nebenh6hlen. In: Denker A, Kahler O. Die krankheiten der luftwege und der mundh6hle. Berlin: Springer, 1925:$1-95. 6. Lang J. Clinical anatomy of the nose, nasal cavity and paranasal sinuses. New York: Thieme Medical Publishers, Inc., 1989:62-4. 7. Kennedy DW, Josephson JS, Zinreich SJ, et al. Endoscopic sinus surgeryfor mucoceles:a viable alternative. Laryngoscope 1989;99:885-95.