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Babak Saedi Associate Professor of Department of Otolaryngology Tehran University of Medical Sciences sktopDefault.aspx?tabindex=14&t.

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Presentation on theme: "Babak Saedi Associate Professor of Department of Otolaryngology Tehran University of Medical Sciences sktopDefault.aspx?tabindex=14&t."— Presentation transcript:

1 Babak Saedi Associate Professor of Department of Otolaryngology Tehran University of Medical Sciences sktopDefault.aspx?tabindex=14&t abid=115&lang=fa-IR

2 Anatomy  Uncinate process  Agger Nasi ault.aspx?tabindex=14&tabid=115&lang=f a-IR

3 Anatomy  Cribriform Plate  Lamina papyracea  Fovea ethmoidalis



6 Anatomic Variations

7 Wormald PJ 2008


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

10 Single Agger Nasi Cell Without Frontal Cells Wormald PJ 2008

11 Single Agger Nasi Cell Without Frontal Cells Wormald PJ 2008

12 Single Agger Nasi Cell Without Frontal Cells Wormald PJ 2008

13 Transition From Frontal Sinus To Frontal Recess Wormald PJ 2008

14 Frontal Cells Kuhn FA 1994

15 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

16 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.



19 Finding The Frontal Recess


21 Endoscopic Frontal Sinusotomy  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

22 Endoscopic Frontal Sinusotomy Principles  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


24 ault.aspx?tabindex=14&tabid=115&lang=f a-IR


26 Draf Procedures

27 Draf I  Anterior ethmoid cells  Uncinate process  Obstructing frontal cells

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

29 Draf III  Modified Lothrop  Interfrontal septum  Nasal septum  Frontal sinus floor

30 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

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 Combined Approaches

33 Endoscopic Frontal Sinoplasty  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K Kuhn FA 2006

34 Modified Lothrop

35 Frontal Recess & Frontal Beak Wormald PJ 2008

36 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

37 Osteoplastic Flap Vs. Draf III

38 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.

39 Osteoplastic Flap  May be modified to fit the patient

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

41 Riedel's Procedure  Osteomyelitis of the anterior wall of the frontal sinus  Failure of frontal sinus obliteration  Some tumors of the frontal sinus

42 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

43 Pearl # 2 Identify the Anterior Ethmoidal Artery  Superior extension of anterior wall of bulla  Nipple on the medial orbital wall  1-4 mm’s below skull base  Typically posterior to supraorbital ethmoid cells

44 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

45 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

46 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

47 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

48 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?

49 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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