Frontal sinus –anatomy,classification of

frontal aircells, conditions of frontal sinus.

Mucoceles of PNSopen and endoscopic
approaches to frontal sinus
Presenter: Dr.Uma
Moderator:Dr.Niveditha
Development of frontal sinus:
Most variable sinus in size and shape
Originates from anterior ethmoid complex
Pneumatization of frontal bone begins at 16th week of gestation.
At birth ,appear as a small blind pocket difficult to distinguish from
anterior ethmoid cells
Seen in imaging by 8yrs
Reaches to adult proportions by 12yrs
Continues upto 18yrs.
Anatomy of frontal sinus:
Paired, posterior to supraciliary arches between outer and inner tables of
frontal bone.
Underlies triangular area on the surface of the face, angles formed by nasion,
a point 3cm above nasion and junction of medial third and lateral two-thirds
of supraorbital margin
Asymmetric, further divided into a number of communicating recesses by
incomplete bony septa
Average dimensions:
height=3.2cm
Breadth=2.6cm
Depth=1.8cm
Contd.
Unilateral aplasia of frontal sinus is present in present in 15% of
adults and bilaterally in 5%
Vascular supply:
Arterial – supraorbital and anterior ethmoudal arteries
Veins drain into anastomotic vein in supraorbital notch that connects
supraorbital and superior ophthalmic veins.
Lymphatic drainage to submandibular nodes
General sensation: supraorbital nerves
Parasympathetic secretomotor: orbital branches of pterygopalatine
ganglia.
Surgical anatomy of PNS:
Consistent anatomical landmarks during endoscopic sinus surgery
are:
1)Maxillary sinus
2)Orbit from maxillary sinus roof/orbital floor and medial orbital wall
3)Skull base posteriorly by sphenoid sinus
These form paranasal surgical box with horizontal and vertical
components
Developmental and functional anatomy of
PNS:
PNS are paired structures lined by ciliated pseudostratified columnar
respiratory epithelium.
PNS are divided into functional units based upon drainage pathways
1)anterior,
2)posterior and
3)sphenoid compartments
Anterior functional Posterior functional unit Sphenoid
unit functional unit

Maxillary, Posterior Sphenoid

Anterior ethmoid, ethmoid sinus sinus
Frontal sinus

Superior Sphenoethmoid
omc meatus recess
Anterior functional unit:
Uncinate process:
Sickle shaped bone
Attaches inferiorly to inferior turbinate and palatine bone ,
anterosuperiorly to lacrimal bone.
True maxillary ostial opening is covered by the uncinate process
Uncinate along with a fold of mucosa (anterior and posterior
fontanelle) cover the opening of maxillary sinus.
Accessory ostia may be present in the fontanelle which can be
mistaken
Failure to correctly identify true ostia and connect it with common
sinus cavity may result in mucous recirculation phenomenon.
During recirculation mucous is redirected to natural ostia along the
mucociliary drainage pathway and re-enters sinus through accessory
ostia.
Ethmoid bulla:
Largest and most consistent anterior ethmoid cell
Attaches to lamina papyracea laterally and variable attachments to skull
base and basal lamella
HALLER CELL is a normal anatomy in this region
It is an infraorbital anterior ethmoid cell that pneumatizes into
maxillary sinus and may cause obstruction to maxillary ostium.
This complete removal of ethmoid bulla is critical to define medial
orbital wall as a landmark
Middle turbinate:
Complex shape divided into 3 segments- saggital,coronal and axial
Sagittal segment attaches to skull base at lateral lamella.
Coronal segment creates the basal lamella which separates anterior
ethmoid and posterior ethmoid cavities
Axial segment of middle turbinate attaches to lateral nasal wall and is
the entry point of terminal branch of sphenopalatine artery
Agger nasi, posterosuperior uncinate process
and frontal ethmoid cells:
Anterior structures encroaching on frontal recess include
1) agger nasi
2)lateral uncinate process and
3)frontal cells
Agger nasi:
Anterior most ethmoid cell
Medial border formed byuncinate process
Degree of pneumatization of agger nasi influences position of superior
uncinate process an the thickness of bony nasofrontal beak
 The frontal recess drainage pathway is medial to uncinate process in85% of
cases.
Kuhn classification of frontal cell:
Type I - single frontal ethmoidal cell above agger nasi
Type II - Tier of cells in frontal recess above ager nasi cells
Type III - single massive cell pneumatizing into floor of frontal sinus
Type IV single isolated cell within frontal sinus
Wormold further modified the above classification
as type 3 cells as FEC that fill <50% of frontal sinus and type 4 if >50%
Posterior structures encroaching on frontal recess include:
1)supraorbital ethmoid cells
2)suprabulla cells
3)ethmoid bulla
Clinical significance of supraorbital ethmoid cells:
1)can cause obstruction of frontal recess
2)can be falsely mistaken for true frontal sinus leading to incomplete
removal surgical dissection
3)associated with low position of anterior ethmoid artery
 Medial structures encroaching on frontal recess:
1)intersinus septal cells
2)medially inserting uncinate process

Lateral structures encroaching include:

1)frontal cells
2)agger nasi
3)lateral uncinate process attachment
Mucociliary clearance of frontal sinus:
Unique in frontal sinus.
Mucus travels up along the interfrontal septum, along the roof
laterally, along the floor medially and exits through the natural
ostium
Only in frontal sinus mucus is actively transported inwardly.
Less than 60% exits the sinus in any given circuit. Hence , there is a
significant recirculation of the mucus.
Frontal recess:
Boundaries:
Anteriorly= agger nasi and frontal process of maxilla, the frontal beak
Medial border= superior attachment of middle turbinate
Lateral lamella of cribriform plate
Lateral boundary= lamina papyracea
Posterior boundry= upward continuation of anterior surface of bulla
If bulla lamella is absent superiorly, suprabulla space will communicate with
frontal recess, so the anterior ethmoidal artery is not protected by the bulla
lamella. Hence at risk during dissection.
Diagnosis:(History taking)
Sinus headaches are uncommon
Jones explains that majority of people presenting with symmetrical
frontal headache have tension type headache.
Unilateral episodic headache= vascular in origin
h/o headache is important to exclude frontal sinusitis
Other relevant history:
1)Facial trauma,
2) previous sinonasal surgery
3)comorbidities like asthma and aspirin sensitivity
Rarely swelling may be present=tender?
Painful percussion is s/o acute frontal sinusitis or even
osteomyelitis(Pott’s puffy tumor)
Painless swelling may indicate mucocele.
Endoscopy:
Routinely performed = anterior rhinoscopy
Gold standard = nasal endoscopy
3mm scopes are better tolerated than 4mm traditional rigid
endoscopes.
In patients with previous surgery, an angled scope (30 or 45deg) is
useful for frontal recess examination.
Imaging:
Plain xrays are inadequate for routine diagnosis
If used, occipitofrontal sinus plain x ray is recommended.
Scintigraphy is useful in osteomyelitis of frontal bone for extent and
its follow-up.
CT:
1st choice for sinus disease and for planning surgery.
Parasagittal views are especially important to identify complex cells
within frontal sinus and also its drainage pathways.
Imaging(contd.):
MRI:
Useful in differentiating tumor from retained secretions
Tumors tend to enhance with T1-weighted gad.enhanced scans
Mucus and secretions tend to avidly enhance on T2-weighted images
Helpful in assessing dual interfaces between nasal cavity and the orbit and
intra cranial cavity
Highly predictive of dural invasion by malignancy:
1)dural thickening of >2mm
2)Loss of hypointense zone and nodular enhancement
Contd..
Particularly useful in assessing patients with ongoing symptoms who
have previously undergone osteoplastic flap with obliteration
It is recommended in the cases of unilateral sinus disease both CT
and MRI to be routinely performed as they are complementary
Congenital lesions:
May be secondary to craniofacial dysostosis or persistence of
embryonic remnants.
Congenital midline nasal lesions include:
1)nasal dermoids
2)encephaloceles
3)gliomas
Nasal dermoids, cyst and fistulae:
Can present as cyst , sinus or fistulae or with intra-cranial extension.
incidence = 1:20,000 -40,000 live births.
May extend from skin to frontal bone, non-compressible and can discharge
sebaceous material.
May cause- 1) pressure atrophy
2)local infection
3)meningitis
4) brain abscess
Typically, midline mass anywhere between base of columella, along dorsum
to glabellar region.
Contd..
Pathogenesis:
Sessions was first to coin the term “nasal dermal sinus cyst”.
As the neuroectodermal tract recedes dermal attachments are drawn in.
As the duramater recedes from prenasal space it may pull nasal ectoderm
upward and inward to form a sinus or a cyst.
Imaging:
CT and MRI provide complimentary information.
Widened foramen caecum & bifid crista galli do not necessary indicate intra
cranial extension.But being normal rule out intracranial
Surgery:
Principles important while considering ideal surgical approach:
1)permit access to midline cystand allow access for medial and
lateral osteotomies.
2)allow access to skull base
3)facilitate reconstruction of any resulting nasal deformity
4)finally cosmetically acceptable scar
Midline vertical approach for extra cranial lesions, for better
cosmesis some prefer external rhinoplasty approach.
Combined approach with neurosurgical team if intracranial
extension.
Endoscope assisted excision of extra cranial dermoids using bilateral
inter cartilaginous incisions.
Recurrence are low , but may occur after many years later surgery. So
need long term follow up.
Acute frontal sinusitis:
ARS is sudden in onset and often follows URTI.
DEFINITION:
Increase in symptoms after 5days or persistence of symptoms after
10days with <12 weeks duration
0.5-2% of viral URTI are complicated by bacterial infection.
PREVALENCE:
6-12%
As a part of generalized acute rhinosinusitis
Medical management:
Aim = to reduce infective and inflammatory load to both reduce
severity and duration of illness
Intra nasal corticosteroids
Antibiotics
Nasal decongestants
Chronic frontal sinusitis:
Multifactorial
Higher prevalence of anaerobes
Medical management with appropriate antibiotics, nasal irrigation,
intra-nasal /oral steroid therapy
Surgical intervention may be necessary.
Anatomical variations, inflammation and scarring of frontal recess
play an important role in chronic sinusitis.
Studies say that ongoing mucosal inflammation is the most
important factor leading to frontal sinusitis.
Best surgical approach is the graduated one as mentioned below
Choice of the procedure used depends on the following factors:
No frontal recess exploration:
In the absence of clinical symptoms and positive CT findings , frontal
sinus or recess should not be explored.
It can cause mucosal injury and adhesion formation
Balloon sinuplasty:
Introduced in 2006.
Minimally invasive approach for CRS.
BALLOON OVER AN ILLUMINATED GUIDEWIRE

CONFIRM ITS POSITION IN FRONTAL SINUS

BALLOON IS DILATEDD WITH A CONTROLLED INFLATION DEVICE

This gently enlarges ostium by effecting microfractures of
surrounding bone and compressing the soft tissue.
Soft tissue injury is minimal but rate of synechia formation is equal to
what is seen in conventional endoscopic sinus surgery.
Complications:
Inability to cannulate the sinus
CSF leak.
Balloon dilation is combined with ESS ,hence termed HYBRID
PROCEDURE.
Draf type I(ethmoidectomy and frontal
sinusotomy):
Commonest procedure performed for CRS.
AIM:
Clear obstructive disease inferior to the level of frontal ostium- the
frontal recess.
Key step = to perform a complete ethmoidectomy.( includes removal
of 1) any anterosuperior ethmoid cells
2) the agger nasi
3) uncinate process)
Best when with only minor pathology in frontal sinus.
Draf type II frontal sinusotomy:
If conservative surgical approach fails.
Cells extending into frontal sinus are removed.
Draf type II

Draf type IIa Draf type IIb

Frontal ostium if widened from If this opening extended beyond

lamina papyracea to middle middle turbinate to nasal septum
turbinate

Using Kerrison or Hajek-Kofler punch Involves removal of anterior end of

middle turbinate and drilling floor of
sinus to midlline
Draf type III(modified endoscopic
Lothrop,MELP):
Also known as median drainage procedure or frontal sinus drill-out
1ST described by Lothrop as an external procedure in 1914, then Draf
described an intranasal microscopic approach.
MELP is a minimally invasive alternative to frontal sinus obliteration.
Procedure consists of creating a large common drainage pathway for paired
frontal sinuses by resecting 1)upper nasal septum
2)frontal intersinus septum
3)floor of both frontal sinuses.
Performing septectomy early allows surgeon to work more freely.
Reasons for failure of frontal recess and sinus surgery:
1)ongoing mucosal disease
Persistent or recurrent nasal polyps obstruction of sinuses
Eosinophilic CRS fare less well
Patients with asthma and nasal polyps may require revision surgery
2)incomplete dissection with retained uncinate process and residual
cells in frontal recess
3)lateralization of middle turbinate
Incidence in revision surgery = 36-78%
Frontal sinus rescue procedure is done for frontal recess stenosis
 Mucosa dissected from the
turbinate

Stump trimmed back to skull base

Medial mucosa discarded and

lateral mucosa from sinus draped
over the stump
4)scarring and synechiae
5)osteoneogenesis:
Failure to preserve mucosa  scarring and osteoneogenesis
Secondary to combined factors like persistent inflammation, ongoing
infection and surgical trauma
This may contribute to frontal recess stenosis
Osteoplastic flap procedure:
Developed for chronic frontal sinus disease refractory to procedure such as
external frontoethmoidectomy which were a/w high failure rates.
Obliteration with fat was introduced later and popularized by Goodale and
Montgomery.
Gold standard treatment with success rate over 90% but with longterm failure
rate of 25% and significant morbidity.
CSF leaks, persistent forehead numbness , severe headaches without e/o
recurrent disease, frontal bossing, supraorbital neuralgia, mucocele
formation, donor site complications after abdominal fat
Harvesting and difficulties with donor site complications.
In graduated approach,this step is considered as final step as frontal
sinus is non functional.
An OPF can be performed through coronal, brow and mid forehead
incisions
Zigzag coronal incisions are better camouflaged in male pattern
baldness
LA(Ligno 1%)+vasoconstrictors(adr 1:1000)+ steroid (Adcortyl 5mg) and
Hylase (1,500 iu) aid dissection and minimize bleeding.
Frontal sinus trephination:
Performed in cases of complicated acute frontal sinusitis not
responding to medical management.
A small incision 1-1.5cm below the medial eyebrow and supra orbital
rim through the periosteum

Periosteum elevated and drill used to make a small window at the

junction of floor and anterior wall of frontal sinus

Sinus is irrigated and drain placed in situ

Modified frontal trephine technique:
Mini trephine is useful during surgery for chronic frontal sinus
disease
Use of fluorescein stained saline to irrigate trephine can aid in
dissection of frontal recess pathway
Landmarks are identified
Fluorescein stained saline to irrigate the trephine done which aids in
dissection of frontal recess pathway.
One must ALWAYS aspirate prior to irrigation
Pre-op CT is essential for extent and depth of pneumatization
Complications:

Intracranial penetration --> CSF leak, periorbital trauma

Incision related infection
External frontoethmoidectomy:
Historical procedure
bony support of frontal recess removed
Causing scarring and obstruction of outflow tract
Performed via external curved incion LYNCH incision.
Indications of Lynch incision:
To externally access the anterior ethmoidal artery
Drainage of periorbital abscess
To trephine the floor of frontal sinus
Cranialization of frontal sinus:
Rarely performed
For refractory chronic frontal sinusitis
Along with the team of neurosurgeons for craniotomy
Commonest indication= extensive fractures of frontal sinus
Others= tumors, osteomyelitis
Procedure:
Midfrontobasal craniotomy used
Posterior wall and floor of sinus removed
Mucosa of outflow tract is inverted into nasal cavity
Sealed with fascia and fibrin glue
Success depends on the removal of entire frontal sinus mucosa and
drilling the sinus with diamond Burr.
Dead space filled with fat or vascularized pericranial flap.
Complications:

Dural injury with CSF leak

Bone flap necrosis
Frontal bone trauma
Intracranial mucocele formation
Riedel's procedure:
Involves removing the floor, anterior and entire mucosal lining of
frontal sinus
Done in patients where frontal sinus drainage cannot be established
and frontal sinus obliteration has failed
Main problem= cosmetic defect
Mucosa within the sinus is removed,hence recurrent complications
are uncommon
TUMORS:
Sinonasal tumors
60% maxillary sinus
20% in nasal cavity
5% in ethmoid sinus
3% sphenoid and frontal sinuses
55% sinonasal malignancies are carcinomas, commonest being SCC
Imaging in tumors:
Nature of tumor
Extent
Point of origin
To distinguish from inflammatory reactions
MRI helps to differentiate between benign and malignant sinonasal
disease
CT - often initial investigation
Useful for bony details
General principals of tumor surgery of frontal
sinus:
Ideally it is preferable to remove using most minimally invasive
technique
Surgical approach depends on
1) site
2) Tumor characteristics
3) involvement of adjacent structures
4) local expertise
Final management decision should be done by multidisciplinary team
Stepwise approach is recommended
1) Endonasal
2) osteoplastic flap
3) above and below( Endoscopic and frontal craniotomy)
4) subcranial, subfrontal and transcranial
Generally with OPF approaches for tumor removal,frontal sinus
obliteration should be contraindicated.
Endoscopic considerations:
1) Experience in dealing with inflammatory disease
2) Endonasal duroplasty is mandatory
In tumor surgery it is necessary to visualize the site of the lesion and
area to instrument with curettes and drills
Degree of frontal sinus pneumatization is an important factor
General guidelines for operating on tumors of frontonasal
sinus:
Benign tumors:Inverted papilloma:
Relatively uncommon epithelial tumor of nasal cavity
Locally aggressive
Tendency to recur
Associated with malignancy
Histology= epithelium inverting into stroma with intact basement
membrane
Pathogenesis: HPV
Viral DNA found in adjacent normal appearing cells
May be associated with recurrences and residual disease
site of origin
1) ethmoid region - 48%
2) lateral nasal wall and maxillary sinus -28%
3) frontal sinus -2.5%
Imaging:
CT- hyperostosis is a common finding.
Site of origin
MRI - to distinguish mucus from papilloma
Success of surgery depends on defining eent of disease
Identification of site of origin and it's attachments
Full extirpation of all affected lesion
OPF provides wide exposure of frontal sinus, hence preferred
traditionally
Recent systemic review suggests more aggressive primary approach
may facilitate better disease control
Follow up for minimum of 3yrs.
FIBRO-OSSEOUS LESIONS:
Include
1)Osteomas
2) Fibrous dysplasia
3) ossifying fibroma
Osteomas:
MC benign tumor of PNS
Prevalence = 3%
Most often seen in ethmoids followed by frontal sinus
Etiology = 3 theories
1) Developmental ( reactivation of embryonic stem cells)
2) Traumatic
3) Infectious
( Inflammatory process is the initiating factor in above both)
Histology = 3 types
1) Ivory or compact
2) mature or cancellous
3) mixed
Attachment = broad based or via stalk
IOC - CT
CT - homogenous,dense well circumscribed lesions
MRI- done if extra sinus involvement
Symptoms:
Mostly asymptomatic
Headache or sensation of pressure being commonest
Surgical approach:
1) External
2) Endoscopic
3) combination of above
OPF approach: Gold standard
Recent trend toward Draf IIb or MELP/ Draf III
Combined OPF+ MELP = long-term patency can be maintained
Limitations of Endoscopic approach:
1) extent of intracranial extension
2) significant orbital involvement
3) erosion of posterior / anterior wall of frontal sinus
Grading system of Osteomas(contd.):
Grade I and II- removed endonasally
Grade III and IV - managed endoscopically
Tumors extending through anterior table - best by external approach
Most important variables in determining the approach are:
1) degree of pneumatization
2) interorbital width
3) A-P dimension of floor of frontal sinus
Gardner's syndrome:
Triad of multiple osteomas., Colorectal polyps, skeletal abnormalties,
supernumerary teeth
Autosomal dominant
100% risk of malignant transformation of colonic polyps by the age of
40.
Symptoms:
Present by 2nd decade
Rectal bleeding
Pain, diarrhea
All patients presenting with frontal sinus Osteomas should have
thorough systemic enquiry.
Fibrous dysplasia:
Slow growing, tumor like lesion of bone.
Occurs when normal cancellous bone- replaced by abnormal Fibrous
tissue
Fibrous tissue replaces spongiosa and fills the medullary cavity with
poorly calcified trabeculae
Mutation: GNAS1 Gene on christmas.20q13
75% cases diagnosed<30 yrs.
2 forms:
1) Monostotic (80%) - craniofacial involvement in 25% of cases.
2) Polyostotic (20%)- craniofacial (40-50%) and various areas of
skeleton.
McCune Albright syndrome- Polyostotic Fibrous dyplasia and
endocrine dysfunction (precocious puberty+/- hyperthyroidism), cafe
au lait spots.
Rare, primarily seen in females
Low rate of malignant transformation 0.5% in Polyostotic forms, 4% of lesions
with McCune Albright syndrome
Patients with Monostotic forms - frequent asymptomatic diagnosed
incidentally.
Polyostotic Fibrous dysplasia present early with symptoms of bone pain and
deformity
Vascular and neurological compression
Craniofacial disease- headache and facial asymmetry
Sphenoid and frontal sinus FD- optic nerve compression and mucocele
formation respectively
Imaging:
CT- homogenous with ground glass appearance,
Cotton wool areas as bone scleroses
MRI - helps evaluate soft tissue component and distinguish from
other lesions.
Surgical strategy:
Medical treatment provides only symptomatic relief
Bisphosphonates useful in decreasing fractures and bone pain.
Monostotic FD, asymptomatic--> observed
Endoscopic sinus surgery- symptomatic relief
Cosmetic deformity- local controlled resection and recontouring
Rate of malignant transformation to osteosarcoma- 0.5%
Ossifying fibroma:
3 categories:
1) ossifying fibroma
2) cemento- ossifying fibroma (COF)
3) Aggressive psammamatoid ossifying fibroma (APOF) or juvenile
aggressive OF
Histology = 2 main components
1) Fibrous stroma
2) Bone elements
APOF:
Irregular bony spicules with in a cellular Fibrous stroma.
" Psammomatoid bodies"
COF:
Similar histology with cementum like material present throughout
the lesion
Symptoms:
Often asymptomatic
Proptosis, diplopia, epiphora
Facial swelling
Nasal obstruction,epistaxis
Headache
Endoscopy:
smooth mucosally covered masses
Locally destructive tumor
MC in facial skeleton- 75% in mandible
Outside mandible- affect mostly ethmoid and maxillary sinus.
Multiple sinus involvement = not uncommon
COF- mc in maxillary and ethmoid sinus rarely in frontal and
sphenoid sinus.
CT findings:
OF- sharply circumscribed round lesions with an egg shell rim and
central radiolucency are typical of ossifying fibroma
APOF,COF- thicker bony rima nd central ground glass appearance
MRI resemble Fibrous dysplasia
Endoscopic biopsy is required to confirm diagnosis
Treatment strategy:
Biopsy recommended if OF is suspected on imaging
Ideally, complete surgical excision to be done. But it depends on site
and symptoms
If little or no symptoms--> conservative approach
Surgical resection --> Endoscopic approach
Extensive disease-- combined approach
Recurrence rate- low
Malignant tumors:

Primary tumors of frontal sinus - very rare

SCC - commonest tumor affecting maxillary sinus up to 30% and frontal sinus
<1%
Other primary tumors- Adenocarcinoma, non epithelial malignant tumors like
lymphoma
Frontal sinus - by direct extension
Diagnosis:
1) tissue biopsy
2)CT
3) MRI
Principles of surgery:
1) complete resection of tumor by least invasive approach
2) to achieve negative resection margins.
Endonasal route:
If no major bone destruction and tumor is just reaching the frontal
sinus
According to Raveh et.al subcranial technique to be employed if
more extensive tumor by coronal incision.
Subcranial approach also allows management of malignancies with
skull base or even intraxural involvement
Step ladder of 3 surgical techniques :
1) Endonasal
2) Mid facial degloving
3) subcranial approach
Advantage:
Avoidance of visible scars
Lateral rhinotomy- if exenteration of orbit is needed simultaneously
Frontal pneumosinus dilatans:
Uncommon condition
Abnormal large aerated sinus
Can affect all PNS,but predilection for frontal sinus
When associated, aeration extend beyond normal margin of frontal
bone
Characteristic= walls of sinus are normal in thickness
No evidence of erosion
Focal or generalized
Etiology:
Various theories being postulated
1) mucocele growth and it's spontaneous rupture
2)One way valve mechanism (most favoured)
3) hormonal influence affecting bone resorption
4) congenital defect
Clinical features:
2nd -4th decade
Male preponderance
Mostly asymptomatic
Frontal bossing
Pressure symptoms - diplopia,headache
Associated with pathological conditions like:
1) Planum meningiomas
2) arachnoid cysts
3) Fibrous dysplasia
4) acromegaly
5) prolonged CSF shunting
6) congenital Polyostotic Fibrous dysplasia
Management:
Address any pathology obstructing the sinus ventilation
If functional and with cosmetic deformity --> direct, full thickness
resection of horizontal bone strips of anterior wall of sinus.
Mucocele of paranasal sinuses:
Definition:
A mucocele is an epithelium-lined mucus-filled sac within one of the
paranasal sinuses with expansion of the sinus cavity and remodelling
of the sinus walls.
secondary to obstruction of the outflow tract of the involved sinus
together with an inflammatory process within the sinus
lined by pseudostratified or low-columnar epithelium
Frontal, ethmoid, maxillary and sphenoid sinuses are involved in
descending order of frequency
Frontal sinus mucoceles are probably more common because of the
complex and narrow drainage pathway of the frontal sinus
Can be seen in other aerated structures like superior and middle
turbinate
lacrimal sac mucocele or dacryocele
Site of involvement:
Etiology
Pathogenesis:
2 factors are essential:
1) obstructed sinus outflow tract
2) inflammatory process with in the sinus
Osteolytic cytokine IL-1 and TNF are present in epithelial lining
Cytokine --> responsible for bony erosion
Clinical features:
Depends on sinus involved:
1) visible mass seen on forehead. Medial canthus, cheek
2) ophthalmological symptoms - periorbital swelling, pain,
exophthalmos.
3) limited ocular mobility, visual disturbance and diplopia
4) optic neuropathy
5) nasal obstruction
6) epiphora and cystic swelling
Radiology:
CT- homogenous isodense lesion in expanded sinus with bony
remodelling of sinus walls.
DDx:
1) benign or malignant lesions
2) allergic fungal sinusitis
3) cholesterol granuloma
Surgical management:
Wide marsupialization of the sac
Frontoethmoidal mucocele:
1st line for simple mucocele- Endoscopic surgery with wide
marsupialization
For more complex - MELP
Recurrence rate- 0-25%
Combined Approach for laterally located mucocele- with thick bony
septations
Lynch - Howarth approach
Long-term frontal outflow obstruction:
OPF+ MELP for lessons lying far laterally in frontal sinus
Trans orbital neuroendoscopi. Surgery ( TONES) and superior eyelid
approach - alternative andess invasive
Stenting - controversial
Obliteration of frontal sinus high success rate- 93% but complication
rate over 20%
Contraindication: extensive erosion of posterior table of sinus due to
inability to remove normal respiratory epithelium in dura.
Maxillary sinus mucocele:
a wide middle meatal antrostomy will usually suffice.
A partial medial maxillectomy with preservation of the lacrimal
system may be required to gain access to laterally located mucocele
Sphenoid sinus mucocele:
A wide sphenoidotomy and intra-nasal marsupialization are all
that is required for sphenoid sinus mucoceles
No attempt is made to remove the lateral sphenoid sinus mucosa as
bony erosion place the internal carotid artery or optic nerve at
risk of injury.
Complications:
Great care needs to be taken when decompressing a large, tense frontal
mucocele that displaces the frontal lobe of the brain
as sudden expansion of the cranial contents can disrupt the dural vessels and
cause
a subdural haematoma, or
disrupt the dura and cause
a cerebrospinal fluid (CSF) leak.
Close post-operative monitoring is therefore essential in such patients.
Because recurrence can occur decades later, long-term follow-up is required.
Thank you