1. The document discusses the embryology and anatomy of the frontal sinus and frontal recess. It develops from ethmoidal cells that pneumatize into the frontal bone. 2. It describes different surgical approaches to access and drain the frontal sinus including external approaches and various types of endoscopic frontal sinusotomies. 3. Type 1 and 2 endoscopic procedures involve draining the frontal sinus via the frontal recess and removing obstructions. Type 3 is a more extensive procedure that creates a common chamber between the frontal sinus and nasal cavity via an intranasal modified Lothrop procedure.

1. APPROACHES TO FRONTAL
SINUS
Dr. Vaibhav Lahane

2. EMBRYOLOGY
• Ethmoturbinal ridges - A series of five to six ridges first
appear during 8th week of gestation, due to fusion and
regression only three to four ridges persists.
• First ET Ridge –
Ascending portion – Agger nasi
Descending portion – Uncinate
• Second ET Ridge- middle turbinate
• Third ET Ridge – superior turbinate
• Fourth & Fifth – supreme turbinate
• Maxillo-turbinal ridge – inferior turbinate

3. EMBRYOLOGY
• 1st Primary furrow- between first & second ET
• Descending aspect – ethmoidal infundibulum, hiatus
semilunaris, middle meatus.
• Ascending aspect – frontal recess
• 2nd primary furrow – superior meatus
• 3rd primary furrow – supreme meatus

4. EMBRYOLOGY
 SCHAEFFER and KASPER proposed four frontal
pits or furrows.
First frontal pit – agger nasi cell
Second frontal pit – frontal sinus cell
Third and fourth frontal pit – other anterior ethmoid
cell such as suprabullar cell, supraorbital cell.

5. EMBRYOLOGY
• At birth,volume of cranial vault is seven times the facial
skeleton. This ratio decreases steadily in infancy and
childhood due to growth and development of four
pairs of paranasal sinuses .These sinuses develop from
invaginations of nasal cavity that extend into
surrounding bones.
• Frontal sinus is absent at birth and develop at second
year of birth from the anterior most ethmoidal cells
which grow into frontal bone.

6. FRONTAL RECESS ANATOMY
• Frontal sinus drains in to middle meatus and nasal
cavity by a complex passage called frontal recess.
• Previously known as nasofrontal duct ( tubular
structure conducting fluids between frontal sinus and
nasal cavity).
• After understanding of more accurate anatomy the
term frontal recess was recommended.
• KILLIAN is credited for coining the term frontal recess.
• Now a days the better term is frontal sinus drainage
pathway.
.

7. FRONTAL RECESS ANATOMY
• Stammberger - frontal recess is superior
continuation of ascending groove between
first and second ET’s and frontal sinus
originates from anterior pneumatization of
frontal recess in frontal bone.
• Boundaries –
laterally - Lamina papyracea, uncinate process
medially – Middle turbinate
anteriorly- anterior wall of Agger nasi cell ( when
present )
posteriorly- Anterior wall of Ethmoidal bulla ( if
ethmoidal bulla is not reached up to skull
base,frontal recess will also connect to
suprabullar recess )

8. CT saggital view showing Frontal recess

9. FRONTAL RECESS ANATOMY
• In a saggital section
frontal recess along
with frontal
infundibulum and
frontal ostium forms
hourglass shaped
structure.
• Thus frontal sinus is
much anterior to frontal
recess when viewed
endoscopically.

10. CT coronal view sagital view
Normal frontal recess anatomy. Coronal (a) and sagittal (b) CT images show the right
frontal recess (dotted red line), which is bounded anteriorly and laterally by an agger
nasi cell (white arrow) and a type 1 frontal cell (black arrow), medially by the middle
turbinate, and posteriorly by the ethmoid bulla and bulla lamella. The nasofrontal
process (arrowhead in b) forms the floor of the frontal sinus and demarcates the level
of the frontal sinus ostium.

11. Agger nasi cell
Forms a bulge anterior to the
middle turbinate on the lateral
wall…under a plain
structureless area lined by
nasal mucosa called as atrium.

12. AGGER NASI CELL
• Agger nasi cell plays a significant role in frontal recess
obstruction, it may fill the recess but obstruction develops after
a modest degree of oedema .
• In previous surgery if agger nasi cap left in place, it may form
scar in contact to bulla leads to iatrogenic frontal sinus disease.
• During endoscopic dissection medial and posterior wall
should be located and removed to prevent leaving cap
behind.

13. FRONTAL CELLS by KUHN
• Anterior ethmoidal cells migrate anterosuperiorly in frontal
recess to produce different kind of frontal cell:
• Type I - Single cell above the agger nasi
• Type II - Two or more cells above the agger nasi cell
• Type III - Single cell extending from the agger nasi cell into the
frontal sinus
• Type IV - Isolated cell within the frontal sinus (loner cell)

14. FRONTAL CELLS
Frontal recess with type I frontal cell

15. SUPRAORBITAL ETHMOID CELL
• Role of supraorbital ethmoid cells in sinus obstruction was
described by Owen and Kuhn.
• Develops posterior to agger nasi cell, frontal cell, and frontal
sinus.
• This cell should be suspected when on CT , pneumatization
from ethmoid sinus out over the orbit seen.
• Mistaking supraorbital ethmoid cell for frontal ostium is a
potential problem, so internal frontal ostium may be left
unopened and remain obstructed.

16. SUPRAORBITAL ETHMOID CELL
• Septum between frontal sinus and supraorbital ethmoid cell should be
removed, this provides a large common chamber for drainage in frontal
recess.
• Supraorbital ethmoidal cell (astreix) pneumatizes over orbit (coronal
image) and opens into posterior and lateral portion of true frontal sinus
(axial image)

17. RECESSUS TERMINALIS
• In 80 % cases uncinate process attaches to lamina payracea in form of
dome. Recess enclosed in the dome called as recessus terminalis
• This attachment of uncinate in frontal recesss is described as egg-shell in
an inverted egg cup
• Causes the ethmoid infundibulum to open in a blind pocket.
• In this case frontal sinus drains medially directly in middle meatus

18. SURGICALAPPROACHES TO
FRONTAL SINUS

19. History of Frontal Sinus Surgery
First surgical procedure was defined in 1750. Still the optimal
approach remains unclear.
Frontal sinus disease is highly morbid with the danger of life
threatening complications, because of its anatomic proximity to
anterior skull base and orbit.
History of frontal sinus surgery can be divided into following eras:
1. Era of trephination (1750):
2. Era of radical ablation procedures (1895):
3. Era of conservative procedures (1905):
4. External fronto-ethmoidectomy 1897 – 1921:
5. Osteoplastic anterior wall approach (1958):
6. Endoscopic intranasal approach (recent advancement)

20. Aims of ideal treatment modality of frontal sinus disease are:
1. Eradication of underlying disease process
2. Preservation of function of the sinus
3. To cause least morbidity and cosmetic deformity.

21. Era of trephination (1750):
Frontal sinus surgery was first described
in 1750. It was in 1884 Alexander Ogstun
described a trephination procedure where
an opening was made in the anterior table
of frontal sinus to evacuate the sinus
cavity.
He also dilated the nasofrontal duct (a
duct connecting the infundibulum and
frontal sinus ) and curetted its mucosa for
better drainage from the frontal sinus and
placed a drainage tube inside the
nasofrontal duct to prevent stenosis.

22. Era of radical ablation procedures (1895):
• Kuhnt in 1895 described a procedure where he removed the
anterior wall of frontal sinus to clear the frontal sinus off the
diseased mucosa.
• He stripped the mucosa up to the frontal recess and stented the
frontonasal duct to improve the drainage.
• In 1898 Riedel performed obliteration of frontal sinus.
• He advocated complete removal of anterior table and floor of
frontal sinus with stripping of mucosa which was performed in a
patient with osteomyelitis of frontal bone but caused an
unsightly deformity of skull.

23. Killian in 1903 advocated retention of 1 cm bar of supraorbital
rim.
Killian was able to avoid deformity by retaining this bar of bone
and also advocated ethmoidectomy combined with rotation of
mucosal flap to cover the frontal recess area.
Killian’s procedure had complications like restenosis, supraorbital
rim necrosis, post op meningitis and mucocele formation etc.

24. Era of conservative procedures (1905):
Major advantage is avoidance of cosmetic defects.
They involved intranasal approach to frontal sinus.
It was Knapp in 1908 who performed external Fronto ethmoid
surgery. He approached the frontal sinus through its floor,
removed the diseased mucosa and stented the frontonasal duct to
prevent restenosis.
In 1908 Halle chiseled out the frontal process of maxilla and used a
burr to remove the floor of frontal sinus.

25. In 1914 , Lothrop enlarged the frontal sinus drainage pathway
using intranasal approach.
He combined intranasal ethmoidectomy with external ethmoidal
approach and managed to create a common fronto-nasal
communication by removing the frontal sinus floor, intersinus
septum and the superior portion of nasal septum.
He also said that resection of medial orbital wall caused prolapse
of orbital contents into the ethmoid area causing obstruction to
frontal sinus drainage.

26. External fronto-ethmoidectomy 1897 – 1921:
In 1897 Jenson performed the first external Fronto
ethmoidectomy in Germany.
Lynch and Howarth in 1921 popularized resection of
floor of the frontal sinus with dilatation of the frontal
sinus outlet via external approach.
This approach is hence known as Lynch Howarth
procedure.
• A curvilinear incision is made just below the medial
end of eyebrow. It is curved medial to the medial
canthus.
• The frontal process of maxilla and lamina papyracea
is removed.
• Frontal sinus is entered via its floor and the lining
mucosa is curetted.
• A stent is placed in the frontal sinus osteum to
prevent stenosis.
• The stent is left in place for a period of 4 weeks.
• Boyden used silicone tube to prevent stenosis.

27. Osteoplastic anterior wall approach
(1958):
This procedure became popular
during 1960’s. Backer introduced
radiographic plate to outline the
frontal sinus. This procedure was
fraught with the risk of hemorrhage.
Endoscopic intranasal approach:
With the advent of nasal
endoscopes (angled) approach to the
frontal sinus outflow tract has become
easy.

28. SURGICAL APPROACHES TO FRONTAL SINUS
EXTERNAL APPROACHES –
• Frontal sinus Trephination
• External frontoethmoidectomy
ENDOSCOPIC APPROACHES ( FULADA CONCEPT )
• Type-1 Simple Drainage ( DRAF 1 )
• Type-2 Extended Drainage ( DRAF 2 )
• Type -3 Endonasal median Drainage ( DRAF 3 , Modified
Lothrop )
• Axillary flap approach

29. INTEGRATEED APPROACH TO FRONTAL
SINUS SURGERY
• Endoscopic frontal sinusotomy
• Above and below approach ( trephine + endoscopic )
• Frontal sinus rescue procedure
• Intranasal modified Lothrop
• Above and Below ( osteoplastic + endoscopic )

30. FRONTAL SINUS TREPHINATION WITH
ENDOSCOPY
Modification of trephination using
endoscopes for inspection and
smaller interventions.
1 cm incision is made just above the
medial end of eyebrow and with a
0.5 cm drill hole the anterior wall
of frontal sinus is opened.
Under Endoscopic control irrigation
and inspection is possible.
Preoperative CT should be done to
see extent of frontal sinus and to
prevent injury to dura.

31. FRONTAL SINUS TREPHINATION

32. EXTERNAL FRONTOETHMOIDECTOMY
• A Curved medial and concave incision is taken towards medial canthus of
eye straight down to bone.
• Frontal sinus is reached by osteoclastic resection of lacrimal bone, part of
frontal process of maxilla and frontal sinus floor.
• Ethmoid cell system is resected to obtain an open cavity between frontal
sinus, ethmoid and nasal cavity.

33. Results of External Fronto-ethmoidectomy
• Danger of supraorbital and
supratrochlear nerve injury.
• Two third bony margins of frontal
recess is resected and replaced by scar
tissue, which may contract and lead to
formation of mucocele. To overcome
this complication stents are placed to
prevent stenosis.
• Trochlea mobilization may lead to
diplopia (as it might lead to damage to
superior oblique muscle.)
Supraorbital
N.
Supratrochl
ear N.
Supraorbit
al A.

34. ENDONASAL SURGERY OF FRONTAL SINUS
( FULADA CONCEPT )
TYPE I DRAINAGE
INDICATIONS-
• Acute rhinosinusitis ( failure
of conservative surgery )
• Chronic rhinosinusitis ( first
time surgery, no risk factors,
revision after incomplete
ethmoidectomy.
TYPE II DRAINAGE
INDICATIONS
• Serious complications of
acute rhinosinusitis
• Medial mucopyocoele
• Tumour surgery
• Good quality mucosa

35. TYPE III DRAINAGE INDICATIONS-
• Difficult revision surgery
• Patients with severe polyposis and samter’s traid
• Mucoviscidosis ( cystic fibrosis )
• Kartagener’s syndrome
• Primary ciliary dyskinesia

36. TYPE 1 SIMPLE DRAINAGE ( Draf I Procedure/ NFA I)
(as per May and Schaitkin)
• Indicated when frontal sinus disease persists despite more conservative
approaches. In cases of minor pathology in the frontal sinus and the patient
does not suffer from ‘prognostic risk factors” like aspirin intolerance and
asthma, which are associated with poor quality of mucosa and possible
problems in outcome.
• This procedure involves complete removal of the anterior ethmoid cells and
uncinate process ,Obstructive frontal cells surrounding the frontal recess to
the frontal ostium.
• In the majority of cases the frontal sinus heals because of the improved
drainage via the ethmoid cavity.

37. ENDOSCOPIC DRAF II PROCEDURE ( TYPE 2
EXTENDED DRAINAGE )
• This extended drainage procedure involves
, after ethmoidectomy, resection of the
floor of the frontal sinus from lamina
papyracea to middle turbinate ( IIa / NFA
II) or nasal septum anterior to the ventral
margin of the olfactory fossa (IIb / NFA III).
• In the classification of May and Schaitkin
type IIa corresponds with NFA II
(nasofrontal approach) and type IIb with
NFA III.
• When type IIa drainage is considered to be
too small in regard to the underlying
pathology , it is better to perform type IIb
drainage.

38. It has been assessed that the maximum size of the neoostium of frontal sinus
that can be achieved in Type IIa procedure is 11 mm with a mean of 5.6mm
(Hosemann et al.).
If neoostium is less than 5 mm in diameter , soft flexible silicon stents are used.
If one needs to achieve a larger drainage opening like type II-b, a drill is used
because of the increasing thickness of the bone medially towards the nasal
septum. At this point microscope assistance is required.
In revision cases after incomplete ethmoidectomy, it is recommended that a
wide approach to the ethmoid sinuses is created using a microscope and drill or
punch when possible.
Wide approach to ethmoid is achieved by resection of ;
• Lacrimal bone
• Part of agger nasi cells
• Frontal process of maxilla till lamina papyracea is clearly visible.
This allows better visualization of frontal recess.

39. Frontal recess is identified by using middle turbinate and
where identifiable anterior ethmoidal artery as landmark .
Frontal infundibulum is exposed and anterior ethmoidal
cells are resected.
Preoperative CT scan may reveal the presence of so called
frontal cells. These are anterior ethmoidal air cells that has
encroached into the frontal sinus giving a false impression
that the frontal sinus has been properly opened.
If these frontal cells are present, a procedure known as
uncapping the egg is performed resulting in type IIa
drainage.
After type IIa drainage , further widening to produce a
type IIb drainge is done by introducing a diamond burr into
the clearly visible gap in the infundibulum which is then
drawn across the bone in medial direction.
A large ethmoidal cell (blue)
could be seen extending up
to the level of frontal sinus.
The frontal sinus could be
drained only by uncapping
this large ethmoidal air cell
(frontal cell). This procedure
is known as the uncapping
the egg. (Black dotted lines)

40. During surgery , frontal sinus opening is bordered by bone on all side but mucosa is
preserved on atleast one side.
Rubber finger stall can be introduced into the sinus for 5 days .
They provide safe hemostasis, are a stimulator of re-epithelialization of bare bone, are
cost-effective and painless to remove.
The risk of adhesions and synechiae is low because this type of packing suppresses the
development of granulations.
Post operative CTscan - after Draf II drainage

41. Endonasal frontal sinus drainage
(A) Type I drainage (Simple drainage,
right side). area, anterior ethmoidal
artery; lp, lamina papyracea; mt, middle
turbinate; ns, nasal
septum; oc, olfactory cleft.
(B) Type II a drainage (enlarged
drainage, a, right side). Opening of
frontal sinus between lamina papyracea
and middle turbinate. Mostly possible
without
drill.
(C) Type IIb drainage (enlarged drainage,
b, right side). Drainage of the frontal
sinus between lamina papyracea and
nasal septum. Usually medially drill
necessary.

42. Postoperative Frontal Sinusitis after Type I and Type II Drainage –
Sometimes after ethmoidectomy and type I as well as type II drainage, the
patients may develop more problems in the frontal sinus than before surgery.
Postoperative sinus CT will provide information if frontal sinusitis has
developed.
The pathogenesis of recurrent frontal sinusitis after surgery
Remnant ethmoidal cells Mechanical irritations of the mucosa
in the frontal recess
l/trecurrent sinusitis can result in a severe scar around
Killian’s infundibulum.
Both pathologies may result in blockage of the frontal sinus drainage

43. This can be avoided by performing ;
1. A complete anterior ethmoidectomy .
2. Using extremely atraumatic handling of the frontal recess mucosa.
For treatment the following procedures recommended :
1. Type IIa drainage if a type I procedure was performed.
2. Previously a type IIb drainage if a type IIa.
3. Type III Drainage after a previous type IIb.

44. ENDOSCOPIC DRAF III PROCEDURE
(MODIFIED LOTHROP, Endonasal MEDIAN DRAINAGE / NFA IV )
• This procedure involves removal of the inferior portion of
the interfrontal septum, the superior part of the nasal
septum, and the frontal sinus floor till the lamina
papyracea. The lamina papyracea and posterior walls of
the frontal sinus remain intact.
• To achieve maximum possible opening , it is helpful to
identify 1st oflactory fibre on both sides.
• To achieve the maximum possible opening of the frontal
sinus, it would be helpful to identify the olfactory fibers on
both sides.
• Frontal T –
long crus – represented by post border of perpendicular
ethmoid lamina resection
Shorter wings on both sides – provided by posterior margin of
frontal sinus floor resection.

45. (D) Type III drainage (median
drainage) with “Frontal T” (red)
and first olfactory fiber on
both sides (View from left
inferior).
(E) Type III drainage (median
drainage) sagittal view: removal
of the frontal sinus floor
in front of the olfactory cleft

46. • A rubber finger stall is placed into each frontal sinus and two are put into ethmoid
cavity on each side for 7 days.
Leaving rubber finger stalls for one week carries the following advantages –
1. The fibrinoid phase of wound healing is somehow overcome. Reclosure of the large
drainage by scars is remarkably reduced, since bare bone is re-epithelialized almost
completely.
2. Sedation and general anesthesia are not necessary for packing removal. Rubber
finger packs do not bind to the wound.
• Major part of surgical cavity gets re-epithelised making postoperative treatment
simple.
• Advantage over classical Jansen , Lynch and Howarth approach –
Bony margins around frontal sinus drainage are preserved increasing long term stability
and reducing scarring and complications like frontal sinusitis and mucocele formation.

47. In revision cases, type III drainage can begin from possible two points, from
the lateral or medial side.
Primary medial approach
If previous ethmoidal surgery was complete, and
the middle turbinate is absent.
The medial approach starts with the partial
resection of the perpendicular plate of ethmoid
of the nasal septum, followed by identification of
the olfactory fibers on each side.
Primary lateral approach
If previous ethmoidal surgery was
incomplete and the middle turbinate
is still present as a landmark.

48. Post operative Therapy –
The patients are given the following instructions to ensure proper healing:
1. Irrigate the nasal cavities with saline solution at least once a day, sometimes more
frequently.
2. Use one of the corticosteroid sprays 1–3 times/ day.
3. The recommendation is made to use liquid paraffin 1 hour after the use of
corticosteroid spray, for general care of the mucosa.
Antibiotics – for 1 to 2 weeks.
Antiallergic treatment - for 6 weeks in proven cases of allergy.

49. Post operative evaluation –
• Mean follow up period – 10 – 12 years .
• Criteria for assessment – objective and subjective categorized in following grades ;
Grade 1 - endoscopically normal mucosa , independent of subjective complaints.
Grade 2 – endoscopically inflamed mucosa with subjectively free of symptoms.
Grade 3 – endoscopically inflamed mucosa with no subjective improvement.
• Maximum success rate is usually achieved by type III drainage followed by type II
and I .
• Recurrence rate - lesser compared to osteoclastic techniques of Jansen – Ritter and
Riedel.

50. Reclosure after Type III Drainage -
a)The “chimney” between the anterior ethmoid and the frontal sinus has not been
opened well. It is important that after the anterior ethmoidal artery is identified, the
surgeon proceeds along the skull base medial to the lamina papyracea to enter into
the frontal sinus.
b) The anterior-posterior opening of the frontal sinus floor, particularly in the midline, is
too small. The identification of the first olfactory fiber bilaterally and the creation of
the “Frontal T” are very helpful to avoid this problem.
c) The resection of the septum has been missed or was not performed to a satisfying
degree. The new curved drills between 15° and 60° angle are ideal for this purpose.
d) The resection of the superior nasal septum was too small. The diameter of resection
must be 1.5 cm just in front of the “Frontal T” and below the frontal sinus floor.
e) The packing between the ethmoid and the frontal sinus was not left long enough.
7 days proved to be the best time frame for using rubber finger packings.

51. Frontal sinus rescue procedures:
a. These procedures are indicated to
clear up frontal sinus obstruction by
laterally retracted middle turbinate and
scar tissue.
b. The scar tissue obstructing the frontal
sinus drainage is resected first.
After resection of scar tissue the
remnant of middle turbinate becomes
visible.
c. The medial osseous and mucosal
lamina of middle turbinate are resected,
the lateral mucosal lamina is preserved.
d. This lateral mucosal lamina is turned
medially covering the skull base. The
frontal sinus neoostium is epithelized.

52. Postoperative CT scan of Draf III procedure
Coronal CT in a patient following modified Lothrop (Draf III)
procedure. The frontal sinuses are well-aerated and an extensive
drainage pathway has been created. The surgical defect in the nasal
septum (arrow) should not be misinterpreted as an unintended
septal perforation

53. Conclusion –
The endonasal frontal sinus type I–III drainage procedures provide suitable
surgical options for the treatment of frontal sinus disease.
In cases where the endonasal approach is not possible or is unsuccessful, the
osteoplastic flap procedure with or without obliteration may provide a
solution.
The chance of complete re-epitheliazation of eventually bare bone is very likely
with the endonasal frontal sinus operations, since they respect the outer
osseous borders of the newly created frontal sinus drainage and minimize the
danger of frontal sinus outlet shrinking, thus preventing mucocele formation.
This concept has revolutionized frontal sinus surgery, so that the classic
external frontoorbital frontal sinus operations according to Jansen-Ritter or
Lynch or Howarth are considered obsolete for the treatment of chronic
inflammatory diseases of the frontal sinus.

54. AXILLARY FLAPAPPROACH
• Axillary flap technique was designed to overcome the
problems in ESS while surgical field is bloody, and longer time
consumption for placing angled endoscopes in frontal recess
before surgical dissection takes place.
• This procedure allows a large part of dissection in frontal sinus
with 0 degree telescope.

55. Surgical technique
• Making a incision 8mm
above axilla of middle
turbinate and bring this
8mm forward, turned down
vertically up to axilla,
turned back under axilla on
to the roof of middle
turbinate.

56. • Full thickness flap elevated
with freer elevater.

57. • A Hajek koeffler punch is
used to remove ant wall of
agger nasi cell.
• Agger nasi cell enterd and
probe is passed in frontal
drainage pathway and all
obstructing cells are
removed and flap reposited
back.

58. • Mucosal flap is carefully
kept to prevent scarring
• And completely
covering the osteum
back.

59. Osteoplastic Flap with Frontal Sinus Obliteration
Today , about 5 % of all frontal sinus operations are external.
Osteoplastic frontal sinus approach is regarded as a preferred approach
particularly if problem frontal sinus occurs.
Described by Tato and Bergaglio in 1949 as removal of diseased mucosa and
obliteration with abdominal fat.
INDICATIONS-
• Failure of correctly performed type III drainage.
• Type III drainage technically not possible ( AP diameter < 8 mm )
• Laterally located mucopyocoele.
• Major destruction of posterior wall
• Inflammatory complications after trauma (alloplastic material )
• Major benign tumours with and without obliteration( osteoma)
• Problem frontal sinus sometimes in combination with complete endonasal
ethmoidectomy

60. OSTEOPLASTIC FLAP SURGERY
• Preoperative HRCT and X-ray
occipito-frontal view should be
done.
• From image a contours of frontal
sinus are cut out as a template.
• A bitemporal coronal incision is
preferred ( invisible scar )
• Scalp flap elevation done up to
bilateral supraorbital ridges and
over root of nose, carefully to avoid
damage to supraorbital and
supratrochlear nerve damage.
Supratrochle
ar nerve
Supra orbital
nerve
Supra orbital
artery

61. A Template from X-ray is placed on root of nose for
marking the borders of frontal sinus on periosteum

62. • Periosteum is incised 1.5 cm outside the bony markings.
• Osteotomy is made in the bone , few mm inside the marked
line, for this 30 degree oscillating saw is used.
• Frontal intersinus septum is broken with angled chisel.
• The fracture and elevation of bony lid is undertaken with a
wide osteotome.
• Supraorbital ridge is preserved.

63. Formation of a bone flap with a saw corresponding to the limits
of frontal sinus. Periosteum is elevated from the area of bone
incision

64. An oblique incision through the bone enlarges the area
of replacement of bony flap
1. Elevated galea periostium
2. Pathologically altered mucosa of frontal sinus

65. Then the anterior wall of frontal sinus is elevated with
two broad chisels. This ends in a fracture of floor just
posterior of supraorbital ridges.
3. Drill holes

66. Appearance after down fracturing of anterior wall of
frontal sinus
4. Bony flaps hinged on periosteum , anterior
wall of frontal sinus.

67. The mucosa is completely
removed and using the
operation microscope the
internal table drilled with
burr.

68. After blockage of the osteum, frontal sinus drainage by inverting
mucosa, covering cartilage with preserved fascia or galea-
periosteum and fixing with fibrin glue, frontal sinus is filled with
pieces of fat

69. Situation at the end of operation after bony flap
is replaced and closure done -
• 5. preserved fascia
• 6. cartilage
• 7. transplanted fat with
fibrin glue
• 8.fibrin glue
• 9. resorbable sponge
• 10. rubber finger pack

70. Frontal sinus unobliteration procedure –
Done in cases secondary to trauma or osteom having a healthy frontal sinus
mucosa.
In such cases , decision has to be taken whether the mucosa around the
infundibulum is sufficiently healthy to preserve the frontal sinus or whether
obliteration should be done.
Where sinus is preserved , a type III median drainage is performed from above
and is called as Frontal sinus unobliteration procedure .

71. Results of osteoplastic flap procedure
• This procedure is very useful in patients in whom the frontal
sinus can not be treated with endo-nasal approach.
• Most important intra-operative complication is exposure of
orbital fat and unintentional fracture of anterior wall,
incorrect placement of anterior wall ,frontal contour change (
depression, embossment ).
• Postoperative MRI is valuable in detecting recurrent mucocele
and differentiating vital adipose tissue from fat necrosis in
the form of oil cysts.

72. CRANIALIZATION OF FRONTAL SINUS
Performed by Donald and Bernstein in 1982.
Indications –
1. Comminuted fracture of frontal sinus
2. Incomplete removal of frontal sinus mucosa
3. Severe post traumatic oedema of frontal lobe
4. Intracranial foreign body
5. Destruction of posterior frontal sinus wall.

73. Surgical steps –
The initial part of the procedure is same as osteoplastic frontal sinus procedure.
Remnant of posterior wall are completely removed.
Mucosa of the floor of frontal sinus is completely removed or inverted into the nose.
Depending on A-P diameter of frontal sinus ,
If small – the connection to the nose is obliterated with conchal cartilage or galeal
periosteal flaps.
Large dead space b/w ant wall and dura – obliterated with abdominal fat , cancelous
bone from iliac crest , hydroxyapatite.
Anterior wall reconstructed with an additional bone graft from temporal area if required.

74. RHINOFRONTAL SINUS SEPTOSTOMY
• A COMBINED INTRA-EXTRA NASAL APPROACH
• Similar to combined external and internal technique of
Lothrop but includes immediate re-epithelisation of frontal
sinus area drainage with free mucosa grafts.
• This procedure is useful to manage difficult frontal sinus
disease which has recurred even after repeated surgeries.
This procedure was first developed by Stenert.

75. Surgical technique
1. The external approach.
2. Resection of frontal sinus disease.
3. Total resection of frontal intersinus septum
4. Partial endonasal resection of nasal septum.
5. Bilateral subtotal resection of free dependant part of middle
turbinate.
6. Bilateral endoscopic ethmoidectomy.
7. Maximal enlargement of the isthmus area between both
frontal sinuses and nasal cavities, including the anterior
ethmoids.
8. Complete epithelization of the neo-communication with free
mucosal graft and closure of Jansen-Ritter approach

76. Results:
• Widely patent epithelized nasofrontal communication
post operatively
• Complete symptomatic relief.
• No requirement of revision surgery
• Only complication encountered :CSF leak

77. THANK YOU…