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Concepts of Endoscopic
Sinus Surgery:
Causes of Failure
Cummings Chp. 52
Wed 1/9/13
Irene A. Kim
Key Points
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Long-term success rate
of FESS + medical
therapy: 80-90%.
Anatomic variants no
longer considered
underlying etiology of
disease
FESS GOAL:
 Surgically remove
inflamed tissue from
critical points in
mucociliary clearance
pathways
ABSOLUTE Indications
for Sinus Surgery
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1. Rhinosinusitis
complications
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2. Expansile mucoceles
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3. Allergic/Invasive fungal
rhinosinusitis
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4. Suspected neoplasia
Mucoceles
Frontal sinus mucoceles
 Skull base identified in
posterior ethmoid
 Follow anteriorly until
bone of lesion found
 Remove inferior
portion
 Remove all osteitic bone
from region of obstruction
 Bony margins flush
should be
flush with surrounding wall
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Fungal Sinusitis
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Invasive
Chronic invasive fungal rhinosinusitis
 Fulminant invasive disease
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Noninvasive
Fungal balls
 Allergic fungal rhinosinusitis
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Indications for Tumors, Skull Base
Defects, Other Noninflammatory
Lesions
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Benign tumors
Inverted papilloma
Juvenile angiofibroma
Skull base defects
Orbital problems
Encephaloceles, meningoceles
Closure of CSF rhinorrhea
Malignant tumors
Relative Indications
for Sinus Surgery
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Symptomatic nasal polyps
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Symptomatic chronic or recurrent acute
rhinosinusitis
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Unresponsive to medical therapy
Unresponsive to medical therapy
***Medical therapy is cornerstone of mgmt
of inflammatory disease
Poor Indicators of
Successful FESS
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Persistent environmental exposures
Uncontrolled allergies
Continued chemical exposures
Smoking
Increased granulation tissue
 Increased incidence of frontal recess stenosis
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Extent of Surgery
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Mucosal preservation is *key* (ethmoid)
Resection of inflamed bone important
Removal of osteitic partitions
Uncinate process
 Ethmoid sinuses
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Avoid leaving exposed bone behind
Pre-op Evaluation & Management
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Know amount and duration of:
Antibiotic therapy
 Anti-inflammatory treatments
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Treat severe polyposis, hyperreactive
mucosa
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Oral steroids (Prednisone 20-30mg x 3-10
days)
Imaging
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CT key, but MRI needed when CT shows
disease adjacent to skull base erosion
Evaluate lateral cribiform plate lamella
Evaluate vertical height of post ethmoid
Evaluate sphenoid sinus in axial/coronal
planes
Evaluate frontal recess in triplanar views
Concepts of Antrostomy
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Maxillary sinus opening should
communicate with natural ostium to
PREVENT surgical failure
Long term causes of failure
Ostenoneogenesis from stripped mucosa
 Retained foreign body
 Mucous draining into sinus from persistent
frontal recess inflammation
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Ethmoidectomy
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Work from “known” to “unknown”
Medial orbital wall is first critical landmark
Goal: Marsupialized cavity lined by healthy,
intact mucosa
Skull base is second critical landmark
Common results of failed ethmoidectomy:
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Lateralized middle turbinate
Retained uncinate process
Failure of removal of uncinate superiorly
Residual agger nasi cells
Sphenoidotomy
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Re-review scans: coronal and axial planes
Review course of optic n., carotid a.
Endoscopic transnasal approach
Transethmoid/transmaxillary approach
Transseptal approach
Sphenoid Anatomy:
Key Structures
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Carotid artery
Optic nerve
Cavernous sinus
3rd, 4th, 5th CN
Frontal Sinusotomy
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Most challenging
Potential for persistent, recurrent disease
Most difficult decision: to explore or not
Review coronal, axial, sagittal views
Review AP/lateral diameters
Examine pneumatization of sinus
Frontal recess dissection
Turbinate Management
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Remove exposed bone (MT)
Stabilize floppy MT
Controlled scar to nasal septum
 Postoperatively, can lyse adhesions
 Suture turbinate to septum
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Postop Medical Management
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Long-term topical steroid sprays
Saline spray
Nasal saline irrigation
Debridement
Loss of olfaction: sensitive sign of return of
disease
Management of the
Frontal Sinuses
Cummings Chp. 53
Wed 1/9/13
Irene A. Kim
Key Points
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Frontal sinus drains
into middle meatus
through frontal recess
Frontal recess located
at junction of frontal
sinus and is most
anterosuperior part of
ethmoid sinus
Preserve mucosa
around frontal recess
Acute Frontal Sinusitis
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Symptoms
Low-grade fever
 Malaise
 Frontal headache
 Tenderness of medial aspect of infraorbital
margin
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Common organisms
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S.pneumo, H. flu, anaerobic strep, Bacteroides,
S. aurus, S. epidermidis, S. milleri
Treatment Approaches
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Topical decongestant high in middle meatus
Trephine the frontal recess by:
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Incision in medial aspect of eyebrow
Open frontal sinus endoscopically by
removing ethmoid air cells surrounding
recess
Complications of Surgery
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Damage to mucosa
 Adhesions
 Stenosis
Periorbital cellulitis
Periorbital abscess, subdural empyema, meningitis,
cavernous, sup sagittal sinus thrombosis
*Obtain URGENT CT if:
 CNS involvement seen
 Visual problems
 Spiking pyrexia not resolving in 36 hours
Surgery in Chronic Frontal
Sinusitis
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Disease likely started by unnecessary instrumentation
of frontal recess
PRIMARY indication for instrumentation:
 When maximal medical treatment partial anterior
ethmoidectomy have failed
 Primary fungal disease
 Barotrauma
 Mucocele
 Osteoma
 OsteomyelitisTumors
Causes of Frontal Sinus
Surgery Failure
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Remnant frontal recess cells
Retained uncinate process
Middle turbinate lateralization
Osteoneogenesis
Scarring or inflammatory mucosal thickening
Recurrent polyposis
Endoscopic Frontal
Sinusotomy
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Boundaries of frontal
recess
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Anterior
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Lateral
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Lamina papyracea
Medial
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Agger nasi
Most ant/superior
portion of middle turb
Posterior
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Ethmoid bulla, bulla
lamella
Frontal Recess Cells
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Type I: Single cell superior to agger nasi cell
Type II: Tier of two or more cells above the
agger nasi cell
Type III: Single cell extending from the agger
cell into the frontal sinus
Type IV: Isolated cell within the frontal sinus
Frontal Recess Cells
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Bulla frontalis
 High anterior ethmoid cell that has pneumatized into
frontal bone
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Supraorbital cell
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Posterior cell in ant ethmoid complex that is well pneumatized
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Can displace frontal recess posteriorly and medially
Can extend laterally into frontal bone over orbit
Can also narrow frontal recess by pushing forward
*Prevalance of these variations does NOT appear to
correlate with presence or absence of frontal sinus
disease
Opening the Frontal Recess
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Goal:
1. Deflating the cells of ethmoid air cells
 2. Preserve mucosa around recess
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Median frontal sinus drainage procedure
Obliteration of frontal sinuses
Median Frontal Sinus
Drainage Procedure
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Frontal recesses
opened by removing:
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top of septum
Frontal interspinus
septum
Anterior beak of frontal
bone
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Frontal Sinus Obliteration
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Coronal flap or eyebrow incision
Make outline of frontal sinus with template,
image guidance, or endoscopically
Remove anterior plate
Remove all mucosa of frontal sinuses
before obliteration
Frontal recess separated from nasal
airway with sheet of fascia lata
Use fat to obliterate sinuses
Indications for External Approach

Situations where removal of pathology
and/or drainage is difficult to achieve
endoscopically
Lateral loculation, lateral mucocele
 Fibrosis or new bone around frontal recess
 Paget’s disease of frontal bone, osteomyelitis,
SCCa
 Gross prolapse of orbital contents
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Riedel’s Procedure
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Important role in mgmt of patients with
recurrent infections
Removes ant wall and floor of frontal sinus
and all its mucosal lining
Help eradicate frontal sinus disease when
Drainage and obliteration have failed and
 There is persistent disease involving the ant
wall of the frontal sinus or the sinus itself
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Main complaint: postoperative
disfigurement
Cranialization of Frontal Sinuses
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Performed for:
Requirement for posterior wall removal
 Anterior skull base tumors
 Severe communication of posterior wall with
frontal sinus
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Ant intracranial contents separated from
paransal sinuses and nasal airway by:
Fascia lata
 Pericranial flap
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Specific Pathologic
Conditions
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Pneumosinus Dilatans
 Rare, benign expansion of an aerated sinus
beyond normal margin of frontal bone
 Hypersinus: enlarged sinus with normal walls
Mucoceles
 Epithelium-lined sac containing inspissated
mucous
Osteoma
 Only complaints are cosmetic
 Very common, 3% of people have them
Fractures of Frontal Sinus
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Ant wall fractures do not require exploration UNLESS:
 It affects the frontonasal duct
POSTERIOR wall fractures
 Nondisplaced and w/o complications: manage
conservatively
 Compound comminuted fracture affecting posterior
wall or near frontonasal duct:
 Cranialization of frontal sinus
Images
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http://search.babylon.com/imageres.php?iu=http://uwmsk.org/sinusanatomy2/images/axial.frontalmucocele.jpg&ir=http://uwmsk.org/sinusanatomy2/FrontalAbnormal.html&ig=http://t0.gstatic.com/images?q=tbn:ANd9GcQAB-0_DUmc13JMscXED8RGxcG5ubw62-944bbpTn6vUB4gZtWI704bZU&h=377&w=395&q=expansile+mucocele&babsrc=SP_ss
http://search.babylon.com/imageres.php?iu=http://www.phytoscience.ca/images/endoscopic%2520sinus%2520surgery%2520diagram.jpg&ir=http://www.phytoscience.ca/
articles/Nasal%20Polyps.html&ig=http://t2.gstatic.com/images?q=tbn:ANd9GcTvstLF-0MDNGBmYBkVL1rd2nncNJwGQVtt7_Ov0KaR5uEP17Ih8Hn45E&h=337&w=344&q=fungal+sinsuitis+flow+chart&babsrc=SP_ss
http://www.phytoscience.ca/images/endoscopic%20sinus%20surgery%20diagram.jpg
http://search.babylon.com/imageres.php?iu=http://www.nyee.edu/images/ent_rss_sts_008.jpg&ir=http://www.nyee.edu/ent_rss_sts_sphenoid01.html?large_print=1&ig=htt
p://t2.gstatic.com/images?q=tbn:ANd9GcRoFmf0M41wC03FDJe_k8DmR6VoTg7ZfOY2irnRDknCnNHBvTch6zP2Hk&h=290&w=409&q=sphenoid+sinus+anatomy&babsrc=SP_ss
http://www.medicalgrapevineasia.com/mg/wp-content/uploads/2012/08/Figure-1b-Nasal-Polyps.jpg
http://2.bp.blogspot.com/-vea4b1pTcDs/Tg5hLzlHcTI/AAAAAAAAAPU/LkmPr3ZGS_4/s1600/nasal_polyp.jpg
http://www.bing.com/images/search?q=sinus+mucocele&FORM=HDRSC2#view=detail&id=38146D4F21BE6E2F4051DF40518555AE2F252949&selectedIndex=0
http://www.sciencedirect.com/science/article/pii/S1043181003001313
http://www.bing.com/images/search?q=riedel%27s+procedure&FORM=HDRSC2#