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Chapter 11
The Frontal Sinus and Nasal Polyps
11
James A. Stankiewicz, James M. Chow
Core Messages
쐽 (Overview) All patients with significant
nasal polyposis generally have frontal sinus
disease
쐽 Most patients prior to medical therapy or
sinus surgery have minimal or no symptoms related to the frontal sinus
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . .
87
Nasal Polyps in the Primary Scenario . . . . . . . . . .
87
Nasal Polyposis in the Frontal Sinus –
Secondary or Revision Surgery . . . . . . . . . . . . .
91
Postoperative Care After Frontal Sinus Polyp Surgery .
92
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . .
93
References . . . . . . . . . . . . . . . . . . . . . . . . .
93
쐽 In most cases, surgical opening of the frontal ostia/sinuses is not necessary
쐽 Only patients with symptoms or signs
referable to the frontal sinus refractory to
medical therapy require frontal sinus surgery
– Patients with pain, headaches, pressure
– Patients with purulent drainage from the
frontal sinus
쐽 Postoperatively, polyps will most likely
return in the upper ethmoid/frontal recess
and are not problematic in most cases
쐽 Medical therapy can control symptomatic
recurrent frontal recess/sinus polyps in
most cases
쐽 The choice of surgical procedure to control
frontal sinusitis/polyps is dependent upon
extent and location of disease and anatomy
Introduction
Nasal polyposis is a genetic disorder where upon reactive nasal/sinus mucosa fueled by chronic inflammation/infection from immunologic stimulation
cause marked mucosal edema with development of
nasal polyps. Several studies have discussed the etiology and pathogenesis of nasal polyps [10–12]. This
chapter discusses how to clinically approach nasal
polyps affecting the frontal recess and sinus from the
viewpoint of observation versus that of medical therapy versus that of surgery in primary and revision
case scenarios.
Nasal Polyps in the Primary Scenario
Nasal polyps, in most cases, even in obstructive polyposis, do not cause major symptoms ascribed to the
frontal sinus. It is rare for these patients to complain
of headache, pressure, or pain.
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James A. Stankiewicz, James M. Chow
Most patients with nasal polyps complain of:
쐽
쐽
쐽
Nasal obstruction
Drainage
Loss of smell related to nasal obstruction
and/or infection
Rarely, polyposis can be so severe as to cause bone
thinning and dehiscence in the frontal recess or frontal sinuses. More commonly, the CT scans show opacification or mucosal thickening of the frontal sinuses
in these patients. No author has done a study to show
what comprises frontal sinus opacification – polyps,
fluid, or mucosal thickening.
쐽
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It is fair to say that diffuse polyposis, which
exists in the lower sinuses, especially the ethmoid, does not occur to the same extent in the
frontal.
The recent study by Larsen and Tos showed that most
polyps originated from mucosa of the ostia, clefts or
recesses which do not exist inside the frontal sinuses
[10]. Of 69 autopsies reviewed, polyps existed in 32%
but were symptomatically “silent”. This would suggest that when considering surgical intervention in
patients with medically refractory polyposis, conservatism in dealing with the frontal sinus should be the
rule. In this chapter, we outline a protocol or care
plan on how to deal with the frontal sinus in an operable nasal polyposis patient.
In patients in whom the symptoms are not related
to the frontal sinus, the frontal sinus should be generally left untouched at the initial surgery. Del Gaudio
reported that of 207 patients with frontal recess or
frontal disease, only 32% of polyp patients had headaches [5]. Of patients with frontal sinus opacification,
only 26% had pain or headache. Endoscopic removal
of frontal recess polyps and agger nasi cells is all that
is generally necessary. It is important in patients with
asymptomatic frontal sinus disease that polyp disease in the frontal recess be removed without ostioplasty, taking care not to injure mucosa posteriorly,
laterally, or medially. Irrigation of the frontal sinus
can be performed to remove mucus or debris. Another study by Del Gaudio et al. nicely showed how
nasal polyposis can expand sinus walls [4]. It is not
uncommon to see frontal recess/ostia expansion due
to polyposis, which allows the frontal sinus better
drainage and less chance of postoperative stenosis. If
on CT scan the frontal ostium is dilated or widened, a
curved microdebrider can remove polyps obstructing the recess/ostium up into the sinus without danger of stenosis. A narrow ostium on CT scan should
not be instrumented except for irrigation. Also given
the reason that the frontal/upper ethmoid area is the
first area to develop recurrent polyps, rarely is aggressive frontal ostioplasty or Lothrop (modified)
primarily necessary. Three papers, two by Jacobs and
the other by Kennedy (both Triologic theses) indicate
that patients who had their polyps removed were
markedly improved subjectively, but had visible nasal polyps in the frontal recess postoperatively [6–8]
(Fig. 11.1). Guidelines for performance of frontal sinus surgery are listed in Table 11.1. While some surgeons recommend routine preservation of the middle turbinates, best success is achieved with middle
turbinate reduction or removal, allowing the frontal
sinus better drainage. (Table 11.2) In most cases, patients will do well.
In patients with symptoms related to the frontal
sinus, the frontal sinus will often also do well once
surgery has been determined to be necessary, with
removal of disease from the lower sinuses and judicious irrigations. Medical therapy should obviously
be initiated prior to surgical therapy in most patients
(Fig. 11.2). First-line therapy in these patients who often complain of headache or severe pressure is antiinflammatory medication. If polyps aren’t medically
reduced to allow for drainage, then patients will not
Table 11.1. Guidelines for frontal endoscopic sinus surgery
(ESS) in the polyposis patient
1. Patient with acute or chronic complicated frontal
sinusitis invading into orbit or skull base
2. Patients with chronic pain, marked pressure, or frontal
headache with or without purulence refractory to medical therapy
3. Failed endoscopic sinus surgery in symptomatic
chronic frontal sinusitis/polyposis
4. Mucocele and polyposis
The Frontal Sinus and Nasal Polyps
Chapter 11
Fig. 11.1. A Postoperative persistent/recurrent nasal polyps in
the frontal recess in an asymptomatic patient. B Modified
Lothrop with polypoid changes in an asymptomatic patient
improve. Antibiotics alone are not sufficient. Oral
and topical corticosteroids are the best medications
to reduce the size of polyps. Usually a short 7–10-day
burst is sufficient to improve symptoms, although
prolonged steroids for up to 1 month may be necessary [9]. In patients who have fungal polyposis, corticosteroids may be necessary for 1 month or more.
This treatment along with antifungals or antibiotics
as necessary will control most symptomatic patients.
Aggressive medical therapy can frequently reverse
symptomatic frontal disease due to polyposis.
Indications for surgical intervention include:
쐽
쐽
Persistence of frontal symptoms
Abnormal physical examination with purulence from the frontal sinus despite aggressive
medial therapy
Often, endoscopic total ethmoidectomy and opening
the frontal recess or ostia will allow for drainage of
the frontal sinuses. Where polypoid and fungal de-
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James A. Stankiewicz, James M. Chow
Table 11.2. Guidelines for extent of sinus surgery with nasal
polyposis
1. Total ethmoidectomy
2. Wide maxillary antrostomy
3. Wide/large sphenoidotomy
4. If patient not asthmatic and without fungal disease
– Consider saving middle turbinates.
5. Asthmatic patients with fungus, ASA Triad –
– Remove middle turbinates
6. Primarily and revision surgery – asymptomatic frontal
sinus
– Conservative removal polyp frontal recess/ostium
7. Symptomatic frontal sinus patients – primary & revision
A. Start out with ostioplasty if frontal recess/ostia dilated or widened by disease
B. If ostia narrow remove lower polyps and irrigate
sinuses
C. Modified Lothrop or create wide ostium if frontal
markedly stenotic or closed
D. External sinus surgery – Osteoplastic flap
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bris are anticipated in the frontal sinuses, endoscopic
irrigation will often remove fungal debris unblocking the frontal ostia. Since, as earlier mentioned,
polyposis will often expand the frontal ostia, endoscopic irrigation and judicious removal via a microdebrider of obstructive polyps is possible. It is important to remember that frontal ostioplasty, in patients without frontal sinus expansion, is difficult to
perform due to osteitic changes. Great care must be
taken to avoid causing frontal ostial stenosis. Conservative treatment around frontal recess/ostia works
best in these patients. Only those patients with symp-
tomatic refractory or complicated polypoid disease
require consideration for a modified Lothrop or an
osteoplastic flap. Since in these patients the floor of
the frontal sinus is often attenuated by disease causing expansion, a modified Lothrop is a good procedure to consider. Certainly, extensive polypoid tissue
with or without fungus, mucocele, or infection unable to be cleared with a modified Lothrop should be
considered for an osteoplastic flap and, in some cases, a craniofacial procedure (Fig. 11.3). It is rare that
acute complicated sinusitis will occur in a patient
with nasal polyposis in the frontal sinus. The goal of
surgery in these patients is to drain all involved sinuses. Trephination, endoscopic frontal ostioplasty,
modified Lothrop, or osteoplastic flap should be considered.
Fig. 11.2. Patient with nasal polyps and purulent frontal recess
with headache/pressure
The Frontal Sinus and Nasal Polyps
Chapter 11
nus surgery is a beginning treatment and not the
end. Most patients with polyps, especially asthmatics
with or without aspirin sensitivity, will require longterm medical care to control polyposis.
In our own experience, the need for revision surgery
is as follows:
쐽
쐽
쐽
Fig. 11.3. A Markedly expanded frontal polyposis into the skull
base (MRI, sagittal and coronal view) B Markedly expanded
ethmoid polyposis with proptosis (CT scan, coronal)
Nasal Polyposis in the Frontal Sinus –
Secondary or Revision Surgery
After endoscopic sinus surgery for nasal polyposis
and chronic rhinosinusitis, very few patients are
cured despite a significant improvement in their
symptoms. Indeed, in most patients, endoscopic si-
Patients with nasal polyps without asthma –
30%
Patients with polyps and asthma – 50%
Samter’s triad (aspirin triad) – about
70%–80%
Therefore, medical therapy is important for control
of disease. All patients are maintained on a topical
steroid spray. Oral and topical steroids are used as
necessary along with antibiotics or antifungals. Each
patient is individualized to a therapeutic regimen to
best control their polyps. Given as noted that polyposis is a genetic disorder almost all patients will, to a
certain degree, regrow polyps. Indeed, as mentioned,
the frontal ethmoid area is the first area for polyps to
reappear after sinus surgery. In most cases, polyps
block the frontal sinus postoperatively, but patients
remain asymptomatic.
Patients who become symptomatic may require
revision surgery.
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James A. Stankiewicz, James M. Chow
Symptom recurrence in these patients is most frequently due to:
쐽
쐽
11
Frontal sinus blockage by polyps and infection
or
Frontal sinus ostial stenosis after frontal ostioplasty
Prior to surgical intervention, a trial of topical steroid drops (not sprays) along with oral prednisone
or injection of triamcinolone (40 mg/ml) into the
polyps may reduce polyp size and symptoms [3].
Topical steroid drops, which can be ophthalmic or
nasal drops, placed in ether a head-back (Mygind) or
head-down (Moffitt) position can be effective.
Oral prednisone can be continued for up to
1 month or used in 3–4 months bursts to control disease [2, 3, 9]. Patients with fungal disease and polyposis may benefit from antifungal irrigations, nebulization, or steroid nebulization.
Patients with persistent symptomatic frontal sinus
polyposis refractory to medical therapy require revision surgery. If endoscopic sinus surgery is chosen,
then the frontal ostia should be opened as widely as
possible but not circumferentially. Debris is cautiously irrigated, removing all secretions and fungi.A
curved microdebrider can actually remove or debulk
frontal sinus polypoid disease. A modified Lothrop
provides not only a wider entrance into the frontal sinus but also removal of the upper septum, causing
less chance of polypoid growth below the frontal sinus. Since chronic frontal sinus polyposis can often
cause thinning of the sinus floor, a modified Lothrop
is made less difficult in these cases. Severe expanded
sinus polypoid disease with or without a mucocele
can undergo treatment with an osteoplastic flap if it
is not manageable using endoscopic techniques. The
frontal sinus can either be obliterated or the floor
opened from above (Lothrop) into the nose. Stenting
should be considered for the endoscopic modified
Lothrop if the anterior-posterior width is narrow and
there is marked osteitic bone thickness present.
Stents should be left for at least 3 months. In a trou-
blesome revision case, stents should be left in place
for perhaps a year or more.
Postoperative Care After Frontal Sinus
Polyp Surgery
Surgery for nasal polyposis in general requires an individualized regimen of short- and long-term care.
Anti-inflammatory medications, primarily steroids,
are the drugs of choice. Together with oral steroid
bursts or taper, topical steroids used as a drop can
help control recurrent frontal recess/ostial polyps
[2]. Injection of steroids into the polyps can also control recurrent frontal recess/ostial polyps. Leukotriene inhibitors should also be considered. Antifungal irrigation, nebulizations, or oral medications are
costly and help temporarily in fungal-sensitive individuals. Their use should be individualized. Not staying on a regimen of selected medications will result
in recurrence of the disease. In the most sensitive
ASA Triad patients, aspirin desensitization should be
considered (Fig. 11.4) [1].
Table 11.3 lists short- and long-term care considerations in frontal/frontal recess polyposis.
Fig. 11.4. ASA Triad (Samter’s) patient controlled on topical
steroids after aspirin desensitization
The Frontal Sinus and Nasal Polyps
Table 11.3. Short- and long-term postoperative treatment for
best control of nasal polyposis
Short-term
1. Oral prednisone burst, which can be repeated every
4 months.
2. Topical nasal steroid drops e.g., Dexamethasone
– One month postoperative
3. Antibiotics which are culture directed for persistent
bilateral infection
4. Saline irrigations
5. Leukotriene inhibitor
6. Antifungal (oral, topical, or irrigation) medications as
needed
7. Triamcinolone injection
Long-term
1. Oral prednisone every 3–4 months
2. Topical steroid drops or nebulization
3. Leukotriene (if helpful)
4. Prednisone 5 mg qd or qod for more difficult cases,
increasing to 10 mg qd with URI
5. Antifungal irrigations, nebulizations, or oral medications (as needed)
6. Select long-term regime individually
7. Triamcinolone injection
Conclusion
t
Frontal sinus anatomy relative to the lower and anterior paranasal sinuses will often shield the frontal
sinuses from symptomatic disease, especially with
nasal polyposis. Conservative treatment with antiinflammatory medications controls disease in most
cases. Symptomatic frontal recess/sinus polyposis
refractory to medical therapy requires wide osteoplasty, modified Lothrop, or external open procedures to best control disease and relieve symptoms.
Chapter 11
References
1. Berges-Gimeno MP, Simon RA, Stevenson DD (2003) Long
term treatment with aspirin desensitization in asthmatic
patients. J Allergy Clin Immunol 111 : 180–186
2. Bonfils P, Nores JM, Halimi P et al (2003) Corticosteroid
treatment of nasal polyposis with a three year follow-up.
Laryngoscope 113 : 683–688
3. Citardi MJ, Kuhn FA (1998) Endoscopically guided frontal
sinus beclomethasone instillation for refractory frontal
sinus/recess edema and polyposis. Am J Rhinol 12(3) :
179–182
4. Del Gaudio JM (2003) Race and gender differences in frequency of skull base erosion in allergic fungal sinusitis.
Am J Rhinology, publication pending. Presented at Fall
2003 ARS meeting. Orlando, Florida
5. Del Gaudio JM, Wise SK (2004) Consideration of degree of
frontal sinus disease to the presence of frontal headache.
Am J Rhinology, publication pending – Department of
Otolaryngology-Head and Neck Surgery, Presented Spring
ARS/COSM 2004 meeting, Phoenix, Arizona
6. Jacobs J (1997) One hundred years of frontal sinus surgery.
Laryngoscope 100 : Supp. 83 : 1–36
7. Jacobs J (1998) Conservative approach to inflammatory
nasofrontal duct disease. Ann Otol 107 : 658–661
8. Kennedy DW (1992) Prognostic factors, outcomes and
staging in ethmoid sinus surgery. Laryngoscope 102
(Suppl) 1–18
9. Kuhn FA, Javer AR (2002) Allergic fungal sinusitis: A four
year follow-up. Am. J. Rhinology 14 : 149–156
10. Larsen PL, Tos, M (2004) Origin of nasal polyps: An endoscopic autopsy study. Laryngoscope 114 : 710–719
11. Norlander T Fukami, M Westin KM (1993) Formation of
mucosal polyps in the nasal and maxillary/sinus cavities
by infection. Otolaryngol-Head and Neck Surgery 109 :
522–529
12. Settipane GA (1987) Nasal polyps: Pathology, immunology, and treatment. Am J Rhinol 1 : 119–126
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