A golden experience: Fifty years of experience managing the frontal sinus.

OBJECTIVES/HYPOTHESIS: The frontal sinus is one of the most anatomically complex and inaccessible of the paranasal sinuses. As a result, surgeons have continually tried to improve surgical management of the frontal sinus. The senior author (c.w.g.) shares 50 years of experience managing the frontal sinus. DATA SOURCES: PubMed literature search. REVIEW METHODS: Review of the literature regarding landmark innovations in frontal sinus surgery. RESULTS: Open approaches established that the frontal sinus is accessible, and in certain circumstances, such as with large osteoma or papilloma, are still required. The endoscope changed the surgical landscape and allowed for greater finesse and decreased morbidity. Sinus balloon dilation is the newest change in frontal sinus management and shows promise in properly selected cases. CONCLUSION: Surgery of the frontal sinus continues to evolve and improve. Although there are new techniques, the older techniques are still pertinent.

Pediatric septoplasty.

This article discusses the importance of obtaining the correct anatomic location of a nasal obstruction in the pediatric patient, the relative and absolute indications for septoplasty, and surgical techniques. Because disruption of the developing nasal septum can alter craniofacial growth patterns, the current understanding of the effect of septoplasty on craniofacial growth is also discussed.

Endoscopic localization of the anterior and posterior ethmoid arteries.

OBJECTIVES: Understanding the endoscopic locations of the anterior and posterior ethmoid arteries is important during endoscopic sinus or endoscopic skull base procedures so that these arteries can be avoided. Therefore, the objective of this study was to define the endoscopic locations of the ethmoid arteries. METHODS: Twenty-four cadaver heads were used to identify the endoscopic location of the ethmoid arteries via an external incision. An image guidance system was used to record the locations of these arteries. The anterior ethmoid artery was referenced to the axilla of the middle turbinate, and the posterior ethmoid artery to the anterior wall of the sphenoid sinus. The closest lamella to these arteries was identified. RESULTS: Forty-eight nasal cavities were dissected. The mean distance from the axilla to the anterior ethmoid artery was 17.5 mm. The anterior ethmoid artery was located immediately anterior to (31%), at (36%), or immediately posterior to (33%) the superior attachment of the basal lamella. The mean distance from the posterior ethmoid artery to the anterior ethmoid artery was 14.9 mm. The mean distance from the posterior ethmoid artery to the anterior wall of the sphenoid sinus was 8.1 mm. The posterior ethmoid artery was either anterior to (98%) or at (2%) the anterior face of the sphenoid sinus. CONCLUSIONS: Specific endoscopic anatomic relationships and measurements have been presented for the anterior and posterior ethmoid arteries.

Risk factors for recurrent sinus surgery in cystic fibrosis: review of a decade of experience.

BACKGROUND: Patients with cystic fibrosis (CF) who undergo endoscopic sinus surgery often require multiple revision procedures. Our objective was to identify risk factors for revision sinus surgery in patients with CF, to better identify this subset of patients who might be better suited for alternative interventions at their initial procedure. METHODS: Patients with CF who presented to our academic tertiary care sinus clinic between 1994 and 2003 were reviewed. Data were collected from CT scans using the Lund-Mackay scale. Data are collected on demographics, comorbidities, CF genotype, number and type of sinus surgeries, and pulmonary function tests. RESULTS: Eighty-one patients met inclusion criteria. Fifty patients were <18 years old at presentation. Forty-one patients were A508 homozygotes, 32 patients were A508 heterozygotes, and 5 patients were non-A508 heterozygotes. Respiratory comorbidities were asthma alone (28%) and aspirin triad (5%). Eighteen (22%) patients either smoked or lived with smokers. The mean Lund-Mackay score before the initial surgery was 16. Twenty patients were treated with medication only; 35 patients underwent 1 surgery; 14 patients underwent 2 surgeries; 8 patients underwent 3 surgeries; 2 patients underwent 4 surgeries; and 2 patients underwent 5 surgeries. Patients with higher Lund-Mackay scores at their initial CT were more likely to undergo repeat surgeries (p < 0.05). CONCLUSION: CF patients with high Lund-Mackay scores at their initial surgery are more likely to undergo several revision surgeries. These patients should be considered for more alternative initial management of their sinuses.

Initial surgical treatment for chronic frontal sinusitis: a pilot study.

OBJECTIVES: The initial surgical treatment for chronic frontal sinusitis is not well defined. Our objective was to determine the effectiveness of anterior ethmoidectomy for chronic frontal sinusitis. METHODS: Patients with chronic frontal sinusitis who underwent anterior ethmoidectomy as initial surgical treatment were reviewed. Data were collected from computed tomography scans with use of the Lund-Mackay scale. Data on demographics, comorbidities, management, postoperative recovery, and follow-up were collected. RESULTS: Seventy-seven patients representing 121 diseased frontal sinuses met the inclusion criteria. The respiratory comorbidities were asthma alone (8.3%), asthma and polyps (6.6%), aspirin triad (5.8%), and cystic fibrosis (0.8%). Nineteen of 121 frontal sinuses (15.7%) belonged to smokers. Fourteen of 121 frontal sinuses (11.5%) exhibited postoperative evidence of disease. Of these 14 frontal sinuses, 10 (8.3%) underwent revision surgery. Frontal sinuses of patients with aspirin triad, with both nasal polyposis and asthma, or with inter-frontal sinus septal cells were more likely to fail Draf I surgery (p < .05). CONCLUSIONS: Anterior ethmoidectomy for drainage of frontal sinuses appears to be effective initial surgical treatment for chronic frontal sinusitis. Patients with aspirin triad, both asthma and polyposis, or inter-frontal sinus septal cells are more likely to fail this procedure.

Steroid injection for sinonasal polyps: the University of Virginia experience.

BACKGROUND: Sinonasal polyps are treated with topical steroids, systemic oral steroids, surgical excision, and intrapolyp steroid injection. Use of steroid injection is not widespread because of reported complications. The objective of this study was to evaluate the complications of intrapolyp steroid injections and compare it to the complications of surgical removal of polyps. METHODS: All patients seen between 1994 and 2003 with a diagnosis of nasal polyps were reviewed retrospectively. Demographics, complications, follow-up, and comorbidities were collected. Frequency of each treatment modality used and complications of each treatment were compared. RESULTS: Three hundred fifty-eight patients were in the study with a mean follow-up of 30 months. Respiratory comorbidities were asthma alone (35%), aspirin triad (16%), and cystic fibrosis (15%). Other comorbidities were smokers (21%). Treatment modalities were medical treatment alone (14%); medical treatment and steroid injections (19%); medical treatment and surgery (33%); and medical treatment, injections, and surgery (34%). Patients who underwent injection had fewer surgeries (p < 0.001). There was 1 minor complication associated with 1495 injections and 11 major and 16 minor complications associated with the 310 surgeries. The differences in complication rates were statistically significant (p < 0.001). There was no significant difference in demographics, follow-up, or comorbidities between patients who received injections and patients who underwent surgery. CONCLUSION: Intrapolyp steroid injection is associated with a significantly lower rate of complication than is surgical excision of sinonasal polyps. Steroid injection also may decrease the need for further surgical intervention of polyps.

Tornwaldt's cyst: incidence and a case report.

Tornwaldt's cyst is an uncommon type of nasopharyngeal cyst that may cause clinically significant symptoms. We reviewed reports of 31,855 computed tomography (CT) scans and 21,158 magnetic resonance imaging (MRI) scans to ascertain how many Tornwaldt's cysts were discovered incidentally. These images had been obtained between Jan. 1, 1994, and Dec. 31, 1999, at the University of Virginia Health Sciences Center. We found that 32 Tornwaldt's cysts had been incidentally detected in 20 women and 12 men. Four of these cysts had been found on CT (0.013%; mean size: 0.66 cm3) and 28 on MRI (0.13%; mean size: 0.58 cm3). The overall rate was 0.06% (32/53,013). The most common indications for imaging in these patients were headache, seizures, dizziness/vertigo, and pharyngeal symptoms. We also report the case of a patient with a symptomatic Tornwaldt's cyst whose symptoms resolved after treatment with endoscopic marsupialization. Tornwaldt's cyst should be remembered as an uncommon but potentially treatable cause of many symptoms seen in a typical otolaryngology practice.

Limits of endoscopic visualization and instrumentation in the frontal sinus.

BACKGROUND: Endoscopic limitations in the frontal sinus are poorly defined. We set out to define these limits. METHODS: Fifteen cadaveric heads underwent endoscopic frontal sinusotomies (Draf IIA, IIB, III). Areas of frontal sinus openings were calculated. Coordinates of the most distant points for instrumentation, visualization, and instrumentation with visualization in the frontal sinus were identified with the use of image guidance. RESULTS: Twenty-eight frontal sinuses were evaluated. The mean sinus opening areas were 47.5 mm2, 105.1 mm2, and 246.4 mm2 for Draf IIA, IIB, and III. Visualization exceeds instrumentation and visualized reach (P<0.05) regardless of different frontal sinusotomies. Anterior and lateral instrumentation and visualized reach increase as the frontal sinus opening increases (PIIB>IIA (P<0.04). There is no statistical difference for superior visualization, instrumentation, and visualized reach among various sinusotomies (P>0.05). CONCLUSIONS: Endoscopic visualization exceeds instrumentation and instrumentation exceeds visualized reach. Enlarging frontal sinus opening area increases instrumentation and visualization.

Expression of leukotriene C4 synthase and plasminogen activator inhibitor 1 gene promoter polymorphisms in sinusitis.

BACKGROUND: Studies have described polymorphisms in genes involved with both leukotriene synthesis and remodeling. Leukotriene C4 synthase (LTC4S) is the critical terminal pathway enzyme involved in regulation of cysteinyl leukotriene (CysLT) synthesis. An A-to-C base exchange in the promoter region of the LTC4S gene influences its expression. The plasminogen activator inhibitor (PAI) 1 gene is associated with tissue fibrosis. The presence of either 4G or 5G residues in the promoter region has been associated with altered transcription. The role of these polymorphisms was investigated in patients with sinusitis and polyps. We performed a prospective study of patients undergoing endoscopic sinus surgery at a university hospital between 1996 and 2004. METHODS: Demographic data and sinus tissue were collected from patients. Patients were classified into four groups: controls, chronic hyperplastic eosinophilic sinusitis (CHES), aspirin exacerbated respiratory disease (AERD), and chronic inflammatory sinusitis (CIS). DNA was analyzed for the LTC4S and the PAI-1 promoter polymorphisms using standard PCR techniques. RESULTS: There were 133 patients with 76 women and 57 men (mean age, 42 years). Sixty-six people were in the control group, 16 people were in the CIS group, 51 people were in the CHES group, and 22 people were in the AERD group. The LTC4S allelic frequencies were controls, A = 0.81 and C = 0.19; CIS, A = 0.73 and C = 0.27; CHES, A = 0.69 and C = 0.31; AERD, A = 0.67 and C = 0.33. The C allele was more frequent in CHES versus controls (p = 0.04). The PAI-1 allele frequencies were controls, 5G = 0.55 and 4G = 0.45; CIS, 5G = 0.47 and 4G = 0.53; CHES, 5G = 0.56 and 4G = 0.44; AERD, 5G = 0.54 and 4G = 0.46. Increased expression of the 4G allele of the PAI-1 gene was observed in CIS; however, this genetic variance between the four groups was not statistically different (p > 0.05). CONCLUSION: There appears to be a genetic component that contributes to nasal polyp formation in sinusitis. Although the LTC4S polymorphism has previously been associated with aspirin-sensitive asthma, this is the first demonstration that the polymorphism is associated with CHES and this is independent of aspirin sensitivity.

FloSeal use in endoscopic sinus surgery: effect on postoperative bleeding and synechiae formation.

PURPOSE: The objective of this study is to evaluate the effect of the hemostatic agent, FloSeal (FS), on bleeding and healing after functional endoscopic sinus surgery. METHODS: We performed randomized, double-blinded, controlled study at a tertiary care center. Patient nasal sides were randomized to FS or control. After completion of sinus surgery, FS was placed in the appropriate nasal cavities followed by saline-soaked neuropatties in both nasal cavities. Control sides received saline-soaked neuropatties alone, without FS. RESULTS: Forty-five patients were enrolled. Mean time to cessation of bleeding in recovery was 16.4 and 30.8 minutes for the FS- and control-treated sides, respectively (P = .028). Patients maintained diaries for 7 days postoperatively and reported similar durations of bleeding at home, but indicated less discomfort on the FS-treated side. Postoperative endoscopic examinations revealed significantly less crusting in FS-treated nasal cavities at 1 week, but significant difference at 1 and 3 months. There were no differences in postoperative scarring or middle turbinate lateralization. CONCLUSIONS: Use of FS after functional endoscopic sinus surgery resulted in less bleeding, immediately postoperatively, and less discomfort, and did not increase the incidence of crusting or scarring compared with control.

Endoscopic sinus surgery in patients older than sixty.

OBJECTIVE: Rhinosinusitis is the sixth most common chronic condition of the elderly. Functional endoscopic sinus surgery (FESS) has developed over the last 20 to 30 years into a widely accepted treatment modality for chronic rhinosinusitis in adults who have failed maximal medical management. The aim of this study was investigate the safety and efficacy of FESS in the geriatric population as compared to that of the adult population. METHODS: Retrospective review of prospective measurement of outcomes in consecutive patients over 60 years of age who underwent FESS. Fifty-six patients over 60 years of age underwent FESS and were evaluated preoperatively and postoperatively at 3, 6, and 12 months with the Sino-Nasal Outcome Test-20 (SNOT-20) questionnaire, and a rigid nasal endoscopy scoring system. Data analysis was performed using the Student's t test to compare mean scores. Any complications were noted. RESULTS: Patients evaluated by the SNOT-20 scoring system experienced 64% improvement of symptom scores at 3 months, 73% improvement at 6 months, and 75% improvement at 12 months. Rigid nasal endoscopy scores improved by 76% at 3 months, 65% at 6 months, and 76% at 12 months. There were very few minor complications and no major complications of the surgery. These results are comparable to those of the literature that address outcomes in the adult population undergoing FESS. CONCLUSIONS: FESS in the geriatric population is a safe and effective treatment modality for rhinosinusitis that is refractory to medical therapy. EBM RATING: C.

Endoscopic management of cerebrospinal fluid rhinorrhea.

PURPOSE: Most anterior skull base defects causing cerebrospinal fluid (CSF) rhinorrhea can be readily approached using endoscopic techniques when surgical repair is necessary. We present our data from endoscopic repair of CSF rhinorrhea with long-term follow-up. METHODS: Retrospective data analysis of patients that were diagnosed with anterior skull base CSF rhinorrhea and underwent endoscopic repair at a tertiary institution. Data were analyzed to determine the etiology and location of CSF leaks. Diagnostic techniques, surgical techniques, and surgical outcomes were reviewed. RESULTS: Ninety-two patients were diagnosed with CSF rhinorrhea and underwent endoscopic repair over a 12-year period. Forty-eight were males, and 44 were females. The average age was 49 (range 6-81) years. Average follow-up was 25 months, with a range of 12 to 82 months. The etiology of CSF leak was prior endoscopic sinus surgery in 23 patients (25%), idiopathic in 19 (21%), neurosurgery in 17 (18%), trauma in 18 (20%), and the presence of meningocele/encephalocele in 11 patients (12%). The most common location of the defect was the sphenoid sinus (n = 36, 39%), followed by ethmoid roof (n-27, 29%), and cribriform plate (n = 24, 26%). Endoscopic repair was initially successful in 78 (85%) patients. Seven additional patients underwent successful revision endoscopic repair for an overall success rate of 92% (n = 85). Five (6%) large skull base defects were eventually repaired by neurosurgery using open intracranial techniques. No major complications were encountered. CONCLUSION: The intranasal endoscopic approach is an effective and safe technique in the surgical management of anterior skull base CSF rhinorrhea. Long-term success rate in our patient population was 92%.

Long-term results of the Lothrop operation.

With continued surgical instrument advancement, endoscopic sinus surgery techniques continue to evolve with an overall improvement of our ability to offer surgical treatment for a variety of surgical disorders of the sinuses and anterior skull base. Frontal sinusitis and the extent of surgery performed in the frontal recess once medical management fails are constantly debated in the literature. It seems that even though instrumentation has greatly improved, surgical management of frontal sinusitis remains a frustrating endeavor for otolaryngologists. Open approaches to the frontal sinus, including the osteoplastic flap with frontal sinus obliteration using adipose tissue, have been the gold standard, but require external incisions and complete removal of sinus mucosa with destruction of the frontal sinus. The endoscopic modified Lothrop technique involves removal of the frontal sinus floor bilaterally with frontal septectomy and resection of the nasal septum to create a large nasofrontal communication. Recent postoperative results of this technique rival the results after frontal sinus obliteration in selected patients while avoiding the morbidity associated with the open destructive approach.

Endoscopic management of benign sinonasal tumors: a decade of experience.

BACKGROUND: A variety of benign tumors present in the nasal and paranasal sinuses. METHODS: We review our experience over the last 10 years with endoscopic management of these tumors and discuss (presentation, diagnostic considerations, and therapeutic options. RESULTS: Eighteen patients with benign sinonasal tumors were managed with endoscopic techniques. Representative cases are presented, including pleomorphic adenoma, ameloblastoma, meningioma, cholersterol granuloma, ossifying fibroma, fibrous dysplasia, and osteomas. Three patients (16.7%) required one revision endoscopic sinus procedure. Average follow-up was 4 years. CONCLUSIONS: With the treatment of more complex cases being undertaken endoscopically, the need for individual therapeutic consideration and close follow-up is stressed. The combination of removal of benign tumors endoscopically and endoscopic surveillance in the outpatient setting has allowed a less radical surgical approach while resulting in decreased morbidity and better tumor control.

Three-dimensional computed tomography of congenital nasal anomalies.

OBJECTIVE: To determine the utility of performing three-dimensional (3D) computed tomography (CT) of congenital naso-frontal anomalies for preoperative planning and counseling and compare it with standard two-dimensional (2D) imaging and intraoperative findings. STUDY DESIGN: Prospective case evaluation of imaging studies and medical records in cohort of patients with congenital nasal anomalies. METHODS: We performed 3D CT imaging of three different types of congenital nasal lesions. Additional preoperative imaging consisted of standard 2D CT scans and/or magnetic resonance imaging (MRI). Information obtained from the 3D CTs was compared with other standard imaging and intraoperative findings. RESULTS: 3D CT was most useful in the case of a large encephalocele with a significant bony defect of the anterior cranial fossa. It provided moderate utility when used to evaluate a nasal dermoid with nasal bone and septal abnormalities and was of limited benefit in the case of a bifid nose with significant external soft tissue deformity and relatively normal bony anatomy. CONCLUSION: Congenital midline nasal anomalies are rare lesions with the potential for intracranial extension and anterior skull base abnormalities. The safe surgical treatment of these lesions depends upon accurate preoperative imaging to assist in establishing the diagnosis, to help guide surgical planning, and to assist in communicating the diagnosis and surgical approach for optimal counseling of families. 3D CT was instrumental in providing additional useful information in cases with significant bony abnormalities at little additional cost or time. It is also beneficial for preoperative counseling of patients and families with limited medical knowledge.

Skull base erosion by sphenoid fungus balls: diagnosis and endoscopic treatment.

BACKGROUND: Fungus balls typically are innocuous lesions found in immunocompetent hosts. They are located most commonly in the maxillary sinus but may be life-threatening when found in the sphenoid sinus. METHODS: We review our series offour sphenoid fungus balls with skull base erosion. RESULTS: Our average patient age was 68.7 years old (56-86 years) with three women and one man. One patient was insulin-dependent diabetic, the other three patients were otherwise healthy. The most common presenting symptoms were headache and dizziness with relatively few sinus-specific complaints. Endoscopy revealed polyps in two of the four patients. Computerized tomography scans revealed thickened osteitic bone in three cases and two of the four computed tomography scans showed microcalcification. All patients had bony erosion over the internal carotid arteries. Additionally, one patient internal carotid artery thrombosis, one patient had erosion of the planum sphenoidale, and a third patient had erosion to the brainstem inferior to the sella turcica. Three patients had magnetic resonance imaging that revealed heterogeneous lesions. Two magnetic resonance images showed hypointense T1 and T2 imaging. The third was isointense on T1 and hypointense on T2. All patients were treated with endoscopic marsupialization and removal of all gross fungal debris without complications. All pathological specimens were diagnostic for fungus balls. One offour cultures was positive for fungus. All patients are asymptomatic at time of lastfollow-up. CONCLUSIONS: Sphenoid fungus balls present with vague, non-rhinological symptoms, but may have significant local expansion and destruction. These potentially lethal lesions usually can be suspected on preoperative imaging and are best treated with endoscopic removal.

The endoscopic modified Lothrop: long-term follow-up on 44 patients.

BACKGROUND: The gold standard for surgical treatment of chronic frontal sinusitis has been the osteoplastic flap with obliteration. In an attempt to preserve the frontal sinus, we have been performing the endoscopic modified Lothrop orfrontal drill-out. METHODS: Retrospective chart review. RESULTS: We performed the modified Lothrop on 54 patients between 1993 and 1998. The modified Lothrop was successful (no revision surgeries and only an occasional need for antibiotics) after one procedure in 68% (30/44) of patients followed up for > or =1 year. Six patients underwent successful revision, bringing the overall success rate to 82% (36/44). Eight patients (18%) eventually underwent osteoplastic flap with obliteration, three of those after attempted revision. Mean follow-up was 40 months with failures occurring a mean of 12 months after initial Lothrop. Overall complication rate was 11%. CONCLUSIONS: The modified Lothrop is a technically challenging operation that provides an acceptable alternative to the osteoplastic flap with obliteration.

Pitfalls in the endoscopic drainage of subperiosteal orbital abscesses secondary to sinusitis.

OBJECTIVE: To review the safety and efficacy of endoscopic drainage of subperiosteal orbital abscesses (SPOAs) secondary to sinusitis and to evaluate risk factors that may be associated with failure. STUDY DESIGN: Retrospective chart review. METHODS: All patients admitted to the University of the Virginia Health System with a diagnosis of SPOA between 1992 and 1999 were reviewed. RESULTS: Seven of the 10 SPOAs identified, each located medially, resolved without complication after endoscopic drainage. The remaining three patients required a second drainage. One patient had an inferiorly located SPOA, which recurred laterally after endoscopic drainage. A second pediatric patient, who did not undergo a routine second-look procedure, developed middle turbinate lateralization and synechiae, which led to recurrent SPOAs. A third patient with a significant history of sinusitis was found to have an ethmoid sinus mucocele extending into the medial and posterior orbit. All patients eventually resolved their symptoms. CONCLUSIONS: Endoscopic drainage of medial SPOAs appears to be safe and effective. However, several risk factors must be recognized when present. Management of these risk factors is discussed.