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CC BY-NC-ND 4.0 · Int Arch Otorhinolaryngol 2020; 24(03): e364-e375
DOI: 10.1055/s-0040-1713923
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The Frontal Sinus and Frontal Recess: Anatomical, Radiological and Surgical Concepts

Camila S. Dassi 
1   São Paulo Skull Base Center, São Paulo, SP, Brazil
2   São Paulo Ear, Nose, and Throat Center, Hospital Edmundo Vasconcelos, São Paulo, SP, Brazil
,
Flávia R. Demarco 
1   São Paulo Skull Base Center, São Paulo, SP, Brazil
2   São Paulo Ear, Nose, and Throat Center, Hospital Edmundo Vasconcelos, São Paulo, SP, Brazil
,
João Mangussi-Gomes 
1   São Paulo Skull Base Center, São Paulo, SP, Brazil
2   São Paulo Ear, Nose, and Throat Center, Hospital Edmundo Vasconcelos, São Paulo, SP, Brazil
,
Raimar Weber 
2   São Paulo Ear, Nose, and Throat Center, Hospital Edmundo Vasconcelos, São Paulo, SP, Brazil
,
Leonardo Balsalobre 
1   São Paulo Skull Base Center, São Paulo, SP, Brazil
2   São Paulo Ear, Nose, and Throat Center, Hospital Edmundo Vasconcelos, São Paulo, SP, Brazil
,
Aldo C. Stamm 
1   São Paulo Skull Base Center, São Paulo, SP, Brazil
2   São Paulo Ear, Nose, and Throat Center, Hospital Edmundo Vasconcelos, São Paulo, SP, Brazil
› Author Affiliations
Further Information

Publication History

24 April 2020

10 May 2020

Publication Date:
31 July 2020 (online)

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Abstract

Introduction The frontal sinus (FS) is the most complex of the paranasal sinuses due to its location, anatomical variations and multiple clinical presentations. The surgical management of the FS and of the frontal recess (FR) is technically challenging, and a complete understanding of its anatomy, radiology, main diseases and surgical techniques is crucial to achieve therapeutic success.

Objectives To review the FS and FR anatomy, radiology, and surgical techniques.

Data Synthesis The FS features a variety of anatomical, volumetric and dimensional characteristics. From the endoscopic point of view, the FR is the point of greatest narrowing and, to have access to this region, one must know the anatomical limits and the ethmoid cells that are located around the FR and very often block the sinus drainage. Benign diseases such as chronic rhinosinusitis (CRS), mucocele and osteomas are the main pathologies found in the FS; however, there is a wide variety of malignant tumors that can also affect this region and represent a major technical challenge to the surgeon. With the advances in the endoscopic technique, the vast majority of diseases that affect the FS can be treated according to Wolfgang Draf, who systemized the approaches into four types (I, IIa, IIb, III).

Conclusion Both benign and malignant diseases that affect the FS and FR can be successfully managed if one has a thorough understanding of the FS and FR anatomy, an individualized approach of the best surgical technique in each case, and the appropriate tools to operate in this region.

Keywords

frontal sinus - frontal recess - frontal sinus drainage pathway - endoscopic sinus surgery - draf classification - modified lothrop procedure
 

  • References

  • 1 Ting JY, Wu A, Metson R. Frontal sinus drillout (modified Lothrop procedure): long-term results in 204 patients. Laryngoscope 2014; 124 (05) 1066-1070
    CrossrefPubMedGoogle Scholar
  • 2 Shama SA. Frontal sinus outflow tract: Multi-detector CT assessment. Egypt J Radiol Nucl Med 2017; 48 (04) 897-903
    CrossrefGoogle Scholar
  • 3 Peynegre R, Rouvier P. Anatomy and Anatomical Variations of the Paranasal Sinuses. In: Gershwin ME, Incaudo GA. , editors. Diseases of the Sinuses [Internet]. Totowa, NJ: Humana Press; 1996: 3-32 . Available from: http://link.springer.com/10.1007/978-1-4612-0225-7_1
    Google Scholar
  • 4 Duque CS, Casiano RR. Surgical Anatomy and Embryology of the Frontal Sinus. In: Kountakis SE, Senior BA, Draf W. , editors. The Frontal Sinus [Internet]. Berlin/Heidelberg: Springer-Verlag; 2005: 21-31 . Available from: http://link.springer.com/10.1007/3-540-27607-6_3
    Google Scholar
  • 5 Loury MC. Endoscopic frontal recess and frontal sinus ostium dissection. Laryngoscope 1993; 103 (4 Pt 1): 455-458
    CrossrefPubMedGoogle Scholar
  • 6 Karanfilov BI, Kuhn FA. The Endoscopic Frontal Recess Approach. In: Kountakis SE, Senior BA, Draf W. , editors. The Frontal Sinus [Internet]. Berlin/Heidelberg: Springer-Verlag; 2005: 179-89 . Available from: http://link.springer.com/10.1007/3-540-27607-6_20
    Google Scholar
  • 7 Friedman M, Bliznikas D, Vidyasagar R, Landsberg R. Frontal sinus surgery 2004: update of clinical anatomy and surgical techniques1 1The authors received no financial support in connection with this article, and deny any off-label or investigational usage of any product. Oper Tech Otolaryngol--Head Neck Surg 2004; 15 (01) 23-31
    Google Scholar
  • 8 Ximendes R, Mangussi-Gomes J, Balieiro FO. , et al. Anatomical relations between the frontal sinus drainage pathway and the agger nasi cell. J Otolaryngol ENT Res 2018
    PubMedGoogle Scholar
  • 9 Gaafar H, Abdel-Monem MH, Qawas MK. Frontal sinus outflow tract “anatomic study”. Acta Otolaryngol 2001; 121 (02) 305-309
    CrossrefPubMedGoogle Scholar
  • 10 Stamm A, Nogueira JF, Americo RR, Solferini Silva ML. Frontal sinus approach: the ‘vertical bar’ concept. Clin Otolaryngol 2009; 34 (04) 407-408
    CrossrefPubMedGoogle Scholar
  • 11 Daniels DL, Mafee MF, Smith MM. , et al. The frontal sinus drainage pathway and related structures. AJNR Am J Neuroradiol 2003; 24 (08) 1618-1627
    PubMedGoogle Scholar
  • 12 H S. . W P. Functional Endoscopic Sinus Surgery. Concept, Indications and Results of the Messerklinger Technique [Internet]. European archives of oto-rhino-laryngology: official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS): affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 1990 [cited 2020 Mar 13]. Available from: https://pubmed.ncbi.nlm.nih.gov/2180446/?from_term=stammberger+frontal+sinus&from_pos=9
    PubMed
  • 13 Fatu C, Puisoru M, Rotaru M, Truta AM. Morphometric evaluation of the frontal sinus in relation to age. Ann Anat 2006; 188 (03) 275-280
    CrossrefPubMedGoogle Scholar
  • 14 Lee D, Brody R, Har-El G. Frontal sinus outflow anatomy. Am J Rhinol 1997; 11 (04) 283-285
    CrossrefPubMedGoogle Scholar
  • 15 Bent JP, Cuilty-Siller C, Kuhn FA. The Frontal Cell As a Cause of Frontal Sinus Obstruction. Am J Rhinol 1994; 8 (04) 185-191
    CrossrefGoogle Scholar
  • 16 Wormald P-J, Hoseman W, Callejas C. , et al. The International Frontal Sinus Anatomy Classification (IFAC) and Classification of the Extent of Endoscopic Frontal Sinus Surgery (EFSS). Int Forum Allergy Rhinol 2016; 6 (07) 677-696
    CrossrefPubMedGoogle Scholar
  • 17 Weber RK, Hosemann W. Comprehensive review on endonasal endoscopic sinus surgery. GMS Curr Top Otorhinolaryngol Head Neck Surg 2015; 14: Doc08
    PubMedGoogle Scholar
  • 18 Kasbekar AV, Swords C, Attlmayr B, Kulkarni T, Swift AC. Sinonasal papilloma: what influences the decision to request a magnetic resonance imaging scan?. J Laryngol Otol 2018; 132 (07) 584-590
    CrossrefPubMedGoogle Scholar
  • 19 Reitzen SD, Wang EY, Butros SR, Babb J, Lebowitz RA, Jacobs JB. Three-dimensional reconstruction based on computed tomography images of the frontal sinus drainage pathway. J Laryngol Otol 2010; 124 (03) 291-296
    CrossrefPubMedGoogle Scholar
  • 20 Wormald PJ. The agger nasi cell: the key to understanding the anatomy of the frontal recess. Otolaryngol Head Neck Surg 2003; 129 (05) 497-507
    CrossrefPubMedGoogle Scholar
  • 21 Kennedy DW, Senior BA. Endoscopic sinus surgery. A review. Otolaryngol Clin North Am 1997; 30 (03) 313-330
    CrossrefPubMedGoogle Scholar
  • 22 Teshima M, Shinomiya H, Otsuki N. , et al. Complications in Salvage Surgery for Nasal and Paranasal Malignant Tumors Involving the Skull Base. J Neurol Surg B Skull Base 2018; 79 (03) 224-228
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Snidvongs K, Pratt E, Chin D, Sacks R, Earls P, Harvey RJ. Corticosteroid nasal irrigations after endoscopic sinus surgery in the management of chronic rhinosinusitis. Int Forum Allergy Rhinol 2012; 2 (05) 415-421
    CrossrefPubMedGoogle Scholar
  • 24 Kuhn FA, Melroy CT, Dubin MG, Ventrapragada S. Frontal Sinus Instrumentation. In: Kountakis SE, Önerci M. , editors. Rhinologic and Sleep Apnea Surgical Techniques [Internet]. Berlin, Heidelberg: Springer Berlin Heidelberg; 2007: 27-39 . Available from: http://link.springer.com/10.1007/978-3-540-34020-1_3
    Google Scholar
  • 25 Bruggers S, Sindwani R. Evolving trends in powered endoscopic sinus surgery. Otolaryngol Clin North Am 2009; 42 (05) 789-798 , viii
    CrossrefPubMedGoogle Scholar
  • 26 Graham SM, Nerad JA. Orbital complications in endoscopic sinus surgery using powered instrumentation. Laryngoscope 2003; 113 (05) 874-878
    CrossrefPubMedGoogle Scholar
  • 27 Dalgorf DM, Sacks R, Wormald P-J. , et al. Image-guided surgery influences perioperative morbidity from endoscopic sinus surgery: a systematic review and meta-analysis. Otolaryngol Head Neck Surg 2013; 149 (01) 17-29
    CrossrefPubMedGoogle Scholar
  • 28 Metson R. Image-guided sinus surgery: lessons learned from the first 1000 cases. Otolaryngol Head Neck Surg 2003; 128 (01) 8-13
    CrossrefPubMedGoogle Scholar
  • 29 Kolia NR, Man L-X. Total intravenous anaesthesia versus inhaled anaesthesia for endoscopic sinus surgery: a meta-analysis of randomized controlled trials. Rhinology 2019; 57 (06) 402-410
    PubMedGoogle Scholar
  • 30 Wormald PJ, van Renen G, Perks J, Jones JA, Langton-Hewer CD. The effect of the total intravenous anesthesia compared with inhalational anesthesia on the surgical field during endoscopic sinus surgery. Am J Rhinol 2005; 19 (05) 514-520
    CrossrefPubMedGoogle Scholar
  • 31 Hathorn IF, Habib A-RR, Manji J, Javer AR. Comparing the reverse Trendelenburg and horizontal position for endoscopic sinus surgery: a randomized controlled trial. Otolaryngol Head Neck Surg 2013; 148 (02) 308-313
    CrossrefPubMedGoogle Scholar
  • 32 Ping W-D, Zhao Q-M, Sun H-F, Lu H-S, Li F. Role of tranexamic acid in nasal surgery: A systemic review and meta-analysis of randomized control trial. Medicine (Baltimore) 2019; 98 (16) e15202
    CrossrefPubMedGoogle Scholar
  • 33 Ottoline ACX, Tomita S, Marques Mda PC, Felix F, Ferraiolo PN, Laurindo RSS. Antibiotic prophylaxis in otolaryngologic surgery. Int Arch Otorhinolaryngol 2013; 17 (01) 85-91
    PubMedGoogle Scholar
  • 34 Shah J, Roxbury CR, Sindwani R. Techniques in Septoplasty: Traditional Versus Endoscopic Approaches. Otolaryngol Clin North Am 2018; 51 (05) 909-917
    CrossrefPubMedGoogle Scholar
  • 35 Draf W. Endonasal Frontal Sinus Drainage Type I–III According to Draf. In: Kountakis SE, Senior BA, Draf W. , editors. The Frontal Sinus [Internet]. Berlin/Heidelberg: Springer-Verlag; 2005: 219-32 . Available from: http://link.springer.com/10.1007/3-540-27607-6_24
    Google Scholar
  • 36 DeConde AS, Smith TL. Outcomes After Frontal Sinus Surgery: An Evidence-Based Review. Otolaryngol Clin North Am 2016; 49 (04) 1019-1033
    CrossrefPubMedGoogle Scholar
  • 37 Stamm AC, Draf W. , Eds. Micro-endoscopic Surgery of the Paranasal Sinuses and the Skull Base [Internet]. Berlin, Heidelberg: Springer Berlin Heidelberg; 2000. . Available from: http://link.springer.com/10.1007/978-3-642-57153-4
    CrossrefGoogle Scholar
  • 38 Rudert H. [Microscope and endoscope-assisted surgery of inflammatory diseases of the paranasal sinuses. Value of the Messerklinger infundibulotomy]. HNO 1988; 36 (12) 475-482
    PubMedGoogle Scholar
  • 39 Carney AS. Draf III frontal sinus surgery: “How I do it”. Am J Rhinol Allergy 2017; 31 (05) 338-340
    CrossrefPubMedGoogle Scholar
  • 40 Sahu N, Casiano RR. Nasal branch of the anterior ethmoid artery: a consistent landmark for a midline approach to the frontal sinus. Int Forum Allergy Rhinol 2019; 9 (05) 562-566
    CrossrefPubMedGoogle Scholar
  • 41 Conger Jr BT, Riley K, Woodworth BA. The Draf III mucosal grafting technique: a prospective study. Otolaryngol Head Neck Surg 2012; 146 (04) 664-668
    CrossrefPubMedGoogle Scholar
  • 42 Anderson P, Sindwani R. Safety and efficacy of the endoscopic modified Lothrop procedure: a systematic review and meta-analysis. Laryngoscope 2009; 119 (09) 1828-1833
    CrossrefPubMedGoogle Scholar
  • 43 Naidoo Y, Bassiouni A, Keen M, Wormald PJ. Long-term outcomes for the endoscopic modified Lothrop/Draf III procedure: a 10-year review. Laryngoscope 2014; 124 (01) 43-49
    CrossrefPubMedGoogle Scholar
  • 44 Naidoo Y, Bassiouni A, Keen M, Wormald P-J. Risk factors and outcomes for primary, revision, and modified Lothrop (Draf III) frontal sinus surgery. Int Forum Allergy Rhinol 2013; 3 (05) 412-417
    CrossrefPubMedGoogle Scholar
  • 45 Graham SM. Complications of Frontal Sinus Surgery. In: Kountakis SE, Senior BA, Draf W. , editors. The Frontal Sinus [Internet]. Berlin/Heidelberg: Springer-Verlag; 2005: 267-73 . Available from: http://link.springer.com/10.1007/3-540-27607-6_29
    CrossrefGoogle Scholar
  • 46 Psaltis AJ, Schlosser RJ, Banks CA, Yawn J, Soler ZM. A systematic review of the endoscopic repair of cerebrospinal fluid leaks. Otolaryngol Head Neck Surg 2012; 147 (02) 196-203
    CrossrefPubMedGoogle Scholar
  • 47 Schlosser RJ, Bolger WE. Nasal cerebrospinal fluid leaks: critical review and surgical considerations. Laryngoscope 2004; 114 (02) 255-265
    CrossrefPubMedGoogle Scholar
  • 48 Welch KC, Palmer JN. Intraoperative emergencies during endoscopic sinus surgery: CSF leak and orbital hematoma. Otolaryngol Clin North Am 2008; 41 (03) 581-596 , ix–x
    CrossrefPubMedGoogle Scholar
  • 49 Han JK, Higgins TS. Management of orbital complications in endoscopic sinus surgery. Curr Opin Otolaryngol Head Neck Surg 2010; 18 (01) 32-36
    CrossrefPubMedGoogle Scholar
  • 50 Goldstein GH, Kennedy DW. Long-term successes of various sinus surgeries: a comprehensive analysis. Curr Allergy Asthma Rep 2013; 13 (02) 244-249
    CrossrefPubMedGoogle Scholar