Alternative Surgical Techniques

It is possible to approach the frontal recess anteriorly with a 0° scope if there is a large agger nasi air cell. A mucosal flap on the lateral nasal wall based anteriorly can be made so that the prominence in the lateral nasal wall created by the agger nasi air cell is uncovered. A Hajek-Kofler punch is then used to remove the "armpit" of this area where the middle turbinate

Agger Nasi Air Cells

Fig. 5.61 a An olive ended sucker or ball probe can be used to help define whether you have located the frontal sinus. Place it within the "possible" frontal sinus and note its angle and pinch it with your fingers at the maxillary spine. b Then remove it and place it at the same angle and distance from the maxillary spine. If it is around the medial canthal area, you have not reached the frontal sinus. c If the probe is high above the supraorbital margin, it is probably in the frontal sinus. If it turns abruptly laterally, check that there is no bulla frontalis or supraorbital cell that can also extend this high up.

Fig. 5.61 a An olive ended sucker or ball probe can be used to help define whether you have located the frontal sinus. Place it within the "possible" frontal sinus and note its angle and pinch it with your fingers at the maxillary spine. b Then remove it and place it at the same angle and distance from the maxillary spine. If it is around the medial canthal area, you have not reached the frontal sinus. c If the probe is high above the supraorbital margin, it is probably in the frontal sinus. If it turns abruptly laterally, check that there is no bulla frontalis or supraorbital cell that can also extend this high up.

Fig.5.62a-d Sequential coronal CT scans showing agger nasi > air cells, the drainage channel (arrow) of the frontal sinus: build up a 3D image of the cells in your mind. e View of right frontal recess from above with a track of blood going down to the in-fundibulum frontalis. f The same patient from below, showing that the frontal sinus drains medially (arrow).

FundibulumFrontal Recess

Fig. 5.63 a A Kuhn curette is in the terminal recess. b The bony shell is lateralized. c A ball probe helps to atraumatically lateralize the shells of bone higher up. d This exposes the bulla frontalis laterally and the frontal recess medially. e An overview showing the frontal recess area in front and a supraorbital cell behind. f The anterior ethmoid artery can be seen in the roof of the supraorbital cell. g The end result of a type I frontal sinus-otomy.

Frontal Sinus Minitrephine

attaches onto the lateral nasal wall and by doing this the anterior part of the agger nasi air cell is opened. The agger nasi cell can then be removed submucosally, the mucosa of the frontal recess lateralized, and the lateral flap placed over any raw bone to reduce the chance of any stenosis in this area. Surgery in the armpit area where the middle turbinate attaches to the lateral nasal wall often results in the middle turbinate becoming lateralized. We are not concerned about this as it helps to open the olfactory cleft.

If the middle turbinate has been resected in previous surgery or if the frontal sinus is very stenosed due to previous instrumentation in this area, this can make access to the frontal recess difficult. Extra care is needed as reported series have shown that complications are more common in this patient group. It is safest to palpate anteriorly where the bone is very thick, but you must not angle your probe medially (and risk a CSF leak) or laterally into the orbit. A "mini trephine" can help define the site of the frontal recess when the techniques mentioned have not worked.

A small incision is made within the eyebrow just medial to the notch on the supraorbital rim where the vessels and nerves come out. An incision of approximately 0.5 cm followed by soft-tissue dissection is needed before a small burr hole is made into the sinus. Fluorescein dye can then be placed into the frontal sinus and sought endoscopically within the nose to see where it comes out. Though it is often not necessary, but a blue filter can be used to define the site if there is only a small amount of fluorescein passing into the nose.

Where previous surgery has caused stenosis of the frontonasal duct, the main problem that needs to be overcome is the presence of all the scar tissue, and secondly the amount of prolapse of soft tissue that may have been caused by excessive removal of bone forming the lateral wall of the frontal recess. This is not uncommon after an external frontoethmoidectomy and is known to occur in approximately a one-third of patients who have had a Lynch-Howarth external eth-moidectomy approach. The alternative ways of overcoming this problem are discussed in Chapter 14.

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