Alternative Surgical Techniques

Instead of creating a central drainage channel, it is possible to support and reconstruct the lateral wall of the frontal recess if collapse of that area is the primary problem (Fig. 14.35). This particularly applies when an external ethmoidectomy has led to a loss of bone lateral to the frontal recess. There is often a great deal of fibrosis in the area of the frontal recess when it has stenosed after an external ethmoidectomy. The old idea of using as large a stent as possible in the belief that "the larger the stent the greater the chance the recess will have of not stenosing down completely when the stent is removed" is wrong. The pressure necrosis that the large stent causes induces a lot of fibroblast activity (Fig. 14.36). An alternative technique is to replace the fibrosed mucosa with new mucosa.

It is rarely possible to reflect a septal flap that extends into this area; a free turbinate graft works well. A free cartilage graft from the septum or conchal bowl is sutured in position with mucosa over it and a loose stent is placed to hold it open. The stent is loose in order to avoid any pressure necrosis on the graft. This will provide lateral support and reduce the chance of further stenosis. Two weeks after surgery, endoscopy will show that the stent is loose and surrounded by healthy mucosa in the frontal recess. This technique is successful in approximately 80% of patients after 5 years in our hands.

Another alternative is obliteration of the frontal sinuses. This is a large procedure, particularly if the

Frontal Sinus Stents
Fig. 14.36 A stent in the frontal sinus with ongoing infection. The authors do not recommend stents as they appear to stimulate granulation tissue and fibroblast activity.

sinuses are well pneumatized, as is often the case in these patients (Fig. 14.37a-d). A coronal flap is done after a plain occipitofrontal radiograph has been taken to work out a template of the extent of the frontal sinuses. It is worth dissecting the periosteum off the frontal bone down to the supraorbital margin. This differs from conventional descriptions of the anterior wall as being hinged on a flap of periosteum inferiorly. This is rarely possible without having tatters of periosteum between areas where bone has been divided along its inferior margin. To add to this, the mucosa of the entire frontal sinus needs to be removed, not only from the posterior wall but the anterior flap, and this is difficult to do thoroughly while it is still attached to the periosteum. It is important to remove all the mucosa from the whole of the frontal sinus because if any is left a mucocele will form. The template is used to estimate the outline of the frontal sinus and an initial hole is made into the sinus in its lateral third. A blunt-ended hook can be used to check the outline of the extent of the frontal sinus, and if it is rotated it to where its end reaches the limit of the frontal sinus it can be followed around with a fissure burr (Murphy and Jones, 2004).

An alternative technique is to place an endoscope into the frontal sinus; its light will illuminate the exact extent of the anterior wall and this will help exact removal. In addition, the surgeon can see where the end of the drill is by looking at the endoscopic view on the screen. This reduces the degree of overhang left after the anterior wall is removed and makes removal of the mucosa easier. It is unwise to make an entry hole high a

Alternative Turbinate Surgery

Fig. 14.37 a Pus discharging from a fistula due to an infected implant that had been placed in the sinus. b Drill-out of the sinus, with careful removal of every piece of mucosa. c Fat obliteration of the frontal sinus. d Reconstruction of the anterior wall with split calvarial bone.

Fig. 14.37 a Pus discharging from a fistula due to an infected implant that had been placed in the sinus. b Drill-out of the sinus, with careful removal of every piece of mucosa. c Fat obliteration of the frontal sinus. d Reconstruction of the anterior wall with split calvarial bone.

in the midline where the venous sinuses are large as entry there can cause torrential bleeding. Before the whole anterior plate is removed, it is worth fixing miniplates onto the anterior wall (these will be removed subsequently) and making burr holes into the cranium to match these plates; this will make replacement of the plate at the end of the procedure not only more accurate but quicker. There are invaginations of mucosa that follow veins into the posterior wall of the frontal sinus and it is important that the posterior wall is drilled to reduce the chance of remnants of mucosa being left behind. The sinus is best obliterated with fat and the frontal recess should be blocked with fascia; both can be obtained from the thigh or abdomen. The anterior bone flap is susceptible to infection and prophylactic antibiotic cover should be given.

A further technique that can be used when there is osteomyelitis or a loss of much of the anterior wall of the frontal sinus is to remove the whole anterior wall and the mucosal lining, and smooth the supraorbital rims—Riedel's procedure (Fig. 14.38 a-d) (Raghavan and Jones, 2004).

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