The primary indication for having a good reason to instrument the frontal recess is when:
• Maximum medical treatment has failed to help frontal sinus symptoms.
• A partial anterior ethmoidectomy has not succeeded.
It is important that the periodicity of frontal symptoms is associated with upper respiratory tract infections or changes in barometric pressure, or that symptoms are associated with a purulent discharge.
Opacification of the frontal recess on its own is not a reason to instrument the frontal recess, as it will often resolve with an anterior ethmoidectomy and medical treatment.
There are few other reasons for operating on the frontal recess before trying a partial anterior eth-moidectomy. These include: the presence of fungal disease in the frontal sinus (Fig. 5.42 a, b); barotrauma, mucocele, or osteoma causing obstruction with evidence of mucosal disease (Fig. 5.43 a, b); or other pathology in this area that requires wide exposure for access.
The normal frontal recess is narrow and tenuous (this raises questions about the role of anatomical variations in the pathogenesis of rhinitis). The prevalence of such "variations" and anatomical "restrictions" appears to be no more greater in a control population than in patients with proven rhinosinusitis (Jones et al., 1997 a). It seems likely that the primary problem is the mucosal pathology, and this is the reason why one individual will have chronic rhinosinusitis and another will not.
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