This operation is currently considered the gold standard whenever an external approach to the frontal sinus is required after failure of previous endonasal procedures or when the disease cannot be adequately reached transnasally. The anterior wall of the frontal sinus may be exposed through a coronal incision, which is carried out far posteriorly to be hidden by the hair line, or a "butterfly" or "seagull" incision, which is performed along the superior border of the eyebrows (Fig. 5.19). Our preference is for coronal incision, since the latter may leave the patient with a visible scar and some numbness of the forehead. Soft tissue dissection is then carried along the plane between the galea and the pericranium to leave the pericranium adherent to the underlying bone, so as to maintain an adequate vascularization to the bone. With the help of a template of the frontal sinus, obtained from a Caldwell view the superior margin of the sinus is identified and a cut is made in the bone along this margin with an oscillating saw (Fig. 5.20). Using a chisel, the bony flap is gently down-fractured attached to the pericranium i j
Fig. 5.19. Different incisions for osteoplastic frontal sinusotomy: coronal incision (broken red line) and "butterfly" or "seagull" incision (solid red line)
and the frontal sinus is entirely exposed. The original technique includes careful removal of the disease (i.e., mucocele, osteoma) together with all the mucosa lining the sinus, plugging of both frontal infundibula with cartilage and/or muscle, and obliteration of the sinus with fat obtained through a small incision made in the abdominal wall. In our experience, in selected patients who have an extremely localized disease not involving the infundibulum area in an otherwise well ventilated sinus, obliteration of the sinus may be avoided.
A coronal approach is routinely indicated for osteomyelitis of the frontal bone, which usually complicates an acute frontal rhinosinusitis. The entity of bony resection must be tailored to the extent of the osteomyelitic process. If the anterior wall is involved, obliteration of the sinus with fat is obtained and reconstruction of the bony wall is secondarily performed, when there will be clear clinical and radiological signs that the inflammatory process has been controlled. When osteomyelitis affects the posterior wall of the frontal sinus, this needs to be resected; cranialization of the sinus is performed after sealing both frontal infundibula with cartilage or muscle to prevent any contamination from the nasal cavities.
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