45 Indications for Operating the Frontal Sinus: Primary Surgery or Always Second Line?

Nsangou Ghogomu and David B. Conley

Abstract

Should frontal sinus surgery be done primarily or always secondarily for frontal chronic rhinosinusitis (CRS)? Historically, chronic sinus outflow obstruction was considered the etiology of frontal CRS, and thus surgery limited to the osteomeatal complex (OMC) or frontal recess (Draf I/anterior ethmoidectomy) was the logical first surgery following failure of medical management. Our current understanding of the etiology of CRS suggests a multifactorial disease that includes a broad range of inflammatory mediators as well as mucociliary dysfunction that persist even in the presence of sinus ostial and recess patency. With this in mind, the goal of frontal sinus surgery is not only the relief of obstruction but also the provision of access for saline irrigation and topical medications such as steroids. This is much more likely to be accomplished following sinus ostial (at least Draf II) surgery where diseased septations consisting of mucosa and bone as well as part of the frontal beak are removed. With the advent of steroid-eluting frontal ostium implants, the risk of postoperative frontal sinus ostium stenosis has decreased, making surgery of the frontal ostium safer than it was just a few years ago. We thus consider Draf IIa as the first-line surgery in frontal CRS, except in the rare case of reversible inflammatory conditions such as mild unilateral CRS without nasal polyps (CRSsNP) associated with OMC obstruction.

Key words

chronic rhinosinusitis - frontal sinus - anterior ethmoidectomy - osteomeatal complex - Draf - Lothrop - endoscopic modified Lothrop procedure

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