AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Acute sinusitis is arbitrarily defined as the rapid onset and persistence of 2 or more major signs and/or symptoms or of 1 major and 2 minor signs and/or symptoms. Major signs and symptoms include fever, facial pain or pressure, nasal obstruction, or nasal discharge with purulence, and hyposmia/anosmia. Cough, dental pain, headache, and ear pain or ear fullness are considered minor signs and symptoms. Other factors suggesting acute bacterial sinusitis include worsening of symptoms over a 5- to 7-day period or persistence of symptoms for longer than 10 days. Sinusitis that persists for longer than 3 weeks is designated as chronic sinusitis.

Acute frontal sinusitis is considered a more serious type of acute sinus infection because of its complications. Frontal sinus surgery is performed to prevent potentially life-threatening complications when the infection is unresponsive to maximal medical treatment.

This article addresses current surgical strategies in the treatment of acute frontal sinusitis. For excellent patient education resources, see eMedicine's Headache Center. Also, visit eMedicine's patient education article, Sinus Infection.

For further reading, please see the eMedicine articles Sinusitis, Maxillary, Acute, Surgical Treatment; Sinusitis, Acute, Medical Treatment; Sinusitis, Sphenoid, Acute, Surgical Treatment; and Sinusitis, Ethmoid, Acute, Surgical Treatment.

History of the Procedure

Trephination of the frontal sinus was performed as early as prehistoric times by scraping or incision. Two Peruvian skulls at the Museum of Man in San Diego show trephines with evidence of the patients' survival. Early surgeries also described removing part of the anterior frontal sinus wall, leaving the patient with a significant cosmetic deformity. More refined surgery of the frontal sinus was first described in the 19th century, and options for treatment have expanded since the advent of endoscopic sinus surgery.

Frequency

When computed using radiographic criteria, the frequency of sinusitis during upper respiratory tract infection may be as high as 90%. This figure may overestimate the true clinical frequency of acute sinusitis that was determined using symptomatic diagnostic criteria. An estimated 50 million people are affected by sinusitis annually in the United States, but the incidence of clinical frontal sinusitis specifically is much lower. CT scans depict sinus abnormalities in 31-45% of the asymptomatic pediatric population.¹ The incidence of intracranial complications in all patients hospitalized with sinusitis has been reported as 3.7%.² Sinusitis is implicated as a source of subdural abscess in 35-65% of cases; it has surpassed middle ear and mastoid disease as the most common source of infection in patients with brain abscesses.³ The frontal sinus is the most common sinus associated with intracranial infection.

The prevalence of frontal sinusitis in the pediatric population remains much lower than the prevalence in adults. Pediatric patients with upper respiratory tract symptoms have mucosal abnormalities on CT scans in 9-13% of cases.¹ A higher prevalence exists, particularly in adolescent and young adult males. This is thought to be a result of a peak in the vascularity of the diploic bone of the frontal sinus and development and enlargement of the sinus itself. In the pediatric population, involvement of the frontal sinus in acute sinusitis increases the odds ratio by 20-fold for the development of intracranial complications.⁴

Pathophysiology

Because of the close anatomic relationship of the ethmoid and frontal sinuses, obstruction of the ethmoid air cells often leads to frontal sinusitis. This obstruction may be caused by nasal polyps, tumor, septal deviation, trauma, mucosal swelling, or acute infection. Obstruction impedes the drainage of the frontal and ethmoid sinuses via the frontal recess and hinders the sinuses' mucociliary function. 

Mucociliary clearance in the frontal sinus travels in a counterclockwise direction in the right sinus and in a clockwise direction in the left, transporting secretions along the septal wall to the sinus roof and from there, laterally along the roof to medially along the floor to reach the ostium. Secretions that are retained because of obstruction serve as a nidus and as growth media for infections. Particular anatomic variants that can lead to obstruction of nasofrontal outflow include a massive concha bullosa, a laterally rotated uncinate process that contacts the middle turbinate, and, conversely, a medially convex middle turbinate that contacts the lateral nasal wall. Previous middle turbinate resection can also lead to stenosis of the frontal sinus ostium because of soft tissue scarring or residual bony fragments.

Clinical

Patients typically experience headache, purulent drainage or rhinorrhea, and pain over the frontal bone, at the bridge of the nose, and in the supraorbital region. Typical bacterial isolates are Haemophilus influenzae, Streptococcus species, and Moraxella catarrhalis. More recently, the incidence of Staphylococcus aureus and coagulase-negative Staphylococcus has increased in cultures obtained from frontal sinuses at surgery, especially during revision frontal sinus surgery. When a patient begins to have headache, confusion, and eyelid pain, concern for the complications of frontal sinusitis should arise. Radiologic studies, especially coronal and axial paranasal CT scan or MRI, can be diagnostic and aid in preoperative preparation. Intravenous contrast enhancement should be considered if abscess formation is suspected.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

As mentioned, surgical treatment for acute frontal sinusitis is undertaken when the infection fails to respond to conservative therapy (defined as the use of intravenous antibiotics and mucolytic agents along with topical and systemic decongestants for 3-5 days) or when dangerous complications arise. An additional indication is recurrent acute sinusitis, defined as 3-4 infections per year. (Specific indications for each procedure are discussed in Surgical therapy).

The complications of frontal sinusitis are divided into intracranial and ocular types. Intracranial complications include meningitis, brain abscess, epidural empyema, subdural empyema, and cerebral empyema. Ocular complications are preseptal or orbital cellulitis, subperiosteal abscess, and cavernous sinus thrombosis. A Pott puffy tumor is a subperiosteal abscess with soft tissue swelling that causes pitting edema over the frontal bone. Acute infection of the diploic vein resulting in thrombophlebitis causes a Pott puffy tumor. A sinocutaneous fistula can also develop from osteomyelitis of the frontal bone. A few of these complications are relative contraindications to endoscopic sinus surgery (see Contraindications).

Indications for operative intervention in acute frontal sinusitis in children are similar to those in adults, but surgery is uncommon. Clinicians reserve surgical treatment for situations involving serious complications of frontal sinusitis, such as intracranial, bony, or orbital infection, and for failure of acute infection to respond to 24-48 hours of maximal medical therapy. Surgery should be minimal and focused because sinus surgery in the pediatric population can alter facial growth. Other concerns include the proximity of vital structures, bone fragility, and these patients' smaller anatomy, which makes avoiding stenosis of the nasofrontal duct more difficult. For recurrent disease, endoscopic approaches to the frontal sinus are preferred. External approaches are typically reserved for recurrent serious acute frontal sinusitis.

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The frontal sinus develops from small grooves in the cartilage of the lateral nasal wall near the middle meatus during the third and fourth fetal month. It forms an outgrowth from the area of the nasofrontal recess. The frontal recess itself is a space within the anterior ethmoid sinuses, bordered by the agger nasi (the most anterior ethmoid cell) anteriorly and the ethmoidal bulla cells posteriorly between the middle turbinate and lamina papyracea (see Images 1-3). It may be indistinguishable from the anterior ethmoid cells.

The frontal sinus opens into the anterior part of the middle meatus, the frontal recess, or directly into the anterior end of the infundibulum. This relationship to the infundibulum and middle meatus serves to protect the frontal sinus from the spread of disease in the ostiomeatal complex. Inspection of the frontal sinus reveals its natural ostium in the posteromedial aspect of the sinus floor. The agger nasi is also intimately involved, either adjoining or abutting the floor of the frontal sinus. The posterior wall of the agger nasi forms the anterior border of the frontal recess, which then passes posteromedially to the agger nasi and supraorbital cells. This recess is present in 77% of patients. In the other 23%, drainage occurs via a frontal sinus ostium.⁵

The frontal recess relates medially to the lateral lamella of the cribriform and the cribriform plate. This is a potential area for a cerebrospinal fluid (CSF) leak during surgery. There are also 2 patterns to the frontal sinus outflow tract: those that drain medial to the uncinate process and those that drain lateral to the uncinate process. Those that drain medially are more common and are significantly related to the presence of frontal sinusitis.

The frontal sinus drainage pathway marks itself laterally with the orbit and posteriorly with the skull base and bulla ethmoidalis. The mucociliary clearance of the frontal sinus is an active process that involves the inward transport of mucus, which starts laterally and forms a whorl-like pattern.

The frontal sinus is incompletely developed at birth and is first visible radiographically in patients aged 6 years. The sinus enlarges vertically in older adolescents to reach its adult volume of 4-7 cm³. Pneumatization of the frontal sinus extends into the squamous part of the frontal bone and posteriorly into the orbital part of the frontal bone to form a supraorbital cell. The inner plate of the frontal sinus is compact bone, while the outer plate is cancellous bone.

Pneumatization in the agger nasi region is variable; the following 4 variations have been described:

• Type I refers to a single frontal recess cell above the agger nasi cell.
• Type II is a tier of cells in the frontal recess above the agger nasi cell.
• Type III involves a single large cell pneumatized into the frontal sinus.
• Type IV is a single isolated cell within the frontal sinus.

The ethmoid sinus itself can pneumatize into the orbital plate of the frontal bone posterior to the frontal sinus. This supraorbital cell usually opens more posteriorly and laterally, as compared with the frontal sinus.

The supraorbital and supratrochlear arteries, which branch off the ophthalmic artery, form the arterial supply of the frontal sinus. The superior ophthalmic vein provides venous drainage, and the supraorbital and supratrochlear branches of the trigeminal nerve supply innervation. The layers encountered between the air cell of the sinus and the frontal lobe of the brain are, in order, as follows: compact bone of the posterior table of the frontal sinus, diploic or cancellous portion of frontal bone with diploic veins, inner table of compact bone, dura mater, arachnoid mater, and pia mater. The dura mater actually provides the venous drainage for the inner table, the periorbita for the orbital plate, and the cranial periosteum for the outer table. This is in addition to the diploic veins and all venous structures that communicate in the venous plexuses of the inner table, periorbita, and cranial periosteum.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Contraindications to the various surgical treatments depend on the procedure used. The primary contraindication to trephination is the presence of an aplastic frontal sinus. The main contraindications to external approaches are a history of keloid development and previous failure of an external approach. The presence of hypoplastic frontal sinuses obviates the use of osteoplastic flap procedures with frontal sinus obliteration.

Contraindications to functional endoscopic sinus surgery (FESS) for the treatment of acute frontal sinusitis include large osteomas, lesions at the most lateral aspect of the frontal sinus, and very thick and complete intrasinus septa with disease beyond or lateral to the septa. Additional contraindications are osteomyelitis or Pott puffy tumors, malignant neoplasms, and dehiscence of the posterior table. Small frontal sinus ostia (<4 mm) and hypertrophic mucosa obstructing the sinus are relative contraindications to FESS. The possibility of too much bleeding and granulation tissue is a concern with FESS because bleeding and granulation tissue interfere with the postoperative results and healing. Any bony dehiscence or defect in the anterior lateral lamella of the cribriform plate, as well as a prior CSF leak, is also a relative contraindication to FESS.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Lab Studies

• The diagnosis of acute frontal sinusitis mainly rests on the features of the history and physical examination, as described above (see Clinical).
• A white blood cell count with examination of the neutrophil count may indicate an acute inflammatory or infectious process, but it is nonspecific.
• The role of culture is not well defined. At best, its findings are also nonspecific because most bacterial isolates are Streptococcus pneumoniae and H influenzae.

Imaging Studies

• The role of imaging in acute frontal sinusitis is to establish its extent and help depict any orbital or intracranial complications. Conventional radiography, consisting of the acquisition of Caldwell, Waters, lateral, and submentovertex views, is mainly of historical interest because of the current widespread availability of more sophisticated imaging modalities (ie, CT scanning and MRI).
• CT scanning is the imaging study of choice because it depicts optimal bony, soft tissue, and air detail in the setting of sinus disease. Coronal and axial paranasal CT images can be diagnostic and aid in preoperative preparation. Intravenous contrast enhancement should be considered if abscess formation is suspected.
• • Three-millimeter nonenhanced coronal sections are recommended for the following reasons: They best correlate with surgical approaches, they demonstrate the ostiomeatal complex and channels, and they accurately depict the relationship of the brain to the fovea ethmoidalis and ethmoid sinus and the relationship of the orbits to the sinuses.
  • CT scanning allows visualization of important anatomic variations such as the position of the ethmoid roof, which lies above the cribriform plate in more than two thirds of cases but below it in one third of cases.
  • Appropriate windows for soft tissue and air are chosen at a width of 2000 Hounsfield units (HU) with a level of -200 HU.
  • An air-fluid level is a typical finding in acute sinusitis in general, but it is not pathognomonic because blood can have the same appearance. The air-fluid level has intermediate attenuation on CT scans when it is acute.
  • Other findings may include complete opacification of the sinus or smooth or nodular mucosal thickening.
• MRI provides excellent soft tissue detail but less air and bony detail. Since acute sinusitis is a disease of the air passages, MRI is not the initial imaging study of choice. MRI is very sensitive in providing sinus mucosal definition, however. Acute inflammation and infection have high signal intensity on T2-weighted images. MRI has been used to follow the frontal sinus after obliteration.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Medical therapy

The cornerstone of the treatment of acute frontal sinusitis, or pansinusitis in general, is antibiotic therapy. The antibiotic chosen should cover the most commonly involved organisms, as listed previously. Amoxicillin may be a reasonable first choice, but some strains of H influenzae (20-30%) and M catarrhalis are resistant to amoxicillin. The emergence of antibiotic resistance has made combination medications with a penicillinase inhibitor, such as amoxicillin-clavulanic acid, first-line oral treatment. Second-generation cephalosporins, including cefprozil and cefuroxime, have appropriate spectrums of coverage. Macrolides, such as azithromycin and clarithromycin, are also effective against the 3 main pathogens. Quinolones, such as levofloxacin, are important but are not yet considered first-line treatments by all because of their relatively high cost.

A 10-day to 2-week course is typical, and switching antibiotics is recommended when the patient's condition has not improved in 3-5 days or when symptoms last longer than 2 weeks. Impending complications such as intracranial extension of frontal sinusitis require the use of parenteral antibiotics such as third generation cephalosporins and agents against anaerobic organisms. Alternative antibiotics are used according to the patient's history and in clinical settings when less common organisms, such as Pseudomonas species, are suspected.

Adjuvant therapy following resolution of the acute infection involves treating the underlying allergy with antihistamines, corticosteroids, mucolytic agents, saline nasal rinses, and mast cell stabilizers. Symptomatic treatment includes the use of topical and/or systemic decongestants. Nasal irrigation and moist heat can relieve symptoms and can be therapeutic. Underlying pathologic conditions such as immunodeficiency must be treated or controlled. Further detail can be found in Sinusitis, Acute, Medical Treatment.

Surgical therapy

Trephination

Trephination, an ancient procedure now modified, is used in the treatment of acute purulent frontal sinusitis, sinusitis refractory to conservative management, and intracranial and orbital complications of frontal sinusitis. In children, loss of the afferent pupillary reflex is an important sign of orbital complications.

Under local anesthesia, a small incision (usually 1 cm long) is made below the medial eyebrow and supraorbital rim down through the periosteum. The periosteum is then elevated. A drill or chisel helps in gaining access to the anterior table of the sinus. Purulent drainage is then evacuated, and catheters are inserted for future irrigation or drainage (see Image 4). Four-millimeter 0° and 30° scopes are used upon entering the sinus to identify the nasofrontal duct. This procedure can be performed in combination with endoscopic sinus surgery (see Endoscopic approaches to acute frontal sinusitis).

The intersinus septum is removed when the frontal sinusitis is unilateral to provide drainage through the contralateral frontal sinus recess. Irrigating solution is allowed to drain through the recess. This procedure is performed for 7-10 days (no longer than 14 d) to help restore the function of the outflow tract. Adequate imaging of the frontal sinus by means of axial and coronal CT scanning is paramount. (Formerly, Caldwell or lateral plain radiographs were used.) Trephination does not guarantee healing of the ostiomeatal complex and anterior ethmoids. The main contraindication to the trephination procedure is the presence of an aplastic frontal sinus.

External approaches to frontal sinusitis

Many techniques are used to perform an external frontoethmoidectomy. External frontoethmoidectomy can be used for the treatment of acute sinus disease with frontal extension, such as in the case of mucoceles, pyoceles, sinocutaneous fistulae, and for the treatment of various intracranial complications of frontal sinusitis. Primary contraindications to the external approaches are a history of keloid development and previous failure of an external approach.

The Lynch approach involves a curvilinear or gull-wing incision above the caudal margin of the lateral nasal bone halfway between the nasal dorsum and medial canthus. The trochlea and medial canthal ligament must be avoided. The incision is made through the periosteum, and the periosteum is then elevated off the lacrimal fossa, lamina papyracea, and floor of the frontal sinus. The anterior ethmoidal artery, seen in the frontoethmoidal suture line, can be clipped or cauterized. The frontal sinus is then opened medially with a burr or chisel, and the medial floor is removed until the area of acute infection is identified. The modified Lynch procedure preserves as much of the normal mucosa as possible, as well as the middle turbinate and frontal process of the superior maxilla. Mucosa should be preserved, especially in the frontal recess to prevent stenosis. The frontal recess may be opened with a stent and rolled silicone for several weeks to further impede stenosis.

The advantage of the Lynch approach is that it is technically simple, and, as such, it can be performed rapidly, especially in elderly patients or in those with high medical risks. This procedure causes some disfigurement, most notably when the supraorbital rim is removed. The risks of recurrence and of mucocele and mucopyocele formation are higher than in other procedures. The Lynch approach is also not the optimal procedure if the sinus is widely pneumatized because removing the mucosa (and eradicating all disease) is difficult with this technique (see Image 5).

The Killian method is used in very tall frontal sinuses. In the first step, an anterior ethmoidectomy and middle turbinectomy help remove the floor and much of the anterior wall of the frontal sinus. Only a 10-mm strut of bone at the supraorbital rim remains to support the brow and prevent deformity. This operation is technically difficult and has no notable advantages.

In the Reidel method, the entire anterior wall and floor of the sinus, including the mucosa, is removed. This procedure is reserved for disease of the entire anterior wall. A modification of the Reidel approach involves removing the posterior wall. The advantage of the Reidel method is that the sinus can be completely obliterated if its anteroposterior diameter is narrow, but obliteration can be difficult and produces significant frontal depression if the diameter is large. Cranioplasty is sometimes required later to protect the frontal lobes.

The Lothrop or Chaput-Meyer technique is used mainly for chronic bilateral frontal sinusitis, but modifications are used in the treatment of acute infection. The external technique involves resection of the intersinus septum, superior nasal septum, and medial frontal sinus floor, connecting the 2 outflow tracts and thereby creating a large frontonasal communication. Drainage via the healthy side of the sinus can be used to treat unilateral frontal sinus disease. This operation is more effective than others in eradicating persistent frontal sinus disease, although it can be used in treating acute frontal sinusitis. One of the disadvantages of this procedure is that it causes medial collapse of the orbital soft tissues, which may result in stenosis of the nasofrontal communication. Also, the procedure is technically difficult, and the cribriform plate is directly posterior to the dissection, increasing the risk of intracranial injury.

Osteoplastic flap with obliteration of the frontal sinus

The osteoplastic flap is typically reserved for chronic cases of refractory frontal sinusitis or for those accompanied by intracranial complications. Conservative medical management and/or surgical drainage procedures must be performed prior to the consideration of obliteration. The presence of hypoplastic frontal sinuses is a contraindication for the obliteration procedure.

The particular advantages of the osteoplastic flap procedure are the excellent visualization of the sinus, an ability to correct problems of the posterior table and dura, the elimination of the need to establish a frontonasal communication, and an overall low failure rate. A drawback of the osteoplastic flap procedure is difficulty in postoperative follow-up because the sinus is obliterated. Despite these complications, the osteoplastic flap procedure remains the criterion standard in chronic refractory or recurrent acute frontal sinusitis. Current modifications include the use of a pericranial flap and cancellous bone grafts (see Image 6).

Endoscopic approaches to acute frontal sinusitis

Although endoscopic procedures for acute frontal sinus disease are more technically difficult than open/external procedures, the endoscopic method provides some important advantages. Endoscopic frontal sinus procedures are used to treat sinusitis that is unresponsive to intravenous antibiotics and local vasoconstrictor therapy. Endoscopic procedures are cosmetically preferable to open procedures because they leave no external scar. In addition, lateral bony support to the sinus is preserved, so medial soft tissue collapse does not occur and ethmoid disease can be eradicated. Opening the lower anterior ethmoid and agger nasi region may relieve any frontal sinus outflow obstruction, obviating entrance into the frontal sinus. The purpose of functional endoscopic sinus surgery (FESS) is to provide a wide and patent frontonasal communication, prevent recurrent obstruction, and create conditions conducive to re-epithelialization.

Contraindications to FESS for the treatment of acute frontal sinusitis are as follows:

• Large osteomas
• Lesions at the most lateral aspect of the frontal sinus
• Thick and complete intrasinus septa with disease that extends beyond or lateral to the septa
• Osteomyelitis
• Pott puffy tumors
• Malignant neoplasms
• Posterior table dehiscence
• Bony dehiscence or defect in the anterior lateral lamella of the cribriform plate
• Prior CSF leak

Relative contraindications to the procedure include small frontal sinus ostia (<4 mm) and hypertrophic mucosa that obstructs the sinus.

More recently, endoscopic frontal sinuplasty has been described. It can be considered the least invasive of all procedures; however, it requires the surgeon to be as familiar with the anatomy as in a standard endoscopic frontal sinusotomy. It can be used in conjunction with this latter procedure or as a stand-alone procedure by dilating the drainage of the frontal sinus without damaging mucociliary clearance. The medial agger nasi cell wall is pushed laterally and the ethmoid bulla lamella is pushed posteriorly. It is best used in isolated frontal sinus disease but can be used with sinuplasty of other sinuses in chronic cases. There is minimal long-term data at this time.

Combination external and internal approaches

Trephination can be used in conjunction with endoscopic approaches to help locate the frontal sinus ostium/outflow tract and can be used to irrigate the sinus from an external approach intraoperatively. Very recently, a transblepharoplasty approach with endoscopic frontal recess dissection and ethmoidectomy has been described by Knipe et al to treat frontal sinus mucoceles and disease sequestered in the lateral frontal sinus.⁶

Intraoperative Details

Osteoplastic frontal sinus obliteration

In the osteoplastic frontal sinus procedure, the following 3 approaches are possible: 

• The coronal approach
• The midline forehead approach
• The brow incision approach

The coronal incision is useful and cosmetically acceptable if the patient is not balding, but it involves more blood loss. The midline forehead incision is incorporated into a patient's forehead wrinkles, if present. The brow incision is the least cosmetically acceptable and may cause postoperative pain, anesthesia, or paresthesias. A Caldwell-Luc image obtained preoperatively at a distance of 6 feet provides a template for the frontal sinus, which is used intraoperatively after it is sterilized. Ipsilateral tarsorrhaphy also should be performed to protect the globe.

After one of the 3 approaches is used, the frontal periosteum is cleaned of subcutaneous tissues. The template aids in outlining the frontal sinus. The periosteum is then incised 5 mm above the outline of the sinus and elevated to just below the sinus outline. A power saw is used to cut into the sinus by beveling the saw blade downward and inward. The template helps ensure that the bone cuts are in the frontal sinus and do not enter the anterior cranial fossa inadvertently. Small cuts above the glabella may be necessary to weaken the frontonasal suture. The osteoplastic flap is then fractured forward from above, exposing the contents of the frontal sinus and allowing meticulous removal of all sinus mucosa, the removal of the intersinus septum, or the removal of both.

The sinus is commonly drilled out with a polishing burr to ensure adequate bone exposure and complete removal of mucosa in preparation for the fat graft. If the posterior table of the frontal sinus is involved with osteomyelitis or is absent because of an expanding frontal sinus mucocele, it can be removed, allowing the dura to move forward to occupy the frontal sinus space (ie, cranialization of the frontal sinus).

Generally, the posterior frontal sinus is intact, and after complete removal of mucosa, it can be packed with fat or other materials before replacing the ostiomeatal flap and suturing the periosteum and the incision in layers. A variety of substances can be used, including Gelfoam, Teflon, fat, paraffin, silastic sponge, and cartilage. Autogenous fat, typically harvested from subcutaneous abdominal adipose tissue, is currently the preferred substance for obliteration because it is thought to prevent osteoneogenesis and impede regrowth of the mucoperiosteum.

Endoscopic approaches

Endoscopic surgery for acute frontal sinusitis is performed under general anesthesia. Local anesthetic is injected in a usual manner for field blocks, and vasoconstrictor-soaked pledgets (Neo-Synephrine) are packed intranasally for approximately 10 minutes. The patient is also appropriately positioned with elevation and extension of the head. Nasal endoscopy is performed by using 0°, 30°, 45°, and 70° telescopes. An area between the superior attachment of the middle turbinate and the superior end of the uncinate process or infundibulum houses the frontal outflow tract (FOT).

To create a widely patent FOT, uncinectomy, anterior ethmoidectomy, agger nasi removal, and resection of the anterosuperior attachment of the middle turbinate may all be necessary. An ostium probe or ball-tip seeker may be used to locate the outflow tract. To remove the anterior nasofrontal beak, which is the shelflike bony process anterior to the FOT, a variety of instruments can be used, including a Kerrison rongeur, a drill, and bony curettes.

Further drainage may require removal of the superior aspect of the nasal septum, especially for a bilateral frontal sinus drill-out procedure. To allow re-epithelialization, the surgeon must not remove the posterior table mucosa. Mucosal preservation is of utmost importance in routine uncomplicated frontal sinus surgery.

A stent is used in more complicated cases where mucosal preservation may be difficult and typically when the neo-ostium is less than 5 mm in diameter. The stent is placed in the tract by using a 3- to 4-mm endotracheal tube with additional holes created near the tip of the tube. Stents are inserted until the roof of the frontal sinus is reached. Then, they are pulled out 2-3 mm and sutured to the membranous nasal septum and cut to lay flush with the external limit of the nares. The patient must irrigate the stents frequently (2-3 times a day) for 5-7 weeks. Presence of a dehiscent posterior table contraindicates this irrigation. Foreign body reactions to the stent material are a concern with stent use.

FESS can also be used with trephination in the presence of thick septations, high frontal cells within the sinus, and lateralized frontal sinus disease. Extended drainage of the sinus can be achieved by means of resection of the frontal sinus floor. The modified Lothrop procedure, described by Gross et al, helps prevent nasofrontal duct stenosis due to medial collapse of orbital soft tissue by preserving the lateral bony wall, and it is entirely intranasal/endoscopic and bilateral.⁷ The frontal recess is cannulated on one side. A soft tissue shaver can then be used to remove the perpendicular plate mucosa anterior to the frontal recess and the anterior aspect of the frontal recess bordered by the anterosuperior attachment of the middle turbinate.

A wire probe is placed through the nasofrontal isthmus into the frontal sinus to assist in orientation. A bone-cutting drill is used to cut the bone of the anterior face of the frontal recess unilaterally. This area is the nasofrontal beak. The perpendicular plate is removed as far as the nasal floor of the sinus, while the surgeon stays well anterior to the wire probe. The drill then enters the floor anterior to the nasofrontal isthmus in the nasal crest, which is then removed. The contralateral frontal recess and isthmus are opened to communicate with the frontonasal opening. Bone is removed until a thin rim of bone exists around the frontonasal opening in the glabellar region.

In frontal sinuplasty, an endoscope is used to place a 70° or 90° guiding cannula into the upper middle meatus, and the guide wire is passed through it into the frontal sinus. Image guidance can be used to identify the entrance to the frontal recess, which is medial against the middle turbinate and more posterior than expected. Fluoroscopy is also used to confirm position of the guide wire, and the cannula is repositioned as needed. A balloon catheter is passed over the cannula into the frontal sinus and then inflated to dilate the frontal sinus ostium completely. The balloon serves to fracture the surrounding bone and as little as 6 atmospheres of pressure may be enough. It is important to keep pressure to the minimum necessary because of subsequent mucosal edema.

In the transblepharoplasty approach, standard endoscopic techniques are used to perform ethmoidectomy and remove agger nasi and frontal recess cells while exposing the ethmoid skull base. The upper eyelid crease on the affected side is injected; an incision is placed in the skin fold above the tarsal plate at least 8 mm above the lid margin with care to prevent webbing by not extending too far medially. The lateral limit is rarely beyond the bony orbital rim. The orbital portion of the orbicularis oculi is located and the muscle is incised. Then a plane is developed between this muscle and the levator aponeurosis toward the orbital rim while keeping the orbital septum intact.

The preseptal plane must be maintained to keep the levator intact, and then a periosteal incision is made anterior to the orbital septum at the superior orbital rim. A subperiosteal dissection is completed in all directions, with the medial limit defined by the supraorbital notch and neurovascular bundle and the lateral and posterior limits defined by the extent of frontal sinus pneumatization. The frontal sinus floor is directly accessible and the area of dehiscence (in case of mucocele) is easily identified and treated, and the flap is redraped in place once the patency of the outflow tract is determined endoscopically.

Postoperative Details

Endoscopic approaches

Postoperative care is similar to that of any endoscopic procedure. Removal of crust, clots, granulation tissue, and polyps may be necessary. The advantages of this procedure are less pain and edema, less blood loss, and better cosmesis than those achieved with the use of an osteoplastic flap. Surgeons can address disease of the anterior ethmoids at the same time. The use of a second donor site and its attendant morbidity are completely avoided. The difficulty involved in postoperative evaluation after obliteration is also avoided because patients can be followed up endoscopically and radiographically; this ability is especially helpful in evaluating frontal pain. The disadvantages of FESS include an inability to access disease in any supraorbital frontal sinus cell. Also, this procedure is technically difficult, and much effort is required in postoperative care.

Confirming the patency of the nasofrontal communication is difficult in the initial postoperative period, and close follow-up and possible debridement are important. Stent use may decrease the need for debridement.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Trephination

The trephination procedure has notable complications, including the following: osteomyelitis, nasofrontal duct stenosis with chronic sinusitis, trochlear or extraocular muscle injury, injury to the medial canthal ligament, hemorrhage, and blindness. Injury to the posterior table may cause a dural tear, meningitis, intracranial abscess, hemorrhage, or even frontal lobe trauma. Long-term complications include mucocele or pyocele.

External approaches

Complications with the external approaches occur less often than with endoscopic techniques. Injuring the periosteal attachment of the trochlea may cause diplopia, but the diplopia may spontaneously resolve if the periosteum is reapproximated well. Neuralgias can occur with injury to the supraorbital and supratrochlear nerves, which can occur if the incision extends too far superiorly and laterally. Damage to the optic nerve, artery, vein, or extraocular muscles can occur, but these occur less often with the external approach because of generous exposure. Other complications include deformity or concavity, synechiae to the septum, stenosis of the sphenoid os, recurrence, anosmia, CSF leak, and meningitis. A septal mucosal flap that is rotated posteriorly and supported by packing for 5-7 days with antibiotics helps in the management of CSF leaks. Long-term complications include mucocele or pyocele.

Osteoplastic flap

The complications of an osteoplastic flap procedure with frontal sinus obliteration include cerebral contusion, CSF leak, forehead neuralgia and/or numbness, recurrence or need for revision, and poor cosmetic appearance. Operating on a patient with a previous osteoplastic obliteration is difficult because the frontal sinuses are difficult to view after the first operation. One group of investigators reported a total complication rate of 19%, including a 2.8% incidence of CSF leak, a 9% revision rate, and a 6% frontal headache rate.

Failure or recurrence (usually marked by frontal pain) with this procedure may be due to incomplete occlusion of the frontonasal opening, incomplete removal of the sinus mucosa, or infection of the fat or obliterative substance. Persistent disease or mucosa in the frontal recess may lead to a mucocele. Intraoperative blood loss is high. Other disadvantages or complications include anesthesia or paresthesia in the distribution of the supraorbital and supratrochlear nerve. Long-term complications include mucocele or pyocele.

Endoscopic approaches

Complications of endoscopic sinus procedures are stratified into major and minor categories. Minor complications are epistaxis, orbital/periorbital ecchymoses and emphysema, dental pain, adhesions, and stenosis. Stenosis in the frontal recess occurs for 3 reasons: overly aggressive dissection with stripping of the mucosa, incomplete removal of the agger nasi and frontal cells causing adhesions and scarring, and excessive removal of the middle turbinate. Hyposmia and asthma are also included in the category of minor complications.

Some major complications are similar to the complications of untreated or aggressive frontal sinusitis. These include meningitis and brain abscess. Others are a direct result of intraoperative trauma: CSF leaks, intraorbital hemorrhage, diplopia, blindness, epiphora, intracranial injury, cerebrovascular trauma, tension pneumocephalus, significant epistaxis, and anosmia.

Ophthalmoplegia, proptosis, and changes in pupil size may be a result of intraorbital hemorrhage, which is a surgical emergency. Postoperative bedside measures to treat this complication include the removal of nasal packing, administration of intravenous steroids and mannitol, and lateral canthotomy and cantholysis of the lower lid. Any other ophthalmologic complications warrant, at least, an urgent consultation with an ophthalmologist. Mucosal grafts (with or without muscle or fascia, depending on the size of the dural defect) may be used to patch defects and repair CSF leaks; intermittent clear rhinorrhea is an indication for their use. Composite septal cartilage-mucosal grafts or conchal cartilage may be used to repair larger bony defects.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Uncomplicated acute sinusitis, as a whole, has a spontaneous resolution rate as high as 40%. Concerning trephination, one study from Finland reported that patients undergoing trephination had a 22% rate of a delayed healing process or recurrences in the first year after trephination.⁸ Another study from Finland involved a method for prediction of the clinical outcome of acute frontal sinusitis after trephination by using measurements of the nasofrontal duct. Rhinomanometry of the frontal recess was measured by means of a trephination drain. The patient breathes through a flow mask, and concurrent pressure changes inside the frontal sinus are recorded via the drain with a pressure channel that connects to the drain by a short plastic tube.

The ventilation test was proved to be highly predictable if the ventilation was considered open (pressure changes during breathing and forced breathing >50% compared with the nasal airflow) or if it was totally obstructed (no pressure changes obtainable). This finding underlines the importance of the pathology of the frontal recess/infundibulum in causing acute and recurrent frontal sinusitis.

Osteoplastic flap obliteration procedures have varying rates of complications (as high as 18%), depending on the substance used for obliteration and if a donor site is needed. In a study by Montgomery and Hardy (1976), 35% of patients undergoing osteoplastic flap obliteration had persistent postoperative sensory deficits in the supraorbital nerve distribution.⁹ However, one study had an 81% success rate for complete cure of mucoceles.¹⁰ A 30% recurrence rate has been noted for some external approaches.

Postoperative results in one study indicated a 5% surgical revision rate with FESS for frontal sinusitis, with 40% of the frontal sinuses visualized at endoscopy.¹¹ The use of endoscopic surgery for frontal sinusitis in one study had a 25% improvement in the number of medications used and in overall improved general health.¹² Increased risk of recurrence of acute frontal sinusitis occurs in patients with chronic rhinitis, polyps, and previous sinus surgery. A history of atopic disease appears to have an impact on overall duration of infection.¹³ Other studies comparing the risk of recurrence between trephination and FESS over 6 months demonstrated a 60% versus a 91% chance of recurrence.¹⁴

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Many aspects of the surgical treatment of acute frontal sinusitis have yet to be studied thoroughly. One aspect is the long-term outcomes of the various surgical treatments. Analysis of short-term outcomes for endoscopic frontal sinus drill-out procedures in one study revealed a higher than 80% success rate, along with a 12.5% failure rate. However, these results were tabulated for patients with a history of chronic sinusitis. Long-term outcome data for acute frontal sinus disease managed with endoscopic sinus surgery are minimal.

A recent review of patients undergoing frontal sinus obliteration with adipose tissue had a 12-year follow-up period. In the study, a 10.2% incidence of persistent changes in frontal contouring and a 9.8% incidence of mucocele were documented with MRI results. MRI results also showed a significant decrease in the amount of adipose tissue with time, as revealed by a median half-life of 15.4 months. This study demonstrated the value of MRI in the follow-up of patients after obliteration in that MRI results can be used to differentiate the distribution of fatty and fibrous tissue.

A review of the outcome data on frontal sinus obliteration leads to another controversy, namely, which obliterative substance to use. Otolaryngologists, plastic surgeons, and neurosurgeons have debated this subject. Otolaryngologists promote adipose tissue as the ideal autogenous obliterative substance because the fat revascularizes and, thus, is theoretically more resistant to postoperative infection than other substances. The drawbacks, as described previously, include donor site morbidity.

A 1995 article published in Plastic and Reconstructive Surgery highlighted the advantages of using cancellous bone implants for obliteration.¹⁵ These included good vascularization and complete obliteration of the nasofrontal duct in a cat model, as opposed to less complete obliteration by fat. Adequate obliteration can also be achieved with osteoneogenesis, allowing the sinus to obliterate itself after the inner bony cortex and mucosa is removed and a transfrontal ethmoidectomy is performed. This technique obviously avoids donor site morbidity.

Another subject of debate in the surgical treatment of acute and chronic frontal sinus disease involves the role and duration of frontal recess stent placement. Many authors advocate the use of stents any time the frontal sinus ostium is surgically enlarged. Varieties of stents and sheeting have been studied for this purpose. These include silicone drainage catheters, rolled silicone sheeting, Foley catheters, and Dacron prostheses. Most recently, Freeman and Blom (2000) reported the successful use of a double-ended flanged silicone stent.¹⁶ The shape of the stent allowed controlled retention, making it easier for the surgeon to determine the duration of the stent placement. Typically, preventative stents are left in place for 1-8 weeks, and stents placed after correction of frontal outflow tract stenosis are left in place for 6-12 months. Experienced endoscopists have presented arguments for each of these time frames. Again, no long-term data are available on stent placement in the setting of surgically treated acute frontal sinusitis.

An additional subject of debate is the use of mitomycin C (MMC), an antifibrotic agent used to help prevent scarring in the frontal recess or in the frontal sinus outflow tract. One study looked at one-time intraoperative topical application of MMC at 0.5mg/mL for 4 minutes; however, no difference was found in the degree of stenosis at 1, 3, and 6 months when compared with a control group.¹⁷ A different study demonstrated an 86% patency rate with follow-up of up to 32 months, but the investigators used multiple applications of the drug.¹⁸ Clearly, no standard protocol for application has been developed, so the efficacy of MMC is still in question.

A final area of controversy is the use of empiric antibiotics in an age of antibiotic resistance. The underlying principle in medical treatment of acute frontal sinusitis should be the judicious use of antibiotics. Penicillins, especially penicillinase-resistant penicillins and those with beta-lactam inhibitors (amoxicillin-clavulanate) continue to be first-line therapy in uncomplicated cases of acute sinusitis, even though 20% of H influenzae strains are positive for beta-lactamase. Macrolides (eg, clarithromycin) have adequate coverage against Haemophilus species and should be used in the case of penicillin allergy. Quinolones have much broader spectrums and have excellent activity against more common pathogens in sinusitis, but again, they are more expensive, and liberal use of the quinolones leads to more antibiotic resistance. Thus, they should not be used as first-line therapy in uncomplicated infection.

Surgery for acute frontal sinusitis has a history longer than 100 years. Despite its long history, much remains to be elucidated about long-term outcomes for surgical techniques and postoperative care and follow-up.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  (A) Frontal sinus, (B) middle turbinate, (C) ethmoid bulla, (D) hiatus semilunaris, (E) uncinate process, and (F) superior turbinate.
	View Full Size Image
Media type:  Image

Media file 2:  Axial section through right nasal cavity depicts the following: (A) middle turbinate (or concha); (B) ethmoid bulla; (C) drainage sites for frontal sinus (3 shaded areas); (D) uncinate process; (E) nasolacrimal duct; (F) hiatus semilunaris; (G) basal lamella; (H) septal cartilage.
	View Full Size Image
Media type:  Image

Media file 3:  (A) Frontal sinus, (B) sphenoid sinus, (C) cut surface of the middle turbinate, (D) ethmoid bulla, and (E) hiatus semilunaris.
	View Full Size Image
Media type:  Image

Media file 4:  (A) Curved incision under eyebrow to periosteum, (B) underlying bone exposed by periosteal elevator, with burr holes created with small drill, (C) two small plastic tubes inserted for daily irrigation of the frontal sinus.
	View Full Size Image
Media type:  Image

Media file 5:  (A) Incision under brow extending about 1 cm below the medial palpebral (canthal) ligament, (B) medial orbital wall entered with removal of posterior edge of nasal process of maxilla and lacrimal and anterior portions of lamina papyracea, (C) removal of posterior ethmoid cells, (D) superiorly based mucoperiosteal flaps lining of new frontal nasal communication, intranasal tube into frontal sinus.
	View Full Size Image
Media type:  Image

Media file 6:  (A) Incision (above or below eyebrows), (B) superiorly based skin flap, with use of template of frontal sinus and a cut through periosteum along the superior, medial, and lateral edges, (C) saw blade of sagittal plane saw used to make a beveled cut through bone with inferior hinge of intact periosteum, with a line of fracture of bone-periosteum flap, (D) osteotome used along cut edges to elevate bone-periosteum flap, (E) flap reflected downward to expose sinus (in this case, osteoma is seen in the sinus; otherwise, in frontal sinus disease, all mucosa of sinus must be removed).
	View Full Size Image
Media type:  Image

Media file 7:  (A) After obliteration, the flap is returned, and the periosteum reapproximated with absorbable suture, (B) outline of extension of brow incision in bilateral frontal sinus disease, (C) coronal incision in female patient to obviate brow incision.
	View Full Size Image
Media type:  Image

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

1. Talbot AR. Frontal sinus surgery in children. Otolaryngol Clin North Am. Feb 1996;29(1):143-58. [Medline].
2. Altman KW, Austin MB, Tom LW, Knox GW. Complications of frontal sinusitis in adolescents: case presentations and treatment options. Int J Pediatr Otorhinolaryngol. Jul 18 1997;41(1):9-20. [Medline].
3. Hakim HE, Malik AC, Aronyk K, Ledi E, Bhargava R. The prevalence of intracranial complications in pediatric frontal sinusitis. Int J Pediatr Otorhinolaryngol. Aug 2006;70(8):1383-7. [Medline].
4. Lang EE, Curran AJ, Patil N, Walsh RM, Rawluk D, Walsh MA. Intracranial complications of acute frontal sinusitis. Clin Otolaryngol Allied Sci. Dec 2001;26(6):452-7. [Medline].
5. Metson R. Endoscopic treatment of frontal sinusitis. Laryngoscope. Jun 1992;102(6):712-6. [Medline].
6. Knipe TA, Gandhi PD, Fleming JC, Chandra RK. Transblepharoplasty approach to sequestered disease of the lateral frontal sinus with ophthalmologic manifestations. Am J Rhinol. Jan-Feb 2007;21:100-104.
7. Gross WE, Gross CW, Becker D, et al. Modified transnasal endoscopic Lothrop procedure as an alternative to frontal sinus obliteration. Otolaryngol Head Neck Surg. Oct 1995;113(4):427-34. [Medline].
8. Sipilä J, Suonpää J, Wide K, Silvoniemi P. Prediction of the clinical outcome of acute frontal sinusitis with ventilation measurement of the nasofrontal duct after trephination: a long-term follow-up study. Laryngoscope. Mar 1996;106(3 Pt 1):292-5. [Medline].
9. Hardy JM, Montgomery WW. Osteoplastic frontal sinusotomy: an analysis of 250 operations. Ann Otol Rhinol Laryngol. Jul-Aug 1976;85(4 Pt 1):523-32. [Medline].
10. Rubin JS, Lund VJ, Salmon B. Frontoethmoidectomy in the treatment of mucoceles. A neglected operation. Arch Otolaryngol Head Neck Surg. Apr 1986;112(4):434-6. [Medline].
11. Wigand ME, Hosemann W. Endoscopic surgery for frontal sinusitis and its complications. Am J Rhinol. 1991;5:85-9.
12. Seiden AM, Stankiewicz JA. Frontal sinus surgery: the state of the art. Am J Otolaryngol. May-Jun 1998;19(3):183-93. [Medline].
13. Wide K, Suonpaa J, Laippala P. Recurrent and prolonged frontal sinusitis. Clin Otolaryngol. 2004;29:59-65.
14. Wide K, Antila J, Siplia J et al. Healing results of prolonged acute frontal sinusitis treated with endoscopic sinus surgery. Rhinology. 2002;40 (4):189-194. [Medline].
15. Rohrich RJ, Mickel TJ. Frontal sinus obliteration: in search of the ideal autogenous material. Plast Reconstr Surg. Mar 1995;95(3):580-5. [Medline].
16. Freeman SB, Blom ED. Frontal sinus stents. Laryngoscope. Jul 2000;110(7):1179-82. [Medline].
17. Chan KO, Gervais M, Tsaparas Y, Genoway KA, Manarey C, Javer AR. Effectiveness of intraoperative mitomycin C in maintaining the patency of a frontal sinusotomy: a preliminary report of a double-blind randomized placebo-controlled trial. Am J Rhinol. May-Jun, 2006;20(3):295-9. [Medline].
18. Amonoo-Kuofi K, Lund VJ, Andrews P, Howard DJ. The role of mitomycin C in surgery of the frontonasal recess: a prospective open pilot study. Am J Rhinol. Nov-Dec, 2006;20 (6):591-4. [Medline].
19. Amble FR, Kern EB, Neel B 3rd, et al. Nasofrontal duct reconstruction with silicone rubber sheeting for inflammatory frontal sinus disease: analysis of 164 cases. Laryngoscope. Jul 1996;106(7):809-15. [Medline].
20. Bailey BJ, Calhoun KH, Deskin RW, eds. Head & Neck Surgery-Otolaryngology. 2nd ed. Philadelphia, Pa: Lippincott-Raven;1998.
21. Becker DG, Moore D, Lindsey WH, et al. Modified transnasal endoscopic Lothrop procedure: further considerations. Laryngoscope. Nov 1995;105(11):1161-6. [Medline].
22. Betz C, Issing W, Matschke J, Kremer A, Uhl E, Leunig A. Complications of acute frontal sinusitis: a retrospective study. Eur Arch Otorhinolaryngol. Aug 2007;[Medline].
23. Brook I. Acute and chronic frontal sinusitis. Curr Opin Pulm Med. 2003;9:171-174. [Medline].
24. Cummings CW, Fredrickson JM, Harker LA, eds. Otolaryngology-Head & Neck Surgery. Vol 2. 3rd ed. St Louis, Mo: Mosby;1998.
25. Fairbanks DN. Inflammatory diseases of the sinuses: bacteriology and antibiotics. Otolaryngol Clin North Am. Aug 1993;26(4):549-59. [Medline].
26. Giannoni CM, Stewart MG, Alford EL. Intracranial complications of sinusitis. Laryngoscope. Jul 1997;107(7):863-7. [Medline].
27. Har-El G, Lucente FE. Endoscopic intranasal frontal sinusotomy. Laryngoscope. Apr 1995;105 (4 Pt 1):440-3. [Medline].
28. Kuhn FA. An integrated approach to frontal sinus surgery. Otolaryngol Clin N Am. 2006;39:437-461.
29. Lang EE, Curran AJ, Patil N et al. Intracranial complications of acute frontal sinusitis. Clin Otolaryngol. 2001;26:452-457.
30. Lore JM. An Atlas of Head and Neck Surgery. 3rd ed. Philadelphia, Pa: Saunders;1988.
31. Maccabee M, Hwang PH. Medical therapy of acute and chronic frontal rhinosinusitis. Otolaryngologic Clinics of North America. 2001;34:41-47. [Medline].
32. Metson R, Gliklich RE. Clinical outcome of endoscopic surgery for frontal sinusitis. Arch Otolaryngol Head Neck Surg. Oct 1998;124(10):1090-6. [Medline].
33. Nguyen QA, Leopold DA. Current concepts in the surgical management of chronic frontal sinusitis. Otolaryngol Clin North Am. Jun 1997;30(3):355-70. [Medline].
34. Ramadan HH. History of frontal sinusitis. Arch Otolaryngol Head Neck Surg. Jan 2000;126:98-99.
35. Schaefer SD, Close LG. Endoscopic management of frontal sinus disease. Laryngoscope. Feb 1990;100(2 Pt 1):155-60. [Medline].
36. Suonpaa J, Sipila J, Aitasalo K, et al. Operative treatment of frontal sinusitis. Acta Otolaryngol Suppl. 1997;529:181-3. [Medline].
37. Turgut S, Ercan I, Sayin I, Basak M. The relationship between frontal sinusitis and localization of the frontal sinus outflow tract. Arch Otolaryngol Head Neck Surg. June 2005;131:518-522.
38. Weber R, Draf W, Keerl R, et al. Osteoplastic frontal sinus surgery with fat obliteration: technique and long-term results using magnetic resonance imaging in 82 operations. Laryngoscope. Jun 2000;110(6):1037-44. [Medline].
39. Weber R, Draf W, Keerl R, et al. Magnetic resonance imaging following fat obliteration of the frontal sinus. Neuroradiology. 2002;44:52-58. [Medline].
40. Wide K, Sipila J, Suonpaa J. The value of computerised rhinomanometry and a simple manometry with saline in predicting the outcome of patients with acute trephined frontal sinusitis. Rhinology. Sep 1996;34(3):151-5. [Medline].
41. Zinreich J. Imaging of inflammatory sinus disease. Otolaryngol Clin North Am. Aug 1993;26(4):535-47. [Medline].

Article Last Updated: Feb 6, 2008