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Surgery of the frontal sinus is an effective form of treatment of tumors and chronic sinusitis.

An expert to anatomical knowledge of the area is a prerequisite

operations in the area. Surgery to the frontal recess should be approached with caution as stenosis can cause long term sequela. The Otolaryngologist should be well versed in different approaches to the frontal sinus and should be willing to use combinations to achieve the best results for their patients (Francis et al,2008). The general rule is to choose the least invasive procedure with which the surgeon is comfortable and which will accomplish the task Additional procedures then may be employed as the situation . most cases can be managed endoscopically .If the case is started endoscopically and the disease cannot be reached or the anatomical problem solved however additional more aggressive procedures can be added in a stepwise fashion. Aims of ideal treatment modality of frontal sinus disease are! ". #radication of underlying disease process $. %reservation of function of the sinus &. To cause least morbidity and cosmetic deformity The ability of image'guidance systems to provide the surgeon with enhanced anatomic locali(ation during frontal sinus surgery offers the potential for improved clinical outcome .

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#ndonasal

frontal

sinusotomy

indicated

in

Severe

mucositis polyps with )ypoplastic Spina nasalis interna A'% diameter *arge and +road Anterior ethmoid (Wormald,2002) . There are several principles important to frontal recess surgery. The number and the location of frontal recess cells should be determined in order to know the number of barriers needed to be removed to reach the frontal sinus ostium. ,issection should be performed from posterior to anterior and from medial to lateral to avoid damaging the thinnest areas of bone surrounding the frontal recess. The posterior frontal recess table is commonly very thin and sub-ect to penetration with subsequent cerebrospinal fluid ./S01 leak. The same pertains to the medial posterior frontal recess bounded by the lateral cribriform plate lamella. 2hen drilling care is taken not to violate the

mucosa on the lateral and posterior wall of the frontal recess in order to prevent complications and postoperative stenosis %reserve all frontal recess mucus membrane because sinus mucus membrane does not regenerate over bare bone with normal cilia.

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+alloon Sinuplasty effective way of opening up blocked sinus ostia to restore normal physiological sinus drainage 3 ventilation. #xpanded indications to include the whole spectrum of sinus disease (Dubin et al,2007). patients selection for the endoscopic modified *othrop

procedure ( Kountakis,2005). Ideally an anteroposterior dimension at the cephalad

margin of the frontal recess between the nasal bones at the root of the nose and the anterior skull base should be at least ".4 cm. Ideally the nasofrontal beak should be less than " cm. If A the above dimensions are not ideal then the

accessible dimension should be at least 4mm. large septectomy is required to provide better instrument access and adequate drainage of frontal sinuses and to prevent postoperative crusting. the #5*% is quickly becoming the procedure of choice for the treatment of complex frontal sinus disease (Karanfilov and Ku n,2005). If a frontal recess boundary is not fixed then it may collapse into the frontal recess and cause secondary frontal recess6ostium stenosis 0S7 offers several distinct advantages 2hen treating patients who have failed conservative surgical therapy or are at high risk for surgical failure due to unfavorable anatomy or mucosal disease postoperative stenting of the frontal sinus may be a useful ad-unctive measure. Stents may be placed within the frontal sinus
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A variety of stent types are available but it is critically important that soft materials be used to minimi(e local ischemia and mucosal disruption. 7olled silicone sheeting is preferred choice for stenting recent evidence suggests that longer periods of postoperative stent maintenance such as 8 months may yield improved longterm outcomes (!rlandi and Kni" t,200#). There is still a role for open approaches to the paranasal sinuses for patients with Inadequate intranasal attempts at opening the nasofrontal drainage system may well domore harm than good and defining an adequate opening may be difficult and dependent on native anatomy. A congenitally narrow and shallow nasofrontal drainage system will be much more difficultto manipulate and alter in such a way as to maintain long'term postoperative patency than a wide system absent or distorted intranasal landmarks erosion ($elro% et al,200&). 2idespread experience with endoscopic sinus surgery techniques and instrumentation has allowed operating on the skull base through the nose with minimally invasive techniques. Skull base procedures such as skull base defects of the sinonasal cavity have been repaired with relatively high success rates using these accepted endoscopic techniques .It has truly become the standard of care in routine /S0 leaks of the anterior cranial skull base ('anation et al,200#). failed endoscopic approaches evidence of lateral disease or posterior table

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(ummar%
The surgical management of frontal sinus diseases has been a continuing source of controversy since the late "9
th

century

when the anatomy of the sinuses was first elucidated and initial intranasal and external surgical approaches were first described. The recent advances in imaging and endoscopic techniques have resulted in the resurgence of intranasal procedures for the treatment of frontal sinus disease. 0rontal sinus disease particularly chronic frontal sinusitis is a highly morbid and

sometimes life'threatening condition because of its potential complications. ,espite the fact that over the years the incidence of complications complications has decreased orbital and intracranial intra' including meningitis subdural abscess

cerebral abscess and osteomyelitis continue to occur.

The integrated approach to #ndoscopic 0 S surgery include! )) *ndosco+ic frontal sinu+last%, 2hat this system accomplishes specifically is the dilatation of the sinus ostia by advancing balloon catheters under fluoroscopic guidance to the narrowed segment and inflating them with high pressure. 2) *ndosco+ic frontal sinusotom%, 0unctional endoscopic intranasal frontal sinusotomy combined with proper frontal recess. /T evaluation can eliminate frontal sinus obstruction and re'establish normal frontal sinus drainage.

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-) $odified intranasal endosco+ic .ot ro+, *othrop:s concept was to create a large common frontal sinus opening into the nose. )e approached the frontal sinus from one side removing the interfrontal sinus septum the medial frontal sinus floor and the upper nasal septum. /) *ndosco+ic trans0se+tal frontal sinusotom%. The septum is translocated translocation of the septum especially in cases of a. narrow nasal vault allows improved visuali(ation and instrumentation and minimi(es the si(e of the planned then removing the interfrontal sinus septum the medial frontal sinus floor and the upper nasal septum septal perforation.
5) Frontal sinus rescue +rocedure,

0S7 was designed for those patients whose middle turbinate had been amputated previously and whose middle turbinate remnant had laterali(ed. &) 1bove and belo2 a++roac (tre+ ine and endosco+ic), This technique is used for frontal sinus lesions or cells that cannot be reached from below. The frontal recess should first opened endoscopically from below then a trephine through the anterior frontal sinus table to provide access to the obstructing cells from above. 7) Frontal sinus obliteration 0rontal sinus obliteration remains one of the few indications for an open approach such as fractures with disruption of the frontal out flow tract significant anterior table bone loss and mucopyocele. Frontal (inus (tentin"

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5inimi(ing postoperative stenosis and improve mucosali(ation of the frontal sinus outflow tract following frontal sinus surgery. *3tended 1++lications of *ndosco+ic Frontal (inus (ur"er% 0*ndosco+ic endonasal skull base sur"er% Indicated in complete resection of the (one of insertion and exophytic growth into paranasal sinuses of benign 3 malignant tumours. 0*ndosco+ic $ana"ement of Frontal (inus An inlay or onlay free tissue graft may be used to patch the site of /S0 *eaks . 0*ndosco+ic $ana"ement of 4eni"n Frontal (inus 5umors 0ibro'osseous lesions may be managed expectantly. Inverted papillomas with their high rate of associated malignancy should be completely removed. 0*ndosco+ic mana"ement of frontal (inus Fracture The treatment algorithm for patients with fractures of the frontal sinus remains controversial. 6evision *ndosco+ic Frontal (inus (ur"er% Successful revision endoscopic frontal sinus surgery starts with proper patient selection and medical management of co'morbidities and environmental influences. /ommon anatomical causes for revision include a retained superior uncinate process superior cap of the ethmoid bulla agger nasi cells laterali(ed middle turbinate remnants frontal recess and supraorbital ethmoid cells.

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Francis T.K. Ling, Ioannis G. Skoulas, Stilianos E. Kountakis.(2008) . Rhinologic and

Sl

! "!n a Surgical T chni#u s

Heidelberg, Germany$ Marion Philipp/ Springer

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