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S. Hayes and S. Carrie
Fig. 35.4 (a–d) Endoscopic images demonstrating a left-
sided anterior ethmoid artery (AEA) ligation. (a) A leftsided Lynch-Howarth incision is performed followed by a
(b) subperiosteal dissection along the medial orbital wall.
Open-Approach Ethmoidectomy
(c) The periorbita (PO) lateralised exposing the AEA
24mm from the anterior lacrimal crest along the frontoethmoidal suture. (d) The AEA is ligated with clips.
Photographs courtesy of Mr Gerald McGarry
of the maxilla, lacrimal bone and lamina papyra-
cea are all exposed with a periosteal elevator
Although rarely performed in recent times, it is
important for the endoscopic surgeon to appreciate this technique when faced with an older
patient, who may have undergone this procedure
in the past.
In the very rare situation where an openapproach ethmoidectomy is required, the
approach of choice would be via a transcutaneous
incision, as described earlier. The frontal process
[10]. Bipolar haemostasis of the inferior distal
branches of the angular vessels may be required
at this point [10]. Using a malleable retractor, the
orbital contents are gently lateralised and the
anterior ethmoidal artery is ligated [10]. Entry
into the ethmoidal sinuses is made through the
anterior two thirds of the lamina papyracea [13].
The ethmoidal mucosa is resected. Medially, the
middle turbinate can be excised for greater access
35 Open Approaches totheParanasal Sinuses
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457
[13]. Dissection can proceed posteriorly into
sphenoid sinus [13, 16]. Once the ethmoidectomy is complete, the incision is closed in layers
with careful reattachment of the medial canthus
to the underlying periosteum [13, 16].
Tip
• The frontoethmoidal suture and anterior eth-
moidal artery are accurate landmarks for the
fovea ethmoidalis and anterior cranial fossa
(at the junction of the frontal bone and lamina
papyracea), and as such dissection should not
proceed superiorly to these landmarks [17].
Frontal Sinus
Endoscopic approaches are the procedure of
choice in the management of most frontal sinus
pathologies. However, there are specic anatomical and pathological instances when an external
approach may be required [18]. In addition to the
anatomical complexity, excessive instrumentation of the frontal recess can lead to restenosis,
resulting in surgical failure despite repeated
endoscopic surgeries. The two commonest open
approaches used today include frontal trephination and the frontal osteoplastic ap.
Risk andComplications
Frontal trephination is a safe and effective adjunct
in the management of complex frontal sinus surgery with a reported complication rate of <10%
[20, 21]. However, due to the close vicinity of
critically important anatomical structures, complications can be severe when they happen.
Within the literature, reported complications
include infection at trephine site; external scar;
numbness of the forehead, upper eyelid and nasal
bridge (supraorbital and supratrochlear nerves);
bleeding and haematoma (supraorbital and supratrochlear arteries and veins); cerebrospinal uid
leak (transgression of the anterior skull base);
and damage to the orbital contents [10, 20].
Pre-procedural CT Scan Assessment
To minimise the risk of complications, preoperative evaluation of the CT scan is essential to
assess frontal sinus depth, the position of the
sinus septum and the relationship of the frontal
sinus to the orbit and skull base.
Conventional Frontal Trephination
Technique
Frontal Trephination
Frontal trephination is the most common and
least invasive open approach to the frontal sinus.
First described by Runge in 1750 for draining pus
in acute frontal sinusitis, it remains a useful procedure predominantly for this pathology [19].
Using a trephine to drain, decompress and obtain
a microbiological sample in a symptomatic or
intracranially complicated acute frontal sinusitis
may be preferrable to endoscopically accessing a
severely inamed anatomically complex and friable frontal recess. A conventional frontal trephine is usually performed in this setting due to
the exibility of burr size, allowing for removal
of thick pus and/or placement of a drain or
catheter.
Although most commonly performed under a
general anaesthetic, a frontal trephine can be performed under a local anaesthetic, if required. The
transcutaneous approach is usually performed
with a medial brow incision. A 0.5–1cm incision
is made between the midline and the supraorbital
foramen, being careful to avoid both the supratrochlear and supraorbital neurovascular bundles
[10]. Dissection is made down to the frontal bone
and the periosteum is elevated to expose the thin
inferior wall of the frontal sinus [10]. A trephine
is made using a 3mm cutting burr (Fig.35.5a).
Correct placement of the trephine can be conrmed by suctioning with a 20mL syringe (partially lled with saline) or, if possible, by direct
inspection through the trephine with an endoscope [22]. Pus is sent for microbiological analysis and the sinus is irrigated with normal saline.
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S. Hayes and S. Carrie
a
Fig. 35.5 (a, b) Clinical photograph showing a (a) right-sided conventional frontal sinus trephine. (b) Closure of the
Lynch-Howarth incision with drain in situ. Photographs courtesy of Mr Gerald McGarry
Either a drain or a catheter (for ushing) is placed
into the sinus and secured to the skin. Excessive
incision margins are closed around the drain/
catheter (Fig.35.5a).
b
aspect of the eyebrow [19]. Care must be taken to
avoid the supraorbital bundle located along the
supraorbital rim approximately 22–24 mm from
the facial midline and 26–28mm from the temporal crest of the frontal bone [23]. An anteriorposterior depth of at least 7 mm is essential to
Frontal Trephination Technique Using
aMini-trephination Set
avoid transgression into the anterior cranial fossa
[19]. Inltration is performed with 2% Lidocaine
in 1:80,000 adrenaline and a full-thickness stab
The Medtronic mini-trephination set (Medtronic
ENT, Jacksonville, FL) has become popular in
recent years as it contains all instruments
(Fig.35.6a) required to perform a quick and safe
frontal trephination with a good postoperative
cosmetic result. The mini-trephine is usually performed electively in combination with endoscopic sinus surgery to help conrm the correct
opening of the frontal recess in patients with
severe oedema or with a narrowed recess complicated by additional frontoethmoidal cells (particularly Type 3 or Type 4 cells) [20]. The
mini-trephine also facilitates ushing of fungal
debris, mucus and eosinophilic mucin from the
lateral limits of the frontal sinus [20].
The optimum external entry point is reported
as 10 mm from the midline within the medial
incision is made down to the bone (scalpel with
size 15 blade). Iris scissors can be used to divide
tissue layers to help facilitate placement of the
drill guide directly onto the bone. The drill is
placed within the drill guide (Fig.35.6b, c), and
using irrigation, the anterior table is carefully
drilled using short pulses until the frontal sinus is
breached [20]. Replacing the drill with the guide-
wire, the frontal cannula is fed over the wire into
the trephine and secured with careful rotations
until ush with the skin (Fig.35.6d, e). Using a
5–10mL syringe, partially lled with saline, cor-
rect placement of the trephine is conrmed with
aspiration of either air bubbles, pus or blood
(Fig.35.6f). Aspiration of clear uid may indicate
CSF and possible transgression of the posterior
table [20]. To help conrm the true frontal drain-
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Fig. 35.6 (a) The Medtronic mini-trephination set
(Medtronic ENT, Jacksonville, FL). Contents (left to
right) guidewire, drill guide, drill bit component 1, cannula, drill bit component 2. (b) Drill guide. (c) The two
drill bit components are assembled, attached to the
debrider handpiece and fed over the drill guide. (d) After
the trephine is performed, the drill guide is held in place,
whilst the drill bit is replaced with the guidewire. (e) The
cannula is then fed over the guidewire and secured into
place within the trephine. (f) A saline-lled syringe is
attached to the cannula and aspirated to conrm correct
placement
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S. Hayes and S. Carrie
age pathway, uorescein dye (0.5mL of 5% uorescein in 500 mL of saline) can be instilled
through the frontal cannula whilst observing the
recess endoscopically from below [20]. At the end
of the procedure, the cannula is gently removed
from the trephine site and pressure is placed on
the incision for 5min. These small incisions are
not routinely sutured but covered with a simple
plaster or steri-strip and generally heal very well.
Tips
• Initial ushing of the frontal sinus must be
performed slowly with direct observation of
the ipsilateral eye and immediately halted in
the presence of any orbital swelling or proptosis [20].
• In the presence of a posterior table or supe-
rior orbital rim/lamina papyracea dehiscence,
no pressure should be applied when instilling
saline or uorescein dye through the frontal
trephine [20].
• To reduce postoperative restenosis of the fron-
tal recess, corticosteroid cream can be
instilled through the frontal cannula before
removal at the end of the procedure [20].
• If clinically required, the frontal cannula can
remain in situ postoperatively for up to 5days
to facilitate regular frontal sinus saline ushes
or instillation with corticosteroid or decongestant drops [20].
External Frontoethmoidal Surgery
Initially, radical surgery was thought to be the
answer for chronic frontal sinus disease, and it
was Kuhnt (1895) and Riedel (1898) who rst
described fully excising both the anterior wall
and sinus oor [24]. However, this left patients
with unsightly facial disgurement, and despite
modications by Killian (1903) to improve cosmesis, these procedures were largely abandoned
for more conservative techniques [24]. The frontal osteoplastic ap was rst described by
Schonborn in 1894, but due to the lack of radiology and concern over re-approximation of bone
aps, it was not commonly performed until the
1950s when Macbeth (1954) re-described the
technique with modern concepts [25], and
Goodale and Montgomery (1957) demonstrated
high success rates with low levels of restenosis
[26]. The procedure provided the option of oblit-
erating the frontal sinus with fat and became very
popular until the introduction of endoscopic sinus
surgery. Allowing comprehensive access to all
areas of the frontal sinus, the osteoplastic ap
remains one of the few external frontal proce-
dures still in use today.
Frontal Osteoplastic Flap Withor
Without Frontal Sinus Obliteration
The frontal osteoplastic ap is generally consid-
ered an endpoint procedure in frontal sinus sur-
gery performed in cases where endoscopic sinus
surgery either has failed or is not appropriate.
The possible indications are listed in Table 35.1
[2]. Removing the anterior table allows access to
all areas of the frontal sinus and provides the
option of obliteration if required [18, 22, 27].
Table 35.1 Possible anatomical and pathological indica-
tions for an osteoplastic ap approach to the frontal
sinuses
Anatomical Pathological
Narrow anteriorposterior diameter
associated with a
small frontal sinus
Narrow or scarred
frontal recess
Recurrent frontal bone
osteomyelitis
Neo-osteogenesis causing
stenosis of frontal sinus
outow tract
Lateral frontal sinus disease
(e.g. large osteoma, inverted
papilloma, mucocoele,
mycetoma)
Chronic frontal sinusitis
refractory to endoscopic
management
Anterior table bro-osseous
lesions (e.g. ossifying
broma)
Posterior table defect with
cerebrospinal uid leak
Complex frontal sinus
fracture
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Procedure
the pre-auricular fold, taking care to avoid dam-
aging the supercial temporal artery and frontal
In the past, a frontal sinus template was made
either from a Caldwell radiograph or from using
transillumination. More recently, CT-image
guidance has been demonstrated to be more
accurate, faster and safer than the original techniques [28]. Bilateral tarsorrhaphy sutures are
performed to protect the eyes [26]. After inltration with 2% Lidocaine in 1:80,000 adrenaline, a bicoronal incision is performed starting
in the midline, following the hairline down to
branch of the facial nerve [26]. The bicoronal
ap is raised anteriorly in the subgaleal plane.
An incision is made 2cm posterior to the supra-
orbital and supratrochlear neurovascular bun-
dles, and the dissection continues anteriorly in a
subperiosteal plane, raising a pericranial ap
whilst exposing the entire frontal sinus
(Fig.35.7a, b) [22]. The frontal sinus is marked
out using either the template or CT-image guid-
ance (Fig.35.7c), and the anterior wall is excised
Fig. 35.7 (a–d) A frontal osteoplastic ap. (a) Following
elevation of the subgaleal ap, a pericranial ap is outlined beyond the peripheral margins of the frontal sinuses.
(b) Pericranial ap raised inferiorly. (c) Frontal sinus mar-
gins are mapped out using image guidance. (d) Using a
high-speed ssure burr, the anterior table of the frontal
sinus is removed
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S. Hayes and S. Carrie
using a high-speed ssure burr. The ssure burr
is preferred over a drill as this reduced the gap
left between the ap and bone (Fig.35.7d) [10,
22, 26]. However, a small oscillating saw is also
useful for minimising bone loss and bevelling
the bone for later ap replacement. The intersi-
nus septum is fractured with an osteotome to
release the bone ap (Fig. 35.8a, b), which is
removed and placed in sterile saline [22]. The
frontal sinus pathology is managed as planned.
If obliteration is planned, all mucosa is removed
from the sinus and bone ap and burred with a
Fig. 35.8 (a) Elevation of anterior table exposing the
limits of the frontal sinus (b). (c) Following the planned
frontal sinus procedure, the anterior frontal wall is xed in
place with titanium plates. (d) The bicoronal incision is
closed in layers
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diamond drill. The frontal recess is plugged
with the bone, temporalis muscle or fascia and
the sinus obliterated with abdominal fat [22,
26]. However, the modern approach is to com-
bine the osteoplastic ap with a Draf type III
midline frontal sinusotomy, which allows endoscopic postoperative inspection. Obliteration is
best avoided, if possible, to prevent the risk of
burying mucosa or disease [26].
The bone ap is replaced and secured with
titanium plates (Fig.35.8c). The bicoronal ap is
replaced and closed in layers with a drain left in
place for 24–48h (Fig.35.8d). The tarsorrhaphy
sutures are removed and a compression dressing
applied for 48–72h.
Managing Disease intheSmall
Frontal Sinus
With advancements in image guidance, the size
of the frontal sinus has become less important
than the pneumatisation and pathology of the
frontal recess, which will both determine whether
an adjunctive external approach is required.
Tips
• A midbrow, lateral brow or gull-wing incision
can be used in unilateral cases, but often
results in poorer cosmesis, and the risk of
supraorbital nerve damage is higher.
• Pre-drilling the screw holes for securing the
titanium plates before removal of the anterior
table will help to provide landmarks for re-
approximation of the bone ap and increase
the ease of xation at the end of the
procedure.
• A pericranial ap can be raised if cranialisa-
tion is planned.
• Riedel’s procedure, the removal of the ante-
rior table of the frontal sinus, may be required
in cases of recalcitrant frontal sinusitis/
osteomyelitis.
• Cranialisation, the removal of the posterior
frontal sinus table, is generally performed by
neurosurgical colleagues in complex posterior
table fractures.
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Fig. 35.9 Clinical photograph of a left lateral rhinotomy
with lip split. Photographs courtesy of Mr Gerald McGarry
Lateral Rhinotomy, Midfacial
Degloving andCraniofacial
Resections
The lateral rhinotomy approach was traditionally
used to access tumours of the middle meatus,
maxillary and ethmoid sinuses. However, both
the surgical access and postoperative cosmesis
were poor, leaving patients with scars running
from the medial canthus along the lateral aspect
of the nose to the alar crease and sometimes
through the lip (Fig.35.9) [29]. Today, the lateral
rhinotomy is used more often as part of more
extended procedures to access and remove
aggressive malignant tumours of the maxillary
sinus [29]. In comparison, the midfacial degloving approach was traditionally used for tumours
of the central anterior skull bases, such as juvenile angiobromas, but in recent times, this procedure has been largely superseded by endoscopic
sinus surgery [29]. Malignant tumours of the
frontoethmoidal sinuses can also be accessed via
an endoscopic or open craniofacial resection, but
these procedures are beyond the scope of this
text.
Conclusion
With huge advancements in endoscopic sinus
surgery, open approaches to the paranasal sinuses
have largely been abandoned. However, sinus
anatomy and pathology can be very complex and
occasionally beyond the capability of endoscopic
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S. Hayes and S. Carrie
sinus surgery alone. In specic cases, the use of
open-approach techniques (particularly the frontal osteoplastic ap), alone or in combination
with endoscopic surgery, may be essential for a
safer procedure and better outcome. It is therefore essential for the rhinologist to be familiar
with these techniques in order to achieve the best
surgical outcomes for their patients.
Key Learning Points
• Open approaches should be familiar to those
involved with both emergency and elective
surgical practices.
• There are no didactic rules as to when an open
approach may be required; it is dependent on
the individual patient’s anatomy, the patho-
logical process and the skillset of the
surgeon.
• Pathologies of the frontal sinus, particularly
neoplastic, may require an open approach for
complete removal. The treating surgeon
should refer to a tertiary centre if unfamiliar
with these procedures.
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