What is a safe frontal sinus?

From the Guidelines

The safe frontal sinus approach involves using endoscopic techniques to access the frontal sinus while minimizing complications, as open surgical procedures are still required in certain cases, such as the extent and location of the sinuses involved 1. When considering a safe frontal sinus approach, several key factors must be taken into account, including:

• The use of endoscopic approaches as the surgical standard of care for chronic infectious sinusitis, especially if there is evidence of mechanical blockage of the ostiomeatal complex 1
• The importance of identifying key anatomical landmarks, such as the axilla of the middle turbinate, the anterior attachment of the uncinate process, and the agger nasi cell
• The need to preserve the middle turbinate attachment and mucosa to prevent scarring and stenosis
• The use of frontal sinus trephine and postoperative irrigation as a valid consideration in patients with acute or chronic frontal sinusitis 1
• The consideration of frontal sinus obliteration with fat as a viable option when endoscopic surgical techniques fail to resolve chronic frontal sinusitis, even with revised surgical intervention 1

In terms of specific techniques, the surgeon should:

• Remove the agger nasi cell, which serves as the floor of the frontal sinus
• Identify the frontal recess and carefully enlarge the natural drainage pathway
• Maintain orientation by identifying the lamina papyracea laterally and the skull base superiorly to avoid orbital or intracranial complications Postoperatively, patients typically require:
• Saline irrigations to maintain patency of the newly created drainage pathway
• Topical steroids to reduce inflammation and prevent restenosis
• Regular follow-up endoscopic examinations to ensure healing and prevent restenosis, as recommended in the practice parameter update 1

From the Research

Definition of a Safe Frontal Sinus

A safe frontal sinus can be defined as one that is free from disease and complications, and can be managed successfully with endonasal procedures or other surgical techniques.

Factors Affecting Frontal Sinus Safety

Several factors can affect the safety of the frontal sinus, including:

• The presence of chronic rhinosinusitis (CRS) or other inflammatory diseases of the paranasal sinuses 2, 3
• The extent of disease, with completely opacified frontal sinuses potentially indicating more severe disease 4
• The surgical technique used, with endonasal procedures and balloon catheter dilation (BCD) being alternative options to traditional endoscopic sinus surgery (ESS) 2, 3
• The avoidance of unnecessary dissection in the frontal recess during surgery 5

Surgical Management of Frontal Sinus Disease

The surgical management of frontal sinus disease can involve various techniques, including:

• Endonasal frontal sinus drainage, with different types of drainage (type 1,2, and 3) having varying success rates 3
• Balloon catheter dilation (BCD), which has been shown to be a safe and effective alternative to traditional ESS in some cases 2
• Traditional endoscopic sinus surgery (ESS), which can be used in conjunction with other techniques or as a standalone procedure 2, 5

Radiographic Evaluation of Frontal Sinus Disease

Radiographic evaluation of the frontal sinus can be used to assess the extent of disease and monitor the effectiveness of treatment.

• Computed tomography (CT) scans and magnetic resonance imaging (MRI) can be used to evaluate the frontal sinus and detect any abnormalities or disease 5, 4
• The Lund-McKay CT scoring system can be used to assess the extent of disease and monitor the effectiveness of treatment 2