What is radical frontoethmosphenoidectomy?

Radical Frontoethmosphenoidectomy: Definition and Context

Radical frontoethmosphenoidectomy is an extensive surgical procedure that involves complete removal of the frontal, ethmoid, and sphenoid sinuses along with significant resection of inflamed or dysfunctional mucosa and diseased bone, typically performed for severe chronic rhinosinusitis with osteitis, allergic fungal rhinosinusitis (AFRS), or anterior skull base pathology. 1

Surgical Extent and Terminology

The term "radical" in sinus surgery refers to significant removal of inflamed or dysfunctional mucosa and diseased bone, distinguishing it from more conservative "functional" approaches. 1 This procedure encompasses:

• Complete frontal sinus opening (often including Draf III procedures for maximal frontal recess exposure) 1
• Total anterior and posterior ethmoidectomy with removal of all ethmoid air cells 1
• Wide sphenoidotomy providing full visualization and access to the sphenoid sinus 1, 2
• Removal of osteitic (inflamed) bone while preserving critical protective barriers (lamina papyracea, skull base, carotid arteries) 1

Primary Indications

Chronic Rhinosinusitis with Osteitis

Removal of osteitic bony partitions is recommended because these inflamed bone structures provide an ongoing source of inflammation leading to persistent mucosal edema and treatment failure. 1 Patients with significant osteitis who undergo "radical" ESS demonstrate lower Lund-Kennedy and Lund-Mackay scores at 1 year compared to those receiving "functional" ESS alone. 1

Allergic Fungal Rhinosinusitis (AFRS)

Complete visualization and removal of all eosinophilic mucin and fungal debris is essential in AFRS management, making radical approaches necessary. 1 Simple ostial dilation is inadequate because:

• It does not allow complete debris removal 1
• It fails to provide full sinus cavity visualization 1
• It prevents adequate postoperative topical medication penetration 1

Anterior Skull Base Lesions

The approach may be combined with transcranial procedures for tumors extending into the paranasal sinuses, nasal cavity, orbit, nasopharynx, or upper clivus. 3, 4, 5 The lateral rhinotomy with medial maxillectomy-ethmosphenoidectomy coupled with frontal approaches allows resection of anterior skull base tumors with minimal facial deformity. 4

Surgical Technique Considerations

Endoscopic vs. Open Approaches

• Endoscopic techniques provide superior visualization of residual disease, particularly in suprasellar and parasellar extensions when combined with transsphenoidal approaches 6, 7
• The transsphenoethmoid approach extends familiar otolaryngological procedures to access the sphenoid sinus and clivus with minimal morbidity 2
• Combined approaches may be necessary for extensive disease 3, 4, 5

Critical Anatomic Preservation

Despite the "radical" nature of the resection, preservation of the lamina papyracea (orbital wall), skull base dura, and carotid arteries is mandatory to prevent catastrophic complications. 1

Complications and Risks

Major complications occur in approximately 0.36% to 1.5% of cases and include: 1

• Cerebrospinal fluid leak (0.17% in nationwide data) 1
• Hemorrhage requiring transfusion (0.76%) 1
• Orbital injury (0.07%) 1
• Meningitis 1
• Skull base injury 1

The risk profile increases with more extensive procedures (e.g., Draf 3 frontal approaches carry higher risks than simple agger nasi cell removal). 1

Critical Pitfalls to Avoid

Inadequate Disease Removal

• Ostial dilation alone is contraindicated in cases of significant osteitis or AFRS because it fails to remove diseased bone or allow complete debris clearance 1
• Incomplete ethmoidectomy leaves residual disease sources that perpetuate inflammation 1

Insufficient Postoperative Management

Routine follow-up between 3 and 12 months postoperatively is essential to assess symptom relief, quality of life, complications, and need for ongoing topical therapy. 1 Nasal endoscopy should be performed to detect:

• Retained secretions requiring irrigation 1
• Mucus recirculation through multiple ostia 1
• Adhesion formation 1
• Persistent hyperplastic disease 1

Prevention of Postoperative Infection

When combined with skull base surgery, establishment of wide drainage routes through ESS prevents dead space and postoperative infection, particularly in patients with preoperative active sinusitis. 3

Postoperative Expectations

Patients require continued medical management including: 8

• Nasal saline irrigation to enhance mucociliary clearance 8
• Intranasal corticosteroid therapy to reduce inflammation 8
• Optimization of underlying allergic rhinitis if present 8

The goal is to create sinus cavities that incorporate natural ostia, allow adequate ventilation, facilitate mucociliary clearance, and permit instillation of topical therapies—the hallmarks of "functional" outcomes even after radical resection. 1