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Anatomy of the Frontal Sinus and Frontal Recess

Frontal Sinus Instructional Course

Christopher T. Melroy, MD Frederick A. Kuhn, MD, FARS, FACS

Frontal Sinus Anatomy


The Frontal Recess is the most common single site of recurrent or persistent disease after intranasal ethmoidectomy.
Kuhn FA & Kennedy DW, Analysis of Causes of Recurrent / Persistent Disease Following Intranasal Ethmoidectomy, 8th ISIAN, Baltimore Md., June 1989.

Frontal Sinus Drainage Pathway

Frontal sinus
Internal infundibulum Internal frontal ostium Frontal recess

Frontal Infundibulum

Narrowing of the frontal sinus before it drains into the internal frontal ostium

Frontal Infundibulum

CM FS infun

Frontal Recess
Imagine yourself up in a frontal sinus floating down, over, and around the tops of a complicated group anterior ethmoid cells And finally entering the nose in the middle meatus, behind the uncinate

THIS IS THE FRONTAL RECESS !!

Frontal Recess

Frontal Recess

Agger nasi cell

Frontal Sinus Anatomy


Frontal Recess: Term first used by Killian in 1898 Used by J. Parsons Schaeffer 1916, 1920 Used extensively by Dr. Van Alyea 1934, 1939, 1941 and 1946
Van Alyea, D.E., Archives of Otolaryng., 29:881-901, 1939.

Frontal Sinus Anatomy


(Embryology)

Frontal Sinus Anatomy


(Embryology)
Schaeffer and Kasper - 4 frontal pits 1st pit - Agger Nasi cell 2nd pit - Frontal Sinus 3rd pit - Supraorbital ethmoid cell 4th pit - other anterior ethmoid cells
Schaeffer, JP, Amer J Anatomy, 20:125-145, 1916. Kasper, KA, Archeves of Otolaryn, 23:322-343, 1936.

Frontal Sinus Embryology


(the frontal pits/furrows)
Develop from the lateral nasal wall
1st Agger Nasi cell 2nd Frontal Sinus

3rd Supraorbital Ethmoid Cell


Develops behind the FS and extends over the orbit

Frontal Sinus Anatomy

Frontal Sinus Anatomy

Frontal Sinus Anatomy


Frontal Recess Cells:
Agger Nasi cell Frontal cells Supraorbital ethmoid cell Frontal Bulla cell Suprabullar cell

Agger Nasi Cell


ANC
MT basal lam. Bulla lam.

MT basal lam.

Agger Nasi Cell, M.T. basal lamella

Bulla Lamella M.T. basal lamella

Frontal Sinus Anatomy


Opaque Frontal Recess Obstructed by ANC

Frontal Cells

Current Definition Impinges on frontal recess or frontal sinus Communicates with frontal recess distinct from agger nasi, supraorbital ethmoid, suprabullar & frontal bullar 4 variations, types I-IV

Frontal Cell Types


Type I - Single cell, above Agger Nasi cell Type II - Tier of cells may invade frontal s. Type III - Single massive cell, invades frontal sinus, attached to ant. table Type IV - Single isolated cell in frontal sinus no obvious connection to frontal recess, not attached to ant. or posterior table

Frontal Cells
Type I Frontal cell Type II frontal cell

Type II Frontal Cells

* *
A N C

Type III Frontal Cell

Type III Frontal Cells

Type III Frontal Cell


- fixing the bad result -

III

skull base

Type IV Frontal Cell


Type IV frontal cell Type IV frontal cell?

no.

Supraorbital Ethmoid Cell

From 3rd frontal furrow Posterior and lateral to frontal sinus Pneumatizes into the frontal bone over the orbit and behind the FS May extend lateral to FS Partition separates this from FS

Supraorbital Ethmoid Cell

CM SOE

The FS is anterior and medial to the SOE

Supraorbital Ethmoid Cell


Supraorbital ethmoid
Pneumatizes over orbit, behind FS

The FS is anterior and medial to the SOE

Supraorbital Ethmoid Cell

The FS is anterior and medial to the SOE

Frontal Sinus Anatomy

Frontal Sinus Anatomy


Pre-op Post-op

Frontal Sinus Anatomy (R)


Pre-op Post-op

SOE was mistaken for FS FS is closed

FS is anterior and medial to SOE

Frontal Bulla Cell


Frontal Bulla Cell vs. Suprabullar Cell

Frontal Bulla Cell

Suprabullar Cell

Suprabullar Cell
Frontal ostium Supraorbital ethmoid cell

Suprabullar Cell

Interfrontal Sinus Septal Cell


IFSSC Pneumatization of the septum between the frontal sinuses May involve a pneumatized crista galli May drain high into FS or low into frontal recess

Interfrontal Sinus Septal Cell

CM IFSSC

Frontal Sinus Anatomy


Must be mastered before performing frontal sinus surgery.

Balloon Dilation of the Frontal Sinus Outflow Tract


Frontal Sinus Instructional Course

Christopher T. Melroy, MD Frederick A. Kuhn, MD, FARS, FACS


Disclosure: I have received honoraria for physician training and speaking engagements from Acclarent, Inc.

Balloon Frontal Sinusotomy


Rationale
Most minimally-invasive way to open a frontal sinus drainage pathway

Concept
Cell walls in the frontal recess are fractured to widen the frontal sinus drainage pathway

Balloon Frontal Sinusotomy


- technique -

CM bratch

Balloon Frontal Sinusotomy


- technique -

CM bratch

Balloon Frontal Sinusotomy


- technique -

CM bratch

Balloon Frontal Sinusotomy


- technique -

Balloon Frontal Sinusotomy


- technique -

CM bratch

Balloon Frontal Sinusotomy


- contraindications -

Extensive polyposis Known skull base trauma or defect

Balloon Frontal Sinusotomy


Applications / Indications:
Primary surgery Revision surgery Management of postop ostial stenosis Including use in the office Finding the frontal sinus Moving cell walls within the frontal sinus

Balloon Frontal Sinusotomy


- uses Management of postop ostial stenosis Including use in the office

CM FS scar

Balloon Frontal Sinusotomy


- uses Moving cell walls within the frontal sinus

Without trephination

Without osteoplastic flap

Balloon Frontal Sinusotomy


- complications Complications (FDA database) Orbital injury n=2
Passing guidewire through lamina No sequelae CSF leak n=1 One reported case: standard instrumentation was also used. Frontal surgery-> leak at sph. COMPLICATION RATE 0.010% of pts (1/10,000) = 0.0035% of sinuses