Challenges of open frontal sinus surgery

Abstract

Over the past century, frontal sinus surgery has undergone substantial transformation, with advances in imaging, optics, and instrumentation contributing to current treatment paradigms. This review article is devoted to the evolution of surgical methods for treating frontal sinus diseases, demonstrates the complexity of surgical access, anatomical features, and the high rate of postoperative complications in this area. The historical development of frontal sinus surgery is outlined, from ancient trepanation practices, first thoroughly described in the 18th century, to modern minimally invasive endoscopic techniques. Particular attention is given to the transition from radical external approaches, such as the Ogston–Luc procedure, radical ablation, and complete sinus obliteration, to more conservative procedures aimed at preserving anatomical integrity and frontal sinus function. The review includes an analysis of early surgical milestones by Ogston, Kuhnt, Riedel-Schenke, and Killian, and examines the evolution of external frontoethmoidectomies known as Lynch–Howarth procedures. The limitations of these techniques, including high restenosis rates, scarring, and cosmetic deformities, are discussed, along with the development of various modifications intended to improve drainage and reduce postoperative complications. The article also addresses the challenges of intranasal approaches, such as limited visualization and the risk of intracranial complications. Advances in osteoplastic techniques are reviewed, noting their high efficacy alongside technical difficulty and risks such as cerebrospinal fluid leak and neuralgia. Despite the rise of endoscopic methods, external approaches remain relevant for certain specialists due to the unique anatomy of the frontal sinus, limited surgical experience, or complex disease course, either as stand-alone options or part of combined strategies. The review demonstrates that optimizing surgical treatment of the frontal sinus remains a relevant challenge, requiring continuous refinement of techniques and an individualized approach to each patient.

Keywords

frontal sinus / chronic frontal sinusitis / radical frontal sinus surgery / open frontal sinusotomy

References

[1] Patel AB, Cain RB, Lal D. Contemporary applications of frontal sinus trephination: A systematic review of the literature. Laryngoscope. 2015;125(9):2046–2053. doi: 10.1002/lary.25206

[2] Patel A.B., Cain R.B., Lal D. Contemporary applications of frontal sinus trephination: A systematic review of the literature // Laryngoscope. 2015. Vol. 125, N 9. P. 2046–2053. doi: 10.1002/lary.25206

[3] Batra PS, Cannady SB, Lanza DC. Surgical outcomes of drillout procedures for complex frontal sinus pathology. Laryngoscope. 2007;117(5):927–931. doi: 10.1097/MLG.0b013e31803dd2ee

[4] Batra P.S., Cannady S.B., Lanza D.C. Surgical outcomes of drillout procedures for complex frontal sinus pathology // Laryngoscope. 2007. Vol. 117, N 5. P. 927–931. doi: 10.1097/MLG.0b013e31803dd2ee

[5] Knisely A, Barham HP, Harvey RJ, Sacks R. Outside-in frontal drill-out: how i do it. Am J Rhinol Allergy. 2015;29(5):397–400. doi: 10.2500/ajra.2015.29.4175

[6] Knisely A., Barham H.P., Harvey R.J., Sacks R. Outside-in frontal drill-out: how i do it // Am J Rhinol Allergy. 2015. Vol. 29, N 5. P. 397–400. doi: 10.2500/ajra.2015.29.4175

[7] Stevenson RS, Guthrie D. A history of otolaryngology. Baltimore: Williams and Wilkins; 1949.

[8] Stevenson R.S., Guthrie D. A history of otolaryngology. Baltimore: Williams and Wilkins, 1949.

[9] Wells S. Abscess of the frontal sinus; operation; cure. Lancet. 1870;1:694–695.

[10] Wells S. Abscess of the frontal sinus; operation; cure // Lancet. 1870. Vol. 1. P. 694–695.

[11] Ogston A. Trephining the frontal sinus for catarrhal diseases. The Medical Chronicle. 1884;3:235–238.

[12] Ogston A. Trephining the frontal sinus for catarrhal diseases // The Medical Chronicle. 1884. Vol. 3. P. 235–238.

[13] Luc H. Lessons on the suppurations of the middle ear and the accessory cavities of the nasal cavities and their endocranial complications. Paris: Baillere; 1900. (In France.)

[14] Luc H. Lecons sur le suppurations de l’oreille moyenne et des cavities accessoires des fosses nasales et leurs complications endocraniennes. Paris: Baillere; 1900.

[15] Blotsky AA, Antipenko VV. Inflammatory diseases of the ENT. Blagoveshchensk; 2021. 553 p. (In Russ.)

[16] Блоцкий А.А., Антипенко В.В. Воспалительные заболевания ЛОР-органов. Благовещенск, 2021. 553 с.

[17] Lyman EH. The place of the obliterative operation in frontal sinus surgery. Laryngoscope. 1950;60(5):407–441. doi: 10.1288/00005537-195005000-00001

[18] Lyman E.H. The place of the obliterative operation in frontal sinus surgery // Laryngoscope. 1950. Vol. 60, N 5. P. 407–441. doi: 10.1288/00005537-195005000-00001

[19] Goodale RL. The radical obliterative frontal sinus operation; a consideration of technical factors in difficult cases. Ann Otol Rhinol Laryngol. 1955;64(2):470–486. doi: 10.1177/000348945506400217

[20] Goodale R.L. The radical obliterative frontal sinus operation; a consideration of technical factors in difficult cases // Ann Otol Rhinol Laryngol. 1955. Vol. 64, N 2. P. 470–486. doi: 10.1177/000348945506400217

[21] Killian G. The killian radical operation of chronic sinusitis. further casuistic material and summary. Arch Laryngol Rhinol. 1903:59–65. (In German.)

[22] Killian G. Die killianische radicaloperation chronischer stirnhohleneiterungen. Weiteres kasuistisches material and zusammenfassung // Arch Laryngol Rhinol. 1903. P. 59–65.

[23] Rauchfuss A. Complications of endonasal surgery of the paranasal sinuses. Special anatomy, pathomechanisms, surgical management. HNO. 1990;38(9):309–316. (In German.)

[24] Rauchfuss A. Komplikationen der endonasalen chirurgie der nasennebenhöhlen. Spezielle anatomie, pathomechanismen, operative versorgung // HNO. 1990. Vol. 38, N 9. P. 309–316.

[25] Knapp A. The surgical treatment of orbital complications in disease of the nasal accessory sinuses. JAMA. 1908;(4):299–301. doi: 10.1001/jama.1908.25410040031001j

[26] Knapp A. The surgical treatment of orbital complications in disease of the nasal accessory sinuses // JAMA. 1908. N 4. P. 299–301. doi: 10.1001/jama.1908.25410040031001j

[27] Schaeffer JP. Cited by Sier Rouillons. Arch Int Laryngol. 1911;31:709.

[28] Schaeffer J.P. Cited by Sier Rouillons // Arch Int Laryngol. 1911. Vol. 31. P. 709.

[29] Halle M. External or internal surgery of sinus suppurations. Berlin Clinical Weekly. 1906;43:1369–1372, 1404–1407. (In German.)

[30] Halle M. Externe oder interne Operation der Nebenhöhleneiterungen // Berliner Klinische Wochenschrift. 1906. Vol. 43. P. 1369–1372, 1404–1407.

[31] Lothrop HA. XIV. Frontal sinus suppuration: the establishment of permanent nasal drainage; the closure of external fistulae; epidermization of sinus. Ann Surg. 1914;59(6):937–957. doi: 10.1097/00000658-191406000-00014

[32] Lothrop H.A. XIV. Frontal sinus suppuration: the establishment of permanent nasal drainage; the closure of external fistulae; epidermization of sinus // Ann Surg. 1914. Vol. 59, N 6. P. 937–957. doi: 10.1097/00000658-191406000-00014

[33] Becker DG, Moore D, Lindsey WH, et al. Modified transnasal endoscopic Lothrop procedure: further considerations. Laryngoscope. 1995;105(11):1161–1166. doi: 10.1288/00005537-199511000-00004

[34] Becker D.G., Moore D., Lindsey W.H., et al. Modified transnasal endoscopic Lothrop procedure: further considerations // Laryngoscope. 1995. Vol. 105, N 11. P. 1161–1166. doi: 10.1288/00005537-199511000-00004

[35] Jansen A. On opening the sinuses of the nose in chronic suppuration. Arch Laryng Rhinol (Berl). 1894;1:135–157. (In German.)

[36] Jansen A. Zur Eröffnung der Nebenhöhlen der Nasebei chronischer Eiterung // Arch Laryng Rhinol (Berl). 1894. Vol. 1. S. 135–157.

[37] Ritter G. A new method for the preservation of the anterior frontal sinus wall in readical operations of chronic frontal sinus suppurations. German Medical Weekly. 1906;32:1294–1296. (In German.)

[38] Ritter G. Eine neue Methode zur Erhaltung dervorderen Stirnhöhlenwand bei Readikaloperationen chronischer Stirnhöhleneiterungen // Deutsche Medizinische Wochenschrift. 1906. Vol. 32. S. 1294–1296.

[39] Hardy JM, Montgomery WW. Osteoplastic frontal sinusotomy: an analysis of 250 operations. Ann Otol Rhinol Laryngol. 1976;85(4 Pt 1):523–532. doi: 10.1177/000348947608500414

[40] Hardy J.M., Montgomery W.W. Osteoplastic frontal sinusotomy: an analysis of 250 operations // Ann Otol Rhinol Laryngol. 1976. Vol. 85, N 4 Pt 1. P. 523–532. doi: 10.1177/000348947608500414

[41] Boyden GL. Surgical treatment of chronic frontal sinusitis. Annals of Otology, Rhinology & Laryngology. 1952;61(2):558–566. doi: 10.1177/000348945206100227

[42] Boyden G.L. Surgical treatment of chronic frontal sinusitis // Annals of Otology, Rhinology & Laryngology. 1952. Vol. 61. N 2. P. 558–566. doi: 10.1177/000348945206100227

[43] McNaught RC. Refinement of the external frontoethmosphenoid operation: A new nasofrontal pedicle flap. Arch Otolaryngol. 1936;23(5):544–549. doi: 10.1001/archotol.1936.00640040554003

[44] McNaught R.C. Refinement of the external frontoethmosphenoid operation: A new nasofrontal pedicle flap // Arch Otolaryngol. 1936. Vol. 23, N 5. P. 544–549. doi: 10.1001/archotol.1936.00640040554003

[45] Sewall EC. XXXI. The Operative Treatment of Nasal Sinus Disease. Annals of Otology, Rhinology & Laryngology. 1935;44(2):307–316.

[46] Sewall E.C. XXXI. The operative treatment of nasal sinus disease // Annals of Otology, Rhinology & Laryngology. 1935. Vol. 44, N 2. P. 307–316.

[47] Dedo HH, Broberg TG, Murr AH. Frontoethmoidectomy with Sewall-Boyden reconstruction: alive and well, a 25-year experience. Am J Rhinol. 1998;12(3):191–198. doi: 10.2500/105065898781390181

[48] Dedo H.H., Broberg T.G., Murr A.H. Frontoethmoidectomy with Sewall-Boyden reconstruction: alive and well, a 25-year experience // Am J Rhinol. 1998. Vol. 12, N 3. P. 191–198. doi: 10.2500/105065898781390181

[49] Walsh TE. Experimental surgery of the frontal sinus. The role of the ostium and nasofrontal duct in postoperative healing. Laryngoscope. 1943;53(2):75–92. doi: 10.1288/00005537-194302000-00001

[50] Walsh T.E. Experimental surgery of the frontal sinus. The role of the ostium and nasofrontal duct in postoperative healing // Laryngoscope. 1943. Vol. 53, N 2. P. 75–92. doi: 10.1288/00005537-194302000-00001

[51] Brown JM. Frontal sinusitis. Laryngoscope. 1946;56:116–119. doi: 10.1002/lary.5540560303

[52] Brown J.M. Frontal sinusitis // Laryngoscope. 1946. Vol. 56. P. 116–119. doi: 10.1002/lary.5540560303

[53] Hajek M. Pathology and treatment of the inflammatory diseases of the nasal accessory sinuses. St. Louis: CV Mosby; 1903. Р. 34–52.

[54] Hajek M. Pathology and treatment of the inflammatory diseases of the nasal accessory sinuses. St. Louis: CV Mosby, 1903. Р. 34–52.

[55] Goodale RL, Montgomery WW. Experiences with the osteoplastic anterior wall approach to the frontal sinus; case histories and recommendations. AMA Arch Otolaryngol. 1958;68(3):271–283. doi: 10.1001/archotol.1958.00730020281001

[56] Goodale R.L., Montgomery W.W. Experiences with the osteoplastic anterior wall approach to the frontal sinus; case histories and recommendations // AMA Arch Otolaryngol. 1958. Vol. 68, N 3. P. 271–283. doi: 10.1001/archotol.1958.00730020281001

[57] Tato JM. Cirurgia del frontal injerto de grosa. Nueva tecnica (surgery of frontal sinus. Fat grafts: new technique). Otolaryngologica. 1949;3(1):504–521. (In Ital.)

[58] Tato J.M. Cirurgia del frontal injerto de grosa. Nueva tecnica (surgery of frontal sinus. Fat grafts: new technique) // Otolaryngologica. 1949. Vol. 3, N. 1. P. 504–521.

[59] Lyman EH. The place of the obliterative operation in frontal sinus surgery. The Laryngoscope. 1950;60(5):407–441.

[60] Lyman E.H. The place of the obliterative operation in frontal sinus surgery // The Laryngoscope. 1950. Т. 60, N 5. P. 407–441.

[61] Becker DG, Moore D, Lindsey WH, et al. Modified transnasal endoscopic Lothrop procedure: further considerations. Laryngoscope. 1995;105(11):1161–1166. doi: 10.1288/00005537-199511000-00004

[62] Becker D.G., Moore D., Lindsey W.H., et al. Modified transnasal endoscopic Lothrop procedure: further considerations // Laryngoscope. 1995. Vol. 105, N 11. P. 1161–1166. doi: 10.1288/00005537-199511000-00004

[63] Lee YH, Lee JY, Lawson W. Indications and outcomes of the osteoplastic flap procedure with or without obliteration. J Craniofac Surg. 2020;31(8):2243–2249. doi: 10.1097/SCS.0000000000006717

[64] Lee Y.H., Lee J.Y., Lawson W. Indications and outcomes of the osteoplastic flap procedure with or without obliteration // J Craniofac Surg. 2020. Vol. 31, N 8. P. 2243–2249. doi: 10.1097/SCS.0000000000006717

[65] Langton-Hewer CD, Wormald PJ. Endoscopic sinus surgery rescue of failed osteoplastic flap with fat obliteration. Curr Opin Otolaryngol Head Neck Surg. 2005;13(1):45–49. doi: 10.1097/00020840-200502000-00011

[66] Langton-Hewer C.D., Wormald P.J. Endoscopic sinus surgery rescue of failed osteoplastic flap with fat obliteration // Curr Opin Otolaryngol Head Neck Surg. 2005. Vol. 13, N 1. P. 45–49. doi: 10.1097/00020840-200502000-00011

[67] Likhachev AG, Neiman LV, Scherbatov II. Manual on otorhinolaryngology. Vol. 4. Moscow: Medgiz; 1963. 518 p. (In Russ.)

[68] Лихачев А.Г., Нейман Л.В., Щербатов И.И. Руководство по оториноларингологии. Т. 4. Москва: Медгиз, 1963. 518 с.

[69] Bokshtein FS. Intranasal surgery. Moscow: Medgiz; 1956. 231 p. (In Russ.)

[70] Бокштейн Ф.С. Внутриносовая хирургия. Москва: Медгиз. 1956. 231 с.

[71] Likhachev AG. Diseases of the ear, throat, and nose: a textbook for medical schools. 5th edition. Moscow: Meditsina, 1969. P. 82. (In Russ.)

[72] Лихачев А.Г. Болезни уха, горла и носа: Учебник для медицинских училищ. 5-е изд., исправ. и доп. Москва: Медицина, 1969. C. 82.

[73] Karpishchenko SA, Bolozneva EV, Goreva EA. Endoscopic revision frontotomy sinus operated by external access. Practical Medicine. 2016;2-2(94):15–17. EDN VSEKLP (In Russ.)

[74] Карпищенко С.А., Болознева Е.В., Горева Е.А. Эндоскопическая ревизионная фронтотомия пазухи, оперированной наружным доступом // Практическая медицина. 2016. № 2-2(94). С. 15–17. EDN VSEKLP

RIGHTS & PERMISSIONS

Eco-Vector