anatomy of frontal sinus & recess
DESCRIPTION
anatomy of frontal sinus & recessTRANSCRIPT
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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
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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.
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Internal frontal ostium
Frontal recess
Frontal sinus
Internal infundibulum
Frontal Sinus Drainage Pathway
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• Narrowing of the frontal
sinus before it drains
into the internal frontal
ostium
Frontal Infundibulum
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CM
FS
infu
n
Frontal Infundibulum
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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
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Frontal Recess
Frontal Recess
Agger nasi cell
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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
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Frontal Sinus Anatomy(Embryology)
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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.
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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
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Frontal Sinus Anatomy
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Frontal Sinus Anatomy
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Frontal Sinus Anatomy
Frontal Recess Cells:
•Agger Nasi cell
•Frontal cells
•Supraorbital ethmoid cell
•Frontal Bulla cell
•Suprabullar cell
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Agger Nasi Cell
Agger Nasi Cell, M.T. basal lamella Bulla Lamella M.T. basal
lamella
ANC MT basal lam. MT basal lam.Bulla lam.
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Frontal Sinus Anatomy
Opaque Frontal Recess … Obstructed by ANC
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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
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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
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Frontal Cells
Type I Frontal cell Type II frontal cell
**
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Type II Frontal Cells
*
*
A
N
C
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Type III Frontal Cell
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Type III Frontal Cells
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III
skull base
Type III Frontal Cell- fixing the bad result -
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Type IV Frontal Cell
Type IV frontal cell Type IV frontal cell?
no.
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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
*
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Supraorbital Ethmoid Cell
CM SOE
The FS is anterior and medial to the SOE
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Supraorbital Ethmoid Cell
Supraorbital ethmoid Pneumatizes over
orbit, behind FS
The FS is anterior and medial to the SOE
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Supraorbital Ethmoid Cell
The FS is anterior and medial to the SOE
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Frontal Sinus Anatomy
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Frontal Sinus Anatomy
Pre-op Post-op
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Frontal Sinus Anatomy (R)
Pre-op Post-op
SOE was mistaken for FS
FS is closed
FS is anterior and medial
to SOE
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Frontal Bulla Cell
Frontal Bulla Cell vs. Suprabullar Cell
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Frontal Bulla Cell
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* *
Suprabullar Cell
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Frontal ostium
Supraorbital
ethmoid cell
Suprabullar Cell
Suprabullar Cell
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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
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Interfrontal Sinus Septal CellC
M IF
SS
C
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Frontal Sinus Anatomy
Must be mastered before
performing frontal sinus
surgery.
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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.
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• 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
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Balloon Frontal Sinusotomy- technique -
CM
bra
tch
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Balloon Frontal Sinusotomy- technique -
CM
bra
tch
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Balloon Frontal Sinusotomy- technique -
CM
bra
tch
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Balloon Frontal Sinusotomy- technique -
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Balloon Frontal Sinusotomy- technique -
CM
bra
tch
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• Extensive polyposis
• Known skull base trauma or defect
Balloon Frontal Sinusotomy- contraindications -
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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
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Management of postop ostial stenosis
• Including use in the office
CM
FS
sca
r
Balloon Frontal Sinusotomy- uses -
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Moving cell walls within the frontal sinus
Without trephination Without osteoplastic flap
Balloon Frontal Sinusotomy- uses -
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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
Balloon Frontal Sinusotomy- complications -