Abstract
The objective of this retrospective study was to evaluate the osteoplastic flap (OPF) for the obliteration of the frontal sinus in this current era of endoscopic management of frontal sinus disease. A review of consecutive OPF procedures (n = 43) performed by the senior author (J.A.D.) from 1992 to 1997 was carried out. Data were gathered regarding chief symptom, medical history, previous sinus surgery, endoscopic findings in the office and at surgery, CT scan findings, and follow-up results (mean 19.4 months). Previous endoscopic management of frontal sinus disease had failed in 24% of patients; 97% had eventual resolution of frontal sinusitis with OPF. After OPF, 63% also had improvement or resolution of disease in other paranasal sinuses. Statistically significant, Positive correlations (P < 0.05) were noted between the resolution of frontal sinusitis and improved or resolved pain, as well as the resolution of frontal sinusitis and improved or resolved infections in other paranasal sinuses. In 1998 OPF remains the standard for treating frontal sinus disease refractory to other methods. OPF can decrease the pain associated with frontal sinus infections and has a Positive impact on inflammatory disease in other paranasal sinuses.
Otolaryngologists are well aware of the rare but Potentially devastating consequences of frontal sinusitis. Orbital, cranial, and central nervous system complications of frontal sinus disease are still encountered in the Postantibiotic era. These complications are well documented in the literature. 1 Osteoplastic flap (OPF) with frontal sinus obliteration has been the gold standard in the management of frontal sinus disease since the mid-1960s. At that time, failure to adequately control frontal sinus disease and Poor cosmetic results with the Lynch operation led to renewed interest in the osteoplastic anterior wall approach.
Initially described by Schonborne 2 in 1894, OPF did not gain widespread acceptance until 1958, when Montgomery and coworkers 3-5 reported their series and follow-up data. They documented a 93% overall cure rate with a 6% revision surgery rate in their Population and low perioperative complications relative to other open approaches. The advent of endoscopic techniques in the 1980s raised interest in treating these patients with closed procedures instead of more traditional open approaches. 6,7 Endoscopic frontal sinusotomy and frontal sinus trephination have been primarily used for addressing frontal sinus disease in the endoscopic era. Developments in Powered rhinologic instrumentation in the 1990s have fueled the search for techniques to avoid open approaches. In 1995 Gross et al 8,9 described their modification to Lothrop's procedure and advocated it as a less invasive and less morbid alternative to OPF. The basic premises of the Lothrop modification and the earlier modification described Draf 10 are that varying amounts of nasal septum, frontal sinus floor, and nasofrontal beak area are resected. The goal is establishment of wide drainage pathways through the enhanced nasofrontal ducts. These procedures are technically demanding, and long-term follow-up results have yet to be established in a large series. 8,9 Recently published literature has evaluated the relationship of frontal sinus disease development after endoscopic paranasal sinus pro-cedures. 11 Some of these patients eventually come to OPF with frontal sinus obliteration. Finally, diseased supraorbital ethmoid cells are often not accessible by endoscopic drill-out procedures. 9
Our experience in treating patients with frontal sinusitis has indicated that there are certain groups of patients in whom endoscopic management of their frontal sinus disease ultimately fails: patients with extensive Polypoid degeneration of the frontal sinus mucosa, a narrow anterior-Posterior diameter in the frontal recess, highly compartmentalized frontal sinuses, or very thick, inspissated secretions in the frontal sinuses. Patients with allergic fungal sinusitis (AFS), inverting papilloma, or frontal sinus fractures have also traditionally done Poorly with endoscopic approaches. It has also been our belief that persistent disease in the frontal sinus often has a “run-down effect” on the other paranasal sinuses, promoting relapses of sinusitis. In this era of endoscopic surgery and Powered instrumentation, the role of OPF with frontal sinus obliteration warrants reevaluation. The purpose of this investigation is to evaluate the indications, technique, and results of OPF with frontal sinus obliteration and to compare these to historical controls.
METHODS AND MATERIAL
Experimental Design
A retrospective review of consecutive OPF procedures performed by the senior author (J.A.D.) from January 1992 to January 1997 was carried out. Indications for OPF in this patient Population included inflammatory disease—recurrent or persistent bacterial and AFS, mucopyocele, and subperiosteal abscess; and neoplastic disease—fibrous dysplasia, osteoma, and inverting papilloma. The decision to proceed with OPF was reached through evaluation of each patient's history, physical findings, clinical course, and coronal sinus CT scans. Patients were excluded from the study if they had previously undergone OPF with frontal sinus obliteration by a surgeon other than the senior author. This allowed control for variability in the operative technique. Chief symptom, medical history, previous sinus operations, endoscopic findings in the office and at operation, CT scan results, and final outcome were assessed as independent variables. Dependent variables assessed in this study included Possible cofactors to frontal sinus disease such as AFS, asthma, aspirin sensitivity, diabetes mellitus, environmental allergies, nasal Polyposis, and tobacco use. Outcomes measured included perioperative occurrences, short- and long-term complications, resolution of disease, operative time, blood loss, length of hospitalization, and improvement/resolution of the chief presenting symptoms of the subjects.
All data were entered into a database with Microsoft Excel 5.0 (Microsoft Corp, Seattle, WA). Statistical analysis was performed with StatView 1.03 (Abacus Concepts Inc, Berkeley, CA). Scheffe's F test was used to analyze the data. Comparisons were made to historical controls 5 with particular attention directed toward outcomes and morbidity.
Surgical Technique
The technique of standard bicoronal incision to approach the frontal sinus was used in most cases. In men with evidence of pattern baldness, a brow or mid-forehead approach may be used. The frontal sinus is assessed before surgery with a 6-ft Caldwell view radiograph. The film is then brought to the operating room, trimmed, and sterilized. When the sinus is entered, the film is used as a template. Other paranasal sinuses may be addressed endoscopically at the same setting as OPF with frontal sinus obliteration. An oscillating sagittal saw is used to create the superior osteotomies while the nasofrontal suture osteotomy is performed with a 7-mm chisel. All mucosa is removed from the sinus, and a cutting burr is then used to remove any residual disease. The frontal ducts are plugged with abdominal fat, and then the remaining sinus is also obliterated with fat. The anteroinferior pericranium is left attached, and the osteoplastic bone flap is then held in its natural anatomic Position with microplates. Closed suction drains are used. A 10-mm, flat, fully perforated drain is placed at the fat donor site and also under the bicoronal scalp flap. The head is dressed with fluff sponges and elastic tape. Finally, the nasal cavity is packed bilaterally with 6 ft of Vaseline gauze impregnated with mupirocin ointment. The pressure dressing and nasal packing are removed on Postoperative day 1. The scalp and abdominal drains are removed on Postoperative day 2, and the patient is discharged from the hospital.
RESULTS
Demographics
Thirty-eight consecutive patients were included in the study, with 43 procedures being performed in this patient Population. Fifty-three percent of patients identified were male, and 47% were female, with an overall mean age of 40.7 years. All patients had sufficient data to be included in the final analysis. No patients were lost to follow-up. Mean follow-up in this group was 19.4 months (1.62 years).
Chief Symptoms
All patients had recurrent or persistent infection in the frontal sinus as part of their presenting symptoms. Additionally, all subjects had recurrent infection in at least 1 other paranasal sinus for which they sought treatment. Thirty-four (89%) reported pain in the frontal region. Eleven (29%) patients reported exacerbation of their baseline asthma when the frontal sinus infections recurred. Nasal obstructive symptoms were noted in 12 (32%) patients. Anosmia or hyposmia was seen in 3 of the subjects (8%).
Indications
All patients had evidence of frontal sinus infection documented either by endoscopic evaluation in the clinic or through CT scan confirmation. Four patients (11%) had a mucocele or mucopyocele. AFS was encountered in 6 patients (16%) and confirmed by classic fungal changes on CT scan or through evaluation of surgical cultures and smears. Two patients (5%) had regional complications from frontal sinus infection, specifically orbital abscesses. Four other patients (11%) had facial/periorbital edema without evidence of abscess at the time of presentation. One patient each had fibrous dysplasia (3%), osteoma (3%), and a cerebrospinal fluid leak (CSF) (3%) from previous surgery at another institution.
Potential Cofactors and Previous Surgical History
Seventy-six percent of patients had history of allergy to inhalant allergens for which they had skin test confirmation. Fifty-three percent had asthma, and as previously stated, some reported increased frequency or severity of attacks. Seventy-six percent had evidence of nasal Polyposis documented endoscopically either in the frontal recess or in another paranasal sinus. Three percent had diabetes, and 21% used tobacco. The classic triad of nasal Polyposis, aspirin sensitivity, and asthma was encountered in 18% of the patients in this Population. Other Potential comorbidities included a 3% incidence each of serum sickness after insect stings, IgG subclass deficiency, and herpes zoster of the forehead region.
Thirty-four (89%) patients had previously undergone some form of endoscopic sinus surgery (ESS) before requiring OPF with frontal sinus obliteration. Thirteen (34%) of these had had this surgery under the care of the senior author. Endoscopic frontal sinusotomy had been performed in 9 (24%) patients in an attempt to clear their frontal sinus disease. Seven of these (18%) were performed by the senior author. Limited open access to the frontal sinus through frontal trephination had been performed in 15 patients (39%). Four patients (11%) came to our institution with complications of previous sinus surgery that included 1 CSF leak after bilateral Lynch procedures, 1 orbital abscess, 1 orbital abscess that had progressed to subdural empyema and hemiparesis, and 1 fistula at the left nasofrontal area after bilateral Lynch procedures.
Clinical Findings and CT Documentation
Endoscopic findings in the clinic or at the time of operation identified Polyps in 1 or more frontal recess in 23 (61%) patients. Scarring was noted in the frontal recesses of 8 patients (21%), whereas 24 (63%) had pus emanating from 1 or more frontal recesses.
All subjects had evidence of frontal sinus disease, either acute or persistent, noted on coronal CT scans of the sinuses. Opacification of the sinus was noted in 92% of the scans reviewed. Sixty-three percent of these were bilateral or “complete” sinus opacification, whereas 29% had only unilateral disease. Air-fluid levels were seen in 24% of scans, with a breakdown of 13% bilateral and 11% unilateral. Classic AFS changes were documented in 11% of patients. At the time of surgery, Polypoid degeneration of the frontal sinus mucosa correlated with CT findings of opacification in 50% of patients. Forty-five percent of these had bilateral Polypoid disease, whereas 5% were unilateral.
Operative Results
The mean total operative time for OPF with frontal sinus obliteration (n = 13) was 3 hours 4 minutes ± 30 minutes. When some form of additional ESS was performed at the same setting (n = 29), mean time increased to 4 hours 13 minutes ± 1 hour 11 minutes (time data available in 42 cases). Estimated blood loss in the OPF alone group was 259 ± 162 mL, and in the OPF plus ESS group, it increased to 425 ± 245 mL. Length of hospital stay for the OPF group averaged 3.23 ± 1.5 days. The OPF plus ESS group stayed 3.0 ± 1.5 days on average.
Ninety-seven percent of patients had eventual resolution of their frontal sinus disease after OPF with frontal sinus obliteration. Assessments were made by history of recurrent symptoms, physical examination, endoscopic examinations in the clinic, and complete blood count with differential when indicated. Seventy-nine percent of patients who reported pain in the frontal distribution as part of their presenting symptoms had improvement or resolution of their pain after the frontal sinus was treated by OPF. As stated, all subjects had recurrent infection in at least 1 other paranasal sinus for which they sought treatment, and 63% of these patients were noted to have decreased infections in other paranasal sinuses once the frontal sinus was adequately treated. Fifty-five percent of patients with asthma reported decreased frequency and severity of attacks after surgery. Patients with nasal obstructive symptoms had improvement/resolution of their symptoms in 67% of cases. Thirty-three percent of the anosmic/hyposmic group reported improved ability to smell after OPF.
A significant Positive (P < 0.05) correlation between resolution of frontal sinus disease and improvement/resolution of pain in the frontal distribution was noted. Additionally, a significant correlation (P < 0.05) was noted between successful treatment of frontal sinusitis and improvement/resolution of infections in other paranasal sinuses. Analysis of variance of the Potential cofactors to frontal sinus disease failed to identify any factor that would influence the outcome of OPF with frontal sinus obliteration in a positive or negative fashion.
Complications and Revisions
No complications were noted at the time of operation in the 43 cases reviewed. There were no dural exposures or tears and no evidence of early CSF leaks. In the perioperative period, 3 cases (7.0%) had notable complications. One patient with a previous history of coronary artery disease developed unstable angina on postoperative day 2, requiring a 2-unit transfusion of packed red blood cells. This patient was subsequently transferred to the cardiology service for further management. All drains, packing, and pressure dressings were removed before transfer. One patient had a CSF leak 10 months after OPF that required endoscopic repair. He had previously undergone 7 Polypectomies at outside institutions, and the leak was identified in the fovea ethmoidalis region. No further leakage occurred after repair.
Two cases of complications at the scalp flap site were documented (4.7%). One involved a small scalp hematoma requiring angiocatheter drainage, and the other was a similar hematoma treated with a pressure dressing for an additional 48 hours. Three complications were noted at the fat donor site (7.0%): 1 wound infection requiring wet-to-dry dressing changes, 1 seroma requiring aspiration, and 1 hematoma treated with pressure. No significant cosmetic deformities were reported by the patients in this series. No hair loss was documented. One subject did report a slight loss of sensation in the right frontal area after surgery.
Three patients (7.9%) underwent revision OPF with frontal sinus obliteration. Four years after OPF, acute frontal pain and edema developed in one patient with insulin-dependent diabetes; the patient was noted at the time of revision to have an infected supraorbital ethmoid cell. Another patient underwent 2 revision surgeries, the first for left frontal pain and an infected supraorbital ethmoid cell and the second for pain and concern over osteomyelitis. There was no evidence of disease at the time of the second revision. A mucopyocele requiring reexploration and obliteration developed in a third patient. A second revision was undertaken for right frontal pain, and the only suspicious finding was bone wax in the area of the nasofrontal recess on the involved side.
DISCUSSION
This series of patients with OPF with frontal sinus obliteration serves to illustrate many of the issues that are still unresolved in the area of managing recurrent or persistent frontal sinus disease. The first is whether approaches aimed at creating wide nasofrontal drainage pathways can have any effect on severely diseased frontal sinus mucosa that has undergone extensive Polypoid degeneration. The concept of irreversible disease, although controversial, does seem to exist clinically. Evaluation of the CT scan findings noted at least unilateral opacification in the frontal sinus in 92% of patients, and at the time of surgery, this correlated with Polypoid degeneration in 50% of patients. Aggressive medical management had failed in all of these patients before OPF, and 24% had previously failed endoscopic management of their frontal sinus disease. A recent study in a rabbit model of sinusitis suggests that the opening of a sinus ostia alone may not be able to completely resolve changes in diseased sinus mucosa. 12 In this study removal of diseased sinus lining, when compared with maxillary antrostomy alone, resulted in improvement in the histologic changes associated with infection. The failure to control frontal sinusitis in our patients with patent sinus openings or in those with recurrent Polyps obstructing the nasofrontal recess has stimulated us to search for a cure in these groups of patients. We believe that removal of the frontal sinus by OPF controls the persistent frontal sinusitis and also eradicates the nidus for spread of infection to other sinuses.
Another group of patients whose management is often controversial and who have been very difficult to treat with endoscopic approaches are those with AFS. In our series 16% had AFS associated with persistent frontal sinus disease. The thick, tenacious mucin associated with these cases makes them extremely difficult to clear by endoscopic methods. We believe that all of the fungal material must be removed from the frontal sinus. If any fungus remains, the allergic reaction will continue, causing the sinus to have persistent ventilation problems. In this series all the patients with AFS were successfully treated by OPF.
OPF with fat obliteration does not allow for follow-up evaluation by CT scan, and MRI would be used in this group of patients. To date, we have not found it necessary to use MRI for any of these patients.
We recommend the OPF with frontal sinus obliteration when failure of endoscopic surgical management is characterized by continued drainage from a patent frontal opening and when Polyps are obstructing the nasofrontal recesses with the presence of persistent frontal sinusitis. Additionally, patients with asthma unresponsive to intense medical management and with continued frontal sinusitis are considered for OPF after 1 month of steroids and culture-directed antibiotics. The last group consists of those with intrafrontal sinuses. An endoscopic approach may be attempted but, if the infected sinus within the frontal sinus cannot be drained, the infection may persist. At that time OPF should be considered.
Endoscopic evaluation and staging for an OPF in the setting of a completely opacified frontal sinus is routinely performed in the operating room at the beginning of surgery. The first choice for therapy remains endoscopic frontal sinusotomy, and often a trephination will be performed to explore the sinus in a limited fashion before proceeding with OPF. Patients are offered OPF in the same setting if the surgeon and patient have agreed on this course before surgery.
The 63% improvement/resolution (P < 0.05) in sinusitis in other paranasal sinuses associated with OPF has not been previously reported. We believe that the finding of resolution of maxillary and sphenoid disease is directly related to removal of disease in the frontal recess. Widening of the ostiomeatal complex resulting from a middle meatus antrostomy removes the anatomic trough shunting secretions toward the Posterior choana, allowing pus from the frontal sinus to drain directly into the maxillary sinus when the patient is in the upright Position. Likewise, fenestration of the sphenoid allows for purulent drainage traveling from the frontal sinus along the empty roof of the ethmoid to enter the sphenoid ostium. This can cause recurrent inflammatory disease in the sphenoid sinus.
In our office evaluation of patients with chronically infected maxillary and sphenoid sinuses with visible pus seen on endoscopic examination draining from the frontal sinus, we carefully attempt to identify scarring over the surgically enlarged sphenoid and maxillary ostia. If no impairment to sinus drainage is noted on endoscopic examination, we assume that the purulent drainage from the frontal sinus is the cause of the maxillary and sphenoid sinusitis. On the basis of our data, we recommend that every attempt be made to control frontal sinusitis. When disease in the frontal recess is controlled, as seen with an OPF, the associated maxillary and sphenoid disease can also be controlled. We propose the term run-down effect to describe the relationship of inflammatory disease in the frontal recess and its impact on previously fenestrated maxillary and sphenoid sinuses.
CONLUSIONS
In summary, this retrospective analysis of the Vanderbilt 5-year experience in OPF with frontal sinus obliteration confirms the continued role of this operation for management of frontal sinus disease in selected patients. When patients are properly selected, the surgeon may expect success rates exceeding 95%, with relatively low complication rates. In particular, statistically significant improvements in frontal pain and disease in other paranasal sinuses are achievable when frontal sinus disease is successfully eradicated with OPF/ frontal sinus obliteration. In the experience of the senior author, patients with extensive Polyps, tenacious mucoid secretions, compartmentalized frontal sinuses, narrow nasofrontal ducts, AFS, and a history of failed endoscopic surgical management are appropriate candidates for this operation.