The Frontal Sinus E-Book

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1069

Veröffentlichungsjahr: 2022

Beschreibung

"This book will be a valuable resource for novice surgeons approaching one of the most challenging anatomical subsites, since it provides a stepwise approach to understanding the anatomical background, the radiological aspects, and the broad spectrum of different surgical approaches to the frontal sinuses.The authors are to be congratulated for this masterpiece, which will become the gold standard for experts and beginners." —Paolo Castelnuovo

Edited by renowned rhinologists and skull base surgeons Christos Georgalas and Anshul Sama, this complete guide to frontal sinus surgery covers surgical anatomy and radiology, frontal-specific pathology, surgical techniques, technical advancements, and controversies. It focuses on those starting surgical practice and it is also of interest to well-established surgeons.

This book brings together some of the leading surgeons across the globe to provide varied and complementary perspectives. The content is organized in five sections: surgical anatomy, specific conditions of the frontal sinus, open surgical approaches, endoscopic surgical approaches, and controversies.

Key Features

• More than 600 full-color images and diagrams illustrating surgical concepts and demonstrating detailed techniques
• Stepwise descriptions of surgical techniques with a "tips and tricks" section in each chapter drawn from the authors' experience
• Clinical case presentations in each chapter illustrating key concepts and techniques
• A truly global and balanced perpective with world-leading authors from all continents
• Controversial topics analyzed from evidence-based medicine (EBM) perspective

This is a must-have resource for otolaryngology–head and neck surgery residents, fellows, and specialists that may also benefit neurosurgeons, maxillofacial surgeons, plastic surgeons, and other clinicians who deal with this challenging and complex area.

This book includes complimentary access to a digital copy on https://medone.thieme.com.

Leseprobe

To access the additional media content available with this e-book via Thieme MedOne, please use the code and follow the instructions provided at the back of the e-book.

The Frontal Sinus

Surgical Approaches and Controversies

Christos Georgalas, MD, PhD, DLO, FRCS (ORL-HNS), FEBORL-HNS (Hon.)Professor of Head and Neck SurgeryUniversity of Nicosia Medical SchoolNicosia, Cyprus;Director of Endoscopic Skull Base AthensHygeia HospitalAthens, Greece

Anshul Sama, MBBS, FRCS (Gen Surg), FRCS (ORL-HNS)Consultant Rhinologist and Endoscopic Skull Base SurgeonNottingham University Hospital NHS TrustNottingham, UK

614 illustrations

ThiemeNew York • Stuttgart • New York • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication Data is available from the publisher

© 2022. Thieme. All rights reserved

Georg Thieme Verlag KG

Rüdigerstraße 14, 70469 Stuttgart, Germany

www.thieme.de

+49 [0]711 8931 421, [email protected]

Cover design: © Thieme

Cover image source: © Thieme/Martina Berge

The cover image was composed using following images

Head: © SciePro/stock.adobe.com

Drawings in circles: © Thieme/Katja Dalkowski

Typesetting by Ditech, India

Printed in Germany by Beltz Grafische Betriebe 5 4 3 2 1

ISBN 978-3-13-240052-8

Also available as an e-book:

eISBN 978-3-13-242669-6

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page.

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

Thieme addresses people of all gender identities equally. We encourage our authors to use gender-neutral or genderequal expressions wherever the context allows.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

To my children, Odysseas and Fivos, born between countries, between eras, and to whom the future belongs.

To the victims and fighters of COVID-19 pandemic—those struggling to bring light in a time of darkness.

Christos Georgalas

To my wife, Sohini, for her patience and endurance.

Anshul Sama

Foreword

It is my great pleasure to write a foreword for this illuminating work which probably represents one of the most complete dissertations about the management of frontal sinus pathologies, with a special emphasis on surgical treatments. The authors have a great experience in dealing with nose and paranasal sinus pathologies, having shown a deep expertise on this argument and a clear intention to expand the limits of discovery in such a fascinating anatomical compartment; with this work they make available a huge wealth of knowledge for everyone concerned with this topic.

This book will be a valuable resource for novice surgeons approaching one of the most challenging anatomical subsites, since it provides a stepwise approach to understanding the anatomical background, the radiological aspects, and the broad spectrum of different surgical approaches to the frontal sinuses. However, it also represents a valuable tool for senior specialists, since it offers an overview of innovative advanced approaches presented by leading experts in the international surgical scene.

The essential skills to treat safely and effectively inflammatory, neoplastic, and traumatic diseases affecting the frontal sinuses are provided; in addition, the limits of different approaches and controversial topics in current practice are presented in detail.

Both external and endoscopic approaches are systematically presented, focusing on indications and contraindications, providing a step-by-step description of the surgical techniques with useful tips and tricks, aswell as an overview of their complications. Additionally, the authors have included various conservative treatment strategies and minimally invasive modifications of traditional approaches which are currently employed in clinical practice.

Several photographic reproductions, crisp and clear illustrations, anatomical specimens, and representative clinical cases make the concepts easy to understand and its reading enjoyable. I could not find words to describe the stunning beauty of the images.

Finally, the authors take a look at the future, presenting the latest innovations in the field of techniques and technologies, opening new horizons toward effective and increasingly less invasive approaches which represent the frontier of contemporary surgery. The authors are to be congratulated for this masterpiece, which will becomethe gold standard for experts and beginners.

Highly accurate and effective works such as this are crucial to further solidify the surgical prowess of the ENT surgeons of the future.

Paolo Castelnuovo, MD, FRCSEd, FACSProfessor and ChairmanHead of Department of OtorhinolaryngologyHead of Department of Specialized SurgeriesUniversity of InsubriaVarese, Italy

Foreword

“I wish that I knew... when Iwas younger.” This line from the band Faces, covered by Rod Stewart, captures exactly how I feel about this book on frontal sinus surgery! For me, the book captures more than 20 years of personal trial and error to find the most successful approaches to this complicated region. These approaches have been beautifully catalogued and described so that the reader can learn from the experts, who have already found success with them. Christos and Anshul have managed to compile every meaningful aspect of frontal sinus surgery and have covered it in detail. It is obvious that the descriptions and chapters have been honed by years of teaching courses, especially the "Frontal Sinus Surgery Course" in Nottingham, UK. This course has been sold out for over a decade, and I have been privileged enough to participate in it, along with my friends and colleagues. I never thought “work” could be so fun, and it is all due to my “sinus friends” (the authors and editors of this book) who have made it so. I am sure you will like reading about and understanding the frontal sinus with this book as all the members of our group did producing it, led by Christos and Anshul!

I will leave you with another slightly silly quote—there was an advert in the States for Prego spaghetti sauce in the 1980s—and it ended with “It’s in there!” The implied meaning was that everything good was in the sauce—well for Frontal Sinus Surgery, I can assure you “It’s in there!”

James N. Palmer, MDProfessor and DirectorDivision of Rhinology;Co-Director, Center for Skull Base SurgeryDepartment of ORL:HNS and NeurosurgeryUniversity of PennsylvaniaPhiladelphia, Pennsylvania, USA

Preface

“The most beautiful sea hasn’t been crossed yet. The most beautiful child hasn’t grown up yet. Our most beautiful days we haven’t seen yet.”

–Nazim Hikmet

The last decade has brought a “democratization” of frontal sinus surgery—more and more people are interested in it, are writing about it, and are practicing it: What used to be the “final frontier” of endoscopic sinus surgery, exclusive domain of a small group of highly specialized rhinologists, is nowpart of the surgical armamentarium of a larger group of otolaryngologists dealing with frontal sinus pathology. This is reflected not only in practice logbooks but also in the success of dedicated frontal sinus courses (such as the Nottingham course) and the growth of publications on frontal sinus surgery over the last decade (a more than doubling in PubMed citations over the last 20 years). This book is both a result and a celebration of this trend.

There has been a proliferation of new techniques in conjunction with a better understanding of the role of surgery in the management of inflammatory disease. Although it would be elegant to present the evolution of frontal sinus surgery as a smooth transition from more traumatic (external) approaches to less invasive (intranasal) ones, reality is different: The history of frontal sinus surgery is more like a pendulum—from more extended (open) approaches to more conservative (mini functional endoscopic sinus surgery [FESS 1 ], limited FESS, balloon sinuplasty), and again back to more extended (full house FESS, Draf III, Denker), as better understanding of pathophysiology of what is primarily a medical disease makes us more humble and more open to different approaches. We understand that there is no place for “god-derived truths” in frontal sinus surgery—different approaches can be combined; different techniques, materials, and concepts have their place; and one should be careful in choosing the approach that fits the patient, the pathology, and the surgeon.

Looking back over the last 20 years makes us think how many new ideas have been introduced and subsequently abandoned. Precision medicine and the role of biologics are revolutionizing the management of inflammatory sinus disease. However, we feel that anatomy will always be key to its management as creating the space and providing local treatment to the frontal sinus will remain important. Endoscopic skull base surgery is both a product and a driving force of frontal sinus surgery techniques. Advances in reaching and operating in the frontal sinus have facilitated dealing with anterior skull base lesions and defects endoscopically, while our confidence in reaching intradural lesions has expanded the indications and applications of frontal sinus surgery.

The book is divided into five parts: Anatomy of the frontal sinus, endoscopic and open surgical techniques, management of specific frontal sinus pathologies, and controversies in managing the frontal sinus. Most parts are supplemented by video materials meant to illustrate the concepts and techniques described in the chapters.

Almost half of the book is dedicated to controversies: That is part of the book that we most cherish—we enjoyed being challenged by some of the authors, and having “crossed swords” in different settings, we consider the plurality of opinions not a weakness but a strength of the book.

Enjoy this book with an open mind, and we are looking forward to discussing the concepts, when the epidemic ends, in an open setting. Feel free to challenge us, the editors, the authors, and the publisher for anything you may disagree with. Remember:

vīta brevis, ars longa, occāsiō praeceps, experīmentum perīculōsum, iūdicium difficile.

[Life is short, and art long, opportunity fleeting, experimentations perilous, and judgment difficult.]

Christos Georgalas, MD, PhD, DLO, FRCS (ORL-HNS), FEBORL-HNS (Hon.) Anshul Sama, MBBS, FRCS (Gen Surg), FRCS (ORL-HNS)

Acknowledgments

Wewould like to thank Dr. Alexandros Poutoglidis, MD, MSc, PhD, Dr. Nikolaos Tsetsos, MD, MSc, PhD, and Dr. Amanda Oostra, MD, MSc, who very kindly reviewed and further amended the proofs.

Christos Georgalas, MD, PhD, DLO, FRCS (ORL-HNS), FEBORL-HNS (Hon.) Anshul Sama, MBBS, FRCS (Gen Surg), FRCS (ORL-HNS)

Contributors

Waleed M. Abuzeid, BSc (Hons), MBBS

Associate Professor;

Director of Rhinology Research

Division of Rhinology and Endoscopic Skull Base Surgery

Department of Otolaryngology

Head and Neck Surgery

University of Washington

Seattle, Washington, USA

Nithin D. Adappa, MD

Associate Professor

Department of Otorhinolaryngology

Penn Medicine

University of Pennsylvania

Pennsylvania, Philadelphia, USA

Shahzada Ahmed, MBChB, BSc (Hons), DLO, FRCS (ORL-HNS), PhD

Consultant Rhinologist and Skull Base & Surgeon

Clinical Service Lead

Department of Ear, Nose and Throat (ENT) Surgery

University Hospitals Birmingham NHS Foundation Trust

Birmingham, UK

Fahad Alasousi, MBBCh, SB-ORL

ENT Senior Specialist

Endoscopic Sinus and Anterior Skull Base Surgery

Farwaniyah Hospital

Farwaniyah Governorate, Kuwait

Isam Alobid, MD

Skull Base Unit

ENT department

Hospital Clinic, Barcelona;

Professor Barcelona University

Barcelona, Spain

Abdulaziz Al-Rasheed, MD

Assistant Professor

Department of Otolaryngology

King Abdulaziz University Hospital

King Saud University

Riyadh, Saudi Arabia

Jeremiah A. Alt, MD, PhD, FACS

Associate Professor, Department of Surgery

Vice Chair, Equity, Diversity and Inclusion

Division of Otolaryngology – Head and Neck Surgery

University of Utah

Salt Lake City, Utah, USA

Klementina Avdeeva, MD

Otorhinolaryngologist

Department of Otorhinolaryngology

Clinical Diagnostic Center Medsi

Moscow, Russia

Catherine Banks, MBChB, FRACS (OHNS)

Otolaryngologist – Adult and Pediatric

Rhinology and Skull Base Surgery

Department of Otolaryngology – Head and Neck Surgery

Prince of Wales Hospital

Sydney Children's Hospital

University of New South Wales

Sydney, New South Wales, Australia

Martyn Barnes MD FRCS (ORL-HNS)

Consultant Rhinologist

Southend University Hospital NHS Foundation Trust

Essex, UK

Hazan Basak, MD

Professor

Department of Otorhinolaryngology

Head and Neck Surgery

Ankara University Medical School

Ankara University

Ankara, Turkey

Pete S. Batra, MD, FACS

Stanton A. Friedberg, MD Endowed Chair and Professor;

Clinical Leader, ENT, Dermatology, and Audiology Service Line;

Co-Director, Rush Center for Skull Base and Pituitary Surgery;

Medical Director, Rush Sinus, Allergy, and Asthma Center

Department of Otorhinolaryngology – Head andNeck Surgery

Rush University Medical Center

Chicago, Illinois, USA

Paolo Battaglia, MD

Professor

Department of Otorhinolaryngology

University of Insubria

Varese, Italy

Manuel Bernal-Sprekelsen, MD, PhD

Head

ENT Department

Hospital Clinic of Barcelona;

Chair of ENT Department

University of Barcelona

Barcelona, Spain

Suha Beton, MD

Department of Otorhinolaryngology, Head and

Neck Surgery

Ankara University Medical School

Ankara University

Ankara, Turkey

Yves Brand, MD

Head of Department

Department of Otolaryngology

Cantonal Hospital Graubunden

Chur, Switzerland;

Associate Professor

University of Basel

Basel, Switzerland

Paul Breedveld, MSc, PhD

Antoni van Leeuwenhoek Distinguished Professor; Director

3mE Graduate School; Chair

Section of Minimally Invasive Surgery & Bio-Inspired Technology

Department of Bio-Mechanical Engineering; Faculty

Mechanical, Maritime & Materials Engineering (3mE)

Delft University of Technology

Delft, the Netherlands

Hans Rudolf Briner, MD

Otorhinolaryngologist and Head and Neck Surgeon

ORL-Zentrum Klinik Hirslanden

Zurich, Switzerland

Christian von Buchwald, MD, DMSc

Professor

Department of Otorhinolaryngology, Head & Neck Surgery and Audiology

Copenhagen University Hospital

Copenhagen, Denmark

Ricardo L. Carrau, MD, MBA

Professor

Department of Otolaryngology – Head & Neck Surgery;

Director of the Comprehensive Skull Base Surgery Program

The Ohio State University Medical Center

Columbus, Ohio, USA

Sean Carrie, Mb, ChB, FRCS, FRCS (ORL)

Consultant ENT Surgeon;

Honorary Senior Lecturer, Newcastle University

The Newcastle upon Tyne Hospitals NHS Foundation Trust

Newcastle upon Tyne, UK

Paolo Castelnuovo, MD, FRCSEd, FACS

Professor and Chairman

Head of Department of Otorhinolaryngology

Head of Department of Specialized Surgeries

University of Insubria

Varese, Italy

Vasileios Chatzinakis, MD, MSc

Consultant Otorhinolaryngologist – Head and Neck Surgeon

Endoscopic Sinus and Skull Base Center

Head and Neck Department

HYGEIA Hospital

Athens, Greece

Philip A. Chen, MD

ENT Specialist

Department of Otolaryngology – Head and Neck Surgery

University of Texas Health San Antonio

San Antonio, Texas, USA

Deborah Chute, MD

Associate Professor of Pathology

Department of Pathology

Cleveland Clinic

Cleveland, Ohio, USA

Caroline S. Clarke, PhD

Senior Research Associate in Health Economics

UCL Research Department of Primary Care and Population

Health

University College London

London, UK

David B. Conley, MD

Associate Professor

Department of Otolaryngology – Head and Neck Surgery

Northwestern University

Chicago, Illinois, USA

James Constable, MD

ENT Registrar

Department of Adult Ear Nose and Throat

University Hospitals Bristol NHS Foundation Trust

Bristol, UK

John R. Craig, MD

Division Chief, Rhinology and Endoscopic Skull Base Surgery

Department of Otolaryngology – Head and Neck Surgery

Henry Ford Health System

Detroit, Michigan, USA

Anali Dadgostar, MD, MPH, FRCSC

Clinical Instructor

Department of Surgery

Faculty of Medicine

The University of British Columbia

Vancouver, Canada

Iacopo Dallan, MD

Surgeon

ENT and Phoniatric Unit

Azienda Ospedaliero-Universitaria Pisana

Pisa, Italy

John M. DelGaudio, MD, FARS

Professor and Vice Chair

Department of Otolaryngology – Head and Neck Surgery;

Chief of Rhinology;

Director

Emory Sinus, Nasal, & Allergy center

Emory University

Atlanta, Georgia, USA

Ioannis I. Diamantopoulos, MD, DAvMed, Colonel HAF, FAsMA

Consultant Otorhinolaryngologist;

Clinical Director

ENT Head & Neck Surgery Department

Hellenic Air Force General Hospital

Athens, Greece

M Reda El Badawey, MB ChB, FRCS, FRCS ORL-HNS, MD

Consultant of Otolaryngology – Head and Neck Surgery

Freeman Hospital

Newcastle upon Tyne, UK;

Associate Professor of Otolaryngology

Tanta University

Tanta, Egypt

Jean Anderson Eloy, MD, FARS

Professor and Vice Chair

Department of Otolaryngology – Head and Neck Surgery

Rutgers New Jersey Medical School

Newark, New Jersey, USA

Samer Fakhri, MD, FACS, FRCS(C)

Professor & Chair

Medical Director, ORL Specialty Clinics

Department of Otorhinolaryngology – Head & Neck Surgery

American University of Beirut Medical Center

Beirut, Lebanon;

Department of Otolaryngology

Kelsey-Seybold Clinic

Houston, Texas, USA

Judd H. Fastenberg, MD

Otolaryngologist

Department of Otorhinolaryngology – Head & Neck Surgery

Northwell Health

New York City, New York, USA

Enrico Fazio, MD

Professor

Department of Otorhinolaryngology

University of Insubria

Varese, Italy

Ulrik A. Felding, MD, PhD

ENT Specialist

Department of Otorhinolaryngology

Nordsjællands Hospital

Hillerød, Denmark

Marvin P. Fried, MD

Professor and Chair Emeritus

Department of Otorhinolaryngology – Head & Neck Surgery

Albert Einstein College of Medicine

New York City, New York, USA

Christos Georgalas, MD, PhD, DLO, FRCS (ORL-HNS), FEBORL-HNS (Hon.)

Professor of Head and Neck Surgery

University of Nicosia Medical School

Nicosia, Cyprus;

Director of Endoscopic Skull Base Athens

Hygeia Hospital

Athens, Greece

Anne E. Getz, MD

Associate Professor

Otolaryngology – Head and Neck Surgery;

Associate Residency Program Director

University of Colorado School of Medicine

Aurora, Colorado, USA

Nsangou Ghogomu, MD

Otolaryngologist

Colorado Permanente Medical Group

Denver, Colorado, USA

Tomasz Gotlib, MD

Associate Professor

Department of Otorhinolaryngology – Head andNeck Surgery

Medical University of Warsaw

Warsaw, Poland

David A. Gudis, MD, FACS, FARS

Chief

Division of Rhinology and Anterior Skull Base Surgery

Department of Otolaryngology – Head and Neck Surgery;

Department of Neurologic Surgery

Columbia University Irving Medical Center

NewYork-Presbyterian Hospital

New York City, New York, USA

Edward Hadjihannas, MD

Consultant ENT Surgeon

Aretaeio Hospital

Nicosia, Cyprus

Richard J. Harvey, MD, PhD

Professor and Program Head

Rhinology and Skull Base Research Group

Macquarie University;

University of New South Wales

Sydney, Australia

Philippe Herman, MD

Head

Department of ENT, Maxillofacial and Skull Base Surgery

Skull Base Center;

Head of DMU Neurosciences Adults/Neuroscience CEO

Lariboisière Hospital, AP-HP

University of Paris

Paris, France

Roland Hettige, FRCS (ORL-HNS), MBBS, BSc, MSc

Consultant Rhinologist and ENT Surgeon

Princess Margaret Hospital,

Windsor, Berkshire, UK

Claire Hopkins, FRSC (ORLHNS), DM (Oxon)

Professor of Rhinology

King's College

London, UK

Qasim Husain, MD

Assistant Professor

Department of Otolaryngology

Hackensack Meridian School of Medicine

Seton Hall University

Coastal Ear, Nose, and Throat

Holmdel, New Jersey, USA

Dimitris Ioannidis, MD, PhD

Consultant ENT

East Suffolk and North Essex NHS Foundation Trust

Colchester, UK

Roger Jankowski, MD, PhD

Professor

ORL Department CHRU Brabois

University of Lorraine

Vandoeuvre Cedex, France

Amin Javer, MD, FRCSC, FARS

Director/Head

St. Paul's Sinus Centre

Clinical Professor of Surgery;

Research Co-Director

The University of British Columbia

Vancouver, Canada

Hari Jeyarajan, MD

Assistant Professor

School of Medicine

Department of Otolaryngology

The University of Alabama at Birmingham

Birmingham, Alabama, USA

Vivek V. Kanumuri, MD

Resident

Department of Otolaryngology–Head and Neck Surgery

Harvard Medical School

Harvard University

Cambridge, Massachusetts, USA

Apostolos Karligkiotis, MD

Professor

Division of Otorhinolaryngology – Head & Neck Surgery

Circolo Hospital and Macchi Foundation

Varese, Italy

Robert C. Kern, MD

George A. Sisson Professor of Otolaryngology;

Chair, Department of Otolaryngology

Head and Neck Surgery;

Professor, Otolaryngology – Head and Neck Surgery

Medicine-Allergy-Immunology

Feinberg School of Medicine

Northwestern University

Chicago, Illinois, USA

Nadim Khoueir, MD

Professor

Otolaryngology Head & Neck Surgery

Rhinology/Endoscopic Sinus & Skull Base Surgery

Faculty of Medicine

Saint Joseph University;

Hotel Dieu de France University Hospital;

Beirut Eye & ENT Specialist Hospital

Beirut, Lebanon

Roger Jankowski, MD, PhD

Professor

ORL Department CHRU Brabois

University of Lorraine

Vandoeuvre Cedex, France

Amin Javer, MD, FRCSC, FARS

Director/Head

St. Paul's Sinus Centre

Clinical Professor of Surgery;

Research Co-Director

The University of British Columbia

Vancouver, Canada

Hari Jeyarajan, MD

Assistant Professor

School of Medicine

Department of Otolaryngology

The University of Alabama at Birmingham

Birmingham, Alabama, USA

Vivek V. Kanumuri, MD

Resident

Department of Otolaryngology–Head and Neck Surgery

Harvard Medical School

Harvard University

Cambridge, Massachusetts, USA

Apostolos Karligkiotis, MD

Professor

Division of Otorhinolaryngology – Head & Neck Surgery

Circolo Hospital and Macchi Foundation

Varese, Italy

Robert C. Kern, MD

George A. Sisson Professor of Otolaryngology;

Chair, Department of Otolaryngology

Head and Neck Surgery;

Professor, Otolaryngology – Head and Neck Surgery

Medicine-Allergy-Immunology

Feinberg School of Medicine

Northwestern University

Chicago, Illinois, USA

Nadim Khoueir, MD

Professor

Otolaryngology Head & Neck Surgery

Rhinology/Endoscopic Sinus & Skull Base Surgery

Faculty of Medicine

Saint Joseph University;

Hotel Dieu de France University Hospital;

Beirut Eye & ENT Specialist Hospital

Beirut, Lebanon

Guillermo Maza, MD

Resident Physician

Department of Otolaryngology

SIU School of Medicine

Springfield, Illinois, USA

Kelsey McHugh, MD

Assistant Professor of Pathology

Department of Pathology

Cleveland Clinic

Cleveland, Ohio, USA

Cem Meço, MD, FEBORL-HNS

President

Confederation of European Otorhinolaryngology, Head and

Neck Surgery;

Vice President and Examiner

European Board Examination in ORL-HNS by UEMS;

Faculty

Department of Otorhinolaryngology, Head and Neck Surgery

Salzburg Paracelsus Medical University

Salzburg, Austria;

Professor and Past Chairman

Department of Otorhinolaryngology, Head and Neck Surgery

Ankara University Medical School

Ankara, Turkey

Lodovica Cristofani Mencacci, MD

Surgeon

ENT and Phoniatric Unit

Azienda Ospedaliero-Universitaria Pisana

Pisa, Italy

Stephen Morris, PhD

RAND Professor of Health Services Research

Department of Public Health and Primary Care

University of Cambridge

Cambridge, UK

David Morrissey, MBBS (HONS), FRACS (ORL)

Senior Lecturer

School of Medicine

The University of Queensland;

Otolaryngologist – Head and Neck Surgeon

Darling Downs Health Service

Toowoomba, Queensland

Salil Nair MD, FRCS ORL-HNS, FRCS Eng, FRCS Ed, MB ChB

Consultant ORL Surgeon

Honorary Associate Professor

University of Auckland

Auckland, New Zealand

Prepageran Narayanan, FRCS

Department of Otorhinolaryngology

Faculty of Medicine

University Malaya

Kuala Lumpur

Malaysia

Richard R. Orlandi, MD

Professor

Otolaryngology – Head and Neck Surgery;

Associate Chief Medical Officer

Ambulatory Health

University of Utah Health

Salt Lake City, Utah, USA

Charles F. Palmer, MD

Resident Physician

Department of Psychiatry and Behavioral Sciences

Department of Neurosciences

Medical University of South Carolina

Charleston, South Carolina, USA

James N. Palmer, MD

Professor and Director

Division of Rhinology;

Co-Director, Center for Skull Base Surgery

Department of ORL: HNS and Neurosurgery

University of Pennsylvania

Philadelphia, Pennsylvania, USA

Arjun K. Parasher, MD

Assistant Professor

Rhinology and Skull Base Surgery,

Department of Otolaryngology – Head and Neck Surgery

University of South Florida

Tampa, Florida, USA

Zara M. Patel, MD

Associate Professor

Director of Endoscopic Skull Base Surgery;

Rhinology – Sinus and Skull Base Surgery

Department of Otolaryngology – Head & Neck Surgery

Stanford School of Medicine

Stanford, California, USA

Michael J. Pfisterer, MD

ENT Specialist

Department of Otolaryngology – Head and Neck Surgery

Sutter Health

Fairfield, California, USA

Carl M. Philpott, MB, ChB, DLO, FRCS (ORL-HNS), MD, PGCME, SFHEA

Professor of Rhinology & Olfactology

Norwich Medical School

University of East Anglia

Norwich, UK

Giacomo Pietrobon, MD

Division of Otolaryngology and Head and Neck Surgery

IEO, European Institute of Oncology IRCCS;

Former Professor

Department of Biotechnology and Life Sciences

Division of Otorhinolaryngology

University of Insubria

Milan, Italy

Georgiy A. Polev, MD, PhD

Chief of Head and Neck Surgery Center

Ilyinskaya Hospital;

Senior Researcher

Department of Oncology and Pediatric Surgery

Dmitry Rogachev National Research Center of Pediatric

Hematology, Oncology and Immunology

Moscow, Russia

Daniel M. Prevedello, MD

Professor

Department of Neurological Surgery;

Director, Minimally Invasive Cranial Surgery Program;

Co-Director, Comprehensive Skull Base Center at The James;

Director, Pituitary Surgery Program

The Wexner Medical Center

The Ohio State University

Columbus, Ohio, USA

Alkis J. Psaltis, MBBS (HONS), PhD, FRACS (ORL)

Professor of Otolaryngology – Head and Neck Surgery

University of Adelaide;

Head of Department

Otolaryngology – Head and Neck Surgery

The Queen Elizabeth Hospital

Adelaide, South Australia

Yujay Ramakrishnan, MBBChir, MA, MRCS (Ed), DOHNS, MFPM, FRCS (ORL-HNS)

Consultant Otolaryngologist

Queens Medical Centre

Nottingham, UK

Ashok Rokade, MS, DLO(RCS), FRCSI, FRCS(ORL-HNS)

Consultant ENT surgeon

Royal Hampshire County Hospital, Winchester

University Hospital Southampton, UK

Christopher Roxbury, MD

Assistant Professor of Surgery

Department of Otolaryngology – Head and Neck Surgery;

Director

Endoscopic Skull Base Surgery

UChicago Medicine

Chicago, Illinois, USA

Raymond Sacks, MBBCH, FCS (SA) ORL, FRACS

Clinical Professor and Head

Department of Otolaryngology – Head & Neck Surgery

Faculty of Medicine and Health Sciences

Macquarie University;

Clinical Professor

University of Sydney

Sydney, Australia

Anshul Sama, MBBS, FRCS (Gen Surg), FRCS (ORL-HNS)

Consultant Rhinologist and Endoscopic Skull Base Surgeon

Nottingham University Hospital NHS Trust

Nottingham, UK

E. Ritter Sansoni, MD

Assistant Professor

Department of Otolaryngology – Head and Neck Surgery

Division of Rhinology and Skull Base Surgery

Division of Head and Neck Surgery

University of Tennessee Health Science Center

Memphis, Tennessee, USA

Alfonso Santamaría-Gadea, MD, PhD

Otorhinolaryngologist and Head and Neck Surgeon

Rhinology and Skull Base Surgery Unit

Otolaryngology Service

Ramón y Cajal University Hospital

Madrid, Spain

Rodney J. Schlosser, MD

Professor and Director of Rhinology

Department of Otolaryngology – Head and Neck Surgery

Medical University of South Carolina

Charleston, South Carolina, USA

Veronica Seccia, MD, PhD

Surgeon

ENT and Phoniatric Unit

Azienda Ospedaliero-Universitaria Pisana

Pisa, Italy

Raj Sindwani, MD, FACS, FRCS(C)

Vice Chairman and Section Head

Rhinology, Sinus & Skull Base Surgery Head and Neck;

Co-Director

Minimally Invasive Cranial Base & Pituitary Surgery Program

Burkhardt Brain Tumor & Neuro-Oncology Center;

Vice Chair of Enterprise Surgical Operations

Cleveland Clinic

Cleveland, Ohio, USA

Kristine A. Smith, MD

Assistant Professor

Department of Otolaryngology – Head and Neck Surgery

Health Sciences Centre

Winnipeg, Canada

Kato Speleman, MD

Consultant

ENT & Head and Neck Surgery

AZ Sint-Jan Brugge-Oostende AV

Bruges, Belgium

Soma Subramaniam, MBBCH, MMED, FRCS (ORL)

Senior Consultant and Clinical Director;

Adjunct Assistant Professor

Department of Otolaryngology – Head & Neck Surgery

Ng Teng Fong General Hospital

National University Hospital Singapore

Singapore

Pavol Šurda, MD

Consultant Rhinologist and Skull Base Surgeon

Guy’s and St Thomas’ NHS Foundation Trust

London, UK

Bobby A. Tajudeen, MD

Head

Section of Rhinology and Skull Base Surgery;

Vice, Research Affairs;

Assistant Professor

Department of Otorhinolaryngology

Rush University Medical Center

Chicago, Illinois, USA

Neil Cheng-Wen Tan, FRCS(ORL-HNS), MEd, PhD

Consultant Rhinologist and Honorary Senior Lecturer

Royal Cornwall Hospital

University of Exeter Medical School

Truro, United Kingdom

Dennis Tang, MD

Assistant Professor of Surgery

Division of Otolaryngology - Head and Neck Surgery

Cedars-Sinai Medical Center

Los Angeles, California, USA

Ing Ping Tang, FRCS

Consultant ORL-HNS

ORL-HNS Department

University of Malaysia, Sarawak

Sarawak, Malaysia

Osama Tarabichi, MD

Department of Otolaryngology – Head and Neck Surgery;

Department of Genetics

Washington University School of Medicine

St. Louis, Missouri, USA

Marc A. Tewfik, MDCM, MSc, FRCSC

Associate Professor

Department of Otolaryngology – Head & Neck Surgery

McGill University Health Centre

Montreal, Quebec, Canada

Kiranya E. Tipirneni, MD

Resident Physician

Department of Otolaryngology and

Communication Sciences

State University of New York Upstate Medical University

Syracuse, USA

Mario Turri-Zanoni, MD

Professor

Unit of Otorhinolaryngology – Head & Neck Surgery

University of Insubria;

ASST Sette Laghi

Circolo Hospital and Macchi Foundation

Varese, Italy

Benjamin K. Walters, MD

ENT Resident

San Antonio Military Medical Center

United States Air Force

San Antonio, Texas, USA

Bradford A. Woodworth, MD, FACS

James J. Hicks Endowed Professor of Otolaryngology;

Adjunct Professor of Neurosurgery;

Vice Chair of Clinical Affairs

Department of Otolaryngology

University of Alabama at Birmingham;

Senior Scientist

Gregory Fleming James Cystic Fibrosis Research Center Birmingham, UK

Peter John Wormald, MD, FAHMS, FRACS, FCS(SA), FRCS (Ed), MBChB

Chairman (Otolaryngology)

Head and Neck Surgery

Professor of Skull Base Surgery

University of Adelaide

Adelaide, Australia

Ahmed Youssef, MD, MRCS

Fellow

Department of Otolaryngology – Head and Neck Surgery

Queen Elizabeth Hospital Birmingham

Birmingham, UK

Contents

Foreword

Paolo Castelnuovo

Foreword

James N. Palmer

Preface

Acknowledgments

Contributors

Videos

Section I Anatomy of the Frontal Sinus and Frontal Recess

1Developmental Bases of the Anatomy of the Frontal Sinus

1.1Introduction

1.2Frontal Sinuses and Ethmoid Lateral Masses have Different Evolutionary and Developmental Origins

1.2.1The Ethmoid Develops from the Olfactory Cartilaginous Capsule

1.2.2The Frontal Sinuses Pneumatize after Erythropoietic Bone Marrow Conversion into Fatty Marrow

1.3The Nitric Oxide “Story” of the Paranasal Sinuses Makes them Play a Role in Blood Oxygenation on Demand

1.4Pneumosinus Dilatans and Arrested Pneumatization Could Bear Witness to Sinus Development

1.4.1Pneumosinus Dilatans

1.4.2Arrested Pneumatization

1.5Conclusion

2Radiological Anatomy

2.1Introduction

2.2Lamina Papyracea

2.3Uncinate Process

2.4Floor of Olfactory Recess

2.5Agger Nasi Air Cell

2.6Accessory Air Cells

2.7Anterior Ethmoidal Artery

2.8Bulla Ethmoidalis

2.9Middle Turbinate

2.10Conclusion

3Applied Surgical Anatomy

3.1General Considerations

3.2Applied Anatomy for Endonasal Approaches

3.3Applied Anatomy for External Approaches

3.3.1Coronal Approach

3.3.2Transpalpebral Approach

3.4Blood Supply

3.5Innervation

3.6Anatomical Variations and Surgical Considerations

3.7Conclusions

Section II Endoscopic Surgical Approaches to Frontal Sinus Disease

4Draf Frontal Sinusotomy I and IIa

4.1Indications

4.2Surgical Steps

4.3Tips and Tricks

4.4Case Examples

4.5Complications Management

4.6Conclusion

5Draf Frontal Sinusotomy IIb

5.1Indications

5.2Anatomy

5.3Surgical Steps

5.3.1Lateral Approach

5.3.2Median Approach

5.4Tips and Tricks

5.5Complications

6Extended Draf IIb and Other Modifications of the Lothrop Procedure

6.1Introduction

6.2Indications

6.3Surgical Steps

6.3.1Overview of Standard Draf IIb

6.4Modifications of the Standard Draf IIb Procedure

6.4.1Modified Hemi-Lothrop Procedure (Eloy IIC)

6.4.2Modified Mini-Lothrop Procedure (Eloy IID)

6.4.3Modified Subtotal-Lothrop Procedure (Eloy IIE)

6.4.4Modified Central-Lothrop Procedure (Eloy IIF)

6.5Tips and Tricks

6.6Case Examples

6.6.1Example 1

6.6.2Example 2

6.6.3Example 3

6.7Complications

6.7.1Recurrence and Chronic Scarring

6.7.2Cerebrospinal Fluid Leak

6.7.3Orbital Injury

6.7.4Anterior Ethmoid Artery Injury

7The Frontal Sinus Rescue Procedure

Fahad Alasousi, Anali Dadgostar, and Amin Javer

7.1Indications

7.2Surgical Steps

7.2.1Step 1

7.2.2Step 2

7.2.3Step 3

7.2.4Step 4

7.3Reverse Frontal Rescue Procedure

7.4Complications

7.5Tips and Tricks

7.6Conclusion

8Draf III (Endoscopic Modified Lothrop)— Inside-Out and Outside-In Approaches

8.1Indications

8.1.1Relative Contraindications

8.2Surgical Steps

8.3Lateral-to-Medial/Inside-Out Technique ▶ [168]

8.4Outside-In/Medial-to-Lateral Technique

8.5Tips and Tricks

8.6Case Examples

8.6.1A Case of Allergic Fungal Rhinosinusitis with Fronto-orbital Mucocele

8.6.2A Case of Chronic Frontal Sinusitis with a High Posterior Frontal (Type 3) Cell

8.6.3A Case of Chronic Frontal Sinusitis—Riedel’s Procedure Reversal

8.7Postoperative Management

8.8Complications and their Management

8.8.1Skull Base Injury and Cerebrospinal Fluid Leak

8.8.2Hemorrhage

8.8.3Orbital Injury

8.8.4Skin Injury

8.8.5Stenosis of the Frontal Sinus Neo-ostium

9Transseptal Approach

Bobby A. Tajudeen and Pete S. Batra

9.1Background and CT Review

9.2Indications and Contraindications

9.3Advantages

9.4Disadvantages

9.5Surgical Steps

9.6Tips and Tricks

9.6.1Case Example

9.7Complications

10Endoscopic Endonasal Orbital Transposition for Lateral Frontal Sinus Lesions

10.1Indications

10.2Surgical Steps

10.3Tips and Tricks

10.4Case Example

10.5Complications

11The Role of Frontal Sinus in Anterior Skull Base Surgery and the Transcribriform Approach

11.1Indications

11.2Surgical Steps

11.3Tips and Tricks

11.4Complications

12Extended Endonasal Anterior Skull Base Approaches

12.1Indications

12.2Surgical Steps

12.2.1Principles

12.2.2Operative Setup

12.2.3Surgical Technique

12.2.4Reconstruction

12.2.5Postoperative Considerations

12.3Tips and Tricks

12.4Case Examples

12.4.1Esthesioneuroblastoma (Rranscribriform Approach)

12.4.2Tuberculum Sellae Meningioma: Endoscopic Transtuberculum/Transplanum Approach

12.5Complications and Management

12.5.1Vascular Complications

12.5.2Cranial Nerve Injury

12.5.3Cerebrospinal Fluid Fistulas

12.5.4Postoperative Infection

12.5.5Other Complications

13Revision Endoscopic Frontal Sinus Surgery

13.1Introduction

13.2Indications

13.2.1Ongoing Mucosal Disease

13.2.2Incomplete Dissection

13.2.3Lateralization of the Middle Turbinate

13.2.4Scarring and Synechiae

13.2.5Neo-Osteogenesis

13.3Patient Selection

13.4Preoperative Planning

13.4.1Analyzing the Computed Tomography Imaging

13.4.2Computer-Assisted Navigation during Surgery

13.4.3Endoscopes and Equipment

13.5Choice of Procedure

13.6Surgical Steps

13.6.1The Axillary Flap Technique

13.6.2Frontal Sinus Mini-Trephine

13.7Specific Scenarios

13.7.1Retained Cells in the Frontal Recess or Extending into the Frontal Sinus (Draf I or International Classification of Extent of Endoscopic Frontal Sinus Surgery Grades 1–3)

13.7.2A Narrow Frontal Ostium and/ or Extensive Supra Agger/Bulla Frontal Cells, or Ongoing Significant Burden of Disease (CRSwNP, Aspirin- Sensitive Asthma, Allergic Fungal Disease [Draf III/EFSS 6])

13.8Tips and Tricks

13.9Case Example

13.10Complications: Management

13.10.1Scarring and Restenosis

13.10.2Anterior Ethmoid Artery

13.10.3Orbital Injury

13.10.4Cerebrospinal Fluid Leak

14Complications of Frontal Sinus Surgery

14.1Introduction

14.2Epidemiology and Etiology

14.3Specific Complications of Endoscopic Approaches to the Frontal Sinus

14.3.1Failure to Accomplish the Specific Aim of the Procedure

14.3.2Pain

14.3.3Bleeding

14.3.4Infection

14.3.5Scar/Stenosis

14.3.6Mucocele Formation

14.3.7Anterior Skull Base Injury/Cerebrospinal Fluid Leak

14.3.8Orbital Injury

14.4Prevention of Complications

14.4.1Preoperative Planning

14.4.2Perioperative Technique

14.4.3Postoperative Care

15Delivery of Topical Therapy to the Frontal Sinus

15.1Introduction

15.2Basic Science Research on Topical Distribution to the Sinuses

15.3Clinical Research on Topical Distribution to the Sinuses

15.3.1Tips and Tricks

15.4Conclusion

16Postoperative Management: Dressings and Toilet

16.1Natural History of Sinus Ostia after Surgery

16.2Intranasal Packing

16.2.1Nonabsorbable Packs

16.2.2Absorbable Packings

16.3To Pack or Not to Pack

16.4Inert Stents

16.5Drug-Eluting Stents

16.6Postoperative Care

16.6.1Saline Irrigations

16.6.2Endoscopic Debridement

16.6.3Topical Treatments

16.7Conclusion

17Office-Based Frontal Sinus Procedures

17.1Indications

17.1.1Anatomic Considerations

17.1.2Patient Selection

17.1.3Frontal Sinusitis

17.1.4Frontal Mucoceles

17.1.5Nasal Polyps

17.2Surgical Steps/Anesthesia

17.3Postoperative Management and Procedures

17.3.1Nasal Irrigations and Topical Therapies

17.4Tips and Tricks

17.4.1Case Examples

17.5Controversies

17.5.1Balloon Catheter Dilation

17.6Emerging Technologies

17.7Conclusion

Section III Open Surgical Approaches to Frontal Sinus Disease

18Mini- and Maxi-Trephines

David A. Gudis, Charles F. Palmer, and Rodney J. Schlosser

18.1Indications

18.2Surgical Steps

18.3Tips and Tricks

18.4Case Example

18.5Complications

19Osteoplastic Flap Approach with and without Obliteration

Arjun K. Parasher and James N. Palmer

19.1Indications

19.2Surgical Steps

19.2.1Osteoplastic Flap without Obliteration

19.2.2Osteoplastic Flap with Obliteration

19.3Tips and Tricks

19.4Complications: Management

19.5Conclusion

20Riedel’s Procedure and Cranialization of the Frontal Sinus

Kato Speleman and Anshul Sama

20.1Riedel’s Procedure

20.1.1Historic Perspective

20.1.2Indications

20.1.3Technique

20.2Cranialization of the Frontal Sinus

20.2.1Historic Perspective

20.2.2Indications

20.2.3Technique

Section IV Management of Specific Frontal Sinus Conditions

21Frontal Sinus Barosinusitis

Ioannis I. Diamantopoulos

21.1Epidemiology and Etiology

21.2Clinical Presentation and Investigations

21.3Management

21.4Case Example (Courtesy of Christos Georgalas)

22Frontal Sinus in Patients with Cystic Fibrosis

Kiranya E. Tipirneni, Hari Jeyarajan, and Bradford A. Woodworth

22.1Epidemiology and Etiology

22.2Clinical Presentation and Investigations

22.2.1Radiographic Abnormalities in Cystic Fibrosis and the Frontal Sinus

22.3Management

22.3.1Medical Therapy

22.3.2Nasal Saline Irrigations

22.3.3Corticosteroids

22.3.4Topical Antibiotics

22.3.5Oral Antibiotics

22.3.6Dornase Alfa

22.3.7Cystic Fibrosis Transmembrane Conductance Regulator modulators

22.3.8Surgical Therapy

22.3.9Endoscopic Approaches

22.4Complications: Management

23Pneumosinus Dilatans

Ing Ping Tang, Yves Brand, and Prepageran Narayanan

23.1Introduction

23.2Epidemiology and Etiology

23.3Clinical Presentation and Investigations

23.4Diagnosis

23.5Management

23.6Complications

23.7Conclusion

24Frontal Sinusitis in Chronic Rhinosinusitis without Nasal Polyposis

Kristine A. Smith, Jeremiah A. Alt, and Richard R. Orlandi

24.1Introduction

24.2Epidemiology

24.3Pathophysiology

24.3.1Anatomic Factors

24.3.2Physiological Factors

24.4Management

24.4.1Medical Management

24.4.2Surgical Management

24.5Conclusion

25Frontal Sinus Surgery in CRSwNP, AFRS, and ASA Triad

Nsangou Ghogomu and Robert C. Kern

25.1Epidemiology and Etiology

25.1.1Chronic Rhinosinusitis with Nasal Polyps

25.1.2Aspirin-Exacerbated Respiratory Disease

25.1.3Allergic Fungal Sinusitis

25.2Clinical Presentation and Investigations

25.2.1Chronic Rhinosinusitis with Nasal Polyps

25.2.2Aspirin-Exacerbated Respiratory Disease

25.2.3Allergic Fungal Sinusitis

25.3Management Overview

25.3.1Chronic Rhinosinusitis with Nasal Polyps

25.3.2Aspirin-Exacerbated Respiratory Disease

25.3.3Allergic Fungal Sinusitis

25.4Extent of Surgery and Outcomes

25.4.1Goals of Surgery

25.4.2Effect of Extent of Surgery on Outcomes for Maxillary and Ethmoid Sinuses

25.4.3Effect of Extent of Surgery on Outcomes for the Frontal Sinus

25.5Case Examples

25.5.1Samter’s Triad Successfully Managed with Draf IIa

25.5.2Samter’s Triad Only Controlled after Draf III

25.5.3Nasal Polyp Recurrence in Frontal Ostium Managed in the Office

25.5.4Allergic Fungal Sinusitis Presenting with Proptosis

25.6Complications

26Frontal Sinus Mucoceles

James Constable and Anshul Sama

26.1Terminology

26.2Epidemiology

26.3Pathology

26.4Clinical Presentation

26.5Investigations

26.6Classification

26.7Management

26.8Outcomes

26.9Conclusion

27Frontoethmoidal Osteomas

Christos Georgalas and Edward Hadjihannas

27.1Epidemiology and Etiology

27.2Histology.

27.3Clinical Presentation and Investigations

27.4Management

27.5Approaches for Frontoethmoidal Osteomas

27.5.1External Approaches

27.5.2Endoscopic Approaches

27.6Summary

27.7Case Examples

27.7.1Case 1

27.7.2Case 2

27.7.3Case 3

27.7.4Case 4

28Frontal Inverted Papilloma

Paolo Battaglia, Apostolos Karligkiotis, Giacomo Pietrobon, Paolo Castelnuovo, and Mario Turri-Zanoni

28.1Epidemiology and Etiology

28.2Clinical Presentation and Investigations

28.3Management

28.4Case Examples

28.4.1Case 1

28.4.2Case 2

28.4.3Case 3

28.5Complications: Management

29The Frontal Sinus: Fibro-Osseous Lesions

Catherine Banks and Raymond Sacks

29.1Fibrous Dysplasia

29.1.1Epidemiology and Etiology

29.1.2Clinical Presentation and Investigations

29.1.3Management

29.2Ossifying Fibroma

29.2.1Epidemiology and Etiology

29.2.2Clinical Presentation and Investigations

29.2.3Management

29.2.4Surgical Steps

29.2.5Consent

29.3Summary

30Malignant Disease Involving the Frontal Sinus

Dennis Tang, Christopher Roxbury, Kelsey McHugh, Deborah Chute, and Raj Sindwani

30.1Epidemiology and Etiology

30.2Clinical Presentation and Investigation

30.3Staging

30.4Management

30.5Case Example

30.6Complications: Management

30.7Tips and Tricks

31Acute Frontal Osteomyelitis: Intracranial and Orbital Complications

Ashok Rokade and Dimitris Ioannidis

31.1Epidemiology and Etiology

31.1.1Epidemiology

31.1.2Etiology

31.2Clinical Presentation and Investigations

31.2.1Orbital Complications

31.2.2Intracranial Complications

31.2.3Osseous Complications

31.2.4Investigations

31.3Management

31.3.1Frontal Sinus Drainage Techniques

31.3.2Management of Orbital Complications

31.3.3Management of Intracranial Complications

31.3.4Management of Osseous Complications

31.4Case Examples

31.4.1Case 1: Subperiosteal Abscess (Contrast-Enhanced CT)

31.4.2Case 2: Orbital Abscess (Magnetic Resonance Imaging

31.4.3Case 3: Cerebral Abscess (Magnetic Resonance Imaging)

31.4.4Case 4: Epidural Abscess (Contrast-Enhanced CT)

31.4.5Case 5: Subdural Abscess (Contrast-Enhanced CT)

31.4.6Case 6: Pott’s Puffy Tumor

32Fungal Frontal Sinusitis: Allergic and Nonallergic

Fahad Alasousi, Anali Dadgostar, Amin Javer, and Carl M. Philpott

32.1Introduction

32.2Epidemiology and Etiology

32.2.1Invasive

32.2.2Noninvasive

32.3Clinical Presentation and Investigations

32.3.1Invasive

32.3.2Noninvasive

32.3.3Special Considerations in Frontal Sinus Fungal Disease

32.4Management

32.4.1Medical Management

32.4.2Surgical and Postoperative Management in the Frontal Sinus

32.4.3Complications: Management

32.5Conclusion

33Frontal Sinus Trauma and Its Management

Ulrik A. Felding and Christian von Buchwald

33.1Epidemiology and Etiology

33.1.1Anatomy

33.1.2Trauma Mechanism

33.2Clinical Presentation and Investigations

33.2.1Initial Examination of the Patient

33.2.2Imaging and Paraclinical Investigations

33.3Management

33.3.1Surgical Techniques

33.3.2Surgical Decision-Making

33.4Case Example

33.5Complications: Management

34Cerebrospinal Fluid Leak in the Frontal Sinus: Endoscopic Management

Hari Jeyarajan, Benjamin K. Walters, and Bradford A. Woodworth

34.1Epidemiology and Etiology

34.1.1Etiologies

34.2Clinical Presentation and Investigations

34.3Management

34.3.1Surgical Management

34.3.2Endoscopic versus Open Repair

34.3.3Postprocedural Care

34.3.4Postprocedural Adjuvants

34.3.5Outcomes

34.4Case Examples

34.5Complications: Management

34.6Conclusion

Section V Controversial Topics in Current Practice

35The Use of Flaps in Frontal Sinus Surgery

Nadim Khoueir and Philippe Herman

35.1Published Evidence

35.1.1Background

35.1.2Rationale for Flaps

35.1.3Literature Review and Surgical Techniques

35.2Controversies and Opinions

35.2.1Promising Outcome for Flaps

35.2.2Recommendation for Future Studies

35.2.3Flaps Feasibility

35.2.4Illustrative Cases

35.3Surgical Tips

35.4Unanswered Questions

36Osteitis and the Frontal Sinus

36.1Introduction

36.2Epidemiology and Etiology

36.2.1Definitions

36.2.2Histology: Pathophysiology

36.2.3Allergy

36.2.4Bacteriology

36.2.5Biofilms

36.2.6Incidence

36.3Clinical Presentation and Investigations

36.3.1Radiological Features

36.3.2Clinical Implications

36.3.3Prognostic Factor

36.4Management

36.5Case Example

36.6Summary

36.7Key Points

37Extreme Lateral Lesions: What Is the Limit of Endoscopic Surgery?

Cem Meco, Suha Beton, and Hazan Basak

37.1Published Evidence

37.1.1Traditional External Approaches for Far Lateral Lesions

37.1.2Endonasal Endoscopic Surgery and Evolution of Lateral Disease Management

37.1.3Evolution of Far Lateral Frontal Sinus Surgery: Exploring Limits of ESS

37.2Controversies and Opinions

37.3Unanswered Questions

38Use of Image Guidance Technology: Mandatory or Not

38.1Introduction

38.1.1Indications

38.1.2Applications

38.2Published Evidence

38.2.1Complications

38.2.2Revision Rate

38.2.3Clinical and Quality-of-Life Outcomes

38.2.4Medicolegal Concerns

38.2.5Cost

38.3Controversies and Opinions

38.3.1Indications

38.3.2Surgical Train

38.3.3Future Use

38.4Unanswered Questions

39Balloon Technology in the Frontal Sinus: Useful or Gimmick

Claire Hopkins and Roland Hettige

39.1Published Evidence

39.1.1Level 1 Evidence

39.1.2Nonrandomized Studies

39.2Controversies and Opinions

39.2.1Diffuse versus Localized CRS

39.2.2Polyp Disease

39.2.3Miscellaneous Uses

39.2.4Contraindications

39.2.5Preoperative Preparation

39.2.6Training Requirements

39.2.7Complications

39.3Unanswered Questions

39.3.1Cost-Effectiveness

39.3.2Extrapolation to Wider Patient Cohort

40Minimum versus Maximal Surgical Sinusotomy

Anne E. Getz and Todd T. Kingdom

40.1Published Evidence

40.1.1Balloon Dilation

40.1.2Draf I

40.1.3Draf IIa

40.1.4Draf IIb

40.1.5Draf III

40.1.5Draf III

40.2Controversies and Opinions

40.3Case Studies

40.3.1Case 1

40.3.2Case 2

40.3.3Case 3

40.4Unanswered Questions

41Patient-Reported Outcome Measures and Outcomes in Frontal Sinus Surgery: Do They Make a Difference?

Yujay Ramakrishnan, M. Reda El Badawey, and Sean Carrie

41.1Published Evidence

41.1.1Patient-Reported Outcome Measures in Rhinology

41.1.2Patient-Reported Outcome Measures in Frontal Sinus Treatment

41.2Controversies and Opinions

41.3Unanswered Questions

42Symptoms of Frontal Sinus Disease: Where Is the Evidence?

Zara M. Patel

42.1Published Evidence

42.2Controversies and Opinions

42.3Case Examples

42.3.1Case 1

42.3.2Case 2

42.3.3Case 3

42.3.4Case 4

42.3.5Case 5

42.4Unanswered Questions

43Anatomy and Classification of Frontoethmoidal Cells

Tomasz Gotlib, Anshul Sama, and Christos Georgalas

43.1Introduction

43.2Published Evidence

43.3Controversies and Opinions

44To Drill or Not to Drill

Alfonso Santamaría-Gadea, Isam Alobid, and Manuel Bernal-Sprekelsen

44.1Published Evidence

44.2Indications for Drilling Approaches of the Frontal Sinus

44.3Results of Drilling Approaches of the Frontal Sinus

44.4Complications

44.5Controversies and Opinions

44.6Unanswered Questions

45Indications for Operating the Frontal Sinus: Primary Surgery or Always Second Line?

Nsangou Ghogomu and David B. Conley

45.1Introduction

45.2Controversies and Opinions

45.2.1Does OMC/Frontal Recess Obstruction Cause Frontal CRS?

45.2.2Is Anterior Ethmoidectomy (Draf I) Optimal as First-Line Surgery for Frontal CRS?

45.2.3What Are the Clinical Characteristics of PatientsWho Fail Draf I?

45.2.4Why Is Draf I not Successful in Some Patients with Frontal CRS?

45.2.5Is Primary Draf IIa Effective as an Initial Surgical Intervention for Frontal CRS?

45.3Case Studies

45.3.1Case 1: Mild Diffuse CRSwNP Involving the Frontal Sinus

45.3.2Case 2: Failed Draf I Procedure Requiring at least Draf IIa—Ciliary Dysfunction?

45.3.3Case 3: Severe CRSwNP Requiring EMLP as Initial Surgical Intervention

45.3.4Case 4: Odontogenic Frontal CRS

45.4Unanswered Questions .

46Economic and Quality-of-Life Evaluation of Surgery and Medical Treatment for Chronic Rhinosinusitis

Caroline S. Clarke, Carl M. Philpott, and Steve Morris

46.1Published Evidence

46.1.1What is Known about the Economic Burden of Chronic Rhinosinusitis?.

46.1.2What Are the Wider Costs of CRS?.

46.1.3What Is the Impact of CRS on QOL?.

46.1.4Cost and Cost-Effectiveness of Treatment for CRS

46.2Controversies Surrounding the Cost- Effectiveness of Treatment for CRS

46.3Unanswered Questions and Future Research

47Training Models and Techniques in Frontal Sinus Surgery

Abdulaziz Al-Rasheed, Philip A. Chen, and Marc A. Tewfik

47.1Introduction

47.2Published Evidence

47.3Controversies and Opinions

47.4Unanswered Questions

48Augmented Reality in Frontal Sinus Surgery

Pavol Šurda and Martyn Barnes

48.1Role of Augmented Reality in Preoperative Planning

48.2Role of Augmented Reality during Surgery

49Robotic Surgery: Beyond DaVinci

Paul Breedveld

49.1Published Evidence

49.1.1Shortcomings of DaVinci

49.2Steering at Greater Simplicity

49.3Steering at Reduced Dimensions

49.4Controversies and Opinions

49.4.1Maneuvering beyond DaVinci

49.5Maneuvering Like a Snake

49.6Future Steps toward Clinical Practice

49.7Unanswered Questions

50Pathophysiology of the Failed Frontal Sinus and Its Implications for Medical Management

Li-Xing Man, Zeina Korban, and Samer Fakhri

50.1Introduction

50.2Failure due to Errors in Patient Selection

50.3Local Causes of Recalcitrant Frontal Sinus Disease

50.4Systemic Causes of Recalcitrant Frontal Sinus Disease

50.5Conclusion

Index

Videos

Video 4.1

CRSwNP, Draf type I (Case 1)

Video 4.2

CRS, Draf type I (Case 2)

Video 4.3

CRS, Draf type IIa example 2 (Case 3)

Video 4.4

CRS, Draf type I, axillary flap approach (Case 4)

Video 4.5

CRS, Draf type IIa example 1 (Case 5)

Video 4.6

CRS, Draf type IIa, concha bullosa (Case 6)

Video 4.7

CRSwNP, Draf IIa approach (Case 7)

Video 6.1

Modified Hemi-Lothrop procedure for recurrent left frontal mucocele

Video 6.2

Modified subtotal Lothrop procedure for cholesterol granuloma of the right frontal sinus

Video 6.3

Modified central lothrop procedure for left frontal mucocele

Video 7.1

Frontal sinus rescue procedure

Video 8.1

Lateral fronto-orbital mucocele Draf III approach (Case 8.6.1)

Video 8.2

Outpatient endoscopic view after Draf III for fronto-orbital mucocele (Case 8.6.1)

Video 8.3

Live surgery – Inside out Draf III with laterally based flap (Case 8.6.2)

Video 8.4

Outpatient endoscopic view after Draf III for recurrent frontal sinusitis (Case 8.6.2)

Video 9.1

Transeptal frontal sinus approach for frontal sinus mucocele with osteogenesis (Case 9.6.1)

Video 13.1

Frontal drillout

Video 17.1

Frontal mucocele – Intact bulla approach: example 1

Video 17.2

Frontal mucocele – Intact bulla approach: example 2

Video 17.3

Frontal sinus mucocele – Trans bulla approach

Video 17.4

Outpatient endoscopic frontal polypectomy – example 1

Video 17.5

Outpatient endoscopic frontal polypectomy – example 2

Video 22.1

Frontal sinus surgery in a cystic fibrosis (CF) patient

Video 27.1

Case 3 – Draf III for a frontal osteoma

Video 27.2

Endoscopic removal of a giant frontal sinus osteoma

Video 34.1

Post traumatic cerebrospinal fluid (CSF) leak

Video 34.2

CSF/Dural repair post resection of meningioma

Video 36.1

Case example Osteitis – Draf IIb performed as part of Live surgery on a patient with frontal sinusitis

Video 36.2

Case example: Draf III performed in the same patient following osteitis recurrence

Video 37.1

Far lateral right frontal recurrent inverted papilloma

Video 37.2

Frontal cholesteatoma. Extending far lateral to middle cranial fossa and temporalis muscle

Section I

Anatomy of the Frontal Sinus and Frontal Rece

1 Developmental Bases of the Anatomy of the Frontal Sinus

2 Radiological Anatomy

3 Applied Surgical Anatomy

1 Developmental Bases of the Anatomy of the Frontal Sinus

Roger Jankowski

Abstract

The frontal sinus starts its development after birth. Pneumatization in the frontal bone leads multiple gas-filled cavities to coalesce and form a polylobed cavity, which finally communicates with the lateral mass of the ethmoid. Nitric oxide (NO), the gas produced throughout life by the sinus epithelium, is actively released into the nasal cavity to be mixed up with the inspiratory airflow. At the level of the alveolar capillary membrane, nitric oxide facilitates the alveolar oxygen transfer into the bloodstream and increases arterial blood oxygenation. Thus, the frontal sinus and the other paranasal sinuses, or the maxillary and sphenoid sinuses (the ethmoid is not a sinus), cannot be seen as physiologically meaningless cavities.

This modern concept of paranasal sinuses development and physiology challenges the classical concept, proposed more than a century ago by Zuckerkandl, Mouret, and others, suggests that sinuses are ethmoidal cells which expand into the frontal, maxilla, and sphenoid bones and remain ventilated and drained through small openings called ostia. Neither the osteoclastic attribute necessary to the respiratory mucosa for bony expansion, nor the ventilation function of the ostium could have ever been demonstrated.

This chapter summarizes evidence in favor of the modern concept of frontal sinus development.

Keywords: paranasal sinuses, ethmoid, nitric oxide, arrested pneumatization, pneumosinus dilatans, evo-devo

1.1 Introduction

The frontal sinus starts its development after birth. Pneumatization in the frontal bone leads multiple gasfilled cavities to coalesce and form a polylobed cavity, which finally communicates with the lateral mass of the ethmoid. 1 Nitric oxide (NO), the gas produced throughout life by the sinus epithelium, is actively released into the nasal cavity to be mixed up with the inspiratory airflow. 2 At the level of the alveolar capillary membrane, nitric oxide facilitates the alveolar oxygen transfer into the bloodstream and increases arterial blood oxygenation. Thus, the frontal sinus and the other paranasal sinuses, or the maxillary and sphenoid sinuses (the ethmoid is not a sinus), 1 cannot be seen as physiologically meaningless cavities.

This modern concept of paranasal sinuses development and physiology challenges 3 the classical concept, proposed more than a century ago by Zuckerkandl, 4 Mouret,5,6 and others, suggests that sinuses are ethmoidal cells which expand into the frontal, maxilla, and sphenoid bones and remain ventilated and drained through small openings called ostia. Neither the osteoclastic attribute necessary to the respiratory mucosa for bony expansion,7 nor the ventilation function of the ostium3 could have ever been demonstrated. This chapter summarizes evidence in favor of the modern concept of frontal sinus development.

1.2Frontal Sinuses and Ethmoid Lateral Masses have Different Evolutionary and Developmental Origins

1.2.1The Ethmoid Develops from the Olfactory Cartilaginous Capsule

The human ethmoid bone structure seems a priori to result from a remodeling of the anterior cranial base over the last several million years of evolution, since bipedalism began in our primate ancestors.

The mammalian quadruped ethmoid is formed by two olfactory chambers. They are separated from each other by the perpendicular plate, from the respiratory nasal passages lying below by the transverse lamina and from the skull base posteriorly by the cribriform plate through which the olfactory nerves pass to the olfactory bulb. These chambers open anteriorly in a vestibule which is common to the olfactory and respiratory noses. 1 They are entirely covered with olfactory mucosa and the surface of the olfactory mucosa is increased manyfold by the development of the transverse ethmoturbinates into the chambers. 8

Bipedalism freed the hand and so humans acquired the upright posture. This evolutionary process led to the bending of skull base, a retraction of the snout occurred and the orbits migrated anteriorly. 9 According to the evo-devo theory, 1 the complex evolutionary craniofacial remodeling led to the squeezing of the mammalian ethmoturbinals and to the loss of their olfactory mucosa. As a result the lateral masses of the ethmoid were formed. In humans, olfactory mucosa remained located at the upper recess of the olfactory clefts and at the cribriform plates. The olfactory bulb shifted from a posterior almost vertical position to a superior horizontal position, following the development of the frontal lobes of the brain. Moreover, the transverse lamina disappeared and so the anatomical partition between the olfactory and respiratory epithelium led to the formation of the nose as a single organ.

In fact, human development tells us that the olfactory and respiratory parts of the nasal cavity are of different origins. The olfactory part develops from the olfactory placodes which invaginate toward the brain into olfactory pits. On the other hand, the respiratory part develops beneath the olfactory pits at the expense of the oral cavity by a remodeling of the bones of the secondary palate. 1 The olfactory pits differentiation give rise to all the anatomical structures of the fibrocartilaginous nose (alar and septolateral cartilages, olfactory fascia, and mucosa). 10–12 The fibrocartilaginous nose is attached to the anterior skull base, thanks to the embryological spreading of the tip end mucosa of the olfactory pits into the reliefs of the olfactory cartilaginous capsule that develops in the mesenchyme between the brain and olfactory pits around the eighth week of embryological formation. This olfactory cartilaginous capsule is the forerunner of the ethmoid bone which ossifies after birth. By contrast, the bones forming the respiratory nose (inferior turbinates, palatal apophyses of the maxilla and palatal bones, pterygoids, and vomers) despite their profound remodeling and repositioning remain attached to the maxillary bones. Even the vomer that forms the septum of the respiratory part of the nose below the septum of the olfactory nose. The septum is formed by the quadrangular cartilage and the perpendicular plate.

The ethmoid cartilage or bone appears to be involved in housing the olfactory mucosa in all the vertebrates, since the most primitive ones like the agnathan fish. Fish and amphibians do not have paranasal sinuses. Bony pneumatic recesses that resemble sinuses can only be observed in terrestrial animals. Bone pneumatization actually appears associated with life in earth that form paranasal sinuses and concerns not only the paranasal bones but also the petrous bones in humans and may even extend throughout other skeletal pieces of bone in birds (vertebrae, ribs, girdles, and proximal limb elements). 7

1.2.2The Frontal Sinuses Pneumatize after Erythropoietic Bone Marrow Conversion into Fatty Marrow

Bone pneumatization appears in fact as a biological mechanism, which follows the same rules independently developing bone. Pneumatization seems to proceed by the replacement of the erythropoietic bone marrow with “empty” sac diverticula. These diverticula might not be filled with air during the initial stage of their formation but with some gas resulting from the biochemical resorption of bone marrow. This gas may finally escape when the bony diverticula communicates with the respiratory tract. Many diverticula may form one single part of bone around the initial one, into which they drain successively.

These stages of bone pneumatization have been observed both in animals 13–15 and humans. 16 In the pigeon, a large proportion of the skeleton becomes pneumatized by conversion of the erythropoietic bone marrow into fatty marrow,. This phenomenon starts at 1 month after hatching. At the age of 6 months posthatching,bone marrow has been displaced, its volume has decreased in correlation to the increasing pneumaticity and conversion to fatty marrow. 15 Bone pneumatization has also been well studied in young children using MRI of the bone marrow at the level of the sphenoid. 16,17 Until the age of 4 months, the basisphenoid contains red bone marrow. At this time, sphenoid marrow commences fatty conversion with most individuals showing significant fatty marrow conversion by the age of 2 years. After 3 years of age most children demonstrate pneumatized diverticula in association to fatty conversion images. With respect to the sphenoid, complete pneumatization occurs between the ages of 1 and 5 years. Thus, the authors conclude that fatty change before pneumatization is a normal developmental process and should not be misinterpreted as a pathological condition. 16

Nothing is known about fatty conversion of the bone marrow before pneumatization in the frontal bones, bones. However, images of arrested pneumatization (see next section) that the mechanism of pneumatization in the frontal should be similar to the sphenoidal one.

Almost nothing is known about the process of pneumatization at the cellular and tissue levels, and even less about pneumatization processes. However, the nitric oxide “story” of the sinuses that might be the clue to understand how pneumatization occurs.

1.3The Nitric Oxide “Story” of the Paranasal Sinuses Makes them Play a Role in Blood Oxygenation on Demand

The role and function of the paranasal sinuses, that is the frontal, maxillary and sphenoid bony cavities, have long been debated. Paranasal sinuses may have no function but could have been coopted in evolution for their beneficial effects in many domains: Head lightening, energetics, maintaining strength with minimizing materials, assistance in facial growth and architecture, skull base widening for the support of the large palate to accommodate the permanent dentition, functional pillars for dispersal of masticatory forces, protection for the brain, thermal insulation for central nervous system and sense organs, increase of the surface area for the olfactory mucosa, resonance of the voice, etc.

The true, genuine function of the paranasal sinuses may, however, have been inferred, in the context of evolution, from their ability to produce, store, and release NO ( ▶ Fig. 1.1). The discovery of the physiological role of NO produced by blood vessel endothelial cells as a powerful vasodilator was awarded the Nobel Prize for Medicine in 1998. Until this discovery, this gas was regarded as merely an atmospheric pollutant, with no biological role. In fact, its physiological role extends to many other cell and tissue functions, notably in the respiratory, nervous, and immune systems. The presence of NO in exhaled air was discovered in 1991. 18

Fig. 1.1Ostial emission of a gas bolus of maxillary origin during left ethmoidectomy (a), the lower part of the unciform apophysis (*) adjacent to the presumed position of the maxillary ostium (arrow), (b) introducing the mobile bit of the retrograde forceps (*) in the infundibulum reveals a gas bolus (arrows), (c) ablating the lower part of the unciform apophysis partially reveals the maxillary ostium, (d) the maxillary ostium appears open.

The role of the upper airway system in NO production was demonstrated by measuring exhaled NO in tracheostomized subjects at the cannula, oral and nasal cavity levels were low in the cannula, intermediate in the oral and high in the nasal cavity. 19 Nasal administration of NO synthetase (NOS) inhibitors showed, no significantly reduced production. Maxillary sinus catheterization revealed a much higher level of NO in the maxillary sinus than that of the exhaled air in the nose approximating in some subjects the maximum authorized atmospheric concentration of 25 ppm. 20,21 Moreover, iterative sinus sampling revealed rapid recovery of NO levels, suggesting the continuous sinus production. Intrasinus injection of NOS inhibitors reduced NO levels by 80%, confirming the active enzymatic NO synthesis in the sinus. 21 Finally, maxillary sinus mucosa biopsy demonstrated that the enzyme responsible for this continuous NO production was iNOS (NOS-2), 22 the classically inducible calcium-independent isoform of the NO synthetase enzyme, which was located at the apical pole of the epithelium covering the inner surface of sinus cavity. 21 The surprise was that iNOS, which had never been detected in healthy tissue, was spontaneously and permanently active in the sinus epithelium. 2 In contrast, only weak NO synthetase activity was detected in the epithelium of the nasal cavity. 21

It takes less than 3 minutes for the depleted sinus NO reserve to fully recover, and it has been shown that intermittent NO bolus release by the sinuses can be induced by humming for about 10 seconds during nasal expiration. 23 The mean nasal exhaled NO rate in humming is about five fold higher than in silent nasal expiration. 24 Humming causes the exhaled airflow to vibrate, and its impact on NO flowrate seems to be related to the vibration frequency. 24 The role of acoustic vibrations in sinus ostium patency has already been described in 1959 by Guillerm et al 25. Regarding ultrasound, which, added the nasal aerosol therapy, and facilitated the sinus drug penetration.

Humming like ultrasonorization of inhaled air is, however, not a normal function. However, speaking, shouting, crying, laughing, snoring, etc. also cause intermittent vibrations of the nasal airflow, which could physiologically stimulate repeated, independent NO boli release by paranasal sinuses. Sinus ostia are classically passive openings of the bony cavities as no nerves, vessels, or muscles can be found in their surface. Therefore, the functional role of a sphinchter could be given in their mucosal line. 26 We have, however, recently observed during endoscopic procedures under general anesthesia that paranasal sinuses ostia could be active structures controlling the independent opening and closure of the different paranasal sinuses, thereby being able to control the release of NO boli into the nasal airflow. What we have observed is a relatively quick, edematous, reversible swelling of the circumferential mucosa bordering the ostium. 27 Our hypothesis is that this lies in the physiology of the cells bordering the ostium. Such a mechanism is present in the guard cells surrounding the leaves stomata that are controlling gas exchange (CO2, O2, H2O) in plants. Stomata, located in the plant epidermidis, consist of a pair of guard cells, and their enclosing pore. Stomata open and close through turgor changes driven by massive ion fluxes, . They mainly occur through the guard cell plasma membrane and tonoplast. Fine control of stomatal aperture is achieved through an exquisite sensitivity of the guard cells to multiple environmental and endogenous signals including light, humidity, temperature, CO2, plant water status, and plant hormones. Signals like vibrations in the nasal airstream, sinus content or concentration of NO, humidity, temperature, etc. could in the same way drive the physiology of the cells surrounding the paranasal sinuses ostia.

These hypotheses would be worth testing, because NO appears as a regulator of respiratory exchange in lung physiology, modulating the respiration/perfusion ratio, reducing pulmonary vascular resistance, and facilitating alveolar oxygen transfer into the bloodstream. Adding NO to the inspiratory circuit of intubated patients reduces pulmonary vessel resistance and enhances arterial blood oxygenation. 28 Other reports confirm that adding small amounts of NO (10-100 ppb) to inhaled air has significant impact on pulmonary vessel resistance and arterial blood oxygenation in acute respiratory distress syndrome. 29,30 Compared to oral respiration, nasal respiration reduces pulmonary vessel resistance and enhances arterial blood oxygenation in healthy subjects. 28,31 Adding 100 ppb NO to ambient orally inhaled air reproduces the effect of nasal respiration.31 Moreover, it has been shown that endogenous NO produced by paranasal sinuses is inhaled at similar concentrations in normal breathing, 32,33