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Sinusitis frontal

Condition Overview:

The frontal sinus is an air pocket in the bone of the lower forehead. Put your fingertip on the root of your nose, right between your eyes. Now move your fingertip one finger’s-breadth up. This is the dead center of your frontal sinus (assuming that you have one; it is absent in some people). It is shaped roughly like an inverted pyramid, with the apex pointing downwards, towards the nose. There is usually a bony partition down the middle of the sinus, which explains why we talk about frontal sinuses (plural.) As with any sinus, the frontal sinus is lined with a specialized tissue called mucosa. Mucosa produces a steady flow of mucus, which drains into the nose through holes in the apex of the pyramid.

There are a number of ways to obliterate the frontal sinus. The sinus can be approached directly, via a seagull-shaped incision through the skin immediately below both eyebrows. It can also be approached via a coronal incision, which traces out a huge arc, from ear to ear, over the top of the head. The seagull incision is smaller, of course, but it can leave an obvious scar. The coronal incision tends to be rather bloody, but the scar is usually less obvious because it is hidden in the hair.

Once the incision is made, the skin and all tissue between skin and the forehead bone is carefully elevated away from the underlying bone. A special saw is then used to cut away, in one block, the bone overlying the frontal sinus. An X-ray taken prior to surgery is used as a template, so that the surgeon knows exactly where to make the bone cuts. In some techniques, this bone is removed entirely (it will be reattached at the end of the case), while in other techniques, the bone is allowed to remain "hinged" at one edge.

What’s the point of all of this? The frontal sinus must be opened very widely so that the surgeon can remove all of the mucosa that lines the sinus. The mucosa is first scraped away, and then a fine drill (called a "diamond bur," because it is coated with tiny industrial diamonds) is used to remove any last bits of mucosa. If any mucosa is left behind, it can grow back as a mucocele, which is sort of a water balloon from hell. The only way to prevent mucocele formation is to get rid of all of the mucosa in the first place.

Now for the obliteration: how do you get rid of an empty space? Why, fill it, of course! The patient’s fat, harvested from the belly or thigh, is most commonly used for obliteration. A new material known as "bone cement" (hydroxyapatite) shows great promise for obliteration and is being used with increasing frequency. Some ENTs think that it isn’t necessary to put anything at all in the sinus, but it is still more common to fill than to not fill.

One critical step that I have not yet mentioned: the holes which drain the frontal sinus must be blocked. Bone chips from the skull can be used for this, as can a dense tissue called fascia, which can be harvested from the thigh when the fat is harvested. By blocking the drainage holes, the surgeon prevents nasal mucosa from growing back into the frontal sinus.

The bone that was cut from the forehead is now placed back over the sinus, and it is reattached to the surrounding bone with tiny titanium plates and screws. (No, your friend will not set off airport alarms with her new hardware.) The incisions are closed; if the larger coronal incision is used, it is common to place two drains in the wound to suck away any of the fluids which ooze from a fresh wound. As soon as this oozing slows down (typically after a day or two) the drains are removed.