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Associated Neurological Findings

Optic disk examination and documentation of increased intraocular or intracranial pressure (papilledema) should be obtained because tumors in the olfactory groove or sphenoid ridge (e.g., meningiomas) can cause the Foster Kennedy syndrome, which is composed of three clinical hallmarks--ipsilateral anosmia or hyposmia, ipsilateral optic atrophy, and contralateral papilledema. Although rare, visual disturbances are caused by some forms of sinusitis, which can also alter chemosensation. For example, optic neuropathy has been reported secondary to cocaine-induced osteolytic sinusitis. y Altered visual contrast sensitivity, color perception, and perception of the visual vertical may provide additional information about a more diffuse chemosensory disorder. Hearing problems may reflect viral or bacterial infections in the middle ear that alter taste function in the anterior tongue via chorda tympani nerve (CN VII) damage or inflammation, as well as more general nasal sinus...

Transnasal Transethmoid Approach

The endoscopic version of this approach is the most common one used today for access to the sphenoid sinus. This approach is certainly appropriate in cases where the ethmoid and the sphenoid sinuses require simultaneous exploration. A common example is ethmoid and sphenoid sinusitis with without polyposis. However, if the goal of the surgical procedure is to address isolated sphenoid sinus disease, or to use the sphenoid sinus as an access to adjacent structures, violation of the ethmoid complex can be avoided by using the direct transnasal approach. Transnasal eth-moidectomy, although a very common procedure, is not without potential complications and sequelae. Possible immediate serious complications are well known and, fortunately, uncommon. However, delayed sequelae are not rare and may result in significant morbidity. They include synechiae formation, nasal airway obstruction, ethmoid sinusitis, frontal outflow tract obstruction and possible frontal sinusitis, maxillary outflow...

Results of Endonasal Frontal Sinus Surgery

Judging the results of endonasal frontal sinus surgery requires a postoperative follow-up of 10 years or more 21, 22 . The failure rate of Neel et al. 21 with a modified Lynch procedure increased from 7 at a mean follow-up of 3.7 years to 30 at 7 years. Weber et al. 30 carried out in 1995 and 1996 two studies. In the first retrospective study, patients who underwent en-donasal frontal sinus drainage (471 type I drainages, 125 type II drainages and 52 type III drainages) between 1979 and 1992 were evaluated. From these groups, random patients were examined 42 patients with type I drainage, 43 with type II drainage and 47 with type III drainage were included into the study. In each patient the indication was chronic polypoid rhinosinusitis, except in five cases with type III drainage in which an orbital complication existed associated with acute sinusitis. The follow-up period was between 1 and 12 years, with a median of 5 years. Application of subjective and objective criteria to...

Preoperative Workup

A selective combination of nasal irrigations, antibiotics, leukotriene antagonists, topical, nebulized and or oral steroids is often required. Such aggressive preoperative care is mandatory postoperatively as well to prevent restenosis of nasofrontal drainage leading to disease recurrence. This is especially important for patients with more aggressive disease, such as hyperplastic rhinosinusitis, sarcoidosis, Wegener's granulo-matosis, and Samter's triad.

Preoperative Evaluation

Preoperative evaluation of the sinus patient begins with a complete otolaryngologic history and physical examination 20 . The typical complaints that a patient with hyperplastic rhinosinusitis presents with polyposis are nasal obstruction and anosmia 24 . A significant number of patients will have a history of repeated sinus infections, headache, and may have a medical history significant for asthma and aspirin sensitivity 11 . Environmental allergy may also be prevalent 1 . Since the major complaint associated with hyperplastic rhinosinusitis and nasal polypo-sis is subjective in nature, many institutions advocate the use a preoperative sinonasal questionnaire. Many different questionnaires exist in the literature and all are focused on defining the baseline symptomatology of the disease as well as the level of exacerbation of the disease process 13 . Important in establishing the history of hyperplas-tic rhinosinusitis and nasal polyposis is the establishment of previous therapy for...

Detection and Screening

Routine ear, nose and throat evaluation, including inspection of the oral mucosa for ulcers, indirect and direct laryngoscopy and nasopharyngoscopy may be included in the screening process to ensure a thorough assessment of the mucosa. It is important to look for nasal scarring, as this may interfere with the normal movement of mucus and sinus drainage, leading to recurrent sinusitis. The soft tissue of the head and neck should be evaluated for muscle hy-poplasia, fibrosis and ulceration. Irradiated skin often has impaired vascularity and the resultant thin skin is highly susceptible to minor trauma.

Bone and Connective Tissue Disease

Chronic sinusitis is more likely to occur in patients who have a history of atopy or hypogammaglobu-linemia. Aggressive management of sinus infections with the guidance of ENT specialists is required. Patients should have their sinuses evaluated at least yearly by history and physical exam, and CT of the sinuses should be obtained as clinically indicated.

Endoscopic Management

In 2002, Smith et al. 40 reported a series of seven patients with displaced anterior table fractures and potential nasofrontal outflow tract injury by multiplanar CT scanning. Five of the seven patients experienced spontaneous sinus ventilation with conservative treatment. The two patients that did not ventilate had concomitant nasoorbital ethmoid fractures and were successfully treated with endoscopic frontal sinus surgery with 2 years follow-up. Chandra et al. 2 confirmed these findings in patients who presented with complications several years after conservative management of frontal sinus fractures. These complications included mucoceles in nine patients, chronic sinusitis in three patients and osteomyelitis in one patient. All patients underwent endoscopic frontal sinusotomy with image guidance and had no evidence of disease up to 3 years postoperatively. In experienced hands, the combination of medical therapy and endoscopic sinusotomy appears to be a safe and effective...

Long Term Effect in Pediatric Population

Potential pulmonary complications of therapy leading to a range of respiratory manifestations have been reported by the Childhood Cancer Survivor Study. Study participants were asked whether they had ever been told by a physician, or other healthcare professional, that they have or had a particular diagnosis, e.g. pulmonary fibrosis. This self-report study demonstrated that long-term survivors described a statistically significant increased relative risk of lung fibrosis, recurrent pneumonia, chronic cough, pleurisy, use of supplemental oxygen, abnormal chest wall, exercise-induced SOB, bronchitis, recurrent sinus infection and tonsillitis for all time periods, including during therapy, from the completion of therapy to 5 years off therapy and 5 years after therapy. Significant associations existed between the development of fibrosis and treatment with radiation therapy, and between the use of supplemental oxygen, recurrent pneumonia, chronic cough and pleurisy and treatment with...

Complications and Outcomes

The trephination incisions usually heal well and are hidden near the eye brow, but cosmetic deformity is a risk. Other possible complications include osteomyelitis, nasofrontal duct stenosis with chronic sinusitis, trochlear or extraocular muscle injury, injury to the medial canthal ligament, hemorrhage and blindness. Injury to the posterior table may cause a dural tear, meningitis, intracranial abscess, hemorrhage or even frontal lobe trauma. Long-term complications include mucocele or pyocele. Patients should also be counseled regarding possible numbness in the distribution of the supratrochlear and supraorbital nerves if the supraorbital notch neurovascular bundle is injured.

Patient Selection and Preoperative Work

Patient selection, as with any other surgical intervention, is an essential starting point in testing the efficacy of any new procedure. Appropriate medical clearance and documentation of rhinosinusitis with a detailed history and a thorough otolaryngologic examination and noncontrast CT of the sinuses needs to be obtained prior to intervention, which is standard to FESS as well.

Presentation and diagnosis

Patients with vasculitis may present with isolated pulmonary haemorrhage, but usually there is also systemic involvement. Most patients with Wegener's granulomatosis have granulomatous lesions in the upper respiratory tract which result in chronic sinusitis, epistaxis, chronic otitis media, and deafness. Involvement of the trachea can present with life threatening stridor. Granulomas are also found in many sites outside the respiratory system including the kidney, central nervous system, prostate, parotid and orbit.3 Patients with microscopic polyangiitis and Wegener's granulomatosis also present with systemic symptoms secondary to the small vessel vasculitis. Urine abnormalities include microscopic haema-turia and proteinuria, with red cell casts on microscopy. The serum creatinine may initially be in the normal range, but acute renal failure tends to develop quite rapidly. Renal and respiratory involvement both have a significant effect on mortality.3 24 25 Other organs in which...

Cranial and Spinal Subdural Empyema

Subdural empyema is a pyogenic infection in the space between the dura mater and the arachnoid and represents 13 to 20 percent of localized intracranial infections. The arachnoid is not a very strong barrier, and subdural empyema may breach the arachnoid and cause subpial infection. y The most common predisposing condition that leads to the development of a subdural empyema is paranasal sinusitis, especially frontal sinusitis. Paranasal sinusitis is the primary cause of a subdural empyema in 50 to 80 percent of patients, and otitis media is the primary cause in 10 to 20 percent. y , y Superficial infections of the scalp and skull, craniotomy, or septic thrombophlebitis from sinusitis, otitis, or mastoiditis may extend to the subdural space causing empyema. y Subdural empyema in infants usually represents an infected subdural effusion complicating a bacterial meningitis. y , y An empyema may rarely develop in the subdural area of the spinal cord. Clinical...

And Antrostomy Nasoantral Window

Chronic polypoid maxillary sinusitis unresponsive to conservative intranasal procedures Acute complicated maxillary sinusitis In the treatment of oroantral fistulae As a route to biopsy Infraorbital nerve Maxillary sinus mass As an approach to the orbital floor To treat fracture The Caldwell-Luc procedure is a sublabial approach to the maxillary sinus through the anterior wall under the upper lip. Traditionally it was used to treat chronic maxillary sinusitis with irreversible changes of the maxillary sinus respiratory epithelium. During the procedure all the lining mucosa of the maxillary sinus is removed and will be replaced by a rind of scar tissue covered by cuboidal nonciliated epithelium as the sinus heals. Because there is no longer any active transport of mucous within the sinus, drainage must be created inferiorly through the inferior meatus. Since the floor of the maxillary sinus is lower than the floor of the nose, gravity does not serve entirely to drain the sinus. After a...

Type III Endonasal Median Drainage

Howarth Lynch Operation

The principal difference between the endonasal median frontal sinus drainage and the classic fron-toorbital external Jansen 13 , Lothrop 16 , Ritter 23 , Lynch 17 and Howarth 12 operation is that the bony borders around the frontal sinus drainage are preserved. This makes it more stable in the long term and reduces the likelihood of reclosure by scarring 2 , which may lead to recurrent frontal sinusitis or a mucocele, not to mention the avoidance of external scar.

Cranial and Spinal Epidural Abscess

The clinical presentation of an intracranial epidural abscess is an unrelenting hemicranial headache or persistent fever that develops during or after treatment for frontal sinusitis, mastoiditis, or otitis media. Focal neurological deficits, seizures, and signs of increased ICP do not develop until the infection extends into the subdural space. y Approximately 10 percent of epidural abscesses are associated with a subdural empyema. y An epidural abscess that develops near the petrous bone and involves the fifth and sixth cranial nerves presents with ipsilateral facial pain and lateral rectus weakness (Gradenigo's syndrome). A spinal epidural abscess presents as fever and pain at the affected spinal level. Heusner y described a characteristic clinical pattern of symptom progression. Back pain is

Approaches to the Ethmoid and Sphenoid Sinuses

Chronic ethmoid sinusitis unresponsive to conservative intranasal procedures. As an approach to the orbital apex for optic nerve decompression. No true ethmoidectomy is necessary, just the exploration of the medial orbital wall. For the treatment of acute complicated ethmoid sinusitis.

Acute Bacterial Meningitis

S. pneumoniae is the most common causative organism of community-acquired bacterial meningitis in the adult. Pneumonia and acute and chronic otitis media are important antecedent events. Chronic disease, specifically alcoholism, sickle cell anemia, diabetes, renal failure, cirrhosis, splenectomy, hypogammaglobulinemia, and organ transplantation are predisposing conditions for pneumococcal bacteremia and meningitis. The pneumococci are a common cause of recurrent meningitis in patients with head trauma and cerebrospinal fluid (CSF) rhinorrhea. In the older adult (50 years of age and older), S. pneumoniae is likely to cause meningitis in association with pneumonia or otitis media, and gram-negative bacilli are the likely organisms to cause meningitis in association with chronic lung disease, sinusitis, a neurosurgical procedure, or a

The Lothrop Procedure

Indications are chronic frontal sinusitis unresponsive to conservative intranasal procedures where hope still exists of reconstructing the nasofrontal drainage system. Fig. 22.4. A frontal sinus trephination and lynch procedure for acute frontal and ethmoid sinusitis complicated by cerebritis and brain abscess Fig. 22.4. A frontal sinus trephination and lynch procedure for acute frontal and ethmoid sinusitis complicated by cerebritis and brain abscess

Frontal Sinus Obliteration

Although obliteration has been touted as the gold standard and safest method to treat the injured frontal sinus, there are many disadvantages, including facial scarring, frontal bone embossment, frontal neuralgia due to surgical injury of the supraorbital and supratrochlear sensory nerves, and donor site morbidity. In addition, the loss of physiologic ventilation of the sinuses hampers the use of radiographic studies in the evaluation of sinus disease. Patients may also complain of chronic frontal headache, which presents a diagnostic dilemma owing to limitations in radiographic evaluation of the sinus. Patients undergoing osteoplastic flap with autogenous adipose tissue obliteration display partial replacement of the fat graft with soft tissue (granulation and fibrosis) in most cases, and there are no consistent MRI features to distinguish recurrent sinusitis or early mucopyocele formation from expected adipose graft remodeling 23 .

Directed Neurological Examination

Essential components of the directed physical examination include a neurological evaluation emphasizing the cranial nerves and orbital contents (to direct attention to lesions of the skull base) as well as a general evaluation of the ears, upper respiratory tract, and head and neck. Although much can be gained by evaluating the nose using anterior rhinoscopy, nasal endoscopy allows a more thorough assessment. With this procedure, the rhinologist can often directly visualize the olfactory neuroepithelium and establish whether airflow access to the epithelium is blocked. In the nasal examination, the nasal mucosa is evaluated for color, surface texture, swelling, inflammation, exudate, ulceration, epithelial metaplasia, erosion, and atrophy. Discovery of purulent rhinorrhea, especially its site of origin, is considered significant if it is present throughout the nasal cavity, rhinitis is suggested. If rhinorrhea is present in the middle meatus, maxillary or anterior ethmoid sinusitis is...

Skin and Mucous Membranes

Tion or as late as 1-5 years and is irreversible. Scarring and fibrosis of the nasal mucosa can alter sinus drainage and predispose patients to persistent rhi-nosinusitis. Children may complain of symptoms of chronic sinusitis, which include chronic nasal discharge, postnasal drip, headache and facial pain and headache. Smell acuity is significantly affected by radiation treatment of the olfactory mucosa, and, although this is not usually voiced as a specific complaint, it can contribute to decreased appetite and poor nutrition.

Tumours of the Nasopharynx Clinical Features

These are relatively rare in the nasopharyngeal region. The distribution is maxillary antrum 58 , nasal cavity 30 , ethmoid sinuses 10 and frontal and ethmoid sinuses 1 each (Lewis and Castro, 1972). They are commonest on the lateral nasal wall. Tumours in the maxillary antrum may be misdiagnosed as chronic sinusitis, delaying treatment. Sinonasal squamous carcinomas occur predominantly in males, often in their 60s.


Artery exits the orbit and traverses the skull base). The anterior ethmoid artery marks the posterior aspect of the frontal recess. (c) Examine the skull base and lamina papyra-cea for any evidence of dehiscence, particularly in patients with a history of trauma or prior surgery and in cases of sinus neoplasm mucocele, allergic fungal sinusitis, or long standing sinonasal polyposis

Postoperative Care

Optimum medical treatment is required to reduce mucosal inflammation and subsequent stenosis or obstruction and hence ensure a successful outcome. A combination of postoperative antibiotics for 10 days, high-dose mucolytics, intranasal steroid sprays and twice daily nasal saline irrigations using syringe or mechanized irrigation devices is recommended. In highly refractory cases such as hyperplastic sinusitis and nasal polyposis, asthma, Samter's triad, or eosin-ophilia with or without polyposis, patients may benefit from short-term tapering doses of oral steroids. Endoscopic debridement of nasal crusts in the clinic 1 week postoperatively and every 2 weeks thereaf

Future Directions

The endoscopic modified Lothrop procedure is mainly used in patients with recalcitrant frontal sinusitis. Its use is expanded for the treatment of mucoceles, inverted papillomas invading the frontal sinus, osteomas, and frontal sinus trauma. Although short-term results are favorable, longer follow-up is required to determine the efficacy of this procedure especially in cases of mucoceles, where recurrence can occur up to 20 years postoperatively. Although the osteoplastic flap procedure is still considered the gold standard, the endoscopic modified Lothrop procedure is quickly becoming the procedure of choice for the treatment of complex frontal sinus disease.


Hyperplastic rhinosinusitis with nasal polyps represents a reactive, inflammatory disease that results in nasal obstruction, hyposmia, recurrent sinus infection, recalcitrant sinus infections, headache, and asthma exacerbations. Allergies as well as conditions like cystic fibrosis and Samter's triad can all play a role in the hyperreactive disorder. Medical therapy can provide relief in some patients, but a considerable number of patients require surgical intervention to establish a patent sinonasal cavity. Surgical intervention requires careful planning and attentive surgical technique. Preservation and identification of normal anatomic structures is essential. Success rates with a single surgery and adequate postoperative medical therapy can approach between 85 and 90 .


AFRS is a relatively new clinicopathological entity. Many studies have been performed to better characterize the disease and determine appropriate treatment strategies. AFRS is a subset of chronic rhinosinusitis potentiated by atopy to fungal antigens. The subsequent inflammatory cascade produces allergic fungal mucin that resides in affected sinuses and can cause bony remodeling and erosion of surrounding sinus walls. Surgical therapy is an important arm in the combined treatment approach to AFRS. The goals of surgery include extirpation of disease, providing permanent drainage of involved sinuses, and creating easy access to sinuses such that they can be monitored easily in the postoperative period. Concomitant therapies in the postoperative period include systemic corticosteroids and immunomodulation. Despite aggressive therapy regimens, the rates of recidivism are high and are affected primarily by noncompliance to immunotherapy and inadequate initial surgical extirpation.

Anatomic Site

There are a number of specific considerations regarding endoscopic repair of frontal sinus CSF leaks and encephaloceles. Successful repair of the CSF leak is essential, but long-term patency of the frontal sinus or obliteration with meticulous removal of all mucosa in the sinus is essential and unique to this anatomic location. Endoscopic repairs of defects adjacent to the frontal recess may create iatrogenic mu-coceles or frontal sinusitis if graft material, packing, or synechiae obstruct the frontal sinus outflow tract. In addition, defects located within the frontal recess are very difficult to approach surgically, because the superior extent of the defect may be difficult to reach via an endoscopic repair from below and an external approach from above. If an endoscopic repair is planned, adequate experience with angled endoscopes and frontal giraffe instruments is essential for success in this area. External approaches are certainly adequate in this area and still have a primary...


Late complications occur months to years after the initial operation and include chronic sinusitis, osteomyelitis, subdural empyema, meningitis and muco-celes. Mucoceles are encapsulated collections of mucus that cause bony erosion and remodeling as they enlarge. They can erode into the nasal sinuses, orbit, and soft tissue of the forehead or even the anterior cranial fossa. They are generally asymptomatic until they are extensive and involving surrounding structures. Xie et al. 51 described their experience with frontal sinus trauma over a 30-year period. The authors found the rate of mucocele formation to be the highest when anterior table (6 ), posterior table (14 ) and both anterior and posterior table (11 ) without evidence of outflow tract injury were treated by observation. Chronic headache is also a common complaint after frontal sinus surgery 12 . A retrospective study of 11 patients who underwent cranialization for posterior table fractures demonstrated no major...


There is at present no specific cure effective against this viral disease. In mild cases, symptoms disappear in 7-10 days, although physical or mental depression may occasionally persist. Influenzal pneumonia is rare but often fatal. Bronchitis, sinusitis, and bacterial pneumonia are among the more common complications, and the last can be fatal if untreated. Influenza is generally benign, and even in pandemic years, mortality is usually low - 1 percent or less - the disease being truly life-threatening for only the very young, the immunosuppressed, and the elderly. However, this infection is so contagious that in most years multitudes contract it, and thus the number of deaths in absolute terms is usually quite high. The sequelae of influenza are often difficult to define, but evidence indicates that the 1920s global pandemic of


The majority of cases of rhinosinusitis are secondary to obstruction of the ostiomeatal unit, which is an area located in the middle meatus. This obstruction will lead to poor ventilation and stasis of secretions, resulting in inflammation or infection. Obstruction can be due to several causes, the most common being anatomical anomalies, viral infections and allergic rhinitis. Certain conditions that can affect mucociliary clearance of the sinuses can also cause rhinosinusitis. Such conditions include cystic fibrosis, ciliary dyskinesia and immotile cilia. Several other conditions can affect the development of rhinosinusitis. Other than allergic rhinitis, immune deficiencies and reflux disease are conditions that may impact the response to treatment of rhinosinusitis 4, 19, 20 . Rhinosinusitis is classified into four categories 1. Acute rhinosinusitis symptoms last up to 2 weeks but not more than 4 weeks. 2. Subacute rhinosinusitis symptoms last 2-4 weeks but not more than 3 months....

Imaging Studies

Coronal computed tomography (CT) of the sinuses is the imaging study of choice for the evaluation of children with chronic rhinosinusitis. Plain films in these patients have a poor sensitivity and specificity. Plain films can be helpful in cases of acute rhinosinusitis. For the CT scan to help in the management of children with chronic rhinosinusitis, it should be performed at the end of maximal medical management. A CT scan is also the preferred imaging modality in evaluating children with complicated rhinosinusitis 2, 14 (Fig. 21.3). Symptoms of rhinosinusitis in children may vary by age. Younger children present with colored nasal discharge and cough, while older ones will complain of nasal stuffiness obstruction and headache. The most common symptoms of chronic rhinosinusitis include nasal discharge (75 ), cough (73 ), nasal congestion (72 ) and headache (72 ) (Fig. 21.1) 10, 13, 21 . Fig. 21.1. The most common presenting symptoms of chronic rhinosinusitis in that children

Absolute Indications

Coronal computed tomography scan of the sinuses of a child with chronic rhinosinusitis through the ostiomeatal complex area. It shows disease in the anterior ethmoid, maxillary sinuses and maxillary sinus ostium Oral antibiotics are the mainstay of treatment of rhinosinusitis in children according to the 2005 practice guidelines 15 . High-dose amoxicillin or amoxi-cillin-clavulanic acid is recommended as first line of treatment. Cephalosporins or macrolides can be used as a second line of treatment or for those with penicillin allergy. There is no consensus on the duration of treatment, but most agree that it should be at least 34 weeks. Antibiotics can be repeated, depending on the response of the child. Adjunct treatment consists of topical nasal steroids and oral antihistamines for those with allergic rhinitis. Topical or systemic decongestants can be used, although studies have not shown them to be effective 3 . The role of intravenous antibiotics for the treatment of...

Relative Indications

This category includes children who have signs and symptoms of chronic rhinosinusitis or children who have recurrent acute rhinosinusitis despite adequate medical treatment. Controversy prevails about when to operate and what procedure to perform 10 . Some physicians are of the opinion that an adenoidecto-my should be performed on all children prior to ESS 18 . Agreements exist that surgery should be a last resort for children with CT evidence of disease who fail maximal medical treatment 11, 12 . Chronic rhinosinusitis with anatomical abnormalities Children with symptoms of asthma secondary to refractory chronic rhinosinusitis who are not responding to systemic steroids Children with chronic rhinitis without evidence of rhinosinusitis

Sphenoid Sinus

Fibrous Scarring Following Mucocele

Mucoceles within the sphenoid sinus occur secondary to circumferential scarring of the sphenoid ostium as a result of chronic sinusitis or postsurgical scarring. Obstruction to sinus outflow may also be the result of extrinsic tumors or polyps. Rarely, fibroosseous tumors such as fibrous dysplasia can lead to secondary development of sphenoid mucoceles (Fig. 16.4). In these cases, marsupialization of a sphenoid mucocele will require either subtotal or complete resection of the obstructing tumor and then enlargement of the sphenoid ostium (Video 16.2). If circumferential scarring is the underlying cause, the use of a self-irrigating diamond burr drill may be needed to remove os-teoneogenic bone.

The Nasal Cavity

Basal Lamella Sinuses

The lateral part of the nasal cavity is thus subdivided by the turbinates into four meati (Fig. 2.2). The inferior meatus is the space between the lateral side of the inferior turbinate and the medial wall of the maxillary sinus. It contains the distal opening of the na-solacrimal duct, covered by a mucosal valve (Hasner's valve). The middle meatus is the space lateral to the middle turbinate, and is often functionally referred to as the ostiomeatal complex 18 . It contains the drainage pathways for the anterior ethmoids, the maxillary and the frontal sinuses. The middle meatus is the area that is most commonly involved in the pathophysiology of chronic rhinosinusitis.


Onstrated that the mucocele lining is composed of normal respiratory mucosa, namely, ciliated pseudostrati-fied columnar epithelium. Thus, the development of a mucocele can be extrapolated to an event resulting in retained mucus with loss of a normal outflow tract. One proposed mechanism implicates the cystic degeneration of a seromucinous gland with formation of a retention cyst 2 . Sinus outflow obstruction resulting from benign or malignant intranasal neoplasm may also contribute to mucocele formation. Iatrogenic mucocele formation was demonstrated in the setting of both external and endoscopic sinus surgery secondary to trapped mucosa or scarring of a paranasal sinus ostium. One series reported a 9.3 incidence of frontal sinus mucocele following osteoplastic flap 8 . Other etiologic factors include a history of chronic rhinosinusitis, allergic rhinitis, and previous maxillofacial trauma. Common causes of paranasal sinus mucoceles are chronic rhinosinusitis, prior sinus surgery...

Brain Abscess

Brain abscess is a rare disease in immunocompetent individuals. In adults, otitis media and paranasal sinusitis (frontal, ethmoidal, or sphenoidal sinuses) are the most common predisposing conditions for brain abscess formation. In children, otitis media and cyanotic congenital heart disease are the most common predisposing conditions for brain abscess formation. Individuals with the acquired immunodeficiency syndrome (AIDS) are at increased risk for focal intracranial infections caused by Toxoplasma gondii. Organ transplant recipients are at risk for brain abscesses caused by Aspergillus fumigatus. Patients receiving chronic corticosteroid therapy and those who are immunosuppressed from bone marrow transplantation are at a particular risk for CNS candidiasis manifested as multiple intraparenchymal microabscesses mainly in the territory of the middle cerebral artery. Brain abscesses may develop as a result of cranial trauma, either penetrating brain...

Laboratory Studies

Diagnostic workup of children with chronic rhinosinusitis should include an allergy evaluation, immune deficiency testing, cilia biopsy and reflux evaluation. Fig. 21.3. Coronal computed tomography scan of the sinuses of a child with chronic rhinosinusitis through the ostiomeatal complex area. It shows disease in the anterior ethmoid, maxillary sinuses and maxillary sinus ostium

Physical Examination

Any patient who had their first operation for chronic sinusitis or polyposis before the age of 18 should be evaluated for a cystic fibrosis variant, if this has not been previously done. However, the possibility of cystic fibrosis should also be considered in patients who present even later in life, if they have had multiple disease recurrences.

Surgical Approaches

Currently, there are many available surgical approaches to the sphenoid sinus, endoscopic and nonendoscop-ic. The decision as to which approach to use depends on factors such as the nature of the lesion, the exact location of the lesion, the extent of the lesion, coexisting pathologic processes, the goal of the surgery (e.g., complete tumor removal vs. biopsy), and the experience and comfort of the surgeon with the different approaches. For example, a polypoid process that involves also the ethmoid sinuses will probably dictate transeth-moid sphenoidotomy isolated acute sphenoid sinusitis which requires a large opening for drainage may dictate direct transnasal sphenoidotomy a midline non-infectious process which does not require permanent drainage may benefit from the relatively clean trans-septal route.The extracranial approaches to the sphenoid sinus can be summarized as follows

The Sphenoid Sinus

Fig. 14.2. a This skull base defect is located in the ethmoid roof posterior to the frontal recess. The ethmoid roof is skeletonized for exposure of the defect and the frontal recess is meticulously dissected with mucosal sparing technique. A frontal sinusotomy is necessary for exposure and prevention of iatrogenic frontal sinusitis or muco-cele from packing material. b Triplanar CT imaging of a patient with a similar defect just posterior to the frontal recess

Clinical Outcomes

In an updated series Lanza et al. 8 reported on 29 patients undergoing TSFS between 1995 and 1999. The main indication for TSFS was chronic frontal sinusitis in the setting of previously failed endoscop-ic surgery other indications included mucocele formation and nasofacial trauma. Twenty-four patients (83 ) were available for telephone interview postoperatively with a mean follow-up period of 45 months (range 9-69 months). In this subset of patients, 18 of 24 (75 ) reported at least 50 improvement of symptoms, while 14 of 24 (58 ) reported 80 or greater improvement of their symptoms. Four (16.6 ) patients underwent further frontal sinus surgery, with three having frontal sinus obliteration 8 . Complications included CSF leaks (two cases), unplanned anterior inferior septal perforation (one case), and chronic crusting at the planned perforation (one case). One

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