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anatomy of frontal sinus & recess
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Anatomy of the Frontal Sinus
and Frontal Recess
Frontal Sinus Instructional Course
Christopher T. Melroy, MD
Frederick A. Kuhn, MD, FARS, FACS
Frontal Sinus Anatomy
The Frontal Recess is the most
common single site of recurrent or
persistent disease after intranasal
ethmoidectomy.
Kuhn FA & Kennedy DW, Analysis of Causes of Recurrent /
Persistent Disease Following Intranasal Ethmoidectomy, 8th
ISIAN, Baltimore Md., June 1989.
Internal frontal ostium
Frontal recess
Frontal sinus
Internal infundibulum
Frontal Sinus Drainage Pathway
• Narrowing of the frontal
sinus before it drains
into the internal frontal
ostium
Frontal Infundibulum
CM
FS
infu
n
Frontal Infundibulum
Imagine yourself up in a frontal
sinus…
floating down, over, and around
the tops of a complicated group
anterior ethmoid cells…
And finally entering the nose in
the middle meatus, behind the
uncinate
THIS IS THE FRONTAL RECESS !!
Frontal Recess
Frontal Recess
Frontal Recess
Agger nasi cell
Frontal Recess:
• Term first used by Killian in 1898
• Used by J. Parsons Schaeffer 1916, 1920
• Used extensively by Dr. Van Alyea –
1934, 1939, 1941 and 1946
•Van Alyea, D.E., Archives of Otolaryng., 29:881-901, 1939.
Frontal Sinus Anatomy
Frontal Sinus Anatomy(Embryology)
Frontal Sinus Anatomy (Embryology)
Schaeffer and Kasper - 4 frontal pits
• 1st pit - Agger Nasi cell
• 2nd pit - Frontal Sinus
• 3rd pit - Supraorbital ethmoid cell
• 4th pit - other anterior ethmoid cells
Schaeffer, JP, Amer J Anatomy, 20:125-145, 1916.
Kasper, KA, Archeves of Otolaryn, 23:322-343, 1936.
Frontal Sinus Embryology(the frontal pits/furrows)
Develop from the lateral
nasal wall
1st – Agger Nasi cell
2nd – Frontal Sinus
3rd – Supraorbital Ethmoid
Cell•Develops behind the FS and
extends over the orbit
Frontal Sinus Anatomy
Frontal Sinus Anatomy
Frontal Sinus Anatomy
Frontal Recess Cells:
•Agger Nasi cell
•Frontal cells
•Supraorbital ethmoid cell
•Frontal Bulla cell
•Suprabullar cell
Agger Nasi Cell
Agger Nasi Cell, M.T. basal lamella Bulla Lamella M.T. basal
lamella
ANC MT basal lam. MT basal lam.Bulla lam.
Frontal Sinus Anatomy
Opaque Frontal Recess … Obstructed by ANC
Frontal Cells
Current Definition
• Impinges on frontal recess or frontal
sinus
• Communicates with frontal recess
• distinct from agger nasi, supraorbital
ethmoid, suprabullar & frontal bullar
• 4 variations, types I-IV
Frontal Cell Types
Type I - Single cell, above Agger Nasi cell
Type II - Tier of cells may invade frontal s.
Type III - Single massive cell, invades
frontal sinus, attached to ant. table
Type IV - Single isolated cell in frontal sinus
no obvious connection to frontal
recess, not attached to ant. or
posterior table
Frontal Cells
Type I Frontal cell Type II frontal cell
**
Type II Frontal Cells
*
*
A
N
C
Type III Frontal Cell
Type III Frontal Cells
III
skull base
Type III Frontal Cell- fixing the bad result -
Type IV Frontal Cell
Type IV frontal cell Type IV frontal cell?
no.
Supraorbital Ethmoid Cell
• From 3rd frontal furrow
• Posterior and lateral to
frontal sinus
• Pneumatizes into the
frontal bone over the
orbit and behind the FS
• May extend lateral to FS
• Partition separates this
from FS
*
Supraorbital Ethmoid Cell
CM SOE
The FS is anterior and medial to the SOE
Supraorbital Ethmoid Cell
Supraorbital ethmoid Pneumatizes over
orbit, behind FS
The FS is anterior and medial to the SOE
Supraorbital Ethmoid Cell
The FS is anterior and medial to the SOE
Frontal Sinus Anatomy
Frontal Sinus Anatomy
Pre-op Post-op
Frontal Sinus Anatomy (R)
Pre-op Post-op
SOE was mistaken for FS
FS is closed
FS is anterior and medial
to SOE
Frontal Bulla Cell
Frontal Bulla Cell vs. Suprabullar Cell
Frontal Bulla Cell
* *
Suprabullar Cell
Frontal ostium
Supraorbital
ethmoid cell
Suprabullar Cell
Suprabullar Cell
IFSSC
•Pneumatization of the septum
between the frontal sinuses
•May involve a pneumatized crista galli
•May drain high into FS or low into
frontal recess
Interfrontal Sinus Septal Cell
Interfrontal Sinus Septal CellC
M IF
SS
C
Frontal Sinus Anatomy
Must be mastered before
performing frontal sinus
surgery.
Balloon Dilation
of the Frontal Sinus
Outflow Tract
Frontal Sinus Instructional Course
Christopher T. Melroy, MD
Frederick A. Kuhn, MD, FARS, FACS
Disclosure: I have received honoraria for physician training and speaking engagements from Acclarent, Inc.
• Rationale
– Most minimally-invasive way to
open a frontal sinus drainage
pathway
• Concept
– Cell walls in the frontal recess are
fractured to widen the frontal
sinus drainage pathway
Balloon Frontal Sinusotomy
Balloon Frontal Sinusotomy- technique -
CM
bra
tch
Balloon Frontal Sinusotomy- technique -
CM
bra
tch
Balloon Frontal Sinusotomy- technique -
CM
bra
tch
Balloon Frontal Sinusotomy- technique -
Balloon Frontal Sinusotomy- technique -
CM
bra
tch
• Extensive polyposis
• Known skull base trauma or defect
Balloon Frontal Sinusotomy- contraindications -
Applications / Indications:
– Primary surgery
– Revision surgery
– Management of postop ostial stenosis
• Including use in the office
– Finding the frontal sinus
– Moving cell walls within the frontal sinus
Balloon Frontal Sinusotomy
Management of postop ostial stenosis
• Including use in the office
CM
FS
sca
r
Balloon Frontal Sinusotomy- uses -
Moving cell walls within the frontal sinus
Without trephination Without osteoplastic flap
Balloon Frontal Sinusotomy- uses -
Complications (FDA database)
• Orbital injury n=2
• Passing guidewire through lamina
• No sequelae
• CSF leak n=1
• One reported case: standard instrumentation
was also used. Frontal surgery-> leak at sph.
COMPLICATION RATE – 0.010% of pts (1/10,000)
= 0.0035% of sinuses
Balloon Frontal Sinusotomy- complications -