Current Controversies in Rhinologic Surgery

When they heal up, if you put it in the wrinkle appropriately, you can hardly tell they had a surgery. I think this is the best way to go cosmetically; it gives direct access right to the frontal sinus, and you don’t have to pull the whole forehead and part of the scalp down to get at it, he said.

Brow incisions should be done as a last resort. Most people don’t place it correctly. You can get problems with the eyelid, hair, and numbness, he said. The key to the surgery is planning the bone cuts. A six-foot Caldwell template can be used to outline the frontal sinus prior to incision. However, an item of identification, such as a dime taped to the patient’s forehead, should be used so the surgeon knows that the six-foot Caldwell is true to size.

If it’s oversized and try to make bone cuts into the frontal sinus, you can get into the brain, he said. Other ways to identify the proper bone cut include trephination with transillumination, fluoroscopy, or with image guidance. With image guidance, you can go ahead and outline that whole frontal sinus area, and it gives you more degree of safety, he said.

Are Osteoplastic Flaps Obsolete?

Are osteoplastic frontal flaps, which were developed in 1954, an anachronism? In rare cases, the procedure can still be of use. Dr. Stankiewicz described several cases in which it helped. One was a 50-year-old woman with acute and chronic sinusitis who had failed multiple endoscopic sinus surgery (ESS) procedures, including two modified Lothrops. She had persistent frontal infection and pain. An osteoplastic flap resolved the problem.

Another was a 45-year-old man who presented with several fractures in his frontal sinus. He underwent the procedure to repair the fractures, with good results.

A third case was a 70-year-old woman with chronic osteomyelitis in the frontal bone of the frontal sinus, with significant deformity in her forehead and sinuses. Here, a sinusectomy was performed with osteoplastic flap and hydroxyl apatite reconstruction.

A fourth case was a 71-year-old man with a right frontal mucocele, who had already undergone modified Lothrop. There was significant osteitic bone on the right side, making it difficult to get into the right frontal sinus. The lateral two-thirds of the mucocele was inaccessible.

A fifth common type of case is an osteoma that blocks the frontal sinus drainage.

Generally, there is still a limited place for the osteoplastic flap in the treatment of frontal sinus pathology and trauma. And it’s rarely used and rarely taught…. In private practice, unless you had an outstanding experience with this, I don’t think otolaryngologists should be doing either procedure. You need to send it to a center that has experience with it, Dr. Stankiewicz said.