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Neurosurgical Approaches to and Through the Frontal Sinus Using Osteoplastic Frontal Sinusotomy

Neurosurgical Approaches to and Through the Frontal Sinus Using Osteoplastic Frontal Sinusotomy

KISEP J Korean Neurosurg Soc 36 : 107-113, 2004

Clinical Article Neurosurgical Approaches to and through the Frontal using Osteoplastic Frontal Sinusotomy

Dong-Hun Kang, M.D.,1 Seong-Hyun Park, M.D.,1 Jae Chan Park, M.D.,1 Yeun-Mook Park, M.D.,1 Murali Guthikonda, M.D.,2 In-Suk Hamm, M.D.1 Department of Neurosurgery,1 Kyungpook National University Hospital, Daegu, Korea Department of Neurosurgery,2 Wayne State University, Detroit, Michigan

Objective : The is frequently a troublesome anatomical obstacle to gain access to the medial anterior cranial base. Surgical approaches to and through the frontal sinus using osteoplastic frontal sinusotomy provide significant advantages to the treatment of lesions of the medial anterior cranial base in addition to the frontal sinus itself. However, appropriate management is necessary to avoid postoperative complications such as leakage, infection, mucocele formation, and deformity of the forehead. Methods : The advantages and shortcomings of the approach along with the surgical technique are reported based on our clinical experience with pertinent literature review. The approach using the osteoplastic frontal sinusotomy was applied to two cases of osteoma in the frontal sinus, seven cases of craniofacial tumors, a case of chordoma in the sphenoid and , and two cases of intradural lesions in the . The frontal sinus was managed in such a way as to prevent the postoperative complications. Results : All patients underwent gross total resection of the tumors. With a mean follow-up of 26 months, there were no postoperative complications related to frontal sinus violation. Conclusion : The neurosurgical approaches via the frontal sinus using osteoplastic frontal sinusotomy are versatile for various lesions of the anterior cranial base in patients with large frontal sinuses. In situations that the frontal sinus have to be violated to approach medial anterior cranial base, the osteoplastic frontal sinusotomy provides such advantages as optimal frontal sinus control to prevent postoperative complications; increases viewing angle with superior trajectory from nasofrontal suture; lower incidence of pnemocephalus due to minimal dural exposure; and excellent cosmesis without frontal burr holes.

KEY WORDS : Anterior base·Combined craniofacial surgery·Frontal sinus· Osteoplastic frontal sinusotomy·Postoperative complication.

Introduction originating in the and . Intrad- ural neoplasms such as olfactory groove or he frontal sinuses are paired pyramidal cavities with a meningiomas also occupy the medial anterior cranial fossa. T centrally positioned intersinus septum although several For the patients with large frontal sinuses, osteoplastic frontal septa can be observed in many patients. The sinuses are sinusotomy can provide an appropriate window to gain access located within the squamous portion of the frontal above to the medial frontal fossa in addition to the frontal sinus the nasal root and medial orbits, and therefore are in the way itself. of transcranial approaches to the medial cranial base30,46).By In this report we present our clinical experiences based on age 20, they reach adult size, measuring 28mm high, 24mm four variations of the neurosurgical approaches to and wide in each side, and 20mm deep on the average with wide through the frontal sinus using osteoplastic frontal individual variation46). sinusotomy (so-called transfrontal sinus approach). The medial anterior cranial fossa is often invaded by tumors Materials and Methods Received：March 15, 2004 Accepted：May 12, 2004 Address for reprints：Jae Chan Park, M.D., Department of Neurosurgery, Kyungpook National University Hospital, 50 Samduk Patient population 2-ga, Jung-gu, Daegu 700-721, Korea During the past five years, 12 patients underwent neuro- Tel : 053) 420-5647, Fax : 053) 423-0504 surgical approaches to or through the frontal sinus using E-mail : [email protected] / [email protected] osteoplastic frontal sinusotomy (Table 1). The first nine cases

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Table 1. Review of 12 patients who underwent neurosurgical approaches to and through the frontal sinus using Surgical procedure osteoplastic frontal sinusotomy Simple osteoplastic frontal Age (yrs), Tumor Tumor Case No Procedures Sex Histology Location sinusotomy (Case 10, 11) lt ethmoid/ 1 43, M combined craniofacial surgery A bicoronal scalp incision nasal cavity, orbital wall 2 67, F inverted papilloma bil ethmoid/maxillary sinus was made behind the hairline combined craniofacial surgery recurrent nasal cavity and carried just anterior to the lt ethmoid/maxillary sinus 3 20, F chondrosarcoma combined craniofacial surgery tragus bilaterally. The disse- nasal cavity 4 54, F adenocarcinoma lt ethmoid/maxillary sinus ction proceeded beneath the combined craniofacial surgery recurrent nasal cavity, orbital floor galea with elevation of the lt frontal sinus 5 55, M ameloblastoma lt ehmoid/maxillary sinus superficial layer of the tempo- combined craniofacial surgery 3rd molar ralis fascia and the fat pad to lt ethmoid/maxillary sinus 6 27, M schwannoma combined craniofacial surgery protect the frontalis branches nasal cavity sphenoid body subfrontal transbasal approach of the facial . The peri- 7 60, M chordoma upper clivus with orbital osteotomy cranium was incised at the transcranial intradural approach 8 45, F meningioma olfactory groove with orbital osteotomy posterior limit of exposure transcranial intradural approach 9 38, F meningioma tuberculum sellae and along the superior tempo- with orbital osteotomy 10 30, M osteoma frontal sinus frontal sinusotomy only ral line, then elevated anteri- 11 38, F osteoma frontal sinus frontal sinusotomy only orly along the supraorbital rim 12 71, M esthesioneuroblastoma ethmoid & frontal sinuses transcranial approach and the nasofrontal suture to bil : bilateral, lt : left, M : male, F : female be used for later reconstru- in the table 1 we- ction of the cranial base15,26). The supraorbital were re operated by t- released from the supraorbital notch or foramen with an wo authors (M. osteotome. G. & J. P), and t- The shape of the frontal sinus was then outlined with a he last three cas- marking pen by applying a sterilized X-ray template from 6- es were operated feet Caldwell view with a magnification factor, almost 1.0 by another author (Fig. 1). The anterior wall of the frontal sinus was cut with (Y. M. P). Seven cases were cran-

Fig. 1. X-ray of 6-feet Caldwell view with a iofacial tumors. magnification factor, almost 1.0, which is Six of the seven confirmed with a coin on the . The craniofacial tu- inlet shows a sterilized X-ray template cut from the Caldwell view. mors were rese- cted by combined A B anterior craniofacial surgery, and one case was removed by transcranial approach only. The tumors originated in the nasal cavity or paranasal sinuses and invaded anterior cranial base. They revealed various pathologies such as esthesioneu- roblastoma, inverted papilloma, chondrosarcoma, adenocar- cinoma, ameloblastoma, and schwannoma. One of the twelve C D cases was a chordoma involving sphenoid body and upper clivus. It was resected by the transfrontal sinus-transbasal Fig. 2. Photographs demonstrating the osteoplastic frontal approach. Intradural lesions that were resected by the bilateral sinusotomy. The anterior wall of the frontal sinus is cut with oscillating saw or high-speed drill (Midas Rex C1 drill bit). The blade or drill bit is orbitofrontal craniotomy in addition to the transfrontal sinus angled to create an oblique cut to assure an osteotomy within the approach were an olfactory groove meningioma and a confines of the sinus(A). The lower limit of cutting is the nasofrontal suture(B). A photograph after cutting the frontal sinus in another tuberculum sellae meningioma. patient is shown(C). An osteotome is used to transect the intersinus The remaining two cases were osteomas in the frontal septum and to pry the sinus open(D). sinuses.

108 J Korean Neurosurg Soc 36 DH Kang, et al.

was allowed to drain freely from the dural opening to aid extradural brain retraction. The operation was then carried out with an osteotomy through the planum sphenoidale and the roof of the ethmoids on the A B C cranial side, opening the ethmoid air cells from above (Fig. 4)39). In Fig. 3. Case 2, a case of combined craniofacial surgery. A : Schematic illustration showing that craniofacial tumor is attacked from above and below. B & C : Preoperative sagittal (B) & coronal (C) the case of unilateral involvement T1-weighted magnetic resonance image after Gd-DTPA administration demonstrating of , olfaction was heterogeneous enhancement of the lesion occupying the maxillary sinuses, nasal cavity, and ethmoid sinuses. preserved by leaving the contrala- teral side of the cribriform plate with olfactory rootlets intact. After extirpation of the tumorous lesion, the dura was closed with a con- tinuous suture and the pedicled pericranial flap was rotated over the defect onto the floor of the A B C anterior cranial fossa. It was then Fig. 4. A & B : Illustrations showing the steps of the combined craniofacial surgery. The is secured to the basal dura and the removed with a narrow-tipped rongeur after removing the posterior wall of the frontal sinus (A). The bony skull base. After obliteration anterior and posterior ethmoidal at the ethmoidal foramina are cauterized with bipolar of the dead space of the frontal cautery and the adjacent dura is cut sharply (B). C : A photograph just before entering the . sinus with abdominal fat, the anterior wall of the sinus was oscillating saw or high-speed drill (Midas Rex C1 drill bit) restored and secured with minip-lates and screws (Fig. 5). with a lower limit of cutting through the nasofrontal suture. The facial component of the craniofacial tumor was The blade or drill bit was angled to create an oblique cut to resected by maxillectomy, often combined with ethmoid- assure an osteotomy within the confines of the sinus. An ectomy, or orbital exenteration after lateral rhinotomy, osteotome was used to transect the intersinus septum and to Weber-Ferguson incision, or sublabial facial degloving pry the sinus open (Fig. 2). The lesion in the frontal sinus was approach. A case of esthesioneuroblastoma was removed by totally removed. The mucosa of the sinus was thoroughly the transcranial component only. removed with a drilling burr, and the frontal sinus was packed with abdominal fat. Anterior wall of the frontal sinus was Bifrontal transbasal approach to the sphenoid body reattached with miniplates and screws. and clivus (Case 7) The procedure of transbasal extradural approach to the Combined craniofacial surgery (Case 1-6) & trans- sphenoid body cranial surgery (Case 12) for craniofacial tumors and clivus was Osteoplastic frontal sinusotomy was followed by removing extended from the posterior wall of the frontal sinus. In 6 cases of combined osteoplastic fron- craniofacial surgery (Fig. 3), transcranial component was tal sinusotomy, directed to unroof the ethmoid sinus. Since frontobasal dura removal of the was adherent to the cribriform plate and tethered by the posterior wall of olfactory nerves, the dura was incised and the olfactory the frontal sinus, rootlets were cut sharply from the cribriform plate. In and untethering bilateral procedures the crista galli was removed with a the dura with narrow-tipped rongeur. The anterior and posterior ethmoidal olfactory rootlets Fig. 5. A photograph showing the anterior wall of the frontal sinus which is secured with arteries at the ethmoidal foramina were cauterized with from the cribri- miniplates and screws after obliteration of the bipolar cautery and the adjacent dura was cut sharply. CSF form plate. The dead space of the sinus with abdominal fat.

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bone drilling was allowed an increased viewing angle from the orbitofrontal continued poster- craniotomy. Therefore, Osteoplastic frontal sinusotomy iorly to open the provided sufficient window to gain access to the frontal sinus, . cribriform plate, ethmoid sinus, sphenoid sinus, and upper Bone between the clivus. tuberculum sellae To approach intradural lesions such as olfactory groove and and the pituitary tuberculum sellae meningiomas, transfrontal sinus approach fossa was comp- had to be combined with bilateral orbitofrontal craniotomy. letely removed to Such an extension of craniotomy provided less brain expose the dura retraction. covering the pit- Olfaction could be preserved by unilateral removal of uitary gland. The cribriform plate in combined craniofacial surgery and by tumor in the sph- dissecting olfactory nerves from the base of the frontal lobes enoid sinus and in intradural subfrontal approach. upper clivus was There were no surgical complications. No patients had removed witxhin inadvertent dural lacerations during frontal sinusotomy. After Fig. 6. Schematic drawing of the transfrontal the limit of bilat- closure of the wound, the forehead showed excellent contour sinus approach to intradural lesions. The osteoplastic frontal sinusotomy is combined eral internal c- without any burr holes. The bicoronal scars were concealed in with unilateral or bilateral frontal/orbitofrontal arotid arteries. the hairline. With a mean follow-up of 26 months, there were craniotomy according to the extent of the The transfrontal no complications related to frontal sinus violation - CSF lesion. sinus approach leakage, infection, and mucocele formation - detected by provided an increased viewing angle of the upper clivus clinical examination, CT, and MRI. allowing the surgeon to look under the pituitary fossa. Discussion Approach to the intradural lesions through the frontal sinus (Case 8, 9) urgical violation of the frontal sinus can cause various To approach intradural lesions that were olfactory groove S postoperative complications34,41). The complications and tuberculum sellae meningiomas, the transfrontal sinus include CSF leakage, pneumocephalus, and infections such as approach was combined with bilateral orbitofrontal , osteomyelitis, , and . craniotomy (Fig. 6). The secondary craniotomy started at the Mucocele or pyomucocele formation is one of the important epidural space exposed from the previous frontal sinusotomy delayed complications12,31). without additional frontal burr holes. During the subfrontal One of the most important concepts in the treatment of the approach, olfactory nerves were preserved by dissecting them violated frontal sinus is the removal of mucosa and the from the base of the frontal lobes along with minimal brain prevention of mucosal regrowth in the sinus14,23,30,47). Such a retraction45). situation causes cysts or cavities causing abscesses. The pathology entails mucoceles, pyomucoceles or sinusitis with Results or without osteomyelitis. Denuding of mucosa or its cautery probably cannot remove the mucosa from the frontal sinus pproaches using osteoplastic frontal sinusotomy were completely because the mucosal lining dips into the small A performed for the patients with large frontal sinuses. vascular pits at the site of the diploic vein of Breschet. These All patients underwent gross total resection of the tumors that vessels are connected to the marrow cavity of the frontal were confirmed by postoperative CT and MRI. Two cases of bone. It is therefore essential to burr away a thin layer of the osteoma in the frontal sinus were treated easily with the bone in the sinus to ensure complete removal of the mucosa simple osteoplastic frontal sinusotomy. In seven cases of from the vascular pits, and to open the Haversian system, craniofacial tumors, transfrontal sinus approach provided which will promote bone formation and revascularization of sufficient exposure to remove cribriform plate and to enter the the fat graft16). Even after complete removal, the mucosa in ethmoid sinus. In a case of transbasal approach to the the frontal sinus can be rapidly replaced by regeneration of sphenoid body and upper clivus, transfrontal sinus approach the mucosa from the nasofrontal duct8,29,32,49). It is thus also

110 J Korean Neurosurg Soc 36 DH Kang, et al. recommended to completely remove the mucosa down to the distance; d is the object-film distance28). Minimizing the nasofrontal duct, to invert the mucosa over itself and to plug object-film distance to near zero by tilting the vertical grid by the duct ostium with fat, muscle or bone. Free fat, muscle, 15 degrees and resting the patient's nose and forehead on the pericranial flaps, and cancellous bone are used to obliterate grid device makes the magnification factor near one2). This the rest of the frontal sinus8,29,32,36,49). Gelfoam or bone wax can be checked by placing a coin on the forehead and packed in the sinus are to be avoided as these materials can be ensuring it is the same size as on the X-ray film. The a potential source of infection. procedure can be accomplished without X-ray template by During a frontal or bifrontal craniotomy for various transilluminating the frontal sinus. Sinus telescope or neurosurgical procedures the frontal sinus is purposely or laryngoscope light carrier can be delivered into the frontal inadvertently opened3,18,25,27,38,43,44). The residual basal sinus sinus through a trephination hole in anterior wall of the sinus can be treated by obliteration with autogenous material or by or through the nasofrontal duct7). Also, the frontal sinus covering the basal part with an inferiorly based pericranial volume can be reconstructed with the neuronavigator and flap, thus creating a residual mini-sinus. In the report of W. frontal sinus limits accurately mapped22). Mann, et al.34) about the state of the frontal sinus after In as much as the skull base tumors usually begin in the craniotomy, the evidence of infected frontal sinus was nose and paranasal sinuses, combined anterior craniofacial detected after 2 years follow-up in 7 out of 39 patients whose surgery is an excellent approach for treatment of this frontal sinus was opened during craniotomy. This is why pathology1,5,6,11,13,40,42). The anterior craniofacial surgery complete opening of the sinus and obliteration are preferred. incorporates a combination of transfacial and transcranial Our surgical techniques adopted in the current study dealt procedures. The transfacial procedure includes ethmoid- with the frontal sinus and the nasofrontal duct optimally to ectomy, maxillectomy, and/or orbital exenteration through a prevent CSF leakage, to isolate epidural space from the nasal lateral rhinotomy, Weber-Ferguson incision, or sublabial cavity, and to prevent mucosal regrowth. Cranialization of the facial degloving approach according to the extent of frontal sinus with complete removal of the mucosa, drilling pathology. A transcranial procedure can be done through the and sealing of the nasofrontal duct with autogenous material, frontal sinus providing a limited, but adequate exposure and covering the anterior cranial base with pedicled because many tumors have minimal intracranial spread and pericranial flap along with water-tight dural closure are are confined to small areas behind the frontal sinus. reliable maneuvers available in the surgical field to prevent In a transbasal approach to the sphenoid body and clivus, the complications. the approach with osteoplastic frontal sinusotomy could be a The osteoplastic obliterative frontal sinusotomy (osteopl- kind of "extended" approach from the conventional bifrontal astic excision of the anterior wall of the frontal sinus and craniotomy. The frontal sinusotomy is low through the obliteration with autogenous material) has been well-known nasofrontal suture, and allows an increased viewing angle of treatment for frontal sinus disease such as chronic sinusitis, the upper clivus. mucocele, pyocele, and trauma to the frontal sinus in the field Intradural lesions in medial anterior cranial base such as of otolaryngology17,19,20,30,33,37,48). It has been a safe, rapid, and olfactory groove and tuberculum sellae meningiomas usually reliable procedure4,21,33). Hardy, et al. reported that in only 3 of exceed the limit of the frontal sinus. The smaller area of the 250 operations of the osteoplastic frontal sinusotomy, the visibility afforded by the approach has to be overcome by bone cuts were inadvertently made outside the confines of the combining frontal or fronto-orbital craniotomy according to frontal sinus resulting in small dural lacerations that were the extent of the lesion10). However, for the patients with very easily controlled without sequelae21). large frontal sinuses, the approach using the osteoplastic Osteoplastic frontal sinusotomy needs an X-ray template of frontal sinusotomy can provide adequate exposure24). the frontal sinus made from 6-feet Caldwell view. The Other applications of the osteoplastic frontal sinusotomy roentgen image of an object is larger than the object because have been reported in the literature. It can be used to enter the of the divergence of the roentgen rays. The amount of this with an entirely extracranial technique when the frontal distortion is affected by the anode-film distance and the sinus is large9). It can also be used in the management of CSF object-film distance, and magnification factor is decided by fistula of anterior cranial base, the technique affords implementing the following equation : I/O = D/(D-d), where extradural inspection and repair of dural fistulas bilaterally I/O denotes the magnification factor; I is the image behind the frontal sinus, and above the cribriform plate and dimension; O is the object dimension; D is the anode-film orbital roofs without undue brain retraction35).

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