The patency of the naso-frontal duct is a key issue in the surgical management of chronic frontal sinusitis. Most of the current operative techniques only provide access to the paramedian portions of the frontal sinus. A canalization approach that allows a functional frontal sinus to be maintained while providing good access to the most lateral areas of the sinus is described herein. Two cases of severe post-traumatic frontal sinusitis, operated on successfully by canalization method based on the conservation of the frontal sinus and the maintenance of the patency of the naso-frontal duct, using both open and endonasal approaches, are reported. One patient was followed-up for 8 years and the other for 7 months. Canalization requires validation in a larger series. This approach provides an alternative to both cranialization and strictly endoscopic methods in lateralized frontal sinus retentions and allows mucocele to be avoided.
Chronic sinusitis (CS) markedly reduces quality of life and may occur many decades after frontal sinus fracture. Infectious complications occurring in frontal sinus fractures, such as CS, are often related to an injury of the naso-frontal duct, especially when there are associated naso-ethmoidal or supraorbital fractures. Current therapies for CS due to frontal sinus fracture are either endoscopic or based on an open approach such as cranialization or obliteration. Two cases of chronic frontal sinusitis due to lateral bony septa after frontal sinus fractures, treated by a novel functional approach combining a modified cranialization and catheterization of the naso-frontal duct, are reported here.
The cases of two patients with post-traumatic chronic frontal sinusitis refractory to several attempts of antibiotic treatment were addressed to our maxillofacial surgery department. The frontal sinus fractures were subsequent to direct trauma due to traffic accidents in both cases. No surgical management had been performed during the acute phase after the initial trauma.
The first patient was a 48-year-old male with a history of left frontal sinus fracture 12 years prior. He had undergone an unsuccessful iliac crest bone graft intended to reconstruct the outer table of the frontal sinus 8 years after the initial trauma. A computed tomography (CT) scan obtained at 12 years after the initial trauma showed infection in all paranasal sinuses, with an osseous septum in the latero-distal corner of the left frontal sinus, as well as bilateral obstruction of the naso-frontal ducts due to a thickening of the nasal mucosa ( Fig. 1 a). The second patient was a 39-year-old male with a history of right frontal sinus fracture 15 years prior. A CT scan obtained at 15 years after the initial trauma showed complete blockage of the right frontal sinus, with anterior and inferior wall fractures, as well as an obstruction of the right naso-frontal duct.
Surgical management was similar in both cases. A Cairns–Unterberger incision was made. A pedicled periosteal temporal flap was elevated across the midline towards the contralateral superficial temporal aponeurosis. A frontal bone window was performed in order to provide good access to the lateral septa and mucosa. The infected bone and sinus mucosa were resected, but the healthy sinus mucosa was preserved. The inner table of the frontal sinus was then resected in order to clear the frontal sinus from inflammatory and potentially infected components. The naso-frontal duct was catheterized and its ostium was enlarged on the sinus side. An anterior ethmoidectomy and removal of the unciform process allowed visualization of the middle meatus. The middle turbinate was resected and the naso-frontal duct was localized; its ostium was enlarged on the nasal side. The naso-frontal duct was catheterized up to the lateral side of the frontal sinus using a rolled silicone sheet. The periosteal flap was positioned between the dura and the silicone tube and sutured to the dura (with reinforcement using glue) in order to obtain a substitute for the inner table and isolate the dura from the sinus. The silicone tube was covered with the periosteal flap and the latter was sutured to the outer table in order to re-establish a sinus cavity ( Fig. 2 ). The dura was suspended around the frontal flap and the flap was closed with two drains.