The decision to operate on the frontal sinus is based on persistent symptoms that have been refractory to appropriate medical therapy with associated radiographic evidence of disease by computed tomography. There is currently no evidence to support operating on radiographically negative frontal sinuses, regardless of the availability of technology or site of service options. There are many surgical procedures as well as a variety of different technologies available for the treatment of symptomatic, medically refractory frontal sinus disease. Balloon catheter dilation can be performed safely in an office setting with outcomes comparable to those in traditional operating room settings.
Key points
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The decision to operate on the frontal sinus is based on persistent symptoms that have been refractory to appropriate medical therapy with associated radiographic evidence of disease by computed tomography.
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There is currently no evidence to support operating on radiographically negative frontal sinuses, regardless of the availability of technology or site of service options.
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There are many surgical procedures as well as a variety of different technologies available for the treatment of symptomatic, medically refractory frontal sinus disease.
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Balloon catheter dilation of the frontal sinus outflow tract allows for sinus ostial dilation with the option to spare tissue as a stand-alone procedure or as an adjunct to traditional endoscopic sinus surgery.
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Balloon catheter dilation can be performed safely in an office setting with outcomes comparable to those in traditional operating room settings.
Introduction
The surgical treatment of medically refractory frontal sinus disease offers a unique opportunity to significantly improve patients’ quality of life. The decision to operate on the frontal sinus outflow tract should not be made without great thought. This anatomic region can be quite complex, is normally narrow, and tends to scar easily when mucosa is not handled with care. Included in the thought process of recommending frontal sinus surgery should be an understanding of the underlying abnormality (inflammatory vs neoplastic), the unique anatomy of the frontal recess, the need for adequate exposure, the impact of the particular procedure on long-term postoperative follow-up, and the unique features of a wide array of surgical instrumentation available. Innovation and technology have significantly increased the specific surgical options for medically refractory disease in the frontal sinus. In general, balloon catheter dilation (BCD) has been shown to produce durable ostial patency. However, ostial patency alone may not be enough to assure an ideal outcome. Perhaps the most important factor in the choice of procedure and tools is a thorough understanding of the nature of the disease process. In stand-alone BCD procedures, there is no tissue removal. Therefore, if there is suspicion for or documentation of neoplastic disease, stand-alone BCD is contraindicated. Stand-alone BCD may also not be sufficient in patients with polyps or eosinophilic disease, where tissue removal is often necessary and where widening of the outflow tract by removing frontal recess cells facilitates local drug delivery. Finally, although there may be limited evidence that dilating a radiographically normal maxillary sinus improves symptoms, there is currently no evidence for operating on a radiographically normal frontal sinus. Although there may be anecdotal reports of improved headaches, there is no evidence to support using BCD or any other instrumentation to operate on frontal sinuses without inflammatory disease.
The purpose of this article is to discuss the indications, relative contraindications, and techniques for using BCD of the frontal sinus outflow tract. It is important to state at the onset that the decision to intervene surgically is not instrument or site of service dependent. Before consideration for surgery, patients should have failed appropriate medical therapy, have persistent symptoms, and demonstrate abnormality on computed tomography (CT).
In general, BCD offers the unique opportunity to achieve durable sinus ostial and outflow tract dilation while sparing tissue in the process. Specifically for the frontal sinus outflow tract, this technology allows for fracturing and lateral displacement of the medial and superior wall of obstructing frontal cells, medial displacement of an obstructing intersinus septal cell wall, and/or dilating soft tissue stenosis in previously operated patients ( Figs. 1 and 2 ). Luong and colleagues have reported on isolated BCD of the frontal sinus in the office setting. Using topical anesthesia, they found that durable patency was achieved in all 6 frontal sinuses dilated, with only one patient requiring a second dilation.
The largest study to date including in-office BCD of the frontal sinuses reported that 251 of 268 frontal sinuses were successfully dilated (93.7%) with 5 frontal sinuses requiring revision procedures (2%).
Chan and colleagues and Askar and colleagues reported separately on 294 and 100 frontal sinuses operated using traditional functional endoscopic sinus surgery (FESS) techniques. Long-term patency was achieved in 88% and 90%, respectively. At first glance, it would appear the BCD achieves higher patency rates. However, patients undergoing BCD generally have a lower burden of disease than those undergoing traditional FESS procedures; this points to the importance of carefully selecting the appropriate procedure for the unique clinical situation.
Relative contraindications for BCD as a stand-alone procedure include cases where the underlying histology is in question, dense neo-osteogenesis of the frontal sinus outflow tract where sufficient displacement of bony walls is unlikely, and extensive polyposis. In these cases, traditional instrumentation should either be used to complement BCD technology or in its stead. Also, as stated previously, operating on frontal sinuses in the absence of demonstrable disease is not indicated regardless of the technology or site of service options.
An additional consideration for BCD is the ability to use this technology in the office setting. Office setting utilization has the obvious advantages of the elimination of the risks and recovery of general anesthesia and avoidance of cost associated with it and with the hospital outpatient department or ambulatory surgical facility. Proper patient selection is paramount. At minimum, patients should tolerate rigid diagnostic nasal endoscopy in the office setting before proceeding with in-office BCD. In-office BCD has been shown to be safe and well tolerated with outcomes similar to those achieved in traditional venues.
Introduction
The surgical treatment of medically refractory frontal sinus disease offers a unique opportunity to significantly improve patients’ quality of life. The decision to operate on the frontal sinus outflow tract should not be made without great thought. This anatomic region can be quite complex, is normally narrow, and tends to scar easily when mucosa is not handled with care. Included in the thought process of recommending frontal sinus surgery should be an understanding of the underlying abnormality (inflammatory vs neoplastic), the unique anatomy of the frontal recess, the need for adequate exposure, the impact of the particular procedure on long-term postoperative follow-up, and the unique features of a wide array of surgical instrumentation available. Innovation and technology have significantly increased the specific surgical options for medically refractory disease in the frontal sinus. In general, balloon catheter dilation (BCD) has been shown to produce durable ostial patency. However, ostial patency alone may not be enough to assure an ideal outcome. Perhaps the most important factor in the choice of procedure and tools is a thorough understanding of the nature of the disease process. In stand-alone BCD procedures, there is no tissue removal. Therefore, if there is suspicion for or documentation of neoplastic disease, stand-alone BCD is contraindicated. Stand-alone BCD may also not be sufficient in patients with polyps or eosinophilic disease, where tissue removal is often necessary and where widening of the outflow tract by removing frontal recess cells facilitates local drug delivery. Finally, although there may be limited evidence that dilating a radiographically normal maxillary sinus improves symptoms, there is currently no evidence for operating on a radiographically normal frontal sinus. Although there may be anecdotal reports of improved headaches, there is no evidence to support using BCD or any other instrumentation to operate on frontal sinuses without inflammatory disease.
The purpose of this article is to discuss the indications, relative contraindications, and techniques for using BCD of the frontal sinus outflow tract. It is important to state at the onset that the decision to intervene surgically is not instrument or site of service dependent. Before consideration for surgery, patients should have failed appropriate medical therapy, have persistent symptoms, and demonstrate abnormality on computed tomography (CT).
In general, BCD offers the unique opportunity to achieve durable sinus ostial and outflow tract dilation while sparing tissue in the process. Specifically for the frontal sinus outflow tract, this technology allows for fracturing and lateral displacement of the medial and superior wall of obstructing frontal cells, medial displacement of an obstructing intersinus septal cell wall, and/or dilating soft tissue stenosis in previously operated patients ( Figs. 1 and 2 ). Luong and colleagues have reported on isolated BCD of the frontal sinus in the office setting. Using topical anesthesia, they found that durable patency was achieved in all 6 frontal sinuses dilated, with only one patient requiring a second dilation.
