eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Nasal & Sinus Diseases

Sinusitis, Frontal, Acute, Surgical Treatment: Follow-up

Author: Priya Krishna, MD, Assistant Professor, Division of Laryngology, Department of Otolaryngology, University of Pittsburgh School of Medicine
Coauthor(s): Dennis Lee, MD, MPH, Director, Assistant Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, Southern Illinois University School of Medicine
Contributor Information and Disclosures

Updated: Feb 6, 2008

Outcome and Prognosis

Uncomplicated acute sinusitis, as a whole, has a spontaneous resolution rate as high as 40%. Concerning trephination, one study from Finland reported that patients undergoing trephination had a 22% rate of a delayed healing process or recurrences in the first year after trephination.8 Another study from Finland involved a method for prediction of the clinical outcome of acute frontal sinusitis after trephination by using measurements of the nasofrontal duct. Rhinomanometry of the frontal recess was measured by means of a trephination drain. The patient breathes through a flow mask, and concurrent pressure changes inside the frontal sinus are recorded via the drain with a pressure channel that connects to the drain by a short plastic tube.

The ventilation test was proved to be highly predictable if the ventilation was considered open (pressure changes during breathing and forced breathing >50% compared with the nasal airflow) or if it was totally obstructed (no pressure changes obtainable). This finding underlines the importance of the pathology of the frontal recess/infundibulum in causing acute and recurrent frontal sinusitis.

Osteoplastic flap obliteration procedures have varying rates of complications (as high as 18%), depending on the substance used for obliteration and if a donor site is needed. In a study by Montgomery and Hardy (1976), 35% of patients undergoing osteoplastic flap obliteration had persistent postoperative sensory deficits in the supraorbital nerve distribution.9 However, one study had an 81% success rate for complete cure of mucoceles.10 A 30% recurrence rate has been noted for some external approaches.

Postoperative results in one study indicated a 5% surgical revision rate with FESS for frontal sinusitis, with 40% of the frontal sinuses visualized at endoscopy.11 The use of endoscopic surgery for frontal sinusitis in one study had a 25% improvement in the number of medications used and in overall improved general health.12 Increased risk of recurrence of acute frontal sinusitis occurs in patients with chronic rhinitis, polyps, and previous sinus surgery. A history of atopic disease appears to have an impact on overall duration of infection.13  Other studies comparing the risk of recurrence between trephination and FESS over 6 months demonstrated a 60% versus a 91% chance of recurrence.14

Future and Controversies

Many aspects of the surgical treatment of acute frontal sinusitis have yet to be studied thoroughly. One aspect is the long-term outcomes of the various surgical treatments. Analysis of short-term outcomes for endoscopic frontal sinus drill-out procedures in one study revealed a higher than 80% success rate, along with a 12.5% failure rate. However, these results were tabulated for patients with a history of chronic sinusitis. Long-term outcome data for acute frontal sinus disease managed with endoscopic sinus surgery are minimal.

A recent review of patients undergoing frontal sinus obliteration with adipose tissue had a 12-year follow-up period. In the study, a 10.2% incidence of persistent changes in frontal contouring and a 9.8% incidence of mucocele were documented with MRI results. MRI results also showed a significant decrease in the amount of adipose tissue with time, as revealed by a median half-life of 15.4 months. This study demonstrated the value of MRI in the follow-up of patients after obliteration in that MRI results can be used to differentiate the distribution of fatty and fibrous tissue.

A review of the outcome data on frontal sinus obliteration leads to another controversy, namely, which obliterative substance to use. Otolaryngologists, plastic surgeons, and neurosurgeons have debated this subject. Otolaryngologists promote adipose tissue as the ideal autogenous obliterative substance because the fat revascularizes and, thus, is theoretically more resistant to postoperative infection than other substances. The drawbacks, as described previously, include donor site morbidity.

A 1995 article published in Plastic and Reconstructive Surgery highlighted the advantages of using cancellous bone implants for obliteration.15 These included good vascularization and complete obliteration of the nasofrontal duct in a cat model, as opposed to less complete obliteration by fat. Adequate obliteration can also be achieved with osteoneogenesis, allowing the sinus to obliterate itself after the inner bony cortex and mucosa is removed and a transfrontal ethmoidectomy is performed. This technique obviously avoids donor site morbidity.

Another subject of debate in the surgical treatment of acute and chronic frontal sinus disease involves the role and duration of frontal recess stent placement. Many authors advocate the use of stents any time the frontal sinus ostium is surgically enlarged. Varieties of stents and sheeting have been studied for this purpose. These include silicone drainage catheters, rolled silicone sheeting, Foley catheters, and Dacron prostheses. Most recently, Freeman and Blom (2000) reported the successful use of a double-ended flanged silicone stent.16 The shape of the stent allowed controlled retention, making it easier for the surgeon to determine the duration of the stent placement. Typically, preventative stents are left in place for 1-8 weeks, and stents placed after correction of frontal outflow tract stenosis are left in place for 6-12 months. Experienced endoscopists have presented arguments for each of these time frames. Again, no long-term data are available on stent placement in the setting ofsurgically treated acute frontal sinusitis.

An additional subject of debate is the use of mitomycin C (MMC), an antifibrotic agent used to help prevent scarring in the frontal recess or in the frontal sinus outflow tract. One study looked at one-time intraoperative topical application of MMC at 0.5mg/mL for 4 minutes; however, no difference was found in the degree of stenosis at 1, 3, and 6 months when compared with a control group.17 A different study demonstrated an 86% patency rate with follow-up of up to 32 months, but the investigators used multiple applications of the drug.18 Clearly, no standard protocol for application has been developed, so the efficacy of MMC is still in question.

A final area of controversy is the use of empiric antibiotics in an age of antibiotic resistance. The underlying principle in medical treatment of acute frontal sinusitis should be the judicious use of antibiotics. Penicillins, especially penicillinase-resistant penicillins and those with beta-lactam inhibitors (amoxicillin-clavulanate) continue to be first-line therapy in uncomplicated cases of acute sinusitis, even though 20% of H influenzae strains are positive for beta-lactamase. Macrolides (eg, clarithromycin) have adequate coverage against Haemophilus species and should be used in the case of penicillin allergy. Quinolones have much broader spectrums and have excellent activity against more common pathogens in sinusitis, but again, they are more expensive, and liberal use of the quinolones leads to more antibiotic resistance. Thus, they should not be used as first-line therapy in uncomplicated infection.

Surgery for acute frontal sinusitis has a history longer than 100 years. Despite its long history, much remains to be elucidated about long-term outcomes for surgical techniques and postoperative care and follow-up.

 


More on Sinusitis, Frontal, Acute, Surgical Treatment

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Treatment: Sinusitis, Frontal, Acute, Surgical Treatment
Follow-up: Sinusitis, Frontal, Acute, Surgical Treatment
Multimedia: Sinusitis, Frontal, Acute, Surgical Treatment
References
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Further Reading

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Keywords

sinus infection, acute sinusitis, bacterial sinusitis, chronic sinusitis, acute frontal sinusitis, upper respiratory infection, sinusitis, ethmoid sinus, frontal sinus, nasal polyps, nasal tumor, septal deviation, nasal trauma, mucosal swelling, mucociliary clearance, rhinorrhea, sinus headache, Haemophilus influenzae, Streptococcus species, Moraxella catarrhalis, meningitis, brain abscess, epidural empyema, subdural empyema, cerebral empyema, preseptal cellulitis, orbital cellulitis, subperiosteal abscess, cavernous sinus thrombosis, Pott puffy tumor, sinocutaneous fistula, osteomyelitis, trephination, frontoethmoidectomy, endoscopic sinus surgery, mucoceles, pyoceles, Lynch approach, Killian method, Reidel method, cranioplasty, Lothrop technique, Chaput-Meyer technique, osteoplastic flap, obliteration of the frontal sinus, nasal endoscopy, functional endoscopic sinus surgery, sinus surgery

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Contributor Information and Disclosures

Author

Priya Krishna, MD, Assistant Professor, Division of Laryngology, Department of Otolaryngology, University of Pittsburgh School of Medicine
Priya Krishna, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and Voice Foundation
Disclosure: Nothing to disclose.

Coauthor(s)

Dennis Lee, MD, MPH, Director, Assistant Professor, Department of Otolaryngology, Division of Pediatric Otolaryngology, Southern Illinois University School of Medicine
Dennis Lee, MD, MPH is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Laryngological Rhinological and Otological Society, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Eric Moore, MD, Residency Director, Assistant Professor, Department of Otorhinolaryngology/Head and Neck Surgery, Mayo Graduate School of Medicine
Eric Moore, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, and American Rhinologic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Erik Kass, MD, Chief, Department of Clinical Otolaryngology, Associates in Otolaryngology of Northern VA
Erik Kass, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Association for Cancer Research, American Medical Association, and American Rhinologic Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Advanced Headache Intervention Consulting fee Consulting; Covidien Corp Consulting fee Consulting

 
 
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