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

Sinusitis, Frontal, Acute, Surgical Treatment

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

Introduction

Acute sinusitis is arbitrarily defined as the rapid onset and persistence of 2 or more major signs and/or symptoms or of 1 major and 2 minor signs and/or symptoms. Major signs and symptoms include fever, facial pain or pressure, nasal obstruction, or nasal discharge with purulence, and hyposmia/anosmia. Cough, dental pain, headache, and ear pain or ear fullness are considered minor signs and symptoms. Other factors suggesting acute bacterial sinusitis include worsening of symptoms over a 5- to 7-day period or persistence of symptoms for longer than 10 days. Sinusitis that persists for longer than 3 weeks is designated as chronic sinusitis.

Acute frontal sinusitis is considered a more serious type of acute sinus infection because of its complications. Frontal sinus surgery is performed to prevent potentially life-threatening complications when the infection is unresponsive to maximal medical treatment.

This article addresses current surgical strategies in the treatment of acute frontal sinusitis. For excellent patient education resources, see eMedicine's Headache Center. Also, visit eMedicine's patient education article, Sinus Infection.

For further reading, please see the eMedicine articles Sinusitis, Maxillary, Acute, Surgical Treatment; Sinusitis, Acute, Medical Treatment; Sinusitis, Sphenoid, Acute, Surgical Treatment; and Sinusitis, Ethmoid, Acute, Surgical Treatment.

History of the Procedure

Trephination of the frontal sinus was performed as early as prehistoric times by scraping or incision. Two Peruvian skulls at the Museum of Man in San Diego show trephines with evidence of the patients' survival. Early surgeries also described removing part of the anterior frontal sinus wall, leaving the patient with a significant cosmetic deformity. More refined surgery of the frontal sinus was first described in the 19th century, and options for treatment have expanded since the advent of endoscopic sinus surgery.

Frequency

When computed using radiographic criteria, the frequency of sinusitis during upper respiratory tract infection may be as high as 90%. This figure may overestimate the true clinical frequency of acute sinusitis that was determined using symptomatic diagnostic criteria. An estimated 50 million people are affected by sinusitis annually in the United States, but the incidence of clinical frontal sinusitis specifically is much lower. CT scans depict sinus abnormalities in 31-45% of the asymptomatic pediatric population.¹ The incidence of intracranial complications in all patients hospitalized with sinusitis has been reported as 3.7%.² Sinusitis is implicated as a source of subdural abscess in 35-65% of cases; it has surpassed middle ear and mastoid disease as the most common source of infection in patients with brain abscesses.³ The frontal sinus is the most common sinus associated with intracranial infection.

The prevalence of frontal sinusitis in the pediatric population remains much lower than the prevalence in adults. Pediatric patients with upper respiratory tract symptoms have mucosal abnormalities on CT scans in 9-13% of cases.¹ A higher prevalence exists, particularly in adolescent and young adult males. This is thought to be a result of a peak in the vascularity of the diploic bone of the frontal sinus and development and enlargement of the sinus itself. In the pediatric population, involvement of the frontal sinus in acute sinusitis increases the odds ratio by 20-fold for the development of intracranial complications.⁴

Pathophysiology

Because of the close anatomic relationship of the ethmoid and frontal sinuses, obstruction of the ethmoid air cells often leads to frontal sinusitis. This obstruction may be caused by nasal polyps, tumor, septal deviation, trauma, mucosal swelling, or acute infection. Obstruction impedes the drainage of the frontal and ethmoid sinuses via the frontal recess and hinders the sinuses' mucociliary function. 

Mucociliary clearance in the frontal sinus travels in a counterclockwise direction in the right sinus and in a clockwise direction in the left, transporting secretions along the septal wall to the sinus roof and from there, laterally along the roof to medially along the floor to reach the ostium. Secretions that are retained because of obstruction serve as a nidus and as growth media for infections. Particular anatomic variants that can lead to obstruction of nasofrontal outflow include a massive concha bullosa, a laterally rotated uncinate process that contacts the middle turbinate, and, conversely, a medially convex middle turbinate that contacts the lateral nasal wall. Previous middle turbinate resection can also lead to stenosis of the frontal sinus ostium because of soft tissue scarring or residual bony fragments.

Presentation

Indications

As mentioned, surgical treatment for acute frontal sinusitis is undertaken when the infection fails to respond to conservative therapy (defined as the use of intravenous antibiotics and mucolytic agents along with topical and systemic decongestants for 3-5 days) or when dangerous complications arise. An additional indication is recurrent acute sinusitis, defined as 3-4 infections per year. (Specific indications for each procedure are discussed in Surgical therapy).

The complications of frontal sinusitis are divided into intracranial and ocular types. Intracranial complications include meningitis, brain abscess, epidural empyema, subdural empyema, and cerebral empyema. Ocular complications are preseptal or orbital cellulitis, subperiosteal abscess, and cavernous sinus thrombosis. A Pott puffy tumor is a subperiosteal abscess with soft tissue swelling that causes pitting edema over the frontal bone. Acute infection of the diploic vein resulting in thrombophlebitis causes a Pott puffy tumor. A sinocutaneous fistula can also develop from osteomyelitis of the frontal bone. A few of these complications are relative contraindications to endoscopic sinus surgery (see Contraindications).

Indications for operative intervention in acute frontal sinusitis in children are similar to those in adults, but surgery is uncommon. Clinicians reserve surgical treatment for situations involving serious complications of frontal sinusitis, such as intracranial, bony, or orbital infection, and for failure of acute infection to respond to 24-48 hours of maximal medical therapy. Surgery should be minimal and focused because sinus surgery in the pediatric population can alter facial growth. Other concerns include the proximity of vital structures, bone fragility, and these patients' smaller anatomy, which makes avoiding stenosis of the nasofrontal duct more difficult. For recurrent disease, endoscopic approaches to the frontal sinus are preferred. External approaches are typically reserved for recurrent serious acute frontal sinusitis.

Relevant Anatomy

The frontal sinus develops from small grooves in the cartilage of the lateral nasal wall near the middle meatus during the third and fourth fetal month. It forms an outgrowth from the area of the nasofrontal recess. The frontal recess itself is a space within the anterior ethmoid sinuses, bordered by the agger nasi (the most anterior ethmoid cell) anteriorly and the ethmoidal bulla cells posteriorly between the middle turbinate and lamina papyracea (see Images 1-3). It may be indistinguishable from the anterior ethmoid cells.

The frontal sinus opens into the anterior part of the middle meatus, the frontal recess, or directly into the anterior end of the infundibulum. This relationship to the infundibulum and middle meatus serves to protect the frontal sinus from the spread of disease in the ostiomeatal complex. Inspection of the frontal sinus reveals its natural ostium in the posteromedial aspect of the sinus floor. The agger nasi is also intimately involved, either adjoining or abutting the floor of the frontal sinus. The posterior wall of the agger nasi forms the anterior border of the frontal recess, which then passes posteromedially to the agger nasi and supraorbital cells. This recess is present in 77% of patients. In the other 23%, drainage occurs via a frontal sinus ostium.⁵

The frontal recess relates medially to the lateral lamella of the cribriform and the cribriform plate. This is a potential area for a cerebrospinal fluid (CSF) leak during surgery. There are also 2 patterns to the frontal sinus outflow tract: those that drain medial to the uncinate process and those that drain lateral to the uncinate process. Those that drain medially are more common and are significantly related to the presence of frontal sinusitis.

The frontal sinus drainage pathway marks itself laterally with the orbit and posteriorly with the skull base and bulla ethmoidalis. The mucociliary clearance of the frontal sinus is an active process that involves the inward transport of mucus, which starts laterally and forms a whorl-like pattern.

The frontal sinus is incompletely developed at birth and is first visible radiographically in patients aged 6 years. The sinus enlarges vertically in older adolescents to reach its adult volume of 4-7 cm³. Pneumatization of the frontal sinus extends into the squamous part of the frontal bone and posteriorly into the orbital part of the frontal bone to form a supraorbital cell. The inner plate of the frontal sinus is compact bone, while the outer plate is cancellous bone.

Pneumatization in the agger nasi region is variable; the following 4 variations have been described:

• Type I refers to a single frontal recess cell above the agger nasi cell.
• Type II is a tier of cells in the frontal recess above the agger nasi cell.
• Type III involves a single large cell pneumatized into the frontal sinus.
• Type IV is a single isolated cell within the frontal sinus.

The ethmoid sinus itself can pneumatize into the orbital plate of the frontal bone posterior to the frontal sinus. This supraorbital cell usually opens more posteriorly and laterally, as compared with the frontal sinus.

The supraorbital and supratrochlear arteries, which branch off the ophthalmic artery, form the arterial supply of the frontal sinus. The superior ophthalmic vein provides venous drainage, and the supraorbital and supratrochlear branches of the trigeminal nerve supply innervation. The layers encountered between the air cell of the sinus and the frontal lobe of the brain are, in order, as follows: compact bone of the posterior table of the frontal sinus, diploic or cancellous portion of frontal bone with diploic veins, inner table of compact bone, dura mater, arachnoid mater, and pia mater. The dura mater actually provides the venous drainage for the inner table, the periorbita for the orbital plate, and the cranial periosteum for the outer table. This is in addition to the diploic veins and all venous structures that communicate in the venous plexuses of the inner table, periorbita, and cranial periosteum.

Contraindications

Contraindications to functional endoscopic sinus surgery (FESS) for the treatment of acute frontal sinusitis include large osteomas, lesions at the most lateral aspect of the frontal sinus, and very thick and complete intrasinus septa with disease beyond or lateral to the septa. Additional contraindications are osteomyelitis or Pott puffy tumors, malignant neoplasms, and dehiscence of the posterior table. Small frontal sinus ostia (<4 mm) and hypertrophic mucosa obstructing the sinus are relative contraindications to FESS. The possibility of too much bleeding and granulation tissue is a concern with FESS because bleeding and granulation tissue interfere with the postoperative results and healing. Any bony dehiscence or defect in the anterior lateral lamella of the cribriform plate, as well as a prior CSF leak, is also a relative contraindication to FESS.

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