Frontal Sinus Stenting Techniques 

Updated: Dec 19, 2018
Author: Devyani Lal, MD; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

Endoscopic surgery is now commonly used in the management of simple and complex pathologies of the frontal sinus. As experience with the endoscopic technique has grown, use of these procedures for frontal sinus surgery has increased. The goals of endoscopic frontal sinus surgery include disease eradication, implementation and maintenance of an adequate drainage and ventilation pathway, and the restoration of mucociliary function.

Frontal sinus pathology is particularly challenging to treat due to the narrow and complex anatomy of the frontal outflow tract (see the images below).

Anatomy of the lateral nasal wall, schematic: (1) Anatomy of the lateral nasal wall, schematic: (1) Sphenoid sinus, (2) anterior cranial fossa, (3) anterior ethmoid cell, (4) frontal sinus, (5) agger nasi, (6) infundibulum, (7) posterior ethmoid cell
Anatomy of the frontal recess. The frontal recess Anatomy of the frontal recess. The frontal recess is an hour glass-shaped space (green shaded area) with the waist at the frontal ostium and its narrowest part that drains into the ethmoid infundibulum: (1) frontal sinus, (2) frontal ostium, (3) agger nasi cell, (4) bulla ethmoidalis, (5) anterior cranial fossa, (6) infundibulum

Stenosis of the frontal recess or failure to establish a tract can lead to disease persistence and iatrogenic complications. Postoperative stenosis of the frontal sinus outflow due to formation of scar tissue, synechiae, or osteogenesis is the most common cause of frontal sinus surgery failure.[1]

Stenosis of the frontal recess is best prevented by avoiding unnecessary manipulation of the outflow tract and meticulous surgical technique. Without formal frontal ostium dissection, anterior ethmoidectomy with exposure of the frontal recess has been shown to result in resolution of frontal sinus disease.[2] The indications for a formal frontal sinusotomy should therefore be carefully determined. If frontal recess dissection is undertaken, meticulous tissue handling with avoidance of any mucosal trauma is key to a successful outcome. Routine frontal stenting is unnecessary (see image below).

3A: Intraoperative endoscopic view of the dissecte 3A: Intraoperative endoscopic view of the dissected frontal ostium after total anterior ethmoidectomy and Draf 2a frontal ostioplasty (70º endoscope view): (A) nasal beak, (B) frontal neo-ostium, (C) anterior skull base. Postoperative view of frontal ostium with a 70º endoscope. 3b: Well-healed, mucosalized frontal neo-ostium 3 months after Draf 2a (frontal ostioplasty). No stent was used in this case.

The most common cause of restenosis of the frontal sinus outflow tract is iatrogenic (postoperative scarring, adhesions, and middle turbinate lateralization). Severe inflammatory pathology, obstructive polyposis, and nonsurgical trauma are other common causes.

The incidence of persistent frontal sinusitis with symptoms after endoscopic sinus surgery is 2-11% based on numerous studies, all with relatively short follow-up.[3] The necessity of longer follow-up after frontal sinus surgery to determine the true incidence of disease relapse was demonstrated by Neel et al. In their study, failure rate after modified Lynch procedure increased from 7% at 3.7 years to 30% at 7 years.[4] Frontal sinus stenting may help prevent failure of standard endoscopic treatment of frontal sinus disease by maintaining patency and structural integrity of the frontal sinus outflow tract while regeneration of the frontal neo-ostium mucosal lining takes place.[5] In many situations, such as after a drill-out procedure (modified Lothrop or Draf III) for neo-osteogenesis or tumor removal, the mucosal lining is absent or significantly violated. Stenting may be useful in such situations.

Surgically placed stents to maintain ventilation and drainage of the frontal sinuses have been used for over a century. The first frontal sinus stents were gold tubes used in 1905 by Ingals.[5] In 1921, Lynch first described his frontoethmoidectomy technique, of which a key component was 1-cm rubber tubing used to stent the frontal sinus.[6] Progress in both surgical instrumentation and new stent material has been made over subsequent years. Numerous options are now available for stenting in cases that have an anticipated high risk of surgical failure. Stents differ in terms of material, shape, and the techniques used to deploy them.

Indications

Despite the long history of frontal sinus stents, no universally accepted criteria exist for their use. Stenting may be considered in a patient who has failed standard ethmoidectomy or frontal sinusotomy, or in whom a high likelihood of failure to maintain a patent recess is expected.

Authors have advocated different criteria to stent the frontal recess. The size of the frontal sinus neo-ostium created after frontal sinusotomy has been used as a guide for sinus stenting by some authors.[4, 5, 7] However, as the natural size of the recess itself is small, stenting is likely unnecessary unless extensive mucosal disruption exists. In a study correlating frontal neo-ostium size to postoperative patency, Hosemann et al found the postoperative stenosis rate of a frontal neo-ostium less than 5 mm in diameter to be 33%, whereas the stenosis rate was 16% with an intra-operative neo-ostium diameter of greater than 5 mm.[8] Thus, for a neo-ostium size of less than 5 mm, stenting may be indicated.

Additional indications for frontal sinus stenting include the presence of osteitic bone, purulence, or granulation indicating severe inflammatory disease. The presence of vasculitides or granulomatous disease, previous surgical failure, excessive removal or destabilization of the middle turbinate predisposing to lateralization, traumatic fracture of the frontal sinus outflow tract,[9] and the presence of extensively denuded or circumferentially exposed bone around the neo-ostium perimeter[5] are other proposed indications.

In the case of stripped mucosa surrounding the frontal neo-ostium, stents have also been used to hold a mucosal graft in place. Dubin and Kuhn described endoscopic resection of 12 frontal sinus osteomas with preservation of the natural frontal sinus outflow. They stented all cases with greater than 40% denuded frontal recess mucosa.[10] Some authors have also advocated using soft silastic stents in uninjured frontal recesses to assist with postoperative debridement.[10] The stents are removed 2-3 weeks after surgery. During removal, the adherent clots and crusts caught within the stents are reported to be more easily removed.

Frontal sinus stenting can therefore be a valuable technique to maintain an adequate ventilation and drainage pathway. In select cases, this minimally invasive procedure is a reasonable alternative to more extensive and aggressive frontal recess surgeries such as the endoscopic-modified Lothrop procedure, osteoplastic flap, or frontal obliteration.[5]

Relative indications for frontal sinus stenting are as follows:

  • Circumferentially exposed bone (after modified Lothrop for tumor resection or extensive mucosal denudation)

  • Traumatic fracture of outflow tract

  • Restenosis after surgery

  • Frontal neo-ostium smaller than 5 mm

  • Middle turbinate destabilization

  • Recalcitrant inflammatory disease (purulence, granulation, osteitic bone, polypoid obstruction, granulomatous disease)

Contraindications

No absolute contraindications exist to placement of a frontal recess stent. The key to prevention of frontal recess stenosis is meticulous mucosal preservation. Routine stenting of the frontal recess is unnecessary. Manipulation and trauma of the frontal recess during frontal stent placement and any inflammatory reaction caused by the stent itself may lead to scarring and poor healing of the recess. Concern also exists for the formation of biofilms, which are known to perpetuate an inflammatory tissue response. Stenting should only be used for limited indications for a well-defined period of time.

Technical Considerations

Best Practices

Several methods of frontal sinus stent placement exist, including both endonasal and external approaches. Endoscopic insertion is always preferable and is most commonly used. Endoscopic frontal sinusotomy should be conducted by surgeons experienced in recognizing anatomic variations, especially in the face of disease, bleeding, or distorted anatomy. An array of angled telescopes (30º, 45º, and 70º), as well as frontal instruments of various angles and lengths, are necessary for frontal recess dissection and stent placement. Computer-assisted image guidance systems are extremely helpful, and may be essential for complicated or revision cases.[7]

Procedure Planning

Surgical planning requires careful preoperative assessment including a thorough endoscopic examination and CT evaluation to aid in assessing the bony boundaries of the frontal recess, as well as soft-tissue anatomy. A high-definition, fine cut (1-2 mm) CT scan is recommended. The dimensions of the widest frontal recess in all 3 planes (axial, coronal, and sagittal) should be studied. The boundaries of the frontal recess are limited as follows:

  • Medial - Middle turbinate

  • Lateral - Lamina papyracea

  • Anterior - Agger nasi

  • Posterior - Bulla ethmoidalis

A narrow dimension in any plane should be noted preoperatively and stenting used as deemed necessary.

Complication Prevention

Frontal sinus stents are generally well tolerated, and the complication rate is low. Nonetheless, some concern exists that stents can serve as a potential nidus for recurrent infections (see the image below).

Frontal stents encased in crusting (A) and granula Frontal stents encased in crusting (A) and granulation (B). (Images courtesy of Timothy L. Smith, MD.)

In a study by Perloff and Palmer, evidence of bacterial biofilms was found ubiquitously on silastic frontal sinus stents removed from six patients at 1-4 weeks following endoscopic sinus surgery.[11] The clinical significance of this finding in predisposing to recurrent infection, however, is unknown.

Stents can also serve as a source of iatrogenic obstruction of the frontal sinus outflow tract when they are trimmed too short, in which case granulation tissue can form across the stent, embedding it in place. A stent that is too long may cause crusting at the distal end, which can lead to nasal congestion and an unpleasant odor.[9] Avoidance of these complications requires proper trimming of the stent after insertion. Stents should be trimmed approximately to the level of the inferior border of the middle turbinate.

Toxic shock syndrome (TSS) is a rare life-threatening risk following frontal sinus stenting.[12] Vigilance for symptoms of TSS such as high fever, hypotension, diffuse macular erythroderma, mucosal hyperemia, mental status changes, and desquamation is required. TSS onset can occur several weeks postoperatively, as in Chadwell’s case,[12] in which symptoms developed on postoperative day 18 after the patient had completed a 7-day course of cephalexin.[12] Antibiotic prophylaxis has been relatively unsuccessful in the prevention of TSS, which is related to toxin-producing Staphylococcus aureus.

A potential for stent migration and accidental aspiration also exists. During stent removal, a theoretical risk of stent breakage can leave remnants in areas of the sinus with limited or difficult access.

 

Periprocedural Care

Equipment

The frontal recess is difficult to access endoscopically without the use of specialized equipment designed to navigate its complex anatomy. This equipment includes curved suctions, angled endoscopes (30º, 45º, and 70º), frontal giraffe instruments (various angles, lengths, and types), a frontal sinus seeker, and image guidance system. Many stents of different shapes and materials are commercially available. Some surgeons prefer to fashion their own stents with various materials (see the image below).

Examples of frontal sinus stents: (A) Sheet of 1/1 Examples of frontal sinus stents: (A) Sheet of 1/100-inch thick silastic fashioned into a T-shaped stent, (B) reinforced silastic sheet used for Draf 3 cavity, (C) Rains silastic stent, (D) Silastic T-tube stent, (E) Acclarent Relieva Stratus MicroFlow Spacer, (F) Intersect ENT Propel sinus implant (FDA approved for use in the ethmoid sinus; use in the frontal sinus as a stent is off-label).

Historically, different materials have been used to construct stents. These include gold, tantalum foil, polyethylene terephthalate (Dacron), and polymeric silicone (Silastic).[9] One of the most influential studies directing the design of stents was that of Neel et al, in which the superiority of soft versus rigid stents was demonstrated based on outcomes in a dog model. They found that the use of firm tubing hampered epithelialization and stimulated osteoblastic activity and scar formation.[13] This was thought to be due to local ischemia, impaired drainage, and infection around the rigid tubes.

Since this landmark study, various soft stenting materials have been introduced (see the image below).

Examples of frontal sinus stents: (A) Sheet of 1/1 Examples of frontal sinus stents: (A) Sheet of 1/100-inch thick silastic fashioned into a T-shaped stent, (B) reinforced silastic sheet used for Draf 3 cavity, (C) Rains silastic stent, (D) Silastic T-tube stent, (E) Acclarent Relieva Stratus MicroFlow Spacer, (F) Intersect ENT Propel sinus implant (FDA approved for use in the ethmoid sinus; use in the frontal sinus as a stent is off-label).

These include rolled silicone sheeting, silicone tubing, soft catheter devices, Merocel spacers, soft rubber T-tubes, and numerous proprietary devices, such as the Rains self-retaining stent with a tapered collapsible bulb at the distal end (see the image below),[7] Freeman bi-flanged silicone stent,[14] Jacobs radiopaque silicone frontal sinus cannula, and Parrell frontal sinus T-stent. U-shaped or H-shaped stents can be used for bilateral frontal sinus stenting in Draf III or endoscopic Lothrop procedures.[15] Other variations include biliary-type or specially designed T-tubes that can be used when the frontal intersinus septum is taken down.[5]

Endoscopic placement of right frontal sinus stent Endoscopic placement of right frontal sinus stent after a revision Draf 2b frontal ostioplasty in a patient with previous surgery and radiation for esthesioneuroblastoma. (A) 1/100 thick silastic sheet is cut into a T shape based on the size of the frontal ostium, (B) right frontal ostium; view with a 70º endoscope, (C) the sheet is to be rolled into a stent, grasped with giraffe forceps, and the T flange inserted into the frontal sinus, (D) the rolled part of the stent lines the area of the frontal recess.

Stent modifications include the use of radiopaque markers, expandable elements, winged flanges for self-retention, as well as suture tails to facilitate easy removal in the office setting. More recently, experimentation with drug-eluting stent materials (see Medications section) has occurred. Hosemann et al presented one of the first drug-releasing stents in 2002, which was capable of releasing dexamethasone for a period of at least 25 days.[16] Dexamethasone-releasing stents were shown to decrease granulation formation and stroma thickness without impeding epithelial differentiation when compared to placebo in rabbit sinusotomies.[17]

Herrmann and colleagues showed paclitaxel-impregnated stents were well tolerated in a sheep model and hypothesized this local drug delivery method may minimize postoperative scarring.[18] Doxycycline-releasing stents were subsequently introduced by Huvenne et al who demonstrated suppressed bacterial growth and improved visual analog scale for the frontal region at 3 months when compared with placebo.[19] The AcclarentRelieva Stratus MicroFlow Spacer designed with a microporous reservoir for drug release is approved in the United States for use with saline. Recently, the Propel mometasonefuroate-releasing stent designed by Intersect ENT received premarket approval from the FDA for use in the ethmoid sinus, making it the only drug-eluting nasal implant with FDA approval to date.[20] This device was evaluated for safety and efficacy by numerous studies prior to FDA approval.[21, 22, 23, 24]

Use of the Propel device in the frontal sinus as a stent is currently off-label.

Table 1. Drug-Eluting Stent Studies by Author and Year (Open Table in a new window)

Drug

First Author

Year

Subjects

Dexamethasone

Hosemann[16]

2003

Human

Paclitaxel

Herrmann[18]

2004

Animal

Dexamethasone

Beule[17]

2008

Animal

Doxycycline

Huvenne[19]

2008

Human

Mometasone furoate

Li[21]

2009

Animal

Mometasone furoate

Murr[22]

2011

Human

Mometasone furoate

Forwith[23]

2011

Human

Mometasone furoate

Marple[24]

2012

Human

Patient Preparation

Anesthesia

General anesthesia is used for the vast majority of sinus surgery. However, in-office frontal sinus stenting can be performed in select patients whose statuses are post ethmoidectomy and post frontal sinusotomy with an amenable frontal neo-ostium. In-office stenting requires frontal sinus equipment, as well as topical and infiltrative local anesthesia.

Monitoring and Follow-up

Perioperative management

In the perioperative period before and after placement of frontal sinus stents, patients should perform a regimen of frequent nasal saline irrigation and topical nasal steroids to minimize blockage from dried mucus and ameliorate scarring and adhesions. Many sinus surgeons also advocate for a course of postoperative oral antibiotics; however no consensus exists as to the optimal duration of therapy. Oral steroids[9] and topical budesonide irrigations (off-label use) are also recommended by some surgeons, especially in cases of marked polypoidal disease.

Patients should be followed with periodic office visits for intranasal examination, debridement, and stent cleaning, which helps maintain patency. Stents are removed in the office after a variable period of time. The goal is to keep them for the minimum duration that allows for remucosalization. Although stents are well tolerated by most patients, potential complications include stent displacement and the need for removal due to patient discomfort.

Duration of stenting

Frontal sinus stents are typically removed after the frontal sinus outflow tract has remucosalized and the healing process is complete (see the image below).

Frontal sinus stenting in a Draf III cavity. A Dra Frontal sinus stenting in a Draf III cavity. A Draf III (endoscopic modified Lothrop) procedure was performed in a patient with right frontal muco-pyocele and extensive osteitis in the frontal recess. (A) Frontal neo-ostium after modified Lothrop with extensive bone devoid of mucosal lining. (B) Soft silastic stent placed in the neo-ostium for 6 weeks. (C) Well-healed and remucosalized frontal neo-ostium at 6 months postoperatively.

The optimal duration of frontal sinus stent maintenance has yet to be determined by empiric evidence, but stents should be removed as early as possible given clinical circumstances. Authors have recommended stenting periods ranging from 1 week to 6 months or longer. Primary frontal sinusotomies likely require a shorter duration of stenting. Metson used a 4-mm silastic stent in cases in which the frontal sinus ostium had been surgically enlarged. The stent was removed 1-8 weeks after surgery (average 3.2 weeks). The healed neo-ostium remained patent at follow-up 19-24 months postoperatively.[25]

In Rains’ series of 102 stents, average stent removal was performed at 35 days, with a range of 6-130 days. This was predicated upon re-epithelialization of the ethmoidectomy site, absence of significant purulence, and resolution of polypoid mucosa.[7] However, according to other literature, wound healing in the paranasal sinuses following major surgery may take up to 3 months.[16] When considering stent duration, thought should also be given to Perloff and Palmer’s finding of bacterial biofilms on frontal recess stents removed from patients 1-4 weeks after placement.[11]

Recent developments include a trend toward long-term maintenance of frontal sinus stents in patients deemed to be at high risk of restenosis. Long-term frontal sinus stents are defined as those in place for 3 months or longer. Numerous studies have shown long-term stenting to be well tolerated by patients.[3, 9, 15, 26] Weber et al showed that stents left in place for 6 months are more effective than those removed earlier based on outcomes measures.[15]

Lin and Witterick found that stents could be safely left in place for an average of 16.3 months but recommended long-term stenting only in patients with chronic frontal sinus disease resistant to standard endoscopic frontal sinusotomy.[26] In 2009, Orlandi and Knight published their data of frontal sinus stents placed over a 6-year period, revealing an average stenting duration of 32.6 months, with only 2 of 9 patients requiring removal of stents up to 6 years after placement.[3] Hunter’s series of 3 patients tolerating stents from 48 to over 60 months adds support for patient tolerance and functionality of long-term stenting.[9]

 

Technique

Approach Considerations

Various techniques may be used for the placement of frontal sinus stents, including intranasal endoscopic placement, "above and below" techniques using both endoscopic frontal sinusotomy and frontal sinus trephination, and external approaches.[5] Despite the approach used, several common key points can decrease the risk of restenosis during frontal sinusotomy. First, all efforts must be made to preserve the middle turbinate. Second, agger nasi cell walls including dome and any osteitic bone should be removed. Anterior ethmoid cells should also be removed, and midfrontal or supraorbital cells should be opened. Mucosal preservation is paramount, especially along the posterior and medial walls. Finally, working from posterior to anterior improves surgical safety by minimizing skull base injury.[7]

Endonasal Stent Placement

Endonasal stent placement using standard endoscopic sinus instrumentation is the least invasive approach and preferred method of frontal sinus stenting. In this technique, the surgeon completes an uncinectomy, anterior ethmoidectomy, and frontal sinusotomy. Care must be taken not to destabilize the middle turbinate. The frontal sinus surgical ostium (see the image below) is inspected to ensure it will accommodate a stent with minimal pressure on the surrounding mucosa or bone.

Endoscopic placement of right frontal sinus stent Endoscopic placement of right frontal sinus stent after a revision Draf 2b frontal ostioplasty in a patient with previous surgery and radiation for esthesioneuroblastoma. (A) 1/100 thick silastic sheet is cut into a T shape based on the size of the frontal ostium, (B) right frontal ostium; view with a 70º endoscope, (C) the sheet is to be rolled into a stent, grasped with giraffe forceps, and the T flange inserted into the frontal sinus, (D) the rolled part of the stent lines the area of the frontal recess.

Agger nasi cells and obstructing soft tissue and osteitic bone should be removed as needed to enlarge the frontal sinus outflow tract. The choice of stent type and size depends on the size of the neo-ostium. The frontal sinus is cannulated from below using an up-curved suction tip (with suction off), curved curette, guide wire, or specially designed stent introducer. The frontal sinus stent can then be slid over the cannulating instrument, which is angled at 45º, and advanced upward into the frontal sinus. The stent canal is so be introduced with the help of frontal giraffe instruments (see the image above).

Stents can then be trimmed to approximate the level of the inferior border of the middle turbinate or at the midlevel of the vertical septal height.[5] Care must be taken at this step, as stents with insufficient length are prone to obstruction with granulation tissue and stents with excess length predispose to airflow obstruction and crusting.[5] Finally, the frontal sinus can be irrigated via the stent.[9]

Above and Below Approach with Frontal Sinus Trephination

The above (retrograde) and below technique may be useful in cases of refractory frontal sinus disease with unfavorable anatomy in which purely endoscopic access is not possible. This approach uses a combination of external frontal sinus trephination and intranasal endoscopy, which improves access to the entirety of the frontal sinus and thus facilitates treatment of disease in areas with limited access. Frontal sinus trephination is useful in enhancing visualization in complex anatomy due to the presence of type III and type IV frontal cells. It also has been proposed to allow for better visualization of the frontal sinus outflow tract and more precise stent placement.[5] This technique, however, is more invasive than a simple endonasal approach and requires an external incision.

Preoperative CT scans should be studied to determine the optimal frontal sinus entry site, and injury to the nasofrontal recess should be avoided. Stereotactic image guidance may also be helpful during frontal sinus trephination. Once the entry site is planned, a 1-2 cm curvilinear incision is made medial to the brow along the supraorbital rim. This incision may be hidden within the brow by moving the brow medially over the planned area of trephination. Injury to hair follicles is prevented by beveling the incision parallel to the follicles, as well as avoiding the use of electrocautery.[5]

The periosteum is elevated along the floor of the frontal sinus and over the anterior aspects of the frontoethmoid suture line,[14] taking care not to injure to the supraorbital nerve. Trephination of the frontal sinus is then performed with a cutting burr or osteotome. Once the mucosal lining of the sinus is exposed, it should be incised sharply to minimize the degree of mucosal injury. Alternatively, a frontal sinus mini-trephine can be placed and used for irrigation of the frontal sinus with Fluorescein-stained saline. The frontal sinus drainage pathway can then be followed endonasally by following the Fluorescein-stained saline into the frontal sinus.[27]

At this point, endoscopic visualization via the frontal trephination is conducted.[5] Once the natural drainage pathway is identified, the frontal neo-ostium is opened, and a soft frontal sinus stent is introduced either endonasally or through the trephination and advanced through the nasofrontal recess. A suture tail, which can be grasped from below, may assist with more precise placement.

Modified Lynch Frontoethmoidectomy

The modified Lynch frontoethmoidectomy is an older technique described by Neel and colleagues in 1976,[4] the use of which has declined due to the advent of endoscopic technology. This technique uses a modified Lynch frontoethmoidectomy.[6] Contemporary use of the external frontoethmoidectomy in the United States is rare. In this procedure, first an intranasal ethmoidectomy and frontal sinusotomy are performed. Subsequently, a modified Killian incision is made, extending from the medial brow onto the nasal sidewall. The periosteum is elevated and retracted along with the trochlea of the superior oblique muscle and orbit. The medial canthus is cut, exposing bone.

A portion of the lacrimal bone is removed at the superomedial angle of the orbit, allowing for exposure and removal of a segment of the floor of the frontal sinus. With this exposure, the nasofrontal tract can be enlarged with a Kerrison rongeur. A stent is then passed from above and advanced into the widened nasofrontal tract. The stent is trimmed intranasally to the appropriate length and may be anchored to the nasal septum or lateral nasal wall with suture.[5] Currently, this technique is rarely if ever used given the advances in image-guidance and instrumentation making less-invasive approaches feasible.

Outcomes

Frontal sinus stents may help prevent scar tissue formation across the frontal sinus opening, thereby allowing epithelialization to occur along the surface of the stent. Most studies have used subjective improvement or resolution of frontal sinus symptoms as the main outcome measure. Objective data, however, was gathered by Weber et al, who compared the long-term results of patients with and without stents in a prospective fashion, finding a patent frontal outflow tract in 80% of stented patients versus 33% of unstented patients.[28] Rains reported a 94% patency rate over 8-46 months follow-up with the his proprietary stent.[7] Banhiran et al, however, reported no difference in ostium patency and symptom improvement between short-term stenting and nonstented patients after endoscopic-modified Lothrop procedure.[29]

Discussion

The authors use frontal sinus stenting in very limited situations. The most frequent indication in their experience is with a modified Lothrop cavity with significant demucosalized bone due to the drill-out procedure (see the image below).

Endoscopic placement of right frontal sinus stent Endoscopic placement of right frontal sinus stent after a revision Draf 2b frontal ostioplasty in a patient with previous surgery and radiation for esthesioneuroblastoma. (A) 1/100 thick silastic sheet is cut into a T shape based on the size of the frontal ostium, (B) right frontal ostium; view with a 70º endoscope, (C) the sheet is to be rolled into a stent, grasped with giraffe forceps, and the T flange inserted into the frontal sinus, (D) the rolled part of the stent lines the area of the frontal recess.

Middle meatal spacers (absorbable or nonabsorbable packing) and suture medialization of the middle turbinate can be used to preempt middle turbinate lateralization and prevent adhesion formation as needed. Various soft stents are now available, including a recently FDA-approved steroid-eluting bioabsorbable implant.[30] An endoscopic endonasal approach to the frontal recess is preferred. Frontal sinus trephination or mini-trephine with Fluorescein-stained saline can be used with an above and below approach, as an alternative. Overall, frontal sinus stents are well tolerated by patients. The duration of stenting is variable. Frontal sinus stenting appears to be a useful intervention for prevention of neo-ostium restenosis in selected patients.

Conclusions

Frontal sinus stenting is a valuable technique for treating complicated frontal sinus disease; however the need for stenting should be carefully considered. Placement of stents can create additional trauma and promote iatrogenic scarring. Stents can also harbor biofilms and promote inflammation leading to granulation tissue, neo-osteogenesis, and restenosis. Accidental aspiration is an additional risk. Thus, the procedure is indicated in limited situations. In patients who have failed aggressive medical management, conservative surgery, multiple surgeries, or are at high risk for restenosis of the neo-ostium or obstruction of frontal sinus outflow, stenting may be an option. Stenting of the frontal sinus should be used by experienced surgeons with a clear understanding of frontal recess anatomy and chronic rhinosinusitis pathophysiology.

 

Medication

Medication Summary

Little consensus exists regarding timing and length of postoperative medical treatment following frontal sinus stenting; however, common regimens include regular saline irrigation and topical steroids. Oral antibiotic and systemic steroid use is not ubiquitous.