The surgical approach to frontal sinus disease has been subject to much variation. Experimental evidence for new treatment modalities is quite limited. Frontal osteoplasty, while probably the best procedure to date, has up to a 25 percent failure rate. Possible complications include recurrent disease, incomplete bony obliteration (Macbeth technique), infection of the adipose implant, frontal bossing or depression, and laceration of the dura. Four experimental groups were designed using the canine frontal sinus model. Results indicated that stripping the mucosa in a normal sinus with intact periosteum and a patent nasofrontal duct will not consistently lead to normal mucosal regeneration. Second, the additional factor of removing the periosteum (as in osteoplasty by osteoneogenesis), leads to partial fibrous obliteration complicated by mucocele formation. Third, sinus obliteration by osteoneogenesis was much more consistent with concurrent closure of the nasofrontal duct. Fourth, intentionally leaving a strip of mucosa leads to failure of obliteration by osteoneogenesis 100 percent of the time. Finally, bony-fibrous obliteration increases with time but is still incomplete after one year. In light of these results, fat obliteration with closure of the nasofrontal duct is probably more reliable than obliteration by osteoneogenesis.

Tumors of the lacrimal sac are rare, and are discussed primarily in the ophthalmological literature. The otolaryngologist, however, often performs the definitive surgery and must, therefore, be familiar with this disease. The lacrimal apparatus secretes and then drains lubricating fluid from the eye. This report focuses on the drainage mechanism which is anatomically and functionally a single structure composed of the canaliculi, the lacrimal sac, and the nasolacrimal duct. By 1963, 184 lacrimal sac tumors had been reported in the world literature. We have collected an additional 21 patients from the literature. This brings the total malignant tumors to 125, of which 74 were of epithelial origin. One sarcoma and four poorly differentiated epidermoid tumors treated in our department are presented in detail. The diagnosis is often evasive though the history of mass and epiphora is typical. Conservative treatment for dacryocystitis only temporizes. Work-up should include external and slitlamp examination, complete rhinological evaluation, sinus x-rays, tomograms of the bony lacrimal sac area, and dacryocystograms. Biopsy gives pathological confirmation. The largest group is epidermoid carcinoma, mostly of the poorly differentiated nonkeratinizing type. The treatment for benign lesions is local excision. Preoperative irradiation is indicated for epidermoid carcinoma, followed by wide local excision. Radical maxillectomy may be reserved for recurrences, and neck dissection for palpable nodes may be helpful. Mesenchymal tumors respond best to radiotherapy. Death in lacrimal sac cancer results from metastases, most often to the neck and lung. Five year survival rates appear to be slightly greater than 50%.

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