Osteoplastic Frontal Sinus Surgery With Fat Obliteration: Technique and Long‐Term Results Using Magnetic Resonance Imaging in 82 Operations

Abstract

Objective: To evaluate the intraoperative and late complications of osteoplastic sinus surgery with fat obliteration with long-term magnetic resonance imaging (MRI) follow-up. Methods: The operative records of all patients who underwent osteoplastic frontal sinus surgery with fat obliteration between January 1, 1986 and December 31, 1997 were reviewed and the postoperative clinical course and magnetic resonance imaging (MRI) scans were analyzed if available. MRI analyses revealed that changes in the distribution of fatty and fibrous tissue, the development of necrosis or oil cysts, recurrences, inflammatory complications, and mucoceles were time-dependent occurrences. Results: Eightytwo operative records were evaluated and 59 patients were followed 1 to 12 years after surgery. Eighty-six MRI scans in 51 patients were available for analysis. The most frequent intraoperative complications were exposure of orbital fat (19.5%), unintentional fracture of the anterior wall (19.5%), incorrect placement of the anterior wall (17%), and dural injury (9.8%). Persistent changes of the frontal contour (embossment, depression) occurred in 10.2% and the esthetic result was unfavorable in 5.1% of the cases. Mucoceles could be detected in 5 of 51 cases (9.8%). The amount of adipose tissue detectable in the last scan was less than 20% in the majority of cases (53%), and more than 60% in only 18% of the cases. The amount of adipose tissue decreased significantly with time (the median half-life was 15.4 mo). Conclusions: Osteoplastic frontal sinus surgery with fat obliteration is very useful and successful in patients in whom the frontal sinus is not accessible via an endonasal approach or the natural drainage cannot be reestablished. MRI is currently the most valuable diagnostic tool to evaluate the frontal sinus after obliteration with adipose tissue. The method has some limitations with regard to detection of small recurrent mucoceles and differentiating vital adipose tissue from fat necroses in the form of oil cysts. In these difficult cases, long-term MRI follow-up is necessary. Key Words: Frontal sinus surgery, osteoplastic flap operation, frontal sinus obliteration, fat transplantation, magnetic resonance imaging, frontal sinus mucocele.

Delayed development of frontal mucocele after fronto-orbital advancement in a child with craniosynostosis

“…Mucocele is known to develop from the frontal sinus in 51% to 98% of cases after sinus surgery and less than 1% after frontal craniotomy of routine neurosurgeries [3,14,[16][17][18]. Because 67% to 100% of mucoceles occur several years or decades after surgery, some authors have recommended that patients who have received frontal sinus trauma or surgery should be followed up for at least 5 to 10 years or for their remaining lifetime [2,6,7,19].…”

“…Frontal sinus mucoceles develop as a consequence of inadequate sinus ventilation that arises due to inflammation, allergy, polyps, tumors, surgery, and trauma [3,9,14,16,18], and it is known that improved ventilation will lead to normally functioning sinus epithelium [5]. Treatment of mucoceles consists of removal of the mucocele by an obliteration procedure and a marsupialization that attempts to enhance ventilation.…”

Obliteración del seno frontal mediante injerto de tibia y plasma rico en plaquetas para el tratamiento de la osteomielitis crónica

“…Se han de tener en cuenta unos principios esenciales para el éxito de la obliteración sinusal 8,16,21,25 : -Extirpación meticulosa de toda la mucosa sinusal y de la cortical de las paredes del seno inmediatamente por debajo de la mucosa, preferentemente con magnificación.…”

“…El fallo de estas técnicas, se debe a la reabsorción del tejido, infección o rechazo del injerto 19,22 . Para examinar el grado de obliteración del seno tras la intervención, e identificar los pacientes de riesgo de recurrencia de la enfermedad sinusal después del proceso quirúrgico, se aconseja realizar TC o RM 18,25 . La obliteración del seno frontal mediante la implantación de tejido adiposo autógeno, introducido por Bergara e Itoiz, y posteriormente popularizado por Montgomery, es el método más utilizado por la mayoría de los cirujanos 21,25 .…”

“…Para examinar el grado de obliteración del seno tras la intervención, e identificar los pacientes de riesgo de recurrencia de la enfermedad sinusal después del proceso quirúrgico, se aconseja realizar TC o RM 18,25 . La obliteración del seno frontal mediante la implantación de tejido adiposo autógeno, introducido por Bergara e Itoiz, y posteriormente popularizado por Montgomery, es el método más utilizado por la mayoría de los cirujanos 21,25 . Complicaciones encontradas con su uso son: infección del injerto, necrosis de la grasa, infección sinusal crónica recurrente, complicaciones a nivel abdominal (abscesos, seromas o hematomas) 6,17,18 .…”