The Frontal Sinus and Frontal Recess: Anatomical, Radiological and Surgical Concepts

Abstract

Introduction The frontal sinus (FS) is the most complex of the paranasal sinuses due to its location, anatomical variations and multiple clinical presentations. The surgical management of the FS and of the frontal recess (FR) is technically challenging, and a complete understanding of its anatomy, radiology, main diseases and surgical techniques is crucial to achieve therapeutic success. Objectives To review the FS and FR anatomy, radiology, and surgical techniques. Data Synthesis The FS features a variety of anatomical, volumetric and dimensional characteristics. From the endoscopic point of view, the FR is the point of greatest narrowing and, to have access to this region, one must know the anatomical limits and the ethmoid cells that are located around the FR and very often block the sinus drainage. Benign diseases such as chronic rhinosinusitis (CRS), mucocele and osteomas are the main pathologies found in the FS; however, there is a wide variety of malignant tumors that can also affect this region and represent a major technical challenge to the surgeon. With the advances in the endoscopic technique, the vast majority of diseases that affect the FS can be treated according to Wolfgang Draf, who systemized the approaches into four types (I, IIa, IIb, III). Conclusion Both benign and malignant diseases that affect the FS and FR can be successfully managed if one has a thorough understanding of the FS and FR anatomy, an individualized approach of the best surgical technique in each case, and the appropriate tools to operate in this region.

Mucocele frontal: reporte de caso

“…El crecimiento expansivo causa aumento de la presión llevando a la atrofia y destrucción de las paredes óseas del seno paranasal, el mucocele se extiende así hacia las regiones de menor resistencia, ya sea hacia la órbita, senos adyacentes, cavidades nasales e incluso a nivel intracraneal. En esta paciente ocurrió una extensión a nivel de la órbita del lado izquierdo con un importante desplazamiento ocular, así como también hacia la cavidad intracraneal entrando en contacto con las meninges (7,8).…”

The Draf III procedure: A review of indications and techniques

“…The entire frontal beak, frontal sinus floor, and bony septum should be removed, ensuring a smooth transition between the nasal bone and anterior frontal table. The frontal process of the maxilla should also be removed until the periosteum is exposed 8 . A 4‐mm diamond burr is used while drilling the posterior frontal sinus floor anterior to the first olfactory fiber, due to the vulnerable anatomy at this location.…”

“…If the face of the ethmoid bulla is still intact, it can serve as a useful posterior landmark to help identify the frontal recess. 8 Care must be taken not to strip the frontal sinus mucosa during this process as this can lead to scarring. 20 After the adequate opening of the frontal recess is achieved bilaterally, an approximately 2 cm septal window is then made caudally to dorsally just below the floor of the frontal sinus and extended inferiorly to approximately half the vertical length of the remaining middle turbinate.…”

“…The Draf Ⅲ is the most extensive and involves bilateral Draf Ⅱb procedures combined with a superior septectomy and removal of the intersinus septation to create a common frontal sinus cavity (Figure 2). 5,6 The Draf Ⅲ limits of resection are the external periosteum of the frontal process of the maxilla anteriorly, the lamina papyracea of the orbit laterally, and the first olfactory fibers posteriorly 8 …”

“…As the surgeon approaches the cribriform plate, the nasal branch of the anterior ethmoid artery will be encountered first, just anterior to the first olfactory fiber. The first olfactory fiber delineates the posterior‐most extent of the Draf Ⅲ, but the nasal branch of the anterior ethmoid artery is often confused with the first olfactory fiber given their close proximity 8 …”