Utility of intraoperative flexible endoscopy in frontal sinus surgery

Abstract

Background: Surgical management of the frontal sinus can be challenging. Extensive frontal sinus pneumatization may form a far lateral or supraorbital recess that can be difficult to reach by conventional endoscopic surgical techniques, requiring extended approaches such as the Draf III (or endoscopic modified Lothrop) procedure. Rigid endoscopes may not allow visualization of these lateral limits to ensure full evacuation of the disease process.

Methods: Here we describe the utility of intraoperative flexible endoscopy in two patients with far lateral frontal sinus disease.

Results: In both cases, flexible endoscopy allowed confirmation of complete evacuation of pathologic material, thereby obviating more extensive surgical dissection.

Conclusion: In cases where visualization of the far lateral frontal sinus is inadequate with rigid endoscopes, flexible endoscopy can be used to determine the need for more extensive dissection.

Figure 1.

(A–C) Coronal, axial, and sagittal computed tomographies with intravenous contrast, demonstrating an expansile lesion in the left frontal sinus, with bony remodeling and dehiscence of the posterior table of the frontal sinus and superior orbital wall; note the heterogeneous appearance of the frontal sinus lesion consistent with fungus ball. (D–F) Images, showing appearance of frontal sinus after endoscopic frontal sinusotomy; note complete removal of the fungus ball.

Figure 2.

(A) A maximal lateral view of the frontal sinus when using a rigid 70° endoscope. (B) Further lateral view when using a flexible endoscope. (C) Lateral recess completely visualized by using a flexible endoscope.

Figure 3.

Coronal (A and B) and axial (C) computed tomographies, demonstrating an expansile lesion in the left frontal sinus with thinning of the orbital roof with extension into the calvarium. Coronal (D and E) and axial (F) T2-weighted magnetic resonance image of the same patient, showing material expanding the left frontal sinus, with mild protrusion into the superior extraconal space; no intracranial extension was noted.

Figure 4.

(A) A maximal lateral view of the frontal sinus by using a rigid 70° endoscope. (B) A further lateral view by using a flexible endoscope. (C) A lateral recess completely visualized by using a flexible endoscope.