Endoscopic view of frontal sinus polyps.

A 25-year-old man complained of nasal congestion and frontal pain of approximately 2 years' duration. He had used numerous medications. He had no previous allergy or surgical treatment. Of note was that he worked as a spray painter in an auto body shop. In addition, he also was taking flying lessons and was having difficulty with pressurization in a small plane, as he would experience increasing facial pain and frontal headaches.

Nasal endoscopy revealed a pale, boggy, watery nasal mucosa with multiple polyps. His condition was more marked on the left side than on the right. Computed tomography (CT) of the sinuses showed bilateral ethmoid and maxillary sinusitis with polypoid tissue. CT also revealed a polypoid mass in the right frontal sinus.

The patient underwent bilateral functional endoscopic sinus surgery under general anesthesia. Multiple polyps were removed from both nasal cavities with a microdebrider. The right frontal sinus was explored via the frontal recess, and a polyp on the floor of the sinus was removed (figure).

The right lateral nasal wall was examined with a 0[degrees] telescope (figure, A). It showed the middle meatus, frontal recess, and middle turbinate. The polyp was pulled out from the frontal recess with a suction tip. The region of the frontal sinus ostium was examined with a 30[degrees] telescopic view of the frontal sinus lumen (figure, B). It is important for the endoscopic surgeon to know that in most cases there is no anatomically defined "nasal frontal duct," but rather a frontal recess, which is the area of the junction of the frontal and anterior ethmoid sinuses. [1] As described by Kuhn, the frontal recess is an inverted funnel-shaped space. [2] It has a narrow upper portion in the internal frontal ostium and a lower bell-shaped end in continuity with the anterior ethmoid sinus wall.

A 30[degrees] telescopy (figure, C) of the enlarged frontal sinus ostium revealed a small cyst and a medium-sized polyp on the floor of the frontal sinus. The opening was enlarged with Kuhn-Bolger frontal recess curettes and a microdebrider with a curved cutting blade. A KuhnBolger frontal sinus probe was used to explore and palpate the interior of the frontal sinus. As the tip of the 30[degrees] telescope was advanced, a closer view of the cyst and the polyp was obtained (figure, D). These lesions were removed with a Kuhn-Bolger giraffe frontal sinus cup forceps. The patient's facial pain and nasal congestion resolved after surgery, and 2 years later he was still asymptomatic.

Endoscopic excision of a polyp in a frontal sinus is much more difficult than that in other paranasal sinuses. The location and size of the polyp should be carefully studied by preoperative CT. The surgeon should be familiar with the anatomy of the frontal recess and the frontal sinus. Computer-guided surgical systems are useful during endoscopic frontal sinus surgery in difficult cases.

From the Department of Otolaryngology, University of South Florida College of Medicine, Tampa (Dr. Christmas), and the Southern New England Ear, Nose, Throat, and Facial Plastic Surgery Group, New Haven, Conn.; the Section of Otolaryngology, Hospital of St. Raphael, New Haven; and the Section of Otolaryngology, Yale University School of Medicine, New Haven (Dr. Yanagisawa).

References

(1.) Rains BM. Powered instrumentation in the management of chronic frontal Sinusitis. In: Krouse JH, Christmas DA, eds. Powered Endoscopic Sinus Surgery. Baltimore: Williams and Wilkins, 1997. Ch. 8.

(2.) Kuhn FA. Chronic frontal sinusitis: The endoscopic frontal recess approach. Operative Techniques in Osolaryngology--Head and Neck Surgery 1996;7:222-9.