Atlas of Frontal Sinus Surgery: A Comprehensive Surgical Guide

323 Pages·2022·41.01 MB·English

by  David R. Lobo, Jaime Viera Artiles, Javier A. Ospina

David R. Lobo
Jaime Viera Artiles
Javier A. Ospina
Editors
Atlas of Frontal
Sinus Surgery
A Comprehensive Surgical Guide
123
Atlas of Frontal Sinus Surgery
David R. Lobo • Jaime Viera Artiles
Javier A. Ospina
Editors
Atlas of Frontal Sinus Surgery
A Comprehensive Surgical Guide
Editors
David R. Lobo Jaime Viera Artiles
Department of Otolaryngology Department of Otolaryngology
Marqués de Valdecilla University Hospital Marqués de Valdecilla University Hospital
Valdecilla Biomedical Research Institute Research and Innovation Surgery Group-IDIVAL
Santander, Spain Santander, Spain
Javier A. Ospina
Otolaryngology
Fundación Santa Fe de Bogotá
Bogotá D.C., Colombia
ISBN 978-3-030-98127-3 ISBN 978-3-030-98128-0 (eBook)
https://doi.org/10.1007/978-3-030-98128-0
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To my beautiful wife Monica; and my dear sons Juan and Pablo
To my teachers: Drs López-Cortijo, Davies and Ramírez-Camacho
And to my patients with frontal sinus pathology
- David R. Lobo
Foreword
Almost 20 years ago, a passionate and enthusiastic young resident from Spain came to train in
endoscopic sinus surgery with me in Atlanta. Dr. David Lobo’s inquisitive mind, eagerness to
learn, and advanced skills in endoscopic sinus surgery made me think then that he would have
a bright and successful professional journey; he proved me right.
During the progression of his career, and teaching residents and fellows, Dr. Lobo observed
learning challenges and difficulties that most young surgeons face while operating on the fron-
tal sinus. Recognizing the advances made in frontal sinus surgery and the paucity of textbook
publications on the topic, the inspiration for this book was born.
The Atlas of Frontal Sinus Surgery provides a comprehensive step-by-step approach that
helps develop the skills and knowledge to perform safe and successful frontal sinus surgery.
The book is methodically structured to allow for gradual learning of the different surgical
techniques. It is a must-read for young surgeons in training and an outstanding reference for
more experienced clinicians.
Lobo, Artiles, and Ospina recruited a renowned ensemble of international authors with vast
knowledge in the field, who presented their experiences in an easy-to-follow and didactic man-
ner. The chapter on “Ergonomic Aspects and Instrumentation in Frontal Sinus Surgery” is of
distinct significance. Highlighting the importance of posture and comfort will help prevent
surgeons from developing musculoskeletal injuries during surgery, a very prevalent problem in
our specialty.
I am certain that the Atlas of Frontal Sinus Surgery will become a reference book that will
help endoscopic sinus surgeons improve their surgical skills and better understand the nuances
of frontal sinus surgery
Pablo Stolovitzky, MD
Department of Otolaryngology
Emory University
Atlanta, Georgia
vii
Preface
Throughout history, the scientific literature on frontal sinus surgery has reminded us that it is
regarded as one of the most complex and advanced rhinological procedures. It entails working
in a narrow cavity, close to critical structures (e.g., the orbit and the skull base), often using
highly angled optics and instrumentation. There is also a notable risk of complications, of
undesirable scarring that leads to restenosis, and of the persistence or appearance of new
symptoms.
In the case of inflammatory pathology—one of the most frequent indications for frontal
sinus surgery—it is common to encounter a bleeding field where visibility is not optimal, thus
compromising the safety and the expected outcome of the surgery. Medium-term results are
sometimes not satisfactory, due to recurrence of the inflammatory pathology or to stenosis of
the drainage tract of the frontal sinus.
The first endonasal approaches to the frontal sinus were associated with unacceptable mor-
bidity and mortality and were, therefore, largely abandoned in favor of external approaches.
These approaches, which continue to have their indications today, represented the gold stan-
dard of treatment for many years, even though they had a nonnegligible rate of surgical failure
and complications.
The revolution came with endoscopic surgery and the development of endoscopic
approaches to the frontal sinus. The indications have expanded ever since, either to treat the
specific pathology of the frontal sinus or as a preliminary step for other surgical approaches.
These procedures are, therefore, increasingly used despite their complexity.
In developing their technical skills, rhinologists will face cases of different difficulty so that
it is essential to select cases in accordance with their current technical level in order to achieve
an optimal result without exposing the patient to unnecessary risk or incomplete surgery.
In practice, this is not always the case. Failure to achieve the desired result may be because
the most appropriate approach was not selected in a particular case, or because a complete and
meticulous resection of all involved cells was not carried out, resulting in suboptimal exposure
of the frontal recess, which is a frequent cause of failure.
On the other hand, the surgeon may be unduly aggressive in performing the surgery, and if
associated with inexperience, this may put the patient at risk of major complications.
Because of all the above-mentioned complexities, frontal sinus surgery is considered
undoubtedly difficult and requires a long learning curve.
Fortunately, the hard work and effort of many rhinologists throughout history and advances
in recent decades have contributed to making this surgery much safer and more efficient today.
This has been made possible in many ways: through a better understanding both of frontal
sinus pathology and of surgical and radiological anatomy; through the technical advances in
surgical instrumentation and image navigation systems; through the use of mucosal flaps; and
through improvements in preoperative and intraoperative preparation and in postoperative
care.
The aim of the book is to offer readers a guide that will increase their confidence in under-
taking progressively more difficult cases. Moreover, mastering frontal sinus surgery opens up
the possibility of performing complex skull base surgeries in which frontal sinus surgery forms
ix
x Preface
part of the approach and, therefore, this book provides the entire spectrum of current under-
standing of frontal sinus surgery.
The book follows a logical sequence of preparation for surgery, from the simplest and least
invasive procedures for common cases to the most advanced and complex techniques for
unusual and challenging cases. Readers can, of course, choose to consult any specific chapter
or section in search of the relevant information required for a particular case.
The coordination of this book has been immensely interesting, and the whole process has
been a thoroughly enjoyable and enriching experience. It is hoped, therefore, that readers will
derive the same benefits, given that all the authors are proven experts and renowned specialists
with vast experience in this field.
The book is generally addressed to ENT specialists who perform nasosinusal endoscopic
surgery, to rhinologists with experience in this field, and also to those beginning their training.
Nevertheless, it may also be of interest to ophthalmologists, maxillofacial surgeons, and neu-
rosurgeons, since they often work closely with the otolaryngologist, especially if their field of
interest includes endoscopic skull base and/or orbit surgery.
The book covers the full range of frontal sinus surgery, from balloon sinuplasty to extended
frontal sinus procedures. Among many other topics, the book describes complete bone removal
(Draf III), open and combined approaches for craniofacial resection, frontal sinus tumor sur-
gery, open approaches such as osteoplastic flaps with or without frontal sinus obliteration, and
other indications for endoscopic approaches to the frontal sinus such as septal perforation
repair, and large skull base defect reconstruction with pedicle flaps.
The reader should anticipate that this book does NOT aim to provide comprehensive
descriptions of the pathogenesis of diseases affecting the frontal sinus.
The book is structured in a way that allows a gradual learning of the different surgical tech-
niques. It helps both the young surgeon in training and the more experienced practitioner to
progress in endoscopic surgery and to adopt a more complete and safe approach to the frontal
sinus. Given the professional and academic profile of the authors, who have acquired great
experience in this type of surgery, their descriptions and advice will be useful not only for
those who are new to these approaches but also for rhinologists and otolaryngologists with a
special dedication to this subspecialty.
Readers are fortunate to have in their hands a book in which the authors have not only
expressed their deep knowledge and wisdom on this subject, but have done so in a profoundly
educational way, with clear and easy-to-follow explanations. The book is also full of pearls and
technical details that will delight attentive readers.
It conveys the anatomy and detailed steps of each procedure clearly through concise, step-
by- step instructions and easy-to-read descriptions of the surgical procedures accompanied by
many illustrations.
One of the hallmarks of the book is that it includes new aspects that reflect recent develop-
ments in the field. It discusses topics that are seen as important and helps to provide optimal
patient care before, during, and after surgery with detailed information on relevant anatomy,
surgical indications, instrumentation, potential pitfalls, and postoperative considerations.
In recent years, there have been great advances in endoscopic sinus surgery but they have
been particularly prominent in frontal sinus surgery with new anatomo-surgical and radiologi-
cal classifications and descriptions of the complexity of the surgery. These have been aided by
advances in such aspects as image processing techniques, surgical instruments, navigation
systems, presurgical checklists, and pre-, intra- and postoperative management, all of which
have greatly improved the safety and results of this complex surgery, which has a potential risk
of major complications. Where relevant, details on all these aspects have been included in the
different chapters of this book.
The book is divided into three parts.
The first part consists of eight chapters that cover all the prior knowledge that a frontal sinus
surgeon must acquire for a solid preparation for safe surgery with the best chance of success.
The chapters deal with novel, lesser known and revolutionary aspects of frontal sinus surgery
Preface xi
that can truly change the way many readers perform frontal sinus surgery. They not only pro-
vide knowledge of surgical anatomy and radiology but also give clear indications on how to
assess the degree of difficulty of a specific surgery.
The knowledge of anatomy acquired from practice on virtual or cadaver models and of
radiological anatomy through the capability of performing reconstructions on three planes or
virtual endoscopies, in which hidden structures (e.g., anterior ethmoidal artery or the skull
base) can be previewed, affords a better understanding both of the frontal sinus in general and
of the particular case to be treated. These eight chapters, as well as a comprehensive coverage
of preparation for surgery, also address key elements for the performance of safe and complete
procedures (training, ergonomics and instrumentation, patient selection, preoperative analy-
ses, indications and contraindications, etc.).
In Chap. 1 Shekhar Rawal introduces the topic and contextualizes frontal sinus surgery in
terms of its importance from different angles including its historical, epidemiological, eco-
nomic, and medicolegal aspects.
In Chap. 2, Gaurav Medikeri, from his extensive experience, provides valuable first-hand
tips and information about training in frontal sinus surgery. While the learning curve usually
begins during a residency program, continuous training is necessary throughout a surgeon’s
career through participation in courses, hands-on workshops, fellowships, etc.
In Chap. 3 Irene Monjas, who along with her neurosurgical team, gives talks all over the
world about skull base 3D anatomy, reviews the surgical anatomy of the frontal sinus in detail.
Readers will be able to build a mental reconstruction of the frontal recess, will understand all
the cells affecting the frontal recess or the frontal sinus itself, and recognize all the anatomical
variations that may pose the greatest difficulty or risk during surgery.
In Chaps. 4 and 6 Claudio Callejas reviews the indications for frontal sinus surgery, and the
recent international classifications for frontal sinus surgery relating to radiological anatomy,
the difficulty of surgery, and the different endoscopic approaches to the frontal sinus (to be
developed in Part II). These chapters are essential, since the international classifications, in
addition to their immense consensus value that allows professionals to understand each other,
play an important educational role by helping to understand this complex anatomy, the differ-
ent approaches, and the range of difficulties involved in every frontal sinus surgical
intervention.
Presurgical preparation is essential to obtain optimal results and Yvonne Chan and Alkis
Psaltis enlighten us about the best management based on the most recent literature and their
own experience in Chap. 5.
Serafín Sánchez, who contributes Chap. 7, has for many years run an international course
on preoperative analysis of endoscopic sinus surgery and has a wealth of experience in preop-
erative image analysis, 3D reconstruction, and surgical planning, which is reflected in this
marvelous chapter.
Ergonomics is addressed in Chap. 8. Endoscopic sinus surgery (ESS) has been associated
with physical discomfort and musculoskeletal disorders. This might be related to poor ergo-
nomics within the operating room (OR) environment, but also to the strong demands that this
procedure imposes upon the surgeon. The incidence of cervicobrachial disorders in surgeons
who perform minimally invasive procedures is high. Recognition of this problem has resulted
in the creation of new equipment, improvements in the design and distribution of the OR as
well as greater postural awareness. The chapter is essential for a long and healthy career in this
field. Additionally, ergonomic improvements in the OR contribute to the safety and efficiency
of surgical procedures, and result in greater comfort for the surgeon and better results for the
patient.
The 20 chapters of Part II take the reader through the different surgical techniques, from
balloon sinuplasty, through all Draf approaches and the more recently described Eloy
approaches, to open techniques, together with their application to the resolution of specific
frontal sinus pathology such as osteoma, inverted papilloma, mucocele, fracture, etc., which
have their singularities. Also described are different surgical procedures in which frontal sinus
xii Preface
surgery is a necessary prior step, such as the closure of cerebrospinal fluid leaks, closure of
septal perforations, resection of skull base tumors, etc. These chapters are covered by several
of the world’s foremost rhinologists and most renowned and recognized leaders in sinus
surgery.
The detailed description of the surgical procedure is supported, where possible, with clear
schemata or drawings, and high-quality illustrative video clips. Illustrations and short video
clips will serve to clarify different aspects of surgical technique. The authors’ extensive experi-
ence will make even the tiniest details invaluable.
Sinus balloon sinuplasty is a fairly new technique, approved by the United States Food and
Drug Administration (FDA) in 2005. Increasingly, balloon sinuplasty is being recognized and
fully covered by medical insurance companies. A 2017 study found that the number of balloon
sinus procedures performed in the U.S. increased 59 percent annually from 2011 to 2014. A
whole chapter devoted to this topic is well justified and is, therefore, comprehensively covered
in Chap. 9, which describes the evidence-based medicine, possible controversies, and pitfalls
of sinus balloon sinuplasty.
Finally, the five chapters of Part III cover frontal sinus surgery complications, postoperative
management, debates and controversies concerning frontal sinus surgery, and the future of
frontal sinus surgery.
Stephen Ball and Richard Douglas, in Chap. 29, address frontal sinus surgery complications
and how to identify and manage them, while Maite Pinilla and Beatriz Arellano discuss in
Chap. 30 the management of orbital and central nervous system (CNS) complications of fron-
tal sinusitis. They provide magnificent chapters on this topic.
Postoperative care is essential to achieve the best results and Yvonne Chan and Alkis Psaltis
summarize in Chap. 31 a number of postoperative strategies that can be employed to enhance
wound healing of the sinonasal mucosa after successful sinus surgery.
In an excellent Chap. 32, Mark Arnold and John DelGaudio offer us an impressive overview
of what constitute the challenges and the most controversial aspects of frontal sinus surgery
today. Undoubtedly, it is an inspiring chapter for all those who with their work and effort are
providing ever increasing evidence of the best therapeutic approaches to frontal sinus diseases
or offering new therapeutic solutions for these diseases.
This book aims to provide a highly practical and useful guide to frontal sinus surgery, but it
is also hoped that it might also prove inspiring by dealing with the most recent advances in the
field. In this regard, the final chapter covers the most recent advances in frontal sinus physio-
pathology and new treatments with biologic drugs that may revolutionize sinus therapy in the
near future.
This Atlas gets right to the point, to the heart of the matter, which is to build surgeon skills,
references, and knowledge for a complete and safe frontal sinus surgical procedure. We really
believe that the book can help many colleagues to better understand and perform frontal sinus
surgery. It aims to help surgeons develop new skills step by step and to make steady progress
in their surgical expertise.
If this book helps a colleague to improve his or her surgical results, to progress safely, and
to have the confidence and skills to face cases of increasing difficulty, it will have been worth
the effort.
Santander, Spain David R. Lobo
Santander, Spain Jaime Viera Artiles
Bogotá D.C., Colombia Javier A. Ospina