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 Table of Contents  
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 2-5

Role of bi-portal endoscopic approach to frontal sinus in managing frontal sinus diseases

Department of Otorhinolaryngology, Cairo University, Cairo, Egypt

Date of Submission27-Dec-2019
Date of Acceptance13-Apr-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Sameh M Zamzam
Building 279, Portsaid Street, Elsayeda Zainab, Cairo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajr.pajr_23_19

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In spite of recent evolution of endoscopic frontal sinus surgery, some cases are still challenging due to the difficulty to reach the lateral frontal sinus even with Draf type III. This study aims to highlight the bi-portal approach to the frontal sinus disease.
Materials and methods
This study is a prospective study that was conducted on four patients with mean age of 56 years. Two cases were presented with allergic fungal sinusitis, one case showed an inverted papilloma and a single case of granulomatous fungal sinusitis. All patients underwent bi-portal surgery which entailed endoscopic frontal sinus surgery either Draf IIb or III plus as an external approach through the upper eyelid.
Complete removal of the disease with no major postoperative complications, with no detection of recurrence during the 12–30-month-follow-up period.
Bi-portal frontal sinus approach is an easy noninjurious technique with very little cosmetic drawbacks allowing rhinologists to access the whole aspects of the frontal sinus, especially the lateral part.

Keywords: bi-portal, endoscopic, eyelid, frontal sinus

How to cite this article:
Ali AY, Zamzam SM. Role of bi-portal endoscopic approach to frontal sinus in managing frontal sinus diseases. Pan Arab J Rhinol 2020;10:2-5

How to cite this URL:
Ali AY, Zamzam SM. Role of bi-portal endoscopic approach to frontal sinus in managing frontal sinus diseases. Pan Arab J Rhinol [serial online] 2020 [cited 2020 Nov 30];10:2-5. Available from: http://www.PAJR.eg.net/text.asp?2020/10/1/2/288578

  Introduction Top

Frontal sinus surgeries have been recently upgraded from open trephine or osteoblastic flap surgeries to endoscopic transnasal surgery due to modern advances in sinus endoscopy with angled view and specific instruments for frontal sinus surgery. This evolution aimed to decrease cosmetic troubles and shorten the postsurgery recovery time [1],[2],[3] . Unfortunately, there are still some situations that need more exposure to avoid leaving a residual disease; such situations include mucopyocele and inverted papilloma and fungal sinusitis or other lateral frontal sinus disease. Approach to the lateral frontal sinus still presents a challenge even with the Draf III approach[4].

  Aim Top

We have tried in this study to highlight the bi-portal approach to the frontal sinus surgery. We have elucidated the surgical techniques with summarizations of its benefits and its role to expand the role of the endoscopic approach to frontal sinus.

  Materials and Methods Top

This study has been approved by ethical committee of ENT department. This study is a prospective study conducted on four female patients aged from 48 to 63 years presented with frontal sinus disease at Otolaryngology Department of Cairo University, Egypt, between 2016 and 2019. All patients were subjected to computed tomography scan on the frontal sinus with coronal, axial, and sagittal views. Also, all patients were asked to sign a written informed consent [Figure 1].
Figure 1: Preoperative computed tomography scan of the patient.

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All patients underwent bi-portal endoscopic frontal sinus surgery for unilateral frontal sinus disease. This technique includes two parts.

The first part is the endoscopic transnasal frontal sinus surgery which entailed medialization of the middle turbinate and ethmoidectomy, followed by Draf IIb in three patients and Draf III in a single patient. Draf IIb includes opening the frontal sinus between the lamina papyracea laterally and the septum medially[5]. On the other hand, the Draf III technique includes an additional step which removal of the interfrontal sinus bony septae[5].

The second part is an external approach through the upper eyelid, steps started with infiltration of saline/adrenaline 1: 200 000 concentration and a horizontal incision parallel to the lid skin crease was made using scalpel size 11 just lateral to the mid-pupillary line for a length of 10–15 mm; a self-retained retractor was applied; dissection was carried out parallel and superior to muscle fibers to reach the periosteum with preserving the supraorbital artery and nerve. The periosteum was incised and the bone was drilled to reach the frontal sinus. Then the frontal sinus remnant lesion or disease was removed using endoscopy and instruments through this port. After finishing the periosteum was closed using Vicryl 3-0 and the skin was closed by Prolene 5-0 [Figure 2].
Figure 2: Incision of the external port.

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  Results Top

We have carried out four cases by the bi-portal frontal sinus approach shown [Table 1]. Two cases had allergic fungal sinusitis: one of them was a recurrent case, the third patient had an inverted papilloma, and the fourth one had chronic granulomatous fungal sinusitis. All patients have shown no short-term or delayed complications apart from mild local edema and mild ptosis just for few days which was improved by medical treatment. We have followed up the patients by endoscopic examination weekly and by computed tomography scan after 6 months and 1 year postoperatively with no clear disease recurrence [Figure 3], [Figure 4] and [Table 1].
Figure 3: Frontal sinus endoscopic view through the external port.

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Figure 4: Transillumination of the frontal sinus after removing the pathology, an external port view.

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Table 1: Details of this study cases

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  Discussion Top

Kennedy et al.[6] had concluded that endoscopic frontal sinus surgery failed to reach superior and lateral lesions of the frontal sinus in a study published in 1989 which entailed performing an endoscopic frontal sinus surgery for cases of frontal mucoceles.

Draf and Weber have published a modern concept regarding endoscopic approaches to the frontal sinus in 2001. These approaches include removal of mucosal disease of the ostium (Draf type I) and removal of frontal sinus floor from lamina papyracea to the middle turbinate (Draf type IIa) and removal of frontal sinus floor from the lamina papyracea to the nasal septum including removal of the middle turbinate (Draf type IIb) and resection of the frontal sinus floor on both sides with interfrontal septectomy (Draf type III), thereby giving an access to the lateral frontal sinus[5]. However, when the frontal sinus disease is beyond the endoscopic operative field an external open approach is required if the lesion requires complete removal.

Batra et al.[7] have reported the 'above and down' procedures in 2005, above means the external trephine approach and below means endoscopic endonasal technique. They applied this technique on 22 cases with a variety of pathologies (mucocele-frontal sinus-inverted papilloma-osteoma-fibrous dysplasia). Knipe et al.[8] have reported a combination of endoscopic frontal sinus surgery and transblepharoplasty approach to eradicate frontal sinus disease. They applied their study on five cases of mucoceles, two of those patients showed recurrence after 5 months.

In this study, we performed four cases of 'bi-portal endoscopic' approach with a mean age of 56 years having allergic fungal sinusitis, inverted papilloma, and granulomatous fungal sinusitis. On the other hand, a study by Kopelovich et al.[9] have published the same surgical approaches for three patients with a mean age of 61 years and had mucoceles and inverted papilloma. Four cases of inverted papilloma have been surgically operated by the same technique by Albathi et al.[10]. They reported successful removal of the disease and no recurrence after a follow-up period of 7–53 months.

Another study by Makary et al.[11] have been conducted on seven cases with the same pathological entity like the Kopelovich study; both studies had declared the success of this combined approach to achieve extended access to the lateral frontal sinus which helped in the eradication of the disease. Hicks et al.[12] have published a case report that entailed a single female patient with frontal osteoblastoma with second mucocele; They carried out the same technique with additional removal of some orbital roof bone to achieve complete removal of the lesion. We have collected the data of different similar previous studies in [Table 2].
Table 2: Comparison between different studies

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  Conclusion Top

However, this study's limitation is the lack of large number of cases with more pathological entities, but we can declare that bi-portal frontal sinus approach is an easy minimally invasive technique with very little cosmetic drawbacks allowing rhinologists to access the whole aspects of the frontal sinus especially the lateral part helping entire removal of the frontal sinus disease when compared to endoscopic approach only which sometimes has limited access to lateral part of the sinus and also when compared to the old osteoplastic flap technique alone which resulting in serious cosmetic troubles.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lee JM, Palmer JN. Indications for the osteoplastic flap in the endoscopic era. Otolaryngol Head Neck Surg 2011; 19:11–15.  Back to cited text no. 1
Isa AY, Mennie J, McGarry GW. The frontal osteoplastic flap: does it still have a place in rhinological surgery? J Laryngol Otol 2011; 125:162–168.  Back to cited text no. 2
Sautter NB, Citardi MJ, Perry J, Batra PS. Paranasal sinus mucoceles with skull-base and/or orbital erosion: is the endoscopic approach sufficient? Otolaryngol Head Neck Surg 2008; 139:570–574.  Back to cited text no. 3
Becker SS, Bomeli SR, Gross Charles W, Han JK. Limits of endoscopic visualization and instrumentation in the frontal sinus. Otolaryngol Head Neck Surg 2006; 135:917-921.  Back to cited text no. 4
Weber R, Draf W, Kratzsch B, Hosemann W, Schaefer SD. Modern concepts of frontal sinus surgery. Laryngoscope 2001; 111:137-146.  Back to cited text no. 5
Kennedy DW, Josephson JS, Zinreich SJ, Mattox DE, Goldsmith MM. Endoscopic sinus surgery for mucoceles: a viable alternative. Laryngoscope 1989; 99:885–895.  Back to cited text no. 6
Batra PS, Citardi MJ, Lanza DC. Combined endoscopic trephination and endoscopic frontal sinusotomy for management of complex frontal sinus pathology. Am J Rhinol 2005; 19:435-441.  Back to cited text no. 7
Knipe TA, Gandhi PD, Fleming JC, Chandra RK. Transblepharoplasty approach to sequestered disease of the lateral frontal sinus with ophthalmologic manifestations. Am J Rhinol 2007; 21:100–104.  Back to cited text no. 8
Kopelovich JC, Baker MS, Potash A, Desai L, Allen RC, Chang EH. The hybrid lid crease approach to address lateral frontal sinus disease with orbital extension Ann Otol Rhinol Laryngol 2014; 123:826–830.  Back to cited text no. 9
Albathi M, Ramanathan M, Lane AP, Boahene KDO. Combined endonasal and eyelid approach for management of extensive frontal sinus inverting papilloma. Laryngoscope 2018; 128:3-9.  Back to cited text no. 10
Makary CA, Limjuco A, Nguyen J, Ramadan HH. Combined lid crease and endoscopic approach to lateral frontal sinus disease with orbital extension annals of otology. Rhinol Laryngol 2018; 127:637–642.  Back to cited text no. 11
Hicks KL, Moe KS, Humphreys IM. Bilateral transorbital and transnasal endoscopic resection of a frontal sinus osteoblastoma and orbital mucocele: a case report and review of the literature. Ann Otol Rhinol Laryngol 2018; 127:1–6.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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