The Laryngoscope C 2015 The American Laryngological, V
Rhinological and Otological Society, Inc.
Systematic Review
Contemporary Applications of Frontal Sinus Trephination: A Systematic Review of the Literature Alpen B. Patel, MD; Rachel B. Cain, MD; Devyani Lal, MD Our objective was to perform a systematic review of the literature on contemporary indications and outcomes for frontal sinus trephination and present an illustrative case of an endoscopically assisted repair of a subcutaneous frontal sinus fistula by trephination technique. PubMed and Ovid databases were used as data sources. A systematic review of the English literature was completed to review reports of frontal trephination from 1980 to 2014. Articles meeting inclusion criteria for inflammatory and noninflammatory indications were reviewed. Articles were systematically reviewed and graded by evidence-based medicine level. An illustrative case from our institution is then presented. The systematic review identified 2,621 published studies. Thirty-eight studies were identified for inclusion. The indications, techniques, outcomes, safety, and complications were reviewed for noninflammatory and inflammatory conditions. There were 32 retrospective case series, reports, or cohort studies (level 4), four systematic reviews (level 3), one prospective analysis (level 3), and one metaanalysis (level 2). Due to the heterogeneity of study cases and inclusion criteria, a meta-analysis was not feasible. We also present a novel closure of an anterior skull base defect resulting in a subcutaneous fistula with use of a frontal trephination approach. The frontal sinus trephination should not be regarded as a procedure of the past, as it useful in the armamentarium of the modern sinus and skull base surgeon. This approach provides access for instrumentation for hard-to-reach frontal sinus disease either purely through a trephination approach or as a supplementation to the transnasal endoscopic approach. Evidence supporting frontal sinus trephination is of levels 2, 3, and 4. Key Words: Endoscopic sinus surgery, frontal sinus, trephination, minitrephination, external approach, fistula. Level of Evidence: NA Laryngoscope, 125:2046–2053, 2015
INTRODUCTION Indications for endoscopic surgical approaches to the frontal sinus have expanded with increasing experience with endoscopic techniques. The frontal trephination technique is a very useful adjunct to reach far lateral and superior disease in frontal sinus surgery, when endoscopic access alone is not sufficient.1–4 The use of the combined endoscopic-trephination approach can potentially supplement the need for a conventional external approach such as the osteoplastic flap technique.5,6 Conventionally, surgeons chose between traditional open approaches (osteoplastic flap, frontal trephination) or purely endoscopic approaches (endoscopic frontal sinusotomy, endoscopic modified Lothrop).6,7 However, the combination of trephination with endoscopic techniques is increasingly being utilized for
From the Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, U.S.A. Editor’s Note: This Manuscript was accepted for publication January 21, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Devyani Lal, MD, Assistant Professor of Otolaryngology, Department of Otolaryngology, Mayo Clinic, 5777 E. Mayo Blvd., Phoenix, AZ 85054. E-mail: [email protected] DOI: 10.1002/lary.25206
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frontal sinus surgery for rhinosinusitis and associated pathology.5–8 This article focuses on use of frontal sinus trephination performed for both inflammatory and noninflammatory indications. Historically, trephination has been used to emergently treat acute frontal sinusitis or complications related to acute frontal sinusitis.9,10 However, a minitrephination can also provide an additional porthole for endoscopic visualization and instrumentation to treat myriad pathologies in the frontal sinus.7 Simultaneous insertion of the endoscope and surgical instruments can be performed through a trephination, augmenting in some cases, access through the transnasal endoscopic approach.5,6 Endoscopic frontal trephination is a useful adjunctive procedure for frontal sinus surgery with minimal morbidity with many contemporary indications.1–6 Our goal was to highlight the versatility of the frontal trephination approach through our case report and through a systematic literature review. We performed a systematic literature review to study the indications for and outcomes of frontal sinus trephination used for inflammatory and noninflammatory indications in today’s contemporary era of endoscopic sinus surgery. We also describe repair of an aircontaining subcutaneous fistula from a breach of the frontal roof–posterior wall junction using a purely Patel et al.: Applications of Frontal Trephination
TABLE I. Studies by Level of Evidence. Level
No. of Studies
Type of Study
1
0
NA
2 3
1 5
Meta-analysis Prospective, systematic review
4
32
Retrospective case series
5
0
Expert opinion
NA 5 not available.
frontal trephination approach through a brow incision. To our knowledge, there has not been a similar report of a case, or a critical systematic evaluation of the clinical outcomes of endoscopic frontal trephination for both inflammatory and noninflammatory diseases.
METHODS An independent review of the literature was completed by two authors. PubMed (www.ncbi.nlm.nih.gov/pubmed/) and Ovid databases were searched with relevant terms, which included the following: “trephination,” “mini-trephination,” “frontal sinus,” “combined endoscopic and mini-trephination,” “sinus fistula,” “craniotomy fistula,” “subcutaneous fistula,” and “external approach.” A comprehensive review of the English literature was carried out with review of articles from 1980 to 2014. Duplicate articles were excluded. Our inclusion criteria included studies related to noninflammatory or inflammatory causes for surgical intervention via frontal trephination. Studies consisted of a meta-analysis, review articles, systematic reviews, and case reports. Included studies analyzed the procedure, indications, outcomes, and complications. Due to the heterogeneity of study cases, a meta-analysis was not feasible. This study was deemed exempt by the Institutional Research Board, Mayo Clinic, Phoenix, Arizona.
RESULTS Systematic Review The systematic review identified 2,621 studies published between 1980 and 2014. Careful review of the full-length articles identified 38 studies reporting sufficient data deemed appropriate for inclusion in the analysis. Each article was then reviewed and graded on level of evidence as ranging from level 1 (highest) to level 5 (Oxford Center for Evidence-Based Medicine; http://
www.cebm.net/index.asp). There were 32 retrospective case series, reports, or cohort studies (level 4), four systematic reviews (level 3), one prospective analysis (level 3), and one meta-analysis (level 2). The 38 studies were analyzed for indications and outcomes for frontal trephination, safety, techniques, and complications of the procedure. Of the 38 studies included for review (Table I), all articles were evidence-based medicine (EBM) levels 2, 3, or 4. Thirty-three articles were reviews describing the indications and outcomes for frontal sinus trephination. One article was a meta-analysis of level 2 evidence. Five of these articles were of level 3 evidence, one of which was a prospective trial. Three of these articles included discussion of complications. The remaining five articles focused solely on the complications (two articles) and aspects of safety surrounding the procedure (three articles). Indications—noninflammatory disease (EBM levels 3, 4). Twenty-three studies, all of level 3 or level 4 evidence, discussed the role of frontal sinus trephination and the rationale for its use for noninflammatory disease (Table II). Fifteen studies discuss specific indications for noninflammatory pathology, whereas eight studies serve as reviews regarding the use and technique of frontal sinus trephination. If indications for noninflammatory and inflammatory pathology are both present within the same study, the inflammatory indications will be discussed later in this article. Seiberling et al., Sieden and el Hefny, Busch, and Batra et al. discuss the role of frontal sinus trephination for removal of osteomas.5,11–13 Busch provided the initial description of osteoma in 1992.13 In these four studies, 14 cases of complete osteoma removal have been described, one case via external frontal sinus trephination approach alone, and 13 patients using frontal trephination as adjunct to endoscopic sinus surgery via an “above and below” approach.5,11–13 Senior and Lanza affirm this in their review describing trephination for benign lesions in the frontal sinus.14 Zacharek et al. and Batra et al. described the removal of fibrous dysplasia in four patients through trephination.4,5 Batra et al., Sautter et al., Cohen and Wang, Yoon et al., and Walgama et al. have all described removal of inverted papilloma through trephination procedures in a total of 14 patients.5,7,15–17 Batra et al. has also described frontal trephination for the treatment of one patient with
TABLE II. Indications for Noninflammatory Disease. Indication
Patients
First Author, Year
Fibrous dysplasia/osteoma Inverted papilloma
19 14
Seiberling, 20092; Zacharek, 20064; Batra, 20055; Seiden, 199512; Busch, 199213 Batra, 20055; Cohen, 200716; Yoon, 200917; Sautter, 200715; Walgama, 20127
CSF leaks
14
Crozier, 201319; Purkey, 200920; Das, 201121
Posterior table fracture Meningioma
2 2
Chaaban, 201223; Koento, 201224; Jatana, 200822 Kabil, 200618
Pneumocephalus
1
Batra, 20055
CSF 5 cerebrospinal fluid.
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TABLE III. Indications for Inflammatory Disease. Indication
Patients
First Author, Year
Narrow frontal recess, severe edema, severe polyps, obstructing frontal cells
163
Seiberling, 20092
Acute frontal sinusitis/chronic frontal sinusitis
86
Mucoceles, frontal sinusitis
38
Cohen, 200716; Gallagher, 19999; Gerber, 199327; Fry, 198026; Benoit, 200129 Batra, 20055; Courson, 20148
Mucoceles, type 4 frontal cells, frontal recess stenosis or ossification
10
Zacharek, 20064
Chronic frontal sinusitis, frontal bone osteomyelitis Pediatric frontal sinusitis
14 2
Hahn, 20096 McIntosh, 200728
Type 4 frontal cell
1
Maeso, 20093
Mucocele
1
Cho, 201025
pneumocephalus after craniectomy.5 Kabil presented excision of two meningiomas through trephination.18 Crozier et al. and Purkey et al. describe the repair of cerebrospinal fluid (CSF) leak resulting from noninflammatory causes through a sole trephination approach in five patients.19,20 Das and Balasubramanian published the concomitant use of endoscopic frontal sinusotomy and access holes drilled through the anterior frontal sinuses in nine patients.21 Lastly, posterior table fracture repair in one patient was described retrospectively by Jatana et al., and one patient was reviewed through a prospective trial by Chaaban et al.22,23 Koento further supports anterior table and posterior table fractures repair through frontal sinus trephinations.24 Mucoceles were not included in this section, as all studies did not discuss whether these were secondary to noninflammatory pathology. The remainder of the review articles focused on the description and use of frontal sinus trephination, often as an adjunctive procedure, in challenging frontal sinus pathology. Indications—inflammatory disease (EBM levels 2, 3, 4). Frontal sinus trephination has been discussed for inflammatory disease in 10 additional studies (Table III). Three studies described earlier (Zacharek et al., Batra et al., and Cohen and Wang) describe indications for both noninflammatory and inflammatory disease.4,5,16 All studies are of levels 2, 3, or 4 evidence. Seiberling et al. provide the largest series, with 163 patients with indications for narrow frontal recess, severe edema/polyps, obstructing frontal cells (type 3/ type 4 frontoethmoidal cells and intersinus septum cell).2 Courson et al. provide a meta-analysis reviewing the contemporary management of frontal sinus mucoceles via an external or combined approach. Twenty-one patients underwent external-only or combined approach.8 Zacharek et al. additionally described indications for inflammatory disease in 10 patients for superiorly or laterally based mucoceles (three patients), type 4 frontal cells (three patients), and frontal recess stenosis or ossification (four patients).4 Batra et al. describe a combined approach for mucoceles (15 patients) and frontal sinusitis (two patients).5 Maeso et al. present a case report of trephination for frontal sinus type 4 cell disease where a combined approach was used.3 Cho et al. Laryngoscope 125: September 2015
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describe a case report for treatment of a frontal sinus mucocele.25 Gallagher and Gross (16 patients), Fry et al. (16 patients), Cohen and Wang (12 patients), and Gerber et al. (two patients) describe the use of frontal trephination for acute or chronic frontal sinusitis.9,16,26,27 McIntosh and Mahadevan present two cases of trephination approach for pediatric frontal sinusitis.28 Hahn et al. describe trephination use for chronic frontal sinusitis (11 patients) and frontal bone osteomyelitis (three patients).6 Benoit and Duncavage reported on combined external and endoscopic frontal sinusotomy with stent placement in 40 patients with chronic frontal sinusitis.29 Outcomes (EBM levels 2, 3, 4). All studies demonstrating outcome measures were of level 2, 3, or 4 evidence. There was no heterogeneity with outcomes reported, including frontal sinus patency (Table IV). If outcomes were present in the studies, they have been reported here. Courson et al. showed that endoscopic techniques for the treatment of frontal and frontoethmoid mucoceles have similar recurrence rates compared to open techniques with indications for external approaches including unfavorable anatomy, lateral disease, and scarring. Strong evidence supported surgical treatment of frontal mucoceles with results from endoscopic and open approaches comparable.8 Crozier et al. demonstrated resolution of CSF leaks after repair via frontal trephination, with no recurrence at an average of 37 months.19 Walgama et al. had recurrence of inverted papilloma in 1/5 patients; however, this was not procedure related. There was no mention of frontal sinus patency.7 Seiden and el Hefny achieved complete excision of an osteoma and showed full resolution at the 8-month follow-up.12 Sautter et al. showed complete removal of inverted papilloma in one patient, with no recurrence at 16.8 months and no mention of frontal sinus patency.15 Yoon et al. had recurrence of inverted papilloma in 1/5 patients; however, this was not procedure related. There was no mention of frontal sinus patency.17 Cohen et al. showed no recurrence of inverted papilloma in one patient at 14 months.16 Seiberling et al. demonstrated complete excision of osteoma in 10 patients with no recurrence. There was no mention of frontal sinus patency.11 Zacharek et al. had 1/13 patients requiring revision surgery, with Patel et al.: Applications of Frontal Trephination
TABLE IV. Outcomes of Trephination Approach. First Author, Year
Patients
Type of Study/EBM Level
Outcome
Crozier, 201319
4
RR/level 4
Full resolution of CSF leaks, no recurrence at 37 months follow-up
Walgama, 20127
5
Systematic review/level 3
Recurrence of inverted papilloma in 1/5 patients at average 17.5 months follow-up, however not procedure related
Chaaban, 201223
1
Prospective/level 3
Seiberling, 20092
151
RR/level 4
Hahn, 20096
20
RR/level 4
Full resolution of the defect with 100% endoscopic patency at 17 months follow-up Total of 149 bilateral and 39 unilateral with 151 patients showing endoscopic patency at an average 25.5 months 8/14 required revision surgery with 15/20 patients improved at 12.8 months
Seiberling, 200911
10
RR/level 4
Complete excision of osteoma, no recurrence
Yoon, 200917
5
RR/level 4
Recurrence of inverted papilloma in 1/5 patients, however not procedure related
Maeso, 20093 Cho, 200825
1 1
RR/level 4 RR/level 4
Full resolution of disease at 36 months Full endoscopic patency at 5 months
Cohen, 200716
13
RR/level 4
12/13 patients free of disease at follow-up of 14.2 months with patency in 23/24
Cohen, 200716
1
RR/level 4
Sautter, 200715
1
RR/level 4
Zacharek, 20064
13
RR/level 4
Complete excision of inverted papilloma, no recurrence at 14 months Complete excision of inverted papilloma, no recurrence at 16.8 months 1/13 patients requiring revision surgery, 29 months average follow-up
Batra, 20055
5
RR/level 4
19/22 patients with endoscopic patency, 16.2 months average follow-up
Benoit, 200129
40
RR/level 4
Complete patency in 79%, symptom improvement in 78%
Gallagher, 19999
16
RR/level 4
Seiden, 199512
1
RR/level 4
Complete patency in 15/16 patients at 3.8 months follow-up Complete excision of an osteoma with full resolution at 8 months follow-up
Gerber, 199327
2
RR/level 4
Full resolution of disease at 4 months
CSF 5 cerebrospinal fluid; EBM 5 evidence-based medicine; RR 5 retrospective review.
all others showing complete resolution of symptoms at a follow-up of 29.9 months.4 Chaaban et al. had no complications with a posterior table fracture repair and showed full resolution of the defect with 100% endoscopic patency at 17 months.23 Batra et al. showed 19/22 (86%) with endoscopic patency at a 16.2-month average followup.5 Maeso et al. demonstrated no recurrence of symptoms postmanagement of frontal sinus type 4 cell disease at 3 years.3 Gallagher and Gross show complete patency of the frontonasal recess in 15/16 patients at 3.8 months.9 Gerber et al. show full resolution of symptoms in their two patients at an average of 4 months.27 Hahn et al. showed a total of 8/14 (57.1%) of all trephines during the study period requiring revision surgery, with 15/ 20 (80%) patients showing improvement at 12.8 months.6 Seiberling et al. had a total of 149 bilateral and 39 unilateral, with 151 (92%) patients showing endoscopic patency of the frontal sinus at an average 25.5 months.2 Cohen and Wang demonstrated 12/13 (92%) patients to be free of disease at a follow-up of 14.2 months, with 23/24 (96%) of frontal recesses deemed Laryngoscope 125: September 2015
patent.16 Cho et al. demonstrated full endoscopic patency at 5 months after removal of a frontal sinus mucocele.25 Benoit and Duncavage reported on combined external and endoscopic frontal sinusotomy with stent placement in 40 patients, with overall patency of the nasofrontal duct and subjective patient improvement rate at 79% and 78%, respectively.29 Complications (EBM level 4). Both inflammatory and noninflammatory related studies were examined for complications related to the frontal sinus trephination procedure (Table V). All studies examined were of level 4 evidence. Seiberling et al. had the largest series with 188 patients, and showed multiple complications, the most frequently encountered being periorbital cellulitis and facial cellulitis in 4/188 patients (2.1%). This study also showed asystole, CSF leak, proptosis, and bleeding in 1/188 patients each (0.5%).2 Batra et al. showed facial cellulitis or periorbital cellulitis in 1/22 patients (4.5%).5 Walgama et al. reported a CSF leak in 1/5 patients.7 Gallagher et al. had a CSF leak in 1/16 (6.3%) of patients. This study also showed a complication of skin Patel et al.: Applications of Frontal Trephination
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TABLE V. Complications. Complication
Patients
Total Patients
Author
1/22, 4/188
4.5% 2.1%
Batra, 20055; Seiberling, 20092
1/188, 1/5, 1/16
0.5%, 20.0%, 6.3%
Asystole
1/188
0.5%
Seiberling, 20092; Walgama, 20127; Gallagher, 19999 Seiberling, 20092
Proptosis
1/188
0.5%
Seiberling, 20092
Bleeding Superior oblique palsy/trochlea damage
1/188 1/1
0.5% NA
Seiberling, 20092 Bartley, 201230
Retro-orbital fluid dissection
1/1
NA
Andrews, 201331
Burns
2/16
12.5%
Gallagher, 19999
Facial cellulitis/periorbital cellulitis Cerebrospinal fluid leak
NA 5 not available.
burns from the procedure in 2/16 (12.5%).9 Bartley reported a case of superior oblique palsy/trochlear injury in one patient.30 Similarly, Andrews et al. reported a case of retro-orbital fluid collection in one patient.31 Safety (EBM level 4). Several studies have reviewed the safety of frontal sinus trephination given the risk of injury to critical structures. Traditionally, there has been a paucity of literature describing the ideal location for trephination; however, recent studies have analyzed this further. Lee et al. reviewed computerized tomography (CT) of 200 patients. They were able to show the mean depth of frontal sinus at 5 mm, 10 mm, and 15 mm from midline to be 11.26 mm (range, 0– 21.8 mm), 11.45 mm (range, 0–23.1 mm), and 11.48 mm
(range, 0–28.1 mm), respectively.32 This study showed no statistical difference in frontal sinus depth measurements performed at 5 mm, 10 mm, and 15 mm from a midline passing through the crista galli. They concluded that the sinus can be successfully trephined at 5 mm, 10 mm, or 15 mm in a majority of patients.32 Piltcher et al. reviewed 69 CT scans similarly at measurements of 5 mm, 10 mm, and 15 mm from midline. Men presented a frontal sinus significantly larger in the distances of 5 mm and 10 mm when compared to women, but there was no statistical difference in the depth of the sinus at 15 mm.33 The frontal sinus depth measured at 5 mm of the midline was significantly larger than that at 10 and 15 mm, just as the measure at 10 mm was significantly
Fig. 1. Intraoperative images using the three-dimensional computerized image guidance system. The bottom right panel shows the intraoperative endoscopic image with the probe into the fistula. The computed tomography (CT) images show the axial, coronal, and sagittal correlates of the tip if the probe. The probe has been inserted into the fistula after performance of the frontal trephination. The CT images also show the preoperative view of the fistula in the three dimensions. The fistula between the right frontal sinus and subcutaneous area is denoted by the white broken line, and the metal plate is clearly visualized (intersecting lines).
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Fig. 2. Intraoperative images of the surgical approach and repair. (A) A right brow incision has been performed after mapping the frontal sinus and the area of the fistula with the intraoperative image guidance. The subcutaneous tissue has been carefully retracted, protecting the surrounding neurovascular pedicles medially. (B) Using a pediatric 30 endoscope, the fistula (arrow) is visualized at the superolateral part of the right frontal sinus. (C) The mucosal edges of the fistula and the fistula tract have been removed to prepare for the multilayered repair. The metallic plate is clear visualized (arrow). (D) The multilayered repair has been completed, with the final layer utilizing a free nasal mucosal graft. The frontal ostium area was debrided of the bone wax (not shown here) and the sinus was not obliterated.
higher when compared to that at 15 mm (12.22 vs. 11.78 mm, 12.22 mm vs. 10.78 mm, 11.78 mm vs. 10.78 mm).33 In their study, the sinus depth when measured at 5, 10, and 15 mm away from the midline showed statistically significant differences, demonstrating that the closer the proximity to the midline, the deeper it was. They however concluded that the usual distance of 10 mm from the midline proved to add more advantages for trephination when the risk of crossed trephination at the 5-mm mark and the risk of sinus hypotrophy at 15 mm are considered.33 Ponde et al. reviewed 98 CT scans for dimensions and volume. The average anteroposterior diameter was 12.01 mm in males and 10.16 mm in females. The average transverse diameter was 56.53 mm in males and 51.05 mm in females. The average sagittal diameter was 31.72 mm in males and 28.57 mm in females.34 The average volume was 129.99 mm3 in males and 80.26 mm3 in females. They concluded that knowledge of the anatomic variations of the frontal sinus is important with surgical approaches through the supraciliary arch to avoid complications.34
Case A 58-year-old male underwent a revision right frontotemporal craniotomy for a resection of an anterior Laryngoscope 125: September 2015
cranial fossa meningioma. During surgery, an inadvertent breach of the right frontal sinus at the junction of the lateral roof and posterior wall was created. Intraoperative repair with absorbable Gelfoam was attempted, but in the postoperative period, the patient noted the right forehead scalp to inflate with air upon noseblowing and use of continuous positive airway pressure (CPAP). Initially, the patient was observed for spontaneous resolution; however, after 7 months, his symptoms continued. Further investigation with CT and magnetic resonance imaging (MRI) showed a subcutaneous aircommunicating fistula extending from the cranioplasty site to the far superolateral frontal table (Fig. 1). A small bony defect was noted in the superolateral aspect of the right frontal sinus, with air below the craniotomy plate extending inferolaterally in the right scalp. Further intervention was indicated, as there was risk for dural contamination from the sinus contents. The patient was referred to the endoscopic skull base surgeon for evaluation. After careful consideration, endoscopic frontal trephination and repair was deemed feasible. Image guidance was used for preoperative planning. The patient was noted to have a hyperpneumatized frontal sinus reaching far lateral, and as a result, a frontal trephination was planned lateral to the supraorbital Patel et al.: Applications of Frontal Trephination
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Fig. 3. Magnetic resonance imaging performed 6 months later for surveillance of the frontal meningioma. Both the coronal (left) and axial (right) images using T1-weighted sequences with gadolinium enhancement show the subcutaneous fistula to be fully healed. The right frontal recess shows no mucosal thickening and is healthily aerated. (B) On the left is the patient performing a Valsalva maneuver; no frontal subcutaneous air is noted. On the right is a close-up view of the brow showing that the incision is well healed and well concealed.
notch. Image guidance was used to plan the approach and avoid intracranial breach. A 1-cm brow incision was created, with the scalpel beveled to preserve the brow trichia. The supraorbital and supratrochlear nerves were identified and retracted away. Next, a cutting burr was used to enter into the frontal sinus, and a 1 cm 3 1 cm opening into the anterior frontal table was created with the use of Kerrison rongeurs and the diamond burr. The pediatric 0 , 30 , and 45 endoscopes were inserted through this minitrephination to visualize the area of the fistula (Figs. 1 and 2). The fistula was then resected, carefully avoiding any dural injury. Next, a multilayered, air-tight closure was performed (Fig. 2) using acellular tissue matrix (Alloderm), bovine collagen matrix (DuraGen), and a free mucosal graft in layers. DuraGen was first used to plug a high defect in the undersurface of the metallic plate used in the initial craniotomy repair. Alloderm was then placed in the subcutaneous plane over the superficial aspect of the plate and was tucked under edges of bony recess. Finally, a free mucosal graft harvested from the left nasal septum was placed over the frontal sinus defect to repair the mucosa as an overlay layer. The area of the frontal recess was found partially plugged with bone wax from previous repair. This was carefully removed, making sure that the mucosa in the frontal recess was not injured at all (to prevent problems with iatrogenic frontal recess obstruction). No intraoperative complications were noted and the patient was discharged home the same day. He remains symptom free at 18 months of follow-up and uses CPAP without problems. The trephine incision healed as a well-camouflaged scar. MRI performed 9 months postoperatively for tumor surveillance showed Laryngoscope 125: September 2015
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full resolution of the fistulous tract and no recurrence of tumor (Fig. 3).
DISCUSSION Evidence of frontal trephination approaches date back as early as prehistoric times. Two specimens demonstrating the trephination approach for frontal sinus pathology were collected in the second decade of this century in Peru dating back approximately 600 years.35 The approach was first described in the literature by Runge in 1750, and Hutchinson further described the procedure in 1939 as a puncture technique into the frontal sinus.9,10 Since that time period, this procedure has undergone considerable advancement.10,36 In 1991, Hoffman and May described an “above and below” approach to the frontal sinus using the trephine porthole.37 Subsequent studies have been published reviewing patients who underwent a combined trephination with frontal sinusotomy for complex frontal sinus pathology.5–8 However, due to difficulties with endoscopic access to the lateral-most extent of the sinus, combined with the need for preservation of the frontal sinus outflow tract and minimization of postoperative scarring, there has been continued evolution of technique and instrumentation for access to this area.1–5,10,15,36 Within the era of endoscopic sinus surgery, frontal sinus trephination has remained the most routinely utilized of all external procedures.1–5,36 Frontal trephination allows surgery to be performed through a small and well-camouflaged external incision without disruption of the frontal sinus outflow tract.36,37 Although transnasal endoscopic approaches can be attempted for pathology in Patel et al.: Applications of Frontal Trephination
the lateral frontal sinus, the anatomy is often not conducive to such approach in addition to the longer operative time and surgical skill required. With a transnasal approach, there is always risk of permanent scarring of the frontal recess necessitating revision surgery in the future.36 In challenging cases and/or revision cases, however, the trephine can be used as an adjunct to an endoscopic approach through an above and below visualization and dissection technique.5–8 To this day, frontal sinus trephination remains a simple, direct, and cosmetically excellent alternative. The exit point for the supraorbital neurovascular pedicle and awareness of the supratrochlear nerve bundle is important to ensure safe dissection.19,37,38 It affords minimal morbidity when compared to other external approaches and allows for preservation of physiologic sinus function.
CONCLUSION Frontal sinus trephination should not be regarded as a procedure of the past, as it useful in the armamentarium of the modern sinus and skull base surgeon. As our case report and systematic literature review suggests, indications for noninflammatory use in the contemporary era include trauma, tumor, and repair of skull base defects resulting in CSF leak and pneumocephalus. Furthermore, frontal trephination continues to have a pivotal role in treatment of inflammatory disease. The approach may be used as a supplement to the transnasal endoscopic approach (above and below approach) or purely through a trephination approach. Such an approach provides adequate access for both endoscopic visualization and instrumentation into the far lateral and superior areas of the frontal sinus.
BIBLIOGRAPHY 1. Schneider JS, Archilla A, Duncavage JA. Five ‘nontraditional’ techniques for use in patients with recalcitrant sinusitis. Curr Opin Otolaryngol Head Neck Surg 2013;21:39–44. 2. Seiberling K, Jardeleza C, Wormald PJ. Minitrephination of the frontal sinus: indications and uses in today’s era of sinus surgery. Am J Rhinol Allergy 2009;23:229–231. 3. Maeso PA, Deal RT, Kountakis SE. Combined endoscopic and minitrephination techniques in the surgical management of frontal sinus type IV cell disease. Am J Otolaryngol 2009;30:337–339. 4. Zacharek MA, Fong KJ, Hwang PH. Image-guided frontal trephination: A minimally invasive approach for hard-to-reach frontal sinus disease. Otolaryngol Head Neck Surg 2006;135:518–522. 5. 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. 6. Hahn S, Palmer JN, Purkey MT, Kennedy DW, Chiu AG. Indications for external frontal sinus procedures for inflammatory sinus disease. Am J Rhinol Allergy 2009;23:342–347. 7. Walgama E, Ahn C, Batra PS. Surgical management of frontal sinus inverted papilloma: a systematic review. Laryngoscope 2012;122:1205– 1209. 8. Courson AM, Stankiewicz JA, Lal D. Contemporary management of frontal sinus mucoceles: a meta-analysis. Laryngoscope 2014;124:378–386. 9. Gallagher RM, Gross CW. The role of mini-trephination in the management of frontal sinusitis. Am J Rhinol 1999;13:289–293.
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10. Jacobs JB. 100 years of frontal sinus surgery. Laryngoscope 1997;107(11 pt 2):1–36. 11. Seiberling K, Floreani S, Robinson S, Wormald PJ. Endoscopic management of frontal sinus osteomas revisited. Am J Rhinol Allergy 2009;23: 331–336. 12. Seiden AM, el Hefny YI. Endoscopic trephination for the removal of frontal sinus osteoma. Otolaryngol Head Neck Surg 1995;112:607–611. 13. Busch R. Frontal sinus osteoma: complete removal via endoscopic sinus surgery and frontal sinus trephination. Am J Rhinol 1992;6:139–143. 14. Senior BA, Lanza DC. Benign lesions of the frontal sinus. Otolaryngol Clin North Am 2001;34:253–267. 15. Sautter NB, Citardi MJ, Batra PS. Minimally invasive resection of frontal recess/sinus inverted papilloma. Am J Otolaryngol 2007;28:221–224. 16. Cohen AN, Wang MB. Minitrephination as an adjunctive measure in the endoscopic management of complex frontal sinus disease. Am J Rhinol 2007;21:629–636. 17. Yoon BN, Batra PS, Citardi MJ, Roh HJ. Frontal sinus inverted papilloma: surgical strategy based on the site of attachment. Am J Rhinol Allergy 2009;23:337–341. 18. Kabil MS, Shahinian HK. The endoscopic supraorbital approach to tumors of the middle cranial base. Surg Neurol 2006;66:396–401; discussion 401. 19. Crozier DL, Hwang PH, Goyal P. The endoscopic-assisted trephination approach for repair of frontal sinus cerebrospinal fluid leaks. Laryngoscope 2013;123:321–325. 20. Purkey MT, Woodworth BA, Hahn S, Palmer JN, Chiu AG. Endoscopic repair of supraorbital ethmoid cerebrospinal fluid leaks. ORL J Otorhinolaryngol Relat Spec 2009;71:93–98. 21. Das PT, Balasubramanian D. External frontal sinusotomy and endoscopic repair of cerebrospinal fluid fistula in the posterior wall: preliminary report of a new technique. J Laryngol Otol 2011;125:802–806. 22. Jatana KR, Ryoo C, Skomorowski M, Butler N, Kang DR. Minimally invasive repair of an isolated posterior table frontal sinus fracture in a pediatric patient. Otolaryngol Head Neck Surg 2008;138:809–811. 23. Chaaban MR, Conger B, Riley KO, Woodworth BA. Transnasal endoscopic repair of posterior table fractures. Otolaryngol Head Neck Surg 2012; 147:1142–1147. 24. Koento T. Current advances in sinus preservation for the management of frontal sinus fractures. Curr Opin Otolaryngol Head Neck Surg 2012;20: 274–279. 25. Cho SH, Lee YS, Jeong JH, Kim KR. Endoscopic above and below approach with frontal septotomy in a patient with frontal mucocele: a contralateral bypass drainage procedure through the frontal septum. Am J Otolaryngol 2010;31:141–143. 26. Fry TL, Biggers WP, Fischer ND. Frontal sinus trephination: a new technique for office procedure. Laryngoscope 1980;90(5 pt 1):838–841. 27. Gerber ME, Myer CM III, Prenger EC. Transcutaneous frontal sinus trephination with endoscopic visualization of the nasofrontal communication. Am J Otolaryngol 1993;14:55–59. 28. McIntosh DL, Mahadevan M. Frontal sinus mini-trephination for acute sinusitis complicated by intracranial infection. Int J Pediatr Otorhinolaryngol 2007;71:1573–1577. 29. Benoit CM, Duncavage JA. Combined external and endoscopic frontal sinusotomy with stent placement: a retrospective review. Laryngoscope 2001;111:1246–1249. 30. Bartley J, Eagleton N, Rosser P, Al-Ali S. Superior oblique muscle palsy after frontal sinus mini-trephine. Am J Otolaryngol 2012;33:181–183. 31. Andrews JN, Lopez MA, Weitzel EK. Case report of intraoperative retroorbital fluid dissection after frontal mini-trephine placement. Laryngoscope 2013;123:2969–2971. 32. Lee AS, Schaitkin BM, Gillman GS. Evaluating the safety of frontal sinus trephination. Laryngoscope 2010;120:639–642. 33. Piltcher OB, Antunes M, Monteiro F, Schweiger C, Schatkin B. Is there a reason for performing frontal sinus trephination at 1 cm from midline? A tomographic study. Braz J Otorhinolaryngol 2006;72:505–507. 34. Ponde JM, Metzger P, Amaral G, Machado M, Prandini M. Anatomic variations of the frontal sinus. Minim Invasive Neurosurg 2003;46:29–32. 35. Canalis RF, Cabieses F, Hemenway WG, Aragon R. Prehistoric trephination of the frontal sinus. Ann Otol Rhinol Laryngol 1981;90(2 pt 1):186– 189. 36. Murr AH. Contemporary indications for external approaches to the paranasal sinuses. Otolaryngol Clin North Am 2004;37:423–434. 37. Hoffmann DF, May M. Endoscopic frontal sinus surgery: frontal trephine permits a two-sided approach. Oper Tech Otolaryngol Head Neck Surg 1991;2:257–261. 38. Harvey RJ, Gallagher RM, Sacks R. Extended endoscopic techniques for sinonasal resections. Otolaryngol Clin North Am 2010;43:613–638.
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Rhinological and Otological Society, Inc.
Systematic Review
Contemporary Applications of Frontal Sinus Trephination: A Systematic Review of the Literature Alpen B. Patel, MD; Rachel B. Cain, MD; Devyani Lal, MD Our objective was to perform a systematic review of the literature on contemporary indications and outcomes for frontal sinus trephination and present an illustrative case of an endoscopically assisted repair of a subcutaneous frontal sinus fistula by trephination technique. PubMed and Ovid databases were used as data sources. A systematic review of the English literature was completed to review reports of frontal trephination from 1980 to 2014. Articles meeting inclusion criteria for inflammatory and noninflammatory indications were reviewed. Articles were systematically reviewed and graded by evidence-based medicine level. An illustrative case from our institution is then presented. The systematic review identified 2,621 published studies. Thirty-eight studies were identified for inclusion. The indications, techniques, outcomes, safety, and complications were reviewed for noninflammatory and inflammatory conditions. There were 32 retrospective case series, reports, or cohort studies (level 4), four systematic reviews (level 3), one prospective analysis (level 3), and one metaanalysis (level 2). Due to the heterogeneity of study cases and inclusion criteria, a meta-analysis was not feasible. We also present a novel closure of an anterior skull base defect resulting in a subcutaneous fistula with use of a frontal trephination approach. The frontal sinus trephination should not be regarded as a procedure of the past, as it useful in the armamentarium of the modern sinus and skull base surgeon. This approach provides access for instrumentation for hard-to-reach frontal sinus disease either purely through a trephination approach or as a supplementation to the transnasal endoscopic approach. Evidence supporting frontal sinus trephination is of levels 2, 3, and 4. Key Words: Endoscopic sinus surgery, frontal sinus, trephination, minitrephination, external approach, fistula. Level of Evidence: NA Laryngoscope, 125:2046–2053, 2015
INTRODUCTION Indications for endoscopic surgical approaches to the frontal sinus have expanded with increasing experience with endoscopic techniques. The frontal trephination technique is a very useful adjunct to reach far lateral and superior disease in frontal sinus surgery, when endoscopic access alone is not sufficient.1–4 The use of the combined endoscopic-trephination approach can potentially supplement the need for a conventional external approach such as the osteoplastic flap technique.5,6 Conventionally, surgeons chose between traditional open approaches (osteoplastic flap, frontal trephination) or purely endoscopic approaches (endoscopic frontal sinusotomy, endoscopic modified Lothrop).6,7 However, the combination of trephination with endoscopic techniques is increasingly being utilized for
From the Department of Otolaryngology–Head and Neck Surgery, Mayo Clinic, Phoenix, Arizona, U.S.A. Editor’s Note: This Manuscript was accepted for publication January 21, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Devyani Lal, MD, Assistant Professor of Otolaryngology, Department of Otolaryngology, Mayo Clinic, 5777 E. Mayo Blvd., Phoenix, AZ 85054. E-mail: [email protected] DOI: 10.1002/lary.25206
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frontal sinus surgery for rhinosinusitis and associated pathology.5–8 This article focuses on use of frontal sinus trephination performed for both inflammatory and noninflammatory indications. Historically, trephination has been used to emergently treat acute frontal sinusitis or complications related to acute frontal sinusitis.9,10 However, a minitrephination can also provide an additional porthole for endoscopic visualization and instrumentation to treat myriad pathologies in the frontal sinus.7 Simultaneous insertion of the endoscope and surgical instruments can be performed through a trephination, augmenting in some cases, access through the transnasal endoscopic approach.5,6 Endoscopic frontal trephination is a useful adjunctive procedure for frontal sinus surgery with minimal morbidity with many contemporary indications.1–6 Our goal was to highlight the versatility of the frontal trephination approach through our case report and through a systematic literature review. We performed a systematic literature review to study the indications for and outcomes of frontal sinus trephination used for inflammatory and noninflammatory indications in today’s contemporary era of endoscopic sinus surgery. We also describe repair of an aircontaining subcutaneous fistula from a breach of the frontal roof–posterior wall junction using a purely Patel et al.: Applications of Frontal Trephination
TABLE I. Studies by Level of Evidence. Level
No. of Studies
Type of Study
1
0
NA
2 3
1 5
Meta-analysis Prospective, systematic review
4
32
Retrospective case series
5
0
Expert opinion
NA 5 not available.
frontal trephination approach through a brow incision. To our knowledge, there has not been a similar report of a case, or a critical systematic evaluation of the clinical outcomes of endoscopic frontal trephination for both inflammatory and noninflammatory diseases.
METHODS An independent review of the literature was completed by two authors. PubMed (www.ncbi.nlm.nih.gov/pubmed/) and Ovid databases were searched with relevant terms, which included the following: “trephination,” “mini-trephination,” “frontal sinus,” “combined endoscopic and mini-trephination,” “sinus fistula,” “craniotomy fistula,” “subcutaneous fistula,” and “external approach.” A comprehensive review of the English literature was carried out with review of articles from 1980 to 2014. Duplicate articles were excluded. Our inclusion criteria included studies related to noninflammatory or inflammatory causes for surgical intervention via frontal trephination. Studies consisted of a meta-analysis, review articles, systematic reviews, and case reports. Included studies analyzed the procedure, indications, outcomes, and complications. Due to the heterogeneity of study cases, a meta-analysis was not feasible. This study was deemed exempt by the Institutional Research Board, Mayo Clinic, Phoenix, Arizona.
RESULTS Systematic Review The systematic review identified 2,621 studies published between 1980 and 2014. Careful review of the full-length articles identified 38 studies reporting sufficient data deemed appropriate for inclusion in the analysis. Each article was then reviewed and graded on level of evidence as ranging from level 1 (highest) to level 5 (Oxford Center for Evidence-Based Medicine; http://
www.cebm.net/index.asp). There were 32 retrospective case series, reports, or cohort studies (level 4), four systematic reviews (level 3), one prospective analysis (level 3), and one meta-analysis (level 2). The 38 studies were analyzed for indications and outcomes for frontal trephination, safety, techniques, and complications of the procedure. Of the 38 studies included for review (Table I), all articles were evidence-based medicine (EBM) levels 2, 3, or 4. Thirty-three articles were reviews describing the indications and outcomes for frontal sinus trephination. One article was a meta-analysis of level 2 evidence. Five of these articles were of level 3 evidence, one of which was a prospective trial. Three of these articles included discussion of complications. The remaining five articles focused solely on the complications (two articles) and aspects of safety surrounding the procedure (three articles). Indications—noninflammatory disease (EBM levels 3, 4). Twenty-three studies, all of level 3 or level 4 evidence, discussed the role of frontal sinus trephination and the rationale for its use for noninflammatory disease (Table II). Fifteen studies discuss specific indications for noninflammatory pathology, whereas eight studies serve as reviews regarding the use and technique of frontal sinus trephination. If indications for noninflammatory and inflammatory pathology are both present within the same study, the inflammatory indications will be discussed later in this article. Seiberling et al., Sieden and el Hefny, Busch, and Batra et al. discuss the role of frontal sinus trephination for removal of osteomas.5,11–13 Busch provided the initial description of osteoma in 1992.13 In these four studies, 14 cases of complete osteoma removal have been described, one case via external frontal sinus trephination approach alone, and 13 patients using frontal trephination as adjunct to endoscopic sinus surgery via an “above and below” approach.5,11–13 Senior and Lanza affirm this in their review describing trephination for benign lesions in the frontal sinus.14 Zacharek et al. and Batra et al. described the removal of fibrous dysplasia in four patients through trephination.4,5 Batra et al., Sautter et al., Cohen and Wang, Yoon et al., and Walgama et al. have all described removal of inverted papilloma through trephination procedures in a total of 14 patients.5,7,15–17 Batra et al. has also described frontal trephination for the treatment of one patient with
TABLE II. Indications for Noninflammatory Disease. Indication
Patients
First Author, Year
Fibrous dysplasia/osteoma Inverted papilloma
19 14
Seiberling, 20092; Zacharek, 20064; Batra, 20055; Seiden, 199512; Busch, 199213 Batra, 20055; Cohen, 200716; Yoon, 200917; Sautter, 200715; Walgama, 20127
CSF leaks
14
Crozier, 201319; Purkey, 200920; Das, 201121
Posterior table fracture Meningioma
2 2
Chaaban, 201223; Koento, 201224; Jatana, 200822 Kabil, 200618
Pneumocephalus
1
Batra, 20055
CSF 5 cerebrospinal fluid.
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TABLE III. Indications for Inflammatory Disease. Indication
Patients
First Author, Year
Narrow frontal recess, severe edema, severe polyps, obstructing frontal cells
163
Seiberling, 20092
Acute frontal sinusitis/chronic frontal sinusitis
86
Mucoceles, frontal sinusitis
38
Cohen, 200716; Gallagher, 19999; Gerber, 199327; Fry, 198026; Benoit, 200129 Batra, 20055; Courson, 20148
Mucoceles, type 4 frontal cells, frontal recess stenosis or ossification
10
Zacharek, 20064
Chronic frontal sinusitis, frontal bone osteomyelitis Pediatric frontal sinusitis
14 2
Hahn, 20096 McIntosh, 200728
Type 4 frontal cell
1
Maeso, 20093
Mucocele
1
Cho, 201025
pneumocephalus after craniectomy.5 Kabil presented excision of two meningiomas through trephination.18 Crozier et al. and Purkey et al. describe the repair of cerebrospinal fluid (CSF) leak resulting from noninflammatory causes through a sole trephination approach in five patients.19,20 Das and Balasubramanian published the concomitant use of endoscopic frontal sinusotomy and access holes drilled through the anterior frontal sinuses in nine patients.21 Lastly, posterior table fracture repair in one patient was described retrospectively by Jatana et al., and one patient was reviewed through a prospective trial by Chaaban et al.22,23 Koento further supports anterior table and posterior table fractures repair through frontal sinus trephinations.24 Mucoceles were not included in this section, as all studies did not discuss whether these were secondary to noninflammatory pathology. The remainder of the review articles focused on the description and use of frontal sinus trephination, often as an adjunctive procedure, in challenging frontal sinus pathology. Indications—inflammatory disease (EBM levels 2, 3, 4). Frontal sinus trephination has been discussed for inflammatory disease in 10 additional studies (Table III). Three studies described earlier (Zacharek et al., Batra et al., and Cohen and Wang) describe indications for both noninflammatory and inflammatory disease.4,5,16 All studies are of levels 2, 3, or 4 evidence. Seiberling et al. provide the largest series, with 163 patients with indications for narrow frontal recess, severe edema/polyps, obstructing frontal cells (type 3/ type 4 frontoethmoidal cells and intersinus septum cell).2 Courson et al. provide a meta-analysis reviewing the contemporary management of frontal sinus mucoceles via an external or combined approach. Twenty-one patients underwent external-only or combined approach.8 Zacharek et al. additionally described indications for inflammatory disease in 10 patients for superiorly or laterally based mucoceles (three patients), type 4 frontal cells (three patients), and frontal recess stenosis or ossification (four patients).4 Batra et al. describe a combined approach for mucoceles (15 patients) and frontal sinusitis (two patients).5 Maeso et al. present a case report of trephination for frontal sinus type 4 cell disease where a combined approach was used.3 Cho et al. Laryngoscope 125: September 2015
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describe a case report for treatment of a frontal sinus mucocele.25 Gallagher and Gross (16 patients), Fry et al. (16 patients), Cohen and Wang (12 patients), and Gerber et al. (two patients) describe the use of frontal trephination for acute or chronic frontal sinusitis.9,16,26,27 McIntosh and Mahadevan present two cases of trephination approach for pediatric frontal sinusitis.28 Hahn et al. describe trephination use for chronic frontal sinusitis (11 patients) and frontal bone osteomyelitis (three patients).6 Benoit and Duncavage reported on combined external and endoscopic frontal sinusotomy with stent placement in 40 patients with chronic frontal sinusitis.29 Outcomes (EBM levels 2, 3, 4). All studies demonstrating outcome measures were of level 2, 3, or 4 evidence. There was no heterogeneity with outcomes reported, including frontal sinus patency (Table IV). If outcomes were present in the studies, they have been reported here. Courson et al. showed that endoscopic techniques for the treatment of frontal and frontoethmoid mucoceles have similar recurrence rates compared to open techniques with indications for external approaches including unfavorable anatomy, lateral disease, and scarring. Strong evidence supported surgical treatment of frontal mucoceles with results from endoscopic and open approaches comparable.8 Crozier et al. demonstrated resolution of CSF leaks after repair via frontal trephination, with no recurrence at an average of 37 months.19 Walgama et al. had recurrence of inverted papilloma in 1/5 patients; however, this was not procedure related. There was no mention of frontal sinus patency.7 Seiden and el Hefny achieved complete excision of an osteoma and showed full resolution at the 8-month follow-up.12 Sautter et al. showed complete removal of inverted papilloma in one patient, with no recurrence at 16.8 months and no mention of frontal sinus patency.15 Yoon et al. had recurrence of inverted papilloma in 1/5 patients; however, this was not procedure related. There was no mention of frontal sinus patency.17 Cohen et al. showed no recurrence of inverted papilloma in one patient at 14 months.16 Seiberling et al. demonstrated complete excision of osteoma in 10 patients with no recurrence. There was no mention of frontal sinus patency.11 Zacharek et al. had 1/13 patients requiring revision surgery, with Patel et al.: Applications of Frontal Trephination
TABLE IV. Outcomes of Trephination Approach. First Author, Year
Patients
Type of Study/EBM Level
Outcome
Crozier, 201319
4
RR/level 4
Full resolution of CSF leaks, no recurrence at 37 months follow-up
Walgama, 20127
5
Systematic review/level 3
Recurrence of inverted papilloma in 1/5 patients at average 17.5 months follow-up, however not procedure related
Chaaban, 201223
1
Prospective/level 3
Seiberling, 20092
151
RR/level 4
Hahn, 20096
20
RR/level 4
Full resolution of the defect with 100% endoscopic patency at 17 months follow-up Total of 149 bilateral and 39 unilateral with 151 patients showing endoscopic patency at an average 25.5 months 8/14 required revision surgery with 15/20 patients improved at 12.8 months
Seiberling, 200911
10
RR/level 4
Complete excision of osteoma, no recurrence
Yoon, 200917
5
RR/level 4
Recurrence of inverted papilloma in 1/5 patients, however not procedure related
Maeso, 20093 Cho, 200825
1 1
RR/level 4 RR/level 4
Full resolution of disease at 36 months Full endoscopic patency at 5 months
Cohen, 200716
13
RR/level 4
12/13 patients free of disease at follow-up of 14.2 months with patency in 23/24
Cohen, 200716
1
RR/level 4
Sautter, 200715
1
RR/level 4
Zacharek, 20064
13
RR/level 4
Complete excision of inverted papilloma, no recurrence at 14 months Complete excision of inverted papilloma, no recurrence at 16.8 months 1/13 patients requiring revision surgery, 29 months average follow-up
Batra, 20055
5
RR/level 4
19/22 patients with endoscopic patency, 16.2 months average follow-up
Benoit, 200129
40
RR/level 4
Complete patency in 79%, symptom improvement in 78%
Gallagher, 19999
16
RR/level 4
Seiden, 199512
1
RR/level 4
Complete patency in 15/16 patients at 3.8 months follow-up Complete excision of an osteoma with full resolution at 8 months follow-up
Gerber, 199327
2
RR/level 4
Full resolution of disease at 4 months
CSF 5 cerebrospinal fluid; EBM 5 evidence-based medicine; RR 5 retrospective review.
all others showing complete resolution of symptoms at a follow-up of 29.9 months.4 Chaaban et al. had no complications with a posterior table fracture repair and showed full resolution of the defect with 100% endoscopic patency at 17 months.23 Batra et al. showed 19/22 (86%) with endoscopic patency at a 16.2-month average followup.5 Maeso et al. demonstrated no recurrence of symptoms postmanagement of frontal sinus type 4 cell disease at 3 years.3 Gallagher and Gross show complete patency of the frontonasal recess in 15/16 patients at 3.8 months.9 Gerber et al. show full resolution of symptoms in their two patients at an average of 4 months.27 Hahn et al. showed a total of 8/14 (57.1%) of all trephines during the study period requiring revision surgery, with 15/ 20 (80%) patients showing improvement at 12.8 months.6 Seiberling et al. had a total of 149 bilateral and 39 unilateral, with 151 (92%) patients showing endoscopic patency of the frontal sinus at an average 25.5 months.2 Cohen and Wang demonstrated 12/13 (92%) patients to be free of disease at a follow-up of 14.2 months, with 23/24 (96%) of frontal recesses deemed Laryngoscope 125: September 2015
patent.16 Cho et al. demonstrated full endoscopic patency at 5 months after removal of a frontal sinus mucocele.25 Benoit and Duncavage reported on combined external and endoscopic frontal sinusotomy with stent placement in 40 patients, with overall patency of the nasofrontal duct and subjective patient improvement rate at 79% and 78%, respectively.29 Complications (EBM level 4). Both inflammatory and noninflammatory related studies were examined for complications related to the frontal sinus trephination procedure (Table V). All studies examined were of level 4 evidence. Seiberling et al. had the largest series with 188 patients, and showed multiple complications, the most frequently encountered being periorbital cellulitis and facial cellulitis in 4/188 patients (2.1%). This study also showed asystole, CSF leak, proptosis, and bleeding in 1/188 patients each (0.5%).2 Batra et al. showed facial cellulitis or periorbital cellulitis in 1/22 patients (4.5%).5 Walgama et al. reported a CSF leak in 1/5 patients.7 Gallagher et al. had a CSF leak in 1/16 (6.3%) of patients. This study also showed a complication of skin Patel et al.: Applications of Frontal Trephination
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TABLE V. Complications. Complication
Patients
Total Patients
Author
1/22, 4/188
4.5% 2.1%
Batra, 20055; Seiberling, 20092
1/188, 1/5, 1/16
0.5%, 20.0%, 6.3%
Asystole
1/188
0.5%
Seiberling, 20092; Walgama, 20127; Gallagher, 19999 Seiberling, 20092
Proptosis
1/188
0.5%
Seiberling, 20092
Bleeding Superior oblique palsy/trochlea damage
1/188 1/1
0.5% NA
Seiberling, 20092 Bartley, 201230
Retro-orbital fluid dissection
1/1
NA
Andrews, 201331
Burns
2/16
12.5%
Gallagher, 19999
Facial cellulitis/periorbital cellulitis Cerebrospinal fluid leak
NA 5 not available.
burns from the procedure in 2/16 (12.5%).9 Bartley reported a case of superior oblique palsy/trochlear injury in one patient.30 Similarly, Andrews et al. reported a case of retro-orbital fluid collection in one patient.31 Safety (EBM level 4). Several studies have reviewed the safety of frontal sinus trephination given the risk of injury to critical structures. Traditionally, there has been a paucity of literature describing the ideal location for trephination; however, recent studies have analyzed this further. Lee et al. reviewed computerized tomography (CT) of 200 patients. They were able to show the mean depth of frontal sinus at 5 mm, 10 mm, and 15 mm from midline to be 11.26 mm (range, 0– 21.8 mm), 11.45 mm (range, 0–23.1 mm), and 11.48 mm
(range, 0–28.1 mm), respectively.32 This study showed no statistical difference in frontal sinus depth measurements performed at 5 mm, 10 mm, and 15 mm from a midline passing through the crista galli. They concluded that the sinus can be successfully trephined at 5 mm, 10 mm, or 15 mm in a majority of patients.32 Piltcher et al. reviewed 69 CT scans similarly at measurements of 5 mm, 10 mm, and 15 mm from midline. Men presented a frontal sinus significantly larger in the distances of 5 mm and 10 mm when compared to women, but there was no statistical difference in the depth of the sinus at 15 mm.33 The frontal sinus depth measured at 5 mm of the midline was significantly larger than that at 10 and 15 mm, just as the measure at 10 mm was significantly
Fig. 1. Intraoperative images using the three-dimensional computerized image guidance system. The bottom right panel shows the intraoperative endoscopic image with the probe into the fistula. The computed tomography (CT) images show the axial, coronal, and sagittal correlates of the tip if the probe. The probe has been inserted into the fistula after performance of the frontal trephination. The CT images also show the preoperative view of the fistula in the three dimensions. The fistula between the right frontal sinus and subcutaneous area is denoted by the white broken line, and the metal plate is clearly visualized (intersecting lines).
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Fig. 2. Intraoperative images of the surgical approach and repair. (A) A right brow incision has been performed after mapping the frontal sinus and the area of the fistula with the intraoperative image guidance. The subcutaneous tissue has been carefully retracted, protecting the surrounding neurovascular pedicles medially. (B) Using a pediatric 30 endoscope, the fistula (arrow) is visualized at the superolateral part of the right frontal sinus. (C) The mucosal edges of the fistula and the fistula tract have been removed to prepare for the multilayered repair. The metallic plate is clear visualized (arrow). (D) The multilayered repair has been completed, with the final layer utilizing a free nasal mucosal graft. The frontal ostium area was debrided of the bone wax (not shown here) and the sinus was not obliterated.
higher when compared to that at 15 mm (12.22 vs. 11.78 mm, 12.22 mm vs. 10.78 mm, 11.78 mm vs. 10.78 mm).33 In their study, the sinus depth when measured at 5, 10, and 15 mm away from the midline showed statistically significant differences, demonstrating that the closer the proximity to the midline, the deeper it was. They however concluded that the usual distance of 10 mm from the midline proved to add more advantages for trephination when the risk of crossed trephination at the 5-mm mark and the risk of sinus hypotrophy at 15 mm are considered.33 Ponde et al. reviewed 98 CT scans for dimensions and volume. The average anteroposterior diameter was 12.01 mm in males and 10.16 mm in females. The average transverse diameter was 56.53 mm in males and 51.05 mm in females. The average sagittal diameter was 31.72 mm in males and 28.57 mm in females.34 The average volume was 129.99 mm3 in males and 80.26 mm3 in females. They concluded that knowledge of the anatomic variations of the frontal sinus is important with surgical approaches through the supraciliary arch to avoid complications.34
Case A 58-year-old male underwent a revision right frontotemporal craniotomy for a resection of an anterior Laryngoscope 125: September 2015
cranial fossa meningioma. During surgery, an inadvertent breach of the right frontal sinus at the junction of the lateral roof and posterior wall was created. Intraoperative repair with absorbable Gelfoam was attempted, but in the postoperative period, the patient noted the right forehead scalp to inflate with air upon noseblowing and use of continuous positive airway pressure (CPAP). Initially, the patient was observed for spontaneous resolution; however, after 7 months, his symptoms continued. Further investigation with CT and magnetic resonance imaging (MRI) showed a subcutaneous aircommunicating fistula extending from the cranioplasty site to the far superolateral frontal table (Fig. 1). A small bony defect was noted in the superolateral aspect of the right frontal sinus, with air below the craniotomy plate extending inferolaterally in the right scalp. Further intervention was indicated, as there was risk for dural contamination from the sinus contents. The patient was referred to the endoscopic skull base surgeon for evaluation. After careful consideration, endoscopic frontal trephination and repair was deemed feasible. Image guidance was used for preoperative planning. The patient was noted to have a hyperpneumatized frontal sinus reaching far lateral, and as a result, a frontal trephination was planned lateral to the supraorbital Patel et al.: Applications of Frontal Trephination
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Fig. 3. Magnetic resonance imaging performed 6 months later for surveillance of the frontal meningioma. Both the coronal (left) and axial (right) images using T1-weighted sequences with gadolinium enhancement show the subcutaneous fistula to be fully healed. The right frontal recess shows no mucosal thickening and is healthily aerated. (B) On the left is the patient performing a Valsalva maneuver; no frontal subcutaneous air is noted. On the right is a close-up view of the brow showing that the incision is well healed and well concealed.
notch. Image guidance was used to plan the approach and avoid intracranial breach. A 1-cm brow incision was created, with the scalpel beveled to preserve the brow trichia. The supraorbital and supratrochlear nerves were identified and retracted away. Next, a cutting burr was used to enter into the frontal sinus, and a 1 cm 3 1 cm opening into the anterior frontal table was created with the use of Kerrison rongeurs and the diamond burr. The pediatric 0 , 30 , and 45 endoscopes were inserted through this minitrephination to visualize the area of the fistula (Figs. 1 and 2). The fistula was then resected, carefully avoiding any dural injury. Next, a multilayered, air-tight closure was performed (Fig. 2) using acellular tissue matrix (Alloderm), bovine collagen matrix (DuraGen), and a free mucosal graft in layers. DuraGen was first used to plug a high defect in the undersurface of the metallic plate used in the initial craniotomy repair. Alloderm was then placed in the subcutaneous plane over the superficial aspect of the plate and was tucked under edges of bony recess. Finally, a free mucosal graft harvested from the left nasal septum was placed over the frontal sinus defect to repair the mucosa as an overlay layer. The area of the frontal recess was found partially plugged with bone wax from previous repair. This was carefully removed, making sure that the mucosa in the frontal recess was not injured at all (to prevent problems with iatrogenic frontal recess obstruction). No intraoperative complications were noted and the patient was discharged home the same day. He remains symptom free at 18 months of follow-up and uses CPAP without problems. The trephine incision healed as a well-camouflaged scar. MRI performed 9 months postoperatively for tumor surveillance showed Laryngoscope 125: September 2015
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full resolution of the fistulous tract and no recurrence of tumor (Fig. 3).
DISCUSSION Evidence of frontal trephination approaches date back as early as prehistoric times. Two specimens demonstrating the trephination approach for frontal sinus pathology were collected in the second decade of this century in Peru dating back approximately 600 years.35 The approach was first described in the literature by Runge in 1750, and Hutchinson further described the procedure in 1939 as a puncture technique into the frontal sinus.9,10 Since that time period, this procedure has undergone considerable advancement.10,36 In 1991, Hoffman and May described an “above and below” approach to the frontal sinus using the trephine porthole.37 Subsequent studies have been published reviewing patients who underwent a combined trephination with frontal sinusotomy for complex frontal sinus pathology.5–8 However, due to difficulties with endoscopic access to the lateral-most extent of the sinus, combined with the need for preservation of the frontal sinus outflow tract and minimization of postoperative scarring, there has been continued evolution of technique and instrumentation for access to this area.1–5,10,15,36 Within the era of endoscopic sinus surgery, frontal sinus trephination has remained the most routinely utilized of all external procedures.1–5,36 Frontal trephination allows surgery to be performed through a small and well-camouflaged external incision without disruption of the frontal sinus outflow tract.36,37 Although transnasal endoscopic approaches can be attempted for pathology in Patel et al.: Applications of Frontal Trephination
the lateral frontal sinus, the anatomy is often not conducive to such approach in addition to the longer operative time and surgical skill required. With a transnasal approach, there is always risk of permanent scarring of the frontal recess necessitating revision surgery in the future.36 In challenging cases and/or revision cases, however, the trephine can be used as an adjunct to an endoscopic approach through an above and below visualization and dissection technique.5–8 To this day, frontal sinus trephination remains a simple, direct, and cosmetically excellent alternative. The exit point for the supraorbital neurovascular pedicle and awareness of the supratrochlear nerve bundle is important to ensure safe dissection.19,37,38 It affords minimal morbidity when compared to other external approaches and allows for preservation of physiologic sinus function.
CONCLUSION Frontal sinus trephination should not be regarded as a procedure of the past, as it useful in the armamentarium of the modern sinus and skull base surgeon. As our case report and systematic literature review suggests, indications for noninflammatory use in the contemporary era include trauma, tumor, and repair of skull base defects resulting in CSF leak and pneumocephalus. Furthermore, frontal trephination continues to have a pivotal role in treatment of inflammatory disease. The approach may be used as a supplement to the transnasal endoscopic approach (above and below approach) or purely through a trephination approach. Such an approach provides adequate access for both endoscopic visualization and instrumentation into the far lateral and superior areas of the frontal sinus.
BIBLIOGRAPHY 1. Schneider JS, Archilla A, Duncavage JA. Five ‘nontraditional’ techniques for use in patients with recalcitrant sinusitis. Curr Opin Otolaryngol Head Neck Surg 2013;21:39–44. 2. Seiberling K, Jardeleza C, Wormald PJ. Minitrephination of the frontal sinus: indications and uses in today’s era of sinus surgery. Am J Rhinol Allergy 2009;23:229–231. 3. Maeso PA, Deal RT, Kountakis SE. Combined endoscopic and minitrephination techniques in the surgical management of frontal sinus type IV cell disease. Am J Otolaryngol 2009;30:337–339. 4. Zacharek MA, Fong KJ, Hwang PH. Image-guided frontal trephination: A minimally invasive approach for hard-to-reach frontal sinus disease. Otolaryngol Head Neck Surg 2006;135:518–522. 5. 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. 6. Hahn S, Palmer JN, Purkey MT, Kennedy DW, Chiu AG. Indications for external frontal sinus procedures for inflammatory sinus disease. Am J Rhinol Allergy 2009;23:342–347. 7. Walgama E, Ahn C, Batra PS. Surgical management of frontal sinus inverted papilloma: a systematic review. Laryngoscope 2012;122:1205– 1209. 8. Courson AM, Stankiewicz JA, Lal D. Contemporary management of frontal sinus mucoceles: a meta-analysis. Laryngoscope 2014;124:378–386. 9. Gallagher RM, Gross CW. The role of mini-trephination in the management of frontal sinusitis. Am J Rhinol 1999;13:289–293.
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10. Jacobs JB. 100 years of frontal sinus surgery. Laryngoscope 1997;107(11 pt 2):1–36. 11. Seiberling K, Floreani S, Robinson S, Wormald PJ. Endoscopic management of frontal sinus osteomas revisited. Am J Rhinol Allergy 2009;23: 331–336. 12. Seiden AM, el Hefny YI. Endoscopic trephination for the removal of frontal sinus osteoma. Otolaryngol Head Neck Surg 1995;112:607–611. 13. Busch R. Frontal sinus osteoma: complete removal via endoscopic sinus surgery and frontal sinus trephination. Am J Rhinol 1992;6:139–143. 14. Senior BA, Lanza DC. Benign lesions of the frontal sinus. Otolaryngol Clin North Am 2001;34:253–267. 15. Sautter NB, Citardi MJ, Batra PS. Minimally invasive resection of frontal recess/sinus inverted papilloma. Am J Otolaryngol 2007;28:221–224. 16. Cohen AN, Wang MB. Minitrephination as an adjunctive measure in the endoscopic management of complex frontal sinus disease. Am J Rhinol 2007;21:629–636. 17. Yoon BN, Batra PS, Citardi MJ, Roh HJ. Frontal sinus inverted papilloma: surgical strategy based on the site of attachment. Am J Rhinol Allergy 2009;23:337–341. 18. Kabil MS, Shahinian HK. The endoscopic supraorbital approach to tumors of the middle cranial base. Surg Neurol 2006;66:396–401; discussion 401. 19. Crozier DL, Hwang PH, Goyal P. The endoscopic-assisted trephination approach for repair of frontal sinus cerebrospinal fluid leaks. Laryngoscope 2013;123:321–325. 20. Purkey MT, Woodworth BA, Hahn S, Palmer JN, Chiu AG. Endoscopic repair of supraorbital ethmoid cerebrospinal fluid leaks. ORL J Otorhinolaryngol Relat Spec 2009;71:93–98. 21. Das PT, Balasubramanian D. External frontal sinusotomy and endoscopic repair of cerebrospinal fluid fistula in the posterior wall: preliminary report of a new technique. J Laryngol Otol 2011;125:802–806. 22. Jatana KR, Ryoo C, Skomorowski M, Butler N, Kang DR. Minimally invasive repair of an isolated posterior table frontal sinus fracture in a pediatric patient. Otolaryngol Head Neck Surg 2008;138:809–811. 23. Chaaban MR, Conger B, Riley KO, Woodworth BA. Transnasal endoscopic repair of posterior table fractures. Otolaryngol Head Neck Surg 2012; 147:1142–1147. 24. Koento T. Current advances in sinus preservation for the management of frontal sinus fractures. Curr Opin Otolaryngol Head Neck Surg 2012;20: 274–279. 25. Cho SH, Lee YS, Jeong JH, Kim KR. Endoscopic above and below approach with frontal septotomy in a patient with frontal mucocele: a contralateral bypass drainage procedure through the frontal septum. Am J Otolaryngol 2010;31:141–143. 26. Fry TL, Biggers WP, Fischer ND. Frontal sinus trephination: a new technique for office procedure. Laryngoscope 1980;90(5 pt 1):838–841. 27. Gerber ME, Myer CM III, Prenger EC. Transcutaneous frontal sinus trephination with endoscopic visualization of the nasofrontal communication. Am J Otolaryngol 1993;14:55–59. 28. McIntosh DL, Mahadevan M. Frontal sinus mini-trephination for acute sinusitis complicated by intracranial infection. Int J Pediatr Otorhinolaryngol 2007;71:1573–1577. 29. Benoit CM, Duncavage JA. Combined external and endoscopic frontal sinusotomy with stent placement: a retrospective review. Laryngoscope 2001;111:1246–1249. 30. Bartley J, Eagleton N, Rosser P, Al-Ali S. Superior oblique muscle palsy after frontal sinus mini-trephine. Am J Otolaryngol 2012;33:181–183. 31. Andrews JN, Lopez MA, Weitzel EK. Case report of intraoperative retroorbital fluid dissection after frontal mini-trephine placement. Laryngoscope 2013;123:2969–2971. 32. Lee AS, Schaitkin BM, Gillman GS. Evaluating the safety of frontal sinus trephination. Laryngoscope 2010;120:639–642. 33. Piltcher OB, Antunes M, Monteiro F, Schweiger C, Schatkin B. Is there a reason for performing frontal sinus trephination at 1 cm from midline? A tomographic study. Braz J Otorhinolaryngol 2006;72:505–507. 34. Ponde JM, Metzger P, Amaral G, Machado M, Prandini M. Anatomic variations of the frontal sinus. Minim Invasive Neurosurg 2003;46:29–32. 35. Canalis RF, Cabieses F, Hemenway WG, Aragon R. Prehistoric trephination of the frontal sinus. Ann Otol Rhinol Laryngol 1981;90(2 pt 1):186– 189. 36. Murr AH. Contemporary indications for external approaches to the paranasal sinuses. Otolaryngol Clin North Am 2004;37:423–434. 37. Hoffmann DF, May M. Endoscopic frontal sinus surgery: frontal trephine permits a two-sided approach. Oper Tech Otolaryngol Head Neck Surg 1991;2:257–261. 38. Harvey RJ, Gallagher RM, Sacks R. Extended endoscopic techniques for sinonasal resections. Otolaryngol Clin North Am 2010;43:613–638.
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