Eur Arch Otorhinolaryngol DOI 10.1007/s00405-014-2967-9

Rhinology

Frontal sinus obliteration with autologous calvarial bone graft: indications and results Pierre Vironneau · André Coste · Virginie Prulière‑Escabasse 

Received: 7 December 2013 / Accepted: 19 February 2014 © Springer-Verlag Berlin Heidelberg 2014

Abstract  Despite increasing advances in endonasal frontal sinus surgery, frontal sinus obliteration (FSO) is sometimes necessary after failure of other surgical techniques. This procedure has been reported with autologous tissue or synthetic material, but few studies have reported results with autologous calvarial bone graft. The aim of this study was to report our experience with osteoplastic FSO calvarial bone graft. A retrospective review was performed on 11 patients operated upon for FSO with autologous calvarial bone graft from 2005 to 2011. Obliteration was indicated for chronic symptomatic frontal sinusitis with nasofrontal duct stenosis in five cases of nasal polyposis with a history of endoscopic sinus surgery, two cases of frontal trauma, two of surgery for frontal inverted papilloma and two of chronic frontal purulent sinusitis. Ten patients had a history of one or two previous functional endoscopic sinus surgery (FESS) procedures. On outcome assessment, eight patients had no residual complaints after FSO and all patients showed improvement in symptoms. Frontal sinus obliteration with autologous calvarial bone graft showed low donor site morbidity and good aesthetic results. This procedure should be considered in severe frontal sinusitis after repeated FESS procedures have failed.

Keywords  Frontal sinus · Surgical procedure · Frontal sinus obliteration · Chronic sinusitis · Frontal trauma · Indication · Autologous bone graft · Calvarian bone graft · Complication · Outcomes

Introduction Before the advent of endoscopic sinus surgery, frontal sinus obliteration (FSO) was commonly performed for frontal sinusitis refractory to medical treatment. First described in the mid-eighteenth century, the technique was steadily improved until Goodale and Montgomery [1] widely popularised FSO using an osteoplastic flap, in a large series published in the 1970s. With the rapid evolution and spread of endoscopic endonasal sinus surgery, most pathologies of the frontal sinus could progressively be reached with new angled endoscopes and instruments. Frontal sinus drainage procedures such as the median drainage described by Draf [2] and the modified Lothrop procedure [3] gained popularity from the early 1990s for the treatment of chronic and severe frontal sinusitis. Even so, there is still a limited role for FSO in modern rhinology, in frontal sinusitis in which repeated endoscopic procedures fail to cure both disease and symptoms. The present study reports our experience with osteoplastic FSO using calvarial bone graft.

P. Vironneau (*) · A. Coste · V. Prulière‑Escabasse  Department of Otorhinolaryngology and Cervicofacial Surgery, Hôpital Intercommunal de Créteil and Centre HospitaloUniversitaire Henri Mondor [AP-HP (Assistance Publique, Hôpitaux de Paris)], 40, Avenue de Verdun, 94000 Créteil, France e-mail: [email protected]

Patients and methods

A. Coste · V. Prulière‑Escabasse  Paris-Est Créteil University, UPEC (Pôle de Recherche Et D’Enseignement Supérieur), Créteil, France

The admissions and surgery records of the Department of Otorhinolaryngology of the Intercommunal Hospital of

Patients

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Creteil (France) were scanned for patients who had undergone osteoplastic FSO with calvarial bone graft between January 2005 and March 2011. Surgery was indicated after systematic assessment of history, physical status, clinical course and status and preoperative CT and/or MRI. Data pertaining to patient demographics, previous endoscopic parasinus surgery, number of previous frontal repermeabilisation procedures, preoperative symptomatology (frontal pain/headache, frontal swelling, rhinorrhea, proptosis/eye swelling, nasal obstruction, visual alteration, and sinus infection requiring medical therapy) and preoperative otolaryngologic and CT findings were collected for each patient. Postoperative evolution of symptomatology, rhinoscopic examination findings, immediate and late postoperative complications and aesthetic results were analysed.

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the anterior table of the bony sinus flap was fixed by nonresorbable suture. In other cases, the sinus was gently overfilled with bony paste to reshape the anterior wall, taking into account the possibility of slight long-term bone powder resorption. After resorbable periosteal suture, suction drainage and scalp closure were performed classically. A pressure bandage was applied for 72 h, with drains left in place. Intra-operative intravenous antibiotics (amoxicillin  + clavulanic acid, 3 g per day) were systematically administered, followed by a 10-day course of postoperative oral antibiotic therapy. Patients were discharged after 4–5 days. Postoperative controls were carried out at 14 days, 3 and 9 months.

Results Operative technique Below, we describe the various steps of frontal osteoplasty, along with some useful modifications of the procedure originally described [4]. Skin was prepared with antiseptic solution (Betadine® scrub) and the nasal cavities were packed with gauze soaked in Xylocaine naphazoline® for endoscopy. 1 % lidocaine with 1:100,000 epinephrine was infiltrated into the planned incision area to reduce bleeding. A coronal incision was made through the skin down to the level of the frontal bone periosteum. Periosteum was incised only beyond the contour of the frontal sinus. The periosteal flap was elevated to the supraorbital rim to prevent supraorbital nerve damage. In large frontal sinuses in which it was intended to conserve the anterior wall, after measurement on CT, a bony flap was resected from the anterior sinus wall using an oscillatory saw. In small frontal sinuses, the anterior sinus wall was simply drilled to obtain maximum opening. The frontal sinus mucosa was then totally removed, and specimens were collected for bacteriologic culture and pathology. The interfrontal septum was removed only in bilateral obliteration procedures. Using a diamond burr, the sinus walls were gently drilled to be sure that the mucosa had been totally removed. Through the coronal approach, the parietal vault was bilaterally exposed after elevation of an H-shaped periosteal flap. The calvarial bone graft was harvested by progressively drilling the parietal vault, and bone powder was collected with a specific suction device (Aspeo®, Anthogyr, France) (Fig. 1). At the same time, 20 ml of peripheral blood was sampled by the anaesthesia team and placed in a cupula for 15 min. After coagulation, supernatant plasma was mixed with bone powder to obtain a bony paste. The fronto-nasal duct was then sealed with a graft of connective tissue (temporalis fascia, galea periosteum), which was impacted with a piece of parietal bone. The sinus cavity was totally filled with the bony paste. When preserved,

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Eleven patients were included in the study. Over the same period, 110 surgical procedures were performed for frontal sinus disease. Mean age was 50 years (range 34–75 years), with a male to female ratio of 2:1. Mean follow-up was 1.2 years (range 0.1–3.8 years). All patients had recurrent or persistent frontal sinus infection with severe symptoms. Symptom frequency was daily to 3 times per year. 81.8 % of patients (9/11) reported pain in the frontal region, and two in other locations (internal cantus and maxillary sinus, respectively). One patient presented anteroposterior rhinorrhea with unilateral purulent secretion in the anterior ethmoid. Endoscopic findings clearly identified fibrosis in the frontal recess or anterior ethmoid in six patients (54.5 %). Preoperative CT found an osteogenic reaction in the frontal recess or frontal sinus in seven patients (63.6 %). Preoperative MRI was performed in four patients and showed high signal intensity on T1-weighted images, corresponding to chronic retention. The main indication for surgery functional endoscopic sinus surgery (FESS) was nasal polyposis in five patients (45.6 %), two of whom presented with Samter’s triad syndrome (asthma, nasal polyps and aspirin sensitivity) [5] with high rate of symptom recurrence (nasal obstruction, facial pain, post nasal drip and anosmia) and more extensive sinonasal disease. Four underwent bilateral anteroposterior ethmoidectomy and one unilateral anterior ethmoidectomy. Two patients (18.1 %) underwent FSO several years after frontal trauma, with compound open fracture of the frontal anterior wall; two (18.1 %) had a history of frontal sinus surgery for inverted papilloma with extension to the nasofrontal duct; two (18.1 %) presented chronic frontal sinusitis with recurrent purulent secretion; five (45.5 %) had a history of one endonasal frontal sinusotomy and five (45.5 %) of two.

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Obliteration Obliteration was unilateral in eight patients (72.7 %) and bilateral in three (27.3 %), systematically using a coronal approach. The anterior table of the frontal sinus was conserved in four patients (36.4 %). There was one intra-operative complication (infraction of the orbital roof, repaired during surgery), but no major intra-operative complications. There were two postoperative complications: one palpebral oedema at 2 days due to infraction of the orbital roof, requiring surgical revision, and one frontal haematoma, requiring no revision. Outcomes On outcome assessment, eight patients (72.7 %) had no residual complaints after surgery, and the other three showed improvement in symptoms. One patient with Samter’s triad syndrome had recurrent facial pain due to exacerbations of nasal polyposis. Three patients developed frontal hypo- or dys-esthesia, persisting at 6 months in two cases. All patients reported that they were pleased with the aesthetic result and frontal contour (Fig. 2).

Discussion Although frontal sinus surgery with fat obliteration has often been replaced by endoscopic procedures such as the modified Lothrop or Draf type III drainage operations, it remains a valuable approach to the frontal sinus [6, 7]. Neo-osteogenesis of the frontal recess after endoscopic surgery, trauma or frontal bone osteomyelitis is the most common indication for an external approach in chronic and symptomatic frontal sinusitis. In the present study, most patients (45.4 %) underwent osteoplastic FSO after FESS for nasal polyposis due to iatrogenic stenosis of the nasofrontal duct; two underwent obliteration after frontal trauma; two had a history of frontal sinus surgery for inverted papilloma and two for chronic frontal sinusitis. Previous studies showed a similar pattern of indications. Weber [8], in a study of 82 patients, reported that the majority (65.3 %) of patients who underwent FSO for mucopyocele or recurrent acute sinusitis had a history of surgery disturbing the natural drainage pathway; other indications were frontal trauma (14.6 %) and benign tumour (14.6 %). In a study of 19 patients, Mendians indicated FSO systematically after previous FESS for chronic frontal sinusitis [9]. Weymuller [10] reported that nearly all FSO patients (94.9 %) had a history of sinus surgery. All these studies highlight the fact that FESS should be conducted with great caution in the frontal recess, as it appears as the

Fig. 1  Drilling and harvesting calvarial bone graft

main cause of nasofrontal duct stenosis and, therefore, of subsequent indication for FSO. In the present study, ten patients (90.9 %) had had one or two endonasal frontal sinusotomies: FSO may, therefore, be indicated after one failure of this procedure. According to Soyka et al. [11] FSO with autologous calvarial bone graft should be the first-line treatment for large or lateral osteoma, malignant disease, most posterior sinus wall fractures with CSF leakage, osteomyelitis, and pathologies in small underdeveloped sinuses with narrow floor. In rare cases of endoscopically inaccessible mucocele located within the lateral aspect of the frontal sinus, FSO is still a valid treatment option [1, 12]. In the present series, two patients underwent FSO after frontal trauma with compound anterior wall fracture. FSO was not performed in first intention, but was in several cases secondary to trauma because of iterative frontal oedema and frontal pain. This suggests that FSO could be indicated as first-line treatment in open compound fracture of the frontal anterior wall. According to Weber et al. [13] complete meticulous removal of the all visible mucosa and of the inner cortex of the sinus wall, permanent occlusion of the nasofrontal duct and choice of appropriate material for obliteration are the essential principles for successful FSO. Several authors have assessed various materials used for obliteration and tried to establish criteria. According to Peltola et al., a FSO material should be available at any time and in any quantity, be economical, not cause donor site morbidity or foreign body reaction, not transmit infection or be toxic, not prolong surgery time or disturb follow-up procedures, and be easy to handle and possible to shape or mould during the operation [14].

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Abdominal fat is the most frequently used material for obliteration and has the longest history in FSO [8–10, 15– 18]. Hardy et al. [16] in the largest FSO series, reported that the overall complication rate in FSO using fat was 18 %, including abdominal donor site morbidity, wound complications, postoperative infection, fat necrosis and recurrent chronic sinusitis; the complication rate specifically due to abdominal fat harvesting was 6.3 %. Furthermore, Weber et al. [8] in an MRI study of 82 patients, reported that the amount of adipose tissue detectable was less than 20 % in the majority of cases (53 %), and more than 60 % in only 18 %. However, avascular graft involves an elevated risk of resorption and infection as well as of donor site morbidity. A regional vascular flap may be used to obliterate small sinuses, with less morbidity. Hydroxyapatite has been investigated in experimental and clinical FSO [19–21]. It is a new biomaterial that has been used for reconstruction of the lateral skull base [22] suboccipital [23] and temporal bone [24]. Taghizadeh [21], reporting a series of 38 patients who underwent FSO with hydroxyapatite cement after mucocele resection, considered this material safe and effective for obliteration of frontal sinuses infected with mucocele, with minimal morbidity and excellent postoperative contour. In a recent comparative study of total operating room costs, total operating time and potential complications in FSO using autologous abdominal fat versus hydroxyapatite cement, autologous abdominal fat appeared cost-effective; a slight difference in total operating time was not statistically significant and this factor alone should not be a deterrent [25]. Kang et al. [26] reported a modified FSO technique using calvarial bone and TISSEEL glue: it appeared to be suitable and cheap, with low donor site morbidity, using the same surgical approach as in the standard procedure. Moreover, bioactive glass, osteoconductive and antimicrobial, appeared to be a reliable FSO material [27]. Indeed, the reconstructions with bioactive glass and hydroxyapatite are associated with good functional and aesthetic results without donor site morbidity [28]. In our experience, calvarial bone graft avoids abdominal site morbidity. Progressive drilling avoids dural exposure or injury. Moreover, calvarial bone graft allows aesthetic frontal reconstruction. The frontal osteoplastic flap procedure combined with FSO was once the gold standard in surgical management of medically refractory frontal sinus disease. It offered easy access and direct visualisation of the frontal sinus, with success rates ranging from 79 to 95 % [1, 4, 8, 9, 11, 15, 16]. It was, however, sometimes associated with significant morbidity. Montgomery and Goodale [1], in a series of 250 patients, reported a complication rate of 18 % with revision in 5 % of cases. More recently, complication rates ranged from 10 to 51.3 % [9–11, 29, 30].

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Fig. 2  CT scan 6 months after left frontal sinus obliteration with autologous calvarial bone graft

Soyka et al. [11], in a study of 77 patients, found an overall complication rate of 37.4 %. In a series of 82 osteoplastic flap procedures with fat obliteration, Weber et al. [8] reported exposure of orbital fat in 19.8 % of cases, unintentional fracture of the anterior wall of the frontal sinus in 19.5 %, incorrect placement of the anterior wall in 17 %, and dural exposure or dural injury because of a too large anterior flap in 8.5 %. In the present series, the complication rate was of a similar order (36.4 %), with no major complications. There was only one intra-operative complication: orbital fat exposure due to infraction of orbital roof, successfully repaired peroperatively. There was one periorbital oedema, repaired on surgical revision, and one minor complication (local haematoma, resolved by puncture under local anaesthesia). There were no complications associated with bone graft harvesting. In a series of 43 patients, Ulualp [7] reported one case of intra-operative cerebrospinal fluid (CSF) leakage. In the present series, centripetal drilling was preferred for small sinus cavities and when the anterior wall of frontal sinus was not conserved (63.3 % of cases): this technique avoids dural injury and allows perfect exposure of the frontal sinus cavity for meticulous removal of all visible mucosa. There was dys- or hypo-aesthesia of the forehead persisting more than 6 months in two patients (18 %). This complication has been described in 5.2 to 13 % of patients in others series [7, 8, 11]. Weber et al. [8] reported 3.4 to 6.8 % rates of embossment and frontal depression, respectively, in a series of 59 patients seen 1–12 years after surgery. Lawson and Reino [31] found a 10 % incidence of embossment in a group of 103 patients; onset was within a few months of surgery,

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with gradual progression for up to approximately 1-year. Soyka et al. [11] reported this complication in 2.6 % of cases. In the present series, two patients (18 %) presented light frontal depression, but all were cosmetically satisfied. All patients showed improvement in their main presenting symptom. However, one patient had persistent recurrent frontal pain and also described global facial pain related to Samter’s syndrome where sinonasal exacerbations are more frequent than in isolated nasal polyposis [32]. In a recent study of 20 patients, Mendians and Marks [9] reported 100 % patient satisfaction; there was statistically significant pre- to post-operative improvement in overall sinus discomfort, headache, drainage, congestion and frequency of sinus infection. In the largest series of Hardy and Montgomery [16], 93 % of patients had no significant symptoms. Thus, this procedure may be considered an efficient option in frontal sinus surgery.

Conclusion Advances in angled endoscopes, endoscopic drilling and intra-operative guidance have led to an increase in the use of endoscopic access to the frontal sinus. Even though the need for FSO has been reduced, this technique still has a role where total removal of pathological tissue within the sinus or drainage cannot be achieved endoscopically. Our experience of FSO with autologous calvarial bone graft shows that the technique has several advantages: low donor site morbidity, optimal sinus cavity exposure and good aesthetic results.

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magnetic resonance imaging in 82 operations. Laryngoscope 110(6):1037–1044 9. Mendians AE, Marks SC (1999) Outcome of frontal sinus obliteration. Laryngoscope 109(9):1495–1498 10. Alsarraf R, Kriet J, Weymuller EA Jr (1999) Quality-of-life outcomes after osteoplastic frontal sinus obliteration. Otolaryngol Head Neck Surg 121(4):435–440 11. Soyka MB, Annen A, Holzmann D (2009) Where endoscopy fails: indications and experience with the frontal sinus fat obliteration. Rhinology 47(2):136–140 12. Goodale RL, Montgomery WW (1958) Experiences with the osteoplastic anterior wall approach to the frontal sinus; case histories and recommendations. AMA Arch Otolaryngol 68(3):271–283 13. Weber R et al (1999) Obliteration of the frontal sinus—state of the art and reflections on new materials. Rhinology 37(1):1–15 14. Peltola MJ et al (2008) Long-term microscopic and tissue analytical findings for 2 frontal sinus obliteration materials. J Oral Maxillofac Surg 66(8):1699–1707 15. Correa AJ et al (1999) Osteoplastic flap for obliteration of the frontal sinus: five years’ experience. Otolaryngol Head Neck Surg 121(6):731–735 16. Hardy JM, Montgomery WW (1976) Osteoplastic frontal sinusotomy: an analysis of 250 operations. Ann Otol Rhinol Laryngol 85(4 Pt 1):523–532 17. Loevner LA et al (1995) MR evaluation of frontal sinus osteoplastic flaps with autogenous fat grafts. AJNR Am J Neuroradiol 16(8):1721–1726 18. Montgomery WW (1964) The fate of adipose implants in a bony cavity. Laryngoscope 74:816–827 19. Rosen G, Nachtigal D (1995) The use of hydroxyapatite for obliteration of the human frontal sinus. Laryngoscope 105(5 Pt 1):553–555 20. Snyderman CH et al (2001) Hydroxyapatite: an alternative method of frontal sinus obliteration. Otolaryngol Clin North Am 34(1):179–191 21. Taghizadeh F, Kromer A, Laedrach K (2006) Evaluation of hydroxyapatite cement for frontal sinus obliteration after mucocele resection. Arch Facial Plast Surg 8(6):416–422 22. Kveton JF, Friedman CD, Costantino PD (1995) Indications for hydroxyapatite cement reconstruction in lateral skull base surgery. Am J Otol 16(4):465–469 23. Kveton JF et al (1995) Reconstruction of suboccipital craniectomy defects with hydroxyapatite cement: a preliminary report. Laryngoscope 105(2):156–159 24. Kamerer DB et al (1994) Hydroxyapatite cement: a new method for achieving watertight closure in transtemporal surgery. Am J Otol 15(1):47–49 25. Fattahi T, Johnson C, Steinberg B (2005) Comparison of 2 preferred methods used for frontal sinus obliteration. J Oral Maxillofac Surg 63(4):487–491 26. Kang GC, Sng KW, Tay AG (2009) Modified technique for frontal sinus obliteration using calvarial bone and Tisseel glue. J Craniofac Surg 20(2):528–531 27. Peltola M et al (2006) Bioactive glass S53P4 in frontal sinus obliteration: a long-term clinical experience. Head Neck 28(9):834–841 28. Aitasalo KM, Peltola MJ (2007) Bioactive glass hydroxyapatite in fronto-orbital defect reconstruction. Plast Reconstr Surg 120(7):1963–1972; discussion 1973–1974 29. Parhiscar A, Har-El G (2001) Frontal sinus obliteration with the pericranial flap. Otolaryngol Head Neck Surg 124(3):304–307 30. Kristin J et al (2008) Frontal sinus obliteration—a successful treatment option in patients with endoscopically inaccessible frontal mucoceles. Rhinology 46(1):70–74

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31. Lawson W, Reino AJ (1996) Management of embossment following the frontal osteoplastic operation. Laryngoscope 106(10):1259–1265

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Frontal sinus obliteration with autologous calvarial bone graft: indications and results.

Despite increasing advances in endonasal frontal sinus surgery, frontal sinus obliteration (FSO) is sometimes necessary after failure of other surgica...
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