Above and Beyond: Periorbital Suspension for Endoscopic Access to Difficult Frontal Sinus Pathology

Abstract

Objectives/Hypothesis: The periorbital suspension (PS) is an advanced adjunctive technique performed during endoscopic approaches to frontal sinus pathology that would be too far lateral or superior to address using traditional endoscopic transnasal approaches. The objectives of this study are to characterize the utility of this technique for frontal sinus pathology, determine anatomic limitations, and assess clinical outcomes following surgical treatment.Study Design: Prospective case series. Methods: Patient data including demographics, etiology, technique, complications, and clinical follow-up were collected. Preoperative computed tomography scans were reviewed for maximum lateral and superior extent of pathology, supraorbital recess height, anterio-posterior (AP) diameter of the frontal sinus, interorbital distance, and orbital-first olfactory neuron distance.Results: The PS approach was used in 30 surgeries (29 patients) for cerebrospinal fluid leaks (n = 5), benign tumors (n = 17), malignant tumors (n = 5), allergic fungal sinusitis (n = 2), and mucocele (n = 1) between 2018 and 2020. Approaches included 15 Draf IIB and 15 Draf III frontal sinusotomies. All pathology was surgically accessible using the PS approach and there were no intraoperative or postoperative complications. Postoperative follow-up was 11.7 AE 7.6 months. Mean recorded measurements (in mm) were as follows: maximum lateral extent À15.0

Transnasal endoscopic management of frontal sinus anterior table fractures improves cosmetic quality‐of‐life outcomes

“…Bilateral anterior table, NOE, and concurrent posterior table fractures were also fixed successfully. Because periorbital suspension approaches can reach almost any area of the frontal sinus, 5 the only contraindications would be sizeable lacerations that do not require enlargement (fracture can be repaired directly) or if craniotomy is required and the anterior table will already be exposed for fixation.…”

“…Anterior table fractures were repaired using our previously described techniques. 1,2,5 Briefly, a Draf IIB or Draf III was used to approach the fractures. Using a 70-degree endoscope, we inserted a curved suction or frontal sinus curette to reduce the inferior or medial sections of the fracture, followed by reduction of the superior or lateral fragments (Figure 1).…”

“…Anterior table fractures were repaired using our previously described techniques 1,2,5 . Briefly, a Draf IIB or Draf III was used to approach the fractures.…”

“…Bilateral anterior table, NOE, and concurrent posterior table fractures were also fixed successfully. Because periorbital suspension approaches can reach almost any area of the frontal sinus,5 the only contraindications would be sizeable lacerations that do not require enlargement (fracture can be repaired directly) or if craniotomy is required and the anterior table will already be exposed for fixation.Endoscopic repair of frontal sinus fractures eliminated external surgical scarring, removed the need for hardware implantation, and resulted in excellent contour with minimal residual displacement. In addition, patients reported outstanding cosmetic QOL.…”

Advances in Sinus Surgery for Nasal Polyps

“…Multiple studies, including a randomized controlled trial, have demonstrated that mucosal-free grafts and vascularized pedicled flaps confer long-term patency of frontal sinus neo-ostium in larger dimensions following the Draf 3/endoscopic-modified Lothrop procedures at significantly better rates than leaving the remaining bone bare. [23][24][25][26][27][28][29][30][31][32][33][34][35] Placement of steroid-eluting implants can be considered for preservation of patent outflow in the immediate postoperative period as well as for consistent topical medical therapy to the surgical bed. Steroid-eluting stents have consistently shown superiority in maintaining frontal sinus patency in CRSwNP.…”