Die endonasale Chirurgie der Stirnhöhle

Abstract

Endonasal frontal sinus surgery aims to create adequate access to the frontal sinus, remove specific pathologic processes, and establish a permanent and sufficient drainage and ventilation. We present a concept of frontal sinus surgery that depends on the individual anatomy of the frontal and ethmoid sinuses and includes a stepwise intensity of the surgical procedure. Endonasal frontal sinus drainage according to Draf ranges from uncinectomy to the maximal procedure, type III drainage; these procedures are outlined in detail. A comprehensive overview of technical aspects to optimize the operative technique and postoperative results is given. Surgical details include the application of nasal packing, mitomycin C, mucosal transplants, silicone foils or stents, and the new technology of balloon sinuplasty. Specific instrumentation and endoscopic equipment are recommended. Part 1 deals with types I and II frontal sinus drainage. Part 2 explains type III drainage, technical details, and special aspects of postoperative care.

Comprehensive review on endonasal endoscopic sinus surgery

“…Different classifications have been elaborated, among them especially the classification of frontal sinus drainages (according to Draf) has been widely accepted. Details of such a classification would be: uncinectomy (infundibulotomy), maxillary sinus fenestration/maxillary sinus surgery, anterior ethmoidectomy, posterior ethmoidectomy, sphenoid sinus fenestration/sphenoid sinus surgery, frontal sinus drainage/frontal sinus surgery type I-III, and pansinus surgery [ 83 ], [ 240 ], [ 246 ], [ 247 ], [ 248 ].…”

“…Hereby the posterior part of the septum can additionally be removed in order to create a broad opening transnasally to the sphenoid sinus because the postoperative care may be rather difficult according to our experience. In analogy to surgeries of the maxillary and frontal sinuses, a “sphenoid drill-out” is described with removal of the complete anterior wall of the sphenoid sinus and the septum of the sphenoid sinus and the adjacent nasal septum in therapy resistant chronic sphenoid sinusitis [ 248 ], [ 348 ]. In cases of straight septum and (nonetheless) narrow local anatomy, a transseptal approach via a hemi-transfixion incision or via a separate dorsal incision may be reasonable and less traumatizing than a transethmoid one.…”

“…During surgery, the step-by-step technique consisting of preparing cell by cell according to the obvious gaps and clefts and removing them specifically, has been established as surgical technique. Removal (“scoopin out”) of the (mostly) last bony shell at the transition of the frontal sinus to the frontal recess was called “uncapping the egg” [ 247 ], [ 248 ], [ 268 ].…”

“…The classification of frontal sinus surgeries according to Draf with types I, IIa, IIb, and III has been internationally established [ 242 ], [ 248 ], [ 358 ], [ 359 ] even if some weak points and gaps of the concept have been identified because the anatomical variety of the anterior ethmoid and the frontal sinus are not sufficiently taken into account.…”

Nasal packing and stenting

“…The main problem is the inadequate forms available (round with a diameter of 4–6 mm), which do not always coincide with individual frontal sinus openings. The author currently prefers optimizing surgical technique with special instruments for the frontal sinus [94], [95] and uses stents less often that a number of years ago. Wenn SHPH are used, one should:…”