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Role of Miniosteoplastic flap in frontal sinus surgery

 

By

 

Dr. T. Balasubramanian M.S. D.L.O.

 

 

Introduction:
Access to frontal sinus is really challenging because of its geometry, varying dimensions and highly variable frontal out flow tract areas.  Treatment of small frontal sinus tumors like Osteomas, encephaloceles is really troublesome because of the difficulty in accessing these lesions.  Approaching these lesions using endoscopes is again troublesome due to the angulations involved.  Using a bicoronal flap procedure to reach out for these small lesions is highly unwarranted.   Moreover bicoronal flap procedures are fraught with complications like forehead numbness, alopecia at the incision site, paralysis of frontalis branch of facial nerve.
This is where Miniosteoplastic flap procedure can be used.  The real advantage of this procedure is that it allows adequate exposure of the interior of frontal sinus through a small window created through the classical Lynch incision.  With the advent of image guidance systems it is fairly simple to perform this procedure with fewer risks.  This procedure was first described by Salamone & Tami.  They used this procedure to remove lesions involving the posterior table of frontal sinus.

Procedure:

  1. Image guidance system if available should be put to use.  (Not mandatory).
  2. Patient is positioned as for any other nasal surgery
  3. Corneal protectors should be used to protect it
  4. A classic Lynch incision (subciliary) is made under the brow on the side of the lesion
  5. Another incision is made across the nasion perpendicular to this incision
  6. Angular vein will be encountered and may cause troublesome bleeding and hence must be cauterized
  7. Supraorbital neurovascular bundle should  be preserved
  8. Periosteum should be elevated inferiorly as this would help in retraction of orbit
  9. Bone cut is made using a Kerrison’s Ronguer in the floor of frontal sinus along the supraorbital rim up to the lacrimal bone.
  10.  A medially based Miniosteoplastic flap is created.
  11.  The bone is fractured in a superomedial direction.
  12.   The frontal sinus can now be entered.
  13.  The lesion can now be resected.  The dural defect if any should be closed.
  14.  After excision of the lesion the bone flap is replaced and secured using an absorbable craniofacial plate.

Complications:

    • Forehead anesthesia due to damage to supraorbital neurovascular bundle.
    • Obstruction to frontal sinus drainage channel
    • CSF leaks in case dura is breached.

     

     

     

     

     

     

     

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