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Frontal Sinus Osteoplastic Flap

last modified on: Fri, 11/10/2017 - 11:15

Frontal Sinus Osteoplastic Flap

return to: Paranasal Sinus Surgery Protocols

  1. GENERAL CONSIDERATIONS
    1. Indications
      1. Frontal sinus fractures: nasofrontal duct involvement, anterior and posterior tables involved
      2. Frontal sinus disease unresponsive to more conservative approaches
      3. Approach for benign or malignant disease involving the sinus
      4. Complications of previous frontal sinus fractures, i.e., mucocoele
  2. PREOPERATIVE PREPARATION
    1. Evaluation
      1. CT scan: axial and coronal
      2. Six-foot Caldwell view with copy to serve as template for bone cuts (leave original Caldwell view intact to refer to in operating room and use other x-ray material to cut template including upper orbital rims for reference).
      3. Presence or absence of hair (+/- family history of receding hairline in males) to determine approach: coronal flap versus brow incision
    2. Consent
      1. Describe procedure
        1. "Open up the forehead sinus by making cuts in the bone"
      2. Describe risks
        1. Bleeding, infection, reaction to anesthesia
        2. Damage to adjacent structures: orbital and intracranial entry
        3. Forehead deformity
        4. Scar
        5. Forehead numbness, brow weakness
  3. NURSING CONSIDERATIONS
    1. Room Setup
      1. See Basic Soft Tissue Room Setup
        1. Mayfield headrest (available only)
        2. Back table x 2
    2. Instrumentation and Equipment
      1. Standard
        1. KLS Oto Trauma Implant - Instrument Tray
        2. Fracture Tray
        3. Bipolar Forceps Trays
        4. Minor Instrument Tray, Otolaryngology x 2
        5. Nasal Sharp Tray
        6. Sinus Tray
        7. Hall Micro Sagittal Saw Tray (Pneumatic)
        8. Retractor Tray, Small
      2. Special
        1. Bien Otologic Electric Drill Trayand burrs
        2. KLS Free Flap Implant - Instrument Tray
        3. Raney scalp hemostatic clips (available only)
        4. Syringe, Luer tip, 30 cc, with 18-gauge blunt needle, for irrigation while drilling
        5. Colorado microtip monopolar cautery
    3. Medications (specific to nursing)
      1. 1% lidocaine with 1:100,000 epinephrine
      2. Ocular lubricant ointment
      3. Antibiotic ointment
      4. Gentian violet
    4. Prep and Drape
      1. Standard prep, 10% providone iodine
      2. Drape
        1. Head drape
        2. Square off with towels around face and neck, leaving eyes exposed. If fat graft needed, then prep and square off with towels the specified area of the abdomen (along with extra sterile sheet over the abdomen).
        3. Split sheet: allow access to the fat graft by placing a towel with a towel clamp over fat graft so it may be felt over the sterile drape, then cut through sterile drape (leave a drape between sites so there is no cross-contamination).
        4. Irrigation pouch with suction attachments under head.
    5. Drains and Dressings
      1. Antibiotic ointment to suture line
      2. Adaptic, large, 3 x 8 in
      3. Fluffs x 3
      4. Kling wrap 4 in x 2
      5. Penrose drain 0.25 in (abdomen)
      6. At fat graft donor site, apply antibiotic ointment, adaptic, 4 x 4 gauze, fluffs, then Elastoplast tape
      7. Suction drains for coronal incision
    6. Special Considerations
      1. Bicoronal incision
      2. Sinus x-rays in the room
      3. Two setups: one for the sinus obliteration, and one for the harvest of fat from the abdomen
      4. May place tarsorhaphy sutures to protect the cornea
      5. Sterile x-ray film available if a template of the frontal sinus is made
      6. Rigid telescope may be used to transilluminate frontal sinus
  4. ANESTHESIA CONSIDERATIONS
    1. General Anesthesia
      1. Oral endotracheal intubation
      2. Throat pack only if other intranasal/sinus procedures to be done concomitantly
      3. Foley catheter if extra procedures to be performed concomitantly
  5. OPERATIVE PROCEDURE
    1. Incision
      1. Begin up to 4 cm behind hairline with V-shaped peak anteriorly in midline. Continue laterally to level of upper ear (further extension inferiorly in preauricular crease if needed for exposure). Consider alternative to V-shaped peak due to concern regarding alopecia.
      2. Raney clips are applied immediately with incision through galea to control bleeding.
      3. Blunt dissection in subgaleal plane to level of supraorbital rims with care to preserve periosteum.
    2. Place template over frontal sinuses and mark with gentian violet on 25-gauge needle upper and lateral borders of frontal sinuses. Additional security for frontal sinus entry in selected patients may be achieved by the following techniques.
      1. Place fiberoptic telescope (flexible or rigid) and transilluminate frontal sinuses with room darkened to delineate border of sinus
      2. Frontal sinus trephination and transilluminate through trephine site
    3. Incise periosteum with cautery 2 to 3 cm above region marked for proposed bone cuts.
      1. Elevate periosteum to 0.5 cm inferior to proposed bone cuts.
      2. Try to maintain periosteal attachments to bone inferiorly to maintain blood supply to flap.
    4. Bone Cuts
      1. Rotating burr to "postage stamp" openings into frontal sinus along border.
      2. Complete with side cutting burr, beveled 30° into sinus.
      3. Bone cuts through supraorbital rims may be completed with chisel.
      4. May require separate chisel cut (curved chisel) through septum to glabella to permit down-fracture of anterior table.
      5. Alternatively, may make all bone cuts with Midas-Rex drill.
      6. Most important: Always underestimate the size of the sinus to avoid dural and brain injury.
      7. Perform midline cuts last so that quick entry can be made in case of sagittal sinus injury.
    5. Frontal Sinus Obliteration (if indicated)
      1. Elevate and remove mucoperiosteum with Freer elevator.
      2. Turn in mucosa of frontal nasal ostium, abrade, and plug with temporalis fascia or bone fragment.
      3. Use rotating diamond burr to drill down all surfaces of sinus to remove any remaining mucosa; drill down intersinus septum.
    6. Harvest Fat
      1. Periumbilical incision: Approximately 180° around inner aspect of umbilicus permits retrieval of fat without a visible scar.
      2. Alternatively, left lower quadrant incision may be used.
      3. Attempt to harvest fat in one segment atraumatically without the monopolar cautery
      4. Meticulous hemostasis is important.
      5. Penrose drain placed.
    7. Closure
      1. Bone flap is replaced over sinus and fat.
      2. Secure bone back in place with microplates or wires.
      3. Close periosteal incision if possible with vicryl sutures.
      4. Scalp incision closed in layers with care to include the galeal layer in the deep closure.
      5. Skin is closed with nylon sutures or staples.
  6. POSTOPERATIVE CARE
    1. Pressure dressing for both scalp and abdomen
    2. Penrose drain from scalp removed on postoperative day 1 or 2
    3. Drain from fat donor site removed on postoperative day 1
  7. SUGGESTED READING
    1. Fung MK. Template for frontal osteoplastic flap. Laryngoscope. 1986;96:578-579.
    2. Maniglia AJ, Dodds BL. A safe technique for frontal sinus osteoplastic flap. Laryngoscope. 1991;101:908-910.