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Frontoethmoidectomy: Its role in the treatment of complicated Frontoethmoid Rhinosinusitis

Urmen Desai, MD MPH, William A. Numa, MD Elie E. Rebeiz
Tufts Medical Center- Department of Otolaryngology; Boston, MA


PURPOSE OF STUDY
Endoscopic sinus surgery has redefined the way we surgically manage chronic sinus disease as well as its complications. Furthermore, it has been established as the Standard of Care in the treatment of chronic rhinosinusitis and most cases of complicated rhinosinusitis. As a result, we have evolved to become more proficient with endoscopic techniques. By the same token we are increasingly reliant on this approach, sometimes overlooking the usefulness and advantages of primary External Frontoethmoidectomy for selected cases. In spite of the advantages of endoscopic management, a rigorously selected subset of patients may still be treated through a primary External Frontoethmoidectomy approach. We set out to define criteria to determine surgical candidacy for External Frontoethmoidectomy.

METHODS USED:
A retrospective review of medical records from patients requiring open ethmoidectomy/frontoethmoidectomy as a primary surgical treatment for complicated sinonsasal disease in a tertiary care facility. A database search was carried out based on ICD-9 and CPT codes for complicated rhinosinusitis and frontoethmoidectomy. Inclusion criteria include patients presenting with sinonasal/intraorbital/intracranial complications of rhinosinusitis, who underwent primary surgical treatment via open ethmoidectomy/frontoethoidectmy. Patients who underwent solely an endoscopic treatment were excluded.

SUMMARY OF RESULTS:
Of the 229 selected patients, 223 were excluded, resulting in a total of six patients for analysis. The overall success rate of this case series for External Frontoethmoidectomy was 83%. No major surgical complications resulted. There was one minor complication involving persistent disease. All patients were satisfied with the cosmetic results of the surgery with no scar revision procedures needed. Mean total follow-up time was 6.70 years postoperatively (9 months 9.35 years).

CONCLUSIONS:
For a highly select subset of sinonasal pathology, an open- or combined-approach could be used for the treatment of complicated rhinosinusitis. Our recommended indications for an open or combined approach include: 1) Cases where the ability to obtain endoscopic access was difficult, 2) Disease processes distant from the immediate vicinity of the sinus cavities, as well as 3) Highly selected cases with skull based extension. Graduating residents are generally well experienced and proficient in the endoscopic technique. Given the infrequency with which External Frontoethmoidectomy is performed, a less robust and more heterogeneous comfort level may exist with regards to performing an external approach. Experienced Otolaryngologists must make an effort in training the next generation of surgeons the appropriate indications and techniques for external management of sinonasal disease. Therefore, we must be sure to keep the External Frontoethmoidectomy in our armamentarium and not disregard its usefulness or consider it the ultimate failure in an attempt to accomplish a successful endoscopic outcome.

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