See the corresponding editorial in this issue, pp J Neurosurg 116: , 2012

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1 See the corresponding editorial in this issue, pp J Neurosurg 116: , 2012 Cranialization of the frontal sinus the final remedy for refractory chronic frontal sinusitis Clinical article J. Marc C. van Dijk, M.D., Ph.D., 1 Michiel Wagemakers, M.D., 1 Astrid G. W. Korsten-Meijer, M.D., Ph.D., 2 C. T. Kees Buiter, M.D., Ph.D., 2 Bernard F. A. M. van der Laan, M.D., Ph.D., 2 and Jan Jakob A. Mooij, M.D., Ph.D. 1 Departments of 1 Neurosurgery and 2 Otorhinolaryngology/Head and Neck Surgery, University Medical Center Groningen, University of Groningen, The Netherlands Object. Chronic sinusitis can be a debilitating disease with significant impact on quality of life. Frontal sinusitis has a relatively low prevalence, but complications can be severe due to its anatomical location. After failure of conservative measures, typically endoscopic procedures are performed to improve the drainage of the frontal sinus. The cranialization of the frontal sinus is the final surgical measure, in which the affected frontal sinus is truly removed. In this study the authors describe the surgical technique of cranialization of the frontal sinus for refractory chronic frontal sinusitis, systematically search the literature for its application, and assess patient satisfaction in a cohort of consecutively treated patients after long-term follow-up. Methods. A consecutive cohort of 15 patients with refractory chronic frontal sinusitis was treated by cranialization of the frontal sinus and followed over a 20-year period ( ) for the direct results and complications of the surgery. Long-term follow-up (mean 6.5 years) was obtained to assess the long-term effects of the cranialization. Results. In all patients the signs and symptoms of chronic frontal sinusitis responded very well to the cranialization. Five patients had surgical complications, of which 2 were serious. One patient died of an unrelated cause and 1 patient was lost to follow-up. The remaining 13 patients had a long-term follow-up, which revealed that 12 of them thought that their life was better after the surgical procedure. Conclusions. Cranialization of the frontal sinus deserves consideration as the final remedy for refractory chronic frontal sinusitis after definite failure of other options. (DOI: / JNS101849) Key Words frontal sinus cranialization craniotomy chronic sinusitis endoscopic failure infection Chronic sinusitis can be a debilitating disease that has a significant impact on quality of life. In comparison with other chronic diseases, such as congestive heart failure, angina, chronic obstructive pulmonary disease, and back pain, these patients suffer more from their medical condition in all domains of life, including bodily pain, general health, vitality, and social functioning. 5,13 In the Netherlands, each year more than 9000 hospital admissions are registered for chronic sinusitis (see Hospital admissions for chronic sinusitis , [Accessed November 29, 2011]). Consequently, the disease also has socioeconomic influences. No specific epidemiological data about chronic frontal sinusitis are known, but in a study by Gordts et al. 6 this disease was reported to have a prevalence of 2% on MR imaging in a non-ent population. Nevertheless, Abbreviation used in this paper: ENT = ear, nose, and throat. the impact of frontal sinusitis and its complications can be severe due to its proximity to the intracranial cavity. 2,8 The treatment of chronic frontal sinusitis is at first conservative, with a combination of antibiotics, nasal decongestants, and nasal steroids. If this strategy fails, however, surgical measures are indicated. Typically, the primary surgical step is a transnasal endoscopic approach to regain ventilation of the frontal sinus. Because the anterior ethmoid is the key region in the cure of frontal sinusitis, an endoscopic ethmoidectomy is the initial procedure. If necessary, this is done in a stepwise manner followed by more extensive endoscopic drainage techniques, eventually leading to a frontal sinus drill-out. 11 Nevertheless, unfortunately ostial restenosis regularly occurs. The frontal sinus is the most difficult paranasal sinus to reach with an endonasal technique, because it has a funnel-shaped entrance that is often not straight and that has a variable direction dependent on the patient s 531

2 J. M. C. van Dijk et al. anatomy, which can be at a right angle to a transnasally introduced instrument. Therefore, in the past numerous external approaches to the frontal sinus have been developed. A drastic example is the Lynch procedure (1931) that consists of an external ethmoidectomy with resection of the anterior part of the middle turbinate through an incision in the medial canthal area, followed by excision of the floor of the frontal sinus and placement of a (temporary) stent in the nasofrontal connection. Nowadays, as a last attempt, an osteoplastic frontal sinus exploration (osteoplastic flap procedure) is often recommended, in which the anterior wall of the frontal sinus is temporarily removed, followed by the meticulous removal of the mucosa and optional packing of the sinus cavity with fat, using either a coronal or an eyebrow incision. 16 Among rhinologists there is an ongoing debate about the efficacy and utility of obliteration of the frontal sinus in this manner. Nevertheless, this technique is a valuable open surgical adjunct in the treatment algorithm for refractory chronic frontal sinusitis. This paper describes the cranialization of the frontal sinus as an open surgical alternative to the above-mentioned procedures. The surgical technique is outlined, and the results, complications, and patient satisfaction after long-term follow-up are analyzed in a consecutive series of patients treated at a single tertiary referral hospital. Methods A systematic literature review was performed, searching Internet databases PubMed and Embase (up to March 2008) with the key words ( frontal sinus OR paranasal sinus ) AND ( craniotomy OR cranialization ) AND ( chronic sinusitis ). Additionally, the reference sections of relevant papers were scrutinized for other related titles. All languages were considered. Surgical Technique The surgical technique for cranialization of the frontal sinus by a craniotomy was described in 1978 by Donald and Bernstein 3 in their report on the management of compound frontal sinus penetration with intracranial injury. They quickly noticed that it was a durable technique, without the occurrence of bone absorption or infection, which were supposed to be expected in that era. This was further confirmed by the report of van Dijk and Thomeer, 14 which described the midfrontobasal craniotomy for treatment of midline lesions of the anterior and middle fossae. The procedure is started with a lumbar puncture to remove approximately 50 ml of CSF. This procedure lowers the intracranial pressure and subsequently facilitates the intended overview of the anterior skull base. A coronal incision is made behind the hairline, and a separate pericranial vascularized flap is obtained from the forehead. Three 6-mm bur holes in a triangular arrangement are connected using the craniotome or for cosmetic reasons preferably the Gigli saw (Fig. 1). Both basal bur holes are placed as far laterally as necessary to comprise the Fig. 1. Drawing showing the triangular midfrontobasal bone flap, containing the frontal sinus, seen from the inside. lateral borders of the frontal sinus. The upper bur hole is placed in the midline over the superior sagittal sinus, well above the rostral border of the frontal sinus. Although drilling over the sagittal sinus was avoided in earlier times, in practice this never leads to injury to the superior sagittal sinus. The use of frameless stereotaxy can be of assistance in the exact placement of the bur holes. Great care is taken to free the dura mater undamaged from the posterior wall of the frontal sinus with dissectors, to avoid CSF leakage. The (infected) frontal sinus is, therefore, for the most part contained within the bone flap. This approach yields a panoramic perspective over the basal part of the frontal sinus that frequently extends over the orbital roofs in small niches. The overview is important, because it is vital that all mucosa is meticulously removed from the entire frontal sinus to avoid late postoperative complications, such as a mucocele. This is done with a high-speed diamond drill. All recesses are widely opened and the posterior wall of the frontal sinus is removed, also from the bone flap. After inversion of the mucosa of the frontal sinus outflow tracts into the nasal cavity, both tracts are blocked with a vascularized strip of pericranium or temporal muscle, which is sealed with fibrin glue. The remaining vascularized pericranium flap can be laid into the frontal floor as an additional barrier. The bone flap is fixed back into its original position with plates or sutures. Particularly after the use of the Gigli saw, this is easy because of the beveled edges. 15 If there is any cosmetic concern, the bur holes can be filled with bone cement. At the end of the procedure, the frontal 532

3 Cranialization for chronic frontal sinusitis sinus no longer exists and has become a part of the intracranial cavity. No postoperative antibiotic therapy is administered. The cohort described in this paper consists of a consecutive series of 15 patients, all of them treated for refractory chronic frontal sinusitis by a cranialization of the frontal sinus performed at University Medical Center Groningen in the Netherlands over a 20-year period ( ). The following data were collected: patient age and sex, current complaints and comorbidity, previous medical and surgical treatment of the frontal sinusitis, results and complications of the cranialization procedure, and postoperative radiological studies. The decision to perform the cranialization was made during a monthly multidisciplinary conference with ENT surgery, neurosurgery, and radiology. The follow-up was accomplished in both the ENT surgery and neurosurgery outpatient clinic. In 2008, a survey was conducted to obtain long-term follow-up and to assess the satisfaction of the patients with the surgery. The patients were requested to score the overall effect of their frontal sinus complaints on their quality of life, comparing their present state of health to their preoperative state. Results The Internet database query in PubMed and Embase revealed 18 papers, which were published between 1976 and Based on the abstracts, 2 relevant papers about cranialization of the frontal sinus for infectious reasons could be identified, one by Ameline et al. 1 and the other by Rinehart et al. 10 A further search performed by analyzing the reference sections of both papers revealed an additional paper by Lerner et al. 7 about cranialization for frontal sinusitis in childhood. The patient characteristics are summarized in Table 1. The cohort consisted of 15 patients, 10 men and 5 women, with a mean age of 49.4 years (range years). Without exception, the patients had a long history of chronic frontal sinusitis, on average more than 20 years. As a result, all patients had already endured countless antibiotic treatments and had undergone many unsuccessful endoscopic or open surgical therapies. Two patients were treated by osteoplastic frontal sinus exploration without sufficient effect before the cranialization was performed. The surgical procedure of the cranialization through a midfrontobasal craniotomy was well tolerated by all patients. The mean duration of the surgical procedure was 3.5 hours (range hours). The patients were discharged after a mean hospital stay of 9 days (range 5 16 days). Due to increasing efficiency measures on the part TABLE 1: Characteristics in 15 patients with refractory chronic frontal sinusitis Characteristic Value sex ratio (M/F) 10:5 mean age (yrs) 49.4 mean duration of preop complaints (yrs) 20.8 mean op duration (hrs) 3.5 mean hospital stay (days) 9 mean postop follow-up (yrs) 6.5 of the hospital organization, this stay became significantly shorter over the years. The complications encountered are summarized in Table 2. Two complications were considered as serious events: an inadvertent injury to the frontal lobes and a bone flap infection. The course of 2 cases with an epidural pneumocranium was good, without necessitating further surgery. One patient reported transient memory problems after the surgical procedure, although neuroimaging did not support a direct relationship. The memory problems resolved without treatment. No CSF leakage was encountered, despite the fact that the dura mater occasionally had to be repaired during the surgical procedure. At the first surgical follow-up at a mean of 6 weeks, the patients with noncomplicated cases were discharged from the neurosurgical outpatient clinic. The ENT surgeon followed the patients for a longer period, but this was because of the residual complaints of other paranasal sinuses. Just focusing on the signs and symptoms of the frontal sinus pathology, all patients were satisfied with the cranialization, with the exception of the one whose case was complicated by infection of the bone flap. This result was confirmed in 10 patients by a postoperative CT or MR imaging study of the skull. In 2008, a survey was conducted to obtain the surgical outcome after a mean long-term follow-up of 6.5 years (range years). One patient had died of pancreatic cancer during follow-up, and 1 patient was lost to follow-up. The remaining 13 patients could be reached and reported no recurrent frontal sinus problems. Twelve of them responded to the request to assess their current quality of life in comparison with the preoperative situation. Looking back, all but one patient thought their life TABLE 2: Complications in 15 patients who underwent cranialization procedures Complication No. major frontal lobe laceration 1 bone flap infection 1 minor epidural pneumocranium 2 transient memory problem 1 533

4 J. M. C. van Dijk et al. was better after cranialization of the frontal sinus, and the majority declared that they would have wanted the surgery many years earlier if they had known about the possibility. Discussion It is remarkable that although open surgical therapy for infection of the frontal sinus dates from the 18th century, 12 the number of papers about cranialization of the frontal sinus for chronic sinusitis is limited. Most likely this is due to the good results of antibiotic therapy and the popularity of endoscopic techniques. Three papers were identified as relevant in the literature review. At a closer look, though, the paper by Rinehart et al. 10 describes a rather more extensive craniofacial approach, with cranial bone grafting and the application of a vascularized myofascial flap, than the standard cranialization of the frontal sinus used in our patient cohort. The paper by Lerner et al. 7 is not about the treatment of chronic frontal sinusitis either, but reports 4 pediatric cases in which cranialization of the frontal sinus was performed as part of the craniotomy for intracranial complications of acute frontal sinusitis and pansinusitis. This leaves the paper by Ameline et al. 1 as the single identifiable report of cranialization of the frontal sinus as a more or less routine therapy for (refractory) chronic frontal sinusitis. In 2001, they described a series of 19 cranializations over a 13-year period, of which 4 were for cases of chronic frontal sinusitis. Parallel to our experience, in their series the surgical procedure was well tolerated and the dreaded high complication rate of bone flap infections, CSF leakage, and cosmetic problems was not encountered. Nevertheless, and in contrast with the high popularity of cranialization in cases of frontal sinus fractures, the position of cranialization in the treatment algorithm of chronic frontal sinusitis has not been widely accepted so far. The number of cases of cranialization for chronic frontal sinusitis presented in this paper is by far the largest series published in the literature. Still, regarding the 20-year period and the prevalence of frontal sinusitis, the total number of 15 surgical procedures is extremely low. In our institution this is due to the fact that in the treatment algorithm of chronic frontal sinusitis, cranialization is only considered after failure of all conservative measures and ENT surgical possibilities. Two patients endured an osteoplastic flap procedure, without durable success, before the option of cranialization was considered. In the literature and in our experience, the cranialization procedure is well tolerated, yields a high success rate, and carries, particularly in relation to the burden of the disease, an acceptable complication rate. In comparison, a radical endoscopic technique as in the Draf III or the modified Lothrop procedure yields a cure rate of 88% 95%, and complications have been reported in nearly 20% of the cases. 4,17 Cosmetic results of the cranialization procedure are very good, in contrast to some other open surgical approaches to the frontal sinus. For example, the application of the Riedel procedure, 9 in which the anterior wall of the frontal sinus is removed, is not very attractive to patients, particularly in the presence of a large frontal sinus. Nevertheless, in our cranialization series 2 serious complications were encountered (13%). The laceration of the frontal lobe was the result of a vast crista frontalis that caused the guide of the Gigli saw to follow the wrong route when it was shifted between the bur holes. This can be avoided if the anterior wall of the frontal sinus is cut with a craniotome or a reciprocating saw and the (usually thin) posterior wall is gently fractured when taking out the bone flap. The second serious complication was a wound infection that extended toward the bone flap and caused an osteomyelitis. The patient had to undergo another operation, with removal of the bone flap and insertion of an acrylic osteoplasty at a later stage. As minor complications, 2 cases of epidural pneumocranium and 1 case of transient memory problems were encountered. Leakage of CSF, although often mentioned in other series, was not encountered in our study. Long-term follow-up was obtained after a mean period of 6.5 years, confirming the durable result of the cranialization procedure. Only 1 patient reported a decrease in quality of life due to the cranialization procedure, in close relation to an infection of the bone flap; the remaining, vast majority of patients were very satisfied, and would again undergo a cranialization, preferably earlier in the course of treatment. The survey thus confirms that the cranialization of the frontal sinus can be regarded as a reliable treatment method with an acceptable complication rate that yields a very high rate of effectiveness, both in the eyes of the treating physician and in the experience of the patient. Conclusions Cranialization of the frontal sinus by a midfrontobasal craniotomy deserves consideration as the final remedy for refractory chronic frontal sinusitis after definite failure of endoscopic and surgical treatment options, including an osteoplastic flap procedure. Disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. Author contributions to the study and manuscript preparation include the following. Conception and design: van Dijk, Buiter, Mooij. Acquisition of data: van Dijk, Wagemakers. Analysis and interpretation of data: all authors. Drafting the article: van Dijk, Korsten-Meijer, van der Laan. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: van Dijk. Statistical analysis: Wagemakers. Administrative/technical/material support: van Dijk, Wagemakers, Mooij. Study supervision: van Dijk, Buiter, van der Laan, Mooij. 534

5 Cranialization for chronic frontal sinusitis Acknowledgments The authors are thankful to G. S. Poelma, medical student, for her effort in collecting the patient material, as well as to P. van der Maade, medical illustrator, for preparing Figure 1. References 1. Ameline E, Wagner I, Delbove H, Coquille F, Visot A, Chabolle F: [Cranialization of the frontal sinus.] Ann Otolaryngol Chir Cervicofac 118: , 2001 (Fr) 2. Diaz I, Bamberger DM: Acute sinusitis. Semin Respir Infect 10:14 20, Donald PJ, Bernstein L: Compound frontal sinus injuries with intracranial penetration. Laryngoscope 88: , Draf W: Endonasal frontal sinus drainage type I-III according to Draf, in Kountakis SE, Senior BA, Draf W (eds): The Frontal Sinus. Berlin: Springer-Verlag, 2005, pp Gliklich RE, Metson R: The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg 113: , Gordts F, Clement PA, Buisseret T: Prevalence of sinusitis signs in a non-ent population. ORL J Otorhinolaryngol Re l at Sp e c 58: , Lerner DN, Choi SS, Zalzal GH, Johnson DL: Intracranial complications of sinusitis in childhood. Ann Otol Rhinol Lar yngol 104: , Morgan PR, Morrison WV: Complications of frontal and ethmoid sinusitis. Laryngoscope 90: , Raghavan U, Jones NS: The place of Riedel s procedure in contemporary sinus surgery. J Laryngol Otol 118: , Rinehart GC, Jackson IT, Potparic Z, Tan RG, Chambers PA: Management of locally aggressive sinus disease using craniofacial exposure and the galeal frontalis fascia-muscle flap. Plast Reconstr Surg 92: , Samaha M, Cosenza MJ, Metson R: Endoscopic frontal sinus drillout in 100 patients. Arch Otolaryngol Head Neck Surg 129: , Tato JM, Sibbald DW, Bergaglio OE: Surgical treatment of the frontal sinus by the external route. Laryngoscope 64: , Teul I, Zbisławski W, Baran S, Czerwiński F, Lorkowski J: Quality of life of patients with diseases of sinuses. J Physiol Pharmacol 58 (Pt 2 Suppl 5): , van Dijk JM, Thomeer RT: Control of complications in the midfrontobasal approach. Acta Neurochir (Wien) 139: , Van Dijk JM, Thomeer RT: Use of the Gigli saw in performing a mid-frontobasal or pterional craniotomy. Br J Neurosurg 11: , Weber R, Draf W, Keerl R, Kahle G, Schinzel S, Thomann S, et al: Osteoplastic frontal sinus surgery with fat obliteration: technique and long-term results using magnetic resonance imaging in 82 operations. Laryngoscope 110: , Weber R, Schauss F, Keerl R, Draf W: [Osteoplastic surgery of the frontal sinus: indications, procedures and results apropos of 75 cases.] Rev Laryngol Otol Rhinol (Bord) 118:91 94, 1997 (Fr) Manuscript submitted November 1, Accepted November 8, Please include this information when citing this paper: published online December 16, 2011; DOI: / JNS Address correspondence to: J. M. C. van Dijk, M.D., Ph.D., De partment of Neurosurgery, AB71, University Medical Center Gron ingen, PO Box 30001, 9700 RB Groningen, The Netherlands. jmcvandijk@gmail.com. 535