Utilityofimage-Guidance Infrontalsinussurgery: Gretchen M. Oakley,, Henry P. Barham,, Richard J. Harvey

Utility of Image-Guidance
in Frontal Sinus Surgery

a, c a,b,1
Gretchen M. Oakley, MD *, Henry P. Barham, MD , Richard J. Harvey, MD, PhD
KEYWORDS
Frontal sinus Frontal Sinusitis Rhinosinusitis Image guidance Navigation
KEY POINTS
Image guidance is a surgical tool that is widely accepted by endoscopic surgeons and
used in most frontal sinus surgeries.
The use of image guidance can help identify critical structures and distorted anatomic
landmarks, increasing the surgeon’s confidence and ability to perform a more complete
dissection.
Image-guided placement of limited external frontal sinusotomy allows access to and man-
agement of frontal sinus disease that is beyond the endoscopic reach while avoiding the
need for an osteoplastic flap.
BACKGROUND ON IMAGE GUIDANCE IN ENDOSCOPIC SINUS SURGERY
The use of image-guided surgery (IGS) in endoscopic sinus surgery (ESS) has
expanded during the last 2 decades. A 2010 survey of American Rhinologic Society
members1 suggests that more surgeons have access to IGS and are using this tech-
nology in a greater percentage of cases compared with a similar survey conducted
in 2005.2 With respect to frontal sinus procedures, 71% of respondents thought
there was a relative or absolute indication for its use in primary frontal sinus explo-
ration, 96% in revision frontal sinus exploration, and 98% in modified Lothrop
Disclosure Statement: R.J. Harvey has served on an advisory board for Schering Plough and
GlaxoSmithKline; has acted as a consultant for Medtronic, Olympus, and Stallergenes; has
served on the speakers bureau for Merck Sharp Dohme and Arthrocare; and has received
grant support from NeilMed Pharmaceuticals. G.M. Oakley and H.P. Barham has no conflicts
of interest to declare pertaining to this article.
a
Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of
New South Wales, 405 Liverpool St, Sydney, NSW 2011, Australia; b Faculty of Medicine and
Health Sciences, Macquarie University, Building F10A, Ground Floor, 2 Technology Pl., Sydney,
NSW 2109, Australia; c Department of Otolaryngology Head and Neck Surgery, Louisiana State
University, 433 Bolivar St, New Orleans, LA 70112, USA
1
Present address: Ground Floor, 67 Burton Street, Darlinghurst, New South Wales 2010,
Australia.
* Corresponding author. Ground Floor, 67 Burton Street, Darlinghurst, New South Wales 2010,
Australia.
E-mail address: gmoakley@gmail.com
Otolaryngol Clin N Am 49 (2016) 975–988

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976 Oakley et al
procedures.1 Although it is well known that IGS is not a substitute for sound
anatomic knowledge and clinical decision-making,3 it may help minimize the risk
of injury by verifying the location of vital structures surrounding the paranasal si-
nuses and assist in a more complete clearance of disease. Logically, this would
translate into fewer surgical complications and improved patient outcomes, the
former of which was a conclusion of a recent meta-analysis of surgical cohorts
with and without IGS in sinus surgery.4
Complication rates for ESS have been reported to range from 0.36% to 3.1%.5–7
Although all aspects of ESS can present challenges, surgery of the frontal sinus is
the most technically demanding. The complex and varied anatomy, acute nasofrontal
angle, and proximity to critical structures, such as the olfactory fossa, skull base,
vascular structures (anterior ethmoid artery), and orbit contribute to the technical dif-
ficulty of frontal recess surgery. In addition, distorted anatomy from chronically
inflamed mucosa and absent anatomic landmarks from prior surgery only add to
the potential risk. However, IGS has uses well beyond simply avoiding complications.
It can facilitate identifying the appropriate location for an external frontal trephine (or
minitrephine), mapping an osteoplastic flap, or defining the extent of nasofrontal
beak exposure before Draf III sinusotomy. Some procedures, such as an image-
guided external biopsy of lateral frontal sinus disease, depend entirely on the IGS
technology.
Image-guidance systems typically used in ESS can be either optically based
or electromagnetic-based, and consist of a computer workstation, tracking system,
and specially designed navigation instruments (Fig. 1). The patient’s image-
guidance compatible computed tomography (CT) scan, usually an axial
noncontrast CT with 1 mm or thinner cuts, is loaded into the system either by
CD-ROM or over a broadband network preoperatively. Once the image guidance
is registered to the patient, intraoperative localization of a given navigation
instrument is displayed in real time on the patient’s preoperative CT in axial,
Fig. 1. Standard image guidance system used in ESS (A) with associated instrumentation (B).
Utility of Image-Guidance in Frontal Sinus Surgery 977
coronal, and sagittal planes (Fig. 2). Image-guidance accuracy has been shown
to be within 2 mm8 and a variety of frontal sinus navigation instruments have
been developed to make it well suited for this type of surgery. Although
excellent for general localization or reorienting the surgeon, they are not accurate
enough to help with submillimeter decision-making around critical skull base
anatomy.
UTILITY OF IMAGE GUIDANCE IN ENDOSCOPIC SINUS SURGERY
Several studies directed at IGS use in ESS have been performed to analyze its asso-
ciated complication rate, revision rate, patient quality of life outcomes, cost, and medi-
colegal role.4,6,8–16
Complications
In an evidence-based review with recommendations (EBRR) by Ramakrishnan and
colleagues,13 6 studies reported complication rates in IGS compared with non-IGS
Fig. 2. Standard image guidance real-time view. The location of the tip of the probe is
shown on the patient’s preoperative CT scan in all 3 planes.
978 Oakley et al
groups. Four of the 6 studies showed no statistically significant difference in compli-

cation rates with IGS,11,15–17 whereas 2 studies did show a significant difference in
major complications with IGS use. One of these studies showed fewer major compli-
cations with IGS use (intracranial injury, orbital injury, major hemorrhage, and aborted
procedure) but no difference in minor complications (not specifically defined),10
whereas the other actually showed an increased rate of orbital injuries with the use
of IGS but no other significant differences.6 There was determined to be a preponder-
ance of benefit versus harm based on C-level quality of evidence, making the use of
IGS for the reduction of complications an option. In a meta-analysis of 13 relevant
studies, including 5 of the 6 studies in the previously mentioned EBRR, Dalgorf and
colleagues4 reported that the rate of major complications and total complications
did favor the use of IGS with statistical significance when the data was pooled.
Revision Rate
In a retrospective review of 120 subjects who underwent ESS with use of IGS, 16.5%
of subjects went on to require revision surgery, although there was no comparison
group in this study.15 Fried and colleagues10 retrospectively reviewed 160 subjects
and did report a significantly higher need for revision surgery in the non-IGS patient
group than in the IGS group. However, a similarly designed study with 203 subjects
had contradicting findings.11 More recently, 2 separate meta-analyses found no signif-
icant difference in subsequent revision rates with or without the initial use of IGS.4,14
Quality of Life Outcomes

Three studies compared subject quality of life outcomes after ESS with or without the
use of IGS. One retrospective chart review found no difference in Sino-Nasal Outcome
Test (SNOT)-20 scores at least 6 months after surgery.15 Two prospective, non-
randomized studies found conflicting results, 1 with improved Rhinosinusitis Outcome
Measure (RSOM)-31 scores 6 months after IGS and the other with no difference in vi-
sual analog scale (VAS) scores 12 months after IGS.12,16 Although these studies show
varied results individually, when their data were pooled by Dalgorf and colleagues4
there was no evidence of a significant difference in quality of life outcomes whether
or not IGS was used.
Cost and Medicolegal Concerns

The cost of IGS is an accumulation of the navigation system, disposable supplies or
equipment costs, and any added operative time. One study reported that in otherwise
similar subject groups, IGS was 6.7% more expensive than non-IGS.11 They noted,
however, that significant intangible benefits of this surgical adjunct may justify its
use despite the increased cost but be too difficult to illustrate.
With respect to medicolegal situations, whether or not IGS was used did not play a
role in ESS litigation initiation or outcomes from 2004 to 2013.9 Case-specific factors
and expert opinion from the operating surgeon should determine whether or not the
cost and extra setup time is justified, instead of a habitual practice of defensive
medicine.
The literature illustrating advantages or disadvantages of IGS is very limited. For
example, to show a statistical difference in complication rate with IGS, power analyses
have indicated that thousands of subjects would need to be enrolled in a prospective
study.16,18 That image guidance is currently widely accepted as being indicated in
certain scenarios based on expert opinion makes future randomized studies (in which
some subjects will be randomized away from IGS use even if the surgeon feels it is
necessary) ethically impossible.19 The American Academy of Otolaryngology–Head
and Neck Surgery endorses the use of IGS during ESS in select cases guided by
expert opinion, surgeon preference, and patient-specific factors. These indications
are at the discretion of the surgeon and include revision surgery, distorted anatomy,
extensive sinonasal polyposis, frontal or posterior sinus disease, disease-abutting vi-
tal structures, skull base defects, and neoplasms.20
ENDOSCOPIC USES OF IMAGE GUIDANCE

Maximizing the Frontal Sinusotomy
The frontal sinus and its outflow tract are known for variable anatomy, surrounding vi-
tal structures, and a narrow ostium predisposed to scarring and obstruction following
surgical manipulation. The frontal recess is bordered medially by the middle turbinate,
laterally by the lamina papyracea, anteriorly by the agger nasi cell, and posteriorly by
the superior aspect of the ethmoid bulla along with the anterior ethmoid artery. In addi-
tion to the agger nasi cell anteriorly, there can be 1 or numerous frontal cells that sit
above the agger nasi and pneumatize into the frontal recess, into the frontal sinus,
or be isolated within the frontal sinus (Fig. 3A). Posteriorly and laterally to the frontal
recess, patients can have frontal bullar cells or supraorbital cells that similarly
encroach on the outflow space (Fig. 3B).
Frontal cells, supraorbital cells, and agger nasi cells can all be mistaken for the frontal
recess.21 Chiu and Vaughan22 studied 67 subjects who were undergoing revision frontal
sinus surgery to determine what led to their initial surgical failure and found that 79%
had residual agger nasi and/or ethmoid bulla remnants; 49% had scarring of the frontal
recess, often along with obstructing ethmoid cells or uncinate process (39%); 36% had
lateralized middle turbinate remnants with scarring of the frontal recess; and 12% had
unopened supraorbital ethmoid or frontal recess cells. In addition to careful preopera-
tive planning with review of the patient’s CT imaging, intraoperative image guidance can
assist the surgeon in performing a more complete dissection, particularly in the setting
of confusing frontal and supraorbital ethmoid cells.
IGS can help optimize the chances for success by assisting the surgeon in safely
maximizing the final frontal recess dimensions. A completed Draf IIa frontal sinusot-
omy should be bound only by a clean lamina papyracea with no residual partitions,
nasal beak, middle turbinate attachment, and the posterior table of the frontal sinus
should be relatively continuous with the ethmoid roof and cribriform plate (Fig. 4). A
Fig. 3. (A) Sagittal view of a frontal recess that is narrowed anteriorly by the presence of a
type III frontal cell, which sits atop the agger nasi and pneumatizes into the frontal sinus. (B)
This frontal recess is narrowed posteriorly by a large frontal bullar cell, which is a pneuma-
tized bulla lamella that extends into the frontal sinus.
980 Oakley et al
Fig. 4. Intraoperative view of a completed Draf IIa. The limits of dissection are shown,
including lamina papyracea, nasal beak, middle turbinate attachment, and that the poste-
rior table of the frontal sinus should be relatively continuous with the ethmoid roof and
cribriform plate.
Draf IIb will be similar but with the medial border being septum rather than middle
turbinate attachment. A Draf III (modified Lothrop) should have exposed nasal beak
periosteum anteriorly, clean lamina papyracea bilaterally, and first olfactory neuron
posteriorly (see later discussion). Critical structures such as the anterior ethmoid ar-
tery, skull base, and orbit can be verified intraoperatively during these dissections.
This is particularly helpful in cases of dehiscent or low-hanging anterior ethmoid artery,
asymmetric skull base, or dehiscent lamina papyracea (Figs. 5 and 6).
Modified Lothrop Procedure

The modified endoscopic Lothrop procedure is an established technique for manag-
ing recalcitrant inflammatory frontal sinus disease by reinstating drainage through a
common pathway and providing much needed access for topical therapies. This pro-
cedure is also used for treating mucoceles, cerebrospinal fluid (CSF) leaks, and frontal
or anterior skull base tumors. A systematic review with meta-analysis reported a suc-
cess rate of 86% and significant symptom improvement in 82% of subjects following
Fig. 5. Coronal CT scan showing low anterior ethmoid arteries. These are at risk of injury
during frontal recess dissection if the surgeon is not aware of their location.
Fig. 6. Sagittal CT scan showing an asymmetric skull base. The asymmetry is secondary to a
significant bony dehiscence with associated encephalocele.
modified Lothrop.23 Since Professor Draf’s first description of his approach to the
common frontal sinusotomy, the landmarks of a frontal drillout remain unchanged.24
However, endoscopically, the approach varies among surgeons and institutions. Im-
age guidance is used in 80% of modified Lothrop procedures23 to identify critical land-
marks and distorted anatomy, particularly given that this patient population often has
had multiple prior surgeries and ongoing sinonasal mucosal inflammation. Image guid-
ance can be used in this setting to easily mark the site of the septal window (Figs. 7
and 8). The outside-in approach to the modified Lothrop uses fixed landmarks that
are not easily distorted by disease, therefore maintaining easy surgical orientation.25
The first olfactory neuron is a critical landmark to avoid the skull base and preserve
olfactory bearing mucosa.26 Early identification of the periosteum keeps the surgical
field wide and ensures surgeon confidence in the bony removal. This technique leads
to a safe and efficient opening of a wide Lothrop cavity (Fig. 9).
Fig. 7. Intraoperative view of image guidance used for help marking the septal window in
an outside-in modified Lothrop procedure.
982 Oakley et al
Fig. 8. Making the septal window as an initial step in the modified Lothrop procedure. The
first olfactory neuron marks the posterior limit.
EXTERNAL USES OF IMAGE GUIDANCE

Limited or Directed External Sinusotomy
The increasing use of endoscopic approaches for paranasal sinus and skull base dis-
eases has made the need for external approaches less and less common. However,
there are limitations to what can be accessed endoscopically, so external approaches
to frontal sinus disease still play an important role in management of certain disease
processes. Perhaps the most common scenario is in the case of superior or lateral
frontal sinus lesions, frequently mucoceles. Traditionally, these lesions would require
an osteoplastic flap for surgical clearance. Directed external sinusotomy, or frontal
trephination, is a more minimally invasive approach that can provide a portal for endo-
scopes and instruments to access isolated or superolateral lesions that otherwise do
not require the wide access of an osteoplastic flap but cannot be reached from below.
Fig. 9. The final intraoperative view after outside-in approach to modified Lothrop.
Fig. 10. (A) Image guidance to localize a right frontal fibro-osseous lesion. (B) Coronal CT
scan of a lateral right frontal sinus mucocele. (C) Coronal CT scan showing an opacified
type 4 frontal cell. All of these lesions can be accessed via directed external frontal
sinusotomy.
984 Oakley et al
Although surface anatomy can be used for a traditional external sinusotomy approach
through the inferomedial portion of the anterior table of the frontal sinus, the use of im-
age guidance helps mark the site with increased accuracy and can offer trajectory
planning. Some examples of disease for which image-guided external frontal sinusot-
omy has been effective include fibro-osseous lesions, lateral mucoceles, type III or IV
frontal cells (Fig. 10), and frontal recess stenosis or ossification.27
An added benefit of using image guidance is that it allows adjustment of the external
sinusotomy site as needed to precisely target the frontal disease. Incisions can be hid-
den in the lateral brow or a forehead crease to keep cosmesis optimized, while keep-
ing the safety margin high and still avoiding the added morbidity of the traditional
osteoplastic flap (Fig. 11). In addition to allowing access to isolated disease beyond
endoscopic reach or functioning as a portal for a combined above-and-below
approach, a limited external frontal sinusotomy can also provide a direct route for
an intersinus septectomy or even a frontal sinus obliteration if the sinuses are small
enough.
Intersinus septectomy via limited external frontal sinusotomy has been described as
a method to address unilateral frontal sinus disease when endoscopic techniques are
not an option.28,29 Frontal sinus drainage is reinstated by diverting it to the contralat-
eral outflow tract (Fig. 12). Another use of IGS is to localize a posterior table fracture
with associated CSF leak and position an external frontal sinusotomy for the repair.
This technique for CSF leak repair can obviate standard frontal sinus obliteration via
osteoplastic flap or intracranial approach.30,31
Defining the Osteoplastic Flap

If an osteoplastic flap is necessary, image guidance can precisely mark the edges of
the sinus for the bony cuts. Although osteoplastic flap with frontal sinus obliteration
has a high success rate at 93%,32 there is a high risk of complications from the frontal
bony cuts, such as dural exposure, dural injury with CSF leak, and orbital fat expo-
sure.33 The precision with which the sinus margins are identified is important because
overestimating the margins leads to the previously mentioned complications. Alterna-
tively, underestimating and leaving a bony lip makes complete obliteration of mucosa
under the lip difficult and predisposes the patient to a higher risk of subsequent muco-
cele formation. Previously, 6-foot Caldwell radiography and transillumination were the
Fig. 11. (A) Intraoperative view of a directed external frontal sinusotomy incision positioned
in the brow for optimal access and postoperative cosmetic results. (B) Drilling the external
frontal sinusotomy.
Fig. 12. (A) Preoperative and (B) 6 month postoperative coronal CT scans following intersi-
nus septectomy to reinstate frontal sinus drainage through the contralateral outflow tract.
methods used to plan osteoplastic flap cuts. In the former, a radiograph is taken at a
distance of 6 feet from the beam emitter at a 15 to 20 angle from the Frankfort plan,
cut out of the film, sterilized, and placed on the patient’s forehead and used to trace
the frontal sinus.34,35 In the latter, the frontal sinus margin is determined to be at the
Fig. 13. A bicoronal incision is made for the osteoplastic flap approach (A). Image guidance
is secured to the skull and used to identify the frontal sinus margins. The osteoplastic flap is
then drilled (B), and the frontal sinus disease is addressed and the sinus is obliterated (C).
986 Oakley et al
interface between light and dark areas of the frontal bone when shining a light exter-
nally or from the sinuses below.34,36 Carrau and colleagues37 were the first to describe
frontal sinus mapping using image guidance in 1994, and studies comparing the effi-
cacy of image guidance for this purpose with other methods, such as 6-foot Caldwell
radiography and transillumination, have shown image guidance to be the most accu-
rate and quickest34,38,39 (Fig. 13).
SUMMARY
Image guidance is a surgical tool that helps verify vital structures and manage disori-
enting surgical conditions. Although it does not replace sound knowledge of anatomy,
critical decision making, or technical expertise, it can improve surgeon confidence in
performing safer surgery and more completely clearing disease. It has a variety of ap-
plications in endoscopic and external approach sinus surgery, and has contributed to
the expanding role of endoscopic surgical approaches for paranasal sinus inflamma-
tory and neoplastic disease.
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Utility of Image-Guidance

in Frontal Sinus Surgery

BACKGROUND ON IMAGE GUIDANCE IN ENDOSCOPIC SINUS SURGERY

Otolaryngol Clin N Am 49 (2016) 975–988

UTILITY OF IMAGE GUIDANCE IN ENDOSCOPIC SINUS SURGERY

groups. Four of the 6 studies showed no statistically significant difference in compli-

Quality of Life Outcomes

Cost and Medicolegal Concerns

ENDOSCOPIC USES OF IMAGE GUIDANCE

Modified Lothrop Procedure

EXTERNAL USES OF IMAGE GUIDANCE

Defining the Osteoplastic Flap

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