History of frontal sinus surgery

The first frontal sinus surgical procedure was first described in 1750. Despite more than 2 centuries since the description of the procedure on frontal sinus, the optimal procedure is still not clear. Frontal sinus disease could be highly morbid with the danger of life threatening complications, because of its anatomic proximity to anterior skull base and orbit.

“Surgical treatment of chronic frontal sinusitis is difficult, often unsatisfactory and sometimes disastrous” Ellis 1954.

Aims of ideal treatment modality of frontal sinus disease are:

1. Eradication of underlying disease process
2. Preservation of function of the sinus
3. To cause least morbidity and cosmetic deformity.

Historically the ideal surgical procedure has been flip flopping from External to intranasal. With the recent advancement in imaging techniques and nasal endoscopes, Endoscopic frontal sinus surgery is becoming really popular these days. Resolution and details provided by modern imaging modalities have gone a long way in reducing the potential surgical complications of endoscopic surgery.

History of frontal sinus surgical procedures can be divided into following era:

Era of trephination (1750):

Frontal sinus surgery was first described in 1750. It was in 1884 Alexander Ogstun described a trephination procedure where an opening was made in the anterior table of frontal sinus to evacuate the sinus cavity. He also dilated the naso frontal duct and curetted its mucosa. He believed this procedure could facilitate better drainage from the frontal sinus. He advocated placement of drainage tube inside the naso frontal duct to prevent stenosis.

It was about the same time Luc described a similar procedure. This procedure was aptly known as Ogstun Luc procedure. This procedure failed commonly because of increased incidence of nasofrontal duct stenosis.

Alexander Ogstun

Era of radical ablation procedures (1895):

Kuhnt in 1895 described a procedure where in he removed the anterior wall of frontal sinus in an attempt to clear the frontal sinus of the diseased mucosa. He stripped the mucosa up to the frontal recess and stented the frontonasal duct to improve the drainage. In 1898 Riedel performed obliteration of frontal sinus. He advocated complete removal of anterior table and floor of frontal sinus with stripping of mucosa. He performed this procedure in a patient with osteomyelitis of frontal bone. This procedure caused an unsightly deformity of skull. Killian in 1903 advocated retention of 1 cm bar of supraorbital rim. Killian was able to avoid deformity by retaining this bar of bone. Killian also advocated ethmoidectomy combined with rotation of mucosal flap to cover the frontal recess area. Killian’s procedure was fraught with complications like Restenosis, supraorbital rim necrosis, post op meningitis, mucocele formation etc.

Era of conservative procedures (1905):

Major advantage of conservative procedure is avoidance of cosmetic defects. Conservative procedures involved intranasal approach to frontal sinus. It was Knapp in 1908 who performed external Fronto ethmoid surgery. He approached the frontal sinus through its floor, removed the diseased mucosa and stented the Fronto nasal duct to prevent Restenosis.

In 1908 Halle chiseled out the frontal process of maxilla and used a burr to remove the floor of frontal sinus.

In 1914 Lothrop enlarged the frontal sinus drainage pathway using intranasal approach. He combined intranasal ethmoidectomy with external ethmoidal approach. He managed to create a common frontal nasal communication by removing the frontal sinus floor, intersinus septum and the superior portion of nasal septum. He also said that resection of medial orbital wall caused prolapse of orbital contents into the ethmoid area causing obstruction to frontal sinus drainage.

External frontoethmoidectomy 1897 – 1921:

In 1897 Jenson performed the first external Fronto ethmoidectomy in Germany. Lynch and Howarth in 1921 popularized resection of floor of the frontal sinus with dilatation of the frontal sinus outlet via external approach. This approach is hence known as Lynch Howarth procedure. A curvilinear incision is made just below the medial end of eyebrow. It is curved medial to the medial canthus. The frontal process of maxilla and lamina papyracea is removed. Frontal sinus is entered via its floor and the lining mucosa is curetted. A stent is placed in the frontal sinus ostium to prevent stenosis. The stent is left in place for a period of 4 weeks. Boyden used silicone tube to prevent stenosis.

Figure showing Lynch Howarth incision

Osteoplastic anterior wall approach (1058):

This procedure became popular during 1960’s. Backer introduced radiographic plate to outline the frontal sinus. This procedure was fraught with the risk of hemorrhage.

Endoscopic intranasal approach:

With the advent of nasal endoscopes (angled) approach to the frontal sinus outflow tract has become easy.

Figure showing endoscopically widened frontal sinus outflow tract