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Describe the Bent Kuhn classification of frontal cells.
- Type I - single frontal sinus cell above agger cell and below frontal sinus
- Type II - over 1 cell in frontal recess above agger cell and below frontal sinus
- Type III - large single cell pneumatizing cephalad into the frontal recess
- Type IV - single isolated cell in the frontal sinus
What is the volume of the maxillary sinus at birth?
At what age may the sphenoid begin to pneumatize?
2 years. Matures by 14 years.
What percentage of adults have an aplastic frontal sinus?
- 15% unilateral
- 5% bilateral
Describe the most common pediatric immunodeficiencies which can lead to recurrent bacterial rhinosinusitis.
- Transient hypogamma-globulinemia of infancy
- IgG subclass deficiency
- Impaired polysaccharide responsiveness (partial antibody deficiency)
- Selective IgA deficiency
What is the nasal nitric oxide measurement and how does it relate to pediatric sinusitis?
- Produced by paranasal sinus epithelium.
- Contributes to local host defense, modulates ciliary moility and helps to maintain adequate ventilation/perfusion matching in the lung.
- Reduced values of nasal NO (nNO) have been reported in acute and chronic sinusitis, cystic fibrosis, primary ciliary dyskinesia, and nasal polyps.
What is the initial recommended surgical procedure for children with chronic pediatric rhinosinusitis? What is the efficacy of this procedure?
- Meta-analysis of 9 studies looking at adenoidectomy for rhinosinusitis
- 69.3% of patient have significant improvements post-op as measured by cough, rhinorrhea, post-nasal drip, and congestion.
- authors strongly recommended adenoidectomy as the initial surgical procedure for children with chronic rhinosinusitis.
When should you consider treating a child with acute bacterial rhinosinusitis?
Consider treating only Severe ARS (Presence of high fever and purulent nasal discharge for minimum of 3-4 days) or persistent ARS (symptoms that last >10-14 days).
What antibiotics are recommended as first line treatment in children with acute rhinosinusitis? What antibiotics are typically recommended if the first line treatment fails?
amoxicillin, as it is generally effective, has narrow spectrum of activity, relative safety, and low cost. Standard dosing is 45mg/kg BID, which can be increased to 90mg/kg BID if other risk factors or resistance present.
What is the cystic fibrosis transmembrane conductance regulator (CFTR)?
- CFTR functions as a regulated chloride channel, which, in turn, may regulate the activity of other chloride and sodium channels at the cell surface.
- CF causes abnormal transport of sodium and chloride ions which manifests as disordered cilia motility and impaired mucociliary clearance.
- The disease leads to chronic sinus and pulmonary infections which are the main source of morbidity and mortality in patients with CF.
What is the likelihood that a CF patient has radiologic evidence of sinus disease?
Although 90-100% of patients have radiologic evidence of sinus disease, the frequency of nasal polyposis is quite variable and may be found in 6-67% of patients. Clinically symptomatic sinusitis is found in only about 10% of patients with CF.
What bacteria typically are found in the sinuses of cystic fibrosis patients? Does the type of bacteria found relate to the age of the patient?
- Staph. aureus is the most common isolate found in the maxillary sinuses in children with CF, followed by P. aeruginosa and H. influenzae.
- The most common pathogen cultured in the sinuses of adults with CF is Pseudomonas aeruginosa
What is the role of FESS in CF patients?
- Studies show improvement in sinus symptoms and exercise tolerance after FESS
- improvement in overall quality of life.
- FESS seems reasonable in cystic fibrosis patients with significant sinus disease to improve quality of life and facilitate application of topical antibiotics.
- Controversy remains regarding the timing.
How would you differentiate between the natural and accessory maxillary Ostia?
The natural ostium is elliptical and accessory ostia are round and present in 10% of patients.
Where does the sphenoid ostium drain?
The ostium opens into the sphenoethmoid recess that lies posterior to the superior turbinate.Sphenoid ostium is located approx halfway up the anterior wall of the snius, and is medial to the posterior end of the superior turbinate in 83% of cases.
Describe the anatomy of the anterior skull base.
Comprises the cribriform plate medially. The lateral lamella of the cribiform plate joins the fovea ethmoidalis, which extends laterally to form the roof of the ethmoid sinuses. The lateral lamella is considerably thinner than the ethmoid roof.
Review the embryology of the paranasal sinuses.
- Frontal sinus: does not appear until 5-6 years of age, usually about 4-7ml in volume by 12-20 yrs old
- Maxillary sinus: first to develop in utero, biphasic growth at 3 and 7-18 yrs, 15ml in vol
- Ethmoid sinus: 3-4 cells at birth, around 10-15 aerated cells, total volume of 2-3ml. reach adult size at 12-15 years
- Sphenoid sinus: evagination of nasal mucosa into sphenoid bone, 0.5-8ml in volume, reaching adult size around 12-18 years
Frontoethmoid cells that don't fall into the Bent-Kuhn classification
- Supraorbital ethmoid cell
- Suprabullar cell
- Frontal bullar cell (anterior wall extends into the frontal sinus)
- Interfrontal sinus septum
What is a Draf I?
Endoscopic procedure designed to drain the frontal sinus. A Draf I removes the uncinate and anterior ethmoid cells around the frontal recess.
What is a Draf II procedure?
Endoscopic procedure designed to drain the frontal sinus. A Draf II removes the uncinate and anterior ethmoid cells (as in Draf I) plus the anterior face of the frontal recess and floor of the frontal sinus.
What is a Draf III (modified Lothrop procedure)?
Used for the most severe forms of chronic frontal sinusitis where osteoplastic flap with obliteration is the only alternative. In addition to the Draf II, this procedure involves removal of the inferior portion of the interfrontal septum, the superior part of the nasal septum, and the frontal sinus floor to the orbit laterally.
Indications for osteoplastic flap and frontal sinus obliteration?
- chronic frontal sinusitis refractory to endoscopic surgery
- severe trauma with fractures involving the drainage pathways
- resection of large frontal tumors near the frontal recess
Risks of frontal sinus obliteration
- Failure rate of 6-25%
- frontal bossing
- supraorbital neuralgia
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