Uncinate Process

Babak Saedi
Associate Professor of Department
of Otolaryngology
Tehran University of Medical
Uncinate process
 Agger Nasi
Cribriform Plate
 Lamina papyracea
 Fovea ethmoidalis
Anatomic Variations
Wormald PJ 2008
A common reason for ESS failure is
inadequate removal of cells
obstructing the outflow of the frontal
Single Agger Nasi Cell Without Frontal Cells
Wormald PJ 2008
Single Agger Nasi Cell Without Frontal Cells
Wormald PJ 2008
Single Agger Nasi Cell Without Frontal Cells
Wormald PJ 2008
Transition From Frontal Sinus To Frontal Recess
Wormald PJ 2008
Frontal Cells
Kuhn FA 1994
Frontal Cells
Type I - Single cell above the agger nasi
 Type II - Two or more cells above the
agger cell
 Type III - Single cell extending from the
agger cell into the frontal sinus
 Type IV - Isolated cell within the frontal
Surgical Indications
Chronic sinusitis unresolved with
maximal medical therapy;
 Polyps and allergic fungal sinusitis
 Intracranial complications of sinusitis
 Mucoceles or mucopyoceles
 Benign neoplasms such as osteomas,
inverting papillomas, or fibrous
Finding The Frontal Recess
Finding The Frontal Recess
Endoscopic Frontal Sinusotomy
Understand the
patient’s frontal
recess anatomy
Ascertain the
anatomical reason
for frontal
recess/frontal sinus
Determine the best
surgical approach to
the problem
Endoscopic Frontal Sinusotomy
Dissection should be
performed from posterior to
anterior and from medial to
Preserve all frontal recess
mucus membrane
The frontal ostium can be
stented or left alone!!!!
Kuhn FA 2006
Draf Procedures
Draf I
Anterior ethmoid cells
 Uncinate process
 Obstructing frontal cells
Draf II
Floor of the frontal sinus
 Lamina papyracea to Septum
 Anterior face of Frontal
Draf III
Modified Lothrop
 Interfrontal septum
 Nasal septum
 Frontal sinus floor
Surgical Outcomes Following the
Modified Lothrop Procedure
Conclusion: EMLP is a safe and
effective surgical alternative to OPF
for patients with recalcitrant frontal
sinus disease. Major complications are
rare. A large percentage of patients
may require revision surgery
Laryngoscope, 117:765–769, 2007
Frontal Sinus Trephination
Finding the frontal recess
 Mucoceles
 Isolated Type IV frontal cells
 With endoscopic techniques to assist
with Draf II and III
Combined Approaches
Endoscopic Frontal Sinoplasty
The least invasive
It can be used as a
stand-alone procedure
or with ethmoidectomy
It pushes the medial
agger nasi cell wall
laterally and the
ethmoid bulla lamella
Kuhn FA 2006
Modified Lothrop
Frontal Recess & Frontal Beak
Wormald PJ 2008
Osteoplastic Flap Vs. Draf III
Narrow Nasal Airway
Small Frontal Sinus
Deep Nasion
Floor of sinus < 1.5 cm
Heavy thick nasofrontal beak
Proliferative osteitis, complicated chronic
Favor Draf III for mucoceles
Osteoplastic Flap Vs. Draf III
The frontal osteoplastic flap: does it still have
a place in rhinological surgery
The frontal osteoplastic flap still has a
role in frontal sinus surgery.
The Journal of Laryngology & Otology (2011), 125, 162–168.
Osteoplastic Flap
May be modified to
fit the patient
Osteoplastic Flap Approach
Osteoplastic and
endoscopic (above
and below
Frontal sinus
Wynn R, et al 2007
Riedel's Procedure
Osteomyelitis of the anterior wall of the
frontal sinus
 Failure of frontal sinus obliteration
 Some tumors of the frontal sinus
Pearl #1 Carefully Examine the Anatomy in
more than one CT plane
Size of the frontal recess
 Size of the frontal sinus
 Bony thickening or neo-osteogenesis
 Identify the frontal sinus drainage
 Note the position of the anterior
ethmoidal artery
Pearl # 2 Identify the Anterior
Ethmoidal Artery
Superior extension of anterior wall of
 Nipple on the medial orbital wall
 1-4 mm’s below skull base
 Typically posterior to supraorbital
ethmoid cells
Pearl #3: Plan the least invasive
approach possible
Ethmoidectomy with Middle Meatal
Antrostomy without frontal recess surgery
Frontal recess surgery
Endoscopic frontal sinusotomy
Frontal sinus trephination
Unilateral extend frontal sinus surgery
(Draf II)
Endoscopic Modified Lothrop (Draf III)
Osteoplastic flap with or without obliteration
Pearl #4 Positively Identify the Skull
Base Posteriorly
Skeletonize from posterior to anterior
 Open cells immediately posterior to the
middle turbinate
 Identify the sinus with a seeker
Pearl #5 Positively identify the frontal
sinus with a probe
Need a relatively dry field
 45 degree telescopes are helpful
 Identify medial orbital wall and stay
close to it dissecting superiorly
 Opening to frontal sinus typically medial
 Identify opening with a probe
Pearl # 6 Preserve the Mucosa
Consider leaving polyps if sinus is open
 Remove osteitic intersinus septae carefully
 Do not traumatize unless sinus can be
opened widely
 Standard frontal sinusotomy
 Draf Type II
 Works well if you can:
○ Preserve mucosa
○ Remove bony partitions
○ Create an ostium >4-5 mm
Pearl #7 Keep the Sinus Open
Remove fibrin and blood from frontal
recess and frontal sinus
 Remove residual bone
 Antibiotics, topical steroids?
 Oral Steroids?
Very little evidence based medicine
 Do the least invasive procedures first
 Be aware of various surgical options
 Image guidance a valuable tool
 First do no harm

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