Management of Frontal

S i n u s Tu m o r s
Anne Morgan Selleck, MDa, Dipan Desai, BSa, Brian D. Thorp, MD
a
,
Charles S. Ebert, MD, MPHa, Adam M. Zanation, MDa,b,*

KEYWORDS
 Frontal sinus  Tumor  Endoscopic  Sinonasal malignancy  Draf IIb  Draf III

KEY POINTS
 Accurate diagnosis of tumor type and appropriate staging are crucial to choosing the op-
timum management strategy.
 Considerations in determining the approach to frontal sinus tumors include frontal anat-
omy, tumor location, and tumor attachment sites.
 The endoscopic approaches to the frontal sinus include Draf IIa, IIb, and III procedures.
These procedures are a continuum affording progressive access and exposure.
 The Draf IIb involves resection of the frontal sinus floor between the lamina papyracea and
the nasal septum. The Draf III involves the bilateral removal of the frontal sinus floor
through an anterosuperior septectomy, allowing confluence of the bilateral frontal sinuses.
 Although these tumors can often be approached via endoscopic techniques, surgeons
should always be prepared to use open techniques.

OVERVIEW

Surgical management of frontal sinus tumors has traditionally challenged otolaryngol-

ogists because of the inherently narrow confines of the frontal sinus and its proximity
to critical structures such as the anterior skull base, lamina papyracea, and anterior
ethmoidal artery. Historically, removal of the various tumors that can occupy this
space necessitated an open approach. After early and often morbid attempts at treph-
ination and sinus obliteration, the use of osteoplastic flaps (OPFs), often with sinus
obliteration, became the mainstay of surgical access to the frontal sinus.1,2 Although

Conflict of interest: There are no conflicts of interest in the production of this article.
a
Department of Otolaryngology—Head and Neck Surgery, University of North Carolina at
Chapel Hill, 170 Manning Drive, CB #7070, Physician’s Office Building, Room G-190, Chapel
Hill, NC 27599-7070, USA; b Department of Neurosurgery, University of North Carolina at
Chapel Hill, 170 Manning Drive, CB #7070, Physician’s Office Building, Room G-190, Chapel
Hill, NC 27599-7070, USA
* Corresponding author. 170 Manning Drive, CB #7070, Physician’s Office Building, Room
G-190, Chapel Hill, NC 27599-7070.
E-mail address: adam_zanation@med.unc.edu

Otolaryngol Clin N Am 49 (2016) 1051–1065

http://dx.doi.org/10.1016/j.otc.2016.03.026 oto.theclinics.com
0030-6665/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
1052 Selleck et al

this technique offered effective visualization and bimanual instrumentation, it too had
the risk of morbidity or failure, including potential mucocele formation and loss of bone
flap caused by chronic osteitis. Furthermore, long-term quality-of-life issues such as
frontal bossing or depression and frontal neuralgia remained a possibility.3–6 Through
significant improvements in optical technologies and power instrumentation, the
endonasal endoscopic approach has become a feasible and popular approach to a
variety of paranasal sinus disorders. Many frontal sinus tumors can now be addressed
with endoscopic techniques or via a combined approach.2,7 Although endoscopic ac-
cess to the frontal sinus can be complicated by the variability of frontal recess pneu-
matization, this approach offers significant advantages compared with previous open
approaches. These advantages include decreased need for sinus obliteration, signif-
icantly easier postoperative monitoring, improved cosmetic results, and decreased
morbidity. This article describes the most common tumors that affect the frontal sinus
and discusses the current surgical approaches that best facilitate their removal.

PRIMARY TUMORS
Osteoma
Osteoma is the most common benign tumor of the paranasal sinuses, with a reported
incidence of 0.5% to 3% in the general population.8,9 These tumors are slow growing
and are often discovered as an incidental finding.10 Although osteomas were previ-
ously thought to occur most often in the frontal sinus, a recent study found that
55% of these tumors were located in the ethmoid sinuses, followed by the frontal si-
nuses at 37.5%.11 Possibly because of their slow growth rate, most paranasal oste-
omas are asymptomatic and tend to only cause symptoms when they grow large
enough to compress local structures or obstruct the sinus drainage pathways. Pre-
senting symptoms can vary based on tumor location, but most frequently include fron-
tal headache, facial pain, and chronic sinusitis.10,12 Less commonly, these tumors can
lead to the development of a mucocele or erode nearby structures such as the orbit or
cranium.13–16
Because of their benign course, osteomas that are small and asymptomatic can be
conservatively managed with observation.12 However, specific indications for surgical
intervention have been proposed. Savic and Djeric17 recommended surgery for oste-
omas that are symptomatic, rapidly growing, obstructing the frontal recess, leading to
rhinosinusitis, causing facial deformity, or extending beyond the frontal sinus (Fig. 1).
More recently, Chiu and colleagues18 proposed a frontal sinus osteoma grading sys-
tem to guide decisions regarding appropriate surgical approach. Their system catego-
rizes osteomas into 4 distinct grades based on 3 primary characteristics: the location
of the base of attachment, anterior-posterior diameter of the lesion, and tumor location
relative to a virtual sagittal plane through the lamina papyracea. Although their original
recommendations for an endoscopic versus open approach based on these grades
have been adjusted with subsequent endoscopic innovation, this grading system re-
mains useful and is widely used in the literature.

Inverted Papilloma
Inverted papillomas (IP) are benign tumors of the paranasal sinuses. The incidence of
IP has been reported at 0.74 per 100,000/y,19 with 1% to 16% of these tumors orig-
inating in the frontal sinus20 (Fig. 2). Overall, the most common site of origin for IP is
the lateral nasal wall.21,22 In addition, there seems to be a male predominance for
these tumors, with a male to female ratio of 3.3:1.20 IPs are typically treated with com-
plete surgical resection because of their risk of recurrence without complete resection
 Management of Frontal Sinus Tumors 1053

Fig. 1. Endoscopic drill-out of a frontal osteoma. (A) Sagittal image revealing an extensive
frontal osteoma completely filling and obstructing the frontal outflow tract. (B) Progressive
drill-out of the noted osteoma with access to the overlying frontal antrum allowing visual-
ization of the margins of resection. (C) Postoperative imaging revealing subtotal resection
of the noted osteoma with reestablishment of the frontal sinus outflow tract. Of note,
because the patient presented with complications secondary to sinus obstruction, the
goal of the procedure was to primarily reestablish a functional frontal sinus.

and potential to be locally destructive. Moreover, these lesions have the capacity to
harbor or transform into squamous cell carcinoma (SCC). A recent meta-analysis of
frontal sinus IP by Walgama and colleagues20 discovered that 4.1% included SCC
on final histopathology. This study also found that IPs of the frontal sinus are found

Fig. 2. Inverted papilloma imaging. (A) Coronal image revealing an extensive frontal in-
verted papilloma with appreciable hyperostosis about the roof of the frontal sinus. (B)
Sagittal image revealing an extensive frontal inverted papilloma with appreciable hyperos-
tosis about the posterior table. The noted hyperostosis indicates the region of tumor origin/
attachment and should be evaluated when determining an appropriate approach.
1054 Selleck et al

bilaterally in about 16% of cases, a rate that is considerably greater than IP in other
locations. This difference may be caused by incomplete initial resections or an intrinsic
inability of the frontal intersinus septum to serve as an effective barrier to spread. One
additional challenge with the removal of IPs is their tendency to recur. Walgama and
colleagues20 reported the rate of frontal sinus IP recurrence to be 22.4%, similar to
previously reported rates of 22% and 16.7%.23,24 These concerning findings show
the importance of ensuring a complete resection when choosing among potential sur-
gical approaches (Fig. 3).

SECONDARY TUMORS
Squamous Cell Carcinoma
SCC is by far the most common sinonasal malignancy and accounts for approximately
41% of such cancers. SCC occurs most frequently in the nasal cavity (46%) and maxil-
lary sinus (40%), and least frequently in the frontal sinus.25,26 Because initial symp-
toms can be vague and easily mistaken for benign sinonasal disease, SCC is
typically diagnosed at advanced stages, and lymphatic metastasis is present in
10% to 20% of patients at the time of diagnosis27,28 (Fig. 4). Thus, SCC carries a
poor overall prognosis, with a reported 5-year survival rate of 50% to 60%.29,30

Fig. 3. Combined endoscopic and open approach to a frontal inverted papilloma. (A) Endo-
scopic approach and resection of the inverted papilloma with radiographic findings seen in
Fig. 2. Note that a Draf IIb has been performed, allowing wide access to the frontal sinus
antrum. (B) Open approach to the noted frontal inverted papilloma via a unilateral osteo-
plastic flap affording access to the posterior table and roof of the frontal sinus to ensure
these sites of origin are adequately addressed. (C) Endoscopic view of the combined
approach with a gloved finger seen traversing the site of the osteoplastic flap.
 Management of Frontal Sinus Tumors 1055

Fig. 4. Sinonasal squamous cell carcinoma imaging. Axial image revealing an extensive fron-
tal sinonasal squamous cell carcinoma with frontal transgression and dural extension with
associated lateral dural enhancement.

Occupational exposures to wood dust, nickel, or formaldehyde have been widely re-
ported as risk factors for the development of both SCC and other sinonasal
cancers.31,32 These irritants may lead to carcinogenesis by eliciting chronic inflamma-
tion.28 In addition, human papillomavirus has been linked to sinonasal SCC via malig-
nant transformation of inverted papilloma tumors.33 As with other sinonasal
malignancies, surgical resection in adherence with oncologic principles with postop-
erative adjuvant therapies is the preferred mode of treatment. Depending on specific
tumor extension and location, modern endoscopic approaches can effectively
achieve complete resections of sinonasal SCC.

Sinonasal Undifferentiated Carcinoma

Sinonasal undifferentiated carcinoma (SNUC) is a rare and highly aggressive neuroen-
docrine malignancy that was first described by Frierson and colleagues34 in 1986. The
age-adjusted incidence is 0.02 per 100000, and there is a significant male predomi-
nance.35,36 SNUC often initially presents with vague symptoms that worsen with rapid
tumor growth. A literature review by Xu and colleagues37 found that nasal obstruction,
epistaxis, visual disturbances, and headache are the most common presenting symp-
toms. Previous studies have reported that most patients are diagnosed with advanced
disease, with nearly 60% of patients having disease extending beyond the paranasal
sinuses. Of those patients, 53% had orbital involvement, 41% had skull base involve-
ment, and 13% had brain involvement.38 Distant metastasis to the neck, lungs, liver,
and bone has also been reported. The long-term prognosis at the time of SNUC diag-
nosis is grim, with a reported median survival of 22.1 months and a 5-year survival of
34.9%.35 Because of this high mortality, SNUC has been treated with a variety of
multimodal approaches, including aggressive surgical resection when possible plus
adjuvant and/or induction chemotherapy and/or radiation. Further research is required
to elucidate the optimum treatment regimen for these aggressive carcinomas.

Small Cell Neuroendocrine Carcinoma

Small cell neuroendocrine carcinomas (SNECs) are poorly differentiated, aggressive
malignancies that predominantly occur in the lung. However, approximately 4% of
1056 Selleck et al

SNECs occur in extrapulmonary sites, including the paranasal sinuses.39 Of note, all
SNEC tumors share similar histologic features. Detailed morphologic and immunohis-
tochemical analysis is crucial for accurate diagnosis and to distinguish these malig-
nancies from other sinonasal neuroendocrine malignancies, namely SNUC and
esthesioneuroblastoma.40 As with SNUC, patients with SNEC often present with
advanced disease, in part because of similar, nonspecific presenting symptoms,
such as epistaxis, nasal obstruction, and nasal discharge. Overall, because of a com-
bination of late presentation and their shared characteristics with pulmonary SNEC,
sinonasal SNECs may be reasonably treated first with a chemotherapy or radiotherapy
regimen, with surgical intervention reserved primarily for nonresponders.41,42 Despite
these interventions, the rates of local recurrence and metastasis are each approxi-
mately 30% and the 5-year survival is only 10%.40

Esthesioneuroblastoma
Esthesioneuroblastoma (ENB), also referred to as olfactory neuroblastoma, is a sino-
nasal neoplasm that is thought to originate from the olfactory neuroepithelium of the
superior nasal cavity. ENB is rare and accounts for 3% to 6% of sinonasal malig-
nancies.43 Although it was previously thought to be a low-grade malignancy, it is
now known that ENB commonly invades local structures, including the paranasal si-
nuses, cranial vault, and orbit, and has a propensity for distant metastases. As with
the previously discussed SNEC and SNUC, proper histology and immunologic anal-
ysis are crucial to avoiding misdiagnosis, which can lead to selection of inappropriate
treatment plans.40,44 Cohen and colleagues45 showed this potential hazard after
reviewing previously diagnosed ENB at their institution and finding that 10 out of 12
of these tumors carried an incorrect diagnosis. The rarity of this tumor has largely
limited the literature to retrospective studies and an ideal treatment method has
been difficult to elucidate. In the past, a craniofacial resection with adjuvant radiation
was the gold standard of treatment,46 but endoscopic resection is now possible and
preferred for certain patients in whom proper oncological principles are feasible. A
large meta-analysis by Devaiah and Andreoli47 found no difference in survival rate be-
tween surgical approaches, a finding also corroborated by Tajudeen and col-
leagues.48 Overall, the combined approach of surgical resection with radiotherapy
and possible chemotherapy seems to be the appropriate treatment modality for
most patients with ENB.44,49–51 Of note, ENB tumors have shown a prolonged time
to both local recurrence and distant metastasis, and proper management necessitates
long-term follow-up for periods even greater than 10 years.49,52,53

Sinonasal Non-Hodgkin Lymphoma

Mature B-cell non-Hodgkin lymphoma (NHL), which includes diffuse large B-cell NHL,
is the second most common sinonasal malignancy after SCC. As a group, these tu-
mors comprise approximately 10% of all sinonasal malignancies and are found
most frequently in the maxillary sinus and nasal cavity, at 36.9% and 34.0%, respec-
tively.26 These malignancies may have similar clinical presentations to other tumors of
this region and typically cause symptoms via mass effect. However, sinonasal mature
B-cell NHL may also have symptoms that are more specific to B-cell lymphomas,
namely fever and weight loss.54 These malignancies have a reported 5-year
disease-specific survival of 63.5% to 68.0%, which compares favorably with survival
rates of other sinonasal malignancies.26,55 Surgery serves virtually no role in the man-
agement of non-Hodgkin lymphoma, and these malignancies are primarily treated
with a combination of chemotherapy and radiation therapy.56
 Management of Frontal Sinus Tumors 1057

SPECIAL CONSIDERATIONS: PEDIATRIC PATIENTS

Frontal sinus development in pediatric patients significantly affects surgical manage-

ment. At birth, the frontal sinus is typically absent. The frontal sinus is the last of the
paranasal sinuses to form and generally begins to pneumatize at age 2 years when
the anterior-most ethmoid cell merges with the frontal bone. This nascent frontal sinus
continues to grow vertically and is fairly well formed by age 8 years. However, it con-
tinues to undergo further development until age 20 years. These anatomic differences
are important to consider when treating pediatric patients.

PREOPERATIVE PLANNING AND PREPARATION

Once the decision is made to surgically remove a frontal sinus tumor, the first surgical
decision in the planning process is to determine the approach. There are 3 broad cat-
egories of surgical approaches to a frontal sinus tumor: open, endoscopic, or a com-
bined approach. In order to make this decision, a computed tomography scan,
compatible with intraoperative navigational systems, of the sinuses is essential.
Frontal sinus dimensions and anatomy are among the initial considerations in the
ability to perform an endoscopic resection.18 According to Draf,57 the endoscopic
Draf III procedure requires a frontal sinus to have an anterior to posterior diameter
of at least 0.8 cm in order for the procedure to be technically possible. Sie skiewicz
and colleagues58 stated that an anterior to posterior diameter of the frontal sinus
less than 10 mm is a contraindication to an endoscopic approach. Sie skiewicz and
colleagues58 also stated that increased convexity of the posterior wall of the frontal si-
nus also makes tumor removal difficult, because a more pronounced convexity mini-
mizes the ability of endoscopic instruments to reach the attachment of the tumor. The
size of the tumor relative to the frontal sinus also needs to be considered. It should also
be noted that frontal sinus tumors limit the amount of space that is available for instru-
ments to be able to access the space and manipulate the tumor.18
The tumor’s location is also an important factor. The frontal sinus can be difficult to
access, so tumors located laterally or with extensive lateral spread are considered by
some clinicians to be a contraindication to an entirely endoscopic approach.58 A Draf
III should be considered in these tumors because it allows for an improved angle of
visualization and the ability to maneuver instrumentation into the more lateral corners
of the frontal sinus. Tumors located behind the virtual plane of the lamina papyracea
are also proposed by some investigators as being more difficult to remove endoscop-
ically.58 The site of attachment is another important consideration, because those tu-
mors with a superior attachment to the posterior wall of the sinus can be difficult to
access.58 Tumors attached to the lower half of the posterior wall of the frontal sinus
are much easier to approach endoscopically.59 Walgama and colleagues20 reviewed
frontal sinus inverting papillomas and found that tumors with a posterior wall attach-
ment had the lowest recurrence rate (0%), although this rate was not statistically sig-
nificant compared with other subsites (P 5 .51).
Another consideration that should be included in the discussion of surgical
approach is the length of surgical time.2 Although endoscopic cases in general can
be prolonged compared with open procedures, surgical time can be particularly pro-
longed in cases of solid ivory-type osteomas given that the endoscopic disposable
burrs tend to break frequently during removal.60 Surgical time can become a signifi-
cant contributor to the decision of surgical approach, especially given certain patient
comorbidities.
Frontal sinus osteomas deserve special mention, because the grading system
created by Chiu and colleagues18 has helped establish endoscopic guidelines. Chiu
1058 Selleck et al

and colleagues18 studied 9 frontal sinus osteomas and decided that the endoscopic
limit for frontal sinus osteomas was a grade II osteoma; III and IV had to be
approached in an open fashion given the risk of cerebrospinal fluid (CSF) leak and
inability to fully access the tumor to allow total resection. A study by Seiberling and
colleagues60 examined 25 cases of frontal sinus osteoma, of which 6 were grade III
and 10 were classified as grade IV. Of this cohort, 2 of the grade III and IV patients un-
derwent OPF procedures, and the rest were approached via a Draf III. Importantly, 2 of
the grade IV patients undergoing the Draf III required an additional approach for tumor
removal, which highlights the potential need for a combined approach in higher-grade
tumors. The investigators concluded that grade III and IV osteomas could be
approached endoscopically with a Draf III, although this approach was balanced
with the increased risk of residual tumor and stenosis of the frontal sinus neo-
ostium. Ledderose and colleagues59 also examined 24 patients with a frontal sinus os-
teoma, 16 of whom had a grade III or IV osteoma. Of the 16 patients, 3 could be
approached completely endoscopically, 4 required an open approach, and the
remaining cohort were approached through a combination endoscopic and open
approach. The investigators stated that the use of an intraoperative navigation system
made a significant difference in their ability to approach tumors endoscopically.
Before the use of navigational systems, they were unable to approach any tumor solely
endoscopically. Rokade and Sama2 discussed factors that they thought made endo-
scopic removal of osteomas difficult, including, “grade III and IV osteomas that
occupy more than 75% of the frontal sinus, significant posterior table erosion, pre-
senting with previous meningitis or CSF leak, extensive intracranial extension, and a
significant supraorbital component with lateral orbital mucoceles”2 (Fig. 5). These
studies highlight the importance of the grading system, emphasize the increased dif-
ficulty in removing higher (III and IV) grade osteomas, and potential other factors to
consider regarding the osteoma.
With regard to the inverting papilloma, total surgical resection is of paramount
concern in order to prevent recurrence and local destruction, and to survey the tumor
for SCC. Walgama and colleagues20 reviewed 11 studies with a total of 49 patients
who had frontal sinus inverting papilloma. They found the following incidence of sur-
gical approach: 42.9% had a Draf II, 20.4% had a Draf III, 26.5% had an osteoplastic
flap, and 10.2% had an endoscopic frontal trephination combined with an additional
endoscopic approach. The recurrence rate was 22.4% for all approaches and no sta-
tistically significant difference was seen between the approaches. The lack of differ-
ence between the recurrence rates indicates the comparable ability of the
endoscopic approach to provide total resection compared with the traditional open
approach. However, the high rate of recurrence of the inverting papilloma in the frontal
sinus speaks to the difficulty of resection in this area.20
Another consideration with regard to the surgical approach is surgeon skill and
experience. The endoscopic approach requires an experienced surgeon given that
these tumors are a rare clinical entity.59
Before surgery the patient can be started on topical or systemic steroids in order to
minimize vascularity and edema. This treatment can allow decreased bleeding and
thus improved visibility during the procedure.61

PROCEDURAL APPROACH

There are several endoscopic approaches to a frontal sinus tumor, including Draf IIa,
IIb, and III approaches. These procedures are on a continuum, allowing increasing ac-
cess and visualization of the frontal sinus. Once the frontal sinus has been approached
 Management of Frontal Sinus Tumors 1059

Fig. 5. Osteoma imaging. (A, B) Coronal and sagittal images revealing an extensive right
frontal osteoma with sinonasal and orbital extension. Given the position of the osteoma
and absence of significant lateral extension this lesion was amenable to endoscopic resec-
tion. (C, D) Coronal and sagittal images revealing an extensive right frontal osteoma with
superolateral extension about the roof of the frontal sinus. Given the position of the oste-
oma and significant lateral extension this lesion was amenable to an open approach for
resection.

and opened the tumor’s attachment site can be localized and the tumor can be
removed. These procedures are conducted under general anesthesia with the patient
in a supine position. When used, a navigation system is always set up before surgery.
Topical vasoconstrictors and 1% lidocaine with epinephrine are used at the discretion
of the surgeon.
Regardless of the approach used, there are several key points to be remembered in
frontal sinus surgery. Identification and awareness of the posterior limit of the frontal
sinus is essential to decrease the risk of injury to the skull base.62 In addition, visual-
ization of the tumor attachment site is critical, because this allows safe and total
removal.58
Surgery on the frontal sinus, unless completed previously, is preceded by an eth-
moidectomy, including comprehensive dissection of the agger nasi region and asso-
ciated frontal cells.57
Following the noted dissections, the determined frontal approach can be per-
formed. A Draf IIa procedure involves removal of the ethmoidal cells protruding into
the frontal sinus. The floor of the frontal sinus between the lamina papyracea and
the middle turbinate is resected. This approach is limited for the use of tumors
because the exposure is minimal. The Draf IIb, also known also the unilateral frontal
sinus drill-out, involves an extended resection of the frontal sinus floor between the
lamina papyracea and the nasal septum63 (Figs. 6 and 7). A Draf III, also known as
1060 Selleck et al

Fig. 6. Left orbitofrontal osteoma. (A) Preoperative coronal image revealing a left orbito-
frontal osteoma without significant lateral or superior orbital extension. (B) Postoperative
coronal image revealing gross total resection following an endoscopic resection.

the endoscopic modified Lothrop approach, provides maximal access by bilateral

removal of the frontal sinus floor and the anterosuperior nasal septum, providing an
orbit-to-orbit exposure.63 This procedure was initially described in 1914 as an external
technique and it was not until 1991 that it was adapted as an endoscopic transnasal
approach.2

Fig. 7. Endoscopic resection of a left orbitofrontal osteoma. (A, B) Progressive resection and
drill-out of the noted osteoma. As the margins of dissection are identified, the frontal
outflow tract is widely opened. (C) Following extensive drill-out the remaining osteoma
about the lamina papyracea is meticulously dissected and removed en bloc.
 Management of Frontal Sinus Tumors 1061

There are several additional considerations that must be kept in mind during an
endoscopic approach to a frontal sinus tumor. Depending on the size and location
of the tumor, it can potentially completely fill the middle meatus and obstruct access
to the frontal recess.64 Drilling with a burr can become a significant challenge when the
tumor completely fills the frontal recess. The frontal sinus anatomy and boundaries
can also be difficult to recognize if the tumor obstructs the potential margins of dissec-
tion, which also increase the risk to the orbit and skull base given how difficult it is for
the surgeon to fully visualize the anatomic boundaries of the frontal sinus.64

POTENTIAL COMPLICATIONS AND MANAGEMENT

The important structures surrounding the frontal sinus include the lamina papyracea,
cribriform plate, skull base, and anterior ethmoidal artery. Complications can occur if
these structures are violated during the course of surgery. Orbital entry can potentially
lead to injury to the eye, ocular muscles, and/or the optic nerve. Bleeding can result
from injury to the anterior ethmoidal artery, leading to intranasal bleeding or intraorbital
bleeding and resulting in a retro-orbital hematoma, which is a surgical emergency.
Intracranial or skull base violation may result in a CSF leak, which must be immediately
identified and repaired.
Often with the Draf III procedure the mucosa of the anterior and lateral walls of the
frontal sinus is removed, leading to osteoneogenesis, scarring, and subsequent steno-
sis or closure of the ostium.65 A study by Seiberling and colleagues60 found that 5 out
of 14 patients who underwent a Draf III procedure for frontal sinus osteoma had sig-
nificant narrowing of the frontal ostium. A review of Draf III procedures, performed
for tumor, chronic rhinosinusitis, and trauma, in 18 studies involving 612 patients,
found that 19% of patients had stenotic or closed frontal sinus ostia.65 Conger and
colleagues65 discussed a method for mucosal grafting in order to prevent stenosis.
Septal mucosa was harvested from the septectomy in the initial stage of the Draf III
procedure and was then positioned over the exposed bone in the anterior and lateral
positions. All 27 patients studied, 14 of whom had a frontal sinus tumor, had a suc-
cessful procedure with less than a 50% reduction in diameter of the frontal sinus ostia.

POSTPROCEDURAL CARE AND RECOVERY

Following surgery, it has been found that hospitalization times are decreased in those
patients undergoing endoscopic procedures. Ledderose and colleagues59 examined
hospitalization time after surgical removal of frontal sinus osteomas, and found an
average stay of 9.2 days for open approaches versus an average of 5.3 days for endo-
scopic approaches.
Postoperative management is crucial for good surgical outcome. Patients are often
given postoperative courses of oral antibiotics of varying duration at the surgeon’s
discretion.62 Patients are instructed to do saline irrigations at least 4 to 6 times a
day. Patients are seen between 7 to 14 days postoperatively in the clinic for an endo-
scopic examination and removal of crusts and adhesions. Subsequent follow-up is
dictated by endoscopic findings, degrees of healing, and surgeon preference.62

OUTCOMES

Recurrence is a common concern with tumor removal. Seiberling and colleagues60

found that, in 4 of their endoscopic cases, 5% to 10% of residual tumor was left at
the osteoma attachment site to the skull base. However, at an average follow-up of
60 months, no recurrence was found in these cases. It is thought that the lack of
1062 Selleck et al

recurrence is secondary to the pattern of growth of the osteoma.66 It is thought that the
growth center of osteomas is centrally located, so by removing the central portion
growth ceases.66 However, there are reports in the literature of the recurrence of os-
teomas when full resection is not achieved.67 Walgama and colleagues20 did a sys-
tematic review of 49 cases of inverted papilloma of the frontal sinus that had an
overall recurrence rate of 22.4%. They also examined the rate of recurrence based
on surgical approach. Recurrence rates for Draf II, Draf III, osteoplastic flap, and endo-
scopic frontal trephination were respectively 23.8%, 30%, 15.4%, and 20%. They
found no statistically significant difference between the 4 surgical approaches.
Outcome data regarding postoperative function or symptoms are sparse. Ledder-
ose and colleagues59 examined their 19 patients with frontal sinus osteoma and
administered a postoperative SNOT-20 (Sino-Nasal Outcome Test 20) quality-of-life
survey, providing some information regarding postoperative change and subjective
assessment of outcome. These results were not separated by surgical approach,
making it difficult to assess the subjective outcome difference attributable to surgical
approach. Further study is needed in this area.

SUMMARY

With the advent of the Draf procedures and ever-improving surgical tools the endo-
scopic approach has become increasingly feasible for the management of frontal si-
nus tumors. Despite these advancements, frontal sinus anatomy in concert with
tumor characteristics can make endoscopic removal difficult and surgeons should
also be versed in open approaches. Although there is literature on the more common
tumors of the frontal sinus, including inverting papilloma and osteoma, there is a
paucity of data on the remaining tumors and associated outcomes. Further study is
essential to further advance endoscopic treatment of frontal sinus tumors.

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