الفهرس 
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Abstract
The frontal recess is the most difficult area to dissect in
endoscopic sinus surgery due to its anatomical variantions, the adjacent
critical areas (orbit and skull base), also due to its angulated direction.
Recently, the progress of imaging modalities especially multislice
CT gave us the chance of good detailed study of anatomical variants in
frontal recess helping the surgeon to create a preoperative threedimentional
imaginary picture, that facilitates the process of widening
the frontal drainage pathway.
In this work, we studied the anatomical variants in frontal recess
area and their impact on endoscopic frontal sinusotomy surgery.
This study was conducted on 50 Egyptian patients 29 male and 21
female their ages ranged from 16ys to 65ys all are suffering from chronic
frontal sinusitis refractory to medical treatment.
Multislice CT was done and coronal, axial and sagittal cuts were
examined for every patient preoperatively to show:
1. Prevalence and size of Agger nasi cells.
2. Frontoethmoidal air cells.
- Frontal cell, type 1.
- Frontal cell, type 2.
- Frontal cell, type 3.
- Frontal cell, type 4.
- Supraorbital ethmoid cell.
- Frontal bullar cell.
- Suprabullar cell.
- Interfrontal sinus septal cell.
3. Anteroposterior diameter of frontal sinus ostium.
4. Superior attachment of uncinate process.
In this study we found that the agar nasi cell were present in 47
patients (94%), which were further divided into bilateral sides in 38
patients (76%) and unilateral in 9 patients (18%) with total number of
sides (85) in coronal, axial and sagittal cuts. The size of agar nasi cells
was and classified these sizes in 3 groups. Small group ranging from <
500 mm3 found in 8 sides representing 8%. Medium sized group ranging
from 500 – 3000 mm3 in 65 side representing 65%. Large agar nasi cell
group with a size bigger than > 3000 mm3 found in 12 sides of this group
representing 12% of all sides.
On surgery, we found that in absent agar nasi cell 5 sides were
easy (33.3%), 7 side were difficult (46.7%) and 3 sides of (20%) were
very difficult. In small sized agar nasi cells we found that 3 sides were
easy in operation (37.5%), 3 side were difficult (37.5%) and 2 sides were
very difficult (25%). In medium sized agar nasi cells, we found that all
sides were easy (100%). In large sized agar nasi cell all 12 sides were
easy (100%). All the results indicated that on decrease the size of agar
nasi cell, surgery is difficult and on increase the size of agar nasi cell,
surgery becomes easy.
For the prevalence of frontoethmoidal cells by examination of
coronal, sagittal and axial cuts. We found frontal cells type (1) in 12
patients (24%) and further subdivided into unilateral in 3 patients (6%)
and bilateral in 9 patients (18%) with total number of sides (21). Frontal
cells type (2) in 7 patients (14%) and further subdivided into unilateral in
2 patients (4%) and bilateral in 5 patients (10%) with total number of
sides (12). Frontal cells type (3) in 7 patients (14%) and further
subdivided into unilateral in 1 patients (2%) and bilateral in 6 patients
(12%) with total number of sides (13). Frontal cells type (4) didn’t
found. Supraorbital ethmoid cell in 3 patients (6%) and further
subdivided into unilateral in 1 patients (2%) and bilateral in 2 patients
(4%) with total number of sides (5). Frontal bullar cell in 4 patients (8%)
and further subdivided into unilateral in 1 patients (2%) and bilateral in 3
patients (6%) with total number of sides (7). Suprabullar cell in 8
patients (16%) and further subdivided into unilateral in 1 patients (2%)
and bilateral in 7 patients (14%) with total number of sides (15).
Interfrantal sinus septum cells were found in 15 patients (36%).
On surgery we found that type (3) frontoethmoidal cells and
interfrontal sinus septal cell were more difficult in endoscopic surgery
than other frontoethmoial cells apart of type (4) frontoethmoidal cells
which we didn’t found in our cases.
In this study, we classified the anteroposterior diameter of frontal
sinus ostium into small sized; ranging from 3 - 6 mm existed in 14 sides
(14%), medium sized; ranging from 6 - 9 mm existed in 60 sides (60%)
and large sized; more than 9 mm existed in 26 sides (26%). On surgery,
the small anteroposter diameter of F.S.O. 5 sides were easy (35%), 4
sides were difficult (30%) and 5 sides were very difficult (35%). In
medium size anteroposterior diameter of F.S.O. 50 sides were easy
(83.3%), 10 sides were difficult (16.7%). In large diameter 26 sides were
easy (100%).
In this study, by examination of the coronal cuts of our patients we
revealed that superior attachment of uncinate process into the lamina
papyracea type (1) in 70 sides (70%), into middle turbinate type (2) in 10
sides (10%), into skull base type (3) in 6 sides (6%), into lamina
papyracea and the middle turbinate type (4) in 5 sides (5%), into lamina
papyracea and the skull base type (5) in 8 sides (8%) and into middle
turbinate and the skull base type (6) in 1 sides (1%).
On surgery, in type (1) attachment 65 sides were easy (92.8%), 3
sides were difficult (4.2%) and 2 sides were very difficult (3%). In type
(2) attachment all 10 sides were easy (100%). In type (3) attachment all
6 sides were easy (100%). In type (4) attachment 2 sides were easy
(40%), 2 sides were difficult (40%) and 1 sides was very difficult (20%).
In type (5) attachment 4 sides were easy (50%), 2 sides were difficult
(25%) and 2 sides were very difficult (25%). In type (6) attachment 1
side was easy (100%).
In this study regarding the total group operative easiness, 80 sides
were easy (80%), 14 sides were difficult (14%) and 6 side were very
difficult (6%).
In this study, all cases was operated by doing Draf type IIa
operation and there was no case needed for external work assistance
(trephine or osteoplastic flap).
In this study, the postoperative patency (endoscopic view) was as;
in the first week 60 sides were patent (60%) and 40 sides were not patent
(40%). In the second week 75 sides were patent (75%) and 25 sides were
not patent (25%). In the third week 90 sides were patent (90%) and 10
sides were not patent (10%). In the third month 95 sides were patent
(95%) while 5 sides were not patent (5%).
In this study regarding the alleviation of symptoms and patients
satisfaction after visual analogue scale. In the first week 25 patients were
satisfied (50%), 15 were fairly satisfied (30%) and 10 patients were
badly satisfied (20%). In the second week 32 patients were satisfied
(64%), 12 patients were fairly satisfied (24%) and 6 patients were badly
satisfied (12%). In the third week 38 patients were satisfied (76%), 7
patients were fairly satisfied (14%) and 5 patients were badly satisfied
(10%). In the third month 42 patients were satisfied (84%), 4 patients
were fairly satisfied (8%) and 4 patients were badly satisfied (8%). This
correlates with the normal healing stages.