Radiologic Review for Frontal Sinus Surgery

  • Joseph M. Hoxworth
  • Devyani Lal


Even prior to the preoperative phase, radiologic studies are helpful to correlate the patient’s symptoms with objective findings. Imaging tests are essential prior to contemplating surgery on the frontal sinuses as they can characterize the type and extent of frontal sinus disease and define the relevant anatomy in detail. These studies help with preoperative planning and intraoperative execution of safe and effective surgery. Noncontrast computed tomography (CT) of the paranasal sinuses is the most common radiologic test utilized for frontal sinus surgery. Additionally, magnetic resonance imaging (MRI) and other radiologic tests are helpful in cases of expansile, mass-like lesions, tumors, skull base pathology, or in circumstances such as in post-obliteration frontal sinus disease to distinguish fat from mucoceles. This chapter will cover:
  • Definition of anatomy, including relevant anatomic variants

  • Characterization of inflammatory sinus disease and any associated complications

  • Evaluation of the postoperative diseased frontal sinus

  • Assessment of expansile mass-like lesions and sinonasal neoplasms


  1. 1.
    Kanowitz SJ, Shatzkes DR, Pramanik BK, Babb JS, Jacobs JB, Lebowitz RA. Utility of sagittal reformatted computerized tomographic images in the evaluation of the frontal sinus outflow tract. Am J Rhinol. 2005;19(2):159–65.CrossRefGoogle Scholar
  2. 2.
    Kuhn FA. Chronic frontal sinusitis: the endoscopic frontal recess approach. Oper Tech Otolaryngol Head Neck Surg. 1996;7(3):222–9.CrossRefGoogle Scholar
  3. 3.
    Wormald PJ. Surgery of the frontal recess and frontal sinus. Rhinology [Review]. 2005;43(2):82–5.Google Scholar
  4. 4.
    Wormald PJ, Hoseman W, Callejas C, Weber RK, Kennedy DW, Citardi MJ, et al. The international frontal sinus anatomy classification (IFAC) and classification of the extent of endoscopic frontal sinus surgery (EFSS). Int Forum Allergy Rhinol. 2016;6(7):677–96.CrossRefGoogle Scholar
  5. 5.
    Bent JP, Cuiltysiller C, Kuhn FA. The frontal cell as a cause of frontal-sinus obstruction. Am J Rhinol. 1994;8(4):185–91.CrossRefGoogle Scholar
  6. 6.
    Surgery AAoO-HaN. Position statement: intra-operative use of computer aided surgery. [11/18/2017]; Available from:
  7. 7.
    Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg [Practice GuidelineResearch Support, Non-U.S. Gov’t]. 2015;152(2 Suppl):S1–S39.Google Scholar
  8. 8.
    Hoxworth JM, Glastonbury CM. Orbital and intracranial complications of acute sinusitis. Neuroimaging Clin N Am [Review]. 2010;20(4):511–26.CrossRefGoogle Scholar
  9. 9.
    Velayudhan V, Chaudhry ZA, Smoker WRK, Shinder R, Reede DL. Imaging of intracranial and orbital complications of sinusitis and atypical sinus infection: what the radiologist needs to know. Curr Probl Diagn Radiol [Review]. 2017;46(6):441–51.CrossRefGoogle Scholar
  10. 10.
    Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope. 1970;80(9):1414–28.CrossRefGoogle Scholar
  11. 11.
    Ni Mhurchu E, Ospina J, Janjua AS, Shewchuk JR, Vertinsky AT. Fungal Rhinosinusitis: a radiological review with intraoperative correlation. Can Assoc Radiol J [Review]. 2017;68(2):178–86.CrossRefGoogle Scholar
  12. 12.
    Middlebrooks EH, Frost CJ, De Jesus RO, Massini TC, Schmalfuss IM, Mancuso AA. Acute invasive fungal Rhinosinusitis: a comprehensive update of CT findings and design of an effective diagnostic imaging model. AJNR Am J Neuroradiol. 2015;36(8):1529–35.CrossRefGoogle Scholar
  13. 13.
    Safder S, Carpenter JS, Roberts TD, Bailey N. The “black turbinate” sign: an early MR imaging finding of nasal mucormycosis. AJNR Am J Neuroradiol [Case Reports]. 2010;31(4):771–4.CrossRefGoogle Scholar
  14. 14.
    Weber R, Draf W, Kratzsch B, Hosemann W, Schaefer SD. Modern concepts of frontal sinus surgery. Laryngoscope [Multicenter StudyValidation Studies]. 2001;111(1):137–46.CrossRefGoogle Scholar
  15. 15.
    Weber RK, Hosemann W. Comprehensive review on endonasal endoscopic sinus surgery. GMS Curr Top Otorhinolaryngol Head Neck Surg [Review]. 2015;14:Doc08.Google Scholar
  16. 16.
    Huang BY, Lloyd KM, DelGaudio JM, Jablonowski E, Hudgins PA. Failed endoscopic sinus surgery: spectrum of CT findings in the frontal recess. Radiographics. 2009;29(1):177–95.CrossRefGoogle Scholar
  17. 17.
    Otto KJ, DelGaudio JM. Operative findings in the frontal recess at time of revision surgery. Am J Otolaryngol. 2010;31(3):175–80.CrossRefGoogle Scholar
  18. 18.
    Valdes CJ, Bogado M, Samaha M. Causes of failure in endoscopic frontal sinus surgery in chronic rhinosinusitis patients. Int Forum Allergy Rhinol. 2014;4(6):502–6.CrossRefGoogle Scholar
  19. 19.
    Hahn S, Palmer JN, Purkey MT, Kennedy DW, Chiu AG. Indications for external frontal sinus procedures for inflammatory sinus disease. Am J Rhinol Allergy. 2009;23(3):342–7.CrossRefGoogle Scholar
  20. 20.
    Konstantinidis I, Constantinidis J. Indications for open procedures in the endoscopic era. Curr Opin Otolaryngol Head Neck Surg [Review]. 2016;24(1):50–6.CrossRefGoogle Scholar
  21. 21.
    Ochsner MC, DelGaudio JM. The place of the osteoplastic flap in the endoscopic era: indications and pitfalls. Laryngoscope [Evaluation Studies]. 2015;125(4):801–6.CrossRefGoogle Scholar
  22. 22.
    Chandra RK, Kennedy DW, Palmer JN. Endoscopic management of failed frontal sinus obliteration. Am J Rhinol. 2004;18(5):279–84.CrossRefGoogle Scholar
  23. 23.
    Kanowitz SJ, Batra PS. Citardi MJ. Comprehensive management of failed frontal sinus obliteration. Am J Rhinol [Comparative Study]. 2008;22(3):263–70.CrossRefGoogle Scholar
  24. 24.
    Langton-Hewer CD, Wormald PJ. Endoscopic sinus surgery rescue of failed osteoplastic flap with fat obliteration. Curr Opin Otolaryngol Head Neck Surg [Review]. 2005;13(1):45–9.CrossRefGoogle Scholar
  25. 25.
    Loevner LA, Yousem DM, Lanza DC, Kennedy DW, Goldberg AN. MR evaluation of frontal sinus osteoplastic flaps with autogenous fat grafts. AJNR Am J Neuroradiol. 1995;16(8):1721–6.PubMedGoogle Scholar
  26. 26.
    Som PM, Lawson W, Lidov MW. Simulated aggressive skull base erosion in response to benign sinonasal disease. Radiology. 1991;180(3):755–9.CrossRefGoogle Scholar
  27. 27.
    Som PM, Shapiro MD, Biller HF, Sasaki C, Lawson W. Sinonasal tumors and inflammatory tissues: differentiation with MR imaging. Radiology. 1988;167(3):803–8.CrossRefGoogle Scholar
  28. 28.
    Lanzieri CF, Shah M, Krauss D, Lavertu P. Use of gadolinium-enhanced MR imaging for differentiating mucoceles from neoplasms in the paranasal sinuses. Radiology. 1991;178(2):425–8.CrossRefGoogle Scholar
  29. 29.
    Van Tassel P, Lee YY, Jing BS, De Pena CA. Mucoceles of the paranasal sinuses: MR imaging with CT correlation. AJR Am J Roentgenol. 1989;153(2):407–12.CrossRefGoogle Scholar
  30. 30.
    Eisen MD, Yousem DM, Montone KT, Kotapka MJ, Bigelow DC, Bilker WB, et al. Use of preoperative MR to predict dural, perineural, and venous sinus invasion of skull base tumors. AJNR Am J Neuroradiol. 1996;17(10):1937–45.PubMedGoogle Scholar
  31. 31.
    Eisen MD, Yousem DM, Loevner LA, Thaler ER, Bilker WB, Goldberg AN. Preoperative imaging to predict orbital invasion by tumor. Head Neck [Comparative Study]. 2000;22(5):456–62.CrossRefGoogle Scholar
  32. 32.
    Anari S, Carrie S. Sinonasal inverted papilloma: narrative review. J Laryngol Otol [Review]. 2010;124(7):705–15.CrossRefGoogle Scholar
  33. 33.
    Sauter A, Matharu R, Hormann K, Naim R. Current advances in the basic research and clinical management of sinonasal inverted papilloma (review). Oncol Rep [Review]. 2007;17(3):495–504.Google Scholar
  34. 34.
    Walgama E, Ahn C, Batra PS. Surgical management of frontal sinus inverted papilloma: a systematic review. Laryngoscope [Review]. 2012;122(6):1205–9.CrossRefGoogle Scholar
  35. 35.
    Schneyer MS, Milam BM, Payne SC. Sites of attachment of Schneiderian papilloma: a retrospective analysis. Int Forum Allergy Rhinol. 2011;1(4):324–8.CrossRefGoogle Scholar
  36. 36.
    Barnes L. Diseases of the nasal cavity, paranasal sinuses, and nasopharynx. In: Barnes L, editor. Surgical pathology of the head and neck. 3rd ed. New York: Informa Healthcare USA, Inc.; 2009. p. 361–71.Google Scholar
  37. 37.
    Mirza S, Bradley PJ, Acharya A, Stacey M, Jones NS. Sinonasal inverted papillomas: recurrence, and synchronous and metachronous malignancy. J Laryngol Otol [Review]. 2007;121(9):857–64.Google Scholar
  38. 38.
    Ojiri H, Ujita M, Tada S, Fukuda K. Potentially distinctive features of sinonasal inverted papilloma on MR imaging. AJR Am J Roentgenol. 2000;175(2):465–8.CrossRefGoogle Scholar
  39. 39.
    Maroldi R, Farina D, Palvarini L, Lombardi D, Tomenzoli D, Nicolai P. Magnetic resonance imaging findings of inverted papilloma: differential diagnosis with malignant sinonasal tumors. Am J Rhinol. 2004;18(5):305–10.CrossRefGoogle Scholar
  40. 40.
    Jeon TY, Kim HJ, Chung SK, Dhong HJ, Kim HY, Yim YJ, et al. Sinonasal inverted papilloma: value of convoluted cerebriform pattern on MR imaging. AJNR Am J Neuroradiol [Validation Studies]. 2008;29(8):1556–60.CrossRefGoogle Scholar
  41. 41.
    Yousuf K, Wright ED. Site of attachment of inverted papilloma predicted by CT findings of osteitis. Am J Rhinol. 2007;21(1):32–6.CrossRefGoogle Scholar
  42. 42.
    Sham CL, King AD, van Hasselt A, Tong MC. The roles and limitations of computed tomography in the preoperative assessment of sinonasal inverted papillomas. Am J Rhinol [Comparative Study]. 2008;22(2):144–50.CrossRefGoogle Scholar
  43. 43.
    Bhalla RK, Wright ED. Predicting the site of attachment of sinonasal inverted papilloma. Rhinology. 2009;47(4):345–8.PubMedGoogle Scholar
  44. 44.
    Kennedy DW. Radiological localization of Schneiderian papilloma. Int Forum Allergy Rhinol [Comment Editorial]. 2011;1(6):492.CrossRefGoogle Scholar
  45. 45.
    Cannady SB, Batra PS, Sautter NB, Roh HJ, Citardi MJ. New staging system for sinonasal inverted papilloma in the endoscopic era. Laryngoscope [Review]. 2007;117(7):1283–7.CrossRefGoogle Scholar
  46. 46.
    Han JK, Smith TL, Loehrl T, Toohill RJ, Smith MM. An evolution in the management of sinonasal inverting papilloma. Laryngoscope. 2001;111(8):1395–400.CrossRefGoogle Scholar
  47. 47.
    Krouse JH. Development of a staging system for inverted papilloma. Laryngoscope. 2000;110(6):965–8.CrossRefGoogle Scholar
  48. 48.
    Buyuklu F, Akdogan MV, Ozer C, Cakmak O. Growth characteristics and clinical manifestations of the paranasal sinus osteomas. Otolaryngol Head Neck Surg [Comparative StudyResearch Support, Non-U.S. Gov’t]. 2011;145(2):319–23.Google Scholar
  49. 49.
    Earwaker J. Paranasal sinus osteomas: a review of 46 cases. Skeletal Radiol [Review]. 1993;22(6):417–23.CrossRefGoogle Scholar
  50. 50.
    Erdogan N, Demir U, Songu M, Ozenler NK, Uluc E, Dirim B. A prospective study of paranasal sinus osteomas in 1,889 cases: changing patterns of localization. Laryngoscope [Comparative Study]. 2009;119(12):2355–9.CrossRefGoogle Scholar
  51. 51.
    McHugh JB, Mukherji SK, Lucas DR. Sino-orbital osteoma: a clinicopathologic study of 45 surgically treated cases with emphasis on tumors with osteoblastoma-like features. Arch Pathol Lab Med. 2009;133(10):1587–93.PubMedGoogle Scholar
  52. 52.
    Alexander AA, Patel AA, Odland R. Paranasal sinus osteomas and Gardner’s syndrome. Ann Otol Rhinol Laryngol [Case Reports]. 2007;116(9):658–62.CrossRefGoogle Scholar
  53. 53.
    Som PM, Lidov M. The benign fibroosseous lesion: its association with paranasal sinus mucoceles and its MR appearance. J Comput Assist Tomogr. 1992;16(6):871–6.CrossRefGoogle Scholar
  54. 54.
    MacDonald-Jankowski DS. Ossifying fibroma: a systematic review. Dentomaxillofac Radiol [Comparative Study Review]. 2009;38(8):495–513.CrossRefGoogle Scholar
  55. 55.
    DeKlotz TR, Kim HJ, Kelly M, Collins MT. Sinonasal disease in polyostotic fibrous dysplasia and McCune-Albright syndrome. Laryngoscope [Research Support, N.I.H., Intramural]. 2013;123(4):823–8.Google Scholar
  56. 56.
    Atasoy C, Ustuner E, Erden I, Akyar S. Frontal sinus mucocele: a rare complication of craniofacial fibrous dysplasia. Clin Imaging [Case Reports]. 2001;25(6):388–91.CrossRefGoogle Scholar
  57. 57.
    Derham C, Bucur S, Russell J, Liddington M, Chumas P. Frontal sinus mucocele in association with fibrous dysplasia: review and report of two cases. Childs Nerv Syst [Case ReportsReview]. 2011;27(2):327–31.CrossRefGoogle Scholar
  58. 58.
    Ricalde P, Horswell BB. Craniofacial fibrous dysplasia of the fronto-orbital region: a case series and literature review. J Oral Maxillofac Surg [Review]. 2001;59(2):157–67; discussion 67–8.CrossRefGoogle Scholar
  59. 59.
    Atalar MH, Salk I, Savas R, Uysal IO, Egilmez H. CT and MR imaging in a large series of patients with craniofacial fibrous dysplasia. Pol J Radiol. 2015;80:232–40.CrossRefGoogle Scholar
  60. 60.
    Camilleri AE. Craniofacial fibrous dysplasia. J Laryngol Otol [Case Reports]. 1991;105(8):662–6.CrossRefGoogle Scholar
  61. 61.
    Casselman JW, De Jonge I, Neyt L, De Clercq C, D’Hont G. MRI in craniofacial fibrous dysplasia. Neuroradiology. 1993;35(3):234–7.CrossRefGoogle Scholar
  62. 62.
    Hanifi B, Samil KS, Yasar C, Cengiz C, Ercan A, Ramazan D. Craniofacial fibrous dysplasia. Clin Imaging. 2013;37(6):1109–15.CrossRefGoogle Scholar
  63. 63.
    Lisle DA, Monsour PA, Maskiell CD. Imaging of craniofacial fibrous dysplasia. J Med Imaging Radiat Oncol [Review]. 2008;52(4):325–32.CrossRefGoogle Scholar
  64. 64.
    Jee WH, Choi KH, Choe BY, Park JM, Shinn KS. Fibrous dysplasia: MR imaging characteristics with radiopathologic correlation. AJR Am J Roentgenol. 1996;167(6):1523–7.CrossRefGoogle Scholar
  65. 65.
    Abi-Fadel F, Smith PR, Ayaz A, Sundaram K. Paranasal sinus involvement in metastatic carcinoma. J Neurol Surg Rep. 2012;73(1):57–9.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Joseph M. Hoxworth
    • 1
    • 2
  • Devyani Lal
    • 3
  1. 1.Neuroradiology Division, Department of RadiologyMayo ClinicPhoenixUSA
  2. 2.Mayo Clinic College of Medicine and SciencesPhoenixUSA
  3. 3.Department of Otolaryngology – Head and Neck SurgeryMayo Clinic College of Medicine and Science, Mayo ClinicPhoenixUSA

Personalised recommendations