Combined Endoscopic Trephination and Endoscopic Frontal Sinusotomy for Management of Complex Frontal Sinus Pathology Pete S. Batra, M.D., Martin J. Citardi, M.D., and Donald C. Lanza, M.D. ABSTRACT Background: The advances in endoscopic sinus surgery have revolutionized the management of frontal sinus disease. De- spite the successes, the purely endoscopic approach has its limitations, especially in patients with alterations in anatomy caused by previous surgical intervention or complex frontal sinus pneumatization patterns. The purpose of this study was to evaluate the efficacy of combined endoscopic trephination and endoscopic frontal sinusotomy (the above and below approach) in the management of these difficult cases. Methods: Chart review was performed on patients undergoing the combined approach from October 1999 to June 2004. Demographic data, symptomatology, comorbidity, previous surgery, and primary pathology were determined. Outcome was assessed based on subjective symptom relief and objective endoscopic patency. Results: Twenty-two patients with a mean age of 49.2 years underwent the combined approach. The primary pathology included mucoceles (15 patients), frontal sinusitis (2 patients), inverted papilloma (2 patients), osteoma (1 patient), fibrous dysplasia (1 patient), and pneumocephalus (1 patient). A total of 25 above and below procedures (22 primary and 3 revision procedures) were performed to manage the pathology. Post- operatively, headaches resolved in 47%, improved in 35%, and remained unchanged in 18% of the patients. Orbital symptoms resolved in 63%, improved in 25%, and remained unchanged in 12% of the patients. Endoscopic patency of the frontal sinusotomy was confirmed in 19 of 22 cases (86%) at a mean follow-up of 16.2 months. Conclusion: Management of complex frontal sinus pathology may require adjunct approaches in conjunction to the standard endoscopic techniques. In this series, the above and below approach was used successfully in 22 patients. The combined approach may serve as an important adjunct for management of complex frontal sinus disease. (American Journal of Rhinol- ogy 19, 435–441, 2005) S uccessful surgical management of chronic frontal sinus disease remains a significant challenge for rhinolo- gists. The drainage pathway of the frontal sinus is hidden from direct endoscopic view by a complex and variable pneumatization pattern of frontal recess cells. The close From Cleveland Clinic Foundation, Head and Neck Institute, Section of Nasal and Sinus Disorders, Cleveland, Ohio Presented at the annual meeting of the American Rhinologic Society, New York, New York, September 18–20, 2004 Dr. Citardi was a member of the scientific advisory board of CBYON (Mountain View, CA) from 1999 to 2003. Currently, he is a member of a scientific advisory board for GE Health- care (Waukesha, WI) Address correspondence and reprint requests to Pete S. Batra, M.D., Section of Nasal and Sinus Disorders, Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A71, Cleveland, OH 44195 Copyright © 2005, OceanSide Publications, Inc., U.S.A. American Journal of Rhinology 435