My friend has had three sinus surgeries in six weeks. If this last one does not work, the doctor has recommended "frontal sinus obliteration." I want information about this procedure. He explained that he would totally remove the frontal sinuses.

D.L.

You have not given me enough information to speculate as to whether or not frontal-sinus obliteration is an appropriate procedure for your friend. However, depending on her degree of confidence in her doctor, she may want to obtain a second opinion before taking this step.
As your friend's doctor indicated, frontal-sinus obliteration is an operation that eradicates the frontal sinuses. It is usually done for incurable cases of frontal sinusitis and also in cases of severe trauma to the frontal sinus. It is a procedure of last resort.

The frontal sinus is an air pocket in the bone of the lower forehead. Put your fingertip on the root of your nose, right between your eyes. Now move your fingertip one finger's-breadth up. This is the dead center of your frontal sinus (assuming that you have one; it is absent in some people). The sinus is shaped roughly like an inverted pyramid, with the apex pointing downwards, towards the nose. There is usually a bony partition down the middle of the sinus, which explains why we talk about frontal sinuses (plural). As with any sinus, the frontal sinus is lined with a specialized tissue called mucosa. Mucosa produces a steady flow of mucus, which drains into the nose through holes in the apex of the pyramid.

There are a number of ways to obliterate the frontal sinus. The sinus can be approached directly, via a seagull-shaped incision through the skin immediately below both eyebrows. It can also be approached via a coronal incision, which traces out a huge arc, from ear to ear, over the top of the head. Once the incision is made, the skin and all tissue between the skin and the forehead bone is carefully lifted away from the underlying bone.

A special saw is then used to cut away, in one block, the bone overlying the frontal sinus. The mucosa inside is then scraped away. Next, a fine drill is used to remove any last bits of mucosa. If any mucosa is left behind, it can grow back as a mucocele, which is sort of a water balloon from hell. Then holes that drain the frontal sinus must be blocked. Bone chips from the skull can be used for this, as can a dense tissue called fascia, which can be harvested from the thigh. By blocking the drainage holes, the surgeon prevents nasal mucosa from growing back into the frontal sinus.

Now for the obliteration: How do you get rid of an empty space? Why, fill it, of course! The patient's own fat, harvested from the belly or thigh, is most commonly used for obliteration. A new material known as "bone cement" (hydroxyapatite) shows great promise for obliteration and is being used with increasing frequency. Some ENTs think that it isn't necessary to put anything at all in the sinus, but it is still more common to fill than to not fill.

The bone that was cut from the forehead is now placed back over the sinus, and it is reattached to the surrounding bone with tiny titanium plates and screws. (No, your friend will not set off airport alarms with her new hardware.) The incisions are closed. If the larger coronal incision is used, it is common to place two drains in the wound to suck away any of the fluids that ooze from a fresh wound. As soon as this oozing slows down (typically after a day or two), the drains are removed.