Intact Bulla Versus Trans-Axillary: Which is a Better Approach to Frontal Sinus?

Background: Frontal sinus is one of the most difficult sinuses to approach endoscopically because of its anatomical location. Challenges and difference in opinions still exist in terms of its surgical management. Endoscopic approach to frontal sinus commonly involves either trans-axillary or intact bulla technique. Trans-axillary technique gives a direct access to the frontal sinus even with a 0° endoscope whereas Intact bulla technique warrants the use of 70° scope. Despite both the techniques now existing for quite some time; literature is still controversial regarding the superiority of one technique over the other.

Methods and materials: A randomised prospective study of 40 patients of frontal sinusitis. Patients were randomly allocated into two groups. In approaching frontal sinus, groupA patients underwent trans-axillary technique and group B patients underwent intact bulla technique. Both the groups were statistically compared in terms of time taken for surgery, post operative results and improvement in symptom score.

Results: The pre-operative endoscopic Lund -Kennedy score in group A was 7.1 ± 1.57 while in group B was 6.95 ± 1.1. The mean post -operative endoscopic Lund Kennedy score in group A was 1.25 ± 0.93. and in group B was 1.05 ± 0.89. The mean pre& SNOT-22 score in group A was 79.85 ± 19.1 and in group B was 80.55 ± 16.94. The mean postoperative SNOT-22 Score in Group A was 4.450 ± 2.136 and group B was 2.579 ± 1. 714.The average time taken in group A to reach frontal sinus was 21.1 ± 5.44 min while in group B it was15.9 ± 3.6 min. At 12 weeks follow up recurrence was seen in 4/20 cases in group A and 3/20 Cases in group B. Ostial Stenosis was seen in 3/20 cases in group A and 2/20 cases in group B. Nasal adhesions were seen in 7/20 cases in group A and 1/20 cases in group B. Middle turbinate lateralization was seen in 8/20 cases in group A and 1/19 cases in group B. Lamina Papyracea injury was seen in 1 case in group B but in 3 cases of group A.

Conclusion: Both the techniques were highly efficacious in improving post-operative endoscopic as well as symptom scores. However, some post operative complications like middle turbinate lateralization were more with trans-axillary technique as compared to intact bulla technique.