The External Frontoethmoidectomy (Lynch Procedure)
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THE EXTERNAL FRONTOETHMOIDECTOMY (LYNCH PROCEDURE)
The transorbital approach to the frontal sinus through its inferior wall was first employed in Europe by Jansen in 1902 & Ritter in 1911. In 1908, Knapp described the procedure in its present form in the American literature. In 1921, Lynch in the United States & Howarth in England simultaneously reported their experience with the transorbital frontal sinusotomy & ethmoidectomy. The operative procedure has remained essentially unchanged since the early part of this century & continues to have many advocates.
The external frontoethmoidectomy gains its widest application in patients with frontal sinus disease who have small or extremely large sinuses. With a small sinus, it may be possible to remove all the diseased mucosal lining. With a large sinus, the successful recreation of the nasofrontal duct may obviate the need for the more extensive osteoplastic flap procedure. When the acute inflammatory disease has extended into the orbit, this approach provides both orbital drainage & decompression & permits the removal of disease in the ethmoid & frontal sinuses. It also offers a direct approach for the removal of the frontoethmoid mucocele & osteoma. The access gained to the superior nasal cavity through the external ethmoidectomy also finds application in the repair of CSF leaks, as well as biopsy of tumors of the sinuses.
Another application of this procedure is to decompress mucoceles with intracranial extension either as primary management or preliminary to performing an osteoplastic flap.
- It can be performed through a relatively small & cosmetically acceptable incision.
- It provides access to the ethmoid & sphenoid sinuses, as well as the frontal sinus.
- It is not deforming as the area of bone removal does not affect facial contour.
- It is for unilateral disease.
- It does not provide adequate exposure for the removal of all the mucosa in a large septate sinus.
- It does not produce sinus obliteration.
- Communication with the nose & other paranasal sinuses may result in infection by contiguous spread.
- The subsequent closure of the new,y enlarged nasofrontal duct will cause recurrent infection or the formation of a mucocele.
Video Case Study:
The patient is an 80-year-old gentleman with an expanding left sinonasal mass that was causing rapid compromise of visual acuity. An intranasal biopsy was positive for B-cell lymphoma. The Lynch procedure was performed to debulk the tumor & decompress the orbit to save this patient’s eyesight. The procedure was performed successfully & the patient had adjuvant chemoradiation for definitive treatment. He is now 6 months post-treatment & has regained his pre-operative visual acuity. Currently, he has no evidence of disease on physical examination.