Challenges of open frontal sinus surgery

Over the past century, frontal sinus surgery has undergone substantial transformation, with advances in imaging, optics, and instrumentation contributing to current treatment paradigms. This review article is devoted to the evolution of surgical methods for treating frontal sinus diseases, demonstrates the complexity of surgical access, anatomical features, and the high rate of postoperative complications in this area. The historical development of frontal sinus surgery is outlined, from ancient trepanation practices, first thoroughly described in the 18th century, to modern minimally invasive endoscopic techniques. Particular attention is given to the transition from radical external approaches, such as the Ogston–Luc procedure, radical ablation, and complete sinus obliteration, to more conservative procedures aimed at preserving anatomical integrity and frontal sinus function. The review includes an analysis of early surgical milestones by Ogston, Kuhnt, Riedel-Schenke, and Killian, and examines the evolution of external frontoethmoidectomies known as Lynch–Howarth procedures. The limitations of these techniques, including high restenosis rates, scarring, and cosmetic deformities, are discussed, along with the development of various modifications intended to improve drainage and reduce postoperative complications. The article also addresses the challenges of intranasal approaches, such as limited visualization and the risk of intracranial complications. Advances in osteoplastic techniques are reviewed, noting their high efficacy alongside technical difficulty and risks such as cerebrospinal fluid leak and neuralgia. Despite the rise of endoscopic methods, external approaches remain relevant for certain specialists due to the unique anatomy of the frontal sinus, limited surgical experience, or complex disease course, either as stand-alone options or part of combined strategies. The review demonstrates that optimizing surgical treatment of the frontal sinus remains a relevant challenge, requiring continuous refinement of techniques and an individualized approach to each patient.