Frontal sinus has significant anatomical variation in frontal outflow unit, frontal cells and extent of pneumatization. The angled visualization and instrumentation has made standard endoscopic technique challenging. There are many techniques of endonasal frontal sinusotomy and extended approach. Superiorly, laterally based diseases require additional external procedure. Fibrous dysplasia, osteoma, Mucocoele, type 4 frontal cells, frontal duct stenosis and entrapment of AFS debris in lateral recess are indications for external trephination. To overcome the difficulties we use a combined endonasal and a mini frontal sinusotomy approach. We may use one or two small stab incisions to pass endoscopes and debriders into frontal sinus.

Fig. 1 : Endoscopically railroaded suture seen coming out of the lateral eye brow incision	Fig. 2 : CT PNS with arrows pointing defect in posterior table of frontal

Combined approach for frontal sinus was used in five patients. Four patients were approached by 5mm medial eyebrow incision and one patient required lateral eyebrow incision. A 22yr old patient with AFRS had subperiosteal orbital extension from lateral end of frontal sinus. After a standard sphenoethmoidectomy, frontal recess clearance and middle meatal antrostomy, he required additional lateral eyebrow incision. Allergic mucin and fungal debris was removed from subperiosteal pocket of orbit and frontal sinus entered through bony defect (Fig. 1). Out of thirty cases of CSF leak operated by endoscopic technique one patient required combined approach. This was a 9 year old girl with a post traumatic CSF leak, which was initially managed by conservative approach. She had recurrence of CSF leak after one year. The CSF leak was localized in the posterior table of frontal sinus just behind the frontal infundibulum by CT & MRI (Fig. 2). Combined ethmoidectomy and frontal sinus exposure was done followed by mini frontal sinusotomy using a 5mm medial eye brow incision (Fig. 3). The leak was localized, frontal mucosa removed in toto. Fat and fibrin glue was used to plug the leak and obliterate the sinus. She has been asymptomatic for the past 6 months. The frontal sinus can be entered by small medial eye brow incision or at the site of dehiscent bone.