Recent advances in paranasal sinus surgery have occurred in the treatment of trauma and neoplasia, rather than in the more traditional management of inflammatory disease. Cranialization of the frontal sinus in severe penetrating trauma was first described in 1978. By removal of the sinus posterior wall, excision of the mucosa, and preservation of the anterior wall fragments, the forehead contour can be preserved and the cavity ablated by the forward expansion of the frontal lobes. Craniofacial surgery for malignancies of the paranasal sinuses has vastly improved the survival rate for these patients. Simultaneous en bloc resection, done transcranially to establish the margins of resection of the superior-most extent and transfacially to ablate the site of origin of the neoplasm, has produced five-year survival rates of 50%. Involvement of even the cavernous sinus can be handled, providing initial control of the internal carotid artery is achieved and an adequate cerebral circulation is ensured. Decompression of the optic nerve following facial trauma that results in fractures of the orbital apex remains controversial. Documented cases of progressively failing vision in such patients provides the clearest indication. Surgical decompression through the transethmoidal sphenoidal route provides excellent access to remove the maximum amount of bone from the optic canal.