Evolution of the endoscopic modified Lothrop procedure: A systematic review and meta-analysis

Influence of Pre-Operative Estimation of Draf III Expected Diameter on Surgical Outcome

Introduction: The DRAF III procedure is indicated for the treatment of benign and selected malignant frontal sinus pathology. Several attempts have been made to find an intra or pre-operative measurement that was predictive of the feasibility of this operation and its success. Among those, the frontal sinus outflow tract anteroposterior diameter (FOAP) appears to be the one with the highest applicability in clinical practice, since it is easy to measure on pre-operative CT scan. The objective of the study is to evaluate whether the minimum and maximum frontal sinus outflow anteroposterior diameters (FOAP min and FOAP max) are associated with the risk of failure and consequently with the need for surgical revision. Secondly, we ought to evaluate whether the angle between the glabella and the nasion on the sagittal plane could influence surgical outcome. Material and Methods: This is a retrospective study on patients who underwent DRAF III for benign pathologies at a tertiary Italian referral center from January 2000 to July 2022. FOAP min and FOAP max were measured on the mid-sagittal sections of a pre-operative CT scan. The glabella-nasion angle (G-N angle) was calculated on the same sagittal section. These measurements were compared between patients who experienced a recurrence and those who did not. If a post-operative CT scan was available, the obtained anteroposterior diameter (OD) of the frontal sinus neo-ostium was also measured on the same section. A correlation analysis was performed between the three pre-operative radiologic parameters and OD. Results: Twenty-nine patients were included in the study. Six patients experienced restenosis requiring surgical revision. The median FOAP max resulted significantly higher in patients who did not experience recurrence (median: 14.8 mm, IQR: 3.84) than in patients who experienced a recurrence (median: 11.9 mm, IQR: 1.14) (p = 0.04). The FOAP max also showed a good positive correlation with OD (p = 0.0001; r = 0.7). The correlation between FOAP min and OD was not statistically significant, nor was a correlation found between FOAP min and recurrence risk. The G-N angle was not significantly different in patients who experienced recurrence and those who did not, nor did it show a correlation with OD. Discussion: The FOAP max might be a valid pre-operative radiologic parameter to guide a surgeon's approach to a DRAF III procedure, as it is easy to measure, shows a good correlation with OD, and seems to influence the risk of recurrence.

[Local flap reconstruction techniques after frontal sinus drainage type II and III according to Draf]

BACKGROUND

Extended endonasal endoscopic frontal sinus surgery is characterized by bone resection beyond the lamellae of the frontal sinus and is currently classified according to Draf as type IIa, type IIb, modified type III (also referred to as type IIc), and type III. This approach is indicated when the surgical goal cannot be achieved through complete removal of the anterior ethmoidal cells. Numerous studies indicate restenosis rates ranging from 7 to 36%, despite creation of maximal openings. Exposed bone, which tends to epithelize slowly with significant crusting and the risk of uncontrolled wound healing depending on the local environment and other factors, is considered a contributing factor. Covering the exposed bone with mucosa can significantly reduce the risk of restenosis.

METHODS AND RESULTS

A variety of flap techniques for frontal sinus drainage in Draf III procedures are presented, including some variants that were part of presentations at the 2023 Congress of the European Rhinologic Society in Sofia, Bulgaria. These include combinations of free mucosal grafts, pedicled mucosal flaps, and hybrids combining both techniques. Additionally, the results of current studies are presented.

CONCLUSION

The results and achieved opening areas in contemporary Draf III surgeries are significantly improved and larger compared to the early stages of these procedures. A multitude of published studies consistently demonstrate that outcomes are markedly improved with mucosal coverage. Depending on the prevailing anatomy, mucosal conditions, and the extent of the surgical intervention, the most suitable technique should be selected. Therefore, proficiency in various methods is crucial. The use of a flap technique (free, pedicled, or combinations thereof) should be defined as the standard when performing extended frontal sinus surgery (Draf IIb, IIc, III, or endonasal frontal sinus surgery [EFSS] 4-6).

Anatomic Relationship Between the Head of the Middle Turbinate and First Olfactory Filum: A Radiographic Assessment

BACKGROUND

The endoscopic modified Lothrop procedure (EMLP) has become a frequently utilized procedure in rhinologic surgery. One of the most serious complications of the procedure is cerebrospinal fluid leak, which may occur due to lack of recognition of the anterior skull base in the region of the first olfactory filum (FOF), or direct injury to the FOF itself.

OBJECTIVES

To evaluate the position of the head of the middle turbinate (MT) relative to the FOF, which is an important landmark in the EMLP.

METHODS

A series of previously obtained patient computed tomography scans of the sinus were reviewed. A reproducible process was implemented to obtain the measurements. First, the FOF was identified on an axial series. Using a localization feature of the radiographic software, this anteroposterior (AP) position could be visualized in a coronal plane. Subsequently, the MT was viewed in a sagittal plane, where a measurement between the head of the MT and the AP position of the FOF could be performed.

RESULTS

The AP distance between the head of the MT and the FOF was measured in 92 patients. The head of the MT was either at or anterior to the FOF in all measured subjects. The mean anterior distance of the head of the MT to FOF was 3.6 mm (±2.4 mm) on the right, and 3.8 mm (±2.2 mm) on the left. The range in AP distance was 0 to 12 mm. There was no significant difference in AP distance between the head of the MT and FOF based on gender (P = .413) or diagnosis (P = .254).

CONCLUSIONS

In our study, the head of the MT was reliably at or anterior to the FOF in all subjects, suggesting its utility as a fixed landmark in endoscopic sinus surgery, particularly in the EMLP.

LEVEL OF EVIDENCE

N/A.

["Radical" versus "functional" surgery of the paranasal sinuses-A contradiction?]

BACKGROUND AND OBJECTIVE

The terms "functional" and "radical" paranasal sinus surgery were often considered to be different operations which were mutually exclusive. This overview aims to look at the basics of these terms and surgical procedures and to work out the resulting surgical concepts for clinically relevant indications.

MATERIAL AND METHODS

Selective literature analysis using the data base PubMed, corresponding textbooks and resulting secondary literature regarding functional and radical or extended paranasal sinus surgery. Similarly, the current literature regarding clinically relevant indications for sinus surgery were analyzed.

RESULTS AND CONCLUSION

Modern pathophysiological knowledge, anatomically and pathophysiologically substantiated endoscopic surgical procedures and the usage of up to date technical possibilities have resulted in concepts which combine functional and so-called radical or extended surgery of the paranasal sinuses that complement each other and sometimes even overlap. The preoperative diagnosis and definition of underlying diseases are decisive and should be as precise as possible, as the extent and surgical details mainly depend on them: a sole creation of free drainage pathways, an additional creation of anatomical access for subsequent topical treatment or a complete (radical) removal of a pathological process.

The role of large cavity sinus surgery in the management of chronic rhinosinusitis in non-steroidal anti-inflammatory drug exacerbated respiratory disease: a single-centre experience and long-term outcomes

OBJECTIVE

This study aimed to discuss the role of large cavity functional endoscopic sinus surgery in the management of chronic rhinosinusitis with nasal polyps in patients with non-steroidal anti-inflammatory drug exacerbated respiratory disease.

METHODS

This was a retrospective review of patients undergoing large cavity functional endoscopic sinus surgery for non-steroidal anti-inflammatory drug exacerbated respiratory disease from January 2016 to March 2022. Population characteristics, pre- and post-operative number of functional endoscopic sinus surgical procedures, endoscopic polyp grade, Lund-Mackay score and nasal symptoms were recorded.

RESULTS

Thirteen consecutive patients with a median age of 47 years were included. They all failed maximal medical treatment and/or conservative functional endoscopic sinus surgery and underwent large cavity sinus surgery followed by post-operative maximal medical therapy. All patients showed an improvement in nasal symptoms with improved Lund-Mackay scores post-operatively. The median length of follow up was 1.5 years.

CONCLUSION

Large cavity functional endoscopic sinus surgery seems to halt the progression of chronic rhinosinusitis with nasal polyps in non-steroidal anti-inflammatory drug exacerbated respiratory disease. In this case series, large cavity functional endoscopic sinus surgery combined with optimal post-operative medical treatment appeared to switch off chronic rhinosinusitis with nasal polyps in patients with non-steroidal anti-inflammatory drug exacerbated respiratory disease.

Utility of flexible interventional endoscopy in endoscopic sinus surgery: a case series

PURPOSE

During endoscopic sinus surgery (ESS), difficult-to-reach pathologies need an extended endoscopic approach or an external approach. We started to use a flexible interventional endoscope (FIE) to evaluate the necessity of those approaches. The study's objective is to describe our experience and define patients who could benefit from this technique.

METHODS

We reviewed every patient who benefited from FIE associated with ESS at our tertiary University Hospital between January 2021 and February 2022.

RESULTS

During this period, we did 107 ESS, and 14 patients benefited from the FIE, representing 13% of our ESS. The median duration of the flexible endoscopy time was 14 min (4-38 min). We identified three groups of patients who can benefit from the FIE. The first one is for patients with a fungal infection, to control and to clean lateral recesses in a noninvasive manner. The second one is for patients with a pathology of the lateral frontal sinus, to remove the frontoethmoidal cells or mucocele with the biopsy forceps through the working channel. The third group is for patients with inverted papillomas, to precisely identify the insertion and to decide on the most appropriate surgical approach.

CONCLUSIONS

In selected cases, using flexible endoscopy during ESS helps decide the optimal surgical approach and sometimes treat the pathology through a limited approach. Prospective studies for each group of patients are needed to confirm the benefit of this new combined procedure.

[History of frontal sinus surgery and current view of the problem. Part 2]

Surgical treatment of inflammatory diseases of the frontal sinus is one of the biggest challenges of modern otorhinolaryngology. Close proximity of the frontal sinus and frontal sinus drainage pathways to the skull base, the orbit and the anterior ethmoid artery, great limitations with its visualization and instrumentation, and high risk of the frontal recess scarring cause difficulties in either endoscopic or external approaches to the frontal sinus. At the same time endoscopic approach to the frontal sinus is considered as preferred method of frontal sinusitis surgical treatment by majority of peers nowadays. The introduction of extended approaches to the frontal sinus pathology treatment with frontal sinus floor and interfrontal sinus septum drill-out as well as superior septectomy with common drainage pathway formation gave an opportunity to greatly decrease a rate of indications for external frontal sinus procedures. In this paper historical backgrounds of endonasal approaches to frontal sinuses are presented, current controversies in proper selection of extent and methods of the frontal sinus surgery are analyzed and endoscopic as well as external approaches to frontal sinuses are summarized.

The Draf III procedure: A review of indications and techniques

The Draf Ⅲ procedure involves the creation of a common frontal sinus cavity. The most common indication for the Draf Ⅲ procedure is chronic rhinosinusitis of the frontal sinuses despite the failure of more conservative interventions such as bilateral Draf Ⅱa procedures. Primary Draf Ⅲ may be indicated in patients with a high risk of failures such as those with severe polyposis and those with a frontal sinus opening less than 4 mm on computed tomography imaging. Other indications for the Draf Ⅲ include access for tumor removal and repair of traumatic fractures of the frontal sinus. The “inside‐out” Draf Ⅲ procedure is the standard approach when the frontal recess anterior–posterior diameter is wide enough for instrument access, usually larger than 4–5 mm. The “outside‐in” Draf Ⅲ procedure can be done when the frontal recess is too narrow to safely accommodate instruments. Regular follow‐up with debridement should be done to prevent neo‐ostium stenosis.

Value of a lateral inferior pedicle flap in Draf IIb for recurrent frontal sinus diseases: a prospective study

Purpose

The Draf IIb procedure allows the widest unilateral access to the frontal sinus in a minimally invasive fashion, with efficiency and safety comparable to the Draf III. However, this technique is still associated with a high postoperative stenosis rate. The exposure of drilled bone induces osteitis predisposing to scarring and neo-osteogenesis causing ostium restenosis. We developed a novel lateral inferior pedicle flap (LIPF) to cover the exposed bone and prevent restenosis during Draf IIb. We aimed to describe our technique.

Methods

Adult patients requiring a Draf IIb for unilateral recurrent frontal sinus disease were prospectively enrolled. A LIPF technique was systematically performed. Demographics and complications were recorded. The primary outcome measure was neo-ostium patency at 12 months. In patients with chronic rhinosinusitis (CRS), the clinical control rate was evaluated at 12 months.

Results

59 patients underwent the Draf IIb with LIPF technique from 2013 to 2021. 49 patients (20 women/29 men, median age of 48.0 years) completed at least 12 months of follow-up (median 41.0 months, range 12–100 months). Indications included recalcitrant CRS (n = 32), inverted papilloma (n = 9) and frontal mucocele (n = 8). Overall, the neo-ostium remained patent at 12 months in all patients, and the clinical control rate of 32 patients with recalcitrant CRS at 12 months was 100%. No main complications were recorded.

Conclusion

The LIPF technique was associated with a high rate of success for a Draf IIb.

Minimally Invasive Endoscopic Sinus Surgery for Frontal Sinus Pathologies Using Interventional Flexible Bronchoscopy: Case Reports

Background: Lateral pathologies of the frontal sinus are difficult to visualize and treat with classical endoscopic sinus surgery (ESS) using rigid endoscopes and instruments. Hence, they often require extended endoscopic or external approaches. Methods and Results: We describe the advantages of using interventional flexible bronchoscopy in frontal ESS without extended approaches in 2 illustrated cases: (1) A fungus ball in the frontal sinus with a frontoethmoidal cell. The flexible bronchoscope allowed treatment of all recesses of the frontal sinuses and the opening of a frontoethmoidal cell through a Draf IIa. (2) A revision surgery with a frontoethmoidal cell obstructing drainage pathway was successfully treated with this same technique. Patients did not experience complications or recurrent symptomatology after, respectively, 4 and 15 months of follow-up. Conclusion: Flexible bronchoscopy allows a good visualization and treatment of lateral frontal sinus pathologies through limited endoscopic approaches. Through-the-scope instruments permit the resection of frontoethmoidal cells.

Development of a nasal mucosa-removal model for evaluating cell therapy

Introduction

Endoscopic sinus surgery is an effective surgical procedure for treating chronic sinusitis; however, extensive exposure of the bone in the nasal cavity can result in permanent disability postoperatively. Particularly, closure of the sinus drainage pathway due to bone hyperplasia associated with bone exposure can trigger the recurrence of sinusitis. It is essential to regenerate the nasal mucosa after surgery to avoid bone hyperplasia. Regenerative medicine, including cell therapy, could be one of the leading options for nasal mucosa regeneration. To date, there is a lack of effective models for evaluating treatments for prevention of bone hyperplasia that occurs after sinus surgery. The purpose of this study was to develop a model of nasal mucosal removal to evaluate cellular therapies.

Methods

The model was created in rabbits, a species with a wide nasal structure, and was generated by approaching the maxillary sinus from the nasal bone side and solely removing the maxillary sinus mucosa without destroying the structures in the nasal cavity. Adipose-derived mesenchymal stromal cell sheets prepared in temperature-responsive cell culture dishes were examined for the effect of transplantation in the animal model. Intranasal evaluation was assessed by micro-computed tomography and tissue staining.

Results

Significant bone hyperplasia in the maxillary sinus occurred on the side of mucosal removal, and no bone hyperplasia occurred in the control sham side in the same rabbits on postoperative day 28. Bone hyperplasia was observed over a short time period, with the presence of bone hyperplasia in the maxillary sinus on day 14 and calcification of the bone on day 28. The adipose-derived mesenchymal stromal cell (ADSC) sheet was transplantable in a nasal mucosa-removal model. No significant differences in bone hyperplasia were found between the transplantation side and the sham side in terms of the effect of transplantation of the ADSC sheet; however, bone hyperplasia tended to be suppressed on the transplantation side.

Conclusions

This animal model is simple, highly reproducible, and does not require special equipment or drugs. In addition, this model can be used for various therapeutic interventions, including cell therapy. The presence or absence of the nasal mucosa affects bone remodeling, which highlights the importance of regeneration of the nasal mucosa. In the nasal mucosal regeneration therapy, the ADSC sheet had an inhibitory effect on bone hyperplasia. The nasal mucosa-removal model allows observation of conditions associated with nasal mucosa removal and evaluation of the effectiveness of cell therapy.

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The nasal mucosa-removal model is simple and highly reproducible.

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The nasal mucosa-removal model does not require special equipment or drugs.

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Bone hyperplasia in the maxillary sinus occurred on the side of mucosal removal.

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This model allows observation of conditions associated with nasal mucosa removal.

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Our model allows evaluation of the effectiveness of cell therapy.

The use of grafts in frontal sinus drill-outs

PURPOSE OF REVIEW

A significant complication of the frontal sinus drill-out procedure is restenosis of the frontal neo-ostium. To improve postoperative healing in this region, various mucosal grafts and pedicled flaps have been designed to reconstruct the mucosal lining of the frontal neo-ostium. We provide an overview of the types of grafts described for reconstruction and discuss the latest evidence on their efficacy.

RECENT FINDINGS

Frontal neo-ostium mucosal reconstruction may be performed using free, pedicled, or a combination of grafts. There are several case series that report good outcomes and low revision rates following the use of grafts in frontal sinus drill-outs, and one randomized controlled study demonstrating increased ostial patency. However, the use of grafts did not alter the rate of revision surgery and only one study reported an improvement in Sino-Nasal Outcome Test-22 scores after one year.

SUMMARY

Studies have suggested that frontal sinus drill-out grafts result in favorable restenosis and graft success rates. However, larger randomized control trials will be required to determine whether frontal sinus drill-out grafts contribute to a tangible clinical benefit for patients.

Surgeon cost feedback through a surgical receipt program reduces cost in sinonasal surgery

BACKGROUND

Operating room (OR) costs are a large portion of healthcare expenses. This study evaluates the impact of a surgeon-targeted surgical receipt cost feedback system on OR supply costs in sinonasal surgery and individual components contributing to procedural cost.

METHODS

Itemized weekly surgical receipts detailing individual case supply costs were analyzed before and after the implementation of a non-incentivized surgeon cost feedback system between January 2017 and June 2019. Supply cost data collected 15 months prior to intervention was compared to cost data 15 months after implementation of the weekly automated receipt dissemination to surgeons. Chi square test was used for categorical data and the Wilcoxon test was used to compare change in cost. Univariate and mediation analyses were performed to assess variables impacting cost.

RESULTS

Of 502 sinonasal procedures analyzed, 239 were before and 264 after cost feedback implementation. There were no significant differences in age/gender, or indication for surgery. The median OR supply cost decreased from $1229.64 to $1097.22 (p = 0.02) after receipt implementation. There were effects of procedure type (p = 0.02), circulating nurse specialization (p < 0.001), steroid eluting stent (p = 0.002), and sinus drill (p < 0.001) on cost. Mediation analysis confirmed full mediation by decreasing use of steroid-eluting stents.

CONCLUSION

Surgeon cost feedback in the form of individualized OR surgical receipts is an effective model to reduce supply cost per case in sinonasal surgery.

Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

OBJECTIVE

To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions.

RESULTS

Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews.

CONCLUSION

Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

Frontal osteoplastic flap without frontal sinus obliteration for orbital roof decompression

Purpose: We describe a novel surgical approach for bilateral orbital roof decompression using a frontal osteoplastic flap without frontal sinus obliteration. This technique utilizes a combined external and endonasal endoscopic approach for wide exposure to the orbital roof bilaterally. We demonstrate this technique for the resection of a massive frontal fibrous dysplasia lesion in a healthy male with bilateral orbital roof involvement. The endonasal endoscopic portion of the technique includes a Draf III frontal sinusotomy (endoscopic modified Lothrop procedure) which precludes the need for frontal sinus obliteration, restores normal frontal sinus function, and allows for postoperative endoscopic surveillance. Methods: Report of novel surgical technique with video demonstration. Results: This technique for orbital roof decompression allows for removal of a frontal lesion, wide decompression of the bilateral orbital roof, and post-operative endonasal endoscopic surveillance of the cavity. The patient in whom we demonstrate this technique had complete resolution of his orbital symptoms and minimal residual fibrous dysplasia postoperatively. Conclusion: Bilateral orbital roof decompression for frontal lesions can be performed safely and effectively with a frontal osteoplastic flap without frontal sinus obliteration, restoring normal orbital and sinus function.

Transpalpebral Frontal Sinus Septectomy: Feasibility and Results

Background

Transpalpebral frontal septectomy (TFS) can be performed for unilateral frontal sinusitis drainage (into the contralateral healthy frontal sinus) or to provide access to the lateral extent of the contralateral frontal sinus. This procedure has demonstrated its usefulness in several problematic situations for the endoscopic surgeon.

Objective

The main objective of our study was to evaluate the feasibility of TFS. Secondary objectives were to define outcomes, early and late complications, contraindications, and failure rates of the TFS.

Methods

We reviewed patient demographics including age and gender, indication for frontal septectomy, prior surgeries, failure rates and necessity of revision surgery, early and late complications, and the side of the approach (ipsi- or contralateral to the frontal sinus pathology). Twenty patients who had undergone TFS were included. Patients were classified into 2 groups according to the surgical indication: group 1—TFS performed for unilateral frontal sinusitis to drain a frontal sinus in the contralateral frontal sinus; and group 2—TFS performed to provide access to the lateral extent of the contralateral frontal sinus. Scarring was assessed using the SCAR-Q questionnaire.

Results

TFS was performed on all patients in Groups 1 and 2 (success rate = 100%). No patients had recurrence of the pathology 6 months after surgery (0%). No patient needed revision surgery (0%). One complication (frontal hypoesthesia) was reported 6 months after surgery. Mean SCAR-Q score was 99.3 ± 2.5 (min = 91/100, max = 100/100).

Conclusion

TFS was feasible for all patients in this study. This procedure permits drainage of the frontal sinus and gives access to the lateral extent of the contralateral frontal sinus, without visible scarring, and with few lasting complications. Authorization to conduct this study was obtained from the Ethical Committee of our institution (APHM, n°2019_65).

Effect of a Superior Lateral Anterior Pedicle Flap for Draf Procedures

Several types of flap techniques have been developed to cover exposed bone after Draf procedures to reduce the possibility of re-stenosis. These techniques are relatively new and detailed measurements of the size of neo-Ostia during follow-up have not been reported. The authors aim to assess outcomes precisely by not only using endoscopic evaluation but also by measuring the diameter of the ostium and the thickness of the nasal beaks on pre- and postoperative computed tomography images. The authors reviewed 25 patients with 37 nasal cavities who have undergone a Draf surgery with a previously-reported superior lateral anterior pedicle flap technique. The anteroposterior (AP) distance of the frontal recess and the thickness of the nasal beaks were measured before, immediately after, and more than 6 months after surgery. Measured distances were statistically analyzed. The neo-ostium remained patent in long-term follow-up of all patients. The AP distance of the frontal recess and the thickness of the nasal beak were preserved during follow-up. Neither synechiae nor orbital injuries occurred. In conclusion, Draf type II and III procedures with superior lateral anterior pedicle flaps are safe and effective. Neo-Ostia remained patent throughout the follow-up period.