Follow-up of University of Virginia experience with the modified Lothrop procedure

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.

Outcomes of the Modified Endoscopic Lothrop Procedure

Background

The aim of this study was to examine the long-term outcomes of the modified endoscopic Lothrop procedure for the management of the most severe forms of recalcitrant chronic frontal sinusitis.

Methods

This case series evaluated 13 consecutive cases of the modified endoscopic Lothrop procedure for chronic frontal sinusitis from April 1996 to December 1999. Patent communication to the frontal sinus was evaluated by postoperative endoscopic exam. Postoperative patient symptomatology and medication requirements were assessed during clinic evaluation and by standardized telephone questionnaire.

Results

At a mean follow-up period of 34.5 months, a 77% patency rate was obtained, with 2 of the 13 patients requiring an osteoplastic flap with obliteration. Telephone questionnaire results indicate improved symptoms and decreased medication requirements in the majority of patients who maintained patency.

Conclusions

These results show that the modified endoscopic Lothrop procedure provides a good alternative to the osteoplastic flap with obliteration for patients with the most severe forms of chronic frontal sinusitis. Initially, high patency rates decline with longer-term follow-up, and severe forms of chronic rhinosinusitis continue to significantly impact patient-perceived quality of life in some patients. The modified endoscopic Lothrop procedure should be reserved for patients who have failed more conservative endoscopic approaches to the frontal recess.

The Endoscopic Modified Lothrop: Long-Term Follow-Up on 44 Patients

Background

The gold standard for surgical treatment of chronic frontal sinusitis has been the osteoplastic flap with obliteration. In an attempt to preserve the frontal sinus, we have been performing the endoscopic modified Lothrop or frontal drill-out.

Methods

Retrospective chart review.

Results

We performed the modified Lothrop on 54 patients between 1993 and 1998. The modified Lothrop was successful (no revision surgeries and only an occasional need for antibiotics) after one procedure in 68% (30/44) of patients followed up for ≥1 year. Six patients underwent successful revision, bringing the overall success rate to 82% (36/44). Eight patients (18%) eventually underwent osteoplastic flap with obliteration, three of those after attempted revision. Mean follow-up was 40 months with failures occurring a mean of 12 months after initial Lothrop. Overall complication rate was 11%.

Conclusions

The modified Lothrop is a technically challenging operation that provides an acceptable alternative to the osteoplastic flap with obliteration.

The Effect of the Modified Endoscopic Lothrop Procedure on the Mucociliary Clearance of the Frontal Sinus in an Animal Model

Background

The surgical management of recalcitrant frontal sinus disease has been a dilemma for otolaryngologists for many years. Although the osteoplastic flap with obliteration has been the gold standard of treatment for years, the modified endoscopic Lothrop (MEL) procedure recently has been advocated as an alternative. However, little is known about the effect of this procedure on the mucociliary drainage of the frontal sinuses postoperatively and this animal study addresses this issue.

Methods

Fourteen sheep underwent the MEL procedure. The sheep were randomized regarding the use of postoperative irrigation via minitrephines. Each sheep had a nuclear medicine γ-scintigraphy frontal sinus clearance study via minitrephines performed on each frontal sinus preoperatively and then 3 months postoperatively. Then, the results of these studies were compared.

Results

The scans revealed a trend toward faster clearance times postoperatively. However, this decrease was not statistically significant. Importantly, there was no trend or significant increase in clearance times postoperatively. Also, the use of postoperative irrigation was associated with a nonsignificant trend toward faster clearance times postoperatively.

Conclusion

The MEL procedure has no adverse effects on the mucociliary clearance of the frontal sinus at 3 months postoperatively. Irrigation of the frontal sinus in the immediate postoperative period showed a trend toward improved postoperative mucociliary function at 3 months.

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

OBJECTIVE

Since first described in the 1990s, the endoscopic modified Lothrop procedure (EMLP) has been the subject of a growing body of literature. We performed a review to compare indications and outcomes of EMLP in an early cohort of publications (1990-2008) versus a contemporary cohort (2009-2016) and compare outcomes associated with follow-up ≥2 years versus <2 years.

DATA SOURCES

PubMed, SCOPUS and Cochrane databases.

REVIEW METHODS

An English-language search of the PubMed and Ovid databases was conducted to identify publications from 1990 to 2016 reporting clinical outcomes of EMLP. Meta-analysis was performed using Statistical Analysis System 9.4.

RESULTS

A total of 1,205 patients were abstracted from 29 articles with a mean follow-up of 29.1 ± 10.3 months. The overall rate of significant or complete symptom improvement was 86.5% (95% confidence interval [CI]: 84.2%-88.7%). The overall patency rate was 90.7% (95% CI: 89.1%-92.3%), with a revision rate of 12.6% (95% CI: 10.6%-14.3%). Compared to the early cohort, patients in the contemporary cohort underwent EMLP more often for tumors (P < .001), had higher rates of complete or significant symptom improvement (90.0% vs. 82.6 %, P < .001); and trended toward greater patency rates (92.1% vs. 88.6%, P = .052). Compared to the short-term follow-up cohort, the long-term cohort showed no differences in symptom improvement or patency, but the revision rate was higher (14.5% vs. 9.2%, P = .016).

CONCLUSIONS

In the last decade, EMLP has been performed more frequently for tumors. Recent studies have demonstrated improved symptom outcomes and a trend toward improved patency rates. The revision rate increased significantly when follow-up exceeded 2 years. Laryngoscope, 128:317-326, 2018.

Economics of Chronic Rhinosinusitis

PURPOSE OF REVIEW

The objective of this article is to provide an updated review of the economic burden of chronic rhinosinusitis (CRS) and discuss how both medical and surgical interventions impact direct and indirect costs related to CRS. By understanding the economics of CRS, clinicians may improve the patient-centeredness of their care and help distinguish between low and high value interventions.

RECENT FINDINGS

Direct costs related to CRS are primarily driven by outpatient physician visits, prescription medical therapy, and endoscopic sinus surgery (ESS). CRS produces large indirect costs and these costs often vary based on the severity of the patients CRS-specific QoL impairment. The overall direct cost related to CRS is estimated to range between $10 and $13 billion per year in the USA. The overall indirect cost related to CRS-related losses in work productivity is estimated to be in excess of $20 billion per year. In the appropriate patients with refractory CRS, ESS provides significant reductions in both direct and indirect costs; however, continued medical therapy alone may be a high value intervention in select patients who have lower severity in their baseline QoL and work productivity.

Outcomes After Frontal Sinus Surgery: An Evidence-Based Review

Endoscopic sinus surgery is an effective intervention at improving quality of life for patients with medically refractory chronic rhinosinusitis. The evidence supporting frontal sinusotomy is limited to single institution case series. However, the data for Draf IIa frontal sinusotomy do demonstrate that most patients experience lasting frontal sinus patency on postoperative endoscopic examination and improvements in quality of life. Salvage endoscopic frontal sinus surgery via a Draf III shows high rates of neo-ostium patency and subjective improvements in symptoms at a 2-year time point in case series.

The Endoscopic Modified Lothrop Procedure for Salvage of Chronic Frontal Sinusitis after Osteoplastic Flap Failure

OBJECTIVE

While reported results utilizing the osteoplastic flap procedure are very good, some patients fail the surgery due to recurrent or persistent frontal sinus disease. This study was performed to evaluate the utility of the endoscopic modified Lothrop sinus surgery for osteoplastic flap failure.

STUDY DESIGN AND SETTING

A retrospective chart analysis and telephone survey of 10 patients from outside our institution for whom an osteoplastic flap with fat obliteration failed were salvaged using a computerized endoscopic modified Lothrop procedure.

RESULTS

The main complaints were headache/pressure and recurrent infection. The usual pathology was chronic sinusitis and/or mucocele. The frontal recess and floor of the frontal sinus were the most common areas of persistent disease. Symptomatic clinical improvement was noted in more than 90% of patients.

CONCLUSION

Salvage endoscopic modified Lothrop sinus surgery is recommended for a limited number of traditional osteoplastic flap failures. Computerized surgical navigation may help avoid complications in situations with abnormal anatomy and previous dissection.

SIGNIFICANCE

The endoscopic modified Lothrop procedure should be considered to salvage failed osteoplastic flap sinus obliteration.

A golden experience: Fifty years of experience managing the frontal sinus

OBJECTIVES/HYPOTHESIS

The frontal sinus is one of the most anatomically complex and inaccessible of the paranasal sinuses. As a result, surgeons have continually tried to improve surgical management of the frontal sinus. The senior author (c.w.g.) shares 50 years of experience managing the frontal sinus.

DATA SOURCES

PubMed literature search.

REVIEW METHODS

Review of the literature regarding landmark innovations in frontal sinus surgery.

RESULTS

Open approaches established that the frontal sinus is accessible, and in certain circumstances, such as with large osteoma or papilloma, are still required. The endoscope changed the surgical landscape and allowed for greater finesse and decreased morbidity. Sinus balloon dilation is the newest change in frontal sinus management and shows promise in properly selected cases.

CONCLUSION

Surgery of the frontal sinus continues to evolve and improve. Although there are new techniques, the older techniques are still pertinent.

Draf III Extension in the Endoscopic Endonasal Transethmoidal, Transcribriform Approach Through the Back Wall of the Frontal Sinus: A Cadaveric Study

BACKGROUND

The Draf III (modified endoscopic Lothrop) procedure has been proposed to extend the endonasal transethmoidal, transfovea ethmoidalis, and transcribriform approach through the back wall of the frontal sinus. The exposure is time-consuming and increases the risk of cerebrospinal fluid leak, and the indications for use are not well described. There are few data quantifying the advantage it conveys over the approach without the Draf III procedure.

METHODS

An endoscopic, endonasal transfovea, transcribriform approach was performed in 5 fresh, injected cadaveric heads. Anatomic boundaries and measurements of the exposure were compared before and after addition of a Draf III procedure. Computed tomography scans were performed before and after dissection, and additional radiographic measurements were made to quantify the additional exposure provided by the Draf III procedure. Also, 2 clinical cases are presented in which a Draf III procedure was used.

RESULTS

The mean anterior to posterior boundary from the frontal sinus to the planum sphenoidale before the Draf III procedure was 3.0 cm and after the Draf III procedure was 3.8 cm with an average change of 0.8 cm. After the Draf III procedure, the mean anterior to posterior boundary from the posterior wall of frontal sinus to the planum sphenoidale increased from 3.0 cm to 4.3 cm. There was an average increase of 1.3 cm with an average increased area of view of 1.79 cm(2).

CONCLUSIONS

This study quantifies the increased field of view provided by the Draf III procedure during anterior skull base dissection. Recommendations for preoperative examination of radiographic evidence are provided to help identify which individuals would benefit from the additional exposure.

Medial and Superior Orbital Decompression: Improving Access for Endonasal Endoscopic Frontal Sinus Surgery

OBJECTIVE

Visualization by Draf I-III endoscopic access to the frontal sinus via drainage pathways is sometimes inadequate. We compare lateral frontal sinus exposures by Draf approaches versus our modification of removing the medial-superior wall of the orbit while preserving the periorbita.

METHODS

Twenty cadaveric heads dissected using Draf IIB, III, and modified Draf III with medial and superior orbital decompression (MSOD) underwent thin-cut computed tomography (CT) scanning. Under image guidance, measurements extended from the midline crista gali to the most lateral point of the frontal sinus. A case report shows the modified Draf III improved frontal sinus access.

RESULTS

Comparing Draf IIB and III with Draf III with MSOD, respectively, distances between midline and most lateral point averaged 19.1 mm, 23.7 mm, and 30.4 mm (left) and 18.7 mm, 25.1 mm, and 32.2 mm (right). Differences between Draf III with/without MSOD were 6.65 mm (left) and 7.09 mm (right); 12 heads were excluded because of under-pneumatization of the sinuses.

CONCLUSIONS

Draf III with MSOD extended surgical access to lateral regions of the frontal sinus. This extension achieved better visualization and instrumentation with minimal removal of the frontal bone's orbital segment anterior and superior to the anterior ethmoidal artery while preserving the periorbita.

Cost of adult chronic rhinosinusitis: A systematic review

OBJECTIVE/STUDY DESIGN

The objective of this systematic review was to summarize the literature evaluating the costs associated with the management of adult chronic rhinosinusitis (CRS) using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

Two separate authors systematically searched eight commonly used medical databases. Included articles were categorized into seven domains: 1) overall healthcare cost (direct and indirect), 2) resource utilization, 3) medical management strategies, 4) overall procedure cost of endoscopic sinus surgery (ESS), 5) intraoperative technologies, 6) ESS litigation, and 7) CRS diagnostics. To maintain a common currency for comparison, all costs were converted to 2014 United States dollars (USD) using an inflation calculator in September 2014.

RESULTS

Forty-four studies were identified for inclusion. The range for overall CRS-related healthcare costs was $6.9 to $9.9 billion 2014 USD per year. Indirect costs were estimated as $13 billion 2014 USD per year. Annual medication costs prior to ESS ranged between $1,547 and $2,700 2014 USD per patient, with a uniform reduction in costs after ESS. The overall US cost of outpatient ESS ranged from $8,200 to $10,500 2014 USD per case. The overall annual economic burden of CRS in the United States was estimated to be $22 billion 2014 USD (direct and indirect costs).

CONCLUSION

The results of this systematic review have demonstrated substantial direct and indirect costs associated with the management of adult CRS. Future research should continue to improve the costing data, which can be used to improve the value of care provided for this chronic inflammatory disease.

Frontal sinus drillout (modified Lothrop procedure): long-term results in 204 patients

OBJECTIVES/HYPOTHESIS

To determine the long-term results of frontal sinus drillout (also known as modified Lothrop procedure) for the treatment of advanced frontal sinus disease.

STUDY DESIGN

Retrospective review.

METHODS

The records of patients who underwent frontal sinus drillout by a single surgeon at an academic medical center from June 1995 through November 2011 were reviewed. Patient demographics and perioperative clinical findings were analyzed for their impact on surgical outcome. Failure was defined as restenosis of the frontal drainage pathways, necessitating additional frontal sinus surgery.

RESULTS

A total of 204 patients underwent frontal drillout surgery (143 bilateral procedures) over the 16-year period. Mean follow-up was 10.2 years (range 0.9-17 years). Symptomatic re-obstruction of the frontal sinus requiring revision surgery occurred in 61 (29.9%) patients. Drillouts performed for a diagnosis of mucocele or tumor had significantly higher failure rate (38.9%, odds ratio [OR] = 2.9, P = 0.022 and 58.3%, OR = 5.3, P = 0.020, respectively). The majority of surgical failures (61%) occurred within 2 years of surgery, but delayed failures were observed up to 12 years after drillout. Clinical outcome did not correlate with a history of smoking, asthma, nasal allergy, aspirin sensitivity, prior sinus surgery, nasal polyposis, or the presence of eosinophilic mucin.

CONCLUSION

For the majority of patients who undergo frontal sinus drillout, patency of the frontal sinus outflow tract appears to be maintained for more than a decade; nevertheless, almost one-third of patients who undergo this procedure will ultimately require additional frontal sinus surgery.

Modified Lothrop procedure in cystic fibrosis patients: does it have a role?

BACKGROUND

The management of frontal sinus disease in cystic fibrosis patients represents a challenge for many surgeons. Procedures can vary from the minimally invasive to those involving extensive open surgery.

OBJECTIVE

This study describes the outcomes of the endoscopic modified Lothrop procedure, in terms of safety and morbidity, for cystic fibrosis patients with frontal sinus disease who did not improve following traditional functional endoscopic sinus surgery.

METHOD AND RESULTS

The study setting was a tertiary referral unit in a London teaching hospital, the largest national base for adult cystic fibrosis patients. Two patients diagnosed in childhood with cystic fibrosis presented with histories of recurrent, severe frontal sinusitis; both had previously undergone multiple endoscopic sinus surgical procedures. The modified Lothrop procedure was performed on both patients. The outcome measures were symptom resolution and post-operative complications.

CONCLUSION

The endoscopic modified Lothrop procedure was beneficial in the cystic fibrosis patients with frontal sinus disease who failed to respond to standard functional endoscopic sinus surgery procedures.

A blinded randomized controlled trial evaluating the efficacy of chitosan gel on ostial stenosis following endoscopic sinus surgery

BACKGROUND

Stenosis of sinus ostia following endoscopic sinus surgery (ESS) is the most common reason for revision surgery. Chitosan-dextran (CD) gel has been shown to be an effective hemostatic agent; however, its effects on ostial stenosis are unknown. This study aims to quantify the effect of CD gel on circumferential scarring following ESS.

METHODS

A prospective, blinded, randomized, controlled trial was conducted in 26 patients undergoing ESS. Measurements of neo-ostia were taken using a standard-sized measuring probe. CD gel was applied unilaterally, while contralateral sides received no gel. Ostial diameters were measured by a blinded observer at 2, 8, and 12 weeks postoperation. Sinus ostial areas calculated as a proportion of the original were compared for each ostium at each time point.

RESULTS

Intraoperative ostial areas were comparable for CD gel and control sides (38 mm(2) vs 39 mm(2) , 131 mm(2) vs 120 mm(2) , and 203 mm(2) vs 193 mm(2) , in frontal, sphenoid, and maxillary ostia, respectively; p > 0.05). CD gel significantly improved sinus ostial patency. The largest difference was seen when ostial areas at 12 weeks were compared with their corresponding baseline areas (66% vs 31% frontal, p < 0.001; 85% vs 47% sphenoid, p < 0.001; and 74% vs 54% maxillary ostia, p = 0.002). The difference between raw ostial areas reached statistical significance in sphenoid (p < 0.001) and maxillary (p = 0.01), but not in frontal ostia (p > 0.05) at 12 weeks.

CONCLUSION

CD gel produced significantly less stenosis of all neo-ostia following ESS and may reduce the necessity for revision surgery in patients with chronic rhinosinusitis.

The outside-in approach to the modified endoscopic Lothrop procedure

OBJECTIVES/HYPOTHESIS

Drilling in modified endoscopic Lothrop procedure (MELP) is traditionally described as commencing from the frontal recess (FR). This is challenging when the FR is involved by tumor, inflammatory disease, or scarring. The outside-in MELP, where the limits of the sinusotomy are first defined and the FR is addressed last, is described.

STUDY DESIGN

Case-control study.

METHODS

Patients undergoing MELP, using the standard or outside-in approach, for inflammatory disease or endoscopic skull base surgery were assessed. Data were collected on demographics, disease characteristics, and FR involvement. Operative time was calculated from intraoperative video recording. Time points recorded were times to frontal sinus and recess connected for outside-in MELP and completion of Lothrop cavity for both groups. Perioperative complications (infection, skin breach or contusion, surgical emphysema, orbital bleeding, cerebrospinal fluid leak, and intracranial complications) were recorded.

RESULTS

Thirty patients (67% female) with a mean age ± standard deviation of 56.0 ± 10.8 years underwent MELP (24 outside-in, six standard). Time for Lothrop completion was shorter for outside-in MELP (30.60 ± 14.10 minutes vs. 69.66 ± 64.52 minutes, P = .002). Among outside-in MELP, mean time to frontal sinus floor discovery was 8.41 ± 6.29 minutes, to recess connected 26.50 ± 12.45 minutes, and were similar regardless of pathology. The time for Lothrop cavity completion was shorter for tumor cases (24.63 ± 6.49 minutes) than for chronic rhinosinusitis without polyps (35.87 ± 20.18 minutes) and chronic rhinosinusitis with polyps (34.62 ± 11.56 minutes) (P = .05). One patient had skin edema. No other complications were recorded.

CONCLUSIONS

The outside-in MELP is technically feasible and safe. Its advantage is a wide approach to the frontal sinus with development of the Lothrop cavity en route resulting in short predictable operative times. Defining the limits of the dissection early provides a robust and efficient approach.

The Draf III Mucosal Grafting Technique

Objective. The Draf III procedure is an advanced surgical option for frontal sinus disease refractory to endoscopic frontal sinusotomy and is used to expose the anterior limit of resection of the skull base during endoscopic management of anterior skull base tumors. Our objective was to evaluate outcomes of a strategy using mucosal grafts to decrease postoperative closure.

Study Design. Prospective cohort.

Setting. Tertiary care facility.

Subjects and Methods. Patients requiring a Draf III procedure were prospectively enrolled in the study. Demographics, reason for the procedure, percentage graft viability, and complications were recorded. The primary outcome measure was anterior-posterior (AP) diameter at 3 months.

Results. Mucosal grafting was performed during 29 Draf III procedures from 2008 to 2011. Twenty-seven patients (average age, 58 years) were available for measurement at 3 months (average postoperative follow-up, 15.4 months; range, 3–30 months). Reasons for the procedure included tumor (n = 14), chronic rhinosinusitis (CRS) with frontal ostium stenosis (n = 12), and trauma (n = 1). Average intraoperative AP diameter was 11.7 mm. All patients met the definition of success (<50% reduction in diameter), maintaining a patent combined frontal sinus ostium for the duration of follow-up (average diameter 10.8 mm at 3 months). Nine patients with CRS and frontal ostium stenosis had openings similar to the entire cohort (>1-year follow-up; average, 19.3 months) with significant symptom reduction (SNOT-22 preop 62.3 ± 20.8 vs 3 months 27.8 ± 14.8 and 1 year 21.4 ± 13.6; P < .0001).

Conclusion. Cicatricial stenosis and osteoneogenesis are common following the Draf III procedure. This study indicates that the use of mucosal grafts may assist with postoperative stenosis and should be considered a routine strategy for preventing closure.

Endoscopic modified Lothrop procedure: a radiographic anatomic study

OBJECTIVE

Radiographic frontal recess and sinus anatomic measurements were obtained to evaluate the feasibility of the endoscopic modified Lothrop procedure.

STUDY DESIGN

Computed tomography anatomic study.

MATERIALS AND METHODS

Computed tomography (CT) scans from 97 patients, 39 male and 58 female, were analyzed in the sagittal plane. Four anatomic parameters were measured 1) midsagittal thickness of the nasal beak, 2) midsagittal distance from nasal beak to skull base, 3) accessible dimension of the frontal recess, and 4) anterior to posterior (AP) dimension of the frontal sinus.

RESULTS

The average and range of each parameter are as follows: 1) midsagittal nasal beak thickness 0.8 cm (0.3-1.4 cm); 2) midsagittal beak to skull base 1.0 cm (0.4-2.4 cm); 3) left and right accessible dimension 0.8 cm (0.3-1.4 cm) and 0.8 cm (0.4-1.5 cm), respectively; 4) left and right AP diameter of the frontal sinus 1.0 cm (0.3-1.8 cm) and 1.1 cm (0.4-1.9 cm), respectively. There is statistically significant differences between the accessible dimension and AP dimension of the frontal sinus on male and female images.

DISCUSSION

Preoperative frontal recess and sinus measurements can aid in the selection of patients for the endoscopic modified Lothrop procedure. A significant portion of the population, especially women, had limiting anatomic factors potentially excluding this procedure.

The frontal osteoplastic flap: does it still have a place in rhinological surgery?

OBJECTIVE

To review outcomes and complications in a series of adults undergoing a frontal osteoplastic flap procedure without obliteration, for endoscopically inaccessible sinus disease.

MATERIAL AND METHOD

Retrospective case note review of patients treated at Glasgow Royal Infirmary between January 2004 and October 2008.

RESULTS

Ten patients were identified (age range 19-81 years, mean age 46.3 years). No major intra- or post-operative complications occurred. There were three minor complications: superficial discharging wound, forehead swelling and haematoma.

CONCLUSION

The frontal osteoplastic flap still has a role in frontal sinus surgery. With minor technical modifications, this procedure may be performed with minimal complication and morbidity for patients with endoscopically inaccessible frontal sinus disease.

Role of maximal endoscopic sinus surgery techniques in chronic rhinosinusitis

There remains a continued debate regarding the extent of endoscopic sinus surgery (ESS) required for patients with chronic rhinosinusitis (CRS). By examining anatomic, etiologic, and postoperative factors that may lead to recalcitrant CRS, this article aims to highlight some of the reasons for performing maximal techniques in ESS. This concept is further expanded in various surgical maneuvers including wide maxillary antrostomy, extended frontal sinus procedures, and intraoperative computed tomography-guided ESS.

An evidence-based review of endoscopic frontal sinus surgery

BACKGROUND

Endoscopic approaches to treat frontal sinus disease gained in popularity over the past 20 years with a plethora of published studies that emphasize the high success rate of such surgeries. This study was designed to determine the levels of clinical evidence in the otolaryngology literature that address the efficacy of endoscopic approaches in the management of frontal sinus disease including frontal sinusitis.

METHODS

Twenty-three publications that reported the surgical outcomes of endoscopic approaches to treat frontal sinus disease were reviewed. Data were collected regarding the study design, operative technique, number of patients, duration of follow-up, diagnostic method, surgical success rate, and method(s) used to assess surgical outcome.

RESULTS

The study designs were a retrospective case series without control (16 articles), prospective case series without control (3 articles), and retrospective case series with internal control (4 articles). Eighty-three percent of the published articles provide an evidence level of IV, while the remaining 17% provide an evidence level of III. The surgical technique was described as frontal sinusotomy (n = 4), frontal sinusotomy or frontal sinus drillout (n = 1), frontal sinus drillout alone (n = 1), endoscopic modified Lothrop procedure (n = 9), Draf types I, II, or III (n = 6); trans-septal frontal sinusotomy (n = 1); and frontal sinus rescue procedure (n = 1). The mean number of subjects was 44, and the average follow-up period was 23.6 months. Surgical success rate ranged from 50 to 100%.

CONCLUSION

Despite the number of reports in the literature that address the surgical outcome of endoscopic approaches for treatment of frontal sinus disease, the majority of these studies have a small population size, short follow-up period, and provide a low clinical evidence level.

[Endonasal frontal sinus surgery. Part 2: Frontal sinus drainage type III (median drainage), tips and tricks, postoperative care]

In Part 2 of our concept of frontal sinus surgery, we explain type III drainage (median drainage or modified Lothrop procedure) and technical details including the application of nasal packing, mitomycin C, mucosal transplants, and silicone foils or stents. Special aspects of postoperative care are highlighted. Specific instrumentation and endoscopic equipment are highly recommended.

An integrated approach to frontal sinus surgery

This article the most useful procedures into into a comprehensive integrated approach to frontal sinus surgery. It begins with the least invasive and progresses to the most invasive procedure in a step-by-step fashion, which can be applied as needed. The selection of procedure is governed the patient's disease anatomy,and the surgeons skill. The least invasive procedure that can be used should be attempted first, and then, if more is needed, other procedures can be added, either at the same sitting or in subsequent revisions.

Frontal ostium neo-osteogenesis and restenosis after modified endoscopic Lothrop procedure in an animal model

All patients who undergo a modified endoscopic Lothrop procedure have postoperative narrowing of the enlarged frontal ostium. The aim of this study is to evaluate neo-osteogenesis and restenosis of the frontal ostium and its effect on mucociliary clearance. Fourteen sheep underwent an endoscopic modified Lothrop procedure. Pre- and postoperative nuclear medicine gamma scintigraphy of the frontal sinuses was performed. The sizes of the frontal ostia were measured and biopsies taken from the bone of the frontal ostium. Histological evidence of new bone formation was found in 56% of biopsies. The average preoperative mucociliary clearance half times (T1/2) at 15 and 30 min were 70 and 74 min, respectively, and postoperatively were 50 and 67 min. There was a non-significant trend towards poorer clearance in sinuses with neo-osteogenesis. The average size of the frontal ostium decreased by 28%. There was no relationship between the size of the ostium and neo-osteogenesis. Neo-osteogenesis was seen in 56% of biopsies with a 28% reduction in size of the frontal ostium after 224 days. Mucociliary clearance did not alter significantly.

Experimental evaluation of drills for extended frontal sinusotomy

OBJECTIVE

Endonasal extended frontal sinusotomy is needed in rare cases of therapy-resistant chronic frontal sinusitis. Several types of burs have been invented to ablate strong bone in the frontal sinus access but nevertheless surgical results seem to differ significantly. The benefits and shortcomings of different burs are subjected to a comparative evaluation.

STUDY DESIGN

Five cadaver specimens were duplicated by means of dental molding and casting techniques to provide identical microanatomy for comparative studies on frontal sinusotomy. Different burs (conventional straight bur, right-angled bur according to Blokmanis, and curved frontal sinus bur) were applied to create a type IIb frontal sinusotomy according to Draf in microanatomical replicas. The geometry of the frontonasal neoostium was measured and its dimensions were contrasted to the collateral damage. Bone ablation was calculated by repeated weighting and the area of damaged mucosa was quantified using a 3D analyzing system.

RESULTS

A frontal sinus neoostium measuring 9 x 10 mm on average was created by type IIb frontal sinusotomy according to Draf. The complementary use of an angled bur showed some specific improvements that applied best to spacious anatomic specimens. Those specimens subjected to an extensive use of the straight drill revealed significant collateral damage forming a contrast to minor enlargement of the neoostium. The curved frontal sinus bur showed considerable technical insufficiencies.

CONCLUSIONS

Judicious use of the straight drill is recommended for those rare cases of therapy-resistant frontal sinusitis treated by an extended type of frontal sinusotomy. New technical refinements of the curved frontal sinus burs should be subjected to repeated evaluation.

Contemporary indications for external approaches to the paranasal sinuses

The term minimally invasive functional endoscopic sinus surgery is surely a misnomer. First, the surgery is not minimally invasive. Extensive surgery, even skull base tumor resection, can be accomplished through the approach. In fact, because of the improved visualization provided by the adaptation of the endoscope to this technique, it can be argued that the surgery is now more invasive than it has ever been historically. More correctly, the technique is "minimal incision" surgery, and this term more accurately reflects the philosophy. External incisions, however, can be cleverly minimized or cosmetically acceptable. Second, the term "functional" is relative. There is no doubt that the greatest advance that the endoscope has afforded is the ability to assess disease in the clinic or office with far more accuracy. Endoscopic assessment has added to the general appreciation of the physiologic function of the sinuses as part of the respiratory tract in general. Certain endoscopic procedures, however, are not entirely directed at improving the physiology of sinuses. The endoscopic Lothrop procedure, for example, does not have a sensible physiologic basis. It does maintain the frontal sinus as an aerated space: this preservation is often, but not always and automatically, an advantage. One of the key factors in successfully disseminating surgical technology is the ability to teach the technique to the physician in clinical practice. This process requires constant research and development in instrument technology and the constant sharing of information and technology at courses and meetings. The types of instruments used to conduct endoscopic surgery have advanced dramatically in the last 10 years. The advent and distribution of image guidance and microdebriders and drills is an important adjunct to endoscopic techniques. Perhaps more important is the refinement that has occurred in the development of angled instruments, micro-throughcutting forceps, and 45 degrees endoscopes that will allow advanced endoscopic technology to be disseminated throughout the otolaryngology community. Nevertheless, many of the external approaches use commonly available instrumentation that is available in every operating room in the United States. This availability is certainly an advantage under certain circumstances. The wastebasket of history sometimes contains procedures that can afford efficient and effective treatment. Ignoring the past will result in a need to rediscover it. A broad perspective and the ability to think creatively about clinical problems will probably result in the occasional need to employ the techniques described in this article.

Long-term results of the Lothrop operation

With continued surgical instrument advancement, endoscopic sinus surgery techniques continue to evolve with an overall improvement of our ability to offer surgical treatment for a variety of surgical disorders of the sinuses and anterior skull base. Frontal sinusitis and the extent of surgery performed in the frontal recess once medical management fails are constantly debated in the literature. It seems that even though instrumentation has greatly improved, surgical management of frontal sinusitis remains a frustrating endeavor for otolaryngologists. Open approaches to the frontal sinus, including the osteoplastic flap with frontal sinus obliteration using adipose tissue, have been the gold standard, but require external incisions and complete removal of sinus mucosa with destruction of the frontal sinus. The endoscopic modified Lothrop technique involves removal of the frontal sinus floor bilaterally with frontal septectomy and resection of the nasal septum to create a large nasofrontal communication. Recent postoperative results of this technique rival the results after frontal sinus obliteration in selected patients while avoiding the morbidity associated with the open destructive approach.

Rhino-frontal sinuseptotomy (RFS): a combined intra-extra nasal approach for the surgical treatment of severely diseased frontal sinuses

OBJECTIVES

Frontal sinus surgery is a challenge to those involved in the treatment of recurrent frontal sinusitis. The purpose of this report is to describe the technique and to present the results of a combined endoscopic and external approach to the frontal sinus (rhino-frontal sinuseptotomy [RFS]).

MATERIAL

RFS was performed in 45 patients by the author; 41 of these patients had a follow-up over 12 months and were included in this series. Indications for RFS were severe chronic frontal sinusitis (n = 23), mucoceles (n = 12), in two cases each with osteoma, inverting papilloma, and malignant tumors of the frontal sinus, respectively. The surgical technique is started with an external approach according to Jansen-Ritter and includes the resection of the interfrontal septum, partial resection of the nasal septum, bilateral subtotal resection of the middle turbinates, bilateral endoscopic ethmoidectomy, and resection of the frontal sinus floor. The nasofrontal communication is epithelialized with free mucosal grafts and fixed with fibrin clue.

RESULTS

After a mean follow-up of 62 months, 40 patients (98%) had a widely patent epithelialized nasofrontal communication. Ninety-one percent of the patients with chronic frontal sinusitis or mucoceles noted complete relief of their frontal discomfort within 1 week after RFS. No patient required revision surgery of the nasofrontal outflow tract after RFS. Only one severe complication was recognized (cerebrospinal fluid leakage).

CONCLUSION

The results reported here with the RFS technique are superior to those reported on external procedures and endoscopic drill-out procedures. The key to successful management is the creation of a large nasofrontal communication, and direct epithelialization with free mucosal grafts obtained from the septum and turbinates.

Frontoethmoidectomy with Sewall-Boyden reconstruction: indications, technique, and philosophy

The Sewall-Boyden flap, as used to reconstruct a frontal recess after frontoethmoidectomy, is conceptually similar to the endoscopic Lothrop procedure for surgical access to the frontal sinus. The operative technique, indications, and philosophy are presented in this article.

The frontal sinus rescue procedure: early experience and three-year follow-up

The frontal sinus rescue (FSR), first described in 1997, has now been performed on 24 patients (32 sides) over a period of three years. It is a functional endoscopic surgical approach to correct an iatrogenically scarred and obstructed frontal recess, which cannot be successfully opened via a normal endoscopic frontal sinusotomy approach. It is utilized primarily for patients whose only remaining option is either a Draf-type drill-out (modified intranasal Lothrop) procedure or frontal sinus obliteration. The FSR is a technically challenging procedure, but faster, less difficult, and less destructive for the patient than a "drill-out" or frontal sinus obliteration. Once learned, it can save the patient from undergoing the more radical drill-out or obliterative procedure. The early experience and three-year follow-up with this new endoscopic procedure is presented in our first 24 patients (32 sides).

Endoscopic Lothrop procedure: the University of Miami experience

Over a 2-year period, 21 patients with clinical and radiologic evidence of persistent or recurrent frontal sinusitis who had a prior ethmoidectomy and/or frontal sinusotomy underwent an endoscopic Lothrop procedure. The patients' chief complaints were headaches (13), nasal obstruction and/or purulent rhinorrhea (4), orbital abscess/cellulitis (2), anosmia (1), and cough (1). Preoperative frontal headaches were present in 19 patients. The common frontal ostium remained patent (> 50% of intraoperative size) by flexible fiberoptic examination and transillumination 2-24 months postoperatively in 12 of 21 patients (57%). Eighteen of 21 patients (86%) had improved or resolved chief complaints. All but 4 of 19 patients (21%) with preoperative frontal headaches had improved or resolved symptoms. Two patients required additional surgery during the follow-up period. The endoscopic Lothrop procedure is a viable option before frontal sinus obliteration in patients with recurring frontal sinusitis who have failed conventional endoscopic techniques. The surgical technique and results will be presented.