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.

Surgical management of rhinosinusitis for the allergist-immunologist

Chronic rhinosinusitis (CRS) is a common chronic inflammatory disease characterized by inflammation of the sinus, with or without nasal passage inflammation, occurring for more than 12 weeks at a time. CRS has historically been classified in 2 categories: CRS without nasal polyps or CRS with nasal polyps (25%-30% of cases). The mainstay of treatment for CRS with or without nasal polyps is medical management, and options may include a combination of saline irrigation, nasal steroids, allergy medications, antibiotics, oral steroids, and treatment with targeted monoclonal antibodies. Unfortunately, up to 60% of patents report symptoms refractory to maximal medical therapy. As such, a combined approach of surgery and medical therapy may be offered. Endoscopic sinus surgery for CRS is approached in a stepwise fashion, ranging from the simplest technique, such as polyp removal, to more expanded approaches that open the paranasal sinuses and allow gravity-dependent drainage. This review article provides a review and in-depth explanation of various surgical approaches for CRS, including the indications, techniques, and respective outcomes for each one.

[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.

Anterior Pedicled Nasal Flap in Frontal Sinus Drill-Out Patients: A Randomised Controlled Pilot Study

Background: The endoscopic modified Lothrop procedure (EMLP) is a common procedure performed in patients with frontal sinus pathology. While performing this procedure, large segments of bone are exposed, which may lead to the promotion of frontal sinus neo-ostium stenosis. Here we examine the peri-operative differences in time to achieve healing in patients where a mucosal flap is used to cover the exposed bone on one side of the neo-ostium. Design: A randomised pilot study with 12 patients undergoing EMLP surgery participated in this study. Methods: Patients were randomised to undergo a mucosal flap on either the left or right side of the neo-ostium. Prior to surgery, patients completed a SNOT-22 and smell identification test. Patients were reviewed until the neo-ostium had healed on both sides. Once healing had occurred, a post-operative SNOT-22 score and smell identification test were recorded. Results: Average time to healing for the frontal sinus neo-ostium was 4.7 vs. 4.2 (p = 0.3) on the flap vs. non-flap side, respectively. There was an average 24.4 point (range: −75 to +9) decrease in SNOT-22 scores post-surgery. The post-operative USPIT score demonstrated an average increase of 6.6 points (range −13 to +27). Conclusion: We did not detect significant differences in peri-operative time toward healing in neo-ostiums where a single flap is utilised. Further studies are needed to determine whether the usage of a single neo-ostium flap affords any benefit over no flap on either ostium. SNOT-22 and UPSIT scores improved post-surgery.

[The efficacy of the extended endoscopic frontal sinus drill-out in cases of repeatedly operated polypous-purulent pansinusitis accompanied by a whistle in the front wall of the frontal sinus]

Treatment of patients with severe chronic and recurrent forms of frontal sinusitis, often caused by scarring as a result of repeated interventions in the frontal sinuses, is a difficult task. In such cases, for adequate drainage of the frontal sinus and ensuring stable patency of the nasolabial anastomosis, an endoscopic extended frontotomy can be the choice operation, the possibility of which certainly depends on the experience of the surgeon, anatomical features of the structure of the frontal sinus and the nature of the pathological process. The article shows the effectiveness of surgical treatment of chronic purulent frontal sinusitis that developed after 5 interventions on the paranasal sinuses with external and combined access, accompanied by the development of a fistulous passage of the anterior wall of the frontal sinus. For wide drainage of the frontal sinus and stable preservation of patency of the nasolabial fistula, the patient underwent extended endoscopic frontotomy (Draf III operation according to the international classification).

Trans-Nasion-Complex Approach for Endoscopic Modified Lothrop Procedure: Conception, Anatomy, and Technique

Background

The endoscopic modified Lothrop procedure (EMLP) is an important procedure used to address frontal and anterior skull-base lesions. Two techniques were established, namely, the inside-out approach and the outside-in approach. The former technique take the frontal recess and the first olfactory filament (FOF) as key landmarks while the latter use the FOF as posterior boundary. In some cases, however, these two landmarks are not available. Therefore, we supplement the outside-in approach and named it trans-nasion-complex approach (TNCA) for EMLP that can be performed without locating these two landmarks.

Methods

Two dry human skulls were used to observe the bony nasion complex. Then, five colored silicon-injected human head specimens were dissected via TNCA for EMLP. Finally, the outcomes of patients who underwent TNCA were reviewed.

Results

The nasion complex is an osseous complex that consists of the nasion and its adjacent structures, including the bilateral root of nasal bones, nasal process of frontal bones, anterior portion of the perpendicular plate of the ethmoid bone that connects with the inferior aspect of the nasal bones, and portions of the bilateral frontal process of the maxillary bones. Surgical landmarks for TNCA include the anterior superior portion of the nasal septum, anterior margin and axilla of the middle turbinate, frontal process of the maxilla bone, nasal process of the frontal bone and upper part of the nasal bone. These structures form a “mushroom sign” during cadaveric dissection and surgery. Twenty-one patients underwent TNCA, of whom 9 had tumors and 12 had chronic rhinosinusitis with nasal polyps (CRSwNP). None of them had major complications.

Conclusion

TNCA is expected to be a safe, and direct route for EMLP. Adequate understanding of the nasion complex and “mushroom sign” will be helpful to complete TNCA.

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.

Frontal Sinus "Hump": An Anatomical Risk Factor for Anterior Skull Base Injury in the Endoscopic Modified Lothrop Approach (Outside-In Frontal Drill-Out)

Skull base injuries caused by the outside-in frontal drill-out technique have not been reported. In this report, we chose an outside-in approach to open the frontal sinus for olfactory neuroblastoma resection. Although we identified the first olfactory fibre, the anterior skull base was damaged while drilling into the frontal sinus on the tumour side. We reconstructed the skull base in multiple layers using fascia and cartilage. Postoperative cerebrospinal fluid leakage or intracranial haemorrhage was not observed. In this case, a morphological difference existed in the posterior wall of the frontal sinus between the right and left sides, like a “hump” in the posterior wall of the frontal sinus. This case of damage to the anterior skull base that could not be avoided by identifying the first olfactory fibre alone is the first published case of skull base injury caused by the outside-in approach due to morphological variations of the frontal sinus and skull base. In this approach, the posterior wall of the frontal sinus cannot be observed because the intraoperative landmark is limited to the first olfactory fibre. Therefore, morphological variations of the posterior wall of the frontal sinus should be analysed in advance to prevent cranial base injury.

Safety and Efficacy of the Draf IIb Procedure: A Systematic Review

OBJECTIVES

To systematically review the literature to evaluate the indications, safety, and efficacy of the Draf IIb procedure and to evaluate the added advantages of technical factors such as stents and flaps.

DATA SOURCES

Articles published until July 2019 on Medline and Cochrane databases.

REVIEW METHODS

After a systematic review based on the 2018 PRISMA guidelines was conducted, 26 of 1533 articles were included and reviewed for indications of Draf IIb; surgical technique; use of flaps, stents, grafts, or mitomycin; complications during and after surgery; and success or recurrence rate.

RESULTS

The main indication for Draf IIb was chronic frontal rhinosinusitis (61.82%). The postoperative patency rate was 87.85%. When flaps/grafts were applied, the rate was 93.5%, but their added value was not statistically significant. Stents could be an alternative for revision surgery. Treating frontal pathologies other than chronic rhinosinusitis was also satisfying. Safety was comparable to Draf III: no perioperative complications were reported, only a few postoperative ones (eyelid ecchymosis and periorbital cellulitis in 0.2% of the cases, hyposmia in 1.55%).

CONCLUSION

When properly indicated, Draf IIb frontal drilling is a safe and highly effective surgical technique for frontal pathology treatment, with efficiency and safety comparable to the Draf III, making it a valid option when a bilateral approach is not needed. More studies are required to confirm the added values of flaps, grafts, and stents.

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.

•

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

•

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

•

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

•

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

•

Our model allows evaluation of the effectiveness of cell therapy.

EUFOREA expert board meeting on uncontrolled severe chronic rhinosinusitis with nasal polyps (CRSwNP) and biologics: Definitions and management

Uncontrolled severe chronic rhinosinusitis with nasal polyps (CRSwNP) is the most bothersome phenotype of chronic rhinosinusitis; it is typically characterized by a type 2 inflammatory reaction and by comorbidities, including asthma, nonsteroidal anti-inflammatory drug-exacerbated respiratory disease, and allergies. Here, the European Forum for Research and Education in Allergy and Airway Diseases proposes structured definitions to enable communication between clinicians and provides a practical algorithm to define type 2 inflammation in CRSwNP in daily clinical practice. A rational approach for the treatment of uncontrolled severe CRSwNP is discussed; it consists of evaluating the perspective and risks of surgery and efficacy and adverse events of biologics on the basis of currently available data. Further, possible combinations of surgery and biologics are discussed, and a rationale is provided. Here, it is of importance to adequately counsel the patient about both approaches to enable a decision-making process with an informed patient. Criteria for the selection of a biologic drug are provided, as several biologics for uncontrolled severe CRSwNP will be available in many countries within a short time. Further, suggestions for monitoring of the drug effects that support recognition of responders to the therapy and, subsequently, the decision regarding continuation or discontinuation of the biologic are proposed.

The Frontal Sinus and Frontal Recess: Anatomical, Radiological and Surgical Concepts

Introduction  The frontal sinus (FS) is the most complex of the paranasal sinuses due to its location, anatomical variations and multiple clinical presentations. The surgical management of the FS and of the frontal recess (FR) is technically challenging, and a complete understanding of its anatomy, radiology, main diseases and surgical techniques is crucial to achieve therapeutic success. Objectives  To review the FS and FR anatomy, radiology, and surgical techniques. Data Synthesis  The FS features a variety of anatomical, volumetric and dimensional characteristics. From the endoscopic point of view, the FR is the point of greatest narrowing and, to have access to this region, one must know the anatomical limits and the ethmoid cells that are located around the FR and very often block the sinus drainage. Benign diseases such as chronic rhinosinusitis (CRS), mucocele and osteomas are the main pathologies found in the FS; however, there is a wide variety of malignant tumors that can also affect this region and represent a major technical challenge to the surgeon. With the advances in the endoscopic technique, the vast majority of diseases that affect the FS can be treated according to Wolfgang Draf, who systemized the approaches into four types (I, IIa, IIb, III). Conclusion  Both benign and malignant diseases that affect the FS and FR can be successfully managed if one has a thorough understanding of the FS and FR anatomy, an individualized approach of the best surgical technique in each case, and the appropriate tools to operate in this region.

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).

Aspirin Exacerbated Respiratory Disease: Epidemiology, Pathophysiology, and Management

The correlation between aspirin sensitivity, asthma, and nasal polyposis was recognized in the early 20th century. Today, this classic triad of symptoms, eponymously named Samter's Triad, is known as aspirin exacerbated respiratory disease (AERD). Aspirin exacerbated respiratory disease affects approximately 0.3⁻0.9% of the general population in the USA and approximately 7% of asthmatic patients. The management of AERD is challenging as no single modality has proven to have high rates of symptom control. Consequently, disease management typically involves a multimodality approach across both medical and surgical disciplines. This review describes the epidemiology of AERD and the current state-of-the-art as it relates to the underlying pathophysiologic mechanisms of this disease process. A significant proportion of the review is focused on the appropriate diagnostic workup for AERD patients including the utility of aspirin provocation testing. The spectrum of medical treatments, including aspirin desensitization and recently introduced immunotherapies, are discussed in detail. Furthermore, surgical approaches to disease control, including advanced endoscopic techniques, are reviewed and treatment outcomes presented.

Size of septectomy does not affect distribution of nasal irrigation after endoscopic modified Lothrop procedure

BACKGROUND

The endoscopic modified Lothrop procedure (EMLP) is commonly performed in recalcitrant frontal sinusitis, in part to achieve better penetration of medicated irrigations postoperatively. Although EMLP requires a septectomy for exposure, it is unknown whether septectomy size affects delivery of irrigations. In this study we evaluated the role of septectomy in delivery of irrigations to the EMLP cavity.

METHODS

EMLP was performed on fresh human cadavers with sequentially increasing septectomy (minimal septectomy: drilling across septum to combine frontal sinuses; standard septectomy: 1.5 cm anterior to middle turbinate and inferiorly to the midlevel of the turbinate; large septectomy: extension to nasal floor). Irrigation with fluorescein-labeled water was performed with a 240-mL irrigation bottle in the vertex position and recorded with a 30° endoscope fixed in a 4-mm trephine in the paramedian EMLP cavity. Two blinded reviewers scored irrigation distribution recordings (0 = nasal cavity only; 1 = frontal recess; 2 = medial distribution; 3 = lateral distribution; 4 = entire sinus lavage). Distribution scores were assessed with Wilcoxon rank sum analysis.

RESULTS

Six specimens (mean age, 75.2 ± 2.4; 50% female) were assessed. Interobserver scores were highly concordant (Kendall's W = 0.86, p < 0.01), internally validating the experiment. Distribution scores did not vary significantly when comparing minimal septectomy with standard or large septectomy (Z = 0.55, p = 0.58, Z = 0.37, p = 0.71).

CONCLUSION

Increasing septectomy does not improve irrigation delivery in patients undergoing EMLP. These results suggest that a limited septectomy for access to the bilateral frontal sinuses is all that is required for effective drug delivery postoperatively. This strategy may reduce morbidity associated with larger septectomies.

Lacrimal sac exposure and a superior lateral anterior pedicle flap to improve outcomes of Draf type II and III procedures

BACKGROUND

Although the efficacy of Draf type II and III procedures for frontal sinus diseases is well recognized, a certain amount of postoperative stenosis of the frontal neo-ostium occurs. Exposed bone induces inflammation and leads to osteoneogenesis. To prevent stenosis, we developed a surgical technique designed to minimize bone exposure while maximizing the frontal neo-ostium area created with Draf type II and III procedures. We fully exposed the lacrimal sac and used a superior lateral anterior pedicle flap to cover the exposed bone during the Draf procedure. We aimed to describe our technique.

METHODS

We reviewed 19 patients who underwent a Draf type II or III procedure with our technique. Endoscopic views from the follow-ups and complications were evaluated.

RESULTS

Overall, the neo-ostium remained patent in all patients. No complications, such as synechiae or orbital injury, were seen in any of the patients.

CONCLUSION

Draf type II and III procedures with lacrimal sac exposure and a superior lateral anterior pedicle flap are convenient and seem to be effective. However, further studies with larger numbers of patients are needed to verify our technique.

The endoscopic modified lothrop procedure: Review of single institution experience and long-term outcomes

Background

Endoscopic Modified Lothrop Procedure (EMLP) has become a fundamental practice in rhinology. Improvements in symptom burden, ostial patency, morbidity, and costs have surpassed that of an open approach to the frontal sinus. Long‐term efficacy has not been well established.

Objective

This study details the long‐term outcomes of EMLP and risk factors for subsequent surgical revision at a single institution.

Methods

This study utilized a retrospective review of patients who underwent EMLP from September 2006 to February 2017 by a single surgeon at an academic tertiary referral center. Patient demographics, indications, symptom burden, and endoscopic assessment of frontal ostium patency were analyzed for their effect on surgical outcome. Risk factors for failures were identified.

Results

Seventy‐six consecutive patients with an average age of 58.1 years met the inclusion and exclusion criteria and underwent EMLP for chronic rhinosinusitis (CRS, 59%), neoplasm (26%), and mucoceles (15%). The average number of standard endoscopic sinus surgeries prior to EMLP was 2.9. The mean follow‐up of the cohort was 34.8 months, at the end of which, EMLP was successful in 78% of all patients, requiring no further surgery. Ninety percent of patients reported significant clinical improvement at the most recent follow‐up. Subgroup analysis of CRS patients revealed an equally high success rate but a higher likelihood of ostial closure. Recurrent disease necessitated revision endoscopic surgery in 17 patients, the majority of whom suffered CRS. Only tissue eosinophilia was identified to significantly increase the risk of revision surgery.

Conclusions

The majority of the patients who undergo EMLP achieve sustained patency of the frontal sinus outflow tract and adequate symptom improvement. Prominent tissue eosinophilia identifies patients at risk of requiring additional frontal sinus surgery.

Level of Evidence

4.

Value of double pedicled mucoperiosteal flaps for the prevention of restenosis in Draf IIb frontal sinusotomy

INTRODUCTION

The extent of bone exposure is one of the major factors contributing to failure of endoscopic frontal sinusotomy procedures. Double flaps providing cover of exposed bone have already been described for Draf III procedures in a cadavre study using posterior and lateral pedicled nasoseptal flaps. As these flaps overlap on the septal side, they cannot be raised from the same nasal cavity in a Draf IIb procedure. We describe a new technique using 2 local mucoperiosteal flaps raised from the same side to entirely cover the bone margins exposed by Draf IIb frontal sinusotomy.

SURGICAL TECHNIQUE

A left Draf IIb procedure was performed to drain a frontal mucocele. A posterior septoturbinal flap (PSTF) was raised to cover the posterior sinusotomy margin. A lateral pedicle nasoseptal flap (LNSF) was raised on the same side to cover the anterior margin. With a follow-up of 6 months, the Draf IIb cavity was fully patent and the flaps were well integrated.

CONCLUSION

PSTF and LNSF flaps can be raised on the same side to cover the posterior and anterior margins of the Draf IIb frontal sinusotomy, respectively.

Patient and surgeon factors explain variation in the frequency of frontal sinus surgery

OBJECTIVES/HYPOTHESIS

Ethmoidectomy may be sufficient to address frontal sinus disease, but some surgeons may perform frontal recess dissection initially. Our objectives were to describe patient-associated factors with frequency of frontal sinus surgery and analyze the association with provider volume.

STUDY DESIGN

Retrospective cohort analysis.

METHODS

The 2013 State Ambulatory Surgery Databases of New Jersey, Florida, and Kentucky were queried to identify adults who underwent anterior ethmoidectomy or total ethmoidectomy using standard Current Procedural Terminology codes. Univariate and multivariate logistic regression was performed to determine the odds of undergoing concurrent frontal sinus exploration along with ethmoidectomy, adjusting for age, gender, race, insurance type, median income, and the metropolitan designation by zip code. We also examined provider and center volume, use of image guidance, and total charges.

RESULTS

There were 10,564 ethmoidectomies, of which 4,726 had concurrent frontal sinus surgery. Women were less likely to have frontal sinus surgery (P = .0011), as were patients with Medicare (P = .007). Hispanics were more likely to have frontal sinus surgery (P = .0003). Surgeons with higher surgical volumes were more likely to perform frontal sinus surgery; it was also more likely to be performed in centers where more sinus procedures occurred (P < .0001, both).

CONCLUSIONS

Variation in the utilization of frontal sinus surgery is associated with patient sex, ethnicity, insurance status, geography, as well as provider and hospital volumes. These data support the idea that nonclinical factors may influence the treatment of frontal sinus disease.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:2008-2014, 2018.

Endoscopic modified Lothrop procedure after failure of primary endoscopic sinus surgery: a meta-analysis

BACKGROUND

The endoscopic modified Lothrop procedure (EMLP) has been used as a salvage technique for frontal sinusitis following failed endoscopic sinus surgery (ESS). We aim to examine the safety and efficacy of the EMLP following failure of primary ESS.

METHODS

All English-language publications from 2000 to 2016 reporting the use of EMLP after primary ESS were identified using the PubMed database and evaluated per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Random effects summaries of patient demographics, comorbidities, and surgical outcomes were obtained through meta-analysis.

RESULTS

Eleven studies constituting 778 patients were included and 86.5% had chronic rhinosinusitis (CRS). Mean follow-up duration was 28.4 months. The mean number of surgeries prior to EMLP was 3.5. Symptom improvement was reported in 82.3%. Subgroup analysis of 7 studies in which all 357 patients had CRS revealed a mean follow-up of 31.5 months. Symptom improvement occurred in 75.9% of cases and 23.1% experienced polyp recurrence. The cerebrospinal fluid leak rate was 2.5%. Restenosis of the neo-ostium occurred in 17.1% with complete closure occurring in 3.9% of cases. The reoperation rate after EMLP was 9.0%. Aspirin sensitivity was associated with an increased risk of cerebrospinal fluid (CSF) leak (p = 0.0339) and a reduced incidence of neo-ostium closure (p = 0.0001). Aspirin sensitivity and asthma were associated with a reduced incidence of reoperation (p ≤ 0.001) and increased symptom improvement (p < 0.005). Restenosis or closure of the frontal neo-ostium was associated with less symptom improvement (p < 0.04) but not with reoperation.

CONCLUSION

The EMLP is an effective salvage procedure for refractory frontal sinusitis based on data from higher-volume centers.

Feasibility of a septal mucosal flap for preventing re-stenosis following the Draf III procedure

Background:

Re-stenosis and a consequent need for revision surgery are the most common problems in the follow-up period following endoscopic modification of the Lothrop procedure.

Method:

This paper reports a new technique for reconstructing and resurfacing of the posterior frontal recess bone for prevention of re-stenosis.

Results:

A 46-year-old man presented with a frontal sinus osteoma, and treatment featured an endoscopic modification of the Lothrop procedure. A vascularised, posteriorly based, septal mucosal flap was used in reconstruction. There have been no reported issues over 24 months of follow up.

Conclusion:

The use of a nasoseptal flap seems feasible to reduce scarring and recurrence of (common) frontal recess stenosis after a Draf III operation.

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.

Development of a novel T-tube frontal sinus irrigation catheter

BACKGROUND

The problem of postoperative management after frontal sinus surgery remains a challenge. The bilateral opening created in the Draf III procedure does not fit any currently available stent, and patients find rinsing the frontal sinus difficult, which thus decreases compliance. The objective of this study was to demonstrate the successful use of a novel frontal sinus catheter fashioned from a biliary T tube by addressing these issues in patients with complicated sinus disease.

METHODS

This was a review of 30 patients who underwent a Draf III procedure between January and October 2014, and who had a T-tube stent inserted at the end of the procedure. Patient charts were analyzed for complications such as bleeding, infection, and restenosis as well as indications of ease of rinsing ability after surgery.

RESULTS

From the chart data, there was only one intraoperative bleed and only one postoperative bleed that required packing. Four patients had infections that required antibiotics after surgery. At the time of data collection, only one patient had signs of restenosis as judged by the operating surgeon. Patients reported an ease of rinsing ability with the T-tube stent.

CONCLUSIONS

The novel biliary T-tube stent use presented in this article is a promising future direction for postoperative care after extended frontal sinus surgery.

First results of frontal sinus obliteration with a synthetic, resorbable and osteoconductive bone graft of ß-tricalcium phosphate

BACKGROUND

Despite advances in endoscopic sinus surgery, frontal sinus obliteration is still indicated in some cases. Current options for obliteration include autologous and synthetic materials. The use of ß-tricalcium phosphate as a resorbable bone graft substitute is a good alternative for frontal sinus obliteration. This study aimed to report our experience with this material.

METHODS

A retrospective chart review of patients who underwent frontal sinus obliteration at our clinic between 2008 and 2013 was performed. Demographic data, indications, previous surgery, and immediate and late complications were examined. Information on persisting symptoms and patient outcomes was collected using a telephone questionnaire in February 2016.

RESULTS

None of the patients underwent further surgery for frontal sinus disease. All of them reported a good cosmetic result and symptom improvement.

CONCLUSION

ß-tricalcium phosphate is a good, safe and cost-effective material for frontal sinus obliteration.

The efficacy of extended Draf IIb procedure by partial nasal septectomy: long-term follow up

Draf IIb procedure is mostly used in a very narrow frontal recess and in a revision frontal sinus surgery. In most cases, the contralateral sinus is not involved. In order to avoid Draf III procedure's reported disadvantages we have commenced the use of the extended Draf IIb procedures in our center. Patients treated with extended Draf IIb procedure at our center between the years 1997 and 2012 were retrospectively evaluated. This procedure includes further widening of the frontal ostium and recces by excising the adjacent most superior nasal septum. Included in our study were patients who have failed previous Draf IIb procedure or had a small and narrow frontal sinus. Collected data included demographics, prior sinus pathology, previous surgical treatment, surgical complications and further treatment if required. All were evaluated by the SNOT-22 questioner pre and post-operatively and all were endoscopically evaluated during the follow up period. 15 patients and 18 frontal sinuses were included in our study, eight males and seven females with a mean age of 50.3 years. The mean pre-operative SNOT-22 fell from 46 to 24 and all patients improved clinically. No surgical complications were reported except for one case of postoperative maxillary sinusitis. Only one patient required further surgical intervention. In most cases the patients had a patent frontal sinus ostium after a follow up of 3-8 years. Extended Draf IIb procedure is less traumatic, safe and effective in the treatment of persistent frontal sinus disease, without surgically involving the healthy contralateral frontal sinus, and may obviate the need for Draf III procedure.

Evaluation and Decision Making in Frontal Sinus Surgery

Management of frontal sinusitis can be challenging for even the most experienced otolaryngologists. A thorough understanding of the anatomy and pathophysiology of the frontal sinus is essential to properly manage disease affecting the frontal sinus. Being able to distinguish acute viral from acute bacterial and acute from chronic sinusitis is crucial because these distinctions guide appropriate management. Nasal endoscopy can confirm diagnosis, and radiologic imaging, including computed tomography and MRI, is often a necessary adjunct that aids in determining appropriate therapeutic decisions. One must be aware of the many procedures used in the surgical treatment of frontal sinusitis.

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.

Standard Endoscopic Approaches in Frontal Sinus Surgery: Technical Pearls and Approach Selection

The mainstay of frontal sinus surgery for chronic rhinosinusitis is to achieve and maintain an adequate frontal outflow tract. Using a stepwise approach and identifying critical endoscopic anatomic landmarks, to minimize complications and obtain long-term good endoscopic surgical results, should achieve this. The goal is to relieve the patient's symptoms, restore functional mucociliary flow, achieve a wide frontal sinus ostium and prevent long-term scarring and stenosis. Meticulous dissection and appropriate use of instrumentation and techniques aids in preventing unnecessary damage to normal mucosa while achieving one's goal of an adequate surgical ostium.

Extended Endoscopic and Open Sinus Surgery for Refractory Chronic Rhinosinusitis

This review discusses extended endoscopic and open sinus surgery for refractory chronic rhinosinusitis. Extended maxillary sinus surgery including endoscopic maxillary mega-antrostomy, endoscopic modified medial maxillectomy, and inferior meatal antrostomy are described. Total/complete ethmoidectomy with mucosal stripping (nasalization) is discussed. Extended endoscopic sphenoid sinus procedures as well as their indications and potential risks are reviewed. Extended endoscopic frontal sinus procedures, such the modified Lothrop procedure, are described. Extended open sinus surgical procedures, such as the Caldwell-Luc approach, frontal sinus trephine procedure, external frontoethmoidectomy, frontal sinus osteoplastic flap with or without obliteration, and cranialization, are discussed.

The nasofrontal beak: A consistent landmark for superior septectomy during Draf III drill out

INTRODUCTION

Cerebrospinal fluid (CSF) leak occurs in 1-11% of endoscopic Draf III, or endoscopic modified Lothrop, procedures. CSF leak can occur during surgery during a superior nasal septectomy. This study investigated whether the posterior edge of the nasofrontal beak (NFB) at the level of the internal frontal ostium is a safe landmark to use to avoid skull base injury when beginning the superior septectomy.

METHODS

Preoperative computed tomography maxillofacial scans were reviewed from 100 patients from the University of Pennsylvania sinus surgery data base. The narrowest anteroposterior distance between the posterior edge of the NFB and the anterior aspect of the olfactory fossa (OF) at the level of the internal frontal ostium was measured in each patient. Measurements were taken in the midline and to the left and right of midline. Six fresh cadaver heads were also dissected to evaluate these relationships.

RESULTS

On computed tomography analysis, the NFB was anterior to the OF on the left and right of the midline in 100% of the patients, with mean distances of 6.04 and 6.41 mm, respectively. The NFB was anterior to the OF in the midline in 98% of patients, with a mean distance of 9.02 mm. In all six cadavers, the posterior edge of the NFB was anterior to the OF in the midline and to the left and right of midline at the level of the internal frontal ostia.

CONCLUSIONS

During Draf III, the posterior edge of the NFB was a reliable landmark for avoiding iatrogenic CSF leak during the superior septectomy.

Indications and outcomes for Draf IIB frontal sinus surgery

BACKGROUND

Extended frontal surgery techniques are often required when maximal medical therapy and standard endoscopic surgical approaches fail in patients. Although outcomes of the Draf III (modified Lothrop) procedure have been widely reported, postoperative outcomes and indications for the Draf IIB frontal sinusotomy have been relatively underreported. We presented our institution's experience with the Draf IIB procedure.

METHODS

Patients who underwent the Draf IIB frontal sinusotomy between 2007 and 2012 were identified by retrospective chart review. Data collected included demographics, imaging, sinus patency, and Sino-nasal Outcome Test 20 scores.

RESULTS

A total of 22 Draf IIB frontal sinusotomies were performed in 18 patients. Thirteen of eighteen patients had previous frontal sinus surgery. The most common indications for the extended approach were chronic frontal sinusitis due to lateralized middle turbinate remnant (8 patients), mucocele (6), postoperative synechiae (5), and frontal sinus mass (3). Sinus ostium patency was maintained in 20 of 22 sinuses over an average follow-up period of 16.2 months. No complications were reported.

CONCLUSIONS

The Draf IIB frontal sinusotomy is a relatively safe procedure, with multiple indications. Long-term sinus ostium patency was maintained in >90% of operated sinuses, which indicated that the Draf IIB procedure may present an acceptable alternative to more aggressive extended frontal sinus approaches in selected patients.

Preclinical study investigating the potential of low-dose-rate brachytherapy with 32P stents for the prevention of restenosis of paranasal neo-ostia

PURPOSE

Ostial restenosis is a common cause of failures in paranasal sinus surgery. The aim of the current study was to investigate the use of low-dose-rate brachytherapy to prevent neo-ostial restenosis in an animal model.

METHODS AND MATERIALS

In 14 rabbits, maxillary neo-ostia were created and measured. One side each was stented with a regular silicone stent, the other side was either not stented (n = 7) or stented with a phosphorous-32 implanted stent depositing a low-dose radiation of 15 Gy (n = 7) within 1 week, after which all stents were removed. After a period of additional 12 weeks of recovery, the animals were sacrificed, the neo-ostia were again measured, and the areas and histopathologic changes compared in between the groups.

RESULTS

After 15-Gy stenting, the mean ostial areas were even slightly enlarged by 5.1% compared to the area at stent removal, whereas a significant reduction in area, indicating a process of restenosis, by 56.1% or 54.0% was seen in the control groups with no stent and normal stent, respectively. Furthermore, no indication for adverse histopathologic radiation effects was seen in the 15-Gy group.

CONCLUSIONS

Low-dose-rate brachytherapy with phosphorous-32 doped silicone stents showed promising results in the prevention of neo-ostium restenosis in this proof-of-concept study, indicating that further preclinical and clinical testing may be warranted.

Endoscopic endonasal orbital transposition to expand the frontal sinus approaches

BACKGROUND

The management of frontal sinus disease still remains a challenging issue for rhinologists. Although endoscopic frontal sinus surgery has significantly advanced over the past years, there are some conditions in which the external approaches are still necessary. Recently, the increasing experience in endoscopic sinus surgery together with important technologic advancements have allowed expansion of the indications for selected lesions localized more and more lateral into the frontal sinus.

OBJECTIVE

The aim of this study was to describe the endoscopic endonasal approach to the far lateral portion of the frontal sinus and to evaluate the outcomes of this technique.

METHODS

A retrospective evaluation was carried out with patients at a single institution, who, from 2004 to 2012, underwent an exclusive endoscopic transnasal approach to the far lateral portion of the frontal sinus at a single institution. The surgical technique included the Draf IIb procedure, a modified Lothrop procedure (Draf III), and endoscopic lateralization of the orbit, differently associated according to the needs of each case.

RESULTS

Twenty-four patients were eligible for the present study. The lesions included were mucoceles in 9 cases, fibro-osseous lesions in 10 cases, and inverted papillomas in 5 cases. The overall follow-up ranged from 12 to 120 months (mean, 40.6 months). At the time of the last follow-up, no recurrence of disease was observed in the patients treated; in one case of osteoma, a small and stable in size (1 mm) persistent lesion was observed in an asymptomatic patient. One scheduled and one accidental cerebrospinal fluid leak with immediate skull base reconstruction occurred. No intraoperative or postoperative early or late orbital complication was observed in any case.

CONCLUSION

The endoscopic endonasal orbital transposition seems to facilitate the endoscopic management of selected far-lateral frontal sinus lesions. However, it is a demanding procedure that requires experience and skill to avoid intraoperative skull base and orbital complications.

Contemporary management of chronic rhinosinusitis with nasal polyposis in aspirin-exacerbated respiratory disease: an evidence-based review with recommendations

BACKGROUND

Chronic rhinosinusitis (CRS) in aspirin-exacerbated respiratory disease (AERD) represents a recalcitrant form of sinonasal inflammation for which a multidisciplinary consensus on patient management has not been reached. Several medical interventions have been investigated, but a formal comprehensive evaluation of the evidence has never been performed. The purpose of this article is to provide an evidence-based approach for the multidisciplinary management of CRS in AERD.

METHODS

A systematic review of the literature was performed and the guidelines for development of an evidence-based review with recommendations were followed. Study inclusion criteria included: adult population >18 years old; CRS based on published diagnostic criteria, and a presumptive diagnosis of AERD. We focused on reporting higher-quality studies (level 2 or higher) when available, but reported lower-quality studies if the topic contained insufficient evidence. Treatment recommendations were based on American Academy of Otolaryngology (AAO) guidelines, with defined grades of evidence and evaluation of research quality and risk/benefits associated with each treatment.

RESULTS

This review identified and evaluated the literature on 3 treatment strategies for CRS in AERD: dietary salicylate avoidance, leukotriene modification, and desensitization with daily aspirin therapy.

CONCLUSION

Based on the available evidence, dietary salicylate avoidance and leukotriene-modifying drugs are options following appropriate treatment with nasal corticosteroids and saline irrigation. Desensitization with daily aspirin therapy is recommended following revision endoscopic sinus surgery (ESS).

Extended applications of the endoscopic modified Lothrop procedure

OBJECTIVE

The endoscopic modified Lothrop procedure is mainly used for refractory frontal sinusitis. However, we have used it as an access procedure to facilitate treatment for an extended range of additional frontal sinus pathologies.

METHODS

A retrospective review of patients who underwent the endoscopic modified Lothrop procedure for 'alternative' frontal sinus pathologies was conducted. Patient data were reviewed. The main outcome parameter measured was signs of recurrence.

RESULTS

Twelve patients (6 males, 6 females) from a 7-year study period, with a mean age of 45.2 years (range, 16-78 years), were analysed. The surgical indications included frontoethmoidal mucoceles, cerebrospinal fluid leaks within the frontal sinus, cystic fibrosis, frontal sinus osteoma, frontal sinus ossifying fibroma and frontal silent sinus syndrome. The mean follow-up period was 33.3 months. There were no known recurrences.

CONCLUSION

We have used the endoscopic modified Lothrop procedure for a range of frontal sinus pathologies, safely and effectively, with no peri-operative complications.

Utility of Image-Guidance in Frontal Sinus Surgery

The frontal sinus can present a challenging surgical dissection for the endoscopic surgeon. Image guidance as a surgical adjunct has become widely accepted for surgeries in this area. It can help verify vital structures and manage disorienting surgical conditions, improving surgeon confidence in performing safer and more complete surgery. It is relied upon heavily for placement of limited external frontal sinusotomies for disease beyond the endoscopic reach, and for mapping the frontal sinus for osteoplastic flap bony cuts. Its use has contributed to the expanding role of endoscopic surgical approaches for paranasal sinus inflammatory and neoplastic disease.

Outcomes of revision endoscopic modified Lothrop procedure

BACKGROUND

Endoscopic modified Lothrop procedure (EMLP) is used to treat patients who fail conventional sinus surgery. The failure rate of a primary EMLP is reported to be between 5% and 32%. The failure rate of revision EMLP has not been reported. We present our institutions data regarding the outcome of patients requiring revision EMLP.

METHODS

Data was collected prospectively. Patients undergoing primary EMLP between January 2001 and December 2013 with a minimum follow-up of 6 months were included. Information related to demographics, asthma status, aspirin sensitivity, 22-item Sino-Nasal Outcome Test (SNOT-22) score, Lund-Mackay scores, intraoperative findings, and endoscopic ostium assessment were collected.

RESULTS

There were 213 primary EMLPs completed with average follow-up of 36 months. The failure rate of primary EMLP was 8.9% (19/213), whereas the failure rate of revision EMLP was 21% (4/19). Risk factors for failure of primary EMLP included the presence of intraoperative pus, more than 5 previous sinus operations and aspirin-exacerbated respiratory disease (AERD). Revision of EMLP was undertaken primarily due to recurrence of nasal polyps or ostium stenosis. Those patients who underwent revision EMLP experienced symptomatic improvement and no major complications following the procedure.

CONCLUSION

The failure rate of revision EMLP is 21% in our series. The majority of revisions were for nasal polyp recurrence. Revision EMLP is a safe and well-tolerated procedure in the small group of patients that require further surgery. Patients with intraoperative pus present at their initial EMLP, more than 5 previous sinus operations, or AERD are at increased risk of failure.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

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.

Geographic and temporal trends in frontal sinus surgery

BACKGROUND

The purpose of this study was to evaluate geographic and temporal trends in frontal sinus surgery procedures.

METHODS

Medicare Part B data files from 2000 to 2011 were examined for temporal trends in various frontal sinus procedures, and the most recent year containing geographic information (2010) was evaluated for Current Procedural Terminology (CPT) code use. Additionally, nationwide charges per procedure were recorded. Regional populations of individuals ≥ 65 years old were obtained from the 2010 U.S. Census, and surgical society websites were used to determine the number of practicing rhinologists and otolaryngologists in each region.

RESULTS

The use of open approaches declined by one third, while endoscopic procedures went from 6463 to 19262 annually, with the most marked increases occurring from 2006 through 2011. Geographic variation was noted, with practitioners in the South Atlantic states performing the greatest number of endoscopic procedures in 2010, whereas the East South Central states had the greatest number when controlling for population. There was an inverse relationship between endoscopic procedures performed and number of fellowship-trained rhinologists (controlling for regional populations) (R(2) = 0.66). The first year frontal sinus ballooning had a unique CPT code illustrated decreased reimbursements for non-balloon endoscopic surgery ($609) relative to balloon approaches ($2635).

CONCLUSION

Declines in open frontal sinus surgery and marked increases in endoscopic approaches have potential implications for residency training. Potential reasons for marked increases in endoscopic approaches include the rising popularity of balloon technologies, although this is speculative. Geographic variation exists in frontal sinus surgery patterns, including an inverse relationship between endoscopic approaches and the number of fellowship-trained rhinologists.

Orbital complications:diagnosis of different rhinological causes

To evaluate the clinical course of orbital complication using a standardised diagnostic pathway. Seventy-three patients with orbital complications underwent a multimodal diagnostic pathway comprising ENT examination, leucocytes/CRP, CT-/MRI-scanning and disease-related data. Twenty-nine patients suffered from rhinosinusitis, 28 from mucoceles, 13 patients from neoplasms and three patients from rheumatic disorders. Clinical examination diagnosed 60 patients with eyelid swelling, 55 patients with ocular pain, 14 patients with diplopia, 4 patients with exophthalmus, 29 patients with visual field defect and 4 patients with visual loss. The diagnostic pathway identified acute rhinosinusitis with a sensitivity/specificity of 90 %/90 %, mucoceles with 79 %/100 %, neoplasms with 100 %/96 % and granulomatosis with polyangiitis with 100 %/100 %, respectively. All patients left the hospital in good general condition and with regular ocular motility; two patients suffered persistent visual loss. The standardised application of a widely accepted diagnostic pathway reliably distinguishes different causes of orbital complication.