Extended Endoscopic and Open Sinus Surgery for Refractory Chronic Rhinosinusitis

Application of expanding bilateral sphenoid sinus plasty in the treatment of sphenoid sinus diseases

Expanding bilateral sphenoid sinus plasty is an essential technique for the treatment of sphenoid sinus diseases, such as refractory sphenoid sinusitis, sphenoid sinus cyst, fungal sphenoid sinusitis, sphenoid sinus carcinoma and sphenoid sinus chordoma. The present study evaluated the potential application of expanding bilateral sphenoid sinus plasty in the treatment of sphenoid sinus diseases. A retrospective medical record review of 42 patients treated with the expanding bilateral sphenoid sinus plasty from December 2012 to December 2018 was performed in a tertiary-care university hospital. A follow-up of the surgical effects and complications was performed. Of the 42 patients, the symptoms were relieved after operation in all except preoperative hyposmia in 2 and impaired vision in one with no obvious improvement. No complications such as nasal bleeding, olfactory hypofunction and perforation of nasal septum occurred. Follow-up data revealed good mucosal epithelization in all patients within a mean time of 8.6 weeks. Endoscopic sinus reexamination demonstrated that the sphenoid sinus orifice was well opened, and no cases of sphenoid sinus orifice closure were observed. Expanding bilateral sphenoid sinus plasty, with advantages of clearly exposed surgical field, full opening of the sinus cavity, high surgical safety, short epithelialization time and intuitionistic postoperative follow-up, demonstrated great promise for greater use in the treatment of sphenoid sinus diseases in the future.

Histopathologic Features of Chronic Rhinosinusitis in Diabetic Patients

OBJECTIVE

To explore how diabetes mellitus impacts chronic rhinosinusitis clinically and on structured histopathology to provide insights on new potential chronic rhinosinusitis endotypes.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary academic center.

METHODS

A retrospective study of chronic rhinosinusitis patients who underwent functional endoscopic sinus surgery from 2015 to 2020 was performed. Structured 13-variable histopathology reports were generated from intraoperative sinonasal specimens. These variables were compared against demographic factors, comorbidities, culture data, and preoperative Lund-Mackay and SNOT-22 scores using logistic regression.

RESULTS

There were 411 patients, including 52 diabetics. Diabetes was associated with higher mean body mass index (34.9 vs 29.2; p < .001), age (57.8 vs 48.0; p < .001), and Gram-negative (40.2% vs 22.7%; p < .030) and coagulase-negative Staphylococcus (49.0% vs 28.5%; p = .008) culture rates. Black (23.1% vs 18.7%) and Hispanic (23.1% vs 8.6%) races were more common with diabetes (p = .026). Gender, smoking, polyp status, and Lund-Mackay and SNOT-22 scores did not differ between groups. Diabetics had more fungal elements (13.5% vs 3.3%, p = .018); no other histopathological differences were seen. When controlling for demographic variables and comorbidities, diabetes independently predicted the presence of fungal elements (HR 4.38, p = .018).

CONCLUSION

Diabetic chronic rhinosinusitis patients demonstrated increased fungal elements on structured histopathology. Other histopathological features were unaffected by diabetes. These findings may have important implications on the medical and surgical management of diabetic chronic rhinosinusitis patients in which early fungal disease assessment is paramount.

The role of the osteoplastic flap in the endoscopic era: a retrospective multicentre experience on revision surgery

Objective

To retrospectively review the experience of five tertiary-care university hospitals on frontal sinus revision surgery with osteoplastic flap (OPF).

Methods

Descriptive analysis of patients who underwent frontal sinus surgery with OPF after one or more endoscopic procedures for benign and inflammatory pathologies from 2000 to 2022. Clinical charts were reviewed for demographics, indications, clinical presentation, previous frontal procedures, OPF technique and outcomes.

Results

Of the 124 patients who underwent an OPF procedure, 33 met inclusion criteria. With a mean of 2.1 previous endoscopic surgeries, Draf III was the most common former procedure. In 30 (91%) cases OPF was part of a combined procedure. The most common indications were inverted papilloma (61%), mucocele (9%) and chronic rhinosinusitis (6%). Frontal outflow stenosis (36%) and mucocele (9%) were the most frequent complications observed. Improvement of overall symptoms and patient satisfaction after the OPF procedure were recorded.

Conclusions

Even in the endoscopic era, OPF still represents a paramount procedure that should be included in the rhino-surgeon's armamentarium, in particular in patients with challenging pathologies and anatomy when previous endoscopic endonasal attempts have failed.

Care for Patients with Type-2 Chronic Rhinosinusitis

In the last 20 years, growing interest in chronic rhinosinusitis (CRS) has become evident in medical literature; nevertheless, it is still difficult to identify the real prevalence of the disease. Epidemiological studies are few and focused on heterogeneous populations and diagnostic methods. Recent research has contributed to identifying CRS as a disease characterized by heterogeneous clinical scenarios, high impact on quality of life, and elevated social costs. Patient stratification with phenotypes and identification of the pathobiological mechanism at the origin of the disease (endotype) and its comorbidities are pivotal in the diagnostic process, and they should be addressed in order to properly tailor treatment. A multidisciplinary approach, shared diagnostic and therapeutic data, and follow-up processes are therefore necessary. Oncological multidisciplinary boards offer models to imitate in accordance with the principles of precision medicine: tracing a diagnostic pathway with the purpose of identifying the patient’s immunological profile, monitoring therapeutical processes, abstaining from having only a single specialist involved in treatment, and placing the patient at the center of the therapeutic plan. Awareness and participation from the patient’s perspective are fundamental steps to optimize the clinical course, improve quality of life, and reduce the socioeconomic burden.

Tips and tricks for management of the dysfunctional maxillary sinus

PURPOSE OF REVIEW

To review the various factors associated with the most common cause of maxillary sinus dysfunction; recalcitrant chronic maxillary sinusitis (RCMS). In addition, available medical and surgical management options are discussed along with various tips and tricks for optimal management.

RECENT FINDINGS

Defects in mucociliary clearance, immunodeficiency, anatomic factors, and infectious etiologies have been implicated in dysfunction of the maxillary sinus leading to RCMS. Medical management including oral antibiotics or topical drugs have shown varying degrees of success. Endoscopic modified medial maxillectomy (EMMM) has been shown to significantly improve symptoms in patients with RCMS.

SUMMARY

A dysfunctional maxillary sinus presents a clinical challenge. A thorough evaluation of any potential contributing factors must be done in addition to an assessment of the adequacy of prior surgical treatment of the maxillary sinus. Beyond the middle meatal antrostomy, EMMM can be used to effectively address RCMS. In cases that fail EMMM, removal of the condemned mucosa to encourage auto-obliteration of the sinus can be considered.

[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.

A Review of the Different Intraoperative Findings of Revision Endoscopic Frontal Surgery

A revision endoscopic sinus surgery (rESS) is considered when the primary surgery fails to improve the symptoms or causes problems. The rESS is still a difficult surgical procedure, despite the use of imaging-guided surgical navigation systems, because the anatomical landmarks are removed or scarred. To determine the causes and indications of rESS observed radiologically or endoscopically in patients with frontal rhinosinusitis. This retrospective clinical study was conducted between 2010 and 2019 in the Ear, Nose, and Throat Department of King Fahad Specialist Hospital, Saudi Arabia. Sixty cases were indicated for revision endoscopic surgery, and all had distorted or lost anatomical landmarks. Most landmark losses were caused by undissected uncinate processes and residual agger nasi with/without ethmoid disease. The rESS surgical procedure remains difficult, despite the use of imaging-guided surgical navigation systems, because most of the anatomical landmarks are removed or scarred. An undissected uncinate process, residual agger nasi with/without ethmoid disease, extensive mucosal disease with polyps obstructing the frontal recess, and lateralized middle turbinates are the most common conditions requiring rESS.

Endoscopic endonasal retrieval of air gun pellet retained in the frontal sinus: A case report

INTRODUCTION AND IMPORTANCE

Foreign bodies in paranasal sinuses are rarely encountered and most commonly present in the maxillary sinus. Guidelines for managing paranasal sinus object removal are limited due to its rarity. However, there are three major management options: open surgery, endoscopic sinus surgery, and observation.

CASE PRESENTATION

We report a rare case of an 18-year-old boy who underwent extended frontal sinus surgery to retrieve a retained air gun pellet in the right frontal sinus and repair the skull base defect resulting from the air gun pellet.

CLINICAL DISCUSSION

Physicians commonly use endoscopic sinus surgery (ESS) for improving sinus drainage in recurrent chronic and acute infective sinusitis. Extended sinus surgery aims to maximize the communication between the paranasal sinuses and the nasal cavity. This extended communication helps improve access to the sinus, enhance drainage, and improve the delivery of topical medications. In addition, the use of ESS with the modified Lothrop procedure allows for better exposure of the skull base, which can help with the repair of a CSF leak.

CONCLUSION

Based on our experience with this patient and similar literature, ESS should be considered a treatment option for patients with retained foreign objects in the frontal sinus.

Dual Purpose of De-Epithelialized Latissimus Dorsi Musculocutaneous Flap for Treatment of Chronic Frontal Sinusitis and Frontal Bone Defect

Treating frontal sinusitis refractory to endoscopic sinus surgery and complicating frontal bone defect remains a challenge. One surgical option determined is free flap transfer, which has the versatility to accommodate adequate sinus obliteration and reconstruct skin and bone defects. After successful free flap transfer, forehead recessus deformity can emerge as an esthetic problem for patients waiting for cranioplasty. Hence, the authors examine three cases in which they performed free latissimus dorsi musculocutaneous (LDM) flaps for chronic frontal sinusitis with frontal bone defect. All LDM flaps survived without complications, and all patients achieved passable forehead contours without cranioplasty and with no occurrence of infection. In our procedure, the muscle portion of the LDM flap was used to obliterate the frontal sinus, which is similar to conventional free LDM flap. Conversely, our procedure also uses the de-epithelialized skin paddle of the LDM flap filled with the frontal bone defect, which is distinct from conventional free LDM flap. Thus, preventing postoperative forehead recessus deformity has been the identified as primary advantage of our procedure. The use of the free de-epithelialized LDM flap transfer fulfills two goals: controlling chronic frontal sinusitis and restoring a passable forehead contour.

Implications of Obesity on Endoscopic Sinus Surgery Postoperative Complications: An Analysis of the NSQIP Database

Objective

To evaluate the influence of body mass index on postoperative adverse events in adult patients undergoing endoscopic sinus surgery.

Study Design

Retrospective cohort study.

Setting

Database of the American College of Surgeons NSQIP (National Surgical Quality Improvement Program) from 2006 to 2018.

Methods

The NSQIP database was queried for adult patients undergoing endoscopic sinus surgery. The total sample (N = 1546) was stratified by nonobese (18.5 kg/m2≤ body mass index <30 kg/m2) and obese (≥30 kg/m2). Demographics, comorbidities, intraoperative variables, and postoperative adverse events were compared via chi-square analysis and multivariable logistic regression.

Results

Obese patients accounted for 49.7% (n = 768) of the cohort. Obese patients had a higher American Society of Anesthesiologists classification (class III, 45.1% vs 29.5%; P < .001), rate of diabetes (18.2% vs 7.2%, P < .001), and rate of hypertension requiring medication (43.1% vs 23.0%, P < .001). Nonobese patients were more likely to be >58 years of age (23.4% vs 29.0%, P = .02) and have disseminated cancer (<1% vs 3.2%, P < .001). The obese cohort had a lower frequency of surgical complications (3.0% vs 5.4%, P = .027), driven by frequency of perioperative bleeding (1.8% vs 3.7%, P = .022). There was no statistical difference in medical complications ( P = .775), unplanned readmissions ( P = .286), unplanned reoperations ( P = .053), or 30-day mortality ( P > .999). After multivariable adjustment, obese subjects had decreased odds of any surgical complication (adjusted odds ratio [aOR], 0.567; 95% CI, 0.329-0.979), perioperative bleeding (aOR, 0.474; 95% CI, 0.239-0.942), and any adverse postoperative event (aOR, 0.740; 95% CI, 0.566-0.968).

Conclusion

Obesity does not increase the risk of 30-day adverse outcomes following endoscopic sinus surgery and may even be protective against perioperative bleeding.

Third window approach assisted middle meatal antrostomy: prospective cohort study of the two ports technique in management of hard to reach maxillary sinus pathology

OBJECTIVE

This study aimed to assess the outcomes of a prelacrimal recess approach assisted middle meatal antrostomy in the management of hard to reach maxillary sinus pathologies.

METHOD

Twenty-five patients with maxillary sinus pathology underwent prelacrimal recess approach assisted middle meatal antrostomy (with a prelacrimal recess width of more than 3 mm). Patients were prospectively evaluated using both the Arabic version of the Sino-Nasal Outcome Test-22 and nasal endoscopy at least 6 months post-operatively.

RESULTS

Our study included 25 maxillary sinuses (13 with antrochoanal polyps, 10 with maxillary fungal ball and 2 with a migrated part of a tooth). At a mean follow-up period of 10.9 months, all patients showed significant improvement in total mean Sino-Nasal Outcome Test-22 score. There was recurrence of one case with antrochoanal polyp and two cases with asymptomatic synechia. Injury to the nasolacrimal duct was not reported.

CONCLUSION

A prelacrimal recess approach assisted middle meatal antrostomy is a reliable and safe technique to manage pathologies in hard to reach regions within the maxillary sinus.

Aspirin-exacerbated respiratory disease: A review

OBJECTIVES

Aspirin-exacerbated respiratory disease (AERD) is a chronic respiratory condition characterized by a triad of symptoms: asthma, chronic rhinosinusitis with nasal polyposis, and a respiratory reaction to aspirin and other cyclooxygenase-1 inhibitors, also known as nonsteroidal anti-inflammatory drugs. The objective of this review is to provide otolaryngologists with an overview of the pathophysiology, diagnosis, and treatment of this under-recognized condition.

DATA SOURCES AND METHODS

Foundational papers on AERD were reviewed, focusing on the clinical otolaryngology and allergy/immunology literature and other high impact journals or trials.

RESULTS

AERD results from increased production of pro-inflammatory leukotrienes and a decrease in production of anti-inflammatory prostaglandins associated with the dysregulation of multiple enzymes influencing eicosanoid metabolism. Diagnosis hinges on a high index of suspicion, careful history, and confirmatory testing for all three elements. Treatments include endoscopic sinus surgery; topical, inhaled, or oral corticosteroids; aspirin desensitization; leukotriene modifying drugs; and the new class of biologics such as dupilumab.

CONCLUSION

AERD is an under-recognized disease associated with substantial patient-reported morbidity. We expect rapid progress in the pathophysiological understanding of this disease and available treatments in the coming decades.

LEVEL OF EVIDENCE

5.

Sphenoid Sinus Fat Packing in Transsphenoidal Surgery: Long-Term Fate Assessment Using Magnetic Resonance Imaging

Background and Objectives: Following the transsphenoidal approach (TSA), appropriate sphenoid sinus fat packing has been preferred to prevent postoperative cerebrospinal fluid leakage; however, studies on the behavior of fat tissue transplanted in the sphenoid sinus are lacking. This study aimed to determine the long-term fate of these fat grafts using magnetic resonance imaging (MRI).Subjects and Method: A total of 139 postoperative MRI scans of 41 patients who underwent sphenoid sinus fat packing using the standard TSA were evaluated. Additionally, MRI time series indicating the vital fat volumes were assessed postoperatively.Results: In 82.9% of cases, the fat volumes measured in the final MRI scans declined to <20% of the initial volumes; only 4.9% of cases exhibited declines to >60% of the initial volume. The fat tissue volume decreased significantly with time, with a median half-life of 18 months. Typically, the sphenoid sinus was eventually almost filled with air rather than transplanted fat. In the subgroup analysis, the fat clearance rate was significantly lower in patients with residual tumors than in those without such remnants (p=0.013).Conclusion: Long-term MRI surveillance of fat grafts in the sphenoid sinus revealed that the transplanted fat graft had degraded and was gradually eliminated.

Surgical fenestrated approach to the maxillary sinus like alternative to Caldwell-Luc technique

INTRODUCTION

In the last few years the surgical treatment of patients with maxillary sinus disease has shifted from more invasive maneuvers to more conservative approaches in order to save intraoral mucosa. Recently, some authors have proposed a modification to the classical Caldwell-Luc's approach (CL) for the removal of dental implants displaced into the maxillary sinus. The modified approach involves a fenestrated approach to the maxillary sinus. The bony pedicled windows of maxillary sinus in some selected cases may limit some of the most common complications and it may reduce healing times.

EVIDENCE ACQUISITION

Evaluation of the middle term results of a maxillary fenestrated sinus approach as an alternative technique to CL and review of literature.

EVIDENCE SYNTHESIS

From 2013 to 2017 thirty-one patients were treated with the CL modified technique, most of which for foreign bodies, displacement of endodontic material and implants in the maxillary sinus, large mucoceles and odontogenic maxillary sinusitis. All patients were subjected to clinical, and in some cases radiological, from 6 months to 18 months follow-up. Different combinations of Keywords and MeSH term were used for the bibliographic research in the main search engines (PubMed, Cochrane library, Medline). Inclusion criteria - fenestrated approach to the maxillary sinus, postoperative complications, description of the operative case.

CONCLUSIONS

No complications occurred in the intraoperative period and during the months of follow-up. There has been no recurrence of the starting problem and all treated patients were free from residual maxillary pathology 18 months after surgery. Four works meeting the inclusion criteria were identified. The surgical fenestrated approach to the maxillary sinus is a valid alternative to the classical Caldwell-Luc techniques that, alone or in combination with endoscopic sinus surgery, allow to treat foreign bodies of maxillary sinus, of mucoceles and other diseases of the maxillary sinus. The proposed technique does not require particular surgical skills, it does not increase the operating time and can also be performed under local anesthesia.

Treatment of Recalcitrant Maxillary Sinusitis With Endoscopic Modified Medial Maxillectomy: A Systematic Review of Safety and Efficacy

Background

Endoscopic sinus surgery is an effective treatment option for patients with chronic rhinosinusitis (CRS), although approximately 20% of patients fail to improve with standard surgical procedures. Expanded procedures such as the endoscopic modified medial maxillectomy (EMMM) have been described in management of refractory maxillary sinusitis.

Objective

This study aims to review the current literature on the safety and efficacy of the EMMM for treatment of refractory maxillary sinusitis.

Methods

A literature search was performed of PubMed, Ovid, and Cochrane databases according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. English-language articles evaluating the EMMM procedure on patients with recalcitrant maxillary sinusitis were included. Full-text articles were obtained and evaluated by 2 reviewers independently, with a third reviewer for mediation of disagreements.

Results

Six studies met eligibility criteria and were included into the study, with follow-up ranging from 12 to 82.8 months. Two studies contained Level 2 evidence and 4 studies contained Level 4 evidence. EMMM was found to be effective in CRS and cystic fibrosis-related CRS (0% and 9.1% revision rate, respectively). Symptom resolution was noted 60% to 80% of patients. Four studies reported complications, with a total of 4 complications out of 211 patients.

Conclusions

There are no high-quality Level 1 studies evaluating the efficacy and safety of the EMMM procedure. Level 2 to Level 4 studies indicate that this procedure is relatively safe with a low complication rate and symptom resolution in up to 80% of patients with recalcitrant maxillary sinusitis.

Endoscopic Medial Maxillectomy With Preservation of Inferior Turbinate: Assessing Results by Acoustic Rhinometry

BACKGROUND

The aim of this study is to demonstrate the effectiveness of the Endoscopic Medial Maxillectomy technique with the preservation of the nasal anatomy and function of the inferior turbinate.

METHODS

From January 2005 to December 2016, the authors performed 27 Endoscopic Medial Maxillectomy with preservation of inferior turbinate on 26 patients. The most frequent pathologies diagnosed were inverted papillomas (13/27) and antrochoanal polyps (7/27). There were 21 primary lesions and 6 patients had been previously treated. There were 19 males and 7 females. On 11 patients the authors could perform an acoustic rhinometry at 4 months postoperatively.

RESULTS

The authors did not find any recurrences. In all cases the authors note the presence of the C-notch being the narrowest area of the nasal cavity, on both the surgical and nonsurgical nasal fossa. The mean area for the C-notch in the nonsurgical nasal cavities was 0.50 cm (0.18-0.82) and it was 0.57 cm (0.08-1.06) in the surgical nasal cavities. The increase of the C-notch after nasal decongestion was 0.10 cm in nonsurgical cavities and it was 0.03 cm in the surgical cavities. The mean distance for the C-notch was 2.18 cm and 2.36 cm before and after nasal decongestion in the nonsurgical fossae. In the surgical cavities were 2.31 and 2.37  cm respectively.

CONCLUSIONS

The authors' rhinometrics data suggest that Endoscopic Medial Maxillectomy with preservation of inferior turbinate is an effective technique that preserves the anatomic structure and the functions of the inferior turbinate after its resection and reposition.

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.

The Role of Free Tissue Transfer in the Management of Chronic Frontal Sinus Osteomyelitis

OBJECTIVES/HYPOTHESIS

Chronic frontal sinus infection is managed with a combination of medical and surgical interventions. Frontal bone osteomyelitis due to recurrent infection following trauma or prior open surgery may require more significant debridement. Free tissue transfer may allow for extensive debridement with replacement of tissue, and definitive eradication of osteomyelitis.

STUDY DESIGN

Retrospective chart review.

METHODS

Patients undergoing free flap obliteration of the frontal sinus for frontal bone osteomyelitis at a single institution were included in the study. Clinical, radiologic, and surgical data were collected. Surgeries before and after free flap obliteration were compared by Wilcoxon signed rank test.

RESULTS

Fifteen patients were identified; however, one patient had less than 6 months of follow-up and was excluded from analysis. Of the remaining 14 patients, mean follow-up duration was 26 months (range, 6-120 months). Mean number of surgeries prior to free flap was 3.7 (range, 1-8 surgeries). Free flap obliteration resolved chronic frontal sinusitis in all patients. Two patients experienced postoperative infection, and the overall complication rate was 29%. Eight patients underwent cranioplasty (six immediate, two delayed) without complication. All patients received planned courses of postoperative antibiotics. A statistically significant decrease in the number of surgeries after free flap obliteration was observed P ≤ .01).

CONCLUSIONS

Extensive debridement followed by free tissue transfer and antibiotics offers a definitive treatment for complicated, recurrent frontal osteomyelitis. Simultaneous cranioplasty provides immediate protective and aesthetic benefit without complication. Consideration should be given for free tissue transfer and cranioplasty earlier in the algorithm for treatment of refractory frontal sinus osteomyelitis.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1497-1504, 2019.

Draf III frontal sinus surgery: "How I do it"

BACKGROUND

The Draf III approach to the frontal sinus can be used during revision endoscopic sinus surgery for chronic rhinosinusitis and to provide access for tumor resection, mucoceles, and repair of cerebrospinal fluid leaks.

OBJECTIVE

To describe a simple and safe way to perform a Draf III approach by using the "outside-in" approach.

METHODS

By using a 0° endoscope and a single 15°, 5-mm, coarse diamond burr, the main steps of the procedure are the following: (1) elevation of the mucosal flaps and creation of the septal window, (2) drilling out the frontal beak, (3) creation of neo-ostium and removal of the interfrontal septum, (4) joining the neo-ostium with the frontal recesses, (5) smoothing off the cavity and lowering of the "frontal T," and (6) use of mucosal flaps and grafts to cover exposed bone.

CONCLUSION

This approach is a quick and easy way to perform a Draf III, and reduces operative time and minimizes complications.

Usefulness of our proposed olfactory scoring system during endoscopic sinus surgery in patients with chronic rhinosinusitis

INTRODUCTION

The primary aim of the current study was to examine the usefulness of our proposed olfactory scoring system in chronic rhinosinusitis (CRS) patients with olfactory disorders (n = 213) receiving endoscopic sinus surgery (ESS).

MATERIALS AND METHODS

Analyzed patients were divided into two groups: an eosinophilic CRS (ECRS) group (n = 153); and a non-ECRS group (n = 60). The T&T recognition threshold test was used to evaluate olfaction at baseline and at 3 and 12 months after ESS. Patients with mean recognition threshold < 2.0 at 3 or 12 months or with a decrease of ≥ 1.0 as compared with baseline were defined as showing clinical improvement. We scored mucosal conditions as normal (0 points), edema (1 point), and polyp (2 points) at the canopy of olfactory cleft (OC), middle and superior turbinates, superior nasal meatus, and sphenoethmoidal recess during ESS. The total score of OCs (SOCs) was calculated (range 0-20 points). We compared SOCs between ECRS and non-ECRS groups. Factors related to olfactory improvement were also investigated using uni- and multivariate analyses.

RESULTS

SOCs in the ECRS and non-ECRS groups showed significant correlations with mean recognition thresholds at baseline and at 3 and 12 months. In the multivariate analysis for predicting improvement of mean recognition threshold, lower SOCs were significantly associated with olfactory improvement factors at 3 and 12 months postoperatively in the ECRS group.

CONCLUSION

SOCs appears promising for estimating olfactory prognosis after ESS in CRS patients.

Utility of intraoperative flexible endoscopy in frontal sinus surgery

Background:

Surgical management of the frontal sinus can be challenging. Extensive frontal sinus pneumatization may form a far lateral or supraorbital recess that can be difficult to reach by conventional endoscopic surgical techniques, requiring extended approaches such as the Draf III (or endoscopic modified Lothrop) procedure. Rigid endoscopes may not allow visualization of these lateral limits to ensure full evacuation of the disease process.

Methods:

Here we describe the utility of intraoperative flexible endoscopy in two patients with far lateral frontal sinus disease.

Results:

In both cases, flexible endoscopy allowed confirmation of complete evacuation of pathologic material, thereby obviating more extensive surgical dissection.

Conclusion:

In cases where visualization of the far lateral frontal sinus is inadequate with rigid endoscopes, flexible endoscopy can be used to determine the need for more extensive dissection.