Revision endoscopic frontal sinus surgery

[History of frontal sinus surgery and current view of the problem. Part 1]

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

The 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.

Frontal Sinus Surgery: Its Evolution, Present Standard of Care, and Recommendations for Current Use

From a historical perspective, frontal sinus surgery has evolved from radical, highly invasive, disfiguring approaches to function-preserving, minimally invasive, and non-disfiguring intranasal procedures. Most sinus surgeons would agree that a sound surgical procedure is one that relieves patients' symptoms and provides a safe sinus in which future intracranial and orbital complications will not occur. For the future, sinus surgeons are searching for the ideal procedure, ie, one that is minimally invasive, reversible, and ensures the patient a safe frontal sinus for the long term. The ideal surgery will also leave minimal morbidity, will leave no cosmetic defect, and will allow for easy postoperative surveillance. To achieve this new standard in frontal sinus surgery, continuous refinements are required in the medical management and understanding of the disease processes that undermine long-term surgical success. Further advancements in instrumentation and visualization techniques are also necessary to enhance surgical precision, spare mucosa, and prevent the scarring and neo-osteogenesis that may cause surgical failures. Perhaps the most important development may be in the selection criteria for appropriate candidates who will benefit most from frontal sinus surgery.

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.

Treatment of chronic frontal sinusitis with difficult anatomy: A hybrid balloon technique in four cases

The presence of frontal cells poses unique challenges when using endoscopic approaches. This study describes the use of a balloon dilation system as an aid for functional endoscopic sinus surgery (FESS) to access the frontal sinus in cases that would traditionally require open approaches. We present a case series of four patients with chronic rhinosinusitis refractive to medical management who underwent FESS with the aid of a balloon dilation system at a tertiary referral center. All patients had variant forms of frontal sinus anatomy. Surgical techniques will be described and use of the balloon system will be reviewed. All patients (aged 13–68 years) successfully underwent fontal sinusotomies with the assistance of a balloon dilation system, which was used in a variety of ways: to dilate the narrow infundibulum of a high intersinus septal cell, to remove an anteriorly located type III frontal sinus cell, to expand the natural frontal ostium in the presence of excessive agger nasi pneumatization, and to remove a type IV frontal sinus cell. All patients were spared an osteoplastic flap or trephination, and there were no intraoperative complications. No postoperative bleeding, infection, or cerebral spinal fluid leaks were reported. Balloon dilation in combination with standard frontal sinus dissection techniques may be beneficial for a select group of patients with complex frontal anatomy. In this series of patients, the balloon dilation system was used as a tool during FESS and eliminated the need for open approaches.

Efficacy of the modified endoscopic frontal sinus surgery for recurrent chronic frontal sinusitis

To modify the endoscopic frontal sinus surgery and improve the therapeutic effect of recurrent chronic frontal sinusitis (RCFS). Eighty-five patients with RCFS were divided into two groups. Endoscopic frontal sinus surgery through an approach of Frontomaxillary Process-Agger Nasi, a modified Draf IIb procedure, was carried out in 51 patients (Group A), and conservative medication was applied in 34 patients as control (Group B). The therapeutic effect was prospectively evaluated with statistically validated measures of sinusitis-specific quality of life, sino-nasal outcome test-20 questionnaire (SNOT-20). Compared with pre-treatment, the average total score of SNOT-20 in RCFS patients was significantly decreased at the time of 6, 12 months after modified endoscopic frontal sinus surgery and medical treatments (p < 0.05). However, the total score of SNOT20 was significantly lower in group A than group B at the same period of the follow-up after treatments (p < 0.05). The overall efficacy evaluated by patients' self showed that the rate of "much improved" and "improved" was respectively 68.6 and 17.6 % in group A, and significantly better than group B (p < 0.001). Furthermore, the frontal sinus patency rate in group A was 85 %, and significantly higher than group B (p < 0.001). Endoscopic frontal sinus surgery through an approach of Frontomaxillary Process-Agger Nasi, a modified Draf IIb procedure, is an effective procedure to treat the RCFS.

Modified mini-Lothrop/extended Draf IIB procedure for contralateral frontal sinus disease: a case series

BACKGROUND

Management of frontal sinus disease represents one of the most challenging aspects of endoscopic sinus surgery. In select cases, anatomic variations (outflow tract osteoneogenesis, scarring, fat prolapsed from previous orbital decompression) may hinder ipsilateral access using traditional endoscopic approaches. We previously proposed a modification of the standard Draf IIB procedure which incorporates a frontal intersinus septectomy (modified mini-Lothrop procedure/extended Draf IIB) to access and manage recalcitrant unilateral frontal sinus obstruction inaccessible ipsilaterally in cadaver specimens. In this study, we describe this technique, and present a case series of 4 patients who benefited from this approach.

METHODS

A retrospective analysis at a large tertiary referral center was performed on all patients undergoing frontal sinus surgery between July 2008 and June 2011. Four patients with frontal sinus recess obstruction inaccessible from the ipsilateral side and treated with the modified mini-Lothrop procedure/extended Draf IIB were identified.

RESULTS

All 4 patients underwent successful frontal sinusotomies via a Modified mini-Lothrop procedure/extended Draf IIB without complications and had a patent drainage pathway assessed endoscopically after a mean follow-up of 21 (range, 9-28) months.

CONCLUSION

The modified mini-Lothrop procedure/extended Draf IIB represents a feasible approach and adequate alternative to more traditional endoscopic and open frontal sinus procedures in select cases. This modification was successful in addressing difficult to access unilateral frontal sinus disease in this small cohort.

Treatment outcomes of endoscopic repairs of sinonasal cerebrospinal fluid leaks

OBJECTIVE

The objectives of the study were to evaluate the clinical characteristics of cerebrospinal fluid (CSF) leaks and determine the clinical parameters affecting endoscopic repair of CSF leaks of the anterior and central skull base.

MATERIALS AND METHODS

A retrospective study was undertaken to analyze the clinical characteristics of 28 patients who underwent endoscopic treatment of sinonasal CSF leaks between 2002 and 2009.

RESULTS

The causes of sinonasal CSF leaks were traumatic (n = 27) and spontaneous (n = 1). The sites of CSF leaks included the frontal sinus and frontal recess (n = 9), ethmoid sinus (n = 9), sella and clivus (n = 6), and sphenoid sinus (n = 4). The success rate at first-attempt endoscopic repair was 86% (24/28). Cerebrospinal fluid leaks from the frontal sinus/recess had a high failure rate (44% [4/9]). Recurrent frontal CSF leaks were successfully salvaged by an open-endoscopic approach. The final success rate at second attempt was 93% (26/28). Among the variables affecting initial endoscopic success, the location of CSF leak and direct visualization were significant factors (P = 0.008 and 0.018, respectively [Fisher exact test]). No postoperative complications were noted.

CONCLUSIONS

Our results showed that endoscopic repair of sinonasal CSF leaks is an effective treatment with a success rate of 93%. Open-endoscopic repair of frontal CSF leaks is feasible in treating endoscopic failures of frontal CSF leaks.

Operative findings in the frontal recess at time of revision surgery

OBJECTIVE

Endoscopic sinus surgery is the gold standard for the treatment of medically refractory chronic rhinosinusitis. There is, however, a population of patients for whom persistent disease is a problem. Of all the sinuses, the frontal sinus is the most likely to have recurrent obstruction. We evaluated the findings causing frontal recess obstruction at the time of revision surgery.

STUDY DESIGN AND SETTING

A retrospective review was performed in a tertiary care academic otolaryngology department.

RESULTS

Findings obstructing the frontal recess at the time of revision sinus surgery were reviewed. Two hundred eighty-nine frontal sinuses were included. Seven findings were identified: mucosal disease (67%), retained ethmoid cells (53%), lateralized middle turbinates (30%), retained agger nasi cells (13%), scar (12%), retained frontal cells (8%), and neoosteogenesis (7%). Most frontal recesses had multiple etiologies for failure listed above, with an average of 1.6.

CONCLUSIONS

Multiple findings can be identified that contribute to frontal recess obstruction requiring revision sinus surgery. A comprehensive approach to address all factors is necessary to prevent surgical failure among patients presenting for endoscopic frontal sinus surgery.

Endoscopic above and below approach with frontal septotomy in a patient with frontal mucocele: a contralateral bypass drainage procedure through the frontal septum

Frontal sinus has complex anatomy and is the most difficult sinus to dissect under the nasal endoscope. In case of difficult accessibility through the frontal recess, we can make a detour to more invasive and external procedures to treat chronic or intractable frontal sinus diseases. However, these approaches usually need advanced surgical skills and sometimes can result in minor and/or major complications. Therefore, we developed a new surgical technique to treat frontal mucocele in a patient with severe new bone formation at the frontal recess and presented our experiences with literature review.

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

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

Endoscopic modified Lothrop procedure for repair of lateral frontal sinus cerebrospinal fluid leak

OBJECTIVE

To describe a previously unreported case of repair of a lateral frontal sinus cerebrospinal fluid leak, using the endoscopic modified Lothrop procedure.

METHOD

Case report of new technique, with reference to the world literature.

RESULTS

An effective endoscopic, transnasal repair of a lateral frontal sinus cerebrospinal fluid leak was achieved in a 60-year-old man. The defect was closed with fat, fascia lata and free mucosal grafts. The left nasal cavity was packed and a lumbar drain left in situ post-operatively. The drain and packs were removed one week later and the patient discharged with no complications, and no recurrence at 12 months' follow up.

CONCLUSION

Such cerebrospinal fluid leaks have traditionally been repaired using an external approach with osteoplastic flaps and obliteration of the sinus. We highlight the endoscopic modified Lothrop technique as an effective alternative approach to repair of cerebrospinal fluid leaks in poorly accessible areas of the frontal sinus.

Measurement of Absolute Dimensions in Endoscopic Sinus Surgery

OBJECTIVE

To develop and evaluate a simple, noninvasive technique for the precise measurement of antrostomy dimensions using standard endoscopic views.

METHODS

We produced an antrostomy probe and devised a method, on the basis of techniques of aerial planimetry, for measuring antrostomies using standardized endoscopic views. Ten shapes of known surface areas were measured independently by three experienced endoscopic sinus surgeons using 30 and 70 degree endoscopes. The accuracies of surgeon assessment and interobserver concordance were calculated.

RESULTS

The three surgeons were able to calculate the surface areas with great precision (Pearson's coefficient of correlation > 0.85 in all cases) using both 30 and 70 degree endoscopes. An intraclass correlation coefficient of 0.92 was obtained, indicating a high degree of concordance between the measurements obtained by different surgeons.

CONCLUSION

This technique shows considerable promise as a tool for precise measurement of antrostomy dimensions in both clinical and research settings.