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Leventi A, Chatzinakis V, Papargyriou GE, Georgalas C. Enhancing Frontal Sinus Surgery: Assessing the Long-Term Impact of Free Grafts and Flaps in Draf III Procedures. J Pers Med 2024; 14:396. [PMID: 38673023 PMCID: PMC11051372 DOI: 10.3390/jpm14040396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/03/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024] Open
Abstract
The frontal sinus medial drainage -Draf Type III (modified endoscopic Lothrop) procedure, has become a cornerstone in frontal sinus surgery over the last three decades. Despite its widespread acceptance, challenges such as restenosis and neo-ostium closure persist, prompting the exploration of various preventive techniques. In this retrospective study, we analyzed data from 111 patients who underwent the Draf III procedure between November 2015 and November 2023, with a mean follow-up period of 3 years and 11 months. Approximately two-thirds of patients (64%) had undergone previous sinus surgery and 16% a previous Draf III. Over half of the patients had inflammatory conditions, with the majority being chronic rhinosinusitis with nasal polyps (CRSwNP) (46%), while 15% were diagnosed with malignant sinonasal tumors, and 23% with benign sinonasal tumors, of which the commonest was osteoma, accounting for 14 cases. The mean follow-up period was 3 years and 11 months. We focused on evaluating the efficacy of mucosal flaps and free grafts in preventing neo-ostium closure. Although it appears that there is no statistically significant correlation between flap usage and the need for revision surgery or ostium patency maintenance overall, subgroup analysis highlighted the benefits of flap reconstruction in patients with chronic rhinosinusitis with nasal polyps. In this subgroup, the use of flaps or grafts reduced the rate of neo-ostium stenosis from 20% to 0% (p < 0.05). Overall revision rate was 11.7%-however this was 8% in patients without acute inflammation at the time of surgery and went up to 31% in the presence of pus in the frontal recess (p = 0.02). This study contributes to the existing literature by providing insights into long-term outcomes, the enduring effectiveness of interventions in frontal sinus surgery, and especially the importance of taking into account the underlying pathology when assessing long-term outcomes.
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Affiliation(s)
- Argyro Leventi
- Endoscopic Skull Base Centre Athens, Hygeia Hospital, 151 23 Athens, Greece; (A.L.); (V.C.); (G.E.P.)
| | - Vasileios Chatzinakis
- Endoscopic Skull Base Centre Athens, Hygeia Hospital, 151 23 Athens, Greece; (A.L.); (V.C.); (G.E.P.)
| | | | - Christos Georgalas
- Endoscopic Skull Base Centre Athens, Hygeia Hospital, 151 23 Athens, Greece; (A.L.); (V.C.); (G.E.P.)
- Medical School, University of Nicosia, Nicosia 2408, Cyprus
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2
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Sommer F, Weber RK. [Local flap reconstruction techniques after frontal sinus drainage type II and III according to Draf]. HNO 2024; 72:272-278. [PMID: 38383938 DOI: 10.1007/s00106-024-01432-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Extended endonasal endoscopic frontal sinus surgery is characterized by bone resection beyond the lamellae of the frontal sinus and is currently classified according to Draf as type IIa, type IIb, modified type III (also referred to as type IIc), and type III. This approach is indicated when the surgical goal cannot be achieved through complete removal of the anterior ethmoidal cells. Numerous studies indicate restenosis rates ranging from 7 to 36%, despite creation of maximal openings. Exposed bone, which tends to epithelize slowly with significant crusting and the risk of uncontrolled wound healing depending on the local environment and other factors, is considered a contributing factor. Covering the exposed bone with mucosa can significantly reduce the risk of restenosis. METHODS AND RESULTS A variety of flap techniques for frontal sinus drainage in Draf III procedures are presented, including some variants that were part of presentations at the 2023 Congress of the European Rhinologic Society in Sofia, Bulgaria. These include combinations of free mucosal grafts, pedicled mucosal flaps, and hybrids combining both techniques. Additionally, the results of current studies are presented. CONCLUSION The results and achieved opening areas in contemporary Draf III surgeries are significantly improved and larger compared to the early stages of these procedures. A multitude of published studies consistently demonstrate that outcomes are markedly improved with mucosal coverage. Depending on the prevailing anatomy, mucosal conditions, and the extent of the surgical intervention, the most suitable technique should be selected. Therefore, proficiency in various methods is crucial. The use of a flap technique (free, pedicled, or combinations thereof) should be defined as the standard when performing extended frontal sinus surgery (Draf IIb, IIc, III, or endonasal frontal sinus surgery [EFSS] 4-6).
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Affiliation(s)
- F Sommer
- Nasen- und Ohrenheilkunde, Kopf- und Hals-Chirurgie, Universitätsklinik für Hals-, Frauensteige 12, 89075, Ulm, Deutschland.
| | - Rainer K Weber
- Klinik für Hals‑, Nasen- und Ohrenheilkunde, Städtisches Klinikum Karlsruhe, Karlsruhe, Deutschland
- Sinus Academy, Karlsruhe, Deutschland
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3
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Loftus CA, Soler ZM, Koochakzadeh S, Desiato VM, Yoo F, Nguyen SA, Schlosser RJ. Revision surgery rates in chronic rhinosinusitis with nasal polyps: meta-analysis of risk factors. Int Forum Allergy Rhinol 2019; 10:199-207. [PMID: 31752051 DOI: 10.1002/alr.22487] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/21/2019] [Accepted: 10/24/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Wide variations in revision endoscopic sinus surgery (ESS) rates for chronic rhinosinusitis with nasal polyposis (CRSwNP) have been reported. It is important to understand expected revision rates and factors that impact the need for revision. METHODS A literature search was conducted on PubMed, Scopus, and the Cochrane Database of Systematic Reviews. Following PRISMA guidelines, a systematic review and meta-analysis was performed on studies that reported revision surgery data for CRSwNP patients. RESULTS Forty-five studies with 34,220 subjects were meta-analyzed, with an overall revision rate of 18.6% (95% confidence interval, 14.1%-23.6%). Studies with extractable follow-up data reported a mean revision rate of 16.2% over a weighted mean follow-up of 89.6 months. Factors associated with increased revision rates included allergic fungal rhinosinusitis (28.7%), aspirin-exacerbated respiratory disease (27.2%), asthma (22.6%), prior polypectomy (26.0%), and publication prior to 2008 (22.7%) (p < 0.05 for all). CONCLUSION Although polyps can recur after ESS, reported long-term ESS revision rates are approximately 14% to 24%. Identifying risk factors for revision surgery can help manage patient expectations and determine optimal personalized treatments.
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Affiliation(s)
- Catherine A Loftus
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Zachary M Soler
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Sina Koochakzadeh
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Vincent M Desiato
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Frederick Yoo
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
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4
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Wang Y, Shen P, Hsieh L, Wormald P. Free mucosal grafts and anterior pedicled flaps to prevent ostium restenosis after endoscopic modified Lothrop (frontal drillout) procedure: a randomized, controlled study. Int Forum Allergy Rhinol 2019; 9:1387-1394. [DOI: 10.1002/alr.22416] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/06/2019] [Accepted: 07/30/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Ying‐Piao Wang
- Department of Otolaryngology‒Head and Neck SurgeryMackay Memorial Hospital Taipei Taiwan
- Department of Audiology and Speech Language PathologyMackay Medical College New Taipei City Taiwan
- School of MedicineMackay Medical College New Taipei City Taiwan
| | - Ping‐Hung Shen
- Department of OtolaryngologyKuang‐Tien General Hospital Taichung Taiwan
| | - Li‐Chun Hsieh
- Department of Otolaryngology‒Head and Neck SurgeryMackay Memorial Hospital Taipei Taiwan
- Department of Audiology and Speech Language PathologyMackay Medical College New Taipei City Taiwan
- School of MedicineMackay Medical College New Taipei City Taiwan
| | - Peter‐John Wormald
- Department of Surgery‒Otolaryngology Head and Neck SurgeryUniversity of Adelaide Adelaide Australia
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Rajapaksa S, Ananda A, Cain T, Oates L, Wormald PJ. The Effect of the Modified Endoscopic Lothrop Procedure on the Mucociliary Clearance of the Frontal Sinus in an Animal Model. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/194589240401800310] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The surgical management of recalcitrant frontal sinus disease has been a dilemma for otolaryngologists for many years. Although the osteoplastic flap with obliteration has been the gold standard of treatment for years, the modified endoscopic Lothrop (MEL) procedure recently has been advocated as an alternative. However, little is known about the effect of this procedure on the mucociliary drainage of the frontal sinuses postoperatively and this animal study addresses this issue. Methods Fourteen sheep underwent the MEL procedure. The sheep were randomized regarding the use of postoperative irrigation via minitrephines. Each sheep had a nuclear medicine γ-scintigraphy frontal sinus clearance study via minitrephines performed on each frontal sinus preoperatively and then 3 months postoperatively. Then, the results of these studies were compared. Results The scans revealed a trend toward faster clearance times postoperatively. However, this decrease was not statistically significant. Importantly, there was no trend or significant increase in clearance times postoperatively. Also, the use of postoperative irrigation was associated with a nonsignificant trend toward faster clearance times postoperatively. Conclusion The MEL procedure has no adverse effects on the mucociliary clearance of the frontal sinus at 3 months postoperatively. Irrigation of the frontal sinus in the immediate postoperative period showed a trend toward improved postoperative mucociliary function at 3 months.
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Affiliation(s)
- S.P. Rajapaksa
- Department of Surgery—Otolaryngology, Head and Neck Surgery, University of Adelaide and Flinders University, Adelaide, South Australia, Australia
| | - A. Ananda
- Department of Surgery—Otolaryngology, Head and Neck Surgery, University of Adelaide and Flinders University, Adelaide, South Australia, Australia
| | - T. Cain
- Department of Nuclear Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - L. Oates
- Department of Nuclear Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - P.-J. Wormald
- Department of Surgery—Otolaryngology, Head and Neck Surgery, University of Adelaide and Flinders University, Adelaide, South Australia, Australia
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Shen J, Chan N, Wrobel BB. The endoscopic modified lothrop procedure: Review of single institution experience and long-term outcomes. Laryngoscope Investig Otolaryngol 2018; 3:105-109. [PMID: 29721542 PMCID: PMC5915830 DOI: 10.1002/lio2.145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/18/2018] [Accepted: 02/13/2018] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Jasper Shen
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine University of Sothern California Los Angeles California U.S.A
| | - Nadia Chan
- Department of Otolaryngology-Head and Neck Surgery Loma Linda University Loma Linda California U.S.A
| | - Bozena B Wrobel
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine University of Sothern California Los Angeles California U.S.A
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Abuzeid WM, Vakil M, Lin J, Fastenberg J, Akbar NA, Fried MP, Fang CH. Endoscopic modified Lothrop procedure after failure of primary endoscopic sinus surgery: a meta-analysis. Int Forum Allergy Rhinol 2017; 8:605-613. [PMID: 29210504 DOI: 10.1002/alr.22055] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 11/01/2017] [Accepted: 11/09/2017] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
- Waleed M Abuzeid
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY
| | - Mayand Vakil
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY
| | - Juan Lin
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Judd Fastenberg
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY
| | - Nadeem A Akbar
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY
| | - Marvin P Fried
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY
| | - Christina H Fang
- Department of Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY
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8
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Shih LC, Patel VS, Choby GW, Nakayama T, Hwang PH. Evolution of the endoscopic modified Lothrop procedure: A systematic review and meta-analysis. Laryngoscope 2017; 128:317-326. [PMID: 28921539 DOI: 10.1002/lary.26794] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 06/02/2017] [Accepted: 06/16/2017] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Liang-Chun Shih
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, U.S.A.,Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Vishal S Patel
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Garret W Choby
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Tsuguhisa Nakayama
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, U.S.A.,Department of Otorhinolaryngology, Jikei University School of Medicine, Tokyo, Japan
| | - Peter H Hwang
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, U.S.A
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DeConde AS, Smith TL. Outcomes After Frontal Sinus Surgery: An Evidence-Based Review. Otolaryngol Clin North Am 2017; 49:1019-33. [PMID: 27450618 DOI: 10.1016/j.otc.2016.03.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Adam S DeConde
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California-San Diego, 200 W Arbor Dr., MC 8895, San Diego, CA 92103-8895, USA
| | - Timothy L Smith
- Division of Rhinology, Sinus, and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Oregon Sinus Center, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, PV-01, Portland, OR 97239, USA.
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10
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Morrissey DK, Bassiouni A, Psaltis AJ, Naidoo Y, Wormald PJ. Outcomes of revision endoscopic modified Lothrop procedure. Int Forum Allergy Rhinol 2016; 6:518-22. [PMID: 26879121 DOI: 10.1002/alr.21715] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 11/19/2015] [Accepted: 12/15/2015] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- David K Morrissey
- School of Medicine, The University of Queensland, Brisbane, Australia.,Department of Otolaryngology-Head and Neck Surgery, The Queen Elizabeth Hospital, Woodville, Australia
| | - Ahmed Bassiouni
- Department of Surgery-Otorhinolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia.,Department of Otolaryngology-Head and Neck Surgery, The Queen Elizabeth Hospital, Woodville, Australia
| | - Alkis J Psaltis
- Department of Surgery-Otorhinolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia.,Department of Otolaryngology-Head and Neck Surgery, The Queen Elizabeth Hospital, Woodville, Australia
| | - Yuresh Naidoo
- Department of Surgery-Otorhinolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia.,Department of Otolaryngology-Head and Neck Surgery, The Queen Elizabeth Hospital, Woodville, Australia
| | - Peter-John Wormald
- Department of Surgery-Otorhinolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia.,Department of Otolaryngology-Head and Neck Surgery, The Queen Elizabeth Hospital, Woodville, Australia
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11
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Illing EA, Cho DY, Riley KO, Woodworth BA. Draf III mucosal graft technique: long-term results. Int Forum Allergy Rhinol 2016; 6:514-7. [PMID: 26833550 DOI: 10.1002/alr.21708] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/05/2015] [Accepted: 11/23/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND The Draf III procedure is an effective endoscopic approach to the treatment of frontal sinus disorders, but has a significant restenosis rate. The objective of the current study is to assess long-term success of the Draf III mucosal grafting technique. METHODS Patients undergoing Draf III with mucosal grafting technique were prospectively enrolled. Demographics, indication for surgery, anterior-posterior (AP) diameter of frontal ostium, and complications were recorded. Failure was defined a priori as closure ≥50% of the intraoperative AP diameter at last clinical follow-up. RESULTS Ninety-six patients requiring Draf III with mucosal grafting were enrolled, 67 of which (average age 54 years; range, 15-84 years) had at least 1 year of follow-up (average 34 months; range, 12-85 months) and were included in the analysis. Reasons for the procedure included chronic rhinosinusitis with frontal ostium stenosis (n = 37), tumor (n = 26), and cerebrospinal fluid leak (n = 4). Average preoperative Lund-Mackay score was 13.9 ± 7.8. Average intraoperative AP diameter was 11.0 ± 1.9 mm. The procedure was highly effective with 97% (65/67) of patients maintaining a patent frontal sinus ostium (>50% intraoperative AP diameter) for the duration of follow-up (average postoperative diameter 9.9 ± 2.2 mm). However, the 2 Draf III failures remained patent, did not need further intervention, and were considered clinically successful. Three patients required reoperation for reasons unrelated to closure of the Draf III. CONCLUSION Common causes of failure following Draf III procedures include osteoneogenesis and stenosis. This study provides long-term data demonstrating excellent outcomes using the mucosal grafting technique.
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Affiliation(s)
- Elisa A Illing
- Department of Otolaryngology, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Do Yeon Cho
- Department of Otolaryngology, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Kristen O Riley
- Department of Neurosurgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Bradford A Woodworth
- Department of Otolaryngology, University of Alabama at Birmingham School of Medicine, Birmingham, AL
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12
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Upadhyay S, Buohliqah L, Vieira Junior G, Otto BA, Prevedello DM, Carrau RL. First olfactory fiber as an anatomical landmark for frontal sinus surgery. Laryngoscope 2015; 126:1039-45. [PMID: 26490546 DOI: 10.1002/lary.25696] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 08/10/2015] [Accepted: 08/28/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Access to the frontal sinuses is technically challenging owing to their anterosuperior location, diverse anatomy, close proximity to critical structures and the need to work in a relatively narrow space with angled-lens endoscopes and instruments. This study attempts to study the relationship of the first olfactory fiber with the frontal sinus posterior wall, assessing its fidelity as a surgical landmark during frontal sinus surgery. STUDY DESIGN Anatomic study. METHODS Fifteen cadaveric specimens were studied. Measurements were obtained bilaterally using the data from individual CT scans. Median A-P was defined as the anteroposterior (A-P) diameter measured just lateral to the intersinus septum, paramedian A-P was measured 5 mm lateral to the septum, and maximum A-P was defined as the maximum anteroposterior diameter on axial images. A surgical navigation device was used to calculate the distance between the first olfactory fiber and the posterior table of the frontal sinus. RESULTS The mean distance between the first olfactory fiber and the posterior wall of the frontal sinus was (4.03 ± 2.7) mm on the right side and (4.2 ± 2.9) mm on the left. This distance strongly correlated with the maximum A-P diameter of the sinus. CONCLUSIONS In a cadaveric model, the first olfactory fiber was found to be an average of 4.0 mm posterior to the frontal sinus. The significant variability of this distance should be considered when using the first olfactory fiber to establish the posterior boundary of a frontal sinusotomy. Drilling no further posterior than 7 mm rostral to the first olfactory fiber would be safe in 91% of patients. LEVEL OF EVIDENCE NA Laryngoscope, 126:1039-1045, 2016.
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Affiliation(s)
- Smita Upadhyay
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Lamia Buohliqah
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Gerival Vieira Junior
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, U.S.A
| | - Bradley A Otto
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio.,Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, U.S.A
| | - Daniel M Prevedello
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio.,Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, U.S.A
| | - Ricardo L Carrau
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio.,Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, U.S.A
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Svider PF, Sekhsaria V, Cohen DS, Eloy JA, Setzen M, Folbe AJ. Geographic and temporal trends in frontal sinus surgery. Int Forum Allergy Rhinol 2014; 5:46-54. [PMID: 25367305 DOI: 10.1002/alr.21425] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 08/02/2014] [Accepted: 08/23/2014] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Peter F Svider
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
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14
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What is the evidence for the use of mucosal flaps in Draf III procedures? Curr Opin Otolaryngol Head Neck Surg 2014; 22:63-7. [PMID: 24335916 DOI: 10.1097/moo.0000000000000023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Recent literature has described the use of mucosal grafts or transplants to reduce the rate of frontal ostium restenosis after the endoscopic-modified Lothrop procedure. This article presents a review of the literature on the rates of revision and restenosis related to Draf III procedures, factors implicated in the causation of restenosis and the evidence to support the role of mucosal grafts in reducing restenosis rates. RECENT FINDINGS Compared to historic data and to the meta-analysis data by Anderson and Sindwani, results from three case series examining the use of mucosal flaps after endoscopic-modified Lothrop procedure look extremely promising compared to a baseline average stenosis rate of 19% and revision rate of 14% quoted in the literature. SUMMARY Although the concept appears sound in principle and the limited series published show potential reduction in revision rates, there is inadequate evidence to state conclusively that this technique will improve the results of Draf III procedures in all surgical hands.
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AlQahtani A, Bignami M, Terranova P, Digilio E, Basilico F, Abdulrahman S, Castelnuovo P. Newly designed double-vascularized nasoseptal flap to prevent restenosis after endoscopic modified Lothrop procedure (Draf III): laboratory investigation. Eur Arch Otorhinolaryngol 2014; 271:2951-5. [PMID: 24609647 DOI: 10.1007/s00405-014-2961-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 02/18/2014] [Indexed: 10/25/2022]
Abstract
Despite advances in endoscopic approaches, instrumentations and imaging guidance systems, the management of frontal sinus is still challenging. Failure of the endoscopic procedure and restenosis of the newly formed ostium have been demonstrated even with large frontal sinusotomy. We describe a newly designed double nasoseptal flap to cover the bare bone after endoscopic modified Lothrop procedure (EMLP). Five fresh, double-injected cadavers were dissected through an endoscopic endonasal approach. Posteriorly based nasoseptal flap on one side and laterally based nasoseptal flap on the other side were harvested before performing wide EMLP. Feasibility of the procedure, versatility of the flap, coverage area and measurements were calculated. Harvesting the mucoperichondrial/mucoperiosteal flap over the septectomy site was straightforward step. Two different designed flaps (one on each side) are more practical to avoid torsion of the flap. The flap measures 2 × 3 cm on average that was able to cover the bare bone of the anterior and posterior wall of frontal sinus. Osteoneogenesis and progressive osteoplastic activity after EMLP plays a major role in restenosis of frontal sinus. Vascularized nasoseptal flap helps in preventing closure of the newly formed ostium. Applying these flaps over the bare bone enhances the healing process and minimizes the crust formation.
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Affiliation(s)
- Abdulaziz AlQahtani
- Department of Otorhinolaryngology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia,
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Ting JY, Wu A, Metson R. Frontal sinus drillout (modified Lothrop procedure): long-term results in 204 patients. Laryngoscope 2013; 124:1066-70. [PMID: 24114727 DOI: 10.1002/lary.24422] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 07/22/2013] [Accepted: 09/05/2013] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine the long-term results of frontal sinus drillout (also known as modified Lothrop procedure) for the treatment of advanced frontal sinus disease. STUDY DESIGN Retrospective review. METHODS The records of patients who underwent frontal sinus drillout by a single surgeon at an academic medical center from June 1995 through November 2011 were reviewed. Patient demographics and perioperative clinical findings were analyzed for their impact on surgical outcome. Failure was defined as restenosis of the frontal drainage pathways, necessitating additional frontal sinus surgery. RESULTS A total of 204 patients underwent frontal drillout surgery (143 bilateral procedures) over the 16-year period. Mean follow-up was 10.2 years (range 0.9-17 years). Symptomatic re-obstruction of the frontal sinus requiring revision surgery occurred in 61 (29.9%) patients. Drillouts performed for a diagnosis of mucocele or tumor had significantly higher failure rate (38.9%, odds ratio [OR] = 2.9, P = 0.022 and 58.3%, OR = 5.3, P = 0.020, respectively). The majority of surgical failures (61%) occurred within 2 years of surgery, but delayed failures were observed up to 12 years after drillout. Clinical outcome did not correlate with a history of smoking, asthma, nasal allergy, aspirin sensitivity, prior sinus surgery, nasal polyposis, or the presence of eosinophilic mucin. CONCLUSION For the majority of patients who undergo frontal sinus drillout, patency of the frontal sinus outflow tract appears to be maintained for more than a decade; nevertheless, almost one-third of patients who undergo this procedure will ultimately require additional frontal sinus surgery.
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Affiliation(s)
- Jonathan Y Ting
- Department of Otolaryngology, Indiana University School of Medicine, Indianapolis, Indiana
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Seyedhadi S, Mojtaba MA, Shahin B, Hoseinali K. The Draf III septal flap technique: a preliminary report. Am J Otolaryngol 2013; 34:399-402. [PMID: 23452383 DOI: 10.1016/j.amjoto.2013.01.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 01/22/2013] [Indexed: 11/29/2022]
Abstract
AIM The most prevalent complication of Draf III surgery is recurrence of frontal recess stenosis. The aim of this study is to introduce a method to prevent closure of the recess. TYPE OF THE STUDY AND SETTING This is a retrospective study that was conducted in Ear, Nose and Throat Referral Center, Amir'Alam Hospital, Tehran. METHODS AND MATERIALS We introduced a new technique for reconstructing frontal recess mucosa and prevention of restenosis following Draf III operation; we covered the posterior wall of the common recess with a vascular mucosal flap from nasal septum. RESULTS During a 6-month period we used septal flaps based on anterior ethmoidal artery on four patients who had undergone endoscopic Draf III operation. During a 3-month follow-up period, frontal recess stenosis did recur in any of the patients. CONCLUSION Applying a precise and astute surgical method along with reconstructing common recess mucosa will improve the outcomes of endoscopic frontal sinus drill-out. We strongly recommend application of septal mucosal flap based on the anterior ethmoidal artery during Draf III operation to decrease the incidence of scar and recurrence of common frontal recess stenosis.
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Affiliation(s)
- Samimiardestani Seyedhadi
- Otolaryngology and Head and Neck Surgery, Tehran University of Medical Sciences, Amir'Alam Hospital, Iran
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Ngoc Ha T, Valentine R, Moratti S, Robinson S, Hanton L, Wormald PJ. A blinded randomized controlled trial evaluating the efficacy of chitosan gel on ostial stenosis following endoscopic sinus surgery. Int Forum Allergy Rhinol 2013; 3:573-80. [PMID: 23322408 DOI: 10.1002/alr.21136] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 09/28/2012] [Accepted: 11/17/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND Stenosis of sinus ostia following endoscopic sinus surgery (ESS) is the most common reason for revision surgery. Chitosan-dextran (CD) gel has been shown to be an effective hemostatic agent; however, its effects on ostial stenosis are unknown. This study aims to quantify the effect of CD gel on circumferential scarring following ESS. METHODS A prospective, blinded, randomized, controlled trial was conducted in 26 patients undergoing ESS. Measurements of neo-ostia were taken using a standard-sized measuring probe. CD gel was applied unilaterally, while contralateral sides received no gel. Ostial diameters were measured by a blinded observer at 2, 8, and 12 weeks postoperation. Sinus ostial areas calculated as a proportion of the original were compared for each ostium at each time point. RESULTS Intraoperative ostial areas were comparable for CD gel and control sides (38 mm(2) vs 39 mm(2) , 131 mm(2) vs 120 mm(2) , and 203 mm(2) vs 193 mm(2) , in frontal, sphenoid, and maxillary ostia, respectively; p > 0.05). CD gel significantly improved sinus ostial patency. The largest difference was seen when ostial areas at 12 weeks were compared with their corresponding baseline areas (66% vs 31% frontal, p < 0.001; 85% vs 47% sphenoid, p < 0.001; and 74% vs 54% maxillary ostia, p = 0.002). The difference between raw ostial areas reached statistical significance in sphenoid (p < 0.001) and maxillary (p = 0.01), but not in frontal ostia (p > 0.05) at 12 weeks. CONCLUSION CD gel produced significantly less stenosis of all neo-ostia following ESS and may reduce the necessity for revision surgery in patients with chronic rhinosinusitis.
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Affiliation(s)
- Thanh Ngoc Ha
- Department of Surgery-Otorhinolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia
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Hildenbrand T, Wormald PJ, Weber RK. Endoscopic frontal sinus drainage Draf type III with mucosal transplants. Am J Rhinol Allergy 2012; 26:148-51. [PMID: 22487293 DOI: 10.2500/ajra.2012.26.3731] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND This study was designed to evaluate the extent of restenosis that occurs after an endoscopic frontal sinus drainage Draf type III (Draf III; modified Lothrop procedure) using a modified technique with reconstruction of the frontal sinus drainage pathway with mucosal transplants, in combination with occlusive postoperative care. METHODS Retrospective case series was performed with 24 consecutive patients undergoing Draf III drainage between 2005 and 2010 using the modified technique of covering the bare bone with mucosal transplants from the nasal septum. To ensure optimal moist wound healing, occlusion of the nose was realized by taping the nose for 2 weeks postoperatively. Frontal ostium measurements were done intraoperatively and at follow-up visits for a minimum of 12 months. Data on patient history, demographics, comorbidities, and computed tomography scans were collected. RESULTS Mean follow-up was 25.6 months. Eight patients were lost to follow-up. Ninety-four percent of frontal sinus neo-ostia remained open. One patient needed revision surgery using an osteoplastic flap with obliteration. The frontal neo-ostium narrowed by an average of 36.9% from 20.5 × 12.5 to 15 × 9.6 mm. On average, three visits were needed for postoperative care. The patients did not experience significant pain throughout the postoperative healing time. CONCLUSION The modified Lothrop procedure is a well-established technique in endoscopic sinus surgery to handle difficult frontal sinus drainage pathways or revision surgeries. The modified technique provides good results in combination with minimized postoperative care and morbidity. A comparative study would be necessary to show superiority to the standard method of Draf III.
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Affiliation(s)
- Tanja Hildenbrand
- Division of Paranasal Sinus and Skull Base Surgery, Traumatology, Department of Ear, Nose, and Throat, Hospital Karlsruhe, Karlsruhe, Germany
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Chin D, Snidvongs K, Kalish L, Sacks R, Harvey RJ. The outside-in approach to the modified endoscopic Lothrop procedure. Laryngoscope 2012; 122:1661-9. [PMID: 22549820 DOI: 10.1002/lary.23319] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 02/06/2012] [Accepted: 02/29/2012] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Drilling in modified endoscopic Lothrop procedure (MELP) is traditionally described as commencing from the frontal recess (FR). This is challenging when the FR is involved by tumor, inflammatory disease, or scarring. The outside-in MELP, where the limits of the sinusotomy are first defined and the FR is addressed last, is described. STUDY DESIGN Case-control study. METHODS Patients undergoing MELP, using the standard or outside-in approach, for inflammatory disease or endoscopic skull base surgery were assessed. Data were collected on demographics, disease characteristics, and FR involvement. Operative time was calculated from intraoperative video recording. Time points recorded were times to frontal sinus and recess connected for outside-in MELP and completion of Lothrop cavity for both groups. Perioperative complications (infection, skin breach or contusion, surgical emphysema, orbital bleeding, cerebrospinal fluid leak, and intracranial complications) were recorded. RESULTS Thirty patients (67% female) with a mean age ± standard deviation of 56.0 ± 10.8 years underwent MELP (24 outside-in, six standard). Time for Lothrop completion was shorter for outside-in MELP (30.60 ± 14.10 minutes vs. 69.66 ± 64.52 minutes, P = .002). Among outside-in MELP, mean time to frontal sinus floor discovery was 8.41 ± 6.29 minutes, to recess connected 26.50 ± 12.45 minutes, and were similar regardless of pathology. The time for Lothrop cavity completion was shorter for tumor cases (24.63 ± 6.49 minutes) than for chronic rhinosinusitis without polyps (35.87 ± 20.18 minutes) and chronic rhinosinusitis with polyps (34.62 ± 11.56 minutes) (P = .05). One patient had skin edema. No other complications were recorded. CONCLUSIONS The outside-in MELP is technically feasible and safe. Its advantage is a wide approach to the frontal sinus with development of the Lothrop cavity en route resulting in short predictable operative times. Defining the limits of the dissection early provides a robust and efficient approach.
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Affiliation(s)
- David Chin
- Division of Rhinology, Skull Base Surgery, St. Vincent's Hospital, Sydney, Australia.
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Selecting the best approach to the frontal sinus. Indian J Otolaryngol Head Neck Surg 2011; 63:79-84. [PMID: 22319722 DOI: 10.1007/s12070-010-0110-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 02/12/2010] [Indexed: 10/18/2022] Open
Abstract
The Messerklinger technique is an endoscopic approach to sinus surgery designed to be minimally invasive and preserve mucosa and hence physiological function. More recently there have been advocates for more radical endoscopic approaches to the frontal sinus such as the Modified Lothrop. This review discusses different approaches to frontal sinus surgery including any advantages and disadvantages to each approach. After examining the evidence from the literature, meticulously performed endoscopic frontal sinusotomy with or without computer guidance appears to be the most effective minimally invasive procedure for treating chronic frontal sinusitis secondary to outflow tract obstruction. Properly performed, it is almost always effective in dealing with even the most diseased frontal sinus. It offers clear advantages in reducing complications and recurrence rates in frontal sinus disease, even for revision cases.
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Burkart CM, Zimmer LA. Endoscopic modified Lothrop procedure: a radiographic anatomic study. Laryngoscope 2010; 121:442-5. [PMID: 21271603 DOI: 10.1002/lary.21168] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Accepted: 07/22/2010] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Radiographic frontal recess and sinus anatomic measurements were obtained to evaluate the feasibility of the endoscopic modified Lothrop procedure. STUDY DESIGN Computed tomography anatomic study. MATERIALS AND METHODS Computed tomography (CT) scans from 97 patients, 39 male and 58 female, were analyzed in the sagittal plane. Four anatomic parameters were measured 1) midsagittal thickness of the nasal beak, 2) midsagittal distance from nasal beak to skull base, 3) accessible dimension of the frontal recess, and 4) anterior to posterior (AP) dimension of the frontal sinus. RESULTS The average and range of each parameter are as follows: 1) midsagittal nasal beak thickness 0.8 cm (0.3-1.4 cm); 2) midsagittal beak to skull base 1.0 cm (0.4-2.4 cm); 3) left and right accessible dimension 0.8 cm (0.3-1.4 cm) and 0.8 cm (0.4-1.5 cm), respectively; 4) left and right AP diameter of the frontal sinus 1.0 cm (0.3-1.8 cm) and 1.1 cm (0.4-1.9 cm), respectively. There is statistically significant differences between the accessible dimension and AP dimension of the frontal sinus on male and female images. DISCUSSION Preoperative frontal recess and sinus measurements can aid in the selection of patients for the endoscopic modified Lothrop procedure. A significant portion of the population, especially women, had limiting anatomic factors potentially excluding this procedure.
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Affiliation(s)
- Collin M Burkart
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio 45267-0528, USA
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Philpott CM, Thamboo A, Lai L, Park J, Javer AR. Endoscopic frontal sinusotomy-Preventing recurrence or a route to revision? Laryngoscope 2010; 120:1682-6. [DOI: 10.1002/lary.20968] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Silverman JB, Prasittivatechakool K, Busaba NY. An evidence-based review of endoscopic frontal sinus surgery. Am J Rhinol Allergy 2010; 23:e59-62. [PMID: 19958599 DOI: 10.2500/ajra.2009.23.3406] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Endoscopic approaches to treat frontal sinus disease gained in popularity over the past 20 years with a plethora of published studies that emphasize the high success rate of such surgeries. This study was designed to determine the levels of clinical evidence in the otolaryngology literature that address the efficacy of endoscopic approaches in the management of frontal sinus disease including frontal sinusitis. METHODS Twenty-three publications that reported the surgical outcomes of endoscopic approaches to treat frontal sinus disease were reviewed. Data were collected regarding the study design, operative technique, number of patients, duration of follow-up, diagnostic method, surgical success rate, and method(s) used to assess surgical outcome. RESULTS The study designs were a retrospective case series without control (16 articles), prospective case series without control (3 articles), and retrospective case series with internal control (4 articles). Eighty-three percent of the published articles provide an evidence level of IV, while the remaining 17% provide an evidence level of III. The surgical technique was described as frontal sinusotomy (n = 4), frontal sinusotomy or frontal sinus drillout (n = 1), frontal sinus drillout alone (n = 1), endoscopic modified Lothrop procedure (n = 9), Draf types I, II, or III (n = 6); trans-septal frontal sinusotomy (n = 1); and frontal sinus rescue procedure (n = 1). The mean number of subjects was 44, and the average follow-up period was 23.6 months. Surgical success rate ranged from 50 to 100%. CONCLUSION Despite the number of reports in the literature that address the surgical outcome of endoscopic approaches for treatment of frontal sinus disease, the majority of these studies have a small population size, short follow-up period, and provide a low clinical evidence level.
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Affiliation(s)
- Joshua B Silverman
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts 02114, USA
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Welch KC, Stankiewicz JA. A contemporary review of endoscopic sinus surgery: Techniques, tools, and outcomes. Laryngoscope 2009; 119:2258-68. [DOI: 10.1002/lary.20618] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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[Endonasal frontal sinus surgery. Part 2: Frontal sinus drainage type III (median drainage), tips and tricks, postoperative care]. HNO 2009; 57:751-62. [PMID: 19517082 DOI: 10.1007/s00106-008-1752-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Anderson P, Sindwani R. Safety and efficacy of the endoscopic modified Lothrop procedure: A systematic review and meta-analysis. Laryngoscope 2009; 119:1828-33. [DOI: 10.1002/lary.20565] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Tran KN, Beule AG, Singal D, Wormald PJ. Frontal ostium restenosis after the endoscopic modified Lothrop procedure. Laryngoscope 2007; 117:1457-62. [PMID: 17585278 DOI: 10.1097/mlg.0b013e31806865be] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To evaluate the time course and extent of the restenosis that occurs after an endoscopic modified Lothrop procedure (EMLP) and to identify factors that contribute to this process. STUDY DESIGN : Retrospective study of prospectively collected data. METHODS Seventy-seven consecutive patients undergoing EMLP between November 1998 and June 2005 with frontal ostium measurements documented intraoperatively and at follow-up visits for a minimum of 12 months were included. Data on patient demographics, medical history, comorbidities, and computed tomography scans were collected. RESULTS Significant restenosis of the frontal sinus neo-ostia was defined as a loss of more than 60% of the original intraoperative area. The mean follow-up in our cohort was 29.2 months. Twenty-two patients were identified with increased stenosis, all of which arose within the first 12 months postsurgery. Nine of these 22 patients required revision EMLP. In all patients, the new frontal ostium narrowed at 1 year by an average of 33% (from 290 to 191 mm2, confidence interval 159-223 mm2). Restenosis and revision surgery are partly predicted by the presence of eosinophilic mucin chronic rhinosinusitis as demonstrated by logistic regression analysis. Linear regression analysis confirmed that the intraoperative frontal ostium size determines the frontal ostium area at 1 year. CONCLUSION This study provides benchmarking values for the time course of the frontal ostium area after EMLP for normal wound healing and increased stenosis. On the basis of our results, patients with a higher risk for developing restenosis and of having revision surgery can be identified preoperatively and during the early postoperative period to facilitate special postoperative care.
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Affiliation(s)
- Khanh N Tran
- Department of Surgery-Otorhinolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia
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Batra PS, Cannady SB, Lanza DC. Surgical Outcomes of Drillout Procedures for Complex Frontal Sinus Pathology. Laryngoscope 2007; 117:927-31. [PMID: 17473698 DOI: 10.1097/mlg.0b013e31803dd2ee] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this report is two-fold: 1) to determine the incidence and 2) to determine the efficacy of drillout procedures in the management of frontal sinus disease in a tertiary rhinology practice. STUDY DESIGN Retrospective data analysis. METHODS Chart review was performed for all patients undergoing frontal sinus surgery from May 1999 to April 2004. The incidence of drillout surgery was determined. Demographic data, symptomatology, type of drillout procedure, and primary pathology were determined. Postoperative outcome was assessed based on subjective symptomatology and objective endoscopic patency. RESULTS A total of 186 patients underwent 207 frontal sinus procedures during this time period; 25 patients (13.4%) required a total of 30 (14.5%) drillout procedures. The patient population had previously undergone an average of 3.2 procedures; four cases were primary and 26 were revision procedures. The breakdown of the procedures was as follows: Draf III, 17; Draf IIB, 7; and transseptal frontal sinusotomy, 6. The major indications included mucoceles (11 cases), chronic frontal sinusitis (6 cases), and tumors (5 cases). Postoperatively, presenting symptomatology resolved in 32%, improved in 56%, and remained unchanged in 12% of the patients. Endoscopic patency of the neo-ostium was noted in 23 cases (92%). Average follow-up was 16.3 months. CONCLUSIONS In this series, drillout procedures were successfully used in 25 patients as an important adjunct to the standard endoscopic techniques for management of complex frontal sinus disease. Because the procedure was used only 30 times during a 5-year period, it was reserved for specific circumstances in carefully selected patients.
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Affiliation(s)
- Pete S Batra
- Section of Nasal and Sinus Disorders, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Banhiran W, Sargi Z, Collins W, Kaza S, Casiano R. Long-term effect of stenting after an endoscopic modified Lothrop procedure. ACTA ACUST UNITED AC 2007; 20:595-9. [PMID: 17181100 DOI: 10.2500/ajr.2006.20.2912] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study was to study the effect of stenting with a silastic sheet on the long-term patency of the common frontal ostium after an endoscopic modified Lothrop procedure (EMLP). METHODS A retrospective analysis was performed of prospectively collected data at an academic tertiary referral center, where 72 patients underwent an EMLP between 1996 and 2003. Patency of the common frontal ostium was studied as an ordinal variable with three classes (patent, stenotic, and closed). RESULTS A common ostium was endoscopically visualized in 94% of the patients (61.1% patent and 33.3% stenotic). Symptoms improved in 75% of the patients. A significant positive correlation was found between ostium patency and symptom improvement. Twenty-five patients were stented postoperatively. There was no statistical difference between the stented and the nonstented groups with regards to ostium patency and symptoms improvement. CONCLUSION Short-term stenting does not appear to reduce the rate of postoperative stenosis of the common frontal ostium after an EMLP.
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Affiliation(s)
- Wish Banhiran
- Department of Otolaryngology, University of Miami-Leonard Miller School of Medicine, Miami, Florida, USA
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Abstract
CONCLUSION The endoscopic modified Lothrop procedure was found to be useful for management of postoperative frontal mucocele. OBJECTIVE The aim of this study was to evaluate the efficacy of the endoscopic modified Lothrop procedure, in which bone resection in the lateral aspect of the frontal recess and frontonasal duct was avoided, for management of postoperative frontal mucocele. PATIENTS AND METHODS The study prospectively assessed six patients who underwent an endoscopic modified Lothrop procedure. Patients had undergone a mean of two previous sinus surgical procedures. In our procedure, the mucosa and bone of the lateral aspect of the frontal recess and frontonasal duct were preserved, while a median drainage in the frontal sinus floor was created as large as possible. RESULTS All patients had a patent median drainage pathway and were free from preoperative symptoms with an average follow-up of 24.5 months. Although scar formation in the anterior aspects of the frontal recess was observed, no patients required revision surgery.
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Affiliation(s)
- Takayuki Nakagawa
- Department of Otolaryngology-Head and Neck Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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Abstract
Benign sinonasal neoplasms are a pathologic and clinically varied group of tumors. Inverting papilloma is a notable member of this group, and it is renowned for its high rate of recurrence, its ability to cause local destruction, and its association with malignancy. This article aimed to familiarize the clinician with all the practical aspects of inverting papilloma and its management. The treatment algorithm for this tumor has undergone a complex evolution that continues today.
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Affiliation(s)
- Christopher T Melroy
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina Hospitals, 101 Manning Drive, CB #7070, Chapel Hill, NC 27514, USA
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Cohen NA, Kennedy DW. Endoscopic sinus surgery: where we are-and where we're going. Curr Opin Otolaryngol Head Neck Surg 2005; 13:32-8. [PMID: 15654213 DOI: 10.1097/00020840-200502000-00009] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Improved understanding of sinonasal mucociliary function as well as technological advancements have led to a renaissance in the management of sinonasal disease. The current techniques, and adjunctive intraoperative technologies, have allowed for a more precise and safer surgical dissection, extending this surgical application to include the routine endoscopic management of skull base lesions and sinonasal malignancies. The anatomic boundaries of the nasal endoscope continue to be redefined. This paper will review the recent advances in the field of surgical rhinology as well as discuss directions for the future. RECENT FINDINGS Advancements in imaging technology including image acquisition, three-dimensional reconstruction, stereotactic navigation, and CT-MRI fusion have aided in more thorough preoperative planning, enabling safer and more precise endoscopic surgical dissection. Refinement of endonasal powered instrumentation including microdebriders and high-speed suction irrigation drills have minimized trauma to normal tissues and accelerated postoperative healing. Increased experience with the endoscope has broadened the endoscopic ventral skull base exposure from the odontoid process to foramen ovale to the olfactory bulb. SUMMARY Endoscopic sinus surgery is no longer exclusively for the management of chronic rhinosinusitis and nasal polyposis. Sinonasal malignancies, as well as anterior skull base lesions have become part of the rhinologist's responsibility. Furthermore, selective lesions managed through traditional craniotomies may now be accessed via trans-sinonasal transcranial endoscopic routes.
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Affiliation(s)
- Noam A Cohen
- Department of Otorhinolaryngology-Head and Neck Surgery, Division of Rhinology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Langton-Hewer CD, Wormald PJ. Endoscopic sinus surgery rescue of failed osteoplastic flap with fat obliteration. Curr Opin Otolaryngol Head Neck Surg 2005; 13:45-9. [PMID: 15654215 DOI: 10.1097/00020840-200502000-00011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The modified endoscopic Lothrop procedure has been used as an alternative to osteoplastic flap with obliteration in the management of chronic frontal sinusitis. More recently it has been used to rescue cases of failed osteoplastic flap. This article reviews the recent literature regarding endoscopic rescue of failed osteoplastic flap with obliteration. RECENT FINDINGS Endoscopic sinus surgery is indicated in cases of osteoplastic flap failure when there is objective evidence of mucocele formation. All patients require CT and MR imaging preoperatively. Clinical improvement can be achieved in up to 89% of patients in the first 12 to 18 months postoperatively. SUMMARY The modified endoscopic Lothrop procedure is effective in the management of failed osteoplastic flap with obliteration in the short term. Long-term evaluation of this technique is still required. Endoscopic rescue is technically challenging and requires an experienced surgeon, ideally with access to image guidance equipment.
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Affiliation(s)
- Claire D Langton-Hewer
- Department of Surgery-Otolaryngology, Head and Neck Surgery, The University of Adelaide and Flinders University, Adelaide, South Australia
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Abstract
PURPOSE OF REVIEW Recurrent or persistent frontal sinus disease after endoscopic sinus surgery poses formidable challenges owing to the frontal sinus outflow tract's complex variable anatomy, close proximity to vital structures, and predilection for scarring and stenosis. Frontal sinus obliteration used to be the preferred technique of most sinus surgeons for addressing difficult frontal sinus disease; however, several effective endoscopic techniques exist as excellent alternative procedures for addressing this difficult clinical problem. RECENT FINDINGS Several endoscopic techniques have been described for addressing these problems including endoscopic frontal sinusotomy, the frontal sinus rescue procedure, endoscopic transseptal frontal sinusotomy, and the modified Lothrop procedure. Advances in treating recurrent frontal sinus disease have included recent articles reviewing the long-term outcomes of some of these techniques, the prevalence of frontal sinus cells, the optimization of medical management, and the spectrum of postoperative debridement regimens. SUMMARY When used in the appropriate setting, these less invasive revision endoscopic techniques provide excellent results with low morbidity and several advantages. This article reviews recent developments in the treatment of recurrent or persistent frontal sinus disease including incorporation of these techniques.
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Affiliation(s)
- Robert E Sonnenburg
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill 27599-7070, USA
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Metson R. Symposium: masters in otolaryngology--update in rhinology. Laryngoscope 2003; 113:1466-9. [PMID: 12972915 DOI: 10.1097/00005537-200309000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The past few years have witnessed several noteworthy advances in the field of rhinology in general and in the treatment of chronic sinusitis in particular. Many of these advances can be classified into three major trends: technology, techniques, and tissue eosinophilia.
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Affiliation(s)
- Ralph Metson
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, USA.
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Abstract
This review summarizes the recent literature published on the microbiology, diagnosis, and medical and surgical management of acute and chronic frontal sinus disease. Two retrospective studies investigated the microbiology of frontal sinusitis in patients that underwent sinus surgery. Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus predominated in acute infection in patients with acute frontal sinusitis, and S. aureus and anaerobic bacteria were commonly isolated in chronic sinusitis. Surgery is indicated to treat patients with acute and chronic sinusitis and their complications. Several surgical procedures were recently evaluated, and these are briefly reviewed.
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Affiliation(s)
- Itzhak Brook
- Department of Pediatrics, Georgetown University School of Medicine, Washington, DC, USA.
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Malhotra R, Wormald PJ, Selva D. Bilateral dynamic proptosis due to frontoethmoidal sinus mucocele. Ophthalmic Plast Reconstr Surg 2003; 19:156-7. [PMID: 12644766 DOI: 10.1097/01.iop.0000055829.79494.37] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 34-year-old man presented with bilateral inferior and lateral globe displacement and spontaneous, dynamic proptosis in both eyes, pulsatile in nature. Computed tomography and magnetic resonance imaging scans confirmed bilateral frontoethmoidal mucoceles with erosion of the orbital roof, and intracranial extension. Following a transcutaneous mini-trephine of the left orbital mucocele, the dynamic proptosis disappeared, and both proptosis and restriction of eye movements in the left eye improved. This is the first reported case of frontoethmoidal sinus mucocele causing bilateral spontaneous dynamic proptosis.
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Affiliation(s)
- Raman Malhotra
- Oculoplastic and Orbital Unit, Department of Ophthalmology, Royal Adelaide Hospital, The University of Adelaide, South Australia, Australia
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Abstract
With continued surgical instrument advancement, endoscopic sinus surgery techniques continue to evolve with an overall improvement of our ability to offer surgical treatment for a variety of surgical disorders of the sinuses and anterior skull base. Frontal sinusitis and the extent of surgery performed in the frontal recess once medical management fails are constantly debated in the literature. It seems that even though instrumentation has greatly improved, surgical management of frontal sinusitis remains a frustrating endeavor for otolaryngologists. Open approaches to the frontal sinus, including the osteoplastic flap with frontal sinus obliteration using adipose tissue, have been the gold standard, but require external incisions and complete removal of sinus mucosa with destruction of the frontal sinus. The endoscopic modified Lothrop technique involves removal of the frontal sinus floor bilaterally with frontal septectomy and resection of the nasal septum to create a large nasofrontal communication. Recent postoperative results of this technique rival the results after frontal sinus obliteration in selected patients while avoiding the morbidity associated with the open destructive approach.
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Affiliation(s)
- Stilianos E Kountakis
- University of Virginia Health System, PO Box 800713, Charlottesville, VA 22901, USA.
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