Long-term effect of stenting after an endoscopic modified Lothrop procedure

Frontal sinus stenting in endoscopic sinus surgery: the 10-year Oxford experience

BACKGROUND

Frontal sinus stents have been introduced to reduce frontal sinus re-stenosis after surgery and to improve outcomes.

METHOD

This study was a retrospective analysis of 19 patients who had endoscopic sinus surgery with approach to the frontal sinus and insertion of a soft sinus stent.

RESULTS

The frontal recess was patent in 78.9 per cent and stenosed in 21.1 per cent of patients; no completely closed recesses were observed. Mean follow up was 20.7 months, and time period of stenting was 9.8 months on average; complications were observed in 47.4 per cent of the patients, with post-operative sinonasal infection being the most common.

CONCLUSION

In the authors' experience, indications for frontal sinus stenting include recalcitrant chronic rhinosinusitis after multiple functional endoscopic sinus surgeries (especially in chronic rhinosinusitis with nasal polyps), patients with history of important craniofacial surgery or trauma, and recurrent mucoceles. The stent was overall well tolerated as only minor complications were observed. Close clinical follow up is mandatory.

The use of modified Montgomery T-tubes as frontal sinus stents: how I do it

Background

Frontal sinus surgery is challenging as the frontal recess is prone to re-stenosis and there is subsequent occlusion of the frontal sinus outflow tract. In an attempt to maintain the frontal recess calibre and reduce frontal sinus re-stenosis, frontal sinus stents have been used with different materials and varying results.

Objective

This paper presents the technique of using a modified Montgomery T-tube as a frontal sinus stent.

Results and conclusion

The use of a soft, self-retaining and non-absorbable stent that can be used for stenting of the frontal sinus is described. Our technique is safe, effective, inexpensive and well tolerated.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

The use of grafts in frontal sinus drill-outs

PURPOSE OF REVIEW

A significant complication of the frontal sinus drill-out procedure is restenosis of the frontal neo-ostium. To improve postoperative healing in this region, various mucosal grafts and pedicled flaps have been designed to reconstruct the mucosal lining of the frontal neo-ostium. We provide an overview of the types of grafts described for reconstruction and discuss the latest evidence on their efficacy.

RECENT FINDINGS

Frontal neo-ostium mucosal reconstruction may be performed using free, pedicled, or a combination of grafts. There are several case series that report good outcomes and low revision rates following the use of grafts in frontal sinus drill-outs, and one randomized controlled study demonstrating increased ostial patency. However, the use of grafts did not alter the rate of revision surgery and only one study reported an improvement in Sino-Nasal Outcome Test-22 scores after one year.

SUMMARY

Studies have suggested that frontal sinus drill-out grafts result in favorable restenosis and graft success rates. However, larger randomized control trials will be required to determine whether frontal sinus drill-out grafts contribute to a tangible clinical benefit for patients.

Outcome and Complications of Frontal Sinus Stenting: A Case Presentation and Literature Review

INTRODUCTION

Frontal sinus surgery remains challenging to manage because of its complex anatomy and narrow outflow tract. A number of studies suggest the success of frontal sinus stenting to reduce postoperative complications in endoscopic frontal sinus surgery. However, failure and complications of frontal sinus stenting may occur.

METHOD

We present a case of frontal sinus stenting with migration of the stent and erosion of the lamina papyracea together with a granulomatous reaction around the stent. PubMed and Medline search was also conducted to study the current evidence on frontal sinus stenting benefits and complications.

RESULTS

Still there are no guidelines or universally accepted indications for the use of frontal sinus stenting in the literature. A limited number of studies suggest the success of frontal sinus stenting to reduce postoperative stenosis in endoscopic frontal sinus surgery. However, failure and complications of frontal sinus stenting may occur. Infection, pain, edema, and stent obstruction may also occur. Our case report also highlights the potential of orbital complications as well as the consequences of inducing a granulomatous reaction.

CONCLUSION

The value of frontal sinus stenting is still a subject of debate. Complications of frontal sinus stenting are not uncommon and thus necessitate regular follow-up.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

DATA SOURCES

PubMed, SCOPUS and Cochrane databases.

REVIEW METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes After Frontal Sinus Surgery: An Evidence-Based Review

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

Extended Endoscopic and Open Sinus Surgery for Refractory Chronic Rhinosinusitis

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

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

OBJECTIVES/HYPOTHESIS

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

DATA SOURCES

PubMed literature search.

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

The outside-in approach to the modified endoscopic Lothrop procedure

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

Case-control study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

The use of an in vitro-cultured porcine nasal mucosa model for the biocompatibility assessment of biodegradable magnesium

The development of an in vitro-cultured porcine nasal mucosa model is described. The model was subsequently used for the biocompatibility testing of resorbable magnesium-based implants, which are intended for use in the nasal cavity of patients with chronic rhinosinusitis (CRS). Test specimens made from either pure magnesium or titanium were incubated with the mucosal tissue for 48 hours. Afterwards, tissue viability, PGE2, IL-6 and IL-8 release, magnesium ion release, succinate dehydrogenase activity, apoptosis and 14C amino acid incorporation, were determined. The results suggested favourable biocompatibility, even in the case of rapidly-degrading pure magnesium. However, presumed effects on protein synthesis and apoptosis could not be confirmed.

Selecting the best approach to the frontal sinus

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.

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

OBJECTIVE

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

MATERIAL AND METHOD

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

RESULTS

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

CONCLUSION

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

Stents and drug-eluting stents

Synechiae and ostial stenosis are common and troublesome complications following endoscopic sinus surgery. Many investigators have advocated the use of stents to minimize the risk of postoperative stenosis while others have found their use to be of no benefit. This article reviews the advantages and disadvantages of various stents used in sinus surgery, and discusses such innovations as drug-releasing stents.

Effects of a dexamethasone-releasing stent on osteoneogenesis in a rabbit model

BACKGROUND

This study is an evaluation of wound healing in an animal model for surgery of frontal sinusitis and treatment effect of topically released dexamethasone using a drug-releasing stent with special emphasis of osteoneogenesis.

METHODS

A prospective, controlled, randomized, double-blinded animal study was performed. Nineteen New Zealand white rabbits were subjected to surgery via an external approach, a 4-mm circular wound was created on the medial side of the maxillary sinus and the underlying bone was denuded of periosteum. The wound was covered in a randomized fashion with either a silicone foil or a new dexamethasone-releasing stent system. Twelve to 30 days later, the animals were killed and a histological examination was performed.

RESULTS

In comparison with the baseline bony thickness (40 micrometer) obtained in one animal, osteoneogenesis occurred on both paranasal sides but was significantly less if a dexamethasone-releasing stent was applied (117 [95% CI, 116-128]; 52 [95% CI, 43-64]; p < 0.001). Maximal bony thickness was observed in both treatment groups between days 20 and 25 with a tendency toward a higher percentage decrease in the dexamethasone-treated sides (p < 0.08). Using a visual analog scale (0-5) a significantly smoother bony surface was observed for dexamethasone (2 [95% CI, 1.1-1.9]; 2 [95% CI, 1.8-2.2]; p < 0.01).

CONCLUSION

Using a new drug-releasing stent system, dexamethasone efficiently decreases postoperative osteoneogenesis in a standardized animal wound model for endoscopic sinus surgery. Therefore, the use of this system may be of value to decrease restenosis rates using corticosteroids in selected patients after frontal sinus surgery, especially the endoscopic modified Lothrop procedure.

Chitosan glycerophosphate-based semirigid dexamethasone eluting biodegradable stent

BACKGROUND

Chitosan is a polysaccharide derived from chitin deacetylation, which can form a biodegradable matrix capable of reversibly binding dexamethasone. The purpose of this study was to optimize the chitosan formulation to produce a pliable sheet, to assess the innate longevity and inflammatory potential of the polymer, and to study the in vivo rate of dexamethasone release over time.

METHODS

Chitosan glycerophosphate (CGP) sheets were produced with varying degrees of deacetylation (70-100%) and analyzed for structural integrity. Two-squared centimeter sheets of 91.7% deacetylated CGP were mixed with dexamethasone and implanted in 12 rabbit maxillary sinuses. Nasal lavage and peripheral blood samples were tested for dexamethasone levels by enzyme-linked immunosorbent assay (ELISA) over 15 days. Sinuses were examined histologically on postoperative days 3, 7, and 15 for persistence of the stent and degree of inflammation when compared with CGP alone.

RESULTS

The 91.7% deacetylated CGP formulation was found to have optimal mechanical properties and remained present with moderate degradation and negligible inflammation through postoperative day 15. Dexamethasone levels were detectable in nasal lavage and blood samples through postoperative day 15 and decayed over time (lavage: day 0, 7.70 +/- 0.97 ng/mL, and day 15, 2.53 +/- 1.71 ng/mL; blood: day 3, 2.51 +/- 0.14 ng/mL, and day 15, 1.70 +/- 0.36 ng/mL).

CONCLUSION

CGP may be used to create a semirigid sheet that is malleable, inert, and capable of eluting steroid over 15 days when implanted intranasally. This material may be used to create a pharmacologically active stent that spontaneously degrades over time.

Balloon catheter dilatation for frontal sinus ostium stenosis in the office setting

BACKGROUND

Frontal sinus ostium stenosis (FSOS) is problematic even for expert surgeons. Balloon catheter (BC) technology has been recently introduced to rhinology. The aim of this study is to assess technical feasibility and effectiveness of BC dilatation of FSOS in the office setting.

METHODS

This retrospective, multi-institutional case series describes all patients who underwent BC dilatation of FSOS in the office setting in the year ending December 31, 2007.

RESULTS

Six adult patients underwent a total of seven BC dilatations of FSOS in the clinical setting. The pretreatment ostium size was 1-2 mm. Four of the dilatations were performed with a 5-mm lacrimal BC (LacriCATH, Quest Medical, Allen, TX) and three dilatations were executed with a 7-mm sinus BC (SinuCATH, Quest Medical). All procedures were performed using topical anesthesia only. No complications occurred. Five of the six dilated FSOS dilatations were deemed successful after one BC dilatation. One ostium contracted >50% and required repeat BC dilatation. All ostia have remained patent with a follow-up range of 4-9 months. No subject has required formal surgical revision.

CONCLUSION

This preliminary report describes BC of FSOS in the office setting. The technique may serve as a safe and feasible alternative, potentially avoiding formal revision sinus surgery in select patients.