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

Enhancing Frontal Sinus Surgery: Assessing the Long-Term Impact of Free Grafts and Flaps in Draf III Procedures

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.

Comprehensive access strategies to the frontal sinus

PURPOSE OF REVIEW

Despite the impressive evolutions in endoscopic endonasal approaches and instrumentations, the frontal sinus remains a challenging area. Different surgical options have been described over the years, but the main criticism lies in choosing the most suitable approach for a given case, based on the anatomy of each patient and the disease to treat. The purpose of this study is to provide a comprehensive review of surgical access strategies currently available to address the frontal sinus, including both endonasal and traditional external procedures, analysing indications, contraindications, complications and outcomes.

RECENT FINDINGS

Frontal sinus surgery includes minimally invasive endonasal approaches (balloon dilatation, Draf type I); extended endonasal approaches (Draf type IIA-IIB-IIC, Draf type III and their modifications via orbital transposition and contralateral pyriform aperture resection); external procedures (superior eyelid incision, frontal osteoplastic flap, Riedel procedure, Riedel-Mosher operation); and combined approaches.

SUMMARY

Recent advances in endoscopic endonasal techniques have deeply reshaped the surgical options to manage frontal sinus diseases, in an attempt to minimize the invasiveness of the procedures and maximize their outcomes. Traditional external procedures should be used in selected cases nonamenable for endonasal surgery. The appropriate selection of cases appears to be of paramount importance to obtain successful outcomes.