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Advances In Endoscopic Frontal Sinus Surgery
Adam J. Folbe MD, Peter F. Svider MD, JeanAnderson Eloy MD, FACS
PII: S1043-1810(14)00018-9DOI: http://dx.doi.org/10.1016/j.otot.2014.02.008Reference: YOTOT623
To appear in: Operative Techniques in Otolaryngology
Cite this article as: Adam J. Folbe MD, Peter F. Svider MD, Jean Anderson Eloy MD,FACS, Advances In Endoscopic Frontal Sinus Surgery, Operative Techniques inOtolaryngology, http://dx.doi.org/10.1016/j.otot.2014.02.008
This is a PDF file of an unedited manuscript that has been accepted for publication. As aservice to our customers we are providing this early version of the manuscript. Themanuscript will undergo copyediting, typesetting, and review of the resulting galley proofbefore it is published in its final citable form. Please note that during the production processerrors may be discovered which could affect the content, and all legal disclaimers that applyto the journal pertain.
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Advances in Endoscopic Frontal Sinus Surgery
Adam J. Folbe, MD1
Peter F. Svider, MD1
Jean Anderson Eloy, MD, FACS2�1Department of Otolaryngology –Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA2Department of Otolaryngology – Head & Neck Surgery, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey, USA
Running Title: Endoscopic Frontal Sinus Surgery
Financial Disclosures: None Conflicts of Interest: None
Corresponding Author:Adam J. Folbe, MD Assistant Professor Director, Rhinology, Allergy and Endoscopic Skull Base Surgery Department of Otolaryngology-Head and Neck Surgery Department of Neurosurgery Wayne State University School of Medicine 540 East Canfield, 5E-UHC Detroit, MI 48201 Phone: (313) 577-0804 FAX: (313) 577-8555 E-mail: [email protected]
ABSTRACT The challenging nature of endoscopic frontal sinus surgery, due to the tendency
for recurrent disease, as well as the close proximity of critical structures mandates a
comprehensive understanding of operative strategies. The development of newer
technologies such as surgical navigation and balloon instruments may instill a false
confidence in the surgeon. The objectives of this uodate are to describe anatomical
principles and surgical techniques involved with the various Draf procedures, and to
review the indications for frontal sinus surgery. The Draf approaches and associated
variations have revolutionized the management of chronic frontal rhinosinusitis, as purely
endoscopic approaches may minimize the morbidities classically accompanying open
procedures.
The management of chronic frontal rhinosinusitis presents several unique
challenges due to the tendency for recurrence, and the proximity of critical structures
such as the orbital and intracranial contents. Until the development of endoscopic sinus
surgery, open techniques such as the Lynch and Lothrop procedures, and later,
osteoplastic flap frontal sinus obliteration, were emphasized for severe disease, as
transnasal approaches were not reliable.1 Writing in 1917 about frontal sinus disease,
Lothrop opined “I believe that the nasal route is inefficient and unnecessarily dangerous
even in skilled hands.” 2
Nearly 80 years later, Draf described several endoscopic approaches to frontal sinus
surgery, all of which result in a widened frontal sinus outflow tract.1,3-7 The Draf
techniques and variations of them have been widely adopted,3,6-11 allowing patients to
avoid the considerable morbidity associated with external approaches. Although there
may still be a role for procedures such as osteoplastic frontal sinus obliteration in certain
situations,12 these endoscopic techniques have largely replaced such procedures and have
become common in many situations.10,13,14
Over the past several years, there have been many courses teaching frontal sinus surgery.
However, with the development of new technology such as surgical navigation and
balloon tools, a false confidence can arise in the surgeon. This chapter will focus on
surgical techniques based on reliable landmarks and safe principles.
By the end of this chapter, the reader should be able to:
1. understand important anatomical relationships in primary and revision frontal
sinus surgery.
2. understand the different techniques involved with the various Draf procedures.
3. understand the indications for the frontal sinus surgery.
PRE-OPERATIVE CONSIDERATIONS
As in all surgeries, patient selection can be the difference between a successful
surgery and a failed surgery. Frontal sinus surgery is no exception, and indications for
each procedure will be discussed in the pertinent section.
A pre-operative review of the anatomy on physical exam and CT scan is very
important. Focusing on the frontal recess, the physician should perform a thorough nasal
endoscopy in the office to determine the status of the middle meatus and superior
attachments of the middle turbinate and the uncinate. If the patient has had previous
sinus surgery, these structures may be removed or scared in variable positions, thus
rendering them less useful in identifying the correct access path to the frontal recess. The
pre-operative review of the CT scan is useful in identifying osteomeatal complex disease,
frontal recess scar tissue or osteoneogenesis, clues to disease process such as mucoceles,
allergic fungal sinusitis or tumors, and specialized frontal cells as described by Bent and
Kuhn. 15
The frontal sinus outflow tract is located between the agger nassi cell (or frontal
infundibular cells) and suprabullar air cells. The orbital roof and the vertical lamella of
the middle turbinate comprise the lateral and medial borders, respectively (Figure 1).
Variations in anatomy can distort the frontal sinus outflow tract and interfere with
normal mechanisms of drainage.16 Cells contributing to this obstruction have previously
been classified by Bent and Kuhn and should be noted on preoperative CT.
Key anatomical structures.
In primary sinus surgery, structures to help identify the frontal recess are the
superior attachment of the middle turbinate, the superior attachment of the uncinate,
agger nasi cell, and the anterior border of supra-orbital cell. The frontal recess can be
found anterior to the supra-orbital cell and posterior to the agger nasi cell (Figure 2).
In revision sinus surgery, most of those landmarks are removed or scarred. Key
landmarks that are relatively constant and can be used to identify the frontal recess are
the natural ostium of the maxillary sinus, the trajectory of the nasolacrimal duct and the
anterior ethmoid artery. As shown (Figure 3), the frontal recess can be triangulated
using the natural ostium of the maxillary sinus for A-P depth, and the trajectory being
parallel to the nasolacrimal duct. The posterior skull base at the level of the anterior
ethmoid artery is also a reliable landmark.
Instruments needed: Angled endoscopes- 30 and 70 degree scopes Angled currettes C-spine currettes Angeled burrs (Figure 4)
SURGICAL TECHNIQUES
Draf I Frontal Sinusotomy
The Draf I endoscopic procedure is the least invasive transnasal approach, as it is
used when the primary cause of disease does not involve the actual frontal sinus. This
procedure targets disease involving the frontal recess, and includes removal of
anterosuperior ethmoid cells causing obstructing disease.1,5 Special care should be taken
to protect the mucosa of the frontonasal outflow track while removing these obstructing
cells. We prefer to use the 30 degree endoscope for most of the procedure with the 70
degree used if needed.5
Using a frontal sinus seeker, the frontal recess is gently probed just anterior to the
ethmoid bullae lamella and posterior to the aggar nasi cell. If it is a revision surgery, then
the natural ostium of the maxillary sinus and the nasolacrimal duct can be used for
guidance (Figure 2,3). Once in the recess, the posterior wall of the agger nasi cell is
dissected inferiorly, away from the skull base, and widening the recess. Any disease
within the recess can be carefully removed using cutting instruments. This will avoid
stripping the mucosa and affecting mucociliary clearance.
Draf IIA Frontal Sinusotomy
This approach encompasses relieving obstruction that directly involves resection
of ethmoid cells that extend into the frontal sinus.5,17 Referred to as “uncapping the
egg,”17 frontal sinus drainage is facilitated by creating a path between the lamina
papyracea and the middle turbinate.5 Indicated for patients experiencing persistent frontal
disease and symptoms after a Draf I procedure, this approach is most appropriate for
individuals possessing frontal sinuses with larger A-P diameters.5,18 Once the posterior
table of the frontal sinus has been identified, then the dissection is directed along the
anterior edge of the frontal sinus, working from a lateral to medial direction.
Transillumination of the frontal sinus helps confirm the frontal sinus. Transillumination
of the medial canthus region shows that the surgeon is in the supra-orbital cell region
(Figure 5).
Draf IIB Frontal Sinusotomy
Frontal sinus polyposis, scarring, and other severe disease processes may
necessitate surgical management beyond opening the frontal recess.5 Consequently,
extended frontal sinusotomy may be appropriate The Draf type IIB frontal sinusotomy is
differentiated from Draf IIA by an expanded outflow tract between the lamina papyracea
and nasal septum, excising the middle turbinate that is anterior to the coronal plane of the
anterior skull base (Figure 6). A 30, 45, or 70 endoscope can be used to identify the
anterior middle turbinate attachment which, in conjunction with the superior lamina
papyracea and roof of the anterior ethmoid, can be used to identify the posterior frontal
sinus boundary.16,19 Special care should be taken during performance of the middle
turbinate excision, making sure this procedure is performed anterior to the posterior
frontal sinus table’s coronal plane, as this prevents accidental disruption of the anterior
cranial fossa.7
Draf III/ Modified Lothrop Procedure
Lothrop originally described a frontal sinus procedure combining transasal
drilling and an external frontoethmoidectomy in 1914.2,11 Drawbacks included poor
visualization (intranasally) and a propensity for orbital soft tissue prolapse (due to the
external approach), the latter of which facilitated subsequent nasofrontal obstruction.11
With technological advancements, namely endoscopic visualization, a modified Lothrop
approach was developed, allowing the entire procedure to be conducted via an intranasal
approach. A Draf III, or modified Lothrop approach, involves creation of a single
outflow tract. It is essentially a Draf IIB procedure and includes removal of the intersinus
septum and anterior superior nasal septum (Figure 7).
This procedure encompasses resection of agger nasi, uncinate, and anterior
ethmoid cells, cannulation of the frontal recess, resection of the anterior superior nasal
septum, and frontal drillout.11 Although widely used in patients with prior surgical
failures of Draf II or Lynch procedures5,20 or cases necessitating access to difficult areas
(such as the lateral recess),9 further modifications have been proposed in certain
situations.
POST-OPERATIVE CARE
Similar to surgical care of the other sinuses, diligent postoperative care is paramount in
facilitating mucosal health and preventing scar formation.21 Nasal packing should not
remain beyond 24 hours, and appropriate patient education regarding the performance of
saline irrigation is invaluable in promoting healing.22 In addition to communicating
specific concerns, providing patient education materials that avoid the use of medical
jargon may facilitate patient understanding.23,24 Careful endoscopic examination can be
used for cleaning and clearance of immature adhesions at the 1-week post-operative
visit.22 Topical steroids have been shown to advance healing and may be considered until
healing is completed or for greater than 6 months.5,25
COMPLICATIONS
Although experience with endoscopic frontal sinus surgery has dramatically increased
over the past decade, there are very few figures citing the rate of specific complications,
and additional studies are needed for determination of long-term safety and efficacy.1,26
One retrospective chart review of 235 patients over two decades reported the rate of
“major” or permanent complications to be 2.7% over this time period.27
Frontal sinus surgery complications have the potential to be significant due to
their location, technical complexity associated with interventions, and potentially higher
post-operative stenosis rates. Consequently, a comprehensive informed consent process
discussing specific risks, alternatives, and benefits may be beneficial for improving the
doctor-patient relationship and minimizing medicolegal liability. Additionally,
expectations of the procedure and mention of the potential for needing additional
procedures should be relayed in this conversation, as confusion regarding these issues
may play a role in facilitating litigation should an adverse outcome occur.28-32
Intraoperative image-guidance technology may be useful for minimizing complications in
endoscopic frontal sinus surgery, particularly with endoscopic dissection of the frontal
recess cell.33 Non-use of this technology when it is not indicated, however, does not
appear make a surgeon more vulnerable to malpractice litigation.34 The AAO-HNS
provides specific recommendations regarding the use of this technology in sinus
surgery.35
CONCLUSIONSThe Draf procedures all result in a widened frontal sinus outflow tract while
minimizing the considerable morbidity typically associated with open approaches. The
surgeon should consider utilizing these purely endoscopic approaches in complicated and
chronic frontal sinus disease where appropriate. Additionally, several nuances that
complement the Draf approaches have been developed in recent years and may be useful
in select cases. A sound understanding of the important anatomical relationships in
primary and revision frontal sinus surgery is critical for effective operative management.
REFERENCES
1. Silverman JB, Prasittivatechakool K, Busaba NY. An evidence-based review of
endoscopic frontal sinus surgery. Am J Rhinol Allergy 2009; 23:e59-62.
2. Lothrop HA. Frontal Sinus Suppuration. Ann Surg 1914; 59:937-957.
3. Gross WE, Gross CW, Becker D, Moore D, Phillips D. Modified transnasal
endoscopic Lothrop procedure as an alternative to frontal sinus obliteration.
Otolaryngology--head and neck surgery : official journal of American Academy
of Otolaryngology-Head and Neck Surgery 1995; 113:427-434.
4. Draf W, Weber R, Keerl R, Constantinidis J. [Current aspects of frontal sinus
surgery. I: Endonasal frontal sinus drainage in inflammatory diseases of the
paranasal sinuses]. Hno 1995; 43:352-357.
5. Weber R, Draf W, Kratzsch B, Hosemann W, Schaefer SD. Modern concepts of
frontal sinus surgery. Laryngoscope 2001; 111:137-146.
6. Eloy JA, Kuperan AB, Friedel ME, Choudhry OJ, Liu JK. Modified hemi-
Lothrop procedure for supraorbital frontal sinus access: a case series.
Otolaryngology--head and neck surgery : official journal of American Academy
of Otolaryngology-Head and Neck Surgery 2012; 147:167-169.
7. Eloy JA, Liu JK, Choudhry OJet al. Modified Subtotal Lothrop Procedure for
Extended Frontal Sinus and Anterior Skull Base Access: A Cadaveric Feasibility
Study with Clinical Correlates. J Neurol Surg B 2013; 74:130-135.
8. Eloy JA, Friedel ME, Kuperan AB, Govindaraj S, Folbe AJ, Liu JK. Modified
mini-Lothrop/extended Draf IIB procedure for contralateral frontal sinus disease:
a case series. International forum of allergy & rhinology 2012; 2:321-324.
9. Eloy JA, Friedel ME, Murray KP, Liu JK. Modified hemi-Lothrop procedure for
supraorbital frontal sinus access: a cadaveric feasibility study. Otolaryngology--
head and neck surgery : official journal of American Academy of
Otolaryngology-Head and Neck Surgery 2011; 145:489-493.
10. Georgalas C, Hansen F, Videler WJ, Fokkens WJ. Long terms results of Draf type
III (modified endoscopic Lothrop) frontal sinus drainage procedure in 122
patients: a single centre experience. Rhinology 2011; 49:195-201.
11. Gross CW, Gross WE, Becker DG. Modified Transnasal Endoscopic Lothrop
Procedure: Frontal Drillout. Operative Techniques in Otolaryngology -- Head and
Neck Surgery 1995; 6:193-200.
12. Silverman JB, Gray ST, Busaba NY. Role of osteoplastic frontal sinus obliteration
in the era of endoscopic sinus surgery. International journal of otolaryngology
2012; 2012:501896.
13. Naidoo Y, Wen D, Bassiouni A, Keen M, Wormald PJ. Long-term results after
primary frontal sinus surgery. International forum of allergy & rhinology 2012;
2:185-190.
14. Anderson P, Sindwani R. Safety and efficacy of the endoscopic modified Lothrop
procedure: a systematic review and meta-analysis. Laryngoscope 2009; 119:1828-
1833.
15. Bent JP, Cuilty-Siller C, Kuhn FA. The Frontal Cell As a Cause of Frontal Sinus
Obstruction. American journal of rhinology 1994; 8:185-191.
16. Casiano RR, Herzallah IR, Anstead ASet al. Advanced Endoscopic Sinonasal
Dissection. In: Casiano RR, ed. Endoscopic Sinonasal Dissection Guide. New
York: Thieme Medical Publishers, 2012.
17. Kuhn FA, Bolger WF, Tisdahl RG. The agger nasi cell in frontal recess
obstruction: an anatomic, radiologic and clinical correlation. Operative
Techniques in Otolaryngology -- Head and Neck Surgery 1991; 2:226-231.
18. Schaefer SD, Close LG. Endoscopic management of frontal sinus disease.
Laryngoscope 1990; 100:155-160.
19. McLaughlin RB, Hwang PH, Lanza DC. Endoscopic trans-septal frontal
sinusotomy: the rationale and results of an alternative technique. American
journal of rhinology 1999; 13:279-287.
20. Casiano RR, Livingston JA. Endoscopic Lothrop procedure: the University of
Miami experience. American journal of rhinology 1998; 12:335-339.
21. Kuhn FA, Citardi MJ. Advances in postoperative care following functional
endoscopic sinus surgery. Otolaryngologic clinics of North America 1997;
30:479-490.
22. Metson R, Sindwani R. Endoscopic surgery for frontal sinusitis--a graduated
approach. Otolaryngologic clinics of North America 2004; 37:411-422.
23. Sanghvi S, Cherla DV, Shukla PA, Eloy JA. Readability assessment of internet-
based patient education materials related to facial fractures. Laryngoscope 2012.
24. Svider PF, Agarwal N, Choudhry OJet al. Readability assessment of online
patient education materials from academic otolaryngology-head and neck surgery
departments. American journal of otolaryngology 2013; 34:31-35.
25. Weber R, Keerl R, Huppmann A, Schick B, Draf W. [Effects of postoperative
care on wound healing after endonasal paranasal sinus surgery]. Laryngo- rhino-
otologie 1996; 75:208-214.
26. Scott NA, Wormald P, Close D, Gallagher R, Anthony A, Maddern GJ.
Endoscopic modified Lothrop procedure for the treatment of chronic frontal
sinusitis: a systematic review. Otolaryngology--head and neck surgery : official
journal of American Academy of Otolaryngology-Head and Neck Surgery 2003;
129:427-438.
27. Hoskison E, Daniel M, Daudia A, Jones N, Sama A. Complications of
Endoscopic Frontal Sinus Surgery 2010; 143:272.
Figure Legends: Figure 1:Sagittal view of the lateral nasal cavity showing the frontal sinus outflow tract between the Agar nasi cell anteriorly and the suprabullar air cells posteriorly.Figure 2:Sagittal view of the lateral nasal cavity showing the frontal recess boundary.The recess is parallel to the nasolacrimal duct starting from the natural ostium of the maxillary sinus. Figure 3:Cadaver dissection with A as the sagittal view and B as the corresponding endoscopic view. The oval in A and the white arrow in B is the nasolacrimal duct.
A: B is the ethmoid bullae, PE is the posterior ethmoids, S is the sphenoid sinus. White arrow is the trajectory into the frontal sinus.
B: Black line is the trajectory into the frontal recess. * is the frontal sinus. Small white arrow and white diamond are the anterior and posterior ethmoid arteries. M is the maxillary sinus, MT is the middle turbinate, S is the sphenoid sinus, P is the posterior ethmoid sinuses. The triangle created by the black line and the two blue lines represents the orbit. Figure 4: Instruments used in frontal sinus dissection. Top left shows a straight cutting burr drilling down the nasal beak. Top right shows the various c-spine currettes, bottom right shows angled powered burrs, and bottom left shows proper hand position during endoscopic frontal sinus surgery. Figure 5: A: Proper trans-illumination of the frontal sinus 6 months post-operative. B: Endoscopic view 6 months post-operative of a Draf IIA. MT is middle turbinate, NS is nasal septum, FS is frontal sinus. Figure 6: Cadaver dissection showing the proper coronal plane of resection, of the middle turbinate anterior to the cribriform plate. Figure 7: A: Endoscopic view of Draf III in a cadaver. B: Post-operative CT scan of a Draf III
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