Author's Accepted Manuscript

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

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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: afolbe@med.wayne.edu

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.

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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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