Rate of dupilumab use and symptom severity of patients with chronic rhinosinusitis with nasal polyposis after Draf 3 frontal sinusotomy.

BACKGROUND: The indications for endoscopic modified Lothrop procedure (Draf 3) in patients with refractory chronic rhinosinusitis with nasal polyposis (CRSwNP) remain unclear. This study evaluates the effectiveness of Draf 3 for refractory CRSwNP focusing on improvements in disease severity and need for subsequent dupilumab rescue therapy. METHODS: Retrospective review of patients with CRSwNP undergoing Draf 3 surgery at a tertiary center between 2012 and 2022. Clinicodemographic variables were compared across those who did versus did not require rescue with postoperative dupilumab. Time to postoperative dupilumab rescue was analyzed and longitudinal disease-specific outcomes were measured using the sinonasal outcomes test (SNOT-22). RESULTS: Within 87 patients with CRSwNP, 24.1% had aspirin-exacerbated respiratory disease (AERD). Significant improvement in SNOT-22 score was found in CRSwNP with AERD (p < 0.001) and without AERD (p = 0.01) up to 24 months postoperative. 14.9% eventually required rescue with a dupilumab. More specifically, of 21 patients with AERD, 24.1% eventually required rescue with dupilumab. Dupilumab rescue was associated with a greater number of prior sinus surgeries (p = 0.02), prior aspirin desensitization (p = 0.02), and worse preoperative Lund-MacKay scores (p < 0.001). No association between biologic rescue and frontal recess antero-posterior diameter was found (p = 0.20). CONCLUSIONS: Draf 3 surgery in CRSwNP was associated with significant improvement in SNOT-22 score at 24 months. Furthermore, only 14.9% of patients required dupilumab rescue. Patients with AERD were more likely to require rescue with dupilumab even though 75.1% avoided treatment with the biologic over the study period.

Dynamic radiologic changes in repeated barotraumatic frontal sinusitis: A CARE case report.

INTRODUCTION: Flight staff are at particular risk of iterative sinus barotrauma. We here report a case of barotraumatic atelectasic frontal sinusitis with dynamic radiologic change in frontal sinus volume. CASE REPORT: A 46-year-old air pilot was referred for right frontal pain occurring at each landing. Two sinus CT scans were taken: one after a period of intense flying and the other after a month without flying. In the right frontal sinus, a type-3 Kuhn cell changed in volume from 6×11×12mm to 13×18×19mm. The alteration involved a modification in the medial wall, which was demineralized and changed position within the frontal sinus. Removal during endoscopic frontal sinusotomy allowed complete resolution of pain. DISCUSSION: This article reports radiologic change in a frontal sinus wall in a setting of repeated barotraumatic frontal sinusitis with a dynamic atelectasic component. In iterative barotrauma, we advocate imaging at different time points. When the ostial obstruction is identified, functional aeration surgery can be applied.

[History of frontal sinus surgery and current view of the problem. Part 2]. / Istoriya khirurgii lobnoi pazukhi i sovremennyi vzglyad na problemu. Chast' 2.

Surgical treatment of inflammatory diseases of the frontal sinus is one of the biggest challenges of modern otorhinolaryngology. Close proximity of the frontal sinus and frontal sinus drainage pathways to the skull base, the orbit and the anterior ethmoid artery, great limitations with its visualization and instrumentation, and high risk of the frontal recess scarring cause difficulties in either endoscopic or external approaches to the frontal sinus. At the same time endoscopic approach to the frontal sinus is considered as preferred method of frontal sinusitis surgical treatment by majority of peers nowadays. The introduction of extended approaches to the frontal sinus pathology treatment with frontal sinus floor and interfrontal sinus septum drill-out as well as superior septectomy with common drainage pathway formation gave an opportunity to greatly decrease a rate of indications for external frontal sinus procedures. In this paper historical backgrounds of endonasal approaches to frontal sinuses are presented, current controversies in proper selection of extent and methods of the frontal sinus surgery are analyzed and endoscopic as well as external approaches to frontal sinuses are summarized.

[History of frontal sinus surgery and current view of the problem. Part 1]. / Istoriya khirurgii lobnoi pazukhi i sovremennyi vzglyad na problemu. Chast' 1.

Surgical treatment of inflammatory diseases of the frontal sinus is one of the biggest challenges of modern otorhinolaryngology. Close proximity of the frontal sinus and frontal sinus drainage pathways to the skull base, the orbit and the anterior ethmoid artery, great limitations with its visualization and instrumentation, and high risk of the frontal recess scarring cause difficulties in either endoscopic or external approaches to the frontal sinus. At the same time endoscopic approach to the frontal sinus is considered as preferred method of frontal sinusitis surgical treatment by majority of peers nowadays. The introduction of extended approaches to the frontal sinus pathology treatment with frontal sinus floor and interfrontal sinus septum drill-out as well as superior septectomy with common drainage pathway formation gave an opportunity to greatly decrease a rate of indications for external frontal sinus procedures. In this paper historical backgrounds of endonasal approaches to frontal sinuses are presented, current controversies in proper selection of extent and methods of the frontal sinus surgery are analyzed and endoscopic as well as external approaches to frontal sinuses are summarized.

Outcomes of Frontal Sinus Stenting With Steroid Impregnated Microsponge Versus Steroid-Eluting Implant.

BACKGROUND: Mometasone-eluting poly-L-lactide-coglycolide (MPLG) is available commercially for frontal sinus ostium (FSO) stenting. An alternative chitosan polymer-based drug delivery microsponge is also available at a lower cost per unit. OBJECTIVE: To compare the outcomes of MPLG stents versus triamcinolone-impregnated chitosan polymer (TICP) microsponge in frontal sinus surgery. METHODS: Patients who underwent endoscopic sinus surgery from December 2018 to February 2022 were reviewed to identify those with the intraoperative placement of TICP microsponge or MPLG stent in the FSO. FSO patency was evaluated by endoscopy at follow-up. Twenty-two-item sinonasal outcome test (SNOT-22) was also recorded, and complications were noted. RESULTS: A total of 68 subjects and 96 FSOs were treated. TICP was first used in August 2021 and MPLG in December 2018. MPLG placement in a Draf 3 cavity was excluded since TICP had not been used during Draf 3 procedure. Both cohorts (TICP 20 subjects, 35 FSOs; MPLG 26 subjects, 39 FSOs) had similar clinical characteristics. At a mean total follow-up of 249.2 days for TICP and 490.4 days for MPLG, FSO patency was 82.9% and 87.1%, respectively (P = .265). At an equivalent follow-up of 130.6 days in TICP and 154.0 days in MPLG, patency was 94.3% and 89.7%, respectively (P = .475). Both groups showed significant reductions in SNOT-22 (P < .001). MPLG demonstrated crusting within the FSO at 1 month (none in TICP). CONCLUSION: FSO patency for both stents was similar, although TICP had significantly lower costs per unit. Additional comparative trials may be helpful for guiding clinicians on the appropriate clinical situations for the use of these devices.

Radiopathologic predictors of 1- and 2-year frontal sinusotomy outcomes in a southeast Asian chronic rhinosinusitis population.

BACKGROUND: The frontal sinus and its drainage pathway are difficult spaces to navigate surgically. The complexity of the frontal recess anatomy as well as inflammatory factors may influence outcomes of endoscopic frontal sinusotomy. It is not clear which factors are more important in determining post-operative frontal ostium patency. OBJECTIVE: The objective is to investigate whether the distribution of fronto-ethmoidal cells, frontal recess dimensions and sinonasal inflammation predict frontal ostium patency at 1- and 2-years after endoscopic frontal sinusotomy. METHODS: A retrospective review of 94 chronic rhinosinusitis patients (185 sides) who had undergone endoscopic frontal sinusotomies between 2015 and 2019 was conducted. Computed tomography was used to evaluate the type of fronto-ethmoidal cells present and determine the dimensions of the frontal recess. The International Classification of the Radiological Complexity of frontal recess and frontal sinus was used to grade the complexity of frontal recess anatomy. Mucosal inflammation was graded according to a structured histopathology report. Frontal ostium patency at 1- and 2-years post-operatively was recorded. RESULTS: The frontal ostium patency rates were 80.9% and 73.4% at 1- and 2-years respectively. Eosinophilic predominance (adjusted OR 3.5, 95% CI 1.6-8.0, p = 0.003) and mucosal ulceration on histology (adjusted OR 4.5, 95% CI 1.1-17.9, p = 0.033) predicted ostial stenosis at 1 year. Smoking (adjusted OR 7.6, 95% CI 2.4-24.7, p = 0.001), aspirin exacerbated respiratory disease (AERD) (adjusted OR 7.6, 95% CI 1.9-30.1, p = 0.004) and histological findings of severe inflammation (adjusted OR 8.9, 95% CI 1.9-41.2, p = 0.005) were independent predictors of ostial stenosis at 2 years. Frontal cell patterns, frontal recess dimensions and frontal recess complexity did not predict frontal ostium stenosis at both 1- and 2-years post-operatively. CONCLUSION: Post-operative control of sinonasal inflammation is important in maintaining frontal ostium patency, regardless of frontal cell patterns or frontal recess dimensions.

Ostial Patency Measurements After Endoscopic Sphenoidotomies and Frontal Sinusotomies.

BACKGROUND: Sphenoid and frontal sinuses have narrow ostia and are prone to stenosis. However, their relative rates of patency are not well established, and descriptive rates of sphenoid stenosis have never been reported. The objective is to measure the patency of the sphenoid and frontal sinus ostia postoperatively. METHODS: A prospective multi-institutional cohort study was performed. Ostial patency was measured at surgery and 3 and 6 months postoperatively. Pertinent clinical history such as the presence of nasal polyps and prior history of ESS as well as the use of steroid eluting stents were recorded. Overall stenosis rates were calculated for both the sphenoid and frontal sinuses, and Wilcoxon-Signed Rank Test was used to compare intraoperative and postoperative ostial areas. Factorial Analysis of Variance (ANOVA) was performed to determine effects of 5 clinical factors. RESULTS: Fifty patients were included. The mean sphenoid sinus ostial area decreased 42.2% in size from baseline to 3 months postoperatively (T0 55.2 ± 28.7 mm vs T3 m 31.8 ± 25.5 mm, P < .001). The mean frontal sinus ostial area decreased 39.8% in size from baseline to 3 months postoperatively (T0 33.7 ± 17.2 mm vs T3 m 19.9 ± 15.1 mm, P < .001). Neither the sphenoid nor the frontal sinus ostial patency demonstrated statistically significant change from 3 to 6 months postoperatively. CONCLUSION: Both sphenoid and frontal sinus ostia routinely narrow postoperatively, predominately from baseline to 3 months. These findings can serve as a reference for both clinical outcomes and future studies of these surgeries.

Silent sinus syndrome with interfrontal sinus retraction: A 3-case series using CARE methodology.

INTRODUCTION: Silent sinus syndrome (SSS) is a rare entity, almost exclusively involving the maxillary sinus, frontal location being very rarely reported. The aim of the present study was to describe clinical and radiological characteristics and surgical treatment using the CARE methodology. RESULTS: One woman and 2 men were referred for chronic unilateral frontal pain with imagery showing silent sinus syndrome. All showed partial or complete liquid opacification of the affected sinus associated with a thin interfrontal sinus (IFS) retracted toward the affected sinus. Functional endoscopic sinus surgery was performed in all cases, with good functional results. DISCUSSION: We describe 3 cases of SSS with IFS involvement. The frontal sinus wall seemed most vulnerable, probably most liable to be weakened by atelectasis. The study suggests that frontal SSS can be an etiology in chronic frontal sinusitis. Preoperative findings of IFS retraction are useful for surgical restoration of frontal sinus ventilation, relieving chronic pain and preventing complications.

Remote Training of Functional Endoscopic Sinus Surgery With Advanced Manufactured 3D Sinus Models and a Telemedicine System.

Objective: Traditionally, cadaveric courses have been an important tool in surgical education for Functional Endoscopic Sinus Surgery (FESS). The recent COVID-19 pandemic, however, has had a significant global impact on such courses due to its travel restrictions, social distancing regulations, and infection risk. Here, we report the world-first remote (Functional Endoscopic Sinus Surgery) FESS training course between Japan and Australia, utilizing novel 3D-printed sinus models. We examined the feasibility and educational effect of the course conducted entirely remotely with encrypted telemedicine software. Methods: Three otolaryngologists in Hokkaido, Japan, were trained to perform frontal sinus dissections on novel 3D sinus models of increasing difficulty, by two rhinologists located in Adelaide, South Australia. The advanced manufactured sinus models were 3D printed from the Computed tomography (CT) scans of patients with chronic rhinosinusitis. Using Zoom and the Quintree telemedicine platform, the surgeons in Adelaide first lectured the Japanese surgeons on the Building Block Concept for a three Dimensional understanding of the frontal recess. They in real time directly supervised the surgeons as they planned and then performed the frontal sinus dissections. The Japanese surgeons were asked to complete a questionnaire pertaining to their experience and the time taken to perform the frontal dissection was recorded. The course was streamed to over 200 otolaryngologists worldwide. Results: All dissectors completed five frontal sinusotomies. The time to identify the frontal sinus drainage pathway (FSDP) significantly reduced from 1,292 ± 672 to 321 ± 267 s (p = 0.02), despite an increase in the difficulty of the frontal recess anatomy. Image analysis revealed the volume of FSDP was improved (2.36 ± 0.00 to 9.70 ± 1.49 ml, p = 0.014). Questionnaires showed the course's general benefit was 95.47 ± 5.13 in dissectors and 89.24 ± 15.75 in audiences. Conclusion: The combination of telemedicine software, web-conferencing technology, standardized 3D sinus models, and expert supervision, provides excellent training outcomes for surgeons in circumstances when classical surgical workshops cannot be realized.

Comparison between the endoscopic scores of bolgerization versus partial resection of the middle turbinate for management of the postoperative lateralization in the early follow-up period after endoscopic frontal sinusotomy: A randomized controlled study.

BACKGROUND: Frontal sinusotomy is a challenging procedure that needs meticulous handling due to its unique anatomical position. Postoperative middle turbinate lateralization is critical comorbidity for the success rate, and many techniques are adopted to prevent it. The study aimed to compare the effect of middle turbinate bolgerization and partial resection on the postoperative endoscopic scores and assess their impact on the middle meatus and the frontal recess outcome. PATIENT AND METHODS: This prospective study was conducted on forty-one patients undergoing bilateral frontal sinusotomy for chronic frontal sinusitis. Nasal cavities were randomized so that partial middle turbinate resection technique was done alternately with bolgerization approach in every patient. Each participant acted as their control. Both sides were compared using Lund Kennedy Endoscopic Score (LKES) and Perioperative Sinus Endoscopy Score (POSE) at the baseline, 1st, 3rd, and 12th-month intervals postoperatively. Also, middle turbinate status was assessed at the end of the 12th-month interval using POSE score. RESULTS: The total frontal sinus patency rate was 82.9% (63/76 operated sinus). Baseline scores, LKES (3.79 ± 0.777 vs 4.05 ± 0.769, p = 0.142, for the side of resection and the side for bolgerization respectively) and POSE (1.79 ± 0.413 vs 1.82 ± 0.393, p = 0.777, for the side of resection and the side for bolgerization respectively). Regarding LKES, the differences between both operated sides were fluctuating with p values: 0.001*, 0.171, and 0.044* for the 1st, 3rd, and 12th months follow-up intervals, respectively. Regarding the POSE score of the frontal sinus, the difference between both groups was steadily increasing with p values: 0.318, 0.119, and 0.017* for the 1st, 3rd, and 12th months follow-up intervals. The middle turbinate's POSE score at the 12th month was significantly higher in the side allocated for bolgerization (p-value = 0.008*). CONCLUSION: Partial middle turbinate resection showed favorable endoscopic outcomes than bolgerization at the 12th month follow up period in patients undergoing primary ESS for chronic frontal sinusitis.

Long Term Olfactory Outcomes Following Frontal Sinus Surgery in Chronic Rhinosinusitis.

OBJECTIVES/HYPOTHESIS: No studies have evaluated the impact of the types of frontal sinus surgery (FSS) on objective olfaction scores. This study evaluated olfactory function and quality of life (QOL) in chronic rhinosinusitis (CRS) patients before and after total ethmoidectomy with frontal sinusotomy (FS). STUDY DESIGN: Prospective cohort study. METHODS: A prospective study of adult CRS patients undergoing FSS (Draf 2 or Draf 3 procedures) was conducted at a tertiary care center. Primary outcomes included brief smell identification test (BSIT) and sinonasal outcome test-22 (SNOT-22), which were assessed during preoperative evaluation, 6 to 9 weeks postoperatively, and 12 to 24 weeks postoperatively. Normosmia was defined as BSIT ≥9. Statistical significance was determined using the Wilcoxon signed-rank test with α = .05. RESULTS: Thirty-eight patients followed up 12 to 24 weeks after FSS. The differences between baseline and long-term outcomes for BSIT (6.11 vs. 8.24, P = .00034) and SNOT-22 (55.49 vs. 24.32, P < .00001) scores were found to be statistically significant. Although both subgroups had clinically significant olfactory improvements, only the Draf 2 cohort experienced a statistically significant improvement in olfaction at long-term follow-up. There was no statistically significant change in data from 6 to 9 weeks to 12 to 24 weeks postoperatively. CONCLUSIONS: Patients undergoing total ethmoidectomy with FS demonstrated statistically significant increases in olfaction and QOL at long-term postoperative follow-up. This study demonstrated that FS does not negatively impact the olfactory improvement seen in sinus surgery. The lack of statistically significant changes in these olfactory metrics from short to long-term follow-up suggests that there is no additional negative effect of FSS in the long term. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2173-2178, 2021.

The impact of bolgerization versus partial resection of the middle turbinate on frontal sinusotomy patency outcome: A randomised controlled study.

OBJECTIVES: This study aimed to compare the effects of middle turbinate resection vs bolgerization on the incidence of middle meatus synechia and their prognostic value on the patency outcomes after frontal sinusotomy. DESIGN: A randomised controlled study. SETTING: Tertiary centre hospital. MAIN OUTCOME MEASURES: Thirty-eight patients undergoing bilateral frontal sinusotomy for chronic frontal sinusitis were included. Partial middle turbinate resection was alternated with bolgerization in both nasal cavities of every patient. The Lund-Kennedy endoscopic scores (LKESs) for both sides were compared at the first, third and sixth months postoperatively. Middle meatus synechia was assessed using the visual analogue score (VAS). Sinus patency was assessed at the end of the sixth month using a 70° nasal endoscope. RESULTS: The sinus patency outcome was significantly higher in the resected group (34\38) than the bolgerized group (26\38), (P = .047*). The VAS scores suggested that the middle turbinate bolgerization group showed a significantly higher incidence of middle meatal synechia than the partial middle turbinate resection group (4.47 ± 2.617 vs 3.29 ± 2.301; P = .040*). CONCLUSION: Middle turbinate resection showed more favourable results than bolgerization concerning the sinus patency outcome after frontal sinusotomy. It also showed a lower incidence of middle meatus synechia postoperatively.

The prognostic variables affecting the frontal sinusotomy patency outcome and how to manage: A prospective study.

OBJECTIVES: The study aimed to assess the factors affecting the frontal sinus patency after endoscopic frontal sinusotomy. DESIGN: A prospective cohort study. SETTING: Tertiary centre hospital. MAIN OUTCOME MEASURES: Fifty patients with refractory chronic frontal sinusitis (83 operated frontal sinuses) had frontal sinusotomy and followed up for six months. Multiple operative factors were included the type of the procedure, intraoperative sinus findings, degree of mucosal preservation and middle turbinate stability. Other factors were also assessed, including smoking, the presence of allergic rhinitis, asthma, gastroesophageal reflux and other associated medical comorbidities. RESULTS: The sinus patency success rate was 75.9%. There was a significant difference regarding the intraoperative anteroposterior sinus ostium diameter (5.36 ± 1.45 mm vs 8.88 ± 2.38 mm, P-value: .001* in the failed group and the success group, respectively). There was a significant association between the patency outcome and the presence of associated medical comorbidities (P-value: .001*), the presence of allergic rhinitis (P-value: .001*), the degree of sinus mucosal preservation (P-value: .012*) and the degree of middle turbinate stability (P-value: .001*). The multivariate analysis showed that the intraoperative anteroposterior diameter of the sinus ostium, middle turbinate stability and presence of allergic rhinitis were significant predictors (P-value: .012*, .042* and .013*, respectively). CONCLUSION: Sinuses with anteroposterior ostium diameters less than 5.36 mm are more susceptible to restenosis. The flail middle turbinate increases the risk of postoperative middle meatus synechia and frontal sinus patency failure. The presence of allergic rhinitis has a negative impact on the patency outcome.

The preoperative radiological findings associated with failure of frontal sinusotomy: A prospective study.

OBJECTIVES: The study aimed to assess the association between the preoperative CT findings and the patency outcome of the frontal sinus after endoscopic frontal sinusotomy in the early follow-up period. DESIGN: A prospective cohort study. SETTING: Tertiary hospital centre. MAIN OUTCOME MEASURES: The study measures the association between the frontal sinusotomy outcome and the standard preoperative radiological scores, including Harvard, Kennedy and Lund-Mackay. It also measures the impact of the degree of sinus mucosal thickness on the outcome. Furthermore, it measures the effect of the anteroposterior lengths of both the frontal sinus ostium and the frontal recess on postoperative frontal sinus patency. RESULTS: Harvard, Kennedy and modified Lund-Mackay scores showed no evidence of association with the frontal sinusotomy patency outcome (P-values .397, .487 and .501), respectively. Still, the Lund-Mackay score showed a negative correlation with symptom improvement. Sinuses with a high-grade mucosal thickness on CT scan were associated with high failure rates (P-value: .009*). The anteroposterior length of the frontal sinus ostium significantly affects the outcome (P-value: .001*). In contrast, there was no association between the anteroposterior length of the frontal recess and the outcome (P-value: .965). CONCLUSION: The Harvard, Kennedy and Lund-Mackay scores could not predict the frontal sinusotomy patency outcome. Failed cases were associated with advanced degrees of mucosal pathology in the preoperative CT scan. Sinuses ostia with anteroposterior diameters less than 5.36 mm showed more susceptibility for sinus restenosis postoperatively. The variability of the anteroposterior length of the frontal recess did not affect the surgical outcome.

Frontal Sinus Drainage in Acute Pediatric Sinusitis With Intracranial Complications.

BACKGROUND: The indication for frontal sinus drainage is uncertain when managing pediatric acute sinusitis with intracranial complications. OBJECTIVE: The primary objective was to determine if addressing the frontal sinus reduced need for subsequent surgical procedures in children presenting with acute sinusitis complicated by intracranial abscess. METHODS: A case series with chart review was performed at a tertiary children's hospital between 2007 and 2019. Children under 18 years of age requiring surgery for complicated acute sinusitis that included the frontal sinus with noncontiguous intracranial abscess were included. Outcomes were compared among children for whom the frontal sinus was drained endoscopically, opened intracranially, or left undrained. RESULTS: Thirty-five children with a mean age of 11.1 years (95% CI: 9.9-12.3) met inclusion. Most presented with epidural abscess (37%). Hospitalizations lasted 12.9 days (95% CI: 10.2-15.5), 46% required a second surgery, 11% required three or more surgeries, and 31% were readmitted within 60 days. Initial surgery for 29% included endoscopic frontal sinusotomy, 34% had a frontal sinus cranialization and 37% did not have any initial drainage of the frontal sinus. Groups were similar with respect to demographics, severity of infection, need for repeat surgery, length of stay, and readmissions (p > .05). Further, persistence of cranial neuropathies, seizures, or major neurological sequelae after discharge were no different among groups (p > .05). CONCLUSION: Drainage of the frontal sinus, when technically feasible, was not associated with reduced surgical procedures or increased complications and there is unclear benefit on measured clinical outcomes.

Zero-Degree Endoscopic Visualization of the Frontal Sinus Predicts Improved Topical Irrigation Delivery.

OBJECTIVE: Management of chronic frontal rhinosinusitis is challenging with high rates of treatment failure, exacerbated by limitations of topical irrigation delivery. We hypothesize that intraoperative zero-degree visualization of the frontal sinus predicts improved postoperative irrigation penetration. Extending a Draf IIa frontal sinusotomy with a limited resection of the middle turbinate axilla-agger nasi complex can allow zero-degree endoscopic visualization of the frontal sinus. This study investigates the change in frontal sinus irrigation delivery after standard Draf IIa frontal sinusotomy versus further resection to achieve zero-degree visualization. STUDY DESIGN: This is a prospective cohort study conducted in a surgical skills laboratory. METHODS: The extent of irrigant penetration into the frontal sinuses was evaluated in 10 cadaveric frontal sinuses following Draf IIa sinusotomy using a standardized trephine visualization model. Irrigant penetration was assessed by three blinded reviewers using the following scale: 0 = irrigation restricted to nasal cavity; 1 = irrigation reaches frontal recess; 2 = irrigation reaches frontal sinus proper; 3 = irrigation fills entire frontal sinus. These results were compared to irrigation after achieving zero-degree endoscopic visualization by performing limited resection of the middle turbinate axilla-agger nasi complex. RESULTS: Irrigant penetration following standard Draf IIa frontal sinusotomy improved after the axilla-agger nasi complex was resected to achieve zero-degree endoscopic visualization (median score 2 [interquartile range: 1-2] vs. 3 [interquartile range: 2-3], P < .01). CONCLUSION: This study demonstrates improved penetration of frontal sinus irrigation following limited resection of the middle turbinate axilla-agger nasi complex to achieve zero-degree endoscopic visualization of the frontal sinus as compared to standard Draf IIa frontal sinusotomy. LEVEL OF EVIDENCE: N/A Laryngoscope, 131:250-254, 2021.

Sinus Irrigation Penetration After Proposed Modified Draf IIa Technique in a Side-to-Side Cadaveric Model.

BACKGROUND: Endoscopic sinus surgery (ESS) is an effective intervention for patients with medically refractory chronic rhinosinusitis. Frontal sinusotomy is the most challenging part of ESS, with one of the key outcomes being access for topical irrigations. OBJECTIVE: The purpose of this study is to compare irrigation penetration into the frontal sinus following Draf IIa versus modified Draf IIa frontal sinusotomy. METHODS: Four fresh cadaver heads were used in this experiment. Draf IIa was performed on one side of each head and a modified Draf IIa on the contralateral side. This proposed modification consists of a Draf IIa combined with an agger nasi punch-out procedure and partial trimming of the vertical lamella of the middle turbinate back to the posterior table of the frontal sinus without drilling the beak. Each head was irrigated with methylene blue-dyed water and recorded by rigid endoscopy through an endonasal view (EV) of the frontal sinus and frontal trephination view (TV). Two blinded rhinologists scored the extent of staining (using an ordinal scale of 0 to 3) for each side. A case report where the modified Draf IIa was performed is also described. RESULTS: After modified Draf IIa sinuosotomy, the mean score for the EV was 2.125 and for the TV was 2, versus 0.875 and 0.625 for traditional Draf IIa, respectively. There was a statistically significant increase for both EV (p = 0.019) and TV (p = 0.018) after modified Draf IIa. CONCLUSION: In our cadaveric model, this procedural modification improved penetration of postoperative irrigations into the frontal sinus. This simple technique may be easily adapted into frontal ESS when indicated.

Lynch vs transcaruncular approach: optimizing access to the lateral frontal sinus.

BACKGROUND: Visualization and instrumentation of the frontal sinus is not always possible with a Draf III or modified endoscopic Lothrop procedure (MELP), and external incisions can help augment exposure. We compare lateral frontal sinus access using only a MELP compared to the adjunctive transcaruncular approach and transcutaneous Lynch incision. METHODS: Twelve cadaveric heads underwent thin-cut computed tomography scanning. Measurement of the frontal beak, anteroposterior depth of the frontal sinus, and interorbital distance was performed. There were 4 specimens with poorly pneumatized frontal sinuses that were excluded from the study. Eight cadaveric heads (16 sides) were dissected and a MELP with bilateral transcaruncular and Lynch incisions for access to the lateral frontal sinus was performed. Under image guidance, measurements extended from the midline crista galli to the most lateral point of the frontal sinus visualized using a 0-degree endoscope with straight suction and a 30-degree endoscope with curved suction. RESULTS: The proportion of the ipsilateral frontal sinus accessed through the contralateral nare with a 0-degree endoscope and straight suction using a MELP only, a MELP with transcaruncular approach, and a MELP with Lynch incision, respectively, averaged 41.6%, 51.6%, and 58.9% on the right, and 48.9%, 47.1%, and 61.2% on the left. Using a 30-degree endoscope and curved suction the proportion accessed using a MELP only, a MELP with transcaruncular approach, and a MELP with Lynch incision, respectively, increased to 76.1%, 62.6%, and 91.8% on the right, and 83.2%, 62.7%, and 88.7% on the left. CONCLUSION: Adjunctive external approaches can improve access and instrumentation of the frontal sinus when combined with a MELP.