Clinical features, operative management and surgical results of first Draf III procedure, revision Draf III approach and the use of mucosal flaps and stents: a systematic review.

OBJECTIVES: Draf III procedure is a challenging endoscopic technique, which has gradually gained an increasing popularity in treating frontal sinus pathologies. The main aim of this systematic review is to offer a comprehensive overview on clinical indications, pre-operative evaluation, surgical techniques, post-operative management and complications of the Draf III procedure. As a step forward, such issues have been comparatively evaluated as referred to patients who underwent primary Draf III procedure and revision DRAF III one). Finally, surgical outcomes related to mucosal flaps and stents to prevent re-stenosis are analyzed. METHODS: A systematic literature review has been performed following PRISMA 2020 checklist statement. An automated search has been carried out by applying an extensive set of queries on the Embase/PubMed, Scopus and Cochrane databases, relating to papers published from 2000 to 2021. RESULTS: Frontal chronic refractory sinusitis is the most frequent indication to Draf III procedure (72%), followed by mucoceles (11%) and skull base or paranasal tumors (10%). The success rate of primary and revision Draf III are 83.5% and 71%, respectively. The re-stenosis phenomenon seems to depend on allergic mechanism and polyposis). The use of mucosal flaps could improve the Draf III efficacy, better than the use of stents (87 vs 72% of neo-ostium patency). CONCLUSION: Draf III is a safe and highly effective surgical technique. However, some limited clinical conditions require some careful technical features, such as the use of mucosal flap, in order to prevent re-stenosis.

[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.

[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.

Management of an extensive frontal pyocoele using an external approach: A case report.

Pyocoeles of the paranasal sinuses are pus-filled cavities seen in the sinuses and develop from the infection of the mucocoeles. Pyocoeles most commonly form in the frontal sinus. Endoscopic Sinus Surgery is currently the mainstay of the treatment. We present the case of an 85-year-old female who presented to the ENT OPD of Jinnah Hospital/AIMC, Lahore, in October 2017 with complaints of progressive symptoms of intractable left frontal pain, double vision, and an associated swelling below the medial half of the left eyebrow. A CT scan was done and a diagnosis of extensive frontal pyocoele was made. She was treated successfully with an external approach and remained without any complications till 13-month follow-up after surgery; exceptional cosmetic results were achieved. We wish to bring attention to the possibility of an external approach being used as a primary intervention, if deemed appropriate.

[Prevention of frontal pocket stenosis after endoscopic transnazal surgery on the frontal sinus and endoscopic septoplasty in acute and chronic pathology of frontal sinuses]. / Profilaktika stenozirovaniia lobnogo karmana posle éndoskopicheskoi transnazal'noi operatsii na lobnoi pazukhe i éndoskopicheskoi septoplastiki pri ostroi i khronicheskoi patologii lobnykh pazukh.

The main idea of our manuscript is prevention of frontal recess stenosis after endoscopic endonasal frontal sinus surgery and septoplasty during to acute and chronic frontal sinuses pathology. PURPOSE: To offer an effective method to prevent postoperative frontal recess stenosis after endoscopic endonasal frontal sinus surgery and surgical correction of intra-nasal structures. MATERIAL AND METHODS: In our manuscript we analyzed 274 cases of endoscopic endonasal frontal sinus surgery: postoperative treatment (local and systemic). All of them were operated by endoscopic endonasal approach both initially and repeatedly for acute and chronic frontal sinusities in the ENT department Pavlov First state medical university of Saint Petersburg from 2013 to 2019. RESULTS: In 10 cases, patients with previous endoscopic endonasal frontal sinus surgery underwent revision endoscopic procedure due to frontal recess obstruction, in 4 cases - due to a recurrence of the polypous process involving the frontal sinus, in 6 cases - without visible provoking factors contributing to restenosis of the frontal recess. First step in all cases was a correction of the nasal septum. It is necessary to assess the factors that contribute to restenosis of the frontal recess. Careful endoscopic care of the nasal cavity and the frontal recess in the postoperative period can reduce the risk of restenosis of the latter. Local antibacterial nasal therapy is recommended for the prevention of purulent processes in the nasal cavity in the early postoperative period.

Impact of residual frontal recess cells on frontal sinusitis after endoscopic sinus surgery.

PURPOSE: Endoscopic sinus surgery (ESS) is a well-established treatment for chronic rhinosinusitis (CRS). However, ESS for frontal sinusitis remains complicated and challenging. The aim of this study was to identify the relationship between residual frontal recess cells and primary ESS failure in the frontal sinus. METHODS: We prospectively collected information on 214 sides of 129 patients with CRS who underwent standard ESS from June 2010 to May 2011. To identify risk factors, we retrospectively analyzed clinical data and computed tomography (CT) images before and 3 months after surgery. RESULTS: The posterior side of the frontal recess cells remained relatively common: suprabullar cells (SBCs) were found in 12.2% (16 sides), suprabullar frontal cells (SBFCs) in 20.3% (12 sides), and supraorbital ethmoid cells in 23.7% (14 sides). In contrast, the anterior side of the frontal recess cells, agger nasi cells, supra agger cells, and supra agger frontal cells remained at < 10.0%. Frontal septal cells persisted in 25.0% (5 sides). The presence of residual frontal recess cells was an independent risk factor for postoperative frontal sinus opacification as were well-recognized risk factors such as nasal polyps, the peripheral eosinophil count, and the CT score. Among residual frontal recess cells, SBCs and SBFCs were independent risk factors for opacification. CONCLUSIONS: Residual frontal recess cells, especially SBCs and SBFCs, were independent risk factors for postoperative opacification of the frontal sinus. Complete surgical excision of frontal recess cells may improve surgical outcomes.

Full-Extension Eyebrow Approach with Supraorbital Nerve Preservation for Frontal Sinus Tumors.

Frontal sinus surgery still represents a challenge due to its complex and highly variable anatomy. In this manuscript, we present a detailed anatomical description of an eyebrow approach that allows full exposure of the frontal sinus with a large osteoplastic bone flap and preservation of the supraorbital nerve. Laryngoscope, 134:1633-1637, 2024.

Supraorbital Ethmoid Air Cell - Its Role in Sinonasal Pathologies.

The supraorbital ethmoid air cell (SOEC) is an anatomical variation of the ethmoid air cell system that pneumatizes the orbital plate of the frontal bone. It affects the frontal recess configuration by opening posterior and lateral to the frontal sinus ostium. This cross-sectional observational study includes 100 patients with Supra orbital ethmoid air cells including various pathologies. We picked up the first 100 patients who had SOEC in all the CT PNS done for various sinonasal pathologies. The incidence of the cell was about 43%. The most common type was the cell extending up to the medial wall of the orbit which was noted in 37% of the cases. Cribriform plate was low-lying in patients with SOEC and the most common type was Keros 3 in about 49% of the study group. 83 patients had anterior ethmoid artery (AEA) lying away from the skull base hanging freely in the mesentery. The most common pathologies observed in patients with supraorbital ethmoid cells were chronic rhinosinusitis followed by mucoceles. The recurrence rate of sinusitis is high in patients with SOEC. The recurrences were mostly because of mistaking the SOEC to be frontal sinus or incomplete removal of partition between them. study stresses the importance of SOEC and its orientation preoperatively to avoid complications during and after the surgery. Detailed preoperative evaluation with the CT helps the surgeon to identify the cells, their extent and associated anatomical variations thereby preventing damage to AEA, cribriform plate and lateral lamella and can get good results.

The Frontal Sinus Drainage in Relation to Frontal Sinus Surgery.

In order to perform a successful endoscopic frontal sinus surgery, prevent complications, and lower the recurrence risk, it is essential to understand the anatomy of the frontal sinus (FS) and frontal recess cells with many variations in frontal sinus drainage (FSD). Preoperative assessment of the FSD in three levels in order to find prognostic factors in the decision process regarding the kind and the extent of surgery when required. Three FSD levels were assessed by computed tomography in two dimensions; antero-posteriorly and laterally in 100 consecutive patients with chronic sinusitis symptoms. The first level represents the proper drainage of FS. The second level is the drainage of FS without the effect of the frontoethmoidal cells. The third level is the maximum drainage that can be achieved in a single FS. The relation of FSD levels to FS and frontoethmoidal cells pathology were assisted. Within 100 patients (200 sides, 186 FSs), for the proper FSD, antero-posterior (AP) length was 5.94 ± 3.42 mm in opaque FS and 5.32 ± 2.87 mm in clear FS and its lateral length was 3.04 ± 1.6 mm in opaque FS and 2.30 ± 1.25 mm in clear FS. For the functional FSD, AP length was 8.97 ± 2.7 mm in opaque FS and 8.05 ± 2.7 mm in clear FS and its lateral length was 7.51 ± 1.69 mm in opaque FS and 7.58 ± 1.75 mm in clear FS. In the anatomical FSD, AP length was 11.25 ± 3.07 mm in opaque FS and 10.01 ± 2.87 mm in clear FS and its lateral length was 11.1 ± 2.6 mm in opaque FS and 10.95 ± 1.7 mm in clear FS. This study offers essential data for preoperative assessment in order to improve surgeons' awareness of the frontoethmoidal region for optimal safe EFSS with lower incidence of complications and recurrences.

Above and Beyond: Periorbital Suspension for Endoscopic Access to Difficult Frontal Sinus Pathology.

OBJECTIVES/HYPOTHESIS: The periorbital suspension (PS) is an advanced adjunctive technique performed during endoscopic approaches to frontal sinus pathology that would be too far lateral or superior to address using traditional endoscopic transnasal approaches. The objectives of this study are to characterize the utility of this technique for frontal sinus pathology, determine anatomic limitations, and assess clinical outcomes following surgical treatment. STUDY DESIGN: Prospective case series. METHODS: Patient data including demographics, etiology, technique, complications, and clinical follow-up were collected. Preoperative computed tomography scans were reviewed for maximum lateral and superior extent of pathology, supraorbital recess height, anterio-posterior (AP) diameter of the frontal sinus, interorbital distance, and orbital-first olfactory neuron distance. RESULTS: The PS approach was used in 30 surgeries (29 patients) for cerebrospinal fluid leaks (n = 5), benign tumors (n = 17), malignant tumors (n = 5), allergic fungal sinusitis (n = 2), and mucocele (n = 1) between 2018 and 2020. Approaches included 15 Draf IIB and 15 Draf III frontal sinusotomies. All pathology was surgically accessible using the PS approach and there were no intraoperative or postoperative complications. Postoperative follow-up was 11.7 ± 7.6 months. Mean recorded measurements (in mm) were as follows: maximum lateral extent -15.0 ± 7.7, superior extent 21.2 ± 7.7 in surgical plane and 20.9 ± 9.8 in the vertical plane, supraorbital recess height -2.6 ± 1.9, AP frontal sinus diameter -13.2 ± 4.7, interorbital distance -29.8 ± 5.4, and orbital-olfactory neuron distance -14.8 ± 2.9. CONCLUSIONS: The PS technique can be safely and successfully utilized to provide endoscopic endonasal access to lateral and superior frontal sinus pathology. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:538-544, 2022.

The Draf III procedure: A review of indications and techniques.

The Draf Ⅲ procedure involves the creation of a common frontal sinus cavity. The most common indication for the Draf Ⅲ procedure is chronic rhinosinusitis of the frontal sinuses despite the failure of more conservative interventions such as bilateral Draf Ⅱa procedures. Primary Draf Ⅲ may be indicated in patients with a high risk of failures such as those with severe polyposis and those with a frontal sinus opening less than 4 mm on computed tomography imaging. Other indications for the Draf Ⅲ include access for tumor removal and repair of traumatic fractures of the frontal sinus. The "inside-out" Draf Ⅲ procedure is the standard approach when the frontal recess anterior-posterior diameter is wide enough for instrument access, usually larger than 4-5 mm. The "outside-in" Draf Ⅲ procedure can be done when the frontal recess is too narrow to safely accommodate instruments. Regular follow-up with debridement should be done to prevent neo-ostium stenosis.

A Review of the Different Intraoperative Findings of Revision Endoscopic Frontal Surgery.

A revision endoscopic sinus surgery (rESS) is considered when the primary surgery fails to improve the symptoms or causes problems. The rESS is still a difficult surgical procedure, despite the use of imaging-guided surgical navigation systems, because the anatomical landmarks are removed or scarred. To determine the causes and indications of rESS observed radiologically or endoscopically in patients with frontal rhinosinusitis. This retrospective clinical study was conducted between 2010 and 2019 in the Ear, Nose, and Throat Department of King Fahad Specialist Hospital, Saudi Arabia. Sixty cases were indicated for revision endoscopic surgery, and all had distorted or lost anatomical landmarks. Most landmark losses were caused by undissected uncinate processes and residual agger nasi with/without ethmoid disease. The rESS surgical procedure remains difficult, despite the use of imaging-guided surgical navigation systems, because most of the anatomical landmarks are removed or scarred. An undissected uncinate process, residual agger nasi with/without ethmoid disease, extensive mucosal disease with polyps obstructing the frontal recess, and lateralized middle turbinates are the most common conditions requiring rESS.

Trans-Nasion-Complex Approach for Endoscopic Modified Lothrop Procedure: Conception, Anatomy, and Technique.

Background: The endoscopic modified Lothrop procedure (EMLP) is an important procedure used to address frontal and anterior skull-base lesions. Two techniques were established, namely, the inside-out approach and the outside-in approach. The former technique take the frontal recess and the first olfactory filament (FOF) as key landmarks while the latter use the FOF as posterior boundary. In some cases, however, these two landmarks are not available. Therefore, we supplement the outside-in approach and named it trans-nasion-complex approach (TNCA) for EMLP that can be performed without locating these two landmarks. Methods: Two dry human skulls were used to observe the bony nasion complex. Then, five colored silicon-injected human head specimens were dissected via TNCA for EMLP. Finally, the outcomes of patients who underwent TNCA were reviewed. Results: The nasion complex is an osseous complex that consists of the nasion and its adjacent structures, including the bilateral root of nasal bones, nasal process of frontal bones, anterior portion of the perpendicular plate of the ethmoid bone that connects with the inferior aspect of the nasal bones, and portions of the bilateral frontal process of the maxillary bones. Surgical landmarks for TNCA include the anterior superior portion of the nasal septum, anterior margin and axilla of the middle turbinate, frontal process of the maxilla bone, nasal process of the frontal bone and upper part of the nasal bone. These structures form a "mushroom sign" during cadaveric dissection and surgery. Twenty-one patients underwent TNCA, of whom 9 had tumors and 12 had chronic rhinosinusitis with nasal polyps (CRSwNP). None of them had major complications. Conclusion: TNCA is expected to be a safe, and direct route for EMLP. Adequate understanding of the nasion complex and "mushroom sign" will be helpful to complete TNCA.

Minimally Invasive Endoscopic Sinus Surgery for Frontal Sinus Pathologies Using Interventional Flexible Bronchoscopy: Case Reports.

Background: Lateral pathologies of the frontal sinus are difficult to visualize and treat with classical endoscopic sinus surgery (ESS) using rigid endoscopes and instruments. Hence, they often require extended endoscopic or external approaches. Methods and Results: We describe the advantages of using interventional flexible bronchoscopy in frontal ESS without extended approaches in 2 illustrated cases: (1) A fungus ball in the frontal sinus with a frontoethmoidal cell. The flexible bronchoscope allowed treatment of all recesses of the frontal sinuses and the opening of a frontoethmoidal cell through a Draf IIa. (2) A revision surgery with a frontoethmoidal cell obstructing drainage pathway was successfully treated with this same technique. Patients did not experience complications or recurrent symptomatology after, respectively, 4 and 15 months of follow-up. Conclusion: Flexible bronchoscopy allows a good visualization and treatment of lateral frontal sinus pathologies through limited endoscopic approaches. Through-the-scope instruments permit the resection of frontoethmoidal cells.

A handheld flexible manipulator system for frontal sinus surgery.

PURPOSE: Draf drainage is the standard treatment procedure for frontal sinus diseases. In this procedure, rigid angled endoscopes and rigid curved instruments are used. However, laterally located pathologies in the frontal sinus cannot be reached with rigid instrumentation. In order to assist surgeons with such complicated cases, we propose a novel handheld flexible manipulator system. METHODS: A cross section of 3 mm × 4.6 mm enables transnasal guiding of a flexible endoscope with 1.4 mm diameter and a standard flexible surgical instrument with up to 1.8 mm diameter into the frontal sinus with increased reachability. The developed system consists of an electrical discharge-machined flexure hinge-based nitinol manipulator arm and a purely mechanical handheld control unit. The corresponding control unit enables upward and left-right bending of the manipulator arm, translation, rolling, actuation and also quick exchange of the surgical instrument. In order to verify the fulfillment of performance requirements, tests regarding reachability and payload capacity were conducted. RESULTS: Reachability tests showed that the manipulator arm can be inserted into the frontal sinus and reach its lateral regions following a Draf IIa procedure. The system can exert forces of at least 2 N in the vertical direction and 1 N in the lateral direction which is sufficient for manipulation of frontal sinus pathologies. CONCLUSION: Considering the fact that the anatomical requirements of the frontal sinus are not addressed satisfactorily in the development of prospective flexible instruments, the proposed system shows great potential in terms of therapeutic use owing to its small cross section and dexterity.

Quality of Life Outcomes in Frontal Sinus Surgery.

INTRODUCTION: Although significant experience has been gained in the technical nuances of endoscopic sinus surgery procedures, the patient-reported outcomes of frontal endoscopic sinus surgery procedures are still poorly understood. In this study we used the validated patient outcome measure Sino Nasal Outcome Test-22 (SNOT-22) to assess the preoperative and postoperative quality of life in patients undergoing extended endoscopic frontal sinus surgery (Draf type 2 and Draf type 3 procedures). METHODS: Out of a total of 680 patients undergoing endoscopic sinus and skull base surgery and 186 patients undergoing frontal sinus surgery, 99 chronic rhinosinusitis patients with (CRSwNP) or without (CRSnNP) nasal polyps undergoing Draf 2 or Draf 3 were assessed. RESULTS: The mean preoperative SNOT-22 was 45.6 points for patients undergoing Draf 2 and 59 for patients undergoing Draf 3, while the mean radiological Lund-Mackay Score was 14.3 and 14.5, respectively. Mean SNOT 22 improvement was 22.9 points for Draf 2 and 37 points for Draf 3 respectively and remained significant in all time intervals, including at 4 years after surgery. With the exception of loss of smell/taste, all symptoms improved by a far bigger extent in Draf 3 group, despite the considerably worse starting point. Effect size (Cohen / Standard Deviations) of Draf 3 was greatest in the following symptoms: "being frustrated/restless/irritable" (1.63), "nasal blockage" (1.43), "reduced concentration" (1.35), "fatigue" (1.29) "runny nose" (1.26) and "need to blow nose" (1.17). Frontal sinus (neo) ostium was patent (fully or partly) at last follow up in 98% of Draf 2 patients and in 88% of patients following Draf 3. Patients with non-patent frontal (neo-) ostium however had a mean postoperative SNOT 22 score of 43 compared to 20 of those with patent frontal sinus (neo-) ostium, although the difference was not statistically significant. CONCLUSION: Patients undergoing Draf 3 have a greater burden of disease, including both nasal and emotional/general symptoms compared to Draf 2 patients; surgery results in improvement in both groups, although Draf 3 patients have the greatest benefit, especially in emotional / general symptons. In this way both groups achieve similar postoperative quality of life, despite the different starting points.

[Effect of anatomical changes of frontal recess and frontal sinus on airflow after nasalisation by image reconstruction and numerical simulation].

Objective: To describe the influence of post-operative anatomical structure changes on nasal airflow characteristics by 3D reconstruction and numerical simulation in real cases after nasalisation with Draf Ⅲ so as to explore the correlation between the changes of anatomical structure and subjective symptoms as well as airflow characteristics. Methods: Ten patients underwent nasalization with Draf Ⅲ in Department of Rhinology in Beijing Tongren Hospital from 2006 to 2018 were selected retrospectively. Postoperative follow-up of all patients was more than 1 year. All patients had no abnormalities in their paranasal sinus CT scans and Lund-Kennedy scores were 0 except scar. VAS scores including nasal obstruction, stimulation in frontal sinus, and headache were collected at the same period. The control model was a normal person. Numerical simulation was used for calculating airflow characteristics in deep inspiratory period of both models. Independent sample Mann-Whitney U test and Spearman correlation test were used by software SPSS 22.0. Results: The airflow pressure in frontal sinus ostium was (7.21±1.39)×10(4) Pa (Mean±SD), which was lower than that in normal subjects (8.99×10(4) Pa) under deep inspiratory simulation. But, the velocities in frontal sinus ostium and frontal sinus were (40.10±2.46) m/s and (28.19±1.73) m/s respectively, which were higher than those in normal one (2.70 m/s, 0.73 m/s). The airflow patterns of the two models were basically similar. There was no significant difference in the opening size and volume of frontal sinus between different groups after grouped by three symptoms respectively. No correlation could be found between the opening size and volume of the frontal sinus with the appearance and severity of three subjective symptoms. Conclusions: The airflow pattern and distribution after nasalisation with Draf Ⅲ are like those of normal person. There is no correlation between the changes of anatomy in frontal recess and frontal sinus and nasal airflow characteristics as well as subjective symptoms.

Giant Frontal Sinus Osteomas: Demographic, Clinical Presentation, and Management of 10 Cases.

BACKGROUND: Osteomas are rare benign and slow-growing osteogenic tumors mainly involving frontal and ethmoid sinuses. OBJECTIVES: The primary objective of our study is to present the management of cases of giant frontal sinus osteomas. Secondarily, we describe our modified unilateral osteoplastic flap approach without obliteration to remove these osteomas. METHODS: Retrospective chart review at a tertiary academic center ("Hôpital de l'Enfant-Jésus") from July 2006 to October 2016. Demographics characteristics, tumor characteristics, presenting symptoms, frontal sinus surgery technique (osteoplastic flap, endoscopic surgery, or a combination of both), and outcomes of giant frontal sinus osteomas (≥30 mm) were recorded. For laterally placed osteomas, tumors with posterior wall involvement, orbital roof involvement, or intracranial extension, the modified unilateral osteoplastic flap approach was used. A decision-making algorithm is proposed for the choice of surgical approach. RESULTS: Ten giant frontal osteomas were analyzed (7 men and 3 women). The mean age at diagnosis was 38 years old (range, 24-55 years; median, 39 years; standard deviation, 11 years). The most common presenting symptom was headache (43% of symptomatic patients). Five patients had complications preoperatively due to tumoral extension (sinusitis, cellulitis, mucocele, optic nerve compression, and convulsions). One patient was treated endoscopically, 3 patients had an open approach and 6 patients had a combined technique. One patient experienced a postoperative complication (local infection treated with oral antibiotics). Six patients had minimal residual tumor with one patient needing reoperation. CONCLUSION: Osteomas are rare paranasal sinus tumors. Due to the proximity to noble structures, a giant frontal osteoma should be managed surgically. The modified unilateral osteoplastic flap without obliteration offers good long-term surgical and aesthetic results. Osteomas are not known for malignant transformation and recurrences are rare; thus, subtotal resection is warranted and safe when a cleavage plan is not found.

Value of double pedicled mucoperiosteal flaps for the prevention of restenosis in Draf IIb frontal sinusotomy.

INTRODUCTION: The extent of bone exposure is one of the major factors contributing to failure of endoscopic frontal sinusotomy procedures. Double flaps providing cover of exposed bone have already been described for Draf III procedures in a cadavre study using posterior and lateral pedicled nasoseptal flaps. As these flaps overlap on the septal side, they cannot be raised from the same nasal cavity in a Draf IIb procedure. We describe a new technique using 2 local mucoperiosteal flaps raised from the same side to entirely cover the bone margins exposed by Draf IIb frontal sinusotomy. SURGICAL TECHNIQUE: A left Draf IIb procedure was performed to drain a frontal mucocele. A posterior septoturbinal flap (PSTF) was raised to cover the posterior sinusotomy margin. A lateral pedicle nasoseptal flap (LNSF) was raised on the same side to cover the anterior margin. With a follow-up of 6 months, the Draf IIb cavity was fully patent and the flaps were well integrated. CONCLUSION: PSTF and LNSF flaps can be raised on the same side to cover the posterior and anterior margins of the Draf IIb frontal sinusotomy, respectively.

Patient and surgeon factors explain variation in the frequency of frontal sinus surgery.

OBJECTIVES/HYPOTHESIS: Ethmoidectomy may be sufficient to address frontal sinus disease, but some surgeons may perform frontal recess dissection initially. Our objectives were to describe patient-associated factors with frequency of frontal sinus surgery and analyze the association with provider volume. STUDY DESIGN: Retrospective cohort analysis. METHODS: The 2013 State Ambulatory Surgery Databases of New Jersey, Florida, and Kentucky were queried to identify adults who underwent anterior ethmoidectomy or total ethmoidectomy using standard Current Procedural Terminology codes. Univariate and multivariate logistic regression was performed to determine the odds of undergoing concurrent frontal sinus exploration along with ethmoidectomy, adjusting for age, gender, race, insurance type, median income, and the metropolitan designation by zip code. We also examined provider and center volume, use of image guidance, and total charges. RESULTS: There were 10,564 ethmoidectomies, of which 4,726 had concurrent frontal sinus surgery. Women were less likely to have frontal sinus surgery (P = .0011), as were patients with Medicare (P = .007). Hispanics were more likely to have frontal sinus surgery (P = .0003). Surgeons with higher surgical volumes were more likely to perform frontal sinus surgery; it was also more likely to be performed in centers where more sinus procedures occurred (P < .0001, both). CONCLUSIONS: Variation in the utilization of frontal sinus surgery is associated with patient sex, ethnicity, insurance status, geography, as well as provider and hospital volumes. These data support the idea that nonclinical factors may influence the treatment of frontal sinus disease. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2008-2014, 2018.