Draf III, Endoscopic Modified Lothrop

History

• 1.

  History of present illness

  • a.

    Document a detailed account of the patient’s current symptoms.

    • 1)

      Up to 16% of people have no change in symptoms after Draf III, and 1.2% have worsening symptoms.

    • 2)

      Asymptomatic recurrent frontal sinus opacification does not necessarily require surgery.

  • b.

    For patients with a history of inflammatory sinus disease, document a thorough review of their sinusitis history, including prior and current medical management.

    • 1)

      Presumed origin of underlying mucosal disease

    • 2)

      Symptoms and their duration including forehead or frontal pressure

    • 3)

      History of nasal polyps

    • 4)

      Hyposmia or anosmia.

    • 5)

      Previous culture results

    • 6)

      Use of oral and/or topical antibiotics

    • 7)

      Use of oral and/or topical steroids

    • 8)

      Use of oral and/or topical antifungals

    • 9)

      Use of nasal saline irrigations

    • 10)

      Evaluation and treatment of allergy

    • 11)

      Results of any immunologic studies performed

    • 12)

      Document compliance to therapies, and ensure that proper techniques have been employed by the patient for topical drug delivery.

    • 13)

      Response to medical management

  • c.

    Document any prior paranasal sinus surgeries with special attention to open or endoscopic frontal sinus surgeries.

  • d.

    Document any history of trauma.

• 2.

  Past medical history

  • a.

    Comorbidities, particularly those that may affect postoperative healing and portend poor outcome:

    • 1)

      Asthma

    • 2)

      Allergies

    • 3)

      Nasal polyposis

    • 4)

      Aspirin-exacerbated respiratory disease (Samter’s triad)

    • 5)

      Autoimmune disease

    • 6)

      Mucociliary disease

      • a)

        Primary ciliary dyskinesia/Kartagener’s syndrome

      • b)

        Cystic fibrosis

    • 7)

      Immunodeficiency

    • 8)

      Endocrine disorders

    • 9)

      Coagulopathies

    • 10)

      History of severe or refractory CRS

  • b.

    Social and family history

    • 1)

      Tobacco smoking or frequent smoke exposure

    • 2)

      Risk factors for malignancy

Physical Examination

• 1.

  Complete examination of the head and neck

  • a.

    Examination should always begin with a thorough examination of the head and neck, including a full examination of the cranial nerves.

  • b.

    Make note of the patient’s intercanthal distance as a narrow intercanthal distance is associated with increased likelihood of stenosis postoperatively.

• 2.

  Nasal endoscopy

  • a.

    In patients with a neoplasm of the frontal sinus or mucocele where no prior surgery has been performed, nasal endoscopy may be completely normal.

  • b.

    Patients with inflammatory sinus disease will likely have had sinus surgery prior to being considered for Draf III.

    • 1)

      Identify existing/remaining landmarks.

    • 2)

      Is middle turbinate or uncinated process scarred laterally?

    • 3)

      Take note of the degree of inflammatory sinus disease present.

    • 4)

      Try to identify a frontal recess on either side.

Imaging

• 1.

  Computed tomography (CT) scan

  • a.

    CT is the imaging study of choice for recurrent inflammatory sinus disease and revision endoscopic sinus surgery. It helps delineate residual sinus anatomy and the degree of sinus disease present. It also provides key information with regard to being able to successfully complete and maintain an open Draf III cavity.

    • 1)

      Assess AP diameter. Studies have shown that patients with an AP diameter less than 1.5 cm have increased rates of stenosis.

    • 2)

      A thick nasofrontal beak will make it more difficult to complete the Draf III.

    • 3)

      Presence of osteitis, particularly of the nasofrontal beak, will also increase the likelihood of stenosis.

  • b.

    CT can identify areas of bony erosion where the likelihood of cerebrospinal fluid (CSF) leak may be higher.

• 2.

  Magnetic resonance imaging (MRI)

  • a.

    MRI can help differentiate between a mucocele, encephalocele, tumor, and mucosal edema. MRI can help better delineate the extent of the tumor versus trapped secretions due to obstruction by the tumor.

Indications

• 1.

  Recalcitrant symptomatic frontal sinus disease despite prior endoscopic frontal sinus surgery

• 2.

  Difficult revision sinus surgery

• 3.

  Failed prior obliteration surgery

• 4.

  Mucociliary disease

  • a.

    Primary ciliary dyskinesia/Kartagener’s syndrome

  • b.

    Cystic fibrosis

• 5.

  Access to frontal sinus tumors such as inverted papilloma, fibrous dysplasia, and osteoma

• 6.

  Select trauma cases

• 7.

  Posterior table CSF leak

• 8.

  Anterior exposure for an endoscopic endonasal approach to the anterior skull base

Contraindications

• 1.

  Poor patient selection: The patient has narrow intranasal anatomy that would be considered a contraindication to performing a Draf III.

• 2.

  Medical comorbidities that place the patient at high risk for general anesthesia

• 3.

  Anterior-posterior diameter less than 1.5 cm

• 4.

  Thick osteitic nasofrontal beak (relative)

• 5.

  Deep radix

• 6.

  Asymptomatic inflammatory disease

• 7.

  Isolated disease located lateral to the mid-pupillary line

• 8.

  Poorly pneumatized/hypoplastic frontal sinus

Preoperative Preparation

• 1.

  Maximize medical management of inflammatory sinus disease.

• 2.

  Prepare for skull base reconstruction if necessary.

• 3.

  Prepare for possible trephination to help identify the frontal ostium intraoperatively.

• 4.

  If using image guidance, make sure imaging is done with the appropriate protocol and appropriate navigation capable frontal sinus instruments will be available.

Anesthesia

General—The Draf III procedure should be performed under general anesthesia due to the length of the procedure, the need for drilling, and the potential for skull base injury and CSF leak.