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8 Modied Mini/Hemi/Subtotal/Central Lothrop for Recalcitrant Chronic Frontal…
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not included within these classication systems. For this reason, a new classication
system consolidating the two previous methods and allowing for inclusion of the
four more recently published modications has been designed (Table8.1). Here we
discuss these modications in the context of the new classication scheme.
Table 8.1 Classication schemes of endoscopic approaches to the frontal sinus
Eloy’s
Nasofrontal
approach
Draf
I I I Anterior ethmoidectomy with drainage of the frontal
IIA II IIA Removal of the anterior ethmoidal cells and frontal cells
IIB III IIB Removal of the frontal sinus oor between the nasal
III IV III Bilateral removal of the oor of the frontal sinus
proposed
modications
IIC Ipsilateral removal of the frontal sinus oor between the
IID Contralateral removal of the frontal sinus oor between
IIE Ipsilateral removal of the frontal sinus oor between the
IIF Central resection of the frontal sinus oor bilaterally,
Description
sinus recess without touching the frontal sinus outow
pathway
protruding into the frontal sinus outow pathway
creating an opening between the middle turbinate
medially and the lamina papyracea laterally
septum medially and the lamina papyracea laterally
nasal septum medially and the lamina papyracea
laterally; superior septectomy for access from the
contralateral side and enhanced access to the lateral
supraorbital frontal sinus and supraorbital ethmoid
regions. This also provides bi-nostril, bimanual
manipulation; previously described as a modied
hemi-Lothrop procedure
the nasal septum medially and the lamina papyracea
laterally with addition of an intersinus septectomy for
drainage of the diseased frontal sinus to the contralateral
recess; previously described as a modied mini-Lothrop
procedure
nasal septum medially and the lamina papyracea
laterally; superior septectomy for access from the
contralateral side and enhanced access to the lateral
supraorbital frontal sinus and supraorbital ethmoid
regions; intersinus septectomy for access to the entire
posterior wall of the frontal sinus; preservation of the
contralateral frontal sinus recess; previously described
as a modied subtotal-Lothrop procedure
with a superior septectomy and frontal intersinus
septectomy, while preserving both frontal sinus recesses;
also termed a modied central-Lothrop procedure
anterior to the middle turbinates from one lamina
papyracea to the next with superior septectomy and
intersinus septectomy; also termed a modied Lothrop
procedure
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Surgical Techniques
Standard Frontal Sinus Approaches
Draf I (Nasofrontal approach I or Eloy I): This procedure consists of an anterior
ethmoidectomy for drainage of the frontal sinus recess without dissection of the
frontal sinus outow pathway (Fig.8.1a). This involves removal of obstructing disease inferior to the frontal sinus recess. In this technique, the anterosuperior ethmoidal cells (including the agger nasi) are resected without disrupting the frontal
sinus outow pathway.
Draf IIA (Nasofrontal approach II or Eloy IIA): This procedure entails the
removal of the anterior ethmoidal cells and frontal cells protruding into the frontal
sinus outow pathway, creating an opening between the middle turbinate medially
and the lamina papyracea laterally (Fig.8.1b). This in turn leads to enlargement of
the frontal sinus outow pathway.
Draf IIB (Nasofrontal approach III or Eloy IIB): This procedure also enlarges the
frontal sinus outow pathway and consists of the removal of the frontal sinus oor
between the nasal septum medially and the lamina papyracea laterally (Fig.8.1c).
Fig. 8.1 Artwork in the coronal plane depicting a (a) Draf I, (b) Draf IIA, (c) Draf IIB, and (d)
Draf III procedure. Area containing the resected structures is depicted with the red outline. © 2015
Chris Gralapp
8 Modied Mini/Hemi/Subtotal/Central Lothrop for Recalcitrant Chronic Frontal…
85
The goal of this procedure is to achieve maximal opening of the frontal sinus outow pathway on one side.
Draf III (Nasofrontal approach IV or Eloy III): In this procedure, bilateral
removal of the oor of the frontal sinus anterior to the middle turbinates from one
lamina papyracea to the next is performed, with a superior septectomy and intersinus septectomy; this is also termed a modied Lothrop procedure (Fig.8.1d). With
this procedure, a contiguous bilateral enlargement of the frontal sinus drainage
pathway is achieved.
Common Surgical Techniques andtheDraf 3
After intubation, the operating room table is rotated 90 degrees with the patient’s
left side facing towards the ventilator and anesthesia team, the patient’s right arm is
tucked, and the head of bed is elevated to 30 degrees. The patient’s nasal hairs are
trimmed, and the nasal cavities decongested using adrenaline (1:1000) soaked cottonoid pledgets that have been marked with uorescein. One percent lidocaine with
1:100,000 epinephrine is used to perform a sphenopalatine block, as well as injected
into the middle turbinate axilla and lateral nasal wall. Depending on the disease
process, the appropriate sinuses are opened widely in the standard fashion using
both hand and powered instruments and the bilateral frontal sinus ostia are identied when possible.
Depending on the extent of surgical resection that is planned, a superior septectomy is performed beginning at the level of the head of the middle turbinate and
carried anteriorly and superiorly up to the level of the axilla of the middle turbinate.
Superior septal mucosa can be harvested and used later as a graft or can be sacriced. Using the inside-out technique, the bilateral frontal sinusotomies are widened
using powered instrumentation (combination of cutting and diamond burrs) anteriorly and then connected in the midline, staying anterior to the rst olfactory ber.
The nasofrontal beak is drilled down to the periosteum anterolaterally. Drilling is
continued, with the help of curettes where necessary, to create the largest common
cavity feasible. A free mucosal graft, either from the septectomy or harvested from
the nasal oor, can be placed over the exposed bone on the anterior table. This may
be utilized in select cases to minimize post-operative stenosis. Silastic sheeting, or
a steroid eluting stent, is used to secure the graft.
Modifications toDraf Techniques
Modified Hemi-Lothrop Procedure (Eloy IIC)
The modied hemi-Lothrop procedure (Eloy IIC) has previously been described as
a technique used to improve access to the lateral recess (supraorbital extension) of
an affected frontal sinus or supraorbital ethmoid cell (Fig.8.2a–d) [5–7]. The procedure combines an ipsilateral Draf IIB (removal of the frontal sinus oor from the
nasal septum medially to the lamina papyracea laterally) and a superior septectomy.
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M. S. Hegazin et al.
a b
Fig. 8.2 (a) Artwork in the coronal plane showing the approach to the contralateral frontal sinus
with Eloy IIC procedure, also known as the modied hemi-Lothrop procedure. (b) Coronal computed tomography scan in patient post procedure. (c, d) This technique allows for bi-nostril bimanual instrumentation. © 2011 Chris Gralapp
The superior septectomy window allows insertion of an endoscope and instruments
via the contralateral side, thus providing greater access and visualization of the lateral frontal sinus recess of the affected ipsilateral frontal sinus or supraorbital ethmoid. This technique also provides bi-nostril and bimanual instrumentation
(Fig.8.3a, b). The ability to perform bi-nostril and bimanual dissection is of particular importance in cases of soft tissue tumors of the lateral frontal sinus recess or
supraorbital ethmoid.
Modified Mini-Lothrop Procedure (Eloy IID)
The modied mini-Lothrop procedure (Eloy IID) is a procedure intended to treat
frontal sinus disease when ipsilateral access to the frontal sinus recess is not possible [9, 10]. Ipsilateral access to the frontal sinus recess can be hindered by one of
many circumstances, including scarring, outow tract osteogenesis, or orbital fat
prolapse from previous medial orbital wall decompression or trauma (Fig.8.4a–d).
The procedure combines the removal of the contralateral frontal sinus oor (Draf
IIB) and an endoscopic frontal intersinus septectomy (Fig.8.5a, b). While the modied Lothrop procedure as originally described did not require a complete intersinus
septectomy, it is desirable to perform a total intersinus septectomy in the modied
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8 Modied Mini/Hemi/Subtotal/Central Lothrop for Recalcitrant Chronic Frontal…
Fig. 8.3 Axial (a) and coronal (b) computed tomography scan of a patient with an obstructed right
frontal sinus. There is improved access with Eloy IIC (green arrow with white bracket showing the
septectomy window) compared to standard ipsilateral approach (red arrow). © 2013 American
Academy of Otolaryngology—Head and Neck Surgery Foundation
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Fig. 8.4 Coronal (a) and axial (b) computed tomography scan in a patient with orbital fat pro-
lapse. (c) Intraoperative view of nasal cavity and sinus immediately after Eloy IID or modied
mini-Lothrop procedure. (d) Eight-month postoperative nasal endoscopic view of the sinonasal
cavity after the Eloy IID procedure. © 2012 American Rhinological Society—American Academy
of Otolaryngologic Allergy, LLC
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Fig. 8.5 (a) Artwork in the coronal-plane demonstrating Eloy IID (green arrow) in a patient with
fat prolapse preventing an ipsilateral frontal sinusotomy (red arrow). (b) Depiction of drainage via
the contralateral nasal cavity after the Eloy IID procedure. © 2011 Chris Gralapp
M. S. Hegazin et al.
mini-Lothrop procedure (Eloy IID) since this window is designed to be the contralateral diseased frontal sinus only drainage pathway.
Modified Subtotal-Lothrop Procedure (Eloy IIE)
The modied subtotal-Lothrop procedure (Eloy IIE) is designed for the treatment of
recalcitrant bilateral frontal sinus disease and ipsilateral anterior skull base lesion
resection, with an emphasis on preserving as much of the normal sinonasal architecture as possible (Fig.8.6a–d) [11, 12]. This procedure can be used for large posterior frontal sinus encephaloceles, in which access to the bilateral posterior frontal
sinus table and bimanual manipulation are desired. This technique is also appropriate for unilateral sinonasal tumor resection in which the contralateral frontal sinus
recess is uninvolved (Figs.8.7a-f and 8.8a-d). The procedure involves the removal
of the frontal sinus oor unilaterally (Draf IIB) with the addition of a superior septectomy and an intersinus septectomy. This allows for access and visualization of
the ipsilateral and contralateral frontal sinus and bi-nostril and bimanual instrumentation (Video 8.1). The contralateral frontal sinus recess and contralateral middle
turbinate are left undisturbed.
Modified Central-Lothrop Procedure (Eloy IIF)
The modied central-Lothrop procedure (Eloy IIF) has not been previously
described in the literature. In this procedure, emphasis is on preserving as much of
the normal sinonasal architecture as feasible (Figs.8.9a–d and 8.10a–f). The procedure involves the removal of the medial frontal sinus oor bilaterally with the addition of a superior septectomy and an intersinus septectomy. This allows for access
and visualization of both frontal sinuses and affords bi-nostril and bimanual instrumentation. This procedure can be used for frontal sinus disease located near the
midline. It can result in scarring and subsequent obstruction of the created central
opening. However, preservation of both frontal sinus recesses lateral to the midline
opening, and resection of the frontal intersinus septum should allow ample
cd
Declarations
89
a b
Fig. 8.6 (a) Artwork in the coronal plane showing bilateral frontal sinus access with Eloy IIE
(modied subtotal-Lothrop procedure) with preservation of the contralateral frontal sinus recess.
(b–d) Coronal computed tomography scans of patient postoperatively after tumor resection utilizing Eloy IIE. Intact anterior septum (b), access to both frontal sinuses (c), and intact contralateral
frontal sinus recess (d) are seen. © 2014 Chris Gralapp
communication between the two sides with an exit pathway in either of the
untouched frontal sinus recess.
Tips and Pearls
– Choosing the appropriate approach to the frontal sinus depends on the patient’s
individual anatomy and surgical needs.
– The modied hemi-Lothrop procedure (Eloy IIC) is a good option for those
patients in which lateral recess access is required.
– The modied mini-Lothrop (Eloy IID) can be used to access the bilateral frontal
sinuses in situations where access to one frontal sinus is impossible.
– The modied subtotal-Lothrop procedure (Eloy IIE) is useful in situations where
an anterior skull base resection has been performed to preserve normal sinonasal
architecture as much as possible.
– The modied central-Lothrop procedure (Eloy IIF), a newer technique, can be
useful for midline frontal sinus disease with preservation of both frontal sinus
recesses.
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M. S. Hegazin et al.
Fig. 8.7 (a) Artwork in the coronal plane showing bilateral frontal sinus access with a left Eloy
IIE (modied subtotal-Lothrop procedure) with preservation of contralateral frontal recess.
Endonasal view of intraoperative modied subtotal-Lothrop procedure in a patient with an olfactory neuroblastoma: (b) Initial intraoperative view of the lesion. (c) Using a 30-degree rigid endoscope, a left Draf IIB is performed. (d) A superior septectomy is performed and the medial
contralateral frontal sinus oor is resected. (e) The intersinus septectomy is subsequently performed. The right (contralateral) frontal sinus recess as well as the right middle turbinate are preserved. (f) View from the contralateral (right) nasal cavity after completion of left Draf IIB,
superior septectomy, and intersinus septectomy. © 2014 American Rhinological Society—
American Academy of Otolaryngologic Allergy, LLC
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8 Modied Mini/Hemi/Subtotal/Central Lothrop for Recalcitrant Chronic Frontal…
Fig. 8.8 (a) Preoperative coronal T1-weighted gadolinium enhanced paranasal sinus MRI of a
patient with a left sinonasal olfactory neuroblastoma. (b) Intraoperative endoscopic view of the
anterior skull base defect after tumor resection. (c) Coronal postoperative CT scan of the same
patient showing a patent modied subtotal-Lothrop procedure (Eloy IIE). (d) Six-month postoperative endoscopic image of the patent frontal sinus cavity. © 2014 American Rhinological
Society—American Academy of Otolaryngologic Allergy, LLC
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a
c
Fig. 8.9 (a) Artwork in the coronal plane showing bilateral frontal sinus access with Eloy IIF
(modied central-Lothrop procedure) with preservation of the bilateral frontal sinus recesses ©
2015 Chris Gralapp. (b) Intraoperative 30-gegree endoscopic view of the modied central-Lothrop
procedure (Eloy IIF). (c) Close up view of the central opening. (d) Endoscopic view of steroid
eluting stent placement
b
d