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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5226_Библиотеки_им_академика_М_И_Перельмана.pdf
The Outside-in Draf III Procedure
11
Peta-LeeSacks , KachornSeresirikachorn ,
andRichardJ.Harvey
Key Points
• The Draf III procedure is an important technique for accessing the frontal sinus
and can be useful in some situations as a primary surgery and in recalcitrant
frontal sinusitis.
• The outside-in approach is a method to approach the frontal sinus that relies on
landmarks and uses near-straight instrumentation to avoid entry into the frontal
sinus until the end of the procedure.
• The outside-in technique may be particularly useful in situations where frontal
recess anatomy is complex or there is a substantial disease or tumor burden.
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 89191- 5_11.
P.-L. Sacks (*)
Department of Otolaryngology, Macquarie University Hospital, Sydney, NSW, Australia
K. Seresirikachorn
Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University,
Bangkok, Thailand
R. J. Harvey
Rhinology and Skull Base, Applied Medical Research Centre, St Vincent’s Hospital,
Darlinghurst, NSW, Australia
Department of Otolaryngology, UNSW and Macquarie University, Sydney, NSW, Australia
e-mail: richard@richardharvey.com.au
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
J. T. Lee et al. (eds.), Advances in Surgical and Medical Interventions for
Recalcitrant Chronic Rhinosinusitis,
https://doi.org/10.1007/978-3-031-89191-5_11
115
116
P.-L. Sacks et al.
Background
The modied endoscopic Lothrop was initially performed for salvage surgery
but over the past two to three decades, with the advancement of endoscopic
endonasal surgery, it has become a commonly performed operation both for
access in neoplastic and inammatory disease as well as in anterior skull base
reconstruction. Draf III procedures are important techniques for accessing the
frontal sinus, the purpose of which depends on the pathology or anatomy
involved. Classically, the Draf III was an operation that typically took a prolonged period of time and required multiple angled instruments, angled endoscopy, and curved powered instrumentation. The evolution of anterior skull base
surgery created the need for the Draf III procedure to be just a small part of the
surgery and therefore needed to be performed more efciently and with a lower
risk of complications.
The traditional approach to the Draf III focused on the identication and dissection of the frontal recess using angle endoscopes and early entry into the frontal
sinus cavity in order to complete the bone removal. This is often referred to as the
“inside-out” approach and the technique has been well dened by Wormald, etal.
[1], who is often credited as bringing the original “lothrop” into the modern endoscopic era.
The outside-in approach does not require navigation of complex and variable
frontal recess anatomy. Rather, it relies on anatomic landmarks, of the nasofrontal beak and anterior cranial fossa, that serve as boundaries for creating a common cavity. The limits of the endoscopic Lothrop cavity are well recognized.
Laterally, these are the orbital plates of the frontal bone and periosteum of the
skin over the frontal process of the maxilla laterally. Posteriorly, the rst olfactory neuron on each side demarcates the forward projection of the olfactory bulb.
Anteriorly, the dissection is taken to the plane of the anterior table of the frontal
sinus [2].
This approach both utilizes a straight or zero-degree endoscope and nearstraight instrumentation and avoids entry into the frontal sinus where mucosa is
often inamed and risk of intraoperative bleeding is higher, until very near the
end of the procedure. It also successfully avoids the need for dissection of the
frontal recess, until the end of the procedure, and this is particularly useful where
frontal recess anatomy is complex and signicant disease or tumor burden is
present. The technique allows a signicantly quicker operative time with bone
drilling usually less than 30min [2]. The evolution of the modied endoscopic
Lothrop procedure to an Outside-In approach has allowed for a frontal recessindependent orientation, safer and more efcient Draf III common sinusotomy of
frontal sinus to be performed. Indications for the outside-in Draf III are listed in
Table11.1.
11 The Outside-in Draf III Procedure
117
Table 11.1
– Alternative to external access to frontal sinus
– Frontal sinus intraoperative access where:
Drilling in the frontal sinus is required
Access to anterior skull base
Lateral access within the frontal sinus
Bimanual dissection in the frontal sinus
– Frontal sinus post surgery access for:
Access for topical therapies
Prevent mucus plugging
Overcome mucostasis—From disease or treatment (e.g., radiotherapy)
Disease surveillance
Rarely utilized for simple frontal sinus ventilation which is adequately achieved with
Surgical indications for the Outside-In Draf-III
Draf IIa or IIb for all but very complex anatomy
Surgical Technique
Patient Positioning andPreparation
The patient is positioned with the head extended using an under-shoulder support
cushion. The surgical bed is placed at 20 degrees reverse Trendelenburg. The endotracheal tube is placed towards the right side. Nasal preparation is adrenaline based.
The authors’ preference is to use topical 1% ropivacaine and 1:2000 adrenaline on
neurosurgical cottonoids. The surgical eld is inltrated with 10mL comprised of
8mL 1% ropivacaine, 1ml adrenaline 1:10,000 adrenaline and 1mL of 100mg/mL
of tranexamic acid which is inltrated locally into the septum, lateral nasal wall
down to the inferior turbinate and anterior to the piriform, and middle turbinate. The
patient should be given a bradycardic (HR< 70 pbm) anesthetic with the use of
either total intravenous anaesthesia or the use of a beta-blocker and clonidine.
Surgical Steps
Often a complete sphenoethmoidectomy will be performed; however this is not always
essential and would be dictated by the indication for the Draf III procedure. At a minimum, the osteomeatal complex is dissected in order to dene the medial orbital wall.
Large inferior based lateral wall aps are created that commence at about the root of
the middle turbinate, superiorly in the apex of the nasal cavity and then down the piriform bone edge. The incision on the lateral wall begins high above the axilla at the
nasal roof by needle-point diathermy, setting 12 (0016AM Megadynne, NJ, USA).
118
P.-L. Sacks et al.
The posterior incision, at a depth of the middle turbinate insertion, is carried vertically
down to the middle turbinate. The superior incision is carried at the very apex of the
nasal cavity forward to the pyriform aperture and then vertically down, just behind the
pyriform aperture, to a level approximating the midpoint of the middle meatus. These
incisions are to the bone, and the inferior-based lateral wall mucosal ap is elevated
subperiosteally, with the ap retracted down and exposing the axilla and lateral wall
bone (Fig.11.1). The septal window mucosa is often removed anterior enough to allow
a direct approach to the anterior aspect of the nasofrontal beak or frontal sinus. This
septal window can be extended to include any superior septal deviation but is usually
less than one third the height of the septum. The mucosa on the septum is folded back
to the olfactory cleft. A small emissary vein is usually seen prior to the rst olfactory
neuron running in a lateral direction. The rst olfactory neuron is more adherent to the
skull base and denes the posterior limit of dissection. It is only in the midline where
inadvertent entry into the anterior cranial fossa can potentially occur and so it is vital
that the surgeon expose the rst olfactory neuron to prevent posterior dissection.
Once the olfactory neuron is identied, a superior septectomy is performed with
a 2mm 40 degree Kerrison rongeur. A full thickness incision is made in the anteroinferior location. The rongeur is placed in the anteroinferior opening and taken to the
abc
def
Fig. 11.1 Large inferior-based lateral wall aps, septal window creation, and rst olfactory neuron identication. (a) The posterior incision of left lateral wall aps is carried vertically down to
the middle turbinate. The superior incision is carried at the very apex of the nasal cavity forward to
the pyriform aperture (white arrow) and then vertically down, just behind the pyriform aperture, to
a level approximating the midpoint of the middle meatus. (b) The inferior-based lateral wall mucosal ap is elevated subperiosteally, with the ap (asterisk) retracted down and exposing the axilla
and lateral wall bone. (c) The septal window mucosa is folded back to the olfactory cleft. (d) Right
inferior-based lateral wall aps (asterisk) (e) The right rst olfactory neuron is dened as the posterior limit of dissection. (f) The left rst olfactory neuron is dened
11 The Outside-in Draf III Procedure
119
anterior limit on the oor of the frontal sinus. The septum is then resected up to the
skull base as drilling will start at the septal attachment to the oor of the frontal sinus.
A 4 or 5mm 15 degree high speed rough diamond bur is used to remove the bone.
Drilling proceeds with a zero-degree endoscope and 4-mm 15° diamond burr, at
30,000 revolutions-per-minute (Straightshot M5 Micordebrider, Medtronic, FL,
USA), removing the entire axilla-agger nasi-maxillary-frontal process complex.
The bone is removed laterally to dene the periosteum overlying the maxillary process of the frontal bone. The lateral limits are the periosteum and nasolacrimal sac
at the level of the frontal process of the maxilla. Identication of these landmarks
allows for maximal widening of the surgical eld. Drilling then proceeds to remove
the entire axilla lateral to the middle turbinate insertion. This denes the lateral
boundary of resection. As the lateral boundary is approached, there is a transition in
color from the yellow hue of bone to the white of the periostium. The bone lateral
to the middle turbinate, anterior to the frontal recess, and medial to the periosteum
is referred to as “Ritter’s triangle” and needs to be removed until the mucosa of the
frontal recess is “blue lined” before the nasofrontal beak is removed (Fig.11.2).
ab c
de f
Fig. 11.2 Drilling and ap and free graft replacement steps. (a) Drilling removes the septal bone
attachment to the oor of the frontal sinus. (b) Drilling removes the entire axilla-agger nasi-maxillary-frontal process complex. The lateral limits at the level of the frontal process of the maxilla
bone are the periosteum (black arrow) and nasolacrimal sac. Then, drilling proceeds to remove the
entire axilla, lateral to the middle turbinate insertion. The bone lateral to the middle turbinate,
anterior to the frontal recess, and medial to the periosteum is referred to as “Ritter’s triangle (dash
line triangle).” (c) The nasofrontal beak bone centrally is drilled away. (d, e) Complete resection of
the bone anteriorly to the level of the anterior table of the frontal sinus and laterally to remove bone
in order to “square off” the common frontal sinusotomy and be able to visualize the orbital roof
(white arrow). (f) The right (white dash arrow) and left (black dash arrow) thin free mucosal grafts
are placed to cover exposed bone. Posterior table of left frontal sinus (number sign)
120
P.-L. Sacks et al.
Once both the posterior (rst olfactory neuron and frontal recess mucosa) and
lateral limits (periosteum) have been dened, all the bone centrally is drilled away.
It is preferable to avoid entering the frontal sinus itself until late in the dissection in
order to prevent any mucosal bleeding due to mucosal inammation in the cavity.
The bone being drilled is the bone of the frontal beak. The frontal recess and the
frontal sinus itself lies between the anterior nasal beak and thus protects against
entry into the anterior cranial fossa as long as the surgeon remains anterior to the
rst olfactory neuron.
Complete resection of the bone anteriorly to the level of the anterior table of the
frontal sinus and laterally to remove bone in order to “square off” the common frontal sinusotomy and visualize the orbital roof.
Once the bone between the surgical cavity and the frontal recess is thinned, the
remaining thin bone is removed with a 2mm 40 degree Kerrison rongeur, either
from above down or from below up. The frontal recess partitions are removed with
the 2.5-mm 45° cutting forceps and 4.3 m quadcut straight microdebrider
(Straightshot M5 Microdebrider, Medtronic, FL, USA). The 5-mm 70° Hosemann
frontal sinus punch can complete the removal of bone edges.
The use of both inferiorly based lateral wall aps and free mucosal grafts can aid
in remucosalization of the exposed frontal bone at the anterior aspect of the dissection cavity and minimize osteoneogenesis. The free mucosal grafts are best harvested from the soft tissue posterior ends of the inferior turbinates. It is important to
ensure that the submucosa of the graft is excised to create a thin graft (Fig.11.3).
Multiple techniques for vascularized aps have been described [3].
Once all grafting materials are placed, the Draf III cavity is packed. The authors
prefer to use a silastic sheet template that is fashioned (0.51 mm Medtronic,
Jacksonville, FL) into the frontal sinus cavity. This is then supported in situ by either
carboxycellulose foam (nasopore, stryker, MI) with or without hyaluronic acid gel
(Bioregen, Changzhou, China). Alternatives include drug-eluting frontal stents or
nger-in-glove Merocel packs (Video 11.1).
abc
Fig. 11.3 Postoperative view of outside in Lothrop cavity. (a) Postoperative view from the left
nasal cavity. (b, c) Postoperative view from the right nasal cavity. Anterior nasal beak that covers
with free mucosal graft (white arrow), anterior edge of the septal window (white dash arrow), right
middle turbinate (black dash arrow), posterior edge of the septal window (black arrow), posterior
table of the left frontal sinus (number sign)
11 The Outside-in Draf III Procedure
121
Post-Operative Management
Patients are often discharged on the day of surgery. Amoxicillin/ clavulanic acid is
given for 10days, and prednisone was given at 25mg maximum daily for 7–21days
to reduce edema/congestion and varies on pathology. Nasal saline irrigations commence day 1 postoperatively and are performed twice daily. The silastic template
and any residual packing is removed after 3–4weeks post-operatively (Video 11.2).
Reported Outcomes
Patient Reporting Outcome Measures
Disease-specic quality of life scores (SNOT-22 and nasal symptom score) and
global nasal function have been shown to have signicant improvement following
the Outside-In Draf III in a retrospective study [4]. Similarly, olfactory function has
been shown to have improved signicantly following surgery [4]. The olfactory
neuroepithelium of the septum and superior turbinate is protected throughout the
procedure and hence may explain these outcomes.
Operative Time
The Outside-In approach to Draf III procedure has been demonstrated to be an efcient technique for nding the frontal sinus regardless of pathology. Chin etal. demonstrated a mean time to frontal sinus oor discovery of 7.82+/− 6.79min and to
completion of cavity of 26.92+/−11.20min. For endoscopic skull base surgery and
chronic rhinosinusitis without nasal polyposis, the mean time to completion was
18.45 and 24.66min respectively and was signicantly faster then when it was performed for chronic rhinosinusitis with nasal polyposis with a measured mean time
of 33.32min (p=0.02) [2].
Complications
Potential complications include CSF leak, orbital or intracranial complications,
bleeding, infection, and stenosis. Serious complications are rare. Chin etal. found
one patient with early post-operative skin edema which settled over 1week without
intervention but no other complications recorded [2]. Takeda reported a single case
of inadvertent CSF leakage where the rst olfactory neuron was dened intraoperatively but the anatomy of the anterior cranial fossa was aberrant and the point is
made that a pre-operative CT scan in a sagittal view is important to ensure the validity of the rst olfactory neuron as a landmark to the posterior table of the frontal
sinus [5].
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P.-L. Sacks et al.
Failure of Draf III procedures includes neoosteogenesis and stenosis. This can be
dramatically reduced by the use of free mucosal grafting and vascularised aps with
success being reported as high as 97% [6]. If hypertrophic soft tissue is present at
the anterior limit of the common sinusotomy at 3months post-op, then 0.2–0.4mL
of triamcinolone (40mg/mL) is injected with 1 mL syringe and long (1.5 inch)
25G needle.
Tips and Pearls
• The septal window can be variable but is rarely much more anterior than the
bone-cartilage junction.
• The septal window should incorporate any high septal deections and the septal
swell body.
• Trim the middle turbinate root back to just posterior to the posterior septal win-
dow and both of these are just anterior to the rst olfactory neuron exit point.
• Remove all of Ritter’s triangle and see the “blue” of the frontal recess before
continuing the superior bone removal.
• When removing the bone, do so on a broad front and avoid tunneling.
• Square off the opening to ensure that the orbital roof can be visualized.
• Very large and broad inferior based lateral wall aps provide better access and
healing.
• Soft tissue of the interior turbinate tail is a low morbidity option to harvest for
free mucosal grafting. Stay outside the bone/inferior turbinate artery when
harvesting.
• Leave silastic sheeting or other packing in for at least 3–4 weeks
postoperatively.
References
1. Wormald PJ. Salvage frontal sinus surgery: the endoscopic modied Lothrop procedure.
Laryngoscope. 2003;113(2):276–83.
2. Chin D, Snidvongs K, Kalish L, Sacks R, Harvey RJ.The outside-in approach to the modied
endoscopic Lothrop procedure. Laryngoscope. 2012;122(8):1661–9.
3. Oostra A, Koutsarnakis C, Georgalas C.Advances in vascularized aps for skull base recon-
struction. Curr Opin Otolaryngol Head Neck Surg. 2021;29(1):36–43.
4. Wong EH, Do TQ, Harvey RJ, Orgain CA, Sacks R, Kalish L. Patient-reported olfac-
tion improves following outside-in Draf III frontal sinus surgery for chronic rhinosinusitis.
Laryngoscope. 2019;129(1):25–30.
5. Takeda T, Omura K, Torng H, Ebihara T, Aoki S, Tochigi K, etal. Frontal sinus "hump": an ana-
tomical risk factor for anterior Skull Base injury in the endoscopic modied Lothrop approach
(outside-in frontal drill-out). Case Rep Otolaryngol. 2021;2021:3402496.
6. Illing EA, do Cho Y, Riley KO, Woodworth BA.Draf III mucosal graft technique: long-term
results. Int Forum Allergy Rhinol. 2016;6(5):514–7.
Part III
In-Office Procedures for Recalcitrant
Chronic Sinusitis, Chronic Rhinitis,
and Chronic Nasal Obstruction
Balloon Sinuplasty
12
AngelaM.Donaldson
Key Points
• Chronic rhinosinusitis is a common condition impacting 28 million adults.
• Most patients may successfully treat symptoms with medical therapy. However,
despite appropriate medical therapy, some patients have persistent or progressive
disease requiring surgical intervention.
• Balloon sinuplasty is a treatment option for patients with limited chronic rhino-
sinusitis without nasal polyps and those with recurrent acute rhinosinusitis.
• This technique was a rapidly accepted procedure based on its short procedure
time, recovery time, and exibility to perform the procedure in the ofce.
Background
Chronic rhinosinusitis has an estimated prevalence of 2.1–13.8% in the United
States. While medical therapy is successful in most cases, approximately 320,000
endoscopic sinus surgeries (ESS) are performed each year [1]. Balloon sinuplasty
(BSP) is a minimally invasive technique in which the device microfractures and thus
dilates the natural ostium of the maxillary, frontal, and/or sphenoid sinuses. The
major benet of this technique is that bone and soft tissue are displaced without
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 89191- 5_12.
A. M. Donaldson (*)
Department of Otolaryngology Head and Neck Surgery, Mayo Clinic Florida,
Jacksonville, FL, USA
e-mail: Donaldson.angela@mayo.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
J. T. Lee et al. (eds.), Advances in Surgical and Medical Interventions for
Recalcitrant Chronic Rhinosinusitis,
https://doi.org/10.1007/978-3-031-89191-5_12
125