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72
A. Miglani and D. Lal
Table 7.3
Procedure
Draf IIA Complete removal of all
Draf IIb Removal of the medial/
Indications for Draf IIa and Draf IIb
Description
anterior ethmoidal cells in
the frontal recess with
widening of the frontal
ostium from the medial
orbital wall to the vertical
attachment of the middle
turbinate medially.
anterior attachment of the
middle turbinate with
extension of the frontal
ostium extending from the
medial orbital wall to the
nasal septum.
Indications for revision surgery
– Revision surgery for chronic sinusitis without
– Frontal mucoceles
– Frontal mucopycoceles
– Acute frontal sinusitis
– Frontal barotrauma
– Recurrent acute frontal sinusitis
– Lateralized middle turbinate
– Synechiae
– Revision surgery for CRSsNP and CRSwNP
– Lateralized middle turbinate or turbinate
– Frontal mucocele
– Frontal mucopycocele
– Osteoneogenesis
– Resection of benign of malignant neoplasm
– Posterior table cerebrospinal uid leak or
– Unilateral approach to cranial base of medial
nasal polyps (CRSsNP) and CRSwNP
remnant
encephalocele
and superior orbit
other complicating factors, an extended Draf IIa with removal of the nasal beak or a
Draf IIb procedure may be necessary.
Imaging Review
A decision to pursue revision frontal sinus surgery is often associated with the persistence or recurrence of CRS symptoms. Updated computed tomography (CT)
imaging is indicated for revision surgery planning. Imaging review for revision
frontal sinus surgery should determine the following features [19]:
– Nature and extent of previous surgery.
– Patency of the drainage pathway.
– If frontal outow is occluded, determine if the occlusion is related to soft tissue,
bone, or both.
– Presence of residual structures narrowing the frontal recess, with specic atten-
tion to a lateralized middle turbinate, residual frontoethmoidal cells, and remnant
uncinate tissue.
– AP dimension of the frontal ostium.
– Integrity of the skull base or orbital roof and medial wall.
– Degree of opacication of the frontal sinus.
– Any expansile features to raise concern for underlying mucocele.
7 Revision Sinus Surgery for Recalcitrant Chronic Frontal Rhinosinusitis: Draf…
73
Magnetic resonance imaging may play a complementary role with its superior
soft tissue characterization and should be employed in cases of suspected intracranial complications of rhinosinusitis or concern for neoplasm [19]. The radiographic
features can help determine the most suitable approach and extent of revision
surgery.
Determining Extent ofRevision Surgery
The extent of surgery and choice of technique remain subjects of healthy debate
within the rhinologic community. Decision-making involves determining what
approach will provide an adequate neo-ostium size to facilitate delivery of topical
medications while minimizing risks and convalescence for the patient.
The Draf IIa procedure may be considered for primary and revision frontal surgery for CRS, frontal mucoceles, acute frontal sinusitis, frontal barotrauma, and
recurrent acute frontal sinusitis. Askar, etal. reviewed 48 patients undergoing revision Draf IIa frontal sinusotomy for CRS, nding a 92.4% ostial patency rate at
6months, suggesting that most patients with refractory frontal sinus disease can be
managed with such an approach [20]. An extended Draf IIa with removal of part of
the nasal beak may also be considered as described by the EFSS classication. This
allows for a wider ostium, more direct access using 0-degree scope to the frontal
recess, improved ease of debridement, and improved ability to instrument high up
within the frontal sinus.
The Draf IIb procedure is typically considered for revision surgery for CRS,
particularly in setting of a lateralized middle turbinate or its remnant, mucocele,
osteoneogenesis, frontal neoplasm, or for endoscopic repair of posterior table cerebrospinal uid leak or meningoencephalocele. In a series of 18 patients undergoing
Draf IIb, 13 were revision and long-term patency was achieved in 91% of patients
[18]. In a separate series of 21 patients, all had patent neo-ostium at 15.7months
and no complications were noted except hyposmia that was reported in 14.3% of
patients [21]. Comparing outcomes to the Draf III approach, similar patency and
long-term symptom outcomes were noted, but Draf III patients were found to
require more frequent ofce visits and debridement as well as antibiotics compared
to Draf IIa patients.
There are trade-offs when comparing less aggressive to more aggressive
approaches. A less aggressive approach such as a Draf IIa may minimize risks of
complications but could also result in an inadequate opening to control frontal sinus
disease. Conversely, a more aggressive approach such as the Draf IIB may provide
a larger ostium, but may be associated with increased risk of complications (e.g.,
cerebrospinal uid leak secondary to middle turbinate resection and hyposmia).
Ultimately, an individualized approach with consideration of the severity of disease,
local anatomy, procedure risks, patient health, and patient preference should be
undertaken to identify a suitable approach.
74
A. Miglani and D. Lal
Surgical Technique
Draf IIA
The approach to Draf IIA is dictated by the extent of prior surgery and remnant
bony and soft tissue obstruction. A complete and thorough ethmoidectomy with
removal of any remnant frontoethmoidal cells, lateralized middle turbinate tissue, or
remnant uncinate tissue that may narrow the drainage pathway is crucial. Preservation
of mucosa is paramount to minimize risk of cicatrization. The steps are as follows:
1. Perform a complete ethmoidectomy, delineating the medial orbital wall and the
mid/posterior ethmoid skull base.
2. Identify the skull base just posterior to the frontal recess and frontoethmoidal
cells (i.e., just behind bulla and suprabulla cells).
3. Probe and identify the natural drainage pathway if intact, resecting partitions
including frontoethmoidal cells and any remnant uncinate process.
4. Using angled scopes and instrumentation, meticulously dissect any cells extend-
ing to and above the frontal ostium, including supra agger/supra agger frontal
cells and suprabullar/suprabullar frontal cells.
5. Widen the frontal outow tract from the nasal beak anteriorly to the ethmoid roof
posteriorly, to the medial orbital wall laterally, and to the middle turbinate
medially.
Extended Draf IIA withRemoval ofNasal Beak (Video 7.1)
In settings of osteitis, narrow anatomy, or frontoethmoidal cells extending above the
frontal ostium, and extended Draf IIa with removal of part of the nasal beak aids in
achieving a wider frontal sinus access and visualization. This technique involves
creating a mucosal ap, drilling the nasal beak between the middle turbinate attachment and medial orbital wall, and widening of the frontal sinusotomy. The steps are
as follows:
1. Perform a Draf IIa as described above.
2. Create an inferiorly based lateral nasal wall mucosal ap with three mucosal
incision (Video 7.1).
3. Elevate the mucosal ap and reect it inferiorly.
4. Drill the bone overlying the frontal process of the maxilla, resecting the axilla
and nasal beak while skeletonizing the periosteum overlying the medial
orbital wall.
5. Continue dissection with a Kerrison, curette, or further drilling to widen the
frontal outow tract.
7 Revision Sinus Surgery for Recalcitrant Chronic Frontal Rhinosinusitis: Draf…
75
6. Redrape the inferiorly based ap to cover the lateral nasal wall and promote
re-mucosalization.
7. Place a Merocel pack or other packing material in the middle meatus to stabilize
the ap and stent the middle meatus, minimizing the risk of middle turbinate
lateralization.
Draf IIB (Video 7.2)
The Draf IIB involves completion of the Draf IIa followed by resection of the anterior attachment of the middle turbinate with medial extension of the frontal sinusotomy to the nasal septum. The steps are as follows:
1. Perform a Draf IIa as described above.
2. Verify the anticipated location of the middle turbinate resection using CT
navigation.
3. Conduct a targeted and controlled middle turbinate resection using through-
cutting instruments, resecting the anterior portion of the middle turbinate to the
level of the cribriform plate.
4. Extend the frontal sinusotomy medially to the nasal septum by resecting the
frontal sinus oor anterior to the cribriform. Consider use a combination of rongeurs, through-cutting instruments, and a diamond burr as needed.
Postoperative nasal endoscopies for the three approaches can be visualized in
Fig.7.2.
ab c
Fig. 7.2 Postoperative clinic nasal endoscopies reveal patency of frontal outow tracts. Figure2a
represents a standard revision Draf 2a with intact middle turbinate (white arrowhead). Figure2b
demonstrates a Draf 2a with resection of nasal beak (blue shaded oval). Figure2c demonstrates a
postoperative Draf 2b with resection of the anterior attachment of the middle turbinate (white
arrow) (Property of Mayo Clinic Arizona)
76
A. Miglani and D. Lal
Adjunctive Techniques andReported Outcomes
Trephine and external techniques: In the last century, endoscopic techniques have
become standard of care for most frontal sinus procedures. Despite this shift in
practice, open approaches still retain utility in appropriate clinical circumstances
and may be considered as part of a sinus surgeon’s armamentarium, particularly in
revision frontal sinus operations.
Indications for external approaches include specic instances of frontal sinus
trauma, CSF leaks, complicated rhinosinusitis, mucoceles with orbital involvement,
and tumors. Perhaps the most commonly employed external frontal procedure is the
trephine. The trephine’s initial indication was treatment of acute complicated frontal
sinusitis (i.e., Pott’s puffy tumor). However, indications have expanded and it is
commonly used as an adjunct to endoscopic frontal approaches to identify the frontal outow tract or access regions high within the frontal sinus (e.g., cells extending
high above the frontal ostium). In acutely inamed, infected, or highly recalcitrant
cases, placement of a small cannula may be performed to deliver topical medications directly to the sinus and outow tract.
Most providers prefer to perform the trephination under general anesthesia with
patient supine. Important anatomic landmarks to identify include the superior
orbital rim and supraorbital notch as the trephine will always be medial to the notch.
Incision location should be at the inferomedial quadrant at the apex of the frontal
bossing anterior projection of the sinus. Computerized image guidance can assist in
conrming appropriate incision placement. Once the incision is marked, local anesthetic is inltrated in this region and an approximately 1.5cm incision is made taking care to avoid injury to the supraorbital bundle. The soft tissue and periosteum is
incised and a freer or similar elevator is used to elevate the periosteum circumferentially. Hemostasis can be achieved using cautery, dissolvable hemostatic agents, and
pledgets as needed. Conrmation of the trephination site can be performed throughout the procedure as needed using image guidance. A high speed 3–4mm drill can
be used to drill away anterior table [22]. Before entering the mucosa (and encountering further bleeding), further surrounding bone can frequently be removed with a
Kerrison as needed. Lastly, the mucosa is incised and entered completing the
trephination.
Outcomes within the published literature are favorable. Crozier used trephines
for repair of frontal sinus CSF leak and found no recurrences with follow-up period
of 37months [23, 24]. A separate study found excellent frontal outow patency in
86% of patients with 16months of follow-up who underwent a combined above and
below approach for complex frontal sinus indications [25].
Other external techniques include frontal sinusotomy with osteoplastic ap,
external frontoethmoidectomy, frontal sinus obliteration, and cranialization. While
endoscopic approaches have become the mainstay for most frontal sinus procedures, external techniques including the trephine retain a crucial role despite the
higher burden of immediate and long-term postoperative complications and sequela.
External procedures may be considered for frontal sinus neoplasms, fractures,
7 Revision Sinus Surgery for Recalcitrant Chronic Frontal Rhinosinusitis: Draf…
77
cerebrospinal uid leaks, or in cases of recalcitrant inammatory sinus disease that
are not adequately addressed by prior endoscopic procedures or where disease is far
lateral and inaccessible through endoscopic approach.
Stents: Early literature regarding stenting focused on non-dissolvable materials
such as silastic sheeting/tubing. More recent innovation has introduced dissolvable
drug eluting stents. A recent review evaluating steroid-eluting implants analyzed six
prospective randomized clinical trials and demonstrated that the implants can
improve postoperative results following ESS with reduction in recurrence of nasal
polyp and decrease the need for additional surgery. These results suggest that
implants could be used as a substitute for the benecial effect of systemic steroid
use. A limitation is the long-term results and impact of steroid eluting stents.
Additionally, there is concern whether these interventions are cost effective [26].
While these interventions hold promise, further high-level studies with longer follow-up are needed.
Tips and Pearls
• Detailed review of preoperative imaging will help inform the appropriate frontal
sinus procedure.
• An individualized, patient-centered approach with consideration of the severity
of disease, local anatomy, procedure risks, patient health, and patient preference
should be undertaken to identify the most suitable frontal sinus approach.
• Meticulous and thorough dissection to maximize frontal recess dimensions while
preserving mucosa within the frontal recess is important in optimizing patency
and minimizing risk of restenosis.
• Use of angled scopes and angled instrumentation can improve visualization and
access of cells pneumatizing high within the frontal sinus.
• Draf IIa is suitable for most recalcitrant chronic frontal sinusitis cases. Extended
Draf IIa with removal of the nasal beak and Draf IIb may improve access through
a wider frontal drainage pathway and should be considered in appropriate clini-
cal circumstances.
• Ideally, the postoperative ostia size should measure 4.5–5mm to maintain long-
term patency.
• Treatment adjuncts, including frontal trephination, use of dissolvable drug-
eluting stents, and postoperative debridement, can aid in maintaining frontal out-
ow patency.
References
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2001;34(1):49–58.
2. Draf W. Endonasal micro-endoscopic frontal sinus surgery: The fulda concept. Oper Tech
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article/pii/S1043181010800879.
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3. Draf W.In: Kountakis SE, Senior BA, Draf W, editors. Endonasal frontal sinus drainage type
I–III according to Draf BT—The Frontal Sinus. Berlin: Springer; 2005. p.219–32. https://doi.
org/10.1007/3- 540- 27607- 6_24.
4. Wormald P-J, Hoseman W, Callejas C, Weber RK, Kennedy DW, Citardi MJ, etal. The international frontal sinus anatomy classication (IFAC) and classication of the extent of endoscopic frontal sinus surgery (EFSS). Int Forum Allergy Rhinol. 2016;6(7):677–96.
5. DeConde AS, Smith TL.Outcomes after frontal sinus surgery: an evidence-based review.
Otolaryngol Clin N Am. 2016;49(4):1019–33.
6. Schuman TA, Senior BA. In: Lal D, Hwang PH, editors. Identifying and addressing causes of failure in frontal sinus surgery BT—frontal sinus surgery: a systematic approach. Cham: Springer International Publishing; 2019. p. 199–209. https://doi.
org/10.1007/978- 3- 319- 97022- 6_12.
7. Otto KJ, DelGaudio JM.Operative ndings in the frontal recess at time of revision surgery.
Am J Otolaryngol. 2010;31(3):175–80.
8. Valdes CJ, Bogado M, Samaha M.Causes of failure in endoscopic frontal sinus surgery in
chronic rhinosinusitis patients. Int Forum Allergy Rhinol. 2014;4(6):502–6.
9. Bolger WE, Kuhn FA, Kennedy DW.Middle turbinate stabilization after functional endoscopic
sinus surgery: the controlled synechiae technique. Laryngoscope. 1999;109(11):1852–3.
10. Naidoo Y, Wen D, Bassiouni A, Keen M, Wormald PJ.Long-term results after primary frontal
sinus surgery. Int Forum Allergy Rhinol. 2012;2(3):185–90.
11. Hosemann W, Kühnel T, Held P, Wagner W, Felderhoff A. Endonasal frontal sinusotomy in surgical management of chronic sinusitis: a critical evaluation. Am J Rhinol.
1997;11(1):1–9.
12. Shen SA, Jafari A, Qualliotine JR, DeConde AS.Follow-up adherence is associated with outcomes after endoscopic sinus surgery. Ann Otol Rhinol Laryngol. 2020;129(7):707–14.
13. Miglani A, Divekar RD, Azar A, Rank MA, Lal D.Revision endoscopic sinus surgery rates by
chronic rhinosinusitis subtype. Int Forum Allergy Rhinol. 2018;8(9):1047–51.
14. Wu AW, Ting JY, Platt MP, Tierney HT, Metson R. Factors affecting time to revision sinus
surgery for nasal polyps: a 25-year experience. Laryngoscope. 2014;124(1):29–33.
15. Mendelsohn D, Jeremic G, Wright ED, Rotenberg BW.Revision rates after endoscopic sinus
surgery: a recurrence analysis. Ann Otol Rhinol Laryngol. 2011;120(3):162–6.
16. Hopkins C, Slack R, Lund V, Brown P, Copley L, Browne J.Long-term outcomes from the
English national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis.
Laryngoscope. 2009;119(12):2459–65.
17. Chandra RK, Palmer JN, Tangsujarittham T, Kennedy DW. Factors associated with
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2004;131(4):514–8.
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surgery. Am J Rhinol Allergy. 2016;30(1):70–3.
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23. Patel AB, Cain RB, Lal D.Contemporary applications of frontal sinus trephination: a systematic review of the literature. Laryngoscope. 2015;125(9):2046–53.
24. Crozier DL, Hwang PH, Goyal P.The endoscopic-assisted trephination approach for repair of
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79
Modified Mini/Hemi/Subtotal/Central
Lothrop forRecalcitrant Chronic Frontal
Sinusitis
MichaelS.Hegazin, ChristinaH.Fang, PrayagS.Patel,
JordonG.Grube, andJeanAndersonEloy
Key Points
• The Draf I-III can provide adequate access to the frontal sinuses, but modica-
tions can be made to accommodate the surgical needs of the individual patient.
• The modied hemi-Lothrop procedure (Eloy IIC) involves an ipsilateral Draf
IIB and an anterosuperior septectomy window for access to the lateral recess of
the ipsilateral frontal sinus via the contralateral nasal cavity.
• The modied mini-Lothrop procedure (Eloy IID) involves a contralateral Draf
IIB and a frontal intersinus septectomy. This allows drainage of an ipsilaterally
obstructed frontal sinus through the intersinus septectomy window and eventually through the contralateral frontal sinus oor opening.
• The modied subtotal-Lothrop procedure (Eloy IIE) involves an ipsilateral Draf
IIB with a superior septectomy and frontal intersinus septectomy. The contralateral frontal sinus recess is preserved in this technique.
8
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 89191- 5_8.
M. S. Hegazin
Department of Otolaryngology—Head and Neck Surgery, Rutgers New Jersey Medical
School, Newark, NJ, USA
C. H. Fang
Department of Otorhinolaryngology—Head and Neck Surgery, Monteore Medical Center,
The University Hospital of Albert Einstein College of Medicine, Bronx, NY, USA
P. S. Patel
Department of Otolaryngology—Head & Neck Surgery, Maimonides Medical Center,
Brooklyn, NY, USA
J. G. Grube
Department of Otolaryngology—Albany Medical College, Albany Medical Center,
Albany, NY, USA
© 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_8
81
82
M. S. Hegazin et al.
• The modied central-Lothrop procedure (Eloy IIF) involves resection of the
frontal sinus oor bilaterally, with a superior septectomy and frontal intersinus
septectomy, while preserving both frontal sinus recesses.
• These alterations represent expansion on the current Draf or nasofrontal classi-
cation systems and approaches.
Background
The frontal sinus has proven to be anatomically challenging, both with respect to
surgical access and management of chronic and recurrent disease. There exist
numerous anatomic variations between patients and even between sides in the same
patient [1]. Treatments for frontal sinus disease range from conservative medical
management to more aggressive open surgical procedures. Advances in frontal
sinus surgery have allowed for movement away from the more invasive and potentially disguring open approaches to less aggressive, endonasal endoscopic
approaches.
The Lothrop procedure, rst described in 1914, consisted of an intranasal ethmoidectomy followed by an external Lynch-type approach with resection of the
medial frontal sinus oor, superior nasal septum, and intersinus septum, which created a large frontonasal communication. The micro-endoscopic and endoscopic
modications to Lothrop’s original technique have been described in the literature,
notably by Draf [2], Gross, etal. [3], and Close, etal. [4] These authors have detailed
an endonasal approach similar in concept to Lothrop that also involves creating a
large common drainage pathway between the paired frontal sinuses. In the last
decade, further modications to the procedure have been developed to reduce invasiveness and preserve the natural architecture of the frontal sinus. This has led to the
description of the modied hemi-Lothrop procedure [5–8], the modied miniLothrop procedure [9, 10], and the modied subtotal-Lothrop procedure by the
senior author [11, 12].
Current and common methods of classication for endonasal frontal sinus drainage techniques include the Draf and nasofrontal approaches [13]. In the last decade,
modications of endonasal frontal sinus techniques have been developed, but are
J. A. Eloy (*)
Department of Otolaryngology—Head and Neck Surgery, Rutgers New Jersey Medical
School, Newark, NJ, USA
Department of Otolaryngology—Facial Plastic Surgery, Cooperman Barnabas Medical
Center, Robert Wood Johnson Barnabas Health, Livingston, NJ, USA
Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey,
Rutgers New Jersey Medical School, Newark, NJ, USA
Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School,
Newark, NJ, USA