Current Controversies in Rhinologic Surgery

The modified Lothrop (Draf III) is a frontal sinus drill-out that has been successful at opening these areas widely, he said. It was developed in the mid-1990s and entails removal of the interfrontal septum, the superior part of the nasal septum, and the frontal sinus floor from orbit to orbit laterally.

There are three general parts of the operation. The first is creating the superior septal perforation and removing the anterior 1 cm of the middle turbinates. In the second, one or both frontal recesses are identified, and a bur is used to remove the frontal floor from posterior to anterior. In the third, the surgeon moves across the midline, removing bone to create the largest possible oval opening to both frontal sinuses.

As an endoscopic procedure, the modified Lothrop is less invasive and has less blood loss compared with an external approach. It leaves no external scar, and postoperative surveillance can be done with CT and endoscopy. The disadvantages are that it is a technically difficult procedure in an area with dangerous anatomy, such as nearby brain and eye tissue. Postoperative care can be extensive, and it is less likely to be successful in patients with hypertrophic bone or active disease.

Indications for the procedure can include inverted papilloma and mucoceles. I love to do mucoceles this way, because they open up so nicely and then tend to heal quite well, Dr. Leopold said.

However, there can be unpleasant results, such as recurrence of fungal disease and polyps. Furthermore, close to 20% of patients may need a repeat Lothrop. He reported that in his experience about 15% of patients note a decrease in their sense of smell afterward.

Overall, the modified Lothrop has radically changed the management of FSS, and gives the largest frontal opening. It is also one of the most difficult frontal sinus operations we perform, he said.

Osteoplastic Flap

On the other hand, the modified Lothrop can help prevent the need for an osteoplastic flap, according to James Stankiewicz, MD, Chairman of Otolaryngology at Loyola University Medical Center in Chicago. He spoke about the pros and cons of osteoplastic frontal flap for treating frontal sinus disease.

The indications for the procedure include acute complications in the frontal sinus, chronic (and complicated) sinusitis, and frontal sinus tumors or fractures.

The standard incision is the coronal incision. Dr. Stankiewicz noted that he prefers a forehead incision. He suggests making the incision in a crease of a wrinkle in the forehead.