Current Controversies in Rhinologic Surgery

ORLANDO, FL-The modified Lothrop procedure is becoming the standard method for treating severe frontal sinus disease, but the osteoplastic frontal sinusotomy still has a role. Patients who qualify for having these operations performed are few, and less aggressive endoscopic frontal procedures should be tried first. Indeed, because of the complicated anatomy and risks involved, only specially trained surgeons should even perform them.

These were the key cautions about the two procedures described at a recent Controversies in Rhinology session hosted by the American Rhinologic Society at the annual Combined Otolaryngology Spring Meeting. To set the stage, Donald Leopold, MD, Chairman of Otolaryngology-Head and Neck Surgery at the University of Nebraska, described some of the historical problems with trying to treat frontal sinus symptoms (FSS).

In fact, how best to treat frontal symptoms is a historical question that has been dealt with by otolaryngologists for more than 100 years, he said. He pointed out that throughout most of the 20th century, there’s been this seesaw back and forth between internal and external procedures. Neither is ideal.

The osteoplastic flap approach to the frontal sinuses was popular in the latter part of the 20th century. It was a big operation… and people typically had numb foreheads afterward, he said. Patients would come back months to years later with fever and pain, often with a cold.

How do you evaluate these folks? This has been the biggest stumbling block for me. Do these patients have an infection? Or do they simply have a migraine headache? he said.

Endoscopy and computer-aided surgical navigation devices have revolutionized how most FSS patients are treated, he said. Obviously, the rules are important in this game. You have to preserve mucosa. You need to be able to see to operate. If you can’t see the tip of your instrument, you shouldn’t be there. You need to learn techniques to control bleeding, Dr. Leopold said.

However, once in a while (rarely, in fact) there are cases in which pathology will not allow for good access through the nose. In these situations, a hybrid approach using both endoscopic and external techniques can be useful.

Use all planes of the CT to really know the anatomy. Depending on the case, a Draf I or a Draf II opening into the frontal sinus can be helpful. The agger nasi cell is the key to this…. And be very careful to find this cell anatomically as you do this operation. Understand the anatomy very, very clearly, Dr. Leopold said.

The Modified Lothrop Procedure

If ipsilateral procedures fail, then the modified Lothrop can be an effective alternative. But few otolaryngologists are trained to do this procedure, and because of the sensitive surrounding anatomy it is a risky approach, he said.

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.

When they heal up, if you put it in the wrinkle appropriately, you can hardly tell they had a surgery. I think this is the best way to go cosmetically; it gives direct access right to the frontal sinus, and you don’t have to pull the whole forehead and part of the scalp down to get at it, he said.

Brow incisions should be done as a last resort. Most people don’t place it correctly. You can get problems with the eyelid, hair, and numbness, he said. The key to the surgery is planning the bone cuts. A six-foot Caldwell template can be used to outline the frontal sinus prior to incision. However, an item of identification, such as a dime taped to the patient’s forehead, should be used so the surgeon knows that the six-foot Caldwell is true to size.

If it’s oversized and try to make bone cuts into the frontal sinus, you can get into the brain, he said. Other ways to identify the proper bone cut include trephination with transillumination, fluoroscopy, or with image guidance. With image guidance, you can go ahead and outline that whole frontal sinus area, and it gives you more degree of safety, he said.

Are Osteoplastic Flaps Obsolete?

Are osteoplastic frontal flaps, which were developed in 1954, an anachronism? In rare cases, the procedure can still be of use. Dr. Stankiewicz described several cases in which it helped. One was a 50-year-old woman with acute and chronic sinusitis who had failed multiple endoscopic sinus surgery (ESS) procedures, including two modified Lothrops. She had persistent frontal infection and pain. An osteoplastic flap resolved the problem.

Another was a 45-year-old man who presented with several fractures in his frontal sinus. He underwent the procedure to repair the fractures, with good results.

A third case was a 70-year-old woman with chronic osteomyelitis in the frontal bone of the frontal sinus, with significant deformity in her forehead and sinuses. Here, a sinusectomy was performed with osteoplastic flap and hydroxyl apatite reconstruction.

A fourth case was a 71-year-old man with a right frontal mucocele, who had already undergone modified Lothrop. There was significant osteitic bone on the right side, making it difficult to get into the right frontal sinus. The lateral two-thirds of the mucocele was inaccessible.

A fifth common type of case is an osteoma that blocks the frontal sinus drainage.

Generally, there is still a limited place for the osteoplastic flap in the treatment of frontal sinus pathology and trauma. And it’s rarely used and rarely taught…. In private practice, unless you had an outstanding experience with this, I don’t think otolaryngologists should be doing either procedure. You need to send it to a center that has experience with it, Dr. Stankiewicz said.

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