Ebook Rhinology and skull base surgery: Part 1

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Rhinology and Skull Base Surgery From the Lab to the Operating Room: An Evidence-based Approach Christos Georgalas, PhD, DLO, FRCS (ORL-HNS) Director, Endoscopic Skull Base Center Department of Otorhinolaryngology Academic Medical Center Amsterdam, The Netherlands Wytske Fokkens, MD, PhD Professor Department of Otorhinolaryngology Academic Medical Center Amsterdam, The Netherlands With contributions by Nithin D Adappa, Robert V Almeyda, Isam Alobid, Jastin Antisdel, Humera Babar-Craig, Samuel S Becker, Brett Bell, Rajiv K Bhalla, Benjamin S Bleier, Ulrike Bockmühl, Andrea Bolzoni Villaret, Cornelius Jan Brenkman, Hans Rudolf Briner, Ricardo L Carrau, Paolo Castelnuovo, Marco D Caversaccio, Daniel T T Chua, Roxana Cobo, Noam A Cohen, Vassilios Danielides, Pascal Demoly, Leo F S Ditzel Filho, Wolfgang Draf, Patrick Dubach, Nicolas Dulguerov, Davide Farina, Berrylin J Ferguson, Juan C Fernandez-Miranda, Wytske Fokkens, Nicole J M Freling, Paul A Gardner, Christos Georgalas, Philippe Gevaert, Mitchell R Gore, Jan Gosepath, Haralampos Gouveris, Hakon Hakonarson, Samuel Heimgartner, Peter W Hellings, Philippe Herman, Claire Hopkins, Nick S Jones, Amin B Kassam, Robert M Kellman, Daniel F Kelly, Bhik Kotecha, Stilianos E Kountakis, Haytham Kubba, Jean-Silvain Lacroix, Basile Nicolas Landis, Donald C Lanza, Annie S Lee, Sarah Lovell, Tim C Lueth, Franklin Mariño-Sánchez, Nancy McLaughlin, Ralph Metson, Joaquim Mullol, Piero Nicolai, Gilbert J Nolst Trenité, Reza Nouraei, James N Palmer, Vasileios Papanikolaou, Kalpesh S Patel, Santdeep H Paun, Oliver Pfaar, Daniel M Prevedello, Emmanuel Prokopakis, Susanne M Reinartz, Herbert Riechelmann, Peerooz Saeed, Hesham Saleh, Glenis K Scadding, Rodney J Schlosser, Brent Senior, Jian-Bo Shi, Li Shi, Daniel Simmen, Ameet Singh, Elisabeth Victoria Sjoegren, Carl H Snyderman, Zachary M Soler, Alla Y Solyar, Gero Strauss, Andrew C Swift, Ingrid Terreehorst, Timoleon F Terzis, Marc A Tewfik, Matthew J Tormenti, Elina Toskala, Bert van der Baan, Wouter R van Furth, Cornelius M van Drunen, Thibaut Van Zele, Carel D A Verwoerd, Henriette L Verwoerd-Verhoef, De-Yun Wang, Stefan Weber, William Ignace Wei, Ronald B Willemse, Peter-John Wormald, Giannis Yiotakis, Bing Zhou 979 illustrations Thieme Stuttgart • New York Library of Congress Cataloging-in-Publication Data Rhinology and skull base surgery : from the lab to the operating room : an evidence-based approach / edited by Christos Georgalas, Wytske Fokkens p ; cm Includes bibliographical references and index ISBN 978-3-13-153541-2 I Georgalas, Christos II Fokkens, Wytske J [DNLM: Rhinitis surgery Sinusitis surgery Nose Diseases physiopathology Nose Neoplasms surgery Rhinoplasty Skull Base surgery WV 335] 617.5’1059 dc23 2012032355 Important note: Medicine is an ever-changing science undergoing continual development Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book Such examination is particularly important with drugs that are either rarely used or have been newly released on the market Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page Illustrator: Katja Dalkowski, MD, Buckenhof, Germany © 2013 Georg Thieme Verlag KG, Rüdigerstrasse 14, 70469 Stuttgart, Germany http://www.thieme.de Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA http://www.thieme.com Cover design: Thieme Publishing Group Typesetting by Maryland Composition, USA Printed in China by Everbest Printing Ltd, Hong Kong ISBN 978-3-13-153541-2 Also available as e-book: eISBN 978-3-13-164461-9 Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain This book, including all parts thereof, is legally protected by copyright Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage To my parents, Eleni and Kostas, to whom I owe everything To my wife, Amanda, for embarking with me on this journey To those who cross borders, by choice or need: our collective past, present, and future Christos Georgalas To my beloved parents, Onno and Joke, who taught me, among many other things, to enjoy questioning and exploring; and my teacher Carel Verwoerd who taught me a lot more than rhinology To the loves of my life, my husband Casper and my three children Sybren, Anne, and Lywke, who lovingly and courageously try to keep me in line Wytske Fokkens To access additional material or resources available with this e-book, please visit http://www.thieme.com/bonuscontent After completing a short form to verify your e-book purchase, you will be provided with the instructions and access codes necessary to retrieve any bonus content vii Foreword Over the last 20 years there have been a number of books broadly covering the many facets of the nose and sinuses However, such is the interest in this area and the pace of progress in its investigation and treatment that this major work is a welcome addition to the field Underpinned by the wide-ranging expertise of Professor Wytske Fokkens and Christos Georgalas at the Academic Medical Center, this multinational collaboration covers the full range of rhinology, from basic anatomy and physiology, through diagnostic techniques, to the entirety of sinonasal pathology The international authorship guarantees a balanced approach and includes many well-known contributors in the field as well as some “new blood” providing a fresh view on old problems As well as the usual topics, consideration is given to some less well-understood but expanding areas of interest in the nose and sinuses, such as genetics and rare disorders such as the silent sinus syndrome and pneumosinus dilatans The concept of “one airway” is now generally accepted, but the importance of this in understanding the pathophysiology and management of rhinosinusitis is emphasized by authors able to authoratively consider both the upper and lower respiratory tract Despite this, we often struggle to improve the lot of our patients with recalcitrant CRS and welcome practical advice offered on the management of these patients Rhinology, of course, is a multifaceted subject and, in addition to the full range of sinonasal pathology, the editors have commendably included rhinoplasty and all of the well-established, extended applications of endoscopic surgery to adjacent structures of the orbit and skull base This comprehensive and holistic approach is to be applauded, making this a “must have” text for anyone interested in the nose and sinuses Valerie J Lund, CBE Professor of Rhinology, University College London viii Preface “ .When you set sail for Ithaca, wish for the road to be long, full of adventures, full of knowledge .” Constantin P Cavafy “The Road to Ithaca,” Collected Poems It is fair to say that, if the fifties and sixties were the decades of otology and the seventies and eighties those of head and neck surgery, the last 20 years have witnessed an unprecedented boom in rhinology Advances in basic science leading to better understanding of disease pathophysiology, improved phenotyping, advances in endoscopic sinonasal and skull base surgery, and an increasingly multidisciplinary outlook have all brought a (r)evolution in rhinology Today, the nose is aptly regarded as an anatomic and physiologic interface that mirrors our professional interfacing with neurosurgeons and neurologists, allergists and chest physicians, opthalmologists and orbital surgeons This book aims to reflect this by presenting all the facets of this dynamic subspecialty We believe that any real progress in medicine, or rhinology for that matter, can only be the result of creative integration of basic science and clinical medicine With this in mind, we have brought together some of the brightest clinicians and researchers of our generation We are humbled by the enthusiasm of our contributors; indeed, they testify to the dynamic and extrovert outlook of current rhinology Over 90 world-class experts, presenting the most up-to-date and authoritative information from 17 countries and continents The writing of this book started in 2010 and continued throughout 2012, resulting in chapters that are current and up-todate, with both the European Position Paper on the Endoscopic Management of Tumors of the Nose, Paranasal Sinuses and the Skull Base from 2010 as well as the European Position Paper on Rhinosinusitis and Nasal Polyps from 2012 given consideration It is intended as a study and reference book for young and experienced rhinologists alike, with questions and answers, key points, tips and tricks, and notes included in every chapter The DVD included, with almost 80 videos, constitutes an integral part of the textbook, illustrating the pathology described in various chapters, demonstrating surgical approaches step-by-step, as well as providing a wealth of other material including data files for use in statistical exercises and three-dimensional imaging reconstructions Nevertheless, in a rapidly changing world, every textbook should come with a health warning: “Consume with moderation, for 50% of what you know to be correct today in medicine may be proven to be untrue tomorrow.” Although all the information we provide is accepted to be correct and accurate at the time of writing, we not claim to provide eternal certainties If this textbook makes you search the internet, debate with colleagues, and even email the authors, then we have succeeded Do not accept anything written in here at face value—“nullis in verba”—challenge authority, or as Socrates already taught us: “True wisdom comes to each of us when we realize how little we understand about life, ourselves, and the world around us.” (Socrates, 469–399 BC) Wytske Fokkens, MD, PhD Christos Georgalas, PhD, DLO, FRCS (ORL-HNS) II Rhinitis and Rhinosinusitis 396 22 Approaches to the Frontal Sinus Fig 22.37a–d Erosion of the frontal sinus floor, frontal beak, and intersinus septum and part of the nasal septum in a patient with a posttraumatic mucocele a b c d Draf III may also be required in cases with multiple mucoceles, where only a wide outflow pathway can prevent recurrence (Fig 22.38) ■ Benign Tumors of the Frontal Sinus: Limits of the Endoscopic Approach The most common benign tumors involving the frontal sinus are osteomas, inverted papillomas, and fibrous dysplasias (see Chapters 42 and 43) Osteomas are usually drilled out, starting from their core and subsequently proceeding toward their edges, until they are paper thin, at which point they can be broken out and removed The bony walls of the frontal sinus are rarely completely eroded from the tumor; however, occasionally CSF leak has to be anticipated and repaired at the end of the procedure Nevertheless, the limits of endoscopic removal remain a subject of controversy The first systematic attempt to codify the limits of endoscopic resection for osteomas was by Chiu et al,35who developed a grading system, maintaining that only grade and osteomas can be removed endoscopically (Table 22.3) Several surgeons, including Bignami et al,32 supported Chiu et al’s grading system, stating that an endoscopic approach was not feasible in cases with intracranial extension, large orbital involvement, anteroposterior diameter of the frontal sinus Ͻ 10 mm, lateral extension behind a virtual plane through the lamina papyracea, and erosion of the posterior or anterior wall of the frontal sinus.32 However, endoscopic surgery has been evolving at a very fast pace, and several surgeons have challenged these assumptions, including Dubin and Kuhn,33 who reported successful endoscopic removal of grade III tumors either attached anterosuperiorly in the frontal sinus or extending lateral to the plane of the lamina papyracea In this article, an osteoplastic flap was recommended only for removal of tumors with Ͼ cm vertical extension into the frontal sinus or occupancy of 100% of the frontal sinus In 2009, Seiberling et al36 reported their results with 23 patients with varying sizes of frontal sinus osteomas treated endoscopically, including patients with a grade IV tumor and with a grade III tumor A Draf III procedure was used for 15 of these tumors (including all grade and tumors) In four out of eight grade (filling the entire frontal sinus) tumors, a residual was left toward the posterior frontal plate, as the authors felt that the risk of penetrating the dura was too high In two cases, a second procedure was necessary for the complete removal of the tumor, while in one patient with extensive orbital extension, an external blepharoplasty incision was used, and an extended trephine incision was used in another one In 2010, Ledderose et al37 proposed that, in carefully selected individual cases, it is possible to remove grade and even grade osteomas endonasally They described the endoscopic removal of eight osteomas, three of which would have been classified nonresectable endoscopically according to Chiu et al’s classification: specifically, two grade tumors were removed via a Draf IIb approach and a grade tumor via a Draf III approach What we know now is that, although there is no number of external approaches that can prove the limits Specific Pathological Considerations Mucocele frontal recess L Kuhn type cell R a Pus anterolaterally to the Kuhn cell b c d Lateral orbital mucocele Frontal sinus septum Kuhn type Ager nasi e Fig 22.38a–f a, b Patient with ASA triad was referred with recurrent orbital cellulitis associated with multiple frontoethmoidal mucoceles He had undergone multiple endoscopic and three external frontal sinus procedures As a result of the mucoceles and a failed Lynch–Howarth approach, he developed a chronically discharging medial canthal fistula f c, d A right supraorbital mucocele with pus anterolateral to a Kuhn type cell e The left supraorbital mucocele directly draining into the canthal fistula f Draf III neo-ostium years later: patient is well and the neo-ostium is patent 397 II Rhinitis and Rhinosinusitis 398 22 Approaches to the Frontal Sinus Table 22.3 Frontal sinus osteoma grading system Grade Base of attachment is posteroinferior along the frontal recess Tumor is medial to a virtual sagittal plane through the lamina papyracea Anteroposterior diameter of the lesion is Ͻ 75% of the anteroposterior dimension of the frontal recess Grade Base of attachment is posteroinferior along the frontal recess Tumor is medial to a virtual sagittal plane through the lamina papyracea Anteroposterior diameter of the lesion is Ͼ 75% of the anteroposterior dimension of the frontal recess Grade Base of attachment is anteriorly or superiorly located within the frontal sinus and/or tumor extends lateral to a virtual sagittal plane through the lamina papyracea Grade Tumor fills the entire frontal sinus Adapted from Chiu AG, Schipor I, Cohen NA, Kennedy DW, Palmer JN Surgical decisions in the management of frontal sinus osteomas Am J Rhinol 2005;19(2):191–197 of endoscopic surgery, a small number of endoscopic approaches can shatter the myth of “unresectability.” We feel that it is not the anteroposterior diameter or the lateral extension of the tumor that defines its resectability endoscopically, but rather the relation between the interorbital distance, the anteroposterior diameter of the frontal beak, and the lateral height of the frontal sinus Our experience with the endoscopic approach to osteomas had been presented elsewhere.38 Lateral Extent Using the wide access provided by a Draf III procedure and curved drills, it is possible to access the lateral supraorbital ridge well beyond the medial orbit We maintain that it is not the plane of the lamina papyracea or the 2-cm lateral to it that defines the lateral limits of respectability, but rather the ratio of lateral tumor extension to interorbital distance Following the removal of the superior septum and the drilling of the nasal beak, lateral access to the frontal sinus is restricted primarily by the orbital walls In patients with a relatively large intercanthal distance, the lateral access that can be gained is increased, whereas the opposite is true for a narrow nasal inlet Large Tumors Attached to the Posterosuperior Frontal Walls Ͼ cm Superiorly in the Frontal Sinus Similarly, tumors extending superiorly to the posterior frontal plate or associated with complete opacification of the frontal recess can be removed endoscopically (Fig 22.39) In our experience, the removal of such tumors is time consuming, as the curved drills operating at 10,000 rpm (as opposed to the 80,000-rpm straight drills) would frequently fail and had to be changed In one such case, our approach was staged, and the osteoma was removed completely in the second approach with the use of a (much more effective) 80,000-rpm straight drill The development of high-speed curved drills may further facilitate the removal of such large laterally located osteomas Fig 22.39 Osteoma of the frontal recess, attached to the posterior frontal plate, completely obstructing the frontal ostium and associated with secondary mucoceles It was removed via a Draf III approach Specific Pathological Considerations Fig 22.40a, b Osteoma extending anteriorly and compressing the nasolacrimal duct resulting in epiphora It was removed via a combined endonasal/external (transconjunctival) approach a b Orbital Extension removal is done in combination with an endoscopically trained neurosurgeon Orbital extension is not in itself a contraindication to the endonasal approach (Fig 22.40) However, as stated by others,36 an external incision may be required if the tumor extends anteriorly We found that extension anteriorly to the nasolacrimal duct rather than in the orbit is an indication for an external incision In most cases, the external approach can be performed via a subconjunctival incision, with no cosmetic consequences Intracranial Extension We maintain that limited endocranial extension does not always preclude the use of the endoscope As we progress to manage intracranial/intradural tumors endoscopically, the limitation of posterior wall erosion/endocranial extension appears irrelevant, with the proviso that the a b c d Anterior Extension A limitation to endonasal approaches that withstands the test of time is anterior extension Extension of the tumor through the anterior frontal plate is normally impossible to access endoscopically, whereas the associated bony defect and deformity necessitate an external approach for reconstruction (Fig 22.41) The evolution of contraindications to the endoscopic approach is presented in Table 22.4 Inverted papillomas (unless recurrent) rarely grow deep into the frontal sinus, and what appears on CT as tumor can often be recognized on T2-weighted MRI as retained secretions Hence, complete removal of the inverted papillomas can usually be accomplished via a simple frontal sinusotomy Fig 22.41a–d Patient presenting with facial deformity and exophthalmos This osteoma was associated with posterior frontal plate and orbital roof erosion It was removed via an osteoplastic approach, and the anterior defect was reconstructed with titanium mesh No reconstruction was necessary for the posterior wall or the orbital defect 399 II Rhinitis and Rhinosinusitis 400 22 Approaches to the Frontal Sinus Table 22.4 Limits of the endoscopic approach for osteomas of the frontal sinus38 Anatomical limitations Schick60 Chiu35 Attachment to anterior frontal plate Dubin and Kuhn33 Bignami et al32 Yes No Yes Extension Ͼ cm superiorly in frontal sinus Lateral to lamina papyracea sagittal plane No (may need to leave remnant) Yes Yes Yes Yes Yes Complete obstruction of frontal recess Yes Intracranial extension/ erosion of posterior table No No No No No No No No Yes No Yes Yes No Yes Yes No No No No Extension anterior to nasolacrimal duct Significant orbital extension No No Yes Yes Complete opacification of frontal sinus No Relative cm lateral to orbit Erosion of anterior table No Yes Yes Yes AMC38 Yes (when associated with a large defect or very high attachment) Yes Attachment to superior frontal sinus Ledderose et al37 Yes Attachment to posterior frontal plate Frontal sinus diameter Ͻ cm Castelnuovo61 Seiberling et al36 Yes Yes Yes No (may require additional incision) No Yes, contraindications; No, no contraindications procedure (Fig 22.42) Limited extension into the frontal sinus (not lateral to the midorbit) can be approached with a Draf IIb procedure, whereas more extensive involvement usually requires a Draf III approach for visualization and access Very rarely, lateral extension of an inverted papilloma requires an osteoplastic approach In all cases, the bone at the area of attachment needs to be drilled with a diamond bur and the surrounding mucosa cauterized to prevent recurrence For recurrent inverted papillomas of the frontal recess, anecdotal reports (and our experience) suggest the usefulness of topical application of mitomycin or 5-FU cream Fibrous dysplasia must be differentiated from juvenile psammomatoid ossifying fibroma, which is associated with a much more aggressive presentation and tendency to recur In the case of the latter, incomplete removal almost guarantees recurrence within a few months ■ Malignant Tumors of the Frontal Sinus A discussion of approaches to malignant tumors goes beyond this chapter, and the reader is referred to Chapters 42 and 43 Wide access to the frontal sinus (as fashioned by a Draf II/III procedure) may be necessary for tumors that have been occupying most of the anterior skull base Specific Pathological Considerations b a Fig 22.42a, b a Papilloma involving the anterior ethmoids and frontal recess on the right Intraoperatively, it was found to involve the mucosa around the anterior ethmoid artery This was gently teased off the artery, the surrounding mucosa was removed, and the anterior skull base drilled b After 4½ years, the mucosa has healed, and there is no sign of recurrence Fig 22.43 T1-weighted MRI of a malignant melanoma in the skull base removed endoscopically Note on the sagittal plane how the tumor reaches the posterior limit of the frontal recess As part of its removal, a Draf IIb was performed to gain access to the frontal sinus and get access to the anterior limit of the tumor 401 II Rhinitis and Rhinosinusitis 402 22 Approaches to the Frontal Sinus (Fig 22.43) However, extensive involvement of the frontal sinus and anterior skull base is still primarily managed by a combined/endoscopic craniofacial resection ■ Developmental Disorders of the Frontal Sinus Barotrauma/Barosinusitis Dermoids Although it has been suggested that simple drainage may suffice (see Chapter 32), our experience has been that complete excision is crucial As these lesions more often than not are located laterally, an osteoplastic approach is usually required This needs to be coupled with the complete removal of the dermoid, with the use of a diamond drill to remove any cyst remnants (Fig 22.44) Acetylsalicylic Acid Triad Patients with ASA triad tend to have a more recalcitrant form of CRS (see also Chapter 18) In our series, they had a among the highest rates of frontal neo-ostium stenosis; thus, we tend to be more radical in our surgical approach They are probably the only patients with CRS in whom we would consider a Draf III as a primary procedure for severe chronic frontal sinusitis Patients with recurrent frontal barosinusitis associated with frontal recess obstruction are candidates for type 2a frontal sinusotomy Otherwise healthy sinuses and mucosal disease limited to the frontal ostium contribute to relatively high success rates (Fig 22.45) Cystic Fibrosis In our experience, this is one of the hardest groups to treat The revision rate for Draf III in patients with CF is the highest in our study, and it should be explained to the patients that the operation will be only part of a lifelong treatment Such results correlate with most authors’ experience (see Chapter 18) (Fig 22.46) b Fig 22.44a–c a T2-weighted MRI of a lateral frontal sinus dermoid presenting as a hard mass associated with headache and facial deformity in a young girl b, c It was removed via an osteoplastic flap approach c Specific Pathological Considerations a b Fig 22.45a, b a Patient with obstructed frontal sinus and barosinusitis b View of the ostium years after a Draf IIa procedure Fig 22.46 An adult patient with CRS and cystic fibrosis (CF) undergoing a revision Draf III Note the extensive vascularity and neo-osteogenesis typical in such patients 403 22 Approaches to the Frontal Sinus II Rhinitis and Rhinosinusitis 404 a b Fig 22.47a, b a An olfactory meningioma completely removed via a transcribriform approach A Draf III was performed at the start of the procedure to access the anterior part of the tumor b Endoscopic view at the outpatient visit with wellvascularized Haddad flap and open frontal sinuses Transnasal Craniotomy/The Frontal Sinus as a Pathway The transfrontal and transcribriform corridor to the anterior skull base requires wide access to the frontal sinus, normally accomplished via a Draf III procedure In this way, benign tumors of the anterior skull base or sinonasal malignancies can be approached and removed with reduced morbidity (Fig 22.47) Preoperative and Postoperative Management Preoperative and anesthetic issues relating to sinus surgery are discussed in Chapter 30 More specifically, for frontal sinus surgery, all patients receive preoperatively nasal steroid drops We use several checklists preoperatively to confirm that the patient has been appropriately prepped and that all the required operation instruments as well as imaging are available All patients receive intraoperative coverage with broad-spectrum antibiotics (usually amoxicillin/clavulanic acid, 1200 mg intravenous [IV], during induction) Purpose-made cotton buds soaked in 1:1000 adrenaline and crystalline cocaine powder (total of 100 mg per side) are applied under direct vision to the area of the sphenopalatine, anterior ethmoid, and greater palatine foramina (see also Chapter 30) We have found that total IV anesthesia coupled with controlled hypotension can improve significantly the operating field and reduce intraoperative blood loss Navigation is used in most frontal sinus procedures We feel that drains (even soft ones) can induce pressure necrosis and scarring, so we avoid their use At the end of Draf III procedures, we place antibiotic- and steroid-impregnated gauze in the neo-ostium Patients are discharged the day after the operation and are reviewed in the outpatient clinic after week In the case of Draf III procedures, the gauze is removed endoscopically from the neo-ostium at the first outpatient visit, or days postsurgery (Fig 22.48) Subsequently, the patients are advised to rinse their nose at least three times daily with copious Outcomes neo-ostium and removal of clots and crusts are made after 1, then weeks, and subsequently every weeks or as needed until healing is complete, which, depending on the amount of bare bone, can be anywhere between and weeks Culture-guided antibiotics are prescribed for purulent exacerbations, while polyps growing into the neo-ostium are managed with topically applied steroid and antibiotic cream, as well as systemic steroids, as required As part of our “sandwich treatment” concept, medical treatment of CRS (long-term antibiotics and/or oral steroids) is prescribed, if necessary, during the preoperative as well as the postoperative period Outcomes Fig 22.48 Endoscopic view of the neo-ostium of the patient seen in Fig 22.38, 12 days postoperatively and after removal of the paraffin gauze The ostium is open, but note the presence of clots and retained mucus amounts of normal saline (either self-made or purchased saline with baby shampoo decreases surface tension and is particularly effective) and use twice daily steroid nasal drops, for a minimum of months after surgery Outpatient appointments for gentle débridement of the Outcomes after endoscopic sinus surgery are discussed in Chapter 18 The studies presenting outcomes after frontal sinus surgery are presented in Tables 22.5 and 22.6 What is clear from these tables is that, until now, the evidence at best has been level III It is beyond the scope of this chapter to discuss individual studies; however, what most of these retrospective studies consistently show are similar positive endoscopic and clinical outcomes with few complications Our experience from 122 Draf III procedures Table 22.5 Review of the outcomes of endoscopic frontal sinus procedures Study Gross16 Year Procedure Patients (n) Follow-up (mo) Revision cases Type of outcome measured Revision rate 1995 Draf III 10 100% Endo 100%, clinical 80% 0% 62 1997 Draf III 20 12 100% Endo 95%, clinical 100% 0% Casiano and Livingston40 1998 Draf III 21 100% Endo 57%, clin 86% 9.5% McLaughlin et al21 1999 Draf III 20 12 95% Endo 100, clinical 89.5% N/A 2000 Draf III 24 9.6 56% Endo 56% all sinus (clinical same) 34% 2000 Draf III 15 N/A 100% Endo 100%, clinical 86.6% 13.7% Gross et al 22 Kuhn et al Ulualp et al 41 43 2002 Draf III 13 34.5 100% Endo 69%, clinical 69% 15% 44 2002 Draf III 54 40 Most Endo 77%, clinical 82% 32% Wormald et al 45 2003 Draf III 16 18.9 100% Endo 94%, clinical 75% 6% Wormald et al 46 2003 Draf III 17 25 100% Endo 100% 17.5% Wormald63 2003 Draf III 83 21.9 100% Endo 93%, clin 75% 7% Stankiewicz and Wachter48 2003 Draf III 10 34 100% Clinical 90% 50% Tran et al34 2007 Draf III 13 34.5 100% Endo 28% 11.% 2007 Draf III 97 18 N/A Endo 77%, clinical 98% 23% 2011 Draf III 122 33 96% Endo 90%, clinical 88% 20% Schulze et al Schlosser et al 52 Shirazi et al 18 Georgalas et al N/A, not available; Endo, endoscopically assessed patency of neoostium; clinical, clinical improvement; SF-36, Short Form 36; TSFS, transseptal frontal sinusotomy 405 22 Approaches to the Frontal Sinus Table 22.6 Review of outcomes of Draf II procedures Study Draf et al64 Weber et al 65 53 Year Procedure Patients (n) Follow-up (mo) Revision cases Type of outcome measured Revision rate 1995 Draf II 43 60 N/A Endo 61% N/A 1996 Draf II 83 51 N/A Endo 70% N/A 2000 Draf II 200 12.2 0% Endo 67% 33% 54 2003 Drill-out 100 49 Most Endo 80%, clinical 80% 20% 55 Chandra et al 2004 Frontal sinusotomy 130 N/A Endo 82% Chiu and Vaughan56 2004 Frontal sinusotomy 67 32 100% Endo 86.6%, clinical 57% 10.5% Hwang et al57 2005 Frontal sinusotomy 16 25 100% (all osteoplastic flaps) Endo 81%, clinical 81% 19% Friedman et al58 2006 Frontal sinusotomy 152 72 0% Endo 67% 23% Eviatar et al59 2006 Draf II 25 30 Most Endo 96% No full text found Friedman et al Samaha et al 8.3 over the past few years18 is presented as follows: 122 consecutive patients undergoing the Draf III procedure for recalcitrant CRS (71%), frontal sinus mucocele (15%), benign frontal sinus tumors (9%), and CF with severe CRS (5%) were followed up for an average of 33 months (range Table 22.7 Neo-ostium stenosis by indication Ostium status Closed Indication CF CRS Total 40% 60% 100% 21 4.3% 95.7% 22 20% 80% 100% Mucocele 17 5.6% 94.4% 53 10.2% Osteoma 16.7% 11 9.7% 89.8% 83.3% 102 90.3% CF, cystic fibrosis; CRS, chronic rhinosinusitis; NP, nasal polyps 1.0 100% Inverted papilloma NP Total Partly or completely open 8% 6–90 mo) At the end of follow-up, 90% of patients had a patent neo-ostium, and 88% were either clinically better or completely asymptomatic The only factors associated with restenosis was asthma and the presence of allergy (P ϭ 04) Although the numbers required for comparison did not reach statistical significance, it was noticeable that two out of five (40%) patients with CF had a closed ostium at the end of follow-up (Table 22.7) Thirty-nine patients required some form of endoscopic revision surgery, such as polyp removal, but sometimes also significant neo-osteogenesis (some of which was performed under local anesthetic in an outpatient setting), but eventually underwent frontal sinus obliteration (Fig 22.49) Sixty percent of revision surgeries were 18 100% 0.8 Cum Patients II Rhinitis and Rhinosinusitis 406 0.6 0.4 58 100% 0.2 100% 113 0.0 10 20 30 40 50 60 Time to revision surgery (months) 100.0% Fig 22.49 Kaplan-Meier estimator graph showing time from surgery (Draf III) to revision References Review Questions 100 For a patient with symptoms of chronic rhinosinusitis (CRS), pus in the region of the anterior ethmoids, and opacified anterior ethmoid and frontal sinus who failed medical treatment, the best initial surgical option would be a Frontal sinus obliteration b Draf III approach c Draf IIb (frontal sinus drill-out) d Anterior ethmoidectomy 80 95% Cl 60 40 20 RSOM 31 preop RSOM 31 post RSOM Nasal RSOM Nasal RSOM General RSOM General preop post preop post Fig 22.50 RSOM 31 subscale scores before and after surgery (Draf III) (From Georgalas C, Hansen F, Videler WJ, Fokkens WJ Long-term results of Draf type III (modified endoscopic Lothrop) frontal sinus drainage procedure in 122 patients: a single centre experience Rhinology 2011;49(2):195–201, with permission.) performed during the first years Rhinosinusitis Outcome Measure 31 (RSOM-31) showed significant improvement in both general and nasal symptoms, while on a to 100 visual analogue scale, headache improved significantly, from 57.7 preoperatively to 37.8 postoperatively (P ϭ 02) (Fig 22.50) There were no major complications (CSF or intracranial or orbital injury) during any of the procedures A single, large, growing, symptomatic osteoma in the frontal sinus a Is always an indication for an osteoplastic flap approach b Should be managed medically c Depending on its location, can often be removed via an endoscopic endonasal approach d Should prompt an investigation for Gardner syndrome Regarding the nomenclature of endoscopic frontal sinus approaches, a Draf III is synonymous with modified endoscopic Lothrop and median drainage procedure b Frontal sinus rescue procedure is a type of Draf I approach c The difference between the Draf I and II approach is the use of drilling to enlarge the ostium in the case of the latter d The axillary flap technique is a modification of a Draf II procedure, whereas septal mucosa is used to line the neo-ostium Key Points • The vast majority of frontal sinus pathologies (including inflammatory disease, mucoceles, and benign tumors) can be treated safely and effectively via endoscopic endonasal approaches • A stepwise approach is suggested in cases of frontal sinus pathology A type frontal approach as described by Draf (Draf I, uncinectomy, and anterior ethmoidectomy) should be the first surgical step for frontal sinusitis • The key to effective endonasal frontal sinus surgery is preservation of the mucosa of the frontal recess • Extensive endoscopic endonasal approaches (Draf III/ modified endoscopic Lothrop) are associated with significant mucosal damage; however, the key for their success lies in the size of the opening created • A Draf III procedure can, depending on the size of the nasofrontal beak and the intercanthal distance, provide lateral access at least as far as the midorbit • Long-term results of Draf III approaches show good clinical and endoscopic (patent ostium) success rates; patients 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frontal sinus surgery I: Endonasal frontal sinus drainage in inflammatory diseases of the paranasal sinuses HNO 1995; 43:352–357 65 Weber R, Draf W, Keerl R, Behm K, Schick B Long-term results of endonasal sinus surgery HNO 1996;44:503–509 409 ... Analysis 17 1 Publishing Outcomes 17 1 Key Points 17 1 Review Questions 17 1 References 17 2 10 Facial Pain .17 5 Nick S Jones Summary 17 5 Introduction... 10 5 Clinical Examination and Differential Diagnosis in Rhinology 13 2 Patient-reported Outcome Measures and Measurement Tools in Rhinology 15 4 10 Facial Pain 17 7 11 Olfaction and. .. Conditions 18 7 The Overlap between Conditions 18 8 Comment on Contact Points 18 8 Key Points 19 1 Review Questions 19 2 References 19 2 11 Olfaction and Its Disorders