Frontal Sinusotomy (Draf I, II, III)

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Frontal Sinusotomy (Draf I, II, III)

Surgical Procedures
Rhinosinusitis
Rhinology
Author Credentials 

Garret W. Choby, MD
Clinical Instructor
Department of Otolaryngology – Head and Neck Surgery
Division of Rhinology and Endoscopic Skull Base Surgery
Stanford University
801 Welch Rd
2nd floor M/C 5739
Stanford, CA 94305-5739
chobygw@stanford.edu

 

Module Summary

Frontal sinus surgery for refractory disease is one of the most challenging portions of endoscopic sinus surgery, due to its challenging anatomy and close proximity to brain and orbit. The Draf frontal sinusotomy procedures have been described as a stepwise approach to address frontal sinus disease with increasing complexity. In order to perform these surgeries safely, a thorough anatomic understanding is imperative to understand this complex region.

Module Learning Objectives 
  1. Explain the complexity of frontal sinus anatomy. 
  2. Discuss the rationale underlying surgical approaches to the frontal sinus. 
  3. Develop a stepwise process for approaching frontal sinus surgery including the Draf I, Draf II and Draf III frontal sinusotomy procedures. 
  4. Analyze the advantages and disadvantages of specific techniques for frontal sinus surgery. 
  5. Recognize common errors in surgical technique. 
  6. Describe the complications of frontal sinus surgery. 

Embryology

Learning Objectives 

Be familiar with the embryologic development of the frontal sinus.

  1. Sequential development of the paranasal sinuses
    1. Maxillary
    2. Ethmoid
    3. Sphenoid
    4. Frontal
  2. Frontal sinus development, along with corresponding ethmoid sinus pneumatization, is variable and may impact surgical approaches.
  3. Frontal sinus development is usually not complete until late adolescence.
References 
  1. Duque CS and Casiano RR. Surgical anatomy and embryology of the frontal sinus. In: Kountakis S, Senior B, Draf W, editors. The frontal sinus. Heidelberg, Germany: Springer; 2005:21-32.
  2. Halewyck S, Louryan S, Van Der Veken P, Gordts F. Craniofacial embryology and postnatal development of relevant parts of the upper respiratory system. B-ENT. 2012;8 Suppl 19:5-11.

Anatomy

Learning Objectives 

Understand the anatomic complexities of the frontal sinus: 

  1. Be familiar with the pneumatization pattern of the ethmoid air cells which affect frontal sinus drainage
    1. Agger nasi
    2. Ethmoid bulla
    3. Suprabullar cells
    4. Frontal intersinus septal cells
    5. Uncinate process
  2. The pneumatization of the frontal sinus is frequently asymmetric
    1. Degree of pneumatization
    2. Unilateral agenesis or hypoplastic development
    3. Asymmetry of corresponding anterior ethmoid cells between sides
  3. The classic boundaries of the frontal outflow tract are:
    1. Agger nasi
    2. Ethmoid bulla
    3. Lamina papyracea
    4. Middle turbinate
  4. Understand the relationship of the frontal sinus and middle turbinate to the cribriform plate
  5. Anatomical classification and description of pneumatization patterns
    1. International frontal sinus anatomy and classification (IFAC)
References 
  1. Wormald PJ. The agger nasi cell: the key to understanding the anatomy of the frontal recess. Otolaryngol Head Neck Surg. 2003;129(5):497-507.
  2. Duque CS and Casiano RR. Surgical anatomy and embryology of the frontal sinus. In: Kountakis S, Senior B, Draf W, editors. The frontal sinus. Heidelberg, Germany: Springer; 2005:21-32.
  3. Dalgorf DM, Harvey RJ. Chapter 1: Sinonasal anatomy and function. Am J Rhinol Allergy. 2013;27(Suppl 1):S3-6.
  4. Wormald PJ, Hosoeman W, Callejas C, et al. The international frontal sinus anatomy classification (IFAC) and classification of the extent of endoscopic frontal sinus surgery (EFSS). Int Forum Allergy Rhinol. 2016;6(7):677-96.

Pathogenesis

Learning Objectives 

Know the pathogenesis of chronic frontal sinusitis, as well as alternative indications for frontal sinus surgery: 

  1. Acute sinusitis
    1. Prevention of secondary complications
  2. Chronic rhinosinusitis (CRS)
    1. Criteria for diagnosis
    2. Role of medical therapy
    3. Predisposing conditions
      1. Anatomic variables
        • Pneumatization pattern
        • Osteoma
        • Mucocele
      2. Systemic disease
        • Immunodeficiency
        • Cystic fibrosis
    4. CRS without nasal polyposis (CRSsNP) vs CRS with nasal polyposis (CRSwNP)
  3. Alternative indications for frontal sinus surgery
    1. Neoplasm
      1. Benign
        • Inverted papilloma
        • Osteoma
      2. Malignant
        • Esthesioneuroblastoma
        • Squamous cell carcinoma
        • Sarcoma
        • Minor salivary gland malignancies
    2. CSF leak
    3. Encephalocele
    4. Trauma
References 
  1. Orlandi RR, Kingdom TT, Hwang PH, et al. International consensus statement on allergy and rhinology: rhinosinusitis. Int Forum Allergy Rhinol. 2016;Suppl 1:S22-209.
  2. Scangas GA, Gudis DA, Kennedy DW. The natural history and clinical characteristics of paranasal sinus Mucocele: a clinical review. Int Forum Allergy Rhinol. 2013;3(9):712-7.
  3. Guy WM, Brissett AE. Contemporary management of traumatic fractures of the frontal sinus. Otolaryngol Clin North Am. 2013;46(5):733-48.
  4. Lund VJ, Howard DJ, Wei MI, et al. Craniofacial resection for tumours of the nasal cavity and paranasal sinuses – a 17-year experience. Head Neck. 20:97-105.

Basic Science

Learning Objectives 

Understand the basic physiologic principles underlying the pathogenesis of CRS:

  1. Microbiology and the microbiome 
  2. Immune mechanisms
  3. Local development of chronic inflammation
  4. Mucosal epithelial barrier
  5. Mucociliary clearance
  6. Unified airway theory
References 
  1. Hulse KE. Immune mechanisms of chronic rhinosinusitis. Curr Allerlgy Asthma Rep. 2016;16(1):1.
  2. Orlandi RR, Kingdom TT, Hwang PH, et al. International consensus statement on allergy and rhinology: rhinosinusitis. Int Forum Allergy Rhinol. 2016;Suppl 1:S22-209.
  3. Demirdag YY, Ramadan HH. Direct measurement of upper airway inflammation in children with chronic rhinosinusitis: implications for asthma. Curr Opin Allergy Clin Immunol. 2016;16(1):16-23.

Incidence

Learning Objectives 

Understand the frequency and healthcare impact of CRS

  1. True incidence of CRS remains unknown
  2. CRS has numerous direct and indirect costs to healthcare
    1. Diminished productivity
    2. Work days missed
    3. Reduced cognition and sleep quality
    4. Chronic fatigue
References 
  1. DeConde AS, Soler ZM. Chronic rhinosinusitis: epidemiology and burden of disease. Am J Rhinol Allergy. 2016;30(2):134-9.
  2. Rudmik L. Chronic rhinosinusitis: an under-researched epidemic. J Otolaryngol Head Neck Surg. 2015;5(44):11.

Genetics

Learning Objectives 

Understand that the role of genetics and immune dysregulation is becoming increasingly well understood in CRS:

  1. Defects in adaptive and innate immunity may play a role in the development of CRS
  2. Potential genetic links for the predisposition to refractory CRS are increasingly being studied
References 
  1. Halderman A, Lane AP. Genetic and immune dysregulation in chronic rhinosinusitis. Otolaryngol Clin North Am. 2017;50(1):13-28.

Patient Evaluation

Learning Objectives 

For each patient, recognize the symptoms, disease history, medical therapy and previous surgical therapy:

  1. Overall health
    1. Presence of underlying pulmonary disease
      1. Asthma
      2. Cystic fibrosis
      3. Bronchiectasis
    2. Other comorbidities
      1. Allergies
      2. Autoimmune disease
      3. Immunocompromised patients
      4. Diseases affecting ciliary function
      5. Anticoagulation status
  2. Validated symptom scores
    1. SNOT-22
  3. Disease history
    1. Duration of symptoms
    2. Type of symptoms
    3. Previous and current medication history
      1. Symptom response to individual medications
  4. Previous surgery
  5. Imaging
  6. Alternative testing
    1. Olfaction evaluation
    2. Allergy testing
References 
  1. McCoul ED, Tabaee A. A practical approach to refractory chronic rhinosinusitis. Otolalryngol Clin North Am. 2017;50(1):183-98.
  2. Desrosiers M, Evans GA, Keith PK, et al. Canadien clinical practice guidelines for acute and chronic rhinosinusitis. J Otolaryngol Head Neck Surg. 2011;Suppl 2:S99-193.
  3. Orlandi RR, Kingdom TT, Hwang PH, et al. International consensus statement on allergy and rhinology: rhinosinusitis. Int Forum Allergy Rhinol. 2016;Suppl 1:S22-209.

Imaging

Learning Objectives 

Understand the critical role that imaging plays in understanding the distribution of disease and for surgical planning:

  1. CT scan
    1. Non-contrast CT scan is the only necessary imaging in most cases of frontal sinus surgery for CRS
      1. Should include axial, sagittal and coronal images
      2. Fine cuts preferred (2mm or less)
    2. Vitally important to evaluate extent of disease
    3. Helps to identify “danger zones” of surgery
      1. Slope of skull base
      2. Integrity of orbit
      3. Location of anterior ethmoid artery
      4. Relationship of posterior table to cribriform plate
  2. MRI
    1. Useful in cases where surgery is planned for neoplasm
    2. Helps to differentiate soft tissue vs. intracranial contents vs. inspissated secretions
      1. Encephalocele
      2. CSF leak
References 
  1. Figueroa RE, Sullivan J. Radiologic anatomy of the frontal sinus. In: Kountakis S, Senior B, Draf W, editors. The frontal sinus. Heidelberg, Germany: Springer;2005.21-32.
  2. Rao VM, Sharma D, Madan A. Imaging of frontal sinus disease: concepts, interpretation and technology. Otolaryngol Clin North Am. 2001;34(1):23-39.

Pathology

Learning Objectives 

Recognize the importance of pathology in various disease processes of the frontal sinus:

  1. CRS
    1. CRSsNP vs. CRSwNP
      1. CRSwNP
        • Eosinophil vs. neutrophil predominance
    2. Allergic fungal sinusitis
      1. Charcot-Leyden crystals
      2. Allergic mucin
    3. Autoimmune disease
      1. Granulomatosis with polyangitis
      2. Sarcoidosis
  2. Neoplasm
    1. Benign
      1. Inverted papilloma
      2. Osteoma
      3. Hamartoma
    2. Malignant
      1. Squamous cell carcinoma
      2. Lymphoma
      3. Mucosal melanoma
      4. Sinonasal undifferentiated carcinoma
      5. Salivary gland origin tumors
        • Adenocarcinoma
        • Adenoid cystic carcinoma
      6. Sarcoma
      7. Hemangiopericytoma
      8. Plasmacytoma
      9. Metastatic disease
        • Prostate
        • Thyroid
        • Breast
        • Lung
        • Renal cell carcinoma
References 
  1. Montone KT. Pathology of fungal rhinosinusitis: a review. Head Neck Pathol. 2016;10(1):40-6.
  2. Vazquez A, Baredes S, Setzen M, Eloy JA. Overview of frontal sinus pathology and management. Otolaryngol Clinc North Am. 2016;49(4):899-910.

Medical Therapies

Learning Objectives 

Understand the importance of appropriate medical management in CRS: 

  1. Antiinflammatory therapy
    1. Topical corticosteroids
    2. Systemic corticosteroids
  2. Saline irrigations
  3. Antihistamine therapy
    1. Topical antihistamines
    2. Systemic antihistamines
  4. Mucolytics
  5. Antimicrobial therapy
    1. Culture directed antibiotics
    2. Topical antibiotics
    3. Macrolide therapy
      1. Antibacterial and anti-inflammatory effects
  6. Other
    1. Aspirin exacerbated respiratory disease
      1. Aspirin desensitization
      2. Anti-leukotriene agents
    2. Cystic fibrosis
      1. Hypertonic saline
References 
  1. Chandra RK. Medical management of chronic rhinosinusitis. In: Thaler ER, Kennedy DW, eds. Rhinosinusitis: a guide for diagnosis and management. New York, NY: Springer; 2008:75:92.
  2. McCoul ED, Tabaee A. A practical approach to refractory chronic rhinosinusitis. Otolalryngol Clin North Am. 2017;50(1):183-98.

Pharmacology

Learning Objectives 

Understand pharmacologic implications for commonly used medications to treat CRS:

  1. Corticosteroids (topical and systemic)
    1. Dosing
    2. Side effects
    3. Long-term implications
  2. Antimicrobial therapy
    1. Antibiotics
      1. Side effects
      2. Dosing
      3. Medication interactions
      4. Other considerations
        • Macrolide therapy: QT prolongation
    2. Antifungals
      1. Liver function testing
  3. Other therapies
    1. Antihistamines
    2. Leukotriene receptor antagonists
    3. 5-Lipooxygenase inhibitors
References 
  1. Simon RA, Dazy KM, Waldram JD. Aspirin-exacerbated respiratory disease: characteristics and management strategies. Expert Rev Clin Immunol. 2015;11(7):805-17.
  2. Chandra RK. Medical management of chronic rhinosinusitis. In: Thaler ER and Kennedy DW, Editors. Rhinosinusitis: a guide for diagnosis and management. New York, NY: Springer; 2008:75-92.

Surgical Therapies

Learning Objectives 

Understand the stepwise progression of surgical interventions that are available: 

  1. Draf I
    1. Complete anterior ethmoidectomy without actually addressing the frontal outflow tract
    2. Typically reserved for cases when ethmoid disease is felt to secondarily cause frontal sinus disease
  2. Draf II
    1. Draf IIa
      1. Removal of ethmoid cells and opening the frontal sinus outflow tract between the middle turbinate and the lamina papyracea
        • Includes “uncapping the egg” of the agger nasi
    2. Draf IIb
      1. Removal of the frontal sinus floor between the nasal septum and lamina papyraea
        • Involves removal of anterior portion of the middle turbinate
  3. Draf III
    1. Includes removal of the upper portion of the nasal septum and lower portion of the frontal sinus septum, in addition to bilateral Draf IIb’s
    2. Alternatively called “endoscopic modified Lothrop procedure” or “frontal sinus drillout”
    3. Often used as an alternative to traditional external approaches or to reach the superior lateral portion of the frontal sinus
References 
  1. Chiu AG, Kennedy DW. Revision endoscopic frontal sinus surgery. In: Kountakis S, Senior B, Draf W, editors. The frontal sinus. Heidelberg, Germany: Springer; 2005.191:199.
  2. Eloy JA, Marchiano E, Vazquez A. Extended endoscopic and open sinus surgery for refractory chronic rhinosinusitis. Otolaryngol Clin North Am. 2017 Feb;50(1):165-82.
  3. Turner JH, Vaezeafshar R, Hwang PH. Indications and outcomes of Draf IIb frontal sinus surgery. Am J Rhinol Allergy. 2016;30(1):70-3.
  4. Patel ZM, Thamboo A, Rudmik L, Nayak JV, Smith TL, Hwang PH. Surgical therapy vs continued medical therapy for medically refractory chronic rhinosinusitis: a systematic review and meta-analysis. Int Forum Allergy Rhinol. 2017 Feb;7(2):119-127.
  5. http://www.american-rhinologic.org/videos (Surgical dissection videos on the ARS website, for members. ARS membership is FREE for residents.)

Case Studies

  1. 56yoM with classic CRS symptoms for 2 years, including right sided forehead pressure when flying. He has undergone previous appropriate medical therapy. No previous sinus surgery. Endoscopy is normal. CT scan demonstrates bilateral anterior ethmoid disease and mild right sided frontal mucosal thickening
    1. What are your treatment options?
    2. If you recommend surgery, what surgical approaches to the frontal sinus are appropriate?
  2. 35yoF with history of aspirin-exacerbated respiratory disease who has undergone two previous sinus surgeries. She has previously undergone aspirin desensitization therapy, but now has symptomatic left frontal pressure and headaches. CT scan now demonstrates a left sided supero-lateral frontal sinus mucocele with posterior table erosion.
    1. What are your options for management?
    2. What are the pro’s and con’s of your proposed procedures?

Complications

Learning Objectives 

Understand the various complications that can occur with these surgical techniques and principles of management of these complications: 

  1. Bleeding
    1. Anterior ethmoid artery injury
  2. Orbital complications
  3. CSF leak
  4. Unfavorable healing/scarring
    1. Mucocele formation
References 
  1. Eloy JA, Svider PF, Setzen M. Preventing and managing complications in frontal sinus surgery. Otolaryngol Clin North Am. 2016 Aug;49(4):951-64.
  2. Graham SM. Complications in frontal sinus surgery. In: Kountakis S, Senior B, Draf W, editors. The frontal sinus. Heidelberg, Germany: Springer; 2005. p 267-73.
  3. Thamboo A, Patel ZM. Office Procedures in Refractory Chronic Rhinosinusitis. Otolaryngol Clin North Am. 2017 Feb;50(1):113-128.

Review

Review Questions 
  1. What are the classically described boundaries of the frontal sinus outflow tract?
  2. Describe frontal sinus procedures (Draf I, II and III) and a potential indication for each.
  3. What advantage in frontal sinus access does the Draf III hold over the other Draf procedures?
  4. What is the role of imaging in various pathologies affecting the frontal sinus?
  5. What are the potential complications associated with frontal sinus surgery?
Resources 

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