Abstract
Aim
The most prevalent complication of Draf III surgery is recurrence of frontal recess stenosis. The aim of this study is to introduce a method to prevent closure of the recess.
Type of the Study and Setting
This is a retrospective study that was conducted in Ear, Nose and Throat Referral Center, Amir’Alam Hospital, Tehran.
Methods and Materials
We introduced a new technique for reconstructing frontal recess mucosa and prevention of restenosis following Draf III operation; we covered the posterior wall of the common recess with a vascular mucosal flap from nasal septum.
Results
During a 6-month period we used septal flaps based on anterior ethmoidal artery on four patients who had undergone endoscopic Draf III operation. During a 3-month follow-up period, frontal recess stenosis did recur in any of the patients.
Conclusion
Applying a precise and astute surgical method along with reconstructing common recess mucosa will improve the outcomes of endoscopic frontal sinus drill-out. We strongly recommend application of septal mucosal flap based on the anterior ethmoidal artery during Draf III operation to decrease the incidence of scar and recurrence of common frontal recess stenosis.
1
Introduction
Performing endoscopic frontal sinus operations in patients with fibrosis and massive ossifications in frontal sinus area is difficult and challenging. Generally the most complicated part of endoscopic nasal operations is approaching the frontal sinus. The obscure location of the recess, along with its anatomical variations and perilous adjacent structures could dissuade the surgeon from performing a comprehensive operation on this area which might necessitate further revisions and inevitably development of major complications . Since the year 1991 when Professor Draf introduced approaches of endoscopic operations on frontal sinus there has been several modifications in this field . Draf III is the latest and the most comprehensive approach in patients with ossified frontal sinus. To form the common recess by this method, frontal recess floor is completely opened from one lamina papyracea to the other one and even the upper part of the nasal septum is resected. Incidence of recess restenosis has been reported to be 4% to 33% in different studies . Development of recess restenosis does not necessarily impose secondary surgery. A need for a secondary surgery in the study of Shirazi and colleagues in the year 2007 on 97 patients during an 8-year follow-up period was 23% but others have reported lower figures.
2
Methods and materials
During a 6-month period we performed endoscopic Draf III operation and used septal flap based on the anterior ethmoidal artery to reconstruct the mucosa of the posterior part of common frontal duct in patients with extensive adhesions in frontal recess or bony stenosis of frontal recess due to refractory sinusitis, mucocele or other causes of chronic inflammation or trauma. We had four patients with aforementioned conditions during that period which underwent mucosal reconstruction by the flap.
2.1
Surgical technique
Under general anesthesia we performed stereotactic computerized navigation-guided endoscopic nasal operation. We used local decongestion of nasal cavity by application of phenylephrine-soaked mesh as well as injection of 1:100,000 epinephrine to mucosa adjacent to the location of attachment of the middle cornea and cornea itself, nasal septum and anterior to uncinate process. Firstly according to the patients’ pathology, routine anterior–posterior operation is performed. After elimination of the pathology in other sinuses and before Draf III approach to frontal recess, a septal flap is formed based on the anterior ethmoidal artery. At the side which the nasal septum is more concave the flap with an anterior–posterior base which is based on the possible location of anterior ethmoidal artery entrance to cribriform plate is made. The part of the nasal septum between recesses and anterior to middle corneas of both sides is resected and then parts of frontal recess floor between two recesses are resected by drill, microdebrider and punch. Drilling is performed on the frontal beak as possible. After that the postero-inferior part of the posterior wall of common recess is thinned to form “frontal T” (junction of the perpendicular plate of ethmoid bone and posterior margin of frontal sinus floor). Length of bare area of the posterior part of common recess is estimated with frontal curette and by adding 25% increment to that, septal flap length is revised. During this phase of the surgery, the location of the anterior ethmoidal artery is visible so the base of the flap is narrowed ( Fig. 1 ). After washing, the septal flap is pulled on the posterior drilled area ( Fig. 2 ) and is packed with gel foam. The gel foam is supported by nasal mesh and the operation ends. Patients were discharged 2 days after the surgery with prescription of Co-Amoxiclav (amoxicillin/clavulanic acid) and the nasal mesh was removed 4 days later. Nasal cavity rinsing was started on the fourth day. Two to 3 weeks after the surgery, endoscopy was performed to remove the crusts and corticosteroid spray was prescribed. Figs. 1 and 2 depict Draf III operation on a patient with CSF leakage in the upper part of the right frontal recess and severe bilateral frontal recess stenosis which was reconstructed with septal flap based on the anterior ethmoidal artery ( Figs. 3, 4, and 5 ).
2
Methods and materials
During a 6-month period we performed endoscopic Draf III operation and used septal flap based on the anterior ethmoidal artery to reconstruct the mucosa of the posterior part of common frontal duct in patients with extensive adhesions in frontal recess or bony stenosis of frontal recess due to refractory sinusitis, mucocele or other causes of chronic inflammation or trauma. We had four patients with aforementioned conditions during that period which underwent mucosal reconstruction by the flap.
2.1
Surgical technique
Under general anesthesia we performed stereotactic computerized navigation-guided endoscopic nasal operation. We used local decongestion of nasal cavity by application of phenylephrine-soaked mesh as well as injection of 1:100,000 epinephrine to mucosa adjacent to the location of attachment of the middle cornea and cornea itself, nasal septum and anterior to uncinate process. Firstly according to the patients’ pathology, routine anterior–posterior operation is performed. After elimination of the pathology in other sinuses and before Draf III approach to frontal recess, a septal flap is formed based on the anterior ethmoidal artery. At the side which the nasal septum is more concave the flap with an anterior–posterior base which is based on the possible location of anterior ethmoidal artery entrance to cribriform plate is made. The part of the nasal septum between recesses and anterior to middle corneas of both sides is resected and then parts of frontal recess floor between two recesses are resected by drill, microdebrider and punch. Drilling is performed on the frontal beak as possible. After that the postero-inferior part of the posterior wall of common recess is thinned to form “frontal T” (junction of the perpendicular plate of ethmoid bone and posterior margin of frontal sinus floor). Length of bare area of the posterior part of common recess is estimated with frontal curette and by adding 25% increment to that, septal flap length is revised. During this phase of the surgery, the location of the anterior ethmoidal artery is visible so the base of the flap is narrowed ( Fig. 1 ). After washing, the septal flap is pulled on the posterior drilled area ( Fig. 2 ) and is packed with gel foam. The gel foam is supported by nasal mesh and the operation ends. Patients were discharged 2 days after the surgery with prescription of Co-Amoxiclav (amoxicillin/clavulanic acid) and the nasal mesh was removed 4 days later. Nasal cavity rinsing was started on the fourth day. Two to 3 weeks after the surgery, endoscopy was performed to remove the crusts and corticosteroid spray was prescribed. Figs. 1 and 2 depict Draf III operation on a patient with CSF leakage in the upper part of the right frontal recess and severe bilateral frontal recess stenosis which was reconstructed with septal flap based on the anterior ethmoidal artery ( Figs. 3, 4, and 5 ).
