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News -> March, 2003 News
Stilianos Kountakis, M.D.
Frontal sinusitis and the extent of surgery performed in the frontal recess once medical management fails, is constantly debated in the literature. Despite significant advancement of endoscopic instrumentation, frontal sinus surgery remains challenging because of the complex anatomy of the frontal recess and the proximity of important structures such as the skull base and lamina papyracea.
Open non-preservation and obliterative surgical techniques were popularized by Montgomery et al in the 1960s.1,2 These techniques became the gold standard since they avoided the complex anatomy of the intranasal frontal recess approach and thus, they minimized complications involving important frontal recess proximal structures. Recent reports however revealed frontal mucoceles on MRI in 9.4% of the patients an average of 2 years after frontal sinus obliteration.3 In addition, in my practice, I have seen patients with frontal mucoceles requiring revision at least 20 years after frontal sinus obliteration.
The endoscopic modified Lothrop procedure preserves mucosa and involves removal of both frontal sinus floors with a septectomy to create a large common nasofrontal pathway. Success of this surgery depends on the patient's anatomy and underlying mucosal disease.4 Poor outcomes can be encountered in patients with small frontal sinuses and sinuses with an anterior-posterior dimension of less than 1.5 cm at the level of the cephalad margin of the frontal recess. In addition, patients with mucosal diseases such as allergic hyperplastic sinusitis, sarcoidosis and Wegener's granulomatosis should be expected to have persistent postoperative mucosal inflammation unless the underlying disease is medically controlled.
The endoscopic modified Lothrop procedure begins with identification of the frontal recess and frontal ostium of one side. Drilling is then initiated in an anterior direction through the anterior insertion of the middle turbinate until the level of the nasal bones is reached. The direction of drilling then changes medially, part of the nasal beak is removed, and the nasal septum is approached. A septectomy is then performed and then drilling continues toward the opposite side removing the remnant of the nasal beak and continues until the opposite lamina papyracea is reached. Care is taken to preserve the mucosa at the posterior margin of the frontal recess to prevent circumferential scarring.
Post-operatively, endoscopic debridements are performed in the office until all debris is removed. In addition, medical management is maximized to ensure mucosal healing.4 We recently published our long-term results with this technique and reviewed the literature.5 The overall success rate was 82% and if patients failed, they seem to do so at approximately 18 months after surgery. If patients treated with the Lothrop procedure ultimately require frontal sinus obliteration, the obliteration can be easily performed using a pericranial flap to reconstruct the missing frontal sinus floors. Thus I recommend that the endoscopic modified Lothrop procedure should be attempted, if possible, prior to considering frontal sinus obliteration.
Case report
A patient who benefited from the modified Lothrop procedure was a male in his late twenties who suffered from nasal obstruction, congestion, pressure, and pain. He had frequent post-nasal drip and thick drainage despite maximal medical therapy. His endoscopic exam revealed extensive nasal polyposis with obstruction and copious nasal secretions.
Initially, he underwent functional endoscopic sinus surgery with nasal polypectomy. Despite a good response to the surgery with control of disease in his maxillary and ethmoid sinuses, he had persistent mucosal disease in his frontal sinuses with polypoid tissue in his frontal recesses. These findings are demonstrated in the CT scan image.
The patient then underwent endoscopic modified Lothrop surgery to address this frontal sinus disease. Mucocilliary clearance was preserved by minimizing injury to the mucosa of the lateral frontal recess. Circumferential scarring was avoided by preserving the mucosa of the posterior wall of the frontal sinus at the level of the frontal ostium. The endoscopic photograph illustrates the paired ostia leading into the right and left frontal sinuses in this patient six months after surgery.
References
- Hardy JM, Montgomery WW. Osteoplastic frontal sinusotomy: an analysis of 250 operations. Ann Otol Rhinol Laryngol 1976, 85:253-232.
- Gooddale RL, Montgomery WW. Anterior osteoplastic frontal sinus operation. Five years experience. Ann Otol Rhinol Laryngol 1961, 70:860-880.
- Weber R, Draf W, Kratzsch B, et al. Modern concepts of frontal sinus surgery. Laryngoscope 2001, 111:137-146.
- Schlosser RJ, Kountakis SE, Gross CW. Postoperative management of endoscopic sinus surgery. Curr Opin Otolaryngol Head Neck Surg 2002, 10:36-39.
- Kountakis SE, Gross CW. Lonf term results of the Lothrop operation. Curr Opin Otolaryngol Head Neck Surg 2003, 11:37-40.
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