Biomedical subjects
Publications and source records attributed to W E Gross.
The use of powered soft-tissue shavers in standard functional endoscopic sinus surgery offers significant advantages over the use of standard instrumentation. Increased safety, improved results, decreased blood loss, and potential cost savings are significant advances offered by the use of this instrumentation.
Persistent frontal sinusitis traditionally has been treated with external procedures such as osteoplastic frontal sinus obliteration or the Lynch procedure. Currently, functional endoscopic sinus surgery can be used in most cases to remove disease from the frontal recess, the most frequent site of frontal sinus obstruction, thereby relieving the sinusitis. In some cases, however, frontal recess exploration has failed to relieve the obstruction of the frontal sinus, necessitating an osteoplastic frontal sinus obliteration. We present our experience with a transnasal modification of the Lothrop procedure. The Lothrop procedure, first described in 1914, uses a combined external and transnasal approach to resect the median frontal sinus floor, superior nasal septum, and intersinus septum to drain the frontal sinus. This procedure was largely abandoned and forgotten by modern otolaryngologists. However, with the advent of the computed tomography scan and endoscopic techniques, we sought to reassess the basic tenant of the Lothrop procedure (i.e., wide median frontal sinus drainage). An anatomic study of cadaver heads was performed to quantify the surprisingly large potential opening and to better understand the pertinent anatomy. This procedure was performed on 10 patients, with no resulting complications and no failure to maintain patency of the frontal sinus drainage throughout the follow-up period (mean, 7 months). We are encouraged by our initial favorable results and intend to use the procedure in the future as needs arise.
The Lothrop procedure resects the medial frontal sinus floor, superior nasal septum, and intersinus septum to create a large frontonasal communication. However, the external approach often allowed medial collapse of soft tissue and stenosis of the nasofrontal communication. We describe a modified transnasal endoscopic Lothrop procedure in which drills are used for cases in which frontal recess exploration fails to relieve obstruction of the frontal sinus. The lateral bony walls are preserved, and medial collapse does not occur. The mucosa of the posterior table and posterior nasofrontal duct is preserved, and a single common frontal opening is created. We have found this approach to be safe and reliable. Fourteen patients have undergone this procedure without complication, achieving resolution or improvement of their symptoms and maintaining wide patency of the frontonasal opening. We recognize that long-term follow-up will be required but remain encouraged with our favorable results to date.
In summary, functional endoscopic sinus surgery has become a widespread tool for the treatment of chronic sinus conditions. Within the office, under local anesthesia, aggressive post-operative care can greatly diminish the need to return to the operating room for revision endoscopic sinus surgery. Under local anesthesia, most limited procedures performed in the operating room can also be performed in the office. Effective post-operative care is critical to obtain the best possible results. Any and all means necessary must be taken to assure expert, detailed, and timely post-operative care.
Current surgical treatment of the frontal sinus disease include external approaches to obliterate or ablate the sinus and both external and transnasal methods to restore drainage into the nasal cavity. The original Lothrop procedure resects the medial frontal sinus floor, superior nasal septum, and intersinus septum, creating a large frontonasal communication. However, as described, the external approach used in this procedure often allowed medial collapse of soft tissue and the stenosis of the nasofrontal communication. This report further relates our experience with the modified transnasal endoscopic Lothrop procedure using suction drills for cases in which frontal recess exploration had failed to relieve obstruction of the frontal sinus. We present an update of the University of Virginia experience in performing the modified Lothrop procedure in 20 patients from 10/93 to 4/95. Our findings over the follow-up period (average 12 months) have verified that this procedure is effective, with a 95% patency rate for the surgically enlarged frontal sinus ostium. When compared to osteoplastic flap with fat obliteration, the modified transnasal Lothrop procedure offers the advantages of a less invasive procedure with a shorter and usually no hospitalization, less morbidity, and the increased ability to evaluate post-operatively for recurrent disease. A patient charge analysis was also performed comparing patients undergoing frontal sinus obliteration during the same time period, revealing an additional benefit of decreased patient costs for the modified transnasal Lothrop procedure. None of our patients experienced complications, and all showed significant improvement, if not complete resolution of their symptoms. Although this procedure has produced favorable results, it should be noted that this procedure is technically demanding and will require further long term follow-up to verify its efficacy and proper role in the spectrum of surgical approaches for the treatment of chronic sinusitis.