Laterally located mucocele in a hyperpneumatized frontal sinus causing exophthalmos: A total endoscopic approach

Frontal sinus mucoceles are mucous secretory lesions within the sinus, presenting a slow – growing pattern, mostly behaving like a space-occupying mass with subtle symptoms until a bone erosion of the surrounding structures takes place. Intracranial and intraorbital expansion are regarded as the most considerable complications, demanding adequate surgical management in order to avoid recurrence. Endoscopic drainage is thought to be the current treatment of choice, with external approaches or combined approaches being considered for more severe cases where anatomy and disease extension restricts adequate endoscopic visualization of the lesion. We present a case of a 31-year-old female patient with a left frontal sinus mucocele, demonstrating with an unusual lateral frontal expansion and orbit invasion, causing exophthalmos and ophthalmoplegia. She was adequately managed by a Draf III endoscopic procedure achieving wide marsupialization and enough drainage of the mucocele. No sign of recurrence was noticed during the last 6-month follow-up. Giant mucoceles of the frontal sinus are a rare pathology. To our knowledge, endoscopic endonasal approach is a treatment modality that can provide an adequate drainage pathway, thus resulting in optimal clinical outcomes, compared with external approaches. Keywords: Frontal sinus; Mucocele; Exophalmos; Pneumosinus dilatans; Pneumocele.

Safety and Efficacy of the Draf IIb Procedure: A Systematic Review

Objectives To systematically review the literature to evaluate the indications, safety, and efficacy of the Draf IIb procedure and to evaluate the added advantages of technical factors such as stents and flaps. Data Sources Articles published until July 2019 on Medline and Cochrane databases. Review Methods After a systematic review based on the 2018 PRISMA guidelines was conducted, 26 of 1533 articles were included and reviewed for indications of Draf IIb; surgical technique; use of flaps, stents, grafts, or mitomycin; complications during and after surgery; and success or recurrence rate. Results The main indication for Draf IIb was chronic frontal rhinosinusitis (61.82%). The postoperative patency rate was 87.85%. When flaps/grafts were applied, the rate was 93.5%, but their added value was not statistically significant. Stents could be an alternative for revision surgery. Treating frontal pathologies other than chronic rhinosinusitis was also satisfying. Safety was comparable to Draf III: no perioperative complications were reported, only a few postoperative ones (eyelid ecchymosis and periorbital cellulitis in 0.2% of the cases, hyposmia in 1.55%). Conclusion When properly indicated, Draf IIb frontal drilling is a safe and highly effective surgical technique for frontal pathology treatment, with efficiency and safety comparable to the Draf III, making it a valid option when a bilateral approach is not needed. More studies are required to confirm the added values of flaps, grafts, and stents.

Treatment of Frontal Sinus Osteomyelitis in the Age of Endoscopy

Objective Frontal sinus osteomyelitis is a severe complication which can result from chronic rhinosinusitis, trauma, or as a complication of reconstruction or obliteration of the frontal sinus. The objective of the current study is to evaluate the contemporary management of frontal sinus osteomyelitis in light of recent advancements in endoscopic surgical techniques. Methods Review of a prospectively collected database of patients with frontal sinus pathology was performed from 2008–2020. Data from individuals with frontal sinus osteomyelitis was collected including demographics, etiology, surgical technique, adjunctive medical treatments, complications, and clinical follow up. Results Sixteen patients (average age 48.3, range 8–84) were included in the study. An open approach was utilized in 6 patients (2 osteoplastic flaps, 3 Reidel procedures, 1 cranialization). Seven patients underwent completely endoscopic approaches (3 Draf IIB, 4 Draf III), while 3 individuals had combined procedures (Lynch with Draf III, osteoplastic flap + Draf III, fistula excision + Draf IIb). All patients received 6 weeks of antibiotics. Average clinical follow up was 24.4 months with no patients requiring revision procedures. Conclusion Endoscopic, endoscopic-assisted, and open approaches were utilized successfully in the current series of patients with osteomyelitis of the anterior table of the frontal sinus. While the progression of endoscopic techniques allows an additional surgical treatment option, it is important to select patients appropriately as open procedures continue to have an important role in the treatment algorithm.

Frontal sinus inverted papilloma managed with Draf III

Inverted papilloma (IP) is a rare benign tumor that originates from nasal and paranasal sinus mucosa. Although it is considered a benign lesion, it is locally aggressive and has risk between 7 and 15% for malignant transformation. The management of frontal sinus (FS) IP is still challenging due to its rarity and local invasiveness. We report a rare case of IP originating from FS, and to review the literature to delineate the possible surgical strategy. A 52-year-old male presented with long-standing history of bilateral nasal obstruction and left eye proptosis. Sinus navigation computed tomography showed soft tissue density occupying frontal, ethmoid, right sphenoid sinuses with extension to nasal cavities, postnasal space and left orbital space plus erosive bony changes. Transnasal endoscopic biopsy suggested IP the lesion was completely resected by Draf III procedure. After 1 month of the surgery, the patient is doing well with no complaints.

Modified Lothrop (Draf III) procedure for the treatment of a recurrent orbitofrontal cholesterol granuloma: A case report

Orbitofrontal cholesterol granuloma is a rare occurrence. Here, we present a case involving a 64-year-old man with a recurrent orbitofrontal cholesterol granuloma treated by the Modified Lothrop (Draf III) procedure. The patient, who had a history of trauma and previous sinus surgery, presented with chief complaints of nasal congestion, olfactory impairment, and diplopia. We suspected chronic sinusitis; computed tomography showed a soft-tissue shadow extending from the bilateral frontal sinuses to the ethmoid sinuses, with a cyst in the right orbitofrontal region. We performed endoscopic surgery for removal of the mass, and histopathological analysis of the resected specimen confirmed a diagnosis of cholesterol granuloma. The lesion recurred 2 months later, and we performed revision surgery using the Modified Lothrop or Draf III procedure. The patient showed no relapse at the 5-year follow-up. These findings suggest that the Draf III procedure is an effective surgical treatment for cholesterol granulomas.