4/11/2013 The endoscopic modified Lothrop procedure in chronic rhinosinusitis with nasal polyposis. Matthew W. Ryan, MD p of Otolaryngology y g gy Head and Neck Surgery g y Dept University of Texas Southwestern Medical Center Dallas, Texas Treatment of CRS/NP CRSNP is prone to recurrence T t Treatment t approach h combines bi surgery and d medical therapy Goals of Surgery include: 1) removal of polyps 2) establishment of sinus drainage 3) exposure to facilitate topical therapy 1 4/11/2013 The Frontal recess is a common location for polyp recurrence DL Daniels, et al. AJNR 2003;24:1618-1626 2 4/11/2013 3 4/11/2013 EMLP provides wide access for topical therapy Frontal Sinus Surgical Options Restore Ventilation/Drainage Endoscopic Draf Family Draf I Draf IIa Draf IIb Draf III (Mod Lothrop) or Obliterate External Trephine Osteoplastic flap 4 4/11/2013 Frontal Sinus Surgical Options Selection of surgical approach is based upon: Patient characteristics Disease characteristics Surgeon experience Frontal Instrumentation 5 4/11/2013 Frontal Sinus Drainage Pathway Anatomy Determines the Feasibility of EMLP DL Daniels, et al. AJNR 2003;24:1618-1626 Unfavorable Frontal Anatomy 6 4/11/2013 Unfavorable Frontal Anatomy 7 4/11/2013 Favorable Frontal Anatomy Favorable Frontal Anatomy 8 4/11/2013 9 4/11/2013 10 4/11/2013 Technique for Endoscopic Modified Lothrop Procedure Perform Draf 1 frontal sinusotomy Perform Draf 2a frontal sinusotomy Perform Draf 2b frontal sinusotomy Perform a superior septectomy under frontal ouflow tract Remove frontal sinus septum Technique for Endoscopic Modified Lothrop Procedure Remove all ethmoid lamellae from frontal recess region Remove anterior attachment of middle turbinate back to first olfactory filum Drill out frontal sinus floor from lamina to septum, anteriorly until you see the anterior table Perform a superior p septectomy p y under frontal outflow tract Remove frontal sinus septum 11 4/11/2013 Draf Frontal Sinus Procedures Weber R. Laryngoscope 2001;111(1):137-146 Draf IIa Technique – complete resection of frontal recess ethmoid cells Weber R. Laryngoscope 2001;111(1):137-146 12 4/11/2013 Draf IIb Technique – removal of ipsilateral floor of frontal Requires Removal of anterior attachment of MT Weber R. Laryngoscope 2001;111(1):137-146 Draf III Farat F. Op Tech in Otolaryngol—Head Neck Surg 2004;15:4-7 13 4/11/2013 Draf III Draf III (Endoscopic Modified Lothrop Procedure) 14 4/11/2013 Does the EMLP reduce systemic steroid requirements in polyp patients? 523 charts reviewed of p patients who underwent endoscopic frontal sinusotomy at UT Southwestern Medical Center from 2006 to 2011. Patients were divided into 2 groups: Endoscopic Modified Lothrop Procedure Any endoscopic frontal sinusotomy (non-Lothrop) Methods Inclusion criteria: - Chronic rhinosinusitis with polyposis - Minimum of 6 month follow up prior to and after surgery (total 1 year minimum) - Endoscopic frontal sinus surgery at UT Southwestern 15 4/11/2013 Methods Exclusion criteria: - Age less than 18 years - Acute or sub-acute sinusitis - Immunodeficiency - Tumors -Sinonasal Si l pathology th l other th th than CRSNP (Wegener’s, (W ’ etc.) Methods Outcome measures: - Courses of oral steroids before surgery and after surgery (annualized) - Endoscopic appearance of frontal outflow tract at last follow-up 16 4/11/2013 Results Number of previous sinus surgeries and Length of followup p g g p EMLP (n=58) Control (n=66) p‐value Number of previous 2.12±2.04 1.36±1.28 0.017 sinus surgeries Length of followup 15.45±13.94 16.29±6.52 0.681 (months) Comorbidities in Patient Groups yp y E M L P (n = 5 8 ) C o n t r o l (n = 6 6 ) p ‐ v a l u e A L L E R G I C R R H I N I T I S : 0 0 . 3 1 4 4 Y E S 4 1 ( 7 1 % ) 4 1 ( 6 2 % ) N O 1 7 ( 2 9 % ) 2 5 ( 3 8 % ) B . A s t h m a 0 . 2 9 6 4 Y E S 2 1 ( 3 6 % ) 3 0 ( 4 5 % ) N O 3 7 ( 6 4 % ) 3 6 ( 5 5 % ) A s p ir i n h y p e r s e n s i ti v i t y 0 . 5 7 4 9 Y E S 6 ( 1 0 % ) 9 ( 1 4 % ) N O 5 2 ( 9 0 % ) 5 7 ( 8 6 % ) A F R S 0 . 0 5 2 1 Y E S 5 5 ( ( 9 % ) 1 4 ( ( 2 1 % ) ) N O 5 3 ( 9 1 % ) 5 2 ( 7 9 % ) 17 4/11/2013 Systemic steroid requirements were reduced in both groups 3 2.5 2 1.5 EMLP 1 control 0.5 0 Pre-OP Post-Op Lothrop: 2.17→ 0.72 courses of systemic steroids per year The EMLP yields superior patency compared to other frontal techniques Endoscopic appearance of frontal Endoscopic appearance of frontal outflow tract at last followup outflowtract at last followup EMLP (n=58) Control (n=66) p‐value NORMAL 55 (95%) 42( 64%) <.0001 PARTIALY OBSTRUCTED 2 ( 3%) 14( 21%) <.0001 COMPLETE OBSTRUCTED 1 ( 2%) 10( 15%) <.0001 p‐value is from Fisher’s exact test 18 4/11/2013 Our patency rate using endoscopic exam is 95% in EMLP comparison to 64% with Draf 1, 1 Draf 2A or 2B. The need for systemic steroid was reduced in both groups after endoscopic frontal surgery: 66% with EMLP EMLP, 58% with endoscopic frontal recess surgery Possible reasons for post-op reduction in systemic steroid requirements All p patients underwent complete p ((or, in revision cases, ‘completion’) endoscopic sinus surgery; thus the patients’ sinus mucosa is more accessible for topical therapy Almost all p patients were treated with budesonide 0.5mg/2mL as a drop or spray long term 19 4/11/2013 Conclusion For patients with previous sinus surgery and recurrent polyps in the frontal recess recess, the Lothrop procedure may be used to create a durable frontonasal connection to facilitate topical medication use. Indications for EMLP in Nasal Polyp Disease Must meet a general indication for ESS Previous adequate frontal sinusotomy Need to create access for topical p intranasal steroid treatment Adequate anatomy 20