Treatment of CRS/NP

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
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The Frontal recess is a common
location for polyp recurrence
DL Daniels, et al.
AJNR
2003;24:1618-1626
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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
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Frontal Sinus Surgical Options

Selection of surgical
approach is based
upon:



Patient characteristics
Disease characteristics
Surgeon experience
Frontal Instrumentation
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Frontal Sinus Drainage Pathway Anatomy
Determines the Feasibility of EMLP
DL Daniels, et al. AJNR 2003;24:1618-1626
Unfavorable Frontal Anatomy
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Unfavorable Frontal Anatomy
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Favorable Frontal Anatomy
Favorable Frontal Anatomy
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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
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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
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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
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Draf III
Draf III (Endoscopic Modified
Lothrop Procedure)
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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
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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
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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
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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
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
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
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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
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