III) Endoscopic Modified Lothrop Procedure (EMLP)

The remote location and anatomic complexity of the frontal recess along with its close proximity to the lamina papyracea and anterior skull base, Lothrop state that an intranasal approach for frontal sinus drainage was too dangerous to perform. Instead, described an external approach, which consisted of external ethmoidectomy to enlarge the nasofrontal drainage pathway. This included removal of the frontal sinus floors that were connected through a large nasal septectomy, and bilateral removal of the lacrimal bone and portion of the lamina papyracea that caused medialorbital fat collapse, with later stenosis of the newly created nasofrontal outflow communication ( Kountakis ,2005). Indications of EMLP: Failure of appropriate medical therapy and primary endoscopic frontal sinusotomy in the treatment of persistent chronic frontal sinusitis. Patients with underlying mucosal disease such as hyper- -plastic rhinosinusitis with nasal polyposis,sarcoidosis, Wegener's

granulomatosis, and Samter's triad. Revision cases when scarring or persistent disease in the frontal recess and internal frontal ostium interferes with frontal sinus drainage. Trauma of the frontal sinus (Kountakis and Gross,2003). The total anterior-posterior dimension at the cephalad margin of the frontal recess between the nasal bones at the root of the nose and the anterior skull base not below 1.5 cm.The anterior-posterior thickness of the nasal beak not exceed 1 cm lateralized middle turbinate new bone formation ( Kountakis ,2005).

Fig.6-9:The anterior-posterior dimension of the should be at least 1.5 cm. A Axial sinus CT through the cephalad margin of the frontal recess. B Endoscopic picture 3 weeks after EMLP(Roche et al, 2001). Contraindications of EMLP : Hypoplastic frontal sinus and frontal recess. Lack of experience by the surgeon. Lack of proper instrumentation. Disease in a supra-orbital ethmoid cell not in FS (Roche et al, 2001).

Technique:
It has the same surgical concept of Draf Type III but instead it is performed totally under endoscopic guidance. Surgery is performed with the patient under general anesthesia. If the maxillary, ethmoid and sphenoid sinuses are diseased, these are dealt with before the EMLP (Becker et al , 1995). The use of a CT-based image guidance system is indicated in the entire spectrum of surgical procedures of the frontal sinus. The associated anatomic variations, proximity of neurovascular structures, angled nature of the dissection, and frequent anatomic distortion from prior procedures support the use of image guidance. The triplanar radiographic display provides critical information throughout the procedure including surgical planning and intraoperative identification of the frontal recess,lamina papyracea, and anterior cranial fossa(Metson,2003).