surgical technique

STRAIGHTSHOT MAGNUM Handpiece & RAD 55 Curved Sinus Bur from Xomed

Modified Transnasal Endoscopic Lothrop Procedure: Frontal Drillout

presented by Charles W. Gross, MD, FACS; William E. Gross, MD; & Daniel G. Becker, MD

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Modified Transnasal Endoscopic Lothrop Procedure

Philosophy
Surgical technique presented by Charles W. Gross, MD, FACS; William E. Gross, MD; & Daniel G. Becker, MD The Lothrop procedure resects the medial frontal sinus floor, superior nasal septum, and intersinus septum, creating a large frontonasal communication which is completely supported by bone. However, the external approach, which is not surrounded by bone, often allows medial collapse of soft tissue and stenosis of the frontonasal communication. We describe a modified transnasal endoscopic Lothrop procedure, using powered instrumentation for cases in which frontal recess exploration has failed 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. The described Modified Lothrop procedure is reserved for those patients with frontal sinus pathology for whom more conservative surgical approaches have failed. This procedure is an advanced procedure and should be undertaken by experienced endoscopic sinus surgeons with extensive experience in surgery of the frontal sinus and the intranasal use of powered instrumentation. Figure 1 Anatomy Of The Paranasal Sinuses

Nota Bene: The technique description herein and the use of instructions for the related procedures are made available by Xomed Surgical Products, Inc. to the health care professional to illustrate the authors suggested treatment for the uncomplicated procedure. In the final analysis, the preferred treatment is that which, in the health care professionals judgment, addresses the needs of the individual patient.

Modified Transnasal Endoscopic Lothrop Procedure

Figure 2 Straight Blade Removes Superior Portion Of Uncinate Process & Anterior Ethmoid Cells On The Right Side

Surgical Technique
The modified transnasal Lothrop procedure is performed under general anesthesia. The nose is injected and topicalized with local anesthesia (lidocaine and epinephrine). The patient is positioned as for conventional functional sinus surgery using endoscopes. The patients coronal and axial CT scans are in the room for reference. Step 1: Resect the agger nasi, superior uncinate, and anterior ethmoid cells. If agger nasi, superior uncinate, or anterior ethmoid cells are present, they are removed using the soft tissue shaver with a 4mm blade (TRICUT, #18-84004) or conventional hand instruments. The 40 blade (RAD 40, #18-84006) is helpful at times in accessing and enlarging the frontal recess. (Figures 2 & 3)

Figure 3 Curved Blade Removes Agger Nasi And Superior Ethmoid Cells

Step 2: Locate the frontal recess. The frontal recess on one side is cannulated if possible. The procedure is typically bilateral so the more easily accessible frontal recess is chosen. If landmarks are obscured, an external mini-trephination and irrigation of the frontal sinus (Xomeds Mini-Trephine Set #18-92000) is one method that may be used to help verify the location of the frontal sinus drainage path. (Figure 4). (Intraoperative, real-time CT guidance systems are also helpful.) Step 3: Takedown of the anterior superior nasal septum. The superior septum in the region between the

Modified Transnasal Endoscopic Lothrop Procedure

Figure 4 Mini-Trephine Irrigation Locates Drainage Paths

two frontal recesses, anterior to the nasofrontal isthmus, is resected (Figure 5). This is accomplished early in the procedure because it greatly facilitates exposure and provides a window to work through so that the endoscope placed through one nostril can visualize the bur tip placed through the opposite nostril. This produces broad exposure of the operative area and provides greater maneuverability. The septum is taken down posteriorly to just beyond the anterior tip of the middle turbinate. Experience has shown that when the septum is not taken down inferiorly enough, crusts or sinus drainage may catch on the superior surface of the remaining septum. Septal takedown begins with mucosal takedown on both sides of the septum using the soft tissue shaver with a 4mm TRICUT blade (#18-84004). This minimizes avulsion of the mucous membrane, which is particularly important with regard to the olfactory region posterosuperiorly.

Figure 5 Reduction Of The Anterior Superior Portion Of The Nasal Septum

Bony and cartilaginous septum are taken down using a sickle knife and conventional straight and backbiting forceps. Once the septum has been adequately taken down, the surgeon can visualize both frontal recess areas and the intranasal floor of the frontal sinus. Step 4. Preparation of the frontal sinus floor for drilling. Using the soft tissue shaver with a 40 or 60 blade (RAD 60 #18-84016), mucosa is removed from the area of the frontal sinus floor between the two frontal recesses. The white remnant of cartilaginous and bony septum superiorly and just posteriorly to

Modified Transnasal Endoscopic Lothrop Procedure

Figure 6 Frontal Recess Soft Tissue Removal

the area of drilling serves as a helpful midline marker (Figure 6). Step 5: Frontal drillout. An irrigated straight or 55 suction bur (RAD 55 #1883670) is used in forward direction to remove bone from the anterior face of the frontal recess on one side, taking care to stay anterior to the back wall of the recess (trephine irrigation may be helpful to verify location). This bone that is removed comprises part of what is known as the nasofrontal beak of bone (Figure 7). The 55 bur is used to enter the floor of the frontal sinus anteriorly and just medially to the frontonasal isthmus, in an area named by Lothrop as the nasal crest. The nasal crest is removed and the frontal sinus is progressively opened (Figure 8). With the posterior table under direct

Figure 7 55 Bur Enters Anterior Floor of Frontal Sinus

Figure 8 Removal of Nasal Crest

Modified Transnasal Endoscopic Lothrop Procedure

Figure 9 Drilling of the Crest Proceeds Beyond Midline

visualization, drilling proceeds to the midline and beyond (Figure 9). Drilling continues until the contralateral frontal recess and isthmus are opened and in communication with the frontonasal opening. The 55 curved bur is typically used at the outset; as the drilling proceeds a 4.5mm Round or Aggressive Router bur (#18-84560, #18-84562) may be used to remove bone more rapidly as needed. An endoscopic lens cleaning system, such as the EndoScrub from Xomed, is very helpful in maintaining a clear endoscope during the drilling. The surgeon removes as much bone as possible anteriorly, until only a thin bony shell around the frontonasal communication at the glabellar area remains. Mucosa of the posterior table and posterior nasaofrontal duct are preserved, and a single common

Figure 10 The Opening Is Typically Semicircular or Crescent-like In Shape

frontal opening that includes both nasofrontal ducts and the floor of the frontal sinus is created (Figure 10). Using angled scopes, the entire contents of the frontal sinus can be visualized. The opening is typically semicircular or crescentic in shape.

Postoperative Care
Frequent office visits for postoperative care are required to assure patency of the opening. This may require removal of clots, crusts, polyps, and granulation tissue. The postoperative care is similar to that of the standard functional endoscopic sinus surgery.

Authors Note: Instrumentation recommended in this technique may be substituted at the surgeons discretion and is not necessarily exclusive.

Modified Transnasal Endoscopic Lothrop Procedure

Ordering Information
18-83670 RAD 55 Curved Sinus Bur
Single use, sterile packaged without irrigation tubing

18-84006 RAD 40 Curved Sinus Blade

Single use, sterile packaged without irrigation tubing

Diameter
3.6mm

Speed
3,000-6,000RPM

Qty
3/box

Diameter
4.0mm

Speed
2,000-3,000RPM

Qty
5/box

18-84004 TRICUT Blade

Single use, sterile packaged with irrigation tubing

18-84016 RAD 60 X-TREME Curved Sinus Blade

Single use, sterile packaged without irrigation tubing

Diameter
4.0mm

Speed
2,000-3,000RPM

Qty
5/box

Diameter
4.0mm

Speed
2,000-3,000RPM

Qty
5/box

18-84560 Round Bur, 4.5mm

Single use, sterile packaged without irrigation tubing

18-84562 Aggressive Router Bur, 4.5mm

Single use, sterile packaged without irrigation tubing

Diameter
4.5mm

Speed
5,000-6,000RPM

Qty
5/box

Diameter
4.5mm

Speed
5,000-6,000RPM

Qty
5/box

XPS Model 2000: System 1 & System 2

System 1 includes: Console, STRAIGHTSHOT MAGNUM Handpiece, Multi-Function Footswitch, & Irrigator Pump System 2 includes: Console, STRAIGHTSHOT MAGNUM Handpiece, & Single-Function Footswitch

Product
18-96000X XPS Model 2000: System 1

Qty
1 ea

Product
18-96001X XPS Model 2000: System 2

Qty
1 ea

Reference
This clinical article is provided for additional background material related to the Endoscopic Modified Lothrop procedure herein. The health care professional should seek out and review all other clinical reference materials as dictated by an individual patients clinical condition.

1. Gross, Charles W, MD, FACS; Gross, William E, MD; & Becker, Daniel, G, MD: Modified Transnasal Lothrop Procedure: Frontal Drillout, Operative Techniques in Otolaryngology Head and Neck Surgery, Vol 6, No 3 (Sept), pp 193-200, 1995. Copyright 1995 W.B. Saunders.

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