Consumer summary. Endoscopic modified Lothrop procedure for the. treatment of chronic frontal sinusitis

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1 ASERNIP S Australian Safety and Efficacy Register of New Interventional Procedures Surgical Consumer summary Endoscopic modified Lothrop procedure for the treatment of chronic frontal sinusitis (The report of the Review Group has been adapted for consumers by Ms E. Ahern) To navigate in this document in Word: Click on the word (underlined in blue) to link to glossary. Use back arrow on tool bar to return to original place in document. Introduction Endoscopic modified Lothrop procedure (EMLP) is a surgical technique that has been developed for treating chronic frontal sinusitis. ASERNIP-S has reviewed the available published evidence to compare the safety and effectiveness of this procedure with the osteoplastic flap procedure with or without fat obliteration (OPF), which is an alternative surgical treatment for this condition. 1

2 What is chronic frontal sinusitis? The nasal sinuses are the spaces inside the bones around the nose that open into the main nasal cavity. There are four pairs of sinuses: frontal, ethmoid, sphenoid and maxillary (see figure 1). Air passes in and out of these spaces and mucus drains from the sinuses into the nose. The function of the nasal sinuses is unclear. However, like the tubes leading to the lungs, the sinuses are covered with a layer of cells secreting mucous; this thick fluid moistens the air we breathe and traps any foreign particles, directing them away from the lungs. Sinusitis is the medical term for an infection of the nasal sinuses. This very common disease may be caused by a blockage to the normal drainage of the sinuses due to a cold, allergy or diseased cells. Build-up of mucous in the sinuses may lead to changes in the mucous secreting cells, more secretions and ultimately polyp and mucocele formation. Symptoms of sinusitis include tiredness, headache, facial pain, and a thick yellowish/green discharge from the nose. If the infection lasts for more than three months, the person suffers from chronic sinusitis. This condition appears to be on the increase, with more than 37 million cases reported in the United States in Additional symptoms include a persistent cough, bronchitis, bad breath, feeling unwell, and depression. Chronic infection of the frontal sinuses can lead to serious complications, such as brain abscesses (with a risk of dying of 20 to 30%), meningitis, and inflammation of the bone. 2

3 Figure 1: Nasal sinuses Figure 2: Osteoplastic flap (OPF) procedure 3

4 Conventional treatments for chronic frontal sinusitis There are two main types of treatment available to treat chronic frontal sinusitis: Medical. This may involve applying steroids via nasal sprays, saline (salt water) in sprays and solution, or antibiotics against bacteria found in the sinuses. Treatment should be given for a minimum of six weeks. Surgical. 1. Initially, an endoscope is used to clear the passage between the nose and the frontal and ethmoid sinuses, or to widen the opening to the maxillary sinus. 2. Should this treatment fail, or complications arise, other types of surgery may be necessary, which may involve removal of sinuses and permanent closure of their drainage pathways. The current benchmark treatment of this type of surgery is the osteoplastic flap (OPF) procedure. A cut is made across the upper eyebrow edge or along the hairline. The bone at the outer edge of the frontal sinus is converted into a flap connected across the sinus floor; this ensures that the bone and its mucous-producing lining remain continuous. The septum between the pair of sinuses is then removed, together with any diseased lining cells. In some cases, fat taken from the left wall of the abdomen is used to fill or obliterate the space of the sinus and seal its opening into the drainage pathway. The bone flap is then returned to its original position (see figure 2). 4

5 The little data available has shown the OPF procedure to be relatively safe. Cutting through the skin gives the surgeon a good view of, and access to, the region. However, this highly invasive procedure may result in complications such as headache around the frontal sinus area (23%), higher than average blood loss, collections of blood under the scalp, infections involving fat grafts, piercing of the membranes around the brain, and cosmetic changes. In terms of effectiveness, the reported success rate for the OPF procedure is high, ranging from 95% to100% in a limited number of studies. The rate of recurrence of the disease is under 8%. One limitation of the OPF is that the procedure does not correct obstruction of the drainage pathways between the frontal sinus and the nose, should the disease recur. Furthermore, it is difficult to diagnose recurrences in patients who have had the procedure with fat obliteration, which limits the use of x-rays. Finally, OPF is not suitable for patients with conditions which hinder complete removal of the mucosa. How does the endoscopic modified Lothrop procedure compare with the conventional osteoplastic flap approach? During the 1990s new forms of minimally invasive surgery were developed to treat chronic frontal sinusitis based on a technique first reported by Lothrop over a hundred years ago. The endoscopic modified Lothrop procedure (EMLP) treats this condition by widening the drainage pathway of the frontal sinus into the nose, keeping most of the 5

6 sinus and its mucous-producing lining intact. An endoscope is passed through the nose to the sinus area while the patient is under general anaesthesia. Parts of the septum and bones surrounding the frontal sinus are removed. This creates a large permanent space between the nasal cavity and the frontal sinus, enabling air to pass through and mucous to drain freely (see figure 3). Figure 3: Endoscopic modified Lothrop procedure (EMLP) 6

7 There is little good quality evidence available on the comparative safety and effectiveness of EMLP and the conventional OPF approach. However, the following information may be used as a guide. In terms of safety, studies suggest that EMLP causes fewer complications than OPF, with none of the complications generally associated with OPF occurring in any EMLP patient. However, EMLP is more likely to cause a leak of the fluid from the brain and spinal cord (cerebrospinal fluid or CSF), with around 10% of patients affected in some studies. One study reported numbness in the nose (37%) and headache (55%) following EMLP using cuts through the skin at the side of the nose to approach the sinuses. No deaths were reported following EMLP. In terms of effectiveness, studies suggest that symptoms ceased in a higher percentage of patients following the OPF procedure than EMLP. Some studies recorded that up to 90% of EMLP patients thought their symptoms had improved following the procedure, while one report on OPF claimed a rate of 95% to100%. Little information was available concerning the long-term follow-up of either operation. Shorter hospital stays were reported following EMLP than after conventional OPF surgery; EMLP was performed as an outpatient procedure in a number of cases. The percentage of patients requiring further operations was similar following the EMLP and OPF procedure. In the small amount of data available, 74% of EMLP patients thought 7

8 their quality of life had improved, compared to 65% of patients reporting satisfaction after conventional OPF surgery. Although studies suggest that EMLP may not be suitable for some patients, for example those with small frontal sinuses, the less invasive procedure may be better for others, including those undergoing reoperation, sufferers of bronchial asthma, or patients who can t tolerate aspirin. What is the recommended surgical procedure for treating chronic frontal sinusitis? Due to the lack of good quality evidence, it is not possible to decide whether EMLP is as safe and effective as the conventional OPF procedure for treating this condition. While many of the complications associated with the OPF procedure are absent in EMLP patients, the risk of leak of the cerebrospinal fluid is increased. All factors need to be considered carefully by the patient and the surgeon before choosing the most suitable operation. The Royal Australasian College of Surgeons recommends that EMLP only be performed on appropriately selected patients by a properly trained otolaryngological surgeon, ideally in the setting of a national audit. An audit of the OPF procedure is also recommended. Key words: sinus surgery, Lothrop, frontal drillout November

9 Important Note: The information contained in this report is a distillation of the best available evidence located at the time the searches were completed as stated in the protocol. Please consult with your medical practitioner if you have further questions relating to the information provided, as the clinical context may vary from patient to patient. For further information about ASERNIP-S Contact Professor Guy Maddern, ASERNIP-S Surgical Director, PO Box 688, North Adelaide, SA 5006, ph. (08) , fax (08) , or visit the website ( If you would like to provide feedback on this consumer summary, please contact us at consumer.asernip@surgeons.org. ASERNIP-S is a programme of the Royal Australasian College of Surgeons (RACS). 9

10 Glossary brain abscess: collection of pus in a cavity in the brain cerebrospinal fluid (CSF): fluid in the brain and the spinal cord chronic sinusitis: a sinus infection lasting longer than three months EMLP: endoscopic modified Lothrop procedure endoscope: a tube with a viewing mechanism at the end, used to see inside hollow organs in the body and to perform various surgical procedures fat obliteration of sinuses: sinuses may be filled with fat taken from the left side of the abdomen of the patient highly invasive operation: operation accessing the site through large surgical cuts membrane: thin layer of cells covering a surface meningitis: infection of the layer of cells lining the brain mucocele: swelling of a cavity due mucous secretion; a mucous polyp. Problems arise if the swelling pushes onto surrounding tissues e.g. of the eye or brain. mucosa: mucous lining cells mucous: thick fluid containing salts and cells that is secreted by glands nasal: concerning the nose OPF: osteoplastic flap procedure with or without fat obliteration otolaryngology: medicine concerning disease of the ear, nose and throat polyp: growth in the lining cells which push onto the inside of the cavity septum: dividing wall sinuses of the nose: cavities or spaces inside the bones surrounding the nose sinusitis: a sinus infection 10

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