DRAF IIB and III Frontal Sinusotomy in Cystic Fibrosis Patients

Objective: To examine the short-term effectiveness of bilateral Draf IIB and Draf III frontal sinusotomy in the management of chronic frontal sinusitis in patients with Cystic Fibrosis.

Methods: Retrospective chart review to identify patients with Cystic Fibrosis who underwent bilateral Draf IIB or Draf III frontal sinusotomy between November 2012 and August 2013. Records were examined including pre-operative CT and pre- and post-operative nasal endoscopy. Presumed frontal sinus disease symptoms included frontal headache, pain or pressure. Preoperative decision to perform bilateral Draf IIB or Draf III was based upon severity of initial frontal symptoms since the pre-operative CT scans showed complete opacification of the frontal sinus in all patients. Complications were defined as major (injury to the eye, extraoculomotor muscles and/or brain) or minor (synechiae, epistaxis, or CSF leak). Frontal sinus patency was determined by follow up endoscopy.

Results: Eight patients between 17 and 37 years old (mean 23.9), four male (50%). Four patients underwent bilateral Draf IIB and four underwent Draf III frontal sinusotomy. All were revision cases. Follow up ranged from 2 to 5 postoperative visits (mean 3.4 visits) spanning 4 to 20 weeks (mean 10.1 weeks). Mometasone furoate eluting stents (PROPEL^®, Intersect ENT) were used in 7 of 8 patients. Patent frontal sinuses were achieved in 7 of 8 patients postoperatively throughout the follow up period. One patient who underwent Draf III procedure had severe polyposis and recurrence of the polyps 4 weeks after surgery, despite optimal medical therapy. Frontal sinus symptoms were specifically present in 7 of 8 patients. One patient had complete opacification of the sinuses but no specific frontal sinus symptoms. This patient underwent revision sinus surgery including bilateral Draf IIB procedure to clear the frontal sinus secretions. In those patients with frontal sinus symptoms, 5 of 7 experienced postoperative relief (2 of 4 undergoing Draf III and 3 of 3 undergoing bilateral Draf IIB) at an average of 6 weeks (range 2–10). One patient continued with frontal headaches 9 weeks postoperatively, despite frontal sinus patency confirmed by endoscopy. There were no major complications. The only minor complications were synechiae identified in two patients (25%), each 4 weeks postoperatively (one Draf IIB, one Draf III). In both cases these were divided in the office and temporary Merocel packs were placed. Neither patient experienced return of synechiae.

Conclusions: Bilateral Draf IIB and Draf III frontal sinusotomy seem to guarantee frontal sinus patency and to improve symptoms in a short-term follow-up in the cystic fibrosis population. Limitations to this study include the retrospective nature, short-term follow-up and sample size lacking the power to establish statistical significance. Long-term follow-up and a larger patient population are necessary to identify the optimal role of these procedures in this difficult population.