Endoscopic Techniques in Frontal Sinus Surgery

  • Devyani Lal
  • Peter H. Hwang


The frontal sinus is arguably the most challenging paranasal sinus to address surgically. Surgery is technically demanding and carries a higher risk of complications. Postoperative stenosis may necessitate revision surgery. The goals of frontal sinus surgery are to address medically refractory disease effectively while minimizing risks and complications. Clinical indications and expectations of benefit from surgery should be thoughtfully evaluated prior to proceeding with surgery. To perform surgery safely, effectively, and efficiently, the frontal surgeon must commit to mastering knowledge of frontal anatomy and instrumentation. They must develop and hone skills in meticulous tissue handling and commit to zealous postoperative care.

This chapter will detail the editors’ techniques in performing endoscopic frontal sinus surgery. The chapter details practical steps in performing endoscopic frontal sinus surgery. The chapter also highlights clinical indications of the Draf I, Draf II, and Draf III (endoscopic modified Lothrop) procedures. The frontal surgeon must understand the advantages and disadvantages of each endoscopic technique as well as their own level of technical expertise to personalize applications in the clinical realm.


Frontal sinusotomy Draf I Draf II Draf III Endoscopic modified endoscopic Lothrop procedure Ethmoidectomy 

Supplementary material

Video 6.1

Right primary frontal dissection (Draf IIA) with audio demonstrating the “ABC “technique for dissection (mp4 48446 kb)

Video 6.2

Infiltration of left lateral nasal wall and axilla with approximately 1 cc solution of lidocaine 1% epinephrine with 1:100,000 using a 25 gauge needle (mp41372 kb)

Video 6.3

Right lateral wall injection followed by performance of a “relaxing incision” (mp4 2302 kb)

Video 6.4

Left primary frontal sinusotomy with dissection of supra-agger cells (mp4 24608 kb)

Video 6.5

Left Draf IIB; handheld instruments (MPG 71874 kb)

Video 6.6

Left Draf IIB with drilling, Silastic stent placement (mp4 20787 kb)

Video 6.7

CSF leak during right Draf IIB with mucosal graft repair (mp4 17779 kb)

Video 6.8

Middle turbinate suture medialization (mp4 3271 kb)

Video 6.9

Balloon-assisted right frontal dissection (mp4 16740 kb)

Video 6.10

Draf III inside-out (MPG 149120 kb)

Video 6.11

Right Draf IIB to address lateralized middle turbinate (mp4 67842 kb)

Video 6.12

Draf IIB for right frontal sinus inverted papilloma (mp4 80854 kb)

Video 6.13

Draf III outside-in for narrow frontal sinus (mp4 20491 kb)

Video 6.14

Frontal trephination for flushing and debridement of tenacious, impacted debris as part of “above and below” approach (mp4 35513 kb)

Video 6.15

Well-healed sinuses (WMV 6740 kb)

Video 6.16

Left injection, relaxing incision, pledget (mp4 5419 kb)


  1. 1.
    Stammberger H. FESS: uncapping the egg. The endoscopic approach to frontal recess and sinuses. Tuttlingen, German: Storz GmbH; 2015.Google Scholar
  2. 2.
    Draf W, Weber R. Draf microendoscopic sinus procedures Am J Oto 1999.pdf. Am J Otolaryngol. 1993;14(6):394–8.CrossRefGoogle Scholar
  3. 3.
    Stankiewicz JA, Donzelli JJ, Chow JM. Failures of functional endoscopic sinus surgery and their surgical correction. Oper Tech Otolaryngol Neck Surg. 1996;7(3):297–304.CrossRefGoogle Scholar
  4. 4.
    Vining A, Eugenia W, David W. The transmigration of endoscopic sinus surgery from Europe to the United States.:10–3.Google Scholar
  5. 5.
    Stankiewicz JA, Lal D, Connor M, Welch K. Complications in endoscopic sinus surgery for chronic rhinosinusitis: a 25-year experience. Laryngoscope. 2011;121(12):2684–701.CrossRefGoogle Scholar
  6. 6.
    Dalgorf DM, Sacks R, Wormald PJ, Naidoo Y, Panizza B, Uren B, et al. Image-guided surgery influences perioperative morbidity from endoscopic sinus surgery: a systematic review and meta-analysis. Otolaryngol Head Neck Surg (United States). 2013;149:17–29.CrossRefGoogle Scholar
  7. 7.
    Wormald PJ. Salvage frontal sinus surgery: the endoscopic modified Lothrop procedure. Laryngoscope. 2003;113(February):276–83.CrossRefGoogle Scholar
  8. 8.
    Stammberger H. Functional endoscopic sinus surgery. Philadelphia: B.C. Decker; 1991.Google Scholar
  9. 9.
    Snidvongs K, Pratt E, Chin D, Sacks R, Earls P, Harvey RJ. Corticosteroid nasal irrigations after endoscopic sinus surgery in the management of chronic rhinosinusitis. Int Forum Allergy Rhinol. 2012;2(5):415–21.CrossRefGoogle Scholar
  10. 10.
    Snidvongs K, Kalish L, Sacks R, Sivasubramaniam R, Cope D, Harvey RJ. Sinus surgery and delivery method influence the effectiveness of topical corticosteroids for chronic rhinosinusitis: systematic review and meta-analysis. Am J Rhinol Allergy. 2013;27(3):221–33.CrossRefGoogle Scholar
  11. 11.
    Sillers MJ, Melroy CT. In-office functional endoscopic sinus surgery for chronic rhinosinusitis utilizing balloon catheter dilation technology. Curr Opin Otolaryngol Head Neck Surg. 2013;21(1):17–22.CrossRefGoogle Scholar
  12. 12.
    Patel ABAB, Cain RBRB, Lal D. Contemporary applications of frontal sinus trephination: a systematic review of the literature. Laryngoscope. 2015;125(9):2046–53.CrossRefGoogle Scholar
  13. 13.
    Zacharek MA, Fong KJ, Hwang PH. Image-guided frontal trephination: a minimally invasive approach for hard-to-reach frontal sinus disease. Otolaryngol Head Neck Surg. 2006;135(4):518–22.CrossRefGoogle Scholar
  14. 14.
    Orlandi RR, Kingdom TT, Hwang PH, Smith TL, Alt JA, Baroody FM, et al. International consensus statement on allergy and rhinology: rhinosinusitis. Int Forum Allergy Rhinol. 2016;6(November 2015):S22–209.PubMedGoogle Scholar
  15. 15.
    Fokkens W, Lund V, Mullol J. European position paper on rhinosinusitis and nasal polyps. Rhinology. 2007;(20):1–136.Google Scholar
  16. 16.
    Poetker DM, Jakubowski LA, Lal D, Hwang PH, Wright ED, Smith TL. Oral corticosteroids in the management of adult chronic rhinosinusitis with and without nasal polyps: an evidence-based review with recommendations. Int Forum Allergy Rhinol. 2013;3(2):104–20.CrossRefGoogle Scholar
  17. 17.
    Lee WT, Kuhn FA, Citardi MJ. 3D computed tomographic analysis of frontal recess anatomy in patients without frontal sinusitis. Otolaryngol Head Neck Surg. 2004;131(3):164–73.CrossRefGoogle Scholar
  18. 18.
    Wormald PJ, Hoseman W, Callejas C, Weber RK, Kennedy DW, Citardi MJ, et al. The international frontal sinus anatomy classification (IFAC) and classification of the extent of endoscopic frontal sinus surgery (EFSS). Int Forum Allergy Rhinol. 2016;0(0):1–20.Google Scholar
  19. 19.
    Pianta L, Ferrari M, Schreiber A, Mattavelli D, Lancini D, Bottazzoli M, et al. Agger-bullar classification (ABC) of the frontal sinus drainage pathway: validation in a preclinical setting. Int Forum Allergy Rhinol. 2016;6(9):981–9.CrossRefGoogle Scholar
  20. 20.
    Wormald PJ. Surgery of the frontal recess and frontal sinus. Rhinology. 2005;43(2):82–5.PubMedGoogle Scholar
  21. 21.
    Lund VJ, et al. European position paper on the anatomical terminology of the internal nose and paranasal sinuses. Rhinol Suppl. 2014;24:1–34.PubMedGoogle Scholar
  22. 22.
    Landsberg R, Friedman M. A computer-assisted anatomical study of the nasofrontal region. Laryngoscope. 2001;111(12):2125–30.CrossRefGoogle Scholar
  23. 23.
    Socher JA, Santos PG, Correa VC, De Barros E, Silva LC. Endoscopic surgery in the treatment of crista galli pneumatization evolving with localizated frontal headaches. Int Arch Otorhinolaryngol. 2013;17(3):246–50.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Han JK, Becker SS, Bomeli SR, Gross CW. Endoscopic localization of the anterior and posterior ethmoid arteries. Ann Otol Rhinol Laryngol. 2008;117(12):931–5.CrossRefGoogle Scholar
  25. 25.
    Jang DW, Lachanas VA, White LC, Kountakis SE. Supraorbital ethmoid cell: a consistent landmark for endoscopic identification of the anterior ethmoidal artery. Otolaryngol Head Neck Surg (United States). 2014;151(6):1073–7.CrossRefGoogle Scholar
  26. 26.
    Bent JP, Guilty-Siller G, Kuhn FA. The frontal cell as a cause of frontal sinus obstruction. Am J Rhinol. 1994;8(4):185–91.CrossRefGoogle Scholar
  27. 27.
    Nair S, Collins M, Hung P, Rees G, Close D, Wormald P-J. The effect of beta-blocker premedication on the surgical field during endoscopic sinus surgery. Laryngoscope. 2004;114(6):1042–6.CrossRefGoogle Scholar
  28. 28.
    Tankisi A, Cold GE. Optimal reverse trendelenburg position in patients undergoing craniotomy for cerebral tumors. J Neurosurg. 2007;106(2):239–44.CrossRefGoogle Scholar
  29. 29.
    Ko MT, Chuang KC, Su CY. Multiple analyses of factors related to intraoperative blood loss and the role of reverse Trendelenburg position in endoscopic sinus surgery. Laryngoscope. 2008;118(9):1687–91.CrossRefGoogle Scholar
  30. 30.
    Higgins TS, Hwang PH, Kingdom TT, Orlandi RR, Stammberger H, Han JK. Systematic review of topical vasoconstrictors in endoscopic sinus surgery. Laryngoscope. 2011;121(2):422–32.CrossRefGoogle Scholar
  31. 31.
    Lothrop HA. Frontal sinus suppuration: the establishment of permanent nasal drainage; the closure of external fistulae; Epidermization of Sinus. Ann Surg. 1914;59(A):937–57.CrossRefGoogle Scholar
  32. 32.
    Getz AE, Hwang PH. Basal lamella relaxing incision improves endoscopic middle meatal access. Int Forum Allergy Rhinol. 2013;3(3):231–5.CrossRefGoogle Scholar
  33. 33.
    Wormald PJ. The axillary flap approach to the frontal recess. Laryngoscope. 2002;112(3):494–9.CrossRefGoogle Scholar
  34. 34.
    Chin D, Snidvongs K, Kalish L, Sacks R, Harvey RJ. The outside-in approach to the modified endoscopic lothrop procedure. Laryngoscope. 2012;122(8):1661–9.CrossRefGoogle Scholar
  35. 35.
    Lanza DC, McLaughlin RB, Hwang PH. The five year experience with endoscopic trans-septal frontal sinusotomy. Otolaryngol Clin North Am. 2001;34:139–52.CrossRefGoogle Scholar
  36. 36.
    McLaughlin RB, Hwang PH, Lanza DC. Endoscopic trans-septal frontal sinusotomy: the rationale and results of an alternative technique. Am J Rhinol. 1999;13(4):279–87.CrossRefGoogle Scholar
  37. 37.
    Nishiike S, Yoda S, Shikina T, Murata J. Endoscopic Transseptal approach to frontal sinus disease. Indian J Otolaryngol Head Neck Surg. 2015;67(3):287–91.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Devyani Lal
    • 1
  • Peter H. Hwang
    • 2
  1. 1.Department of Otolaryngology – Head and Neck SurgeryMayo Clinic College of Medicine and Science, Mayo ClinicPhoenixUSA
  2. 2.Department of Otolaryngology – Head and Neck SurgeryStanford University School of MedicineStanfordUSA

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