Nasal Polyposis: Aggressive Sinus Marsupialization Including the Frontal Drillout (Modified Lothrop) Procedure

Effective surgical management of the frontal sinus relies on a complete removal of inflammatory disease and a wide frontal drainage pathway. Incomplete or partial removal of cells in the frontal recess and sinus increases the risk of scarring and restenosis. Therefore, we advocate for an all or nothing philosophy with a complete removal of all cells with clear visualization of the frontal sinus. The extent of surgery should be evaluated prior to surgery based on the anatomical classification which indicates the grade of complexity. A clear understanding of the anatomy prior to surgery is mandatory and should result in a surgical plan. A planning software can facilitate the evaluation of the anatomical challenges and a difficult frontal recess should be identified before the surgery is done. In cases with aggressive polyposis, particularly in high-risk subgroups of polypoid CRS, the Draf 3 drill-out procedure is beneficial, as recurrence rates are lower compared to standard endoscopic approaches. The main rationale of the approach is to create a maximum anteroposterior diameter of the neo-ostium to achieve optimal postoperative care for topical medical delivery. The patency of the neo-ostium ranges between 80% and 90% and improves long-term outcomes with a reduced the need for revision surgery. The largest possible diameter of the frontal ostium is the most important factor in the success of an Draf 3 drill-out procedure, even in the patients with poor surgical prognosis.