Size of septectomy does not affect distribution of nasal irrigation after endoscopic modified Lothrop procedure

Abstract

The endoscopic modified Lothrop procedure (EMLP) is commonly performed in recalcitrant frontal sinusitis, in part to achieve better penetration of medicated irrigations postoperatively. Although EMLP requires a septectomy for exposure, it is unknown whether septectomy size affects delivery of irrigations. In this study we evaluated the role of septectomy in delivery of irrigations to the EMLP cavity. EMLP was performed on fresh human cadavers with sequentially increasing septectomy (minimal septectomy: drilling across septum to combine frontal sinuses; standard septectomy: 1.5 cm anterior to middle turbinate and inferiorly to the midlevel of the turbinate; large septectomy: extension to nasal floor). Irrigation with fluorescein-labeled water was performed with a 240-mL irrigation bottle in the vertex position and recorded with a 30° endoscope fixed in a 4-mm trephine in the paramedian EMLP cavity. Two blinded reviewers scored irrigation distribution recordings (0 = nasal cavity only; 1 = frontal recess; 2 = medial distribution; 3 = lateral distribution; 4 = entire sinus lavage). Distribution scores were assessed with Wilcoxon rank sum analysis. Six specimens (mean age, 75.2 ± 2.4; 50% female) were assessed. Interobserver scores were highly concordant (Kendall's W = 0.86, p < 0.01), internally validating the experiment. Distribution scores did not vary significantly when comparing minimal septectomy with standard or large septectomy (Z = 0.55, p = 0.58, Z = 0.37, p = 0.71). Increasing septectomy does not improve irrigation delivery in patients undergoing EMLP. These results suggest that a limited septectomy for access to the bilateral frontal sinuses is all that is required for effective drug delivery postoperatively. This strategy may reduce morbidity associated with larger septectomies.