Wong Eugene H, Do Timothy Q, Harvey Richard J, Orgain Carolyn A, Sacks Raymond, Kalish Larry
Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia.
Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.
Laryngoscope. 2019 Jan;129(1):25-30. doi: 10.1002/lary.27352. Epub 2018 Sep 19.
The Draf III frontal sinusotomy is an established surgical procedure with an important role in the surgical management of recalcitrant chronic rhinosinusitis (CRS). In 2012, the outside-in approach to the Draf III was described as a safe and efficient procedure. Smell recovery in inflammatory CRS is challenging, and to date there is limited evidence suggesting that Draf III improves patient-reported olfactory dysfunction from CRS.
A consecutive series of patients who underwent an outside-in Draf III for inflammatory CRS by a single, tertiary rhinologist were reviewed. Patients were excluded if the Draf III was performed for noninflammatory conditions. Postoperatively, patients were maintained on long-term corticosteroid irrigations, and adherence was assessed. Prospectively collected data included patient demographics, a visual analogue scale for smell, overall Sinonasal Outcome Test Score (SNOT-22), global nasal function score, and a clinician-graded clinical outcome score.
One hundred and four patients (41.1% female) aged 54 ± 12 years underwent an outside-in Draf III. The median follow-up time was 30.6 months (range 12.2-72.1). The majority of patients rated their smell loss as moderate or worse preoperatively; however, this was significantly improved at postoperative review (71.2% vs. 27.6%; Kendall tau-b, P < 0.01). The SNOT-22 score improved after surgery (2.32 ± 1.09 vs. 0.78 ± 0.69, P < 0.0001). Medication adherence was significantly associated with improved clinical outcome score (Kendall tau-b, P < 0.004). Aspirin exacerbated respiratory disease was found to be a significant risk factor predicting poor clinical outcome on univariate analysis (Odds Ratio = 4.69 (1.03-21.2), P = 0.04).
The outside-in Draf III appears to facilitate sustained, meaningful improvement in several self-reported outcomes, including smell. However, further study and comparison to less aggressive surgery will be required to confirm its true benefit.
Level 4 Laryngoscope, 129:25-30, 2019.
Draf III型额窦切开术是一种成熟的外科手术，在顽固性慢性鼻-鼻窦炎（CRS）的外科治疗中具有重要作用。2012年，Draf III型的由外向内入路被描述为一种安全有效的手术方法。炎性CRS患者的嗅觉恢复具有挑战性，迄今为止，仅有有限的证据表明Draf III型手术能改善患者自述的CRS所致嗅觉功能障碍。
回顾了由一位三级鼻科医生为炎性CRS患者实施由外向内入路Draf III型手术的一系列连续病例。若Draf III型手术是针对非炎性疾病进行的，则将患者排除。术后，患者接受长期糖皮质激素冲洗治疗，并评估其依从性。前瞻性收集的数据包括患者人口统计学资料、嗅觉视觉模拟量表、鼻窦结局测试总分（SNOT-22）、整体鼻腔功能评分以及临床医生分级的临床结局评分。
104例患者（41.1%为女性）接受了由外向内入路Draf III型手术，年龄为54±12岁。中位随访时间为30.6个月（范围12.2 - 72.1个月）。大多数患者术前将其嗅觉丧失评为中度或更严重；然而，术后复查时这一情况有显著改善（71.2%对27.6%；肯德尔tau-b检验，P < 0.01）。术后SNOT-22评分有所改善（2.32±1.09对0.78±0.69，P < 0.0001）。药物依从性与改善的临床结局评分显著相关（肯德尔tau-b检验，P < 0.004）。单因素分析发现阿司匹林加重性呼吸疾病是预测临床结局不佳的一个显著危险因素（比值比 = 4.69（1.03 - 21.2），P = 0.04）。
由外向内入路Draf III型手术似乎能使包括嗅觉在内的多项患者自述结局得到持续、有意义的改善。然而，需要进一步研究并与侵袭性较小的手术进行比较，以证实其真正益处。
4级 《喉镜》，2019年，第129卷，第25 - 30页
