Frontal Sinus Draf Procedures: Their Role in Endoscopic Management of CSF Rhinorrhea

Introduction: Drainage of frontal sinuses has always been a surgical target during external approaches designed to repair dural lesions. Today, this is still an important issue in the era of the endonasal endoscopic approach, which has become the mainstream management option of CSF fistulas with few exceptions. One limitation of the endoscopic approach has been CSF leaks originating from the frontal sinus itself, due to the poor visualization, accessibility, and manipulation capacity through the narrow opening of the frontoethmoid recess. Also, repair of ethmoid roof lesions extending to the frontoethmoid recess poses the risk of hindering frontal sinus drainage. Frontal sinus Draf procedures gradually enable a wider opening to the frontal sinuses, improving endoscopic ease to access and manipulate around the lesions to an extent, as well as leaving an adequate drainage postoperatively. In this study, we investigated the role of Draf procedures in endoscopic management of CSF fistulas.

Method: During an 8-year period, 117 patients who underwent dura repair in 2 tertiary institutions were evaluated for the following criteria; etiology; endonasal endoscopic surgery; anatomical location of the dural lesion; intraoperative requirement for Draf procedure type I, IIA, IIB, or III; postoperative success for CSF fistula closure; postoperative frontal sinus drainage and recess patency for ≥6 months in follow-ups; and postoperative requirement for frontal sinus surgery and Draf procedure type I, IIA, IIB or III.

Results: The frontal sinus Draf procedure appeared to be an important adjunct during endoscopic management of CSF fistulas at the frontal sinus and frontoethmoid recess. Draf type I or IIA was applied in nearly all cases to observe any CSF leakage from the frontal sinus. In all frontal sinus posterior wall CSF fistulas that were operated on endoscopically, a Draf type IIB or III procedure was done to reach and repair the defect. Eight patients who had type I or IIA drainage during the initial surgery developed obstruction of frontal sinus drainage due to overhealing in the first 6 months and required type IIB or III drainage with revision surgery, after which they had no more problems. In 7 patients, type IIB or III drainage was needed during the initial surgery for dura repair and sinus ventilation, and those had no obstructive problems during the follow-ups.

Discussion: Frontal sinus Draf procedures, especially types IIB and III drainage, are important adjuncts in the endoscopic management of CSF rhinorrhea. When necessary, they do not only extend the applicability of endoscopic duraplasty techniques into the frontal sinus, but also help manage and reduce postoperative inflammatory complication rates.