Patient-reported olfaction improves following outside-in Draf III frontal sinus surgery for chronic rhinosinusitis

Objectives: 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. Methods: 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. Results: 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). Conclusion: 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 of Evidence: Level 4.