Brown Syndrome Following Endoscopic Modified Lothrop Procedure

Abstract

A 41-year-old female with a history of allergic fungal rhinosinusitis underwent endoscopic sinus surgery (ESS) 2 years prior. A bilateral total ethmoidectomy, sphenoid, maxillary, and Draf IIb frontal sinusotomies were performed. Over the course of 2 years, the patient experienced progressive symptoms of frontal pressure and discolored thick secretions. On nasal endoscopy there was significant crusting and allergic mucin bilaterally requiring repeated debridements. The mucin was predominantly observed from the anterior ethmoid cavity and frontal recess area. There were also moderate polypoid changes throughout her sinus cavities. A non-contrast CT scan was performed revealing moderate mucoperiosteal thickening of her frontal and ethmoid sinuses with osteoneogenesis (Fig. 8.1). After failing multiple attempts at maximum medical therapy including high-volume irrigations, oral and topical corticosteroids (including budesonide), and culture-directed topical and oral antibiotics, revision surgery was advised. An extended sphenoidotomy, mega-maxillary antrostomies, and extended frontal sinusotomy (Draf III or modified Lothrop procedure) were performed to facilitate long-term debridements as well as the use of topical anti-inflammatory and antimicrobial management of the respective sinus cavities. During the surgery, dense allergic mucin, osteoneogenesis, and polypoid mucosa were present in all the sinuses. During the modified Lothrop portion of the surgery, the left anterosuperior orbital periosteum, in the area of the trochlea, was thinned with a cutting burr resulting in an inadvertent perirobita laceration. Mild bleeding in the tiny rent of torn periorbita was controlled with suction cautery followed by a topical 1:1000 adrenaline-soaked neurosurgical cottonoid.