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Benefits-Harm Assessment: Benefits balance risks but may not outweigh costs. Value Judgments: Although numerous prospec tive studies, including RCTs, have emerged show ing benefit, the exclusion of patients with more dif fuse paranasal sinus inflammatory disease limits broader applicability to all CRS patients. Policy Level: Option. Intervention: Balloon catheter dilation may have benefit for patients with limited maxillary sinus disease with or without anterior ethmoid disease inCRSsNP. XII.D.1.d. Extent of Frontal Surgery Determining the appropriate extent of frontal surgery can pose challenges. Greater extents of frontal surgery have been postulated to enhance relief of inflammatory burden, improve ventilation, and improve delivery of topical treat ments. However, more extensive dissection can be techni cally challenging and hold greater potential for complica tions. In 1991, Wolfgang Draf published a classification sys tem for the extent of frontal surgery, which is still widely accepted and used: Draf I – removal of ethmoidal cells without altering the frontal ostium; Draf IIa – removal of ethmoidal cells in the frontal recess with widening of the frontal sinusotomy from the lamina papyracea to the mid dle turbinate; Draf IIb – removal of frontal sinus floor to extend the frontal sinusotomy from the lamina papyracea to the septum; Draf III – removal of superior nasal septum and the frontal sinus septum to extend the frontal sinu sotomy from medial orbital wall to contralateral medial orbital wall (also known as endoscopic modified Lothrop procedure). 2010,2011 There is evidence that a Draf I procedure has effi cacy as an intervention for selected patients with chronic frontal sinusitis in one retrospective 2012 and 1 prospective study. 2013 The retrospective study reviewed patients with CT evidence of frontal sinusitis who underwent a Draf I procedure. The success rate of Draf I for treating frontal sinusitis was > 90%, with 8.3% of patients requiring revi sion surgery. Patients with AERD or frontal septal cells were more likely to fail. 2012 The prospective study was a multi-institutional study comparing outcomes of Draf I ethmoidectomy with those of frontal sinusotomy pro cedures (Draf IIa, IIb or III). Both groups had compara ble improvement in SNOT-22 scores, with a 0% revision surgery rate in the Draf I group (vs 2.6% in the compari son group). Noting a skew toward more severe CRS in the frontal sinusotomy group, the authors cautioned that selec

tion of Draf procedure should reflect severity of the frontal sinusitis. 2013 Outcomes of Draf IIa procedures have been studied extensively. A recent review identified an overall 67.5% to 92% patency rate of Draf IIa frontal sinusotomy, 2014 with diameter over 4.5 mm at completion of the proce dure being the most significant factor in achieving patency. Years earlier, Hosemann had also shown that the steno sis rate was 16% for an ostium size of 5 mm, vs 50% when the ostium size was 2 mm. 2015 A large retrospective case series review of 109 patients undergoing a primary Draf IIa procedure by a single surgeon demonstrated significant symptom improvement in 78% of patients, with 92% sinus patency rate and a revision surgery rate of less than 9%. 1813 One challenge in interpreting these studies is that other sinuses are usually surgically treated in conjunction with the frontal sinus, thus making it difficult to determine the degree of subjective symptom improvement attributable to frontal sinusotomy. The most common indications for a Draf IIb proce dure are chronic frontal sinusitis due to lateralized mid dle turbinate, mucocele or mucopyocele, synechiae from previous surgery, and a frontal sinus mass. 2016 In a case series of 18 patients undergoing a Draf IIb procedure, 13 were revision surgeries, and a 91% long term patency was achieved. In another case series of 21 patients, 1991 all patients had a patent neo-ostium at an average of 15.7 months follow-up, with clinically significant symptom improvements. One patient required revision by conver sion to a Draf III procedure. There were no major compli cations except for hyposmia, which was reported in 14.3% of the patients. A recent meta-analysis of publications reporting out comes of Draf III procedure between 2000 and 2016 reported a symptom improvement rate of 75.9% in 357 patients. 2017 A restenosis rate of 17.1% was identified; how ever, most studies did not establish a quantitative standard for defining restenosis. Smaller case series have reported a reduction of the restenosis rate using mucosal grafts or stents in the neo-ostium. 1824,2018 There is sparse comparative evidence to guide the decision-making process between the various extents of frontal surgeries. In 1 study, Draf III patients were found to require more office visits and debridement, as well as antibiotics, when compared to Draf IIa patients in the early post-operative period. 2019 However, the study period was limited to the first 8 weeks postoperatively, and long term outcome comparison was not available. Another study directly compared Draf IIb and III procedures, and found earlier symptom improvement in the Draf IIb group, and equivalent long term symptom improvement, patency, revision, and complication rates. 1991 This is despite a cadaveric study demonstrating increased frontal