Frontal Sinus Irrigation After Draf 2a: Carolyn's Window Versus Angled Frontal Sinusotomy

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Abstract
Objectives: Access to the frontal sinus after receiving angled Draf 2a frontal sinusotomy remains challenging, while adequate postoperative irrigation is essential in managing chronic inflammatory sinus disease. This study compared frontal sinus irrigation distribution between the angled Draf 2a and Carolyn's window approaches, a modification of Draf 2a which removes the nasofrontal beak by drilling to permit direct 0° endoscopic access. Methods: Fresh human cadaver heads underwent sequential dissection with angled Draf 2a followed by Carolyn's window approach. Each cavity was irrigated using a 250 mL high‐pressure squeeze bottle filled with 1/1000 10% fluorescein‐labeled water in the Frankfort horizontal position. Fluid irrigation was recorded using an endoscope placed within the frontal sinus. Blinded grading of fluid distribution was performed using a 0–4 scale: 0 (nasal cavity only), 1 (frontal recess), 2 (medial half), 3 (lateral half), and 4 (complete lavage). Scores were compared between two surgical approaches. Results: Eight cadaveric specimens (16 frontal sinuses) were evaluated. Compared with angled Draf 2a frontal sinusotomy, Carolyn's window approach achieved a greater distribution: grade 1 (50.0% vs. 0%), grade 2 (31.3% vs. 0%), grade 3 (6.3% vs. 43.8%), and grade 4 (12.5% vs. 56.3%). The median (IQR) distribution grade following angled Draf 2a frontal sinusotomy was 1.5 (1, 2), and 4 (3, 4) for the Carolyn's window approach ( p < 0.01). Conclusion: Carolyn's window significantly enhances frontal sinus irrigation compared to angled Draf 2a by improving access and distribution. This technique is robust for enhancing postoperative topical therapy in chronic frontal sinus disease. Level of Evidence: N/A.

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