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(A) Axial, (B) coronal, and (C) sagittal computerized tomography (CT) scan revealing mycotic sinusitis of the frontal sinuses (right>left) with lysis of the orbital wall, the posterior wall of the right frontal sinus, and the interfrontal wall. Demonstration of 2 left supraorbital frontoethmoidal cells (*) with lateral retention.
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On the left side, there was a mucus or a fungal retention lateral to pneumatized frontoethmoidal cells (Figure 1).
Intraoperative pictures after a right Draf IIa procedure. (A) 0  rigid optic vision, (B) 45  rigid optic vision, (C) bronchoscopic vision revealing a persistence of fungus ball in frontal sinus after rinsing using the Wigan aspiration, (D) right lateral recess before rinsing with the bronchofibroscope, (E) right lateral recess after rinsing with the bronchofibroscope, (F) medial wall of left frontal sinus before rinsing with the bronchofibroscope, (G) medial wall of left frontal sinus after rinsing with the bronchofibroscope, and (H) diagram illustrating the exploration and rising of the frontal sinuses using the bronchofibroscope through the Draf IIa.
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We performed a conventional bilateral endoscopic Draf IIa under vision with a rigid 4 mm 0  and 45  rod telescope (Karl Storz and Co) and rigid angulated instruments (Figure 2A and B). D, F and H). Direct vision allowed complete removal of the remaining fungus ball in the anterior part and in the lateral recess with rinsing through the 2 mm working channel of the bronchoscope (Figure 2E and G).
(A) Intraoperative picture with the flexible bronchofibroscope of the left frontoethmoidal cell (* left frontoethmoidal cell, X medial part of the left frontal sinus), (B) intraoperative picture of frontoethmoid cell wall resection using biopsy forceps through the working channel of the bronchofibroscope (# superior wall of frontoethmoidal cell,   biopsy forceps), and (C) diagram of frontoethmoid cell wall resection using flexible bronchoscope and biopsy forceps.
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Through-the-scope flexible biopsy forceps (1.8 mm biopsy forceps, Olympus) allowed the controlled removal of the left frontoethmoidal cell's wall through the right Draf IIa (Figure 3A-C).
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(A) Coronal and (B) sagittal computerized tomography (CT) scan revealing a frontoethmoidal cell (*) filling the drainage path of the right frontal sinus with lateral retention.
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The CT revealed retention in the right frontal sinus lateral to a frontoethmoidal cell that could be the etiology of his symptoms (frontoethmoidal cell obstructing the frontal sinus drainage path) (Figure 4A and B).
(A) Sagittal section and (B) coronal section of the excision of the right frontoethmoidal cell wall with the flexible bronchoscope and biopsy forceps through the working canal.
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These were efficiently addressed in 15 min using the flexible interventional bronchoscope (Video Bronchoscope BF-P190, 4.2 mm outer diameter, Olympus) and a through-the-scope biopsy forceps with the two surgeon's technique (Figure 5A and B).