Comparative Restenosis and Revision Rates of Draf IIB Versus Draf III Frontal Sinusotomy in Chronic Rhinosinusitis: A Meta-Analysis Stratified by Endotype

Background No prior meta-analysis has directly compared restenosis or revision rates between Draf IIb and Draf III in chronic rhinosinusitis (CRS) or evaluated how Type 2 versus non-Type 2 endotypes influence these outcomes. Methods Following PRISMA guidelines, PubMed, MEDLINE, Embase, and ClinicalTrials.gov were searched on 5 January 2025 for studies reporting restenosis or revision after Draf IIb or Draf III in adults with CRS. Random-effects meta-analyses of proportions (Freeman–Tukey transformation; Hartung–Knapp CIs), pooled restenosis and revision rates, with subgroup analyses by procedure type and endotype. Results Thirty-eight studies met inclusion criteria (restenosis n = 1550; revision n = 1305). The pooled restenosis proportion across procedures was 9% (95% CI: 5-14%) and the pooled revision proportion was 9% (95% CI: 5-13%). Restenosis was lower after Draf IIb than Draf III (0.8% vs. 12%), with revision rates showing a similar pattern (2% vs. 10%). Type 2 CRS demonstrated higher pooled rates of restenosis (8% vs. 1%) and revision (12% vs. 3%) compared with non-Type 2 CRS. Conclusions Draf IIb is associated with lower pooled restenosis and revision rates than Draf III in CRS. Type 2 inflammatory endotype confers substantially higher risk of adverse frontal sinus outcomes. Incorporating endotype into procedural decision-making may improve prognosis. Prospective, endotype-stratified studies are needed to refine indications for Draf IIb versus Draf III and optimize adjunctive management strategies.