Goals of Surgery in Patients with Rhinosinusitis

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■ Why Surgery Can Help the Diseased Mucosa

Surgery in patients with rhinosinusitis can have several goals. These goals very much depend on the nature of the underlying pathology (Table 4.1;

• Opening sinus ostia to help restore mucociliary function.

• Removing diseased tissue to relieve the symptoms of nasal obstruction.

• Aiding the delivery and distribution of topical nasal treatment to any diseased mucosa, and in particular to the paranasal sinuses.

• Reducing the surface area from which diseased mucosa arise, e.g., polyposis.

• Opening the olfactory cleft to improve sense of smell.

• Removal of diseased tissue in benign nasal lesions (the treatment of inverted papilloma needs qualifying).

• Removal of foreign material from the sinuses: e.g., a dental root in the maxillary sinus, saprophytic aspergillosis.

• Reducing mucosa-mucosa contact: this is thought by some to be a factor in the etiology of polyposis. Removing contact areas also improves mucociliary clearance.

• Removal of bony anatomical variations causing obstruction of the airway, e.g., a very large concha bul-losa.

However, it is important to emphasize that many nasal and paranasal sinus conditions are due to mucosal disease that is associated with the upregulation and production of inflammatory mediators or a reduced immunity. There may be a genetic predisposition, e.g., atopy and allergic rhinitis, or in a few cases an inherited immunodeficiency; but in many there are inflammatory changes that are poorly understood, e.g., late-onset asthma and polyposis.

■ Rationale and Goals of Surgery in Specific Conditions

The reasons for surgery in specific conditions other than rhinosinusitis are more straightforward and are discussed below.

Unknown Pathology/Biopsy

• Histology is vital in order to make the right treatment plan (Diamantopopolous and Jones, 2000) (Fig. 4.2a, b).

Sphenoethmoidectomy
Fig. 4.1 a Preoperative and b postoperative views after a sphenoethmoidectomy—this illustrates many of the goals listed.

Table 4.1 Goals of surgery in chronic rhinosinusitis

Pathology

Goals

Realistic expectations for each symptom category

Chronic bacterial rhinosinusi-tis (resistant to medical treatment)

Recurrent acute bacterial rhinosinusitis (check if genuine, best to witness at least one episode and confirm with endoscope)

Fungal rhinosinusitis (mycetoma, non-allergic, noninvasive form of aspergillosis)

Idiopathic polyposis ("simple" inflammatory)

Polyposis associated with late-onset asthma

Improve mucociliary clearance and sinus aeration; allow douching (Stammberger, 1986)

Improve mucociliary clearance and sinus aeration and alter the environment to make it less favorable for pathogens

Improve mucociliary clearance and sinus aeration and alter the environment to make it unsuitable for pathogens.

Obstruction: Help Smell: Partial loss is often helped Mucus: Mucky. It becomes clear but may not cease Pressure or pain: Can be helped if there is a good association with the above symptoms, if there are exacerbations with purulent episodes, and if the pain is better when the mucus is no longer purulent after antibiotics

Obstruction: Not an associated symptom

Smell: Not an associated symptom

Mucus: Not an associated symptom

Pressure or pain: Can be helped, but be cautious, as many types of facial pain and pressure are not due to rhi-

nosinusitis. It is best to have good objective evidence at endoscopy or CT (even then, 1 in 3 of asymptomatic people have changes on CT)

Obstruction: If polyposis, surgery will help Smell: If associated with polyposis, will help Mucus: One of the few conditions where surgery does usually reduce mucus production

Pressure or pain: It is unusual for pain or pressure to be a feature of any form of fungal infection

Debulk the diseased mucosa; • Obstruction: Improvement, average return of symptoms reduce the mucosal surface area; aid access for douching and topical nasal treatment

Reduce the mucosal surface area; reduce mucosa-mucosa contact; restore mucociliary clearance; aid access for topical nasal treatment

Debulk disease and reduce

Polyposis associated with asthma and aspirin sensitivity the surface area from which polyps can originate

Polyposis associated with purulent disease

Polyposis associated with cystic fibrosis

Restore mucociliary clearance, reduce the mucosal surface area, aerate sinuses

Debulk diseased tissue; reduce the mucosal surface area; restore mucociliary clearance; aid access for douching and topical nasal treatment

6 years

Smell: Normally quoted as 70% better, but often does not persist for > 6 months in spite of topical treatment. With opening of the olfactory cleft (see text), the results are better

Mucus: Disappointing

Pressure or pain: Infrequently associated with polyposis Obstruction: Helps

Smell: Usually quoted as 70% better but often for

< 6 months. If the ethmoid sinuses are removed to allow lateralization of the middle turbinate, the improvement is superior in quality and length of time

Mucus: Inconsistent

Pressure or pain: Rarely a symptom

Obstruction: Helps, but symptoms are often only better for 12-48 months

Smell: Disappointing

Mucus: Disappointing

Pressure or pain: Rarely a symptom

Obstruction: Good Smell: Good Mucus: Good Pressure or pain: Good

Obstruction: Good, but often not > 12 months Smell: Poor

Mucus: No improvement—needs regular douching Pressure or pain: Rarely a symptom in this condition a

Middle Turbinate

Fig. 4.2 a A harmless-looking polyp in the right middle mea-tus. b A CT image of the harmless looking polyp in a, which proved to be an adenocarcinoma.

Fig. 4.2 a A harmless-looking polyp in the right middle mea-tus. b A CT image of the harmless looking polyp in a, which proved to be an adenocarcinoma.

Define Pterygopalatine Fossa
Fig. 4.3 a Clinical and b CT views showing a right frontal mu-cocele.

• Endoscopic access and visibility are often best (Howard and Lund, 1993).

• Studying the CT image helps to define the site for biopsy.

• Inflammatory polyps occur around a malignant lesion—avoid sampling only these.

• Endoscopic biopsy is associated with less morbidity than an external approach in some circumstances, e.g., the pterygopalatine fossa or orbit.

• An exception is an angiofibroma, as its MRI features are diagnostic.

Mucoceles

• The primary goal is marsupialization and not enu-cleation.

• Wide drainage with preservation of mucosa around the lumen. (Fig. 4.3 a, b).

• If accessible, endoscopic drainage provides less morbidity (Kennedy, 1994). 10

Antrochoanal Polyp

Remove the entire polyp along with its stalk and base (Fig. 4.4a, b).

Benign and Malignant Tumors

• Ensure total resection is achievable endoscopically, or warn the patient if an external approach may be needed (Fig.4.5a-4.7b).

• Endoscopic postoperative monitoring helps to detect any recurrence.

Endoscopic View OropharynxEndoscopic View Oropharynx

Fig. 4.4 a Axial CT scan and b an endoscopic view of an antro-choanal polyp that has extended into the nasopharynx and oropharynx.

Fig. 4.4 a Axial CT scan and b an endoscopic view of an antro-choanal polyp that has extended into the nasopharynx and oropharynx.

Choanal Polyp

Fig.4.5a, b Adenoameloblastoma that originated from the maxilla, for which a lateral rhinotomy may be needed to complete the resection.

Fig.4.5a, b Adenoameloblastoma that originated from the maxilla, for which a lateral rhinotomy may be needed to complete the resection.

Scan Sinus Polyps

Fig. 4.6a, b Lymphoma of the left orbit that also produced a nasal polyp. A biopsy of this helped make the diagnosis.

Fig. 4.6a, b Lymphoma of the left orbit that also produced a nasal polyp. A biopsy of this helped make the diagnosis.

Nasal Polyps Histology
b

Fig. 4.7 a Facial appearance and b CT findings in an amelanotic melanoma of the right paranasal sinuses that presented with epiphora and epistaxis.

Fig. 4.7 a Facial appearance and b CT findings in an amelanotic melanoma of the right paranasal sinuses that presented with epiphora and epistaxis.

Fig.4.8 a Peroperative and b CT views of an inverted papilloma—it should be checked for any evidence of atypia or malignancy.

Inverted Papilloma

• The key goal is to remove all macroscopic disease.

• This tissue must be examined for atypia or malignancy. Malignant transformation is rare if there is no evidence of atypia or malignancy in the resected tissue (Fig.4.8a, b).

• You need to inform the patient if external access may be needed, e.g., disease within the frontal sinus. nyr> 14

Periorbital Abscess

Barotrauma

• Ventilate the sinus and preserve mucosa at all cost.

Choanal Atresia

• Endoscopes aid access and visibility to allow an adequate airway.

• Cause as little trauma as possible to the mucosa (Fig.4.10a, b).

Epistaxis

• Localizing the site of bleeding is of the utmost importance.

• Avoid packing as this causes trauma to the nasal mucosa, making it difficult to find the site (Fig. 4.11 a, b).

• A primary aim is to occlude the vessel near its distal site. ny¡> 13

Distal Nasolacrimal Duct Obstruction

• A dacryocystorhinostomy creates a nasal fistula or rhinostomy in distal nasolacrimal duct obstruction (Fig. 4.12 a-c).

Nasal Turbinate Cauterization
Fig. 4.10a, b Surgical view of left choanal atresia in a newborn child with bilateral atresia
Imaging Traumatic Csf Leaks

Fig. 4.11 a, b Torrential epistaxis (arrow) from one branch of the sphenopalatine artery stopped by endoscopic cautery.

Fig. 4.11 a, b Torrential epistaxis (arrow) from one branch of the sphenopalatine artery stopped by endoscopic cautery.

Choanal Atresia Repair

• A dacryocystorhinostomy is less effective in the presence of coexisting proximal obstruction.

• A dacryocystorhinostomy may help functional outflow obstruction, but with mixed results, nyn 18

Repair of Dural and Skull Base Defects

• Confirm that it is a true CSF leak (beta-2-transfer-rin) (Fig,4,13 a-c),

• Precisely localize the defect,

• Endoscopic multilayered occlusion gives best results,

• Tell patients with defects of the frontal sinus that an external approach may be required,

• Not suitable if associated with malignancy,

• High-pressure leaks also need a shunt, nyn 15

Pituitary Surgery

• To provide access and visibility for tumor removal, ¡y/t> 17

Decompression of the Orbit

• The orbit may require decompression for cosmetic reasons,

• Decompress the orbital contents for corneal exposure, pain, or compromised optic nerve function (Fig, 4,14a, b),

• Helps in dysthyroid eye disease with reducing vision when steroids and radiotherapy fail,

Decompression of the Optic Nerve

• Early in the presence of reduced vision after trauma to the optic nerve,

• Visual evoked potentials are important as a useful objective test in lightly anesthetized or unconscious patients (Jones, 1997) (Fig, 4,15a-c),

Chronic rhinosinusitis has a significant adverse effect on patients' perception of quality of life (Gliklich and Metson, 1995), Over the last few years, there has been an increasing realization that improving nasal symptoms has a dramatic effect on patients' enjoyment of life that goes far beyond the nose (Fig,4,16), Discussion of this issue is also important in convincing healthcare providers that sinus surgery is of great value,

Fig. 4.12a-c Epiphora due to a dacryolith in the nasolacrimal sac.

Csf Leak Surgery Images
Fig. 4.13 a Clear unilateral rhinorrhea due to a CSF leak. b Endoscopic view of the left sphenoid sinus showing a CSF leak from the sphenoid sinus between the optic nerve (*) and carotid artery (+). c Axial CT scan showing the same defect (arrow) as in b with a fluid level of CSF.
Enophthalmos PicturesEnophthalmos Pictures

Fig. 4.15 a Left enophthalmos, periorbital ecchymosis, and subconjunctival hemorrhage secondary to a fracture of the medial wall of the orbit. b An axial CT scan showing disruption of the medial wall of the orbit toward its apex (arrow). c Peroperative endoscopic view showing the bony spicule that was pressing on the optic nerve.

Fig. 4.15 a Left enophthalmos, periorbital ecchymosis, and subconjunctival hemorrhage secondary to a fracture of the medial wall of the orbit. b An axial CT scan showing disruption of the medial wall of the orbit toward its apex (arrow). c Peroperative endoscopic view showing the bony spicule that was pressing on the optic nerve.

Walls The Orbit
Nerves Middle Turbinate
Fig. 4.16 A smell scientist testing new odors.

Endoscopic sinus surgery for chronic sinusitis results in an improvement in a general indicator of health, namely the SF-36 "Health Survey Questionnaire," as well as in disease-related symptoms (Win-stead and Barnett, 1998). The greatest negative general health impact of chronic rhinosinusitis in the study by Winstead and Barnett was on bodily pain, social functioning, and vitality when compared with a control group. These criteria were improved 12 months after surgery, along with physical functioning, mental health, and emotional status. Endoscopic sinus sur gery has also been shown to improve pulmonary function in patients with asthma and chronic rhinosinusi-tis (Ikeda et al., 1999), with an improvement in their average peak expiratory flow and a reduction in their need for corticosteroids.

In spite of these positive studies, we need to improve our understanding of the pathophysiology of rhinological conditions, their definition, and the staging procedures, and to validate all of these in order for us to improve the way we compare treatment strategies.

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