Principles of Practice

■ Accurate Diagnosis Is the Key to Success

A good surgeon is also a good physician. The best surgical results are often obtained by optimizing medical treatment both preoperatively and postoperatively (Fig. 1.1a, b). Optimizing medical treatment before surgery makes it less traumatic, reduces the chances of complications, and helps preserve olfactory mucosa. In order to optimize medical treatment, the surgeon needs to have an understanding of the mucosal disease. Postoperative medical treatment is frequently required to maintain the improvement that surgery produces.

The surgeon needs to have a good understanding of mucosal disease. History and examination should allow basic categorization of the disease present, but they are often insufficient to make an accurate diagnosis. It is often necessary to undertake other investigations (see Chapter 3) or to have a trial of medical treatment to clarify the underlying pathology.

Each of the clinical appearances shown in Table 1.1 can be associated with different pathological processes (Fig. 1.2a-f). Try to arrive at a diagnosis that fits into one of the broad groups that are used for the classification of rhinosinusitis. These groups are shown in Table 1.2.

In the light of history and examination, along with the relevant special investigations, the physician can

Table 1.1 Possible clinical criteria for diagnosing rhinosinusitis on the basis of length of history and observation

Length of history

Observation

Acute < 3 weeks

Subacute > 3 weeks, < 3 months

Chronic > 3 months

Erythema Edema

Hyperplastic mucosa

Polyposis Granular

mucosa

Purulent secretion

Dry mucosa

Table 1.2 Classification of rhinosinusitis

Infectious

Noninfectious

Viral

Allergic:

Bacterial

Intermittent or persistent

Fungal

Nonallergic:

Hormonal

Drug related

Vasculitis

Granulomatous

Autonomic

Idiopathic

Nasal Polyps Before And After

Fig. 1.1 Nasal polyps a before and b after medical treatment.

Infected Turbinate SymptomsHyperplastic Mucosa Allergy
Fig. 1.2 a Idiopathic rhinitis with erythema. b Hyperplastic mucosa due to allergic rhinitis. c Severe hypertrophy with edema. d Polyposis in a nonatopic patient. e Granular mucosa. f Dry mucosa.

obtain an idea of the underlying pathology (Table 1.3; Figs. 1.3a-d, 1.4a-d). Based on this, medical and surgical treatment can be maximized.

Allergic Rhinitis Medical Treatment

Fig. 1.3 a Normal middle meatus. b Serous secretions in marked allergic rhinitis. c Purulent bacterial secretions. d Purulent fungal secretions.

Table 1.3 Pathology of rhinosinusitis

Infectious

Viral

Bacterial (including TB, leprosy,

syphilis, etc.)

Fungal

Noninfectious

Allergy

Seasonal (intermittent) Perennial (persistent)

Idiopathic (no systemic evidence

of allergy or local infection)

Rhinitis medicamentosa

Excessive use of local sympathomimetic agents

Hormonal

High-estrogen contraceptive pill; pregnancy

Autonomic

Primary symptom is rhinorrhea often reduced by ipratropium bromide; few other nasal symptoms; patients often elderly. Important not to include in idiopathic group.

Sarcoidosis

Vasculitis

Wegener granulomatosis, systemic lupus erythematosus, overlap syndrome

Drug induced

Beta blockers, ACE inhibitors

Nasal Post Ethmoidectomy
Fig. 1.4a, b Endoscopic appearance of granulations and crusts in Wegener granulomatosis. c Coronal CT scan showing the mucosal changes consistent with Wegener granulomatosis;

■ Focus on the Patient's Main Complaint

The patient may mention any of a large array of symptoms in nasal disease. There are four primary symptoms that are always worth asking about:

1 Nasal obstruction

2 Sense of smell

3 Secretions

4 Pain or pressure

Nasal Erosion
there is often bony erosion as well. d Collapse of the nasal dorsum often seen in nasal Wegener granulomatosis.

It is important to rank these symptoms in their order of priority to the patient. This not only helps to make a diagnosis, but it focuses the surgeon's mind on how best to meet the patient's needs—underline the patient's main complaint.

Nose Dorsum Erosion
Fig. 1.5 a The amount of secretions produced per day. b Postnasal mucus in the pharynx. c Mucociliary pathways of mucus.

■ Dealing with the Patient's Expectations

The patient's priorities may differ from what the surgeon can achieve. For example, the patient's main concern might be their postnasal discharge, but the surgeon may only be able to improve the symptoms of obstruction with little alteration to the postnasal drip (Fig. 1.5a-d). It is therefore vital that the surgeon is forthcoming and makes it as clear as possible to the patient which symptoms can and cannot be improved or resolved. When the physician overlooks this prior to treatment, the patient is likely to be disappointed with the outcome. Be aware that some patients may believe that even symptoms that they have not mentioned will be cured.

The patient's expectations should coincide with the surgeon's prognosis. Thus, it is worth communicating to them which specific symptoms will not be helped.

Middle Meatus
d Purulent secretions from the middle meatus tracking over clear secretions.

■ Optimize Medical Treatment

While it is accepted that medical treatment will complement surgery in making the mucosa as healthy as possible, it is less well recognized that it can be a useful predictor of what can be achieved by surgery. For example, in a patient with anosmia and nasal polypo-sis, the use of oral and topical steroids can indicate the patient's remaining olfactory potential. If the patient has no sense of smell after a course of oral steroids (Fig. 1.6a-d), not even temporarily, then the surgeon must be very guarded in promising the patient that their sense of smell will be improved by surgery.

Topical Steroid Before After
Fig. 1.6a, b Endoscopic and c, d CT views before and after oral

■ Tailor the Surgery to Fit the Extent of the Problem

There is a price to be paid for extensive tissue removal. That price may include the loss of olfactory mucosa, frontonasal stenosis, altered sensation, dryness, and an increased risk of violating the boundaries of the paranasal sinuses (Fig. 1.7a, b).

Surgery is primarily aimed at improving ventilation of the sinuses and restoring mucociliary clearance. Removal of tissue alone does not cure mucosal disease. After a trial of full medical treatment, it is possible to see where surgery will be of most benefit. This means

Steroid Granules Rotator Cuff
steroids.

that it is often possible to preserve valuable tissue, such as mucosa in the olfactory cleft, that might otherwise be removed (Fig. 1.8a-d). Far less surgery is needed if medical treatment has been successful.

■ Minimize Surgical Morbidity

Morbidity can be caused by poor surgical technique, but it can also arise from excessive tissue removal. Good surgical technique is based on setting explicit goals and achieving these with the minimal amount of tissue trauma.

Removal Turbinate Bones
Fig. 1.7 a Endoscopic and b CT views after overzealous removal of olfactory mucosa.
Olfactory Mucosa
Fig. 1.8 a Right nasal airway showing severe nasal polyposis after oral steroids just prior to surgery. b Peroperative view after ethmoidectomy. c Peroperative gentle lateralization of the middle turbinate (note preservation of olfactory mucosa). d Postoperative CT view to show open olfactory cleft.
How Remove Polyp Sinus Hajek Forceps

Fig. 1.9 a Use of Hajek forceps to neatly remove the mucosa and bone of a right uncinate process. b Through-cutting forceps joining natural and accessory ostia.

Fig. 1.9 a Use of Hajek forceps to neatly remove the mucosa and bone of a right uncinate process. b Through-cutting forceps joining natural and accessory ostia.

Purulent Discharge From Turbinates

Fig. 1.10 a Nasal polyps in the olfactory area medial to the middle turbinate, deliberately not removed at surgery. b The superior turbinate can now be seen after lateralization of the middle turbinate along with 2 months of topical nasal steroids.

Fig. 1.10 a Nasal polyps in the olfactory area medial to the middle turbinate, deliberately not removed at surgery. b The superior turbinate can now be seen after lateralization of the middle turbinate along with 2 months of topical nasal steroids.

How Can This Be Achieved?

Work out what surgical steps are needed and then take them systematically. This strategy will not only avoid unnecessary tissue removal but is also very time efficient. Progress is made step by step rather than by aimlessly exploring the sinuses. You must decide which step needs to be done next and then do this as atraumatically as possible. This means:

• Punching tissue rather than tearing it.

• Preserving mucosal integrity in the frontonasal recess.

• Respecting olfactory mucosa.

• Avoiding mucosal damage to adjacent surfaces (Fig. 1.9a, b).

The surgeon must be aware of the variations in anatomy that can occur and the potential to cause damage to the surrounding structures (see further discussion in Chapter 6).

■ Sense of Smell Should Be Preserved at All Costs

Surgeons unfortunately often underestimate the importance of sense of smell to the patients. It is a sense that is all too often forgotten and may escape the notice of both surgeons and patients. The reason may be that the loss of this sense often creeps up on the patient slowly or that the patient does not recognize that this loss is responsible for the reduced enjoyment of food. In any case, the rewards for patients in preserving or restoring their sense of smell are enormous.

■ The Importance of Postoperative Treatment

Unfortunately, surgery on its own cannot achieve or maintain healthy nasal mucosa in most patients with noninfective rhinosinusitis. Accompanying medical treatment takes on a central role. During the operation, diseased mucosa is removed that has not recovered during preoperative medical treatment, thereby optimizing the drainage zones from the sinuses. Surgery may be able to overcome mucosa-

mucosa contact and restore mucociliary clearance, remove diseased tissue, and allow access to topical nasal treatment, but surgery in and of itself cannot cure intrinsic nasal disease (Fig. 1.10a, b).

Patients need to be made aware of the need for continuing treatment in order to achieve the best possible result and an improved quality of life. One way of getting this message across to your patients with intrinsic mucosal disease is to tell them that it is like "asthma of the nose," and they will need to keep the lining under control by regular medical treatment. This will help to prevent disappointment.

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