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■ Who Will Most Likely Profit from Surgery?

In determining which patients to select for surgery, the decision must be founded on the likelihood that surgical treatment is capable of offering the desired improvement. Patients with a diagnosis of rhi-nosinusitis and nasal polyposis who have not become symptom-free after maximum medical treatment are most likely to profit from surgery. These patients may have had a very good response to oral steroids, but their symptoms of hyposmia and congestion may start to return, even with continued topical treatment.

The key-question is: What symptoms does the patient have and how pronounced are they?

In making your selection, a patient's surgical history must also be considered carefully. If the patient has had previous sinus surgery that did not help, think twice before operating again. If surgery failed the first time, why should it work the second time? It is impor tant to be sure that the surgery was done well the first time, that the sinus ostia are open, and that there is no residual disease.

It is common to find that patients who have had previous surgery have some mucosal thickening of the lining of their sinuses on CT in spite of the sinus ostia being open. This does not necessarily mean that they have ongoing significant sinus disease. In this situation, it is important to go over the history, examination, and response to treatment in detail before embarking on surgery again (Fig. 2.1a, b).

■ Symptom-oriented Patient Selection

Other criteria in determining which patients to select are, of course, their symptoms. While surgery can provide an invaluable benefit in restoring patients' health and wellbeing, advocating surgery is not an appropriate response to all symptoms that our patients may report. Which are the cardinal symptoms?

cm cm

Pituitary After Surgery
Fig. 2.1a, b Typical CT images in two different patients showing changes after surgery. These mucosal changes in themselves do not mean that further surgery is warranted.

Nasal Obstruction

This is the main reason for operating, as it is one symptom that surgery can almost be guaranteed to help (Fig. 2.2). However, be careful about operating on anyone whose primary symptom is not nasal obstruction-think twice!

Also be careful about operating on someone who complains about nasal congestion but in whom there is no objective sign of poor airflow.

Facial Pain and Pressure

Facial pain and pressure are often wrongly attributed by patients and their primary care physicians as being due to rhinosinusitis (West and Jones, 2001).

In patients with chronic pain involving the face and/or head, it is important to see whether their symptoms are associated with, or exacerbated by, an upper respiratory tract infection and, furthermore, to see whether there is a temporal relationship with any purulent discharge. If they have no significant nasal symptoms and if their nasal endoscopy is normal, it is unlikely that their facial pain is due to rhinosinusitis. However, patients who have facial pain and purulent secretions at endoscopy do well with surgical or medical treatment, as over 80% will be helped.

Beware if pain and pressure are the patient's main symptoms. The majority of patients with nasal polypo-sis have no facial pain or pressure due to rhinosinusitis unless there are purulent secretions present as well (Fahy and Jones, 2001) (Fig. 2.3a, b).

However, if patients have symptoms of pain or pressure in addition to nasal obstruction and a loss of sense of smell, especially if the pain and pressure get worse with a cold or when flying or skiing, then you can advise the patient that these symptoms may be helped by surgery.

Disordered Sense of Smell

The patient whose sense of smell returns after oral steroids, only to deteriorate thereafter, is the patient whose sense of smell may benefit from surgery. A patient with anosmia who has had previous surgery is unlikely to regain any sense of smell if systemic steroids have not helped (Fig. 2.4). However, a patient with anosmia who has not had previous surgery and did not respond to oral steroids still has a small chance of regaining their sense of smell through an eth-moidectomy and gentle liberalization of the middle turbinate. It is vital that the middle and superior turbi-nate are treated with absolute care in these patients when surgery is done to open the olfactory cleft (Fig. 2.5a-d).

Reduction Turbinates
Fig. 2.2 Gross polyposis where the patient will appreciate the improvement in their airway after removal of the polyps.
Allergic Rhinitis Scan
Fig. 2.3 a The distribution of pain in a patient with a clear airway and b normal CT scan in a patient whose symptoms were due to midfacial segment pain.
Nate Exam Answers
Fig. 2.4 A patient with anosmia would give incorrect or negative answers on the patient questionnaire for the smell-screening test.

Anterior Rhinorrhea

Anterior rhinorrhea is usually secondary to viral or allergic rhinitis. The reason for anterior rhinorrhea in a viral rhinitis is not only an increase in mucus production but also paralysis of the cilia. The degree of cilial stasis that is needed to produce anterior purulent bacterial rhinor-rhea is unusual in bacterial infections and normally only occurs in cystic fibrosis and ciliary dyskinesia.

Posterior Rhinorrhea

As with facial pain, be very cautious about recommending surgery if posterior rhinorrhea is the patient's primary symptom (Fig. 2.6a, b). Surgery can help reduce the discoloration of the postnasal mucus by helping drainage, but it is important not to promise the patient a "cure," as mucus secretion may be due to systemic mucosal disease. Because of this, ongoing medical treatment is often important. Patients with asthma can expect an improvement in their lower respiratory symptoms. It is also important to take time to explain to the patient the connection between the upper and lower respiratory tracts.

Normally, the paranasal sinuses produce a cupful of mucus a day, and this is swallowed along with 1.5 liters of saliva. The sensation of an increase in mucus production felt in the back of the throat is called "postnasal drip." Patients often complain of a sensation of "something" in the back of the throat that they cannot clear and persistently attempt to clear their throat. Frequently, these symptoms are due to a hyperaware-ness of normal mucus. It is particularly important to warn these patients that this symptom cannot be helped by surgery. Other strategies, however, may help these patients; for example, breaking a cycle of repeated throat clearing, snorting, or hawking by swallowing ice-cold sparkling water instead.

■ Disease-oriented Patient Selection

Which pathological processes benefit from surgery? The symptom-oriented approach applies to the majority of patients with rhinosinusitis, whether they have polyps or not. However, there are specific diseases that deserve special mention.

Chronic Infective Rhinosinusitis

Patients with chronic infective rhinosinusitis who have not responded to medical treatment usually benefit from surgery unless they have an immunodeficiency or a disorder of ciliary motility (Fig. 2.7a, b).

Aspergillosis/Fungal Disease

Patients with saprophytic fungal disease have a good prognosis with surgery (Fig.2.8a-c). Allergic fungal disease responds well to surgery in combination with topical steroids (Simmen et al., 1998). It is possible to a c

Middle Turbinate Lateralization

Fig. 2.5 a Peroperative right ethmoidectomy. b Gentle lateral-ization of the middle turbinate to open the olfactory cleft.

Fig. 2.5 a Peroperative right ethmoidectomy. b Gentle lateral-ization of the middle turbinate to open the olfactory cleft.

c A lateralized middle turbinate after surgery. d Postoperative view of open olfactory cleft in the same patient at 6 months.

Olfactory CleftPee Was Clear Now Light Green And Cloudy
Fig. 2.7a, b A patient with purulent secretions that partially responded to prolonged medical treatment but remained symptomatic with middle meatal edema.
Olfactory CleftFungal Histology
Fig. 2.9 a Preoperative and b postoperative coronal CT scans in invasive fungal sinusitis. c Histology showing Aspergillus invading a blood vessel (arrow).
Olfactory Cleft

reverse much of the mucosal disease and reduce the amount of surgery required by giving itraconazole for 3 weeks before surgery. A similar postoperative course will reduce the risk of recurrence. Systemic steroids are best avoided as they can transform noninvasive or allergic aspergillosis into its invasive form. Invasive fungal disease has conventionally required surgical excision accompanied by medication with amphotericin (Fig. 2.9a-c). The introduction of itraconazole obviates the need for surgery in most cases of invasive aspergil-losis as long as there is no blood vessel invasion. However, if the disease has invaded blood vessels and is fulminant, then wide debridement and intravenous amphotericin are mandatory.

Maxillary Sinusitis Secondary to Dental Disease

Endonasal surgery is rarely required. If maxillary sinusitis persists in spite of good root canal or apicectomy treatment, then sinus surgery can help eradicate residual sinus disease.

Antrochoanal Polyp

Surgery is always indicated for this type of polyp because it does not response well to medical treatment. If the whole base of the polyp in the maxillary sinus is removed, the prognosis is good; otherwise, the polyp recurs (Fig.2.10a-d).

Images Antrochoanal Polyp
Scan Sinus Polyps
Fig. 2.10 a An antrochoanal polyp in the nasopharynx. b An antrochoanal polyp in the nasal airway. c Coronal CT scan of an antrochoanal polyp. d Surgical specimen of an antrochoanal polyp with its pedicle.
Inverted Papilloma Lip

Fig. 2.11 a The endoscopic appearance of inverted papilloma is typically whiter and less translucent than inflammatory polyps. b CT appearance of inverted papilloma with some loss of bony definition and expansion around the soft-tissue mass.

Fig. 2.11 a The endoscopic appearance of inverted papilloma is typically whiter and less translucent than inflammatory polyps. b CT appearance of inverted papilloma with some loss of bony definition and expansion around the soft-tissue mass.

Pictures Soft Mass NostrilAdenocarcinoma Ethmoid Sinus

Fig. 2.12 a A unilateral nasal lesion due to adenocarcinoma. b Endoscopic appearance of an adeno carcinoma of the ethmoid sinuses.

Inverted Papilloma

It is vital to send the whole specimen for histological examination, as 8-15% of inverted papillomas are associated with malignancy or atypia. If there are no features of malignancy, the prognosis depends on removing all the diseased tissue (Fig. 2.11 a, b). If there is any atypia or malignancy, a more radical en bloc procedure is indicated. OVl* 14

Unilateral Nasal Polyps Associated with Neoplasia

Surgery is necessary for biopsy and/or excision (Fig. 2.12a, b). Any unilateral nasal polyp should be treated with suspicion, even if it looks harmless (Fig. 2.13). It may disguise an underlying tumor or atypical infection (Fig. 2.14). A biopsy should be taken in order to ensure that no infection or tumor has been overlooked.

Benign and Malignant Tumors

Today, many tumors can be removed endonasally. Here, the complete removal of the tumor base is critical. If this is not tumor-free, the endonasal procedure must be accompanied by an external one.

Pediatric Rhinosinusitis

It is well recognized that adenoid hypertrophy and allergic rhinitis are common in children, as are recurrent upper respiratory tract infections (Fig. 2.15). The main causes of symptoms associated with rhinosinusitis in children are rhinorrhea, nasal obstruction, mouth breathing, hyponasal speech, and snoring. In children, adenoid hypertrophy reduces in size and the number

Adenoid Hyperplasia
Fig. 2.13 A neurofibroma originating from the sphenopalatine area. A unilateral polyp may disguise an underlying tumor or atypical infection.
Causes Turbinate Hypertrophy

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  • Minto
    What is the treatment of right adenoid hyperplasia tumor?
    4 years ago
  • Dennis
    How to cure antrochoanal polyp?
    3 years ago

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