Rhinology/allergy and immunology [First edition.] 9789351524564, 9351524566

Table of contents :
Cover
Contributors
Foreword
Preface
Acknowledgments
Contents
Section 1 : History Of Rhinology
The History Of Rhinology— From Ancient Times To The 21st Century
Section 2 : Embryology, Anatomy And Physiology
Evolution Of The Human Nasal Respiratory Tract: Nose And Paranasal Sinuses
Embryology And Development Of The Nose And Paranasal Sinuses
Anatomy Of The Nose, Paranasal Sinuses, And Anterior Skull Base
Physiology Of The Nose And Paranasal Sinuses
Section 3 : Evaluation Of The Nose And Paranasal Sinuses
Clinical Evaluation Of The Nose And Paranasal Sinuses
Acoustic Rhinometry And Objective Measures Of Nasal Airway Obstruction
Clinical Evaluation And Treatment Of Smell And Taste Disorders
Diagnostic Imaging In Rhinology
Measuring Quality Of Life And Outcomes In Rhinology
Practice Management, Coding, And Career Pathways In Rhinology
Section 4 : Allergy
Epidemiology And Pathophysiology Of Allergic Rhinitis
Evaluation And Diagnostic Testing Of Allergic Rhinitis
Treatment Of Allergic Rhinitis
Allergy, Reactive Airway Disease, And Rhinosinusitis: The Unified Airway
Section 5 : Disorders Of The Nose
Granulomatous And Inflammatory Diseases Of The Nose And Paranasal Sinuses
Fibro-osseous Lesions Of The Paranasal Sinuses
Benign Neoplasms Of The Nose And Paranasal Sinuses
The Nose And Sleep Disorders
Sinonasal Effects Of Drugs And Toxins
Epistaxis
Headache And Facial Pain
Section 6 : Rhinosinusitis: Etiology, Pathophysiology And Medical Therapy
Classification And Diagnosis Of Rhinosinusitis
The Pathogenesis Of Rhinosinusitis
Genetic Basis Of Rhinosinusitis
Immunologic Aspects Of Rhinosinusitis
Acute Rhinosinusitis
Bacteria In Rhinosinusitis: Infection, Biofilms, And Superantigens
Nasal Polyposis
Fungus In Paranasal Sinus Disease
Osteitis
Odontogenic Sinusitis
Reflux And Sinusitis
Complications Of Rhinologic Disorders
Antibiotic Therapy In Rhinosinusitis
Anti-inflammatory Therapy For Rhinosinusitis
Complementary Therapy And Integrative Medicine In Sinonasal Disease
Refractory Chronic Rhinosinusitis
Section 7 : Anesthesia
Local Anesthesia
Anesthesiology
Section 8 : Functional Surgery Of The Nasal Airway
Surgery Of The Nasal Septum
Surgical Management Of The Nasal Turbinates
Functional Rhinoplasty
Section 9 : Surgery For Inflammatory Sinusitis
Office-based Rhinologic Procedures
Endoscopic Sinus Surgery For Chronic Rhinosinusitis: Historical Evolution, Indications, And Outcomes
Training For Sinonasal Surgery: Past, Present And Future
Innovations In Optics And Instrumentation
Surgical Radiology And Image Guidance Surgery
Primary Endoscopic Sinus Surgery For Chronic Rhinosinusitis
Revision Sinus Surgery
Endoscopic Surgery Of The Frontal Sinus
Minimally Invasive Sinus Surgery And Balloon Sinuplasty
Open Approaches To The Paranasal Sinuses For Inflammatory Disorders
Odontogenic Disease And Oral–antral Fistula
Complications In Endoscopic Sinus Surgery
Section 10 : Endoscopic Skull Base Surgery
Endoscopic Surgery Of The Sella And Suprasellar Region
Endoscopic Surgery Of The Anterior Skull Base
Endoscopic Surgery Of The Pterygopalatine And Infratemporal Fossae
Endoscopic Surgery Of The Clivus, Craniocervical Junction, And Posterior Fossa
Endoscopic Surgery Of The Cavernous Sinus And Petrous Apex
Section 11 : Endoscopic Surgery Of The Orbit
Orbital Decompression
Endoscopic Dacryocystorhinostomy
Section 12 : The Future Of Rhinology: The Next Frontiers
The Future Of Rhinology: The Next Frontiers
Index
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Series Editor: Robert T Sataloff

 

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Sataloff’ Comprehen ive extbook of tolaryngology ead and e k Surgery MD DMA FACS

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rhinology/Allergy nd mmunology

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MD DMA FACS

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hinology/Allergy nd mmunology a

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Series Editor: Robert T Sataloff

 

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Sataloff’ Comprehen ive extbook of tolaryngology ead and e k Surgery

Vol. 2 Volume Editors

Marvin P Fried MD FACS Professor and University Chairman Department of Otorhinolaryngology—Head and Neck Surgery Montefiore Medical Center The University Hospital for Albert Einstein College of Medicine Bronx, New York, USA

Abtin Tabaee MD FARS FACS Associate Professor of Otolaryngology Department of Otolaryngology Weill Cornell Medical College New York, New York, USA

The Health Sciences Publisher New Delhi | London | Philadelphia | Panama

 

Jaypee Brothers Medical Publishers (P) Ltd

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The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. Inquiries for bulk sales may be solicited at: [email protected] Sataloff’s Comprehensive Textbook of Otolaryngology: Head and Neck Surgery: Rhinology/Allergy and Immunology (Vol. 2) First Edition: 2016 ISBN: 978-93-5152-456-4 Printed at

Dedication This book is dedicated to my wife, Rita, and my daughters, Jaimie and Karen, and their families who have always been there for me. They are my foundation. To those who have taught me and have been and are my colleagues, I am truly grateful. Marvin P Fried It is with eternal gratitude that I dedicate this book to the nurturing guidance of my mentors, the love and support of my wife, family and friends, and most of all, to the wisdom, sacrifice and dedication of my parents. It is through their collective words and deeds that the foundations of my career and life are based. Abtin Tabaee

Contributors Waleed M Abuzeid MD Assistant Professor Department of Otolaryngology— Head and Neck Surgery Montefiore Medical Center and Albert Einstein College Bronx, New York, USA Robert T Adelson MD Albany ENT and Allergy Albany, New York, USA Mohammad Al Bar MD University of Miami Miller School of Medicine Miami, Florida, USA Jeremiah A Alt MD PhD Assistant Professor Division of Otolaryngology University of Utah Salt Lake City, Utah, USA Vijay K Anand MD Clinical Professor of Otolaryngology Department of Otorhinolaryngology Weill Medical College of Cornell University New York, New York, USA Martin Anderson MD Resident Department of Otolaryngology Saint Louis University St Louis, Missouri, USA Jastin Antisdel MD Assistant Professor Department of Otolaryngology Saint Louis University School of Medicine St Louis, Missouri, USA Leonardo Balsalobre MD MPH Sao Paulo Ear, Nose, and Throat/Skull Base Center Complexo Hospitalar Edmundo Vasconcelos São Paulo, São Paulo, Brazil

Jacqueline A Bello MD Professor of Clinical Radiology Department of Radiology Montefiore Medical Center and Albert Einstein College of Medicine Bronx, New York, USA Michael S. Benninger MD Chairman, Professor of Surgery Head and Neck Institute The Cleveland Clinic Cleveland, Ohio, USA Seth M Brown MD MBA FACS Assistant Clinical Professor Department of Surgery Division of Otolaryngology University of Connecticut School of Medicine Farmington, Connecticut, USA Raewyn G Campbell MD Instructor, Division of Rhinology Department of Otorhinolaryngology— Head and Neck Surgery University of Pennsylvania Philadelphia, Pennsylvania, USA Roy R Casiano MD FACS Professor and Vice Chairman Department of Otolaryngology University of Miami Miller School of Medicine Miami, Florida, USA Peter J Catalano MD Professor Department of Otolaryngology Tufts University Chief of Otolaryngology St. Elizabeth Medical Center Boston, Massachusetts, USA Mohamad R Chaaban MD University of Alabama at Birmingham Medical Director Lanier Nasal and Sinus Institute Birmingham, Alabama, USA

Rakesh Chandra MD Associate Professor Department of Otolaryngology Vanderbilt University Nashville, Tennessee, USA Jerry Chao MD Assistant Professor Department of Anesthesiology Montefiore Medical Center and Albert Einstein College of Medicine Bronx, New York, USA Philip G Chen MD Assistant Professor Department of Otolaryngology— Head and Neck Surgery University of Texas Health Science Center San Antonio San Antonio, Texas, USA Nipun Chhabra MD Otolaryngologist, OSF Healthcare Peoria, Illinois, USA Alexander G Chiu MD Professor and Chair Department of Otolaryngology— Head and Neck Surgery University of Arizona Tucson, Arizona, USA Patrick Colley MD Department of Otolaryngology— Head and Neck Surgery Mount Sinai Health Systems New York, New York, USA Jacquelynne P Corey MD FACS FAAOA Professor, Department of Surgery Section of Otolaryngology— Head and Neck Surgery University of Chicago Chicago, Illinois, USA Ryan A Crane MD Resident, Department of Otolaryngology—Head and Neck Surgery University of Cincinnati Cincinnati, Ohio, USA

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Dustin M Dalgorf MD FRCSC Clinical Lecturer Department of Otolaryngology— Head and Neck Surgery University of Toronto Toronto, Ontario, Canada Subinoy Das MD Adjunct Clinical Assistant Professor Department of Otolaryngology— Head and Neck Surgery The Ohio State University Columbus, Ohio, USA Gabriele de Vos MD Assistant Professor Department of Medicine Division of Allergy and Immunology Albert Einstein College of Medicine Bronx, New York, USA

James Duncavage MD Professor, Department of Otolaryngology Vanderbilt University Medical Center Nashville, Tennessee, USA Jean Anderson Eloy MD FACS Professor and Vice Chairman Director, Rhinology and Sinus Surgery Director, Otolaryngology Research Co-Director, Endoscopic Skull Base Surgery Program Department of Otolaryngology— Head and Neck Surgery Rutgers New Jersey Medical School Newark, New Jersey, USA Joaquim Farinhas MD Associate Professor of Clinical Radiology Department of Radiology Montefiore Medical Center Bronx, New York, USA

Adam S DeConde MD Assistant Clinical Professor Department of Surgery Division of Otolaryngology— Head and Neck Surgery University of California, San Diego San Diego, California, USA

Berrylin J Ferguson MD Professor, Division of Sinonasal Disorders and Allergy Department of Otolaryngology University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania, USA

John M DelGaudio MD Professor and Vice Chair Chief of Rhinology and Sinus Surgery Residency Program Director Department of Otolaryngology Emory University Atlanta, Georgia, USA

Juan C Fernandez-Miranda MD Associate Professor of Neurological Surgery Director, Surgical Neuroanatomy Lab University of Pittsburgh Pittsburgh, Pennsylvania, USA

Richard L Doty MD Director and Professor Smell and Taste Center Department of Otorhinolaryngology— Head and Neck Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania, USA Eugenie Du MD Resident Department of Otorhinolaryngology— Head and Neck Surgery Albert Einstein College of Medicine Montefiore Medical Center Bronx, New York, USA

Carrie E Flanagan MD Ear, Nose, and Throat Andrews Air Force Base Maryland, USA Rebecca E Fraioli MD Otolaryngology—Head and Neck Surgery Montefiore Greene Medical Arts Bronx, New York, USA Marvin P Fried MD FACS Professor and University Chairman Department of Otorhinolaryngology— Head and Neck Surgery Montefiore Medical Center The University Hospital for Albert Einstein College of Medicine Bronx, New York, USA

Mark E Friedel MD MPH Clinical Associate Department of Otorhinolaryngology University of Pennsylvania Advanced Ear, Nose and Throat Voorhees, New Jersey, USA Paul A Gardner MD Assistant Professor of Neurological Surgery Director, Center for Skull Base Surgery University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania, USA Jamie L Gentile MD Resident Physician Department of Otolaryngology— Head and Neck Surgery University of Cincinnati Cincinnati, Ohio, USA Rachel Georgopoulos MD Department of Otolaryngology Temple University Philadelphia, Pennsylvania, USA Marc J Gibber MD Assistant Professor Department of Otolaryngology— Head and Neck Surgery Montefiore Medical Center Bronx, New York, USA Arel Golombeck MD Assistant Professor Department of Radiology Mount Sinai Hospital New York, New York, USA Satish Govindaraj MD FACS Associate Professor Department of Otolaryngology— Head and Neck Surgery Icahn School of Medicine at Mount Sinai New York, New York, USA Sezelle Gereau Haddon MD Integrative Otolaryngology Mount Sinai Beth Israel Integrative Medicine New York, New York, USA

Contributors Richard J Harvey MD Professor and Program Head Radiology and Skull Base Applied Medical Research Center University of New Southwest and Macquarie University Sydney, Australia

Alexis H Jackman MD Assistant Professor Department of Otorhinolaryngology— Head and Neck Surgery Albert Einstein College of Medicine/ Montefiore Medical Center Bronx, New York, USA

Samuel N Helman Medical Student Albert Einstein College of Medicine Bronx, New York, USA

Joseph B Jacobs MD Professor Department of Otolaryngology New York University Langone Medical Center New York, New York, USA

Brian L Hendricks MD Resident Department of Otolaryngology— Head and Neck Surgery University of Cincinnati Cincinnati, Ohio, USA Mira Herman MD Resident Department of Radiology Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York, USA Diego Rodrigo Hermann MD Ear, Nose and Throat Surgeon Department of Ear, Nose and Throat and Skull Base Centro de Otorrinolaringologia de São Paulo São Paulo, São Paulo, Brazil Yan W Ho MD Resident, Department of Otolaryngology— Head and Neck Surgery The Icahn School of Medicine at Mount Sinai New York, New York, USA Nicole M Hsu MD Resident, New York Presbyterian Hospital New York, New York, USA Peter H Hwang MD Professor and Chief Division of Rhinology and Endoscopic Skull Base Surgery Department of Otolaryngology— Head and Neck Surgery Stanford University School of Medicine Stanford, California, USA

Elina Jerschow MD Assistant Professor Department of Medicine Allergy/Immunology Division Albert Einstein College of Medicine/Montefiore Medical Center Bronx, New York, USA Ashutosh Kacker MD Professor of Clinical Otolaryngology Department of Otolaryngology— Head and Neck Surgery Weill Cornell Medical College New York, New York, USA Azeem S Kaka MD Resident Department of Otolaryngology— Head and Neck Surgery The Ohio State University Columbus, Ohio, USA Rachel Kaye MD House Staff, PGY-4 Department of Otorhinolaryngology— Head and Neck Surgery Montefiore Medical Center Bronx, New York, USA David W Kennedy MD Rhinology Professor Otorhinolaryngology— Head and Neck Surgery Hospital of the University of Pennsylvania Philadelphia, Pennsylvania, USA

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Robert C Kern MD George A Sisson Professor of Otolaryngology Chair, Department of Otolaryngology— Head and Neck Surgery Professor, Otolaryngology— Head and Neck Surgery and Medicine-Allergy-Immunology Northwestern University Feinberg School of Medicine Chicago, Illinois, USA Osaama H Khan MD Western Hospital, University of Toronto Toronto, Ontario, Canada Esther Kim MD Walter Reed National Military Medical Center Bethesda, Maryland, USA Richard A Kraut DDS Chairman, Department of Dentistry Montefiore Medical Center Bronx, New York, USA Daniel Krieger MD Chief Resident, Department of Radiology Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York, USA John H Krouse MD PhD Professor and Chairman Department of Otolaryngology— Head and Neck Surgery Temple University Philadelphia, Pennsylvania, USA Arjuna B Kuperan MD Rhinology Fellow, Department of Otolaryngology—Head and Neck Surgery University of Miami Miami, Florida, USA Jeffrey T Laitman PhD DMedSc (Hon) FAAAS FAAA FALA

Distinguished Professor Professor and Director of Anatomy and Functional Morphology Professor of Otolaryngology Professor of Medical Education Director of Gross Anatomy Center for Anatomy and Functional Morphology Icahn School of Medicine at Mount Sinai New York, New York, USA

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Kent Lam MD Department of Otolaryngology— Head and Neck Surgery Northwestern University Feinberg School of Medicine Chicago, Illinois, USA Andrew P Lane MD Professor Department of Otolaryngology— Head and Neck Surgery Johns Hopkins School of Medicine Baltimore, Maryland, USA Donald C Lanza MD MS Director Sinus and Nasal Institute of Florida Foundation Saint Petersburg, Florida, USA Adrienne M Laury MD Assistant Professor Department of Otolaryngology Brooke Army Medical Center JBSA—Fort Sam Houston San Antonio, Texas, USA William Lawson MD Professor Department of Otolaryngology Mount Sinai Hospital New York, New York, USA Jenna Le MD Resident Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York, USA Philip Lebowitz MD Professor of Clinical Anesthesiology Department of Anesthesiology Albert Einstein College of Medicine Montefiore Medical Center Bronx, New York, USA

Stella Lee MD Assistant Professor Department of Otolaryngology University of Pittsburgh Pittsburgh, Pennsylvania, USA Seth M Lieberman MD Assistant Professor Department of Otolaryngology New York University Langone Medical Center New York, New York, USA Giant Lin MD Private Practice Mount Arlington, New Jersey, USA Sandra Y Lin MD Associate Professor Department of Otolaryngology— Head and Neck Surgery Johns Hopkins School of Medicine Baltimore, Maryland, USA Patricia A Loftus MD Resident Department of Otorhinolaryngology— Head and Neck Surgery Albert Einstein College of Medicine Bronx, New York, USA Songhui Ma MD Clinical Instructor Department of Medicine Mount Sinai School of Medicine New York, New York, USA Samuel Márquez MD Assistant Professor Department of Cell Biology Department of Otolaryngology SUNY Downstate Medical Center Brooklyn, New York, USA

Richard A Lebowitz MD Associate Professor Department of Otolaryngology New York University School of Medicine New York, New York, USA

Andrew McClelland MD PhD Chief Resident Diagnostic Radiology Residency Program Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York, USA

Jimmy Lee MD Department of Ophthalmology and Visual Sciences Montefiore Medical Center Bronx, New York, USA

Edward D McCoul MD Clinical Instructor Department of Otolaryngology University of Washington Seattle, Washington, USA

Caitlin McMullen MD Resident Department of Otorhinolaryngology— Head and Neck Surgery Albert Einstein College of Medicine Montefiore Medical Center Bronx, New York, USA Ralph Metson MD Clinical Professor Department of Otology and Laryngology Harvard Medical School Boston, Massachusetts, USA Justine BF Millar MD Doctor Department of Otolaryngology St. Vincents Hospital Darlinghurst NSW, Australia James W Mims MD Associate Professor Department of Otolaryngology Wake Forest University School of Medicine Winston-Salem, North Carolina, USA Sam P Most MD FACS Professor Department of Otolaryngology— Head and Neck Surgery Stanford University School of Medicine Stanford, California, USA Gurston G Nyquist MD Assistant Professor Department of Otolaryngology Thomas Jefferson University Philadelphia, Pennsylvania, USA Richard R Orlandi MD Professor Division of Otolaryngology— Head and Neck Surgery University of Utah Salt Lake City, Utah, USA Whitney Pafford MD Ear, Nose, Throat and Sinus Associates Lima, Ohio, USA Anthony S Pagano MD Clinical Instructor Mount Sinai Hospital Icahn School of Medicine at Mount Sinai New York, New York, USA

Contributors James N Palmer MD Professor and Director Division of Rhinology Department of Otorhinolaryngology— Head and Neck Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania, USA Purvi Parikh MD Clinical Instructor Department of Medicine and Pediatrics New York University School of Medicine New York, New York, USA Steven Y Park MD Assistant Professor Department of Otorhinolaryngology Albert Einstein College of Medicine Bronx, New York, USA Charles Parker MD Resident, Department of Otolaryngology— Head and Neck Surgery University of Cincinnati Cincinnati, Ohio, USA James Phillips MD Department of Surgery Division of Otolaryngology— Head and Neck Surgery University of Alabama at Birmingham Birmingham, Alabama, USA Michael Platt MD Boston University School of Medicine Boston Medical Center Boston, Massachusetts, USA Steven D Pletcher MD Associate Professor Department of Otolaryngology— Head and Neck Surgery University of California, San Francisco San Francisco, California, USA

Jeremy T Reed MD Assistant Professor Department of Otolaryngology Uniformed Services University of the Health Sciences Bethesda, Maryland, USA Dale H Rice MD Professor Department of Otolaryngology— Head and Neck Surgery University of Southern California Los Angeles, California, USA Kenneth Rodriguez MD Chief of Rhinology, Allergy, and Anterior Skull Base Surgery Department of Otolaryngology— Head and Neck Surgery University Hospitals Case Medical Center Assistant Professor of Otolaryngology— Head and Neck Surgery Case Western Reserve University School of Medicine Cleveland, Ohio, USA Marc R Rosen MD Professor Department of Otolaryngology— Head and Neck Surgery and Neurological Surgery Thomas Jefferson University Philadelphia, Pennsylvania, USA David L Rosenstreich MD Professor Departments of Medicine, Microbiology and Immunology and Otorhinolaryngology Albert Einstein College of Medicine and Montefiore Medical Center Bronx, New York, USA

David M Poetker MD MA Associate Professor Division of Otolaryngology Zablocki VA Medical Center Milwaukee, Wisconsin, USA

Bradley A Schiff MD Associate Professor Department of Otorhinolaryngology— Head and Neck Surgery Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York, USA

Roheen Raithatha MD Clinical Instructor Department of Otolaryngology Icahn School of Medicine at Mount Sinai New York, New York, USA

Robert Schwarcz MD Associate Adjunct Surgeon New York Eye and Ear Infirmary of Mount Sinai New York, New York, USA

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Theodore H Schwartz MD Professor Neurological Surgery Weill Cornell Medical College New York, New York, USA Allen M Seiden MD Professor Department of Otolaryngology— Head and Neck Surgery University of Cincinnati College of Medicine Cincinnati, Ohio, USA Brent A Senior MD Professor Otolaryngology—Head and Neck Surgery University of North Carolina at Chapel Hill Chapel Hill, North Carolina, USA Michael Setzen MD Clinical Associate Professor Otolaryngology— Head and Neck Surgery New York University School of Medicine New York, New York, USA Josef Shargorodsky MD Coastal Ear, Nose and Throat Jersey Shore University Medical Center Neptune, New Jersey, USA Raj Sindwani MD FACS FRCS(C) Vice Chairman and Section Head Rhinology, Sinus and Skull Base Surgery Head and Neck Institute The Cleveland Clinic Foundation Cleveland, Ohio, USA Ameet Singh MD Assistant Professor of Surgery (Otolaryngology) and Neurosurgery Co-Director Endoscopic Pituitary and Skull Base Surgery The George Washington University Washington, DC, USA Timothy L Smith MD MPH Professor Department of Otolaryngology— Head and Neck Surgery Oregon Health and Science University Portland, Oregon, USA

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James B Snow, Jr MD Professor Philosophy Department Loyola University Baltimore, Maryland, USA

Jeffrey D Suh MD Assistant Professor Department of Head and Neck Surgery University of California, Los Angeles Los Angeles, California, USA

Carl H Snyderman MD MBA Professor Departments of Otolaryngology and Neurological Surgery University of Pittsburgh Pittsburgh, Pennsylvania, USA

Abtin Tabaee MD FARS FACS Associate Professor of Otolaryngology Department of Otolaryngology Weill Cornell Medical College New York, New York, USA

Alla Y Solyar MD Sinus and Nasal Institute of Florida St. Petersburg, Florida, USA

Brian Thorp MD Otolaryngologist University of North Carolina Chapel Hill, North Carolina, USA

Susan Sotardi MD Albert Einstein College of Medicine Bronx, New York, USA Ari Spiro Md Resident Department of Radiology Montefiore Medical Center Albert Einstein College of Medicine Bronx, New York, USA Aldo Cassol Stamm MD Director Sao Paulo Ear, Nose and Throat and Skull Base Hospital Professor Edmundo Vasconcelos Sao Paulo, Sao Paulo, Brazil James A Stankiewicz MD Professor and Chair Department of Otolaryngology— Head and Neck Surgery Loyola University of Chicago Chicago, Illinois, USA

Troy Woodard MD Department of Otolaryngology Head and Neck Institute The Cleveland Clinic Cleveland, Ohio, USA

Oscar Trujillo MD Department of Otolaryngology— Head and Neck Surgery Weill Cornell Medical College New York, New York, USA

Bradford A Woodworth MD James J. Hicks Associate Professor of Surgery Department of Surgery Division of Otolaryngology University of Alabama at Birmingham Birmingham, Alabama, USA

Satyen Undavia MD Private Practice Havertown, Pennsylvania, USA Christopher Vanison MD Resident Physician Otolaryngology— Head and Neck Surgery Northwestern Memorial Hospital Chicago, Illinois, USA Eduardo de Arnaldo Silva Vellutini Neurosurgeon DFV Neuro São Paulo, São Paulo, Brazil

Janalee K Stokken MD Otolaryngology Rhinology Fellow Cleveland, Ohio, USA

Andrea S Wang MD Assistant Professor Weill Cornell Medical College New York, New York, USA

Calvin C Wei MD Department of Otolaryngology— Head and Neck Surgery Mount Sinai St. Luke’s— Roosevelt Hospital New York, New York, USA Sarah K Wise MD Assistant Professor Director of Resident Education Otolaryngology— Head and Neck Surgery Emory University Atlanta, Georgia, USA

Elina M Toskala MD PhD Professor Department of Otolaryngology— Head and Neck Surgery Temple University Philadelphia, Pennsylvania, USA

Michael G Stewart MD MPH Professor and Chairman Weill Cornell Medical College New York, New York, USA

Eric W Wang MD Assistant Professor Department of Otolaryngology University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania, USA

Peter-John Wormald MD Professor and Chairman Department of Otolaryngology— Head and Neck Surgery University of Adelaide Adelaide, South Australia, Australia MD

Bozena B Wrobel MD Assistant Professor Department of Otolaryngology— Head and Neck Surgery University of Southern California Los Angeles, California, USA Whitney Zirkle MD Chicago, Illinois, USA

Foreword Sataloff’s Comprehensive Textbook of Otolaryngology: Head and Neck Surgery is a component of the most extensive compilation of information in otolaryngology—head and neck surgery to date. The six volumes of the comprehensive textbook are part of a 12-volume, encyclopedic compendium that also includes a six-volume set of detailed, extensively illustrated atlases of otolaryngologic surgical techniques. The vision for the Comprehensive Textbook was realized with the invaluable, expert collaboration of eight world-class volume editors. Chapter authors include many of the most prominent otolaryngologists in the world, and coverage of each subspecialty is extensive, detailed and scholarly. Anil K Lalwani, MD edited the volume on otology/neurotology/skull base surgery. Like all six of the volumes in the Comprehensive Textbook, the otology/neurotology/skull base surgery volume is designed not only as part of the multivolume book, but also to stand alone or in combination with the atlas of otological surgery. Dr Lalwani’s volume covers anatomy and physiology of hearing and balance, temporal bone radiology, medical and surgical treatment of common and rare disorders of the ear and related structures, occupational hearing loss, aural rehabilitation, cochlear and brainstem implantation, disorders of the facial nerve, and other topics. Each chapter is not only replete with the latest scientific information, but also accessible and practical for clinicians. The rhinology/allergy and immunology volume by Marvin P Fried and Abtin Tabaee is the most elegant and inclusive book on the topic to date. Drs Fried and Tabaee start with a history of rhinology beginning in ancient times. The chapters on evolution of the nose and sinuses, embryology, sinonasal anatomy and physiology, and rhinological assessment are exceptional. The volume includes discussions of virtually all sinonasal disorders and allergy, including not only traditional medical and surgical therapy but also complementary and integrative medicine. The information is state-of-the-art. Anthony P Sclafani’s volume on facial plastic and reconstructive surgery is unique in its thoroughness and practicality. The volume covers skin anatomy and physiology, principles of wound healing, physiology of grafts and flaps, lasers in facial plastic surgery, aesthetic analysis of the face and other basic topics. There are extensive discussions on essentially all problems and procedures in facial plastic and reconstructive surgery contributed by many of the most respected experts in the field. The volume includes not only cosmetic and reconstructive surgery, but also information on diagnosis and treatment of facial trauma. The volume on laryngology edited by Dr Michael S Benninger incorporates the most current information on virtually every aspect of laryngology. The authors constitute a who’s who of world experts in voice and swallowing. After extensive and practical discussions of science and genetics, the volume reviews diagnosis and treatment (traditional and complementary) of laryngological disorders. Chapters on laser physics and use, voice therapy, laryngeal dystonia, cough, vocal aging and many other topics provide invaluable “pearls” for clinicians. The volume also includes extensive discussion of surgery for airway disorders, office-based laryngeal surgery, laryngeal transplantation and other topics. For the volume on head and neck surgery, Drs Patrick J Gullane and David P Goldstein have recruited an extra­ ordinary group of contributors who have compiled the latest information on molecular biology of head and neck cancer, principles of radiation, immunobiology, medical oncology, common and rare head and neck malignancies, endocrine neoplasms, lymphoma, deep neck space infections and other maladies. The surgical discussions are thorough and richly illustrated, and they include definitive discussions of free flap surgery, facial transplantation and other subjects. Dr Christopher J Hartnick’s vision for the volume on pediatric otolaryngology was expansive, elegantly scholarly and invaluable clinically. The volume begins with information on embryology, anatomy, genetics, syndromes and other complex topics. Dr Hartnick’s contributors include basic discussions of otolaryngologic examination in a pediatric patient, imaging, hearing screening and aural rehabilitation, and diagnosis and treatment of diseases of the ear, nose, larynx, oral cavity, neck and airway. Congenital, syndromic and acquired disorders are covered in detail, as are special, particularly vexing problems such as chronic cough in pediatric patients, breathing and obstructive sleep apnea in children, pediatric voice disorders, and many other subjects. This volume will be invaluable to any otolaryngologist who treats children.

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Rhinology/Allergy and Immunology

All of us who have been involved with the creation of the six-volume Sataloff’s Comprehensive Textbook of Otolaryngology: Head and Neck Surgery and its companion six-volume set of surgical atlases hope and believe that our colleagues will find this new offering to be not only the most extensive and convenient compilation of information in our field, but also the most clinically practical and up-to-date resource in otolaryngology. We are indebted to Mr Jitendar P Vij (Group Chairman) and Mr Ankit Vij (Group President) of M/s Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, India, for their commitment to this project, and for their promise to keep this work available not only online but also in print. We are indebted also to the many otolaryngologists who have contributed to this work not only by editing volumes and writing chapters, but also by asking questions that inspired many of us to seek the answers found on these pages. We also thank especially the great academic otolaryngologists who trained us and inspired us to spend our nights, weekends and vacations writing chapters and books. We hope that our colleagues and their patients find this book useful. Robert T Sataloff MD DMA FACS Professor and Chairman Department of Otolaryngology—Head and Neck Surgery Senior Associate Dean for Clinical Academic Specialties Drexel University College of Medicine Philadelphia, Pennsylvania, USA

Preface The field of rhinology has undergone a dramatic evolution in the past two decades. Landmark events that have occurred during this period include the widespread adoption of advanced technologies, the expansion of endoscopic techniques to complex skull base pathologies, and a dedicated focus on clinical and basic science research. This process has been, in large part, fueled by the increasing sub-specialization of the field, including the continued growth of fellowship programs and clinician-scientists dedicated to rhinology. As the breadth of the field has expanded, so too have our horizons. It is interesting that the trends in rhinology have moved in different directions for various aspects of the field. For example, the indications and capabilities of endoscopic approaches for skull base tumors have increasingly expanded; at the same time, there has been a greater interest in minimally invasive techniques for inflammatory sinusitis, including balloon dilation technology. Integral to the development of novel surgical techniques and technology is a greater emphasis on a more holistic approach to surgical outcome analysis, including an emphasis on patient-scored quality-of-life measures. In parallel, the striking increase in the number and quality of basic science research articles is beginning to address fundamental questions, including the pathophysiologic basis of inflammatory sinusitis. This is an exciting time in rhinology as the field collectively looks back on its recent advances and towards the future to the remaining unanswered questions. In creating this volume, our primary goal has been to provide a comprehensive reference for the field of rhinology, including the fundamental underpinnings of anatomy, physiology, and radiology; a practical approach to the evaluation of patient with sinonasal disorders; a description of the full spectrum of rhinologic disorders, including the different subtypes of rhinitis and sinusitis; and a comprehensive approach to medical and surgical management of sinonasal disorders. Sections reviewing sinonasal malignancy, trauma, and cosmetic rhinoplasty can be found in the volumes dedicated to these disorders. Advanced surgical techniques are discussed in detail, including indications, techniques, and outcomes. We have also included thought-provoking chapters on the history and future of rhinology, current models of rhinology training, and practical aspects of practice management. We are fortunate to have a dynamic and storied list of authors, each with an exceptional level of expertise and wisdom. Their individual contributions to this volume have helped to create a seminal reference for the field of rhinology. Marvin P Fried MD FACS Abtin Tabaee MD FARS FACS

Acknowledgments The editors would like to thank Joseph Rusko, Marco Ulloa, Carol Rogers Field, Bridget Meyer, Thomas Gibbons and the rest of the Jaypee Brothers team. Without their perseverance and hard work, this volume would not have been possible. Special thanks are offered to the authors, who have shared their expertise and experience in order to improve the care of rhinology/allergy and immunology patients. We would also like to thank Mr Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President), Ms Chetna Malhotra Vohra (Associate Director), Mr Umar Rashid (Development Editor) and Production team of Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, India.

Contents Section 1: History of Rhinology 1. The History of Rhinology—From Ancient Times to the 21st Century

3

Patrick Colley, Marvin P Fried, Abtin Tabaee

Section 2: Embryology, Anatomy and Physiology 2. Evolution of the Human Nasal Respiratory Tract: Nose and Paranasal Sinuses

17

Samuel Márquez, Anthony S Pagano, William Lawson, Jeffrey T Laitman

3. Embryology and Development of the Nose and Paranasal Sinuses

43

Martin Anderson, Jastin Antisdel, Raj Sindwani

4. Anatomy of the Nose, Paranasal Sinuses, and Anterior Skull Base

53

Ameet Singh, Abtin Tabaee

5. Physiology of the Nose and Paranasal Sinuses

73

Richard A Lebowitz, Whitney Pafford

Section 3: Evaluation of the Nose and Paranasal Sinuses 6. Clinical Evaluation of the Nose and Paranasal Sinuses

83

Steven D Pletcher

7. Acoustic Rhinometry and Objective Measures of Nasal Airway Obstruction

91

Mohamad R Chaaban, Jacquelynne P Corey

8. Clinical Evaluation and Treatment of Smell and Taste Disorders

101

Richard L Doty, James B Snow, Jr

9. Diagnostic Imaging in Rhinology

117

Mira Herman, Daniel Krieger, Andrew McClelland, Susan Sotardi, Ari Spiro, Jenna Le, Caitlin McMullen, Arel Golombeck, Jimmy Lee, Jacqueline A Bello, Joaquim Farinhas

10. Measuring Quality of Life and Outcomes in Rhinology

169

David M Poetker, Timothy L Smith

11. Practice Management, Coding, and Career Pathways in Rhinology

179

Seth M Brown, Michael Setzen

Section 4: Allergy 12. Epidemiology and Pathophysiology of Allergic Rhinitis

191

James W Mims

13. Evaluation and Diagnostic Testing of Allergic Rhinitis David L Rosenstreich, Elina Jerschow, Purvi Parikh, Gabriele de Vos

201

xx

Rhinology/Allergy and Immunology

14. Treatment of Allergic Rhinitis

215

Stella Lee, Michael Platt, Sandra Y Lin

15. Allergy, Reactive Airway Disease, and Rhinosinusitis: The Unified Airway

233

Rachel Georgopoulos, Elina M Toskala, John H Krouse

Section 5: Disorders of the Nose 16. Granulomatous and Inflammatory Diseases of the Nose and Paranasal Sinuses

249

Caitlin McMullen, Alexis H Jackman

17. Fibro-Osseous Lesions of the Paranasal Sinuses

263

James Phillips, Bradford A Woodworth

18. Benign Neoplasms of the Nose and Paranasal Sinuses

273

Brian Thorp, Kenneth Rodriguez, Brent A Senior

19. The Nose and Sleep Disorders  

285

Steven Y Park, Samuel N Helman

20. Sinonasal Effects of Drugs and Toxins

297

Carrie E Flanagan, Sarah K Wise

21. Epistaxis

319

Patricia A Loftus, Alexis H Jackman

22. Headache and Facial Pain

331

Charles Parker, Jamie L Gentile, Brian L Hendricks, Ryan A Crane, Allen M Seiden

Section 6: Rhinosinusitis: Etiology, Pathophysiology and Medical Therapy 23. Classification and Diagnosis of Rhinosinusitis

359

Troy Woodard, Michael S Benninger

24. The Pathogenesis of Rhinosinusitis

365

Michael S Benninger, Janalee K Stokken

25. Genetic Basis of Rhinosinusitis

377

Andrew P Lane, Josef Shargorodsky

26. Immunologic Aspects of Rhinosinusitis

391

Songhui Ma

27. Acute Rhinosinusitis

413

Yan W Ho, Satish Govindaraj

28. Bacteria in Rhinosinusitis: Infection, Biofilms, and Superantigens

427

Raewyn G Campbell, James N Palmer

29. Nasal Polyposis

439

Stella Lee, Berrylin J Ferguson

30. Fungus in Paranasal Sinus Disease

451

Kent Lam, Christopher Vanison, Robert C Kern

31. Osteitis

469

Adam S DeConde, Alexander G Chiu, Jeffrey D Suh

32. Odontogenic Sinusitis Adam S DeConde, Alexander G Chiu, Jeffrey D Suh

479

Contents 33. Reflux and Sinusitis

xxi 485

Adrienne M Laury, John M DelGaudio

34. Complications of Rhinologic Disorders

493

Philip G Chen, Peter-John Wormald

35. Antibiotic Therapy in Rhinosinusitis

507

Patricia A Loftus, Abtin Tabaee, Marvin P Fried

36. Anti-Inflammatory Therapy for Rhinosinusitis

515

Alla Y Solyar, Donald C Lanza

37. Complementary Therapy and Integrative Medicine in Sinonasal Disease

531

Roheen Raithatha, Sezelle Gereau Haddon

38. Refractory Chronic Rhinosinusitis

549

Whitney Zirkle, Rakesh Chandra

Section 7: Anesthesia 39. Local Anesthesia

571

Azeem S Kaka, Subinoy Das

40. Anesthesiology

577

Jerry Chao, Philip Lebowitz

Section 8: Functional Surgery of the Nasal Airway 41. Surgery of the Nasal Septum

595

Waleed M Abuzeid, Sam P Most, Peter H Hwang

42. Surgical Management of the Nasal Turbinates

615

Andrea S Wang, Nicole M Hsu, Michael G Stewart

43. Functional Rhinoplasty

631

Rebecca E Fraioli, Satyen Undavia

Section 9: Surgery for Inflammatory Sinusitis 44. Office-Based Rhinologic Procedures

647

Oscar Trujillo, Ashutosh Kacker

45. Endoscopic Sinus Surgery for Chronic Rhinosinusitis: Historical Evolution, Indications, and Outcomes

651

Robert T Adelson, David W Kennedy

46. Training for Sinonasal Surgery: Past, Present and Future

669

Rachel Kaye, Marc J Gibber, Marvin P Fried

47. Innovations in Optics and Instrumentation

677

Arjuna B Kuperan, Jean Anderson Eloy, Roy R Casiano

48. Surgical Radiology and Image Guidance Surgery

689

Jeremiah A Alt, Richard R Orlandi

49. Primary Endoscopic Sinus Surgery for Chronic Rhinosinusitis Bozena B Wrobel, Dale H Rice

707

xxii

Rhinology/Allergy and Immunology

50. revision Sinus Surgery

717

Justine BF Millar, Dustin M Dalgorf, Richard J Harvey

51. endoscopic Surgery of the Frontal Sinus

735

Calvin C Wei, Joseph B Jacobs

52. minimally invasive Sinus Surgery and Balloon Sinuplasty

743

Peter J Catalano

53. Open Approaches to the Paranasal Sinuses for Inflammatory Disorders

755

Esther Kim, James Duncavage

54. odontogenic disease and oral–Antral Fistula

765

Richard A Kraut

55. Complications in endoscopic Sinus Surgery

787

James A Stankiewicz

Section 10: Endoscopic Skull Base Surgery 56. endoscopic Surgery of the Sella and Suprasellar region

805

Osaama H Khan, Roheen Raithatha, Vijay K Anand, Theodore H Schwartz

57. endoscopic Surgery of the Anterior Skull Base

821

Carl H Snyderman, Paul A Gardner, Juan C Fernandez-Miranda, Eric W Wang

58. endoscopic Surgery of the Pterygopalatine and infratemporal Fossae

837

Mark E Friedel, Marc R Rosen, Gurston G Nyquist

59. endoscopic Surgery of the Clivus, Craniocervical Junction, and Posterior Fossa

849

Aldo Cassol Stamm, Diego Rodrigo Hermann, Leonardo Balsalobre, Eduardo de Arnaldo Silva Vellutini

60. endoscopic Surgery of the Cavernous Sinus and Petrous Apex

859

Seth M Lieberman, Mohammad Al Bar, Roy R Casiano

61. management of Skull Base defects: Cerebrospinal Fluid rhinorrhea, meningoencephalocele and endoscopic Skull Base Surgery

871

Edward D McCoul, Abtin Tabaee

Section 11: Endoscopic Surgery of the Orbit 62. orbital decompression

899

Eugenie Du, Robert Schwarcz, Bradley A Schiff

63. endoscopic dacryocystorhinostomy

913

Nipun Chhabra, Giant Lin, Ralph Metson

Section 12: The Future of Rhinology: The Next Frontiers 64. The Future of rhinology: The next Frontiers

925

Jeremy T Reed, David W Kennedy

Index

939

Section History of Rhinology

1

Chapter 1: The History of Rhinology—From Ancient Times to the 21st Century

3

Chapter

The History of Rhinology— From Ancient Times to the 21st Century

1

Patrick Colley, Marvin P Fried, Abtin Tabaee Medicine is defined by a continuous stream of innovation and evolution. As such, change, often for better, at times for worse, is a fundamental feature of its history. In reviewing our collective understanding of the nose and paranasal sinuses from ancient times to the present, several general themes emerge. Advances throughout history have often reflected the cultural and disease-related needs of the civilization at that time. For example, detailed descriptions of treatment for syphilis-related ozena are prominent throughout the preantibiotic history of medicine. An additional theme is the propagation of concepts that are ultimately disproven by divergent thinkers including seminal concepts in physiology and anatomy. Further, the major diagnostic and treatment advances in medicine have had successful application to nasal and paranasal sinus disorders. This includes microscopy, anesthesia, radiography, and antimicrobial therapy. Finally, techno­ logy has been a major force in the development of rhinologic surgeries, especially over the past century. The adage that in order to know where you are going, you must first know where you came from has truth in the field of rhino­ logy whose history is colored with innovation, misdirection, and evolution.

ANCIENT HISTORY Interest in the nose and the diseases that affect it has puzzled human civilizations throughout history. Ancient Persian writings note that male noses with a “hawk type” appearance resembling that of King Cyrus were admired. The Huns during the age of Attila routinely used bandages to flatten the noses of their infants. The Old Testament

comments on prejudices against “flat-nosed people.”1 Conditions such as nasal polyps, ozena, and epistaxis have plagued people of all civilizations since the first medical documents were written. Our knowledge about the anatomy and pathology of the nose has progressed over the centuries resulting in the current field of modern rhinology. The ancient Egyptians were the first to demonstrate an understanding of the nasal anatomy and its surrounding structures. Egyptian papyri from 3500 Bc shows that specially trained priests in charge of the embalming process were the first to access the brain through a transnasal technique; the brains of the deceased were removed through the nasal cavity using specially designed instruments. This precursor to the transnasal approach to the intracranial cavity shows the detailed anatomic knowledge of the ancient Egyptians. This civilization also provides information on the earliest historical figure who performed the role of a physician in approximately 3500 Bc. Engraving on the pharaoh Sahura’s tomb states that an attendant named Sekhet’ enanch “healed the King’s nostils.”2-4 While the Egyptians were using the nose as a means of accessing the brain, the Hindus were also investigating the function and physiology of the nose. The Hindu document Sushruta Samhita provides the first detailed description of a nasal exam. It was written before the sixth century BC and notes a nasal speculum made of bamboo tree.3,5 The Hindus developed multiple treatments for diseases of the head and neck and noted their findings in a document known as the Sanskrit Atharvaveda. In this document, they describe surgeries to remove nasal polyps and reconstructive techniques for nasal injury and

4

Section 1: History of Rhinology

amputation, a common form of punishment at the time. Surgeons used local flaps from the cheek and forehead to reconstruct these defects and in doing so were the first to describe several important aspects of rhinoplasty and reconstruction still in use today.3,4 The ancient Chinese civilizations were using tradi­ tional eastern medical practices such as acupuncture to treat many nasal conditions. The Chinese also used their pharmacologic knowledge to provide relief to individuals with nasal congestion with a small shrub endemic to their area known as ma huang. This herb was documented to be an effective stimulant and nasal decongestant during the Han Dynasty in the second century AD.1,6 It was not until the 19th century that the active chemical in ma huang, ephedrine, was discovered and produced commercially. Nasal ailments are even described in religious texts including the Bible. In 2 Kings 4:35, the phenomenon of sneezing is described. Treatment of epistaxis using hemlock or other plant remedies is also detailed. “Lord God formed man of the dust of the ground and breathed into his nostrils the breath of life” (Genesis 2:7) represents one of the first documented references to the respiratory function of the nose.7

ANCIENT GREECE AND ROME The “Father of Medicine,” Hippocrates, wrote extensively about nasal disorders in the 5th century BC including management of nasal fractures, polyps, and epistaxis. Nasal trauma was commonplace during the time of Hippocrates in both Greek athletes and soldiers. For mildly displaced fractures, Hippocrates recommended lifting the fragments of bone and cartilage back into place within the first 24–36 hours after injury and using bandages and internal stents made of leather to keep the reduced fragments in the proper position. He detailed the use of a large external splint made of olive tree branches or a leather thong that would be tied around the head and kept in place using glue in order to reduce severely displaced nasal fractures. Hippocrates also wrote detailed descriptions of his methods of removing nasal polyps. This technique consisted of tying several sponges along a string, placing them deep into the nose or nasopharynx and slowly pulling them out in the hopes of removing the polyps along with the sponges. He was also the first to describe polyp removal using a snare.4,8 These techniques were revolutionary for their time and were practiced well into the 19th century. The Romans played a large role in advancing medical knowledge and the study of rhinology. A Roman

nobleman by the name of Aulus Cornelius Celsus is belie­ ved to have documented the extent of Roman medical knowledge during the first century AD in his eight volume encyclopedia, De Medicina. These eight volumes are all that survived from a much larger collection. They were discovered in the papal library in the early 15th century AD and published in 1478. His work details information regarding diet, pharmacology, and surgery practiced in the Roman Empire. Celsus is the first to note the four cardinal signs of inflammation: dolor, calor, rubor, and tumor. He translated the work of his Greek predecessor Hippocrates and became the first person to use the Latin term cancer to refer to a malignant lesion.4 It is unclear whether he was a practicing physician himself, but he documented medical treatments and often provided his opinion on the subject. In his works, he described the, “two nasal passages separated by an intermediate bone.” Like many other physicians or anatomists of the time, Celsus believed that, “these passages break up into two branches, one for respiration and one leading to the brain through which we get our sense of smell.” His treatment for nasal polyposis involved both the use of caustic material and surgical removal. Using specially designed instruments including a spatula shaped rod and a sickle knife or hook, he located and severed the stalk of the polyp prior to removal. Celsus also made the first note of a unified airway when he discussed lung infections possibly originating from the contents of the nasal cavities.9 Approximately two centuries after Celsus, another Roman played a large role in the advancement of medicine and rhinology. Claudius Galenus was a physician in the 2nd century AD who advanced medical knowledge and anatomy in such a major way that many of his theories were taught in medical schools until the 18th century (Fig. 1.1). His dissections of pigs and monkeys provided detailed information regarding many areas in anatomy, in particular the upper respiratory tract. He provided anatomic descriptions of the external and internal portions of the nose and continued the theory of the nose acting as the beginning of the respiratory tract. Galen divided nasal disease into two general categories: polyps and ozena. He noted the proximity of the nose and sinuses to the brain and believed that the sinuses contained fluid and mucus produced by the brain and pituitary gland. These fluids were thought to be waste products excreted by the brain. The work of these Greek and Roman physicians provided the basis for the study of medicine and rhinology for the next 1000 years.4,10

Chapter 1: The History of Rhinology—From Ancient Times to the 21st Century

Fig. 1.1: Second century AD physician, Claudius Galenus, played a large role in advancing the medical and anatomic knowledge of the nose and paranasal sinuses. Courtesy: National Library of Medicine.

THE ITALIAN RENAISSANCE Progress in the study of rhinology, and in medicine in general, slowed during the early Middle Ages. During this period, most physicians believed that the function of the paranasal sinuses was to store oils used to lubricate the eyes or to function as drainage space for malignant spirits. As late as the 16th century, names such as “la cloaca del cerebro” were given to the sinuses demonstrating the continuation of this belief. Although not discovered until 1901, Leonardo da Vinci drew the nasal conchae and paranasal sinuses in detail in 1489.1 Andreas Vesalius described the anatomy of the nasal bones, nasal cartilage, choanae and maxillary, sphenoid, and frontal sinuses in his landmark publication De humani corporis fabrica in 1543.11 He also notes that these sinuses are air filled and not full of humor or spirits. Bartholomeus Eustachius,

5

another anatomist of the time, played a large role in advancing rhinology and otolaryngology by describing most of the structures within the middle ear. In his 1562 treatise Epistola de auditus organis (Examination of the Organ of Hearing), he described a tube that “originates at the anterior portion of the base of the skull, and takes an anterior course towards the pterygoid process of the sphenoid bone.”12 Although the function of the Eustachian tube was not completely understood at the time, the renewed emphasis on the study of medicine and the human body during the Renaissance laid the groundwork for advancements that would take place in medicine in the years to come. Gaspare Tagliacozzi (1545–1599) made an impact during this time period through the publication of his book Treaty on Rhinoplasty. In it, he detailed the “Italian method” of rhinoplasty that differed from the “Indian method” that was detailed in Sushruta Samhita years earlier. Tagliacozzi developed pedicled flaps from the upper extremities and shaped them to cover the nasal defects. The upper extremity was then bandaged in an elevated position for approximately 20 days before the pedicle was transected and the transferred skin was trimmed to its final shape (Fig. 1.2).13 Other important European anatomists and physicians of the time also played a role in advancing the treatment of diseases affecting the nose. Gabriel Fallopius wrote in detail regarding his use of a wire snare to remove nasal polyps.14 Petrus Forestus, known as the “Hollandic Hippocrates” claims in his 1591 text Observationum et Cura­ tionum Medicinalium Libri to have cured a girl of ozena by copious nasal douching “with perfumed white wine in which were dissolved cypress, roses and myrrh.” In this same text, Forestus also treats ozena with silver nitrate and alum rubbed up with honey and applied with a probe. He was one of the first physicians to detail the findings in patients with nasal syphilis and notes that they should be treated differently than lesions of other etiologies.15 Another European physician practicing at the same time as Forestus was Hieronymus Fabricius. He described treatment of intranasal ulcers secondary to ozena using cautery by a “glowing hot instrument.” The cautery was to be continued until the area “was thoroughly cleansed of crusts.”1

EUROPE 17TH–19TH CENTURIES During the 17th century, physicians and anatomists made major strides in describing the function of the nose and

6

Section 1: History of Rhinology

Fig. 1.2: Italian surgeon Gaspare Tagliacozzi designed pedicled flaps from the upper extremities for use in reconstruction of the nose. Courtesy: National Library of Medicine.

Fig. 1.3: An engraving from the British surgeon and anatomist Nathaniel Highmore's treatise Corporis Humani Disquisitio Anato­ mica detailing the anatomy of the maxillary sinus and antrum. Courtesy: New York Academy of Medicine.

paranasal sinuses. Until this time, the belief that nasal mucus and secretions were actually “purgings of the brain” dominated most medical teachings. These secretions were believed to percolate through the bony foramina of the anterior skull base to enter the nasal cavity. Conditions such as halitosis or facial acne were associated with the nose and paranasal sinuses. The recommended treatment of such conditions was total or partial middle turbinectomy.4 In 1651, the British surgeon and anatomist Nathaniel Highmore published his treatise Corporis Humani Disqui­ sitio Anatomica in which he described and illustrated the antrum of the maxillary sinus, a structure that later became known as Highmore’s antrum (Fig. 1.3). Highmore also became the first person to use the term ostomy to refer to an opening made to permanently drain an organ.16

Ten years after Highmore published his work, a German physician named Conrad Victor Schneider made the asser­ tion that nasal secretions did not come from the cranial cavity. In his published treatise on the membranes of the nose, De Catarrhis, Schneider stated that nasal secretions actually originated from the mucous membranes of the nose and sinuses.17 This change of belief would have important implications for future rhinologists. In 1707, two English physicians named James Drake and William Cowper published a medical treatise Antro­ pologica Nova in which they described multiple cases of halitosis caused by suppuration of the maxillary sinus. This suppuration was relieved by removal of maxillary teeth creating an oral antral fistula that allowed drainage of the sinus through the alveolus.18 In 1768, French surgeon Louis Lamorier described a similar method of

Chapter 1: The History of Rhinology—From Ancient Times to the 21st Century draining the maxillary sinuses. After its description, Lamorier’s transalveolar technique remained the procedure of choice for the treatment of maxillary sinus suppuration for nearly a century.19 An 1889 paper by Dr. Joseph H Bryam, one of the four founding physicians of the Episcopal Eye, Ear and Throat Hospital of Washington DC, notes that the best surgical method to drain an abscess of the maxillary sinus is to remove a molar tooth and perforate into the antrum through the alveolus.20 A new technique of accessing the maxillary sinus was developed by Charles Joseph Heath of London in 1889 and William Robertson of Newcastle–on-Tyne in 1892. It involved trephination of the anterior maxillary wall and removal of all sinus contents.21 In 1893, George Walter Caldwell, a physician in New York, published his method of opening the maxillary sinus using trephination of the anterior maxillary wall. However, Caldwell also created an inferior antrostomy through the lateral nasal wall.22 At roughly the same time as Caldwell described his technique, the French physician Luc independently reported his technique for opening the maxillary sinus using a nearly identical technique to Caldwell’s.23 This surgical tech­ nique became known as the Caldwell–Luc operation and remains in practice to this day.24,25 In addition to surgical developments in rhinology, the 19th century also heralded vast leaps in our understanding of the histology, physiology, and anatomy of the nose and sinuses. The development of the microscope in the 1830s allowed individuals like Rudolph Virchow and Friedrich Henle of Germany along with J.F.L Deschamps of France to study the epithelia of the nose and sinuses. Henle provided detailed descriptions of the different types of epithelia. He also first noted the function of the cilia­ ted epithelium found throughout the upper respiratory tract.4,26 In 1870, Emil Zuckerkandl of Austria published an extremely detailed anatomic and pathologic descrip­ tions of the paranasal sinuses. Other anatomists such as L. Grunwald of Munich, M. Hajek of Austria, Adolf Onodi of Hungary, and Harris Mosher of Boston also contributed to the rapidly growing fund on rhinology knowledge.4 Technology was also developing rapidly during this era. The rhinologic exam became much more informative and accurate following German physician Phillip Bozzini’s creation of endoscopy in 1806 (Fig. 1.4).27 In addition to developing laryngoscopy, Czech physician Johann Czermak further improved the nasal exam by promoting the use of the nasal speculum, head mirror with reflected light, and endoscope in 1879.28 Following the discovery of

7

Fig. 1.4: The endoscopic light source developed by German physician Philip Bozzini involved candle light reflected by a mirror into the endoscope. Courtesy: National Library of Medicine.

the analgesic properties of cocaine by Carl Koller of Austria in 1884, these tools contributed greatly to the surgical and anatomic teachings of physicians.4 With these new tools in hand, surgeons began to deve­ lop new treatments for old ailments. In 1893, Charles Henry Burnett of Philadelphia detailed a number of conditions that he believed were due to hypertrophy of the inferior turbinates and recommended inferior turbinectomy as an effective treatment. These conditions all related to “nasal stenosis” and consisted of habitual mouth breathing, rhinorrhea, excessive nasal mucous, serous otitis media, obstruction of the lacrimal duct, nasopharyngitis, laryngeal hyperemia, laryngitis, and secondary lung disease.29 Others such as D. Braden Kyle30 and Chevalier Jackson31 of Philadelphia along with William Jarvis of New York supported this procedure and its benefits. As a result of the popularity of inferior turbinectomies, investigators in the United States and Europe evaluated nasal

8

Section 1: History of Rhinology

airflow patterns and developed anterior and posterior rhinomanometric methods still in use today.32-36 The understanding and treatment of nasal polyps improved during the 19th century as well. As far back as the times of Galen (200 Ad), nasal polyps were believed to be “a constitutional disease due to the state of the humors of the body.” They were treated with knotted thread, caustic agents, and snare ligation.37-39 Deschamps was one of the first people to describe nasal polyps as a local disease of the nasal and sinus mucosa. He developed a classification system for nasal polyps consisting of “fungous and vascular, mucous and lymphatic, scirrhous, and sarcomatous.”26 The Austrian surgeon Theodore Billroth later described nasal polyps as adenomatous in nature while Virchow called them myxomata. Treatment of these lesions impro­ ved due to the use of the endoscope, nasal speculum, and topical anesthetics such as cocaine. Due to its effectiveness, the primary method of polyp removal remained the wire snare. While the design of this instrument improved during the 19th century, it still relied on principles present for hundreds of years.4 In 1881, Dr. Francke Bosworth of New York City published one of the first otolaryngology textbooks, A Textbook of Diseases of the Nose and Throat. In it, he details a multitude of pathologies affecting the nose and discusses how these can affect the entire body. He provides des­ criptions of thorough nasal exams and demonstrates an impressive understanding of nasal and sinus anatomy. Dr. Bosworth is often referred to as the “Father of Rhino­ logy” in North America due to his extensive work on the subject.40,41 Besides Dr. Bosworth, many other American physi­ cians of the 19th century advanced the field of rhinology. Drs. Morris Asch,41 Fletcher Ingals,42 Robert Weir44, and John Rowe43 played large roles in the development of new nasal surgery techniques. These “early rhinologists” were all part of the American Laryngological Association, a group formed in 1878 to promote knowledge “in all that pertains to the diseases of the upper air passages.” This interest in rhinology as well as laryngology and otology grew to such an extent that specialty eye and ear hospitals opened in New York (1820) followed by hospitals in Philadelphia and Boston.4

THE 20TH CENTURY The beginning of the 20th century continued the rapid progression of rhinology seen in the previous century.

This progression was largely due to advancements in surgi­ cal techniques that allowed for more effective treatment of nasal ailments. Drs. Otto “Tiger” Freer and Gustav Kilian built on septal surgery techniques taught by Ephraim Ingals of Chicago 20 years earlier and developed the submucous resection of the nasal septum.45 To aid in this procedure, Freer produced new surgical instruments including new nasal speculae, rasps, scissors, knives, forceps and eleva­ tors. He published extensively on this procedure and described the areas of the septum that can be safely resected, proper postoperative follow up, the proper use of cocaine, and post-operative packing. It is noteworthy that Freer’s surgical teachings and instruments remain in use today.46-48 At the same time that Freer was publishing his works in Chicago, Killian of Germany developed a similar method of submucous septal resection that yielded comparable results. Freer and Kilian’s work quickly turned septal surgery into a popular procedure performed by rhinologists throughout North America and Europe.49-51 This popularity lead others to further refine the technique, deve­ lop new instruments and decrease the operative time. During this time, most nasal surgeries were performed under local anesthesia using cocaine or epinephrine that did not allow for long procedures. Freer claimed to require 45 minutes to complete his procedure.52 William Ballenger’s invention of the swivel knife and John Mackenty’s technique for application of local anesthetic reduced to ave­ rage operative time for a submucous nasal septal resection to 20-30 minutes by 1908.53 Septal surgery was not the only rhinologic procedure that took leaps forward during this century. Surgery on the ethmoid and sphenoid sinuses was developed in the early 20th century by Albert Jansen. His transantral route to the ethmoid and sphenoid sinuses relied on the widely taught Caldwell-Luc procedure to provide access to the lateral nasal wall. Mosher, a prominent anatomist and physician in Boston, noted that this route was effective in treating “combined empyema of the antrum, ethmoid region and the sphenoid.”54 However, Jansen’s procedure required removal of the majority of the lateral nasal wall including the middle and inferior turbinates that likely resulted in significant atrophic rhinitis. This led to the procedure falling out of favor among many rhinologists.55,56 In 1912, Mosher published one of the first descriptions of an intranasal method of performing an ethmoidectomy. The procedure required wide exenteration of the labyrinth and complete removal of the middle turbinate. This wide dissection performed through a small nasal cavity lead

Chapter 1: The History of Rhinology—From Ancient Times to the 21st Century others to question the safety of this method of ethmoidec­ tomy.57 Mosher eventually became disenchanted with this procedure and in 1929 noted that “it has proved to be one of the easiest operations with which to kill a patient.”58 In response to the poor success rate of intra­ nasal and transantral access to the ethmoid sinuses, Robert Lynch of New Orleans59 and W. Howarth of London60 des­cribed external approaches to these sinuses that did not leave unsightly scars or bony deformities. The Lynch frontoethmoidectomy provided a safe and relatively effective method of opening and treating the anterior eth­ moid and frontal sinuses. Mucosal flaps and stents were also deve­loped in the hopes of improving the patency of the frontoethmoid recess but none of them were used with any success.61 In order to treat patients who did not receive relief from their frontal sinus disease after a Lynch procedure, rhinologists of the time developed external approaches to this sinus. Originally, these procedures led to defects in the anterior table and left unsightly scars. However, a new technique developed by Howard Lothrop of Boston in 1917 allowed for treatment of frontal sinus disease with minimal aesthetic impact. Lothrop developed a method to bypass the nonfunctional frontal sinus by removing the inter-sinus septum and frontal floor to allow sinus contents to drain through the opposite side.62,63 In 1964, Robert Goodale and William Montgomery of Boston combined the osteoplastic flap with fat obliteration of the frontal sinuses to treat chronic frontal sinus disease.64 This technique became the treatment of choice for chronic frontal sinus disease for many years afterwards. Another common surgical technique that developed in the early 20th century was the inferior meatus antrostomy. This procedure was promoted by Jan Mikulicz-Radecki of Austria and Lothrop for the treatment of chronic maxillary sinusitis.65 Critics of the time did not like that it did not remove the diseased mucosa of the sinus. However, poorly controlled rabbit model studies conducted by A. C. Hilding suggested that the natural ostium of the maxillary sinus should not be surgically altered.66 This misinformation influenced the rhinology community for over 40 years until it was finally disproven by Messerklinger.67-70 In addition to surgical advancements, the 20th century let to technologic advancements that benefitted the field of rhinology. The first of these was radiography. Cornelius Coakley of New York City was the first otolaryngologist to report using this new equipment. He described how he was able to diagnose frontal sinus disease using a posterioranterior view with an exposure time of 3.5 minutes.71

9

The Waters, Caldwell, and lateral views were all in use by 1915 and played a major role in the diagnosis of sinus disease before computed tomography was developed.72,73 According to Stammberger, the lack of detail found in these early radiographs likely delayed the understanding of the complex surgical sinus anatomy.4 In addition to radiology, advancements in nasal endo­ scopy were coming about during the mid-20th century. Although the first endoscope had been invented in 1801 by Bozzini, it was not frequently used by physicians due to poor visualization and illumination. Endoscopic examinations were limited to the peritoneum and bladder. In 1853, French physician Antonin D'Esormeux demonstrated an alcohol illuminated urethroscope. Following the deve­ lopment of electricity, distal illumination improved signi­ ficantly that led Max Nitze of Germany and Joseph Leiter of Austria to develop the Nitze–Leiter cystoscope. Using a modified version of this instrument, E. Zaufal examined the Eustachian tube orifice during the 1880s. Twenty years later, Alfred Hirschmann of Germany described the first nasal endoscopy using a special 4.0 mm diameter endoscope. He examined the middle meatus and maxillary sinus ostia through the nose as well as via the molar tooth socket. Roughly at this same time, M Reichert, also of Germany, described minor manipulation of sinus tissue using endoscopy. However, Hirschmann’s and Reichert’s advancements and their possible applications to the field of rhinology were ignored for the next six decades. Harold Hopkins of England designed the modern endoscope 1948. He drew influence from the work of John Baird earlier in the century who patented the transmission of images through glass fibers. Over the next two decades, Hopkins and German manufacturers improved endoscope technology to provide a precise, detailed picture. Using Hopkin’s new technology, surgeons of the day slowly began performing more endoscopic examinations and eventually surgical procedures.74-77 Important figures in rhinology were plentiful early in the century. Arthur Proetz, an otolaryngology professor at Washington University, wrote his thesis entitled “The Displacement Method of Sinus Diagnosis and Treatment.” In this thesis Proetz describes using sophisticated equipment and head positions to diagnose and treat an array of sinus conditions. For his work, Proetz was awarded the Castlebury Prize from the American Laryngological Association in 1931.78-81 Ten years later, Professor Van Alyea of Chicago authored a legendary textbook entitled “Nasal Sinuses.” In the book, he details information about nasal anatomy

10

Section 1: History of Rhinology

Fig. 1.5: Maurice Cottle was a founding member and the first president of the American Rhinologic Society. His teaching and leadership in the field of rhinology spurred its growth that led to his nickname “the father of rhinology.”

and physiology as well as the role that allergy may play in sinus disease. The book discusses newer concepts such as the mucociliary blanket, mucosal information and the role of new medications known as antibiotics in the treatment of sinusitis.82 Maurice Cottle of Chicago is often referred to as the “rhinologist of the century” for his work in this field and his dedication to its advancement (Fig. 1.5). He is considered to have restored rhinology to the same prominence as laryngology and otology. Dr. Cottle is known as a great educator who taught his functional approach to nasal and sinus surgery at his lecture series beginning in 1944. The series became known as “Cottle courses” and soon attracted specialists from around the country.4 It was at one of these courses at Johns Hopkins Hospital in 1954 that the American Rhinologic Society (ARS) was formed and Dr. Cottle was elected the first president of the group. His leadership and mentoring helped the ARS flourish and grow from a somewhat small group of practitioners to a robust academic society with a strong presence in the otolaryngology community. Although the interests of the ARS originally concerned the structure and function of the nose, the advent of nasal endoscopy and surgery shif­ted its focus towards disease of the paranasal sinuses

and skull base. The development of the ARS spurred the academic study of diseases affecting the paranasal sinuses and aided in the dissemination of effective endoscopic surgical techniques for the treatment of these conditions.83 In the latter half of the 20th century, pioneers such as Walter Messerklinger of Austria entered the field of rhinology and embraced the new technology and concepts introduced earlier in the century. Endoscopes developed by Hopkins were refined by German manufactures and provided significantly better visualization of the nasal cavity and sinuses than previous versions. Messerklinger was the first person to use these endoscopes to examine and treat sinus disorders.84 He provided detailed endoscopic anatomy using this new technology and opened the gates for other pioneers to follow. David Kennedy from Johns Hopkins,85 Heinz Stammberger of Austria,70 and Wolfgang Draf of Germany4 built on these concepts and further developed modern endoscopic sinus surgery. Their work showed the importance of mucociliary function and detailed the need for proper antrostomies in the treatment of chronic rhinosinusitis. The rapid evolution of endoscopic sinus surgery also required development of new surgical instruments and other supportive technologies. The removal of only diseased mucosa and sparring of normal tissue required through cutting and power instrumentation. These instru­­ ments allowed for precise cutting of mucosal edges in order to avoid stripping mucosa and exposing the under­ lying bone.86 Computed tomography, developed by Geoffrey Hounsfield in 1969 allowed for improved preoperative visualization of complex sinus anatomy and aided in the diagnosis and treatment of sinusitis. Improve­ ments in computed tomography lead to the development of intraoperative image guidance navigation. These sys­ tems were developed to satisfy a clinical need for better intraoperative orientation and localization. Modern navi­ gation technologies are based on stereotactic systems developed for neurosurgery.87 As endoscopic surgery progressed, rhinologists began pushing the boundaries of indications and patho­logies for transnasal surgery. Endoscopic septoplasty and endo­ scopic ligation of the sphenopalatine artery for refractory epistaxis became commonly performed procedures. Transnasal endoscopic orbital procedures such as endo­ scopic dacryocystorhinostomy and orbital decompressions for optic neuropathy and Graves’ disease were developed. Based on the work of Draf and others, frontal sinus surgery evolved from primarily an open procedure

Chapter 1: The History of Rhinology—From Ancient Times to the 21st Century into one with multiple methods of endoscopic treatment.4 The increase in endoscopic sinonasal surgery naturally lead some rhinologists and neurosurgeons to begin to explore the application of this new technology to the field of neurosurgery. Gerard Guiot of France with Karl Bushe and E. Halves of Germany reported the first use of a transnasal endoscope to access a pituitary lesion in 1970.88 Over two decades later, Hae-Dong Jho and Ricardo Carrau from Pittsburgh published their first series using strictly endonasal transsphenoidal approach to resect pituitary tumors.89 Their success led others to develop methods of accessing and treating anterior skull base, clival, and infratemporal fossa lesions. Mirroring the paradigm shifts that have occurred throughout the history of rhinology, the past quarter of a century has refined our understanding of the pathophy­ siology of sinusitis. The disease began to be viewed not just as an infectious process but also the result of an inflammatory process within the mucosa itself. Mediators of inflammation such as cytokines and interleukins became targets of research and potential intervention.90-92 The role of eosinophils in chronic sinusitis and the des­ tructive inflammatory contents that they release became better understood.93 Bent et al. detailed the pathogenesis of allergic fungal sinusitis.94 Multiple research groups des­ cribed the bacteriostatic role nitrous oxide plays within the paranasal sinuses.95 Others showed that this substance that is naturally found in high concentrations within the sinuses also has antiviral properties and upregulates mucociliary activity. The end of the 20th century and the beginning of the 21st century saw many changes in the medical management of sinusitis due to the improved understanding of its pathophysiology. Evidence supporting a polymicrobial etiology of chronic rhinosinusitis became more prevalent and the role of bacterial biofilms began to be investigated.96 Antimicrobial therapy remained the mainstay of treatment for both acute and chronic sinus disease. However, treatment methods directed at inflammation took on a larger role in the management of chronic sinusitis.97 In addition to improved basic science research into the pathophysiology of chronic sinusitis, the 21st century also witnessed an emphasis on patient-centered quality of life measures in defining treatment outcomes in rhino­ sinusitis. Using psychometrically validated questionnaires and large patient databases, a more robust measure of treatment intervention and impact of comorbidities has become available.98,99 As patient databases grow and

11

researchers abilities to analyze information improve, rhino­ logists are sure to refine their treatments methods even further to the benefit of the millions of patients with sinus disease. The history of rhinology can be traced back to the ear­ liest cultures on earth. Our understanding of the anatomy and pathologies in this field has advanced steadily over the past 3 millennia leading to the fevered pace of study that has taken place in the last four decades. As more information is discovered, more questions arise. Research directed at the pathophysiology and treatment of sinus disease, collaborative dissemination of information, and technolo­gical advances will continue to advance the field of rhinology.

REFERENCES 1. Wright J. A History of Laryngology and Rhinology. Phila­ delphia: Lea and Febiger; 1914. 2. Ebers Papyrus. Trans Joachim H. Berlin, 1890. 3. Lascaratos JG, Segas JV, Trompoukis CC, et al. From the roots of rhinology: the reconstruction of nasal injuries by Hippocrates. Ann Otol Rhinol Laryngol. 2003;112(2): 159-62. 4. Stammberger H. History of rhinology: anatomy of the para­ nasal sinuses. Rhinology. 1989;27(3):197-210. 5. Pirsig W. History of rhinology: nasal specula around the turn of the 19th-20th century. Rhinology. 1990;28:13-22. 6. Stevenson RS, Guthrie N. A History of Otolaryngology. Edinburgh: Livingstone; 1949. 7. Black WG. Folklore Medicine. London; 1883. 8. Hippocrates. Trans Jones WHS and Withingtion ET. London: Loeb Classical Library; 1923. 9. Celsus OC. De medicina. Trans Spencer WG. London: Loeb Classical Library; 1935-38. 10. Galen C. Works Trans Broc AJ. London: Loeb Classical Library; 1916. 11. Vesalius A. De humani corporis fabrica. Venice; 1543. 12. Eustachius B. Epistola de auditus organis. Venice; 1562. 13. Tagliacozzi G. De curtorum chirurgia per insitionem. Venezia: R Berolini; 1597. 14. Fallopius G. Observationes anatomicae. Venice; 1561. 15. Forestus P. Observationum et Curationum Medicinalium Libri. Paris; 1591. 16. Highmore N. Corporis humani disquisitio anatomica. The Hague; 1651. 17. Schneider CV. Liber primus de catarrhis. Wittenberg; 1660. 18. Drake J, Cowper W. Anthropologica Nova. London; 1707. 19. Tange RA. Some historical aspects of the surgical treatment of the infected maxillary sinus. Rhinology. 1991;29(2): 155-62. 20. Bailey BJ. Landmark perspective; abscess of the antram. JAMA. 1983;250:400-3.

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Section 1: History of Rhinology

21. Macbeth R. Caldwell, Luc, and their operation. Laryngo­ scope. 1971;81:1652-7. 22. Caldwell GW. Diseases of the accessory sinuses of the nose and an improved method of treatment for suppuration of the maxillary antrum. NY J Med. 1893;58:526-8. 23. Luc H. Une nouvelle methode operatoire pour la cure radicale et rapide de l'empyeme chronique du sinus maxillaire. Arch Laryngol (Paris). 1897;10:273-85. 24. Hinkel FW. A report of the operative treatment of seven cases of frontal and maxillary sinusitis. Trans Am Laryngol Assoc. 1899;21:153-8. 25. De Roaldes AW. Report of a few cases of chronic empyema of the antrum of Highmore; operation by the Caldwell-Luc method. Trans Am Laryngol Assoc. 1899;21:159-79. 26. Deschamps JFL. Dissertation sur les maladies des fosses nasales. Paris; 1804. 27. Bozzini P. Lichtleiter, eine Erfindung zur Anschauung innerer Teile und Krankheiten, nebst der Abbildung. J practischen Arzneykunde and Wunderzneykunst. 1806;24: 107-24. 28. Czermak IN. Der Kcwkopfspiegel. Leipzig: W Engelmann; 1863. 29. Burnett CH. System of diseases of the ear, nose, and throat. Vol II. Philadelphia: JB Lippincott Co.; 1893. p. 41. 30. Kyle DB. A textbook of diseases of the ear, nose. Philadelphia WB Saunders; 1899. 31. Jackson C. Deviation of the nasal septum: why do our corrective operations fail? Laryngoscope. 1902;12:184-90. 32. Jarvis WC. Deviated septum in nasal catarrh. Trans Am Laryngol Assoc. 1882;4:69-77. 33. Panlson E. Experimentelle Untersuchungen Uber die Stromung der Luft in der Nalenhohle. Sher Akad Wesnech z Wien (Math-Natur). 1882;85:352-8. 34. Courtade A. Obstruction nasale: etude clinique et physio­ logique. Arch Int Laryngol Otol Rhinol. 1903;12:320, 498; 844. 35. Franke Y. Experimentelle Untersuchungen uber Loftdruck, Luftbewegung, und Luftweschetn in der Nase und ihren Nebenhohlen. Arch Laryngol. 1894;1:230-41. 36. Goodale JL. An experimental study of the respiratory function of the nose. Boston Med Surg J. 1896;135:457. 37. Vancil ME. A historical survey of treatments for nasal polyposis. Laryngoscope. 1969;79:435-45. 38. Bloom SM. Nasal polyps. J Asthma Res. 1969;6:137-46. 39. Yonge ES. Polyps of the nose. London: Sherratt and Hughes; 1906. 40. Bosworth FH. A manual of diseases of the throat and nose. New York: William Wood & Co.; 1881. 41. Delavan DB. Address of the president. Trans Am Laryngol Assoc. 1928;50:19-29. 42. Asch MJ. A new operation for deviation of the nasal septum with report of cases. Trans Am Laryngol Assoc. 1890;12: 76-80. 43. Ingals EE. Deflection of the septum narium. Trans Am Laryngol Assoc. 1882;4:61-9.

44. Weir RE. On restoring sunken noses without scarring the face. NY Med J. 1892;56:443-51. 45. Lienhart W. Compendium der chururgischen Operations­ lehre. Vienna: Wilhelm Braumuller;1867. p. 55. 46. Freer OT. The correction of deflections of the nasal septum with a minimum of traumatism. JAMA. 1902;38:636-42. 47. Freer OT. The window resection operation for the correction of deflections of the nasal septum. JAMA. 1903;41:1391-8. 48. Freer OT. Deflections of the nasal septum: a critical review of the methods of their correction by the window resection, with a report of 116 operations. Trans Am Laryngol Assoc. 1905;27:29-79. 49. Killian G. Einleitung zur der Discussion uber die operative Therapie der Septumdeviationen. Verhandlungen Gesells­ chaft Deutscher Naturforscher und Aerzte. Leipzig: FCW Vogel; 1899. pp. 392-3. 50. Killian G. Die submukose Fensterresektion der Nasen­ scheidewand. Arch Laryngol Rhinol (Berl). 1904;16:362-87. 51. Killian G. Beitrage zur submukosen Fensterresektion der Nasenscheidewand. Beitrage zur Anatomic, Physiologic, Pathologic, und Therapie des Ohres (Berl). 1908;7:183-93. 52. Mackenty JE. The submucous operation on the nasal septum, with a plea for a more rapid technique. Am J Surg. 1908;22:146-9. 53. Ballenger WL. The submucous resection of the nasal septum: a new technic with the author's swivel knife, reducing the average time of the operation several minutes. Ann Otol Rhinol Laryngol. 1905;14:394-416. 54. Mosher HR. The anatomy of the sphenoid sinus and tile method of approaching it from the antrum. Laryngoscope. 1903;3:177-214. 55. Jansen A. Die Killian'sche Radical-Operation Chronischer Stiruhohleneiterungen. Ohren Nasen Kehlkopfneil. 1902; 56:10-2. 56. Jansen A. Zur Eroffnung der Nebenhohlen der Nase bet chronischer Eiterung. Arch Laryngol Rhinol (Berl). 1894; 1:135-57. 57. Mosher HR. The applied anatomy and the intranasal surgery of the ethmoid labyrinth. Trans Am Laryngol Assoc. 1912;34:25-45. 58. Mosher HR. The surgical anatomy of the ethmoid labyrinth. Ann Otol Rhinol Laryngol. 1929;38:869-90. 59. McNally WJ, Stuart EA. A 30-year review of frontal sinusitis treated by the external operation. Trans Am Laryngol Assoc. 1954;75:175-212. 60. Howarth W. History of frontal sinus surgery. J Laryngol Otol. 1921;36:417. 61. Lynch RC. The technique of a pansinus operation which has given me the best results. Laryngoscope. 1921;31:1-5. 62. Lothrop HA. Empyema of the antrum of Highmore: a new operation for the cure of obstinate cases. Boston Med J. 1897;36:455-66. 63. Lothrop HA. Frontal sinus suppuration with results of new operative procedure. JAMA. 1915;65:153-60.

Chapter 1: The History of Rhinology—From Ancient Times to the 21st Century 64. Goodale RC, Montgomery WW. Technical advances in osteoplastic frontal sinusectomy. Arch Otolaryngol. 1964; 79:522-9. 65. Mikulicz J. Zur operativen Behandlung das Empyens der Highmoreshohle. Lagenbeck's Archiv fur Klinisehe Chirurgie. 1887;34:626-34. 66. Hilding AC. Experimental sinus surgery: effects of operative windows on normal sinuses. Ann Otol. 1941;50:379-92. 67. Messerklinger W. Uber die Drainage der menschlichen Nasennebenhohlen nnter normalen und pathologischen Benkingungen: II. Mitteilung: Die Stirnhohle und ihr Ausfuhrangssystem. Monatsschr Ohrenheilkd. 1967;101: 313-26. 68. Wigand ME, Steiner W. Endonasale Kieferhohlenoperation mit endoskopischer Kontrolle. Laryngol Rhinol Otol (Stuttg). 1977;56:421-5. 69. Kennedy DW. Functional endoscopic sinus surgery. Arch Otolaryngol. 1985;111:643-9. 70. Stammberger H. Endoscopic endonasal surgery-concepts in treatment of recurring rhinosinusitis. Otolaryngol Head Neck Surg. 1986;94:143-56. 71. Coakley C. Skiagraphy as an aid in diagnosis and treatment of diseases of accessory sinuses of the nose. Ann Otol. 1905;4:16-20. 72. Waters CA, Waldron CW. Roentgenology of accessory nasal sinuses describing modification of occipitofrontal position. AJR Am J Roentgenol. 1915;2:633-9. 73. Caldwell EW. Skiagraphy of the accessory nasal sinuses of the nose. Am Q Roentgenol. 1906-7;1:27-33. 74. Messerklinger W. Background and evolution of endoscopic sinus surgery. Ear Nose Throat J. 1994;73:449-50. 75. Stammberger H. The evolution of endoscopic sinus surgery. Ear Nose Throat J. 1994;73:451-5. 76. Draf W. Endoscopy of the paranasal sinuses: technique, typical findings and t0herapeutic possibilities. New York: Springer; 1983. pp 24-27. 77. Kirkup J. The evolution of surgical instruments: an illustrated history from ancient times to the twentieth century. Novato, CA: Norman Publishing; 2006. 78. Proetz AW. A system of exact olfactometry. Ann Otol Rhinol Laryngol. 1924;33:746-63. 79. Proetz AW. Air currents in the upper respiratory tract and their clinical importance. Ann Otol Rhinol Laryngol. 1951;60:439-67. 80. Proetz AW. The thyroid and the nose. Ann Otol Rhinol Laryngol. 1947;56:326-33. 81. Proetz AW. Nasal ciliated epithelium with special reference to infection and treatment. J Laryngol Otol. 1934;49:557-70. 82. van Alyea OE. Nasal sinuses. Bahimou: Williams and Wilkins; 1951.

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83. Vining E. ARS History. Retrieved from https://www.ameri­ can-rhinologic.org/history 84. Messerklinger W. Endoscopy of the nose. Baltimore: Urban and Schwartzenberg; 1978. 85. Kennedy OW, Zinreich SJ, Rosenbaum AE, et al. Functional endoscopic sinus surgery. Theory and diagnostic evaluation. Arch Otolaryngol. 1985;111:576-82. 86. Kuhn FA. Citardi MJ. Advances in postoperative care following functional endoscopic sinus surgery. Otolaryngol Clin North Am. 1997;30:47-90. 87. Luxenherger W, Kole W, Stammhcrger H, et al. Computer assisted localization in endoscopic sinus sur­gery-state of the art? The Insta Trak system. Laryngo­rhinootologie. 1999; 78:318-25. 88. Guiot G. Transsphenoidal approach in surgical treatment of pituitary adenomas. General principles and indications in non-functioning adenomas. In: Kohler PO, Ross GT (eds), Diagnosis and treatment of pituitary tumors. New York: American Elsevier; 1973 pp. 159-78. 89. Jho HD. The expanding role of endoscopy in skull base surgery. Indications and instruments. Clin Nuerosurg. 2001;51:435-44. 90. Hamilos DI, Leung DY, Wood R. et al. Evidence for distinct cytokine expression in allergic versus nonallergic chronic sinusitis. Allergy Clin Immunol. 1995;96:537-44. 91. Wright ED, FrenkieJ S, Ghaffar O, et al. Monocyte chemo­ tactic protein expression in allergy and non-allergyassociated chronic sinusitis. J Otolaryngol. 1998;27:281-7. 92. Hamilos DL, Leung DY, Wood R, et al. Eosinophil infiltration in non-allergic chronic hyperplastic sinusitis with nasal polyposis (CHS/NP) is associated with endothelial VCAM-l upregulation and expression of TNF-alpha. Am J Respir Cell Mol. 1996;15:443-50. 93. Harlin SL, Ansel DG, Lane SR, et al. A clinical and pathologic study of chronic sinusitis: the role of the eosinophil. J Allergy Clin Immunol. 1988;81:867-75. 94. Bent JP 3rd, Kuhn FA. Diagnosis of allergic fungal sinusitis. Otolaryngol Head Neck Surg. 1994;111:580-8. 95. Yariktas M Ramakrishnan V, Palmer JN. Nitric oxide level in the nasal and sinus mucosa after exposure to electro­ magnetic field. Otolaryngol Head Neck Surg. 2005;132: 713-6. 96. Suh JD, Doner F, Ozguner F, et al. Biofilms. Otolaryngol Clin N Am. 2010;43:521-30. 97. Settipane RA. Chronic rhinosinusitis. Am J Rhinol Allergy. 2013;27 (Suppl 1):S11-5. 98. Soler ZM. Patient-centered decision making in the treatment of chronic rhinosinusitis. Laryngoscope. 2013;123:2341-6. 99. Clinger JD. Quality-of-life outcomes following multiple revision endoscopic sinus surgery. Int Forum Allergy Rhinol. 2012;2:444-52.

SECTION Embryology, Anatomy and Physiology

2

Chapter 2: Evolution of the Human Nasal Respiratory Tract: Nose and Paranasal Sinuses

17

CHAPTER

Evolution of the Human Nasal Respiratory Tract: Nose and Paranasal Sinuses

2

Samuel Márquez, Anthony S Pagano, William Lawson, Jeffrey T Laitman

INTRODUCTION From our humble beginnings as lobe-finned fish to our current role as the dominant species on planet Earth, the nasal cavity has been at the forefront of our evolutionary story. It is not a single unit but rather a composite struc­ ture with several developmental and evolutionary origins. These have each undergone considerable change, espe­ cially among the early mammals and during the rise of the primates. The modern human nasal cavity is thus the product of many millions of years of adaptation and pre­ adaptation to novel functional demands. It is through the study of this evolutionary past that one may gain a deeper understanding of disease etiology and malformations of the nasal cavity and related structures. This chapter will focus on nasal evolution among humans and the non­ human primates from the primitive mammalian condition to our extremely specialized anatomy. In conceptualizing the human nasal cavity, one must understand its composite origins. That is, the external nasal vestibule, nasal cavity floor, lower and upper con­ chae, cribriform plate, and choanae all arose at sepa­ rate times and in relation to varied functional demands. Indeed, this complicated evolutionary history is reflected in the various functions performed by the modern human nasal complex, which acts directly in the transport and conditioning of respiratory airflow, olfaction, the percep­ tion of flavor in food, production of nitric oxide gas (in the paranasal sinuses), and regulation of brain temperature via the pterygoid plexus of veins. It also serves several pas­ sive functions as the nasal cavity floor both braces against masticatory stresses and allows proper suckling by infants

(achieved through complete separation of the nasal and oral cavities) while the cartilaginous Eustachian tube and soft palate attach to its posterior wall and floor, respec­ tively.

SEGMENTATION AND THE BEGINNINGS OF THE PREOTIC HEAD A discussion of the evolutionary origins of the various components comprising the nasal complex may best begin with head segmentation. Among the earliest to consider head segmentation was Goethe in a series of unpublished letters. His argument was later elaborated in several formally published works.49,51,93 Early authors held that the entirety of the axial skeleton and its soft tissues, including the head, grows from iterative segments. The skull was believed to have formed from modified vertebra and, as described by Owen,94 was derived from as many as four separate cranial vertebrae. Huxley62 later challenged this paradigm, citing that only the anterior two thirds of the skull grow from the notochord (which is the main embryologic progenitor of the vertebral column) and that several basicranial cartilages remain unsegmented and continuous throughout vertebrate growth (reviewed by Northcutt91). By the time of Goodrich,52 discussion of head segmen­ tation no longer centered on cranial vertebrae, but rather on series of somites and pharyngeal arches. He argued that the three anterior-most somites contribute to the pre­ otic skull (mostly the facial skeleton) while the posterior four are successively associated with developing branchial

18

Section 2: Embryology, Anatomy and Physiology

arches and cranial nerves. This paper is important in con­ tributing to the modern concept of skull segmentation over gastrulation and distinguishing between the preotic and periotic divisions. These roughly correspond to the division observable in the nasopharyngeal wall between the anterior and posterior portions, which are distinct in anatomy, histology, and development. Gans and Northcutt48 later proposed separate evolu­ tionary origins for the pre- and postotic portions of the vertebrate skull. The former was derived from a series of sensory adaptations for active predation, developing exclusively from neural crest cells while ectodermal placo­ des contribute to the development of the sensory organs and some nerves. The vertebrate skull was thus an ectoder­ mal addition to the basic protochordate body plan (with the notochord progressing only as anterior as the basic­ranial fenestra). The distinct origins of the elements compo­sing the anterior and posterior nasopharyngeal walls may thus be as old as the appearance of the first vertebrates. The developmental evidence cited by Gans and North­ cutt48 were corroborated by Couly et al.27 who mapped the fates of neural crest, somitic, and mesodermal cells in the cranial development of the chicken. Tissue grafts were taken from quail embryos and implanted into chicken embryos between E8 and E12 (the 8th and 12th days of embryological growth, respectively). It was determined that the splanchnocranium, mandible, frontal bone, and parietal bones were all derived from neural crest cells. The sphenoid was divided into an anterior neural crestderived half and a posterior mesoderm-derived half. The otic capsule was shown to contain elements from all three sources. These results favor the “new head” hypothesis of Gans and Northcutt48 by confirming the neural crest origin of the prechordal skeleton and by describing the separate de­ velopmental trajectories of areas corresponding to the an­ terior and posterior nasopharyngeal walls. Further evolutionary depth is given to the division of the pre- and postotic head in a synthesis by Baker and Bronner-Fraser.4 They argue that the homologs of verte­ brate neural crest cells and ectodermal placodes may be present in nonvertebrate chordates such as the cephalo­ chordates, which are classified in the subphylum Chor­ data and are defined by the presence of a notochord that persists throughout the life of the organism (e.g. lancelets). These possible homologs are ectodermally derived and tend to migrate over development. It is also argued that homologs for the neural crest and placodes may be found

in the neural cords of enterpneust worms, which are con­ sidered good models for the condition of the last common ancestor of all chordates.

BEGINNINGS OF THE NASAL CAVITY PROPER: IMPORTANCE OF THE CHOANAE Fossil evidence suggests that the presence of choanae may have been among the earliest occurring synapomorphies (i.e. a shared derived trait) characterizing the tetrapods.63 Panchen and Smithson97 gave the first formal anatomical definition of ancestral tetrapodomorph choanae (i.e. fourlimbed tetrapods) as being constrained laterally by the premaxilla and/or maxilla and medially by the vomer. The osteolepiformes, a group of fossil lobe-finned fish likely related to stem tetrapods, share synapomorphic choanal morphology with tetrapods but predated the earliest known terrestrial vertebrates by approximately 30 million years.63 This condition is distinct from most fishes, which possess a pair of anterior and posterior nostrils on the external snout. von Bischoff 8 first described the presence of choanae in the lungfishes and grouped them with amphibians. They were considered excellent models for the respiratory morphology of early tetrapods as they appeared inter­ mediate in morphology between the amphibians and fishes. Lungfishes exhibit choanal morphology similar to that seen in the primitive tetrapod condition, as spaces that communicate between the nasal sac and oral cavity (Fig. 2.1). However, a nasopharynx sensu stricto may not be found in lungfish or ancestral tetrapods including lobe-finned fishes as no distinct airway is present. The communi­cative channel between the anterior and poste­ rior nares remains, as in most fishes, an olfactory pathway lined with specialized epithelia (see the description by Derivot37). These are used specifically for olfaction in aquatic environments and are closed off during air swallowing by specialized valves.37 As can be inferred from modern lungfish, air breathing animals that lack a means of nasal respiration may engage in an activity known as air swallow­ ing (see description and review by Smith124) in which air is passed to the lungs through the mouth. Given the anti­ quity of the choanae and their function in lungfish, it appears that these apertures may not have evolved as respi­ ratory pathways. Indeed, choanae are absent among the African lungfish (Polypterus), which instead exhibits a primitive nasopalatal duct.2

Chapter 2: Evolution of the Human Nasal Respiratory Tract: Nose and Paranasal Sinuses

Fig. 2.1:  Above is an Australian lungfish (Neoceratodus forsteri) exposing its oral cavity. Note that the choanae open ventrally into the hard palate. This is not a respiratory airway as the lungfish passes inspiratory air directly through its oral cavity. Rather, the nasal cavity houses specialized olfactory epithelia that function in aquatic environments. Photograph of specimen catalog # 55451, Group 7, from the Division of Ichthyology at the American Museum of Natural History, Collection of Fishes. Courtesy: Anthony S. Pagano, Icahn School of Medicine at Mount Sinai, NY, USA.

The phylogenetic polarity of the lungfish choanae has long been debated.142 The choanata was erected by SaveSoderbergh112 as a taxonomic group including all tetra­ pods, lungfishes, and lobe-finned fishes that possessed choanae or choana-like apertures, which communicate with the palate. Similarly, Romer108 proposed the inclu­ sion of all choanate fishes into the taxon Choanichthyes. Rosen et al.109 were some of the most recent authors to suggest that lungfish choanae are homologous to those of tetrapods. Yet, despite the presence of gross similarities, evidence from both the fossil record and cladistic analysis suggest that the ancestors of the modern lungfish may have homoplastically (i.e. independently) evolved choanae. Chang22 first described Diabolepis, an extinct lungfish that exhibits the primitive piscine morphology of both an ante­ rior and posterior set of nostrils that did not communicate with the oral cavity. In addition, a primitive piscine con­ figuration of the maxillary nerve occurs in which it runs medial to the posterior nasal aperture among extant and extinct representatives of the lungfish. It has been dis­ placed even further medially from its ancestral position by the migration of the posterior nostril into the oral cavity over lungfish evolution.63

19

Zhu and Ahlberg142 were the first to describe a genus (Kenichthys) that exhibited a morphology intermediate between that of fishes and tetrapods, in which the choanae were present at the junction of the maxilla and premaxilla. It evolved as a displaced posterior external nostril, which was redirected ventrally from its primitive position on the snout to the lateral edge of the maxilla. These choanae are more laterally located than those of early tetrapods but clearly differ from the primitive piscine morphology. In addition, the maxillary nerve is located lateral to the choa­ nae, a synapomorphy with tetrapods and their osteolepi­ form relatives.63 The evidence suggests that the anatomical configuration of the tetrapod choanae (arguably the ear­ liest aspect of the nasopharyngeal boundaries to evolve) may have resembled Kenichthys, first evolving from the standard posterior nostril bounding the piscine nasal sac and later migrating to a position on the palate. The pala­ tine choanae of early tetrapods also appears similar to the condition seen during human embryologic growth, poten­ tially serving as a resume of evolutionary history (as per Crelin28).

Amphibians The earliest land tetrapods were probably amphibians.25,77 Modern amphibians are extremely specialized relative to the first land tetrapods, which possessed dermal plates overlying the skull and lacked occipital condyles, among other primitive traits expressed in common with their pis­ cine ancestors.25 Nonetheless, they maintained choanae that communicate between the nasal cavity and oral cav­ ity, which allowed them to pass air through the external nares and nasal cavity into the oral cavity via the inferiorly oriented choanae (Figs. 2.2A and B). Once air reached the oral cavity, they may have used a bucchal pump system similar to modern anurans (frogs) in which the inspired air is pumped downward toward a nearly intraoral glottis by specialized pharyngeal muscles. There is thus no naso­ pharyngeal airway among amphibians as they lack clear postnasal separation between the airway and alimentary tract. The nasal cavity itself is an anteroposteriorly closed sac bounded by the external nares superiorly and the choanae inferiorly in most amphibians.99 Anurans pos­ sess the most intricate of amphibian nasal cavities; they are multichambered with at least one nasal concha and separate areas for respiratory air conditioning, olfaction, and the potential homolog of the vomeronasal organ.92,99 The only known terrestrial tetrapod to possess completely

20

Section 2: Embryology, Anatomy and Physiology

A

B

Figs. 2.2A and B:  (A) Frontal view of a bullfrog (Rana catesbeiana) with the right anterior naris indicated by a black arrow. (B) Basal view of the same specimen with the right choana indicated by a black arrow. Note that the choanae exit into the oral cavity. Courtesy: Joy S. Reidenberg, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

occluded choanae as part of its adult morphology is Atreto­ choana eiselti, a large lungless salamander from the cold, mountain habitats of the Andean highlands.136 It conducts respiration solely through specialized epithelia over its skin, much like other members of the Plethodontidae (i.e. the family of lungless salamanders).

JUMPING FORWARD IN TIME: EVOLUTION OF THE SECONDARY PALATE Among most reptiles, as in the amphibians, there is no nasopharyngeal space sensu stricto. Rather, the choanae end in the oral cavity, opening between the parasphenoid wings and epipterygoid bone at the roof of the alimentary tract.59 The pterygoid plates are ventrally oriented and located far from the choanae, which lay anteriorly at the junction of the primary and secondary palate derivatives between the premaxilla and maxilla (Figs. 2.3A and B). As per Fuchs’47 classic description of reptilian nasal embryology, the nasopharyngal duct is defined as the posterior ending of a space overlying a well-developed secondary palate as seen in the Crocodilia and mammals but not in most extant reptiles, which lack this structure. Parsons,98 however, used the term more broadly to describe the area of the cavum nasi leading into the choanae in all reptiles.

The mammalian nasal cavity can arguably be identified as having arisen with the appearance of the secondary pal­ ate present among the earliest cynodonts (early mammallike reptiles). It has been argued that a transversal ligament spanning between the tubercles of the vomer and the vomerine processes of the maxillae on either side ventrally covered the choanae to create a ligamentous precursor of the secondary palate.5,13,15,30,79,127 Barghusen5 and Maier et al.79 argue that the development of this palatal precur­ sor within the common ancestors of therocephalians and cynodonts (early, mammal-like reptiles) was tied to the development of bony choanal crests to anchor fleshy choanal folds capable of separating the nasal cavity from the oral cavity. These choanal crests were believed to be the precursor of the osseous portion of the secondary palate.5 Maier et al.79 suggest that this was an adaptation to carnivory, which allowed for the continued patency of the airway during deglutition of large meat boluses, which could not be reduced via mastication as no shearing or occluding postcanine dentition had yet evolved among early therocephalians and cynodonts. In addition to alimentation, other functional demands may have influenced the evolution of the mammalian secon­dary palate. Our highly specialized morphology may be defined by the presence of an elongated, composite (primary and secondary) hard palate, and velum along with well-defined pharyngeal constrictor musculature.

Chapter 2: Evolution of the Human Nasal Respiratory Tract: Nose and Paranasal Sinuses

A

21

B

Figs. 2.3A and B:  (A) Frontal view of a sea turtle (Lepidochelys sp.) with the enlarged choanal opening visible through the anterior naris (arrow on left choanal communication). (B) A basal view of the same specimen illustrating the position of the choanae opening into the oral cavity (black arrow indicating the position of the left choana). Courtesy: Joy S. Reidenberg, Icahn School of Medicine at Mount Sinai, New York, NY, USA. Photograph by Samuel Marquez and Anthony S. Pagano.

The former trait likely evolved alongside a differentiated nasal cavity containing an olfactory recess (a probable adaptation for heightened olfactory acuity) separated from a nasopharyngeal duct inferiorly by a transverse ethmoi­ dal lamina. In addition, this specialized morphology may have evolved to allow more efficient suckling among neo­ nates.79 Proper suckling is mediated by the induction of negative pressure in the oral cavity, which must be com­ pletely separated from the nasal cavity. Such separation is normally achieved via the passive action of the hard palate and active contraction of the velar and pharyngeal constrictor muscles, which can separate the nasopharynx from communication with the alimentary tract. The func­ tional importance of this mechanism is demonstrated in cases of cleft palate infants who exhibit insufficient sepa­ ration of the oral and nasal cavities, thus rendering normal suckling difficult.24,107 Despite the presence of choanal crests and a secondary palate among therodonts (a group of early mammals), the choanae are ventrally oriented and the pterygoid plates do not appear to border the choanae laterally. It is not until the Triassic period among early anomodont mammals such as the dicynodonts that truly posteriorly oriented cho­anae are observable. In Kombuisia, the choanae take on an elongated, funnel-shaped appearance with the pterygoid

element at the caudal end of a long process of the palatine bone (see figures within Frobisch46). The choanae among early anomodonts are primarily bounded by the pala­ tine bones as in the therodonts, although the position of the pterygoid element in the former group may signify a transition to the choanal morphology of extant mammals (Figs. 2.4A and B).

Distinguishing Primates—Microsmatic Versus Macrosmatic Among mammals, primates are a decidedly derived (i.e. departing from the primitive mammalian condition) order in many aspects of cranial and postcranial anatomy. This may be reflected in the century-old debate on their proper classification and the traits that distinguish them from other archontons such as Tupaia (the tree shrew). However, within the order Primates, strepsirhines (i.e. lemurs and lorises) exhibit primitive morphology in aspects of the face and upper respiratory tract related to olfactory acuity, a condition called macrosmia. A major feature distinguishing macrosmatic mammalian species is the percentage of the nasal airway that is covered by olfactory epithelium (OE). In rodents, OE covers a rela­tively large area of the nasal cavity and confers greater olfactory acuity than among monkeys and humans, who possess

22

A

Section 2: Embryology, Anatomy and Physiology

B

Figs. 2.4A and B: Basal views of a red kangaroo (Macropus rufus) (A) and whitetail deer (Odocoileus virgineanus) (B). Note the location of the choanae is posterior and superior to the hard palate, even among distantly related mammals. This creates a separation of oral and nasal cavities not present among reptiles. Courtesy: Joy S. Reiden­berg, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

OE only on the superior-most reaches of the nasal cavity walls.55 In a histological examination of the nasal region of F344 rats (i.e. Fischer laboratory rodents that exhibit good re­ productive performance, big litters, and low level of aggression toward their handlers) Gross et al.54 found OE covering about 50% of their nasal cavity. In contrast, Sorokin125 found that neuropeithelium covered 500 mm2 in the human nasal cavity, comprising only 3% of its total surface area. Primates, such as the haplo­rhines (tarsiers, monkeys, apes, and humans), lack these specializations and are thus considered microsmatic. This division has long been discussed in relation to morphological variation in the primate nose.18,19,20,120,132 Although there is currently no reliable histological criterion for distinguishing macros­ matic primates from microsmatic ones,119,121 certain soft tissue and skeletal features of the nasal cavity tend to distinguish these two groups. Morphologically, macrosmats often possess a rhina­ rium (i.e. wet nose), a patent nasopalatine duct serving as the entrance to the vomeronasal organ, greater cover of the lateral nasal wall by OE, and a greater number of ethmoturbinals that are vertically arrayed and separated from respiratory air flow by a posterior transverse lamina or lamina transversalis posterior,20,120 otherwise known as

the “schlussplatte” of Zuckerkandl.143 At the end of this recess lies the vertically oriented cribriform plate. A “naso­ pharyngeal duct”123 is created in the space between the posterior transverse lamina and the hard palate, which ends in a vertically reduced (compared with haplorhines) choanal opening. The medial pterygoid plates usually take on an elongated, funnel-shaped appearance as in other nonprimate mammals, which may be a structural conse­ quence of a long, narrow rostrum, and nasopharyngeal duct. These features are shared among most placental mammals and suggest that the earliest representatives of the order Primates exhibited skeletal traits related to the enhancement of olfactory acuity, which are absent among most haplorrhines. However, some haplorhines have been shown to exhibit a high degree of olfactory acuity, necessitating caution when inferring sensorial abilities from gross anatomy.18,120 Relative to most generally macrosmatic strepsirhines, microsmatic haplorhines are characterized by a dry external nose covered in skin, an anteroposteriorly shorter hard palate and nasal cavity, a reduced lamina transversa­ lis posterior, a weakly defined or absent olfactory recess, fewer ethmoturbinals (usually two), reduction of the nasoturbinal (the agger nasi of humans), and choanal apertures not bounded anteriorly by a nasopharyngeal duct.120 Accompanying relative foreshortening of the ros­ trum and nasal cavity, the medial pterygoid plates reach laterally at a relatively obtuse angle with the posterior hard palate. The choanae take on a tall, narrow appearance and are variably angled anteroinferiorly. Accompanying these traits is orbital convergence, frontation, and retraction of the nasal cavity under the forebrain, which characterizes anthropoids relative to other primates (discounting the highly specialized orbital morphology of Tarsius). Ross and Ravosa110 argue that orbital convergence among haplorhines renders facial, nasal, orbital, and anterior cerebral morphology part of a single functional unit so that, when any of these struc­ tures undergoes morphologic change, it influences basi­ cranial flexion to a greater degree than among the strep­ sirhines. They measured internal basicranial flexion (angle made at the intersection of the lines connecting the planum sphenoideum with the occipital clivus) from late­ral plain-film radiographs of a diverse sample of non­ human haplorhine and strepsirhine primate crania. It was found that, among haplorhines, basicranial flexion was posi­ tively and significantly (p  50% reduction in postoperative AHI and the final AHI  1 ppm. Inhalation of concentrations of 100 ppm is immediately dangerous to life. Long-term exposure has been associated with an increased risk of sinonasal and other respiratory cancers.85

WORLD TRADE CENTER EXPOSURE In the aftermath of the World Trade Center (WTC) dis­ aster on September 11, 2001, tens of thousands of first responders, volunteers, and service restoration workers were exposed to a complex mixture of toxins released as dust, metal fumes, acid mists, smoke, and combustion products.86 WTC dust characterization, although delayed and incomplete, demonstrated the dust had an alkaline pH (9.2–11.5) and consisted of 98% respirable size particles, which included cement, cellulose, glass fibers, asbestos, lead, polychlorinated biphenyls, and polyaromatic hydrocarbons.87,88 Studies revealed a higher proportion of fine (inhalable) particles closer to the center of the disaster

Section 5: Disorders of the Nose

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Worldwide urbanization has led to a focus on the health impact of vehicle emissions, manufacturing pollutants, and greenhouse gases. Humans inspire between 10,000 and 20,000 L of environmental air each day,54 and this increasingly contaminated air carries toxins and pollu­ tants into the respiratory tract, including the sinonasal mucosa. Children exposed to high pollutant levels have increased epistaxis, nasal crusting, obstruction, dryness, and sinusitis.89 Nasal mucosa from similarly exposed children demonstrates basal cell and goblet cell hyper­ plasia, abnormal or absent cilia, squamous meta­ plasia, intraepithelial inflammatory infiltrates, and DNA damage.89 91 Multiple studies have linked environmental pollutants to rhinitis and rhinosinusitis.52,92 94 Recent studies show an association between high air pollution levels and increased risk of allergic sensitization and rhinitis.95 Medical historians note that allergic rhinitis was much less prevalent before the industrial revolution and hypo­ thesize that urban pollution contributes significantly to increased immunologic responses.6 Interestingly, air pollution has been shown to increase the availability of airborne pollen allergens by triggering the release of allergen granules from grass pollen,95 whereas pollen morphology is altered due to particle agglomeration on pollen granules.94 Urban air pollution differs dependent upon the type and number of industrial factories and the amount and composition of traffic in the area.96 Nitrogen oxides, sulfur dioxide, large and small particulate matter, carbon monoxide, and ozone are associated with upper and lower respiratory illness and are regulated by the Clean Air Act.52,93,97 Traffic related particles coagulate and condensate seconds after emission. Those living near a major road are exposed to higher amounts of traffic derived particles



ENVIRONMENTAL EXPOSURES

and gases and to a potentially more toxic freshly emitted aerosol. Multiple studies indicate that persons exposed to transport related air pollution may be at increased risk for asthma, bronchitis, rhinitis, and sinusitis.92,94,95,98 100 However, other studies do not demonstrate consistent associations between pollutants and respiratory disease, making the literature inconclusive.94 Particulate matter consists of a complex suspension of minute solid material in a gaseous or liquid medium (i.e. nitric and sulfuric acids, organic chemicals, metals, and soil or dust particles).101 Particles 2.5–10 μm, found near roadways and dusty industries, are “inhalable coarse particles”101 and have the ability to reach the lower airway.94 Particles under 2.5 μm are “fine particles” and are emitted from fires and power plant, industry, or automobile gases.98,101 “Fine” particles can cause cardiopulmonary impairment.52 There is a positive association with an increase in particulate matter and increased prevalence of respiratory and atopic disease.94,101,102 Higher levels of particulate matter are significantly associated with sneezing and nasal obstruction during the first 2 years of life.98 Diesel exhaust persists for prolonged periods in the atmosphere and consists of hundreds of organic and inorganic gaseous and particle compounds.100 Diesel exhaust causes eye and nose irritation after short term exposure and increases upper airway cytokines and chemokines, histamine release, IgE expression, and degra­ nulation of eosinophils, mast cells, basophils, neutrophils, B cells, and macrophages.52,95,96,100 This is similar to early and late phases of a type I hypersensitivity response. Long term exposure may increase allergic sensitivity.52 Nitrogen oxides are highly reactive gases that form from automobiles, power plants, and off road equipment emissions, contributing to ground level ozone forma­ tion and fine particle pollution.103 Short term exposures (5 minutes to 24 hours) are associated with increased respiratory symptoms, particularly asthma.103 Epidemio­ logic studies associate NO2 with increased dry cough and asthma by age 1, as well as respiratory hypersen­ sitivity and allergic rhinitis, although these findings are not universal among studies.95,98,99 Sulfur dioxide is most notable from power plant and industrial fossil fuel combustion.104 SO2 and other sulfur oxides may cause or worsen asthma, emphysema, and lower respiratory disease.104 SO2 is also correlated with increased patient visits for allergic rhinitis and upper respiratory complaints.95,102

­

site, and although diminished over time, remained present almost 9 months later.87 Thousands have developed chro­ nic respiratory issues related to their exposure, primarily asthma, bronchitis, and aggravated COPD.86,88 Studies have shown that the majority of these individuals also have concomitant upper airway complaints, with over 75% of workers evaluated complaining of rhinitis, sinu­ sitis, pharyngitis and laryngitis.88 In addition, substan­ tial impairment in olfactory and trigeminal sensitivity was identified in workers and volunteers compared with a control group.86



310

Chapter 20: Sinonasal Effects of Drugs and Toxins Ozone is produced by chemical reactions of volatile hydrocarbons and nitrogen oxides in the presence of sunlight.90,105 Primary sources include industrial facility, electric utility, motor vehicles exhaust, gasoline vapor, and chemical solvent emissions. Ground level ozone is the main constituent of smog105 and is a potent nonradical oxidant and known respiratory epithelial irritant.52,90,96 Approximately 40% of inhaled ozone is taken up in healthy human nasal passages106 and demonstrates nasal epithelial damage.90 Ozone may promote the new development of pollen sensitization, as well as increased IgE reactivity, eosinophil infiltration, mucous cell metaplasia, and MUC5AC gene expression.52,96 Ozone exposure can also increase release and decrease degradation of local tachykinins, which are proinflammatory neuropeptides that promote vasodilation, plasma exudation, and broncho­ constriction.106 Direct airway epithelial injury by ozone may involve oxygen free radical generation.106 Nasal mucosa from ozone-exposed children revealed increased DNA damage of nasal epithelial cells.90 There is also evidence suggesting that urban pollution may increase risk for sinonasal carcinomas. In Mexico City, a highly industrialized and populated area, DNA damage (strand breakage) is rapidly induced upon arrival and exists in permanent residents. In children, the per­ centage of nasal-damaged DNA strongly correlates with age and outdoor exposure time. Children’s nasal epithelial cells show a threefold increase in 8-hydroxydeoxygua­ nosine versus matched controls.90 A significant increase in nasal cell proliferation is seen in exposed permanent residents and in newly arrived subjects after 1 week in the city, which could increase the potential for development of sinonasal malignant neoplasms.107

INTRANASAL DRUG DELIVERY Intranasal administration of systemic and CNS medica­ tions has become an area of increasing interest. Currently, there are many medications that are formulated for intranasal use for a wide range of indications, including pain management, hormone replacement therapy, and smoking cessation, with many others under investigation (Table 20.7). The nasal mucosa is readily accessible, facili­ tating drug administration and potentially improving compliance.108 Nasal mucosal absorption is efficient and pharmacologic onset is rapid due to the highly vascu­ larized subepithelium and porous endothelial basement membrane.109-111 It circumvents gastrointestinal degrada­ tion and hepatic first-pass metabolism. It is also an ave­ nue by which the blood-brain barrier can be bypassed, resulting in direct CNS drug delivery.108,111,112

311

Intranasal drug delivery also has limitations and chal­ lenges. The nasal cavity volume is 15–20 mL, and surface area is approximately 150 cm2, restricting the volume of administered drug to 100–150 μL.108 The nasal mucosa permeability to larger, hydrophilic compounds (i.e. pep­ tides, proteins) is low.111,112 Mucosal proteases can result in drug degradation, and MCC continuously removes substances from nasal mucosa, decreasing drug absorp­ tion time.108,112 Systemic absorption of intranasally applied drugs occurs by several mechanisms. Paracellular transport occurs between adjacent epithelial cells through hydro­ philic porous and tight junctions and is the mode of transport for polar drugs. Rate of transport is inversely related to molecular weight (MW); compounds with an MW > 1 kDa have very poor intranasal absorption.108,110 Transcellular absorption occurs by passive diffusion through the cell’s interior, especially for small, lipophilic drugs.108 Compounds with an MW > 1 kDa (peptides and proteins) are transported transcellularly by an endocytic process or via specific transporters.108 The rate of trans­ cellular transport is dependent on lipophilicity.110 The exact mechanism by which intranasal drugs reach the CNS and bypass the blood–brain barrier is not well understood, although several mechanisms have been postulated. The olfactory epithelium may allow trans­ cellular and paracellular transport, and neuronal transport along the olfactory bulb or trigeminal nerve seems to be critical.108,110,113 Drug transporters have been identified in the olfactory epithelium and bulb108,114 and vascular, cerebrospinal fluid, and lymphatic pathways have been identified as candidates for transport.110

Factors Influencing Intranasal Drug Delivery There are several factors that affect intranasal drug absorption. Nasal cavity properties considered during drug development include membrane permeability, pH, MCC, disease status, nasal mucosal enzymes, and transporter proteins.108 Nasal MCC rate is inversely related to drug residence time, and thus, absorption. Conditions affecting MCC include smoking, environmental pollutants, asthma, cystic fibrosis, diabetes, and rhinosinusitis.108 Condi­ tions causing vasoconstriction also decrease intranasal absorption.108 A drug formulation produced for nasal application usually consists of the drug, a vehicle, and the excipients (solubilizer, preservatives, antioxidants, humectants, etc.).113

312

Section 5: Disorders of the Nose

Table 20.7: Various intranasally administered medications108,112,113,116

Developed drug

Drug under investigation

Indication

Butorphanol Fentanyl Ketorolac Morphine

Hydromorphone Ketamine NSAIDs Sulfentanil + ketamine

Pain management

Naloxone

Opioid overdose

Flumazenil

Benzodiazepine overdose

Dihydroergotamine Sumatriptan Zolmitriptan

Migraine and cluster headaches

Lorazepam Midazolam

Diazepam Clonazepam

Antiseizure

Dexmedetomidine Ketamine Midazolam

Diazepam

Preoperative sedation and anxiolysis

Triazolam

Insomnia

Cyanocobalamin

Vitamin B12 deficiency

Salmon calcitonin

Postmenopausal osteoporosis Melatonin

Jet lag

Desmopressin

Diabetes insipidus, nocturnal enuresis

Oxytocin

Labor induction; lactation stimulation; treatment of social, cognitive and mood disorders Human growth hormone

Growth hormone deficiency

Testosterone

Testosterone deficiency

Progesterone

Infertility, amenorrhea

Estradiol

Hormone replacement

Buserelin

Prostate cancer

Nafarelin

Endometriosis; precocious puberty

Gonadorelin

Undescended testicle Sildenafil

Erectile dysfunction

Glucagon

Antihypoglycemic Mild cognitive impairment, Alzheimer’s disease, obesity

Davunetide

Schizophrenia, Alzheimer’s disease

L dopa

Parkinson’s disease

-

Insulin

Nicotine

Smoking cessation

Metoclopramide

Antiemesis Interferon beta

Multiple sclerosis

Influenza vaccine, live attenuated

Flu prevention

 

A variety of drug physiochemical properties must be considered when developing an intranasally administered drug. Absorption for compounds with MW < 300 kDa

is not significantly influenced by the drug’s physiochemi­ cal properties; it occurs rapidly, likely via paracellular routes.108,110 Because the nasal mucosa is lipophilic, small

Chapter 20: Sinonasal Effects of Drugs and Toxins (MW  1 kDa.110,113 Polar drugs are also poorly absorbed (1–10%).116 Hence, proteins and peptides show insufficient nasal bioavailability ( 90%) was that the study was not an RCT or had no blinding. The authors concluded that the overall quality of evidence for CAM RCTs is poor but improving slowly

INTEGRATIVE MODALITIES FOR SINUSITIS

–

ISSUES WITH CAM RESEARCH

Legal guidelines do exist for incorporating CAM therapies into one’s practice. Michael Cohen, a lawyer who has worked with IM legal issues for many years, has devised a common sense way to advise patients on its use. This algorithm is summarized in Table 37.2.7

–



can be viewed as fraught with the potential for litigation should a patient encounter an adverse effect, either from use of remedies or from deferring use of more conventional medical treatment. Many resources exist for the naïve practitioner who would like to learn more about integrative therapies. Excellent online databases exist, some of which are included in Table 37.1.

ISSUES OF LIABILITY

–

  







Source

over time, at about the same rate as that of biomedicine. Thus, most CAM services are provided without a level of evidence of benefit that is acceptable to allopathic practitioners.6 Much of the CAM research that relates to sinonasal issues deal specifically with the treatment of allergy. Throughout this chapter we chose to refer to these articles as many of these modalities can be considered in the treatment of sinusitis as well.

DIETARY MANIPULATIONS Certain dietary interventions are frequently proposed for patients with sinusitis.8 Among these are: • Elimination of dairy products • Elimination of processed sugar • Elimination of alcohol • Elimination of wheat products • Food intolerance and elimination diets

Chapter 37: Complementary Therapy and Integrative Medicine in Sinonasal Disease

533

Table 37.2: Potential for malpractice liability with IM therapies

Evidence supports safety but efficacy is unclear

Evidence supports safety and efficacy

Therapeutic posture: Tolerate with caution but monitor effectiveness closely

Therapeutic posture: Recommend, but monitor

Example: Anti-inflammatory diets for sinusitis

Example: Dead Sea salt nasal irrigation for rhinitis

Liability risk: Potential exists, but acceptable

Liability risk: Unlikely

Evidence supports significant risk or clear inefficacy

Evidence supports efficacy, but safety is unclear

Therapeutic posture: Avoid use and actively discourage patient

Therapeutic posture: Consider tolerating with caution and closely monitor side effects

Example: Ear candling for cerumen impaction

Example: Ginkgo biloba for tinnitus

Liability risk: Probably liable

Liability risk: Potential exists, but most likely acceptable

Fig. 37.1: Mediterranean diet. Source: Redrawn from Rakel D. Integrative Medicine, 3rd edition. Saint Louis, MO: Saunders; 2012. p. 796.

• Antifungal dietary regimens • Anti-inflammatory dietary regimens In the absence of true food allergy, clear evidence suppor­ting any of these interventions is lacking, and much of the data that exists refers to patients with asthma and/or allergies. Confounding variables and effect modification affects interpretation of many of these studies.9 While there is no clear supporting evidence for elimination of dairy products, alcohol, processed sugar or wheat, there appears to be a correlation between the development of asthma and atopy and consumption of junk food in teenaged

children.10 It has also been shown that adherence to the Mediterranean diet is associated with a lower incidence of asthma in 10–12 years olds.11 The Mediterranean diet pyramid is displayed in Figure 37.1.12 There is a general trend in the integrative community to attribute chronic rhinosinusitis (CRS) to an overgrowth of yeast. It is unclear if this approach is as classic allergic fungal sinusitis (AFS), or thought of as presence of fungus in the sinus cavity, or an issue of chronic systemic candidiasis. Others conjecture that the yeast itself acts as a “super-antigen,” residing in the sinus cavity protected by biofilm, or in the gut, resulting in general dysbiosis.13 Yeastand carbohydrate-free diets are commonly recommended to patients with nasal symptoms of various sorts. These sometimes are combined with antifungal agents, such as Diflucan, Nystatin, Itraconazole, or herbal antifungals such as Candibactin BR or Candisol. Candibactin BR is a proprietary herbal blend that contains a number of plants, including Coptis chinensis, Berberis aquifolium, Berberine, Scutellaria baicalensis, Phellodendron chinense, Zingiber, Glycyrrhiza uralensis, and Rheum officinale. While there are no human studies supporting its use for this purpose, some of its components have been shown in vitro and in animal studies to have activity against a number of types of yeast. Berberine in particular has been shown to have strong anti-Candida activity and appears to have a synergistic effect with Fluconazole.14,15 CRS has been associated with both TH1 and TH2 inflammatory patterns and production of arachidonic acid.13 One could argue that foods that seem to inhibit these reactions are beneficial for patients with rhinosinusitis. A list of food inhibitors of arachidonic acid production is included in Table 37.3.16 Intake of such foods is encouraged in patients with recurrent sinonasal symptoms.

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Section 6: Rhinosinusitis: Etiology, Pathophysiology and Medical Therapy

Table 37.3: Food inhibitors of arachidonic acid (AA)

Table 37.4: Anti-inflammatory diet

Onions

• Total daily dietary protein to ≤10–15%

Apples

• Use plant proteins preferentially

Turmeric

• Eliminate milk and dairy, possibly gluten

Curcumin

• Include natural antioxidants – fruits, vegetables

Rosemary

• Eat organic when possible

Red pepper

• Eliminate saturated fats and transfatty acids

Capsaicin

• Increase intake of omega 3 essential fatty acids

Ginger

IMMUNE ENHANCEMENT



Anti-inflammatory diets are thought to generally reduce inflammation in the body. They are based on fresh fruits and vegetables, beneficial dietary fats, whole grains and plant based proteins. Anti-inflammatory diets are proposed for a number of conditions thought to be related to chronic inflammation, including atopy. An example of one such diet is outlined in Table 37.4.

Probiotics ­

Probiotics are defined as live microbial food ingredients beneficial for health. By definition they are safe for inges tion, stable to acid and bile, and able to adhere to the intestinal mucosa. It is also important that their beneficial physiological effects have been proven scientifically.18 There are thought to be two distinct effects of oral probiotics on immune responses. One is the suppression of an undesired immune response, such as allergic and autoimmune reactions. The second is a generalized immunostimulatory effect. These two effects are thought to be achieved via a variety of mechanisms, some via direct action on the mucosa of the gut, others by absorption and interaction with various cell types in immune competent tissues. Overall, these actions are outlined in Figure 37.2.19 Interestingly, it is also clear that dendritic cells from different anatomical sites respond differently to specific probiotics, and that individual probiotic strains affect different responses depending on the site in which their effect is expressed (i.e. different in the gut than the spleen). In addition, these organisms are in constant surveillance, able to monitor their environment, and may alter their behavior and characteristics depending on host characteristics.20 Phagocytosis, in response to probiotics, occurs differently in allergic versus healthy subjects. For example, probiotics help healthy individuals to mount an immuno stimulatory effect, in response to antigens, whereas in allergic subjects there is more of a downregulation of the immune response.21 Therefore, the same probiotic bacteria appear to have the ability to respond directly to the immunologic state and needs of the host. These beneficial bacteria are most frequently Lactobacillus or Bifidobacterium species. Many species already ­

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­

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Hundreds of botanicals are claimed to have immunomodu latory effects, but clear evidence that they are able to regulate immunological responses against defined antigens is lacking. While one can measure changes in white blood cell function in response to a product, it is impossible to know what that does to the system as a whole, or that the specific effect is the one desired therapeutically. In fact, one might argue that allergy, atopy, chronic inflammation, and infection are the result of an already over-stimulated immune system. Screening botanicals for immunomodulatory activity after oral ingestion is difficult due to unknowns such as bioavailability (depending in part on issues such as formulation and concomitant food intake), the amount of active ingredient in the botanical selected, optimal dose, and appropriate assay.17 Many herbal remedies are combination products, and it is unclear which product or individual component within the product imparts the desired effect. Of those herbal preparations reviewed, those included had either the clearest in vitro or in vivo clinical evidence supporting efficacy, or are commonly recommended in the integrative community. Appropriate dosages for both adults and children and common side effects are reflected in Table 37.5. Note that for many of these products pediatric dosages are unknown.





IMMUNE MODULATION WITH CAM THERAPIES

Management of the Microflora

Chapter 37: Complementary Therapy and Integrative Medicine in Sinonasal Disease

Fig. 37.2: Proposed mechanisms of action of probiotics. 1. Direct antibacterial action on potential pathogens 2. Production of local and systemic secretory IgA 3. Enhancement of intestinal barrier function 4. Interaction with intestinal epithelial cells with modulation of the maturation and phenotype of dendritic cells. 5. Uptake of organisms by M cells or directly by dendritic cells to coordinate antigen presenting cells and T cell responses. 6. Interaction with the enteric parasympathetic nervous system which can modulate efferent vagal discharge, releasing neuropeptides that inhibit macrophage activation and modulating systemic inflammatory responses. Source: Redrawn from Rakel D. Integrative Medicine, 3rd edition. Saint Louis, MO: Saunders; 2012. p. 799.

535

exist in human commensal microbiotia. Human monocytes and mononuclear cells incubated with certain lacto­ bacilli show a downregulation of the TH2 response and shifting toward TH1 including increased production of IL-12, IL-18, and IFN-g.22 Daily consumption of a fermented dairy product containing Lactobacillus casei increased specific antibody responses to influenza vaccination in nursing home subjects.23 A study of Finnish children in day care centers who consumed Lactobacillus rhamnosis GG enriched milk for 7 months in winter had 17% fewer upper respiratory tract infections compared to controls.24 A reduction in the common cold and enhanced T suppressor cells (CD8+) and T helper cells (CD4+) was noted in patients supplemented for 3 months during the winter and spring with Lactobacillus gasseri, Bifidobacterium longum, and Bifidobacterium bifidum.25 Some common in patients with allergies and/or sinus disease probiotics that have been used for immune modula­ tion include: • Lactobacillus strains: –– Acidophilus –– Bulgaricus –– Casei –– Plantarum

Table 37.5: Dosages and side effects of selected herbals and supplements

Daily dose-pediatric (4 and older) Not recommended for children

Product 1,8-cineol

Daily dose - adult 200 mg TID

Andrographis Paniculata AHCC

60-300 mg daily standardized to 4-6% andrographolide up to 3 g daily

200 mg per day standardized to 11.2 mg andrographolide Not recommended for children

Bromelain

200-400 mg TID

Not recommended for children

Butterbur

50-75 mg of standardized extract BID

6-9 years old 25 mg BID-TID > 9 years old 50 mg BID-TID

Formulation comments Eucalyptol

Possible side effects Heartburn, gastritis, headache, hypo­ glycemia, cytochrome P450 interactions Allergy, infertility

Nausea, diarrhea, bloating, headache, fatigue, and foot cramps GI upset and diarrhea, cross allergenicity with wheat flour, celery, papain, carrot, fennel, cypress , ragweed and grass pollen, potentiates the effects of Amoxi­ cillin and Tetracycline. Hepatotoxicity, cross allergenicity with ragweed pollen Contd..

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Section 6: Rhinosinusitis: Etiology, Pathophysiology and Medical Therapy

Contd..

60–300 mg of andrographolide

Larix arabinogalactan

3-9 gm of powdered extract Please consult resource daily for proper dosage for preparation used

N-acetylcysteine

600 mg BID

Panax Ginseng

1–2 g of whole herb, or 200 mg extract standardized to 4% to 7% ginsenosides

c

n

ot recommended

30 gtts TID of standardized extract 3 caps BID-TID

n

­

n

c

an be used as young as one month old. Please consult resource for proper dosage for route of administration

ot recommended

20 gtts tid of standardized extract n/a

tandardized extract of Andrographis paniculata SHA-10, 85 mg, containing 5g. 25 mg andrographolide and deoxyandrographolide with extract of Eleutherococcus senticosus 9.7 mg. s

2 pills TID or standardized to 30 mg andrographolide

a

4-6 years old 1-2 tabs TID 6-12 years old 2 tabs TID

Panax quinquefo- 400 mg daily × 4 months lium (Cold FX) Pelargonium Sidoides Phytocort

n

Kan Jang

ot recommended

loating and flatuence, Can intefere with immunosupressive medications ausea, vomiting, abdominal pain, constipation, urticaria, bronchospasm in asthmatics, Rarely, generalized urticaria with mild fever, sulfhemoglobinemia, headache, hypotension, rash, and hepatotoxicity, allergy nsomnia, blood pressure and cardiac abnormalities, headache, loss of appetite, diarrhea, itching, rash, dizziness, mood changes; avoid in patients on coumadin, or patients with autoimmune disease or breast cancer GI, CNS and CV adverse effects similar to placebo bnormal bleeding, allergy, GI upset eight gain, GI upset b

2–3 g whole herb or 300–400 mg of extract 3 tabs TID

ame

n

Eleutherococcus senticosus Esberitox

Possible side effects ausea, vomiting, diarrhea, dizziness, wheezing, high blood pressure, allergic reactions, hepatotoxicity, cross reactivity with ragweed allergy Nasal mucosal irritation (burning , stinging, or dryness an elevate Digoxin levels void in patients with autoimmune disorders, or who have known allergy to the components. allergy, infertility

i

1.8% irrigation 2 sprays/ nostril TID daily

Formulation comments

a

Dead Sea Salt

s

Daily dose - adult One softgel TID daily

w

Daily dose-pediatric (4 and older) Not recommended

Product Candibactin AR

Contd..

Chapter 37: Complementary Therapy and Integrative Medicine in Sinonasal Disease

537

Contd.. Product Quercitin

Daily dose - adult 400-500 mg TID

Daily dose-pediatric (4 and older) n/a

Formulation comments

Resist Aid

1–2 “shots” daily

1 shot daily

proprietary blend combines 1500 mg of Larch arabinogalactan with Inulin and 120 milligrams vitamin C

Reboost Sinupret

1-2 puffs TID 2 tablets TID

Tinospora cordifolia

300 mg TID

same check resource for children's formulation dosage n/a

Urtica dioica

300 mgs leaf extract 3–7 × daily

n/a

Xylitol

12 mg dissolved in 240 mL water; 120 mL per nostril once daily for 10 days 4.5-24 mg every 1-3 hours for 3-14 days.

same

Zinc

GI side effects and allergic reactions Tinofend

Check resource for children's formulation dosage

–– Rhamnosis GG –– Reuteri –– Gasseri • Bifidobacterium strains: –– Lactis –– Longum –– Bifidum Dosage should be 6–10 billion colony-forming units daily.

Herbal Immune Enhancers Sinupret Sinupret is a trademarked German herbal preparation for treatment of sinusitis that is available in either liquid or tablet form. It has gained popularity in the United States and contains five herbal extracts: Gentiana lutea, root; Primula veris, flower; Rumex sp., herb; Sambucus nigra, flower; Verbena officinalis, herb. A number of studies have examined its use for rhinosinusitis. In a study performed in 1984, Sinupret was compared to placebo for patients with maxillary and frontal sinusitis, confirmed by sinus X-rays

Possible side effects do not give concomitantly with quinolone antibiotics as can lessen effects abdominal cramping

nasal pain, headache, hypoglycemic effects, might intefere with immunosupressive drugs hypotension, hypoglycemia, diuretic effect, can affect androgen and estrogen metabolism sweet taste, sore throat, can intefere with absorption of copper bad taste, nausea

and physical examination. Results showed improvement in 12 of 16 patients, but it is unclear how such improve­ ment was documented, and statistical significance was not reported.26 Other trials in the literature compare Sinupret as an adjunct to antibiotics and/or decongestants in patients with acute rhinosinusitis. Ninety patients were randomized to receive Doxycycline alone, Doxycycline plus Sinupret, or Esberitox. Radiographic improvement of sinusitis was used as an end point of treatment. Both herbal preparation groups had greater statistically significant improvement than with antibiotics alone.26 A second such study showed similar trending but failed to reach statistical significance.27 More recent studies have demonstrated in vitro antiviral activity of both dry extract and oral drops against a variety of common upper respiratory pathogens.28

Esberitox Esberitox is another herbal immune enhancer containing the herbs Thuja occidentalis, Baptisia tinctoria, and Echinacea

538

Section 6: Rhinosinusitis: Etiology, Pathophysiology and Medical Therapy

­

­

­

Andrographis Paniculata A paniculata is a shrub used in India, Asia, and Scandi navia for immune enhancement, and is known as “Indian Echinacea.” It is unclear which chemical constituents of this herb account for its therapeutic activity, but it has been commonly attributed to the andrographolide and arabinogalactan proteins.41 A 2004 meta-analysis found seven double-blind, controlled trials, for a total of 896 participants, evaluating the use of a proprietary A. paniculata extract (Kan Jang) for the treatment of acute respiratory infections. The combined results suggest that this extract is more effective than placebo for cold symptoms.42,43 The effect of Kan Jang appears to be particularly helpful for nasal congestion and rhinorrhea, though improvements have also been noted in sore throat, fatigue, and earache.44 As with many herbal therapies, Andrographis should be started within 24-72 hours of onset of symptoms.45

­

Active hexose correlated compound (AHCC) is a food product widely used in Japan. It is formulated from shiitake and other mushrooms fermented in rice bran. In addition to activating NK cells and macrophages, an increase in circulating dendritic cells has also been noted.32 AHCC enhances CD4(+), CD8(+), and T-cell immune responses (IFN-g and TNF-a) in persons 50 years and older taking 300 mg twice daily for at least 30 days. This effect remained for up to 30 days after discontinuing treatment with this compound.33 There have been no studies examining its use specifically in patients with sinusitis. Human studies have confirmed its safety, even with intraperitoneal administration, though it induces CYP450 2D6, which could decrease the activity of any drugs taken concomitantly.34,35

Ginsengs

­



Three different herbs are commonly called ginseng: Asian or Korean ginseng (Panax ginseng), American ginseng (Panax quinquefolius), and Siberian ginseng (Eleutherococcus senticosus). Ginseng is considered in the class of herbs known as adaptogens. Adaptogenic herbs are thought to help the body adapt to stresses of various kinds, cause no side effects, and be effective in treating a wide variety of illnesses, regardless of their origin.36 P quinquefolius seems to have some efficacy for fighting colds and flu. Cold FX, a proprietary extract from



Active Hexose Correlated Compound

­

­

Certain mushrooms, particularly of the Shiitake and Maitake species have been investigated for many years for their ability to upregulate various immune factors. The b-glucans are thought to be responsible for much of this effect. b-glucans are a group of glucose polymers, found in the cellular structure of fungi, algae, and some bacteria and plants. They have the ability to stimulate cells of the innate human immune system and have been shown in vivo to have antimicrobial properties against viruses, bacteria, and fungi.31

­

Mushrooms

North American ginseng root contains mainly poly-furanosylpyranosyl-saccharides, unlike other Asian or American ginseng products, which contain more polysaccharides and ginsenosides. Studies in mice show Cold Fx is capable of enhancing the production of splenic lymphocytes. It has also been shown to increase the production of interleukin IL-i, IL-6, TNF-a, and nitric oxide from peritoneal macro phages in vitro, and to increase the production of mouse serum Ig G levels.37 Two double-blind, placebo-controlled studies support the use of this product taken at 400 mg daily for 4 months to prevent the common cold.34,38 E senticosus, while loosely related to this family of herbs, is commonly referred to as Russian or Siberian gin seng. There are several double-blind studies that support its use in conjunction with the herb Andrographis for treatment of upper respiratory tract infections (URTIs).39,40

angustifolia. Native Americans traditionally use these herbs for various immune disorders. This product has been shown to activate macrophages and is thought to nonspecifically induce immunoglobulin production.29 In patients with chronic bronchitis, Esberitox has been shown to shorten time to improved FEV 1 when combined with macrolide antibiotics, as compared to placebo.30

Larix Occidentalis Arabinogalactan is a branched polysaccharide extracted from the bark of the larch (Larix occidentalis) tree. This substance has been shown to stimulate innate immunity by increasing NK cell cytotoxicity and enhancing the phagocytic capacity of macrophages and monocytes in cultured human blood cells.46 A total of 199 patients were examined in a recent double-blinded, placebo-controlled randomized trial examining a proprietary Larch blend for symptoms of the common cold. During the study period, participants received 4.5 g of this blend (Resist Aid) versus placebo. Using a self-reported infection rate and

Chapter 37: Complementary Therapy and Integrative Medicine in Sinonasal Disease symptom diary, it was documented that study subjects had statistically significant less incidences of URTIs and a decrease in symptoms during such attacks.47 Larix has also been shown to increase IgG responses to the 23-valent pneumococcal vaccine.48 No significant side effects were noted.

Pelargonium Sidoides Pelargonium sidoides is a South African plant, the roots of which are used to formulate the herbal compound EPs7640, marketed as Umckaloabo. Its effect on URTIs is thought to occur through a number of actions. In vitro studies suggest that polyphenols in Umckaloabo can stimulate release of TNF and interleukin activity, resulting in interferon production and increased NK cell activity.49 This product can also promote phagocytosis and decrease adhesion of bacteria to tissues.50 In addition, P sidoides is thought to have mucolytic effects, improve cilia function, and increase production of secretory IgA.51 It is used for the treatment of self-limited URTIs. The Cochrane database examined eight randomized clinical trials of P sidoides with acceptable methodologies. Two trials showed that P sidoides was effective in relieving all symptoms, in particular cough and sputum production in adults with acute bronchitis. Similarly, P sidoides was effective in resolving symptoms of acute bronchitis in 819 children studied, but the evidence was considered low quality in both age groups. In acute sinusitis and the common cold, P sidoides was effective in resolving all examined symptoms including headache and nasal discharge in adults when taken for an extended time period. There was no valid data for treatment of other acute URTIs.48,52

ANTI-ALLERGY, MAST CELL STABILIZERS, LEUKOTRIENE INHIBITORS Antiasthma Herbal Medicine Intervention Antiasthma herbal medicine intervention (ASHMI) is an extract of three Chinese herbal medicines: LingZhi (Ganoderma lucidum), Ku Shen (Sophora flavescentis), and Gan Cao (Glycyrrhiza uralensis). It has received FDA investigational new drug approval and is currently

539

in clinical trials in the United States. In mice, it has been shown to decrease allergen-specific IgE and Th2 cytokine levels and also to increase IFN-g. These changes persist at least 8 weeks posttherapy.53 In a trial of 51 child­ ren with allergic rhinitis (aged 5–14 years), subjects were randomized to receive either inhaled corticosteroid and placebo or steroid and ASHMI. The steroid with ASHMI group showed a greater reduction in total IgE, serum eosinophilic cationic protein, and significantly increased IFN-g and serum cortisol levels compared to steroid plus placebo. Symptoms were also significantly lower in the experimental versus the control group.54 The herbal product currently marketed in the United States known as Phytocort contains similar ingredients along with noni fruit. Dosage is three capsules TID or twice daily for maintenance.

Butterbur (Petasites hybridus) The leaves and rhizomes of the butterbur plant contain a form of eremophilan-type sesquiterpenes known as petasin. They are pharmacologically active and exist in iso and neo isomers and their sulfuric analogs. These molecules have been shown in vitro to inhibit leukotriene synthesis, histamine binding, intracellular calcium mobili­ zation, phospholipase activity and degranulation of certain inflammatory mediators. Petasins have been shown in vivo to inhibit Th2 cytokines Il-4 and Il-5, thereby affecting allergic airway inflammation and hyper-responsiveness.55 In a randomized, double-blind parallel group of 125 participants, butterbur was just as effective as cetiri­zine for ocular and nasal allergy symptoms.56 The subjects were scored on number of allergic symptoms, including sneezing, rhinorrhea, itchy nose, and congestion. Although symptom-specific outcomes were not individually exami­ ned, overall, butterbur’s effects were similar to those of cetirizine. There were no significant side effects noted with butterbur, although the cetirizine group noted an increased incidence of drowsiness. A specific prepara­tion of Butterbur, Ze339 used for 2 weeks in either low (16 milligrams of Petasin) or high (24 milligrams of Petasin) dose has been shown to have a dose-dependent effect on symptoms of allergic rhinitis, both superior to placebo. There was no significant diffe­ rence in reported side effects for all 3 groups.57 Care should be taken in patients with ragweed allergy, as there is potential cross reactivity. Preparations should be free of pyrrolizidine alkaloids which are hepatotoxic.

Section 6: Rhinosinusitis: Etiology, Pathophysiology and Medical Therapy

Nettles (Urtica dioica) Nettles are micronutrient dense herbs that have been shown in vitro to prevent mast cell degradation and inhibit COX enzymes.61 A double-blind randomized study of 69 participants noted symptomatic improvement in allergy symptoms slightly more than placebo.62 Notably, stinging nettles have traditionally been used as a food in pregnant and lactating women and are used in some cultures as a lactogogue. As their safety in pregnancy and breastfeeding has not been established, their use in medicinal form is not recommended at this time. In order to be most effective, nettles should be started at the first symptoms of allergy.

Tinospora Cordifolia

­

­

Widely used in Ayurveda (traditional Indian medicine) for fever, cough, and asthma, Tinospora is commonly called guduchi. While this herb has many immunostimulatory effects, in allergic rhinitis it is thought to work by inhibit ing mast cell degranulation. It contains an a-glucan poly saccharide that can activate NK, T and B cells, thus inducing production of ILs-1,6,12,18.63 In a randomized, placebo-controlled trial of 75 subjects with symptoms of allergic rhinitis, a significant reduction in sneezing, nasal discharge, obstruction, and pruritus was noted in the Tinospora group versus controls. There was also a statistically significant decrease in eosinophil and

MUCOLYTICS Bromelain

­

­

Bromelain is derived from the stem and the fruit of pineapple and is composed of a mixture of various thiol endo peptidases and other enzymes such as phosphatase, glucosidase, peroxidase, cellulase, escharase, and several protease inhibitors. In vitro and in vivo studies demonstrate that bromelain exhibits various fibrinolytic, anti thrombotic, and anti-inflammatory activities. In vitro experiments have shown that bromelain has the ability to modulate surface adhesion of molecules to T cells, macrophages, and natural killer cells and that it can induce the secretion of IL-1b, IL-6, and TNF-a.65 It inhibits prostaglandins and serves as a mucolytic and anti-inflammatory.66 A 2005 German study did demonstrate statistically significant faster recovery in children with sinusitis treated with bromelain compared to other therapies.67

N-acetylcysteine The route of administration might affect the mucokinetics of N-acetylcysteine (NAC). Nebulized, NACs reputation as a mucolytic stems from the ability of its sulfhydryl group to bind to and cleave disulfide cross-linkages, making smaller, less viscous components.68 A 2000 meta-analysis of double-blind, placebo-controlled trials of patients with chronic bronchopulmonary disease showed a statistically significant difference compared to placebo when used for at least 3 months.69 Given orally, NAC may act as an anti oxidant, as it is required for glutathione synthesis, which protects against free radical damage.70 In a randomi zed, placebo-controlled, double-blind clinical trial of 262 Italian seniors, 600 mg of NAC taken twice daily for 6 months significantly decreased the frequency (51% vs 29%) and severity of influenza-like episodes.71 ­



­

Quercetin has a number of properties that make it ideal for use in patients with recurrent sinusitis. In vitro it exhibits anti-inflammatory activity via inhibition of cyclooxygenase and lipoxygenase, thus potentially a regulator of leuko triene and prostaglandin metabolism. In addition, in vitro studies utilizing human nasal epithelium have shown that quercetin is able to stabilize mast cells and inhibit the release of histamine, even after IgE activation. It does so more effectively than cromolyn sodium.58 It has been shown to decrease the frequency of URTIs in elite athletes, without a definitive change in immunomodulators being demonstrated.59 Quercetin is a dietary flavonoid that occurs abundantly in foods such as red wine, tea, onions, kale, tomatoes, broccoli, green beans, asparagus, apples, and berries, but absorption from food sources is highly variable.60 Most studies have used 400–500 mg two times daily. While no side effects have been reported, quercetin may lessen the effects of quinolone antibiotics, and these should not be taken simultaneously.

neutrophil, goblet cells in nasal smears, versus an increase in these factors in the control group.64 Three hundred milligrams of the aqueous stem extract is typically used for up to 8 weeks. There is some concern that it can produce hypoglycemic effects, so it should be used with caution in patients on medications to lower blood sugar.

­

Quercetin

Volatile Oils A number of essential and volatile oils have been sugges ted as mucous thinners, particularly in cough and cold ­

540

Chapter 37: Complementary Therapy and Integrative Medicine in Sinonasal Disease preparations. Very few of them have been well researched, but traditional use is widespread. Eucalyptol (1,8-cineol) has been investi­gated in a double-blind, placebo-controlled study examining steroid-dependent asthmatics. Daily prednisone requirements were decreased 36% with eucalyptol use compared with a 7% decrease with placebo.72

OTHER MODALITIES Acupuncture For certain world populations, acupuncture remains a mainstay for treatment of sinusitis. A 2006 systematic review of CAM for rhinitis and asthma published in the Journal of Allergy and Clinical Immunology argues that the majority of studies on acupuncture and allergic rhinitis and were not randomized, controlled, or descriptive.73 Some studies do support the use of acupuncture for nasal symptoms. In 2009, a randomized, placebocontrolled study by Fleckenstein et al. examined acupuncture versus placebo electro-acupuncture for a number of parameters associated with allergic rhinitis: nasal obstruction, rhinorrhea, sneezing, postnasal drip, itching, watery eyes, headache, ringing or popping sensation in the ears, which they termed “nasal sickness score.” There was a significant difference in the treatment versus placebo group, but the total number of participants in the study was small (24 total). Also, direct measurement of nasal patency using acoustic rhinomanometry failed to show a post-treatment difference in either group.74 In a study of over 200 participants, acupuncture versus sham acupuncture versus no acupuncture was compared looking at certain nasal symptoms including nasal obs­ truction, rhinorrhea, sneezing, and itching. Other quality of life (QOL) issues were also assessed. In this study, sham acupuncture consisted of light acupuncture at non­ acupuncture points. The acupuncture groups received treatment three times weekly for 4 weeks. Differences were noted between all three groups in the nasal symp­ tom scores, with the acupuncture group having the most significant change as compared to the sham and non­ acupuncture group. There was no difference in the QOL parameters between the acupuncture and sham acupu­ ncture group other than sleep, but there was a significant difference between the acupuncture and nonacupuncture group on all study parameters.75 In a study of children with sinusitis, Ng et al. studied 72 children ages 6–20 years, randomized to receive either acupuncture or sham acupuncture for 8 weeks. During both the treatment period and the 12-week follow-up

541

period, the acupuncture group reported significantly better daily rhinitis scores and more symptom free days. There were, however, no significant differences found in use of relief medication, nasal or blood eosinophil counts, or serum immunoglobulin E levels. None of the benefits persisted beyond 10 weeks.76 Xue et al. found similar results in a study of 30 adults in a randomized, placebo-controlled crossover study.77 These studies suggest that acupuncture could be effective in relieving SAR symptoms, but treatment duration and frequency need to be further examined. In one of the few studies that look at acupuncture specifically for sinusitis, Rossberg et al. performed a randomized, single-blinded three-armed study of patients with CT-documented mucoperiosteal thickening and symptoms of sinusitis. Patients were randomized to one of three study arms: 2–4 weeks of conventional medication (with antibiotics, corticosteroids, nasal saline irrigations, and local decongestants [n = 21]), 10 treatments with traditional Chinese acupuncture (n = 25), or 10 treatments with sham acupuncture (minimal acupuncture at nonacupoints [n = 19]). Results included documented changes in CT scan, reported nasal symptoms, rhinorrhea, midfacial headache, nasal congestion, frontal headache, anosmia, and generally feeling well. Other QOL issues were also examined. Radiographic confirmation of improvement of sinusitis was seen only in the conventional group. There were other signs of improvement in symptoms over 4 weeks in all three groups. Four-week changes in symp­ tom scores showed a nonsignificant difference between the conventional medicine and the sham group, and less difference between the conventional medicine and the tradi­tional Chinese acupuncture groups. No differences were noted between the groups after 12 weeks or 12 months which the authors conjecture could indicate a lack of long-term effect of treatment.78 The evidence to date does not strongly suggest including acupuncture alone as a treatment for chronic sinusitis. It is important to note that traditional Chinese medicine is meant to be a medical system, combining not only acupuncture but herbs, dietary interventions, massage and movement, such as Qi Gong or Tai Chi. It is also important to understand that study design in acupuncture is fraught with issues of randomization, how the diagnosis is formulated, what constitutes placebo, type of acupuncture performed (sham versus electro-acupuncture versus light acupuncture versus none for controls), which points are included, etc. Because it is such an individualized form of treatment, it is difficult to formulate appropriate clinical studies.

Section 6: Rhinosinusitis: Etiology, Pathophysiology and Medical Therapy Three combination products marketed here in the US deserve mention. Euphorbium, currently sold under the trade name Reboost, has been shown to decrease symptoms of rhinitis.68 An in vitro study using virus plaque reduction assays showed its antiviral activity against RSV and HSV-1. A minimal antiviral effect was also noted against influenza A virus and human rhinovirus.83 Similarly, a nasal spray for allergic rhinitis, Luffa compositum, has shown efficacy when compared to Cromolyn sodium. Another product, marketed as Grippheel, was examined in a multicenter, observational cohort study of patients with mild viral URTIs. Results suggested equivalent effective ness of homeopathy and conventional medications.84

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NASAL IRRIGANTS Dead Sea Salt Spray (Lavi) Hypertonic saline has been shown to provide a greater improvement in mucociliary clearance, as compared to normal saline. This is due to the fact that hypertonic saline is a mildly alkaline solution, and thus, keeps mucus in sol phase and thereby reduces the mucociliary transit time. Its most commonly reported side effect is nasal mucosal irritation. Dead Sea salt (DSS) solutions have long been used to treat various dermatologic conditions (like allergic derma titis, atopic dermatitis, and psoriatic dermatitis) based on their observed anti-inflammatory properties. DSS solu tions differ from regular saline solutions with regards to their unique mineral content (Ca, K, Br, Zn, Mg). Magne sium salts, which comprise 35% of DSS solutions, have the ability to bind water, enabling them to influence epidermal proliferation/differentiation and to enhance permeability barrier repair. Thus, it has been shown that skin bathed in the Dead Sea (or DSS solutions) demonstrates decreased inflammation, increased hydration, and decreased redness.85 Prior studies have shown the value of DSS in the treatment of allergic rhinitis or has shown its superior effectiveness compared to hypertonic saline alone.86,87 A recent study by Friedman et al. compared DSS irrigations versus hypertonic saline plus fluticasone. Patients were included if they had a confirmed diagnosis of CRS based on the Rosenfeld criteria and nasal endoscopy findings. They were then blinded to either 1.8% DSS solution (2 sprays/nostril three times daily) or 1.8% hypertonic ­

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Homeopathy is based on the principle of “similitude,” or like cures like and the nanopharmacology of “ultrahigh dilutions,” where the more dilute the preparation, the more potent. Samuel Hahnemann, considered by most to be the father of homeopathy, self-administered cinchona bark, and reported symptoms of malaria. Hahnemann collected and administered a number of such substances and recorded the symptoms that resulted. This process, in homeopathic medicine, is known as “proving.” Today, homeopathic formulations use these same substances, macerated with alcohol, producing what is known as a “mother tincture.” One portion of this tincture is then diluted in 99% alcohol, shaken a certain number of times, to formulate what is known as a 1C dilution. At the 12C level, the substance has been diluted to a solution of 10–24. Thus by Avogadro’s number it is impossible for there to be any molecules of the original substance in the remedy. This preparation is then administered as medicine according to homeopathic principles. While it can be argued that homeopathic remedies are merely placebo, Linde et al. published a meta-analysis in the Lancet, which showed that the odds ratio was 1.66 that the effects were due to placebo alone.79 The authors conclude that while it is unlikely that all the effects of homeopathy can be accounted for by placebo effect, there is insufficient evidence to support that it works for any single clinical condition. A 2003 review examined some 93 randomized or double-blind, controlled trials for effi cacy of homeopathy verses placebo. Hayfever and upper respiratory tract infections were among eight conditions for which homeopathy appeared to have a positive effect.80 Homeopathy can be used in low or high dilution, as a single remedy, or in combination. Of the single remedies utilized for allergic rhinitis, sulfur, calcarea carbonica, lycopodium, pulsatilla, silicea, arsenicum album, and Nux vomica were the most frequently mentioned products that demonstrated clinical success.81 Some combination products are noteworthy. A French homeopathic remedy, L52 containing Eupatorium perfoliatum, Aconitum napellus, Bryonia alba, Arnica montana, Gelsemium sempervirens, Cinchona, Belladonna, Drosera, and Senega showed promising results compared to placebo in a double-blind study examining its use for symptoms of upper respiratory tract infection.82

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Chapter 37: Complementary Therapy and Integrative Medicine in Sinonasal Disease saline/fluticasone. Patients completed a SNOT-20 question­ naire and University of Pennsylvania Smell Identification Test (UPSIT) at their initial visit as well. Upon their return at 4 weeks following daily treatment, patients underwent repeat nasal endoscopy, UPSIT, and SNOT-20. The posttreatment SNOT-20 scores between the two groups was significantly reduced from baseline in both cases; however, was not statistically different between the two treatment groups, thus proving the efficacy of DSS solutions.88 Given that DSS is well tolerated as an intranasal spray, it should be considered as therapy for CRS given its effectiveness compared to a topical intranasal steroid and hypertonic saline solution.

Xylitol (Xlear) Xylitol is a five-carbon sugar alcohol that has been show to enhance the body’s innate bactericidal mechanisms. The idea of the therapeutic role of xylitol in chronic rhinosi­ nusitis comes from basic research on the airway surface liquid (ASL), which coats the apical surface of airway epithelia and is known to contain multiple antimicrobial agents like lactoferrin and lysozyme.89 It has been shown that in respiratory epithelium affected by inflammation, irritation, and CF, the ASL chloride concentration is higher than normal.90 Increasing chloride concentrations causes the antibacterial properties of normal ASL to dimi­nish. When xylitol has been applied to CF respiratory epithelium, it has been able to lower the ASL chloride con-centration to values seen in normal samples. Moreover, common airway pathogens in CF (Pseudomonas aeruginosa, Staphylococcus aureus, coagulase-negative Staphylococcus, and Staphylococcus saprophyticus) were unable to utilize the xylitol for growth.89 In the same study, colony counts of S aureus were significantly reduced with xylitol sprays as compared to saline. A recent prospective, randomized, double-blinded, controlled crossover pilot study91 was undertaken to compare xylitol versus saline irrigations in the management of chronic rhinosinusitis in patients who had previously undergone endoscopic sinus surgery. SNOT-20 and visual Analog scores (VAS) were the primary outcome measures. There was a statistically significant decrease in SNOT-20 scores in the xylitol group as compared to saline group; however, the VAS remained unchanged. Xylitol as a spray is very well tolerated. One out of 20 subjects reported transient stinging, but it did not cause the patient to stop using the spray. Further studies with longer treatment

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courses and more subjects, however, will be needed to further delineate these findings, but this study proves that xylitol nasal sprays may have a role in the future. The dose of xylitol used was 12 mg dissolved in 240 mL water. 120 mL was then irrigated into each nasal cavity once a day for 10 days total.

VITAMINS, MINERALS, AND SUPPLEMENTS Omega-3-Fatty Acids Fish oil contains eicosapentaenoic and docosahexaenoic acids, which are omega-3-polyunsaturated fatty acids.92 They have anti-inflammatory effects and there is a link between declining consumption of them and a rise in the prevalence of allergic diseases.93 This was shown as maternal perinatal consumption of fish oil and omega3-polyunsaturated fatty acids has been postulated to prevent the development of allergic disease in infants. Recent evidence has also shown that the intake of omega-3 polyunsaturated fatty acids may be associated with a reduced prevalence of allergic rhinitis.94

Selenium A previous study showed that blood samples from 44 children undergoing tympanostomy tube placement had lower levels than adults of eicosapentaenoic acid, vitamin A, and selenium.95 Selenium is a trace metal that is a component of glutathione peroxidase, which decreases reactive oxygen species.96 A recent study95 treated four pediatric patients with chronic/recurrent sinusitis with lemon-flavored cod liver oil and a children’s multivitamin (mineral with selenium). Three out of four patients had a positive response with decreased sinus symptoms, fewer episodes of acute sinusitis, and fewer doctor visits. This was a small, open-label, dose-titration study. Thus, a definitive, large, well-controlled study will need to be performed before any definitive conclusions can be made.

Vitamin D Cholecalciferol is the naturally occurring form of vitamin D and is obtained from dietary sources or from 7-dehydrocholsterol (7-DHC). 7-DHC absorbs ultraviolet B rays, which causes it to be transformed to cholecalciferol. Calcidiol (25-hydroxyvitamin D) is a prehormone that is made from cholecalciferol and is what is tested when

Section 6: Rhinosinusitis: Etiology, Pathophysiology and Medical Therapy

CAM is widely used among patients in the United States, and for many worldwide is the mainstay of treatment for chronic sinonasal conditions. As the literature continues to evolve and the field of Integrative Medicine emerges, allopathic physicians will be required more and more to counsel patients in various therapies. There are clear ways to approach such remedies from an objective evidence base while remaining open to other possibilities of healing. As always, the otolaryngologist will be called upon to counsel patients in the best way to approach conditions of the ear, nose, and throat. It serves us well to be prepared to respond to patients’ needs, truly practicing in a fashion that integrates the best that medicine has to offer.

REFERENCES

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http://nccam.nih.gov/health/whatiscam http://www.imconsortium.org/about/home.html http://www.abpsus.org/integrative-medicine Barnes PM, Bloom B, Nahin RL. Complementary and alter native medicine use among adults and children: United States, 2007. National Health Statistics Reports: No. 12. Hyattsville, MD: National Center for Health Statistics; 2008. 4. Newton JR, Santanengeli L, Shakeel M, et al. Use of comple mentary and alternative medicine by patients attending a rhinology outpatient clinic. Am J Rhinol. 2009; 23(1):59-63. 5. Shakeel M, Newton R, Ah-See KW, et al. Complementary and alternative medicine use among patients undergoing otolaryngologic surgery. J Otolaryngol Head Neck Surg. 2009;38(3):355-61.



1. 2. 3. 3a.



Zinc inhibits rhinoviral replication by preventing the formation of viral capsid proteins and has been tested in trials for the treatment of the common cold. Human rhinovirus attaches to nasal epithelium via intracellular adhesion molecule (ICAM)-1 to cause most colds. It is presumed that zinc has an affinity for ICAM-1 and may exert an antiviral effect by attaching to ICAM-1.105 A recent Cochrane review105 identified 15 RCTs, enrolling 1360 participants of all age groups, comparing zinc with placebo. It was found that zinc (either lozenges or syrup) was beneficial in reducing the duration and severity of the common cold in healthy people, when taken within 24 hours of onset of symptoms. It was seen that people taking zinc were less likely to have persistence of their cold

CONCLUSIONS



Zinc

symptoms beyond 7 days of treatment. In those that took zinc supplementation for at least five months, they were found to have a reduced incidence of the common cold, less school absenteeism, and reduced need of antibiotics. However, they were more likely to experience adverse effects, such as bad taste or nausea. No studies were undertaken in patients with underlying medical problems, thus the use of zinc cannot be recommended in patients with underlying chronic illness, immunodeficiency, or asthma. Also given the variability in the populations studied, dose, formulation, and duration of zinc used in the included studies, more research is needed to address these variabilities and determine the optimal duration of treatment as well as the dosage and formulations of zinc that will produce clinical benefits without increasing adverse effects, before making general recommendations for zinc in treatment of the common cold.



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measuring vitamin D blood levels. Calcitriol (1,25-dihydroxyvitamin D) is made from calcidiol (mainly in the kidneys) and is the active form of vitamin D.97 Helper T1 (Th1) and Th2 cells are direct targets of calcitriol. Activation of CD4+ T cells results in a fivefold increase in vitamin D receptor expression, enabling calci triol to regulate at least 102 identified genes.103,104 There have been multiple studies showing the importance of vitamin D in asthma and allergic rhinitis. One showed a positive correlation between vitamin D deficiency in individuals with asthma as compared with control individuals.98 Another showed that allergic rhinitis increased with serum levels of vitamin D.99 A third found that higher maternal intake of vitamin D during pregnancy was associated with a lower risk of allergic outcomes in children by 5 years of age.100 There has been a lack of literature with regards to chronic rhinosinusitis and the role of vitamin D. One study found that vitamin D levels were significantly lower in African American patients with CRS as compared with age-matched and sex-matched controls.101 Moreover, a recent study out of Poland evalu ated the role of vitamin D in vitro in the reduction of fibroplast proliferation from nasal polyps in patients with CRS. Tissue samples were treated with varying doses of calcitriol and a tacalcitol, with and without budesonide. There was a statistically significant decrease in fibroblast proliferation with treatment with calcitriol and tacalcitol, nothing that higher dose concentrations had more of an effect than lower doses. This is a beginning step in the potential use of topical vitamin D analog for the treatment of CRS.102



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Chapter 37: Complementary Therapy and Integrative Medicine in Sinonasal Disease 65. Rajendra P, Sapna J, Shraddha, et al. Properties and thera­ peutic application of bromelain: a review. Biotechnol Res Int. 2012:1-6. 66. Helms S, Miller A. Natural treatment of chronic rhino­ sinusitis. Altern Med Rev. 2006;11(3):196-207. 67. Braun JM, Schneider B, Beuth HJ. Therapeutic use, effi­ ciency and safety of the proteolytic pineapple enzyme Bromelain POS in children with acute sinusitis in Germany. In Vivo. 2005;19:417-21. 68. Sheffner AL. The reduction in vitro in viscosity of muco­ protein solution by a new mucolytic agent. N-acetyl-Lcysteine. Ann NY Acad Sci. 1963;106:298-310. 69. Grandjea E, Berthet I, Ruffmann R, et al. Efficacy of oral long-term N-acetylcysteine in chronic bronchopulmonary disease: a meta-analysis of published double-blind, placebo-controlled clinical trials. Clin Ther. 2000;22(2): 209-21. 70. Yuta A, Baraniuk J. Therapeutic approaches to mucus hypersecretion. Curr Aller Asthma Rep. 2005;5:243-51. 71. De Flora S, Grassi C, Carati L. Attenuation of influenzalike symptomatology and improvement of cell-mediated immunity with long-term N-acetylcysteine treatment. Eur Respir J. 1997;10:1535-41. 72. Juergens UR, Dethlefsen U, Steinkamp G, et al. Antiinflammatory activity of 1,8-cineol (eucalyptol) in bronchial asthma: a double-blind placebo-controlled trial. Respir Med. 2003;97:250-56. 73. Tran NP, Vickery JB, Michael S. Management of rhinitis: allergic and non-allergic. Allergy Asthma Immunol Res. 2011;3(3):148-56. 74. Fleckenstein J, Raab C, Gleditsch J. Impact of acupuncture on vasomotor rhinitis: a randomized placebo-controlled pilot study. J Altern Complement Med. 2009;15(4):391-8. 75. Choi SM, Sul JU, Hong Z, et al. A multicenter, randomized, controlled trial testing the effects of acupuncture on allergic rhinitis. Allergy. 2013;68(3):365-74. 76. Ng D, Chow P, Ming S, et al. A double-blind, randomized, placebo-controlled trial of acupuncture for the treatment of childhood persistent allergic rhinitis. Pediatrics. 2004; 114:1242-7. 77. Xue CC, English R, Zhang JJ. Effect of acupuncture in the treatment of seasonal allergic rhinitis: a randomized controlled clinical trial. Am J Chin Med. 2002;30(1):1-11. 78. Rössberg E, Larsson P, Birkeflet O, et al. Comparison of traditional Chinese acupuncture, minimal acupuncture at non-acupoints and conventional treatment for chronic sinusitis. Complement Ther Med. 2005;13(1):4-10. 79. Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homoeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet. 1997;350:834-43. 80. Mathie RT. The research evidence base for homeopathy: a fresh assessment of the literature. Homeopathy. 2003; 92(2):84-91. 81. Paolo B, Riccardo O, Francesco P, et al. Immunology and Homeopathy. 4. Clinical studies – Part 2. Evid Based Complement Alternat Med. 2006;3(4):397-409.

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82. Paolo B, Riccardo O, Francesco P, et al. Immunology and homeopathy. 4. Clinical Studies—Part 1. Evid Based Complement Alternat Med. 2006;5:293-301. 83. Glatthaar-Saalmuller B, Fallier-Becker P. Antiviral action of Euphorbium compositum® and Its Components, For­ schende Komplementärmedizin und Klassische Natur­ heilkunde. 2001;8(4):207-12. 84. Rabe A, Weiser M, Klein P. Effectiveness and tolerability of a homoeopathic remedy compared with conventional therapy for mild viral infections. Int J Clin Pract. 2004; 58(9):827-32. 85. Schiffner R, Schiffner-Rohe J, Wolfl G, et al. Evaluation of a multicentre study of synchronous application of narrowband ultraviolet B phototherapy (TL-01) and bathing in Dead Sea salt solution for psoriasis vulgaris. Br J Dermatol. 2000;142:740-47. 86. Cordray S, Harjo JB, Miner L. Comparison of intranasal hypertonic dead sea saline spray and intranasal aqueous triamcinolone spray in seasons allergic rhinitis. Ear Nose Throat J. 2005;84:426-30. 87. Friedman M, Vidyasagar R, Joseph N. A randomized, prospective, double-blind study on the efficacy of dead sea salt nasal irrigations. Laryngoscope. 2006;116:878-82. 88. Friedman M, Hamilton C, Samuelson C, et al. Dead Sea salt irrigations vs saline irrigations with nasal steroids for symptomatic treatment of chronic rhinosinusitis: a randomized, prospective double-blind study. Int Forum Allergy Rhinol. 2012;2(3):252-7. 89. Zabner J, Seiler MP, Launspach JL, et al. The osmolyte xylitol reduces the salt concentration of airway surface liquid and may enhance bacterial killing. Proc Natl Acad Sci USA. 2000;97:11614-19. 90. Gilljam H, Ellin A, Strandvik V. Increased bronchial chloride concentration in cystic fibrosis. Scand J Clinical Lab Invest. 1989;49:121-4. 91. Weissman J, Fernandez F, Hwang P. Xylitol nasal irrigation in the management of chronic rhinosinusitis: a pilot study. Laryngoscope. 2011;121:2468-72. 92. Li-Xing M. Complementary and alternative medicine for allergic rhinitis. Curr Opin Otolaryngol Head Neck Surg. 2009;12:226-31. 93. Blumer N, Renz H. Consumption of omega-3-fatty acids during perinatal life: role in immunomodulation and allergy prevention. J Perinatal Med. 2007;35(Suppl 1):S12-18. 94. Hoff S, Seiler H, Henrich J, et al. Allergic sensiti­ zation and allergic rhinitis are associated with omega-3-poly­ unsaturated fatty acids in the diet and in red blood cell membranes. Eur J Clin Nutrition. 2005;59:1071-80. 95. Linday L, Dolitsky J, Shindledecker C, et al. Lemon-flavored cod liver oil and a multivitamin-mineral supplement for the secondary prevention of otitis media in young children: pilot research. Ann Otol Rhinol Laryngol. 2002;111:642-52. 96. Linday L, Dolistsky J, Shindledecker R. Nutritional supple­ ments as adjunctive therapy for children with chronic/recurrent sinusitis: pilot research. Int J Pediatr Otorhinolaryngol. 2004;68(6):785-93.

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102.







103.





105.





104.







97. Akbar N, Zacharek M. Vitamin D: immunomodulation of asthma, allergic rhinitis, and chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg. 2011;19:224-8. 98. Freishtat R, Iqbal S, Pillai D, et al. High prevalence of vitamin D deficiency among inner-city African American youth with asthma in Washington, DC. J Pediatr. 2010;156:948-52. 99. Wjst M, Hyppnen E. Vitamin D serum levels and allergic rhinitis. Allergy. 2007;62:1085-6. 100. Erkkola M, Kaila M, Nwaru B, et al. Maternal vitamin D intake during pregnancy is inversely associated with asthma and allergic rhinitis in 5-year-old children. Clin Exp Allergy. 2009;39:875-82. 101. Pinto J, Schneider J, Perez R, et al. Serum 25-hydroxyvitamin D levels are lower in urban African American subjects with

chronic rhinosinusitis. J Aller Clin Immunol. 2008;122: 415-17. Rostkowska-Nadolska B, Fraczek M, Gawron W, et al. Influence of vitamin D(3) analogues in combination with budesonide R on proliferation of nasal polyp fibroblasts. Acta Biochem Pol. 2009;56:235-42. Mahon B, Wittke A, Weaver V, et al. The targets of vitamin D depend on the differentiation and activation status of CD4 positive T cells. J Cell Biochem. 2003;89:922-32. Abuzeid W, Akbar N, Zacharek M. Vitamin D and chronic rhinitis. Curr Opin Allergy Clin Immunol. 2012;12:13-17. Singh M, Das RR. Zinc for the common cold. Cochrane Database Syst Rev. 2013;6:CD001364.

Chapter 38: Refractory Chronic Rhinosinusitis

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Chapter

Refractory Chronic Rhinosinusitis

38

Whitney Zirkle, Rakesh Chandra

INTRODUCTION Chronic rhinosinusitis (CRS) is one of the most common health-care problems in the United States today, affecting up to 15% of Americans.1 With the prevalence of disease continuing to rise, CRS has been estimated to affect even more people than common chronic diseases such as hyper­ tension and arthritis, which place a huge demand on medical practitioners.2 Perhaps more concerning than the immense economic burden related to caring for these patients is the detrimental impact on quality of life (QOL), which has been shown to be more severe in refractory cases of CRS than in other chronic diseases such as angina, hypertension, head and neck cancer, migraine, and chronic obstructive pulmonary disease.3 The majority of patients with CRS will respond to first-line medical therapies including nasal steroid sprays and oral steroids, nasal saline, and courses of oral anti­ biotics. Patients who fail these medical therapies undergo the next accepted step in treatment, which is functional endoscopic sinus surgery (FESS). While most studies suggest FESS to be effective in approximately 80% of patients, this leaves a significant subset of patients with persistent signs and symptoms of CRS despite appropriate medical and surgical therapy.4 This refractory group of patients has led researchers and clinicians to take a closer look at the possible underlying mechanisms for the pathogenicity of more severe forms of CRS in order to develop more effective medical and surgical therapies. The heterogeneity within the CRS population as a whole is also seen within the subset of patients with recalcitrant disease, suggesting the possible need to tailor treatments to the individual patient and specific disease phenotype.4

PATHOPHYSIOLOGY OF REFRACTORY CHRONIC RHINOSINUSITIS Most cases of CRS are idiopathic with the underlying etio­ logy of disease like a multifactorial process with various modifying influences. CRS is really a group of disorders, including chronic rhinosinusitis with nasal polyps (CRSwNP) and chronic rhinosinusitis without nasal polyps (CRSsNP). Chronic inflammatory processes appear criti­ cal to the development and persistence of disease and are believed to occur primarily at the sinonasal mucosal level. This mucosal interface between the host and environment is thought to be the setting for a dysfunctional immune response to exogenous factors that then leads to the clinical signs and symptoms of CRS.5,6 Proposed contributing and predisposing factors for CRS include exogenous factors such as microbial infections and environmental irritants as well as host factors such as atopy and asthma, mucociliary dysfunction, osteitis, sino­ nasal obstruction, and genetic and epigenetic variation.5,7,8 The heterogeneity of patient responses to therapies targeting many of these proposed factors suggests that there is still much to be learned in order to better direct our treatment strategies. Researchers and clinicians have worked to further delineate possible mechanisms respon­ sible for the subset of patients who continue to complain of symptoms despite proper medical and surgical manage­ ment. Disease outside of the paranasal sinuses can contri­ bute to the signs and symptoms of CRS and may prevent successful treatment if not properly identified and man­ aged. Immune deficiency is gaining more and more interest as a contributor to refractory disease with many arguing the importance of screening in this subset of CRS patients.

Section 6: Rhinosinusitis: Etiology, Pathophysiology and Medical Therapy

Also, the role of biofilms and the underlying impact of osteitis on refractory CRS are key areas of interest in refractory disease.

Systemic Disease and CRS Imitators

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In a small subset of patients, the etiology of CRS can be traced to an underlying systemic disease including certain genetic disorders affecting mucociliary function and granulomatous diseases with widespread intrinsic mucosal inflammation. Kartagener’s triad (sinusitis, bronchiectasis, and situs inversus) and cystic fibrosis (CF) affect mucociliary trans port through ciliary dysmotility and increased mucous viscosity, respectively.9 The resultant ineffective trapping and clearance of foreign materials and potential antigens from the sinonasal mucosa is thought to explain the increased rates of CRS, which is often difficult to manage and can lead to exacerbations of lower airway disease in these patients.10 The saccharine mucociliary transport test can be used to test for general mucociliary transport dysfunction. Diagnostic confirmation through histologic demonstration of the 9:2 dynein arm configuration in Kartagener’s syndrome and the sweat chloride test in CF should at least be considered in the refractory subset of CRS patients. Granulomatous disorders such as sarcoidosis, Wegener’s granulomatosis, and systemic lupus erythematosus (SLE) can present with significant sinonasal mucosal inflammation, nasal crusting, rhinorrhea, and congestion with

Fig. 38.2: Lupus pernio in a patient with sarcoidosis. Reddish or violaceous inflammatory lesions are characteristic of lupus pernio and result from cutaneous granulomatous infiltration. Note the involvement of the skin of the cheek, perioral area, and nasal dorsum with significant soft tissue erosion and resulting deformity of the nasal alar rim.

progression of disease leading to complications such as septal perforation and orbital complications11 (Fig. 38.1). Characteristic cutaneous lesions of the face, such as the malar ‘butterfly’ rash of SLE or lupus pernio of sarcoid, may be the first clues for diagnosis but are not always present (Fig. 38.2). Biopsy results showing vasculitis with granuloma formation along with a positive C-ANCA can confirm Wegener’s granulomatosis. SLE can be diagnosed through testing for antinuclear antibody, antidoublestranded DNA, and anti-Smith antibodies, and sarcoidosis is typically associated with noncaseating granulomas on biopsy, elevated angiotensin-converting enzyme, and perihilar nodules on chest X-ray. Left undiagnosed and untreated, these disorders can contribute to treatment failure for CRS and increasing frustration for the patient and physician. Foreign bodies within the nose and paranasal sinuses may present with nasal congestion, sinus pain or pressure, and rhinorrhea that may be purulent and foul-smelling. While children are known for placing any number of objects up their noses, adults may harbor foreign bodies as well. Examples include metallic filings or other inhaled debris among construction or factory workers, loose hardware in patients with previous surgery for facial trauma, and other retained materials from prior surgery (Fig. 38.3). Failure to identify and remove these objects may result in persistent symptoms despite medical therapies and can lead to significant soft tissue injury in some cases. ­

Fig. 38.1: Characteristic sinonasal involvement with sarcoidosis. This is an endoscopic view of granulomatous infiltration with associated submucosal nodularity, which is particularly common on the nasal septum and turbinates.



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Fig. 38.3: Retained maxillary sinus foreign body. Computed tomography and endoscopic images demonstrate an infection of the right maxillary sinus associated with a piece of Gore-Tex originating from a prior orbital floor reconstruction (arrow).

Pathologies outside of the sinuses may impact sinus symptoms, preventing effective treatment for CRS if left undiagnosed and untreated. Dental disease particularly involving the maxillary tooth roots can contribute to maxi­ llary sinus disease (Fig. 38.4). Evaluation with sinus com­ puted tomography (CT) may show periapical lucencies warranting further dental evaluation. While not identified as a cause of chronic sinusitis, extra-esophageal reflux disease may also contribute to CRS symptoms such as postnasal drip, limiting subjective improvement after CRS treatment. Other nasopharyngeal processes such as a Thornwaldt cyst or enlarged adenoids can also become inflamed with production of thick postnasal drip and congestive symptoms that may be missed if nasopha­ ryngeal exam is not included during endoscopic evalua­ tion. Allergic rhinitis may also mimic or exacerbate CRS

symptoms and can sometimes be difficult to discern from CRS especially with perennial allergies.11 A thorough physical exam with allergy testing may be important in these patients to further direct appropriate management as worsened surgical outcomes for CRS have been asso­ ciated with failure to treat allergic rhinitis.12

Immune Defects While chronic immunosuppression and severe immuno­ deficiency (i.e. HIV) are known to be associated with more severe forms of CRS, there is a growing amount of evidence to suggest that even more subtle immune deficiencies have an increased prevalence in the refractory CRS popula­ tion.13 It has been suggested that in the CRS population, an abnormal sinonasal mucosal immune response may accompany exposure to certain triggers including fungi,

Section 6: Rhinosinusitis: Etiology, Pathophysiology and Medical Therapy but TLR2 and TLR9 are decreased compared with respon ders to surgery.15 TLR9 is associated with Th1 skewing of the adaptive immune response, with decreases in expres sion potentially leading to a Th2-dominant inflammatory response, which is often seen in CRSwNP. An in vitro study analyzing epithelial cells from medi cally and surgically recalcitrant CRSwNP patients showed an increase in mRNA expression of the inflammatory cytokine IL-33 in comparison to responsive patients.14 IL-33 is released by sinonasal epithelial cells and promotes a Th2 polarization of the adaptive immune response with increased production of IL-4, IL-5, and IL-13 inflam matory cytokines in addition to eosinophilia. CRSwNP patients are known for recalcitrant disease with as many as 50% of patients showing recurrent polyps despite longterm systemic steroids with 30% requiring revision surgery. Although levels of Th2 cytokine have not been directly correlated with severity of disease, Il-33-driven increases in Th2 cytokine expression after surgery may promote return of polyps in patients with recalcitrant disease.14 Polymorphisms in IL-33 receptor gene may further show a protective effect against the development of severe forms of CRS.17 Alterations in the adaptive humoral response may also play a role in recalcitrant CRS. A retrospective review of 79 patients with medically and surgically recalcitrant CRS showed an unexpectedly high prevalence of quanti tative immunoglobulin deficiency with common variable immunodeficiency (CVID) identified in 9.9%, low IgG in 17.9%, low IgA in 16.7%, and low IgM in 5.1% of patients. Selective IgA deficiency was also found in 6.2% of patients, while 26.3% of 60 tested patients showed a decreased response to T cell mitogens.13 A 2011 retrospective review by Carr et al. found a prevalence of specific antibody deficiency (SAD) of 11.6% in 129 patients with medically recalcitrant CRS undergoing FESS.18 SAD is diagnosed when a patient demonstrates an impaired response to immunization with polysaccharide antigens in the setting of normal quantitative immunoglobulin levels. The most common manifestation of SAD is recurrent pyogenic sinopulmonary mucosal infection with polysaccharideencapsulated organisms commonly including Strepto coccus pneumoniae, Moraxella catarrhalis, Haemophilus influenzae, and S. aureus.19 The immune workup in refractory CRS patients has been suggested to include immunization with pneumococcal vaccine in order to exclude a polysaccharide-specific immunodeficiency. Interestingly, the study by Carr et al. also found a 72% rate of low baseline antipneumococcal antibody titers

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Staphylococcus aureus (S. aureus), and bacterial biofilms. The fact that exposure to many of these agents does not typically generate a chronic inflammatory process in healthy individuals suggests an additional immune dysfunction underlying CRS.14 Several alterations of imm une marker expression have been discovered in the CRS population and may provide insight into the underlying pathogenesis of disease. More specifically, alterations in innate and adaptive immunity within the recalcitrant CRS population may help predict which patients are less likely to respond to therapy. A prospective study of medically recalcitrant CRSwNP patients undergoing FESS showed increased expression of inflammatory genes associated with the innate immune response including those encoding for MIP-1α, RANTES, GM-CSF, and TLR2, a member of a family of pattern recognition receptors expressed in airway epithelial cells called the Toll-like receptors (TLRs).15 TLRs work through recognition of certain pathogen-associated molecular patterns (PAMPs) to activate nuclear transcription factors in an inflammatory cascade.16 In patients with early recur rence of polyps after sinus surgery, MIP-1α is increased

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Fig. 38.4: Odontogenic sinusitis. Computed tomography images demonstrate left maxillary sinusitis resulting from an infection of the maxillary dentition. The arrow points to the bony dehiscence in the floor of the maxillary sinus at the location of the now extracted infected tooth. On endoscopic view, retained purulent secretions are noted within the left maxillary sinus.



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Chapter 38: Refractory Chronic Rhinosinusitis among patients prior to vaccination, which raises the question of whether low baseline antibody levels or SAD may contribute to the severity of CRS or the need for surgery.18

Biofilms Bacterial biofilms are thought to play a role in the patho­ genesis of CRS and have been of particular interest in recalcitrant disease. Biofilms are highly organized struc­ tures encasing bacteria in an extracellular matrix that provides physical protection in addition to observed phenotypic and genotypic changes promoting bacterial survival.20-22 Implicated in other chronic otolaryngologic diseases including otitis media with effusion, chronic ton­ sillitis, and cholesteatoma, biofilms are thought to create a relapsing and remitting disease state based on periodic shedding of pathogen, with the inability to eradicate the biofilm through traditional therapies leading to persis­ tence of disease. Most studies fail to show sinonasal biofilm formation in non-CRS patients, while the prevalence among CRS patients has been cited between 40% and 80%.20 Biofilms have been associated with polymicrobial infections and individual bacteria including S. aureus, H. influenzae, Pseudomonas aeruginosa, and various anaerobes. S. aureus in particular has been linked to more severe CRS and has been associated with fungal biofilms in some patients.21 While a direct role for bacterial biofilms in the pathogenesis of CRS is yet to be confirmed, the presence of specific features of certain bacterial pathogens in the setting of defective host immunity may allow for biofilm formation and associated chronic mucosal inflamma­tory changes. An example of this host immune dysfunction is the downregulation of the antimicrobial peptide lacto­ ferrin that has been shown in CRS patients, particularly in the presence of biofilm formation.20 Scanning electron microscopy studies of bacterial biofilms have shown evidence of epithelial destruction with loss of cilia, which suggests a link between biofilm formation and mucociliary dysfunction.23 Biofilm formation has been linked to recalcitrant disease through studies showing more severe preoperative disease in addition to worsened postsurgical outcomes and increased risk of multiple surgeries in patients with known biofilm formation.20,24 Biofilms have also been suggested to play a role in the fostering of intracellular infection of sinonasal epi­ thelial cells by S. aureus, which has been proposed as a potential reservoir of pathogenic organisms leading to persistent/recalcitrant CRS. In a prospective study of CRS

553

patients undergoing FESS, confocal microscopic studies of sinonasal mucosa in combination with fluorescent in situ hybridization showed intracellular S. aureus in 56% of CRS patients (in comparison to 0% of controls). The presence of biofilms was seen in 100% of patients with intracellular S. aureus versus 50% of patients with CRS and no evidence of biofilm formation.25 Intracellular S. aureus may influence the recalcitrant nature of CRS with one study showing significantly higher risk of late clinical and microbiological relapse in patients with intracellular S. aureus and biofilm formation versus patients with biofilm alone.26 Limitations of this study, however, include potential confounding factors that were not controlled for the higher rates of nasal polyps and revision surgeries in the group of patients positive for intracellular S. aureus. Intracellular S. aureus may avoid medical therapies and host defenses through the ability to undergo phenotype switching, whereby bacteria alter their phenotype upon internalization into a cell to become more antibiotic resistant (thicker cell walls, lysozyme resistance).26

Osteitis While mucosal changes, defects in local immune response, and biofilms have generally gained more attention within the CRS literature than osteitis, some studies have sugges­ ted a potential role for osteitis in CRS. Osteitis, as opposed to osteomyelitis, is an inflammatory process involving bone that lacks a marrow space, such as the bones of the paranasal sinuses. Osteitis has been used interchan­ geably with terms including bony inflammation and remo­ deling, neo-osteogenesis, and hyperostosis. While there is no gold standard test for the diagnosis of osteitis, identi­ fication of histologic changes (such as periosteal changes, osteoclast proliferation and bone resorption, new bone formation, fibrosis and cellular infiltrates) is considered to be the most accurate diagnostic method, although its routine use for diagnosis is somewhat impractical. Bony involvement can be diagnosed on CT or SPECT by signs of irregular bony thickening and increased bone density (Fig. 38.5). Many different CT staging systems have been proposed for osteitis, although none have been standar­ dized. The prevalence of bony changes associated with CRS on CT imaging ranges from 2% to 64% in the literature.27 In diagnosis, it is important to identify potential confoun­ ding factors including underlying bone disease such as Paget’s as well as history of prior sinus surgery or radiation, which can also induce similar appearing bony changes on CT.

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in addition to increased severity on CT, endoscopy, and olfactory scores.29 One study demonstrated pathologically proven osteitis in 6.7% of primary FESS patients versus 58% of revision cases.27 Osteitis may play a role in medi cal and surgical treatment failure of CRS and has been associated with reduced improvement in at least some QOL measures postoperatively.29 Expert opinion recom mends surgical removal of osteitic bone when possible, which may lead to the need for more aggressive surgery. Remnants of osteitic bone may provide a nidus for per sistent inflammation despite normalization of drainage pathways and re-establishment of more normal airflow through primary FESS. There is little evidence for longterm IV antibiotic management in the treatment of osteitis, especially in the setting of lack of demonstrable bacterial invasion of bone.

SURGICAL THERAPY

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Full-House Functional Endoscopic Sinus Surgery

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A common revision strategy after primary FESS limited to opening of the maxillary sinuses and anterior ethmoids only is the completion full-house FESS (FHF). Shen et al. define FHF as endoscopic sinus surgery including maxillary antrostomies, complete anterior and posterior ethmoi dectomies, wide sphenoidotomies, and Draf IIA frontal sinusotomies.31 Proponents of FHF argue that more comp lete removal of sinus tissue prevents unintended obstruc tion from mucosal edema related to surgery, improves ­

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Osteitis as a main etiologic factor in the pathogenesis of CRS has not been established. However, osteitis may play a role as a disease modifier with a potential contribu tion over time to mucosal scarring and increased potential for bony adhesions. One proposed mechanism for osteitis is the direct bacterial invasion of bone, although as of yet no one has been able to demonstrate presence of bacteria within sinonasal bone in sinusitis. Another proposed mechanism involves overlying biofilms with associated release of inflammatory mediators stimulating bony changes. Speculation for the association between bony remodeling and osteitis comes in part from evidence in the orthopedic literature of biofilm involvement in osteo myelitis of the long bones.28 Expression of inflammatory cytokines, such as the TGF-b family and the bone morpho genic protein (BMP) family, may be important for bony remodeling seen in CRS.27 There is speculation that remodeling processes may become irreversible at some point, possibly leading to recalcitrant CRS.28 An association between osteitis and worsened baseline CRS has been suggested with an incre ased prevalence of nasal polyps and revision surgeries

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Fig. 38.5: Osteitis of the sphenoid sinuses. Computed tomography images demonstrate the irregular bony thickening that is characteristic of bony osteitis. The overlying mucosal inflammation and narrowing of the sinus cavity as seen on the endoscopic view of the sphenoid sinus are frequently associated with underlying osteitis (asterisk = surgically opened ostium into the sphenoid sinus).

Once a patient demonstrates failure of first-line medical therapy for CRS, FESS is recommended with a primary goal of improving paranasal sinus ventilation and mucociliary function through mucosal-sparing techniques. While many patients find significant benefit with primary FESS, a subset of patients will complain of recurrent symptoms prompting discussion of various options for revision sur gery. Approximately 10% of patients will require revision surgery within the first 3 years after primary FESS.30 Persis tent symptoms leading to revision surgery may be due to problems such as persistent mucosal thickening and inflammation, polypoid edema, biofilm colonization, and persistent pooling of thick, allergic mucin. Various tech niques for revision surgery exist with controversy over the relative effectiveness of surgical strategies emphasizing more targeted approaches versus those emphasizing more aggressive procedures with complete opening and connec tion of all paranasal sinuses.

Chapter 38: Refractory Chronic Rhinosinusitis surveillance of the sinuses in postsurgical follow-up, and provides better access for topical medications and rinses.30 More limited or incomplete surgery may lead to postoperative obstruction through retained uncinate or remnants of the agger nasi and ethmoid bulla, lateralized middle turbinate, unopened or scarred frontal recess, maxillary antrostomy stenosis or incomplete anterior, and posterior ethmoidectomies.30 Wide antrostomies are thought to allow for more effective removal of bacterial biofilms through better access of topical medications and irrigations to the affected sinuses. More complete surgical resections also allow for more effective removal of osteitic bone, which has been proposed as a possible nidus for persistent postoperative mucosal inflammation. In a retrospective review of 21 patients undergoing FHF for recalcitrant CRS, marked improvement in endo­ scopic mucosal appearance, radiographic Lund–MacKay scores, and patient symptoms determined by the Patient Response Score (PRS) was seen on postsurgical follow-up between 6 and 24 months. There was no significant diffe­ rence in symptom scores or objective outcomes between patients with and without nasal polyps despite an associa­ tion of CRSwNP and increased number of revision surgeries in the literature.31 Definitive conclusions regarding the relative efficacy of FHF to other revision surgery techniques require more studies with direct comparative data.

Radical FESS Procedures Proponents of radical FESS techniques believe in the complete removal of potential anatomic obstructions in patients who have already failed more limited surgical approaches. Preservation of the middle turbinate and its enveloping mucosa is thought to be important for normal sinonasal function and is part of the mucosasparing technique of primary FESS. Although removal of the middle turbinate remains controversial in endo­ scopic sinus surgery, there may be a role for partial remo­ val of the middle turbinate in revision surgery. This is particularly true in cases where the middle turbinate has lost its functional capacity and is contributing to obstruc­ tion. Lateral scarring of the middle turbinate with subseq­ uent middle meatal obstruction and persistent frontal/ maxillary sinusitis may represent one example where par­ tial resection improves postsurgical outcome. In patients with more severe disease such as in recalcitrant nasal polyp patients, it has been suggested that middle turbi­ nate reduction may help improve postoperative nasal endoscopy scores and sense of smell.32

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In comparison to traditional FESS, a more radical “nasalization” procedure combining radical sphenoeth­ moidectomy with wide maxillary antrostomy, resection of the middle turbinate, and frontotomy has shown impro­ ved symptom scores, improved endoscopic findings, and lower recurrence rates for severe nasal polyp patients with recalcitrant disease in a retrospective case series.33 Patients who are unresponsive to repetitive surgeries have also shown improvement after Denker’s procedure, a technique that combines the nasal cavity and the paranasal sinuses into one common cavity (with the exception of the frontal sinuses). More specifically, Denker’s procedure involves complete sphenoethmoidectomy in addition to removal of the lateral wall of the nasal cavity and the middle and inferior turbinates.3 This procedure has been associated with improved QOL scores in recalcitrant CRS patients. A prospective study of 21 patients, all of whom had at least three prior sinus surgeries, demonstrated symp­tom reduction and improved QOL after undergoing Denker’s procedure, which is a nasalization technique that.3 Outcomes were based on patient responses to the Medical Outcome Study 36-item Short-Form health sur­ vey (SF-36), which assesses health-related QOL, and the McGill Pain Questionnaire, which assesses pain. Per report, no patients demonstrated any of the potential signifi­ cant complications of radical surgery including damage to the nasolacrimal duct with resultant epiphora, empty nose syndrome, or excessive scarring or crusting. These complications are reportedly rare, although extensive nasal crusting must be prevented with an aggressive post­ operative nasal irrigation regimen.

Revision Maxillary Sinus Surgery For revision surgery dedicated to the maxillary sinus, several techniques have been described ranging from more mucosal-sparing endoscopic procedures to more invasive traditional open approaches such as the Caldwell-Luc pro­ cedure. Patients with maxillary disease failing primary FESS may benefit from simply widening the maxillary antrostomy. This mucosal-sparing technique focuses on improving mucociliary clearance and drainage from the natural maxillary ostium without significant muco­ sal stripping (Fig. 38.6). The antrostomy should include com­plete removal of the uncinate process and any pote­ n­tially obstructing Haller cells as well as the posterior fontanelle and any accessory ostia. The inferior limit of the antros­ tomy should reach the insertion of the inferior turbinate.30

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Despite widening of the natural ostium and complete uncinate resection, recalcitrant maxillary sinusitis may persist secondary to proposed mechanisms such as longstanding inflammation, scarring from prior surgeries, immunodeficiency, pathogen resistance, or osteitis. In these more severe cases, improvement in mucociliary clearance and more effective delivery of sinus irrigations has been seen with extension of the maxillary antrostomy to the maxillary sinus floor through a “mega-antrostomy” approach. The endoscopic modified mega-antrostomy (EMMA) involves resection of the posterior half of the inferior turbinate with extension of the antrostomy to the floor of the nose.34 In a retrospective review of 28 patients with surgically recalcitrant maxillary sinusitis undergoing EMMA, authors reported complete or marked symptom resolution in 74% of patients at an average follow-up time of 11 months with no complications and no revision surgeries.34 Potential complications of the procedure include bleeding from the descending branch of the sphenopalatine artery (SPA), which was addressed by cauterization of the posterior stump of the inferior turbinate. Injury to the nasolacrimal duct (NLD) could occur by extension of the antrostomy too far anteriorly, leading authors to propose avoiding excision of the inferior turbinate beyond the posterior half. A more

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Fig. 38.6: Postsurgical maxillary antrostomy on long-term follow-up. Transnasal endoscopic view of the right nasal cavity demonstrates surgical-widening of the natural maxillary ostium. The neo-ostium is well mucosalized, and despite its significant size, there is preservation of the normal mucociliary transport pattern with mucous directed anteriorly toward the region of natural outflow (arrow). A large maxillary antrostomy further facilitates sinus irrigations, topical drug delivery, and improved visualization and suctioning capabilities during clinic follow-up visits.

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aggressive alternative to EMMA includes the modified endoscopic medial maxillectomy (MEMM) approach, which includes en bloc resection of the medial maxillectomy wall with subtotal resection of the inferior turbinate. Wang et al. found complete resolution of disease with this procedure in 37 of 46 patients (80%) with recurrent chronic maxillary sinusitis in a retrospective chart review, although resolution of disease was lower in patients with cultures positive for P. aeruginosa and S. aureus.35 Proponents of EMMA argue for a more mucosa-preserving approach that may preserve greater function and avoid risk of injury to the NLD, although there is a lack of direct comparative data in the literature. Revision middle meatal antrostomy combined with inferior meatal antrostomy with extension anterior and inferior to Hasner’s valve has also been proposed as a method to avoid NLD injury. All of these various endoscopic techniques for recalci trant maxillary sinusitis are thought to be less invasive mucosal-sparing alternatives to the more traditional open procedures. While endoscopic techniques have now taken over as the primary surgical method for tackling maxillary sinusitis, there is argument for more traditional open pro cedures, such as the Caldwell-Luc procedure, for select recalcitrant patients with disease in challenging-to-reach places. Persistent disease in the far anterior and inferior reaches of the maxillary sinus may prove inaccessible even with 70–120 degree telescopes and curved instrumentation. In some severe cases of persistent mucosal inflammation with overlying thick mucin unresponsive to repeated mucosal-sparing endoscopic procedures and medical therapy, some anecdotal evidence exists for radical removal of the diseased mucosa often requiring the more direct access of an open approach. Maxillary sinoscopy, or a sublabial canine fossa puncture, can be performed ideally at the intersection of the midpupillary line and a line exten ding horizontally from the floor of the nasal vestibule.32 This allows for visualization of the most anterior and inferior portions of the maxillary sinus. A Caldwell-Luc procedure can be used for further access by expanding the puncture site with a Kerrison rongeur. This approach is common for difficult-to-access benign tumors, such as inverting papilloma, but may be used for CRS as well (Fig. 38.7). Potential complications, cited to be less than 1–3% in the literature, include injury to the maxillary tooth roots and injury to the infraorbital and anterior superior alveolar nerves. Controversy remains in the literature regarding the efficacy of open over endoscopic procedures for CRS with a recent randomized-controlled trial by Lee et al.

Chapter 38: Refractory Chronic Rhinosinusitis

Fig. 38.7: Caldwell-Luc procedure. Computed tomography image guidance demonstrates the location of the tip of the straight suction within the right maxillary sinus during a Caldwell-Luc procedure for recurrent inverting papilloma of the right maxillary sinus floor and lateral wall in the setting of chronic maxillary sinusitis. Endoscopic image shows the intraoral approach with the straight suction inserted through the surgically created defect in the anterior maxillary sinus wall.

showing no difference in outcomes between endoscopic maxillary antrostomy and Caldwell-Luc procedure.36 Others who have found success with open approaches argue that the variability of disease severity in the literature makes definitive conclusions difficult.32

Revision Frontal Sinus Surgery While standard of care for frontal sinusitis relies on endo­ scopic mucosal-sparing techniques for opening of the fron­ tal recess, there are several procedures that have been developed for the subset of patients with persistent frontal sinusitis despite first-line surgical and medical therapies. A popular technique for complete frontal sinusotomy is the Draf IIa procedure, which involves removal of the agger nasi cell in addition to any obstructing frontal or supra­orbital cells. In a study of 717 patients undergoing frontal sinus surgery, this technique provided effective manage­ment in 92% of patients.30 Persistent or recurrent frontal disease after frontal sinusotomy techniques may be secondary to mucosal stripping with neo-osteogenesis, restenosis, osteitis, retained frontal cells, and difficult to

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access far lateral disease.30 For severely recalcitrant patients, the traditional gold standard technique has been frontal sinus obliteration with external osteoplastic flap and abdo­ minal fat harvesting. However, the significant morbidity potentially associated with this procedure including prolon­ ged hospital stays, risk of postsurgical mucocele forma­tion, rare intracranial injury, potential poor cosmesis, risk of supraorbital numbness, persistent frontal headache and difficulties with postoperative monitoring for disease recurrence have led rhinologists to seek alternative therapies.37 The endoscopic modified Lothrop procedure or Draf III technique is a transnasal approach for creation of a wide common outflow tract for both frontal sinuses for maximal ventilation and mucociliary clearance. First descri­ bed in 1981, the Draf III procedure involves the endo­ scopic removal of a portion of the superior nasal septum, the frontal beak, bilateral frontal sinus floors, and the frontal intersinus septum (Fig. 38.8). The most common reasons for proceeding with the Draf III procedure include mucocele formation and refractory frontal disease. While the significant drilling of bone involved in the Draf III procedure does not follow mucosal-sparing technique, the creation of a large enough common frontal sinus drainage pathway is thought to be sufficient to maintain patency despite inevitable circumferential scarring and granula­ tion tissue formation37 (Fig. 38.9). Support for the Draf III procedure is widespread with several retrospective studies showing successful outcomes in the majority of patients who have failed prior conservative surgeries.37,38 A 2009 meta-analysis and systematic review of the literature available for the Draf III procedure showed an overall 82% rate of symptomatic improvement and 95.9% patency rates in refractory patients with a mean follow-up time of 28.5 months.39 The most common reasons for a Draf III procedure include mucocele formation and persistent frontal disease. Risk of major complications including CSF leak, posterior table dehiscence, and tension pneumo­ cephalus are cited at less than 1% in the literature.30 Far lateral disease of the frontal sinuses remains particularly challenging and may not be accessible by even the most complete endoscopic endonasal procedures such as the Draf III procedure. In these cases, an open approach may be necessary. Frontal sinus trephination can provide better access for difficult-to-reach lateral areas and may also be used when significant distortion of anatomy precludes endoscopic identification of the fron­ tal recess. The location for the frontal sinus trephine is

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Section 6: Rhinosinusitis: Etiology, Pathophysiology and Medical Therapy

Fig. 38.8: Modified endoscopic Lothrop procedure (Draf III). Computed tomography and endoscopic views demonstrate the creation of a common drainage pathway with drilling away of both frontal sinus floors, removal of the superior nasal septum, and frontal intersinus septum.

Surgical Precautions The benefits of revision surgery should be weighed against the potential increased surgical risk as well as increased risk of treatment failure. While success rates for primary FESS range from 75% to 98%, the rate of success after revision surgery is generally accepted to be lower with a range of 50–92% seen in the literature.31 Data is lacking regarding the comparative efficacies of various revision ESS techniques with outcomes likely dependent on indivi dual patient factors as well as surgeon experience and comfort with specific techniques. Use of intraoperative CT scanning has been proposed to help ensure surgical ­

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traditionally at the point of greatest depth of the frontal sinus, about 1–1.5 cm lateral to midline just below or within the brow, taking care to avoid the supratrochlear and supraorbital neurovascular bundles32 (Fig. 38.10). Image guidance may be used for more specific disease localization and entry, and endoscopic instruments and irrigations may be introduced through the trephine. Trephi nation may also be combined with an endoscopic app roach. Complications include external scar formation, eyebrow alopecia, wound infection, and more serious complications (although rare) including posterior table penetration, cerebrospinal fluid leak, and injury to the eye.32

Chapter 38: Refractory Chronic Rhinosinusitis

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Fig. 38.9: Long-term follow-up after an endoscopic modified Lothrop procedure (Draf III). Transnasal endoscopic view with a 70-degree endoscope shows a persistent, widely patent, wellhealed, mucosalized common drainage pathway from the bilateral frontal sinuses on long-term postsurgical follow-up.

Fig. 38.10: Frontal sinus trephination. Surgical approach begins with a skin incision demonstrated just below the brow line, 1–1.5 cm lateral to midline with care taken to avoid the supratrochlear and supraorbital neurovascular bundles. Opening of the anterior frontal sinus wall may then be performed.

completeness during ESS and continues to be evaluated for its effectiveness in lowering rates of revision surgery.30 It is important to remember that the goal of surgery in some recalcitrant patients is not always curative and is rather an attempt to improve symptoms through enlarging sinus openings for drainage and aeration and removing diseased mucosa. Sinus surgery often does not directly address mucosal inflammation, which may be the reason for persistence or recurrence of symptoms in patients with recalcitrant disease.5 The ultimate success of revision surgery often relies on adequate postoperative follow-up with endoscopic debridements as well as patient commit­ ment to a lifelong regimen of nasal irrigations and medical therapy in order to provide maximum benefit.

to physically disrupt biofilms, wash out mucous and infectious debris, and deliver medications directly to the sinonasal mucosa. With regard to biofilms, increased concentrations of systemic medications are needed for eradication of biofilms, which can pose an increased risk of systemic toxicities without a guarantee of effectiveness.40 An appropriate topical antibiotic has the potential to deliver high therapeutic concentrations to the sinonasal mucosa while minimizing the risk of systemic side effects.

TOPICAL MEDICAL THERAPY The current accepted medical management of CRS includes a combination of courses of topical steroids, saline irriga­ tions, courses of antibiotics as well as nasal decongestants, and oral steroids. Failure of these above medications to rid patients of their symptoms then leads to recommenda­ tion for endoscopic sinus surgery. However, a subset of patients has persistent symptoms even after revision surgery, leading practitioners to look for additional adjunc­ tive medical therapies in these recalcitrant patients. Topical medical treatments have been studied and app­ lied to improve symptom management in these difficultto-treat patients. Irrigations have been used in attempts

Topical Antibiotics Interest in the use of topical antibiotics to treat CRS has increased in the setting of failure of culture-directed systemic antibiotics to eradicate disease in a subset of patients. Topical antibiotics have the theoretical advantage of increased local concentration at the target site with decreased systemic absorption and related toxicities. They may also play a role in increased penetration in the case of relatively antibiotic-resistant bacterial biofilms with difficult to treat organisms such as S. aureus and P. aeruginosa. A randomized, double-blinded, placebocontrolled, cross-over study of 14 patients with S. aureuspositive refractory CRS looked at the effect of nebulized bacitracin and colimycin versus saline-based placebo on sinus symptoms.41 While there is still some debate over the importance of S. aureus in the underlying patho­ genesis of CRS, its predominant presence in the recal­ citrant patient population makes it an area of interest for

Section 6: Rhinosinusitis: Etiology, Pathophysiology and Medical Therapy



topical mupirocin over placebo, despite higher culturenegativity for S. aureus (at least initially), supports the proposed multifactorial nature of CRS with the role of S. aureus still not fully understood. Pseudomonas colonization of the sinuses has not only been implicated in refractory CRS but has also been linked to worsened lower airway function particularly in the CF population, where it is a major factor in poor postoperative outcome after lung transplant.45 Topical aminoglycosides have been used in the CF population with success in decreasing pulmonary complications after lung transplant. In the recalcitrant CRS population, P. aeruginosa has been demonstrated to form biofilms that may be resistant to multiple surgeries and high doses of long-term systemic antibiotics. An in vivo study of topical tobramycin against P. aeruginosa sinonasal biofilms was conducted to determine the efficacy of biofilm eradication in a rabbit model.40 While very high concentrations of topical tobramycin were shown to eradicate bacteria in the sinonasal lumen, P. aeruginosa attached to the mucosa was still detected on scanning electron microscopy. With a lack of convincing evidence for the efficacy of topical antibiotics over nasal saline, some authors have looked for alternative antimicrobial agents. NVC-422, a novel broad-spectrum, non-antibiotic antimicrobial has shown some preliminary success with biofilm eradication in a sheep model.46 Irrigations with manuka honey, which is thought to contain natural antimicrobial agents inclu ding hydrogen peroxide and methylglyoxal, have also shown an ability to eradicate biofilms in vitro.11 What this means for symptom management and improvement of mucosal inflammation in patients with refractory CRS remains uncertain. Topical antibiotics have been administered via liquid form in saline irrigations and as a nebulized form using a variety of devices (bulb syringe, irrigation bottles, aerosols).47 Nasal rinses are proposed as a superior method of delivery given the unsatisfactory ability of sprays and ointments to penetrate the sinuses. However, without prior surgery to enlarge the sinus ostia, access to the sinuses is minimal regardless of delivery technique. High-volume positive-pressure nasal lavage has been shown to provide maximal penetration of the sinuses postoperatively.42,48 The role of maxillary sinus antrostomy tubes (MAST) surgically placed through an inferior meatal antrostomy has been explored as an alternative method to FESS for effective delivery of antibiotic irrigations. While one prospective study showed reduced symptom and endoscopy ­





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antibiotic therapies. Frequent colonization of S. aureus in the recalcitrant CRS population may contribute to the pathogenesis of resistant disease through biofilm forma tion and superantigen production.42 Bacitracin is known to have in vitro activity even against methicillin-resistant Staphylococcus aureus.41 Colimycin is an older antibiotic effective against many multidrug-resistant gram-negative organisms such as P. aeruginosa, although its significant systemic toxicity promotes its use more often for topical preparations. While patients in the treatment arm of this study showed improvement in symptoms based on the Visual Analog Score (VAS) and SF-36 responses, the lack of significant difference with the placebo arm suggests no benefit of this topical antibiotic regimen over nebulized saline. Topical mupirocin has been compared with several other antibiotics for the treatment of refractory CRS with initial data showing potential improved effectiveness over topical vancomycin, ciprofloxacin, and gallium nitrate in the treatment of bacterial biofilms.11 Mupirocin has strong activity against S. aureus, but is rapidly degraded when given systemically, limiting its use to topical applications. Its application has already been established for the eradication of S. aureus colonization of the nasal vestibule for prevention of nosocomial infections and has been shown to be effective against biofilms in vitro.42 Uren et al. performed a prospective study of the efficacy of treatment with topical mupirocin in 16 patients with surgically recalcitrant CRS and cultures positive for S. aureus.42 After 3 weeks of treatment with twice daily nasal lavages with 0.05% mupirocin, 15/16 patients had endoscopic improvement and negative cultures for S. aureus, and 12/16 patients had improvement in symptoms. However, major limitations of this study include the short follow-up time and lack of comparison with a control arm. A randomized, doubleblinded, placebo-controlled trial from 2012 compared the effects of mupirocin versus saline sinonasal rinses in 25 S. aureus-positive patients with recalcitrant CRS.43 While the study showed more effective eradication of S. aureus and initial improvement in endoscopic findings in the treatment group, endoscopic improvements did not persist at follow-up times greater than 1 month, and QOL scores showed no significant improvement over placebo. Symptoms scores were improved in both groups after treatment but were not sustained at delayed follow-up. S. aureus has been shown in some studies to have a high reculture rate after mupirocin rinses with more long-term follow-up.44 Lack of significant patient improvement with



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Chapter 38: Refractory Chronic Rhinosinusitis scores with antibiotic delivery via MAST, lack of a placebo-controlled arm has again led to the argument that mechanical debridement of saline irrigations may be just as effective as antibiotic irrigations despite changes in delivery technique.47 No placebo-controlled trial to date has been able to show a benefit to antibiotic irrigations over saline.7

Topical Antifungals While the role for fungus in the pathogenesis of CRS remains controversial, there has been some interest in the presence of fungal elements and resultant inflammation as a source for recalcitrant disease. Some clinicians have employed topical antifungal therapy with amphotericin B despite inconsistent support from the literature with regard to its efficacy as a treatment modality. Amphotericin B is known to have a large side effect profile when taken systemically, but its lack of mucosal absorption has made it a drug of interest for topical therapy. To provide more guidance for the use of topical Amphotericin B in CRS, a systematic review was performed of the literature identifying 6 prospective studies, including 3 placebo-controlled trials, looking at the efficacy of topical amphotericin B in treating patients with CRS.49 The overall conclusions of the analysis suggested no statistically significant difference in post-treatment CT, endoscopy, and symptom scores between treatment with topical amphotericin B and saline.

Topical and Injectable Steroids Interest in the use of steroid treatment for recalcitrant CRS stems from the emphasis on mucosal inflammation as a key factor in the pathogenesis of CRS. The use of syste­ mic steroids in CRS has been shown to reduce mucosal inflammation and is frequently used for CRSwNP. The significant side effect profile including but not limited to hyperglycemia, avascular necrosis of the hip, cataracts, elevated intraocular pressure, psychological disturbances, osteoporosis, and hypothalamic-pituitary-adrenal axis dysfunction precludes some patients from being able to take these medications in systemic forms.50 This has led many practitioners to try topical and locally injectable steroids as a way to decrease systemic side effects while applying medication directly to the sinonasal mucosa. Topical steroid sprays have become a standard first-line therapy in the treatment of CRS. Steroid-eluting stents are also being used now in FESS to help maintain ostia

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patency and decrease mucosal inflammation. Different forms of steroid applications have been further studied in patients with recalcitrant disease despite first-line medical and surgical therapies. While two Cochrane systematic reviews have demon­ strated steroid spray effectiveness in decreasing polyp size, preventing polyp recurrence, and decreasing sinonasal symptoms in patients with CRSsNP and CRSwNP, these reviews also emphasize the importance of delivery tech­ nique and prior surgery for best access of topical steroids to the sinuses.51,52 Direct delivery of topical steroids to the sinuses has shown more beneficial symptom reduc­ tions than simple corticosteroid nasal sprays alone.51 One placebo-controlled study of medically and surgically recalcitrant CRS patients with comorbid allergic rhinitis showed symptoms improvement and decreased mucosal inflammatory markers and Th2 cytokines when sinuses were directly instilled with budesonide through the MAST technique.53 Rhinologists have also turned to steroid irrigations as a noninvasive attempt in recalcitrant patients with surgically opened sinuses to maximize treatment effect and elevate intrasinus steroid concentrations through positive-pres­ sure high-volume delivery devices. Steroid irrigations have been demonstrated to be a safe form of delivery with minimal systemic absorption despite frequent delivery in much greater concentrations than steroid nasal sprays.50 It has been argued that more effective administration of steroid irrigations to the sinuses allows for better treat­ ment effect while at the same time minimizing dosage to a small fraction of drug delivered since most of the irriga­ tion is washed out. This may be safer than nasal steroid drops, where swallowing of high residual concentrations with resultant GI absorption may be the cause of reports of systemic toxicity with Cushing’s syndrome and adrenal suppression.54 Irrigations have shown to be not only safe but also effective in improving symptoms in the surgically recalcitrant CRS population. Snidvongs et al. showed symptom improvement and decreased endoscopy scores with budesonide or betamethasone irrigations in the post­ operative period of refractory CRS patients undergoing endoscopic sinus surgery for the creation of a “common cavity.”54 However, further studies with direct comparison to steroid sprays and saline irrigations will need to be per­ formed to allow for additional conclusions regarding relative treatment efficacy. Other forms of topical steroid therapy attempted in the recalcitrant CRS population include topical intranasal

Section 6: Rhinosinusitis: Etiology, Pathophysiology and Medical Therapy

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SYSTEMIC MEDICAL THERAPY

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Systemic medical therapies including antibiotics and oral steroids are frequently used to treat CRS exacerbations. However, potential longer-term management with syste mic therapies in the recalcitrant CRS patient has led to increased concern for significant systemic toxicity and microbial resistance. Theoretically safer options for longterm systemic treatments include strategies based on low-dose regimens. This has led to the study of the thera peutic effect of long-term low-dose antimicrobial thera pies for recalcitrant CRS. In patients with underlying immune deficiencies, vaccination against pyogenic micro bials including S. pneumoniae has been suggested to ­

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Chemical and biologic surfactants work as amphipathic molecules that are solvent in both water and organic sub strates. This enables surfactants to act as mucolytic agents through disrupting the epithelial adherence of mucous while also decreasing viscosity and surface tension. A second proposed property of chemical surfactant irriga tions is its antibacterial effect through a known ability to disrupt bacterial cell membranes and their attachments within biofilms. Chemical surfactant irrigations have shown effective eradication of bacteria from orthopedic wounds in animal models and are now being attempted as an adjunctive therapy in recalcitrant CRS.55 Baby shampoo is an inexpensive relatively mild solu tion of multiple surfactants that has been studied in the CRS population. A small noncomparative study demonst rated efficacy in vitro of eradicating planktonic forms of pseudomonas in addition to inhibiting biofilm formation at an optimal concentration of 1% in normal saline. The second part of this study looking at in vivo irrigations with 1% baby shampoo showed improvement in symptoms (particularly postnasal drainage and thickened mucus), endoscopic findings, and smell testing in over 50% of

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Surfactants

tested patients with medically and surgically refractory CRS.55 However, eradication of preformed Pseudomonas biofilms in vitro and in vivo was not seen. This may be secondary to the mild form of surfactants used in baby shampoo with the proposed inability to disrupt the extra cellular matrix bonds surrounding bacterial biofilms. The lack of a control arm in this study again begs the question of whether saline irrigations show similar clinical benefit. Attempts to identify a stronger chemical surfactant for sinonasal irrigations led to the study of citric acid/zwitte rionic surfactant (CAZS) in an animal model. Despite promi sing results with biofilm eradication, a concerning finding was the disruption of sinonasal mucosa with almost 85% temporary loss of cilia after a single treatment com pared with saline.11 An interesting finding in a study compa ring the combined use of the hydrodebrider with either CAZS or saline showed a nonsignificant trend toward improved biofilm reduction in the hydrodebrider + saline group over saline flush alone, untreated and CAZS groups. Through the use of confocal scanning laser microscopy, this study again showed significant adverse effects of CAZS on sinonasal cilia, possibly leading to mucociliary transport dysfunction.56 The hydrodebrider is suggested to be a potentially beneficial topical delivery method through the production of shearing forces that allow for stronger mechanical disruption of mucosal biofilms. Again, as is the case with other topical therapies described in this section, further placebo-controlled trials evaluating the relative efficacy of surfactants and their comparison to other topical treatments need to be perfor med. This will allow for additional conclusions regarding comparative treatment effect and the potential benefit of medications beyond simple mechanical washing of sino nasal mucosa as is seen with nasal saline. ­

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mometasone furoate gel, which is thought to provide prolon ged adherence to the sinonasal mucosa with gradual release of steroid. A recent retrospective review of in-office endoscopic-guided application of the gel into previously surgically opened sinuses showed only short-term improve ment in endoscopic findings and a nonsignificant trend toward decreased need for systemic steroids. Again, the need for larger studies and more randomized-controlled trials looking at the relative efficacies of different forms of topical steroids in comparison to nasal saline will help further define medication effect. Finally, there are some proponents for intranasal steroid injections for refractory nasal polyp patients. Intra nasal steroid injections have been used for allergic rhinitis and nasal polyps for decades although concern has been raised regarding the rare complication of transient and permanent visual loss thought to occur secondary to involvement of the ethmoidal circulation. Schneider et al. argues that in difficult-to-treat nasal polyp patients, injec tion of steroid directly into nasal polyps has been used effectively to decrease the need for surgery and improve surgical outcomes, with recent studies of thousands of intranasal steroid injections showing no visual or systemic complications.32



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Chapter 38: Refractory Chronic Rhinosinusitis improve CRS severity. Development of novel monoclonal antibody therapies is also underway in hopes of targeting underlying immune dysfunction thought to be critical in the pathogenesis of CRS. Finally, a recent pilot study on alternative medical therapies in CRS may provide some patients with more choice in treatment options for disease failing more conventional strategies.

Long-Term Low-Dose Antibiotics Long-term antibiotic regimens of 3 months or greater are often prescribed for difficult-to-treat CRS cases despite limited supporting data in the literature. Disadvantages to long-term systemic treatment include increased risk of systemic toxicity such as ototoxicity or hepatic and renal toxicity, photosensitivity, infusion site infections and embolism with IV delivery, pathogen resistance. Monitoring for systemic side effects often requires addi­ tional patient inconvenience with frequent blood testing. To minimize systemic toxicity, long-term low-dose anti­ biotic regimens have gained increasing interest for the management of recalcitrant CRS. The macrolide family has been of particular interest in refractory CRS given its anti-staph activity, relatively low side effect profile, and proposed intrinsic anti-inflam­ matory action. Anti-inflammatory effects on neutrophils in addition to inhibition of a variety of cytokines including IL-8, NF-kB, TGF-β, and GM-CSF have been demonstrated with macrolide therapy. Initial reports also support decreased mucous secretion, possible mucosal reparative effect, anti-biofilm properties and improved sinus-related symptoms with macrolide therapy.57 However, the beneficial effects of long-term low-dose macrolide treatment in CRS have not been supported in randomized-controlled trials. The 2011 randomized, doubleblinded, placebo-controlled, multicenter macrolides in chronic rhinosinusitis (MACS) trial evaluated the use of long-term low-dose azithromycin in the treatment of recal­citrant CRS. After 3 months of treatment with lowdose azithromycin, there was no statistically significant improvement in symptom scores, QOL, nasal endoscopic findings, smell testing or microbiology in comparison to placebo.58 While a 2012 retrospective review of longterm low-dose treatment with either trimethoprim-sulfame­ thoxazole or different macrolides did suggest an improvement in symptoms and nasal endoscopic findings after therapy, conclusions are limited by the lack of comparison with placebo.59 Furthermore, the treatment doses of macrolide therapy in this study were higher than that used

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in the MACS trial, with no placebo-controlled studies of this higher dosing regimen available to confirm these results. Although several small studies have shown no evid­ ence of development of resistant microbial strains in indivi­ dual patient,57 the risk of systemic toxicity and patho­gen resistance remain real concerns with this method of treatment, especially in the setting of limited clinical evidence for treatment efficacy.

Antifungals There is some evidence to support an interaction between fungi and the sinonasal mucosal immune response in CRS, namely in the subgroup of allergic fungal rhino­ sinusitis where an IgE-mediated hypersensitivity reaction to fungus is demonstrated.7 Theoretically, clearing of fun­ gal elements from the sinuses could disrupt a potential trigger for the underlying abnormal mucosal inflammation seen in CRS. While widespread fungal colonization of the sinuses has been demonstrated in CRS patients, normal individuals are commonly colonized as well, suggesting that the presence of fungi does not equate to a role in the patho­genesis of disease. As discussed previously, topical Amphotericin B has not been shown to be effective in a meta-analysis including several randomized-controlled trials.49 Studies including systemic antifungals have also failed to show therapeutic benefits in CRS patients. A meta-analysis of the literature for both topical and systemic antifungal treatment in the routine management of CRS demonstrated no benefit of antifungal therapy over placebo.60 Analysis of subgroups including patients with more recalcitrant disease was not performed. However, adverse events were found to be higher in the antifungal group leading authors to advocate against use of antifungal treatment in the management of most patients with CRS. A 2011 Cochrane review of randomized, double-blinded trials including 5 studies on topical therapy and 1 study on systemic therapy showed no benefit to antifungal therapy and actually found better symptoms scores in patients treated with placebo.61

Pneumococcal Vaccine Subtle immunodeficiencies such as SAD and CVID have been shown to be more prevalent in recalcitrant CRS patients.18 Low baseline antipneumococcal antibody titers or selective antibody deficiency may contribute to disease severity in CRS as the presence of serotype-specific

Section 6: Rhinosinusitis: Etiology, Pathophysiology and Medical Therapy

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New Horizons

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The Th2 inflammatory cytokine IL-5, which is also an important activator of eosinophils, has been detected in high concentrations in polyp tissue, nasal secretions, and serum of CRSwNP patients. Anti-IL-5 monoclonal anti bodies including mepolizumab and reslizumab have been shown to reduce eosinophilia in tissues and blood, suggesting a role in the treatment of selected CRSwNP patients. Two randomized, double-blinded, placebocontrolled clinical trials have been performed with preli minary data supporting treatment with anti-IL-5 anti bodies through reduction in endoscopic polyp scores and decreased sinus opacification on CT imaging.7 Omalizumab is another monoclonal antibody under going active research for the treatment of CRSwNP. This recombinant DNA-derived humanized IgG monoclonal antibody selectively binds to IgE with resultant reduction

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Monoclonal Antibodies

in free circulating IgE and secondary reductions in immune cell IgE receptors, eosinophils, and Th2 cytokines.62 This anti-IgE antibody has been used in the past for patients with severe allergic asthma and patients with CRSwNP and atopy, where high levels of IgE are thought to contri bute to more severe disease. Patients with CRSwNP and comorbid asthma have also demonstrated high levels of IgE in polyp tissue independent of systemic IgE. In this group of patients, omalizumab is thought to neutralize the IgE produced locally in polyp tissue and perhaps in the peripheral lower respiratory tissues as well.62 A recently published 2013 randomized, doubleblinded, placebo-controlled phase II trial demonstrated positive effects of treatment with omalizumab in the management of allergic and nonallergic patients with both nasal polyps and asthma.63 This study showed a reduction in the primary end point of endoscopically gra ded polyp size as well as improvements in secondary end points including nasal and asthma symptoms and QOL scores. It has been noted that the subset of patients with most severe CRSwNP includes those patients with con current asthma. These patients are most likely to exhibit recalcitrant disease to standard treatment options. The above study suggests a potential role for omalizumab in the treatment of CRSwNP patients with asthma, with or without atopy. The fact that atopy did not seem to affect treatment success supports the need for further studies to analyze the role of omalizumab as a treatment option in other recalcitrant CRSwNP patients.62 Potential side effects of omalizumab include anaphylaxis, cardiovascular events, thrombocytopenia, and cancer.7 While treatment with monoclonal antibodies is costly, the expense may be outweighed by the cost of multi ple sinus surgeries in some patients with refractory nasal polyps. The question of cost, toxicities, comparison to standard therapy, and long-term benefits are still being addressed and require additional study. ­

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antibodies to pneumococcal bacteria is thought to be impor tant against pyogenic mucosal infection.19 Cross-reactions between pneumococcal capsular polysaccharides and other polysaccharide capsular antigens can provide protective immunity to other pyogenic bacteria. Vaccination with the pneumococcal vaccine is then indicated when antibody titers are found to be low. An inappropriately low immunoglobulin response to immunization with pneumococcal vaccine may diagnose a polysaccharide-specific immunodeficiency and should be evaluated for in patients with recalcitrant CRS.18,19 IgG2 is particularly important for protection against capsular polysaccharides of pyogenic bacteria such as S. pneumoniae and H. influenzae (both seen in rhinosinusitis). Administration of the polyvalent pneumococcal vaccine induces specific antibody production particularly from the IgG2 subclass. The pneumococcal vaccine includes an inactive bacterial substance allowing for vaccination in immunodeficient patients without risk of infection. One study showed normalization of serotype-specific antibodies to pneumococcal antigens after vaccination with the pneumococcal vaccine in the majority of patients, with IgG subclass-deficient patients who responded to the vaccine showing no progression in sinusitis episodes.19 When compared with CVID patients, IgG subclass-deficient patients showed improved response to pneumococcal vaccine with fewer repor ted episodes of recurrent rhinosinusitis. Treatment with IVIG may have a role in preventing recurrent infections and CRS in patients with CVID.



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Alternative Medicine In the setting of failed attempts at conventional therapies for CRS, some patients have turned to complementary and alternative medicine hoping for success in symptom management. An early study of acupuncture in CRS suggested improved sinus-related pain in 60% of patients undergoing acupuncture versus 30% with placebo.64 A recent prospective nonrandomized pilot study from 2012 looked further into the impact of integrative EastWest medicine (IEWM) on sinonasal symptoms and QOL in patients with refractory CRS.64 Specifically, acupuncture,

Chapter 38: Refractory Chronic Rhinosinusitis acupressure, and counseling on dietary modifications and lifestyle changes were employed. Results of the study showed statistically significant improvements in some QOL measures (based on SF-36 and SNOT-20 responses) including runny nose, reduced ability to concentrate, need to blow the nose, and feelings of frustration, restlessness or irritability. With 73% of study patients having undergone at least one sinus surgery, preliminary data suggest the potential for symptom improvement in the recalcitrant CRS population with no adverse effects. Further rando­ mized-controlled studies should be performed to provide additional evidence for the role of alternative medical therapies in patients with CRS.

SUMMARY Chronic rhinosinusitis (CRS) places a huge economic burden on the U.S. health­care system in addition to detrimentally impacting patient QOL. Patients with refractory CRS present a particularly challenging task to the treating physician to develop treat­ment strategies that will succeed in a setting where uni­versally accepted first-line therapies have failed. In alignment with the proposed multifactorial etiology of CRS, alternative therapeutic strategies have been explored targeting a variety of potential pathogenic factors in order to break the cycle of disease. While the primary underlying mechanism for the development of CRS is not clearly understood, many factors playing a diseasemodifying role have been identified. With regard to the refractory nature of CRS, proposed contributing and predisposing factors discussed in this chapter include underlying systemic diseases and diseases that imitate CRS symptoms, immune defects and defici­ encies, bacterial biofilms, and osteitis. Revision surgical therapies for refractory CRS focus on improving drainage and aeration of the sinuses and range from mucosalsparing minimally invasive techniques to more invasive mucosal-stripping procedures. Another goal of revision surgery is to provide better access to medical therapies including saline irrigations, which are often thought to be critical for maximal treatment benefit in the post­ operative patient. Treatment with topical medical thera­ pies including antimicrobials, antifungals, steroids, and surfactants has been employed to target proposed patho­ genic processes at the sinonasal mucosal level including biofilms and chronic inflammation. However, data suppor­ ting relative therapeutic efficacy of topical therapies over the mechanical effects of normal saline irrigations remains limited. The role of systemic medical therapies

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including long-term low-dose antibiotics, antifungals, and vaccination against pyogenic bacteria remains contro­ versial in the treatment of refractory disease. Further development and study of novel therapies including mono­ clonal antibodies and alternative medical practices inclu­ ding acupuncture may provide not only additional insight into the multifactorial nature of disease but also additional weapons for the management of this phenotypically diverse group of patients.

REFERENCES 1. Senior BA, Kennedy DW, Tanabodee J, et al. Long-term results of functional endoscopic sinus surgery. The Laryn­ goscope. 1998;108(2):151-7. 2. Benninger MS, Ferguson BJ, Hadley JA, et al. Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg.: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 2003;129(3 Suppl):S1-32. 3. Videler WJ, van Drunen CM, van der Meulen FW, Fokkens WJ. Radical surgery: effect on quality of life and pain in chronic rhinosinusitis. Otolaryngol Head Neck Surg.: Official Journal of American Academy of OtolaryngologyHead and Neck Surgery. 2007;136(2):261-7. 4. Fokkens WJ. Recalcitrant rhinosinusitis, the diagnosis and treatment and evaluation of results. Rhinology. 2010;48(3): 257-8. PubMed PMID: 21038012. 5. Kern RC, Conley DB, Walsh W, et al. Perspectives on the etiology of chronic rhinosinusitis: an immune barrier hypo­ thesis. Am J Rhinol. 2008;22(6):549-59. 6. Littman DR, Pamer EG. Role of the commensal microbiota in normal and pathogenic host immune responses. Cell Host Microbe. 201120;10(4):311-23. 7. Fokkens WJ, Lund VJ, Mullol J, et al. The European position paper on rhinosinusitis and nasal polyps 2012. Rhinology. 2012;Suppl. 23:1-299. 8. Tan BK, Schleimer RP, Kern RC. Perspectives on the etiology of chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg. 2010;18(1):21-6. 9. Ooi EH, Psaltis AJ, Witterick IJ, et al. Innate immunity. Otolaryngol Clin North Am. 2010;43(3):473-87, vii. 10. Campbell R. Managing upper respiratory tract complica­ tions of primary ciliary dyskinesia in children. Curr Opin Allergy Clin Immunol. 2012;12(1):32-8. 11. Woodbury K, Ferguson BJ. Recalcitrant chronic rhino­ sinusitis: investigation and management. Curr Opin Otola­ ryngol Head Neck Surg. 2011;19(1):1-5. 12. Lane AP, Pine HS, Pillsbury HC, 3rd. Allergy testing and immunotherapy in an academic otolaryngology practice: a 20-year review. Otolaryngol Head Neck Surg.: Official Journal of American Academy of Otolaryngology—Head and Neck Surgery. 2001;124(1):9-15. 13. Chee L, Graham SM, Carothers DG, Ballas ZK. Immune dysfunction in refractory sinusitis in a tertiary care setting. The Laryngoscope. 2001;111(2):233-5.

Section 6: Rhinosinusitis: Etiology, Pathophysiology and Medical Therapy ­

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30. Lee JM, Chiu AG. Role of maximal endoscopic sinus sur gery techniques in chronic rhinosinusitis. Otolaryngol Clin North Am. 2010;43(3):579-89, ix. 31. Shen PH, Weitzel EK, Lai JT, et al. Retrospective study of full-house functional endoscopic sinus surgery for revision endoscopic sinus surgery. Int Forum Allergy Rhinology. 2011;1(6):498-503. 32. Schneider JS, Archilla A, Duncavage JA. Five “nontraditional” techniques for use in patients with recalcitrant sinusitis. Curr Opin Otolaryngol Head Neck Surg. 2013;21(1):39-44. 33. Jankowski R, Pigret D, Decroocq F. Comparison of func tional results after ethmoidectomy and nasalization for diffuse and severe nasal polyposis. Acta Otolaryngologica. 1997;117(4):601-8. 34. Cho DY, Hwang PH. Results of endoscopic maxillary megaantrostomy in recalcitrant maxillary sinusitis. Am J Rhinol. 2008;22(6):658-62. 35. Wang EW, Gullung JL, Schlosser RJ. Modified endoscopic medial maxillectomy for recalcitrant chronic maxillary sinusitis. Int Forum Allergy Rhinol. 2011;1(6):493-7. 36. Lee JY, Lee SH, Hong HS, et al. Is the canine fossa puncture approach really necessary for the severely diseased maxillary sinus during endoscopic sinus surgery? The Laryngo scope. 2008;118(6):1082-7. 37. Georgalas C, Hansen F, Videler WJ, et al. Long terms results of Draf type III (modified endoscopic Lothrop) frontal sinus drainage procedure in 122 patients: a single centre experience. Rhinology. 2011;49(2):195-201. 38. Schulze SL, Loehrl TA, Smith TL. Outcomes of the modified endoscopic Lothrop procedure. Am J Rhinol. 2002;16(5): 269-73. 39. Anderson P, Sindwani R. Safety and efficacy of the endo scopic modified Lothrop procedure: a systematic review and meta-analysis. The Laryngoscope. 2009;119(9):1828-33. 40. Chiu AG, Antunes MB, Palmer JN, Cohen NA. Evaluation of the in vivo efficacy of topical tobramycin against Pseudo monas sinonasal biofilms. J Antimicrob Chemother. 2007; 59(6):1130-4. PubMed PMID: 17405780. 41. Videler WJ, van Drunen CM, Reitsma JB, et al. Nebulized bacitracin/colimycin: a treatment option in recalcitrant chronic rhinosinusitis with Staphylococcus aureus? A double-blind, randomized, placebo-controlled, cross-over pilot study. Rhinology. 2008;46(2):92-8. 42. Uren B, Psaltis A, Wormald PJ. Nasal lavage with mupirocin for the treatment of surgically recalcitrant chronic rhino sinusitis. The Laryngoscope. 2008;118(9):1677-80. 43. Jervis-Bardy J, Boase S, Psaltis A, et al. A randomized trial of mupirocin sinonasal rinses versus saline in surgically recalcitrant staphylococcal chronic rhinosinusitis. The Laryngoscope. 2012;122(10):2148-53. 44. Jervis-Bardy J, Wormald PJ. Microbiological outcomes following mupirocin nasal washes for symptomatic, Staphy­ lococcus aureus-positive chronic rhinosinusitis following endoscopic sinus surgery. Int Forum Allergy Rhinol. 2012;2 (2):111-5. 45. Holzmann D, Speich R, Kaufmann T, et al. Effects of sinus surgery in patients with cystic fibrosis after lung trans plantation: a 10-year experience. Transplantation. 2004;77 (1):134-6.

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14. Reh DD, Wang Y, Ramanathan M, Jr., Lane AP. Treatmentrecalcitrant chronic rhinosinusitis with polyps is associated with altered epithelial cell expression of interleukin-33. Am J Rhinol Allergy. 2010;24(2):105-9. 15. Lane AP, Truong-Tran QA, Schleimer RP. Altered expres sion of genes associated with innate immunity and inflam mation in recalcitrant rhinosinusitis with polyps. Am J Rhinol. 2006;20(2):138-44. PubMed PMID: 16686375. 16. Vroling AB, Fokkens WJ, van Drunen CM. How epithelial cells detect danger: aiding the immune response. Allergy. 2008;63(9):1110-23. 17. Castano R, Bosse Y, Endam LM, et al. Evidence of association of interleukin-1 receptor-like 1 gene polymorphisms with chronic rhinosinusitis. Am J Rhinol Allergy. 2009;23(4): 377-84. 18. Carr TF, Koterba AP, Chandra R, et al. Characterization of specific antibody deficiency in adults with medically refrac tory chronic rhinosinusitis. Am J Rhinol Allergy. 2011;25(4): 241-4. PubMed PMID: 21819760. 19. May A, Zielen S, von Ilberg C, Weber A. Immunoglobulin deficiency and determination of pneumococcal antibody titers in patients with therapy-refractory recurrent rhino sinusitis. Eur Arch Otorhinolaryngol.: Official Journal of the European Federation of Oto-Rhino-Laryngological Societies. 1999;256(9):445-9. 20. Foreman A, Jervis-Bardy J, Wormald PJ. Do biofilms contribute to the initiation and recalcitrance of chronic rhinosinusitis? The Laryngoscope. 2011;121(5):1085-91. PubMed PMID: 21520128. 21. Foreman A, Psaltis AJ, Tan LW, Wormald PJ. Characterization of bacterial and fungal biofilms in chronic rhinosinusitis. Am J Rhinol Allergy. 2009;23(6):556-61. 22. Suh JD, Cohen NA, Palmer JN. Biofilms in chronic rhino sinusitis. Curr Opin Otolaryngol Head Neck Surg. 2010;18 (1):27-31. 23. Galli J, Calo L, Ardito F, et al. Damage to ciliated epithelium in chronic rhinosinusitis: what is the role of bacterial biofilms? Ann Otol Rhinol Laryngol. 2008;117(12):902-8. 24. Singhal D, Psaltis AJ, Foreman A, et al. The impact of biofilms on outcomes after endoscopic sinus surgery. Am J Rhinol Allergy. 2010;24(3):169-74. PubMed PMID: 20537281. 25. Tan NC, Foreman A, Jardeleza C, et al. The multiplicity of Staphylococcus aureus in chronic rhinosinusitis: correla ting surface biofilm and intracellular residence. The Laryngoscope. 2012;122(8):1655-60. 26. Tan NC, Foreman A, Jardeleza C, et al. Intracellular Staphy­ lococcus aureus: the Trojan horse of recalcitrant chronic rhinosinusitis? Int Forum Allergy Rhinology. 2013;3(4): 261-6. 27. Videler WJ, Georgalas C, Menger DJ, et al. Osteitic bone in recalcitrant chronic rhinosinusitis. Rhinology. 2011;49(2): 139-47. 28. Bhandarkar ND, Sautter NB, Kennedy DW, Smith TL. Osteitis in chronic rhinosinusitis: a review of the literature. Int Forum Allergy Rhinol. 2013;3(5):355-63. 29. Bhandarkar ND, Mace JC, Smith TL. The impact of osteitis on disease severity measures and quality of life outcomes in chronic rhinosinusitis. Int Forum Allergy Rhinology. 2011;1(5):372-8.



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Chapter 38: Refractory Chronic Rhinosinusitis 46. Singhal D, Jekle A, Debabov D, et al. Efficacy of NVC-422 against Staphylococcus aureus biofilms in a sheep biofilm model of sinusitis. Int Forum Allergy Rhinol. 2012;2(4):30915. PubMed PMID: 22434724. 47. Moshaver A, Velazquez-Villasenor L, Lavigne F, et al. Selec­ tive irrigation of paranasal sinuses in the treatment of recalcitrant chronic sinusitis. Am J Rhinol Allergy. 2010;24 (5):371-3. 48. Liang J, Lane AP. Topical drug delivery for chronic rhino­ sinusitis. Curr Otorhinolaryngol Reports. 2013;1(1):51-60. PubMed PMID: 23525506. 49. Isaacs S, Fakhri S, Luong A, et al. A meta-analysis of topical amphotericin B for the treatment of chronic rhinosinusitis. Int Forum Allergy Rhinol. 2011;1(4):250-4. 50. Welch KC, Thaler ER, Doghramji LL, et al. The effects of serum and urinary cortisol levels of topical intranasal irrigations with budesonide added to saline in patients with recurrent polyposis after endoscopic sinus surgery. Am J Rhinol Allergy. 2010;24(1):26-8. 51. Snidvongs K, Kalish L, Sacks R, et al. Topical steroid for chro­ nic rhinosinusitis without polyps. Cochrane Database Syst Rev. 2011 (8):CD009274. 52. Kalish L, Snidvongs K, Sivasubramaniam R, et al. Topical steroids for nasal polyps. Cochrane Database Syst Rev. 2012;12:CD006549. 53. Lavigne F, Cameron L, Renzi PM, et al. Intrasinus admini­ stration of topical budesonide to allergic patients with chro­nic rhinosinusitis following surgery. The Laryngoscope. 2002;112(5):858-64. 54. Snidvongs K, Pratt E, Chin D, et al. Corticosteroid nasal irrigations after endoscopic sinus surgery in the manage­ ment of chronic rhinosinusitis. Int Forum Allergy Rhinol. 2012;2(5):415-21.

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55. Chiu AG, Palmer JN, Woodworth BA, et al. Baby shampoo nasal irrigations for the symptomatic post-functional endo­ scopic sinus surgery patient. Am J Rhinol. 2008;22(1):34-7. 56. Valentine R, Jervis-Bardy J, Psaltis A, et al. Efficacy of using a hydrodebrider and of citric acid/zwitterionic surfactant on a Staphylococcus aureus bacterial biofilm in the sheep model of rhinosinusitis. Am J Rhinol Allergy. 2011;25(5): 323-6. 57. Soler ZM, Smith TL. What is the role of long-term macro­ lide therapy in the treatment of recalcitrant chronic rhino­ sinusitis? The Laryngoscope. 2009;119(11):2083-4. 58. Videler WJ, Badia L, Harvey RJ, et al. Lack of efficacy of longterm, low-dose azithromycin in chronic rhinosinusitis: a randomized controlled trial. Allergy. 2011;66(11):1457-68. 59. Videler WJ, van Hee K, Reinartz SM, et al. Long-term lowdose antibiotics in recalcitrant chronic rhinosinusitis: a retrospective analysis. Rhinology. 2012;50(1):45-55. 60. Sacks PLt, Harvey RJ, Rimmer J, et al. Antifungal therapy in the treatment of chronic rhinosinusitis: a meta-analysis. Am J Rhinol Allergy. 2012;26(2):141-7. 61. Sacks PL, Harvey RJ, Rimmer J, et al. Topical and systemic antifungal therapy for the symptomatic treatment of chro­ nic rhinosinusitis. Cochrane Database Syst Reviews. 2011 (8):CD008263. 62. Kern RC. Biologics and the treatment of chronic rhino­ sinusitis. J Allergy Clin Immunol. 2013;131(1):117-8. 63. Gevaert P, Calus L, Van Zele T, et al. Omalizumab is effective in allergic and nonallergic patients with nasal polyps and asthma. J Allergy Clin Immunol. 2013;131(1):110-6 e1. 64. Suh JD, Wu AW, Taw MB, et al. Treatment of recalcitrant chronic rhinosinusitis with integrative East-West medi­cine: a pilot study. Arch Otolaryngol Head Neck Surg. 2012;138 (3):294-300.

Section Anesthesia

7

Chapter 39: Local Anesthesia

571

Chapter Local Anesthesia

39

Azeem S Kaka, Subinoy Das The development and widespread acceptance of endo­ scopic sinus surgery have been, in large part, predicated on technological advances in instrumentation and visuali­ zation. Equally important to the development of endo­ scopic sinus surgery, however, has been the refinement of local anesthetic techniques. The optimal use of local anesthetics reduces bleeding and pain, and enhances visualization of the surgical field, allowing for safe and precise intranasal surgery. As a result, it is critically impor­ tant for endoscopic sinus surgeons to possess a mastery of the selection and use of appropriate local anesthetics and awareness of the complication risks that they possess.

INTRODUCTION Anesthesia and Sinus Surgery Endoscopic sinus surgery is typically performed via the combined use of general anesthesia and topically applied local anesthetics. However, surgery may also be performed completely via local anesthesia. Local anesthesia with orally or intravenously delivered sedation avoids some of the risks inherent with general anesthesia, allows for the use of in-office surgical techniques, allows for real-time monitoring of vision and pain, and may provide for an additional level of safety. Previous studies have reported that patients undergoing endoscopic sinus surgery under local anesthesia with sedation have decreased operative times and satisfaction levels comparable to that of general anesthesia. Exclusive use of local anesthetics has a distinct advan­ tage in that inhalational anesthetics are avoided. Volatile

agents used in the maintenance phase of anesthesia typi­ cally cause vasodilatation, which is particularly harmful to the endoscopic sinus surgical field. Techniques such as controlled hypotension have been developed to assist in the surgical field; however, these are typically accomp­ lished with increased concentrations of these volatile agents that often result in rebound tachycardia and greater vasodilatation, and demonstrate equivocal effects on the quality of the surgical field. Furthermore, controlled hypotension increases the risk of end-organ damage and specifically increases the risk for hypoperfusion-induced strokes. Propofol, introduced in 1989 by the AstraZeneca Corpo­ ration, was the first of a new class of intravenous anesthetics known as alkyl phenols. Propofol is a sedative-hypnotic agent that can be used for induction of general anesthesia as well as the maintenance of anesthesia via a continuous infusion. Propofol is advantageous over inhalational anes­ thesia during sinus surgery in that it induces arterial hypotension without significant reflex tachycardia, and not does have peripheral vasodilatory effects comparable with those of volatile inhalational anesthetics. Propofol also causes less postoperative nausea and vomiting compared to volatile anesthetics; however, it causes pain on injection and requires strict aseptic tech­ nique since it is delivered as a lipid emulsion and carries a risk of serious bloodstream infections. Propofol has a distribution half-life of 2–4 minutes but readily distributes to peripheral fat and has an elimination half-life of 2–4 hours. Therefore, significant amounts of propofol can build up in a patient’s fat stores if propofol is continuously used over several hours. This can adversely increase extubation times from anesthesia.

Section 7: Anesthesia

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Local anesthetics and vasoconstrictors also play an impor­ tant role in minimizing postoperative pain and improving the surgical field during endoscopic sinus surgery. There are a myriad of mixtures and protocols used for local anesthesia and vasoconstriction. Two basic classes for local anesthetics exist: the amino esters and the amino amides. Cocaine, a naturally occurring amino ester, was the first anesthetic to be discovered and was introduced into Europe in the 1800s following its isolation from coca beans. William Halsted, an American surgeon who was one of the founding four members of Johns Hopkins hospital, became an early champion of cocaine and unfortunately became addicted to the substance through self experimen­ tation. Procaine, the first synthetic derivative of cocaine, was developed in 1904. Lofgren later developed lidocaine in 1943 during World War II. Lidocaine, an amino amide, has become the most widely used cocaine derivative and is ubiquitously used during surgical procedures.



Local Anesthetics and Vasoconstrictors

Cocaine and its derivatives produce anesthesia by inhibiting excitation of nerve endings and/or blocking conduction in peripheral nerves by reversibly binding and inactivating sodium channels. This prevents depolariza­ tion of nerve cells and thus causes a loss of sensation in the local area innervated by the sensory nerve. The mecha­ nism for differential block of pain perception as compared to motor function is still poorly understood. Cocaine derived anesthetics contain a chemical struc­ ture that possesses an intermediate chain with a hydro­ philic amine on one end connected to an aromatic ring on the other end. There are two classes of local anesthe­ tics: amino esters and amino amides. Amino esters have an ester link between their intermediate chain and their aromatic ring, and amino amides have an amide link. Common esters include cocaine, procaine, tetracaine, and benzocaine. Common amides include lidocaine, mepiva­ caine, prilocaine, bupivacaine, and ropivacaine. Amino esters and amino amides differ in several important aspects. Esters are metabolized in plasma via pseudocholinesterases, whereas amides are metaboli­ zed in the liver. Esters are unstable in solution, whereas amides are very stable. Esters are more likely to cause true allergic reactions. All esters and amides are vasodilators with the exception of cocaine, which is a vasoconstrictor. Thus, the combination of anesthesia and vasoconstriction makes cocaine an ideal anesthetic for intranasal surgery. However, the euphoria and highly addictive nature of cocaine have made it one of the most widely abused recreational drugs and thus made it illegal in most coun­ tries. As a result, cocaine is more difficult to use for legiti­ mate medical purposes. Cocaine is also known to cause cardiac arrhythmias and many have recommended its abandonment8 with the use of safer mixtures. Epinephrine, a human adrenergic catecholamine, is a potent vasoconstrictor commonly added to local anes­ thetics at a variety of concentrations. Epinephrine acts peripherally by inducing alpha receptor contraction of myoepithelium to produce vasoconstriction. Concen­ trations vary from 1 in 1,000 parts epinephrine to 1 in 200,000 parts epinephrine. As a result, care must be taken to prevent syringe mislabeling so as to not inject more potent concentrations of epinephrine meant for topical use directly into the bloodstream. Oxymetazoline is a selective alpha 1 agonist and partial alpha 2 agonist that are often used as a topical decongestant. Developed by Merck, Inc., oxymetazoline, given the trade name Afrin, was first sold as a prescription ­

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The advent of fentanyl congeners and target con­ trolled infusion pumps, which permit delivery of intra­ venous agents in a manner superior to that of manual injection, has allowed for the advent of total intravenous anesthesia (TIVA). Typically, the combination of propo­ fol with alfentanil can be used without the need for inhalational agents for maintenance. In a prospective, randomized controlled trial Wormwald et al. compared TIVA with traditional anesthesia with sevoflurane and found a significant improvement in a validated grading system of the surgical field independent of heart rate or mean arterial blood pressure. Furthermore, in patients with a high preoperative Lund Mackay score (> 12), a British study showed there was a significantly decreased amount of intraoperative blood loss using TIVA. While TIVA possesses these many advantages over inhalational anesthesia, there are several barriers that have precluded its widespread adoption. Variability in patient drug requirements, particularly in obese patients, is significant. The anesthetic plane and depth of anesthesia are limited compared to that of inhala­ tional agents. TIVA combined with muscle relaxants allows for the risk of “awareness” with the inability to move. In addition, TIVA drugs are often significantly much more expensive than traditional agents. Nevertheless, TIVA in combination with topical local anesthetics may prove to be a superior option for many types of intranasal surgery.



572

Chapter 39: Local Anesthesia medicine in 1966 and became an over-the-counter medica­ tion in 1975. Oxymetazoline acts by activating alpha-1 receptors and endothelial postsynaptic alpha-2 receptors primarily within the inferior turbinates, which tempo­ rarily increases the diameter of the nasal airway lumen and minimizes fluid exudation from postcapillary venules within septal and turbinate mucosa. While persistent use of oxymetazoline leads to rhinitis medicamentosa and possible permanent turbinate hyperplasia, the periope­ rative use of oxymetazoline is very effective for improving visualization of nasal and sinus anatomy and minimizing bleeding. Phenylephrine, commonly marketed as Neo-Syneph­ rine, is also a selective alpha-1 receptor agonist and is used as a vasoconstrictor during intranasal surgery, though its effectiveness as a vasoconstrictor has been brought into question through multiple placebo-controlled trials.

INJECTION LOCATIONS Greater Palatine Block The authors utilize bilateral greater palatine blocks in most cases, particularly when total ethmoidectomies and/or sphenoidotomies are being performed (Fig. 39.1). Three milli­liters of 1% lidocaine with 1:100,000 epinephrine are delive­red into a 5 mL Luer lock syringe. The expiration date and the proper concentration and labeling of the lidocaine and epinephrine on the stock container are confirmed by the surgeon and drawn directly from the bottle into the syringe by the surgeon. This minimizes the risk of acci­ dental injection of a different concentration. A 1 and a ½ inch 25 gauge needle is measured with a ruler and bent at 60° at a length of 25 mm for all adults. After the patient has been intubated and the bed turned, two tongue blades are placed in the mouth and used to palpate the hard palate/soft palate junction. The greater palatine foramen is typically located just anterior to the border of this junction. It can often be seen as a subtle depression in the hard palate mucosa and/or palpated with a glove finger. Although historically described as next to the second maxillary molar, the foramen is next to the third molar appro­ ximately 50% of the time. The needle is placed into the greater palatine foramen and advanced to the bend of the needle. Occasionally, the needle is marched anteriorly from the hard palate border when the greater palatine foramen is difficult to find. The needle is then aspirated for blood to prevent an intravascular injection. If no blood is obtained, then 1.5 mL of the anesthetic is delivered

573

Fig. 39.1: Intraoral greater palatine injection.

slowly to the canal. If the needle is properly placed, then there will be moderate resistance to the fluid being delivered into the canal. If there is very minimal resistance, it is likely that the needle went through the soft palate into the nasopharynx, and is not correctly placed in the canal. The same procedure is repeated for the contralateral canal.

Sphenopalatine Block The sphenopalatine foramen is injected transnasally poste­ rior and superior to the horizontal portion of the basal lamella at the posterior aspect of the middle turbinate. One percent of lidocaine with 1:100,000 epinephrine is used. This is a technically difficult injection that is perfor­ med by placing a 30° bend in the first centimeter of a spinal needle or by using an angled tonsil needle. The tip of the needle is used to palpate the foramen. The needle is placed in an upward and lateral direction and used to bleb up the mucosa adjacent to the sphenopalatine foramen. Typically, blanching is already seen by a pro­perly injected greater palatine foramen block, and the sphenopalatine injection augments this blanching (Fig. 39.2). If the foramen is unable to be reached, then a bleb near the foramen will diffuse to the foramen and cause vasospasm of the sphenopalatine branches. Alternatively, the injec­ tion can be placed medially at the rostrum of the septum between the middle turbinate and the inferior turbinate to minimize bleeding from the posterior nasal artery. As always, care should be taken to aspirate before injecting to prevent an intravascular injection. Lateral nasal wall injections: The lateral nasal wall is injected with 1% lidocaine with 1:100,000 epinephrine

574

Section 7: Anesthesia Table 39.1: Toxicity of commonly used local anesthetics

Local anesthetic

Class

Toxic plasma concentration

Lidocaine

Amino 4 mg/kg (without epinephrine) amide 7 mg/kg (with 1:100,000 epinephrine)

Bupivacaine Amino 2.5 mg/kg (without epinephrine) amide 3.0 mg/kg (with 1:100,000 epinephrine) Prilocaine

Amino 7 mg/kg (without epinephrine) amide 8 mg/kg (with 1:100,000 epinephrine)

Cocaine

Amino 3 mg/kg ester

Complications

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Optimal local anesthesia is essential for the performance of in office sinus surgery such as balloon sinuplasty. Many techniques are used. The authors prefer premedicating patients with 5 mg of valium. Next, patients are given aerosolized sprays of a lidocaine/oxymetazoline mixture. Pledgets containing tetracaine are then applied to the middle meatus for a minimum of 5 minutes, and then reap­ plied deeper in the middle meatus on the face of the ethmoid bulla. Despite these applications, the procedure can be painful, particularly during inflation of the balloon.

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APPLICATION TECHNIQUES FOR IN-OFFICE SINUS SURGERY

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via a 25 gauge needle typically with a slight bend at the tip. The optimal injection is superior and anterior to the anterior attachment of the middle turbinate. The inferior portion of the uncinate process, the inferior border of the middle turbinate, the septum, the superior turbinate, and other supplemental injections are utilized depending on the disease process and type of operation. The benefits of this injection must be weighed against the nuisance bleeding that can occur from these injection sites that can interfere with the performance of the operation. Recent randomized controlled trials have shown that there is a statistically significant improved surgical field, reduced blood loss, and reduced postoperative pain in using a bilateral greater palatine block or an endoscopic sphenopalatine block in sinus surgery. The authors suggest that either of these techniques are used in all cases.

Lidocaine toxicity is a result of excessive blood concen­ trations that cause central nervous system or cardiovas­ cular reactions (Table 39.1). Excessive blood concentrations can result from direct intravascular injection or, less com­ monly, from vascular absorption. Lidocaine toxicity on the central nervous system is biphasic; first, inhibitory fibers are blocked resulting in stimulation with tingling, numbness, mental status changes, and eventually seizures. Eventually, excitatory pathways are also blocked that can cause unconsciousness, respiratory depression, and arrest. Cardiovascular effects are from effects on sodium channels in the heart that lead to arrhythmias. The first sign of toxi­ city is central nervous system symptoms akin to alcoholic inebriation with lightheadedness, vertigo, and possible perioral tingling. Patients are treated by securing an airway, mechanical ventilation, and circulatory support. Seizures are controlled with benzodiazepines and succinylcholine. Arrhythmias are best treated with bretylium. The maxi­ mal dosage of lidocaine (without intravascular injection) is between 2 mg/kg and 4 mg/kg, with many individual factors affecting serum concentrations. Epinephrine limits lidocaine absorption due to vasoconstriction. Maximal dosage with epinephrine is typically 7 mg/kg. Patients may rarely develop anaphylaxis to local anesthetics, though this is more common with esters. Cocaine toxicity results primarily from its vasocons­ trictive property and its effect to stimulate the sympa­ thetic nervous system. Cocaine administration will lead to increased concentrations of catecholamines (norepine­ phrine and dopamine) in the synaptic cleft, which then leads to increased sympathetic tone. These properties have been shown to lead to increased coronary vasospasm, myocardial ischemia, arrhythmias, hypertension, and tachy­ cardia. This effect of myocardial ischemia may be seen as

Fig. 39.2: Transnasal sphenopalatine injection.

Chapter 39: Local Anesthesia late as 6 weeks after the last administered cocaine dose. Given these potential disastrous complications and the rising rates of premorbid cardiac conditions, cocaine use has been largely abandoned in sinus surgery.

CONCLUSION The proper use of local anesthetics and injection techni­ ques is an essential aspect of performing surgery safely and effectively. A comprehensive working knowledge of local anesthetics including their pharmacodynamics, risks, and benefits is mandatory for otolaryngologists.

FURTHER READING 1. Ahmed HM, Abu-Zaid EH. Role of intraoperative endo­ scopic sphenopalatine Ganglion block in sinonasal surgery. J Med Sci. 2007(7):1297-303. 2. Ahn HJ, Chung SK, Dhong HJ, et al. Comparison of surgical conditions during propofol or sevoflurane anaesthesia for endoscopic sinus surgery. Br J Anaesth. 2008;100(1):50-54.

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3. Das S, Kim D, Cannon TY, et al. High-resolution computed tomography analysis of the greater palatine canal. Am J Rhinol. 2006;20:603-8. 4. Das S, Senior BA. Injection and anesthetic techniques. In: Kountakis SE, Onerci M (Eds). Rhinologic and Sleep Apnea Surgical Techniques. New York: Springer; 2007. 5. Hashisaki GT, Johns ME. Cocaine applications in otorhino­ laryngologic anesthesia. Contemp Anesth Pract. 1987;9: 31-45. 6. Ismail SA, Anwar HMF. Bilateral sphenopalatine Ganglion block in functional endoscopic sinus surgery under general anaesthesia. Alex J Anesth Intensive Care. 2005;8(4): 46-53. 7. Johnson DA, Hricik JG. The pharmacology of alphaadrenergic decongestants. Pharmacotherapy. 1993;13 (6Pt2):110S-15S. 8. Marcus MAE, Cox B, Durieux ME. Toxicity of local anes­ thesia. Best Pract Res Clin Anaesthesiol. 2003;(17):111-36. 9. Wormald PJ, van Renen G, Perks J, et al. The effect of the total intravenous anesthesia compared with inhalational anesthesia on the surgical field during endoscopic sinus surgery. Am J Rhinol. 2005;19(5):514-20.

Chapter 40: Anesthesiology

577

Chapter Anesthesiology

40

Jerry Chao, Philip Lebowitz

HISTORICAL PERSPECTIVE OF CURRENT PRACTICE Although botanicals like opium and cocaine, as well as alcohol, have been used since antiquity to relieve pain and provide a disordered sensorium, the modern era for anesthesia began in the 19th century when a highly publicized search for an inhaled substance that could transiently produce a state of unawareness and analgesia led to the near-simultaneous discovery of nitrous oxide, diethyl ether, and chloroform as anesthetics.1 Although a number of individuals had earlier experimented with nitrous oxide, it fell to Horace Wells, a dentist, to demon­ strate the utility of this gas for his own dental extraction. William TG Morton, another dentist, happened upon sulfuric ether, which he used with success in his dental practice. On October 16, 1846, Morton was allowed to give his “Letheon” to a young man whose vascular neck tumor was to be excised by the chief surgeon at the Massachusetts General Hospital in Boston, John Collins Warren. The procedure was a success and Morton’s “discovery” was immediately hailed by Warren, saying “This is no humbug”. The event was quickly celebrated in the Boston Medical and Surgical Journal (antecedent of the New England Journal of Medicine), and ether inhalation for surgery was established as the standard of its time. Oliver Wendell Holmes gave it the name anesthesia: Greek for an, without, and esthesia, feeling. Wells, Morton, and Charles Jackson (who had sug­ gested sulfuric ether to Morton) all vied for the prestige (and hoped-for wealth) that attended the discoverer of this “boon to mankind”. To complicate the picture, Crawford

Long had used ether for surgical pain relief as early as 1842, but he did it in the state of Georgia, which did not attract the attention of the Western medical establishment as had Morton in Boston. Spontaneous ventilation and support of the circulation were well maintained with ether, though it was flammable and frequently caused postoperative nausea and vom­i­ ting. The continued search for a better inhalational agent led to James Simpson’s use of chloroform in England within the year. Chloroform became the mainstay in England for surgical and obstetrical pain relief, but was eventually removed from use because of hepatotoxicity and the tendency to cause ventricular fibrillation. Nitrous oxide regained popularity in the 1860s and, despite the controversy over its side effects, remains in use to this day. Diethyl ether, the eventual successor to Morton’s version, lost its popularity as nonflammable inhalational agents were introduced into anesthetic practice. Halothane, introduced clinically in 1956, was nonflam­ mable, less emetic, and more potent; it quickly replaced ether and other flammable agents like cyclopropane. Unfortunately, some patients who had been anesthetized with halothane developed hepatic injury, occasionally to the point of fatal hepatic necrosis. The prototype of the clinically utilized methyl–ethyl ethers was methoxyflurane, but that was found to be nephrotoxic in dose-dependent fashion. Subsequent variants, enflurane and isoflurane, were progressively less likely to injure the kidneys, and isoflurane continues to be used today. More recently, sevoflurane and desflurane—volatile liquids that, as gases, are inhaled via anesthesia machine breathing circuits— have come to dominate modern practice. In contrast to

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­

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of nerve blocks for chronic pain as well as for regional anesthesia as the sole or the adjunctive mode of surgical anesthesia. Modern anesthetic practice generally involves an IV infusion with ports for administering IV medications, an anesthesia delivery system, and electronic patient moni toring. The principal breathing circuit is termed a semiclosed circle system and includes separate inspiratory and expiratory flow valves, a carbon dioxide absorption system, an excess gas relief and scavenger, a reservoir bag, a ventilator, a valve to separate the reservoir bag from the ventilator, and an attachment to the common gas outlet of the anesthesia machine itself. The anesthesia machine includes a dual oxygen supply (wall/ceiling and tanks—also called cylinders), pressure-reducing valves from the oxygen tanks, oxygen (and often air and/or nitrous oxide) flowmeters, oxygen analyzers, fresh gas apportioners, vaporizers, and an auxiliary oxygen outlet. The newest version of anesthesia machine incorporates microprocessors that obviate the need for older, mechanical safety devices. Standard monitoring in current practice includes continuous electrocardiography, intermittent noninvasive blood pressure, continuous pulse oximetry, continuous capnography/capnometry, and temperature. Today’s monitors also include the capability of invasive pressure measurements, such as continuous intra-arterial and central venous pressure determinations. Increasingly, automated electronic anesthesia record-keepers are replac ing the conventional pen-and paper graphic forms.

MECHANISMS OF ANESTHETIC ACTION ­

Despite the span of time since Morton’s ether demon stration, the precise explanation for how anesthetics affect the central nervous system to eliminate awareness/ consciousness, prevent pain perception and blunt the autonomic responses to stressful surgical stimuli, pro duce immobility in the face of those noxious stimuli—in essence reduce the patient to a comatose state—then return the patient to the sentient person he or she was before the anesthetic, remains elusive.2 In general, drugs act by attaching to cellular receptors that, in turn, initiate signal transduction mechanisms in the cell. The merged effects on cells, organs, and the whole body by drugs are complex and involve the regulation of many receptors and channels. Anesthetic drugs, in particular, affect numerous receptors. Principal among them are G protein-coupled ­



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nitrous oxide, which is analgesic but only a partial anes thetic under normal conditions, the other named agents are full anesthetics. The characteristics of potent inhaled anesthetics include analgesia (the absence of pain), amnesia (the absence of awareness), and immobility (the absence of movement). At an appropriate, individualized brain con centration, each of the potent inhalational anesthetics produces anesthesia under which is subsumed the afore mentioned characteristics. Aside from opioids like mor phine, intravenous (IV) hypnotic/sedatives did not regularly enter the clinical sphere until hexobarbital was intro duced in 1932. Sodium thiopental followed in 1934 and constituted a building block in balanced anesthesia, where general anesthesia was allegedly more safely produced by using smaller doses of several drugs. In expert hands, thiopental became the predominant, safe IV anesthetic induction agent and was ubiquitous until propofol’s ascendancy in the 1990s. The other class of drugs, besides hypnotic/sedatives, opioids, and nitrous oxide, that constituted balanced anesthesia was the muscle relaxants or, more properly, neuromuscular blocking drugs. The first clinically useful compound was d-tubocurarine or curare, which was introduced in 1940 and served to relax patients’ muscles to improve surgical exposure and wound closure. Succinyl choline, a depolarizing drug, and the nondepolarizing triad of vecuronium, rocuronium, and cisatracurium constitute the array of neuromuscular blocking drugs in today’s practice. The use of these drugs facilitates endotracheal intubation and produces a state of surgical relaxation at lower concentrations of inhaled anesthetic than would be required if the inhaled anesthetic was given alone. Regional anesthesia—the use of local anesthetics to transiently defunctionalize the spinal cord, nerve bundles, individual nerves, or a localized distribution of dendritic nerve terminals—is a discipline that harkens back to the late 19th century and the isolation of cocaine from the dried leaves of the coca plant in 1856. Sigmund Freud gave some cocaine to Carl Koller, who applied the drug topically to a patient’s eye and was able to perform superficial surgery. Following this demonstration in 1884, William Halsted investigated the use of cocaine solution to block a variety of nerves or nerve distributions with good results. Procaine (Novocaine) was synthesized in 1905, followed by tetracaine in 1932, lidocaine in 1948, and bupivacaine in 1963, among others. Advances in radiological guidance and now ultrasonic guidance have fostered an abundance

Chapter 40: Anesthesiology receptors on the extracellular surface of the cell that couple to intracellular effector systems via intermediary guanine nucleotide proteins (G proteins). G protein systems include the adrenergic, muscarinic cholinergic, opioid, serotonin, histamine, cannabinoid, cholecystokinin, endothelin, and substance P receptors. Additionally, anesthetics can affect ion channels that are specialized for gating ion movement and generating electrical signals in response to specific chemical neuro­ transmitters, such as acetylcholine (ACh), glutamate, gly­ cine, and gamma-aminobutyric acid (GABA). Initiators of ion channel gating include the nicotinic cholinergic receptor, inhibitory amino acid (GABAA) receptors (which bind benzodiazepines, barbiturates, and ethanol), and excitatory synaptic (N-methyl-d-aspartate or NMDA) recep­ tors (which bind phencyclidine, ketamine, and glycine). Voltage-gated ion channels underlie the physiology of nerve and muscle, among others. Growth factor receptors, transmembrane guanylate cyclase-type receptors, and the nitric oxide system also contribute to the complex molecular pharmacology of receptor channels and signal transduction. The interaction of anesthetics with these systems continues to be elaborated, but, in summary, inhal­ ational anesthetics appear to affect all of these systems to greater or lesser degrees. Even the essential question of where in the body anes­ thetics exert their effects remains uncertain. Although one might presume that the principal site is the brain, evidence suggests that anesthetizing the cerebrum can produce amnesia and unconsciousness, but surgical immobility derives from anesthetic effects on the spinal cord. Anal­ gesia, on the other hand, has been far better eluci­dated. Opioid receptors (principally mu-type) are located in both the brain and in the dorsal horn of the spinal cord. It is likely that G protein-coupled receptors play a role in mediating the stimulation of mu receptors by morphinetype medications, as well as endogenous enkephalins and endorphins. In this fashion, opioids produce analgesia by inhibiting directly the ascending transmission of nociceptive impulses from spinal cord and by activating pain control circuits that descend from the midbrain via the rostral ventromedial medulla to the spinal cord dorsal horns. Local anesthetics, in contrast, exert their effects by diffusing through axonal nerve membranes and interfering with impulse transmission along the nerve. Local anes­ thetics prevent impulse-associated depolarization at the point(s) where they have penetrated the nerve membrane.

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Their likely binding site is the Na+ channel, which is the locus for propagation of the electrochemical stimulus that, in turn, initiates depolarization. The result is a stabilized nerve that is transiently incapable of being stimulated. Sensory, motor, and autonomic effects, depending upon the particular nerve, are thus blunted until the local anes­ thetic molecules sufficiently diffuse away from the nerve.

PRINCIPLES OF ANESTHETIC MANAGEMENT Patients undergoing surgery are subjected by definition to nonphysiological trespass that threatens to destabilize their homeostasis.3 Consequently, the anesthesiologist needs to take an active role in the process from the outset and must work closely with the surgical team in order to bring the patient through the operation without adverse outcome. This coordinated effort involves preopera­ tive patient evaluation, optimization of the patient’s compo­site organ function or dysfunction, provision of an appropriate anesthetic with appropriate physiological monitoring, careful patient positioning, preservation of cardiovascular stability, maintenance of oxygenation and ventilation, and smooth emergence from the anesthetized state to the recovering state.

Anesthetic Agents, Adjuvants, and Drug Interactions There are many pharmacologic agents available in the armamentarium of the anesthesiologist to provide surgical anesthesia to the patient and enable optimal operating conditions. These include the inhaled anesthetics, IV agents that produce a hypnotic and amnestic state, anxio­ lytic medications such as benzodiazepines, opioids, and local anesthetics. There is no single ideal anesthetic drug that accomplishes complete surgical anesthesia. Success­ ful anesthetic management therefore depends on a balanced approach utilizing multiple agents from different drug classes.

Inhaled Anesthetics The inhalational agents most commonly employed in modern anesthetic practice include nitrous oxide and the potent halogenated ethers: isoflurane, sevoflurane, and desflurane. The inhaled agents are utilized in both the induction and maintenance phases of anesthesia. Induction with inhaled agents, termed an inhalational

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induction (as opposed to an IV induction), is a technique used mostly for pediatric and neonatal patients in whom IV access has not been established. Adult patients with a phobia of needles who request an inhalational induction are rare exceptions. Inhalational agents possess the properties of being able to generate an unconscious state in which the patient spontaneously breathes but is insensate and possibly immobile; they also possess mild analgesic properties as well. The pharmacologic principle of minimal alveolar concentration (MAC) is defined as the inhaled concentration of anesthetic at which 50% of subjects do not move in response to a surgical stimulus. Nitrous oxide is a weak inhalational anesthetic and has a MAC of 105%. The potent volatile anesthetics have MAC values of 1.2%, 2%, and 6% for isoflurane, sevoflurane, and desflurane, respectively. Another pharmacologic principle of inhaled anesthetics is the blood/gas solubility or blood/ gas partition coefficient. This property determines the propensity of the gas to dissolve in blood and has important clinical implications for the speed of inhalational anes­ thetic induction and speed of emergence from general anesthesia. Nitrous oxide has the lowest blood/gas parti­ tion coefficient followed by desflurane, sevoflurane, and finally isoflurane. The lower the coefficient, the less the particular agent tends to dissolve in blood and the faster the induction and emergence from anesthesia. Conver­ sely, the higher the blood/gas coefficient, the slower the induction and emergence. Nitrous oxide is a weak inhalational agent and is used most commonly as an adjunct agent to decrease the amount of potent volatile agent needed. It also has a long history of use for sedation in dental anesthesia. Many practitioners choose to utilize nitrous oxide in tonsillectomy and adenoidectomy surgery because it enables the maintenance of general anesthesia while helping to speed emergence at the end of surgery. Nitrous oxide dissolves into air-filled spaces at a rate many times faster than oxygen. Therefore, it may be prudent to avoid nitrous oxide in any clinical scenario where the surgery may create or involve hollow cavities. Classically, bowel surgeries, ophthalmologic surgeries, otologic surgery, and trauma situations (possible pneumothorax) would be examples of surgeries in which avoidance of nitrous oxide may be prudent. Nitrous oxide is emetogenic, and patients administered this agent may develop nausea and vomit­ ing. Prophylactic treatment with 5-HT receptor blockers (e.g. ondansetron) and dexamethasone may prevent this adverse response.

The potent volatile agents such as isoflurane, sevo­ flurane, and desflurane are all structurally related ethers with fluorinated side groups. They possess the properties of being potent with low MAC values and are all cardio­ pulmonary depressants. They are potent vasodilators and cause a decrease in systemic vascular resistance. Isoflurane is the oldest of the three anesthetics, followed by sevoflurane and finally desflurane. Sevoflurane has the property of smelling less pungent (it is described as possessing a sweeter smell) and is the most often used volatile anesthetic agent for inhalational inductions in modern anesthetic practice. Desflurane is the anesthetic agent with the lowest blood/gas partition coefficient and can be used for faster wake-up times.

Intravenous Anesthetics Propofol is a commonly used anesthetic agent for IV sedation and induction of general anesthesia. Its chemical structure consists of a phenol ring with two isopropyl groups (2,6-diisopropylphenol) prepared in an emul­ sion of egg lecithin, soybean oil, and glycerol. When administered, it causes a variably severe burning sensation at the injection site. At low doses, it provides sedation and unconsciousness with spontaneous respiration and, at higher (induction) doses, it causes apnea and hypotension from vasodilation. Ketamine is a phencyclidine derivative that can be administered intravenously or intramuscularly for the purposes of sedation or general anesthesia. It has the properties of being a sympathomimetic, i.e. it poten­ tiates the sympathetic nervous system and produces tachycardia and hypertension. It is less of a respiratory depressant and has the added benefit of being a potent bronchodilator, which is useful in patients with reactive airway disease. Ketamine can cause excessive salivation as well as hallucinations and other psychological side effects such as dysphoria when not coadministered with a benzodiazepine. Patients administered ketamine by itself develop a dissociated, catatonic state of being. Because it is not as potent of a cardiopulmonary depressant, ketamine is unique in its use for the care of unstable patients in shock or cardiac tamponade. In uncooperative patients unable to receive either an IV or mask induction, ketamine can be delivered intramuscularly to induce a sedated and anesthetized state. Etomidate is a carboxylated imidazole dissolved in propylene glycol. It is used primarily to induce general anesthesia in patients who are hemodynamically unstable

Chapter 40: Anesthesiology because it holds the distinction of being the least cardio­ vascularly depressing of the IV anesthetics. However, it can produce masseter muscle spasticity and also causes adrenocortical suppression in a transient, dose-dependent manner.

Opioids Opioids bind to receptors located throughout the central nervous system and are potent analgesics as well as possessing a mild-to-moderate sedating effect. Endor­ phins, enkephalins, and dynorphins are examples of endogenous peptides that produce a similar effect by binding to the same receptors. By blocking nociceptive neuronal transmission, the opioids attenuate the pain res­ ponse to surgical stimulus. In anesthetic doses, all opioids depress ventilation and raise the apneic threshold, i.e. the highest PaCO2 at which a patient remains apneic. They also all slow gastric motility and prolong gastric emptying time. Fentanyl is highly lipid soluble and can be administered intravenously, transmucosally, as well as transdermally. It has a rapid onset of action and a short duration of action because it is quickly redistributed to other tissue compartments. Morphine is poorly lipid soluble and therefore slow to cross the blood–brain barrier. This explains morphine’s slower onset of action and prolonged duration of action. It is biotransformed in the liver to form morphine 3-glucuronide and morphine 6-glucuronide that are renally cleared. These metabolites may cause prolonged sedation and increased respiratory depression in the setting of end-stage renal disease. Remifentanil is unique by virtue of its metabolism by nonspecific esterases in blood. The effective half-life is approximately 5–10 minutes. Therefore, remifentanil is extremely useful in producing a deep analgesic state, but its effects cease soon after discontinuation of drug adminis­ tration. This distinction makes remifentanil a superior drug for use in cases in which a deep analgesic state is required with rapid awakening and return of spontaneous ventilation [i.e. direct laryngoscopy and endoscopic sinus surgery (ESS)].

Neuromuscular Blocking Agents Neuromuscular blocking agents bind to the nicotinic ACh receptor at the neuromuscular junction and produce a state of muscle relaxation. Two mechanistically distinct groups of neuromuscular blocking agents exist: the depolariz­ ing relaxants (succinylcholine) and the nondepolarizing relaxants.

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As the name implies, the depolarizing relaxants induce a strong depolarization and lead to the deactivated state of the ACh receptor, termed phase I blockade. The onset of neuromuscular blockade is rapid (30–60 seconds) and duration of action is short (less than 10 minutes after a 1 mg/kg dose). Succinylcholine is the only depolarizing agent used in clinical practice. Clinically, succinylcholine is used in settings where rapid muscle relaxation and intubation are required in patients at high risk of aspira­ tion of gastric contents. The nondepolarizing neuromuscular relaxants pro­ duce competitive antagonism at the ACh receptor and prevent normal muscle contraction. There are a variety of nondepolarizers and they are grouped into two struc­ turally distinct groups: the benzylisoquinolines and the steroidal compounds. Steroidal compounds tend not to affect heart rate, while the benzylisoquinolines tend to release histamine. Examples of steroidal muscle relaxants include pancuronium, vecuronium, and rocuronium. Vecuronium and rocuronium are the two most commonly used nondepolarizing neuromuscular blocking drugs in modern anesthetic practice. Benzylisoquinoline relaxants include atracurium and cisatracurium.

Local Anesthetics Local anesthetics are of particular interest to the oto­ rhinolaryngologist because of the drugs’ myriad uses in ambulatory and inpatient surgery. Mechanistically, the local anesthetics work by blocking voltage-gated sodium channels and nociceptive neuronal transmission. Sensitivity to nerve blockade is inversely related to axonal diameter and degree of myelination. The potency of a local anesthetic correlates with lipid solubility where the more lipid soluble an agent is, the greater the degree of penetration through the lipid nerve membrane. Local anesthetics are all weak bases. The pKa is a biochemical property of a drug that determines the relative con­ centration of the nonionized lipid-soluble form of the anesthetic to the ionized water-soluble form in tissues. The closer the pKa of an agent is to physiologic pH, the higher the concentration in tissue of the nonionized base and the greater the ability of the drug to diffuse through the lipid neuronal membrane, hence the faster the onset of action. Duration of action of an agent is also correlated with lipid solubility, where the higher the lipid solubility, the longer the duration of action. Toxicity of local anesthetics relates to systemic absorption and action at undesired endorgans, most notably the brain and the heart. The rate

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Table 40.1: ASA physical status classification

I

A normal healthy patient

II

A patient with mild systemic disease

III

A patient with severe systemic disease

IV

A patient with severe systemic disease that is a constant threat to life

V

A moribund patient who is not expected to survive without the operation

VI

A declared brain-dead patient whose organs are being removed for donor purposes

E

Emergency operation (appended to the foregoing, e.g. III E)

of systemic absorption is proportional to the vascularity of the injection site with an IV site obviously having the highest rate of absorption. This is followed by tracheal, intercostals, caudal, paracervical, epidural, brachial ple­ xus, and subcutaneous sites. Local anesthetics can be classified structurally into the amino-esters and the amino-amides. Ester local anes­ thetics are the older of the two classes with cocaine being a classic example as well as chloroprocaine, pro­caine, and tetracaine. Ester local anesthetics are metabolized predominantly by pseudocholinesterase and undergo ester hydrolysis. Amide local anesthetics include lidocaine, bupivacaine, mepivacaine, and ropivacaine. They undergo hep­ atic metabolism by microsomal P-450 enzymes. Conditions of hepatic dysfunction or failure will reduce the metabolism of these drugs and place the patient at risk of toxicity. Lidocaine and bupivacaine (Marcaine) are the two most commonly used local anesthetics in clinical practice. Lidocaine is a medium-potency local anesthetic with fast onset and a moderate duration of action. Bupivacaine has a slow onset of action and a long duration of action. Bupivacaine possesses the undesirable distinction of being the most cardiotoxic local anesthetic and may cause lifethreatening arrhythmias such as ventricular tachycardia and ventricular fibrillation when toxic limits are reached. It is therefore always important to exercise good technique when injecting bupivacaine (and all local anesthetics in general) by first aspirating back on the syringe and ruling out blood return. Signs and symptoms of local anesthetic toxicity include circumoral numbness, a metallic taste, and dizziness; tinnitus and blurred vision may also occur. Awake patients may describe restlessness, paranoia, agitation, and a sense of unwellness. Severe CNS toxicity may lead to generalized tonic-clonic seizures.

DRUG INTERACTIONS Anesthetic agents tend to be synergistic in terms of their effects; i.e. the use of any one agent will decrease the dose needed of another anesthetic agent. Intravenously administered local anesthetics decrease the MAC require­ ments of volatile anesthetics by up to 40%. Similarly, opioids also decrease MAC requirements. Neuromuscular agents, while not strictly speaking a type of anesthetic, decrease the requirement for anesthetic agents in order to provide good operating conditions.4

PREOPERATIVE EVALUATION AND PREPARATION The most basic stratification of preoperative patient health is the American Society of Anesthesiologists’ (ASA) physical status classification system5 that dates back to 1941. Although relatively uncomplicated, it offers a timehonored method of categorizing the level of concern that an anesthesiologist should apply in considering a given patient’s anesthetic (Table 40.1). Although anesthesio­ logists have debated for decades precisely which patients fall into which categories, the ASA has declared that “there is no additional information that will help you further define these categories.” Just the same, the Cleveland Clinic has publicized on its web site the following examples6 listed in Table 40.2. This system was not conceived as a means of stratify­ ing risk, but rather a means of getting anesthesiologists to think about their patients’ preoperative condition with an eye toward modifying the anesthetic that they would be administering. Just the same, the ASA physical status classification appears to be as good a prognosticator of postoperative complications as more recent and complex methodologies such as the well-known Cardiac Risk Index published by Goldman et al. in 1977.7 In order to classify a patient’s preoperative physical state, it is necessary to obtain a detailed history, perform a physical examination, and consider relevant laboratory test results. As Roizen describes8 for tests reported over a continuous range of results, the distribution in a popu­ lation is Gaussian, i.e. a normal distribution. Arbitrarily, 2.5% of lab test results for healthy patients will fall above the “normal” range and another 2.5% of the same test results for healthy patients will fall below the “normal” range. Furthermore, ordering multiple tests increases the probability of an “abnormal” finding in a healthy patient.

Chapter 40: Anesthesiology Table 40.2: Illustrations of ASA physical status categories

I

No organic, physiologic, or psychiatric disturbance; excludes the very young ( 70 years); healthy with good exercise tolerance

II

No functional limitations; has a well-controlled disease of one body system; controlled hypertension or diabetes without systemic effects, cigarette smoking without chronic obstructive pulmonary disease (COPD); mild obesity, pregnancy

III

Some functional limitation; has a controlled disease of more than one body system or one major system; no immediate danger of death; controlled congestive heart failure (CHF), stable angina, old heart attack, poorly controlled hypertension, morbid obesity, chronic renal failure; bronchospastic disease with intermittent symptoms

IV

Has at least one severe disease that is poorly controlled or at end stage; possible risk of death; unstable angina, symptomatic COPD, symptomatic CHF, hepatorenal failure

V

Not expected to survive > 24 hours without surgery; imminent risk of death; multiorgan failure, sepsis syndrome with hemodynamic instability, hypothermia, poorly controlled coagulopathy

From The Cleveland Clinic Foundation.6

There is no established standard among anesthesio­ logists as to what testing needs to be done preoperatively. Rather, it is more logical to obtain laboratory information on the basis of the patient’s underlying conditions and medications. While healthy patients undergoing minor, noninvasive procedures need not have any laboratory testing whatsoever, a patient with multisystem disease undergoing major surgery needs extensive evaluation. Even so, many surgeons have had the unfortunate experience of having evaluated (or having had evaluated for them by an internist or an anesthesiologist) a patient some days prior to surgery, only to have a different anes­ thesiologist on the day of surgery hold up the surgery by requiring additional testing. It goes without saying that it is insufficient simply to have had an internist “clear” the patient without understanding the implications of that patient’s medical condition on the conduct of the anesthetic and surgery. In effect, only the anesthesiologist on the day of surgery can “clear” the patient. Good anes­ thesiologists, however, do look to a good internist’s or a colleague’s evaluation of a patient’s physical status, particularly from the beneficial viewpoint of a relevant longitudinal history, as an important means of assessing that patient’s optimization for surgery.

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The best way to avoid having a patient’s surgery delayed (or worse, having the patient unsafely undergo the procedure) is to apply consistently an appreciation of the interactions of a patient’s medical condition with anesthesia and surgery. A group of anesthesiologists should ideally gravitate to a consistent approach over time, particularly with regard to required laboratory test­ ing. Having already stated that there is no standard among anesthesiologists in this regard, we might suggest the following schema (modified from Roizen8) for adult patients undergoing rhinological surgery under general anesthesia: • CBC, including platelet count • Electrolytes (Na+, Cl–, K+, HCO3–), BUN, creatinine, glucose • INR, PTT • Liver function tests • ECG for age more than 50 or symptomatic • Chest X-ray only for patients with worsening pul­ monary symptoms. This list is not exhaustive nor does it preclude other testing as indicated by the patient’s history or physical examination. Likewise, it includes testing where the yield is likely to be low. Its purported value is its sharing a common ground for most anesthesiologists in order to minimize delays or cancellations on the day of surgery. This discussion may be moot if hospital policies have been elaborated that dictate the extent and timing of the preoperative evaluation and laboratory testing. To that last point, there is no standard among anes­ thesiologists regarding how recently the history, physical examination, and laboratory testing need to have been done in order to be considered useful. In the absence of new symptoms and to the degree that a given patient is known to have been stable in terms of medical conditions and medications, repeated testing becomes less important. Conversely, new or interval change in symptoms, medical instability, and/or changed medication regimens all heighten the need for testing close to the day of surgery. The preceding general discussion of preoperative evaluation and preparation can be more definitively refi­ ned for adult patients with cardiac disease undergoing noncardiac surgery. The American College of Cardiology (ACC) and the American Heart Association (AHA) jointly published9 their most recently revised set of practice guidelines for this subgroup of patients in 2007. This algorithm, based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients

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50 years of age or greater, provides a stepwise description of the types of further cardiac investigation that are recommended for patients with cardiac disease relative to the type of surgery planned. A summary of the algorithm follows: • Emergency noncardiac surgery requires no further workup. The procedure needs to be performed, so perioperative surveillance and treatment are imple­ mented both in the operating room and during recovery. • Nonemergency surgery allows greater discretion on the parts of the caregivers to assess the patient’s cardiac status and, if needed, define the extent of disease and treat it accordingly. • Active cardiac disease encompasses unstable or severe angina, recent myocardial infarction, decompensated heart failure (i.e. New York Heart Association Class IV patients who should be at complete rest, confined to bed or chair; any physical activity brings on discomfort and symptoms occur at rest), significant arrhythmias, and severe valvular disease. • Low-risk surgery (risk of cardiac death and nonfatal myocardial infarction  5%) relates to vascular surgery. • A person with an exercise tolerance of four metabolic equivalents (METs) can climb a flight of stairs or walk up a hill, walk on level ground at 4 mph (6.4 km per hour), run a short distance, do heavy work around the house like scrubbing floors or lifting or moving heavy furniture, participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football. • A patient without active cardiac disease having low-risk surgery or exhibiting functional capacity equivalent of greater than or equal to four METs without symptoms can proceed to surgery without further workup. • A patient with active cardiac disease undergoing lowrisk surgery can proceed directly to surgery. • A patient with active cardiac disease with a functional capacity equal to or greater than four METs without symptoms undergoing intermediate- or high-risk sur­ gery can proceed to surgery if noninvasive testing will not alter treatment. • A patient with active cardiac disease undergoing intermediate- or high-risk surgery with less than four

METs exercise tolerance needs an evaluation of his/ her clinical risk factors. These include ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease. • If the person does not have any of these clinical risk factors, the planned surgery should proceed. Other­ wise, it is recommended to proceed with surgery in patients with one to three clinical risk factors unless noninvasive testing will change management. • Patients with three or more clinical risk factors requi­ ring vascular surgery need further testing if it will change anesthetic management. • Assessment for coronary artery disease risk and functional capacity includes a 12-lead electrocardio­ gram, exercise stress testing, and pharmacological stress testing. • Supplemental preoperative cardiac evaluation consists of left ventricular function by radionuclide angio­graphy, echocardiography, and contrast ventri­culography. While the foregoing algorithm is complicated, its application, in brief, is that patients undergoing inter­ mediate-risk surgery who do not have functional capacity greater than four METs or who do have cardiac symptoms need to be evaluated by a cardiologist or internist. If that patient is appraised as having no clinical risk factors (listed above), one may proceed with the planned surgery. Patients with 1, 2, or 3 clinical risk factors may proceed to surgery, particularly with heart rate control, if management will not likely be affected. Alternatively, these patients should undergo noninvasive testing if it will likely change the patient’s perioperative management. The nebulous nature of these last two statements suggests that the surgeon, anesthesiologist, and cardiologist or internist confer prior to the day of surgery in order to arrive at common ground. A patient’s integrated cardiopulmonary performance can be limited by lung disease in the absence of heart problems. Auscultation of the lungs with a stethoscope can quickly determine the presence or absence of rhonchi, wheezes, or rales. A chest X-ray in the absence of history or physical examination findings suggestive of cardiopulmonary disease is unlikely to add any useful information and is an unnecessary screening test. In the presence of positive historical or physical evidence, how­ever, a chest X-ray can serve as a valuable basis for postoperative comparison. Pulmonary function testing (PFT) is an objective means by which to quantify a patient’s respiratory dysfunction

Chapter 40: Anesthesiology beyond that achieved after obtaining a medical history and performing a physical examination. PFTs are done to predict how well a patient with lung disease will deal with the stressors of surgery and anesthesia so as to avoid perioperative pulmonary complications (PPCs), such as atelectasis, pneumonia, respiratory failure, and exacerbation of long-standing lung disease. Useful PFTs include arterial blood gas measurement and spirometry. The latter includes forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), the FEV1/FVC ratio, peak flow, and forced expi­ ratory flow between 25% and 75% of lung volume (FEF 25–75%)—before and after bronchodilator treatment. Examination of the flow-volume loop configuration, in addition to providing the aforementioned data, can be informative about the location of fixed or variable airway obstruction. Essentially, PFTs, including arterial blood gas analysis, offer information about whether a patient’s pulmonary disease is obstructive versus restrictive, whe­ther the patient has a propensity to retain carbon dio­xide, and whether the patient’s pulmonary disease has a reversible component. Asthmatic patients will tell you specifically what makes them better and what makes them worse. Continuing their established treatment or prevention regimen through the day of surgery and prophylactically by administering an inhalable bronchodilator before induction of anesthesia will, along with a smoothly conducted anesthetic, serve to minimize perioperative bronchospasm. In 2006, the American College of Physicians10 elaborated a set of guidelines for risk assessment and reduction of PPCs. They stated that significant preoperative risk fac­ tors for PPCs are chronic obstructive pulmonary disease, age more than 60 years, ASA physical status class II or higher, serum albumin levels less than  3.5 g/dL, functional depen­ dence, and recumbent congestive heart failure. They also determined that surgery more than  3 hours duration, abdominal surgery, and general anesthesia were signi­ ficant risk factors for PPCs in these patient populations. The guidelines concluded that these patients at risk should receive preoperative PFTs and postoperative incen­ tive spirometry. Preoperative measures to improve lung function include smoking cessation, mobilization of secretions, bron­ chodilator treatment, and improved stamina. Although smoking-induced destruction of lung architecture cannot be reversed, smoking cessation results in decreased airway secretions, decreased airway reactivity, and improved mucociliary transport. Just the same, these benefits may not be realized for 2–4 weeks. Smoking cessation on the day

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prior to surgery will only improve the picture by decreasing the carbon monoxide carried by blood. Reducing the percentage of circulating carboxyhemoglobin will, how­ ever, improve the amount of oxygen carriage by the blood. A related and, given the current obesity epidemic, an increasingly important issue is that of obstructive sleep apnea (OSA).11 The reason why OSA has interested anesthesiologists and for which the ASA has issued a set of guidelines is that OSA patients risk airway obstruction during induction of anesthesia and upon emergence from anesthesia. Coupled with their increased sensitivity to anesthetics, manifested as respiratory depression, OSA patients in the supine position tend more than other patients to have their tongue, tonsils, and soft palate come to rest against their hypopharynx, thus obstructing airflow above the level of the larynx. The insertion of an endotracheal tube effectively stents the upper airway, allowing free passage of air or anesthetic gases to the lungs. Even if tracheal intubation has been performed successfully (though not necessarily easily), removal of the endotracheal tube at the end of surgery can result in life-threatening airway obstruction. Consequently, the ASA guideline urges that extubation be performed in the semi-upright, upright, or nonsupine position after full neuromuscular recovery has been verified and the patient has fully awakened. Problems arise in these patients when the patient struggles against the presence of the endotracheal tube but has not sufficiently regained consciousness so as to maintain airway patency. Deep extubation is clearly contraindicated. The principle of avoiding extubation while the patient is excitedly emerging from anesthesia but has not yet achieved suf­ ficient recovery so as to protect the airway needs to be followed in these patients scrupulously. In performing a preoperative evaluation, the anes­ thesiologist should always examine the patient’s airway anatomy to determine whether ventilation of the patient’s lungs by anesthesia facemask or direct laryngoscopy and intubation of the patient’s trachea might prove to be difficult.12 The airway examination consists of assessing the patient’s cervical range of motion (particularly active neck extension), maxillary–mandibular alignment (otherwise referred to as the thyromental distance), mouth opening, state of dentition, and the patient’s Mallampati Airway Classification.11 Although the Mallampati Airway Classification does not by itself provide an infallible correlation between class

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score and ease of laryngoscopy, its simplicity has earned it widespread application. The examiner directs the patient to sit up straight, open the mouth, stick out the tongue, but not phonate. The classification is as follows: Class 1: visualization of soft palate, fauces, uvular, and tonsillar pillars; Class 2: visualization of soft palate, fauces, and uvula; Class 3: visualization of soft palate and uvular base; Class 4: visualization of the hard palate only. The guiding principle holds that alignment of the oral, pharyngeal, and laryngeal axes for direct visualization of the larynx is most easily accomplished in patients with full neck extension at the atlanto-occipital joint, matched maxillary–mandibular alignment, BMI less than  25 kg/m2, neck circumference less than  40 cm, normal mouth opening, and Mallampati 1 classification, aided by the absence of maxillary dentition. Conversely, limited neck extension, retrognathia, BMI more than  30 kg/m2, neck circumference more than  40 cm, limited mouth opening, and Mallampati 4 classification, made more difficult by full maxillary dentition, separately, or in combination, can lead to poor alignment of the oral, pharyngeal, and laryngeal axes and an inability to visualize the larynx directly. Other airway features such as a large or immobile tongue, radiation fibrosis of airway structures, or tumors of the head and neck can likewise complicate the ease of lung ventilation by anesthesia facemask and/or tracheal intubation. The anesthesiologist, in planning for a general endo­ tracheal anesthetic, must decide whether, given the cons­ tellation of physical findings, he or she believes that ventilation of the patient’s lungs by anesthesia facemask and direct laryngoscopic visualization of the patient’s larynx can be accomplished without inordinate difficulty, once anesthesia induction has commenced. When dif­ ficult ventilation and/or difficult tracheal intubation are contemplated, the anesthesiologist must make provision for these potential difficulties by arranging for the avail­ ability and usability of auxiliary airway management devices and, if possible, the assistance of a second anes­ thesiologist. The anesthesiologist, furthermore, has to decide whether these auxiliary devices can be safely employed after the patient has been anesthetized or, if not, whether the airway needs to be secured prior to the patient’s having received an anesthetic. The commonest approach in such patients is awake/sedated fiberoptic laryngoscopy and tracheal intubation. Even so, despite careful evaluation and sound clinical judgment, the anes­ thesiologist will occasionally encounter a patient whom he or she believed to be safely intubatable but whose larynx eludes visualization and whose trachea eludes intubation.

In such situations, the anesthesiologist should apply the principles of the ASA Difficult Airway Algorithm,13 a stepwise sequence of branched decision making, the goal of which is an unharmed patient. If, for example, initial intubation attempts have proved unsuc­ cessful, the anesthesiologist must ventilate the patient’s lungs by anesthesia facemask. If ventilation is adequate, a nonemergency pathway can be followed where alternative approaches to intubation can be tried, includ­ ing allowing the patient to awaken. If, however, facemask ventilation is not adequate, a laryngeal mask airway (LMA) should be inserted, if feasible. If LMA ventilation proves adequate, the anesthesiologist can return to the nonemergency pathway. If LMA ventilation is not adequate, the anesthesiologist must follow the emergency pathway that leads either to the patient’s awakening or to the insertion of an emergency invasive airway access device, i.e. a tracheostomy or a cricothyroidotomy. Another issue that unites (but sometimes divides) surgeon and anesthesiologist is NPO (Latin: nil per os = nothing by mouth) status. The consequence of aspiration of solids or liquids into the trachea can range from obstruc­ tion of the airway to soilage of the pulmonary parenchyma and, potentially, pneumonitis and even death. Pulmo­ nary aspiration of acidic gastric contents is particularly problematic: pulmonary morbidity from aspiration is proportional to the volume of aspirate and inversely pro­ portional to the pH of the aspirated material. Risk fac­ tors for pulmonary aspiration include a “full stomach”, pregnancy, obesity, gastroesophageal dysfunction (includ­ ing prior esophageal surgery, symptomatic hiatal hernia, and dysphagia), functional or mechanical obstruction to digestion, and vocal cord malfunction. Gastroparesis, idiopathic or associated with diabetes mellitus, com­ pounds the problem. Alkalinizing the gastric contents with proton pump inhibitors, histamine-2 antagonists, and/or a nonparticulate antacid like sodium citrate by mouth can ameliorate the potential injury to the lungs by eliminating the acid component of the aspirate. In these situations, the anesthesiologist modifies rou­ tine practice by performing a rapid sequence induction, doing an awake fiberoptic intubation, or entirely avoiding general anesthesia, where possible. A rapid sequence induction involves preoxygenation, the administration of a rapidly acting induction drug and the near-simultaneous administration of a rapidly acting muscle relaxant, usually while an assistant applies cricoid pressure to compress the esophagus between the cricoid cartilage and the vertebral column. Although the utility of cricoid pressure has lately

Chapter 40: Anesthesiology been criticized as ineffectual and, what’s worse, distort­ ing to the intubator’s laryngoscopic view, the cardinal principle is that the trachea be protected by a cuffed endotracheal tube in as short a time period as possible after loss of consciousness (with the attendant loss of protective airway reflexes). The best way to avoid such risks is to keep the patient’s stomach empty. Hence, the traditional NPO dictum that elective patients have nothing to eat or drink after mid­ night. The ASA, having examined the literature on this subject, helpfully offers some guidelines to consider in making go/no-go decisions.14 In summary, a patient may consume clear liquids (liquids through which one can see, e.g. water, nonpulp fruit juice, carbonated beverages, clear tea, black coffee) up to 2 hours prior to anesthetic induction. There is some evidence that ingestion of clear liquids actually aids gastric emptying. The guidelines state that breast milk requires 4 hours for gastric emptying. More directly applicable to adults, the guidelines suggest 6 hours for a modest amount of nonhuman milk, infant formula or a light meal, such as toast and clear liquids. The guidelines get less prescriptive after that: “Meals that include fried or fatty foods or meat may prolong gastric emptying time. Both the amount and type of foods ingested must be considered when determining an appropriate fasting period.” Our version of today’s best practice requires patients to be NPO after midnight, discouraged from having pizza and beer at 11:59, allowed—even encouraged—to have clear liquids up to 2 hours preoperatively, and considered to have a “full stomach” the entire calendar day after ingesting a full meal. Establishing an agreement on principles among a hospital’s surgeons and anesthesiologists can prevent confusion and conflict when patients fail to do what they are asked to do.

ANESTHETIC MANAGEMENT FOR RHINOLOGICAL SURGERY Standard Monitoring Techniques Upon completion of the preoperative assessment and when the patient is deemed a suitable candidate for gene­ ral anesthesia, the patient is brought into the operating room and placed on the OR table, at which point standard monitoring is placed on the patient in order to enable continuous observation of vital signs during surgery. These monitors include 5-lead electrocardiography, pulse oximetry, and blood pressure. Additional monitors are

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capnography (tidal CO2) and temperature. Once these continuous monitors are applied to the patient, IV access is achieved. Administration of 100% oxygen to the patient by facemask is begun with the goal of preoxy­ genating or denitrogenating the patient; i.e. the functional residual capacity of the patient is filled with 100% oxygen instead of the 21% FiO2 of room air. During this time, the anesthesiologist may choose to administer an IV benzo­ diazepine or opioid with the goal of alleviating anxiety and beginning to sedate the patient. A good seal of the facemask enables determination of the gases that the patient is inhaling and exhaling, including oxygen, carbon dioxide, and any inhalational anesthetics chosen by the anesthesiologist to administer to the patient. Once the end-tidal oxygen approaches 100%, the anesthesiologist administers IV induction agents to achieve a state of general anesthesia.

Airway Management Proper airway management begins in the preoperative assessment as detailed above with the determination of the relative difficulty or ease of delivering positive-pressure ventilation to the patient’s lungs and potential endo­ tracheal intubation. Prior to inducing general anesthesia, the otolaryngologist and anesthesiologist should decide what type of airway is most appropriate for the case. Is an LMA acceptable or an endotracheal tube preferred? A standard endotracheal tube may be sufficient but the otolaryngologist may prefer to have an oral or nasal rightangle endotracheal tube, reinforced tube, or armored tube. Upon achieving an apneic state after induction, the anesthesiologist will attempt to deliver a positive pressure breath and determine the adequacy of ventilation and oxygenation. Clinical signs of successful ventilation include chest rise, fogging in the mask and transparent anesthesia right-angle elbow piece, the tactile feel of lung compliance in the manual ventilation bag, as well as the appearance of tidal CO2 on the anesthesia machine monitor. Ventilation is the single most important clinical maneuver to achieve and verify after induction of general anesthesia, and it is a synthesis of different clinical data. If the anesthesiologist is unable to adequately mask ventilate the patient, a quick escalation of care must occur in order to ensure that the patient’s airway be secured, or hypoxia and the sequelae of hypoxia may ensue, ultimately lead­ ing to ischemic injury of vital organs. Typical maneuvers include increasing the positive pressure administered by dialing up the adjustable pressure limiting valve of the

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anesthesia machine. Simultaneous maneuvers to alleviate and overcome upper airway obstruction can be carried out including a chin lift, jaw thrust (one-handed or twohanded), and oropharyngeal and/or nasopharyngeal airway placement. If the patient has not already been optimally positioned in the “sniffing position,” this can be carried out by placing a roll under the shoulders and by elevating and extending the head. If these maneuvers continue to be unsuccessful, the anesthesiologist should activate the ASA difficult airway algorithm by calling for help and either attempting direct laryngoscopy or plac­ ing a LMA. A variety of advanced airway equipment can be used to help achieve endotracheal intubation including video laryngoscopes, intubating LMAs, flexible fiberoptic bronchoscopes, and a Combitube. If all efforts to non­ invasively secure the airway fail, a surgical airway may need to be achieved via cricothyroidotomy or tracheostomy.

INDUCTION AND MAINTENANCE OF ANESTHESIA Unless there is an underlying airway or cardiopulmonary issue, induction of anesthesia for rhinological surgery often commences with an IV dose of midazolam for anxiolysis, followed, after oxygenation/denitrogenation of the lungs, by IV propofol in a dose sufficient to produce unconsciousness and apnea. After assuring the ability to ventilate the patient’s lungs by mask, the anesthesiologist will usually administer a neuromuscular blocking drug intravenously in order to provide ideal conditions for tracheal intubation. As described above, succinylcho­line is used for a rapid sequence induction, when the procedure is too short to accommodate a longer-acting relaxant, or when the surgeon intends to use a nerve stimulator. In other situations, the anesthesiologist may give a nondepo­ larizing relaxant, which has fewer side effects than succinylcholine but whose muscle weakness will need to be antagonized by an anticholinesterase coupled with an anticholinergic at the conclusion of sur­gery. Because of succinylcholine’s tendency to produce bradycardia in children and because succinylcholine may trigger malig­ nant hyperthermia, anesthesiologists tend to avoid this drug in children and will often intubate a child’s trachea under deep anesthesia without benefit of any relaxant. The decision to use an LMA for airway management instead of an endotracheal tube for rhinological proce­ dures is controversial. On the one hand, LMA insertion

is generally easier than an endotracheal tube, does not require muscle relaxant use, and avoids potential trauma to the larynx. On the other hand, because of its superglottic position, an LMA is not protective against laryngospasm and its consequences or against pulmonary aspiration of gastric contents. In the specific situation of rhinological surgery, blood trickling from the nose into the hypopharynx may escape suctioning above the LMA, stimulate the vocal cords and induce laryngospasm, and/ or be aspirated causing hypoxemia. Surgical preparation of the nose for surgery by injec­ tion of local anesthetic with epinephrine, as well as by the topical application of vasoconstrictor-soaked pled­ gets, frequently leads to a transient tachycardia from absorbed catecholamine. The combination of epinephrine and cocaine, when used as a nasal vasoconstrictor, is particularly worrisome. Injection and absorption of a suf­ ficient quantity of both together can result in malignant hypertension, severe tachycardia, multifocal PVCs, ventri­ cular tachycardia, and even ventricular fibrillation. Cocaine, by preventing the reuptake of norepinephrine at nerve endings, enhances the cardiovascular sequelae of the injected epinephrine. Oxymetazoline, for example, does not share cocaine’s systemic pharmaco­logical effects and is safer. Once the procedure is under way, the anesthesiolo­ gist can contribute to the surgeon’s ease and efficiency by keeping the blood pressure low in order to limit nasal bleeding. The readily available strategy of employing higher than usual concentrations of the inhaled anesthetic is often sufficient to maintain the patient’s systolic pressure below 100 mm Hg. Alternative or adjunctive measures to reduce vascularity include the use of a 15° head-up position to decrease venous pressure, IV beta blockers like labetalol or metoprolol, and direct vasodilators like IV hydralazine. The anesthesiologist has to balance the advantage to the surgeon of producing deliberate or intentional hypotension with the patient’s need for adequate organ perfusion. Inhaled anesthetics interfere with autoregu­ lation—the maintenance of blood flow over a wide range of systemic blood pressures—with the consequence that a lower blood pressure may put organs like heart, brain, and kidney at risk. Maintaining adequate hydration can minimize the reduction in blood flow to these organs, but there is no question that their blood flow is decreased under these circumstances.

Chapter 40: Anesthesiology

STRATEGIES FOR EMERGENCE FROM ANESTHESIA In considering emergence from anesthesia, the anesthetics used for maintenance, their dosing intervals, and their functional half-lives must be reckoned, as these are crucial for the discontinuation of effect in preparation for wake-up. Neuromuscular blockade, if employed, must be reversed, and maintenance anesthetics must be discontinued. As the patient is waking up, the anesthesiologist may decide if he wishes to perform a deep or an awake extubation. An awake extubation is the most common strategy and, as its name implies, involves removal of the airway device when the patient is fully awake and has regained full airway reflexes. In a deep extubation, the anesthesiologist is making a judgment that the patient, despite still being deeply anesthetized, will be able to oxygenate and ventilate (exhale CO2) without an endotracheal tube or LMA, and that the risk/benefit analysis justifies his/her action. Benefits of a deep extubation include possible avoidance of bucking and straining on the airway and prevention of a Valsalva-type reaction in which intracranial, intra­ thoracic, and airway pressures become elevated, thereby jeopardizing underlying coagulated tissues and suture lines. Once a deep extubation has been performed, the patient should be monitored closely for maintenance of adequate ventilation and oxygenation either in the OR or, when the anesthesiologist deems it safe to transport the patient, in the PACU. During transport and in the PACU, the patient should continue to be monitored closely with­ out being disturbed until recovery of consciousness. Contraindications to a deep extubation may include difficult airway management (i.e. ventilation, intubation), rapid sequence indication, OSA syndrome, obesity, as well as blood emanating from the nose into the oropharynx. Since deep extubation is problematic in many rhino­ logical procedures, anesthesiologists have devised diverse strategies for maintaining a suitable anesthetic depth while surgery is proceeding yet achieving a smooth but prompt recovery from anesthesia once surgery has ended. These strategies include the use of droperidol (along with an opioid) to create in the patient a partial neuroleptic state, i.e. a level of consciousness where the patient is aware of his/her environment but lacks the affective or emotional component of the usual wakeful state. Droperidol is a butyrophenone, similar to phenothiazines, that is also antiemetic, slightly vasodilatory, and sedative. Its use has been limited by an FDA “black box warning” that

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alerts practitioners to droperidol’s tendency to prolong patients’ electrocardiographic QT interval. The warning limits the drug’s use to 2.5 mg IV in patients without preexisting QT prolongation unless special precautions are taken. Patients given higher doses and/or having preexisting QT prolongation stand at higher-than-normal risk of developing torsades de pointes, a form of ventricular fibrillation. Alternatively, a dexmedetomidine (Precedex) infusion can be used to bridge the gap between surgical anesthesia and wakefulness. Dexmedetomidine is an alpha2 agonist that is sedating while preserving spontaneous ventilation. Every drug has its side effects, and this drug can produce treatment-refractory hypotension, as well as bradycardia and even hypertension, particularly if given as a bolus. Infusions given without a loading dose are better tolerated.

POST-ANESTHESIA RECOVERY Goals during post-anesthesia recovery include monitoring for adequate ventilation and oxygenation, stable vital signs, pain control, and careful observation for the appearance of any surgical complications. Patients who have undergone rhinological procedures under general anesthesia have usually also received intranasal local anesthetic injections (with epinephrine) and/or instillation of vasoconstrictors (including cocaine). The residual local anesthetic effects reduce the postoperative requirement for IV or PO anal­ gesics. Nausea and vomiting are, however, enhanced by the swallowing of nasopharyngeal blood and subsequent gastric irritation. Typical antiemetics for rhinological sur­ gery include ondansetron, dexamethasone, and droperi­ dol, though there are many alternatives. Individual anes­ thesiologists and ORL surgeons may use their personal preference, though the use of some antiemetic regimen is recommended. The combination of several antiemetics that function at different sites at the chemoreceptor trigger zone in the medulla is more effective in preventing or mitigating postoperative nausea and vomiting than any single drug used alone.

REGIONAL ANESTHESIA FOR RHINOLOGICAL SURGERY Regional nerve blockade in the head and face can be a useful adjunct in providing both intraoperative anesthesia and postoperative pain control. Nerve blockade entails drug injection (usually local anesthetic) into the extra­ neural or paraneural spaces, providing complete

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anes­thesia in the region supplied by that nerve distal to the site of injection.15,16 Specific nerve blocks are described in detail in other chapters of this book.

Patient Positioning and Related Injuries The most common position for patients undergoing rhino­ logical surgery is supine or supine-back elevated. Regard­ less of position, an immobile, insensate patient who stays in the same position for hours on end may experience pressure injury to subcutaneous tissue and skin. Patients in the supine position are at particular risk for ulnar nerve compression and neuropathy, pressure injury to the dependent parts of the head (occiput), feet (heels), and back. Ulnar nerve compression and neuropathy can be avoided by carefully supinating the hands and by padding the ulnar groove. The patient’s face is also at risk for injury during rhinological surgery from pressure or puncture by misdirected instruments.

Monitored Anesthesia Care Monitored anesthesia care refers to a plane of sedation less than that provided by general anesthesia. The patient is allowed to breathe spontaneously and is provided sup­ plemental oxygen via nasal cannulae. Monitored anes­ thesia care can quickly escalate to levels approaching general anesthesia as the patient is deepened to provide optimal operating conditions. Obese patients or those with OSA may develop unacceptable upper airway obstruction and hypoxemia as the anesthetic is escalated. Thus, the anesthesiologist may have to provide additional airway support and convert to a general anesthetic if needed. A case booked as “MAC only” should therefore never be underestimated, and the anesthesiologist should always be prepared for general anesthesia. The anesthesiologist should always carefully screen a patient for MAC as though general anesthesia was planned. Despite its implied simplicity, monitored anesthesia care (or as it formerly was termed—“local-sedation”) is in many ways more difficult than providing general anesthesia. The anesthesiologist has to balance the drug effects that produce anxiolysis, sedation, and even unawareness against the accompanying loss of muscle tone and respiratory depression. The reduced muscle tone allows the patient’s tongue to fall backward and partially or completely block gas movement through the oropharynx and, potentially, the nasopharynx. This is a particular problem in rhinological surgery since the nasal

passageways may themselves be blocked by pathology, instruments, packs, and blood. Lifting the patient’s chin and/or the angles of the jaw may lift the patient’s tongue up from the hypopharynx but is itself stimulating and may awaken the patient. Nearly all sedative drugs are central respiratory depressants that decrease minute ventilation and, consequently, raise end-tidal CO2. Proper patient selection and thorough local anesthetization of the nose promote the procedure’s being successfully accomplished with less sedative medication.

TOTAL INTRAVENOUS ANESTHESIA Total intravenous anesthesia (TIVA) has been shown in some studies to optimize cardiovascular parameters, reduce blood loss, promote hemostasis, and improve surgical field visualization during functional endoscopic sinus surgery compared with a balanced technique incor­ porating inhalational anesthesia.17,18 The ability to pre­ cisely titrate TIVA to specific hemodynamic values and create controlled conditions of hypotension may reduce blood loss and improve surgical conditions. Even though a balanced technique involving inhalational anesthesia can provide the same degree of hypotension, there may be effects specific to TIVA (and especially remifentanil) that provide superior operating conditions. Recent metaanalyses of the available clinical trials, however, have challenged the validity of these studies and have placed into doubt the purported benefits of TIVA.19,20 Another recently published prospective randomized trial consisting of 33 patients undergoing ESS found there was no significant difference in blood loss and surgical conditions with TIVA versus inhalation anesthesia.21 The limited number of controlled trials, insufficient powering, variability among inhalation anesthetics without detailed reporting of the concentrations used, and lack of standardization of grading of visibility scores and perioperative characteristics prevent definitive demonstration of the superiority of TIVA. More high-quality studies are needed before declaring the superiority of TIVA over inhalational anesthesia.

REFERENCES 1. Larson MD. History of anesthetic practice. In: Miller RD (Ed). Miller’s Anesthesia, 6th edition. Philadelphia: Elsevier Churchill Livingstone; 2005. pp. 3-52. 2. Berkowitz DE. Cellular signal transduction. In: Shwinn DA (Ed). Atlas of Anesthesia: Scientific Principles of Anesthesia. Philadelphia: Churchill Livingstone; 1998. pp. 1.1-1.10.

Chapter 40: Anesthesiology 3. Lebowitz P, Richards M, Bryan-Brown C. Anesthesia and management of anesthetic complications of laparoscopic urological surgery. In: Ghavamian R (Ed). Complications of Laparoscopic and Robotic Urologic Surgery. New York: Springer; 2010. pp. 7-18. 4. Morgan G, Mikhail M, Clinical Anesthesiology, 4th edition, New York: McGraw-Hill Companies; 2006. pp. 174, 197, 199, 202, 274. 5. Saklad M. Grading of patients for surgical procedures. Anesthesiology. 1941;2:281-4. 6. http://my.clevelandclinic.org/services/Anesthesia/hic_ ASA_Physical_Classification_System.aspx 7. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297:845. 8. Roizen MF. Preoperative evaluation. In: Miller RD (Ed). Miller’s Anesthesia, 6th edition. Philadelphia: Elsevier Churchill Livingstone; 2005. pp. 927-98. 9. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. J Am Coll Cardiol. 2007;50:159-242. 10. Qaseem A, Snow V, Fitterman N, et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physi­ cians. Ann Intern Med. 2006;144:575-80, 581-95, 596-608. 11. Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. A Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology. 2006;104:1081-93. 12. Mallampati S, Gatt S, Gugino L, et al. A clinical sign to pre­ dict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32:429-34.

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13. Practice Guidelines for Management of the Difficult Air­ way—an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003;98:1269-77. 14. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patient Undergoing Elective Procedures – a report by the American Society of Anesthesiologists Task Force on Preoperative Fasting. Anesthesiology. 1999;90:896-905. 15. Salam G. Regional anesthesia for office procedures: Part I. Head and neck surgeries. Am Fam Physician. 2004;69(3): 585-90. 16. Jourdy DN, Kacker A. Regional anesthesia for office-based procedures in otorhinolaryngology. Anesthesiol Clin. 2010; 28(3):457-68. 17. Amorocho MR, Sordillo A. Anesthesia for functional endo­ scopic sinus surgery: a review. Anesthesiol Clin. 2010; 28(3):497-504. 18. Khosla AJ, Pernas FG, Maeso PA. Meta-analysis and literature review of techniques to achieve hemostasis in endoscopic sinus surgery. Int Forum Allergy Rhinol. 2013;3(6):482-7. 19. Deconde AS, Thompson CF, Wu EC, Suh JD. Systematic review and meta-analysis of total intravenous anesthesia and endoscopic sinus surgery. Int Forum Allergy Rhinol. 2013 Jul 10. 20. Kelly EA, Gollapudy S, Riess ML, et al. Quality of surgical field during endoscopic sinus surgery: a systematic litera­ ture review of the effect of total intravenous compared to inhalational anesthesia. Int Forum Allergy Rhinol. 2013; 3(6):474-81. 21. Chaaban MR, Baroody FM, Gottlieb O, et al. Blood loss during endoscopic sinus surgery with propofol or sevofl­ urane: a randomized clinical trial. JAMA Otolaryngol Head Neck Surg. 2013;139(5):510-4.

SECTION Functional Surgery of the Nasal Airway

8

Chapter 41: Surgery of the Nasal Septum

595

CHAPTER

Surgery of the Nasal Septum

41

Waleed M Abuzeid, Sam P Most, Peter H Hwang

INTRODUCTION Within the human body, there are few anatomic structures that have been operated on with greater frequency or using a wider array of techniques than the nasal septum.1 Abnormalities of the nasal septum have been documented for centuries. Indeed, in 1657, MacKenzie analyzed 2152 skulls and noted that 75% of these demonstrated a nasal septal deformity. Later, these deformities were associated with nasal obstruction, as well as less likely maladies includ­ ing psychosis and emphysema.1,2 An increased under­ standing of the functional role of the nasal septum has better defined the disease states that result from septal deformity, and has allowed for the development of various techniques that aim to re-establish normal function.

Fig. 41.1: Anatomy of the nasal septum.

This chapter will cover the surgical anatomy of the nasal septum, and the indications, techniques, and outcomes of surgery for nasal septal deviation and perforation.

SURGICAL ANATOMY The nasal septum is the central support structure of the nose, and consists of an anterior membranous component, a posterior osseous segment, and an intervening carti­ laginous segment2,3 (Fig. 41.1). The membranous septum is located between the medial crura of the lower lateral cartilage and the quadrangular cartilage, the latter of which constitutes the cartilaginous portion of the septum. As a result, the quadrangular cartilage is often termed the septal cartilage. The quadrangular cartilage provides

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Section 8: Functional Surgery of the Nasal Airway

Fig. 41.2: Coronal view of the articulation of the septal cartilage with the maxillary crest. Note the decussation of the perichondrial and periosteal fibers.

Fig. 41.3: Neurovascular supply of the nasal septum.

struc­tural integrity to the nasal dorsum from the rhinion to the supratip region.4 Immediately posterior to the quad­ rangular cartilage is the osseous septum consisting of the perpendicular plate of the ethmoid bone, the nasal crest of the palatine and maxillary bones, and the vomer.3 The anterior edge of the perpendicular plate of the ethmoid articulates with the posterior edge of the quadrangular cartilage. Inferiorly, both structures articulate with the wedge-shaped vomer.2 The premaxillary crests of the maxilla are fused with the vomer in the midline, forming a groove into which the inferior edge of the quadrangular cartilage intercalates in a “tongue-and-groove” manner.4 Traumatic displacement of the quadrangular cartilage off of its midline perch on the maxillary crest can result in cartilaginous and bony septal spurs along the floor of the nose. At the articulation between quadrangular cartilage and maxillary crest, the mucoperichondrium of the septal cartilage is densely adherent to the periosteum of the maxillary crest, including decussating perichondrial fibers that cross the midline and interweave with the contralateral mucoperichondium2,3 (Fig. 41.2). During septoplasty, the decussating fibers must be discretely divided to enable the elevation of a contiguous submucoperichondrial flap that extends from quadrangular cartilage to the nasal floor.2 Caudally, the superior aspect of the septum contri­ butes to the internal nasal valve, which is a slit-like struc­ ture bounded by the upper lateral cartilage superiorly, the head of the inferior turbinate laterally, and the nasal floor inferiorly. The internal nasal valve is the narrowest segment in the human airway with an average cross-sectional area

of only 0.73 cm2.3 Due to the narrow cross-sectional area of the internal nasal valve, this site contributes approximately 50% of the airflow resistance of the combined upper and lower airway.4 Consequently, relatively subtle cartilaginous septal deviations that narrow the internal nasal valve have a seemingly disproportionate effect on airway obstruction. The vascular supply of the septum originates from two primary sources: the internal and external carotid arteries (Fig. 41.3). The external carotid artery gives rise to the facial artery and internal maxillary artery. The former contributes the superior labial and angular arteries, while the latter gives rise to the sphenopalatine artery. The superior labial and angular vessels supply the anteroinferior nasal septum and columella. The posterior septal branch of the sphenopalatine artery supplies the posteroinferior septum. The ophthalmic branch of the internal carotid artery gives rise to the posterior and anterior ethmoid arteries, which supply the posterosuperior and anterosuperior septum, respectively. This rich blood supply maintains viability of the mucoperichondrium and mucoperiosteum flaps, and is critical for the survival of the underlying septal carti­ lage.3 The incisive artery travels along the superior border of the vomer and passes into the incisive canal. Significant bleeding from the incisive artery can occur during resection of a deviated maxillary crest. The external carotid branches contribute to a rich anastomotic plexus that also receives input from the internal carotid system. This area, Kiesselbach’s plexus, is located in the anteroinferior septum where it is suscep­ tible to the drying effects of nasal airflow and digital trauma. Consequently, the anteroinferior septum is the

Chapter 41: Surgery of the Nasal Septum most common site of epistaxis. The mechanosensory nerve supply of the nasal septum is provided entirely by the trigeminal nerve. The nasopalatine branch of the maxillary nerve (CN V2) supplies the posteroinferior sep­ tum. This nerve travels through the vomer and enters the incisive canal. Resection of the maxillary crest or vomer during septoplasty can result in a transient hypesthesia of the central incisors and premaxilla. The anterosuperior portion of the septum is supplied by the anterior ethmoidal branches of the nasociliary nerve that, in turn, arises from the ophthalmic nerve (CN V1). The olfactory nerve gives rise to multiple fila that perforate the cribriform plate and supply the superior septum.3 Overly aggressive superior dissection can result in anosmia and cerebrospinal fluid leak through transected fila. A working knowledge of the discussed anatomic highlights is imperative for an understanding of the intricacies of surgical technique, as well as an appreciation of potential surgical complications.

SEPTOPLASTY The most common indication for septoplasty is nasal obstruction, which is the most common presenting complaint in a rhinologic practice. As a result, septoplasty is among the three most commonly performed procedures in otolaryngology.5 Septoplasty is performed for nasal obstruction in about 100,000 patients annually. However, up to 90% of people will have incidental septal deformity without any symptoms of nasal obstruction. In these individuals, obstructive symptoms only ensue with addi­ tional contributing factors such as mucosal edema.6 These patients can often be managed using medications. Septoplasty is commonly used as an adjunctive proce­ dure to optimize surgical access for endoscopic sinus and skull base surgery, and to facilitate postoperative in-clinic evaluation. Significant septal deviation has been associated with chronic sinusitis and correction of septal deformity in this setting is indicated. Marked deviation of the septum may exacerbate obstructive sleep apnea; septoplasty may be indicated to improve nasal resistance and improve tolerance of continuous positive airway pressure devices. Less commonly, septoplasty is used for relief of contact point headaches and for the treatment of epistaxis related to mucosal drying from turbulent airflow generated by anteroinferior septal deviation. Lastly, septoplasty is indicated for cosmetic procedures in which concurrent changes to the nasal skeleton would otherwise produce nasal obstruction.5,7

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History and Physical Examination Diagnosis of clinically relevant septal deviation must begin with an adequate history. Specific points that should be elicited include the duration, frequency, and laterality of obstructive symptoms; the presence of peren­nial or seasonal obstruction; a detailed history of trauma and previous nasal surgery; the frequency and severity of epistaxis episodes; evidence of atopy; and the effectiveness of previously tried medical treatments. If obstructive symptoms are seasonal rather than perennial or occur only in certain environments, allergy must be considered as a significant contributor, which is better managed medically.2 Medical comorbidities that may be contraindications to septoplasty should be identified, including Wegener’s granulomatosis, intranasal cocaine use, bleeding diathesis, extensive prior nasal surgery, or large septal perforation. The physical examination is performed to identify the sites of nasal obstruction and to discern fixed anatomic obstruction, such as that resulting from a deviated nasal septum or polyps, or from reversible or dynamic obstruc­ tion related to nasal mucosal inflammation or nasal valve collapse.6,8 The size, shape, and symmetry of the external nose are carefully evaluated. Significant deviation of the carti­ laginous septum may be seen as an external deviation of the dorsum or twisting of the nasal tip.7,9 In this situation, an open septorhinoplasty approach may be necessary in order to allow for correction of the nasal skeleton, as discussed elsewhere in this volume. The nares should be inspected for patency and symmetry; a deflected or widened columella may be seen with deviation of the caudal septum or malformed medial crural cartilages. The external nasal assessment ends with palpation of the nasal tip to evaluate for tip support and ptosis that may contribute to obstructive symptoms. The posterior and anterior septal angles are carefully palpated to assess for caudal septal deviation. Dislocation of the posterior septal angle off the anterior nasal spine will necessitate an open or endonasal approach.8 The patient should be evaluated for the laterality of any obstruction by occluding airflow through each nos­ tril separately, and then asking the patient to breathe normally. The nasal sidewall should be inspected during nasal breathing and evaluated for collapse of the external nasal valve, the internal nasal valve, or both. The Cottle maneuver, which entails lateral distraction of the cheek skin to stent open the internal and external nasal valve, may reduce obstructive symptoms related to nasal valve

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Section 8: Functional Surgery of the Nasal Airway

collapse or caudal septal deviation. False positive results are common.9 A more accurate “modified” Cottle maneu­ ver entails use of a cotton-tipped applicator placed in the nose to lateralize the upper lateral cartilage and, thus, assess the internal nasal valve in isolation. When mildto-moderate inspiration collapses the nasal sidewall, correction of nasal valve stenosis will likely require not only septoplasty but also correction of the upper and/or lower lateral cartilages, as well as reduction in the inferior turbinate.9 Anterior rhinoscopy is performed after evaluation of the external nose, and should be conducted both before and after application of topical decongestants. Subjective and objective responses to topical decongestants allow the surgeon to discern the relative contributions of the nasal mucosa versus fixed anatomic lesions to the obstructive symptoms. Rigid nasal endoscopy is performed after decongestion (and topical anesthesia) to systematically evaluate for possible septal spurs and deflections, septal perforations, nasal valve compromise, polyps, purulent discharge, tumors, or hypertrophic adenoid tissue. In pati­ ents who report an improvement in obstructive symp­ toms despite an absence of objective correlates, the improvement is likely related to a very slight reduction in mucosal thickness. Optimal management for these patients is most likely to be medical therapy. Conversely, a minority of patients will deny any subjective improvement after topical decongestion despite overt objective evidence of airway enlargement. Such patients are likely to be poor surgical candidates.2 Overall, the initial clinical assessment has been shown to have a high predictive value in determining which patients are most likely to experience relief of nasal obstruction from septoplasty. In a retrospective analysis of 137 patients presenting with nasal obstruction and a deviated nasal septum, clinical assessment was highly accurate in predicting which patients would fail intra­ nasal corticosteroid therapy and, ultimately, require a septoplasty.6 Indeed, the positive predictive value of clini­ cal assessment in determining the need for septoplasty was 93.6% with a negative predictive value of 96.4%.6 This highlights the importance of a comprehensive history and physical examination.

SURGICAL TECHNIQUES FOR SEPTAL DEVIATION Descriptions of treatment for septal deviation predate the modern era to the time of the ancient Egyptians. Killian

and Freer were the first contemporary surgeons to describe the submucous resection (SMR). This involved elevation of mucoperichondrial flaps with resection of septal cartilage, thereby sparing the overlying mucosa. These two pioneers also recognized the importance of maintaining a generous L-shaped dorsal and caudal cartilaginous strut to maintain nasal support.3 Septoplasty techniques have since evolved with the aim of preserving as much quadrangular cartilage as possible and avoiding trauma to the overlying mucosa.

ENDONASAL SEPTOPLASTY Indications Endonasal septoplasty can be used to treat osseous and cartilaginous septal deflections, including some caudal septal deviations, without an external incision. Relative contraindications include those septal deviations that are associated with marked external deformity or severe caudal deformity, in which an open approach is indicated. The endonasal septoplasty technique generally follows the seven steps proposed by Huizing and de Groot: patient analysis (discussed above), approach, mobilization, resec­ tion, reposition, reconstruction, and fixation.10

Surgical Technique Approach Endonasal techniques can be performed under general or local anesthesia. The surgical approach begins with application of topical decongestants such as oxymetazo­ line, 1:1000 epinephrine, or 4% cocaine. Bilateral submu­ coperichondrial injection of an anesthetic and vasocon­ strictor – e.g. 1% lidocaine with 1:100,000 epinephrine – is performed.6 Some authors advocate an additional injec­ tion into the greater palatine foramen bilaterally to provide posterior hemostasis. Radioanatomic studies have shown that the pterygopalatine fossa can be safely injected via the greater palatine foramen with minimal risk to intraorbital contents by bending a 27-gauge needle 45° and advancing the needle into the foramen to a distance of 2.5 cm in those greater than 12 years of age, 2.0 cm in those aged 6–12 years, and 1.2 cm in those under 6 years old.24 Inclusion of sphenopalatine injection is especially indica­ ted in patient undergoing concomitant endoscopic sinus surgery. The initial incision is made with a #15 blade. Generally, the incision will be made on the side of the deflection as mucoperichondrial flap elevation can be easier over a convex surface. This is not a requirement, however, and

Chapter 41: Surgery of the Nasal Septum selection of the side of the incision can be modified by factors such as a septal spur, which complicates elevation of an intact mucoperichondrial flap. The choice of incision—hemitransfixion versus Killian—is based on surgeon preference as well as the cau­ dal extent of the deviation. The hemitransfixion incision

599

is classically made at the leading edge of the caudal sep­ tum, at the transition between vestibular skin and septal mucosa (Fig. 41.4).11 The primary advantage of this app­ roach is that all parts of the cartilaginous and osseous septum can be accessed. One relative disadvantage of the hemitransfixion incision is that it can be more challenging to dissect the fibrous attachments near the caudal border of the septum in order to find the submucoperichondrial plane of dissection. In contrast to the hemitransfixion incision, the Killian incision is placed 1–2 cm posterior to the caudal edge of the septum, through the septal mucosa. A Killian incision is suitable for septal deflections involving the middle or posterior third of the septum (Fig. 41.4). Although identification of the submucoperichondrial plane is often easier through a Killian incision, relative dis­ advantages of the Killian incision include the inability to access caudal septal deviations, and the risk of tearing the delicate mucosal incision during flap elevation.3

Mobilization Fig. 41.4: Lateral view of the Killian incision and hemitransfixion incision. The Killian incision is placed 1–2 cm behind the edge of the caudal septum. The incision is designed such that it begins dorsally and curves downward toward the nasal floor, taking care to incise through the mucoperichondrium while leaving the under­lying cartilage intact. The hemitransfixion incision is placed 2–3 mm behind the anterior columella, along the edge of the caudal septum.

A

All deformed parts of the septum must be exposed and mobilized.11 Flap elevation proceeds in an anterior to posterior fashion. The classic approach to flap elevation, as initially described by Cottle, involves creation of a superior and inferior tunnel12 (Figs. 41.5A and B). The supe­ rior tunnel, referring to the mucoperichondrial flap above the level of the maxillary crest, is routinely elevated in all septoplasty operations. The inferior tunnel, along the

B

Figs. 41.5A and B: Elevation of septal flaps. Flap elevation proceeds using a Cottle or Freer elevator. This can often be elevated as a single large flap. However, in cases with deviation of the caudal septum or maxillary crest, a “two tunnel” approach can be useful. The superior tunnel, above the maxillary crest, is first elevated. A second inferior tunnel is then created along the maxillary crest and nasal floor. Lastly, the decussating mucoperiosteal and mucoperichondrial fibers between the two tunnels are divided to create a single con­ tiguous flap. A similar “two tunnel” technique can be used above and below a septal spur to preserve flap integrity.

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nasal floor, is required in cases of quadrangular cartilage dislocation off the maxillary crest or deviation of the crest itself. By elevating the two tunnels separately, and then connecting them by sharply transecting the decussating fibers described in the “Surgical Anatomy” section above, the risk of tearing the flap is markedly reduced.11 The superior tunnel is elevated in a submucoperi­ chondrial plane along the underlying septal cartilage, while using a nasal speculum to facilitate visualization. As the flap is elevated posteriorly, the use of a longer nasal speculum often becomes necessary to maintain adequate visualization. Avoidance of flap trauma can be facilitated by elevating along a broad front. The most likely sites of flap trauma overlie bony septal spurs. Here, flap elevation superior and inferior to the spur is performed initially, in order to provide some flap laxity while gently elevating the flap off the spur3 (Figs. 41.5A and B). Once the flap has been elevated posteriorly beyond the bony cartilaginous junction, a contralateral flap dissection is performed in order to isolate the deviated portions of bone and cartilage from their contralateral mucoperichondrial and mucoperiosteal attach­ments. Contralateral access is typically achieved by sharply incising through the septal cartilage just anterior to the point of maximal deflection, in order to carefully enter the contralateral submucoperichondrial space. When both mucoperichondrial flaps have been raised, the intervening deviated septal cartilage and bone are fully exposed. When there is a deflection of the cartilaginous septum off the maxillary crest or deviation of the crest itself, an inferior tunnel is developed along the nasal floor using a sharp elevator to elevate a mucoperiosteal flap.9 The inferior tunnels, after being elevated bilaterally, are then connected to the superior tunnels via sharp dissection.

Resection, Reposition, and Reconstruction Submucous resection: The SMR is the most aggressive of modern resection techniques, and can be used to treat the range of septal deviations. It involves the removal of the majority of the quadrangular cartilage, with the preservation of 1 cm or greater width of caudal and dorsal cartilage, forming an inverted L-shaped strut (Fig. 41.6). Failure to preserve an adequate strut caudally can compromise tip support and lead to tip ptosis.3 Compromising the dorsal strut can disrupt the integrity of the nasal dorsum leading to collapse. A scalpel, swivel knife, or scissors can be used to make the cartilage cuts and to disarticulate the quadrangular cartilage from the

Fig. 41.6: Lateral view of the “L-strut.” This is a 1.5 cm caudal and dorsal segment of the septal cartilage that must be preserved for structural integrity of the nasal septum. The shaded area repre­ sents the excised segment of septal cartilage.

osseous septum and maxillary crest. Deviations in the osseous septum can then be addressed using through-cut instruments or the Jansen-Middleton forceps. Conservative septoplasty: The classic SMR has largely been replaced by conservative septoplasty where speci­ fic areas of septal deviation are resected, thereby preserv­ ing a maximal amount of cartilage.3 Central septal deflections are identified and are selectively resected. It is often easiest to start with a posterior vertical cut that disarticulates the bony-cartilaginous junction, followed by horizontal cuts superiorly and inferiorly to the deflection. A vertical cartilaginous incision just anterior to the deflection frees the segment, which is then carefully removed with forceps.3,9 There should be no pulling or twisting movements outside of the anteroposterior axis to minimize the risk of cribriform fracture due to torsion on the perpendicular plate of the ethmoid. A similar method can be used to address cartilaginous or bony septal spurs. Septal spur removal can be facilitated by medial displacement of the spur using the nasal speculum, after making superior and inferior horizontal cuts above and below the spur. This reduces the risk of mucosal perforation.3,11 Low spurs along the nasal floor are addressed using the two-tunnel approach with elevation of mucoperichondrium above and mucoperiosteum below the deviation, followed by elevation of the intervening mucosa (Figs. 41.5A and B). The deviated segment is freed by making a horizontal superior cut followed by fracture and removal with the Takahashi forceps.9

Chapter 41: Surgery of the Nasal Septum

601

A

B Figs. 41.7A and B: Septal correction using the swinging door technique. The top panel illustrates conservative resection of the caudal septum that is then brought to midline and reinserted along the groove of the maxillary crest where it is secured with monofilament suture. The bottom panel indicates overcorrection of the septum. The septum is not trimmed but is translocated to the opposite side of the maxillary crest and secured here with monofilament.

Septal reconstruction: Septal reconstruction techniques are used primarily for deviations in the quadrangular cartilage that involve critical portions of the dorsal and caudal “L”-strut. While cartilage can be scored with one-sided partial-thickness weakening incisions to allow for reshaping of the cartilage, the degree of change in curvature is challenging to predict and use of this method in isolation often results in relapse due to cartilage “memory.”13 Given this, we feel that scoring techniques are unreliable and should not be used in critical areas. Tangential shaving of thick cartilage can also be used to remove bowing.9 High dorsal bowing can also be addressed by suturing a rectangular cartilage graft, harvested from excised septal cartilage, between the quadrangular cartilage and the upper lateral cartilage. This acts as a splinting spreader graft preventing dorsal septal bowing.9 A commonly encountered deformity involves dis­ placement of the anteroinferior quadrangular cartilage off the maxillary crest or deviation of the maxillary crest itself. This is a major contributor to nasal obstruction. The

Metzenbaum “swinging door” procedure can effectively address this caudal septal deviation (Figs. 41.7A and B). First, the two-tunnel method is used to effectively free the muco­ periosteum and mucoperichondrium from the maxillary crest and nasal floor. A horizontal wedge of cartilage is then excised from the convex side of the septal deformity using a #15 blade.14 Deviation of the maxillary crest is addressed by excision using an osteotome.9 Thus, a superiorly based swinging septal flap is created and is repositioned to the midline maxillary crest. A modification of this technique encourages repositioning the septum to the other side of the anterior septal spine such that the spine acts as a buttress preventing the septum from returning to its native position14 (Figs. 41.7A and B). An excessively deviated caudal septum that cannot be straightened can be trimmed, although this must be done with care, as over-resection of the critical caudal strut cartilage can compromise tip support.9 In these cases, a modified extracorporeal septoplasty, or anterior septal reconstruction, may be required.15 Full discussion of this technique is beyond the scope of this text.

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Section 8: Functional Surgery of the Nasal Airway

Once the cartilaginous septum has been addressed, resection of any posterior osseous deviation is performed using Jansen-Middleton and Takahashi forceps.3 Care must be taken to avoid torque on the skull base during treatment of bony deviations. Furthermore, the dorsal strut at the bony cartilaginous junction must be preserved. This area is called the “keystone” as it is critical in maintaining dorsal support of the nose. Disarticulation of this area causes the dorsal L-strut of the septum to collapse, resulting in a saddle nose.

Fixation Following SMR or conservative septoplasty, all cartilages that have been detached, mobilized, or reposi­ tioned must be fixed in position. Caudally deflected septal cartilage that has been corrected by the “swinging door” procedure described above is fixed by securing the repositioned cartilage to the maxillary crest and ante­ rior nasal spine using absorbable monofilament suture (Figs. 41.7A and B). The caudal tip of the cartilage can be fixed in the midline by using the “tongue-in-groove” technique where retrograde dissection between the medial crura creates a pocket into which the caudal septum is interposed. Columellar-septal mattress sutures are then passed through both medial crura and the intervening caudal septum to provide stabilization.16 The mucoperichondrial flaps are laid back into position and the nasal cavity is carefully inspected bilaterally to ensure resolution of the deviated segment, and to detect unappreciated tears in the mucoperichondrial flaps. Some surgeons advocate morselization and reinsertion of unused, resected septal cartilage between the muco­ perichondrial flaps. This potentially reduces the risk of postoperative septal perforation and flail septum (abnor­ mal billowing of the septal mucosa with nasal breathing). Reimplantation of cartilage is particularly useful in situ­ ations where opposing, bilateral mucosal perforations have been created.9 A number of techniques can be used to reapproximate the mucoperichondrial flaps with goals of stabilizing the repositioned cartilage and bone, prevention of synechiae between the septum and lateral nasal wall, and avoid­ ance of septal hematoma. Tacking sutures can be placed through-and-through the mucoperichondrial flaps at several points. Alternatively, a continuous quilting suture can be placed that begins anteriorly, runs posteriorly, and then returns anteriorly (Fig. 41.8). Large tears in the muco­ perichondrial flaps should be considered for possible closure with absorbable suture, although most flap tears

Fig. 41.8: Schematic representation of septal “quilting” suture tech­ nique. Absorbable suture is used to coapt the mucoperichondrial flaps starting anteriorly and working in a posterior direction before returning anteriorly.

heal uneventfully without repair if the contralateral flap is intact in the area opposing the ipsilateral flap tear. Nonabsorbable packing can be used as an adjunct to or in place of suturing techniques, although the outcomes of septoplasty without postoperative packing are quite satisfactory. In a study of 697 patients who underwent septoplasty and were randomized to either trans-septal suturing or Merocel packing, there was no difference bet­ ween groups in postoperative bleeding rates, synechiae formation, septal perforation, or hematoma formation. There was, however, significantly more postoperative pain in the patients who received nasal packing.17 Coupled with the negative effects of nasal packing on sleep, increased risk of hypoxia in patients with obstructive sleep apnea, and reports of toxic shock syndrome, nasal packing in our experience is best avoided after septoplasty.18,19 Silastic splints are a more recent alternative to nasal packing. One prospective, randomized trial demonstrated that, in comparison to nonsplinted controls, presence of a properly placed splint – such that it does not contact the nasal floor or roof – does not add to patient discomfort, and reduces mucosal erosions and synechiae.20 After apposition of the mucosal flaps, the Killian or hemitransfixion incision is closed using absorbable suture.

ENDOSCOPIC SEPTOPLASTY Indications The development of functional endoscopic sinus surgery in the 1980s and its, subsequent, dissemination paved the way for novel endoscopic techniques. Lanza and Stammberger

Chapter 41: Surgery of the Nasal Septum

603

Fig. 41.9: Elevation of submucoperichondrial flap using endo­ scopic septoplasty technique. A submucoperichondrial flap is ele­ vated with a suction Freer elevator through a Killian incision. The septal cartilage is brilliant white and avascular when elevation is performed in the correct plane as shown above.

Fig. 41.10: Endoscopic resection of deviated septal cartilage. Bilateral submucoperichondrial flaps have been elevated and the intervening deviated septal cartilage isolated. This is incised supe­ riorly and inferiorly with endoscopic scissors and then removed, taking care to preserve an adequate L-strut.

were the first to detail endoscopic septoplasty.21,22 Use of an endoscope obviates the need for a nasal speculum and, thus, the nasal anatomy can be viewed without distortion.23 Endoscopic septoplasty is suitable for the nearly all septal deflections that would otherwise be accessible via an endonasal approach. The endoscopic approach, owing to the combination of excellent illumination, magnification, and visualization, is particularly well suited to treating isolated posterior septal deflections, isolated septal spurs, and deviations in close proximity to septal perforations.5,24 The high-definition view offered with modern endoscopic platforms has increased use of this approach for revi­ sion septoplasty due to enhanced visualization of tissue planes.5 Relative contraindications for endoscopic septo­ plasty are significant caudal deflection and/or the pre­ sence of associated external deformity, for which an open septorhinoplasty approach would be indicated.23

(Fig. 41.9). The use of an irrigating endoscope sheath to prevent soiling of the scope tip by blood is helpful and improves operative efficiency. The magnified endoscopic view allows one to recognize areas of thinned, tenuous mucosa, and to evaluate the amount of tension being applied to the mucoperichondrium during elevation, potentially reducing the risk of septal perforation. Further­ more, flap lacerations can be recognized early before extension of the injury.5,24 Deviated portions of septal cartilage and bone are excised and/or mobilized in the same manner as in tradi­ tional septoplasty (Fig. 41.10). Removal of bone and cartilage using powered instrumentation has also been described with the endoscopic approach, offering the potential advantage of concurrent aspiration of debris and blood during tissue removal. Both microdebriders and drills can be used to safely resect cartilage and bone under endoscopic visualization. This technique is not indicated for caudal deflections but can, otherwise, be used without increasing the risk of perforation or postoperative hematoma.25,26 Following resection of the septal deviation, the muco­ perichondrial flaps are laid back in position and the endo­ scope passed into the nasal cavities bilaterally to inspect and palpate any residual deviation that can then be corrected. Once all necessary deflections have been addressed, the mucoperichondrial flaps are reapproximated with a quil­ ting stitch using 4-0 nonabsorbable suture on a small Keith

Surgical Technique Preparation of the nose for endoscopic septoplasty is the same as for traditional headlight septoplasty. The Killian or hemitransfixion incision is performed nonendoscopically under direct visualization and the subperichondrial plane of elevation is initiated for 1–2 cm.23 The surgeon then transitions to an endoscopic view using a suction Freer instrument to continue flap elevation while concurrently aspirating blood so as to maintain an optimal view5

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Section 8: Functional Surgery of the Nasal Airway

needle.5,24 As discussed above, morselized cartilage can be placed between the mucoperichondrial flaps prior to closure.23 A major advantage of the endoscopic approach is the ability to perform a limited septoplasty. For example, a posterior deflection limited to the region of the bonycartilaginous junction can be accessed by making a posterior mucosal incision just in front of the deflection, raising limited flaps and selectively resecting the deflected segment of cartilage.5 Because of the limited dissection, no closure sutures or splinting is required. This is of particular benefit when treating a septal deviation in the setting of a pre-existing septal perforation. The mucosal incision and flap elevation can be limited to the area of the deflection, leaving the mucosa surrounding the perforation undis­ turbed, thereby reducing the risk of enlarging the per­ foration. Septal spurs can be effectively addressed via a mini­ mally invasive endoscopic approach by placing the septal incision horizontally along the apex of the spur. Muco­ perichondrial flaps are elevated superiorly and inferiorly. The spur is then incised along its superior border and the contralateral mucoperichondrium is then gently elevated to isolate the spur. The spur can then be removed through the apical incision. The superior and inferior flaps are laid back into position; closure with absorbable suture is optional.5,21

approach. Lastly, disarticulation of the osseous and carti­ laginous septum can also be addressed.

Surgical Technique The surgical approach used for open septoplasty is, essen­ tially, identical to that used for external (or open) septorhinoplasty. The surgery can be performed under intravenous sedation or general anesthesia, though the latter is recommended. In all cases, local anesthetic with a vasoconstrictor (1% lidocaine with 1:100,000 epinephrine) is infiltrated into the nasal dorsum, columella, and nasal base using a 30-gauge needle. A 27-gauge needle is then used to inject the septum in a submucoperichondrial plane to produce hydrodissection as discussed above. Decongestion is recommended in the preoperative area prior to induction, and can additionally be performed using oxymetazoline-soaked neurosurgical pledgets after injection.7 A standard columellar inverted “V“ or “W” incision is made with a #15 blade with placement of the incision at the narrowest point of the columella. Marginal incisions are then made with the same blade just below the caudal edge of the lower lateral cartilage (Fig. 41.11). Converse or other fine scissors are used to begin elevation of the columellar skin anteriorly over the nasal tip. Nasal tip skin is retracted with skin hooks and dissection performed in

EXTERNAL SEPTOPLASTY Indications External (or open) septoplasty is most commonly indi­ cated when septal deviation is a component of a larger nasal deformity involving the nasal tip, dorsum and/or nasal bones, that cannot typically be addressed by more conservative approaches.3 Severe deviation of the anterior septum within 2 cm of the caudal septal edge is another common indication for external septoplasty.7 This is in contrast to less severe caudal septal deviation that can be addressed by the endonasal “swinging door” technique. Some authors advocate the external approach for all caudal septal deviations as it permits easy access and pre­ cise repositioning of the septum.14 High deviations of the dorsal septum can also be addressed via this approach through the placement of spreader grafts.7 Significant deviation of the septum, often with associated external deformity, may require near total excision of the septum and extracorporeal septoplasty via an external rhinoplasty

Fig. 41.11: Marginal and columellar incisions. Typically an “inver­ ted V” configuration is used for the columellar incision that is per­ formed with a #11 blade scalpel. The marginal incision can then be performed using a #15 blade and is connected to the previously made columellar incision. The marginal incision skirts the bottom edge of the lower lateral cartilage but care must be taken not to incise cartilage.

Chapter 41: Surgery of the Nasal Septum

Fig. 41.12: Complete transfixion incision. The complete transfixion incision involves a through-and-through incision along the caudal edge of the septum and medial crura. This effectively separates the skin and soft tissue of the columella from the caudal septum.

the submusculoaponeurotic plane, beginning medially and then working laterally. The skin-soft tissue envelope is then retracted with an Aufricht or Gruber retractor. The skin-soft tissue envelope is thus elevated to the nasal bone junction (rhinion). At this point, a subperiosteal pocket is developed up to the nasofrontal suture. In cases with central septal deflection or anterior septal deflection, the medial crura are separated via a complete transfixion incision to allow for direct access to the septum (Fig. 41.12). The anterior septal angle is identi­ fied and a Cottle elevator is used to sharply elevate the mucoperichondrium bilaterally. A Freer elevator is used to widely elevate the mucoperichondrial flaps. In order to facilitate access, the quadrangular cartilage is separated from the upper lateral cartilage up to the inferior edge of the nasal bones using a D-knife. This maneuver can be performed without the preceding transfixion incision in patients with isolated dorsal deviations.7 For the majority of central and posterior septal devi­ ations, the bilateral mucoperichondrial flaps are elevated posteriorly beyond the bony-cartilaginous junction. A #15 blade or D-knife can be used to resect the deflected segment while preserving an adequate L-strut. It cannot be emphasized enough that preservation of the dorsalmost 1–1.5 cm of the bony-cartilaginous junction of the septum (the keystone) is critical to preventing compli­ cations of both airway compromise and saddle nose deformity. Dorsal septal deviation, accessed via the stan­ dard transfixion incision or through disarticulation of the

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Fig. 41.13: Cartilage scoring techniques for septal correction. The convex side of the septal deviation is scored with a series of hori­ zontal incision to weaken the integrity of the cartilage and permit reshaping. Alternatively, serial wedges can be excised from the convex side. The cartilage is then straightened and the mucoperi­ chondrial flaps coapted.

upper lateral cartilage, can be addressed by placement of a unilateral spreader graft on the concave surface to correct the deformity. Symmetric and asymmetric bila­ teral spreader grafts can also be used to straighten and strengthen the dorsal septum. These can be harvested from the quadrangular cartilage.7,9 Dramatic deviations in the dorsal septum may need to be excised and the dorsal septum reconstituted with a cartilage graft obtained from the septum or from rib. These rhinoplasty techniques are discussed elsewhere in this volume. Regardless of the technique used, the upper lateral cartilage must be reat­ tached to the septum in order to avoid internal nasal valve collapse. Caudal septal deflections are typically accessed via a transfixion incision. The most conservative methods of addressing caudal deviation involve wedging or scoring the caudal component of the L-strut. Generally we recommend against scoring methods, as these tend to unpredictably weaken this important strut. Incisions are made in the convex surface of the caudal strut, and can be partialthickness scoring incisions or serial wedges (Fig. 41.13). This is effective for mild-to-moderate septal deviation, but cannot address severe deviations. Furthermore, there is concern that this technique compromises tip-support mechanisms and, in the long term, may result in tip ptosis.14 Mild-to-moderate caudal deviation can also be managed through suture technique where the caudal strut

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Section 8: Functional Surgery of the Nasal Airway

is scored, and then a series of two to four Mustarde-type sutures are placed to straighten the deflected segment.14 Septal repositioning is an alternative technique where the deflected caudal septum is brought to the midline, and secured to the periosteum of the anterior nasal spine with mattress sutures (see Fig. 41.7). An overly long caudal septum may need to be trimmed, as discussed earlier, prior to repositioning in the midline. The tongue-and-groove technique can be readily used via the open approach as this allows for disarticulation of the medial crura, careful interposition of the caudal septum edge between the footplates, and precise placement of columellar-septal mattress sutures.7,14 This technique also allows adjustment of tip projection and rotation if concomitant aesthetic changes are desired. A deviated caudal septum can also be stabilized through the use of rigid spreader grafts, harvested from the ethmoid perpendicular plate, and placed such that they extend beyond the caudal border of the upper lateral cartilages, and “sandwich” the caudal septum.14 Care must be taken to avoid overly widening the columella. Complete separation of the osseous and cartilaginous septum is a very difficult problem that must be avoided. If it occurs, it can be addressed by drilling holes in the perpendicular plate of the ethmoid, and then passing PDS suture through the holes and into the quadrangular cartilage to reapproximate the bony and cartilaginous components. This repair often needs to be combined with bilateral spreader grafts to stent the internal nasal valve, as well as a dorsal onlay graft to camouflage step off between the nasal bone and the nasal dorsum.7 These techniques are discussed elsewhere in this volume.

Extracorporeal Septoplasty Although first described by King and Ashley as an endo­ nasal technique in 1952, most surgeons perform extra­ corporeal septoplasty via an external approach.14 The most severe septal deformities resulting from trauma, previous surgery, or congenital malformations can be addressed by extracorporeal septoplasty where the entirety of the nasal septum is removed, straightened, and then reimplanted. This may serve to correct any resultant external nasal deformity as well.3 The dorsal septum is separated from the upper lateral cartilages bilaterally after elevation of mucoperichondrial flaps. The premaxillary attachments are transected and inferior tunnels dissected along the nasal floor. Paramedian osteotomies are then performed to remove the bony septum from the nasal dorsum. The

entire cartilaginous and osseous septum are then remo­ ved as a single unit.27 A more recent modification to this technique is the anterior septal reconstruction, which involves leaving a portion of the native dorsal septum intact so as not to compromise dorsal support.15 Multiple strategies can then be applied to straighten the removed septum.27 Redundant cartilage and fracture lines can be excised and sutured together into a stable, straightened construct. Partial-thickness incisions made on the concave side of a deflected segment of cartilage can reduce tension and facilitate reshaping of the cartilage. Bony irregularities can be smoothed with a drill. Overly pliable pieces of cartilage can be reinforced with spreader grafts sewn with PDS suture to the upper border of the septum. In post-traumatic cases with multiple fracture lines, the individual fracture segments are often straight and can be dissected apart and then reassembled into a neoseptum. This can be facilitated by using PDS foil as a stabilizing template to which the fragments can be sutured. The fractures must be overlapping, however, as end-toend fusion of the cartilage in critical load-bearing areas is not reliable. In the postoperative scenario with minimal residual cartilaginous septum, the bony septal fragments can be used to construct an L-strut, thereby recreating the dorsal and caudal septum. The reconstructed septum is then replanted between the mucoperichondrial flaps. Stable fixation is critical. This is achieved by aligning the upper border of the neoseptum with the upper lateral cartilage, temporarily fixing the construct with needles, and then passing PDS suture through both upper lateral cartilages and the interposed neoseptum. A hole is drilled through the anterior nasal spine and two sutures used to anchor the caudal cartilage to the spine.27 Fascial onlay grafts can be used to prevent postoperative irregularities of the nasal dorsum. The skin-soft tissue envelope is returned to position and the columellar and marginal incisions closed with absorbable suture. A quilting suture and silastic splints are used to reapproximate the mucoperichondrial flaps. Given the increase risk of notching and requirement for dorsal grafting in extracorporeal septoplasty patients, anterior septal reconstruction is a good alternative.15 The approach is similar to the above, except a dorsal strut of 1.5–2 cm is left intact, extending from the bony-cartila­ ginous junction caudally (Fig. 41.14). The upper lateral carti­lages are released, and a septal reconstruction graft, often taken from the native septum, can be used to recon­ struct the caudal strut. Rather than suture to the maxillary

Chapter 41: Surgery of the Nasal Septum

Fig. 41.14: Anterior septal reconstruction. This is a modified extra­ corporeal septoplasty technique allowing for the reconstitution of anterior septal deviations. The septal graft is taken from the native septum.

spine, the spine is gently split with a 4 mm straight osteo­ tome, creating a 3 mm deep groove. The graft is notched at its inferior edge, and this notch is placed in the groove of the maxillary spine. This prevents lateral and anteroposterior movement of the graft. The graft is secured to the dorsal strut on its concave side, acting as a spreader graft. This can be augmented further with additional spreader grafts. This technique has been validated using the NOSE out­ comes instrument—discussed below—and offers the advantage of reduced risk to the dorsal profile.

OUTCOMES Multiple published studies have indicated that septoplasty produces improvements in nasal obstruction. Stewart et al. designed a multicenter, prospective observational study involving 59 patients with chronic nasal obstruction refractory to medical management who then underwent nonendoscopic septoplasty, with or without inferior turbi­ nectomy. There was a significant improvement in scores on a validated instrument for assessing nasal obstruction (Nasal Obstruction Symptom Evaluation Scale) at 3 months postseptoplasty and this was sustained at 6 months after surgery.28 The improvement in scores was at least two times the standard deviation of the baseline pretreatment scores indicating a large beneficial effect of surgery. Additionally, 94% of patients reported satisfaction postoperatively, and reported significant decreases in oral decongestant and nasal steroid use at 3 months after surgery.28 Clinical efficacy has been demonstrated for open, endo­ nasal and endoscopic septoplasty approaches. Siegel et al., in a prospective study evaluating 93 patients undergoing

607

nonendoscopic septoplasty, applied the gen­eral health survey (SF-12) and a nasal specific health mea­sure (Nasal Health Survey) prior to surgery, and at 6 and 12 months postoperatively. At a mean of 9 months follow-up, both the symptom and medication usage scores on the Nasal Health Survey were significantly impro­ved. These results held even when patients who underwent concurrent turbinate reduction or external nasal framework surgery were excluded from the analysis. Over­all, 71% of patients demonstrated a clinically significant improvement as determined by at least a 50% decrease in duration of nasal symptoms.29 Bothra and Mathur performed a prospective, randomized study to compare nonendoscopic versus endoscopic septoplasty techniques for limited septal devi­ ations and spurs. They found no differences in outcomes or complications over a 2-year follow-up period.30 Recent studies using objective measures of nasal air­ way patency have indicated a measurable benefit from septoplasty. These objective measures include rhino­ manometry, which measures nasal patency by quantifying nasal airflow and pressure gradients during normal brea­ thing; acoustic rhinometry, which measures the mini­mum cross-sectional airway of the nasal airway; and nasal peak inspiratory flow, which provides a physiologic measure of nasal airflow with maximum effort.31 In a systematic review of 14 studies—seven (460 patients) involving rhino­ manometry, six (182 patients) using acous­tic rhinometry, and one (22 patients) analyzing nasal peak inspiratory flow—septoplasty resulted in measurable objective improve­ ments in nasal patency.31 When comparing postoperative to preoperative readings, there were significant decreases in mean unilateral nasal resistance, increases in mini­ mum cross-sectional area, and increases in peak nasal inspiratory flow.31

SEPTAL PERFORATION Nasal septal perforations are common, occurring in up to 0.9% of the general population.32 As detailed earlier in this chapter, a rich anastomotic network of blood vessels in the septal mucoperichondrium creates a redundant blood supply to nourish the underlying avascular cartilage. However, any disruption to this blood supply can lead to ischemia or necrosis of the underlying septal cartilage. When the vascular supply is disrupted bilaterally in the same region of septal cartilage, the patient is prone to full-thickness tissue loss and development of septal per­ foration.33

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Section 8: Functional Surgery of the Nasal Airway

Pathophysiology Septal perforations disrupt intranasal laminar airflow by causing turbulent eddy currents.8 This turbulent air­ flow impairs mucosal function and induces ciliary loss, resulting in a dry, obstructed nasal cavity. Compensa­ tory vasodilatation of the mucosal vasculature can induce rhinorrhea that can dry to propagate nasal crust forma­ tion.33 A low-grade perichondritis can also contri­ bute to significant crusting and bleeding.34 Nose picking can worsen the perichondritis and lead to enlargement of the perforation.33 Progressive enlargement of a septal perforation may compromise the integrity of the dorsal and caudal septal struts causing external nasal defor­ mity.32 Generally, the more anterior the perforation, the more likely a patient is to be symptomatic and to seek evaluation.34

Causes of Septal Perforation (Table 41.1) Traumatic Traumatic disruption of the mucosal vasculature is an extremely common cause of septal perforation. Trauma can be intentional, such as septal piercing to accom­ modate nose rings; habitual, as in the case of chronic nose picking; accidental, in the case of blows to the external nose that disrupt septal cartilage and overlying mucoperichondrium; or iatrogenic.33 Septal trauma can induce a hematoma that, if untreated, can result in dis­ solution of the septal cartilage with eventual perforation.34 Septoplasty is the surgical procedure most commonly

associated with perforation, often as a result of opposing tears in bilateral mucoperichondrial flaps over an area where septal cartilage has been removed. Nasal cautery for epistaxis can also lead to perforation. The use of tight nasal packs – either for epistaxis control or post-septoplasty – can lead to ischemic mucosal damage and perforation. Nasogastric tubes and nasotracheal intubation can induce pressure necrosis and localized inflammation resulting in septal perforation.34

Systemic Disease Chronic vasculitides such as Wegener’s granulomatosis and sarcoidosis have been associated with septal perfora­ tion. Infectious diseases including tuberculosis, syphilis, diphtheria, fungal infections, and AIDS can also result in perforation, as can connective tissue diseases such as systemic lupus erythematosus, Crohn disease, dermato­ myositis, and rheumatoid arthritis. Malignancies are a rare but well-established cause of septal perforation.33

Drugs Illicit substances have long been associated with septal perforation. Cocaine is a potent vasoconstrictor, and with chronic use, the resultant necrosis of septal mucosa com­ promises the vascular supply to the underlying septal cartilage. However, the role of cocaine in inducing septal perforation is multifactorial. Cocaine is a potent local anesthetic and, consequently, trauma to the nasal mucosa—both digital and from drug paraphernalia—is not felt. Adulterants mixed into cocaine such as talcum

Table 41.1: Causes of septal perforation

Inflammatory

Infectious

Traumatic/Iatrogenic

Neoplastic

Inhalants

Sarcoidosis

Syphilis

Septoplasty

Lymphoma

Steroids

Granulomatosis with polyangiitis

Tuberculosis

Mucosal laceration

Squamous cell carcinoma

Decongestants

Systemic lupus erythematosus

Invasive fungal sinusitis

Cauterization for epistaxis

Melanoma

Cocaine

Churg–Strauss syndrome

Leishmaniasis

Nose picking

Cryoglobulinemia

Industrial exposure (chromic acid, potash fumes)

Rheumatoid arthritis

Leprosy

Nasogastric tube placement

Crohn disease

Rhinoscleroma

Nasal piercing

Dermatomyositis

Acquired immunodefi­ ciency syndrome

Foreign body

Chapter 41: Surgery of the Nasal Septum powder and borax directly contribute to mucosal necrosis.33 Even a one-time use of intranasal cocaine can induce a perforation.34 Chronic use of over-the-counter topical nasal decongestants can also induce perforation from a vaso­constrictive effect. In rare cases, intranasal steroids have the potential to induce septal perforation. Inhaled corticosteroids, through their suppressive effect on proinflammatory cytokines, may produce a net reduction in angiogenesis, perfusion and permeability of the septal mucosa, potentially initiating an ischemic cascade that results in septal perforation.33 Nasal spray preservatives such as benzalkonium chloride have been hypothesized to possibly contribute to the propensity for perforation by inducing local irritation and squamous metaplasia.

Chemical Irritants Industrial irritants related to chrome plating cause severe inflammation of the nasal mucosa and perforation. Simi­ larly, the inflammatory response induced by aerosolized dust—such as in grain silos, glass manufacturing, and cement factories—can also lead to perforation.34

History and Physical Examination The initial workup for septal perforation must incorporate a detailed history. The presence of the aforementioned inflammatory, infectious, and malignant conditions should be determined as this may preclude surgical repair. Ongoing use of cocaine is an absolute contraindication to surgery as the repair will invariably fail.32 The most common symptom of perforation is bleeding (58%). Other symptoms include crusting (43%), obstruc­ tion (39%), pain (17%), whistling (10%), and foul nasal discharge. Approximately, 15% of patients are completely asymptomatic.33 Smaller perforations are typically asso­ ciated with worse whistling due to the increased velocity of airflow through the perforation. The time of onset of the perforation should be determined when possible. Contributing factors such as previous nasal cautery, septo­ rhinoplasty, or occupational exposures to inhaled irritants should be queried. An understanding of the patient’s nasal hygiene is also pertinent including the use of nasal saline irrigation, topical ointments, intranasal medications, and propensity for digital trauma.32 Examination of the external nose can reveal a saddle deformity or tip ptosis when the integrity of the carti­ laginous L-strut is compromised by a large perforation. An

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abundance of nasal crusts may prevent examination, and these patients should receive a course of emollients and irrigation before evaluation.34 Nasal endoscopy should be performed to characterize the anatomic location of the perforation and to measure the anteroposterior and superoinferior dimensions of the perforation.32 The presence of generalized mucosal crusting, nodularity, or ulceration that is not limited to the perforation is sug­ gestive of a granulomatous or vasculitic process. The septum should be palpated with a cotton-tip applicator to delineate the boundaries of the cartilage relative to the edge of the perforation. An absence of cartilage, as may occur in post-septoplasty perforations, can complicate the elevation of the mucoperichondrial flaps during repair. In contrast, perforations from cocaine abuse are often sharply demarcated with cartilage preservation up to its edges.34 The workup concludes with laboratory investigations, if warranted, to facilitate identification of the underlying etiology. For example, elevations in p-ANCA are asso­ ciated with Churg–Strauss syndrome, increases in c-ANCA will occur with Wegener’s granulomatosis, and ACE levels are increased in sarcoidosis. The posterior edge of the perforation can be biopsied and sent for culture and patho­ logy in patients with an unclear cause for their perforation. Enlarging the vertical height of the perforation with biopsies should be avoided.32

NONOPERATIVE MANAGEMENT The mainstay of nonoperative management of nasal sep­ tal perforation is the establishment and maintenance of adequate nasal hygiene. Digital trauma or instrumentation of the nose with, e.g. cotton swabs should be avoided. Nasal saline spray or irrigating solution can effectively debride the perforation and reduce the accumulation of crusts. Petroleum-based ointment, gently applied intranasally a few times daily, can also prove effective against crust accumulation. Visible mucosal inflammation or intranasal tenderness suggestive of an infective process should be treated with antibiotic-based ointments.32 In patients who elect to forego surgical closure of their perforation, who harbor comorbidities precluding safe surgery under general anesthesia, or in whom the configuration of the perforation prevents the use of the techniques described below to effect surgical closure, a septal button can be used as an alternative treatment. This prosthetic device is made of soft silicone (Silastic), and has been used since the 1970s to close septal perfora­ tions for months to years.35 Septal buttons can be effective

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Section 8: Functional Surgery of the Nasal Airway

in reducing the morbidity associated with nasal septal perforation. In one study, patients reported a 70% reduction in the severity of stenosis, crusting, and bleeding.36 The septal button device is available in a variety of sizes and placement can be performed under local or topical anesthesia. Insertion technique consists of folding the flanges on one side of the septal button and passing this through the perforation using an alligator or bayonets to pull the flanges through. Upon release, the septum should be sandwiched between the two round flanges of the septal button. The septal button should extend superiorly into the region of the internal nasal valve and inferiorly to the level of the nasal floor. Avoiding direct contact with the nasal floor permits for a more comfortable placement.32 Septal buttons have been associated with complica­ tions including increased frequency of epistaxis, intranasal pain, and enlargement of the perforation secondary to pressure necrosis around the edges.32 Approximately, twothirds of patients will require removal of the septal button within 4 years. Among this group, nearly two-thirds will have the septal button removed within 2 months. Removal rates are significantly higher in patients with nasal septal perforations resulting from septoplasty with cartilage resection.36 In this group of patients, in those intolerant of the septal button, and in patients electing primary surgical repair, a variety of operative techniques can be used to affect closure of the septal perforation.

SURGICAL TECHNIQUES The primary goal of surgical perforation repair is to restore the normal function of the nose. Consequently, recently described techniques entail the use of intranasal advance­ ment flaps to maintain a functional intranasal lining. The use of skin or buccal mucosal grafts can effectively close the perforation, but may result in persistent nasal dryness due to replacement of the respiratory epithelium with nonphysiologic tissue.32,34 The second aim of surgery is to achieve a tension-free closure of the perforation as the septal mucosa, with its lack of elasticity, is particularly prone to dehiscence. Another significant determinant of success is the vertical height of the perforation and the size of the perforation relative to the available septal mucosa. A smaller perforation in the setting of plentiful mucosa is the most likely to be successfully repaired. Perforations that extend all the way to the nasal dorsum or down to the nasal floor are the most technically challenging to repair, as any advancement flaps cannot be reliably secured superiorly or inferiorly.

The absence of septal cartilage is also problematic due to the difficulty in elevating the mucoperichondrial flaps.34

Endonasal Approach The endonasal approach is indicated for the repair of small (0–10 mm) septal perforations. This approach can be facili­ tated through the use of an endoscope. A hemitransfixion incision is made and bilateral mucoperichondrial flaps are broadly elevated around the perforation and are extended posteriorly beyond the back edge of the perforation. Mucosal rotation/advancement flaps, typically based posteriorly, are configured from the septal mucosa superior and inferior to the perforation to provide the laxity necessary for mucosal closure (Figs. 41.15A and B). Optimal flap closure may require elevation of bilateral flaps to ensure satisfactory overlap of the advancement flaps. An inter­ positional graft can be placed between the mucoperi­ chondrial flaps as a scaffold to reinforce the closure, but in general cannot serve as the sole layer for any part of the closure.32,34 Septal or calvarial bone or cartilage, obtained from the nasal septum or auricular concha, is commonly used as an interpositional graft. Other options include pericranium, temporalis fascia, and acellular dermal allo­ graft, the latter of which avoids donor site morbidity. The graft material is configured to be significantly larger than the perforation and is then sandwiched between the mucoperichondrial flaps. The mucoperichondrial flaps are then advanced to reapproximate the edges of the perfora­ tion and to conceal the interpositional graft.32 Suture fixation of the flaps with monofilament absorbable suture helps to ensure satisfactory coverage of the perforation with viable tissue. Care is taken to stagger the closure lines on each side of the nose such that they are not directly apposed. Silastic splints are placed and left in position for 2–3 weeks.

External Approach The external approach is advocated as the preferred ap­ p­roach for closure of most septal perforations up to 3 cm in diameter owing to excellent exposure around the perforation, and more complete mucoperichondrial flap elevation allowing for success rates exceeding 90%.34 The surgical technique is essentially identical to that described earlier for external septoplasty. In brief, after application of a local anesthetic and vasoconstrictor, columellar and bilateral marginal incisions are made, the skin-soft tissue envelope is elevated, and the medial crura are separated to allow access to the septum.

Chapter 41: Surgery of the Nasal Septum

A

611

B

Figs. 41.15A and B: Mucosal rotation-advancement flap for septal perforation closure. Use of a posteroinferior-based rotation-advance­ ment flap, along with a superiorly based advancement flap, to affect closure of a large septal perforation.

Fig. 41.16: Bipedicled mucoperichondrial flap for septal perforation closure. An inferior based bipedicled flap can be created through a lateral incision in the inferior meatus. The flap is then advanced toward the perforation. Closure can be facilitated by recruiting additional mucosa with a superior bipedicled mucoperichondrial flap that is mobilized downward to meet the inferior flap.

At this point, the mucoperichondrial flaps are elevated bilaterally as described earlier. The posterior extent of dissection must proceed, at a minimum, 1 cm beyond the edge of the perforation but, ideally, to just beyond the bony-cartilaginous junction. The flaps are elevated up to the upper lateral cartilages that are then separated sharply from the septum. The inferior portion of each mucoperichondrial flap is elevated off the nasal floor and this dissection continues laterally to the insertion of the inferior turbinate into the lateral nasal wall. If necessary, a septoplasty is performed to allow for greater laxity of

the elevated mucoperichondrial flaps. At this point, the surgeon should have a clear view of the elevated muco­ perichondrial flaps on each side and the intervening septal cartilage.34 A bipedicled mucoperichondrial flap is created by making a lateral releasing incision just inferior to the attachment of the inferior turbinate to the lateral nasal wall (Fig. 41.16). This can then be advanced medially to close the perforation. Further flap movement can be achieved by making a transverse incision that begins at the anterior nasal spine, travels just posterior to the

612

Section 8: Functional Surgery of the Nasal Airway

nasal sill, and then meets the lateral releasing incision. A similar transverse “back cut” incision can be performed from the posterior end of the lateral releasing incision. For larger perforations, a superiorly based flap that pro­ vides a few additional millimeters of movement may facilitate closure. The mucoperichondrium is elevated from the undersurface of the upper lateral cartilages and septum above the perforation.32 Additional movement of the superior flap can be achieved by incising through the mucoperichondrium at the junction of the upper lateral cartilage and septum, effectively creating another bipedicled flap.34 The released mucoperichondrial flaps are then advan­ ced to reapproximate the freshened mucosal edges of the perforation. Exposed bone along the nasal floor resulting from flap advancement will remucosalize. Foil from a suture pack is shaped to be slightly larger than the perforation and inserted between the mucoperichondrial flaps. This allows for closure of each mucosal defect with 5-0 chromic gut suture from posterior to anterior, without inadvertent catching of the contralateral mucoperichondrial flap. The foil barrier is then removed and an interpositional graft placed. The graft material must be advanced posteriorly to at least 1 cm beyond the edge of the perforation. Anteriorly, the graft may extend to within 1–2 mm of the caudal edge of the septum. The mucosal flaps and interpositional graft are then secured using 4-0 chromic gut suture on a straight needle.32 A continuous quilting suture can then be placed. The medial crural footplates are reapproximated as detailed above. Tension along the closure lines and signi­ ficant flap elevation can cause unwanted tip rotation.

Refinement of the nasal tip may be required, and is discussed elsewhere in this volume. The skin-soft tissue envelope is redraped and the columellar and marginal incisions closed. Bilateral Silastic intranasal splints are placed on either side of the septum, and are left in position for 2–3 weeks. The surgical site can be monitored through the clear Silastic sheeting and, if necessary, the splints can be left in place longer if there are nonhealing areas apparent on examination.

Alternative Techniques Intranasal flaps may be inadequate for the closure of large perforations exceeding 2–3 cm in size, or those that are located in challenging anatomic areas. Alternative techniques have been developed to address these cases. The inferior turbinate pedicled flap can be used to repair perforations of the caudal septum up to 3 cm in diameter and those involving the columella (Fig. 41.17). The procedure can be performed through an endonasal approach.37 Patients who have had previous turbinate sur­ gery and those with atrophic rhinitis are not candidates for this technique. The flap is pedicled anteriorly and the inferior half of the turbinate is the donor tissue. Under endoscopic view, a knife incision is made vertically from the inferior edge of the medial, posterior turbinate in a superior direction. This transitions to a horizontal incision along the superior aspect of the turbinate toward the pedicle anteriorly. A through-and-through scissor cut is made along this incision line. The flap is rotated anteriorly to cover the perforation after opening the distal portion

Fig. 41.17: Inferior turbinate flap for septal perforation closure. An anteriorly based inferior turbinate flap is created, and then swung forward toward the perforation. The free end is unfurled and stitched around the perforation with the mucosal surface facing outward. The pedicle is transected 3 weeks post-inset.

Chapter 41: Surgery of the Nasal Septum such that mucosa constitutes one surface and submucosa the opposite side. The flap is sutured in position using 4-0 plain gut. The submucosa is left exposed on one side to heal by secondary intention over approximately 3 weeks. Three weeks later, the pedicle is taken down under local anesthetic. Postoperative care includes intranasal saline spray and topical ointment to maintain humidification.37 Reported complications include nasal obstruction from the bulkiness of the flap, synechiae between the septum and residual inferior turbinate, and a low risk of complete flap failure. Tardy advocates the use of a tunneled sublabial muco­ sal flap for closure of large anterior perforations.38 The ipsilateral buccal mucosa is incised and a medially based flap is raised and passed through a midline sublabial incision into the nose. This is then interposed between elevated septal mucoperichondrial flaps. Flap failure has been reported due to constriction of the oronasal tunnel. There is also a risk of a persistent oronasal fistula. This latter risk can be attenuated through use of the facial artery musculomucosal flap, which is based on the facial artery and can be used to close perforations 2–4 cm in size.32 The buccal mucosa and mucosa of the inferior gingi­ vobuccal sulcus is raised and tunneled into the piriform aperture using a subperiosteal dissection. The graft is then sewn into position. The largest perforations, such as those created through long-term cocaine abuse, can be closed using radial forearm free tissue transfer.39 The flap, although initially quite bulky, thins with time, becoming less obstructive. However, this surgery is a last resort for perforation repair due to the technical challenges of microvascular anastomosis, the lengthiness of the pro­ cedure, and significant donor site morbidity.

OUTCOMES The wide variety of septal perforation repair techniques in use and lack of standardization in reporting the size and configuration of a perforation have complicated outcome analysis. The absence of randomized prospective trials in the literature has prevented meta-analysis. However, systematic reviews evaluating outcomes have been con­ ducted to identify factors that predict overall rates of suc­ cessful repair.40,41 Incorporating data from 59 studies, Kim and Rhee noted that large perforations, those greater than 2 cm in diameter, are successfully repaired in 78% of patients. Smaller and moderately sized perforations had a significantly higher closure rate of 93%.40 Although not quantified in published studies, posterior perforations

613

are anecdotally more difficult to repair. However, these posterior perforations are rarely symptomatic and often do not require repair. Among pedicled mucosal flap techniques, lower clo­ sure rates of 30–70% have been associated with the inferior turbinate flap.41 Consequently, it has been suggested that this flap be preferentially used in patients with scar­ red tissue precluding the use of a mucoperichondrial advancement flap. These mucoperichondrial flaps are associated with a significantly greater success rate. This is particularly true when bilateral mucoperichondrial flaps are used, as described above, rather than a single-layer unilateral flap (84.5% vs. 73.5%).40 This success rate may be enhanced to greater than 90% through the use of an intervening interposition graft, such as septal cartilage, acellular human dermis, or temporalis fascia, to act as a scaffold for mucosal migration.34,41 Although the open rhinoplasty approach has been shown to have a higher surgical failure rate than the endo­ nasal approach, this finding is confounded by the more frequent use of the open approach for the repair of larger, more technically challenging perforations.40 There is no definitive evidence that surgical approach influences per­ foration closure rate.41 There are, however, distinct advan­ tages to each approach as described earlier. In summary, the size of the septal perforation is the primary determinant in closure rate. The repair technique also influences success rates with higher closure rates achieved through the use of bilateral mucoperichondrial flaps. The use of an interpositional graft may further enhance the success rate. The surgical approach selected should be decided on the basis of surgeon experience and comfort as this is less likely to directly influence closure rates.

CONCLUSION Successful surgery of the nasal septum is predicated on a detailed preoperative evaluation to identify appropriate operative candidates and, perhaps more importantly, to determine which patients will not benefit. The goal of the surgeon should be to maintain physiologic function of the nose whenever possible through conservative cartilage-sparing techniques. Maintenance of an adequate dorsal and caudal strut, as well as preservation of muco­ perichondrium, forms the mainstay of good surgical tech­ nique. Adherence to these principles will often result in a satisfying outcome for both the patient and the surgeon.

614

Section 8: Functional Surgery of the Nasal Airway

REFERENCES 1. Singh A, Patel N, Kenyon G, et al. Is there objective evidence that septal surgery improves nasal airflow? J Laryngol Otol. 2006;120(11):916-20. 2. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr Surg. 2002;109(3): 1128-46; quiz 45-6. 3. Fettman N, Sanford T, Sindwani R. Surgical management of the deviated septum: techniques in septoplasty. Oto­ laryngol Clin North Am. 2009;42(2):241-52, viii. 4. Lane AP. Nasal anatomy and physiology. Facial Plast Surg Clin North Am. 2004;12(4):387-95, v. 5. Getz AE, Hwang PH. Endoscopic septoplasty. Curr Opin Otolaryngol Head Neck Surg. 2008;16(1):26-31. 6. Sedaghat AR, Busaba NY, Cunningham MJ, Kieff DA. Clinical assessment is an accurate predictor of which patients will need septoplasty. Laryngoscope. 2013;123(1):48-52. 7. Chaaban M, Shah AR. Open septoplasty: indications and treatment. Otolaryngol Clin North Am. 2009;42(3):513-9. 8. Eccles R. Nasal airflow in health and disease. Acta Oto­ laryngologica. 2000;120(5):580-95. 9. Kridel RWH, Kelly PE, Holzapfel AM. The nasal septum. In: Flint PW, Haughey BH, Lund VJ, et al. (eds), Cummings Otolaryngology Head & Neck Surgery. Philadelphia: Mosby Elsevier; 2010. p. 481-95. 10. Huizing EH, de Groot JAM. Functional Reconstructive Nasal Surgery. Stuttgart, Germany: Georg Thieme Verlag; 2003. 11. Mlynski G. Surgery of the nasal septum. Facial Plast Surg. 2006;22(4):223-9. 12. Cottle MH, Loring RM, Fischer GG, et al. The maxillapremaxilla approach to extensive nasal septum surgery. AMA Arch Otolaryngol. 1958;68(3):301-13. 13. Fry H, Robertson WV. Interlocked stresses in cartilage. Nature. 1967;215(5096):53-4. 14. Haack J, Papel ID. Caudal septal deviation. Otolaryngol Clin North Am. 2009;42(3):427-36. 15. Most SP. Anterior septal reconstruction: outcomes after a modified extracorporeal septoplasty technique. Arch Facial Plast Surg. 2006;8(3):202-7. 16. Kridel RW, Scott BA, Foda HM. The tongue-in-groove technique in septorhinoplasty. A 10-year experience. Arch Facial Plast Surg. 1999;1(4):246-56; discussion 57-8. 17. Cukurova I, Cetinkaya EA, Mercan GC, et al. Retrospective analysis of 697 septoplasty sur­gery cases: packing versus trans-septal suturing method. Acta Otorhinolaryngologica Italica. 2012;32(2):111-4. 18. Kristensen S, Bjerregaard P, Jensen PF, et al. Post-opera­ tive nocturnal hypoxia in septoplasty: the value of nasal packing with airway tubes. Clin Otolaryngol Allied Sci. 1996;21(4):331-4. 19. Fairbanks DN. Complications of nasal packing. Otolaryngol Head Neck Surg. 1986;94(3):412-5. 20. Jung YG, Hong JW, Eun YG, et al. Objective usefulness of thin silastic septal splints after septal surgery. Am J Rhinol Allergy. 2011;25(3):182-5. 21. Lanza DC, Kennedy DW, Zinreich SJ. Nasal endoscopy and its surgical applications. In: Lee KJ (ed.), Essential

22. 23. 24. 25. 26. 27. 28.

29. 30. 31.

32. 33. 34. 35. 36. 37. 38. 39. 40. 41.

Oto­laryngology: Head and Neck Surgery, 7th edition. New York: Appleton & Lange; 1999. pp. 407-25. Stammberger H. Functional Endoscopic Sinus Surgery. Philadelphia: B.C. Decker; 1991. Hwang PH, McLaughlin RB, Lanza DC, et al. Endo­scopic septoplasty: indications, technique, and results. Otola­ ryngol Head Neck Surg. 1999; 120(5):678-82. Sautter NB, Smith TL. Endoscopic septoplasty. Otolaryngol Clin North Am. 2009;42(2):253-60, viii. Raynor EM. Powered endoscopic septoplasty for septal deviation and isolated spurs. Arch Facial Plast Surg. 2005; 7(6):410-2. Sousa A, Iniciarte L, Levine H. Powered endoscopic nasal septal surgery. Acta Medica Portuguesa. 2005;18(4):249-55. Gubisch W. Extracorporeal septoplasty for the markedly deviated septum. Arch Facial Plast Surg. 2005;7(4):218-26. Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg. 2004;130(3):283-90. Siegel NS, Gliklich RE, Taghizadeh F, et al. Outcomes of septoplasty. Otolaryngol Head Neck Surg. 2000;122(2): 228-32. Bothra R, Mathur NN. Comparative evaluation of conven­ tional versus endoscopic septoplasty for limited septal deviation and spur. J Laryngol Otol. 2009;123(7):737-41. Moore M, Eccles R. Objective evidence for the efficacy of surgical management of the deviated septum as a treatment for chronic nasal obstruction: a systematic review. Clin Otolaryngol. 2011;36(2):106-13. Watson D, Barkdull G. Surgical management of the septal perforation. Otolaryngol Clin North Am. 2009;42(3):483-93. Lanier B, Kai G, Marple B, et al. Pathophysiology and progression of nasal septal perforation. Ann Allergy, Asthma Immunol. 2007;99(6):473-9; quiz 80-1, 521. Kridel RW. Considerations in the etiology, treatment, and repair of septal perforations. Facial Plast Surg Clin North Am. 2004;12(4):435-50, vi. Facer GW, Kern EB. Nasal septal perforations: use of Sila­ stic button in 108 patients. Rhinology. 1979;17(2):115-20. Dosen LK, Haye R. Silicone button in nasal septal perfora­ tion. Long term observations. Rhinology. 2008;46(4): 324-7. Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbi­ nate flap for repair of nasal septal perforation. Laryngo­ scope. 2003;113(8):1425-8. Tardy ME, Jr. “Practical suggestions on facial plastic sur­ gery—how I do it”. Sublabial mucosal flap: repair of septal perforations. Laryngoscope. 1977;87(2):275-8. Mobley SR, Boyd JB, Astor FC. Repair of a large septal perforation with a radial forearm free flap: brief report of a case. Ear Nose Throat J. 2001;80(8):512. Kim SW, Rhee CS. Nasal septal perforation repair: predic­ tive factors and systematic review of the literature. Curr Opin Otolaryngol Head Neck Surg. 2012;20(1):58-65. Goh AY, Hussain SS. Different surgical treatments for nasal septal perforation and their outcomes. J Laryngol Otol. 2007;121(5):419-26.

Chapter 42: Surgical Management of the Nasal Turbinates

615

Chapter

Surgical Management of the Nasal Turbinates

42

Andrea S Wang, Nicole M Hsu, Michael G Stewart

INTRODUCTION Inferior turbinate hypertrophy is a common cause of chronic nasal obstruction. While the normal inferior turbi­ nates warm, filter, and humidify inhaled air, edema and engorgement of the inferior turbinates largely obstruct nasal airflow. Inferior turbinate hypertrophy may be bilateral or unilateral. Bilateral turbinate hypertrophy is associated with nasal inflammation from allergens, infections, other environmental factors such as tobacco smoke, or preg­ nancy.1 Unilateral turbinate hypertrophy usually occurs in association with a deviated nasal septum toward the contralateral side. Turbinate hypertrophy may be primarily mucosal, osseous, or both. Medical treatment consists of nasal steroids, decon­ gestants, and antihistamines that address the mucosal turbinate hypertrophy. Surgery is reserved for cases that are refractory to medical treatment. Many surgical tech­ niques and instruments have been described in the otolaryngology literature, with no consensus for a gold standard approach. Over the last three decades, there has been a gradual evolution away from total turbinate resection, toward more minimally invasive, submucosal reduction, or partial resection. In this chapter, we will review turbinate surgery by approach, beginning with turbinectomy (including total and partial turbinate resec­ tion), turbinoplasty (or submucous resection of turbinate bone), mucosal ablation, submucosal reduction, and turbinate lateralization (Table 42.1). For each approach, there are variations in technique and tools that may be used. In addition, some of the surgical tools may be used to accomplish multiple techniques. For example,

microdebrider may be used in both partial resection and submucosal reduction in the turbinate. We will also review comparative outcomes of the various approaches (Table 42.2).

TURBINECTOMY Turbinectomy, or turbinate resection, encompasses a variety of procedures, which can range from extensive resection of the entire inferior turbinate to limited resec­ tion of the anterior turbinate head.

Total Turbinate Resection This technique, first reported around the turn of the twen­ tieth century, typically requires an initial fracturing of the turbinate bone medially, toward the septum, with a Freer elevator. A clamp is applied to the portion of inferior turbinate to be resected in order to assist with hemostasis. Heavy scissors are then utilized to resect the turbinate. The cut is made along the lateral attachment of the inferior turbinate bone (Fig. 42.1). Additional hemostasis of the cut edge can be achieved with electrocautery. Total or extensive subtotal resection is no longer com­ monly performed as it is believed to predispose patients to atrophic rhinitis or paradoxical nasal obstruc­ tion.2 Moore et al.3 performed a retrospective analysis of pati­ents who had undergone total inferior turbinectomy and repor­ ted a significant morbidity associated with the pro­ cedure. Of the 18 patients who had undergone bilateral total turbinectomy and were followed for 3–5 years, 66% developed atrophic rhinitis (chronic nasal crusting

616

Section 8: Functional Surgery of the Nasal Airway

Table 42.1: Surgical techniques for inferior turbinate reduction

Technique Total turbinectomy

Advantages Long-term relief of nasal obstruction

Partial turbinectomy Turbinoplasty/submucous turbi­ nate resection

Long-term relief of nasal obstruction Preserves mucosal function Reduces bony hypertrophy Excellent long-term nasal patency Easy to learn May be performed in office under local anesthesia May be performed in office under local anesthesia Minimal bleeding due to hemostasis Easy to learn May be performed in office under local anesthesia Mucosal preservation Maintenance of ciliary function May be performed in office under local anesthesia Minimal bleeding, no need for postoperative packing Easy to learn Submucosal resection with preservation of mucosa and ciliary function Excellent long-term results May reduce some bony hypertrophy Easy to learn Can be combined with other procedures

Mucosal electrocautery

Laser

Submucosal electrocautery

Radiofrequency ablation (RFA)

Microdebrider-assisted turbinate reduction (MATR)

Lateralization

and foul odor), 22% experienced ozena (crusting, foul odor, and anosmia secondary to destruction of olfactory nerve endings), and only 11% were symptom free with an imp­roved nasal airway. Chhabra and Houser4 described paradoxic nasal obstruc­ tion, otherwise known as “empty nose syndrome,” which is another potential complication of turbinate resection. They estimated that approximately 20% of pati­ents who have undergone total inferior turbinectomy develop this iatrogenic disorder. It is thought to result from paucity of mucosal surface area within the nasal cavity, leading to a paradoxical sensation of nasal obstruction due to lack of sensation of airflow despite a widely patent nasal passage. However, there have been various studies that have reported good long-term effectiveness after total turbi­ nectomy with minimal complications.5-8 Ophir et al.7 per­ formed a long-term follow-up of 186 patients over 10–15 year period after total turbinectomy. They demonstrated

Disadvantages Increased risk of postoperative bleeding Risk of atrophic rhinitis Synechiae formation Bleeding Technically difficult to learn Bleeding Symptoms may return in months to years Postoperative crusting, pain, adhesions Cost of equipment Laser training required Postoperative eschar and crusting Symptoms may return in months to years Postoperative crusting, pain Symptoms may return after 1 year

Possible bleeding and mucosal tears Equipment cost

Does not address hypertrophied mucosa Minimal relief when performed alone

82% of patients had subjective relief of obstruction and widely patent airway on rhinoscopy. And, despite living in a dry, dusty climate, none of the patients in their study suffered excessive crusting or dryness, suggesting the function of the remaining mucosa within the nasal cavity was not impaired. Although the long-term outcomes of inferior turbi­ nectomy and the risk of potential complications remain controversial, total turbinectomy has largely fallen out of favor. This is largely secondary to the availability of more physiologic treatments and the desire to avoid the potentially permanent morbidity associated with empty nose syndrome in a patient with a quality of life symptom.

Partial Turbinate Resection Partial resections are believed to have lower risk of potential complications because there is greater preservation of the

Allergic rhinitis

Turbinate hypertro­ phy

Retrospective

Prospective, randomized, single blinded, placebo controlled

Prospective, randomized

Prospective, randomized, single blinded

Prospective cohort

Lin26 (2010)

Porter39 (2009)

Liu35 (2009)

Kizilkaya34 (2008)

Yanez28 (2008)

Harrill37 (2007) Prospective, nonrandomized

Nasal obstruction

Turbinate hypertro­ phy

Nasal obstruction

Allergic rhinitis

Nasal obstruction

Prospective

Turbinate hypertrophy

Cingi38 (2010)

29

Case series

Patient selection

Aksoy (2010)

Author (year of publication) Type of study

In office RFA, in OR RFA and septoplasty

MATR

MATR, RFA

MATR, RFA

RFA

RFA

MATR, RFA

Lateralization

Surgical techniques

Table 42.2: Surgical management of inferior turbinate literature

77

350

30

120

32

146

268

40

10 years

6 months

3 years

2 years

5 years

3 months

6 months

Follow-up period

NOSE validated on form 6 months questionnaire

VAS, nasal endoscopy, acoustic rhinometry, mucociliary saccharin transit time

VAS, saccharine transit time, ciliary beat frequency, anterior rhinomanometry

VAS, anterior rhinoma­ nometry, saccharin test

VAS

VAS, patient satisfaction questionnaires

Rhinomanometry, subjective symptoms, patient satisfaction

CT

Number of patients Outcome measures

Contd...

Improvement in both groups; consider in-office cost savings.

Significant and equal improvement in VAS and rhinometry at 6 months; STT and CBF unchanged.

Significant and equal improvement in VAS and rhinometry at 6 months STT and CBF unchanged

All outcomes improved in microdebrider group at 3 years. RFA group improved up to 1 year, but declined at 3 years

Sustained symptom improvement at 2 years compared with baseline.

15% received other nasal surgery for RFA failure. VAS scores while improved at 6 months, trended back to baseline at 5 years

Nasal obstruction improved in microdebrider and RFA at 3 months, but greater in microdebrider

Inferior turbinates remained in lateralized position at 6 months

Key findings

Chapter 42: Surgical Management of the Nasal Turbinates

617

Prospective

Cavaliere25 (2005) Turbinate hypertrophy Turbinoplasty, RFA

75

308

6 months

6 years

VAS

Anterior rhinoma­ nometry, acoustic rhinometry, nasal mucociliary transport time, measurement of secretory immuno­ globulins

VAS, nasal endoscopy, 3 months anterior active positional rhinomanometry, sac­ charin tests

Symptom questionnaire, 7.8 years rhinomanometry

Number of Follow-up patients Outcome measures period 113 Symptom questionnaire, 3–5 years rhinomanometry

Prospective, ran­ Turbinate hypertrophy RFA 32 domized, single blinded, placebo controlled Turbinectomy, 382 Passali30 (2003) Prospective, rand­ Chronic allergic or omized vasomotor rhinitis laser, electrocau­ tery, cryothera­ py, submucosal resection, submucosal resection with lateralization

Nease23 (2004)

Nasal obstruction

Retrospective

Testa40 (2006)

CO2 laser

Surgical Patient selection techniques Turbinate hyper­trophy Ho:YAG, secondary to allergic diode laser or vasomotor rhinitis

Author (year of publication) Type of study Sroka16 (2007) Retrospective

Contd...

Contd...

Only SMR resulted in longterm nasal patency and restoration of mucociliary clearance and local secre­ tory IgA production. Lateral displacement of the inferior turbinate improved the longterm results.

Significant long-term improvement in nasal obstruction and blockage in both hypertrophy rhinitis and allergic rhinitis. Aller­gic rhinitis patients had reduced rhinorrhea and sneezing. However, severe chronic allergic rhinitis patients continued to require H2 an­ tagonists or steroids during allergy season. Both monopolar and bipolar RFA resulted in similar reduction in nasal symp­ toms, nasal resistance, and maintenance of nasal function at 20 months Significant improvement in treatment group at 6 months

Key findings Subjective improvement in 67.5% after Ho:YAG and in 74.4% after diode laser treatment. Both groups had improved airflow on rhino­ manometry at 6 months and 3 years after treatment. Ho:YAG laser had shorter pe­ riod of postoperative edema and crusting than diode laser

618 Section 8: Functional Surgery of the Nasal Airway

Prospective, randomized

Turbinate hypertro­ phy secondary to allergic or vasomotor rhinitis Turbinate hyper­ trophy secondary to allergic or vasomotor rhinitis

Turbinate hypertro­ phy secondary to allergic or vasomotor rhinitis

Retrospective

Retrospective

Retrospective

Lippert42 (1998)

Lippert43 (1997)

Lippert44 (1997)

Total turbinectomy

112

118

CO2, Nd:YAG 227 laser, submu­ cosal diathermy

CO2 laser

CO2 and Nd:YAG laser

120

357

6 years

3 months

Follow-up period

Symptom questionnaire, 2 years rhinomanometry

Symptom questionnaire, 2 years rhinomanometry

Symptom questionnaire, 6 weeks objective grading of inferior turbinates Symptom questionnaire, 5 years rhinomanometry

Symptom questionnaire

VAS, rhinomanometry, nasal mucociliary trans­ port time

Number of patients Outcome measures

RFA, CO2 laser, 45 partial turbinec­ tomy

Surgical techniques

Nasal obstruction, tur­ MATR binate hypertrophy

Prospective

Nasal obstruction

Turbinate hypertrophy

Patient selection

Friedman41 (1999)

Talmon8 (2000) Retrospective

Sapci32 (2003)

Author (year of publication) Type of study

Contd... Key findings

Contd...

80.4% patients with improve­ment after 2 years with no significant differ­ ence in outcomes between allergic and nonallergic rhinitis patients Both laser groups had better long-term satisfac­ tion (79.6% CO2 laser and 68.3% Nd:YAG) compared with submucosal diathermy (36%) at 2 years. Nd:YAG caused prolonged postop­ erative edema and crusting compared with CO2. How­ ever, the entire turbinate is ultimately reduced with Nd:YAG, while CO2 laser affects only the anterior head.

At 5 years after treatment, 77.1% of CO2 laser patients and 64.5% in Nd:YAG laser patients reported improved nasal airway

75% had no post-op nasal obstruction

Nasal mucociliary transport time in RFA and partial turbinectomy were near normal at 3 months. Nasal mucociliary transport time in CO2 laser was twice that of normal No atrophic rhinitis. 1.7% with postoperative bleeding

Chapter 42: Surgical Management of the Nasal Turbinates

619

Nasal obstruction due to perennial allergic or non-allergic rhinitis Perennial allergic rhinitis

Prospective, randomized, double-blind

Retrospective

Retrospective

Retrospective

Cook45 (1993)

Kawamura46 (1993)

Ophir7 (1991)

Wight47 (1990)

Turbinate hypertro­ phy secondary to allergic or vasomotor rhinitis

Turbinate hypertro­ phy

Chronic rhinitis

Retrospective

Mucci (1994)

12

Patient selection

Author (year of publication) Type of study

Contd...

Total turbinec­ tomy, partial turbinectomy (anterior trim­ ming)

Total turbinec­ tomy

CO2 laser

CO2 laser, submucosal diathermy

Partial tur­ binectomy, septoplasty

Surgical techniques

27

186

72

29

55

Rhinomanometry, subjective symptoms, questionnaire

Symptoms question­ naire, anterior rhinos­ copy

Subjective symptoms

Symptom questionnaire and peak nasal flow meter

Symptom questionnaire

Number of patients Outcome measures

Mean 20.5 months for total turbi­ nectomy, mean 22.8 months for partial tur­ binectomy

10–15 years (mean 12.3 years)

24 months

1 year

12–39 months

Follow-up period

Contd...

Decrease in nasal resistance in 83% of total turbinec­ tomy patients. However, 37.5% had worsening nasal obstruction between 2 and 20 months, and 18.8% felt that postoperative nasal obstruction was the same as preoperative obstruc­ tion. Partial turbinectomy patients had decreased resistance, but no improve­ ment in sensation of nasal obstruction; 67% of these patients converted to total turbinectomy

82% with sustained improvement in nasal obstruction. No patients with atrophic rhinitis.

84.7% had improvement in symptoms at 2 years. However, 37.5% of patients required a second treatment due to recurrence of symp­ toms within 24 months.

Laser therapy patients maintained improved nasal flow 1 year after surgery, while submucosal dia­ thermy patients did not

13 patients underwent inferior partial turbinectomy alone; 92.3% reported improved nasal obstruction

Key findings

620 Section 8: Functional Surgery of the Nasal Airway

Turbinate hypertro­ phy secondary to allergic or vasomotor rhinitis

Nasal obstruction

Turbinate hypertro­ phy

Prospective, randomized

Retrospective

Retrospective

Wight48 (1988)

Meredith31 (1987)

Fanous12 (1986)

14

Turbinate hypertro­ phy

Patient selection

Mabry (1988) Case series

Author (year of publication) Type of study

Contd...

Partial turbi­ nectomy (ante­ rior turbinec­ tomy)

Mucosal elec­ trocautery with lateralization, partial turbi­ nectomy

Total turbinec­ tomy, partial turbinectomy (anterior trim­ ming)

Turbinoplasty

Surgical techniques

220

162

18

40

Subjective symptoms

Symptom questionnaire

Rhinomanometry, sub­ jective symptoms

Subjective symptoms

Number of patients Outcome measures

6 months to 4 years

33 months

2 months

3–5 years

Follow-up period

Contd...

94% with good to excellent improvement. No patients with atrophic rhinitis. 2.7% with postoperative bleeding

69% who underwent mucosal electrocautery with lateralization reported improvement in nasal obstruction, compared with 86% who underwent partial turbinectomy and reported improvement in nasal obstruction.

Total turbinectomy resulted in decreased subjective and objective nasal obstruc­ tion. Partial turbinectomy had decreased objective nasal resistance, but did not decrease subjective nasal obstruction

Improved nasal airway with no complications of bleeding, persistent crusting or dryness, or foul nasal discharge

Key findings

Chapter 42: Surgical Management of the Nasal Turbinates

621

Turbinate hypertro­ phy

Retrospective

Martinez5 (1983)

Total turbinec­ tomy

Total turbinec­ tomy

CO2 laser

Surgical techniques

29

18

140

Symptom questionnaire

Symptom questionnaire

Subjective symptoms

Number of patients Outcome measures

2–60 months

3–5 years

1–12 months

Follow-up period

25 patients with marked improvement in airway.

66% with atrophic rhinitis and 22% with ozena. Only 11% symptom-free with improved airway

At 1 month, 36% with excellent reduction in nasal obstruction, rhinorrhea, and sneezing. At 1 year, 77% with excellent or good results. 17% had recurrence of symptoms requiring revaporization within 9–12 months

Key findings

(RFA: Radiofrequency ablation; MATR: Microdebrider assisted turbinate reduction; VAS: Visual analog scale; NOSE: Nasal Obstruction Symptom Evaluation scale).

Turbinate hypertro­ phy

Perennial allergic rhinitis refractory to conservative treat­ ment

Retrospective

Retrospective

Patient selection

Moore3 (1985)

49

Fukutake (1986)

Author (year of publication) Type of study

Contd...

622 Section 8: Functional Surgery of the Nasal Airway

Chapter 42: Surgical Management of the Nasal Turbinates

Fig. 42.1: Total turbinectomy. (Figure created by David Hsu.)

Fig. 42.3: Microdebrider partial turbinectomy. (Figure created by David Hsu.)

normal mucosa. By limiting resection to specific areas of the inferior turbinate known to restrict airflow, nasal aerodynamics can be improved while being mindful of soft tissue conservation. The resection is usually limited to the anterior turbinate head (Fig. 42.2), relieving obstruction at the internal nasal valve, or along the anteroposterior length of the caudal aspect of the turbinate, which can improve airflow along the nasal floor.9,10 Partial resections may be performed with endoscopic turbinectomy scissors or a microdebrider. The scissors may be implemented in a similar fashion to total turbinectomy, where the resection is limited to the anterior head of the inferior turbinate. When using the microdebrider, the blade is placed along the inferior aspect of the turbinate and used to remove some of the mucosa and bone. Depen­ ding on the area of obstruction, the microdebrider can be used to selectively debulk the head of the turbinate, the posterior aspect, or the entire length of the turbinate (Fig. 42.3). Hemostasis is achieved with coagulation and/ or nasal packing.

623

Fig. 42.2: Partial anterior turbinectomy. (Figure created by David Hsu.)

Fanous11 performed a review of 220 patients who had undergone anterior turbinectomy and were followed for 6 months to 4 years. In 61 patients, anterior turbinectomy was performed alone; of these patients, 35 had previously undergone septoplasty with no significant improvement in breathing. The remaining 159 patients underwent con­ current septoplasty with anterior turbinectomy. He found 94% of patients reported good to excellent improvement in their nasal obstruction after anterior turbinectomy, while none developed atrophic rhinitis. Of the 35 patients who had undergone previous septoplasty, all reported a satisfactory improvement in their breathing. Mucci and Sismanis12 reported a case series of 54 pa­ tients with chronic rhinitis who underwent inferior partial turbinectomy and were followed for 12–39 months (mean follow-up 18 months). Of these patients, 39 had concur­ rent septoplasty and 2 had functional endoscopic sinus surgery, while 13 patients underwent inferior partial turbi­ nectomy alone. They found that 92.3% of all patients reported an improvement in their nasal obstruction with no cases of atrophic rhinitis reported. Of the 13 patients who underwent inferior partial turbinectomy alone, 92.3% reported improved nasal obstruction. Based on these and other results, partial turbinectomy has been favored over total turbinectomy. Decreased nasal obstruction can be achieved with lower rates of atrophic rhinitis and no significant change in other complications, such as bleeding, crusting, or synechiae.13

TURBINOPLASTY Submucosal turbinate bone resection, also commonly referred to as inferior turbinoplasty, can be implemented when there is a significant bony component of the turbinate

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Section 8: Functional Surgery of the Nasal Airway

contributing to nasal obstruction. To determine if bony resection is necessary, careful preoperative evaluation of the inferior turbinate is imperative. If the turbinate mucosa responds well to decongestion with a significant improvement in the nasal obstruction, it suggests that submucosal/mucosal hypertrophy is the major cause of obstruction. However, if the inferior turbinate appears bulky and there is persistent obstruction despite adequate decongestion, the inferior turbinate bone itself could be the obstructive source. An L-shaped incision is made from the anterior turbi­ nate head extending along the caudal margin of the inferior turbinate. The mucoperiosteum is elevated off both the medial and lateral surfaces of the turbinate bone with a Freer elevator. The bone is resected using biting forceps (such as a Jansen-Middleton rongeur) or turbinate scissors. The redundant mucosa is trimmed and the lateral mucoperiosteal flap is then redraped over the reduced inferior turbinate bone. The medial and lateral mucoperiosteal flaps can be reapproximated using absorb­ able sutures or by applying gentle packing along the infero­ lateral aspect to allow for adhesion and healing of the mucoperiosteum to the residual turbinate bone. While this procedure facilitates functional mucosal preservation, it is technically more challenging than most other procedures discussed (Fig. 42.4). Mabry14 described his long-term outcomes with infe­ rior turbinoplasty in 40 patients. Patients had decreased nasal obstruction with no bleeding, crusting, foul nasal discharge, or atrophic rhinitis after 3–5 year follow-up, which he attributed to the remaining flap of soft tissue and mucosa. Mabry emphasized that the etiology of nasal obstruction from inferior turbinate hypertrophy (bony versus mucosal hypertrophy) needs to be identified in each patient to determine the appropriate surgical technique. If the underlying cause of the turbinate hypertrophy is not aptly addressed, recurrent obstruction can and probably will occur.

MUCOSAL ABLATION For patients with significant nasal obstruction secondary to mucosal hypertrophy of the inferior turbinates, proce­ dures focused primarily on mucosal ablation are effective surgical options. Unfortunately, mucosal ablation can lead to loss of mucosal ciliary and secretory function, as well as significant postoperative pain, crusting, and scarring, when compared to other methods.

Fig. 42.4: Preoperative and postoperative views of turbinoplasty. The postoperative view shows the resection of bone. (Figure created by David Hsu.)

Electrocauterization Mucosal electrocautery with a monopolar or bipolar device has been used to cauterize the inferomedial surface of the turbinate linearly in a posterior to anterior manner. The coagulated tissue shrinks in size, and the scarring that occurs during the healing process leads to addi­ tional tissue reduction. Electrocautery results in impaired muco­sal function, as well as increased irritation, crusting, and scarring compared to submucosal techniques. Effects are commonly short lived and repeat cauterization is often required. While otolaryngologists frequently utilize this simple technique, there are very little data on the longterm outcomes of mucosal electrocautery.

Lasers Various lasers have been used for mucosal ablation, including carbon dioxide (CO2), diode, neodymium-yttrium aluminum garnet (Nd:YAG), potassium-titanyl-phos­ phate (KTP), argon-ion, and holmium-yttrium alumi­ num garnet (Ho:YAG) lasers.15 Lasers generate a beam of coherent light absorbed by the tissue, and the extent of absorption and the depth of effect depend on the wavelength of the laser. CO2 laser light (λ = 10,600 nm) is strongly absorbed by water, which makes CO2 laser ideal for cutting and superficial vaporization of tissue. Nd:YAG laser light (λ = 1,064 nm) is able to penetrate deeply into the tissue, thereby inducing large coagulation areas in noncontact mode. Additionally, Nd:YAG laser can be utilized with contact application that generates effective

Chapter 42: Surgical Management of the Nasal Turbinates cutting and vaporizing qualities. Diode laser light (λ = 940 nm) is predominately absorbed by water and blood, and also provides excellent coagulation capabilities in noncontact mode.15-17 KTP (λ = 532 nm) and argon-ion laser (λ = 488/514 nm) emit light that are absorbed by endogenous chromophores, such as hemoglobin, and hence are often used for the management of vascular malformations. Ho:YAG laser (λ = 2,100 nm) provides good cutting capabilities for both bone and soft tissue and achieve good hemostasis. All these lasers, except the CO2 laser, are applied with the use of a flexible quartz fiber in a contact or noncontact mode.16 When utilizing these lasers, the light is applied to the mucosa but the energy is transmitted to the deeper layer, producing less mucosal injury and allowing for submucosal soft tissue destruction and scarring. Typi­ cally, the laser fiber is used to make linear stripes along the inferior surface or a crosshatch pattern on the medial surface of the turbinate. Alternatively, lasers can be utilized in a single- or multiple-spot technique on the anterior head of the turbinate to induce shrinkage and scarring of the soft tissue. Lasers allow for precise ablation of the hypertrophic region with limited damage to the surrounding tissue, and minimal bleeding and discomfort. Many have favored this technique as it can be performed in an outpatient or office setting under local anesthesia. An eschar forms at the site of treatment and patients can experience crusting for several weeks after the procedure. There is concern for potential stray laser injury, and the cost of equipment and laser safety training must be incorporated when determining the cost-effectiveness of this technique. Additionally, similar to the electrocautery technique, the mucosa often regenerates and repeated laser treatments may be needed. As there are numerous types of lasers available, the outcomes of laser reduction in the inferior turbinate are difficult to summarize from the literature. Janda et al.15 performed a comparative review on the various types of lasers that have been used for turbinate reduction. They reported that after 1 year of follow-up, studies showed laser treatment had comparable results to most of the conventional surgical techniques, including electro­ cautery, cryotherapy, chemical cauterization with fewer complications of bleeding, nasal dryness, synechia, and pain. The variations in laser type, laser parameters, and treatment areas on the turbinates within the referenced studies did not allow for a meaningful comparison of the different lasers. The effectiveness of laser reduction in

625

Fig. 42.5: Preoperative and postoperative view of submucosal reduction. The reduction can be accomplished via electrocautery, radiofrequency ablation, or microdebrider. (Figure created by David Hsu.)

the turbinate hypertrophy is contingent on the surgeon’s knowledge and experiences with the chosen laser, along with parameters used, and technique.

SUBMUCOSAL REDUCTION Several studies have shown that submucosal resection results in restoration of mucociliary clearance and longterm nasal patency. However, submucosal resection or turbinoplasty can be technically difficult to perform with­ out injuring the overlying mucosa, resulting in muco­ sal tears, bleeding, and crusting. In recent years, sur­gical techniques that reduce the volume of the inferior turbi­ nates and preserve mucosa with few incisions have become increasingly preferred (Fig. 42.5). These tech­niques include submucosal electrocautery, radiofrequency ablation (RFA), and microdebrider-assisted turbinate reduction (MATR).

Submucosal Electrocautery The oldest of these techniques, submucosal electrocautery or diathermy, was first reported in 1907 by Neres,18-19 who directed a current to a gold needle buried in the turbinate. Further popularized by Simpson and Groves in 1958,19 sub­ mucosal electrocautery involves the longitudinal insertion of monopolar or bipolar needles into the inferior turbinate with the application of electrocautery as the needles are withdrawn. This produces thermal injury and necrosis of the tissue. Postoperative inflammation, fibrosis, and scar

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Section 8: Functional Surgery of the Nasal Airway

contracture result in reduction in tissue. While several devices are available, submucosal electrocautery may also be performed with a spinal needle inserted along the length of the inferior or medial aspect of the turbinate. Electrocautery is then applied to the needle as it is slowly removed. This technique may be performed as an office procedure. The main disadvantage of this technique is regrowth of the inferior turbinate tissue with return of symptoms, which has been reported after months or years.20-21 Complications include crusting and nasal dryness. There have also been reports of bone necrosis requiring local debridement.

Radiofrequency Ablation RFA or radiofrequency volumetric turbinate reduction similarly utilizes a probe that delivers a low-power radiofrequency current to the turbinate, causing ionic agitation and a thermal lesion of the tissue. The main difference between RFA and submucosal electrocautery is the tem­perature and degree of surrounding thermal injury. With RFA, the temperature ranges from 60°C to 90°C, whereas with submucosal electrocautery, the temperature ranges from 750°C to 900°C.22 As cell death occurs when temperatures reach 49.5°C, submucosal electrocautery results in excessive heat and far more adjacent tissue damage. There are several systems available, which vary in probe design (monopolar or bipolar), temperature con­ trol, and use of conductive gels, which theoretically cause tissue ablation with less heat. To perform the technique, the probe is inserted into the head of the inferior turbinate and passed through its length, being careful to keep the probe in a submucous plane. Similar to electrocautery, the ablation occurs as the probe is slowly withdrawn. Several passes may be performed to produce multiple tunnels of thermal injury and to achieve greater tissue volume reduction. Initially, there may be turbinate edema that resolves within 1 week. Other complications include crusting and nasal dryness; postoperative packing is generally not needed. Like submucosal electrocautery, this procedure can be performed in the office with local anesthesia. Clinical studies have shown excellent short-term results. Nease and Krempl23 conducted a prospective, rando­mized, single-blinded, placebo-controlled study of 32 patients to evaluate the short-term efficacy of RFA with the use of

visual analog scales (VAS). The placebo group underwent a sham procedure, in which a radiofrequency probe was inserted into the turbinate, but no current was delivered. They found a significant improvement in frequency of nasal obstruction, severity of obstruction, and ability to breathe at 2 months and 6 months after RFA treatment compared with placebo. Garzaro et al.24 reported on 40 consecutive patients who received RFA and were followed at 2 months and 2 years with nasal endoscopy, anterior rhinomanometry, Nasal Obstruction Symptom Evaluation (NOSE) scale, and olfactory testing. Thirty-five patients completed follow-up, and improvements in total basal nasal resistance, olfactory function, and NOSE score were noted, and were sustained 2 years after treatment. Cavaliere et al.25 compared mono­ polar and bipolar RFA in a randomized, prospective study in 150 patients. They reported that both instruments provi­ ded similar reduc­tion in nasal symptoms, decreased nasal resistance, and maintenance of nasal function at 20 months. Long-term outcomes with RFA have been more vari­ able, with several studies reporting a return of nasal obstruction symptoms. Lin et al.26 reported on long-term outcome and efficacy of RFA in patients with allergic rhinitis in a retrospective review of 146 consecutive patients. One-hundred nineteen of these patients were followed for 5 years postoperatively. Almost 15% of patients were unresponsive to RFA and went on to have other inferior turbinate surgery. The remaining 101 patients were evaluated with a VAS and a patient satisfaction ques­ tionnaire. The patient satisfaction questionnaire included an item on whether the patient would undergo the same procedure again. The mean VAS for nasal obstruction improved greatly from baseline (6.65) to 6 months (2.74). However, at 5 years, the mean VAS for nasal obstruction had increased to 4.45, trending toward the preoperative value. In terms of patient satisfaction, 37.6% of patients would not undergo the same procedure again. Some variables that may improve long-term results include multiple treatment sessions, multiple passes in the turbinate, and the power of the radiofrequency energy. Atef et al.27 conducted a prospective nonrandomized study of 102 patients who received up to five treatments of RFA with 1-year follow-up. Outcome measures included symptom evaluation with VAS and acoustic rhinometry. They found that 88% of the study population achieved relief of nasal obstruction, and that at least three sessions were required to maintain results at 1-year follow-up.

Chapter 42: Surgical Management of the Nasal Turbinates

Microdebrider-Assisted Submucosal Turbinate Reduction Microdebrider-assisted endoscopic sinus surgery has natu­ rally led to MATR, with the development of specialized microdebrider turbinate blades that allow for submucosal resection of tissue. In contrast to tissue reduction through thermal injury, MATR mechanically removes the tissue. The head of the turbinate is injected with local anes­ thetic with epinephrine for hydrodissection and vaso­ constriction of the tissues. A stab incision is made in the head of the turbinate with a scalpel or the leading edge of the turbinate blade. The turbinate blade is then inserted into the head of the inferior turbinate just medial to the bone and a submucosal tunnel is created. The blade is then passed repeatedly from anterior to posterior and is rotated 360° for debridement and suction of soft tissue, being careful to stay within the submucosal plane. The anterior portion of the turbinate is especially important to address, because this is the most significant area of nasal airflow obstruction. The posterior portion of the turbinate can also be addressed with extension of the submucosal tunnel; however, care must be taken to avoid injury to branches of the sphenopalatine artery. The microdebrider can sometimes provide a limited resection of the bone as well as soft tissue. The original stab incision may be cauterized, and nasal packing may or may not be used. Complications include bleeding and mucosal injury. Yanez and Mora28 performed a prospective cohort study to evaluate the long-term efficacy of MATR. Threehundred fifty nonallergic patients with chronic hyper­ trophy of the inferior turbinates who underwent MATR and 323 normal patients with no nasal obstruction symptoms were followed for 10 years, with periodic assessments including VAS, endoscopy, mucociliary clearance, and acoustic rhinometry. About 91.3% of the surgical patients reported no nasal obstruction at the 10-year follow-up. The surgical group also had improved nasal resistance, normal mucociliary clearance, and improved nasal endoscopy at 10-year follow-up.

LATERALIZATION Lateralization or “outfracturing” of the inferior turbinate alters the turbinate’s angle of attachment to the maxillary and palatine bones. This lateral displacement of the turbinate allows for better airflow through the nasal cavity. While this procedure is rarely sufficient as a stand-alone procedure, it is often combined with other turbinate reduction procedures to enhance the nasal airway.

627

In order to laterally displace the turbinate, a flat, blunt instrument, such as a Boies/Goldman elevator, is used to apply force in an inferolateral vector along the bony attachment to the lateral nasal wall. This technique typically results in adequate lateralization; however, the turbinate bone will occasionally only “greenstick” frac­ture, and will not stay lateralized. Initial fracturing of the turbinate medially (often referred to as “infracturing”) followed by a lateral fracture (“outfracturing”) can be helpful in obtaining a complete fracture and sustained lateralization. A Freer elevator is placed lateral to the infe­ rior turbinate in the inferior meatus and force is applied in a superomedial vector until a “crack” is heard or felt. Then the turbinate can easily be displaced laterally as described above. Fracturing the turbinate in multiple locations additionally helps promote a lateralized position. Packing the nasal cavity is not necessary; however, it does promote maintenance of this lateral position during the healing process. There are few studies examining the benefits of isolated lateralization, although Aksoy et al.29 showed that patients who underwent the turbinate lateralization maintained the lateralized position for at least in the first 6 months postoperatively.

COMPARATIVE OUTCOMES Passali et al.30 conducted a prospective randomized trial of 382 patients comparing six surgical techniques (total turbinectomy, laser cautery, electrocautery, cryotherapy, submucosal resection, and submucosal resection with lateralization) with a 6-year follow-up period and multiple outcome measures. Of the six techniques, only submucosal resection resulted in long-term nasal patency, mucociliary clearance, and IgA production after 6 years, with the addition of lateralization of the turbinates improving the results. Patients who underwent total turbinectomy also experienced an improvement in long-term nasal patency; however, mucociliary transport time and secretory IgA concentration remained below normal. Laser cautery, electrocautery, and cryotherapy provided only short-term improvements in nasal resistance and volume. In terms of complications, patients receiving total turbinectomy, laser cautery, electrocautery, and cryotherapy had more chronic crusting. Synechiae was most common in the electrocautery group, while bleeding was more common in the submucosal resection and total turbinectomy groups. Meredith31 reported a case series of 162 patients com­ paring outcomes of mucosal electrocautery with latera­ lization, versus partial turbinectomy. From July 1979 to August 1981, there were 81 patients with nasal obstruction

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due to inferior turbinate hypertrophy who underwent electrocautery and lateralization. Of these patients, 69% had improvement in their nasal obstruction at 33 months after surgery. However, 31% of patients complained of recurrent obstruction due to a return of their inferior turbi­ nate hypertrophy. Therefore, the author elected to change his surgical technique. From August 1981 to December 1982, there were 81 patients who underwent resection of the inferior aspect of the turbinate. Of these patients, 86% showed improvement in nasal obstruction at 33 months after surgery. Meredith concluded that patients who underwent partial turbinectomy had significantly better long-term improvement in nasal obstruction when compared to mucosal electrocautery and lateralization. There have been prospective studies that have shown comparable results between RFA and other methods, with short-term follow-up. Sapci et al.32 compared RFA, CO2 laser ablation, and partial turbinectomy in a prospective randomized clinical trial. Forty-five patients were rando­ mized into one of three groups: group A received laser ablation on one side and partial turbinectomy on the other side, group B underwent RFA on one side and partial turbinectomy on the other side, and group C were the con­ trol subjects and did not receive surgery. Outcome mea­ sures included subjective change in symptoms measured with VAS, nasal resistance measured by rhinomanometry, and mucociliary clearance measured by nasal mucociliary transport time. At 12 weeks, all patients in groups A and B experienced significant symptom improvement and decrease in nasal resistance. RFA and partial turbinectomy resulted in preservation of mucociliary function with near normal mucociliary transport times, while laser ablation disrupted mucociliary function with mean mucociliary transport time more than double the control. There was no difference in subjective (symptoms) or objective nasal obstruction (as measured by rhinomanometry) between sides. Cavaliere et al.33 conducted a prospective trial of 75 patients randomized into three groups—group A turbinoplasty, group B RFA, and group C control. Nasal endoscopy, VAS, rhinometry and saccharin tests were used to assess outcomes with a follow-up of 3 months. Significant symptom improvement was seen in both treatment groups, compared to control at 3 months. Both Sapci and Cavaliere studies were limited by very short follow-up periods. Several prospective randomized trials have compared MATR with RFA turbinate reduction. Kizilkaya et al.34

compared RFA and MATR in 30 symptomatic patients with inferior turbinate hypertrophy. VAS, saccharin test, ciliary beat frequency, and acoustic rhinometry were done preoperatively and postoperatively at 3 months and 6 months. Significant and equivalent improvements in VAS and acoustic rhinometry were found in both groups, whereas saccharin test and ciliary beat frequency were essentially unchanged in both groups at 6 months. While this follow-up period was just 6 months, Liu et al.35 conducted a prospective, randomized trial of 120 patients, comparing the long-term results of MATR and RFA. Outcome measures included VAS, anterior rhino­ manometry, and mucociliary clearance with saccharin transit time, with follow-up at 6 months, 1, 2, and 3 years after surgery. They found an improvement in all three outcome measures at all time periods for the MATR group. The RFA group, however, had improvement from 6 months to 1 year, but no further improvement and a gradual return to preoperative baseline values at 2–3 years postoperatively.

CONCLUSION Many surgical treatment options exist for the management of inferior turbinate hypertrophy. In general, surgeon experience and preference dictate the choice of one over another. Some authors have advocated for a treatment algorithm that initially favors office based minimally invasive techniques. If this fails, partial turbinectomy or submucosal resection would be performed next, follo­ wed by more extensive turbinectomy if all other treat­ ments are ineffective.36 Another consideration is that laser, electrocautery, and RFA may be performed in an office setting, with significant cost reduction. Harrill et al.37 compared office-based radiofrequency inferior turbinate reduction and hospital-based radiofrequency reduction with septoplasty in patients with both septal deviation and turbinate hypertrophy using the NOSE patient-based outcome scale. Results demonstrated significant and equivalent improvement in NOSE scores in both groups at 6-month follow-up. The author estimated that hospitalbased septoplasty and radiofrequency turbinate ablation cost over 25 times that of office-based radiofrequency turbinate ablation. Even with several studies showing that these office-based procedures may have only shortterm efficacy and potential necessity of retreatment, the cost-effectiveness of these procedures may still sup­port them as first-line treatment. There is an addi­ tional level of consideration – beyond this chapter – on the

Chapter 42: Surgical Management of the Nasal Turbinates cost-effectiveness of office-based versus operating roombased procedures. Obviously, much depends on the need for additional procedures, such as septoplasty or sinus surgery, but these factors should be considered as sur­ geons decide on the best treatments for their patients. While there are limited direct comparisons, it does appear that partial resection is effective and well tolerated in many patients, but might have a higher complication rate. Among reduction procedures, the microdebriderassisted submucosal reduction technique is quite effective, with some evidence of improved long-term outcomes when compared to cautery and radiofrequency reduction.

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31. Meredith GM. Surgical reduction of hypertrophied inferior turbinates: a comparison of electrofulguration and partial resection. Plast Reconstr Surg. 1988;81:891-7. 32. Sapci T, Sahin B, Karavus A, et al. Comparison of the effects of radiofrequency tissue ablation, CO2 laser ablation, and partial turbinectomy applications on nasal mucociliary functions. Laryngoscope. 2003; 113:514-9. 33. Cavaliere M, Mottola G, Iemma M. Monopolar and bipolar radiofrequency thermal ablation of inferior turbinates: 20-month follow-up. Otolaryngol Head Neck Surg. 2007; 137:256-63. 34. Kizilkaya Z, Ceylan K, Emir H, et al. Comparison of radio­ frequency tissue volume reduction and submucosal resec­ tion with microdebrider in inferior turbinate hypertrophy. Otolaryngol Head Neck Surg. 2008;138:176-81. 35. Liu CM, Tan CD, Lee FP, et al. Micro­ debrider-assisted versus radiofrequency-assisted inferior turbinoplasty. Laryn­ goscope. 2009;119:414-8. 36. Jackson LE, Koch R, James MD. Controversies in the man­ agement of inferior turbinate hypertrophy: a comprehen­ sive review. Plast Reconstr Surg. 1999;103:300-12. 37. Harrill WC, Pillsbury HC III, McGuirt WF, et al. Radiofrequency turbinate reduction: a NOSE evaluation. Laryn­ goscope. 2007;117:1912-9. 38. Cingi C, Ure B, Cakli H, et al. Microdebrider-assisted versus radiofrequency-assisted inferior turbinoplasty: a prospective study with objective and subjective outcome measures. Acta Otorhinolaryngol Ital. 2010;30:138-43. 39. Porter MW, Hales NW, Nease CJ, et al. Long-term results of inferior turbinate hypertrophy with radiofre­quency treat­ ment: a new standard of care? Laryngoscope. 2006;116: 554-7.

40. Testa D, Motta G, Galli V, et al. Outcome assessment in patients with chronic obstructive rhinitis CO2 laser treated. Acta Otorhinolaryngol Ital. 2006;26:32-7. 41. Friedman M, Tanyeri H, Lim J, et al. A safe, alternative technique for inferior turbinate reduction. Laryngoscope. 1999;109:1834-7. 42. Lippert BM, Werner JA. Long-term results after laser turbi­ nectomy. Lasers Surg Med. 1998;22:126-34. 43. Lippert BM, Werner. CO2 laser surgery of hypertrophied inferior turbinates. Rhinology. 1997;35:33-6. 44. Lippert BM, Werner JA. Comparison of carbon dioxide and neodymium: yttrium-aluminum-garnet lasers in sur­ gery of the inferior turbinate. Ann Otol Rhinol Laryngol. 1997;106:1036-42. 45. Cook JA, McCombe AW, Jones AS. Laser treatment of rhinitis – 1 year follow-up. Clin Otolaryngol Allied Sci. 1993; 18:209-11. 46. Kawamura S, Fukutake T, Kubo N, et al. Subjective results of laser surgery for allergic rhinitis. Acta Otolaryngol Suppl. 1993;500:109-12. 47. Wight RG, Jones AS, Beckingham E. Trimming of the infe­ rior turbinates: a prospective long-term study. Clin Oto­ laryngol Allied Sci. 1990;15:347-50. 48. Wight RG, Jones AS, Clegg RT. A comparison of anterior and radical trimming of the inferior nasal turbinates and the effects on nasal resistance to airflow. Clin Otolaryngol Allied Sci. 1988;13:223-6. 49. Fukutake T, Yamshita T, Tomoda K, et al. Laser surgery for allergic rhinitis. Arch Otolaryngol Head Neck Surg. 1986;112:1280-82.

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Functional Rhinoplasty

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Rebecca E Fraioli, Satyen Undavia

INTRODUCTION Nasal airway obstruction is a common symptom promp­ ting otolaryngologic evaluation. There are a myriad poten­ tial sources of nasal obstruction, and it is important to rule out neoplastic, allergic, or medical causes before con­ sidering surgical intervention. Anatomic causes of nasal airway obstruction that may be improved with surgery include nasal septal deviation, inferior turbinate hyper­ trophy, and nasal valve compromise. In cases where nasal septal deviation is found to be the cause of airway obstruction, nasal septoplasty has been shown to improve nasal airway patency and quality of life.1,2 However, there remains a subset of patients whose airway obstruction is more complex and cannot be effectively treated by traditional septoplasty and inferior turbinate reduction alone. Functional rhinoplasty may be neces­ sary to address the nasal obstruction in these patients.

ANATOMY The upper one third of the nose is bony, whereas the lower two thirds are cartilaginous. The upper lateral cartilages (ULCs) sit just caudal to the nasal bones, and help main­ tain the patency of the nasal airway through their tight attachments cephalically to the nasal bones, medially to the nasal septum, and laterally to the maxillary bone. However, the caudal margin of the ULCs is not attached to any rigid support, and may move somewhat with inspiration.3,4 Caudal to the ULCs sit the paired lower lateral carti­ lages (LLCs). The LLCs are not tightly attached to the ULCs the way the ULCs are tightly attached to the nasal bones, and they do not reach laterally to the piriform aperture.

Instead, a variable number of small sesamoid cartilages are embedded in thick connective tissue extending late­ rally toward the piriform aperture. First described by Mink in 1903, the term “nasal valve” refers to the narrowest portion of the nasal airway.5 Cur­ rently, the nasal valve is understood to have two distinct portions: the internal nasal valve (INV), which in most people is the site of highest airway resistance, and the exter­ nal nasal valve (ENV), which can contribute to increa­sed airway resistance in certain pathologic situations. The INV is located at the junction of the caudal edge of the ULC with the dorsal septum (Fig. 43.1). The normal angle of the INV is 10°–15°. Figure 43.2 shows a normal INV on nasal endoscopy. The inferior turbinate sits just inferior to the INV, and the area between the INV and the inferior turbinate is referred to as the INV area. Pathology in this area will narrow the space available for airflow and thereby increase the nasal airway resistance. Pathology may be mucosal (e.g. edema, polyps, or synechiae), or it may be structural (weakness and inward collapse of the ULC narrowing the INV angle). The ENV begins at the alar rim, and it extends up the nasal sidewall to the level of the INV (Fig. 43.1). Certain pathologic situations may cause static or dynamic narro­ wing of the ENV that may make this the site of maximal resistance to nasal airflow. As discussed above, the ULCs have strong attachments both to the nasal bones cephalically and to the maxillary bone laterally. Because of these strong attachments, in the nonpathologic nose, the ULCs are able to resist mode­ rate deforming forces such as the negative pressure of inspi­ ration. By contrast, the lack of similar bony attachments

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Fig. 43.1: Boundaries of the internal nasal valve and external nasal valve.

Fig. 43.2: Normal internal nasal valve (INV) as viewed on nasal endoscopy. The normal INV angle is 10–15°.

for the LLCs means that the LLCs are much more suscep­ tible to such deforming forces.4 A strong, rapid inspira­ tion, even in a normal individual, can cause collapse of the ENV. In patients with weakened skeletal support of the nasal sidewall in the ENV area, this collapse occurs at a lower pressure threshold, and may occur even with normal inspiration. An analogous collapse may also occur in the area of the INV when there is weakness of the ULCs, however, usually to a lesser degree.

varying diameter. Therefore, as the cross-sectional area of the nasal passageway decreases, the velocity of airflow increases. This increased airflow velocity (increased kinetic energy) in turn causes the pressure of the air inside the nose to decrease, as total energy in the system must be constant. Therefore, the more narrow the airway, the faster the velocity of the inspired air, and the more negative the pressure inside the airway compared to the atmospheric pressure outside of the nose. This negative pressure inside the nose then places significant stress on the nasal sidewall. At some point, the deforming force of the negative pres­ sure will be sufficient to overcome the strength of the nasal sidewall support, resulting in collapse of the lateral nasal wall and nasal airway obstruction. This effect, based on Bernoulli’s principle and the continuity principle, is called the Venturi effect.

PHYSIOLOGY The external nose plays a key role in the regulation of airflow into the respiratory tract. The nasal valve acts as a resistor to airflow through the nose, essentially channeling air from a large diameter tube to a narrow tube. This decrease in cross-sectional airway at the nasal valve has several effects on the velocity and pattern of flow through the nose. The laws of fluid dynamics govern these changes. Resistance in the nasal airway is frequently described using Poiseuille’s law, which states that in an idealized tube with laminar airflow and a constant circular crosssectional diameter, the resistance (R) of the airway is inversely proportional to the radius (r) to the fourth power: R = 8lh/πr4. Although the nose is not an idealized tube, the relationship holds that even a very small decrease in cross-sectional radius of the nasal cavity will significantly increase nasal airway resistance. Bernoulli’s principle can also be used to under­ stand the dynamics of airflow through the nasal cavities. Bernoulli’s continuity equation states that the rate of mass flow stays constant as it flows through a tube of

PATHOLOGY There are many different causes of nasal valve obstruction. It is important to properly diagnose both the site and the cause of the obstruction, because the treatment options vary depending on the etiology. Terminology is also important. Nasal valve compromise and nasal valve collapse are not synonymous. Nasal valve compromise may refer to any cause of narrowing of the nasal valve, including a high septal deviation narrowing the valve, circumferential scar­ ring with stenosis, and inward collapse of the ULC due to weakness of the nasal sidewall. Nasal valve collapse refers only to the last of these. A brief discussion of the common causes of nasal valve compromise follows.

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Causes of INV Compromise

Saddle Nose Deformity

INV compromise results from any process that narrows the angle between the dorsal septum and the ULC. Both medialization (inward collapse) of the ULC toward the septum and lateralization (deviation) of the dorsal portion of the septum toward the ULC will narrow this angle and result in INV compromise.

Collapse of the cartilaginous nasal dorsum, as is seen in patients with a saddle nose deformity, causes loss of sup­ port for the nasal sidewall and results in INV compromise. Intranasal findings in cases of traumatic saddle nose deformity may show inward collapse of both the ULCs and the dorsal septum. A nasal endoscopy image of a patient with a fixed nasal airway obstruction due to posttraumatic collapse of the dorsal septum and ULCs is shown in Figure 43.3D.

Nasal Sidewall Collapse Inward collapse of the ULCs is often a result of weakness caused by prior surgery or trauma. Trauma may weaken the attachments of the ULCs to the nasal bones or maxilla. Rhinoplasty with dorsal hump reduction may likewise weaken or sever these attachments and cause nasal valve collapse. In fact, it was the long-term follow-up of rhino­ plasty patients who developed INV collapse that promp­ted Sheen to describe the spreader graft, the initial technique developed for treating INV collapse.3 Sheen descri­ bed three patient characteristics that predispose to INV collapse following aesthetic rhinoplasty. These are short nasal bones, thin skin, and weak cartilages. Sheen recom­ mended that spreader grafts be placed in all primary rhino­ plasties where resection of the cartilaginous roof was necessary. It is particularly important to place primary spreader grafts in the patients that Sheen identified as high risk for developing postoperative nasal valve coll­ apse. Figure 43.3A demonstrates INV compromise due to inward collapse of the ULC.

High Septal Deviation Dorsal nasal septal deviation may also narrow the INV angle and cause a fixed INV compromise. Because the dorsal septum comprises part of the supportive “L-strut” of the nose, deviations in this area cannot be addressed via a traditional septoplasty approach. Functional rhino­ plasty is often necessary in these cases in order to straighten the dorsal septum and open the INV angle. Moreover, in cases of post-traumatic deviated noses, the deviated dorsal septum is often held in place by its attachment to the deviated nasal bones and perpendicular plate of the ethmoid bone; in these cases the nasal bones must be straightened in order to maintain the dorsal septum in the midline. Figure 43.3B shows a dorsal septal deviation narrowing the right INV. Figure 43.3C shows compromise of the left INV in a different patient due to a combination of a high septal deviation and inward collapse of the ULCs.

Inferior Turbinate Hypertrophy The inferior turbinate forms the inferior border of the INV area. As a result, turbinate hypertrophy can reduce the space for airflow and cause INV compromise. Figure 43.3E demonstrates obstruction of the right INV by a combina­ tion of a dorsal septal deviation and right inferior turbi­ nate hypertrophy.

Synechiae Synechiae or cicatricial narrowing may occur in the nasal valve area and cause nasal valve compromise. An example of synechiae narrowing the INV is shown in Figure 43.3F.

Causes of ENV Compromise As with the INV, ENV compromise may be caused by inward collapse of the lateral nasal wall, septal deviation, or scarring. Weakness of the lateral nasal wall usually results in a dynamic collapse that occurs with inspiration due to the Venturi effect. Caudal septal deviation and scarring, by contrast, tend to cause a fixed, static obstruction.

Collapse of the Alar Rim Inward collapse of the lateral nasal wall in the area of the ENV is frequently caused by overzealous cephalic trim of the LLCs during aesthetic rhinoplasty. A minimum lateral crural width of 6 mm should be maintained during cephalic trim; 8–10 mm is preferable to prevent postoperative weakness and buckling. Weakness of the lateral crura causing dynamic inward collapse of the ENV with inspiration may also be seen following trauma, or can be idiopathic. Trauma may also cause fracture, buck­ ling, weakness, or scarring of the LLCs, which can all lead to inward collapse of the lower nasal sidewall and alar rim.

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A

B

C

D

E

F

Figs. 43.3A to F: Causes of internal nasal valve pathology. (A) Right upper lateral cartilage (ULC) collapse causing internal nasal valve (INV) narrowing. (B) Dorsal septal deviation narrowing the right INV. (C) Left INV narrowing caused by a combination of a dorsal septal deviation and inward collapse of the left ULC. (D) Obstruction of the left INV due to inward collapse of the dorsal septum and ULC in a patient with a post-traumatic saddle nose deformity. (E) Obstruction of the right INV caused by a combination of dorsal septal deviation and right inferior turbinate hypertrophy. (F) Synechiae narrowing left INV.

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A

B

C

Figs. 43.4A to C: Caudal septal deviation narrowing the external nasal valve (ENV) (A) Left ENV. (B) Right ENV. (C) Cicatricial narrowing of the left ENV.

Cephalically Oriented LLCs In some patients, the lateral crura are oriented in a cephalic direction rather than extending laterally toward the piriform aperture. Cephalically oriented lateral crura can be suspected based on physical examination findings, including a “parenthesis deformity” of the nasal tip. In such cases, the nasal sidewall in the area of the ENV is weak due to the absence of the supportive lateral crura in this area. Surgical reorientation of these cartilages more cau­ dally into their native position will increase the support of the sidewall and improve both the nasal airway and the appearance of the nasal tip.6

that the nasal sidewall is longer than the lateral crus. This results in an unsupported nasal sidewall, similar to the situation in cases of cephalically oriented lateral crura.

Caudal Septal Deviation Deviations of the caudal septum are analogous to those of the dorsal septum in that they similarly affect the septal L-strut and also often require a rhinoplasty approach. However, caudal septal deviations often narrow the exter­ nal, rather than the INVs. Figures 43.4A and B show nasal endoscopy views of caudal septal deviation narro­ wing the ENV.

Over Projected Nose with Narrow, Slit-like Nostrils

Circumferential Scar

An over projected nose often results in long, slit-like nos­ trils with easily collapsible sidewalls, likely due to the fact

Trauma or prior surgery may result in cicatricial narrowing of the ENV, causing a static ENV obstruction. A patient

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with a history of a nasal injury in infancy followed by a failed prior functional rhinoplasty with subsequent cica­ tricial narrowing of the right ENV is shown in Figure 43.4C.

PATIENT EVALUATION Medical History The evaluation of a patient with nasal obstruction begins with a thorough medical history. It is important to fully explore the patient’s symptoms including the onset and duration of symptoms, the severity of the obstruction, and any aggravating or alleviating factors. Airway obstruc­ tion that is seasonal or that is associated with sneezing, itching, or watery eyes may be caused by allergic rhinitis. However, edematous mucosa and turbinate hypertrophy may coexist with a structural deformity of the nose, and both problems must be identified and treated for maxi­ mum improvement in the nasal airway. Patients should be questioned regarding the ade­ quacy of their olfaction. Decreased olfaction is a common symptom in patients presenting with nasal obstruction. Complete loss of olfaction is often a sign of an inflamma­ tory condition such as chronic rhinosinusitis or nasal poly­ posis, but these problems may also coexist with structural problems of the nose. Likewise, facial pain or pressure and chronic rhinorrhea, especially if the nasal discharge is thick or discolored, may indicate chronic rhinosinusitis. Such patients should be treated with culture-based anti­ biotics and undergo workup including CT scan prior to making a final determination as to the surgical plan. It is also important to ask the patient to describe his or her subjective sensation of nasal obstruction. Specifi­ cally, the examiner should inquire as to whether one side of the nose is more obstructed than the other, and whe­ther any activities aggravate or alleviate the obstruction. Patients with dynamic nasal valve collapse often report worsening of their obstruction with exercise. Other patients may have discovered that they can breathe better when they digitally manipulate their cheeks (Cottle maneuver) or nasal tip. Still others will have tried Breathe Right strips, or silicon nasal stents and report that these help ease their obstruction. It is also important to ask the patient what treatments they have tried, including allergy medications and overthe-counter nasal sprays. Prior use of antihistamine or nasal steroid sprays without improvement makes the diagnosis of allergy less likely as the cause of nasal obstruc­ tion. Chronic use of over-the-counter nasal decongestant

sprays (oxymetazoline, phenylephrine) is responsible for the rebound nasal congestion known as “rhinitis medica­ mentosa.” This condition may be contributing to the patient’s nasal obstruction; however, it is the authors’ experience that patients who become chronic nasal decon­ gestant users often do so in response to a structural nasal deformity underlying their chronic nasal obstruction and predating their decongestant use. In addition, inquiry must be made as to any history of prior nasal trauma or nasal surgery. A history of prior functional nasal surgery should prompt the examiner to look for scarring, truncated turbinates and nasal septal perforation, which may contribute to nasal dryness and a sensation of decreased nasal airflow. If a patient presents with a history of prior aesthetic rhinoplasty, it is important to determine whether the airway obstruction preceded the cosmetic surgery or developed postoperatively. Jessen and colleagues demons­ trated an increase in postoperative nasal airway resistance in patients undergoing rhinoplasty without functional septoplasty.7 Dorsal reduction in cosmetic rhinoplasty may weaken the ULCs that support the middle third of the nose, and if this is not recognized and the ULCs resup­ ported at the time of the initial surgery, airway compromise in the area of the INV may result.3 Finally, overzealous cephalic trim or dome division of the LLCs may cause ENV collapse. It is also important to ask patients whether one side of their nose is more obstructed than the other. Patients frequently note obstruction on the side contralateral to the visualized septal deviation.8 Although the reasons for this may be complex, this may be an indication that nasal valve compromise rather than septal deviation is the source of the airway obstruction.

Physical Examination The physical examination should begin with an evaluation of the patient at rest. This initial observation may be done best while taking the history from the patient, before the patient knows that he is being observed. Note should be made of mouth breathing or of collapse of the nasal alae on routine inspiration. Nasal deviation and asymme­ tries of the nasal bones or cartilaginous dorsum may often be visible from across the room, before approaching the patient for the formal examination. A crooked nasal dorsum may indicate the presence of a deviated dorsal septum. A narrow middle third of the nose

Chapter 43: Functional Rhinoplasty suggests that there may be a narrow INV. An “inverted V” deformity, where the demarcation between the nasal bones and the ULCs is visible as an inverted, V-shaped depression, is a sign of ULC collapse and INV compromise. Similarly, deep alar grooves or a pinched nasal tip may indicate weakness of the LLCs and should prompt the examiner to look for evidence of ENV compromise. A ptotic nasal tip may indicate weakness of the nasal cartilages with poor tip support, or conversely may be a result of an overly long caudal septum. The nose should then be formally inspected and palpated for any less obvious deviations, saddle defor­ mities, scars, and asymmetries. The nasal base should be inspected for alar collapse or asymmetry. Caudal deflec­ tions of the septum may also be appreciated on the basal view. Palpation should be performed to assess the structural rigidity of the cartilages of the nose. Gentle downward pressure on the nasal tip toward the upper lip allows assessment of the degree of cartilaginous support for the tip. Release of the downward pressure allows assess­ ment of the tip recoil, which helps determine how much inherent strength lies within the cartilages. The alar cartilages should be inspected with bimanual palpation to assess for thickness and resilience. Palpation of the caudal septum is also critically important, as very anterior deviations of the septum are easy to underappreciate with both anterior rhinoscopy and nasal endoscopy. The nasal cavities should be carefully examined with anterior rhinoscopy using a nasal speculum and a light source. The INVs should be visualized to assess their shape and approximate angle. Care should be taken not to iatrogenically open the valve with the speculum. A zero degree telescope can be helpful in assessing the INV and the posterior septum. The posterior septum should be inspected for any bony spurs and high deviations. The nasopharynx should also be visualized to rule out adenoid hypertrophy or a mass obstructing the posterior nasal airway. Visualization of the nasal cavities should be performed both before and after topical decongestion of the nose so as to assess the relative contribution of mucosal edema versus fixed obstruction to the patient’s sensation of nasal obstruction. The entire septum should be evaluated for the pre­ sence of a septal perforation. A septal perforation may be contributing to the patient’s feeling of nasal obstruction. It is also an indicator that septal cartilage may not be available for use as graft material. Preoperative identifica­ tion of the septal perforation also allows a preoperative

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discussion with the patient regarding their increased risk for a symptomatic septal perforation, and allows a plan to be made for intraoperative closure of the existing septal perforation. Additionally, in a patient without a prior history of septoplasty or nasal trauma, identification of a septal perforation should prompt an evaluation for the cause of the perforation. In addition to the static nasal examination, it is also important to functionally assess the nose. The Cottle maneuver is a method by which the nasal valve angle is manually opened in order to assess whether this improves nasal airflow. The Cottle maneuver is positive when it improves the subjective sense of nasal airflow on the side being examined. In the traditional Cottle maneuver, the skin over the maxilla is pulled superiorly and laterally to open the nasal valve. In practice, the modified Cottle maneuver is more useful for identifying the site of the valve compromise. In this technique, a cerumen curette is placed in the area of suspected cartilage weakness or valve narrowing and is lifted superiorly and laterally. The modified Cottle maneuver mimics the expected result from the placement of surgical support grafts, and can direct the surgical plan. However, it is important not to overcorrect when performing the modified Cottle mane­ uver, and not to overpromise: patients should be counse­ led that their postsurgical result may not be as open as when the curette manually opens the nasal valve. Another technique that can help identify nasal valve pathology is the use of Breathe Right strips. Although these may be used in the office to help identify the site of obstruction, it is generally more useful to ask patients to use them at home during their normal activities and during sleep. If a patient reports improvement in their nasal breathing when using the Breathe Right strips, it is another indicator that the patient’s pathology may lie in the area of the nasal valve. Patients with tip ptosis causing ENV narrowing may demonstrate, via digital manipulation of their nose, that their breathing is improved when they push upward on their nasal tip. In patients with a ptotic nasal tip who do not volunteer this information, the examiner may man­ ually support the tip upwards and ask the patient if this subjectively improves the breathing. Standardized color photography is essential in the preoperative planning for functional rhinoplasty. Although done for functional and not aesthetic purposes, rhinoplasty may still change the shape of the nose from its preoperative appearance. Standard views for rhinoplasty photography

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include a minimum of six views: frontal, basal, right and left lateral, and right and left oblique. A solid background of a single color is necessary. A blue background is ideal for the photographs because it complements rather than detracts from skin tone and allows for a greater depth of field than a dark background.

Patient Counseling Patients should be counseled, as with aesthetic rhino­ plasty, regarding preoperative nasal and facial deviations and asymmetries, as well as to what they can realistically expect their nose to look like after surgery. Patients with a severely deviated nose from trauma should be counseled that their nose should be straighter, but will not be identi­ cal to the nose that they had pretrauma. Patients requiring spreader grafts should be counseled that these might cause slight widening of the middle one third of the nose. Preoperative counseling for patients requiring func­ tional rhinoplasty is as important as for patients under­ going aesthetic rhinoplasty, and in some cases may be more difficult. A patient with a narrow middle third of the nose and INV collapse may nonetheless be happy with the appearance of the nose and may not like the idea that surgery may make the nose wider. A patient with an overly long caudal septum and a resultant ptotic nasal tip may feel that “all the members of my family have this nose” and may respond to the surgeon’s suggestion to trim the caudal septum and resupport the nasal tip by replying “I don’t want to have an upturned nose.” Con­ versely, other patients may require only limited functional rhinoplasty, such as spreader grafts or alar batten grafts, but may expect a complete aesthetic rhinoplasty to be performed “because you’re going to be there anyway.” It is important to communicate clearly and effectively with the patient preoperatively to ensure that the surgeon and patient have the same expectations regarding the outcome of surgery.

Objective Measurements Several attempts have been made to objectively measure nasal function. Traditionally, the two main techniques for objective assessment of nasal patency have been rhinomanometry and acoustic rhinometry. However, both techniques have significant limitations for clinical prac­ tice. Most importantly, measured nasal airway resistance does not always correlate with the patient’s subjective nasal obstruction. Furthermore, objective nasal airway

examinations require specialized equipment and may be cost and time prohibitive. As a result, these techniques are mostly relegated to research studies and are rarely used in clinical practice. Nevertheless, a brief discussion of these techniques is presented below. Rhinomanometry is a dynamic test that can simulta­ neously measure nasal airflow and transnasal pressure (the pressure difference between the nostril and the naso­ pharynx). In active rhinomanometry, which is most comm­ only used, the patient actively breathes through one nostril while an intranasal probe and an external, tightly fitting facemask measure pressure differences. Nasal resis­tance at a given transnasal pressure can then be calculated from these two measurements. The results are graphed on a pressure curve that can be interpreted to provide the objective pressure needed to inhale and exhale through the nose. Acoustic rhinometry, by contrast, is a static test that is done while the patient is not breathing. To perform the test, a probe is fed into the nasal vestibule with an emitter and a microphone. The acoustic impedance changes as a function of the cross sectional area; therefore, this technique can be used to measure the cross-sectional area of the airway at a varying distance from the nostrils. These measurements can then be used to calculate the volume of the airway between two points. Each study has advantages and disadvantages. Rhino­ manometry studies flow, whereas acoustic rhinometry measures topography. Acoustic rhinometry is faster and less invasive to perform, and has the additional advantage that it can identify the site of obstruction within the nasal cavity. However, because it is a static study, it may not accurately reflect the state of the airway during physiologic breathing. Rhinomanometry studies active breathing, but with a nasal sensor and facemask in place, which may alter pressure and flow data as compared to normal respira­ tion. Moreover, both tests require specialized equipment and an experienced test operator. The nascent field of computational fluid dynamics (CFD) shows promise as an objective method by which to study nasal airflow. CFD uses CT images to reconstruct a three-dimensional model of a specific patient’s nasal airway. Complex mathematical models and advanced computer technology then allow simulation of nasal airflow and nasal resistance in this virtual nasal cavity. However, many limitations must still be overcome before the utility of CFD for clinical practice can be evaluated. At this point, even the generation of the computer model of

Chapter 43: Functional Rhinoplasty the nasal airway from the CT scan images requires the input of the surgeon and can be time-consuming. Moreover, CFD technology requires a decision as to whether to use a laminar or turbulent flow model. Because we do not fully understand which factors cause turbulent flow, it is hard to accurately make this decision. CFD may turn out to be very useful in helping us to understand which local factors correlate with the patient’s sensation of nasal obstruction. However, as with the other objective studies, at this time CFD is not useful for clinical practice.9 Imaging studies may have a role in the workup of a patient with nasal obstruction if findings from the history and physical exam suggest that there may be an infectious, inflammatory, or neoplastic cause of the obstruction. A suspicion of chronic sinusitis or a large concha bullosa may be verified with a CT scan following appropriate medical therapy. However, CT or MRI imaging is not rou­ tinely indicated for the evaluation of septal deviation or nasal valve compromise.

Subjective Measurements The goal when evaluating the objective measures of nasal airway obstruction is to find a measure that will accurately predict which abnormalities will cause nasal obstruction, and which surgical modifications will best relieve this obstruction. However, because of the complexities of dynamic versus fixed obstruction, humidification versus dryness of the nasal mucosa, and laminar versus turbulent airflow, no objective test has so far been able to reliably predict the patient’s subjective feeling of obstruction. As a result, subjective measurements of nasal airway obstruc­ tion are generally felt at this point to be as useful or more useful than objective studies in determining a patient’s response to therapy10 In particular, validated quality of life surveys such as the Nasal Obstruction Symptom Evalua­ tion (NOSE) Scale11 have been useful in demonstrating the utility of surgery in improving patient quality of life.1 12,13 In summary, nasal valve compromise, including both weakness of the lateral nasal cartilages and dorsal or caudal septal deviations, is best diagnosed based on the history and physical examination. Rigid zero-degree nasal endoscopy may aid in diagnosis and in ruling out other intranasal pathology. Conventional imaging studies are generally not felt to be beneficial in the diagnosis of nasal valve compromise. Objective tests of nasal patency including rhinomanometry and acoustic rhinometry are more commonly used for research purposes than for clini­ cal diagnosis. As agreed upon in the clinical consensus

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statement by Rhee et al., there is no current gold standard for the diagnosis of nasal valve compromise.10

TREATMENT OPTIONS Nonsurgical Options In patients with symptoms of nasal allergy or chronic rhinitis, or with signs of mucosal edema on physical exami­ nation, a trial of allergy medication including nasal steroid spray should be given prior to considering surgical options. Some of these patients may benefit from evaluation with allergy testing and even immunotherapy. However, a trial of nasal steroids is not indicated for patients whose history and physical examination do not have findings consis­tent with allergic rhinitis.10 Breathe Right strips (GlaxoSmithKline), discussed above for their utility as a diagnostic tool, were designed as a therapeutic device. Likewise, soft silicon intranasal stents that physically hold open the nasal valve are avail­ able in a variety of sizes for both daytime and nighttime use. For patients with medical contraindications or who wish to avoid surgery, these options may provide tempo­ rary relief of nasal obstruction. However, neither option is well tolerated long term, and given the option, most patients opt for surgery over permanent dependence on these devices.

Surgical Options Several studies have demonstrated postoperative improve­ ment in both nasal airflow as measured by rhinomano­ metry and in validated quality of life measures following rhinoplasty with treatment of the external and/or INVs.8,12,13 The first step in the surgical management of nasal valve obstruction is to identify the site and cause of the obstruction. Different techniques are indicated based on the identified pathology. In some cases, there are several techniques that may have benefit. Techniques will be discussed below based on their indication.

INV Collapse The classic treatment for INV collapse, described by Sheen in 1984,3 is placement of spreader grafts. Spreader grafts are thin, rectangular pieces of cartilage that are placed between the septum and ULC, thereby pushing the ULC out laterally and increasing the INV angle. Figure 43.5 demonstrates the ideal placement of spreader grafts. Dimen­sions of the spreader graft are generally 2–3 mm

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Fig. 43.5: Illustration of the proper placement of spreader grafts, alar batten grafts, and alar strut grafts.

high by 15–25 mm in length; the graft should be long enough to span the length of the ULC. Spreader grafts are ideally carved from septal cartilage, as septal cartilage most often provides a straight and resilient graft. If septum is not available, conchal cartilage grafts can be used for the purpose of opening the valve angle. However, when it is also necessary for the spreader grafts to splint a deviated dorsal septum into place, conchal cartilage may not have the necessary rigidity. In such cases, an autogenous or allogenic costal cartilage graft may be necessary. Sheen originally described placement of spreader grafts via an endonasal rhinoplasty approach into a tight sub­ mucoperichondrial pocket between the septum and ULC. When placed in this manner, spreader grafts generally do not need to be sutured in place. This is still a useful technique for patients who have pathology limited to weakness and inward collapse of the ULCs, as seen as a late complication of aesthetic rhinoplasty. When performing functional rhinoplasty on a patient without a history of prior rhinoplasty, isolated ULC weak­ ness and collapse is less common, and in many patients, surgical correction of a dorsal septal deviation may also be necessary. In such patients, the submucosal dissec­ tion necessary to address the septal deflection often pre­ cludes the creation of a tight pocket for the endonasal placement of the spreader graft. In these cases, the ULCs may be sharply divided from the dorsal septum, and the spreader grafts placed in between the dorsal septum and the ULCs. The grafts are then fixated in place and the ULCs reattached to the septum and spreader grafts using

horizontal mattress sutures. Care should be taken not to enter the mucosa of the nasal cavity while placing these sutures. Since the original description of spreader grafts by Sheen, several other options for the surgical manage­ ment of INV collapse have been described. The choice of which technique to use should be based on the other problems that need to be addressed in the nose, the choice of cartilage graft material available, and the surgeon’s comfort with the technique. A brief description of these techniques follows. The “autospreader” flap14 is similar to a spreader graft, but uses excess width of the ULC following dorsal hump removal rather than a septal cartilage graft to act as a spacer between the ULCs and the dorsal septum. The medial aspect of the ULC is detached from the septum and turned inward; the free edge is then advanced to approxi­ mately the same location that a spreader graft would have, and is then sutured in place in a fashion similar to that used to place spreader grafts via the open approach. This technique has two main advantages: it does not require septal cartilage, and because it is an attached flap rather than a graft, it retains some spring and may help further lateralize the INV. Clark and Cook have described the use of a conchal cartilage “butterfly graft,” carved into an elliptical shape and placed over the cartilaginous dorsum at the caudal border of the ULCs (supratip region). The graft is held in place using suture fixation to the ULC. The graft can be placed via an endonasal or external rhinoplasty approach. Resection of the dorsum in the area of the graft may be required to prevent contour irregularities. Clark and Cook found that 97% of patients undergoing secon­ dary rhinoplasty reported complete resolution of brea­ thing problems after functional rhinoplasty using this technique.15 A subsequent study by Friedman and Cook reported that 90% of patients undergoing primary rhinoplasty using the butterfly graft reported improved breathing postoperatively.16 Because this technique relies on conchal rather than septal cartilage, it may be a good choice when no septal cartilage is available for spreader grafts. Guyuron and colleagues describe a conchal cartilage “splay graft” that is placed in a pocket between the caudal ULCs and the mucosa.17 Islam and colleagues described a modification of this technique that allows the use of an endonasal approach for graft placement.18 Alar batten grafts, traditionally used to strengthen the lateral nasal wall in the area of the ENV, may also help

Chapter 43: Functional Rhinoplasty correct INV collapse if placed in a slightly more cephalic position.19 Alar batten grafts are discussed in more detail in the discussion of treatment options for ENV collapse. The use of sutures has also been described to open the nasal valve. Park described the use of a 4-0 nylon flaring suture placed vertically through the caudal aspect of each ULC and tied over the dorsum.20 The suture is designed to pull the ULCs up and out in order to increase the angle of the nasal valve. A follow-up study evaluating this technique in cadavers using acoustic rhinometry revealed this technique to be most helpful as an adjuvant to the placement of spreader grafts.21 Several authors have described variations of suspen­ sion sutures that attach to the nasal cartilages at the point of maximal dynamic collapse, and extend out superiorly and laterally to be anchored through a bony opening or bone-anchored screw to the bony facial skeleton.22 Advan­ tages of this technique are that it does not require a rhinoplasty approach and is relatively quick to perform. In this technique, a suture anchored to the bone at the infraorbital rim is passed subcutaneously to the ULC at the region of maximal collapse. A long curved needle is used to aid in proper placement of the suture. The suture is then threaded back to the anchor and tied down until the collapse is properly corrected. To expose the infraorbital rim, a small cutaneous incision can be made just below the lid, or a transconjunctival approach can be used to avoid external scars. Permanent sutures are used, but loss of sus­ pension has been reported in up to 35% of patients. High infection rates (up to 24%) have also been reported.23 Nevertheless, in the properly selected patient this can be a very useful procedure. This technique is particularly useful in the rehabilitation of patients with INV com­ promise due to facial paralysis. It may be performed early on without waiting to fully assess for recovery, and it does not preclude structural rhinoplasty in the future.22

External Nasal Valve Collapse In some patients with anatomical variations of the LLCs, repositioning or other modification of the patient’s native cartilage may improve nasal sidewall support and decrease ENV collapse. In patients with an over projected nose and long, slit-like nostrils, deprojection of the nose allows the length of the nasal sidewall to better correspond with the length of the lateral crura of the LCs. This allows better for support of the lateral nasal wall and the ENV. In patients with cephalically oriented lateral crura, repositioning of the lateral crura to a more caudal position will increase

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the support for the nasal sidewall in the ENV and will often prevent ENV collapse. If ENV collapse is not fully improved with the proce­ dures described above, further cartilage grafting to streng­ then the nasal sidewall may be necessary. Such grafts are also used in cases of secondary rhinoplasty, when the nasal sidewall is weak due to over-aggressive cephalic trim of the lateral crura. Patients with a history of nasal trauma may have severely scarred, twisted, and weak, LLCs, and cartilage grafting techniques may be necessary in these patients as well. The two main structural grafts to strengthen the LLCs and prevent ENV collapse are alar batten grafts and alar strut grafts. Alar batten or alar strut grafts are used to strengthen the lateral crura of the LLCs and provide support to the ENV area. Alar batten grafts are rectangular grafts measu­ ring 10–15 mm long and 5–8 mm wide. Septal or conchal cartilage may be used. Batten grafts overlap the lateral surface of the lateral crus and are placed into a precise pocket overlying the piriform aperture. In this way, the cartilaginous support for the nasal sidewall in the area of the ENV is established all the way to the maxillary bone at the area of the vestibular aperture. To aid in proper posi­ tioning, it is often helpful to mark the skin externally at the desired location of graft placement. The pocket can be created via either open or closed approaches. It is impor­ tant not to place the pocket too superficially, as that can lead to contour irregularities or undesirable fullness.19 The proper placement for these grafts is illustrated in Figure 43.5. First described by Gunter, the lateral crural strut graft is a thin rectangular cartilage graft measuring 3–4 mm by 15–25 mm.24 The strut is ideally made of septal cartilage, but conchal or costal cartilage may also be used. The strut graft is then placed in a pocket deep to the lateral crura and sutured to the undersurface of the lateral crura. A subcutaneous pocket is created laterally in a location that will best relieve the obstruction. This can be either at the piriform aperture or the alar base. It is often helpful to taper the medial aspect to create a natural contour of the graft. The lateral end of the graft should be placed caudal to the alar groove to minimize visibility.

Dorsal or Caudal Septal Deviation Narrowing the Internal Nasal Valve In cases where the dorsal or caudal septum is severely deviated and narrowing the INV or ENV, a rhinoplasty app­ roach is often necessary in order to straighten the septum

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Section 8: Functional Surgery of the Nasal Airway

A

B

C

D

Figs. 43.6A to D: Excision and resupport of a severely deviated L-strut.

and open the valve angle. It is critical to recognize these patients on preoperative examination, as traditional septo­ plasty will often fail in these patients. Although some caudal deflections may be managed through an endonasal approach, the only options for managing dorsal septal deviations endonasally are to resect the deviation or to leave it untouched. Leaving the deviation untouched will often cause the surgery to be unsuccessful, but resec­ ting these areas without reconstructing the L-strut can result in a saddle nose deformity or loss of tip support. Eventually, worsening nasal airway obstruction will result. Via a rhinoplasty approach, the dorsal septum may be separated from the ULCs to allow better access and evalua­ tion. The cartilages should be freed from scar tissue, as the scar tissue may be tethering the septum and contri­ buting to the deviation. The concave side of the deviation may be gently scored, releasing some of the tension and helping to straighten the septum. Spreader grafts may be placed on either side of the dorsal septum to splint the straightened septum in place. For a deviated caudal septum, the spreader grafts may be left long as extended spreader grafts, which can extend caudally to the anterior septal angle and can help stent the caudal septum in the midline. A severely deviated segment of the L-strut that cannot be straightened with the techniques described above must be excised and reconstructed. Spreader grafts or a simi­lar

cartilaginous strut graft may be sutured to the cartilage on either end of the gap, thereby bypassing the gap and providing support to the septum. This tech­nique is illus­ trated in Figures 43.6A to D. Another option for the severely deviated L-strut is extracorporeal septoplasty.25 In this technique, the entire quadrangular cartilage with the adjacent portions of the perpendicular plate is separated from its attachments and taken to the back table. Once removed, the surgeon may thin, modify, and reconstruct the septum as needed. PDS plate may be helpful in reinforcing the reconstruc­ ted septum. The new septal construct is then replanted between the septal leaflets and closed as described for the placement of spreader grafts. Spreader grafts are also helpful in this situation. Caudal septal deviations may also be addressed by the above techniques. Several other techniques are also available to help straighten a deviated caudal septum. A suture may be placed from the caudal septum into the fascia overlying the nasal spine. If the fascia is absent, an 18-gauge needle may be used to bore a hole through the nasal spine itself; a suture can then be passed through this hole and through the caudal septum to anchor it in the midline. Another option, known as the swinging door tech­ nique, involves flipping the septum from where it sits on one side of the nose over the nasal spine, and suturing it

Chapter 43: Functional Rhinoplasty

643

Fig. 43.7: The swinging door technique for straightening a deviated caudal septum.

in place so that it sits on the contralateral side to the initial deviation. This technique is illustrated in Figure 43.7. Another maneuver to straighten the caudal septum is to advance it between the medial crura in a tongue-in-groove fashion, where it serves in place of a columellar strut graft to support the nasal tip. In order for this to be an option, the cartilage must have excess length. If it does not, a caudal septal extension graft may be sutured to the native caudal septum and will serve to extend the length of the septum. The extension graft may then be placed between the medial crura with the same effect as described above. Finally, a thin rectangular or square graft of cartilage or perpendicular plate may be carved from donor cartilage and placed on the convex side of the caudal septum in order to help stabilize the deviated cartilage in the midline. This graft is called a caudal septal strut graft, and it will help straighten a caudal septal deviation with weak or scored cartilage. However, for a strong and severely deviated caudal septal deviation, excision of the deviated segment may still be necessary.

Other Causes of ENV Compromise For nasal valve compromise caused by scarring and circumferential narrowing of the ENV, Z-plasty may be beneficial in opening the airway in cases of small defects. More severe defects may require release of the scar and placement of a composite graft of skin and cartilage from the ear.

CONCLUSION Functional rhinoplasty is a general term for a collec­ tion of techniques that can be performed via rhinoplasty

approaches in order to improve the nasal airway. Nasal valve compromise is the indication for functional rhino­ plasty, and there are many causes of nasal valve compro­ mise. The specific techniques used in a particular patient will vary based on the patient’s specific pathology. A patient’s subjective evaluation of improvement in nasal airway is as good or better an outcome measure than currently existing objective measures.

REFERENCES 1. Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septo­ plasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg. 2004;130(3):283-90. 2. Singh A, Patel N, Kenyon G, et al. Is there objective evidence that septal surgery improves nasal airflow? J Laryngol Otol. 2006;120(11):916-20. 3. Sheen J. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73(2):230-36. 4. Bruintjes TD, Van Olphen AF, Hizing EH, et al. A functional anatomic study of the relationship of the nasal cartilages and muscles to the nasal valve area. Laryngoscope. 1998; 108(7):1025-32. 5. Mink P. Le nez comme voie respiratorie. Presse Otolaryngol (Belg). 1903:481-96. 6. Hamra ST. Repositioning the lateral alar crus. Plast Reconstr Surg. 1993;92(7):1244-53. 7. Jessen M, Jacobsson S, Malm L. On rhinomanometry in rhinoplasty. Plast Reconstr Surg. 1988;81(4):506-11. 8. Constantian MB, Clardy RB. The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty. Plast Reconstr Surg. 1996;98(1):38-54; discussion 55-8. 9. Quadrio M, Pipolo C, Corti S, et al. Review of computational fluid dynamics in the assessment of nasal air flow and analysis of its limitations. Eur Arch Otorhinolaryngol. 2014;271(9): 2349-54.

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10. Rhee JS, Weaver EM, Park SS, et al. Clinical consensus state­ ment: diagnosis and management of nasal valve compro­ mise. Otolaryngol Head Neck Surg. 2010;143(1):48-59. 11. Stewart MG, Witsell DL, Smith TL, et al. Development and validation of the Nasal Obstruction Symptom Evalua­tion (NOSE) scale. Otola­ryngol Head Neck Surg. 2004;130(2): 157-63. 12. Rhee JS, Poetker DM, Smith TL, et al. Nasal valve surgery improves disease-specific quality of life. Laryngoscope. 2005;115(3):437-40. 13. Most SP. Analysis of outcomes after functional rhinoplasty using a disease-specific quality-of-life instrument. Arch Facial Plast Surg. 2006;8(5):306-9. 14. Yoo S, Most SP. Nasal airway preservation using the auto­ spreader technique: analysis of outcomes using a diseasespecific quality-of-life instrument. Arch Facial Plast Surg. 2011;13(4):231-3. 15. Clark JM, Cook TA. The ‘butterfly’ graft in functional secon­ dary rhinoplasty. Laryngoscope. 2002;112(11):1917-25. 16. Friedman O, Cook TA. Conchal cartilage butterfly graft in primary functional rhinoplasty. Laryngoscope. 2009;119 (2):255-62. 17. Guyuron B, Michelow BJ, Englebardt C. Upper lateral splay graft. Plast Reconstr Surg. 1998;102(6):2169-77.

18. Islam A, Arslan N, Felek SA, et al. Reconstruction of the internal nasal valve: modified splay graft technique with endonasal approach. Laryngoscope. 2008;118(10):1739-43. 19. Toriumi DM, Josen J, Weinberger M, Tardy ME. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1997;123(8):802-8. 20. Park SS. The flaring suture to augment the repair of the dysfunctional nasal valve. Plast Reconstr Surg. 1998;101 (4):1120-22. 21. Schlosser RJ, Park SS. Surgery for the dysfunctional nasal valve. Cadaveric analysis and clinical outcomes. Arch Facial Plast Surg. 1999;1(2):105-10. 22. Soler ZM, Rosenthal E, Wax MK. Immediate nasal valve reconstruction after facial nerve resection. Arch Facial Plast Surg. 2008;10(5):312-5. 23. Nuara MJ, Mobley SR. Nasal valve suspension revisited. Laryngoscope. 2007;117(12):2100-106. 24. Gunter JP, Friedman RM. Lateral crural strut graft: tech­ nique and clinical applications in rhinoplasty. Plast Reconstr Surg. 1997;99(4):943-52; discussion 953-5. 25. Gubisch W. Extracorporeal septoplasty for the markedly deviated septum. Arch Facial Plast Surg. 2005;7(4):218-26.

Section Surgery for Inflammatory Sinusitis

9

Chapter 44: Office-Based Rhinologic Procedures

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Chapter

Office-Based Rhinologic Procedures

44

Oscar Trujillo, Ashutosh Kacker

INTRODUCTION As a result of several trends in medical practice in the United States, there has been a shift of operative procedures from the operating room (OR) to the physician’s office. Contributing to the shift are factors such as improved technology, the advent of minimally invasive procedures, improved cost structure, and increased efficiency in the healthcare industry. These factors will become increas­ ingly important as the healthcare reform initiatives take effect in the near future. A retrospective study conducted from 2006 to 2011 compared current procedure terminology codes to per­ form a cost analysis of office-based versus OR proce­dures in rhinology. The study demonstrated that mean total charges in office-based procedures were significantly lower than OR procedures, and that office-based proce­ dures were reimbursed at similar or higher rates than OR procedures.1 Accordingly, in appropriate patient popu­ lations, performing simple rhinologic procedures in the office, instead of in the OR, has the potential to lower costs without affecting reimbursement rates. This is not to imply that the physician’s office can completely supplant the OR given the equipment, anesthesia, and level of invasiveness required by most procedures. Based on these and other factors, successful patient and procedure selection are paramount to a physician’s ability to establish a successful office-based surgical practice. Notwithstanding the poten­ tial benefits discussed herein, it is important to recog­nize at the outset that transition to office-based surgery does not alter the appropriate, medically accepted course of action required for proper diagnosis and management of disease.

CLASSIFICATION OF OFFICE PROCEDURES Facilities in which office-based procedures are performed are classified as Level I, II, or III based on the type of anesthesia used and the complexity of the procedures performed. A Level I facility performs minor procedures under topical, local (including digital block), or no anes­ thesia. Such categories of anesthesia do not involve drug-induced alteration of consciousness. Preoperative medi­cations are not required or used in such procedures, other than minimal preoperative and perioperative oral or intramuscular antianxiety drugs. In a Level I office setting, the likelihood that complications will arise that are severe enough to require hospitalization is remote. A Level II facility performs procedures that require administration of minimal or moderate intravenous, intra­ muscular, or rectal sedation and analgesia. In this setting, anesthesia includes local or peripheral nerve block, minor conduction blockage, and Bier block. This level of sedation or analgesia therefore requires postoperative monitoring. Level II facilities are limited to procedures associated with only a moderate risk of surgical and anesthetic com­ plications. The likelihood of hospitalization as a result of such complications remains relatively remote. A Level III facility performs any procedure that may require the use of deep sedation and analgesia, general anesthesia, or major conduction blockade. The known complications of the proposed surgical procedure may be serious or life threatening. In order to perform surgical procedures in an office setting, a practitioner is subject to certain requirements.

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Section 9: Surgery for Inflammatory Sinusitis

It is the acceptable and prevailing medical practice that a practitioner only performs those surgical procedures and anesthesia services that are commensurate with the practitioner’s level of training and experience. In order to demonstrate competence to perform such procedures, a physician must possess state licensure, procedure-specific education, training, experience, and must have completed a successful evaluation appropriate for the patient popu­ lation being treated (e.g. pediatrics and geriatrics). For the physician practitioner, certification or eligibility by the American Board of Medical Specialists (ABMS) or an equivalent certification as determined by the board or other entity governing the regulation of nonphysician practitioners is required. Alternatively, a training program in a field of specialization recognized by the Accreditation Council for Graduate Medical Education (ACGME) for expertise and proficiency in the field is completed. The practitioner should also participate in peer and quality review, possess documentation related to any profes­ sional misconduct or malpractice, have adequate profes­ sional malpractice insurance coverage with regard to the specialty, and participate in continuing education consistent with the requirements of statute and of the practitioner’s professional organization. In addition to these general requirements, the practi­ tioner must be competent with regard to the specific procedure including indications, technique, equipment, and complication management. The scope of competence encompasses education, training, experience and evalu­ ation, including, but not limited to, the following: (i) adherence to the standards of the relevant professional society, (ii) hospital and ambulatory surgical privileges for the scope of services performed in the office-based setting, (iii) credentials approved by a nationally recognized accre­ dition and credentialing organization, and (iv) a didactic course complimented by hands-on experience subject to professional observation and review. Training should also be complemented by the performance of a specific number of cases supervised by a practitioner already competent in the respective procedure, in accordance with the standards and guidelines of the relevant professional society.

RHINOLOGIC OFFICE-BASED PROCEDURES Most of the office-based procedures in rhinology are classified as Level I. Level I procedures require proper selection of patient and anesthesia. The practitioner must

also select the appropriate procedure under the specific clinical circumstances. It is the acceptable and prevailing medical practice for the practitioner to pursue continuing medical education in such subject areas as proper drug dosage, management of toxicity, and hypersensitivity to local anesthesia and other drugs administered in this set­ ting. The practitioner should obtain Advanced Cardiac Life Support certification, and if performing procedures on neonates, infants, or children, Pediatric Advanced Life Support. Some mildly sedating drugs are used in Level I proce­ dures. The use of any sedatives or analgesic drugs that may cause cardiorespiratory depression mandates the presence of certain emergency equipment during the procedure, including basic intravenous supplies, basic airway management equipment, advanced airway manage­ ment equipment, pharmacologic antagonists, and emer­ gency medications. With regard to basic airway man­ agement equipment, the facility should have available a source of compressed oxygen, a source of suction (inclu­ ding Yankauer-type suction as well as suction for oral and nasal airway), lubricant, and a positive pressure ventila­ tion device.2 For practitioners with intubation skills, laryngoscope handles, endotracheal tubes, and a stylet are recommended in the event of an emergency.2 Medications that should be available in case of emergencies include epinephrine, atropine, antihistamine, corticosteroids, nalo­ xone, flumazenil, amiodarone, nitroglycerin, ephedrine, vasopressin, diazepam, or midazolam.2 According to pre­ vailing medical practice for Level I office-based procedures, assistance is not required unless it is dictated by the surgical procedure, and accreditation is not necessary.

Patient Selection Patient selection is the cornerstone of a successful officebased practice. A detailed history and physical exami­ nation will aid in the identification of patients who will tolerate well and be suitable candidates for office-based procedures. As only mild sedation is administered, in the form of oral benzodiazepine or mild narcotic, patients with a lowthreshold for pain or very anxious patients are not good candidates. An anxious patient may be extremely ingratiating, have rapid speech, or otherwise demonstrate agitation. Patients with a history of significant cardiovascular disease, bleeding disorders, or difficulty tolerating a nasal endoscopy examination are not ideal candidates. Additionally, directing a patient to suspend the course of medications that may prolong bleeding will help to keep blood loss at a minimum.

Chapter 44: Office-Based Rhinologic Procedures

Anesthesia Selection With regard to anesthesia, the preference for rhinologic office-based surgery is a combination of topical and inject­able local anesthesia with mild sedation. Options for topical anesthesia include lidocaine, pontocaine, and cetacaine, each in liquid, viscous, and gel form. Topical cocaine is also an alternative, but the cost and misuse potential associated with this anesthetic are considerations that likely discourage its utilization in the office. Use of aerosolized 4% lidocaine with oxymetazoline or phenylephrine is highly effective for topical anesthesia, both clinically and with regard to cost. Regarding inject­ able local anesthesia, lidocaine with epinephrine in vari­ ous strengths and bupivacaine are excellent options. Another important consideration is the interaction of various drugs, such as commonly prescribed antibiotics and depressants, which can inhibit the metabolism of lidocaine, as lidocaine is processed through the cyto­ chrome P450 oxidase system. Patients consuming such medications may be more susceptible to lidocaine toxi­ city. The practitioner should screen for medications including but not limited to macrolides, antidepressants, antihistamines, benzodiazepines, antiulcer medications, anticonvulsants, cholesterol lowering agents, and anti­ fungal agents.3 Regardless of the type selected by a practitioner, it is crucial to allow for sufficient time for the topical anesthesia and decongestant to become effective prior to injecting local anesthesia. Commonly used anxiolytics or sedatives include short-acting benzo­diaze­ pines, such as midazolam, which are particularly useful for outpatient procedures because it has a short recovery period. In 2001, a placebo-controlled double-blinded study was performed to investigate the use of oral premedication with local anesthesia while performing procedures on the face and hair-bearing areas of the skull in an officebased setting. The study compared procedures in which midazolam, morphine, and clonidine were used as anxio­ lytics and sedatives, with local anesthesia provided by 1% lidocaine with epinephrine. The study’s conclusions suggested that patients undergoing procedures on the head and neck would benefit from the use of clonidine, as patients to whom this medication was administered had stable or low blood pressure both intraoperatively and postoperatively.4 Such conditions aid in the maintenance of a blood-free surgical field, as well as in the prevention of postoperative hematomas. While it is arguable that the study of 150 patients may have been too small to yield

649

statistically significant comparisons among groups, the conclusions nonetheless suggest that clonidine was supe­ rior to morphine and midazolam in decreasing anxiety, relieving pain, and stabilizing cardiovascular hemody­ namics. Accordingly, clonidine in combination with local anesthesia may be preferable to alternative forms of anes­ thesia when performing procedures on the face in the office. It should be noted that clonidine must be admini­ stered to the patient 60–90 minutes prior to the procedure in order to fully realize the benefit suggested by this study.4

Procedure Selection Equally as important as patient population selection and anesthesia selection, the practitioner must select the appropriate procedure in light of the circumstances. The most common office-based rhinologic procedures are integral to the care of the postoperative sinus surgery pat­ient, including removal of packing material, debride­ ment, and resection of synechia. Additional procedures that may be performed in an office-based setting include (i) minor septal surgery; (ii) inferior turbinate procedures including reduction by any modality; (iii) sinonasal and nasopharyngeal biopsies; (iv) primary and revision sinus surgery including clearance of obstructive synechia, stenosis, bony partitions, and limited polypoid tissue; (v) limited revision ethmoid and maxillary sinus surgery using conventional ESS techniques and instrumentation; (vi) maxillary, frontal, and sphenoid sinus balloon proce­ dures; (vii) resection of limited sinonasal lesions; and (viii) control of epistaxis. It is important to note that the only procedures that should be performed in the physician’s office are those whose complications can be managed in the physician’s office. The practitioner should create an appropriate setting for performing the procedure, taking into consideration privacy, ease of movement, and the availability of proper assistance, if required. With regard to performance of the aforementioned procedures in an office-based setting, equipment should include the following: a comfortable procedure chair, video endoscopy arranged with a light source, a basic sinus tray, a microdebrider, and options for hemostasis, including chemical, electrocautery, and packing options. The following commonly used instru­ ments in office-based rhinology procedures should be available: (i) frontal and maxillary sinus seekers, (ii) Freer elevators, (iii) both curved and straight suction tips in varying sizes connected to an adequate suction

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Section 9: Surgery for Inflammatory Sinusitis

apparatus, (iv) backbiters, (v) angled and straight-through cutting forceps, (vi) giraffe forceps, (vii) Kerrison rongeurs, and (viii) both straight and angled mushroom punches.5 It is essential for the practitioner to train office medical assistants, physician assistants, and nurses so that mem­ bers of the office staff are familiar with the procedures and able to assist in the event of an emergency. There should be a well-coordinated effort between the physician and assisting staff in order to instill confidence in the patient.

KEY POINTS A practitioner performing office-based surgery must select a patient who is likely to tolerate an office-based proce­ dure well, both medically and mentally. A complete and appropriate assessment includes the performance of all indicated workup, as well as a thorough history, physical examination, and review of all medications. To ensure prompt and proper reimbursement, the practitioner should establish administrative protocols for the purpose of obtaining preapproval from insurance companies prior to performing the procedure. To improve both skill and confidence in the perfor­ mance of the particular procedure, the practitioner should perform the procedure in the OR prior to any attempt in an office-based setting. In the office, the practitioner must allow for adequate time in administering topical and local

anesthesia, both for the comfort and safety of the patient, and to ensure for the practitioner a calm atmosphere in which to perform the procedure. In certain cases, a mild anxiolytic administered prior to the operation may be required. Once anesthesia has been administered and is effective, the practitioner should perform a nasal endo­ scopy and palpate the necessary structures prior to open­ ing any disposable products. As a final note, the use of any anesthesia or anxiolytic mandates the availability of proper resuscitation equipment in the event of an emergency.

REFERENCES 1. Prickett KK, Wise SK, DelGaudio JM. Cost analysis of officebased and operating room procedures in rhinology. Int Forum Allergy Rhinol. 2012;2:207-11. 2. Horton JB, Reece EM, Broughton II G, et al. Patient safety in the office-based setting. Plast Reconstr Surg. 2006;117: 61e-80e. 3. Bill TJ, Clayman MA, Morgan RF, et al. Lidocaine meta­ bolism: pathophysiology, drug interactions, and sur­gical implications. Aesth Surg J. 2004;24:307-11. 4. Beer GM, Spicher I, Seifert B, et al. Oral premedication for operations on the face under local anesthesia: a placebocontrolled double-blind trial. Plast Reconstr Surg 2001;108: 637-43. 5. Goyal P, Hwang PH. In-office surgical treatment of sinus disease: Office-based surgical procedures in rhinology. Operative Techniques in Otolaryngology. 2006;17:58-65.

Chapter 45: Endoscopic Sinus Surgery for Chronic Rhinosinusitis

Endoscopic Sinus Surgery for Chronic Rhinosinusitis: Historical Evolution, Indications, and Outcomes

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Chapter

45

Robert T Adelson, David W Kennedy

INTRODUCTION Chronic rhinosinusitis (CRS) is an inflammatory disorder of the nose and paranasal sinuses of multifactorial, incom­ pletely elucidated etiology and great individual and socie­ tal impact. CRS is presently defined by the presence of at least two of the following symptoms for > 12 weeks (hypo­ smia, nasal obstruction, facial pain/pressure, and anterior/ posterior nasal drainage) in addition to endoscopic and/or radiographic evidence of sinonasal inflammation.1 Symp­ toms of CRS can be debilitating, with patients reporting quality of life (QOL) scores in some domains akin to those for patients with chronic obstructive pulmonary disease and congestive heart failure.2 With an incidence of approxi­mately one in seven adults in the United States,3 CRS has a preva­ lence three to four times greater than asthma, peptic ulcer disease, and chronic bronchitis.4 An estimated 4.7 million emergency room visits and 61.2 million lost workdays are estimated to be attributed to CRS.4 As a result, CRS is responsible for billions of dollars in healthcare-related costs, with parallel loses resulting from decreased producti­ vity and absenteeism from work.5 The personal and public ramifications of CRS are significant, especially as the inci­ dence of this chronic condition appears to be increasing.1,6 Despite this, our understanding of the pathogenesis of CRS remains incomplete and therefore our treatment options remain similarly compromised. While initially considered to be either an infectious pro­ cess driven by pathogenic bacteria or the result of obstruc­ tive anatomic abnormalities of the nose and sinuses, CRS is now widely accepted as a complex interplay of multiple host, environmental and disease related factors with a

phenotypic endpoint of persistent sinonasal mucosal inflam­ mation1 (Table 45.1). As in other multifactorial disease states with incompletely understood etiologies, a variety of treat­ ment strategies are available. The mutually aligned goals of decreasing mucosal inflammation, improving mucoci­ liary clearance, controlling infection, removing inflamed bone, and improving the delivery of medication to the target organ are approached through a variety of medical and surgical interventions. While the management of CRS remains medical, functional endoscopic sinus surgery (FESS) plays a powerful role as an adjunctive procedure when medical therapy has failed to provide the desired control of sinonasal inflammation. In these cases, FESS provides a method for the removal of inflamed tissue and bone, widening the natural outflow tracts of the paranasal sinuses, and facilitating the penetration of topical medi­cal therapy into the sites of disease. Furthermore, the tech­ niques of FESS established the foundation for extended techniques in surgery of the nose, paranasal sinuses and skull base, allowing the endoscopic technique to become the preferred method for addressing epistaxis, CSF (cere­ brospinal fluid) leaks, and a wide range of benign and malignant tumors. An understanding of the historical evolution of FESS, its general principles, surgical indica­ tions, and treatment outcomes better illuminates the role of FESS in the treatment paradigm of CRS.

HISTORICAL EVOLUTION OF ENDOSCOPIC SINUS SURGERY Evolution is certainly an appropriate term when applied to the story of surgery of the nose and paranasal sinuses.

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Table 45.1: Multifactorial etiology of chronic rhinosinusitis

Host, environmental, and pathogen features contribute in variable degrees to the development and persistence of sinonasal inflam­mation Infection Bacterial Viral Fungal Biofilms Local abnormalities Ciliary dyskinesia Scarring from previous surgery Odontogenic infection Foreign bodies Anatomic abnormalities Septal deviation Haller cell Concha bullosa Local inflammation Gastroesophageal reflux disease Allergic rhinitis Osteitis Bacterial superantigens Biofilms (bacterial/fungal) Systemic conditions Asthma Cystic fibrosis Systemic lupus erythematosus Churg–Strauss syndrome Diabetes Allergy Allergic fungal rhinosinusitis Aspirin sensitive asthma Food allergy Atopy Immune disorders HIV/AIDS Selective immunoglobulin deficiency IgA deficiency IgG deficiency Common variable immune deficiency Immunosuppression Organ transplantation Bone marrow transplantation Chemotherapy Autoimmune disorders Wegener’s granulomatosis Sarcoidosis Deficiencies of innate immunity Environmental Cigarette smoke Pollutants

It has not been a straight-line march of progress to the present moment as its teleological end, but rather multiple lines of progress and departure, fits and starts, and improve­ ments in our knowledge and instrumentation over the past 150 years. With this, we recognize that the present state of the art is far from the final or perfect formulation for rhinologic operations, but rather somewhere along a continuum, with further innovations certain to humble us in the future. The earliest endeavors of rhinologists were directed toward infectious conditions of the nose and sinuses. During the era prior to the introduction of penicillin, intra­ cranial infections from sinus and otologic disease were responsible for 1 in every 40 mortalities.7 As such, the earliest rhinologic operations were undertaken to address complicated sinusitis and tended to be more destructive in nature. Heightened attention was paid to conditions of the frontal sinus as complications from these infections posed the greatest risk of mortality to the patient. Simple incision and drainage of purulent conditions of the frontal sinus were reported as early as 1870.8 More extensive operations to obliterate the frontal sinus by removing the anterior wall were described by Kuhnt in 1895.9 Further efforts to exenterate the frontal sinus culminated in Reidel’s 1898 description of removal of both the anterior wall and floor, though the disfiguring nature of the procedure remained a major barrier to acceptance.9 External procedures remained common, yet advance­ ments in surgical technique recognized the importance of procedures that would provide for normal drainage of the frontal sinus through its outflow tract. Caldwell’s landmark description of the canine fossa approach to the maxillary sinus codified an open approach to this location that would be familiar to the modern rhinologist.10 Knapp pub­ lished his method of addressing this goal through an external ethmoidectomy and surgery of the frontal recess in 1908.11 Lynch had developed an external approach for frontoethmoidectomy by 1921, which was later modified by subsequent surgeons who employed mucosal flaps to reduce the rate of stenosis of the frontal sinus drainage pathway.12,13 Lothrop developed the concept of creating a median frontal sinus drainage pathway in 1917, which fore­ shadowed some of the advances that are commonplace in the modern practice of rhinology. Lothrop’s cadaver studies of the frontal sinus drainage pathway allowed this deft surgeon to remove the frontal sinus floor through both a transnasal approach and a small supraorbital trephina­ tion, though the technical difficulty placed this operation

Chapter 45: Endoscopic Sinus Surgery for Chronic Rhinosinusitis beyond the scope of his contemporary surgeons until modern instrumentation and improved methods of visuali­ zation revived the concept in the 1990s.14–16 For a period of time between the development of modern endoscopic sinus surgery and the aforementioned destructive operations of the frontal sinus, osteoplastic flap procedures represented the pinnacle of surgical intervention for disease in this location. Obliteration of the frontal sinus through an osteoplastic flap was initially described by Hoffman in 1904, preserving a normal con­ tour of the frontal bone while removing the offending sinus mucosa.17 By 1956, Goodale and Montgomery published the classical description of frontal sinus osteoplasty, including obliteration with abdominal fat.18 Despite excel­ lent surgical exposure and meticulous technique by experienced surgeons, this operation was associated with complication rates above 50% and early failure in 10–15% of cases.19,20 Advances in understanding and instrumenta­ tion, as well as issues with postoperative imaging, would soon encourage surgeons to migrate from frontal sinus osteoplasty and obliteration to the novel surgical tech­ niques that enhance normal drainage pathways rather than obliterative procedures that attempt to remove the frontal sinus. While obliteration is distinctly rare in the modern era, the frontal osteoplastic flap retains a role for the management of frontal sinus pathology that remains inaccessible to completely endoscopic approaches.21 Endoscopes, or their early analogs, have been intro­ duced into nearly every anatomical space over the past 100 years. Hirschmann likely became the first nasal endo­ scopist in 1901, when he introduced a modified cystoscope into the nose.22 Reichert similarly could lay claim to the first endoscopic sinus surgery when he utilized a 7-mm endoscope through an oral-antral fistula to operate on a diseased maxillary sinus.23 Although Maltz had, by 1925, recognized the diagnostic value of endoscopy in evalua­ ting the nose and sinuses, a process he referred to as “sinuscopy” was limited by the technology of his era.22 While endoscopes are the basic working tools of modern rhinology and one of the great sparks for innova­ tion in the field, these instruments were not the first attempt by surgeons to improve the magnification and illumi­ nation of the nasal cavity. The operating microscope that revolutionized otology in the 1960s and 1970s had been applied to the ethmoid labyrinth by the 1970s, yet technical difficulties precluded both a consistent binocular view and widespread acceptance. The magnification afforded by an operating microscope was translated in a monocular fashion with the rod optic endoscope system patented

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by the British Professor Harold Hopkins in 1959 and first put into production by Karl Storz in 1967, providing the keystone instrument that would facilitate a great leap forward in surgery of the nose and paranasal sinuses.24 Draf is credited with the first published report of endoscopic examination of the nose in 1973.25 It now became possible to perform detailed examination and surgery of the lateral nasal wall and paranasal sinuses with a portable system that, while lacking the depth perception of a binocular view, did provide important advantages over the operating microscope. The introduction of endoscopes with deflec­ ted viewing angles allowed the application of high illumi­ nation, and crisp image resolution to overcome line of sight issues and view regions of the nose that had not been previously accessible. Within the paranasal sinuses, modern endoscopes ushered in a renaissance in the basic science and clinical practice of rhinology. European surgeons were the first to incorporate this novel technology into their nasal opera­ tions, and the senior author traveled to spend time with Wigand, Draf, Baum, and Messerklinger at their home insti­ tutions, observing the methods by which these pioneers were advancing the diagnosis and performing early surgi­ cal management of sinonasal disease. In 1978, Messerk­ linger published his classic work illustrating mucociliary clearance patterns of the paranasal sinuses in human cadavers and the intricate diagnostic and anatomic details that could be delineated by technical advances in nasal endoscopy. However, the concept of endoscopic surgical intervention was not mentioned.26 Endoscopic demonst­ ration of the consistency of mucociliary transport patterns in humans, initially documented in rabbits by Hilding in the 1930s, would prove to be an important foundational concept in constructing the modern surgical approach to CRS.27 The senior author’s background in neuro-otology, prior surgical experience with microscopic endonasal ethmoi­ dectomy and skull base surgery, and his earlier research in sinus mucociliary transport enabled him to begin the pro­ cess of incorporating, refining, and transmigrating the early European experience to the American medical comm­ unity.28 By 1985, sufficient experience with endoscopic surgery and a recognition of the potential impact of these techniques on CRS allowed the senior author to publish two landmark papers that detailed the theoretical and diagnostic principles, as well as the surgical techniques of what he modified to become functional endoscopic sinus surgery. The early success of this procedure, designed to

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Section 9: Surgery for Inflammatory Sinusitis

Fig. 45.1: Letter to Mr Norman Silbertrust at Karl Storz Endoscopy America, Inc, dated April 20, 1984, detailing the need for specially designed instrumentation for endoscopic surgery of the nose and sinuses.

re-establish ventilation and enhance mucociliary clearance from the paranasal sinuses, was reflected in the acronym FESS that would be adopted rapidly into the permanent surgical lexicon of otolaryngology.29–31 The introduction of the technique of FESS and its early refinements to the American audience enabled a number of unmet needs to be addressed within the nascent discip­ line of rhinology. For the field to flourish, advances in operative instrumentation, radiographic imaging, and the education of both residents in training and practicing otolaryngologists would be required. The surgical goals envisioned for surgery of the nose and sinuses would require specialized instrumentation that is complementary to the endoscope. A collaborative effort with Karl Storz Endoscopy was initiated, resulting in the development of surgical tools for a procedure whose name had not yet been coined (Fig. 45.1). Small telescopes with a variety of viewing angles require similarly angled hand instruments for tissue removal. Angled suction and through-cutting is instruments that allow access to the lateral nasal wall, skull base, and frontal recess were develo­ped in conjunction with the senior author and his European counterparts to reflect surgical needs and the growing body of basic science research that supports mucosal preservation, removal of osteitic bone, and enhancement of the natural drainage pathways by com­ plete surgical dissection in the absence of mucosal strip­ ping. These through-cutting handheld instruments, curved

probes and angled forceps provided the basis for all instru­ mentation in endoscopic sinus surgery and its later expan­ sion into endoscopic surgery of the orbit and skull base. In later years, the introduction of powered instruments (microdebrider, drills) and scope cleaning devices would further the visualization and the ability to preserve mucosa by which surgeons could address the nose and paranasal sinuses. Appropriate radiographic imaging studies that reflect the improved understanding of mucociliary clearance pathways became a fundamental requirement for perfor­ ming safe and complete endoscopic sinus surgery. Plain films that assess the frontal and maxillary sinuses became rapidly outdated as the paradigm for treating CRS shifted from external approaches with mucosal destruction to endoscopic methods that facilitated normal mucociliary flow. Zinreich’s work with Kennedy was instrumental in developing and promulgating the use of coronal plane CT scan as the standard view for delineating the anatomy of the lateral nasal wall.32 Adoption of the coronal view rapidly became the standard of care for surgeons addres­ sing sinus disease; however, the importance of reviewing axial and sagittal planes cannot be overstated in the mod­ ern radiographic evaluation for paranasal sinus surgery. Appropriate education in the theory and techniques of this new method of performing sinus surgery was critical to its widespread adoption. The first postgraduate course for instruction in endoscopic sinus surgery was held in the United States in 1985, codifying the surgical method and sharing this technique through cadaver dissection, an approach which remains a critical component of teaching in rhinology.33 Although residency education and cadaver training courses remain integral to rhinology education, the future of clinical and academic rhinology is largely based on the ongoing development and rapid growth of fellowship training.

INDICATIONS FOR ENDOSCOPIC SINUS SURGERY The absolute indications for FESS remain somewhat rare, and in some cases, controversial. Absolute indications for surgical intervention in sinus disease include purulent complications involving the orbit or intracranial space, expansile mucoceles, invasive fungal rhinosinusitis, and neoplasms. Modern techniques greatly favor endo­scopic techniques for the vast majority of paranasal sinus disease; however, when considering the acute manage­ ment of suppurative complications, frontal osteomyelitis,

Chapter 45: Endoscopic Sinus Surgery for Chronic Rhinosinusitis

Fig. 45.2: A left subperiosteal orbital abscess is depicted with inflammatory changes in the adjacent ethmoid sinuses. Courtesy: Kevin Welch, MD, Loyola University, Chicago, IL, USA.

and unfavo­rable anatomy, external approaches retain a position of surgical relevance. In our institution, suppura­ tive compli­ cations of frontal sinusitis may be treated urgently with trephination, drainage of the abscess, and irrigation of the frontal sinus along with antibiotics modi­ fied on the basis of culture, and in the presence of severe acute inflamma­tion, endoscopic drainage may be delayed. More controversial is the absolute indication for sur­ gery in orbital complications of sinusitis. Subperiosteal orbital abscesses are uncommon complications of ethmoid sinusitis (Fig. 45.2). The need for medical management and continuous inpatient monitoring of this disease process is emphasized by all investigators34; however, the absolute indications for surgery are less certain. Large case series of subperiosteal abscesses secondary to sinusitis35,36 as well as retrospective reviews of the literature37 have identified several features that favor surgical therapy. Abscesses that are not medially located within the orbit, those with volume > 0.5 mL or dimensions of width > 4.5 mm and length > 17 mm, or any associated with loss of visual acuity, proptosis > 5 mm, intraocular pressure > 20 mm Hg, or the onset of ophthalmoplegia should be addressed surgi­ cally.34–38 In general, a failure to improve or clinical deterio­ ration within 48 hours of the initiation of medical therapy represents an additional absolute indication for surgical intervention.36,37 Relative indications for sinus surgery, which in the modern era is synonymous with endoscopic sinus surgery, are those conditions that improve maximally with surgical techniques and remain less responsive, if at all, to medical management. Mucoceles represent a class of paranasal sinus disease in which anatomic abnormalities result in an

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Fig. 45.3: Obstruction of the frontal sinus drainage pathway resul­ ted in expansile changes in the associated bony boundaries of the frontal sinus with extension of a frontal sinus mucocele into the left orbit. The image guidance instrument demonstrates that surgical access has been gained into the lateral extent of the mucocele, allowing the cavity to drain into the nose via an enhanced pathway. Courtesy: Calvin Wei, MD, Mount Sinai and Lennox Hill Hospitals, New York, NY, USA.

obstructive process that can be remedied through endo­ scopic surgery directed toward the obstruction (Fig. 45.3). Wide marsupialization of the mucocele and attentive post­ operative debridements, along with appropriate medical therapy, provide uniformly high success rates in the treat­ ment of these largely obstructive processes. While mucoceles are the most manifest of the inflam­ matory paranasal disorders for which surgery is indicated, for the remainder of the spectrum of rhinosinusitis the relationship between anatomic variations and sinonasal inflammation remains controversial. Recurrent acute rhino­ sinusitis (RARS) is a particularly vexing condition, as this most likely represents hyper-reactivity of the sinonasal mucosa, a variable or subtle immunodeficiency, or repea­ ted exposures to environments or infectious agents that are troublesome for a particular patient. FESS should be broached with caution in RARS, and probably not at all unless the patient has some persistent inflammation between episodes, as patients will still probably experience repeated acute infections. The one potential advantage of surgery in this situation is that it may allow greater delivery of topical medical therapy to the involved sites and impro­ ved levels of baseline control of nasal inflammation. On the other hand, if there is an environmental or allergic component, surgery will open up virgin mucosa to the same environmental factors that be a factor in the patient’s RARS.

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Section 9: Surgery for Inflammatory Sinusitis

A similar degree of prudence should be exerted when considering FESS for the patient with facial pain and pres­ sure or headache. In a population of patients under­going CT scan for indications other than disease related to the sinuses, between 10% and 50% of scans demon­strated radiographic abnormalities consistent with sinusitis.39,40 There remains an intersection between the population of patients with headaches and those with asymptomatic radiographic findings. Unlike acute sinusitis, patients with chronically inflamed paranasal sinus mucosa do not experi­ ence marked pain. Normal sinonasal mucosa is more sensitive to pain derived from ostial obstruction than is chronically thickened mucosa. Episodes of barosinusitis during flying, or scuba diving and acute sinusitis can be associated with more marked pain symptoms than in CRS, and is a good indication for surgery or balloon dilatation. On the other hand, there is no clear association demon­ strated between weather changes, headache, and sinu­sitis. Appropriate diagnostic studies should be considered in the longstanding CRS patient with new development of severe pain, as this can indicate dural inflammation, neural involvement, neoplasm, or an infectious complication of rhinosinusitis. The rhinologist must discriminate between these patient subsets to improve the satisfaction with sur­ gery and avoid subjecting the vast majority of patients who have vascular variant headaches to surgical intervention. Thorough endoscopic examination as well as adjunctive consultations with a neurologist and, occasionally, pain management specialists can be helpful in appropriately addressing the patient with facial pain and pressure in the absence of paranasal sinus findings. While medical management is an essential component of the management of all inflammatory conditions of the nose and sinuses, there are a few processes in which relative indications for surgery predominate and current trends favor surgical intervention earlier in the disease process. CRS with nasal polyposis can be better controlled after an initial and complete operation to remove the inflam­ matory polyps, widely ventilate the paranasal sinuses and improve the penetration of topical medical therapy. Simi­ larly, allergic fungal rhinosinusitis (AFRS) represents a subset of CRS with nasal polyposis for which medical therapy is greatly enhanced by surgery. Though immuno­ modulation with corticosteroids and/or mold allergen desensitization therapy is fundamental to the manage­ ment of AFRS, wide surgical ventilation of the paranasal sinuses and removal of all eosinophilic mucin is the critical

component for successful management, along with com­ plete removal of the bony intracellular partitions and longterm endoscopic surveillance.41 The most common indication for FESS is the persis­ tence of symptoms of CRS despite appropriate courses of medical therapy. Though there is a lack of uniformity among various medical treatment protocols for CRS, there is some consensus regarding the minimum of medical care. The majority of treating physicians reported prescri­ bing oral antibiotics, oral steroids, and intranasal cortico­ steroid sprays, with over 90% of survey respondents recommending oral antibiotics for average durations approaching 4 weeks in combination with intranasal corti­ costeroids.42 Rhinologists are more likely to use oral corti­ costeroids than are other otolaryngologists, with mean peak prednisone doses over 50 mg.42,43 Mucolytics, topical decongestants, allergy testing, surfactants, and large volume irrigations, sometimes incorporating high-dose topical steroids, are helpful adjuncts to the aforementioned medi­ cal strategies. There also exist a variety of interventions that are used infrequently or rarely and for which there is relatively little evidence of efficacy, including antifungal sprays, nebulized antibiotics, or intravenous antibiotics as a routine component of medical management in the patient with CRS. Optimization of the patient’s risk factors for CRS is always considered prior to proposing surgery. Often, this will include allergy testing and management of atopic conditions, eliminating exposure to cigarette smoke and other environmental hazards, enhanced medical control of reactive airway disease, as well as a battery of immunologic tests in select refractory cases. Patients experiencing ongoing symptoms of CRS despite diligent medical evaluation and treatment are most likely to appreciate significant improvements following FESS and are the ideal candidates for whom surgery is indicated.

PREOPERATIVE COUNSELING FOR ENDOSCOPIC SINUS SURGERY The goals for and role of endoscopic sinus surgery in the overall management of CRS are fundamentally different from the commonly understood functions of operative procedures for most other disease processes. As such, it is incumbent upon the otolaryngologist to educate the patient properly regarding surgery and perioperative care. Appropriate management of expectations is of critical importance when addressing a process of ongoing inflam­ mation, as the patient’s cooperation in preoperative prepa­ ration and postoperative office-based procedures are requirements for a successful surgical result.

Chapter 45: Endoscopic Sinus Surgery for Chronic Rhinosinusitis Treatment of CRS is overwhelmingly medical, with surgery reserved for a minority of patients who fail to respond appropriately to oral corticosteroids, intranasal corticosteroids, oral antibiotics, and control of allergic inflammation. Considered broadly, endoscopic sinus sur­ gery is typically not curative for CRS, but rather plays an adjunctive role in the global management of sinonasal inflammation. Preoperative counseling that emphasizes the long-term strategy for management of CRS enables patients to have an understanding of treatment goals as well as the need for ongoing medical management follo­ wing successful surgery. Surgeons should communicate to their patients that the primary treatment of CRS is medi­ cal and not surgical. Surgery augments medical regimens by the removing inflammatory tissue, facilitating proper drainage from the paranasal sinuses, and allowing penetration of topical medical therapy into the affected sinuses. Recent studies suggest an increasingly important role for surgery as a route of medication delivery, as the paranasal sinuses are directly accessed by intranasal sprays and irrigations only after proper surgical access has been achieved.44 Con­ versely, one significant disadvantage of surgical interven­ tion is that, if the underlying predisposing cause for the rhinosinusitis was environmental and this is not controlled, surgical intervention opens up additional virgin mucosa to the same environmental factors. Unlike most other surgi­ cal procedures, patients play an active role in modula­ tion of the operative site during the postoperative period. The operative site is evaluated by the surgeon on a weekly basis and debrided as necessary until the endoscopic examination of the mucosa stabilizes. During this period, the patient is treated with oral corticosteroids, irrigations, topical corticosteroids, and, as necessary, office-based debridements. Meticulous postoperative care is an absolute requirement for a successful result. The persistent and careful removal of residual bone fragments, mucus, clots, and early synechiae decreases the burden of bacteria and fungus within the operative field, preserves the enhanced drainage pathways, and reduces overall sinonasal inflamma­ tion.45 We believe that proper counseling prior to surgery can improve patient compliance with medical therapy in the pre- and postoperative periods, which is integral to the overall success of endoscopic sinus surgery.

GENERAL PRINCIPLES OF FESS Our practice and understanding of the role of FESS conti­ nues to evolve. Following the introduction of FESS in 1985,

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there has been a steady progression of basic science and clinical outcomes knowledge that guides the present tech­ niques of FESS. Though Naumann had originally deline­ ated the ostiomeatal complex in 1965, the area was not widely accessible to physicians as the anatomic knowl­ edge predated the wide introduction of imaging tech­ niques and viewing modalities that would later reshape the field of rhinology.46 When the ostiomeatal complex became clinically accessible at the dawn of the endo­ scopic era and CT imaging of the sinuses, the pendulum swung to an overemphasis of the importance of this region in the pathogenesis of CRS. The notion of CRS as largely an obstructive phenomenon predominated the field for many of the early years, and vestiges of this notion still persists in some quarters. No longer is it accepted that CRS is a simple process of ostial obstruction that results in bacterial infection of the associated sinus. Although surgery directed to improving ventilation and drainage through the ostiomeatal complex remains an important component of treating CRS, the role of anatomic varia­ tion and obstructive phenomena have been relegated to a supporting position. CRS is broadly recognized as a spec­ trum of signs and symptoms that arise from a persistent inflammatory process of paranasal sinus mucosa and bone.47 As such, the management of CRS is directed to the etiologic agents of inflammation (Table 45.1), largely thro­ugh medical therapy to control infection, reduce allergic responses, and restore normal mucociliary flow. When surgery is indicated, the technique of FESS is employed and mucosa is maximally preserved. While controversy exists regarding methods of performing sinus surgery, the formerly held notions supporting the stripping and com­ plete removal of “condemned mucosa” has long been rele­ gated to history. Discussed elsewhere in this text, balloon catheter dilation of sinus ostia and surgery of the transition spaces within the nose are surgical techniques that result in less surgical trauma and less mucosa scarring that tradi­ tional FESS. However, these minimally invasive opera­ tions do not allow for the removal of involved bone, and its associated inflammation.48 It is clear that CRS is not just an issue of sinus obstruction. Moving forward, however, it is likely that the management CRS will migrate toward more minimally invasive procedures in combination with topical anti-inflammatory therapy. Hybrid procedures that incorporate balloon catheter technology for dilation of some paranasal sinuses in combination with traditional endoscopic techniques for removal of diseased bone and associated mucosa have been suggested to offer low revi­ sion rates in treatment of CRS, though methodologic issues in assessing the success of this approach remain.49

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Section 9: Surgery for Inflammatory Sinusitis other topical therapeutic interventions that can be delive­ red into the paranasal sinuses with lesser degrees of ana­ tomic disruption.51 At present, well-controlled investiga­ tions into a clinically available, bioabsorbable implant that elutes mometasone directly into the postoperative ethmoidectomy defect have demonstrated successful reduction of postoperative synechiae, mucosal inflamma­ tion, early polyp formation, and middle turbinate laterali­ zation52–54 (Fig. 45.4).

OUTCOMES RESEARCH IN FESS

Fig. 45.4: A drug eluting implant placed within a Draf 2A frontal sinusotomy exerts a centrifugal force against the surrounding tis­ sue and releases mometasone into the surrounding tissues over 30 days before degrading over the following several weeks after drug elution is complete.

Our current practice of FESS places great importance on the preservation of mucosa and the removal of osteitic bone while endeavoring to appropriately ventilate the associated paranasal sinuses. When mucosa is completely stripped, the epithelium that eventually regenerates in a traumatized location will possess a significantly reduced population of ciliated cells with compromised mucoci­ liary clearance.50 Surgically exposed bone experiences a greater degree of inflammation and frequently this bone becomes osteitic, undergoes neo-osteogenesis, and may sometimes be associated with chronic pain and pressure. Preservation of mucosa is a fundamental step in avoiding a cascade of inflammatory responses within the bone that requires long-term medical management and possibly surgical revision. When osteitic bone is noted in revision surgery, its complete removal is recommended to reduce the inflammatory burden and the associated implications with persistent mucosal disease and scarring. The extent of FESS in CRS is generally directed to perform complete operations that address one sinus beyond the disease process noted on preoperative CT scan or the inflammation present at the time of surgery. Complete uncinectomy is performed in every operation, as the failure to remove the entire uncinate process has been associated with persistent inflammation, maxillary sinus obstruction, and the need for revision surgery. Future developments in the evolution of our specialty may support more minimally invasive techniques, espe­ cially with the introduction of drug eluting implants and

For nearly three decades, surgical practice and the medical literature has clearly established the role of FESS in the management of CRS. As our knowledge base expands, a critical analysis of outcomes research allows surgeons to better counsel patients with CRS regarding the expecta­ tions for FESS. Outcome data have become available for a wide array of subjects related to CRS and its surgical management. Review of the outcome data for FESS as it related to QOL scores, particular symptoms of CRS, and various surgical techniques will allow surgeons to better understand the expected impact on patient satisfaction, which in CRS is the ultimate indicator of successful management.

Outcomes of FESS in the Management of CRS While only a minority of patients with CRS will eventually undergo FESS, the technique is well established as the gold standard for surgical intervention in inflammatory disease of the paranasal sinuses. Outcomes assessments have become fundamental tools in the evaluation of sur­ gical procedures. In disease states such as CRS, where the goal is improved control of an ongoing inflammatory process, an understanding of treatment success from a patient’s perspective has become a fundamental tool in the assessment of management strategies. Numerous out­ comes studies have established FESS as both a safe and a highly successful intervention that, when combined with appropriate postoperative care, provides durable improve­ ments in sinonasal symptoms and overall health. While level 1 evidence supporting FESS in CRS is not as robust in numbers, there is an abundance of published level 2 and 3 evidence that supports the previously described role for FESS in the management of CRS in adult patients.55 It is now generally accepted that rates for symptomatic improvements following FESS should be attainable in the

Chapter 45: Endoscopic Sinus Surgery for Chronic Rhinosinusitis vast majority of patients with CRS.56 Some of the largest early studies showed symptomatic improvements, in the absence of validated surveys, between 80% and 89% of patients with an average follow-up of 17 months.57 The senior author prospectively followed 120 patients and repor­ted symptomatic improvement in 97.5% an average of 18 months after FESS in conjunction with appropriate medical therapy.58 Use of validated questionnaires in prospective studies has become a fundamental compo­ nent of outcomes assessment in CRS.59 Metson and Gliklich demonstrated significant improvements in symptoms and health as well as reductions in medication usage in 88% of patients meeting criteria to undergo surgery for CRS, based upon prospectively obtained validated question­ naires.60 Similar reports of improvement after FESS with SNOT-20 symptom scores are reported as early as 3 months and persist or improve at 12 months following surgery.61 The senior author has shown these subjectively reported improvements after FESS to remarkably durable. With nearly 8 years of postoperative follow-up, 98.4% of patients experienced continued symptomatic relief, although 18% of patients, most of whom had had prior surgical inter­ ventions elsewhere, required revision surgery during this follow up period.45 Longer-term studies of FESS have demonstrated overall improvements in QOL assessments based on patient responses to validated surveys. Khalid et al. found patient’s overall health status to remain signifi­cantly improved at 3 years after undergoing FESS and appropriate medical therapy for medically refractory CRS.62 It is expec­ ted that postoperative patients, with appropriate medical management, will achieve QOL scores that are equivalent to general population counter­parts without CRS.62 While the overall expectations remain high for improve­ ments in QOL after FESS, several patient features have been suggested to decrease overall improvements in evaluated symptom domains. Smith et al. found primary FESS patients to experience significantly greater improve­ ments than revision FESS patients on overall QOL inventories.63 Furthermore, there is evidence that aspirin intolerance and depression may be predictive of poorer overall QOL outcomes.64 Despite this, severity of depres­ sion has been shown to significantly improve after FESS.65 The use of cigarettes remains an interesting and mildly controversial subject, with regard to outcome data. Though the revision rate for endoscopic sinus surgery is known to be elevated,45 there are outcome data that suggest no or limited difference in QOL scores between smokers and nonsmokers undergoing FESS for CRS.66 There are signifi­ cant differences, however, in the postoperative endoscopy

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scores when light smokers are compared to heavy smo­ kers.66 All patients who smoke cigarettes should be coun­ seled toward cessation as a primary intervention in improving their sinonasal symptoms. It is the practice of the senior author to avoid elective, nonurgent sinus surgery on active smokers, given our findings that suggest patients with more extensive inflammatory disease are especially prone to require revision operations when they continue to smoke.45 An understanding of some of the preoperative features that portend reduced QOL outcomes will allow surgeons to properly counsel patient regarding appro­ priate postoperative expectations.

Outcomes for Medical Therapy versus Surgery in the Management of CRS Medical therapy and surgery are both appropriate treat­ ment strategies for long-term management of CRS, and are complementary in their objectives. Recent literature indicates that patient-based outcomes are significantly improved in the patient population undergoing combi­ nation therapy. Patients undergoing FESS for CRS after failing initial medical therapy reported superior QOL improvements, decreased absenteeism from work/school, as well as reduced use of antibiotics and oral corticosteroids over first 6 months as compared to the cohort selecting ongoing medical management.67 A 12-month follow-up of this study population allows greater understanding of the outcomes for FESS when compared to surgical manage­ ment for medically refractory CRS. Not only did the surgi­ cal cohort report a significantly greater improvement in QOL scores than did the medically managed group, but one third of the medically managed patients crossed over to the surgical arm after medical therapy failed to improve their symptoms. Both the surgical group and the cross-over group experienced significantly greater QOL improve­ ments than did the medically managed group.68 The demonstrated efficacy of surgery in providing significant improvements in QOL, especially after demonstrating the inability of medical therapy alone to achieve the desi­ red results, is a powerful argument for the role of FESS as an integral adjuvant component in the CRS treatment strategies.

Outcomes for Olfaction after FESS Hyposmia is a common and challenging symptom to im­prove in patients with CRS. There are multiple and often coexisting mechanisms for olfactory impairment, inclu­ ding mechanical obstruction and inflammatory damage

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directly to the olfactory neuroepithelium. Recently, several authors have demonstrated that both local and systemic eosinophilia correlates with greater levels of olfactory dysfunction, though the precise mechanism of sensory loss remains incompletely understood.69,70 While the pathogensis of olfactory loss remains incompletely under­ stood, our appreciation for the benefits of FESS in parti­ cular populations of patients with CRS has been better elucidated by recent outcomes studies. For olfactory function alone, surgery is a powerful adjunct when compared to medical therapy alone. A matched, nonrandomized study comparing medical therapy alone to combined therapy with FESS followed by intranasal corticosteroid sprays, found the surgical group to expe­ rience significantly improved olfactory func­tion in CRS with nasal polyposis.71 Though surgical intervention in CRS has been demonstrated, repeatedly, over the past few decades to successfully improve the symptoms of CRS, specific examinations of the effects of FESS on olfaction have been less encouraging. A prospective trial of 111 patients undergoing FESS for CRS demonstrated the surprising finding that patients with more severe olfactory dysfunction experienced a significant and sustained improvement in performance on standardized tests of olfaction, whereas those with lesser degrees of hyposmia did not.72 These findings sup­ port improved olfactory outcomes in anosmic patients with obstructing polyps, while those without obstructive disease are more likely to have sustained additional injury to the olfactory neuroepithelium for which surgery alone is not reparative. Complementing this study is a prospec­ tive work that reviewed the degree of olfactory cleft opacifi­ cation in 52 patients with CRS with nasal polyps who later underwent FESS. It was shown that patients with lesser degrees of inflammatory disease of the anterior olfactory cleft improved to a greater degree than did those with more severe mucosal inflammation on preoperative CT scan.73 Despite this, overall results for olfaction after FESS remain somewhat troubling. Pade prospectively evaluated 206 patients with CRS with nasal polyps and reported subjectively appreciated olfactory improvements in only 23%.74 Objective data for patients in a similar prospective trials of CRS patients including populations with and without nasal polyps found only cautiously optimistic improvements for this symptom. Performance on olfac­ tory discrimination tests 5 years after primary surgery showed improvements in only 53%.75 Patients undergoing

revision FESS demonstrate similar rates of improvement in olfaction as those reported in studies of primary FESS operations. A prospective analysis of hyposmic patients undergoing revision FESS demonstrated rates of improve­ ment on postoperative objective olfactory testing at 47.8% between 12 and 24 months after surgery.76 The irregularity with which any prognostication can be made regarding expected olfactory outcomes contin­ ues to bedevil those who counsel patients regarding hypo­ smia as a result of CRS. Jiang prospectively evaluated 70 patients with CRS and failed to demonstrate any signifi­ cant difference in either the objective or subjective olfactory function outcomes.77 The group did, however, show a correlation between severity of changes on CT scan and olfaction testing, supporting previous authors that demonstrated more severe inflammation in patients with worse olfactory outcomes.77 Despite this correlation, there are no more specific data that allow surgeons to reliably counsel patients on features that portend positive or negative olfactory results after surgery. The extent of sino­ nasal inflammation, degree of nasal airway obstruction, coexisting diagnosis of allergic rhinitis, or the presence of nasal polyps in this population have not been shown to be predictive of olfactory improvement following FESS.78 These examinations of olfactory function have parsed patient populations most likely to improve with surgery and medical management as well as the expected degree of improvement. A better understanding of olfactory outcomes following FESS allows for proper counseling of CRS patients considering surgery. Multiple features of olfactory impairment, including improvement on oral steroids, age, duration of inflammatory disease, number of prior operations, and degree of nasal polyposis, must make surgeons cautious when prognosticating long-term improvement in hyposmia for many patients with CRS. In general, postoperative olfactory outcomes are better in those populations with anosmia and nasal polyposis and somewhat diminished for those with hyposmia and non­ polypoid inflammatory disease. More severe radiographic changes preoperatively, and specifically those that involve the anterior olfactory cleft, are associated with worse olfac­ tory outcomes. There does not appear to be a significant difference in olfactory outcomes between primary and revision operations. Preoperative counseling should take into consideration the available outcome data regarding olfaction to properly manage surgical goals and patient expectations.

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Outcomes for Specific Surgical Maneuvers in FESS There is a paucity of literature related to outcomes of speci­ fic maneuvers during FESS. There are, however, a few opera­ tive techniques among the many components of FESS procedures for which some outcome data have been pro­ duced. Management of the middle turbinate, extended frontal sinus operations, and the creation of an enormous maxillary sinus antrostomy are surgical maneuvers rhinologists have to consider in refractory disease.

Outcomes in Determining the Anatomic Extent of Maxillary Antrostomy The maxillary sinus is, arguably, the most commonly addressed sinus by surgeons performing FESS. Despite the frequency with which this sinus undergoes surgical intervention, substantial differences persist regarding the degree of opening necessary to achieve improved results. Key components of the decision-making process in this operation relate to the effects of antrostomy on maxillary sinus nitric oxide concentrations and adverse effects of nasal airflow on the newly exposed sinus mucosa, and the ability to introduce topical therapies into the maxillary sinus. Nitric oxide is produced in the paranasal sinuses and is thought to contribute to the normal function of these spaces both by its role in ciliary function as well as through its antibacterial properties. Basic science investigations into the relationship of maxillary antrostomy size and nitric oxide concentrations do demonstrate a decrease in levels with larger antrostomies, yet clinical outcomes have not been correlated with diminished nitric oxide levels. Despite the basic science demonstration that nitric oxide concentrations decrease with an antrostomy > 5×5 mm, there is a lack of clinical outcome data linking lower nitric oxide levels to chronic maxillary sinusitis.79 Albu and Tomescu evaluated prospectively the relationship between small ( 16 mm) maxillary antrostomies, yet no significant correlation was demons­ trated between the improvement in a patient’s symptoms of CRS and the resultant antrostomy size.80 An extensive meta-analysis of the available literature addressing nitric oxide levels within the paranasal sinuses failed to demons­ trate any negative clinical outcomes of a large maxil­ lary antrostomy as a result of diminished nitric oxide concentrations.81

Fig. 45.5: Mega-antrostomy/modified maxillary antrostomy. The endoscopic modified medial maxillectomy can be used in the salvage of a chronically infected though otherwise patent maxil­ lary sinus. This extended operation allows for maximum irrigation, improved penetration of topical therapy, and results in a form of “marsupialization” of the sinus that facilitates debridement in the office setting. Note the continuity between the right maxillary sinus floor and the nasal floor after removal of the medial maxillary wall.

There is some agreement on one population for whom a very aggressive maxillary antrostomy has been shown to be associated with improved outcomes: chronic maxil­ lary sinusitis refractory to prior well-performed surgery and medical therapy. In these cases, endoscopic removal of the medial maxillary wall such that the antrostomy connects with the nasal floor has been demonstrated to be an effective technique.82 This dramatically larger ope­ning of the maxillary sinus facilitates office-based debridement, improves penetration of topical medical therapy, and allows greater access for irrigation and removal of retai­ ned mucous. In populations with impaired mucociliary clea­ rance this procedure offers the benefit of an enlarged drainage pathway without the need for mucociliary flow against gravity toward the natural ostium (Fig. 45.5). In prospectively evaluated cystic fibrosis patients, this proce­ dure significantly improved both sinonasal symptom scores and endoscopic scores 1 year following surgery.83 Cho and Hwang reported symptomatic improvement in 100%, and complete resolution of symptoms in 74% of retrospectively reviewed patients treated for medically and surgically recalcitrant maxillary sinusitis.84 Similar overall outcomes for this operation have been reported by Schlosser’s group; however, success rates were lower in the groups with cultures positive for Pseudomonas aeruginosa and worse still for those with Staphylococcus aureus.85

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A

B

Figs. 45.6A and B: Although there are valid disagreements regarding the size of a maxillary antrostomy, the procedure should always incorporate the natural ostium at this most anterior extent to prevent complications related to recirculation of the mucociliary flow from the maxillary sinus. Part (A) demonstrates a right maxillary antrostomy with synechiae separating the right natural ostium from the sur­ gical antrostomy with resultant recirculation. Part (B) demonstrates a more idealized left maxillary antrostomy with incorporation of the natural ostium at the anterior extent of the surgical dissection. Note the pear shaped antrostomy with the apex anterosuperiorly.

The negative effects of nasal airflow on maxillary sinus mucosa have been more definitively demonstrated than those postulated for a reduced nitric oxide concentration. Animal studies clearly depict a slowing or cessation of mucociliary clearance in the presence of maxillary sinus airflow.86 The combination of these effects may be a factor in biofilm formation within the maxillary sinus, accoun­ ting for a portion of residual and refractory disease in patients despite widely patent antrostomies. When the posterior limits of the maxillary sinus protrude medially, large antrostomies can create an “air scoop” with resultant drying of the maxillary sinus mucosa. This anatomic configu­ ration should be recognized preoperatively to allow either minimal opening of the maxillary sinus or an extensive opening back to the pterygoid plates, as both of these sur­ gical approaches would limit airflow that is drying to the maxillary mucosa. Avoiding this airflow would prevent the subsequent ciliary stasis and possible promotion of biofilm formation despite a patent maxillary antrostomy. Though there is a paucity of strict clinical outcome data, there is sufficient information to enable surgical decision making with regard to the size of a maxillary antrostomy. Surgeons must have clear understanding of their goals for a particular patient when evaluating the existing out­ come data and determining the desired size of an antro­ stomy. Larger antrostomies should be favored in cases of allergic fungal rhinosinusitis and in fungal ball of the

maxillary sinus, as postoperative surveillance and removal of material from the maxillary sinus are anticipated. Simi­ larly, when treatment goals include penetration of topical medical therapy into the maxillary sinuses, larger antros­ tomies have been shown to allow greater postoperative penetration of irrigated solutions.87 Regardless of the selected antrostomy size, the unci­ nate process should always be removed completely during surgery. This structure is involved early in CRS and, when retained following surgery, the remnant uncinate bone and associated mucosa acts as a persistent source of inflam­ mation and obstruction to normal mucociliary flow from the maxillary sinus.88 The natural ostium should be directly visualized during dissection and this requires the use of 45° or 70° angled endoscopes. Surgery and subsequent postoperative care should endeavor to maintain a gene­ rally pear-shaped antrostomy, regardless of gross size, that includes the natural ostium at its most anterior extent and remains free of synechiae89 (Figs. 45.6A and B).

Outcomes for Extended Frontal Sinus Operations for Inflammatory Disease Over the past 20 years, there has been a dramatic increase in both the frequency and the extent to which surgery is performed for frontal sinus disease. The introduction of trans-septal frontal sinusotomy (TSFS) broadened the

Chapter 45: Endoscopic Sinus Surgery for Chronic Rhinosinusitis

Fig. 45.7: Draf 2A operative site. In the vast majority of primary and revision FESS, removal of all partitions within the frontal sinus drainage pathway and meticulous preservation of the associated mucosa of the medial orbital wall, skull base and middle turbinate, provides a successful surgical intervention for the frontal sinus.

range of conditions amenable to endoscopic procedures while the availability of image guidance and novel instru­ mentation has increased the total number of frontal sinus operations.90 Outcome data are now available that have helped shape the approach to the frontal sinus when exten­ ded operations may be considered. In the vast majority of surgical patients including both primary and revision surgery, a formal endoscopic frontal sinusotomy, or Draf 2A procedure is successful (Fig. 45.7). A review of 717 such operations at a tertiary referral center found > 92% were effectively managed with­ out extended frontal sinus procedures.91 There are, how­ ever, generally agreed upon indications for which TSFS is accepted: severe osteoneogenesis within the frontal recess, traumatic injury to the frontal sinus drainage path­ way, resection of sinonasal neoplasms, complex frontal recess cells, failed frontal sinus obliteration procedures, mucoceles, and frontal anatomy associated with a nar­ rowed or osteitic drainage pathway.92 While patency of the frontal sinusotomy is critical, there is emerging research that the postoperative frontal ostium size correlates with persistence of symptoms, and larger sinusotomies may offer improved symptom control.93 A review of the out­ come data for TSFS operations indicates a high degree of success, with at least one author offering this more exten­ sive operation as a primary surgical intervention for cer­ tain subsets of patients with CRS.

663

Wormald demonstrated a success rate of 93% among prospectively enrolled revision patients with recalcitrant frontal sinusitis undergoing TSFS.94 Similarly, improve­ ment in symptoms of CRS has been reported in as many as 98% of patients undergoing TSFS.95 A meta-analysis of the literature found an overall patency rate of 95.9% for TSFS at an average follow-up interval of 28.5 months in the 394 patients for whom endoscopic postoperative results were reported, with similar complication rates to those reported in the literature for traditional FESS procedures.96 The favorable outcomes of TSFS in a difficult patient popu­ lation has prompted some authors to investigate the utility of this extended frontal sinus operation as a primary surgical intervention. In one study, the presence of asthma, polyposis, frontal ostia  16 were identified as risk factors for failure of a standard frontal sinusotomy and a primary TSFS may be considered in these patients.97 TSFS affords additional access for instrumentation of the frontal sinus, removal of inflammatory disease burden, particularly when the pathology is a lateral within the sinus and increased penetration of postoperative topical medical therapy. However, the vast majority of patients with CRS, including patients with a previous failed frontal sinusotomy, will respond to a meticulously performed Draf 2A procedure (Fig. 45.8).

Outcomes in Middle Turbinate Management Debate regarding management of the middle turbinate during surgery prompted several prospective and retro­ spective investigations. Development of outcome data for middle turbinate surgery in FESS has provided surgeons with more solid data upon which surgical decisions can be based. Brescia et al. retrospectively reviewed their experience with 48 patients undergoing FESS for CRS with nasal polyposis and did not identify a statistically signifi­ cant difference in nasal obstruction or endoscopic score between the group that underwent middle turbinate resection and the group for which the turbinates were pre­ served.98 Prospective studies comparing middle turbinate resection with middle turbinate preservation have been undertaken with similar results. Byun and Lee showed that there was more extensive inflammatory disease in the group undergoing middle turbinate resection, and a diffe­ rence persisted postoperatively, with worse endoscopic

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Fig. 45.8: In revision cases, a transseptal, frontal sinusotomy is recommended for opening of a frontal sinus that is involved with more severe osteitis, inflammatory mucosa, or scarring from prior frontal sinus surgery. A frontal sinus mucocele with significant osteitis of the drainage pathway is a typical case for which a Draf 3 procedure would be performed to allow wide ventilation and drainage of the involved sinus as well as access for postoperative surveillance and augmented penetration of topical medical therapy. Courtesy: Kevin Welch, MD, Loyola University, Chicago, IL, USA.

scores in these patients at 12 months.99 Subjective assess­ ment with Sino-Nasal Outcome Test 20 and a visual analogue scale did show differences between the groups 1 year following surgery.99 Conversely, Soler et al.’s prospective study demon­ strated greater improvements in the endoscopic examina­ tion for those patients undergoing middle turbinate resec­ tion, though subjective QOL measures did not differ significantly between these groups.100 The difference in endoscopic findings may indicate greater severity of the baseline inflammatory process, differences in the type of postoperative topical medical therapy, or that the absence of middle turbinates in the postoperative cavity represents a loss of some natural protection to an environmental feature that provokes inflammation. Though recent literature has destigmatized middle turbinate resection with regards to outcome data, the deci­ sion to resect middle turbinates should be undertaken with additional caution. It is the senior author’s practice

to preserve the middle turbinate unless it is diseased. If middle turbinate bone is exposed during the surgical procedure, the exposed bone is resected, even if it may lead to the turbinate becoming somewhat poorly suspended. Middle turbinates that have become lateralized or altered by prior surgical interventions may be resected when their retention prevents completion of the planned opera­ tion, especially if the bone is osteitic (Fig. 45.9). Middle turbinate lateralization is a common cause of failure after primary FESS, with an incidence between 11% and 78% reported by revision surgeons in tertiary care settings.101,88 Prophylactic surgical techniques that facilitate both preservation of the middle turbinate and a reduced risk of lateralization have been in wide use for many years. Suture techniques102 and controlled placement of a temporary or permanent synechiae103 between the middle turbinate and the nasal septum optimize middle meatal access both during surgery and in the office for postoperative endoscopic debridements (Fig. 45.10). Outcome studies of middle

Chapter 45: Endoscopic Sinus Surgery for Chronic Rhinosinusitis

665

Fig. 45.9: Lateralization of the middle turbinates is one of the most common reasons for revision sinus surgery. Middle turbinates that have been destabilized during sinus surgery, or improperly medialized, can adopt a position that approximates the lateral nasal sidewall. This lateral orientation both hinders normal postope­ rative care and can obstruct the frontal sinus drainage pathway.

Fig. 45.10: Middle turbinate preservation is the favored technique of the senior author, preserving this important anatomic land­ mark and limiting the removal of normal tissue from the nose and sinuses. Immediate intraoperative appearance of middle turbinate lateralization with suture technique of patient in Figure 45.6.

turbinate medialization techniques demonstrate a high degree of success in preventing middle meatal cicatricial complications,104 and despite concerns regarding narro­ wing of access to the olfactory cleft, these maneuvers do not appear to impair olfaction after FESS.105 Severe polypoid disease, osteitic bone, or abnormal positioning that hinders postoperative care or the penet­ ration of topical medical therapy are several common reasons for resection. The middle turbinate provides an exceptional landmark for general surgical navigation and, even in cases when resection is planned, the use of this landmark during the operation can facilitate the proce­ dure and perhaps resection should be delayed until the conclusion of surgery. When resecting the middle turbi­ nate, avoidance of common iatrogenic complications is paramount. The vertical lamella should be removed such that lateralization is not likely to occur. In cases with narrow frontal sinus drainage pathways or insubstantial rigidity of the remnant vertical lamella, the middle turbinate should be removed up to the skull base. Visualization with angled endoscopes and the use of curved frontal sinus through-cutting instruments are necessary to remove the vertical component, prevent intracranial entry, and avoid leaving denuded bone in this critical region of the operative cavity. Removal of the horizontal component of the middle turbinate can be complicated by bleeding, as a branch

of the sphenopalatine artery enters the middle turbinate in this location posteroinferiorly. Proper use of cautery at the middle turbinate remnant along the lateral nasal wall as well as gentle postoperative debridement at this site will be required. Outcome data indicate that subjective results are not impaired by middle turbinate resection; however, surgeons should remain thoughtful in their app­ roach to this structure, removing the turbinate only when it is felt that preservation would adversely affect their treatment strategy.

CONCLUSION A better understanding of future expectations for endo­ scopic sinus surgery for CRS can be obtained by a more complete awareness of the history of this unique operative technique. The field of rhinology has experienced a rapid evolution, and this is certain to continue as basic science research unlocks some of the fundamental questions regar­ ding the pathogenesis of CRS that remain. The evolution in surgical techniques will probably continue toward more minimally invasive surgical techniques, such as balloon dilation combined with anti-inflammatory topical thera­ pies. Currently, FESS offers minimally invasive tech­ niques for maximal surgical intervention within the nose, paranasal sinuses, and skull base. Since CRS is really a

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syndrome of diseases, treatment in any one case needs to be carefully individualized, based in part on predispos­ ing factors and environmental exposures. FESS will con­ tinue to evolve in concert with new scientific discoveries as the platform for surgical intervention and medical management of CRS.

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75. Briner HR, Jones N, Simmen D. Olfaction after endoscopic sinus surgery: long-term results. Rhinology. 2012;50(2): 178-84. 76. Hsu CY, Wang, Shen PH. Objective olfactory outcomes after revision endoscopic sinus surgery. Am J Rhinol. 2013; 27(4):96-100. 77. Jiang JW, Lu, FJ, Liang KL, et al. Olfactory function in patients with chronic rhinosinusitis before and after func­ tional endoscopic sinus surgery. Am J Rhinol. 2008;22(4): 445-8. 78. Jiang RS, Su MC, Liang KL. Preoperative prognostic factors for olfactory change after functional endoscopic sinus surgery. Am J Rhinol. 2009;23(1):64-70. 79. Kirihene RK, Rees G, Wormald P. The influence of the size of the maxillary sinus ostium on the nasal and sinus nitric oxide levels. Am J Rhinol. 2002;16(5):261-4. 80. Albu S, Tomescu E. Small and large middle meatus antros­ tomies in the treatment of chronic maxillary sinusitis. Otolaryngol Head Neck Surg. 2004;131(4):542-7. 81. Phillips PS, Sacks R, Marcells GN, et al. Nasal nitric oxide and sinonasal disease: a systematic review of published evid­ence. Otolaryngol Head and Neck Surg. 2011;144:159-69. 82. Woodworth BA, Parker RO, Schlosser RJ. Modified endo­ scopic medial maxillectomy for chronic maxillary sinusitis. Am J Rhinol. 2006;20(3):317-19. 83. Virgin FW, Rowe SM, Wade MB, et al. Extensive surgical and comprehensive postoperative medical management for cystic fibrosis chronic rhinosinusitis. Am J Rhinol. 2012;26: 70-75. 84. Cho D, Hwang PH. Results of endoscopic maxillary megaantrostomy in recalcitrant maxillary sinusitis. Am J Rhinol. 2008;22(6):658-62. 85. Wang EW, Gullung JL, Schlosser RJ. Modified endoscopic medial maxillectomy for recalcitrant chronic maxillary sinu­sitis. Int Forum Allergy Rhinol. 2011;1(6):493-7. 86. Kennedy DW, Shaalan H. Reevaluation of maxillary sinus surgery: experimental study in rabbits. Ann Otol Rhinol Laryngol. 1989;98:901-6. 87. Harvey RJ, Goddard JC, Wise SK, et al. Effects of endoscopic sinus surgery and delivery device on cadaver sinus irriga­ tion. Otolaryngol Head Neck Surg. 2008;139(1):137-42. 88. Musy PY, Kountakis SE. Anatomic findings in patients undergoing revision endoscopic sinus surgery. Am J Otolaryngol. 2004;25(6):418-22. 89. Kennedy DW, Adappa ND. Endoscopic maxillary antro­ stomy: not just a simple procedure. Laryngoscope. 2011; 121:2142-5. 90. Psaltis AJ, Soler ZM, Nguyen SA, et al. Changing trends in sinus and septal surgery, 2007-2009. Int Forum Allergy Rhinol. 2012;2(5):357-61.

91. Hahn S, Palmer JN, Purkey MT, et al. Indications for exter­nal frontal sinus procedures for inflammatory sinus disease. Am J Rhinol Allergy. 2009;23(3):342-7. 92. Close LG. Endoscopic Lothrop procedure: when should it be considered? Curr Opin Otolaryngol Head Neck Surg. 2005;13(1):67-9. 93. Naidoo Y, Wen D, Bassiouni A, et al. Long-term results after primary frontal sinus surgery. Int Forum Allergy Rhinol. 2012;2(3):185-90. 94. Wormald PJ. Salvage frontal sinus surgery: the endo­scopic modified Lothrop procedure. Laryngoscope. 2003;113(2): 276-83. 95. Shiarazi MA, Silver AL, Stankiewicz JA. Surgical outcomes following the endoscopic modified Lothrop procedure. Laryngoscope. 2007;117(5):765-9. 96. Anderson P, Sindwani R. Safety and efficacy of the endo­ scopic modified Lothrop procedure: a systematic review and meta-analysis. Laryngoscope. 2009;119(9):1828-33. 97. Naidoo Y, Bassiouni A, Keen M, et al. Risk factors and outcomes for primary, revision and modified Lothrop (Draf III) frontal sinus surgery. Int Forum Allergy Rhinol. 2013;3(5):412-17. 98. Brescia G, Pavin A, Giacomelli L, et al. Partial middle turbinectomy during endoscopic sinus surgery for extended sinonasal polyposis: short- and mid-term outcomes. Acta Otolaryngol. 2008;128(1):73-7. 99. Byun JY, Lee JY. Middle turbinate resection versus preser­ vation in patients with chronic rhinosinusitis accom­ panying nasal polyposis: baseline disease burden and surgical outcomes between the groups. J Otolaryngol Head Neck Surg. 2012;41(4):259-64. 100. Soler ZM, Hwang PH, Mace J, et al. Outcomes after middle turbinate resection: revisiting a controversial topic. Laryngo­ scope. 2010;120(4):832-7. 101. Gore MR, Ebert CS, Zanation AM, et al. Beyond the “central sinus”: radiographic findings in patients undergoing revision functional endoscopic sinus surgery. Int Forum Allergy Rhinol. 2013;3:139-46. 102. Lee MR, Marple BF. Middle turbinate medialization for improved access during endoscopic sinus surgery. Int Forum Allergy Rhinol. 2011;1(3):187-90. 103. Bolger WE, Kuhn FA, Kennedy DW. Middle turbinate stabilization after functional endoscopic sinus surgery: the controlled synechiae technique. Laryngoscope. 1999;109 (11):1852-3. 104. Hewitt KM, Orlandi RR. Suture medialization of the middle turbinates during endoscopic sinus surgery. Ear Nost Throat J. 1008;87(12):11-13. 105. Dutton JM, Hinton MJ. Middle turbinate conchopexy during endoscopic sinus surgery does not impair olfaction. Am J Rhinol. 2011;25(2):125-7.

Chapter 46: Training for Sinonasal Surgery: Past, Present and Future

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Chapter

Training for Sinonasal Surgery: Past, Present and Future

46

Rachel Kaye, Marc J Gibber, Marvin P Fried

INTRODUCTION To properly understand the history of training techniques used for sinus surgery, it is imperative to first have a strong understanding of the history of treatment of sinus dis­ orders. Up until the development of endoscopic equipment in the mid to late twentieth century, training techniques were limited due to the difficulty and danger posed by this very complex region. Because of this, training was largely based on the literature and description of procedures. Beyond this, there was little more than the “see one, do one, teach one” approach, which combined with cadaveric training when available, was the predominant form of training throughout the nineteenth and early twentieth century. The beginning of modern endoscopy dates back the early twentieth century during which time endoscopic sur­ gery was mostly restricted by the limitations of the endo­ scopes themselves; by their optical capacity (the Nitze system of a succession of glass lenses)1 and illumination (mostly containing flame or electric bulbs). The rapid development and superior quality of endoscopy in the 1960s and 1970s (i.e. the Hopkins rod system1 and Karl Storz angled endoscopes2) produced the culture and standar­ dization of endoscopic sinus surgery (ESS) that is preva­ lent today. It also allowed for a much greater ability to teach sinonasal anatomy and procedures to trainees and students.

Endoscopic Sinus Surgery Endoscopic sinus surgery was first widely introduced in the 1970s to 1980s and has since been established as the

standard of care for operative treatment of the sinuses and nasal cavity.2–5 This technique provides the surgeon with excellent visualization, supplemented by an array of instru­ ments that permit access to the depths of the sinuses, and to the base of the skull. The use of computer-based image guidance systems adds to these capabilities by providing unprecedented navi­ gational support to reach the pathology while delineating the surrounding anatomy that is not at pathologic risk. The applications of endoscopic procedures have expanded widely as safety and efficacy have been documented.6–8 Tumor resection at the cranial base can be safe and effec­ tive. The growing application of the endoscopic approach to the pituitary for adenoma removal has diminished the morbidity and hastened the recovery of an expanding number of patients. It has also opened the technology to an entire specialty that previously had no exposure to the technique. Surgery of the orbit can be facilitated by improved optics (endoscopes) and anatomical depiction (navigation and tracking) of the critical anatomy. Although the concept of ESS is quite straightforward, skillfully performing the procedure safely can be quite challenging.9 The relevant anatomy is highly complex and compact, with the added concern of having critical struc­ tures such as the brain, orbital contents, and carotid artery closely juxtaposed and therefore at surgical risk.10,11 Thus, the acquisition of surgical proficiency in ESS is of utmost importance not only because of the difficulty in manipula­ ting the instruments and endoscopes but also because of the complicated anatomy with propensity for signifi­ cant individual variation and the potential for disastrous complications. The advances made in the field of ESS

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occurred due to multiple developments, including grea­ ter comprehension of anatomic structures, advanced endo­ scopic surgical techniques, precision endoscopes and cameras, CT and MRI guidance systems, and unique instru­ mentation, however complications still arise.12,13 The overall incidence of complications from ESS range from 4% to 17%14 and the push is continuously toward improving patient safety. In addition, the surgeon must navigate and manipulate in this environment with both dominant and nondominant hands simultaneously, while coordinating movements indirectly with the aid of a televi­ sion monitor. Well-developed hand-eye coordination is an obvious prerequisite. Emphasis is therefore placed on the quality and quantity of training that an endoscopic surgeon must have prior to his/her independent perfor­ mance on any procedure.

NEED FOR TRAINING Currently, training of residents in ESS is predicated on direct observation of procedures in the operating room. As residents progress in their training, they are given more of an active role in the operating room, ultimately becoming the major participant. The technical acumen required for basic ESS procedures is not achieved, for the most part, until the later half of a resident’s training. The learning curve is significant with a decline in major complications with increased exposure and case volume.15 Stankiewicz16,17 was one of the first to describe a significant learning curve as he reported a sharp decline in his major and total complication rates when comparing his first 90 cases to his second series of 90 cases. His major complications (hemorrhage, CSF leak, and blindness) decreased from 5% in his first 90 cases to 0.7% in his subsequent 90 cases. Furthermore, his overall complication rate decreased from 29% to 2.2% when comparing these two series of patients. Similarly, Marks18 reported his complication rates with his own first 393 cases and found a significant difference in minor complication (synechiae, ecchymosis, stenosis, epiphora) rates between the first and second half of his series (8.5% vs. 2.5%). With the increase in the complexity of microdissection equipment and the ever-increasing demand to broaden the indications of ESS, there is a real need to make residents more familiar with the technical skills of ESS at an earlier stage in training. This has neces­ sitated the supplementation of skills training with video training tapes, cadaver or animal dissection, and simula­ tors [ranging from low-fidelity to virtual reality (VR)].

It comes as no surprise that with the continued techno­ logical advancements of today; computer-assisted devices have already had significant success in augmenting the education and training of surgical residents in several fields.19–22

HOW TRAINING IS ASSESSED? Surgical skills training should be predicated on standard and well-tested methods of instruction. However, in general, such a universal curriculum in surgery remains elusive. Cadavers have been used by some institutions to provide the first surgical experience for residents learning ESS. Stankiewicz has long been a proponent of a rigorous curriculum using cadaveric dissection prior to performing the first sinus surgery.11 Furthermore, there have been efforts to validate the utility of training prior to performing ESS. Keerl reported that complications were reduced when surgeons underwent a multimedia learning program before performing sinus surgery, demonstrating that those sur­ geons who participated in the learning program had fewer dural and orbital complications.23

CADAVERS Akin to temporal bone dissection, for which cadaveric courses have been successfully used, ESS is landmark based and thus a fundamental dynamic anatomical know­ ledge is essential.24 Furthermore, cadaveric training offers a safe environment without risk to patient safety and a bloodless surgical field. The transition to training on cada­ vers was reliable and necessary as the new technology became available. Currently, training courses are a reput­ able part of otolaryngology head and neck surgical train­ ing.25 The combination of proper training, cadaveric course participation, and supervision is considered to be a formula for the execution of safe surgical procedures by trainee.26,27 In fact, a recent study reported that cadaveric sinus dissection improves both subjective and objective skills for all training levels,14 while an international multi­ center study found that such dissection courses are both well received and considered valuable by surgical trai­ nees.28 Sinus laboratory settings are well perceived by trainees and increase their comfort.29 However, a signifi­ cant drawback to cadaver training is the insufficient availability of specimens and high costs, curtailing the accessibility of cadaver training for all.30

Chapter 46: Training for Sinonasal Surgery: Past, Present and Future

TRAINING COURSES Surgical skill courses are increasing in popularity in paral­ lel with the movement of surgical education away from the traditional model of apprenticeship.30 This progression has been, in part, driven by the field of endoscopic surgery. Conventional otolaryngology training programs are predi­ cated on a finite number of procedural cases, which could produce haphazard and unpredictable learning.30 The maintenance and acquisition of surgical skills requires repeat practice at regular intervals, something that may not be provided for in the standard clinical training. As such, supplementary training courses are in high demand and are looked for as a means to propel one’s anatomical knowledge and surgical skills. Such workshops provide the trainee with opportunities to practice good techniques, eliminate poor technique, and receive timely feedback that further cements the training.31 Training courses may introduce new skills or reinforce an acquired one. Courses have been standardized such that guidelines and recom­ mendations exist.30 The “ideal” course provides fixed learning objectives, senior faculty members, a combination of short presentations and technical skills stations, with further reinforcement often occurring in small peer groups. A recent international study showed that ESS dissection courses were both widely accepted and considered bene­ ficial by the trainees. Furthermore, when participants were questioned about the best way of gaining anatomical knowledge, most (66%) considered ESS dissection courses as the primary way to obtain and also to improve their knowledge.28 Furthermore, minimally invasive training was not found to inhibit adequate training.31

CREDENTIALING COMPETENCY IN RESIDENCY AND BEYOND The Accreditation Council for Graduate Medical Educa­ tion (ACGME) currently assesses residents through the use of case log numbers that are meant to be indicators of resident experience, but do not necessarily confer resi­ dent competence. Although the highest minimum number of key indicator procedures required lies within rhinology at 40 ethmoidectomies (as of 2013), simply completing a finite number of surgical procedures does not necessarily confirm competence especially when taking into account patient variability and the individual resident’s learning curve. To that end, the ACGME has incorporated 16 mile­ stones to be included in the Next Accreditation System

671

annual program review, in effect July 1, 201432 The mile­ stones identify target levels of competence, which for rhinology includes completing ESS procedures only with oversight (as apposed to guidance), and identification of “nasal endoscopic pathological findings in the previously operated patient.33” Thus, the ACGME has evolved to standardize a graduation requirement of not just expe­ rience, but also competency; this lends itself the interes­ ting question of just how competency will be (and should be) evaluated. In contrast to the direct oversight over otorhino­ laryngology residency programs by the ACGME, there does not currently exist an authority or agency responsible for quality assurance in rhinology fellowships. With the increase of subspecialization within otolaryngology trai­ ning, an additional year or multiple years of training in the field of rhinology and skull base surgery, beyond the standard residency training has become more popular. From the late 1940s through the first half of the 1950s a group of physicians led by Dr Maurice Cottle was instru­ mental in establishing the American Rhinological Society (ARS), which was a society dedicated to pathology, physio­ logy, and aesthetic qualities of the nose.34 The creation and subsequent work of the ARS created a home base for those focused on this anatomic region, and was instru­ mental in the further development of dedicated training in rhinology. As endoscopic techniques and abilities imp­roved in the 1980s and 1990s, so too did the interest of otolaryngologists looking to focus primarily on this area. Individual year long fellowships started to be offered in the late 1980s; however, the application process only became formally organized in 2006 with a centralized match pro­ cess under the auspices of the ARS. As interest in this subspecialty continues to grow, the registered fellowship applicants and programs have also increased dramatically. However, to date the goals and educational experiences of rhinology fellows are not com­ pletely defined, and so an inherent disparity between different fellowship experiences is a very real hazard. In 2009, Tabaee et al. published the responses of the past 6 years of fellows to a survey to which 66% responded and overall showed a favorable response (graded on a Likert scale) when questioned whether the fellowship experience met stated goals and whether fellows felt comfortable performing rhinologic surgery. However, this study also highlighted the need for a continuous examination of the subspecialty training, given the inherent differences

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Section 9: Surgery for Inflammatory Sinusitis

between training programs and a lack of assessment of core competencies following training.35 Later, a similarminded survey was conducted under the purview of the American Rhinologic Society (ARS) that surveyed all fellowship graduates between 1990 and 2009 and corrobo­ rated many of the data from the previous study. They had a 55.4% response rate and found that the overall fellowship experience was rated positively in all respondents (on a Likert scale). They also found that the average number of rhinologic procedures performed during fellowship was more than  200 in 34 (58.6%), 151–200 in 16 (27.6%), 101–150 in 7 (12.1%), and less than 100 in 1 (1.7%) and that surgical caseload was deemed “just right” by 94.7% of respondents. However, this study did make note that case load alone is not an adequate assessment of quality educa­ tion and called for further reviews and discussions toward a programmatic education within this fellowship.36 As the future of creden­tialing continues to evolve, educators must decide what methods will best assess and address the competency of graduating residents and fellows, keep­ ing in mind these methods should be well-studied and validated.

SIMULATOR TRAINING AND APPROXIMATING REAL SURGERY Stricter regulations with regard to hands-on training has created combined with the technological revolution of the twenty-first century has brought about a new and exciting approach to medical education and training. Specifically, the ability to create highly realistic three-dimensional surgical simulators has opened a new avenue by which surgeons can be trained. High-fidelity virtual reality (VR) simulators have long had an impact on improving the skill level of military and commercial pilots, and they hold similar promise for the medical field. Based on the lessons from aviation training over the past three decades, com­ puter-assisted devices have had significant success in augmenting the education and training of surgical resi­ dents in several fields.19,37,38 VR simulation has already played an introductory role in the training of residents for laparoscopic, gastrointestinal, plastic, ophthalmologic, dermatologic, and urologic procedures.39–45 The field of otolaryngology has been at the forefront of simulator training specifically in the areas of tem­ poral bone and ESS. Both low-fidelity and high-fidelity simulators have been proposed. One type of low-fidelity simulator was described by Wais et al. and involved

Fig. 46.1: Endoscopic view of ES3 during the navigation task showing targets (hoops for the trainee to navigate through) and virtual anatomy instruction, labeled nasal passage, middle turbinate, and agger nasi cell.

inexpensive and commercially available materials that set out to simulate navigation (through rings), tool locali­ zation (touching numbered stickers), and maxillary antro­ stomy (remove a foam square).46 Although this is a very inexpensive model with ingenuity that could be easily reproduced, the simulated tasks and view do not replicate endoscopic sinus anatomy and the haptic feedback is limited by the material used and may not be similar to operative experience. Despite these setbacks, they were able to show that trainees were able to improve essential basic endoscopic sinus surgical skills when tested on a cadaveric model.47 Although low-fidelity simulators are potentially more widely available (due to cost), they do not replicate the operating room experience with the visual cues and haptic feedback that exist within high-fidelity simulators; while endoscopic navigation can be taught well, combining anatomical knowledge and task dexterity to produce a surgical outcome may best be addressed by high-fidelity simulators. The group led by Fried et al. conducted multiple stu­ dies using a simulator (ES3) created by Lockheed-Martin (Figs. 46.1 to 46.4). This particular simulator employed virtual anatomy and instruments, both visual and haptic (force) feedback, voice commands, phased instruction, and performance monitoring to create a virtual reality environment that can be potentially be utilized to teach otolaryngology residents.48–51 The ES3 is a procedural simu­ lator that trains and assesses the performance of an entire task (such as an ethmoidectomy, which requires complex endoscope navigation, ambidexterity, and surgi­ cal precision). Users of the ES3 perform ESS on a virtual

Chapter 46: Training for Sinonasal Surgery: Past, Present and Future

673

Fig. 46.2: Endoscopic view of ES3 during the injection task showing targets (bulls-eye target) for the trainee to inject with the virtual needle seen in the center of the screen. The virtual ana­ tomy prompts are present, highlighting the nasal passage, middle turbinate, agger nasi cell, and the uncinate process.

Fig. 46.3: Endoscopic view of ES3 during dissection task showing Freer tool used to medialize the middle turbinate. The simulator provides haptic feedback during real-time dissection tasks.

Fig. 46.4: Endoscopic view of ES3 during dissection task showing microdebrider tool used to remove the uncinate process. In addition to haptic feedback, the ES3 also provides for an accurate anatomical depiction of virtual surgery, here showing the resected tissue (black arrows) and bony spurs (white arrows).

Fig. 46.5: Operating room configuration of typical ESS at our insti­ tution. The surgical instructor (attending) coaches the trainee (resi­ dent) as the trainee uses an endoscope and operating tool while viewing the endoscopic screen.

patient with an interface consisting of a mannequin out­ fitted with a multipurpose tool and endoscope that closely resembles the operative experience (Figs. 46.5 and 46.6). The tool delivers haptic feedback to the user and the virtual instructor guides the user by stating mistakes, errors, and misses while the system records overall and task-specific completion scores for each performance in real time. The road toward validation of a surgical simulator is an arduous one and can include face/content, discrimi­nant, construct, concurrent, and predictive validity. The group

led by Fried et al. was able to show that the ES3 provided a reliable assessment of factors that are important to the acquisition of minimally invasive surgical skills, demons­ trating construct validity.52 They were then able to com­ plete the construct validity assessment of the ES3 by demonstrating its discriminant capabilities; the simulator established expert surgeon benchmark performance cri­ teria and furthermore shows that the ES3 can consistently train novice subjects to attain that performance level.53 The group was able to perform a study, which showed

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Section 9: Surgery for Inflammatory Sinusitis can also benefit anatomic and procedural knowledge while maintaining a wider availability; however, the anatomic knowledge and interface does not completely correlate with the visual and force feedback that one experiences during surgery. Despite their differences, both types of simulation seek to provide an alternative to early expe­ rience on live patients for novices in order to improve patient safety.

THE FUTURE OF SURGICAL SIMULATION

Fig. 46.6: ES3 simulator showing the endoscope and multiuse tool within the mannequin, as well as the apparatus utilizing screen guidance in a similar fashion to the operating room.

simulator training improves resident technical skills so that each individual attains a proficiency level, despite the existence of an inherent range of individual abilities. This proficiency level translates to at least equal, if not superior, actual real-time operative performance compared with that of current conventional training and its associated finite repetition of live surgical procedures. This vital study was one of the first published that showed objective improvement in operating room performance by those that train on simulators.54

BARRIERS TO SIMULATOR ADOPTION One of the main prerequisites of surgical simulators as a training tool is confirmed construct and predictive validity.55 Validity studies must remain rigorous and with a large sample size in order to justify utilizing simulators during residency credentialing; this is often difficult to attain within subspecialties given the inherent small number of residents. Furthermore, although virtual reality and high-fidelity simulation has many diverse advan­ tages, the major drawbacks are high cost and software development. This translates into a wide range of avail­ ability between training institutions. Low-fidelity simulators

As the technology becomes cheaper and more accessible, simulation and virtual training will assume a larger role in the training arsenal especially in the fields of minimally invasive and endoscopic surgery. A required or suggested simulation-based training curriculum would possibly drive down costs due to increased demand and production. Simulation-training curricula are gaining interest, and in 2012, Zevin et al. demonstrated a consensus-based metho­ dology to design and implement a simulation-based train­ ing curriculum with input from international surgeons that were considered experts in surgical education.56 As we move toward standardizing these curricula, the process toward validation and implementation could be streamlined thereby increasing simulator accessibility throughout institutions. The ACGME is now redefining how to assess surgical competency, especially in the new age of work-hour restric­ tions. This has already made an interesting turn of events within the field of general surgery, as the American Board of Surgery now requires the Fundamentals of Laparo­ scopic Surgery course (includes simulation exer­ cises) 57 for certification. It is not unforeseeable that simulators could be used as a credentialing tool due to their poten­ tial to produce defined and validated metrics of tech­ nical performance that pose no risk to patient safety. Furthermore, several high-fidelity simulators (including the ES3) have the ability to load a patient’s CT images, thereby creating an individualized virtual environment that fosters surgical planning for even the expert surgeon. This creates a virtual model of each individual patient and allows the surgeon to hone surgical technique to the unique ana­ tomy presented by the patient. As we move more toward individualized medicine, surgical simulation is certainly a wonderful asset. As technology continues to evolve, surgical simulation will continue to gain a greater role in the training of rhinologic procedures.

Chapter 46: Training for Sinonasal Surgery: Past, Present and Future

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20. Satava RM. Virtual reality surgical simulator: the first steps. Surg Endosc. 1993;7(3):203-5. 21. Gorman PJ, Meier AH, Krummel TM. Computer-assisted training and learning in surgery. Comput Aided Surg. 2000; 5(2):120-30. 22. McGovern KT. Applications of virtual reality to surgery. BMJ. 1994;308(6936):1054-5. 23. Keerl R. Value of multimedia educational software in training of the paranasal sinus surgeon. Laryngorhinootologie. 2000;79(1):34-8. 24. Delap T. Endoscopic sinus surgery: are junior doctors being properly trained?. Ann R Coll Surg Engl. 1999;81(2):142. 25. Gurr A, Hansen S, Minovi A, et al. [The relevance of anatomical courses in ENT-education]. Laryngorhinooto­ logie. 2009;88(12):789-92. 26. Kinsella JB, Calhoun KH, Bradfield JJ, et al. Complications of endoscopic sinus surgery in a residency training pro­ gram. Laryngoscope. 1995;105:1029-32. 27. Nguyen QA, Cua DJ, Ng M, et al. Safety of endoscopic sinus surgery in a residency training program. Ear Nose Throat J. 1999;78:898-902, 904. 28. Braun T, Betz CS, Ledderose GJ, et al. Endoscopic sinus surgery training courses: benefit and problems—a multi­ centre evaluation to systematically improve surgical trai­ ning. Rhinology. 2012;50(3):246-54. 29. Bent JP, Porubsky ES. The rhinology laboratory. Laryngo­ scope. 1999;109:1059-63. 30. Kneebone RL. Twelve tips on teaching basic surgical skills using simulation and multimedia. Med Teach. 1999;21(6): 571-5. 31. Rogers DA, Elstein AS, Bordage G. Improving continuing medical education for surgical techniques: applying the lessons learned in the first decade of minimal access surgery. Ann Surg. 2001;233(2):159-66. 32. Accreditation Council for Graduate Medical Education [Internet]. Chicago (IL): Accreditation Council for Graduate Medical Education 2013 [cited 2013 Nov 11]. Available from: https://www.acgme.org/ 33. Accreditation Council for Graduate Medical Education [Internet]. Chicago (IL): Accreditation Council for Graduate Medical Education 2013—Otolaryngology milestones; 2013 [cited 2013 Nov 11]; available from: http://www. acgme.org/acgmeweb/Portals/0/PDFs/Milestones/ OtolaryngologyMilestones.pdf 34. Vining, E. History of American Rhinologic Society [Inter­ net]. Warwick (NY): American Rhinologic Society; 2011 August. [cited 2013 Nov 11]. Available from: www.ameri­ can-rhinologic.org/history. 35. Tabaee A, Luong A, Fried MP. Fellowship training in rhino­ logy: a survey of fellows from the past 6 years. Arch Otolaryngol Head Neck Surg. 2009;135(6):571-4. 36. Batra PS, Kingdom TT, Citardi MJ. American Rhinologic Society Fellowship Committee. Fellowship training in rhino­ logy: American Rhinologic Society survey of U.S. graduates. Int Forum Allergy Rhinol. 2011;1(3):206-11. 37. Satava RM. Virtual reality surgical simulator: the first steps. Surg Endosc. 1993;7(3):203-5.

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38. Gorman PJ, Meier AH, Krummel TM. Computer-assisted training and learning in surgery. Comput Aided Surg. 2000; 5(2):120-30. 39. Satava RM. Virtual endoscopy: diagnosis using 3D visuali­ zation and virtual representation. Surg Endosc. 1996;10 (2):173-4. 40. Baillie J, Evangelou H, Jowell P, et al. The future of endo­ scopy simulation: a Duke perspective. Endoscopy. 1992;24 (Suppl 2):542-3. 41. Fried MP, Moharir VM, Shinmoto H, et al. Virtual laryngo­ scopy. Ann Otol Rhinol Laryngol. 1999;108(3):221-6. 42. Peugnet F, Dubois P, Rouland JF. Virtual reality versus conventional training in retinal photocoagulation: a first clinical assessment. Comput Aided Surg. 1998;3(1):20-6. 43. Gladstone HB, Raugi GJ, Berg D, et al. Virtual reality for dermatologic surgery: virtually a reality in the 21st century. J Am Acad Dermatol. 2000;42(1 Pt 1):106-12. 44. Berg D, Raugi G, Gladstone H, et al. Virtual reality simula­ tors for dermatologic surgery: measuring their validity as a teaching tool. Dermatol Surg. 2001;27(4):370-4. 45. Oppenheimer P, Gupta A, Weghorst S, et al. The represen­ tation of blood flow in endourologic surgical simulations. Stud Health Technol Inform. 2001;81:365-71. 46. Leung RM, Leung J, Vescan A, et al. Construct validation of a low-fidelity endoscopic sinus surgery simulator. Am J Rhinol. 2008;22(6):642-8. 47. Wais M, Ooi E, Leung RM, et al. The effect of low-fidelity endoscopic sinus surgery simulators on surgical skill. Int Forum Allergy Rhinol. 2012;2(1):20-6. 48. Edmond CV Jr, Heskamp D, Sluis D, et al. ENT endoscopic surgical training simulator. Stud Health Technol Inform. 1997;39:518-28.

49. Wiet GJ, Yagel R, Stredney D, et al. A volumetric approach to virtual simulation of functional endoscopic sinus surgery. Stud Health Technol Inform. 1997;39:167-79. 50. Weghorst S, Airola C, Oppenheimer P, et al. Validation of the Madigan ESS simulator. Stud Health Technol Inform. 1998;50:399-405. 51. Rudman DT, Stredney D, Sessanna D, et al. Functional endoscopic sinus surgery training simulator. Laryngoscope. 1998;108(11 Pt 1):1643-7. 52. Arora H, Uribe J, Ralph W, et al. Assessment of construct validity of the endoscopic sinus surgery simulator. Arch Otolaryngol Head Neck Surg. 2005;131(3):217-21. 53. Fried MP, Sadoughi B, Weghorst SJ, et al. Construct validity of the endoscopic sinus surgery simulator: II. Assessment of discriminant validity and expert benchmarking. Arch Otolaryngol Head Neck Surg. 2007;133(4):350-7. 54. Fried MP, Kaye RJ, Gibber MJ, et al. Criterion-based (profi­ ciency) training to improve surgical performance. Arch Otolaryngol Head Neck Surg. 2012;138(11):1024-9. 55. Liss MA, McDougall EM. Robotic surgical simulation. Cancer J. 2013;19(2):124-9. 56. Zevin B, Levy JS, Satava RM, et al. A consensus-based framework for design, validation, and implementation of simulation-based training curricula in surgery. J Am Coll Surg. 2012;215(4):580-6.e3. 57. The American Board of Surgery [Internet]. Philadelphia (PA). The American Board of Surgery—ABS to Require ACLS, ATLS and FLS for General Surgery Certification; 2008 August 15 [cited 2013 Nov 11]. Available from: http://www.absurgery. org/default.jsp?news_newreqs.

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Chapter

Innovations in Optics and Instrumentation

47

Arjuna B Kuperan, Jean Anderson Eloy, Roy R Casiano

INTRODUCTION The development of new instruments for use in the endo­ scopic management of sinus and skull base pathology has grown exponentially over the past few decades. From its inception, we have witnessed endoscopic sinus and skull base surgery (ESSBS) continually expand the limits of its domain due in part to the technologic advances the discipline has championed. This chapter serves to describe and analyze the current instrumentation, latest advances, and future developments in sinus and anterior skull base surgery.

OPTICS The rigid endoscope is the most essential element of ESSBS. It allows the surgeon to visualize with unparalleled clarity the surgical field and execute precise maneuvers. Historically, the first nasal endoscope was used by Hirs­ chmann in 1901 to view the maxillary sinus through the oral cavity.1 From this experience, the development and patenting of the rod lens system by Harold Hopkins led to a rigid endoscope with a much narrowed diameter as a result of using glass rods rather than lenses in the instrument shaft. Hopkins later joined with Karl Storz to develop endoscopes that incorporated the rod lens system with fiberoptic light transmission.1,2 The Hopkins rod endoscope is the primary scope system in use today. The scopes vary from 2.7 to 4.0mm depending on pediatric or adult use, respectively. The rigid endoscopes allow angled visualization based on the prism used in each device. Commonly used endoscopes are the 0-, 30-, and 70-degree telescopes

Figs. 47.1A to C: The (A) 0-degree endoscope, (B) 30-degree endoscope, and (C) 70-degree endoscope are the three most commonly used for endoscopic sinus and skull base surgery.

(Figs. 47.1A to C), as well as the 45-degree telescope that is less commonly used. Traditionally, surgery was performed with direct visualization through the endoscope eyepiece. However, further technologic advances including the high-definition video camera adaptation, monitor, and recording devices have ushered in significant improve­ ments (Fig. 47.2). First, viewing the image on the screen allows for manipulation of the image size without com­ promising clarity. In addition, the ability to teach and instruct residents and students is made much easier with use of the monitor. The ability to record high-definition videos and images has paved the way for creating highquality surgical technique guides and publications that

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One challenging aspect of ESSBS is keeping the lens of the endoscope, which is the key to visualization, clean. Blood and other debris can contaminate the lens and obscure the image. Aside from routine removal of the endoscope from the nasal cavity for cleaning, there are sheaths available that irrigate the lens via a foot pedal (Figs. 47.3A to D). These devices obviate the need for manual cleaning and disruption of the endoscopic view. The sheaths are variable in different sizes and can add significant circumference to the endoscope making mani­ pulation, especially with other instruments, more cum­ bersome. The irrigation from the device can also obscure the surgical field requiring suctioning for removal; for the single surgeon operating this may be an impediment. However, they can be particularly useful in three or four handed technique endoscopic skull base procedures where one surgeon is using two hands and can suction the irrigation run off. Usually the light source input is located 180 degree from the beveled lens surface; however, there are endo­ scopes available where the light input is on the same side. This is of benefit in endoscopic skull base surgery (ESBS) with three and fourhanded techniques in which the light cable is physically limiting. Rigid endoscopes with a rotatable lens are available that allow visualization from 0 to 90 degrees with the same device; the only negative aspect to these instruments is the decrease in clarity and light transmission resulting from the rotating lens design. The endoscopes used in ESBS (Fig. 47.3A to D) are longer than those used in traditional endoscopic sinus -

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continue to push the field forward. Lastly, the incorporation of the video camera with the endoscope allows the surgeon more distance from the patient thus improving his or her comfort that can make a significant difference especially in longer procedures. The 0 degree telescope allows for an excellent initial straight on view of the surgical field. Structures that lie directly in its view include the septum, middle and inferior turbinates, ethmoid sinuses, and sphenoid sinus. It is more difficult to view around corners or peer into more obtusely positioned cavities like the maxillary, frontal, and lateral sphenoid recess. The major disadvantage of the 0 degree telescope is that it does not allow for a dynamic view of the surgical field; the view the endoscope provides is only changed by anterior or posterior and medial or lateral movement of the actual device. The advantage of using angled telescopes like the 30 and 70 degree variants is that it allows for a dynamic view of the surgical field with rotation of the beveled lens allowing for greater visualization of the area of interest. For example, the maxillary sinus is better visualized with a 30 or 70 degree telescope by turning the bevel of the lens toward the cavity than it can be by using a 0 degree telescope from a similar vantage point. Furthermore, endoscopic approaches to the frontal sinus and anterior skull base must be done with an angled endoscope, pre­ ferably the 45 and 70 degree endoscope, because they allow for optimal visualization of these areas. Placing the endoscope below the instrument allows the surgeon to see the surgical field clearly while avoiding instrument contact interference or “fencing.”

Figs. 47.3A to D: (A) The extended length endoscope with irrigating sheath is seen in comparison to shorter sinus endoscope. (B) Cupped up-biting skull base forceps. (C) Long malleable PMT suction with graded control hole. (D) Up-biting Kerrisonrongeur.



Fig. 47.2: The endoscopic tower consists of a high-definition monitor, digital video and still photograph recorder, and light source.

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Figs. 47.4A to E: The Blakesley forceps are either straight (A) or up-biting (B). The through-cut forceps are either straight (C) or up-biting (D). The back-biting through-cut (E) can be rotated to achieve the desired direction.

Fig. 47.5: The cervical spine curettes come in different sizes and can be used to remove the bone of the nasofrontal beak or sphenoid rostrum, in lieu of a drill.

surgery (ESS). These endoscopes are usually fitted with an irrigating sheath attachment to lessen the need for withdrawal of the scope for cleaning, especially when using high-speed drills. In addition the longer endoscope allows the camera head, and camera holder’s hand, to be a greater distance from the region of instrument access. This added space allows for increased maneuverability when using three and fourhanded techniques.

the endoscope, especially posteriorly in the nasal cavity, allows for the more efficacious use of the Cottle and Freer elevators when performing a septoplasty for surgical access or septal deviation. The ball tip probes include the maxillary and frontal sinus seekers. Probes are essential tools of sinus surgery as they allow for gentle identification of sinus ostia with minimal risk of iatrogenic trauma. Various curettes may be used in order to remove bone of the frontal sinus ostium as well as the thick bone of the sphenoid rostrum. Frontal sinus curettes with an acute angle curvature are useful in exposing the frontal recess and removing suprabullar or agger nasi cells. Cervical spine curettes prove very useful in extended frontal sinus procedures when removing the nasofrontal beak, in lieu of a high-speed drill, where there is osteoneogenic bone (Fig. 47.5). The cervical spine curettes cause less trauma to the bone and may result in decreased frontal sinus stenosis from less osteogenic bone formation. Care must be taken to avoid upward and posterior movements with the curette to avoid inadvertent skull base penetration. Due to the superior and anterior location of the frontal sinus, and its close proximity to the skull base, delicate giraffe instruments were developed (Figs. 47.6A to D). These noncutting forceps allow for removal of soft tissue and loose bone fragments along the frontal sinus outflow tract and anterior skull base. A through-cutting giraffe also exists for fine bony and mucosal cuts and is paramount in preventing postsurgical frontal recess or ostium stenosis. The instruments open in a side-to-side or front-to-back fashion depending on the orientation of the tissue being

COLD STEEL INSTRUMENTATION The workhorses of ESS include the through-cut and noncutting forceps (Figs. 47.4A to E). The non-cutting forceps are available in different sizes and angles including 0-, 45-, and 90-degree. The non-cutting instruments are primarily used for removing already loose or detached fragments of tissue. These can inadvertently strip or tear mucosa and must be used with caution with adherent tissue. The through-cut forceps are available in straight and 45-degree versions, as well as a 90-degree punch. These are available in different orientations like the down-biting, side-biting, and back-biting variants as well as a single multi-purpose instrument in which the head can be rotated to achieve the desired positions. Through-cutting forceps and punches are best used to sharply and precisely cut mucosa, cartilage, or bone resulting in minimal mucosal stripping. Further traditional instruments for endoscopic, endo­ nasal surgery include elevators and probes. Cottle and Freer elevators are certainly not unique to endoscopic endonasal surgery and were in use long before the advent of the rigid endoscope. The improved visualization with

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Section 9: Surgery for Inflammatory Sinusitis

cautery and it is much safer to brain parenchyma if con­ trolling bleeding at the skull base. The microdebrider works by suctioning tissue into the tip of the instrument’s shaft while a rotating serrated blade cuts the tissue. Different disposable cutting blades are available based on individual companies that make the microdebriders, including aggressive blades that more easily cut bone. A straight microdebrider blade is the mainstay for ethmoid and sphenoid sinus surgery, as well as inferior and middle turbinate surgery. The curved microdebrider is available in 15 , 30 , 40 , 60 , 75 , 90 , and 110 degree (Figs. 47.7A to C). The 60 degree blade is most commonly used for the maxillary sinus, frontal sinus, and exposing and preserving the mucosa of the fovea ethmoidalis, although other curvatures may be used as needed. A new product called the Diego Elite (Olympus Gyrus ACMI, Southborough, MA) is a fusion of the microdebrider and either the suction monopolar or bipolar cautery (Figs. 47.8A and B). This device is likely to significantly reduce operative time because it negates the need to switch instruments for cauterization, which over the course of a long case, can be substantial. In addition, because the device can seamlessly cauterize, it may result in a less bloody operative field. The instrument is available in straight and various angled microdebrider attachments with the serrated and aggressive blades. The Diego Elite is poised to be a practical and efficacious addition to the ESSBS armamentarium. A major advantage of the instrument is its ability to suction blood and debris from the surgical field and is

The powered microdebrider, or tissue shaver, is a corner­ stone of ESS. Its first endonasal use was documented in 1993 by Setliff and Parsons.3 Since this initial description, the instrument has continued to gain popularity and notoriety among endoscopic sinus surgeons. The success of this instrument, and the expansion of endoscopic surgery to include the anterior skull base, prompted the development of irrigating drills for removing bone. The microdebriders and drills can be used in conjunction with the same hand piece that allows for rotation of the instrument head. The recent advent of the bipolar cautery function to the microdebrider tip also allows for controlled coagulation without changing instruments. There is much less diffuse thermal injury compared to the monopolar

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removed. The cup can be 2 or 3 mm and the angle of the instrument ranges from 45 to 110 degree. The ESBS instruments are generally longer than those used in ESS (Figs. 47.3A to D). The instruments much reach to the skull base and beyond for intracranial dis­ section. The suction is longer with a graded control hole allowing for greater variability in vacuum forces. The instruments are also smaller at the tip allowing for finer and gentle grasping of tissues. The Kerrison Rongeur is also a useful instrument for removal of bone at the skull base, particularly the sella turcica of the sphenoid sinus. Finally, adaptation of neurosurgical microinstruments additionally allows for soft tissue dissection within the intracranial cavity -

Figs. 47.7A to C: The straight (A), curved 40-degree (B), and curved 60-degree (C) microdebriders are used to efficiently suction and microdebride soft tissue and bone.

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Figs. 47.6A to D: The giraffe forceps come in a vertical side-toside or front-to-back opening (A and B), as well as a horizontal front-to-back and side-to-side variants (C and D).

Chapter 47: Innovations in Optics and Instrumentation

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B

Figs. 47.8A and B: The Diego Elite (Olympus Gyrus ACMI, Southborough, MA) with the console and both the (A) microdebrider/monopolar and (B) microdebrider/bipolar instruments.

Fig. 47.10: The Medtronic Stylus (Medtronic, Jacksonville, FL) transnasal skull base drill with protected shaft and angled irrigating burr.

particularly advantageous to the endoscopic surgeon with only one free hand for instrumentation. The shaft of the instrument varies from 2 to 4 mm; the wider the shaft the less likely the instrument is to clog and require manual cleaning, ultimately prolonging operative time. Maintenance of strong suction and a sock in the suction canister to collect the shaved tissue contents is critical for cutting efficacy and pathologic analysis, respectively. The only significant negative attribute to this instrument is the rapidity of its action and the catastrophic damage that can occur in seconds. Detailed knowledge of the anatomy and preoperative review of the computed

Figs. 47.9A and B: The 60-degree curved irrigating cutting barrelburr (A) and the straight diamond irrigating bullet burr (B) are two examples of drill attachments that are used to remove bone of the nasal cavity and skull base.

tomography (CT) scan is crucial to avoid iatrogenic injury to the skull base, orbit, and nondiseased mucosa. Cold steel instrumentation is slower at tissue removal but the risk of significant iatrogenic injury is lower; regardless of instrument choice, there is no substituting knowledge of technique and surgical landmarks. Irrigating and suctioning drill attachments were devel­ oped for the removal of dense bone during endoscopic sinus and skull base procedures. Some applications include, but are not limited to, drilling the nasofrontal beak during a Draf III frontal sinusotomy, removal of the sphenoid rostrum, resection of the anterior skull base, dacryocystorhinostomy (DCR), and choanal atresia repair. Various irrigating shaped bits in cutting and diamond forms at angles from 0- to 70-degree are available includ­ ing the barrel, shielded barrel, ball, bullet, taper, and DCR burrs (Figs. 47.9A and B). The location of drilling dictates the burr selection; e.g. a shielded barrel burr is excellent for removing the nasofrontal beak because it decreases the circumferential damage to the frontal sinus ostium that may result in osteoneogenic bone formation. During ESBS a high-speed drill proves useful for efficient and controlled removal of bone. The drill attach­ ments for the microdebrider system are excellent, but the revolutions per minute (RPM) do not exceed 15,000. The high-speed drill, in contrast, can attain RPM up to 60,000. The Medtronic Stylus (Medtronic, Jacksonville, FL) skull base drill has a long protective sheath and an irrigating angled tip with diamond and cutting burr attachments (Fig. 47.10). This instrument allows access to the clivus

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Section 9: Surgery for Inflammatory Sinusitis

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Figs. 47.11A to D: (A) The right sphenoid before dilation and (B) after dilation. (C) The left sphenoid before dilation and (D) after dilation.

BALLOON SINUS DILATION

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Lanza described the first balloon dilation of the frontal sinus in 1993 with the use of Fogarty catheters in post functional endoscopic sinus surgery (FESS) patients to achieve temporary opening of the frontal sinus outflow tract.4 The first sinus balloon catheter was approved by the FDA in 2005. Since then numerous studies have shown its efficacy in maintaining ostium patency and safety of the device in the short term and 2 year follow up, with level 4 evidence consisting mostly of retrospective reviews.5 8 However, the indications for when balloon sinus dilation is appropriate and its outcomes compared to traditional FESS are less clear.

The device is used to open the maxillary, sphenoid, and frontal sinuses. The mechanism of the balloon sinus catheter is different from previously designed devices for the coronary artery, e.g. in that it is semirigid and noncompliant and therefore is able to expand bony and soft tissue openings. The device consists of an introducer, guide wire, a catheter balloon, a pump, a pressure gauge (manometer), and a lavage catheter. The primary technique for using the device is the Seldinger technique that involves identification of the sinus ostium, cannulation with a guide wire, and passage of the balloon over it into the sinus with saline inflation. In this example, the right and left sphenoid sinuses are identified, cannulated, and opened with the saline filled balloon catheter (Figs. 47.11A to D). Another example shows the right frontal sinus outflow tract identified, cannulated, and opened with the balloon catheter (Figs. 47.12A to D). The sinus can be redilated as needed to achieve the desired opening.

and upper cervical spine, in addition to more traditional uses at the fovea ethmoidalis, planum sphenoidale, and sphenoid rostrum.

Chapter 47: Innovations in Optics and Instrumentation

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Figs. 47.12A to D: (A) The right frontal recess denoted by the asterisk is cannulated with the guidewire (B) and then dilated with the saline filled balloon (C). The end result is a widely patent frontal sinus ostium and outflow tract (D).

Balloon sinus dilation was first introduced as a procedure to be done in the operating room as a primary surgery for sinus obstruction. The impetus for their popularity was due in part to maximal mucosal preser­ vation since the device could open the sinus with mini­ mal adjacent trauma. It has since evolved into use in the office for initial surgery or for revision dilations of stenotic ostia under only local anesthetic agents.9 With the growing applicability and familiarity with balloon devices, their popularity has grown among sinus surgeons. However, despite their continued utilization there are few prospective studies to compare their efficacy with that of traditional FESS. A prospective randomized study by Plaza et al. compared Draf 1 frontal sinusotomy to balloon dilation with hybrid FESS (traditional ethmoidectomy with balloon dilation of the frontal sinus outflow tract). Visual analog scores, rhinosinusitis disability index scores, Lund– McKay scores, and olfactory thresholds were statistically

improved in both groups. Lund-McKay scores for the frontal sinus were improved with statistical significance to nearly the same score in both groups. Frontal sinus patency and resolution of disease were marginally better in the balloon group though not statistically significant. The study, in the end, did not have sufficient data to prove equivalency between balloon dilation of the frontal sinus and Draf 1 sinusotomy.10 Balloon sinuplasty is a useful adjunct in the man­ agement of chronic rhinosinusitis (CRS). More prospective studies with randomization must be performed in order to truly assess its comparative utility with FESS. Clearly, patients with osteogenesis, significant polyposis, and high Lund-McKay scores are poor candidates for balloon procedures. As the data on balloon dilation grows so will our understanding of its most appropriate applica­ tions to CRS.

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Section 9: Surgery for Inflammatory Sinusitis

STENTS

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Fig. 47.13: The Propel nasal stent (Intersect ENT, Menlo Park, CA) is shown with small steroid-eluting reservoirs at the apex of each individual rhomboid.

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of this stent and shown significant reductions in polyposis, adhesions, postoperative inflammation, and the need for postoperative oral steroids.19 22 The stent debate is far from over and will continue to evolve as further studies document the long term effi­ cacy and safety of these devices. Most rhinologists would agree that routine surveillance of stented sinus cavities is critical to maintain device position and functionality. In the interim, the decision to use structural or drug eluting stents remains at the surgeon’s discretion as there are currently no definitive indications or contraindications to their use.

THREE-DIMENSIONAL ENDOSCOPY

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Most otolaryngologic and neurosurgical procedures are done with a three dimensional (3D) view either with the unaided eyes or the microscope. ESS and ESBS have traditionally been limited by a monocular view. Surgeons, therefore, must rely on haptic feedback, monocular visual cues, and knowledge of the anatomy. The key limitation of high definition two dimensional (2D) endoscopy is the lack of depth perception as defined by vertical disparities, convergence, and stereopsis. Obtaining separate views from different angles allows the visual cortex to superimpose the images and create stereopsis, or a 3D picture. Until the advent of the latest 3D endoscopy technology images were of poor resolution and often caused the user to experience eye fatigue in addition to nausea or headaches. The newest generation of 3D stereoendoscopes utilizes a microscopic -

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Stents are most commonly used for the frontal sinus and more recently the ethmoid sinus cavity. Use of sinus stents dates back to 1905 when Ingals used a gold tube to maintain the patency of the frontal sinus.11 Since then, different materials were used to similar ends with variable results. In a landmark animal model study by Neel et al., it was found that firm tubing caused increased osteoblastic activity and scar formation as compared to softer mate­ rials.12 This discovery propelled stent development strongly in the direction of softer materials. Stent placement in the frontal sinus may prevent stenosis by maintaining the patency of the outflow tract while allowing mucosal regeneration in cases where it has been stripped due to osteitic bone formation or tumor burden.11 There are no strict indications for stent placement, but relative indications include stenosis after surgery, circumferential bone exposure, neo ostium less than 5 mm, trauma to the outflow tract, and lateralization of the middle turbinate. In a study by Hoseman et al. they found the postoperative stenosis rate with a neo ostium greater than 5 mm was 16% versus 33% with the same opening less than 5 mm.13 The duration of stent place­ ment remains controversial with studies recommending placement anywhere from 1 week to 5 years in cases of refractory chronic frontal sinusitis14,15 Most commonly stents are used for weeks to months. It is important to note that bacterial biofilms were found on stents removed 1–4 weeks after surgery, although the prognostic signifi­ cance of this is unclear.16 A variety of stent materials are described in the literature like rubber, gold, Silastic, and Dacron.17 Some stents are dilated at one end to avoid extrusion from the sinus cavity rather than requiring suturing to stay in place. The newest developments include drug eluting stents that administer steroids into the stented sinus cavity. A spacer stent with a reservoir to slowly disperse steroids topically exists for the frontal and ethmoid sinuses; however, the device is only FDA approved for administering saline despite initially promising results with triamcinolone.18 Most recently, in 2012 the FDA approved the first drug eluting nasal stent called the Propel stent (Intersect ENT, Menlo Park CA). It is a frontal sinus and ethmoid cavity expanding co polymer bioabsorbable mometasone furoate releasing stent (Fig. 47.13). It releases 370 µg of the steroid locally for 30 days and then resorbs without requiring removal. Several large studies have proven the safety and efficacy

Chapter 47: Innovations in Optics and Instrumentation array of video lenses, like an arthropod’s compound eye, to generate multiple images that are processed into a 3D image on a stereoscopic monitor and viewed with polarized glasses. 23 This new 3D stereoendoscope technology developed by Visionsense Ltd. (Orangeburg, NY) has spawned a rebirth in enthusiasm for its use in ESSBS. Numerous studies from cadaveric comparative dissections between 2D and 3D endoscopy to prospective randomized trials have validated the improved spatial representation with 3D images. No otolaryngology or neurosurgery studies have shown a decrease in operative time, complications, or length of hospital stay with 3D stereoendoscopy.24-28 Some limitations of the 3D technology include a reduced field of view up to a 52% reduction as determined in a controlled lab setting.29 Furthermore, image sharpness is more significantly affected by minimal lens debris along with insufficient light in tight nasal passages and central darkness. The adverse user side effects like nausea, headaches, and eye fatigue were not experienced in any of the studies highlighting a significant improvement from the older technology.26,27,30 Based on current trends in the literature, it is clear that use of 3D endoscopy is preferential toward ESBS. Only one noncadaveric study used the 3D technology for ESS and this was in select more complex cases.26 As 3D endoscopy gains popularity, more studies will continue to explore if it improves patient outcomes assessed by various measures. Improvements in this new video lens array will also continue to improve image quality, especially with angled endoscopes, and further expand its utility.

ROBOTIC SKULL BASE SURGERY The only FDA-approved robotic system for otolaryngology is the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA). The use of this device is well documented in head and neck surgery for transoral robotic surgery (TORS) as well as transaxillary robotic surgery for thyroid and parathyroid disorders.31-33 The da Vinci robot has not been used clinically for strictly transnasal sinus or skull base surgery largely due to the limitations the system has with providing access through the narrow nasal corridor. In 2007, Hanna et al. described a transantral use of the da Vinci robot to access the sella turcica, planum sphe­ noidale, and cribriform plate through bilateral supe­rior vestibular incisions in cadavers. This approach provided good access but presented the added morbidity of trans­ maxillary dissection.34 TORS for skull base tumors was

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later described in cadaveric studies for resection of lower and middle clivus lesions, as well as the infratemporal fossa (ITF).35 Difficulty accessing structures cephalad to the hard palate was circumvented in cadaveric studies by both cervical–transoral robotic surgery (C-TORS) that includes the addition of transcervical ports lateral to the submandibular gland, as well as suprahyoid transcervical ports for access to the ITF.36,37 A cadaveric study proved an invasive posterior hard palate resection with TORS allows for transnasal or transoral placement of the endoscope with transoral instrumentation and exposure of the skull base from the crista galli to C1.38 Further studies combined use of the extended endonasal approach(EEA) with TORS to achieve resection of a clival chordoma and an adenoid cystic carcinoma extending from the nasopharynx into the clivus and ITF. The endoscopic approach was performed first for exposure superior to the eustachian tube, and the soft palate was then retracted superiorly with a rubber catheter to facilitate TORS gross total resection.39 At present, there is still no strict TORS due in part to the limitations of the robotic arm size and instrument attach­ ments for the da Vinci system. One critical limitation is the lack of a robotic drill instrument for bony resection of the skull base. There are currently several robotic prototypes in design specifically for endonasal use; however, they are still in development.40,41 Some of these prototypes are trying specifically to include either optical or electromagnetic navigation that the current robotic system does not afford. Designing a system that is applicable entirely through the nose would be a major step forward in robotic sinus and skull base surgery. Furthermore, the development of haptic feedback technology is particularly paramount when operating near the critical neurovascular structures at the skull base interface.

CONCLUSION ESBS has experienced tremendous growth and deve­ lopment over the past 30 years due to significant contributions from pioneers in the field. Since the deve­ lopment of the rod lens system, one technological advancement after another has continually kept the field on the cutting edge. Further studies must be conducted to fully validate the efficacy of the tools we use like balloon sinus catheters and nasal stents to ensure that patients continue to receive the best possible surgical and medical treatments for their specific pathology. With new advances like 3D endoscopy and robotic surgery, there must be a systematic methodology to determine if the new technology truly provides superior treatment before

Section 9: Surgery for Inflammatory Sinusitis

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1. Jennings CR. Harold Hopkins. Arch Otolaryngol Head Neck Surg. 1998;124:1042. 2. Linder TE, Simmen D, Stool SE. Revolutionary invention in the 20th century. The history of endoscopy. Arch Otol Head Neck Surg. 1997;123:1161 3. 3. Setliff R, Parsons D. The “Hummer”: new instrumentation for functional endoscopic sinus surgery. Am J Rhinol. 1994; 8:275 8. 4. Lanza DC. Postoperative care and avoiding frontal recess stenosis. In: Abstracts of the International Advanced Sinus Symposium. Philadelphia; 1993. 5. Batra, PS. Evidence based practice: Balloon catheter dila­ tion in rhinology. Otolaryngol Clin North Am. 2012;45: 993 1004. 6. Bolger WE, Brown CL, Church CA, et al. Safety and out­ comes of balloon catheter technology: a multicenter 24 week analysis of 115 patients. Otolaryngol Head Neck Surg. 2007;37:10 20. 7. Kuhn FA, Church CA, Goldberg AN, et al. Balloon catheter sinusotomy: one year follow up outcomes and role of in functional endoscopic sinus surgery. Otolaryngol Head Neck Surg. 2008;139(3 Suppl):S27 S37. 8. Friedman M, Schalch P, Lin HC, et al. Functional endo­ scopic dilatation of the sinuses: patient satisfaction, post­ operative pain, and cost. Am J Rhinol. 2008;22:204 9. 9. Eloy JA, Friedel ME, Eloy JD, et al. In office balloon dilation of the failed frontal sinusotomy. Otolaryngol Head and Neck Surg. 2011;146:320. 10. Plaza G, Eisenberg G, Montojo J, et al. Balloon dilation of the frontal recess: a randomized clinical trial. Ann Otol Rhinol Laryngol. 2011;120:511 8. 11. Malin BT, Sherris DA. Frontal sinus stenting techniques. Oper Tech Otolaryngol Head Neck Surg. 2010;21:175 80. 12. Neel HB, Whicker JH, Lake CF. Thin rubber sheeting in frontal sinus surgery: animal and clinical studies. Laryngo­ scope. 1976;86:524 36. 13. Hosemann W, Kuhnel T, Held P, et al. Endonasal frontal sinusotomy in surgical management of chronic sinusitis: a critical evaluation. Am J Rhinol. 1997;11:1 9. 14. Orlandi RR, Knight J. Prolonged stenting of the frontal sinus. Laryngoscope. 2009;199:190 192. 15. Metson R. Endoscopic treatment of frontal sinusitis. Laryngoscope. 1992;102:712 6. 16. Perloff JR, Palmer JN. Evidence of bacterial biofilms on frontal recess stents in patients with chronic rhinosinusitis. Am J Rhinol. 2004;18:377 80. 17. Hunter B, Silva S, Youngs R, et al. Long term stenting for chronic frontal sinus disease: case series and literature review. J Laryngol Otol. 2010;124:1216 22.





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REFERENCES

18. Catalano PJ, Thong M, Weiss R. The MicroFlow Spacer: a drug eluting stent for the ethmoid sinus. Indian J Otolaryngol Head Neck Surg. 2011;63:279 84. 19. Li PM, Li PF, Downie D, et al. Controlled steroid delivery via absorbable stent: safety and performance in a rabbit model. Am J Rhinol Allergy. 2009;23:591 6. 20. Murr AH, Smith TL, Hwang PH, et al. Safety and efficacy of a novel bioabsorbable, steroid eluting sinus stent. Int Forum Allergy Rhinol. 2011;1:23 32. 21. Forwith KD, Chandra RK, Yun PT, et al. ADVANCE: a multisite trial of bioabsorbable steroid eluting sinus implants. Laryngoscope. 2011;121:2473 80. 22. Marple BF, Smith TL, Han JK, et al. Advance II: A pros­ pective, randomized study assessing safety and efficacy of bioabsorbable steroid releasing sinus implants. Oto­ laryngol Head Neck Surg. 2012;146:1004 1011. 23. Singh A, Saraiya R. Three dimensional endoscopy in sinus surgery. Curr Opin Otolaryngol Head Neck Surg. 2013; 21:3 10. 24. Tabaee A, Anand VK, Fraser JF, et al. Three dimensional endoscopic pituitary surgery. Neurosurg. 2009;64:288 95. 25. Kari E, Oyeaiku N, Dadashev V, et al. Comparison of tradi­ tional 2 dimensional endoscopic pituitary surgery with new 3 dimensional endoscopic technology: intraoperative and early postoperative factors. Int Forum Allergy Rhinol. 2012;2:2 8. 26. Manes RP, Barnett S, Batra PS. Utility of novel 3 dimensional stereoscopic vision system for endoscopic sinonasal skull base surgery. Int Forum Allergy Rhinol. 2011;1:191 7. 27. Brown SM, Tabaee A, Singh A, et al. Three dimensional endoscopic sinus surgery: feasibility and technical aspects. Otolaryngol Head Neck Surg. 2008;138:400 402. 28. Roth J, Fraser J, Singh A, et al. Surgical approaches to orbital apex: comparison of endoscopic endonasal and transcranial approaches using novel 3D endoscope. Orbit. 2011;30:43 8. 29. Van Gompel JJ, Tabor MH, Youssef AS, et al. Field of view comparison between two dimensional and three dimen­ sional endoscopy. Laryngoscope. 2014;124(2):387 90. 30. Shah RN, Leight D, Patel MRA, et al. A controlled laboratory and clinical evaluation of three dimensional endoscope for endonasal sinus and skull base surgery. Am J Rhinol Allergy. 2011;25:141 4. 31. Weinstein GS, O’Malley BW, Snyder W, et al. Transoral robotic surgery: supraglottic partial laryngectomy. Ann Otol Rhinol Laryngol. 2007;116:19 23. 32. Guilianotti PC, Addeo P, Buchs NC, et al. Robotic thyroid­ ectomy: an initial experience with the gasless transaxillary approach. J Laparoendosc Adv Surg Tech. 2012;22:387 91. 33. Lee J, Chung WY. Current status of robotic thyroidectomy and neck dissection using a gasless transaxillary approach. Curr Opin Oncol. 2012;24:7 15. 34. Hanna EY, Holsinger C, DeMonte F, et al. Robotic endoscopic surgery of the skull base: a novel surgical approach. Arch Otolaryngol Head Neck Surg. 2007;133:1209 1214.



mainstream adaptation ensues. Amidst the changing landscape of ESBS, there is one constant; a fundamental and dynamic understanding of the anatomy is the key to unlock the potential of the field’s constant innovations.



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Chapter 47: Innovations in Optics and Instrumentation 35. Lee JY, O’Malley BW Jr, Newman JG, et al. Transoral robotic surgery of the skull base: a cadaver and feasibility study. ORL J Otorhinolaryngol Relat Spec. 2010;72:181-7. 36. O’Malley BW Jr, Weinstein GS. Robotic anterior and mid­ line skull base surgery: preclinical investigations. Int J Radiat Oncol Biol Phys. 2007;69:S125-S128. 37. McCool RR, Waren FM, Wiggins RH 3rd, et al. Robotic surgery of the infratemporal fossa utilizing novel suprahyoid port. Laryngoscope. 2010;120:1738-43. 38. Ozer E, Durmus K, Carrau RL, et al. Applications of transoral, transcervical, transnasal, and transpalatal corridors for robotic surgery of the skull base. Laryngoscope. 2013;123(9): 2176-9.

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39. Carrau RL, Prevedello DM, de Lara D, et al. Combined transoral robotic surgery and endoscopic endonasal app­ roach for the resection of extensive malignancies of the skull base. Head Neck. 2013;35(11):E351-8. 40. Schneider JS, Burgner J, Webster III, RJ, et al. Robotic surgery for the sinuses and skull base: what are the possibilities and what are the obstacles? Curr Opin Otolaryngol Head Neck Surg. 2013;21:11-6. 41. Trevillot V, Garrel R, Dombre E, et al. Robotic endoscopic sinus and skull base surgery: review of the literature and future prospects. Eur Ann Otorhinolaryngol, Head Neck Dis. 2013;130(4):201-7.

Chapter 48: Surgical Radiology and Image Guidance Surgery

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Chapter

Surgical Radiology and Image Guidance Surgery

48

Jeremiah A Alt, Richard R Orlandi

INTRODUCTION Radiological imaging is paramount in performing safe endoscopic sinus surgery (ESS); therefore, mastery in ordering appropriate imaging to assess disease processes and reading radiographic studies with its corresponding anatomy is a prerequisite for the sinus surgeon. Studying and analyzing preoperative imaging arms the surgeon with the anatomical knowledge to successfully navigate the nasal cavity and paranasal sinuses, reducing the risk of potential catastrophic complications. Following key anatomical landmarks in a thoughtful, careful, and precise manner can significantly reduce complications. However, minor and major complications can and still do occur due to various factors including anatomical variants, altered anatomy due to previous surgery, severe polyposis, and decreased visibility from bleeding. In these instances, image guidance has become more widely used. Nonetheless, the surgeons’ familiarity with each patient’s unique ana­ tomy and pathology, gleaned from preoperative imaging, may be one of the most important variables in reducing the risk associated with ESS and will be discussed herein.

IMAGING IN SINONASAL PATHOLOGY: IMAGING MODALITIES Standard Roentgenographs (Plain Film Radiography) Röntgen discovered the X-ray over 100 years ago. His contribution advanced the fields of both physics and medi­ cine, and was awarded the Nobel Prize. Since the initial

discovery, the X-ray has been widely used in medicine. The X-ray was particularly well adapted and successfully used in the evaluation of the maxillofacial skeleton. The four standard views used to display sinonasal anatomy are the Waters’ view, Towne’s view, lateral view, and submen­ tovertex views. These views are adequate in displaying the maxillary sinus, a general outline of the frontal sinus, and views of the mid-sagittal sphenoid sinus. However, these views are inadequate at visualizing the inferior third of the frontal sinus, ethmoid skull base, and posterior ethmoid sinuses. In addition, inflammatory disease, polyposis, and anatomic variations are inadequately assessed with the X-ray. In summary, although plain films have been used in the past to assess sinonasal anatomy, this modality inade­ quately assesses the anatomical complexities needed for modern ESS.

Computed Tomography The advent of high-resolution thin-cut multiplanar com­ puted tomography (CT) has dramatically improved the assessment of the complex detail of the sinonasal ana­ tomy. Traditional imaging in the axial and coronal planes was a dramatic improvement over X-ray-based plain films. However, anatomic relationships especially within the frontal recess and skull base were not always definitive despite these multiplanar views. The advent of tri-planar imaging with the inclusion of the sagittal plane allowed detailed radiologic assessment of the frontal recess.1-4 For these reasons, plain films and multiplanar imaging have largely been replaced by tri-planar CT imaging due to the improved bony detail and discrimination. Of the three

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Mucoceles The CT scan excels in assessing mucoceles, allowing assess­ ment of bony remodeling and dehiscence. MRI can be complicated with variable signal intensity, such that the T1 and T2 signals may be hyperintense or hypointense depending on the level of desiccation. One caveat to this is the utility of MRI in distinguishing intracranial and intraorbital structures from the mucocele. A mucopyocele (infected mucocele), on the other hand, can be delineated by a contrast enhanced MRI that typically demonstrates enhancement. -

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views, the coronal images can be considered the most use­ ful for surgical planning as they closely resemble the surgeons’ endoscopic surgical view. However, certain aspects of sinonasal anatomy are ideally visualized with axial and sagittal images. Contrast is usually not needed for inflammatory sinonasal disease. New low dose CTs may be advantageous to reduce radiation exposure.5 Ultimately, tri planar CT imaging is a critical tool for the sinus surgeon to obtain, as it designates and represents a roadmap for safe ESS.

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Historically, plain films were the mainstay of diagnosing and evaluating the sinusitis following failure of medical management. Plain films are unable to show detailed bony anatomy and inflammatory pattern in detail due to overlapping of structures and lack of resolution, making the evaluation of key areas including the ostiomeatal complex, ethmoid sinuses, middle meatus, and sphenoid sinus somewhat limited. It is now common that all uncom­ plicated sinusitis is evaluated with a CT scan. To eliminate the effects of reversible mucosal thicken­ ing, patients undergoing CT for evaluation of chronic sinus disease are best scanned 4–6 weeks after medical therapy and not during an acute infection. Although the MRI has a rather limited role in evaluating uncomplica­ ted sinusitis, it has a significant potential in evaluating complicated sinusitis including patients with meningitis, thrombophlebitis, subdural empyemas, intracranial, or intraorbital abscesses.

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The CT and MRI complement each other when evaluating sinonasal neoplasms. The CT is more sensitive in defining the bony confines and boundaries evident by surrounding osseous destruction, and is particularly useful at the skull base and/or orbital walls. MRI, on the other hand, offers improved soft tissue detail with improved sensitivity in evaluating extra sinus extension. Extra sinus extension dictates downstream management, thereby, determining, e.g. if the neoplasm can be resected endoscopically. Differentiation between inflammatory changes and the neoplastic mass is also facilitated by MRI. Our intent is not to review imaging modalities for every sinonasal neo­ plasm. We present a selected list of the most common, or those neoplasms with unique imaging characteristics.

BENIGN SINONASAL NEOPLASMS Fibro-osseous Lesions Fibro osseous lesions such as fibrous dysplasia, osteomas, aneurysmal bone cysts, and osteoblastoma of the sino­ nasal structures are best characterized with CT imaging, as it defines the exact extent of the lesion. The propor­ tion of both the osseous and fibrous component of the disease will dictate its appearance on imaging, such that the fibrous components appear more radiolucent, while those lesions of equal proportion have a ground glass appearance. Cortical osteomas produce complete signal void on all MRI sequences, and are indistinguishable from the surrounding air, making the diagnosis more diffi­ cult. In addition, fibrous dysplasia can have an aggressive appearance on MRI and be mistaken for a malignant tumor. In this situation, the CT scan should be obtained to help confirm the diagnosis. -

IMAGING IN INFLAMMATORY DISEASE Sinusitis

SINONASAL NEOPLASMS

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As the boundaries of endoscopic sinonasal surgery have progressed, magnetic resonance imaging (MRI) has increas­ ingly become more important in assessing patients with sinonasal neoplasms, aggressive inflammatory conditions, and intracranial processes. Tri planar MRI imaging pro­ vides the radiologist and surgeon with detailed anatomic information by differentiating proteinaceous fluid from solid material. When evaluating the skull base, the MRI is particularly useful as it can differentiate between scar tissue, mucoceles, encephaloceles, trapped secretions, or sinonasal neoplasms. MRI has also been deemed more useful in characterizing aggressive lesions and evaluating perineural spread.

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Magnetic Resonance

Chapter 48: Surgical Radiology and Image Guidance Surgery

Inverted Papilloma Inverted papillomas, also known as schneiderian papil­ lomas, are one of the most common benign lesions of the nasal cavity and paranasal sinuses. Although benign, they commonly destroy bone and 13% of the time they are associated with squamous cell carcinoma (SCC).6 Inverted papillomas are most likely to be located in the lateral nasal wall involving the ostiomeatal complex and maxillary sinus followed by ethmoid, sphenoid, and frontal sinu­ ses. Imaging is important for surgical planning and for evaluating deeper invasion, which is characteristic of malignant transformation. Inverted papilloma enhances with contrast on CT imaging and is most commonly seen occupying the lateral nasal wall. If malignant transfor­ mation is a concern, MRI is often used to further delineate the involvement of the extrasinonasal cavity.

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a homogenous contrast-enhancing lesion with an associ­ ated dural base. Hyperostosis of the adjacent bone is seen in a large percentage of patients. On MRI, the lesion has a broad dural base and is isointense or hypointense when compared to normal brain with a characteristic dural tail.

Malignant Sinonasal Tumors Patients with sinonasal malignancies present with symp­ toms similar to rhinosinusitis such as nasal obstruction, epistaxis, headaches, and facial pain. A CT scan with con­ trast is useful to determine the bony erosion and extent of the disease, while adjunct MRI is useful for neurovascular invasion or need for better soft tissue detail. Although a biopsy of the mass will ultimately delineate the pathology, preoperative imaging is very useful to help guide surgical planning and staging of sinonasal malignancies.

Juvenile Angiofibroma

Sinonasal Squamous Cell Carcinoma

Juvenile angiofibroma is an uncommon neoplasm with a pathognomonic site of origin at the level of the pterygo­ palatine fossa. It almost exclusively occurs in the second decade of life and nearly always affects boys. Benign and slow growing, blood supply is obtained from a variety of vessels, the most common being the internal maxillary artery. The lesion may spread through various pathways of the skull base foramina and fissures. At early onset, the angiofibroma may extend through the sphenopalatine foramen into the nasopharynx. Through bony erosion, some tumors may reach the anterior or middle cranial fossa and extend into the cavernous sinuses via the sphe­ noid sinus. Hypervascularized lesion emanating from behind the middle turbinate strongly suggests the diag­ nosis of juvenile angiofibroma and can be further confir­ med with CT or MRI scanning that highlights three major features: the area of origin located at the level of the pterygopalatine fossa, the hypervascular appearance after contrast enhancement (flow voids in the lesion), and the pattern of growth.

Sinonasal SCC is a malignant tumor from sinonasal mucosal epithelium, and accounts for 80% of sinonasal malignancies. It is the most common sinonasal epithelial tumor and is most commonly found in the maxillary sinus with a 30–50% 5-year survival rate.7 Other sinonasal epi­ thelial tumors, such as adenocarcinoma, adenoid cystic carcinoma, and esthesioneuroblastoma (ENB), are more commonly found in the ethmoidal air cells. SCC is a fast growing, aggressive tumor that commonly invades the maxillary inferolateral wall and surrounding structures such as the orbit; therefore, the CT scan is useful in deter­ mining the bony erosion and extent of the disease. On MRI, SCC is characterized by low-signal intensity on T2 scans, allowing differentiation between retained secre­ tions, which are typically bright in signal intensity. Lastly, tumors originating in the maxillary sinus are more likely to present with hypesthesia of the infraorbital nerve (V2) with concern of perineural invasion that is evaluated by gadolinium MRI imaging. Imaging should be carefully evaluated to trace the branches of the trigeminal nerve (pterygopalatine fossa, foramen rotundum, foramen ovale, orbital fissures) to identify perineural spread.

Meningioma Meningiomas arise from meningothelial cells most com­ mon in the arachnoid villi. Usually meningiomas are diag­ nosed in the sixth to seventh decade of life and are more commonly seen in women. More than 90% are intracranial and can be multiple in patients with NF-2. Meningiomas are encapsulated and attached to the dura. They are classi­ fied as typical, atypical, or malignant. CT imaging shows

Salivary Gland Tumors Minor salivary gland tumors and melanoma are the next most common malignancies to affect the sinonasal cavity after SCCA. Minor salivary gland tumors represent a wide variety of histologic types, including adenocarcinoma, adenoid cystic carcinoma, mucoepidermoid carcinoma,

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Esthesioneuroblastoma

Lateral Nasal Wall

ENB is a rare malignant sinonasal tumor thought to arise from the olfactory epithelium8 and usually seen high in the nasal cavity on imaging. ENB falls under a group of sinonasal neoplasms referred to as “small blue cell tumors” because histopathologically they show sheets of small round blue cells with sparse cytoplasm and hyperchro­ matic nuclei with unsuspecting nucleoli. Other “small blue cell tumors” include sinonasal melanoma, lymphoma, sarcoma, and various neuroendocrine tumors. Evaluation of ENBs proves similar to other neoplasm of the anterior skull base requiring imaging evaluation. Imaging studies include a chest X ray to rule out pulmonary disease and a bone scan if symptoms suggest bone metastasis. CT proves helpful to assess bony destruction at the cribriform plate while MRI imaging will better delineate soft tissue intracranial extension. Similar to many other sinonasal malignancies, ENBs have low signal intensity on T2 weigh­ ted MRI images.

Understanding the anatomy of the lateral nasal sidewall with its associated anatomical structures, spaces, and sinus ostia is necessary prior to interpreting preoperative CT scans. Projecting from the lateral nasal sidewall are three conchae or turbinate bones. They are named in ascen­ ding sequential order according to their position on the lateral nasal wall. The turbinates in ascending order from inferior to superior are as follows: the inferior turbinate, middle turbinate, superior turbinate, and if present there is a fourth turbinate termed the supreme turbinate. Below each turbinate is a meatus or space; whereby its name is derived from the turbinate above. Each meatus receives unique drainage from corresponding paranasal sinuses. The nasolacrimal duct empties into the inferior meatus, which sits below the inferior turbinate. Hasner’s valve is the distal opening of the nasolacrimal duct that is covered by a small mucosal flap. The nasolacrimal duct is best identified on axial CT cuts and becomes the most ante­ rior limit of dissection when opening the maxillary sinus. The middle meatus is located lateral to the middle turbi­ nate and is the most complex and utmost important to the endoscopic sinus surgeon. The middle meatus accepts drainage from the frontal, maxillary, and the anterior eth­ moid sinuses. Posteriorly, the superior meatus is below the superior turbinate, which accepts drainage from the posterior ethmoid air cells. The drainage continues medi­ ally into the sphenoethmoidal recess, which also accepts drainage from the sphenoid sinus.

When evaluating a CT preoperatively for ESS, several key anatomical associations need to be assessed. A good grasp of sinonasal anatomy is required; therefore, a general overview of the anatomy will be discussed to present important relationships that should be examined prior to ESS. However, this chapter is not meant to provide a detailed explanation of sinonasal anatomy. Those areas that should be systematically reviewed during surgical plan­ ning include but not limited to: • Lateral nasal wall • Ostiomeatal complex with its associated anatomy • Anterior ethmoid cells • Uncinate process attachment and relationship to lamina • Ethmoid roof height, cribriform plate, and lateral lamella • Maxillary infundibulum and presence of Haller cells

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PREOPERATIVE CHECKLIST FOR SURGERY



• Anterior ethmoid arteries and their relationship to the skull base • Sphenoid sinus and relationship to neurovascular structures • Sphenoethmoidal air cells (Onodi cells) • Frontal recess and the associated frontal air cells • Nasal septum

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and undifferentiated carcinoma. Of these tumors, ade­ noid cystic carcinoma is the most common variety and has three major variant histologic growth patterns of ACC: cribriform, tubular, and solid. Its signal intensity may be high or low on MRI T2 scans, secondary to the degree of tubular or cribriform histologic pattern, as well as cystic spaces, necrosis, and tumor cell density.

Ostiomeatal Unit The ostiomeatal unit (OMU) is a complex anatomic area within the middle meatus, which can be defined as the functional unit of the anterior ethmoid complex, thereby acting as the common drainage pathway of the fron­ tal, anterior ethmoid, and maxillary sinuses.9 The OMU includes the following structures: • Anterior ethmoid cells • Uncinate process

Chapter 48: Surgical Radiology and Image Guidance Surgery • Ethmoid bulla • Maxillary infundibulum • Hiatus semilunaris Obstruction of the OMU is commonly the cornerstone seen in the pathophysiology of chronic rhinosinusitis (CRS), which is best observed on a coronal CT scan. Obstruction may be secondary to inflammation or ana­ tomic variations of the OMU such as paradoxical middle turbinates, concha bullosa, Haller cells, agger nasi cells, or nasal septal deviation. This anatomic relationship is important as ESS specifically addresses the OMU as a functional unit by targeting diseased cells. This enables the return of normal mucociliary drainage within the OMU. The endoscopic surgeon should carefully evaluate the anatomic variations on preoperative imaging within the OMU to address the underlying disease process. The OMU can best be understood by reviewing the coronal CT images prior to ESS.

Anterior Ethmoid Cells The ethmoid air cell system is highly variable and varies across individuals. The middle turbinate has several criti­ cal areas of attachment that further defines the ethmoid air cells. The middle turbinate’s intraethmoidal attach­ ment is commonly called the basal or ground lamella and attaches medially to the lamina papyracea. Posteriorly, the basal lamella curves superiorly and becomes orien­ ted in a coronal plane and divides the ethmoid air cells into an anterior and posterior division. This anatomic barrier between the anterior and posterior air cells is best observed on an axial CT scan. Those air cells in front of the basal lamella are classified as anterior ethmoid air cells and drain into the middle meatus, while the poste­ rior ethmoid sinuses are posterior to the basal lamella and drain into the superior meatus.

Uncinate Process The uncinate process is a sickle-shaped bone that appears as a fold on the lateral nasal sidewall that extends from the inferior turbinate to its anterior–superior attachments at the skull base and lamina papyracea. The superior attachment of the uncinate process has a tremendous amount of variation and is best assessed with CT coronal views, as the location of its attachments has direct conseq­ uence on drainage patterns of the frontal sinus and dic­ tates surgical approach. The uncinate process can also

693

present with pneumatization occluding the infundibulum of the maxillary sinus. The superior attachment of the uncinate process is an important landmark when performing frontal recess surgery. Its superior attachment is highly variable and was originally classified with three distinct attachment sites including the lamina papyracea, skull base, or middle turbi­ nate (Figs. 48.1A to C). A more descriptive classification was described by Landsberg and Friedman who classified the insertion into 6 different categories10: • Types 1 and 2 inserted into the lamina papyracea • Type 3 inserts into both the lamina papyracea and the junction of the middle turbinate with the cribriform plate • Type 4 inserts at both the junction of the middle turbinate and the cribriform plate • Type 5 attaches to the skull base • Type 6 inserts on the middle turbinate  Of these subtypes type 1 and 2 are reported as being the most prevalent at 62.6%.11 Understanding the variations in the superior insertion of the uncinate process will enable the endoscopic sur­ geon to predict where the frontal sinus drainage will be located. When the uncinate process inserts into the lamina papyracea, the ethmoid infundibulum ends as a blind pouch named the recessus terminalis.12 In this instance, the frontal sinus will drain medially into the middle meatus or the suprabullar recess. However, when the uncinate attaches to either the skull base or the middle turbinate, the frontal recess drains into the middle meatus through the ethmoid infundibulum. The uncinate process can be atelectatic and/or inti­ mately opposed to the lamina seen in conditions such as silent sinus syndrome or maxillary hypoplasia (Fig. 48.2A) or pushed medially as a result of nasal polyposis. If this space is not respected, the surgeon may inadvertently enter the orbital cavity. For instance, the distance between the uncinate process and the lamina papyracea can be as narrow as 0.1 mm.13 Likewise, natural congenital dehi­ scence of the lamina is reported to be as high as 10% and should be avoided at the time of surgery. Temporally remote trauma can also cause lamina dehiscence (Fig. 48.2B), which can alter lateral nasal sidewall anatomy, which increases the potential for intraoperative injury while perfor­ming the uncinectomy. Therefore, careful dissec­ tion is required in these instances to prevent lamina penetration. This can be assessed intraoperatively, with external orbital pressure while visualizing the lamina endoscopically.

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Section 9: Surgery for Inflammatory Sinusitis

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C

Figs. 48.1A to C: Coronal computed tomography (CT) scan images in a bone window algorithm showing the three most common superior attachments (arrows heads) of the uncinate process: (A) lamina papyracea, (B) anterior skull base, and (C) the middle turbinate.

Maxillary Infundibulum and Hiatus Semilunaris

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The maxillary infundibulum is a three dimensional space that is bounded by the lamina papyracea laterally, the uncinate process medially, and the ethmoid bulla poste­ riorly. The infundibulum can be likened to a hallway, which collects drainage from the frontal, ethmoid, and the maxillary sinus and subsequently directs the secretions medially to the hiatus semilunaris. The hiatus semilunaris, (exit) is a two dimensional space that is defined by the free edge of the uncinate and the anterior face of the

ethmoid bulla. The hiatus semilunaris can be seen with nasal endoscopy at the most posterior–inferior portion of the uncinate, is difficult to identify on coronal images, and is best seen on sagittal cuts. In contrast, the infundibular space cannot be visualized endoscopically unless the uncinate is removed, which is the first step to surgically access the natural maxillary ostium.

Ethmoid Roof Height Iatrogenic injury to the skull base is a major complication that can occur during ESS. The height of the skull base

Chapter 48: Surgical Radiology and Image Guidance Surgery

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Figs. 48.2A and B: Coronal computed tomography (CT) scan images in a bone window algorithm demonstrating anatomic variations that need to be identified on operative imaging. (A) A left hypoplastic maxillary sinus with associated atelectatic uncinate process draped over the lamina papyracea. This resulted in obstruction of the maxillary sinus outflow and resultant maxillary opacification. (B) Prior maxillofacial trauma to the left orbit caused a dehiscence of the lamina papyracea (arrow heads), thereby altering the lateral nasal sidewall anatomy.

Fig. 48.3: Coronal computed tomography (CT) scan image in a bone window algorithm demonstrating the olfactory cleft and fossae. The length of the lateral lamella of the cribriform plate (LLCP) is depicted in this coronal image as measured according to Keros. Note the relationship of the LLCP with the insertion of the basal lamella of the middle turbinate (MT), as well as the fovea ethmoidalis (FE) laterally. The LLCP is commonly asymmetric, resulting in a deeper right ethmoid fovea as depicted. This asymmetric anatomical variation should be recognized on presurgical planning to prevent iatrogenic cerebrospinal fluid leaks.

can dramatically vary between patients. Evaluating the skull base preoperatively by determining if it is “low” can potentially help prevent this serious complication. Recogniz­ ing the relationship of the cribriform plate, fovea ethmoi­ dalis, and the insertion of the middle turbinate should be assessed on coronal CT preoperative imaging. Histori­ cally skull base height has been assessed with the Keros classification, which helps identify a low cribriform plate. In 1962, Keros classified the olfactory fossa based on how low the cribriform plate sat in relationship to the ethmoid skull base. This relationship between the olfactory fossa and the ethmoid roof was classified into three types,14 such that Keros type I is 1–3 mm deep, type II is 4–7 mm deep, and Keros Type III is ≥ 8 mm deep (Fig. 48.3). The lateral lamella of the cribriform plate (LLCP) extends superiorly from the cribriform plate and arti­ culates with the roof of the ethmoid skull base, which is the medial extension of the frontal bone. The LLCP is the thinnest bone of the skull base and can be easily damaged. Therefore, investigations have tried to quantify the LLCP using CT imaging that has demonstrated signi­ ficant asymmetry with the right LLCP being deeper than the left14-16 with an average depth of 0–3.9 mm.17 This is critical to assess with on preoperative imaging, as the more asymmetric ethmoid roof height—the higher incidence

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Figs. 48.4A and B: Coronal computed tomography (CT) scan in a bone window algorithm at the level of the anterior ethmoid artery (AEA) as it exits through the anterior ethmoidal foramen. (A) A highly pneumatized ethmoid sinus is associated with a low hanging anterior ethmoid artery (arrow head) and should be noted on preoperative imaging to prevent inadvertent injury to the artery. (B) An endoscopic intraoperative visualization of a low AEA (arrow head) just posterior to the frontal recess.

Anterior Ethmoid Artery

Frontal sinus anatomy is formed by the superior pneu­ matization of the anterior ethmoid air cells in the fourth fetal month. A basic knowledge of the structural bound­ aries of the frontal sinus and its outflow tract is required for appreciating the complex anatomy when evaluating preoperative imaging. The frontal bone is composed of horizontal and vertical components, which comprise the orbital roof and forehead respectively. The vertical compo­ nent is variably pneumatized in the majority of people, dividing the sinus into a thicker anterior table and a thinner posterior table.22 The posterior table forms the anterior border of the cranial vault and is adjacent to the

The anterior ethmoid artery (AEA) is a critical structure for the endoscopic sinus surgeon to identify on preopera­ tive imaging. The AEA and posterior ethmoidal arteries (PEA) are terminal branches of the ophthalmic artery that arise from the internal carotid artery. The anterior ethmoidal foramen transmits the AEA and nerve. It is usually found 20–24 mm posterior to the anterior lacrimal crest. In the same sagittal groove at the posterior aspect, the PEA travels through the posterior ethmoidal foramen. The average distance separating the anterior and posterior

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ethmoidal foramen is about 12 mm (range: 10–17 mm).20 The optic foramen is located at an average distance of 12 mm (range: 8–16 mm) distal to the posterior ethmoidal foramen.21 The above distances are important references that serve as important surgical landmarks. The AEA is primarily seen at the skull base, but in well aerated eth­ moid sinuses the AEA is commonly seen within a bony mesentery, several millimeters below the skull base in a coronal plane (Figs. 48.4A and B). When the AEA is within a bony mesentery, the risk of inadvertent injury is increased while operating near the roof of the anterior ethmoid cells. Injury to the artery can result in intraorbital bleeding with increased orbital pressure and loss of vision or intracranial bleeding.

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of iatrogenic injury. The endoscopic surgeon should be aware that injury has been reported to be more common on the side with the lower ethmoid skull base.16 CT images in the coronal plane can provide adequate information about the LLCP and its variations. While the Keros classification is useful in defining the LLCP and olfactory fossa, it is not useful for defining the overall general height of the skull base, which is critical when entering the posterior ethmoids through the basal lamella as inadver­ tent injury can occur. Measuring the height of the skull base from a horizontal midorbital line on a coronal sinus CT image is an objective useful technique to identify a low skull base. Using the maxillary sinus roof intraope­ ratively serves the same purpose, thereby decreasing inadvertent breach into the skull base causing a cerebro­ spinal fluid leak.18 19

Frontal Recess

Chapter 48: Surgical Radiology and Image Guidance Surgery underlying dura. The cribriform plate abuts the frontal sinus posteriorly and represents a critical location for injury during ESS. The nasofrontal outflow tract does not form a true duct but rather an hourglass-shaped space formed by the boundaries of this drainage pathway. General boundaries include the agger nasi cell anteriorly, the middle turbinate medially, the skull base posterior– superiorly, lamina papyracea laterally, and the ethmoid bulla posterior–inferiorly. The agger nasi cell is the first pneumatized cell located immediately anterior and supe­ rior to the attachment of the middle turbinate. The cell is found lateral to the middle turbinate, medial to the lacrimal bone, and posterior to the frontal process of the maxilla. The uncinate process and the agger nasi cell are the two key anatomical landmarks in ESS. The superior attachment of the uncinate process is affected by the pneumatization of the agger nasi cell, with or without involvement of the frontal ethmoidal air cells ultimately affecting the anatomical relationships within the frontal recess.

Frontal Cell Types Understanding the agger nasi cell and its relationship with surrounding anatomical frontal recess anatomy is critical to performing endoscopic frontal sinus surgery. A large pneumatized agger nasi cell can narrow the frontal recess resulting in the uncinate attaching medially onto the middle turbinate. When a frontal ethmoid cell rests immediately superior to the agger nasi cell, this is termed a type one cell or a Kuhn type I frontal cell. When greater than one frontal ethmoid sits atop the agger nasi cell,

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this is termed a Kuhn type II configuration. When there is significant pneumatization of a frontal ethmoid cell and it extends beyond the frontal recess into the frontal sinus, this is termed a Kuhn type III cell. This configuration encroaches into the frontal sinus laterally, thereby narro­ wing the frontal sinus ostium. Another cell that is commonly overlooked is the intersinus septal cell or a medial frontal ethmoidal cell and can be visualized pushing into the frontal recess medially as its name suggests. An air cell that is isolated within the frontal sinus is called a type IV Kuhn cell (Figs. 48.5A to D).

Sphenoid Sinus Evaluating the integrity of the bony walls of the sphenoid sinus, the ethmoid sinus, and the optic nerve for possible dehiscence is a critical aspect of surgical planning. The sphenoid sinus is the most posterior sinus and is surro­ unded by critical neurovascular structures including the pituitary gland, the cavernous sinus, optic nerve, internal carotid artery, maxillary division of the trigeminal nerve, and the vidian nerve. As these neurovascular structures are just beyond the wall of the sphenoid sinus, there is an associated potential risk of severe adverse outcomes if damage to these structures occurs. Therefore, these structures and their relationship to the sphenoid sinus should be carefully evaluated prior to ESS. The sphenoid ostium lies in the sphenoethmoidal recess and can be easily seen medially to the superior turbi­ nate after the inferior one-third of the superior turbinate is removed. The sphenoid sinus ostium is 7 cm posterior at a 30° angle from the nasal spine in adults. The sphenoid

A Figs. 48.5A: Computed tomography (CT) images in a bone window algorithm demonstrating the four types of frontal air cells (Kuhn Classification I–IV): (A) type I cell (I) directly above the agger nasi cell (*).

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B

C

ostium can also be localized by measuring 1–1.5 cm above the superior aspect of the posterior choana between the nasal septum and the superior turbinate.

The roof of the sphenoid sinus is termed the planum sphenoidale and is posterior to the cribriform plate, a thicker contiguous flat bone that serves as an important

D

Figs. 48.5B to D: Computed tomography (CT) images in a bone window algorithm demonstrating the four types of frontal air cells (Kuhn Classification I–IV): (B) type II cell (II) that is above both the agger nasi cell (*) and type I cell, (C) type III Kuhn cell (III), the coronal and sagittal CT imaging shows a left Kuhn type III frontal air cell that is above the agger nasi cell (*) and extends into the frontal sinus. (D) Type IV Kuhn cell (IV), isolated within the left frontal sinus.

Chapter 48: Surgical Radiology and Image Guidance Surgery

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B

Figs. 48.6A and B: Coronal and axial computed tomography (CT) images in a bone window algorithm at the level of the sphenoid sinus. (A) In this cut, the bony impressions of the carotid artery (C) and optic nerve (ON) and the opticocarotid recess (*) are visible. The vidian nerve (VN) and the maxillary division of the trigeminal nerve (V2) can be seen inferior and laterally. (B) An example of the opticocarotid recess (*) and the bony protrusions of the carotid artery (C) and optic nerve (ON) seen intraoperatively using a zero degree endoscopic.

landmark for the sphenoid sinus and the optic nerve. It is bordered posteriorly by the optic chiasm and the superior aspect of the sella or the diaphragma sellae also known as the sellar diaphragm. Anteriorly it articulates with the planum ethmoidale. The junction of the sella and planum sphenoidale is called the tuberculum sellae. The postero­ lateral wall of the sphenoid sinus is made up of the lesser wing of the sphenoid. The lesser wing of sphenoid forms the anterior clinoid process, marking the location of the optic nerve superiorly and supracavernous internal carotid artery inferiorly. The pituitary gland is housed within the sella turcica. Sphenoid sinus pneumatization can be classified into presellar, sellar, and postseller types and is best visualized with sagittal CT images. Pneumatization does not extend past a vertical plane posterior to the anterior clinoid pro­ cess, in the presellar type. The sellar classification is associated with a well-pneumatized sphenoid, allowing straightforward surgical access to the sella turcica. In the conchal type, the sella is surrounded by bone, making surgical access to the pituitary more difficult. In a wellpneumatized sphenoid sinus, the floor of the sella turcica can be easily visualized medial to the bony prominences of the carotid and optic nerve. The carotid and optic protuberances can be seen on the lateral nasal sidewall of the sphenoid sinus (Figs. 48.6A and B). The recess between the bony prominences of the optic and carotid artery is termed the opticocarotid recess. The vidian nerve is located in at the floor of the

sphenoid sinus in an inferior–lateral position, and can be in a bony mesentery in highly pneumatized sphenoid. This is easily visualized on coronal imaging and should be noted if dissecting inferiorly while performing the sphenoidotomy. Just medial to the vidian is the palatovaginal canal also called the pharyngeal canal. It transmits the pharyngeal artery and nerve. Lateral to the sphenoid sinus and sella turcica is the cavernous sinus. The cavernous sinus con­ tains vital neurovascular structures: oculomotor nerve (CN III), trochlear nerve (CN IV), two branches of the trigeminal nerve (CNV), the ophthalmic nerve (CN V1), the maxillary nerve (CNV2), and the abducens nerve (VI) that runs alongside the internal carotid artery. Dehiscence of the neurovascular structures can be easily assessed on both axial and coronal CT views. The prevalence of carotid dehiscence ranges from 1.5% to 25%, while optic nerve dehiscence ranges from 3.6% to 12.5%.23-25 The sphenoid intersinus septum separates the left and right sphenoid sinus, has varied attachments, and can be pneumatized. It is critical to determine if the sphenoid intersinus septum attaches to either the carotid bony canal or the bony canal of the optic nerve. The sphenoid intersinus septum has been reported to insert onto the carotid canal in 37.5% of cases, and directly onto the optic nerve canal in 30.5% of cases.25 This anatomical knowledge is critical to prevent inadvertent injury to these vital structures, which is best analyzed with a detailed preoperative analysis of both coronal and axial CT views.

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Section 9: Surgery for Inflammatory Sinusitis

Fig. 48.7: Coronal computed tomography (CT) scan image in a bone window algorithm showing right sphenoethmoidal air cells (Onodi cells; O), which can be seen superior and lateral to the sphenoid sinus (S). The optic nerve and carotid artery are seen as bony protrusions in the sphenoethmoidal air cells, rather than along the lateral wall of the left sphenoid sinus.

Fig. 48.8: Coronal computed tomography (CT) scan image in a bone window algorithm showing bilateral pneumatization in the head of the middle turbinates (*) also called concha bullosa. Infra­ orbital ethmoid air cells (Haller cells) are seen as pneumatized air cells off the inferior orbital floor (arrow head).

Sphenoethmoidal Air Cells (Onodi Cells)

and can be involved in the pathophysiology sinus disease. Large concha bullosa function as large “balloons” in the middle meatus obstructing normal mucociliary drainage. The amount and location of the pneumatization varies with the most common location being the head of the middle turbinate (Fig. 48.8). This anatomic variation can easily be seen on both coronal and axial views and should be addressed during surgery.

The posterior most ethmoid air cell’s relationship to the sphenoid sinus needs to be critically assessed as this cell can extend superiorly, posterior and laterally, thereby resulting in an intimate relationship with the optic nerve and carotid artery at its lateral wall. This anatomic variation was commonly designated as an Onodi cell, but is now more commonly referred to as a sphenoethmoidal cell that accurately reflects the anatomical position of this air cell. Especially perilous is when the optic nerve has no bony shell and is exposed within the Onodi cell; thereby increasing risk of injury. Onodi cells are present in 9% to 47.9%26 of patients. This cell should be localized and opened intraoperatively to locate and define the posterior skull base during ESS. The sphenoethmoidal cell is best visualized on the coronal CT views, giving the appearance of a horizontal split of the sphenoid sinus. The angle at which the sphenoid sinus should be entered is also appreciated on sagittal reconstruction. However, all three views (coronal, sagittal and axial) should be reviewed to clarify that the origin of the cell is from the posterior ethmoids, rather than the sphenoid sinus that is medial and inferior (Fig. 48.7).

Concha Bullosa Zuckerkandl coined the term concha bullosa when pneumatization of the middle turbinate was present. Pneu­ matization of the middle turbinate can narrow the OMC

Infraorbital Recess Cells (Haller Cells) Infraorbital ethmoid air cells (Haller cells) are seen as pneumatized air cells that grow out of the inferior orbital floor at the roof of the maxillary sinus (Fig. 48.8). Infraorbital ethmoid cells are seen as distinctive air cells separate from the anterior ethmoid bulla. These cells are important to identify as they have the potential to narrow the ethmoid infundibulum and/or maxillary sinus infundibulum. The coronal CT is the best view for diagnosing these air cells.

Nasal Septal Deviation Although commonly overlooked, it is important to assess the nasal septum prior to sinus surgery. Significant nasal septal deviation and septal spurs can prevent access to the sinuses during ESS. Surgical planning can be improved by using CT coronal and axial views of the nasal sep­ tum in conjunction with nasal endoscopy. In certain circumstances the septum may need to be addressed with

Chapter 48: Surgical Radiology and Image Guidance Surgery functional rhinoplasty due to severe septal deviation, very anterior caudal deflection, or dynamic valve collapse that can be addressed with concurrent ESS.

IMAGE GUIDANCE IN ENDOSCOPIC SINUS AND SKULL BASE SURGERY History of Image Guidance Image guidance has been referred to over the years by many terms: image-guided surgery (IGS), computer aided surgery, or surgical navigation. It began in the field of stereotactic intracranial surgery in the early 1900s with the development of a stereotactic apparatus for neuro­ surgical navigation. With the refinement of stereotactic frames in the 1950s, stereotactic surgery was being perfor­ med throughout the world, principally in perfor­ ming thalamotomies for movement disorders. With the develop­ ment of improved medical therapies, thalamotomies and stereotactic image guidance fell into disuse. CT’s emer­ gence in the 1970s and 1980s revived interest in stereo­ tactic techniques. Software development in the 1980s combined CT data and stereotactic surgery, resulting in three-dimensional surgical targeting. In the early 1990s, the development of frameless stereotactic systems allowed probes and instruments to be tracked during procedures with the first such systems, developed for neurosurgery, used mechanical arms. During this same period, interest in functional ESS exploded throughout the world. Naturally, the trajectories of ESS and IGS intersected. The initial experiments using IGS in the field of rhinology were performed by a group of surgeons in Aachen, Germany in the late 1980s using a passive articulated arm.27 The Aachen group subsequently published their experience using this technology, finding that IGS was useful for intraoperative orientation and suggesting a 2% reduction in complication rate could be expected.28 At about the same time Anon et al. pub­ lished their report of computer-assisted ESS using this articulated arm, known as the Viewing Wand (ISG Technologies, Mississauga, Ontario, Canada).29 The armbased Viewing Wand had a detachable probe attached to its multiarticulated mechanical arm linked to an intra­ operative computer with a high-resolution monitor. These authors found the IGS accuracy to be in the range of 2 mm and concluded the technology was generally useful. In 1995, Roth et al. added their experience with IGS using the Viewing Wand in 12 cases and found similar accu­ racy.30 Importantly, they articulated several important

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deficiencies and outlined five goals that needed to be set in order for future systems to be adopted widely: (1) accuracy within 2–3 mm should be maintained, (2) the requirement for a second CT should be eliminated, (3) the computer should update for head movement, (4) suctions and dissection instruments should be tracked, and (5) the device must be easily operated by the surgeon in order to eliminate the technician. By the late 1990s, these goals had been reached through further advances in technology and clinical application and are minimum requirements for modern systems.

The Technological Basis of Image-Guided Surgery At its core, IGS matches a large data set of radiologic spa­tial points—a patient’s virtual anatomy—to the actual anatomy involved in a particular procedure. This alignment of the virtual anatomy and actual anatomy allows the sur­ geon to track an instrument’s position in real-time rela­ tive to tri-planar imaging or three-dimensional formatted reconstruction. All IGS systems incorporate a computer that is used to store the dataset, image processing software, a localization system, specialized instrumentation, and a monitor to display the radiographic images and the position of the tracked instrument. Early systems used arrays that were fixed in space, usually to the operating table, as a reference points. This setup then required the patient’s head to be fixed to the table as well. These systems were quickly replaced by systems that used reference points on arrays that were attached to the patient’s head, allowing the patient’s head to move in space during the procedure while maintaining accurate navigation. Navigating within the sinuses has also evolved. As men­tioned above, the earliest systems used an articulated arm to localize the tip of the probe in space. Using tech­ nology analogous to proprioception, the arm was fixed to the operating table, as was the patient’s head. The next generation of devices used optical imaging to determine the location of the patient and instruments in space. Infrared light emitting arrays attached to the patient’s head and to instruments were localized by an infrared sensing camera. These active tracking systems were sub­ sequently complemented with passive tracking systems, where the light was emitted and tracked by the same overhead device. Reflective materials were placed on the instruments and reference arrays in order to provide track­ ing, eliminating the cords, or batteries that the active

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Practical Uses for Image-Guided Surgery

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IGS is a powerful tool for confirming anatomic points during sinus and skull base surgery. By its nature, endo­ scopic surgery relies on no external landmarks. ESS entails a surgical dissection in an area surrounded by the orbit and brain, leaving little tolerance for positional error. Moreover, there are a limited number of anatomic land­ marks available, some of which may be altered or des­ troyed by disease or previous surgery. While IGS can be a tremendous asset in ESS, like any powerful tool it can be misused, with potentially disastrous consequences. The major danger of this technology is the potential for over reliance. An accuracy of 1–2 mm in a surgical volume of hundreds of cubic centimeters is an entirely impressive accomplishment of engineering. Never­ theless, 1–2 mm is a large distance compared to the thick­ ness of the LLCP, the lamina papyracea, or the thin bone covering the optic nerve. Additionally, 1–2 mm accuracy is a best case scenario. IGS is a tool best used when complementing the surgeon’s skill and knowledge, not as an attempt to replace them. Image guidance must always be utilized as an anatomy confirming device, not an anatomy seeking device.34 Image guidance is an expensive technology and must therefore be used in appropriate situations, where it is most likely to benefit the patient. Each surgeon’s skill set will vary, as will the clinical situation of his/her patient. Overall, IGS is felt to be most valuable in cases where the anatomy is unusual or is particularly complex. Indica­ tions for use have been promulgated by the American Academy of Otolaryngology—Head and Neck Surgery (AAO HNS) for over a decade and have remained constant: -



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The matching of the patient’s anatomy to the radiologic dataset requires matching known points, a process known as registration. Registration is a stepwise process of mov­ ing from known points in three dimensional space to unknown points. In early systems, registration was a com­ plex and not entirely intuitive process. Along with the advances in technology over the last 25 years, there have been similar advances in the “user friendliness” of these devices so that registration is brief and intuitive. There are essentially two registration strategies. One is to use a small number of fixed points, either anatomic points (canthi, tragus, rhinion, etc.) or to use skin or even bone anchored fiducials that are placed prior to the CT scan. Skin and bone anchored fiducials are impractical for a number of reasons, not the least of which is that they necessitate an additional scan; therefore, are rarely used in rhinologic applications. Anatomic fiducial registration requires selecting known points on the radiographic images and then correlating the patient’s anatomy to these same points. The second strategy for registration, more commonly used today, is surface mapping registration. In this app­ roach, hundreds of points are acquired from the patient’s face, forming a virtual mask. The patient’s facial surface mask is then fitted to another virtual mask created from the radiologic images, thus registering the patient to the radiologic images. In both approaches, exactness in registration is critical in order to navigate accurately throughout the proce­ dure. Accuracy of IGS is dependent on multiple factors



The Registration Process



including, quality of the dataset, stability of the fiducial points, number of fiducial points used during registration, and the three dimensional spacing of the fiducial points around the target area.31 Using points distributed through­ out the surgical volume and along all three axes is criti­ cal in order to match the virtual and actual anatomy most accurately. Investigations evaluating the accuracy have found these systems to be within 2 mm with a mean degradation of 0.89 mm during the procedure.32 While registration is typically quick and accurate, the accuracy should be routinely checked during the surgical case.33 The most common source of inaccuracy is movement of the reference array during the procedure. It is easy to appreciate how just 1 mm of array movement can have important consequences for navigation accuracy at the skull base. -

systems required. One drawback of the optical systems is that the line of sight between the instrument array and the detection camera must remain intact. This charac­ teristic makes it impossible to track instruments that may move within the sinuses, such as bendable catheters and other devices. In addition to optical systems, electromagnetic sys­ tems have been developed since the 1990s. These systems consist of an emitter and a detector that respond to chan­ ges in an electromagnetic field. By attaching emitters to instruments with known geometry, the location of the tip of a rigid instrument can be determined. As emitters become miniaturized, there is an increasing opportunity to place them into the tips of the instruments them­ selves. This advance allows the tracking of deformable instruments within the sinuses.

Chapter 48: Surgical Radiology and Image Guidance Surgery “The AAO—HNS endorses the intraoperative use of computer-aided surgery in appropriately select cases to assist the surgeon in clarifying complex anatomy during sinus and skull base surgery. There is sufficient expert consensus opinion and literature evidence base to sup­ port this position. This technology is used at the discre­ tion of the operating surgeon and is not experimental or investigational. Furthermore, the AAO—HNS is of the opinion that it is impossible to corroborate this with Level 1 evidence. These appropriate, specialty specific and surgically indicated procedural services should be reimbursed whether used by neurosurgeons or other qua­ lified physicians regardless of the specialty. Examples of indications in which use of computer-aided surgery may be deemed appropriate include: 1. Revision sinus surgery 2. Distorted anatomy of development, postoperative or traumatic origin 3. Extensive sinonasal polyposis 4. Pathology involving the frontal, posterior ethmoid, and sphenoid sinuses 5. Disease abutting the skull base, orbit, optic nerve, or carotid artery 6. CSF rhinorrhea or conditions where there is a skull base defect 7. Benign and malignant sinonasal neoplasms.”34a As endoscopic skull base techniques have advanced beyond the sinuses into the orbit, pterygopalatine fossa, infratemporal fossa, and intracranially, IGS has played a critical role in fostering these minimally invasive advances. Undoubtedly, IGS is a valuable adjunct in endo­ scopic anterior skull base procedures extending beyond the sinuses.

Clinical Evidence for Image-Guided Surgery The cost–benefit relationship of IGS has been a subject of interest nearly since its introduction in rhinology. Many substantial benefits can result from the use of image guidance in endoscopic sinus and skull base surgery. Rapid and accurate confirmation of the patient’s anatomy may shorten surgery time, provide more thorough dis­ section within the sinuses, and potentially decrease com­ plications from dissection beyond the surgical field. These potential benefits must be balanced by real and potential drawbacks. IGS systems are major capital expenditures and these expenses will naturally be passed on to patients.

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Gibbons et al. reviewed their experience before and after the availability of image guidance at the University of Alabama.35 In their retrospective analysis, they found the times of surgery for these two groups were, in fact, not different. They did, however, find a small (2.6%) increase in charges for patients who underwent image guidance. Third party payer reimbursement for these charges can vary so that the true economic impact of image guidance is difficult to assess. While there are potential benefits to offset these costs, the actual benefit of IGS has been difficult to fully assess. Complications in ESS are fortunately rare.36 This infrequency makes demonstrating a reduction in the complication rate difficult, requiring large numbers of subjects in a clinical trial. Moreover, most experts would feel uncomfortable randomizing patients prospectively to an arm of a study where IGS was not used in cases where it would be otherwise indicated. For this reason, a prospective randomized trial of IGS will likely never be performed.37 Nevertheless, more recent larger scale analyses have drawn some firmer, though conflicting, conclusions. A recent systematic review and meta-analysis found that major and minor complications were more common in the non-IGS group.38 In contrast, another meta-analysis found no reduction in complications or need for revision surgery with the use of IGS.39 Taken as a whole the cumu­ lative literature suggests that IGS has not been shown to decrease surgical complications or improve surgical outcomes. These evidence-based recommendations are based on limited literature with suboptimal research methodology. However, the utility and acceptance of IGS in ESS via expert opinion is supported by the available literature. Therefore in summary, the use of IGS in ESS is an option and should be based on clinical judgment and applied on a case-by-case basis.36

Recent and Future Advances IGS continues to play an important role in sinus and anterior skull base surgery. The technology has evolved significantly over the last two decades in rhinology. In parallel, IGS has become routinely available as part of the endoscopic sinus surgeons’ armamentarium.40-41 While preoperative CT images are most commonly used, pre­ operative MRI images may be used as well, or even fused with the CT images. This technologic advance is espe­ cially useful for skull base neoplasm resections. Moreover,

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1. Kim KS, Kim HU, Chung IH, et al. Surgical anatomy of the nasofrontal duct: anatomical and computed tomographic analysis. Laryngoscope. 2001;111(4 Pt 1):603 8. 2. Kanowitz SJ, Shatzkes DR, Pramanik BK, et al. Utility of sagittal reformatted computerized tomographic images in the evaluation of the frontal sinus outflow tract. Am J Rhinol. 2005;19(2):159 65. 3. Jain SA, Manchio JV, Weinzweig J. Role of the sagittal view of computed tomography in evaluation of the naso­ frontal ducts in frontal sinus fractures. J Craniofac Surg. 2010;21(6):1670 3. 4. Hilger AW, Ingels K, Joosten F. Sagittal computerized tomography reconstruction of the lateral nasal wall for functional endoscopic sinus surgery. Clin Otolaryngol Allied Sci. 1999;24(6):527 30. 5. Hagtvedt T, Aalokken TM, Notthellen J, et al. A new low dose CT examination compared with standard dose CT in the diagnosis of acute sinusitis. Eur Radiol. 2003;13(5):976 80. 6. Bailey BJ, Johnson JT, Newlands SD. Head & neck surgery otolaryngology, 4th edition. Philadelphia: Lippincott Williams & Wilkins; 2006. 2 v. p. 7. Stern SJ, Goepfert H, Clayman G, et al. Squamous cell carcinoma of the maxillary sinus. Arch Otolaryngol Head Neck Surg. 1993;119(9):964 9. 8. Jethanamest D, Morris LG, Sikora AG, et al. Esthesioneu­ roblastoma: a population based analysis of survival and prognostic factors. Arch Otolaryngol Head Neck Surg. 2007;133(3):276 80. 9. Stammberger HR, Kennedy DW. Paranasal sinuses: anatomic terminology and nomenclature. Ann Otol Rhinol Laryngol Suppl. 1995;167:7 16. 10. Landsberg R, Friedman M. A computer assisted anatomical study of the nasofrontal region. Laryngoscope. 2001;111(12):2125 30. 11. Ercan I, Cakir BO, Sayin I, et al. Relationship between the superior attachment type of uncinate process and presence of agger nasi cell: a computer assisted anatomic study. Otolaryngol Head Neck Surg. 2006;134(6):1010 4. 12. Kennedy DW, Senior BA. Endoscopic sinus surgery. A review. Otolaryngol Clin North Am. 1997;30(3):313 30. 13. Awad Z, Bhattacharyya M, Jayaraj SM. Anatomical margins of uncinectomy in endoscopic sinus surgery. Int J Surg. 2013;11(2):188 90. 14. Keros P. [On the practical value of differences in the level of the lamina cribrosa of the ethmoid]. Z Laryngol Rhinol Otol. 1962;41:809 13.





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intraoperative CT and MRI acquisition can be utilized to update the dataset. Early experience with these techno­ logies appears to demonstrate a significant potential to impact outcomes.42 43

Chapter 48: Surgical Radiology and Image Guidance Surgery 32. Metson R, Gliklich RE, Cosenza M. A comparison of image guidance systems for sinus surgery. Laryngoscope. 1998;108(8 Pt 1):1164-70. 33. Metson R, Gray ST. Image-guided sinus surgery: practical considerations. Otolaryngol Clin North Am. 2005;38(3): 527-34. 34. Kingdom TT, Orlandi RR. Image-guided surgery of the sinuses: current technology and applications. Otolaryngol Clin North Am. 2004;37(2):381-400. 34a. http://www.entnet.org/Practicepolicy Intra Operative Surgery. cfm. Accessed October 7, 2013. 35. Gibbons MD, Gunn CG, Niwas S, et al. Cost analysis of computer-aided endoscopic sinus surgery. Am J Rhinol. 2001;15(2):71-5. 36. Ramakrishnan VR, Orlandi RR, Citardi MJ, et al. The use of image-guided surgery in endoscopic sinus surgery: an evidence-based review with recommendations. Int Forum Allergy Rhinol. 2013;3(3):236-41. 37. Smith TL, Stewart MG, Orlandi RR, et al. Indications for image-guided sinus surgery: the current evidence. Am J Rhinol. 2007;21(1):80-3.

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38. Dalgorf DM, Sacks R, Wormald PJ, et al. Image-guided surgery influences perioperative morbidity from endo­ scopic sinus surgery: a systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2013;149(1):17-29. 39. Sunkaraneni VS, Yeh D, Qian H, et al. Computer or not? Use of image guidance during endoscopic sinus surgery for chronic rhinosinusitis at St Paul’s Hospital, Vancouver, and meta-analysis. J Laryngol Otol. 2013;127(4):368-77. 40. Chiu AG, Vaughan WC. Revision endoscopic frontal sinus surgery with surgical navigation. Otolaryngol Head Neck Surg. 2004;130(3):312-8. 41. Justice JM, Orlandi RR. An update on attitudes and use of image-guided surgery. Int Forum Allergy Rhinol. 2012;2(2):155-9. 42. Jackman AH, Palmer JN, Chiu AG, et al. Use of intraoperative CT scanning in endoscopic sinus surgery: a preliminary report. Am J Rhinol. 2008;22(2):170-4. 43. Batra PS, Kanowitz SJ, Citardi MJ. Clinical utility of intraoperative volume computed tomography scanner for endoscopic sinonasal and skull base procedures. Am J Rhinol. 2008;22(5):511-5.

CHAPTER Primary Endoscopic Sinus Surgery for Chronic Rhinosinusitis

49

Bozena B Wrobel, Dale H Rice Although Hirschmann first used a modified cystoscope in 1901 to examine the nasal cavity,1 it was not until the advent of the rod lens endoscope by Harold Hopkins in the 1960s that the modern era of endoscopic sinus surgery (ESS) began.2 The other major advances that allowed for the development of ESS included refinements in compu­ ted tomography, seminal research in sinonasal physio­ logy, and the development of modern instrumentation. This chapter covers the principles and techniques of pri­ mary ESS. Chronic rhinosinusitis (CRS) is a common though poorly defined disease which is difficult to treat. As Poul Anderson said, “I have yet to see any problem, how­ ever complicated, which, when you look at it the in right way, did not become still more complicated.” Suggested possible causes of CRS include repeated acute infections, allergic inflammation, nonallergic inflammation, anatomic variance, ciliary dysfunction, superantigens, fungi, and a variety of immune factors. The basis of ESS is the assumption that obstruction of the paranasal sinus outflow tracts, including in the middle meatus area of the anterior ethmoid sinuses, secondarily block the maxillary, frontal and posterior ethmoid sinuses. The second assumption is that relief of this obstruction, particularly in the middle meatus, will allow improved physiology of the other paranasal sinuses and thus return to normal function. It is assumed in the vast majority of cases that the mucosal disease itself is reversible. A more modern concept is that one of the primary benefits of ESS is the creation of widely patent outflow tracts that allow for delivery of topical therapy in the postoperative setting. Although sinus disease is complicated in terms of its polymicrobial bacteriology, multiple possible causes of

chronic inflammation, and numerous possible anatomic variations, there are two basic approaches based on two basic types of chronic disease: classic ostiomeatal complex disease and pansinusitis.

CLASSIC OSTIOMEATAL COMPLEX DISEASE The classic ostiomeatal complex disease involves the anterior ethmoid sinuses, often the maxillary sinus and less fre­ quently the frontal sinus. Generally, the posterior ethmoid and sphenoid sinuses are spared. While surgery can be done under local or general anesthesia, most commonly, in this country, general anesthesia is used. The authors prefer the use of laryngeal mask anesthesia over intuba­ tion. This largely reduces the frequent sore throat patients have from intubation, potential for laryngeal trauma and the risk of the patient bucking on the tube with associated bleeding at the end of the procedure. Prior to starting the procedure, the CT scan should be carefully reviewed including disease pattern and surgical anatomy. A preoperative checklist of normal and variant sinonasal anatomy is reviewed including the integrity of the lamina papyracea and skull base, the thickness and slope of the ethmoid roof, depth of the cribriform plate, location and possible dehiscence of the anterior ethmoidal and internal carotid arteries, and common anatomic variants (i.e. infraorbital and sphenoethmoid cells). Careful consideration is given to performance of nasal septoplasty. Indications include relieving nasal airway obstruction symptoms, and improving access both during the surgery and for postoperative care. Local anesthesia is

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Figs. 49.1A and B: Sinus seeker behind uncinate process.

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the uncinate process may be lateralized and adherent to the orbit. In these patients, a retrograde uncinectomy is preferable. This is performed by gentle anterior deflection of the uncinate process by a ball tipped seeker followed by resection with a side biting forceps in a posterior to anterior direction (Figs. 49.2 and 49.3). The next step following uncinectomy is to visualize the natural ostium of the maxillary sinus that lies posterior to the uncinate but anterior to the bulla ethmoidalis. The ostium lies within the hiatus semilunaris in proximity to the bulla. This may be seen with a 0° endoscope (Figs. 49.4A and B) but often a 30° (Figs. 49.5A and B) or 45° endoscope will be necessary. If the ostium cannot be visualized, one can palpate the fontanel area just superior to the inferior turbinate with a curved olive tip suction or ball tipped seeker. The maxillary sinus ostium may be enlarged, particularly if work needs to be done within the maxillary sinus cavity. The ostium can be enlarged anteriorly using backbiting forceps. One should be careful to not go more anterior then the attachment of the uncinate process as you risk injuring the nasolacrimal duct that lies about 1 cm anterior. The ostium can also be enlarged posteriorly using thru cutting forceps.3 The posterior dissection is quite safe. There is no clear consensus as to the ideal size of the maxillary ostium, but 1 cm should be adequate. For many years, the senior author has done nothing to the maxillary ostium, regardless of size, if it can be easily visualized following the uncinectomy and no work needs to be done within the sinus. However, it is important that the natural maxillary ostium be identified and included in this antrostomy to avoid the risk of mucus recirculation. For the same reason, should one identify an accessory -

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administered at the onset of ESS. One percent xylocaine with 1:100,000 of epinephrine is infiltrated into the sub­ mucosal plane of key areas including the nasal septum, the middle turbinate, the sphenopalatine foramen, and the lateral nasal wall in the area of the uncinate process. A greater palatine block may also be performed transorally in patients with severe polyposis. Decongestant (i.e. oxy­ metazoline, or xylocaine with epinephrine) soaked pled­ gets are then placed into the middle meatus and between the septum and the lateral wall, anterior to the middle turbi­ nate. At least 5 minutes is allowed to elapse. During this time, the medications have time to take effect and the rise in blood pressure caused by the epinephrine injection will have subsided. It is preferable to have hypotensive anes­ thesia throughout the procedure. ESS is started by inspecting the entire nasal cavity with a 0° endoscope. Assuming relatively normal anatomy, the procedure is started by removing the uncinate process. This can be done in a variety of ways. One common method is to make an incision at the base of the uncinate process with a sickle knife, Freer or Cottle elevator. The uncinate is then medialized and removed with straight Blakesley forceps. Others prefer to use a ball tipped seeker (Figs. 49.1A and B) to fracture the uncinate anteriorly and then remove it with a microdebrider. Regardless of the method used, one needs to ensure a complete resection of the entire width and height of the uncinate process. Care additionally needs to be given to avoid over resection as the base of the uncinate is quite close to orbital contents. The width of the uncinate is approximately 5 mm. Proximity to the orbit is a particularly important consideration in patients with maxillary sinus atelectasis and hypoplasia where

Chapter 49: Primary Endoscopic Sinus Surgery for Chronic Rhinosinusitis

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Figs. 49.2A and B: Pediatric backbiter resecting uncinated process.

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Figs. 49.3A and B: Completing the resection of the uncinated process.

A Figs. 49.4A and B: Maxillary ostium viewed with a 0° endoscope.

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Section 9: Surgery for Inflammatory Sinusitis

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Figs. 49.5A and B: Maxillary ostium viewed with a 30° endoscope.

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Figs. 49.6A and B: Resection of bulla ethmoidalis with microdebrider.

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clearance of polypoid tissue, mucosa and thin bone. The lack of mucosal stripping, active suctioning of blood and consistently sharp cutting surface are distinct advantages. Although the impact on the incidence of major complica­ tions is unknown, it is clear that the severity of the injury is greater with powered instrumentation. Therefore, care is given to maintain excellent visualization of the cutting blade and avoid apposition directly againstcritical areas including the skull base and orbit. The microdebrider can safely remove tissue freely accessible within the sinus, such as tissue curreted from the underlying bone. The limited ability to provide anatomic localization from the specimen collected from a microdebrider trap becomes an important issue in patients with occult neoplasm ­

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ostium posterior to the natural ostium, the two should be converted into one by removing the intervening mucosal bridge. The next step is to complete the anterior ethmoidec­ tomy by opening the bulla ethmoidalis and removing it (Figs. 49.6A and B) and all other anterior ethmoid air cells (Figs. 49.7A and B) to the level of the basal lamella. Throughout this chapter, straight and upbiting thru cut­ ting and Blakesely forceps will be mentioned frequently. In most of these instances, the procedure being discussed could be performed with a microdebrider as well. A lengthy discussion of the advantages and disadvantages of powered instrumentation is beyond the scope of this chapter. In brief, microdebriders allow for efficient

Chapter 49: Primary Endoscopic Sinus Surgery for Chronic Rhinosinusitis

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Figs. 49.7A and B: Completing anterior ethmoidectomy.

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Figs. 49.8A and B: Frontal recess area.

in the setting of chronic inflammation. It is therefore impor­ tant to separate the contents of the two sides in bilateral procedures that are captured in specimen containers from the powered devices. Routine analysis of specimens obtained with cold instrumentation and distinctly identi­ fied anatomic sites addresses this issue. Powered instru­ ments are nearly essential for advanced endoscopic procedures including skull base surgery, frontal sinus drill-out procedures and endoscopic DCRs. If the frontal sinus is normal on the preoperative CT scan, no dissection in the frontal recess area is necessary and might in fact prove harmful. On the other hand, if the sinus is diseased, the frontal recess area must be cleared of obstructing ethmoid air cells. If this is known and

planned from the beginning, this maneuver may be done following the uncinectomy but prior to removing the bulla ethmoidalis. This is because the frontal sinus generally physiologically clears between these two structures and can be easily located by following the bulla ethmoidalis superiorly to the area posterior to the anterior-superior attachment of the middle turbinate. The area is best visualized with 45° and 70° endoscopes (Figs. 49.8A and B). The ethmoid cells in the frontal recess area should be removed with 45° and 70° instrumentation until the frontal sinus ostium can be easily visualized (Figs. 49.9A and B). A variety of instruments are available including front-back, side-side cutting forceps, angled mushroom forceps, and angled curettes. Bear in mind that the ostium is close to

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Section 9: Surgery for Inflammatory Sinusitis

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Figs. 49.9A and B: Frontal sinus ostium.

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Figs. 49.10A and B: Incision in concha bullosa.





allow for excellent space for sinus physiology and access for postoperative care. Some surgeons do this routinely, paradoxically bent or not. A concha bullosa may be managed by making an incision into the anterior head of the middle turbinate with a sickle knife (Figs. 49.10A and B). One can then use straight cutting middle turbinate scissors to make an incision along the inferior edge of the middle turbinate and then an incision along the superior part of the lateral wall of the concha bullosa below the superior attachment. The lateral wall can then be grasped with cutting instru­ mentation and removed.6 This will greatly widen the middle meatus (Figs. 49.11A and B). Care must be taken when doing this maneuver to not destabilize the mid­ dle turbinate, which will significantly increase the risk of

the back wall of the frontal sinus and just posterior to that is the anterior ethmoidal artery and the anterior cranial fossa. Therefore, the trajectory of movements should be mostly in a posterior to anterior trajectory. In standard uncomplicated ostiomeatal complex disease, the procedure would now be complete. In general, the middle turbinate is left undisturbed if it is in a position and anatomic configuration to allow for outflow tract patency. However, if there is a paradoxically bent middle turbinate or a concha bullosa within the middle turbinate, additional procedures are probably warranted.4,5 The paradoxically bent middle turbinate (convex laterally) is best managed by removing the bottom two thirds of the turbinate back to the basal lamella. This will completely uncover the ostiomeatal complex and

Chapter 49: Primary Endoscopic Sinus Surgery for Chronic Rhinosinusitis

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Figs. 49.11A and B: Widened middle meatus following resection of lateral wall of concha bullosa.

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Figs. 49.12A and B: Perforating basal lamella.

adhesions to the lateral wall. A few technical points are in order. It is probably safest to remove the uncinate process and the anterior ethmoid air cells with straight biting forceps or a microdebrider. The bulla ethmoidalis should be first opened medially close to the middle turbinate. The straight biting forceps should be held vertically so that the articulating jaw does not point toward the lamina papyracea. The natural drainage pathways of the anterior ethmoid air cells are medial. The anterior tip of the middle turbinate may also be resected when there is polypoid degeneration of the mucosa, which can lead to difficult visualization postoperatively. The extent of ethmoidectomy that should be per­ formed in patients with limited ethmoid disease is not well defined. Potential advantages of performing a total

ethmoidectomy in patients with disease limited to the anterior ethmoid sinuses include maximizing patency and the theoretical principle of extending the surgery one level beyond the disease. Disadvantages include potentially disrupting healthy sinonasal function, exposure of the patient to unnecessary risk from additional surgical dissection and propagating spread of the infection. However, if the patient has posterior ethmoid disease then a complete ethmoidectomy is clearly in order. One should remember that the sphenoid ostium and the maxillary ostium are on approximately the same axial plane. So the basal lamella should be perforated with a straight biting forceps on the same axial plane as the maxillary ostium and close to the middle turbinate attachment to the basal lamella (Figs. 49.12A and B). The posterior ethmoid air

Section 9: Surgery for Inflammatory Sinusitis



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either by identifying the natural sphenoid ostium in the sphenoethmoid recess and extending it laterally or by opening the anterior face of the sphenoid sinus in the posterior most ethmoid cell. The natural ostium is gene­ rally identifiable in the sphenoethmoid recess, medial to the superior turbinate, lateral to the nasal septum, and directly above the basisphenoid, approximately 10–12 mm above the choana (Figs. 49.3A and B). If not visible secon­ dary to mucosal inflammation, gentle palpation in this area with a ball tipped seeker or a curette will generally allow for its identification. Of note, the ostium is typically positioned at the upper two thirds of the entire height of the sphenoid sinus. Therefore, once identified, the sphenoid sinus ostium is expanded initially in an inferior direction to minimize the risk of inadvertently injuring the planum sphenoidale. The initial down fracture can be performed with a curette forceps and then expanded with a sphenoid punch or downbiting Kerrison forceps. To bring the sphenoidotomy into continuity with the ethmoid cavity, the antrostomy is extended laterally and the lower edge of the superior turbinate may be removed. Alternatively, the sphenoidotomy may be performed through a transethmoidal approach. This is performed by creating a controlled fracture of the anterior face of the sphenoid sinus in the posterior most ethmoid sinus. Maintenance of a downward and medial trajectory is necessary to minimize the risk of skull base or carotid injury. Once the sphenoid sinus cavity is identified, the ostium is circumferentially widened. Powered instrumentation should be used selectively and with great care and ideally only after the sphenoid sinus landmarks are visible. The risk of major neurovascular injury is especially heightened in patients with dehiscence of the optic nerve or internal carotid artery. Arterial bleeding from the posterior nasal septal branch of the sphenopalatine artery is often encountered and is marked by pulsatile bleeding at the inferior edge of the sphenoidotomy. This should be controlled with cauterization at the time of surgery. It is rarely necessary or worthwhile to do any work within the sphenoid sinus itself in patients with inflammatory CRS. Remember that the intersinus septum is rarely midline and is often attached posteriorly to the carotid canal.

PANSINUSITIS

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cells can then be widely opened with a straight biting forceps or microdebrider with care being taken not to go superiorly until the sphenoid sinus is reached. The superior turbinate is a good landmark for identifying the sphenoid ostium. Once the front face of the sphenoid sinus is reached, the posterior ethmoid air cells are opened laterally to the lamina papyracea. One should then change to the upbiting forceps in addition to the microdebrider for the more superior cells. There are now three landmarks clearly in view: (1) the maxillary ostium, (2) the sphenoid ostium, and (3) the anterior superior attachment of the middle turbinate. Using these landmarks, one can then start to exenterate the superior ethmoid air cells under direct vision. Remember that the maxillary ostium is on the same parasagittal plane as the lamina papyracea in the overwhelming majority of patients and this is easily confirmed on preoperative CT scan. Initially, the advance­ ment superiorly should be close to the lamina papyracea as the bone of the roof of the ethmoid is typically thicker laterally close to the orbit than it is medially as it appro­ aches the cribriform plate. The lateral lamella of the cribri­ form plate is the most common site of iatrogenic CSF leak.7 This is attributed to its thinness, variable and often low position, and proximity to the medial boundary of the dissection. Assessment of the depth of the cribriform plate on preoperative CT scan is an important step in pre­ operative planning and can be classified by the Keros classification. In performing clearance of the superior eth­ moid cell partitions, the superior boundary is the fovea ethmoidalis. This is most easily identified in the posterior ethmoid cells given their larger size and fewer numbers. This anatomy is well visualized on the sagittal images of the preoperative CT scan. A posterior to anterior dissection of the superior ethmoid cells takes advantage of both the ease of identification of the fovea ethmoidalis in the posterior ethmoid cells and the natural downward slope of the skull base. In a posterior to anterior dissection, a straight horizontal vector of force will avoid the skull base since it is at its lowest point at the start of the movement. The final step in a posterior anterior dissection involves clearance of anterior superior ethmoid partitions and allows for a widely exteriorized ethmoidectomy cavity with the following boundaries: middle turbinate medially, lamina papyracea laterally, fovea ethmoidalis superiorly and anterior face of the sphenoid sinus posteriorly. Once the ethmoidectomy is complete, the sphenoid sinus can be opened if that is necessary. Most commonly, the sphenoid antrostomy is designed to be in conti nuity with the ethmoidectomy cavity. This can be achieved



714

Although the surgical principles, techniques and instrumen­ tation are similar when applied to different phenotypic variants of CRS, important distinctions do exist. In patients

Chapter 49: Primary Endoscopic Sinus Surgery for Chronic Rhinosinusitis with pansinusitis, especially with severe polyposis, the operation should be approached somewhat differently. The primary goals of creating widely patent outflow tracts and clearance of obstructive polypoid tissue have the equally important goals of mitigating the ongoing inflammatory process and improving access for topical therapy. Therefore, it is often efficacious to consider a partial middle turbinectomy. This may involve clearance of grossly polypoid tissue and preservation of the nor­ mal architecture. Preservation of the middle turbinate whenever possible is appropriate, given the potential adverse events that may occur with resection: arterial bleeding, skull base injury, postoperative lateralization of the stump with obstruction of the middle meatus and frontal recess, loss of an important surgical landmark for future revision cases, permanent loss of olfactory function. In patients with severe, refractory, polypoid CRS, the ability to manage the postoperative cavity is paramount and it may be appropriate to consider a partial resection of the middle turbinate. This may target the inferior and lateral portions of the middle turbinate and maximizes the patency of the paranasal sinus outflow tracts. This is most easily accomplished by clamping the middle turbinate with straight tonsil forceps for 30–60 seconds. This will leave behind a crushed area that will not bleed. The straight cutting endoscopic scissors or thru-cut forceps can then be used to cut along this crushed area to the front face of the sphenoid sinus and the lower part of the middle turbinate removed. Hemostasis with a cautery may be required. This maneuver alone will accomplish a significant part of the ethmoidectomy, particularly posteriorly. The complete ethmoidectomy is then performed as previously described. The maxillary ostium is identified and enlarged as needed. The frontal recess area is then cleared of obstructive polypoid tissue and ethmoid partitions. Although the techniques and instrumentation are similar to the previously described concepts, there are important distinctions. Powered instrumentation is particularly useful in these cases to clear polypoid tissue and maintain visualization, even with an increased amount of bleeding. Maximizing the dimensions of the outflow tracts is important in these patients to allow for increased delivery of topical therapy in the postoperative setting. Finally, obtaining hemostasis is especially challenging in these patients. A variety of things can be done to assist with hemostasis. Systematic use of topical decongestants, local anesthesia, and hypotensive anesthesia as described above

715

is essential. A variety of absorbable and nonabsorbable packing materials are commercially available with the theo­ retical goals of hemostasis, splinting the middle meatus open, and preventing adhesions. The authors have tried a large number of materials over the years and most worked satisfactorily. The cheapest and most effective at this time seems to be a topical hemostatic powder made from potato starch.

POSTOPERATIVE MANAGEMENT There are a variety of ways of doing the postoperative care-probably as many as there are surgeons doing this procedure. Many do aggressive saline irrigations followed by steroid sprays while others do essentially nothing. As a rule, regardless of the postoperative care, the results are generally excellent (Figs. 49.13 and 49.14). Most surgeons see the patients frequently in the office in the postoperative period for debridement of the opera­ tive site to hopefully accelerate healing with the least amount of scar tissue formation. The debridement is done under local anesthesia using suction and forceps as necessary to remove crusts, thick mucus, adhesions, etc. Management of the ongoing inflammation and infection in the early postoperative is critical to overall success. There are several occasions with specific diseases where slight alterations in the normal care of the patient are in order. One of these is Samter’s triad (nasal polyposis, asthma, aspirin sensitivity). It has become quite clear in recent years that if patients are desensitized to aspirin in

Fig. 49.13: CT scan of patient with classic ostio­meatal complex disease.

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Section 9: Surgery for Inflammatory Sinusitis

Fig. 49.14: Postoperative CT scan of patient in Figure 49.13.

Fig. 49.15: Preoperative CT scan of patient with allergic fungal sinusitis.

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polyps. During the course of the procedure in this dis­ ease one will encounter very thick tenacious mucus that is a dirty brown gray color reminiscent of peanut butter. The key to success in this procedure is to remove all fungal elements from all involved sinuses and to create widely patent outflow tracts. The senior author routinely irrigates all involved sinuses with betadine solution at the end of the procedure since betadine is fungicidal. When this is done successfully, recurrence is unusual (Figs. 49.15 and 49.16).



1. Draf W. Endoscopy of the paranasal sinuses. New York: Springer Verlag; 1983. 2. Messerklinger W. Uber dia Drainage der Menschlichen Nasmebenhohler uiter normmalen und pathologischen Berdingunger. Monatsschr Ohrenheilkd. 1967;101:313 26. 3. Rice DH. Basic surgical techniques and variations of endoscopic sinus surgery. Otolaryngol Clinics N Am. 1989;22:713 26. 4. Saidi IS, et al. Pre and postoperative imaging analysis for frontal sinus disease following conservative partial middle turbinate resection. Ear Nose Throat J. 1998;77:326 8. 5. Fortune DS, Duncavage JA. Incidence of frontal sinusitis following partial middle turbinectomy. Ann Otol Rhinol Laryngol. 1998;107:447 53. 6. Rice DH. Management of the middle turbinate in endo­ scopic surgery. Oper Tech Otolaryngol Head Neck Surgery. 1995;6:144 8. 7. Chin GY, Rice DH. Transnasal endoscopic closure of cerebrospinal fluid leaks. Laryngoscope. 2003;113:136 8.

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the early postoperative period, they will do much better over time. Desensitization needs to be done by an allergist skilled in this procedure. In the end, the patient generally may take aspirin for life. For that reason, the desensitization should be performed after the surgery, not before, in order to avoid a break in the aspirin regimen. A second disease of note is allergic fungal sinusitis. This may be a unilateral or bilateral process. The patients generally present with complete nasal airway obstruc­ tion and polyps. Generally, one will be suspicious of the diagnosis on the preoperative CT scan, which frequently shows heterogeneous material within the involved sinus or sinuses and often bone expansion and virtually always



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Fig. 49.16: Postoperative CT scan of the patient in Figure 49.15.





REFERENCES

CHAPTER Revision Sinus Surgery

50

Justine BF Millar, Dustin M Dalgorf, Richard J Harvey Although endoscopic sinus surgery (ESS) is generally highly successful, failure has been reported to be in the vicinity of 10–25%.1 This chapter examines some of the reasons due to which surgery can fail. Surgical failure usually arises from poor disease factors, suboptimal surgical technique, and insufficient postoperative maintenance therapy. Revi­ sion surgery is often more challenging, but the principles of surgery remain the same, i.e. to create a single func­ tional sinus cavity preserving mucosa and allowing topical access so adjunctive medical therapy is permitted. Revi­ sion surgery will succeed through attention to both anato­ mical landmarks, ensuring a single functional cavity, and addressing the intrinsic mucosal factors driving chronic rhinosinusitis (CRS).

WHY IS THERE PERSISTENT MUCOSAL DISEASE? Disease Pathogenesis Chronic rhinosinusitis is considered similar to other chronic inflammatory epithelial diseases, where failure of normal mechanical and innate immunity results in a dysfunctional host response.2 Mucosal disease in CRS is considered to be the result of three main driving forces, namely, that of intrinsic mucosal inflammation, local microbial colonization, and mucociliary dysfunction.3 Individuals often exhibit a dominant contributing factor within this triad, with the other two factors being disease modifiers.

Mucosal Inflammation Mucosal inflammation is the defining feature of CRS and other chronic airway conditions.4 CRS evolves from

a cascading progression of disease events. Patients with CRS can be classified either by phenotype or endotype. Endotype is confirmed on histopathology and is gene­ rally either eosinophilic or noneosinophilic. Eosinophilic disease is associated with asthma, aspirin sensitivity, and nasal polyposis. The propagating event in eosinophilic dis­ ease is usually intrinsic mucosal inflammation (Figs. 50.1A to C). The mucosal inflammation leads to mucosal ulcer­ ation that in turn promotes pathogenicity of local microbial community resulting in invasion of the epithelium. The subsequent epithelial damage, edema, and mucus changes lead to impaired mucociliary function. Impaired mucoci­ liary transport consequently may also lead to local infec­ tion. The local microbial community contributes to the cascade by exposing mucosa to proinflammatory products, such as exotoxins. Mucosal damage can also occur directly from environmental factors such as cigarette smoke inhala­ tion, or indirectly from inhalent allergens via immune responses.3

Local Microbial Community Local microbial community forms the second contributing feature of the triad of CRS. The microbial community can exist as either as a planktonic form or in a biofilm and includes viruses, bacteria, and fungi. The planktonic microbial community interacts with the mucosa through proinflammatory mediators such as exotoxins and capsular polysaccharides. These trigger an acute inflam­ matory response and impair mucociliary motion. This response is propagated by microbial communities living in biofilms.

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Section 9: Surgery for Inflammatory Sinusitis

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Figs. 50.1A to C: Significant sinus disease with histological appearance of eosinophilia and features of remodeling.

Treatment of Propagating Factors Managing Mucosal Inflammation Mucosal inflammation can be treated with macrolides and corticosteroids. Long term macrolide therapy has been shown to be affective in the modulation of IL 8 production and thus works as a neutrophilic modulator. However, there is no evidence to show that macrolides work on eosino­ philic disease.7 Macrolides also function by interfering with biofilm formation, reduce mucosal inflammation, and as a result diminish mucous production.7 Systemic steroids act as generalized immune suppressants. Topical steroids, in the form of irrigation, have a good effect on -

Mucociliary function is impaired in CRS; however, it is rarely the primary cause of CRS. The mucociliary apparatus comprises a mucous blanket with beating cilia and is the major mechanism of innate immunity. Abnormalities in cilial function occur in conditions of altered cilial structure, function, and coordination. This may occur primarily or secondarily. Primary ciliary dysfunction includes primary ciliary dyskinesia associated with Kartagener syndrome. Most patients with CRS demonstrate secondary ciliary dysfunction, which is a result of inflammation and infec­ tion.6 The mucous properties are affected by hydration and glycoprotein composition. Volume of mucous produc­ tion is affected by the hypersecretory states as seen in CRS. Mucociliary clearance is impeded by ostial obstruc­ tion and recirculation. This delayed mucociliary flow prolongs contact time with microbes, antigens, and inflam­ matory substances, promoting further microbial coloni­ zation and inflammation, creating a perpetuating cycle (Fig. 50.2).3

Chronic rhinosinusitis is by definition a chronic disease where treatment is focused on symptom control rather than on cure; however, normal mucosa is always the goal. The triad of mucosal inflammation, microbial com­ munity, and mucociliary dysfunction coexists with posi­ tive feedback between them (Fig. 50.2). This leads to the involvement of all three factors in the disease process. Defining the propagating factor of the triad, however, is critical in the treatment strategy.3 Currently, patients with discrete mucociliary dysfunction or simple untreated infection appear to have the best prognosis. In contrast, those with intrinsic mucosal inflammation require greater care and are more resistant to shor term treatment. -

Mucociliary Dysfunction

IMPLICATION FOR TREATMENT

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Superantigens such as Staphylococcus may induce eosino­ philic inflammation in at least some cases of CRS. Bacterial infection can be facilitated by mucosal inflammation and impairment of ciliary function caused by viral infec­ tions.5 Although the local microbial community can ini­ tiate an inflammatory response, they are considered to function more as disease modifiers than etiologic factors.

Chapter 50: Revision Sinus Surgery

719

Fig. 50.2: Chronic rhinosinusitis (CRS) triangle.

Restoring Microbial Community

Fig. 50.3: Patient using sinus rinse.

open sinus mucosa with minimal systemic absorption8 (Fig. 50.3). If the steroid wash cannot penetrate into the sinuses, e.g. due to postoperative scarring, then they may influence turbinate reactivity and reduce some nasal symp­ toms without actually modifying the disease process. Adeq­uate surgery allows effective maintenance therapy. Patients with a predominant inflammatory component to their disease, such as asthma and atopic disease, respond to corticosteroid therapy. Doxycycline has also been shown to reduce polyp size in patients with inflammatory disease when compared to placebo.9

Microbial communities can be treated with antibiotics and surfactants. Planktonic bacteria can be effectively treated with targeted antibiotic therapy. Most antibiotics have little effect on bacterial biofilms, with the exception of macrolides. Topical antibiotics can be effective in high concentrations. Surfactants applied topically can physi­ cally disrupt biofilms and inhibit biofilm formation.10 As with other topical therapies, surfactants and antibiotics are only effective if they have contact with sinus mucosa, and only in the postoperative state.8 Current research indicates that restoring the normal sinus microbiome has protective mechanisms, although the exact mechanism by which these microbes protect sinuses is as yet unknown. Lactobacilli, e.g. have been shown to lower the surrounding pH through their production of lactic acid. This changes the local environment of the sinuses and is thought to influence the coexistence of other more pathogenic microbes.11 More pathogenic microbes such as superantigen exotoxin producing Staphylococcus aureus have been shown to stimulate eosinophilic inflamma­ tion through production of Th2 cytokines and local IgE formation.5 Consequently restoring the normal sinus micro­biome is thought to reduce Staphylococcus aureus colonization, leading to a reduction in sinus mucosal inflammation.

Section 9: Surgery for Inflammatory Sinusitis

WHY DID THE PRIMARY SURGERY FAIL? Incorrect Diagnosis Disease Process Not One of Ostial Occlusion Chronic rhinosinusitis is generally a result of the interac­ ting triad of intrinsic mucosal inflammation, local micro­ bial community and mucociliary dysfunction. Ostial occlu­ sion has been shown to induce sinus infection and deranged mucociliary clearance; however, it is rare in the absence of other pathology.14 Relieving ostial occlusion in most patients with CRS without follow through with ongoing topical therapy has little effect.15 This is especially so in patients with nasal polyps and concomminant airway conditions like asthma.16

Inflammatory Disease Process Patients with CRS can be subclassified according to either phenotype or endotype. Phenotype takes into account what is seen on nasendoscopic examination and divides patients into either CRS with or without

 

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Persistent Rhinitis It is important to separate the etiology of nasal symp­ toms. As many as 40 % patients with CRS will have a con­ comminant history of persistent rhinitis (usually allergic). Allergic rhinitis (AR) is common, as much as 25% of the population,18 and can produce nasal congestion, mucus production, loss of smell, and other CRS like symptoms. Patients with significant AR in need of concurrent turbi­ nate procedures should also be offered appropriate immunotherapy. -

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Endoscopic sinus surgery is widely employed to manage CRS refractory to medical treatment. Traditional concepts for surgery in CRS have centered on relieving ostial obstruc­ tion and enhancing ventilation. Historically, the postulated effects of ESS include improved mucociliary mass mucous blanket transport, overall reduction in inflammatory mucosal surface area, and brief shift in Th1 inflammatory response in the postoperative healing mucosa.13 It is becoming increasingly evident that the most powerful effects of ESS may simply be topical access to sinus mucosa. Current postoperative care regimes may be the intervention factor that resolves continuing inflammation rather than the surgery itself.

Iatrogenic Endoscopic sinus surgery has evolved from microsurgi­ cal techniques with mucosal stripping to minimal tech­ niques to maximal open cavity techniques with mucosal preservation. This shift has resulted from an improved understanding of the pathogenesis of CRS. Simple surgical techniques to improve ventilation of the sinuses, while adequate in some situations, are now considered insuf­ ficient to treat CRS alone and have led to higher levels of treatment failure. Studies have shown that approximately 10% of patients require revision surgery within 3 years.19 Other studies have reported up to 50–100% recurrence rates for patients with nasal polyposis.20 The problem with limited ESS techniques is that it may induce scarring, iatrogenically affecting sinus outflow tract or creating mucus recirculation. This iatrogenic induced scarring of sinus outflow results in both ongoing CRS and exacerba­ tion of symptoms. Poor cavity healing precludes effective application of topical therapies. Additionally, nasal mucous recirculates either if the true sinus ostium is not ­

Treatment Philosophy

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Mucociliary clearance is most commonly treated with saline irrigation. Saline irrigation can augment or replace mucociliary clearance by physically removing proinflam­ matory substances (eosinophilic mucin, infected crusts or antigens).12 Patients with crusting, as a result of dehydrated secretions, are excellent candidates for this. Saline irriga­ tion can also be mixed with antibiotic preparations or steroids to allow adequate delivery of these substances to open sinuses.

polyps. Endotype is confirmed on histopathology and is classified as either eosinophilic (> 10 eosinophils per high power field) or noneosinophilic.17 Eosinophilic CRS is often associated with nasal polyps. However, the pheno­ type and endotype are different in many patients, as tissue eosinophilia is also present in up to 19% of patients with CRS without polyps.17 Eosinophilic CRS is associated with clinical severity, poor outcome, and high recurrence rate after ESS15. This group of patients is likely to require long term anti inflammatory therapy. Single modality therapy such as ESS alone is unlikely to produce satis­ factory results. Failure to recognize these patients pre­ operatively and continue anti inflammatory treatment in the postoperative setting can lead to treatment failure. (Figs. 50.4A to D).15 ­

Replacing Mucociliary Clearance

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Chapter 50: Revision Sinus Surgery

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Figs. 50.4A to D: (A and B) Clinical photographs showing obstructed sinus due to polyps; (C) CT of same patient demonstrating nasal polyps and obstructed sinuses; (D) postoperative clinical photograph demonstrating healthy, wide-open sinus cavity.

opened or if accessory ostium is created iatrogenically. This recirculation increases the risk of persistent sinus infection. Musy and Kountakis evaluated a prospective series of patients undergoing revision ESS and reported that the most common alterations include lateralization of the middle turbinate (78%), incomplete anterior ethmoi­ dectomy (64%), scarred frontal recess (50%), retained agger nasi cell (49%), incomplete posterior ethmoidec­ tomy (41%), middle meatal antrostomy stenosis (39%), and retained uncinate process (37%).21 These findings have been confirmed in other case series.22 Other reasons for incomplete surgery may be due to reports of approaches to safe posterior dissection recommending proceeding parallel to the maxillary ostium that may leave ethmoid cells behind.23 All of these anatomic findings suggest incomplete surgery that has led suboptimal cavity design and ultimately surgical failure.

Systemic Disease While local factors are the main cause of CRS, occasionally, when patients fail to respond to therapy, the cause may be an underlying systemic disease. There are a substantial number of systemic diseases that can cause CRS. These can be characterized as vasculitic and granulomatous diseases, neoplastic diseases, immunodeficiency diseases, and mucociliary diseases. Inflammatory disease includes Wegener granulomatosis, sarcoidosis, and Churg-Strauss Syndrome. Immunodeficiency diseases include acq­uired immunodeficiency disease syndrome (AIDS), or patients on chemotherapy for neoplastic and hematological diseases. Mucociliary disease is made up of primary ciliary dyskinesia associated with Kartagener syndrome and cystic fibrosis. Pathologic changes in systemic disease occur in three general ways. First, the general pathophysiology of the disease may affect the tissues of the sinonasal tract.

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Section 9: Surgery for Inflammatory Sinusitis

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Figs. 50.5A and B: Computed tomography showing osteitis.

WHAT IS GOING TO BE ACHIEVED BY REVISION? Which Corners of the CRS Treatment Model Will Be Improved by Revision?

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All corners of the treatment model should be improved with revision surgery. Revision sinus surgery creates an open sinus cavity that permits the topical delivery of corti­ costeroids, surfactants, antibiotics, and saline irrigation. The first and dominant disease corner is mucosal inflam­ mation. Bad mucosal disease driven predominantly by intrinsic mucosal inflammation may result in large polyps obstructing the sinuses. Large polyps are unlikely to resolve simply with medical treatment without surgery.24 This is because they obstruct the delivery of topical therapy and often contain remodeling changes not resolved by medical treatment alone. Even though large polyps should be removed during revision surgery, care must be taken not to strip the mucosa because there is good evid­ ence to suggest that stripping mucosa induces osteitis25 (Figs. 50.5A and B). Osteitis once established is difficult

to treat. In addition, the other two disease corners, local microbial community and mucociliary dysfunction, also contribute to reasons for revision surgery. The role of sur­ gery is not only to clear diseased tissue but also to create a cavity that patients can manage with topical treatment.

Sump Effects A sinus sump is defined as an area of the sinuses that does not drain adequately. Sumps can be seen in either the maxillary or sphenoid sinuses. Maxillary sinus sumps are often seen in patients with highly pneumatized maxillary sinuses. This is where the sinus is pneumatized below the floor of the nose (Figs. 50.6A to C). These patients expe­ rience pooling of secretions within this sump and as a result local microbial communities become established and the cycle of mucosal inflammation starts up. Medical treatment of the sump is difficult because washes are retained in the sinus and may contribute to the disease process. Treatment of sump effects of the maxillary sinus involves medial maxillectomy to the nasal floor. In cases where the maxil­ lary sinus is pneumatized beyond the floor of the nose, treatment becomes very challenging. Sphenoid sinus sumps are also seen in patients with well pneumatized sphenoid sinuses. The sump can occur due to inadequate surgery where the floor of the sinus is not visualized and as a result secretions and topical therapies are retained in the sinus. To treat the sphenoid sinus adequately, it is necessary to lower the front face of the sphenoid sinus until the posterior septal branch of the sphenopalatine artery is reached. Treatment of the sphenoid sinus sump involves a sphenoid sinus Lothrop with adequate visuali­ zation of the sphenoid floor. -

Second, the unique mucosal histology of the sinonasal tract may make an otherwise minor pathologic process more severe and apparent. Third, a systemic disease may affect the tissues of the sinonasal tract as part of a symptom complex. Patients with systemic disease are difficult to treat and tend to display worse CRS and are maybe refractory to treatment. Although patients with systemic disease need investigation of other involved organs and may require systemic therapy, their local treatment often remains unchanged to primary CRS patients.

Chapter 50: Revision Sinus Surgery

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Not Topical Access Topical therapy delivery for CRS is shaped by a variety of factors. Factors include delivery techniques, surgical site of the sinus cavity, delivery device, and fluid dynamics.26 The ability of the therapy to reach the appropriate region of the paranasal system is vital. Studies have demonstrated that there is very little distribution of topical solution to the nonoperated sinuses. Distribution in nonoperated sinuses is probably partial and only in the order of less than 2% of the total irrigation volume27 and only 3% with nebulization.28 The frontal and sphenoid sinuses are essentially inaccessible before surgery.26 An ostial size of greater than 4–5 mm is required to even begin seeing penetration to the maxillary sinus.26 The access afforded by a large fronto-maxillary-sphenoid-ethmoidectomy cavity facilitates adequate topical therapy. However, once the therapy has reached the target site, its success is heavily dependent on the local microenvironment. The local microenvironment includes the presence and composition

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Figs. 50.6A to C: (A) Clinical photograph demonstrating maxillary sinus sump with accumulation of debris; (B) Computed tomo­graphy showing highly pneumatized maxillary sinus with sinus sump. (C) Postoperative photograph demonstrating open and healthy maxillary cavity.

of the mucus blanket, the mucociliary clearance, direct mucin-drug binding, and the permeability of the mucosa. The efficiency of the therapy is mediated by two poten­ tially competing actions these are mechanical lavage and drug delivery. The role of saline irrigation has historically been to mechanically clear mucous. However, there is an increas­ ing perception that saline also has a contributory role in the resolution of inflammation and potentially works by enhancing ciliary beat activity, removing antigen, biofilm, inflammatory mediators, and playing a part in sinonasal mucosa protection. Topical saline preparations vary from commercial single use and multiuse products to home­ made solutions. Regardless of the solution used, it appears that large volume delivery such as with a squeeze bottle is best at managing CRS29 (Fig. 50.3). In addition to clearing the mucous blanket, saline preparation allows other drugs, such as corticosteroids to be delivered to the sinus mucosa.

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Section 9: Surgery for Inflammatory Sinusitis

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Revision surgery is required when there is inadequate access for topical treatment. This may either be due to obstruction by large polyps or iatrogenic scarring, or from insufficient previous surgery. Adequate topical treatment is the cornerstone to successful outcomes post revision ESS.

SURGICAL TECHNIQUE Understanding Sinus Anatomy as Fixed Landmarks and the Boundaries of the “Box” Orbital Line

 

Fig. 50.7: Computed tomography of orbital floor never being higher than sphenoid roof.

fixed anatomical landmarks are reassuring for the surgeon planning revision surgery where the normal landmarks may be lost, and as long as the orbital floor and medial wall are identified the surgery can proceed safely.

Boundaries of the Frontal as “Box”



Conceptually the anatomy of the sinuses can be divided into two basic boxes.32 These can be defined as the main surgical box and a vertical frontal box. During revision surgery, understanding the boundaries of the surgical boxes is crucial for surgical planning as well as for intra­ operative orientation when the normal anatomy is distor­ ted. Failure to recognize the boundaries of these boxes can result in incomplete surgery or complications. The paranasal sinus box boundaries include the olfactory recess (middle and superior turbinates) medially, orbital wall laterally (lamina papyracea), and the skull base superiorly (Figs. 50.8A and B). Within the confines of this box, a series of pneumatized air cells and variants of this normal anatomy must be dissected. The clinical significance of an Onodi cell is that it can pneumatize over the optic nerve exposing it to injury during surgery. These cells can also be mistaken for the true sphenoid sinus, leading to incomplete surgery if not recognized. The vertical or frontal box sits directly above and within the confines of the anterior box. The boundaries of the vertical box define the frontal sinus recess and include the middle turbinate and intersinus septum medially, orbital wall laterally, nasofrontal beak anteriorly, and skull base and posterior table of the frontal sinus laterally.

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Revision surgery is challenging because, in contrast to operating on virgin sinuses, the usual landmarks have been removed or altered by previous surgery. Nasal land­ marks can be divided into anterior and posterior land marks.30 There are seven recognized anterior landmarks. They include the nasal floor and inferior turbinate, poste­ rior choana and eustachian tube opening, maxillary sinus roof (orbital floor), posterior wall, and the medial orbital wall. There are three posterior landmarks. They include the posterior skull base, lateral sphenoid wall (defining the orbital apex and optic canal), and skull base (sphenoid roof to posterior frontal table and clear view of orbital axis). The uncinate process, turbinates, and ethmoids may all be unrecognizable or absent from previous surgery; therefore, orientation depends on fixed anatomic landmarks. The most reliable fixed landmark is the nasal floor. The orbit is also an essential fixed landmark. The orbital floor forms the roof of the maxillary sinus.30 Harvey et al. reviewed 300 CT of sinuses and found that orbitalfloor or maxillary sinus roof was never higher than the sphenoid roof or lowest cribriform height30 (Fig. 50.7). Patients who had a very high and well pneumatized maxillary sinus had a reduced distance between the orbital floor and critical anatomy, but the orbital line was still always below the skull base. Patients with a well pneumatized maxillary sinus were also more likely to have a tighter and narrower corridor to the sphenoid and cribriform. The average distance from the orbital floor to the sphenoid roof was 11 mm and to the cribriform was 10.1 mm; this is within one or two instrument depths. Casiano looked at direct distances from the medial orbital wall to the carotid, optic nerve, ethmoid roof, and anterior ethmoid artery.31 He found that there was approximately 14 mm between these landmarks and none of them were less than 10 mm. These

Chapter 50: Revision Sinus Surgery

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Figs. 50.8A and B: (A) Clinical photograph showing sinus box (B).

To define the limits of the frontal recess (vertical box), various cells that may encroach on this space from the anterior, posterior, medial and lateral directions must be considered during surgery. Anterior structures intruding into this space include the agger nasi cell, the lateral uncinate process, and frontal cells. Supraorbital ethmoid cells, suprabulla cells, and the ethmoid bulla make up the posterior structures intruding on the frontal recess. These cells can become quite large and can be mistaken for the skull base or frontal sinus. Failure to recognize this preoperatively on CT imaging will also result in incomplete surgical dissection of the frontal recess. Medial structures intruding on the frontal box include intersinus septal cells and medially inserting uncinate process. Lateral imping­ ing structures include frontal cells, the agger nasi, and a lateral uncinate process attachment.

The Salvage Operation Fontal Sinus Salvage (aka Lothrop/Draf3) The outside-in modified endoscopic Lothrop procedure (MELP) is based on the traditional MELP. MELP has become recognized as an option in managing a wide range of different pathologies, including refractory frontal sinus inflammatory disease,33 mucoceles,34,35 frontal sinus cerebrospinal fluid (CSF) leaks,36 and in the management of frontal sinus tumors.37 Access provided by the Lothrop cavity also facilities postoperative tumor surveillance and topical therapy.38,39 The Lothrop cavity is bounded laterally by the orbital plates of the frontal bone and periosteum of the skin over the frontal process of the maxilla on both sides.40 The posterior limit is the first olfactory fascicle.

This demarcates the forward projection of the olfactory bulb. The anterior limit of the dissection is the plane of the anterior table of the frontal sinus41 (see Figs. 50.11A to H). Open approaches to the frontal sinus include the osteoplastic flap approach.42 The problems associated with an external approach include cutaneous scarring, scalp hematoma,43 embossment, and cosmetic deformity. MELP avoids these problems. The traditional inside-out MELP requires the identification of anatomical landmarks that may be lost in revision surgery. This is because in traditional MELP bony removal follows the identification of one frontal recess at the first step. This often involves the use of angled endoscopes and identification of the frontal sinus recess may be difficult in revision surgery. The outside-in approach identifies the limits of the endo­ scopic Lothrop cavity early and allows wide-open access making it technically feasible and a safe procedure for revision surgery (Figs. 50.9A and B and 50.1).

Surgical Technique41 The surgical steps required for this procedure involve, firstly, removing the mucosa over the frontal process of the maxilla. This is medial to the plane in line with the medial orbital wall. The anterior septal window is created anterior to the insertion of the middle turbinates at the level of the upper half to the upper one-third of the middle turbinate to allow bilateral access. This dissection is anterior to the first olfactory fascicle on each side, which is discovered posteriorly. The superior bony septum is drilled down to give a smooth working surface. Dissection starts at the demucosalized area on the frontal process of the

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Section 9: Surgery for Inflammatory Sinusitis

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Figs. 50.9A and B: Photographs showing outside in Lothrop cavity (MELP): (A) operative photograph; (B) 12-month postoperative clinical photograph.

Surgical management of chronic maxillary sinusitis via standard middle meatal antrostomy is highly effective with success rates approaching 90%.44 Despite surgery and aggressive medical therapy, a subset of patients will continue to have mucosal inflammatory disease and recalcitrant maxillary sinusitis. Traditional techniques

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Maxillary Sinus Salvage (Also Known as Modified Medial Maxillectomy)

used to treat maxillary sinusitis such as Caldwell–Luc procedures and inferior meatal windows may in fact contribute to the inflammatory mucosal disease. Odonto­ genic disease may also provide a persistent inflammatory stimulus.45,46 The maxillary sinus also contrasts to other gravity dependent drainage pathway sinuses in that the mucociliary clearance must work against gravity. The dependent portion of the maxillary sinus may serve as a reservoir for tenacious secretions and persistent inflam­ mation. After Caldwell Luc surgery, the inferior portion of the maxillary sinus may be left with scaring. The modified medial maxillectomy (MEMM) developed from the need to address these issues, but its application is broad. The MEMM has been demonstrated to improve inflammatory maxillary disease47 in two ways. The first one by allowing increased delivery of nasal wash to the maxillary sinus and the second by improving access to the inferior and dependent portion of the maxillary sinus. The canine puncture technique described by Sathananthar et al.48 is also an effective method for removal of inflammatory disease polyps in the inferior aspect of the maxillary sinus. The MEMM has the added advantage of improving access to the maxillary sinus in the postoperative setting, improving gravity dependent drainage, and reducing the sump effect. Wang et al.49 in a retrospective review of 46 patients who underwent MEMM found that 37 patients had complete resolution of their disease at 3 months. Woodworth et al reported successful treatment in 18 of 19 patients who underwent MEMM.47 Revision surgery on recalcitrant maxillary sinus disease is well served by the wide open exposure gained from the MEMM technique. -

maxilla. This is continued laterally until the periosteum of the overlying skin is identified on one side and then the contralateral side. A wide operative field is quickly developed as the bone is removed between these lateral margins. The mucosa of the floor of the frontal sinus is rapidly identified. Bone removal is continued on a broad front, avoiding entry into the frontal sinus mucosa until there is wide access to the floor of the frontal sinus on both sides. The dissection is continued anteriorly and superiorly to the frontal recesses laterally and the first olfactory fascicle medially. This ensures that the frontal recess and inferior part of the frontal sinus always lies between the drill head and the skull base. The floor of the frontal sinus is removed. A thin shelf of bone that remains anteriorly at the frontal recess is removed using a 2 mm Kerrison rongeur bilaterally. At this stage, an angled endoscope may be used, if required for better visualization of the ante­ rior wall that defines the anterior limit of the cavity. Any remaining bony overhang in the frontal beak area is removed. The interfrontal sinus septum is lowered toward the first olfactory fascicle to achieve the final cavity.

Chapter 50: Revision Sinus Surgery

Surgical Technique After topical decongestion and infiltration of the lateral nasal wall and inferior turbinate, endoscopic evaluation of the maxillary sinus is performed to ensure communication of the antrostomy with the natural ostium of the maxil­ lary sinus.49 The anterior third of the inferior turbinate is preserved to prevent atrophic rhinitis and damage to the nasolacrimal duct. A posterior stump of the inferior turbi­ nate is also maintained to allow for effective cauterization of the sphenopalatine artery branches that enter the infe­ rior turbinate. A mucosal flap based on the floor of the nose is then created by elevating the mucosa of the lateral nasal wall of the inferior meatus in the subperiosteal plane. The medial maxillary wall is then resected. At the completion of the resection, the inferior extent of the resec­ tion should approximate the floor of the nose. The posterior resection should approximate the posterior wall of the maxillary sinus, although branches of the sphenopala­ tine artery may be encountered with extensive dissection. Care should be taken to avoid injury to the descending palatine nerve posteriorly and the lacrimal system ante­ riorly. When indicated, the maxillectomy can be extended anteriorly underneath the lacrimal duct. After achieving wide access to the maxillary sinus, polyps and nonfunc­ tional hyperplastic mucosa are removed but the mucosa is not stripped. After thorough irrigation of the sinus, the mucosal flap is laid across the nasal floor into the maxillary sinus to cover the area of exposed bone along the inferior maxillary bony cut (Figs. 50.10A to F).

Sphenoid Sinus Salvage (aka Sphenoidotomies and Septectomy, Sphenoid Lothrop) Common causes of sphenoid sinus dysfunction include severe osteitic bone and contracted lumens, which can be caused by iatrogenic mucosal stripping, a fungus ball, or chronic sphenoid sinusitis. Radical mucosal stripping procedures have been previously used in obliteration techniques with fat or other materials. These are not routinely performed for inflammatory disease, but have been used for repair of CSF leaks such as is seen after pituitary surgery. The sphenoid is difficult to truly oblite­ rate as there is a risk of injury to surrounding structures. Therefore, the obliteration techniques often exacerbate sinus disease. Modern surgical approaches to the sphenoid are typically endoscopic. Unlike the frontal and maxillary sinuses due to its deep-seated location, no real option for open surgery exists. Establishing a patent outflow tract and creating access for topical medical therapy are critical for surgical success. Options for access are either unilate­ral

727

or bilateral.50 Unilateral sphenoid sinuso­ tomies can be performed using the transethmoid or direct parasagittal approach. The principle of surgery for sphe­noid disease is mucosal preservation and maximal sphe­ noidotomy dimensions. Revision surgery cases typically have osteitic bone, which has a tendency to scar and contract more than nonosteitic sinuses. The sphenoid sinus “Lothrop” is to establish a wide-open sphenoid sinus cavity (Figs. 50.11 and 50.12, and 50.2).

Surgical Technique Submucosal elevation over the face of the sphenoid will help avoid the posterior septal branch of the spheno­ palatine artery. After elevation of this mucosal flap, a wide open sphenoidotomy is created using a Kerrison punch. Taking down much of the floor of the sphenoid can often be advantageous in creating a large neo-ostia. Every effort should be made to preserve the mucosa while resecting the osteitic bone. Once the bony opening is enlarged to skull base, orbit, inner sinus septum, and inferiorly as much as possible, the sphenoid sinus mucosa can be incised and any pus, fungal concretions, or other inflammatory mucous within the sinus can be removed. If the natural outflow tract of the sphenoid scars postoperatively but the inner sinus septectomy remains patent, then the sinus will remain ventilated and safe, even though the outflow tract is nonanatomic through the contralateral sinus. The approach to surgery is typically similar to that for trans-septal pituitary surgery. A large posterior nasal septectomy is performed for access. Bila­ teral sphenoidotomies are then performed so that both sphenoid sinuses, the rostrum, and the planum can be visualized with one view of the endoscope. The inner septum is then removed back to the face of the sella. As with the inner sinus septectomy of the frontal sinuses, this site is often untraumatized by prior surgery and less likely to scar and contract than revision surgery through the previously operated area of the native sphenoid os. Care must be taken to perform this inner sinus septectomy with cutting instruments or drills. Twisting and pulling of the inner sinus septum can result in an indirect injury to the internal carotid artery, because the inner sinus septum often inserts into the carotid.

Osteitis What Does It Mean? The mechanism of osteitis in CRS is poorly understood and is yet to be fully defined. Osteitis is generally found to

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Section 9: Surgery for Inflammatory Sinusitis

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Figs. 50.10A to F: Operative photographs showing medial maxillectomy steps. (A and B) Left maxillary sinus obstructed with scar and inflammatory tissue; (C) Inferior turbinate resected with anterior third being preserved to prevent atrophic rhinitis and damage to the nasolacrimal duct; (D) Medial wall taken down to nasal floor; (E) A posterior stump of the inferior turbinate is also maintained to allow for effective cauterization of the sphenopalatine artery branches that enter the inferior turbinate; (F) Final maxillary sinus cavity.

Chapter 50: Revision Sinus Surgery

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Figs. 50.11A to F: Operative photographs showing sphenoid sinus Lothrop steps. (A) Right nasal cavity after decongestion; (B) Left nasal cavity after decongestion; (C) Photograph showing sphenoid sinus obstruction with scar tissue; (D) Diathermy used to make incision; (E) Incision on septum right; (F) Incision on septum left with submucosal elevation over the face of the sphenoid to help avoid the posterior septal branch of the sphenopalatine artery.

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Section 9: Surgery for Inflammatory Sinusitis

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Figs. 50.11G and H: (G) Large posterior nasal septectomy is performed for access; (H) Bilateral sphenoidotomies are then performed so that both sphenoid sinuses, the rostrum, and the planum can be visualized with one view of the endoscope.

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Figs. 50.12A to D: Operative photographs showing sphenoid sinus Lothrop steps. (A) Removal of sphenoid sinus floor; (B) Drill used to remove sphenoid floor and inner septum, which is then removed back to the face of the sella; (C and D) Final sphenoid cavity.

Chapter 50: Revision Sinus Surgery be associated with previous surgery (Fig. 50.5). Its occur­ rence appears to rise with the rising number of previous operations.51 However, mucosal loss from surgery is not a simple answer to the origins and implication of osteitis. Osteitis is also experienced in nonoperated patients with an incidence of 552–33%.51 Bacteria may play a role in the pathogenesis of osteitis by infecting the sinus walls either in planktonic or biofilm form. However, bacteria have not been found to be present in bone of the paranasal sinuses.53 Osteitis is thought to be due to an inflammatory process rather than a chronic bone infection of osteomyelitis. The osteitic bones potentially serve as a nidus for inflammation. This may explain medical and surgical treatment failures. Osteitis is a feature of CRS that is associated with both systemic and local tissue eosinophilia. Severe inflamma­ tion may contribute to circulating cytokines that promote neo-osteogenesis and these patient may need to be consi­ dered for longer courses of postoperative systemic corticosteroid.25

POSTOPERATIVE CARE Meticulous postoperative care is important to realize a successful result following ESS surgery. Failure of ade­ quate postoperative care can lead to potentially avoidable complications. Such factors as exposed bone, the mix of old blood, retained secretions and unresorbed packing predispose the patient to infection and inflammation. Inflammation provides a potential framework for scarring and early disease recurrence. Avoidable complications include ostial stenosis, synechiae, middle turbinate laterali­ zation, and rapid polyp recurrence. The return of normal mucosal histology and ciliary function often takes longer than 12 weeks following surgery.54 Diligent postoperative follow-up is recommended to ensure that the sinus cavity healing is on track. Currently various postoperative care regimes are employed. Rudmik et al. recommended in a recent multiinstitutional review the use of nasal saline irrigations, in-office sinus cavity debridement, and topical nasal steroid sprays.55 The only counter recommendation was use of routine topical decongestants because of the risk of increasing pain and rhinitis medicamentosa. To standar­ dize postoperative care protocols, more research is required.

Nasal Irrigations The role of saline irrigations in early postoperative period remains controversial. However, despite the controversy

731

in the literature, most experts agree that the benefits of early postoperative saline irrigation use outweigh the harm. Saline solution douching has been well established as a treatment adjunct in CRS.29 The timing of use in post­ operative care for patients with CRS is still under debate. There is significant variation in the volume, delivery mode, and frequency of saline irrigations. Nasal douching should aid with debris removal and soften crusting in the nose potentially making in-office debridement easier. A number of randomized trials have been conducted to evaluate the impact of saline irrigation on outcomes following ESS.56,57 It is difficult to draw conclusions from these trials because all study methodologies were hetero­ geneous and used different postoperative care protocols with different saline irrigation volumes and frequencies. No study was able to demonstrate consistent improve­ ment with saline irrigation. Although saline irrigation has been demonstrated to be useful in the management of CRS when used in high volumes, the effects of saline volume in the early postoperative setting have not yet been properly evaluated. There was no real consensus as to the best time to start irrigation. However, most saline irrigation regimes were implemented within 24–48 hours after ESS.

Corticosteroids Local Topical corticosteroid therapy, delivered as either a spray or irrigation, is a central component of anti-inflammatory CRS medical therapy.39 The effectiveness of using topical corticosteroids in the early postoperative state is still the subject of debate with the optimal delivery method, timing and dose of topical corticosteroids the key points of discussion. The success of local drug delivery to the paranasal sinuses depends on both the surgical state of the sinuses and the method of topical delivery. A wideopen surgical corridor allows topical access to the sinus mucosa. The high volume irrigation containing ‘off label’ steroid formulations seem to have a better sinus penetra­ tion in comparison with nasal sprays. Steroid nasal spray tends to provide a better nasal coverage. Topical steroid nasal irrigation may be safer because there is less systemic absorption compared to steroid sprays. Unlike systemic steroids, topical steroids have minimal systemic effects and therefore can be used in the long term. High volume steroid irrigation regimes commonly consist of 1 mg bude­ sonide in 240 mL of saline. A four-spray dose delivers a 256 µg dose to the nasal cavity. Common topical nasal

Section 9: Surgery for Inflammatory Sinusitis

REFERENCES -

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The patient failing ESS, especially one performed “else­ where,” is rarely a simple case of poor surgery. Revision ESS patients should be considered for both local anatomical and disease factors that may contribute to the poor outcome. When surgery is contemplated, a clear goal of what is to be achieved from revision surgery is important.



CONCLUSION





Post ESS infections can develop as a result of several factors including temporary ciliary dysfunction, retained secretions, old blood, and incomplete remucosalization and colonization with bacteria and biofilm. Infections can lead to increased nasal crusting, discharge, and scar­ ring. Traditionally, post operative antibiotics have been recommended for 7–10 days. Recent randomized cont­ rolled trials comparing postoperative antibiotics to placebo have demonstrated small improvements in post­ operative endoscopic appearance at the 5 and 12 day mark. The antibiotics of choice should be either culture direc­ ted or penicillin based or macrolide that target common sinonasal pathogens.





1. Soler ZM, Poetker DA, Rudmik L, et al. Multi institutional evaluation of a sinus surgery checklist. The Laryngoscope. 2012;122(10):2132 6. 2. Kern RC, Conley DB, Walsh W, et al. Perspectives on the etiology of chronic rhinosinusitis: an immune barrier hypo­ thesis. Am J Rhinol. 2008;22(6):549 59. 3. Timperley D, Schlosser RJ, Harvey RJ. Chronic rhinosinusitis: an education and treatment model. Otolaryngol Head Neck Surg. 2010;143(5 Suppl 3):S3 8. 4. Fokkens W, Lund V, Mullol J. European Position Paper on R, Nasal Polyps g. European position paper on rhinosinusitis and nasal polyps 2007. Rhinology Supplement. 2007;20: 1 136. 5. Stow NW, Douglas R, Tantilipikorn P, et al. Superantigens. Otolaryngol Clin North Am. 2010;43(3):489 502, vii. 6. Gudis DA, Cohen NA. Cilia dysfunction. Otolaryngol Clin North Am. 2010;43(3):461 72, vii. 7. Harvey RJ, Wallwork BD, Lund VJ. Anti inflammatory effects of macrolides: applications in chronic rhinosinusitis. Imm­ unol Allergy Clin North Am. 2009 Nov;29(4):689 703. 8. Harvey RJ, Goddard JC, Wise SK, et al. Effects of endoscopic sinus surgery and delivery device on cadaver sinus irriga­ tion. Otolaryngol Head Neck Surg.: Official Journal of American Academy of Otolaryngology Head and Neck Surgery. 2008;139(1):137 42. 9. Van Zele T, Gevaert P, Holtappels G, et al. Oral steroids and doxycycline: two different approaches to treat nasal polyps. J Allergy Clin Immunol. 2010;125(5):1069 76 e4. 10. Le T, Psaltis A, Tan LW, et al. The efficacy of topical anti­ biofilm agents in a sheep model of rhinosinusitis. Am J Rhinol. 2008;22(6):560 7. 11. Abreu NA, Nagalingam NA, Song Y, et al. Sinus micro­ biome diversity depletion and Corynebacterium tuberculo­ stearicum enrichment mediates rhinosinusitis. Sci Transl Med. 201212;4(151):151ra24. 12. Harvey RJ, Psaltis A, Schlosser RJ, et al. Current concepts in topical therapy for chronic sinonasal disease. J Otolaryngol Head Neck Surg. 2009;39(3):217 31. 13. DeMarcantonio MA, Han JK. Systemic therapies in manag­ ing sinonasal inflammation. Otolaryngol Clin North Am. 2010;43(3):551 63, ix.

POSTOPERATIVE ANTIBIOTICS

Video 50.1: Modified medial maxillectomy. Video 50.2: Salvage bilateral sphenoidotomy.



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Although systemic steroids provide excellent improve­ ment in CRS clinical status, balancing the benefits with the potential for harm remains a challenge. To minimize the risk of adverse events, most experts use short course protocols such as durations between 7 and 14 days with moderate doses of 30–40 mg.58 The use of a tapering dose schedule is controversial. Patients with eosinophilic nasal polyposis seem to have a greater response to oral pre­ dnisone than patients with noneosinophilic nasal polyposis.







VIDEO LEGENDS



SYSTEMIC DELIVERY

Completion surgery and salvage procedures have fixed anatomical landmarks for surgical orientation. Relying on image guidance will not replace the skills required in revision surgery. Greater focus on the inflammatory nature of CRS via both systemic and local therapies is usually associated with improved outcomes.



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steroid sprays include fluticasone, mometasone, and bude­ sonide. There have been several randomized, double blind, placebo controlled trials evaluating topical nasal sprays in the early postoperative period. In these trials patients with nasal polyps seem to respond best from postoperative topical steroids with reported success rates of up to 94%.These patients also experienced a reduction in nasal polyp recurrence and an increased length of time to polyp recurrence. Failure to respond to topical steroid treatment may be predicted by poor response to oral prednisone in the preoperative period. The timing for starting topical nasal steroid is poorly defined but most studies start between 2 and 6 weeks after surgery.



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Chapter 50: Revision Sinus Surgery 14. Hassab MH, Kennedy DW. Effects of long-term induced ostial obstruction in the rabbit maxillary sinus. Am J Rhinol. 2001;15(1):55-9. 15. Snidvongs K, Chin D, Sacks R, et al. Eosinophilic rhino­ sinusitis is not a disease of ostiomeatal occlusion. The Laryngoscope. 2013;123(5):1070-4. 16. Chin D, Harvey RJ. Nasal polyposis: an inflammatory condi­ tion requiring effective anti-inflammatory treatment. Curr Opin Otolaryngol Head Neck Surg. 2013;21(1):23-30. 17. Snidvongs K, Lam M, Sacks R, et al. Structured histopatho­ logy profiling of chronic rhinosinusitis in routine practice. Int Forum Allergy Rhinol. 2012;2(5):376-85. 18. Derebery MJ, Berliner KI. Prevalence of allergy in Meniere’s disease. Otolaryngol Head Neck Surg.: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 2000;123(1 Pt 1):69-75. 19. Bhattacharyya N. Clinical outcomes after revision endo­ scopic sinus surgery. Arch Otolaryngol Head Neck Surg. 2004;130(8):975-8. 20. Bonfils P. [Medical treatment of paranasal sinus polyposis: a prospective study in 181 patients]. Annales d’oto-laryngo­ logie et de chirurgie cervico faciale : bulletin de la Societe d’oto-laryngologie des hopitaux de Paris. 1998;115(4): 202-14. 21. Musy PY, Kountakis SE. Anatomic findings in patients under­ going revision endoscopic sinus surgery. Am J Otolaryngol. 2004;25(6):418-22. 22. Chiu AG, Vaughan WC. Revision endoscopic frontal sinus surgery with surgical navigation. Otolaryngol Head Neck Surg.: Official Journal of American Academy of Otolaryngo­ logy-Head and Neck Surgery. 2004;130(3):312-8. 23. Stankiewicz JA, Chow JM. The low skull base-is it important? Curr Opin Otolaryngol Head Neck Surg. 2005;13(1):19-21. 24. Becker SS. Surgical management of polyps in the treatment of nasal airway obstruction. Otolaryngol Clin North Am. 2009;42(2):377-85, x. 25. Snidvongs K, McLachlan R, Chin D, et al. Osteitic bone: a surrogate marker of eosinophilia in chronic rhinosinusitis. Rhinology. 2012;50(3):299-305. 26. Harvey RJ, Schlosser RJ. Local drug delivery. Otolaryngol Clin North Am. 2009;42(5):829-45, ix. 27. Snidvongs K, Chaowanapanja P, Aeumjaturapat S, et al. Does nasal irrigation enter paranasal sinuses in chronic rhino­ sinusitis? Am J Rhinol. 2008;22(5):483-6. 28. Hyo N, Takano H, Hyo Y. Particle deposition efficiency of therapeutic aerosols in the human maxillary sinus. Rhinol. 1989;27(1):17-26. 29. Harvey R, Hannan SA, Badia L, et al. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database Syst Rev. 2007(3):CD006394. 30. Harvey RJ, Shelton W, Timperley D, et al. Using fixed anatomical landmarks in endoscopic skull base surgery. Am J Rhinol Allergy. 2010;24(4):301-5. 31. Casiano RR. A stepwise surgical technique using the medial orbital floor as the key landmark in performing endoscopic sinus surgery. The Laryngoscope. 2001;111(6):964-74. 32. Dalgorf DM, Harvey RJ. Chapter 1: Sinonasal anatomy and function. Am J Rhinol Allergy. 2013;27 Suppl 1:3-6.

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33. Wormald PJ. Salvage frontal sinus surgery: the endoscopic modified Lothrop procedure. The Laryngoscope. 2003;113 (2):276-83. 34. Wormald PJ, Ananda A, Nair S. Modified endoscopic lothrop as a salvage for the failed osteoplastic flap with oblitera­ tion. The Laryngoscope. 2003;113(11):1988-92. 35. Wormald PJ, Ananda A, Nair S. The modified endoscopic Lothrop procedure in the treatment of complicated chro­ nic frontal sinusitis. Clin Otolaryngol Allied Sci. 2003;28(3): 215-20. 36. Jones V, Virgin F, Riley K, et al. Changing paradigms in frontal sinus cerebrospinal fluid leak repair. Int Forum Allergy Rhinol. 2012;2(3):227-32. 37. Yoon BN, Batra PS, Citardi MJ, et al. Frontal sinus inverted papilloma: surgical strategy based on the site of attachment. Am J Rhinol Allergy. 2009;23(3):337-41. 38. Harvey RJ, Debnath N, Srubiski A, et al. Fluid residuals and drug exposure in nasal irrigation. Otolaryngol Head Neck Surg.: Official Journal of American Academy of Otolaryn­ gology-Head and Neck Surgery. 2009;141(6):757-61. 39. Snidvongs K, Kalish L, Sacks R, et al. Topical steroid for chronic rhinosinusitis without polyps. Cochrane Database Syst Rev. 2011(8):CD009274. 40. McLaughlin RB, Hwang PH, Lanza DC. Endoscopic transseptal frontal sinusotomy: the rationale and results of an alternative technique. Am J Rhinol. 1999;13(4):279-87. 41. Chin D, Snidvongs K, Kalish L, et al. The outside-in app­ roach to the modified endoscopic Lothrop procedure. Laryngoscope. 2012;122(8):1661-9. 42. Gross CW, Zachmann GC, Becker DG, et al. Follow-up of University of Virginia experience with the modified Lothrop procedure. Am J Rhinol. 1997;11(1):49-54. 43. Correa AJ, Duncavage JA, Fortune DS, et al. Osteoplastic flap for obliteration of the frontal sinus: five years’ expe­ rience. Otolaryngol Head Neck Surg.: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 1999;121(6):731-5. 44. Kennedy DW, Zinreich SJ, Shaalan H, et al. Endoscopic mid­ dle meatal antrostomy: theory, technique, and patency. The Laryngoscope. 1987;97(8 Pt 3 Suppl 43):1-9. 45. Gosepath J, Pogodsky T, Mann WJ. Characteristics of recur­ rent chronic rhinosinusitis after previous surgical therapy. Acta Otolaryngol. 2008;128(7):778-84. 46. Richtsmeier WJ. Top 10 reasons for endoscopic maxillary sinus surgery failure. The Laryngoscope. 2001;111(11 Pt 1): 1952-6. 47. Woodworth BA, Parker RO, Schlosser RJ. Modified endo­ scopic medial maxillectomy for chronic maxillary sinusitis. Am J Rhinol. 2006;20(3):317-9. 48. Sathananthar S, Nagaonkar S, Paleri V, et al. Canine fossa puncture and clearance of the maxillary sinus for the seve­ rely diseased maxillary sinus. The Laryngoscope. 2005; 115(6):1026-9. 49. Wang EW, Gullung JL, Schlosser RJ. Modified endoscopic medial maxillectomy for recalcitrant chronic maxillary sinusitis. Int Forum Allergy Rhinol. 2011;1(6):493-7. 50. Schlosser RJ. Surgical salvage for the non-functioning sinus. Otolaryngol Clin North Am. 2010;43(3):591-604, ix-x.

Section 9: Surgery for Inflammatory Sinusitis

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55. Rudmik L, Soler ZM, Orlandi RR, et al. Early postoperative care following endoscopic sinus surgery: an evidence based review with recommendations. Int Forum Allergy Rhinol. 2011;1(6):417 30. 56. Fooanant S, Chaiyasate S, Roongrotwattanasiri K. Com­ parison on the efficacy of dexpanthenol in sea water and saline in postoperative endoscopic sinus surgery. J Med Assoc Tha= Chotmaihet thangphaet. 2008;91(10):1558 63. 57. Pinto JM, Elwany S, Baroody FM, et al. Effects of saline sprays on symptoms after endoscopic sinus surgery. Am J Rhinol. 2006;20(2):191 6. 58. Rudmik L, Smith TL. Evidence based practice: postoperative care in endoscopic sinus surgery. Otolaryngol Clin North Am. 2012;45(5):1019 32.

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51. Georgalas C, Videler W, Freling N, et al. Global Osteitis Scoring Scale and chronic rhinosinusitis: a marker of revi­ sion surgery. Clin Otolaryngol.: Official Journal of ENT UK; Official journal of Netherlands Society for Oto Rhino Laryngology & Cervico Facial Surgery. 2010;35(6):455 61. 52. Lee JT, Kennedy DW, Palmer JN, et al. The incidence of concurrent osteitis in patients with chronic rhinosinusitis: a clinicopathological study. Am J Rhinol. 2006;20(3):278 82. 53. Videler WJ, Georgalas C, Menger DJ, et al. Osteitic bone in recalcitrant chronic rhinosinusitis. Rhinology. 2011;49(2): 139 47. 54. Inanli S, Tutkun A, Batman C, et al. The effect of endoscopic sinus surgery on mucociliary activity and healing of maxil­ lary sinus mucosa. Rhinology. 2000;38(3):120 3.



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Chapter 51: Endoscopic Surgery of the Frontal Sinus

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Chapter

Endoscopic Surgery of the Frontal Sinus

51

Calvin C Wei, Joseph B Jacobs

CHALLENGES TO ACCESSING THE FRONTAL RECESS The frontal sinus is the most difficult sinus to address sur­ gically due to the relatively inaccessible location of the frontal recess above and behind the anterior insertion of the middle turbinate. The close proximity of the medial orbital wall, cribriform plate, anterior ethmoid artery, and anterior cranial fossa impairs visualization and access to the frontal recess. In addition, the high degree of variabi­ lity in frontal cell configuration can make identification of the frontal recess difficult. The presence of frontal recess cells results in mucosal surfaces being in close proximity, increasing the potential for mucosal scarring and frontal sinus stenosis after surgical manipulation. These factors make the maneuvering of instruments in this limited space difficult and increase the risk of surgical failure.1

frontal cells (type I–IV), frontal bullar cells, suprabullar cells, and interfrontal sinus septal cells. There are four types of frontal cells as classified by Bent and Kuhn (Figs. 51.1 to 51.4). These include a type I cell, which is a single cell just above the agger nasi cell; type II cells, which are a tier of air cells above the agger nasi cell; a type III, cell which is a single cell extending into frontal sinus; and a type IV, which is a single cell contained completely within frontal sinus.2 Type I and II frontal cells are located below the level of the frontal sinus floor, while type III and IV frontal extend into the frontal sinus itself. A thorough under­ standing of the configuration of these cells is important

BOUNDARIES OF THE FRONTAL RECESS The boundaries of the frontal recess are the superior attachment of the middle turbinate medially, the lamina papyracea laterally, the skull base superiorly, the nasofrontal beak anteriorly, the ethmoid bulla posteriorly and the inferior wall of the agger nasi cell inferiorly. The frontal recess is a potential space that is funnel-shaped with the most narrow superior portion being the internal frontal sinus ostium. The frontal recess is a space which is subject to narrowing by frontal recess cells, which include the agger nasi cell, supraorbital ethmoid cells,

Fig. 51.1: The type I frontal cell is a single cell above the agger nasi cell.

736

Section 9: Surgery for Inflammatory Sinusitis

Fig. 51.2: Type II frontal cells are a tier of air cells above the agger nasi cell.

Fig. 51.3: The type III frontal cell is a single cell extending into the frontal recess.

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had a long term failure rate of 25% and was associated with frontal bossing, supraorbital neuralgia, donor site complications, and difficulty with postoperative surveil­ lance of mucocele development.1 In 1991, Draf described a series of endoscopic techniques for addressing the frontal sinus ostium with increasing levels of invasiveness (Draf I–III). The goal of these frontal sinusotomy techniques is to create a durable communication between the nasal cavity and frontal sinus specifically tailored to the patho­ logy that is being addressed, whether inflammatory or neoplastic. The most invasive of these techniques, the Draf III procedure, also known as the endoscopic modi­ fied Lothrop procedure (EMLP), was based on the exter­ nal technique invented by Lothrop in the 1800s in which the medial frontal sinus floor, superior nasal septum, and intersinus septum were resected.3 Fig. 51.4: The type IV frontal cell is single cell contained completely within the frontal sinus.

in identifying the frontal sinus outflow tract when per­ forming a frontal recess dissection.

HISTORICAL PERSPECTIVE The osteoplastic flap with frontal sinus obliteration has been accepted as the surgical gold standard for the treat­ ment of chronic frontal sinus until the endoscopic era. The osteoplastic flap with frontal sinus obliteration, however,

DRAF I DRAINAGE The Draf I frontal sinusotomy is the least invasive of the frontal sinus approaches. The Draf I sinusotomy consists of a thorough removal of the anterosuperior ethmoidal cells obstructing the frontal sinus outflow tract and does not manipulate the frontal recess itself.

Indications Draf recommends that the Draf I drainage procedure be utilized when chronic frontal sinusitis is the result of

Chapter 51: Endoscopic Surgery of the Frontal Sinus

737

obstruction of the frontal sinus outflow tract at the level of the frontal recess, either from inflammatory or iatrogenic causes.4 The Draf I sinusotomy clears ethmoidal disease inferior to the level of the frontal ostium and restores ventilation of the frontal sinus by relieving obstruction of the frontal sinus outflow tract. The Draf I sinusotomy can also be utilized in revision endoscopic sinus surgery when residual ethmoid partitions obstruct the frontal sinus outflow tract.

Perioperative Considerations Examination of the CT before starting the Draf I drainage should focus on identification of high risk anatomy, including the presence of the anterior ethmoid artery below the skull base, dehiscence of the lamina papyracea (especially in revision surgery), the depth of the lateral cribriform lamella and the height and slope of the ethmoid skull base. The CT should also be studied to determine the location of the frontal sinus outflow tract in relation to frontal cells, including the agger nasi, frontal, and suprabullar cells. For example, an agger nasi cell will displace the frontal sinus outflow tract posteriorly and a suprabullar cell will displace the frontal sinus outflow tract anteriorly. While the agger nasi cell itself is not removed during a Draf I frontal sinusotomy, the precise localization of the frontal sinus outflow tract will allow successful clearance of the anterosuperior ethmoid cells obstructing the frontal sinus outflow tract.

Technique After middle turbinate medialization, uncinectomy, and ethmoidectomy are performed, a 45° mushroom punch, Bachert and Hosemann forceps are used to remove anterosuperior ethmoid cells that are obstructing the frontal sinus outflow tract. The mucosa of the frontal sinus outflow tract is carefully preserved without manipulating cells within the frontal recess itself. A 30, 45, and/or 70° endoscope may be helpful in visualization of the anterosuperior ethmoid cells.

DRAF IIA DRAINAGE The Draf IIA frontal sinusotomy involves removal of the frontal cells that extend into the frontal recess (Fig. 51.5). By removing these cells that impinge on the frontal sinus outflow tract, the frontal recess is cleared to its maximal extent. The frontal recess cells which may impinge on

Fig. 51.5: The Draf IIA procedure removes the frontal cells that protrude into the frontal recess.

the frontal sinus outflow tract include the agger nasi cell, supraorbital ethmoid cells, type I–IV frontal cells, frontal bullar cells, suprabullar cells, and interfrontal sinus septal cells. Removal of the agger nasi cell (“uncapping the egg”) and the anterior wall of the ethmoid bulla will most commonly reveal the frontal recess and allow clearance of the frontal recess by removal of adjacent frontal recess cells.

Indications Indications for Draf IIA drainage include chronic rhino­ sinusitis that involves the frontal recess or sinus, nasal polyps obstructing the frontal sinus outflow tract or involv­ ing the frontal sinus, complicated acute frontal sinu­ sitis necessitating immediate drainage, medially based frontal sinus mucoceles, and removal of benign tumors including osteomas and inverted papillomas involving the medial aspect of the frontal sinus. Draf suggests that the presence of healthy mucosa is a prerequisite for per­ forming the Draf IIA sinusotomy in order to ensure that the widened frontal ostium heals open.4 Anatomic con­ siderations should also be weighed before performing the Draf IIA sinusotomy. The Draf IIA sinusotomy is more likely to be successful when the removal of frontal recess cells yields a wide natural frontonasal outflow tract.5 A type IIA drainage procedure is recommended in fron­ tal sinuses with a large anterior-posterior dia­meter with

Section 9: Surgery for Inflammatory Sinusitis through cutting frontal sinus punches. Angled giraffe forceps can also be used to remove free bony partitions. A common pitfall of the Draf IIA frontal sinusotomy is failure to remove the superior cap of the agger nasi cell when mistaking the endoscopic appearance of the agger nasi cell body for the frontal sinus itself. Additional frontal cells that impinge upon the frontal sinus outflow tract are resected. Frontal cells (types I–IV) can be down fractured and removed with a combination of through cutting forceps and giraffe forceps. Type III and type IV cells, due to their superior based location within the frontal sinus, may necessitate trephination if located beyond the reaches of standard frontal sinus instrumentation. Resection of the bony partition between the supraorbital ethmoid cell and frontal ostium may widen the frontal recess further. The supraorbital ethmoid cell results from pneumatization of orbital plate of the frontal bone by air cells from the frontal recess or suprabullar recess. It is usually located posterior to the frontal ostium and anterior to the anterior ethmoid artery and may narrow the frontal recess posteriorly. If the supraorbital ethmoid cell is present, the partition between it and the frontal ostium can be resected using a through cutting forceps. It is important not to mistake the supraorbital recess for the frontal sinus itself. The supraorbital ethmoid cell is removed in a similar fashion with through cutting forceps with particular attention paid to identifying and protecting the skull base.

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Thorough evaluation of a CT scan is essential before per­ forming a Draf IIA drainage procedure. The sagittal view of the frontal recess provides critical information about the anterior posterior dimension of the frontal recess. A larger anterior posterior frontal recess dimension allows greater room for manipulation of instrumentation and less chance for injury to the skull base. A greater working dimension also prevents stripping and trauma to the nasal mucosa which may lead to frontal ostium stenosis and osteoneogenesis. The sagittal view provides the best overview of the cell configurations that may impinge on the frontal recess. As discussed earlier, these include the agger nasi cell, supraorbital ethmoid cells, type I–IV frontal cells, frontal bullar cells, suprabullar cells, and interfrontal sinus septal cells. Preoperative understanding of the configuration of these cells facilitates their complete removal.

Technique After performing a standard uncinectomy, maxillary antrostomy, anterior and posterior ethmoidectomy and sphenoidectomy as warranted, the anterior ethmoid artery is defined at the insertion of the basal lamella of the middle turbinate at the skull base. This area marks the transition between the axial and coronal planes of the skull base. Accurate identification of the medial orbital wall and skull base are essential. The frontal sinus outflow tract is identified by using direct visualization and by probing with frontal sinus seekers or angled curettes. The most common configuration of the frontal recess is the agger nasi cell anteriorly and the supraorbital ethmoid and ethmoid bulla posteriorly; thus, the frontal sinus outflow tract will be located between these bony partitions. The cell walls are fractured anteriorly and inferiorly and the resulting bony fragments are removed with 55° and/or 90° Kuhn

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Perioperative Considerations

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an anticipated minimum diameter of the frontal neo ostium of 5 mm or more.6 It is also indicated in those patients with a hypoplastic internal nasal spine and a broad ethmoid.4 As the majority of revision frontal sinus surgery is performed to address remnant uncinate pro­ cesses, agger nasi cell partitions and/or frontal recess cells, the Draf IIA sinusotomy is sufficient for the majority of revision cases if the anterior posterior dimension of the frontal sinus is sufficient for the frontal recess to remain patent after surgery.

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DRAF IIB DRAINAGE A Draf IIB drainage involves unilateral resection of the frontal sinus floor between the lamina papyracea and the nasal septum (Fig. 51.6). The head of the middle turbinate is resected to gain access the medial frontal sinus floor. A combination of punches or drills may be used depend­ ing on the thickness of the frontal sinus floor. The Draf IIB sinusotomy creates the maximal opening of the frontal sinus on one side.4

Indications Indications for Draf IIB drainage include revision frontal sinus surgery for persistent frontal sinus disease or significant osteoneogenesis of the frontal recess, and pathology that involves the lateral aspect of the frontal sinus. Draf writes that the recommended indications for type IIB drainage include all indications for a type IIA drainage; however, if the resulting frontal sinus ostium is less than 5 × 7 mm from the type IIA approach, a type IIB

Chapter 51: Endoscopic Surgery of the Frontal Sinus

Fig. 51.6: The Draf IIB procedure removes the frontal sinus floor from the lamina papyracea to the nasal septum.

drainage should be performed. While the Draf IIB drain­ age is not usually performed as an initial procedure, the presence of a narrow anterior-posterior or medial-lateral dimension, osteitic middle turbinate and/or the presence of an interfrontal septal cell may necessitate a Draf IIB sinusotomy to create a durably patent frontal ostium.7

Perioperative Considerations Perioperative considerations for the Draf IIB frontal sinusotomy are similar to those of the Draf IIA procedure. The axial view on CT is helpful for assessing the anteriorposterior dimension of the frontal sinus floor that will be removed during the procedure. The depth of the lateral cribriform plate should be examined to prevent violation of the skull base medially.

Technique A type IIB frontal sinusotomy is performed by resecting the frontal sinus floor medially from the lamina papyracea to the nasal septum. After the frontal ostium is clearly identified, an upturned mushroom punch or Hosemann punch are used to remove the frontal sinus floor. After the anterior-posterior dimension of the frontal recess is identified, the medial-lateral dimension of the sinusotomy is widened. Extending the frontal sinusotomy into an interfrontal septal cell is another technique to widen the frontal recess.

739

Fig. 51.7: The Draf III procedure removes the frontal sinus floor from the lamina papyracea to the contralateral lamina papyracea.

DRAF III DRAINAGE The Draf III procedure, otherwise known as the endo­ scopic modified Lothrop procedure (EMLP), creates the maximal communication of the frontal sinus into the nasal cavity by removal of the superior nasal septum and fron­ tal sinus floor from lamina papyracea to the contra­lateral lamina (Fig. 51.7). Draf first described the endoscopic modification of the Lothrop procedure in 1991.

Indications The Draf III sinusotomy is indicated when endoscopic frontal sinusotomy has failed. The presence of neo-oste­ ogenesis or poor-quality mucosa would also necessitate a Draf III sinusotomy to create a durable frontal sinusotomy. While not usually performed as an initial procedure, Draf suggests this procedure as the primary surgery in patients with poor prognostic factors, which include severe poly­ posis, Samter's triad, mucoviscidosis, Kartagener’s syndrome, and ciliary immotile syndrome. He also recommends a Draf III approach for the removal of benign tumors, including inverted papilloma and osteomas that are loca­ted medial to a vertical line through the lamina papyracea, in addition to certain malignant tumors that just reach the frontal recess.8 Certain anatomic factors, such as frontal sinuses with a narrow anterior-posterior diameter, a hyper­ plastic internal nasal spine or a highly narrow ethmoid cavity would favor utilizing the Draf III approach.4

Section 9: Surgery for Inflammatory Sinusitis

Postoperative Care For the entire spectrum of Draf frontal sinusotomies, postoperative care is essential to maintaining patency of the frontal recess or frontal neo ostium. After performing Draf IIA, IIB, and III drainage procedures, it is essential to debride the frontal recess or frontal neo ostium of blood clot and mucous to prevent superinfection, restenosis, or mucosal scar formation. The timing of postoperative debridement varies between surgeons, but typically occurs from postoperative day 3–7. Medical management during the postoperative period is crucial. Some authors use soft, flexible silastic stents, or finger stalls to facilitate hemostasis and re epithelialization of denuded bone.

OUTCOMES OF DRAF PROCEDURES The vast majority of outcome studies for endoscopic frontal sinus surgery centers on the Draf III procedure, otherwise known as the endoscopic modified Lothrop procedure (EMLP). Several evidenced based reviews have been performed evaluating the efficacy of EMLP versus osteoplastic flap for the management of frontal sinus disease. The osteoplastic flap with frontal sinus obliteration is the gold standard against which the EMLP is compared.13 However, assessing outcomes of the EMLP is difficult secondary to the lack of studies with long term follow up. -

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After a frontoethmoidectomy is performed and the skull base and lamina papyracea are clearly visualized, the head of the middle turbinate is removed using angled frontal through cutting forceps. The frontal ostium is widened and removal of frontal cells impinging upon the frontal recess is performed with a combination of Bachert, upbiting mushroom, and angled frontal through cutting instruments. Removal of the frontal sinus floor proceeds from the ipsilateral lamina papyracea to the septum using frontal sinus punches. This series of maneuvers is also performed on the contralateral side. The superior nasal septum is removed. The diameter of this opening should be approximately 1.5 cm.4 The removal of the superior nasal septum at the junction of the superior nasal septum at the junction of the quadrangular cartilage and perpendicular plate of the ethmoid is important to facilitate the removal of the medial frontal sinus floor and assists in widening the surgical field.8 The triangle of bone formed by the anterior frontal sinus floor known as the nasofrontal beak is removed with a burr. Identification of the first olfactory fiber forms the posterior boundary of the sinusotomy to prevent violation of the cribriform plate. Special care should be made to avoid circumferential mucosal injury,

The possible complications for the Draf I–III frontal sinusotomies are similar and include injury to the skull base with dural laceration and CSF leak, injury to the peri­ orbita, and postoperative disturbance of sense of smell. As the anatomy encountered during Draf procedures, especially in revision cases, can be distorted with absent anatomic landmarks, the accurate identification of the medial orbital wall and the skull base is essential to avoiding complications.

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Technique

Complications

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Of critical importance when determining the feasibility of the Draf III approach is the total anteroposterior dimension at the floor of the frontal sinus. While the exact cutoff varies between studies, a good working distance would be at least 1.5 cm.10 This measurement includes the thickness of the nasal beak. Narrower anteroposterior dimensions make manipulation of instrumentation difficult and increase the risk of injury to the skull base. Another measurement to take into account is the so called “accessible dimension” that represents the space available to maneuver instruments within the frontal ostium and to remove the frontal sinus floor. This dimension is defined as the distance between the tangential line to the skull base into the frontal sinus and the tangential line to the posterior aspect of the nasal beak. This distance should be more than 5 mm to ensure adequate space for frontal sinus instrumentation.11

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Perioperative Considerations

particularly at the lateral and posterior mucosal margins of the frontal sinus. Messerklinger found that frontal sinus cilia transport mucus up the interfrontal sinus septum, across the frontal sinus roof in a lateral direction, and medially along the frontal sinus floor to the ostium.12 Forty to sixty percent of mucus is cleared out of the frontal sinus along the lateral aspect of the frontal recess; thus, it is critical that injury to the lateral frontal sinus mucosa be minimized.

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Contraindications to the EMLP include small, underdeve­ loped frontal sinuses and a narrow anteroposterior dia­ meter between the anterior skull base and nasal bones.9

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Chapter 51: Endoscopic Surgery of the Frontal Sinus Determining the results of endoscopic frontal sinus surgery requires a long postoperative follow-up, as frontal sinus stenosis can occur years after frontal sinus surgery.14 While the osteoplastic flap with frontal sinus obliteration has success rates of 93% with an 8-year follow-up as quoted in the literature, it is not without significant morbidity, includ­ ing forehead numbness, frontal bossing, osteomyelitis of the frontal bone flap and mucocele formation.15 In addi­ tion, the procedure has possible complications that are secondary to misdirected osteotomies beyond the confines of the frontal sinuses, including dural exposure, dural lacera­ tion with cerebrospinal fluid leak, and orbital injury.16 Anderson et al. performed a literature search and metaanalysis of studies examining the safety and efficacy of the EMLP. They found 18 studies that fulfilled their inclusion criteria, nine of which were level II-2 evidence and nine of which were level III-3 evidence. The indications, preoperative evaluation, surgical details, and outcomes for EMLP were evaluated for this aggregate population of 612 patients. They found that the most common indications for EMLP formation were chronic frontal sinusitis (75.2%) and mucocele (21.3%). Almost all EMLP patients (> 99%) were discharged home within 24 h of surgery. The rate of major complications, which included CSF leak, tension pneumocephalus and posterior table dehiscence, occur­ red in less than  1% of patients; and minor complications, including increased crust formation, epistaxis, anosmia or hyposmia, nasal bone dehiscence, philtral pressure ulcer and transient blurry vision, occurred in 4% of this population. Objective, direct endoscopic evaluation of the frontal sinus cavity following surgery was performed in 12 of these studies. In these patients, serial examination of the frontal cavity revealed patency or partial stenosis in 95.9% at last follow-up. Most studies noted that stenosis of the neo-ostium occurred within the first year following surgery.13 Subjective symptom data were also examined following EMLP. A total of 82% of patients reported significant improvement or total resolution of their frontal symptoms, 16% reported no significant change, and 1.2% reported worsening of their symptoms. They found that the failure rate of EMLP, defined as the need for any revi­ sion surgery in the frontal sinus, was 13.9% (85 out of 612 patients).

Frontal Sinus Rescue The frontal sinus rescue procedure is formally known as the revision endoscopic frontal sinusotomy with

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mucoperiosteal flap advancement. This procedure is an alternative technique to the Draf IIA, IIB, III drainage procedures and is specifically utilized when frontal sinus stenosis occurs after endoscopic sinus surgery when a destabilized, partially resected middle turbinate moves laterally and compromises the patency of the frontal recess.

Technique Under endoscopic visualization with a 45° or 70° endo­ scope, the lateral attachment or adhesion of the middle turbinate remnant is released. Mucosa from the medial and lateral aspect of the middle turbinate is elevated. The medial based mucoperiosteal flap is developed. The bony middle turbinate remnant is removed using a giraffe for­ ceps. The lateral based mucoperiosteal flap is preserved and advanced over the former middle turbinate attach­ ment point. The mucosa of the lateral frontal recess is not disturbed as natural mucociliary flow of the frontal sinus is directed along the lateral frontal recess. An extended fron­ tal sinus rescue procedure has also been described when the frontal recess is too narrow for adequate mucus clear­ ance. A channel is cut into the middle turbinate from its attachment at the agger nasi to its skull base attachment; the lateral based mucoperiosteal flap is then preserved and advanced as with the frontal sinus rescue procedure.17

COMBINED ABOVE AND BELOW APPROACH The first description of the combined endoscopic trephi­ nation and frontal sinusotomy was made by Wigand in 1978.18 The Above and Below approach consists of the standard endoscopic view combined with an additional trephination through which angled endoscopes can be inserted to further visualize the frontal sinus from above. In certain situations in which a purely endoscopic approach is inadequate, the combined Above and Below approach may be indicated. Indications for the Above and Below approach include laterally based frontal sinus lesions; obstructive type III or IV frontal cells; large tumors or inflammatory lesions involving the lateral frontal sinus including osteomas, inverted papillomas or fibrous dys­ plasia; frontal sinus trauma with involvement of the frontal recess or posterior table; revision frontal sinus cases with extensive scarring or neo-osteogenesis; and emergent decompression of Pott’s puffy tumor.

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Once the endoscopic frontal recess dissection is per­ formed to its full extent, the external approach is initiated. A 1–2 cm incision is made through the medial eyebrow. A self retaining retractor is placed. A 4 mm drill bit is used to perform the external trephination and a Kerrison ron­ geur is used to enlarge the trephination. An angled endo­ scope is inserted through the trephine and the remaining pathology is visualized through the trephine. The location of the trephination can be altered to target the pathology being addressed. While the standard incision for trephina­ tion is located in the brow line medial to the supraorbital neurovascular bundle, the incision can be placed lateral to the supraorbital notch for management of lateral frontal sinus mucoceles or osteomas.19 Image guided trephina­ tion has also been utilized to localize the trephination loca­ tion to the precise pathology within the frontal sinus.20 The supraorbital and supratrochlear neurovascular bundles must be protected during trephination. The trephine can be enlarged to 6–8 mm to allow both the endoscope and instrumentation to be passed through it. Additional pathology, whether it be a residual superior aspect of a type III or IV frontal cell, inverted papilloma, or osteoma, can be resected using appropriate instrumentation.



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6. Schaefer SD, Close LG. Endoscopic management of frontal sinus disease. Laryngoscope. 1990;100:155 60. 7. Eviatar E, Katzenell U, Segal S, et al. The endoscopic Draf II frontal sinusotomy: non navigated approach. Rhinology. 2006;44:108 13. 8. Draf W, Minovi A. The “frontal T” in the refinement of endonasal frontal sinus type III drainage. Oper Tech Otolaryngol. 2006;17:121 5. 9. Wormald PJ, McDonogh M. ‘Bath plug’ technique for the endoscopic management of cerebrospinal fluid leaks. J Laryngol Otol. 1997;111(11):1042 6. 10. Gross CW, Harrison SE. The modified Lothrop procedure: indications, results and complications. Otolaryngol Clin North Am. 2001;34(1):133 7. 11. Farhat FT, Figueroa RE, Kountakis SE. Anatomic measure­ ments for the endoscopic modified Lothrop procedure. Am J Rhinol. 2005;19(3):293 6. 12. Messerklinger W. On the drainage of the normal frontal sinus of man. Acta Otolaryngol. 1967;63(2):176 81. 13. Anderson P, Sindwani R. Safety and efficacy of the endo­ scopic modified Lothrop procedure: a systematic review and meta analysis. Laryngoscope. 2009;119:1828 33. 14. Kennedy DW, Senior BA. Endoscopic sinus surgery: a review. Otolaryngol Clin North Am. 1997;30:313 29. 15. Hardy JM, Montgomery WW. Osteoplastic frontal sinuso­ tomy: an analysis of 250 operations. Ann Otol Rhinol Laryngol. 1976;85(4):523 32. 16. Weber R, Draf W, Keerl R, et al. Osteoplastic frontal sinus surgery with fat obliteration: technique and long term results using magnetic resonance imaging in 82 operations. Laryngoscope. 2000;110(6):1037 44. 17. Kuhn FA. An integrated approach to frontal sinus surgery. Otolaryngol Clin North Am. 2006;39(3):437 61. 18. Wigand ME, Steiner W, Jaumann MP. Endonasal sinus surgery with endoscopic control: from radical operation to rehabilitation of the mucosa. Endoscopy. 1978;10:255 60. 19. Batra PS, Citardi MJ, Lanza DC. Combined endoscopic trephination and endoscopic frontal sinusotomy for management of complex frontal sinus pathology. Am J Rhinol. 2005;19(5):435 41. 20. Zacharek MA, Fong KJ, Hwang PH. Image guided frontal trephination: a minimally invasive approach for hard to reach frontal sinus disease. Otolaryngol Head Neck Surg. 2006;135(4):518 22.



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1. Wormald PJ. Salvage frontal sinus surgery: the endoscopic modified Lothrop procedure. Laryngoscope. 2003;113:276 83. 2. Bent JP, Cuilty Siller C, Kuhn FA. The frontal cell as a cause of frontal sinus obstruction. Am J Rhinol. 1994;8(4):185 91. 3. Jacobs JB. 100 years of frontal sinus surgery. Laryngoscope. 1997;107(S83):1 36. 4. Weber R, Draf W, Kratzsch B, et al. Modern concepts of frontal sinus surgery. Laryngoscope. 2001;111:137 46. 5. Kuhn FA, Bolger WE, Tisdahl RG. The agger nasi cell in frontal recess obstruction: an anatomic, radiologic and clinical correlation. Oper Tech Otolaryngol Head Neck Surg. 1991;2:226 31.



REFERENCES

Chapter 52: Minimally Invasive Sinus Surgery and Balloon Sinuplasty

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Chapter

Minimally Invasive Sinus Surgery and Balloon Sinuplasty

52

Peter J Catalano The field of rhinology has undergone significant change and has seen substantial innovation over the past 15 years, with much more to come in the near term. However, before we can move forward, we must have a solid understanding of the past, so we can participate in the innovation and help create the future. In this chapter, the topics of minimally invasive sinus surgery and balloon sinuplasty (BSP) will be addressed, as both have had a significant hand in moving the specialty forward. Minimally invasive sinus surgery must not be confused with minimal access surgery. The latter simply means we use an “abdominal port” instead of an incision, or a single burr hole instead of a craniotomy. In the case of rhinology, we use the nostrils instead of facial incisions. What defines minimally invasive surgery is what happens after minimal access is achieved, and it is here that consensus is often lost. At present, functional endoscopic sinus surgery (FESS) has no definition, other than that it is performed using an endoscope with minimal access to the nose and sinuses via the nostrils. Beyond this, there is no consensus on what FESS means, how it should be performed, its goals, and how to measure its outcomes. Are we treating a patient or an X-ray? Why do we require a different burden of proof for different procedures, and different authors? Despite the progress in rhinology, there are many unsettled and confusing issues for many of us. In this chapter, I will define MIST, and answer these troubling questions. MIST, or minimally invasive sinus techniques, is the embodiment of minimally invasive sinus surgery and was the first truly minimally invasive sinus procedure descri­ bed. MIST is unique for the following reasons:

• It is the only intranasal sinus procedure with a defined beginning and end; thus the surgeon knows when to stop operating (a novel concept!). • It is based on a step-wise anatomic progression, which allows the surgeon to perform the operation in a structured manner, akin to all other surgical proce­ dures (i.e. parotidectomy). • It is consistent and reproducible from patient to patient, so that if someone were to say “I had a MIST procedure,” everyone would know what operation was performed. This is in contrast to FESS, which transfers little information to the patient or treating physicians. • It leaves all ostia intact, and instead targets the sinus transition spaces (ethmoidal infundibulum, frontal recess, and hiatus semilunaris superioris). • It leaves no bone exposed at the end of the procedure, thus preserving all mucosa, even if edematous and seemingly diseased (mucosal reversibility). • It minimizes the use of forceps or “grab and tear” metal instruments in favor of dissection with a microdebrider which permits real time suction and true tissue cutting at the tip of the instrument. • It does not use nasal packing, septal splints or sutures. • It preserves the middle turbinates. • It does not require postoperative debridement (Figs. 52.1 to 52.5). If one compares this definition to what is currently done under the guise of “functional” sinus surgery, the differences should be readily apparent. Thus, MIST is a targeted tissue sparing procedure that is consistent from one patient to the next, and whose goal is to perform the

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Section 9: Surgery for Inflammatory Sinusitis

Fig. 52.1: Injection sites into the left middle turbinate (MT) prior to MIST. (S: Nasal septum).

Fig. 52.2: Pediatric backbiter is placed into the middle meatus, then opened so that the cutting blade can be placed into the ethmoidal infundibulum via the hiatus semilunaris. (UP: Uncinate process; MT: Middle turbinate).

Fig. 52.3: After uncinotomy with the backbiter, a microdebrider is used to remove the remainder of the uncinate process (UP). (EB: Ethmoid bulla).

Fig. 52.4: A complete uncinectomy is performed, exposing the maxillary sinus ostium inferiorly, the ethmoid bulla (EB), and the hiatus semilunaris superioris (arrows).

Fig. 52.5: Ethmoid bulla removed with a microdebider, showing the maxillary sinus osmium (MO), anterior ethmoid sinus ostium at tip of seeker, and anterior ethmoid sinus drainage pathway via the hiatus semilunaris superioris (HSS).

Chapter 52: Minimally Invasive Sinus Surgery and Balloon Sinuplasty minimal amount of surgery required to restore normal function to the nose and sinuses. It is a patient-centric procedure, meaning it is designed to address patient symptoms, not the extent of disease on a CT image. It is important to obtain CT imaging in all patients seen with a chronic sinus history; however, one must remember that CT imaging is only one piece of data, one test result, and should be used to aid the physician in his/her decision making and management. It is not the ultimate or definitive piece of information upon which management should be based. One of the main tenants of MIST is that sinus disease, mucosal disease, is reversible and that aggressive surgery is not required to make patients better. There are several peer-reviewed manuscripts on outcomes from MIST,1–5 and all are very favorable, thus proving that a maxillary sinus antrostomy (MSA) is not required as a routine part of ESS. In fact, there are now compelling data to show that an MSA can actually promote more virulent sinus bacteria and lead to biofilm formation.6 The take home message here is that while an MSA can work, it is not necessary in the majority of sinus procedures. Furthermore, there is not a single medical article that proves the need for, or efficacy of, an MSA! There is NO DATA to support a procedure that has been performed as a matter of routine, since 1987, and yet there is convincing data to show that an MSA is not needed and that there is no functionally critical size for maxillary sinus ostia. I have visited many sinus surgeons in their operating rooms over the years and just as they were about to make an MSA I would ask, “Why are you going to do that?” The answers I received in almost all cases were either “Because that is what I always do?,” or “Isn’t that what you were taught?,” or “Because we have to open the sinus and look inside.” These replies prove nothing more than a simple truth—that surgeons are often victims of their training and experience. While we all rely on the teachings of our mentors, I would hope there is no mentor who believes that a student’s learning ended when they graduated from residency or fellowship, or that management of patients in 1987 should be the same as in 2013. Learning is a continuous process that extends throughout one’s career and it is impossible for any one person to know all, or to anticipate new information that might alter patient management in the future. For if changes were not inevitable and necessary, we would still be using candles, riding horses, and walking barefoot. The irony is that the concepts of MIST are not new, and actually precede those of contemporary ESS where an MSA is commonplace. Messerklinger’s “functional” concepts

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did not include an MSA, and its origin remains elusive to this day. Messerklinger7 believed in the reversibility of diseased mucosa, in transition space surgery instead of surgery on the sinus itself, in sparing mucosa and middle turbinates, and restoring mucociliary function by eliminating mucosal contact. It is the departure from these principles that has allowed for MIST to emerge and for new technology to transform rhinology. The history of MIST begins with Messerklinger; however, he did not describe a technique as much as he provided a philosophy of management. This is likely why the MSA “crept” into the FESS procedure and became routine. After Messerklinger, there was a hiatus until the mid-1990s when Reuben Setliff, frustrated by his results with FESS, searched for a better alternative. In 1994, he introduced what was then called “small-hole surgery” and first presented his technique in a chapter in Otolaryngology Clinics of North America.8,9 Reuben realized that the MSA was more of a problem than a solution and thought by avoiding the MSA, surgical morbidity would be reduced, revision rates would be lowered, and outcomes might even improve. In about 1994, he first introduced the microdebrider,10 thereby eliminating the need for the typi­ cal “grab and tear” forceps of the day, and provided true cutting capability and real-time suction at the working end of the device. We are all aware of how this technology has revolutionized rhinologic surgery worldwide, but few realize that it was also this technology that allowed “smallhole surgery” to be done with even less morbidity than had been predicted or appreciated. At this same time, Dave Parson introduced the retro­ grade approach10 to the uncinate process and ethmoid infundibulum. This technique eliminated the risks and inaccuracies of using a sickle knife to incise the anterior attachment of the uncinate to the lateral nasal wall. Retrograde approach allowed the surgeon to open the infundibulum from a posterior-medial position, which is furthest from the lamina papyracea and therefore a much safer technique. The risk of orbital injury has been significantly reduced by use of this retrograde approach. Figures 52.1 to 52.7 demonstrate the step-wise anatomical progression that is the hallmark of the MIST procedure. In the late 1990s—early 2000 time period, all the elements were in place for consolidation into what was to be called MIST—the minimally invasive sinus technique. Thus, MIST combined Setliff’s philosophy of small-hole surgery, with the true cutting accuracy of the microde­ brider, and the retrograde uncinotomy described by Parson. Outcomes from MIST were reported in 20032 and

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Section 9: Surgery for Inflammatory Sinusitis

showed for the first time that less invasive, targeted sinus surgery (without an MSA) could reliably produce dura­ ble results that were even better than those from FESS. The authors compared 100 patients who had MIST with 100 patients previously reported by Glichlich et al. who had FESS. The FESS group results were reported after a followup of 1 year while the MIST outcomes were reported after a follow-up of 2 years. Both groups were closely matched with respect to demographics and extent of disease, and both studies used the chronic sinusitis survey that was the only validated outcome metric for rhinology at the time. Morbidity in the MIST group was extremely low and the revision rate over the 2-year period was only 6%. Interpretation of this last bit of data means that 94% of patients were treated appropriately with a less invasive procedure, while 6% needed more surgery than originally appreciated. It also means that had FESS been performed initially, 94% of patients would have been “overoperated upon,” or subjected to a larger, more morbid operation than necessary. It is this latter point that is the crucial and validating point in minimally invasive rhinology—namely that the vast majority of patients need a targeted and limited intranasal intervention to eliminate symptoms, and therefore procedures such as MIST should be the initial surgical procedure, or procedure of choice, for treating inflammatory sinus disease. To further prove the reduced morbidity of MIST, a subsequent study was performed and published on MIST in the geriatric population, aged 65–93 years.1 The purpose

of this study was to evaluate if MIST produced an increase in surgical or medical comorbidities in the elderly. The results again showed that surgical morbidity was extremely low and exacerbation of medical comorbidities was similarly very low. The later included minor complications such as urinary retention (1), transiently elevated blood pressure (2), transient atrial fibrillation (1), and selflimiting dizziness (2). The main outcome point was that MIST could be safely performed in the oldest, most frail members of society with very low surgical and medical morbidity, thus availing these patients of a surgical option for their chronic sinusitis that might not have been considered with FESS. In 2004, Albu and Tomescu5 from Romania published their report on 133 patients who underwent ESS and either had an uncinectomy or MSA (follow-up was 19 months). They concluded that “the size of the maxillary sinus open ing had no influence on the outcome of ESS for chronic maxil lary sinusitis.” Their work further supports the concept that an MSA is unnecessary in most patients and should not be performed as a routine part of ESS. Currently, my indications for an MSA are limited and include surgery in the pterygopalatine space, removal of inverted papilloma from the maxillary sinus, creation of a mega-antrostomy in cases of recalcitrant maxillary sinusitis, and patients with Sampter’s triad or fungal sinusitis. In the latter two cases, the MSA is no larger than 10 mm. It is important to remember that the surgeon can always revise his/her surgery and perform an MSA if

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Fig. 52.7: At the completion of the procedure, a thin piece of gelfilm (GF) may be placed between the septum and the MT, and an absorbable dressing (N) is placed in the middle meatus.



Fig. 52.6: At completion of MIST dissection, the ethmoid bulla (EB) is opened. The middle turbinate (MT) is preserved, and the frontal recess leading to the frontal sinus can often be visualized (arrow). (LP: Lamina papyracea).

Chapter 52: Minimally Invasive Sinus Surgery and Balloon Sinuplasty

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Fig. 52.8: Suction-capable guide catheter.

Fig. 52.9: Various balloon catheters.

clinically indicated; hence, the 6% revision rate reported for MIST. In my experience, most patients want the least amount of surgery possible. When performing MIST, the surgeon should counsel the patient that a limited proce­ dure is appropriate for their condition and that a 5 mm. In the case of the latter, mucosal tears are linear in nature and heal quickly without clinical consequence. Circumferential tears are more likely to cause secondary contracture and are rarely, if ever, seen with proper BSP technique. BSP tools can be used alone as a sole intervention for one or more sinuses, or in combination with more conventional endoscopic sinus surgical techniques, the so-called hybrid procedure. The most common scenario

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Fig. 52.16: Osmotic dilation device.

Chapter 52: Minimally Invasive Sinus Surgery and Balloon Sinuplasty nose with highest flow rates between the middle turbinate and lateral nasal wall. Xiong et al. then repeated their experiments using CT images from post-ESS patients who had a surgical ethmoidectomy and MSA. In these patients, there is a striking increase in maxillary and ethmoid sinus airflow. Khirene et al. recently measured intrasinus airflow before and after various sized MSAs and found that measurable airflow occurred within the maxillary sinus once the size of the middle meatal opening exceeded 20 mm2.14 Coincidentally, the cross-sectional area of a 5 mm diameter sinus balloon is exactly 20 mm2. This natural mechanical defense mechanism of the sinuses suggests that the uncinate process and anterior middle turbinate help filter inspired air and prevent exposure of the sinus mucosa to inhaled debris in the form of pollutants, allergens, carcinogens, etc. There is a second natural defense mechanism that exists within the paranasal sinuses, herein termed the chemical defense mechanism. The latter consists of an interesting molecule called “NO,” or nitric oxide.15 The molecule is not the same as nitrous oxide (N2O), the general anesthetic. NO is made within the maxillary sinus by the enzyme nitric oxide synthase. Research has shown that the natural concentration of NO within the normal maxillary sinus reaches toxic concentrations if inhaled. However, at these concentrations, NO has local antiviral, antibiotic, and antifungal properties, and will increase ciliary beat frequency. In fact, the Nobel Prize was awarded in the mid-1990s to researchers who discovered the vasodilatory effects of NO and labeled it a signaling molecule within the body.16 We have come to learn that NO comes in many forms. The free radical form is present within the vascular system and has a very short half-life, whereas the form active within the sinuses and airway is not a free radical and can persist for up to 11 minutes. It has also been shown that small amounts of NO (approximately 3 parts per billion) are inhaled into the lungs with each breath. Inhaled NO at this concentration has a vasodilatory effect on the lung increasing oxygen absorption. Inhalation of NO is now used as a therapy for hypoxic infants with immature pulmonary systems.17 Diffusion of gas from within the normal maxillary sinus has been shown by several researchers to be very slow, taking up to minutes to completely replace its volume by simple diffusion. NO is also heavier than air, thus the highest concentrations of NO occur at the floor of the maxillary pyramid depending upon the patient’s position. Note that the maxillary os is always at the apex of the

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pyramid when we are in either the upright, supine, or lateral position. Thus, with the uncinate process in place, a small amount of NO leaks out of the maxillary sinus and into the lung with each inspiration. Subsequently, NO has a positive physiologic effect on oxygen uptake and sinus health. Furthermore, NO levels in inspired or exhaled air are undetectable after ESS in which an MSA has been performed. Thus, the washout of maxillary sinus NO, as predicted by Xiong, is a consequence of the MSA and may have untoward physiologic consequences as discussed next. Can all of these findings relative to sinus airflow and NO production and function be purely coincidental? Is the bacteriology of recurrent CRS after ESS (virulent atypical organisms like Pseudomonus, Escherichia coli, and Klebsiella) in any way related to the loss of NO from the sinus after an MSA? Is uncinate preservation more important to the delicate balance of the gaseous physiology of the sinuses than some are willing to acknowledge? How else do we explain the high concentrations of NO within the normal maxillary sinus, its absence in CRS, and its vasodilatory effects on the pulmonary vasculature when inhaled in minute concentrations? One could argue that not all patients who have an MMA are disadvantaged, or are colonized by virulent pathogens, or show any measurable adverse pulmonary effects. While this may be true, the converse is as well, and thus knowingly creating an MSA when a primary, clinically valid alternative exists, seems irresponsible. I submit that a majority of patients given these facts would opt for conservatism, tissue preservation, and a more functional surgery. Note that the MIST procedure does not disturb the size of the natural maxillary sinus os and therefore there is no washout of NO, nor any of the unwanted consequences of an MSA noted previously. There have been over 50 articles published on the use of BSP and it is impossible to review them all. The most important data are derived from the CLEAR studies, published in 2008 and 2009.18–20 The studies were sponsored by Acclarent and involved some of the most notable rhinologists of our time, including Michael Sillers, William Bolger, Fred Kuhn, Winston Vaughn, and others. The three manuscripts report on the outcomes of BSP at 6, 12, and 24 month timepoints. All patients were followed using the SNOT-20 outcome metric, Lund-MacKay sinus CT grading scale, and endoscopic examination of the targeted sinus when possible. Approximately 80% of sinus ostia were able to be seen postoperatively to determine patency, but one can

Section 9: Surgery for Inflammatory Sinusitis





from 19.2 to 3.6 after BSP and from 18.6 to 4.2 after FESS. Frontal sinus-specific LM scores were reduced from 1.9 to 0.5 after BSP and from 2.0 to 0.4 after FESS. Endoscopic frontal sinus patency was better after BSP (73% vs. 62%), but this difference was not statistically significant. Four patients required revisions surgery during the 12-month follow-up: one in the BSP group and three in the FESS group. Other than some minor postoperative bleeding, there were no complications in either group. These results support the general experience that balloon dilation of the frontal sinus is a safe and equally effective treatment for patients with CRS involving the frontal sinus. Ramadan published his work on BSP for pediatric sinusitis by first reporting a feasibility study in early 2010,23 followed by a prospective nonrandomized study comparing outcomes after BSP to that for adenoidectomy alone.24 The latter had been the “gold standard” treatment for recurrent sinusitis in children at the time.25 His data clearly showed that BSP was a safe procedure in children with recurrent sinus symptoms and that BSP alone was far more successful than adenoidectomy in improving the symptoms of chronic sinusitis (82% vs. 52.6%, respectively). Several other authors have since shown similar outcomes using BSP alone to treat chronic sinusitis in children. Most recently, Cutler et al.26 reported their results of a prospective, randomized study comparing patients undergoing FESS with those undergoing BSP alone in a clinic setting. Patients were matched for extent of disease and other demographics. Follow-up was 6 months, and outcome metrics included SNOT-20 scores, time out of work, number of postoperative debridements, and post operative discomfort. Their results showed patients under going BSP with or without ethmoidectomy required much fewer debridements, returned to work sooner, had less postoperative discomfort, and better SNOT-20 scores than those in the FESS arm. This is the first head-to-head com parison between ESS and BSP populations to be reported, and clearly supports the roles for BSP in treating surgical candidates with CRS. Perhaps the issues that remain regarding the use of BSP relate to patient selection and cost. The latter will likely be addressed by simple market forces as more balloon devices are developed and more choice is available for surgeons. Market competition should drive prices down, as will less expensive technologies (i.e. SinuSys). To date, there are five different US medical device companies that manufacture and sell balloon dilation systems for chronic sinusitis. Patient selection is also becoming more ­

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understand with a preserved uncinate process how this can be a challenging and difficult process. The results at each timepoint show a statistically significant and durable improvement in reduced SNOT-20 scores, reduced Lund-MacKay scores, and ostial patency. One major problem with the study was the lack of rigorous criteria to determine which patients received a hybrid versus BSP procedure. Instead, this was left up to the discretion of the surgeon. These data are also unfairly critiqued as being “influenced by conflict of interest”; however, the surgeons involved are of the highest moral character and have never been accused of this type of behavior in prior work. To better determine the benefit of BSP in some of the worst clinical conditions affecting the frontal sinus, Payne et al.21 reviewed the radiographic changes in the frontal sinus after BSP. Study patients had either a completely opacified frontal sinus secondary to CRSwNP, or a clinical history of Sampter’s triad, fungal sinusitis, or hyperplastic sinusitis. All patients underwent ESS, but had their frontal sinus(es) treated with a 5-mm balloon. Minimum follow-up was 6 months. Overall, 48% of patients had radiographic improvement in their frontal sinus for a minimum of 6 months after BSP, with over 60% showing durable improvement in the CRSwNP group. All patients had statistically significant improvements in SNOT-20, but these data were not reported because other sinuses were also treated simultaneously and there was no way to isolate SNOT-20 changes to frontal BSP alone. Using radiographic changes as the sole metric for improvement will only underestimate the number of patients who were clinically improved because radiographic changes are unlikely to normalize in patients with Sampter’s or hyperplastic sinusitis despite a significant reduction in symptom scores. Many interpreted these outcomes as proof that BSP is not effective in relieving frontal sinus disease in clinically advanced cases. However, another interpretation, and the one intended by the authors, was to show that at least 50% of patients with clinically advanced frontal sinus disease can achieve significant improvement without aggressive frontal sinus surgery, thus sparing 50% of patients from unnecessary morbidity. This was followed by a prospective study of 34 patients who failed medical therapy and required surgery of their frontal sinus. Patients were randomized into 2 groups; half of the patients received conventional Draf I or Draf IIa frontal sinus surgery and the other half underwent frontal BSP.22 In this study, Plaza et al. demonstrated similar resolution of frontal sinus disease between the two groups on CT imaging. Overall Lund-MacKay scores were reduced



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Chapter 52: Minimally Invasive Sinus Surgery and Balloon Sinuplasty clear, with BSP being well accepted for patients with RARS, CRSw/oNP, and some patients with CRSwNP. However, many surgeons are pushing this envelope as well, espe­ cially with the advent of improvements in topical and targeted adjuvant medical therapy and are now using BSP when treating most of their patients with nasal polyps, and even some with Sampter’s and fungal sinusitis. As stated earlier, BSP is a very forgiving technology, and in cases where outcomes were less than desired, leaves the surgeon and patient with the same treatment options after BSP as before. In conclusion, minimally invasive sinus surgery is fast becoming the primary option for the surgical treatment of inflammatory nasal and sinus disease. It is based on sound principles, proven science, and excellent clinical outcomes. BSP, as an outgrowth or extension of minimally invasive surgery, has been placed under undue scrutiny and held to exceptional standards by those who hold fast to, and have a preference for, FESS. However, the data strongly support BSP and an equally effective treatment option for many patients with CRS and boast an unprecedented safety profile. Innovation causes change, and change requires an open mind and a vision for the future. BSP has been a “disruptive” technology for otolaryngology in many ways, and we and our patients are all the better for it. To this point, the majority of rhinologists worldwide envision the future of this specialty to be dependent upon catheter-based surgery coupled with drug delivery/elution technologies and that future begins now.

REFERENCES 1. Catalano PJ, Catalano LA, Setliff RC. Minimally invasive sinus surgery in the geriatric patient. Oper Tech Otolaryngol. 2001;12(2):85-90. 2. Catalano PJ, Roffman E. Long-term outcome in patients with chronic sinusitis following MIST. Am J Rhinol. 2003; 17(1):18-23. 3. Salama N, Oakley RJ, Skilbeck CJ, et al. Benefit from the minimally invasive sinus technique. J Laryngol Otol. 2009;123:186-90. 4. Kuehnemund M, Lopatin A, Amedee RG, et al. Endonasal sinus surgery: extended versus limited approach. Am J Rhinol. 2002;16:187-92. 5. Albu S, Tomescu E. Small and large middle meatal antrostomies in the treatment of chronic maxillary sinusitis. Otolaryngol Head Neck Surg. 2004;131(4):542-7. 6. Jardeleza C, et al. The effects of nitric oxide on Staphy­ lococcus aureus biofilm growth and its implications in chronic rhinosinusitis. Int Forum Allergy Rhinol. 2011; 1(6):438-44. 7. Messerklinger W. Endoscopy of the Nose. Baltimore: Urban and Schwartzenberg; 1978.

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8. Setliff RC. Minimally invasive sinus surgery, the rationale and technique. Otolaryngol Clin North Am. 1996;29(1): 115-24. 9. Setliff RC. The small-hole technique in endoscopic sinus surgery. Otolaryngol Clin North Am. 1997;30(3):341-54. 10. Setliff RC, Parsons DS. The hummer; new instrumentation for FESS. Am J Rhin. 1994;8:275-8. 11. Nayak DR, Balakrishnan R, Deepak Murty K, et al. Func­ tional anatomy of the uncinate process and role in ESS. Indian J Otolaryngol Neck Surg. 2001;53(1):27-31. 12. Xiong G, Zhan JM, Jiang HY, et al. Computational fluid dynamics simulation of airflow in the normal nasal cavity and paranasal sinuses. Am J Rhinol. 2008;22(5):477-82. 13. Xiong G, et al. Numerical flow simulation in the post-ESS nasal cavity. Med Biol Eng Comput. 2008;46:1161-7. 14. Kirihene RK, et al. The influence of the size of the maxillary sinus ostium on the nasal and sinus nitric oxide levels. Am J Rhinol. 2006;16:201-6. 15. Lundberg JO. Nitric oxide and the paranasal sinuses. Anat Rec (Hoboken). 2008;291(11):1479-84. 16. Thomas DD, Liu X, Kantrow SP, Lancaster JR Jr. The biological lifetime of nitric oxide; implications for the perivascular dynamics of NO and O2. Proc Natl Acad Sci USA. 2001;98(1):355-60. 17. Finer NN, Barrington KJ. Nitric oxide for respiratory failure in infants born at or near term. Cochrane Database Sys Rev. 2006;4:CD000399. 18. Bolger WE, et al. Safety and outcomes of balloon catheter technology: a multicenter 24-week analysis of 115 patients. Otolaryngol Head Neck Surg. 2007;37(1):10-20. 19. Kuhn FA, Church CA, Goldberg AN, et al. Balloon cathe­ ter sinusotomy: one year follow-up outcomes and role of in FESS. Otolaryngol Head Neck Surg. 2008;139(3 suppl):S27-37. 20. Weiss RL, et al. Long-term outcome analysis of balloon catheter sinusotomy: 2 year follow-up. Otolaryngol Head Neck Surg. 2008;139(3 suppl):S38-46. 21. Catalano PJ, Payne S. Balloon dilation of the frontal sinus outflow tract in the setting of advanced chronic rhinosinusitis. Ann Otolaryngol. 2009;118(2):107-12. 22. Plaza G, et al. Balloon dilation of the frontal recess: a randomized clinical trial. Ann Otol Rhinol Laryngol. 2011; 120(8):511-18. 23. Ramadan HH. Safety and feasibility of balloon sinuplasty for treatment of chronic rhinosinusitis in children. Ann Otol Rhinol Laryngol. 2010;118(3):161-5. 24. Ramadan HH, Terrell AM. Balloon catheter sinuplasty and adenoidectomy in children with chronic rhinosinusitis. Ann Otol Rhinol Laryngol. 2010;119(9):578-82. 25. Vandenberg SJ, Heatley DG. Efficacy of adenoidectomy in relieving symptoms of chronic sinusitis in children. Arch Otolaryngol Head Neck Surg. 1997;123:675-78. 26. Cutler J, et al. Stand-alone BSP vs sinus surgery for chronic rhinosinusitis: a prospective, multicenter, randomized control trial. Am J Rhinol Allergy. 2013;27:1-7.

Chapter 53: Open Approaches to the Paranasal Sinuses for Inflammatory Disorders

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Chapter

Open Approaches to the Paranasal Sinuses for Inflammatory Disorders

53

Esther Kim, James Duncavage

INTRODUCTION Endoscopic surgery fundamentally altered surgical appro­ aches to the paranasal sinuses when first popularized in the mid-1980s. This minimally invasive approach to the sinuses saved patients from external incisions and allowed surgeons improved visualization of the sinus cavities themselves. And so the open approach techniques began to wane significantly as the endoscopic techniques were perfected. In the modern era, external approaches are rarely used, and graduates of otolaryngology residencies seldom see these techniques. However, the “old” open approach techniques retain their relevance despite the advances in endoscopic approaches. In the following sections, we will describe the techniques themselves and discuss the current indications for these procedures in the endoscopic era. We hope that this chapter will serve as a guide to students and surgeons regarding the utility of open sinus procedures.

MAXILLARY SINUS The endoscopic approach to the maxillary sinus has become the gold standard for treatment of maxillary sinus disease. In the majority of cases, the diseased maxillary sinus can be adequately treated with endoscopic maxillary antrostomy and appropriate postoperative medication regimen. However, two issues make the endoscopic approach alone insufficient in some cases. First, views of the most anterior, inferior, and lateral portions of the maxil­ lary sinus can be difficult with standard endoscopes, even with 70° or 120° endoscopes. Inferior turbinate anatomy and the anterior-posterior distance from nares to posterior

border of the nasolacrimal duct may be sufficiently large to prevent the surgeon from positioning the endoscope to visualize the inferior, anterior and lateral mucosa of the sinus. In patients with recalcitrant maxillary disease des­ pite aggressive medical and endoscopic surgical therapy, mucosal abnormalities in these difficult-to-view areas may be the cause. Second, the severity of the disease process may not be sufficiently addressed with even advanced endoscopic techniques. Recent literature challenges the idea that endo­ scopic maxillary antrostomy, either standard or megaantrostomy, is sufficient to treat severe disease.1,2 The mucosa in severe cases of chronic rhinosinusitis with or without nasal polyps may be overwhelmingly edematous and covered with thick mucin, and thus may be resistant to medical treatments even in the presence of a sufficient middle meatus antrostomy. Anecdotal experience exists that complete removal of severely diseased mucosa, or at least a significant debulking, results in significantly improved postoperative course and lower revision surgery rates.3 This remains a controversial concept with limited supportive evidence. Additionally, the ability to distinguish between condemned and potentially salvageable mucosa remains challenging. Regardless, the ability to remove that mucosa is limited in endoscopic techniques because of visualization and instrument rigidity. Access to that mucosa requires a more radical approach through the ante­ rior wall of the maxillary sinus. To address these issues, the sinus surgeon must look back to more traditional sinus surgery techniques including maxillary sinoscopy via canine fossa puncture and the Caldwell-Luc, canine fossa trephine approach.

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Section 9: Surgery for Inflammatory Sinusitis

One option for investigation of the mucosa is maxillary sinuscopy through a sublabial, canine fossa puncture. For the sinuscopy, the surgeon uses an endoscopic trocar to traverse the canine fossa into the maxillary sinus. This trocar should be short, between 5 and 7 cm, so that the endoscope and instruments can be passed and all aspects of the maxillary sinus can be addressed, including the most anterior inferior region. Robinson and Wormald described an ideal point of anterior entry into the sinus at the intersection of the midpupillary line and the hori­ zontal line through the floor of the nasal vestibule.4,5 Figure 53.1 depicts this point. Once this landmark is identified, a trocar is twisted to puncture the bone of the anterior wall of the maxillary sinus (Fig. 53.2). When the disease process is severe enough, endoscopic instruments may not be sufficient to remove the disease mucosa. To extend the sinoscopy approach into a Caldwell Luc, the puncture siteis expanded using biting instruments such as Kerrison rongeurs and powered drills. The periosteum overlying the bone is carefully elevated to not injure the nerves. Primary closure of the puncture site is rarely indica­ ted if the mucosal incision is no larger than the trocar itself. For the Caldwell Luc, interrupted sutures with vicryl or chromic are sufficient to close the mucosal incision. In both procedures, the trocar should not be hammered into the sinus because of the possibility of fracture of the anterior wall through the branches of the infraorbital nerve

and anterior superior alveolar nerve with resultant facial numbness. Also, injury to the posterior wall of the sinus is a possibility. One must be mindful of the tooth roots, and stay above them with the puncture. With concomitant use of surgical navigation, the placement and trajectory of the puncture can be precisely planned. Careful atten­ tion to these guidelines will diminish the risk for dental numbness, facial hypoesthesia, and dentition injury. In general, published rates of complications from this proce­ dure are 1–3%.6,7 The opposition to these procedure stems in large part from the concern for morbidity.8 However, the data have shown that complications are minimal in experienced hands.6,7,9–11 Additionally, evidence is building that this approach is successful in addressing severe disease. Cutler and Duncavage10 reviewed 133 Caldwell Luc procedures with a follow up of 1–6 years. They found a 92% success rate with an average follow up of 23.5 months. The most common risk for the Caldwell Luc procedure is the failure of the surgery to cure the infection. Eight percent (n = 53) of subjects in this review did not respond to the surgery. In two of these three cases, failure was caused by trapped mucosa and these cases were successfully salvaged with a repeat Caldwell Luc procedure. Other evidence demon­ strates the utility of canine fossa trephine in recalci­ trant disease.1,2,12 Sieberling et al.12 demonstrated that in 67 patients with an average of 2.83 previous endoscopic -

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Fig. 53.2: Maxillary sinoscopy being widened using Kerrison rongeur after trocar entry. Redrawn from Kim and Duncavage.5



Fig. 53.1: Intersection of the midpupillary line and the horizontal line through the floor of the nasal vestibule. Redrawn from Kim and Duncavage.5

Chapter 53: Open Approaches to the Paranasal Sinuses for Inflammatory Disorders

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Fig. 53.3: Widening the maxillary window using a Kerrison rongeur.

Fig. 53.4: Removing the lining of the maxillary sinus using a curette.

Fig. 53.5: Suctioning the contents of the maxillary sinus.

Fig. 53.6: Closing the gingival labial incision using a chromic gut suture.

sinus surgeries, the Caldwell-Luc trephine procedure resul­ ted in clearance of disease. This is contrary to evidence by Lee et al.11 that showed no difference in outcomes in a randomized control trial comparing Caldwell-Luc pro­ cedure and endoscopic maxillary antrostomy. But as Sieblerling et al.12 point out, the variability in severity of disease across these studies makes definitive conclusions difficult. Maxillary sinuscopy and the Caldwell-Luc procedure are important tools rhinologists should consider in the most difficult-to-treat patients, as it allows the surgeon to access and address potentially disease altering tissue. While the evidence is not definitive, these procedures should not be forgotten nor condemned.

Illustrative case: This patient had chronic maxillary sinusitis and after endonasal endoscopic maxillary antro­ stomy, it was determined that endoscopic instruments could not adequately address the most anterior-inferior portion of the diseased tissue. A Caldwell-Luc approach was used to remove the diseased mucosa (Figs. 53.3 to 53.6).

FRONTAL SINUS Endoscopic approaches to the frontal sinus have been widely described,13–15 and advances in treating the fron­ tal sinus with the endoscopic modified Lothrop13 have significantly decreased the use of external approaches. However, the frontal recess contains complex anatomy that requires great understanding in order to manage chronic

Section 9: Surgery for Inflammatory Sinusitis

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Illustrative case: This 24 year old gentleman had pre­ vious sinus surgery prior to visiting us. He presented with significant frontal sinus disease with symptoms of pres­ sure and pain. On endoscopic examination, no clear fron­ tal sinus tract was identifiable. Evaluation of his CT scan (Figs. 53.8 and 53.9) demonstrated that on the left side, his frontal sinus was blocked by neo osteogenic bone formation, and we could not safely drill from below using -

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A frontal sinus trephine allows the manipulation of hard to reach areas in the frontal sinus by allowing endoscopes and instruments to be passed into areas that otherwise could not be reached via standard endoscopic approaches. It is also useful as an adjunct to standard endoscopic frontal sinus surgery to find the recess when the anatomy is severely distorted from previous surgery, scarring, ossifi­ cation, or infection.17–19 The authors perform a frontal sinus trephine as an adjunct to endonasal techniques only if the target region is not accessible via standard endoscopic approaches. The forehead is prepped and the medial brow is injected with 1% lidocaine with epinephrine 1:100,000. A 0.5–1 cm inci­ sion is made approximately 1–1.5 cm from the midline at the inferomedial margin of the brow or within the brow. If the incision is placed within the brow, the blade should be beveled parallel to the hair follicles to avoid eyebrow alopecia and a better cosmetic result. The soft tissues are gently dissected, sparing the supratrochlear and supra­ orbital neurovascular bundles, until the frontal bone is exposed. The periosteum is dissected off the bone and the location for the trephine marked. The location of the frontal sinus trephine has not been formally established. Traditional teaching recom­ mends performing it close to the floor of the sinus, about 1–1.5 cm from the midline where the depth of the frontal sinus is the greatest thus minimizing the risk of posterior table penetration. Lee et al. recently measured the depth of the frontal sinus at 0.5, 1.0, and 1.5 cm from the mid­ line and found no statistically significant difference in measurements. Lee did find an increased risk of cross trephination when performed 0.5 cm from midline because of the variable location of the intersinus septum.20 Image guided surgery can be used to locate the safest

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Frontal Sinus Trephination

area for the trephine. Image guidance trephination offers several advantages over “blind entry” in that it can specifi­ cally localize the target lesion, minimizes the size of the skin incision and trephination, and lowers the risk of intracranial entry.21 Once the trephination site is localized, a 4 mm burr is used to drill the anterior table and enter the frontal sinus in an area that is strategic and will provide the greatest access to the disease. Bone cutting instruments can be used to enlarge the opening if desired. Endoscopes are introduced through the trephine and the sinus cavity and drainage pathways are evaluated. Instruments are inserted through the trephine and the pathology is removed. If the frontal recess anatomy is distorted, cannulating or irriga­ ting through the trephine while visualizing the recess endonasally may find the opening to the frontal sinus. A frontal sinus stent may be placed through the trephine or endoscopically. The periosteum is approximated with absorbable sutures and the skin incision sutured. The combined use of a frontal sinus trephine with endoscopic frontal sinus surgery spares the patient the need for more invasive procedures. Benoit and Duncavage found no statistically significant difference in symptom improvement and patency rate after a combined approach versus an endoscopic Lothrop procedure. They found a patency rate of 79% and 82% for the combined approach and the endoscopic Lothrop, respectively.22 A trephine also allows for preservation of natural frontal outflow drainage pathway, facilitates endoscopic and radio­ graphic surveillance postoperatively and is cosmetically appealing.23 A disadvantage of the frontal sinus trephinination is external scar formation. There should be gentle soft tissue manipulation and the trephine should not be larger than 0.5 cm to avoid soft tissue prolapse and poor cos­ metic results.24 Minor complications have been reported including facial cellulitis and wound infection.23 Other rare but potential complications are penetration of the posterior table, cerebrospinal fluid leak, forehead hypes­ thesia and ophthalmologic injury.

frontal sinusitis and other pathology. Despite extensive training on the anatomy, physiology, and management, the frontal sinus remains one of the most challenging areas to treat.16 Scarring of the frontal recess after surgery, air cells within the sinus, disease at the far lateral aspect of the sinus, and the presence of tumors may present obstacles to a successful endoscopic approach. Below we describe two open frontal sinus approaches that can assist with challenging disease processes; the frontal sinus trephination and the osteoplastic flap.



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Chapter 53: Open Approaches to the Paranasal Sinuses for Inflammatory Disorders

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Fig. 53.7: Position of the frontal trephine skin incision.

Fig. 53.8: Coronal view of the opacified frontal sinus of the illustrative case.

Fig. 53.9: Coronal view of the scarred and narrowed frontal outflow tract of the illustrative case.

Fig. 53.10: Six-foot Caldwell with the frontal sinus outlined.

the endoscope. Via a trephination approach, we identified the left frontal sinus and then, using the image guidance, we were able to create a passage from above and remove the bone with curettes and kerrisons. The frontal duct was then stented (Figs. 53.7 to 53.9).

It may be used for disease processes other than chronic sinusitis, most often for benign and malignant tumors of the frontal sinus when endoscopic access is insufficient and the posterior table of the frontal sinus is uninvolved. Obliteration was utilized by many surgeons to treat chronic frontal sinusitis prior to advanced endoscopic techniques. Because diseased mucosa was believed to be untreatable by medical therapy, the mucosa was removed and the dead space filled with fat, hydroxyapatite, or allowed to scar via secondary intention. The technique has been described for both bilateral and unilateral disease.26,27 Prior to the image guidance era, a six-foot Caldwell frontal sinus X-ray was obtained (Fig. 53.10). Using this X-ray, a template of the frontal sinus is cut out and sterilized for use in surgery. Alternatively,

Osteoplastic Flap with or without Obliteration The osteoplastic flap was originally described in 1894,25 and achieved prominence in the late 20th century. Func­ tionally, one must differentiate between the osteoplastic flap approach and the obliteration technique for refractory chronic frontal sinusitis. This distinction is important in that the flap itself is simply an approach to the frontal sinus.

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Section 9: Surgery for Inflammatory Sinusitis

image guidance can be used to outline the osteotomies for the osteoplastic flap. The hair is then parted for a bicoronal incision, no shaving is necessary. One percent lidocaine with 1:100,000 epinephrine is injected into the planned bicoronal incision site. The scalp is incised through the galea aponeurotica, preserving the pericra­ nium. Raney clips are used to control bleeding. Laterally, the temporalis fascia is not incised, thereby protecting the frontal branch of the facial nerve. The supraorbital notch is palpated prior to elevating at the supraorbital rim (Fig. 53.11). Care is taken to elevate the supraorbital neuro­ vascular bundle intact with the scalp (Fig. 53.12). The six foot Caldwell template or the image guidance is used to outline the planned frontal bone cut. Here, the surgeon is encouraged to be conservative, planning the cut smaller than the frontal sinus itself so that accidental intracranial entry is prevented. The pericranium is then incised with the bovie electrocautery in the pattern of the planned bone cut. It is then elevated approximately 5 mm inferiorly from the planned bone cut. An oscillating saw and chisel are used to perform the osteotomies, typically after pilot holes are drilled in the line of the cut (Figs. 53.13 and 53.14). The inferior cut can be achieved by using the saw, or by levering the osteoplastic flap up with osteotomes after a cut is made through the glabella. Care must be taken to separate the bone flap from the intersinus septum. With the frontal sinus exposed, attention is then tur­ ned to the disease process. In patients undergoing oblite­ ration, the diseased mucosa would be removed with

curettes, and then the bone flap and frontal sinus drilled with a diamond drill to burr away the mucosal cells that remained in the invaginations of the foramina of Breschet. With the sinus mucosa gone, obliteration was then per­ formed with fat, hydroxyapatite, cancellous bone, or methy­ lmethacrylate.26,28–30 The bone was replaced and secured with titanium plates. The osteoplastic flap with obliteration has fallen out of favor for two reasons: better endoscopic techniques and the long term complications. In particular, the forma­ tion of delayed mucoceles within the obliterated space up to 10 years postoperatively has necessitated revision surgery on some patients. However, the approach is still important as these patients may need to be reobliterated if the sinus cannot be “rescued” endoscopically. The endoscopic rescue has been described; however, if the mucoceles are particularly high or lateral in the oblitera­ ted cavity, reobliteration may be the best option. It should be noted that obliteration may still be a valid treatment in some cases when the modified endoscopic Lothrop procedure has not alleviated symptoms.



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Fig. 53.12: Template from the six-foot Caldwell positioned to outline the frontal sinus. Redrawn from Kim and Duncavage.26

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Illustrative case: A 44 year old male presented to us with severe frontal headaches. He had previously undergone open and endoscopic resection of anterior skull base fibrous dysplasia 10 years prior to evaluation. He then developed a frontoethmoid mucocele that was treated with an osteoplastic flap with fat obliteration 1 year after his resection. He presented 9 years later with CT scans -

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Fig. 53.11: Identifying the supraorbital notch and the supraorbital neurovascular bundle. Redrawn from Kim and Duncavage.26

Chapter 53: Open Approaches to the Paranasal Sinuses for Inflammatory Disorders

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Fig. 53.13: Osteotome used to make pilot holes for the oscillating saw. Redrawn from Kim and Duncavage.26

Fig. 53.14: Oscillating saw to complete the frontal osteotomy. Redrawn from Kim and Duncavage.26

Fig. 53.15: Sagittal CT demonstrating mucocele.

Fig. 53.16: Coronal CT demonstrating multiple mucoceles.

demonstrating multiple mucoceles present in the previ­ ously obliterated frontal sinus (Figs. 53.15 to 53.18). Given the multiple sites and the presence of muco­celes high in the frontal sinus, the patient underwent reobliteration via an osteoplastic flap approach. This case demonstrates both how the obliteration procedure can fail, and also that it may be used to rescue that failure.

techniques associated with the endoscopic approach.31,32 Superior visualization of the fovea ethmoidalis and its rela­ tionship to the cribiform plate make the endoscopic approach safer in most cases of chronic sinusitis. However, there are some cases where an external approach may facilitate improved access and improved treatment. The approach to the ethmoid sinus can be combined with access to the inferior aspect of the frontal sinus and the frontal duct. They can be categorized as approach to primary disease, approach to frontal-ethmoidal junction, and approach for complications of sinus surgery.

ETHMOID SINUS External approaches to the ethmoid sinus have largely fallen out of favor given the excellent visualization and

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Section 9: Surgery for Inflammatory Sinusitis

Fig. 53.18: Axial CT demonstrating multiple mucoceles along the periphery of the original dissection.

clipped or bipolared. The classic description of a 21–24 mm distance between the lacrimal crest and the anterior ethmoid artery, 12–14 mm from the anterior ethmoid artery to the posterior ethmoid artery, and 6–7 mm from the poste­ rior ethmoid artery to the optic nerve holds true in most cases, although significant variability may exist. In the posterior dissection, careful attention must be paid to the identification of the frontoethmoid suture line, as this line allows the surgeon to predict the relative height of the anterior skull base. Once the sinus cavity is entered, one must be below this line to prevent skull base injury. The ethmoid partitions themselves are then taken down with through biting instruments or curettes. Once the excision is completed, the medial canthus is repositioned in its original position with a tacking suture. The orbit is allowed to return to its original position and the subcutaneous tissue and skin are closed accordingly. Figure 53.19 shows the approximate outline of the bony resection. Note that the frontoethmoid suture line is above the superior border within the orbit.32 Approach to the frontal–ethmoidal junction may be necessary in the case when endoscopic tools are insufficient to access the frontonasal tract secondary to bony anatomy. The Sewall Boyden modification involves extension of the bony resection to involve the inferior portion of the frontal bone and dorsum of the nasal bone to expose the inferior portion of the frontal sinus and the frontonasal duct. The frontal beak can then be resected with a drill or rongeurs. This may be useful when the anatomy of the frontal duct is restricted secondary to vertically long beak, a prominent beak or extensive osteitis. The challenging

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The approach in all cases is similar. The approach was originally described using a Lynch incision midway between the medial canthus and the nasion. The inci­ sion can incorporate a Z or W plasty to hide the scar. The incision is kept anterior to the lacrimal sac and inferior to the eyebrow. Dissection through the soft tissue will result in exposure of the angular artery, which may be ligated. Once the nasal bone has been encountered, dissection in the subperiosteal plan is performed such that the lacri­ mal system can be pushed inferolaterally out of its bony seat. The periorbita is then identified and preserved, pushed laterally such that the lamina papyracea is isolated. Depending on the depth of dissection, the anterior and posterior ethmoid arteries are then identified and either

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Fig. 53.19: Approximate outline of the bone removed during an open ethmoidectomy.



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Fig. 53.17: Axial CT demonstrating multiple mucoceles.

Chapter 53: Open Approaches to the Paranasal Sinuses for Inflammatory Disorders portion of this procedure is elevating and rotating the medial mucosal flap from the nasal bones and septum to recreate a mucosal-lined frontal sinus tract. This flap can be pedicled laterally, medially, or with two attachments. The complications of this procedure are the same as for the external ethmoidectomy, including bleeding, infection, orbital and intracranial injury, and epiphora. However, the most common complication is stenosis of the fronto­ nasal tract. Often a stent will be used in conjunction to main­ tain patency of the tract. Perhaps the best description of this procedure is found in Murr’s 2010 article.33 For primary or even revision surgery, these techniques are rarely indicated. Narrow nasal anatomy between the orbit and the middle turbinate or septum that prevents endoscopic tools from reaching the superior ethmoid sinus and frontal recess may require an external approach in order to move the orbital contents laterally, but this is rare. More importantly, these techniques are useful in dealing with complications from sinusitis and sinus surgery. Orbital abscesses are easily accessible via the external ethmoidectomy approach.34 One must be careful to evalu­ ate the lamina papyracea on the preoperative CT scan and intraoperatively to ensure that the ethmoid sinuses themselves are treated appropriately. Bleeding from the anterior or posterior ethmoid artery after sinus surgery may be vision-threatening if an orbital hematoma deve­ lops. An external ethmoidectomy approach may be nee­ded to control the bleeding and may be more timely in case of lack of endoscopic instrumentation.35,36

CONCLUSION External approaches to the paranasal sinuses are not simply historically interesting. As we have shown in this chapter, they can be quite useful for select patients. Unfortunately, they are rare, and increasingly absent in otolaryngology training programs. Familiarity with these procedures is necessary for rhinologists and for any otolaryngologist who treats patients with sinusitis.

REFERENCES 1. Sathananthar S, Nagaonkar S, Paleri V, et al. Canine fossa puncture and clearance of the maxillary sinus for the severely diseased maxillary sinus. Laryngoscope. 2005;115: 1026-9. 2. Seiberling KA, Church CA, Tewfik MA, et al. Canine fossa trephine is a beneficial procedure in patients with Sampter’s triad. Rhinology. 2012;50:104-8.

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3. Becker SS, Roberts DM, Beddow PA, et al. Comparison of maxillary sinus specimens removed during Caldwell-Luc procedures and traditional maxillary sinus antrostomies. Ear Nose Throat J. 2011;90(6):262-6. 4. Robinson S, Wormald PJ. Patterns of innervation of the anterior maxilla: a cadaver study with relevance to canine fossa puncture of the maxillary sinus. Laryngoscope. 2005; 115:1785-8. 5. Kim E, Duncavage JA. Prevention and management of complications in maxillary sinus surgery. Otolaryngol Clin North Am. 2010;43(4):865-73. 6. Matheny KE, Duncavage JA. Contemporary indications for the Caldwell-Luc procedure. Curr Opin Otolaryngol Head Neck Surg. 2003;11:23-6. 7. Defreitas J, Lucente FE. The Caldwell-Luc procedure: institu­ tional review of 670 cases: 1975–1985. Laryngoscope. 1988; 98:1297-300. 8. Kennedy DW, Adappa ND. Endoscopic maxillary antros­ tomy: not just a simple procedure. Laryngoscope. 2011;121 (10):2142-5. 9. Singhal D, Douglas R, Robinson S, et al. The incidence of complications using new landmarks and a modified tech­ nique of canine fossa puncture. Am J Rhinol. 2007;21: 316-9. 10. Cutler JL, Duncavage JA, Matheny KE, et al. Results of Caldwell-Luc after failed endoscopic middle meatus antros­ tomy in patients with chronic sinusitis. Laryngoscope. 2003; 113:2148-50. 11. Lee JY, Lee SH, Hong HS, et al. Is the canine fossa puncture approach really necessary for the severely disease maxil­ lary sinus during endoscopic sinus surgery? Laryngoscope. 2008;118:1082-7. 12. Seiberling K, Ooi E, MiinYip J, et al. Canine fossa trephine for the severely diseased maxillary sinus. Am J Rhinol Allergy. 2009;23(6):615-8. 13. Gross WE, Gross CW, Becker D, et al. Modified transnasal endoscopic Lothrop procedure as an alternative to frontal sinus obliteration. Otolaryngol Head Neck Surg. 1995;113 (4):427-33. 14. Anderson P, Sindwani R. Safety and efficacy of the endo­ scopic modified Lothrop procedure: a systematic review and meta-analysis. Laryngoscope. 2009;119:1828-33. 15. Hosemann W, Kuhnel T, Held P, et al. Endonasal frontal sinusotomy in surgical management of chronic sinusitis: a critical evaluation. Am J Rhinol. 1997;11(1):1-9. 16. McLaughlin RJ, Rehk RM, Lanza DC. Clinically relevant frontal sinus anatomy and physiology. Otolaryngol Clin North Am. 2001;31:1-21. 17. Benoit CM, Duncavage JA. Combined external and endo­ scopic frontal sinusotomy with stent placement: a retro­ spective review. Laryngoscope. 2001;111:1246-9. 18. Walgama E, Ahn C, Batra PS. Surgical management of frontal sinus inverted papilloma: a systematic review. Laryngoscope. 2012;122:1205-9.

Section 9: Surgery for Inflammatory Sinusitis

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28. Shumrick KA, Smith CP. The use of cancellous bone for frontal sinus obliteration and reconstruction of frontal bony defects. Arch Otolaryngol Head Neck Surg. 1994;120: 1003 9. 29. Manson PN, Crawley WA, Hoopes JE. Frontal cranioplasty: risk factors and choice of cranial vault reconstructive mate­ rial. Plastic Reconstr Surg. 1986;77:888 904. 30. Petruzzelli GJ, Stankiewicz J. Frontal sinus obliteration with hydroxyapatite cement. Laryngoscope. 2002;112:32 6. 31. Lawson W. The Intranasal ethmoidectomy: evolution and an assessment of the procedure. Laryngoscope. 1994; 104:1 49. 32. Murr AH, Hwang PH. External approaches to the paranasal sinuses. In: Kennedy DW, Hwang PH (Eds). Rhinology, 1st edition. New York: Theime; 2012. pp. 512 25. 33. Murr AH. The Sewall Boyden technique of reconstructing the frontonasal tract. Oper Tech Otolaryngol. 2010;21: 122 9. 34. Mann W, Amedee RG, Maurer J. Orbital complications of pediatric sinusitis: treatment of periorbital abscess. Am J Rhinol. 1997;11:149 53. 35. Ramakrishnan V, Palmer J. Prevention and management of orbital hematoma. Otolaryngol Clin North Am. 2010;43 (4):789 800. 36. Patel Z, Govindaraj S. The prevention and management of complications in ethmoid sinus surgery. Otolaryngol Clin North Am. 2010;43(4):855 64.

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19. Hahn S, Palmer JN, Purkey MT, et al. Indications for external frontal sinus procedures for inflammatory sinus disease. Am J Rhinol. 2009;23(3):342 7. 20. Lee A, Schaitkin BM, Gillman G. Evaluating the safety of frontal sinus trephination. Laryngoscope. 2010;120:639 42. 21. Zacharek MA, Fong KJ, Hwang PH. Image guided frontal trephination: a minimally invasive approach for hard to reach frontal sinus disease. Otolaryngol Head Neck Surg. 2006;135:518 22. 22. Hahn S, Palmer JN, Purkey MT, et al. Indications for external frontal sinus procedures for inflammatory sinus disease. Am J Rhinol. 2009;23:342 7. 23. Batra PS, Citardi MJ, Lanza DC. Combined endoscopic trephination and endoscopic frontal sinusotomy for manage­ ment of complex frontal sinus pathology. Am J Rhinol. 2005; 19:435 41. 24. Bent JP, Spears RA, Kuhn FA, et al. Combined endoscopic intranasal and external frontal sinusotomy. Am J Rhinol. 1997;11:349 54. 25. Wittkop A. Ein Beitrag zur Casuistik der Erkrankungen des Sinus Frontalis. Fromme; 1894. 26. Kim E, Duncavage JA. Osteoplastic flap with and without fat obliteration. Oper Tech Otolaryngol. 2010;21:134 7. 27. Welch KC. Osteoplastic approach to the frontal sinus, unilateral. Oper Tech Otolaryngol. 2010;21:138 42.



764

CHAPTER Odontogenic Disease and Oral–Antral Fistula

54

Richard A Kraut

INTRODUCTION Odontogenic etiology accounts for at least 10%1 and per­ haps as much as 40%2 of cases of maxillary sinusitis. The spread of dental infections into the maxillary sinus is due to the close relationship of the maxillary posterior teeth to the maxillary sinus. Routine dental procedures such as endodontic therapy or tooth extractions can result in foreign bodies being introduced into the sinus. Tumors originating in the palate often erode the palatal bone and the maxillary alveolar process and advance into the sinus. The relatively frequent occurrence of odontogenic patho­ logy and its influence on the maxillary process warrants an overview of odontogenesis, a review of dental anatomy, and the management of dental infections. This chapter includes a review of selected cysts and tumors (Table 54.1) including diagnosis and treatment. Contemporary topics of dental implant reconstruction and bisphosphonaterelated osteonecrosis of the jaws (BRONJ) and their impact on the maxillary sinus will be reviewed.

ODONTOGENESIS Odontogenic cysts and tumors that affect the jaws and oral cavity are derived from the tissues associated with tooth formation. These tumors and cysts can arise long after tooth formation is complete. Formation of teeth in different shapes and sizes and at defined locations is a result of sequential and reciprocal interactions between epithelial and mesenchymal tissues. Tooth development begins at approximately 4 weeks in utero and extends into the late teen years. At approximately 4 weeks, the mandibular and

Table 54.1: Odontogenic cysts and tumors

Cysts Radicular cyst Dentigerous cyst Residual cyst Calcifying odontogenic cyst Nasal palatine cyst Tumors Included Ameloblastoma

Epithelial

Benign

Odontogenic keratocystic tumor Central giant cell tumor Calcifying epithelial odontogenic tumor Odontoma

Epithelial

Benign

Epithelial Epithelial

Benign Benign

Mixed epithelial and mesenchymal

Benign

Epithelial

Benign

Epithelial

Benign

Epithelial Epithelial

Malignant Malignant

Epithelial Mesenchymal Mesenchymal Mesenchymal Mesenchymal Mesenchymal Mixed epithelial and mesenchymal Mixed epithelial and mesenchymal

Malignant Benign Benign Benign Benign Malignant Benign

Not included Adenomatoid odontogenic tumor Squamous odontogenic tumor Malignant ameloblastoma Clear cell odontogenic carcinoma Odontogenic carcinoma Odontogenic fibroma Cementoblastoma Odontogenic myxoma Cementifying fibroma Ameloblastic fibrosarcoma Ameloblastoma fibroma Ameloblastoma fibroodontoma

Benign

Section 9: Surgery for Inflammatory Sinusitis

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Clinical Evaluation

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Dental radiographs obtained during a routine office visit may lead to incidental discovery of cysts or tumors. A panograph will often confirm clinical suspicions. In addition, cone beam scans that are used for dental implant treatment planning increase the likelihood of incidental findings and subsequent diagnosis.6 Management of odontogenic pathology requires obtai­ ning a complete history and thorough physical exami­ nation. The age and general health of the patient are often important considerations in both the diagnosis and the treatment. The examination should include careful inspection, palpation, percussion, and auscultation of the affected part of the jaw and overlying dentition. The patient should be questioned about pain, loose teeth, occlusal problems, delayed tooth eruption, swelling, or intraoral bleeding. In addition, paresthesia, trismus, and significant malocclusion may indicate a malignant pro­ cess. To the extent possible, the onset and growth rate of a lesion should be elicited. The patient should be queried about medications, particularly bisphosphonate based medications. In general, well demarcated lesions outlined by scle­ rotic borders suggest benign growth, while aggressive lesions tend to be ill defined radiolucent lesions with pos­ sible root resorption. With larger more aggressive lesions, computerized tomography may more clearly identify bony erosion and/or invasion into adjacent soft tissues. Once a problem is detected, a differential diagnosis is developed and tissue is obtained for histologic identi­ fication. Fine needle aspiration is excellent for ruling out vascular lesions prior to open biopsy and may be helpful to diagnose inflammatory or secondarily infected lesions. Open biopsy may be incisional (preferred especially for larger lesions prior to definitive therapy) or excisional (for smaller cysts and unilocular tumors).7 -



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maxillary arches are formed. The teeth are formed from cells that migrate from the neural crest to the primitive alveolus at about 6 weeks. In this initiation stage of deve­ lopment, the ectoderm thickens and extends strands into the underlying mesenchyme forming the dental lamina. In the bud phase of development, the lamina grows into small rounded structures overlying the area of condensing connective tissue and beginning the development of the enamel organ. In the cap phase of development, the bud becomes indented and covers the condensing mesenchy­ mal cells of the dental papilla. The rest of the mesenchymal cells will form the dental follicle. The cells of the cap diffe­ rentiate into four layers: an inner and outer enamel epi­ thelium, the stratum intermedium, and stellate reticulum. They signal the overlying epithelial cells to send down a cord of cells (the dental lamina) that becomes the enamel organ. Together these cells are known as the tooth germ. In the next stage of development, the enamel organ becomes a bell shaped structure overlaying the papilla that has the shape of the future tooth. The appositional stage sees formation of the crown and the beginning of calcification. Preameloblasts from the inner enamel epi­ thelium induce cells from the papilla to become odonto­ blasts producing the dentin matrix that in turn induces the preameloblasts to become ameloblasts that produce the enamel matrix. Ameloblasts are responsible for enamel production and eventual crown formation. After the crown forms, the inner and outer layers of the enamel organ squeeze out the two middle layers: the stratum intermedium and stellate reticulum. At the cervical area of the papilla, the inner and outer enamel epithelium forms a root sheath, which in turn induces the odontoblasts to form the root dentin. Cells from the dental sac contribute to the formation of the periodontal ligament. Cementoblasts and fibroblasts from the dental follicle deposit cementum on the root surface and form the periodontal membrane. The penetration of these cells through Herwig sheath at the edge of the enamel organ gives rise to epithelial rests of Malassez within the periodontal ligament. The enamel organ becomes squamoid and ultimately fuses with the gingiva during eruption. When tooth formation is complete, remnants of odon­ togenic epithelium remain in the periodontal ligament and gingiva. In the gingiva, they are called rests of Serres and in the periodontal ligament they are known as the rests of Malassez. Odontogenic tumors arise from the Serres and Malassez rests.3 5

RADICULAR CYST Odontogenic cysts are characterized by epithelium lining a fibrous cyst wall. Radicular cysts arise from proliferation of epithelial cells in the rests of Malassez, while dentiger­ ous cysts arise from the rests of Serres. Both cystic lesions are noteworthy in their potentially destructive nature.8 Radicular cysts are localized at the periapical region of a tooth. In the maxilla, proximity of the cyst to the sinus floor may lead to invasion of the sinus and development of sinusitis. Arising from inflamed epithelial cells of the rests

766

Chapter 54: Odontogenic Disease and Oral–Antral Fistula

767

Fig. 54.1: Gutta-percha placed in facial fistula to determine the etiology of the fistula.

Fig. 54.2: Buccal mucosa is intact and did not reveal first molar as the source of the facial fistula.

of Malassez, the radicular cyst is the most common of the inflammatory cysts, accounting for approximately 50–65% of all cysts.9 Most radicular cysts originate in pre-existing periapical granulomas. During the past few decades, some authors have per­ petuated the notion that nearly half of all periapical lesions are radicular cysts.10 However, studies, based on meticu­ lous serial sectioning of periapical lesions completely retrieved, have shown that the actual incidence of radicular cyst is only about 15% of all periapical lesions. Equally sig­ nificant was the discovery in 1980 that radicular cysts exist in two structurally distinct classes. Those containing cavi­ ties completely enclosed in epithelial lining (periapical true cysts) and those containing epithelium-lined cavities that are open to the root canals (periapical pocket cysts). From a clinical point of view, a periapical pocket cyst may heal following conventional root canal therapy whereas a periapical true cyst is less likely to be resolved.9 Radiographically, a radicular cyst presents as a small well-defined periapical lucency at the root apex of a nonvi­ tal tooth. Radiographic differentiation of granulomas and radicular cysts has minimal impact on treatment as shown in Figures 54.1 to 54.3. Large cysts may involve a complete quadrant with some of the teeth mobile, some root resorption, and some nonvital pulps. Although the cyst is painless when sterile, it will be painful when infected. Histologically, the cyst has a connective tissue wall that may vary in thickness, a stratified squamous epithelium lining, and foci of chronic inflammatory cells within the lumen. Radicular cysts that violate the sinus are surgically excised and the area curetted

in conjunction with, or prior to, definitive treatment of sinusitis. Otherwise, affected teeth are extracted and cyst excised. Alternately, endodontic therapy can be performed if the tooth can be preserved. Endodontic therapy removes of the pulp from within the internal chamber and canals of the tooth. This void is obturated with an inert material and isolates the internal component of the tooth from the oral environment. The successful completion of root canal therapy with appropriate removal of vital pulp pre­ vents progression of the infection. Endodontic therapy is effective, though not without failure as shown in Figures 54.4 to 54.6. Due to differences in root anatomy, long-term outcome for posterior dentition is more guarded when compared to the anterior dentition. Proximity of the pos­ terior dentition to the floor of the antrum is critical with regard to direct extension of the cyst into the maxillary sinus. The vast majority of radicular radiolucencies resolve following endodontic therapy. The mechanism involved in this resolution may be the dissolution of epithelial lining due to the inflammatory exudate. Residual periapical lesions are typically treated with apicoectomy.

DENTIGEROUS CYST This is the most common developmental cyst, accounting for 20–25% of all odontogenic cysts.11 It originates from the separation of the follicle from around the crown of an unerupted tooth. This cyst develops via the accumula­ tion of fluid between reduced enamel epithelium and a

768

Section 9: Surgery for Inflammatory Sinusitis

Fig. 54.3: Gutta-percha points to maxillary first molar that has a periapical radiolucency indicating need for endodontic therapy secondary to a necrotic pulp that has caused an infected granuloma.

Fig. 54.5: The lateral wall of antrum was exposed to gain access to the antrum for removal of the foreign body.

completed tooth crown. It is most commonly associated with mandibular third molars, although maxillary canines and third molars may be affected. Dentigerous cysts are rarely associated with unerupted deciduous teeth. These cysts are most prevalent in the second to fourth decades and are more prominent in white males. Most dentigerous cysts are asymptomatic, but large lesions can cause displacement or resorption of adjacent

teeth and pain. The maxillary sinus is most usually affected by cysts involving one of the maxillary canines or third molars as shown in Figure 54.7. Maxillary anterior teeth may be displaced into the floor of the nose and maxillary posterior teeth may move through the sinus to the floor of the orbit. As the lesion extends into the sinus, bone deformity or infection may occur. The cyst may also cause resorption of the roots of adjacent teeth.



Fig. 54.4: Image showing massive extrusion of root canal filling material into the right antrum causing sinusitis.

Chapter 54: Odontogenic Disease and Oral–Antral Fistula

769

Fig. 54.6: Coronal aspect foreign body removed from infected sinus showing granulation tissue above the zinc oxide and eugenol.

Fig. 54.7: Cone beam panoramic radiograph showing opaque left antrum secondary to a dentigerous cyst displacing the maxillary left third molar just below the orbit. A supernumerary tooth can be seen posterior to the maxillary second molar.

Fig. 54.8: Dentigerous cyst has displaced the maxillary third molar to the medial wall of the antrum.

Fig. 54.9: Coronal computed tomography of dentigerous cyst that has displaced the right third molar; the cyst is below the Schneiderian membrane.

Radiographically, the cysts appear as expanded uni­ locular radiolucencies with a well-defined muco­periosteal border as shown in Figures 54.8 to 54.10. However, an infec­ ted cyst may show ill-defined borders. Oftentimes the border of the lucent area will originate at the cemento­ enamel junction of the tooth. It can be difficult to distin­ guish bet­ween a dentigerous cyst and an enlarged follicle. Further-more, other odontogenic tumors such as unilocu­ lar ameloblastomas and OKTs have similar radiographic features.

The histology of the cyst varies, depending on whether the cyst is inflamed. The noninflamed cyst is composed of thin connective tissue walls loosely arranged and con­ tains considerable glycosaminoglycan ground substance. The fibrous walls may include islands of inactive odonto­ genic epithelial rests. The epithelial lining consists of two to four layers of nonkeratinizing epithelium. Treatment is with enucleation and extraction of the unerupted tooth. Large dentigerous cysts may be marsupialized that allows decom­pression followed by excision of the cyst. Recur­ rence is rare.12,13

770

Section 9: Surgery for Inflammatory Sinusitis

Fig. 54.10: Dentigerous cyst associated with upper left wisdom tooth has caused tooth to migrate to the antral floor.

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CALCIFYING ODONTOGENIC CYST (GORLIN CYST)

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A residual cyst is an inflammatory cyst that fails to resolve after root canal therapy or tooth extraction. Most often the cysts occur following endodontic therapy that did not eliminate the initial cause of inflammation or that did not treat all canals. Radiographically most present as an enlarged and darkened radiolucency with no bony expansion. Residual cysts rarely occur after tooth extrac­ tions so other causes should be considered for any subsequent radiolucency. A primordial odontogenic kera­ tocyst, ameloblastoma, myxoma should be considered. Pulp testing of adjacent teeth is recommended to rule out a radicular cyst, followed by enucleation and removal of any inflammatory stimulus. Endodontic therapy, apicoectomy, and tooth removal may also be required.14

in teenagers. Most often, the cyst is identified as part of a routine dental exam. The cyst varies in size from 1 to 8 cm with 3 cm being the average. The cyst is asymptomatic unless growth causes significant expansion. The calcifying odontogenic cyst is primordial in origin arising from the rests of Serres. They are not associated with an impacted tooth. At first the cyst will be radiolucent but as it matures it develops calcifications that have a mixed radiolucent radiopaque appearance. These cysts can exhibit one of three radiographic patterns: one is a salt and pepper pattern of flecks, the second is a fluffy cloud like appearance, and the third is a crescent shaped pattern on one side of the radiolucency. Because of these three patterns of radio­ graphic appearance, three different list of differential diagnosis must be considered. A unilocular radiolucency could suggest an OKT, an ameloblastoma, an adenomatoid odontogenic tumor (AOT), or an ameloblastic fibroma. However, a radiolucent radiopaque lesion with a salt and pepper flecked pattern suggests the AOT, an odontoma, an ossifying fibroma, or a calcifying epithelial tumor. If the cyst presents as an extraosseous cyst, the differential diagnosis includes a gingival cyst, a peripheral ossifying fibroma, and a chronic periodontal abscess.

RESIDUAL CYST

The calcifying odontogenic cyst is much less aggressive than the odontogenic keratocystic tumor (OKT) and has a low incidence of recurrence following the usual treatment of curettage and enucleation. This cyst is very rare but occurs most frequently in the maxilla of females, particularly

Chapter 54: Odontogenic Disease and Oral–Antral Fistula

Fig. 54.11: Nasopalatine duct cyst has obliterated the subnasal sulks.

Fig. 54.13: Nasopalatine duct cyst has eroded the labial premaxilla and the anterior portion of the hard palate.

Histologically, the calcifying odontogenic cyst is usu­ ally a unilocular cyst with a lining is composed of stratified squamous epithelium with a basal layer that may be polarized away from the basement membrane. The lumen con­ tains eosinophilic keratinized cells (ghost cells) in which the nuclei have degenerated, sometimes completely.15,16

Nasal Palatine Cyst (Incisive Canal Cyst) The nasal palatine cyst is a nonodontogenic develop­ mental cyst derived from embryonic epithelial remnants of the nasopalatine ducts. It usually occurs in adults 30–60 years of age with twice as many occurrences in

771

Fig. 54.12: Sagittal view of nasopalatine duct cyst showing destruction of the hard palate and obliteration of the nasal labial fold and destruction of the buccal bone.

males as opposed to females. It is usually a well-delinea­ ted, heart-shaped unilocular radiolucency located between, and apical to, the maxillary central incisors in the midline. Cysts may form at any point along the duct’s course from the posterior palatal midline to the soft tissue palatine papilla as shown in Figures 54.11 to 54.13. Cells may be activated by an infection similar to branchial cysts or may activate spontaneously. The cyst usually presents as a soft tissue swelling along the midline. Palatal swelling is common, as is root resorption. Cysts limited to the palatine papilla exhibit swelling behind the maxillary central incisors. The cyst is often discovered as part of a routine dental exam and is usually asymptomatic. Histologically the cyst may be lined by stratified squamous epithelium, pseudostratified columnar epithelium, with or without cilia, or both. Mucous cells may be present. Treatment consists of enucleation from a labial approach, after which recurrence is rare. With large lesions, careful dissection is required to prevent a palatal tear since the cyst wall may adhere to the periosteum.

Ameloblastoma Odontogenic tumors can be classified by their tissue of origin: epithelial, mesenchymal, or a mixed lesion. Studies reveal that there may be no clear divisions among many types of tumors, but rather a transition from one to another. Tumors may show areas that resemble different types of tumors within a single lesion. Odontogenic tumors comprise a small percentage of the lesions found in the jaw. The majority are benign,

Section 9: Surgery for Inflammatory Sinusitis





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between diagnosis of the primary tumor and development of metastasis. Radiographs show a well circumscribed, expansile radiolucency with clearly demarcated scalloped borders that have been described as resembling a honeycomb or soap bubble. The unilocular lesion is indistinguishable from an odontogenic cyst. The extent of root resorption may indicate a neoplastic process. Histologically, most ameloblastomas have the folli­ cular or plexiform pattern, although basal cell or granular cell variations may also be seen. Classic features are sheets and islands of tumor cells showing an outer rim of columnar ameloblasts with nuclei polarized away from the basement membrane. The center of these nests is composed of stellate shaped epithelial cells that mimic the stellate reticulum. Rarely, they can exhibit cytologic features of malignancy with squamous differentiation ( 150 ng/mL in combination with typical clinical symptoms.14 In patients with a prolactinoma, endo­ crinological remission is defined as postoperative PRL levels of