Anaesthesia for endoscopic sinus surgery

Endoscopic sinus surgery is commonly performed and has a low risk of major complications. Intraoperative bleeding impairs surgical conditions and increases the risk of complications. Remifentanil appears to produce better surgical conditions than other opioid analgesics, and total intravenous anaesthesia with propofol may provide superior conditions to a volatile‐based technique. Moderate hypotension with intraoperative β blockade is associated with better operating conditions than when vasodilating agents are used. Tight control of CO₂ does not affect the surgical view. The use of a laryngeal mask may be associated with improved surgical conditions and a smoother emergence. It provides airway protection equivalent to that provided by an endotracheal tube in well‐selected patients, but offers less protection from gastric regurgitation. Post‐operatively, multimodal oral analgesia provides good pain relief, while long‐acting local anaesthetics have been shown not to improve analgesia.     

Measuring competence in endoscopic sinus surgery.

BACKGROUND: Competence based education is currently being introduced into higher surgical training in the UK. Valid and reliable performance assessment tools are essential to ensure competencies are achieved. No such tools have yet been reported in the UK literature. OBJECTIVE: We sought to develop and pilot test an Endoscopic Sinus Surgery Competence Assessment Tool (ESSCAT). The ESSCAT was designed for in-theatre assessment of higher surgical trainees in the UK. METHODS: The ESSCAT rating matrix was developed through task analysis of ESS procedures. All otolaryngology consultants and specialist registrars in Scotland were given the opportunity to contribute to its refinement. Two cycles of in-theatre testing were used to ensure utility and gather quantitative data on validity and reliability. Videos of trainees performing surgery were used in establishing inter-rater reliability. RESULTS: National consultation, the consensus derived minimum standard of performance, Cronbach's alpha = 0.89 and demonstration of trainee learning (p = 0.027) during the in vivo application of the ESSCAT suggest a high level of validity. Inter-rater reliability was moderate for competence decisions (Cohen's Kappa = 0.5) and good for total scores (Intra-Class Correlation Co-efficient = 0.63). Intra-rater reliability was good for both competence decisions (Kappa = 0.67) and total scores (Kendall's Tau-b = 0.73). CONCLUSION: The ESSCAT generates a valid and reliable assessment of trainees' in-theatre performance of endoscopic sinus surgery. In conjunction with ongoing evaluation of the instrument we recommend the use of the ESSCAT in higher specialist training in otolaryngology in the UK.     

Navigated control in functional endoscopic sinus surgery

This study designs and evaluates a mechatronic system to assist ENT surgery, taking as an example a navigation controlled shaver as used in paranasal sinus surgery. The on/off status of the shaver is regulated automatically, depending on the current position of the shaver tip. The working space for the navigation controlled shaver is planned preoperatively as a three-dimensional model and is based on the individual patient's CT data. Within this area the shaver reacts to signals from the surgeon. If the tip of the shaver moves outside the predefined working space, the shaver's automatic drive control is interrupted by an electrical pulse. The planning software was evaluated using CT data sets from 32 patients. The accuracy of the registration was analysed on an anatomical model with the aid of 451 measurements on titanium screws attached endonasally, whilst the implementation of the working space was evaluated on 5 technical models. The average time taken for segmenting the working space was found to be 4.23 minutes. The average accuracy of the shaver registration was 1.08 mm. The selected cavity was to be resected without any restrictions. The preoperatively determined working space was implemented with a mean deviation of 3.1 mm over all levels. The study proves the feasibility of a mechatronic assistance system taking as an example the navigation controlled shaver used in paranasal sinus surgery. In contrast to isolated CAS solutions, this conceptual approach provides for the redundancy of the surgeon and eases their cognitive burden. We can foresee numerous applications in ENT surgery of the future following the principle presented here, in the control systems of power tools such as cutters, high frequency scalpels and lasers.     

Image-guided functional endoscopic sinus surgery.

INTRODUCTION: Computer-aided surgery (CAS) technology in functional endoscopic sinus surgery (FESS) has engendered considerable discussion. OBJECTIVE: The goals of this study were to describe CAS preoperative planning (software-based CT image analysis) and to develop intraoperative CAS strategies for endoscopic sinus surgery. Study Design: Between October 1, 1997, and December 31, 1998, the StealthStation (Sofamor Danek, Memphis, TN) was used in 61 FESS cases, and a retrospective review of the findings was performed. The indication for surgery in all instances was chronic rhinosinusitis refractory to medical management. The StealthStation was used to review all CT scans before surgery. Anatomic fiducial registration supplemented by contour mapping was used. RESULTS: Localization accuracy was estimated to be within 2 mm or better. The StealthStation was used for both CT image review and intraoperative localization. CAS was useful in the frontal recess, sphenoethmoid region, posterior ethmoid system, and skull base area. CAS was deemed helpful in situations where the surgical anatomy was altered by previous surgery and extensive inflammatory disease (polyposis, fungal sinusitis, and pansinusitis). CONCLUSION: The paradigm of image-guided FESS surgery, which integrates CAS into FESS, will serve to increase surgical effectiveness and decrease surgical morbidity.     

Induced hypotension for endoscopic sinus surgery

The purpose of the present investigation is to examine whether induced hypotension can improve the dryness of the surgical field in endoscopic sinus surgery (ESS). ASA physical status I and II adult patients with chronic sinutitis undergoing ESS were studied. All patients were not premedicated. Anesthesia was induced with propofol and maintained with sevoflurane and fentanyl. The patients were allocated randomly into two groups. In patients of Group C, mean arterial blood pressure (MAP) was maintained around 80 mmHg. In Group H, sodium nitroprusside was infused to maintain controlled hypotension with MAP around 60 mmHg. Blood loss, dryness of the surgical field, volume of fluid infusion and urine output, and surgical as well as anesthetic time were compared. Blood loss and dryness of the surgical field were significantly different between the groups. Volume of infused fluid, urine output, and surgical as well as anesthetic time were not significantly different. Induced hypotension with sodium nitroprusside improved surgical conditions and decreased blood loss in ESS.     

Video documentation of endoscopic sinus surgery

A simple, reliable technique for videotaping endoscopic sinus surgery is described. This system may be used for teaching purposes and patient education. It may also be used to document pathologic conditions of the sinus as well as for documenting the surgical procedure itself.     

Functional endoscopic sinus surgery for isolated sphenoid sinus disease

Background. This article reviews 12 cases of isolated sphenoid sinus disease: chronic inflammatory sinusitis (7), mucoceles (2), aspergillus lesions (2), and isolated polyp (1). Methods. Criteria for diagnosis were based on clinical symptoms, nasal endoscopic evaluation, and computed tomography (CT). Magnetic resonance imaging was used only in cases of bone erosion and when patients presented with vision problems. All patients were treated by functional endoscopic sphenoidotomy. Any postoperative complications were noted. Conclusion. The reported good results, on the basis of regression of functional symptoms and with nasal endoscopic and CT evaluation, suggest that intranasal sphenoidotomy under endoscopic control is a safe and effective method of treatment of nonmalignant isolated sphenoid disease. The mean follow-up is 26 months. © 1994 John Wiley & Sons, Inc.     

Frameless computer-aided surgery system for revision endoscopic sinus surgery

To increase the intraoperative safety factor and to acquire anatomic assistance during revision endoscopic sinus surgery (RESS), we used an optical computer-aided surgery (CAS) system that we developed collaboratively in Bern, Switzerland. During 1 year, 25 RESSs were performed with CAS: recurrent polyposis (n = 20), recurrent frontal recess stenosis (n = 3), and recurrent frontal recess stenosis with mucocele (n = 2). These patients were compared with a control group of 10 patients undergoing RESS without CAS. The same surgeon (M.C.) performed all operations, and there were no minor or major complications in either group. The clinical inaccuracy of our system is between 0.5 and 2 mm with paired-point and surface matching. The navigation system is an important aid to surgeons in identifying anatomic landmarks that are typically difficult to visualize in this type of surgery, thus reducing the stress placed on the surgeon.     

Partial endoscopic middle turbinectomy augmenting functional endoscopic sinus surgery.

Endoscopic sinus surgery has gained acceptance in the otolaryngologic community as an effective and safe method of treating inflammatory disease of the paranasal sinuses. At our institution, partial endoscopic middle turbinectomy has become a standard component of the procedure and our experience is reported. Middle turbinectomy enhances surgical exposure, specific anatomic anomalies are more completely corrected, and subpopulations of patients at risk for failure because of their underlying disease enjoy decreased rates of synechiae formation and closure of the middle meatus antrostomy when followed over time. Photodocumentation of the surgical technique and a discussion regarding the impact of middle turbinectomy on normal nasal physiology are presented. It is reported that the procedure is safe, and no complications directly attributable to middle turbinectomy (including atrophic rhinitis) are reported in a series of 298 patients.     

Much ado about functional endoscopic sinus surgery

BACKGROUND: Reported success rates in endoscopic sinus surgery vary from 74 to 97%. However, the methods of evaluation and the functional endoscopic sinus surgery (FESS) techniques are not standard in these series. In our practice, some patients failed to attend the 3-monthly follow up claiming all was well. With this experience, the aim of this study is to document a standard minimal technique with minimal follow up, which may be applicable to selected patients. METHODS: An open prospective clinical trial was conducted. A total of 102 selected patients were subjected to minimal FESS surgery and discharged after a 3-month follow up with instructions to return if problems re-ensued. RESULTS: In a telephone follow up ranging from 28 to 40 months postoperatively, 12 patients could not be traced. All of the other patients expressed satisfaction with the results. There were no patients who were dissatisfied with the outcome. However, two patients have persisted with postoperative check-up visits on their own accord. CONCLUSION: It is possible in selected patients to resort to minimal FESS surgery with expectation of a good clinical outcome. It is stressed that, 'rigid selection criteria' apply.     

Airway complication following functional endoscopic sinus surgery

Difficulty breathing after upper airway surgery requires immediate evaluation and treatment. We present a case of airway compromise after sinus surgery due to edema of the uvula. The patient was admitted for observation overnight and discharged the next day. A discussion of potential airway changes after sinonasal surgery is presented.     

Outcome predictors for endoscopic sinus surgery.

OBJECTIVE: The outcomes management of endoscopic sinus surgery (ESS) is a major effort to improve the quality of chronic sinusitis treatment. The objective of this study was to investigate the factors that may predict a variety of outcomes of ESS. STUDY DESIGN AND SETTING: Two hundred and thirty consecutive patients who underwent ESS were prospectively evaluated by computerized axial tomography scan of the sinus and a validated chronic sinusitis survey (CSS) before surgery. The effects of prognostic factors were then investigated. RESULTS: Extent of disease was a consistent predictor (P < 0.05) for bleeding, complication occurrence, medical resource utilization, subjective sinus-specific health status, and physicians' objective evaluation of surgical outcomes. The preoperative CSS total score and extent of disease significantly (P < 0.05) predicted the postoperative CSS total score. Subjective and objective outcomes were significantly correlated (r = 0.58, P = 0.0001). These findings suggested the necessity of disease severity stratification when reporting ESS outcomes. CONCLUSION: Operation-related events, medical resource utilization, physician evaluation, and sinus-specific health status of patients are all integral parts of reporting outcomes of ESS. We have concluded that computerized axial tomography scan of the sinuses and CSS are efficient ways of providing reliable baseline information before ESS.     

Cost-utility analysis for endoscopic sinus surgery.

OBJECTIVE: To undertake cost-utility analysis for endoscopic sinus surgery (ESS) in order to analyze the cost-effectiveness of different chronic sinusitis severity groups. METHODS: One hundred ninety-two patients with chronic sinusitis were evaluated with a Chronic Sinusitis Survey (CSS) before and 1-year after ESS. Direct health care cost data during the first year after operation were retrieved. The utility gain is defined as change in the CSS total score. The cost-utility ratio was defined as cost per utility gain. Patients are stratified by disease severity using the Harvard Staging System. RESULTS: The average total direct cost attributable to ESS is 40,829 NT dollars in the first postoperative year and the average cost-utility ratio is 2194.42 NT dollars. The high cost-utility ratio of 3246.45 NT dollars for pansinusitis cases is due to the higher cost and limited utility gain. CONCLUSIONS: Treating mild and moderate chronic sinusitis are most cost-effective because of their favorable utility gain and relatively reasonable cost. However, there is no proportional linear relationship between disease severity and cost-utility ratio.     

Effects of endoscopic sinus surgery and delivery device on cadaver sinus irrigation

OBJECTIVE: Assess paranasal sinus distribution of topical solutions following endoscopic sinus surgery (ESS) using various delivery devices. STUDY DESIGN: Experimental prospective study. SUBJECTS AND METHODS: Ten cadaver sinus systems were irrigated with Gastroview before surgery, after ESS, and after medial maxillectomy. Delivery was via pressurized spray (NasaMist), neti pot (NasaFlo), and squeeze bottle (Sinus Rinse). Scans were performed before and after each delivery with a portable CT machine (Xoran xCAT), and blinded assessments were made for distribution to individual sinuses. RESULTS: Total sinus distribution was greater post-ESS (P < 0.001). Additional distribution was gained with medial maxillectomy (P = 0.02). Influence of delivery device on distribution was significantly higher with neti pot > squeeze bottle > pressurized spray (P < 0.001). Frontal sinus penetration was greatest after surgery (P = 0.001). CONCLUSION: ESS greatly enhances the delivery of nasal solutions, regardless of delivery device. Pressurized spray solutions in un-operated sinuses provide little more than nasal cavity distribution. Use of squeeze bottle/neti pot post-ESS offers a greatly enhanced ability to deliver solutions to the paranasal sinuses.     

Smoke exposure and outcome of endoscopic sinus surgery in children

OBJECTIVE: The study goal was to determine whether cigarette smoke exposure in children who are undergoing endoscopic sinus surgery (ESS) for chronic sinusitis will have an impact on the outcome. DESIGN: We conducted a cohort study in a tertiary care children's hospital setting. PATIENTS AND METHODS: The study population consisted of 118 patients who underwent ESS between January 1994 and June 1999. The mean age was 6.5 (range, 2 to 13 years). The outcome of ESS was measured > or =1 year after the operation. A questionnaire was mailed to the caretakers to measure success. Those who required revision subsequently were considered as failures. RESULTS: Multivariate logistic regression analysis was performed with smoke exposure as an independent variable and outcome measured as success of procedure. The overall success rate was 83%. Univariate analysis of smoke exposure and outcome of surgery revealed that children exposed to smoke in household had a 70% success rate compared with children not exposed to smoke, who had a 90% success rate (P = 0.007). Multivariate analysis revealed smoke exposure continued to be an independent predictor of success. CONCLUSION: ESS in children with cigarette smoke exposure predisposes to a poorer outcome. This needs to be taken into consideration when recommending ESS for those children.     

Frontal skull base surgery combined with endonasal endoscopic sinus surgery

BACKGROUND: Postoperative infection remains a serious complication after radical resection of anterior skull base lesions because intracranial, nasal, and paranasal cavities are opened during surgery. To prevent complications from postoperative infection, we combined endonasal endoscopic sinus surgery (ESS) with the frontal transbasal approach in patients with skull base lesions. METHODS: Patients (n = 16) with anterior skull base lesions extending to the paranasal or nasal cavity underwent surgical resection via the frontal transbasal approach. After removal of the lesion via the transcranial approach, enlargement of the ostium or sinusotomy was performed bilaterally using our endonasal ESS procedure. The main purpose of ESS is the establishment of a wide drainage route to avoid dead space and postoperative infection. Furthermore, we confirmed the absence of residual lesion and leakage of cerebrospinal fluid (CSF), endoscopically. RESULTS: The frontal transbasal approach combined with endonasal ESS was performed in 16 patients with frontal skull base lesions. There were 8 malignant tumors, 6 benign tumors, and 2 mucoceles. Although 11 patients had preoperative active paranasal sinusitis, most frequently at the ethmoid sinus, none experienced postoperative infection. There was no complication related to ESS procedure. Furthermore, leakage of CSF and extracranial residual tumor were not found. CONCLUSION: Endonasal ESS after frontal skull base surgery is a highly useful technique for preventing postoperative infection, especially for the cases with large skull base tumors extending into other regions involving the paranasal sinuses or nasal cavity and with active paranasal sinusitis.