The effect of maxillary sinus antrostomy size on xenon ventilation in the sheep model.

OBJECTIVE: A major goal of maxillary antrostomy is to increase sinus ventilation. Limited data exist regarding the effect of maxillary antrostomy size on sinus ventilation. We sought to quantify the effect of uncinectomy, small antrostomy, and large antrostomy on maxillary sinus ventilation using xenon-enhanced CT in the sheep model. MATERIALS, STUDY DESIGN, AND METHODS: A xenon-oxygen-air mixture was delivered to 8 fresh cadaveric sheep heads while repeated CT scans were performed through the maxillary sinuses. Baseline and postoperative studies were performed after an endoscopic uncinectomy, small antrostomy, or large antrostomy was created. Images were analyzed to measure the density of the xenon gas in the maxillary sinus as a function of time, generating a time constant. RESULTS: The time constants for both small antrostomy and large antrostomy were significantly different compared to baseline ( P = 0.003 for both). The time constant comparison between small antrostomy and large antrostomy was not significant ( P = 0.948). CONCLUSIONS: A small antrostomy produces a statistically significant increase in maxillary sinus ventilation over baseline. No significant further ventilation increase is obtained by creating a large antrostomy in the sheep model. This lends credence to the use of small antrostomies to improve maxillary sinus ventilation in human sinus surgery.     

Variations in the surgical treatment of maxillary sinusitis

From September 2001. to February 2004. in the Institute for ENT and Maxillofacial Surgery were investigated 107 patients with the inflammatory diseases of the maxillary sinuses. Patients with sinusitis were separated into group of patients with rhinogenic (72) and patients with odontogenic maxillary sinusitis (35). We found that the etiology of odontogenic sinusitis was mostly artificial caused after some dental surgery (88%), what is totally opposite to the spontaneous etiology of rhinogenic sinusitis. Surgical treatment of rhinogenic sinusitis mostly was endonasal polypectomy with operation by Caldwell-Luc or FESS. Odontogenic sinusitises were mostly treated by FESS and surgical "closing" of oral-antral fistula by local mucogingival flap (51%).     

Transantral revision of recurrent maxillary and ethmoidal disease following functional intranasal surgery.

Recurring disease in the maxillary sinus, despite inferior meatal antrostomies, has led to the widespread use of middle meatal antrostomy or simple decompression of the natural ostium of the middle meatus in attempts to restore function to the maxillary sinus. We have reported recurrent disease in the maxillary sinus in patients with stage III or stage IV hyperplastic rhinosinusitis in whom attempts at functional surgery of the middle meatus were unsuccessful in reversal of retrograde changes. One hundred patients who had previously undergone intranasal sphenoethmoidectomy with removal of the middle turbinate, decompression of the maxillary ostium, and removal of overt hyperplastic disease of the middle meatus underwent revision transantral ethmoidectomy. All recurrent or residual diseased mucosa was removed, including polyps, occasional mucoceles, and hyperplastic changes that occurred despite patency of a middle meatal maxillary ostium. In many of these patients the maxillary sinus was widely marsupialized secondarily into the posterior nasal vault. While the initial overall polyp recurrence rate after intranasal sphenoethmoidectomy in these patients was as high as 19.2%, the rate of polyp recurrence after transantral revision was less than 5% in from 18 to 48 months postoperatively. The experience in this series suggests that mucosal changes have played a primary role in unsuccessful treatment, independent of whether or not adequate functional egress for maxillary secretion, drainage, or ventilation has been created or restored.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bacteriology of chronic sinusitis after amoxicillin-clavulanate potassium therapy

The bacteriology of chronic sinusitis was studied after amoxicillin-clavulanate potassium therapy. Patients with chronic sinusitis were randomly divided into 2 groups. In the study group, 90 patients were given a 2-week course of amoxicillin-clavulanate potassium before functional endoscopic sinus surgery. In the control group, 113 patients did not take any antibiotics within 2 weeks before the surgery. Swab specimens were taken from the maxillary and ethmoid sinuses during surgery and sent for aerobic and anaerobic culture. In the study group, the culture rates of maxillary and ethmoid sinuses were 45.6% and 28.9%, respectively. In the control group, the culture rates of maxillary and ethmoid sinuses were 53.1% and 34.5%, respectively. The culture rates between the control group and the study group were not significantly different, either for the maxillary sinus or the ethmoid sinus. This showed that treatment with amoxicillin-clavulanate potassium did not change the bacteriology of chronic sinusitis.     

Infraorbital nerve dehiscence: the anatomic cause of maxillary sinus "vacuum headache"?

Vacuum disorders of the paranasal sinuses are well described. Patients with facial pain in the distribution of the infraorbital nerve are often labelled as suffering from a "vacuum maxillary sinusitis" and empirically treated by intranasal antrostomy. A variety of mechanisms have been postulated for the production of symptoms in this condition, but all ignore the fact that the maxillary sinus is a relatively insensitive structure. This article introduces a dehiscence of the bony infraorbital nerve canal within the antrum as an anatomic variant and suggests that it may provide the anatomic basis for vacuum sinusitis in the presence of a small natural ostium. Definitive diagnosis is made by outpatient antroscopy, and surgical treatment takes the form of a middle or inferior meatal antrostomy. Persistent symptoms may benefit from an infraorbital neuropexy to provide added protection to the exposed nerve.     

Therapie odontogener Kieferhöhlenerkrankungen

In contrast to rhinogenic sinusitis, the management of acute and chronic maxillary sinusitis of dental origin requires treatment of the odontogenetic source, e.g. chronic oroantral fistulae, apical infections, foreign bodies and aspergillosis. The modern concept of functional endoscopic sinus surgery (FESS) facilitates a minimally invasive approach and a reduction of morbidity for the patient. Using these techniques we use a refined algorithm in the management of chronic maxillary sinusitis of dental origin. In cases that require an osteoplastic approach via the anterior maxillary wall for treatment of the odontogenetic source of infection, drainage of the maxillary sinus is performed via the inferior meatus or via the middle meatus using an infundibulotomy depending on the patency of the ostiomeatal complex. In cases with no necessity for an external osteoplastic approach via the anterior maxillary wall, the odontogenetic source of infection is managed locally and the drainage of the maxillary sinus is performed via the inferior meatus or via an infundibulotomy.     

The utility of concurrent rhinoplasty and sinus surgery: a 2-team approach

OBJECTIVE: To evaluate the safety and efficiency of and patient satisfaction with a 2-team approach for combined rhinoplasty and sinus surgery. METHODS: We conducted a retrospective medical chart analysis of consecutive patients with sinus disease and functional nasal obstruction. Forty-four patients (29 women and 15 men; age range, 22-75 years) had severe nasal obstruction with chronic sinusitis and were found to have indications for this procedure. All patients were followed up for a minimum of 6 months after surgery. Patients completed a standardized questionnaire at the time of medical chart review, and 36 patients completed a telephone interview. RESULTS: All 44 patients underwent rhinoplasty with an endoscopic sinus procedure. Twenty-seven procedures (61%) were endonasal, whereas 17 (39%) were open rhinoplasty. Patients with internal nasal valve collapse underwent 28 butterfly grafts, 6 spreader grafts, and 8 batten grafts. The endoscopic sinus procedures consisted of maxillary antrostomy (30/44 [68%]) and ethmoidectomy (28/44 [63%]). Overall, 20 (65%) of 31 patients reported a postsurgical nasal airway that was significantly improved. Most sinus symptoms were resolved postoperatively, with 25 (71%) of 35 patients describing their improvement as significant. Thirty-two (92%) of 36 patients stated that they would recommend the concurrent procedure. CONCLUSION: Patients presenting with nasal obstruction and chronic sinusitis tolerated combined rhinoplasty and sinus procedures without added morbidity.     

Endoscopic endonasal approach to the pterygopalatine fossa: anatomic study

OBJECTIVE: The pterygopalatine fossa is a relatively small anatomic region. Because of its rich vasculonervous contents and its connections with several intracranial and extracranial compartments, it is of particular surgical interest. Because of its deep localization and despite its small size, however, it can require extensive anatomic approaches, especially for invasive cranial base lesions. We performed a cadaveric study through a minimally invasive endoscopic endonasal approach to the pterygopalatine fossa. METHODS: We studied 16 pterygopalatine fossae in eight adult cadaveric heads in which the arteries and veins were injected with latex. For visualization, we used rod-lens endoscopes, 4 mm in diameter and 18 cm in length, with 0-, 30-, 45-, and 70-degree lenses. An endonasal middle meatal transpalatine approach, an endonasal middle meatal transantral approach, and an endonasal inferior turbinectomy transantral approach were used. RESULTS: The middle meatal transpalatine approach allows for medial exposure of the pterygopalatine fossa contents, the middle meatal transantral approach allows a lateral view, and the inferior turbinectomy transantral approach allows the widest view and room for surgical maneuvering in the medial and lateral compartments of the pterygopalatine fossa and the infratemporal fossa. CONCLUSION: Our anatomic study shows that this approach can be considered a valid minimally invasive option to approach pterygopalatine fossa lesions.     

Ethmoid mucocele as a late complication of endoscopic ethmoidectomy.

OBJECTIVE: Our goal was to describe ethmoid mucocele as a late complication of endoscopic ethmoidectomy. STUDY DESIGN: This was a retrospective review of 14 patients who were diagnosed with ethmoid mucoceles after endoscopic ethmoidectomy. Reviewed data included patient demographics, indication for the original surgery, presenting symptoms, computed tomography results, surgical treatment, operative findings, and recurrence of disease. RESULTS: The mucoceles were diagnosed 1 to 13 years after endoscopic ethmoidectomy. The most common presenting symptom was facial pressure or pain. Twelve patients had middle meatal adhesions. A round mass was seen by endoscopy in the ethmoid cavity in 5 patients. Nine mucoceles were located in the anterior ethmoid and 3 were located in the posterior ethmoid, and 2 involved both. The mucoceles were marsupialized via revision endoscopic ethmoidectomy in 12 patients, whereas 2 had both external and endoscopic approaches taken. CONCLUSION: Ethmoid mucocele can form as a late complication of endoscopic ethmoidectomy. It is commonly associated with middle meatal adhesions.     

Endoscopic endonasal surgery--concepts in treatment of recurring rhinosinusitis. Part II. Surgical technique

Our endoscopic endonasal surgery, under the guidance of rigid endoscopes, aims at the primary focuses in the anterior ethmoid, clearing stenotic clefts and infected ethmoidal cells of diseased mucosa. The maxillary ostium is enlarged into the anterior nasal fontanelle to provide drainage and ventilation. There is no need for any fenestration into the inferior nasal meatus. Once the ethmoidal focus is cleared, the dependent larger sinuses usually heal without having been touched--even if their mucosal pathologies seemed almost irreversible. The endoscopic procedure, which except in children is carried out under local and surface anesthesia, is described in detail. Excellent results with this method, developed by Messerklinger, indicate that there is seldom need for a Caldwell-Luc operation as the state-of-the-art procedure in chronic recurring sinusitis.     

Modifications to the Endoscopic Approach for Anterior Skull Base Lesions Improve Postoperative Sinonasal Symptoms

Background/Objective Our institution previously showed that patients experience significant postoperative sinonasal symptoms for the first few months after endoscopic transnasal transsphenoidal skull base surgery (eTNTS). Since our initial study we have modified our technique, discontinuing routine resection of the middle turbinate, maxillary antrostomies, and nasoseptal flaps. In this study, we analyze whether these technical modifications decrease postoperative sinonasal morbidity after eTNTS. Methods A retrospective review was performed of 93 consecutive patients who underwent eTNTS at a tertiary academic medical center from August 2011 to August 2012. Main Outcome Measures  Sino-Nasal Outcome Test (SNOT)-20 and SNOT-22 scores preoperatively and after surgery. Results Compared with our previous study, our new cohort experienced a significant improvement (p < 0.05) in SNOT scores for the need to blow nose, runny nose, postnasal discharge, thick nasal discharge, wake up at night, reduced concentration, and frustrated/restless/irritable. Within the new cohort, patients who did not have a nasoseptal flap or middle turbinate resection had less worsening and faster improvement of nasal symptom scores after surgery. Conclusions Preserving normal sinonasal physiology during eTNTS by limiting middle turbinate resections, avoiding unnecessary maxillary antrostomies, and reducing the use of nasoseptal flaps when feasible results in less sinonasal morbidity and more rapid recovery during the postoperative period.     

Antrochoanal polyps: clinical presentation and the role of powered endoscopic polypectomy

Antrochoanal polyps are a rare clinical entity. In this review of patients treated between January 1996 and September 2002, there were 18 cases of antrochoanal polyps. The mean age of patients was 20 years. Nasal obstruction was the most common symptom (17 cases, 94%), followed by rhinorrhoea (44%), epistaxis (33%), postnasal drip (28%), and snoring (22%). Chronic sinus was the most common associated rhinological finding (50%). Various surgical approaches were used: endoscopic polypectomy and middle meatal antrostomy in seven patients (38.9%), endoscopic polypectomy and inferior meatal antrostomy in three patients (16.7%) and Caldwell-Luc surgery in one patient (5.6%). No complications were noted in patients treated with powered instrumentation, including the three patients in whom combined transcanine approaches were used. We concluded that powered endoscopic polypectomy was safe and effective. It allowed a more complete dissection and may diminish the chance of recurrence.     

鼻内镜手术治疗慢性鼻窦炎后症状无缓解的处理与相关因素分析

目的探讨慢性鼻窦炎鼻内镜手术后症状无缓解的相关因素及治疗策略。方法回顾性分析我科2007年7月~2014年5月收治的179例已接受鼻内镜手术治疗但临床症状无缓解的患者的临床资料,分析其无缓解的原因及治疗策略。结果所有无缓解病例均行修正性鼻内镜手术,治愈159例,有效20例。经多因素分析,慢性鼻窦炎发病原因、医生的学历、职称、鼻内合并症、术中和术后情况是影响慢性鼻窦炎鼻内镜手术后症状无缓解的相关因素。结论手术技巧不熟练,解剖知识欠缺,鼻窦炎发生的原因、鼻内合并症、术中和术后情况是导致慢性鼻窦炎鼻内镜手术失败的根本原因。     

Endoscopic endonasal surgery--concepts in treatment of recurring rhinosinusitis. Part I. Anatomic and pathophysiologic considerations

Many years of endoscopic investigation and observation proved that most infections of the paranasal sinus are rhinogenic, spreading from the nose into the sinuses. The common focus of infection in cases of recurring sinusitis is the stenotic areas of the anterior ethmoid, with infection recurring in the larger sinuses. The anterior ethmoid, especially its infundibulum, is thus a key location for infection or cure, and maxillary as well as frontal sinuses are fully dependent on the pathophysiologic conditions there. Histologic examination demonstrates that massive changes of the nasal glands are the reason for permanent mucosal thickening. Retention cysts, highly viscous mucus, mucus extravasations, and metaplastic epithelial changes add to the vicious cycle of blockage of the ostium-meatus unit.     

Endoscopic endonasal skull base surgery: Part 2--The cavernous sinus.

OBJECTIVE: An endoscopic endonasal approach to the cavernous sinus was developed with cadaver study and, subsequently, has been used in patient treatment. METHODS: The endoscopic anatomy, surgical approaches, and ideal head positioning were studied with six cadaver head specimens in order to develop endoscopic endonasal surgery of the cavernous sinus. Three illustrative patient cases are also reported. RESULTS: Horizontal placement of the forehead-chin line of head specimens provided the ideal head positioning for endoscopic endonasal cavernous sinus surgery. Three different surgical approaches were developed to access the cavernous sinus: the paraseptal, middle meatal and middle turbinectomy approaches. While the ipsilateral middle meatal approach provided straight anterior exposure, the contralateral paraseptal approach provided anteromedial exposure at the cavernous sinus. The middle turbinectomy approach rendered straight anterior exposure ipsilaterally and anteromedial exposure contralaterally. The sympathetic nerve climbed up on the surface of the carotid artery. When the dura mater was opened at the anterior wall of the cavernous sinus, the S-shaped carotid siphon was exposed. Cranial nerves III and IV were located inside the C-shaped carotid siphon. Cranial nerve VI was just lateral to the inferior arch of the carotid siphon. The ophthalmic branch of the trigeminal nerve was lateral to cranial nerve VI. When used in patient treatment, this technique was observed to be minimally invasive. CONCLUSION: Endonasal endoscopy for cavernous sinus surgery was studied in cadaver dissection, and subsequently, was used in patient treatment with satisfactory outcomes.     

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.     

Initial report on postoperative healing after endoscopic sinus surgery with the microdebrider

Synechiae formation is a frequent occurrence after endoscopic sinus surgery and may cause symptomatic sinus outflow tract obstruction. Various means are used to reduce the incidence of synechiae formation. These include meticulous operative technique, partial middle turbinate resection, middle meatus spacers or stents, and postoperative debridement. The microdebrider is a powered rotary shaving device that precisely resects tissue, minimizing inadvertent mucosal trauma and stripping. We present 40 cases of endoscopic sinus surgery performed with the microdebrider. Patients had at least a 5-month follow-up and demonstrated rapid mucosal healing, minimal crust formation, and a low incidence of synechiae formation. These initial data suggest that the microdebrider may be advantageous in surgery for chronic sinusitis. (Otolaryngol Head Neck Surg 1998;118:800-3.)     

What is the Best Route to the Meckel Cave? Anatomical Comparison between the Endoscopic Endonasal Approach and a Lateral Approach

Background Traditionally, a pterional approach is utilized to access the Meckel cave. Depending on the tumor location, extradural dissection of the Gasserian ganglion can be performed. An endoscopic endonasal access could potentially avoid a craniotomy in these cases. Methods We performed an endoscopic endonasal approach as well as a lateral approach to the Meckel cave on six anatomic specimens. To access the Meckel cave endoscopically, a complete sphenoethmoidectomy and maxillary antrostomy followed by a transpterygoid approach was performed. For lateral access, a pterional craniotomy with extradural dissection was performed. Results The endoscopic endonasal approach allowed adequate access to the Gasserian ganglion. All the relevant anatomy was identified without difficulty. Both approaches allowed for a similar exposure, but the endonasal approach avoided brain retraction and improved anteromedial exposure of the Gasserian ganglion. The lateral approach provided improved access posterolaterally and to the superior portion. Conclusion The endoscopic endonasal approach to the Meckel cave is anatomically feasible. The morbidity associated with brain retraction from the open approaches can be avoided. Further understanding of the endoscopic anatomy within this region can facilitate continued advancement in endoscopic endonasal surgery and improvement in the safety and efficacy of these procedures.     

Effects of systemic steroid treatment in chronic polypoid rhinosinusitis evaluated with magnetic resonance imaging.

BACKGROUND: The aim of this prospective study was to evaluate the efficacy of a combined (local and systemic) steroid therapy on the extent of chronic polypoid rhinosinusitis and patient symptoms. METHODS AND PATIENTS: Subjects of this study were 20 patients with severe chronic polypoid rhinosinusitis with total or subtotal narrowing of the all sinuses. A nasal budesonide spray (2 x 0.1 mg/day) and an oral fluocortolone medication with a daily reduction during a 12-day period (total dose: 560 mg = group 1) and a 20-day period (total dose: 715 mg = group 2), respectively, were administered. Before and after the steroid treatment we evaluated the extent of the sinusitis with MRI and patient symptoms with symptom-related questionnaires. RESULTS: A significant reduction (> 30%) of the chronic polypoid rhinosinusitis was observed in 50% of MRI findings. The steroid effect on polypoid masses was heterogeneous in different anatomic areas (maxillary sinus 40%, anterior ethmoid 19%, posterior ethmoid 33%, sphenoidal sinus 61%, frontal sinus 46%). Most sinusitis-related symptoms were distinctly diminished in most patients (80%). No major side effects were observed. CONCLUSIONS: A combined short-term steroid therapy is highly effective in chronic polypoid rhinosinusitis, reducing the mucosal inflammation mainly in the large sinuses and reducing the incidence of symptoms significantly. However, this therapy was insufficient in the anterior ethmoid and cannot replace the current surgical treatment concept of the osteomeatal complex in CPR. The indication for such a short-term steroid therapy is the preoperative treatment. It facilitates functional endoscopic sinus surgery by reducing the extent of surgical procedures, the time, and thereby the risks of sinus surgery.     

Sinus-nasal polyposis: one-year outcome after endoscopic sinus surgery followed by topical corticosteroid therapy in 72 patients

Nasal polyposis (NP) is considered as an inflammatory disease for which first line therapy is topical and/or oral corticosteroid. In this paper we attempted to determine the efficacy of endoscopic endonasal surgery followed by topical corticoid in 72 adults suffering from bilateral NP refractory to corticosteroid therapy and to delineate the clinical characteristics of this cohort of patients. NP was confirmed endoscopically and with computed tomography. Visual analog scale for the subjective evaluation and endoscopic examination of the paranasal cavities for the objective evaluation were obtained 3 and 12 months postoperatively. Endoscopic endonasal surgery was based on a radical removal of the NP with wide opening of all the sinuses in the vast majority of the cases. Topical corticoid therapy was started 2 months after surgery. Clinical characteristics of the 72 patients revealed: 29.2% of coexisting allergy; 34.7% of coexisting asthma; 19.4% with food and/or aspirin intolerance. Anterior and posterior ethmoid sinus and maxillary sinus were the most affected sinuses. 53.5% of our patients presented a stage II. One year after surgery we observed that 59.1% of our patients revealed a marked decrease of their symptoms with no polyp on nasal endoscopic evaluation, that 28.8% revealed a marked decrease of their symptoms with recurrence of the NP on nasal endoscopic evaluation and that 12.1% presented moderate to severe symptoms with recurrence of NP on nasal endoscopic evaluation. Based on this experience, we think that endoscopic endonasal surgery will continue to play an important role in the management of NP when the patient becomes refractory to corticoid.