Repetitive endoscopic sinus surgery failure: a role for radical surgery?

OBJECTIVES: Endoscopic sinus surgery (ESS) is considered to be the golden standard for surgery in patients with chronic rhinosinusitis and nasal polyposis. However, there is still a small group of patients unresponsive despite repetitive surgery. Radical surgery aimed at reduction of the inflammatory burden and optimization of drainage of the sinuses has been suggested as a last resort for these patients. STUDY DESIGN: A prospective, questionnaire-based study was conducted in a group of 23 patients who underwent Denker's procedure for refractory chronic rhinosinusitis. Symptoms were evaluated before Denker's procedure and 12 months and 2 years after surgery. RESULTS: Patients reported improvement of feelings of congestion in 74%, rhinorrhea in 70%, and nasal obstruction in 60% of the cases. The following postoperative improvements were statistically significant: rhinorrhea (P = 0.001), feelings of congestion (P = 0.02), and nasal obstruction (P = 0.03). Reduced olfactory perception and asthma did not improve. CONCLUSION: Radical surgery may be a viable treatment option in case of recurrent ESS failure. EBM rating: C-4.     

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.     

Concurrent functional endoscopic sinus surgery and rhinoplasty: pros

Despite historical concerns about the spread of infection from the sinuses to the nasal tissues,concurrent septorhinoplasty and endoscopic sinus surgery may be performed safely in most patients who meet the criteria for sinus surgery. However, otolaryngologists should use good medical judgment in selecting patients appropriate for the combined procedures.Patients with extensive sinus pathology or systemic illness are not the ideal candidates for concurrent surgery. It is recommended to perform the septal and sinus surgery first, so that the surgeon may postpone the elective rhinoplasty procedure if unfavorable intraoperative circumstances develop. Overall, when performed in carefully selected patients, contemporaneous rhinoplasty and endoscopic sinus surgery is safe and effective and offers many advantages for the patient.     

The minimally invasive, endoscopic approach to sinus surgery

When anatomic abnormalities of the nose and sinuses contribute to sinusitis, and when medical therapy has failed, these anatomic or structural abnormalities can be surgically corrected. Examples of anatomic problems include nasal polyps, nasal septal deviations, and blockage of the osteomeatal complex--the "crossroads" of the sinuses. Endoscopic techniques allow sinus specialists to diagnose and treat these problems more easily than in the past, allowing them to be more proactive in the management of anatomic nasal abnormalities. In this article we review the minimally invasive, endoscopic approach to sinus surgery and discuss recent advances in sinus surgery. Specifically, we discuss the utility of powered instrumentation and image guidance in endoscopic sinus surgery.     

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.     

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.     

Pediatric functional endonasal sinus surgery: review of 210 cases.

Functional endonasal sinus surgery (FESS) is an effective treatment for chronic or recurrent sinusitis in children, most of whom have failed more conservative medical treatment. The endoscopes used in FESS allow direct visualization of the diseased tissue and restoration of physiologic mucociliary clearance, enabling the sinus mucosa to return to its normal condition after the procedure. For a period of 3 to 36 months, we followed the recovery of 210 children who underwent FESS between 1986 and 1989. The age range of the children at the time of the procedure was 14 months to 16 years. Eighty percent of these patients had improvement of their sinusitis. There were no major complications. Eight percent of the 210 children needed revision surgery. Pediatric FESS is a two-stage operation requiring follow-up nasal cleaning under general anesthesia. The most common findings during the second-stage endoscopy were adhesions and granulation formation.     

A transpubic approach to radical prostatectomy.

A transpubic approach to radical prostatectomy is presented in a series of 15 cases. The main advantages and some typical complications of this approach are described.     

Informed consent in functional endoscopic sinus surgery: the patient's perspective.

OBJECTIVE: Informed consent is essential prior to functional endoscopic sinus surgery (FESS). The content of this discussion is often determined by each surgeon. Many doctors discuss all potential complications. This may provoke anxiety or deter from beneficial surgery. Our goal was to examine the process from the patient's perspective.Study design A list of potential complications was reviewed with FESS patients. Patients were asked questions concerning their consent and the potential complications before and after FESS. RESULTS: Both before and after surgery, patients felt that discussion of most potential complications was important. Vision changes and cerebrospinal fluid leak (CSF) received the highest scores. No significant differences were found between primary and revision cases. CONCLUSION: Patients wanted most potential FESS complications to be discussed. Even though this triggered anxiety, they felt it was important to have a thorough disclosure. Findings presented may impact how surgeons counsel patients prior to FESS.     

Combined open septorhinoplasty and functional endoscopic sinus surgery.

OBJECTIVE: To compare perioperative and early postoperative complication rates of performing open septorhinoplasty (OSR) and functional endoscopic sinus surgery (FESS) concomitantly or individually. STUDY DESIGN AND SETTING: Retrospective chart review of 55 patients treated at an academic referral center who had undergone combined OSR and FESS. Complication rates for the combined procedures were compared with published complication rates for the individual procedures. RESULTS: Patients' ages ranged from 14 to 77 years (average, 43 years). Among the 55 cases, there were no major complications and 6 (11%) minor complications: 4 cases of cellulitis (7%; previously published risk, 1%-3%) and 2 cases of postoperative epistaxis (4%). CONCLUSION: OSR and FESS may be performed safely in combination without a clinically significant increased risk of complications. SIGNIFICANCE: The slightly increased risk of cellulitis may warrant the use of intraoperative sinus irrigation and postoperative antibiotic prophylaxis after combined OSR and FESS.     

右美托咪啶在全麻鼻内镜手术控制性低血压中的应用

目的 探讨右美托咪啶在全麻鼻内镜手术控制性低血压中应用的安全性及有效性.方法 对60例择期全麻下行鼻内镜手术患者按随机数字表法随机分为两组(每组30例),采用硝普钠(N组)、右美托咪啶(D组)行控制性低血压,维持平均动脉压( MAP)在60 mm Hg～70 mm Hg(1 mm Hg=0.133 kPa).记录诱导前5min(T0)、手术开始后30 min(T1及拔管即刻(T2)时的心率(HR)、MAP及达标时间、手术时间、降压持续时间、拔管时间、出血量及尿量,对术野质量和苏醒期清醒镇静程度进行平定并观察有无副作用.结果 两 组患者年龄、体重、性别比、手术时间、控制降压持续时间组间比较,差异无统计学意义(P＞0.05).所有患者术中MAP均能维持在目标范围.两组患者T0时点MAP、HR组间比较,差异无统计学意义(P ＞.05)；降压达标时间D组(16.7±3.7) min较N组(10.1±1.8) min慢(P＜0.05)；T2、T1时点与T0时点比较,N组HR(105+7)、(82±5)次/min较(78±6)次/min明显增快(P＜0.05),D组HR(74±7)、(69±8)次/min较(79±8)次/min明显减慢(P＜0.05)；组间比较,T2、T1时点N组HR(105±7)、(82±5)次/min明显高于D组(74±7) 、(69±8)J/min(P＜0.05).N组拔管时出现反跳性高血压,D组拔管时MAP(84+10) mm Hg仍低于诱导前水平(95±8) mm Hg(P＜0.05).D组术野质量评定(scores of surgical field quality,SSFQ)(1.2±0.4)分优于N组的(1.9±0.5)分(P＜0.05)；N组的拔管时间(14.5±1.8) min要短于D组的(16.5±2.7)min(P＜0.05)；N组苏醒期清醒镇静评分(1.5±A5)分优于D组的(2.0±0.3)分(P＜0.05),但N组有6例出现术后躁动；D组出血量(111±45) ml较N组的(191±43)ml少(P＜0.05),D组尿量(390±105) ml较N组的(230±83) ml多(P＜0.05).所有患者术后随访无术中知晓、呼吸抑制等麻醉并发症发生.结论在全麻鼻内镜手术中应用右美托咪啶行控制性低血压安全可行,能提供更好的术野质量,同时副作用更少,值得推广应用.     

Considerations against concurrent functional endoscopic sinus surgery and rhinoplasty

Over the last decade, functional endoscopic sinus surgery (FESS) has become the surgical modality of choice in the treatment of inflammatory sinus disease refractory to medical therapy. During the same interval, interest in cosmetic surgery procedures, including rhinoplasty, has exploded. Some of the published literature endorses the performance of concurrent FESS and rhinoplasty. This article addresses some of the concerns regarding the combined approach and its limitations. It offers the reader a framework for surgical risk assessment when concurrent procedures are considered.