Tailored endoscopic surgery for the treatment of sinonasal inverted papilloma

BACKGROUND: This retrospective study was designed to evaluate the efficacy of tailored endoscopic surgery. Tailored endoscopic surgery aims at resecting the inverted papilloma completely with a customized surgical approach, especially when an en-bloc excision cannot be comprehensively or routinely achieved because of the immense extent of the tumor. METHODS: Between November 1991 and March 2002, 43 patients with sinonasal inverted papillomas were treated by tailored endoscopic surgery. The average duration of follow-up for this population was 25.3 months (range, 9-150 months). A staging system developed by Krouse was adopted for tumor grading. On the basis of tailored endoscopic surgery, 15 localized lesions and 12 smaller extensive lesions (Krouse stages 1 and 2) were treated by ordinary endoscopic resection, whereas 16 larger extensive lesions (Krouse stages 3 and 4) in which the tumors were immense were subjected to sequential segmental endoscopic surgery (SSES). Seven of these 16 larger extensive lesions combined with endoscopic medial maxillectomy because of extensive encroachment of maxillary sinus antrum. RESULTS: Four patients (9.3%) had residual disease, each requiring one revision surgery. All tumors were successfully resected. No patient required lateral rhinotomy or midfacial degloving procedure. No major complications were encountered in any of the patients. None of the patients had residual disease at the time of this writing. CONCLUSIONS: Tailored endoscopic surgery is a safe and effective treatment that obviates the need for more extensive surgery for the management of inverted papilloma. Proper preoperative evaluations, intraoperative determination of extent and attachment of the tumor, close endoscopic follow-up, and expert application of endoscopic techniques are the keys to the successful use of tailored endoscopic surgery.     

鼻内镜手术治疗鼻腔鼻窦内翻性乳头状瘤

目的探讨鼻内镜手术治疗鼻腔鼻窦内翻性乳头状瘤的方法及可行性,观察其疗效。方法回顾性分析2008年1月～2012年12月57例鼻腔鼻窦内翻性乳头状瘤的临床资料,均行鼻内镜下切除手术。根据病变程度和范围,选择经典式鼻内镜手术,鼻内镜中鼻道、下鼻道联合上颌窦开窗术,鼻内镜辅助下Caldwell—Luc手术。观察术后复发率。结果随访1～3年,（23±9）月。复发率10．5％（6／57）,其中经典式鼻内镜手术9．7％（3／31）,鼻内镜中鼻道、下鼻道联合上颌窦开窗术10．0％（2／20）,鼻内镜辅助下Caldwell—Lue手术16．7％（1／6）。复发6例均行二次鼻内镜手术,随访6—12个月,平均7．5月,无再次复发。结论鼻内镜下手术治疗鼻腔鼻窦内翻性乳头状瘤手术损伤小,术后复发率低,临床疗效较好。     

Endoscopic surgery of inverted papillomas under image guidance--a prospective study of 42 consecutive cases at a Danish university clinic.

BACKGROUND: To evaluate the feasibility of endoscopic surgery with image guidance in the treatment of inverted papillomas. STUDY DESIGN AND SETTING: This prospective cohort study comprised 42 consecutive patients with biopsy-confirmed inverted papillomas that were diagnosed between 1998 and 2003. All patients were treated by the first author (C.B.). Image guidance based on preacquired CT scans of the patients was used to assist the surgeon aiming at endoscopic resection of inverted papilloma. The success of the surgery was judged primarily by the recurrence rate and the treatment morbidity. RESULTS: The study group consisted of 30 males and 12 females with a median age of 61 years. The follow-up period ranged from 9 months to 69 months (median, 37 months). The only additional procedure performed was the Caldwell-Luc procedure (8 cases). Recurrence was diagnosed in 10 cases (24%), all in the original tumor site. Eight of these had undergone previous surgery for inverted papilloma. The recurrences were predominantly located in the maxillary or in the frontal sinus (8 cases). In 2 cases, the recurrence was simply removed endoscopically while performing the biopsy procedure. All recurrences were identified within the first 9 months. Associated malignancy was not shown. No severe complications occurred. CONCLUSIONS: A treatment based on endoscopic resection with image guidance appears to offer a safe treatment modality of inverted papilloma with insignificant morbidity. Predominantly cases with nonmedial involvement of the maxillary sinus still require a supplement with the Caldwell Luc procedure. Although all the recurrences were found within 9 months postoperatively, later recurrences cannot be excluded. Long-term follow-up is recommended.     

Fungal diseases of the sinuses

With recent advances in medicine, fungal diseases are becoming not only better understood, but also increasingly important in the management of patients with paranasal sinus disease. Fungal sinus diseases run the gamut from allergic fungal rhinitis and allergic fungal sinusitis, through fungus balls, to invasive and fulminant fungal sinusitis. Allergic fungal sinusitis may be thought of as the sinus counterpart of allergic bronchopulmonary fungal disease. Patients typically are first seen with chronic sinusitis. They may be atopic, and the peripheral blood often shows elevated IgE levels and absolute eosinophil counts. Such patients may be managed conservatively, requiring only surgical drainage and corticosteroid therapy. Fungus balls are typified by the so-called "aspergilloma." Although patients often have some predisposing factor, such as local tissue hypoxia or massive fungal exposure, most patients are not immunocompromised. Fungus balls may be treated with the traditional Caldwell-Luc operation or with newer endoscopic procedures. Invasive or fulminant fungal sinusitis generally occurs in immunosuppressed patients and merits aggressive surgical excision and debridement, as well as systemic chemotherapy, usually amphotericin B. In this article, we review fungal disease of the paranasal sinuses and present findings from our review of patients with chronic sinusitis.     

Endoscopic and endoscope-assisted resections of inverted sinonasal papillomas.

OBJECTIVE: To evaluate the success of endoscopic and endoscope-assisted resection of inverted sinonasal papillomas and to assess the indications for adjunctive external procedures. STUDY DESIGN: Retrospective chart review. RESULTS: Fifty patients were treated surgically during the 10-year study period and had greater than 1 year of follow-up care. These patients had a recurrence rate of 14% (7/50) with a mean follow-up of 31.1 months. Of these 7 patients with recurrences, 3 were treated primarily at this institution, and 4 had been treated prior to referral. Recurrence was 11% (3/27) for primary resections and 17% (4/23) for secondary resections. Average time to recurrence was 11.7 months. Of the patients, 38% (19/50) had adjunctive external procedures either during the initial resection or for the management of recurrent disease. CONCLUSIONS: Endoscopic and endoscope-assisted resections of inverted papilloma are effective techniques for managing inverted papilloma. The intraoperative findings, most importantly the site(s) of tumor attachment, dictate whether an endoscopic procedure is sufficient to complete resect the inverted papilloma or whether an adjunctive external procedure is required. Appropriate patient selection and an aggressive surgical approach are necessary for the management of these neoplasms.     

COMPLICATIONS OF THE CALDWELL-LUC OPERATION AND HOW TO AVOID THEM

The complications of the Caldwell-Luc operation were retrospectively studied in 1990. The case records were analysed and updated information from telephone interviews and posted questionnaires were available for most patients. One hundred and eighty-five patients with 216 procedures with a mean postoperative follow-up period of 33.5 months were studied. The commonest indication for the operation was for chronic sinusitis. There were three common complications found: facial swelling (61.9%), pain and/or numbness of the face (46.0%) and pain and/or numbness of the teeth/gums (30.9%). Rare complications are postoperative epistaxis (0.4%), oroantral fistulae (0.4%), epiphora (0.4%) and dental discoloration (0.4%). This paper discusses the pathophysiology of these complications and surgical techniques on how to avoid them. Although the use of the Caldwell-Luc operation has declined in recent years with the development of endoscopic sinus surgery, it still has occasional indications and a set of practical guidelines on how to prevent complications would be useful. The basis for treating chronic sinusitis with functional endoscopic sinus surgery at the expense of the more traditional form of treatment is also discussed.     

鼻内镜治疗颅底疾病112例报告

目的探讨鼻内镜径路治疗颅底疾病的价值。方法2002年5月~2006年12月,对112例颅底疾病行鼻内镜径路手术,其中脑脊液鼻漏39例,垂体瘤4例,脑膜膨出或脑膜脑膨出3例,蝶筛囊肿9例,蝶窦炎伴息肉2例,真菌性蝶窦炎12例,内翻性乳头状瘤11例,鼻咽纤维血管瘤6例,骨化纤维瘤2例,骨纤维异常增殖2例,脊索瘤7例,颅咽管瘤2例,鳞癌10例,未分化癌1例,乳头状瘤癌变2例。结果全组均在鼻内镜下处理,其中20例病变为次全切除,包括鳞癌8例、未分化癌1例、脊索瘤7例、颅咽管瘤2例、骨纤维异常增殖2例。脑脊液鼻漏1次手术成功31例(79.5%),2次成功4例,3次成功4例,最终成功率100%。1例脑膜脑膨出术后2个月复发并伴脑脊液漏,内镜下再次手术成功。1例内翻性乳头状瘤术后11个月复发,改行鼻侧切开术。1例真菌性蝶窦炎术后4个月复发行再次内镜手术。1例脑脊液鼻漏术后颅内感染。结论鼻内镜径路可以处理多种颅底疾病,是一种安全、有效、微创的手术方式,但仍需严格掌握手术适应证,特别是恶性肿瘤。     

Small and large middle meatus antrostomies in the treatment of chronic maxillary sinusitis.

OBJECTIVE: The study goal was to compare the postoperative endoscopic appearance of the middle meatus antrostomy with symptomatic relief in patients undergoing endoscopic endonasal sinus surgery for chronic maxillary sinusitis. STUDY DESIGN: We conducted a prospective randomized study encompassing 133 patients with chronic rhinogenic maxillary sinusitis who underwent endoscopic ethmoid surgery and middle meatal antrostomies. One of the tasks was to compare small-sized (less than 6 mm) antrostomies with large-sized (more than 16 mm) antrostomies in relieving the symptoms of chronic maxillary sinusitis. During follow-up an attempt was made to correlate endoscopic findings with symptomatic failure. RESULTS: We could not demonstrate a statistically significant correlation between the degree of improvement of the main sinusitis symptoms (obstruction, headache, and nasal discharge) and the postoperative size of the antrostomy. Nevertheless, persistent accessory maxillary ostia, scarring within the ethmoid were statistically significant predictors of poor surgical outcome. CONCLUSION: We conclude from this study that the size of the middle meatal antrostomy has no influence on the outcome of endonasal surgery for chronic rhinogenic maxillary sinusitis.     

Classification of fungal sinusitis in immunocompetent patients.

OBJECTIVE: The objective of this study was to review the subgroup classification of fungal sinusitis in immunocompetent patients. METHODS: The study design included 19 immunocompetent patients with fungal sinusitis who were operated on between 1993 and 1998. RESULTS: Ten of 19 patients showed a fungus ball. They underwent a limited surgical endoscopic procedure, and no further treatment was needed. Four patients had allergic fungal sinusitis and were treated postoperatively with irrigation, topical steroids, and oral steroids in 2 patients as well. Five patients had chronic sinusitis with significant bone erosion. All 5 underwent an extensive endoscopic procedure and were treated postoperatively by repeated irrigation, endoscopic cleaning, and no antifungal preparation. Two patients of this group are reported broadly. CONCLUSIONS: Fungal sinusitis in immunocompetent patients is not a rare condition and can be divided into 3 categories: 1) fungus ball, 2) chronic erosive (noninvasive) fungal sinusitis, and 3) allergic fungal sinusitis. The symptomatology, treatment, and prognosis varied significantly among the 3 different categories.     

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.     

鼻内镜手术治疗真菌性鼻窦炎19例

目的探讨鼻内镜手术冶疗真菌性鼻窦炎的疗效。方法2000年1月～2003年12月对19例真菌性鼻窦炎在鼻内镜下清理中鼻道息肉或肉芽，切除钩突，扩大各窦口，清除窦内病变。术中3％H2O2反复冲洗窦腔。中隔偏曲致病侧中鼻道狭窄影响窦口引流，一期行鼻中隔矫正术。结果术后5例症状缓解，14例症状消失。19例随访6～48个月，平均14个月，17例未复发，2例复发，再次行Caldwell-Luc手术，无一例并发症发生。结论鼻内镜手术治疗非侵袭型真菌性鼻窦炎有较好的临床疗效，但对严重上颌窦真菌病仍不能替代Caldwell-Lues手术。     

Neurosurgical implications of allergic fungal sinusitis

OBJECT: Allergic fungal sinusitis (AFS) is a form of paranasal mycosis that often involves bone destruction and extension into the orbit and anterior skull base. Treatment consists of surgical extirpation and a course of corticosteroids. Despite frequent intracranial involvement, AFS is rarely reported in the neurosurgical literature. METHODS: The records of 21 patients with the histological diagnosis of AFS were reviewed. The histological diagnosis was based on findings of branching septated fungi interspersed with eosinophilic mucin and Charcot-Leyden crystals without fungal invasion of soft tissue. The average age of the 21 patients in this study was 25 years (range 9-46) and the male/female ratio was 3.75:1. All patients were immunocompetent. All had a history of chronic sinusitis and imaging findings of expansile disease involving multiple sinuses. Fifteen patients had nasal polyposis, eight had erosion of bone, which was observed on computerized tomography (CT) scans, eight had disease extending intracranially, and six had disease that involved the lamina papyracea. All patients underwent transnasal and/or transmaxillary endoscopic approaches for debridement and irrigation, six underwent orbital decompression, and three underwent a bifrontal craniotomy for removal of intracranial extradural disease. No patient had a cerebrospinal fluid leak. Postoperatively, one patient was treated with amphotericin B and the other 20 were treated with a short course of corticosteroids. The follow-up period ranged from 2 to 19 years. CONCLUSIONS: Allergic fungal sinusitis is a unique form of fungal disease that may mimic anterior skull base and paranasal sinus tumors. A cranial base team approach of neurosurgeons and otolaryngologists is recommended. Most cases can be successfully managed with transnasal and/or transmaxillary endoscopic techniques. A craniotomy is rarely indicated unless there is the suspicion of dural invasion or extensive intracranial and/or intraorbital involvement that is inaccessible from below.     

Conservation surgery for inverted papillomas

To evaluate the role of conservation surgical treatment of inverted papillomas of the nose and paranasal sinuses, the clinical course of 46 patients treated during a 10-year period was evaluated. Twelve patients were noted to have either invasive squamous cell carcinoma or carcinoma in situ and were excluded from analysis. Of the remaining 34 patients, 19 had previous treatment for inverted papilloma. Subsequently, 20 patients were treated with lateral rhinotomy and medial or partial maxillectomy. Fourteen patients were treated with conservation surgical therapy. There were 5 recurrences (15%), which all occurred in the conservation-treated group. Four of six (66%) patients treated with an intranasal procedure recurred but only 1 of the 8 (12%) patients treated with a Caldwell-Luc approach combined with an intranasal procedure. Successful treatment was achieved in all patients undergoing salvage surgery for recurrence. The role of conservation treatment in the management of inverted papillomas of the nose and paranasal sinuses is discussed.     

The Caldwell-Luc procedure in 1991.

In the pre-antibiotic era, George Caldwell and Guy Luc both designed an operation to remove infected polypoid tissue from the maxillary antrum, as well as to provide drainage and ventilation of the sinus. With the development of antibiotics and the surgical endoscopes, many of the former indications for the Caldwell-Luc procedure have changed. However, the Caldwell-Luc procedure still offers optimal exposure for decompression of Grave's ophthalmopathy, pterygomaxillary space surgery, management of some maxillary trauma, removal of antral foreign bodies, repair of some oral-antral fistulae, management of maxillary osteomyelitis and benign maxillary tumors, and irreversible mucosal disease and endoscopic surgical failures.     

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%).     

Surgical treatment of Aspergillus mycetomas of the maxillary sinus: review of the literature.

The present study reviews the literature concerning the surgical treatment of Aspergillus mycetoma (AM) in the last 20 years to identify a gold standard surgical technique. Aspergillus mycetoma of the maxillary sinus, or mycetoma (fungus ball), is a noninvasive or extramucosal mycotic infection. Surgical removal of the sinus fungal masses to ensure drainage and aeration is performed using the traditional Caldwell-Luc (CL) procedure or endoscopic sinus surgery (ESS). Results of this review suggest that the gold standard surgical technique for AM is ESS with middle meatal antrostomy. General or local antifungal drugs are not indicated. Combined approach with an intraoral surgical access from the anterolateral wall of the maxillary sinus has to be reserved for selected cases in which ESS doesn't permit complete extraction of all fungal concretions or foreign bodies. The CL procedure should be avoided, because it has detrimental consequences for sinus physiology.     

非侵袭性真菌性鼻窦炎46例临床分析

目的探讨非侵袭性真菌性鼻窦炎的临床表现、诊断和手术疗效。方法回顾性分析46例非侵袭性真菌性鼻窦炎患者的临床资料。结果 46例患者平均随访2.6（1～5）年,筛窦、蝶窦单发真菌感染鼻内镜手术5例,术后均无复发。上颌窦真菌感染鼻内镜手术33例,2例复发,复发率6.1%;鼻内镜联合改良柯-陆氏手术8例,术后均无复发。结论非侵袭性真菌性鼻窦炎经鼻内镜手术是一种有效的治疗方法,鼻内镜联合改良柯-陆氏手术清除上颌窦真菌更彻底,能减少复发。     

Medial maxillectomy: a comparative study as a surgical procedure.

OBJECTIVE: The purpose of this study was to compare the long-term results of endoscopic and conventional medial maxillectomy. STUDY DESIGN: A prospective study. SUBJECTS AND METHODS: This study was conducted on 28 patients. No patient had intracranial or intraorbital extension. Thirteen patients (4 with adenocarcinoma, 5 with inverted papilloma, and 4 with malignant melanoma) underwent endoscopic medial maxillectomy, and 15 patients (5 with adenocarcinoma, 5 with inverted papilloma, and 5 with malignant melanoma) underwent conventional medial maxillectomy with a postoperative follow-up of 12 to 48 months. RESULTS: In group 1 (the endoscopic group), recurrence was seen in one case (7.6%) with malignant melanoma 3 months after the surgery and was managed by revision endoscopic removal of the disease. The overall success rate in this group was 92.4%. In group 2 (the conventional group), the disease recurred in one (6.6%) patient with malignant melanoma. The overall recurrence rate was 7.2%. CONCLUSIONS: The precise determination of tumor origin and extent of tumor during the surgery is the key to a successful outcome.     

Endoscopic frontal sinus obliteration: a new technique for the treatment of chronic frontal sinusitis.

OBJECTIVES: Patients who fail endoscopic drainage procedures for chronic frontal sinusitis often require obliteration of the frontal sinus with abdominal fat. The purpose of this study was to evaluate an endoscopic technique for frontal sinus obliteration. STUDY DESIGN AND SETTING: Retrospective case-control. Thirty-five patients underwent frontal sinus obliteration using either an endoscopic (n=10) or conventional osteoplastic flap (n=25) technique from 1994 to 2004 at an academic medical center. RESULTS: Patients undergoing endoscopic obliteration had less blood loss (P = 0.006), decreased operative time (P = 0.016), and a shorter hospital stay (P = 0.003) compared to osteoplastic control subjects. All 3 surgical complications occurred in the control group. No patients required additional surgery for frontal sinusitis. CONCLUSIONS: The endoscopic approach to frontal sinus obliteration appears to reduce patient morbidity and should be considered in the surgical management of advanced frontal sinus disease. SIGNIFICANCE: This is the first report of a minimally-invasive technique for frontal sinus obliteration.     

鼻内翻性乳头状瘤手术径路的选择与疗效

目的探讨鼻内镜及鼻内镜联合径路治疗鼻内翻性乳突状瘤的疗效。方法回顾性分析我科2002年1月～2010年9月有随访资料的鼻内翻性乳头状瘤45例,按Krause分期T1期2例和他期32例采用单纯鼻内镜术,T3期10例采用鼻内镜联合柯-陆氏术式,T3期1例采用鼻内镜联合鼻侧切开术。结果45例平均随访3．5年（6个月-9年）,5例术后复发,复发率为11．1％。结论鼻内镜术治疗鼻内翻性乳头状瘤是一种有效的方法。Krause T1、T2期肿瘤可采用单纯鼻内镜术,Krause T3期肿瘤可采用鼻内铺联合传统手术径路。