Powered endoscopic septoplasty for septal deviation and isolated spurs

Septoplasty is commonly performed for nasal airway obstruction or rhinologic headache due to contact irritation, often in conjunction with other nasal procedures, including cosmetic rhinoplasty and endoscopic sinus surgery.Traditionally, it is performed before these procedures via a "headlight" technique. This article describes the use of the microdebrider in 29 cases of endoscopic septoplasty. Many of the procedures were performed in conjunction with functional endoscopic sinus surgery; however, several were performed as an isolated procedure or with inferior turbinoplasty. The technique is described in detail. All 29 patients had significant improvement in their symptoms, and no patient developed a perforation or postoperative hematoma. Conversion to a traditional septoplasty was required in 1 case because of the severity of the deviation. Power-assisted endoscopic septoplasty is a useful adjunct in cases involving isolated septal spurs or moderate septal deviations. Patients with severe nasal obstruction due to caudal deflection of the septum off the nasal spine are better served with traditional headlight septoplasty.     

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.     

Use of nebulized antibiotics for acute infections in chronic sinusitis

OBJECTIVE: Infections in patients with chronic sinusitis after surgery can be difficult to treat. Nebulized antimicrobial therapy was studied as a treatment option. Study Design: Patients with chronic sinusitis, previous sinus surgery, and an acute infection were offered nebulized antibiotics or standard therapy. Cultures were taken and sensitivity testing was performed. Retrospective chart reviews were also performed. RESULTS: Forty-two patients were included. The most common side effects were sore throat and cough. Symptomatic and endoscopic data before and after nebulized therapy showed a longer infection-free period (average, 17 weeks) compared with standard therapy (average, 6 weeks). Improvements in posterior nasal discharge, facial pain/pressure, and emotional consequences were noted. CONCLUSION: Nebulized therapy was safe and effective in this cohort. Endoscopy and outcome measure changes showed consistent improvements. SIGNIFICANCE: A novel therapy for acute sinus infections in patients with chronic sinusitis and previous endoscopic sinus surgery is presented.     

A targeted endoscopic approach to chronic isolated frontal sinusitis.

OBJECTIVE: Chronic isolated frontal sinusitis occurs infrequently. In this condition, most of the ethmoid cells are well aerated and the frontal sinus is involved secondary to anatomical obstruction or inflammatory changes confined to the frontal recess. The purpose of this study was to evaluate a targeted endoscopic technique where standard anterior ethmoidectomy is unnecessary in the treatment of chronic isolated frontal sinusitis. STUDY DESIGN AND SETTING: This retrospective study was conducted in a large university-affiliated hospital and included 11 patients with chronic isolated frontal sinusitis who underwent endoscopic sinus surgery limited to the frontal sinus outflow. The ethmoid bulla was untouched in all cases. Follow-up continued for 19 to 40 months (mean 28.6 months). RESULTS: Frontal sinus outflow patency was verified in 9 patients (81.8%). Nine patients, including one with an apparent nonpatent frontal ostium, reported improvement. Two patients-one of whom had a patent frontal ostium-reported no improvement. There were no complications. CONCLUSION: Chronic isolated frontal sinusitis can be effectively treated in selected cases by a targeted endoscopic procedure, limited to reestablishment of frontal sinus outflow. EBM rating: C-4.     

Treatment of nasal obstruction from nasal valve collapse with alar batten grafts

Nasal obstruction may require treatment with rhinoplasty techniques. One cause of nasal obstruction is known as nasal valve collapse. This refers to narrowness and weakness at the nasal valve, the narrowest part of the nasal airway. There are a number of surgical approaches available to treat nasal valve collapse. Selection of the appropriate surgical intervention depends on proper identification of the anatomic cause of the collapse. Alar batten grafts are especially useful for addressing nasal valve collapse caused by a weak nasal sidewall. In this report, we review the senior author's experience with the use of alar batten grafts for nasal valve collapse. Twenty-one patients had septoplasty with placement of alar batten grafts; all patients noted improvement in their nasal breathing. Seven patients underwent ear cartilage harvest with alar batten grafts, and five of them noted improvement, one noted partial improvement, one noted no improvement. Six patients underwent revision septorhinoplasty with alar batten grafting, and ten patients underwent revision septorhinoplasty with ear cartilage harvest and alar batten grafting. These patients all reported improvement in their nasal breathing postoperatively. Six patients underwent revision rhinoplasty (no septoplasty) with ear cartilage and battens. These patients hold special interest because no other intranasal procedures were performed that affected nasal breathing. All six of these patients reported significant improvement of their nasal breathing and all patients were satisfied with their postsurgical cosmetic appearance. The nasal valve area is considered to be the location of the least cross-sectional area in the nose. When narrowing of the nasal valve is a result of collapse of the nasal sidewall, alar batten grafts are a useful technique to address the patient's nasal obstruction.     

Routine histopathology in uncomplicated sinus surgery: is it necessary?

OBJECTIVE: To evaluate the incidence of occult pathology in routine, uncomplicated endoscopic sinus surgery, and to suggest guidelines for when to send specimens for histopathologic exam. STUDY DESIGN AND SETTING: Retrospective analysis of case records of 790 patients who underwent 868 endoscopic sinus surgeries at a tertiary care center from 1986 to 2003. Indications were chronic sinusitis, recurrent acute sinusitis, nasal polyposis, or combinations of these diagnoses. All cases were considered routine and did not involve preoperative suspicion of neoplasm or other complicating factors. Charts were reviewed for surgical indication, patient age, laterality of disease, history of prior sinus surgery, intraoperative suspicion of tumor, and final histopathology. RESULTS: In 868 cases of endoscopic sinus surgery, occult neoplasm was diagnosed in 2 patients (0.23%). In one patient, the initial surgery cured the lesion. Final histopathology of the remaining 866 (99.8%) specimens was consistent with inflammation and/or nasal polyposis. In 121 cases of unilateral sinusitis, none was positive for neoplasm. In 277 cases involving bilateral nasal polyposis and 13 involving unilateral polyposis, no neoplasms were found. Intraoperative suspicion of neoplasm occurred in 12 cases, with all specimens read as consistent with sinusitis and/or polyposis. CONCLUSIONS: Histopathologic review of every specimen obtained in routine sinus surgery for sinusitis and/or nasal polyposis is not indicated. Submission of specimen is indicated in routine cases when: 1) there is intraoperative suspicion of tumor, 2) unilateral nasal polyposis is present, 3) unilateral sinus opacification is present, and 4) additional diagnostic information is needed (eg, presence of eosinophils, fungal forms, etc.). SIGNIFICANCE: Establishes a safe and reasonable standard of care, with potential cost savings and medico-legal ramifications.     

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.     

The endoscopic modified Lothrop procedure for salvage of chronic frontal sinusitis after osteoplastic flap failure

OBJECTIVE: While reported results utilizing the osteoplastic flap procedure are very good, some patients fail the surgery due to recurrent or persistent frontal sinus disease. This study was performed to evaluate the utility of the endoscopic modified Lothrop sinus surgery for osteoplastic flap failure. STUDY DESIGN AND SETTING: A retrospective chart analysis and telephone survey of 10 patients from outside our institution for whom an osteoplastic flap with fat obliteration failed were salvaged using a computerized endoscopic modified Lothrop procedure. RESULTS: The main complaints were headache/pressure and recurrent infection. The usual pathology was chronic sinusitis and/or mucocele. The frontal recess and floor of the frontal sinus were the most common areas of persistent disease. Symptomatic clinical improvement was noted in more than 90% of patients. CONCLUSION: Salvage endoscopic modified Lothrop sinus surgery is recommended for a limited number of traditional osteoplastic flap failures. Computerized surgical navigation may help avoid complications in situations with abnormal anatomy and previous dissection. SIGNIFICANCE: The endoscopic modified Lothrop procedure should be considered to salvage failed osteoplastic flap sinus obliteration.     

Endosinusal treatment impact and prognostic value of IL-5 in chronic maxillary sinusitis

Objectives: The aim of the study was to evaluate subjective outcomes in patients with chronic maxillary sinusitis after steroid/antibiotic endosinusal treatment. Furthermore, the aim was to test the hypothesis that pretreatment levels of interleukin-5 (IL-5) in sinus fluid could predict response to endosinusal steroid/antibiotic treatment.Methods: Thirty patients with chronic maxillary sinusitis were recruited for the study. Patients were treated endosinusally with 2 mg dexamethasone and 40 mg gentamycine per maxillary sinus for 5 days. Patients rated nasal/CRS disease-specific symptoms and completed a self-administered questionnaire concerning sinusitis symptoms at inclusion and after 30 days. Sinus lavage, collected at inclusion, was analyzed for IL-5 concentration.Results: 56.6% of patients had improvement after endonasal treatment with decrease in symptoms (responders), and 43.4% were unchanged or worsened after treatment (nonresponders). Significant improvement was noted for overall sinusitis symptoms score (P = 0.02) and for obstruction, postnasal drip, headache, sneezing, and cough (P < 0.05). There is positive correlation between baseline IL-5 level in sinus lavage and improvement rate of overall sinusitis symptoms score (P < 0.01) and improvement rate of nasal secretion score (P < 0.01).Conclusions: Steroid-antibiotic endosinusal treatment in patients with chronic maxillary sinusitis was proven effective in reducing subjective sinusitis symptoms. Improvement rate to endosinusal treatment is expected be higher in patients with increased level of IL-5 in maxillary sinus lavage. Increased concentrations of IL-5 in sinus fluid might be used as a predictor of a good response to endosinusal treatment of maxillary chronic sinusitis.     

Indications for the Caldwell-Luc approach in the endoscopic era.

OBJECTIVE: Caldwell and Luc described the Caldwell-Luc operation more than 100 years ago as the surgical treatment for maxillary sinus disease. During the last decades less radical interventions using endoscopic approach have mainly replaced the classical procedures done for chronic and recurrent maxillary sinusitis. STUDY DESIGN AND SETTING: Between 1991 and 2002, 62 patients had the Caldwell-Luc approach for different indications. RESULTS: Twenty (32%) patients had chronic sinusitis, 16 (26%) patients had inverted papilloma, 9 (15%) patients had suffered from nasal polyposis, 4 patients (6%) had dentigerous cyst, 4 (6%) patients had fungal ball, and 9 (15%) patients were operated for other indications. CONCLUSIONS: The use of this surgical approach is rational in cases of fungal disease and in endoscopic medial maxillectomy for treating inverted papilloma. In all other cases, the preferred approach should now be endoscopic.     

Uncommon anatomic variations in patients with chronic paranasal sinusitis.

OBJECTIVE: Some uncommon anatomic variations would be encountered with the increasing number of patients with chronic paranasal sinusitis who have undergone functional endoscopic sinus surgery. The correct identification and proper treatment for these variations are important. STUDY DESIGN AND SETTING: A retrospective study of serial computed tomography scan images was conducted in 100 patients collected randomly. Uncommon anatomic variations were recorded and clinical features were analyzed. RESULTS: Five (5%) cases with uncommon anatomic variations were found. These variations included bilateral pneumatization of uncinate process (1%), large uncinate process mimics the middle turbinate (1%), nontraumatic protrusion of orbital contents through dehiscence of lamina papyracea (1%), and nasal septal pneumatization (2%). Two of these 5 cases caused some modifications of routine functional endoscopic sinus surgery procedures and another 2 variants commanded further caution during routine uncinectomy. CONCLUSION AND SIGNIFICANCE: Uncommon anatomic variations, though unusual, are not rare in chronic paranasal sinusitis patients. Procedures should be tailored for most of these special conditions.     

Adjunctive cosmetic procedures during rhinoplasty and sinus surgery

A number of patients undergoing nasal surgery such as endoscopic sinus surgery and rhinoplasty request whether facial cosmetic procedures can be performed at the same time. This report outlines some of the more common adjunctive procedures.     

阿司匹林对鼻内镜手术围术期出血影响的临床观察

目的探讨阿司匹林对鼻内镜手术围术期出血的影响。方法回顾性分析2018-10—2021-03于郑州大学第一附属医院鼻科行鼻内镜手术并长期口服阿司匹林的67例患者的临床资料。根据围术期阿司匹林用药情况分为持续用药组(31例)和停药组(36例)。选取同期行鼻内镜手术未口服阿司匹林的中老年患者为对照组(30例)。记录术中出血量、血栓弹力图、术后出血情况及并发症,并对影响长期口服阿司匹林患者行鼻内镜手术的危险因素行Logistic回归分析。结果(1)3组患者中两两间的最大振幅(MA)、凝血综合指数(CI)差异均有统计学意义(P<0.05)。3组术后均有1例发生出血,行数据方差分析,3组间差异无统计学意义(P>0.05)。(2)鼻窦炎伴鼻息肉患者中,以及单纯鼻窦炎患者中,3组患者两两间的术中出血量差异均无统计学意义(P>0.05)。当显著性水平为0.05时,影响鼻内镜手术的独立危险因素为停用阿司匹林和BMI值。结论阿司匹林对鼻内镜手术围术期出血无明显影响,长期口服阿司匹林患者鼻内镜手术前可不停用阿司匹林。     

Analysis of outcomes after functional rhinoplasty using a disease-specific quality-of-life instrument

OBJECTIVE: To measure the efficacy of functional rhinoplasty techniques with a validated quality-of-life instrument. DESIGN: Prospective observational outcomes study of patients with severe nasal obstruction owing to septal deviation, internal or external valve collapse, and turbinate hypertrophy who subsequently underwent functional rhinoplasty. Preoperative and postoperative evaluations were performed using the Nasal Obstruction Symptoms Evaluation scale. RESULTS: Forty-one patients completed preoperative and postoperative evaluations. No complications occurred. There was a significant improvement in mean Nasal Obstruction Symptoms Evaluation score postoperatively for the entire cohort (P<.01). Nasal Obstruction Symptoms Evaluation scores were also examined based on the procedure performed, such as spreader grafting, septoplasty, external valve suspension, and turbinectomy. Each subgroup also demonstrated airway improvement. CONCLUSIONS: Functional rhinoplasty techniques are effective in improving nasal airway function as measured by a patient-based, disease-specific, quality-of-life instrument. The specific techniques considered to treat nasal obstruction can be tailored to address the areas of concern, including septal deviation, internal or external valve collapse, and turbinate hypertrophy.     

Middle meatus anstrostomy: patency rates and risk factors

Two hundred patients with chronic sinusitis were operated on using functional endoscopic sinus surgery (FESS) techniques. These patients were followed closely over 3 years. Patency of the endoscopic middle meatotomy was recorded using actuarial life-table methods. The overall patency rate of the endoscopic middle meatotomy was 93.55%, and the actuarial patency rate at 36 months was 87.47%. The presence of seasonal allergy with nasal polyps was the most important variable in predicting closure. Middle turbinectomy was the most important variable in predicting patency. Symptoms were evaluated by questionnaire at 1 year. Questionnaire data indicate that 96% of these patients are improved or asymptomatic.     

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。     

Concomitant Transsphenoidal Approach to the Anterior Skull Base and Endoscopic Sinus Surgery in Patients with Chronic Rhinosinusitis

Objectives To describe outcomes of endoscopic resection of sellar tumors with concomitant endoscopic sinus surgery for patients with chronic rhinosinusitis (CRS).Design Retrospective chart review.Setting Tertiary care medical center.Participants Patients who underwent endoscopic transsphenoidal surgery for excision of anterior skull base lesions and simultaneous functional endoscopic sinus surgery (FESS) for CRS between January 2006 and January 2011 by senior authors (MRR and JJE).Main Outcomes Measured Short- and long-term postoperative complications.Results Fourteen patients were identified. Average follow-up was 27 months. All patients had preoperative symptoms consistent with CRS. No patients were treated with preoperative antibiotics. Surgical pathology revealed chronic sinusitis in all specimens. Pathology of the intracranial lesions included 11 pituitary macroadenomas, one craniopharyngioma, one chondrosarcoma, and one cholesterol granuloma. Short-term postoperative morbidities included a sphenoid polyp, one adhesion, and one case of pharyngitis. Long-term outcomes included one frontoethmoidal mucocele, one recurrence of nasal polyps, and three cases of acute sinusitis. There were no intracranial complications for the entire follow-up period.Conclusions Transsphenoidal surgery can safely be performed in the setting of CRS without increased risk of intracranial complications.     

Labiocolumellar Graft Combined with Tip Graft in the Management of Inadequate Tip Projection

The short distance of the nasal tip from the alar crease indicates inadequate projection. Tip grafts are commonly used for the management of this problem. In addition to tip grafts, labiocolumellar augmentation by cartilage grafts also provides further elevation of the tip complex for patients with poor tip definition, excessive alar base width, inadequate tip projection, or plunging nasal tip. In addition to standard rhinoplasty procedure and tip grafting for nasal tip augmentation, a linear cartilage graft was inserted centrally just behind the labiocolumellar angle for further tip elevation. The graft was placed in the subdermal plane just anterior to the orbicularis oris muscle to prevent graft displacement and clicking during muscle motion. This procedure was performed for 45 rhinoplasty patients, only three of whom underwent tip plasty procedures alone. During 1 year, 43 patients were followed up. Most of the patients (75%) were satisfied with the results of the procedure. Tip graft combined with labiocolumellar graft is an effective technique for obtaining satisfactory tip projection and correcting the acute labiocolumellar angle. Presented at The XVI. Congress of ISAPS, 26–29 May 2002, Istanbul, Turkey, and should be attributed to Department of Plastic and Reconstructive Surgery, Cerrahpasa School of Medicine, Istanbul University, and Haseki Hospital, Department of Otolaryngology Istanbul, Turkey.     

功能性鼻内镜手术中减少出血的麻醉管理研究进展

功能性鼻内镜手术(FESS)已被广泛应用于鼻窦炎和鼻息肉患者的临床治疗。外科医师必须依赖最佳的手术视野来确认解剖位置,但鼻腔空间狭小,即使是少量出血也会造成解剖结构难以辨别,导致手术时间延长,手术并发症的发生率增加。目前,鼻内镜手术出血原因主要包括3个方面,即手术因素、患者自身因素以及麻醉因素。本文从麻醉方式、机械通气、术中控制性降压、围术期用药等方面对能够减少鼻内镜手术中出血的麻醉技术进行综述,以期为该类手术的麻醉管理提供参考。     

Isolated sphenoid sinus disease: etiology and management.

OBJECTIVE: To evaluate the diagnosis and management of isolated sphenoid sinus disease by using the current rhinologic standard of care. STUDY DESIGN: Retrospective chart review. RESULTS: Fifty sequential, symptomatic patients were studied. Presenting symptoms included headache or facial pain (88%), rhinorrhea (46%), and nasal congestion (26%). All patients underwent CT imaging, demonstrating bony changes or dehiscences (42%), a mass (24%), or complete opacification of the sphenoid sinus (22%). Eighty percent required surgical intervention. The most frequent diagnoses were as follows: sinusitis (38%), fungal ball (20%), neoplasm (16%), and mucocele (12%). Treatment resulted in clinical or endoscopic improvement or resolution in 87% of the patients. CONCLUSION: The presenting symptoms of isolated sphenoid sinus disease can be nonspecific and may result in an inordinate delay in diagnosis. Nasal endoscopy and radiologic imaging are central to making an accurate and timely diagnosis. Medical treatment or minimally invasive surgical techniques can successfully manage the majority of patients with persistent or refractory symptoms.