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.     

Draf额窦鼻内引流术的疗效观察

目的探讨Draf额窦鼻内引流术的临床疗效。方法回顾性分析2009年12月～2012年6月因额窦良性病变行Draf额窦鼻内引流术49例（68侧）的临床资料,以鼻部主观症状评分及内窥镜复查为观察指标,参考慢性鼻窦炎内镜手术疗效评定标准评价疗效。结果全组随访12～37个月,平均17．5月,总有效率80．9％（55／68）,其中Draf I型有效率80．0％（36／45）,Draf IIa／b型81．0％（17／21）,DrafⅢ型100％（2／2）。术中及术后无严重及永久并发症。结论Draf额窦鼻内引流术对于额窦内的炎症及良性病变不失为一种好的选择,避免了不必要的鼻外径路手术,同时有较为确定的疗效。在术式的选择上要兼顾额窦的解剖、病变的性质、范围等。     

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.     

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.     

鼻内镜下经鼻丘径路治疗慢性额窦炎

目的探讨鼻内镜下鼻丘径路治疗慢性额窦炎的疗效。方法对慢性额窦炎27例在鼻内镜下通过切除鼻丘气房暴露额窦开口,开放额窦。结果27例全部开放成功。除3侧眶周青紫外,无并发症发生。鼻内镜检查额窦口引流良好。27例术后随访6个月,18例额窦炎症状全部消失,7例明显改善,2例无明显改善。结论鼻内镜下经鼻丘径路微创治疗慢性额窦炎手术安全有效,值得在临床推广。     

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。     

Quality of life and complications following image-guided endoscopic sinus surgery.

OBJECTIVES: To compare the quality of life (QOL) outcome and incidence of complications following image-guided versus non-image-guided endoscopic sinus surgery (ESS). STUDY DESIGN: The operative, office, and hospital charts of patients who underwent primary ESS for chronic sinusitis by a single surgeon with (2002-2005) or without (1997-2002) image guidance were reviewed for patient demographics, incidence of complications, and revision procedures. A telephone survey was used to administer the QOL survey to both cohorts. RESULTS: In comparing patients who underwent image-guided (60) versus non-image-guided surgery (179), respectively, there was no statistically significant difference in the incidence of major intraoperative complications (6.6% vs 5.6%), major postoperative complications (5% vs 3.9%), revision procedures (6.6% vs 7.3%), and postoperative SNOT-20 symptom scores (23.6 vs 23.4). A higher incidence of intraoperative cerebrospinal fluid leak was noted in the non-image-guided group (0% vs 2.2%). CONCLUSIONS: Our study does not demonstrate an improvement in the incidence of complications, need for revision procedures, or quality-of-life outcome for patients undergoing primary ESS for chronic sinusitis. The use of image guidance may result in a lower incidence of skull base trauma and cerebrospinal fluid leak. EBM rating: B-2b.     

Characteristics of sinus-related pain

OBJECTIVES: The goal of this study was to determine possible distinctive features of facial pain when caused by chronic sinusitis and to validate the pain characteristics previously described in the literature. METHODS: Included were 82 patients with radiographic and endoscopic evidence of chronic sinusitis and significant facial pain who underwent functional endoscopic sinus surgery and were available for 1-year follow-up. A modified McGill pain questionnaire was filled out before surgery, and follow-up data were obtained at 1 year. RESULTS: At 1 year 38% of patients had persistent facial pain despite the lack of any evidence of persistent sinusitis. A consistent use of pain adjectives and other distinctive features was noted in patients reporting improvement of headache. There was no correlation between the severity of pain and the extent or location of mucosal disease. The site of pain did not correlate with the site of disease. CONCLUSIONS: Sinusitis-related pain has distinctive features that set it apart from primary headache disorders and other causes of facial pain. Nonsinus causes account for the headache in 1 of 3 patients undergoing sinus surgery.     

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。     

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.     

Management of acute complicated sinusitis: a 5-year review.

Acute sinusitis is a relatively common problem; however, sinusitis associated with a complication is less frequent. Currently there is debate as to whether acute complicated sinusitis should be managed by frontal sinus trephine and sinus washout or by immediate frontoethmoidectomy/functional endoscopic sinus surgery. To assess the effectiveness of frontal sinus trephine in the management of acute complicated frontal sinusitis, we reviewed all patients admitted to Groote Schuur Hospital with acute pansinusitis (includes frontal, maxillary, and ethmoid) from 1989 to 1993. Eighty-seven patients were admitted, of whom 43 were treated medically and 44 were treated surgically. Of the surgical patients 38 had frontal trephines and management of associated complications. Thirty (80%) of the patients who received frontal trephines recovered without further surgery, and 8 required further sinus surgery for persistent disease. Frontal trephine with management of associated complications is an acceptable management option for patients with acute complicated pansinusitis. Frontoethmoidectomy or functional endoscopic sinus surgery can be held in reserve for those patients with persistent disease that does not resolve after the initial frontal trephine.     

鼻内镜辅助下上颌窦根治术治疗真菌性上颌窦炎的临床研究

目的探讨鼻内镜辅助下上颌窦根治术治疗真菌性上颌窦炎的临床价值。方法选择40例患者在鼻内镜辅助下上颌窦根治术治疗真菌性上颌窦炎，并与常规开放上颌窦根治术的患者比较，观察两组手术时间、术中出血以及总住院时间，并统计两组术后发生的并发症。结果观察组术中出血显著少于对照组（P〈0．05），总住院时间显著短于对照组（P〈0．05），观察组术后出现引流不畅、上唇麻木以及术后出血的比率均显著低于对照组（P〈0．05）。结论鼻内镜辅助下上颌窦根治术治疗真菌性上颌窦炎其手术创伤小，术后恢复快，并发症少，值得临床推广。     

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.     

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.     

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.     

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.     

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.     

Outcome of reflux therapy on pediatric chronic sinusitis.

OBJECTIVE: The cause of pediatric chronic sinusitis is multifactorial, but nasal edema appears to be the initial pathologic step. The objective of this study is to evaluate gastronasal reflux as a possible cause of pediatric sinusitis. METHODS: Thirty children with chronic sinusitis were believed to be appropriate candidates for functional endoscopic sinus surgery. Children were evaluated retrospectively for their response to reflux therapy with regard to their sinus symptoms and avoidance of sinus surgery. RESULTS: Two of the 30 children were eventually excluded because they were taken to surgery for the specific purpose of contact point release. Chart review at 24-month follow-up indicated that 25 of the 28 children (89%) avoided sinus surgery. CONCLUSION: After reflux treatment, the number of children requiring sinus surgery was dramatically reduced. The results of this preliminary pediatric study indicate that gastronasal reflux should be evaluated and treated before sinus surgical intervention.     

Osteoplastic flap for obliteration of the frontal sinus: five years' experience.

The objective of this retrospective study was to evaluate the osteoplastic flap (OPF) for the obliteration of the frontal sinus in this current era of endoscopic management of frontal sinus disease. A review of consecutive OPF procedures (n = 43) performed by the senior author (J.A.D.) from 1992 to 1997 was carried out. Data were gathered regarding chief symptom, medical history, previous sinus surgery, endoscopic findings in the office and at surgery, CT scan findings, and follow-up results (mean 19.4 months). Previous endoscopic management of frontal sinus disease had failed in 24% of patients; 97% had eventual resolution of frontal sinusitis with OPF. After OPF, 63% also had improvement or resolution of disease in other paranasal sinuses. Statistically significant, positive correlations (P < 0.05) were noted between the resolution of frontal sinusitis and improved or resolved pain, as well as the resolution of frontal sinusitis and improved or resolved infections in other paranasal sinuses. In 1998 OPF remains the standard for treating frontal sinus disease refractory to other methods. OPF can decrease the pain associated with frontal sinus infections and has a positive impact on inflammatory disease in other paranasal sinuses.