Revision Sinus Surgery-Springer-Verlag Berlin Heidelberg (2008)

Stilianos E. Kountakis · Joseph B. Jacobs · Jan Gosepath (Eds.
)
Revision Sinus Surgery
Stilianos E. Kountakis · Joseph B. Jacobs
Jan Gosepath (Eds.)
Revision Sinus
Surgery
With 274 Figures and 41 Tables
123
Stilianos E. Kountakis, MD, PhD Jan Gosepath, MD, PhD
Department of Otolaryngology – Department of Otolaryngology –
Head and Neck Surgery Head and Neck Surgery
Medical College of Georgia Dr. Horst Schmidt Kliniken
1120 Fifteenth Street, Suite BP-4136 Ludwig-Erhard-Straße 100
Augusta, GA 30912-4060 65199 Wiesbaden
USA Germany
Email: skountakis@mail.mcg.edu Email: jan.gosepath@hsk-wiesbaden.de
Joseph B. Jacobs, MD
New York University Medical Center
Department of Otolaryngology
530 First Avenue, Suite 3C
New York, NY 10016-6402
USA
Email: joseph.jacobs@med.nyu.edu
ISBN 978-3-540-78930-7 e-ISBN 978-3-540-78931-4
DOI 10.1007/978-3-540-78931-4
Library of Congress Control Number: 2008923578
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Dedication
To the Memory of my mother, Eftihia Kountakis.

To my wife Eleni, our children and our new baby girl Alexandra Elena.
To my sister Maria Kountakis for her support during the difficult years.
To my Rhinology Fellows for a lifetime of learning.
Stilianos E. Kountakis, MD
To the Memory of my mother, Helen Jacobs.

To my wife Patti and my children Stacy and Allison.
To my sons-in-law Rich and Jeff.
To my granddaughter Ava.
To the department of Otolaryngology at New York University.
Joseph B. Jacobs, MD
To my wife Anja
To my academic teacher Professor Wolf J. Mann
Jan Gosepath, MD, PhD
Preface
The field of rhinology has rapidly advanced over the last sinus surgery patient. Revision Sinus Surgery is the first
two decades, enabling surgeons to utilize endoscopic textbook available dedicated to this topic.
techniques and instrumentation to perform the majority International leading rhinologic experts were invited
of operations within the paranasal sinuses. Despite sig- to author the book. Pertinent topics include specific sur-
nificant progress with medical management and surgi- gical indications and techniques, pre- and post-operative
cal instrumentation, however, many patients who suffer medical management and recognition and treatment of
from chronic sinonasal disease develop recurrences of surgical complications. Chapters are arranged with bul-
symptomatic disease requiring revision endoscopic sinus leted tips and pearls, as well as numerous illustrations
surgery. to highlight the text. A DVD accompanies the book,
Anatomic alteration due to prior sinus surgery, muco- containing videos that demonstrate actual procedures
sal scarring and associated chronic mucosal inflammation performed by the contributing authors. This book is a
all increase the complexity of such procedures. Therefore, comprehensive volume that can be used as a complete
even in the hands of experienced sinus surgeons, in- reference source by all otolaryngologists.
creased risk of negative outcomes exists. This project was
undertaken to develop a concise reference that provides Stilianos E. Kountakis, MD, PhD
an exhaustive source of information relating to the com- Joseph B. Jacobs, MD
plex pre- and post-operative management of the revision Jan Gosepath, MD
Contents
Chapter 1 Chapter 8
Imaging Anatomy in Revision Sinus Surgical Instruments in Revision
Surgery .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Endoscopic Sinus Surgery .. . . . . . . . . . . . . . 63
Ramon E. Figueroa Vijay R. Ramakrishnan and Todd T. Kingdom
Chapter 2 Chapter 9
Indications for Revision Endoscopic Anesthetic Choices, Techniques,
Sinus Surgery .. . . . . . . . . . . . . . . . . . . . . . . . . . . 13 and Injections . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Marc A. Tewfik and Martin Desrosiers W. Derek Leight and Brent Senior
Chapter 3 Chapter 10
Predictors of Failure of Primary Surgery 19 Tips and Pearls in Revision Sinus Surgery 79
Iman Naseri and John M. DelGaudio Alexander G. Chiu and David W. Kennedy
Pathophysiology of Inflammation Septal and Turbinate Surgery in Revision
in the Surgically Failed Sinus Cavity . . . . . . 25 Sinus Surgery .. . . . . . . . . . . . . . . . . . . . . . . . . . 91
Wytske J. Fokkens, Bas Rinia Joseph Raviv and Peter H. Hwang
and Christos Georgalas
Chapter 12
Chapter 5 Revision Endoscopic Surgery
Medical Management after Primary of the Ethmoid and Maxillary Sinus .. . . . . 101
Surgery Failure and Preoperative Medical Biana G. Lanson, Seth J. Kanowitz,
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Richard A. Lebowitz, and Joseph B. Jacobs
Jan Gosepath
Chapter 13
Chapter 6 Revision Endoscopic Surgery
New Technologies for Revision Sinus of the Sphenoid Sinus .. . . . . . . . . . . . . . . . . . 109
Surgery .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Richard R. Orlandi
Elisa M. Lynskey, Richard A. Lebowitz,
Joseph B. Jacobs, and Marvin P. Fried
Chapter 14
Endoscopic and Microscopic Revision
Chapter 7 Frontal Sinus Surgery . . . . . . . . . . . . . . . . . . . 117
Surgical Anatomy in Revision Ulrike Bockmühl and Wolfgang Draf
Sinus Surgery .. . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Adam J. Folbe and Roy R. Casiano
Contents
Revision Endoscopic Frontal Allergy and the Patient Requiring
Sinus Surgery .. . . . . . . . . . . . . . . . . . . . . . . . . . 127 Revision Sinus Surgery .. . . . . . . . . . . . . . . . . 193
Patricia A. Maeso, Subinoy Das, Li-Xing Man and Berrylin J. Ferguson
and Stilianos E. Kountakis
Chapter 24
Chapter 16 Staging of Disease after Sinus Surgery
Postoperative Medical Management . . . . 135 Failure .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Dennis F. Chang, David B. Conley, Valerie J. Lund
and Robert C. Kern
Chapter 25
Chapter 17 Headache and the Patient
Evaluation and Treatment of Recurrent who Failed Primary Sinus Surgery .. . . . . . 217
Nasal Polyposis . . . . . . . . . . . . . . . . . . . . . . . . . 143 William H. Moretz III
Frederick C. Roediger and Stilianos E. Kountakis
and Andrew N. Goldberg
Chapter 26
Chapter 18 Complications in Revision Sinus Surgery:
Revision Surgery for Allergic Fungal Presentation and Management . . . . . . . . . 223
Rhinosinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . 153 John Scianna and James Stankiewicz
Subinoy Das, Patricia A. Maeso,
and Stilianos E. Kountakis
Chapter 27
Revision Dacryocystorhinostomy . . . . . . . 235
Chapter 19 Metin Onerci
Revision Endoscopic Surgery
for Benign Sinonasal Tumors .. . . . . . . . . . . 159
Michael J. Sillers and Yvonne Chan Chapter 28
Revision Endoscopic Transsphenoidal
Hypophysectomy .. . . . . . . . . . . . . . . . . . . . . . 245
Chapter 20 Karen A. Kölln and Brent A. Senior
Recurrent Cerebrospinal Fluid Leaks
and Meningoencephaloceles .. . . . . . . . . . . 167
Sarah K. Wise, Richard J. Harvey, Chapter 29
and Rodney J. Schlosser Revision Image-Guided Functional
Endoscopic Sinus Surgery .. . . . . . . . . . . . . . 251
Martin J. Citardi and Pete S. Batra
Chapter 21
Delayed Complications Following
Sinus Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Chapter 30
David M. Poetker and Timothy L. Smith Revision Endoscopic Sinus Surgery
in Children .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Hassan H. Ramadan
Chapter 22
Recurrent Mucoceles .. . . . . . . . . . . . . . . . . . . 185
Benjamin Bleier, James N. Palmer, Chapter 31
and Bradford A. Woodworth Open Approaches after Failure
of Primary Sinus Surgery .. . . . . . . . . . . . . . . 275
Mark C. Weissler
Contents XI
“Above and Below” Techniques Objective and Subjective Outcomes
in Revision Sinus Surgery . . . . . . . . . . . . . . . 281 after Revision Sinus Surgery . . . . . . . . . . . . 317
Timothy Haegen, Ryan M. Rehl, Michael G. Stewart and Scott M. Rickert
and Winston C. Vaughan
Chapter 37
Chapter 33 Bioabsorbable Materials in Revision
Revision Endoscopic Skull-Base Surgery 289 Sinus Surgery .. . . . . . . . . . . . . . . . . . . . . . . . . . 329
Aldo C. Stamm, João Flávio, Rakesh K. Chandra and Robert C. Kern
and Richard J. Harvey
Chapter 38
Chapter 34 Endoscopic Approach after Failure
Stenting in Revision Sinus Surgery . . . . . . 301 of Open Sinus Procedures .. . . . . . . . . . . . . . 337
Seth J. Kanowitz, Joseph B. Jacobs, Raymond Sacks and Larry Kalish
and Richard A. Lebowitz
Subject Index .. . . . . . . . . . . . . . . . . . . . . . . . . . 347

Chapter 35
Use of Intravenous Antibiotics
in Sinus Surgery Failures . . . . . . . . . . . . . . . . 309
Seth M. Brown, Abtin Tabaee,
and Vijay K. Anand
Contributors
Vijay K. Anand, MD Roy R. Casiano, MD

772 Park Ave University of Miami
New York, NY 10021 1475 NW 12th Ave
USA Suite 4025
Email: vijayanandmd@aol.com Miami, FL 33136-1002
USA
Pete S. Batra, MD Email: rcasiano@med.miami.edu
Section of Nasal and Sinus Disorders
Head and Neck Institute Yvonne Chan, MD, FRCSC
Cleveland Clinic Foundation Georgia Nasal and Sinus Institute
9500 Euclid Ave, A71 4750 Waters Avenue
Cleveland, OH 44195 Suite 112
USA Savannah, GA 31404-6220
Email: batrap@ccf.org USA
Email: y.chan@utoronto.ca
Benjamin Bleier, MD
Department of Otorhinolaryngology Rakesh K. Chandra, MD
University of Pennsylvania Northwestern Sinus and Allergy Center
3400 Spruce Street Department of Otolaryngology – Head and Neck
Philadelphia, PA 19104 Surgery
USA Northwestern University
Email: benjamin.bleier@uphs.upenn.edu Feinberg School of Medicine
675 N. St. Clair St.-Galter 15-200
Ulrike Bockmühl, MD, PhD Chicago, IL 60611
Department of Otorhinolaryngology – Head and Neck USA
Surgery Email: rickchandra@hotmail.com
University Hospital Gießen
Klinikstraße 29 Dennis F. Chang, MD
35392 Gießen Loma Linda University Sinus and Allergy Center
Germany Department of Otolaryngology – Head and Neck
Email: ulrike.bockmuehl@hno.med.uni-giessen.de Surgery
Loma Linda University Medical Center
Seth M. Brown, MD, MBA 11234 Anderson Street #2586A
12 North Main St., Suite 30 Loma Linda, CA 92354
West Hartford, CT 06107 USA
USA Email: dfchang@llccp.net
Email: sethmbrown@msn.com
XIV Contributors
Alexander G. Chiu, MD Wolfgang Draf, MD, Hon MD, PhD, FRCSC

Division of Rhinology INI International Neuroscience Institute
Department of Otorhinolaryngology ENT Department
University of Pennsylvania Rudolf-Pichlmayr-Straße 4
3400 Spruce Street 30625 Hannover
Philadelphia, PA 19104-4283 Germany
USA Email: wdraf@aol.com
Email: alexander.chiu@uphs.upenn.edu
Berrylin J. Ferguson, MD
Martin J. Citardi, MD Division of Sino-Nasal Disorders and Allergy
Department of Otorhinolaryngology – Head and Neck Department of Otolaryngology
Surgery University of Pittsburgh School of Medicine
University of Texas Medical School at Houston Eye and Ear Institute
6431 Fannin, MSB 5.202 200 Lothrop Street, Suite 500
Houston, TX 77030 Pittsburgh, PA 15213-2546
USA USA
Email: martin.j.citardi@uth.tmc.edu Email: fergusonbj@upmc.edu
David B. Conley, MD Ramon E. Figueroa, MD

Department of Otolaryngology Department of Radiology
Northwestern University Medical College of Georgia
Feinberg School of Medicine 1120 Fifteenth Street, Suite BA-1414
303 East Chicago Avenue Augusta, GA 30912
Chicago, IL 60611-3008 USA
USA Email: rfiguero@mcg.edu
Email: dbcentmd@northwestern.edu
João Flávio, MD
Subinoy Das, MD Hospital Prof. Edmundo Vasconcelos
Department of Otolaryngology – Head and Neck Rua Borges Lagoa, 1450
Surgery Vila Clementino
Medical College of Georgia CEP 04038-905, Sao Paulo
1120 Fifteenth Street, Suite BP-4136 Brazil
Augusta, GA 30912-4060
USA Adam J. Folbe, MD
Email: sdas@mcg.edu Department of Otolaryngology – Head and Neck
Surgery
John M. DelGaudio, MD Wayne State University
Department of Otolaryngology 4201 St. Antoine
The Emory Clinic 5E UHC
1365 Clifton Road, NE Detroit, MI 48201
Atlanta, GA 30322 USA
USA Email: afolbe@med.wayne.edu
Email: john.delgaudio@emoryhealthcare.org
Wytske J. Fokkens, MD
Martin Desrosiers, MD, FRCSC Department of Otorhinolaryngology
Montreal General Hospital, Room A2-141 Academic Medical Centre
1650 Cedar Avenue University of Amsterdam
H3G 1A4 Montreal, Quebec Postbus 22660
Canada 1100 DD Amsterdam
Email: desrosiers_martin@hotmail.com The Netherlands
Email: w.j.fokkens@amc.nl
Contributors XV
Marvin P. Fried, MD Peter H. Hwang, MD

Albert Einstein College of Medicine Department of Otolaryngology
Department of Otolaryngology Stanford University
3400 Bainbridge Avenue, 3rd Floor 801 Welch Road
Bronx, NY 10467 Stanford, CA 94304
USA USA
Email: mfried@montefiore.org Email: phwang@ohns.stanford.edu
Christos Georgalas, MD Joseph B. Jacobs, MD

Academic Medical Centre New York University Medical Center
University of Amsterdam Department of Otolaryngology
Postbus 22660 530 First Avenue, Suite 3C
1100 DD Amsterdam New York, NY 10016-6402
The Netherlands USA
Email: joseph.jacobs@med.nyu.edu
Andrew N. Goldberg, MD, MSCE, FACS
University of California, San Francisco Larry Kalish, MBBS (Hons), MS, MMed (Clin Epi),
Department of Otolaryngology – Head and Neck FRACS
Surgery Department of Otorhinolaryngology
San Francisco, CA 94143 Concord Repatriation Hospital
USA Concord, Sydney
Email: agoldberg@ohns.ucsf.edu NSW Australia
Email: lhkalish@mac.com
Jan Gosepath, MD, PhD
Department of Otolaryngology – Head and Neck Seth J. Kanowitz, MD
Surgery Ear, Nose, Throat – Head and Neck Surgery
Dr. Horst Schmidt Kliniken Advanced Sinus and Nasal Surgery
Ludwig-Erhard-Straße 100 95 Madison Avenue, Suite 105
65199 Wiesbaden Morristown, NJ 07960
Germany USA
Email: gosepath@hno.klinik.uni-mainz.de Email: sethkanowitzmd@gmail.com
Timothy Haegen, MD David W. Kennedy, MD

Head and Neck Surgery Department of Otolaryngology
Naval Hospital Camp Pendleton University of Pennsylvania
PSC 477 Box 555191 3400 Spruce Street
Camp Pendleton, CA 92055 5th Floor – Ravdin Building
USA Philadelphia, PA 19104-4283
Email: timothy.haegen@med.navy.mil USA
Email: kennedyd@uphs.upenn.edu
Richard J. Harvey, MD
Medical University of South Carolina Robert C. Kern, MD
Department of Otolaryngology Department of Otolaryngology
PO Box 250550 Northwestern University
135 Rutledge Ave., Suite 1130 Feinberg School of Medicine
Charleston, SC 29425 303 East Chicago Avenue
USA Chicago, IL 60611-3008
Email: richard@richardharvery.com.au USA
Email: rkern@nmff.org
XVI Contributors
Todd T. Kingdom, MD Valerie J. Lund MS FRCS FRCSEd

Department of Otolaryngology Institute of Laryngology and Otology
University of Colorado University College London
AO-1, 12631E 17th Ave, B205 Royal National Throat Nose and Ear Hospital
P.O. Box 6511 330 Grays Inn Road
Aurora, CO 80045 London WC1X 8DA
USA United Kingdom
Email: todd.kingdom@uchsc.edu Email: v.lund@ucl.ac.uk
Karen A. Kölln, MD Elisa M. Lynskey, MD

G0412 Neurosciences Hospital Department of Otolaryngology
101 Manning Drive New York University
Chapel Hill, NC 27599-7070 462 First Avenue, NBV 5E5
USA New York, NY 10016
Email: kkolln@unch.unc.edu USA
Email: elisa.lynskey@med.nyu.edu
Stilianos E. Kountakis, MD, PhD
Department of Otolaryngology – Head and Neck Patricia A. Maeso, MD
Surgery Department of Otolaryngology – Head and Neck
Medical College of Georgia Surgery
1120 Fifteenth Street, Suite BP-4136 Medical College of Georgia
Augusta, GA 30912-4060 1120 Fifteenth Street, Suite BP-4136
USA Augusta, GA 30912-4060
Email: skountakis@mail.mcg.edu USA
Email: pmaeso@mcg.edu
Biana G. Lanson, MD
Department of Otolaryngology Li-Xing Man, MD, MSc
New York University Department of Otolaryngology
462 First Avenue Unversity of Pittsburgh School of Medicine
NBV 5E5 Eye and Ear Institute
New York, NY 10016 200 Lothrop Street, Suite 500
USA Pittsburgh, PA 15213-2546
Email: bgl201@med.nyu.edu USA
Email: manl@upmc.edu
Richard A. Lebowitz, MD
Department of Otolaryngology William H. Moretz III, MD
New York University Medical Center Department of Otolaryngology – Head and Neck
530 First Avenue, Suite 3C Surgery
New York, NY 10016-6402 Medical College of Georgia
USA 1120 Fifteenth Street, Suite BP-4136
Email: richard.lebowitz@nyumc.org Augusta, GA 30912-4060
USA
W. Derek Leight, MD Email: wmoretz@mcg.edu
Department of Otolaryngology – Head and Neck
Surgery Iman Naseri, MD
The University of North Carolina at Chapel Hill Department of Otolaryngology
G0412 Neurosciences Hospital, CB #7070 The Emory Clinic
Chapel Hill, NC 27599 1365 Clifton Road, NE
USA Atlanta, GA 30322
USA
Contributors XVII
Metin Önerci, MD Joseph Raviv, MD

Department of Otorhinolaryngology – Head and Neck Department of Otolaryngology – Head and Neck
Surgery Surgery
University of Hacettepe Northwestern University Feinberg School of Medicine
06100 Sıhhıye, Ankara Evanston, IL
Turkey USA
Email: metin@tr.net Email: j-raviv@enh.org
Richard R. Orlandi, MD, FACS Ryan M. Rehl, MD

Division of Otolaryngology – Head and Neck Surgery Arizona Sinus Center
University of Utah School of Medicine 1515 North 9th Street, Suite B
50 North Medical Drive, 3C120 Phoenix, AZ 85006
Salt Lake City, UT 84132 USA
USA Email: rrehl@arizonasinus.com
Email: richard.orlandi@hsc.utah.edu
Scott M. Rickert, MD
James N. Palmer, MD Department of Otorhinolaryngology
Hospital University of Pennsylvania Weill Cornell Medical College
3400 Spruce Street 1305 York Avenue, 5th Floor
5th floor, Ravdin Building New York, NY 10021
Philadelphia, PA 19104 USA
USA Email: smr139@columbia.edu
Email: james.palmer@uphs.upenn.edu
Bas Rinia, MD
David M. Poetker, MD, MA Department of Otorhinolaryngology
Department of Otolaryngology Academic Medical Centre
and Communication Sciences University of Amsterdam
Medical College of Wisconsin Postbus 22660
9200 W. Wisconsin Ave 1100 DD Amsterdam
Milwaukee, WI 53226 The Netherlands
USA
Email: dpoetker@mcw.edu Frederick C. Roediger, MD
University of California, San Francisco
Hassan H. Ramadan, MD Department of Otolaryngology – Head and Neck
Department of Otolaryngology Surgery
West Virginia University San Francisco, CA 94143
PO Box 9200 USA
Morgantown, WV 26506-9200 Email: froediger@ohns.ucsf.edu
USA
Email: hramadan@hsc.wvu.edu Raymond Sacks, MD, Bch FCS, ORL FRACS
Head of Department of Otorhinolaryngology
Vijay R. Ramakrishnan, MD Concord Repatriation Hospital
Department of Otolaryngology Suite12, Level 1, The Madison
University of Colorado 25–29 Hunter Street
AO-1, 12631E 17th Ave, B205 Hornsby
P.O. Box 6511 NSW Australia 2075
Aurora, CO 80045 Email: rsacks@commander360.com
USA
XVIII Contributors
Rodney J. Schlosser, MD Michael G. Stewart, MD, MPH

Department of Otolaryngology Department of Otorhinolaryngology
Medical University of South Carolina Weill Cornell Medical College
PO Box 250550 1305 York Avenue, 5th Floor
135 Rutledge Ave., Suite 1130 New York, NY 10021
Charleston, SC 29425 USA
USA Email: mgs2002@med.cornell.edu
Email: schlossr@musc.edu
Abtin Tabaee, MD
John Scianna, MD 10 Union Square East
Department of Otolaryngology Suite 4J
Loyola University New York
2160 South First Avenue USA
Maywood, IL 60153-3304 Email: atabaee@hotmail.com
USA
Marc A. Tewfik, MD
Brent A. Senior, MD, FACS Montreal General Hospital, Room A2-141
Department of Otolaryngology – Head and Neck 1650 Cedar Avenue
Surgery H3G 1A4 Montreal, Quebec
The University of North Carolina at Chapel Hill Canada
G0412 Neurosciences Hospital, CB #7070 Email: marc.tewfik@mail.mcgill.ca
Chapel Hill, NC 27599
USA Winston C. Vaughan, MD
Email: brent_senior@med.unc.edu Stanford Sinus Center
Stanford University
Michael J. Sillers, MD, FACS R-135 Edwards Building
Alabama Nasal and Sinus Center 300 Pasteur Drive
7191 Cahaba Valley Road Stanford, CA 94305
Birmingham, AL 35242 USA
USA Email: sinusmd@aol.com
Email: michaelsillers@charter.net
Mark C. Weissler, MD, FACS
Timothy L. Smith, MD, MPH University of North Carolina
Oregon Sinus Center G0412 Neurosciences Hospital
Department of Otolaryngology/Head and Neck Surgery CB 7070
Oregon Health and Science University (OHSU) Chapel Hill, NC 27599
3181 SW Sam Jackson Park Rd., PV-01 USA
Portland, OR 97239 Email: mark_weissler@med.unc.edu
USA
Email: smithtim@ohsu.edu Sarah K. Wise, MD
Department of Otolaryngology
Aldo C. Stamm, MD, PhD Medical University of South Carolina
Director of ENT Sao Paulo Center PO Box 250550
Rua Alfonso Bras 525 - Cj 13 135 Rutledge Ave., Suite 1130
04511-010 Sao Paulo Charleston, SC 29425
Brazil USA
Email: cof@centrodeorl.com.br Email: wisesa@musc.edu
James Stankiewicz, MD Bradford A. Woodworth, MD

Department of Otolaryngology Division of Otolaryngology
Loyola University Department of Surgery
2160 South First Avenue University of Alabama – Birmingham
Maywood, IL 60153-3304 BDB 563, 1530 3rd Ave S
USA Birmingham, AL 35294
Email: jstank@lumc.edu USA
Email: bwoodwo@hotmail.com
Chapter 1
Imaging Anatomy
in Revision Sinus Surgery 1
Ramon E. Figueroa
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
■ An intimate knowledge of sinus anatomy and a clear Caldwell-Luc and Nasoantral Windows . . . . . . . . . . . . . 2
understanding of the baseline postsurgical anatomy Imaging Anatomy in Post-FESS Ostiomeatal Complex . 2
are required for safe and effective revision sinus
Septoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
surgery.
■ Appropriate utilization of computer-assisted surgi- Turbinectomies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
cal navigation with CT crossregistration improves Uncinectomy and Maxillary Sinus Ostium Opening . 4
safety margins on revision sinus surgery. Internal Ethmoidectomy . . . . . . . . . . . . . . . . . . . . . . . . 5
■ Rhinologists should evaluate each side of the face as
Frontal Sinus Drainage Surgery . . . . . . . . . . . . . . . . . . . . 6
a completely independent anatomic, functional, and
surgical entity. Endoscopic Frontal Recess Approach
■ Familiarity with anatomic variants in the frontal re- (Draf I Procedure) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
cess is required for safe anterior skull base and fron- Endoscopic Frontal Sinusotomy (Draf II Procedure) . 7
tal recess surgery. Median Frontal Drainage
■ Persistent mucosal polypoid changes in a surgical (Modified Lothrop Procedure or Draf III) . . . . . . . . . 8
site on follow-up postsurgical computed tomogra-
Frontal Sinus Trephination . . . . . . . . . . . . . . . . . . . . . . 9
phy, retained surgical surfaces (uncinate process,
agger nasi, frontal bulla cells), or new bone forma- Osteoplastic Flap with Frontal Sinus Obliteration . . 9
tion are negative prognostic signs. Endoscopic Sphenoidotomy . . . . . . . . . . . . . . . . . . . . . . . 9
Negative Prognostic Findings Post-FESS . . . . . . . . . . . . 10

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
anatomy is still intact. In addition, it must identify the

Introduction
presence of any scar tissue formation, retraction of mu-
The resulting imaging anatomy of the paranasal sinuses cosal surfaces, and unresolved sinus drainage issues. In
following initial functional endoscopic sinus surgery cases were revision surgery is needed to solve persistent
(FESS) must be thoroughly evaluated to establish the new sinus obstruction or postsurgical synechiae, a detailed
postsurgical baseline of the sinonasal anatomy. These presurgical mapping of the anatomy must be performed
postsurgical changes may vary from subtle remodeling of with emphasis on the identification of endoscopic land-
anatomy to extensive resection with loss of sinus landmarks related to the anatomic surgical targets, especially
marks, frequently resulting in widely open sinus spaces if the surgical target is close to the lamina papyracea, crib-
into the nasal cavity. The great variability of the postsurgi- riform plate, or sphenoid sinus walls.
cal changes is a reflection of the variety of accepted sur- The recent introduction of multidetector helical scan-
gical techniques, the surgeon’s perception of the specific ning with its seamless high-resolution imaging databases
problem prior to FESS, and the individualized surgical and the wide availability of computer-assisted surgical
approach to the resolution of the identified problem. The navigation workstations allow today a real-time mapping
detailed assessment of the postsurgical changes must em- of the progress through the surgical procedure, even in
phasize which structures have been resected and which postsurgical fields devoid of residual endoscopic anatomic
Ramon E. Figueroa
landmarks. The combination of improved imaging clar-

1 ity from surgical navigation with computed tomography
Imaging Anatomy in Post-FESS
Ostiomeatal Complex
(CT) crossregistration and recent development of new
powered instruments and modern endoscopic devices The postsurgical CT anatomy of the ostiomeatal complex
is effectively extending the surgical safety margin, allow- will reflect the presurgical anatomic problems leading to
ing the rhinologist to solve more complex sinonasal and surgery combined with the surgical management chosen
skull-base problems. by the surgeon to address the patient’s clinical problem.
An almost infinite variety of surgical changes result from
the appropriately tailored surgical approach selected by
experienced rhinologists, who must carefully individu-
Caldwell-Luc and Nasoantral Windows
alize the extent of the procedure to the specific patient’s
The Caldwell-Luc operation, named after the American problem (Fig. 1.2). These surgical changes, alone or in
physician George Caldwell and the French laryngologist combinations, may include septoplasty, turbinate remod-
Henry Luc, was first described in the late nineteenth cen- eling/resection, uncinectomy, middle meatal antrostomy,
tury as a surgical decompressive technique to remove dis- internal ethmoidectomy, sphenoidotomy, and/or frontal
eased mucosa from the maxillary sinus, be it infectious or recess/frontal bulla cell/agger nasi decompression [2, 3].
tumor [1]. The procedure is performed via direct trocar
puncture through the anterior maxilla above the second ■ The first step in a comprehensive evaluation of a post-
molar tooth, allowing for initial decompression of the surgical nasal cavity is to determine which structures
maxillary disease, followed by the opening of a nasoan- have been previously resected and which structures
tral window at the inferior meatus to connect the maxil- remain, thus establishing the new anatomic baseline
lary sinus lumen to the nasal cavity. This procedure is rec- of the nasal cavity.
ognized on sinus CT by the associated focal defect of the ■ The second step in this evaluation is to determine the
anterior maxillary wall above the alveolar process and the relationship between the postsurgical changes and the
opening within the inferior meatus into the lumen of the patient’s current symptoms.
maxillary sinus (Fig. 1.1). This operation, which has been ■ The third and final step is to review the danger zones
used widely over the last century, is being performed with of the nasal cavity in the light of the distorted postsur-
less frequency today, having been replaced by the more gical anatomy prior to any revision surgery.
physiologic endoscopic middle meatal antrostomy. Still,
this surgery is considered safe and effective when removal This relationship is inferred by the presence of acute sinus
of all of the diseased maxillary sinus mucosa is desired. fluid levels, sinus opacity, or persistent sinus mucosal dis-
Fig. 1.1a,b Caldwell-Luc procedure. Coronal and axial comput- a and b) as a result of Caldwell-Luc surgery, combined with infe-
ed tomography (CT) images at the level of the maxillary sinuses, rior meatal nasoantral windows (asterisks). Notice also the right
showing bilateral anterior maxillary sinus-wall defects (arrows in middle meatal antrostomy and right inferior turbinectomy
Imaging Anatomy in Revision Sinus Surgery
Fig. 1.2 a and b Middle meatal antrostomies. There are bilat- plete resection of the uncinate processes and the wide pattern
eral middle meatal antrostomies (double-headed arrows), with of communication with the middle meatus. There is also a left
a right-sided middle turbinectomy (arrow in b). Notice the com- paradoxical middle turbinate
ease. Soft-tissue density within the surgical ostia is an im- Partial or subtotal resection of the middle turbine may
portant postsurgical finding, suggesting the presence of be necessary whenever a concha bullosa or a lateralized
scar tissue formation, polyps and/or hyperplasic mucosal middle turbinate is producing a mass effect toward the
changes, all of which are indistinct by CT findings. lateral nasal wall. Whenever truly indicated, middle tur-
binate surgical remodeling must be carefully performed
to the minimal degree that solves the clinical problem,
taking into consideration the fact that its mucosa is criti-
Septoplasty
cal for olfactory function. Its basal lamella is one of the
Septoplasty is a common adjunct finding in FESS due to most important surgical landmarks for safe endonasal
the frequency of septal deviations producing asymmetric navigation, maintaining turbinate stability by function
nasal cavity narrowing, occasionally to the point of lat- of its three-planar attachments (vertical attachment to
erally deflecting the middle and/or inferior turbinates. the cribriform plate, coronal attachment to the lamina
After septoplasty, the nasal septum will appear unusually papyracea, and axial attachment to the medial maxillary
vertical and straight, with a thin mucosa and no appar- sinus wall at the prechoanal level). The iatrogenic fracture
ent nasal spurs. Postsurgical complications such as septal of the middle turbinate vertical attachment is a dreaded
hematomas or septal ischemia may lead to triangular car- complication, resulting in the risks of cerebrospinal fluid
tilage chondronecrosis, resulting in nasal septal perfora- fistula at the cribriform plate, floppy middle turbinate be-
tions or saddle-nose deformity. havior, and postsurgical lateralization and scaring. Thus,
the resulting postsurgical appearance of the middle tur-
binate may vary from a barely perceptible thinning of its
bulbous portion, to a small residual upper basal lamella
Turbinectomies
stump in cases of subtotal resection.
Partial resection of the inferior turbinate is seen fre-
quently in patients with symptoms of chronic nasal con- ■ Lateralization of the middle turbinate is an important
gestion and polyposis, with the reduction of turbinate postsurgical finding, since it secondarily narrows the
surface increasing meatal diameters, thus increasing the middle meatus, potentiates synechia formation, and
total air volume through the nose. Inferior turbinectomy predisposes to recurrent obstruction of the underlying
is recognized on coronal CT as a foreshortened “stumped” drainage pathways by granulation tissue and scaring
inferior turbinate (Fig. 1.3). (Fig. 1.4).
Ramon E. Figueroa
Fig. 1.3a–d Inferior turbinectomies. a Coronal image showing rior ethmoid sinus. b Coronal image of the selective right infe-
extensive changes as a result of functional endoscopic sinus sur- rior turbinate prechoanal resection (arrow) showing prominent
gery (FESS), with subtotal right inferior turbinectomy (arrow) widening of the inferior meatal airway. c,d A different patient
and partial left inferior turbinectomy (asterisks), wide bilateral with extensive FESS showing by coronal (c) and axial CT (d),
middle meatal antrostomies, and left internal ethmoidectomies loss of all lateral wall landmarks bilaterally, except for the right
Note the persistent polypoid mucosal disease in the right ante- middle turbinate (MT)
tion, presence of Haller cells, large bulla ethmoidalis, or

Uncinectomy and Maxillary
the configuration of the adjacent orbital wall. Any soft
Sinus Ostium Opening
tissue within the natural ostium of the maxillary sinus or
Resection of the uncinate process is an important element in the ethmoidal infundibulum must be identified due to
in the performance of a functional maxillary sinusotomy. its potential for impairment of the mucociliary clearance.
Its incomplete resection is recognized by CT as a visible The presence of a nasoantral window is a good clinical
uncinate process within the surgical field, usually sur- indicator for the surgeon to look for the phenomenon
rounded by soft tissue from a scar/granulation reaction. of mucus recirculation, where mucociliary clearance al-
This granulation and scar, a part of the postsurgical heal- ready in the middle meatus may return to the maxillary
ing response, may contribute to recurrent obstruction at sinus lumen through a surgical nasoantral window, thus
the natural ostium of the maxillary sinus, the ethmoidal increasing the mucus load and potential for sinus colo-
infundibulum, or even toward the frontal sinus outflow nization with nasal pathogens. Naturally occurring pos-
tract, depending upon where the residual uncinate pro- terior fontanelles must also be taken into consideration
cess is located (Fig. 1.5). Widening of the maxillary sinus during the planning for revision FESS to avoid mistaking
ostium is also variable, depending on the uncinate resec- this space endoscopically with the maxillary sinus os-
Fig. 1.4a,b Lateralized middle turbinate in a patient 4 months (arrow) obstructing the middle meatal antrostomy, already with
after FESS, with recurrent facial pain and fever. These sequential active mucosal disease in the right maxillary sinus. Note also
coronal images show lateralization of the right middle turbinate subtotal resection of both inferior turbinates (asterisk)
Fig. 1.5a,b Residual uncinate process. Axial (a) and coronal (b) mucosal thickening in both maxillary sinuses, which is worse
CT images demonstrate persistent uncinate processes (arrows) on the right side
bilaterally in spite of previous FESS. Note the persistent active
tium, which would result in a maxillary sinusotomy not tial resection of the bulla ethmoidalis followed by resec-
bearing mucociliary clearance. tion of the ethmoidal cells, located anterior and inferior
to the basal lamella of the middle turbinate. If a poste-
rior ethmoidectomy is also needed, the basal lamella of
the middle turbinate is then penetrated to decompress
Internal Ethmoidectomy
the posterior ethmoidal air cells. This approach is also
The internal ethmoidectomy is an intranasal endoscopic extendable to the sphenoid sinus (transethmoidal sphe-
procedure that is performed to manage mucosal disease noidotomy). An internal ethmoidectomy appears by CT
within the anterior ethmoidal air cells. It requires the ini- as a wide ethmoidal cavity that is devoid of septations
Ramon E. Figueroa
(Fig. 1.6). It is important that residual opaque ethmoidal 3. Type 3: a single cell extending from the agger cell into
1 air cells are identified, since they may be an indicator for the frontal sinus.
recurrent sinus disease. The presence of mucosal polyp- 4. Type 4: an isolated cell within the frontal sinus.
oid changes and mucosal congestion within any residual
ethmoidal cells is also a concern as they obscure the un- The frontal sinus ostium may also be narrowed by supra-
derlying anatomic landmarks that are necessary for safe orbital ethmoid cells arising posterior to the frontal sinus
surgery near the skull base. and pneumatizing the orbital plate of the frontal bone.
The frontal sinus ostium communicates directly with the
frontal recess inferiorly, a narrow passageway bounded
anteriorly by the agger nasi, laterally by the orbit, and me-
Frontal Sinus Drainage Surgery
dially by the middle turbinate. The posterior limit of the
The frontal sinus drainage pathway is one of the most frontal recess varies depending upon the ethmoid bulla or
complex anatomic areas of the skull base. Its drainage bulla lamella, reaching to the skull base. When the bulla
pathways, the frontal sinus ostium and the frontal recess, lamella reaches the skull base, it provides a posterior wall
are modified, shifted, and narrowed by the pneumatized to the frontal recess. When the bulla lamella fails to reach
agger nasi, anterior ethmoid cells, frontal cells, supraor- the skull base, the frontal recess communicates posteri-
bital ethmoid cells, and the surrounding anatomic struc- orly, directly with the suprabullar recess, and the anterior
tures (vertical insertion of the uncinate process and bulla ethmoidal artery may become its only discrete posterior
lamella) [4]. The complexity of the frontal sinus variable margin. The frontal recess opens inferiorly to either the
drainage pathway starts at the frontal sinus ostium, which ethmoid infundibulum or the middle meatus depending
is oriented nearly perpendicular to the posterior sinus on the uncinate process configuration. When the ante-
wall, indented anteriorly by the nasal beak. Its caliber is rior portion of the uncinate process attaches to the skull
modified by the presence and size of pneumatized agger base, the frontal recess opens to the ethmoid infundibu-
nasi and/or frontal cells. When markedly pneumatized, lum, and from there to the middle meatus via the hiatus
agger nasi cells can cause obstruction of the frontal sinus semilunaris. When the uncinate process attaches to the
drainage pathway and thus have surgical implications. A lamina papyracea instead of the skull base, the frontal re-
second group of frontal recess cells, the frontal cells, are cess opens directly to the middle meatus [6].
superior to the agger nasi cells. Bent and Kuhn described
the frontal cells grouping them into four patterns [5]: ■ Each pneumatized sinus space grows independently,
1. Type 1: a single cell above the agger nasi. with its rate of growth, final volume, and configuration
2. Type 2: a tier of two or more cells above the agger cell. being determined by its ventilation, drainage, and the
Fig. 1.6a,b Internal ethmoidectomy. a Coronal image showing the asymmetric lack of internal septations in the left ethmoid
bilateral internal ethmoidectomies (IE) and left middle turbi- labyrinth internal ethmoidectomy
nectomy (arrow). b Axial image at the level of the orbit shows
corresponding growth (or lack of it) of the competing less mucosal shrinkage and secondary obstruction. If the
surrounding sinuses and skull base. endoscopic approach fails to provide long-term drain-
age of the frontal sinus, then an external approach with
This independent and competing nature of the structures obliteration of the frontal sinus still remains as a viable
surrounding the frontal recess adds an additional dimen- surgical alternative.
sion of complexity to the frontal sinus drainage pathway.
It is thus understandable why chronic frontal sinusitis
secondary to impaired frontal recess drainage is so diffi-
Endoscopic Frontal Recess
cult to manage surgically, as reflected by the wide range of
Approach (Draf I Procedure)
surgical procedures devised for frontal sinus decompres-
sion over the years. The spectrum of treatment options Dr. Wolfgang Draf popularized a progressive three-stage
ranges from surgical ostiomeatal complex decompression endoscopic approach to the management of chronic fron-
combined with conservative long-term medical manage- tal sinus drainage problems for patients in whom classic
ment, to endoscopic frontal recess exploration, the more ostiomeatal endoscopic sinus surgery is unsuccessful [8].
recent endoscopic frontal sinus modified Lothrop proce- The Draf type I procedure, or endoscopic frontal recess
dure, external frontal sinusotomy, osteoplastic fat oblit- approach, is indicated when frontal sinus disease persists
eration, or multiple variations of all of these [7]. in spite of more conservative ostiomeatal and anterior
Most endoscopic frontal sinus procedures are per- ethmoid endoscopic approaches. The Draf I procedure
formed in patients who had previous ostiomeatal com- involves complete removal of the anterior ethmoid cells
plex surgery in whom long-term conservative medical and the uncinate process up to the frontal sinus ostium,
management failed. In these patients, it is not uncom- including the removal of any frontal cells or other ob-
mon to find frontal recess scarring, osteoneogenesis, and structing structures to assure the patency of the frontal
incompletely resected anatomic variants, particularly in- sinus ostium.
complete removal of obstructing agger nasi cells and/or
frontal cells leading to chronic frontal sinusitis (Fig. 1.7).
Modern endoscopic surgical techniques and instru-
Endoscopic Frontal Sinusotomy
ments, combined with image-guided three-dimensional
(Draf II Procedure)
navigation techniques have resulted in increased endo-
scopic management of most frontal sinus pathology. En- The endoscopic frontal sinusotomy, or Draf II procedure,
doscopic approaches tend to preserve the sinus mucosa, is performed in severe forms of chronic frontal sinusitis
with less scar tissue than external approaches, resulting in for which the endoscopic frontal recess approach was un-
Fig. 1.7a,b Postinflammatory osteoneogenesis. Coronal (a) and axial (b) sinus CT sections at the level of the frontal sinuses show
osteoneogenesis with persistent frontal sinus inflammatory mucosal engorgement (black arrows)
Ramon E. Figueroa
successful. The previous endoscopic drainage procedure

1 is extended by resecting the frontal sinus floor from the
Median Frontal Drainage
(Modified Lothrop Procedure or Draf III)
nasal septum to the lamina papyracea. The dissection also
removes the anterior face of the frontal recess to enlarge The modified Lothrop procedure, or Draf III procedure,
the frontal sinus ostium to its maximum dimension. The first described in the mid-1990s, is indicated for the most
Draf II procedure looks very similar to the Draf I procedure severe forms of chronic frontal sinusitis, where the only
on coronal images, requiring the evaluation of sequential other choice is an osteoplastic flap with frontal sinus
axial or sagittal images to allow the extensive removal of obliteration. This procedure involves the removal of the
the anterior face of the frontal recess and the frontal sinus inferior portion of the interfrontal septum, the superior
floor. Endoscopic frontal sinusotomy (Draf II) procedure part of the nasal septum, and both frontal sinus floors.
can also be easily distinguished from the Draf III proce- The lamina papyracea and posterior walls of each fron-
dure (see below) by the lack of resection of the superior tal sinus remain intact. This procedure results in a wide
nasal septum and the entire frontal sinus floor. opening into both frontal sinuses (Fig. 1.8).
Fig. 1.8a–d Draf III (modified Lothrop) procedure. Axial (a,b) coronal (c), and sagittal CT images
■ The surgical defect component in the superior nasal osteotomy cuts through the frontal bone prevent collapse
septum after a Draf III procedure should not be mis- of the anterior table into the sinus lumen upon postop-
taken for an unintended postoperative septal perfora- erative closure. Frontal sinus obliteration requires all of
tion. the mucosa to be drill-removed and the frontal recess
occluded. The sinus is then packed with fat, bone mar-
row, pericranial flaps, or synthetic materials, and then the
bony flap is replaced.
Frontal Sinus Trephination
The postoperative imaging appearance by CT and/or
The trephination procedure is a limited external approach magnetic resonance imaging (MRI) is highly variable
for frontal sinus drainage. An incision is made above the due to the spectrum of tissues used for sinus packing,
brow and a hole is drilled through the anterior wall of the with imaging behavior reflecting fat, chronic inflamma-
frontal sinus taking care to avoid the supratrochlear and tory changes, retained secretions, granulation tissue, and
supraorbital neurovascular bundles (see Chap. 33). The fibrosis. MRI may be of limited utility in distinguishing
inferior wall of the frontal sinus is devoid of bone mar- symptomatic patients with recurrent disease from as-
row, which may lessen the risk of developing osteomyeli- ymptomatic patients with imaging findings related to scar
tis. Frontal sinus trephination is indicated in complicated tissue. Imaging is useful for the early detection of post-
acute frontal sinusitis to allow the release of pus and ir- operative mucocele formation, which is recognized by its
rigation of the sinus to prevent impending intracranial mass effect and signal behavior of inspissated secretions
complications. It can also be used in conjunction with [10, 11].
endoscopic approaches to the frontal sinus in chronic
frontal sinusitis or frontal sinus mucoceles, where the
trephination helps to identify the frontal recess by pass-
Endoscopic Sphenoidotomy
ing a catheter down the frontal recess, also allowing it to
be stented and to prevent its stenosis. This approach pro- The postsurgical appearance of the sphenoethmoidal
vides fast and easy access to the frontal sinus to place an recess following endoscopic sphenoidotomy varies de-
irrigation drain in the sinus. Its main disadvantages are pending upon whether the sphenoidotomy was transna-
the risks of associated scarring, sinocutaneous fistula for- sal, transethmoidal, or transseptal. Transnasal sphenoid-
mation, and injury to the supraorbital nerve bundle and otomy may be performed as a selective procedure, where
the trochlea, which can cause diplopia [9]. Image guid- the only subtle finding may be a selective expansion of
ance is critical for accurate trephine placement in par- the sphenoid sinus ostium in the sphenoethmoid recess.
ticularly small frontal sinuses or to gain access to isolated Transethmoidal sphenoidotomies, on the other hand, are
type 4 frontal sinus disease. performed in the realm of a complete functional endo-
scopic surgery, where middle meatal antrostomy changes,
internal ethmoidectomy changes, and sphenoid sinus ros-
trum defects ipsilateral to the ethmoidectomy defects be-
Osteoplastic Flap with Frontal
come parts of the imaging constellation (Fig. 1.9). Finally,
Sinus Obliteration
transseptal sphenoidotomy changes are a combination
■ Long-term stability of the mucociliary clearance of of septal remodeling with occasional residual septal split
the frontal sinus must be maintained for endoscopic appearance combined with a midline sphenoid rostrum
surgery of the frontal sinus to be successful. If this is defect and variable resection of the sphenoid intersinus
not achieved, an osteoplastic flap procedure with sinus septum. These changes are seen typically in the realm of
obliteration may be the only remaining option. more extensive sphenoid sinus explorations or surgical
exposures for transsphenoidal pituitary surgery. The ac-
The indications for this procedure include chronic fron- curate imaging identification of the optic nerves, inter-
tal sinusitis in spite of prior endoscopic surgery, muco- nal carotid arteries, maxillary division of the trigeminal
pyocele, frontal bone trauma with fractures involving nerve, and the vidian neurovascular package in reference
the drainage pathways, and resection of frontal tumors to the pneumatized sphenoid sinus is even more impor-
near the frontal recess. The outline of the sinus can be tant in postsurgical sphenoid re-exploration, since the
determined by using a cut template made from a 6-foot usual anatomic and endoscopic sinus appearance may be
(1.83 m) Caldwell x-ray, which approaches the exact size significantly distorted by previous procedures, postsurgi-
of the frontal sinus. Other methods include the use of a cal scar and/or persistent inflammatory changes. Imaging
wire thorough an image-guidance-placed frontal sinus guidance is thus critical for the safe and accurate depiction
trephination to palpate the extent of the sinus. Beveled of all of neighboring structures of the sphenoid sinus.
10 Ramon E. Figueroa
Fig. 1.9a,b Sphenoidotomy. a Axial CT showing bilateral in- of the rostrum of the sphenoid showing open communication
ternal ethmoidectomies and transethmoidal sphenoidoto- into the sphenoid sinus (SS), with no residual sphenoethmoid
mies (asterisks). Note the persistent polypoid disease (arrow) recess components. Note the absent left-middle and bilateral
in the left posterior ethmoid sinus. b Coronal CT at the level inferior turbinates from prior turbinectomies
Negative Prognostic Findings Post-FESS Conclusion

There is a series of postsurgical imaging findings that The postsurgical anatomy of the paranasal sinus drain-
imply a persistent underlying physiologic problem, with age pathways and their surrounding structures must be
poor prognostic implications for recurrence of sinus dis- evaluated in an integrated fashion, emphasizing the in-
ease. These CT findings may include a wide range of ele- terrelationship between sinus anatomy and function. The
ments, such as incomplete resection of surgical structures presence of residual surgical structures, mucosal nodular
(especially uncinate process, agger nasi, or frontal bulla changes at areas of prior surgical manipulation or postin-
cells), mucosal nodular changes at areas of prior surgi- flammatory new bone formation are poor prognostic fac-
cal manipulation (mucosal stripping, granulation tissue, tors for recurrent postsurgical sinus disease.
mucosal scarring, synechiae formation, polyposis), or
postinflammatory increased bone formation (osteoneo-
genesis). All of these changes should be detectable in a
References
good-quality postsurgical sinus CT, which should be per-
formed ideally at least 8 weeks after the surgical trauma 1. KE Matheny, JA Duncavage (2003) Contemporary indica-
to allow for reversible inflammatory changes to resolve. tions for the Caldwell-Luc procedure. Curr Opin Otolaryn-
These changes result in recurrent or persistent obstruc- gol Head Neck Surg 11:23–26
tion of the mucociliary drainage at the affected points, 2. Stammberger HR, Kennedy DW, Bolger WE, et al. (1995)
with increased potential for recurrent symptoms. Persis- Paranasal sinuses: anatomic terminology and nomencla-
tent nasal septal deviation leading to a narrowed nasal ture. Ann Rhinol Otol Laryngol (Suppl) 167:7–16
cavity and lateralization of the middle turbinate against 3. Kayalioglu G, Oyar O, Govsa F (2000) Nasal cavity and
the lateral nasal wall are two additional factors with poor paranasal sinus bony variations: a computed tomographic
prognostic implications for recurrent sinus disease. The study. Rhinology 38:108–113
relevance of these CT findings must be judged by the 4. Daniels DL, Mafee MF, Smith MM, et al. (2003) The frontal
rhinologist based on the presence of mucosal congestion sinus drainage pathway and related structures. AJNR Am J
and/or fluid accumulation in the affected sinus space in Neuroradiol 24:1618–1626
combination with assessment of the patient’s clinical be- 5. Bent JP, Cuilty-Siller C, Kuhn FH (1994) The frontal cell as a
havior (persistent sinus pressure, pain and/or fever). cause of frontal sinus obstruction. Am J Rhinol 8:185–191
Imaging Anatomy in Revision Sinus Surgery 11
6. Perez P, Sabate J, Carmona A, et al. (2000) Anatomical vari- 9. Lewis D, Busaba N (2006) Surgical Management: Sinus-
ations in the human paranasal sinus region studied by CT. itis; Taylor and Francis Group, Boca Raton, Florida, pp
J Anat 197:221–227 257–264
7. Benoit CM, Duncavage JA (2001) Combined external and 10. Melhelm ER, Oliverio PJ, Benson ML, et al. (1996) Opti-
endoscopic frontal sinusotomy with stent placement: a ret- mal CT evaluation for functional endoscopic sinus surgery.
rospective review; Laryngoscope 111:1246–1249 AJNR Am J Neuroradiol 17:181–188
8. Draf W (1991) Endonasal micro-endoscopic frontal sinus 11. Weber R, Draf W, Keerl R, et al. (2000) Osteoplastic fron-
surgery: the Fulda concept. Operative Tech Otolaryngol tal sinus surgery with fat obliteration: technique and long-
Head Neck Surg 4:234–240 term results using magnetic resonance imaging in 82 op-
erations. Laryngoscope 110:1037–1044
Chapter 2
Indications for Revision

Endoscopic Sinus Surgery 2
Marc A. Tewfik and Martin Desrosiers
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
■ The goal of assessment of the patient with symptoms Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
suggestive of persistent or recurrent sinus disease is Incomplete Previous Surgery . . . . . . . . . . . . . . . . . . . . 14
to identify the presence of technical, mucosal, and
Complications of Previous Surgery . . . . . . . . . . . . . . . 15
systemic factors contributing to poor outcome by
using appropriate investigations. Recurrent or Persistent Sinus Disease . . . . . . . . . . . . . 15
■ The goal of surgery is to improve medical manage- Histological Evidence of Neoplasia . . . . . . . . . . . . . . . 16
ment by reducing disease load and improving access Preoperative Workup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
for continuing medical care for those with severe
Assessment of the Patient with Post-ESS Symptoms 16
mucosal disease.
■ Indications for revision endoscopic sinus surgery Imaging Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
can be categorized as follows: (i) incomplete previ- The Role of Image-Guided Surgery . . . . . . . . . . . . . . . 17
ous surgery, (ii) complications of previous surgery, Other Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
(iii) recurrent or persistent sinus disease, and (iv)
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
histological evidence of neoplasia. These criteria are
not absolute and the decision to reoperate is most
often based on clinician judgment and experience.
■ The most common technical factors associated with
failure of primary surgery are: (i) middle-meatal
Introduction
scarring and lateralization of the middle turbinate,
and (ii) frontal sinus obstruction from retained ag- The management of chronic rhinosinusitis (CRS) can be
ger nasi or anterior ethmoid cells. These common quite challenging, even to the experienced rhinologist.
situations must be actively sought out with endos- This is particularly true for severe CRS that has not re-
copy and radiologic imaging. sponded to an initial surgical attempt (refractory CRS).
■ Given the multiple factors that contribute to the Revision surgery may have a role in the continuum of
persistence of disease, combinations of both medi- management of the patient’s disease condition; however,
cal therapy and surgery may play a role in the con- the clinician should understand that different care may be
tinuum of management as the patient’s disease con- required at different time points, depending on the un-
dition evolves over time. derlying factors contributing to sinus disease.
■ The patient should be informed that further surgery The decision to reoperate on a patient with sinus dis-
may be necessary in the future. ease is centered principally on the demonstration of a
symptomatic obstruction to sinus drainage or the pres-
ence of significant disease load in the sinuses. This must
be tempered by the clinician’s judgment, experience, and
comfort level. Given the nature of endoscopic sinus sur-
gery (ESS) and the close proximity of numerous critical
structures, special care must be taken to avoid serious in-
traoperative complications as a result of damage to adja-
cent structures [8,10,16]. Preoperative sinus imaging and
14 Marc A. Tewfik and Martin Desrosiers
a precise understanding of the patient’s anatomy are thus

of paramount importance.
Indications for revision sinus surgery can be grossly
2 divided into four main categories:
1. Incomplete previous surgery.
2. Complications of previous surgery.
3. Recurrent or persistent sinus disease.
4. Histological evidence of neoplasia.
The first occurs when prior surgery has been incomplete.

Such is the case when there is refractory CRS or recur-
rent acute sinusitis with persistence of ethmoid cells, or
a deviated nasal septum not adequately repaired and
causing obstruction to access or drainage. Incompletely
resected cells can be identified by their typical appear-
ance and position. Often, the agger nasi and anterior
ethmoid cells have been left in place while surgery clears
a straight-line back through the posterior ethmoids up
to the skull base (Fig. 2.1). Unopened infraorbital eth-
moid (Haller) cells can obstruct maxillary sinus outflow.
The “missed ostium sequence,” as described by Parsons
et al. [13], occurs when there is incomplete removal of Fig. 2.1 Symptomatic frontal sinus obstruction. Screen shot
the most anterior portion of the uncinate process, thus from a computer-assisted navigation system demonstrating
obscuring the position of the natural maxillary sinus os- frontal sinus obstruction in three planes on computed tomogra-
tium. This prevents the middle meatal antrostomy from phy (CT). Persistent agger nasi cells and anterior ethmoid cells
communicating with the natural ostium, resulting in a responsible for obstruction are best identified on a sagittal view
recirculation phenomenon. In this instance, mucociliary (top right)
flow causes mucus to re-enter the sinus, causing a func-
tional obstruction of the maxillary sinus and continued
sinus disease.
Several series have looked at the causes of postsurgical sinus ostial stenosis (27%), frontal sinus ostial stenosis
persistent or recurrent disease, and provide information (25%), and a separate maxillary sinus ostium stenosis
regarding the frequency of various anatomic findings. (15%). In their series of 67 patients requiring revision
Chu et al. [7] evaluated 153 patients requiring revision frontal sinus surgery, Chiu and Vaughn [6] identified re-
ESS, and found that the most common surgical alteration sidual agger nasi cell or ethmoid bulla remnants in 79.1%
associated with recurrent sinus disease was middle-me- of cases, retained uncinate process in 38.8%, lateralized
atal scarring and lateralization of the middle turbinate. middle turbinate remnant in 35.8%, recurrent polypo-
This was usually the result of partial middle turbinectomy sis in 29.9%, unopened frontal recess cells in 11.9%, and
during the initial surgery. neo-osteogenesis of the frontal recess in 4.5%. A maxim
Musy and Kountakis [11] reported that the most com- to guide the surgeon is that the patient can never truly
mon postsurgical findings associated with primary sur- be deemed a failure of therapy until all obstructions to
gery failure are: drainage and ventilation (or irrigation) are corrected.
1. Lateralization of the middle turbinate (78%).
2. Incomplete anterior ethmoidectomy (64%).
3. Scarred frontal recess (50%).
Indications for Surgery
4. Retained agger nasi cell (49%).
5. Incomplete posterior ethmoidectomy (41%).
Incomplete Previous Surgery
6. Retained uncinate process (37%).
7. Middle meatal antrostomy stenosis (39%). 1. Persistence of symptoms and signs of CRS with
8. Recurrent polyposis (37%). or without nasal polyposis or recurrent acute si-
nusitis with persistent ethmoid cells on com-
Ramadan [14] reviewed 52 cases and found that the most puted tomography (CT).
common cause of failure was residual air cells and adhe- 2. Deviated nasal septum not adequately repaired at pri-
sions in the ethmoid area (31%), followed by maxillary mary surgery and causing obstruction.
Indications for Revision Endoscopic Sinus Surgery 15
Fig. 2.2 Mucocele. Left frontal sinus

mucocele presenting as a painless left
exophthalmos. Note the circular, sphere-
like form typical of mucoceles. A three-di-
mensional, computer-generated illustration
of the lesion is also shown (right)
3. Persistent maxillary sinus disease in the setting of a surgery. A mucocele can be suspected on CT when there
retained uncinate process. is smooth, round enlargement of a completely opacified
sinus cell with associated bony remodeling and thinning
(Fig. 2.2). It is useful to follow a graded approach to the
frontal sinus; a discussion of frontal sinus techniques is
Complications of Previous Surgery
presented later on.
Complications of prior ESS constitute the second major The surgeon should always be alert to the risk of pre-
group of indications for surgical revision. These include: existing CSF leaks, which may have gone unnoticed dur-
1. Suspected mucocele formation. ing previous surgery. A significant proportion of CSF
2. Suspected cerebrospinal fluid (CSF) leak for which leaks are iatrogenic in origin. They occur most commonly
conservative management was unsuccessful. in the areas of the olfactory fossa and fovea ethmoida-
3. Synechiae causing obstruction of the nasal passage or lis (Fig. 2.3). The skull-base bone in these areas can be
sinus outflow tract. extremely thin, and may be penetrated by direct instru-
mentation or cauterization for control of bleeding [15]. In
Due to its narrow anatomic outflow pathway, the fron- some cases, bony remodeling expose the once-protected
tal sinus is particularly susceptible to this group of com- vital structures to trauma during surgery.
plications, and thus is often the target of revision sinus
Recurrent or Persistent Sinus Disease

Recalcitrant inflammatory sinus disease is the third cat-
egory of indications for revision ESS. This includes:
1. Recurrent acute sinusitis.
2. CRS with or without nasal polyps.
3. Allergic fungal rhinosinusitis (Fig. 2.4).
Another indication included in this category is in the

management of patients with nasal polyposis who have
an intolerance or contraindication to oral corticosteroids.
It remains, as a whole, a poorly understood group of dis-
eases. Considerable research efforts are currently focused
on improving the management of these difficult patients.
Although discussions of these entities and of medical
management are presented in depth in later chapters, a
Fig. 2.3 Cerebrospinal fluid leak. Coronal CT demonstrating guiding principal is that an adequate trial of maximal
a possible skull-base defect (arrowhead), which proved to be a medical therapy must be attempted preoperatively and
pre-existing trauma at the time of surgery documented in the chart.
Fig. 2.4 Allergic fungal rhinosinusitis. Involvement of all of the sinus cavities is shown on CT in the
bone window (left); examination in the soft-tissue window (right) shows evidence of allergic fungal
sinusitis/eosinophilic mucinous rhinosinusitis in all sinuses
warranted [5]. This option should be discussed with the

Histological Evidence of Neoplasia
patient before administration.
1. Unexpected diagnosis of neoplasia on pathological It is important to consider the potential contribu-
analysis with subtotal resection. tion of allergy to symptoms or disease, as a significantly
2. Localized severe disease suspicious for neoplasia, such higher percentage of these patients will have allergies as
as inverted papilloma. compared to the general population. A total serum IgE
level, as well as a hemogram with differential cell count to
Once diagnosed, these patients are reoperated for com- detect serum eosinophilia, may be useful to further char-
plete removal of the tumor. These most commonly con- acterize patients. Allergy testing and management should
sist of inverted papillomas [12,17,18]; however, they may be included in their care to minimize the contribution of
be any of a variety of benign or malignant nasal or para- allergy to the disorder. Allergen reduction or avoidance,
nasal sinus tumors [2]. medications, and possibly immunotherapy may play a
role in management.
Cigarette smoking has been associated with statisti-
cally worse outcomes after ESS based on disease-specific
Preoperative Workup
quality-of-life measures [4].
Sinonasal endoscopy, preferably rigid, is essential in
Assessment of the Patient
evaluating persistent disease. It may help identify struc-
with Post-ESS Symptoms
tural anomalies, masses, or secretions not seen on ante-
The clinician should attempt to elicit the patient’s symp- rior rhinoscopy. The bacteriology of CRS may vary in an
toms and classify them according to their severity. The individual patient over time. Obtaining endoscopically
goal of the medical workup is to identify the mucosal, guided cultures from the middle meatus or the spheno-
systemic, and environmental factors responsible for poor ethmoid recess (not the nasal cavity) will help in the se-
outcome. A history of underlying immune deficiency, lection of antibiotic therapy, particularly in cases that are
connective tissue disorder, malignancies, or genetic dis- unresponsive to empiric therapy. Care must be taken to
order such as cystic fibrosis or primary ciliary dyskinesia avoid contact with the nasal wall or vestibule to minimize
should be sought. A complete immune workup, and pos- contamination, and to sample directly within purulent
sibly a vaccine response, should be ordered to rule out secretions when present, rather than adjacent areas.
immune deficiency if it is suspected. Blood work is also
helpful to rule out other systemic disorders such as We-
gener’s granulomatosis and sarcoidosis. Defects in func-
Imaging Studies
tional immune response not evident in static testing have
been identified in certain patients who have refractory CT of the sinuses is essential for completing the assess-
CRS. In the absence of a response to all other therapies, ment of the patient with persistent post-ESS complaints.
a 6-month trial of intravenous immunoglobulin may be CT may be used to assess disease load or to identify tech-
Indications for Revision Endoscopic Sinus Surgery 17
nical factors that may not be revealed on endoscopy, such pain: neuralgia, migraine equivalent (midfacial head-
as residual ethmoid cells, obstructions to sinus drainage, ache), or dental problems may be responsible. The axial
or mucocele formation. Disease load can be determined CT should be used to carefully assess the possibility of a
by identifying the number of sinuses involved with disease small periapical dental abscess producing pain. In indi-
and the extent of their involvement (mucosal thickening viduals with a history of migraine or multiple surgeries, a
vs. opacification). The Lund-MacKay staging system is an trial of amitriptyline may be warranted.
effective method of standardizing reporting of radiologic
severity of disease [3,9]. Care must be exercised in the
face of exuberant local disease out of proportion to the
Surgery
rest of the sinus cavities to ensure against a missed diag-
nosis of neoplasm such as inverted papilloma. The role of revision surgery is principally to improve med-
When frontal sinus involvement is suspected, helical ical management, and surgery should be planned and exe-
CT with three-dimensional reconstruction is needed for cuted to optimize this. This is achieved by either reducing
analysis of the anatomy of the frontal recess. Frontal sinus disease load, by removing recurrent nasal polyps or hyper-
opacification is often noted on CT. However, this radio- trophic sinonasal mucosa (Fig. 2.5), or improving access
logic finding also needs to be assessed in terms of clinical for continuing medical care in the form of topical solu-
context by assessing the patient’s symptoms. For exam- tions. Wide antrostomies are created for problem sinuses
ple, it is not unusual in extensive sinonasal polyposis for in order to provide better access for irrigating solutions.
patients to demonstrate a significant amount of frontal Continued postoperative medical therapy is essential and
sinus involvement. Thus, in patients with nasal polypo- can be considered an integral part of surgical care.
sis, frontal sinus opacification in the absence of frontal
symptoms or bony remodeling is not in and of itself an Tips and Pearls
indication for revision.
1. Ensure an adequate trial of maximal medical
therapy before planning surgery.
2. Surgery is indicated only after failure of appropri-
The Role of Image-Guided Surgery ate medical management.
3. Be wary of pain as a sole presenting symptom in
When ordering imaging studies, consideration should be
the absence of other physical findings.
given to the possibility of image-guided surgery as part
4. Know when and how to use navigation.
of the initial evaluation of the potential surgical patient.
5. Know your limitations as a surgeon – be realistic.
The rationale for this is that normal anatomy is invariably
altered in previously operated patients, and the usual ana-
tomic landmarks – including the middle turbinate, unci-
nate process, and basal lamella – may have been removed.
Formal indications for computer-aided surgery endorsed
by the American Academy of Otolaryngology – Head and
Neck Surgery are [1]:
1. Revision sinus surgery.
2. Distorted sinus anatomy of development, postopera-
tive, or traumatic origin.
3. Extensive sinonasal polyposis.
4. Pathology involving the frontal, posterior ethmoid,
and sphenoid sinuses.
5. Disease abutting the skull base, orbit, optic nerve, or
carotid artery.
6. CSF rhinorrhea or conditions where there is a skull-
base defect.
7. Benign and malignant sinonasal neoplasms.
Fig. 2.5 Recurrence of sinonasal polyposis. Sagittal CT showing

Other Causes
extensive soft-tissue changes and polypoid disease in the region
In patients with post-ESS symptoms where no origin for of the frontal recess. Note is made of the persistence of the ante-
their symptoms can be identified, other causes of sinona- rior ethmoid cells, which indicates that previous surgery has not
sal symptoms should be considered. In the case of facial addressed these areas
9. Kountakis SE, Bradley DT (2003) Effect of asthma on si-

References
nus computed tomography grade and symptom scores in
2 1. AAO-HNS Policy on Intra-Operative Use of Computer-
Aided Surgery (2005) American Academy of Otolaryngol-
patients undergoing revision functional endoscopic sinus
surgery. Am J Rhinol 17:215–219
ogy-Head Neck Surgery. http://www.entlink.net/practice/ 10. Maniglia AJ (1991) Fatal and other major complications of
rules/image-guiding.cfm endoscopic sinus surgery. Laryngoscope 101:349–354
2. Batra PS, Citardi MJ (2006) Endoscopic management of si- 11. Musy PY, Kountakis SE (2004) Anatomic findings in pa-
nonasal malignancy. Otolaryngol Clin North Am 39:519– tients undergoing revision endoscopic sinus surgery. Am J
637, x–xi Otolaryngol 25:418–422
3. Bhattacharyya N (1999) Computed tomographic staging 12. Oikawa K, Furuta Y, Itoh T, et al. (2007) Clinical and patho-
and the fate of the dependent sinuses in revision endo- logical analysis of recurrent inverted papilloma. Ann Otol
scopic sinus surgery. Arch Otolaryngol Head Neck Surg Rhinol Laryngol 116:297–303
125:994–999 13. Parsons DS, Stivers FE, Talbot AR (1996) The missed os-
4. Briggs RD, Wright ST, Cordes S, et al. (2004) Smoking tium sequence and the surgical approach to revision func-
in chronic rhinosinusitis: a predictor of poor long-term tional endoscopic sinus surgery. Otolaryngol Clin North
outcome after endoscopic sinus surgery. Laryngoscope Am 29:169–183
114:126–128 14. Ramadan HH (1999) Surgical causes of failure in endo-
5. Chee L, Graham SM, Carothers DG, et al. (2001) Immune scopic sinus surgery. Laryngoscope 109:27–29
dysfunction in refractory sinusitis in a tertiary care setting. 15. Schlosser RJ, Bolger WE (2004) Nasal cerebrospinal fluid
Laryngoscope 111:233–235 leaks: critical review and surgical considerations. Laryngo-
6. Chiu AG, Vaughan WC (2004) Revision endoscopic frontal scope 114:255–265
sinus surgery with surgical navigation. Otolaryngol Head 16. Stankiewicz JA (1989) Complications of endoscopic sinus
Neck Surg 130:312–318 surgery. Otolaryngol Clin North Am 22:749–758
7. Chu CT, Lebowitz RA, Jacobs JB (1997) An analysis of sites 17. Wormald PJ, Ooi E, van Hasselt CA, et al. (2003) Endo-
of disease in revision endoscopic sinus surgery. Am J Rhi- scopic removal of sinonasal inverted papilloma includ-
nol 11:287–291 ing endoscopic medial maxillectomy. Laryngoscope
8. Dessi P, Castro F, Triglia JM, et al. (1994) Major complica- 113:867–873
tions of sinus surgery: a review of 1192 procedures. J Lar- 18. Zhang G, Rodriguez X, Hussain A, et al. (2007) Outcomes
yngol Otol 108:212–215 of the extended endoscopic approach for management of
inverted papilloma. J Otolaryngol 36:83–87
Chapter 3
Predictors of Failure
of Primary Surgery 3
Iman Naseri and John M. DelGaudio
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
■ Surgical success should be defined as significant Patient Selection Factors . . . . . . . . . . . . . . . . . . . . . . . . . . 20
symptom improvement or resolution, in addition Comorbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
to improvement of mucosal inflammation and sinus
Disease Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
obstruction.
■ Identification and maximal medical management of Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
coexisting disease factors must be considered prior
to ensuing surgical treatment to improve the results
of endoscopic sinus surgery.
■ Smoking has been found to increase the likelihood The overall success rate of primary endoscopic sinus sur-
of a poor surgical outcome, and reflux disease is gery ranges from 80 to 97% based on several criteria used
more common in surgically refractory patients with to measure success [4, 9, 12, 13, 16, 24, 28, 36, 37, 43,
chronic rhinosinusitis. 44]. It was shown that the extent of the disease measured
■ Significant nasal polyposis and advanced Lund- preoperatively by computed tomography (CT) may dic-
MacKay scores increase the chance of long-term tate the surgical outcome [16]. CT scans and endoscopic
failure of primary surgery. examinations are used as outcome measurements in con-
junction with subjective symptom evaluations. Among
the staging systems that utilize CT scans, the Lund-
MacKay staging system has been recommended by the
Task Force on rhinosinusitis of the American Academy of
Otolaryngology – Head and Neck Surgery [27, 45]. Two
Introduction
tests have been used most in clinical practice for symp-
Endoscopic sinus surgery (ESS) is the preferred treat- tom evaluation, the sinonasal outcome test (SNOT-20)
ment for patients with chronic rhinosinusitis (CRS) that and the symptom score instrument [26, 35].
has failed to respond to maximal medical treatment. ESS Prior to discussing the factors that predispose to in-
has been found to be effective in up to 90% of patients, creased risk of failure of ESS we need to define what
with long-term symptomatic improvement in up to 98% would be considered a failure.
of patients [7, 16, 17, 24, 37, 39].
Multiple factors are implicated in the increased the risk ■ If the goal of sinus surgery is to improve or resolve
for failure of primary ESS. These include [6, 7, 16, 39]: sinonasal symptoms, sinus obstruction, and mucosal
1. Allergies. inflammation, then failure to accomplish these goals
2. Tobacco use. should be considered a failure.
3. Gastroesophageal reflux (GER) disease.
4. Previous open sinus procedures. By using this definition of failure, we can divide the pre-
5. Severe mucosal disease. dictors of failure into several categories, including patient
6. Stage of sinus disease. selection factors, comorbidities, disease factors, and ana-
7. Inadequate postoperative care. tomic and surgical factors.
8. Scarring and synechiae.
9. Inadequate surgery.
20 Iman Naseri and John M. DelGaudio
spectively reviewed 182 patients who had undergone ESS

Patient Selection Factors
to determine the prognostic factors for poor outcome [7].
A successful surgical procedure begins with appropriate They found that a history of GER was the only historical
indications. ESS is indicated for CRS refractory to maxi- factor that was a predictor of poor symptom outcome af-
mal medical therapy, mucoceles, extrasinus extension of ter ESS. DelGaudio showed that patients with persistent
3 CRS, and tumors. symptoms of CRS and sinonasal inflammation after ESS
have significantly greater degrees of reflux at all levels of
■ Sinus surgery may not be effective in resolving symp- the aerodigestive tract, especially the nasopharynx, when
toms of postnasal drip (PND) or headache, even if the compared to controls.
surgical procedure is technically perfect and the sino-
nasal mucosa is healthy in the postoperative period. ■ This study is the first to demonstrate that direct na-
sopharyngeal reflux of gastric acid is found in adults
Also, the extent of surgery performed should be dictated with surgically refractory CRS at a significantly higher
by the degree of sinus disease observed on a preoperative frequency than in control patients
CT scan. Failure to address involved sinuses at the pri-
mary procedure is likely to result in failure. The likely mechanism of effect on the nasal mucosa is
PND is a common symptom that can be found in pa- mucosal edema and impaired mucociliary clearance. As
tients with a myriad of sinonasal diseases. In patients with acid travels up the digestive tract it reaches areas with less
PND as the primary symptom, especially when there is ability to protect against the acid and digestive enzymes
minimal sinus disease on CT scan, the surgeon should be present in the refluxate. It is likely that the nasopharyn-
careful to treat other conditions that may be more likely geal and nasal mucosa have a lower threshold for injury
to cause the PND prior to recommending surgery. Wise from gastric contents. These results support the possibil-
and DelGaudio found that in patients with and without ity that even more minor pH drops can cause harmful
CRS, those with a complaint of PND were significantly effects in the upper aerodigestive tract as a result of acid
more likely to have pathologic reflux at the level of the na- or pepsin exposure [11].
sopharynx and the hypopharynx [47]. Appropriate medi- The role of reflux in CRS is especially evident in the
cal treatment of reflux should be performed prior to at- pediatric population [34]. Treatment of GER in these pa-
tributing this symptom to CRS, especially in the absence tients leads to improvement of their sinus disease. Studies
of purulent nasopharyngeal drainage. have also shown that medically refractory chronic sinus-
itis patients have improvement after treatment for GER
■ Sinus surgery may not be effective as a treatment for [1]. Similarly, a significant reduction in the need for sinus
headache in the absence of sinus CT findings that cor- surgery was also seen in such patients who underwent
relate with the location of the headache treatment for their reflux. Thus, one must recognize that
reflux may play a role in worsening of symptoms of sinus
Multiple studies have found that over 90% of patients with disease, and the sinus surgeon should be wary of advocat-
a diagnosis of sinus headache and a normal CT scan of the ing surgery without proper diagnosis and treatment for
sinuses meet the International Headache Society criteria this condition.
for migraine headache [38]. DelGaudio has found that ap- The deleterious effects of tobacco smoke on the aerodi-
proximately 90% of patients presenting with a diagnosis gestive tract are well documented. Despite the strong as-
of sinus headache and a normal or minimally diseased CT sociations, there is a lack of controlled trials demonstrat-
scan of the sinuses have reduction or resolution of their ing the deleterious effects of tobacco smoke on sinonasal
headaches with treatment with triptans (personal commu- structures. Cigarette smoking has been shown to impede
nication). Patients with sinus disease on CT scan and head- mucociliary transport and increase nasal resistance [3].
ache should be counseled that the sinus surgery may not Although not a contraindication for ESS, patients who
resolve their headaches, especially if the headache loca- continue to smoke postoperatively are at a higher risk for
tion does not correlate to the area of sinus involvement. complications and a worse outcome [6, 39]. This is most
likely due to chronic mucosal irritation from the smoke,
resulting in mucosal edema, poor mucosal healing, and
increased postoperative scarring and synechiae forma-
Comorbidities
tion. Little is known about the impact of smoking cessa-
Reflux disease has been implicated to be associated with tion and the reversal of these effects. Patients should be
CRS, and has specifically been shown to be associated counseled on the effects of tobacco use on the success of
with a worse prognosis for ESS. Chambers et al. retro- ESS [8].
Predictors of Failure of Primary Surgery 21
Many systemic diseases can affect the health of the si- to the sequelae from decreased mucociliary transport
nonasal mucosa and negatively impact the results of ESS. may explain such observations [10].
Diseases such as sarcoidosis and Wegener’s granuloma- As expected, patients with nasal polyposis have worse
tosis affect the respiratory tract and cause nasal mucosal postoperative endoscopic findings and symptom scores
inflammation, crusting, and dryness, which have a signif- than their CRS counterparts. Even at 1 year postopera-
icant negative impact on healing after surgery. These pa- tively, they have been found to have more severe disease,
tients have extensive edema and crusting postoperatively as evidenced by CT and endoscopy [45]. When bilateral
that frequently results in scarring and synechiae forma- nasal polyposis exists along with allergies, various im-
tion. ESS should only be performed in these patients if mune interactions exist to cause a significant increase in
absolutely necessary, and only after maximal medical their recurrence rates after surgery [40–42]. Thus, it is
therapy has failed and the underlying systemic inflamma- important to identify such patients and maximize their
tory condition has been controlled as much as possible. treatment for allergies.
■ Asthma has been indicated for causing a significant

increase in the need for revision surgery, and some
Disease Factors
would argue that it is the most important prognostic
The most important factors that determine whether a pa- indicator for surgical failure [20, 22].
tient is likely to have a poorer long-term outcome from
ESS are related to the underling sinonasal disease factors. The frequency increases to 36–96% in aspirin-sensitive
Like other chronic conditions, the worse the disease at patients with asthma [2, 21]. Various reports have quoted
the time of surgery, the greater the likelihood of persis- the rate of nasal polyposis in asthmatics to be as high as
tence or recurrence. Factors that have been shown to pre- 41% [22, 30]. Lawson et al. demonstrated a 50% success
dict failure of primary ESS include nasal polyps, ciliary rate with asthmatics undergoing primary surgery, com-
dysmotility, advanced Lund-MacKay score, hyperostosis pared to 88% success among nonasthmatics [22]. Batra
of the sinonasal bones, and asthma. et al. demonstrated that improved postoperative sinonasal
Nasal polyps, regardless of their underlying etiology, symptoms correlate directly with Lund-MacKay scores.
represent an advanced stage of mucosal inflammation. In In addition, aspirin-sensitive patients had higher Lund-
addition to causing sinonasal obstruction, the polypoid MacKay scores pre- and postoperatively when compared
mucosa inhibits normal mucociliary clearance [46]. Since with their aspirin-tolerant counterparts [2].
the treatment of inflammation is predominantly a medi- In patients with advanced disease, chronic use of sys-
cal endeavor, it is not surprising that patients with polyps temic steroids has been associated with the need for revi-
have a lower long-term success rate with ESS when com- sion ESS. These patients are likely to have hyper-reactive
pared to CRS patients without polyps. airway disease and must be properly identified because
they are more likely to fail primary surgery and will re-
■ Sinus surgery in patients with polyps is directed at require longer follow-up [31]. Strict control of asthma is
ducing the obstructive symptoms and reducing the in- strongly encouraged in the perioperative management of
flammatory load so that medical therapy has a greater such patient groups.
likelihood of controlling the underlying disease
■ The correlation between asthma and CRS/nasal polyps
There is an established relationship between nasal polypo- most likely reflects the effect of an inflammatory pro-
sis and the need for revision ESS [15, 20, 23]. There is also cess on the entire respiratory tract (the unified airway
a higher rate of revision surgery in the polyp versus CRS concept).
patients [10]. Liu et al. demonstrated that sinus surgery
in patients with bilateral maxillary rhinosinusitis from Recurrence rates are also higher in patients recognized to
polyps has a 20.5% success rate [25]. Overall, patients have Samter’s triad (asthma, nasal polyps, and sensitiv-
with nasal polyposis typically have worse postoperative ity to aspirin). Endoscopic sinus surgery for such patients
outcomes both objectively and subjectively when com- has indicated a reduction of both upper- and lower-air-
pared to CRS alone. Higher preoperative Lund-MacKay way symptoms. This has been demonstrated by lower
scores seen in the presence of nasal polyposis may be Lund-MacKay scores and improved pulmonary function
attributed to the bulk and mass effect of the polyps on tests [2]. Although not adopted as a standard regimen,
imaging. Subjectively, patients with polyps have higher the use of leukotriene inhibitors may have a role in the
SNOT-20 scores than those with CRS. Deal et al. postu- treatment of nasal polyposis, especially in the presence of
late that higher degrees of nasal obstruction in addition Samter’s triad.
22 Iman Naseri and John M. DelGaudio
Chronic rhinosinusitis is very common among patients

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Conclusion
14. Jang YJ, Koo TW, Chung SY, Park SG (2002) Bone involve-
Primary ESS has a very high rate of success, especially ment in chronic rhinosinusitis assessed by 99mTc-MDP
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Predictors of Failure of Primary Surgery 23
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28. Matthews BL, Smith LE, Jones R, Miller C, Brookschmidt concepts in treatment of recurring rhinosinusitis. Part II.
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Otolaryngol Head Neck Surg 104:244–246 156
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30. McFadden EA, Woodson BT, Fink JN, Toohill RJ (1997) in patients with chronic sinusitis and nasal polyps. Eur
Surgical treatment of aspirin triad sinusitis. Am J Rhinol Arch Otorhinolaryngol 264:1003–1008
11:263–270 46. Waguespack R (1995) Mucociliary clearance patterns fol-
31. Moses RL, Cornetta A, Atkins JP Jr, Roth M, Rosen MR, lowing endoscopic sinus surgery. Laryngoscope 105:1–40
et al. (1998) Revision endoscopic sinus surgery: the 47. Wise SK, Wise JC, DelGaudio JM (2006) Association of na-
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Chapter 4
Pathophysiology of Inflammation
in the Surgically Failed Sinus Cavity 4
Wytske J. Fokkens, Bas Rinia and Christos Georgalas
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
■ Chronic rhinosinusitis with or without polyps is Intrinsic factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
an inflammatory disease. Treatment should always Allergy and Atopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
consist of a sandwich of optimal medical treatment,
Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
if necessary followed by surgery and than always fol-
lowed by a (sometimes extensive) period of medical Acetylsalicylic Acid intolerance . . . . . . . . . . . . . . . . . . 26
treatment. “Osteitis” – the Role of Bone . . . . . . . . . . . . . . . . . . . . 27
■ Both extrinsic and intrinsic patient factors may be Cystic Fibrosis and Primary Ciliary Dyskinesia . . . . 27
associated with an unfavourable outcome after en-
Immune Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
doscopic sinus surgery.
■ A careful assessment of these factors may serve as a Non-acquired Immunodeficiency Disorders . . . . . . . . 27
helpful prognostic indicator of the outcome of en- Specific Mucosal Diseases . . . . . . . . . . . . . . . . . . . . . . . 27
doscopic sinus surgery. Wegener’s Granulomatosis . . . . . . . . . . . . . . . . . . . . . . 28
■ Optimising the management of underlying systemic
Sarcoidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
disease is vital in order to achieve a satisfactory out-
come, especially in revision surgery. Churg-Strauss Syndrome . . . . . . . . . . . . . . . . . . . . . . . 29
External Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Microbiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Bacteria and Biofilms . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Fungus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Introduction
Environmental Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Chronic rhinosinusitis (CRS) with or without polyps is Acquired Immunodeficiency Disorders . . . . . . . . . . . . . 31
an inflammatory disease of the nose and the paranasal
Human Immunodeficiency Virus . . . . . . . . . . . . . . . . 31
sinuses characterised by symptoms of nasal blockage/ob-
struction/congestion, nasal discharge (anterior/posterior Bone Marrow Transplantation . . . . . . . . . . . . . . . . . . . 31
nasal drip), facial pain/pressure, and deterioration or loss Helicobacter pylori and Laryngopharyngeal
of the sense of smell [1]. Treatment should always consist Reflux . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
of a sandwich of optimal medical treatment, if necessary Immunopathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . 32
followed by surgery and then always followed by a (some-
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
times extensive) period of medical treatment.
The primary goal of medical treatment is the reduction
or resolution of the underlying inflammation. The pri-
mary goal of surgical treatment is to remove irreversibly
diseased mucosa, to aerate the sinuses and to render them eventually undergo a secondary surgical procedure [2].
more accessible to medical treatment. Although most In this chapter we will assess the role of inflammation in
ear-nose-and-throat surgeons currently use sandwich patients who fail sinus surgery, including the role of in-
therapy, approximately 10% of patients respond poorly trinsic patient factors and external factors that adversely
to sinus surgery with concomitant medical therapy and influence surgical outcome.
26 Wytske J. Fokkens, Bas Rinia and Christos Georgalas
ity (60%) are sensitive to multiple allergens [11]. Just like

Intrinsic factors
in asthma, there are some indications that in patients with
CRS most likely consists of different phenotypes. The dif- more severe forms of CRS, allergy is less important [11].
ferent phenotypes of CRS are often lumped together as Notwithstanding the lack of hard epidemiologic evidence
a single disease entity, because at this moment it seems of a clear causal relationship between allergy and CRS, it
impossible to clearly differentiate between them [1]. CRS is obvious that failure to address allergy as a contributing
with nasal polyps (NP) is one of the subgroups that has factor to CRS diminishes the chances of success of surgi-
4 the most distinctive characteristics; some studies have at- cal intervention [12]. Half of the patients who have had
tempted to use inflammatory markers in order to differ- sinus surgery before, believed that the surgery alone was
entiate CRS with NP from the other subgroups [3–5]. Al- not sufficient to completely resolve the recurrent episodes
though some of these studies point to more pronounced of infection [12]. However, the rate of revision surgery
eosinophilia and interleukin-5 expression in patients with was not significantly different between atopic and non-
NPs than in patients with CRS, these studies also suggest atopic patients [9].
the existence of a continuum in which differences might
be evident towards the ends of the spectrum, but no clear
cut-off point exists between patients with NP and other
Asthma
forms of CRS. In this chapter we will refer to CRS as a
single entity except when clear differences between differ- Asthma is frequently associated with CRS and NP. In pa-
ent phenotypes are described in the literature. tients with concomitant asthma, a trend to suffer from
There are several intrinsic factors that can give rise more severe forms of sinus disease is observed [13]. In
to, or affect the clinical course of CRS. They need to be addition, CRS is self-reported in a very high percentage
recognised and considered because they can adversely (70%) of patients suffering from asthma [14]. Asthmatic
influence sinus surgery outcome. Some of these factors patients with concomitant CRS had more asthma exac-
may also require specific therapeutic interventions, in ad- erbations, worse asthma scores, worse cough and worse
dition to sinus surgery. sleep quality than those without CRS.
At the cellular level the difference between asthmatic
and non-asthmatic patients suffering from CRS/NP be-
comes evident: Patients with NP who have concomitant
Allergy and Atopy
asthma tend to have a more prominent eosinophilic in-
■ Although there is still no clear evidence of a causal link filtration . This suggests a more aggressive inflammatory
between allergy and CRS, the chances of symptomatic response, especially in the subgroup with aspirin-intoler-
improvement after endoscopic sinus surgery (ESS) are ant asthma [15–22].
optimised if the underlying allergy is addressed. These data clearly support a strong link between
the lower and the upper airways. Medical and/or sur-
It is tempting to speculate that allergic inflammation in gical treatment of the upper airways of asthmatics
the nose predisposes the atopic individual to the develop- with CRS/NP, positively influences the course of bron-
ment of CRS. Both conditions share the same trend of chial asthma. Several studies report asthma symptom im-
increasing prevalence [6] and frequently coexist in the provement, less asthma attacks, less steroid use (topical
same individual. It has been postulated that swelling of and systemic) and improvement in peak expiratory flow
the nasal mucosa in allergic rhinitis at the site of the si- after surgery and medical treatment of the upper airways
nus ostia may compromise ventilation and even obstruct [23–25]. There is no clear evidence that CRS/NP patients
them completely, leading to mucus retention and infec- with asthma benefit less from sinus surgery than patients
tion. Furthermore, there is a growing consensus that the without asthma [13, 26, 27]. Nevertheless, post-operative
mucosa of the nasal airway is in a continuum with the endoscopic findings were worse in patients with concom-
paranasal sinuses, as reflected by the use of the term “rhi- itant asthma [28–30], and patients with asthma did re-
nosinusitis” rather than “sinusitis”. quire significantly more revision sinus procedures overall
However, critical analysis of the papers citing atopy as [31].
a risk factor for chronic rhinosinusitis reveals that whilst
there appears to be a higher prevalence of allergy in pa-
tients presenting with symptoms consistent with sinusitis
Acetylsalicylic Acid intolerance
than would be expected in the general population, this
may be the result of selection bias, as the doctors involved ■ Patients with asthma and acetylsalicylic acid (ASA)
often had an interest in allergy [7, 8]. Among CRS pa- intolerance tend to have worse outcomes following
tients undergoing sinus surgery, the prevalence of sensiti- functional ESS (FESS) and require revision surgery
sation ranges from 30 to 62% [9–11], of which the major- more often.
Pathophysiology of Inflammation in the Surgically Failed Sinus Cavity 27
Already in 1922, Widal described a triad of symptoms, Long-term antibiotics and local/systemic steroids are
which later came to be known as the Samter’s triad: in- the cornerstones of treatment. Multiple surgical proce-
tolerance to ASA compounds (e.g. aspirin), bronchial dures are often needed in order to achieve symptomatic
asthma and (often severe) CRS with NP. The mechanism relief of the upper, as well as the lower, airways. Since
of the hypersensitivity reaction to aspirin is not immuno- mucociliary clearance is compromised in both diseases,
logical, but may be related to the inhibition of cyclo-oxy- simple FESS is often not sufficient. In addition to nasal
genase (COX-1 and COX-2), an enzyme responsible for lavages, radical sinus surgery is often unavoidable [38,
prostaglandin synthesis, by aspirin. 39]. Perioperative morbidity is assumed to be higher in
Symptoms of this ASA triad usually commence around CF patients, due to underlying medical issues, such as ac-
the 20th year of life. Initially, patients present with nasal quired coagulopathies and advanced pulmonary disease.
blocking, rhinorrhea and hyposmia followed in a couple
of years by the formation of NPs and (often steroid de-
pendent) asthma. Ingestion of aspirin (or another non-
Immune Disorders
steroidal anti-inflammatory drug, NSAID) results in an
exacerbation of rhinitis and asthma, but independent of Several acquired and non-acquired immunodeficiencies
the exposure to NSAIDs, the disease will continue life- can cause CRS (with or without NP). They may gravely
long. Patients suffering from CRS and/or NP with ASA affect the patient’s clinical course and influence the re-
intolerance tend to suffer from more extensive sinus sponsiveness of CRS to standard medical and surgical
disease. They benefit from sinus surgery, but to a lesser treatment. They should always be considered in cases of
extent than patients without ASA intolerance [32]. How- recalcitrant sinus disease.
ever, they are more prone to disease recurrence and more
frequently have to undergo revision surgery than ASA- ■ In cases of recalcitrant disease that is resistant to both
tolerant CRS/NP patients [32–34]. medical and surgical treatment, the patient must be
assessed for the presence of underlying congenital
immunodeficiencies. However, with the exception of
humoral deficiency, which may necessitate treatment
“Osteitis” – the Role of Bone
with intravenous immunoglobulin, the significance of
Areas of increased bone density and irregular bony thick- subtle immunodeficiencies is uncertain.
ening are frequently seen on CT in areas of chronic in-
flammation in patients with CRS and may be a marker
of the underlying chronic inflammatory process [35–37].
Non-acquired Immunodeficiency Disorders
Although to date bacterial organisms have not been iden-
tified in the bone of either humans or animal models of A high percentage of patients with severe CRS, refractory
CRS, it has been suggested that this irregular bony thick- to medical treatment, seem to suffer from impaired T-cell
ening is a sign of bony involvement, which might in turn function, impaired granulocyte function [40], some form
maintain mucosal inflammation [35–37]. of immunoglobulin deficiency and common variable im-
munodeficiency [41–43]. The prognostic value of these
findings, nevertheless, is limited [44–46].
Non-acquired immunodeficiencies may affect hu-
Cystic Fibrosis and Primary Ciliary Dyskinesia
moral, cellular and frequently both immune response
Both cystic fibrosis (CF) and primary ciliary dyskinesia pathways. These patients are at an increased risk of de-
(PCD) manifest, among other things, with recurrent up- veloping CRS [47–49]. Some examples include common
per and lower respiratory tract infections. Patients with variable immunodeficiency, ataxia telangiectasia and
CF almost without exception suffer from CRS, and de- X-linked agammaglobulinaemia. Currently, there is not
velop NP in approximately 50% of cases. CRS is also al- enough data to evaluate the role of sinus surgery in this
most always present in patients with PCD, but the preva- group of patients. In patients with an identified humoral
lence of NP in this group of patients is only about 5%. deficiency, there may be a role for concomitant intrave-
Both CF and PCD are autosomal recessive genetic dis- nous immunoglobulin therapy [50].
eases and should be considered in children with CRS with
or without NP.
When suspected, CF can be diagnosed by means of a
Specific Mucosal Diseases
sweat test or DNA analysis. Ciliary activity in PCD can be
investigated in a mucosa biopsy from the upper or lower A few systemic inflammatory conditions are associated
airways, if necessary after culturing. A nasal brush is also with CRS. Three of the most frequently encountered in-
a possibility as a way of collecting nasal epithelial cells. clude Wegener’s granulomatosis (WG), sarcoidosis and
Churg-Straus syndrome. These can cause severe nasal and

paranasal sinus complaints and need to be recognised,
because they need specific therapeutic interventions.
Wegener’s Granulomatosis
4 ■ The role of surgery in active WG is essentially limited
to providing a sample of diseased mucosa for histo-
logical diagnosis.
WG is a multisystem disease with a complex genetic back-

ground, characterised by vasculitis with multi-organ in-
volvement. The most common features include granulo-
matous inflammation of the upper and lower respiratory
tracts and glomerulonephritis. It usually presents at age
30–50 years, and affects males approximately 1.5 times
more often than females. In up to 95% of the patients, the
head and neck region is the first to be affected [51].
Nasal involvement becomes evident mostly as persis-
tent purulent rhinorrhoea and sinusitis, sometimes with Fig. 4.1 Patients with nasal granulomatosis. This figure shows
ulcerating lesions of the nasal and sinus mucosa. Findings destructive/necrotising granulomatous inflammation of the sep-
on nasal examination may range from a purulent infec- tal and lateral nasal wall mucosa. ci Concha inferior, S septum
tion with no obvious mucosal abnormalities to (destruc-
tive/necrotising) granulomatous lesions of the septal and
lateral nasal wall mucosa (Fig. 4.1). Destruction of the
septum may result in the characteristic saddle-nose de- ogy and, if the nose is affected, a biopsy sample should be
formity (Fig. 4.2). taken from the affected mucosa while the patient is not
A positive (c)anti-neutrophil cytoplasmic antibody using corticosteroids. There is no point in taking a biopsy
test and a raised erythrocyte sedimentation rate together sample from macroscopically healthy mucosa.
with a characteristic clinical picture are highly suggestive Untreated WG is usually fatal. Patients should be
of WG. However, the diagnosis is confirmed with histol- jointly managed with a clinical immunologist. In gener-
Fig. 4.2 Patient with nasal deformity due

to destruction of the septum
alised disease, the induction treatment is systemic and

consists of cytostatics (e.g. cyclophosphamide) combined
with steroids [51, 52] After achieving remission, main-
tenance therapy usually consists of azathioprine (an im-
munosuppressant) 2 mg/kg daily. When WG is localised
only to the nose, the treatment can consist of cotrimoxa-
zol 960 mg daily and topical steroid drops or steroid oint-
ment applied to the nasal mucosa with a cotton bud. The
outcome of FESS in these cases is frequently disappoint-
ing and therefore surgery should be avoided. Reconstruc-
tion of the saddle deformity should only be considered
if the disease is in complete remission. Even then, nasal
surgery could induce disease recurrence [51].
Sarcoidosis
Sarcoidosis is a chronic noncaseating granulomatous
disease of unknown aetiology, principally affecting the
(lower) respiratory tract. The overall incidence is approx-
imately 6–10 per 100,000 [53]. Sinonasal involvement is Fig. 4.3 Patient with nasal septal perforation
rare, with reported incidences of 0.7–6% in the literature
[54].
Most frequent complaints suggestive of nasal in- Churg-Strauss syndrome (CSS) is a rare necrotising
volvement are reduced airflow, rhinorrhoea, anosmia granulomatous vasculitis of unknown aetiology. It af-
and crusting. Findings on examination of the nose may fects small- to medium-sized blood vessels. The most fre-
range from mild mucosal changes such as turbinate hy- quently involved organs are the nose, paranasal sinuses,
pertrophy and a strawberry-like appearance of the nasal lungs and peripheral nervous system. Many other organs
mucosa, to severe crusting, septal perforation and even a can also be involved, such as the heart, kidneys, skin and
saddle-nose deformity (Fig. 4.3) [54]. gastrointestinal tract. The American College of Rheuma-
A diagnosis of sarcoidosis is made on the basis of clini- tology established six criteria for the diagnosis of CSS:
cal findings, a plain chest X-ray (showing bilateral hilar 1. A history of asthma.
lymphadenopathy), raised angiotensin-converting en- 2. Eosinophilia > 10%.
zyme titre in serum and a biopsy of the affected mucosa. 3. Mononeuropathy or polyneuropathy.
Sarcoidosis patients with sinonasal involvement tend 4. Non-fixed pulmonary infiltrates.
to have lower remission rates and to require more often 5. Paranasal sinus abnormalities.
long-term systemic treatment [54]. Treatment of the nose 6. Biopsy showing extravascular eosinophils.
with local steroids is often not effective, and systemic
treatment, in the form of oral steroids, immunosuppres- The diagnosis of CSS is made when four or more of these
sants such as methotrexate (a folic acid antagonist) or criteria are present.
azathioprine is necessary. Surgery for sinonasal sarcoid- Clinically, the disease process can be divided into three
osis is controversial; although it may alleviate symptoms phases: The prodromal phase, consisting of asthma pos-
on the short-term, surgery alone does not eradicate the sibly associated with allergic rhinitis and often compli-
disease or prevent recurrence [55]. cated by sinonasal polyposis and recurrent rhinosinusitis.
The second phase is characterised by peripheral blood
eosinophilia and/or eosinophilic tissue infiltrates (i.e. eo-
sinophilic pneumonia or gastroenteritis). The third phase
Churg-Strauss Syndrome
is dominated by manifestations resulting from systemic
■ In sarcoidosis, as in Churg-Strauss syndrome, the role vasculitis (i.e. polyneuropathy).
of surgery is controversial: It may occasionally be used Nasal involvement is seen in approximately 69–75%
concurrently with steroids and immunosuppressants; of patients [56, 57]. Presenting nasal symptoms are those
however, its effects seem to be limited to short-term related to allergic rhinitis, rhinosinusitis, NP and crusting
symptomatic improvement. lesions throughout the nose.
The diagnosis can be confirmed by laboratory testing from within the epithelial cells. An immune defect, either
(leukocytosis with more than 10% eosinophils) and tis- in the innate or adaptive immunity, might be responsible
sue biopsy sampling (necrotising vasculitis, extravascular for this phenomenon. Follicle-like structures and lym-
necrotising granulomas and tissue eosinophilia). phocyte accumulations, specifically binding enterotoxins,
Since the first phase of the disease is barely distin- can be found within the mucosal tissue. Interestingly, IgE
guishable from common chronic (allergic) rhinosinusitis antibodies to enterotoxins can be found in the majority of
and polyposis, patients frequently undergo FESS. This ASA-sensitive patients, including those with NP as well
4 does not negatively influence the disease outcome, but as severe asthma. However, therapeutic approaches are so
revision surgery is usually needed. Once the diagnosis far limited and empirical, and inadequate in dealing with
is made, treatment options should again be determined this currently underestimated clinical challenge. In con-
in close consultation with a clinical immunologist. Many clusion, these data suggest that SAEs are at least modifiers
of these patients require systemic steroids and in severe of disease in CRS with NP [65, 66].
cases, azathioprine or cyclophosphamide for a long pe- Another interesting finding in CRS is the formation
riod of time. Some patients might benefit from immuno- of bacterial biofilms [67, 68]. A biofilm is defined as an
globulin or interferon-α treatment [58, 59]. organised community of bacteria, adherent to a surface
and contained in an extracellular polymeric substance
produced by the bacteria themselves (containing poly-
saccharides, nucleic acids and proteins) [69]. Because
External Factors
of the protective function of this matrix and their low
metabolism, bacteria in biofilms are less susceptible to
Microbiology
both innate and adaptive host defence mechanisms, as
well as to antibiotics. Biofilms allow bacteria to remain
Bacteria and Biofilms
attached to the mucosa for months to years, with inter-
■ The recent focus on Staphylococcus aureus enterotox- mittent acute exacerbations. CRS possesses the hallmarks
ins (SAEs) and biofilms as central factors in the patho- of a biofilm-mediated disease since it is a chronic disease
physiology of CRS may serve as a helpful paradigm in that is characterised by acute exacerbations. The involved
explaining some cases of medical and surgical failure. micro-organisms are often difficult to culture and define
Novel forms of treatment that would potentially target and are resistant to eradication, even with directed an-
them are required. tibiotics. Bendouah et al. evaluated semi-quantitatively
the bacterial ability to form biofilms in patients who had
The role of bacteria in chronic sinus disease is far from undergone an FESS procedure for CRS [70]. They con-
clear. Bhattacharyya [60] showed that aerobic as well as clude that there is a correlation between in vitro biofilm-
anaerobic species could be cultured from both diseased producing capacity by both S. aureus and P. aeruginosa
and non-diseased sinuses. Polymicrobial colonisation is and unfavourable evolution after FESS, as determined
often found. The most frequently cultured “pathogens” by symptom scores and endoscopic signs. This suggests
in CRS appear to be coagulase-negative Staphylococcus a possible role for biofilm production in chronic recalci-
species (24–80%), S. aureus (9–33%), Streptococcus pneu- trant sinus disease. However, the relative importance of
moniae (0–7%) and anaerobes (0–8%) [61]. Pseudomonas these biofilms, as well as possible therapeutic strategies
aeruginosa is also cultured in some cases [62–64]. Bacte- against biofilms, requires further investigation.
riology in patients with CRS/NP who have been medi- Prophylactic antibacterial treatment should not differ
cally and surgically treated does not seem to differ much much between primary and revision sinus surgery. In case
from that in untreated patients. of severe disease and/or many recurrences, perioperative
Gram-positive S. aureus bacteria have the innate capa- treatment specifically targeted against cultured pathogens
bility of releasing classical and egc-locus-derived entero- is suggested. Together with topical and/or systemic anti-
toxins, which show superantigen activity and effectively inflammatory treatment, this maximises the chances of
modify the functions of T and B cells, eosinophils and healing of the affected mucosa.
other inflammatory and structural cells. The stimulation
may lead to a type 2 T-helper (TH)-cell-polarised eosin-
ophilic inflammation as well as a multiclonal immuno-
Fungus
globulin E (IgE) production, exacerbating airway disease
in the upper and lower respiratory tracts. Recently, S. ■ There is controversy regarding the role of fungi in the
aureus has been demonstrated to reside intra-epithelially pathogenesis of common forms of CRS and evidence
and potentially to release superantigens into the tissue that treatment with topical antifungals is not effective.
There is increasing interest in the concept that the most with invasive fungal disease, early and aggressive sur-
common forms of sinus disease may be caused by the gical and medical treatment is mandatory.
inflammation stimulated by airborne fungal antigens. In
1999 it was proposed that most patients with CRS exhibit
eosinophilic infiltration and the presence of fungi by his-
Human Immunodeficiency
tology or culture [71]. This assertion was based on find-
Virus
ing a positive fungal culture by using a new culture tech-
nique in 202 of 210 (96%) patients with CRS who were The most common causes of acquired immunodeficien-
evaluated prospectively in a cohort study. Using this new cies in patients suffering from CRS are human immuno-
culture technique, the same percentage of positive fungi deficiency virus (HIV) infection and bone marrow trans-
cultures was found in normal controls [72]. plantation (BMT).
Some authors suggest that non-IgE-mediated mecha- Patients with HIV have a higher risk of developing
nisms underlying the response to fungal spores might CRS, especially at CD4 counts below 50 cells/mm3, with
be responsible for the eosinophilic inflammation seen reported prevalence ranging from 10 to 70% [79–81].
in some individuals [73]. Shin et al. found that patients Many pathogens can be identified in the sinuses of HIV-
with CRS had an exaggerated humoral and TH1 and TH2 positive patients with CRS. Most frequently these are
cellular response to common airborne fungi, particularly Staphylococcus (coagulase negative), P. aeruginosa, Strep-
Alternaria. No increase in type I sensitivity was found in tococcus and Aspergillus fumigates [81]. Clearly, first-line
patients as compared with controls [74]. treatment of CRS in HIV-positive patients should be
The fungal hypothesis, based of the premise of an al- directed against the identified organism. If this targeted
tered local immune (non-allergic) response to fungal medical treatment fails, FESS has been reported to be
presence in nasal/sinus secretions resulting in the genera- beneficial in retrospective studies [79, 82].
tion of chronic eosinophilic rhinosinusitis and NP [71],
has led to the concept of treating CRS with and without
NP with a topical antimycotic. The use of topical or sys-
Bone Marrow Transplantation
temic antifungal agents, however, has not consistently
been shown to help patients with CRS [75, 76]. BMT is also a frequent cause of acquired immune defi-
ciency. Allogeneic BMT in particular is notorious for
being associated with impairment of cellular as well as
humoral immunity, due to the necessity of intensive im-
Environmental Factors
munosuppression. Approximately 40–50% of allogeneic
Cigarette smoking was shown to be associated with BMT recipients develop CRS [79, 83]. The sinus mi-
a higher prevalence of rhinosinusitis in Canada [77], crobiology of patients with CRS after BMT reveals pre-
whereas this observation was not confirmed in a nation- dominantly Gram-negative bacteria (56.7%; including P.
wide survey in Korea [78]. Other lifestyle-related factors aeruginosa and Searratia marescens), followed by Gram-
are undoubtedly involved in the chronic inflammatory positive bacteria (26.7%) and various fungi (16.6%) [84].
processes of rhinosinusitis. For instance, low income was Again, treatment should be directed primarily against the
associated with a higher prevalence of CRS [77]. Despite causative pathogens. This suggests that a culture swab
in vitro data demonstrating the toxicity of pollutants on from the middle meatus, or a biopsy sample if necessary,
respiratory epithelium, there is no convincing evidence should be performed in all BMT patients suffering from
of a causal link between pollutants and toxins, such as sinus disease. Limited surgical approaches with intensive
ozone, and CRS. post-operative care seems appropriate in a selected group
of BMT patients with CRS who are refractory to medi-
cal treatment [85]. Nevertheless, there is insufficient data
to allow us to adequately assess the role of FESS in BMT
Acquired Immunodeficiency Disorders
patients suffering from CRS.
■ Patients with acquired immunodeficiency (patients Both HIV and BMT patients are at risk of developing
with AIDS and bone marrow transplant recipients) invasive fungal rhinossinusitis, a condition that carries
tend to present with CRS associated with atypical a high mortality rate. If this condition is detected early,
pathogens. Targeted antibiotics against the causative combined surgical and antifungal treatment may be ben-
pathogens is the mainstay of treatment, with surgery eficial [86, 87].
preserved only with those patients who fail medical
management. However, in those patients who present
disease [100]. In CRS and NP, MMP-9 is significantly

Helicobacter pylori
higher compared to healthy controls. Also, the pre-opera-
and Laryngopharyngeal Reflux
tive level of MMP-9 is related to the healing process after
Helicobacter pylori DNA has been detected in between surgery, with patients with lower MMP-9 levels demon-
11% [88] and 33% [89] of sinus samples from patients strating better mucosa healing. This holds true for MMP-
with CRS, but not from controls. Although this suggest a 9 concentration in nasal lavages [101], as well as MMP-9
link, no causal relationship has been established. expression in the extracellular matrix [100]. After sinus
4 surgery, the level of MMP-9 rises. Again, the lowest in-
creases are seen in patients with better healing mucosa.
MMP-9 might be a potential factor to predict and moni-
Immunopathophysiology
tor mucosal healing quality after sinus surgery. Inflamma-
■ A better understanding of the pathophysiology of mu- tory cells represent the major source of increased MMP-9
cosal inflammation in patients with CRS, including expression, which is linked to poor healing quality.
the role of matrix metalloproteinase (MMP)-9 in heal-
ing may help us in the future in selecting patients who
are more likely to benefit from surgery.
Conclusion
So far, there are only a few reports concerning underlying It appears that the “inflammatory state” of the parana-
immunologic processes and their relation with disease sal sinus mucosa is negatively correlated with the out-
intensity and sinus surgery outcome. come after sinus surgery. More extensive inflammation,
Both CRS and NP are characterised by abundant mu- which is seen for example in (ASA-intolerant) asthmatic
cosal infiltration by inflammatory cells. In CRS these patients, significantly reduces the healing quality of the
are predominantly neutrophils and eosinophils. NP is mucosa. In order to reduce the need for revision sinus
typified by a uniquely eosinophilic inflammation. In both surgery to a minimum, it is thus crucial to simultaneously
CRS and NP the eosinophilic influx is higher in asthmatic reduce tissue inflammation at the time of FESS. This can
patients when compared with non-asthmatic patients be achieved by topical steroid treatment, nasal lavages
[15–18, 21]. This difference in eosinophilic influx is even and if necessary, systemic steroids, combined with sys-
more marked in ASA-intolerant patients [19, 20, 22, 90]. temic antibiotics.
Eosinophilia seems to be correlated with disease sever-
ity [91] and prognosis [92]. This correlation between the
extent of eosinophilia and disease severity is also seen in
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Chapter 5
Medical Management after Primary

Surgery Failure and Preoperative 5
Medical Management
Jan Gosepath
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
■ Despite growing evidence of common pathways in Etiological Evaluation
underlying immunologic deficiencies or sensitiza- and Preoperative Medical Treatment . . . . . . . . . . . . . . . 38
tions, medical therapy has still to address a spec- Preoperative Medical Treatment . . . . . . . . . . . . . . . . . 40
trum of potentially causative etiologic factors of
Postoperative Care and Long-Term Medical
chronic rhinosinusitis (CRS).
Management to Prevent Recurrence . . . . . . . . . . . . . . . . 40
■ A complete etiological workup is the key to defining
Topical and Systemic Steroids . . . . . . . . . . . . . . . . . . . 40
an individualized medical treatment protocol suit-
able to prevent or reduce the risk of repeated recur- Topical Antifungal, Antiseptic, or Antibiotic
rence after primary surgery failure. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
■ In postoperative medical management, effective Systemic Antibiotics and Antihistamines . . . . . . . . . . 41
topical treatment should be combined with well-tol-
Aspirin Desensitization . . . . . . . . . . . . . . . . . . . . . . . . . 41
erated, long-term systemic therapy as the causative
mechanisms in CRS always represent a systemic dis- Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
ease.
■ Disturbances of the arachidonic acid pathway and
consecutive pathologic leukotriene release have
been identified as a common pathway and frequent
Introduction
driving force behind mucosal inflammatory disease
of the upper as well as the lower airway, especially, A difficult challenge in treating chronic rhinosinusitis
but not only, in patients with aspirin intolerance. (CRS) is to offer patients with recurrent disease after
■ Aspirin desensitization can be performed success- previous surgical treatment a therapeutic concept that
fully and, using a novel low-dose protocol, can be addresses individually relevant etiological factors, but is
applied as a life-long treatment. As this is effective at based on well-standardized criteria and validated path-
the enzyme level of the arachidonic acid pathway, it ways of medical therapy. So far, regardless of the surgical
is more causative and, based on clinical trials, more technique applied, a fair amount of patients, especially
effective than leukotriene antagonists. those with polypoid changes, will at some point in time
present with recurrent disease.
Until today, we have not succeeded in elaborating a
universal causative medical treatment for recurrent – es-
pecially polypous – CRS that would reverse the disease
process and make a surgical revision obsolete. The goal
therefore is to evaluate the individual constellation of
pathophysiological aspects of a patient. An emerging de-
velopment with increasing relevance for the future is the
application of in vitro assays validated to individually test
patients for the relevance of single etiologic factors. This
38 Jan Gosepath
will help to better target medical treatment both pre- and where a piece of saccharin is placed on the head of the
postoperatively in an effort to reduce the risk of yet an- inferior turbinate and the time taken until a sweet sensa-
other recurrence after the necessary surgical revision. tion is clearly felt in the pharynx is measured. Physiologi-
cally, a sweet sensation will be noticed after between 8
and 20 min. The functional integrity of the ciliary cells
as motor units can be further evaluated with the help of
Etiological Evaluation
video-interference contrast microscopy. In the case of a
and Preoperative Medical Treatment
prolonged STT, this is a very valuable method to rule out
Exploration of patients suffering from CRS is complex. syndromes of primary ciliary dyskinesia.
5 It is crucial to evaluate the relevance of several possible
etiological factors and pinpoint those that play a role in ■ Any impairment of mucociliary transport can be clini-
the individual pathogenetic development. A complete cally relevant, as persistent stasis of the mucus blanket
workup should include taking the following aspects into will trigger recurrent rhinosinusitis.
consideration:
1. Inhalant allergies. In a study published in 1997 we showed that patients
2. Ciliary dysfunction. suffering from recurrent CRS often do have a prolonged
3. Aspirin intolerance (AI). STT, but rarely a significant decrease in ciliary activ-
4. Immunodeficiency. ity [14]. These observations could be explained either
5. An immunologic reaction to fungi. by poor coordination of ciliary activity in these patients
6. Presence of bacteria that are resistant to the applied and/or alterations of the nasal mucus in terms of viscosity
antibiotic treatment. and its content of enzymes, inflammatory mediators, and
toxic proteins released from eosinophilic granulocytes.
Testing for inhalant allergies includes prick, intracuta- However, this study was able to show that endonasal si-
neous, and running anaerobic sprint testing followed by nus surgery may improve mucociliary transport time, as
nasal provocation testing, if clinically indicated [11]. The measured by STT, in patients with severe CRS.
relevant sensitization-specific immunotherapy or the in- One critical group in the range of patients suffering
creasingly accepted sublingual immunotherapy should from CRS, and especially in the subgroup with nasal pol-
be performed for 3 years continuously. Although this is yposis, are individuals with AI. It was understood early
not a causative treatment option for CRS, it may reduce on that this particular entity is associated with a very high
one relevant concomitant inflammatory stimulus render- risk of recurrence of sinonasal polyposis independent of
ing the mucosa prone to recurrent disease, and in some the number and kind of previous surgical interventions
patients may help to prevent the development of allergic [7]. The diagnosis of AI is not always associated with the
bronchial asthma. full clinical picture of the aspirin triad, which consists of:
Dysfunction of mucociliary clearance can be detected (1) nasal polyposis, (2) intrinsic bronchial asthma, and
using the clinical test for saccharin transit time (STT), (3) aspirin-induced worsening of asthmatic symptoms,
Fig. 5.1 Interaction between nonsteroidal

anti-inflammatory drugs (NSAIDs) and the
arachidonic acid pathway. AA Arachidonic
acid, ASS acetylsalicylic acid, COX cyclo-
oxygenase, 5-LOX 5-lipoxygenase, LTC4
leukotriene C4, LTD4 leukotriene D4, LTE4
leukotriene E4, PLA2 phospholipase A2, pLT
peptidoleukotriene
Medical Management after Primary Surgery Failure and Preoperative Medical Management 39
often along with naso-ocular symptoms [23]. However, in Table 5.1 Clinical parameters after a 2-year course of low-dose
sensitive individuals even very small single doses of aspi- aspirin desensitization with a daily maintenance dose of 100 mg
rin may cause rhinorrhea, bronchiolar constriction, and (n = 18 patients). FEV1 forced expiratory volume in 1s
pseudoanaphylactic shock symptoms related to a non-
IgE-mediated pharmacological hypersensitivity reaction Free of recurrent nasal polyps 15/18
[24]. Not only aspirin, but most other nonsteroidal anti-
inflammatory drugs interact with the eicosanoid pathway Improved FEV1 7/12
(Fig. 5.1). All patients diagnosed with AI have a consid-
Improved sense of smell (sniffin’ sticks) 11/18
erable chance of clinical improvement or decreased risk
of recurrence if adaptive desensitization therapy is per- Revision due to recurrent polyps 1/18
formed.
■ A low-dose, low-risk, aspirin-desensitizing protocol

using a maintenance dose of only 100 mg of oral aspi- patients undergoing desensitization using a daily main-
rin per day is effective in the management of patients tenance dose of as little as 100 mg of aspirin revealed the
with Samter’s (aspirin) triad [8]. treatment to be effective both clinically as well as in vitro
(Table 5.1, Fig. 5.2) [10]. Eicosanoid levels shifted back
This low dosage, along with its minimal risk of adverse to a normal release pattern during therapy, with an in-
side effects, offers the option of a long-term and, if pos- crease of prostaglandin in relation to leukotriene release.
sible, life-long treatment, which is ultimately mandatory This underlines a prominent role of cyclo-oxygenase
as a lasting effect of the desensitization. (COX)-dependant mediators, which is in keeping with
In 143 patients characterized in a retrospective in- findings in recurrent nasal polyposis of aspirin-tolerant
vestigation we diagnosed AI in 55 (38.5%) [15]. Patients patients. Immunohistochemical staining of polypoid tis-
diagnosed with AI revealed to be the subgroup with (1) sue revealed a downregulation of COX-2 in these tissues
the highest rate of revision surgeries performed over time as compared to normal nasal mucosa [13]. This unveils
and (2) the shortest interval between the respective op- a possible mechanism of increased proinflammatory leu-
erations. According to the definition of AI it is obvious, kotriene release in nasal polyps, since COX-mediated
that the subgroup of CRS patients with nasal polyps is prostaglandin E2 (PGE2) release inhibits leukotriene re-
likely to have the highest incidence of AI. lease in the nasal mucosa of normal controls.
In vitro analysis of eicosanoid release from mixed leu- The exact etiologic mechanisms underlying the forma-
kocyte cultures using a functional enzyme immunoassay tion of nasal polyps remain obscure. However, this entity
offers a new tool not only to help establish the diagno- of chronic inflammatory disease of the nasal respiratory
sis of AI, but also to individually monitor the effect and mucosa is associated with remarkable edema. Vascular
verify the success of a desensitization therapy over time. permeability/vascular endothelial growth factor (VPF/
Long-term follow up over at least 3 years in a group of VEGF) plays an important role in inducing angiogenesis
Fig. 5.2 The corresponding in vitro

parameters of the same group of patients
(n = 18) shown in Table 5.1 after 2 years
of low-dose aspirin desensitization with
a daily maintenance dose of 100 mg. PGE2
Prostaglandin E2
40 Jan Gosepath
and/or modulating capillary permeability. We investi- pha as well as peptidoleukotriene (pLT) and PGE2 levels
gated the expression and localization of VPF/VEGF in are still detectable and appear to play a role in the persis-
nasal polyps as compared to healthy controls in order to tence of inflammation in CRS [16].
evaluate its significance in the pathophysiology of nasal
polyps. The expression of VPF/VEGF in specimens of na- ■ Initial postoperative medical management should fo-
sal polyps was markedly stronger than in specimens of cus on the support of immediate wound healing and
healthy nasal mucosa of controls [12]. VPF/VEGF label- the prevention of scarring, synechiae formation, and
ing in polypous tissue was located in vascular endothelial wound infections.
cells as well as in basilar membranes and epithelial cells.
5 The observed expression pattern in nasal polyps as op- The preferred protocol to achieve these goals varies to
posed to controls of healthy nasal mucosa suggests that a certain extent between surgeons and is mostly based
VPF/VEGF might play a significant role in the etiology on topical applications of irrigations and solutions in-
of nasal polyposis. These findings need to be discussed cluding creams, decongestants, and steroids. Patients
with respect to the differential expression of COX iso- are usually seen in the office at weekly intervals for en-
enzymes -1 and -2 (COX-1 and COX-2, respectively) in doscopic follow up and crust removal from the surgi-
nasal polyps, where COX-1 is upregulated and COX-2 is cal cavity, as necessary.
downregulated, following immunohistochemical analy- The goal of long-term medical treatment in the post-
sis. Studies involving intestinal hyperplastic polyps sug- operative phase is to achieve a steady decrease of relevant
gest that COX-1 in particular can upregulate VPF/VEGF inflammatory mediators and thus to prevent the forma-
[25]. This mechanism might play a key role in polyp tion of recurrent disease. Common regimens to accom-
growth and edema formation in nasal polyposis. plish this include:
1. Topical and systemic steroids.
2. Topical antifungal, antiseptic, or antibiotic treatment.
3. Systemic antibiotics and antihistamines.
Preoperative Medical Treatment
4. Aspirin desensitization.
When patients present with moderate symptoms and
limited mucosal changes after primary surgery, a com-
bination of nasal irrigations, culture-guided antibiotics if
Topical and Systemic Steroids
purulent secretions, as well as topical and/or short-term
oral steroids can reduce or even resolve symptoms and Steroids, used topically or systemically or both gener-
endoscopic findings. There is evidence that in some pa- ally have a strong anti-inflammatory effect and can re-
tients a long-term course of low-dose macrolides can help duce eosinophilia as they directly interact with several
to reduce the presence of biofilm and inflammatory me- chemokines and cytokines involved in the inflammatory
diators [27]. In the majority of patients with recurrent na- process. In particular, the suppressive effect on the T-cell
sal polyps, however, medical preoperative treatment can production of IL-5 is an important aspect in this regard
only serve to control the inflammatory reaction as much [1]. A large number of symptomatic clinical reports as
as possible and to optimize conditions until the necessary well as prospective studies involving objective measure-
surgical revision is performed. ment of nasal function have established the role of topical
steroids in polypoid CRS [6]. The main indication seems
to be in the postoperative period, where they seem to
have beneficial effects on the rate and frequency of re-
Postoperative Care and Long-Term Medical
lapsing polyps. Systemic corticosteroids were evaluated
Management to Prevent Recurrence
in nasal polyposis and seem to result in temporary symp-
Certain applications of medical therapy should have a tomatic relief and can help to delay or facilitate surgical
prominent role in the treatment of CRS and can be valu- interventions [3].
able in reducing the risk of recurrent nasal polyposis, es-
pecially in patients who have previously undergone one
or multiple surgical interventions. In an untreated course
Topical Antifungal, Antiseptic,
of CRS, patients may show improvement of subjective
or Antibiotic Treatment
symptoms to an extent of approximately 25% in so-called
“stable episodes” over a 4-week period, whereas objective Initial reports using nasal washed with amphotericin
clinical parameters vary insignificantly. In such episodes, B showed promising results and so controlled clinical
mRNA of interleukin (IL)-1beta, IL-6, IL-8, monocyte trials were initiated to further define the role of intra-
chemoattractant protein-1 and tumor necrosis factor-al- nasal antifungal treatment in patients with CRS [21].
Heterogeneous experiences on the effectiveness of this

Systemic Antibiotics and Antihistamines
treatment option have been published [5, 27]. Practi-
cal clinical experience suggests that the individual re- Antibiotic treatment has not been established as an ef-
sponse to antifungal agents appears to be unpredictable, fective treatment in patients with CRS. A prominent
but the chance of a positive effect on the course of CRS pathogenic role of bacteria seems to be limited to acute
seems to increase with the duration of treatment. Some forms of rhinosinusitis and is doubtful in CRS [18, 19].
of the existing studies reporting ineffectiveness were un- Thus antibiotic treatment has mostly been proven effec-
blinded after only short-term applications of 8–12 weeks tive in acute sinusitis [4]. There are only limited data from
and suffered from a preselection of patients with mas- controlled studies on antibiotic treatment in CRS, and in
sive polyposis. The latter certainly should be a criterion most of these, a long-term effect on the course of CRS
to take caution with any topical intranasal treatment could not be shown [17]. Long-term applications of mac-
as solutions and/or nebulized substances will not even rolides for at least 3 months may, however, have beneficial
penetrate into the paranasal cavities. However, further effects on clinical and in vitro parameters of CRS [26]. In
evaluation of this treatment modality in prospective, addition to the antimicrobial mode of action, these drugs
placebo-controlled trials will help to shed more light on are known to have direct anti-inflammatory effects and
its place in our armamentarium and on patient selection may improve the viscoelasticity of the mucous blanket
criteria. [20]. An inhibitory effect on biofilm production of Pseu-
domonas aeruginosa has also been described [2].
■ Whenever applying topical solutions intranasally, po- Antihistamines are known to play a role in the adju-
tential side effects on mucociliary clearance should vant treatment of sinusitis, but no efficacy has been estab-
not be overlooked. lished for antihistamines in CRS without allergic rhinitis
being present as an underlying condition [22].
In an in vitro study on primary human nasal respiratory
cell cultures we evaluated the effects of different con-
centrations of several topical solutions on mucociliary
Aspirin Desensitization
clearance, as measured by ciliary beat frequency (CBF)
over time [9]. In controls, perfused with cell culture me- The best timing to initiate a scheduled aspirin desensiti-
dium (RPMI) only, CBF was measured at an average of zation after sinus surgery is following the initial wound
9.5±1.7 Hz, which remained constant over more than healing, at around the 3rd or 4th, but no later than the
12 h. Perfusion with a 5% solution of ofloxacin as an an- 6th postoperative week, before edematous or polypoid
tibiotic solution led to an average CBF of 8 Hz, but ciliary changes recur. To start desensitization therapy, patients
activity ceased after 7 h. With a 50% ofloxacin solution, need to be hospitalized for 2 days for close monitoring
the average CBF was only 7.5 Hz and stopped after 6 h for potential pseudoanaphylactic reactions. Oral aspirin
30 min. Using antiseptic solutions, perfusion with 5% is given in increasing dosages over these 2 days (day 1:
of Betadine revealed an average CBF of 7 Hz, which was increase up to 100 mg, day 2: increase up to 500 mg).
kept up for 1 h 30 min; however, with 10% it was down Doses are slowly increased only after a repeated check
to 4.5 Hz and lasted for only 30 min. Hydrogen perox- of airway resistance and forced expiratory volume in 1 s
ide was used in a 1% and in a 3% solution and seemed (FEV1), excluding a decrease in FEV1 of 25% or greater
less ciliotoxic than Betadine, as 1% led to an average CBF after the respective preceding dose. Should that occur, the
of 7 Hz, which was kept up for over 8 h, and 3% to 6 Hz previous dose is repeated without further increase at the
for 5 h 30 min. Using antifungal solutions, amphotericin time of the next application until lung function has re-
B revealed only little ciliotoxicity in low concentrations, covered. On the 3rd day aspirin is reduced to 100 mg/day
as CBF was measured at 9 Hz for 8 h at a concentration for long-term maintenance. In prospective trials, clinical
of 2.5% and at 8 Hz for 7 h at 5%. After increasing the reassessments as well as the functional in vitro assay were
concentration to a 10% solution, CBF dropped to 3.5 Hz repeated at each follow-up visit of every patient, in an at-
and lasted only 2 h. Interestingly, no dose-dependent ef- tempt to identify changes in the release of eicosanoids
fect was observed after perfusion with clotrimazole at all over time and to correlate these with the clinical course
three chosen concentrations of 10%, 20%, and 50%. CBF [10]. Since there is a relative overproduction of pLT in
remained at a constant average frequency of 9 Hz, but aspirin-sensitive individuals, it is desirable to achieve an
stopped after no more than 30 min in all experiments. increase in the “PGE2/pLT index” over time. We observed
The strongest dose dependence was seen for itraconazole: a significant improvement of in vitro findings, which was
at a concentration of 0.25%, a CBF of 6 Hz lasted for 7 h positively correlated to the individual clinical course and
45 min; at 0.5%, ciliary activity lasted only 1 h 15 min at the recurrence rate of nasal polyps observed in this group
6 Hz and at 1% it was only 3 Hz for 30 min. of patients [8].
42 Jan Gosepath
The data underline the role of the in vitro assay and

rin-desensitizing protocol, this treatment can be
indicate the effectiveness of a desensitization protocol
maintained long term without adverse side effects.
that can be maintained as a long-term treatment without
6. Pathologic eicosanoid release patterns similar
adverse side effects. The excellent compliance and low
to those of patients suffering from AI have been
rate of adverse effects associated with a dose of 100 mg
demonstrated in patients with recurrent nasal
of aspirin per day was sufficiently validated in large co-
polyposis and are currently being evaluated as
horts of cardiovascular and neurological patients, using
therapeutic targets in these patients.
equivalent dosages for prevention protocols. Results sug-
gest that the recurrence rate of nasal polyps after surgical
5 therapy can be reduced; however, only long-term treat-
ment can secure a beneficial outcome over time.
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Chapter 6
New Technologies for Revision

Sinus Surgery 6
Elisa M. Lynskey, Richard A. Lebowitz,
Joseph B. Jacobs, and Marvin P. Fried
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
■ Technological advances continue to enhance endo- Intraoperative Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
scopic sinus surgical procedures. The development Endoscopic Sinus Surgery Simulator . . . . . . . . . . . . . . . . 47
and utility of these techniques and devices continues
Balloon Sinus Ostial Dilatation . . . . . . . . . . . . . . . . . . . . 49
to evolve and at this time the final chapter cannot yet
be written. New technologies should enhance pre-
operative, intraoperative, and postoperative surgical
treatment and care. Our ability to treat inflamma-
tory as well as neoplastic disease will benefit from
Introduction
the availability of such devices.
■ Intraoperative computed tomography as well as The advent of endoscopic sinus surgery has revolutionized
magnetic resonance imaging are presently available. the surgical management of sinus disease. This minimally
There are several devices that have the capability of invasive approach was initially based on the development
demonstrating surgical anatomic change, and such of illuminated endoscopes and video systems, which oc-
data can be transferred to update image guidance. curred simultaneously with enhancements in computed
This exciting development should enhance surgical tomography (CT) scanning techniques. Refinement in
procedures for both inflammatory and neoplastic surgical equipment, such as powered shavers and cutting
disease. instrumentation, permitted careful and meticulous re-
■ Endoscopic sinus surgery simulation facilitates moval of diseased mucosa and anatomic structures with
educational opportunities for resident training and minimal surgical trauma. The advent of image guidance
education as well as increasing skill set develop- enabled rhinologic surgeons to accurately localize surgi-
ment for practitioners. These computerized systems cal instruments while performing paranasal sinus and
provide a novel interactive scenario during which a skull-base surgery for chronic inflammatory processes as
specific surgical procedure can be programmed for well as neoplastic disease. Further development of these
simulation prior to a definitive procedure. image-guidance systems and the related instrumentation
■ The development of balloon sinus ostial dilation has extended the indications for endoscopic procedures
provides an alternative method for the treatment of involving the base of skull. However, despite the accuracy
localized anatomic and mucosal obstruction of si- of current image-guided systems, they are limited by the
nus outflow tracts. Initial experience confirms the utilization of preoperative scan data, which do not reflect
feasibility and safety of the technique, and early re- the surgical changes that occur as bone and soft tissue are
sults suggest improved sinus function. removed. Several exciting and revolutionary intraopera-
tive imaging systems have been developed that can pro-
vide intraoperative images, which can be used to update
the image-guided system.
Surgical simulation training is currently being used in
several surgical specialties.
46 Elisa M. Lynskey, Richard A. Lebowitz, Joseph B. Jacobs, and Marvin P. Fried
■ The endoscopic sinus surgery simulator (ES3) is an More recently, the C-arm has been used to create recon-
interactive computer-based platform, adapted from structed images for three-dimensional navigation by neu-
military flight simulation, which provides a virtual rosurgeons and orthopedists [7, 10]; recently, Brown and
surgery experience for surgical education. colleagues investigated utilizing this technology during
endoscopic sinus surgery [4]. In their initial experience
Several different modes, reflecting various skill sets and with 14 patients, image quality was poor, but adjustments
levels of difficulty, are available for training purposes. The were made and for the final 6 patients they were able to
ES3 has been validated by a multi-institutional study, and produce images that allowed for evaluation of disease and
with the increasing focus on outcomes and assessment anatomical structures with navigation accuracy similar to
tools, may become an integral part of resident training that found with CT images (within 2 mm). Limitations
and physician credentialing. included image distortion and artifact caused by na-
6 Balloon sinus catheterization has been introduced for sal packing and blood in the sinuses, as well as reduced
the treatment of frontal, sphenoid, and maxillary sinus image quality in patients with extensive nasal polyposis
outflow obstruction. Initial published results are promis- (Figs. 6.1 and 6.2).
ing in the setting of mucosal and anatomic obstruction. One concern about intraoperative imaging is that of
Additional studies including long-term outcome results radiation exposure for the patient, the physician, and the
are needed to define the role of this technology in the operating room personnel. Traditional stereotactic surgi-
treatment of rhinosinusitis. cal techniques utilize the preoperative CT scan data and
therefore do not require intraoperative imaging with the
associated radiation exposure. Manarey’s group inves-
tigated the amount of radiation exposure during Fluo-
Intraoperative Imaging
roCAT fluoroscopy to reconstruct triplanar images for
Intraoperative imaging may prove to be one of the most stereotactic surgery [9]. Cumulative radiation exposures
important advances in image-guided revision endoscopic were measured for two separate scans in all three modes.
sinus surgery, particularly in the setting of neoplastic dis- The maximum surface and central radiation exposure
ease, and surgery at the skull base. (range 1.89–10.7 mG, depending on fluoroscopic mode)
was significantly less than that of a sinus CT with image-
■ Intraoperative imaging allows the surgeon to identify guidance protocol (85.4 mG).
the limits of the skull base and orbit with greater accu- Current technology also allows for intraoperative
racy, and to determine the extent of surgical resection magnetic resonance imaging (MRI). This modality pro-
and its potential effect on the anatomic relationship vides superior soft-tissue imaging without radiation ex-
between the surrounding vital structures. posure. The soft-tissue detail is particularly beneficial in
cases of endoscopic resection of tumors of the anterior
Stereotactic image-guided surgery was first introduced in skull base. Disadvantages of MRI include expense, longer
conjunction with neurosurgical procedures to guide abla- scanning time, and the necessity of specialized, nonfer-
tion of discrete areas; these initial cases were calibrated
using plain films, anatomic landmarks, and anatomic at-
lases [2]. From that point, a series of framed stereotactic
systems was developed. In 1986, Roberts and associates
published reports of a frameless navigation system that
utilized radiopaque glass beads as fiducial markers [11].
Since then, computer-aided surgery has undergone dra-
matic advances and become increasingly more available
and user-friendly.
■ Stereotactic image-guidance systems are still limited

by their reliance on images obtained preoperatively. As
surgery progresses and anatomy is altered, the images
remain static and do not reflect the surgical changes.
Recent innovations have allowed for intraoperative up-

dating of the images used in stereotactic surgery. Fluo-
roscopy has been used extensively in the operating room Fig. 6.1 Xoran X-cat intraoperative computed tomography
for neurosurgical, orthopedic, and vascular procedures. (CT) scanner in use
New Technologies for Revision Sinus Surgery 47
Fig. 6.2 Preoperative CT images (a) and intraop-

erative updated images (b) showing a mucocele
before and after drainage, respectively
romagnetic operating room equipment and instruments.

Endoscopic Sinus Surgery Simulator
Early experience utilizing intraoperative MRI was been
reported, and demonstrated the feasibility and accuracy Endoscopic sinus surgery requires the ability to work
of this modality [8]. More recently, Anand et al. published with both hands in a small space around delicate struc-
their experience with intraoperative MRI during endo- tures. Varied anatomy and the close proximity of vital
scopic transsphenoidal resections of pituitary tumors. structures such as the orbit and skull base contribute to
Residual tumor was identified in three out of ten patients the difficulty in gaining proficiency in these procedures.
using intraoperative MRI. Additional endoscopic resec- Residents typically acquire these skills through a process
tion was performed and there were no intraoperative that begins with observation and progresses to operative
complications [1]. experience under the supervision of attending surgeons.
Ultimately, the utility of intraoperative imaging will Practice on cadaver models is available, but is limited by
be judged based on its benefits, technical difficulties and the cost and availability of cadaveric specimens. In re-
limitations, and potential risks. sponse to the need for repeated practice to develop these
skills, the idea of a surgical simulator was explored. The set period of time. All of these factors will help to acceler-
field of aviation has used simulators for years to train and ate the learning curve for students and residents, while
improve the skills of both commercial and military pilots. enhancing patient safety. The simulator also provides an
As a Department of Defense contractor, Lockheed Martin objective assessment of surgical skill and would help to
has been responsible for the development and implemen- standardize residency training programs with regard to
tation of many of these flight simulators and assembled a endoscopic sinus procedures.
team to engineer a surgical training device. In a prospective, multi-institutional study by Fried
The result of these efforts is the endoscopic sinus and associates, 10 expert otolaryngologists, 14 residents,
surgery simulator (ES3), which utilizes both visual and and 10 medical students were evaluated using the ES3
haptic (force) feedback in a virtual reality environment. [6]. They each performed 23 trials with the simulator, be-
There are four principle components of this system: (1) ginning at novice mode and ending at advanced mode.
6 a Silicon Graphics Inc. Octane workstation, which serves Their findings show that in the novice mode, there is a
as the simulation host platform, (2) a personal computer significant difference in the starting point between all
(PC)-based haptic controller, which provides control and three groups, but as the number of repetitions increases,
coordination between an instrument handle and a set of the scores improve and the gap between attending phy-
virtual surgical instruments, (3) a PC-based voice recog- sicians, residents and medical students closes, with all
nition-enabled instructor, which operates the simulator three groups achieving the same endpoint after ten rep-
based on spoken commands, and (4) an electromechani- etitions. After completing the novice trials, exercises per-
cal platform, which includes a replica of an endoscope, formed in the intermediate and advanced modes did not
a surgical tool handle, and a mannequin head (Figs. 6.3 show any statistically significant differences between the
and 6.4). three groups’ total scores. The results in the novice mode
clearly demonstrate three different skill levels at the be-
■ The endoscopic sinus surgery simulator collects and ginning, with all three levels ultimately ending at a level
analyzes performance data in real time to provide im- of high performance. Moreover, the variations seen at the
mediate feedback to the participant regarding perfor- outset in all three groups were significantly narrowed, in-
mance errors. dicating that the performance was comparable between
the members of each group. Thus, simulator training can
The system also archives data for end-results analysis. bring individuals to a higher level of proficiency as well as
It provides an opportunity for residents to practice ma- decrease the variability within each group. These findings
neuvers repeatedly to gain proficiency without the risk support prior data published by Weghorst and her group,
of patient harm. It also allows for residents to repeat a which validates the ability of the simulator to distinguish
specific scenario as needed, and since the perioperative among varying levels of initial expertise, as well as the
aspects of patient care have been eliminated, the simula- ability of the simulator to increase the level of proficiency
tor allows for more procedures to be completed within a with repeated trials [12].
Fig. 6.3 The endoscopic sinus surgery simulator

in use
Fig. 6.4 The video monitor of the endoscopic sinus

surgery simulator
A study by Edmond takes the assessment of surgical tion. Under fluoroscopic guidance, a sinus guide wire is fed
skills one step further by addressing the impact of the through the cannula into the sinus and the balloon cath-
surgical simulator on operating room performance [5]. eter is then advanced over the guide wire. The proximal
In this setting, some of the junior residents were trained and distal portions of the balloon are radiopaque to allow
using the surgical simulator and others were not. Surgi- for visualization and correct placement within the ostia;
cal performance in the operating room was then rated by the distal mark should be visualized within the sinus and
senior surgeons watching videotapes. The two residents the proximal mark should be external to the sinus. The
who were trained with the simulator were consistently balloon is then inflated with a radiopaque fluid to ap-
rated better across all measures than the two residents ply 6–10 atm (608–1013 kPa) of pressure. The balloon
who weren’t. Although this study size was small, it was should remain inflated for a few seconds and may then be
the first to look at how endoscopic sinus simulation expe- deflated, repositioned, and reinflated if necessary. After
rience would translate to surgical skill. It shows that the dilation, the guide wire may also be used to position a
simulator appears to have a positive impact on residents’ sinus lavage catheter. Upon completion of the procedure,
operative skill. A controlled multi-institutional study in- endoscopic visualization of the sinus ostia should con-
volving larger groups of trainees is currently underway to firm its patency (Fig. 6.5).
confirm the ability of the ES3 to enable skills that can be This procedure has its limitations, however, and can-
transferred from the simulation laboratory to the operat- not be used in patients with sinonasal polyposis or ex-
ing room. tensive sinonasal osteoneogenesis. Extensive scar tissue
from prior surgical procedures may also limit the ability
to dilate the sinus drainage pathways. Due to the nature of
this procedure and the anatomy of the ethmoid sinuses,
Balloon Sinus Ostial Dilatation
traditional endoscopic surgery techniques are necessary
A recent introduction to endoscopic sinus surgery is the to facilitate drainage of this area. Because of these limita-
use of balloon catheters for dilation of sinus ostia. This tions, the patient and surgeon must always be prepared to
approach was introduced based on the concept of cath- proceed with debridement using traditional techniques.
eter dilation used in other disciplines such as cardiology The balloon catheter technique also requires fluoroscopic
and urology. It is hypothesized that this procedure will re- guidance, which exposes both the patient and operating
duce mucosal trauma as compared to typical endoscopic room staff to radiation. Bolger et al. found that the av-
surgery techniques, thus reducing the formation of scar erage amount of radiation exposure during surgery was
tissue and restenosis at sinus ostia. approximately 730 mrem (16 µC/kg), comparable to the
Balloon sinus ostial dilation involves the cannulation amount of radiation exposure during a chest CT scan
of the maxillary ostia, sphenoid ostia, or frontal sinus (800 mrem, or 17 µC/kg) [3]. Although precautions such
outflow tract by a balloon catheter. A hollow cannula is as radiological shields should be worn, the cumulative
placed near the sinus ostia under endoscopic visualiza- dose to the surgeon and operative staff is a concern and
Fig. 6.5 Fluoroscopic views of balloon catheter dilation of the frontal sinus outflow tract. The proximal and distal radiopaque mark-
ers of the balloon can be visualized (arrows)
the benefit of the procedure must outweigh the risk and technique may be particularly advantageous in the dila-
additional cost involved. tion of frontal sinus outflow tracts, where minimal mu-
A prospective, multicenter study conducted by Bolger cosal trauma is highly desirable to prevent scar tissue and
and colleagues followed 109 patients for 6 months after stenosis.
endoscopic balloon catheter sinusotomy [3]. They were
able to successfully cannulate and dilate 96.9% of sinus
ostia and there were no serious adverse postoperative se-
References
quelae (cerebrospinal fluid rhinorrhea, orbital injury, or
epistaxis requiring packing). At the end of the 6-month 1. Anand VK, Schwartz TH, Hiltzik DH (2006) Endo-
follow-up period, endoscopy revealed that 80.5% of the scopic transphenoidal pituitary surgery with real-time
dilated sinus ostia remained patent, 1.6% were nonpatent, intraoperative magnetic resonance imaging. Am J Rhinol
and 17.9% could not be adequately visualized. A quality- 20:401–405
of-life questionnaire also revealed statistically significant 2. Anon JB (1998) Computer-aided endoscopic sinus surgery.
improvement in patient symptoms after balloon dilation. Laryngoscope 108:949–961
Revision surgery was required in three patients (2.75%); 3. Bolger WE, Brown CL, Church CA, et al. (2007) Safety and
appropriate patient selection criteria appear to be essen- outcomes of balloon catheter sinusotomy: a multicenter
tial to successful outcomes with balloon sinuplasty. 24-week analysis in 115 patients. Otolaryngol Head Neck
137:10–20
■ Balloon catheter dilation appears to be a promising 4. Brown SM, Sadoughi B, Cuellar H, et al. (2007) Feasibility
new tool in the quest for minimally invasive interven- of near real-time image-guided sinus surgery using intra-
tions. operative fluoroscopic computed axial tomography. Oto-
laryngol Head Neck 136:268–273
Based on current reports, balloon catheter dilation could 5. Edmond CV Jr (2002) Impact of the endoscopic sinus sur-
potentially provide durable results and improvement. It gical simulator on operating room performance. Laryngo-
remains to be seen, however, whether or not these dilated scope 112:1148–1158
ostia will remain patent over longer periods of time. This
6. Fried MP, Sadoughi B, Weghorst SJ, et al. (2007) Construct 10. Richter M, Geerling J, Zech S, et al. (2005) Intraoperative
validity of the endoscopic sinus surgery simulator: II. As- three-dimensional imaging with a motorized mobile c-arm
sessment of discriminant validity and expert benchmark- (SIREMOBIL ISO-C-3D) in foot and ankle trauma care: a
ing. Arch Otolaryngol 133:350–357 preliminary report. J Orthop Trauma 19:259–266
7. Holly LT, Foley KT (2003) Three-dimensional fluoroscopy- 11. Roberts DW, Strohbehn JW, Hatch JF, et al. (1986) A frame-
guided percutaneous thoracolumbar pedicle screw place- less stereotaxic integration of computerized tomographic
ment. Technical note. J Neurosurg 99:324–329 imaging and the operating microscope. J Neurosurg 65:
8. Hsu L, Fried MP, Jolesz FA (1998) MR-guided endoscopic 545–549
sinus surgery. Am J Neuroradiol 19:1235–1240 12. Weghorst S, Airola C, Oppenheimer P (1998) Validation of
9. Manarey CR, Anand VK (2006) Radiation dosimetry of the the Madigan ESS simulator. Stud Health Technol Inform
FluoroCAT scan for real-time endoscopic sinus surgery. 50:399–405
Otolaryngol Head Neck 135:409–412
Chapter 7
Surgical Anatomy in Revision

Sinus Surgery 7
Adam J. Folbe and Roy R. Casiano
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
■ Revision sinus surgery depends on knowing con- Nasal Cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
stant bony anatomical landmarks that are unaltered Maxillary Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
by prior surgery or advanced pathology.
Ethmoid Labyrinth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
■ A wide maxillary antrostomy exposes the posterior
Sphenoid Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
lamellae and the medial orbital floor (MOF).
■ The superior margin of the maxillary sinusotomy Frontal Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
(junction of the inferior aspect of the lamina papy- Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
racea and MOF) forms a “bony ridge,” which delin-
eates the anterior ethmoid cells (medially) from the
orbital floor (laterally).
■ The posterior margin of the maxillary sinusotomy
(posterior fontanelle remnant), delineates the middle middle turbinate) may be removed or scarred in different
turbinate/sphenopalatine foramen (medially) from locations, making revision surgery more difficult.
the posterior wall of the maxillary sinus (laterally). Correlating computed tomography (CT) scan anat-
■ The relationship between the MOF and adjacent omy with endoscopic anatomy is very important. As
structures can help guide the surgeon. discussed in other chapters, the use of navigational sys-
■ The posterior ethmoid cells lie superior to the pos- tems during surgery can aid the surgeon during revision
terior orbital floor adjacent and medial to the ridge sinus surgery. However, there is a margin of error with
of the antrostomy. the systems and they require precise calibration. The sur-
■ The sphenoid sinus lies inferior to the MOF, adja- geon should not substitute good fundamental knowledge
cent to the nasal septum, approximately 7 cm from of the anatomy with a navigational system. Because the
the columella. paranasal sinuses are in such close proximity to the or-
■ The nasolacrimal duct runs anterior, but parallel to the bit and brain, the changes in anatomy surrounding them
direction of the frontal recess and infundibulum. can result in dreaded complications. For example, by not
properly identifying the medial orbital wall, inadvertent
penetration through the periorbita can result in an or-
bital hematoma or blindness. In another example, if the
surgeon encounters the posterior ethmoids and thinks it
is the sphenoid sinus, they may inadvertently penetrate
Introduction
the skull base causing a cerebrospinal fluid leak or brain
The understanding of anatomy is crucial during any injury.
operation. Once the anatomy has been understood, the This chapter will focus on bony landmarks, knowledge
surgeon can proceed using designated landmarks to di- of measurements from the columella, and relationships
rect the surgery. However, during sinus surgery, because with adjacent sinus structures. With the understanding of
much of the paranasal sinus contents are thin bone struc- these items, the “difficult” anatomy of revision sinus sur-
tures with overlying soft tissue, some landmarks (i.e., the gery will become more easily understandable. Through-
uncinate, ethmoid bullae, the basal or ground lamellae, out the chapter, it will become apparent that the orbital
54 Adam J. Folbe and Roy R. Casiano
floor along with adjacent structures, are key landmarks turbinate and the tail and horizontal attachment of the
for understanding sinus anatomy. middle turbinate, are commonly left untouched.
■ The posterior fontanelle is located superior to the lat-

eral attachment of the posterior one-third of the infe-
Nasal Cavity
rior turbinate.
Structures visualized in the nonoperated nasal cavity in- ■ The sphenopalatine foramen is located at the coronal
clude the inferior turbinate, uncinate, middle turbinate, plane and slightly superior to the tail of the middle
ethmoid bullae, and the septum. These are valuable land- turbinate.
marks for primary sinus surgery. However, these struc- ■ Both can be used as landmarks to identify the level of
tures are often modified or removed during surgery. the middle meatus [3, 7, 10].
Fortunately, some structures in the nasal cavity are fairly
constant (Fig. 7.1). The bulge or convexity on the ante-
7 rior lateral nasal wall created by the nasolacrimal duct is
Maxillary Sinus
a constant landmark pre- or postoperatively. As will be
mentioned later, this is a valuable landmark by which to The maxillary sinus is the first sinus to develop in the in-
locate the maxillary sinus ostium as well as the frontal fant. It is shaped like a pyramid, with the base being the
sinus recess. Often, the anterior/superior attachments posterior wall; the peak is associated with the facial sur-
of the uncinate and middle turbinate are left intact, and face of the maxilla. The posterior wall of the maxillary si-
provide additional landmarks for the frontal recess. More nus consists of thin bone that separates the pterygomaxil-
posteriorly, the nasopharynx and its surrounding struc- lary fossa medially and the infratemporal fossa laterally.
tures can be visualized. The choanal arch and the relation- The floor is the alveolar process of the maxilla and the
ship between the posterior nasal septum, eustachian tube, hard palate. The roof of the maxillary sinus corresponds
tail of the inferior turbinate, posterior extent of middle to the floor of the orbit. Along the roof, the maxillary
turbinate at the basal lamellae, and nasal floor can be ap- division of the trigeminal nerve (V2) can often be seen
preciated. Even in revision surgery, the tail of the inferior running in anterolateral direction toward the infraorbital
Fig. 7.1 a Sagittal view of lateral nasal wall starting anteriorly, ST superior turbinate, MT middle turbinate, IT inferior turbi-
the approximate location of the nasolacrimal duct is highlighted nate. b The structures around the posterior nasopharynx remain
in yellow. The white line along the anterior face of sphenoid sinus fairly constant in revision sinus surgery. The choanal arch is
lies 7 cm from the columella. It also demarcates the posterior denoted by the small white arrows. The sphenoethmoidal recess
wall of the maxillary sinus and the coronal plane just anterior can be seen behind a septal spur (white asterisk). ET Eustachian
to the level of the sphenopalatine foramen and anterior wall of tube, IT tail of the inferior turbinate, MT tail of the middle tur-
sphenoid sinus. A secondary ostium is denoted by the white as- binate, NS posterior nasal septum
terisk. C Cribriform, S sphenoid sinus, PF posterior fontanelle,
Surgical Anatomy in Revision Sinus Surgery 55
■ Therefore, anteroposterior resection of the uncinate

with a sickle knife or microdebrider may inadvertently
enter above the level of the natural ostium and result
in orbital penetration.
Also, in revision surgery, these structures are usually ab-

sent or scarred. As mentioned previously, the use of the
posterior fontanelle and the bony nasolacrimal duct can
help outline the maxillary sinus sinusotomy, while ensur-
ing incorporation of the natural ostium within the surgi-
cal sinusotomy. During surgery, the margin of the orbital
floor is followed anteriorly until the surgical antrostomy
is connected with the area of the natural ostium, just
posterior to the nasal lacrimal duct, and inferior to the
level of the orbital floor. Care should be taken not to dis-
sect too far inferiorly, in order to avoid transecting the
lateral attachment of the inferior turbinate and inadver-
Fig. 7.2 Endoscopic view of large maxillary antrostomy viewed tent entry into the inferior meatus (Fig. 7.3). With a wide
with a 30° telescope: the distance between the orbital floor and antrostomy, a bony “ridge,” as described by May et al. in
the lateral attachment of the inferior turbinate is greater over 1994, is formed [9]. This ridge demarcates the remnant
the posterior one-third of the inferior turbinate (black line) than of the posterior fontanelle, and is a critical landmark in
over the anterior one-third of the inferior turbinate (white line). determining the approximate location of the anterior and
The maxillary division of the trigeminal nerve (V2) runs along posterior ethmoid sinuses. The ethmoid sinuses are lo-
the roof of the maxillary sinus (white arrows). The horizontal cated medial to this ridge, whereas the maxillary sinus
bony ridge of the antrostomy (white diamonds) lies medially, and medial orbital floor (MOF) are located lateral to the
and the medial orbital floor and medial orbital wall lie laterally. ridge. The MOF is a key landmark that will help guide the
The asterisk indicates the location of the natural ostium. The surgeon through the rest of the anatomy.
posterior maxillary wall (PM) lies in the coronal plane with the
face of the sphenoid sinus and sphenopalatine artery, which lie ■ The posterior wall of the maxillary sinus demarcates
medial to the vertical ridge of the antrostomy (black arrows) the approximate level of the anterior sphenoid sinus
wall in the coronal plane, as one proceeds posteriorly
through the ethmoid labyrinth.
foramen (Fig. 7.2). The medial maxillary wall makes up

the lateral walls of the middle and inferior meati. The
posterior fontanelle is located between the posterior
one-third of the middle and inferior turbinate. Often, a
secondary maxillary ostium may be observed in this area
(Fig. 7.1a). The distance between the orbital floor, which
inclines anteroinferiorly, as one proceeds anterior along
the middle meatus, and lateral attachment of the inferior
turbinate, is much greater here. This anatomical relation-
ship can be utilized to enter the maxillary sinus when the
natural ostium is obscured by disease, scarring, or previ-
ous surgery. The surgeon merely finds the posterior fon-
tanelle area above the posterior one-third of the inferior
turbinate and enters blindly into the maxillary sinus with
minimal chance of inadvertent orbital penetration. The
natural ostium of the maxillary sinus may be found pos-
terolateral to the uncinate process, and inferolateral to the
ethmoid bulla. Fig. 7.3 Endoscopic view of maxillary sinus antrostomy. If dis-
section is carried to far inferiorly, the superior aspect of the in-
■ The superior margin of the maxillary ostium is also ferior turbinate (IT) may be cut, and the inferior meatus may be
the junction of the medial orbital floor and the infero- inadvertently entered. The ostium seeker is directed through the
medial orbital wall (infundibulum). defect in the superior aspect of the inferior turbinate
Fig. 7.4 a Borders of the anterior ethmoids, and safe entry into
the posterior ethmoids. A triangle of safe entry into the infe-
rior posterior ethmoids exists along the basal lamella (BL) of the
middle turbinate. A horizontal line is drawn parallel to the nasal
floor from the posterior bony ridge to the nasal septum (black
line), at the level of the posterior medial orbital floor. A second
line is drawn from the junction of the posterior ridge of the an-
trostomy, medial orbital floor, and posterior wall of maxillary
antrostomy to the tail of the middle turbinate (blue line). The
third line is along the medial aspect of the basal lamella (white
line) and medial orbital wall (O). The black arrow demarcates
the posterior lamella of the middle turbinate. b Completed eth-
moidectomy after removal of the “safe triangle.” O Medial orbital
7 wall/lamina papyracea, P posterior ethmoids, ST remnant of su-
perior turbinate. c The area within the blue triangle represents
the orbital “cone.” The orbital apex is located at the apex of the
cone, at the coronal plane of the posterior wall of maxillary si-
nus and approximately 7–8 cm from the columella. The anterior
ethmoid artery is denoted by the white arrow; the posterior eth-
moid artery is denoted by the white diamond; the frontal sinus
is denoted by the asterisk. The vertical lamellae of the middle
turbinate (MT) at its attachment to the skull base is lateral to
the olfactory cleft. The black line (base of orbital cone triangle)
reflects the trajectory into the frontal infundibulum from the
most anterior point of the maxillary antrostomy/natural ostium
to a point a few millimeters behind the anterior attachment of
middle turbinate, and parallel to the convexity of the nasolacri-
mal duct (white line). M Maxillary sinus, P posterior ethmoids,
S sphenoid sinus
■ Surgeons should exercise extreme care when dissect-

Ethmoid Labyrinth
ing or probing medially along the ethmoid roof, in
The anterior ethmoids are comprised of multiple cells of order to minimize the risk of inadvertent intracranial
variable dimensions and thin bone. Because of the vari- penetration (Fig. 7.5).
able and complex relationships of these cells within the
ethmoid bullae, the anterior ethmoid sinuses are also As mentioned earlier, the three important lamellae when
called the ethmoid labyrinth [2]. The most anterior cells discussing surgery and ethmoid anatomy are the uncinate
are called the agger nasi cells. These will be discussed fur- process, ethmoid bulla, and basal or ground lamellae.
ther in the frontal sinus section, because they lie along the These are valuable landmarks in sinus surgery. However,
anterior border of the frontal recess. The anterior ethmoid these landmarks are commonly removed or altered dur-
cavity is bordered medially by the vertical lamellae of ing primary sinus surgery. As a result, they are not neces-
middle turbinate inserting into the skull base and lateral sarily dependable for revision sinus surgery anatomy.
cribriform plate, laterally by the lamina papyracea or me- Dependable anatomical structures in the ethmoid re-
dial orbital wall, and posteriorly by the horizontal attach- gion during revision sinus surgery are:
ment of the middle turbinate to the lateral nasal wall and 1. MOF.
orbit. The latter structure is also referred to as the basal 2. Bony ridge of the maxillary antrostomy.
or ground lamellae of the middle turbinate (Fig. 7.4). The 3. Superior attachment of the middle turbinate.
basal lamella divides the anterior and posterior ethmoid
cells. Superiorly, the ethmoids are bound by the fovea eth- The MOF helps demarcate several important regions [5].
moidalis or roof of the ethmoid sinus. The anterior and First, it helps identify the lateral extent of the surgeon’s
posterior ethmoid arteries run from a lateral-to-medial dissection. Second, it exposes the level of the skull base at
direction along the ethmoid roof. The ethmoid roof is the posterior ethmoids, which should lie superior to the
bony and runs in an inferomedial direction towards the MOF, as described previously in Figs. 7.4 and 7.6. Finally,
cribriform plate. In 1965, Keros described three classifi- it provides a level for safe entry into the sphenoid sinus
cations for the depth of the cribriform in relation to the or posterior ethmoid sinuses, giving the surgeon greater
roof of the ethmoids. As can be seen, the bone is typically space to navigate posteriorly into the nose and parana-
thicker on the lateral side, adjacent to the orbital wall. sal sinuses, and define the superior and lateral limits of
Fig. 7.5 Coronal view of the olfactory clefts and fossae. The Fig. 7.6 Locations of sphenoid sinus (S) and posterior ethmoids
double-headed arrow indicates the length of the lateral lamella of (P) in relation to the medial orbital floor (MOF). Most of the
the cribriform plate, defining the type of olfactory fossa accord- posterior ethmoid air cells are located superior to the MOF
ing to Keros. Type 1 corresponds to an olfactory fossa 1–3 mm while most of the sphenoid sinus is mostly inferior to it (white
deep in relation to the roof of the ethmoids. Type 2 is 4–7 mm line) and adjacent to the nasal septum. This line also transects
deep. Type 3 is a depth of 8 mm and above the approximate level of natural ostium of the sphenoid sinus
superomedial to the tail of the superior turbinate (white arrow)
dissection. The bony ridge of the maxillary antrostomy, through a 0° or 30° telescope, the natural ostium of the
along with the MOF, gives the surgeon the proper trajec- sphenoid, and therefore safest area to enter, is always at
tory when working in an anterior-to-posterior direction the level the posterior MOF, adjacent to the nasal septum.
while dissecting the ethmoid cavity. Finally, the vertical The posterior wall of the sphenoid sinus is the skull base
attachment of the middle turbinate to the skull base is a and usually measures approximately 9 cm from the colu-
good landmark to demarcate the medial aspect of the dis- mella. The intersinus septum can be variable in position.
section of the superior ethmoid cells. The olfactory cleft Often, the septum curves laterally and attaches at the face
will be found medial to this attachment. of the bone covering the carotid artery. Care should be
Two special ethmoid cells deserve mention because taken not to inadvertently avulse this bony insertion onto
they can distort the anatomy and confuse an unsuspect- the anteromedial face of the carotid artery, with resultant
ing surgeon. First, the Onodi cells (sphenoethmoid cells) life-threatening hemorrhage.
are sphenoethmoid recess cells, and can vary in their
7 pneumatization. These cells can extend superior and lat- ■ By opening the sphenoid and identifying the level of
eral to the sphenoid sinus. As a result, they can expose the skull base and lateral wall, at this level, the sur-
the optic nerve, which can run through the cell. If not geon can confidently continue their dissection in an
identified on preoperative CT scans, an optic nerve in- anterior direction to open up the superior and lateral
jury may result with dissection in this area. Second, the aspects of the posterior and anterior ethmoid sinuses.
supraorbital ethmoid cells are superior ethmoid cells that
can arise posterior to the frontal recess and extend over The lateral wall of the sphenoid sinus has several criti-
the orbit (supraorbital extension). They can interfere with cal structures that should be recognized. Based on the
frontal sinus drainage posteriorly in a similar way that the degree of pneumatization, some structures may be more
agger nasi cells can act anteriorly. Often, these cells are pronounced than others (Fig. 7.8). Four prominences
confused with the frontal sinus [11]. Transillumination along the wall that should be identified from superior to
of these cells typically causes illumination of the medial inferior are the optic nerve, internal carotid artery, sec-
canthal area, and not the frontal bone. ond branch of the trigeminal nerve as it travels toward
the foramen rotundum, and the vidian nerve [8]. In si-
nuses with a significant degree of lateral pneumatization,
V2 and the vidian nerve can mark the superior and in-
Sphenoid Sinus
ferior boundaries, respectively, into the lateral recess of
The sphenoid sinus is located in the midline, along the the sphenoid. This may become significant for patients
skull base, at the junction of the anterior and middle cra- with cerebrospinal fluid leaks through Sternberg’s canal,
nial fossae. The sinus can be variable in size and shape lateral to the V2 canal [6].
from one side to the next. Preoperative CT scans are im- The hypophysis, olfactory tracts, and posterior fron-
portant to review these anatomical variants. Fortunately, tal gyri are found posterosuperior to the sphenoid roof.
the anatomy involved in describing the sinus is fairly con- The anterior wall of the sphenoid is bounded by the su-
stant with regard to both primary and revision surgery. perior nasopharyngeal structures (rostrum of the nasal
However, the neurovascular structures that are intimately septum and mucosa), and branches of the sphenopala-
involved with the sinus are very important. They course tine artery coursing toward the nasal septum. The vidian
through the bony walls of this sinus and can be fairly com- nerve courses superficially, along a variable bony canal in
plex and variable. Most of these critical structures are in the lateral floor of the sphenoid and can be dehiscent at
the lateral and superior part of the sinus. Therefore, safe times. It exits through the vidian foramen. Parasympa-
access to the sphenoid sinus involves entry into this cavity thetic fibers to the nose and lacrimal gland from the vid-
as far medial as possible. This also assures that the sphe- ian nerve synapse at the otic ganglion medially within the
noid ostium is incorporated in the surgical sinusotomy. pterygomaxillary fossa. The brainstem and basilar artery
There are several landmarks that can be used to iden- lie posterior to the sphenoid sinus
tify a safe entry point into the sinus. The anterior wall of
the sphenoid is approximately 7 cm from the columella
at a 30° angle from the nasal floor (Fig. 7.7). As described
Frontal Sinus
extensively in the literature, the natural ostium lies supe-
rior and medial to the tail of the superior turbinate [4]. Similar to the sphenoid sinus, the frontal sinus can be
If the tail of the superior turbinate has been removed variable in its degree of development. The frontal sinus
or distorted from prior surgery, the combination of us- drains via the frontal recess, which is very narrow and
ing the MOF and the septum can be used to identify the hourglass shaped. In primary surgery, useful landmarks
location of the sphenoid ostium (Fig. 7.6). When viewed to find the frontal sinus recess include the anterior eth-
Fig. 7.7 a The location of the natural ostium of the sphenoid turbinate removed, showing the location of the sphenoid ostium.
(asterisk) is located between the nasal septum (NS) and the tail Wire is placed in the ostium. The superior turbinate (ST) and tail
of the superior turbinate (ST). b Sagittal view with the middle (arrow) show the relationship between the ostium and the ST
Fig. 7.8 a Endoscopic view from a cadaveric dissection showing tographs courtesy of Islam Herzallah, MD. b Lateral wall of the
the detailed anatomy of the lateral wall of the sphenoid sinus. sphenoid after removal of the bony wall and medial dural sheath
Three convexities make up the lateral wall of the sphenoid si- of the cavernous sinus. C Carotid artery, CN III cranial nerve III,
nus. The optic carotid recess is denoted by the white asterisk. C CN VI cranial nerve 6, O optic nerve, VI ophthalmic division
Cavernous portion of the carotid artery, O optic nerve, VN vid- of trigeminal nerve, V2 maxillary division of trigeminal nerve.
ian nerve, V2 maxillary division of the trigeminal nerve. Pho- Photos courtesy of Islam Herzallah, MD [8]
Fig. 7.9 Sagittal view showing the relationship

between the sinuses. From anterior to posterior,
the nasolacrimal duct (white oval) is parallel to the
direction toward the frontal sinus from the natural
ostium of the maxillary sinus (white arrow), just
behind the anterior attachment of the middle turbi-
nate. More posteriorly are seen the ethmoid bullae
(B), posterior ethmoids (PE), and the sphenoid (S)
moid cells, anterior superior attachments of the middle cells, as described later. As mentioned earlier, the amount
turbinate, and the uncinate process. However, in revision of pneumatization of the agger nasi can affect the outflow
surgery, these structures are usually altered or removed. of the frontal sinus [12]. Posteriorly, supraorbital cells can
As a result, other landmarks have been sought after to obscure the recess. In previous surgery, the suprabullar
safely enter the frontal sinus. cells may be damaged and the frontal recess can become
The key to revision frontal surgery is to have some scarred with bone and debris. The recognition and re-
landmark directing the surgeon in the general direction moval of these cells is critical for confident entry into the
and appropriate superior trajectory of the frontal infun- frontal sinus and resolution of the patient’s symptoms.
dibulum, and not toward the anterior skull base, which is In the frontal sinus itself, there can be variable struc-
located slightly posterior to this area. These are: tures. The intersinus septum can be midline or laterally
1. Natural ostium or most anterior portion of maxillary
antrostomy.
2. Remnant of the anterior attachment and vertical la-
mella of the middle turbinate.
3. Convexity of the nasolacrimal duct [5].
Starting at the anterior maxillary antrostomy (or prefer-

ably the natural ostium of the maxillary sinus), and fol-
lowing a line parallel to the nasolacrimal duct, the frontal
recess can be confidently accessed using a small probe,
a few millimeters behind the anterior attachment of the
middle turbinate (Figs. 7.4c and 7.9). In well-pneuma-
tized frontal sinuses, a supraturbinal (laterally) or transep-
tal (medial) penetration, anterior to the coronal plane of
the frontal infundibulum and anterior attachment of the
middle turbinate, may be possible. Posterior landmarks
also exist. By following the roof of the ethmoids anteri-
orly, the surgeon can identify the anterior ethmoid artery
as it runs along the posterior aspect of the frontal recess
and infundibulum. Once the anterior ethmoid artery is
seen, the surgeon identifies the area of the frontal infun- Fig. 7.10 Type I is a single air cell above the agger nasi. Type
dibulum by also following the medial orbital wall superi- II is a group of small air cells above the agger nasi, but below
orly, as it defines the lateral extent of this opening into the the orbital roof. Type III is a single air cell extending from
frontal sinus. Medially, the border of the frontal infun- the agger nasi into the frontal sinus. Finally, type IV is an iso-
dibulum is the vertical lamella of the middle turbinate. lated air cell within the frontal sinus not contiguous with
Anteriorly lie the agger nasi cell and variable frontal sinus the agger nasi. A Agger nasi cell, IS inner sinus septum
displaced in either direction. It can also be pneumatized 3. Bolger WE (2001) Anatomy of the paranasal sinuses. In:
and become an isolated air cell. Bent and Kuhn classified Kennedy DW, Bolger WE, Zinreich J (eds) Diseases of the
frontal cells into four types [1]. During revision surgery, Sinuses, Diagnosis and Management. Decker, Hamilton,
some or all of these intersinus cells can be present. Type I Ontario, pp 1–12
is a single air cell above the agger nasi. Type II is a group 4. Bolger WE, Keyes A (2001) Use of superior meatus/tur-
of small air cells above the agger nasi, but below the or- binate in the endoscopic approach to the sphenoid sinus.
bital roof. Type III is a single air cell extending from the Otolaryngol Head Neck Surg 120:308–313
agger nasi into the frontal sinus. Finally, type IV is an iso- 5. Casiano RR (2001) A stepwise surgical technique using the
lated air cell within the frontal sinus not contiguous with medial orbital floor as the key landmark in performing en-
the agger nasi (Fig. 7.10). doscopic sinus surgery. Laryngoscope 111: 964–974
6. Castelnuovo P, Dallan I, Pistochini A, et al. (2007) Endo-
nasal endoscopic repair of Sternberg’s canal cerebrospinal
fluid leaks. Laryngoscope 117:345–349
Conclusion
7. Graney DO, Rice DH (1998) Paranasal sinus anatomy. In:
With a sound understanding of the intricate sinus anat- Cummings CW, Fredrickson JM, Harker LA, et al. (eds)
omy, a surgeon can confidently perform revision sinus Otolaryngology – Head and Neck Surgery, 3rd edn. Mosby,
surgery. The navigational systems are not a substitute for St. Louis, pp 1059–1064
anatomical knowledge. They can provide a false sense of 8. Herzallah IR, Casiano RR (2007) Endoscopic endonasal
security and may lead the surgery beyond the limits at study of the internal carotid artery course and variations.
which the surgeon feels comfortable. However, the land- Am J Rhinol 21:262–270
marks discussed in this chapter are reliable, and recogniz- 9. May M, Schaitkin B, Kay SL(1994) Revision endoscopic si-
able by any surgeon, and should supersede any naviga- nus surgery: six friendly surgical landmarks. Laryngoscope
tional system. 104:766–767
10. Polavaram R, Devaiah AK, Sakai O, et al. (2004) Anatomic
variants and pearls – functional endoscopic sinus surgery.
Otolaryngol Clin North Am 37: 221–242
References
11. Stammberger HR, Kennedy DW (1995) Paranasal sinuses:
1. Bent J, Kuhn FA, Cuilty C (1994) The frontal cell in frontal anatomic terminology and nomenclature. The Anatomic
recess obstruction. Am J Rhinol 8:185–191 Terminology Group. Ann Otol Rhinol Laryngol Suppl
2. Bodino C, Jankowski R, Gringnon B, et al. (2004) Surgi- 167:7–16
cal anatomy of the turbinal wall of the ethmoidal labyrinth. 12. Wormald PJ (2003) The agger nasi cell: the key to under-
Rhinology 42:73–80 standing the anatomy of the frontal recess. Otolaryngol
Head Neck Surg 129:497–507
Chapter 8
Surgical Instruments in Revision

Vijay R. Ramakrishnan and Todd T. Kingdom
Contents
Core Messages
Introduction and Background . . . . . . . . . . . . . . . . . . . . . 63
■ Continued development and refinement of available Videoscopy and Visualization . . . . . . . . . . . . . . . . . . . . . 64
surgical instrumentation for endoscopic sinus sur- Mucosal-Sparing Instrumentation . . . . . . . . . . . . . . . . . 64
gery (ESS) remains important.
Powered Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . 66
■ The patient undergoing revision ESS may present a
Modifications of Traditional Instruments . . . . . . . . . . . 67
unique set of anatomic and surgical challenges re-
quiring unique instrument solutions. Image-Guided Instrumentation . . . . . . . . . . . . . . . . . . . . 68
■ New developments and refinements have improved Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
visualization (videoscopic equipment), our abil-
ity to precisely handle soft tissue (microdebriders,
through-cutting instruments), our ability to remove
bone efficiently (high-speed burs), and our access and the development of functional surgical techniques.
(angled and malleable instrumentation) during The stated goals of the Messerklinger technique were to
ESS. remove the obstructing anatomic variations causing dis-
■ The revision ESS surgeon must be experienced with ease and to resect only the most severely diseased mucosa
these current and evolving instruments in order to in key locations [7]. To achieve these goals, the surgeon
optimize outcome and safety. must be able to accurately visualize and diagnose endo-
nasal disease, limit the scope of dissection as indicated,
and precisely manipulate variable anatomy. This required
a basic change in instrument design concepts that have
only recently been widely available. Refinements in the
videoscopic chain have enhanced visualization of the
Introduction and Background
surgical field, the development of fine through-cutting
On a basic level, surgical instrumentation and surgical instruments has provided the opportunity for mucosal
concepts are similar for both primary endoscopic sinus sparing procedures, and the introduction of powered in-
surgery (ESS) and revision ESS. However, unique situ- strumentation has expanded the rhinologist’s armamen-
ations and challenges will present during revision ESS, tarium greatly. These developments have been critical to
requiring the surgeon to be familiar with a wide range the evolution of both primary and revision ESS.
of surgical techniques and instrumentation. The surgeon Mucosal preservation has been emphasized as an im-
must be knowledgeable, comfortable, and facile with the portant objective for both successful primary and revi-
available surgical equipment options. The goal of this sion sinus surgery. Much of the technology presented in
chapter is to review current surgical instruments of value this chapter focuses on this important concept – preci-
for use in revision ESS. sion dissection and mucosal preservation. Clinical expe-
Historically, surgical concepts behind the management rience suggests that surgical efficiency, mucosal recovery,
of sinus disease have centered around “radical” therapy and patient outcomes are improved with mucosal preser-
for “irreversible” mucosal disease. Messerklinger’s work, vation. Meticulous removal of soft tissue and attempted
which began in the 1950s, introduced new concepts of mucosal preservation ought to be goals of the sinus sur-
reversible mucosal disease, mucosal sparing approaches, geon in both primary and revision cases.
64 Vijay R. Ramakrishnan and Todd T. Kingdom
■ Mucosal preservation is an important objective for ■ The operating surgeon must be aware of increasing
both primary and revision ESS. distortion and disorientation and decreasing illumi-
■ New instrument design focuses on the surgeon’s need nation with increasing telescopic angle of the endo-
for precision in a variety of clinical situations. scope.
Improvements in camera technology have addressed

concerns of illumination, color rendition, and weight.
Videoscopy and Visualization
Color rendition and depth perception on the videoscopic
With the use of assorted endoscopes, the surgeon is ca- projection are less accurate than that of the direct endo-
pable of direct visualization of most sites within the surgi- scopic view, yet current technology has mitigated these
cal field. The zero-degree endoscope is preferred because concerns. In addition, operating from the projection
of its optimal lighting and minimal optical distortion and screen facilitates the four-handed technique, which may
disorientation; however, it may be inadequate in meet- be of benefit in difficult revision cases and endoscopic
ing the needs of many revision procedures. Angled en- skull-base procedures [4]. High-definition (HD) video
doscopes, including 30, 45, and 70°, have been designed technology is the latest evolution in endoscopic visual-
8 to facilitate visualization around “corners” and to extend ization. HD-compatible video camera systems provide
the surgeon’s “reach” (Fig. 8.1). Current technology has 1920 × 1080 pixels of resolution in a native 16:9 aspect ra-
improved the width of view and degree of illumination tio. Potential advantages include higher input resolution
for angled telescopes, but the operating surgeon must delivering more detail and depth of focus, larger view-
still consider the increasing distortion and disorientation ing format with the 16:9 aspect ratio supported by wide-
associated with increasing telescopic angle [3]. Revision screen monitors, and enhanced color brilliance. Though
ESS often requires extended visualization and access, thus in its infancy, HD videoscopic technology should prove
surgeon comfort with angled endoscopes is essential. valuable in the differentiation between soft-tissue types
Several attempts at creation of a three-dimensional endo- and further augment extended rhinologic surgical
scope have provided a superior stationary image, but can approaches.
be disorienting when rotated laterally, and have not been
widely utilized [4].
Mucosal-Sparing Instrumentation
Although mucosal preservation has been a tenet of pri-
mary and revision ESS since Messerklinger’s early work,
appropriate instrumentation had not been widely avail-
able for many years. Until recently, ESS surgical instru-
ments were too large and promoted more of a “rip and
tear” technique when removing mucosal disease. Mu-
cosal loss and bone exposure has been associated with
increased scarring and mucosal sequestration, decreased
ciliary function, chronic inflammation, neo-osteogenesis,
and a propensity toward persistent pain [5,8]. Although
intuitive, the true value of mucosal sparing techniques
has not been objectively established. A prospective, ran-
domized, controlled study in 24 patients with chronic
rhinosinusitis comparing the use of microdebriders to
conventional instrumentation found no statistical dif-
ference in symptoms, saccharin transport times, or en-
doscopic findings of synechiae and ostial reocclusion at
3-, 6-, and 13-month follow up [9]. Vauterin et al. per-
formed a prospective, randomized, double-blinded ex-
periment comparing the use of through-cutting forceps
to noncutting forceps. At 3-week and 12-month follow
up, there was no statistical difference in patient symp-
Fig. 8.1 Rigid nasal endoscopes with angles ranging from 0 to toms or endoscopic findings of parameters including
70° (drawing by Scott Baird, adapted from Karl Storz Endoscopy adhesions, polyps, edema, crusting, and secretions [11].
America, Culver City, California) Certainly, further studies are needed to define the effects
Surgical Instruments in Revision Endoscopic Sinus Surgery 65
of mucosal preservation on microscopic and clinical out- ■ Instrument shaft and handle lengths vary depend-
come. As of today, however, mucosal preservation and ing on the intended objective: 13–15 cm for standard
meticulous soft-tissue removal ought to be fundamental ESS, extending to 18 cm for endoscopic skull-base ap-
goals of the sinus surgeon. Consequently, instrument de- proaches.
sign and technique development focuses on the concept
of mucosal preservation and minimally-invasive surgical The current selection of mucosal sparing instrumentation
principles. allows the surgeon to match the instrument to the tissue
A wide array of instruments for ESS is now available type to be removed and the access needed to accomplish
from several manufacturers. Fine, through-cutting in- the task. Quite literally, there are numerous instruments
struments with straight and up-biting jaws have been de- to choose from to fit the surgeon’s goals and objectives.
signed for both mucosal dissection and removal of thin Several chapters within this textbook will be devoted to
bone. The cutting width of these tools ranges from sub- revision maxillary, ethmoid, sphenoid, and frontal sinus
millimeter to 4 mm in size. These instruments also come surgery. To avoid redundancy only brief comments on
in a variety of angles, with the operating portion angled frontal sinus instrumentation will be included in this
up, down, or curved to the side (Fig. 8.2). The design of section. The evolution of mucosal sparing frontal sinus
the cutting end of these instruments can include a mi- instruments represents one of the most significant ad-
croscissor blade and linear or circular cutting punches vances in revision ESS. The frontal sinus surgeon can
(Fig. 8.3). In addition, there are differences in the strength now select from a variety of fine, angled instruments
of these cutting instruments. to manipulate the frontal recess and to access the fron-
tal sinus. Circular punches and through-cutting forceps
Fig. 8.2 Through-cutting, mucosal sparing forceps: a straight, b upturned 45° (Karl Storz Endoscopy America, Culver City, Cali-
fornia, USA)
Fig. 8.3 a Microscissors, curved. b Curved through-cutting

forceps. c Circular cutting punches (Karl Storz Endoscopy
America)
with shaft angles ranging from 45 to 110° facilitate pre- synechiae formation, and ostial occlusion, in patients who
cise mucosa-sparing dissection (Fig. 8.4). More robust underwent ESS with a microdebrider when compared to
punches with 70 and 90° angled shafts are available for standard techniques [6]. Bernstein’s findings echoed these
precise yet aggressive bone removal in the frontal recess conclusions in a retrospective, uncontrolled analysis with
region (Fig. 8.5). In addition, a variety of angled curettes, a mean follow-up of 16 months [1].
picks, and probes are available to augment this type of The basic components of a microdebrider system are
dissection. the power source, irrigation system, suction source, hand-
piece, and interchangeable disposable blades. The irriga-
■ Wide selections of mucosal sparing ESS instruments tion flow rate is adjustable to suit the surgeon’s preference,
are available to the surgeon, including options in shaft and the linear suction path has been tailored to reduce
length, angle, size, and cutting action. the amount of clogging. Blade speed may be adjusted to
maximize tissue cutting without system plugging. Micro-
debrider blades contain a fenestrated, blunt outer sheath
to minimize tissue trauma, and a mobile inner blade with
Powered Instrumentation
the cutting surface. This design eliminates avulsion of ad-
8 Powered instrumentation has aided tremendously in jacent tissue to be preserved, which may occur with tradi-
the challenges of revision sinus surgery, especially in the tional instrumentation. Angled microdebrider blades up
treatment of recurrent polyposis, synechiae, and osteitic to 120 ° are now available and have facilitated surgery in
bone. Microdebriders have been used intranasally for over areas of difficult access, such as the far reaches of the fron-
10 years [10]. Their use allows for rapid sharp dissection, tal and maxillary sinuses (Fig. 8.6). In addition, short-ra-
reduced bleeding, constant suction and irrigation, and dius curved blades and rotating blade heads have made
immediate tissue removal from the field. This provides ex- surgery in these areas easier. Video 8.1 demonstrates the
cellent continuous visualization, allowing the surgeon to use of the microdebrider for the removal of nasal polyps.
operate without removing the instrument from the nose. Microdebrider technology has been extended to in-
clude the development of high-speed burs and drills uti-
■ When used properly, microdebrider technology has lizing the same platform. Handheld suction-irrigation
reduced mucosal stripping, which has been shown to drills allow the surgeon to drill, irrigate, and utilize suc-
accelerate wound healing and decrease synechiae for- tion while under direct visualization of the target. Revi-
mation. sion cases often include situations that require aggressive
removal of osteitic bone or removal of bone for extended
In a retrospective, nonblinded analysis, Krouse reported access. Angled burs allow for access to the frontal sinus
more rapid mucosal healing, with reduction in crusting, with focused removal of bone from the frontal process
Fig. 8.4 Mucosal sparing and cutting frontal sinus instruments Fig. 8.5 70° cutting frontal sinus punches (Karl Storz Endos-
65° circular cutting punch (Karl Storz Endoscopy America) copy America)
tion, and orbital injury are possible and potentially disas-

trous with the use of powered instrumentation. Video 8.2
demonstrates the use of a high-speed diamond bur for
bone removal during an optic nerve decompression.
■ A variety of blades for soft-tissue removal and burs for

bone removal are available based on the same power
platform.
■ The surgeon must be aware of the potential hazards
associated with the use of powered instrumentation in
sinus surgery.
Modifications of Traditional Instruments

Traditional instruments have also been modified to in-
crease their utility and efficacy. Visualization is funda-
mental to all intranasal procedures, and thus it seems
Fig. 8.6 Microdebrider blades with rotating cutting openings intuitive to modify traditional instruments with the ad-
and shaft angles of 40, 60, 90, and 120° (Medtronic, Jacksonville, dition of suction.
Florida, USA)
■ Suction instrumentation facilitates surgical precision
and efficiency.
of the maxilla while keeping the amount of postoperative
bone exposure to a minimum (Fig. 8.7). Chandra et al. re- Suction elevators are particularly useful for endoscopi-
ported on their experience using a 70 ° diamond bur for cally limited or revision septoplasty. A selection of suc-
Draf IIb and Draf III procedures [2]. They emphasized tion curettes, elevators, punches, probes, hooks, and
the precise and efficient bone removal afforded with this picks exist, and are extremely useful for difficult frontal
device. The continuous irrigation helps to maintain bone
viability by minimizing thermal damage, while the drill
design resists skipping in such a tight area. Recent devel-
opments have focused on the design of high-speed burs
for extended skull-base approaches in the region of the
sella, sphenoid sinus, and clivus. Devices with a variety of
shaft lengths and angles, and bur sizes and types are cur-
rently under development (Fig. 8.8).
The application of powered instrumentation for soft-
tissue and bone removal in revision ESS has proven to be
an invaluable advancement. However, one must remem-
ber that extensive removal of mucosa, skull-base penetra-
Fig. 8.8 High-speed skull-base burs with shaft angles ranging

from 15 to 90° degrees. Diamond and cutting burs are available
Fig. 8.7 70° degree high-speed diamond bur (Medtronic) with fluted or round designs (Medtronic)
recess dissections, tumor removal, and extended revision

Image-Guided Instrumentation
procedures. Malleable suction probes, elevators, and cu-
rettes have been created to aid surgical access; these in- The use of image guidance technology is discussed in
struments have a working length of 11 cm, with the last great detail in Chap. 30. The currently available image-
4 cm being of a malleable nature. Malleable instruments guided surgery (IGS) systems can track a wide variety of
each have a predetermined strength appropriate for their instruments. Commonly used tracked instruments in-
individual uses, but have a finite lifespan due to intrinsic clude straight and angled suctions, forceps, and probes.
metallic properties. Powered instrumentation – microdebriders and drills
The ability to control hemorrhage becomes more rele- – may also be tracked, although higher levels of caution
vant in revision ESS cases and extended rhinologic proce- must be exercised with these instruments. Suffice it to say,
dures. Endoscopic cautery devices have been developed IGS has assumed an important role in revision ESS and
to assist with this challenge. Bipolar cautery, combined extended rhinologic procedures.
with small size, suction, and angled tips are ideal design
goals. Several options are available that satisfy many of
these objectives and have proven useful during endo-
8 scopic procedures (Fig. 8.9). In addition, endoscopic vas-
Summary
cular clip appliers have been developed by several manu- The challenges presented by revision endoscopic sinus
facturers to aid in the control of intranasal hemorrhage surgery – difficult anatomy, synechiae formation, bone
(Fig. 8.10). Although still of limited value due to design removal, and precision soft-tissue removal – may be as-
limitations, these instruments can be quite useful in se- suaged by the use of refined instrumentation. Mucosal
lect situations. Video 8.3 demonstrates the use of bipolar preservation is stressed, and is also enhanced with the
cautery, the vascular clip applier, and microscissors dur- surgeon’s knowledge of currently available technology
ing endoscopic tumor removal. and instrumentation. Visualization may be improved
Fig. 8.9 a Stammberger endoscopic bipolar device

(Karl Storz Endoscopy America). b Wormald endo-
scopic bipolar device (Medtronic)
Fig. 8.10 Endoscopic clip applier (Karl Storz En-

doscopy America; recommended clips: ligating clip
cartridge, medium titanium clips. Ligaclip Extra
by Ethicon, Cincinnati, OH, USA)
with use of angled telescopes, improved cameras and 4. Kennedy DW (2007) Technical innovations and the evolu-
monitors, and the introduction of HD technology. Speed, tion of endoscopic sinus surgery. Ann Otol Rhinol Laryn-
hemostasis, and precision are hallmarks of powered in- gol Suppl 196:3–12
strumentation. Through-cutting instruments and refine- 5. Kennedy DW (2000) Functional endoscopic sinus surgery:
ments of existing instruments also help to address the concepts, surgical indications, and instrumentation. In:
unique challenges presented in difficult revision cases. Kennedy DW, Zinreich SJ, Bolger W (eds) Diseases of the
The sinus surgeon who embarks upon complicated revi- Sinuses: Diagnosis and Endoscopic Management. Decker,
sion cases must have a complete knowledge of the avail- Hamilton, Canada, pp 197–210
able instruments, and feel comfortable with their use in 6. Krouse JH, Christmas DA Jr (1996) Powered instrumenta-
the appropriate circumstance. tion in functional endoscopic sinus surgery. II: A compara-
tive study. Ear Nose Throat J 75:42–44
7. Messerklinger W (1978) Endoscopy of the Nose. Baltimore:
Urban Schwarzenberg
References
8. Moriyama H, Yanagi K, Ohtori N, et al. (1996) Healing
1. Bernstein JM, Lebowitz RA, Jacobs JB (1998) Initial report process of sinus mucosa after endoscopic sinus surgery.
on postoperative healing after endoscopic sinus surgery Am J Rhinol 10:61–66
with the microdebrider. Otolaryngol Head Neck Surg. 9. Selivanova O, Kuehnemund M, Mann WJ, et al. (2003)
118:800–803 Comparison of conventional instruments and mechanical
2. Chandra RK, Schlosser R, Kennedy DW (2004) Use of the debriders for surgery of patients with chronic rhinosinus-
70-degree diamond burr in the management of compli- itis. Am J Rhinol 17:197–202
cated frontal sinus disease. Laryngoscope 114:188–192 10. Setliff RC III, Parsons DS (1994) The “hummer”: new in-
3. Kang SK, White PS, Lee MS, et al. (2002) A randomized strumentation for functional endoscopic sinus surgery. Am
control trial of surgical task performance in frontal recess J Rhinol 8:275–278
surgery: zero degree versus angled telescopes. Am J Rhinol 11. Vauterin T, Vander Poorten V, Jorissen M (2006) Long
16:33–36 term effects of cutting forceps in endoscopic sinus surgery.
Rhinology 44:123–127
Chapter 9
Anesthetic Choices,
Techniques, and Injections 9
W. Derek Leight and Brent Senior
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
■ General anesthesia using total intravenous anesthe- Anesthetic Choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
sia (TIVA) with propofol and remifentanyl may im- Pharmacology of General Anesthesia . . . . . . . . . . . . . . . 72
prove endoscopic vision in the surgical field.
Volatile Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
■ TIVA may provide patients with a better postopera-
Intravenous Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . 72
tive recovery period due to the antiemetic effects of
propofol and the decreased hangover effect due to Propofol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
the fast metabolism of these two drugs. Opioid Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
■ If TIVA is unavailable, the use of inhaled anesthet-
Balanced Anesthesia Versus TIVA . . . . . . . . . . . . . . . . . . 73
ics should be minimized to avoid vasodilation with
reflex tachycardia, which may worsen the surgical Anesthesia for Sinus Surgery . . . . . . . . . . . . . . . . . . . . 73
field. Pharmacology of Local Anesthetics . . . . . . . . . . . . . . . . 73
■ Perioperative beta-blockers may also be useful in Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
improving the quality of vision in the surgical field.
Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
The use of these drugs should be discussed preop-
eratively with an anesthesiologist. General Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
■ Both inhaled anesthetics and propofol infusions Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
degrade platelet function, which may contribute to Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
an overall worsening of the quality of vision in the
surgical field over time.
■ Local injections are safe and reliable methods to en-
hance visualization in the surgical field.
Anesthetic Choices
Local anesthesia with sedation has been a widely em-
ployed method for endoscopic sinus surgery. Several
authors have reported this as the anesthetic method of
choice, reporting fewer side effects, shorter operative
Introduction
times, and less perioperative bleeding.[5, 8] In addition,
Since its inception in the 1980s, functional endoscopic it is thought of as being theoretically safer, due to the fact
sinus surgery (FESS) has become an important tool in that dissection in high-risk areas such as the anterior and
the treatment of sinonasal disease. Technological ad- posterior ethmoid bundles and lamina papyracea is more
vances have improved surgical techniques, which in turn likely to induce pain and therefore allow the patient to
have led to a widening of the scope of surgically treat- alert the surgeon before an injury occurs [13]. Local an-
able diseases. In comparison to traditional otolaryngo- esthesia with sedation is more technically challenging for
logic surgery, methods of anesthetic administration for the anesthesiologist, as a balance must be achieved be-
FESS are more influential in determining the quality of tween patient comfort, respiratory drive, airway protec-
the surgical field. tion, surgical access, and positioning [13]. It is also depen-
72 W. Derek Leight and Brent Senior
dent upon the patient’s level of cooperation, which may

Intravenous Anesthesia
tend to decrease over time. FESS under local anesthesia
can produce patient anxiety, particularly during cases Intravenous (IV) anesthesia using sedative/hypnotics
with heavy mucosal bleeding. Rising patient anxiety also such as barbiturates and benzodiazepines are important
tends to impact the surgeon and potentially the quality in the induction phase of general anesthesia. These drugs
of the operation. Some groups use local anesthesia on a produce rapid-onset hypnosis and sedation. Since the in-
regular basis for straightforward cases; however, these are troduction of propofol in the late 1980s, IV anesthetics
carefully selected beforehand [4]. In addition, the routine have also become popular in the maintenance phase of
use of image-guidance systems makes the local anesthetic anesthesia.
technique less feasible due to positioning factors and the
necessity of patient immobility. The author’s group be-
lieves that these limitations outweigh the theoretical ana-
Propofol
tomic advantage of local anesthesia.
General anesthesia consists of the following three Propofol, whose chemical name is isopropylphenol, rep-
phases: induction, maintenance, and emergence. The goal resents a new class of IV anesthetics, the akylphenols. It
of general anesthesia is to safely produce, while maintain- is the most widely used IV induction agent in anesthetic
ing physiologic stability: practice. It is lipophilic, and almost completely insoluble
9 1. Hypnosis. in aqueous solution. It is therefore produced in a milky
2. Analgesia. emulsion with lecithin, glycerol, and soybean oil. This
3. Amnesia. formulation is a potential medium for bacterial growth,
4. Anesthesia. and must therefore be used with meticulous sterile tech-
5. Areflexia. nique and should be used within 6 h of opening the vial.
6. Anxiolysis. Because lecithin comes from egg yolk, patients with egg
allergies may be susceptible to allergic reactions. Because
General anesthesia for FESS is usually either a variant of of its high lipophilic nature, propofol is rapidly parti-
balanced anesthesia, using a combination of sedative/hyp- tioned across the blood-brain barrier upon injection. This
notics, inhaled anesthesia, opioids, and neuromuscular accounts for the quick onset of its sedative and hypnotic
blocking agents, or total intravenous anesthesia (TIVA), effects. Plasma clearance and redistribution into skeletal
using a combination of propofol and synthetic opioids. muscle and fat is faster than its hepatic metabolism. The
high plasma clearance rate combined with its action as an
antiemetic is thought to contribute to its low “hangover
effect,” which makes it useful for outpatient surgery.
Pharmacology of General Anesthesia
■ Propofol:
Volatile Anesthetics
1. Acts through potentiation of GABA receptors in the
Inhaled or volatile anesthetics are an important part of central nervous system.
balanced anesthesia. They have been in use since the mid- 2. Produces profound respiratory depression.
nineteenth century and represent one of the most impor- 3. Produces systemic vasodilation at the level of arteries
tant advances in the history of medicine. Although their and veins.
mechanism of action remains unclear, they are known 4. Reduces cardiac preload and afterload.
to produce profound central nervous system depression 5. Causes systemic hypotension with little or no reflex
resulting in unconsciousness and amnesia. They are also tachycardia due to inhibition of the baroreceptor re-
known to produce respiratory depression, myocardial flex and therefore does not increase cardiac output.
depression, dose-dependent decreases in mean arterial 6. Produces little or no analgesia [12].
blood pressure (MAP), and reflex tachycardia [12]. 7. Produces a small “hangover effect,” which make it use-
ful for outpatient surgery.
■ Volatile anesthetics are traditionally used in the main-
tenance phase of general anesthesia and to improve the
surgical field by producing “controlled hypotension.”
Opioid Agonists
■ They produce dose-dependent hypotension with re-
flex tachycardia and profound vasodilation, which Opioid agonists such as fentanyl produce analgesia
may worsen the surgical field when used alone. without loss of touch, proprioception, or consciousness.
Fentanyl, sufentanil, alfentanil, and remifentanyl are syn-
Anesthetic Choices, Techniques, and Injections 73
thetic opioids that are derivatives of morphine. Fentanyl reported in each group, which might have potentially
is approximately 100 times more potent than morphine. confounded any statistical difference. Interestingly, they
It has a more rapid onset and shorter duration of action. provide evidence of increased platelet dysfunction after
It is more lipid soluble than morphine, which determines 45 min in both groups, with the propofol group being sig-
its potency and onset. It is quickly redistributed into fat nificantly worse than the sevoflurane group [1].
and skeletal muscle, with these sites becoming easily satu- With balanced anesthesia, the anesthesiologist at-
rated. Therefore, during a continuous infusion the plasma tempts to improve the surgical field by increasing the con-
clearance decreases significantly, causing a precipitous centration of inhaled anesthetic, which causes peripheral
drop in clearance rates. This can lead to prolonged ven- vasodilation, thereby lowering systemic vascular resis-
tilatory depression and analgesia in cases of infusions tance and decreasing MAP. Inhaled anesthetics, however,
longer than 2 h. Remifentanyl is a μ-selective opioid re- do not decrease cardiac output, and in fact, increasing
ceptor agonist with an analgesic potency similar to that concentrations of common inhaled anesthetics result in
of fentanyl. It is more rapid acting than fentanyl, yet it is a direct increase in heart rate. It has been postulated that
susceptible to hydrolysis by plasma and tissue esterases, lowering the blood pressure in this manner may actually
which gives it a very quick offset. Its clearance is inde- worsen the surgical field [3, 15]. While propofol adminis-
pendent of liver and kidney function. The metabolites are tration results in a drop in blood pressure through vaso-
inactive, and therefore produce noncumulative effects. In dilation, the venodilator effect produces a decrease in car-
addition, remifentanyl is known to produce hypotension, diac output by decreasing cardiac preload [9]. In addition,
whereas fentanyl does not [12, 15]. the baroreceptor reflex is blunted and there is no resultant
increase in heart rate. Interestingly, these studies point to
the potential importance of remifentanyl in improving
the surgical field during TIVA. It is known that propofol
Balanced Anesthesia Versus TIVA
combined with remifentanyl synergistically produces hy-
There is controversy regarding the method of choice for potension and bradycardia [14]. Using modern anesthe-
anesthetic delivery during FESS. The importance of ob- sia techniques such as target-controlled infusion, TIVA
taining the optimal surgical field in FESS has prompted with propofol and remifentanyl most likely produces a
several studies on the topic. In 1993, Blackwell et al. ret- superior surgical field for FESS, with the added benefit of
rospectively showed a decrease in blood loss in patients superior control of hypotension and heart rate due to the
undergoing ESS using propofol anesthesia compared short-acting nature of these drugs. This produces a the-
to those using isoflurane [2]. Eberhart et al. showed an oretical safety advantage as controlled hypotension may
improvement in a visual analog scale assessment of the precipitate ischemic organ failure in rare instances [11].
surgical field in patients treated with propofol and remi-
fentanyl versus those treated with isoflurane and alfen-
tanyl. There was no significant difference between groups
Anesthesia for Sinus Surgery
in terms of MAP or estimated blood loss. Heart rate was
significantly lower in the TIVA group [7]. Wormald et al. Propofol and remifentanil used in combination produce
showed in a prospective randomized trial that TIVA us- significant hypotension and better blunting of hemody-
ing propofol and remifentanyl produced superior surgical namic responses to endotracheal intubation than any
fields when compared to traditional balanced anesthesia. other combination of sedative/hypnotic and opioid [14].
This study found a positive correlation between surgical Propofol and remifentanyl may produce a synergistic
grade and MAP for both conditions, as well as an overall drop in MAP and heart rate, thereby significantly low-
positive correlation with heart rate. When compared at ering cardiac output, which may be responsible for the
specific MAPs, the TIVA group produced superior surgi- improved surgical field with TIVA.
cal grades. This suggests that TIVA produces a surgical
field that is more sensitive to MAP than balanced anes-
thesia [15]. A recent study by Beule et al. compared an-
Pharmacology of Local Anesthetics
esthesia using propofol and fentanyl versus sevoflurane
and fentanyl. This study found no significant difference Key points:
in the amount of blood loss or quality of the surgical 1. Amino esters are more likely to produce allergic reac-
field as assessed by a visual analog scale. Several features tions.
of this study are potentially confounding, including the 2. Amino esters are metabolized by plasma cholinester-
use of fentanyl instead of remifentanyl, and the overall ases and so are less likely to produce sustained plasma
high volumes of blood loss with large standard deviations concentrations.
3. Amino amides are metabolized by the liver. Patients The authors commonly use 1% lidocaine with 1:100,000
with liver disease or with decreased hepatic flow, such epinephrine for injections.
as in congestive heart failure, may experience in-
creased plasma levels of anesthetics.
4. Administration of local vasoconstrictors such as epi-
Injections
nephrine potentiate the duration of the effect while
decreasing the systemic absorption. Key points:
1. The greater palatine foramen injection is an effective
The most commonly used local anesthetics are tertiary method for controlling bleeding and providing anes-
amines composed of a lipid-soluble benzene ring con- thesia during endoscopic sinus surgery.
nected to an amine group by an alkyl group containing 2. A combination of the sphenopalatine block with the
either an amide or ester linkage. This linkage divides the greater palatine block leads to profound vasoconstric-
tertiary amines into two major groups: amino amides tion in the posterior portion of the nasal cavity and
and amino esters. Tertiary amines are weak bases. They significantly reduces bleeding.
can exist in solution in two forms: an unprotonated, neu-
tral (lipid soluble) form or a protonated, charged (water The greater palatine foramen is located posteromedially
soluble) form. The main mechanism of action of tertiary to the third maxillary molar and anteromedially to the
9 amine local anesthetics is postulated to occur on the in- maxillary tuberosity and pterygoid hamulus (Fig. 9.1).
terior of the axon, by reversibly inhibiting voltage-gated The foramen opens into the greater palatine canal, which
sodium channels on the inner surface of the membrane. courses superiorly into the pterygopalatine fossa. Here,
The lipid-soluble form is able to traverse the cell mem- the third portion of the internal maxillary artery and its
brane easily, while the water-soluble form is responsible multiple branches supply the nose, paranasal sinuses,
for binding to the sodium channel and blocking action- pharynx, orbit, palate, teeth, and facial skin. The closed
potential propagation. The specific properties of tertiary space and bony walls of the pterygopalatine fossa make
amines create important clinical differences in efficacy it ideal for local anesthesia. The optimal injection is de-
and potency. First, the dissociation constant is a mea- livered at the opening of the greater palatine canal, me-
sure of how likely the amine group is to be protonated dial to the sphenopalatine foramen, where the terminal
(hydrophilic) or neutral (lipophilic) at a particular pH, portion of the internal maxillary artery lies. Superiorly,
which determines how quickly an anesthetic can traverse
a membrane to exert an effect. Second, lipid solubility de-
termines the likelihood of the anesthetic moving through
myelin or other supporting cells. Consequently, anesthet-
ics with higher lipid solubility tend to have increased time
to onset and offset of effect due to increased sequestration
in myelin. Increasing lipid solubility also tends to increase
potency. For FESS, lidocaine is the most widely used local
anesthetic. Discovered in 1948, it was the first amino am-
ide local anesthetic. Its amide bond makes it more stable
and less likely to cause allergic reactions than amino es-
ters. Cocaine is a naturally occurring amino ester that has
excellent anesthetic properties as well as vasoconstrictive
properties, which make it ideal for FESS. It is the only
tertiary amine that acts as a vasoconstrictor; all others are
vasodilators. However, the euphoria and highly addictive
nature of cocaine have made it one of the most widely
abused recreational drugs. Therefore, it is now illegal in
most countries and more difficult to use for legitimate
medical purposes. Cocaine is also known to cause cardiac
arrhythmias and many have recommended its abandon-
ment for the use of safer mixtures [10].
Epinephrine, a human adrenergic catecholamine, is
commonly added to local anesthetics at a variety of con- Fig. 9.1 The location and orientation of the greater palatine fo-
centrations. Epinephrine induces peripheral vascular re- ramen and canal is clearly seen on this computed tomography
sistance via alpha-receptor-stimulated vasoconstriction. scan (arrows)
tracheal anesthesia is induced in the operating room, the

patient is turned 90 degrees counterclockwise to facilitate
the use of stereotactic computed tomography guidance.
The patient is then placed in the beach chair position,
which elevates the head approximately 10–20 degrees,
as the reverse Trendelenburg position has been shown
to reduce intracranial MAP without reducing cerebral
perfusion pressure [14]. The CT guidance system is then
registered and its accuracy confirmed.
Local Anesthesia
■ The authors utilize bilateral greater palatine blocks in
nearly all cases.
Three milliliters of 1% lidocaine with 1:100,000 of epi-

Fig. 9.2 The location of the sphenopalatine foramen at the pos- nephrine are drawn into a Luerlock syringe. Before use,
terior aspect of the middle turbinate is indicated by the asterisk the expiration date and concentration of the lidocaine
and epinephrine on the stock container are confirmed by
the surgeon. A 25-gauge needle is measured with a ruler
the pterygopalatine fossa is limited by the anterior basal and bent to an angle of 60 degrees at a length of 25 mm
portion of the greater wing of the sphenoid bone. The for all adults (Fig. 9.3).
inferior orbital fissure is located anterosuperiorly in the
pterygopalatine fossa and the superior orbital fissure and ■ The greater palatine foramen is usually located ante-
optic foramen lie just above it. The foramen rotundum is rior to the junction of the hard and soft palate just me-
located posteriorly, superiorly, and laterally to the sphe- dial to the second maxillary molar.
nopalatine foramen. The mean distance of the greater
palatine foramen to the sphenopalatine foramen is 28 mm It can often be palpated, or seen as a subtle depression
in men and 27 mm in women. The mean distance of the in the hard palate mucosa. The needle is placed into the
greater palatine foramen to the inferior orbital fissure is greater palatine foramen and advanced to the bend of the
40 mm in men and 37 mm in women [6]. The sphenopal- needle. The needle is then aspirated for blood to prevent
atine foramen can also be injected transnasally. Here, the an intravascular injection. Then, 1.5 ml of anesthetic is in-
sphenopalatine artery and several branches of the maxil- jected. If the needle is properly placed, there is moderate
lary nerve and pterygopalatine ganglion enter the nose resistance to the injection. If there is minimal resistance,
just posterior to the posterior attachment of the middle it is likely that the needle is in the nasopharynx, and is
turbinate (Fig. 9.2).
A combination of the sphenopalatine block with the
greater palatine block leads to profound vasoconstriction
in the posterior portion of the nasal cavity and signifi-
cantly reduces bleeding.
Techniques
General Anesthesia
Prior to the start of each day, the overall anesthetic plans
are reviewed with the anesthesiologist. The authors’ pref-
erence is TIVA with propofol and remifentanyl when pos-
sible. The adjunctive use of beta blockade is discussed, but
left up to the discretion of the anesthesiologist. In the pre-
operative suite, the patient is given oxymetazoline sprays Fig. 9.3 A 25-gauge needle with a 60 angle at length 25 mm
in each nostril 2 h prior to surgery. After general endo- from the tip of the needle
not correctly placed in the canal. The same procedure is

Conclusions
repeated for the contralateral canal (Video 9.1).
After the patient has been prepped and draped, a A thorough knowledge and understanding of the differ-
0 degrees Hopkins rod is used to place oxymetazo- ent options available for anesthesia and local anesthetic
line-soaked cotton pledgets in the nasal cavities. This is injections is critical to consistent operative success in en-
performed endoscopically to prevent the trauma to the doscopic sinus surgery. A close, open working relation-
septal mucosa or middle turbinate that can occur with ship with the anesthesia team is a key to safe, effective,
blind placement and to prevent nuisance bleeding that and efficient delivery of anesthetic and better surgical
could degrade the surgical field. Next, the remainder of outcomes.
the instrumentation is set up, including the image-guid-
ance system, camera, monitors, DVD recording system,
and microdebrider. The authors routinely use an endo-
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Chapter 10
Tips and Pearls in Revision

Sinus Surgery 10
Alexander G. Chiu and David W. Kennedy
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
■ Successful revision endoscopic sinus surgery starts Patient Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
with proper patient selection and medical manage- Important Points to Consider when Deciding
ment of comorbidities and environmental influenc- to Operate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
es.
Nasal Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
■ Preoperative planning in at least two and prefer-
CT Scan Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
ably three computed tomography planes is needed
in order to plan the surgical approach and identify Preoperative Workup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
problem areas. Surgical Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
■ A complete sphenoethmoidectomy is the best pro-
Surgical Navigation Systems . . . . . . . . . . . . . . . . . . . . . 83
cedure for long-term success.
■ A surgical approach is most safely done when iden- Angled Endoscopes and Instruments . . . . . . . . . . . . . 84
tifying the medial orbital wall, roof of the maxillary Intraoperative CT Scans . . . . . . . . . . . . . . . . . . . . . . . . 85
sinus, and skull base posteriorly within the sphenoid Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
sinus.
General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
■ All bony fragments should be removed from their
Maxillary Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
attachment along the medial orbital wall, skull base,
and frontal recess. Inferior Ethmoid Sinus . . . . . . . . . . . . . . . . . . . . . . . . . 86
■ As with primary surgery, the mucoperiosteum Sphenoid Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
should be preserved.
Superior Ethmoid Sinus . . . . . . . . . . . . . . . . . . . . . . . . 87
■ Nearly as important as a good technical surgery is me-
Frontal Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
ticulous long-term postoperative debridements and
surveillance to ensure patency and mucosal health. Packing and Stenting . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Introduction
3. Symptomatic from persistent mucosal inflammation
Short- and long-term outcome studies have shown func- and purulence due to inadequate clearance of ethmoid
tional endoscopic sinus surgery (FESS) to be successful cells and/or mucosal stripping from previous surgery.
in over 90% of cases [3, 5]. Those patients who remain
symptomatic following surgery often fall into three gen- The keys to success in performing a revision FESS are to
eral categories: correctly identify those patients in the latter two catego-
1. Symptomatic due to persistent mucosal inflammation ries and address their revision procedure by managing
and purulence despite adequate technical surgery. their comorbidities perioperatively, thoroughly examin-
2. Symptomatic from isolated pathology within a se- ing their preoperative radiography, and utilizing a me-
lected sinus (i.e., the frontal sinus) that is secondary to ticulous mucosa-sparing technique in performing a com-
scarring or closure of the individual natural ostium. plete sphenoethmoidectomy.
80 Alexander G. Chiu and David W. Kennedy
have not yet stopped smoking. Smoking postoperatively

Patient Selection
tends to cause significant scarring, has a major impact on
When evaluating a patient for a revision FESS, it is impor- outcomes, and is a major factor in surgical failure.
tant to review the patient’s symptoms, associated comor- In order to evaluate whether the initial surgery(s) was
bidities, and radiographic studies. Quality of life question- technically inadequate, the initial preoperative report
naires, such as the Rhinosinusitis Outcome Measure and should be reviewed along with an examination of the
Sino-Nasal Outcome Test, are helpful in eliciting patient pre- and post-surgical CT scans. An initial operative re-
symptoms and importance to their overall quality of life. port that does not mention the dissection of superior eth-
moid cells, agger nasi cells, and/or frontal recess cells may
Tips and Pearls mean that a proper frontal recess dissection was never
performed. Other details to look for include the descrip-
1. Managing the expectations of the patient is a criti-
tion of the dissection of the skull base and sphenoid sinus.
cal part in the revision surgery process.
Reviewing postoperative CT scans is an appropriate next
2. A patient who complains of clear, postnasal drain-
step, and is an objective aid in determining a cause for
age with a significant history of allergic rhinitis
persistent disease. By understanding patient symptoms
and minimal mucosal disease on computed
and expectations and correlating those with areas on na-
tomography (CT) scan is not likely to find relief in
sal endoscopy and CT scan that may explain their symp-
that symptom from a second surgery.
toms, a calculated decision can be made on whether or
3. On the other hand, a patient with a chief com-
not a patient will benefit from revision surgery.
10 plaint of thickened, purulent postnasal drainage
and evidence of mucus recirculation on CT scan is
likely to benefit from a revision surgery.
Important Points to Consider
when Deciding to Operate
Before deciding on the necessity for any type of revision
surgery, it is advisable to review the original CT scan 1. Review indications for initial surgery.
before any surgery is performed. This helps the surgeon 2. Have a complete understanding of the patient’s expec-
to evaluate the indications for the original surgery and tations.
is particularly important for the frontal sinus, where the 3. Review the initial operative report.
primary surgical indication may be headache. In general, 4. Make sure maximal medical therapy has been per-
the symptom of headache correlates poorly with chronic formed.
rhinosinusitis and it is important to establish the pres- 5. Review initial and postoperative CT scans.
ence or absence of disease in the frontal sinus prior to
the first operation. If this remains the primary symptom,
a revision surgery on asymptomatic iatrogenic mucosal
Nasal Endoscopy
change may be avoided.
As with the original CT scan, evaluating prior medi- Rigid or flexible nasal endoscopy is the most important
cal therapy, postoperative care, and medical compliance part of the physical exam for a sinus surgeon. Using
is important in selecting patients who will benefit from a angled endoscopes during the initial patient evaluation
revision surgery. Maximal medical therapy of a prolonged will allow inspection of the maxillary sinus and natural
course of systemic oral steroids and culture-directed anti- ostium. Mucus recirculation in the maxillary sinus is one
biotics should be performed prior to any surgical proce- of the most common causes for revision surgery [4]. This
dure. In many cases, a patient may remain symptomatic is often secondary to a synechia that has developed be-
from an original surgery not for technical reasons, but for tween the natural ostium and antrostomy, or to a residual
antibiotic-resistant bacteria commonly found in postsur- uncinate process. Both of these are difficult to ascertain
gical patients, such as Staphylococcus aureus or Pseudomo- from a straight-on examination using a 0° endoscope or
nas aeruginosa. Endoscopic-directed cultures can guide sometimes even with a 30° telescope. A 45 ° or 70° endo-
antimicrobial therapy and often resolve these infections scope is needed to completely eliminate this subtle find-
without any additional surgery. Careful consideration ing (Fig. 10.1).
should also be given to the environmental and general Endoscopy of the anterior nasal cavity will determine
host factors that predispose to recurrent disease. Un- whether or not there are significant synechiae between
derlying factors such as allergic rhinitis, granulomatous the middle turbinate and medial orbital wall. Synechiae
disorders, and underlying immune deficiencies should be between the nasal septum and inferior turbinate can be
investigated, and where possible, managed before any re- a significant cause for nasal obstruction. Synechiae be-
vision surgery is undertaken. In general, elective revision tween the middle turbinate and lateral nasal wall can
sinus surgery should not be performed in patients who prevent examination of the ethmoid cavity and spheno-
Tips and Pearls in Revision Sinus Surgery 81
Fig. 10.1 Endoscopic view of a patient with mucus re-circula- scope (c) shows the scar band between the natural ostium and
tion following a functional endoscopic sinus surgery (FESS) antrostomy that is creating the recirculation. Once the mucus is
procedure. A 0° endoscope shows thickened mucus at the an- cleared, the scar band is clearly visualized (d)
trostomy (a). Closer inspection with a 30° scope (b) and 70°
ethmoid recess. These can often be lysed in clinic after lergic mucin or retained fungal elements in the inferior
topical analgesia, and a temporary spacer can be placed portion of the sphenoid sinus, as well as within the max-
lateral to the middle turbinate to prevent the formation of illary sinus, are a common source for persistent purulent
additional synechiae. rhinorrhea. Thick allergic mucus should also be submit-
The degree of mucosal edema and presence of mu- ted for pathology for examination with fungal stains and
copurulence should be determined in the endoscopic for the presence of Charcot-Leyden crystals.
examination of the ethmoid cavity. Cultures should be Finally, the frontal recess should be examined with an
taken of any purulence and examined for the presence of angled endoscope. Signs to look for include the presence
pathogenic aerobic, anaerobic, and fungal organisms. The of polypoid edema, mucopurulence, and residual cells
sphenoid ostium should then be visualized and, if pos- or bony partitions that may obstruct the frontal recess.
sible, examination of the sinus itself should be performed Endoscopic findings should then be correlated with their
to determine the presence of mucus within the sinus. Al- radiographic appearance.
Sagittal and axial views are important in determining the

anterior-to-posterior dimension of the frontal recess, and
the identification of a supraorbital ethmoid, frontal recess,
and/or interseptal frontal sinus air cell. Sagittal views are
also instructive in demonstrating the vertical slope of the
skull base and the degree of ethmoid bony partitions at-
tached to the skull base.
The most common anatomical areas identified in revi-
sion surgery are the following:
1. Remnant uncinate process with resultant mucus re-
circulation between the natural maxillary ostium and
previously made maxillary antrostomy (Fig. 10.2).
2. Ethmoid bony partitions attached to the medial orbital
wall and skull base. In patients with inflammatory pol-
yps or neo-osteogenesis, these bony partitions may be
Fig. 10.2 Coronal computed tomography (CT) scan of a patient osteitic, serve to increase the surface area where pol-
with a previous FESS who has a retained uncinate on the left and yps can grow, and as a nidus for persistent mucosal
right sides (red circle) inflammation (Fig. 10.3).
3. Remnant infraorbital ethmoid cells that are obstruct-
10 ing the natural maxillary ostium.
4. Lateralized middle turbinate against the medial orbital
CT Scan Review
wall or scarred to an agger nasi cell and/or ethmoid
Reviewing CT scans are best done in multiple planes. bulla remnant (Fig. 10.4).
In-office consultation should result in a review of axial 5. Residual sphenoethmoidal (Onodi) cell or posterior
and coronal sections, at a maximum of 3-mm sections, ethmoid cell.
through the paranasal sinuses. Many image-guidance 6. Remnant supraorbital or frontal recess cells.
companies now offer work-stations that allow for the re- 7. Synechiae between the middle turbinate and lateral
view of CT scans in the sagittal plane, as well as the coro- nasal wall and/or medical orbital wall.
nal and axial views. The coronal view is excellent in deter- 8. Neo-osteogenesis of the skull base and frontal recess
mining the presence of a remaining agger nasi, uncinate from previous mucosal stripping and/or prolonged
process, frontal recess, and/or supraorbital ethmoid cells. mucosal inflammation
Fig. 10.3 Coronal and sagittal views of patient with nasal polyposis who had undergone a previous FESS. Note
the multiple bony ethmoid partitions off the skull base on the sagittal view (red circle). Revision surgery will be aimed
at removing these osteitic bony partitions
cigarette smoking should be stopped at least 3 weeks prior

to surgery as well as in the 6 weeks following surgery to
limit its deleterious effects on the nasal mucosa.
Patient comorbidities should also be optimized prior
to surgery. In the case of FESS, asthma is the most com-
mon comorbidity and should be well controlled prior
to surgery with inhalers and/or systemic steroids. Sys-
temic hypertension should also be under good control,
as poorly controlled intraoperative blood pressures can
certainly worsen mucosal bleeding and complicate endo-
scopic visualization.
Prior to surgery, the informed consent process should
also be carefully addressed. Compared to primary FESS,
revision FESS often carries a greater risk for cerebrospi-
nal fluid leaks, orbital injury, and postoperative drug-re-
sistant infections. Major as well as minor complications
Fig. 10.4 Coronal CT scan of a patient with isolated left frontal should be discussed with the patients and it is prudent to
recess disease. The left middle turbinate has lateralized against have an FESS-specific consent form signed and witnessed
the medial orbital wall, resulting in the obstruction (red circle) prior to surgery [1].
Tips and Pearls

1. Preoperative oral steroids and antibiotics can often
Preoperative Workup decrease mucosal edema and intraoperative bleed-
ing.
Once the decision is made to perform a revision endo-
2. The patient should refrain from cigarette smoking
scopic procedure, it is imperative in the preoperative
at least 3 weeks prior to surgery.
period to review each patient’s anatomy, the amount of
3. Obtain FESS-specific informed consent.
disease, and underlying comorbidities. CT scan and na-
sal endoscopy are the best modalities to use to assess the
remnant bony partitions and areas of scarring that are
Surgical Equipment
obstructing the natural ostium of each sinus. Revision
FESS is most often performed for recurrent nasal pol- Once the decision is made to perform a revision proce-
yposis, persistent mucosal inflammation, mucoceles, or dure, specialized instruments should be used to achieve
iatrogenic sinus disease. In each of these cases, mucosal a sound surgical technique of sparing mucosa while per-
inflammation should be kept at a minimum prior to the forming a complete sphenoethmoidectomy that removes
case in order to decrease surgical bleeding and improve osteitic ethmoid bony partitions.
endoscopic visualization.
Systemic steroids and oral antibiotics are helpful in
stabilizing mucosal inflammation prior to surgery. Oral
Surgical Navigation Systems
prednisone is started 1 week prior to surgery and con-
tinued for at least 2 weeks after surgery or until mucosal With the advent of surgical navigation in the late 1980s,
inflammation has resolved, as assessed by endoscopic ex- endoscopic surgeons have been increasingly utilizing this
amination. A prednisone dose of 0.6 mg/kg/day for 3 days technology for intraoperative localization and preopera-
followed by 0.4 mg/kg for 3 days is given starting 1 week tive planning. Fine-cut axial CT scans, often 1 mm in sec-
prior to surgery. Along with this, culture-directed antibi- tion, are reformatted into coronal and sagittal views and
otics are started 1 week prior to surgery. If no purulence allow for a greater understanding of the anatomy, which
is present, an empiric antibiotic such as a fluoroquinolone has been distorted by previous surgery, polypoid mucosa,
or combination of clindamycin and bactrim can be used and/or anatomical variants. Preoperatively, image-guid-
to help stabilize the mucosa. ance workstations can be used to plan out the dissection
Patients are also instructed to stop aspirin or nonste- and identify areas that need to be addressed. Specifically,
roidal anti-inflammatory drug use 1 week prior to sur- the frontal recess and the cells obstructing the frontal
gery. Other agents that can potentially increase surgical recess are best visualized utilizing the three views made
bleeding, such as vitamin E and the herbal supplements available by the workstations, providing the surgeon with
ginger, gingko, and ginseng, are encouraged to be discon- the ability to truly conceptualize the three-dimensional
tinued at least 3 weeks prior to surgery. In addition, active surgical anatomy prior to the procedure. In addition, os-
teitic bony partitions along the skull base and medial or- ing a complete sphenoethmoidectomy and skeletonizing
bital wall are best seen using multiple views. the skull base and medial orbital wall of bony ethmoid
Intraoperatively, image guidance is useful in dissecting partitions.
out remnant bony partitions while identifying the skull
base and medial orbital wall. In many cases, previously
operated and diseased ethmoid bone becomes osteitic
Angled Endoscopes and Instruments
and hardened, thus taking away the tactile difference be-
tween the skull base and ethmoid bone that is often ap- Angled instruments are essential in revision endoscopic
preciated and relied upon in primary surgery. sinus surgery. Endoscopes of 30 °, 45 °, and 70 ° allow di-
Some image-guidance systems also offer a virtual im- rect visualization of the natural ostium of the maxillary
age update. Using computer software packages, a surgeon sinus, frontal recess, and anterior skull base.
can trace their dissection and “virtually” eliminate the Revision surgery along the skull base necessitates the
bony partitions and mucosal disease seen in the preop- use of angled through-cutting instruments. Powered
erative images (Fig. 10.5). This device can aid in perform- instrument companies have devised angled debrider
10
Fig. 10.5 An intraoperative endoscopic

view with triplanar CT imaging of a patient
with a left supraorbital ethmoid mucocele
and corresponding skull base erosion (a).
Upon entering the mucocele, the Eraser
software program begins to digitally “erase”
the mucocele based on the path of the
instrument (b)
blades, as well as drills, diamond and cutting, that may be revision procedure, and these real-time pictures can be
attached to hand-held microdebriders. The 70 diamond used to update image-guidance systems if additional sur-
suction irrigation drill has, in particular, made a dramatic gery is needed.
difference for revision frontal sinus surgery. In particular,
the drill reduces the amount of trauma and exposed bone
during an extended frontal recess approach [2]. There is
Surgical Technique
a variety of 90 ° instruments designed to reach around
the nasofrontal beak and into the frontal recess. These
General Principles
instruments, specifically designed for the frontal recess,
are also useful in accessing pathology within the floor and In revision surgical procedures the anatomy can be sig-
anterior portion of the maxillary sinus. Fungal debris or nificantly distorted and landmarks such as the middle
mucus retention cysts along the floor of the sinus can be turbinate may be partially resected, making them unreli-
irrigated and instrumented out by using angled giraffe able for anatomic localization. Image guidance is a help-
forceps and curettes. Revision procedures often become a ful tool, but should not be trusted blindly. Accurate iden-
methodic process of cut, remove, suction, and reexamine. tification of static anatomical landmarks that cannot be
These specialized instruments allow for the preservation altered from previous surgery can help guide the revision
of mucosa and removal of fine bony fragments, which if procedure and minimize the risk of complications.
left behind, can serve as a nidus for scarring and infection
along the maxillary sinus and anterior skull base. Tips and Pearls – I
1. Landmarks to be used include the roof of the max-
illary sinus, the medial orbital wall, and the skull
Intraoperative CT Scans base.
2. The skull base is usually most easily identified in
A more recent development that is currently limited in
the posterior ethmoid or sphenoid sinuses, where
accessibility but may become more prevalent in the fu-
it is more horizontal and the cells are larger.
ture is the use of an intraoperative CT scanner to assess
3. The roof of the maxillary sinus is closely related
the thoroughness of revision surgery. Xoran Technologies
to the approximate height of the sphenoid sinus.
(Ann Arbor, MI, USA) has developed a mobile intraop-
Staying at this vertical level of the maxillary sinus
erative CT scanner that is able to perform 0.4-mm slice
roof during dissection posteriorly keeps the sur-
thickness scans of the paranasal sinuses while the patient
geon from venturing into the anterior skull base.
is on the operating room table (Fig. 10.6). This allows the
4. Be careful where the skull base slopes down medi-
opportunity to assess the extent and thoroughness of the
ally toward the attachment of the middle turbi-
nate in the region of the anterior ethmoid artery.
The ethmoid roof is at its thinnest in this area,
and may even be membranous in part, making it
particularly vulnerable to injury. As this area is ap-
proached, it is important to stay close and parallel
to the medial orbital wall while remembering that
the opening of the frontal sinus is most frequently
medial, close to the attachment of the middle
turbinate to the skull base.
Since revision FESS is most often performed for persis-

tent mucosal edema and mucoceles, it is recommended
that the procedure should be a complete sphenoethmoid-
ectomy. For isolated mucus recirculation of the maxil-
lary sinus or frontal sinus mucoceles, the procedure can
be tailored to the specific sinus. But for the most part,
a complete and thorough dissection removing remnant
Fig. 10.6 Intraoperative CT with the xCAT™ – a mobile cone- ethmoid bony partitions and skeletonizing the medial
beam scanner. A special head rest allows rotation of the gantry orbital wall and anterior skull base gives the patient
for image acquisition. CT scans are then transferred into the their best opportunity for a lasting surgical procedure.
surgical navigation system of preference for a real-time update Removing remnant osteitic bony partitions requires the
of the images use of through-cutting instruments. Additional mucosal
stripping in a revision procedure can result in even more bony walls of the infraorbital ethmoid cell can be visu-
neo-osteogenesis, which can be particularly crippling in alized and removed using the combination of a ball tip
the sphenoid and frontal sinus. The steps to performing probe, 90 ° forceps, and back-biter. Keep in mind its rela-
a revision FESS are identical to those of a primary FESS. tion to the inferior orbital wall and infraorbital nerve as it
The maxillary sinus is first identified, and the medial or- courses along the roof of the maxillary sinus.
bital wall is skeletonized free of ethmoid bony partitions. The floor of the maxillary sinus should be addressed in
Dissection is then carried low and posterior through the any revision procedure. Remnant fungal debris or mucus
inferior ethmoids and basal lamellae into the posterior retention cysts should be identified and removed. Angled
ethmoids. The superior turbinate is then identified along endoscopes such as the 45 ° or 70 ° are often needed to
with the natural os of the sphenoid sinus. Once the sphe- visualize these areas. Instruments normally used for the
noidotomy is enlarged, the skull base is identified and frontal recess, such as a 90 ° curette or giraffe forceps, are
dissection is carried posterior to anterior along the skull helpful in reaching down to the floor and removing de-
base with angled endoscopes and instrumentation. Eth- bris. Irrigation with normal saline is also useful in remov-
moid bony partitions along the skull base are removed. ing thick allergic mucin or fungal debris from the sinus.
The anterior ethmoid artery is identified and preserved
and the frontal recess is dissected out.
Inferior Ethmoid Sinus
Tips and Pearls – II
Once the maxillary sinus antrostomy is revised, remnant
10 1. Be methodical in revision surgery. Remove all
ethmoid bony partitions off the medial orbital wall should
ethmoid bony partitions along the skull base and
be removed flush to the bone. The roof of the maxillary
medial orbital wall.
sinus can serve as a guide to the height of dissection
2. Spare the mucosa and use through-cutting instru-
through the ethmoid cavity as the surgeon moves pos-
ments.
teriorly through the basal lamellae and into the posterior
3. Identify the skull base within the sphenoid sinus
ethmoid cells. The basal lamella has an inferior, horizon-
or posterior ethmoids.
tal segment and a superior, vertical segment.
4. Make a large antrostomy within the maxillary,
sphenoid, and frontal sinus in patients with polyp-
oid disease.
■ Care should be taken to preserve the horizontal seg-
ment of the basal lamella to prevent postoperative lat-
eralization of the middle turbinate.
Maxillary Sinus
Another specific area to address is the medial border of
■ Identifying a remnant uncinate process is the most the ethmoid bulla. Often, this bony segment can be left
critical step in revising a maxillary antrostomy. untouched from a previous surgery in which the bulla
was entered centrally and “cored” out with a microde-
Mucus recirculation is a common cause of recurrent brider. The medial border can become osteitic, serve as
symptoms following FESS and is due to a mucosal or a platform for polyp formation, and is best removed with
bony partition between the natural ostium and the sur- a J-curette placed medial and posterior to the bony seg-
gical antrostomy. Scarring can be a cause, as well as a ment.
remnant uncinate process. A back biter or angled ball- Once the dissection is carried through the basal lamel-
tip probe is a useful instrument to reach posterior to the lae and into the posterior ethmoid air cells, care should
uncinate process and resect anteriorly to its attachment be taken to identify and remove any remaining ethmoid
along the lacrimal bone. Once the hard bone of the lacri- cells behind the maxillary sinus and against the posterior
mal is palpated, no further resection is performed to pre- medial orbital wall or orbital apex. Often these retro max-
vent a nasolacrimal duct injury. The superior attachment illary cells can be left behind from a previous surgery and
of the uncinate should also be removed. This attachment can again serve as a nidus for inflammation and polypo-
is often fused to the anterior face of the agger nasi cell, sis.
and can be a source for frontal recess obstruction follow- The superior turbinate is then addressed. The superior
ing initial sinus surgery. turbinate serves as an anatomical landmark for the natu-
ral sphenoid os. Resecting the lower half of the superior
■ Infraorbital ethmoid or Haller cells can also be a source turbinate allows visualization of the os while preserving
of persistent obstruction of the maxillary sinus. olfactory function found in the superior portion of the
superior turbinate. The basal lamellae of the superior tur-
These cells are easily missed because they are often more binate as it attaches to the medial orbital wall can also be
anterior than expected. Using an angled endoscope, the removed and debrided of inflammation and polyps.
Again, the use of angled endoscopes and through-cutting

Sphenoid Sinus
forceps is recommended to improve visualization and
■ The sphenoid sinus can be safely entered through the remove ethmoid bony fragments while preserving the
natural os of the sinus. skull-base mucosa.
As the dissection along the skull base is carried forward,
The os is located medially and inferior and can be entered the anterior ethmoid artery typically lies in a superior ex-
with a straight J-curette. The thin bone of the anterior tension of the anterior wall of the bulla ethmoidalis at,
face of the sphenoid sinus often turns into hardened, os- or somewhat below, the skull base, and courses anteriorly
teitic bone in revision surgery. In addition, dissection in as it travels medially (Fig. 10.7). The openings of one, or
this area can be highly vascular and bleeding can easily more frequently two, supraorbital ethmoid cells often lie
obscure the visual field. Sphenopalatine artery injections anterior to the vessel and extend laterally and superiorly.
of lidocaine with epinephrine can aid in decreasing mu-
cosal bleeding and improving endoscopic visualization.
This may be performed prior to dissection through a
Frontal Sinus
transpalatal injection through the greater palatine fora-
men, or transnasally by injecting in a region near the The opening to the frontal sinus is frequently not im-
lateral insertion of the middle turbinate. In either case, mediately evident, so it is important that the surgeon has
sphenopalatine injections can greatly aid in performing conceptualized the location of the drainage pathway prior
a sphenoidotomy. to the surgical procedure. Very fine malleable probes have
With bleeding under control, the anterior face of the been developed that can be utilized to gently probe the
sphenoid should be removed superiorly to the skull base openings and help determine which of these ostia truly
and inferiorly to the level of the septal branch of the sphe- passes superiorly into the frontal sinus. Once the opening
nopalatine artery. has been clearly identified, adjacent bony partitions may
be fractured with specialized frontal sinus instruments to
■ It is advantageous to create a large sphenoidotomy open the frontal sinus. Bony fragments are then teased
especially in a highly inflamed field, since the small out and redundant mucosa is trimmed with through-cut-
surface area of the sphenoid makes it more likely to ting instruments. Common areas of attention for revision
stenose in the postoperative period. surgery include the agger nasi cell and superior uncinate
process. In addition, a lateralized superior segment of the
Heavy through-cutting hand instruments, such as the middle turbinate can cause iatrogenic frontal sinusitis.
straight mushroom punch and Kerrison forceps, are of- This can be addressed by either resecting the middle tur-
ten needed to cut through the thick bone of the sphenoid. binate to its insertion along the skull base or by cutting
The anterior face of the sphenoid should then be removed the synechiae and medializing the middle turbinate with
laterally to the orbital apex and medial orbital wall. An a stitch or a middle meatal spacer.
angled endoscope can then be used to view the floor of
the sphenoid. Any remaining fungal debris or mucin
should then be removed or irrigated from the sinus.
Packing and Stenting
Sphenoethmoidal (Onodi) cells are ethmoid cells that
lie superior and lateral to the sphenoid sinus. There is ■ As long as there is at least 180 ° of intact frontal recess
a typically an oblique bony partition that separates the mucosa, stents are rarely needed in the frontal recess.
cell from the sphenoid sinus. In maximally enlarging the
sphenoid, this horizontal bony partition should be re- In extended frontal sinus procedures in which a drill is
moved with a through-cutting forceps, while bearing in used to denude the mucosa and remove bone more than
mind that it may be attached posteriorly to either the op- 180 around the frontal recess, stents can be employed to
tic or carotid canal. try to keep the recess open. However, there is not good
evidence that they are better than local postoperative
care, even in this situation. There are commercially avail-
able silicone stents, but we prefer using a thin silastic stent
Superior Ethmoid Sinus
rolled into a tube and placed within the frontal recess,
■ The skull base can be safely identified along the roof of when for one reason or another, a decision to use a stent
the sphenoid sinus. Once identified, dissection is car- is made. These are easily removed in the clinic and can
ried from a posterior to anterior direction along the unfurl to cover the entire recess.
skull base to remove the superior ethmoid bony rem-
nants attached to the skull base. ■ Medializing the middle turbinate following surgery is
often critical to the success of the procedure.
This allows easier postoperative access for debridements

and helps prevent iatrogenic frontal recess obstruction
from a lateralized middle turbinate. Often in revision
cases, the horizontal portion of the basal lamellae has
been removed, making the middle turbinate less stable.
Medializing the middle turbinate against the septum can
be done in a variety of methods. Scarring the medial sur-
face of the middle turbinate and the opposing surface of
the septum while placing a spacer in the middle meatus
can create a controlled synechia, keeping the middle tur-
binate medialized (Fig. 10.8). Other techniques involve
suturing both middle turbinates together through the
septum.
Postoperative Care
■ In the case of revision sinus surgery, postoperative care
is often as important as the actual surgery itself.
10
Revision sinusotomies must be carefully and diligently
examined following surgery. A failure to actively debride
the recess and ostia, ensure its patency, and suction con-
taminated blood and mucus from the sinus is a recipe for
restenosis and failure. To do this in a setting of an awake,
often anxious patient, with topical analgesia alone makes
this portion of the process very challenging, but can be
aided by the careful application of topical ponticaine or
even cocaine solution to the site. Where local debride-
ments are necessary, 1% lidocaine with 1:100,000 epi-
nephrine can be injected using a fine bent needle and a
small syringe.
The timing of the first postoperative debridement var-
ies with the individual surgeon’s preference. Some de-
bride on postoperative day one, while others wait for an
additional 3–7 days. It is advantageous to have a full set of
sinus instruments available in the clinic. This is coupled
with angled suctions that are long and curved enough to
reach into the frontal sinus and lateral and inferior re-
gions of the maxillary sinus. Debridements should be
aimed at clearing away fibrin debris and any loose bony
fragments, while keeping trauma to the surrounding mu-
cosa to a minimum.
While the mechanical care of revision antrostomies
are important to prevent restenosis, medical manage-
ment of the disease state is essential to long-term suc-
cess. In a patient with significant polypoid edema, post-
operative oral steroids can be used to keep the edema to
a minimum. Intranasal steroids sprayed in the Moffit or
head-down position, can help with delivery to the frontal
Fig. 10.7 Coronal CT scan views of an anterior ethmoid artery recess. Postoperative antibiotics should also be given in
within the skull base (a) and traveling below the skull base (b). an infectious setting, and antibiotics with good bone pen-
c An endoscopic view with a 30 ° endoscope. The black arrow- etration should be used in patients with evidence of neo-
head is pointing to an anterior ethmoid artery below the skull osteogenesis. Other considerations in the management
base and without a bony mesentery of these difficult patients includes local or oral antihis-
Fig. 10.8 Endoscopic views of creating a controlled synechiae nude opposing surfaces of the middle turbinate and septum (a).
between the right middle turbinate and nasal septum to prevent A merocel sponge is then placed lateral to the middle turbinate
middle turbinate lateralization. The microdebrider is used to de- and kept in place for 1–3 days (b)
tamines, antileukotriene medications, long-term irriga- anatomy that is contributing to patient’s symptoms and
tions, or an even a trial of itraconazole. In the latter situa- disease process, and the institution of aggressive adjuvant
tion, the patient’s liver function tests should be evaluated medical therapy.
prior to therapy and monitored during the treatment, and
the patient should be aware of the off-label usage of this
medication in this situation.
References
This routine of mechanical debridement and postop-
erative medication should be continued on a weekly basis 1. Bowden MT, Church CA, Chiu AG, et al. (2004) Informed
until the mucosa of maxillary, ethmoids, and frontals are consent in functional endoscopic sinus surgery: the patient’s
healed. The medical treatment is guided almost entirely perspective. Otolaryngol Head Neck Surg 131:126–132
by the endoscopic appearance of the cavity and the pres- 2. Chandra RK, Schlosser R, Kennedy DW (2004) Use of the
ence of residual, typically asymptomatic, disease. Once 70-degree diamond burr in the management of compli-
the cavity is secure, routine surveillance by nasal endos- cated frontal sinus disease. Laryngoscope 114:188–192
copy should continue for the life of the patient. 3. Glicklich RE, Metson R (1997) Effects of sinus surgery on
quality of life. Otolaryngol Head Neck Surg 117:12–17
4. King JM, Caldarelli DD, Pigato JB (1994) A review of re-
vision functional endoscopic sinus surgery. Laryngoscope
Conclusion
104:404–408
Revision endoscopic sinus surgery remains a great chal- 5. Senior BA, Kennedy DW, Tanabodee J, et al. (1998) Long-
lenge to all who practice sinus surgery. Surgical technique term results of functional endoscopic sinus surgery. Laryn-
aside, the most important decisions are still made in the goscope 108:151–157
office. These entail assessing whether or not the patient is
a good surgical candidate, identification of the patient’s
Chapter 11
Septal and Turbinate Surgery

Joseph Raviv and Peter H. Hwang
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
■ Septal deviation and turbinate variants can encroach Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
on sinus drainage pathways and may benefit from Septum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
correction in the revision surgical patient.
Turbinates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
■ Preoperative nasal endoscopy is critical to formulat-
Association with Rhinosinusitis . . . . . . . . . . . . . . . . . . . . 93
ing a surgical plan regarding treatment of the sep-
tum and turbinates. Preoperative Workup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
■ Endoscopic septoplasty provides excellent visual- Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
ization and facilitates dissection in cases of revision
Endoscopic Septoplasty . . . . . . . . . . . . . . . . . . . . . . . . 93
septoplasty.
■ Surgical release of the lateralized middle turbinate Incision Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
may require adjunctive medialization techniques to Surgical Technique Principles . . . . . . . . . . . . . . . . . . . . 95
prevent reformation of scarring. Inferior-Turbinate Reduction . . . . . . . . . . . . . . . . . . . . 95
Advantages of Microdebrider Inferior-Turbinate

Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Excision of Middle-Turbinate Concha Bullosa . . . . . 96
Lateralized Middle-Turbinate Release . . . . . . . . . . . . 97
Introduction
Superior-Turbinate Resection . . . . . . . . . . . . . . . . . . . 97
Functional endoscopic sinus surgery has a long-term suc-
cess rate of approximately 90% for improving symptoms
in patients with medically refractory chronic rhinosi-
nusitis [10]. In the evaluation of patients with persistent
postoperative disease, the paranasal sinuses are typically
scrutinized for causative factors, but the closely related the nasal cavity, and expresses olfactory neuroepithelium.
nasal septum and turbinates may often be overlooked. The membranous septum connects the columella to the
This chapter will discuss the role of the nasal septum and caudal margin of the quadrangular cartilage, which com-
turbinates in chronic sinus disease and the specific treat- prises the majority of the anterior septum. The posterior
ment techniques available for successful outcomes in the septum is bony, consisting of the perpendicular plate of
revision surgical treatment of patients with chronic rhi- the ethmoid bone posterosuperiorly and the vomer pos-
nosinusitis. teroinferiorly. Finally, the nasal, frontal, maxillary, and
palatine bones each contribute nasal crests to the periph-
ery of the septum. The cartilaginous and bony portions
of the septum align during fetal development and fuse
Anatomy
to form bony cartilaginous junctions. Displacement of
the bony–cartilaginous interfaces results in deviations or
Septum
deflections of the septum; this may occur congenitally as
The nasal septum separates the two nasal cavities, pro- well as during periods of rapid facial growth, or conse-
vides structural support for the nose, influences airflow in quent to external trauma.
92 Joseph Raviv and Peter H. Hwang
nose; the middle meatus by the space between the infe-

Turbinates
rior and middle turbinates; and the superior meatus by
The turbinates are intrinsic to the normal functioning of the space between the middle and superior turbinates.
the nasal airway. They facilitate the filtering, warming,
and humidification of inspired air. The middle and supe- ■ The turbinate bones are encased by pseudostratified
rior turbinates also participate in olfaction. ciliated columnar respiratory epithelium, which con-
tributes to mucociliary clearance of the nose. The infe-
■ In light of the functional nature of the turbinates, deci- rior turbinate also possesses a vasoactive submucosal
sion making in turbinate surgery requires a judicious stroma that may hypertrophy and contribute to nasal
consideration of the potential impact of surgical mod- obstruction.
ification on nasal function.
Anatomic variations of turbinate structure are common,
The precursors of the nasal turbinates can be identi- with pneumatization being the most commonly observed
fied during the 8–10th week of fetal development as variant (Fig. 11.1). Concha bullosa of the middle turbinate
outgrowths from the lateral nasal wall [12]. These out- is perhaps the most commonly encountered anatomic
growths, or ethmoturbinals, ultimately yield the middle variant during surgery. A study reviewing 202 consecutive
and superior turbinates. The inferior turbinate is derived computed tomography (CT) scans found pneumatization
from the maxilloturbinal, a separate structure located in- of the vertical lamella of the middle turbinate in 46.2%,
ferior to the ethmoturbinals. Given its distinct embryonic of the inferior or bulbous segment in 31.2%, and both the
derivation, the inferior turbinate is subject to fewer of the lamella and bulbous portion in 15.7% of cases [1]. Sep-
anatomic variations commonly seen in the middle and tal deviation and middle-turbinate concha bullosa often
11 superior turbinates. occur concurrently [11]. Nearly 80% of patients with a
The three scroll-like turbinate bones divide the nasal dominant concha bullosa have a concurrent deviated sep-
lumen into meati. The inferior meatus is defined by the tum. There is also a strong association between unilateral
space between the inferior turbinate and the floor of the concha bullosa and contralateral septal deviation. Pneu-
Fig. 11.1 Middle-turbinate pneumatization variants. a Pneumatization of the bulbous segment of the middle turbinate.
b Pneumatization of the vertical lamella of the middle turbinate
Septal and Turbinate Surgery in Revision Sinus Surgery 93
matization of the superior turbinate is not uncommon The middle turbinate should be examined carefully for
[15, 17], and pneumatization of the inferior turbinate is evidence of previous middle-turbinate resection or scar-
a rare but acknowledged variant as well. ring to the lateral nasal wall. Several studies of patients
requiring revision endoscopic sinus surgery found that
the most common surgical alteration associated with re-
current sinus disease was partial middle turbinectomy
Association with Rhinosinusitis
resulting in middle meatal scarring and lateralization of
■ Variations in septal and turbinate anatomy may play a the middle turbinate [4, 9].
role not only in nasal obstruction, but also in the de-
velopment of chronic sinus disease. This is believed to ■ Lateralization and adhesions of the superior aspect of
be due to both anatomic narrowing of the ostiomeatal the middle turbinate may indicate underlying iatro-
complex (OMC) as well as to disruption of mucocili- genic frontal sinus obstruction.
ary function.
The superior turbinate and sphenoid ostia should be visu-
For example, septal deviation may displace the middle alized as well if possible. Recirculation around the supe-
turbinate laterally, encroaching upon the maxillary os- rior turbinate may occur if there is discontinuity between
tium. Likewise, a pneumatized middle turbinate or supe- the surgical sphenoidotomy and the natural ostium of the
rior turbinate may narrow the middle meatus or superior sphenoid sinus. Finally, an endoscopic assessment of the
meatus, respectively [16]. Middle-turbinate concha bul- nasal septum should be performed. Difficulty accessing
losa has been associated with anterior ethmoid disease, the middle meatus during the office endoscopy indicates
while septal deviation has been associated with disease of a strong likelihood that septoplasty would be beneficial.
the ostiomeatal complex, anterior ethmoid, and posterior Septoplasty is often a necessary complement to en-
ethmoid [2, 6]. doscopic sinus surgery for both intraoperative and post-
In addition to contributing to anatomic narrowing of operative access [3]. During surgery, endoscopic access
the OMC, septal deviation may also contribute to rhi- to the middle meatus can be impaired by otherwise as-
nosinusitis by impairing mucociliary clearance. Septal ymptomatic deflections of the septum. Postoperatively,
deviation has been associated with significantly longer examination and debridement of the sinus cavities can be
mucociliary clearance times than in normal controls. No- more difficult if obstructive septal deflections are left un-
tably, normalization of mucociliary clearance has been corrected. In postsurgical failures, it is important to assess
observed after septoplasty [4, 13]. whether either lack of or incomplete correction of septal
deviation contributed to the poor outcome. Evidence of
prior septoplasty should be recognized prior to revision
septal surgery and may be easier to assess endoscopically
Preoperative Workup
by palpation of the septum with a probe or suction as op-
Assessment of the revision surgical patient should include posed to simple inspection.
a historical review of previous septal or turbinate surgical
procedures. Evidence of previous surgical treatment of
the turbinates and/or septum should be correlated with
Surgical Technique
findings on nasal endoscopy.
Diagnostic nasal endoscopy is an essential component
Endoscopic Septoplasty
of the evaluation of the revision surgical patient, and in-
spection of the turbinates and septum forms a key com- Please refer to Video 11.1. Traditional techniques for cor-
ponent of the endoscopy. The inferior turbinates should rection of septal deformity have relied on headlight il-
be examined before and after application of topical de- lumination. The application of endoscopic techniques to
congestant, in order to adequately assess the degree of septoplasty was initially described in 1992 [8], and offers
soft tissue hypertrophy. Evidence of previous surgical several important advantages [5, 7] .
treatment of the inferior turbinate can often be identified,
including resection or out-fracture. ■ Utilization of the endoscope allows excellent illumina-
tion and visualization, including enhanced identifica-
■ If inspection of the inferior meatus reveals an acces- tion of dissection planes, better assessment of posterior
sory surgical antrostomy, the region should be care- septal deflections, and earlier recognition of flap tears.
fully evaluated for possible recirculation around the
inferior turbinate between the inferior meatal and In addition, the endoscopic technique permits limited,
middle meatal antrostomies. minimally invasive approaches for isolated deviations by
moving the incision to the immediate vicinity of an iso- surgical exposure. Finally, the endoscopic approach pro-
lated septal deflection (Fig. 11.2). vides an excellent teaching tool. Demonstration of sur-
gical anatomy and technique on the video monitor pro-
■ The ability to minimize mucosal elevation is a particu- vides an invaluable learning opportunity for students,
lar advantage in revision septoplasty, where adherent residents, and surgical assistants.
flaps from prior submucous resection may be difficult The patient is positioned, prepared, and draped for
to dissect. septoplasty as is standard for endoscopic sinus surgery.
Topical oxymetazoline is applied for decongestion and
Furthermore, simultaneous endonasal endoscopic ex- 1% lidocaine with 1:100,000 epinephrine injected sub
amination allows the surgeon to gauge the progress made perichondrially.
toward achieving relief of nasal obstruction and adequate
11
Fig. 11.2 Limited endoscopic septoplasty for isolated septal cision of the deviated cartilage and bone. d Reapposition of the
deflection. a Posteriorly placed incision just anterior to septal mucosal flap and confirmation of adequacy of resection
deviation. b–c Elevation of the mucoperichondrial flap and ex-
Incision Design Inferior-Turbinate Reduction

■ The incision is typically placed on the ipsilateral side Refractory chronic sinus disease is not typically due to
of maximal deviation. inferior turbinate hypertrophy. However, symptoms of
■ For a broadly deviated septum, a standard hemi-transnasal obstruction are common among patients with sig-
fixion incision is used. nificant sinonasal inflammation, and therefore inferior-
■ For more posterior isolated deformities or in revision turbinate reduction should be considered in the revision
septoplasty, a more posteriorly placed incision in the FESS candidate with turbinate hypertrophy and obstruc-
immediate vicinity of the deformity can be made with tive symptoms.
an angled scalpel blade.
■ The goal of inferior turbinate reduction is to provide a
controlled reduction of the inferior turbinate soft tis-
sue with maximal mucosal preservation.
Surgical Technique Principles
■ Once the plane of dissection is established, the mu- Several different techniques are currently available for in-
coperichondrial flaps are elevated with a suction ferior turbinate soft-tissue reduction including laser, ra-
Freer or Gorney elevator under direct endoscopic diofrequency, and microdebrider submucous resection.
visualization. The authors prefer the use of powered instrumentation
■ A scope irrigator can greatly enhance visualization for submucous resection of the inferior turbinates and
while working beneath the septal flaps. believe that it offers several advantages.
■ After complete elevation of the ipsilateral septal flap,
the septal cartilage is incised at the point of maximal
deflection, and the contralateral flap elevated.
Advantages of Microdebrider
■ Flap elevation is continued bilaterally until the com-
Inferior-Turbinate Reduction
plete extent of septal deformity has been dissected.
■ The deviated septum is then excised using standard ■ Microdebrider reduction is clinically efficacious while
septoplasty instruments as well as endoscopic scissors, offering excellent mucosal preservation.
punches, or forceps. ■ The surgeon can sculpt targeted anatomic regions
■ The adequacy of the septoplasty is confirmed by per- of the inferior turbinate that may not be as well ap-
forming serial endoscopy of the nasal cavity. proached with other techniques, including the su-
■ Closure involves reapposition of the septal flaps, fol- perior–anterior and most inferior aspect of the
lowed by a running quilting stitch, which is placed turbinate.
endoscopically with a 4–0 plain gut suture on a Keith ■ Finally, while thermal reduction techniques depend
needle. on the contracture of turbinate tissue that occurs over
■ When a hemi-transfixion incision has been made, the time as necrosed regions are replaced by fibroblasts, the
incision is closed under direct visualization with a 5–0 results with microdebrider reduction are immediate.
plain gut suture.
■ When the incision has been placed posteriorly for The procedure can be performed in either the office or the
limited septal work, no closure of the incision is re- operating room setting. A total of 1–2 ml of 1% lidocaine
quired. with 1:100,000 epinephrine solution is injected in the
■ No nasal packing is required. anterior aspect of the inferior turbinate. An incision at
the anteriormost aspect of the inferior turbinate is made
The endoscopic septoplasty technique is also useful for just behind the mucocutaneous border. The incision can
removing isolated septal spurs. A longitudinal incision is be made with a number 15 scalpel or with a specially
made along the apex of the spur and mucosal flaps are designed turbinate microdebrider blade with a built-in
then elevated above and below the spur to reveal the spur dissector (Medtronic, Jacksonville, Florida, USA). A sub-
and allow its removal. The superior and inferior flaps can mucoperiosteal flap is elevated along the anterior half of
be then be reapproximated and the incision usually does the inferior turbinate. The turbinate blade is then placed
not need to be closed with suture. This approach mini- facing outward to reduce the soft tissue under endoscopic
mizes the degree of flap dissection and reduces the risk of visualization via serial passes of the blade from posterior
flap perforation. to anterior. The reduction in size of the inferior turbi-
nate is usually recognized immediately as the procedure
progresses. Out-fracture of the inferior turbinate using
a Boies elevator is frequently performed concurrently the skull base) and resection of only the lateral half of
as a complementary procedure. Hemostasis is typically the turbinate (Fig. 11.3).
achieved with topical epinephrine, and packing is very
rarely required. The incision need not be closed. The extent of middle-turbinate pneumatization is evalu-
ated on CT scans and allows the surgeon to anticipate
points of safe entry into the lumen of the concha bullosa.
Local anesthetic is injected as is routine for FESS, includ-
Excision of Middle-Turbinate Concha Bullosa
ing the middle turbinate mucosa. The concha bullosa is
■ Surgical resection of a concha bullosa entails careful then entered with sharp dissection using either a sickle
preservation of the medial lamella (which attaches to knife or sharp Freer elevator. Because the lumen of the
11
Fig. 11.3 Surgical resection of the concha bullosa. a The con- c The lateral aspect of concha bullosa is resected with through-
cha bullosa is entered sharply with a sickle knife. b The incision cutting forceps. d The medial lamella mucosa and attachment to
is extended superiorly and inferiorly with endoscopic scissors. the cribriform plate are preserved
concha bullosa is a functional ethmoid air cell, great care binate remnant and the lateral nasal wall, parallel to the
must be taken to enter the turbinate without disrupting medial orbital wall. The synechiae can be divided with en-
the mucosal lining of the interior of the concha bullosa. doscopic scissors or a small through-cutting instrument,
Once proper entry is confirmed by endoscopic visualiza- such as a pediatric Blakesley forceps (Fig. 11.4). Once the
tion, the incision is extended from superior to inferior turbinate has been released from its lateral scarred posi-
with either endoscopic scissors or sickle knife, taking care tion, the degree of previous middle-turbinate resection
to not destabilize the attachment of the medial lamella to can be more fully assessed. When previous middle-turbi-
the cribriform plate. Turbinate scissors and through-cut- nate resection has been limited, releasing the lateralized
ting forceps are then used to continue dissection poste- turbinate will reveal a near-normal appearing middle-
riorly. Removal of the lateral lamella may be performed turbinate remnant.
with a microdebrider or in a piecemeal fashion with
through-cutting forceps. In certain cases, the pneuma- ■ The goal in cases with middle-turbinate lateralization
tized middle turbinate may be approached from the pos- is to allow the middle turbinate to heal in a medial po-
terior free edge of the lateral lamella; dissection in these sition.
situations can proceed from posterior to anterior using a
back biter forceps. This can be achieved by placement of a middle meatal
In the revision surgical approach to the partially re- stent for approximately 7 days. Optional scarification
sected concha bullosa, care should be taken to ensure that of the middle turbinate to the nasal septum can be per-
all areas of pneumatization have been addressed. Inad- formed concurrently by abrading the apposing surfaces
equate resection of the inferior bulbous portion of the of the middle turbinate and adjacent septum; middle
middle turbinate can result in narrowing of the middle meatal stenting will bring these surfaces together to fa-
meatus, while incomplete resection of the pneumatized cilitate a favorable adhesion. Alternatively, suturing of the
vertical lamella of the pneumatized turbinate can narrow middle turbinate to the septum is an effective method of
the ethmoid cavity and frontal recess. turbinate medialization. A simple dissolvable mattress
suture (4–0 plain gut on a straight Keith needle) placed
endoscopically will allow sufficient time for the medial-
ized turbinate to heal without reforming adhesions to the
Lateralized Middle-Turbinate Release
lateral nasal wall.
Lateralization of the middle turbinate is a common find- If the middle-turbinate remnant is substantially trun-
ing in the post-FESS patient and may occur as a result of cated or ossified from prior resection, restoration of the
several factors. First, the turbinate may be attenuated and turbinate to a medial position may not be possible. In
“floppy” due to over resection. Secondly, surgical trauma such cases, selective resection of the lateralized portions
to the mucosal surface of the turbinate may predispose to of the turbinate may actually be necessary to relieve eth-
the development of adhesions with the lateral nasal wall. moid or frontal obstruction.
Thirdly, inadequate postoperative debridement may allow Regardless of the surgical strategy employed, post-
early granulation to mature into adherent synechiae. Be- operative inspection and debridement of granulation is
cause middle-turbinate lateralization may collapse, scar, important to prevent early scar formation and relateral-
and narrow the sinus outflow tracts, surgical correction is ization.
often indicated in the revision FESS patient.
The patient is positioned, prepared, and draped as is
standard for endoscopic sinus surgery. Topical oxymetazo-
Superior-Turbinate Resection
line or epinephrine (1:1000) is applied preoperatively for
decongestion. Intraoperative surgical navigation may be Although less common, revision surgery involving the
helpful during the initial diagnostic endoscopy, confirm- superior turbinate can pose similar challenges to those
ing the relationship of the middle-turbinate remnant to posed by the middle turbinate. Just as the middle turbi-
the medial orbital wall. The position of the skull base and nate forms the medial border of the anterior ethmoid cav-
cribriform plate should also be determined. Once these ity, the superior turbinate defines the medial border of the
critical anatomic structures are delineated, safe infiltra- posterior ethmoid cavity. As imprecise anterior ethmoid
tion of the middle-turbinate remnant and medial orbital and frontal recess dissection can lead to destabilization
wall with 1% lidocaine with 1:100,000 epinephrine solu- and scarring of the middle turbinate, so too can posterior
tion is performed. ethmoid and sphenoid surgery lead to superior-turbinate
The initial step is a release of the scarred middle tur- scarring and postsurgical failure.
binate from the lateral nasal wall. The release is achieved When sphenoidotomy is performed through a trans-
through a vertically oriented incision between the tur- ethmoidectomy approach, the inferior portion of the
11
Fig. 11.4 Release of the lateralized middle turbinate. a Previ-

ous resection of the middle turbinate with lateralization and
scarring to the lateral nasal wall. b Dense scar tissue between
the middle-turbinate remnant and medial orbital wall. c Verti-
cally oriented release of synechiae and medialization of the
middle-turbinate remnant
superior turbinate is resected with a through-cutting in- superior turbinate should be performed with a through-
strument to expose the natural sphenoid ostium within cutting forceps. The sphenoid ostium can then be en-
the sphenoethmoid recess. Once identified, the sphe- larged and brought into continuity with the remainder of
noid ostium is enlarged and the anterior wall of the si- the surgical sphenoidotomy, as necessary.
nus removed using through-cutting punches and forceps.
In situations where the inferior portion of the superior ■ Conservative resection of the inferior third of the su-
turbinate is not resected cleanly, the remnant superior perior turbinate should not result in significant distur-
turbinate may form adhesions with adjacent tissue. The bance of the olfactory neuroepithelium.
sphenoid outflow may then be compromised because ei-
ther the natural ostium is obstructed or recirculation of
mucous has developed around the superior turbinate be- Tips and Pearls to Avoid Complications
tween the natural ostium and surgical sphenoidotomy.
1. Palpate the septum carefully in revision septo-
Surgical correction of a scarred superior turbinate is
plasty in order to anticipate the extent of prior
relatively straightforward. The first step is to identify and
submucous resection. Take extra caution in elevat-
cannulate the natural ostium of the sphenoid sinus. At
ing the mucosal flaps over absent septal bone or
this point, resection of the scarred inferior aspect of the
6. Elahi MM, Frenkiel S, Fageeh N (1997) Paraseptal struc-

cartilage, or move the incision posteriorly to avoid
tural changes and chronic sinus disease in relation to the
dissecting in areas of prior surgery.
deviated septum. J Otolaryngol 26:236–240
2. If possible, minimize dissection of the posterior
7. Hwang PH, McLaughlin RB, Lanza DC, et al (1999) En-
third of the inferior turbinate during soft-tissue re-
doscopic septoplasty: indications, technique, and results.
duction. This area may carry feeding vessels from
Otolaryngol Head Neck Surg 120:678–682
the sphenopalatine artery and may be more prone
8. Lanza DC, Kennedy DW, Zinreich SJ (1991) Nasal endos-
to postoperative bleeding.
copy and its surgical application. In: Lee KJ (ed) Essential
3. Always confine concha bullosa excision to the lat-
Otolaryngology: Head and Neck Surgery, 5th edn. Medical
eral aspect of the turbinate. The medial turbinate
Examination, New York, pp. 373–387
carries the attachment to the skull base and should
9. Musy PY, Kountakis SE (2004) Anatomic findings in pa-
be left undisturbed.
tients undergoing revision endoscopic sinus surgery. Am J
4. Be aware of the presence of middle-turbinate la-
mellar cells, which can harbor disease and should
10. Senior BA, Kennedy DW, et al (1998) Long-term results
be opened along with pneumatized portions of the
of functional endoscopic sinus surgery. Laryngoscope
bulbous middle turbinate.
108:151–157
11. Stallman JS, Lobo JN, Som PM (2004) The incidence
of concha bullosa and its relationship to nasal septal de-
viation and paranasal sinus disease. Am J Neuroradiol
References
25:1613–1618
1. Bolger WE, Butzin CA, Parson DS (1991) Paranasal si- 12. Stammberger H (1991) Functional Endoscopic Sinus Sur-
nus bony anatomic variations and mucosal abnormalities: gery. Decker, Philadelphia
CT analysis for endoscopic sinus surgery. Laryngoscope 13. Ulusoy B, Arbag H, Sari O, et al (2007) Evaluation of the
101:56–64 effects of nasal septal deviation and its surgery on nasal
2. Calhoun KH, Waggenspack GA, Simpson CB, et al (1991) mucociliary clearance in both nasal cavities. Am J Rhinol
CT evaluation of the paranasal sinuses in symptomatic and 21:180–183
asymptomatic populations. Otolaryngol Head Neck Surg 14. Uslu H, Uslu C, Varoglu E, et al (2004) Effects of septo-
104:480–483 plasty and septal deviation on nasal mucociliary clearance.
3. Cantrell H (1997) Limited septoplasty for endoscopic sinus Int J Clin Pract 58:1108–1111
surgery. Otolaryngol Head Neck Surg 116:272–276 15. van Alyea OE (1939) Ethmoid labyrinth. Arch Otolaryngol
4. Chu CT, Lebowitz RA, Jacobs JB (1997) An analysis of sites 29:881–902
of disease in revision endoscopic sinus surgery. Am J Rhi- 16. Yasan H, Dögru H, Baykal B, et al (2005) What is the re-
nol 11:287–291 lationship between chronic sinus disease and isolated
5. Chung BJ, Batra PS, Citardi MJ, et al (2007) Endoscopic nasal septal deviation? Otolaryngol Head Neck Surg
septoplasty: revisitation of the technique, indications, and 133:190–193
outcomes. Am J Rhinol 21:307–311 17. Zuckerkandl E (1882) Normale und pathologische Anato-
mie der Nasenhöhle und ihrer pneumatischen Anhänge.
Wilhelm Braumüller, Wien
Chapter 12

of the Ethmoid and Maxillary Sinus 12
Biana G. Lanson, Seth J. Kanowitz,
Richard A. Lebowitz, and Joseph B. Jacobs
Contents
Core Messages Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Causes for Surgical Failures . . . . . . . . . . . . . . . . . . . . . . 101
■ Revision FESS is substantially more complex than Preoperative Workup and Indications . . . . . . . . . . . . . 104
primary surgery due several factors.
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
■ Etiologies for recalcitrant postsurgical chronic rhi-
General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
nosinusitis are classified broadly as environmental,
host, or iatrogenic. Revision Maxillary Sinus Surgery . . . . . . . . . . . . . . . 105
■ In order to maximize the success rate of revision Revision Ethmoid Sinus Surgery . . . . . . . . . . . . . . . . 106
FESS the surgeon must be familiar with the evalua-
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
tion, diagnosis, surgical anatomy, and management
of these complex patients. Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Introduction Causes for Surgical Failures

Functional endoscopic sinus surgery (FESS) is indicated Causes of treatment failures following FESS include en-
for the treatment of symptoms of chronic rhinosinusitis vironmental factors, host systemic diseases, iatrogenic
(CRS). Success rates after FESS have been reported as problems, and surgical deficiencies [6]. Taken as a whole
ranging from 74 to 97.5% [13, 14, 22], leaving 2.5–26% these are thought to impair normal mucociliary clear-
of patients still suffering from persistent symptoms and ance and cause postoperative surgical treatment failures.
signs of chronic infectious and/or inflammatory sinus Environmental control is an important component in the
disease following surgery. As more and more primary medical management of patients with CRS; exposure to
FESS procedures are performed, the number of patients irritants and allergens should be minimized or eliminated
who are being evaluated for revision sinus surgery is also whenever possible [6].
increasing. This chapter will help to educate the otolar- Similarly, host systemic diseases may cause excessive
yngologist about patients who present with failure of pri- mucosal inflammation and result in further impairment
mary maxillary and ethmoid sinus surgery, whether due of mucociliary clearance. These conditions include aller-
to inadequacy of the primary surgery or the recurrence gic diathesis [14], the recurrent sinonasal polyposis that
of sinonasal mucosal disease resulting from underlying can result from the inflammatory response seen in Churg
medical or immunologic conditions. The chapter will also Strauss Syndrome or Job’s Syndrome, cystic fibrosis [19],
provide a guideline for the diagnosis, management, and granulomatous disease, neoplasia, and immotile ciliary
treatment of patients presenting with persistent symp- syndrome [1]. Some authors propose that the presence
toms of CRS after sinus surgery. of eosinophilic infiltration, as seen in both allergic and
nonallergic rhinosinusitis, can be an important variant in
predisposing a patient to the closure of a middle meatal
antrostomy with subsequent persistence of inflammatory
102 Biana G. Lanson, Seth J. Kanowitz, Richard A. Lebowitz, and Joseph B. Jacobs
changes within the maxillary sinus [8, 10]. Similarly, in ■ Surgical antrostomies that do not communicate with
patients with sinonasal polyposis, a history of previous si- the natural ostia can also generate a “recirculation
nus surgery, asthma, or allergy predicted recurrence and phenomenon” in which mucus is swept by the cilia
need for revision surgery [23]. out of the maxillary sinus via the natural ostium but
Iatrogenic causes of treatment failure can result from then reenters the sinus though the improperly placed
poor surgical technique (i.e., an improperly placed max- surgical antrostomy (Fig. 12.1) [21]. This may lead to
illary antrostomy), middle-turbinate resection with lat- persistence of maxillary sinus disease.
eralization of the turbinate remnant, inadequate post-
operative nasal debridement, or deficient postoperative Surgical trauma to the nasal mucosa, associated with
medical management leading to a persistent infectious mucosal stripping and bone exposure, can often result
or inflammatory mucosal response. Furthermore, over- in synechiae, fibrosis, regrowth of poorly ciliated epi-
aggressive removal of healthy mucosa resulting in bone thelium, osteoneogenesis, and osteitis (Fig. 12.2), which
exposure during primary FESS or, alternatively, failure have all been implicated as potential etiologies of surgical
to remove diseased bony ethmoid partitions may lead to failure [21]. Bacterial invasion of exposed bone and the
significant scarring or an osteitic response. subsequent chronic inflammatory reaction are thought
to potentiate the osteoneogenesis process. Inflammation
A suggested important reason for surgical failure is a within the bone is difficult to eradicate and can be a nidus
“missed ostium sequence” [21]: for local production of additional inflammatory media-
■ Inadequate surgical removal of the most anterior por- tors causing persistent mucosal disease and inhibition of
tion of the uncinate process blocks visibility of the healing [6]. In addition, mucosal stripping and the cre-
most anterior fontanelle leading to failure to identify ation of raw surfaces may result in postoperative lateral-
the natural maxillary ostium and incorporate it in the ization of the middle turbinate and subsequent synechiae
maxillary sinus antrostomy. An accessory maxillary formation adhering the middle turbinate to the lateral
12 ostium may be mistakenly enlarged resulting in per- nasal wall (Fig. 12.3). Secondary anatomic obstruction of
sistent disease due to mucociliary flow being directed the ostiomeatal pathways often results.
toward the obstructed natural outflow tract rather Ramadan reviewed 398 patients who did not have a
than toward the surgically created antrostomy. medical history of immunodeficiency, systemic disor-
ders, cystic fibrosis, or ciliary abnormality, but whose
Fig. 12.1a,b Maxillary recirculation. a Endoscopic visualization (30 endoscope) of an improperly placed maxillary an-
trostomy. The natural maxillary sinus osier (yellow arrow) is not in continuity with the posterior maxillary antrostomy
(white arrow) or accessory ostium (white arrowhead), as a result of either scar tissue formation or improper placement
of the antrostomy in the posterior fontanelle during primary functional endoscopic sinus surgery (FESS). b After revi-
sion, the new maxillary antrostomy now includes the natural ostium, accessory ostium, and the antrostomy that had
been created during primary FESS
Revision Endoscopic Surgery of the Ethmoid and Maxillary Sinus 103
Fig. 12.2 Osteitis. Preoperative coronal

computed tomography (CT) scan or the
paranasal sinuses in a patient undergo-
ing revision FESS. Areas of osteitic bone
within the ethmoid cavity (yellow arrows),
retained uncinate process (white arrows)
leading to scarring of the maxillary antros-
tomy, and an undissected concha bullosa
(white asterisk) have likely contributed to
this patients primary FESS failure
CRS symptoms persisted after their primary FESS proce-

dure. Fifty-two of these patients required a revision FESS
procedure. He found that the revision cases had a higher
mean computed tomography (CT) score, according to
the Lund-MacKay staging system, compared with non-
revision cases. Fifty six percent of the revision cases had
evidence of adhesions, and the most common cause of
revision surgery was the presence of residual air cells and
stenosis of sinus ostia [22] . Chambers et al. and Hinohira
et al. noted that scarring in the middle meatus, residual
ethmoid cells, and stenosis of the maxillary sinus ostium
are the common causes for surgical failure [4, 12]. Chu et
al. reported 153 patients requiring revision sinus surgery
and found that the most common surgical alteration to be
partial middle turbinectomy with resulting lateralization
of the middle turbinate remnant and subsequent scarring
of the middle meatus [5]. Thus, mucosal preservation
during both primary and revision FESS is essential for
a successful outcome. This can be achieved with use of
Fig. 12.3 Lateralized middle turbinate. Endoscopic visualiza- through-cutting instruments and directed powered mu-
tion (0 endoscope) of a lateralized right middle turbinate (aster- cosal shaving techniques.
isk). A web of scar tissue (yellow arrow) has formed between the Incomplete surgery resulting in persistent symptoms
middle turbinate (asterisk) and the lateral nasal wall (red arrow- following primary FESS may be due residual ethmoid
heads), thus leading the lateralization of the middle turbinate air cells or the failure to address anatomic findings such
and persistence of chronic rhinosinusitis after primary FESS as pneumatization of the middle turbinate (concha bul-
losa), deviation of the nasal septum, and the presence of steroid therapy as well as systemic antibiotic and steroid
infraorbital (Haller) cells [3, 20]. In a study by Musy and therapy as part of the initial medical management of their
Kountakis, among 70 patients with primary surgical fail- recurrent sinus disease. Many otolaryngologists advocate
ure, 70% had a lateralized middle turbinate and 64% had a short burst of high-dose oral steroids just prior to revi-
an incomplete anterior ethmoidectomy [17]. A retained sion surgery, in order to reduce sinonasal mucosal edema
foreign body (e.g., infected dental implant in the maxil- and facilitate the delineation of anatomic structures. Pre-
lary cavity) can also cause persistent sinonasal infection operative steroids, 20–40 mg/day for 4–10 days can re-
and disease. duce polyp size, stabilize or reduce mucosal edema, and
reduce intraoperative bleeding [6].
A recent CT scan of the paranasal sinuses is required
after maximal medical therapy. In the case of revision
Preoperative Workup and Indications
maxillary and ethmoid sinus surgery, close attention
Evaluation for revision sinus surgery begins with the should be paid to evaluation of the residual uncinate pro-
patient’s history, including a thorough review of the past cess, residual ethmoid cells and septae, supraorbital eth-
medical history, as well as the physical exam. Potential moid cells, infraorbital ethmoid cells, and the presence
environmental and host factor influences are carefully of mucoceles. It is imperative to evaluate the skull base
discussed. Close attention is paid to eliciting a history of height (Keros I–III) and position of the lamina papyra-
immunodeficiency, cystic fibrosis, granulomatous and cea, as well as to check for evidence of previous breach
autoimmune disease, and genetic syndromes, such as of these boundaries. An example of a residual uncinate
Kartagener’s syndrome and Churg Strauss Syndrome. The process seen on coronal CT of the sinuses is shown in
surgeon should also obtain original records and radio- Fig. 12.4.
graphs whenever possible. Prior surgical technique, peri- Magnetic resonance imaging (MRI) can be a useful
operative medical therapy as well as a schedule of post- adjunct radiologic modality in the evaluation of patients
12 operative surgical debridements should to be reviewed. with skull-base dehiscence, previous orbital injury, or in
It is prudent to know whether a mucosal-preserving cases of sinonasal neoplasia. MRI can identify the pres-
technique was used, appropriate antibiotics and steroid ence of a meningoencephalocele, help distinguish be-
treatments prescribed, adequate and timely debridement tween tumor, polyps, mucin, and secretions, and assess
procedures performed, and whether the patient had used the integrity of the periorbita and dura.
sterile nasal saline irrigation and/or any other alternative
therapies that may have complicated treatment [6].
Nasal endoscopic evaluation of the patient is also of
utmost importance. The degree of inflammation and/or
infection of the sinuses can be assessed. Moreover, most
surgically created anatomic problems can be identified:
retained uncinate process, scaring and synechiae forma-
tion, lateralized middle-turbinate remnants, improperly
placed maxillary antrostomy, or residual infraorbital cells
[6]. The mucosal findings are potentially reversible, es-
pecially if not associated with anatomic obstruction. The
patient’s symptoms can often be correlated with the en-
doscopic findings and therefore should be carefully docu-
mented. The revision surgeon should be convinced of the
rhinologic origin of the patient’s symptoms before plan-
ning surgery.
Preoperative identification and treatment of a resistant
bacterial infection can aid in revision surgery. Staphylo-
coccus aureus, methicillin-resistant S. aureus, and Gram-
negative organisms, such as Pseudomonas, are the most
common bacteria in patients presenting for revision sur- Fig. 12.4 Retained uncinate. Preoperative coronal CT scan
gery [2, 18]. Purulent secretions should be cultured and of the paranasal sinuses in a patient undergoing bilateral revi-
culture-directed antibiotics initiated prior to surgery. sion endoscopic maxillary antrostomy. Fragments of retained
Therapy in patients suffering from allergic fungal sinus- uncinate process (yellow arrows) lead to scarring and eventual
itis or eosinophilic mucin rhinosinusitis may include sys- stenosis of the maxillary antrostomy bilaterally. As a result, the
temic and topical antifungals and steroids [9]. patient suffered from chronic maxillary rhinosinusitis after pri-
The majority of the patients are treated with topical mary FESS
The use of intraoperative computer-assisted stereo- debrided with curettes. In the case of diffuse osteitis, a
tactic surgical navigation has enhanced potential access high-speed suction irrigation, diamond-tipped drill can
with decreased morbidity to altered anatomic structures be utilized.
in complicated revision procedures [11]. Needless to say,
the surgeon should still be vigilant about the identifica-
tion of key anatomic structures and should not rely solely
Revision Maxillary Sinus Surgery
on the navigation system. Also, repeated visual confirma-
tion of registration should be performed throughout the ■ Key landmarks during maxillary sinus surgery in-
surgery. clude:
Appropriate counseling of patients is also imperative 1. Floor of the orbit.
once the decision has been made to proceed with surgery. 2. Lamina papyracea.
Goals of surgery, increased risks of revision sinus surgery, 3. Superior attachment of the inferior turbinate.
patient expectations, need for long-term follow-up, post- 4. Ascending process of the maxilla.
operative debridement, and medical management should
all be addressed. If the maxillary sinus roof (orbital floor) can be visualized
through the previous maxillary antrostomy, the plane of
the lamina papyracea can be established. The sinus should
be visualized with angled telescopes. If the antrostomy
Technique
is patent then it can be probed with a maxillary ostium
seeker, making sure the angle of dissection is inferolateral
General
and away from the orbit. The seeker can also be used to
Recent radiographic studies must be present in the op- palpate the ascending process of the maxilla. A flexible
erating room and the surgeon should reference these fiberoptic endoscope can be helpful for visualization of
materials before and during the surgery. Correlation of the antrum via a small antrostomy.
CT images and intraoperative endoscopic findings can be If a retained uncinate process is visualized, it should
especially helpful in revision surgery when the patient’s be removed using a 90 Blakesley forceps, microdebrider,
sinonasal cavity lacks the usual anatomic landmarks. An back-biting forceps, or down-biting forceps. Care must
attempt should also be made to identify the anterior eth- be taken to avoid injury to the nasolacrimal duct ante-
moid artery on the CT images as the normal bony cov- riorly. This region should be palpated with a maxillary
ering may have been removed during previous surgery, ostium seeker prior to removal of any bony fragments.
thus making inadvertent injury more likely during revi- Remnants of the uncinate process can be gently medial-
sion procedures. ized to help avoid damage to the nasolacrimal duct. If the
Before initiating surgery, decongestion and vasocon- natural maxillary ostium is obstructed, it can be enlarged
striction of the sinonasal cavity may be achieved with using angled-through cutting forceps or Blakesley for-
topical oxymetazoline and injection of 1% xylocaine ceps. In the case of a maxillary antrostomy having been
with 1:100,000 or 1:200,000 epinephrine. As in all sur- placed posteriorly, it should be brought into continuity
gical procedures, the surgeon is to work from “known” with the natural ostium. This can be achieved by using
to “unknown.” Both the maxillary and ethmoid cavities through-cutting instruments to incise the soft tissue be-
should be inspected with angled rigid endoscopes, and tween the antrostomy and the natural ostia. It is helpful to
appropriate cultures obtained with suction traps. The remember that natural maxillary ostia are oblique – not
primary landmarks in revision surgery are the middle in the same plane as the lateral nasal wall. Thus, visualiza-
turbinate/turbinate remnant, roof of the maxillary sinus, tion of the natural ostium with a 70 rigid endoscope is
medial orbital wall, and skull base. key to verify that it is in continuity with the newly created
If the middle turbinate is scarred laterally and ob- antrostomy.
structing access to the ethmoid cavity it should be gently
medialized. Synechiae and scarring should be released ■ In cases of patients who suffer from failure of muco-
with a sharp sickle knife or through-cutting forceps, and ciliary transport, such as cystic fibrosis or Kartagener’s
all attempts should be made to preserve the mucosa [4]. syndrome, a large maxillary ostium is to be created
that should encompass most of the medial wall of the
■ It is important to remember that when medializing the maxillary sinus. This allows for copious nasal irriga-
middle turbinate it may be thickened due to osteoneo- tion and drainage by gravity with appropriate head
genesis, thus making medialization more difficult and positioning.
the risk of injury to the skull base greater.
In some cases a limited Caldwell-Luc approach for inser-
When encountering osteitic bone, the bone should be tion of sinus instruments or endoscopes may be helpful
to access disease located inferiorly or laterally within the

when performing surgery in the previously oper-
maxillary sinus. The disease processes that may require
ated maxillary sinus.
such extended maneuvers include retained foreign bodies
4. Key anatomic landmarks during revision ethmoid
and fungal balls.
sinus surgery include the skull base, lamina papy-
Finally, the maxillary sinus can have persistent dis-
racea, and face (rostrum) of the sphenoid.
ease from the infected secretions draining down from the
5. The sphenoethmoid cell, the orbitoethmoid cell,
frontal and ethmoid sinuses. Addressing the frontal/eth-
and most anterior and superior ethmoid cells can
moid disease is thus imperative in this situation.
be the most challenging and important cells for
marsupialization into the sinonasal cavity during
revision ethmoid sinus surgery.
Revision Ethmoid Sinus Surgery
Revision ethmoid sinus surgery seeks retained ethmoid
Complications
cells, septae, and scarring that impairs mucociliary flow
and clearance. In addition, foci of inflammatory mucosal Surgical complications of revision sinus surgery resonate
disease and osteitis are identified and addressed. Care is those of primary sinus surgery. However, the revision
taken to open residual air cells and their septae as well as surgeon should take special care in the surgical approach,
to remove foci of inflammatory disease while sparing as as some of the normal anatomic landmarks may be ab-
much nasal mucosa as possible. The sphenoethmoid cell, sent or distorted by the previous surgery, and defects in
the orbitoethmoid cell, and most anterior and superior the lamina and or skull base may be present.
ethmoid cells can be the most difficult and challenging Complications can be divided into local, orbital, skull
cells to incorporate into the sinonasal cavity during revi- base, and intracranial events [24]. Local events include
sion ethmoid sinus surgery. When the bone has become bleeding and synechiae formation. Orbital complications
12 markedly thickened from osteitis, part of the revision include violation of the lamina papyracea, with orbital
ethmoidectomy can be performed with a suction-irriga- bleeding or injury to the medial rectus muscle, injury to
tion drill [6]. the anterior ethmoid artery resulting in bleeding and/or
As during primary FESS, it is imperative to identify orbital hematoma, and injury to the optic nerve. Skull-
the skull base, lamina papyracea, and sphenoid rostrum base injuries can manifest as an intraoperative or post-
early during the surgical procedure. The preoperative CT operative CSF leak and subsequent formation of a me-
scan is essential for the assessment of the integrity of the ningocele or encephalocele. Finally, intracranial injuries
lamina papyracea and skull base, which may be thinned include subarachnoid hemorrhage, pseudoaneurysm,
or eroded due to chronic disease or prior surgery. Some and extra-axial, parenchymal, or intravetricular hemor-
surgeons advocate finding the skull base in patients with rhage. With the use of powered instrumentation, more
extensive ethmoid disease or scarring by first entering the severe complications can occur from inadvertent viola-
sphenoid sinus [7] and/or using image guidance to con- tion of the lamina or skull base.
firm its location.
If a bony skull-base defect is identified, MRI should be
considered to determine whether a meningocele or en-
Postoperative Care
cephalocele is present. Intrathecal injection of fluorescein
may also be used to diagnose a meningocele and demon- ■ Aggressive medical therapy:
strate a cerebrospinal fluid (CSF) leak. 1. Culture-directed antibiotics based on intraopera-
tive microbiology specimen results.
Tips and Pearls to Avoid Complications 2. Systemic corticosteroids are often indicated. If eo-
sinophil-predominant polyps and mucus point to
1. Recent radiographic studies must be present in the
an underlying allergic component, longer courses
operating room and the surgeon should reference
or frequent bursts may be indicated.
these materials before and during the surgery.
3. Topical steroids. The physician should try to mini-
2. Key anatomic landmarks during revision maxillary
mize oral steroid use and transition to a combina-
sinus surgery include the floor of the orbit, lamina
tion of topical and mechanical treatments as soon
papyracea, superior attachment of the inferior
as the endoscopic exam findings allow.
turbinate, and ascending process of the maxilla.
4. Sterile nasal saline irrigation.
3. Back-biting forceps, down-biting forceps, angled
5. Management of underlying host and environmen-
microdebrider, maxillary ostium seeker, and flex-
tal factors, such as allergies.
ible fiberoptic endoscope are useful instruments
■ Meticulous postoperative debridement based upon 4. Chambers DW, Davis WE, Cook PR, et al. (1997) Long-
endoscopic findings and close monitoring of the sino- term outcome analysis of functional endoscopic sinus
nasal mucosa. surgery: correlation of symptoms with endoscopic exami-
nation findings and potential prognostic variables. Laryn-
■ Close endoscopic follow-up with reevaluation of med- goscope 107:504–510
ical therapy based on exam findings: 5. Chu CT, Lebowitz RA, Jacobs JB (1997) An analysis of sites
1. Endoscopic surveillance is an important tool in the of disease in revision endoscopic sinus surgery. Am J Rhi-
postoperative care of revision sinus surgical pa- nol 11:287–291
tients. 6. Cohen NA, Kennedy DW(2006) Revision endoscopic sinus
2. Medical therapy can be either tapered or reinitiated surgery. Otolaryngol Clin North Am 39:417–435
based on findings of mucosal inflammation, aera- 7. Cullen MM, Bolger WE (2001) Revision endoscopic sinus
tion, or secondary infection. surgery for recurrent rhinosinusitis. In: Kennedy DW, Bol-
ger WE, Zinreich SJ (eds) Diseases of the Sinuses. Diagno-
■ Culture-directed antibiotic therapy for acute exacer- sis and Management. Decker, Hamilton, Ontario, Canada,
bations of chronic rhinosinusitis. pp 245–254
■ CT studies if the original symptoms persist or new 8. Davis WE, Templer JW, Lamear WR (1999) Middle meatus
symptoms occur that cannot be explained by endo- antrostomy: patency rates and risk factors. Otolaryngol
scopic findings. Head Neck Surg 104:467–472
9. DeShazo RD, Chapin K, Swain RE (1997) Fungal sinusitis.
N Engl J Med 337:254–259
10. Elwany S, Bassyouni M, Morad F (2002) Some risk fac-
Outcomes
tors fro refractory chronic sinusitis: an immunohisto-
Moses et al. studied 90 revision FESS cases and reported chemical and electron microscopic study. J Laryngol Otol
a success rate of 67%. Extent of disease, history of pol- 116:112–115
yps, allergy, previous traditional endonasal sinus surgery, 11. Fried MP, Moharir VM, Shin J, et al. (2002) Comparison
male gender, chronic steroid use, and the presence of a of endoscopic sinus surgery with and without image guid-
deviated septum all appeared to adversely affect revision ance. Am J Rhinol 16:193–197
FESS outcome [16]. McMains and Kountakis studied 125 12. Hinohira Y, Yumoto E, Hyodo M, et al. (1995) Revision en-
patients who underwent revision sinus surgery after fail- doscopic sinus surgery – long-term follow up and operative
ing both maximum medical therapy and prior sinus sur- findings. Nippon Jibiinkoka Gakkai Kaiho 98:1285–1290
gery for chronic rhinosinusitis. They followed their pa- 13. Kennedy DW (1992) Prognostic factors, outcomes and
tients over a 3-year period and found an overall success staging in ethmoid sinus surgery. Laryngoscope 102:1–18
rate of 92% when evaluating patient symptom scores, 14. Levine HL (1990) Functional endoscopic sinus surgery:
Sinonasal Outcome Test (SNOT-20), and nasal endos- evaluation, surgery, and follow-up of 250 patients. Laryn-
copy scores. Patients with nasal polyposis were more apt goscope 100:79–84
to fail revision FESS than patients with other medical 15. McMains KC, Kountakis SE (2005) Revision functional
conditions [15]. We believe that close endoscopic moni- endoscopic sinus surgery: objective and subjective surgical
toring of the patient’s sinonasal cavities and timely treat- outcomes. Am J Rhinol 19:344–347
ment of early recurrent disease can help avoid repetitive 16. Moses RL, Cornetta A, Atkins JP Jr, et al. (1998) Revision
surgeries. endoscopic sinus surgery: the Thomas Jefferson University
experience. Ear Nose Throat J 77:190, 193–195, 199–202
17. Musy PY, Kountakis SE (2004) Anatomic findings in pa-
tients undergoing revision endoscopic sinus surgery. Am J
References
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Surg 117:S50–S52 12:233–241
2. Bolger WE (1994) Gram negative sinusitis: an emerging 19. Nishioka GJ, Cook PR, Davis WE, et al. (1994) Immuno-
clinical entity? Am J Rhinol 8:279–283 therapy in patients undergoing functional endoscopic si-
3. Bolinger WE, Woodruff WW, Parsons DS, et al. (1990) nus surgery. Otolaryngol Head Neck Surg 110:406–412
Maxillary sinus hypoplasia: classification and description 20. Parsons DS, Nishioka GI (2001) Pediatric sinus surgery. In:
of associated uncinate process hypoplasia. Otolaryngol Kennedy DW, Bolger WE, Zinreich SJ (2001) Diseases of
Head Neck Surg 103:759–765 the Sinuses: Diagnosis and Management. Decker, Hamil-
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21. Parsons DS, Stivers FE, Talbot AR (1996) The missed os- 23. Wynn R, Har-El G (2004) Recurrence rates after endo-
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tional endoscopic sinus surgery. Otolaryngol Clin North scope 114:811–813
Am 29:169–183 24. Zeifer B (2002) Sinusitis: postoperative changes and surgi-
22. Ramadan HH (1999) Surgical causes of failure in endo- cal complications. Semin Ultrasound CT MR 23:475–491
scopic sinus surgery. Laryngoscope 109:27–29
12
Chapter 13

of the Sphenoid Sinus 13
Richard R. Orlandi
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
■ Revision sphenoid sinus surgery is usually most eas- Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
ily performed after a complete ethmoidectomy. Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
■ The sphenoid sinus natural ostium can typically be
Postoperative Care and Outcomes . . . . . . . . . . . . . . . . . 113
found using the superior turbinate as a landmark,
even in revision cases. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
■ Once a decision is made to enlarge the sphenoid
sinus ostium, a maximally wide opening will mini-
mize the risk of stenosis.
■ Attempts at widening the natural ostium inferiorly
Evaluation
and medially do not typically improve the chances
of a patent ostium postoperatively and can lead to
bleeding and unnecessary mucosal disruption. Tips and Pearls
1. Sphenoid sinusitis following previous surgery is

best evaluated both endoscopically and radio-
graphically.
2. Many “revision sphenoidotomies” involve previ-
ously unopened sphenoid sinuses, where a poste-
rior ethmoid cell was mistaken for the sphenoid
sinus.
3. Thorough analysis of the cause of the previous
failed sphenoidotomy minimizes the chances of it
recurring.
Introduction
The need for revision of altered anatomic structures in Persistent or recurrent sphenoid disease may complicate
the sphenoid region is not as common as in the ethmoid up to 10% of primary sphenoidotomies [7]. Assessment
or frontal regions [5]. Nevertheless, even primary sphe- of a previous sphenoidotomy can be achieved both ra-
noid sinus surgery challenges many sinus surgeons due diographically and endoscopically. Because the anterior
to the proximity of the optic nerve and internal carotid wall of the sphenoid sinus runs in the coronal plane, axial
artery. Landmarks in the posterior ethmoid sinus are few, images are most helpful in assessing this structure. Re-
making accurate identification of the natural ostium and view of coronal imaging may yield clues as to the cause
verification of presence within the sphenoid sinus, not a of the sphenoidotomy failure, such as the presence of a
posterior ethmoid cell, difficult. The alteration of the sur- sphenoethmoidal (Onodi) cell superior and lateral to the
gical field in revision sphenoid surgery serves to intensify sphenoid sinus (Fig. 13.1).
these difficulties. While complications occur in 13% of Endoscopic evaluation of the sphenoid sinus is typi-
sphenoidotomies overall and tend to be minor, the vast cally performed as part of a diagnostic nasal endoscopy
majority occur in revision cases [7]. in a patient who has undergone previous sinus surgery.
110 Richard R. Orlandi
Fig. 13.1 Coronal (a) and sagittal (b) computed tomography moidal cell, not the sphenoid sinus. In the sagittal image (a), the
(CT) scan of the sphenoid sinuses (S), demonstrating a right- continuity of the sphenoethmoid cell with the remaining poste-
sided sphenoethmoidal cell (asterisk). Note that the right optic rior ethmoid complex is clearly seen
nerve (arrowhead) runs in the lateral wall of the sphenoeth-
13
Visualization of the surgical ostium of the sphenoid sinus terior ethmoid cells and sphenoethmoidal (Onodi) cells
is facilitated by using the middle and superior turbinates can often be mistaken for the sphenoid sinus. In these
as reference landmarks. These two structures run in the cases, revision of the sphenoid sinus is not a true revision
same parasagittal plane and share a skull-base attach- at all, but instead amounts to a primary sphenoidotomy
ment, with the superior turbinate extending posteriorly via an operated posterior ethmoid sinus. Preoperative
and superiorly from the middle turbinate (Fig. 13.2) [6]. imaging can assist in determining if the sphenoid sinus
The superior turbinate forms a critical and nearly con- was previously opened. The natural bone aperture of the
stant landmark for the sphenoid sinus [2]. Even patients sphenoid sinus ostium is typically only 3–4 mm in diam-
who have undergone middle-turbinate resection will typ- eter so that a larger bone gap seen on imaging indicates
ically have a superior-turbinate remnant medially within a sphenoidotomy has likely been performed previously
the posterior ethmoid complex (Fig. 13.3). (Fig. 13.5). The natural ostium of the sphenoid sinus
The posterior ethmoid cavity should be assessed for empties into the sphenoethmoidal recess, medial to the
persistent inflammation, which may contribute to con- superior turbinate in all cases [4]. Openings in the sinus
tinuing sphenoid rhinossinusitis. Scarring among residual lateral to the superior turbinate indicate that the sinus has
posterior ethmoid partitions, particularly medially near probably been previously opened surgically, but also that
the superior turbinate, indicates likely involvement of the the opening probably did not include the natural ostium.
sphenoid sinus drainage in the scarring. Occasionally pu- Other causes of failure can be seen on radiology as well
rulence can be seen in the nasopharynx, descending ver- as endoscopy. Previous sphenoidotomies may fail due to in-
tically from the sphenoethmoidal recess (Fig. 13.4). sufficient opening of the anterior sphenoid wall, excessive
Planning for a revision sphenoidotomy begins with mucosal disruption with resulting scar contracture, and
an analysis of why the previous surgical intervention retained posterior ethmoid partitions and inflammation.
failed. The first task in assessing patients with sphenoid Attention to these issues and learning from them reduces
sinus disease following previous sinus surgery is to deter- the chances of repeating them during revision surgery.
mine whether the sphenoid sinus was indeed previously
opened. During endoscopic sinus surgery, identification
of the true sphenoid cavity can be challenging. Large pos-
Revision Endoscopic Surgery of the Sphenoid Sinus 111
Fig. 13.2 Endoscopic view of the left middle (MT) and supe- Fig. 13.3 Endoscopic view of the right ethmoid complex, dem-
rior turbinates (ST) following a correction of a deviated nasal onstrating a partially resected middle turbinate and a superior
septum. The common skull base attachment of the turbinates turbinate remnant (black arrowheads). A posterior ethmoid cell
(asterisk) is seen (asterisk) is seen lateral to the superior turbinate remnant, and
the sphenoid ostium (white arrowhead) is seen medial to it
Fig. 13.4 Endoscopic view of the right nasopharynx. Purulence Fig. 13.5 Axial CT scan of the sphenoid and ethmoid sinuses.
is seen emanating from the sphenoethmoidal recess (white ar- The sphenoid ostium opens medial to the superior turbinate
rowhead), between the superior turbinate and the septum. Pu- (continuous with the more anterior middle turbinate at this
rulence from the middle meatus (black arrowhead) is also seen, level) and has about a 3-mm opening. The scale at the bottom of
lateral to the middle turbinate this figure is in centimeters
jury to the internal carotid artery and optic nerve. These

Surgery
structures, found in the lateral wall of the sphenoid sinus,
lack a bone covering in a substantial number of patients.
Tips and Pearls Cutting instruments that are designed to avoid injuring
the lateral wall while removing the anterior wall are pre-
1. Blunt instruments can be useful for probing the
ferred in this area. Image guidance can be helpful in iden-
sphenoid ostium, while through-cutting instru-
tifying the sphenoid sinus among posterior ethmoid cells
ments should be used whenever possible to widen
where numerous landmarks have been altered by previ-
the opening. Thick bone may require the use of
ous surgery. Revision surgery, posterior ethmoidectomy,
non-through-cutting instruments.
and sphenoidotomy are all acceptable indications for the
2. The transethmoid route to the sphenoid sinus pro-
use of this technology [1].
vides wider access and addresses residual posterior
Preoperative medical therapy should be directed at
ethmoid disease. This route facilitates a wide open-
minimizing mucosal inflammation in order to diminish
ing of the sphenoid sinus.
bleeding. Oxymetazoline spray is given just before sur-
3. The superior turbinate provides a nearly constant
gery and is used throughout surgery on cotton pledgets to
landmark for the sphenoid natural ostium, even in
control hemorrhage. Injection of 1:100,000 epinephrine
revision cases.
into the area of the sphenopalatine artery as it enters the
4. Mucosal disruption medial and inferior to the
nose significantly diminishes bleeding during sphenoid-
sphenoid natural ostium gains little and risks
otomy [3, 9].
circumferential stenosis.
The route to the sphenoid sinus can be either transna-
sal – medial to the middle turbinate – or transethmoid –
Instrumentation for revision surgery of the sphe- lateral to the middle turbinate. The transnasal route is
noid sinus is similar to that of primary sphenoidotomy more direct and does not require a total ethmoidectomy.
(Fig. 13.6). Blunt instruments for probing can be helpful However, the narrowness of the space between the middle
in safely identifying the previous surgical ostium, while turbinate and nasal septum typically requires fracture lat-
13 forceps that cut close to the coronal plane assist in widen- eralization or resection of the middle turbinate. Leaving
ing the ostium maximally. Through-cutting punches are the posterior ethmoid cells intact also limits the extent to
much preferred over grasping instruments in order to which the sphenoid sinus ostium can be widened laterally
maximally preserve mucosa and thus speed healing post- and potentially ignores a source of continued inflamma-
operatively. Occasionally the thick bone of the anterior tion near the sphenoid sinus outflow. For these reasons,
sphenoid wall necessitates the use of Kerrison punches, the author typically prefers the transethmoid approach to
but this is uncommon. In these rare cases, great care must the sphenoid sinus, especially in revision cases.
be employed to avoid unnecessary mucosal loss. Powered Thorough dissection of the posterior ethmoid sinuses,
cutting instruments should be used with great care, if at with removal of all residual partitions between the su-
all, in the sphenoid region due to the potential for in- perior turbinate and lamina papyracea, facilitates iden-
Fig. 13.6 Instruments useful for revision

endoscopic sphenoid sinus surgery
Fig. 13.7 Endoscopic view of the dissected left anterior and Fig. 13.8 Closer view of the superior turbinate, showing the
posterior ethmoid sinuses, using a 0 telescope placed lateral sphenoethomidal recess (arrowhead) between the superior tur-
to the middle turbinate. The superior turbinate is seen directly binate and the septum (S). Adapted from Orlandi et al. [6]. Used
posterior to the middle turbinate, in the medial portion of the with permission, OceanSide Publications
posterior ethmoid sinuses (PE). The maxillary sinus (M) has
also been opened. Adapted from Orlandi et al. [6]. Used with
permission, OceanSide Publications
tification and maximal opening of the sphenoid sinus. making it desirable to leave as much ostial mucosa intact
The superior turbinate is identified medially within the while maximally widening the opening. For this reason
posterior ethmoid field, posterior to the middle turbinate only superior and lateral widening, with its inherent dis-
(Figs. 13.7 and 13.8). This landmark reliably identifies ruption of the ostial mucosa is recommended. Inferior
the anterior wall of the sphenoid sinus and, if its infe- and medial widening has nearly no advantage in typical
rior 3–4 mm are removed, facilitates identification of the cases and greatly increases the risk of stenosis or com-
sphenoid natural ostium (Fig. 13.9). plete closure. Moreover, dissection inferior to the sphe-
Some surgeons prefer to enter the sphenoid sinus noid ostium endangers bleeding from the septal branch
medial to the superior turbinate (through the natural os- of the sphenopalatine artery, which crosses the sphenoid
tium), while others enter lateral to the superior turbinate anterior wall 2–3 mm below the ostium.
[2, 6]. In revising the sphenoidotomy, the previous ostium
should be sought and widened maximally. Cutting instru-
ments are used to widen the opening laterally toward the
Postoperative Care and Outcomes
lamina papyracea, and superiorly to the skull base. Pal-
pating behind each partition prior to its removal reduces
the risk of dissection beyond the limits of the sphenoid Tips and Pearls
and posterior ethmoid sinuses. Maximal widening me-
1. Postoperative diagnostic endoscopy, possibly
dially entails incorporating the sphenoid natural ostium
with debridement, is as important with revision
while preserving the majority of the superior turbinate,
sphenoid sinus surgery as it is following any endo-
thus reducing the risk of olfactory loss (Fig. 13.10) [8].
scopic sinus procedure.
The vomer joins the pneumatized body of the sphe-
2. While outcome data for revision sinus surgery
noid just medial to the sphenoid ostia. The thickness of
is lacking, patency rates appear to diminish over
the bone in this area precludes extension of the sphenoid-
time, necessitating a sufficiently long follow-up to
otomy medial to the natural ostium with conventional
determine success.
instrumentation. Likewise, the clivus rapidly increases in
3. Like any endoscopic sinus surgery, revision sphe-
thickness inferior to the sphenoid natural ostium, mak-
noidotomy requires postoperative nasal endoscopy
ing inferior extension of the sphenoidotomy difficult.
to debride crusting and retained secretions, and to
Wound contracture that takes place during the normal
guide medical therapy.
healing process tends to close circumferential defects,
Fig. 13.9 The inferior portion of the superior turbinate has been Fig. 13.10 The sphenoid anterior wall has been removed supe-
sharply resected, showing the sphenoid ostium. Adapted from Or- rior and lateral to the natural ostium. No dissection has taken
landi et al. [6]. Used with permission, OceanSide Publications place inferior or medial to the natural ostium and the superior
turbinate remnant is intact. Adapted from Orlandi RR [6]. Used
with permission, OceanSide Publications
13 Removal of crusts within the sphenoid opening, either sphenoid sinus surgery, even in revision cases. The ability
with saline irrigation or debridement (or both), is essen- to widen the sphenoid ostium is confined medially and
tial to remove accumulated fibrin and other debris. These inferiorly by thick bone. Once mucosal disruption of the
items can act as a scaffold for matrix deposition within sphenoid ostium has taken place, a maximally wide open-
the wound, with eventual scarring and stenosis. They can ing is encouraged in order to minimize the risk of post-
also impede secretion transport out of the sinus, favoring operative stenosis due to wound contracture. The risk
bacterial colonization and perpetuating inflammation. of complications appears to be higher in revision versus
Postoperative medical therapy is aimed at reducing this primary sphenoid sinus surgery, and a sufficiently long
inflammation and is managed according to the endo- endoscopic follow-up period is necessary to ensure the
scopic appearance of the sphenoid and posterior ethmoid patency of the surgical ostium.
sinuses at each visit.
Outcome data for revision sphenoid sinus surgery is
generally lacking. It is essential in evaluating patient suc-
References
cess that sufficiently long follow-up be performed. As
for the frontal sinus, the patency of the sphenoid sinus 1. AAO-HNS policy on intra-operative use of computer-
ostium can diminish over time. One study evaluated 74 aided surgery (2005) [cited 2007]. Available from: http://
patients following endoscopic sphenoidotomy and found www.entlink.net/practice/rules/imageguiding.cfm
100% sphenoid patency at 1 month postoperatively. The 2. Bolger WE, Keyes AS, Lanza DC (1999) Use of the supe-
patency rate decreased to 82% over the ensuing follow- rior meatus and superior turbinate in the endoscopic ap-
up period, which ranged from 6 months to nearly 6 years proach to the sphenoid sinus. Otolaryngol Head Neck Surg
[7]. 120:308–313
3. Douglas R, Wormald PJ (2006) Pterygopalatine fossa in-
filtration through the greater palatine foramen: where to
bend the needle. Laryngoscope 116:1255–1257
Conclusion
4. Millar DA, Orlandi RR (2006) The sphenoid sinus natural
Revision endoscopic surgery of the sphenoid sinus is ostium is consistently medial to the superior turbinate Am
challenging due to its anatomic relationships. The supe- J Rhinol 20:180–181
rior turbinate forms a reliable landmark in endoscopic
5. Musy PY, Kountakis SE (2004) Anatomic findings in pa- 8. Say P, Leopold D, Cochran G, et al. (2004) Resection of
tients undergoing revision endoscopic sinus surgery Am J the inferior superior turbinate: does it affect olfactory
Otolaryngol 25:418–422 ability or contain olfactory neuronal tissue? Am J Rhinol
6. Orlandi RR, Lanza DC, Bolger WE, et al. (1999) The for- 18:157–160
gotten turbinate: the role of the superior turbinate in endo- 9. Wormald PJ, Athanasiadis T, Rees G, et al. (2005) An evalu-
scopic sinus surgery Am J Rhinol 13:251–259 ation of effect of pterygopalatine fossa injection with local
7. Rosen FS, Sinha UK, Rice DH (1999) Endoscopic surgi- anesthetic and adrenalin in the control of nasal bleeding
cal management of sphenoid sinus disease Laryngoscope during endoscopic sinus surgery Am J Rhinol 19:288–292
109:1601–1606
Chapter 14
Endoscopic and Microscopic

Revision Frontal Sinus Surgery 14
Ulrike Bockmühl and Wolfgang Draf
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
■ There must be a reasonable correlation between a Preoperative Workup . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
patient’s complaints and radiologic findings. Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
■ High-resolution computed tomography and mag-
Type I Drainage According to Draf . . . . . . . . . . . . . . 120
netic resonance imaging are the most valid imaging
modalities. Type II Drainage According to Draf . . . . . . . . . . . . . 121
■ Revision surgery is most often necessary due to in- Type III Drainage According to Draf . . . . . . . . . . . . 121
complete removal of obstructing agger nasi cells, Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
superior attachment of the ethmoid bulla or unci-
Outcomes and Complications . . . . . . . . . . . . . . . . . . . . 124
nate process (incomplete anterior ethmoidectomy),
lateralization of middle-turbinate remnants, neo- Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
osteogenesis of the frontal recess, and polypoid mu-
cosa obscuring the recess.
■ Endonasal revision frontal sinus surgery requires
detailed anatomical knowledge.
Introduction
■ In the majority of patients revision can be managed
successfully via the endonasal route by performing Chronic frontal sinusitis is a disease that continues to
Draf ’s type I–III drainages. pose a significant challenge to surgeons despite consider-
■ In aspirin triad, patients with severe polyposis, able advances in instrumentation and surgical techniques
Draf ’s type III drainage is indicated as the first revi- [4, 5, 11, 31, 33]. Primary endoscopic or microscopic
sion procedure. sinus surgery can often result in scarring of the frontal
■ Contraindications for endonasal frontal sinus revi- recess, especially when there is an incomplete removal of
sion surgery are anterior–posterior dimension less obstructing agger nasi cells, superior attachment of the
than 0.5 cm, inadequate surgical training, and lack ethmoid bulla, or uncinate process [3, 5]. Failure to rec-
of proper instrumentation. ognize frontal recess cells and supraorbital ethmoid cells
■ The external osteoplastic, mostly obliterative frontal can mislead the surgeon into believing the frontal recess
sinus operation must be part of the armamentarium has been opened. Other common causes of failure of pri-
of the experienced sinus surgeon for the resolution mary surgery, including lateralization of middle-turbi-
of exceptionally difficult frontal sinus problems. nate remnants, neo-osteogenesis of the frontal recess, and
polypoid mucosa obscuring the recess, all contribute to
the difficulty and danger of revision surgery [4]. Histori-
cally, surgeons treating recurrent or persistent frontal si-
nus disease advocated either reestablishing drainage from
an intranasal approach, reestablishing drainage from an
external approach, or obliteration of the sinus. Since the
introduction of endoscopic technology to manage para-
nasal sinus diseases, interest in reestablishing drainage
118 Ulrike Bockmühl and Wolfgang Draf
from an intranasal approach has flourished and several

Preoperative Workup
endoscopic techniques, many bearing a resemblance to
procedures developed by Draf [6], have been described. The decision for revision surgery is not easy to make for
These include: either the patient or the surgeon. If the patient complains
1. Anterior ethmoidectomy without alteration of the about persistent or recurrent symptoms like frontal head-
frontal ostium itself (i.e., drainage type I according to ache, reduced smelling or nasal obstruction, endoscopy of
Draf) [6]. the nose is indicated first followed by magnetic resonance
2. Endoscopic frontal sinusotomy according to Stamm- imaging (MRI) verification and, in case of likelihood
berger and Posawetz, characterized as “uncapping the for revision surgery, computed tomography (CT) scans
egg” [32]. should be performed. CT images should be scanned in
3. Enlargement of the frontal ostium medially until the the axial direction with a maximum of 0.65-mm sections,
middle turbinate (i.e., drainage type IIa according to and from there, coronal as well as sagittal views should
Draf) [6]. be reconstructed. The most common sign of persistent or
4. Removal of the entire frontal floor on one side until recurrent disease is mucosal thickening within the frontal
the nasal septum in front of the olfactory fossa (i.e., recess and/or sinus.
drainage type IIb according to Draf) [6].
5. Median drainage of frontal sinuses removing both ■ Anatomic evaluation of the frontal sinus region with
frontal sinus floors, upper nasal septum, and septum CT scans is key to the feasibility and safety of endo-
(septa, if several) sinuum frontalium (i.e., drainage scopic or microscopic revision frontal sinus surgery.
type III according to Draf or endoscopic modified
Lothrop procedure) [6, 13]. CT scans should reveal the number and location of frontal
recess air cells, as well as barriers that have to be removed
In general, the first two procedures are indicated in pri- to reach the internal frontal sinus ostium [10, 39].
mary surgery, techniques 3 and 4 mainly in revision cases,
and Draf ’s type III drainage and the modified Lothrop The coronal CT views are excellent to determine the fol-
procedure are most often performed as rescue surgery. lowing structures:
14 Using maximal medical therapy, a stepwise progression ■ Remaining agger nasi cells or neo-osteogenesis of the
from less to more invasive procedures, and an aggressive frontal recess (Fig. 14.1).
postoperative regimen of debridement, excellent results ■ Superior uncinate process.
can be achieved treating this difficult clinical problem. ■ Depth of the olfactory fossa.
■ Anterior ethmoid artery.
Indications for revision surgery: ■ Bulla frontalis (cell above the agger nasi with expan-
■ Persistent chronic frontal rhinossinusitis as failure of sion into the frontal sinus; Fig. 14.1b).
appropriate medical therapy and/or previous surgery ■ Supraorbital ethmoid cells
due to polypoid mucosa obscuring the recess.
■ Persistent chronic frontal sinusitis due to anatomical Sagittal and axial CT views are important to determine
particularities after previous surgery (e.g., persistent the following structures:
agger nasi cells, superior attached ethmoid bulla or ■ AP dimension of the frontal recess (Figs. 14.2 and
uncinate process, lateralization of the middle turbi- 14.3).
nate, and neo-osteogenesis of the frontal recess). ■ Frontal recess.
■ Patients with aspirin triad (i.e., polyposis, aspirin in- ■ Supraorbital ethmoid cells.
tolerance, and bronchial asthma). ■ Bulla frontalis (cell above the agger nasi with expan-
■ Frontal sinus mucoceles. sion into the frontal sinus).
■ Primary or recurrent tumors (i.e., inverted papilloma, ■ Interseptal frontal sinus cell.
osteoma, ossifying fibroma, and malignancies).
The important anatomic AP dimension is the distance
Contraindications: from the nasal bones at the root of the nose to the ante-
■ Narrow anterior–posterior (AP) dimension of the rior skull base [12, 14, 19, 36]. This dimension includes
frontal sinus floor, hypoplastic frontal sinus. the AP thickness of the nasal beak and the distance from
■ Failure of adequate endonasal type III drainage. the beak to the anterior skull base. Recently, it was de-
■ Patients with aspirin triad and condition after several termined that an accessible dimension of at least 5 mm
endonasal revision procedures. is required to allow safe removal of the nasal beak and
■ Inexperience of the surgeon. frontal sinus floor [10]. An accessible dimension less than
■ Unavailability of proper instrumentation. 5 mm would preclude the patient’s candidacy for endo-
Endoscopic and Microscopic Revision Frontal Sinus Surgery 119
Fig. 14.1 a Coronal computed tomography (CT) view showing cells with expansion into the frontal sinus (bullae frontales).
a recurrent chronic pansinusitis including the frontals sinuses. b Coronal CT scan showing neo-osteogenesis of the right fron-
Above the agger nasi cells left after previous operation there are tal recess
Fig. 14.2 Sagittal CT views showing persistent chronic sinusitis anterior to posterior (AP) dimensions of the frontal recess (black
after incomplete ethmoidectomy, and demonstrating different bar). a Wide AP dimension. b Narrow AP dimension
nasal frontal sinus surgery. Furthermore, it is of utmost that the surgeon operates patients and not CTs or MRIs).
importance to analyze the images for dangerous anatomi- In case of headaches, neurological consultation is some-
cal findings like skull-base and lamina papyracea defects times important, particularly if the patient reports about
or a very deep cribriform plate. Recognizing the so-called migraine in the family.
dangerous frontal bone decreases the danger of creating a
dural defect when removing an incomplete frontal sinus ■ Prior to surgery, the patient’s underlying condition
septum (Fig. 14.3a). causing frontal sinus disease should be optimized
Whenever possible the updated images should be medically.
compared with the previous ones. However, there must
be a reasonable correlation between patients’ complaints Therefore, a selective combination of nasal irrigations,
and radiologic findings (i.e., it should not be forgotten antibiotics, leukotriene antagonists, topical, and/or oral
Fig. 14.3 Axial CT views showing persistent chronic frontal sinusitis, and demonstrating different AP dimensions of the frontal
sinus ostium. Note also the dangerous frontal bone with protruding dura in the spine (asterisks). a Wide AP dimension. b Narrow
AP dimension
steroids is used, which is also mandatory in postopera-

Type I Drainage According to Draf
tive care to prevent restenosis, leading to another dis-
ease recurrence. This is especially important for patients In general, prior to surgery on the frontal recess and si-
with more aggressive disease (i.e., aspirin triad patients). nus, at least an anterior, but better a complete ethmoid-
In preparation for surgery, these patients regularly take ectomy has to be performed. It is important to remove
14 50 mg prednisone per day for the 10 immediately preop- all agger nasi cells. To minimize the risk of complications
erative days. it is essential to visualize the attachment of the middle
turbinate medially, the lamina papyracea laterally, and
the anterior skull base with the anterior ethmoid artery
superiorly. It should be kept in mind that in revision sur-
Surgical Technique
gery the anatomy is significantly distorted and landmarks
Once revision surgery is indicated, careful individual such as the middle turbinate may be partially resected,
planning is essential to decide whether the endonasal making them unreliable for anatomic localization. How-
technique is still suitable or an external procedure should ever, it should be remembered that the skull base is usu-
be preferred. In case of endonasal revision frontal sinus ally most easily identified in the posterior ethmoid or
surgery, in our hands a stepwise progression from less sphenoid sinus, where it is horizontal and the ethmoid
(Draf ’s type I or IIa/b drainages) to more invasive pro- cells are larger. Care always needs to be taken at the eth-
cedures (Draf ’s type III drainage) has stood the test of moid roof near the anterior ethmoid artery and toward
time [6, 8, 9, 14, 18, 36]. For the Draf III drainage to be the attachment of the middle turbinate, as the skull base
successful, special surgical equipment is necessary: 45° is thinnest in this area. Therefore, one should stay close
angled endoscope with irrigation and suction, angled and parallel to the lamina papyracea, opening one or two
instruments, suction irrigation drills (between 35° and supraorbital ethmoid cells that are located anterior to the
70°), and computer image guidance is often helpful. vessel. Once the frontal recess has been clearly identified,
General anesthesia is required for revision frontal si- adjacent bony partitions can be fractured and teased out,
nus surgery. In addition, topical decongestion helps to which is as important as the preservation of mucosa. This
provide a dry field. The nasal cavities are first decongested opening corresponds to a simple drainage or type I drain-
using topical xylometazoline, and then the septum and the age according to Draf (Fig. 14.4). An alternative when
lateral nasal wall at the agger nasi are injected with up to the middle turbinate has been retracted laterally due
12 ml of 1% lidocaine and 1:200,000 epinephrine solution. to previous surgery and is obstructing the frontal sinus
The extent and type of local decongestant applied depends drainage, is the so-called “frontal sinus rescue procedure”
on the medical condition of each individual patient. by Kuhn et al. [20].
Fig. 14.4 Schematic illustration of a type I drainage according Fig. 14.5 Schematic illustration of a type II drainage according
to Draf. The structures marked in red are those that have to be to Draf. The structures marked in red are those that have to be
resected resected
Type II Drainage According to Draf Type III Drainage According to Draf

Type II drainage according to Draf (Fig. 14.5) is an ex- Type III drainage according to Draf (Fig. 14.6) is a me-
tended drainage procedure that is achieved by resecting dian drainage procedure that involves removal of the up-
the floor of the frontal sinus between the lamina papyra- per part of the nasal septum and the lower part of the
cea and the middle turbinate (type IIa) or the nasal sep- frontal sinus septum or septa, if there is more than one, in
tum (type IIb) anterior the ventral margin of the olfac- addition to the type IIb drainage of both frontal sinuses
tory fossa either with the punch, curette, or with angled (Fig. 14.7). To achieve the maximum possible opening
forceps [36]. Hosemann et al. [14, 15] showed in a de- of the frontal sinus it is very helpful to identify the first
tailed anatomical study that the maximum diameter of a olfactory fibers on both sides: the middle turbinate is ex-
neo-ostium of the frontal sinus (type IIa), which could posed and cut, millimeter by millimeter, from anterior
be gained using a spoon or a curette, was 11 mm, with an to posterior along its origin at the skull base. After about
average of 5.6 mm. If one needs to achieve a larger drain- 10–15 mm one will see the first olfactory fiber coming
age opening like type IIb, one has to use a drill because of out of a little bony hole. Finally, the so-called “frontal T”
the increasing thickness of the bone going more medially [7] results (Fig. 14.8). Its long crus is represented by the
toward the nasal septum. Care is needed to ensure that posterior border of the perpendicular ethmoid lamina
the frontal sinus opening is left bordered by bone on all resection, the shorter wings on both sides are provided
sides and that the mucosa is preserved at least on one part by the posterior margins of the frontal sinus floor resec-
of the circumference. In case one feels the type IIa drain- tion. This provides an excellent landmark for the anterior
age opening is too small with regard to the underlying pa- border of the olfactory fossa on both sides, which allows
thology, it is better to perform the type IIb drainage. The the completion of frontal sinus floor resection close to
wide approach to the ethmoid is obtained by exposing the the first olfactory fiber. In difficult revision cases one can
lacrimal bone and reducing it as well as parts of the agger begin the type III drainage primarily from two starting
nasi and part of the frontal process of the maxilla until the points, either from the lateral side, as already described,
lamina papyracea is clearly visible. or from medially. The primary lateral approach is recom-
mended if the previous ethmoidectomy was incomplete
and the middle turbinate is still present as a landmark.
septum, followed by identification of the first olfactory

fiber on each side, as already described. The endonasal
median drainage corresponds with nasofrontal approach
IV [23] and the “modified Lothrop procedure” [13].
The principle difference between the endonasal me-
dian frontal sinus drainage and the classic external opera-
tions according to Jansen [17], Lothrop [21], Ritter [27],
Lynch [22], and Howarth [16] is that the bony borders
around the frontal sinus drainage are preserved. This
makes it more stable in the long term and reduces the
likelihood of reclosure by scarring, which may lead to re-
current frontal sinusitis or a mucocele, not to mention
the avoidance of an external scar.
As an external procedure, the osteoplastic oblitera-
tive frontal sinus operation is the gold standard in surgi-
cal treatment of a chronic inflammatory disease and the
ultima ratio if a frontal sinus problem cannot be solved
via the endonasal route. The decades-old “classic” exter-
nal frontoethmoidectomy according to Jansen [17], Rit-
ter [27], Lynch [22], or Howarth [16], achieved via an in-
Fig. 14.6 Schematic illustration of a type III drainage according fraeyebrow incision, has to be judged as “obsolete” since
to Draf. The structures marked in red are those that have to be the frequency of postoperative mucoceles increases with
resected the duration of postoperative follow up, to 40% and more.
The strategy of the osteoplastic obliterative operation is
to remove very meticulously all mucosa of the frontal si-
nuses using a microscope and endoscope as visual aids.
One should adopt the primary medial approach if the The naked eye is not sufficient! Ear cartilage and fascia are
14 ethmoid has been cleared and/or if the middle turbinate used to create a reliable barrier between the nose and eth-
is absent. The primary medial approach begins with the moid on one side and the frontal sinus on the other. Then
partial resection of the perpendicular plate of the nasal the frontal sinuses have to be filled with freshly harvested
Fig. 14.7 Intraoperative condition after opening the frontal si- Fig. 14.8 Schematic illustration of the “frontal T” according to
nuses in the way of a type III drainage according to Draf (me- Draf. LC long crus, LFSF left frontal sinus floor, LP lamina per-
dian drainage) pendicularis, RFSF right frontal sinus floor, SC short crus
Fig. 14.9 Conditions around the 7th postoperative day showing differences in wound healing. a Severe crusting. b Mild crusting
with swollen mucosa
autogenic fat in smaller cubes. By this method the frontal thereafter until the crusting disappears. We achieve bet-
sinuses are excluded from the paranasal sinus system [2]. ter results and less painful postoperative treatment by
In experienced hands the rate of postoperative mucocele being less aggressive and removing only mobile crusts.
does not exceed 10% [34]. Figure 14.10 shows an optimal postoperative result.
Postoperative Care
Rubber finger stalls are used as nasal packages that will
be left in place for 5 days in type III drainage and 3 days
in type II drainages. Some authors advocated the use
of soft, flexible silicone stents in cases of a frontal sinus
neo-ostium less than 5 mm in diameter, since more rigid
silicone tubes have not given satisfying results [26, 28,
37, 38]. So far, the techniques using soft silicone drainage
devices have not shown promising results in long-term
observations.
All patients with type III drainage are placed on postop-
erative antibiotics (our preferred choice is clarithromycin)
for at least 5 days. After removing the packing, patients
are instructed to perform nasal saline irrigations twice
daily until healing is complete. The degree of crusting can
be very different (Fig. 14.9). In general, leaving rubber
finger stalls for longer reduces crusting because faster re-
epithelization is stimulated, like in a moistened chamber.
In addition, all patients receive an intranasal steroid spray,
and they are requested to use it for at least 3 months. En-
doscopic debridement is performed in the office setting 1 Fig. 14.10 Optimal result after type III drainage according to
and 2 weeks after surgery and is repeated every 2 weeks Draf (3 years postoperatively)
Patients with hyperplastic sinusitis and nasal polypo- of time, the overall patency success rate was reduced.
sis, and aspirin triad patients may benefit from tapering Schlosser et al. [29] followed 44 patients for an average
doses of systemic oral steroids. We achieved positive ef- of 40 months. Of these, 9 (20%) patients required revi-
fects by prescribing 5 mg prednisone daily for 30 days fol- sion modified Lothrop surgery and 8 (18%) eventually
lowed by 2.5 mg for another 40 days. needed an osteoplastic frontal sinus operation with oblit-
eration. Almost similar data are reported by Shirazi et al.
[30], who analyzed 97 patients with a mean follow up of
18 months; 23% required revision surgery. In contrast,
Outcomes and Complications
Wormald et al. [40] indicated a 93% primary patency rate
Complications of endoscopic revision frontal sinus sur- with a mean follow up of 22 months. Recently, Friedman
gery: et al. [11] published the most comprehensive study evalu-
■ Frontal ostium restenosis. ating 152 patients with a mean follow up of 72 months,
■ Orbital injury. and showing a 71.1% overall patency rate.
■ Cerebrospinal fluid leakage. Regardless of the surgical procedure among 67 pa-
■ Intracranial injury. tients, Chiu and Vaughan [5] found 86.6% to have a pat-
■ Bleeding. ent frontal recess and significant subjective improvement
■ Crusting. in symptoms over an average follow up of 32 months.
Judging the results of endonasal frontal sinus surgery re-

quires a postoperative follow up of several years, not only
Future Directions
months [11, 24, 25, 30, 31]. Weber et al. [35, 36] carried
out two retrospective studies evaluating the results of en- Endonasal revision surgery of the frontal sinus remains a
donasal frontal sinus drainages in cases of chronic polyp- great challenge to all surgeons regardless of their experi-
oid rhinosinusitis after a mean follow up of 5 years (range ence. It requires proper training and special instruments.
1–12 years). All patients were examined by endoscopy However, recurrent or persistent frontal sinus disease after
and CT. In the first study, 132 patients from 1 institution surgery can be addressed with endoscopic or microscopic
were analyzed (42 type I, 43 type II, and 47 type III drain- techniques with a high success rate and low complication
14 ages). Applying subjective and objective criteria, they rate. These techniques offer several advantages over fron-
found a success rate of 85.7% in type I drainage, 83.8% tal sinus obliteration and should be in every rhinologist’s
in type II drainage, and 91.5% in type III drainage. In an armamentarium for use in the appropriate clinical situa-
updated survey the authors evaluated the results of three tion. Only long-term follow up can determine whether the
independent institutions summarizing 1286 patients (635 current endoscopic or microscopic methods will result in
type I, 312 type II, and 156 type III drainages). They re- consistently permanently favorable results. Despite the
ported a primary patency rate of 85.2–99.3% in type I progress in surgery, it remains the task to identify the
drainages, 79–93.3% in type II drainages, and 91.5–95% underlying mechanisms causing chronic rhinosinusitis
in type III drainages. This means that despite the choice or triad and to develop appropriate medication to cure
of prognostically unfavorable cases, type III drainages the disease.
appeared to show the best results, although this was not
statistically significant among the three groups. Recently, Tips and Pearls
Eviatar et al. [9] described a rate of ventilated frontal si-
1. Sagittally reconstructed CT scans, especially indica
nuses after type II drainages of 96% in 25 patients, with
ting the AP dimension, are required to assess pa-
a mean follow up of 30 months. Batra et al. [1] presented
tient’s candidacy for an endonasal revision proce-
surgical outcomes of “drill out procedures” for complex
dure.
frontal sinus pathologies. Of 186 patients, 13.4% required
2. For anatomical orientation it is important to de-
type II or III drainages. Postoperatively, symptomatology
termine the presence of remaining agger nasi cells,
was resolved in 32%, improved in 56%, and remained un-
the superior uncinate process, anterior ethmoid
changed in 12% of the patients. Interestingly, endoscopic
artery, bulla frontalis and supraorbital ethmoid
patency of the neo-ostium was noted in 92%.
cells, and the depth of the olfactory fossa.
Reviewing the results of the endoscopic modi-
3. When drilling, care has to be taken to preserve
fied Lothrop procedure, Gross et al. [13] found a 95%
the mucosa on the lateral and posterior wall of the
frontal drainage patency rate with a mean follow up of
frontal recess in order to prevent complications
12 months, but as experience with the procedure accu-
and postoperative stenosis.
mulated and patients were followed for longer periods
12. Gross CW, Schlosser RJ (2001) The modified Lothrop pro-

4. A large resection of the upper nasal septum is re-
cedure: lessons learned. Laryngoscope 111:1302–1305
quired to provide adequate drainage of the frontal
13. Gross WE, Gross CW, Becker D, Moore D, Phillips D
sinuses, and to avoid restenosis.
(1995) Modified transnasal endoscopic Lothrop procedure
5. Pre- and postoperative medical management
as an alternative to frontal sinus obliteration. Otolaryngol
support wound healing, and regular surveillance
should be carried out to assure surgical outcome
14. Hosemann W, Gross R, Goede U, Kuehnel T (2001) Clini-
and prevent disease recurrence.
cal anatomy of the nasal process of the frontal bone (spina
nasalis interna). Otolaryngol Head Neck Surg 125:60–65
15. Hosemann W, Kuhnel T, Held P, Wagner W, Felderhoff A
(1997) Endonasal frontal sinusotomy in surgical manage-
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14
Chapter 15
Revision Endoscopic
Frontal Sinus Surgery 15
Patricia A. Maeso, Subinoy Das, and Stilianos E. Kountakis
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
■ Revision endoscopic frontal sinus surgery is a chal- Patient Selection/Preoperative Evaluation . . . . . . . . . . 127
lenging procedure that should be undertaken only Preoperative Assessment/Planning . . . . . . . . . . . . . . . . 128
by the experienced sinus surgeon.
Relevant Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
■ Evaluation and understanding of the frontonasal
Operative Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
outflow tract in the setting of previously surgically
altered anatomy is essential. Endoscopic Frontal Sinusotomy . . . . . . . . . . . . . . . . 130
■ Choice of procedure for the revision frontal sinus External Frontal Sinus Trephination
surgery depends not only on careful preoperative with Endoscopic Frontal Sinus Surgery:
evaluation of available computed tomography radi- the “Above and Below Technique” . . . . . . . . . . . . . . . 131
ography, but also on the underlying pathology.
Endoscopic Modified Lothrop or Draf III
■ Careful postoperative debridement and monitoring
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
is essential for the success of any revision frontal si-
nus operation. Osteoplastic Flap and External Approaches . . . . . . . 132
Frontal Sinus Stenting . . . . . . . . . . . . . . . . . . . . . . . . . 132
Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Introduction
Revision endoscopic frontal sinus surgery remains one of such as computerized image guidance and advanced
the greatest challenges facing the skilled endoscopic sur- frontal sinus instrumentation when appropriate. Finally,
geon. Primary endoscopic sinus surgery has a long-term medical management directed at the patient’s underlying
success rate greater than 90%; therefore, patients requir- pathophysiology, meticulous postoperative debridement,
ing revision frontal sinus surgery represent a subset of and comprehensive patient education will improve the
patients with advanced or poorly controlled disease. To likelihood of success in this often difficult to manage sub-
increase the chance of success, the endoscopic surgeon set of sinus patients.
should reevaluate the underlying cause of the patient’s
symptoms. If they are attributable to frontal sinus pathol-
ogy, then a thorough evaluation should be performed as
Patient Selection/Preoperative Evaluation
to the cause underlying failure of the previous operation.
The patient’s surgical anatomy should be properly re- Prior to consideration for any revision endoscopic proce-
evaluated and the surgeon should be prepared for altered dure, a thorough reevaluation should be carried out for
and unusual findings, such as missing and/or distorted each patient by performing a comprehensive history and
landmarks, missing bone, prolapsed orbital contents, en- physical examination with angled rigid and/or flexible
cephaloceles, and tumors. A proper revision procedure endoscopy. Initially, a reevaluation should be made as to
should be selected and performed by an endoscopic sur- whether a patient’s signs and symptoms are attributable
geon skilled in this approach, using advanced technology to chronic frontal sinusitis.
128 Patricia A. Maeso, Subinoy Das, and Stilianos E. Kountakis
Tips and Pearls of previous frontal sinus surgery can represent lack of
optimal medical management, persistent disease due to
1. Primary complaints of headache, while more com-
incomplete surgery, iatrogenic disease, and recurrent dis-
mon with frontal sinusitis, are poor predictors of
ease following a successful procedure.
surgically amenable sinus disease.
Prior to consideration of any repeat surgical proce-
2. Evaluation for migraines and other causes of head-
dure, the rhinologist should ascertain the previous medi-
aches by a qualified neurologist should be pursued
cal management of the patient’s disease and, in particular,
with a very low threshold for patients with head-
their compliance to these regimens. Nasal saline irriga-
ache and absent rhinosinusitis symptoms.
tions, culture-directed oral and intranasal antimicrobial
drugs, intranasal steroid sprays and irrigations, mucolyt-
Similarly, evaluation for allergic, rheumatologic, psychiat- ics, and oral anti-inflammatory agents such as leukotri-
ric, and other causes of a patient’s symptomatology should ene inhibitors and oral steroids have all been used with
always be considered. A review of previous records in- varying efficacy in controlling chronic frontal rhinosi-
cluding previous radiology and pathology reports should nusitis. Often, patients with poor outcomes following ini-
be performed whenever possible and will be helpful in tial surgery have a poor history of compliance to medical
ascertaining the true nature of the patient’s disease. regimens. Time spent in the office educating patients on
Chronic mucosal diseases such as aspirin-induced the necessity and proper techniques of medical manage-
asthma (Samter’s triad), cystic fibrosis, ciliary dysmotility, ment may obviate the need for further operations.
allergic fungal rhinosinusitis, chronic eosinophilic hyper-
plastic sinusitis, and others increase the likelihood that the ■ The best likelihood of success with a repeat operation
patient’s symptoms are attributable to recurrent frontal si- is in the setting of persistent disease due to a previous
nusitis. A comprehensive physical examination will allow incomplete or inadequate surgery.
the sinus surgeon to detect possible systemic manifesta-
tions of an underlying disease that may reveal the true The quality of previous surgery in the setting of persistent
diagnosis for a patient. Angled rigid sinonasal endoscopy disease varies significantly, with some patients having
and flexible endoscopy (often performed consecutively) minimal prior frontal recess surgery being performed and
are helpful in evaluating the frontal sinus outflow tract some patients having extensive frontal recess surgery, with
and may alert the sinus surgeon to subtle mucosal disease the critical obstruction of the frontal sinus still remaining.
and iatrogenic findings. Photodocumentation of endo- Reviewing CT scans in multiple planes is very helpful, and
15 scopic findings should be utilized whenever possible. sagittal reconstructions are now available on most image-
Repeat radiographic imaging is essential for analyzing guidance workstations and advanced image viewers.
the diseased frontal sinus. High-resolution computed to-
mography (CT) analyzed in the coronal, axial, and sagit- ■ The most common causes of persistent frontal sinus
tal planes will allow the surgeon to gain an understanding obstruction are obstruction from a remnant agger nasi
of the altered three-dimensional anatomy of the frontal cell and a medially displaced superior remnant of the
sinus and frontal sinus outflow tract. Postoperative films uncinate process (Fig. 15.1).
should be compared to preoperative films whenever pos-
sible. Magnetic resonance imaging should be supple-
mented when necessary, as it allows the surgeon to gain a
better understanding of the soft-tissue anatomy of a pre-
viously operated frontal sinus. This includes distinguish-
ing mucoceles versus encephaloceles, identifying defects
in the lamina with periorbital fat herniation, and alerting
the sinus surgeon to possible tumors such as inverting
papillomas and other rare benign and malignant sinus
and skull-base tumors.
Preoperative Assessment/Planning
If the patient’s disease is attributable to chronic frontal
sinus pathology, then a thorough analysis for the failure
of previous frontal sinus surgery should be performed.
Broadly, causes for frontal sinus disease in the setting Fig. 15.1 Agger nasi obstructing the frontal sinus outflow tract
Revision Endoscopic Frontal Sinus Surgery 129
Often, a remnant cap of an ethmoid bulla (mistaken to be ■ Recurrent frontal sinus disease is most commonly a
the true frontonasal outflow tract) is the cause of persis- result of mucosal edema in the frontal recess outflow
tent frontal sinus outflow obstruction. This is particularly tract and represents a flare-up of the patient’s underly-
common when angled endoscopes were not used in prior ing mucosal pathology.
surgeries, as a 45 and often only a 70 endoscope allow vi-
sualization of the roof of the frontal sinus. Often, recurrent frontal disease responds to topical medi-
cal therapy appropriately delivered to the frontal sinus.
Tips and Pearls Also, limited surgery such as a frontal sinus polypectomy
or removal of a few remnant cells is often all that is needed
Common causes of persistent frontal sinus disease:
to surgically address recurrent frontal sinus disease. The
1. Remnant Agger nasi.
surgeon should pay close attention to the underlying
2. Remnant cap of ethmoid bulla.
remnant anatomy to see if anatomical variations make
3. Retained frontal cells.
the patient prone to recurrences and could be surgically
4. Retained supraorbital ethmoid cells.
ameliorated. On the other hand, the risk of creating iat-
5. Persistent polyps.
rogenic injury and scarring is often higher with revision
6. Iatrogenic scarring of the frontal recess and os-
frontal sinus surgery, and prudence is warranted.
tium.
Other causes of persistent disease include retained frontal

Relevant Anatomy
cells, retained supraorbital ethmoid cells, and persistent
polyps. These persistent entities may critically obstruct In particular, the surgeon should look for radiographic
the frontonasal outflow tract and be missed during initial evidence of iatrogenic causes of frontal sinusitis includ-
surgeries. ing an absent middle turbinate, or a scarred or lateral-
While patients with persistent anatomical obstruction ized middle turbinate or turbinate remnant. Evidence
often have excellent outcomes with revision surgical tech- of a residual superior uncinate or remaining anterior
niques, patients with iatrogenic causes of chronic frontal ethmoid/frontal cells may reveal evidence for previous
rhinosinusitis are often the most difficult to cure. Fur- inadequate surgery (Fig. 15.2). Given the likelihood of
thermore, iatrogenic scarring and neo-osteogenesis can distorted anatomy, the sinus surgeon should have a clear
unfortunately convert a patient with previously mild to three-dimensional understanding of the anatomy of the
moderate symptoms into one with crippling disease. As a patient’s individual frontal recess prior to commencing
result, iatrogenic frontal sinus disease is best avoided by with surgery. The skull base and the lamina should be
using sound and meticulous technique when performing carefully evaluated for any potential dehiscence that may
primary frontal sinus operations. be the result of prior surgery, and intraoperatively, suspi-
Commonly, iatrogenic disease is the result of cicatri- cious areas should be considered dehiscent unless bone is
cial scarring from circumferential stripping of the frontal palpated or confirmed with accurate image guidance. In
recess mucosa. In addition, mucosal stripping can also revision frontal sinus cases, the surgeon should look for
lead to neo-osteogenesis, which leads to the deposition of the following common causes of pathology:
inflamed and hardened bone in the frontal recess, which 1. A partially amputated middle turbinate or lateraliza-
can be very difficult to remove. Often, a drill is required tion of the entire middle turbinate (due to complete
to remove neo-osteogenesis, and leads to the further risk resection of the basal lamella) causing obstruction of
of greater fibrin deposition, neo-osteogenesis, and even- frontal sinus outflow.
tually restenosis. 2. Scarring of the superior uncinate to the middle turbi-
Another common cause of iatrogenic disease is fron- nate medial to the frontal sinus outflow tract.
tal sinus mucocele formation. This can be the result of 3. Scarring, circumferential stenosis, and/or osteoneo-
previous frontal sinus procedures such as frontal sinus genesis in the frontal ostium area.
obliteration with incomplete removal of frontal sinus 4. A remnant ethmoid bulla cap mistakenly considered
mucosa, or other less aggressive forms of frontal sinus the frontal recess.
surgery. Frontal sinus mucoceles can occur several years 5. Agger nasi or frontal cells left undissected, and/or recur-
to decades after previous surgery. They often lead to ero- rence of polyposis in the frontal outflow system [3].
sion of the anterior and/or posterior table of the frontal
sinus and should be suspected particularly if the patient
has had a long asymptomatic interval between symp-
toms.
Fig. 15.2 The recessus terminalis is a blind pouch formed by sinus. The frontal sinus ostium will usually be found posterior
the superior attachment of the uncinate process, as it attaches to and medial to this location
lamina papyracea. It can frequently be mistaken for the frontal
of the frontal sinus outflow tract [7]. It is often used as

Operative Techniques
first-line surgery for management of frontal sinus disease
since it carries minimal risk for scarring of the frontal
Tips and Pearls recess; however, it has little role in revision frontal sinus
surgery.
15 1. The mucosa of the lateral frontal recess should not
be disturbed since this helps restore frontal sinus
function.
2. Frontal sinus obliteration is now utilized infre- Endoscopic Frontal Sinusotomy
quently.
Endoscopic frontal sinusotomy involves enlargement of
3. The “above and below” technique addresses lateral
the frontal sinus outflow tract. This extended drainage
or cephalad frontal sinus lesions and type II or IV
procedure has been classified into Draf IIA, which cor-
frontal cells, which cannot be reached endoscopi-
responds to removing anterior ethmoidal cells that pro-
cally.
trude into and/or obstruct the frontal recess (Fig. 15.3).
4. When using the “above and below” technique,
The goal of this procedure is to create an opening of at
oval-shaped trephinations increase working space
least 5 mm into the frontal sinus between the middle
while minimizing the chance for cosmetic defor-
turbinate medially and the lamina papyracea laterally by
mity.
removing bony partitions, while sparing frontal recess
mucosa. In the presence of a narrow frontal recess, re-
Surgery for frontal sinus disease should follow an or- moval of an intersinus septal cell or a Draf IIB procedure
ganized progression from least aggressive to most ag- may be performed. A Draf IIB involves resection of the
gressive. There are multiple procedures from which to frontal sinus floor between the lamina papyracea and the
choose; however, endoscopic procedures should be at the nasal septum (Fig. 15.4). In revision cases, an incomplete
forefront of the thought process when considering frontal previous frontal sinusotomy may be addressed by care-
sinus surgery. Frontal sinus obliterations should be per- fully identifying the true frontonasal outflow tract and
formed only rarely with the advent of improved frontal removing any obstructing frontal, ethmoid, or agger nasi
sinus instruments and technology. cells. When the middle turbinates have been resected and
The endoscopic frontal recess drainage procedure or the remnant has lateralized and scarred across the fron-
Draf I procedure is a complete anterior ethmoidectomy tal sinus outflow tract, the frontal sinus rescue procedure
with drainage of the frontal recess without manipulation or revision frontal sinusotomy with mucoperiosteal flap
Fig. 15.3 Representative image of a Draf IIA

procedure or frontal sinusotomy where ethmoidal
cells protrude into frontal recess and removal is
necessary via “uncapping the egg”
advancement is used to remove any bony and soft-tissue appealing, yet allows the surgeon to reach areas that are
obstruction caused by the destabilized middle-turbinate not available via endonasal techniques. Among the indi-
remnant [1]. cations for the procedure, the most common remain lat-
eral or cephalad frontal sinus lesions, type II or IV frontal
cells, which cannot be addressed endoscopically, tumors
or inflammatory lesions involving the frontal sinus, fron-
External Frontal Sinus Trephination
tal sinus trauma, and distorted anatomy of the frontal re-
with Endoscopic Frontal Sinus Surgery:
cess (Fig. 15.5). When performing the trephination, the
the “Above and Below Technique”
position of the frontal sinus can be confirmed by utilizing
Endoscopic approaches to the frontal sinus are usually fa- a properly registered and accurate image-guidance sys-
vored; however, there are some circumstances where the tem. If image guidance is not available, then the position
simple trephine along with an endoscopic approach or of the frontal sinus is confirmed on preoperative CT in
the “above and below technique” can facilitate the surgery relation to the supraorbital rim or via a six-foot Caldwell
and obviate the need for a more aggressive approach to radiograph that can be cut to be used as a template in
the frontal sinus. Indications for this procedure are ever order to adequately outline the frontal sinus. The endo-
expanding since it is minimally invasive and cosmetically scopic portion of the surgery should be completed first.
After this is done, an incision is made through the me-
dial eyebrow at the level of the supraorbital rim without
shaving this region. Once the incision is done, a 4 mm
drill bit may be utilized to enter the sinus at the previ-
ously confirmed location. The trephine may be enlarged
up to 6–8 mm to accommodate instruments as well as
the endoscope [6]. Oval-shaped trephinations increase
working space while minimizing the chance for cosmetic
deformity. Having both the endonasal and external ex-
posure gives the surgeon the advantage of better visual-
ization and improved instrumentation in the area of the
frontal sinus, and allows for superior based irrigation of
the frontal sinus, which can be very helpful in identifying
the frontal recess outflow tract with distorted anatomy as
well as in assessing the final opening to the frontal recess
after the frontal sinusotomy is completed. The operation
is done so that both aspects of the procedure are com-
plimentary (Video 15.1). For example, visualization can
be performed endonasally while instrumentation can be
Fig. 15.4 Postoperative view of a Draf IIB procedure done through the trephination, and vice versa. The above
and below approach should be part of any sinus surgeon’s cells are then resected. Drilling is then performed in an
repertoire as it has many applications given its ease of anterior direction through the anterior insertion of the
performance, safety profile, and minimal cosmetic disfig- middle turbinate until the nasal beak is removed and the
urement. nasal bone is reached, and laterally until the plane of the
lamina papyracea is reached. A superior 2 × 2 cm septec-
tomy is then performed at the junction of the quadran-
gular cartilage and perpendicular plate of ethmoid bone.
Endoscopic Modified Lothrop
The contralateral frontal sinus floor is then drilled away
or Draf III Procedure
through the septectomy defect until the opposite lamina
This procedure, also known as the Draf type III proce- papyracea is reached (Fig. 15.6; Video 15.2).
dure, can be utilized as an alternative to osteoplastic flap Contraindications to the modified Lothrop procedure
frontal surgery. The procedure has the surgical objective include:
of creating a large nasofrontal communication by utiliz- 1. Hypoplastic frontal sinus and frontal recess.
ing a totally intranasal approach and avoiding an external 2. Narrow anteroposterior depth of the frontal sinus.
incision, while preserving the frontal sinus mucosa [2]. 3. Surgeon inexperience.
The indications for the endoscopic modified Lothrop 4. Lack of proper instrumentation [4].
procedure include [8]:
1. Failed prior endoscopic sinus surgery techniques. The modified endoscopic Lothrop is a valuable endonasal
2. Significant neo-osteogenesis in the frontal recess and approach that should be readily available and always en-
frontal ostium. tertained for those patients who are candidates for more
3. Frontal recess adhesions. aggressive frontal sinus surgery (Fig. 15.7).
4. Disease processes that have resulted in the loss of the
posterior wall or floor of the frontal sinus.
5. Failed previous osteoplastic flap with obliteration and
Osteoplastic Flap and External Approaches
mucocele formation.
6. Tumor removal from the frontal sinus. The osteoplastic flap has been described historically as
the definitive procedure for the treatment of recalcitrant
The procedure involves identifying the true frontal ostia, frontal sinusitis and frontal sinus disease not amenable
which can be difficult, and often is facilitated by the use to endoscopic approaches [5]. Relative indications to this
15 of computer-aided image guidance, a wire probe, and/or external approach include chronic frontal sinusitis refrac-
an external minitrephination approach with the use of sa- tory to endoscopic surgery, mucopyocele, severe trauma
line/fluorescein. The superior uncinate and frontal recess with fractures involving the drainage pathways, and after
resection of large frontal tumors near the frontal recess.
Other external approaches have also been described for
the management of frontal sinus disease, but have mostly
fallen out of favor.
■ Endoscopic procedures not only have the absence of

any external scars, but they also help maintain the
physiologic ventilation of the sinuses, which is impor-
tant for radiologic and clinical follow up.
Frontal Sinus Stenting

The indications and benefits of frontal sinus stenting has
remained a controversial issue. The purpose of stenting
the frontal sinus outflow tract is to minimize stenosis and
improve mucosalization (Video 3). Although there are
no standardized indications for stenting, there are sev-
eral situations in which stenting may be considered: (1)
Fig. 15.5 Computed tomography scan: coronal image of a type the frontal sinus neo-ostium diameter is less than 5 mm,
IV frontal sinus cell (2) there is extensive or circumferential exposure of bone
Fig. 15.6 Drilling through the nasal beak to remove the opposite a Drilling through the midline. b Completion of the drilling to-
frontal sinus floor and complete the modified Lothrop procedure. ward the opposite frontal sinus modified Lothrop procedure
Fig. 15.7 Persistent frontal disease and frontal recess scar for- gressive revision frontal surgery (endoscopic modified Lothrop
mation after multiple sinus surgeries, necessitating more ag- procedure)
in the frontal sinus outflow tract, (3) there is severe pol- completed. Aggressive medical therapy should also be
yposis, or (4) there is a flail, lateralized middle turbinate continued during the perioperative period to control the
(Fig. 15.8). While there have been reports of benefits with underlying mucosal disease and avoid restenosis of the
frontal sinus stenting, there are several known complica- frontal sinus outflow tract. Finally, long-term follow up
tions: should be individualized for each patient according to the
1. Granulation tissue formation around the stent. pathophysiology of his or her frontal sinus disease.
2. Persistent crusting.
3. Migration.
4. Biofilm formation.
Conclusions
Stents maybe a valuable adjunct in frontal sinus surgery, For successful outcomes the revision surgeon should first
but careful selection and follow up are necessary in order undertake a thorough reevaluation of the patient’s disease,
to obtain good results. followed by efforts to optimize medical therapy. Next, a
thorough investigation into the causes of previous surgi-
cal failure should ensue. The choice of procedure used
for revision frontal sinus surgery should follow an order
Postoperative Care
from least invasive to most, dictated by the anatomy and
Meticulous postoperative care is of extreme importance CT findings as well as by the underlying pathophysiol-
in endoscopic sinus surgery, and particularly in revision ogy. Advancements in optical technology, instrumenta-
frontal sinus surgery. Postoperative care should include, tion, and image guidance have made revision endoscopic
but not be limited to routine nasal saline irrigations, ap- frontal sinus surgery more feasible and safe. Meticulous
propriate antibiotic therapy as deemed necessary, as well postoperative care and adherence to individualized medi-
as topical and systemic agents that control inflammation. cal regimens will lead to greater success in the care of this
difficult subset of patients.
■ Endoscopic debridement of the frontal recess is an in-
tegral part of good postoperative care.
References
Meticulous postoperative debridement will allow the
removal of any crusts and debris, retained mucus, and
15 blood, which promote inflammation and scarring in the
1. Citardi JM, Javer AR, Kuhn FA (2001) Revision endoscopic
frontal sinusotomy with mucoperiosteal flap advancement:
neofrontal ostium. This helps reduce bacterial and/or fun- the frontal sinus rescue procedure. Otolaryngol Clin N Am
gal load and improve mucosal healing. Regular follow up 34:123–132
within 1 week after surgery and closely thereafter should 2. Farhat FT, Kountakis SE (2004) Endoscopic modified
be performed in order to ensure that mucosal healing has Lothrop. Oper Tech Otolaryngol Head Neck Surg 15:4–7
3. Friedman M, Bliznikas D, Vidyasagar R, Landsberg R,
(2004) Frontal sinus surgery: update of clinical anatomy
and surgical techniques. Oper Tech Otolaryngol Head
Neck Surg 15:23–31
4. Gross CW, Gross WE, Becker D (1995) Modified transna-
sal endoscopic Lothrop procedure: frontal drillout. Oper
Tech Otolaryngol Head Neck Surg 6:193–200
5. Jacobs JB (2000) Osteoplastic flap with obliteration: is this
an ideal procedure for chronic frontal sinusitis? Arch Oto-
laryngol Head Neck Surg 126:100
6. Patel AM, Vaughan WC (2005) “Above and Below” FESS:
simple trephine with endoscopic sinus surgery. In: Kounta-
kis SE, Senior BA, Draf W (eds) The Frontal Sinus. Springer,
Berlin, pp 191–199
7. Weber R, Draf W, Kratzsch B, Hosemann W, Schaefer SD
(2001) Modern concepts of frontal sinus surgery. Laryngo-
scope 111:137–146
8. Wormald PJ (2003) Salvage frontal sinus surgery: the mod-
ified Lothrop procedure. Laryngoscope 113:275–283
Fig. 15.8 Postoperative view of a frontal sinus stent in place
Chapter 16
Postoperative Medical Management

Dennis F. Chang, David B. Conley, and Robert C. Kern
16
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
■ A common and frustrating dilemma associated with Postoperative Debridement . . . . . . . . . . . . . . . . . . . . . . 136
sinus surgery is scarring between the middle turbi- Nasal Saline Irrigation and Lavage . . . . . . . . . . . . . . . . 137
nate and lateral nasal wall.
Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
■ The most common adverse event associated with the
Antibiotic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
procedure is failure to alleviate the initial presenting
complaints. Allergic Fungal Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . 140
■ After sinus surgery, mucociliary function of the pa- Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
ranasal sinuses is inhibited for 6–12 weeks.
■ Most sinus surgeons feel that aggressive debride-
ment of the postsurgical sinus cavity is critical for
success.
■ Postoperative debridement may decrease the rate of term postoperative period [33]. Although much has
adhesions and synechiae. been written about the rare, devastating complications of
■ Postoperative nasal saline irrigations reduce crust- FESS – cerebrospinal fluid leak and blindness – the most
ing and edema and improve nasal obstruction. common adverse event associated with the procedure
■ Intranasal corticosteroids play an integral role in the remains failure to alleviate the initial presenting com-
postoperative management of the surgically treated plaints. Meticulous postoperative care and maximal med-
sinus cavities. ical management are widely believed to be crucial to ob-
■ Because of the multiple side effects of long-term oral taining optimal results. In many respects, the techniques
steroid use, short oral steroid bursts should be used and methods employed after the operation to maintain
judiciously, with nasal topical therapy being the pre- healthy and open sinus cavities may be as important as
ferred treatment. the initial surgery itself.
■ In cases of extensive nasal polyps, an ideal solution Multiple obstacles can present themselves in the post-
would involve delivering a large amount of steroid operative patient, but a common and frustrating dilemma
to the diseased sinuses while minimizing systemic is scarring between the middle turbinate and lateral nasal
absorption. wall. This phenomenon often leads to partial or complete
■ Culture-directed antibiotic therapy is necessary for obstruction of the ostiomeatal complex with recurrence of
infectious exacerbations of chronic sinus disease, symptomatology. After FESS, mucociliary function of the
especially after sinus surgery. paranasal sinuses is inhibited for 6–12 weeks [16]. Debris
composed of fibrin, blood clots, crusts, and viscous se-
cretions tend to accumulate during this time period and
the patient is then particularly vulnerable to discomfort,
perioperative infection, and postoperative formation of
synechiae. Numerous protocols and techniques have been
Introduction
formulated to deal with these challenges and optimize
Functional endoscopic sinus surgery (FESS) is one of postoperative healing. The decision as to what constitutes
the most commonly performed operations by otolaryn- the “best” management philosophy is often controversial.
gologists. The popularity and success of this procedure This chapter will cover the following major points: post-
has been attributed in part to excellent improvement in operative debridement, pros, cons, timing, frequency, na-
patient symptoms both in the short term as well as long sal saline irrigation and lavage, steroids, oral, topical, and
136 Dennis F. Chang, David B. Conley, and Robert C. Kern
nebulized antibiotic therapy, and allergic fungal sinusitis gest that these are more critical in the absence of regular
(AFS). postoperative debridements. Probably the best study to
The various methods and packing used to prevent lat- date on the topic, however, included 60 patients in a ran-
eralization of the middle turbinate are beyond the scope domized, partially blinded, controlled, prospective trial
of this chapter and will be covered in detail elsewhere in [3]. Debrided patients had significantly less crusting in
this volume. the sinus cavities as well as significantly less postoperative
adhesion formation compared to those who had saline ir-
rigation alone. The procedure did induce more postop-
erative pain but there was no difference in bleeding. The
Postoperative Debridement
study concluded that increased adhesions from increased
The role of postoperative debridement and the exact tim- crusts and debris may increase the need for revision sinus
ing and frequency of debridement are not standardized. surgery, and that debridements should be undertaken to
The management philosophies are based mainly on em- prevent this as much as possible.
piric data with a dearth of prospective, double-blinded,
randomized, controlled studies addressing this topic. ■ The current weight of evidence supports debridement
Most sinus surgeons feel that aggressive debridement of to remove crusts, bone chips, and fibrin as a method
the postsurgical sinus cavity is critical for success. The ra- to prevent adhesions and synechiae in adult patients
tionale underlying debridement is that if debris composed following FESS.
of crusts, blood clots, bone chips, and fibrin are allowed
to accumulate, there will be a tendency for increased ad- An interesting perspective can be gained by looking at
hesions and synechiae formation with resultant scar and the pediatric FESS population and the role that debride-
recurrent rhinosinusitis. Ancillary arguments for de- ment plays in postoperative management. Pediatric pa-
bridement include more rapid relief of nasal congestion tients have a limited tolerance for office endoscopy and
and fewer postoperative infections [3]. A minority of sur- debridement, traditionally mandating a return to the op-
geons consider debridement unnecessary, opting instead erating room under general anesthesia for second-look
to prevent postoperative adhesions by placing packing in and cleansing of the sinus cavities 2–4 weeks after the
the middle meatus. primary operation. Over time, this management has been
challenged with several groups contending in prospective
■ A major disadvantage to regular and routine aggres- studies that postoperative improvement in nasal obstruc-
sive debridements is the increased bleeding and pain tion, drainage, and chronic cough was identical in pediat-
associated with both injection of local anesthetic and ric patients with and without any postoperative debride-
16 the instrumentation of the sensitive postoperative na- ment [21, 22]. Pediatric patients undergoing revision
sal cavity. surgery and those suffering from cystic fibrosis were ex-
cluded from these trials. Since the extent of sinus surgery,
Debridement also can be time-consuming in the edema- and possibly the disease itself, may be different from the
tous and inflamed surgical cavity and can potentially cause adult population, any conclusions based on data from the
additional mucosal damage that delays wound healing. pediatric FESS literature cannot be readily extrapolated.
The literature on this topic has been somewhat con- The timing and frequency of debridements is also a
flicted and controversial. A study by Nissen et al. [23] matter of contention. Kuhnel et al. [19] noted that avul-
looked at 17 patients and compared symptom scores, sion of epithelium occurred in 23% of patients when de-
healing, and adhesion rates between debrided and non- brided in the 1st week and advised the first postoperative
debrided sides in the same patient over a 3-month period manipulation be delayed until the 2nd week after surgery.
of time. Although there was no statistical significance Bugten et al. performed debridements at 6 and 12 days
shown, the numbers of patients enrolled and the short and found that crusts and adhesions were significantly re-
follow-up period are more consistent with a pilot study duced [3]. A third debridement was reserved for patients
and only limited conclusions can be drawn. Ryan et al. with infections or recalcitrant crusting. Some surgeons
[30] analyzed 120 patients in a retrospective review. His advocate aggressive debridements daily in the 1st week of
group found that despite minimal postoperative follow surgery or weekly over 6–8 weeks until healing is com-
up with an average of only 2.8 visits and 1 debridement, plete, although patient comfort is significantly impacted
78% of patients reported either significant improvement and these regimens have fallen somewhat out of favor.
in symptoms or outright cure at 18 months follow up.
Postoperative antibiotic therapy and topical nasal corti- ■ A recent position statement by the American Rhi-
costeroids were both used routinely and the authors sug- nologic Society maintains that four postoperative
Postoperative Medical Management 137
debridements in a 6-week period for routine FESS antiseptic and a mucolytic [24]. Ultimately there was no
patients is reasonable and six debridements in the difference in efficacy between the two groups, although
complex patient is fair. there was a trend toward significance with the chemical
■ However, treatment ultimately must be tailored to lavage group causing less crusting.
each individual patient and disease case. A commercially available oily mixture made of nasal
emollient derived from pine and eucalyptus has proven
especially effective in relieving patients of excessive nasal
crusting after sinus surgery. This problem is minimized
Nasal Saline Irrigation and Lavage
by preserving the turbinates during surgery; however,
The effectiveness of daily saline irrigation of the sinuses some aspect of crusting is usually unavoidable. In some
and nares in the treatment of chronic rhinosinusitis as cases, the middle turbinates have completely degenerated
well as allergic and nonallergic rhinitis is well established. into polypoid form and preservation is impractical.
Postoperatively, nasal saline remains a crucial component
in maintaining clean, moist, well-aerated sinus cavities.
Crusting is significantly reduced and nasal obstruction
Corticosteroids
and edema are improved. The exact manner, technique,
and volume of delivery will vary from institution to in- Intranasal corticosteroids have long been a part of pre-
stitution at the preference of both the surgeon and the operative maximal medical therapy, having minimal
patient, but there appears to be a consensus that saline systemic absorption and mild, local side effects. The con-
lavage is both recommended and necessary in the post- tinued use of intranasal corticosteroids postoperatively is
FESS patient. justified primarily for two reasons. First, the continued
Nasal saline irrigation protocol: anti-inflammatory effect of the steroid may be increased
1. During postoperative days 1–7, patients are discour- in efficacy since there should theoretically be greater de-
aged from irrigating the nose vigorously as the surgi- livery to the more open postoperative sinus cavity. The
cal site is still fresh and sore. They are encouraged to removal of the uncinate process, the medialization of
begin gently instilling commercially prepared normal the middle turbinate, and the exposed skull base mucosa
saline spray in their nares twice daily. from a complete ethmoidectomy are all anatomic factors
2. After the first postoperative visit and debridement, that facilitate greater distribution of topical medications
they are given an instruction sheet that teaches them to the sinus mucosa. Second, in the case of nasal polyps,
how to mix their own saline solution. disease recurrence is common and the persistent daily use
3. They are taught to adjust both the amount of salt and of intranasal corticosteroids is widely believed to reduce
the temperature of the solution to optimize comfort. the rate of recurrence. Rowe-Jones et al. [29] studied 72
4. Noniodized salt should be used as iodine may irritate patients over a 5-year period in a prospective, random-
the nose. ized, placebo-controlled, and double-blinded manner. A
5. Patients are informed of the various devices for irriga- statistically significant improvement was demonstrated
tion including bottles designed for irrigation or a simi- not only in patient subjective symptoms, but also in en-
lar-sized bulb syringe. doscopic edema and polyp scores and total nasal volume.
6. They are taught to lean over, breathe through their The placebo group also required more oral steroid tapers,
mouth, and passively irrigate one naris and then an- and of the 12 patients who failed the study due to exces-
other without snorting in the saline solution. sive requirements for oral steroid tapers, 10 were from the
7. Saline lavage should be done at least twice a day and placebo group. Older studies using flunisolide and beclo-
separately from any other concurrent nasal steroid methasone have also shown improvement in the preven-
spray. tion of nasal polyp recurrence at 1 year and 2.5 years [11,
8. This regimen is continued for at least 3–6 months 18]. A more recent paper by Desrosiers’ group demon-
while the sinus cavities complete healing. strated an interesting effect of postoperative intranasal
steroid use [8]. In a prospective observational study of
The postoperative course, the presence of polyps, the 157 patients, intranasal corticosteroid use was associated
incidence of perioperative infections, and other factors with lower rates of bacterial recovery, especially for re-
will then determine whether antibiotics and steroids are vision FESS patients. This phenomenon may be partially
added to the saline solution. The only randomized single- explained by the high rate of colonization of post-FESS
blinded trial to look at saline lavage in the postoperative patients with Staphylococcus aureus and the potentially
patient compared mechanical lavage with pressurized sa- anti-inflammatory and proinnate immune actions of in-
line to chemical lavage with saline impregnated with an tranasal corticosteroids, which could result in improved
S. aureus clearance from the sinuses. [31] While cortico- This philosophy is similar to the use of ototopical antibi-
steroids are known to suppress inflammation, it has only otic drops delivered in very high local concentrations to
recently become clear that they enhance the innate im- the external ear canal and middle ear space. Various at-
mune defenses of airway epithelium. tempts to achieve the same effect in the sinuses have been
made. Budesonide respules, which are traditionally used
■ Postoperative corticosteroids appear to not only sup- for asthma treatment, have been adapted for sinusitis. Re-
press inflammation, but also reduce the rate of bacte- spules are dissolved in saline solution and used to irrigate
rial colonization. the postoperative sinus regularly for at least 6–8 weeks.
While there have been anecdotal tales of success, no pro-
Conflicting literature arguing against the beneficial effects spective randomized, controlled trial in the literature has
of topical steroids can also be cited, however. Dijkstra et been performed to study this.
al. [10] followed 162 patients in a prospective, double- Recently, a retrospective review by DelGaudio et al.
blinded, placebo-controlled, randomized study focused [6] studied a variety of topical steroid drops formulated
on fluticasone and found no significant difference in re- for ophthalmic and otologic use and their effect on si-
currence rates of either chronic rhinosinusitis or nasal nus ostia stenosis in the postoperative period of revision
polyps 1 year after sinus surgery. Another paper evaluat- FESS patients. The solutions include dexamethasone
ing Beconase nasal spray and olfaction recovery in post- ophthalmic (0.1%), prednisolone ophthalmic (1%), and
nasal polypectomy patients also revealed no difference ciprofloxacin-dexamethasone otic (0.3/0.1%) drops. They
[13]. These results represent a minority point of view. found that of 67 sides treated, 64% were patent, 14.9%
Oral glucocorticoids are also a mainstay of therapy for were stable, and 20.9% failed. There was only one com-
both allergic rhinitis, chronic rhinosinusitis with and with- plication secondary to lowered morning cortisol levels,
out nasal polyposis, and postoperative mucosal edema which necessitated discontinuation of the drops. Mean
[20]. They are also frequently given both perioperatively follow up was 4.8 months. An interesting perspective was
to decrease inflammation and operative bleeding as well put forth as a possible explanation for the occasional in-
as together with antibiotics for acute sinusitis and exacer- effectiveness of intranasal corticosteroids. Conventional
bations of chronic sinusitis. In the postoperative period, nasal steroid sprays are often deposited in the anterior
oral steroid bursts with either prednisone or methylpred- nasal cavity. With topical steroid drops, patients were
nisolone can be crucial in slowing or preventing nasal instructed to extend the head at a 45 angle and turned
polyp recurrence. Unfortunately, the list of side effects for slightly to the side of drop application for 5 min. This
chronic oral steroid use is potentially problematic. variation of the Mygind technique was shown to improve
The side effects of chronic oral steroid use include: delivery of medication versus sprays [17]. The paper ad-
16 1. Immunosuppression. vocates, based on previous work by Citardi and Kuhn [5],
2. Exacerbation of diabetes or unmasking of latent dia- that anatomic position is critical for the delivery of ste-
betes. roid to the targeted frontal recess.
3. Precipitation into diabetic ketoacidosis.
4. Osteoporosis. ■ The route of topical steroid delivery (spray, drops or
5. Peptic ulcer disease. irrigation) may play a significant role in the efficacy of
6. Hypertension. these therapies.
7. Psychological effects such as depression and psycho-
sis.
8. Muscle wasting.
Antibiotic Therapy
9. Cataracts.
10. Impaired wound healing. Antibiotics therapy is a key component of the manage-
11. Avascular joint necrosis. ment of acute and chronic rhinosinusitis and their role in
12. Facial changes (“buffalo hump” and “steroid facies”). the preoperative setting has been studied extensively and
documented in the literature.
Consequently, even short oral steroid bursts should be Many studies have reported the presence of typical
used judiciously, with nasal topical therapy being the pre- upper respiratory tract organisms in acute and chronic
ferred treatment. rhinosinusitis. Streptococcus pneumoniae, Hemophilus in-
In the setting of polyps in particular, intranasal cor- fluenzae, and Moraxella catarrhalis remain the top three
ticosteroids alone are frequently insufficient to control bacteria implicated in uncomplicated acute rhinosinusitis
postoperative mucosal disease. A more ideal solution [27]. The microbiology of chronic rhinosinusitis particu-
would involve delivering a large amount of steroid to the larly in the postoperative setting is more complicated.
diseased sinuses while minimizing systemic absorption. While S. aureus, anaerobes, and Gram-negative organ-
isms have always been recognized as more significant con- One criticism of using saline to deliver antibiotics cen-
tributors in chronic versus acute disease, their presence ters on the concentration of the antibiotic in the solution.
in the postoperative patient is increased. Bhattacharyya While it offers an improvement over oral ingestion alone,
et al. [2] demonstrated that Strep. pneumoniae, H. influen- the presence of large amounts of saline significantly di-
zae, and M. catarrhalis combined, only made up 10.8% of lutes whatever antibiotic is mixed and ultimately de-
over 290 cultures taken from post-FESS sinus cavities. Of creases the concentration delivered to the sinus cavities.
special interest, S. aureus and coagulase-negative staphy- A more suitable alternative would appear to be the deliv-
lococcus represented the number one and number two ery of a small volume of solution by means of a nebulizer.
most cultured organism, and together represented nearly Initial trials by Vaughan et al. [34] and Desrosiers et al.
30% of all organisms. Pseudomonas aeruginosa was third [7] demonstrated safety as well as improvement in infec-
at 7.2%. Fungal organisms were cultured in only 1.7% of tion clearance rates, nasal symptomatology, and quality
the specimens. of life surveys. Vaughan’s study was an uncontrolled pilot
study, which not only showed a longer disease-free inter-
■ S. aureus frequently colonizes chronic rhinosinusitis val (17 weeks versus 7 weeks) for the nebulized antibiotic
and postoperative patients and may play a role in the treatment group, but also decreased facial pain and post-
progression of mucosal inflammation. nasal drip [34].
S. aureus is widely believed to be a significant pathogen ■ A randomized controlled study on intranasal antibi-
in the etiology of chronic rhinosinusitis and its presence otic use by Desrosiers’ group showed that there was
in the operated sinus cavity is a cause for concern. Re- symptomatic improvement, but comparison between
cent reviews illustrate a convincing argument for staphy- a nebulized saline control group and the nebulized
lococcal superantigens and their nonspecific activation tobramycin group revealed no significant differ-
of local T-cell receptors as a factor in the development of ences [7].
chronic rhinosinusitis with nasal polyposis [32, 36]. An-
other striking finding is the relatively high prevalence of The paper concluded that large-particle nebulized aero-
Pseudomonas bacteria in the postoperative setting; these sol therapy in and of itself may offer a safe and effective
bacteria have a very strong propensity for developing management alternative, but was unable to show any ad-
multidrug resistance. ditional benefit of tobramycin [7].
Antibiotic resistance is an emerging problem in all Recent research has placed new emphasis on biofilm
fields of medicine and post-FESS patients have often formation and the role that it plays in recalcitrant chronic
received multiple long-term courses before undergoing rhinosinusitis, especially in the operated patient. Previ-
surgery. Consequently, it should come as no surprise ous work had demonstrated the increased prevalence
that these patients often present with infections by mul- of Staphylococcus and Pseudomonas species in the post-
tidrug resistance bacteria that are difficult to eradicate. FESS patient and various theories had been advanced as
The study by Bhattacharyya makes a strong argument for to why infections in this patient population were so dif-
culture directed antibiotic therapy in the postoperative ficult to clear [2]. Both Staphylococcus and Pseudomonas
setting and points out that a good FESS should provide are known biofilm producers and it is now thought that
much improved access to at least the maxillary antrum bacterial biofilms help to explain the decreased efficacy of
and ethmoid cavity for representative specimens [2]. oral antibiotics, since the minimal inhibitory concentra-
The issue of resistance coupled with possible systemic tion (MIC) of antibiotics delivered in oral form is simply
side effects from protracted use of oral antibiotics has led inadequate to affect bacteria in biofilms. An impractical
to an increased interest in the topical delivery of anti- solution would simply be to increase the MIC of various
biotics. As nasal saline irrigation was already a well-es- antibiotics, as studies have shown that high MICs are ca-
tablished regimen used by patients, a natural extension pable of overcoming biofilm resistance [15]. As high con-
was the addition of both corticosteroids and antibiotics centrations are difficult to attain in serum due to systemic
to the wash. The philosophy was to increase delivery of toxicity, the focus is placed on topical antibiotics, which
antibiotic to the affected sinus cavities while decreasing may achieve concentrations high enough to penetrate
systemic absorption. The prevalence of Staphylococcus biofilms and eradicate bacteria but with negligible sys-
and Pseudomonas in the postoperative patient made the temic absorption. Preliminary work by Desrosiers et al.
addition of two types of antibiotics especially attractive. [9] recently demonstrated the capacity of supra-MIC lev-
For staphylococcal coverage, mucopirocin is added to els of moxifloxacin to kill bacteria in biofilms in vitro. An
saline rinses; gentamycin and tobramycin represent the elegant animal model for both inducing chronic rhino-
most popular antibiotics mixed into saline for pseudo- sinusitis and then studying the effects of various topical
monal coverage. medications on the maxillary sinus through a surgically
implanted irrigating catheter has recently been published cin B therapy in 60 patients in a prospective, controlled,
[4]. Irrigation with saline alone demonstrates no signifi- double-blinded trial. found no difference in any of the
cant difference from untreated animals with regard to the parameters studied. Furthermore, a larger, more recent,
degree of inflammation of sinus mucosa and underlying randomized multi-institutional trial failed to show any
bone, and no changes in the amount of purulence could efficacy with the use of amphotericin nasal rinses [12].
be found. Further work will concentrate on the effects of
topical antibiotics and steroids in the rabbit model and ■ The efficacy of topical antifungal medications for any
future clinical trials to establish safety profiles, dosages, form of chronic rhinosinusitis is currently unproven.
and regimens will also be needed.
Conclusion
Allergic Fungal Sinusitis
The management of chronic rhinosinusitis can be chal-
AFS represents a special subgroup of chronic rhinosinus- lenging. While surgical therapy is often required, the
itis whose treatment is especially challenging [1]. Even postoperative medical management of the disease is be-
with intranasal corticosteroids and multiple courses of lieved to be critical for optimal outcome. Postoperative
systemic steroids, disease recidivism requiring revision debridement, steroids, saline lavages, antibiotics, topical
FESS is common. Part of the difficulty in elucidating op- and nebulized therapy, and the special challenges pre-
timal medical therapy for AFS is the fact that the etiol- sented by AFS have been discussed in detail. Many of
ogy of this disease remains unclear. Complete eradication these issues remain controversial and further research is
of fungus from the sinus cavities with both surgical and needed to clarify their role in the treatment of chronic
medical therapy would appear to be a reasonable goal. rhinosinusitis.
Unfortunately, the extreme toxicity of systemic antifungal
therapy has limited its use in patients with AFS.
The usefulness of postoperative immunotherapy in
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Chapter 17
Evaluation and Treatment

of Recurrent Nasal Polyposis 17
Frederick C. Roediger and Andrew N. Goldberg
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
■ Nasal polyposis is the defining feature of a more se- Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
vere subset of chronic rhinosinusitis. Inhalant Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
■ Patients with primary or recurrent disease should be
Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
evaluated for associated disorders such as asthma,
allergic fungal rhinosinusitis, aspirin sensitivity, Allergic Fungal Rhinosinusitis . . . . . . . . . . . . . . . . . . 146
cystic fibrosis, immunoglobulin subclass deficiency, Aspirin Sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
and primary ciliary dyskinesia. Cystic Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
■ Oral and intranasal corticosteroids are the corner-
Immunoglobulin Subclass Deficiency . . . . . . . . . . . 146
stone of medical therapy for patients with chronic
rhinosinusitis with nasal polyposis. Primary Ciliary Dyskinesia . . . . . . . . . . . . . . . . . . . . 146
■ Patients with medically refractory chronic rhinosi- Young’s Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
nusitis with nasal polyposis or allergic fungal rhino- Unilateral Recurrent Nasal Polyps . . . . . . . . . . . . . . 147
sinusitis are surgical candidates.
Medical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
■ Intensive perioperative medical management and
Patient Selection for Surgical Treatment . . . . . . . . . . . . 148
selective use of powered instrumentation facilitate
safe and effective surgery. Perioperative Medical Care . . . . . . . . . . . . . . . . . . . . . . . 148
■ Close surveillance, early detection of recurrent pol- Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
yposis, and tailored medical therapy are required to
Surgical Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
decrease the need for revision surgery and increase
the interval between surgeries in refractory cases. Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
tomography (CT) scans than their nonpolypoid counter-

parts [14]. CRSwNP patients also commonly have symp-
Introduction
toms that persist despite maximal medical therapy, and
Nasal polyposis (NP) is a clinical and pathological mani- improve less after surgery than patients with CRS without
festation of chronic inflammation in the paranasal sinuses. nasal polyposis (CRSsNP) [14, 29]. Despite ongoing re-
Population-based surveys have shown a prevalence of search, the pathogenesis of NP remains elusive.
2–4% in the general population, while autopsy studies sug-
gest a much higher rate of preclinical lesions [25, 35, 42]. ■ The majority (>80%) of polyps appear to be the product
In the past, the literature referred to NP as a clinical of eosinophilic inflammation, characterized by subep-
entity distinct from chronic rhinosinusitis (CRS). To- ithelial caps of eosinophils, pseudocyst formation with
day, NP is recognized as the defining feature of a more deposition of albumin, and elevated levels of the in-
severe and treatment-refractory subset of rhinosinusitis, flammatory mediators interleukin-5 and eotaxin [6].
CRS with nasal polyposis (CRSwNP) [40]. Patients with
CRSwNP demonstrate decreased disease-specific quality Others, such as those associated with ciliary dysmotility,
of life (QOL) and greater extent of disease on computed are neutrophil-rich, yet may appear identical on clinical
144 Frederick C. Roediger and Andrew N. Goldberg
examination [58]. The reason for these findings is still to assess nasal cavity patency, mucosal health, septal posi-
unknown. Theories explaining polyp formation, regard- tion, and inferior turbinate size and response to vasocon-
less of the inciting event, are numerous and include loss striction.
of autonomic innervation, dysregulation of water and ion Nasal endoscopy is an essential component of the rhi-
transporters, and chronic vascular changes leading to nologic exam in patients with recurrent polyposis. The
congestion and exudation [6, 42]. procedure can define the extent and character of NP, de-
Since NP may be the presenting manifestation of tect subtle mucosal changes in the sinus cavities, and ex-
several conditions, such as allergic fungal rhinosinus- amination of the fovea ethmoidalis, cribriform region, and
itis (AFRS) and cystic fibrosis (CF), specialized testing sphenoid may reveal pulsation related to dehiscence of the
and referrals should be arranged if an underlying disor- skull base or carotid. In addition, movement of nasal con-
der is suspected. Those patients with disease refractory tents during ballottement of the eye during office endos-
to maximal medical therapy are considered for surgical copy can signify dehiscence of the orbital wall. Treatment
intervention. Well-designed and sometimes intensive planning, postoperative care, and surveillance all depend
medical regimens are essential in both the immediate heavily on the findings during nasal endoscopy.
perioperative period and the long-term for successful A contemporary CT scan of the paranasal sinuses with
management. fine cuts should be carefully analyzed for the extent of dis-
ease, skull-base and orbital integrity, nasolacrimal ducts,
middle turbinates, and remaining surgical landmarks.
Hallmarks of specific diagnoses, such as an expansile le-
Evaluation
sion with central serpiginous calcifications in AFRS or
Besides querying symptoms of CRS [10], a treatment his- the dense bone associated with chronic infection, should
tory should be carefully elicited. Prior medical regimens be noted. MRI of the paranasal sinuses with gadolinium
should be assessed for adequacy of dose, duration, pa- enhancement may also be indicated, for example to iden-
tient adherence, and medication interactions. A history tify encephalocele or meningocele when skull-base dehis-
of complications of oral steroid use, such as worsening cence is detected on CT.
hypertension, poor diabetic control, psychological dis- Serum total immunoglobulin E (IgE) levels are helpful
turbances, or osteoporosis, is worrisome, since systemic in patients with concurrent asthma, since IgE levels cor-
corticosteroids play a central role in the treatment of relate with airway hyperresponsiveness [56, 62]. However,
recurrent disease. Early identification of non-steroid-re- the exact role of IgE in predicting the severity of CRS con-
sponsive NP can minimize risks in patients who may not tinues to be debated, with a correlation between serum
derive a benefit from corticosteroids. total IgE level and mucosal disease on CT scan demon-
Past surgical history, including complications and strated in some studies [7] but not others [52]. No sig-
perioperative medical care, is explored to gauge the se- nificant change in IgE is seen 1 year after sinus surgery in
17 verity, extent, and laterality of the disease. Prior operative patients reporting improvement in symptoms, indicating
reports should be scrutinized, noting that although sinus that IgE levels are not a sensitive barometer for changes
surgery has evolved from simple polypectomy under lo- in CRS [34]. In contrast, peripheral eosinophilia has been
cal anesthesia in the pre-endoscopic era to formal FESS shown to correlate with the degree of nasal polyposis [32]
today, a wide range of prior procedures are possible. as well as disease severity on CT scan [7, 32, 52]. For those
patients progressing to sinus surgery, an elevated mucosal
■ Reports of visual disturbance, watery nasal discharge eosinophil level (>5 cells per high-power field) indicates
(particularly unilateral), meningitis, excessive bleed- more severe disease [32].
ing, epiphora, and facial numbness may indicate in- Specialized testing for associated disorders, as out-
volvement of critical structures related to previous lined in Table 17.1, should be considered on a case by
surgery or complications of severe polyposis. case basis.
Although recurrent nasal polyposis most likely indi-
A comprehensive head and neck examination, includ- cates a diagnosis of CRSwNP alone, several associated
ing an assessment of the cranial nerves with attention to disorders must be considered during history-taking (Ta-
trigeminal nerve function and extraocular movements, ble 17.1).
should be performed. Further ophthalmic evaluation
may identify unilateral visual acuity loss, proptosis, or
epiphora. The nose is examined externally for weakened
Inhalant Allergy
cartilaginous support or widening from bony expansion
from nasal polyps or neoplasm. Anterior rhinoscopy pre- Allergic rhinitis (AR) is present in 15–20% of the general
and postapplication of a topical decongestant is then used population [42]. However, although both atopy and NP
Evaluation and Treatment of Recurrent Nasal Polyposis 145
Table 17.1 Disorders associated with nasal polyposis
Disorder Age of onset Laterality Associated findings Confirmatory studies
Allergic Bimodal peaks Bilateral • Pale, edematous inferior turbinates • Allergy skin testing or radio-
rhinitis in early school • Transverse nasal crease allergosorbent test (RAST)
(AR) and early • Dark, edematous infraorbital skin
adult years • Mouth breathing
Asthma May develop Bilateral • Episodic wheeze, cough, and • Pulmonary function
at any age, but difficulty breathing triggered by tests (PFTs) demonstrat-
most (75%) exercise, cold air, or allergens ing variable expiratory
diagnosed be- • Personal/family history of atopy airflow obstruction
fore age 7 years
Allergic Adolescents Often • Unilateral thick, dark rhinorrhea • Elevated serum IgE
fungal and young unilat- • AR, asthma (> 50%) • Type I hypersensitivity by
rhinosinus- adults (mean eral, may • Facial/ocular dysmorphia history, skin testing, or RAST
itis (AFRS) age 22 years) be • Characteristic computed
bilateral tomography scan
• Eosinophilic mucus
• Positive fungal stain
of sinus contents
Aspirin Third to fourth Bilateral • Wheezing, rhinorrhea, nasal • Serial monitoring of PFTs
sensitivity decade congestion, tearing, and/or facial after aspirin challenge
flushing 30–120 min after inges- • Concurrent rise in
tion of aspirin or nonsteroidal urinary leukotrienes
anti-inflammatory drugs
Cystic Most (> 90%) Bilateral • Recurrent respiratory infections • Elevated sweat chloride
fibrosis identified by • Failure to thrive (> 60 mEq/l) on two or more
(CF) age 8 years • Steatorrhea occasions (95% sensitive)
• Molecular testing for 20–30
most common mutations
(> 90% sensitive)
Immuno- Adolescents Bilateral • Recurrent sinopulmonary infections • Complete blood count
globulin and young with common bacterial pathogens with differential
subclass adults • Osteomyelitis, meningitis, • Total IgG, IgA, comple-
deficiency diarrhea, skin infections ment (CH50), and indi-
vidual IgG subclass levels
Primary Children Bilateral • Recurrent respiratory • Endoscopic sinonasal
ciliary infections, bronchiectasis mucosal biopsy with
dyskinesia • Situs inversus electron microscopy
(PCD) • Infertility in men, decreased
fertility in women
Young’s Onset in early Bilateral • Infertility secondary to ob- • Normal CF and PCD testing
syndrome childhood structive azoospermia
• Less sinopulmonary in-
fections as an adult
Antrocho- Young adults Unilateral • Unilateral nasal obstruction, • Surgical excision and
anal polyp (mean age rhinorrhea, protrusion into pathological examina-
27 years) the superior oropharynx tion to exclude inverted
papilloma and AFRS
occur in subsets of patients with CRS, a direct or causal disease than non-AS asthmatics [20]. The triad of aspirin
relationship between inhalant allergies and NP has yet to sensitivity, asthma, and NP is termed Samter’s triad, or
be proven. aspirin-exacerbated respiratory disease.
■ Positive skin tests occur in a similar percentage of pa-

tients with and without nasal polyps [6].
Cystic Fibrosis
Less than 5% of patients with inhalant allergies have NP, ■ CF should be considered in the workup of any child
similar to the general population [42], and the prevalence with NP.
of NP is actually higher in nonallergic rhinitis than the
corresponding allergic form [58]. Most patients with CF present with either recurrent re-
spiratory infections or manifestations of pancreatic insuf-
ficiency, such as failure to thrive or steatorrhea [54]. Most
develop CRS, with approximately 20% of affected patients
Asthma
demonstrating NP on nasal endoscopy and >90% having
The frequencies of NP in allergic and intrinsic asthma pan-opacification of the sinuses on CT [58, 70].
are approximately 5% and 13%, respectively [58]. NP
occurs most frequently in nonatopic asthma patients
over age 40 years with severe, steroid-dependent disease
Immunoglobulin Subclass Deficiency
[58]. Treating sinus disease in asthmatics is an important
component of their care; a reduction of total annual oral Deficiency of one or more of the immunoglobulin G (IgG)
prednisone and antibiotic use in patients with concur- subclasses occurs in up to 20% of the general population,
rent asthma has been well documented after FESS [47, yet most individuals are asymptomatic [46]. Some pres-
57, 64]. ent in adolescence and early adulthood with CRSwNP
and recurrent pulmonary infections. Testing reveals nor-
mal or near-normal total serum IgG with one or more
subclass levels greater than two standard deviations be-
Allergic Fungal Rhinosinusitis
low the age-adjusted mean [26]. Early diagnosis and im-
AFRS is thought to represent a type I hypersensitivity munoglobulin replacement can reduce the frequency and
reaction to noninvasive fungus. Nearly all AFRS patients severity of infections and increase life expectancy.
have NP [55]. Most AFRS patients present with a history
of progressive nasal obstruction, anosmia, and dark nasal
discharge predominantly affecting one side. The charac-
17 teristic CT scan findings include opacification of multiple
Primary Ciliary Dyskinesia
ipsilateral sinuses containing areas of hyperattenuation This autosomal recessive disease is characterized by re-
from calcification and products of fungal metabolism current childhood respiratory infections and CRSwNP
(iron, magnesium, manganese) and expanding borders secondary to ciliary immotility [1]. Fifty percent of cases
caused by mass effect of debris and dense polyposis [5, are associated with situs inversus [44]. The triad of bron-
11]. Bony erosion with skull-base or orbital involvement chiectasis (after repeated pulmonary infections), CRS,
leading to proptosis occurs in roughly half of patients [23]. and situs inversus is termed Kartagener’s syndrome [2].
Recent work suggests that AFRS is a subset of eosinophilic Patients with PCD generally have a normal lifespan and
mucin chronic rhinosinusitis [21, 48]. Despite thorough have a lower rate of decline of lung function than patients
surgical debridement and intensive medical therapy, with CF, so they are more likely to present undiagnosed
AFRS frequently recurs and requires reoperation [33]. as a young adult with NP [44].
Aspirin Sensitivity Young’s Syndrome

Aspirin sensitivity (AS) is a clinical syndrome in which This disorder is characterized by azoospermia, NP, and
patients typically develop refractory CRS and asthma in recurrent sinopulmonary infections [24]. Patients have
the third to fourth decade of life, with acute respiratory normal sweat chloride values and pancreatic function,
exacerbations precipitated by aspirin or nonsteroidal anti- unlike those with CF, and motile cilia, distinguishing
inflammatory drugs, and is associated with NP 36% of the them from patients with PCD.
time [58]. These patients generally have worse respiratory
(amoxicillin/clavulanate), fluoroquinolones (levofloxa-

Unilateral Recurrent Nasal Polyps
cin), or macrolides (erythromycin). The macrolides have
■ Patients with unilateral recurrent nasal polyps should received much attention for their anti-inflammatory and
be closely scrutinized for inverted papilloma and neo- immunomodulatory effects and the potential for induc-
plasm. ing polyp regression when courses longer than 4 weeks
are prescribed [38]. For example, an 8- to 12-week course
Past pathology slides can be requested and examined. of clarithromycin in patients with CRSwNP was shown to
AFRS and antrochoanal polyp can also present with uni- significantly decrease interleukin-8 levels in nasal lavage
lateral disease. and reduce polyp size in 40% of cases [69]. Clinical im-
provement manifests as decreased nasal secretions, post-
nasal drip, and nasal obstruction [38].
Topical application of antibiotics in irrigation solu-
Medical Treatment
tions is a common practice despite little data on their
■ Oral corticosteroids are used frequently in the treat- use in NP patients [66]. One study, in which one-third of
ment of severe, recurrent nasal polyps. patients had NP, showed successful treatment of drug-re-
sistant bacterial exacerbations with mupirocin irrigations
Their efficacy has been noted anecdotally for decades and [59]. Despite one small study of patients with CRSwNP
continues to be documented in the literature [36, 65]. One showing improvements in objective CT findings and en-
small, randomized clinical trial addressed the short-term doscopic scores with the use of topical amphotericin B
effects of systemic steroids [4]. This study showed that [51], larger studies of CRS patients in which the majority
patients with severe NP had significant improvements in (80–100%) had NP have shown no benefit to this therapy
general QOL after a 2-week prednisone burst and taper [19, 67].
compared to a control group with similar disease that Leukotriene blockade provides a benefit in patients
received no treatment [4]. The same investigators also with asthma, especially those with AS, improving lung
showed improvements in nasal symptoms, polyp size, function and decreasing medication use and exacerba-
and nasal patency at 2 weeks with this medical regimen tions [16]. Identification of increased leukotriene release
[9]. Chronic oral steroid use may be necessary in some in the nasal cavities of patients with NP and observations
patients, particularly those with concomitant pulmonary that NP was reduced in Samter’s triad patients treated
disease. Effort should be made to reduce oral steroid lev- with leukotriene inhibitors led to the hypothesis that
els to the lowest possible to control disease with the goal CRSwNP patients would benefit from similar treatment.
of a regimen of every-other-day steroid dosing to mini-
mize adrenal suppression. Patients requiring more than ■ Leukotriene blockade may benefit patients with nasal
three courses of systemic corticosteroids can be consid- polyps.
ered for functional endoscopic sinus surgery (FESS) [13,
45]. Using this guideline, on average 10–30% of patients A recent clinical trial using the cysteinyl leukotriene re-
with CRSwNP undergoing close observation and inten- ceptor antagonist zafirlukast and the 5-lipoxygenase in-
sive medical treatment for 1 year will progress to need hibitor zileuton in patients with NP showed significant
surgery [13, 45]. improvements in sinonasal symptom scores and reduc-
tions in the degree of polyposis and oral steroid use with
■ Intranasal corticosteroids have an exceedingly low leukotriene blockade [49].
systemic bioavailability [3] and should be used in the Aspirin desensitization should be offered to all pa-
long-term to safely suppress inflammation. tients with Samter’s triad. This therapy requires several
days of inpatient treatment with continuous daily aspi-
Intensive medical treatment of NP with the strategy of rin ingestion until the desensitized state is achieved [60].
a combination of short-course systemic and long-term Maintenance with daily aspirin, typically 650 mg of en-
topical corticosteroids is the most common approach to- teric-coated aspirin twice daily, can reduce the number of
day and its efficacy continues to be documented [13, 28, asthma exacerbations and hospitalizations per year, limit
37, 50, 61]. the need for sinus surgery, and reduce antibiotic and cor-
Oral antibiotics are used widely in the medical man- ticosteroid use [63].
agement of recurrent CRSwNP. Coverage should include Adjunctive measures in the treatment of CRSwNP
both aerobic and anaerobic bacteria and should be cul- include nasal saline rinses, smoking cessation, and ad-
ture-directed if possible [43]. In the absence of cultures, dressing atopy. Normal saline applied to the nasal cavities
suitable empiric broad-spectrum antibiotics include three times a day has been shown to decrease sinonasal
penicillin derivatives with a beta-lactamase inhibitor symptoms and endoscopically observed mucosal edema
and secretions, and increase QOL in patients with CRS

Perioperative Medical Care
refractory to medical and surgical therapy [15]. Smok-
ing cessation is highly recommended since a history of It has long been recognized that medical therapy in the
tobacco use portends a prolonged course with increased immediate postoperative period is critical to the success
recurrence rates [30]. Treatment of inhalant allergies is of surgery for NP. Two placebo-controlled clinical trials
important in the overall care of the patient with CRSwNP of budesonide [27] and flunisolide [17] after polypec-
and may help alleviate certain nasal symptoms such as tomy emerged in the early 1980s, showing greater symp-
rhinorrhea or pruritis. Immunotherapy (IT) is unlikely tom improvement, delayed recurrence, and greater inter-
to have a significant direct effect on the degree of nasal val between surgeries for the treatment groups compared
polyposis in CRSwNP, but postoperative IT with specific to placebo.
fungal antigens is highly effective in improving QOL and Current methods include the use of burst and taper oral
endoscopic findings and decreasing steroid use in pa- corticosteroids started the week preceding surgery. Evi-
tients with AFRS [8, 22]. dence to support this approach is now emerging and sup-
ports prior anecdotal descriptions of less inflammation,
reduced polyp size, and improved technical ease during
surgery with the use of perioperative systemic corticoste-
Patient Selection for Surgical Treatment
roids [68]. The taper is continued for at least 2 weeks after
In a comparison of medical and surgical therapy, Blomqvist surgery and adjusted according to nasal endoscopic find-
et al. treated patients with CRSwNP with a 10-day burst ings during postoperative examination and debridement.
and taper of oral prednisolone and a concurrent month Patients with allergic fungal sinusitis may benefit from
of topical budesonide, then randomized the subjects to a slower taper of oral steroids lasting >6 weeks. Broad-
have FESS on either the right or left side [12]. One year spectrum antibiotics are given during the same 3-week
after surgery, patients reported a greater improvement on period surrounding the surgery. Topical corticosteroids
the surgical side compared to the medically treated side are continued for long-term maintenance.
in terms of nasal obstruction, nasal secretions, and sinus
pressure, yet only 25% pursued FESS on the medical side
when it was offered [12].
Surgical Technique
While this intriguing study appears to show an advan-
tage for surgery, in general only patients with CRSwNP Surgery concentrates on complete removal of nasal polyps
refractory to maximal medical therapy are considered and bony septations, particularly in the ethmoid sinus,
candidates for surgical treatment. The basis for this prac- and includes wide openings in the maxillary, sphenoid,
tice is a randomized, controlled clinical trial comparing and frontal regions, if they are involved. The use of Ker-
medical and surgical therapy for CRS, showing improve- rison rongeurs for removal of thick bony partitions and
17 ments in subjective symptoms, QOL, and endoscopic otherwise diseased bone is helpful when osteitic changes
score at 6 and 12 months in both treatment groups with and osteoneogenesis have taken place. Thickened mucosa
no statistical difference between the two arms of the study without polyps is not typically removed, as the regener-
[53]. Roughly 40% of participants had CRSwNP and sub- ated mucosa demonstrates less effective ciliary regrowth
set analysis demonstrated the same findings. and a reduction in mucous gland density.
The use of image guidance is helpful in surgery for re-
■ A course of maximal medical therapy, ideally includ- current NP because landmarks are frequently distorted
ing a macrolide or another appropriate antibiotic, oral or obscured by the disease or absent after prior interven-
and/or topical corticosteroids, and nasal saline irrigation.
tions, is recommended for all CRS patients prior to Powered instrumentation greatly facilitates surgery on
considering sinus surgery. recurrent CRSwNP, allowing the removal of polyps rap-
idly and effectively with reduced bleeding. Continuous
The one notable exception to these guidelines is AFRS, suction is available when using a microdebrider without
since surgery to remove the offending agent is the pri- switching instruments.
mary treatment modality. Also, in patients with persis- Safe use of the microdebrider requires strict adherence
tently refractory disease, it may be reasonable to discuss to several principles:
the role of scheduling FESS at given intervals, when 1. The tip should be visualized at all times, especially
symptom severity peaks. when cutting. The teeth of the microdebrider, even
when not spinning, can abrade mucosa during passage
of the instrument in and out of the nasal cavity.
2. Prior to engaging tissue at any phase of the surgery,

Future Directions
the suction port should be opened by tapping the foot
pedal and spinning the blade a fraction of a turn. In The pathophysiology of recurrent NP, like that of its parent
general, only tissue that moves freely into the open disease, CRS, remains enigmatic. Current investigations
suction is removed. into the various molecular mechanisms of the underlying
3. The cutting face of the tip should be aimed away from inflammatory response as well as the etiologic agents will
important structures. hopefully identify new therapeutic targets. While surgi-
4. There must be constant assessment of the field and de- cal therapy remains an option for medically refractory
cisions made regarding which mucosa to preserve. The disease, more refined medical treatments should further
tip should be pointed away from mucosa that is to be reduce the need for systemic corticosteroids and improve
spared. the overall care of patients with NP.
The microdebrider plays a more prominent role and pro- Tips and Pearls
vides a greater advantage in the polyp-debulking steps of
1. Always consider cystic fibrosis in the workup of
the surgery than during the refined components, such as
children with NP.
identification of the skull base and treatment of sphenoid
2. Suspect AFRS, inverted papilloma, or an underly-
and frontal sinus disease. However, when used judiciously,
ing malignancy in patients with unilateral NP.
the instrument is useful in delicate work and special an-
3. Combine antibiotics such as macrolides, oral and
gulated blades are available. Powered instrumentation
topical corticosteroids, and adjunctive measures
helps achieve the primary surgical goal of removing dis-
such as nasal saline to administer maximal medi-
ease from its origin in the maxillary and ethmoid sinuses.
cal therapy.
The creation of well-aerated, accessible cavities facilitates
4. Always use systemic corticosteroids periop-
office-based endoscopic surveillance and delivery of topi-
eratively to improve the surgical field and make
cal medications in the postoperative and maintenance
refined, thorough, and safe surgery possible.
phases of treatment.
5. Be wary of reducing the postoperative oral steroid
Intraoperative specimen sent for aerobic, anaerobic,
taper too quickly and allowing regrowth of polyps
and fungal culture as well as pathologic analysis of thick
in the surgical healing phase.
secretions and debris can aid in directing antibiotics at of-
6. Regular surveillance is required to improve long-
fending organisms. Pathologic analysis of debris removed
term outcomes and determine the timing of treat-
from the sinuses as well as analysis of tissue specimen can
ment intervention.
identify fungal elements, eosinophilic infiltration, and
tissue invasion that may guide postoperative care and
provide valuable prognostic information.
At the conclusion of surgery, techniques that reduce
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17
Chapter 18
Revision Surgery for Allergic

Fungal Rhinosinusitis 18
Subinoy Das, Patricia A. Maeso, and Stilianos E. Kountakis
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
■ Recurrent disease is common in allergic fungal rhi- Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
nosinusitis (AFR) and close follow-up is necessary. Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
■ Both optimal medical and surgical therapy are need-
Medical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
ed for the adequate treatment of AFRS to minimize
recurrence. Revision Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
■ Care should be taken to avoid dural resection to pre- Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
vent future intracranial dissemination of disease. Open Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
■ Image-guided surgery is useful for revision surgery
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
for AFRS in the face of altered anatomical land-
marks.
■ Recurrence after treatment of AFRS is common.
cated in temperate regions of relatively high humidity.

AFS is most common among adolescents and young
adults, with a similar male to female ratio. Over thirty
fungal species have been identified as a cause for AFRS,
Introduction
with Bipolaris, Curvilaria, and Aspergillus species be-
Over the past 30 years, there has been an increasing un- ing the most common subtypes. Revision surgery for
derstanding of role fungi in chronic rhinosinusitis. Aller- AFRS is common, with up to 80% of patients develop-
gic fungal rhinosinusitis (AFRS) is now believed to be an ing recurrent disease. Close lifetime follow-up is manda-
inflammatory reaction mounted by an immunocompe- tory for patients with AFRS.
tent host to environmental fungi, most commonly of the
dematiaceous species.
The diagnostic criteria for AFRS are as follows:
Clinical Presentation
1. Gel and Coombs type I (IgE-mediated) hypersensitiv-
ity to fungus, as confirmed either by history, serology, AFRS unfortunately tends to be recurrent and resistant
or examination. to even the most aggressive and compliant medical treat-
2. Nasal polyposis. ment, with numerous surgical procedures over the course
3. Characteristic radiographic findings such as hyperat- of a patient’s life being the rule rather than the exception.
tenuation and bony expansion with or without ero- Recurrence can be detected early in the form of mucosal
sion. edema, or later with frank polyps and fungal debris. Rea-
4. Eosinophilic mucin without fungal invasion into sinus sons for recurrence include inadequate initial debride-
tissue. ment, irregular follow-up, and not cleaning the postop-
5. Positive fungal stain of sinus contents removed at the erative cavities appropriately, and of course the nature of
time of surgery. the disease. Appropriate follow-up allows the identifica-
tion of recurrent disease at an earlier stage, thus making
AFRS affects approximated 5–10% of patients affected it more amenable to medical therapy.
by chronic rhinosinusitis. Most cases reported are lo-
154 Subinoy Das, Patricia A. Maeso, and Stilianos E. Kountakis
recurrent polyposis or opacification of residual sinus

cells, or may reveal severe findings similar to the char-
acteristic findings used to diagnose AFRS (Fig. 18.2).
Computed tomography (CT) is typically the first line of
imaging chosen for patients with a history of AFRS, and
careful comparison with preoperative images is required.
Often, with removal of the tenacious allergic mucin, bone
remodeling occurs over time to restore the natural con-
tours of facial anatomy. Areas that are not remodeling
and opacified, particularly in the lateral frontal sinuses,
may signify persistent or recurrent disease. Magnetic res-
onance imaging findings are also sensitive for fungal de-
bris, with hypointense signaling in T1-weighted images,
central signal voids in T2-weighted images, and increased
peripheral T1/T2 enhancement along the sinus walls as
specific indicators for AFRS (Fig. 18.3) [3].
Fig. 18.1 Orbital proptosis secondary to allergic fungal rhino-

sinusitis (AFRS)
Medical Treatment
■ Recurrent symptoms of anosmia and nasal obstruc- Therapy for recurrent AFRS is varied due to the multi-
tion may signal the onset of recurrence. factorial etiology of the disease. After complete surgical
extirpation of all fungal debris, intranasal corticosteroid
Recurrent facial remodeling and/or orbital proptosis are treatment and nasal saline irrigations are the first line of
typically rare in patients educated about their disease therapy for the long-term treatment of AFRS. Intranasal
who maintain regular follow-up appointments, but are steroid irrigations have several advantages:
obviously warning signs of severe disease that may need 1. Their potent anti-inflammatory and immunomodula-
further surgical intervention (Fig. 18.1). tory effects can reverse early polypoid degeneration
and inflammatory damage to sinus mucosa.
2. They dilute and wash away inciting fungal antigens.
3. They lead to greater delivery of steroids to the sinus
Imaging
mucosa with less systemic absorption compared to
Radiologic evaluation of the paranasal sinuses of pa- oral steroids, leading to a much greater safety profile.
tients with recurrent AFRS may reveal mild findings of
18
Fig. 18.2 Axial computed tomography (CT) scan with charac- Fig. 18.3 Magnetic resonance imaging of a patient with AFRS
teristic findings of AFRS
Revision Surgery for Allergic Fungal Rhinosinusitis 155
Intranasal steroid irrigations do cause low levels of sys- As with any revision sinus surgery case, the patient who
temic absorption, and should be used with caution in pa- undergoes revision surgery for AFS should undergo a
tients sensitive to chronic steroid medication. However, complete reassessment of their condition. This is espe-
confirmation of the patient’s use of this medication and cially important in the case of the patient who was previ-
compliance with this regimen is recommended before ously operated on by another surgeon. Specific attention
pursuing revision surgery in most cases. Oral steroids are should be given to the postsurgical scans, which should
effective in reversing the inflammatory cycle that causes ideally consist of coronal, axial, and sagittal imaging, and
recurrent disease in AFRS. However, chronic oral steroid be formatted to be available to image-guidance systems.
use is associated with a significant side effect profile, and All of the following aspects should be comprehensively
therefore should be used with caution. evaluated by studying all CT images [1]:
Leukotriene inhibitors may also be beneficial in the 1. The entire skull base is evaluated for slope, height, ero-
prevention of AFRS recurrence. These drugs are active sions, asymmetry, and neo-osteogenesis.
in blocking the formation and/or action of leukotrienes 2. The medial orbital wall is examined for integrity, re-
in the inflammatory cascade of AFRS, and have a more sidual uncinate process, position, and erosion.
favorable side-effect profile compared to oral steroid 3. The ethmoid vessels are located and their relationship
therapy; however, supportive data is lacking. to the skull base needs to be examined.
Immunotherapy has also been used as an adjunct to 4. The posterior ethmoid sinuses are evaluated for their
AFRS therapy. Studies have suggested that AFRS recur- vertical height, the presence of an Onodi cell, and neo-
rence diminishes markedly in patients who are place in osteogenesis.
an immunotherapy regimen [2]. In addition, the role of 5. The maxillary sinuses are evaluated for Haller cells and
topical antifungals in the treatment of AFRS has been ex- accessory ostia.
plored. Controversy exists regarding their use as AFRS is 6. The sphenoid sinuses are evaluated for the position of
now known to be an inflammatory disease; systemic an- the intersinus septum location and appreciation of a
tifungals have historically been not effective in reversing bony dehiscence of the carotid artery and optic nerve.
the inflammation and are associated with severe systemic 7. The frontal recess and sinuses are evaluated for the
side effects. Recently, daily topical antifungals have been presence of agger nasi and supraorbital pneumatiza-
used in an effort to minimize recurrence of AFRS, but tion, frontal sinus drainage, and anteroposterior diam-
supportive data is pending. eter of the frontal sinus.
8. The presence or absence of the middle turbinate, un-
cinate process, septal defects, and other distortions
should be fully evaluated.
Revision Surgery
Once obvious allergic mucin and polyps are identified In the face of the altered anatomical landmarks as well as
that are not responding to adequate medical therapy, re- any skull-base or orbital erosion that may be encountered
vision surgery is necessary. in AFRS and in revision sinus surgery, the use of com-
puter-aided image guidance is recommended for revision
Tips and Pearls surgery for AFRS.
It is important to understand that while normal ana-
1. The goals of revision surgery are to extirpate
tomical landmarks may be altered in revision surgery for
fungal debris and inflammatory mucin and polyps
AFRS secondary to the disease process itself or because of
completely from the nasal cavities, as well as to
the primary surgery, there are certain constant anatomi-
improve access to nasal cavities for future office
cal landmarks that may provide a guide during revision
surveillance and postoperative irrigations.
sinus surgery:
2. Revision surgery should be staged and/or aborted
1. The junction of the medial and superior maxillary walls
if visualization is poor during the operation, the
indicate the sagittal plane of the lamina papyracea.
surgeon becomes disoriented, or if blood loss or
2. The axial plane at the level of the superior maxillary
anesthetic risk becomes too great.
wall (orbital floor) approximates the location of sphe-
3. Staging the procedure when necessary permits
noid ostium.
the sinus surgeon to reorient himself within the
3. The distance from the anterior nasal spine to the pos-
surgical field and procure additional imaging if
terior maxillary wall approximates the location of the
necessary.
sphenoid rostrum.
4. Utmost importance should be given to preventing
4. Once at the sphenoid, the lowest height of the skull
dural injury and/or cerebrospinal fluid leak during
base can be identified and careful dissection through
the procedure. Intradural contamination can lead
the ethmoid sinuses in a posterior-to-anterior fashion
to devastating consequences and vastly increase
can be done safely.
the difficulty of future operations.
156 Subinoy Das, Patricia A. Maeso, and Stilianos E. Kountakis
It is also important to note that the middle turbinate may that removal of all of the allergic mucin can be very chal-
not always be identifiable in revision sinus surgery cases. lenging. Being patient and using suction and blunt curet-
Dissection should be kept as lateral as possible near the ting instruments along with normal saline irrigation help
medial orbital wall in order to avoid dissecting near the in the removal of this tenacious material (Video 18.1).
middle turbinate insertion to the skull base. This area is Once this material is removed, improved access to the
particularly susceptible to dural violation. Finally, dissec- paranasal sinuses in the face of altered anatomical land-
tion in the area of the frontal recess should be done with marks is obtained.
great care. Given the distorted anatomy, the anterior eth-
moidal artery may lie completely out of its bony covering
and may be prone to injury. Good visualization of both
Complications
the skull base and medial orbital wall is paramount to dis-
section in this area. The incidence of surgical complications is increased in
Allergic mucin and polyps will be encountered in revision sinus surgery cases. As for any revision sinus
patients who undergo revision surgery for AFRS. The surgery case, the most severe complications related to re-
sinuses may be packed with the fungal debris and cavi- vision surgery for AFRS are intraorbital and intracranial
ties will be expanded by both the debris and the sinuses injuries. The most series quote such serious complica-
(Fig. 18.4). The sinus surgeon should take advantage of tions occurring in one out of every 200 cases [1]. Serious
this common feature of the disease when performing re- vascular injuries should also be considered in the case of
vision surgery. Using powered instrumentation, the pol- revision surgery for AFRS. Among the minor complica-
yps can be carefully followed. Slow careful removal of the tions that may be encountered are: scarring, bleeding,
polyps will lead to the sinus ostium and subsequently to infection, epiphora, synechiae formation, mucocele, and
the affected sinus. disease persistence or recurrence with the need for fur-
ther surgery. All of these potential complications need to
■ The slow expansile nature of AFRS can enlarge natural be preoperatively discussed at length with the patient and
sinus openings; therefore, even if fungal mucin resides they should be part of the informed consent.
in areas that are typically difficult to approach, the ex-
pansile tendency enlarges the natural outflow tracts,
enabling greater access to the sinus cavity (Fig. 18.5).
Open Approaches
Thick allergic mucin will be encountered inside the si- Open approaches can serve as a valuable adjunct to en-
nuses and possibly in the nasal cavity itself (Video 18.1). doscopic approaches in revision AFRS cases. External
Careful removal of all the allergic mucin is very important frontal sinus trephination combined with endoscopic
for the success of the surgery. However, it is well known frontal sinusotomy (“the above and below technique”)
can be very valuable for extirpating frontal sinus disease,
particularly with significant disease in the lateral frontal
18 sinus or type IV frontal cells.
■ When thick fungal debris is located in the remote re-

gions of the frontal sinus, above and below techniques
assist in their safe and complete removal.
The Caldwell-Luc approach is typically unnecessary due

to the advent of curved microdebriders and malleable
instruments. Osteoplastic flap with frontal sinus oblit-
eration is now performed uncommonly. AFRS typically
dilates the natural ostia of individual sinuses and the
frontal recess, so if frontal debris can be extirpated, the
frontal sinus typically regains normal function with plen-
tiful access to medical irrigations. As with all operations,
surgeons should not expect that any particular operation
will serve as the definitive procedure for this highly recal-
Fig. 18.4 Coronal CT showing expanded sinus cavities citrant disease.
Revision Surgery for Allergic Fungal Rhinosinusitis 157
Fig. 18.5 a Coronal CT with extensive frontal and superior or- c Postoperative axial CT after endoscopic frontal surgery and
bital wall erosion. Widened frontal recess and ostia. b Axial CT removal of fungal debris. d Postoperative endoscopic view of the
with extensive erosion of the posterior plate of the frontal sinus. widened frontal ostium
Conclusions References
It is important to consider that any one particular surgery 1. Govindaraj S, Antunes M, Kennedy DW (2007) Revision
may not suffice in the treatment of this aggressive disease. sinus surgery. In: Kountakis SE, Onerci M (eds) Rhinologic
Medical therapy should be maximized prior to pursuing and Sleep Apnea Surgical Techniques. Springer, Germany,
any revision surgery and should be directed at modulating pp 199–210
the immune response to fungus. Surgery serves to elimi- 2. Mabry RL, Marple BF, Folker RJ, Mabry CS (1998) Immu-
nate the fungal debris present in the sinus cavities as well notherapy for allergic fungal sinusitis: three years experi-
as to provide access for postoperative debridement and ence. Otolaryngol Head Neck Surg 119:648–651
irrigations. Further harm during revision surgery should 3. Manning SC, Merkel M, Kriesel K, et al. (1997) Computed
be conscientiously avoided. Revision surgery for AFRS tomography and magnetic resonance diagnosis of allergic
is common; however, by following standard anatomical fungal sinusitis. Laryngoscope 107:170–176
landmarks and by staging the procedure when needed, it
can be performed safely with few complications.
Chapter 19

for Benign Sinonasal Tumors 19
Michael J. Sillers and Yvonne Chan
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
■ While benign tumors can be safely and completely Inverted Papilloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
removed from the paranasal sinuses using endo- Preoperative Workup . . . . . . . . . . . . . . . . . . . . . . . . . 160
scopic techniques, there is a generally infrequent
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
but not negligible rate of recurrence.
■ Long-term follow up with endoscopic and appro- Other Benign Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . 164
priate imaging surveillance is critical in recognizing Fibro-osseous Lesions . . . . . . . . . . . . . . . . . . . . . . . . . 164
early tumor recurrence. Angiofibroma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
■ A high index of suspicion should be employed when
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
there is a change in the endoscopic examination.
■ Multimodality imaging is essential when there may
be multiple sites of tumor recurrence.
■ Intraoperative frozen section analysis is a vital step
in assuring complete tumor removal at the time of 4. Was intraoperative frozen section analysis utilized?
revision surgery. 5. Were appropriate surgical techniques employed?
The answers to these questions will shed light on the

reasons for failure and help assure success during subse-
quent surgery.
Introduction
Benign tumors of the nasal cavity and paranasal sinuses
have been successfully removed utilizing transnasal en-
doscopic approaches for over the last two decades. With
increased experience and skill, improved instrument
design, and computer-aided surgery, an endoscopic ap-
proach has become the default choice for most rhino-
logic surgeons for the surgical management of sinonasal
benign neoplastic diseases. Whether utilizing traditional
open approaches or transnasal endoscopic techniques,
there is an infrequent but not negligible rate of recurrent
and residual tumor, which creates a unique clinical situa-
tion that deserves special discussion.
When performing revision surgery, the following
questions should be answered:
1. Why did the previous surgery fail?
2. Was the nature/extent of disease underappreciated
(Figs. 19.1 and 19.2)? Fig. 19.1 Endoscopic view of recurrent pleomorphic adenoma
3. Were certain anatomic or imaging signs not recog- of the nasal septum. The lesion was initially removed during a
nized preoperatively? septoplasty at an outside facility. IT Inferior turbinate
160 Michael J. Sillers and Yvonne Chan
Fig. 19.2 Coronal (a) and axial (b) computed tomography (CT) scans of recurrent pleomorphic adenoma of the nasal septum. The
lesion was isolated to the nasal septum
While most benign tumors encountered in the nasal illoma to be 27.3% with Krouse stage III tumors, while
cavity and paranasal sinuses do not have malignant po- lower stages did not recur [5]. Sautter et al. also found that
tential, the most commonly encountered one, inverted extent of disease was the most important variable and that
papilloma, is reported to undergo malignant degenera- the surgical approach did not impact recurrence [10].
tion in 5–15% of patients, with a working risk of 10% [6,
12]. For this reason, revision surgery for inverted papil-
loma will be discussed in detail, while other less com-
Preoperative Workup
monly encountered tumors will be mentioned in more
general terms. When patients undergo surgery for inverted papilloma,
regular endoscopic surveillance should be performed
(Figs. 19.3 and 19.4). At times, early recurrent or residual
disease can be identified and treated by simple excision in
19 Inverted Papilloma
the office setting. Care should be taken to properly docu-
Inverted papilloma is specifically the most commonly ment the suspected site and the specimen sent to pathol-
encountered Schneiderian papilloma and in general the ogy. When there is suspicion for more advanced disease,
most commonly encountered benign neoplasm of the na- radiographic evaluation should be performed to assist in
sal cavity and paranasal sinuses. determining the stage of disease. Computed tomography
(CT) and magnetic resonance imaging (MRI) are both
■ The recurrence of inverted papilloma ranges from helpful in identifying the extent of disease and allow a
0 to 78% and has been related to surgical approach, preoperative staging of the patient’s recurrent disease.
extent of disease, and prior surgery. CT scan will also serve to demonstrate bony erosion or
invasion into the skull base or the orbit. In patients with
When comparing open vs. endoscopic resection, recur- recurrent disease, there may be multiple distinct sites of
rence rates for endoscopic approaches are favorable, and neoplasia and a pure “stage” may not be determined. Prior
in some recent series, lower. Most of these studies, includ- surgery may also lead to postobstructive changes with mu-
ing one of the most recent, are retrospective reviews and cocele formation, which cannot always be distinguished
meta-analyses [7]. However, as with most disease pro- by CT alone. MRI is helpful in further distinguishing the
cesses, the extent of disease is the single most important nature of CT opacification (i.e., inspissated mucous vs.
factor impacting recurrence. Lee et al. found the recur- soft tissue). In addition to preoperative planning, this also
rence rate in their series of reoperations for inverted pap- has implications for prognosis (Figs. 19.5 and 19.6).
Revision Endoscopic Surgery for Benign Sinonasal Tumors 161
Fig. 19.3 Endoscopic view of recurrent inverted papilloma on Fig. 19.4 Endoscopic inspection of the right lamina papyracea
the right lamina papyracea 2 years postresection of recurrent inverted papilloma
■ Areas of hyperostosis/osteoneogenesis on CT should be When CTs are obtained, a surgical navigation protocol
identified as this has been shown to highly correlate with should be employed so that this technology can be uti-
site of origin of inverted papilloma (Fig. 19.7b) [4, 14]. lized during the revision surgical procedure.
Currently, there are several staging systems for inverted
Comparison with CT imaging taken prior to the initial papilloma, with that proposed by Krouse used most com-
surgical procedure, if available, will be helpful in this monly (Table 19.1) [8]. Citardi et al. have proposed a new
setting as new areas of hyperostosis may be the result of classification that eliminates malignancy, which was in-
prior surgery and not necessarily recurrent tumor origin. cluded in the Krouse system (Table 19.2) [1]. Regardless
Fig. 19.5 Coronal CT showing opacified sphenoid sinus with Fig. 19.6 T1-weighted coronal magnetic resonance image
extensive pterygoid recess pneumatization in a patient with pos- showing intermediate signal intensity in the sphenoid sinus
terior ethmoid sinus inverted papilloma
Fig. 19.7 Coronal (a) axial (b) CT demonstrating hyperostosis of the uncinate process suggesting site of origin of tumor
of the system chosen, the most effective approach is to scription medications (nonsteroidal anti-inflammatory
assimilate the endoscopic and imaging data in order to drugs, aspirin, vitamin E) and herbal products (green tea,
counsel the patient as to the appropriate choice of proce- Ginkgo biloba), which are not often disclosed but can lead
dure as well as prognosis on an individual basis. to troublesome bleeding. Discontinuation of prescription
Once the preoperative stage and the extent of disease anticoagulants is best managed after discussion with the
have been determined, a plan for revision surgery should prescribing physician regarding the risks of medical com-
be made. Patients are instructed to discontinue medica- plications associated with their cessation.
tions that would lead to unnecessary bleeding at the time Commonly encountered risks of endoscopic sinus sur-
of surgery. Decreased visualization related to a bloody gery should be discussed with each patient. Specific risks
field can lead to increased risk for complications and in- related to the extent of proposed surgery should be further
complete surgery resulting in residual/recurrent disease. disclosed. For example, removal of a recurrent osteoma
It is important to ask specifically about the use of nonpre- along the ethmoid roof may require/involve removing a
Table 19.1 Krouse staging system for inverted papilloma [8]

19
T1 Confined to the nasal cavity
T2 Ostiomeatal complex region, ethmoid, or medial maxillary involve-

ment (with or without nasal cavity involvement)
T3 Any wall of the maxillary sinus but medial, frontal sinus, or sphenoid with or without T2 criteria
T4 Any extrasinus involvement or malignancy
Table 19.2 Citardi staging system for inverted papilloma [1]
Group A Confined to the nasal cavity, ethmoid sinuses, or medial maxillary wall
Group B Involvement of any maxillary wall (other than the medial maxillary wall), frontal, or sphenoid sinus
Group C Extension beyond the paranasal sinuses

portion of the ethmoid roof, resulting in an anticipated steps may be time consuming, they will lead to improved
cerebrospinal fluid leak and its attendant repair. hemostasis, which makes the surgical procedure much
less problematic.
■ Depending on the location of the surgery (hospital vs. As an initial step, secretions and crusts are removed
ambulatory surgery center), special arrangements may from the operative site. Suspicious areas should be sam-
need to be made to ensure that intraoperative frozen pled and sent to the pathologist for frozen section analy-
section analysis is available as an integral part of the sis (Fig. 19.8). Care must be taken to document these sites
revised surgical procedure. as there may be multiple separate foci of tumor that needs
to be addressed. En bloc resection is preferred but not al-
ways possible in revision surgery. All gross tumor must
be removed along with surrounding, normal-appearing
Surgical Technique
tissue to assure complete resection. The permanent speci-
Once the patient is brought to surgery, maximal decon- men should be clearly marked for orientation. Intraop-
gestion of the nasal mucosa is started in the preoperative erative frozen section analysis of surgical margins is im-
holding area by applying topical decongestants. In the portant and will help dictate further resection.
operating room, the choice of general anesthetic agents
is important. Wormald et al. have proposed total intra- ■ In general with benign disease, natural barriers such as
venous anesthesia as a method by which the peripheral the lamina papyracea and dura should not be removed
vasodilatation associated with certain inhalation agents unless there is obvious tumor involvement.
is avoided. The importance of controlling the heart rate
in addition to blood pressure is emphasized in this tech- Areas of hyperostosis should be carefully reduced with
nique [13]. Once appropriately anesthetized, local infil- a diamond bur on the microdebrider. Computer-aided
tration of vasoconstrictors is carried out along the lateral surgery is helpful in these instances in gauging progress
nasal wall and in the region of the sphenopalatine artery, (Fig. 19.9). Depending on the location and extent of dis-
either transnasally or transpalatally via the greater pala- ease, the operating surgeon should be comfortable with
tine foramen. Finally, topical vasoconstrictors are applied advanced endoscopic techniques, such as the endoscopic
to the nasal mucosa using cotton pledgets. While these modified Lothrop procedure and the transmaxillary/
Fig. 19.8 Intraoperative view of the right

posterior ethmoid sinus with recurrent
inverted papilloma
Fig. 19.9 Intraoperative view after tumor

resection and reduction of the hyperostotic
region with a diamond bur
transpterygoid approach to an extensively pneumatized for revision surgery are no different than for primary
sphenoid sinus. Hemostasis is achieved in the sur- surgery. Removal of symptomatic recurrent lesions is
geon’s preferred fashion and nasal packing is placed as appropriate and complete tumor removal should be the
indicated. goal (Figs. 19.10 and 19.11). Careful use of powered burs
is helpful in reducing the overall bulk of these lesions. As
with primary surgery, identifying a cleavage plane is help-
ful in separating the base of the lesion from the surround-
Other Benign Neoplasms
ing site of attachment. The use of a curette or osteotome
enables the surgeon to safely remove the tumor while
Fibro-osseous Lesions
avoiding injury to underlying structures. The potential
19 Osteoma, ossifying fibroma, and fibrous dysplasia consti- for orbital and intracranial complications should be dis-
tute the range of fibro-osseous lesions affecting the para- cussed in advance with the patient, including intraopera-
nasal sinuses. It is generally agreed that symptomatic le- tive plans for repair and their impact on recovery should
sions should be removed and complete resection is likely they occur.
with osteoma and ossifying fibroma. However, complete
removal is rarely achievable with fibrous dysplasia as it
usually develops along existing bony planes.
Angiofibroma
■ Sacrifice of vital structures is not appropriate when Angiofibroma is relatively uncommon and recurrence, as
treating benign neoplasia. with other tumors, is often related to the extent of disease
at the time of initial surgery.
Tumor recurrence of osteoma and ossifying fibroma is
related to incomplete resection. At times the operating ■ Angiofibroma skull-base invasion was associated with
surgeon may elect to leave a “shell” of tumor along the recurrence in 27.5% of patients [3].
skull base or lamina papyracea during primary surgery
to avoid the risk of intracranial or intraorbital injury as- Herman et al. urged that all patients, including those with
sociated with complete tumor removal. The indications asymptomatic tumor remnants, be followed closely with
Fig. 19.10 Intraoperative view of recurrent left frontal sinus Fig. 19.11 Intraoperative view of osteoma specimen as it was
osteoma resected
serial CT [3]. Some small remnants may involute, while

References
those that become symptomatic can be treated with ra-
diation therapy or revision surgery. Scholtz et al. found 1. Cannady SB, Batra PS, Sautter NB, Roh HJ, Citardi MJ
as low as 15% recurrence in 14 patients over an 11-year (2007) New staging system for sinonasal inverted papil-
period [11]. Seven patients underwent a transnasal en- loma in the endoscopic era. Laryngoscope 117:1283–1287
doscopic approach, which they conclude to be appropri- 2. Economou TS, Abemayor E, Ward PH (1998) Juvenile na-
ate in patients with lesions that involve the nasopharynx, sopharyngeal angiofibroma: an update of the UCLA expe-
nasal cavity, paranasal sinuses, and pterygopalatine fossa. rience, 1960–1985. Laryngoscope 98:170–175
Preoperative arteriography with embolization has been 3. Herman P, Lot G, Chapot R, Salvan D, Huy PI (1999) Long
shown to reduce intraoperative blood loss [2, 9]. term follow-up of nasopharyngeal angiofibromas: analysis
of recurrences. Laryngoscope 109:140–147
4. Lee DK, Chung SK, Dhong HJ, Kim HY, Kim HJ, Bok KH
(2007) Focal hyperostosis on CT of sinonasal inverted pap-
Conclusion
illoma as a predictor of tumor origin. AJNR Am J Neurora-
Benign tumors presenting in the nasal cavity and para- diol 28:618–621
nasal sinuses can be safely and successfully removed us- 5. Lee TJ, Huang SF, Lee LA, Huang CC (2004) Endoscopic
ing transnasal endoscopic techniques. Success has also surgery for recurrent inverted papilloma. Laryngoscope
been achieved when tumors have extended beyond the 114:106–112
confines of the nasal cavity and paranasal sinuses. The 6. Lesperance MM, Esclamdo RM (1995) Squamous cell
single most important factor in tumor recurrence is the carcinoma arising in inverted papilloma. Laryngoscope
extent of disease at initial presentation. Patients should 105:178–183
be followed closely long term to enable early detection of 7. Mirza S, Bradley PJ, Acharya A, Stacey M, Jones NS (2007)
recurrent disease. Questionable findings on endoscopic Sinonasal inverted papillomas: recurrence, and synchro-
surveillance should be viewed with a high index of suspi- nous and metachronous malignancy. J Laryngol Otol 121:
cion and appropriate biopsy and/or imaging studies ob- 857–864
tained. Depending on the extent of tumor and the skills of 8. Krouse JH (2000) Development of a staging system for in-
the operating surgeon, endoscopic techniques once again verted papilloma. Laryngoscope 110:965–968
can be safely used to address recurrent disease.
9. Onerci TM, Yücel OT, Oğretmenoğlu O (2003) Endoscopic 12. von Buchwald C, Bradley PJ. Risks of malignancy in in-
surgery in treatment of juvenile nasopharyngeal angiofi- verted papilloma of the nose and paranasal sinuses (2007)
broma. Int J Pediatr Otorhinolaryngol 67:1219–1225 Curr Opin Otolaryngol Head Neck Surg 15(2):95–98
10. Sautter NB, Cannady SB, Citardi MJ, Roh HJ, Batra PS 13. Wormald PJ, van Renen G, Perks J, Jones JA, Langton-
(2007) Comparison of open versus endoscopic resection of Hewer CD (2005) The effect of the total intravenous anes-
inverted papilloma. Am J Rhinol 21:320–323 thesia compared with inhalational anesthesia on the sur-
11. Scholtz A, Appenroth E, Kammen-olly K, Scholtz LU, Thum- gical field during endoscopic sinus surgery. Am J Rhinol
fart WF (2001) Juvenile nasopharyngeal angiofibroma: 19:514–520
management and therapy. Laryngoscope 111:681–687 14. Yousuf K, Wright ED (2007) Site of attachment of inverted
papilloma predicted by CT findings of osteitis. Am J Rhinol
21:32–36
19
Chapter 20
Recurrent Cerebrospinal Fluid Leaks

and Meningoencephaloceles 20
Sarah K. Wise, Richard J. Harvey, and Rodney J. Schlosser
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
■ Endoscopic repair of cerebrospinal fluid (CSF) leaks Indications for Transnasal Endoscopic Repair of CSF
and meningoencephaloceles is largely successful, Leaks and Meningoencephaloceles . . . . . . . . . . . . . . . . 168
with rates of skull-base defect closure greater than Contraindications for Transnasal Endoscopic
90%. Repair of CSF Leaks and Meningoencephaloceles 168
■ Certain factors may increase the potential for recur-
Preoperative Workup . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
rence of CSF leak or meningoencephalocele. Iden-
tification of such factors in the preoperative period Diagnosis of CSF Leak – Laboratory . . . . . . . . . . . . 168
allows the surgeon to alter treatment protocols ac- Diagnosis of CSF Leak – Radiology . . . . . . . . . . . . . 168
cordingly. Perioperative Adjuncts . . . . . . . . . . . . . . . . . . . . . . . . . . 170
■ Diagnosis of recurrent CSF leaks and meningoen-
Lumbar Drains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
cephaloceles often incorporates preoperative and
intraoperative techniques. A combination of labo- Intrathecal Fluorescein . . . . . . . . . . . . . . . . . . . . . . . . 170
ratory testing, radiologic imaging, and special pro- Image-Guided Computer Navigation Systems . . . . 171
cedures may be required to accurately diagnose the Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
site of a skull-base defect.
Potential Complications . . . . . . . . . . . . . . . . . . . . . . . . . 174
■ Surgical techniques for endoscopic repair of recur-
Intracranial Complications . . . . . . . . . . . . . . . . . . . . . 174
rent CSF leaks and meningoencephaloceles vary by
the site and size of the skull-base defect, as well as Pneumocephalus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
surgeon experience. Certain types of recurrent CSF Intracranial Hemorrhage . . . . . . . . . . . . . . . . . . . . . . 174
leaks and meningoencephaloceles may require ad-
Creation of New Skull-Base Defects . . . . . . . . . . . . . . 174
ditional perioperative measures for increased repair
success. Ocular Complications . . . . . . . . . . . . . . . . . . . . . . . . . 175
Frontal and Sphenoid Ostium Stenosis . . . . . . . . . . 175
Factors Contributing to Failure in Skull-Base Repair . 175
Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Introduction
In 1926, Dandy reported the first successful intracranial
repair of a cranial defect in a patient with pneumocepha-
lus [9]. Extracranial repair of a skull-base defect and ce- to skull-base defects caused by craniofacial trauma and
rebrospinal fluid (CSF) leak via naso-orbital incision was meningoencephaloceles [24].
subsequently reported in 1948 by Dohlman [10]. The first In present times, success rates for closure of skull-base
report of endonasal endoscopic skull-base defect repair defects by endoscopic techniques remain greater than
occurred in a case of iatrogenic skull-base injury and was 90% in most series [6, 8, 15, 17–19, 21–24, 26, 29, 56],
published by Wigand in 1981 [53]. Following this, Mattox as compared to traditional open skull-base defect repair
and Kennedy described the techniques for endoscopic re- via craniotomy, with success rates reported in the range
pair of CSF leaks in detail and expanded the indications of 60–80% [1, 16, 34]. In addition, endoscopic transnasal
168 Sarah K. Wise, Richard J. Harvey, and Rodney J. Schlosser
approaches for CSF leak repair circumvent the morbidi-

Preoperative Workup
ties of intracranial approaches, which include anosmia,
cerebral edema, seizures, and memory deficits [25]. The
Diagnosis of CSF Leak – Laboratory
exceptional visualization provided by rigid endoscopes
reduced morbidity over craniotomy, and higher success Whether a patient presents with a primary or recurrent
rates as compared to open approaches has made endo- CSF leak, confirmation of true CSF rhinorrhea should be
scopic repair of CSF leaks and meningoencephaloceles made. Studies used in the past, such as fluid analysis for
the preferred approach [15, 18, 24]. glucose, protein, and electrolytes are no longer encour-
As surgeons develop increased comfort with endo- aged due to high false-positive and false-negative rates.
scopic skull-base repair techniques, more challenging Currently, β2-transferrin testing is advocated due to its
cases are being undertaken. Endoscopic surgeons are high sensitivity and specificity for the detection of CSF
increasingly involved in addressing pathology along the [45]. β2-transferrin is found only in the CSF, ocular vit-
skull base and beyond the skull base, often in conjunc- reous humor, and perilymph [45]. While false-positives
tion with their neurosurgical colleagues. In addition, may occur, these cases are rare, arising in patients with
revision skull-base defect repair is frequently performed chronic liver disease, genetic variations of the transfer-
endoscopically following failure of primary endoscopic rin gene, and inborn errors of glycoprotein metabolism
or open procedures. In each case, the endoscopic surgeon [36, 47]. Analysis for β2-transferrin requires only 0.17 ml
should be aware of factors that could lead to failure of of rhinorrhea fluid, and results may be obtained in less
skull-base defect repair. By identifying factors that may than 3 h with immunofixation electrophoresis techniques
contribute to failure, surgeons can employ adjunctive [33].
perioperative and intraoperative measures that may im-
prove the success of their repair. ■ Diagnosis of CSF rhinorrhea by β2-transferrin is the
most sensitive, specific, and readily available labora-
tory technique currently available.
Indications for Transnasal
A second protein, β-trace protein, may also be analyzed
Endoscopic Repair of CSF Leaks
to detect CSF in rhinorrhea fluid. β-trace protein is an
and Meningoencephaloceles
enzyme also known as prostaglandin D synthase, which
1. Active CSF leak. is produced in the leptomeninges and choroid plexus
2. Pneumocephalus. and subsequently secreted into the CSF [52]. Although
3. Skull-base defect with a history of meningitis. β-trace protein is found in fluids throughout the body, its
4. Meningoencephalocele with active CSF leak or history concentration is much higher in the CSF [27], and detec-
of meningitis. tion of this protein is also highly sensitive and specific for
5. Skull-base defect created during endoscopic sinus sur- CSF [3].
gery or skull-base surgery.
6. Skull-base defect accessible by transnasal endoscopic
techniques.
Diagnosis of CSF Leak – Radiology
Following confirmation of CSF rhinorrhea by laboratory
20 testing, radiologic evaluation is undertaken to identify
Contraindications for Transnasal
the site of the skull-base defect. In cases of recurrent CSF
Endoscopic Repair of CSF Leaks
leak, the surgeon should evaluate carefully all areas of
and Meningoencephaloceles
the skull base on imaging studies. Certain patients, such
1. Medical issues that render a patient unfit for surgery as those with traumatic or spontaneous CSF leaks, often
or general anesthesia. have multiple skull-base defects, which may or may not
2. Skull-base defect not accessible by transnasal endo- be actively leaking CSF [38]. In addition, patients who
scopic means. have undergone previous skull-base repair may present
3. Untreated tumor in the area of the skull-base defect. In at a later date with CSF leak from a separate anatomic
this case, the tumor should be treated prior to defini- location [54].
tive repair of the skull-base defect. Computed tomography (CT) scan is generally the ini-
4. Surgeon discomfort or inexperience with endoscopic tial study by which to assess the bony anatomy of the skull
repair techniques. base. CT scans are typically acquired in a thin slice (less
5. Equipment or instrumentation unavailable. than 1.5 mm) axial protocol, with coronal and sagittal im-
6. Active meningitis (relative contraindication). ages created by reformatting the axial data set (Fig. 20.1).
Recurrent Cerebrospinal Fluid Leaks and Meningoencephaloceles 169
Evaluation of images in a bone-window algorithm pro- is invasive and carries the risks of lumbar puncture and
vides the most accurate assessment of skull-base integ- intrathecal contrast.
rity. The roof of the ethmoid and sphenoid sinuses is best When evaluation of soft tissue along the skull base is
viewed in the coronal plane, while the posterior table of necessary, such as in cases of suspected recurrent menin-
the frontal sinus is visualized in the axial or sagittal plane. goencephalocele or skull-base tumor, magnetic resonance
Finally, the integrity of the sella and clivus may also be imaging (MRI) is frequently added to the diagnostic algo-
assessed in the sagittal plane. rithm. Patients with spontaneous CSF leaks have a high
rate of meningoencephalocele formation [6, 32, 38] and
■ Once diagnosis of CSF rhinorrhea is confirmed by lab- present with multiple simultaneous meningoencephalo-
oratory testing, the integrity of the skull base should celes in 31% of cases [38]. In such cases, MRI is valuable
be assessed radiographically. This evaluation typically in determining the presence of meningoencephalocele
begins with a fine-cut axial CT scan, with triplanar im- and the contents of meningoencephalic sacs (Fig. 20.3).
age reformations viewed in bone-window algorithm. In patients with previous treatment for skull-base tumor,
MRI may assist in the assessment of possible recurrence
When multiple bony skull-base defects are visualized on prior to attempting closure of a skull-base defect.
fine-cut CT scan or additional information is needed to Magnetic resonance cisternography is an additional
accurately identify the site of active CSF leak, a CT cister- technique by which to localize CSF leaks, which has a re-
nogram may be obtained by giving intrathecal contrast at ported sensitivity of 85–92% and 100% specificity [46].
the time of the CT scan. The nasal cavity and paranasal si- The MRI protocol involves a fast spin-echo with fat sup-
nuses are then evaluated for pooling of contrast material pression and image reversal [46], which demonstrates
(Fig. 20.2). Since the patient must be actively leaking CSF CSF as black against surrounding tissues, which have di-
during the study for the best results, this test has sensitivi- minished intensity.
ties ranging from 48 to 96% [48]. Low-flow or intermit- Finally, radionuclide cisternograms may be performed.
tent CSF leaks have a decreased chance of being detected This technique involves placement of pledgets at specific
on a CT cisternogram. Although valuable information sites within the nasal cavity (cribriform recess, middle
may be obtained from a CT cisternogram, this procedure meatus, and sphenoethmoid recess), followed by lumbar
Fig. 20.1 Coronal computed tomography (CT) scan in a bone Fig. 20.2 Axial CT cisternogram image in a patient with a spon-
window algorithm, reconstructed from fine-cut axial data set. taneous cerebrospinal fluid (CSF) leak. Contrast enhancement
A left ethmoid roof defect (arrow) is visible following head is seen in the intracranial CSF spaces (arrow). In addition, con-
trauma trast-enhanced CSF is present in the right sphenoid sinus (star)
Fig. 20.3 a Coronal CT scan of a patient with a spontaneous b T2-weighted magnetic resonance imaging (MRI) scan of the
CSF leak. A skull-base defect is noted in the lateral recess of the same patient revealing a large meningoencephalocele protrud-
right sphenoid sinus (arrow). The exact etiology of the sphenoid ing into the right sphenoid sinus
sinus opacification cannot be determined by CT scan alone.
puncture and injection of intrathecal tracer [41]. Radio- bar drains, however, have been associated with numerous
activity is subsequently measured on the pledgets after complications, including the development or worsening
a period of hours. In comparison to other localization of pneumocephalus, headache, nausea and vomiting, ra-
techniques, the sensitivity of radionuclide cisternogram dicular pain, meningitis, vocal cord paralysis, and cere-
is low (62–76%), with a 33% false-positive rate [12, 16, bral herniation [7, 11, 20, 37, 50, 51].
48]. However, for low-volume or intermittent CSF leaks, When the decision is made to use a lumbar drain, the
pledgets may be left in the nasal cavity for days to allow surgeon should ensure that instructions for operating and
for detection of the leak, dependent on the half-life of the monitoring the drain are clear and care of the drain is
tracer used [13]. diligent. In a protocol to prevent the worsening of pneu-
mocephalus with lumbar drains, Chan et al. advocate a
■ Following the assessment of skull-base integrity by passive gravity-dependent drainage system and avoid-
fine-cut CT scan, further testing to localize the site of ance of overdrainage [7]. Our protocol is similar, specify-
the CSF leak (CT cisternogram, magnetic resonance ing the pressure above which CSF should be drained. This
cisternogram, radionuclide cisternogram) or to assess avoids the potential for intracranial “negative” pressures
soft tissue along the skull base (MRI) may be neces- and the development of pneumocephalus, which can be
sary, depending on the individual case. life-threatening. The timing of lumbar drain removal var-
ies depending on surgeon experience and preference, as
20 well as patient-related factors, but in most cases, lumbar
drains are removed 2–3 days postoperatively.
Perioperative Adjuncts
■ Lumbar drains are a useful adjunct to CSF leak repair
Lumbar Drains
in certain cases. The surgeon should be mindful of po-
Lumbar drains are often used as an adjunct in the repair tential complications associated with lumbar drains,
of CSF leaks and meningoencephaloceles, although their however, and ensure that close monitoring and dili-
use is somewhat controversial. A lumbar drain can as- gent care of the drain is available.
sist in decreasing intracranial CSF pressure and alleviat-
ing potential strain on the skull-base repair. This may be
helpful in cases of elevated intracranial pressure, such as
Intrathecal Fluorescein
in trauma patients with cerebral edema, cases of hydro-
cephalus, or spontaneous CSF leaks [43, 44]. In addition, Many surgeons use intrathecal fluorescein as an addi-
the lumbar drain catheter can provide a conduit for injec- tional measure to localize the site of a skull-base defect
tion of intrathecal fluorescein, as described below. Lum- intraoperatively. In this instance, injection of fluorescein
is often performed at the time of lumbar drain insertion An additional tool available with image-guided sur-
in the operating room. Intrathecal fluorescein is not ap- gery systems is the availability of image fusion. With this
proved by the United States Food and Drug Administra- tool, images obtained by different modalities, such as CT
tion, and complications such as seizures, extremity weak- and magnetic resonance, may be fused on a computer
ness, and opisthotonus have been reported [30, 35]. These workstation to allow visualization of both the bone and
complications are rare, however, and may be related to soft-tissue components of the skull-base defect. This can
high concentration, suboccipital injection, or rapid intra- be helpful in assessing meningoencephaloceles and bony
thecal injection [35, 55]. skull-base defects with surrounding soft tissue and scar,
When using intrathecal fluorescein, our protocol in- such as in the case of recurrent CSF leaks.
volves the slow (over 10 min) intrathecal injection of
0.1 ml of 10% sodium fluorescein diluted in 10 ml of CSF. ■ Intraoperative adjuncts for the localization of skull-
At the completion of the intrathecal fluorescein injection, base defects include intrathecal fluorescein and im-
the lumbar drain is clamped and the patient is placed into age-guided navigation systems.
the Trendelenburg position to allow the fluorescein to col-
lect along the skull base. Upon exposure of the skull base
intraoperatively, fluorescein is often visible with routine
Surgical Techniques
endoscopic lighting. However, visualization of fluorescein
may be enhanced with a blue light filter, if necessary. Specific techniques for the endoscopic repair of CSF
Although it may be argued that intrathecal fluorescein leaks and meningoencephaloceles continue to evolve.
is not necessary for every CSF leak repair, the challenge of While changes in technique will continue to occur over
repairing recurrent CSF leaks and meningoencephaloceles time, some basic principles are presented here. Surgery is
may necessitate adjunctive measures such as intrathecal generally performed with the patient under general anes-
fluorescein. In patients who have undergone previous re- thesia and in the supine position. In patients with known
pair of CSF leaks and meningoencephaloceles, recurrence skull-base defects, positive-pressure ventilation with the
may be due to failure of repair at the primary site. How- bag-mask apparatus is avoided during anesthesia induc-
ever, the surgeon should also be mindful that patients tion in order to decrease the risk of pneumocephalus [41,
may present with new skull-base defects at anatomic sites 42]. Once the patient is intubated, a lumbar drain may
remote from the original repair. This is especially true in be inserted if the surgeon prefers, and the patient may
cases of trauma and spontaneous CSF leaks, where mul- be placed in the Trendelenburg position to increase the
tiple bony skull-base defects may be present (Fig. 20.4, chance of identifying clear drainage or fluorescein from
Video 20.1) [38]. In such cases, the entire skull base may the skull base. If a lumbar drain is inserted, the drain is
require intraoperative evaluation, and clear CSF can be typically clamped during the early portions of the proce-
difficult to detect. Intrathecal fluorescein provides an ad- dure to keep CSF pressure high and allow for better de-
ditional tool for intraoperative evaluation of the skull base tection of the site of CSF leak. The nasal cavities are then
and detection of the skull-base defect in need of repair. decongested topically, and perioperative intravenous an-
tibiotics with intrathecal penetration are administered.
Under endoscopic visualization, intranasal structures are
injected with local anesthesia according to surgeon pref-
Image-Guided Computer Navigation Systems
erence.
Image-guidance systems are commonly used in advanced The site of the skull-base defect is then identified, uti-
endoscopic surgery and skull-base surgery. These systems lizing the principles and techniques of endoscopic sinus
may assist the surgeon intraoperatively in localizing skull- surgery. Depending on the specific site of the skull-base
base defects and defining their dimensions. A series of defect, the extent of sinus dissection will vary. However,
endoscopic nasal CSF leak closures with and without the in general, the skull-base defect should be adequately ex-
use of an image-guidance system was reported in 2005 posed to allow for visualization of the entire defect. This of-
by Tabaee et al. [49]. Although a statistically significant ten requires some combination of uncinectomy, maxillary
benefit in the success of CSF leak closure was not found antrostomy, ethmoidectomy, sphenoidotomy, and frontal
with the use of image guidance [49], other authors have sinusotomy, depending on the location of the defect. For
reported an increase in surgeon confidence with the use defects in the lateral recess of the sphenoid sinus, Bolger
of image-guidance systems [2, 28]. In cases of revision has described the endoscopic transpterygoid approach,
CSF leak and meningoencephalocele repair, image-guid- which provides improved access to this difficult area over
ance systems may provide an added benefit of precisely traditional transseptal and transethmoid approaches [4].
localizing the dimensions of a bony skull-base defect in a In addition, while this chapter focuses on endoscopic re-
previously operated and scarred field. pair of skull-base defects, it should be kept in mind that
Fig. 20.4a–c Patient status post traumatic

brain injury, craniotomy, and frontal sinus
fracture repair referred for evaluation of
persistent pneumocephalus 2 months after
the initial injury. a A small bony defect
is visualized in the right frontal sinus pos-
terior table with adjacent pneumocephalus
(arrow). b A second bony defect is noted
in the sphenoid roof (arrowhead). CT
cisternogram contrast is also seen along
the sphenoid defect, but no contrast is
20 pooling in the sphenoid sinus. c Intrathecal
fluorescein highlights a small meningocele
identified intraoperatively along the sphe-
noid roof. Image-guidance pointer rests on
the sella, with the meningocele anterior
most of the principles described may also be applied to endoscopes and giraffe instruments along the anterior
combined open/endoscopic approaches, as well as purely ethmoid roof and in the frontal recess (Fig. 20.5). Angled
open approaches via an osteoplastic flap. The specific lo- endoscopes are also helpful in the lateral recess of the
cation of the defect and surgeon comfort and experience sphenoid sinus, where visualization can be difficult. Dur-
will dictate which approach is necessary to provide ad- ing surgical dissection and exposure of skull-base defects,
equate exposure and visualization of the defect. frontal and sphenoid sinusotomies should also be consid-
As in endoscopic sinus surgery for inflammatory dis- ered to prevent mucocele formation and allow for adequate
ease, dissection is often facilitated by the use of angled assessment of ostia patency in the postoperative period.
Fig. 20.5 a Angled rigid nasal endoscopes improve visualization of the frontal sinus/recess and lateral sphenoid recess for skull-base
defect repair. b Giraffe angled instruments allow frontal sinus/recess manipulation
■ Dissection of the paranasal sinuses surrounding the vents secretion of mucus from any mucosa underlying
skull-base defect should be thorough. This allows for the graft, which may cause the graft to separate from its
adequate visualization and access of instrumentation recipient bed [41, 42]. At this time, any meningoencepha-
to perform the repair. loceles that are present at the site of skull-base defect are
reduced to an intracranial position with bipolar cautery.
Once the skull-base defect is identified and exposed, the This completes preparation of the recipient bed at the site
bone of the defect is denuded of surrounding mucosa of the skull-base defect. At this time, if an active CSF leak
for several millimeters (Fig. 20.6, Video 20.2). This pre- is present, CSF pressure may be diverted away from the
Fig. 20.6a,b Patient with recurrent CSF rhinorrhea following b Presence of a posterior ethmoid meningocele (arrowhead)
craniotomy for resection of olfactory meningioma. a Skull-base confirmed on sagittal MRI images. Video 20.2 shows endoscop-
defect with likely meningocele identified in posterior ethmoid ic reduction of this meningocele and repair of the skull-base
roof (arrow) on coronal CT scan in the bone window algorithm. defect
site of the skull-base defect by taking the patient out of absorbable materials if desired. Placement of absorbable
the Trendelenburg position and placing him/her in a 30 materials in proximity to the graft allows any nonabsorb-
head-up position. If present, the lumbar drain may also able materials to be removed without risking disruption
be opened to drain approximately 5–10 ml per hour for of the graft. Absorbable materials will dissolve naturally
the remainder of the procedure. over a period of approximately 6 weeks.
■ Careful removal of mucosa surrounding the bony

skull-base defect prevents the secretion of mucus,
Potential Complications
which may separate the graft from the recipient bed.
Intracranial Complications
Specific techniques for repair will vary based on the
site, size, and etiology of the defect. For small (less than
Pneumocephalus
3 mm) defects, simple soft-tissue overlay grafts will typi-
cally close the defect successfully. In addition, if there is With a known defect in the skull base, the surgeon should
concern that nerves or vessels may be damaged when dis- be aware of the potential for pneumocephalus, which is
secting the dura away from the skull base, overlay graft- reported to carry a 25% risk of meningitis and 16% mor-
ing is recommended [15]. For larger defects, multilayer tality [31]. Positive pressure from the external environ-
repairs are advocated. Repair layers may consist of soft ment, such as sneezing, vomiting, continuous positive
tissue only, or a structural layer of bone may be added for airway pressure respiratory devices, and application of
support of very large defects or defects in patients with bag-mask apparatus during general anesthesia induction
increased intracranial pressure [41, 42]. can force air intracranially, leading to tension pneumo-
Various grafting materials have been used, and graft cephalus. Patients should be alerted to this potential and
choice will depend on surgeon comfort and preference. instructed accordingly prior to their surgery. In addition,
Free bone graft choices include septal bone, turbinate intubation protocols that avoid positive pressure during
bone, and mastoid bone. Free cartilage grafts may also anesthesia induction are advisable [41, 42].
be used. Autologous septal and turbinate mucosa, tem-
poralis fascia, and abdominal fat have also been used, as
have alloplastic collagen, and cadaveric dermis, fascia,
Intracranial Hemorrhage
and pericardium [42]. One may also consider intranasal
vascularized pedicle grafts in patients with large defects When working along the skull base with a meningoen-
or in patients with significant scarring, history of skull- cephalocele or skull-base tumor, vessels present in the
base radiation therapy, or decreased blood supply to the mass often track intracranially. Traction forces on such
recipient bed. Tissue adhesives may be applied following masses may lead to rupture of the vessels in the intracra-
graft placement, if desired. nial cavity, leading to dangerous hemorrhage [41, 42].
Whenever possible, placement of a soft-tissue or bone Bipolar cautery for reduction of meningoencephaloceles
underlay graft in the epidural space, followed by a soft- and excision of skull-base tumors is typically advocated to
tissue overlay graft intranasally, should be considered. safely cauterize these vessels without avulsing them [18].
A few caveats should be kept in mind, however. First,
mucosal grafts should not be placed in an intracranial
20 underlay position due to the risk of intracranial infec-
Creation of New Skull-Base Defects
tion and mucocele [42]. Secondly, in patients with spon-
taneous CSF leaks and increased intracranial pressure, During the course of preoperative planning for endo-
the entire skull base is often attenuated [42]. Significant scopic skull-base defect repair, the surgeon will carefully
manipulation of the skull base in these patients may lead assess the skull base for the site of possible defects. As
to fracture and creation of larger defects. Finally, when in preparation for endoscopic sinus surgery, sites of po-
placing grafts, the surgeon should remain aware of sur- tential new complications involving the skull base should
rounding sinus ostia and avoid iatrogenic ostia obstruc- also be evaluated, such as asymmetry of the skull base,
tion during graft placement. When working near the low-lying skull base, or tall middle-turbinate lateral la-
frontal sinus outflow tract, short-term (1 week) inser- mellae. Awareness of such anatomic variants will alert
tion of a soft silastic stent may be useful in preventing the surgeon to possible sites for creation of new skull-
iatrogenic obstruction during placement of the graft and base defects. This is especially important in the case of
packing material. recurrent CSF leak or meningoencephalocele, given the
Once the graft materials are in place, the nose is altered anatomy and likely scarring from previous re-
packed to support the graft. Packing should begin with pairs.
absorbable materials against the graft, followed by non-
Ocular Complications Factors Contributing to Failure

in Skull-Base Repair
Ocular complications are generally rare in endoscopic si-
nus surgery, and the same is true for endoscopic skull-base Factors leading to failure of skull-base defect repair have
defect repair. However, the principles that guide the en- not been evaluated comprehensively. However, certain
doscopic surgeon during both types of procedure remain factors may alert the surgeon to potential failure and de-
the same. Assessment of the patient’s anatomy on preop- serve mention. Most frequently, the presence of increased
erative CT scan will alert the surgeon to any anatomic intracranial pressure is cited as placing patients at risk for
variants and the position and integrity of the lamina pap- failure [29, 56]. Various authors have described a clini-
yracea, optic nerve, and optic nerve bony canal. As many cal association between spontaneous CSF leaks, increased
skull-base defects are located in the sphenoid sinus, the intracranial pressure, obesity, and empty sella syndrome
surgeon should be keenly aware of the location of the op- [20, 38–40, 43]. Entities such as spontaneous CSF leaks
tic nerve and cavernous sinus when working in this area. and meningoencephaloceles, traumatic brain injury, and
hydrocephalus may place patients at increased risk of
skull-base repair failure due to the concomitant increased
intracranial pressure. Often, perioperative adjuncts such
Frontal and Sphenoid Ostium Stenosis
as lumbar drains and diuretics, as well as placement of
In the course of repairing skull-base defects, multiple lay- underlay bone grafts are advocated in such patients to de-
ers of grafts and packing material are often required to crease their propensity for failure.
ensure adequate repair. Depending on the site of skull- Lindstrom et al. [20] also note increased failure rate
base defect, the ostia of the frontal or sphenoid sinus may for skull-base defects located in the lateral sphenoid re-
be in the vicinity of the repair if the defect is located in cess, citing the technical difficulty of visualization and
the anterior ethmoid roof or frontal recess. In such cases, repair in this region. Another surgical factor that may
application of sufficient packing material may be difficult make skull-base repair challenging is large skull-base de-
while maintaining the patency of the sinus ostia. Our typ- fect size, especially following significant trauma or extir-
ical protocol in such cases is to adequately open the sinus pation of skull-base tumors [20, 54].
ostia during the course of the repair, leaving as much mu- A recent series at our institution designed to assess
cosa intact around the ostium as possible. The repair is factors differentiating patients undergoing primary skull-
then completed in the routine fashion. Upon completion base defect repair as compared to those undergoing revi-
of repairs near the frontal recess, we consider placement sion repair identified several additional factors thought to
of a soft T-shaped silastic stent for 5–7 days. This stent can play a role in skull-base defect repair failure [54]. These
then be gently removed in the clinic without disturbing the included failure to precisely localize the skull-base defect
graft or packing material and may increase the chances of during the initial surgery (Video 20.3) and identifica-
maintaining frontal patency long term. In addition, dur- tion of a new skull-base defect at an anatomic location
ing the course of postoperative care, a probe or very light remote from the original repair. Factors that may influ-
suction may be carefully passed into the ostium to ensure ence wound healing were also present in higher percent-
its patency while avoiding disturbance of the graft site. ages in revision patients, such as prior skull-base surgery,
prior radiation therapy to the skull base, intracranial in-
Tips and Pearls for Avoiding Complications fection, and history of a skull-base neoplasm (excluding
pituitary neoplasms). This highlights the importance of
1. Carefully evaluate preoperative imaging for ana-
fully assessing each patient’s clinical picture to ensure that
tomic variants of the orbit and skull base, as well as
surgical factors as well as patient-related factors are taken
integrity of the carotid canal and optic nerve canal.
into account to provide the best possible repair circum-
2. Avoid the application of positive pressure to de-
stances.
crease the risk of pneumocephalus.
3. In order to reduce the chance of intracranial
hemorrhage from torn vessels, use bipolar cautery
along the skull base to reduce meningoencephalo- Postoperative Care
celes and resect tumors.
While postoperative care and office debridement is in-
4. For repairs near the frontal sinus ostium, identify
tegral to good surgical outcomes in endoscopic sinus
and enlarge the ostium intraoperatively, meticu-
surgery for inflammatory disease, office debridement
lously preserving surrounding mucosa. Postopera-
is generally minimal in the setting of endoscopic trans-
tively, gently probe or suction the frontal sinus to
nasal CSF leak and meningocele repair. Postoperative
ensure its patency while avoiding disturbance of
protocols will vary depending on the operating surgeon
the skull-base graft.
and the individual case. However, some of our general
principles following endoscopic CSF leak repair are dis- celes with increased intracranial pressure [14, 29], loca-
cussed. tion of a skull-base defect in the lateral sphenoid sinus
At the time of hospital discharge, patients are instructed [20], and a large skull-base defect [20]. Other factors that
to avoid heavy lifting and strenuous activity for approxi- may play a role in predisposing patients to recurrent CSF
mately 6 weeks. We also recommend stool softeners and leaks and meningoencephaloceles include failure to accu-
laxatives as necessary to avoid straining. In patients with rately localize the skull-base defect, development of new
spontaneous CSF leaks and increased intracranial pres- skull-base defects, history of prior skull-base surgery or
sure, we add diuretic therapy to decrease CSF produc- craniotomy, history of skull-base radiation, intracranial
tion and alleviate stress on the repair site. Acetazolamide infections, and skull-base neoplasm (other than pituitary
decreases CSF production by as much as 48% [5], and a neoplasms) [54]. It is important to recognize these sur-
mean reduction in intracranial pressure by 10 cmH2O gical factors and patient-related factors in order to ad-
has been shown with the institution of acetazolamide equately plan for surgery and for the care of the patient in
postoperatively [44]. the perioperative period.
During surgery, the nose is typically packed with both
absorbable and nonabsorbable packing after placement of
graft material over the skull-base defect. In general, non-
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20
Chapter 21
Delayed Complications
Following Sinus Trauma 21
David M. Poetker and Timothy L. Smith
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
■ The most common complication following sinus Rhinosinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
trauma is sinusitis, usually resulting from edema, Mucoceles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
blood, retained bone or soft-tissue fragments, or
Foreign Bodies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
foreign bodies.
■ Craniofacial trauma accounts for approximately Silent Sinus Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
28% of mucoceles. Paranasal Sinus Epidermoids . . . . . . . . . . . . . . . . . . . . . 182
■ Mucoceles can present decades after the inciting Traumatic Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
trauma, so life-long follow up is indicated.
Cerebrospinal Fluid Leak . . . . . . . . . . . . . . . . . . . . . . . . 183
■ Foreign bodies of the paranasal sinuses are associ-
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
ated with trauma in 70% of cases, and most com-
monly involve the maxillary sinus. Thorough and
complete debridement in the acute setting is essen-
tial to prevent long-term complications.
■ Paranasal sinus epidermoids have been reported attempt to review the common, and some of the not-so-
to occur following traumatic implantation of squa- common delayed complications seen following the initial
mous mucosa. management of sinus trauma.
■ Management of paranasal sinus epidermoids in-
volves ventilation of the affected sinuses with long-
term endoscopic follow up.
Rhinosinusitis
■ Traumatic aneurysms of the internal carotid artery
can present as an isolated sinus mass. Acute complications associated with trauma include:
1. Sinus wall fractures.
2. Bleeding.
3. Sinus foreign bodies.
4. CSF leaks.
Introduction
Each of these should be managed in the acute setting.
Maxillofacial trauma is a common occurrence and has However, if they are not appropriately managed, they can
been well studied in the literature. Given the anatomical lead to delayed complications. The most common com-
relationships, the paranasal sinuses are often involved in plication following sinus trauma is rhinosinusitis. Rhino-
this trauma. Interestingly, relatively little has been written sinusitis can result from edema and blood, retained bone
in the literature addressing the various complications of or soft-tissue fragments, or foreign bodies. These can ob-
sinus trauma, and their respective management. Of the struct the outflow tract of the sinus and/or disrupt the
reports on sinus trauma, more attention has been paid mucociliary function of the mucous membrane. Either
to management of the acute complications rather than can lead to mucous retention in the sinus and ultimately
long-term or delayed complications. Management of chronic rhinosinusitis. This has been well described in
such things as reduction of the bony fractures, removal the case of frontal sinus fractures that obstruct the out-
of foreign bodies, and management of cerebrospinal fluid flow tract [11, 14]. Often, at the time of the acute injury,
(CSF) leaks have all been described. In this chapter, we the blood and edema associated with the fracture make it
180 David M. Poetker and Timothy L. Smith
very difficult to identify which frontal sinus fractures will mucoceles are said to account for up to 10% of all mu-
result in obstruction of the outflow tract. Occasionally, coceles, and are less commonly associated with trauma
a computed tomography (CT) scan obtained in a sagit- when compared to frontal mucoceles [2, 10]. Primary,
tal plane will help identify damage to the outflow tract. or true mucoceles, occur when the outflow tract of the
Smith and colleagues have discussed the option of medi- sinus is blocked, either due to trauma or inflammation.
cal treatment and observation of frontal sinus disease fol- Secondary mucoceles occur when fractures result in
lowing the reduction of fractures of the anterior table of mucosal entrapment and subsequent retention cyst for-
the frontal sinus, and any naso-orbitoethmoid fractures mation [3, 15].
[14]. If this fails to resolve the sinus disease, a repeat of Patients present with a variety of signs and symptoms
the medical management is recommended. when suffering from a mucocele. These can range from
severe headache to facial/sinus pressure, facial/sinus pain,
■ Only if the second round of medical management fails vision complaints such as diplopia, and even obvious fa-
do Smith et al. recommend endoscopic sinus surgery cial deformities. It is not uncommon to see bony erosion
addressing the frontal sinus outflow tract [14]. and remodeling of the sinus walls in the case of a muco-
cele. In the frontal sinus, this remodeling can extend an-
This can be done through a Draf II procedure (extended teriorly or posteriorly through the anterior and posterior
endoscopic frontal sinusotomy), or a Draf III procedure tables, respectively. It can also extend inferiorly into the
(an endoscopic modified Lothrop procedure) [14]. These orbit leading to increased pressure on the globe, propto-
endonasal approaches can be augmented with a frontal sis, and diplopia. This bony remodeling and erosion has
sinus trephination. This allows for an additional access been associated with the production of bone-resorbing
point for instrumentation and visualization. An osteo- factors produced by the lining of the mucoceles [15]. It is
plastic flap may be considered in the case of a failed en- also believed that the intramucocele pressure is transmit-
donasal approach or a particularly recalcitrant case of ted to the surrounding sinus bones, thus causing them
frontal rhinossinusitis. to remodel. This remodeling often leads to gross changes
Post-traumatic rhinosinusitis involving the paranasal in the shape of the sinus wall, and thinning of that wall.
sinuses must be managed using the same principles as In the maxillary sinus, bone remodeling and erosion can
non-trauma-related rhinosinusitis. Initial medical man- lead to lateral nasal wall displacement, bulging of the
agement using broad-spectrum antibiotics with good si- hard palate, and even displacement of the maxillary al-
nus penetration, along with a corticosteroid to decrease veolar dentition [2].
outflow tract edema is recommended. Surgically, the si- As mentioned, mucoceles can present years, and even
nus ostia must be opened, facilitating proper mucocili- decades from trauma.
ary function and sinus drainage. In a study reporting on
maxillary sinus evaluation following trauma, the authors ■ The average time between trauma and surgical confir-
report that 9 of the 15 patients (60%) with maxillary si- mation of a mucocele has been reported at 7.5 years
nus fractures report delayed complaints related to rhino- [15].
sinusitis [16]. Six of the 9 patients required medications
for the sinusitis. Follow-up CT scans of the sinuses per- Koudstaal and his colleagues reported a series of three
formed between 9 and 47 months post-trauma (mean mucoceles following maxillofacial trauma. The longest
19.8 months) showed diminished maxillary sinus vol- delay in presentation in their series was 35 years [9]. For
ume in the traumatized sinus, mucosal thickening, and this, they advocate lifelong follow up for patients who
bone defects; 3 patients had their maxillary sinuses filled have suffered sinus trauma. Although these are rare, they
21 with soft tissue [16]. Since the focus of the article was must be kept in the differential for patients presenting
not management, no mention was made of how these with a history of trauma.
patients were treated, or the outcomes following treat- Infection of the mucocele leads to formation of a mu-
ment. copyocele. This infection can lead to rapid enlargement
of the mucocele with increased risks of extrasinus com-
plications.
Mucoceles
■ Pathogens associated with mucopyoceles are often
A mucocele is an expanded, mucous-filled paranasal sinus common sinus pathogens associated with acute and
that is most commonly found in the frontal sinus [5, 10]. chronic rhinosinusitis [15].
Chronic rhinosinusitis and allergic sinonasal disease
are the most common causes of paranasal sinus muco- These rapid expansions of the mucocele increase the risk
celes [10]. Craniofacial trauma is the reported cause in of intracranial complications [5]. Cultrera and colleagues
approximately 28% of mucoceles [9]. Maxillary sinus report a patient who developed meningitis from a frontal
Delayed Complications Following Sinus Trauma 181
sinus mucocele that had eroded through the posterior ta- Another report described a woman who suffered ex-
ble of the frontal sinus, and through the dura. The patient tensive facial fractures following an MVC [8]. These in-
was 9 years out from craniofacial trauma [5]. cluded Le Fort I, II, and III fractures, a midline palatal
fracture, and a mandible fracture. A mold of her palate
■ Management of mucoceles and mucopyoceles due to was made using a synthetic material made up of poly-
maxillofacial trauma observes the same tenets of those acrylic acid and polyethylmethacrylate. She underwent
due to inflammatory mucosal disease. an open reduction of her fractures, and the palate and
mandible fractures were addressed with a gunning splint.
The mucocele must be opened, and the cavity drained. The woman recovered well from her injuries; however,
Although some authors still recommend complete evacu- she began having ipsilateral maxillary sinus complaints
ation of the cystic cavity with complete removal of the as soon as 1 year following the repair. She underwent
respiratory mucosa, most otolaryngologists would argue several courses of antibiotics, and even a sinus washout.
against that [15]. By opening the mucocele and allow- Although these helped, they did not solve the problem.
ing for drainage, mucociliary clearance may be re-estab- Imaging demonstrated a right maxillary sinus opacifica-
lished. Often times, the bony remodeling will return to a tion. Twenty-nine years after her trauma, she underwent
near-normal state, responding to the external pressures resection of a mass from that maxillary sinus. Pathology
on the sinus once the intramucocele pressure has been reports described chronic inflammation with dense fi-
relieved. brosis, spicules of bone, and foreign material. The authors
hypothesized that a small amount of the palate mold was
introduced into the maxillary sinus, and the chronic sinus
issues she suffered was from the sinus foreign body [8].
Foreign Bodies
As discussed, sinus foreign bodies can be identified in
many acute trauma settings. Foreign bodies such as glass,
Silent Sinus Syndrome
bone fragments, gravel, and even teeth have been re-
ported [1, 17]. There have been two reports to date of orbital floor frac-
tures causing a silent sinus syndrome with delayed en-
■ Sinus foreign bodies reportedly occur more than half ophthalmos and hypoglobus (Fig. 21.1) [6,13]. In the first
of the time in the maxillary sinus, and are associated case, a 50-year-old male was struck in the face with a tree
with trauma in 70% [17]. branch, suffering a minimally displaced orbital floor frac-
ture. His ocular motility was normal, as was his vision,
With the use of CT as the gold standard in the diagnostic
imaging of maxillofacial trauma, it seems unlikely that
foreign bodies are not discovered upon the initial radio-
graphic evaluation. However, there are reports of facial
fractures being treated many years ago, before the rou-
tine use of these imaging modalities, so retained foreign
body should remain on the differential. In addition, it is
quite possible to misinterpret the CT findings with the
usual compliment of blood and edema in the sinuses in
the acute setting.
Alessandro and colleagues at the University of Rome
reported a case of a 26-year-old male who presented with
a 14-month history of recurrent headaches and swelling
of the left upper lid region. His history was significant for
a severe motor vehicle collision (MVC) 2 years prior to
evaluation. During that collision, he had suffered a left
fronto-orbital fracture with a laceration over the left eye-
lid [1]. A CT scan demonstrated a foreign body lodged Fig. 21.1 A coronal computed tomography (CT) of the para-
subcutaneously that extended into the anterior table of nasal sinuses demonstrating an opacified right maxillary sinus.
the frontal sinus. The sinus demonstrated mucosal thick- This patient sustained a right orbital blow out fracture 20 years
ening in the area of the foreign body. Upon surgical de- prior to evaluation. She was initially referred to an ophthalmolo-
bridement, it was found to be a fragment of an ink pen gist for contralateral proptosis. Note the right orbital floor pros-
[1]. Long-term follow up reportedly demonstrated reso- thesis and the inferior displacement of the right orbital floor.
lution of the patient’s symptoms. Also note the lateralization of the ipsilateral uncinate process
so the fracture was managed conservatively. At 2 months Patients often experience chronic pain, pressure, chronic
post-trauma, he returned to the clinic for a 2-week pro- infection, and disfigurement due to expansion and ero-
gressive enophthalmos with diplopia. A CT of the orbits sion caused from the epidermoid [3]. In addition, it is
and sinuses revealed a completely opacified ipsilateral felt that these can degenerate into a carcinoma if not ad-
maxillary sinus with a severely depressed orbital floor. He equately addressed [7].
was taken to surgery for maxillary antrostomy and orbital
floor reconstruction. He was found to have obstruction ■ Treatment of epidermoid lesions includes marsupial-
of the natural maxillary ostium from herniated orbital ization and exteriorization of the cyst, as well as com-
contents. His symptoms resolved postoperatively [6]. The plete excision of the cyst lining [3].
second case was of a 27-year-old man who was assaulted
[13]. A CT scan demonstrated a minimally displaced left Chandra and Palmer recently reported a series of three
zygomaticomaxillary fracture and a moderately displaced patients with paranasal sinus epidermoids. One patient
orbital floor fracture, with an air-fluid level in the ipsilat- had extension of a petrous apex epidermoid; however, the
eral maxillary sinus. The patient was managed conserva- remaining two patients both had histories of craniofacial
tively because he had no functional deficit. Six months trauma, supporting the theory of traumatic implantation
after his trauma, he re-presented with vertical diplopia, of the squamous mucosa. One woman had an epidermoid
limited vertical gaze, enophthalmos, and hypoglobus. A of the pterygopalatine space that expanded anteriorly,
repeat CT scan revealed left inferior orbital expansion and causing the posterior wall of the maxillary sinus to bulge
a left maxillary sinus contracture with complete opacifi- anteriorly. The epidermoid was widely marsupialized
cation. The patient underwent maxillary antrostomy with through the posterior wall, using a maxillary antrostomy.
orbital floor reconstruction. At the time of surgery, thick, She remained free of disease for 30 months at last follow-
opaque mucous was cleared from the sinus, with bony up [3].
fragments found obstructing the maxillary ostium. The The second patient was a young woman who developed
patient had resolution of his diplopia. He was observed an expanding mass of the left supraorbital ethmoid. Ini-
for an additional 4 months with no recurrence of his vi- tially it was felt to be a mucocele; however, upon entering
sual disturbances [13]. The two groups hypothesized that into the sinus, keratinaceous debris was encountered. She
the mechanism of action was similar to that believed to too underwent a wide marsupialization into the frontal
cause silent sinus syndrome, where bone or herniated sinus. As of 14 months postdebridement, she was with-
orbital contents led to obstruction of the ostium. This out evidence of disease [3]. The authors acknowledge that
obstruction led to hypoventilation of the sinus, which in more aggressive management such as an osteoplastic flap
turn led to mucosal absorption of the oxygen and a nega- for frontal or ethmoid lesions is possible. They point out
tive pressure within the sinus. This negative pressure col- that the goal of their surgery was to ventilate the sinuses
lapsed the sinus, pulling the orbital floor inferiorly. The with functional mucociliary clearance. They also point
authors advocate management directed at reestablishing out that wide marsupialization without complete excision
the aeration of the sinus in these cases [13]. of the cyst lining requires long-term endoscopic follow
up with regular debridements [3].
Paranasal Sinus Epidermoids

Traumatic Aneurysms
There are approximately two dozen reports of paranasal
sinus epidermoids, or cholesteatomas, in the literature Approximately one half of all intracranial traumatic an-
21 over the past 100 years [3,7]. eurysms involve the internal carotid artery [12]. Of those,
60% occur in the cavernous portion of the internal ca-
■ The most common locations of paranasal sinus epider- rotid artery. They result from injury to all three layers of
moids is the frontal sinus, but have also been reported the artery, and often times are detected in the setting of
in the ethmoid and maxillary sinuses [3]. fractures of the walls of the sphenoid sinus [12,18]. Inter-
estingly, the initial angiograms performed will commonly
Etiologic causes of epidermoid sinus tumors: show no aneurysm (Fig. 21.2); however, the patients may
1. Congenital – they can theoretically be due to: present with delayed epistaxis or an isolated sphenoid
a. Migration of squamous epithelium. or ethmoid mass [12]. A clinical triad of craniofacial
b. Traumatic implantation. trauma, monocular blindness, and epistaxis should result
c. Metaplasia of the native respiratory mucosa. in a high index of suspicion for a traumatic aneurysm.
2. Acquired – usually felt to be due to: This severe epistaxis can occur anywhere from a few days
a. Traumatic implantation. to more than 6 months out from the trauma [12]. It has
b. Metaplasia [3]. been recommended that an angiogram be performed in
Delayed Complications Following Sinus Trauma 183
ernous portion of the right internal carotid artery. This

was successfully embolized, and ultimately the patient
did well [12].
Cerebrospinal Fluid Leak

Cerebrospinal fluid leaks can occur in both the acute
and delayed settings following craniofacial and sinus
trauma. The delayed CSF leaks have been reported to oc-
cur months after the initial trauma [4]. Management of
these delayed leaks is similar to that for a leak following
an acute injury, or of a spontaneous CSF leak. This is out-
lined more extensively elsewhere in this text.
Conclusion
As discussed, there is a paucity of information in the lit-
erature about long-term or delayed complications from
Fig. 21.2 An axial CT of the head demonstrating a fracture of sinus trauma. Even with a remote trauma history, com-
the left lateral wall of the sphenoid sinus in a patient following a plicating factors may arise. One must be aware of these
motor vehicle crash (arrow). An initial angiogram was negative potential pitfalls in order to prepare adequately for their
for an aneurysm; however she remains at risk for development diagnosis and management.
of a traumatic aneurysm
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Tech Otolaryngol Head Neck Surg 17:66–72 Maxillofac Surg 62:1229–1236
12. Ramos A, Tobio R, Ley E, et al. (1996) Traumatic aneurysm 17. Tung T, Chen Y, Santamaria E, et al. (1998) Dislocation of
of the internal carotid artery: a late finding presenting as a anatomic structures into the maxillary sinus after craniofa-
mass in the sphenoid sinus. Am J Neuroradiol 17:222–225 cial trauma. Plast Reconstr Surg 101:1904–1908
13. Ross JJ, Kersten RC (2005) Late enophthalmos mimicking 18. Uzan M, Cantasdemir M, Seckin MS, et al. (1998) Trau-
silent sinus syndrome secondary to orbital trauma. J Cra- matic intracranial carotid tree aneurysms. Neurosurgery
niofac Surg 16:840–843 43:1314–1320
21
Chapter 22
Recurrent Mucoceles
Benjamin Bleier, James N. Palmer, and Bradford A. Woodworth
22
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
■ Management of recurrent mucoceles has shifted Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
from open surgical resection toward more conser- Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
vative, endoscopic marsupialization techniques.
Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
■ Recurrent mucocele formation may result from in-
complete marsupialization of the primary lesion or
unfavorable scarring of a sinus ostium or free muco- Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
sal edge. Frontal Sinus Mucoceles . . . . . . . . . . . . . . . . . . . . . . . 189
■ Mucoceles that violate the boundaries of the sinona-
Maxillary Sinus Mucoceles . . . . . . . . . . . . . . . . . . . . . 190
sal cavity are at higher risk for recurrence due to the
increased complexity of complete marsupialization Ethmoid and Sphenoid Sinus Mucoceles . . . . . . . . . 190
by strictly endoscopic techniques. Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
■ Infected mucoceles (mucopyoceles) can rapidly ex- Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
pand and increase the incidence of local complica-
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
tions.
■ Computed tomography is absolutely required for
evaluation and preoperative management, and mag-
netic resonance imaging is highly recommended if
the primary lesion demonstrates skull-base erosion
Introduction
or frank intracranial extension.
■ The overall goal of revision mucocele surgery in- Sinonasal mucoceles are indolent, expansile cysts that
cludes complete adjacent sinusotomy followed by contain mucus and are lined with functional respiratory
wide-field marsupialization of the cyst wall to mini- epithelium. These benign lesions may be locally destruc-
mize the risk of scarring and entrapment of residual tive due to chronic expansion with reactive bone remod-
secretory mucosa. eling and may become secondarily infected, resulting in
■ Extended frontal sinus procedures, such as the Draf a mucopyocele. Classically, recurrent lesions were felt
III (endoscopic modified Lothrop) procedure, are to require complete surgical resection, often with oblit-
often necessary for recurrent frontal sinus muco- eration of the involved sinus cavities. With the advent of
celes to increase the chances of success. endoscopic surgical techniques and newer imaging mo-
■ Partial (modified) endoscopic medial maxillectomy dalities over the past 30 years, management of recurrent
is recommended for recurrent maxillary sinus mu- mucoceles has shifted toward more conservative marsu-
coceles. pialization techniques.
■ Sphenoid mucoceles are addressed via a transnasal/
transseptal or transethmoid approach.
■ Endoscopic drainage appears to be an effective
Epidemiology
technique with little morbidity in the proper hands.
However, open approaches are still necessary in se- Mucoceles most commonly present between the ages of
lect cases. 40 and 60 years and have no discernable sex predilection
[1]. Those presenting in children are usually idiopathic,
although some authors advocate cystic fibrosis screening
186 Benjamin Bleier, James N. Palmer, and Bradford A. Woodworth
in any child found to have a mucocele [5, 7]. Paranasal si- Bacterial invasion of the cyst can also occur, result-
nus mucoceles occur most frequently in the frontal sinus ing in a mucopyocele. This may lead to rapid expansion
[11]. Several large case series have reported incidences of of the lesion with a resultant increased incidence of lo-
60–90% in the frontal sinus and 8–30% within the eth- cal complications. Common culture isolates from these
moid sinus. Mucoceles of the maxillary and sphenoid si- lesions include Staphylococcus aureus, alpha-hemolytic
nus are rare, although some authors report an incidence Streptococci, Haemophilus influenzae, Pseudomonas aeru-
of up to 5% and 10%, respectively [1, 9, 13]. ginosa, and anaerobes including Propionibacterium acnes,
Prevotella, and Fusobacterium [3, 5].
■ Common etiologies of paranasal sinus mucoceles in-

Pathophysiology
clude:
The current paradigm for management of mucoceles and 1. Chronic rhinosinusitis.
their recurrences derives from a more complete under- 2. Prior sinus surgery (external or endoscopic).
standing of the pathophysiology of this disease. Studies 3. Maxillofacial trauma.
by Lund et al. [14] demonstrated that the mucocele lining 4. Allergy.
is composed of functional respiratory mucosa, namely 5. Neoplasm.
ciliated pseudostratified columnar epithelium. 6. Idiopathic.
■ Primary and recurrent mucocele development can be

extrapolated to an event resulting in retained mucus
Presentation
with a concomitant loss of a normal outflow tract.
Presenting symptoms of a recurrent mucocele are often
One proposed mechanism of primary mucocele forma- referable to its location and include congestion, head-
tion implicates the cystic degeneration of a seromucinous ache, rhinorrhea, and pressure. Diplopia, eye pain, de-
gland with formation of a retention cyst [2]. Sinus out- creased visual acuity, epiphora, and proptosis may be
flow obstruction resulting from intranasal neoplasm or present with significant intraorbital involvement. In
iatrogenic causes may also contribute to mucocele forma- some cases of recurrent disease, prior loss of bony or-
tion. One series reported a 9.3% incidence of frontal sinus bital architecture may result in profound exophthalmos,
mucocele following osteoplastic flap [8]. Recurrent mu- leading to exposure keratopathy and central retinal block
cocele formation may result from incomplete marsupial- [6]. Frontal mucoceles may also present with a fore-
ization of the primary lesion or unfavorable scarring of a head mass secondary to erosion of the anterior table.
sinus ostium or free mucosal edge. Other etiologic factors Conversely, patients with full-thickness posterior table
include a history of chronic sinusitis, allergic rhinitis, and erosion may present with a cerebrospinal fluid leak or
previous maxillofacial trauma. meningitis.
■ Once formed, mucoceles may affect bony remodeling

via an inflammatory cascade focused at the bone–mu-
Preoperative Workup
cocele interface.
The evaluation of a patient with a suspected recurrent
Inflammatory mediators including interleukin (IL)-1 and mucocele relies primarily on history and physical exam
IL-2 as well as fibroblast-derived prostaglandin E2 and coupled with radiographic evaluation. If the prior mar-
collagenase act to promote bone resorption, which in supialization included sinusotomy with skull-base clear-
conjunction with the mass effect of the lesion itself, can ance, a portion of the cyst wall may be readily apparent
22 result in local bony destruction and displacement of adja- on nasal endoscopy. While plain films have been utilized
cent soft tissue structures [14–16]. in the past to assess paranasal sinus disease, computed
Local complications arise from chronic cyst wall ex- tomography (CT) has become the modality of choice to
pansion that may result in intraorbital extension with evaluate these lesions. Mucoceles appear as well-circum-
globe displacement or skull-base erosion. The incidence scribed cysts with homogenous mucoid contents whose
of intracranial extension has been reported as high as attenuation increases with chronicity of the lesion sec-
55%, half of which had a larger intracranial than sinus ondary to increasing protein content (10–40 Hounsfield
component [9]. Lesions that violate the boundaries of the Units). High-resolution images in both axial and coronal
sinonasal cavity tend to be at higher risk for recurrence planes provide valuable information regarding the integ-
secondary to the increased complexity of complete mar- rity of surrounding bony structural elements and help to
supialization by strictly endoscopic techniques [18]. plan surgical intervention.
Recurrent Mucoceles 187
Magnetic resonance imaging (MRI) is also useful

Surgical Technique
when attempting to differentiate between mucocele and
other sinonasal soft tissue lesions, and is highly recom- Traditionally, open surgical resection, rather than marsu-
mended if the primary lesion demonstrates skull-base pialization, was the gold standard treatment for primary
erosion or frank intracranial extension. Mucoceles will be or recurrent sinonasal mucoceles. Techniques such as the
low intensity on T1-weighted and gadolinium-enhanced Lynch-Howarth frontoethmoidectomy or osteoplastic
images, while appearing high intensity on T2-weighted flap with subsequent sinus obliteration were associated
imaging [13]. with significant morbidity and cosmetic deformity as well
as a relatively high recurrence rate [17]. As early as 1921
■ Imaging the characteristics of mucoceles: it was recognized that marsupialization was a rational al-
1. Computed Tomography. ternative to these more radical approaches. This concept
a. Non-contrast enhanced. has been supported by subsequent studies demonstrating
b. Well circumscribed with homogenous mucoid essentially normal mucociliary transport mechanisms
content. within previously marsupialized cavities [10]. With the
i. New lesions 10–18 Hounsfield Units. introduction of nasal endoscopes, microsurgical instru-
ii. Chronic Lesions 20–40 Hounsfield Units. ments, and image-guided surgical navigation, endoscopic
c. Contrast enhanced. transnasal marsupialization has become the treatment of
d. Rim enhancement. choice and obviated the need for external incisions in the
2. Magnetic resonance imaging. vast majority of cases.
a. T1-weighted sequence – dark. Surgical management of recurrent lesions is largely dic-
b. T2-weighted sequence – bright. tated by the location, amount of residual bony partitions,
c. Gadolinium enhanced – does not enhance. and degree of local extension noted on preoperative CT.
Several systems have been devised that classify mucoceles

according to the site and degree of local invasion. Intra-
cranial extent is a critical element in most systems as it
predicts surgical complexity and potential need for skull-
base repair or sinus obliteration at the time of surgery.
■ Classification of paranasal sinus mucoceles [4]:

1. Type 1 – anterior without intracranial extension.
2. Type 2 – anterior with intracranial extension.
3. Type 3 – posterior midline without intracranial ex-
tension.
4. Type 4 – posterior with intracranial extension.
■ As part of the preoperative evaluation the surgeon

should do the following:
1. Perform a complete history and physical examina-
tion including nasal endoscopy.
2. Obtain a high-resolution CT with axial and coronal
cuts. The use of image guidance for recurrent le-
sions is advocated. Fig. 22.1 Supraorbital ethmoid sinus mucocele. A patient with
3. Carefully review CT with specific attention to site a history of right frontal mucocele drained at an outside institu-
of involvement, the presence of bony erosion, and tion presented with proptosis and eye pain. T2-weighted coro-
the degree of intraorbital and/or intracranial exten- nal magnetic resonance imaging scan reveals a right supraor-
sion. bital ethmoid mucocele (white arrow) that probably developed
4. Obtain an MRI with any significant intracranial in- secondary to inadequate drainage and iatrogenic scarring of the
volvement in primary or recurrent lesions or con- supraorbital outflow tract. a Intraoperative triplanar imaging
cern over sinonasal neoplasm. and endoscopic view following drilling with a 70 diamond burr.
b Intraoperative computed tomography (CT) scan and real-time
updating of image-guidance was performed to confirm that the
mucocele was completely marsupialized (c) b–c see next page
22
Fig. 22.1 (continued) b Intraoperative computed tomography (CT) scan and real-time updating of
image-guidance was performed to confirm that the mucocele was completely marsupialized (c)
■ The overall goal of revision mucocele surgery includes ■ A common set-up for recurrence is a reliance on im-
complete adjacent sinusotomy followed by wide-field age-guidance technology in the absence of technical
marsupialization of the cyst wall to minimize the risk skill and a comprehensive understanding of frontal
of scarring and entrapment of residual secretory mu- recess anatomy.
cosa.
Evacuating a frontal sinus mucocele using image-guid-
If significant intraorbital or intracranial extension is pres- ance-based suction without performing a complete
ent, utilization of MRI and image-guidance technologies frontal recess dissection invites a recurrence (Fig. 22.2).
is advocated. An open approach including craniotomy All endoscopic frontal recess dissections are more easily
may be required in select cases [18]. If the technology is performed with 45 or 70 4-mm nasal endoscopes for vi-
available, intraoperative CT scanning with real-time up- sualization. If there is little osteoneogenesis present, the
date of computer-aided systems is valuable for difficult frontal recess should be dissected with frontal sinus hand
cases, especially when the confines of the mucocele are instruments in an attempt to drain the mucocele into the
more difficult to visualize (Fig. 22.1). nose. Careful attention is paid to preserving the mucosa
surrounding the outflow tract to help increase long-term
patency. In cases with abundant osteoneogenesis, a 70
diamond burr is helpful during the dissection. When the
Frontal Sinus Mucoceles
drill is needed or in the case of small frontal openings,
Adequate drainage of frontal mucoceles to establish long- an intraoperative decision must be made to extend the
term patency requires a thorough knowledge of frontal operation to a Draf IIB or Draf III (modified endoscopic
recess anatomy and its variants. All air cells encroach- Lothrop) procedure. If the patient has a recurrent muco-
ing on the frontal sinus outflow tract, such as agger nasi cele in the presence of a prior osteoplastic flap with oblit-
cells anterolaterally or suprabullar cells posteriorly, are eration, a Draf III is an option to unobliterate the frontal
removed in their entirety to increase the chance of long- sinuses. Stenting after endoscopic frontal sinusotomy is
term frontal patency. of controversial benefit and is often left to surgeon prefer-
Fig. 22.2 Frontal sinus mucocele. Triplanar CT imaging and endoscopic view following complete
frontal sinusotomy for a recurrent frontal sinus mucocele. The prior surgeons did not fully resect the
uncinate process or adequately address the frontal recess
ence [9]. If stenting is used, it should be made from a soft, posterior cuts to remove the medial maxillary wall and
conformable material such as silastic and removed within inferior turbinate. The entire cavity is then inspected with
2–4 weeks to prevent bacterial biofilm formation on the 45, 70 and 120 rigid endoscopes. Meticulous preserva-
stent itself, as this might create a nidus for inflammation. tion of mucosa is attempted in all cases. The modified
endoscopic medial maxillectomy permits wide marsupi-
alization of the maxillary sinus to decrease the probability
of recurrence and optimizes distribution of postoperative
Maxillary Sinus Mucoceles
topical medications and mechanical irrigations.
■ Mucoceles recurring in the maxillary sinus are treated Patients with a prior history of Caldwell-Luc op-
with a partial (modified) endoscopic medial maxillec- erations typically had their maxillary mucosa stripped,
tomy (Fig. 22.3) [19]. which may result in a contracted, hypoplastic maxillary
sinus with multiple recurrent loculated mucoceles within
A middle meatal antrostomy is revised first, if necessary, the sinus. Facial trauma patients may also develop lat-
with complete removal of the uncinate process. Using the erally located mucoceles within the maxillary sinus. In
turbinate scissors and through-biting forceps, an inci- these instances, a modified endoscopic medial maxillec-
sion is carried through the anterior one-third of the in- tomy can be performed in conjunction with a Caldwell-
ferior turbinate to the inferior portion of the maxillary Luc procedure to effectively drain and marsupialize these
antrostomy, directing the cut posterior to the distal end lateral mucoceles.
of the nasolacrimal duct (Hasner’s valve). The anterior
portion of the medial maxillary wall is then incised using
the down-biting forceps to make the anterior cut. Using
Ethmoid and Sphenoid Sinus Mucoceles
turbinate scissors, an inferior cut along the junction of
the nasal floor and floor of the maxillary sinus is taken Recurrent ethmoid mucoceles are approached utilizing a
back flush with the posterior maxillary wall, followed by complete ethmoidectomy with removal of the anteroinfe-
22
Fig. 22.3 Maxillary sinus mucocele. A patient with a history of massive facial trauma and multiple
recurrent mucoceles. An inferiorly based left maxillary sinus mucocele is marsupialized with a modi-
fied medial maxillectomy
rior and medial aspects of the mucocele. Recurrent sphe- Tips and Pearls to Avoid Complications
noid mucoceles may be approached via either a transna-
1. Carefully reexamine the CT scan just prior to
sal/transseptal approach or a traditional transethmoid
surgery.
approach (Fig. 22.4). In both instances, locating the natu-
2. Potential landmarks should be identified on the
ral ostium of the sphenoid is the preferred entry point
CT in patients who have distorted anatomy due to
into the sphenoid. Recurrent lesions may be secondary
prior surgery.
to significant scarring and/or prior pituitary surgery, and
3. When chronic infection and inflammation is pres-
thus are likely to have altered anatomy. The superior tur-
ent, a preoperative course of oral antibiotic and
binate is the most reliable landmark if still present. The
steroid therapy helps reduce tissue inflammation
inferior aspect of the superior turbinate is removed to
and vascularity.
identify the natural ostium and a wide sphenoidotomy is
4. Provide careful topical and infiltrative vaso-
performed.
constriction, minimize mucosal trauma (es-
pecially to the nasal mucosa anteriorly in the
nose), and limit dissection in the region of
Postoperative Care the sphenopalatine artery branches. If during
surgery, bleeding persists so that it interferes
Postoperatively nasal saline irrigation and topical nasal
with visualization, it is safer to stop the proce-
steroids are critical in helping to clear the operative site of
dure and if necessary, return at a later time.
debris and maintain patent ostia. Packing is generally not
5. Identify medial orbital wall and skull base early on
required. In the setting of mucopyocele or positive intra-
in the dissection.
nasal cultures, patients are placed on a culture-directed
6. Avoid trauma to the anterior ethmoid artery. Iden-
antibiotic regimen. Patients are monitored and debrided
tify by imaging preoperatively to avoid mistaking
postoperatively until healing and reestablishment of nor-
the artery for a bony septae of an ethmoid cell and
mal mucociliary clearance pathways are complete.
attempting resection. Supraorbital ethmoid muco-
Fig. 22.4 Sphenoid sinus mucocele. This large mucocele with significant skull-base erosion recurred
following sphenoidotomy at an outside institution. A transnasal/transseptal approach was performed
to completely open the face of the sphenoid sinus
2. Batsakis JG (1980) Tumours of the Head and Neck. Wil-

celes are particularly tricky as the artery often lies
liams and Wilkins, Baltimore
just posterior to this sinus.
3. Brook I, Frazier EH (2001) The microbiology of mucopyo-
7. Extruded orbital fat from a periorbital viola-
cele. Laryngoscope 111:1771–1773
tion not only puts the orbit at risk, but can also
4. Delfini R, Missori P, Ianetti G, Ciappetta P, Cantore G
obstruct the frontal outflow tract in the area of the
(1993) Mucoceles of the paranasal sinuses with intracra-
frontal recess. Use extreme care near dehiscent
nial and intraorbital extension: report of 28 cases. Neuro-
lamina and avoid powered instrumentation as
surgery 32:901–906
much as possible in these areas.
5. al-Dousary S, al-Kaharashi S (1996) Maxillary sinus muco-
8. Preserve mucosa within the frontal recess.
pyocele in children: a case report and review of literature.
Int J Pediatr Otol 36:53–60
6. Garston JB (1968) Frontal sinus mucocele. Proc R Soc Med
61:549–551
Outcomes
7. Guttenplan MD, Wetmore RF (1989) Paranasal sinus mu-
In 1989, Kennedy et al. [12] successfully drained 16 of 18 coceles in cystic fibrosis. Clin Pediatr 28:429–430
complicated frontal mucoceles endoscopically, many of 8. Hardy JM, Montgomery WW (1976) Osteoplastic frontal
which had eroded the posterior table, extended into the sinusotomy: an analysis of 250 operations. Ann Otol Rhi-
orbit, or had associated Pott’s puffy tumor. There were no nol Laryngol 85:523–532
mucocele recurrences after 42 months of follow-up. Har- 9. Har-El G (2000) Endoscopic management of 108 sinus mu-
El reported that 107 of 108 paranasal sinus mucoceles coceles. Laryngoscope 111:2131–2143
were successfully managed endoscopically with recur- 10. Har-El G, Dimaio (2000) Histologic and physiologic
rence noted in only 1 patient (0.9%) [9]. This one recur- studies of marsupialized sinus mucoceles. J Otolaryngol
rence was subsequently managed with an open procedure 29:195–198
and obliteration. This case series had a median clinical 11. Howarth WG (1921) Mucocele and pyocele of the nasal ac-
follow-up of 4.6 years. Therefore, endoscopic drainage cessory sinuses. Lancet 2:744–746
appears to be an effective technique with little morbid- 12. Kennedy DW Josephson JS, Zinreich SJ, Mattox DE, Gold-
ity in the proper hands. Mucocele recurrence rates with smith MM (1989) Endoscopic sinus surgery for mucoceles:
modern endoscopic techniques have been reported any- a viable alternative. Laryngoscope 99:885–895
where between 9 and 10%. However, given the scarcity, 13. Lloyd G, Lund VJ, Savy L, Howard D (2000) Optimum im-
no larger series have been reported [9, 18]. aging for mucoceles. J Laryngol Otol 114:233–236
14. Lund VJ, (1991) Fronto-ethmoidal mucoceles: a histopath-
ologic analysis. J Laryngol Otol 105:921–923
15. Lund VJ, Harvey W, Meghji S, Harris M (1988) Prostaglan-
Conclusion
din synthesis in the pathogenesis of fronto-ethmoidal mu-
Sinonasal mucoceles represent benign, expansile lesions coceles. Acta Otolaryngol 106:145–151
that most often occur in the frontal and ethmoid sinus 16. Lund VJ, Henderson B, Song Y (1993) Involvement of
and can result in local bony destruction. In the era of en- cytokines and vascular adhesion receptors in the pathol-
doscopic marsupialization complimented by high-reso- ogy of fronto-ethmoidal mucoceles. Acta Otolaryngol
lution CT imaging, recurrences are rare. When they do 113:540–546
occur, surgery should be directed toward creating a wide 17. Rubin JS, Lund VJ, Salmon B (1986) Frontoethmoidectomy
outflow tract with complete adjacent sinusotomy. In com- in the treatment of mucoceles. A neglected operation. Arch
plex cases with significant orbital or intracranial involve- Otolaryngol Head Neck Surg 112:434–436
ment, open approaches may be required.
22 18. Weitzel EK, Hollier LH, Calzada G, Manolidis S (2002)
Single stage management of complex fronto-orbital muco-
celes. J Craniofac Surg 13:739–745
19. Woodworth BA, Parker RO, Schlosser RJ (2006) Modified
References
endoscopic medial maxillectomy for chronic maxillary si-
1. Arrue P, Thorn Kany M, Serrano E, et al. (1998) Mucoceles nusitis. Am J Rhinol 20:317–319
of the paranasal sinuses: Uncommon location. J Laryngol
Otol 112:840–844
Chapter 23
Allergy and the Patient Requiring

Revision Sinus Surgery 23
Li-Xing Man and Berrylin J. Ferguson
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
■ Allergic rhinitis is an IgE-mediated response to al- Allergy and the Pathogenesis of Chronic
lergens including pollens, fungi, animal danders, Rhinosinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
insects, and dust mites. Allergic Rhinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
■ The role of allergic rhinitis in the pathogenesis of
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
chronic rhinosinusitis is poorly understood, but the
association is strong. In-Vitro Screens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
■ Persistent sinonasal symptoms after endoscopic si- Skin Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
nus surgery may indicate the need for management Medical Therapy for Allergic Rhinitis . . . . . . . . . . . . 195
of an underlying allergy. Evaluation of allergy is
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
therefore an important component in the evaluation
of the patient considering revision sinus surgery.
■ Typical symptoms of allergic rhinitis include nasal
congestion, itching, sneezing, rhinorrhea, and post- This chapter explores the role of allergy in chronic
nasal discharge. rhinosinusitis and reviews the diagnosis and treatment of
■ Pharmacotherapy for allergic rhinitis should be allergic rhinitis in the patient undergoing revision sinus
targeted toward the specific symptom profile of the surgery.
individual patient. Immunotherapy can benefit pa-
tients who fail to achieve symptom relief with en-
vironmental controls and pharmacotherapy, or who
Allergy and the Pathogenesis
have perennial symptoms.
of Chronic Rhinosinusitis
Allergic rhinitis is a symptomatic nasal disorder char-
acterized by IgE-mediated inflammation of nasal mem-
branes triggered by exposure to an allergen [1]. Diagnos-
ing allergic rhinitis in patients with chronic rhinosinusitis
Introduction
is difficult due to shared symptoms such as nasal conges-
Evaluation of allergy is an integral part of the assessment tion and rhinorrhea. Atopy, a state in which elevated
of all patients with sinonasal complaints. Allergic rhini- levels of IgE antibodies to allergens can be detected by
tis affects 10–40% of the population worldwide [30]. In skin-prick, or specific IgE to antigens, can be determined
the largest and most comprehensive national survey to objectively; however, atopic individuals may not have
date, approximately 14% of the adult population in the clinical manifestations of allergic rhinitis [18, 27]. In ad-
United States has been diagnosed with allergic rhinitis dition, only a subset of patients with rhinitis symptoms
[28]. In terms of overall economic burden of illness in the has disease attributable to atopy [18, 27, 35].
United States, allergic rhinitis ranks fifth overall, with an The role of allergic rhinitis in the pathogenesis of
estimated twofold increase in medication costs and phy- chronic rhinosinusitis is unclear. It has been hypoth-
sician visits, 3.5 million lost workdays, and 2 million lost esized that allergen-mediated nasal mucosal inflamma-
schooldays [11, 12, 22]. tion may obstruct the sinus ostia, leading to poor sinus
194 Li-Xing Man and Berrylin J. Ferguson
drainage and ventilation, mucus retention, and bacterial chronic rhinosinusitis refractory to medical management
growth, but the evidence remains unconvincing [2]. The and who subsequently underwent endoscopic sinus sur-
estimated prevalence of allergy in patients undergoing gery, none had received preoperative immunotherapy,
endoscopic sinus surgery ranges from 20 to 84% [6, 8, 13, but 84% tested positive for inhalant allergies [8]. Evalu-
19, 23, 26, 27, 31, 32]. Few studies, however, tested all pa- ation of allergy is an integral part in the assessment of all
tients for atopy using in vivo assays (typically skin-prick patients considering revision sinus surgery.
tests) or in vitro assays for serum IgE antibody to allergens
(Table 23.1). Some studies suggest that atopic patients
have more severe disease when assessed by computed to-
Allergic Rhinitis
mography scan appearance and have less improvement in
symptoms and quality of life after endoscopic sinus sur-
Diagnosis
gery [3, 6, 14, 15, 23]. Other studies found no association
between atopy and either preoperative severity of sinus ■ The diagnosis of allergic rhinitis is suggested by a his-
disease or postoperative symptomatic improvement [19, tory of typical symptoms and confirmed by skin or
25–27, 31, 32]. blood testing for allergies. Symptoms of allergic rhi-
Few studies have explored the role of allergy in the nitis include:
patient requiring revision sinus surgery. Several analy- 1. Nasal congestion.
ses have noted no difference in the rate of revision en- 2. Fatigue.
doscopic sinus surgery between allergic and nonallergic 3. Postnasal discharge.
patients [19, 25, 27]. One series demonstrated a reduction 4. Rhinorrhea.
in prescription antihistamine use after revision endo- 5. Sneezing.
scopic sinus surgery that was not statistically significant
[4]. Another study of patients undergoing revision sinus Many of these symptoms are typical of chronic rhinosi-
surgery showed a nonsignificant trend toward allergic pa- nusitis. The diagnosis of allergic rhinitis is more likely if
tients being more likely to require further surgical man- the patient can relate a history in which symptoms re-
agement [25]. solve in different localities and recur with a return to the
The persistence of sinonasal symptoms in patients home or local environment. Patients with seasonal aller-
with allergy after endoscopic sinus surgery may reflect gic rhinitis have often already made the diagnosis on their
the need for more intensive or specific allergy manage- own, but those with perennial allergic rhinitis are often
ment [19]. In a review of 190 consecutive patients with unaware that they have an allergy.
Table 23.1 Prevalence of allergy in patients undergoing endoscopic sinus surgery for chronic rhinosinusitis. NA Data not available
Study Number of Number tested Prevalence Method of diagnosis for allergy

patients for allergy (%) of allergy
Newman et al. [23] 104 95 (91.3%) 20.0% In vitro testing
Robinson et al. [27] 193 193 (100.%) 30.1% Skin or in vitro testinga
Smith et al. [31] 119 NA 34.5% Patient history
Sobol et al. [32] 393 NA 34.6% Skin testing
Dursun et al. [6] 130 67 (51.5%) 36.2% Skin testing and history
23 Marks et al. [19] 115 0 54.5% Self-reported on survey
Ramadan et al. [26] 141 NA 54.6% Patient historyb
Kennedy [13] 120 NA 57.5% Skin or in vitro testing
Emanuel and Shah [8] 190 190 (100.%) 83.7% Skin or in vitro testing
a
Skin testing of 10% and in vitro testing of 90% of patients (Wormald 2007, personal communication)
b
Study population comprised children aged 3–13 years
Allergy and the Patient Requiring Revision Sinus Surgery 195
■ Allergy testing is valuable in the management of pa- formed initially and additional IDTs within the subgroups
tients with chronic nasal symptoms for two reasons: are performed if the respective mix is positive. There is a
1. Allergy testing can identify allergens that the pa- wide selection of prick-testing devices. The Multitest II
tient did not previously suspect so that environ- device is one of the most popular, most reproducible, and
mental controls can be directed. fastest to apply. A negative Multitest using 14 antigens
2. Allergy testing provides the basis for formulation of plus histamine and glycerin controls indicates that sig-
allergen vials for immunotherapy. nificant inhalant allergy is unlikely. A positive Multitest
may require additional in vitro or IDT testing [17].
■ Immunotherapy is the only treatment modality that has
the potential to cure the patient with allergic rhinitis. ■ The simplest screen for allergies involves either an
Indications for immunotherapy include patients who: in-vitro allergen screen of 6–9 allergens or a Multitest
1. Fail to achieve relief from targeted pharmacother- II prick test. As they are most often associated with
apy. chronic rhinosinusitis, the allergen screen should be
2. Have symptoms over half of the year so immuno- focused on perennial allergens:
therapy becomes a cost-effective alternative. 1. Dust mite.
2. Cockroach.
In-vitro (blood) testing and skin testing are the two major 3. Molds.
forms of allergy testing. There are multiple in-vitro tests 4. Cat (if applicable).
available for allergy testing including, but not limited to,
radioallergosorbent test (RAST), modified RAST, and the The patient probably does not have inhalant allergy if the
Pharmacia CAP System. There are two types of skin test- screen is negative. If the screen is positive, the patient
ing for allergy: intradermal dilutional testing (IDT) and may be allergic to multiple other allergens and may re-
prick testing. A serum total IgE level is not an adequate quire further, more detailed investigation.
screen for allergy, as it can often be within normal limits
and yet the patient will have significant specific IgE-me-
diated hypersensitivity to a few antigens.
Medical Therapy for Allergic Rhinitis
It is essential to control the symptoms of rhinitis in the
allergic patient requiring revision sinus surgery. Manage-
In-Vitro Screens
ment of allergic rhinitis in the patient considering revi-
A mini-allergy screen of six antigens using RAST batter- sion sinus surgery has four components: allergen avoid-
ies of one grass (Timothy), one weed (common ragweed), ance, pharmacotherapy, immunotherapy, and surgery.
one tree (oak), two molds (Alternaria and Helmithospo- The ideal treatment of allergic rhinitis is avoidance of
rium), and one dust mite (Dermatophagoides pteronyssi- allergens that provoke symptoms. Common environmen-
nus) – with epidermals (i.e., cat, horse, etc., added if in- tal agents that trigger IgE-mediated allergic rhinitis symp-
dicated by history – has a predictive value of 75%. If the toms include dust mites, pollens, molds, animal danders,
testing battery is expanded to a total of nine antigens by and insect allergens [7]. In very specific circumstances,
including a second grass (Bermuda), an additional tree environmental control can be as effective as pharmaco-
(mountain cedar), and an additional mold (Cladospo- logic therapy [9]. For example, a pet linked to a patient’s
rium), the predictive value increases to 95% compared to allergy can be removed from the home. There is evidence
a 13-antigen screen [16]. The population for this study that a home-based, total environmental control program
comprised patients living in southwest Texas. Practitio- benefits patients with dust mite and cockroach sensitiv-
ners in other locales should tailor the antigens to the most ity [21, 24, 29]. Other interventions, such as avoidance of
prevalent and likely allergens in their particular region. the outdoors, keeping windows closed, and air condition-
Pollen maps, available from many of the testing compa- ing during peak pollen seasons are often more difficult to
nies, can help guide the selection of these antigens. achieve. Avoidance of all offending allergens is unrealistic
for many patients [20].
When environmental controls are impractical or in-
completely effective, pharmacotherapy is introduced. A
Skin Testing
wide variety of medications is available for the treatment
IDT, also known as skin endpoint titration, is the most of allergic rhinitis. The choice of pharmacologic agent is
sensitive allergy test and is able to establish a safe start- tailored to the individual patient’s symptoms. Medica-
ing dose for immunotherapy. Usually a screen using dust tions and their relative efficacy toward specific symptoms
mite, cat, dog, mold mix, tree mix, and grass mix is per- are outlined in Table 23.2.
■ Medications effective for treating allergic rhinitis in- are effective for nasal itching and sneezing symptoms, but
clude: have little impact on nasal congestion. For this reason,
1. Topical and systemic steroids. antihistamines are often paired with a decongestant. Se-
2. Topical and oral antihistamines. dating antihistamines are available over-the-counter and
3. Topical and oral decongestants. have anticholinergic properties, which thickens nasal se-
4. Leukotriene receptor modulators. cretions and may over-dry the nose in some patients. The
5. Mast cell stabilizers. utility of oral antihistamines in patients with chronic rhi-
6. Anticholinergics. nosinusitis is limited due to the failure of antihistamines
7. Saline nasal washes. to significantly reduce congestion.
8. Anti-IgE. Topical decongestants may be used for short periods
of time to decongest the nose and to optimize drainage.
Nasal steroid sprays provide the most comprehensive re- Prolonged use can lead to rebound swelling. This may be
lief of allergic rhinitis symptoms with the least amount diminished with concurrent use of a topical nasal steroid
of morbidity and are recommended as first-line therapy spray [10]. Most practitioners do not recommend long-
[5, 9]. Nasal steroid sprays are distinct from the other term use of oral decongestants because of the side effects
classes of pharmacotherapy since they control all of the of tachycardia, tremors, and insomnia.
major nasal symptoms of allergic rhinitis: sneezing, rhi- The leukotriene receptor antagonist montelukast is
norrhea, itching, and congestion. In a meta-analysis of 16 moderately effective in relieving symptoms of rhinorrhea,
randomized trials, nasal steroid sprays were significantly congestion, sneezing, and nasal itching. Overall, it is less
better than oral antihistamines at relieving nasal symp- effective than nasal steroid sprays [34]. Certain patients,
toms [33]. Nasal steroid sprays may begin to take effect however, may respond markedly to montelukast.
within 12 h after dosing, but efficacy may not be maxi- The cromone cromolyn is available over-the-counter
mal until 1–2 weeks after initiation of therapy. Patients as a nasal spray. The efficacy data for this product are in-
should always be educated in directing the steroid spray consistent and the effects on nasal symptoms are modest.
away from the septum and toward the lateral wall of the It is often difficult to predict which pharmacologic
nose to minimize septal excoriation, bleeding, and the therapy will be the most effective, but initial treatment
very rare complication of septal perforation. should be directed according to symptom profile. The
Azelastine is a topical antihistamine nasal spray that senior author currently practices a cost-effective method
has a symptom relief profile similar to that of nasal ste- whereby samples of several classes of pharmacologic
roid sprays. Onset of action is within a day. Its use is lim- agents are given to the patient to try serially. Prescrip-
ited by a bad taste appreciated by approximately 30% of tions are filled only if the drug is found to provide relief.
users, and a slight sedation potential. This reduces the number of prescriptions and frequency
Oral antihistamines can be divided into sedating and of clinic visits. Patients who have incomplete relief with
nonsedating drugs. Fexofenadine, loratadine, and deslo- monotherapy may require combination therapy with sev-
ratadine at recommended doses do not cause sedation and eral classes of drugs.
Table 23.2 Medications and their relative efficacy in allergic rhinitis
Medication Congestion Sneezing Rhinorrhea Nasal itching Eye symptoms
Nasal steroid +++ +++ +++ +++ +
Antihistamine
23 Sedating +/– ++ ++ ++ ++
Nonsedating +/– ++ – ++ ++
Decongestant +++ – – – –
Leukotriene receptor antagonist ++ + + + +
Mast cell stabilizer + + + + +/–
Ipratropium – – +++ – –
Allergy and the Patient Requiring Revision Sinus Surgery 197
Allergen immunotherapy is the only treatment modal- 3. Berrettini S, Carabelli A, Sellari-Franceschini S, et al. (1999)
ity with the potential for disease modification. Immuno- Perennial allergic rhinitis and chronic sinusitis: correlation
therapy should be considered in patients who continue to with rhinologic risk factors. Allergy 54:242–248
have significant symptoms despite pharmacotherapy, who 4. Bhattacharyya N (2004) Clinical outcomes after revision
require systemic corticosteroids, or who have comorbid endoscopic sinus surgery. Arch Otolaryngol Head Neck
conditions such as asthma [7]. Typical candidates for im- Surg 130:975–978
munotherapy have severe seasonal symptoms that return 5. Bousquet J, Van Cauwenberge P, Khaltaev N (2001) Aller-
or worsen each year, or perennial symptoms. Subcutane- gic rhinitis and its impact on asthma. J Allergy Clin Im-
ous allergen immunotherapy typically consists of weekly munol 108:S147–S334
doses of a solution containing the culpable allergens that 6. Dursun E, Korkmaz H, Eryilmaz A, et al. (2003) Clinical
are gradually increased to an optimal maintenance dose. predictors of long-term success after endoscopic sinus sur-
Immunotherapy can be stopped after 1 year if there are gery. Otolaryngol Head Neck Surg 129:526–531
no noticeable improvements. 7. Dykewicz MS, Fineman S, Skoner DP, et al. (1998) Diag-
Patients who continue to have residual nasal conges- nosis and management of rhinitis: complete guidelines of
tion after endoscopic sinus surgery should be evaluated the Joint Task Force on Practice Parameters in Allergy,
for turbinate hypertrophy. In patients who have chronic Asthma and Immunology. American Academy of Allergy,
hypertrophy of the inferior turbinate with nasal symp- Asthma, and Immunology. Ann Allergy Asthma Immunol
toms refractory to pharmacotherapy, surgery to reduce 81:478–518
the inferior turbinate may be a useful treatment option. 8. Emanuel IA, Shah SB (2000) Chronic rhinosinusitis: al-
Several inferior turbinate reduction techniques have been lergy and sinus computed tomography relationships. Oto-
described. laryngol Head Neck Surg 123:687–691
9. Ferguson BJ (1997) Allergic rhinitis. Options for pharma-
cotherapy and immunotherapy. Postgrad Med 101:117–
120, 123–116, 131
Conclusion
10. Ferguson BJ, Paramaesvaran S, Rubinstein E (2001) A study
Allergic rhinitis is a common comorbidity in patients of the effect of nasal steroid sprays in perennial allergic rhi-
with chronic rhinosinusitis. Many patients who con- nitis patients with rhinitis medicamentosa. Otolaryngol
tinue to have symptoms of rhinosinusitis despite endo- Head Neck Surg 125:253–260
scopic sinus surgery have not been adequately evaluated 11. Goetzel RZ, Long SR, Ozminkowski RJ, et al. (2004) Health,
and treated for allergic rhinitis. The diagnosis of allergic absence, disability, and presenteeism cost estimates of cer-
rhinitis is based on history, and on in vitro or skin al- tain physical and mental health conditions affecting U.S.
lergy testing. Optimal therapy of allergic rhinitis includes employers. J Occup Environ Med 46:398–412
the identification and elimination of allergen exposure. 12. Kay GG (2000) The effects of antihistamines on cognition
Pharmacotherapy should be targeted toward allergic and performance. J Allergy Clin Immunol 105:S622–S627
symptoms. Immunotherapy can be utilized in patients 13. Kennedy DW (1992) Prognostic factors, outcomes and
who failed to achieve adequate symptom relief with en- staging in ethmoid sinus surgery. Laryngoscope 102:1–18
vironmental controls and pharmacotherapy, or who have 14. Kountakis SE, Arango P, Bradley D, et al. (2004) Molecular
perennial symptoms. Inferior turbinate reduction can and cellular staging for the severity of chronic rhinosinus-
provide relief from nasal congestions in patients with itis. Laryngoscope 114:1895–1905
chronic turbinate hypertrophy. 15. Krouse JH (2000) Computed tomography stage, allergy
testing, and quality of life in patients with sinusitis. Otolar-
yngol Head Neck Surg 123:389–392
16. Lehr AJ, Mabry RL, Mabry CS (1997) The screening
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rhinitis, rhinosinusitis, and asthma: one airway disease. 19. Marks SC, Shamsa F (1997) Evaluation of prognostic fac-
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20. Marple BF, Fornadley JA, Patel AA, et al. (2007) Keys to 28. Schulman, Ronca, and Bucuvalas, Inc (2006) Allergies in
successful management of patients with allergic rhinitis: America: A Landmark Survey of Nasal Allergy Sufferers.
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Otolaryngol Head Neck Surg 136:S107–S124 namerica.com/executive–summary.php. Accessed August
21. Morgan WJ, Crain EF, Gruchalla RS, et al. (2004) Results 6, 2007. Altana Pharma US, Florham Park, NJ
of a home-based environmental intervention among urban 29. Sheikh A, Hurwitz B, Shehata Y (2007) House dust mite
children with asthma. N Engl J Med 351:1068–1080 avoidance measures for perennial allergic rhinitis. Co-
22. Nathan RA (2007) The burden of allergic rhinitis. Allergy chrane Database Syst Rev:CD001563
Asthma Proc 28:3–9 30. Sly RM (1999) Changing prevalence of allergic rhinitis and
23. Newman LJ, Platts-Mills TA, Phillips CD, et al. (1994) asthma. Ann Allergy Asthma Immunol 82:233–248; quiz
Chronic sinusitis. Relationship of computed tomographic 248–252
findings to allergy, asthma, and eosinophilia. JAMA 31. Smith TL, Mendolia-Loffredo S, Loehrl TA, et al. (2005)
271:363–367 Predictive factors and outcomes in endoscopic sinus surgery
24. Platts-Mills TA, Vaughan JW, Carter MC, et al. (2000) The for chronic rhinosinusitis. Laryngoscope 115:2199–2205
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door allergens in the treatment of chronic allergic disease. J analysis of functional endoscopic sinus surgery for chronic
Allergy Clin Immunol 106:787–804 sinusitis. J Otolaryngology 27:252–257
25. Ramadan HH (1999) Surgical causes of failure in endo- 33. Weiner JM, Abramson MJ, Puy RM (1998) Intranasal cor-
scopic sinus surgery. Laryngoscope 109:27–29 ticosteroids versus oral H1 receptor antagonists in allergic
26. Ramadan HH, Hinerman RA (2006) Outcome of endo- rhinitis: systematic review of randomised controlled trials.
scopic sinus surgery in children with allergic rhinitis. Am J BMJ 317:1624–1629
Rhinol 20:438–440 34. Wilson AM, O’Byrne PM, Parameswaran K (2004) Leukot-
27. Robinson S, Douglas R, Wormald PJ (2006) The relation- riene receptor antagonists for allergic rhinitis: a systematic
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23
Chapter 24
Staging of Disease after Sinus

Surgery Failure 24
Valerie J. Lund
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
■ Despite many suggested methods of staging for CRS and NP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
chronic rhinosinusitis, there are intrinsic difficulties Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
in finding the “perfect” solution.
Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
■ Most staging systems have relied on computed
Other Methods of Assessment . . . . . . . . . . . . . . . . . . . . 211
tomography (CT) scoring, endoscopic findings,
symptom scores or combinations thereof and have Use of Staging in Outcome Research . . . . . . . . . . . . . . . 212
concentrated on patients undergoing primary sur- Staging for Neoplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
gery rather than patients with recurrent symptoms
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
awaiting revision surgery.
■ Whilst a correlation can be shown between CT and
endoscopic findings, the correlation between CT
changes and symptoms is generally poor in either
circumstance. tests and investigations, and none more so than in the as-
■ The purpose of staging in inflammation/infection in sessment of patients after surgical treatment. Part of the
contrast to malignancy may relate more to demon- problem has lain with inter- and intra-individual varia-
stration of the disease and as an inclusion criterion tion, partly with the cost, availability and the technical
for clinical research than as a predictive tool. requirements of some of these tests, but above all with the
difficulty in correlating results with symptoms. There is
clearly a need for a universally accepted method of assess-
ing disease extent that might provide criteria for further
therapeutic intervention and allow comparison of results
of treatment between centres. However, this presupposes
Introduction
that the purpose of staging is to correlate extent of disease
“Staging: the determination of the particular stage which a with outcome, using the same premise as that on which
progressive disease or condition has reached.”. the TNM classification is based. Whilst the majority of
Oxford English Dictionary 2003 work in this area has focused on inflammatory conditions
such as chronic rhinosinusitis (CRS) and nasal polyposis
“A staging system is necessary to have meaningful results”. (NP) where the outcomes are ultimately less finite than
Caldwell 1893 [11] in cancer, some mention will also be made of staging in
relation to other conditions such as benign and malig-
“A judgement on prognosis requires an objective assessment nant neoplasia where recurrence and revision surgery are
of the anatomical extent of the disease”. frequently required.
TNM: Classification of Malignant Tumours [23]
Throughout medicine considerable effort has been made

CRS and NP
to quantify and qualify disease processes to facilitate
clinical management and research. In rhinology, this ■ Rhinosinusitis (including NP) is defined [18] as in-
has proved remarkably difficult despite several objective flammation of the nose and the paranasal sinuses
200 Valerie J. Lund
characterised by two or more of these symptoms, one 4–5: M oderately bothersome – symptoms are difficult
of which should be either nasal blockage/obstruction/ to tolerate and may interfere with activities of daily
congestion or nasal discharge (anterior/posterior na- living and/or sleep.
sal drip): 6–7: Very severe – symptoms are so bad that they can-
1. ± Facial pain/pressure. not function all of the time.
2. ± Reduction or loss of smell.
and either However, it should be noted that the “normal” popula-
3. Endoscopic signs of: tion do not score zero, with a mean of 8.8 being found
a. Polyps and/or; in an ostensibly healthy sample versus a mean of 35.3
b. Mucopurulent discharge primarily from the (p = 0.0001) in those with CRS [62].
middle meatus and/or; When considering duration of disease, one is reliant
c. Oedema/mucosal obstruction primarily in the on the definition endorsed by various drugs and thera-
middle meatus. peutic agencies around the world, which were created
and/or largely for the purpose of providing inclusion criteria for
4. Computed tomography (CT) changes: mucosal trials in acute bacterial rhinosinusitis, and which are at
changes within the ostiomeatal complex and/or si- best generalisations and at worst, arbitrary.
nuses.
■ Rhinosinusitis classification:
It would therefore seem sensible to use some, if not all of 1. Acute
these criteria to stage disease, particularly as virtually all a. < 12 weeks.
patients will be undergoing symptom assessment, endos- b. Complete resolution of symptoms.
copy and imaging if they have recurrent problems and are 2. Chronic
being considered for revision surgery. a. > 12 weeks symptoms.
Subjective assessment of symptoms generally consid- b. Without complete resolution of symptoms.
ers the degree and duration of those directly associated
with the condition and it has been shown that in a general CRS may also be subject to exacerbations (i.e. acute on
population of patients with CRS/NP, some of whom had chronic). It would be implicit in an individual requiring
undergone previous surgery, their symptoms could be further surgery that their symptoms had lasted for at least
divided into mild, moderate and severe based on a total 3 months, and therefore the duration has little utility in
severity visual analogue scale (VAS) score (0‑10 cm; see staging.
below) [39]. Considerable debate surrounds the relationship be-
tween CRS and NP, with many researchers believing that
the two are distinct conditions with a different patho-
Not Worst thinkable physiology and inflammatory profile, which may have a
troublesome troublesome bearing on staging. However, others prefer to consider NP
10 cm as part of a spectrum of inflammation that can be generi-
cally referred to as CRS. From a practical point of view
Subjective assessment of symptoms. A VAS >5 affects in the clinical setting, it is probably best to consider the
patient quality of life: condition as CRS without polyps and CRS with polyps, a
1. Mild = VAS 0–3 distinction that can usually be made on endoscopy.
2. Moderate = VAS > 3–7
3. Severe = VAS > 7–10 ■ Definition of CRS with/without polyps in individuals
who have not had previous surgery:
■ To evaluate the total severity, the patient can be asked 1. CRS without NP: no visible polyps in the middle
to indicate on a VAS the answer to the question: “How meatus, if necessary following administration of
troublesome are your symptoms of rhinosinusitis?” decongestant.
This can be factored into any staging of disease as a 2. CRS with nasal polyposis: polyps bilateral, visu-
24 measure of symptom severity (Table 24.1a). alised endoscopically in the middle meatus.
Other consensus documents have recommended a 0–7 This definition accepts that there is a spectrum of disease
scale [45] where: in CRS that includes polypoid change in the sinuses and/
1: None to an occasional limited episode. or middle meatus but excludes those with polypoid dis-
2–3: Mild-steady symptoms but easily tolerable. ease presenting in the nasal cavity to avoid overlap.
Staging of Disease after Sinus Surgery Failure 201
Table 24.1a The Lund-MacKay scoring system [42]: symptom scores using the visual analogue method. Each category is scored on
a scale of 0–10 according to the degree of symptom severity, where 0 = symptoms not present and 10 = greatest possible severity
Symptom Pre-surgery After After After After After

operation 3 months 6 months 1 year 2 years
Nasal blockage or congestion
Headache
Facial pain
Problems of smell
Nasal discharge
Sneezing
Overall
Total points
Table 24.1 b Lund-MacKay scoring system: endoscopic appearances scores
Characteristic Baseline and follow-up
Polyp left (0,1,2,3)a
Polyp, right (0,1,2,3)a
Oedema, left (0,1,2,)b
Oedema, right (0,1,2,)b
Discharge, left (0,1,2)c
Discharge, right (0,1,2)c
Postoperative scores to be used for outcome assessment only

Scarring, left (0.1,2)d
Scarring, right (0.1,2)d
Crusting, left (0,1,2)e
Crusting, right (0,1,2)e
Total points
a
0 = Absence of polyps; 1 = polyps in middle meatus only; 2 = polyps beyond middle meatus but not blocking the nose completely;
3 = polyps completely obstructing the nose
b
Oedema: 0 = absent; 1 = mild; 2 = severe
c
Discharge: 0 = no discharge; 1 = clear, thin discharge; 2 = thick, purulent discharge
d
Scarring: 0 = absent; 1 = mild; 2-severe
e
Crusting: 0 = absent; 1 = mild; 2 = severe
202 Valerie J. Lund
Table 24.1 c Lund-MacKay scoring system: CT scoring system
a
Sinus system Left Right
Maxillary (0,1,2)
Anterior ethmoids (0,1,2)
Posterior ethmoids (0,1,2)
Sphenoid (0,1,2)
Frontal (0,1,2)
Ostiomeatal complex (0 or 2 only)*
Total points
a
0 = no abnormalities; 1 = partial opacification; 2 = total opacification
Table 24.1 d Lund-MacKay scoring system: radiological grading of anatomic variants
a
Anatomic variant Left Right
Absent frontal sinus
Concha bullosa
Paradoxical middle turbinate
Everted uncinate process
Haller cells
Agger nasi cells
Total points
a
Scoring: 0 = no variant, 1 = variant present
Table 24.1 e Lund-MacKay scoring system: surgery scores
a
Surgery Left Right
Uncinectomy
Middle meatal antrostomy
Anterior ethmoidectomy
Posterior ethmoidectomy
24 Sphenoidectomy
Frontal recess surgery
Reduction of the middle turbinate
Total points each side

a
Score: 0 = no procedure done; 1 = surgery done. The maximum score is 14 (7 each side)
Unfortunately the situation is more difficult once sur- interest in reducing radiation exposure. All were origi-
gery has altered the anatomy of the lateral wall. Under nally designed with the evaluation of primary chronic
these circumstances, it has been proposed that the pres- disease in mind but can be adapted to the presence of
ence of polyps is defined as bilateral pedunculated lesions recurrence. However, there are no published scoring sys-
as opposed to cobblestoned mucosa > 6 months after sur- tems for acute bacterial rhinosinusitis. At least nine sys-
gery on endoscopic examination. tems have been published (Tables 24.1 and 24.4–24.11),
some of which formulate a number of stages, usually 0–4
■ Any mucosal disease without overt polyps should be (e.g. Kennedy [34]), whereas others produce a score (e.g.
regarded as CRS. the Lund-MacKay system [42]). This latter system has
probably gained the greatest currency, largely due to its
It should be remembered that other conditions may oc- simplicity and reproducibility. However, few have specifi-
cur concomitantly with CRS/NP and may significantly cally addressed the issue of the patient undergoing revi-
alter the prognosis, and thus the validity of staging sys- sion surgery.
tems, for example cystic fibrosis, gross immunodeficiency The Lund-MacKay system relies on a score of 0–2 depen-
(congenital or acquired), congenital mucociliary prob- dent upon the absence, partial or complete opacification
lems (e.g. primary ciliary dyskinesia), non-invasive and of each sinus system and of the ostiomeatal complex,
invasive fungal disease, systemic vasculitis and granulo- deriving a maximum score of 12 per side (Table 24.1c).
matous diseases, cocaine abuse and neoplasia. It can be used following surgery, but the extent of surgi-
cal disruption will affect its application. Nonetheless, the
presence of mucosal thickening and opacification of ex-
tant sinuses may still be scored. Previous surgery, such
Endoscopy
as Caldwell-Luc, may lead to permanently thickened
This may be performed with or without decongestion mucosa, although this may be fibrotic rather than evi-
and some form of local anaesthesia. Schemes have pro- dence of ongoing inflammation. However, this does not
posed semi-quantitative scores [41] for polyps, oedema, preclude the application of a numerical score in a patient
discharge, crusting and scarring, such as that shown in whose symptoms have warranted a scan.
Table 24.1b, which are designed to provide a baseline It should be noted that incidental abnormalities are
score and can be repeated at regular intervals following found on scanning in up to one-fifth of the “normal”
therapeutic interventions (e.g. at 3, 6, 9 and 12 months). population [40]. Mean Lund-MacKay scores of 4.26 in
The most important factor is the ease with which a par- adults [2] and 2.81 in children aged 1–18 years [25] have
ticular staging system can be taught, performed and re- been reported. In addition, for ethical reasons a CT scan
produced, and this particular one has a high inter-rater is generally only performed post-operatively when there
concordance [1] and can be used in the presence of re- are persistent problems, and therefore CT staging or scor-
current disease and both prior and following revision ing is best regarded as an inclusion criterion for studies
surgery. In the system shown, which has been widely ad- rather than as an outcome assessment.
opted, polyps are scored on a scale of 0–3. However, there This system also allows for a radiological grading of
are at least three other systems ranging from 0–2, 0–4 and anatomic variants (Table 24.1d), some of which may still
0–7 (Tables 24.2 and 24.3) [30, 38, 42]. Johansson showed be present post-surgery and provides a method of scoring
good correlation between a 0‑3 scoring system and their extent of the operation itself (Table 24.1e), which again
own system in which they estimated the percentage pro- may be of use in the revision case.
jection of polyps from the lateral wall and the percentage The Lund-MacKay system has been validated in sev-
of the nasal cavity volume occupied by polyps. However, eral studies [50] and shown to have a high inter- and in-
they did not find a correlation between the size of polyps tra-rater reproducibility. As a consequence it was adopted
and symptoms. by the Rhinosinusitis Task Force Committee of the Amer-
ican Academy of Otolaryngology Head and Neck Surgery
in 1996 [53] as well as several subsequent consensus
documents and guidelines [16, 18]. CT and endoscopic
Imaging
scores correlate well in CRS both with and without polyps
It is widely accepted that plain sinus x-rays play no part [24, 56, 60], but as previously indicated, the correlation
in the diagnosis and thus staging of sinus disease, and between CT findings and symptom scores has generally
we have come to rely on CT scanning as the modality been shown to be poor and is not a good indicator of out-
of choice in inflammation and infection (Figs. 24.1 and come [9, 10, 26, 59]. However, Wabnitz and colleagues
24.2). It is therefore not surprising that this has proved did find a correlation between a total VAS based on the
the mainstay of staging despite the many protocols and sum of five sinonasal symptoms and CT score, although
204 Valerie J. Lund
24
Fig. 24.1 a Coronal CT Scan – Chronic rhinosinusitis, previous

endoscopic sinus surgery, b L&M Score, c R maxillary sinus 1,
L maxillary sinus 1, d Posterior ethmoids R-1, L-1, e Sphenoid
R-0, L-0
Fig. 24.2 a Coronal CTScan – Chronic rhinosinusitis with nasal polyps, b Anterior ethmoids R-2, L-2, c Posterior ethmoids R-2,
L-2, d Sphenoid R-2, L-2
Table 24.2 Lildholt et al. [38]: semi-quantitative scoring of nasal polyps
0 None
1 Cobblestoned
2 Pedunculated polyps only visible endoscopically
3 Pedunculated polyps not protruding below the middle turbinate (equivalent to the
back of the inferior turbinate when the middle turbinate has been resected)
4 Pedunculated polyps below the middle turbinate

206 Valerie J. Lund
Fig 24.3 a Coronal CT scans: Chronic rhinosinusitis with previous nasal polyposis, one previous endoscopic operation, b Anterior
ethmoid cavities R-2, L-2, c Posterior ethmoidal cavities R-1, L-1, d Sphenoid R-0, L-0
24
Table 24.3 Johansson et al. [30]: semi-quantitative scoring of nasal polyps
4 As before
5 Polyps medial to the middle turbinate
6 Polyps medial and lateral to the middle turbinate
7 Nasal cavity completely filled with polyps
Table 24.4 The staging system of Friedman et al. [19]
Stage 0 Normal
Stage I Single-focus disease (involving a single focus or sinus unit)
Stage II Multifocal disease (includes bilateral or multiple areas of disease that are not conflu-
ent or are diffuse throughout the ethmoid labyrinth, bilateral middle-meatal polyps)
Stage III Diffuse disease (extensive bilateral involvement of multiple sinuses) without bony changes
Stage IV Diffuse disease associated with bony changes
Table 24.5 The staging system of Kennedy [34]
Stage 0 Normal
Stage I Anatomic abnormalities

All unilateral sinus disease
Bilateral disease limited to ethmoid sinuses
Stage II Bilateral ethmoid disease with involvement of one dependent sinus
Stage III Bilateral ethmoid disease with involvement of two or more dependent sinuses on each side
Stage IV Diffuse sinonasal polyposis
Table 24.6 The staging system of Levine and May [37]
Stage 0 Normal
Stage I Disease limited to the ostiomeatal complex
Stage II Incomplete opacification of one or more major sinuses (frontal, maxillary, sphenoid)
Stage III Complete opacification of one or more major sinuses, but not all
Stage IV Total opacification of all sinuses

208 Valerie J. Lund
Table 24.7 The staging system of Gliklich and Metson [22]
Stage 0 Normal (< 2 mm of mucosal thickening on any sinus wall)
Stage I All unilateral disease or anatomic abnormality
Stage II Bilateral disease limited to ethmoid or maxillary sinuses
Stage III Bilateral disease with involvement of at least one sphenoid or frontal sinus
Stage IV Pansinusitis
Table 24.8 Radiological scoring system of Jorgensen [31]
Structure Left Right
Frontal-sinus opacificationa
Maxillary-antrum opacificationa
Anterior ethmoidal-labyrinth opacificationa
Posterior ethmoidal-labyrinth opacificationa
Sphenoid-sinus opacificationa
Maxillary-antrum polypb
Hiatus-semilunaris occlusionc
Maxillary-sinus ostium occlusionc
Frontal-recess occlusionc
Ethmoidal-infundibulum occlusionc
a
Score for opacification: none = 0; mild = 1; moderate = 2; marked = 3; complete = 4
b
Score for size of maxillary sinus polyp: none = 0; small = 1; medium = 2; large = 3
c
Score for occlusion: none = 0; mild = 1; moderate = 2; complete = 3
Table 24.9 Worksheet for the radiological grading system of Newman et al. [48]
Maxillary sinusa
Frontal sinusa
Sphenoid sinusa
Ethmoidal sinusb
24
Ostiomeatal complexc
Nasal passages c
Hiatus-semilunaris occlusion c
Maxillary-sinus ostium occlusion c

Table 24.9 (continued)
Frontal-recess occlusion c
Ethmoidal-infundibulum occlusion c
a
Mucosal thickening scores: 0 (0–1 mm); 1 (2–5 mm); 2 (6–9 mm); 3 (> 9 mm)
b
Mucosal thickening scores: 0 (0 mm) 1 (0–1 mm); 2 (2–3 mm); 3 (> 3 mm)
c
Degree of obstruction scores: 0 (none); 1 (mild); 2 (partial); 3 (complete)
Table 24.10 Gaskins [20]: stages of surgical sinus disease
Stage 0: Score = 0 No surgical sinus disease
Stage I: Score< 1.3
Site Inflammation limited to the ostiomeatal complex area
Surgery No prior sinus/nasal surgery except septoplasty and/or inferior meatal antrostomies
Polyps No polyps or localised to < 10% of the sinus space
Infection Well-controlled infection with no active mucopurulent drainage
Immunology No underlying immunologic disease except well-controlled allergy
Stage II: Score + 1.2–2.3
Site Inflammation confined to the maxillary/ethmoid/ostiomeatal areas
Surgery Prior Caldwell-Luc or polypectomy
Polyps Polyp disease, with involvement of 10–50% of the nasal/sinus cavities
Infection Persistent, localised infection with some active purulent drainage
Immunology Low-grade immune disorder or fair allergy control
S tage III: Score 2.3–4.0
Site Pansinus involvement (unilateral or bilateral); isolated sphenoid disease
Surgery Prior anterior ethmoidectomy/middle-turbinate surgery
Polyps Nasal/sinus polyposis filling more than 50% of the nasal and sinus cavities
Infection Poorly controlled multisinus infection with active muco-

purulent drainage; active fungal sinusitis
Immunology Poorly controlled allergic rhinitis or significant immune dis-

order; history of long-term steroid treatment
Stage IV: Score>4.0
Site Sinus disease with extranasal/sinus extension, orbital or intra-

cranial; frontal disease above the nasofrontal duct
210 Valerie J. Lund
Surgery Prior complete ethmoidectomy or sphenoidectomy
Polyps Inverting papilloma or other potentially malignant nasal/sinus neoplasms
Infection Osteomyelitis or infection eroding into the orbit or cranium; mucormycosis
Immunology End-stage immunologic disease; profoundly immunocompromised patient
Table 24.11 Lehman et al. [36]: endoscopic staging worksheet for revision cases. OMC Ostiomeatal complex
Section A: Select the endoscopic classification (for the right and left sides sepa-
rately), that best describes your patient’s endoscopic examination
Points Endoscopic Findings Right Side Left Side
0 Normal mucosal membranes in all the opened

sinuses: otherwise normal remnants of the
OMC or sphenoethmoidal recess structures
1 Mild edema of the anterior or posterior sinus cavi-

ties (or remnants of the OMC and sphenoethmoidal
recess structure) with the other being normal
2 Mild edema of the anterior and poste-

rior sinus cavities (or remnants of the OMC
and sphenoethmoidal recess structure)
3 Marked edema or polypoid changes lim-

ited to the anterior or posterior sinus cavities
(or remnants of the OMC and sphenoethmoidal
recess structure)with the other being normal
4 Marked edema or polypoid changes of the ante-

rior and posterior sinus cavities cavities (or remnants
of the OMC and sphenoethmoidal recess structure); or
marked edema in one and mild edema in the other
5 Frank polyps limited to the anterior or posterior

sinus cavities (or remnants of the OMC and sphe-
noethmoidal recess structure), but not extending
outside the confines of the cavities or meatal area
6 Frank polyps limited to the anterior and posterior

sinus cavities (or remnants of the OMC and sphe-
noethmoidal recess structure), but not extending
outside the confines of the cavities or meatal area
24 7 Frank polyps extending outside the limits of the
anterior and/or posterior sinus cavities or OMC rem-
nants, but not completely obstructing the nasal cavity;
a visible airway is seen along the inferior nasal cavity;
through which the nasopharynx can be examined
8 Frank polyps completely obstruct-

ing the nasal cavity; no visible airway
Section A: Select the endoscopic classification (for the right and left sides sepa-
rately), that best describes your patient’s endoscopic examination
Points Endoscopic Findings Right Side Left Side
Section B: Check off the endoscopic findings below (for the right and left side sepa-
rately), if the patient has discolored mucus or allergic mucin
2 Discolored mucus
or allergic mucin
Total Score for sections A & B (Maximum of 20 points):
Check the stage that matches the total points score above:
– Stage I (Mild disease: 1–6)

– Stage II (Moderate disease: 7–13)
– Stage III (Severe disease: 14–20)
not between CT score and quality of life (QoL) as mea- In a study from Switzerland [21], the Kennedy CT
sured with the Chronic Sinusitis Score [61]. Staging system I–III was used in 77 patients with CRS
Bhattacharyya compared three staging systems with without polyps, and showed that the likelihood of revi-
the Rhinosinusitis Symptom Inventory [7] and found the sion was greatest in those with higher-staged disease.
Lund-MacKay score to correlate best with nasal scores, Bhattacharyya has considered the role of the predictive
but the degree of correlation remained low. value of symptoms and extent of disease on CT in both
It has been suggested that an attempt to quantify the primary and revision endoscopic sinus surgery (ESS) for
percentage of the sinus occupied by inflammatory disease CRS [7, 8], again confirming that extent of disease using
might improve its sensitivity [46], although it would not the Lund-MacKay, Kennedy or Harvard systems corre-
necessarily be easy to reproduce or indeed apply to the lates poorly with symptoms either pre- or post-opera-
post-operative situation. The extent of sinus opacification tively. However, he was able to show that a scoring system
is calculated from the sum of the scores of the five major such the Lund-MacKay could be applied to the revision
sinuses (frontal, maxillary, anterior and posterior eth- patient, with similar scores before the primary and sec-
moid, and sphenoid), each scored on a five-point opacifi- ondary procedure (10.5 vs. 9.7, p = 0.38) [5].
cation scale, where 0 = 0%; 1 = 1–25%; 2 = 26–50%; 3 = 51– In a study considering clinical outcomes after revision
75%; 4 = 76–99%; 5 = 100%. Alternatively, both CT [52] ESS, the Lund-MacKay CT score confirmed the presence
and magnetic resonance imaging (MRI) might be used to of disease (mean score 12.6) and allowed a comparison
assess the volume of inflamed mucosa, but interpretation of results with patients undergoing primary surgery to be
could be difficult due to the reproducibility of the scans, matched according to the extent of their inflammatory
and in the case of MRI, the effect of the nasal cycle and change on imaging [6]. Results were similar in this group
the high incidence of incidental changes renders it over- of refractory CRS patients to that found in the primary
sensitive. As with CT, there is a similar lack of correlation population.
between rhinological symptoms and MRI changes [44].
The University of Miami staging system, which in-
cludes CT and endoscopic assessment, has also been
Other Methods of Assessment
assessed by its creators for inter-rater reliability [36]. In-
ter-rater reliability for the CT and endoscopic arms were A range of investigative tools have been applied to the
good for patients undergoing either primary or revision CRS/NP patient, including measures of mucociliary
surgery. The correlation between endoscopic findings clearance, olfaction and airway, but these are not uni-
and CT staging was also high, again in both primary and versally available and may be subject to intra-individual
revision cases. variation. Consequently, these have generally not featured
212 Valerie J. Lund
in most staging systems. However, an increasing number come Test (SNOT-20 and SNOT-22) have been used in
of studies have used validated questionnaires, consider- several studies to assess outcome, but have not been used
ing QoL and quantification of symptoms. Kountakis and specifically as part of a stratification or staging process,
colleagues attempted a correlation of the level of tissue nor in general focused on a revision population [9, 27].
and systemic eosinophilia and degree of polymorphisms Nonetheless, this approach might reward further investi-
of the leukotriene C4 synthase gene with endoscopy, gation, particularly in those patients likely to relapse (e.g.
CT and a validated sinonasal questionnaire [35]. As ex- CRS+polyps), and the SNOT-20 is regarded as one of the
pected, tissue eosinophilia was associated with polyps, most useful [47].
asthma, allergy, and higher CT and symptom scores. One of the few studies to consider staging instruments
Stratification was proposed, with those with polyps, tis- in revision ESS by McMains and Kountakis [43] utilised
sue and blood eosinophilia representing the most severe, the Lund-MacKay CT score, endoscopic score, VAS and
and those without these features being the least severe. It SNOT-20. CT scores in this group were similar to those
is probable that this would apply to patients irrespective seen in patients undergoing primary surgery (13.4±0.7),
of their surgical status, but has not been used widely in and the score served principally to quantify disease,
clinical practice. whereas the other measures could be used to quantify
General (generic) measurements such as the outcome and confirmed overall improvement. Those pa-
Medical Outcomes Study Short Form 36 [63] enable tients with polyps, not surprisingly, constituted the ma-
the comparison of patients suffering from CRS with other jority of failures.
patient groups, but have not been used to any degree in In a study by Smith et al. [57] concerning predictive
the stratification of CRS, especially not in recurrent factors in ESS for CRS, 119 patients with CRS and a mean
problems. In addition, there are several disease-specific follow-up of 1.4 years were evaluated prospectively. This
questionnaires for CRS that may be more sensitive than group included patients who had undergone surgery.
general health status instruments, but again have not gen- Contributory medical conditions, CT and endoscopy
erally been utilised in staging the extent of disease [3, 4, scores as well as QoL were considered. As usual, CT scores
33, 51, 54]. were worse in the presence of polyps, but interestingly the
CT score was not affected by prior sinus surgery, whereas
endoscopic scores were significantly worse. Nonetheless,
these patients had the greatest improvement in endos-
Use of Staging in Outcome Research
copy score, and CT scores approached significance in
Any attempt at staging, particularly after the anatomy predicting worse outcome. However, other factors such
has been distorted by previous surgery, is open to criti- as aspirin sensitivity and depression were associated with
cism. Both the endoscopic appearances and particularly worse outcome, suggesting that this information needs to
the scan represent a snapshot at a particular moment and be factored into any staging in both primary and revision
may be influenced by the medical treatment that patients surgery.
receive. It is difficult enough to devise schemes to stage If staging based on CT does not correlate well with
primary disease [18, 46] that few have grappled with the symptoms, does it assist in determining other outcomes,
complexities of staging recurrent disease, although they such as complication rates? The Sino-Nasal Audit under-
may have considered studies to prevent disease recur- taken by the Royal College of Surgeons of England on
rence in chronic disease. 3128 consecutive patients undergoing all forms of sino-
Requirements of a staging system [45]: nasal surgery for CRS ± NP confirmed by multivariate
1. Provide an objective means of quantifying the volume analysis that the complication rate was linked to extent of
of inflammatory mucosa and opacification. disease measured in terms of CT score (Lund-MacKay)
2. Be easy to use and require no formal training. as well as symptom severity, health-related QoL, extent of
3. Have high reproducibility, as demonstrated by inter- polyposis and the presence of co-morbidity, but interest-
observer and intra-observer studies. ingly not on extent of surgery. However, this group was a
4. Be able to quantify the patency of the ostiomeatal pas- heterogeneous mix of those having primary and revision
sageways. surgery [28].
24 Virtually all of the systems have been developed for an
This does not mention a relationship to outcome, but also adult population, possibly recognising the changing de-
does not address the issue of revision surgery in recurrent velopment of the sinus system in the paediatric popula-
disease. tion and the high frequency of opacification due to com-
Validated questionnaires that cover some health-re- mon upper-respiratory-tract infections [15].
lated QoL aspects, such as the 20-item Sino-Nasal Out-
realised through careful analysis of imaging studies and

Staging for Neoplasia
addressed surgically, the “recurrence” rate and need for
Even in the area of neoplasia, staging in the nose and si- revision surgery has dropped dramatically from ~25% to
nuses has proved problematic. A variety of systems has <2% [29].
been devised for malignant tumours, but these systems
are generally of less prognostic use than elsewhere in the
head and neck. The nose and sinuses represent an area
Conclusion
of great histological diversity, each with a unique natural
history, which undermines the value of 5-year survival Staging in inflammatory disease is helpful in confirming
rates as malignant tumours can recur many years, even its presence and extent, corroborating the endoscopic
decades later. This combined with late presentation, the findings and clinical diagnosis and serving as inclusion
complexity of the anatomy and proximity to skull base criteria and for case matching in clinical research. Few
and orbit means that most patients present with advanced systems have considered the situation when recurrent
local disease, but rather less often with dissemination, so disease is present or revision surgery contemplated. In
staging is of much less relevance in determining progno- contrast to neoplastic disease, conventional staging does
sis. The standard systems such as TNM [23] are relatively not serve as a strong indicator of prognosis, as symptoms
crude and do not take into account the many different correlate poorly with extent of disease in both primary
histopathologies; nor are they based on the findings of and recurrent CRS/nasal polyposis. Perhaps it is simply
modern imaging and histology. Cantu et al. compared useful to confirm one’s own prejudice and bias!
the 1997 and 2002 American Joint Committee on Can-
cer–Union Internationale Contre le Cancer systems and
their own classification system, perhaps not surprisingly,
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46. Meltzer EO, Hamilos DL, Hadley JA, et al. (2006) Rhinosi- 56. Smith TL, Batra PS, Seiden AM, Hanley M (2005) Evidence
nusitis: developing guidance for clinical trials. Otolaryngol supporting endoscopic sinus surgery in the management
Head Neck Surg 135:S31–S80 of adult chronic rhinosinusitis: A systematic review. Am J
47. Morley AD, Sharp HR (2006) A review of sinonasal out- Rhinol 19:537–543
come scoring systems – Which is best? Clin Otolaryngol 57. Smith TL, Mendolia-Loffredo S, Loehrl TA, et al. (2005)
31:103–109 Predictive factors and outcomes in endoscopic sinus surgery
48. Newman LJ, Platts-Mills TAE, Phillips DC, et al. (1994) for chronic rhinosinusitis. Laryngoscope 115:2199–2205
Chronic sinusitis relationship of computed tomographic 58. Stamm AC (2000) Surgical grading system for inverted
findings to allergy, asthma and eosinophilia. JAMA papillomas. In: Stamm AC, Draf W (eds) Micro-endo-
271:363–367 scopic Surgery of the Paranasal Sinuses and the Skull Base.
49. Oikawa K, Furuta Y, Oridate N (2003) Pre-operative stag- Springer, Berlin, Heidelberg, New York, pp 147–152
ing of sinonasal inverted papilloma by magnetic resonance 59. Stewart MG, Sicard MW, Piccirillo J, et al. (1999) Severity
imaging. Laryngoscope 113:1983–1987 staging in chronic sinusitis: are CT scans findings related to
50. Oluwole M, Russell N, Tan L, et al. (1996) A comparison patient symptoms. Am J Rhinol 13:161–167
of computerized tomographic staging systems in chronic 60. Toros SZ, Bölükbasi S, Naiboğlu B, et al. (2004) Compara-
sinusitis. Clin Otolaryngol Allied Sci 21:91–95 tive outcomes of endoscopic sinus surgery in patients with
51. Piccirillo JF, Merritt MG Jr, Richards ML (2002) Psycho- chronic rhinosinusitis and nasal polyps. Laryngoscope
metric and clinimetric validity of the 20-Item Sino-Nasal 114:1895–905
Outcome Test (SNOT-20). Otolaryngol Head Neck Surg 61. Wabnitz DAM, Nair S, Wormald PJ (2005) Correlation be-
126:41–47 tween preoperative symptom scores, quality-of-life ques-
52. Ponikau JU, Sherris DA, Weaver A, et al. (2005) Treatment tionnaires, and staging with computed tomography in pa-
of chronic rhinosinusitis with intranasal amphotericin B: a tients with chronic rhinosinusitis. Am J Rhinol 19:91–96
randomised, placebo-controlled, double-blinded pilot trial. 62. Walker FD, White PS (2000) Sinus symptom scores: what
J Allergy Clin Immunol 115:125–131 is the range in healthy individuals. Clin Otolaryngol
53. Report of the Rhinosinusitis Task Force Committee Meet- 25:482–484
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yngol Head Neck Surg 117:S1–S68 form health survey (SF-36) I. Conceptual framework and
item selection. Med Care 30:473–483
Chapter 25
Headache and the Patient

who Failed Primary Sinus Surgery 25
William H. Moretz III and Stilianos E. Kountakis
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
■ Headache is a common symptom in patients diag- Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
nosed with chronic rhinosinusitis. Primary Headache Disorders . . . . . . . . . . . . . . . . . . . 218
■ The diagnosis of primary and secondary headache
Migraine Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . 218
disorders is important to avoid unnecessary revision
surgery. Tension-Type Headaches . . . . . . . . . . . . . . . . . . . . . . . 218
■ Headache symptoms attributable to persistent or re- Cluster Headaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
current rhinologic disease may be addressed surgi- Other Primary Headaches . . . . . . . . . . . . . . . . . . . . . 219
cally if medical therapy has failed.
Secondary Headache Disorders . . . . . . . . . . . . . . . . . 219
■ Headache symptoms secondary to rhinologic dis-
Rhinologic Headache . . . . . . . . . . . . . . . . . . . . . . . . . 220
ease have shown significant improvement following
endoscopic sinus surgery. Revision Endoscopic Sinus Surgery . . . . . . . . . . . . . . . . 220
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

The Rhinosinusitis Initiative, consisting of five national

Introduction
societies, created a guideline for evidence-based re-
Headache is a common symptom in patients diagnosed search of rhinosinusitis in 2004 [11]. This guideline
with chronic rhinosinusitis (CRS), being present in up to included headache as a relevant symptom of CRS and
83% of patients [1]. The severity of headaches has been re- recommended its severity documentation for treatment
ported to be one of the highest among the most common assessment. Accordingly, the Rhinosinusitis Initiative
symptoms associated with CRS [2]. Persistent headache has recommended including headache as one of the 11
symptoms after primary functional endoscopic sinus sur- symptoms scored for efficacy assessment in clinical trials
gery (FESS) for CRS may create an unhappy patient and studying CRS [11,12].
a frustrated physician. An appropriate understanding of The treatment of headache associated with CRS is
the differential diagnoses of headache is important for challenging, as its underlying cause is unknown and its
treating patients presenting to a rhinology practice. severity associated with multiple factors. Concomitant
In 1997, the American Academy of Otolaryngology – headache, inappropriately associated with CRS, will not
Head and Neck Surgery Rhinosinusitis Task Force pub- improve following FESS. As such, a rhinologist should
lished recommendations for symptom-based criteria for rely on a comprehensive history and physical examina-
the accurate diagnosis of CRS [8, 20]. Headache is con- tion, along with objective endoscopic and radiologic
sidered a minor diagnostic symptom using these criteria. findings, to ensure appropriate headache management.
■ The Rhinosinusitis Task Force suggests that headache

alone should not constitute a suggestive history for
rhinosinusitis without major nasal symptoms or signs.
218 William H. Moretz III and Stilianos E. Kountakis
A recent analysis by Perry et al. [17] was performed on

Differential Diagnosis
patients with headaches presenting to a tertiary rhinol-
Understanding nonrhinologic headache is important, ogy practice without evidence of rhinosinusitis on CT or
as patients may be referred to otolaryngologists for pre- endoscopic evaluation.
sumed rhinosinusitis without subjective or objective find-
ings to support the diagnosis. ■ The majority of patients with headache as a chief com-
plaint were diagnosed with migraine upon further
■ Primary headache disorders include: evaluation by a neurologist [17].
1. Migraine.
2. Tension-type headache. Other studies have shown similar findings in patients
3. Cluster headaches. seeking treatment for “sinus headaches.” Schreiber et
4. Other less common entities, including primary al. reported that 80% of 2991 patients with “sinus head-
thunderclap headache and hemicrania continua. aches” presenting to primary care physicians fulfilled IHS
migraine criteria [21].
Secondary headache disorders are associated with under-
lying central nervous system pathology [6,15].
Tension-Type Headaches
■ Tension-type headaches are the most common type of
Primary Headache Disorders
primary headache, affecting up to 78% of the general
population [6].
Migraine Headaches
Migraine headaches are common and underdiagnosed The etiology of tension-type headaches is unknown. Sub-
[9]. Approximately 28 million Americans are affected, types of tension-type headache have been described, di-
with the 1-year prevalence of 18% in women and 6% in viding the headaches into episodic or chronic, and with
men [9, 24]. Migraine is an episodic neurovascular head- or without pericranial tenderness on manual palpation.
ache disorder involving moderate to severe attacks lasting Pericranial tenderness is a distinguishing characteristic of
4–72 h, with a pulsating quality [6]. tension-type headaches, but does not necessarily need to
be present for its diagnosis.
■ Migraine headaches are: Diagnostic criteria for episodic tension-type head-
1. Usually associated with nausea. aches have been outlined by the IHS. Episodic tension-
2. Associated with sensitivity to light, sound, or move- type headaches last from 30 min to 7 days, are usually
ment. bilateral, and have a pressing/tightening quality. These
3. Often unilateral. headaches occur for at least 3 months, averaging less
4. With pain described over the frontal and temporal than 15 days out of the month, and are not aggravated
regions. by routine physical activity. Chronic tension-type head-
5. Pain can also be described in the parietal, occipital, aches typically last hours or may be continuous, occur for
and high cervical regions [5]. at least 3 months, averaging 15 or more days per month,
and have the same characteristics of episodic tension-
The pathogenesis of pain in migraine is not completely type headaches [6].
understood; however, it is thought to be a neurovascu-
lar disorder resulting in nerve activation from vascular ■ Perry et al. [17] found that 6% of patients with non-
dilation. The diagnostic criteria defined by the Interna- rhinologic headache presenting to their rhinology
tional Headache Society (IHS) in 2004 are presented in practice with a chief complaint of headache were di-
Table 25.1 [6]. agnosed with tension-type headache upon subsequent
Migraine headaches are divided into two major sub- evaluation by a neurologist.
types, migraine with and without aura. Aura is defined
as a reversible focal neurological symptom that usually
develops gradually over 5–20 min and lasts for less than
25 60 min [6]. The aura occurs at the onset or just prior to a
Cluster Headaches
migraine headache. Auras may include visual symptoms, The IHS describes the cluster headache as a severe, unilat-
including flickering lights, sensory symptoms, which may eral pain located at the orbital, supraorbital, or temporal
involve numbness or sensation of pins and needles, or areas, lasting 15–180 min and occurring from once every
dysphasic speech disturbance. other day to eight times a day. Cluster headaches typically
Headache and the Patient who Failed Primary Sinus Surgery 219
Table 25.1 Revised International Headache Society criteria for chronic migraine
Grade Criteria
A Headache (tension-type and/or migraine) on ≥15 days/month for at least 3 months
B Occurring in a patient who has had at least five attacks, fulfilling criteria for 1.1 migraine without aura
C On ≥8 days/month for at least 3 months headache has fulfilled C1 and/or C2 below, that is,
has fulfilled the criteria for pain and associated symptoms of migraine without aura:
1. Has at least two of a–d:
a. Unilateral location;
b. Pulsating quality;
c. Moderate or severe pain intensity;
d. Aggravation by or causing avoidance of routine physical activ-
ity (e.g. walking or climbing stairs) and at least one of i or ii:
i. nausea and/or vomiting
ii. photophobia and phonophobia
2. Treated and relieved by triptan(s) or ergot before the expected development of C1 above.
D No medication overuse and not attributed to another causative disorder
occur together, lasting for weeks or months, and are sepa- Thunderclap headache is a high-intensity headache
rated by remission periods lasting months or years. of acute onset, reaching maximum intensity in less than
1 min and lasting from 1 h to 10 days. Thunderclap head-
■ Cluster headache attacks are associated with: ache is a diagnosis of exclusion after appropriate work-up
1. Ipsilateral nasal congestion. is performed to rule out intracranial disorders, such as
2. Rhinorrhea. subarachnoid hemorrhage, arterial dissection, and pitu-
3. Facial sweating. itary apoplexy.
4. Conjunctival injection. Primary stabbing headache, cough headache, exer-
5. Lacrimation. tional headache, headache associated with sexual activity,
6. Miosis. and hypnic headache have also been described in the IHS
7. Eyelid ptosis. classification system of primary headache disorders.
8. Eyelid edema.
A sense of restlessness and agitation has been reported by

Secondary Headache Disorders
patients during cluster headaches, and episodes of clus-
ter headaches may be provoked by alcohol, histamine, or Headaches caused by underlying central nervous system
nitroglycerine. Cluster headaches show autosomal domi- pathology are considered secondary.
nant inheritance in 5% of cases and are most common in
adults aged 20–40 years, with prevalence rates 3–4 times ■ Eight categories of secondary headaches are classified
higher in men than women [6]. in the IHS system and include those attributed to [6]:
1. Head and neck trauma.
2. Cranial or cervical vascular disorder.
3. Nonvascular intracranial disorder.
Other Primary Headaches
4. Substance abuse or its withdrawal.
Hemicrania continua describes headaches that are strictly 5. Infection.
unilateral and last for over 3 months. These headaches 6. Disorder of homeostasis.
occur daily and are unremitting without treatment. Ip- 7. Disorder of a facial or cranial structure.
silateral conjunctival injection, lacrimation, nasal con- 8. Psychiatric disorder.
gestion, rhinorrhea, ptosis, or miosis are associated with
hemicrania continua. Complete response is achieved with Headaches attributed to rhinosinusitis are considered
indomethacin. secondary headaches by IHS classification, defined as
pain in one or more regions of the face, developing si- 4. Large ethmoid bulla.
multaneously with the onset or acute exacerbation of 5. Prominent agger nasi cells.
rhinosinusitis, and resolving within 7 days of successful
treatment [6]. Nasal endoscopy and computerized tomography (CT)
evaluation accurately identify anatomic abnormalities in
■ Life-threatening pathology presenting with headache the nasal cavities (Figs. 25.1 and 25.2). Success rates for
should always be considered and include intracranial endoscopic sinus surgery have been reported as high as
hemorrhage, cerebral infarction, meningitis, and in- 83% for patients with anatomic abnormalities and a pri-
tracranial neoplasm. mary symptom of headache [3]. In a separate study of
prospectively collected data on 201 patients with CRS, a
Approximately 50% of patients with brain tumors report 91.9% improvement in headache severity was shown after
headache as their primary complaint. A tumor could be primary FESS [13]. This improvement in headache sever-
suspected if the headache is associated with confusion, ity is consistent with other studies of CRS patients under-
seizures, or neurologic deficit. Other findings that raise going FESS [16, 22].
the possibility of an intracranial mass lesion include a Theories suggest that mucosal contact between these
progressive nature of headache, new onset in adult life areas result in the release of substance P. Substance P is
(>40 years), a change in headache pattern, or a worsening a neuropeptide found in high concentrations within the
of headache with changes in posture or Valsalva maneu- sensory nerve endings of the nasal mucosa and has been
ver [18]. Fortunately, headache alone is a rare presenta- proposed to play a prominent role in pain transmission
tion of an intracranial neoplasm. [4, 23]. The orthodromic impulse from intranasal stimuli
does not localize well to higher cortical centers, resulting
in referred pain to sites in the distribution of the oph-
thalmic and maxillary divisions of the trigeminal nerve.
Rhinologic Headache
An antidromic impulse results in the release of substance
Although headache does not generally suggest rhinosi- P at the nasal mucosa, causing mast cell degranulation,
nusitis in the absence of other symptoms, it may present neurogenic edema, and hypersecretion, resulting in other
as the sole symptom with signs of rhinosinusitis. common symptoms associated with CRS [4, 23].
■ Anatomic abnormalities associated with rhinologic

headache include:
Revision Endoscopic Sinus Surgery
1. Nasal septal deviation.
2. Concha bullosa. Revision endoscopic sinus surgery (RESS) is thought
3. Paradoxical middle turbinate. to have a lower success rate than primary FESS because
25
Fig. 25.1 Coronal sinus computed tomography scan showing Fig. 25.2 Endoscopic picture of a septal spur “stabbing” the left
significant septal deviation with a septal spur pushing against inferior turbinate
the right lateral nasal wall
Headache and the Patient who Failed Primary Sinus Surgery 221
of the associated recurrent rhinologic disease states in- 2. Bhattacharyya N (2006) Clinical and symptom criteria for
cluding nasal polyposis and allergic fungal rhinossinus- the accurate diagnosis of chronic rhinosinusitis. Laryngo-
itis, as well as challenges inherent to distorted anatomic scope 116:1–22
landmarks. Success rates for RESS have been reported 3. Chow JM (1994) Rhinologic headaches. Otolaryngol Head
at between 50 and 93.6% [7, 10, 14], with several studies Neck Surg 111:211–218
showing significant improvement in symptom scores fol- 4. Clerico DM (1995) Sinus headaches reconsidered: referred
lowing RESS. cephalgia of rhinologic origin masquerading as refractory
The initial evaluation of a patient with persistent primary headaches. Headache 35:185–192
symptoms following primary FESS should include a de- 5. Goadsby PJ, Lipton RB, Ferrari MD (2002) Migraine – current
tailed history of symptoms, including those prior to the understanding and treatment. N Engl J Med 346:257–270
primary surgery. If possible, the initial CT should be 6. Headache Classification Committee, et al. (2006) New ap-
evaluated as well as the documented endoscopy findings pendix criteria open for a broader concept of chronic mi-
to identify evidence of disease. Persistent headache symp- graine. Cephalalgia 26:742–746
toms with relatively normal CT and endoscopy prior to 7. Jiang RS, Hsu CY (2002) Revision functional endoscopic
initial FESS should raise suspicion that headache symp- sinus surgery. Ann Otol Rhinol Laryngol 111:155–159
toms may not be associated with CRS. Proceeding with 8. Lanza DC, Kennedy DW (1997) Adult rhinosinusitis de-
RESS to treat persistent headaches in this scenario is not fined. Otolaryngol Head Neck Surg 117:S1–S7
recommended. 9. Lipton RB, Diamond S, Reed M, Diamond ML, Stewart WF
Patients referred to a rhinologist with “sinus head- (2001) Migraine diagnosis and treatment: results from the
aches” following primary FESS should be carefully evalu- American Migraine Study II. Headache 41:638–645
ated for concurrent headache disorders. Pynnonen and 10. McMains KC, Kountakis SE (2005) Revision endoscopic
Terrell [19] evaluated 186 consecutive patients present- sinus surgery: objective and subjective surgical outcomes.
ing to a tertiary care rhinology clinic for the evaluation Am J Rhinol 19:344–347
of CRS-like symptoms; 40% of these patients had no 11. Meltzer EO, Hamilos DL, Hadley JA, et al. (2004) Rhino-
evidence of CRS. In this group, 19% were subsequently sinusitis: establishing definitions for clinical research and
diagnosed with head or facial pain, including tension patient care. Otolaryngol Head Neck Surg 131:S1–S62
headache, migraine headache, and temporomandibular 12. Meltzer EO, Hamilos DL, Hadley JA, et al. (2006) Rhinosi-
dysfunction [19]. Careful evaluation of headache symp- nusitis: developing guidance for clinical trials. Otolaryngol
toms can prevent unnecessary revision surgery. Head Neck Surg 135:S31–S80
13. Moretz WM, Kountakis SE (2006) Subjective headaches
before and after endoscopic sinus surgery. Am J Rhinol
20:305–307
Summary
14. Moses RL, Cornetta A, Atkins JP Jr, et al. (1998) Revision
The evaluation of patients with headache symptoms fol- endoscopic sinus surgery: the Thomas Jefferson University
lowing FESS should include a detailed history of head- experience. Ear Nose Throat J 77:190–202
ache-specific symptoms as well as an analysis of objec- 15. Olesen J (2005) The International Classification of Head-
tive findings prior to surgery. The diagnosis of primary ache Disorders, 2nd edition: application to practice. Funct
and secondary headache disorders in these patients is Neurol 20:61–68
important to avoid unnecessary surgery. Several effective 16. Parsons DS, Batra PS (1998) Functional endoscopic sinus
medical treatment regimens exist for headache disorders. surgical outcomes for contact point headaches. Laryngo-
Accordingly, evaluation and treatment by a headache spe- scope 108:696–702
cialist is appropriate for these complicated, and often un- 17. Perry BF, Login IS, Kountakis SE (2004) Nonrhinologic
happy, patients. Headache symptoms attributable to per- headache in a tertiary rhinology practice. Otolaryngol
sistent or recurrent rhinologic disease may be addressed Head Neck Surg 130:449–452
surgically if medical therapy has failed. Headache symp- 18. Purdy RA (2001) Clinical evaluation of a patient presenting
toms secondary to rhinologic disease have shown signifi- with headache. Med Clin North Am 85:847–863
cant improvement following endoscopic sinus surgery. 19. Pynnonen MA, Terrell JE (2006) Conditions that masquer-
ade as chronic rhinosinusitis. Arch Otolaryngol Head Neck
Surg 132:748–751
20. Rhinosinusitis Task Force Committee (1997) Report of
References
the Rhinosinusitis Task Force Committee Meeting. Alex-
1. Bhattacharyya N (2003) The economic burden and symp- andria, Virginia, August 17, 1996. Otolaryngol Head Neck
tom manifestations of chronic rhinosinusitis: symptoms Surg 117:S1–S68
and surgical outcomes. Laryngoscope 144:1932–1935
21. Schreiber CP, Hutchinson S, Webster CJ, et al. (2004) Preva- 23. Stammberger H, Wolf G (1988) Headaches and sinus dis-
lence of migraine in patients with a history of self-reported ease: the endoscopic approach. Ann Otol Rhinol Laryngol
or physician-diagnosed “sinus” headache. Arch Intern Med 97:3–23
164:1769–1772 24. Stewart WF, Lipton RB, Celentano DD, Reed ML (1992)
22. Senior BA, Kennedy DW, Tanabodee J, et al. (1998) Long- Prevalence of migraine headache in the United States: rela-
term results of functional endoscopic sinus surgery. Laryn- tion to age, income, race, and other sociodemographic fac-
goscope 108:151–157 tors. JAMA 267:64–69
25
Chapter 26
Complications in Revision
Sinus Surgery: Presentation 26
and Management
John Scianna and James Stankiewicz
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
■ Revision surgery holds the same potential hazards Orbital Musculature Injury . . . . . . . . . . . . . . . . . . . . . . . 225
and complications as primary sinus surgery. Orbital Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
■ Revision surgery offers additional difficulties in that
Optic Nerve Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
landmarks may be obscured and natural barriers
dehiscent. Carotid Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
■ Orbital musculature injury, acute orbital hemor- CSF Leak/Skull-Base Penetration . . . . . . . . . . . . . . . . . 230
rhage, delayed orbital hemorrhage, blindness, carot- Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
id injury, and cerebrospinal fluid leak are potential
complications.
■ Prevention remains the best treatment; however,
early recognition of a complication, appropriate in-
tra- and postoperative management, and consulta- Avoiding these potential adverse outcomes requires
tion with colleagues can minimize the adverse out- knowledge of the significant and intricate anatomy of the
comes associated with a complication. paranasal sinuses. This intricate anatomy generally pro-
vides the surgeon with essential landmarks; in revision
sinus surgery, however, this is not the case [31]. The loss
of the virginity of the nasal anatomy associated with pri-
mary sinus surgery can significantly complicate revision
sinus surgery [9]. In understanding that the expected may
Introduction
be absent, and more importantly that the unexpected may
“The time to worry is before you place your bet, not after be present, the revision sinus surgeon can navigate safely
they spin the wheel.” within the nose [17].
Lou Holtz [7] Despite the greatest of understanding, consideration,
and expertise, complications will still occur [30].
■ As Coach Holtz so correctly stated, concerns regard-
ing complications should be considered and under- ■ An outline to limiting the adversity of a complication:
stood well before they ever happen. 1. Prompt recognition.
2. Acute management.
Sinus surgery is fraught with potential significant com- 3. Appropriate follow up and consultation.
plications including orbital injury, acute/delayed orbital
hemorrhage, optic nerve injury, cerebral spinal fluid With this outline to the management of complications,
(CSF) leak, carotid injury, and skull-base penetration the sinus surgeon is better prepared to successfully per-
[16]. Many of these complications can have catastrophic form revision sinus surgery.
adverse effects including blindness, double vision, stroke,
coma, and even death [14].
224 John Scianna and James Stankiewicz
Fig. 26.1 a Normal anatomy of the eye. b Dehiscence of the

lamina papyracea. c Microdebrider injuring the medial rectus
26
Complications in Revision Sinus Surgery: Presentation and Management 225
Orbital Musculature Injury

■ To limit the risk of orbital complications:
1. Evaluate the integrity of the lamina papyracea.
2. Frequently palpate the orbit and keep it visible in
the surgical field.
3. Keep powered instrumentation pointed away from
the lamina.
The anatomic division between the orbital contents and

the paranasal sinuses inherently puts the orbit, and more
specifically the orbital musculature, at risk of injury [11].
The lamina papyracea, so named for its “paper thin” char-
acter, is the only bony barrier between the medial orbital
musculature and the nose. While the periorbita, a fibrous
sheath, encases the orbital fat and musculature, it provides
little protection in the face of powered instrumentation.
In cases of revision sinus surgery, in particular, preexist-
ing dehiscence of the lamina papyracea and/or preexisting
damage to the periorbita places the patient at potentially
increased risk to have inadvertent damage to the orbital
contents, specifically the medial rectus (Fig. 26.1) [21].
Damage to the medial rectus and orbital contents
when performing endoscopic sinus surgery can gener- Fig. 26.2 Orbital press test (Stankiewicz maneuver)
ally occur in one of two ways. First of all, when attempt-
ing to remove any residual uncinate process, the lamina
papyracea and the periorbita can be violated. In revision
cases, the unresected uncinate process can be adherent or from the medial orbital wall. Finally, when performing an
scarred to the lateral nasal wall/lamina papyracea. When uncinectomy with a back-biting forceps, maintaining the
attempting to remove this process with a back-biting for- forceps at an acute angle (Fig. 26.3) will avoid spearing of
ceps, it is feasible to inadvertently puncture the lamina the fully opened instrument through the lamina and into
papyracea and tear the periorbita. If orbital dehiscence is the periorbita. If using a sickle knife or elevator to incise
unrecognized at the time of occurrence, the introduction the uncinate process, especially in a revision case, close
of powered debriders can result in suction of orbital fat observation for orbital fat prolapse is necessary.
and muscle through this dehiscence/puncture and result If the lamina papyracea or the periorbita is injured, im-
in injury to the medial rectus. This exact scenario is what mediate recognition will aid in preventing a more signifi-
can also happen when unrecognized dehiscence in any cant injury to the medial rectus. Again, the orbital press
area of the lamina papyracea is preexisting in revision test can aid in demonstrating a dehiscence [29]. Avoid-
cases [23]. ance of the use of a microdebrider around this area may
Prevention of such an injury is accomplished primar- help in preventing the suction of orbital contents into the
ily with careful preoperative review of the available im- debrider blade and the resultant damage. Without ques-
aging and intraoperative inspection and palpation [27]. tion, in cases of dehiscence the debrider window should
Preoperative examination of the coronal and axial images be turned upward or away from the orbit [5]. Proper prep-
of the sinuses, specifically with a bone window available, ping and draping of a patient, with exposure of the eyes,
can alert the surgeon to a possible lateralized uncinate or and with the eyelids taped along the lateral canthus allows
a dehiscence. Intraoperative examination and palpation for the scrub assistant to notice any unusual bruising or,
of the orbit while examining the lateral nasal wall (the of greater concern, movement of the eye during surgery.
so-called Stankiewicz maneuver or orbital press test) can The use of a properly registered computer image guid-
further demonstrate a potential hazard (Fig. 26.2) [29]. ance probe may also be useful in identifying an area of
In addition, the endoscopic sinus surgeon should be well dehiscence or damage [24]. If, however, the medial rectus
versed in the yellow appearance of orbital fat and how is inadvertently damaged or severed, consultation with
this differs from typical sinonasal pathology and tissue. an ophthalmologist, or more specifically, an oculoplastic
Prior to performing an uncinectomy, a Lusk probe or surgeon, is appropriate. Immediate repair or delayed re-
other blunt, beaded probe can be use to palpate the edge pair of the injury by suturing the cut ends of the muscle
of the uncinate process and can peal the uncinate away have been described with mixed results [8].
Fig. 26.3 a Microdebrider at the correct acute angle. b Endoscopic view of the correct angle. c Microdebrider at an incorrect 90
angle. d Endoscopic view of the incorrect angle
When such an injury occurs, it is important that the 1. Understand that arterial and venous orbital bleed-
appropriate colleagues are consulted for postoperative ing differ significantly in presentation and treat-
observation and follow up. Proper and complete document.
mentation is important. Involvement of tertiary care cen- 2. Always be prepared to perform a lateral canthot-
ters and “experts” in the field may prove beneficial to pa- omy.
tient outcome. Observation of the patient overnight in a
setting where vision and the eye can be routinely assessed Two separate categories of orbital hematoma exist: im-
should also be considered, as any damage to the orbital mediate and delayed. As described above, the proximity
contents can result in an orbital hematoma. of the orbital anatomy and the sparse separation of the
orbital contents from the paranasal sinuses puts the orbit
at risk. Penetration and damage to the existing barrier to
the orbit has been described. An acute or delayed hem-
26 Orbital Hematoma
orrhage and resultant orbital hematoma can ultimately
■ For the management of orbital hematoma: result in blindness [29].
A delayed or slow-forming orbital hematoma can oc- deep to the periorbita. Here, unopposed arterial bleeding
cur when there has been damage to the periorbita and will result in the rapid formation of an orbital hematoma,
orbital fat. The orbital fat has a significant venous blood acutely and greatly increasing intraocular pressures. Left
supply, and a slow bleeder within the orbital cone may unattended, the retinal arterial supply and venous drain-
result in the slow formation of a hematoma. While gen- age will be compromised, ultimately resulting in blind-
erally less catastrophic than an unrecognized/untreated ness in a relatively short period of time (< 90 min) [4].
acute orbital hematoma, a significant rise in ocular pres- Preventing such a complication starts with reviewing
sure can occur with as little as 5 ml of blood in the orbit the coronal sinus imaging preoperatively. Generally, the
and may ultimately result in compromise of the retinal anterior ethmoid artery peak or “nipple” can be identified
blood supply and blindness [35]. on coronal computed tomography imaging (Fig. 26.4)
As will be repeated many times, early recognition of [18]. Recognizing this area and determining if a possi-
damage to the lamina papyracea and periorbita will alert ble dehiscence of the anterior ethmoid artery exists, can
the surgeon to a potential complication. Early periocular signal the sinus surgeon to use considerable care when
bruising can also alert the surgeon to a possibility of a performing an anterior ethmoidectomy. In addition to
slowly forming hematoma. In the face of either of these recognizing this preexisting anatomic potential, proper
circumstances, nasal packing should be used sparingly, prepping and draping of the patient should allow for vi-
as heavy packing can block an intranasal evacuation path sualization and palpation of the orbit during surgery. It is
that the bleeding can follow. Palpation of the orbit may a good habit to routinely palpate the orbit of the patient
demonstrate increased ocular pressure. If high ocular at the start of the case, occasionally throughout the case,
pressure is a concern, then an ophthalmology consult is and at the termination of the procedure prior to extuba-
appropriate. Gentle external palpation of the orbit may tion. This allows for routine assessment of a potential or-
also result in evacuation of the formed hematoma into bital hematoma.
the nasal cavity. If hematoma formation is noted intraop- In the face of a high-pressure orbital hematoma, im-
eratively, one can consider a medial orbital decompres- mediate reaction is required [19]. As mentioned, high
sion via endoscopic or external approaches. In this pro- intraocular pressures can quickly be reached resulting
cedure the remainder of the lamina papyracea is removed in retinal ischemia. Two immediate options exist: lateral
endoscopically and the periorbita is incised using a sickle
knife. This procedure allows for an adequate drainage
path of blood into the nasal cavity and can prevent in-
creasing intraocular pressure. It is generally not advisable
to cauterize within the orbital contents as this can result
in heat damage to the musculature and unwanted scar-
ring [20].
Acute orbital hematoma, as opposed to a delayed he-
matoma, has a separate mechanism of action. Acute or-
bital hematoma is the result of an arterial bleed within an
intact orbital cone. The anterior ethmoid artery is most
often to blame in the cases of such an occurrence. The an-
terior ethmoid artery is an end artery of the internal ca-
rotid system as opposed to the majority of the nasal blood
supply, which is derived from the external carotid system.
The anterior and posterior ethmoid arteries represent
branches of the ophthalmic artery, a direct branch of the
internal carotid artery (ICA). As the ophthalmic artery
courses medial to the medial rectus muscle, branches ex-
tending through the periorbita enter into the superior-
most aspect of the ethmoidal sinuses.
It is this lateral-to-medial course of the anterior eth-
moid artery that potentiates its role as the cause of an
acute orbital hematoma. Occasionally dehiscent as it
passes through the ethmoids and to its ultimate branch-
ing to the dura, intranasal damage can result in retraction Fig. 26.4 Anterior ethmoid artery peaks on a coronal computed
of the severed artery into the boney orbital cone and/or tomography (CT) image of the sinus (black arrows)
canthotomy and medial orbital decompression. The tech- greatest risk for direct damage during endoscopic sinus
nique of medial orbital decompression has been described surgery [1].
previously and can allow for adequate drainage and de- The optic nerve is at risk of being damaged at three
compression of the orbit [20]. While a medial decompres- points during complete functional endoscopic sinus sur-
sion can be challenging for some, it does offer an excel- gery: the maxillary antrostomy, the sphenoidotomy, and
lent, nonexternal alternative to a lateral canthotomy. All the total ethmoidectomy. While a rarity, the orbit can be
sinus surgeons should be capable of performing a lateral entered through the maxillary sinus, resulting in direct
canthotomy. This simple, external procedure decreases injury to the optic nerve. More commonly, the sphenoid-
intraocular pressures and can significantly decompress otomy or ethmoidectomy places the optic nerve at great-
the orbit. A lateral canthotomy requires two instruments, est risk.
a hemostat, and curved Metzenbaum or Mayo scissors. When identifying the natural os of the sphenoid sinus
Initially the hemostat is place in the lateral canthus and it should be found at 7 cm from the nasal sill, at the level
extended until the boney orbital rim is felt. The hemo- of the maxillary sinus and immediately medial to the
stat is then used to crush the blood supply to the lateral middle turbinate [12]. It is not uncommon to be deeper
canthus. After this is accomplished, the scissors are used in the ethmoid or sphenoid sinus than anticipated. The
to make a cut from the lateral canthus to the boney rim, use of a measuring device or computer image guidance
directed laterally. The scissors are then angled inferiorly is especially helpful in revision cases. In revision cases,
and used to cut the lateral attachment of the periorbita scarring, absence of the middle turbinate, or an unnatural
[19]. If this fails to relieve high pressures within the eye, accessory os may be noted. When opening the sphenoid
then medial orbital decompression should be pursued. sinus, opening in a superior and lateral direction with any
Clearly, if either or both of the aforementioned proce- instrument may result in inadvertent damage to the optic
dures are necessary, consultation with the ophthalmolo- nerve. In addition, with the optic nerve being dehiscent
gist is a necessity. Postoperative evaluation and monitor- within the sphenoid sinus approximately 4–6% of the
ing in a unit where vision and the eye can be assessed time, using power instrumentation (or any instrumenta-
should be routine. Repeat ocular and visual examinations tion) blindly within the sphenoid sinus may result in sev-
by the ophthalmologist should be done. Cosmetic repair, ering or directly damaging the optic nerve [34].
if necessary, of the lateral canthotomy site can be sought Direct damage to the optic nerve can also occur dur-
well after the safety and security of the patient’s vision is ing a posterior ethmoidectomy. As mentioned earlier, the
obtained. Again, frank discussions with the patient and optic nerve courses intracranially directly superior to the
proper documentation are essential in such cases. lateral and superior extent of the ethmoid air cells. Overag-
gressive cleaning of the skull base in these areas can result
in skull-base damage and compromise the integrity of the
optic nerve. In addition, a variant of the posterior-most
Optic Nerve Injury
ethmoid cell, known as the Onodi cell, can extend superior
■ To minimize optic nerve injury in revision sinus sur- to the actual sphenoid sinus. The Onodi cell, recognized
gery: by the horizontal bar seen within the sphenoid sinus on
1. Be aware that optic nerve dehiscence can occur up a coronal or sagittal image, may be mistaken as the sphe-
to 4% of the time. noid sinus and thus lead to unwarranted proximity to the
2. Enter the sphenoid sinus medially and inferiorly. posterior, superior, lateral skull base and the optic nerve
3. Recognize the presence of Onodi cells. (Fig. 26.5) [32]. Again, with the suction associated with
powered instrumentation and damage that can be done
The second cranial nerve, the optic nerve, comprises a se- with biting or grasping instruments, unplanned contact
ries of fibers extending from the orbit, through the optic with the optic nerve can result in catastrophic damage.
foramen to the optic chiasm where the fibers continue to Careful review of the axial and coronal computed to-
form the optic tracts leading to the primary visual cen- mography images prior to surgical intervention can alert
ters of the brain. Approximately 20–30 mm of optic nerve the surgeon to the presence of the Onodi cell and/or the
length is present from the orbit to the optic foramen. An possibility of a dehiscent optic nerve within the sphenoid
additional 10 mm carry the optic nerve from the foramen sinus. Identification of the os of the maxillary sinus will
to the optic chiasm. It is this 10 mm of optic nerve, which provide the level of the natural os of the sphenoid sinus
extend intracranially along the skull base in the posterior and prevent the sinus surgeon from carrying a posterior
ethmoid cells, running from superior lateral to superior ethmoid dissection high into the posterior skull base. The
26 medial to reach the optic chiasm, located above the tuber- os of the maxillary sinus also allows for identification of
culum sellae and on the anterior portion of diaphragma the lamina papyracea, which represents the lateral extent
sellae in the superior aspect of the sphenoid, that is at of the dissection. Use of computer image guidance, prop-
cially posterior and lateral) without proper visual-

ization.
The potentially catastrophic complication of ICA injury

can result in life-threatening hemorrhage, hemispheric
stroke, coma, or death [33]. The anatomic relationship of
the cavernous portion of the ICA in the sphenoid sinus
results in a potential risk of injury during endoscopic si-
nus surgery. Ascending toward the posterior clinoid pro-
cess and passing forward by the side of the body of the
sphenoid bone, the ICA curves upward and perforates
the dura mater, forming the roof of the sphenoid sinus. It
is in this lateral and posterior aspect of the sphenoid sinus
that iatrogenic injury can occur.
As one enters the sphenoid sinus, the ICA can be de-
hiscent approximately 20–25% of the time along some
portion of its course [34]. Entering in the lateral, poste-
rior aspect of the sphenoid sinus with a blunt instrument
can pierce the uncovered ICA. In addition, blindly plac-
Fig. 26.5 Coronal CT with Onodi cell (white arrow); note ing a powered debrider or other grasping/biting instru-
the proximity of the optic nerve to roof of the Onodi cell ment into the posterior and lateral aspect of the sphenoid
sinus may result in carotid artery damage.
Visualization, preparation, and finesse will aid the sur-
erly calibrated, can provide additional reinforcement of geon in preventing this potentially lethal complication.
the location of the skull base and the depth of dissection. Identifying a preexisting dehiscence when examining the
Routinely entering the sphenoid sinus in its inferior- and axial computed tomography images will alert the surgeon
medial-most aspect continues to be the safest means by to a potential hazard. Proper visualization and location
which to enter the sphenoid sinus, providing the great- of the natural os of the sphenoid sinus as it has been de-
est distant between any instrumentation and the superior, scribed will also aid in prevention. As mentioned earlier,
lateral course of the optic nerve. the safest method by which to widen the sphenoid sinus
Unfortunately, damage to the optic nerve is unlikely is identification of the natural os and opening the sinus
to be forgiving. Severing or disrupting the fibers of the in its medial- and inferior-most aspect. Avoiding place-
optic nerve will more than likely result in permanent vi- ment of any powered instrumentation or grasping/biting
sual compromise. Heat damage or swelling related to ma- instrument in the posterior and lateral aspect of the sphe-
nipulation of an area around the optic nerve sheath can noid sinus is highly recommended. Routine placement
be treated with high-dose oral steroids and/or an optic of an oropharyngeal throat pack in any patient having
nerve decompression (however, this is usually unsuccess- sphenoid or sinus surgery offers the benefit of potential
ful). An optic nerve decompression relies upon endo- complete oronasopharyngeal tamponade in the case of
scopic release of the optic sheath along its entire course to carotid injury and uncontrolled bleeding.
the annulus of Zinn [15]. In either case, consultation with Identification of a compromise to the integrity of the
ophthalmology and documentation of the patient’s vision ICA is generally not difficult. Occasionally, however,
immediately post-injury and after any intervention is es- subendothelial damage to the ICA may result in a de-
sential. Postoperative monitoring in a unit where routine layed aneurysm, pseudoaneurysm, or delayed rupture of
monitoring of vision can be accomplished is essential. the carotid artery [26]. For small, pinhole-type injuries
where visualization can be accomplished, placement of
small piece of Gelfoam or an epinephrine-soaked pledget
over the area can allow for clot formation. Gentle packing
Carotid Injury
around this area and use of fibrin sealants can also help
■ To avoid injury to the carotid artery in revision sinus control a small manageable defect. Notably, vasospasm of
surgery: the ICA can still occur with this manipulation, resulting
1. Recognize that carotid dehiscence occurs up to in hemispheric stroke [22].
25% of the time. More significant bleeding, however, will quickly ob-
2. Avoid powered instrumentation or biting/grasping scure endoscopic visualization. In such a case, immediate
instrumentation within the sphenoid sinus (espe- packing of the nasal cavity will be required. Placement of
a Foley catheter or other into the posterior nasal pharynx noid sinus or Onodi-type cell medially in too high a man-
and inflating the balloon, in combination with provid- ner can also result in skull-base penetration. With regard
ing counterpressure to the balloon anteriorly allows for to revision surgery, the high-speed cutting drills used in
tight packing within the nasopharynx, tamponading the revision frontal sinus surgery can easily be misplaced or
hemorrhage. With an oropharyngeal throat pack in place, skip into areas adjacent to the frontal sinus recess, result-
any significant nasopharyngeal packing can provide the ing in skull-base injury [28].
required pressure to slow or halt a carotid bleed. Immedi- Prevention begins with careful review and identifica-
ate transfer to an institution/location where endovascular tion of the skull base on preoperative imaging. Evaluation
procedures are performed is a necessity. A neurovascu- for preexisting dehiscence and determination of the level
lar interventional radiologist may be able to control such of the skull base is mandatory. Three-dimensional imag-
damage with endovascular coiling or other hemostatic ing can aid in this endeavor. However, basic coronal imag-
measures. Such procedures can result in hemispheric ing is generally used for determining the skull-base level.
stroke or blindness; however, this risk is overshadowed Multiple classifications have been used to describe the
by the alternative – a fatal hemorrhage [22]. height of the skull base. While the measurements of the
After control of the hemorrhage is achieved, neurolog- Keros classification can be extremely useful, a practical
ical assessment must be accomplished and documented. means of evaluating the skull base can be accomplished
Involvement of the neurologist is a necessity. Discussions by comparing the level of the cribriform to the orbit [3].
with the patient’s family as to the seriousness of this po- A high skull base is at the superior aspect of the orbit,
tentially lethal complication should be undertaken. Ob- whereas a low skull base is located at one-third to one-half
servation in an appropriate hospital unit is a necessity. of the horizontal plane into the orbit. Any skull base at the
level of the medial rectus or below is hazardous (Fig. 26.6).
In addition to understanding the height associated with
the skull base, understanding that in some individuals
CSF Leak/Skull-Base Penetration
the fovea ethmoidalis slopes toward the cribriform plate,
■ To prevent and manage anterior skull-base injuries: whereas in other individuals the fovea ethmoidalis is more
1. Recognize high-risk areas of the fovea ethmoidalis, vertical forming a “goblet” shape (Fig. 26.7) [10].
cribriform plate, and the anterior, medial, superior Beyond preoperative review of imaging, care must be
sphenoid sinus. taken during revision surgery not to accidentally punc-
2. Avoid operating medially, superior to the middle ture the skull base. Computer image guidance can be used
turbinate. to confirm the level of the skull base, understanding that
3. Recognize the presence of CSF as a warning sign visualization of the skull base as it slopes away from the
that the skull base has been penetrated. surgeon supersedes computer imaging. In addition, the
posterior level of the skull base is generally no more than
Clearly, the anatomy of the paranasal sinuses places the en- 7 cm from the nasal sill and slopes in an arc anteriorly.
doscopic sinus surgeon millimeters from the intracranial Care must be taken in the areas of the superior aspect
contents of the anterior cranial fossa. The roof of the nasal of the sphenoid sinus, the cribriform plate, and the fovea
cavity represents the floor of the anterior skull base. The ethmoidalis. In revision cases, the middle turbinate may
thin lateral lamella connecting the cribriform plate with be absent. If present, one must avoid operating superi-
the fovea ethmoidalis provides a fragile barrier between orly medial to the middle turbinate as this is a key “dan-
the nasal cavity and the intracranial contents. Posteriorly, ger” zone and can easily lead to skull-base penetration.
the sloping extension of the planum sphenoidale repre- addition, scraping, using a bone rongeur, or aggressively
sents a potential entry point into the intracranial cavity. cleaning the skull base in a variety of ways can result in a
Injury to the skull base in any of theses areas can oc- CSF leak. Understanding that sinus disease does not re-
cur in a variety of ways. Initially, failure to identify the quire resection to the skull-base mucosa, and allowing for
level of the skull base at any point can enable puncture of a 2- to 3-mm cushion zone, even in revision cases, should
the skull base with sharp, dull, or powered instrumenta- adequately ensure avoidance of skull-base penetration,
tion [13]. An ethmoidectomy carried too far medial and CSF leak, and complication.
superior can result in penetration of the lateral lamella CSF leak is the first sign that the skull base has been
of the cribriform plate or fovea ethmoidalis. It should penetrated; it also represents a clear warning not to pro-
be mentioned that the medial fovea ethmoidalis is up to ceed any further with powered or other instrumentation.
ten times thinner than the lamina papyracea. Aggressive The endoscopic sinus surgeon should be well versed in
26 management of a middle turbinate that inserts into the the appearance of the skull base and recognize the white
lateral lamella can result in a fracture of the skull base in color of the dura. CSF rhinorrhea seen at the time of sur-
this area and resultant CSF leak. Entrance into the sphe- gery is generally evident as gush of clear fluid that washes
Fig. 26.6 a High skull base: the white line indicates the skull base above the upper third of the orbit. b Low-lying skull base: the black
line indicates the skull base at the lower half of the orbit
Fig. 26.7 a Goblet or vertical skull base. b Bowl-shaped or sloping skull base
away blood from the area. This is known as the “washout essential and requiring a separate consent indicating that
sign” [2]. Immediate CSF rhinorrhea may be short lived a risk of seizure and/or chemical meningitis is associated
in that as CSF stores are depleted or as cerebral tissue pro- with intrathecal fluorescein injection, its use can be quite
lapses into the defect, the rhinorrhea may resolve. helpful in isolating the area of a CSF leak (Fig. 26.8, Video
When it is evident that the skull base has been 26.1) [25].
penetrated, intervention must occur. While with skull- In addition to repair, a consultation with neurosurgeon
base trauma, approximately 95% of the time CSF rhinor- is indicated, especially if a lumbar drain is contemplated.
rhea is evident within the 3 months of injury, there is no If intraoperative skull-base penetration is noted, discus-
literature to date that outlines the time line for identify- sion with the anesthetist about avoiding positive-pressure
ing skull-base injury as a result of only endoscopic-sinus- ventilation, which may result in pneumocephalus, should
surgery-induced trauma [25]. Regardless of the timing of occur. The following measures should also be considered:
injury, repair of the skull base is necessary. Skull-base de- no heavy lifting/strenuous activity, avoidance of straws,
hiscence and CSF rhinorrhea unrecognized or untreated avoidance of nose blowing, and an initial period (24 h)
can result in chronic headache, pneumocephalus, menin- of strict bed rest at minimal (< 15°) incline with gradual
gitis, coma, and even death. increase to a 90° position. If cortical injury is suspected,
Multiple methods of skull-base repair exist. A variety discussions with a neurosurgeon and neurologist as ap-
of materials can be used to graft a skull-base injury: syn- propriate are required together with obtaining appropri-
thetic dura materials, septal mucosa, septal or turbinate ate radiographic imaging. A period of observation in a
cartilage, temporalis fascia/muscle, fat, and vascularized monitored setting of at least 24 h should be provided.
tissue such as rectus abdominus. Additionally, on-lay,
over-lay, under-lay, and sandwich grafts have all been de-
scribed as appropriate techniques for endoscopic repair
Conclusion
of a skull-base defect. A traditional open, anterior cranial
approach to the skull base can also be considered in cases All surgery is fraught with potential complications. En-
where endoscopic repair fails. Endoscopic repair, how- doscopic sinus surgery as described herein involves high-
ever, is associated with a high success rate (approximately risk territory with multiple vital structures in the imme-
90%) and considerably lower mortality [6]. Associated diate vicinity. Revision sinus surgery poses significant
with repair of a skull-base defect, the use of CSF-reducing additional risks including operating in a field with po-
medications such as acetazolamide, and the use of lum- tentially dehiscent structures, lack of reliable landmarks,
bar drains have been advocated. In addition, with leaks and scarring, which can result in decreased visualization
found in a delayed fashion, the off-label use of intrathecal secondary to general oozing or bleeding. Understand-
fluorescein at a concentration of one-tenth of 1 ml mixed ing these risks, frank discussions with patients including
with 10 ml of preservative free 0.9% saline or the patient’s well-documented informed consent, proper preoperative
own CSF can aid in the localization of a defect. While not evaluation, radiographic evaluation, and intraoperative
evaluation are mandatory. Avoidance of complications
remains the best treatment. However, early recognition
of a complication can help prevent a minor complica-
tion from becoming a major complication. The ability to
appropriately intervene when a complication becomes
evident relies on surgical skill, anatomic knowledge, and
experience. Involving appropriate colleagues and special-
ists can be an invaluable asset. Observation and diligence
postcomplication is essential. Finally, open discussions
with patients and their families can help prevent legal se-
quelae associated with surgical complications.
Tips/pearls to avoid complications in revision

sinus surgery:
1. Always obtain a detailed informed consent.
2. Always obtain appropriate preoperative imaging.
26 3. Computer image guidance can be helpful in revi-
sion surgery.
Fig. 26.8 Fluorescein-dyed cerebrospinal fluid (CSF) leak
12. Kim HU, Kim SS, Kang SS, et al. (2001) Surgical anatomy
4. Always review all available imaging and previous
of the natural ostium of the sphenoid sinus. Laryngoscope
operative reports and have them available in the
111:1599–1602
operating suite.
13. Lee JC, Song YJ, Chung YS, et al. (2007) Height and shape
5. Recognize areas of potential complication prior to
of the skull base as risk factors for skull base penetration
surgery.
during endoscopic sinus surgery. Ann Otol Rhinol Laryn-
6. Maintain visualization throughout all endoscopic
gol 116:199–205
procedures.
14. Lund VJ, Wright A, Yiotakis J (1997) Complications and
7. Identify key landmarks when available: middle
medicolegal aspects of endoscopic sinus surgery. J Roy Soc
turbinate, maxillary antrostomy, sphenoid os,
Med 90:422–428
nasopharynx.
15. Luxenberger W, Stammberger H, Jebeles JA, Walch C
8. Recognize complications as early as possible.
(1998) Endoscopic optic nerve decompression: the Graz
9. Intervene appropriately and definitively when
experience. Laryngoscope 108:873–882
complications occur.
16. Maniglia AJ (1991) Fatal and other major complication of
10. Involve appropriate colleagues and experts, trans-
endoscopic sinus surgery. Laryngoscope 101:349–354
ferring patients when necessary.
17. May M, Schiatkin B, Kay SL (1994) Revision endoscopic si-
11. Always discuss complications, treatments, and
nus surgery: six friendly surgical landmarks. Laryngoscope
required interventions with patients and their
104:766–767
family.
18. McDonald SE, Robinson PJ, Nunez DA (2007) Radiologi-
cal anatomy of the anterior ethmoidal artery for functional
endoscopic sinus surgery. J Laryngol Otol 122:264–267
19. McInnes G, Howes DW (2002) Lateral canthotomy and
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26
Chapter 27
Revision Dacryocystorhinostomy
Metin Onerci
27
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
■ A small and inappropriately placed bony opening, Preoperative Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . 236
inadequate and improperly opened rhinostomy, Revision Dacryocystorhinostomy . . . . . . . . . . . . . . . . . 238
excessive scar tissue production, anatomical abnor-
Reasons for Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
malities, and concomitant paranasal sinus infec-
tions are the most important causes for the failure of Surgical Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
dacryocystorhinostomy (DCR) surgery. Surgical Technique for Revision Cases . . . . . . . . . . . 239
■ The endonasal approach is well suited for revision Localization of the Lacrimal Sac and Duct . . . . . . . 239
DCR surgery because the residual lacrimal sac can
Mucosal Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
be directly accessed through the previous bony os-
tium created at the time of the primary DCR. Bone Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
■ During revision external surgery, the bony ostium Removal of the Medial Mucosal Wall of the Sac . . . 241
is more easily enlarged through the endonasal ap- Silicone Tubing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
proach.
How Long Should the Silicone Tubes
■ In revision cases a detailed examination should be
Be Kept in Place? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
performed to find the possible causes and the site of
pathology. Mitomycin C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
■ The rhinostomy from the sac into the lateral nasal Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
wall should be created at the correct location and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
with the correct size, which should be over 5 mm
wide.
■ A low rhinostomy may not bypass a midsac or up-
per-sac obstruction. A high rhinostomy leaves the
Introduction
nasolacrimal duct as a blind pouch that is not ad-
equately drained. Despite a patent anastomosis, re- Epiphora is one of the most prevalent functional disabili-
tention produces sump syndrome. ties of the ocular system. Various techniques (Table 27.1)
■ A larger rhinostomy removing enough bone have been developed to treat lacrimal diseases, to elimi-
(15 mm × 15 mm) may prevent sump syndrome. nate the infection, and to reconstruct a functional drain-
■ Any nasal or paranasal abnormalities should be cor- age pathway using very sophisticated instruments.
rected during DCR surgery. The practice of lacrimal surgery has been done by an
■ If the rhinostomy is placed in a wrong location in external approach for a long time. Despite much debate,
the previous surgery, the new rhinostomy should be many ophthalmologists still believe that external DCR
opened in the correct location. provides higher success rates than endoscopic DCR. The
■ The success rate is directly related to the appropriate surgical treatment of DCR is very closely related to the
technique — inadequate surgical training and the inside of the nose. The problem of an endonasal approach
lack of proper instrumentation decrease the success was the difficulty in visualizing the endonasal anatomy.
rate. The introduction of microscopes and endoscopes into
medicine opened the door for visualization of the interior
of the nose, and endoscopic or microscopic endonasal
236 Metin Onerci
Table 27.1 The surgical approaches to the nasolacrimal sac
1. Endocanalicular (a) Lacrimal endoscopy

(b) Balloon dacryocystoplasty
(c) Endocanalicular laser-assisted dacryocystorhinostomy
2. Endonasal approach (a) Transseptal approach

(b) Transnasal (classical) approach
(c) Transnasal (endoscopic or microscopic) approach
(d) Endonasal laser-assisted dacryocystorhinostomy
3. Paranasal approach (a) Transantral approach

(b) Paranasal approach
4. External approach (a) Dacryoethmoidostomy

(b) Falk’s operation
(c) Toti operation
(d) Modifications of Toti operations
lacrimal surgery has become more popular in recent times the help of gravity is indeed an intricate process. Drain-
[21]. Long-term success rates with endonasal techniques age of tears depends on the volume of tear production,
have been equivalent to that achieved with external DCR eyelid position, pump mechanisms, anatomy of the lac-
[10]. However, it is difficult to make evidence-based de- rimal system, gravity, and nasal air convection currents.
terminations about the efficacy of endonasal or external Although clinical evaluation of gross lacrimal function is
approaches. Each approach has its own advantages and not difficult and can be made on the basis of history, de-
disadvantages (Tables 27.2–27.5). termination of the cause may be extremely difficult and
The endonasal approach is well suited for revision DCR requires a variety of diagnostic procedures [7].
surgery because the residual lacrimal sac can be accessed Lacrimal drainage dysfunction can be due to an ana-
directly through the previous bony ostium created at the tomic obstruction, such as nasolacrimal duct fibrosis,
time of primary DCR, and the bony ostium is more eas- or physiologic dysfunction from a failure of functional
ily enlarged [28]. The endoscopic DCR in revision cases mechanisms (for example lacrimal pump inadequacy
also offers several other advantages including a complete caused by poor orbicularis muscle tone); therefore, the
exposure of those anatomical anomalies or inflammatory diagnosis of the cause of epiphora is important. A list of
changes of the normal structures that commonly hinder tests required for the diagnosis of epiphora is given in
conventional external surgery. Before revision surgery, a Table 27.6.
detailed preoperative evaluation is necessary. The routine preoperative evaluation includes dacryos-
cintigraphy or dacryocystography. Dacryocystography is
a safe, quick, and easy procedure using a radio-opaque
material. It is widely established for the demonstration
Preoperative Evaluation
of stenosis. This procedure should not be performed in
Although the tear drainage system appears very simple, the presence of active dacryocystitis. Dacryocystography
draining the tears through the nasolacrimal system with may be useful in demonstrating localized stricture, par-
Table 27.2 The advantages of the external approach
• Unsurpassed exposure of the lacrimal drainage system

• Intraoperative inspection of suspected or unsuspected anomalies
• Biopsies performed easily
• Easy to suture the adjacent flaps of lacrimal and nasal mucosa to pro-
27 vide a patent with an epithelium-lined tract for tear drainage
Revision Dacryocystorhinostomy 237
Table 27.3 The disadvantages of external dacryocystorhinos-

tomy (DCR)
• Cutaneous scar
• Disturbance of the nasolacrimal pump system
• Bleeding
• Acute dacryocystitis with abscess formation
Table 27.4 The advantages of the endonasal DCR procedure
• Less disruption of medial canthal anatomy

• Preservation of lacrimal pumping function
• No external incision, with improved cosmesis
• Decreased postoperative morbidity and enhanced recovery
• No hospital stay required
• Operating under direct vision with minimal trauma
• Addressing the nasal and paranasal sinus abnormalities through the same surgical approach
• Can be performed in patients with acute dacryocystitis with abscess formation
• Endoscopic postoperative evaluation for persistent or recurrent disease
• Decreased operative time
• Excellent visualization
• Ability to evaluate the location and size of the rhinostomy site
• Decreased intraoperative hemorrhage
• Can be used for previously radiated patients
• Can be used for pediatric patients
• Revision procedures
Table 27.5 The disadvantages of the endonasal dacryocystorhinostomy procedure
• Suspicion of lacrimal system neoplasia

• Technical difficulty in patients who have sustained severe midfacial trauma with second-
ary hyperostosis, or altered anatomy involving the bones surrounding the lacrimal sac
• High equipment cost
• Steep learning curve
tial obstruction, lacrimal diverticuli, fistulae, dacryoliths, phy may provide information about physiological func-
and extrinsic and intrinsic tumors of the lacrimal drain- tion. Limiting factors are the methodologically inherent
age system [7]. minimal morphologic information and relatively large
The disadvantage of dacryocystography is that it pro- variations of normal transit times. Dacryocystography
vides restricted functional information, as in dysfunction gives finer anatomic detail; however, dacryoscintigraphy
of the canalicular muscle pump, slight narrowing of the is a more physiologic assessment since no instrumen-
ductal lumen and mucous membranes, since intubation tation is necessary [7, 14]. In revision cases, functional
of the canaliculi and active injection of the contrast ma- dysfunction and canalicular obstruction should be
terial may overcome stenosis. Dacryoscintigraphy is also considered in the differential diagnosis of epiphora be-
a simple, noninvasive physiologic test. Dacryoscintigra- fore surgery.
238 Metin Onerci
Table 27.6 Diagnostic tests for the lacrimal system concomitant paranasal sinus infections are the most im-
portant causes for the failure of DCR surgery.
Dye (fluorescein) disappearance test
Functional obstruction can be diagnosed with dac-
ryoscintigraphy. If it is due to dysfunction of the lacri-
Primary Jones dye test (Jones I and Jones II) mal pump system , the patient should be informed about
the prognosis. Narrowing of the nasolacrimal cana-
Lacrimal irrigation
liculus apparatus sometimes mimics the functional dys-
Ultrasonography function. However, these patients may benefit from the
surgery; at the very least their symptoms improve after
Dacryocystography surgery [41].
Radionuclide dacryoscintigraphy
Computed tomography
Surgical Approach
Computed tomography dacryocystography
Endonasal endoscopic or microscopic DCR is gener-
Magnetic resonance imaging ally the preference of many authors in instances of failed
DCRs [8, 22, 28]. The angled instruments developed for
Magnetic resonance dacryocystography
endoscopic sinus surgery allow the occluded ostium to
Lacrimal endoscopy be relatively safely evaluated under direct endoscopic
visualization. Under direct endoscopic or microscopic vi-
sualization, the ostium can be enlarged and properly po-
sitioned to increase the likelihood of continued patency
[19]. Granulations can be easily trimmed and cauterized,
Revision Dacryocystorhinostomy
adhesions are cut together with resection of the anterior
end of the middle turbinate. A small, high rhinostomy
Reasons for Failure
may cause sump syndrome. The sac should not be opened
Failure of dacryocystorhinostomy (DCR) is attributable very high up without opening it inferiorly in order to
to a variety of causes (Table 27.7). The majority of cases prevent sump syndrome (Figure 27.1). Placement of the
were found to be related to internal nasal problems. A ostium too close to the middle turbinate results in subse-
small and inappropriately placed bony opening, inad- quent adhesion and occlusion,. The endonasal approach
equate and improperly opened rhinostomy, excessive is a one-stage procedure that permits correction of asso-
scar tissue production, anatomical abnormalities, and ciated nasal disorders, such as septal deviation, middle-
Table 26.7 Reasons for failure
• Improper placement of the ostium

• Creating a small bony ostium
• Sump syndrome
• Insufficient membranous rhinostomy
• Scar formation in the area of rhinostomy
• Scarring at the canaliculi–sac junction
• Small cicatrized sacs
• Associated nasal or paranasal abnormalities
• Development of adhesions between the rhinostomy and the middle turbinate or rarely the nasal septum
• Granuloma formation
• Insufficient removal of periosteum
• Leaving bony spicules in the operating area
• Lacrimal pump insufficiency
• Persistence of a lacrimal sac diverticulum that was not drained
• Previous surgery, chemotherapy, or radiotherapy for paranasal sinus malignancy
27
Fig 27.1 High and small rhinostomies may cause sump syndrome. The sac should not be opened very
high up without opening it inferiorly in order to prevent sump syndrome. (Courtesy of TESAV)
turbinate hypertrophy, or polypoidal disease, which may must be corrected. Occasionally, the head of the middle
be a causative factor in the failure of DCR [8]. turbinate needs to be removed to expose the sac area.
Chronic maxillary rhinossinusitis or pansinusitis should
be addressed simultaneously by the same endonasal route.
In revision cases, before starting the operation the lacri-
Surgical Technique for Revision Cases
mal probe is introduced through the superior canaliculus
If it is done under general anesthesia, hypotensive anes- and passed into the area of rhinostomy. In most cases a
thesia is preferred. The inside of the nose is decongested. fibrous membrane is noted to occlude the previously cre-
The head is elevated by bringing the table 20° or 30° in ated channel. The extent of the previous rhinostomy and
a reverse Trendelenburg position. The lateral nasal wall the size of the bony opening are determined [39]. Active
and previous rhinostomy site are examined carefully en- Wegener’s granulomatosis or benign or malignant lesions
doscopically for potential structural issues that may have of the lacrimal sac or the neighboring structures are abso-
contributed to the failure of initial procedure [38]. The lute contraindications for DCR (Table 27.8).
mucosa anterior to the middle turbinate may be infil-
trated with 1 ml lidocaine with 1:100,000 epinephrine.
The disadvantage of this infiltration is that it may obscure
Localization of the Lacrimal Sac and Duct
the bulging of the nasolacrimal sac. It is important not to
traumatize the nasal mucosa, since bleeding prevents vi- The key initial landmark is the posterior border of the
sualization. At this stage any septal deviation, concha bul- frontal process of the maxilla, which is usually identifi-
losa, or paradoxical middle turbinate obstructing the view able as a ridge or an indentation into the nasal airway just
240 Metin Onerci
Table 27.8 Contraindications to DCR
• Benign or malignant lesion in the lacrimal system or the surrounding tissues

• Children less than 1 year of age (obstruction should be treated by probing)
• Active Wegener’s granulomatosis
• Canalicular obstruction
• A functional sac
anterior to the middle turbinate [36]. This ridge extends as is done in the usual way. A rectangular cut is made in
from the highest point of the inferior turbinate upward the mucosa anterior to the middle turbinate and supe-
and ends immediately in front of the middle turbinate rior to the inferior turbinate. Wong et al. [37] advise an
attachment. The nasolacrimal duct and sac lie immedi- oval cut 2 cm × 1 cm into the mucosa. Wormald et al. per-
ately lateral and posterior to this ridge. Superiorly, the forms incision 3–5 mm posterior to and about 8–10 mm
duct joins the sac halfway between the attachments of above the axilla and brings it 10 mm anterior to the axilla
the middle and inferior turbinates. The superior border onto the frontal process of the maxilla. They extend the
of the lacrimal sac is above the middle-turbinate anterior incision inferiorly about two-thirds of the length of the
attachment. anterior end of the middle turbinate to the insertion of
The average position of the apex of the lacrimal sac is inferior turbinate.
6.10 ± 2.02 mm (range, 2–12 mm) above the opercule of Indeed, removal of nasal mucosa 7–8 mm in diam-
the middle turbinate [9]. The anterior attachment of the eter might be enough and unnecessary removal mucosa
uncinate process is at the junction of the lacrimal fossa should be avoided to decrease new scar formation. A
and the orbital plate of the lacrimal bone. The nasolac- canal knife, as used in ear surgery, can be used for this
rimal sac is always situated immediately anterior to the procedure. Since bleeding occurs mainly from the edge
uncinate process and makes the uncinate process a good of the cut mucosa, it is important to make a complete cut,
landmark in DCR operations. It is important not to enter and not to pull and tear the mucosa [24]. After the cut
beyond this point in a lateral direction since it may cause is completed through the mucoperiosteum all the way
orbital penetration. A 20-gauge fiberoptic light pipe may down to the bone, the mucosa is elevated off the bone
also be used to identify the location of the sac and is in- and removed or can be used as a posteriorly based flap.
serted into the lacrimal sac through either of the lacrimal It does not appear to be necessary to apply special muco-
canaliculi. The light is visualized endonasally with a rigid sal flaps [13]. If needed, through-cutting forceps may be
endoscope. used instead of Blakesley forceps to avoid tearing of the
mucosa. To prevent recurrences it is important to remove
the periosteum with the nasal mucosa and to remove all
bony partitions and spicules. The periosteum induces
Mucosal Incision
new bone formation and in turn leads to narrowing or
Soft tissue rather than bony occlusion of the surgical os- closure of the ostium. If the edge of the previous rhinos-
tium is one of the most frequent causes of failure of ex- tomy opening is found, the mucosa around it is elevated
ternal DCR. The most common identified obstruction and the bone is drilled in such a way that the new rhinos-
results from lacrimal sac cicatrization, granulation tissue, tomy be at the correct location. It is important to prepare
fibrosis, and synechia between the opening and adjacent the sac completely exposed.
middle-turbinate mucosa [8]. The nasal mucosal inci-
sion is made slightly more anterior on the frontal pro-
cess of maxilla. Approximately one-half of the lacrimal
Bone Removal
sac fossa lies anterior to the location of the maxillary line;
this supports the recommendation that the nasal mucosal Inadequate bone removal is a common cause of failure in
incision be placed anterior to this landmark [38, 39] The DCR. In all revision operations agger nasi cells should be
periosteum is identified and elevated. The anterior edge checked. In approximately 8% of patients there is an agger
of the previous bony rhinostomy site is found. In some nasi cell in this area. In some cases, agger nasi ethmoid
cases it is not possible to identify the rhinostomy open- cells may extend under the fossa causing confusion dur-
ing either due to wrong placement of the ostium or reclo- ing surgery, and removal of bone results in opening into
sure of the ostium. In such situations DCR is performed the ethmoid cell rather than the lacrimal fossa. If the ag-
27
ger nasi cell has not been opened yet, it will be necessary was found between the size of the ostium at the surgery
to open the agger nasi cell up and go through it before and after healing [18]. Iliff [15] removed a 10-mm diam-
going through the lateral wall and the lacrimal bone into eter piece of bone, with 1 failure out of 87 cases. The mean
the sac. diameter of the healed ostium was 1.8 mm, representing
If the anterior edge of the previous bony rhinostomy an area only 18% of that of the initial anastomosis. So the
site is found, it is widened so as to create a proper rhinos- aim is not to create a very large bony osteotomy, but a
tomy. If there can be found no bony rhinostomy opening, functioning osteotomy of efficient size.
the surgical procedure should be as in primary DCR op- The entire medial bony covering of the sac can be
eration. The sac and duct junction is above the insertion removed under endoscopic or microscopic control. If a
of inferior turbinate, 6 mm below the operculum. Woog chisel is used, attention should be given to removing all
et al. suggest removing the bone overlying the common bony fragments, since if left they may cause obstruction
canaliculus completely and achieving a rhinostomy with later. Previously irradiated patients should be handled
at least 6–8 mm vertical dimension in adults. The medial carefully owing to healing problems and anatomic de-
side of the bone of the maxillary portion of the lacrimal rangements. However, in revision cases using drills is
fossa can be removed either from posterior to anterior more advocated. Thus, following DCR, the sac and the
or from anterior to posterior. Since it is thinner in the duct should coexist as anatomic structures and be incor-
posterior part, it makes sense to start from posterior. porated into the nose.
However, it is really challenging to remove the bone with
conventional endoscopic sinus instruments alone. There
are currently no bone-removing instruments specifically
Removal of the Medial Mucosal Wall of the Sac
designed for this location. Kerrison forceps or backbiting
forceps may be used for this purpose [40]. The surgeon The vascularized white color of the sac is characteristic
may feel safer if he/she starts from the anteromedial part and can easily be identified. The medial part of the lac-
of the bony sac, identifies the sac, and continues poste- rimal sac should be fully exposed. A lacrimal probe may
riorly. The use of a laser takes more time and may cause be used to identify the lacrimal sac. A lacrimal probe is
thermal injury. The laser can only ablate the much thin- passed through a canaliculus and directed medially into
ner lacrimal bone. Removal of part of the frontal process the obstructed sac. The fibrous tissue is tented into the
of the maxilla gives better access and visualization of the nasal cavity with probes to provide a broad soft-tissue re-
lacrimal sac, but a laser cannot ablate this thick bone. gion under tension. The tenting of the medial sac wall by
Weidenbecher et al. [33] suggest removing the entire the probe is visualized endonasally. While it is tented by
medial bony covering of the sac. Whittet et al. [36] in- the lacrimal probe, the sac mucosa is incised with a sickle
sert a Leibrich lacrimal probe into the inferior canalicu- knife. Mucopus, residual contrast material, may drain
lus, direct it against the medial wall of the lacrimal sac from the sac, or dacryoliths may be seen in the interior
in order to tent, and decide how much bone to remove of the sac. Once the sac has been entered, the lacrimal
after this procedure. They advocate leaving approximately probe may be seen. Using Bellucci scissors, one can ex-
5 mm free of bone around the canaliculus, especially at tend the incision and use through-cutting instruments
the junction of attachment of the middle turbinate and to enlarge the intranasal opening. Blakesley forceps are
the lateral nasal wall, a point that demarcates the floor not through-cutting and may tear the sac mucosa; for this
of the lacrimal fossa. Woog et al. [38, 39] suggest creat- reason, through-cutting forceps are preferred. A carbon
ing a generous rhinostomy that extends from above the dioxide laser can also be used. As much of the medial wall
middle-turbinate attachment to the level of the midpoint of the sac should be removed as possible. Metson [19]
of the maxillary line inferiorly. Welham and Wulc [35] advises enlarging of intranasal opening to a diameter of
think that the ideal osteotomy should involve the removal approximately 10 mm, allowing free passage of the lacri-
of all of the bone between the medial wall of the sac and mal probes into the nose from both superior and inferior
the nose. Drills specifically designed for intranasal use canaliculi. In some failed DCRs there is a large sac rem-
make it easier to remove the bone but may be associated nant seen in DCG whereas in others a small cicatrized
with thermal injury and damage to the surrounding mu- sac is present. In patients with small cicatrized sacs it may
cosa. The bony opening should start a few millimeters be difficult to achieve lacrimal and nasal mucosal anas-
above the operculum, and the medial half of the bony tomosis. If there exists any problem to appose the mu-
nasolacrimal sac should be removed in such a way that cosal edges, the nasal mucosal flap is trimmed to fit the
after the surgical bony opening it should be 10–17 mm in size of the lacrimal ostium [28]. According to Woog et al.
diameter (average 11.75 mm). A functional result can be [39] an adequate rhinostomy should permit easy passage
achieved with a fistula of 6 mm2. No statistical correlation of lacrimal probes and removal of the medial wall of the
242 Metin Onerci
lacrimal sac in the area of common canaliculus should be tubes to dilate the common canaliculus opening into
confirmed by direct visualization of the internal common the lacrimal sac; this is especially important for patients
punctum with angled endoscopes. who have functional epiphora rather than to keep the sac
In revision procedures orbital soft tissues and internal open. In revision cases intubation with silicone tubes is
common punctum may be incorporated into the scar tis- generally recommended.
sue. Vigorous avulsion of this cicatrix may cause injury to
orbital soft tissues, medial canthal ligament, and internal
common punctum. Woog et al. [38, 39] recommend to
How Long Should the Silicone
observe the medial commissure while gentle traction is
Tubes Be Kept in Place?
placed on the tissue to be removed at the rhinostomy site.
Excessive movement of the medial commissure by this It is advised to keep silicone stents in place for 2–6 months;
maneuver may signify that deeper tissues than desired however, tubes kept in place over 3 months are associated
are being grasped by the forceps. with inflammation and granulation. Wong et al. [37] and
Weidenbecher et al. [33] advise removing the tubes af-
ter 6 weeks. El Guindy et al. [8] keep the tubes for only
2 months and recommend early removal (at 2 months)
Silicone Tubing
because silicone tubing may incite a granulomatous reac-
A silicone tube is placed through the upper and lower tion. Hartikainen et al. [10] keep the tubes in place for
canaliculi into the nasal cavity, the ends of the tubing are 6 months. Hausler and Caversaccio [11] use the tubes in
grasped with forceps, guided out of the nose, and are tied place for the long term and they have several cases where
and trimmed so that the knot lies within the nasal cavity. silicone tubes have been used for over 3 years without any
The tubing thus forms a continuous loop, which passes complications. They even suggest leaving the tubes per-
through the intranasal ostium and is unlikely to become manently in persistent cases and think that the silicone
dislodged [19]. The knot may be fixed by a suture or a tubing produces a maximal dilatation of the canaliculi
vessel clip. Wong et al. [37] use a black silk suture to tie and a natural aspiration of tear liquid by capillary force.
round the silicone tubes. According to Allen and Berlin However, keeping silicone tubes for at least 2 months is
[1] and Bartley [2], silk sutures can produce pyogenic and generally advocated in revision cases.
giant cell granulomas. Packing of the nose is unnecessary
unless bleeding is a problem.
Silicone intubation may be recommended in cases
Mitomycin C
with canalicular stenosis, a small scarred lacrimal sac, a
tight upper nasal cavity, in reoperations, and if the flaps Mitomycin C, an antiproliferative agent that is widely
of the lacrimal sac and nasal mucosa are not sutured. In used in pterygium excision and trabulectomy with favor-
other cases it is the surgeon’s preference to use silicone able results, was also used to inhibit fibrous tissue growth
tubes or not. Silicone tubing may serve to dilate con- and scarring at the osteotomy site and to decrease the fail-
stricted passages in patients with canalicular or common ure rate. Cottonoids soaked with 0.2 mg/ml mitomycin C
internal punctual stenosis and marks the site of the intra- are applied to the osteotomy site. Kao et al. [16] reported
nasal ostium [6]. Kohn [17] believes that silicone tubing that mytomicin C improved success rates; Zilelioğlu et al.
keeps the anterior and posterior flaps separate, and also [42] found no benefit in using mitomycin C. Use of mito-
discourages cicatricial closure of the bony ostium. Some mycin C needs further investigation.
reports [1, 23] give less favorable results when tubes are
inserted. Allen and Berlin [1] believe that intubation may
be the reason for failure. Tubes may cause inflamma-
Complications
tion, granulation, and slit the canaliculus. Silicone tubing
may incite granulomatous inflammation at the internal Soft-tissue infection after open lacrimal surgery occurs in
ostium, chronic infection, or canalicular laceration. Wal- 8% of patients. It is reduced fivefold with routine admin-
land and Rose [30] did not find any difference in failure istration of antibiotics [31]. Vardy and Rose [29] demon-
rates or inflammation with or without silicone intuba- strated that intraoperative or postoperative broad-spec-
tion. Insertion of silicone tubes is generally encouraged trum antibiotics reduced the incidence of cellulitis after
[3]. Snead et al. [26] showed that silicone intubation did open primary lacrimal surgery. Tsirbas and McNab [27]
not increase canalicular inflammation in animals. Wal- reported 3.8% of cases with secondary hemorrhage after
land and Rose [31] found no significant difference in the DCR. The incidence of bleeding was higher in patients
rate of failure or soft-tissue infection between silicone-in- taking nonsteroidal anti-inflammatory drugs. Severe na-
27 tubated and nonintubated patients. Wormald et al. placed sal hemorrhage requiring nasal packing was also reported
[22, 34]. Orbital complications were also mentioned [25, 2. Bartley GB (1992) Acquired lacrimal drainage obstruc-
32]. Orbital emphysema can be prevented by asking pation: an etiologic classification system, case reports, and a
tients not to blow their nose for at least 2 weeks following review of the literature. Part 1. Ophthal Plast Reconstr Surg
surgery. Prolapsed tubes, punctal widening, corneal ir- 8:237–242
ritation, and intranasal discomfort are the complications 3. Beigi B, Westlake W, Chang B, Marsh C, Jacob J, Chatfield
related to silicone tubing [5]. There are rare reports of ce- J (1998) Dacryocystorhinostomy in South West England.
rebrospinal fluid leaks and meningitis [4, 12, 20]. Meticu- Eye 12:358–362
lous surgery avoiding unnecessary mucosal trauma may 4. Beiran I, Pikkel J, Gilboa M, Miller B (1994) Meningitis as
prevent intranasal adhesions. a complication of dacryocystorhinostomy. Br J Ophthalmol
78:417–418
Tips and Pearls 5. Brookes JL, Oliver JM (1999) Endoscopic endonasal man-
agement of prolapsed silicone tubes after dacryocystorhi-
1. The sac should not be opened very high up with-
nostomy. Ophthalmology 106:2101–2105
out opening it inferiorly in order to prevent sump
6. Burns JA, Cahill KV (1985) Modified Kinosian dacryocys-
syndrome. High and small rhinostomies may
torhinostomy. Ophthalmic Surg, 16:710–716
cause sump syndrome.
7. Dutton JJ (1988) Diagnostic tests and imaging techniques.
2. Preservation of as much mucosa as possible is of
In: Linberg JV (Ed) Lacrimal Surgery. Churchill Living-
paramount importance to decrease scarring.
stone, New York, pp 19–48
3. The bony osteotomy should be as big as the
8. El-Guindy A, Dorgham A, Ghoraba M (2000) Endoscopic
mucosal opening (7–10 mm) and the periosteum
revision surgery for recurrent epiphora occurring after ex-
should be removed with mucosa (since new bone
ternal dacryocystorhinostomy. Ann Otol Rhinol Laryngol
formation requires the presence of periosteum).
109:425–430
4. The bone in the region of the lacrimal fossa may
9. Fayet B, Racy E, Assouline M, Zerbib M (2005) Surgi-
be thicker following a midfacial fracture owing to
cal anatomy of the lacrimal fossa. A prospective com-
callus formation.
puted tomodensitometry scan analysis. Ophthalmology
5. The medial membranous sac wall should be re-
112:1119–1128
moved. Only puncturing the medial membranous
10. Hartikainen J, Antila J, Varpula M, Puukka P, Seppa H,
wall decreases the success rate.
Grenman R (1998) Prospective randomized comparison of
endonasal endoscopic dacryocystorhinostomy and exter-
nal dacryocystorhinostomy. Laryngoscope 108:1861–1866
11. Hauslaer R, Caversaccio M (1998) Microsurgical endo-
Conclusion
nasal dacryocystorhinostomy with long term insertion of
A small bony ostium, inadequate rhinostomy, excessive bicanalicular silicone tubes. Arch Otolaryngol Head Neck
scar tissue production, anatomical abnormalities, and Surg 124:188–191
concomitant paranasal sinus infections are the most im- 12. Heerman J Jr (1991) Rhinologische Aspekte bei Traenen-
portant causes of the failure of DCR surgery. The endo- wegstenosen. Otorhinolaryngol Nova 1:227–232
nasal approach is well suited for revision DCR surgery 13. Hosemann WG, Weber RK, Keerl RE, Lund VJ (2002) Min-
because the residual lacrimal sac can be accessed directly imally Invasive Endonasal Sinus Surgery. Georg Thieme
through the previous bony ostium created at the primary Verlag, Stuttgart, pp 66–70
DCR. The bony ostium is more easily enlarged through 14. Hurwitz JJ (1996) The Lacrimal System. Lippincott Raven,
the endonasal approach. It preserves the pump function Philadelphia
of the sac and avoids an external scar. It allows sinus sur- 15. Iliff CE(1971) A simplified dacryocystorhinostomy. Arch
gery to be performed in the same sitting if needed. The Ophthalmol 85:586–591
success of the surgery depends on accurate diagnosis 16. Kao SCS, Liao CL, Tseng JHS, Chen MS, Hou PK (1996)
ruling out canalicular and functional obstruction, and Dacryocystorhinostomy with intraoperative mitomycin C.
meticulous surgery, avoiding trauma to the mucosa and Ophthalmology 104:86–91
neighboring structures. 17. Kohn R (1988) Ophthalmic Plastic and Reconstructive
Surgery. Lea Febiger, Philadelphia
18. Lindberg JV, Anderson RL, Bumsted RM, Barreras R
(1982) Study of intranasal ostium after external dacryocys-
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torhinostomy. Arch Ophthalmol 100:1758–1762
1. Allen K, Berlin AJ (1989) Dacryocystorhinostomy failure: 19. Metson R (1990) The endoscopic approach for revision
association with nasolacrimal silicon intubation. Ophthal- dacryocystorhinostomy. Laryngoscope 100:1344–1347
mol Surg 20:486–489
244 Metin Onerci
20. Neuhaus RW, Baylis HI (1983) Cerebrospinal fluid 32. Weber R, Draf W, Kolb P (1993) Die endonasale mikro-
leakage after dacryocystorhinostomy. Ophthalmology chirurgische Behandlung von Traenenwegsstenosen. HNO
90:1091–1095 41:11–18
21. Onerci M (2002) Dacryocystorhinostomy. Rhinology 33. Weidenbecher M, Hosemann W, Buhr W (1994) Endo-
40:49–65 scopic endonasal dacryocystorhinostomy. Ann Otol Rhi-
22. Orcutt JC, Hillel A, Weymuller EA Jr (1990) Endoscopic nol Laryngol 103:363–367
repair of failed dacryocystorhinostomy. Ophthal Plast Re- 34. Welham RA, Hughes SM (1985) Lacrimal surgery in chil-
constr Surg 6:197–202 dren. Am J Ophthalmol 99:27–34
23. Psilas K, Eftaxias V, Kastaniondakis J, Kalogeropoulos C 35. Welham RAN, Wulc AE (1987) Management of unsuccess-
(1993) Silicon intubation as an alternative to dacryocys- ful lacrimal surgery. Br J Ophthalmol 71:152–157
torhinostomy for nasolacrimal drainage obstruction in 36. Whittet HB, Shun-Shin GA, Awdry P (1993) Functional
adults. Eur J Ophthalmol 3:71–76 endoscopic transnasal dacryocystorhinostomy. Eye
24. Shun-Shin GA (1998) Endoscopic dacryocystorhinostomy. 7:545–549
Eye 12:467–470 37. Wong RJ, Glicklich RE, Rubin PAD, Goodman M (1998)
25. Slonim CB, Older JJ, Jones PL (1984) Orbital hemorrhage Bilateral nasolacrimal duct obstruction managed with en-
with proptosis following a dacryocystorhinostomy. Oph- doscopic techniques. Arch Otolaryngol Head Neck Surg
thalmic Surg 15:774–775 124:703–706
26. Snead JW, Rathbun JE, Crawford JB (1980) Effects of sili- 38. Woog JJ, Sindwani R(2006) Endoscopic dacryocystorhi-
cone tube on the canaliculus. An animal experiment. Oph- nostomy and conjuctivodacryocystorhinostomy. Otolar-
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27. Tsirbas A, McNab AA (2000) Secondary hemorrhage after 39. Woog JJ, Kennedy RH, Custer PL, Kaltreider SA, Meyer
dacryocystorhinostomy. Clin Exp Ophthalmol 28:22–25 DR, Camara JG (2001) Endonasal dacryocystorhinostomy:
28. Tsirbas A, Davis G, Wormald PJ (2005) Revision dacryo- a report by the American Academy of Ophthalmology.
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29. Vardy SJ, Rose GE (1999) Prevention of cellulitis after open 40. Yung MW, Logan BM (1999) The anatomy of the lacrimal
lacrimal surgery. Ophthalmology 107:315–317 bone at the lacrimal bone at the lateral wall of the nose.
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tomy. Ophthal Surg 25:597–600 nostomy. Otolaryngol Clin North Am 39:539–549
31. Walland MJ, Rose GE (1994) Soft tissue infections after 42. Zilelioğlu G, Uğurbaş SH, Anadolu Y, Akıner M, Aktürk T
open lacrimal surgery. Ophthalmology 101:608–611 (1998) Adjunctive use of mytomicin C on endoscopic lac-
rimal surgery. Br J Ophthalmol 82:63–66
27
Chapter 28
Revision Endoscopic
Transsphenoidal Hypophysectomy 28
Karen A. Kölln and Brent A. Senior
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
■ A multidisciplinary team should be utilized includ- Indications for Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 245
ing an endocrinologist and neuro-ophthalmologist, Contraindications for Revision Endoscopic
in addition to the neurosurgeon and otolaryngolo- Pituitary Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
gist who will be performing the procedure, to maxi-
Preoperative Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . 246
mize perioperative treatment.
■ Computed tomography and magnetic resonance Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
imaging should be used as complementary imaging Tips to Avoid Complications . . . . . . . . . . . . . . . . . . . . . 248
studies. Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
■ Intraoperative stereotactic image guidance is crucial
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
for safe revision endoscopic approaches to the sella.
■ Revision endoscopic transsphenoidal hypophysec-
tomy is associated with an increased risk of cerebro-
spinal fluid leak irrespective of the prior method of
resection.
hypophysectomy, focusing specifically on the indications

and preoperative considerations, surgical technique, and
complications.
Introduction
Approaches to the sella have varied greatly over the past
Indications for Surgery
100 years, with Schloffer performing the first transsphe-
noidal approach to the pituitary in 1907. This was later The indications for revision pituitary surgery are similar
modified by Cushing in 1914 when he described the sub- to those for primary surgery. Recurrence of pituitary le-
labial transseptal approach to the sella, but he eventually sions can occur months to years following primary resec-
abandoned this approach secondary to concern for high tion. Surgical intervention is generally reserved for:
recurrence rates. With the advent of fluoroscopy and the 1. Pituitary adenomas that are nonresponsive to medical
operating microscope, the sublabial transseptal approach management.
again came into favor in the 1970s, decreasing the overall 2. Pituitary masses that cause visual impairment.
morbidity associated with accessing the sella via a fron- 3. Lesions that are increasing in size, as evidenced with
tal craniotomy [3]. The next major advancement came serial imaging.
in 1992 when Jankowski et al. first reported the success- 4. Pituitary apoplexy.
ful use of 0 and 30 endoscopes to approach the sella via
a transnasal approach, and since that time numerous Pituitary apoplexy is considered a surgical emergency
reports have outlined the surgical technique and over- and occurs when necrosis or hemorrhage into pituitary
all safety of the procedure [1, 5, 6, 12]. The aim of this lesions causes abrupt vision loss, headache, cranial neu-
chapter is to review revision endoscopic transsphenoidal ropathies, and sometimes acute adrenal insufficiency.
246 Karen A. Kölln and Brent A. Senior
detailed physical examination should be completed spe-

28 Contraindications for Revision
cifically to evaluate for visual field deficits, visual acuity,
Endoscopic Pituitary Surgery
stigmata of endocrine dysfunction, and cranial neuropa-
Exclusively suprasellar tumor. Relative contraindications thies. Sinonasal endoscopy should be performed in all
are: patients preoperatively to evaluate for septal deviation,
1. Prior craniotomy. nasal polyposis, and purulence.
2. Multiply recurrent tumor.
■ Imaging is of utmost importance in preoperative, as
well as intraoperative, surgical planning in revision
surgery, as scarring can lead to distortion of the anat-
Preoperative Evaluation
omy including medialization of the carotid arteries.
Prior to transsphenoidal hypophysectomy a patient
should be evaluated by a multidisciplinary team to ensure Imaging should include the complementary studies of
proper management in the perioperative period. In addi- a noncontrasted computed tomography (CT) of the pa-
tion to the neurosurgeon and otolaryngologist who will ranasal sinuses with fine (< 3-mm) cuts and a magnetic
be performing the procedure, this team should include an resonance imaging (MRI) scan of the brain with gado-
endocrinologist and neuro-ophthalmologist. linium enhancement, including special focus on the pitu-
itary gland. CT of the paranasal sinuses is used to better
■ Preoperative anesthesia consultation should be con- define the bony anatomy, pneumatization of the sphe-
sidered, especially in those patients with acromegaly noid, presence of a concha bullosa, position and possible
and Cushing’s disease. dehiscence of the carotid artery, location of the intersi-
nus septum, presence of an Onodi sinus, and extent of
Excessive growth hormone affects the heart, leading to postsurgical scarring (Fig. 28.1). MRI of the brain should
cardiac myopathy, as well as pharyngeal tissue, leading be used to define the extent and location of the tumor,
to hypertrophy of the base of tongue and redundant mu- including cavernous sinus involvement and impingement
cosa, creating a potentially difficult intubation, and may of the optic nerve/chiasm, and very importantly, to as-
require tracheotomy. Patients with Cushing’s disease have sess for any vascular abnormalities and the location of the
increased intraoperative anesthetic risk due to their mul- carotid arteries (Fig. 28.2). These images should then be
tiple comorbidities including obesity, diabetes, obstruc- fused for intraoperative stereotactic guidance.
tive sleep apnea, and hypertension.
As mentioned, patients with acromegaly may require
a temporary tracheotomy to establish a safe airway, and
this should also be considered in patients with severe
obstructive sleep apnea, as these patients will not be
able to use continuous positive airway pressure (CPAP)
postoperatively. In addition, the negative pressure from
deep breaths associated with an apneic event can lead to
pneumocephalus postoperatively. Similarly, wide swings
in intracranial pressure occurring during apneic events
may increase the risk of postoperative cerebrospinal fluid
(CSF) leak.
A detailed history and physical examination should be
performed. Special care should be taken to note any his-
tory of sinonasal complaints including nasal congestion
or obstruction, hyposmia/anosmia, rhinorrhea, postna-
sal drip, past nasal trauma, and headache. In addition,
history of other medical problems that could impact the
surgical outcome should be specifically queried includ-
ing diabetes, hypertension, and obstructive sleep apnea.
Review of old operative reports should be performed,
noting the type of approach (sublabial transseptal, frontal
craniotomy, or endoscopic endonasal), side of approach Fig. 28.1 Computed tomography, sagittal view, demonstrating
when applicable, and any perioperative complications. A previous resection and scar within the sphenoid
Revision Endoscopic Transsphenoidal Hypophysectomy 247
Fig. 28.2 Magnetic resonance image (a) axial and (b) coronal views of recurrent pituitary adenoma, note the displacement of the
carotid arteries
Laboratory data including complete blood count, and best visualization and illumination. Angled (45 and occa-
a comprehensive metabolic panel to evaluate for hypo- sionally 70) and longer telescopes can be useful in tumor
natremia, hypokalemia, hypercalcemia and hyperglyce- resection and exploration of the sella. When approaching
mia as well as other metabolic abnormalities should be the sella, the surgeon can use a unilateral or bilateral ap-
obtained. Coagulation studies including partial throm- proach. Early in our experience we preferred the unilat-
boplastin time, prothrombin time, and international eral approach, with the side of the approach determined
normalized ratio should be obtained if there is a family primarily by nasal factors: the presence of septal deviation
history of bleeding disorders. Endocrine evaluation of and concha bullosa, the degree of nasal congestion, and
prolactin, insulin-like growth factor-1, adrenocortico- the location of the sphenoid intersinus septum. If all nasal
tropic hormone, thyroid-stimulating hormone, thyrox- factors are considered equal, the contralateral side usually
ine, follicle-stimulating hormone, luteinizing hormone, confers the better angle of approach in lesions that are off
testosterone, morning cortisol, 24-h urine free cortisol, the midline or that extend into the cavernous sinus.
and 24-h urine free cortisol with low-dose dexametha-
sone suppression should occur as indicated by the clinical ■ We have found with time that the bilateral approach is
scenario [8]. In addition, all of our patients are placed on usually preferred as this allows wide access to the sella
perioperative steroids due to decreased endogenous ste- and the ability to use one side for the endoscope while
roid production. the other is used for instrumentation. In addition, this
can be requisite in patients with thin nasal cavities.
The patient is positioned in the “beach-chair” position

Surgical Technique
with the head and torso elevated and the knees bent, and
Standard-length 4-mm endoscopes fitted with scope ir- the patient’s right arm is tucked by their side. The patient’s
rigation are used to approach the sella, as they afford the head rests in a donut (gel or foam) and the head is rotated
15 toward the surgeon. It may be necessary to tilt the bed be encountered with varying difficulty, as the dura may
28 slightly toward the surgeon in a patient with a large body be scarred and it can be difficult to incise into the dura
habitus. Greater palatine blocks are then performed to without causing a CSF leak. We have found that revision
aid in hemostasis by injecting 1.5 ml of 1% lidocaine with surgery is associated with an increased risk of CSF leak,
1:100,000 epinephrine transorally into each greater-pala- regardless of the prior method of resection.
tine canal. The patient is then registered with the stereo-
tactic computer guidance software to ensure safe tumor ■ In revision hypophysectomy the carotid arteries can
removal. The abdomen is prepped and draped in a sterile be tethered medially; at this point the fused MRI and
manner in case a fat graft is needed; however, the face CT images are crucial for safe entrance into the sella
is not prepped as the instruments are passed through a and subsequent tumor removal.
contaminated nasal cavity. Under endoscopic guidance,
pledgets soaked with 0.05% oxymetazoline hydrochlo- The tumor generally bulges through the opening and
ride are placed into each nasal cavity for decongestion samples are sent for frozen section. The remaining tumor
and then additional lidocaine is injected at the junction is removed using neurosurgical ring curettes and suction
of the horizontal portion of the basal lamella and the lat- (Video 28.3). In order to ensure complete tumor removal,
eral nasal wall to achieve a sphenopalatine artery block. the endoscope can be inserted inside the sella and angled
The sphenoid ostium is then identified; a variable amount telescopes can be used to examine the lateral crevices of
of scar tissue may be present both intranasally and at the the sella. The technique of “hydroscopy,” the system of
face of the sphenoid. normal saline irrigation under pressure flooding the sella,
can be utilized to push the diaphragma up, as well as to
■ We rely heavily on image guidance to aid in the identi- wash away debris and clot [13].
fication of the sphenoid, which can be entirely scarred Following complete tumor removal, hemostasis is
over. obtained by placing a hemostatic substance, such as mi-
crofibrillar collagen in thrombin, over the operative field.
If scar has formed between the middle turbinate and When this is washed away the patient is evaluated for a
septum, it is lysed with a cutting instrument. Stapes and CSF leak.
J-curettes are utilized initially, and then the opening is
serially enlarged using a mushroom punch or Kerrison ■ If no CSF leak is encountered we have found that re-
rongeur. In some cases the sphenoid had been previously construction of the sella is not necessary.
packed with fat and this must be carefully cauterized and
resected using cutting instruments until the face of the In our report in 2003 we determined that there was no
sella is reached (Video 28.1). increase in the rate of postoperative leak (0.4% compared
to reported rates of 0.8–6.4%) and there were no cases of
■ Great care must be taken when resecting tissue within meningitis or empty-sella syndrome [15]. If a CSF leak is
the sphenoid, as the carotid and optic nerves can be encountered, we reconstruct the sella by using microfi-
dehiscent in 10 and 4% of individuals, respectively brillar collagen and a fat graft bolstered by an absorbable
[11]. miniplate cut to fit under the edges of the sella.
Once the sella has been adequately exposed, the mucosa

on the posterior wall of the sphenoid sinus is coagulated
Tips to Avoid Complications
with a bipolar cautery. Knowledge of the previous resec-
tion and presence of a CSF leak can aid the surgeon at this 1. Meticulous dissection should be performed, as incom-
point for safe entry into the sella. There can be significant plete resection is associated with an increased risk of
bone regrowth and it may be necessary to use a high- hemorrhage into the tumor.
speed drill, or else a Kerrison may simply be needed to 2. Consider temporary tracheotomy in patients with
enlarge the previous opening into the sella. The edges of obstructive sleep apnea to minimize the risk of post-
the window into the sella should be adequately exposed operative pneumocephalus and reduce the risk of
in any case, as demonstrated in Video 28.2. The endo- postoperative CSF leak. In addition, consideration for
scope is then attached to a fixed pneumatic holder, or an tracheotomy should be made since CPAP will not be
assistant can hold the scope, allowing the operating sur- able to be utilized during the postoperative period.
geon both hands for instrumentation. The dura is subse- 3. Perioperative steroids are critical in all patients, given
quently cauterized with bipolar cautery and a sickle knife the disruption in endogenous steroid production.
is used to make a cruciate incision. This step again can
Revision Endoscopic Transsphenoidal Hypophysectomy 249
the risk of postoperative meningitis. When this occurs

Complications
postoperatively, the patient may be treated conservatively
There are numerous complications associated with pitu- with bedrest and head elevation, or more aggressively
itary surgery, regardless of whether or not the patient has with lumbar puncture and/or surgical exploration. Some
had previous surgery. The mortality rate associated with authors advocate early surgical intervention, proposing
pituitary surgery is less than 1%, with the most common the following benefits: (1) decreased risk of developing
causes of death being (1) hemorrhage into an incom- meningitis for those who fail conservative management,
pletely resected pituitary tumor and (2) medical compli- (2) avoiding the risk associated with a lumbar drain, and
cations (deep vein thrombosis, pulmonary embolus and (3) potentially a decreased hospital stay [14].
myocardial infarction) [2]. Medical complications are Endocrine complications are common in the post-
found in patients with Cushing’s disease, and these pa- operative period, with diabetes insipidus (DI) occur-
tients should be regarded with an increased risk of peri- ring with the highest frequency. Revision surgery is not
operative mortality. a risk factor for developing DI; however, the presence of
Major complications of pituitary surgery include: a Rathke’s cleft cyst is, and these are apt to recur. In most
1. Carotid injury. instances DI is transient in nature and patients are able to
2. Intracranial hemorrhage. sustain enough oral intake, negating the need for medical
3. Meningitis. intervention. However, if it is sustained or symptomatic,
DDAVP (desamino-8-arginine vasopressin) is used, and
The carotid artery is at risk during pituitary surgery due these patients should be followed closely by their endo-
to its tortuosity, and can be especially at risk during revi- crinologist after discharge from the hospital [9].
sion surgery where scarring can further distort its normal Finally, endonasal complications such as septal perfo-
course along the skull base. Intraoperative damage to the ration, nasal obstruction, and sinusitis occur with a low
carotid artery occurs with an incidence of 0.78–1.16% frequency. We believe this is due to the fact the nose is
[7], and should it occur, the area should be packed and left largely undisturbed, especially laterally, allowing for
an angiogram should be emergently performed and in- continued normal function of the paranasal sinuses. In
tervention performed as deemed necessary. Even if the addition, it has been found that patients undergoing revi-
angiogram is initially normal, it should be repeated on sion endoscopic surgery who had undergone a prior sub-
postoperative day 6–10 to ensure there is no false aneu- labial approach found their recovery to be overall better
rysm or carotid-cavernous fistula [10]. Intracranial hem- with the endoscopic approach, with less pain and better
orrhage occurs with an incidence of 0.4–3% and most nasal airflow. Also, those patients who had nasal packing
commonly in the setting of incomplete removal of a mac- in place postoperatively had a significantly worse postop-
roadenoma, underscoring the need for meticulous and erative experience than those who did not [4].
complete tumor removal [17].
Meningitis occurs with an incidence of 0.15–1.2% and
has been associated with preoperative sinusitis and post-
Conclusion
operative CSF leak. All patients should be evaluated for
signs of acute sinusitis preoperatively, and if purulence Endoscopic transsphenoidal hypophysectomy is over-
is visualized the patient should be treated aggressively all a safe procedure. Revision surgery, although it may
with antibiotics. If the procedure is considered elective, it be technically challenging and is associated with an in-
should be postponed until the infection has resolved [16]. creased risk of CSF fistula, can also be performed in a safe
Chronic sinusitis does not increase the risk of meningitis and effective manner. Care should be taken, however, to
per se; however, if there is any suspicious mucous within avoid complications by meticulous preoperative prepara-
the nasal cavity a culture should be obtained and the pation, intraoperative stereotactic image guidance, careful
tient should be treated. and thorough tumor resection, and heightened awareness
The most common major complication that oc- of possible CSF fistula.
curs following transsphenoidal pituitary surgery is CSF
leak. This is especially common, as seen in our experi-
ence, in revision surgery. This is thought to be because
References
the diaphragma has become scarred and tenuous and/or
because more extensive resection is required due to the 1. Cappabianca P, Cavall LM, de Divitiis E (2004) Endo-
recurrent tumor itself. CSF leak has also been associated scopic endonasal transsphenoidal surgery. Neurosurgery
with large suprasellar tumors where the diaphragma be- 55:933–941
comes thin and incompetent. If the fistula is noted during
the procedure, repair should be performed to decrease
28 2. Ciric I, Ragin A, Baumgartner C, et al. (1997) Complica-

tions of transsphenoidal surgery: results of a national sur-
11. Renn WH, Rhoton AL Jr (1975) Microsurgical anatomy of
sellar region. J Neurosurg 43:288–298
vey, review of the literature and personal experience. Neu- 12. Rosen MR, Saigal K, Evans J, Keane WM (2006) A review
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surgery for pituitary adenomas. J Neurooncol 69:237–256 14:6–13
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transsphenoidal surgery: the patient’s perspective – survey creased role of the otolaryngologist in endoscopic pituitary
results from 259 patients. Surg Neurol 65:332–342 surgery: endoscopic hydroscopy of the sella. Am J Rhinol
5. Jankowski R, Auque J, Simon C, et al. (1992) Endoscopic 19:181–184
pituitary surgery. Laryngoscope 102:198–202 14. Shiley SG, Lionadi F, Delashaw JB, et al. (2003) Inci-
6. Jho HD, Carrau RL, Ko Y, et al. (1997) Endoscopic pituitary dence, etiology and management of cerebrospinal fluid
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surgery. Pituitary 2:163–170 15. Sonnenburg RE, White D, Ewend MG, et al. (2003) Sellar
8. Nemergut EC, Dumont AS, Barry UT, et al. (2005) Periop- reconstruction: is it necessary? Am J Rhinol 17:343–346
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dal pituitary surgery. Anesth Analg 101:1170–1181 rebrospinal fluid leakage during transsphenoidal surgery:
9. Nemergut ED, Zuo Z, Jane JA, et al. (2005) Predictors of postoperative external lumbar drainage reduces the risk for
diabetes insipidus after transsphenoidal surgery: a review meningitis. Pituitary 7:89–93
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Chapter 29
Revision Image-Guided Functional

Martin J. Citardi and Pete S. Batra
Disclosure: Dr. Citardi was a member a consult for CBYON (Mountain View, CA) in 1999–2003.
He has been a consultant for GE Healthcare Technologies (Waukesha, WI, USA) since 2003.
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
■ Image-guided surgery (IGS) incorporates both System Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
computer-enabled review of preoperative imaging Hardware . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
and intraoperative surgical navigation. Rhinolo-
Software . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
gists have embraced IGS as a technological means
to reduce surgical morbidity and improve surgical Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
outcomes. Paired-Point Registration . . . . . . . . . . . . . . . . . . . . . . 254
■ All IGS systems share similar hardware (computer Automatic Registration . . . . . . . . . . . . . . . . . . . . . . . . 254
workstation, display monitor, tracking system, and
Contour-Based Registration . . . . . . . . . . . . . . . . . . . . 254
surgical navigation) and software (data management,
image review, surgical navigation) components. Assessment of Surgical Navigation Accuracy . . . . . . . . 254
■ Registration is the process through which a surgi- Preoperative Considerations and Surgical Indications 255
cal navigation system establishes a one-to-one map- Specific Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
ping relationship between corresponding points in
Ethmoid Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
the operating field volume and the imaging data set
volume. Frontal Sinus Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 256
■ Registration protocols may be classified as paired- Sphenoid Sinus Surgery . . . . . . . . . . . . . . . . . . . . . . . 256
point, automatic, and contour-based. Previous Complications . . . . . . . . . . . . . . . . . . . . . . . 257
■ Surgical navigation is best assessed through deter-
Sinonasal Polyposis . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
minations of target registration error (TRE). In the
clinical realm, the surgeon estimates TRE by local- Limitations of Revision IG-FESS . . . . . . . . . . . . . . . . . . 264
izing against known anatomic landmarks. Special IGS Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . 264
■ The American Academy of Otolaryngology – Head Intraoperative CT and Fluoroscopy . . . . . . . . . . . . . 264
and Neck Surgery has issued a position statement
CT-Magnetic Resonance Fusion . . . . . . . . . . . . . . . . 265
that endorses the use of IGS at the discretion of the
operating surgeon in sinus and skull-base surgery. CT Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
■ Currently, IGS is commonly employed for revision Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
endoscopic sinus surgery involving the ethmoid, Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
frontal, and sphenoid sinuses. IGS is also useful in
cases of sinonasal polyposis. In the setting of previ-
ous orbital and skull-base injury, IGS can provide
critical information.
■ Although prospective, randomized clinical trials
Introduction
for IGS have not been performed, published reports
describe the consensus that IGS reduces morbidity Since its introduction more than two decades ago, func-
and improves outcomes. tional endoscopic sinus surgery (FESS) [17,18] has
emerged as the preferred surgical modality for the man-
agement of chronic rhinosinusitis (CRS) refractory to
252 Martin J. Citardi and Pete S. Batra
medical treatment. Even under ideal circumstances, ap-

Hardware
proximately 10–15% of patients who undergo FESS will
develop recalcitrant CRS [9], and an even smaller propor- The computer workstation is the central component of all
29 tion of these patients will require one or more revision IGS systems as it supports the software that drives the en-
FESS procedures. Rhinologists universally acknowledge tire process. The original operating system for many IGS
that these revision FESS procedures are technically more systems was UNIX; newer systems utilize other operat-
challenging and carry a greater risk of major and minor ing systems, including Windows 2000, Windows XP, and
complications. Both significant inflammatory burden and LINUX. The keyboard and the standard computer mouse
previous procedures serve to obscure surgical landmarks. serve as input devices. A standard computer monitor al-
Thus, rhinologists have embraced computer-aided sur- lows for output of visual information from the system.
gery (CAS) technology as a means to improve outcomes Newer systems with high-resolution, flat-panel, liquid
and reduce morbidity. crystal display screens afford enhanced capabilities for
The term “image-guided surgery” (IGS) has come review of image data sets.
to refer to CAS in FESS. It should be remembered IGS The tracking system allows for monitoring of the rela-
incorporates computer-enabled review of preoperative tive position of the surgical instruments. Current com-
imaging and intraoperative surgical navigation. Early mercially available systems rely on electromagnetic or op-
IGS systems were cumbersome and their surgical navi- tical tracking technology. For electromagnetic tracking,
gation accuracy was suboptimal; however, more recent an electromagnetic receiver provides positional informa-
IGS platforms support a user-friendly interface and more tion in an electromagnetic field generated by a specific
robust navigation. In addition, the image quality has im- emitter attached to the patient. For an optical tracking
proved considerably compared with first-generation sys- system, an overhead camera array, termed the digitizer,
tems from more than 10 years ago. The availability of the tracks the position of light-emitting diodes (LEDs; or re-
technology is now quite good. Consequently, rhinologists flective spheres in a passive system).
now routinely incorporate IGS into most revision sinus Specific surgical instrumentation can be tracked in the
surgery cases. operative field by its attachment to an intraoperative lo-
calization device (ILD). In an optical system, the ILD is
an array of LEDs (or reflective spheres), and in an electro-
magnetic system, the ILD is an electromagnetic sensor.
System Components
Almost any instrument can be adapted for intraoperative
Image-guidance vendors often try to highlight the unique surgical navigation, including straight and curved suction,
aspects of their respective systems. Although this may through-cutting forceps, soft-tissue shavers, and drills.
serve as a useful sales tactic, all IGS systems share certain Data transfer hardware facilitates transfer of the pre-
similar components (Table 29.1). operative dataset to the computer station. This can be
achieved through network linking between the computer
and the radiology department. Alternatively, the data can
be transferred via commonly available digital media, in-
cluding CD-ROM and DVD.
Table 29.1 Image-guided surgery (IGS) system hardware components
Item Details
Computer workstation Unix, Windows 2000, Windows XP, LINUX
Display system Video monitor (cathode-ray tube monitor, high-resolution, flat-panel display)
Tracking system Electromagnetic system, optical system
Surgical instrumentation Straight and curved suction, cutting forceps, soft-tissue shavers, drills
Data transfer hardware Computer network, CD-ROM, DVD

Revision Image-Guided Functional Endoscopic Sinus Surgery 253
Software Registration
User-friendly software is an integral component of a ro- Registration is the process through which a surgical naviga-
bust IGS system; it integrates the various hardware com- tion system establishes a one-to-one mapping relationship
ponents for optimal surgical navigation and other related between corresponding points in the operating field vol-
applications. In general, discussions surrounding IGS ume and imaging data set volume. Three basic paradigms
focus on intraoperative navigation. IGS offers numerous for registration are commercially available: paired-point
software tools that facilitate complex 3D manipulation of registration (PPR), automatic registration (AR), and con-
the preoperative data set. These software tools allow pre- tour-based registration (CBR; Table 29.2). Although spe-
cise preoperative review of images to understand the vital cific approaches to registration are commonly associated
3D anatomic relationships that simply cannot be obtained with specific hardware, such an association is not intrin-
by standard light-box review of radiographic images. This sic to the registration paradigm; rather, these associations
facilitates careful and detailed surgical planning, which reflect decisions made during the design of surgical navi-
can be instrumental for revision image-guided FESS (IG- gation systems. Regardless of the registration paradigm,
FESS). the principles that govern surgical navigation are similar.
Table 29.2 Registration paradigms
Registration Concept Steps

paradigm
Paired-point Manual mapping of corresponding 1. The surgeon selects fiducial points in the preop-
registration points forms the basis for an alignment erative imaging volume (alternatively, software
of the preoperative imaging volume automatically locates external fiducial markers).
and intraoperative surgical field volume 2. The surgeon places a tracking device on the patient.
3. The surgeon calibrates the surgical probe.
4. The surgeon localizes each cor-
responding fiducial point.
5. The computer calculates the registration.
6. The surgeon confirms surgical navigation accuracy.
Automatic Patient wears a headset with built-in 1. The patient wears a special headset with fiducial
registration fiducial markers at the time of the markers during image acquisition and surgery.
preoperative imaging and surgery. The 2. The computer automatically locates the fi-
headset is designed so that it position- ducial points in the imaging data set and
ing is reproducible each time that it then calculates the registration.
is placed upon the patient. Thus, the 3. The surgeon places a tracking device on the patient.
relationships between the fiducial 4. The surgeon calibrates the surgical probe.
points and the patient are the same 5. The surgeon confirms surgical navigation accuracy.
during image acquisition and surgery.
At surgery, the computer locates the
fiducial points in the imaging data
and calculates the registration.
Contour-based The computer builds a 3D model based 1. The computer builds a 3D model of the patient.
registration upon the preoperative imaging. During 2. The surgeon places a tracking system on the patient.
registration, the surgeon localizes con- 3. The surgeon calibrates the surgical probe.
tours on the patient, and the computer 4. The surgeon performs a rough
fits the points on these contours to the paired-point registration.
contours defined by the 3D model. 5. The surgeon localizes points on con-
tours on the patient.
6. The computer calculates the registration.
7. The surgeon confirms surgical navigation accuracy.
The term “calibration” should not be used interchange- may be placed on the surface. These devices serve simply
ably with the term “registration.” Calibration is the pro- to define a surface contour, much as the task of running
cess for confirming or defining the relationship of an in- a rigid tracked probe across a surface defines a contour.
29 strument tip and a tracking device. Calibration must be Finally, the software aligns corresponding contours in the
performed independently of the registration process for preoperative imaging volume and the surgical field vol-
intraoperative surgical navigation. ume to create the registration.
Paired-Point Registration Assessment of Surgical

Navigation Accuracy
PPR requires three steps. First, the fiducial points must
be identified in the preoperative imaging data set. Vari- Registration error theory [24] provides a framework for
ous types of fiducial markers may be used for PPR. Ex- the discussion of the assessment of surgical navigation ac-
ternal fiducial markers may be anchored to bone with curacy. Target registration error (TRE) provides the most
screws or to skin with adhesive. Automated software rou- clinically useful information, since it describes the differ-
tines may identify those external fiducial markers in the ence between the measured position of an instrument tip
preoperative imaging data set, or the surgeon may manu- (i.e., the indicated position in the preoperative imaging
ally identify the points at the computer workstation. Al- volume) and its position in the real world. Unfortunately
ternatively, the surgeon may select anatomic landmarks reports of surgical navigation error in the otolaryngology
to serve as fiducial points. Next, the surgeon manually literature are quite inconsistent; thus, it can be difficult to
localizes each fiducial point in the patient volume with summarize surgical navigation accuracy, because differ-
the navigation probe. Finally, the computer software per- ent reports often use different nomenclature and meth-
forms the registration by aligning corresponding points ods to measure and report accuracy [20]
in the preoperative imaging data set and the operative In the operating room, the surgeon must visually es-
field volume. timate TRE at different anatomic regions throughout the
case. TRE can differ in different parts of the operating
field volume, and mechanical slippage of the headset and
similar hardware issues may increase TRE. Thus, it is im-
Automatic Registration
portant to continuously assess surgical navigation, since
AR depends upon the fiducial headset, which is designed an unrecognized increase in TRE can lead to catastrophic
so that its positioning on the patient is reproducible. Be- complications. Visual estimates of TRE can be prob-
cause of this unique feature, the relationship between lematic when one considers that they are obtained un-
the fiducial array built into the fiducial headset and the der endoscopic visualization, which only provides a 2D,
patient is the same each time the headset is placed upon wide-angled (i.e., with some spherical distortion) view of
the patient. For registration, the software automatically a complex 3D space. As a result, TRE should be estimated
identifies the fiducial markers in the headset worn by the by assessing its individual vector components (x-axis,
patient at the time of preoperative imaging, and then cal- y-axis, z-axis) independently. For example, the medial
culates registration. At the time of surgery, it is assumed orbit, superior maxillary wall (the orbital floor), and the
that the positioning of the headset is functionally identi- posterior maxillary wall can provide TRE information
cal at the time of preoperative imaging and surgery. for the x-axis (medial–lateral), y-axis (superior–inferior),
and z-axis (depth) directions, respectively.
Most published reports present only TRE for specific
systems. Representative studies are summarized in Ta-
Contour-Based Registration
ble 29.3. Several recent reports have highlighted compari-
CBR is similar to PPR in that the surgeon must manually sons of registration protocols. Hardy et al. examined TRE
map points in the surgical volume. For CBR, the com- for PPR with bone-anchored fiducial markers, CBR with
puter builds a 3D model from the preoperative imaging skin contours, and PPR with anatomic fiducial landmarks
data. Then, the surgeon must identify corresponding con- in a cadaveric model for endoscopic sinus surgery using
tours on the surface of the surgical volume. In most sys- a VectorVision surgical navigation system (BrainLab,
tems, this step requires an initial approximate PPR with Munich, Germany) [14]. Both PPR with bone-anchored
three anatomic fiducial points; subsequently, the surgeon fiducial markers and CBR yielded mean TRE values that
runs the surgical probe across contours on the surface of were lower than corresponding TRE values from PPR
the surgical volume to identify 40–500 discrete points. with anatomic fiducial points, but TRE values for PPR
Rather than a fixed probe, a laser-based device may also with bone-anchored fiducial markers and CBR were sta-
serve to identify this contour, or a flexible grid of LEDs tistically similar. Metzger et al. compared PPR with bone-
anchored fiducial markers, CBR with skin contours, PPR

Preoperative Considerations
with bone anatomic landmarks, and PPR for a simulated
and Surgical Indications
intraoral appliance in a cadaveric model for three surgi-
cal navigation platforms: VectorVision (BrainLab, Mu- The American Academy of Otolaryngology – Head and
nich, Germany), Voxim (IVS Solutions, Chemintz, Ger- Neck Surgery (AAO-HNS) has published an official posi-
many), and StealthStation (Medtronic, Jacksonville, FL, tion statement on the utility of IGS:
USA) [28]. They reported TRE values of 1.13 ± 0.05 mm, “The American Academy of Otolaryngology – Head
2.03 ± 0.07 mm, 3.17 ± 0.10 mm, and 3.79 ± 0.13 mm re- and Neck Surgery (AAO-HNS) endorses the intraopera-
spectively. Differences between registration protocols tive use of computer-aided surgery in appropriately select
were deemed statistically significant; however, each sur- cases to assist the surgeon in clarifying complex anatomy
gical navigation platform yielded similar TRE values for during sinus and skull-base surgery. There is sufficient
each registration protocol. Admittedly, this project was expert consensus opinion and literature evidence base
optimized for assessing navigational errors for cranio- to support this position. This technology is used at the
maxillofacial surgery. However, it does provide TRE in- discretion of the operating surgeon and is not experi-
formation that is also relevant for rhinologic surgery. mental or investigational. Furthermore, the AAO-HNS
Empiric data, theoretical considerations and anecdotal is of the opinion that it is impossible to corroborate this
evidence all corroborate common principles for reducing with Level 1 evidence. These appropriate, specialty-spe-
TRE [36]: (1) observed TRE will be lowest at the centroid cific, and surgically indicated procedural services should
(point whose x,y,z coordinates are the mean values of be reimbursed whether used by neurosurgeons or other
the x,y,z coordinates of the fiducial points); that is, the qualified physicians regardless of the specialty.” [1]
observed TRE will be lowest at the center of the space The currently accepted indications for the use of IGS
defined by the fiducial points, (2) fiducial points should as advocated by AAO-HNS are listed in Table 29.4.
be spread in 3D space to provide maximum information
for registration, (3) similarly, distances between fiducial
points should be maximized, and (4) greater numbers of
Specific Applications
fiducial points yield lower TREs, although the incremen-
tal benefit of additional points decreases as the number of Surgical navigation has emerged as an important part of
points increases. revision FESS at most centers. Although it has been dif-
Table 29.3 Reported target registration error for commercially available IGS platforms for sinus surgery. CBR Contour-based regis-
tration, N/A registration protocol not available for the specific system, PPR paired-point registration
System (vendor) Tracking hardware Registration type Reported accuracy
InstaTrak Electromagnetic Automatic 2.28 mm (95% CI 2.02–2.53) [12]

GE Navigation and Visualization
PPR 1.97 mm (95% CI 1.75–2.23) [12]
Lawrence, MA, USA
CBR with touch 1.5 ±0.3 mm [19]
Landmarx Optical Automatic N/A

Medtronic Xomed
PPR 1.69 ± 0.38 mm [26]
Jacksonville, FL, USA
CBR No report
Stryker Navigation System Optical Automatic N/A

Stryker-Leibinger
PPR 1.6 mm (range 0.6–3.7) [34]
Kalamazoo, MI, USA
CBR 2.22 ± 0.91 mm [3]
(“Mask”)
VectorVision Optical Automatic No report

BrainLAB
PPR 1.57 ± 1.1 mm [5]
Hemstetten, Germany
CBR with laser 2.4 ± 1.7 mm [4]
ficult to objectively document the positive impact of IGS scarred frontal recess [8]. In many revision endoscopic
on FESS (see “Outcomes” below), most rhinologic sur- frontal sinusotomy cases, the middle turbinate remnant
geons have concluded that it is helpful in most instances fuses to a partially collapsed frontal recess. In this situ-
29 and thus routinely include it for the more complex cases. ation (as in others) the endoscopic view alone does not
The utility of IGS for sinus surgery is best illustrated by portray the anatomy “in depth;” that is, the endoscope
considering specific cases that demonstrate the technol- alone cannot indicate the structures beneath a healed
ogy in action (Figs. 29.1–29.5). mucosal surface. The addition of surgical navigation gives
It must be emphasized that the true value of IGS begins the surgeon information about the structures beyond the
before surgery commences. IGS provides a platform for healed mucosal surface. This can be especially important
computer-enabled review of preoperative imaging and thus in the frontal recess, where residual frontal recess cells
serves as a platform for preoperative surgical planning. may be “stacked” (Fig. 29.2a). In some cases, the frontal
recess may be obstructed by amorphous scarring that
smoothly blends into the adjacent skull base and orbit;
in this situation, intraoperative surgical navigation is in-
Ethmoid Surgery
valuable (Fig. 29.2b).
During revision endoscopic ethmoidectomy, the surgeon IGS also has been incorporated into traditional tech-
completes a surgical dissection in a field that has been niques for frontal sinus surgery, including frontal sinus
distorted by long-standing inflammatory processes as trephination and osteoplastic frontal sinusotomy. Mel-
well as one or more surgical procedures. Achievement roy et al. analyzed the role of IGS for osteoplastic fron-
of the surgical objectives requires comprehension of the tal sinusotomy in a cadaveric model that compared IGS,
number, shape, and configuration of residual ethmoid traditional Caldwell radiographs, and transillumination
cells (Fig. 29.1a). In addition, recognition of the limits of [25]. In this report, IGS was deemed more accurate than
surgical dissection (i.e., the skull base and orbit) is critical the two other alternatives in determining the extent of
(Fig. 29.1b). frontal-sinus pneumatization, and importantly, IGS did
not seem to overestimate frontal size. In a clinical report,
Zacharek et al. presented a series of 13 patients in whom
placement of the frontal sinus trephine was planned
Frontal Sinus Surgery
through intraoperative surgical navigation [37].
Numerous rhinologic surgeons have commented upon
the complexity of endoscopic frontal sinusotomy, and
daily anecdotal experiences easily corroborate these
Sphenoid Sinus Surgery
teachings. The key to successful endoscopic frontal sinus-
otomy is the appreciation of frontal recess pneumatiza- Surgical navigation also plays an important role in almost
tion patterns. Today, those pneumatization patterns have all endoscopic procedures performed on the sphenoid
been characterized in a clinically useful way through sinus [7]. Because of the asymmetry and variability of
systematic study of frontal recess anatomy at a computer sphenoid anatomy as well as the proximity of critical ad-
workstation with software for review of archived high- jacent structures, sphenoid surgery carries the risk of ma-
resolution computed tomography (CT) data [21]. Thus, jor complications. In the situation where there has been
it is logical to use the computer workstation for preopera- previous surgery, the potential for major complications is
tive review of frontal recess anatomy. even greater. Surgical navigation gives localization above
During surgery, surgical navigation can greatly facili- the relatively simple cues afforded by endoscopic visual-
tate complete endoscopic dissection of an even heavily
Table 29.4 Clinical indications for the use of IGS
• Revision sinus surgery

• Distorted sinus anatomy of developmental, postoperative, or traumatic origin
• Extensive sinonasal polyposis
• Pathology involving the frontal, posterior ethmoid, and sphenoid sinuses
• Disease abutting the skull base, orbit, optic nerve, or carotid artery
• Cerebrospinal fluid rhinorrhea or conditions where there is a skull-base defect
• Benign and malignant sinonasal neoplasms
Fig. 29.1 a In this screen capture obtained with the InstaTrak tomography (CT) images provides information about the num-
3500 Plus (GE Healthcare Navigation and Visualization, Law- ber, shape, and configuration of residual ethmoid partitions, as
rence, MA, USA) during revision endoscopic ethmoidectomy, well as their relationship to the orbit and skull base. (b continued
the surgical aspirator is positioned in the posterior ethmoid. Si- next page)
multaneous review of the coronal, sagittal, and axial computed
ization, and thus, it is an important tool for safe revision with potentially catastrophic consequences. In most in-
endoscopic sphenoidotomy (Fig. 29.3). stances, appropriate recognition and treatment will mini-
mize the immediate morbidity (and mortality) of these
complications, but some of these patients will require
revision procedures for persistent and recurrent inflam-
Previous Complications
matory disease. In these instances, it is critical to recog-
Obviously any procedure performed on the paranasal si- nize occult orbital and skull-base dehiscences, which can
nuses may lead to disruption of the skull base and orbit be found under intact mucosal boundaries. With surgi-
29
Fig. 29.1 (continued) b Skull-base identification is a critical step obtained with the InstaTrak 3500 Plus. This maneuver provides
during revision endoscopic ethmoidectomy. In many cases it is immediate information about depth, a cue whose importance is
possible to pass a tracked instrument through the previously dis- only recognized when one remembers that the view provided by
sected ethmoid to the skull base, as shown in this screen capture the nasal endoscopes is only 2D
Fig. 29.2 a In this screen capture obtained with the InstaTrak is resting upon the fusion point for a partial resected middle
3500 Plus during revision endoscopic frontal sinusotomy, the turbinate that has partially lateralized; however, the navigation
instrument tip has been placed at the floor of the residual agger views more accurately depict the true anatomy. b continued next
nasi cell. In the endoscopic view, it appears as if the instrument page)
29
Fig. 29.2 (continued) b In this case, the left frontal sinus has frontal sinusotomy from endoscopic visual cues alone. Surgi-
been completely obstructed by scarring. The endoscopic view cal navigation can simplify this situation, since it can quickly
alone indicates a rather amorphous lump in the frontal recess; demonstrate the position of the instrument tip relative to the
the key step is to distinguish the obstructed frontal recess tract obstructed frontal recess, the orbit, and the skull base, as dem-
(which is covered in scar) from the adjacent skull base and orbit. onstrated in this screen capture obtained with InstaTrak 3500
It is difficult to assess the entry point for revision endoscopic Plus
Fig. 29.3 In this patient, the sphenoid sinus has been become scopic sinus surgery, shows the entry point into a small sphe-
obstructed by reactive new bone formation. This screen capture, noid sinus whose intraluminal volume has been contracted by
obtained with the InstaTrak 3500 Plus during revision endo- so-called osteitic bone formation
29
Fig. 29.4 In this screen capture, obtained with the InstaTrak moid cell; failure to recognize that this area is actually an orbital
3500 Plus during revision endoscopic sinus surgery, the instru- dehiscence from surgery performed in the distant past would
ment tip rests upon an area of orbital dehiscence, through which have led to a potentially catastrophic orbital complication early
a small amount of orbital fat has prolapsed. The endoscopic view in the revision procedure
alone suggests that this region is simply a residual anterior eth-
Fig. 29.5 Image fusion combines images obtained from the dis- strates different signal characteristics within the opacified sphe-
tinct imaging modalities of CT and magnetic resonance (MR). noid sinus. In this instance, these findings were consistent with a
In this screen capture, obtained with the InstaTrak 3500 Plus mucocele. In other cases, the additional soft-tissue information
during revision endoscopic sphenoidotomy, the upper right can suggest the presence of an occult encephalocele or orbital
panel shows a fused CT-MR hybrid image that clearly demon- dehiscence
cal navigation, it possible to easily recognize these issues CAS in sinus surgery relies on the “rigid box” con-
and then simply work around them to achieve the desired cept, which is ideal for surgical navigation based on
surgical objectives (Fig. 29.4). the preoperative data set. The advent of intraopera-
29 tive volume CT scanning may allow for real-time
update of the image data set for revision IG-FESS
cases.
Sinonasal Polyposis
4. IGS is an enabling technology. It can facilitate re-
Endoscopic surgery for sinonasal polyposis is technically vision IG-FESS procedures by providing detailed
difficult. The inflamed polyp tissue tends to bleed so eas- information about the 3D relationships. However,
ily and profusely limiting the visualization that is among it does not change the nature of the procedure. The
the prime advantages of surgical endoscopy. In the setting surgeon must still adhere to currently accepted
of revision surgery, previous surgery will also distort the surgical principles; in revision cases, functional,
anatomy. Surgical navigation, while not a substitute for mucosal-sparing techniques are still paramount in
direct visualization of a bloodless field, plays an impor- successful execution of surgery.
tant role in revision endoscopic sinus surgery in patients
with sinonasal polyposis.
Special IGS Techniques
Over the past several years, additional capabilities have
Limitations of Revision IG-FESS
been added to IGS systems. These new applications offer
■ It is critical for otolaryngologists to recognize several specific advantages in certain clinical situations.
inherent limitations of CAS when used in revision IG-
FESS:
1. Accurate surgical navigation is dependent on ro-
Intraoperative CT and Fluoroscopy
bust registration. If the registration protocol tightly
maps the preoperative data set to the operative An important criticism of surgical navigation is that the
field, optimal intraoperative surgical navigation commonly available systems rely upon preoperative im-
will be achieved. In theory, bone-anchored fiducial aging and, as a result, the navigation is always relative
markers provide the best TRE from PPR. However, to imaging that does not reflect anatomic changes made
this strategy is impractical, and frankly unaccept- during surgery. This lack of real-time updating is a larger
able, even in revision IG-FESS cases. Alternative issue for more complex procedures in which greater sur-
registration paradigms, such as CBR, PPR with gical manipulations are performed. The incorporation of
anatomic landmarks, and AR provide acceptable intraoperative imaging would overcome this limitation.
registration, and importantly, increase the usability In the late 1990s, intraoperative magnetic resonance
of the system. Given the importance of registra- imaging (MRI) suites were introduced, and their uses
tion for successful surgical navigation, all surgeons for sinus surgery were explored [10, 154]. This strategy
should be capable of troubleshooting registration never gathered much traction for a variety of practical
issues. considerations. MRI surgical suites are expensive; in ad-
2. Although IGS is a powerful surgical tool, it is not a dition to the costs associated with the imaging technol-
substitute for surgical expertise and thorough un- ogy, all instrumentation must be made MRI-compatible.
derstanding of the paranasal sinus anatomy. Thus, Thus, the availability of this technology is limited due to
if a surgeon lacks the proper requisite training to the cost issues, which are considerable even under ideal
perform revision IG-FESS cases, CAS systems will circumstances. Furthermore, MRI does not provide good
not improve the capabilities of the surgeon to com- bony detail, which is desirable for most endoscopic sinus
plete this complex task. On the other hand, in the surgery procedures.
hands of a skilled surgeon, IGS may allow for better In contrast, intraoperative fluoroscopy is common and
preoperative image assessment and surgical plan- relatively inexpensive. Recent technical advances now
ning, resulting in a more complete surgical proce- permit the creation of CT-like images from fluoroscopy
dure with a decreased risk of complications. images, and in concept, these reconstructed fluoroscopic
3. IGS platforms rely on preoperative imaging data CT image sets can be used for surgical navigation. In a
sets. Thus, intraoperative surgical navigation can- preliminary report Brown et al. report an initial series of
not reliably account for changes in the anatomy cases in which fluoroscopic CT images were used dur-
incurred by surgical manipulation. The success of ing image-guided endoscopic sinus surgery; the authors
describe the limitations of this technology in detail [4]. [22]. On some navigational platforms, it possible to seg-
In addition to the costs and complexity associated with ment a 3D model of the ICA and adjacent skull base and
the extra equipment, the quality of the fluoroscopic CT then incorporate this information into surgical planning
is clearly below what most surgeons would deem accept- and intraoperative surgical navigation. Obviously, surgi-
able, although technical modifications may partially ame- cal navigation with 3D-CTA plays a special role during
liorate this problem. Fluoroscopic CT acquisition also complex endoscopic surgery of the sphenoid surgery and
entails additional radiation exposure to the patient and adjacent skull base.
operating room (OR) staff. Nonetheless, as this technol-
ogy matures, it may find a role in the most complex endo-
scopic procedures of the paranasal sinuses.
Outcomes
Most recently, intraoperative CT scanners have been
introduced. With this technology, updated CT imaging Intuitively, IGS should improve surgical outcomes with
can be used for intraoperative surgical navigation. Cu- a decrease in morbidity. Selected series in the literature
mulative experiences with this approach are still sparse. have supported this concept. Almost all reports have
Anecdotal reports suggest that intraoperative CT imag- been case series that highlighted the incorporation of IGS
ing is technically easy and may be useful in select cases. into endoscopic sinus surgery [2, 11, 27,29, 31]. Reardon
Of course, intraoperative CT imaging carries additional compared a group of 400 patients whose sinus surgery
radiation exposure for both the patient and OR person- was performed with IGS, to a second historical control
nel. In addition, it must be remembered that sinuses filled group of 400 patients; no differences in major and minor
with blood and irrigation fluid will appear as opacified on complication rates were noted, although the IGS group
an intraoperative CT scan image, which will only high- cases included entry into more sinuses without an in-
light changes in bony anatomy. crease in operative time [30]. Fried performed a similar
comparison of a group 97 patients whose endoscopic si-
nus surgery included IGS, to a historical control group
of 61 patients whose surgery was performed before the
CT-Magnetic Resonance Fusion
availability of IGS; the rate for major complications was
Through the process of image-to-image registration (IIR), greater in the pre-IGS group compared to the IGS group
computer software can fuse high-resolution CT and mag- (11.1% vs. 1%, p < 0.01) [13].
netic resonance (MR) images to create hybrid images that Strauss et al. proposed a complex methodology for
combine features of both CT and MRI. Then the fused evaluating IGS utilizing surgical efficiency criteria [35].
data set can be during surgical navigation, allowing the A level of quality index was devised to evaluate the avail-
surgeon to navigate with both preoperative CT and MRI able information before and after FESS in 89 cases; the
information simultaneously [6, 23]. Navigation with CT- resultant change in the surgical strategy was measured.
MR fusion is most advantageous during endoscopic skull- For a total of 792 applications with a surgical pointer,
base surgery; it is especially helpful for tumor resection. 47.9% of the applications yielded a change in the surgical
This technology can also be useful for achieving adequate strategy. Less-experienced surgeons used the navigation
marsupialization of loculated mucoceles. Because the MR system more frequently in all cases and found the infor-
scan provides information about the position of the inter- mation to be more valuable than did more experienced
nal carotid artery (ICA), navigation with CT-MR fusion surgeons. The information gained was felt to be greatest
images has a role in endoscopic sphenoidal surgery. CT- at the following locations: sphenoid sinus, orbital lamina,
MR fusion images provide information about the char- frontal base, and frontal recess. The authors also noted a
acteristics of the material within opacified sinuses; these higher adjustment rate in surgical strategy for more ad-
images will help define mucoceles (as well as loculations vanced cases, such as tumor resection and biopsies.
within mucoceles) and encephaloceles (Fig. 29.5). Kacker et al. reviewed a cohort of 110 patients under-
going endoscopic procedures utilizing IGS [16]. The indi-
cations included 85 cases of revision FESS; the remainder
involved sphenoid and frontal disease and cerebrospinal
CT Angiography
fluid leak. No major complications were encountered in
Three-dimensional CT angiography (3D-CTA) provides these series, helping support the concept that IGS may
information about the position of the ICA in the sphe- help minimize complications in revision cases. In addi-
noid sinus, since the image acquisition is performed as a tion, only 12 (11%) patients required revision surgery for
contrast bolus fills the ICA at the skull base. High-resolu- persistent infection, which was reportedly a lower revi-
tion 3D-CTA images may be used for surgical navigation sion rate than without the use of IGS. Thus, the authors
proposed that the use of IGS “may allow for more a com- relationships and development of a surgical plan. Rigor-
plete sinus procedure and improve the efficacy of revision ous adherence to registration principles minimizes the
surgery.” risks of inaccurate navigation and allows for safe execu-
29 More recently, Smith et al. have applied the evidence- tion of the surgical strategy.
based medicine paradigm to the application of IGS in
sinus surgery [33]. After review of 105 articles, a total
of 5 were identified that addressed the following two
References
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complication rates?”, and (2) “Does image-guided sinus 1. American Academy of Otolaryngology – Head and Neck
surgery improve clinical outcomes?” Four series were ret- Surgery (2007) AAO-HNS Policy on Intra-Operative Use
rospective and were deemed level 4 evidence. One study of Computer-Aided Surgery. Retrieved August 12, 2007,
was level 5 and reflected expert opinion. In general, these 2007, from www.entlink.net/practice/rules/image-guiding.
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To date, no prospective trials have been conducted to 3. Arapakis I, Hubbe U, et al. (2005) LED autoregistration in
evaluate the efficacy of IGS for FESS or other advanced navigated endonasal sinus surgery. Laryngorhinootologie
endoscopic applications. Many authors have acknowl- 84:418–425
edged that this would likely be an insurmountable task 4. Brown SM, Sadoughi B, et al. (2007) Feasibility of near real-
given multiple ethical and logistical considerations. Smith time image-guided sinus surgery using intraoperative fluo-
et al. have reported that approximately 35,000 patients roscopic computed axial tomography. Otolaryngol Head
may need to be enrolled to show a statistical reduction in Neck Surg 136:268–273
the rate of major complications, if one establishes a major 5. Cartellieri M, Kremser J, et al. (2001) Comparison of dif-
complication rate of 0.25% for a clinical trial [33]. More- ferent 3D navigation systems by a clinical user. Eur Arch
over, it would be unethical to randomize patients away Otorhinolaryngol 258:38–41
from IGS when clinical experience and data suggest that 6. Chiu AG, Palmer JN, et al. (2005) Use of image-guided
the technology would benefit the potential patient. computed tomography-magnetic resonance fusion for
In a recent review titled “Parachute use to prevent complex endoscopic sinus and skull base surgery. Laryngo-
death and major trauma related to gravitational chal- scope 115:753–755
lenge: systematic review of randomized controlled trials,” 7. Citardi M (2003) Computer-aided sphenoid sinus surgery.
Smith and Pell tackle the question of whether every inter- Oper Techn Otolaryngol Head Neck Surg 14:188–194
vention intended to prevent ill health must be subjected 8. Citardi MJ (2001) Computer-aided frontal sinus surgery.
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“advocates of evidence-based medicine have criticized 9. Desrosiers M (2004) Refractory chronic rhinosinusitis:
the adoption of interventions evaluated by using only pathophysiology and management of chronic rhinosinus-
observational data. We think that everyone might benefit itis persisting after endoscopic sinus surgery. Curr Allergy
if the most radical protagonists of evidence-based medi- Asthma Rep 4:200–207
cine organized (sic) and participated in a double-blind, 10. Fried MP, Hsu L, et al. (1996) Image-guided surgery in a
randomized, placebo-controlled, crossover trial of the new magnetic resonance suite: preclinical considerations.
parachute.” [32]. Laryngoscope 106:411–417
11. Fried MP, Kleefield J, et al. (1997) Image-guided endo-
scopic sinus surgery: results of accuracy and performance
in a multi-center clinical study suing an electromagnetic
Conclusion
tracking system. Laryngoscope 107:594–601
With continued refinement and widespread acceptance, 12. Fried MP, Kleefield J, et al. (1997) Image-guided endo-
IGS has become a transformative technology in the realm scopic surgery: results of accuracy and performance in a
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tion of IGS to revision sinus surgery, or revision IG-FESS, ing system. Laryngoscope 107:594–601
may allow for more complete surgery, with reductions in 13. Fried MP, Moharir VM, et al. (2002) Comparison of endo-
complication rates and less need for additional revision scopic sinus surgery with and without image guidance. Am
procedures. To optimize performance of IGS in revision J Rhinol 16:193–197
FESS, surgeons must be intimately familiar with the hard- 14. Hardy SM, Melroy C, et al. (2006) A comparison of com-
ware and software applications of the image-guidance puter-aided surgery registration methods for endoscopic
technology. Careful preoperative review of CT images al- sinus surgery. Am J Rhinol 20:48–52
lows for a better understanding of the complex anatomic
15. Hsu L, Fried MP, et al. (1998) MR-guided endoscopic sinus 27. Metson RB, Cosenza MJ, et al. (2000) Physician experience
surgery. AJNR Am J Neuroradiol 19:1235–1240 with an optical image guidance system for sinus surgery.
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yngol Clin North Am 38:473–482 tration strategies for computer-aided maxillofacial surgery.
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Surg 13:27–31 32. Smith GCS, Pell JP (2003) Parachute use to prevent death
21. Lee WT, Kuhn FA, et al. (2004) 3D computed tomographic and major trauma related to gravitational challenge: sys-
analysis of frontal recess anatomy in patients without fron- tematic review of randomized clinical trials. Br Med J
tal sinusitis. Otolaryngol Head Neck Surg 131:164–173 327:20–27
22. Leong JL, Batra PS, et al. (2005) Three-dimensional com- 33. Smith TL, Stewart MG, et al. (2007) Indications for image-
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artery for preoperative evaluation of sinonasal lesions 21:80–83
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115:1618–1623 tion error with image guidance systems during endoscopic
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the management of skull base lesions. Otolaryngol Head 131:145–149
Neck Surg 134:868–876 35. Strauss G, Koulechov K, et al. (2006) Evaluation of a navi-
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ance systems for head and neck surgery. Arch Otolaryngol
Chapter 30
Revision Endoscopic Sinus

Surgery in Children 30
Hassan H. Ramadan
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
■ Chronic rhinosinusitis is a very common condition Failure of ESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
in children. Surgical Causes of Failure of ESS . . . . . . . . . . . . . . . . 270
■ Endoscopic sinus surgery (ESS) is gaining popular-
Medical Causes of Failure in ESS . . . . . . . . . . . . . . . . 270
ity in children.
■ The failure rate of ESS ranges between 13–20%. Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
■ Image-guided CT scan should be considered in chil- Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
dren with failure of ESS. Preoperative Workup . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
■ Revision surgery is recommended for children who
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
fail medical treatment.
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Introduction
Endoscopic sinus surgery (ESS) is the surgical procedure
of choice for chronic rhinosinusitis (CRS) in adults [1–3]. Although causes of revision surgery in adults include
Recently it has gained wide popularity as a surgical pro- extent of disease, severe polyposis, and previous nonen-
cedure in children. Despite the fact that it is not the first doscopic sinus procedures, these causes are uncommon
procedure of choice in CRS refractory to medical treat- in children [9]. Extent of disease is limited mainly to the
ment in children, it is being performed more and more in ethmoid and maxillary sinuses. Rarely are the frontal and
these patients. The success of ESS in children is reported sphenoid sinuses involved.
to be approximately 88% [4–6]. Unlike ESS in adults, the
procedure in children is more conservative and is limited ■ ESS in children is not the primary surgical proce-
in most children to anterior ethmoidectomy and maxil- dure for CRS. Adenoidectomy, and/or maxillary sinus
lary sinus antrostomy because those are the sinuses that washing with culture-directed antibiotics are usually
are most commonly involved. Some authors even per- performed prior to ESS [6, 7, 10].
form a maxillary sinus wash at the time of adenoidec-
tomy, before ESS is performed [7]. Surgery on the septum Children who do not respond to these conservative mea-
and turbinates is not very common in these children. The surements are then evaluated with a computed tomog-
main purpose in children is to restore ventilation and raphy (CT) scan and considered for ESS. The surgical
mucociliary clearance of the sinuses. procedure in these children consists of anterior ethmoid-
Children with severe nasal polyposis, allergic fungal ectomy in 88%, maxillary antrostomy in 100%, posterior
sinusitis, or pansinusitis are rare and mainly have cystic ethmoidectomy in 28%, frontal sinusotomy in 6%, and
fibrosis, ciliary dyskinesia, or immune deficiency. They sphenoidotomy in 4% [6].
usually require continued medical management and a
more aggressive surgical intervention [8].
270 Hassan H. Ramadan
failure in those children are very well known. Data were

Failure of ESS
available on 176 children with at least 1 year of follow up;
Failure of ESS in children is reported to be in the range of 23 (13%) children required revision ESS.
12–13%. Failure should be defined as those children who Analysis of the data showed that in the 23 patients, 47
require another surgical procedure or those who continue findings were present causing the failure. Patients may
30 to have signs and symptoms of CRS despite continued have had more than one finding. The most common find-
medical therapy. Causes of failure in children can be di- ing in our revision cases was adhesions in 57% of the cases,
vided into two groups if we exclude those with cystic fibro- followed by maxillary sinus ostium stenosis or missed
sis, immune deficiency, or ciliary abnormalities [4–6]: (1) maxillary sinus ostium in 52% of the cases (Figs. 30.1
children who have a surgical cause of failure, and (2) chil- and 30.2). In 39% of the cases there was recurrent disease
dren who failed because of their age, presence of asthma/ requiring revision surgery in the sinuses that were oper-
allergy, or severity of their disease. These two groups dif- ated on initially. Interestingly however, we found that in
fer in the cause of the failure; however, in some children it 26% of the revision cases surgery was needed because of
may be a combination of those factors. Knowledge of the disease that was present in nonoperated sinuses during
surgical causes of failure, however, may help us reduce the the primary ESS (Fig. 30). Four (17%) of the patients re-
failure rate for some of these children. quired a limited septoplasty at the time of revision that
was thought to be the cause of failure on the side of devia-
tion. In 13% of the children revision was needed because
of a mucocele, which was causing symptoms of sinusitis
Surgical Causes of Failure of ESS
due to obstruction of the sinuses (Fig. 30.4).
Reports on the surgical causes of failure of ESS in children Follow up was available on 19 patients with a range of
are very rare. In 1992, Lazar et al. reported that the most 1–5 years and a mean of 3 years. Fifteen (79%) patients at
common causes of failure in children were recurrence of last follow up were doing well and only 4 (21%) continue
disease, adhesions, and narrowing of the maxillary sinus to have sinusitis requiring medical management. Three
ostium [11]. In adults, numerous articles are available patients required 3 revisions, 14 required 2 revisions, and
concerning causes of failure after ESS, which include ex- 6 required 1 revision.
tent of disease, nasal polyposis, previous traditional sinus
surgery, presence of allergy, and anatomical abnormali-
ties such as a deviated septum [9].
Medical Causes of Failure in ESS
Analysis of the author’s experience between 1993 and
2005 showed that 243 children had ESS. Children with The success of primary ESS ranges between 88 and 92%
cystic fibrosis, immune deficiency/suppression, and cili- [12]. Conversely, those who continue to exhibit problems
ary abnormalities were excluded because the reasons of can either be manifesting a surgical failure as discussed
Fig. 30.1 Endoscopic view after endoscopic sinus surgery (ESS) Fig. 30.2 Endoscopic view of a missed natural maxillary sinus
showing deviated septum and adhesions between the middle ostium
turbinate and lateral nasal wall
Revision Endoscopic Sinus Surgery in Children 271
Fig. 30.3 a Coronal computed tomography (CT) scan of sinuses surgical changes at the maxillary sinus ostium, but now disease
prior to primary sinus surgery showing maxillary sinus disease involving the ethmoid sinuses
but clear sinuses. b Coronal CT sinuses before revision shows
above, or they can be exhibiting certain medical morbidi-

ties. The most common cause of failure of ESS is asthma,
followed by severity of sinus disease as evidenced by CT
score. Age at time of surgery also plays a significant role
in the outcome of surgery [6].
Asthma seems to impact outcome of ESS significantly.
Children with asthma had a 62% success rate compared
to 80% for those without asthma. Severity of disease as
measured by CT score (Lund-McKay system) also seems
to impact the outcome of ESS. Children with a higher CT
score had a higher failure rate than those with a lower CT
score. It was also noted that younger children (less than
6 years of age) had a higher failure rate with ESS than
older children. Children who were older had an 84% suc-
cess rate compared to 60% for the younger children. Al-
lergy, smoke exposure, and day-care attendance have also
been shown to influence the outcome of ESS, although to
a lesser extent than asthma, age, and severity of disease.
Children with cystic fibrosis, immune deficiency/sup-
pression, and those with ciliary abnormalities can be in-
cluded in this section.
Fig. 30.4 Coronal CT scan sinuses shows a mucocele in the left

ethmoid sinus eroding into the orbit post-ESS causing chronic
rhinosinusitis symptoms
dure [6]. Image-guided surgery for revision ESS has been

Indications shown to be advantageous for obtaining a better outcome
Indications for revision ESS are similar to those of pri- and to decrease complications [13]. If not already done,
mary ESS. However, in children the primary procedure these children should have an immunology evaluation and
is usually very conservative. In revision cases the surgeon allergy testing as part of their workup prior to revision
30 can be more aggressive in addressing the diseased sinuses, ESS, and ciliary biopsy at the time of surgery. For those
as done in adults. children with nasal polyposis, a course of oral steroids
Indications of revision sinus surgery in children in- 1 week prior to surgery will help intraoperatively. Using
clude: preoperative antibiotics is controversial and is left to the
1. Complicated rhinosinusitis. discretion of the surgeon. If the child develops an infec-
2. CRS symptoms not responsive to continued medical tion a few days before surgery, it is advisable to treat the
management for at least 3 months with antibiotics and infection and defer the surgical procedure until the child
ancillary medications. is better.
3. Recurrent acute rhinosinusitis with periods of remis-
sion of at least 3 weeks between episodes. Children
with four or more episodes of rhinosinusitis in a 6-
Surgical Technique
month period should be considered for revision.
4. Presence of sinus disease on CT scans of the sinuses. The surgical technique is similar to that done during the
5. Allergic fungal sinusitis. primary procedure, as described elsewhere, especially for
6. Antrochoanal polyp or presence of polyps not re- those sinuses that have not been operated on before [14].
sponding to medical management. Useful recommendations for revision sinus surgery in
7. Mucocele present in the sinuses. children:
1. Use of image-guided technology for a more complete
procedure and decreased likelihood of complications.
2. Use of power tools, especially for cases of nasal pol-
Contraindications
yposis and severe adhesions.
Contraindications can be relative and each surgeon 3. Care should be taken to identify the middle turbinate
should individualize depending on the status of his pa- and to separate it from the lateral nasal wall intact if
tient. Absolute contraindications can be children who are possible.
medically unfit for general anesthesia or those who have 4. Identification of the natural maxillary ostium, es-
a terminal illness where the sinus disease is the least of pecially in cases where a missed ostium is the cause
their worries. of failure. Once identified it should be widened and
Relative contraindications for revision sinus surgery joined to the accessory ostium.
in children include: 5. If a deviated septum is thought to be the cause of fail-
1. Children with cystic fibrosis who did not respond to ure then a limited endoscopic septoplasty should be
prior sinus surgery. performed.
2. Children with developmental/mental delay whose 6. Mucoceles and antrochoanal polyps can be easily
symptoms do not cause any change in their quality of identified and their excision is facilitated with power
life. instruments.
3. Children with ciliary abnormalities who did not re-
spond to prior sinus surgery. Tips and Pearls to Avoid Complications
4. Significant anatomical abnormalities with a high risk
1. Obtain adequate accuracy with the image-guided
of complications; in these cases an open approach may
system used.
be more desirable.
2. Use a 4-mm scope for better visualization when-
5. Disease that is present in the lateral aspect of the fron-
ever possible. In most children a 4-mm scope can
tal sinus.
be used instead of a 2.7-mm scope.
3. Use the 0 and 30 scopes interchangeably during
the procedure.
Preoperative Workup 4. Identify and spare the middle turbinate; it is an
important anatomical landmark for completing
The most important preoperative test in preparation for
the revision procedure.
revision ESS in children is obtaining CT scan to identify
5. Extreme caution is needed while revising the max-
disease and so that it can be used during the surgical proce-
illary antrostomy to avoid orbital fat herniation.
Revision Endoscopic Sinus Surgery in Children 273
3. We discourage blowing of the nose or use of nasal

Complications
sprays for 1 week.
Complications are uncommon in children even in revi- 4. Absorbable packing is used. It will be absorbed by
sion cases. They can be intraoperative or postoperative. around 2–3 weeks, thus debridement in children is not
Intraoperative complications of revision sinus surgery necessary.
in children include:
1. Cerebrospinal fluid (CSF) leak. This needs to be rec-
ognized during the procedure and repaired immedi-
Outcomes
ately.
2. Orbital entry with fat herniation. In most instances 1. Success rate of revision ESS in children ranges between
the procedure can be completed and no intervention 77 and 82%.
is needed. 2. Children may require more than one revision before
3. Orbital hemorrhage with increased pressure. An im- achieving success.
mediate lateral canthotomy should be performed with 3. Major complications in children are extremely rare.
removal of all the packing on that side. An ophthal-
mology consult should be obtained.
4. Stripping of the maxillary sinus mucosa. This needs to
References
be recognized otherwise, even though the bony ostium
is open, the mucosa inside the sinus will be collapsed 1. Bhattacharyya N (2006) Surgical treatment of chronic re-
with no ventilation of the inside of the sinus. current rhinosinusitis: a preliminary report. Laryngoscope
5. Inadvertent injury to the middle turbinate. All at- 116:1805–1808
tempts should be made to preserve it in place. 2. Smith TL, Batra PS, Seiden AM, Hannley M (2005) Evi-
6. Bleeding. If bleeding is considerably impairing the dence supporting endoscopic sinus surgery in the manage-
surgeon’s vision the procedure should be aborted. ment of adult chronic rhinosinusitis: a systematic review.
There is no need to put the patient at risk for blood Am J Rhinol 19:537–543
transfusion. If the bleeding is excessive with respect to 3. Dursun E, Korkmaz H, Eryilmaz A, Bayiz U, Sertkaya D,
the blood volume of the child, the procedure should Samim E (2003) Clinical predictors of long-term success
also be aborted. after endoscopic sinus surgery. Otolaryngol Head Neck
Surg 129:526–531
Postoperative complications of revision sinus surgery 4. Lusk RP, Muntz HR (1990) Endoscopic sinus surgery in chil-
in children: dren with chronic sinusitis. Laryngoscope 100:654–658
1. Bleeding. In most instances it is self-contained. Rarely 5. Parsons DS, Phillips SE (1993) Functional endoscopic sur-
packing or exam in the operating room is needed. gery in children: a retrospective analysis of results. Laryn-
2. Adhesions. Those can be very common depending on goscope 103: 899–903
the age of the child. If they are not causing any symp- 6. Ramadan HH (2004) Surgical management of chronic si-
toms, then they can be left alone. If symptomatic and nusitis in children. Laryngoscope 114:2103–2109
severe, a reexamination to deal with them would be 7. Buchman CA, Yellon RF, Bluestone CD (1999) Alternative
appropriate. to endoscopic sinus surgery in the management of pediat-
3. Orbital swelling and ecchymosis. If eye pressure is ric chronic rhinosinusitis refractory to oral antimicrobial
high, then proceed as in intraoperative increased pres- therapy. Otolaryngol Head Neck Surg 120:219–224
sure. If pressure is normal and the child is cooperative 8. Friedman EM, Stewart M (2006) An assessment of sinus
enough, remove the packing and observe. quality of life and pulmonary function in children with
4. CSF leak. Put the patient on complete bed rest, head cystic fibrosis. Am J Rhinol 20:568–572
elevation, and give stool softeners for 1 week. There is 9. McMains KC, Kountakis SE (2005) Revision functional
no support in the literature for a lumbar drain. If the endoscopic sinus surgery: objective and subjective surgical
CSF persists, then consider endoscopic repair. outcomes. Am J Rhinol 19:344–347
10. Ramadan HH (1999) Adenoidectomy vs endoscopic sinus
surgery for the treatment of pediatric sinusitis. Arch Oto-
laryngol Head Neck Surg 125:1208–1211
Postoperative Care
11. Lazar RH, Younis RT, Long TE, Gross CW (1992) Revi-
1. All patients are given oral antibiotics for 10–14 days. sion functional endonasal sinus surgery. Ear Nose Throat
2. We recommend sleeping with the head elevated for J 71:131–133
7 days.
12. Hebert RL 2nd, Bent JP 3rd (1998) Meta-analysis of out- 14. Ramadan HH (2007) Pediatric sinus surgery. In: Kountakis
comes of pediatric functional endoscopic sinus surgery. SE, Önerci M (eds) Rhinologic and Sleep Apnea; Surgical
Laryngoscope 108:796–799 Techniques. Springer, Heidelberg, pp 211–218
13. Dubin MG, Kuhn FA (2005) Stereotactic computer assisted
30 navigation: state of the art for sinus surgery, not standard of
care. Otolaryngol Clin North Am 38:535–549
Chapter 31
Open Approaches after Failure

of Primary Sinus Surgery 31
Mark C. Weissler
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
■ Consider carefully the cause of failure before em- Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
barking on further open surgery. Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
■ Osteoplastic frontal sinus surgery is the most com-
Osteoplastic Frontal Sinus Obliteration . . . . . . . . . . 276
mon open sinus procedure to be required after failed
primary surgery. The Caldwell-Luc Procedure . . . . . . . . . . . . . . . . . . . 277
■ External ethmoidectomy for failed primary endo- The Lynch Procedure . . . . . . . . . . . . . . . . . . . . . . . . . 278
scopic sinus surgery is rarely, if ever, indicated. The Lothrop Procedure . . . . . . . . . . . . . . . . . . . . . . . . 279
Other Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

4. The patient for whom endoscopic surgery proved in-

Introduction
adequate to achieve the necessary exposure and ana-
The concept of “failed primary sinus surgery” itself requires tomical results.
some discussion. Obviously, surgery may fail because the
infection one sought to cure was not cured. In the most The first question to be asked is whether or not the disease
obvious example, a patient with an intracranial abscess process in question is truly a surgical problem. Were the
related to sinus infection may not be adequately drained symptoms for which the patient initially underwent sinus
and may go on to death; the patient with invasive mucor- surgery really related to sinonasal disease? Headache, for
mycosis of the sinonasal tract may not be adequately de- example, may have been the initial complaint and may
brided and may die. In both examples, intensive medical have been due to some other factor such as migraine
therapy is equally as important as surgical drainage/de- rather than sinonasal disease, or perhaps the migraine
bridement. Fortunately, however, such obvious examples was exacerbated by sinonasal disease, but other factors
of failure rarely occur. More commonly, when we speak are now causing persistent symptoms. Persistent muco-
of failed primary sinus surgery we are speaking about a sal inflammatory disease may or may not be amenable to
patient who remains symptomatic after primary sinus surgical correction. It may instead be secondary to aller-
surgery, or in whom continued objective evidence of on- gic rhinitis or other immune or inflammatory conditions
going inflammation persists after primary sinus surgery. related to environmental factors. Allergic fungal sinusitis
Several groups of failed patients can be identified: is the most obvious of these conditions. Surgery may be
1. The persistently symptomatic patient without objec- necessary, but is not generally sufficient for control of the
tive evidence of sinonasal inflammation with or with- disease process. My subjective impression over the years
out anatomical derangement. is that often misguided initial surgery that is not success-
2. The persistently symptomatic patient with objective ful in relieving a patient’s symptoms may be followed
evidence of sinonasal inflammation with or without by ever more aggressive surgical therapy that is equally
anatomical derangement. misguided and ultimately results in iatrogenically created
3. The patient with a wholly new set of symptoms after dysfunctional sinonasal cavities.
primary sinus surgery that are felt to be iatrogenic in Ultimately, surgical intervention in diseases of the pa-
nature. ranasal sinuses can change anatomy and drain infection.
276 Mark C. Weissler
It cannot intrinsically affect allergy, primary disease of is probably because the frontal sinus is the most likely
the respiratory mucosa, the causes of nasal polyps, or al- to present anatomical features that preclude adequate
ter mucosal sensitivity to the environment. If one must long-term drainage via an endoscopic approach. Overly
operate on the paranasal sinuses, one should set specific aggressive removal of mucosa in the frontal recess may
anatomic objectives and then aim to accomplish those result in scarring and stenosis of the frontal sinus outflow
objectives in as safe a manner as possible. The underly- tract, which is difficult to repair. Although an endoscopic
ing mucosal disease must then be addressed medically. In Lothrop procedure may be possible in some cases, a nar-
31 the best of circumstances, recurrent or persistent local- row anteroposterior diameter of the frontal sinus outflow
ized sinus disease can be clearly related to an identifiable tract may preclude this approach. Failure to adequately
anatomic problem. remove an osteoma, inverted papilloma, or other neo-
Particularly after failed primary sinus surgery, it be- plasm from this area endoscopically may also lead to the
hooves the surgeon to consider carefully and optimally necessity of open surgery.
treat underlying allergic and inflammatory conditions External ethmoid surgery is unlikely to have any real
before embarking on further surgical treatment. advantage in this day and age over revision endoscopic
surgery for ethmoidal sinus disease. In addition, the
Lynch procedure with attempted reconstruction of a
functional nasofrontal outflow tract seems increasingly
Indications
to be of historical interest only.
■ Open approaches for failed endoscopic primary sur-
gery are indicated primarily to correct specific ana-
tomic abnormalities that are not accessible endoscopi-
Procedures
cally.
Osteoplastic Frontal Sinus Obliteration
The number of such abnormalities is increasingly limited.
If primary surgery failed because of underlying mucosal ■ Indications for osteoplastic frontal sinus obliteration:
disease rather than because of some anatomical aberra- 1. Failed primary endoscopic frontal sinus drainage
tion that prevented adequate aeration and drainage en- procedures or failed Lynch or Lothrop procedures.
doscopically, then there is no particular reason to believe 2. Inability to adequately remove neoplasm such as
that open surgery, aimed simply at creating drainage, inverted papilloma from the frontal sinus endo-
would be any more likely to succeed. scopically.
Although it is anathema to some, another indication
for open surgery might be to completely remove irrevers- ■ Contraindications: acute frontal sinusitis, as this may
ibly condemned mucosa, with the intention of replacing lead to infection of the bone flap.
it with nonrespiratory cuboidal epithelium and scar. The
concept of “functional” endoscopic surgery was first pred- The osteoplastic frontal sinus obliteration procedure re-
icated on the theory that no such irreversibly condemned mains an important part of the sinus surgeon’s armamen-
mucosa existed, but rather that through aeration and tarium. Although it can be carried out unilaterally, it is
drainage this mucosa could return to normal. Nonethe- generally performed bilaterally (Fig. 31.1).
less, for practical purposes, it is debatable whether or not
some patients might be better served in specific patho- ■ The keys to success of frontal sinus obliteration are:
logic situations by removal of mucosa and obliteration of 1. Complete removal of all frontal sinus mucosa.
a sinus. True obliteration can only be adequately accom- 2. Burring of the inner table of bone of the sinus cav-
plished in the frontal and sphenoid sinuses. Attempts at ity.
obliteration of the maxillary sinuses with fat failed, but
the end result after a Caldwell-Luc operation is essentially The sinus is generally obliterated with abdominal fat har-
an obliteration of the maxillary sinuses that fill in with vested from the left lower quadrant of the abdomen so as
scar and cuboidal, nonrespiratory epithelium. In a recent not to be confused in the future with an appendectomy
review, Barzalai and Greenberg felt that the only remain- incision. Montgomery has shown in cats, and personal
ing indications for the Caldwell-Luc operation were for experience corroborates, that fat can survive long term
fungal disease and in conjunction with endoscopic sur- within the sinus cavity [2].
gery for the treatment of inverting papilloma [1]. Preoperatively, the patient has a Caldwell view X-ray
The most frequent indication for open surgery after taken from 6 feet (approximately 2 m) away and the fron-
failed primary endoscopic sinus surgery is for persistent tal sinus is cut out of the film to be used as a template
or iatrogenically induced frontal sinus obstruction. This during surgery. Alternatively, one can use intraoperative
Open Approaches after Failure of Primary Sinus Surgery 277
teum, which is then used to reline the floor of the anterior

cranial fossa as a periosteal flap. Bone necrosis is rarely a
problem in these situations.
The Caldwell-Luc Procedure

■ Indications of the Caldwell-Luc procedure:
1. Chronic polypoid maxillary sinusitis unresponsive
to conservative intranasal endoscopic procedures.
2. Acute complicated maxillary sinusitis unresponsive
to intranasal endoscopic procedures.
3. As a route to biopsy of lesions not accessible trans-
nasally:
Fig. 31.1 Osteoplastic frontal sinus operation a. maxillary sinus mass
b. infraorbital nerve.
4. As an approach to the orbital floor when additional
computed tomography guidance or transillumination to exposure is needed:
delineate the borders of the frontal sinus. A coronal flap is a. to treat fracture
elevated in a plane superficial to the periosteum, down to b. for orbital decompression of Grave’s ophthal-
the supraorbital rim. The supratrochlear and supraorbital mopathy.
nerves are spared and may be released from the foramina
as needed. Utilizing the template, or other method, the The Caldwell-Luc procedure is a sublabial approach to
sinus is outlined and an oscillating or sagittal saw used the maxillary sinus through the anterior wall under the
to cut the frontal bone slightly inside the limits shown by upper lip. Traditionally it was used to treat chronic maxil-
the template. There is no need to follow the exact lateral lary sinusitis with irreversible changes of the maxillary si-
contours of the sinus. The saw blade should be greatly nus respiratory epithelium. During the procedure all the
beveled in toward the central sinus. At the supraorbital lining mucosa of the maxillary sinus is removed and will
rims, the very thick bone must be completely transected; be replaced by a rind of scar tissue covered by cuboidal
a horizontal bony incision is made at the nasal root. A nonciliated epithelium as the sinus heals. Because there
fine osteotome is inserted through the superior bony kerf is no longer any active transport of mucous within the si-
and used to divide the interfrontal sinus septum. The os- nus, drainage must be created inferiorly through the infe-
teoplastic flap with vascularized periosteum adherent to rior meatus. Since the floor of the maxillary sinus is lower
its anterior wall is then fractured inferiorly through the than the floor of the nose, gravity does not serve entirely
roofs of the orbits. Next, all mucosa is painstakingly re- to drain the sinus. After a Caldwell-Luc procedure, plain
moved from the frontal sinus, and the lining cortical bone films (Caldwell views) of the maxillary sinus will forever
drilled with a cutting burr. Small, 1–2-mm burrs can be be abnormal with some degree of opacification. In recent
helpful in removing mucosa from small extensions of the times, it has been felt that creating aeration of the max-
sinus. The intersinus septum is completely drilled away. illary sinus via the natural ostium will allow for healing
This dissection extends down into the nasofrontal drain- of the damaged mucosa of chronic sinusitis and reestab-
age system. The sinus is copiously irrigated with saline lishment of the natural mucociliary transport system.
or bacitracin solution. Small pieces of fat or separately Theoretically, respiratory epithelium within the sinus
harvested temporalis muscle are used to obliterate the will regenerate. There may still, however, be a role for this
nasofrontal drainage system and the frontal sinus filled operation in cases in which maximal medical and “func-
with atraumatically harvested abdominal fat. The flap is tional” surgery of the sinus has failed to restore healthy
then returned to anatomic position and fixed in position mucosa to a sinus. Attempts have been made to obliter-
with small wires or miniplates. The periosteum is closed ate the maxillary sinus with fat and other substances, but
with absorbable suture and the coronal skin flap closed these have never been successful. After a well-performed
in layers over closed suction drains that exit separate Caldwell-Luc operation, the sinus is to some extent “oblit-
stab-wound incisions laterally. In recent years, the neces- erated” by the natural course of healing.
sity of keeping the bone flap vascularized by leaving the Other indications for a Caldwell-Luc approach in-
periosteum intact and pedicled inferiorly has been called clude:
into question. When performing craniofacial resection, 1. The treatment of oroantral fistulae.
the bone flap is routinely harvested without the perios- 2. The treatment of malignant exophthalmos.
278 Mark C. Weissler
3. As an approach to biopsy the infraorbital nerve in to remove all of the mucosa. Slow, steady traction is better
cases of suspected perineural invasion by cancer. than rapid tearing to remove large portions of the lining
4. As an approach to the orbital floor in the treatment of mucosa in a single piece.
trauma. Since the respiratory mucosa has been removed, the
5. As an approach to the pterygomaxillary space for liga- sinus will no longer drain via the natural ostium. A naso-
tion of the internal maxillary artery in the treatment of antral window is therefore created via the inferior meatus.
resistant epistaxis. A mosquito-type clamp is inserted approximately 1 cm
31 6. As part of a larger operation to treat benign and malig- back into the inferior meatus to avoid the opening of the
nant neoplasms of the lateral nasal wall, pterygomaxil- nasolacrimal duct. The clamp is directed toward the lat-
lary space, infratemporal fossa, and nasopharynx. eral canthus and bluntly inserted through the lateral wall
of the inferior meatus, and spread. A rat-tail rasp, Ker-
The operation is performed by retracting the upper lip rison forceps, or large Blakesly forceps is then used to en-
superiorly, most effectively with a Johnson-type retractor. large the new ostium anteriorly and posteriorly to about
The soft tissues overlying the canine fossa are infiltrated 1.5–2.0 cm in diameter. If there is no significant bleeding,
with local anesthetic and epinephrine. An incision is no packing is necessary. If bleeding persists, the sinus is
made centered on the canine fossa, slightly convex inferi- packed with 0.5-inch (approximately 13 mm) gauze im-
orly and extending from just short of the midline back to pregnated with antibiotic ointment, brought out via the
the second or third maxillary molar. The incision is kept nasoantral window. The gauze can be used as a file, much
at least 5 mm above the gingival edge to allow enough like dental floss, to smooth the opening of the new antros-
tissue for closure. The incision in carried down to bone tomy by sliding it back and forth through the antrostomy.
and then elevated in a subperiosteal plane superiorly to Finally, the sublabial incision is closed with interrupted
expose the infraorbital foramen and nerve. This elevation simple absorbable sutures. If packing is used it is left for
is done most expeditiously by beginning with a McKenty 1 or 2 days and then removed through the nose.
or other small periosteal elevator and then pushing on a Although the open Lynch and Lothrop procedures are
gauze sponge for further elevation. A 2-mm osteotome discussed here, they are increasingly of historic interest
is used to create a small opening into the maxillary sinus because they are not universally successful at creating
above the level of the maxillary tooth roots; this is then long-term patency of a frontal sinus drainage system and
enlarged with a Kerrison-type rongeur. Most of the en- are more cosmetically deforming than an osteoplastic
largement occurs superiorly up to and even around the frontal sinus procedure. Similarly, in the modern era it
infraorbital nerve (Fig. 31.2). The offending maxillary si- would be very unusual to resort to an external ethmoid-
nus mucosa is then completely stripped from the sinus. ectomy after failed endoscopic ethmoidectomy in the
The roof is saved for last, realizing that the infraorbital treatment of chronic rhinosinusitis.
nerve is frequently dehiscent within the sinus. Great care
is used to avoid damage to the infraorbital nerve. A vari-
ety of small curettes and pituitary-type forceps are used
The Lynch Procedure
■ Indications for the Lynch procedure: failed primary
surgery where hope still exists of reconstructing the
frontal sinus outflow tract.
The Lynch procedure is used in the treatment of persis-

tent frontal sinusitis in an attempt to reconstruct a large
nasofrontal drainage pathway via an external approach.
The operation begins with an external ethmoidectomy,
but with the upper limb of the incision extending further
laterally beneath the brow (Fig. 31.3). There are so many
permutations of the “Lynch Procedure” that no single
method is universally accepted. The original operation
involved removal of the entire bony floor of the frontal
sinus and stripping of all mucosa along with a complete
ethmoidectomy and removal of the middle turbinate. Re-
moval of the frontal sinus mucosa is difficult because of
the limited exposure high and lateral. Eventually, many
Fig. 31.2 Bony incision used for the Caldwell-Luc procedure surgeons stopped trying to remove the mucosa and sim-
Open Approaches after Failure of Primary Sinus Surgery 279
The Lothrop procedure is performed via a unilateral or

bilateral external anterior ethmoidectomy and middle
turbinectomy. The frontal intersinus septum is resected
along with the most anterosuperior portion of the nasal
septum, creating a large drainage pathway. In cases of
unilateral disease, the opposite nasofrontal drainage sys-
tem could theoretically serve as a pathway for egress of
frontal sinus secretions. Like its endoscopic counterpart,
it works best in frontal sinuses with wide anteroposterior
dimensions. Like the Lynch procedure, it assumes that
“irreversibly damaged” mucosa does not exist within the
frontal sinus.
Other Procedures
Fig. 31.3 Incisions for external ethmoidectomy (blue) and ex-
tension for Lynch procedure (red) ■ Sometimes after failed attempts at endoscopic resec-
tion of cranial-base tumors or repair of extensive ce-
rebrospinal fluid (CSF) leaks, it may be necessary to
resort to an external approach.
ply attempted to reconstruct the drainage system. A lat-
eral nasal wall mucosal flap is fashioned with a superior Although unusual, it might at times prove necessary to
base, and turned up at the conclusion of the operation resort to an external craniofacial approach to close a CSF
to reline the nasofrontal drainage system medially. The leak or to resect tumors of the anterior skull base after
reconstructed duct is stented for about 3 months with an failed attempts at endoscopic resection. This would most
endless variety of materials. The most popular is rolled si- likely occur as a result of an error in judgment regard-
lastic sheeting and cut portions of endotracheal tubes that ing the true extent of a tumor or the extent of a defect of
are sewn to the nasal septum. The major complication of the skull base. More commonly, these extensive lesions
this procedure is restenosis of the nasofrontal drainage would be approached via an open approach initially, al-
system and subsequent mucocele formation or recurrent though this is beginning to change. It is important to re-
frontal sinus obstruction and infection. member that at times, endoscopic and open approaches
The Lynch procedure, like other “functional” opera- are complementary and can be used in consort to achieve
tions is predicated on the belief that creating an adequate complete extirpation of particularly extensive lesions.
drainage system for the frontal sinus, in conjunction with
medical therapy, can result in the return to normal of
chronically diseased mucosa within the frontal sinus.
References
1. Barzilai G, Greenberg E, Uri N (2005) Indications for the
Caldwell-Luc approach in the endoscopic era. Otolaryngol
The Lothrop Procedure
■ Indications for the Lothrop procedure: failed primary 2. Montgomery WW (1964) The fate of adipose implants in a
surgery where hope still exists of reconstructing the bony cavity. Laryngoscope 74:816–827
frontal sinus outflow tract.
Chapter 32
“Above and Below” Techniques

Timothy Haegen, Ryan M. Rehl, and Winston C. Vaughan
Contents
Core Messages
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
■ Technological advances in endoscopic sinus surgery Preoperative Workup . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
have limited the indications for external approaches Indications/Contraindications . . . . . . . . . . . . . . . . . . . . 282
to the frontal sinus. Despite this fact, certain condi-
Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
tions of the frontal sinus remain beyond the reach of
the purely endoscopic approach. Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
■ In selected cases, an “above and below” approach Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
may allow access to pathologic diseases of the fron- Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
tal sinus while minimizing morbidity.
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
■ The addition of trephination to endoscopy may pro-
vide improved access to pathology of the lateral fron-
tal sinus, assist in localizing the frontal recess, and
allow postoperative irrigation in selected patients.

Prior to electing a purely external approach, there re-
mains the option of an “above and below” technique. The
idea of a combined intranasal and external approach is
Background
not new. In 1914, Lothrop described the first combined
Surgical management of the frontal sinus has been de- intranasal and external approach to the frontal sinus [13].
bated for over 250 years since Runge first described After the introduction of advanced endoscopic instru-
frontal sinus surgery [15]. In 1903, Killian changed the mentation, Gross et al. popularized a completely endo-
understanding of frontal sinus surgery by advocating scopic modification of the original Lothrop procedure.
the need to reconstitute the frontal recess, and he sug- [10]. The current “above and below” technique includes
gested the formation of a mucosal flap to help maintain an endoscopic sinus approach (below) and an external
patency [11]. Today, frontal sinus procedures reflect a procedure (above). The early edition of the modern day
rapid evolution of technology and a better understand- “above and below” procedure was described by Wigand
ing of sinonasal physiology. Functional endoscopic sinus et al. to manage a fracture of the frontal sinus. This report
surgery (FESS) has become the first-line approach for the by Wigand et al. included an osteoplastic flap [17]. The
majority of frontal sinus pathology. This trend has been less invasive trephine was combined with an endoscopic
facilitated by the introduction of image-guidance and procedure and later described by Bent et al. [3]. These
endoscopic “extended” approaches to open the frontal combined approaches may provide improved visualiza-
sinus from below. Despite the dwindling number of indi- tion and access while theoretically minimizing overall
cations for external frontal sinus techniques, procedures risk and postoperative morbidity when compared with
such as trephination, osteoplastic flap, or cranialization those of an osteoplastic flap. These procedures are also
are considered when endoscopic techniques are unable to congruent with the basic tenets of treating frontal sinus
safely accomplish the goals of frontal sinus surgery. These pathology, which include: eradicate disease, restore func-
more invasive procedures may have the disadvantage of tion, minimize surgical risk, preserve cosmesis, and allow
increased morbidity [16]. adequate surveillance.
282 Timothy Haegen, Ryan M. Rehl, and Winston C. Vaughan
2. Distorted frontal recess anatomy secondary to:

Preoperative Workup
a. Iatrogenic or external trauma.
Patient history, office endoscopy, preoperative computed b. Neo-osteogenesis.
tomography (CT) scan with triplanar (axial, coronal, and c. Obstructing or large-type III or IV frontal cells not
sagittal) analysis, and surgeon experience are critical to amenable to endoscopic dissection.
surgical planning in frontal sinus surgery. It is also im- 3. Laterally based neoplasms/lesions:
portant to recognize that the decision to use the “above a. Osteomas
and below” approach may be made intraoperatively. b. Inverting papilloma
Preoperative counseling regarding the possibility of an c. Fibrous dysplasia
32 adjunctive trephine in the medial- or mid-brow area 4. Contraindications to MELP:
should be undertaken in patients with complex frontal a. Narrow anteroposterior (AP) diameter of frontal
recess anatomy or superior or lateral frontal sinus pa- sinus floor (<1.5 cm).
thology. Procedures such as FESS, modified endoscopic b. Deep radix.
Lothrop procedure (MELP), trephination, and an osteo- 5. Evaluation of the posterior table of the frontal sinus in
plastic flap all have unique risks and benefits that require the setting of:
proper informed consent. Frank discussions regard- a. Trauma
ing postoperative anosmia, bleeding, infection, frontal b. CSF Leak
recess stenosis, cerebrospinal fluid (CSF) leak, orbital c. Pneumocephalus
injury, meningitis, seizure, further surgery, pain, fore-
head hypoesthesia, cellulitis, brow hair loss, and scarring Chiu et al. discussed the role of the “above and below”
should occur. approach in a report on their experience with frontal
osteomas. They describe a grading system for frontal
osteoma and three different surgical approaches (purely
endoscopic, “above and below,” and external). Chiu et al.
Indications/Contraindications
present helpful guidelines for selecting the appropriate
Indications for the “above and below” approach include surgical procedure. They suggest that osteomas attached
disease within laterally based frontal cells (some type III anterosuperiorly in the frontal sinus or those extending
and most type IV), and laterally or superiorly based le- lateral to the lamina papyracea are best addressed with
sions in the frontal sinus. Frontal recess anatomy that has an “above and below” approach [6]. Dubin et al. reported
been altered by prior surgery, trauma, extensive inflam- indications for staged “above and below” treatment of
matory disease, or neoplasm might prevent adequate, safe frontal sinus inverted papilloma [7]. Four of six patients
frontal recess dissection. with frontal sinus inverting papilloma required a staged
“below then above” approach consisting of an endoscopic
■ The trephination procedure provides the following frontal recess dissection followed by an osteoplastic flap
benefits: at a separate operation. In addition to the size of the pap-
1. Access to material for aspiration and culture. illoma and location of the pedicle, a narrow frontal recess
2. Access for irrigation from above to identify the precluded successful purely endoscopic resection. One
frontal recess from below. should note, however, there were no attempts at MELP
3. Access for postoperative irrigation. or endoscopic Draf III in this series. The rest of this chap-
4. Additional visualization of the frontal recess. ter addresses the combined “above and below” approach
5. Direct access for tissue manipulation or removal. rather than the staged procedure described by Dubin
et al.
This approach has proven useful in the setting of muco- In addition to the aforementioned indications, the
cele, recalcitrant chronic sinusitis, inverted papilloma, os- “above and below” approach is useful when a Draf III is
teoma, fibrous dysplasia, and pneumocephalus [1, 6, 7, 9, needed but the surgeon is not experienced with the en-
12]. While absolute indications for the “above and below” doscopic Draf III procedure or MELP, or when the sur-
approach have not been established, relative indications geon feels these procedures would be contraindicated
for the combined are listed here. (deep radix, narrow AP diameter of frontal sinus floor).
Indications for the “above and below” approach: Benoit and Duncavage report similar safety and frontal
1. Chronic sinusitis of the frontal sinus associated with: recess patency rates with the “above and below” approach
a. Potts puffy tumor. compared to the MELP [2]. Casiano and Livingston, re-
b. Allergic fungal sinusitis with laterally impacted porting the University of Miami’s experience with the
mucin. MELP, highlighted the importance of obtaining an AP
c. Lateral mucocele. diameter of 8 mm or greater for the frontal sinus outflow
“Above and Below” Techniques in Revision Sinus Surgery 283
tract. If the AP diameter of the frontal outflow tract is less of the superior roof of the maxillary sinus. The ethmoid
than 8 mm at the conclusion of the surgery, postopera- bulla is removed and, if present, the suprabullar cell is also
tive stenosis is likely [4]. Unless the surgeon is confident removed to identify the skull base and enlarge the frontal
that an 8-mm AP diameter can be obtained by the MELP, recess. A complete sphenoethmoidectomy is performed
an “above and below” approach should be planned. The at this time if indicated. The skull base should be identi-
“above and below” approach need not exclude the MELP; fied posteriorly at the sphenoid face and then followed
however. Wormald et al. described a series of patients with anteriorly if a posterior ethmoidectomy is performed.
mucoceles in previously obliterated frontal sinuses, who Otherwise the skull base should be localized during the
underwent a combination “above and below” unoblitera- anterior ethmoidectomy. Important landmarks include
tion procedure. The below procedure in this series was a the medial orbital wall and the anterior ethmoid artery.
MELP [18]. As stated above, these are relative indications Coronal CT scans often reveal a medial dimpling of the
based on the preoperative evaluation of the patient and lamina papyracea at the location of the anterior ethmoid
the surgeon’s experience. This senior author has previ- artery. Careful preoperative review and intraoperative in-
ously reported a series of ten patients with lateral fron- spection with 30 , 45, or 70 endoscopy will demonstrate
tal sinus lesions or supraorbital mucoceles. One patient remaining anterior ethmoid, agger nasi, and frontal cells.
failed and required the “above and below” approach later. These are identified and removed in a fashion described
Nine patients were successfully addressed by a purely en- by Stammberger [14]. These cells are removed with mu-
doscopic, image-guided procedure [5]. cosal-sparing techniques consisting of limited use of fron-
Contraindications to the “above and below” approach tal sinus seekers, 90 curettes, curved mushroom punches,
are similar to those of external frontal sinus surgery and and giraffe forceps. Once the boundaries of the frontal
include contraindications to general anesthesia. Trephi- recess (lateral, lamina papyracea; anterior, agger nasi; me-
nation is contraindicated in an aplastic or markedly hy- dial, superolateral surface of the middle turbinate; poste-
poplastic frontal sinus. rior, anterior skull base, anterior ethmoid artery, or the
Contraindications to the “above and below” approach: bulla lamella) have been identified, attention is turned to
1. Medical disorders precluding general anesthesia. the frontal sinus pathology.
2. Aplastic/hypoplastic frontal sinus. The 70 telescope is used to visualize the superior fron-
tal recess and the frontal sinus. The author’s group pre-
fers a 70 telescope with a reverse light cable orientation,
which allows easier instrument maneuvering below the
Surgical Technique
eye piece and camera attachment. The 90 and 120 giraffe
The surgical technique may vary slightly depending on forceps, 90 curette, semimalleable suctions, and frontal
the triplanar CT scan findings (see Video 32.1). seekers are used to marsupialize or remove the superior
or lateral frontal sinus pathology. If the limits of endo-
■ In preparation for the above and below” procedure, scopic sinus surgery instruments are reached, a trephina-
when reviewing CT images attention should be paid tion is performed.
to: The trephine is placed to maximize surgical access of
1. AP diameter of the frontal sinus floor. endoscopic instruments from above. Batra et al. stress
2. Pneumatization of the frontal sinuses. the importance of a flexible location of the percutane-
3. Integrity of the bony walls. ous incision and trephine, allowing entrance through the
4. Location of the pathology in the frontal sinus with medial frontal sinus floor, medial anterior table, or lateral
respect to the lamina papyracea. frontal sinus floor [1]. The incision and trephine may be
5. Location of the superior attachment of the uncinate medial or lateral to the supraorbital neurovascular bun-
process. dle, as dictated by the sinus pathology. A 4-mm trephine
is appropriate for frontal sinus pathology that requires
The combined approach begins intranasally with ad- only direct vision or in cases requiring aspiration or ir-
equate nasal decongestion. The patient is prepped after rigation. In this instance, a percutaneous stab incision is
an image-guided system is calibrated and verified (if more appropriate than a larger incision. For cases that
navigation is being used). Lidocaine with epinephrine is require manipulation of frontal sinus pathology, a larger
injected into the uncinate process, superior root of the trephine may be needed. Typically a 6–8-mm trephine
middle turbinate and basal lamella of the middle turbi- is used to place and manipulate both angled endoscopes
nate when these structures are present and accessible. The and instruments.
endoscopic dissection begins with a complete uncinec- This author’s group prefers to place the trephine in-
tomy. This improves frontal outflow tract endoscopic ac- cision in the medial brow. This allows for excellent scar
cess. A maxillary antrostomy is done with identification camouflage, even in the immediate postoperative period.
A transblepharoplasty incision is utilized by some au- with the assistance of the image-guidance suction tip,
thors. Knipe et al. described a series of five patients with the headset is temporarily removed or displaced to al-
frontal sinus disease and ophthalmologic manifestations low access to the medial brow. For cases in which image
[12]. These patients received a combined approach in guidance is not used, the position and size of the frontal
which the percutaneous incision was through a trans- sinus may be aided with transillumination of the frontal
blepharoplasty approach. All five patients had the incision sinus by flexible light, a 6-foot (approximately 2-m) PA
concealed in the upper eyelid skin crease with excellent Caldwell radiograph, or a prefabricated CT template [8].
postoperative cosmesis. Two of the five patients, however, The planned incision is infiltrated with lidocaine and epi-
eventually required revision endoscopic surgery. nephrine and a 1–2-cm incision is performed, beveled
32 Figures 32.1–32.4 show an “above and below” ap- in a direction parallel to the hair shafts of the eyebrow.
proach in a 26-year-old female flight attendant with re- With the aid of a self-retaining retractor, the incision is
current severe, left-frontal headache during flying. De- carried down to bone (Fig. 32.2). A 4-mm drill bit is used
spite treatment with oral antibiotics, oral steroids, and to perform the boney trephination. The author’s group
topical therapy, her symptoms persisted. A CT scan fol- uses the drill attachment for the powered sinus dissec-
lowing medical therapy revealed a lateral frontal spherical tor (Fig. 32.3). Alternately, an otologic drill may be used.
opacification that had decreased in size from her original Care must be taken to keep the trajectory of the drill per-
CT scan at the time of initial presentation to the clinic. pendicular to the frontal bone. The drill is applied until
For the medial brow incision in the “above and below” the mucosa is visible. If there is pulsation of the “mucosa,”
approach, the appropriate eyebrow is prepped in a sterile or it appears pale in color, it is important to reconfirm
fashion. The image-guidance system is used to assist in landmarks as this may be the dura. A fine-needle aspira-
precise placement of the incision and point of entry into tion that produces air or mucous can be reassuring. The
the sinus (Fig. 32.1). For the electromagnetic navigation mucosa is carefully penetrated with sharp instrumenta-
system: after the incision has been planned and marked tion. At this point, intranasal confirmation of successful
Fig. 32.1 After endoscopic frontal recess dissection, the image-guidance system is used to plan the
location of trephination
Fig. 32.2 An incision is made in the medial brow and blunt dis- Fig. 32.3 The drill attachment on the powered sinus dissector is
section is carried out down to the frontal bone. The periosteum used for trephination
is incised and a periosteal elevator is used to expose the area for
drilling
trephination is confirmed with irrigation from above. is used in a manner that limits granulation tissue forma-
If the previous endoscopic dissection did not leave the tion. Proper office debridement is aided by 30 , 45 , and
frontal recess widely patent, intranasal identification of 70 telescopes, 90 semimalleable suctions, 90 curettes,
the frontal recess with irrigation may be facilitated by the and 45 and 90 giraffe forceps. Steroid sprays, drops, or
addition of methylene blue to the saline irrigation. The irrigations are used routinely and culture-directed antibi-
trephine may then be enlarged with Kerrison rongeurs or otics are used for postoperative infection.
the drill, as necessary. Once the frontal recess has been
adequately opened, frontal sinus pathology including ex-
tensive type III cells, lateral type IV cells or tumors that
can be manipulated under angled endoscopic visualiza-
tion are addressed (Fig. 32.4). When possible, the poste-
rior frontal sinus mucosa is everted down into the frontal
recess along the anterior skull base or anterior ethmoid
artery. If indicated, stents are placed from below and visu-
alized from above. The external incision is then closed in
a layered fashion. The skin is reapproximated with nylon
or Prolene sutures. On occasion, a catheter may be left in
the trephine and frontal sinus for approximately 2–5 days
to allow postoperative irrigations.
Postoperative Care
As with all endoscopic frontal sinus surgery, meticulous
postoperative debridement and medical management are
mandatory for optimal surgical results. Skin sutures are Fig. 32.4 A small mucopyocele is identified in the lateral and
removed at 1 week. Patients are followed every 1–2 weeks posterior portion of the frontal sinus. It was completely removed
until the frontal recess demonstrates patency without through the trephine with angled giraffe forceps. The patient’s
crusting or inflammatory reaction. Patency is assessed headache associated with flying resolved upon returning to
with angled endoscopes, and gentle, atraumatic suction work. FR Frontal recess, M mucocele, PT posterior table
Complications 7. As with FESS, mucosal preservation and eversion

into the frontal recess/anterior ethmoid remain
Complications of the combined procedure include all the
essential.
complications of routine endoscopic frontal sinus sur-
8. Consider a course of systemic antibiotics when
gery:
the operative field is grossly involved by purulent
1. Increases the risks of facial or periorbital cellulitis.
material or in immunocompromised and diabetic
2. Posterior table CSF leak.
patients.
3. Cosmetic deformities.
4. Damage to the supraorbital and supratrochlear neu-
32 rovascular bundle with subsequent anesthesia of the
Outcomes
ipsilateral forehead.
In their report on 11 patients who underwent “above
In 62 consecutive “above and below” frontal procedures and below” procedures for frontal sinus mucoceles, Bent
Benoit and Duncavage had no complications [2]. In the et al. found that all patients were free of disease or im-
series reviewed by Batra et al., 3 of 22 patients developed proved with a mean follow-up of 19 months. In this ret-
minor complications of cellulitis [1]. There were no CSF rospective study, three patients did require reoperation.
leaks or cosmetic deformities. In a series of 22 minitrephi- [3]. Benoit and Duncavage reported on 40 patients who
nations by Gallagher and Gross, there were 2 patients with underwent 62 “above and below” procedures with stent
skin burns and 1 CSF leak from intracranial penetration placement (a bilateral procedure was performed in 22 pa-
[9]. Image guidance was not used in this series. Bent et al. tients). Overall patency rates and subjective improvement
had two localized cases of cellulitis in 11 patients treated were 79% and 78%, respectively after a mean follow up
with the “above and below” approach. Both complications of 1 year. Five of their patients required reoperation after
were treated successfully with antibiotics [3]. Prevention the “above and below” procedure. Four of those patients
is the best approach to complications. Minitrephination undergoing reoperation had the frontal sinus obliterated
sets may be used in combination with image guidance with fat [2]. Batra et al. reviewed the outcomes of 22 pa-
to possibly decrease the risk of intracranial penetration. tients with complex frontal sinus pathology treated with
Prophylactic systemic and topical antibiotics may be used the “above and below” approach in 2005. Resolution or
to decrease the likelihood of postoperative cellulitis. improvement of headaches and orbital symptoms oc-
Five millimeters has been recommended as the maxi- curred in 82% and 88% of patients, respectively. In addi-
mum diameter of an anterior table trephine to prevent tion, confirmation of postoperative frontal recess patency
soft-tissue prolapse and cosmetic deformity [3]. This au- was confirmed in 19 of 22 patients (86%). In one patient,
thor has used trephines up to 8 mm in the medial brow frontal sinus patency could not be confirmed because of
without any visible depressions. For larger trephines, partial middle-turbinate lateralization. A CT scan on this
bone replacement can be performed with available prod- patient revealed a well-aerated frontal sinus. Two patients
ucts. Although not reported in their series, Batra et al. had near-complete postoperative stenosis of the frontal
also warn against anterior table trephine in the manage- outflow tract. Follow-up CT scans on these two patients
ment of acute frontal sinusitis due to the risk of seeding revealed partial aeration of the frontal sinus without mu-
the frontal bone and resulting osteomyelitis [1]. cocele formation [1].
Tips and Pearls to Minimize Complications

1. Thorough analysis of frontal sinus anatomy on Conclusion
triplanar CT prior to performing the procedure.
The “above and below” approach is a versatile technique
2. Perform the endoscopic portion first and identify
that is intermediate in invasiveness between pure endo-
important landmarks.
scopic frontal sinus surgery and external osteoplastic flap.
3. Use image guidance to identify the trephine loca-
In fact, it has been reported by some to be a reasonable
tion.
option after obliteration has failed. The “above and be-
4. Reduce damage to the supraorbital neurovascular
low” procedure adheres to the basic tenets of frontal-si-
bundle by blunt dissection and avoid monopolar
nus surgery, which include: remove disease, maintain the
cautery.
patency of the frontal recess, preserve the sinus mucosa,
5. Limit trephines to 6–8 mm.
reduce the surgical risk, and facilitate endoscopic and
6. Use angled scopes and instruments from both
radiographic surveillance. Although high-resolution CT,
directions.
image guidance, and improved instrumentation have ex-
panded the indications for pure endoscopic techniques, 10. Gross WE, Gross CW, Becker et al. (1995) Modified trans-
the “above and below” combined approach remains a nasal endoscopic Lothrop procedure as an alternative to
valuable tool in the rhinologist’s armamentarium. frontal sinus obliteration. Otolaryngol Head Neck Surg
113:427–434
11. Killian G (1903) Die killianische radicaloperation chro-
nischer strinhohleneiterungen: II. Weiteres kasuistisches
References
material und zusammenfassung. Arch Laryngol Rhinol
1. Batra PS, Citardi MJ, Lanza DC (2005) Combined endo- 12:59
scopic trephination and endoscopic frontal sinusotomy 12. Knipe TA, Gandhi PD, Fleming JC, et al. (2007) Trans-
for management of complex frontal sinus pathology. Am J blepharoplasty approach to sequestered disease of the lat-
Rhinol 5:435–441 eral frontal sinus with ophthalmologic manifestations. Am
2. Benoit CM, Duncavage JA (2001) Combined external and J Rhinol 21:100–104
endoscopic frontal sinusotomy with stent placement: a ret- 13. Lothrop HA (1912) Frontal sinus suppuration. Ann Surg
rospective review. Laryngoscope 111:1246–1249 59:937
3. Bent JP 3rd, Spears RA, Kuhn FA, et al. (1997) Combined 14. Stammberger, H (2000) FESS “Uncapping the Egg” The
endoscopic intranasal and external frontal sinusotomy. Am Endoscopic Approach to Frontal Recess and Sinuses. A
J Rhinol 11:349–354 Surgical Technique of the Graz University Medical School.
4. Casiano RR, Livingston JA (1998) Endoscopic Lothrop Endo-Press. Tuttlingen, Germany
procedure: the University of Miami experience. Am J Rhi- 15. Stevenson RS, Guthrie D (1949) History of Otolaryngol-
nol 12:335–339 ogy. Williams and Wilkins, Baltimore
5. Chiu AG, Vaughan WC (2004) Management of the lateral 16. Weber R, Draf W, Keerl R, et al. (2000) Osteoplastic fron-
frontal sinus lesion and the supraorbital cell mucocele. Am tal sinus surgery with fat obliteration: technique and long-
J Rhinol 18:83–86 term results using magnetic resonance imaging in 82 op-
6. Chiu AG, Schipor I, Cohen NA, et al. (2005) Surgical deci- erations. Laryngoscope 110:1037–1044
sions in the management of frontal sinus osteomas. Am J 17. Wigand ME, Steiner W, Jaumann MP (1978) Endona-
Rhinol 19:191–197 sal sinus surgery with endoscopical control: from radi-
7. Dubin MG, Sonnenburg RE, Melroy CT, et al. (2005) Staged cal operation to rehabilitation of the mucosa. Endoscopy
endoscopic and combined open/endoscopic approach in 10:255–260
the management of inverted papilloma of the frontal sinus. 18. Wormald PJ, Ananda A, Nair S (2003) Modified endo-
Am J Rhinol 19:442–445 scopic Lothrop as a salvage for the failed osteoplastic flap
8. Fewins JL, Otto PM, Otto RA (2004) Computed tomogra- with obliteration. Laryngoscope 113:1988–1992
phy-generated templates: a new approach to frontal sinus
osteoplastic flap surgery. Am J Rhinol 18:285–289; Discus-
sion 289–290
9. Gallagher RM, Gross CW (1999) The role of mini-trephi-
nation in the management of frontal sinusitis. Am J Rhinol
13:289–293
Chapter 33
Revision Endoscopic
Skull-Base Surgery 33
Aldo C. Stamm, João Flávio, and Richard J. Harvey
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
■ Revision skull-base surgery (SBS) should be prac- Why an Endoscopic Approach for Revision SBS? . 290
ticed within a multidisciplinary team. The Goals of Endoscopic SBS . . . . . . . . . . . . . . . . . . . 290
■ Standard endoscopic sinus instrumentation is often
The Multidisciplinary Approach . . . . . . . . . . . . . . . . 290
inadequate for SBS and specialized equipment is re-
quired. Preoperative Workup . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
■ Closure of large skull-base defects requires careful Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
preoperative evaluation and planning of reconstruc- Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
tive options.
Endocrine and Hypothalamic Considerations . . . . 292
■ The use of pedicled mucosal flaps and a multilayered
Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
reconstruction is the key to closing large skull-base
defects. Previous Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . 293
■ The potential for complications differs little from Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
open SBS, but the ability for faster recovery and less
General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
morbidity is great.
Dissection from the Cerebrovascular Structures . . 294
Staging the Resection . . . . . . . . . . . . . . . . . . . . . . . . . 294
Hemostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
Operative Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
Introduction Avoiding Complications in Revision
Skull-base surgery (SBS) evolved from a combination Endoscopic SBS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
of craniofacial surgery and neurosurgery in the 19th CSF Leak Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
century. Its earliest applications were for the removal of Transplanum/Transsphenoidal Surgery . . . . . . . . . . . 295
skull-base tumors and intracranial neurosurgery [39, 57].
Transclival Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Modern SBS now encompasses a diverse group of pathol-
ogies (Table 33.1) [54]. The use of endoscopes in surgery Reconstructive Options . . . . . . . . . . . . . . . . . . . . . . . 295
for skull-base lesions has been particularly successful. Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
The management of sphenoid papilloma highlights the Complications and Outcomes . . . . . . . . . . . . . . . . . . . . 298
advantages of an endoscopic approach – minimal opera-
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
tive morbidity, direct access to pathology, and detailed
visual assessment of anatomy and resection limits [14].
However, effective and safe treatment of lesions involving
the skull base remains a challenging problem. Difficulties
in endoscopic SBS and its revision include difficulty of tions [12, 44]. In revision SBS, essential nasal landmarks
access, the relationship between critical anatomy and pa- are often missing. Reconstructive options may be lim-
thology, and reconstructive techniques for large defects. ited and prior radiotherapy can further impede healing.
Revision SBS, either open or endoscopic, is a complex Surgical success depends not only on technological ad-
process with a significant risk of postoperative complica- vances, but also on a variety of factors, including intimate
290 Aldo C. Stamm, João Flávio, and Richard J. Harvey
Table 33.1 Endoscopic skull-base pathologies

The Goals of Endoscopic SBS
• Cerebrospinal fluid leak

There are a variety of indications for which revision en-
• Trauma
doscopic SBS may be performed. Removing recurrent
– Optic nerve decompression
disease is only one indication for those who need revision
• Infection
endoscopic SBS.
– Epidural abscess
– Osteomyelitis
■ Broadly, the goals of revision endoscopic SBS should
– Inflammatory sinus disease
include:
• Mucocele
1. Removal of disease.
2. Treatment of the complications arising from previ-
33 • Allergic fungal sinusitis
ous SBS.
• Benign neoplasms
– Pituitary adenoma
3. Minimize functional loss:
– Fibro-osseous lesions
a. Vision
– Meningioma
b. Other cranial nerve integrity
– Craniopharyngioma
c. Pituitary/hypothalamic function
– Angiofibroma
d. Orbital function
• Malignant neoplasms
– Sinonasal malignancies
An understanding of the significant complications asso-
– Esthesioneuroblastoma
ciated with surgery, whether neurological, orbital, endo-
– Chordoma
crine, or infectious, is paramount to an informed discus-
– Chondrosarcoma
sion with a patient considering revision endoscopic SBS.
– Metastases
• Miscellaneous
– Rathke’s cyst The Multidisciplinary Approach
– Dermoid cyst
– Arteriovenous malformation
The team approach in the management of challenging
– Epidermoid
pathology is still a relatively novel concept in medicine.
Although the multidisciplinary team (MDT) has evolved
only in the last few decades, complication rates from
SBS, since the introduction of such an approach, have
decreased [4]. The MDT approach should include neu-
knowledge of the involved anatomy, adequate instrumen- rosurgery, otolaryngology, intensive care, anesthesiology,
tation, surgical experience, and a structured and appro- pathology, endocrinology, and paramedical staff, such as
priate surgical approach. skilled nursing to care for patients at risk of significant
neurological sequelae [4, 32, 43, 46]. The MDT is even
more applicable to the management of the revision SBS
patient. With complication rates from open revision SBS
Why an Endoscopic Approach for Revision SBS?
approaching 30–50% in some series [12], the need for
The direct transnasal route is ideal for lesions of the an- multiteam discussion and care is essential (Fig. 33.1).
terior and central skull base. There is also increasing ex-
perience in endoscopic management of lateral pathology ■ Indications:
within the infra-temporal fossa [31, 49]. The entire ven- 1. Disease:
tral skull base can be accessed by a transnasal endoscopic a. Removal of persistent disease.
route. Previous radiotherapy, surgery, and reconstructive b. Decompression of cranial nerves with subtotal
efforts often complicate revision cases. An endoscopic resection.
route often allows minimal dissection of surgical planes. c. Planned second stage.
When the initial procedure was performed via an open 2. Common complications from prior SBS:
approach, revision endoscopic SBS may provide fresh a. Cerebrospinal fluid (CSF) leaks
tissue planes with access to regions left untreated during b. Frontal recess occlusion
previous surgeries [43]. In addition, postoperative recov- c. Sphenoid sinus obstruction
ery is generally shorter with endoscopic surgery [8] and d. Mucoceles
morbidity is lower [3]. e. Encephalocele formation
Revision Endoscopic Skull-Base Surgery 291
tum and turbinate removal. The loss of reconstructive op-

tions may be considerable.
Imaging
Imaging is crucial in the evaluation for revision SBS. This
will almost always include both computed tomography
(CT) and magnetic resonance imaging (MRI) modalities.
A minimum slice thickness of 3 mm (preferably less) of
coronal, axial, and sagittal CT images of the sinuses and
skull base are essential in the assessment for surgery. In
addition to diagnostic information, CT offers critical ana-
tomical information such as [59]:
1. The presence and extent of erosions of the skull base.
2. The integrity of the medial orbital wall.
3. The position of anterior skull-base vessels.
4. The integrity and degree of aeration of paranasal si-
nuses (particularly the sphenoid sinus).
Fig. 33.1 The specialist groups involved in the care of the re- 5. The location and presence of intersinus septae.
vision skull-base surgery patient (Reproduced with permission 6. The position and erosion near internal carotid arteries
from Centro de ORL, Sao Paulo, Brazil) (ICAs), optic nerves, and cavernous sinuses.
7. The relationship between the roof of the ethmoid si-
nuses and the cribriform plate.
8. The presence of Onodi cells.
f. Subdural hematoma MRI is the imaging study of choice to assess patients for
g. Osteoradionecrosis recurrent skull-base tumor [66]. MRI is also particularly
important when CT reveals soft-tissue densities adjacent
■ Contraindications: to dehiscent bone in the skull base. The evaluation of de-
1. Acute/subacute rhinossinusitis. hiscent areas becomes even more crucial when located in
2. No MDT service. the lateral sphenoid. Iatrogenic injury to this region can
3. Lack of specialized equipment. result in significant bleeding, the formation of a carotid
pseudoaneurysm, or optic nerve injury.
■ Anatomical areas that pose greater challenges to resec-

Preoperative Workup
tion should be carefully evaluated. These include the:
1. Cavernous sinus
Anatomy
2. Meckel’s cave
Revision endoscopic SBS is often substantially more 3. Jugular foramen
complex than primary surgery because essential nasal 4. ICA.
landmarks have frequently been removed or drastically
altered. The skull base, lamina papyracea, and other natu- The involvement of the carotid artery, the vertebrobasilar
ral barriers to complications may be eroded or removed system, or dural sinuses should also alert the surgeon to
from previous surgery. Posterior septectomy and partial additional risk to the intracranial vasculature [43].
or total amputation of the turbinates are common ana- Appropriate imaging sequences are essential in the
tomical alterations from prior surgery. It is essential in correct interpretation of MRI changes. Previous SBS will
the preoperative endoscopic evaluation to identify these often leave enhancing tissue that may be a combination of
changes in the skull base and nasal cavity. Pathology may, recurrent tumor, scar tissue, and reconstructive grafts.
additionally, be hidden behind previous reconstructive ef-
forts. A careful surgical plan for the reconstruction of any ■ The use of T1-weighted images and fat saturation tech-
skull-base defect is very important. The use of pedicled or niques before and after gadolinium enhancement will
free mucosal grafts might be hindered by previous sep-
reduce misdiagnosis, such as changes related to free fat stalk or involve the hypothalamus. Resection of the pitu-
grafts used in prior reconstruction. itary stalk carries considerable morbidity with hormone
replacement and reproductive dysfunction for adults, and
Scar and other high signal tissues may not be easily dis- has an even greater impact on growth and development
cernable from recurrent disease. Changes on serial exam- for children. Hypothalamic injury may result in severe,
inations, after an early postoperative baseline study, may crippling and life-threatening sequelae, such as adipsia,
be the only characteristic features of residual pathology morbid obesity, sleep disturbances, and behavioral and
[43]. MRI also enables differentiation of tumor from re- cognitive disorders [56]. The decision to attempt complete
tained secretions. tumor removal when resection or injury to these struc-
Magnetic resonance angiography or CT angiography tures is inevitable should be discussed with the patient
(Fig. 33.2) [36] can be used to assess the structure of me- prior to surgery and not left to an intraoperative dilemma
33 dium-to-large arteries in patients when erosion of the when such circumstances arise [17]. Careful preoperative
sphenoid and clivus has occurred. The relationship be- assessment with an endocrinologist, within an MDT, for
tween the basilar arteries and ICAs to pathology is crucial pituitary and hypothalamic dysfunction is essential in the
in this area. Although conventional angiography is not operative planning for these patients [40, 48, 56].
routinely performed, it may verify the functional integ-
rity of the circle of Willis, the extent of any carotid artery
compromise, and differentiate aneurysm from tumor.
Instrumentation
Endoscopic SBS is highly dependant on specialized in-
strumentation and its absence is an absolute contraindi-
Endocrine and Hypothalamic Considerations
cation to surgery. Dissection instruments and drills that
Even with the best preoperative imaging, the relationship are appropriately long enough to perform dissection be-
between tumor and intracranial structures can be diffi- yond the sphenoid are essential. Similarly, high-quality
cult to demonstrate. It is extremely difficult to evaluate endoscopes and video equipment are required. It is not
before surgery whether some tumors are extra-arachnoi- appropriate to perform endoscopic SBS without camera
dal, extrapial-subarachnoidal, or partially intraparenchy- equipment. An entire operative team needs to be visu-
mal-subpial [16]. This weighs heavily on considerations ally informed of the state of surgery. A second surgeon,
to obtain complete resection. Parasellar pathologies such for bimanual dissection, and theater staff should be ac-
as craniopharyngiomas may often encase the pituitary tively involved. The ability to maintain hemostasis and
Fig. 33.2 Computed tomography angiogram of a recurrent clival chordoma. Note the laterally displaced position of the inter-
nal carotid arteries (ICAs). (Reproduced with permission from Centro de ORL, Sao Paulo, Brazil)
Fig. 33.3 Endoscopic skull-base surgery equipment. a 5.2-mm polar forceps. d Long protected drill shafts. (Reproduced with
and 4-mm endoscopes. b Image-guidance systems. c Long bi- permission from Centro de ORL, Sao Paulo, Brazil)
a workable operative field during prolonged surgery is a

Surgical Techniques
demanding aspect of extended endoscopic surgery. Long
endoscopic bipolar forceps and hemostatic materials
General Principles
such as Surgicel or Avatine are essential to this process
(Fig. 33.3) [28]. ■ The medial orbital wall, orbital apex, and prechiasmal
optic nerve axis is a key landmark in revision SBS.
■ Dissection should always proceed from known to un-
known.
Previous Radiotherapy
Precise knowledge of previous radiotherapy fields will Endoscopic dissection in a previously operated skull base
have significant impact on reconstructive options. In ir- can be challenging due to the loss of traditional surgical
radiated tissue, multilayered free graft repair of skull-base landmarks. The use of image guidance has gained in-
defects has a high dehiscence rate in our experience and creasingly popularity since early reports of its use [6]. Im-
elsewhere [45]. Reconstruction of the irradiated skull proving the accuracy of image guidance has an associated
base almost always demands vascularized tissue. Pedicled learning curve [55] and occasional use may prove frus-
mucoperiosteal and mucoperichondrial flaps are used for trating to the unfamiliar. Fusion MRI and CT guidance
reconstruction. Radiotherapy may also thicken the pia may provide more significant information for the sur-
arachnoid tumor interface, obscuring dissection planes, geon operating on the skull base with extensive bone loss
and contribute to a greater risk of neural injury [43]. and altered soft-tissue structures [34]. However, detailed
knowledge of the endoscopic anatomy of the skull base A planned staging of resection in cases of extensive be-
can not be substituted by image guidance [51]. The revi- nign skull-base tumors may be appropriate when pathol-
sion endoscopic skull-base surgeon must have an exquisite ogies involve critical structures or neurovascular planes
knowledge of the anatomy and is referred to two anatom- [14]. This approach may assist with venous hemostasis,
ical series by Jho and Ha [22–24] and Kassam et al. [29, especially within the clivus.
30] for a review of the relevant endoscopic relationships.
Hemostasis
Dissection from the Cerebrovascular Structures
■ The most important hemostatic technique, especially
33 ■ Intradural dissection should be extra-arachnoid and in venous bleeding, may be patience.
preserve the arachnoid tissue and vessels – even for
vessels much smaller than 1 mm in diameter. The principles of hemostasis in endoscopic SBS differ
little from those of the microsurgical era. Prevention of
The technical difficulties posed by reoperation in the bleeding is obviously the best solution. Tumor debulk-
anterior fossa, parasellar region, and posterior fossa are ing, extracapsular sharp dissection, and countertraction
often the result of meningeal inflammation associated using gentle suction still form the foundation of cerebro-
with previous dissection. The arachnoid can be diffusely vascular control [28]. Standard neurosurgical bayonets
tenacious and opalescent, which complicates the estab- are often not appropriate via the long surgical corridor
lishment of microdissection planes and may hinder the of endoscopic SBS. Specialized instrumentation, as dis-
identification of vital structures. Where subtotal tumor cussed previously, is essential. Examples of hemostatic
removal with possible reoperation is planned, it may be techniques are demonstrated in Table 33.2.
preferable to resist dissection in the neural plane. Reoper-
ation of a previously undissected tumor–nerve interface
is typically more effective than attempting to reestablish a
Operative Basics
previously developed plane [43].
■ Adrenaline-soaked cottonoids are used during the
surgery but are replaced with saline cottonoids when
intradural dissection proceeds.
Staging the Resection
■ Staged resection of benign lesions may allow safer dis- Revision endoscopic SBS is performed under general
section of the tumor capsule from critical cerebrovas- controlled hypotensive anesthesia. Cottonoids contain-
cular structures. ing epinephrine 1:1000 are placed in the nasal cavity over
Table 33.2 Endoscopic hemostatic techniques
• Electrocautery
– Monopolar cautery (due to possible current dispersion, it should not be used
within the sphenoidal sinus, on the skull base, or intracranially).
– Bipolar cautery with endoscopic forceps
• Endoscopic clip applicators
– Structured approach to ligating the anterior ethmoidal, sphenopalatine, or poste-
rior ethmoidal artery with a Ligge Clip applicator prior to dissection [20].
• Hemostatic materials
– Surgicell (Johnson and Johnson).
– Avitene (Johnson and Johnson).
– Floseal (Baxter International).
– Syvek (Marine Polymer).
• Saline irrigation
– Hot-water irrigation has been advocated for hemostasis in the nasal mu-
cosa [60, 61] and warm saline is used in some skull-base centers [28].
the areas of surgical access for 10 min before the surgical a previous repair adherent in the prechiasmatic position.
procedure. If septectomy or mucosal flaps are planned, Secondly, the anterior cerebral vessels may be adherent to
the septum is infiltrated with lidocaine with epinephrine the previous repair of a transplanum approach. If the ar-
1:100.000. When the surgery includes the pterygopalatine teries are adherent to fat or fascia then it may be prudent
and infratemporal fossa, the region of the sphenopalatine to leave an island of scar tissue on the vessel rather than
foramen is infiltrated with approximately 2.0 ml of the attempt dissection (Fig. 33.4). Finally, the vasculature of
same concentration solution using an angulated 25-gauge the pituitary may be easily damaged if there is scar tissue
spinal needle after first aspirating. involving the stalk. Most importantly, a recurrent supe-
rior hypophyseal artery may lie within the vasculature of
the pituitary stalk and injury can result in optic nerve or
pituitary injury (Fig. 33.5) [33, 65].
Avoiding Complications in Revision
Endoscopic SBS
CSF Leak Closure Transclival Surgery

There are well established techniques for closing CSF leaks The position of the ICA can be difficult to locate in re-
[68, 69]. The endoscopic management with free grafts is vision SBS. Previous extensive bone removal can leave a
the first option for small defects (<1 cm) in primary and long segment of the ICA in soft tissue. The ICAs usually
revision cases [18, 37, 41]. However, possible failure can remain in a lateral position after previous displacement
be avoided by identification of benign intracranial hyper- by pathology (Fig. 33.6). Intraoperative micro-Doppler
tension, which is often characterized by empty sellae, mul- ultrasound can be used to help locate the vessels in such
tiple skull-base defects, or a broadly attenuated skull base. cases [10]. Prior radiotherapy, especially in chordoma,
These patients and may require additional interventions, may make surgical planes difficult to identify. The role of
such as lumbar drains or CSF diversion, for success [52]. CT angiography may be important in defining pathology
from prior reconstruction (mainly fat) and the basilar ar-
terial system (Fig. 33.2).
Transplanum/Transsphenoidal Surgery
Endoscopic revision surgery for pituitary adenoma is
Reconstructive Options
almost the standard care in many centers [5]. There are
three important implications of previous surgery in this ■ The ability to close large skull-base defects is perhaps
area. Firstly, the optic chiasm may lie superior or infe- the second greatest challenge to endoscopic SBS, after
rior to its original position and will often have fat from the management of cerebrovascular structures.
Fig. 33.4 Recurrent hemangiopericytoma. 1 Anterior cerebral vessels, 2 frontal gyrus. (Reproduced with permission from
Centro de ORL, Sao Paulo, Brazil)
33
Fig. 33.5 Recurrent cystic craniopharyngioma. 1 Olfactory tract, 2 transplanum opening to cyst, 3 Sella. (Reproduced with
permission from Centro de ORL, Sao Paulo, Brazil)
Fig. 33.6 Recurrent chordoma. 1 Basilar artery, 2 vertebral arteries, 3 tumor. (Reproduced with permission from Centro de
ORL, Sao Paulo, Brazil)
Table 33.3 Graft materials used in reconstruction of skull-base defects
• Mucosal flaps
– Posterior rotation septal flap (based on the septal branch of the sphenopalatine artery (SPA); Fig. 33.7a)
– Contralateral transposition septal flap (based on ethmoidal arteries; Fig. 33.7b)
– Inferior turbinate flap (based on turbinate branch of the SPA; Fig. 33.7c)
– Nasal floor flap (based on branches of the SPA and Woodruff’s plexus; Fig. 33.7d)
• Free mucosal or mucoperioteal grafts
– Well-described series with closure of anterior skull-base defects with cerebro-
spinal fluid leaks but not with extensive dural resection [35]
• Tissue glues and substrates – BioGlue [13] Tisseel [27] DuraGen [9] and Duraseal
• Autologus fascia (fascia lata, temporalis fascia)
• Homologus fascia (Alloderm)
• Free fat grafts
• Free flaps [67] (usually requiring conversion to open skull-base surgery)
• Free bone or synthetic materials
■ Multilayered reconstruction with pedicled mucosal Fibrin tissue glue is used to secure the repair. Gelfoam is
flaps is the key to closing large skull-base defects. layered to the area, followed by gauze packing. The pack-
ing is supported by a Foleys balloon catheter (Fig. 33.8).
A variety of reconstructive materials have been used
(Table 33.3). The use of vascularized pedicled flaps has
been the most significant advancement in our institu-
Postoperative Care
tion to reconstruct major skull-base defects (Fig. 33.7,
Video 33.1). Pedicled mucosal flaps have been well de- If the procedure is intradural, recovery is performed with
scribed for a variety of reconstructive procedures such as neurological observations in high dependency. CT is per-
septal perforation repair [47, 53], reconstructive rhino- formed out our institution on the first postoperative day
plasty [2, 42], and choanal atresia repair [11, 58]. How- for evidence of hemorrhage. Antibiotics are used periop-
ever, the use of vascularized mucosal flaps to repair large eratively and continued postoperatively while nasal pack-
skull-base defects [19] or congenital defects [64] has been ing remains in situ. Packing is left in place for 7–14 days as
described only recently. Along with other centers, with most grafts are adherent in bone in 1 week [50]. The onset
endoscopic skull-base experience, we discourage the use of diabetes insipidus is monitored with serum and urine
of free bone grafts and synthetic materials (i.e., titanium sodium/osmolality measurements. Patients are confined
mesh) as these may lead to poor healing and formation of to bed/chair rest with toilet privileges for 48 hrs, have 30 °
sequestra [26]. head elevation, and avoid straining, Valsalva maneuvers,
Free fat grafts are used to fill dead space and form a and nose blowing. Lumbar drains are not used unless
buttress for a subdural fascial graft. This is covered with a there is an additional comorbidity such as raised intra-
combination of pedicled mucoperiosteal/chondrial flaps. cranial hypertension or prior radiotherapy.
Fig. 33.7 Types of pedicled mucosal flaps for repair of large defects. a Posterior pedicled flap based
on the septal artery. b Contralateral septal flap based on the ethmoid arteries, c Inferior turbinate flap
based on the turbinate artery. d Nasal floor flap based on palatal and pharyngeal vessels. (Reproduced
with permission from Centro de ORL, Sao Paulo, Brazil)
comes for olfactory neuroblastoma have been the most

widely reported, with survival rates in excess of 80% at
about 3-year follow-up [7, 63]. Outcomes of recurrent
chordoma, with or without proton beam radiotherapy,
vary between 26% and 75% [15, 17, 62]. The results for
recurrent craniopharyngioma vary even more, depend-
ing on the philosophy of the treating surgical team [25].
Conclusion
33 Endoscopic SBS has both neurosurgical and otorhino-
laryngological origins. The ability of the surgical team to
access the entire ventral skull base endoscopically greatly
benefits patients with a variety of benign and malignant
pathologies. Endoscopic revision SBS presents an even
more challenging set of problems for treatment. The
Fig. 33.8 A cross-section of the completed repair. 1 Fat, 2 sub- management of these complex problems should be firmly
dural fascia, 3 mucosal flaps, 4 fibrin glue, 5 Gelfoam, 6 anti- established within an MDT. Absolute familiarity with en-
biotic-soaked gauze, 7 balloon catheter. (Reproduced with per- doscopic techniques, the ability to control nasal vascula-
mission from Centro de ORL, Sao Paulo, Brazil) ture, reconstruct skull-base defects, and manage cerebro-
vascular structures should be available to the operative
team. These skills combined with a detailed knowledge
Discharge usually occurs at 3–5 days postoperatively of endoscopic skull-base anatomy, and its distortion from
and an MRI scan is performed early for baseline assess- disease, serve as a foundation for addressing the pathol-
ment. This is important as postsurgical MRI signaling is ogy of the skull base.
often difficult to interpret [1].
Tips and Pearls
■ The intercarotid distance, height of the sphenoid
Complications and Outcomes sinus, and position of sellar should be evaluated
on CT to assess the dimensions for a transnasal
■ Major complications: craniotomy.
1. Death.
■ Bleeding from the intercarvenous sinuses can be
2. Infectious (meningitis, ventriculitis, subdural ab-
troublesome. Surgicel packing and patience will
scess).
control most venous bleeding. Persistent manipu-
3. Intracranial bleeding (arachnoid or subdural).
lation often hinders hemostasis.
4. Endocrine disturbances (diabetes insipidus, pitu-
■ Venous hemostasis should be achieved prior to
itary).
intradural dissection.
5. Neurological (cranial nerve deficits, cerebrovascu-
■ The removal of remaining mucosa from the bone
lar accidents, epilepsy, hypothalamic dysfunction).
of the skull base prior to reconstruction will avoid
6. Pneumocephalus.
mucocele formation.
■ Do not use excessive tissue glue as this will lead to
Endoscopic repair of CSF leaks is generally accepted as
potential barriers between reconstructive layers.
the standard of care. Success approaches 95% even with
■ Tight packing of the reconstructed area can oc-
revision cases [21]. However, the incidence of many other
clude the vascular flow of pedicled grafts and
skull-base pathologies is low. Most centers with endo-
should be avoided.
scopic skull-base teams have gained their experience and
skill by treating a diverse group of pathologies. Many of
the surgical steps and techniques are common between le-
sions, but generating large populations for similar lesions
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Chapter 34
Stenting in Revision Sinus Surgery

Seth J. Kanowitz, Joseph B. Jacobs, and Richard A. Lebowitz
34
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
■ Long-term patency rates may be improved by post- Stenting Materials and Design . . . . . . . . . . . . . . . . . . . . 301
operative stenting of the frontal sinus outflow tract. Preoperative Assessment . . . . . . . . . . . . . . . . . . . . . . . . . 303
■ In cases of previous partial middle-turbinate resec-
Indications for Stenting . . . . . . . . . . . . . . . . . . . . . . . . . . 303
tion, stenting of the frontal sinus outflow tract al-
lows for stabilization of the remnant fragment dur- Duration of Stenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
ing revision frontal sinusotomy. Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
■ In cases of extended frontal sinus drillout proce- Postoperative Stent Management . . . . . . . . . . . . . . . . . . 306
dures, stenting allows for improved mucosalization
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
and aids in temporary inhibition of circumferential
stenosis. Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
■ Soft (Silicone) sheets or stents, either prefabricated
or designed in the operating room, are superior to
rigid stents.
■ No absolute length of stenting exists and a determi- ing endoscopic visualization, high-resolution triplanar
nation should be made on a case-by-case basis. computed tomographic (CT) imaging, through-cutting
■ Postoperative stent management includes routine frontal sinus instrumentation, and image-guided surgery
endoscopy with gentle debridement, culture-direct- have occurred since the original external approaches
ed antibiotic therapy, and nasal irrigations. Nasal were described, prevention of FSOT restenosis after revi-
steroid spray is reserved for select cases. sion sinus surgery remains a difficult challenge.
Intrinsic host factors such as sinonasal polyposis,
osteoneogenesis, ciliary dyskinesis, immunodeficiency,
vasculitis, and other autoimmune phenomena may pre-
dispose the patient to a poor outcome regardless of the
surgical technique. Extrinsic factors such as lateralization
Introduction
of the middle turbinate/middle turbinate remnant, post-
Revision frontal sinus surgery is a demanding challenge operative sinus cavity infections, scarring, synechiae, and
that incorporates a keen understanding of three-dimen- incomplete primary sinus surgery may also compromise
sional anatomy, surgical precision, and vigorous post- postoperative healing and ultimately lead to FSOT ste-
operative medical management aimed at maximizing nosis. Historically, failure rates of nearly 30% have been
long-term surgical success. Restenosis of the frontal sinus reported in the literature – and because of this propensity
outflow tract (FSOT) is frustrating and can occur even for postoperative stenosis of the FSOT, stenting remains
under the best of circumstances. The concept of frontal an important component in the surgical and postopera-
sinus stenting to minimize postoperative stenosis, im- tive management of chronic frontal sinusitis during revi-
prove mucosalization, and allow for functional patency sion endoscopic surgery.
of the of the FSOT following frontal sinus surgery has
been reported in the literature for over a century. In the
initial description of the external frontoethmoidectomy
Stenting Materials and Design
that now bears his name, Lynch described postoperative
stenting of the nasofrontal communication. Although From a historical perspective, the initial descrip-
many technological advances in sinus surgery includ- tions of frontal sinus stenting usually involved external
302 Seth J. Kanowitz, Joseph B. Jacobs, and Richard A. Lebowitz
frontoethmoidectomy procedures followed by stenting of and employed Silastic tubing for small endoscopic frontal
the FSOT with a wide variety of rigid or soft materials. sinusotomies (4–6 mm) in four patients [21]. However, a
Initially a gold tube, placed endonasally, was utilized by 50% stenosis rate resulted, which was attributed to a fail-
Ingals to stent the region of the FSOT until it was mu- ure to maintain a postoperative communication between
cosalized [13]. In 1921, Lynch placed a firm rubber tube an air passage and the mucosa, thus resulting in massively
in the FSOT in 15 patients until postoperative day five. hypertrophied mucosa and obstruction of the frontal si-
After 2.5 years of follow-up he reported a 100% success nus ostium. Since then, numerous authors have reported
rate [15]. However, subsequent studies demonstrated a their experience with the external or endoscopic place-
long-term failure rate of approximately 30% [17, 18]. ment of Silicone tubes or rolled sheeting to help maintain
The relative success of these early novel techniques led patency of the FSOT (Fig. 34.1) [1, 3, 5, 6, 9, 11, 12, 14,
others to experiment with different stent materials in the 16, 20, 23–25].
1940s and 1950s. Goodale, Harris, and Scharfe described In cases where an external approach is still neces-
their experiences with the use of tantalum, an inert basic sary, there is some data supporting the role of frontal si-
34 element originally discovered by Eckenberg in 1802, for nus stenting, although none of the reports are compared
frontal sinus stenting [7, 8, 10, 22]. Goodale employed against nonstented controls. In a comprehensive review
the material as a thin sheet sutured to the orbital perios- of 164 cases, Amble placed thin Silicone rubber sheeting
teum during revision external frontoethmoidectomies as to reconstruct the FSOT after a modified external Lynch
a way of minimizing circumferential granulation tissue procedure in which the frontal process of the superior
and scarring [8, 9]. Extending on Goodale’s work, Har- maxilla was preserved [1]. Of the 164 patients studied, 79
ris and Scharfe described their limited series of patients of the patients had previous failed sinus surgical proce-
where tantalum tubes were placed from the frontal sinus dures addressing the frontal sinus and thus were under-
into the nasal cavity [10, 22]. In all cases, patients demon- going a revision. After FSOT reconstruction with Silicone
strated resolution of their symptoms and patency of their sheeting for 6–8 weeks, 96% achieved resolution of their
frontal sinus. Each author noted decreased scarring of the symptoms at a mean follow-up of four years. Only 18%
FSOT, improved epithelialization, and decreased granu- of the patients required a revision procedure to achieve
lation tissue formation. However, it should be noted that 4 years during the study period.
during the time of these procedures antibiotics were em- Yamabosa also reported on his experience in placing
ployed for the first time, and thus are probably partially a silicone T-tube in the FSOT via a Lynch incision in 18
responsible for the improved outcomes. Other materials, patients presenting with frontoethmoid mucoceles [25].
such as Dacron woven arterial graft have also been em- Three of these patients had failed previous external frontal
ployed for similar indications and with similar results. procedures, and all patients failed a transnasal approach
However, Barton employed this material during a Lynch at widening the FSOT due to thick bone formation. Re-
external frontal sinusotomy, for permanent stenting of the moval of the tube was determined by aeration of the frontal
FSOT over a 17-year period in 34 patients [2]. No stents sinus on CT imaging and lack of polypoid mucosa or mu-
were removed and all patients were relieved of their fron- cous discharge on flexible endoscopic exam. Although the
tal headache symptoms. exact length of follow-up is unclear, 16 patients achieved
In contrast to today’s modern soft materials, the origi- patency of the FSOT and resolution of their symptoms.
nal designs involved rigid materials likely employed out The two failures developed scar tissue and polyps of the
of convenience and limited by current technological stan- FSOT at 3 and 5 months after stent removal.
dards. However, in 1976 Neel demonstrated the superior- As the endoscopic era began, more authors started
ity of thin, pliable Silastic sheeting for the first time in to report their experience with endoscopic frontal sinus
a canine model [17]. In those treated with firm rubber stenting. In a limited trial, Schaefer and Close endoscopi-
stents, significant fibrosis and osteoblastic activity with cally placed thin Silastic tubing as a frontal sinus stent
little or no epithelialization resulted. In contrast, normal in patients with small frontal sinusotomies (4–6 mm),
mucosal lining was observed on histological specimens in resulting in a 50% failure rate in the four patients stud-
those ducts stented with thin Silastic sheeting. He attrib- ied [21]. Weber retrospectively reviewed 12 patients who
uted the difference to local ischemia, impaired drainage, underwent various endoscopic Draf-type procedures
and localized infection around the rigid tubes. He subse- for frontal sinusotomy followed by a 6-month course of
quently reviewed a series of patients after an average of FSOT stenting with either a Rains self-retaining Silicone
13.5 years of follow-up and reported a 29% failure rate tube, U-shaped Silicone tube, or an H-shaped Silicone
with rubber tubing and a 17% failure rate with thin Silas- tube [23]. While all patients had improvement or reso-
tic sheeting [18]. lution of their headache symptom, only six FSOTs were
With the dawn of the endoscopic era, Schaefer and endoscopically visible at a mean of 19.4 months of follow-
Close extended upon the ideas initially proposed by Neel up. Five other FSOTs were deemed functionally patent
Stenting in Revision Sinus Surgery 303
due to evidence of aeration on imaging studies. Hoyt re- ■ Evaluate the preoperative CT for radiographic evi-
ported similar results in 21 patients (32 stents) who had dence of extensive sinonasal polyposis, allergic fungal
vented tubular plastic stents placed endoscopically over a sinusitis, and/or osteitis of the bone of the FSOT.
guidewire for an average of 8 weeks [12]. ■ Evaluate the preoperative CT for evidence of lateral-
Using the stent that now bears his name, Freeman ization or scarring of the middle turbinate or middle
placed a biflanged Silicone tube in an external or endo- turbinate remnant.
scopic fashion in 64 sinuses [19]. The Freeman frontal si- ■ Examine the FSOT with angled nasal endoscopes to de-
nus stent is unique in that it requires an introducer and termine the presence of polyposis or hyperplastic mu-
the distal flange is contained within a dissolving gel cap cosa in the frontal recess, scarring or synechiae from
to allow for easier insertion. After a mean follow-up of prior surgery, and previous partial middle turbinec-
29 months, six sinuses eventually required fat obliteration tomy with lateralization of the remnant fragments.
due to return of polyposis or restenosis of the FSOT. Simi-
larly, Rains endoscopically placed 102 stents (soft Silicone
tube with a tapered collapsible bulb) in 67 patients for an
Indications for Stenting
average duration of 35 days [20]. After a follow-up of 8–
48 months, a 94% endoscopic patency rate was reported, While many non-case-controlled reports of FSOT stent-
with allergic fungal sinusitis present in all failures. ing demonstrating successful patency rates exist in the
literature, no standardized indications exist to guide sur-
geons in the implementation of these devices.
Preoperative Assessment
■ Routine stenting in uncomplicated cases is not recom-
■ Carefully review the sinus anatomy on CT to deter- mended, and thus FSOT stents should be employed
mine the potential surgical diameter of the frontal on a case-by-case basis based upon the surgeon’s as-
sinus neo-ostium, as limited by the frontal beak, ante- sessment of the patient’s relative risk of postoperative
rior skull base, medial orbit, and cribriform plate. FSOT stenosis.
Fig. 34.1 Chronic left frontal sinusitis (left upper picture) requiring revision endoscopic frontal si-
nusotomy (right upper picture). A rolled Silastic stent (left lower picture) was placed in the frontal
recess until mucosalization was complete (right lower picture)
Several intrinsic and extrinsic conditions need to be con- 5. Destabilized or lateralized middle turbinate or
sidered as risk factors for FSOT stenosis, and thus, as po- middle turbinate remnant.
tential relative indications for stenting. 6. Draf III or tumor resection procedures with muco-
In one review, Hosemann demonstrated a doubling sal trauma and extensive bone exposure.
(16% vs. 33%) of the rate of FSOT stenosis when the in- 7. Frontoethmoid mucoceles, which usually indicate
traoperative diameter of the neo-ostium was less than long-standing chronic sinus disease or previous
5 mm. [11]. This is similar to the indications (4–6 mm) surgical failures.
employed by Schafer and Close [21]. Therefore, a FSOT
diameter of less than 5 mm at the completion of the fron-
tal sinusotomy is often considered a relative indication
Duration of Stenting
for stenting. Other relative indications for FSOT stenting
during revision frontal sinus surgery are listed below. Similar to the indications for stenting, no prospective
case-controlled studies have been performed to investi-
34 ■ Relative indications for FSOT stenting: gate the optimal duration of FSOT stenting. While most
1. Frontal sinus neo-ostium diameter less than 5 mm. authors recommend a temporary period of stenting,
2. Extensive or circumferential exposure of bone in Barton employed his Dacron woven arterial graft per-
the FSOT, which may lead to long-term postopera- manently over 17 years [2]. Whenever stent removal is
tive crusting. deemed appropriate, all current authors report successful
3. Sinonasal polyposis or hyperplastic mucosa, which removal of the stenting material in the office using endo-
may lead to difficulty with postoperative endoscopes and endoscopic sinus instrumentation.
scopic visualization and debridement The 6-week time frame that is often discussed comes
4. Evidence of osteitic bone or osteo-neogenesis visu- from the canine model by Neel where he demonstrated
alized on CT imaging or encountered intraopera- histologically that re-epithelialization of the FSOT
tively (Fig. 34.2). stented with thin Silicone rubber is complete within
Fig. 34.2 Intraoperative surgical navigation with probe in stenotic left frontal sinus outflow tract
during revision endoscopic frontal sinusotomy. The area of neo-osteogenesis has been removed by
high-speed angled diamond burr and a Parrell frontal sinus stent (Medtronic) placed in the FSOT (*)
as well as a large supraorbital ethmoid cell (#)
approximately 8 weeks [17]. He subsequently employed tistically from a comparison group of nonstented patients
these findings to his patient population and removed Si- undergoing the same Draf III procedure.
lastic sheeting stents beginning at a minimum of 6 weeks Temporary short-term stenting may also play a role
postoperatively (mean 6 months). After a 7-year follow- in revision frontal sinus surgery. In cases of extensive si-
up period he reported an 80% success rate [18]. nonasal polyposis, hyperplastic mucosa, or after techni-
In many of the trials already outlined above, average cally demanding FSOT dissections where the mucosa is
stenting time with soft Silicone stents ranges from 4 to inevitably traumatized and bone exposed, placement of
8 weeks with a success rate of 80–90% [1, 3, 6, 13, 20, 21]. a soft Silastic stent may aid limiting the amount of post-
While the length of follow-up and definition of success or operative crusting and/or endoscopic identification of
patency varies among authors, all arrive at similar con- the FSOT during postoperative endoscopy. The presence
clusions. However, Weber recommended removal of the of a stent inherently limits the amount of FSOT probing
various stents he employed in revision endonasal frontal necessary to debride the operative cavity. Removal of the
sinusotomy at 6 months and cited improved patency with stent at the first or second postoperative visit when the
a longer duration of stenting [23]. The 6-month duration operative cavity is clean and mucosal inflammation con-
was adapted from Montgomery tubes inserted during trolled may enhance long-term results.
tracheal surgery, as it was felt many months were neces-
sary to allow for stabilization of the subepithelial scar.
Freeman also described a period of stenting after revision
Surgical Technique
frontal sinus surgery lasting between 6 and 12 months
for patients stented to correct FSOT stenosis [6]. How- ■ Most commercially available frontal sinus stents can
ever, the duration of stenting was once again determined be easily placed via an endoscopic approach.
arbitrarily. ■ Inadvertent displacement of mucosal flaps into the
More recently, Dubin and Kuhn reported their experi- frontal sinus itself during stent placement should be
ence with the management of the FSOT after open and avoided.
endoscopic procedures for the removal of frontal sinus
osteomas [5]. Five of 12 patients (3 open, 2 endoscopic) After creation of a frontal sinusotomy, the stent is grasped
were stented with rolled Silastic sheeting (0.01 inches, at the end with the flanges using a 90 side-to-side giraffe
or 0.25 mm thick) for an average of 9.2 months (range forceps (Fig. 34.3). The stent is then introduced into the
6–17 months). One patient developed a scarred frontal FSOT under endoscopic visualization with a 70 rigid en-
recess despite 12 months of stenting after an osteoplastic doscope. The forceps are released and the instrument is
flap approach. Casiano employed similar methods (1- gently maneuvered out of the nose. The stent can then
mm-thick rolled Silastic sheeting) to stent the common be manipulated with an angled frontal sinus seeker. The
frontal sinus ostia after endoscopic modified Lothrop stent should move freely within the FSOT and the flanges
procedures [24]. The stent was removed in the office at should be deployed beyond the internal frontal sinus os-
the 2-month postoperative visit. A patency rate of 60% tium. In addition, the mucosa of the FSOT should lay flush
was achieved, while 32% remained stenotic, and symp- around the stent and inadvertent displacement of muco-
tom improvement was achieved in 72% at a mean fol- sal flaps into the frontal sinus itself should be avoided. If
low-up of 22 months (range 6–75 months). However, it the stent does not meet these requirements, then it should
is important to note that these results did not differ sta- be removed and replaced properly. The stent should then
Fig. 34.3 90-degree side-to-side giraffe forceps

grasping a Parrell frontal sinus stent (Medtronic,
Minneapolis, MN, USA). The flanges are grasped
within the forceps to allow for easier endoscopic
placement
Fig. 34.4 Endoscopic view of a Parrell frontal sinus stent

34 (*; Medtronic) in the left frontal sinus outflow tract (FSOT)
placed during revision endoscopic frontal sinusotomy. The
middle turbinate had been previously resected and the remnant
fragment was destabilized and scarred to the lateral nasal wall
be positioned within the anterior ethmoid cavity between Depending on surgeon preferences, nasal irrigation
the lateral nasal wall and vertical strut of the middle tur- usually begins within the first few postoperative days and
binate or middle turbinate remnant (Fig. 34.4). Proper is maintained for at least the duration of stenting. Large-
positioning is best achieved using a 0 or 30 rigid endo- volume irrigations (50 ml twice daily) with a Toomey sy-
scope and Blakesley forceps. This technique can also ringe are employed to manually dislodge crusts. Routine
be applied to rolled Silastic sheeting; however, the stent postoperative endoscopic removal of blood clots, crust-
needs to be fixed to the septum with nondissolvable ing, dried secretions, and granulation tissue from within
through-and-through sutures to prevent extrusion. the nasal cavity and within the stent itself, should be per-
formed in the office on a scheduled basis.
The use of topical and/or oral steroids is recommended
to reduce postoperative inflammation and scar formation
Postoperative Stent Management
around the stent. Weber and Rains both employed topi-
Expert opinion and experience indicates that regular de- cal inhaled nasal steroids as part of their postoperative
bridement of the nasal cavity and stent itself is warranted. medical regimen. [20, 23] However, in the absence of
Regular nasal irrigations also play a key role in limiting other sinonasal indications for oral or topical steroid use
the buildup of debris. (i.e., sinonasal polyposis, mucosal edema, allergic fungal
sinusitis), the presence of a healthy stent alone is not an
■ Routine care of the stent, regardless of the material and absolute indication for utilization of these medications.
placement technique, are necessary to maintain stent Routine empiric antibiotic coverage for the duration
patency, minimize scarring, crusting, and adhesions, of the stenting is not recommended. However, appropri-
and improve long-term results. ate culture-directed antibiotic therapy to control purulent
■ Use topical and/or oral steroids to reduce postop- drainage identified during routine endoscopy or as part
erative inflammation and scar formation around the of an episode of acute frontal sinusitis is warranted. If pu-
stent. rulent drainage persists despite appropriate medical ther-
■ Routine empiric antibiotic coverage for the duration apy, the stent may act as a foreign body or reservoir for
of the stenting is not recommended. Culture-directed biofilms, and consideration should be given to removing
antibiotics are used if purulent drainage occurs post- it. In a pilot study by Perloff and Palmer, six frontal sinus
operatively. stents removed 1–4 weeks after functional endoscopic si-
■ Stents aggregate biofilms given time. nus surgery (FESS) and examined by scanning electron
■ If purulent drainage persists despite appropriate medi- microscopy demonstrated evidence of bacterial biofilms
cal therapy, consider removing the stent. [19]. In five of six of their patients, various staphylococ-
cal species were cultured from the sinuses at the time of
Even during the early days of frontal sinus stenting, Goo- FESS.
dale and Harris routinely probed and cleaned the tanta- FSOT stenting is an extremely safe procedure when
lum tubes with a curved suction [7, 8, 10]. performed by experienced endoscopic surgeons. No cases
of orbital penetration, CSF leaks, or skull-base violations 5. Dubin MG, Kuhn FA (2006) Preservation of natural frontal
have been reported in the literature to date. In rare in- sinus outflow in the management of frontal sinus osteomas.
stances, some stents have required removal under gen- Otolaryngol Head Neck Surg 134:18–24
eral anesthesia due to significant scarring that obscures 6. Freeman SB, Blom ED (2000) Frontal sinus stents. Laryn-
visualization and instrumentation in an office setting [3, goscope 110:1179–1182
5, 6, 24]. However, one case of toxic shock syndrome due 7. Goodale RL (1945) The use of tantalum in radical frontal
to frontal sinus stenting, despite 7 days of postoperative sinus surgery. Ann Otol Rhinol Laryngol 45:757–762
antibiotic prophylaxis, has been reported [4]. 8. Goodale RL (1954) Ten years’ experience in the use of tan-
talum in frontal sinus surgery. Laryngoscope 64:65–72
9. Har El G, Lucente FE (1995) Endoscopic intranasal frontal
sinusotomy. Laryngoscope 105:440–443
Conclusion
10. Harris HE (1948) The use of tantalum tubes in frontal sinus
Frontal sinus stenting may play a role in specific cases of surgery. Cleve Clin Q 15:129–133
revision frontal sinus surgery. In cases of extensive muco- 11. Hosemann W, Kuhnel TH, Held P, et al. (1997) Endonasal
sal trauma, bone exposure, or destabilized middle turbi- frontal sinusotomy in surgical management of chronic si-
nate, stenting may improve long-term FSOT patency and nusitis: A critical evaluation. Am J Rhinol 11:1–19
enhance mucosalization. Regardless of the specific stent 12. Hoyt WH (1993) Endoscopic stenting of nasofrontal com-
chosen, those made of soft Silicone are preferred to more munication in frontal sinus disease. Ear Nose Throat J
rigid materials. Stenting may be employed during revi- 72:596–597
sion external or endoscopic frontal sinus surgery and is at 13. Ingals EE (1905) New operation and instruments for drain-
the discretion of the surgeon. The appropriate duration of ing the frontal sinus. Trans Am Laryngol Rhinol Otol Soc
stenting has not been defined in the literature and should 11:183–189
be determined on a case-by-case basis based upon pa- 14. Jacobs JB (1997) 100 years of frontal sinus surgery. Laryn-
tient characteristics, findings on CT imaging, and intra- goscope 107:1–36
operative observations. Appropriate postoperative stent 15. Lynch RC (1921) The technique of radical frontal sinus sur-
management is crucial in maintaining long-term stent gery operation which has given me the best results. Laryn-
patency and consists of routine irrigation, endoscopic goscope 31:1–5
debridement, and appropriate antibiotic therapy for evi- 16. Mirza S, Johnson AP (2000) A simple and effective frontal
dence of purulence. If granulation tissue and purulence sinus stent. J Laryngol Otol 114:955–956
persist despite adequate medical therapy, then consider- 17. Neel HB, Whicker JH, Lake CF (1976) Thin rubber sheet-
ation should be given to stent removal. ing in frontal sinus surgery: animal and clinical studies.
Laryngoscope 86:524–536
18. Neel HB, McDonald TJ, Facer GW (1987) Modified Lynch
procedure for chronic frontal sinus diseases: rationale, tech-
Acknowledgments
nique, and long-term results. Laryngoscope 97:1274–1279
The authors would like to thank Martin J. Citardi, MD 19. Perloff JR, Palmer JN (2004) Evidence of bacterial biofilms
and Pete S. Batra, MD for providing clinical images for on frontal recess stents in patients with chronic rhinosinus-
the figures. itis Am J Rhinol 18:377–380
20. Rains BM (2001) Frontal sinus stenting. Otolaryngol Clin
North Am 34:101–110
21. Schaefer SD, Close LG (1990) Endoscopic management of
References
frontal sinus disease. Laryngoscope 100:155–160
1. Amble FR, Kern EB, Neel B, et al. (1996) Nasofrontal duct 22. Scharfe ED (1953) The use of tantalum in otolaryngology.
reconstruction with silicone rubber sheeting for inflamma- Arch Otolaryngol 58:133–140
tory frontal sinus disease: analysis of 164 cases. Laryngo- 23. Weber R, Mai R, Hosemann W, et al. (2000) The success of
scope 106:809–815 6-month stenting in endonasal frontal sinus surgery. Ear
2. Barton RT (1972) Dacron prosthesis in frontal sinus sur- Nose Throat J 79:930–932, 934, 937–938, 940–941
gery. Laryngoscope 82:1795–1802 24. Wish B, Dargi Z, Collins W, et al. (2006) Long-term effect
3. Benoit CM, Duncavage JA (2001) Combined external and of stenting after endoscopic modified Lothrop procedure.
endoscopic frontal sinusotomy with stent placement: a ret- Am J Rhinol 20:595–599
rospective review. Laryngoscope 111:1246–1249 25. Yamasoba T, Kikuchi S, Higo R (1994) Transient position-
4. Chadwell JS, Gustafson LM, Tami TA (2001) Toxic shock ing of a silicone T tube in frontal sinus surgery. Otolaryngol
syndrome associated with frontal sinus stents. Otolaryngol Head Neck Surg 111:776–780
Chapter 35
Use of Intravenous Antibiotics

in Sinus Surgery Failures 35
Seth M. Brown, Abtin Tabaee, and Vijay K. Anand
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
■ The management of patients with refractory chronic Indications for Intravenous Antibiotics . . . . . . . . . . . . 309
rhinosinusitis despite adequate surgical and medical Effectiveness of Intravenous Antibiotics . . . . . . . . . . . . 310
treatment remains challenging.
Pediatric Intravenous Antibiotic Treatment . . . . . . . . . 312
■ Intravenous antibiotics may play a role in patients
Method of Delivery of Home-Infused Intravenous
who are considered “surgical failures,” particularly
in those who demonstrate hyperostosis on imaging. Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
■ Intravenous antibiotics are also indicated in intra- Complications of Intravenous Antibiotics . . . . . . . . . . 313
orbital and intracranial complications of sinusitis in Benefits of Intravenous Antibiotics . . . . . . . . . . . . . . . . 314
both adult and pediatric patients.
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
■ Methicillin-resistant Staphylococcus aureus is in-
creasing in prevalence as a pathogen in community-
acquired sinusitis.
■ The trend in intravenous antibiotics is toward home
therapy with peripherally inserted central catheters. with CRS, a critical examination of any treatment modal-
■ Preliminary studies support the cost-effectiveness ity is required prior to widespread adoption.
and safety of home intravenous antibiotic treat-
ment.
Indications for Intravenous Antibiotics

1. Refractory rhinossinusitis.
2. Hyperostotic rhinossinusitis.
3. Extranasal complications from rhinossinusitis.
Introduction
4. Resistant pathogens to oral antibiotics.
Despite advances in the medical and surgical manage- 5. Patient intolerance to oral antibiotics.
ment of chronic rhinosinusitis (CRS), a subset of patients 6. Surgical alternative.
continues to have refractory symptoms despite “maximal 7. Failure of surgical therapy.
therapy.” This group of patients represents a significant
management challenge in the field of rhinology. Multiple The indications for intravenous antibiotics in sinonasal
treatment modalities are described including long-term disorders are currently in evolution. Traditional indica-
broad-spectrum oral antibiotics, topical antibiotics, and tions have included rhinossinusitis with intraorbital or
anti-inflammatory medications [1]. For the patient with intracranial complications and microbial resistance to
recalcitrant disease, this involves additional cost and oral antibiotics on sinonasal cultures, including methicil-
potential treatment-related complications, with limited lin-resistant Staphylococcus aureus (MRSA). Additional
overall efficacy. The goal of this chapter is to describe indications may include patients with medical comor-
the indications, safety, and outcomes of intravenous an- bidities who are not medically fit for surgery and patients
tibiotics in this cohort of patients. Given the significant who have failed traditional medical and surgical therapy
incidence in the general population, negative impact on [8]. The use of antibiotics in the latter group remains con-
quality of life, and health-care expenditure associated troversial. The refractory nature of CRS in this cohort is
310 Seth M. Brown, Abtin Tabaee, and Vijay K. Anand
evidenced by the typical history of multiple courses of The increasing incidence of microbial pathogens resistant
oral antibiotics and surgical procedures with persistent to currently available oral antibiotics, typically MRSA,
symptoms [14, 18]. The potential benefits of intravenous represents a major public health concern. The majority
therapy in this group of patients have been described in a of patients with MRSA sinusitis have a known risk factor
limited number of studies [8, 13, 18]. Intravenous antibi- including a history of hospitalization and multiple treat-
otics may be initiated independently or as an adjunct to ments including antibiotics and surgeries. The incidence
surgical treatment with placement of a peripherally in- of MRSA in patients with refractory CRS is currently es-
serted central catheter (PICC) line in the early postopera- timated to be 2–15% and is likely increasing [10, 11, 14].
tive period [8]. In this model, treatment is initiated based In a study of all sinonasal cultures taken in the senior
on the intraoperative cultures and may include combina- author’s tertiary referral rhinology practice, 9.2% of pa-
tions of vancomycin, ceftriaxone, ceftazidime, and cipro- tients were found to have MRSA [14]. The treatment op-
floxacin [8]. tions for medical therapy in this cohort are limited. In
a subsequent study of intravenous antibiotics for treat-
■ Obtaining and reviewing a computed tomography ment of MRSA sinusitis in this group, negative cultures
(CT) scan is essential in those patients that have failed were achieved in five of six patients at last follow up after
35 surgery. a 6- to 8-week treatment course. The single patient with
■ The presence of hyperostosis on CT scan may suggest persistent cultures was noted to have improvement in
the need for intravenous antibiotics. clinical and endoscopic disease, suggesting the possibility
of MRSA colonization without pathogenicity [18]. These
For patients with persistent symptoms following surgery, results are further supported when looking at 20-item Si-
a critical evaluation of a CT scan is necessary to identify nonasal Outcome Test (SNOT-20) scores. In a study by
mucosal thickening, persistent obstruction of outflow Tabaee et al., SNOT-20 scores improved from a pretreat-
tracts, and diffuse bony changes, termed hyperostosis ment median of 62, to 42 after a 6- to 8-week course of
(Fig. 35.1). The latter finding is felt to result from perios- intravenous antibiotics for MRSA [18].
teal reactions, chronic inflammatory cell infiltrates, bony The role of intravenous therapy in the treatment of
resorption, and osteoneogenesis [12]. Although bacteria MRSA sinusitis is currently unclear. We advocate a treat-
have not been identified within the bone to date, these ment algorithm based on culture-directed sensitivities
changes have been found to correlate with persistent si- (Fig. 35.3). If sensitivity to an oral antibiotic is suggested,
nusitis symptoms resistant to conventional medical man- this is employed initially, often in combination with a sec-
agement, including oral antibiotics [12]. ond broad-spectrum antibiotic with anaerobic and Gram-
The CT scan in patients with refractory CRS allows negative coverage. Intravenous antibiotics are initiated if
the surgeon to determine whether a patient would benefit there is persistent clinical disease following a trial of oral
from additional surgery in cases of polypoid disease or therapy, or if the initial culture results show resistance
sinonasal obstruction. The role of surgery in hyperostosis to all oral alternatives. The role of intravenous antibiot-
alone is unclear. In cases of hyperostosis, often the muco- ics will probably continue to evolve as newer classes of
sal disease is limited, although patients may report local- oral antibiotics become available, such as linezolid. Other
ized pain to the areas of bony abnormalities. Hyperostosis studies have promoted using mupirocin nasal irrigations
has also been found to correlate strongly with the presence for MRSA; however, recurrence rates appear high, with 12
of massive polyposis (Fig. 35.2) [12]. The presence of hy- of 24 patients experiencing at least 1 recurrence in 1 se-
perostosis may also be a marker of refractory disease. In a ries [17]. Finally, despite the potential efficacy of culture-
retrospective review of a single surgical series, Kacker et directed therapy for MRSA rhinossinusitis, long-term
al. identified hyperostosis in 65% of patients undergoing surveillance for this cohort is required. Repeat cultures
revision surgery, compared to 20% in patients undergo- should be performed in patients with recurrent disease
ing primary surgery [12]. In another multi-institutional even if the posttreatment cultures were negative.
study of patients treated with intravenous home-based
antibiotic administration for rhinosinusitis, 44 out of 52
had undergone previous sinus surgery [2]. Looking at
Effectiveness of Intravenous Antibiotics
symptom analysis, significant improvement was seen in
these patients when previous treatment with oral antibi- ■ Intravenous antibiotics appear to be effective for surgi-
otics and/or surgery had failed [2]. cal failures or as an adjunct to surgery, but may be far
less effective when used as an alternative to surgery.
■ Intravenous antibiotics may represent a safe and ef-
fective treatment alternative for patients with MRSA The efficacy of intravenous antibiotics in conjunction with
sinusitis. surgery has been suggested by two recent studies. In a
Use of Intravenous Antibiotics in Sinus Surgery Failures 311
Fig. 35.1 Hyperostosis seen on computed tomography (CT).

a Axial. b Coronal. c Sagittal
multi-institutional study of 52 patients with CT evidence to 19.3), physical domain (from 25.4 to 7.7), functional
of CRS with hyperostosis, Anand et al. reported signifi- domain (from 23.0 to 6.6), and emotional domain (from
cant clinical, endoscopic, and radiographic improvement 19.3 to 5.0) [2]. In a separate study, Gross et al. showed a
following a course of culture-directed intravenous anti- partial or complete response in 11 of 14 patients follow-
biotics [2]. In this study, the Rhinosinusitis Disability In- ing surgery and culture-directed intravenous antibiotics
dex was used as one form of assessment and showed an [8]. Interestingly, the use of culture-directed intravenous
improvement after treatment in average score (from 67.7 antibiotics as an alternative to surgery is not supported
35
Fig. 35.2 Hyperostosis seen in patient with massive polyposis. a Axial CT. b Coronal CT
appropriate, similar to the treatment for osteomyelitis of

the extremities [2]. Additional clinical and basic science
investigation is required prior to definitive treatment
guidelines.
Pediatric Intravenous Antibiotic Treatment

■ The limited studies investigating intravenous antibiot-
ics for pediatric rhinossinusitis suggest overall effec-
tiveness, but a significant incidence of complications.
Don et al. reported an 89% success rate in pediatric pa-

tients with CRS aged 10 months to 15 years treated with
1–4 weeks of culture-directed intravenous antibiotics and
select adenoidectomies [4]. Endoscopic sinus surgery was
reserved for patients failing this treatment course. It is
Fig. 35.3 Demonstration of endoscopic-directed culture also important to note that the majority of patients in the
study (67%) had continuation of therapy with oral anti-
biotics after completion of the intravenous therapy. The
by the available literature. In a study of patients receiving authors noted correlations between treatment failure and
a course of intravenous antibiotic therapy without sur- older patient age, and longer preexisting symptoms [4].
gery, Fowler et al. found an 89% relapse rate at a mean of Although the authors did not report data on antibiotic
11.5 weeks after treatment [5]. or catheter complications, a separate report suggested
In summary, the available literature, although limited, higher complication and discontinuation rates for home-
may support the use of culture-directed intravenous anti- based intravenous therapy in children than in adults [7].
biotics in patients with refractory disease following maxi- However, in the same study they concurred with the high
mal medical therapy and surgery. Treatment duration has success rates in children, reporting excellent outcomes
been arbitrary in the literature, but for cases of surgical even in pediatric patients with early discontinuation of
failure with hyperostosis, a 6- to 8-week course may be treatment [7].
due, in part, to the numerous indications for insertion. In

Method of Delivery of Home-Infused
addition to antibiotic therapy, PICC lines are often used
Intravenous Antibiotics
for home medications including chemotherapy and intra-
Several delivery methods exist for intravenous therapy venous hydration or nutrition. Most studies examining
for CRS. Inpatient, hospital-based treatment, with the use PICC lines for long-term antibiotics have reported low
of traditional peripheral intravenous catheters, is signifi- complication rates related to the catheter itself, as low as
cantly limited by the associated health-care cost, negative 2% in one study of 177 patients [13]. These complications
impact on daily function, and potential for nosocomial included line thrombosis and septicemia [13].
complications. Outpatient, home-based therapy, allows Complications can be divided into those related to the
for more normal daily patient functioning and avoids catheter, such as catheter failure, thrombosis, or infection,
the need for prolonged hospitalization. Multiple meth- and those related to antibiotic therapy, including allergic
ods of delivery are available for home therapy. The least reaction, gastrointestinal upset, or rash/flushing. The lat-
invasive and most frequently used is a PICC. The initial ter is well documented with the use of vancomycin, and
placement may be performed by a variety of health-care is termed “red-man syndrome.” This reaction involves a
practitioners, including interventional radiology or dedi- pruritic and erythematous rash that occurs after infusion
cated nursing. Insertion of PICC lines has been shown of vancomycin (Fig. 35.4). The spectrum of antibiotic-re-
to be highly successful, in one study greater than 96% of lated complications include: neutropenia, elevated liver
patients had a PICC successfully placed; however, 14.6% function tests, allergic reaction, itching, and gastrointes-
required a cut-down for successful placement [15]. The tinal upset, and may occur in up to 16% of patients [13].
line is typically positioned near the antecubital fossa in However, most of these complications are considered mi-
the upper arm. The position of the distal end of the cath- nor, as only 9 of the 29 patients with an antibiotic-related
eter near the superior vena cava is confirmed with radio- complication in a study by Lin et al. required a change
graphic imaging. In the majority of patients, the line is in antibiotic [13]. Most reactions are self-limiting and
expected to function without issues and minimal impact resolve once the antibiotic is switched or stopped. Other
on function for the entire duration of therapy, usually studies have seen much lower antibiotic complication
6–8 weeks. rates, only 11 per 10,000 catheter days [15].
For patients requiring therapy for a greater period of One study compared the delivery method of intrave-
time, such as patients receiving chemotherapy, central venous therapy by comparing PICC to CVC. In this study,
nous catheters (CVC) are placed for home therapy. These PICC lines were found to have a higher complication rate
include such devices as Hickman catheters and porta-
caths. Care usually requires dressing changes around the
insertion site several times a week for both PICC and
Hickman catheters, and instruction on attaching the an-
tibiotic up to the intravenous line. This usually requires a
visiting nurse in the beginning and occasionally for the
entire duration of treatment. Based on evidence from
multiple series [2,8,13,18], the majority of patients are
able to successfully complete a complete course of outpa-
tient intravenous antibiotic therapy. However, given the
potential for significant complications, we recommend a
dedicated protocol as outlined below.
Complications of Intravenous Antibiotics

■ The potential for both minor and major complications
from long-term intravenous antibiotic therapy for si-
nusitis has been described.
■ Most complications appear related to the antibiotic
and not the intravenous line.
In the literature, there has been conflicting data regarding

the incidence of PICC line complications. This may be Fig. 35.4 “Red-man syndrome” seen with vancomycin infusion
then CVC. Looking at the specific complications, PICC throughout the course of therapy. Patients also undergo
lines were associated with a statistically significant increase repeat surveillance sinonasal cultures if there is a history
in the incidence of catheter malfunction, thrombophlebi- of resistant organisms.
tis, and overall complications [16]. Furthermore, the av-
erage time period for development of a complication with
a PICC was 20 days compared to 281 days for a CVC [16].
Benefits of Intravenous Antibiotics
Looking specifically at PICC placed for antibiotic therapy,
however, no significant difference in complications were ■ The quality of life associated with home-based intrave-
noted when compared to CVC [16]. This is more consis- nous therapy is much higher than with hospital-based
tent with another study on safety that found 11% compli- treatment.
cations in CVC compared to only 9% in PICC [9]. ■ The insertion of peripherally inserted catheters, unlike
Despite the overall safety of outpatient intravenous an- most central catheters, does not require a surgical pro-
tibiotic therapy, the potential for major complications do cedure and is generally well tolerated.
exist. Although complications such as catheter malfunc-
tion, thrombophlebitis, and rash may be easily managed, Home-based intravenous therapy requires a dedicated
35 other potential complications are associated with signifi- protocol of medical care and the commitment of the pa-
cant morbidity, including neutropenia and anaphylaxis. tient and family. Although visiting nurse care is often pro-
Additionally, the occurrence of a complication may result vided initially, the patient is taught how to properly attach
in a break or possibly premature termination of therapy, the antibiotics and care for the catheter in a sterile fash-
limiting the treatment efficacy. In light of these issues, we ion. Also, supplies and equipment must be available in
recommend a dedicated protocol for patients receiving the home and the patient’s schedule needs to be designed
therapy, with the goals of minimizing the incidence and for regular medication delivery. Despite these challenges,
morbidity of any complications. the satisfaction and quality of life with home-based in-
travenous therapy is significant. In one study looking at
■ Standard treatment protocol: quality of life on the Short Form-36, significant improve-
1. Initial consultation with an otolaryngologist and ments were found in physical functioning, bodily pain,
infectious disease specialist. and emotional/ mental component summary scale scores,
2. First antibiotic dose given in the physician’s office. in comparing patients on home-based therapy compared
3. Dedicated visiting nursing at regular intervals. to hospital-based treatment [6].
4. Weekly office visits. In analyzing direct costs, home-based intravenous
5. Regularly scheduled serologic testing. therapy appears cost effective compared to hospital treat-
6. Repeat endoscopic cultures. ment. A fivefold decrease in cost is associated with PICC
line insertion when compared to CVC [16]. One study es-
The treatment plan involves initial consultation with timated a potential saving of approximately $50,000 (US)
both our team and an infectious disease specialist. The per patient by using home-based intravenous antibiotic
patient is counseled regarding the indications, potential therapy compared to conventional hospital-based treat-
benefits, and expected treatment course prior to therapy. ment [3]. With the rapidly increasing national health care
Patients are also educated regarding the potential com- expenditure, the trend toward cost-effective therapy, such
plications of therapy and instructed to contact the team as home care, will likely increase over time.
with any concerning issues. The first dose is given in
the office to monitor the patient for potential adverse
events. The supervision of the first dose by the medical
Conclusion
team in the office also increases the patient’s emotional
comfort with the therapy prior to beginning home infu- When appropriately indicated, intravenous antibiotic
sions. Dedicated visiting nurse services are scheduled therapy may be beneficial to selected patients with refrac-
during the initial infusions until the patient can reliably tory rhinosinusitis.
demonstrate competence with PICC care and antibiotic
infusion. Following this, weekly office visits and home Tips and Pearls
nursing visits are scheduled. Patients are also regularly
1. Antibiotics should be considered in those patients
scheduled for serologic testing of antibiotic levels, when
with intracranial and intraorbital complications
indicated, as well as routine hematological and biochemi-
of sinusitis, CRS due to resistant organisms, and
cal testing (given the potential for neutropenia), elevated
refractory CRS following maximal medical and
liver function tests, and renal impairment. The patients
surgical therapy.
are also followed for clinical and endoscopic response
5. Fowler KC, Duncavage JA, Murray JJ, et al. (2003) Chronic

2. The presence of hyperostosis on CT scan in
sinusitis and intravenous antibiotic therapy: resolution, re-
patients with refractory CRS may indicate the
current and adverse events. J Allergy Clin Immunol 111:
potential role of intravenous antibiotic therapy.
s85
3. Routine diagnostic and surveillance sinonasal 6. Goodfellow AF, Wai AO, Frighetto L, et al. (2002) Qual-
cultures are recommended; choice of medications ity-of-life assessment in an outpatient parental antibiotic
is largely based on culture and sensitivity informa- program. Ann Pharmacother 36:1851–1855
tion. 7. Gomez M, Maraqa N, Alvarez A, et al. (2001) Complica-
4. Pediatric patients may be good candidates for tions of outpatient parenteral antibiotic therapy in child-
intravenous antibiotics, either as a surgical adjunct hood. Pediatr Infect Dis J 20:541–543
or alternative to surgery. 8. Gross ND, McInnes RJ, Hwang PH (2002) Outpatient in-
5. PICC lines are well tolerated and less expensive travenous antibiotics for chronic rhinosinusitis. Laryngo-
than centrally placed catheters or hospitalized scope 112:1758–1761
treatment. 9. Hoffman-Terry ML, Fraimow HS, Fox TR, et al. (1999) Ad-
6. The majority of complications associated with verse effects of outpatient parenteral antibiotic therapy. Am
PICC lines and home-based intravenous antibiot- J Med 106:44–49
ics are minor and easily managed; however, the 10. Huang WH, Hung PK (2006) Methicillin-resistant Staphy-
potential for serious complications does exist. lococcus aureus infections in acute rhinosinusitis. Laryngo-
7. A dedicated protocol is required to manage po- scope 116:288–291
tential complications and minimize disruption of 11. Jiang RS, Jang JW, Hsu CY (1999) Post-functional endo-
treatment. scopic sinus surgery methicillin-resistant Staphylococcus
8. The indications for intravenous antibiotic therapy aureus sinusitis. Am J Rhinol 13:273–277
in CRS may be increasing given the rising inci- 12. Kacker A, Huang C, Anand V (2002) Incidence of chronic
dence of resistant organisms and possible role of hyperostotic rhinosinusitis in patients undergoing pri-
hyperostosis in refractory sinus disease. mary sinus surgery compared to revision surgery. Rhinol
40:80–82
13. Lin JW, Kacker A, Anand VK, et al. (2005) Catheter- and
antibiotic-related complications of ambulatory intravenous
References antibiotic therapy for chronic rhinosinusitis. Am J Rhinol
1. Anand VK (2004) Epidemiology and economic impact of 19:365–369
rhinosinusitis. Ann Otol Rhinol Laryngol 113:3–5 14. Manarey CR, Anand VK, Huang C (2004) Incidence of
2. Anand V, Levine H, Friedman M, et al. (2003) Intravenous methicillin-resistant Staphylococcus aureus causing chronic
antibiotics for refractory rhinosinusitis in nonsurgical pa- rhinosinusitis. Laryngoscope 114:939–941
tients: preliminary findings of a prospective study. Am J 15. Ng PK, Ault MJ, Ellrodt AG, et al. (1997) Peripherally in-
Rhinol 17:363–368 serted central catheters in general medicine. Mayo Clin
3. Bernard L, El-hajj, Pron B, et al. (2001) Outpatient paren- Proc 72:225–233
teral antimicrobial therapy (OPAT) for the treatment of os- 16. Smith JR, Friedell ML, Cheatham ML, et al. (1998) Pe-
teomyelitis: evaluation of efficacy, tolerance and cost. J Clin ripherally inserted central catheters revisited. Am J Surg
Pharm Ther 26:445–451 176:208–211
4. Don DM, Yellow RF, Casselbrant ML, et al. (2001) Efficacy 17. Solares CA, Batra PS, Hall GS, et al. (2006) Treatment of
of a stepwise protocol that includes intravenous antibiotic chronic rhinosinusitis exacerbations due to methicillin-re-
therapy for the management of chronic sinusitis in chil- sistant Staphylococcus aureus with mupirocin irrigations.
dren and adolescents. Arch Otolaryngol Head Neck Surg Am J Otolaryngol 27:161–165
127:1093–1098 18. Tabaee A, Anand VK, Yoon C (2007) Outpatient intrave-
nous antibiotics for methicillin-resistant Staphylococcus
aureus sinusitis. Am J Rhinol 21:154–158
Chapter 36
Objective and Subjective Outcomes

after Revision Sinus Surgery 36
Michael G. Stewart and Scott M. Rickert
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
■ Assessment of outcome in revision sinus surgery is Outcomes Assessment in Rhinosinusitis . . . . . . . . . . . 317
multifactorial. Subjective Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . 318
■ There are several ways to assess both objective and
Objective Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . 319
subjective outcomes.
■ In revision surgery, and in chronic disease, the defi- Association Between Objective and Subjective
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
nition of a “successful” outcome likely differs from
that of success after an acute or resolving process. Available Validated Health Status Instruments
■ Existing tools developed for chronic rhinosinusitis for Use in Rhinosinusitis . . . . . . . . . . . . . . . . . . . . . . . . . 321
should be adequate for use in revision surgery. Global QOL Instruments . . . . . . . . . . . . . . . . . . . . . . 321
Disease-Specific Instruments . . . . . . . . . . . . . . . . . . . 321

Results after Revision Endoscopic Sinus Surgery . . . . 321
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Introduction
Assessment of outcome after any type of sinus surgery has
not been uniformly defined or standardized, and assess- poor. This may be of particular importance in revision
ment is likely multifactorial. Objective outcomes, such as surgery for problems such as nasal polyposis
endoscopic examination findings, computed tomography
(CT) scan findings, need for medical treatment, or surgi-
cal revision rate, are important to assess. Subjective out-
Outcomes Assessment in Rhinosinusitis
comes, such as symptoms and quality of life (QOL), are
also important. Furthermore, there is good evidence that Much work has gone into classification and outcomes
the objective and subjective data in chronic rhinosinusitis assessment in chronic rhinosinusitis, and this will be re-
do not always correlate well. Therefore, the assessment of viewed later in the chapter. However, there is a lack of
both outcomes is important. After sinus surgery – and material specifically focusing on revision surgery. Despite
particularly revision sinus surgery – these issues are par- the fact that there are some potential challenges, there is
ticularly salient, since the anatomy is invariably altered no reason that existing outcome tools cannot be used.
and may remain “abnormal” even with complete resolu- Symptoms and QOL should still be important outcomes
tion of symptoms. to assess, and are likely a major driver of patient behav-
ior after surgery – similar to before surgery. In addition,
■ In addition to discussing how to assess outcome, we the impact of sinusitis on the symptoms and severity of
should consider when to assess outcome. In certain other diseases, such as asthma, is likely as important after
diseases (for example, cancer), long-term outcomes revision surgery as any other time. Objective outcome as-
are invariably preferred over short-term outcomes. In sessment, in particular CT scan findings, might require a
other chronic diseases, improvement in short-term modified interpretation after revision surgery, however.
status can be quite beneficial and should be recom- There is limited data on CT mucosal changes that should
mended, even if long-term outcomes are predictably be expected after surgical intervention. Landmarks have
318 Michael G. Stewart and Scott M. Rickert
been removed and anatomy altered, but in fact the degree for “benchmarking” against known problems, but have
of mucosal changes, and the response to medical treat- the disadvantage of being less sensitive to the effects of a
ment, may be different in postsurgical sinuses. For exam- particular disease. For example, even the very successful
ple, some degree of underlying mucosal thickening might treatment of specific problems like hearing loss or visual
be expected and should perhaps be graded as “normal.” loss may result in only small changes on a global QOL
In addition, the timing of outcome assessment is im- instrument. Disease-specific instruments are designed
portant, and we should consider a different model in revi- with content that addresses the disease of interest, and are
sion surgery – with respect to long-term outcome as well much more sensitive to changes in disease status; how-
as “absolute” outcome. In many chronic diseases, the pa- ever, they have the disadvantage of not being comparable
tient will never return to a normal state. In fact, gradual across disease states and therefore they can be difficult
worsening in QOL might be expected. Therefore, suc- to interpret. In other words, what does an increase of 21
cessful treatment could limit the reduction in QOL (even points on scale X actually mean to a patient or interpret-
though it still declines), or prolong the time before reaching physician?
ing a certain level. For example, a patient with chronic
renal failure may always require dialysis, but additional ■ In the assessment of symptoms or QOL, it is also im-
treatment could still improve QOL and be a desirable portant to keep in mind that patients without disease
adjunct. Similarly, in patients with polyposis or other will usually not score 0 (or 100) on scales.
36 chronic mucosal diseases such as cystic fibrosis, need
for revision surgery should not necessarily be counted as As an example, in one study of the Sino-Nasal Outcome
“failure,” and short-term improvements in health status Tool – 16 items, patients with rhinosinusitis scored an av-
or QOL could be considered successful outcomes. On erage of 22.4 (on a scale of 0–48), and patients with ear
the other hand, revision surgery can still result in disease disease scored a mean of 10.5. Other studies have shown
resolution in many cases, so chronic status and eventual similar results. So, the baseline or “normal” score should
failure is not necessarily the norm. be taken into account when reviewing results in any pop-
ulation.
■ Outcomes assessed in chronic rhinosinusitis can be
divided into two general categories: subjective and ■ The popularity and use of QOL tools has grown sig-
objective. Both have been reported frequently in the nificantly, and in general the systematic assessment of
literature, and clinicians typically use both types of QOL yields important information about what patients
outcome in their everyday evaluations. are feeling, and the true effects of many treatments.
■ Most QOL instruments are validated to measure QOL
in populations, not individual patients.
■ QOL instruments might not be the best tools for as-
Subjective Outcomes
sessment of outcome after changes in treatment – par-
Symptoms are a key issue in rhinosinusitis, and are often ticularly in the very short term.
the primary reason that patients seek initial medical at-
tention and return for further treatment. In fact, at one However, the use of QOL instruments is often not fully
time, an international task force on rhinosinusitis used the understood. For example, most QOL instruments are val-
presence of symptoms as the definition of the disease [15]. idated to measure QOL in populations, not individual pa-
This was problematic, however, because some patients tients. The statistical criteria for discrimination between
with symptoms do not actually have rhinosinusitis. Sub- individual patients are more stringent. In addition, many
sequent publications have moved away from the concept instruments are designed to measure QOL averaged over
of symptoms as definitional, but nevertheless symptoms a recent period of time, not day-to-day changes. For ex-
are a key component of the disease and a major driver ample, items on the SF-36 global instrument ask about
of patient’s behavior. There is currently no standardized, the previous 4 weeks, and items on the Chronic Sinusitis
validated tool to measure symptom burden in rhinosi- Survey ask about the previous 8 weeks. Therefore, QOL
nusitis, although some tools have been reported [4]. instruments might not be the best tools for assessment of
An additional assessment of subjective outcome is outcome after changes in treatment – particularly in the
QOL, which is measured using validated instruments. very short term. In such cases, the presence and severity
QOL instruments are generally divided into two types – of symptoms might be more useful. However, there needs
global (or “generic”), and disease-specific. Both global to be some agreement on exactly which symptoms are
and disease-specific instruments have advantages and important to measure. A simple listing of potential symp-
disadvantages. Global instruments have the advantage toms will not suffice, because it will give equal “weight”
of being comparable between diseases and can be used to each symptom. For example, if there are ten possible
Objective and Subjective Outcomes after Revision Sinus Surgery 319
symptoms listed, then each symptom counts for 1/10

Objective Outcomes
(10%) of the total “symptom score.” Rhinologists would
probably agree that purulent rhinorrhea, for example, is a ■ CT staging systems are classificatory systems and were
more important and predictive symptom of sinusitis than, designed to allow standardization, classification, and a
say, headache. If each were on the same list, however, then common language (Fig. 36.1).
changes in each would be counted similarly. Some work ■ CT staging systems were not designed to predict out-
is needed to define and validate a symptom tool for use as come.
an outcome measure in rhinosinusitis [16, 21]. ■ There is a high correlation between endoscopic stage
Despite the obvious importance of symptoms and sub- and CT stage in patients with chronic rhinosinusitis.
jective outcomes, there are problems with using them in ■ CT staging may be more appropriate than endoscopic
isolation – a large problem being that some symptoms staging for frontal sinus disease, due to the remote lo-
and QOL changes will be due to other diseases besides cation of the frontal sinus.
rhinosinusitis. Therefore, subjective outcomes are only
part of the overall picture. A review of subjective out- There are several objective outcomes that can be assessed
comes instruments follows in a later section. after sinus surgery and revision sinus surgery. CT scan
Fig. 36.1 Computed tomography (CT) staging systems for chronic rhinosinusitis
findings are very important as an assessment of mucosal Another potential “objective” outcome is the need for
thickening, ostia obstruction, fluid level, and anatomic oral or topical medications, with the theory being that
extent of disease, as well as demonstrating other impor- successful surgery might reduce the need for extensive
tant information such as bony dehiscence and presence medical treatment. However, use of that as an outcome
of extrasinus extension of disease, for example. There may be problematic for a few reasons. The use of medi-
are several staging systems that have been proposed for cations to control persistent disease or prevent recurrent
sinus CT scans; among the most popular are the Lund- disease may be desirable, and should not necessarily rep-
MacKay, Kennedy, and Harvard systems [17]. These resent “failure.” In addition, medications are often taken
staging systems were designed to allow standardization, for related problems (such as allergies or pulmonary dis-
classification, and a common language – in other words ease). Finally, use of medication is volitional, and patients
they are classificatory systems. They were not designed may use or not use them for different reasons, making
to predict outcome (prognostic systems), although it is medication frequency of use less “objective” than it might
possible that they do so. Potential problems with any initially seem.
CT staging system include missing sinuses, the effect of
previous surgical sinus dissection, and difficulty in dif-
ferentiating mucosal thickening from retained secretions
Association Between Objective
[17]. In revision surgery, these issues can be particularly
36 difficult because of the changed anatomy of the ostiome-
and Subjective Outcomes
atal complex. Despite these issues, however, the CT scan ■ It is now well-established that symptoms and QOL do
is easily available, gives useful anatomic information, and not correlate with CT scan findings in chronic rhino-
is a widely used technique for assessing the sinus mucosa sinusitis [7, 8, 11, 14, 24, 27, 28].
and anatomy. ■ This does not mean that CT scan findings are not im-
There is a staging system for endoscopic findings [17]. portant, or that symptoms are not important, but it
Since endoscopic examination and the CT scan are both does mean that they are not measuring the same thing,
used to assess anatomy and mucosal status, not surpris- and that you cannot predict one simply by knowing
ingly there is a high correlation between endoscopic stage the other.
and CT stage. This is likely particularly true after revision
sinus surgery, where the ostia have been opened and tis- While it is clear that CT scan findings do not predict
sue removed, making endoscopic evaluation of most of symptoms at any given point in time, there is conflict-
the sinuses even easier. However, even after successful ing evidence on whether or not CT findings might actu-
surgery, there are some sinuses, in particular the frontal, ally predict changes in symptoms or QOL after surgery
which might be difficult to assess with endoscopy alone, or other treatment. One prospective study found that the
and CT scans still play an important role. CT scan stage was a significant independent predictor of
Other objective outcomes of potential use in revision improvement in symptoms after sinus surgery [26]. In
sinus surgery include culture results, olfactory testing, that study, patients with higher-stage disease on CT (i.e.,
and the presence and severity of related diseases such as worse mucosal disease) had larger proportional improve-
asthma. In addition, if one of the complaints is nasal ob- ments in disease-specific QOL after surgery. Another
struction, then acoustic rhinometry or rhinomanometry prospective study also found that CT stage approached
can yield objective data [18]. However, neither of those significance as a predictor of outcome [25]. Other pro-
tests is widely accepted in clinical practice and there is spective studies however found that CT stage was not an
debate about the techniques of testing and interpretation. independent predictor of change in disease-specific QOL
Nevertheless, they do provide objective data on the anat- or symptom severity after surgery [6, 8]. All studies have
omy of the nasal airway. shown large overall improvements in disease-specific
Bacteriology, and in particular the presence of resis- QOL after endoscopic sinus surgery.
tant bacteria, or fungus, can be important outcomes in In addition, one study has shown that objective find-
revision sinus surgery. However, many patients are on ings may predict the need for revision sinus surgery [12].
long-term antibiotics, making culture results possibly less Specifically, patients from a tertiary referral practice who
reliable, and there is always the possibility of sampling eventually required revision endoscopic surgery were
error and differences in laboratory techniques when re- statistically more likely to have an abnormal endoscopic
viewing culture results. Olfactory testing is beyond the examination at 18 months after the initial surgery. Inter-
scope of this chapter, but there are reproducible tests of estingly, in that series symptom severity at 18 months was
olfaction. One obvious caveat is that olfactory function not predictive of needing eventual surgical revision.
may be impaired before treatment, or as a result of an-
other disease.
person, and it relates symptoms to limitations on daily

Available Validated Health Status
life. It was designed for CRS, contains 30 items, and has
Instruments for Use in Rhinosinusitis
no designated period of symptom recall. It is scored into
three subscales: emotional, physical, and functional. The
Global QOL Instruments
content of some of the items cover more global QOL is-
There are hundreds of validated global QOL instru- sues than other disease-specific instruments.
ments, any of which could be potentially used as an out- The Rhinosinusitis Quality of Life Survey (RhinoQOL;
come assessment in revision surgery. The Short Form Fig. 36.6) [2] is a validated instrument that was designed
36-item Health Survey (SF-36) has been used in studies to be used for both acute and chronic rhinosinusitis. It
of chronic rhinosinusitis and the effect of sinus surgery, contains 17 items and uses a recall period of 7 days. It is
and it is clearly sensitive to the impact of chronic rhi- scored into three subscales: symptom frequency, symp-
nosinusitis. The instrument comprises 36 questions that tom bother, and symptom effect. While the authors re-
are scored into 8 general health domains, such as, for port that the instrument can be used in acute or chronic
example, bodily pain, vitality, and social functioning. A sinusitis, there is some potential concern that the content
shortened version, the SF-12, is also a global instrument, for those diseases will not be identical.
and it is scored into only two subscales – physical health
component and mental health component. One desirable
characteristic of the SF-36 and SF-12 are that they have
Results after Revision
both been used extensively, and there are good bench-
Endoscopic Sinus Surgery
mark comparison data for healthy individuals and also
multiple diseases. Compared to the volume of literature on primary sinus
Many other global QOL instruments can be used. surgery, there are fewer reports on outcomes after revi-
However, when using any global instrument, it is possible sion sinus surgery. Many of the published reports on re-
that the scale will not be sensitive to the effects of a spe- vision surgery address indications and techniques, but
cific disease. So, lack of response on a global QOL instru- not outcomes. Others report outcome only as success or
ment does not necessarily mean lack of effectiveness. failure rate, usually defined as the need for further revi-
sion surgery. As we have discussed earlier, this is probably
not the ideal outcome to assess in this group of patients.
We briefly describe the results from selected series below;
Disease-Specific Instruments
this is not an exhaustive list.
There are several validated disease-specific instruments One study of 125 patients over a 3-year period under-
for rhinosinusitis in adults, and in fact all have been used going revision endoscopic sinus surgery reported both
successfully in studies. Content, length, period of symp- objective and subjective outcomes [19]. In that series, ob-
tom recall, and scoring are different for each, so there are jective outcomes were CT scan findings, assessed using
several potential options [21]. the Lund-MacKay system, and endoscopy score, assessed
The Chronic Sinusitis Survey (CSS; Fig. 36.2) [10] was using a scoring system described by the 1997 Rhinosinus-
designed for chronic rhinosinusitis, contains six items, itis Task Force [17]. Subjective outcomes were SNOT-20
and was validated for a symptom recall period of 8 weeks. score, and individual symptoms measured on a visual an-
There are two subscales: medication and symptom. The alog scale. The mean number of prior surgical procedures
CSS is very sensitive to change over time, although its was 1.9. The authors found significant and sustained im-
limited content might exclude some aspects of sinusitis provements in both objective and subjective outcomes af-
in some patients. ter revision surgery. In particular, mean SNOT-20 scores
The Rhinosinusitis Outcome Measure (RSOM-31; improved from 30.7 to 7.7 at 2 years of follow-up, and
Fig. 36.3) [22] was originally developed as a 31-question mean endoscopy scores improved from 7.3 to 2.1 at 2-years
comprehensive assessment of sinusitis-specific symptoms follow-up. Six individual symptoms were measured using
with some general health assessment included. Since its Likert scales (nasal obstruction, congestion, rhinorrhea,
initial inception, this particular instrument has been sim- postnasal drip, facial pain/pressure, olfactory dysfunc-
plified and revalidated to be shorter and more sinusitis- tion), and all six showed large-magnitude and statistically
specific. The current widely used version is the Sinona- significant improvements at 2 years. Of the 125 patients,
sal Outcome Test-20 items (SNOT-20; Fig. 36.4), which 59 had nasal polyposis; those 59 patients also had more
contains 20 items, with no designated period of symptom prior surgeries, higher CT scores (worse disease), but
recall. The SNOT-20 is scored as a single scale. lower (better) SNOT-20 scores. The authors did not re-
The Rhinosinusitis Disability Index (RSDI; Fig. 36.5) port postoperative CT scores.
[3] is a validated instrument with items written in the first In another report from a subset (n = 80) of the same
36
Fig. 36.2 Chronic sinusitis survey

Fig. 36.3 Rhinosinusitis outcome measure (RSOM-31)
patient population, patients for revision surgery who also (70% improvement vs. 72.6% improvement) compared
had asthma had significantly worse CT scan findings than to preoperative scores. Therefore, despite worse CT scan
patients without asthma (mean Lund-MacKay scores of findings, patients with asthma had equivalent significant
18.6 vs. 11.7) [13]. However, disease-specific QOL before improvement in symptoms after revision surgery com-
revision surgery was not significantly different (mean pared to patients without asthma.
SNOT-20 scores of 49.6 vs. 44.9). Patients with and with- Another prospective study on revision sinus surgery
out asthma both had highly significant – but statistically reported changes in symptoms using the Rhinosinusitis
indistinguishable – improvements in SNOT-20 score Symptom Inventory, which is a summation of individual
36
Fig. 36.4 Sinonasal outcome test
symptoms (12 in all) from the 1997 Task Force list of main the individual symptoms of “nasal obstruction” and
jor and minor symptoms [5]. A total of 21 patients with “hyposmia,” and moderate improvements were seen in
a mean follow-up of 12.4 months after revision surgery symptoms “facial pressure,” “rhinorrhea,” “headache,”
were reported. The author converted raw symptom score “fatigue,” and “ear pain.” When grouped into four con-
changes into effect sizes to make interpretation easier; the tent domains (nasal, facial, oropharyngeal, systemic), all
effect size is a relative measure of change calculated by domains showed at least moderate improvement in ef-
dividing actual change by the standard deviation of the fect size. These improvements were statistically similar in
baseline value. In this study, all symptoms improved af- magnitude to changes in a group of patients after primary
ter revision surgery. Substantial improvement was seen endoscopic sinus surgery. This series also reported on
Fig. 36.5 Rhinosinusitis disability index (RSDI)

36
Fig. 36.6 Rhinosinusitis quality of life (QOL) instrument
medication use after revision sinus surgery; use of nasal dicts poorer outcome after ESS is controversial, and many
steroids, antihistamines, and antibiotics did not show sta- studies have not found a significant association [25].
tistically significant changes. One retrospective study noted that patients with clas-
Other studies have shown significant improvement in sic Samter’s triad (asthma, nasal polyposis, aspirin sensi-
disease-specific QOL and in frontal recess patency in pa- tivity) had more extensive disease on CT scan scores than
tients undergoing revision frontal sinus endoscopic sur- patients with chronic rhinosinusitis without Samter’s
gery using image guidance [9]. QOL scores were noted to triad. In addition, the Samter’s triad patients required
be clinically as well as statistically significantly improved. a larger number of revision surgeries [1]. However, pa-
Patients with massive nasal polyposis have been re- tients seem to benefit from improved QOL and improved
ported to have a high rate of revision surgery (47%), and control of asthma – even if repeated revision surgery is
in one study, a history of prior sinus surgery or the pres- needed [20, 23]. So the presence of Samter’s triad should
ence of asthma predicted a higher rate of revision sur- not deter the surgeon from pursuing revision surgery if
gery [29]. Whether or not the presence of asthma pre- it is indicated.
■ Difficulties in assessing outcomes in patients undergo- 6. Bhattacharyya N (2006) Radiographic stage fails to pre-
ing revision sinus surgery include the lack of a control dict symptom outcomes after endoscopic sinus surgery for
group. So, even though large improvements were iden- chronic rhinosinusitis. Laryngoscope 116:18–22
tified, it is not clear that they were necessarily due to 7. Bhattacharyya T, Piccirillo JF, Wippold FJ 2nd (1997) Re-
the intervention. However, given the nature of revision lationship between patient-based descriptions of sinusitis
surgery, in particular the fact that it is usually only and paranasal sinus computed tomographic findings. Arch
performed when other treatment options have been Otolaryngol Head Neck Surg 123:1189–1192
exhausted, it would be difficult to perform a study with 8. Bradley DT, Kountakis SE (2005) Correlation between com-
a true control group. Therefore, uncontrolled studies puted tomography scores and symptomatic improvement
might be the best evidence possible in this disease. after endoscopic sinus surgery. Laryngoscope 115:466–469
9. Chiu AG, Vaughan WC (2004) Revision endoscopic frontal
sinus surgery with surgical navigation. Otolaryngol Head
Neck Surg 130:312–318
Conclusions
10. Gliklich RE, Metson R (1995) Techniques for outcomes re-
Outcomes after revision sinus surgery can be divided search in chronic sinusitis. Laryngoscope 105:387–390
into subjective and objective findings. In general, patients 11. Hwang PH, Irwin SB, Griest SE, Caro JE, Nesbit GM (2003)
with rhinosinusitis had significant improvements in ob- Radiologic correlates of symptom-based diagnostic criteria
jective outcomes such as endoscopy score, and subjective for chronic rhinosinusitis. Otolaryngol Head Neck Surg
outcomes such as QOL and symptom burden, after revi- 128:489–496
sion sinus surgery. In fact, outcomes after revision sur- 12. Kennedy DW, Wright ED, Goldberg AN (2000) Objective
gery seem to be equivalent to outcomes after successful and subjective outcomes in surgery for chronic sinusitis.
primary surgery in some cases. Laryngoscope 110:29–31
The CT scan is an important indicator of the anatomic 13. Kountakis SE, Bradley DT (2003) Effect of asthma on si-
extent of disease and severity of mucosal change. However, nus computed tomography grade and symptom scores in
CT findings after revision surgery are not well described, patients undergoing revision functional endoscopic sinus
and surgical changes can modify the interpretation of surgery. Am J Rhinol 17:215–219
anatomic findings. Therefore, symptoms and QOL might 14. Krouse JH (2000) Computed tomography stage, allergy
be somewhat more important as outcome measures after testing, and quality of life in patients with sinusitis. Otolar-
surgery or revision surgery. However, it is generally best yngol Head Neck Surg 123:389–392
to consider subjective and objective outcomes as compli- 15. Lanza DC, Kennedy DW (1997) Adult rhinosinusitis de-
mentary. Researchers and clinicians should choose from fined. Otolaryngol Head Neck Surg 117:S1–S7
a variety of outcomes tools in the evaluation of patients 16. Ling FT, Kountakis SE (2007) Important clinical symp-
being considered for revision sinus surgery. toms in patients undergoing functional endoscopic si-
nus surgery for chronic rhinosinusitis. Laryngoscope.
117(6):1090–1093
17. Lund VJ, Kennedy DW (1997) Staging for rhinosinusitis.
References
Otolaryngol Head Neck Surg 117:S35–S40
1. Amar YG, Frenkiel S, Sobol SE (2000) Outcome analysis of 18. Mamikoglu B, Houser SM, Corey JP (2002) An interpreta-
endoscopic sinus surgery for chronic sinusitis in patients tion method for objective assessment of nasal congestion
having Samter’s triad. J Otolaryngol 29:7–12 with acoustic rhinometry. Laryngoscope 112:926–929
2. Atlas SJ, Metson RB, Singer DE, Wu YA, Gliklich RE (2005) 19. McMains KC, Kountakis SE (2005) Revision functional
Validity of a new health-related quality of life instrument for endoscopic sinus surgery: objective and subjective surgical
patients with chronic sinusitis. Laryngoscope 115:846–854 outcomes. Am J Rhinol 19:344–347
3. Benninger MS, Senior BA (1997) The development of the 20. McMains KC, Kountakis SE (2006) Medical and surgical
Rhinosinusitis Disability Index. Arch Otolaryngol Head considerations in patients with Samter’s triad. Am J Rhinol
Neck Surg 123:1175–1179 20:573–576
4. Bhattacharyya N (2003) The economic burden and symp- 21. Meltzer EO, Hamilos DL, Hadley JA, Lanza DC, Marple BF,
tom manifestations of chronic rhinosinusitis. Am J Rhinol Nicklas RA, Adinoff AD, Bachert C, Borish L, Chinchilli
17:27–32 VM, Danzig MR, Ferguson BJ, Fokkens WJ, Jenkins SG,
5. Bhattacharyya N (2004) Clinical outcomes after revision Lund VJ, Mafee MF, Naclerio RM, Pawankar R, Ponikau
endoscopic sinus surgery. Arch Otolaryngol Head Neck JU, Schubert MS, Slavin RG, Stewart MG, Togias A, Wald
Surg 130:975–978 ER, Winther B; The Rhinosinusitis Initiative (2006) Rhino-
sinusitis: developing guidance for clinical trials. Otolaryn-
gol Head Neck Surg 135:S31–S80
22. Piccirillo JF, Merritt MG, Richards ML (2002) Psycho- 26. Stewart MG, Donovan DT, Parke RB, Bautista MH (2000)
metric and clinimetric validity of the 20-item Sino-Nasal Does the severity of sinus computed tomography findings
Outcome Test (SNOT-20). Otolaryngol Head Neck Surg predict outcome in chronic sinusitis? Otolaryngol Head
126:41–47 Neck Surg 123:81–84
23. Robinson JL, Griest S, James KE, Smith TL (2007) Impact 27. Stewart MG, Sicard MW, Piccirillo JF, Diaz-Marchan
of aspirin intolerance on outcomes of sinus surgery. Laryn- PJ (1999) Severity staging in chronic sinusitis: are CT
goscope 117:825–830 scan findings related to patient symptoms? Am J Rhinol
24. Smith TL, Rhee JS, Loehrl TA, Burzynski ML, Laud PW, 13:161–167
Nattinger AB (2003) Objective testing and quality-of-life 28. Stewart MG, Smith TL (2005) Objective versus subjec-
evaluation in surgical candidates with chronic rhinosinus- tive outcomes assessment in rhinology. Am J Rhinol
itis. Am J Rhinol 17:351–356 19:529–535
25. Smith TL, Mendolia-Loffredo S, Loehrl TA, Sparapani R, 29. Wynn R, Har-El G (2004) Recurrence rates after endo-
Laud PW, Nattinger AB (2005) Predictive factors and out- scopic sinus surgery for massive sinus polyposis. Laryngo-
comes in endoscopic sinus surgery for chronic rhinosinus- scope 114:811–813
itis. Laryngoscope 115:2199–2205
36
Chapter 37
Bioabsorbable Materials
Rakesh K. Chandra and Robert C. Kern
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
■ A spectrum of absorbable biomaterials is available Classification of Absorbable Biomaterials . . . . . . . . . . 330
for revision endoscopic sinus surgery. Selection of Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
■ Each of these agents has unique properties that im-
Collagen or Gelatin Based . . . . . . . . . . . . . . . . . . . . . 330
pact on both the mode of application and mucosal
healing. Hyaluronic Acid Based . . . . . . . . . . . . . . . . . . . . . . . . 331
■ The anatomy of revision sinonasal cavities exhibits Cellulose Based . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
significant variability depending upon the extent of Additional Considerations and Future Directions . . . 334
previous surgery and the healing process.
■ The mucosa of patients with recalcitrant disease
undergoing revision sinus surgery may exhibit sig-
nificant qualitative differences compared to that of
primary cases. tologic and ultrastructural abnormalities including defi-
■ Roles of absorbable biomaterials include potential ciencies of ciliary density, anatomy, and function [1,2,7].
impact on hemostasis as well as mucosal healing. Other factors may include biofilm formation [19] and
■ Properties differ between the available products. osteitis of the underlying bone [14].
■ A complete understanding of the unique features of Our understanding of the pathophysiology of recur-
available bioabsorbable agents and their tissue ef- rent or recalcitrant sinus disease has paralleled an in-
fects is crucial, so that the appropriate material may crease in the application of revision surgery. This, in turn,
be selected for a particular revision surgery. has been facilitated by continued evolution in surgical
instrumentation, medical therapies, and intranasal dress-
ings.
■ Packing agents have been applied after primary and

revision ESS to attain three objectives:
Introduction
1. Hemostasis.
A variety of individual factors may be associated with the 2. Stenting to support the middle turbinate in a me-
need for revision endoscopic sinus surgery (ESS). Some dial position.
of these reflect recurrence (or reexacerbation) of the un- 3. Spacers to prevent the accumulation of blood and
derlying inflammatory disease process, such as regrowth mucus in the surgical cavity.
of polyposis or localized sinus ostial obstruction second-
ary to mucosal edema. Other causes of primary surgical Ideally, absorbable biomaterials should attain these goals
failure may be anatomic in nature, reflecting the quality with optimal patient comfort. Such agents also report the-
of healing or retained anatomy after initial surgery. These oretical enhancements in postoperative mucosal healing.
conditions include the development of synechiae or fixed These are worthy objectives because conventional pack-
ostial stenosis. Certainly any combination of inflamma- ing may be associated with significant patient discomfort
tory, anatomic, and infectious etiologies may exist in any while in place and during removal potentially leading to
one patient. As our understanding of chronic rhinosinus- patient dissatisfaction and increases in oral analgesic use
itis has continued to evolve, it has also become clear that [13]. This fact has been established in controlled stud-
patients with recalcitrant rhinosinusitis may exhibit his- ies comparing absorbable agents to tampon packing [3].
330 Rakesh K. Chandra and Robert C. Kern
Other investigations have revealed that some forms of

Selection of Material
nonabsorbable packing are associated with untoward tis-
sue effects. One such study using a sheep model demon-
Collagen or Gelatin Based
strated that Neuropatties were associated with loss of up
to 50% of the ciliated mucosal surface [23]. In contrast, ■ Main role is as a topical hemostat.
the same group later demonstrated that foam tampons ■ Possible fibrogenic effect.
are not associated with ineffective mucociliary function
following removal [17]. These agents were introduced primarily for their hemo-
Regardless of the packing method and material used, static properties and were initially utilized in cardio-
mucosal healing properties will vary substantially. Fur- vascular applications. Only later were they adapted for
thermore, recent studies have underscored that these rhinologic surgery. The hemostatic effect of these agents
principles are maintained when absorbable dressings are is considered acceptable to manage mild to moderate
utilized. The unique properties of the various available bleeding, where the primary mechanism of action is to
agents must therefore be understood in the context of re- provide a matrix for platelet aggregation of fibrin depo-
calcitrant sinus disease and the challenges encountered sition [3,5,6,9,12]. The latter can be facilitated by addi-
during revision ESS. tion of thrombin solution, usually at a concentration of
The goal of the present chapter is to present a frame- 1000 U/ml. Although this class of materials does have
work for rational selection and application of absorbable significant value in otolaryngology and ESS, known ef-
biomaterials. fects on mucosal healing must be examined.
37 Gelfoam and Gelfilm were both widely utilized in
middle-ear applications prior to adaptation to ESS. The
first report to illustrate that absorbable biomaterials were
Classification of Absorbable Biomaterials
not inert was published in 1997, where Tom et al. assessed
Absorbable materials may be classified according to mo- healing in cavities managed with and without Gelfilm
lecular composition, which significantly affects the bio- in a population of children who underwent a planned
logical properties. second-look 2–3 weeks after ESS [26]. In this investiga-
tion, Gelfilm was associated with adverse healing with
■ Classification of absorbable biomaterials used in sinus increased granulation tissue. Gelfoam appears to have
surgery: more benign effects on the healing of sinonasal mucosa,
1. Collagen/gelatin based: at least when compared to FloSeal. Randomized prospec-
a. Gelfoam – sponge composed of porcine colla- tive evaluation comparing these agents revealed that the
gen. latter was associated with greater prevalence of granula-
b. Gelfilm – sheet composed of porcine collagen. tion tissue and adhesions at 6–8 weeks postoperatively
c. SurgiFlo – microfibrillar porcine collagen pre- [5]. These findings must, however, be interpreted in the
pared with saline or thrombin to create an in- context of additional studies suggesting that crusting and
jectable paste. synechiae were no different at a 1- to 3-month follow-up
d. FloSeal – bovine-derived gelatin matrix prepared when FloSeal is compared to an unpacked control [12].
with thrombin to create an injectable paste. Nonetheless, long-term evaluation of the FloSeal ver-
e. Avitene – microfibrillar bovine collagen pow- sus Gelfoam cohort at 2 years postoperatively demon-
der prepared with saline or thrombin to create a strated that FloSeal was associated with greater preva-
slurry or injectable paste. lence of adhesions and an increased incidence of the
2. Hyaluronic acid based: need to surgically remove adhesions [6]. These observa-
a. SepraPack – wafer composed of hyaluronic acid tions suggest that collagen-based hemostats, particularly
carboxymethyl cellulose. FloSeal, may function as a scaffold for in-growth of gran-
b. Sepragel – hyaluronic acid carboxymethyl cel- ulation tissue and eventually scar. Foreign material has
lulose injectable gel. been noted to incorporate into healing mucosa [5,6,16].
c. Merogel – hyaluronic acid ester fabric. It should be noted that in this series of studies, the ab-
d. Merogel injectable – hyaluronic acid ester in- sorbable hemostatic material was left in place filling the
jectable gel. sinus cavity, even after cessation of bleeding (Fig. 37.1).
3. Cellulose based: This contradicts the initial descriptions for use of these
a. Surgicel – oxidized cellulose fabric. agents, where removal of excess product was advocated
b. Sinu-Knit – carboxymethyl cellulose fabric. after achieving hemostasis.
c. Sinu-Foam – carboxymethyl cellulose inject- The role for these agents appears to be for use as a
able. topical hemostat rather than as a surgical stent. Although
Bioabsorbable Materials in Revision Sinus Surgery 331
revision surgery, as thermal effects are destructive to the

ciliated mucosal surface. Such treatment potentially im-
pairs recovery of optimal mucociliary clearance in this
difficult patient population. Second, revision surgery of-
ten includes dissection and exposure of the skull base and
regions near the orbital apex, such as the sphenoid and
posterior ethmoid region. Use of cautery may be inad-
visable in these anatomic sites given their proximity to
intracranial structures and the optic nerve. In these situ-
ations, an absorbable hemostatic agent should be applied
precisely to the bleeding focus (Fig. 37.2), and the excess
should be suctioned or irrigated from the cavity following
attainment of hemostasis. Leaving the material in situ (as
shown in Fig. 37.1) potentially results in significant fibrin
accumulation within 1 week postoperatively (Fig. 37.3),
potentially leading to meatal stenosis.
Fig. 37.1 Ethmoid cavity filled with FloSeal. Note the particu-
Hyaluronic Acid Based
late nature of the material, which has the consistency of a paste.
Leaving the cavity in this manner may predispose to adhesions ■ Associated with adequate hemostasis.
■ Some preparations may augment optimal healing.
■ Composition affects healing properties.
studies have introduced the possibility of adverse heal-
ing, the hemostatic role may be of significant value in Active research is ongoing for an absorbable biomaterial
scenarios encountered during revision surgery. First, it with ideal properties of simultaneously providing hemo-
may be advisable to limit the application of cautery in stasis and functioning as a stent to support the middle
Fig. 37.2 Focal application of SurgiFlo to a bleeding focus in Fig. 37.3 One week postoperatively following filling of the eth-
the region of the sphenopalatine artery. The excess material moid cavity with FloSeal for stenting of the middle meatus (as
should be suctioned or irrigated from the cavity after cessation shown in Fig. 37.1). The middle turbinate has lateralized with
of bleeding significant fibrin deposition and early adhesions within the eth-
moid cavity, requiring extensive debridement
turbinate while occluding the ethmoid cavity to prevent diovascular applications to reduce platelet adhesion [10].
accumulation of blood and mucus, thus avoiding the pro- In ESS, hyaluronic-acid-based biomaterials have been
motion of fibrosis. Recent trends have included the use associated with adequate hemostatic effects [8], but it
of materials based on hyaluronic acid, or hyaluronan, a remains to be elucidated whether this is secondary to a
glycosaminoglycan found in the extracellular milieu. tamponade effect or an effect on the coagulation system.
Physiologically, this molecule interacts with water to give In any case, the use of packing in ESS simply for hemo-
viscosity to extracellular fluids and has cellular effects in stasis is controversial. Thus, the larger issue regards the
epithelial proliferation and possibly immune regulation. influence of hyaluronic-acid-based materials on wound
Hyaluronic acid has been implicated in the nearly scarless healing.
healing observed in fetal wounds [15]. Polymers of hyal- Hyaluronic acid was first associated with reduction of
uronic acid were initially utilized to prevent adhesions in adhesions in peritoneal applications, where animal stud-
abdominopelvic surgery [4]. Because of these properties, ies suggested that the primary effect is due to its function
preparations have been subsequently developed for use as a barrier that attracts water [25]. This evidence pro-
in sinonasal surgery (Fig. 37.4), but most of the research vided justification for the use of this material in sinonasal
studying the biologic effects of this molecule have been in applications, where additional studies have investigated
abdominal models. the influence of hyaluronic acid on the biology of wound
Unlike collagen-based materials (FloSeal, Surgiflo, healing in respiratory mucosa. Early data from animal
Avitene), hyaluronic acid is not a vigorous promoter of models has suggested that the composition of hyaluronic
coagulation, and in fact, it has even been utilized in car- acid does have a significant effect on healing. Proctor et
37
Fig. 37.4 Hyaluronic acid ester rolled fabric (a) and carboxy-
methyl cellulose wafer (b) each revealing change in consistency
to a gel-like form when hydrated. When hydrated in situ, the
carboxymethyl cellulose wafer takes on a gel-like consistency
that coats mucosal surfaces (c)
al. [20] demonstrated in a rabbit model that woven hyal- included only ten patients with a short follow-up. A ran-
uronic acid ester (Merogel) is associated with increased domized controlled multicenter trial [27] comparing hy-
foamy macrophages, granulation tissue, and ostial steno- aluronic acid carboxymethyl cellulose wafer (SepraPack)
sis when compared to cross-linked hyaluronic acid gel or to no packing in 53 patients followed over 8 weeks sug-
hyaluronic acid conjugated with mitomycin C. The latter gested that SepraPack was associated with significantly
two preparations exhibited greater ostial diameter than less synechiae at 2 weeks. A trend was also observed to-
untreated controls. In this investigation, biomaterials ward decreased synechiae at 8 weeks, although this did
were applied following creation of an antrostomy with not reach significance. This study also demonstrated im-
a 4-mm otologic drill. Another rabbit model, where the proved patient comfort with the biomaterial, as patients
maxillary sinus was stripped of its mucosa, also revealed reported significantly less congestion in experimental
that the woven hyaluronic acid ester was associated with sides at 4 and 8 weeks postoperatively. This is an interest-
incorporation into regenerating mucosa [16]. ing finding given that patients were blinded to which was
Sheep models have suggested that hyaluronic acid es- the experimental versus control side.
ter may augment epithelialization of experimentally in- Although there was no difference in final cavity status
duced mucosal wounds in healthy sheep, when examined between packed and unpacked sides, this data suggests
12 weeks postinjury [17]. This material, however, had no that hyaluronic acid carboxymethyl cellulose wafer is as-
beneficial influence on promotion of reepithelialization sociated with more favorable postoperative recovery sec-
or reduction of synechiae in these animal models [22]. ondary to decreased congestive symptoms and less need
The same group investigated a preparation of hyaluronic for aggressive debridement. Overall, studies of hyaluronic
acid impregnated with insulin-like growth factor 1 (IGF- acid carboxymethyl cellulose materials support the prin-
1) in a sheep model, where improved reepithelialization ciple that composition of hyaluronic acid has a measur-
was observed in healthy sheep. However, this composite able impact on the quality of healing after ESS. Use of this
material actually had an adverse effect on ciliary regen- material should be considered in patients where signifi-
eration in wounds of sheep with chronic rhinosinusitis cant postoperative hemorrhage is not a concern, but the
[21]. This series of animal studies demonstrates that mu- patient would benefit from an agent to support the middle
cosal healing after ESS is affected not only by the bioma- turbinate, particularly in those who exhibit significant ap-
terial that is applied, but also by the underlying inflam- prehension about nonabsorbable packing from untoward
matory state. experiences during previous procedures.
Wormald et al. explored the effects of hyaluronic acid
ester on mucosal healing in patients with chronic rhino-
sinusitis undergoing ESS [28]. No influence was observed
Cellulose Based
on synechiae or mucosal edema when comparing treated
and unpacked cavities. Others have compared tissue heal- ■ Adequate hemostatic effect.
ing between hyaluronic acid ester and a nonabsorbable ■ Paucity of data regarding tissue healing characteris-
tampon, where no significant differences were discovered tics.
[18]. It should be noted, however, that need for lysis of
adhesions during the 8-week study period was less in the The use of Surgicel in multiple surgical applications is
latter group (8% vs. 14%), although the difference did not well known where the primary role has been to augment
reach statistical significance. hemostasis, particularly around vascular anastomoses. In
There are fewer available studies investigating hyal- otolaryngology, Surgicel is commonly used in the man-
uronic acid carboxymethyl cellulose preparations (Se- agement of epistaxis, and data has also demonstrated that
pragel, SepraPack) in animal models. Ongoing work this agent is associated with improved comfort compared
from our group utilizing a rabbit model (unpublished to tampon packing after ESS [24]. In that study, patients
data) compared mucosal regeneration after maxillary described less discomfort while the packing material
sinus stripping in sinuses packed with hyaluronic acid was in place and during removal; in addition, the use of
carboxymethyl cellulose to those packed with hyaluronic Surgicel was associated with less bleeding upon removal.
acid ester. Blinded evaluation by a pathologist revealed Subsequently, other cellulose-based materials (Surgicel,
more untoward healing characteristics in the latter group. Sinu-Knit, Sinu-Foam) have been released specifically for
In contrast, regenerated mucosa in the hyaluronic acid sinonasal application. A possible advantage of cellulose-
carboxymethyl cellulose group was similar to unstripped based fabrics (Surgicel, Sinu-Knit) is that these agents
mucosa and to unpacked controls. are less likely to disturb a clot during pack removal, as
Initial studies using hyaluronic acid carboxymethyl is often observed when a sponge tampon is utilized. Un-
cellulose gel (Sepragel) compared to an untreated control fortunately, there is a paucity of data examining the ef-
in patients undergoing ESS revealed that the former is as- ficacy of these agents in mucosal healing after ESS when
sociated with reduction of synechiae. This study however, left in situ. Given that these materials promote platelet
aggregation and are formulated primarily for hemostasis, mote epithelialization (as was attempted with IGF-1), and
it would appear prudent to avoid leaving these materials those that prevent fibrosis (e.g., mitomycin-C). Further-
in the cavity, as the fabric/platelet plug may be a matrix more, it is clear that agents composed of the same fun-
for fibrosis. In contrast, the Sinu-Foam dressing consists damental molecule, such as hyaluronic acid, may exhibit
of high-viscosity, injectable cellulose-based material that differential properties based on the material composition
can be instilled as a paste and may be more amenable (polymerized as an ester versus carboxymethyl cellulose).
to clearance though mucociliary flow and/or irrigation. The search goes on for the ideal preparation of the ideal
Both animal and human studies are necessary to inves- molecule. In summary, these materials play a significant
tigate the effects of these materials on mucosal healing role in the armamentarium of the revision endoscopic si-
after ESS. nus surgeon, but their strengths and shortcomings must
be considered so the appropriate material can be selected
for the given clinical scenario.
Additional Considerations
and Future Directions
References
Following application of an absorbable biomaterial in the
form of a fabric or wafer, it is important that the agent is 1. Asai K, Haruna S, Otori N, Yanagi K, Fukami M, Mori-
deliberately hydrated with saline. This allows the material yama H (2000) Saccharin test of maxillary sinus mucocili-
to convert to a more gel-like consistency that can be dis-
37 solved by mucociliary clearance and/or by the application
ary function after endoscopic sinus surgery. Laryngoscope
110:117–122
of saline via spray or irrigation (Fig. 37.3). In reality, these 2. Bassiouny A, Abd El Raouf M, Atef A, Nasr S, Talaat S,
“bioabsorbable” agents are more likely to dissolve rather Nasr M, Ayad E (2005) A comparative study between cili-
than undergo true absorption by the surrounding tissues. ary count and the degree of opacity of paranasal sinus CT
Allowing the material to hydrate with ambient blood in scans in chronic rhinosinusitis pre and post FESS. J Laryn-
the cavity may result in the formation of a plug consist- gol Otol 119:950–954
ing of fibrin and platelets, which may subsequently form 3. Baumann A, Caversaccio M (2003) Hemostasis in endo-
a matrix for deposition of a collagen scar. In addition, al- scopic sinus surgery using a specific gelatin-thrombin
lowing the material to persist in the cavity may result in based agent (FloSeal) Rhinology 41:244–249
frank incorporation of particles into the scar tissue or the 4. Beck DE, Cohen Z, Fleshman JW, Kaufman HS, van Goor
regenerated mucosa, as studies have demonstrated [16]. H, Wolff BG (2003) A prospective, randomized, multi-
This observation underscores the importance of ongoing center, controlled study of the safety of Seprafilm adhesion
postoperative management with endoscopic surveillance, barrier in abdominopelvic surgery of the intestine. Dis Co-
debridement, and medical management. lon Rectum 46:1310–1319
Use of biomaterials does not apparently compensate 5. Chandra RK, Conley DB, Kern RC (2003) The effect of
for mucosal stripping during surgery, and in fact, mu- FloSeal on mucosal healing after endoscopic sinus surgery:
rine studies have even demonstrated that hyaluronic a comparison with thrombin-soaked gelatin foam. Am J
acid ester is associated with significant osteoneogenesis Rhinol 17:51–55
if applied directly to denuded bone [11]. The use of ab- 6. Chandra RK, Conley DB, Haines GK 3rd, Kern RC (2005)
sorbable biomaterials may be associated with significant Long-term effects of FloSeal packing after endoscopic sinus
patient comfort compared to a traditional pack and in surgery. Am J Rhinol 19:240–243
some cases may augment healing, but does not replace 7. Cohen NA (2006) Sinonasal mucociliary clearance in health
the roles of mucosal preservation during surgery and and disease. Ann Otol Rhinol Laryngol Suppl 196:20–26
meticulous postoperative care. It should also be stressed 8. Frenkiel S, Desrosiers MY, Nachtigal D (2002) Use of hylan
that no studies have demonstrated improved long-term B gel as a wound dressing after endoscopic sinus surgery. J
outcome between the use of an absorbable and a tradi- Otolaryngol 31:S41–S44
tional tampon pack; therefore, if there is potential for se- 9. Gall RM, Witterick IJ, Shargill NS, Hawke M (2002) Con-
vere postoperative bleeding or if the middle turbinate is trol of bleeding in endoscopic sinus surgery: use of a novel
highly destabilized, use of a nonabsorbable spacer should gelatin-based hemostatic agent. J Otolaryngol 31:271–274
be considered. 10. Gunaydin S, Mccusker K, Vijay V (2005) Clinical perfor-
Future directions include conjugation or impregnation mance and biocompatibility of novel hyaluronan-based
of the current molecules (i.e., hyaluronic acid) with an- heparin-bonded extracorporeal circuits. J Extra Corpor
tibiotics, anti-inflammatory medications (e.g,. steroids), Technol 37:290–295
compounds that dissolve biofilms, mediators that pro-
11. Jacob A, Faddis BT, Chole RA (2002) MeroGel hyaluronic 20. Proctor M, Proctor K, Shu XZ, McGill LD, Prestwich GD,
acid sinonasal implants: osteogenic implications. Laryngo- Orlandi RR (2006) Composition of hyaluronan affects
scope 112:37–42 wound healing in the rabbit maxillary sinus. Am J Rhinol
12. Jameson M, Gross CW, Kountakis SE (2006) FloSeal use in 20:206–211
endoscopic sinus surgery: effect on postoperative bleeding 21. Rajapaksa S, McIntosh D, Cowin A, Adams D, Wormald PJ
and synechiae formation. Am J Otolaryngol 27:86–90 (2005) The effect of insulin-like growth factor 1 incorpo-
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14. Lee JT, Kennedy DW, Palmer JN, Feldman M, Chiu AG effect of a hyaluronic acid–based nasal pack on mucosal
(2006) The incidence of concurrent osteitis in patients with healing in a sheep model of rhinosinusitis. Am J Rhinol
chronic rhinosinusitis: a clinicopathological study. Am J 19:572–576
Rhinol 20:278–282 23. Shaw CL, Dymock RB, Cowin A, Wormald PJ (2000) Ef-
15. Longaker MT, Chiu ES, Adzick NS, Stern M, Harrison fect of packing on nasal mucosa of sheep. J Laryngol Otol
MR, Stern R (1991) Studies in fetal wound healing. V. A 114:506–509
prolonged presence of hyaluronic acid characterizes fetal 24. Shinkwin CA, Beasley N, Simo R, Rushton L, Jones NS
wound fluid. Ann Surg 213:292–296 (1996) Evaluation of Surgicel Nu-knit, Merocel and Va-
16. Maccabee MS, Trune DR, Hwang PH (2003) Effects of solene gauze nasal packs: a randomized trial. Rhinology
topically applied biomaterials on paranasal sinus mucosal 34:41–43
healing. Am J Rhinol 17:203–207 25. Tarhan OR, Eroglu A, Cetin R, Y Nce A, Bulbul M, Altun-
17. McIntosh D, Cowin A, Adams D, Wormald PJ (2005) The tas YR (2005) Effects of seprafilm on peritoneal fibrinolytic
effect of an expandable polyvinyl acetate (Merocel) pack system. ANZ J Surg 75:690–692
on the healing of the nasal mucosa of sheep. Am J Rhinol 26. Tom LW, Palasti S, Potsic WP, Handler SD, Wetmore RF
19:577–581 (1997) The effects of gelatin film stents in the middle me-
18. Miller RS, Steward DL, Tami TA, Sillars MJ, Seiden AM, atus. Am J Rhinol 11:229–232
Shete M, Paskowski C, Welge J (2003) The clinical effects 27. Woodworth BA, Chandra RK, Hoy M, Schlosser RJ, Gil-
of hyaluronic acid ester nasal dressing (Merogel) on intra- lespie MB (2006) SepraPack dressing after sinus surgery: a
nasal wound healing after functional endoscopic sinus sur- randomized trial. Arch Otolaryngol Head Neck Surg 135:
gery. Otolaryngol Head Neck Surg 128:862–869 P74–P75
19. Palmer J (2006) Bacterial biofilms in chronic rhinosinus- 28. Wormald PJ, Boustred RN, Le T, Hawke L, Sacks R (2006)
itis. Ann Otol Rhinol Laryngol Suppl 196:35–39 A prospective single-blind randomized controlled study of
use of hyaluronic acid nasal packs in patients after endo-
scopic sinus surgery. Am J Rhinol 20:7–10
Chapter 38
Endoscopic Approach after Failure

of Open Sinus Procedures 38
Raymond Sacks and Larry Kalish
Contents
Core Messages
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
■ Surgeons need to be familiar with the external surgi- Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
cal approaches including the indications and tech- Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
niques in order to perform revision cases safely.
■ Every effort should be made to obtain a detailed
Patient Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
knowledge of the previous surgery.
■ Potential for complications is greater due to the Anatomical Considerations . . . . . . . . . . . . . . . . . . . . 338
disruption of normal anatomy and pathways and Pathological Factors . . . . . . . . . . . . . . . . . . . . . . . . . . 339
greater likelihood of osteoneogenesis, adhesions,
Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
and breech of sinus boundaries compared to endo-
scopic surgery. Revising the C-L Procedure . . . . . . . . . . . . . . . . . . . . 340
■ Image guidance is useful but does not compensate Endoscopic Revision of the C-L Procedure . . . . . . . . 341
for lack of preoperative planning. Revision of the External Ethmoidectomy . . . . . . . . . 341
■ Always operate from known to unknown and al-
Endoscopic Revision of the External Ethmoidectomy 341
ways be vigilant that significant surgical defects can
be found behind normal anatomy. Revision of the Frontal Sinus Trephine . . . . . . . . . . . 342
Revision of the Lynch-Howarth Procedure . . . . . . . 342
Endoscopic Revision of the Lynch-Howarth
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
Osteoplastic Frontal Sinus Surgery
with and Without Obliteration . . . . . . . . . . . . . . . . . 343
Introduction Endoscopic Revision of the Failed Osteoplastic Flap
External approaches to the sinuses were refined in the Procedure with or Without Obliteration . . . . . . . . . . 343
preantibiotic era when intervention was focused primar- Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
ily on saving lives rather than improving quality of life. Complications and Outcomes . . . . . . . . . . . . . . . . . . . . 344
As our knowledge and ability has improved, so has our
preference for endonasal techniques. Revising open sur-
gical approaches presents some unique challenges. Many
surgeons today have limited experience with open pro-
cedures and many open procedures have been signifi- gist [29], and discuss the implications of their failures for
cantly refined to reduce morbidity and complement en- the endoscopic approach (Table 38.1).
doscopic techniques rather than supplant them. The role Revision endoscopic sinus surgery is often substan-
of the open procedure after failed endoscopic techniques tially more complex than primary surgery because essen-
has been addressed in Chap. 31. The present chapter will tial landmarks are drastically altered [6]. This is especially
focus on some of the challenges and consequences asso- true following open surgery. The surgeon should be inti-
ciated with failure of the open sinus approach. We will mately familiar with concepts involved in external sinus
focus on the open procedures, which most commonly re- surgery in order to facilitate a safe approach during revi-
main in the armamentarium of the modern-day rhinolo- sion surgery [6, 17, 38, 39].
338 Raymond Sacks and Larry Kalish
Table 38.1 External approaches to the paranasal sinuses [29]

Preoperative Workup
• Caldwell-Luc procedure This is an essential component of successful revision sur-

• External ethmoidectomy gery.
• Lynch procedure
• Frontal trephine
• Osteoplastic frontal sinus surgery ± obliteration Patient Factors
The patient’s principal concern and a symptom profile,
both current and initial need to be established [26]. Un-
diagnosed medical conditions may have contributed to
failure of the initial procedures and need to be addressed
prior to further management [45].
Indications
Indications for endoscopic revision after open surgery of
the:
Anatomical Considerations
1. Maxilla:
a. Persistent inflammatory mucosal disease after ■ The Caldwell-Luc (C-L) procedure will result in dis-
failed medical management. torted maxillary anatomy, but this is obscured by a
b. Recurrent benign neoplasms including inverted normal uncinate, especially if no inferior antrostomy
papilloma, juvenile nasopharyngeal angiofibroma was performed.
38 (JNA). ■ Similarly, after external ethmoidectomy physical find-
c. Oroantral fistulae aggravated by maxillary pathol- ings on rhinoscopy and nasendoscopy may be decep-
ogy. tively normal.
d. Orbital decompression.
e. Access to the pterygomaxillary fissure and/or infra- Computed tomography (CT) is the diagnostic modality
temporal fossa. of choice [31]. Bony window (wide window 4000 setting)
2. Ethmoids: fine cuts in coronal, axial, and parasagittal planes are
a. Persistent inflammatory mucosal disease after obtained ideally with soft-tissue views (narrow window
failed medical management. 150–250 setting) with intravenous contrast.
b. Recurrent benign neoplasms including inverted Magnetic resonance imaging (MRI) is particularly im-
papilloma and JNA. portant when CT reveals opacification adjacent to a dehis-
c. Mucocele of an ethmoid sinus cell. cent skull base. In this situation, MRI identifies whether
d. Access to orbital pathology. the erosion is secondary to sinus disease or secondary to
3. Frontal: a prior skull-base erosion or trauma with resultant me-
a. Persistent inflammatory mucosal disease after ningoencephalocele (Fig. 38.1) [6]. T1- and T2-weighted
failed medical management. MRI images with intravenous gadolinium in axial, coro-
b. Frontal mucocele – recurrent or complication of a nal, and parasagittal planes are obtained.
frontal sinus obliteration procedure. The surgeon should have an appreciation of the three-
c. Recurrent benign neoplasms including osteoma dimensional nature of the sinuses and pay particular at-
and inverted papilloma. tention to areas of maximal risk. These include:
1. The skull base, with attention to erosions or thinning,
slope, symmetry, and height of the lateral lamella as
per the Keros classification [18].
Contraindications
2. The medial orbital wall with attention to overall shape,
1. A surgically unfit patient. dehiscence, and possible orbital prolapse obstructing
2. Unrealistic expectations. the frontal recess, the relation to the uncinate process,
3. Appropriate instrumentation and/or imaging not and adjacent Haller cells.
available. 3. The maxillary sinus and the presence of accessory os-
4. Surgical inexperience. tia, previous inferior antrostomy, anterior and lateral
5. Extensive osteoneogenesis. wall neo-osteogenesis, and synechiae following open
6. Limited dimensions of the frontal recess. surgery, integrity of the orbital floor and bone sur-
rounding the nasolacrimal duct.
Endoscopic Approach after Failure of Open Sinus Procedures 339
Fig. 38.1 a Dehiscent cribriform fossae on computed tomography (CT; arrow) confirmed as meningoencephalocele on magnetic
resonance imaging (b, arrow)
4. The ethmoid vessels – assessing the relationship to the tively, a clear understanding of the pathology is required.
skull base and evidence of previous clip ligation. An individualized medical treatment plan should be for-
5. Presence of Onodi cells (posterior ethmoid cells with mulated for each patient. Atypical facial pain should be
pneumatization superior to the sphenoid) and a pos- further assessed and treated prior to any surgical inter-
sible exposed optic nerve and susceptible skull base. vention. Other disorders that cause facial pain should be
6. The internal carotid artery and the cavernous sinus considered [44]. A trial management of the neuropathic
with respect to the sphenoid sinus. pain with carbamazepine or amitriptyline, should preceed
7. The degree of frontal sinus pneumatization with em- surgical intervention [52]. This can also include patients
phasis on anteroposterior dimension as well as dis- who have small mucoceles after frontal sinus obliteration
tance from lamina to lamina. The presence of fron- in order to distinguish symptomatic recurrences from
toethmoidal cells, the specific anatomy of the frontal atypical pain syndromes.
recess, and the presence of septation. Identification and treatment of infection preopera-
tively aids revision surgery, reduces intraoperative blood
Image guidance has been discussed in Chap. 29. It plays loss and enhances postoperative care. Staphylococcus au-
an increasingly important role in revision surgery and reus and Gram-negative organisms such as Pseudomonas
may reduce the complication rate [5, 11]. It is, however, are recovered most commonly in patients presenting for
no substitute for a thorough preoperative assessment, de- revision surgery [32]. Both have been implicated in the
tailed knowledge of the anatomy, and a cautious respect- pathogenesis of chronic rhinosinusitis either as a supe-
ful approach. rantigen stimulus or in biofilm formation [36, 43].
Symptomatic mucoceles occurring after obliteration
procedures require surgical intervention. These can be
geographically removed from the natural sinus; image
Pathological Factors
guidance may be required. Benign tumors recurring after
Current indications for open surgical approaches as de- failed open procedures may act differently from the pri-
scribed above largely incorporate recalcitrant inflamma- mary tumor. The recurrent JNA is frequently fibrosed and
tory disease of the frontal sinus and less frequently the may bleed less. Planes of dissection are more indistinct
maxillary sinus, and then a variety of neoplasms includ- and invasion into vital structures may occur. The possi-
ing inverted papilloma, osteomas, and recurrent JNA. bility of malignant transformation in inverted papillomas
Prior to any revision surgery, maximal medical manage- needs to always be carefully considered. Recurrence can
ment needs to be instituted [3]. In order to do this effec- occur directly onto the periorbita or dura.
Patients are counseled on the importance of con- endoscopic approaches (Fig. 38.2) [49]. However, select
tinuing medical therapy before, during, and after their patients seem to benefit from radical removal of dis-
operation. eased and condemned mucosa through a C-L or one of
its modified procedures, such as the canine fossa punc-
ture [9, 10, 42].
The concepts that one needs to consider specific to the
Surgical Techniques
endoscopic revision of previously performed C-L surgery
include:
Revising the C-L Procedure
1. It is not a physiological procedure.
Caldwell and Luc described the C-L operation more than 2. The inferior meatal antrostomy does not surgically ad-
100 years ago as the surgical treatment for maxillary si- dress the physiologic drainage tract of the maxillary
nus disease [24]. During the last decades, less radical in- sinus, which is directed to the middle meatus through
terventions using the endoscopic approach have mainly the infundibulum and hiatus semilunaris [46].
replaced the classical procedures performed for chronic 3. The term “mucus recirculation phenomenon” is used
and recurrent maxillary rhinossinusitis [2, 37]. Despite to describe an antrostomy that did not accurately in-
the success of endoscopic middle-meatus antrostomy clude the natural ostium of the maxillary sinus at the
coupled with the reports of fairly high morbidity rates middle meatus and can predispose to chronic infec-
with the C-L operation in the literature [4, 8, 16, 23, 30, tion and possibly chronic osteitis (Fig. 38.3).
33, 40, 54], several indications remain, and still many sur- 4. The natural ostium may be patent behind a completely
geons advocate the use of this procedure for endoscopic intact uncinate; however, significant synechiae may lie
failures with irreversible mucosal disease [7, 25]. just beyond, necessitating a wide appropriate antros-
38 Comparative studies of endoscopic sinus surgery tomy.
and C-L have largely favored the endoscopic approach, 5. Synechiae and osteoneogenesis may result in abnor-
demonstrating better ostial patency rates and overall mal barriers preventing access to all of the diseased
patient symptomatic control [37, 49]. This has been at- mucosa in the maxillary sinus, and may interfere with
tributed by some to the increased fibrosis and abnormal disease monitoring.
bony changes of the maxillary sinus that are encountered 6. With angled scopes and instrumentation, endoscopic
in a higher proportion of open procedures compared to repair of oroantral fistulae and retrieval of foreign
Fig. 38.2a–d a, b Preoperative CT scan

axial and coronal views; c, d CT scan
post-Caldwell-Luc procedure showing
significant osteoneogenesis
advertently into the maxilla. A ball-tipped, right-angled

probe is passed through the inferior incision and slid an-
teriorly as close as possible to the uncinate’s insertion into
the lateral nasal wall. We then palpate using the ball probe
for synechiae resulting from the original C-L procedure.
The probe is then pulled anteriorly, gently breaking down
any synechiae and fracturing the uncinate at its insertion.
A 45 °, upturned, through-cutting Blakesley forceps is
used to cut the middle portion of the uncinate flush with
the frontal process of the maxilla. The superior edge of the
uncinate is then divided using a straight, through-cutting
Blakesley forceps. A complete uncinectomy assists in ex-
posing the natural maxillary ostium, accessory ostia, and
surgically created ostia following the previous C-L proce-
dure. A 45 °, angled endoscope is used while performing a
wide maxillary antrostomy to confirm that the natural os-
tium has been incorporated into the surgical antrostomy,
Fig. 38.3 Post-Caldwell-Luc mucus recirculation (arrow) from and to adequately assess the post-C-L antrum.
maxillary antrostomy to inferior antrostomy (not seen) Careful assessment of preoperative imaging will direct
the surgeon to potential areas of pathology behind newly
formed bone and scar bands resulting from the previous
bodies is often safely and expediently achieved [22]. C-L. Angled endoscopes, 45 ° and sometimes 75 °, to-
Following previous C-L procedures, the inferior an- gether with angled microdebriders assist in locating and
trostomy can be utilized for better access for scopes or managing problem areas. Positioning instruments or en-
instruments; however, synechiae and neo-osteogenesis doscopes through a patent inferior antrostomy may also
can again slow progress and present potential traps. be useful. Care is taken to identify the infraorbital nerve
7. The ethmoid complex is seldom addressed and recur- and appreciate floor or orbit dehiscence. Pressure over
rence from missed adjacent disease may need to be the patient’s cheek will identify lateral sinus defects and
treated prior to revising the maxillary disease. aid in medializing pathological mucosa for debridement.
8. Postoperative debridement and monitoring is not al- The ethmoid sinuses are then addressed by performing
ways possible through the inferior antrostomy. complete anterior and posterior ethmoidectomies.
Revision of the External Ethmoidectomy

Endoscopic Revision of the C-L Procedure
Although rarely used these days for inflammatory sinus
The patient is appropriately positioned; the nose is then disease, the external approach to the ethmoids is still
prepared with injection of lidocaine 2% + 1:100,000 epi- encountered in the management of subperiosteal orbital
nephrine using a dental syringe and needle. The points of abscesses, ligation of the ethmoid arteries, and as part of
infiltration are at the axillae of the middle turbinate, the a skull-base approach [29, 35, 41]. Of particular concern
anterior end of the middle turbinate, and the lateral nasal when revising these procedures is medial orbital bone re-
wall. Neuropatties (1 × 1.5-inch) soaked with a mixture moval, which may allow the orbital contents to collapse
of 4% xylocaine solution, epinephrine 1:1000, and oxy- into the ethmoid cavity, resulting in ethmoid and frontal
metazoline are carefully placed into the sphenoethmoidal recess obstruction (Fig. 38.4) [34]. Injury to the nasolac-
recess, lateral to the middle turbinate in the middle me- rimal duct occurs at a slightly higher rate with revision
atal recess, medial to the middle turbinate, and along the surgery following previous radical ethmoidectomy [20].
inferior turbinate.
An uncinectomy is performed by carefully identifying
the free edge of the uncinate with a ball-tipped, right-
Endoscopic Revision of the External
angled probe, always being vigilant of potential synechiae
Ethmoidectomy
and lamina dehiscence from the previous open surgery.
Once the free edge is established, a Microfrance back- A complete uncinectomy and maxillary antrostomy is
biting instrument is used to make the inferior cut of the performed. Care is taken when performing the uncinec-
uncinate. Care is taken to not to drop bony fragments in- tomy to avoid dehiscence of the lamina by gently palpat-
Fig. 38.4 Post-external-ethmoidectomy demonstrating dehiscent lamina, fused middle turbinate to the periorbita (arrow), and ob-
structed frontal recess
38
ing with a ball-tipped, right-angled probe. Intact lamina avoid mucosal necrosis, osteomyelitis, and intracranial
is identified as soon as possible and correlation made complications [19]. When the frontal trephine fails, en-
with preoperative imaging. The scrub assistant performs doscopic frontal sinus surgery is performed as described
frequent balloting of the ipsilateral orbit so that any de- in Chap. 14.
hiscence is recognized early.
The ethmoid bulla may be intact after an open eth-
moidectomy, but the surgeon should be cautious as dehis-
Revision of the Lynch-Howarth Procedure
cent orbital contents may lie just beyond. We minimize
the use of microdebriders and advocate careful curettage In 1921, Lynch in the USA and Howarth in the United
by placing the angled curette medial to the ethmoid bulla Kingdom popularized a procedure to remove the fron-
between the bulla and middle turbinate, palpating for a tal sinus floor but with preservation of the anterior wall,
natural ostium, rotating the curette laterally, and pulling which included removal of the frontal sinus mucosa,
it anteriorly. Similar technique is used throughout the re- dealing with any intranasal obstruction and antral disease
vision case to prevent inadvertent trauma to the perior- and creating a large frontonasal drainage via an ethmoid-
bita or skull base. ectomy [19]. Although multiple techniques to address
The skull base is identified ideally after performing a the frontal recess have been described over the years, the
sphenoidotomy and then followed anteriorly, this allows Lynch-Howarth procedure has remained a viable alter-
the surgeon to identify the skull base posterior to the native. In a severely scarred frontal recess with osteitic
previous surgery; this is important as the external eth- bone after multiple endoscopic surgical approaches, the
moidectomy can remove bone flush with the skull base, Lynch-Howarth approach may still be a procedure worth
leading to the inadvertent breech when revising the case considering, along with modified endoscopic Lothrop
endoscopically. approaches and osteoplastic flap with or without oblitera-
tion (Fig. 38.5).
Revision of the Frontal Sinus Trephine

Endoscopic Revision
Like many external procedures, the frontal trephine has
of the Lynch-Howarth Procedure
evolved from a potentially cosmetically deforming proce-
dure to a minimally invasive adjunct to endoscopic sur- Positioning and preparation of the patient as described
gery [12, 28]. Its original description involved removal above. Image guidance is recommended if available. Care-
of enough bone to allow adequate visualization into the ful assessment of the preoperative imaging is made to de-
sinus and for placement of a drainage tube in order to termine the best approach. The options usually include a
Fig. 38.5 a–d Coronal CT from ante-

rior to posterior showing postoperative
external Lynch-Howarth procedure to
drain an anterolateral mucocele (indicated
by “*” in d) caused by a frontal osteoma
Draf IIb procedure or an endoscopic modified Lothrop

Endoscopic Revision of the Failed Osteoplastic
procedure (Draf III; see below). This is often determined
Flap Procedure with or Without Obliteration
by the degree of orbital content prolapse, the presence of
a middle turbinate, and the underlying pathology. For Infiltration with lidocaine and epinephrine is performed
example, a frontal mucocele secondary to frontal recess above the axilla of the middle turbinate and on both sides
obstruction with an intact middle turbinate may be ad- of the midseptum adjacent to the middle turbinate. The
equately treated by a Draf IIb, whereas a recurrent frontal soft tissue is removed with a microdebrider from the ax-
sinus osteoma in a patient with only a remnant middle illa of the middle turbinate to the roof of the nose, expos-
turbinate will do better with a more aggressive endo- ing the underlying bone. The microdebrider is utilized to
scopic modified Lothrop procedure. remove all mucosa of the septum anterior to the attach-
ment of the middle turbinate, and an area approximately
2.5 × 2.0 cm of mucosa is removed from both sides of the
septum. The visible septal bone and cartilage is removed
Osteoplastic Frontal Sinus Surgery
completely to create a wide window through which one
with and Without Obliteration
can operate on both sides of the nose simultaneously. The
This can be a useful procedure and can be associated with septal window should be low enough that one can clearly
short- and long-term complications [1, 14, 21, 50]. Mu- see the axilla of the middle turbinate with a 0 ° telescope
coceles can occur centrally within the obliterated sinus from the opposite nasal cavity. Frontal trephines have
cavity and are separated from the nasal cavity by bone limited usefulness when an obliteration procedure has
and thick fibrous tissue, resulting in no communication been performed, but in an osteoplastic procedure without
between the mucocele and the nasal cavity, and conse- obliteration there may be an indication to perform frontal
quently no pathway for the surgeon to follow [51, 52]. trephine at this stage for fluorescein guidance.
Obliterated frontal sinuses are frequently smaller than The axilla of the middle turbinate on both sides is
their unobliterated counterparts, and adequate drain- extended superiorly using a Hajek-Koeffler punch or a
age is only achieved by drilling a wide communication, Kerrison rongeur. A 3.2-mm cutting burr is then used
thereby creating a circumferential injury [47]. Surgeons to remove the hardened frontal process of the maxilla
have to allow for significant (30–55%) contracture of the above the axilla until a small amount of skin is exposed,
neo-ostium, and physical space is limited especially in the thus defining the lateral anterior extent of the dissection.
anteroposterior dimension [21] The procedure is performed on the opposite side and the
frontal sinus cavity is entered. The floor between the fron- and debridement until the surgeon is satisfied with the
tal sinus openings on both sides is removed with further mucosal healing. Long-term follow up is also required
removal of the beak of the frontal process of the maxilla. and both surgeon and patient should remain vigilant for
This limits the anterior dissection. It is important to note the signs of recurrence, as a good operative result should
that the dissection is only performed in the superior and facilitate easier access to the sinuses for medical therapy.
lateral direction until the frontal sinus cavity has been en-
tered, so as not to damage the olfactory fossa and cause a
cerebrospinal fluid (CSF) leak.
Complications and Outcomes
Once the frontal sinus has been entered on both sides,
the dissection can now be brought medially until the in- Specific concerns during endoscopic revision following
tersinus septum is seen. The intersinus septum is then re- open surgery have been discussed herein. The surgeon
moved and at this stage, the frontal sinus opening forms should be aware of the increased risk of complication and
a horseshoe appearance. Once this has been achieved, remain vigilant at all times. Complications include:
the frontal bone is removed until there is no anterior lip 1. CSF leak.
of bone separating the frontal sinus from the nasal cav- 2. Orbital and optic nerve injury.
ity. The posterior projection is then thinned down until 3. Major bleeding.
the first olfactory neuron is identified. Fat or any fibrous 4. Nasolacrimal injury.
tissue needs to be gently removed from the frontal sinus 5. Anosmia.
cavity in order to create a continuous cavity from the 6. Neural injury.
frontal sinus into the nose. Malleable frontal curettes and
suction are critical in order to clear fat or other oblitera- There have been very few papers directly addressing the
38 tive tissue from the sinus cavity. A 45 ° or 70 ° endoscope outcome of endoscopic sinus surgery following open
is typically required in order to achieve complete clear- surgery. In a retrospective review, post-C-L failures had
ance of diseased tissue. similar clinical improvements with either revision en-
The use of packing material such as bismuth-iodo- doscopic surgery or revision C-L, 67% and 60%, respec-
form-paraffin paste or absorbable packs such as oxidized tively, and required similar number of revisions, 1.7±1.0
cellulose, is controversial and studies are currently un- and 1.3±0.5, respectively [13]. However, the operative
derway to look at the long-term results of these packing morbidity and potential sequelae of open surgery signifi-
materials. cantly favored an endoscopic approach.
Experimental studies have indicated that mucosal
stripping leads to regeneration of mucosa that bears
patchy, dysmorphic, and dyskinetic cilia [13, 14]. Thus,
Postoperative Care
for endoscopic revision to be successful it depends on
Absorbable packing such as Surgicel Fibrillar (Ethicon) the regeneration of mucociliary function or residual
oxidized regenerated cellulose or Nasopore (Polygan- mucosa left behind after the original open surgery. The
ics) biodegradable fragmentable foam, are preferred for persistence of maxillary sinus disease despite endoscopic
postoperative hemostasis in order to maximize patient evidence of complete uncinectomy and wide patency of
comfort and minimize adhesions and bleeding. Vigorous the ostial outflow tract is likely to occur after complete
hypertonic, buffered-saline sinus irrigation using a bulb mucosal stripping and may require a more aggressive en-
syringe or sinus rinse bottle, in the nasal douche position, doscopic approach including an mega-antrostomy or an
is encouraged to optimize irrigation of the frontal recess endoscopic medial maxillectomy approach [13].
and maxillary sinuses [53]. After frontal sinus surgery, Few studies have addressed endoscopic revision of
the “mini trephines” are left in situ and 4-hourly flushes open frontal sinus surgery including obliteration [15,
with dexamethasone, normal saline, and an antibiotic so- 27, 48, 51]. A significant number of patients with persis-
lution is given for 1–5 days postoperatively. Instruction tent frontal sinusitis after obliteration can be successfully
sheets are given to the patient detailing postoperative managed endoscopically. It is important to select patients
care. Medical management is reinstituted on an individ- carefully. Disease localized in the frontal recess or infero-
ual basis and may include short course oral antibiotics, medial frontal sinus is more likely to be successful than
longer-term macrolide antibiotics, topical and systemic superior and lateral frontal disease, which may be best
steroids, or recommencement of aspirin desensitization. approached externally [15]. MRI and CT can be helpful
All patients are seen in clinic 1 week postoperatively for in guiding the selection of the surgical approach. How-
endoscopic debridement of residual packing, crust, and ever, when radiological findings are equivocal, the sur-
division of any potential early adhesions, and then on a geon must be aware of possible occult disease beyond the
weekly or fortnightly basis for endoscopic surveillance reach of endoscopic techniques. Patients undergoing en-
doscopic salvage should be counseled about the possible 9. Forsgren K, Stierna P, Kumlien J, et al. (1993) Regenera-
need for repeat obliteration if clinical symptoms persist tion of maxillary sinus mucosa following surgical removal.
[15, 48, 51]. Experimental study in rabbits. Ann Otol Rhinol Laryngol
102:459–466
Tips and Pearls 10. Forsgren K, Fukami M, Penttila M, et al. (1995) Endoscopic
and Caldwell-Luc approaches in chronic maxillary sinus-
1. Patient selection – beware of facial pain syn-
itis: a comparative histopathologic study on preoperative
dromes of potential nonrhinological origin.
and postoperative mucosal morphology. Ann Otol Rhinol
Patients with realistic expectations.
Laryngol 104:350–335
2. Preoperative antibiotics and steroids in revision
11. Fried MP, Moharir VM, Shin J, et al. (2002) Comparison
inflammatory surgery.
of endoscopic sinus surgery with and without image guid-
3. Hypotensive bradycardic anesthesiae to minimize
ance. Am J Rhinol 16:193–197
intraoperative bleeding.
12. Gallagher RM, Gross CW (1999) The role of mini-trephi-
4. Experienced scrub nurse familiar with endoscopic
nation in the management of frontal sinusitis. Am J Rhinol
instrumentation.
13:289–293
5. Constant balloting of the eye during ethmoid dis-
13. Han JK, Smith TL, Loehrl TA, et al. (2005) Surgical revi-
section.
sion of the post-Caldwell-Luc maxillary sinus. Am J Rhinol
6. Frequent correlation with imaging and image
19:478–482
guidance is required.
14. Hardy JM, Montgomery WW (1976) Osteoplastic frontal
7. Blunt dissection using probes and curette.
sinusotomy: an analysis of 250 operations. Ann Otol Rhi-
8. Judicious use of powered instrumentation.
nol Laryngol 85:523–532
9. Avoid tight packing material.
15. Hwang PH, Han JK, Bilstrom EJ, et al. (2005) Surgical re-
10. Postoperative aggressive and meticulous debride-
vision of the failed obliterated frontal sinus. Am J Rhinol
ment.
19:425–429
16. Ikeda K, Hirano K, Oshima T, et al. (1996) Comparison
of complications between endoscopic sinus surgery and
Caldwell-Luc operation. Tohoku J Exp Med 180:27–31
References
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41. Sargent LA, Rogers GF (1999) Nasoethmoid orbital frac-
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Trauma 5:19–27
Subject Index
A aspirin desensitization 147

accessible dimension 118 aspirin sensitivity 145, 212
acoustic rhinometry 320 asthma 145, 271
adhesions 136, 270, 273 attention deficit disorder. see ADD
agger nasi 57, 128 attention deficit hyperactivity disorder. see ADHD
allergens 195 aura 218
allergic inflammation 26 azathioprine 29
allergic mucin 154
allergic rhinitis 145, 193 B
– perennial 194 bacterial biofilm 306
– seasonal 194 bacterial infection
allergy – resistant 104
– inhalant 38 balloon catheter 49
allergy testing 195 baroreceptor reflex 73
amino amide 74 basal lamella 86
amino ester 73 beach-chair position 247
amnesia 72 beclomethasone 137
anatomic objective 276 benign neoplasm 338
anatomic variant 203 biofilm 30, 134, 139, 306
anatomy of the eye 224 bipolar cautery 68
anesthesia bipolaris 153
– local 71 blindness 227
aneurysm 292 blue light filter 171
angiogram 183 bone graft 297
angiotensin-converting enzyme 29 bone marrow 9
angled endoscopes 64 bone resorption 186
angled microdebrider 341 bony erosion 160
anterior ethmoid artery 87, 88, 105 bony landmark 53
anti-neutrophil cytoplasmic antibody 28 bony partition 84
antibiotic bony remodeling 186
– culture-directed 106 bony resorption 310
– oral 147 bony ridge 53
antibiotic resistance 139 brain tumor 220
antibiotic treatment 41 budesonide 148
antifungal agent 41 bulla frontalis 118, 119
antihistamines 196
antrochoanal polyp 145 C
arachidonic acid pathway 37 Caldwell-Luc 2, 190
ASA-sensitive patient 30 calibration 254
aspirin-desensitizing 39 canalicular stenosis 242
aspirin-sensitive patient 21 carotid dehiscence 229
348 Subject Index
catheter complication 312 D

cellulitis 286 dacryocystitis 237
cellulose 330 dacryocystography 236
child abuse. see abuse dacryolith 241
choanal arch 54 dacryoscintigraphy 237
chordoma 296 danger zone 2, 230
Chronic Sinusitis Survey 321, 322 delayed epistaxis 182
cigarette smoking 16, 31, 83 devices for irrigation 137
ciliary abnormality 272 dexamethasone ophthalmic 138
ciliary beat frequency 41 diabetes insipidus 249, 297
ciliary dyskinesia 269 diabetic ketoacidosis 138
ciliary dysmotility 21 diamond bur 67
circular punch 65 diplopia
circumferential injury 343 – vertical 182
Citardi staging system for inverted papilloma 162 disease-specific instrument 318
clinical indication disfigurement 182
– IGS 256 distorted landmark 127
clinical outcome 211 diuretic therapy 176
clival chordoma 292 documentation 226
clivus 113 Draf IIB procedure 131
cobblestoned mucosa 203 drainage tube 342
38 cocaine 74
collagen 330 E
colonization efficacy of IGS 266
– rate of 137 eicosanoid-pathway 38
common canaliculus 241 eicosanoid release
complete surgery 266 – vitro analysis of 39
computer workstation 252 electromagnetic tracking 252
concha bullosa 3, 92, 93, 96 embolization 165
confine concha 99 empty sella syndrome 175
congenital immunodeficiency 27 encephalocele 290
congestion 144, 196 endocrine evaluation 247
constant anatomical landmarks 155 endonasal frontal sinus surgery
coronal flap 277 – results 124
cosmetic deformity 131, 286 endoscope irrigation system 76
cotrimoxazol 29 endoscopic clip applier 69
cranial nerve 290 endoscopic debridement 123, 134
craniofacial approach 279 endoscopic findings 320
craniopharyngioma 296 endoscopic frontal sinusotomy 7
craniotomy 189 endoscopic modified Lothrop procedure 133
cribriform plate 291 endoscopic surveillance 107
cruciate incision 248 enophthalmos 182
crust 114 enterotoxin 30
crusting 136 environmental factor 275
CT cisternogram 169 environmental fungius 153
CT scan stage 320 eosinophilia
CT staging 319 – blood 212
culture-directed intravenous antibiotics 312 – tissue 212
culture swab 31 eosinophilic infiltration 26, 101
Cushing’s disease 246 eosinophilic inflammation 143
cyclophosphamide 29 eosinophilic mucin 153
cystic fibrosis 22 eosinophilic mucus 145
eosinophils 143
Subject Index 349
eotaxin 143 fungal debris 156

epinephrine 74 fungal hypothesis 31
epiphora 144, 235 fungal mucin 140
– functional 242 fungal sinusitis
epithelialization 302, 333 – invasive 31
essential landmark 223 fungal stain 153
esthesioneuroblastoma 290
ethmoidal infundibulum 4 G
ethmoid sinus surgery 101 genetic disease 27
ethmoturbinals 92 Giraffe angled instruments 173
Gliklich and Metson
F – staging system 208
facial pain 17 global instrument 318
facial remodeling 154 global instruments 318
fat graft 248, 297 glomerulonephritis 28
fentanyl 72 goal of sinus surgery 19
fiducial marker 255 goal of surgery 13
first olfactory fiber 121 goal of the medical workup 16
flexible silicone stents 123 graft
FloSeal 331 – underlay 174
flunisolide 137, 148 granulation tissue 134
fluorescein 106 granulomatous disease 29
fluoroscopic guidance 49 greater palatine foramen injection 74
fluoroscopy 245 ground lamellae 57
fluticasone 138 growth hormone 246
fontanelle
– posterior 54, 55 H
foramen rotundum 58 headache 80, 128
fovea ethmoidalis 57, 230 hemangiopericytoma 295
fracture hemi-transfixion incision 95
– fronto-orbital 181 hemicrania continua 219
Friedman hemostasis 329
– staging system 207 hemostatic techniques 294
frontal cell 6, 61, 282 herbal supplement 83
frontal infundibulum 60 Hickman catheter 313
frontal recess 6, 260 High-definition (HD) video technology 64
– neoosteogenesis 117 home-based intravenous therapy 314
– pneumatization pattern 256 hyaluronic acid 330, 332
frontal sinus disease hybrid image 265
– iatrogenic 129 hydroscopy 248
frontal sinus drainage pathway 6 hyperostosis 161, 163, 309, 311, 315
frontal sinus floor 8 hypoplastic frontal sinus 283
frontal sinusitis hypotensive anesthesia 294
– iatrogenic 129 hypothalamic injury 292
frontal sinus opacification 17 hypothalamus 292
frontal sinus ostium
– internal 118 I
frontal sinusotomy 259 iatrogenic injury 291
frontal sinus rescue procedure 120 iatrogenic scarring 129
frontal sinus stent 134 iatrogenic sinus disease 83
frontal sinus stenting 134, 302 image fusion 171, 263
frontal T 122 imaging
frozen section 163 – intraoperative 47
350 Subject Index
immunoglobulin E 144 lacrimal sac fossa 240

immunology 209 lamina papyracea 225
immunotherapy 155, 194, 195, 197 landmark 105
– sublingual 38 lateral canthotomy 226, 228
indications for computer-aided surgery 17 lateralization of the middle turbinate 3
inferior meatal antrostomy 340 lateralized middle turbinate 5, 103, 304
inferior orbital fissure 75 leukotriene blockade 147
inferior turbinate Levine and May
– out-fracture 95 – staging system 207
inferior turbinate hypertrophy 95 lidocaine 74
inferior turbinectomy 4 lipid solubility 74
inflammation localization technique 170
– eosinophilic 31, 32 Lothrop 7
– IgE-mediated 193 low-dose aspirin-desensitizing protocol 42
infraorbital ethmoid low-dose macrolides 40
– remnant 82 lumbar drain 232
infraorbital nerve 341 Lund-MacKay 320
inhalant allergy 148, 194 Lund-Mackay scoring system 201
inhaled anesthetics 73 Lund-Mackay system 203
InstaTrak 3500 Plus 257
instrument M
38 – malleable 68 macrolide 147
instrumentation 112 magnetic resonance cisternography 169
interleukin-5 143 magnetic resonance imaging 128
interseptal frontal sinus cell 118 malignant transformation 339
intersinus septum 58, 344 malignant tumours 213
intracranial CSF pressure 170 malleable probes 87
intracranial hemorrhage 175 marsupialization 182, 185, 187
intranasal antibiotic use 139 matrix metalloproteinase 32
intranasal corticosteroid 137 maxillary sinus
intranasal dressing 329 – floor 54
intraoperative – medial 55
– MRI 47 – posterior wall 54
intrathecal fluorescein 170 – roof 54
intravenous immunoglobulin 16 maxillary sinus ostium
invasive fungal disease 31 – missed 270
inverted papilloma 213 maxilloturbinal 92
irradiated tissue 293 mechanical debridement 89
isopropylphenol 72 Meckel’s cave 291
medial maxillectomy 185, 190
J medial rectus 225
Jorgensen medical complication 249
– radiological scoring system 208 medical treatment 25
– primary goal of 25
K meningeal inflammation 294
Kartagener’s syndrome 105, 146 meningitis 168, 174, 249
Kennedy – chemical 232
– staging system 207 Merogel 333
Krouse staging system for inverted papilloma 162 Messerklinger technique 63
methicillin-resistant Staphylococcus aureus 309
L methotrexate 29
lacrimal bone 121 methylene blue 285
lacrimal probe 239, 241 microbiology of chronic
lacrimal sac 236 rhinosinusitis 138
Subject Index 351
microdebrider 66 optical tracking 252

– technology 66 optic chiasm 295
microdebrider blades optic foramen 228
– angled 66 optic nerve 58
middle turbinate optic nerve decompression 229
– lateralized 104 orbital apex 56
– medializing 88, 105 orbital decompression 227
middle turbinate lateralization 89, 97, 286 orbital dehiscence 262
middle turbinectomy 6 orbital emphysema 243
minitrephination 286 orbital fat 192, 227
miosis 219 orbital hemorrhage 223
missed ostium 272 orbital pathology 338
missed ostium sequence 14, 102 orbital press test 225
mitomycin-C 334 oroantral fistulae 340
Montgomery tube 305 ossifying fibroma 164
mucocele 15, 271, 339 osteitic bone 105, 261
– recurrence rates 192 osteitis 22, 103
mucopirocin 139 osteomyelitis 9, 210
mucopyocele 180, 185, 186, 285 osteoneogenesis 7, 10, 102, 161, 334, 340
mucosal inflammation 79 osteoplastic flap 189
mucosal nodular change 10 osteoplastic obliterative frontal sinus operation 122
mucosal stripping 79, 344 osteotome 277
mucus recirculation 80 osteotomy 9
mucus retention cyst 85 ostiomeatal complex 93
multidetector helical scanning 1 outcome 327
multilayered reconstruction 289 oxymetazoline 75
mupirocin 310
Mygind technique 138 P
palate mold 181
N papilloma
nasal beak 6, 133 – sphenoid 289
nasal irrigation 306 Parrell frontal sinus stent 306
nasal saline irrigations 154 patency rate 301
nasal steroid spray 196 patient anxiety 72
naso-orbitoethmoid fracture 180 patient comfort 333
nasoantral window 278 patient selection 345
nasolacrimal canaliculus 238 pedicle graft
nasolacrimal duct 54, 55, 240 – vascularized 174
nebulizer 139 pedunculated polyp 205
neo-osteogenesis 119 performance error 48
neutropenia 314 pericranial tenderness 218
noniodized salt 137 periorbita 225
nonrespiratory cuboidal epithelium 276 periorbital fat herniation 128
nosocomial complication 313 permanent stenting 302
persistent frontal sinus obstruction 128
O pharmacotherapy 193
obesity 175 phenotypes of CRS 26
obstruction of the osteomeatal complex 135 physiologic ventilation 132
olfactory fossa 121 pituitary adenoma 295
olfactory meningioma 173 pituitary apoplexy 245
olfactory neuroblastoma 298 pleomorphic adenoma 159
Onodi cell 228 pneumatic holder 248
operative report 80 pneumocephalus 172, 298
operative time 265 polypectomy 144
352 Subject Index
positive fungal culture 31 Samter’s triad 27, 326

posterior fontanelles 4 sarcoidosis 22
postnasal drip 20 scarring 135
postoperative immunotherapy 140 scar tissue 3
postoperative stenosis 301 Schneiderian papilloma 160
postsurgical CT anatomy 2 SepraPack 333
Pott’s puffy tumor 192, 282 septal deflection 94
powered instrumentation 148 septal deformity 93
prognosis 203 septal deviation 91
proptosis 144 septal excoriation 196
prostaglandin E₂ 39 septal window 343
purulent drainage 306 septectomy 132, 295
purulent rhinorrhea 81 septoplasty 93
– endoscopic 94
Q septum
quality of life 317 – membranous 91
seromucinous gland
R – cystic degeneration 186
radiation exposure 46 severely scarred frontal recess 342
re-epithelialization 304 silastic stent 87
re-epithelization 123 silastic tubing 302
38 real-time updating 264 silent sinus syndrome 181
recalcitrant inflammatory disease 339 silicone T-tube 302
recalcitrant inflammatory sinus disease 15 sinocutaneous fistula 9
recessus terminalis 130 sinonasal anatomy 1
recirculation 4 Sinonasal Outcome Test (SNOT-20) 310, 321, 324
recirculation phenomenon 102 sinus headache 20, 218
reconstruction 293 sinus mucocele
red-man syndrome 313 – classification 187
reflux disease 20 sinus opacification 211
reflux in CRS 20 situs inversus 146
registration error 254 skeletonizing the skull base 84
registration paradigm 253 skill level 48
requirements of a staging system 212 skin endpoint titration 195
residual uncinate process 5 skin testing 195
respiratory depression 72 skull-base defect 167
respiratory epithelium 92 skull-base erosion 186
retained mucus 186 skull base
retained uncinate process 14 – asymmetry of the 174
rhinosinusitis sloping skull base 231
– post-traumatic 180 smoking 19, 80
rhinosinusitis classification 200 spacers 329
Rhinosinusitis Disability Index 321, 325 sphenoethmoidal recess 110, 111
Rhinosinusitis Initiative 217 sphenoethmoid cell 58, 106
Rhinosinusitis Outcome Measure 323 sphenoethmoid recess 9
Rhinosinusitis Quality of Life (QOL) instrument 326 sphenoid ostium 111
Rhinosinusitis Quality of Life Survey 321 sphenoidotomy 109
Rhinosinusitis Symptom Inventory 323 – large 87
rubber finger stalls 123 sphenoid sinus
– transethmoid route 112
S sphenoid sinus ostium 110
saccharin 38 – patency 114
saccharin transit time 38 sphenopalatine block 74
saddle-nose deformity 3, 28 sphenopalatine foramen 54
Subject Index 353
spontaneous CSF leak 168, 170 thickened mucosa 148

staging system 199 thrombophlebitis 314
– University of Miami 211 through-cutting instrument 65
static anatomical landmark 85 thunderclap headache 219
stereotactic surgery 46 tissue-remodelling 32
strenuous activity 176 topical antifungals 30
sublabial approach 277 toxic shock syndrome 307
sublabial incision 278 tracking system 252
subperiosteal orbital abscess 341 transblepharoplasty approach 284
substance P 220 transethmoid approach 191
success rate 19 transillumination of the frontal sinus 284
suction instrumentation 67 transnasal sphenoidotomy 9
suction irrigation 120 transpterygoid approach 164, 171
sump syndrome 238 trauma
superantigen activity 30 – craniofacial 179
superior nasal septum 8 – maxillofacial 179
superior turbinate 86, 110, 113 Trendelenburg position 171
– conservative resection 98 trephination 156, 282
– remnant 98 trisomy 21. see Down syndrome
supraorbital turbinate scissors 97
– remnant 82 type I hypersensitivity reaction 146
supraorbital ethmoid cell 58, 117 type IV frontal sinus cell 132
supraorbital neurovascular bundle 283
surgical equipment 120 U
surgical equipment option 63 uncapping the egg 118, 131
surgical landmark 252 uncinate
surgical navigation 251 – retained 104
surgical performance 49 uncinate process
surgical planning 253 – remnant 82, 86
surgical revision 15 uncontrolled bleeding 229
surgical simulation training 45 underling sinonasal disease 21
surgical simulator 48 unified airway 21
surgical strategy 265 unilateral pain 218
Surgicel 333
SurgiFlo 331 V
surveillance 149, 159, 281 vascular clip applier 68
sweat test 27 vascularized mucosal flap 297
symptomatic obstruction 13 vascularized periosteum 277
symptom score 319 vasculitis 28, 29
synechiae 80, 136, 333 – necrotising granulomatous 29
systemic steroids 147 vasoconstriction 75
systemic vasculitis 29 visual analogue scale 200
systemic vasodilation 72 vomer 113
T W
β2-transferrin 168 washout sign 232
T-cell function 27 when to assess outcome 317
target registration error 255 widened frontal ostium 157
telescopic angle 64 wound contracture 113
temporomandibular dysfunction 221
tenacious material 156 Z
terminal illness 272 zero-degree endoscope 64
tertiary amines 74 zygomaticomaxillary fracture 182
therapeutic strategy 42

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Stilianos E. Kountakis · Joseph B. Jacobs · Jan Gosepath (Eds.

ISBN 978-3-540-78930-7 e-ISBN 978-3-540-78931-4

Library of Congress Control Number: 2008923578

© 2008 Springer-Verlag Berlin Heidelberg

Cover design: Frido Steinen-Broo, eStudio Calamar, Spain

Printed on acid-free paper

To the Memory of my mother, Eftihia Kountakis.

To the Memory of my mother, Helen Jacobs.

Subject Index .. . . . . . . . . . . . . . . . . . . . . . . . . . 347

Vijay K. Anand, MD Roy R. Casiano, MD

Alexander G. Chiu, MD Wolfgang Draf, MD, Hon MD, PhD, FRCSC

David B. Conley, MD Ramon E. Figueroa, MD

Marvin P. Fried, MD Peter H. Hwang, MD

Christos Georgalas, MD Joseph B. Jacobs, MD

Timothy Haegen, MD David W. Kennedy, MD

Todd T. Kingdom, MD Valerie J. Lund MS FRCS FRCSEd

Karen A. Kölln, MD Elisa M. Lynskey, MD

Metin Önerci, MD Joseph Raviv, MD

Richard R. Orlandi, MD, FACS Ryan M. Rehl, MD

Rodney J. Schlosser, MD Michael G. Stewart, MD, MPH

James Stankiewicz, MD Bradford A. Woodworth, MD

anatomy is still intact. In addition, it must identify the

landmarks. The combination of improved imaging clar-

tion, presence of Haller cells, large bulla ethmoidalis, or

successful. The previous endoscopic drainage procedure

Negative Prognostic Findings Post-FESS Conclusion

Indications for Revision

a precise understanding of the patient’s anatomy are thus

The first occurs when prior surgery has been incomplete.

Fig. 2.2 Mucocele. Left frontal sinus

Recurrent or Persistent Sinus Disease

Another indication included in this category is in the

warranted [5]. This option should be discussed with the

Fig. 2.5 Recurrence of sinonasal polyposis. Sagittal CT showing

9. Kountakis SE, Bradley DT (2003) Effect of asthma on si-

spectively reviewed 182 patients who had undergone ESS

■ Asthma has been indicated for causing a significant

Chronic rhinosinusitis is very common among patients

ity (60%) are sensitive to multiple allergens [11]. Just like

Churg-Straus syndrome. These can cause severe nasal and

WG is a multisystem disease with a complex genetic back-

Fig. 4.2 Patient with nasal deformity due

alised disease, the induction treatment is systemic and

disease [100]. In CRS and NP, MMP-9 is significantly

Medical Management after Primary

Fig. 5.1 Interaction between nonsteroidal

■ A low-dose, low-risk, aspirin-desensitizing protocol

Fig. 5.2 The corresponding in vitro

Heterogeneous experiences on the effectiveness of this

The data underline the role of the in vitro assay and

New Technologies for Revision

■ Stereotactic image-guidance systems are still limited

Recent innovations have allowed for intraoperative up-

Fig. 6.2 Preoperative CT images (a) and intraop-

romagnetic operating room equipment and instruments.

Fig. 6.3 The endoscopic sinus surgery simulator

Fig. 6.4 The video monitor of the endoscopic sinus

Surgical Anatomy in Revision

■ The posterior fontanelle is located superior to the lat-

■ Therefore, anteroposterior resection of the uncinate

■ Asthma has been indicated for causing a significant

■ A low-dose, low-risk, aspirin-desensitizing protocol

■ Stereotactic image-guidance systems are still limited

■ The posterior fontanelle is located superior to the lat-

■ Therefore, anteroposterior resection of the uncinate

■ Surgeons should exercise extreme care when dissect-

■ A variety of blades for soft-tissue removal and burs for

■ Endoscopic procedures not only have the absence of

■ Positive skin tests occur in a similar percentage of pa-

cated in temperate regions of relatively high humidity.

■ When thick fungal debris is located in the remote re-