-------------------------------------------------------------------------------- TITLE: ENDOSCOPIC SINUS SURGERY SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: April 8, 1992 RESIDENT PHYSICIAN: Lane F. Smith, M.D. FACULTY: Karen H. Calhoun, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. -------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." ABSTRACT: Functional endoscopic sinus surgery (FESS) is a new and exciting treatment for chronic sinus disease. Our knowledge of the surgery continues to expand. A retrospective and prospective review of 200 patients undergoing undergoing FESS was undertaken at the Houston Ear, Nose and Throat Clinic. Parameters studied included patient symptoms, past medical history, medical therapy and radiologic findings. Also reviewed were hospitalization length, complications and postoperative symptoms. Nasal obstruction was the most common preoperative symptom. Anterior ethmoid and ostiomeatal complex disease were the most common preoperative CT scan findings. 84.5% of the patients were done as outpatient surgery. 8% of patients developed minor complications and only one major complication occurred (0.05%). With a mean follow-up of 17 months, 88% of the patients were symptom free or improved. We conclude that FESS is a highly successful treatment for chronic sinus disease (P < 0.01) and that a strong patient history for sinus symptoms is the most important indication for FESS. INTRODUCTION: Functional endoscopic sinus surgery (FESS) has become an increasingly popular treatment for chronic sinus disease. Although some of the ideas have been present since the turn of the century, the surgical technigue is relatively new. Advances in technology with the development of small fiberoptic endoscopes and computerized tomography (CT) scanning of the paranasal sinuses have allowed a more direct and accurate study of sinus disease then had previously been possible. Work by Messerklinger and others has lead to the development of the following concepts (12,22,24,31,33,38): 1. Most infections of the paranasal sinuses are rhinogenic. Infection spreads from the ethmoid sinuses to secondarily infect the larger maxillary and frontal sinuses. 2. Chronic sinusitis, non-resolving acute sinusitis, or chronic recurrent sinusitis is usually due to obstruction of the major drainage pathways which are located in the ostiomeatal unit. This area consists of the drainage pathways for the frontal sinus, anterior ethmoid sinus and maxillary sinus. This is the where drainage is most narrow and obstruction most likely to occur. 3. It had previously been thought that chronic sinus disease produced irreversible changes in the paranasal sinus mucosa. It is now known that these mucosal changes are reversible with the opening of the stenotic ostia and proper aeration of the sinuses. Based on these principals, and with the help of new technology, FESS has revolutionized the treatment of chronic sinus disease. As with any new technique our knowledge of the surgery continues to expand. We wish to present our experience with 200 patients with regard to observations we have made about patient profile, surgical technique, indications for and complications of FESS. MATERIALS AND METHODS: Data was by retrospective and prospective patient enrollment. The total study population consisted of 200 patients. Approximately one third were enrolled prospectively. The surgical procedures were performed along the guidelines described by Messerklinger and Stammberger with modifications taken from the technique described by Wigand (31,32,34,38.) All patients were intensely evaluated using a chart review, endoscopic nasal examination, examination of all preoperative CT scans by both radiologists and otolaryngologists and close postoperative follow-up. Parameters studied included patient symptoms, prior medical history, medical therapy and radiologic findings. Also reviewed were number of operative procedures, hospitalization length and postoperative improvement. A specific data sheet was used for recording the sinus CT scan and nasal endoscopic examination findings. The study period ran from March of 1988 to January of 1990. A minimum of one year follow-up was obtained with an average of 17 months. Patients who an undergone previous FESS were excluded from the study. Patients who had undergone traditional sinus surgery (nasal-antral windows, etc.), were included in this study. RESULTS: 200 patients were enrolled in the study and underwent FESS. The average age was 38.6 years, range 11 to 75 years (table 1). 58.5% (n=117) of our patients were female. Table 1. lists the patient profile and prior medical history. Prior medical history refers to medical diagnoses given to our patients by other phyiscians prior to being seen in our clinic. All patients underwent extensive medical treatment prior to recommendation for surgery (see bar graph "Results, medical treatment".) 92% (n=184) received antihistamines and/or decongestants. 83% (n=166) received at least one course and often multiple courses of antibiotics. 67% (n=134) received topical nasal steroids and 67% (n=134) received a course of oral or parenteral steroids. 26% (n=52) had allergic findings severe enough to warrant immunotherapy. Preoperative symptoms are listed in the bar graph "Results, Preoperative Symptoms". The most common symptom was nasal obstruction 71% (n=142), followed by headaches/facial pain 65% (n=130), post nasal drip 60.5% (n=121), and recurrent sinusitis 51% (n=102). 95% (n=190) suffered to some degree with at least one of these four most common symptoms and 81% (n=162) had at least two or more. All patients received CT scans with coronal cuts of the sinuses prior to surgery. All CT scans were evaluated by both radiologists and surgeons, and this data was collected on a specific data sheet. The findings are listed in table 2. Table 3. lists the operative procedures performed. The majority of patients, 91% (n=183), underwent bilateral anterior ethmoidectomies, bilateral infundibulotomies, and bilateral enlargement of the natural maxillary sinus ostium. 5% (10) patients required a Caldwell-Luc procedure. This was reserved for patients whose disease could not be removed via maxillary sinoscopy or the natural ostium. Length of hospitalization and surgical complications are shown in the graphs entitled "Results, Length of Hospitalization" and "Results, Complications." The majority of patients, 84.5% (n=169), were done as outpatient surgery. Then mean hospital stay was less then one day. One major complication occurred. This was a left orbital hematoma which resolved without complications . 8% (n=16) had minor complications. 13 complications were due to bleeding. All bleeding was successfully controlled using endoscopic cauterization or nasal packing. 2 patients had exposed orbital fat, and 1 patient developed epiphora after a nasolacrimal duct injury. No permanent sequela occurred. Patient satisfaction with the surgery was high (see pie graph "Results, Postoperative Symptoms.") 58.5% (n=117) were assymptomatic and 29.5% (n=59) were improved. Overall 88% (n=176) had improvement or complete relief of disease after surgery. This is statistically significant (P < 0.01). 8.5% (n=17) felt no improvement of symptoms after surgery and 2.5% (n=5) felt worse. Those patients whose major preoperative symptom was nasal obstruction, 95% (77 of 81 pts.), reported relief of symptoms (P < 0.01%). This was the symptom most successfully improved by FESS with or without septoplasty. The symptom least helped by FESS was post nasal drip. Only 82% (33 of 40 pts.) of those patients whose primary complaint was post nasal drip reported relief of symptoms (P < 0.05%). DISCUSSION Chronic sinusitis has become one of the most common diseases in the United States (21). Many of these patients can be managed successfully with medical therapy. Those who fail intensive medical therapy may be candidates for FESS. 88% of our patients were symptom free or improved after FESS (P < 0.01). All of these patients had failed intensive medical therapy and 17.5% had failed previous traditional sinus surgery. Our results are consistent with those of other studies which have shown 80% to 91% postoperative improvement after FESS (7,19,27,28,29,39). Nasal obstruction 71%, headaches/facial pain 65%, post nasal drip 60%, and recurrent sinusitis 51%d were the most common preoperative symptoms. Nasal obstruction was the symptom most responsive to FESS, 95% reported improvement (P < 0.01). Post nasal drip was the symptom least responsive to FESS treatment. Only 82.4% of patients reported improvement when post nasal drip was their primary complaint (P < 0.05). These findings are consistent with those of other authors (7,37,38). While improvement occurred in 88% of patients, only 58.5% were completely symptom free. 41.5% continued to require treatment for chronic sinus related complaints (mean follow-up 17 months). This is felt to be partly due to the allergic component of chronic sinus disease that some patients have. 41% of our patients had a history of allergic rhinitis and 26% of our patients required immunotherapy (table 2.) The failure of post nasal drip to respond as well as other symptoms to FESS could be partly due to allergy mediated contributions to post nasal drip. The importance of continued treatment, especially of nasal allergies after FESS is clear. Sinus CT scans were obtained on all patients prior to surgery. Sinus CT scans and preoperative nasal endoscopy are indespensible for planning FESS. Careful review of the CT scans by the surgeons often showed that the radiologists tended to under-report disease, frequently missing infundibulum disease. In addition to this disease seen at the time of surgery was often more extensive than that seen on CT scan. Younis et al., reported 20% of patients had intraoperative findings more extensive then that shown on CT scan (39). Because of the aforementioned observations it has become apparent to us that the history is the most important indication for FESS. We now weight patient history as 50%, CT scan 25%, and physical examination 25% importance in deciding when to operate. This is in agreement with Stammberger and Wolf who state that even if physical examination and extensive radiographic and other studies are normal, a patient with a good history for chronic sinus disease will often benefit from FESS (31). Our review of 200 sinus CT scans confirmed the rhinogenic and ostiomeatal complex theories of chronic sinus disease mentioned in the introduction. The most common findings of CT scan were anterior ethmoid, and infundibulum disease. Most patients would have had normal plain radiographs. Only 16 (8%) patients had complete maxillary sinus opacification and 14 (7%) had maxillary sinus fluid levels. 91.5% of our patients underwent bilateral enlargement of the natural maxillary ostium, bilateral infundibulotomies, and bilateral anterior ethmoidectomies (table 5). These are the procedures most closely associated with the ostiomeatal complex and are relatively safe to perform. We feel that chronic sinus disease is most often a bilateral process affecting both the right and left paranasal sinuses. Most patients have bilateral symptoms, or if only unilateral symptoms they have bilateral findings on CT scan or endoscopic examination. Also as previously mentioned many have an allergic component to their chronic sinus disease which usually affects the paranasal sinuses bilaterally. For these reasons we almost always perform the anterior portion of FESS bilaterally. Posterior ethmoidectomy and sphenoidotomy is the more dangerous part of FESS. These areas, while significant are not actually part of the ostiomeatal complex. For these reasons, we were more likely to perform unilateral procedures in these areas. This agrees with the more limited approach esposed by Messerklinger and Stammberger (31,32,34). Partial middle turbinectomy is a prominent component of our surgical technique (table 3). 87% underwent bilateral partial middle turbinectomies. The middle turbinate is a key component of the ostiomeatal unit (40,41). Blockage here can easily lead to infection. We discovered during our early experience with FESS, (results not reported here), that the majority of surgical failures were secondary to synechiae or other obstructions caused by the middle turbinate. Wigand states that removal of the posterior middle turbinate improves the view of the posterior ethmoids and sphenoid sinus ostium and improves the "security of the operation" (38). In addition to this, we feel that partial middle turbinectomy often improves the view of the maxillary ostium and infundibulum area and makes this portion of the operation easier. Kennedy has quoted evidence stating that the anterior end of the middle turbinate bears the brunt of inspiratory airflow (12). We feel that partial middle turbinectomy greatly improves nasal airflow. This may partly explain why 95% of our patients with major complaints of nasal obstruction felt relief after FESS. Toffel et al., who also perform a partial middle turbinectomy, noted a 98% resolution of nasal obstruction in their patients (37). Stammberger, Messerklinger and Kennedy have at times recommended against routine resection of the middle turbinate (10,31,32,34). Reasons sited for this were loss of an important surgical landmark, and possible risks of atrophic rhinitis, and/or anosmia or hyposmia. We feel the base of the middle turbinate can still be used as a landmark throughout the procedure and can even be used as a landmark for revision procedures. Care must be taken not to operate medial to the base of the middle turbinate or to resect the insertion of the middle turbinate to the skull base as this can lead to damage or tearing of the olfactory fibers and a CSF leak (38). When these precautions are taken, loss of surgical landmarks, anosmia or hyposmia and atrophic rhinitis do not occur. We did not have a single case of permanent atrophic rhinitis, although patients will have symptoms similar to atrophic rhinitis until healing has occurred. Wigand has reported that in several thousand operations he has not had a single case of atrophic rhinitis (38). He has also stated "personal observations show that normal olfaction is often preserved even if the middle turbinate is lost up to it's fixed base" (38). 5% of our patients required revision procedures, 6 intraoperatively and 4 as office procedures. These revisions were performed for removal of residual air cells, stenosis of the middle meatal antrostomy or regrowth of polypoid mucosa. This rate of revision procedures is slightly lower then many reports which often quote rates of approximately 10% to 15% (19,27). Our slightly lower rate may be due to the fact that we perform a partial middle turbinectomy. Scaring between the middle turbinate and lateral nasal wall has been quoted as the most common reason for failure of FESS and need for revision procedures (10,12,27). Rice in his reported series of 100 patients states "all unsuccessful operations seemed to occur from scaring in the middle meatus;" he did not, however, go on to advocate middle turbinate resection (27). Postoperative healing was often prolonged and required frequent office visits for removal of crusts and debris. The usual time of healing was 4 to 8 weeks. A few patients required up to 12 weeks before healing was complete. This time to healing is consistent with other authors, who state that the reason for the long recovery time is that the mucosa must regenerate itself and much of the healing occurs by secondary intention (10,12,28,31,34,38). In inexperienced hands, the major complications associated with FESS can include intracerebral hemorrhage, CSF leak, blindness, diplopia, intracranial penetration, meningitis, and severe hemorrhage. (6,29,31,36,38). In our study, only 1 (0.05%) major complication occurred. This was a left orbital hematoma which resolved without sequelae. 16 (8%) minor complications occurred. 13 of these were secondary to minor hemorrhage. All bleeding was successfully controlled with endoscopic cauterization or nasal packing. 1 patient developed eiphora after nasolacrimal duct injury and 2 cases of exposed orbital fat occurred. In 200 cases no permanant sequelae occurred. Our complication rate is similar to those reported in other series (19,27,28,34,37,38). FESS is a very effective and safe procedure when performed by surgeons experienced in the technique. Almost all of our surgeries were performed under general anesthesia. We felt this increased patient comfort and did not prolong hospitalization or lead to increased surgical complications. Advocates of performing the procedure under local anesthesia state that it is safer (10,12,31,34). While this is probably true for surgeons inexperienced in the surgical technique, other series using general anesthesia have noted no increase in the number of complications (27). Schaefer and Rice recommend general anesthesia when performing a total sphenoethmoidectomy, stating that adequate local anesthesia is difficult to obtain for this entire region. CONCLUSIONS: 200 patients who underwent FESS from March 1988 to January 1990 were studied. The mean postoperative follow-up was 17 months, range 12 to 34 months. We conclude the following: 1. FESS is and excellent method for treating chronic sinus disease. 88% of our patients were improved or asymptomatic after surgery (P < 0.01). 2. A history of nasal obstruction, headaches/facial pain, post nasal drainage, and recurrent sinusitis is the most important indication for FESS. We weight the history as 50% importance, CT scan 25%, and physical exam as 25% in deciding whether or not to operate. 3. The preoperative CT scan most often showed anterior ethmoid and infundibulum disease, consistent with a rhinogenic origin of paranasal sinus infections. 4. In most instances, we perform anterior ethmoidectomies, enlargement of the natural ostia, and infundibulotomies as a bilateral procedure. 5. FESS can safely be performed under general anesthesia as an outpatient procedure. 6. The complications of FESS are minimal when performed by an experienced surgeon. 7. Partial middle turbinectomy is a safe and recommended procedure. No cases of atrophic rhinitis occurred. 8. Nasal obstruction is the symptom most likely to be improved after FESS (P < 0.01). 9. Many patients require continued treatment after FESS, especially those patients with allergies. 41.5% of our patients still require medical therapy after FESS. ------------------------------------------------------------------------------ BIBLIOGRAPHY 1. Avant RF, Kennedy DW: Need for a national education program on appropriate care of patients with sinusitis. Otolaryngol Head Neck Surg 1990;103:5 suppl. 2, 855. 2. Calhoun KH, et. al.: Surgical anatomy of the lateral nasal wall. Otolaryngol Head Neck Surg 1990; 102:156-161. 3. Cannon CR: Video documentation of endoscopic sinus surgery. Otolaryngol Nead Neck Surg 1989;101:629-632. 4. Dupechain KJ, et. al.: The role of endoscopic sinus surgery in cystic fibrosis and other forms of sinonasal disease. Arch Otolaryngol Head Neck Surg 1991;117:422-426. 5. Griffies SG, et. al.: Steroids in rhinoplasty. Laryngoscope 1989;99:1161-1164. 6. Hoffman SR, et. al.: Sinus disease and surgical treatment: a results oriented quality assurance study. Otolaryngol Head Neck Surg 1989;100:573-577. 7. Josephson JS: Functional endoscopic sinus surgery. Insights in Otolaryngology 1991;vol. 6:No. 2. 8. Jorgensen RA: Endoscopic and computed tomographic findings in ostiomeatal sinus disease. Arch Otolaryngol Head Neck Surg 1991;117:279-287. 9. Kamel R: Endoscopic transnasal surgery in antrochoanal polyp. Arch Otolaryngol Head Neck Surg 1990;116:841-843. 10. Kennedy DW: Functional endoscopic sinus surgery, technique. Arch Otolaryngol 1985;11:643-649. 11. Kennedy DW, et. al.: Endoscopic sinus surgery for mucoceles: a viable alternative. Laryngoscope 99;Sept 1989:885-895. 12. Kennedy DW, et. al.: Functional endoscopic sinus surgery, theory and diagnostic evaluation. Arch Otolaryngol 1985;111:576- 582. F13. Kennedy DW: First-line management of sinusitis a national problem? Overview. Otolaryngol Head Neck Surg suppl. 103;5:2, 847-854. 14. Kloppers SP: Endoscopic examination of the nose and results of functional endoscopic sinus surgery in 50 patients. S Afr Med J 1987;72:622-624. 15. Levine HL: The office diagnosis of nasal and sinus disorders using rigid nasal endoscopy. Otolaryngol Head Neck Surg 1990;102:370-373. 16. Levine HL: Functional endoscopic sinus surgery: evaluation, surgery and follow-up of 250 patients. Laryngoscope 100;Jan 1990:79-84. 17. Lucente FE, Schoenfeld PS: Calibrated approach to endoscopic sinus surgery. Ann Otol Rhinol Laryngol 99;1990:1-4. 18. Malotte MJ, et. al.: Transantral sphenoethmoidectomy: a procedure for the 1990s? Otolaryngol Head Neck Surg 1991;104:358- 361. 19. Matthews BL, et. al.: Endoscopic sinus surgery; outcome in 155 cases. Otolaryngol Head Neck Surg 1991;104:244-246. 20. May M, et. al.: Video endoscopic sinus surgery: a two-handed technique. Laryngoscope 100;April 1990:430-432. 21. Moss AJ, Parsons VL: Current estimates from the national health interview survey, United States 1985. Hyatsville Maryland: National Center for Health Statistics, 1986:66-67. 22. Messerklinger W: Endoscopy of the nose. Baltimore, Urban and Schwarzenberg, 1978. 23. Nass RL, et. al.: Diagnosis of surgical sinusitis using nasal endoscopy and computerized tomography. Laryngoscope 1989. 24. Pfaltz CR, et. al. Dir therapie der chronischen sinusitis, rundtischgesprach. Laryn Rhinol Otol 64;1985:449-454. 25. Reck L: Die therapeutischen grenzen der endonasalen kieferhohlenfensterung. Laryn Rhinol Otol 65;1986:673-675. 26. Reilly JS: The sinusitis cycle. Otolaryngol Head Neck Surg 1990;103:5 suppl.2, 865-862. 27. Rice DH: endoscopic sinus surgery: results at 2 year follow- up. Otolaryngol Head Neck Surg 1989;101:476-479. 28. Rice DH, Schaefer SD: Endoscopic paranasal sinus surgery: 5.Raven Press, New York, 1988. 29. Schaefer SD, et. al.: Endoscopic paranasal sinus surgery:indications and considerations. Laryngoscope 99;Jan 1989:1-5. 30. Stafford CT: The clinicians view of sinusitis. Otolaryngol Head Neck Surg 1990;103:5 suppl. 2, 870 -879. 31. Stammberger H, Wolf G: Headaches and sinus disease: the endoscopic approach. Ann Otol Rhinol Laryngol 1988 Sept-Oct 134:3- 32. Stammberger H: Unsere endoskopische operationstechnik der lateralen nasenwand, ein endoskopisch-chirurgisches konzept zur behandlung entzundlicher nasennebenhohlenerkrankungen. Laryn Rhinol Otol 64;1985:559-566. 33. Stammberger H: Endoscopic endonasal surgery -- concepts in treatment of recurring rhinosinusitis. Part 1, Anatomic and pathophysiologic considerations. Otolaryngol Head Neck Surg 94:143,1986. 34. Stammberger H: Endoscopic endonasal surgery part II. Otolaryngol Head Neck Surg 94:157,1986. 35. Stammberger H: Nasal and paranasal sinus endoscopy, a diagnostic and surgical approach to recurrent sinusitis. Endoscopy 18;1986:213-218. 36. Stankiewcz JA: Blindness and intranasal endoscopic ethmoidectomy: prevention and management. Otolaryngol Head Neck Surg 1989;101:320-329. 37. Toffel PH, et. al.: Secure endoscopic sinus surgery as an adjunct to functional nasal surgery. Arch Otolaryngol Head Neck Surg. 1989;115:822-825. 38. Wigand EM: Endoscopic surgery of the paranasal sinuses and anterior skull base. Thieme Medical Publishers, Inc., New York 1990. 39. Younis RT, Lazar RH: The approach to acute and chronic sinusitis in children. Ear Nose Throat Journal 70;1:35-39. 40. Zinreich SJ, et. al.: paranasal sinuses: CT imaging requirements for endoscopic surgery. Radiology 1987;163:769-775. 41. Zinreich SJ: Paranasal sinus imaging. Otolaryngol Head Neck Surg 1990;103:5 suppl. 2, 863-869. ----------------------------------END-----------------------------------------