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Concepts of Endoscopic Sinus Surgery: Causes of Failure

Concepts of Endoscopic Sinus Surgery: Causes of Failure. Cummings Chp . 52 Wed 1/9/13 Irene A. Kim. Key Points. Long-term success rate of FESS + medical therapy: 80-90%. Anatomic variants no longer considered underlying etiology of disease FESS GOAL :

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Concepts of Endoscopic Sinus Surgery: Causes of Failure

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  1. Concepts of Endoscopic Sinus Surgery: Causes of Failure Cummings Chp. 52 Wed 1/9/13 Irene A. Kim

  2. Key Points • Long-term success rate of FESS + medical therapy: 80-90%. • Anatomic variants no longer considered underlying etiology of disease • FESSGOAL: • Surgically remove inflamed tissue from critical points in mucociliary clearance pathways

  3. ABSOLUTE Indications for Sinus Surgery • 1. Rhinosinusitis complications • 2. Expansilemucoceles • 3. Allergic/Invasive fungal rhinosinusitis • 4. Suspected neoplasia

  4. Mucoceles • Frontal sinus mucoceles • Skull base identified in posterior ethmoid • Follow anteriorly until bone of lesion found • Remove inferior portion • Remove all osteitic bone from region of obstruction • Bony margins flush should be flush with surrounding wall

  5. Fungal Sinusitis • Invasive • Chronic invasive fungal rhinosinusitis • Fulminant invasive disease • Noninvasive • Fungal balls • Allergic fungal rhinosinusitis

  6. Indications for Tumors, Skull Base Defects, Other Noninflammatory Lesions Benign tumors Inverted papilloma Juvenile angiofibroma Skull base defects Orbital problems Encephaloceles, meningoceles Closure of CSF rhinorrhea Malignant tumors

  7. Relative Indications for Sinus Surgery • Symptomatic nasal polyps • Unresponsive to medical therapy • Symptomatic chronic or recurrent acute rhinosinusitis • Unresponsive to medical therapy • ***Medical therapy is cornerstone of mgmt of inflammatory disease

  8. Poor Indicators of Successful FESS • Persistent environmental exposures • Uncontrolled allergies • Continued chemical exposures • Smoking • Increased granulation tissue • Increased incidence of frontal recess stenosis

  9. Extent of Surgery • Mucosal preservation is *key* (ethmoid) • Resection of inflamed bone important • Removal of osteitic partitions • Uncinate process • Ethmoid sinuses • Avoid leaving exposed bone behind

  10. Pre-op Evaluation & Management • Know amount and duration of: • Antibiotic therapy • Anti-inflammatory treatments • Treat severe polyposis, hyperreactive mucosa • Oral steroids (Prednisone 20-30mg x 3-10 days)

  11. Imaging CT key, but MRI needed when CT shows disease adjacent to skull base erosion Evaluate lateral cribiform plate lamella Evaluate vertical height of post ethmoid Evaluate sphenoid sinus in axial/coronal planes Evaluate frontal recess in triplanar views

  12. Concepts of Antrostomy • Maxillary sinus opening should communicate with natural ostium to PREVENT surgical failure • Long term causes of failure • Ostenoneogenesis from stripped mucosa • Retained foreign body • Mucous draining into sinus from persistent frontal recess inflammation

  13. Ethmoidectomy • Work from “known” to “unknown” • Medial orbital wall is first critical landmark • Goal: Marsupialized cavity lined by healthy, intact mucosa • Skull base is second critical landmark • Common results of failed ethmoidectomy: • Lateralized middle turbinate • Retained uncinate process • Failure of removal of uncinate superiorly • Residual aggernasi cells

  14. Sphenoidotomy Re-review scans: coronal and axial planes Review course of optic n., carotid a. Endoscopic transnasal approach Transethmoid/transmaxillary approach Transseptal approach

  15. Sphenoid Anatomy:Key Structures • Carotid artery • Optic nerve • Cavernous sinus • 3rd, 4th, 5th CN

  16. Frontal Sinusotomy Most challenging Potential for persistent, recurrent disease Most difficult decision: to explore or not Review coronal, axial, sagittal views Review AP/lateral diameters Examine pneumatization of sinus Frontal recess dissection

  17. Turbinate Management • Remove exposed bone (MT) • Stabilize floppy MT • Controlled scar to nasal septum • Postoperatively, can lyse adhesions • Suture turbinate to septum

  18. Postop Medical Management Long-term topical steroid sprays Saline spray Nasal saline irrigation Debridement Loss of olfaction: sensitive sign of return of disease

  19. Management of the Frontal Sinuses Cummings Chp. 53 Wed 1/9/13 Irene A. Kim

  20. Key Points • Frontal sinus drains into middle meatus through frontal recess • Frontal recess located at junction of frontal sinus and is most anterosuperior part of ethmoid sinus • Preserve mucosa around frontal recess

  21. Acute Frontal Sinusitis • Symptoms • Low-grade fever • Malaise • Frontal headache • Tenderness of medial aspect of infraorbital margin • Common organisms • S.pneumo, H. flu, anaerobic strep, Bacteroides, S. aurus, S. epidermidis, S. milleri

  22. Treatment Approaches • Topical decongestant high in middle meatus • Trephine the frontal recess by: • Incision in medial aspect of eyebrow • Open frontal sinus endoscopically by removing ethmoid air cells surrounding recess

  23. Complications of Surgery • Damage to mucosa • Adhesions • Stenosis • Periorbital cellulitis • Periorbital abscess, subdural empyema, meningitis, cavernous, sup sagittal sinus thrombosis • *Obtain URGENT CT if: • CNS involvement seen • Visual problems • Spiking pyrexia not resolving in 36 hours

  24. Surgery in Chronic Frontal Sinusitis • Disease likely started by unnecessary instrumentation of frontal recess • PRIMARY indication for instrumentation: • When maximal medical treatment partial anterior ethmoidectomy have failed • Primary fungal disease • Barotrauma • Mucocele • Osteoma • OsteomyelitisTumors

  25. Causes of Frontal Sinus Surgery Failure • Remnant frontal recess cells • Retained uncinate process • Middle turbinate lateralization • Osteoneogenesis • Scarring or inflammatory mucosal thickening • Recurrent polyposis

  26. Endoscopic Frontal Sinusotomy • Boundaries of frontal recess • Anterior • Aggernasi • Lateral • Lamina papyracea • Medial • Most ant/superior portion of middle turb • Posterior • Ethmoid bulla, bulla lamella

  27. Frontal Recess Cells Type I: Single cell superior to agger nasi cell Type II: Tier of two or more cells above the agger nasi cell Type III: Single cell extending from the agger cell into the frontal sinus Type IV: Isolated cell within the frontal sinus

  28. Frontal Recess Cells • Bulla frontalis • High anterior ethmoid cell that has pneumatized into frontal bone • Can displace frontal recess posteriorly and medially • Supraorbital cell • Posterior cell in ant ethmoid complex that is well pneumatized • Can extend laterally into frontal bone over orbit • Can also narrow frontal recess by pushing forward • *Prevalance of these variations does NOT appear to correlate with presence or absence of frontal sinus disease

  29. Opening the Frontal Recess • Goal: • 1. Deflating the cells of ethmoid air cells • 2. Preserve mucosa around recess • Median frontal sinus drainage procedure • Obliteration of frontal sinuses

  30. Median Frontal Sinus Drainage Procedure • Frontal recesses opened by removing: • top of septum • Frontal interspinus septum • Anterior beak of frontal bone

  31. Frontal Sinus Obliteration • Coronal flap or eyebrow incision • Make outline of frontal sinus with template, image guidance, or endoscopically • Remove anterior plate • Remove all mucosa of frontal sinuses before obliteration • Frontal recess separated from nasal airway with sheet of fascia lata • Use fat to obliterate sinuses

  32. Indications for External Approach • Situations where removal of pathology and/or drainage is difficult to achieve endoscopically • Lateral loculation, lateral mucocele • Fibrosis or new bone around frontal recess • Paget’s disease of frontal bone, osteomyelitis, SCCa • Gross prolapse of orbital contents

  33. Riedel’s Procedure • Important role in mgmt of patients with recurrent infections • Removes ant wall and floor of frontal sinus and all its mucosal lining • Help eradicate frontal sinus disease when • Drainage and obliteration have failed and • There is persistent disease involving the ant wall of the frontal sinus or the sinus itself • Main complaint: postoperative disfigurement

  34. Cranialization of Frontal Sinuses • Performed for: • Requirement for posterior wall removal • Anterior skull base tumors • Severe communication of posterior wall with frontal sinus • Ant intracranial contents separated from paransal sinuses and nasal airway by: • Fascia lata • Pericranial flap

  35. Specific Pathologic Conditions • Pneumosinus Dilatans • Rare, benign expansion of an aerated sinus beyond normal margin of frontal bone • Hypersinus: enlarged sinus with normal walls • Mucoceles • Epithelium-lined sac containing inspissated mucous • Osteoma • Only complaints are cosmetic • Very common, 3% of people have them

  36. Fractures of Frontal Sinus • Ant wall fractures do not require exploration UNLESS: • It affects the frontonasal duct • POSTERIOR wall fractures • Nondisplaced and w/o complications: manage conservatively • Compound comminuted fracture affecting posterior wall or near frontonasal duct: • Cranialization of frontal sinus

  37. Images http://search.babylon.com/imageres.php?iu=http://uwmsk.org/sinusanatomy2/images/axial.frontalmucocele.jpg&ir=http://uwmsk.org/sinusanatomy2/Frontal-Abnormal.html&ig=http://t0.gstatic.com/images?q=tbn:ANd9GcQAB-0_DUmc13JMscXED8RGxcG5ubw62-944bbpTn6vUB4-gZtWI704bZU&h=377&w=395&q=expansile+mucocele&babsrc=SP_ss http://search.babylon.com/imageres.php?iu=http://www.phytoscience.ca/images/endoscopic%2520sinus%2520surgery%2520diagram.jpg&ir=http://www.phytoscience.ca/articles/Nasal%20Polyps.html&ig=http://t2.gstatic.com/images?q=tbn:ANd9GcTvstLF-0MDNGBmYBkVL1rd2nncNJwGQVtt7_Ov0KaR5uEP17-Ih8Hn45E&h=337&w=344&q=fungal+sinsuitis+flow+chart&babsrc=SP_ss http://www.phytoscience.ca/images/endoscopic%20sinus%20surgery%20diagram.jpg http://search.babylon.com/imageres.php?iu=http://www.nyee.edu/images/ent_rss_sts_008.jpg&ir=http://www.nyee.edu/ent_rss_sts_sphenoid01.html?large_print=1&ig=http://t2.gstatic.com/images?q=tbn:ANd9GcRoFmf0M41wC03FDJe_k8DmR6V-oTg7ZfOY2irnRDknCnNHBvTch6zP2Hk&h=290&w=409&q=sphenoid+sinus+anatomy&babsrc=SP_ss http://www.medicalgrapevineasia.com/mg/wp-content/uploads/2012/08/Figure-1b-Nasal-Polyps.jpg http://2.bp.blogspot.com/-vea4b1pTcDs/Tg5hLzlHcTI/AAAAAAAAAPU/LkmPr3ZGS_4/s1600/nasal_polyp.jpg http://www.bing.com/images/search?q=sinus+mucocele&FORM=HDRSC2#view=detail&id=38146D4F21BE6E2F4051DF40518555AE2F252949&selectedIndex=0 http://www.sciencedirect.com/science/article/pii/S1043181003001313 http://www.bing.com/images/search?q=riedel%27s+procedure&FORM=HDRSC2#

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