Benign lesions of the frontal sinus.

Benign tumors of the frontal sinus including fibro-osseous lesions and inverted papillomata present unique problems for the rhinologist. Because of the bony cavity surrounding the frontal sinus and relatively small portal into the nose, conventional techniques including the osteoplastic flap, frontal trephination, and lynch procedure have provided useful approaches to these tumors. The advent of endoscopic techniques in the management of chronic inflammatory disease of the paranasal and, specifically, frontal sinuses, has led to these traditional techniques being augmented successfully, and, in some cases, surpassed by newer endoscopic techniques. This article reviews the diagnosis and management of the two most common types of benign tumors of the frontal sinus, bony tumors and inverted papillomata, with emphasis on the usefulness of the endoscope in managing such lesions.

The forgotten turbinate: the role of the superior turbinate in endoscopic sinus surgery.

The fate of the middle turbinate in endoscopic sinus surgery has been a subject of debate for some time. The superior turbinate's role, however, has been largely passed over. Past anatomic descriptions and illustrations have given surgeons the incorrect impression that this structure is well superior and out of the field of dissection. Injury to the superior turbinate may account for postoperative hyposmia. The superior turbinate also serves as a constant landmark for the sphenoethmoidal recess, and a limited resection allows the surgeon to identify and include the natural ostium of the sphenoid sinus in the sphenoidotomy. The embryology and anatomy of the superior turbinate are reviewed. An approach to the natural ostium of the sphenoid sinus from the lateral side of the middle turbinate, using the superior turbinate as a guide, is described.

Endoscopically assisted anterior cranial skull base resection of sinonasal tumors.

The traditional approach to sinonasal tumors involving the base of skull has been the anterior craniofacial resection. Endoscopic techniques have created the potential to approach the intranasal aspect of skull base lesions without external incisions and still develop an en bloc resection when removed. We report our initial experience with skull base neoplasms in which the otolaryngic portion of the standard resection was accomplished instead through an endoscopic approach. The nature of lesions favorable for this approach and associated technical issues are discussed. Although we do not consider this approach a replacement for the traditional anterior craniofacial resection, it is an important adjunct in the skull base surgeon's armamentarium.

Endoscopic trans-septal frontal sinusotomy: the rationale and results of an alternative technique.

Endoscopic transseptal frontal sinusotomy (TSFS) represents an alternate approach to surgical treatment of chronic frontal sinus disease that is refractory to traditional modes of medical and surgical therapy. We retrospectively reviewed our experience with endoscopic TSFS from 1995-1997. Twenty-one procedures were performed through a transseptal approach. One patient was excluded for failure to follow-up, for a total of 20 procedures. Patients were followed with serial endoscopic examinations and a telephone questionnaire with a mean follow-up of 12 months (Range 1-24 months) and 16 months (range 5-31), respectively. The primary indication for surgery was frontal recess stenosis after previous endoscopic frontal sinusotomy in 17/20 (85%). Three patients were considered poor candidates for a primary endoscopic frontal sinusotomy. Patency was maintained in all patients during the follow-up period. A diameter of greater than 3 mm was confirmed by passage of a curved suction in 19/20 (95%). Of the 19 patients that were evaluated via a telephone questionnaire, 17 patients (89.5%) reported some degree of improvement in their nasal/sinus symptoms, and 12/18 patients (67%) felt the frequency of medication requirements was less than that before undergoing endoscopic TSFS. We conclude that endoscopic TSFS represents an alternate approach to the frontal sinus that may be used by the experienced endoscopist, to augment treatment of refractory frontal sinus disease. This procedure seems especially suited for revision surgery in those patients with acquired frontal sinus stenosis. In revision operations with distorted anatomical landmarks, localization of the frontal sinus may be improved with the aid of 3-dimensional computer assisted localization systems. Unlike traditional frontal sinus obliteration, endoscopic TSFS does not preclude radiographic assessment postoperatively, and allows for endoscopic evaluation of the frontal sinus in the office setting.

Long-term impact of functional endoscopic sinus surgery on asthma.

Using objective and subjective criteria, we performed a study to assess the long-term impact of functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis and asthma at an average follow-up of 6.5 years. One hundred twenty patients who underwent FESS for chronic rhinosinusitis were followed up for an average of 6.5 years (range 6.0 to 10.6 years). Seventy-two (60%) patients responded to a follow-up questionnaire, and 30 (42%) of them reported a history of asthma. Subjective levels of improvement and assessments of medication need were evaluated and statistically assessed with parametric and nonparametric methods. Of these 30 patients, 27 (90%) reported that their asthma was better than it had been before FESS, 6.5 years ago. Average reported improvement increased from 49% at 1.1 years after surgery to 65% at 6.5 years after surgery. Asthma attacks declined in 20 of 27 (74.1%). Medication use for asthma showed similar improvement, with approximately half reporting less inhaler usage and nearly two thirds reporting less oral steroid use. This study demonstrates that a combination of FESS, careful postoperative care, and appropriate medical therapy for chronic rhinosinusitis has a favorable long-term effect on asthma in patients with symptomatic chronic sinusitis. In this study asthma severity, frequency of attacks, and medication need were all improved.

Endoscopic septoplasty: indications, technique, and results.

Endoscopic septoplasty is an attractive alternative to traditional "headlight" approaches to septoplasty. The primary advantage of the technique is the ability to reduce morbidity and postoperative swelling in isolated septal deviations by limiting the dissection to the area of the deviation. This ability to markedly reduce the extent of subperichondrial dissection is particularly valuable in patients who have undergone prior septal cartilage resection. Other advantages include improved visualization, particularly in posterior septal deformities; improved surgical transition between septoplasty and sinus surgery; and its use as an effective teaching tool. We present our experience with endoscopic septoplasty in a series of 111 patients. Surgical indications, technique, and complications are discussed.

Use of the superior meatus and superior turbinate in the endoscopic approach to the sphenoid sinus.

Endoscopic surgery of the posterior ethmoid and sphenoid sinuses can present the operator with a considerable challenge. Although endoscopic training and physician experience have increased significantly in the past decade, surgical complications such as optic nerve trauma and cerebrospinal fluid leak still occur. Surgeons reporting such complications cite a lack of orientation within the dissection field as a primary cause. Because endoscopic sinus surgery is now being performed more routinely, surgical strategies designed to reduce the risk of complications are more important than ever. An anatomic landmark that could reliably orient the dissection within the posterior ethmoids and guide the surgeon to the sphenoid sinus could reduce the possibility of such adverse outcomes. In our experience identification of the superior meatus and superior turbinate provides a reliable landmark within the dissection field that can ensure surgical orientation to the operator. This technique allows safe, reliable dissection of the posterior ethmoids and an efficient approach to the sphenoid sinus, especially in patients undergoing revision surgery. In this article our technique for the identification and definition of the superior meatus and superior turbinate is presented, and the advantages of using this landmark in sinus surgery are discussed. In our experience identification of the superior meatus, superior turbinate, posterior skull base, and medial orbital wall defines a parallelogram-shaped box, which delineates the sphenoid face. This box provides the necessary orientation to guide the surgeon's entrance into the sphenoid sinus through the posterior ethmoid sinus (as Messerklinger described). Techniques for identifying the superior turbinate and meatus and for entering the sphenoid are detailed.

Endoscopic management of sinonasal inverted papilloma.

Since 1992, 42 patients at the University of Pennsylvania have been treated for inverted papilloma (IP). Thirty-three patients were managed endoscopically with or without a Caldwell Luc approach (CLA) and retrospectively analyzed. The CLA, which involves a gingivobuccal incision for access to the maxillary sinus, is distinguished from a formal Caldwell Luc procedure. These 33 patients with histologically confirmed IP were without evidence of malignancy. They also did not have evidence of intracranial, orbital, or frontal sinus IP. Seventeen of 33 patients (17/33) were without prior treatment (primary). Sixteen of 33 (16/33) presented from an outside institution with recurrent IP (secondary). The recurrence rate using this method to treat primary IP was 6% (1/17), and for secondary IP was 25% (4/16). Scheduled postoperative endoscopic surveillance permitted early detection of recurrence and continued endoscopic control of IP. All 33 patients were endoscopically free of disease at the end of the study. These preliminary data are encouraging for the use of intranasal endoscopy with and without CLA as a means of managing and controlling IP in selected cases.

Endoscopically guided cultures in chronic sinusitis.

In chronic sinusitis, culture-directed antibiotics are often recommended as a cornerstone of treatment. The significance of Gram-negative rods (GNRs), coagulase-negative Staphylococci (SCN), and Staphylococcus aureus has been controversial. In an effort to determine host factors which correlate with culture results, 507 endoscopically-guided cultures are reviewed from 265 patients. A history of asthma, allergic rhinitis, prior sinus surgery, and the concurrent use of antibiotics, steroids, and irrigations were some of the host factors compared by X2. The results were compared to a control group of 50 cultures from healthy volunteers. SCN, S. aureus, P. aeruginosa, and Streptococcus were the most common isolates. GNRs were present in 27% of cultures and were more common in patients who had prior sinus surgery or were using irrigations. P. aeruginosa was more common in patients taking systemic steroids. SCN occurred with the same incidence in patients and control subjects but was more prevalent in cultures obtained intraoperatively and in patients taking systemic steroids. No identifiable host factor was associated with S. aureus. S. aureus occurred at similar rates in patients and control subjects but grew heavily in patients and exhibited only light growth in controls. Topical nasal steroids appear to have no statistically significant effect on bacterial cultures. Findings from this study further our understanding of chronic sinusitis and may help guide practitioners in the treatment of this disease.

A schematic approach to preexisting sinus disease for the immunocompromised individual.

Fungal rhinosinusitis is an aggressive and potentially lethal complication of chemotherapy and bone marrow transplant-induced neutropenia. Preexisting noninvasive sinusitis may be a significant risk factor in this population. An illustrative case is presented where preexisting noninvasive fungal sinusitis developed into the tissue-invasive and angio-invasive form of aspergillosis during chemotherapy. We propose an algorithmic approach to all patients before chemotherapy or bone marrow transplantation. If there is a suspicion of sinusitis based on a screening questionnaire, we recommend an otolaryngology consultation and a CT of the paranasal sinuses. Evidence of sinus disease should then be treated aggressively before chemotherapy or a bone marrow transplantation. Close posttreatment surveillance during the neutropenic phase is necessary with "urgent" biopsies if recurrence of disease is suspected.

Histology and histomorphometry of ethmoid bone in chronic rhinosinusitis.

Mucosal changes have been well described in chronic sinusitis, yet little is known about the underlying bone, despite clinical and experimental evidence suggesting that bone may be involved in chronic sinusitis. Techniques of undecalcified bone analysis were used for detailed histologic examination of ethmoid bone in chronic sinusitis compared with controls. Bone synthesis, resorption, and inflammatory cell presence were specifically assessed. Additionally, histomorphometry techniques were used to determine ethmoid bone physiology in individuals undergoing surgery for chronic sinusitis. Overall, individuals undergoing surgery for chronic sinusitis were found to have evidence of marked acceleration in bone physiology with histologic changes including new bone formation, fibrosis, and presence of inflammatory cells. These findings are compared with osteomyelitis in long bone and the jaw. The suggestion that underlying bone may serve as a catalyst for chronic sinusitis is supported and implications for therapy are discussed.

Endoscopic sinonasal surgery in the management of primary headaches.

Primary headaches (migraine, cluster, tension-type) are common disorders thought to be unrelated to nasal and sinus abnormalities. We present data on 19 patients with refractory primary headaches in the absence of significant sinus symptoms. The majority of patients responded with decreased pain to office application of nasal anaesthesia. A high prevalence of sinonasal abnormalities was found on coronal CT scans. Seventy-nine per cent responded with either decreased pain severity or headache frequency after endoscopic sinonasal surgery. We discuss possible underlying mechanisms to explain these findings.

Computer-assisted resection of benign sinonasal tumors with skull base and orbital extension.

OBJECTIVE: To use freehand, real-time, intraoperative, 3-dimensional computed tomography (3-D CT) localization to assist with resection of sinonasal lesions with skull-base and/or orbital extension. DESIGN: The 3-D CT is computer-assisted technology using the preoperative CT scan as a road map for resection of lesions. Previous technology, while resulting in little intraoperative error, required use of a somewhat cumbersome rigid articulated arm and attached probe, limiting mobility and requiring rigid fixation of the head to maintain system reference. A new freehand version of this technology, eliminating these limitations, has been used for resection of benign sinonasal lesions with skull-base and/or orbital extension. SETTING: Tertiary care, university-based practice. PATIENTS: Seven patients prospectively selected with benign lesions involving the sinonasal cavity and orbit and/or skull base. INTERVENTION: All patients underwent surgical resection of their tumors using endoscopic, open, or combined procedures with the assistance of freehand 3-D CT localization. MAIN OUTCOME ASSESSMENTS: Surgeon assessment of usefulness. RESULTS: In several cases, the device assisted the operator in determining the exact location of a displaced optic nerve, ensuring vision preservation, while in other cases, the location and depth of skull-base penetration was clearly determined, allowing resection via a transnasal endoscopic approach. In addition, the device was useful for determining the depth of necessary resection for optimal cosmetic result. In all cases, system accuracy was within less than 2 mm at the operative site. System limitations included need for an additional preoperative CT and time required at the beginning of the case for system setup and registration. CONCLUSIONS: Freehand 3-D CT, while still with limitations, offers the advantage of increased surgical safety, aiding anatomic understanding in distorted surgical fields for resection of benign sinonasal tumors with orbital and skull-base extension.

Heterotopic brain in the pterygopalatine fossa.

Heterotopic brain outside the cranial vault is uncommon. It occurs most frequently in the nasal region, although rests elsewhere in the aerodigestive tract have been reported. We describe a case of heterotopic brain in the pterygopalatine fossa.

Anesthesia in endoscopic sinus surgery.

Successful administration of anesthesia in endoscopic sinus surgery is of critical importance for patient comfort, to reduce bleeding, and for procedure safety. However, surgeons are often reluctant to perform the procedure under local anesthesia with sedation. Over the past four years, patients undergoing ESS have been asked to complete a questionnaire to evaluate their anesthetic experience. A total of 111 completed questionnaires were returned for evaluation. The questionnaire evaluated subjective level of pain, nausea, vomiting, and overall unpleasantness of surgery on a 100 mm visual analog scale. The results from this survey indicate a high level of patient satisfaction with our current anesthetic techniques, while identifying issues with postoperative nausea and vomiting. The results of the survey and a review of the anesthetic issues involved in successfully performing endoscopic sinus surgery are discussed.

New technology.

Our Academy has proposed this primer, The Ethical Otolaryngologist, to serve as guide to help individual otolaryngologists determine the ethical nature of technologic advancements. Ultimately, each otolaryngologist will decide for himself or herself what he or she believes to be ethical. However, we otolaryngologists should make these decisions while recalling our sworn responsibility to our patients and our responsibility to our chosen profession in otolaryngology. Examples and questions that were presented are intended to assist each of us in making ethical determinations about the care we render to patients. There are many facets to the ethical implications of new technology touched on in this chapter, and they include the following: 1. Categories of new technology and technology assessment studies. 2. Otolaryngologists adopting or developing new technologies. 3. Otolaryngologists teaching and learning new technologies. 4. Supervision of clinical applications of new technologies. In conclusion, nearly all of us who are otolaryngologists have entered this aspect of health care because we enjoy patient contact, the challenges of surgery, the continuing education process, and above all, we are interested in helping our patients prevent and alleviate disease. Our training has encouraged us to put the patient's best interests above all else. This is our utmost ethical responsibility.

Advantages and disadvantages of three-dimensional computed tomography intraoperative localization for functional endoscopic sinus surgery.

Intraoperative three-dimensional computed tomography (3-D-CT) localization has been available for use during functional endoscopic sinus surgery (FESS) for several years, although relatively few otolaryngologists operate in conjunction with this technology. Proponents of intraoperative localization believe that operating with stereotaxis enhances surgical precision and reduces complications. A 1-year review was conducted at the University of Pennsylvania from January 1994 through January 1995. During this period 5% of sinus operations were performed in conjunction with intraoperative localization. The advantages and disadvantages of using intraoperative localization were evaluated for each case. Also examined were type and indication for surgery, anesthesia used, added time, and cost. Overall, intraoperative localization was found to be helpful when anatomy was distorted or obscured. However, selecting patients who may have benefited from localization was often not possible using preoperative data. Ideally, localization should be available for all FESS. Criteria are outlined which will need to be met prior to localization becoming a significant aspect of FESS.