Presentation on theme: "Concepts of Endoscopic Sinus Surgery: Causes of Failure"— Presentation transcript:
1Concepts of Endoscopic Sinus Surgery: Causes of Failure Cummings Chp. 52Wed 1/9/13Irene A. Kim
2Key Points Long-term success rate of FESS + medical therapy: 80-90%. Anatomic variants no longer considered underlying etiology of diseaseFESS GOAL:Surgically remove inflamed tissue from critical points in mucociliary clearance pathwaysConcept of FESS: surgically remove inflamed tissue and bone from critical points in the mucociliary pathwaySome papers state success rates as high as 98%.-Anatomic variations should be regarded only as potential predisposing or potentiating factors in CRS, not as underlying etiology of dz (overemphasis of importance of role of OMC in CRS led to inappropriate overemphasis on surgically correcting abnormalities in OMC)-Successful practitioner of FESS is probably somewhat radical in removing all bony partitions in areas of the ethmoid cavity involved in the disease process but is also able to perserve a mucosa-lined cavity on the skull base, medial orbital wall, and middle turbinate.When surgical failure occurs, likely due to:Postoperative scarring orUnaddresed outflow tract obstruction in region of frontal recess
3ABSOLUTE Indications for Sinus Surgery 1. Rhinosinusitis complications2. Expansile mucoceles3. Allergic/Invasive fungal rhinosinusitis4. Suspected neoplasia
4Mucoceles Frontal sinus mucoceles Skull base identified in posterior ethmoidFollow anteriorly until bone of lesion foundRemove inferior portionRemove all osteitic bone from region of obstructionBony margins flush should beflush with surrounding wallIn postop period, mucosa lining the mucocele cavity may undergo significant hypertrophy, and secretions may reaccumulate, requiring suctioning from time to time. But, mucociliary clearance becomes re-established, typically in a few wks, and the mucosal hypertrophy resolves over time.
5Fungal Sinusitis Invasive Noninvasive Chronic invasive fungal rhinosinusitisFulminant invasive diseaseNoninvasiveFungal ballsAllergic fungal rhinosinusitisAllergic fungal rhinosinusitis may be associated with marked bone remodeling that might distort anatomic relations dramatically.Sphenoid/Post ethmoid involvementDural exposureErosion of boneDisplacement of carotid a, optic nerveGOAL of: CHRONIC INVASIVE FUNGAL RHINOSINUSITIS SURGERY-”conservative radical” open approach and a full course of antifungal therapy should include all involved soft tissue and bone that can be safely removed, but care should be taken to avoid resecting or violating the dura and orbital periosteum, b/c both are relatively good barriers to the fungusGOAL of: FULMINANT:-wide resection of invaded tissue, typically via an open approach, IV antifungal agents, reversal of underlying agent of immunocompromiseSurgical goal: remove inspissated material, polypoid mucosaRemove intersinus partitionsMaintain mucoperiosteal coverage of bone w/in cavity
6Indications for Tumors, Skull Base Defects, Other Noninflammatory Lesions Benign tumorsInverted papillomaJuvenile angiofibromaSkull base defectsOrbital problemsEncephaloceles, meningocelesClosure of CSF rhinorrheaMalignant tumorsLesions w//in distal or lateral frontal sinus or defects in supraorbital ethmoid sinus are best addressed through an external approach
7Relative Indications for Sinus Surgery Symptomatic nasal polypsUnresponsive to medical therapySymptomatic chronic or recurrent acute rhinosinusitis***Medical therapy is cornerstone of mgmt of inflammatory disease
8Poor Indicators of Successful FESS Persistent environmental exposuresUncontrolled allergiesContinued chemical exposuresSmokingIncreased granulation tissueIncreased incidence of frontal recess stenosis*Smoking is relative CI to elective ESS b/c there is a significantly greater than usual amt of granulation tissue that develops over any areas of exposed bone AND the incidence of frontal recess stenosis higher-Smoking was the major significant factor in need for revision surgery and a significantly greater factor than prior surgical procedures, allergies, and asthma in determining the need for revision surgery
9Extent of Surgery Mucosal preservation is *key* (ethmoid) Resection of inflamed bone importantRemoval of osteitic partitionsUncinate processEthmoid sinusesAvoid leaving exposed bone behindDenuding of bone results in extremely delayed healing (bone can remain exposed for 6+ months, and ciliary density may never return to normal)Underlying bone of area stripped of mucosa is prone to long-term inflammationUnderlying bone may play significant part in overall chronic disease processMucosal preservation in all sinus should be ephasized, esp within ethmoid sinus (because it has central position in paranasal sinuses)Resection of inflamed bone important because reduced viability and inflammation of the underlying bone may be a significant factor in the dz process-Removal of osteitic partitions esp important in uncinate process and partitions of ethmoid sinuses partitions may potentiate persistence of dz; they tend to thicken up in the presence of persistent and ongoing inflammation, making them less easy to remove-MIST (minimally invasive surgical therapy) recommended only for children and in adults for which early and mild dz might be better treated by aggressive medical therapy- CURRENT recommended approach in adults: more complete removal of underlying partitions in area where mucosa involved w/ dz; preservation of both normal mucosa and mucoperiosteal layer over any remaining bone
10Pre-op Evaluation & Management Know amount and duration of:Antibiotic therapyAnti-inflammatory treatmentsTreat severe polyposis, hyperreactive mucosaOral steroids (Prednisone 20-30mg x 3-10 days)Give oral steroids to reduce mucosal bleeding, also stabilizes lower airway in pts with asthmaa, decreasing chance of intraop or postop bronchospasm
11ImagingCT key, but MRI needed when CT shows disease adjacent to skull base erosionEvaluate lateral cribiform plate lamellaEvaluate vertical height of post ethmoidEvaluate sphenoid sinus in axial/coronal planesEvaluate frontal recess in triplanar viewsEvaluate lateral cribiform plate lamella this medial part of the ethmoid roof is the thinnest part of the skull base and exposed to potential trauma during frontal recess surgery.Skull base is generally more thick laterally than mediallyVertical height determines working room available w/in post ethmoid for access to sphenoid sinus; failure to recognize narrow vertical height may result in inadvertent intracranial entrySphenoid sinus- axial plane shows relation of intersinus septum to carotid arteries and relative sizes of sphenoid sinusCoronal view: demonstrates relation of optic ccanal w/ sinusFrontal recess: good to see in these three views (axial/coronal/sagittal) to understand AP diameter of frontal sinus + relationship to adjacent agger nasi and supraorbital ethmoid cells
12Concepts of Antrostomy Maxillary sinus opening should communicate with natural ostium to PREVENT surgical failureLong term causes of failureOstenoneogenesis from stripped mucosaRetained foreign bodyMucous draining into sinus from persistent frontal recess inflammationIdeal: Protect maxillary sinus ostium, maxillary sinus mucosa from airflowAnother reason to keep surgically created ostium small: nitric oxide is liberated from sinus mucosa at levels that may reach bacteriostatic concentrationsIf natural ostium reopens and a noncontinguous middle meatal antrostomy is present, recirculation of mucous occurs, w/ mucus re-entering the maxillary sinus through the iatrogenic ostium
13Ethmoidectomy Work from “known” to “unknown” Medial orbital wall is first critical landmarkGoal: Marsupialized cavity lined by healthy, intact mucosaSkull base is second critical landmarkCommon results of failed ethmoidectomy:Lateralized middle turbinateRetained uncinate processFailure of removal of uncinate superiorlyResidual agger nasi cellsEthmoidectomy is defined as the excision of the cells of the ethmoid sinus or ethmoid bone. This procedure was originally described using an external approach through the skin between the external nose and the medial canthus (opening to the tear duct). This evolved into an intranasal (through the nose) procedure using either a headlight, operating microscope or an optical endoscope. A third approach is to enter the ethmoid sinus through the maxillary sinus. No matter the approach, the ethmoid sinus is the key or essential element in the surgical treatment of sinusitis. The ethmoid sinus is important because all of the other sinuses drain either through or adjacent to this sinus. Disease within or extending beyond the ethmoid, can obstruct the ability of air to enter the affected sinus and for mucous to drain.Failure to identify medial orbital wall early can lead to dissection in medial part of ethmoid cavity, where skull base is thin and downslopingEthmoid sinus is in close proximity to other three paranasal sinuses, and often FESS includes a complete ethmoidectomy to allow access to each diseased sinusCummings advocates dissection low in anterior-posterior direction, across basal lamella to the sphenoid face, and then identification of skull base in the posterior ethmoid or sphenoid sinus, followed by completion of dissection from posterior to anterior.
14Sphenoidotomy Re-review scans: coronal and axial planes Review course of optic n., carotid a.Endoscopic transnasal approachTransethmoid/transmaxillary approachTransseptal approachIllustration of sagittal (midline) section through right sphenoid sinus. This drawing emphasizes the important neurologic and vascular structures which border the outer wall of the sphenoid sinus. As infectious or neoplastic disease progresses within the sphenoid sinus, patients can develop symptoms referable to any of illustrated nerves or vessels. For example, tumors or infection encroaching upon the maxillary nerve would give rise to mid-face pain. Disease involving the optic nerve would initially present with partial loss of temporal vision (peripheral or lateral vision) and progress to total blindness (modified from Rice DH, Schaefer SD. Endoscopic Paranasal Sinus Surgery, 3rd Ed. Lippincott; PhiladelphiaMRI of patient with acute left sphenoid sinusitis refractive to antibiotic therapy. This patient complained of intense mid face and vertex pain. As is seen in this patient, the sphenoid sinus may extend beyond the body of the sphenoid bone to pneumatize or involve the adjacent regions. In this case, a lateral recess has been formed within the greater wing of the sphenoid sinus. This image illustrates the close proximity of important brain, eye and blood vessels to the sphenoid sinus.Sphenoidotomy is defined as creating an opening into the anterior, or front, wall of the sphenoid sinus. The sphenoid sinus is bordered above by the brain and pituitary gland and laterally, or on its sides, by the optic nerves and the major blood to the anterior brain. Therefore, all surgical approaches to this sinus have evolved from various procedures that are performed through the nose or involve the nasal cavity. The most common approach today is through the nasal cavity, using an optical telescope for visualization of the posterior nose and the sphenoid sinus. This same approach can be performed utilizing an operating microscope or headlight. A second approach is through the nasal septum which directs the surgeon to the midline of the sphenoid sinuses. This transeptal approach is frequently used to visualize and remove tumors of the pituitary gland. The third form of sphenoidotomy is to approach the sphenoid sinus through the maxillary and ethmoid sinuses. This transantral-ethmoidectomy procedure required partial removal of the anterior wall of the maxillary sinus to visualize the ethmoid and sphenoid sinuses. Irrespective of the approach, sphenoidotomy is potentially problematic given the close proximity of this sinus to the eye and central nervous system. No matter the approach, the ethmoid sinus is the key or essential element in the surgical treatment of sinusitis.
15Sphenoid Anatomy: Key Structures Carotid arteryOptic nerveCavernous sinus3rd, 4th, 5th CNThis drawing emphasizes the important neurologic and vascular structures which border the outer wall of the sphenoid sinus. As infectious or neoplastic disease progresses within the sphenoid sinus, patients can develop symptoms referable to any of illustrated nerves or vessels. tumors or infection encroaching upon the maxillary nerve would give rise to mid-face pain.Disease involving the optic nerve would initially present with partial loss of temporal vision (peripheral or lateral vision) and progress to total blindnessComplication Associated Structure(s) Vascular hemorrhage Posterior ethmoidal artery, internal carotid artery, cavernous sinus, sphenopalatine arteryHematoma RetrobulbarIntracerebral injury Cerebrospinal fluid leak, meningitis, cerebritis, abscess, brain injury, pituitary traumaFistula Cavernous sinus: carotid arteryCranial nerve (CN) injury Optic nerve: blindness, pupillary defects Oculomotor nerve (CN III): diplopia, pupillary defects Trochlear nerve (CN IV): diplopia, pupillary defects Abducens nerve (CN VI): diplopia, pupillary defects Trigeminal nerve (CN V1 to Vx): facial numbness*** MOST COMMON LOCAL CAUSES OF FAILURE leading to persistent sphenoid disease: missed or inadequate entry and stenosis (latter b/c of inadequate sinusotomy or b/c of limited postoperative care and scarring of lateral sup turbinate)Sphenoid is surrounded by several critical structures ICA, optic nerve, skull base.Septations in sphenoid frequently have attachments to the ICA.
16Frontal Sinusotomy Most challenging Potential for persistent, recurrent diseaseMost difficult decision: to explore or notReview coronal, axial, sagittal viewsReview AP/lateral diametersExamine pneumatization of sinusFrontal recess dissectionPay attention to extent of pneumatization of frontal sinus b/c hypoplastic frontal sinus likely leads to frontal recess stenosis more than sinus that is well pneumatizedIn Cummings clinical experience:Most common immediate cause of frontal sinus dz: presence of infundibular dz displacing the uncinate process medially, thereby obstructing a frontal sinusThe medially displaced uncinate process can undergo fusion to the middle turbinate#2MCC: mucosal disease and expansion of an agger nasi cell, with resultant posterior displacement of the frontal sinus ostiumConcept of FESS w/ respect to frontal sinus: work in stepwise progression to remove all bony septae from cells present frontal recess dissectionMucosal preservationi s critically importantFrontal cells originate as anterior ethmoid cells that pneumatize into the frontal recess, creating potential for compromise of frontal sinus outflow tract serves as as signficant potential cause of persistent disease.These are the second mostReview in sagittal images to identify and measure the frontal recess. It is critical in assessment of obstructing anterior ethmoid cells.
17Turbinate Management Remove exposed bone (MT) Stabilize floppy MT Controlled scar to nasal septumPostoperatively, can lyse adhesionsSuture turbinate to septum
18Postop Medical Management Long-term topical steroid spraysSaline sprayNasal saline irrigationDebridementLoss of olfaction: sensitive sign of return of diseaseSteroid sprays: Minimized postop edema, reduce need for oral steroid use, decrease potential for late recurrenceDebridement starts postop day 1, performed weekly until entire cavity is healedAny persistent exposed bone is removed, crusts are cleaned, and any pools of blood clots or mucus are suctioned from the cavity
19Management of the Frontal Sinuses Cummings Chp. 53Wed 1/9/13Irene A. Kim
20Key PointsFrontal sinus drains into middle meatus through frontal recessFrontal recess located at junction of frontal sinus and is most anterosuperior part of ethmoid sinusPreserve mucosa around frontal recessFrontal sinus drains into the middle meatus through the frontal recess.Frontal recess is located at junction of the frontal sinus and is the most anterosuperior part of ethmoid sinus.
21Acute Frontal Sinusitis SymptomsLow-grade feverMalaiseFrontal headacheTenderness of medial aspect of infraorbital marginCommon organismsS.pneumo, H. flu, anaerobic strep, Bacteroides, S. aurus, S. epidermidis, S. milleri
22Treatment Approaches Topical decongestant high in middle meatus Trephine the frontal recess by:Incision in medial aspect of eyebrowOpen frontal sinus endoscopically by removing ethmoid air cells surrounding recessTopical decongestant via endoscopy high in middle meatus sometimes allows spontaneous drainage through frontal recess
23Complications of Surgery Damage to mucosaAdhesionsStenosisPeriorbital cellulitisPeriorbital abscess, subdural empyema, meningitis, cavernous, sup sagittal sinus thrombosis*Obtain URGENT CT if:CNS involvement seenVisual problemsSpiking pyrexia not resolving in 36 hours
24Surgery in Chronic Frontal Sinusitis Disease likely started by unnecessary instrumentation of frontal recessPRIMARY indication for instrumentation:When maximal medical treatment partial anterior ethmoidectomy have failedPrimary fungal diseaseBarotraumaMucoceleOsteomaOsteomyelitisTumorsThe normal frontal recess is NARROWThe frequency of frontal recess variations or anatomic restrictions appears no higher in a control population that in a patient with proven rhinosinusitisLIKELY that the primary problem is mucosal pathology or patient’s immunity.
25Causes of Frontal Sinus Surgery Failure Remnant frontal recess cellsRetained uncinate processMiddle turbinate lateralizationOsteoneogenesisScarring or inflammatory mucosal thickeningRecurrent polyposis
26Endoscopic Frontal Sinusotomy Boundaries of frontal recessAnteriorAgger nasiLateralLamina papyraceaMedialMost ant/superior portion of middle turbPosteriorEthmoid bulla, bulla lamellaFrontal sinus drains into the middle meatus through the frontal recess.Frontal recess is located at junction of the frontal sinus and is the most anterosuperior part of ethmoid sinus.One method of accessing the frontal recess: removing the superior remnant of uncinate process
27Frontal Recess Cells Type I: Single cell superior to agger nasi cell Type II: Tier of two or more cells above the agger nasi cellType III: Single cell extending from the agger cell into the frontal sinusType IV: Isolated cell within the frontal sinusFrontal cells originate as anterior ethmoid cells that pneumatize into the frontal recess, creating potential for compromise of frontal sinus outflow tract serves as as signficant potential cause of persistent disease.These are the second most anterior of the ethmoid cells, and so the origins of them are located posterior to the agger nasi cell.Agger nasi cells are anterior ethmoid cells.Each frontal cell then pneumatizes superior to the agger nasi cell into the frontal recess and up into the frontal sinus, where it can cause frontal recess obstructionCoronal CT scan showing frontal sinusitis (1) secondary to frontal cells blocking the sinus from draining into the nose. Although the left frontal sinus is nearly completely filled with mucous, the patient primarily complained of right frontal pain. This reflects the intermittent aeration (2) of the right sinus and its inability to equilibrate to changes in atmospheric pressure. The patient was most symptomatic during descending in an airplane. In contrast, the left frontal sinus was only symptomatic when the mucous within the sinus was infected.***For surgeon performing ESS, the relationship of the cell to the opening of the frontal sinus outflow tract is more important than the extent of the cell within the frontal sinus27
28Frontal Recess Cells Bulla frontalis High anterior ethmoid cell that has pneumatized into frontal boneCan displace frontal recess posteriorly and mediallySupraorbital cellPosterior cell in ant ethmoid complex that is well pneumatizedCan extend laterally into frontal bone over orbitCan also narrow frontal recess by pushing forward*Prevalance of these variations does NOT appear to correlate with presence or absence of frontal sinus diseaseThe normal frontal recess is NARROWThe frequency of frontal recess variations or anatomic restrictions appears no higher in a control population that in a patient with proven rhinosinusitisLIKELY that the primary problem is mucosal pathology or patient’s immunity.???Frontal cells originate as anterior ethmoid cells that pneumatize into the frontal recess, creating potential for compromise of frontal sinus outflow tract serves as as signficant potential cause of persistent disease.These are the second mostReview in sagittal images to identify and measure the frontal recess. It is critical in assessment of obstructing anterior ethmoid cells.
29Opening the Frontal Recess Goal:1. Deflating the cells of ethmoid air cells2. Preserve mucosa around recessMedian frontal sinus drainage procedureObliteration of frontal sinuses
30Median Frontal Sinus Drainage Procedure Frontal recesses opened by removing:top of septumFrontal interspinus septumAnterior beak of frontal bone
31Frontal Sinus Obliteration Coronal flap or eyebrow incisionMake outline of frontal sinus with template, image guidance, or endoscopicallyRemove anterior plateRemove all mucosa of frontal sinuses before obliterationFrontal recess separated from nasal airway with sheet of fascia lataUse fat to obliterate sinusesRemove the mucosa to avoid formation of mucocele
32Indications for External Approach Situations where removal of pathology and/or drainage is difficult to achieve endoscopicallyLateral loculation, lateral mucoceleFibrosis or new bone around frontal recessPaget’s disease of frontal bone, osteomyelitis, SCCaGross prolapse of orbital contents
33Riedel’s ProcedureImportant role in mgmt of patients with recurrent infectionsRemoves ant wall and floor of frontal sinus and all its mucosal liningHelp eradicate frontal sinus disease whenDrainage and obliteration have failed andThere is persistent disease involving the ant wall of the frontal sinus or the sinus itselfMain complaint: postoperative disfigurementReidel’s procedure has a useful role in the management of a small proportion of patients in whom drainage of the frontal sinus cannot be established, in whomem frontal sinus obliteration has failed, or who have osteomyelitis of the anterior wall of the frontal sinus
34Cranialization of Frontal Sinuses Performed for:Requirement for posterior wall removalAnterior skull base tumorsSevere communication of posterior wall with frontal sinusAnt intracranial contents separated from paransal sinuses and nasal airway by:Fascia lataPericranial flap
35Specific Pathologic Conditions Pneumosinus DilatansRare, benign expansion of an aerated sinus beyond normal margin of frontal boneHypersinus: enlarged sinus with normal wallsMucocelesEpithelium-lined sac containing inspissated mucousOsteomaOnly complaints are cosmeticVery common, 3% of people have themHypersinus: this does not extend beyond the normal boundaries of the frontal bonePneumocele: unlike pnuemosinus dilatans has walls with either generalized or focal thinning and total or partial loss of its integrity within the contours of the frontal boneMucoceles: obstruction of the sinus ostium has been suggeted as primary etiologic factorRx: endoscopic marsupialization
36Fractures of Frontal Sinus Ant wall fractures do not require exploration UNLESS:It affects the frontonasal ductPOSTERIOR wall fracturesNondisplaced and w/o complications: manage conservativelyCompound comminuted fracture affecting posterior wall or near frontonasal duct:Cranialization of frontal sinusCranialization of frontal sinus by removal of the posterior wall along with all the mucosa and obliteration of the frontonasal recess is best treatment.Split calvarial and corticocancellous grafts are best for reconstructing the anterior wall if there is a large defect.