NOTES ON THE NOSE AND SINUSES
| IS MINIMAL DISEASE AN INDICATION FOR SURGERY ? Peter H. Hwang, MD, Associate Professor and Director of
Rhinology, Department of Otolaryngology—Head and Neck Surgery, Stanford University School of Medicine, Palo Alto,
CA
|
| Recurrent acute sinusitis: characterized by—episodic symptoms; negative computed tomography (CT) between episodes
(does not rule out diagnosis of recurrent acute rhinosinusitis); patients can have—significant impairment of quality
of life, comparable to that of patients with more radiologically advanced chronic rhinosinusitis (CRS); Lund-
McKay scores approaching normal; management—treat acute episodes; follow patient for 6 to 12 mo before making
decision about surgery; while monitoring patient, determine duration of episodes and whether antibiotics indicated for
managing perceived exacerbations
|
 | Surgical management: limited data available to justify surgery on basis of recurrent acute disease alone; physicians have
yet to determine—how long medical therapy should be maintained before deciding to operate; threshold number of disease
episodes that must occur annually before considering surgery; necessity of obtaining positive CT image before
surgery; which individuals will benefit from surgery; points—patients can be monitored to assess degree of disability
and severity and frequency of disease episodes; some patients with recurrent acute problem and minimal disease on CT
benefit from surgery
|
| Barosinusitis: occurs in divers, pilots, and flight attendants; may occur in conjunction with severe rhinosinusitis on CT,
although, in some cases, CT negative; recommendation—consider operating on grounded pilot with focal disease, negative
CT, and disease pattern consistent with barosinusitis; in one study, 98% of pilots grounded for barosinusitis returned
to work after functional endoscopic sinus surgery (FESS)
|
| Contact-point headache: controversial concept—developed from belief that nasal abnormalities trigger migraine and
other forms of rhinogenic headache; mucosal contact and CRS not considered bona fide clinical headache categories
by International Headache Society; substance P—chemical mediator; potential headache trigger; released when mucosa
displaced by bone or cartilage; stimulates pain fibers and elicits trigeminal nerve irritation; can also lead to local
dilation of blood vessels, mucosal inflammation, and propagation of contact-point headache; patients—typically
present with self- diagnosis of sinusitis; have had multiple negative CT evaluations; often have history of migraine;
may obtain partial relief from pseudoephedrine (eg, Sudafed) or other decongestants; clue—contact-point headache
may improve after use of topical lidocaine and decongestant
|
| Evaluation of patient with negative CT, lateralization of headache, and fairly focal symptomatology: endoscopic
examination—performed when patient reports change in symptoms after administration of nasal spray; look for specific
anatomic contact point that might explain pain, eg, septal spur, contact between middle turbinate and nasal septum,
narrowed middle meatus; when application of nasal spray to potential trouble spot results in decreased pain, apply
swab soaked with anesthetic to point of contact—if headache further decreases, have patient return for repeat endoscopic
evaluation when symptoms recur; if selective anesthetization of contact point without spray reduces pain, discuss surgical
option with patient
|
| Surgery: proceed with caution; selected patients in whom specific point consistently responds to anesthesia benefit from
surgery; all patients with negative CT and “softer” indications should—be followed over time to establish diagnosis; receive
medical therapy first, eg, topical nasal steroids to control allergy; have diagnosis established before considering
surgery; generalized headache with generalized complaints of sinusitis not valid indication for surgery
|
| CT-negative chronic sinusitis: controversial area; patients—provide long list of disabilities; describe symptoms
characteristic of chronic sinusitis; have had therapy lasting >12 wk; also have negative findings on endoscopy; points—
technically, patients with negative CT and endoscopy do not have chronic sinusitis (according to Sinus and Allergy
Health Partnership criteria, definitive diagnosis of chronic sinusitis depends on evidence provided by CT and/or endoscopy);
Lund-McKay score of 2 considered characteristic of CT-negative disease; no good parameters for gauging negative
vs positive CT; data—suggest disease severity as determined by CT may not be important factor for selecting
surgical candidates; show no correlation between symptom severity and CT stage; endoscopy—worthwhile when CT
negative; can detect factors that may change patient from nonsurgical to surgical candidate; conclusions—accurate diagnosis
essential; little support for routinely performing FESS on patients with CT-negative disease; additional CT imaging
helpful as patient’s situation changes; endoscopic findings can contribute to accurate diagnosis
|
| Surgery for minimal disease: rarely indicated; documentation necessary to establish that all therapeutic alternatives
exhausted before surgery performed
|
| FUNCTIONAL ENDOSCOPIC SINUS SURGERY IN THE MANAGEMENT OF PEDIATRIC SINUSITIS —Sanjay R.
Parikh, MD, Assistant Professor of Otorhinolaryngology—Head and Neck Surgery, Albert Einstein College of Medicine
of Yeshiva University, and Chief, Division of Pediatric Otolaryngology, Children’s Hospital at Montefiore, Bronx, NY
|
| Evaluation of CRS: CT imaging standard in children; allergy testing—some centers test all children with CRS; speaker
generally limits testing to patients presenting with physical findings of rhinosinusitis, ie, inflamed turbinates, congestion
in middle meatus, and chronic rhinorrhea; assessment of immunoglobulins—usually obtained on teenager or young child
with CRS and recurrent pneumonia or otitis media; evaluation for cystic fibrosis—sweat chloride and genetic testing; mucociliary
studies—evaluate ciliary motion on wet mount; if motion unusual, perform electron microscopic studies; endoscopic
examination—options include pediatric flexible nasopharyngoscope and small rigid otoscope; look for adenoid
hypertrophy, septal deviation, polyposis, neoplasia, and foreign bodies; grading of hypertrophied adenoid—grade I does
not touch adjacent structures; grade II touches eustachian tube; grade III touches vomer; grade IV touches soft palate
|
| Pediatric FESS: last resort; can place patient at risk for synechiae and becoming “sinus cripple”; indications—chronic
disease (adenoidectomy and tonsillectomy not recommended at time of FESS; staged procedures under evaluation); acute
complications (bony expansion and abnormal changes on imaging; aggressive mucocele pulling into middle meatus);
failure of maximal medical therapy
|
| Medical therapy for CRS: culture-directed antibiotic therapy good option for all children; oral or intravenous (IV)
antibiotics—one approach advocates child with recurrent sinusitis or CRS undergo maximum IV antibiotic therapy in
hospital for 3 to 4 wk or long-term IV therapy at home; speaker prefers administering oral systemic antibiotics (if therapy
fails, consider surgery); other options—decongestants (oxymetazoline safe topical drug to use short term for acute rhinosinusitis);
antihistamines (H2 or H1 blockers); vasoconstrictors; steroids; allergy treatment
|
| Functional endoscopic sinus surgery: animal model raised concerns about facial growth; subsequent data from humans
suggest FESS does not adversely affect facial growth; navigation systems—can be applied in pediatric surgery;
safety and reliable accuracy not demonstrated in children (eg, surgeons uncertain whether 1.5- to 2.0-mm region of accuracy
used in adults can be considered safe in smaller pediatric sinuses); classified as—electromagnetic (fiducial registration
renders headsets unnecessary); infrared systems (upgraded for quick registration); indications for performing image-
guided surgery (designed for adults but generally considered applicable in children): revision surgery; extensive nasal polyposis;
pathology in frontal, posterior ethmoid, and sphenoid sinuses; disease invading skull base; cerebrospinal fluid
(CSF) rhinorrhea; benign or malignant sinonasal neoplasm; factors that can distort pediatric anatomy and are considered indications
for surgery—craniofacial anomalies; cystic fibrosis; mucoceles; allergic fungal sinusitis; neoplasms; periorbital
abscesses; technical pointer— surgeon’s comfort level for operating on children and using surgical navigation systems
remains key consideration when selecting management approach
|
| Periorbital abscesses: child presenting with obvious edema in cornea of eye determined to have raised subperiosteal
abscess in ethmoid that pushed orbit laterally and air in orbit; IV antibiotic therapy—typically administered over 48 hr;
provides safe interval for determining whether antibiotics will prove effective; steroids—role not clearly defined; routine
use avoided by speaker; steroid therapy may mask findings that help determine whether to perform surgery;
ethmoidectomy—may be more important to successful management than actual decompression of orbit (release of pus
from subperiosteal space) because once ethmoidectomy performed, freely communicating channel present between subperiosteal
space, lamina papyracea, and into ethmoid, and decompression of orbit requires minimal work; caveat—once
work done in cavity, navigation system may not provide accurate information because anatomy altered
|
| Child with small subperiosteal abscess: to locate roof of maxillary sinus, create wide maxillary sinus ostium; before creating
opening into lamina papyracea, locate L between lamina papyracea and floor of orbit; to reduce risk for blindness,
avoid—administering oxymetazoline once lamina papyracea opened; suction cautery
|
| Navigation assistance: helpful where frontal sinus growth may be variable (provides opportunity to use small incision) or
anatomy distorted; provides good adjunct for managing neoplasms; has opened new frontiers in endonasal surgery; not
used to operate on patients with disease limited to ethmoid and maxillary sinuses; experience shows navigation appropriate
for performing—more extensive surgery beyond ethmoid and maxillary sinuses; surgery involving skull base, posterior
nasal cavity, sphenoids, or frontal sinus
|
| Postoperative management: second-look under anesthesia and debridement do not seem to alter outcome
|
| AN OVERVIEW OF FUNCTIONAL RHINOPLASTY —Minas Constantinides, MD, Assistant Professor of Otolaryngology,
New York University School of Medicine, New York, NY
|
| Internal nasal valve: located ≈2 cm from anterior nasal airway (site of greatest increase in nasal resistance; adenoids
and spurs located posterior to valve do not affect resistance); functions as Starling resistor (ie, designed to collapse; failure
of valve to collapse can lead to overdrying or ozena); pathology—often seen without speculum; inverted-V deformity
telltale sign of possible internal valve problem after cosmetic rhinoplasty (sometimes seen without rhinoplasty); objective
evaluation of airway—techniques often cumbersome; posterior rhinomanometry (gold standard for evaluating nasal resistance
in dynamic fashion; requires laboratory and difficult-to-calibrate equipment); acoustic rhinometry (typically
static measurement; dynamic approach under development; provides graph of airway)
|
| External nasal valve: located along ala; affected by—structural weakness along ala, alar cartilage, and in piriform aperture;
caudal septal deflections; points—dip in alar concha should arouse suspicion of structural weakness requiring reinforcement;
in some cases, internal and external valve problems must be addressed
|
| Patient evaluation: all patients require anterior rhinoscopy
|
| Breathing assessment: first test that should be performed; requires patient to rate quality of breathing function on scale of
0 to 10; have patient rate breathing function—overall, then on each side of nose independently; at level of internal and
external nasal valves while physician uses curette to support upper lateral cartilage; caveat—avoid operating on patients
who cannot evaluate breathing; accurate postoperative assessment impossible without accurate preoperative
data; turbinates—contribute to nasal obstruction; to assess role of turbinates, have patient rate breathing function on 0
to 10 scale before and after administration of decongestant; physician must determine whether problem caused by—structural
weakness that has caused upper lateral cartilage to prolapse into airway or by septal deviation
|
| Septoplasty with straight caudal septum and dorsal septum (deflection elsewhere): small bridge of septal
support along maxillary crest and anterior nasal spine—result of textbook excision; leaves poor support between perpendicular
plate of ethmoid and quadrangular cartilage; repair—minimize excision of cartilage and bone; to reduce risk for
failure, remove lower portion of perpendicular plate of ethmoid and vomer; preserve upper portion of perpendicular
plate; leave substantial portion of septal cartilage attached to maxillary crest and perpendicular plate of ethmoid (strong
inferior support critical to success; buttresses septum and preserves shape of nose)
|
| Septoplasty for caudal septal deviations: difficult; open approach for managing patient with impaired breathing on
one side of nose and aesthetic concerns—provides excellent septal and bony support along floor of nose (critical for
straighter septum); requires surgeon preserve caudal and inferior margins of septum, free septum from cartilage and
bone, and form pocket of mucosal tissue on affected side; to correct deviation, swing freed portion of septum over nasal
spine and into pocket of mucosal flap; scoring cartilage—multiple scores made in 3 directions will improve crooked cartilage
unit; avoid full thickness cuts through incision; caudal extension graft—used to repair multiply fractured, severely
deviated septum with weakened caudal segment; requires transfer of cartilage from back to front of septum; doubles as
caudal strut graft in patients with rhinoplasty and provides postoperative support of nasal tip
|
| Septoplasty for dorsally deviated septum: technically demanding; open approach allows surgeon to take upper lateral
cartilages off dorsal septum in predictable fashion; spreader grafts—improve appearance of nose; prevent inverted-V
deformity; reduce nasal resistance; work by stiffening internal nasal valve without markedly increasing internal nasal
valve area; applied using open or closed technique; widen middle third of nose (desirable outcome); severe dorsal
deviations—may require full septal reconstruction; spreader grafts used to reinforce and stabilize middle third of nose
|
| Additional tips and techniques: grafts—rib cartilage grafts (used to repair saddle deformities, severe trauma, and
perforated noses with collapsed dorsal segment; may warp); batten grafts (reinforce weak areas; provide excellent support
of airway; thinned and tapered as required; do not have to reach piriform aperture); alar strut grafts (placed beneath
alar cartilage; repair inward buckling of lower lateral cartilage caused by improper placement of dome sutures during rhinoplasty);
thick septal adhesions—potassium titanyl phosphate (KTP) laser most effective means of managing adhesions;
using silastic splints for 1 to 2 wk after surgery prevents readhesion; cartilage overlap procedure—provides double layer
of reinforced cartilage to withstand inspiratory force; used to repair marked knuckling and prolapse of cartilage into airway
after rhinoplasty; associated with loss of projection; osteotomies—can cause nasal obstruction; to avoid fractures of
lateral piriform aperture and narrowing of inferior turbinate complex, stay above inferior turbinate
|
Suggested Reading
Chung BJ et al: Endoscopic septoplasty: revisitation of the technique, indications, and outcomes. Am J Rhinol 21:307,
2007; Constantinides M et al: Quantitative analysis of lateral osteotomies in rhinoplasty. Arch Facial Plast Surg 8:369,
2006; Fischer H, Gubisch W: Nasal valves-importance and surgical procedures. Facial Plast Surg 22:266, 2006; Gheriani
H et al: Endoscopic sinus surgery outcome in patients with symptomatic chronic rhinosinusitis and minimal
changes on computerized tomography. Ir Med J 99:15, 2006; Gross ND et al: Outpatient intravenous antibiotics for
chronic rhinosinusitis. Laryngoscope 112:1758, 2002; Hwang PH: Surgical rhinology: recent advances and future directions.
Otolaryngol Clin North Am 37:489, 2004; Orlandi RR Hwang PH: Perioperative care for advanced rhinology
procedures. Otolaryngol Clin North Am 39:463, 2006; Perikh SR, Fried MP: Navigational systems for sinus surgery:
new developments. J Otolaryngol 31:S24, 2002; Rettinger G, Kirsche H: Complications in septoplasty. Facial Plast
Surg 22:289, 2006.
Educational Objectives
| The goal of this program is to improve the surgical management of common disorders of the nose and sinuses. After
hearing and assimilating this program, the clinician will be better able to:
|
| 1. Define the role of surgery in the management of minimal nose and sinus disease.
|
| 2. Explore options for evaluating and managing contact-point headache and computed tomography (CT)-negative
chronic sinusitis.
|
| 3. Determine the role of functional endoscopic sinus surgery (FESS) in the management of pediatric rhinosinusitis.
|
| 4. Discuss the relative benefits and limitations of navigation-assisted FESS in pediatric patients.
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| 5. Describe various techniques used to perform septoplasty.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning comittee members to
disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the following has been disclosed: Dr. Parikh is affiliated with Alcon and Gyrus ENT. Drs. Hwang
and Constantinides and the planning committee reported nothing to dislose.
Acknowledgements
Dr. Hwang gave his scientific lecture at Ultimate Colorado Mid-Winter Meeting: An Otolaryngology Update and the Colorado
Otology-Audiology Conference, presented January 28 to February 1, 2007, in Vail, CO, by the University of Colorado School of
Medicine; Drs. Constantinides and Parikh gave their lectures at the Otolaryngology Annual Clinic Day presented December 6,
2006, in Uniondale, NY, by the Nassau Surgical Society. The Audio-Digest Foundation thanks the speakers and the sponsors for
their cooperation in the production of this program.
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