ENDOSCOPIC SINUS SURGERY: REASONS FOR FAILURE HOWARD L. LEVINE, MD
Although success rates for treating sinus disease with endoscopic sinus surgery are generally high, some procedures fail and require additional management. Failure is best managed by trying to determine the cause. It should first be determined whether the sinus problem was caused by polyposis, infection, or both; the possible reasons for failure should then be considered. The possible reasons for failure in the patient with polyposis include inadequate removal, postoperative infection, or systemic disease. The possible reasons for failure in the patient with chronic infection include retained infection, adhesions, ostial obstruction, ciliary dysfunction, an unusual infectious agent, chronic rhinitis, deviated septum, systemic disease, or environmental causes such as work or life-style.
Endoscopic sinus surgery has become a common surgical method for managing sinus disease. Although success rates generally continue to be high, some surgical procedures fail and there must be additional management. 1-7 When seeing a patient who has had unsuccessful endoscopic surgery, the rhinologist should begin to think of w h y failure occurred. Determining the cause of failure will often indicate the correct approach to achieve Success.
Most patients have undergone endoscopic sinus surgery because of either nasal/sinus polyposis or infection. It is frequently helpful to think about problems which may have occurred in each of these areas.
THE POLYPOSIS PATIENT One reason for surgical failure in the patient with polyposis is too much or too little removal of tissue. It may be difficult for the physician to decide at the time of surgery what tissue is normal and what tissue is polypoid. There is a growing tendency to try to retain as much normal ciliated mucosa as possible in an attempt to preserve and restore sinus function (personal observation). In attempting to do this, some diseased tissue may be left in place. It is also possible that normal tissue may become edematous and subsequently polypoid. Removing too much normal tissue creates scarring, stasis of secretions, and chronic sinusitis. With greater surgical experience, there should be better judgment as to how much and which tissue to remove. Through-cutting instruments permit accurate removal of tissue, delicately, rather than tearing (Fig 1). This provides a greater chance for preservation of normal tissue. Although polyps can generally be removed from all of the nasal cavity and sinuses, there are times when it is difficult to access the sinus. This may occur because of a From The Mt. Sinai Nasal Sinus Center and the Cleveland Ear, Nose, Throat, and Facial Surgery Group. Address reprint requests to Howard L. Levine, MD, The Mt. Sinai Center for Ear, Nose, Throat and Facial Surgery, 26900 Cedar Road, Suite 22N, Cleveland, OH 44122. Copyright 9 1995 by W.B. Saunders Company 1043-1810/95/0603-0013505.00/0
176
paradoxical turbinate preventing entry into the ostiomeatal complex (Fig 2). Access into the frontal recess and frontal sinus is always a challenge, but more rhinologists are developing the skills to do this. Many surgeons employ C-arm fluoroscopy to identify the frontal sinus, frontal sinus instrumentation and drills to open the frontal recess. Even with this skill and instrumentation, there are those frontal sinuses whose anteroposterior dimension is small or superior height is small, making entry difficult. Some patients have a well pneumatized frontal sinus and although these are relatively easy to open, it may be difficult to reach and remove polyps from the lateral, superior, or posterior extent. Angled endoscopes (30~, 70~, 120 ~) are helpful in identifying disease and are combined with "giraffe" type and flexible forceps to permit thorough removal of disease. Some patients will have recurrence of their polyposis in spite of the best of operations, because of systemic disease. The patient with asthma, aspirin sensitivity, and nasal polyps is one of the most difficult to manage because of the high recurrence rate of the sinus and nasal polyps, s Most of these patients need ongoing medical management with inhaled nasal steroids. Some require secondary procedures to laser photocoagulate the sinus cavity, creating some controlled scarring to reduce the mucus secretion and prevent polypoid recurrence. Patients with cystic fibrosis will have frequent recurrence of polyps and infection. Mucolytics to thin the secretions help. Surgical procedures that allow gravity to be a major factor in sinus drainage are also important because of the poor ciliary function.
RETAINED INFECTION Patients with chronic infection may have persistence of their disease in spite of what seems to be adequate medical and surgical management. Just like the patient with polyposis, there may be persistent or recurrent infection because of retained disease within the sinus. This usually occurs with persistent disease in the frontal or sphenoid sinus (Fig 3). Another reason for retained secretions is difficulty accessing the lateral extent of the sphenoid or frontal sinus. Occasionally, an ethmoid sinus air
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 6, NO 3 (SEP), 1995: PP 176-179
FIGURE 1. Through-cutting forceps (Xomed, Jacksonville, FL), which accurately remove tissue rather than tearing.
FIGURE 3. Coronal CT of the sphenoid sinus with lateral pneumatization making lateral disease removal difficult.
cell is missed and is the source of recurring infection. An accessory maxillary sinus ostium may be mistaken for the natural ostium, and infection persists from the circular movement of mucus from the maxillary sinus out through the natural ostium and back into the sinus through the accessory ostium. This can be corrected by connecting the natural ostium to the accessory ostium. Some patients will have tenacious infected secretions making removal difficult. These retained secretions become the focus for ongoing infection. These secretions are often seen in fungal sinusitis or in patients who have large numbers of eosinophils within the mucus. This often occurs in patients with asthma or nonallergic eosinophilic rhinitis. It is important to remove all of the mucus secretions and irrigate the sinus. Many of these pa-
tients require ongoing medical management with mucolytics, inhaled nasal and/or systemic steroids. Frequent office endoscopy and sinus cleaning helps to achieve success.
FIGURE 2. Paradoxical right middle turbinate making access into the ostiomeatal complex limited.
FIGURE 4. Scar tissue obstructing outflow from the middle meatus, creating recurring sinusitis.
LEVINE
RECURRING INFECTION Sometimes infection seems to have cleared, only to recur at a later time. There may be several causes for this. Occasionally, following endoscopic sinus surgery, adhesions occur that may obstruct the outflow from the sinuses into the nose. This may cause stasis of secretions within the sinus and infection (Figs 4 and 5). In the same manner, a sinus ostium narrowed from
177
FIGURE 6. Scarred and narrowed middle meatal antrostomy, causing recurrent sinusitis. FIGURE 5. Scar tissue filling the middle meatus with scarred and lateralized middle turbinate, causing recurrent sinusitis.
scar may cause poor outflow of secretions from the sinuses (Fig 6). Each of these mechanical obstructions must be identified and opened so that they will drain adequately. Occasionally, small bits of bone are left exposed, especially in the ethmoid sinus. These bony spicules may desiccate and form a sequestrum. This can be a source of granulation tissue or purulent secretions and is necessary to remove both the granulation tissue and the bony spicule. Although the inferior meatal nasal antrostomy has long been an accepted method of aerating the maxillary sinus, it can also be a source of recurring infection. Some patients w h o have had an inferior meatal antrostomy will have persistent maxillary sinus drainage (Fig 7). This may occur because of scar tissue around the antrostomy, which causes ciliary dysfunction. This in turn prevents normal flow of secretions from the floor of the maxillary sinus up to the natural ostium of the maxillary sinus. Likewise, scar tissue from previous nasal or sinus surgery may prevent normal flow of mucus and stasis of secretions. This is a difficult problem to manage. It requires a large middle meatal antrostomy and in a few instances, actually connecting the middle and inferior meatal antrostomy. In the pediatric patient, it is important to consider the tonsils and/or adenoids when there are symptoms of sinus disease. Although recurring infection may seem to be caused by sinusitis, it may be caused by adenoid hypertrophy, which impedes mucus flow through the nose into the nasopharynx. Adenoiditis can also occur and mimic some of the symptoms of sinusitis. An adenoidectomy alone or in combination with tonsillectomy may be indicated. When infections persist, uncommon organisms should be looked for such as anaerobic or fungal organisms, or tuberculosis. This is especially true in the patient who is immunocompromised or debilitated by chronic illness. It is also appropriate to look for immunologic deficiencies 178
in any individual whose infection does not respond as expected. Foreign bodies are uncommon cases of persistent sinusitis, but should especially be looked for especially in children and institutionalized patients.
CHRONIC RHINITIS Allergic or vasomotor rhinitis can be the cause of recurring sinusitis. The rhinitis can cause membranous turbinate hypertrophy, which in turn will obstruct the ostiomeatal complex and the outflow from the sinus.
FIGURE 7. Inferior meatal antrostomy, causing persistent drainage. FAILURE IN ENDOSCOPIC SINUS SURGERY
Turbinate h y p e r t r o p h y m a y also be b o n y rather t h a n m e m b r a n o u s . This can be d e t e r m i n e d b y spraying the nose with a topical d e c o n g e s t a n t . If the e n l a r g e d turbinate decongests, it is vasoactive. If it d o e s not, it is m o s t likely b o n y . The b o n y inferior turbinate can be treated b y a s u b m u cous resection, p r e s e r v i n g the o v e r l y i n g m u c u s m e m brane. The vasoactive turbinate m a y be treated medically with d e c o n g e s t a n t s or cortisone nasal sprays. Laser p h o t o c o a g u l a t i o n of the turbinate can be p e r f o r m e d a n d has b e e n successful. 10
ENVIRONMENTAL FACTORS E n v i r o n m e n t a l factors can be the c a u s e of p e r s i s t e n t s y m p t o m s after functional sinus surgery. Exposure to pollutants at w o r k , outdoors, or at h o m e can cause recurring sinusitis. Cigarette s m o k i n g , b o t h active a n d passive, m a y be a source of pollutants.
SUMMARY W h e n faced w i t h a n y difficult medical p r o b l e m , a s y s t e m atic a p p r o a c h is necessary. Thinking a b o u t sinusitis patients in categories of infection, polyps, anatomic, or sys-
LEVlNE
temic disorders m a y h e l p w h e n dealing with r e c u r r e n t disease. C o m b i n a t i o n s of p r o b l e m s m a y also occur.
REFERENCES 1. Levine HL: Functional endoscopic sinus surgery: Evaluation, surgery, and follow-up of 250 patients. Laryngoscope 100:79-84, 1990 2. Kennedy DW: Prognostic factors, outcomes and staging in ethmoid sinus surgery. Laryngoscope 102:12, 1992(suppl 57) 3. Schaitken B, May M, Shapiro A, et al: Endoscopic sinus surgery: 4-year follow-up on the first 100 patients. Laryngoscope 103:11171120, 1993 4. Smith LF, Brindley PC: Indications, evaluation, complications, and results of functional endoscopic sinus surgery in 200 patients. Otolaryngol Head Neck Surg 108:688-696, 1993 5. Rice DH: Endoscopic sinus surgery: Results of 2-year followup. Otolaryngol Head Neck Surg 101:476-479, 1989 6. Lazar RH, Younis RT, Long TE, et al: Revision functional endonasal sinus surgery. ENT J 71:131-133, 1992 7. King JM, Calderelli DD, Pigato JB: A review of revision functional endoscopic sinus surgery. Laryngoscope 104:404-408, 1994 8. Levine HL, May M: Results of surgery, in Endoscopic Sinus Surgery. New York, NY, Thieme, 1992 9. Davis WE, Templer JW, LaMear WR: Patency rates of endoscopic middle meatal antrostomy. Laryngoscope 101:416-420, 1991 10. Levine HL: The potassium-titanyl phosphate laser for the treatment of turbinate dysfunction. Otolaryngol Head Neck Surg 104:247-251, 1991
179