Endoscopic versus conventional techniques

ENDOSCOPIC VERSUS CONVENTIONAL TECHNIQUES WILLIAM H. FRIEDMAN, MD, FACS, JEFFREY P. KIRSCH, MD, GEORGE P. KATSANTONIS, MD, FACS

There is probably less current controversy concerning whether or not ethmoidectomy should be performed intranasally than at any time during its nearly 100-year history. With the surge in popularity of intranasal endoscopy, a generation of sinus surgeons capable of performing intranasal ethmoidectomy has emerged. There has been a rediscovery of sinus anatomy, including structures that have always been the primary landmarks of intranasal ethmoidectomy. The uncinate process, bulla ethmoidalis, hiatus semilunaris, ethmoidal infundibulum, maxillary ethmoidal cells (Haller cells), and conchae bullosum are now commonly observed by otolaryngologists and radiologists alike. These structures were neither unknown nor invisible before the use of the nasal endoscope. However, the use of the endoscope has provided an impetus for reevaluation of this anatomy by all sinus surgeons. Along with the rediscovery of sinus anatomy has been the emergence of the functional concept of ethmoidal surgery, which teaches the preservation of as many of these structures as possible to conserve, restore, or create function in patients who are considered candidates for intranasal surgery. Opposing views have held that the results of ethmoidectomy during the past 30 years have improved more because of the tendency towards completeness than because of efforts to preserve residual ethmoid cells in the hopes that clearing the infundibulum or hiatis semilunaris will restore function without opening the posterior vault. Central to the concept of functional surgery of any kind is the assumption that the structure preserved or reconstructed does, in fact, subserve some function. Although considerable speculation exists as to the possible function of paranasal sinuses, even the most vocal proponents of functional endoscopic sinus surgery acknowledge that the capricious behavior which these structures demonstrate frequently makes their sacrifice clinically mandated. Preservation of the ethmoids or a portion of the ethmoids or the middle turbinate seems to be desirable to some surgeons for no demonstrable reason. Certainly, the gratuitous sacrifice of normal structures has never been the goal of the classic sinus surgeon, just as attempts to salvage diseased, nonfunctional, or obstructive anatomic landmarks is not the goal of the endoscopic surgeon. The purpose of this article is to stress the rapidly converging points of view that rapprochement has brought to the classic and endoscopic approaches. Happily, the From the Park Central Institute, Deaconess Hospital, and the St. Louis University School of Medicine, St. Louis, MO. Address all reprint requests to William H. Friedman, MD, FACS, Park Central Institute, 6125 Clayton Ave, Suite 430, St. Louis, MO 63139. Copyright 9 1995 by W.B. Saunders Company 1043-1810/95/0603-0007505.00/0

controversy of whether or not to use the endoscope has been resolved in favor of the endoscope. Equally important has been the decline in performance of external ethmoidectomy and the Caldwell-Luc procedure. Ten years ago there was still heated controversy as to the relative merits of intranasal versus external ethmoidectomy. Although there may be differing points of view on the relative merits of preservation of middle turbinates, opening the sphenoid routinely, or other controversial areas, the value of the endoscope in diagnosis, teaching, and visualizing remote, "around-the-corner" areas should no longer be disputed. The frontal recess, the maxillary sinus, retro-orbital and supraorbital ethmoids can now be examined both preoperatively and postoperatively, using the angled telescopes. Equally undisputed at this time is the requirement that classic principles of marsupialization, including the excision of all diseased ethmoid partitions along with middle turbinates, are indicated, particularly in surgery for diffuse polyposis, massive obstructive disease, or recurrent ethmoidal surgery, whether endoscopic or conventional techniques are used.

ANATOMIC CONSIDERATIONS The middle turbinate has been a focal point for controversy. In previous years, the argument of whether the middle turbinate ought to be preserved had resulted in a virtual standoff. Proponents of middle turbinate preservation maintained that crusting, anosmia, or some other undocumented disaster might occur in patients undergoing amputation of the middle turbinate. Although uncontrolled postoperative infection in the preantibiotic era might have resulted in persistent crusting following removal of the middle turbinate or any other part of the ethmoid labyrinth, one of the major improvements in the treatment of patients who have undergone surgery for chronic hyperplastic rhinosinusitis has been the use of postoperative antibiotics. Crusting may occur following any intranasal surgery, the result of bony exposure in a contaminated field with supervening osteitis. Persistent crusting has proven a rare complication in the authors' series of over 4,000 intranasal sphenoethmoidectomies, but crusting has occurred in several patients in w h o m preoperative crusting has been observed and in w h o m postoperative crusting persisted more or less unchanged. Although Klebsiella-like organisms were not cultured in these patients, they invariably responded to antibiotics. The use of postoperative antibiotics for as long as 6 weeks after surgery has minimized crusting or eliminated it in most patients. Atrophic rhinitis has never been documented in these patients and should not be a feature of intranasal ethmoidectomy unless malodorous, crusting rhinitis sicca is a feature of the preoperative disease.

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 6, NO 3 (SEP), 1995: PP 207-212

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There is evidence that olfaction 1 is related to the aerodynamic qualities of the middle turbinate. However, the middle turbinate is often compromised in patients who undergo ethmoidectomy and may obstruct airflow to the olfactory area in these patients. There has been no documentation of the myth that olfaction may actually be subserved by middle turbinate mucosa. Proponents of middle turbinate removal have pointed out that removal of the turbinate results in excellent visualization (with or without the endoscope) of the entire paranasal vault, including the anterior ethmoids, the infundibulum and frontal recess area, the uncinate process, the ethmoidal bulla, posterior ethmoids, and the sphenoid sinus. Messerklinger2 has indicated that, "anatomic variance, such as a paradoxically curved middle concha, a processus uncinatus bent medially . . . or free margin of the middle concha projecting markedly laterally can render endoscopy difficult or impossible. In such cases, endoscopy of the middle meatus is not possible unless it has been opened operatively by an endoscopic resection of the medial infundibular wall. 2 Excision of the middle turbinate at the outset of ethmoidectomy renders the entire infundibular-meatal region totally accessible to the intranasal surgeon either endoscopically or nonendoscopically. Leaving the middle turbinate attached or exfracting the turbinate to gain visualization with an endoscope makes surgery of the middle meatus more difficult and at the same time increases the probability of postoperative synechia between the residual middle turbinate and nearby structures. Once the basal lamella and/or third lamella of the middle turbinate attachment have been severed, whether endoscopically or nonendoscopicaUy, the middle turbinate becomes a frail structure and should not be preserved. Sacrifice of the middle turbinate is sometimes performed solely for visualization, and this reason alone justifies removal of this structure. Between 20% and 40% of middle turbinates are pneumatized as shown by both computed tomographic (CT) evaluation 3 (Fig 1) and by laboratory dissection. In the majority of cases of diffuse

polyposis, the middle turbinate is involved in the disease process as an accessory ethmoid cell. Because this structure, when pneumatized, ordinarily drains into the middle meatus, m a n y surgeons attempt to preserve its medial border. 4 The authors find little merit in this technique. In recurrent nasal polyposis after partial ethmoidectomies, the residual usually becomes a focus of disease, mandating its removal at secondary surgery.

THE SPHENOID SINUS Opening the sphenoid sinus in the classic sphenoethmoidectomy operation s is performed routinely to provide a three-dimensional backdrop for the performance of ethmoidectomy. The presence of the open sphenoid posteriorly provides an excellent landmark for the posterior ethmoidectomy and enables posterior to anterior or anterior to posterior resection to be conducted with a clearcut posterior boundary. Access to the sphenoid sinus is simplified by middle turbinate removal and by the use of axial CT scans, which demonstrate the location of the sphenoids relative to the vomer and sphenoidal septae, and the extent of pneumatization bilaterally. Whereas the sphenoid may be indented laterally by the carotid artery in the cavernous sinus and posterosuperiorly by the pituitary gland, its anteromedial wall ordinarily represents the maximum point of pneumatization and is easily accessed by following the vomer to the sphenoid rostrum and entering directly, not ordinarily through the laterally placed ostia. The sphenoid sinus participates in polyposis, particularly in patients with Stage II or greater disease. More importantly, in patients with diffuse polyposis, the opened sphenoid provides a landmark where other landmarks have been completely obscured by hyperplastic mucosa and increased bleeding, which can be seen at the time of polypectomy before ethmoid excision.

FIGURE 1. Bilateral

conchae bullosa rendering access to stage II ethmoid disease difficult or impossible without turbinectomy. 208

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ETHMOID SINUSES The ostia of the anterior ethmoid cells drain into the middle meatus or infundibulum while the ostia of the posterior ethmoid cells access the superior meatus or sphenoethmoidal recess. The concept that "narrow or stenotic areas (of) the ethmoidal i n f u n d i b u l u m at the entrance to the frontal sinus ''6 provide the surgeon with a convenient means of curing most chronic sinusitis by clearing these areas is the cornerstone for functional endoscopic sinus surgery. However, current experience with ethmoidal surgery does not document the now widespread belief that removal of disease in the infundibulum or other limited forms of ethmoid surgery are associated with improvement in chronic sinusitis, in any except the most limited form of disease. Eichel reported the reason for recurrence in most patients who required revision sphenoethmoidectomy as "a failure of performing a more thorough posterior ethmoidectom,y; and failure to in turn clean out the sphenoid sinuses. 7 Lawson s reported, "a review of the papers describing results of conventional, endoscopic and microscopic intranasal surgery revealed them to often suffer from a lack of uniformity and indications for surgery, to not specify the nature and extent of disease, to provide no information regarding the exact extent of surgery performed, to vary in the definition of major and minor complications, to give ambiguous criteria for success, and to report generally inadequate follow-up intervals. Central to this problem is the lack of a system of disease staging necessary to compare operative results." Lawson's recent staging system s is a physiological system that incorporates presence of asthma or nonasthma, sinusitis (with and without polyps), focal and diffuse disease. The author in previous studies has provided a staging system (Table 1) that is clear, comprehensive, easily remembered, and simple to apply to individual cases. 9-11 This system uses both the preoperative CT scan and physiological response to a medication protocol as its criteria. Stage I is defined as single focus disease; Stage II as multifocal, noncontiguous disease responsive to medication; Stage III as diffuse disease, contiguous throughout the ethmoids with possible involvement of other sinuses, responsive to medication; and Stage IV, as diffuse disease contiguous throughout the ethmoids, as well as most or all other sinuses either poorly responsive or unresponsive to medication. The staging system has been

TABLE 1. Classification Staging System Stage I

Stage II

Single focus disease Unilateral or bilateral Single sinus mucosal thickening Unilateral polyp Cloudy ethmoid, sphenoid, or maxillary sinus Multifocal, noncontiguous mucosal thickening or

polyps

invaluable in the authors' practice in that it has established criteria by which the physician can explain the diagnosis, prognosis, and disease process with accuracy and simplicity to patients and colleagues, while point out the precise nature of the disease to the patient on the CT scan. More importantly, the statistically significant outcomes based on stage of disease have provided a near linear relationship between escalating stages of disease and recurrence of disease following ethmoidectomy (Fig 2).

TECHNIQUE The authors' surgical technique is based on the traditional s p h e n o e t h m o i d e c t o m y originally described by Yankauer, 12 Goldman, s and Morgenstein, 13 and has been modified by the author continuously to the present operation, which is more aptly referred to as marsupialization of the ethmoid sinuses.14 An endoscope is used in every case for preoperative and postoperative evaluation of the frontal recesses, maxillary sinuses, and other difficult-to-access areas. With the patient in the semi-Fowler's position, 10% cocaine packs are used for topical anesthesia. Xylocaine, 2% (Astra Pharmaceutical, Westborough, MA) with 0.5% epinephrine is used through bilateral pterygopalatine fossa injections through the greater palatine canal, sublabial approaches to the infratrochlear and second division of the Vth nerves, and intranasal injection of middle turbinates, the ethmoid vaults, the nasal septum, and overt polyps. A Wilde forceps is used to remove the middle turbinate after first making an incision anteriorly with a scissors, cutting the third lamella of the middle turbinate attachment. The turbinate is then grasped in its posterior one third and removed posterior to anterior. Care is taken to avoid trauma to the cribriform plate and fovea ethmoidalis during resection of the middle turbinate. Posterior ethmoids are then clearly visible and those that obscure the face of the sphenoid sinus are removed. The sphenoid sinus is then entered, either with a Wilde forceps or a suction tip in its pneumatized portion adjacent to the vomer. Care is taken not to damage the roof or lateral wall of the sphenoid sinus, which may be indented by the cavernous portion of the carotid artery (Fig 3). The sphenoid orifice is then enlarged anteriorly so that the lateral walls and roof of the sphenoid can be visualized. A posterior to anterior resection of ethmoids is accomplished so that the roof of the sphenoid and lat30

20

10

Unilateral or bilateral May include one or more different sinus

responsive to medication

0 Stage Ill

Stage IV

Diffuse contiguous disease throughout the ethmoids One or more dependent sinuses may be involved Partially responsive to medication Diffuse, contiguous disease Membrane thickening or overt polyps throughout the ethmoid sinuses and most or all other sinuses

FRIEDMAN ET AL

STAGE I & II 8.8

STAGE III 16.4

STAGE IV 24.1

(ro0.99)

FIGURE 2. Graphic representation of linear recurrence rates by stage following sphenoethmoidectomies (stages I and II are combined). Reprinted with permission. 11 209

a.

edg wall of sphenoid eral walls are aligned with the newly exenterated ethmoid labyrinth. Difficult additional surgery of retroorbital cells, infundibulum, and fovea ethmoidalis can now be undertaken under direct vision or with the nasal endoscope if needed. The maxillary ostium is then enlarged with a rasp and the posterior middle meatus resected, including the posterior fontanelle, back of the pterygoid buttress of the sphenoid bone. Inadvertent entry into the pterygopalatine fossa by this route can cause disruption of the sphenopalatine artery at this point, and this posterior marsupialization requires a knowledge of sphenoid anatomy. At the conclusion of the procedure the cribriform plate and fovea ethmoidalis should be clearly visualized. Mucosa of the cribriform area should be undisturbed. All polyps arising from the posterior septum, cribriform plate, fovea ethmoidalis, retro-orbital cells, posterior and anterior ethmoid cells, infundibulum, frontal recess, and sphenoethmoidal recess should be completely resected with anatomic contiguity between the maxillary sinus, sphenoethmoidal recess, sphenoid sinus, and ethmoid vault. The ethmoidal bulla should no longer be present. The nasofrontal duct should be undisturbed. The marsupialized space (Fig 4) (the paranasal vault) should display scalloped edges of ethmoid remnants and bleeding should be minimal. An endoscope is used to evaluate the surgical field to ensure completeness.

RESULTS An overall recurrence rate of 14.4% was noted by the author 11 in a recent publication. Criteria for recurrence were identical to the criteria for initial staging. The most 210

FIGURE 3. Sphenoid sinus showing indentation of the right lateral wall of the sphenoid by the cavernous portion of the internal carotid artery.

significant feature of this study was the statistical significance and linear recurrence rate associated with escalating stages of hyperplastic rhinosinusitis. Because most patients who were classified as Stage I did not undergo sphenoethmoidectomy, only 24 of these procedures were performed of the 1,609 patients reported. An 8.3% recurrence rate was observed in Stage I patients, after intranasal ethmoidectomy. The most common group of patients observed were in the Stage II category, in which 1,303 sphenoethmoidectomies were performed. An overall 8.1% recurrence rate was noted in this group. Among those in Stage IIIa 16.4% recurrence rate and in Stage IV a 24.1% recurrence rate was noted. Although recurrence rates for patients in Stages I and II, in w h o m sphenoethmoidectomy or endoscopic ethmoidectomy were performed were relatively similar, their treatment modalities differ and many patients with Stage I disease did not undergo surgery, whereas virtually all Stage II patients underwent ethmoidectomy. Regression analysis in this series showed a linear increase of recurrence rate through the various stages (R = .99). Stages I and II were combined because of the similarity of recurrence rates after ethmoidectomy (Fig 2).

DISCUSSION The acronym "FESS" (functional endoscopic sinus surgery) has gradually relinquished its hold on experienced endoscopic surgeons and has become "ESS." This is appropriate because it does not preclude the excision of structures that previously have been held sacrosanct. There is now widespread recognition by endoscopic surENDOSCOPIC VERSUS CONVENTIONAL TECHNIQUES

cribriform plate Jot

hate )henoid sinus posterior remnant of middle turbinate

infundil maxillary sinus FIGURE 4. Marsupialized sphenoethmoidectomy showing scalloping of the lateral remnants of the posterior ethmoids. The sphenoid sinus is shown within sphenoethmoid marsupialization. geons that the ostiomeatal outflow tract has probably been overemphasized, and although crucial in ethmoidal and frontal drainage, does not include posterosuperior ethmoidal clearance. The middle turbinate is now routinely sacrificed by most endoscopic surgeons in patients in whom visualization or participation in disease makes this structure expendable. Widespread efforts to standardize a system for staging disease are now crucial in terms of outcome reporting, but also important in the early decision making process; there can be little doubt that the performance of ethmoidectomy in patients with negative CT scans (Stage Zero) has been responsible for the most important recent surge in the performance of ethmoidectomy. Revision ethmoidectomy has proven to be an extremely popular form of surgery for nearly all busy sinus surgeons. The performance of ethmoidectomy in patients with headaches but no radiologically confirmed disease has probably resulted in synechiae, obstruction of previously normal outflow tracts, and the creation of diseased ethmoids. In these cases as well as in patients in whom massive polyposis has created the need for multiple surgeries, the concept of "functional" ethmoidal surgery is absurd. Complete ethmoidectomy is required and although cures are far from assured in these most difficult cases, improvement in symptomatology, diminished episodes of chronic sinusitis, reduced or eliminated steroid requirements in asthma patients, and FRIEDMAN ET AL

outright cures in others have validated the rationale for ethmoidal marsupialization. In patients with lesser amounts of disease, primarily Stage I and Stage II patients, the endoscopic approach with preservation of as much normal mucosa as possible has merit. It is important that all sinus surgeons recognize the fundamental principles of sinus function by providing adequate drainage pathways, not just in the ethmoidal infundibulum, but throughout the entire paranasal vault system, including the nasofrontal region, the sphenoethmoidal recess, the maxillary outflow, and infundibular tracts. With these principles in mind, controversy can now be centered around approaches to the frontal sinus and the endoscopic removal of neoplasms.

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5. Goldman JL: Intranasal sphenoethmoidectomy and antrostomy, in Goldman JL (ed): The Principles and Practices of Rhinology Part II. New York, NY, Wiley & Sons, 1987, pp 403-412 6. Stammberger H: Endoscopic endonasal surgery--concepts in treatment of recurring rhinosinusitis. Part 1. Anatomic and pathophysiologic consideration. Otolaryngol Head Neck Surg 94:145-147, 1986 7. Eichel BS: Revision sphenoethmoidectomy. Laryngoscope 95:300304, 1985 8. Lawson W: The intranasal ethmoidectomy: An experience with 1,077 procedures. Laryngoscope 101:367-371, 1991 9. Friedman WH, Katsantonis GP, Sivore et al: Computed tomography staging of the paranasal sinuses in chronic hyperplastic rhinosinusitis. Laryngoscope 100(11):1161-1165, 1990

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10. Friedman WH, Katsantonis GP: Staging systems for chronic sinus disease ENT 73:480-484, 1994 11. Friedman WH, Katsantonis GP, Bumpous J: Staging of chronic hyperplastic rhinosinusitis: Treatment strategies. Otolaryngol Head Neck Surg 112:210-214, 1995 12. Yankauer S: Demonstration of intranasal surgery on wet specimens. Laryngoscope 40:642-645, 1930 13. Morgenstein K, Kreiger M: Experiences in middle turbinate. Laryngoscope 90:1596-1603, 1980 14. Friedman WH, Katsantonis GP, Rosenblum BN, et al: Sphenoethmoidectomy: The case for ethmoid marsupialization. Laryngoscope 96:473-479, 1985

ENDOSCOPIC VERSUS CONVENTIONALTECHNIQUES