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Persistent sinusitis from recirculating mucus after inferior turbinectomy
International Congress Series 1240 (2003) 463 – 467
Persistent sinusitis from recirculating mucus after inferior turbinectomy Kevin J. Kane * Royal Victorian Eye and Ear Hospital, 126 Victoria Parade, East Melbourne 3002, Australia
Abstract Recirculation of mucus between adjacent openings into the maxillary antrum is a relatively common cause of persistent sinusitis in either the pre- or postsurgical patient. It is particularly prone to occur if intranasal sinus surgery is performed without the use of angled telescopes. In this situation, the natural ostium is often out of direct vision, and an antrostomy is created in the posterior fontanelle separate from the natural ostium, thus setting the scene for recirculation of mucus with resultant persistent infection. The phenomenon also occurs commonly between a middle meatal opening and an inferior meatal antrostomy usually created at a prior operation, if the inferior turbinate has been significantly excised. The presence of an intact inferior turbinate usually acts as a deflecting baffle to prevent the recirculation process. Recirculation may also be relevant for persistent sinusitis in the sphenoid and frontal sinuses. D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. Keywords: Chronic rhinosinusitis; FESS, Functional Endoscopic Sinus Surgery; Antrostomy; Natural osteum; Inferior turbinectomy
1. Persistent sinusitis from recirculating mucus after inferior turbinectomy There is nothing new about the phenomenon of recirculation of mucus between adjacent ostiums of the paranasal sinuses. Messerklinger was certainly aware of this and in his book published in 1978 there are two illustrations showing recirculation of mucus between the natural ostium of the maxillary antrum and an accessory ostium [1].
* Nose and Sinus Clinic, Suite 10 1st Floor, 166 Gipps Street, East Melbourne 3002, Australia. Tel.: +61-39415-7077; fax: +61-3-9415-7377. E-mail address: [email protected] (K.J. Kane). 0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)00753-2
464
K.J. Kane / International Congress Series 1240 (2003) 463–467
However, it is not clear whether he was aware of the importance of this phenomenon, particularly as a cause of surgical failure after endoscopic sinus surgery. In the Nose and Sinus Clinic at the Royal Victorian Eye and Ear Hospital in Melbourne, we encountered the phenomenon frequently in the early days of FESS adoption by ENT surgeons in the country, particularly between 1985 and 1995. A report of this experience was published in a preceding article [2]. Since then, the frequency with which we have come across the problem has steadily declined, particularly recirculation occurring between the natural ostium of the maxillary antrum and a misplaced antrostomy or an accessory ostium. Now, the most common recirculation observed is that between a middle meatal antrostomy or maxillary ostium and an inferior meatal antrostomy, perhaps performed many years previously. How has this come about? Why was the phenomenon so frequent in the early years of endoscopic sinus surgery, and why does it now appear to have declined so considerably in the last 5– 8 years? Firstly, there was great disparity in what surgeons understood to be meant by Functional Endoscopic Sinus Surgery. In the early years, many surgeons performed an intranasal procedure, which they considered to be FESS yet without using angled telescopes. Others were utilising microscopes, some loops and headlights, and some putting in a nasal telescope for part of the procedure. Although they claimed to be performing a functional operation, the principles of the Messerklinger technique were being ignored. This highlights the need for a common definition of FESS so that surgeons the world over are talking of the same operation. It is also important so that complication rates and surgical outcomes can be compared meaningfully. Perhaps a suitable definition might be: FESS is surgical technique described by the Messerklinger School of Nasal Endoscopists that utilises angle telescopes to clear inflammatory disease within the ethmoid sinus complex, particularly the ethmoidal infundibulum and frontal recess, with the object of establishing aeration and drainage of the major sinuses. Emphasis is placed on tissue conservation, where possible, with preservation of the nasal turbinates. As all FESS surgeons know, it is often difficult to view the natural ostium without a 30j telescope and in a hypoplastic lateralized antrum; a 70j telescope may be required. Quite aside from this are the dangers to the orbit of performing a middle meatal antrostomy working under direct vision, and this, of course, was why middle meatal antrostomies were abandoned early in the last century. When a headlight was utilised, it was common to see the antrostomy sited in the wrong position. The most common noted was an antrostomy in the posterior fontanelle, and the chronic sinusitis problem failed to resolve because of recirculation between the antrostomy and the intact natural ostium anteriorly (Fig. 1). It was not uncommon to see an attempted antrostomy made through the uncinate process itself. The natural ostium remained obstructed either because of the inferior remnant of the uncinate process sealing it off or because of pathology such as polyps in the infundibulum.
K.J. Kane / International Congress Series 1240 (2003) 463–467
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Fig. 1. Recirculation of mucus from right natural osteum to antrostomy (on right of figure).
Fig. 2. Mucus flowing from middle meatal antrostomy over reduced inferior turbinate to inferior meatal antrostomy below.
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K.J. Kane / International Congress Series 1240 (2003) 463–467
Fig. 3. Band of mucus seen flowing over an intact inferior turbinate. The flow was between a middle and inferior meatal antrostomy.
The second cause of the recirculation phenomena and persistent rhinosinusitis after surgery was the enthusiasm at that time for inferior turbinate excision combined with an inferior meatal antrostomy. Recirculation of the thick mucus band or band of coloured mucopus was often noted between the two antrostomies (Fig. 2). It tended to occur in patients who had had significant inferior turbinate resection. If intact, the mucus recirculation is deflected towards the posterior choana, and the recirculation thus impeded or interrupted. However, occasionally, it was noted over an intact turbinate (Fig. 3). If the recirculating mucus is observed over a period of time, it can be noted to change in consistency and colour. Sometimes, it will be clear, and small microbubbles may be visible within it. At other times, there is a grey and at yet other times a frankly yellow pus. Associated antral infection with pus in the maxillary antrum will also be intermittently noted.
2. Treatment The treatment is surgical and consists of removing the bridge of bone and tissue separating the two openings and converting them into one common antrostomy. If the defect is in the middle meatus, a previously formed middle meatal antrostomy will need to be connected to the natural ostium anteriorly. An accessory ostium will need connection to an antrostomy usually anterior to it or the natural ostium itself. Stammberger backbiting forceps as produced by Storz are ideal for this. If the natural ostium is not visible, a J curette can be used to pull down the inferior remnant of the uncinate process where it will be readily identified. Occasionally, in hypoplastic lateralised maxillary antrums, it may be difficult to remove the intervening bar of bone or tissue with backbiting forceps, and a Kuhn –Bolger frontal sinus curette can be inserted into the
K.J. Kane / International Congress Series 1240 (2003) 463–467
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anterior ostium and then pushed posteriorly into the opening behind it, breaking down the intervening bone and tissue in its path. When mucus recirculation occurs between a middle meatal and inferior meatal antrostomy as seen in Fig. 2, the bone and mucosa including the inferior turbinate remnant need to be removed, making one single opening. Bleeding is usually minimal, as most of the inferior turbinate will typically have been removed in the previous surgery. For a period of time, the author tried removal of the bridge of bone of the lateral nasal wall between the two antrostomies, leaving the inferior turbinate remnant intact. However, it was noted that recirculation continued following this procedure, so the practice has been abandoned. Now, the tissue is removed in toto, creating one large common antrostomy.
3. Conclusion Recirculation of mucus and mucopus is a relatively common cause of persistent sinusitis following surgery. This is readily diagnosed with the aid of nasal endoscopes, and surgical correction is readily achieved as a day case procedure under anaesthesia or in a cooperative patient in the surgeon’s office environment.
References [1] W. Messerklinger, Endoscopy of the Nose, Urban and Schwarzenberg, 1978, p. 123. [2] K.J. Kane, Recirculation of mucus as a cause of persistent sinusitis, Am. J. Rhinol. 11 (5) (1997) 361 – 369.
Persistent sinusitis from recirculating mucus after inferior turbinectomy Kevin J. Kane * Royal Victorian Eye and Ear Hospital, 126 Victoria Parade, East Melbourne 3002, Australia
Abstract Recirculation of mucus between adjacent openings into the maxillary antrum is a relatively common cause of persistent sinusitis in either the pre- or postsurgical patient. It is particularly prone to occur if intranasal sinus surgery is performed without the use of angled telescopes. In this situation, the natural ostium is often out of direct vision, and an antrostomy is created in the posterior fontanelle separate from the natural ostium, thus setting the scene for recirculation of mucus with resultant persistent infection. The phenomenon also occurs commonly between a middle meatal opening and an inferior meatal antrostomy usually created at a prior operation, if the inferior turbinate has been significantly excised. The presence of an intact inferior turbinate usually acts as a deflecting baffle to prevent the recirculation process. Recirculation may also be relevant for persistent sinusitis in the sphenoid and frontal sinuses. D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. Keywords: Chronic rhinosinusitis; FESS, Functional Endoscopic Sinus Surgery; Antrostomy; Natural osteum; Inferior turbinectomy
1. Persistent sinusitis from recirculating mucus after inferior turbinectomy There is nothing new about the phenomenon of recirculation of mucus between adjacent ostiums of the paranasal sinuses. Messerklinger was certainly aware of this and in his book published in 1978 there are two illustrations showing recirculation of mucus between the natural ostium of the maxillary antrum and an accessory ostium [1].
* Nose and Sinus Clinic, Suite 10 1st Floor, 166 Gipps Street, East Melbourne 3002, Australia. Tel.: +61-39415-7077; fax: +61-3-9415-7377. E-mail address: [email protected] (K.J. Kane). 0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)00753-2
464
K.J. Kane / International Congress Series 1240 (2003) 463–467
However, it is not clear whether he was aware of the importance of this phenomenon, particularly as a cause of surgical failure after endoscopic sinus surgery. In the Nose and Sinus Clinic at the Royal Victorian Eye and Ear Hospital in Melbourne, we encountered the phenomenon frequently in the early days of FESS adoption by ENT surgeons in the country, particularly between 1985 and 1995. A report of this experience was published in a preceding article [2]. Since then, the frequency with which we have come across the problem has steadily declined, particularly recirculation occurring between the natural ostium of the maxillary antrum and a misplaced antrostomy or an accessory ostium. Now, the most common recirculation observed is that between a middle meatal antrostomy or maxillary ostium and an inferior meatal antrostomy, perhaps performed many years previously. How has this come about? Why was the phenomenon so frequent in the early years of endoscopic sinus surgery, and why does it now appear to have declined so considerably in the last 5– 8 years? Firstly, there was great disparity in what surgeons understood to be meant by Functional Endoscopic Sinus Surgery. In the early years, many surgeons performed an intranasal procedure, which they considered to be FESS yet without using angled telescopes. Others were utilising microscopes, some loops and headlights, and some putting in a nasal telescope for part of the procedure. Although they claimed to be performing a functional operation, the principles of the Messerklinger technique were being ignored. This highlights the need for a common definition of FESS so that surgeons the world over are talking of the same operation. It is also important so that complication rates and surgical outcomes can be compared meaningfully. Perhaps a suitable definition might be: FESS is surgical technique described by the Messerklinger School of Nasal Endoscopists that utilises angle telescopes to clear inflammatory disease within the ethmoid sinus complex, particularly the ethmoidal infundibulum and frontal recess, with the object of establishing aeration and drainage of the major sinuses. Emphasis is placed on tissue conservation, where possible, with preservation of the nasal turbinates. As all FESS surgeons know, it is often difficult to view the natural ostium without a 30j telescope and in a hypoplastic lateralized antrum; a 70j telescope may be required. Quite aside from this are the dangers to the orbit of performing a middle meatal antrostomy working under direct vision, and this, of course, was why middle meatal antrostomies were abandoned early in the last century. When a headlight was utilised, it was common to see the antrostomy sited in the wrong position. The most common noted was an antrostomy in the posterior fontanelle, and the chronic sinusitis problem failed to resolve because of recirculation between the antrostomy and the intact natural ostium anteriorly (Fig. 1). It was not uncommon to see an attempted antrostomy made through the uncinate process itself. The natural ostium remained obstructed either because of the inferior remnant of the uncinate process sealing it off or because of pathology such as polyps in the infundibulum.
K.J. Kane / International Congress Series 1240 (2003) 463–467
465
Fig. 1. Recirculation of mucus from right natural osteum to antrostomy (on right of figure).
Fig. 2. Mucus flowing from middle meatal antrostomy over reduced inferior turbinate to inferior meatal antrostomy below.
466
K.J. Kane / International Congress Series 1240 (2003) 463–467
Fig. 3. Band of mucus seen flowing over an intact inferior turbinate. The flow was between a middle and inferior meatal antrostomy.
The second cause of the recirculation phenomena and persistent rhinosinusitis after surgery was the enthusiasm at that time for inferior turbinate excision combined with an inferior meatal antrostomy. Recirculation of the thick mucus band or band of coloured mucopus was often noted between the two antrostomies (Fig. 2). It tended to occur in patients who had had significant inferior turbinate resection. If intact, the mucus recirculation is deflected towards the posterior choana, and the recirculation thus impeded or interrupted. However, occasionally, it was noted over an intact turbinate (Fig. 3). If the recirculating mucus is observed over a period of time, it can be noted to change in consistency and colour. Sometimes, it will be clear, and small microbubbles may be visible within it. At other times, there is a grey and at yet other times a frankly yellow pus. Associated antral infection with pus in the maxillary antrum will also be intermittently noted.
2. Treatment The treatment is surgical and consists of removing the bridge of bone and tissue separating the two openings and converting them into one common antrostomy. If the defect is in the middle meatus, a previously formed middle meatal antrostomy will need to be connected to the natural ostium anteriorly. An accessory ostium will need connection to an antrostomy usually anterior to it or the natural ostium itself. Stammberger backbiting forceps as produced by Storz are ideal for this. If the natural ostium is not visible, a J curette can be used to pull down the inferior remnant of the uncinate process where it will be readily identified. Occasionally, in hypoplastic lateralised maxillary antrums, it may be difficult to remove the intervening bar of bone or tissue with backbiting forceps, and a Kuhn –Bolger frontal sinus curette can be inserted into the
K.J. Kane / International Congress Series 1240 (2003) 463–467
467
anterior ostium and then pushed posteriorly into the opening behind it, breaking down the intervening bone and tissue in its path. When mucus recirculation occurs between a middle meatal and inferior meatal antrostomy as seen in Fig. 2, the bone and mucosa including the inferior turbinate remnant need to be removed, making one single opening. Bleeding is usually minimal, as most of the inferior turbinate will typically have been removed in the previous surgery. For a period of time, the author tried removal of the bridge of bone of the lateral nasal wall between the two antrostomies, leaving the inferior turbinate remnant intact. However, it was noted that recirculation continued following this procedure, so the practice has been abandoned. Now, the tissue is removed in toto, creating one large common antrostomy.
3. Conclusion Recirculation of mucus and mucopus is a relatively common cause of persistent sinusitis following surgery. This is readily diagnosed with the aid of nasal endoscopes, and surgical correction is readily achieved as a day case procedure under anaesthesia or in a cooperative patient in the surgeon’s office environment.
References [1] W. Messerklinger, Endoscopy of the Nose, Urban and Schwarzenberg, 1978, p. 123. [2] K.J. Kane, Recirculation of mucus as a cause of persistent sinusitis, Am. J. Rhinol. 11 (5) (1997) 361 – 369.