Surgical perspectives on allergic airway disease

Continuing

Medical

Education

This continuing medical education self-assessment program is sponsored by The American Academy of Allergy and Immunology. Support for this program has been made possible by a grant from Glaxo, Inc.

Surgical perspectives airway disease Samuel

on attergic

R. Fisher, MD, and Christopher

Allergic manifestations in the respiratory tract affect a large fraction of the population and are treated by many primary care physicians, pediatricians, and specialists. It is manifested to the medical profession as rhinitis, sinusitis, otitis, asthma, bronchitis, and nasal polyposis. However, to the layperson, it is often disguised under the terms colds, postnasal drip, hay fever, nasal congestion, and “sinuses.” A significant percentage of these people will obtain relief from overthe-counter pharmaceuticals or will “live with their symptoms.” However, many afflicted persons will present to their family physician or pediatrician for help. The medical management of these patients has become more sophisticated and effective during past decades with an increase in awareness, knowledge, and understanding of the immune system and, specifically, with the IgE-mediated reactions. Pharmaceutical companies are producing a vast array of decongestants, antihistamines, and topical sprays (ie, vasoconstrictors and steroids) to treat the patient suffering from allergies. Diagnostic tests for allergic disease have expanded from basic skin testing for allergens in the clinic to radioimmunoassays of specific allergy-mediated immunoglobulins in the laboratory. However, despite these advances, there continues to be a significant percentage of patients who develop conditions refractory to medical therapy and who may benefit from surgical intervention. Also included in this group are patients who have mechanical obstructive problems of the sinonasal tract that are detrimental to achieving relief from antibiotics, decongestants, antihistamines. and topical sprays. Other conditions From the Division of Otolaryngology, Department of Surgery, Duke University Medical Center, Durham, N.C. Reprint requests: Samuel R. Fisher, MD, Division of Otolaryngology, Department of Surgery, Duke University Medical Center, PO Box 3805, Durham, NC 27710.

E. Newman,

MD Durham,

N.C

Abbreviations used CSF: Cerebrospinal fluid CT: Computerized tomography CF: Cystic fibrosis

include refractory sinusitis, nasal polypsis, pyoceles, and turbinate hypertrophy. ANATOMY

OF THE SINONASAL

muco-

TRACT

A knowledge of the anatomy of the sinonasal tract and the paranasal sinuses is indispensable in order to understand the pathophysiology and treatment of allergic diseases and their complications. The nasal cavity is roughly triangular in shape, being narrower at its height and wider at its base. It is separated into paired cavities by the nasal septum. The opening of each nasal cavity is the vestibule, and it is lined by stratified squamous epithelium that contains the vibrissae, or nasal hairs, and sweat and sebaceous glands. The proximal end of the nasal vesituble is referred to as the limen nasi, or internal ostium, and represents the narrowest aspect of the upper airway with a cross-sectional area of 0.3 cm2 on each side.’ The limen nasi also marks the gradual transition from the stratified squamous epithelium of the vestibule to the mucous membrane of the remainder of the nasal cavity. The mucous membrane of the nasal cavity contains numerous mucous and serous glands and is covered by a ciliated pseudostratified columnar epithelium, also referred to as respiratory mucosa on schneiderian membrane. The membrane over the inferior turbinate and, to a lesser extent, over the middle turbinate contains a venous plexus, forming cavernous erectile-type tissue that, when it is engorged, causes swelling

of the turbinates.

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counts for the physiologic cyclical alteration in nasal resistance from one side to the other throughout the day. The medial wall of the nasal cavity is formed by the nasal septum that is cartilaginous anteriorly and osseous posteriorly (Fig. 1). The bony portion is predominantly formed by the perpendicular plate of the ethmoid and vomer bones. The septum commonly has some degree of irregularity that usually is asymptomatic. On occasion ridges, spurs, and deflections of the nasal septum will interfere with nasal respiration and are easily amenable to surgical correction. A normal thickening of the mucous membrane of the septum opposite the anterior tip of the middle turbinate is known as the septal tubercle. In contrast to the simple medial wall, the lateral nasal wall is bounded by the convoluting turbinates, or conchae, and the several ostium of the paranasal sinuses (Fig. 2). The turbinates greatly increase the surface area of the nasal mucosa, thus allowing more efficient humidification and temperature control of inspired air. However, they may cause significant nasal passage narrowing if they are swollen or enlarged. Below each turbinate is an air space, or meatus, which receives the several ostium of the paranasal sinuses. The inferior turbinate is the largest of the turbinates and is easily observed on ordinary rhinoscopy. It is formed by a separate bone that connects with the palatine, ethmoid, maxilla, and lacrimal bones. Its thick mucosal covering contains a plexus of cavernous erectile-type tissue that accounts for its ability to swell enormously and obstruct when it is engorged. The hypertrophic turbinate can usually be shrunken with topical decongestant to allow visualization more posteriorly into the nose, since significantly hypertrophic turbinates can be mistaken for nasal polyps. Inferior and medial to the inferior turbinate is the corresponding meatus that contains only one important orifice,

the nasal lacrimal duct. The opening of the duct is located anteriorly and superiorly on the lateral wall of the meatus approximately 3 to 3.5 cm behind the posterior margin of the nostril. This opening cannot be visualized on anterior rhinoscopy because of obstruction by the anterior tip of the inferior turbinate. Surgery to create a nasal antral window is performed posterior to the nasal lacrimal duct, thus not interfering with its drainage. The middle turbinate is an extension of the ethmoid bone and overhangs the important and complicated middle meatus, which is lined with a respiratory membrane similar to that of the inferior turbinate and can be visualized on rhinoscopy lying above and posterior to the inferior turbinate.’ The stroma of the middle turbinate lacks the extensive venous plexus of the inferior turbinate but does contain more serous and mucous glands.3 The lateral bony attachment of the middle turbinate is shaped like an inverted “V” with a short, steeply ascending anterior limb and long, gradually descending posterior limb.4 Beneath the apex of the attachment within the middle meatus is the frontal recess or nasofrontal “duct.” The superior attachment of the middle turbinate represents an important surgical landmark medial to which lies the cribiform plate. This thin perforated plate forms a major portion of the roof of the nose and transmits the filaments of the first cranial nerve to the olfactory epithelium of the nose. The thin plate of bone can be damaged during surgical procedures within the nose, which may cause CSF rhinorrhea and central nervous system infectious complications. Located beneath the middle turbinate is its corresponding meatus and the ostiae to the frontal, maxillary, and anterior ethmoid sinuses. When the middle meatus is visualized, the prominent convexity along the lateral wall is the bulla ethmoidalis, and located just anterior and inferior to the bulla is a crescentshaped uncinate process of the ethmoid bone. Between the ethmoid bulla and uncinate process is a crescentshaped opening, or hiatus semilunaris, which is the entrance into the ethmoid infundibulum. These are surgically important landmarks and must be identified when intranasal sinus surgery is performed. The infundibulum varies in depth but averages approximately 5 mm. The anterior ethmoid cells open into the anterior infundibulum, whereas the maxillary sinus has its major ostium in the posterior portion. In lo%, an additional accessory ostium to the maxillary sinus lies posterior to its major opening.3 The anterior limit of the infundibulum either ends blindly at the ostium of the anterior ethmoid cells and is separate from the frontal recess, or it may be prolonged upward and be continuous with the frontal recess. Anterior to

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the middle turbinate is a protuberance of the lateral nasal wall that represents the most anterior ethmoid cells referred to as the agger nasi cells. The superior nasal turbinate that is about one half the size of the middle turbinate cannot be visualized on rhinoscopy and lies behind and above the middle turbinate. Its mucous membrane is less vascular than the other conchae and, unlike those membranes, includes olfactory epithelium. The corresponding meatus receives the opening of the posterior ethmoid cells. .4bove and behind the superior turbinate is the sphenoid ethmoidal recess into which the sphenoid ostium drains. Clinically, this structure is of minor importance. The posterior exit of the nasal passageway into the nasopharynx is the choanae, where the cross-sectional area of the airway again narrows. This part of the airway can be examined posteriorly with a nasopharyngeal mirror or can be examined directly with a fiberoptical nasopharyngoscope. On posterior rhinoscopy the patency of the choanae can be assessed, the posterior ends of the middle and inferior turbinates can be visualized, the eustachian tube orifices can be observed, and the adenoid tissue or other nasopharyngeal masses can be assessed. Since the nose accounts for approximately 50% of the resistance of respiratory tract as a whole, prolonged increase in nasal resistance can lead to chronic mouth breathing in children and can result in mandibular and maxillary deformity.’ in the extreme, prolonged upper airway obstruction has been reported as a cause for car pulmonale and cardiomegaly. Paranasal

sinuses

The paranasal sinuses begin as invaginations of the nasal cavity during fetal life to become aerated cavities in the compact bone of the face. Their mucosal lining is continuous with that of the remainder of the respiratory tract and nasal cavity via their natural ostium. The cilia of the sinuses have a specific directional beat toward the natural ostia of the sinus, and it is this action along with the negative air pressure created by inspiration and swallowing that keeps the sinuses well drained and clean. The mucociliary blanket produced by and covering the nasal and sinus mucosa acts as an efficient barrier to the invasion of viruses and bacteria. Conditions that adversely affect either the function of the cilia or production of the mucous layer can lead to inflammatory conditions within the nasosinus complex. The integrity of mucocilary function must be maintained to achieve normal nasal function. Obstruction of the ostia or mechanical failure of the cilia will lead to stasis within the sinuses and eventually to sinusitis. Although this is generally a self-limiting

FIG. 2. Lateral and nasal (From Adams GL, Boies damentals of otolaryngology.

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wall with turbinates removed. LR, Paparella MM. Boies’s fun. 5th ed. @ 1978.292.:

disease in its acute phase, chronic or recurrent obstruction of the sinus ostia resulting in chronic or recurrent sinusitis often require surgicai intervention. The anatomy of the sinuses, the ostium. and adjacent structures is vital to understanding the complications of sinusitis and invaluable in planning wrpery of the paranasal sinuses. The maxillary sinus (antrum of Highmore) is located in the body of the maxilla and has a volume of approximately 15 cm2 when it is fully developed .j The floor of the antrum is formed by the alveolar process and hard palate of the maxilla. Thus, inflammation of the maxillary sinus can cause pain of the maxillary teeth secondary to inflammation ot the alveolar nerves. At birth, the floor of the maxillary sinus lies above the level of the floor of the nasar cavity; however, after its growth and development in childhood, it will finally come to he approximately 5 mm below the floor of the nasal cavity. The roof or the maxillary sinus is formed by the thin bony floor oI’ the orbit and is often disrupted in orbital trauma. The infraorbital nerve is contained in a ridge located in the center of the maxillary roof and exits through the infraorbital foramen anteriorly. The medial wail of the maxillary sinus, which is the lateral wall of the nasal cavity, contains the sinus ostium. The ostium 1s generally located anteriorly and superiorly on the medial wall and drains into the middle meatus as mentioned earher. Often an accessory opening ma?: be observed posterior to the primary opening. Sine:* the oslium of

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the sinus is above the floor of the sinus, natural drainage of the ostium is not dependent on gravity but on an active transport mechanism. The frontal sinuses, which begin their development around the sixth year of life, grow from the region of the anterior ethmoid cells. They expand upward and backward into the diploe of the frontal bone and extend laterally into the orbital roof, and medially, they abut one another to form a septum. The amount of development varies and is almost never symmetric. Approximately 15% of adult skulls have only one sinus and 5% are missing a frontal sinus altogether.5 The sinus does not appear radiographically until approximately 6 years of age. Drainage of the frontal sinus is via the nasofrontal duct or recess in the middle meatus of the nasal cavity. The most common cause of chronic infection of the frontal sinus is impingement of the nasal frontal duct in the middle meatus. This can be caused by mechanical factors, such as a deviated nasal septum, nasal polyps, trauma, or mucosa swelling from inflammation of the middle turbinate or ethmoid labyrinth. Etiologies of mucosal swelling include viral upper respiratory infection, allergic and flammatory allergic response, CF, immunologic disorders, and immotile cilia. The ethmoid sinus or labyrinth lies between the upper part of the lateral nasal wall and the medial wall of the orbit. There are generally seven to 11 air cells on each side that are divided into anterior and posterior ethmoidal cells by their respective drainage below and above the middle turbinates. The ethmoid labyrinth is separated from the orbit by a thin layer of bone, the lamina papyracea. This thin lamina is easily transversed and disrupted in cases of infection and tumors of the ethmoid sinus. The roof of the sinus is separated from the anterior cranial fossa by a thin bone, the fovea ethmoidalis. This thin bone is continuous medially with the cribiform plate that forms the roof of the nasal cavity. The cribiform plate, however, lies 3 to 4 ml below the level of the fovea ethmoidalis and must be kept in mind when contents from the roof of the ethmoid labyrinth are being evacuated. Important external landmarks for the level of the cribifotm plate are the middle pupillary line and medial canthus. The sphenoid sinus pneumatizes during middle childhood, proceeding rapidly after 7 years of age to its final form and extent about 12 to 15 years of age.5 The sphenoid sinus is two cavities divided by a bony septum that is usually deviated to one side. This sinus communicates anteriorly with the superior meatus by the means of its ostium that enters into the sphenoid ethmoid recess. The ostium is located medially and superiorly within the sinus and is obscured on anterior rhinoscopy by the middle turbinates. Laterally, the

sinus is related to the cavernous sinus, internal carotid artery, and optic nerve. Superiorly and posteriorly, the pituitary gland in the sella tursica causes a bulge in the sinus wall and thus allows a surgical approach to pituitary tumors. Anteriorly and inferiorly, the sinus is related to the nasal cavity and nasopharynx. Patient

evaluation

Discussion will now be limited to the patients who have been identified as having allergic and rhinosinusitis. Generally, this type of patient will have been followed for some time after identification of the allergic disorder and will have improved after initiation of medial therapy (immunotherapy, antihistamines, decongestants, topical nasal sprays, and periodic antibiotics for infectious sinusitis). However, once a recurrent pattern of sinusitis or refractory sinusitis has been identified, an otolaryngologist should be involved to determine if an obstructing mechanism intranasally can be identified or whether the sinuses need drainage. Once a history has been taken, or review of past medical history, a complete head and neck examination is performed. Occasionally, serous otitis can be caused secondary to eustachian tube obstruction. The nasal passages are examined with adequate illumination, and the anatomic contents of the nose are closely inspected. Color and size of the nonconstricted turbinate mucosa is helpful initially, but the nose must be vasoconstricted to differentiate mucosal hypertrophy from bony turbinate hypertrophy and to allow full examination of the nasal vault. Nasal polyps can often be misdiagnosed, since pale boggy turbinates have a similar appearance. A septum deviated anteriorly will commonly result in compensatory hypertrophy of the contralateral inferior turbinate. Such a deviation (of the cartilaginous septum) will not appear on radiography of the sinuses, since a bony deviation may commonly appear. Therefore, the clinician cannot assume that a mechanical obstruction is not present if sinus x-ray interpretation does not identify a bony septal deflection. Polyps observed in the pediatric population should alert the clinician to CF and, if they are unilateral, to the possibility of an encephalocele, especially in an infant. Polyps in the adult population are not uncommon and may be unilateral. Oftentimes, polypoid degeneration of the turbinates occurs and may be misinterpreted as nasal polyposis. Based on the clinical course, prior medical therapy, response to present therapy, physical examination, and radiographic findings, the otolaryngologist can determine if surgical intervention may be helpful. Obstruction of the sinus ostia is the key to the development of sinusitis. Allergic reactions may trigger

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TABLE I. Radiologic

TABLE II. Plain x-ray film findings

assessment Sinus

series

Adult Caldwell Waters (open and closed) Lateral Submental vertex Pediatric (<6 yr) Caldwell Waters Lateral

significant edema to occlude the ostia, but in many cases minor mechanical defects, which of themselves are benign, may predispose an allergic patient to significant obstruction of the sinuses and nasal cavity. Mechanical factors, such as deviated septum, hypertrophic turbinates, and nasal polyps, are typically mechanical factors that may predispose to recurrent and chronic sinus disease. Indications for surgical drainage of the sinuses are: 1. 2. 3_ . 4. .5 .

6. 7. 8. 9.

Chronic/recurrent sinusitis Immunocompromised patients Refractory sinusitis Nasal polyps causing obstruction Suspected neoplasia Complications of sinusitis Osteomyelitis Mucocele or mucopyocele Progressive pulmonary dysfunction nusitis

on allergic

with si-

It is important to establish early in the treatment of the allergic patient requiring surgery that specific surgical procedures are designed to eliminate mechanical obstructions, drain infected sinuses, and establish new or better drainage systems for the sinus. Surgery is not designed or intended as a cure for the allergic patient. The correction of a deviated septum and/or reduction of hypertrophic turbinates frequently allows for better application of steroid or antihistamine nasal sprays that were ineffective before surgery, not because of the medication but because of the inability to reach the mucosa secondary to the obstruction. This also holds true for the desensitization shots and oral therapy. The allergist and otolaryngologist should be complementary in the treatment of these patients. An important distinction between adult and pediatric sinus drainage procedures is that surgery is rarely used for removal of diseased tissue in children, as is commonly performed in adults. Effectively drained sinuses will generally not have “irreversibly” diseased

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-

Opacified sinus Infection .4genesis/hypoplastic sinus ‘Tumor Extensive polyposis Air fluid level Generally denotes fluid secondary to obstructed ostia i 4 ):( .--.I si nusitis Mucosal thickening 2 mm considered abnormal 5-8 mm indicates infection Lamina thinning Mucocele Tumor

sinus mucosa, as is commonly found in chronic sinusitis in adults. Radiologic assessment Roentgenographic evaluation of the patient is invaluable in helping to assess the upper airway disorders. Not only are plain x-ray films commonly used in diagnosing and following sinus pathology but they are useful in assessing soft tissue density in the nasopharynx, such as enlarged adenoids or a prolapsed antral choanal polyp. Typically, five views are taken in the adult sinus series: Waters, open mouth and closed mouth views, Caldwell view, submental vertical view, and lateral view. In children less than 6 years of age, in order to decrease radiation exposure, only three views are routinely taken: a Caldwell, a Waters, and a lateral (Table I). The maxillary sinus is best visualized by the occipitomental or Waters view in which a frontal x-ray film is taken with the head tilted backward. The ethmoid and frontal sinuses can best be demonstrated by the occipitofrontal or Caldwell view. The sphenoid sinus is best observed on lateral and submental vertical views.6 Disease states of the sinuses are often represented on plain sinus films as opacity of the sinuses over mucoperiosteal thickening, air fluid levels, or laminar changes (Table II). The correlation of the radiopaque sinus or mucosal thickening of the sinus wall and sinusitis proven bacteriologically varies among studies. In one study, 26% of asymptomatic normal patients had radiographic evidence of maxillary sinusitis, as demonstrated by mucosal thickening.’ Much of these abnormal sinus radiographs depend on the degree of mucosal thickening considered to represent disease. Radiologists commonly refer to mucosal thickening as >2 mm of soft

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III. Preoperative patients

planning

in

Scheduleelective surgery to avoid peak seasonal allergy Other atopic disorders Special diet Medications; no aspirin Hypoallergenic tape Smokelessroom Optimum pulmonary status Anesthesiaevaluation, before surgery Asthmatic attack Acute medical therapy Subcutaneousepinephrine (0.5 cc 1: 1000; 0.01 mg/kg) Aerosols Epinephrine Isoproterenol Isoetharine Metaproterenol Terbutaline Intravenous theophylline (load 5-6 mglkg); maintain 0.6-0.9 mglkg) Intravenous steroids Methylprednisolone (Solu-Medrol*) Dexamethasone (Decadron?) *The Upjohn Co., Kalamazoo,Mich. tMerck Sharp& Dohme,WestPoint, Pa.

tissue density in the wall of the sinus. Mild mucosal edema of the sinuses may be observed in any patient with edema of the nasal mucosa from any number of causes. Evans et al.’ attempted to demonstrate mucosal thickening and its association with positive sinus cultures. In their study, 93% of sinuses with radiographic opacity had abnormal sinus aspirates, and abnormal aspirates were demonstrated in all 12 of the sinuses that had mucosal thickening 28 mm. Conversely, they reported normal sinus punctures in all 34 antral specimens with <8 mm of mucosal thickening and no air/fluid level on radiographic examination. Thus, they advocated 8 mm or more of mucosal thickening as indicative of an infected sinus. However, 4 to 5 mm of mucoperiosteal thickening has more commonly been used as the minimal value representing acute or chronic infection of the sinus. Polypoid changes of sinus mucosa are common findings in the allergic population, many of which are asymptomatic. Allergic sinusitis is often represented radiographically by a diffuse mucosal thickening of all the sinuses with varying degrees of sinus and nasal opacification. Extensive intranasal polyposis will result in homogeneous loss of normal outline of the sinus cavity and may lead to expansion of the walls of the

nasal cavity and ethmoid labyrinth. The essential feature of typical nasal polyposis is the bilateral nature of the radiographic changes that distinguish it from sinus malignancy or mucocele in which changes are commonly unilateral.’ In the pediatric age group, polyposis or pansinusitis should raise the possibility of CF. Ninety-five percent to 100% of children with CF will have opacification of their paranasal sinuses. lo. ’ ’ Mucoceles are radiographically represented by a round enlargement of the sinus cavity. In addition to the increased size of the sinus cavity, there may be thinning of the bony walls and loss of the bony septum exemplified in the frontal sinus by the loss of scalloping of the bony walls. Mucoceles are most commonly found in the frontal sinus or ethmoid complex and may occur secondary to chronic infection or as a result of previous surgery. Sinus opacification may not be appreciated when mucoceles occur because bone destruction and cavity enlargment will negate the suspected increase in density of the fluid-filled cyst; therefore, other radiographic techniques are useful in further evaluating these patients.” Tomography is helpful to assess bony destruction. CT presently is the best method for detecting bone involvement as well as soft tissue expansion of the disease. The role of magnetic resonance imaging has yet to be established, but early studies indicate magnetic resonance imaging is very effective in soft tissue evaluation, especially with coronal views. Not only can the paranasal sinuses be objectively assessed but other definable structures are tubinates, the nasal septum, and the nasopharynx. In cases of complications from sinusitis, CT scanning has been invaluable in assessing potential orbital involvement, as well as defining the anatomic status of the paranasal sinuses, and is mandatory in preoperative assessment with endoscopic sinus surgery.13zI4 Routine radiographs of the sinuses are adequate for screening evaluation of most abnormalities isolated to air spaces and bony structures, such as uncomplicated acute sinusitis and facial fractures. However, CT scanning is indicated when visualization of soft tissues as well as bony structures is vital, as in orbital cellulitis, invasive tumors, evaluation of proptosis, CSF leaks, and complicated facial fractures. SURGERY OF THE AIRWAY Preoperative ptanning Preoperative planning in the allergic patient is essential in order to avoid perioperative complications and to attain maximal results (Table III). In addition to controlling the patient’s allergies adequately with medial therapy before surgery, elective cases should

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be scheduled so as to avoid the peak allergy season for that particular patient. Allergic patients often have other atopic diseases, including allergies to specific foods, codeine, adhesive tape, and smoke-filled rooms. Many of these patients will also have underlying asthma and will be predisposed to an acute asthmatic attack during the perioperative period. The surgeon should have a knowledge of the use of acute asthmatic medications, including subcutaneous epinephrine, aerosols, intravenous theophylline, and steroids. A brief outline of surgeries commonly used for allergic (and nonallergic) patients will be discussed.

TABLE IV. Turbinate

Turbinate

binates with either a nitrous oxide or liquid nitrogen cryoprobe. 15.” The medial aspect of the inferior turbinate is frozen by topical application of the cryoprobe, being careful not to allow the probe to touch the ala, columella, or septum. After the freeze, the frozen turbinate edge will sluff, and healing will occur during a 3-week period, resulting in a smaller turbinate with normal appearing mucosa. Airway improvement generally lasts at least 1 year, and the procedure can be repeated as necessary. Along the same line, the CO? laser has been used to reduce the inferior turbinate. Fukutake et al. ‘* used a defocused beam of CO, laser on the inferior turbinate of 140 patients with perennial allergic rhinitis who were refractory to medical treatment. They repeated the treatment five times at weekly intervals and obtained excellent or good results in 75% af the patients at 1-year follow-up. Submucosal resection of the turbinate is another useful treatment of turbinate hypertropby. ” This procedure involves elevation of the submucosa of the bony turbinate and removal of the bone with biting forceps. It is prudent not to resect excessive turbinate mucosa that may result in the development of iatrogenie atrophic rhinitis, although this is rare.” This entity is characterized by impairment of the mucocilary clearance mechanism with excessive crusting, mucosal drying, recurrent bleeding, and an offensive smell of the nasal cavity. Reversal of this condition is very difficult after it develops and therefore should be avoided.

reductions

Surgical treatment of enlarged turbinates that produce nasal airway obstruction is indicated when patients have nasal airway obstruction and obstruction of the sinuses that do not respond to medical therapy. It is partially effective for the treatment of hypertrophic inferior turbinates secondary to vasomotor rhinitis. It has been reported not to be as useful in allergic rhinitis but clinically does help improve the effectiveness of medical therapy and alleviate nasal obstruction.” It is important first to determine that the patient’s obstructive symptoms are related to turbinate dysfunction. The nose should be examined before and after the use of topical vasoconstrictors, noting the size of the turbinates and status of the septum. A 2% cocaine solution will produce good temporary nasoconstriction as well as anesthesia. If shrinkage of the turbinates does not occur with topical vasoconstrictors, it may be secondary to an enlarged turbinate bone, frequently caused by invading ethmoid air cells, or the cause may be lack of mucosal sensitivity to the vasoconstrictors, as observed in rhinitis medicamentosa and chronic hypertrophic rhinitis. Bony enlargement versus mucosal hypertrophy can be differentiated by gentle palpation of the turbinates after the use of topical decongestants. The several different techniques used to treat turbinate dysfunction are summarized in Table IV. Electrocautery, or diathermy, may be used submucosally or on the surface of the inferior turbinates to cause shrinkage and fibrosis of the mucosa. This is generally restricted to mucosal hypertrophy only. Theoretically, it is believed that some sinusoids will be obliterated and that scar tissue will anchor the mucosa to the periosteum. However, histologic proof of these changes is lacking.16 The results last months to years, and the treatment may need to be repeated. Another treatment for turbinate hypertrophy and chronic vasomotor rhinitis is cryosurgery of the tur-

reduction

Electrocautery or diatherrn> Mucosal Submucosal Cryosurgery Nitrous oxide Liquid nitrogen Laser, CO, Steroid injection Resection Submucosal Amputation

.I_.----

-.

Septoplasty A severely deviated septum can likewise be an important contributing factor to nasal obstruction, and surgical correction alone or along with turbinate reduction is indicated. Until the turn of the century, obstructing deviated septums were treated by throughand-through excision that invariably resulted in a permanent septal perforation. Such complications

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caused excessive nasal crusting, bleeding, sensation of congestion, and “whistling” during inspiration. In 1902, Freer described a submucous resection of cartilage and bone that helped eliminate the complication of septal perforations.*l Since that time, many techniques and improvisations have been introduced to correct the crooked septum. Polypectomy

One of the most common intranasal surgical procedures is the nasal polypectomy. This procedure dates back to Hippocrates (460-370 BC) who avulsed nasal polyps by pulling a sponge attached to a traction string through the nose. The wire snare was introduced by Fallopius (AD 1523-1562) who used iron wire from harpsicords. His method is basically the method used today, only more sophisticated snares are now used.*’ Factors causing the formation of nasal polyps are not well understood. Traditionally, polyps were believed to arise primarily in the allergic patient and children with CF. However, polyps are found in allergic as well as nonallergic individuals and are frequently associated with chronic infections, although cause and effect have never been established. Thus, it appears that nasal polyposis has a multifactorial etiology. Histologically, nasal polyps consist of a reticular network enclosing a myxomatous stroma with inflammatory cells. The surface of the polyp may demonstrate squamous or goblet cell metaplasia. The eosinophil was found to be the prominent inflammatory cell in polyps of both atopic and nonatopic individuals.23 The appearance of asthma with nasal polyps appears to be more than causal. The incidence of asthma in patients with polyps has been reported in ranges from 21% to 71%.23-25In the past it was believed that polypectomy might exacerbate or precipitate the onset of asthma. However, recent studies indicate that the onset of asthma can either precede or follow the formation of polyps and subsequent polypectomy and that there is no evidence for cause and effect.24 Spirometic testing in the pre- and postoperative period after polypectomy in subjects with asthma did not demonstrate any significant deterioration in the pulmonary function.23 In another study of 205 patients with the wellknown triad of aspirin sensitivity, asthma, and nasal polyps who had simple polypectomy or polypectomy along with sinus surgery, 84% were able to significantly decrease the steroid dosage or stop steroids altogether after surgery.26 Nasal polyposis is mainly a disease of adults and rarely affects the pediatric age group, except in children with CF, in whom the incidence ranges from 6.7% to 27%.” In one study of 157 children with polyps and CF, nasal polyposis was the initial symp-

J. ALLERGY CLIN. IMMUNOL. FEBRUARY 1998

tom of their CF in 13 of these patients and preceded the diagnosis of CF by an average of 4 years*‘; therefore, testing is important in any child with nasal polyps for CF. The excretory glandular dysfunction in CF is manifested in the sinonasal tract by general mucosal hyperplasia, dilation of glandular structures, and chronic sinusitis. It is not known whether nasal polyps in patients with CF develop because of the congenital glandular defect or because of the chronic sinusitis. On radiologic examination, children with CF have opacity of the paranasal sinuses nearly 100% of the time. Management of nasal polyps initially is medical if they are asymptomatic, with topical steroid sprays, avoidance of aspirin, antibiotics to clear any infectious process, and immunotherapy in atopic individuals. Frequently, medical therapy alone fails once polyps cause nasal or sinus obstruction, and surgery in concert with medical therapy is required. Surgery for nasal polyposis ranges from simple polypectomy, which can be an office procedure, to complete ethmoidectomy. The decision on the type of surgery depends on the underlying disease entity, the goals of therapy, extensiveness of the disease, previous procedures, competence of the surgeon, and the medical condition of the patient. The large single antral choanal polyp that arises in the maxillary sinus and spills over into the nose and nasopharynx is a different entity than the multiple bilateral ethmoidal polyps traditionally referred to as “allergic” polyps. This polyp can frequently be excised without recurrence as opposed to the multiple recurrences of ethmoidal polyps. Although the antral choanal polyp may be avulsed by simple polypectomy, the definitive treatment has proven to be the CaldwellLuc operation. In one study, patients treated with a Caldwell-Luc operation had one recurrence out of 22 cases, as compared to the 66% recurrence rate by simple polypectomy alone.28 Most commonly observed are the multiple bilateral nasal polyps that arise from the ethmoid labyrinth and the middle meatus but may rarely arise from the septum, the upper and lower vaults, and the floor of the nose. These polyps are frequently associated with aspirin sensitivity, asthma, CF, and allergies. Simple polypectomy on these patients can generally be performed as an office procedure with local anesthesia. After anesthesia with a dilute cocaine solution, the polyp is grasped with a wire snare, and an attempt is made to avulse the polyp at its base. Bleeding can be a problem with this technique. Simple polypectomy is effective in temporarily alleviating obstruction and may be of help with control of local infection; however, this procedure is plagued by a frequent recur-

Perspectives

rence of the polyp. Before this procedure, the patient should be counseled as to the chronicity of his problem and the high likelihood of recurrence after simple polypectomy. Recent studies of the use of the topical corticosteroids have indicated some decrease in the recurrence rate of polyps after polypectomy. ’ Polyps in children are not as easily removed in the office under local anesthesia. Polypectomy in a child with CF does not generally require a prolonged hospitalization, routine preoperative antibiotics, and pulmonary toilet as long as the child is well followed and treated as an outpatient.” Depending on the age of the child and severity of disease, a simple nasal polypectomy without additional sinus procedures is a safe and simple procedure that provides effective relief from sinonasal obstruction and disease. Occasionally, complicating sinus disease will be present, and additional procedures may be indicated; but x-ray film evidence of sinus disease in itself is not an indication for surgery.” Many patients with chronic recurring polyps and paranasal sinus infection will require sinus surgery, most commonly on the ethmoid labyrinth, to control the polyps and sinusitis. The objective of surgical treatment is thorough removal of the diseased tissue and establishment of a wide open permanent drainage of the sinus. This may require surgical exenteration of the ethmoid labyrinth, as well as a nasal antral window, to drain the maxillary sinus. The ethmoid labyrinth may be approached either transorbitally or intranasally. The specific approach should be that with which the surgeon has the most familiarity and through which he or she can best visualize the ethmoids. Complete ethmoidectomy for recurrent or chronic polyposis has proven effective in the management of chronically recurring polyps despite their etiology.6, *’ Sinusitis The actual incidence of sinusitis in adults and children is not known, but it is certainly a common and important cause of morbidity. Predisposing factors for sinusitis include viral upper respiratory infections, allergic rhinitis, nasal polyposis, nasal septal deviation, and adenoid hypertrophy.6 Sinusitis may be classified as acute (2 to 4 weeks), subacute (1 to 3 months), and chronic (more than 2 to 3 months).30 The pathophysiology of sinusitis involves obstruction of the sinus ostium either from mucosal swelling of the ostium, as observed in iral or allergic rhinitis, or from mechanical obstruction from such entities as polyps. septal deflections, foreign bodies, or tumors (Table V). Ostial obstruction results in impaired sinus drainage, stagnation of mucosal secretions, and compromise of gas exchange, resulting in a prime medium

on allergh~

TABLE V. Pathophysiology

alrwai

of sinusitlN

d:3ras6~

369

-

Obstruction of sinus ~W:I (mucosal. structural

Decrease mucociliary

cicaraliz.

Decrease oxygen tension Medium for bacterial p-o\vth

Inflammation

for increased bacterial reproduction. Bacterial infection will in turn cause increased mucosal edema and secretions, in addition to impairing the mucociliary transport system. These changes result in the classic radiographic findings associated with sinusitis of thickened mucosal membrane, air fluid ievels, and sinus opacification. In acute sinusitis, the pathologic changes are generally self-limiting and reversible on medical therapy alone. in 1938. Furstenberg”’ demonstrated the self-limiting nature of acute sinusitis by curing 296 of 300 patients with acute sinusitis by bed rest, promotion of drainage, pain relief, and nutritional support alone. The major symptoms of acute sinusitis include pain over the involved sinus, pressure, nasal drainage, and nasal obstruction. Tenderness is frequently elicited when there is palpation over the involved sinus. Often straining or bending will result in exacerbation of the sinus pain or pressure. A yellow or green mucopurulent discharge, both anteriorly and posteriorly, may be present on examination. Obstruction of the nasal passages and anosmia result from discharge and associated swelling of the nasal mucosa. Anorexia, malaise, and a mildly elevated temperature may be results of toxic products of the bacteria. However, a highly elevated temperature should alert the physician to the systemic spread of infection outside the sinonasal tract and to possible impending complications, such as periorbital and orbital cellulitis, orbital abscess osteomyelitis, meningitis, cavernous sinus thrombosis, intracranial abscess, both subdural and epidural, and mucopyocele The most common offending organisms in acute sinusitis in adults as well as children are Hnemphilus injluenzae and Pneumococcus (Table VI).*. ‘Z-3’ Empirical therapy with antibiotics is commonly based on the above organisms with amoxicillin, cefaclor, or trimethosporin-sulfa. Cultures of specimens from the nose and nasopharynx have not been demonstrated to

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TABLE VI. Organisms

TABLE VII. Sinus

of acute sinusitis %

Organism

H. InjTuenzae S. pneumoniae B. catarrhalis Staphylococcusaureus Streptococcus a-hemolytic Streptococcus

Bacteria 50-74

Sterile

Up to 26 O-10

Virus Anaerobes Fungi

5 5

consistently correspond to the pathologic bacteria and should not be relief on for treatment purposes.” If a sinus culture is desired, this may be obtained by direct sinus aspiration. Culture of sinus aspirates in patients with clinical acute sinusitis are not infrequently sterile (Table III).‘, 32-3sSinusitis refractory to initial antibiotic may be caused by /34actamase producing organisms such as H. infuenzae and Branhamella catarrhalis.

In addition to antimicrobial therapy, promotion of drainage and symptomatic relief may be obtained with oral and/or topical decongestants and pain medications. Rarely, complications of acute sinusitis will occur with infection spreading outside the sinus into adjacent structures (Table VII). These include periorbital and orbital cellulitis , osteomyelitis, meningitis, cavernous sinus thrombosis, and intracranial abscess. In these cases, hospitalization and intravenous antibiotics are warranted. Evaluation of the patient with CT scan is mandatory to determine the extent of the disease and is helpful in planning surgical intervention if it is necessary, especially if the etbmoids or frontal sinus is involved. If mucopus persists despite conservative therapy, then acute sinusitis may enter a chronic phase with or without recurrent acute exacerbations. By definition, chronic sinusitis persists for more than 2 to 3 months. The general lack of pain or systemic symptoms makes chronic sinusitis more difficult to diagnose on history alone. The patient often presents only with nasal stuffiness or persistent rhinorrhea with only vague or no complaints referring to the sinuses. Frequently, the patient may present with recurrent exacerbations of an underlying chronic sinusitis. Radiologic evaluation is a valuable adjunct in the evaluation of these patients. Thickened mucosa, cloudy sinus, and air fluid levels are all observed in chronic sinusitis. Disruption of the bony sinus architecture may be observed in inflammatory processes but more frequently is the result of mucocele formation or tumor growth. Cultures of chronically infected sinuses have yielded different bacteria than those observed in acute sinusitis. Be-

punctures

with

acute sinusitis

60%-80% 20%-37%

up to 12% Uncommon Uncommon

cause of the chronically obstructed sinus and reduced oxygen tension in chronic sinusitis, mixed infections are frequently observed, and anaerobic organisms are cultured in 30% of these cases. Commonly observed organisms include H. injluenzae, Staphylococcus, Streptococcus, Bacteroides, Veillonella, and Gorynebacterium. Fungi are also another cause of chronic sinusitis in the normal as well as the immunocompromised patient, the most common being Aspergillus (Table VIII). 36,37 The treatment of chronic sinusitis frequently requires surgical as well as medical management. In addition to appropriate antibiotics and decongestants, the physician should identify and appropriately treat any constitutional disorders that may alter the resistance of the host to infection. These include abnormalities in the immune system, impaired mucociliary function (Kartagener’s syndrome), allergic conditions, diabetes, mucoviscidosis, or any debilitating disease. Finally, anatomic abnormalities should be considered as a predisposing cause of chronic sinus infection and corrected surgically. Lack of resolution of any sinus infection as demonstrated by continuing of abnormal drainage, persistent sinus pressure or pain, or persistent sinus opacification mandates a more aggressive diagnostic or surgical approach.38 Several different types of surgical procedures are available for the treatment of sinusitis, depending on the anatomic location of the infection and whether the process is acute or chronic. The design of surgical therapy is to provide unobstructed drainage of the sinuses, to promote the restoration of normal mucosa and ciliary function, and to eliminate any source of continuing infection by removal of “irreversibly” damaged tissue or obliterating the sinus. Functional endoscopic sinus surgery is a term coined to characterize a surgical procedure with the use of a fiberoptic nasal endoscope to inspect, and in certain instances surgically open obstructed sinuses. The technique has been supported by surgeons who believe the pathophysiology of maxillary, frontal, and ethmoid disease is directly related to the pathophysiologic events within the anterior and middle ethmoid complex. It is believed that changes within this area

VOLUME 81 NUMBER 2

Perspectives

tostiomeatal complex) subsequently lead to pathogenesis within the sinus caused by obstruction of the normal mucociliary clearance. Many practitioners are recognizing the importance of the mucociliary function of the ethmoid ostiomeatal complex and its role in the pathogenesis of sinus disease. Better diagnosis of inflammatory conditions within diseased sinuses with CT scanning has allowed the application ofendoscopic sinus surgery for the amelioration and treatment of certain diseases. Its popularity is growing with increasing numbers of cases reported with the use of this method. Caution must be urged, however, as standard surgical techniques to treat chronically diseased sinuses should not be abandoned until results of this procedure can be verified. Maxillary

sinus

Surgical approaches to the maxillary sinus or antrum of Highmore include puncture and irrigation, intranasal antrostomy, and the Caldwell-Luc procedure. Anti-al lavage of the maxillary sinus was a major form of therapy in sinusitis in the preantibiotic era. Today, most acute sinusitis will resolve after a lo- to I4-day course of antibiotics and decongestants, rarely requiring aspiration of the sinus. However, antral lavage is still of use when antibiotic treatment has failed to relieve a patient’s symptoms or the sinusitis is refractory to medical management. Not only will lavage relieve the pressure within the sinus but also it may dislodge plugs of inspissated secretion from the area of the antral ostium and allow drainage. Also, evacuation of retained sinus secretions leads to reduction in the number of bacteria, a reduction of proteolytic activity, and an increase in the concentration of proteins that all lead to a decrease in the inflammatory strain on the mucosa and faster recovery time back to normal. 35In addition to its therapeutic use, antral aspiration may be useful diagnostically to obtain secretions for culture or cytology. Antral lavage may be performed either via the natural ostium or more commonly via trochar puncture of the medial sinus wall. Occasionally, this is performed through the anterior wall or canine fossa. X-ray film studies are important before any antral punctures in order to detect any anatomic variations and especially in children in whom the floor of the developing maxillary sinus may still be located above the floor of the nose. The needle is inserted in the upper part of the inferior meatus 1.5 to 2 cm behind the anterior attachment of the inferior turbinate , well behind the nasal lacrimal duct opening. In adults, this is easily performed with local anesthesia as an outpatient; however, general anesthesia is frequently required in children. Intranasal antrostomy or nasoantral window is a

TABLE

VIII. Chronic

on allergic

aiwav

dsgese

371

sinusitis

Aerobes H. injluenzae Staphylococcus S. viriafans

Anaerobes Anaerobic Streptococcus Bacterioids Veillonella Corynebacterium Sterile

Fungal Aspergillus

surgically created opening between the nasal cavity and maxillary sinus. It is generally created through the inferior meatus and designed to provide dependent drainage from the maxillary sinus into the nose when the natural ostium is obstructed. This surgically created ostium is a routine part of the Caldwell-Luc operation or may be created from an intranasal approach, as was initially popularized by Mickulicz in 1886.39 The intranasal approach is a minor surgical procedure that involves making a 1 by 2-cm opening in the inferior meatus leading into the maxillary sinus. It provides the surgeon with limited access to the sinus for removal of diseased mucosa, to perform biopsy, and to culture drainage. In addition to providing a dependent route for drainage of the sinus, it also provides easy access to the sinus before surgery when further sinus washings or cultures are needed. The operation is indicated when the function of the natural ostium is impaired caused by chronic nasal disease not responding to medical therapy. This approach to the antrum as opposed to the Caldwell-Luc procedure is specifically warranted in the pediatric age group with persistent sinusitis because of the higher complication rate of the latter procedure.4o However, in treating a resistant sinusitis in the adult population, controversy exists over the indication of a simple intranasally performed nasoantral window versus the Caldwell-Luc procedure. Intranaaal amrostomy as the only operative measure appears to be less traumatic and less subject to complication than the CaldwellLuc operation. By contrast, the latter offers better access to the antrum and superior ability to make the proper diagnosis and removed diseased tissue. The Caldwell-Luc operation refers to an anterior approach to the maxillary sinus via the canine fossa of the maxilla and formation of an amrostomy into the inferior meatus. The eponym for this procedure is derived from an American, George Caldwell, and a Frenchman, Henry Luc, who described a similar pro-

372

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cedure that they performed in New York (1893) and in Paris (1897), respectively.4’ This procedure offers excellent vision and access to the maxillary sinus for the removal of antral mucosa, the performance of a biopsy of antral tumors, and removal of benign tumors and cysts. The advantage of this procedure, when chronic sinusitis is being treated, is that it allows the operator to remove all of the “irreversibily” diseased sinus mucosa. If the entire lining is meticulously removed, the sinus cavity fills with fibroserous tissue and generally will not present a further source of infection . I6 Follow-up sinus x-ray films often reveal the thickening and are quite difficult to interpret. However, much of the success of this approach depends on the performance of an adequate nasal antral window to provide drainage of the sinus after closing the Caldwell-Luc incision. The main complications associated with this procedure are possible damage to the tooth roots, temporary or permanent dental anesthesia, numbness over the cheek and, rarely, an oral antral fistula.40 This procedure is generally avoided in children because of the increased likelihood of damage to unerupted teeth. McBeth,42 in reviewing the results of 699 Caldwell-Luc procedures, and Yarington,40 in reviewing 43 1 Caldwell-Luc procedures, reported satisfactory results in controlling chronic sinusitis in 88% and 90% of their patients, respectively. Ethmoid

sinus

The ethmoid labyrinth has been referred to as the “keystone” of the paranasal sinuses, occupying a central location and sharing common borders with the orbit, nasal cavity, anterior cranial vault, and sphenoid sinus.6 The drainage of all the sinuses is centered about the ethmoids, and thus ethmoid pathology frequently results in additional obstruction of the frontal and maxillary sinuses. This is typified by the patient who presents with multiple ethmoidal polyps and a picture of pansinusitis on x-ray film. The newly developing field of endoscopic surgery bases its approach to sinus surgery on the fact that frontal and maxillary sinuses are fully dependent on the pathophysiologic condition of the ethmoid sinus.43 Consequently, the focus of endoscopic surgery is on this labyrinth, clearing its stenotic or blocked fissures and cells, and reestablishing ventilation and drainage of the dependent larger sinuses through their natural ostia without actually violating the larger sinuses. Because of the complexity of the labyrinth and the intimate anatomic relationship of several vital structures, surgery of the ethmoid sinus should be approached only with a thorough knowledge of the anatomy of this region. Surgery of this region may be performed through an external approach or intranasally.

J. ALLERGY CLIN. IMMUNOL. FEBRUARY 1988

The external approach was originally described in 1933 by Ferris Smith.22 The principle of ethmoidectomy is to convert the many cells of the ehtmoid labyrinth into a single cavity in continuity with the nasal cavity and to remove all chronically infected mucosa and osteitic bone. The external approach involves a cutaneous incision midway between the medial canthus and the nasal dorsum. The lacrimal sac along with the periosteum is protected and retracted laterally. Access to the ethmoid labyrinth is obtained via removal of the bone from the lacrimal fossa and lamina papyracea. Important landmarks in determining the limits of dissection are the anterior and posterior ethmoidal arteries that penetrate the frontoethmoid suture and correspond with the approximate level of the cribiform plate. The posterior limit of periosteal elevation corresponds to the posterior ethmoidal artery and roughly corresponds to the posterior extent of the posterior ethmoidal cells. The optic nerve canal begins approximately 0.6 cm posterior to the posterior ethmoidal artery and should be left intact to avoid traction on the optic nerve. After exenteration of the anterior and posterior ethmoidal cells, the anterior wall of the sphenoid sinus may be removed, if this sinus is involved in the disease process. This will result in a common cavity between the ethmoid, sphenoid, and nasal cavities. In contrast to the external approach, the ethmoid and sphenoid sinuses may also be approached entirely via the nose. Although the intranasal ethmoidectomy has been condemned by many surgeons“’ because of its potential for serious complications, several otolaryngologists have demonstrated in large series the efficacy of this procedure with minimal complications. X, 4J,46 However, all of those surgeons who advocate the intranasal ethmoidectomy stress that thorough knowledge of anatomy and understanding of the technique are essential to preventing major complications. A limited intranasal ethmoidectomy of the anterior ethmoid cells is very useful after polypectomy for polyps extruding from the middle meatus. The major advantages of the intranasal approach is the obvious fact that it does not require a skin incision and the resultant scar and potentially endangering the superior oblique muscle. This could cause diplopia, but it is uncommon. Ethmoidectomy with either approach has been demonstrated to be a useful technique in the control of recurrent nasal polyps when simple polypectomy and medical therapy have failed. Friedman et al.46reported only 13.3% recurrence of polyps after intranasal sphenoethmoidectomy in patients with asthma. Taylor et a1.45 reported “cures” in 70 of 80 patients with chronic polyposis after ethmoidectomy. External or

Perspectives

VOLUME 87 NUMBER 2

intranasal ethmoidectomy is also useful in clearing infection of the frontal and maxillary sinuses that are related to chronic ethmoiditis. However, the external approach is recommended over the intranasal technique in the cases of ethmoiditis that are complicated by extension of infection into the orbital cavity, for the treatment of ethmoid mucoceles and mucopyoceles. and for ethmoid exploration and performance of a biopsy of tumors. The major complications of ethmoidal surgery may be avoided by meticulous attention to specific anatomic landmarks and adequate visualization during the procedure. Reported complications include CSF rhinorrhea from damage to the roof of the ethmoidal cells or, more commonly, damage to the cribiform plate, and damage to the oblique muscles (diplopia). Simple removal of polypoid disease in this area can result in a small CSF leak that may remain unnoticed until meningitis develops after the operation.47 Damage to the optic nerve, hematoma, or edema of the orbital contents may lead to temporary or permanent loss of vision. Fear of this complication is one major reason many surgeons prefer the external ethmoid approach in which they have better visualization and control of the orbit. Transient and permanent diplopia secondary to orbital muscle injury and damage to the nasal lacrimal duct, although this is uncommon, has also been reported as a complication.29, 46 48 Frontal sinus

Acute frontal sinusitis, as in other forms of acute sinusitis, usually responds promptly to antibiotic therapy and decongestants. Only when intracranial or orbital extension occurs and does not respond immediately to medical therapy does the frontal sinus require prompt surgical drainage. This is most simply and quickly performed by trephination of the frontal sinus. A small skin incision is made in the superior medial aspect of the orbit just below the eyebrow. The floor of the sinus is exposed by elevating the periosteum and a l-cm fenestra is made in the floor with either a burr or a curette. A catheter is generally inserted for drainage and washing purposes. After resolution of the acute inflammatory process, patency of the nasofrontal duct is usually reestablished. This may be confirmed by instilling a diluted methylene blue into the sinus, which should immediately appear within the nasal cavity or throat if the duct is patent.49 Intranasal probing of the nasofrontal duct should be avoided because of the inevitable scarring and stenosis that occurs with trauma to the duct.” More radical frontal sinus surgery is indicated in the case of chronic frontal sinusitis and its complications, mucocele, pyocele, sinocutaneous fistula, or-

TABLE

IX. Frontal

on allergrc ak-wm disease

sinus

surgical

373

procedures

1. Trephination Acute II. Riedel operation (1898) Remove floor and orbital ~311 Osteomyelitis III. Killian operation ( 1904) Modified Ride11 Leave supraorbital rim IV. Lothrop operation (1914) Ethmoid approach Remove sinus septum and posterior nasal septum

Connect two nasofrontal “duets’ V. Lynch frontoethmoidectomy (1920: External ethmoidectomy Remove sinus floor Stents VI. Sewal-Boyden procedure Mucosal flap to form “new” nasofrontal passageway VII. Osteoplasticfap Coronal incision “Butterfly” or blow incision Obliteration versusosteoneogencsis

bital abscess, osteomyelitis (Pott’s puffy tumor). or intracranial extension of infection. Many instances of chronic frontal sinusitis are secondary to obstruction of the nasofrontal duct within the middle meatus and will respond to intranasal surgery of the obstructing defect. This includes deviated septum, nasal polyps, an enlarged middle turbinate, abnormally enlarged ethmoid cells, or chronic ethmoiditis. During the years, many frontal sinus operations have been developed with the goal of eradicating the diseased tissue and either obliterating the sinus or establishing effective frontonasal drainage through the ethmoid sinus (Table IX). Only two of these procedures are in general use today, osteoplastic frontal obliteration and the Lynch frontoethmoidectomy. The Riedel, Lothrop, and Killian operations are of historical significance and only infrequently used today. The Riedel operation (1898) consists of complete removal of the anterior wall and floor of the sinus, permitting the soft tissue to collapse against the posterior wall and thus obliterating the sinus. As would be expected, this procedure is very disfiguring, and its only use today is primarily for extensive osteomyelitis of the frontal bone. The Lothrop operation ( 19 14) consists of unilateral or bilateral ethmoidectomies, removal of the frontal sinus septum and a portion of the upper nasal septum, and connecting the two nasal frontal ducts. The final

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result is a simple large frontal sinus that drains directly into the nasal cavity. This procedure is technically difficult. The Killian operation (1904) consists of an ethmoidectomy and essentially a modified Riedel operation. The floor and anterior wall of the sinus are removed; however, this operation leaves the superorbital rim, which prevents the severe frontal disfigurement. The Lynch frontoethmoidectomy (1920) consists of removal of the frontal sinus floor in combination with external ethmoidectomy to produce a wide open continuous frontoethmoid nasal passageway. A rubber, plastic, or silicone rubber tube is frequently used extending from the frontal sinus into the nasal cavity in an attempt to maintain its patency; however, stenosis of this passageway continues to represent a significant cause of failure in this procedure. Attempts to reduce this problem have resulted in the development of superiorly and medially based mucosal flaps to line the “new” nasal frontal duct in attempt to prevent granulation tissue, adhesions, and stenosis. This nasal frontal duct reconstruction along with the Lynch procedure is frequently referred to as a Sewall-Boyden procedure. In a review of 50 consecutive nasal frontal duct reconstructions, of the 22% that had concomitant inhalant allergy, 86% had resolution of symptoms at follow-up. The remaining 14% had persistence or recurrence of frontal sinus infection.5’ When the procedure is successful, it effectively restores the frontal sinus back to normal mucosa with a mucosa-lined nasal frontal passageway; however, if “irreversibly” damaged mucosa is left in the sinus, recurrence is inevitable, and an obliterative procedure is necessary. Presently, the most popular and definitive means of managing chronic inflammatory disease of the frontal sinus is the osteoplastic flap. Either an eyebrow (“butterfly”) or the more common hairline coronal incision is used to develop a large myocutaneous flap exposing the entire anterior sinus wall. Next, an inferiorly based periosteal-covered bone flap of the anterior sinus wall is raised (“open clam” appearance). This affords direct access to the entire frontal sinus cavity. In the case of chronic sinusitis, all the sinus mucosa is meticulously removed, and the sinus is generally obliterated with a fat graft or allowed to obliterate itself by osteoneogenesis. 5o,52,53 The bone flap is then returned, and the periosteum and skin are closed in layers. The advantages of this technique are that it allows excellent visualization of the frontal sinus cavity and also allows management of any posterior wall defect or dural problems. In addition, this procedure eliminates the source of infection and eliminates the need for a frontal nasal opening. Long-term success rates range from

75% to 93% and are independent of obliteration of the cavity with fat or not.5z The major disadvantage of this procedure is the possibility of leaving any residual mucosa within the obliterated cavity which will inevitably produce recurrent infection or mucocele formation. Devitalization of the anterior wall is uncommon. Successful care of the “allergy’‘-plagued patient is based on appropriate medical management and surgical intervention when it is determined to be necessary. Thus, a teamwork approach between the medical specialist and otolaryngologist is necessary. REFERENCES

1. Kaplan AP, ed. Allergy. New York: Churchill Livingstone, 1985:323-61. 2. Hollinshead WH. Anatomy for surgeons. In: Hollinshead WH. The head and neck, vol. 1. 3rd ed. Philadelphia: Harper and Row, 1982:223-63. 3. Ballenger JJ. The clinical anatomy and physiology of the nose and accessory sinuses. In: Ballenger JJ, ed. Diseases of the nose, throat, ear, head and neck. 13th ed. Philadelphia: Lea and Febiger, 1985:1-23. 4. Mattox DE, Delaney GR. Anatomy of the ethmoid sinus. Otolaryngol Clin North Am 1985;18(1):3-13. 5. Feldman B, Feldman B. Nose and sinuses.In: Lee KJ. Essential otolaryngology. 3rd ed. New York: Medical Examination Pub Co, 1983:379-83. 6. Friedman WH, Slavin RG. Diagnosis and medical and surgical treatment of sinusitis in adults. Clin Rev Allergy 1984; 2(4):409-28. 7. Fascenelli FW. Maxillary sinus abnormalities: radiographic evidence in an asymptomatic population. Arch Otolaryngol 1969;90:98-101. 8. Evans FO Jr, Sydnon B, Moore WEC, et al. Sinusitis of the maxillary antrum. N Engl J Med l ;293(15):735-9. 9. Finn DG, Hudson WR, Baylin G. Unilateral polyposis and mucoceles in children. Laryngoscope 1981;91:1444-9. 10. Bumsted RM. Chronic nasal obstruction and discharge. In: McGuirt FW. Pediatric otolaryngology case studies. 2nd ed. New York: Medical Examination Pub Co, 1984:271-6. 11. Reilly JS, Kenna MA, Stool SE, et al. Nasal surgery in children with cystic fibrosis: complications and risk management. Laryngoscope 1985;95(12):1491-3. 12. Robinson KE. Roentgenographic manifestations of benign paranasal disease. Ear Nose Throat J 1984;63:144-9. 13. Carter BL, Bankoff MS, Fisk JD. Computed tomographic detection of sinusitis responsible for intracranial and extracranial infections. Radiology 1983;143(3):739-42. 14. Kennedy DW, Zimeich SJ, Rosenbaum AE, et al. Functional endoscopic sinus surgery. Theory and diagnostic evaluation. Arch Otolaryngol 1985;111:576-82. 15. Goodes RL. Surgery of the turbinates. J Oto 1978;7(3): 262-8. 16. Mygind N. Nasal allergy, 2nd ed. Oxford: Blackwell Scientific Publications, 1979:271-83. 17. Ozenberger J. Cryosurgery in chronic rhinitis. Laryngoscope 1973;83:508-16. 18. Fukutake T, Yamashita T, Tomocla K, et al. Laser surgery for allergic rhinitis. Arch Otolaryngol Head Neck Surg 1986; 112(12):1280-2.

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2 I. 22. 23. 24. 25. 26.

27.

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29. 30. 3 1. 32. 33. 34.

35.

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House HF. Submucous resection of the inferior turbinal bone. Laryngoscope 1951;61:637-48. Martinez SA, Nissen AJ, Stock CR, et al. Nasal turbinate resection for relief of nasal obstruction. Laryngoscope 1983; 93:x71-5. Bernstein L. Submucous operations on the nasal septum. Otolaryngol Clin North Am 1973;6(3):675. Harrison DFN. Surgery in allergic sinusitis. Otolaryngol Clin North Am 1971;4:79-95. Frenkiel S, Small P, Rochon L, et al. Nasal polyposis-a multidisciplinary study. J Otolaryngol 1982;11(4):275-8. Moloney JR. Nasal polyps, nasal polypectomy, asthma, and aspirin sensitivity. I Laryngol Otol 1977;91:837-46. Settipare GA, Chafee FH. Nasal polyps in asthma and rhinitis. J ALLERGY CLIN IMMUNOL 1977;59:17-21. English GM. Nasal polypectomy and sinus surgery in patients with asthma and aspirin idiosyncrasy. Laryngoscope 1986; 96(4):374-80. Stem RC, Boat TF, Wood RE, et al. Treatment and prognosis of nasal polyps in cystic fibrosis. Am J Dis Child 1982; 136( 12): 1067-70. Fairbanks DN. Dental and allergic aspects of sinusitis and nasal polyposis: a review. Otolaryngol Head Neck Surg 1982; 90(5):527-33. Eichel B.S. The intranasal ethmoidectomy: a 12-year perspective. Otolatyngol Head Neck Surg 1982;90(5):540-3. Bluestone CD. Preface. Pediatric Infect Dis 1984;4 (suppl 6):549. Furstenberg AC. The treatment of acute nasal accessory sinus disease. Ann Otol Rhino1 Laryngol 1938;74:902. Wald ER. Epidemiology, pathophysiology, and etiology of sinusitis. Pediatr Infect Dis 1985;4(6):551-3. Smith JM. The medical treatment of sinusitis. Otolaryngol Clin North Am 1971;4(1):39-50. Gwaltney JM Jr, Sydnor A Jr, Sande MA. Etiology and antimicrobial treatment of acute sinusitis. Ann Otol Rhino1 Laryngol 198 1;9O[Suppl]:68-7 1. Engquist S, Lundberg C, Venge P. Effects of drainage in the treatment of acute maxillary sinusitis. Acta Otolaryngol (Stockh) 1983;95(1-2):153-9.

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