Endoscopic sinus surgery

Abstract

Before 1985, sinus surgery was typically performed through open surgical approaches. At that time, the maxillary sinus was thought to be the most frequent site of sinus disease and the frontal sinus was considered to be the second most common site. When sinus disease within the maxillary sinus persisted despite medical therapy, one of the concepts was to provide dependent drainage to the sinus through an inferior meatal window, an opening created close to the floor of the sinus. If dependent drainage failed, the concept was then to strip the diseased mucosa from the sinus. Sinus surgery was frequently fraught with failure, and patients often ended up with increasing discomfort, persistent infection, and frequently repeated surgical interventions [1,2]. However, since that time, the results of surgical intervention have significantly improved, as has our understanding of sinusitis and its pathogenesis. In part, this occurred because as improved endoscopes were introduced, physicians both in Europe and in the United States began to use them more frequently for nasal endoscopy (Fig. 7.1). As we did so, we noted the frequency of involvement of the ethmoid sinuses and the adjacent middle meatus in both chronic and acute sinusitis and that, in many cases, this involvement occurred even before the maxillary sinus was affected. It also now became possible to identify endoscopically how inflammation in these areas appeared to affect the larger sinuses, causing obstruction and repeated infection (Figs. 7.2, 7.3) [3]. Around the same time, imaging-initially with polytomography and subsequently computed tomography (CT)-allowed improved radiographic visualization within the complex region of the ethmoid sinuses [4]. The ethmoid sinus area had previously been very poorly visualized on plain films because of the averaging created by the multiple ethmoid cells, cells that become superimposed upon each other and averaged in plain film imaging. CT confirmed what had been identified endoscopically: namely, that the ethmoid sinus was indeed the most frequently involved region in chronic sinusitis. We also began to better understand, at this time, the extent to which mucociliary clearance is a very active dynamic process, one that could be identified with microscopic and endoscopic visualization. Additionally, by reperforming experiments initially performed in the first half of the 20th century, we were able to demonstrate conclusively that stripping mucosa was damaging to the sinuses in the long term and should be avoided whenever possible [5]. As a result of these observations and the advent of improved endoscopes, the concept of functional endoscopic sinus surgery (FESS) was born [3,6]. The keystones of this technique are accurate diagnosis of the underlying sites of persistent disease using both endoscopic visualization and CT imaging, the concept of a more limited surgical procedure performed endoscopically, as well as the preservation of mucosa with the goal of redeveloping mucociliary clearance. Since the introduction of FESS, the morbidity of surgical intervention has significantly decreased; and open surgical procedures are now rarely needed. By combining surgery with medical management and endoscopically directed postoperative care, we have demonstrated that it is possible to achieve a marked improvement in patient symptoms in more than 90% of patients with chronic rhinosinusitis and nasal polyposis. Moreover, we can maintain this improvement over at least an 8-year postoperative period [7]. In subsequent years, we have also developed some additional understanding of the causes of chronic rhinosinusitis, and of the application of surgery as an adjunct, rather than an alternative, to appropriate medical management. In the early years of endoscopic sinus surgery- and to some extent still today-enthusiasm for the reduced morbidity, and the thought that perhaps many of these patients would be able to avoid continued medical therapy, led to overuse of endoscopic sinus surgery. As with other new surgical procedures the operation was not, and sometimes still is not today, always performed optimally and with the level of training that the techniques really require [8]. We now know that FESS requires meticulous attention to detail and mucosal preservation intraoperatively, as well as detailed postoperative follow-up, if the best possible results are to be achieved. The surgery should not be performed as an alternative to medical therapy, but rather to augment medical therapy, reduce recurrent infections, and improve overall quality of life. © 2008 Springer Science+Business Media, LLC. All rights reserved.