21

Abstract

The surgical management of chronic rhinosinusi-tis has evolved considerably in the last decade. Wecurrently have a more refined understanding of thevarious disease entities that make up the genericdiagnosis of chronic rhinosinusitis. This has led tothe development of more sophisticated medicaland surgical therapy for the different entities. Fail-ure of maximal medical therapy leads to the con-sideration of surgical intervention with the generalintent of improving the patient’s quality of life.Recent technical innovations such as mucosa-preserving instrumentation and image guidancesystems for intraoperative localization have givensurgeons increased confidence and enabled morecomplete and effective surgical management ofchronic rhinosinusitis, particularly in revision surg-eries or in the presence of distorted landmarks.Improved packing materials and refinement ofpostoperative care are active areas of investiga-tion and innovation that, it is hoped, will also trans-late into improved patient care.

Assumption and Statement of Scope

This article is intended to provide an overview ofthe surgical management of chronic rhinosinusi-tis (CRS). We assumed a general understanding,

on the part of the reader, of sinonasal anatomy andphysiology which are well covered elsewhere andbeyond the scope of this review.1,2

Diagnostic Considerations

Prior to beginning a discussion of surgical man-agement of CRS, it is worthwhile to mention thediagnostic methodology and a classification ofCRS. CRS is primarily a clinical diagnosis basedon history and physical examination. The physi-cal examination of the sinusitis patient must includenasal endoscopy, which can often detect subtle dis-ease that is not visible on anterior rhinoscopy.Adjunctive measures in the diagnosis of CRS mayinclude endoscopically directed culture of themiddle meatus and radiographic imaging withcomputed tomography (CT). CT is a very sensi-tive method for detection of even subtle mucosalthickening in areas of the paranasal sinuses not vis-ible on nasal endoscopy. This imaging modalityalso provides detailed images of the intricateanatomy of the paranasal sinuses, such as the eth-moid sinuses and the ostiomeatal complex (Fig-ure 1). There is also a more limited role for mag-netic resonance imaging when issues of diagnosisconcern a distinction between soft tissue planes andlesions (Figure 2).

Recent years have led to an evolution in ourunderstanding of the disease entities that make upthe all-encompassing term of CRS. Because thetreatment and prognosis of the varying diseaseentities may be quite different, it is worthwhile toconsider a classification scheme for CRS (Table1). For example, in the setting of recurrent acutesinusitis, diagnostic considerations relating to sur-gical intervention would include the presence ofanatomic abnormalities that could predispose the

Rhinitis and Sinusitis

Advances in the Surgical Management of Chronic RhinosinusitisErin D. Wright, MDCM, MEd, FRCSC; Saul Frenkiel, MDCM, FRCSC

E. D. Wright — Department of Otolaryngology, Universityof Western Ontario, London, Ontario; S. Frenkiel —Department of Otolaryngology, McGill University,Montreal, Quebec

Correspondence to: Dr. Erin D. Wright, LondonRhinosinology Centre, St. Joseph’s Health Care, 900Richmond Street, 3rd Floor, London, ON N6A 5B3

22 Allergy, Asthma, and Clinical Immunology / Volume 1, Number 1, October 2004

patient to impaired drainage of the ostiomeatalcomplex. Such abnormalities might include anatelectatic uncinate process or concha bullosa(Figure 3), and the presence of such abnormalitieswould make a patient a surgical candidate likelyto obtain relief from his or her symptoms.

From a clinical and a radiologic perspective,there seem to be distinctions that can be madebetween patients with diffuse mucosal thicken-ing involving the paranasal sinuses (chronichyperplastic rhinosinusitis) but without polypo-sis and those patients with diffuse sinonasal

polyposis with polyps projecting into or com-pletely occluding the nasal airway (CRS withpolyposis). However, the prognostic implica-tions of such distinctions remain to be demon-strated on the basis of scientific evidence.

Within the generic disease of CRS, therehas been a further distinction created to includethose patients with allergic fungal sinusitis, a

Figure 1 Computed tomographic scan of normalparanasal sinuses. A demonstrates the anterior ethmoidand ostiomeatal complex. B demonstrates the posteriorethmoid. Note is made of the absence of mucosal thick-ening or retained fluid.

Figure 2 A, Computed tomographic scan of a patientwho presented with a presumed mucocele of the sphe-noid sinus with extension to the ethmoid and orbit. Therewas concern that the mucocele had eroded intracraniallyin the sphenoid. B, Magnetic resonance image cut thatcorresponds to the CT cut shown in A that fails todemonstrate intracranial extension or dural enhance-ment. This clarified the diagnosis and helped in the sur-gical planning.

A A

B B

Advances in Surgical Management of Rhinosinusitis — Wright and Frenkiel 23

disease entity with some similarities to allergicbronchopulmonary aspergillosis. Although thereis currently considerable controversy regardingthe incidence and pathogenesis of fungal sinusi-tis,3–5 most sinus surgeons would agree that, inat least some patients with CRS and polyposis,reactivity to commensal fungal organisms orsome similar disease process is occurring. Thetypical findings with allergic fungal sinusitisinclude polypoid mucosa and tenacious allergicmucin with abundant eosinophils and eosinophilbreakdown products.

Patient Selection

A logical consequence of the emerging subclassifi-cation of CRS is that the treatment may differ depend-ing on the disease process at work in any givenpatient. Surgical intervention, in terms of scope andexpectations, can vary with the different subtypes ofCRS. Nonetheless, a general rule that is followed isthat patients become candidates for surgical inter-vention for treatment of their sinus disease when theyhave failed maximal medical therapy. Exceptions tothis rule obviously include evidence of impendingcomplications (eg, expanding mucocele or mucopy-ocele) or the suspicion of neoplasm. Depending onthe diagnosis, maximal medical therapy may includea prolonged trial of topical, intranasal corticosteroids,a prolonged trial of broad-spectrum antibiotics, sys-temic corticosteroids, and adjunctive measures suchas saline irrigations. The use of the term surgical can-didate implies that surgery is not absolutely indicatedbut that it becomes an option to help manage ordefinitively treat a patient with CRS.

Taking the example of recurring acute sinusi-tis with the absence of chronic mucosal changes anda normal appearance between episodes, surgicalintervention would be indicated if the acute infec-tions are of sufficient frequency. (Generally

considered to be greater than 3 episodes of acute bac-terial sinusitis per year requiring antibiotic therapy).The aims of surgery in this instance would be thecorrection of anatomic factors that can predisposethe patient to ostial obstruction (Table 2) and theimprovement of sinus outflow tracts. This is typi-cally what is referred to as functional endoscopicsinus surgery,6,7 which consists of an infundibulo-tomy, middle meatal antrostomy, and anterior eth-moidectomy with possible posterior ethmoidec-tomy, sphenoidotomy, or frontal sinusotomy, as

Figure 3 A, Example of an atelectatic uncinate processwith obstruction of maxillary sinus outflow and resul-tant sinus opacification. B, Example of a large con-cha bullosa (patient’s right side) in a patient with ahistory of recurrent acute flare-ups of mild chronic rhinosinusitis.

Table 1 Classification of Chronic Rhinosinusitis

Recurrent acute rhinosinusitisChronic purulent rhinosinusitisChronic hyperplastic rhinosinusitisChronic rhinosinusitis with polyposisSamter’s triad3

Allergic fungal rhinosinusitis4

Eosinophilic mucin rhinosinusitis5

B

A

24 Allergy, Asthma, and Clinical Immunology / Volume 1, Number 1, October 2004

deemed appropriate by the surgeon. These latter twosinuses are frequently left alone in the clinical set-ting of recurrent acute sinusitis.

A different example might include that of thetreatment of CRS with polyposis. In this setting,a candidate for surgical intervention would likelyhave failed trials with topical intranasal cortico-steroids and systemic corticosteroids. Somepatients have contraindications to systemic corti-costeroids or are reluctant to take the medicationbecause of potential side effects. In the setting ofthe patient with polyposis, the aim of surgery isfirst to provide immediate relief of symptomssuch as nasal obstruction and facial pressure or con-gestion and to help in the long-term managementof the inflammatory sinus disease. Patients arefrankly apprised of the high likelihood that furthermedical therapy will still be required to managetheir disease but that marsupialization of the eth-moid sinus cavity with surgical widening of theostia of the secondary sinuses (frontal, maxillary,sphenoid) provides access to topical medicationsand access in the clinic to help identify and con-trol recurrent inflammatory disease. Further, insome instances, surgical cleaning of polyps andobstructing mucosal hypertrophy can result inlong-term control or “cure” of the sinus diseasefrom both objective (endoscopic) and subjectiveperspectives. Thus, it can be seen that the aimand extent of surgical intervention can vary sig-nificantly depending on the presentation, diagno-sis, and impact on the quality of life of the patient.

Indications and goals for revision endoscopicsinus surgery are not dissimilar to those for pri-mary surgical intervention. Again, failure of med-ical therapy is generally a prerequisite. From a tech-nical perspective, there are sometimes indicationsfor revision surgery, such as retained bony parti-tions in the ethmoid, scar formation with resultantobstruction of sinus ostia, and scarring closed ofthe sinus ostia owing to bony or soft tissue

contraction. Obviously, another indication forrevision surgery is recurrent polyp disease that can-not be managed medically or in the office.

Technical State of the Art

The current state of the art in endoscopic sinussurgery includes many recent innovations. Prob-ably the most fundamental change in sinus surgeryhas been the adaptation of rigid endoscopes for usein the nose. These 4 mm endoscopes permit superbvisualization and are available in various anglesranging from 0 to 30, 45, and 70 degrees. Theyalso afford surgeons the opportunity to handleinstruments with their free hand while maintain-ing the view of the operative field. This paradigmshift, in the form of endoscopic sinus surgery,began in North America in the mid- to late 1980s6

and has become the widespread standard of care.From a technical perspective, there has been

the realization that meticulous handling ofsinonasal mucosa results in a better and morerapid return to the function of mucociliary clear-ance. To help achieve this goal, new instrumen-tation has been developed that helps avoid themucosal stripping that can result in impairedmucociliary clearance or neo-osteogenesis orosteitis with bony thickening owing to exposedperiosteum. Examples of such instrumentationinclude sharp through-cutting forceps (Figure 4)and microdébriders (Figure 5). The through-cutting forceps permit the precise removal ofdiseased mucosa and bony partitions withoutstripping of adjacent mucosa that is healthy or has the potential to return to normal function.Microdébriders are a relatively new addition tothe surgical armamentarium. They are devices thatemploy suction in concert with an oscillatingblade that allows the efficient removal of diseasedtissue in a relatively bloodless field with preser-vation of adjacent healthy or recoverable tissue.They are particularly helpful when removingbulky polypoid disease but have also beenimproved to help with removal of ethmoid par-titions and other thin areas of bone. Variousblades can be used in the ethmoid sinus, maxil-lary sinus, and frontal recess, as well as drill tipsthat can be driven by the same handpiece that dri-ves the regular suction débrider blades.

Table 2 Variants of Normal Anatomy that CanPredispose Patient to Chronic Rhinosinusitis

Concha bullosa (pneumatized middle turbinate)Paradoxically curved middle turbinateAtelectatic uncinate processInfraorbital ethmoid pneumatization (Haller’s cell)Agger nasi air cell

Advances in Surgical Management of Rhinosinusitis — Wright and Frenkiel 25

Perhaps the most significant and excitinginnovation in the area of endoscopic sinus surgeryis that of image-guided surgery (Figure 6). Thistechnology uses frameless stereotactic navigationto help surgeons precisely localize their instrumentsin space (and therefore in the patient’s sinuses). Thebasic process involved is that of correlationbetween patients’ actual bony anatomy and theirpreoperative CT scans, which is performed bysophisticated software.

In brief, a patient undergoes a preoperative CTscan using a predetermined protocol, followingwhich the data are downloaded to the image guid-ance system, usually over a network connection.At the time of surgery, the CT data stored in thecomputer are registered, along with known pointsof the patient’s anatomy, after which the com-puter can then give the surgeon the location of var-ious instruments that have been placed in thepatient’s nose. There are currently two types ofimage guidance systems. One such system is basedon electromagnetic technology, whereas the other

is based on optical reference using infrared emit-ters and sensors.

The impact of this new technology has been,theoretically, to increase the safety and com-pleteness of surgery in addition to increasing theconfidence of the surgeon. This accounts for theincreasing numbers of health centres that havepurchased or are considering purchasing a system.To date, however, no scientific studies remain toconfirm an increase in safety (reduced incidenceof complications). A reduction in complicationswith endoscopic sinus surgery would be extremelydifficult to demonstrate because the incidence ofserious complications is, fortunately, already verylow. Image-guided surgery has not yet, and maynever, become the standard of care and is notrequired for routine or limited surgery. Nonethe-less, it is an invaluable tool for the more complexsurgical cases, such as those that involve thefrontal and sphenoid sinuses, as well as for revi-sion surgeries in which the normal anatomy nor-mally used for visual reference has been distorted.

Figure 4 Through-cutting instruments used in endo-scopic sinus surgery. These instruments avoid strippingof healthy or salvageable mucosa.

A

B

Figure 5 Microdébrider and blades used for preciseand efficient removal of polyps, mucosa, and bone inendoscopic sinus surgery.

A

B

26 Allergy, Asthma, and Clinical Immunology / Volume 1, Number 1, October 2004

Another recent innovation in the surgical man-agement of CRS is that of biocompatible dressingsand packing materials. Recent literature describesthe use of such materials, which are generallybased on acellular connective tissue matrix gly-coproteins.8 The body breaks down the packing ordressing, and any residuum can be easily suc-tioned from the sinus cavities. It is likely thatfuture innovations will include the manufacture andmodification of these dressings to deliver med-ication to the healing sinus cavities, which mayhelp suppress inflammation or infection, therebyimproving surgical outcome and minimizing com-plications such as scar band formation and sinusostial obstruction.

Postoperative Care

In recent years, an appreciation has developedfor the importance of postoperative care in the sinus

surgery patient. Currently, postoperative care isdefined to include both endoscopic débridementand monitoring of the sinus cavities in the outpa-tient clinic, as well as medical pharmacotherapy.

In the initial weeks following endoscopicsinus surgery, there is the need for removal ofdevitalized tissue and retained secretions fromthe operated sinuses. This is important because thereturn to normal mucociliary function does not typ-ically occur until 4 to 6 weeks after surgery. Also,any scarring that is beginning to form that maystenose or occlude access to the sinus cavities iseasily divided at this early stage, whereas it ismuch more difficult to deal with mature synechiaeonce formed. Endoscopic assessment of the cav-ities can also determine the effectiveness of heal-ing and the need for further medical therapy in aneffort to optimize outcome.9 Examples of thismedical care include the need for antibiotics in thepresence of purulence or granulation tissue. Also,the need for saline irrigations and even cortico-steroids can be determined.

Figure 6 Example of an optical image guidance sys-tem for intraoperative use in endoscopic sinus surgery.

Figure 7 Commonly used equipment in the outpatientclinic for postoperative débridement and ongoing care.Endoscopic visualization permits suction, tissueremoval, polypectomy, and directed cultures.

Advances in Surgical Management of Rhinosinusitis — Wright and Frenkiel 27

Astrong argument can be made for regular sur-veillance with sinus endoscopy because earlytreatment of ongoing inflammation or infectionmay avoid the need for revision surgery.9 Ongo-ing or recurrent inflammation or infection can bedetected before it becomes overtly symptomatic,at a time when treatment may be easier and moreeffective. This objective assessment of outcomesis gradually gaining acceptance in the literature andin the staging systems used for CRS. In longitu-dinal studies of patients who have undergonefunctional endoscopic sinus surgery, with a meanfollow-up of 7.8 years, a sinus cavity that hasnormalized to endoscopic assessment at 18 monthsfollowing surgery has a strong likelihood ofremaining normal and of that individual avoidingthe need for any revision surgery.10

Given the currently available instrumenta-tion, it is possible to perform many small proce-dures in the outpatient clinic. The use of rigidnasal endoscopes and surgical instruments (Fig-ure 7) permits office débridement of the sinuscavities, directed cultures from the middle mea-tus or marsupialized sinus cavities, and polypec-tomies. Patients presenting for follow-up whoshow evidence of polyps reforming can have theseearly polyps débrided with topical and/or localanesthesia. Such ongoing cavity “maintenance” canoften keep these individuals out of the operatingroom and avoid the need for more extensivesurgery, with its attendant risks. It is even possi-ble to lyse synechiae; revise sinus ostia that haveobstructed, such as the maxillary or frontal; andeven revise ethmoid cavities that have small bonypartitions or fragments that were retained.

Conclusion

Recent innovations in the surgical management ofchronic sinusitis include an improved under-standing of the disease entities being treated,which has enabled more refined diagnostic crite-ria for the various subclassifications of CRS. Thisbetter understanding permits tailored medical ther-

apy for these disease entities. When maximalmedical therapy has failed, patients become can-didates for endoscopic sinus surgery, which isalso tailored to treat the specific disease of anindividual patient. New instrumentation, includ-ing mucosa-sparing techniques and image-guidedsurgery, continues to revolutionize the endoscopicmanagement of CRS. Improved packing and ongo-ing refinements in postoperative care are activeareas of innovation.

References

1. Cummings CW. Otolaryngology—head andneck surgery. 2nd ed. St. Louis: Mosby; 1995.

2. Kennedy D, Bolger W, Zinreich S. Diseases ofthe sinuses: diagnosis and management.Hamilton (ON): BC Decker; 2001.

3. Samter M, Beers RF Jr. Concerning the nature ofintolerance to aspirin. J Allergy 1967;40:281–93.

4. Katzenstein AL, Sale SR, Greenberger PA.Allergic Aspergillus sinusitis: a newly recog-nized form of sinusitis. J Allergy ClinImmunol 1983;72:89–93.

5. Ferguson BJ. Eosinophilic mucin rhinosinusi-tis: a distinct clinicopathological entity.Laryngoscope 2000;110(5 Pt 1):799–813.

6. Kennedy DW. Functional endoscopic sinussurgery. Technique. Arch Otolaryngol1985;111:643–9.

7. Kennedy DW, Zinreich SJ, Rosenbaum AE,Johns ME. Functional endoscopic sinussurgery. Theory and diagnostic evaluation.Arch Otolaryngol 1985;111:576–82.

8. Frenkiel S, Desrosiers MY, Nachtigal D. Useof hylan B gel as a wound dressing after endo-scopic sinus surgery. J Otolaryngol 2002;31Suppl 1:S41–4.

9. Kennedy DW, Wright ED, Goldberg AN.Objective and subjective outcomes in surgeryfor chronic sinusitis. Laryngoscope2000;110(3 Pt 3):29–31.

10. Senior BA, Kennedy DW, Tanabodee J, et al.Long-term results of functional endoscopicsinus surgery. Laryngoscope 1998;108:151–7.