Experts Debate Surgical Approaches To Sinus Disease

Part 1 of 2 articles

PHILADELPHIA-Surgeons are faced with many options for approaching diseases of the sinus, and the right approach is not always clear-cut. Five experts reviewed several approaches at Rhinology World held recently here, with some favoring a more aggressive approach, some preferring to be less aggressive, and others highlighting new technology.

FESS: Often a Good Option

Bradley F. Marple, MD, Professor of Otolaryngology at the University of Texas Southwestern Medical School, cited studies to make the case that functional endoscopic sinus surgery (FESS) is a very good option for patients.

Overall, he said, patient satisfaction levels are high. But he noted that mucociliary clearance is only part of the answer and that inflammatory disease can remain. Further management of inflammation is then needed.

Studies show that those with more severe disease enjoy greater relief, which raises the questions of where the bar should be set, when FESS is actually needed, and whether patients get sufficient treatment before surgery is performed.

But there have been few studies comparing the effects of the surgery to other options, he said.

What do we have in terms of comparative data? It’s limited, Dr. Marple said. Endoscopic sinus surgery undeniably provides a broad ability; it’s a very powerful platform to target disease.

Pros and Cons of FESS

Dr. Marple set out to address the advantages of the surgery as well as its drawbacks.

Sinus surgery can relieve obstruction, provide ventilation, and remove or relocate tissue and structures. Surgery fails to primarily address allergies, viral upper respiratory infections, and many kinds of headaches, Dr. Marple said.

The indicators that sinus surgery might be needed are that medical management of chronic rhinosinusitis and recurrent acute rhinosinusitis has failed, when there are complications associated with acute bacterial rhinosinusitis, the presence of mucocele, chronic anterior headache, problems with smelling, neoplasm, and/or cerebrospinal fluid leaks.

Other indicators are association with a dacryocystorhinostomy, orbital decompression, and choanal atresia.

Some of these indicators are up for debate, though, including whether surgery is always needed when treatment fails, whether it is appropriate for chronic anterior headaches that are caused by problems with the anatomy, and whether it is suitable for handling problems with the sense of smell.

FESS results showed improvements over the years, Dr. Marple said. A 1990 study of 165 patients showed that patients reported subjective improvement after 10 months, but that endoscopic disease continued. In 1992, 97% of 120 patients reported subjective improvement in a symptom-based questionnaire, but, again, the disease persisted. In 1998, at a follow-up of eight years, 98% of 120 patients showed overall improvement, but revision surgery was needed in 18% of the patients.

A 2004 randomized controlled trial-the only such study on the topic, Dr. Marple noted-measured success rates of endoscopic sinus surgery compared to continued medical treatment in 90 patients who failed initial treatment of chronic rhinosinusitis. The results were roughly equivalent for the two groups.

The outcome was a little bit numbing when you look at it from the standpoint of a surgeon, Dr. Marple said. When you look at the outcome at six months and you look at outcome at 12 months, there’s really no statistically significant difference.

One major advantage of FESS is that it can be tailored to the individual, Dr. Marple noted. But there is evidence that FESS can fail at holding down inflammation in CRS.

In chronic rhinosinusitis, the overwhelming data suggest that patients feel better after sinus surgery, Dr. Marple said. Persistence of some inflammation is present-and that raises the question: Are we really accomplishing what we set out to accomplish at the very beginning by simply opening and ventilating sinuses?

In a retrospective review of 188 patients, with follow-up at 12 to 168 months, recurrence occurred in 60% of the patients and revision surgery was required in 27% of the patients.

Studies have also found that ESS can provide beneficial systemic changes in patients with more severe disease, such as CRS with polyps, with studies showing beneficial effects on asthma and that surgery can limit cytokine expression.

Another Surgical Option: Sphenoidectomy

Jean Michel Klossek, MD, PhD, of the University Hospital Poitiers in France, said that a sphenoidectomy involving a total removal of the ethmoidal mucosa is a viable option for patients with chronic rhinosinusitis with polyps. He said that his center has performed the procedure on 35 to 50 such patients each year since 1985.

It’s only for chronic rhinosinusitis with polyps, which is very important, Dr. Klossek said. It’s not for chronic rhinonsinusitis without polyps.

He said that he performs the procedure only after patients have received long-term medical treatment, including three courses of oral steroids per year for two years. He reserves the surgery only for those patients with major discomfort caused by the disease.

His preoperative assessment includes a nasal endoscopy, an evaluation of pulmonary function, and a review of environmental risks such as smoking and work hazards. Before we make a decision, we wait for many years, Dr. Klossek said.

The procedure involves a polypectomy with or without a shaver; a middle meatal antrostomy for remove of large polyps; opening and removal of the ethmoid mucosa; exposure of the orbital wall and the skull base; and a sphenoidotomy.

The standardized technique takes 90 minutes to complete, and eight weeks should be allowed for healing, Dr. Klossek said. Patients must take antibiotics for 10 days, oral steroids for six days, and topical steroids for life.

Dr. Klossek said he is referred 350 patients per year but performs surgery on only 10% to 15% of those.

In a retrospective study of surgery recipients between 1985 and 1998, there were no major complications within the first three months, but there were 43 instances of infections. Of the 563 patients with follow-up at 10 years, 1% had developed mucocele, 0.5% had frontal stenosis, and there were major relapses in 17%.

Dr. Klossek was careful to say that the procedure is not necessarily better than other approaches. It’s just a complement, he said. It’s not a battle between FESS and removal of ethmoid mucosa.

Part 2 of this article will discuss balloon catheterization and minimally invasive techniques.

©2009 The Triological Society