Integrated Approach Key to Evaluating Recalcitrant Rhinosinusitis Patients

Although it hasn’t reached the clinical realm yet, another promising innovation is that of the electronic nose-a technology that has mostly been used in industry.

It’s not really an olfactory device, but a chemosensory array that will electronically detect the volatile aspects of pathogens, Dr. Hwang said. What it can do, for example, is analyze the breath of a patient and detect bacterial sinusitis with fairly good accuracy. It has also been shown to be very sensitive in detecting tuberculosis in culture plates.

Another innovation on the way involves emerging data on the role of biofilms and chronic sinusitis.

It’s clear that some strains of bacteria have a tendency to form biofilms and others don’t, Dr. Hwang said. Data from a recent study showed biofilm forming strains of pseudomonas and staph may be associated with worse outcomes after FESS [functional endoscopic sinus surgery]. So, if we do have the ability to develop a clinically useful biofilm assay, this may be helpful in terms of managing our patients.

Maxillary and Frontal Disease

When addressing recalcitrant maxillary disease, recirculation is probably the most common cause for failed surgery in the maxillary sinus. Canine fossa puncture (CFP) has become the procedure of choice for many in clearing the maxillary sinus of disease.

Canine fossa puncture allows you to access all areas of the maxillary sinus, said Peter John Wormald, MD, of Queen Elizabeth Hospital in Adelaide, South Australia.

But, he noted, there can be a significant risk of postoperative morbidity associated with CFP, with nerve damage being a common side effect.

When you go through the canine fossa, the most common nerve you’re going to injure is the anterior-superior alveolar nerve (ASAN), which traverses the canine fossa in a vast proportion of patients, Dr. Wormald said.

To address this, Dr. Wormald and his colleagues began to look for an alternative landmark for performing CFP.

What we did is take a vertical line through the mid-pupillary line and a horizontal line through the ala, he said. If you perform your CFP at that point, then you are much less likely to injure the nerves. Now, this is a lot further lateral than the standard canine fossa. It’s at least a centimeter further.

Using this new landmark, Dr. Wormald said they were able to significantly reduce the incidence of postoperative morbidity.

We showed that we were able to reduce the incidence of complications using the new landmarks from 75 percent to 45 percent and were able to reduce the rate of persistent complications from 16 percent to 2 percent, he said. So, going that centimeter or so more laterally with your canine fossa trephine, you can avoid significant damage to the anterior-superior alveolar nerves.