Toronto—When dealing with patients who have complex sinus disease who have failed a number of treatments, there are still various approaches the otolaryngologist–head and neck surgeon can use. Some of these include getting additional imaging done to confirm the extent of disease, finding a neurologist who will do specific and even uncommon tests to find the causes of headache, and taking biopsies.
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May 2006These and other approaches were discussed by a panel of experts here at the meeting of the Eastern Section of the Triological Society. Marvin Fried, MD, Professor and Chair of Otolaryngology–Head and Neck Surgery at the Albert Einstein College of Medicine in New York, NY, moderated.
Dr. Fried presented several case studies for discussion, the first being a post-operative sinusitis patient who returned with various symptoms, including persistent left nasal congestion, eustachian dysfunction, anterior left and posterior right septal deviation, and some retraction of the left tympanic membrane. No mucosal disease was present and he had failed topical steroid treatment.
“There are times when even with the most objective data, you sometimes have to put it aside. We are all concerned about operating on negative scans, but we have to remember we’re not operating on the scans but a patient.” – —Marvin Fried, MD
Identifying Cause May Require Neurology Consult
Panelists concurred that a neurologic consult was needed to look for possible etiologies such as neuropathic pain or atypical migraine.
However, “not all neurologists are created equal,” said James N. Palmer, MD, Assistant Professor of Otorhinolaryngology at the University of Pennsylvania in Philadelphia. He suggested encouraging this sort of patient to go to a neurologist who specializes in headache and facial pain.
In pediatrics, “we seldom see patients with rhinogenic headache,” said Sanjay Parikh, MD, Assistant Professor of Otorhinolaryngology–Head and Neck Surgery and Pediatrics at Albert Einstein College of Medicine in New York, NY. He refers young patients with facial pain to neurologists.
If the neurologist is unsuccessful and there is still pain, additional steps can be taken. “I’m not sure I’m excited about doing it,” said Dr. Palmer, “but I do it. I decongest the patient well, then put cocaine on small pledgets and place it in different spots where I see contact points in the nose,” he said.
Scan Can Provide Further Information
If this successfully relieves pain, then the patient is likely suffering pain due to inflammation. The next step is to get the patient to undergo a computed tomography (CT) scan when the headache returns. If images reveal disease in the area that had been numbed, then the patient may benefit from sinus revision surgery in that area.
Some patients may have localized discomfort over the cheek, as well as problems with recirculation of mucous between the maxillary natural ostia and an accessory ostia, said Ian Witterick, MD, Associate Professor of Otolaryngology at the University of Toronto in Ontario, Canada.
If this is the problem, then “suctioning out the mucous or connecting the two ostia surgically to promote proper drainage may improve the symptoms,” he said. Dr. Fried’s sample case likely wasn’t this sort of problem, though.
CT scans don’t always show whole story, though. Dr. Fried’s patient had more extensive disease than CT scans had revealed. The disease was bilateral but the CT showed only unilateral problems. Solving the case required surgery, he said.
“There are times when even with the most objective data, you sometimes have to put it aside. We are all concerned about operating on negative scans, but we have to remember we’re not operating on the scans but a patient,” Dr. Fried said.
Comparing debridement to saline solution for postoperative care, Dr. Parikh said, “I had not seen any significant difference in outcome between the two different modalities of care.” – —Sanjay Parikh, MD
Bleeding Complications
The second case presented was of a patient with a history of progressive left nasal obstruction unresponsive to steroids, and intermittent left epistaxis. Studies showed a unilateral soft tissue mass lesion in the back of the nasopharynx that involved the sphenoid. A resection was done, but a week later the patient started to bleed.
Panelists agreed further surgery was needed to find, and stop, the bleeding source. Another CT should be done. “If there is a lot of bone over the carotid I’m not too worried about the carotid being the source of the bleed. If there is no bone over the carotid, I would probably get an angiogram prior to going to the OR,” Dr. Palmer said.
However, there was some debate as to whether embolizing the bleed during angiogram was a good idea. Dr. Witterick suggested embolization be done if the bleed source was found, while Dr. Palmer advised caution with this because of a possible increased risk of stroke.
Dr. Fried reported that an angiogram was done, the bleed was found and embolization performed.
Handling Preoperative Consent
A third case was of a 62-year-old male with a long history of sinus headache, recent episodes of epistaxis, nasal polyps, and no relief from nasal steroids. There was a polypoid mass obstructing the right nasal cavity, left septal deviation, and no purulent discharge. A CT scan revealed a unilateral soft tissue mass causing diffuse opacification with some aeration in the maxillary sinus. The question posed to panelists was what consent should be done?
“I would consent him as if I was going to do a traditional endoscopic sinus surgery,” said Michael Stewart, MD, Professor and Chair of Otorhinolaryngology at Weill Medical College of Cornell University in New York, NY, and ENToday Board Member. But, if another etiology was present, such as a potential lymphoma or squamous cell carcinoma, then a biopsy should be done. The course of action depends on the findings.
Generally, the panelists agreed they would ask for consent for a wide variety of investigations and procedures.
In pediatrics, the consent process is extensive, said Dr. Parikh. However, with kids there is an advantage in that parents can be asked for consent at almost any point, even during a procedure.
Endoscopic or Open Surgery for Carcinoma?
Further work on the patient revealed a friable mass filling the right ethmoid sinus extending to the face of the sphenoid, and it was squamous cell carcinoma. Panelists had different opinions on what the next step should be.
“I would consider removing it endoscopically,” especially if the mass had a small pedicle, said Dr. Palmer.
In Dr. Witterick’s office, only a biopsy would be done. A metastatic work-up would follow if squamous cell carcinoma was present. “Our primary treatment modality is usually radiation therapy or chemo-radiation. The vast majority of these people will not need any surgical resection,” he said. A traditional craniofacial resection would be performed if there was persistent disease or recurrence.
Dr. Fried reported that in this case, the mass had a small pedicle, was removed and multiple biopsies taken. The patient then underwent radiation therapy for any residual disease.
“I think it’s interesting we have this debate about endoscopic versus open, as if they are mutually exclusive… People get hot and bothered about which one, but in fact you don’t have to declare one side or the other. Endoscopy is a wonderful way to facilitate an open resection,” said Dr. Stewart.
Saline versus Debridement
Panelists then discussed how to proceed with a 55-year old woman with progressive diplopia, bilateral nasal obstruction, left epiphora and forehead pain. She had standard nasal polyposis, had a large left frontal mucopyocele, and had undergone surgery. The question was whether or not post-operative debridement should be done.
“I rely more on saline solution…you have a scab, let it heal and once it falls off it falls off. Have them use a saline rinse,” said Dr. Witterick.
“I think the issue is not how many debridements you do, but how often you see them. It depends on what I see whether I debride them or not,” said Dr. Palmer. He suggested post-surgery follow-ups for one and two weeks, then a one month follow-up. If something such as a papilloma had been removed along with significant mucosa tissue he would add xylometazoline into the equation, along with a rinse containing antibiotics. As for saline, he suggested isotonic be used since hypertonic solution has been shown to destroy cilia.
However, there is little evidence showing either debridement or saline to be superior. “I had not seen any significant difference in outcome between the two different modalities of care,” said Dr. Parikh.
Cerebrospinal Fluid Leaks
Another case was of a 49-year-old woman who presented with left nasal congestion and drainage that was attributed to allergic rhinitis and treated with nasal steroids. However, three years later she continued to have clear fluid discharge. There was a diagnosis of a spontaneous cerebrospinal fluid (CSF) rhinorrhea.
Panelists agreed this was a complicated case, and suggested a variety of investigations. “I routinely use lumbar drainage post-operatively in CSF leaks, that would also give me the ability to use fluorescein localization of the leak,” said Douglas Ross, MD, Associate Professor of Otolaryngology at Yale University School of Medicine in New Haven, Conn.
Dr. Fried stated that the defect was localized at the roof of the ethmoid, repaired, and a lumbar drain was done. However there was a releak two months later and there was suspected benign intracranial hypertension.
Work is being done by researchers at Pennsylvania to develop protocols for treating CSF leaks, said Dr. Ross. He advised that in CSF leak patients, one should get a pressure when putting the lumbar drain in, then leave the drain for two days.
“At 48 hours we’ll clamp it, hook it up to a pressure transducer then get a pressure there.” he said. Then a test in which the neck is compressed can provide more information. With compression “CSF pressure will go up because of the lack of venous outflow. If that goes up… then you know you have a closed system and you know you can get a real pressure,” Dr. Ross said.
Pressure under 20 cm H20 means there will not be releak, between 20 and 30 means possible risk of releaks, and over 30 means there will be releak and it should be shunted. He advised getting a neurosurgeon involved in the case.
Aggressive Approach to Fungal Sinusitis
The final case was of a 43-year-old diabetic man who had chronic sinusitis, intermittent epistaxis, elevated liver function test (LTF), bilateral obstructive polyps, and allergic fungal sinusitis. After three CT-guided procedures for extensive disease, polyposis returned after a year. “He continues to have disease now. He’s on prednisone, oral itraconazole. His LFT started going up. He’s on [montelukast sodium],” said Dr. Fried.
Panelists agreed diabetes made this case especially challenging since steroid treatment is not well tolerated.
One option is to use debridement, remove fungal spores, and treat the patient with anti-inflammatories, said Dr. Stewart. Another more controversial option would be to do allergy testing and immunotherapy.
Aggressive management should be considered, possibly with a pair of surgeries back to back, said Dr. Palmer. “If you don’t get everything completely and it starts to recur right away, that’s trouble. Hit him hard with steroids, do the surgery. Have the steroids and itraconazole on at the same time,” he said.
Still, even this might only provide mediocre results, showing that even the experts can go only so far.
©2006 The Triological Society