For many patients with chronic rhinosinusitis, functional endoscopic sinus surgery (FESS) has provided much needed relief from a condition that, by its daily aggravation, can significantly reduce quality of life.
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January 2010In some patients, however, symptom relief is not achieved even after surgery, or the disease recurs and patients must return for revision surgery. What are the main reasons for revision surgery? How can it be avoided?
Answering these questions is anything but straightforward. A failed surgery in one patient’s eyes may be a success in another’s, and strict criteria for defining what success or failure means clinically are somewhat arbitrary given that the outcome desired—improved quality of life—is not an exact quantifiable outcome.
Despite this ambiguity, experts point to two primary reasons sinus surgery fails. “The two main reasons for FESS failure are doctor-related and patient-related,” said Robert Kern, MD, chief of rhinology at Northwestern University’s Feinberg School of Medicine, Chicago, Ill. In other words, failure results from issues related to the surgical technique and issues related to the chronic nature of the disease.
Surgical Technique
Most of the reasons sinus surgery fails relate to incomplete surgery, according to James Palmer, MD, director of the Division of Rhinology at the Hospital of the University of Pennsylvania in Philadelphia. “The biggest improvement in FESS surgery is the understanding that complete surgery improves outcomes,” he said. Partial surgery, which includes incomplete removal of all bony partitions and incomplete opening of the sinuses, may lead to a worse result, he said.
According to Dr. Kern, opening up all the sinus cells is particularly critical for patients with extensive disease. “If a patient has nasal polyposis, a complete ethmoidectomy will give the best outcomes,” he said, emphasizing that strong surgical skill is required for this.
Agreeing that surgical skill is key to opening up all the sinus cells and that this is critical to improved outcomes, Lanny Garth Close, MD, chairman of the department of Otolaryngology/Head and Neck Surgery at Columbia University in New York, said that some surgeons shy away from opening certain sinus cells, particularly in the areas of the eye and brain, because of the increased potential for morbidity in these areas. “Often, surgeons feel that it is better to leave some cells untouched rather than harm the patient,” he said, despite the potential for a lower success rate.
—Lanny Garth Close, MD
Although Dr. Close believes that complete removal of all bony partitions (i.e., complete surgery) leads to the best long-term results, other surgeons lean toward only opening those cells that show up on imaging as diseased. “Most patients probably do not require every sinus opened,” said Martin Citardi, MD, chair of the department of Otorhinolaryngology-Head & Neck Surgery at the University of Texas Medical School at Houston, adding that the surgery only needs to be comprehensive enough to deal with the disease at hand.
Dr. Citardi also cautioned that incomplete dissection may not necessarily be associated with surgical failure in all patients. “We only see the patients who remain symptomatic [after surgery],” he said, “so it is possible that there are other persons who have similar surgery who are not symptomatic and we don’t see them.”
Also critical for improved outcomes, according to Dr. Close, is preserving the delicate respiratory epithelium that lines the cells. “That is where most surgeons do not do a good job,” he said. “If the surgeon strips the mucosal out inadvertently, two things will happen that will lead to absolute failure—the opening will scar over or, even worse, new bone formation will close the area off.”
According to Peter-John Wormald, MD, chair of the ENT Department at the University of Adelaide in Woodville, Australia, several improvements in recent years are helping to reduce these technical problems, including improved instrumentation and a better understanding of sinus anatomy through three-dimensional imaging that permits a more complete and safer dissection.
“The combination of the surgeon understanding the anatomy better with improved instrumentation and in some cases utilization of computer-aided navigation has allowed even the most complex and recalcitrant sinus patients to have successful surgery,” he said, emphasizing that repeated pre-surgery planning will help surgeons gain confidence and the expertise to remove all obstructing cells from the sinus, subsequently improving outcomes.
For Dr. Palmer, improvement in visualization based on techniques to decrease bleeding into the surgical field is critical to improved outcomes. These techniques include better local injections, use of the laryngeal mask airway to decrease irritation to the larynx, and use of total intravenous anesthesia, which decreases the dilatory effects of inhaled anesthesia.
“If you can decrease your bleeding and improve visualization, that will allow you to do more complete surgery,” he said, adding that this means a reduced likelihood for the need for revision surgery.
Nature of the Disease
Even with the best surgical skill, however, sinus surgery can be considered a failure and the need for revision requested. Chronic rhinosinusitis, like all chronic conditions, requires strong patient participation to improve outcomes, with or without surgery.
Issues related to the patient include compliance with medical therapies as well as cessation of behaviors that complicate sinus problems, such as smoking. Underlying these issues is the primary need for the patient to recognize the nature of chronic rhinosinusitis, the difficulty of treating it, and the expectations of treatment. To this end, patient education is key.
“From my perspective, the patient needs to be educated about the disease process,” Dr. Citardi said. “They need to understand that this is chronic and they are likely to require ongoing medical management even after a good surgical outcome.”
For Dr. Kern, it is imperative that otolaryngologists properly educate patients on their expectations of surgery. For example, he said, patients with severe polyposis, allergic fungal sinusitis, or cystic fibrosis are at high risk of needing additional, sometimes multiple, surgeries and need to be aware of this.
For some patients who are allergic to aspirin, treatment in which they gradually become tolerant to aspirin through a process called aspirin desensitization has been shown to reduce the sinus inflammation in their sinuses.
According to John Bosso, MD, chief of Allergy/Immunology, director of the Aspirin Desensitization Program at Nyack Hospital in Nyack, N.Y. and one of the few experts in the country trained in this highly specialized therapy, about 40 percent of patients with nasal polyps and asthma have aspirin-exacerbated respiratory disease (AERD) and could potentially benefit from aspirin desensitization. Identifying these patients prior to surgery would reduce the need for revision surgery, he said.
Dr. Citardi, who has referred patients for aspirin desensitization, thinks aspirin desensitization plays a definite role in treating select patients. “Aspirin desensitization seems to prevent patients from worsening,” he said, “although I don’t think that it makes the pre-existing inflammatory sinus disease better.”
Overall, recognizing patients with AERD highlights an important message for all otolaryngologists who, along with their patients, are often stymied by the lack of improvement following surgical treatment. When patients continue to not do well, “physicians need to step back and reconsider the assumptions that have been implicit in the entire treatment course before that point,” Dr. Citardi said. ENTtoday
Mary Beth Nierengarten is a medical writer based in St. Paul, Minn.
IMAGE SOURCES: PHOTOS PHANIE/PHOTO RESEARCHERS, INC.