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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5226_Библиотеки_им_академика_М_И_Перельмана.pdf
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13 In-Oce Endoscopic Sinus Surgery forRecalcitrant Chronic Rhinosinusitis
137
Fig. 13.1 (a, b) Preoperative endoscopy of R and L nasal cavity polyps in the middle meatus. (c,
d) Postoperative endoscopy after in-ofce nasal polypectomy
15% of surgical failures. This occurs when there is an abnormal circular ow of
sinonasal secretions between the natural ostium and a secondary surgically created
opening [6, 9]. This can readily be addressed with an ofce-based procedure by
removing any residual uncinate process and connecting the two ostia to create one
large maxillary antrostomy [10]. If the previously placed antrostomy is inferior, it
may be necessary to create a mega antrostomy, extending the sinusotomy through
the inferior turbinate. Through-cutting instruments are used to remove the strut of
bone and mucosa separating the natural and secondary ostia (Fig.13.2).
When stenosis of the antrostomy exists, a ball tip probe can be used to identify
the ostium and enlarge it using through-cutting and back-biting instruments. A
microdebrider can be used to remove any residual inammatory or polypoid disease. Care should be taken to avoid injury to the lacrimal duct and orbit. After
completion, the ostium should be shaped in the form of a teardrop or pear. An angled
138
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Fig. 13.2 (a) Patient with L maxillary sinus recirculation undergoing in-ofce removal of bony/
mucosal strut separating the surgical antrostomy from a posterior fontanelle using a straight
through-cutting instrument. (b) Large contiguous maxillary antrostomy encompassing both ostia
after removal of the strut
D. B. Spielman and J. M. DelGaudio
endoscope is used to conrm completion of the antrostomy and may be particularly
useful to verify that the natural ostium is included in the antrostomy to avoid future
issues with maxillary recirculation. When addressing a mucocele, it is important to
marsupialize the entire structure after draining the contents to prevent recurrence.
Balloon dilation can alternatively be used to enlarge the natural ostium in order
to facilitate drainage. Purulence or debris within the sinus can be cleared using high
pressure large volume irrigation by connecting a luer-lock syringe to a curved maxillary sinus suction. This technique is especially useful to clear fungal balls or allergic fungal mucin. Culture and pathology can be sent when indicated.
Ethmoid Sinus Disease
The role of ofce-based procedures to address the ethmoid sinuses is limited. For
patients who have had prior ethmoidectomies, a microdebrider can be used to
remove recurrent polypoid disease. When removing polypoid disease within the
ethmoids, great care must be taken not to injure the orbit or anterior and posterior
ethmoid arteries. If residual ethmoid partitions are noted, the microdebrider,
through-cutting instruments, or rongeurs can be used to cut the bone, taking care to
minimize removal of surrounding mucosa. The performance of a total ethmoidectomy with removal of all bony partitions can occasionally be performed in the ofce
if needed. This will require sequential repeat administration of topical and local
anesthetic as the procedure progresses posteriorly. Patients who have signicant
residual ethmoid partitions may be better served by having surgery in the operating room.
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13 In-Oce Endoscopic Sinus Surgery forRecalcitrant Chronic Rhinosinusitis
Fig. 13.3 (a) Preoperative endoscopy of polyps obstructing L frontal sinus outow tract. (b)
Postoperative endoscopy of patent L frontal sinus outow tract one year after in-ofce surgery
139
Frontal Sinus Disease
Despite its challenging and narrow drainage pathway, certain frontal sinus issues
can be addressed in the ofce. The most common indication is to address postoperative scarring and stenosis of the frontal sinus outow tract, which is the cause of
surgical failure in 25% of cases [6]. Alternative indications include recurrent frontal
sinus disease or mucocele formation. Angled telescopes, 30°, 45°, or 70°, depending on the patient’s anatomy, are essential for frontal sinus work and the use of
image navigation can be a helpful adjunct. Any mucosal disease or residual ethmoid
partitions narrowing the drainage pathway can be removed with through-cutting
instruments or microdebrider (Fig.13.3). Care must be taken to avoid injury to the
posterior table of the frontal sinus and the anterior ethmoid artery. Patients who
require additional drilling or extended Lothrop procedures should be taken to the
operating room. In the immediate postoperative period, frontal sinus instruments
may be used to gently debride material from the outow tract to restore patency and
prevent further scarring. Frontal sinus balloon dilation is a useful adjunct that can
also be used with or without surgical navigation, or with transillumination.
After enlarging the frontal sinus outow tract, high pressure irrigation delivered
via a curved frontal sinus suction can be used to clear any residual debris. Once the
outow tract is sufciently enlarged, a steroid eluting stent may be placed to prevent
recurrent stenosis [11].
Sphenoid Sinus Disease
Because of its posterior location and proximity to critical neurovascular structures,
the sphenoid sinus is more challenging under local anesthesia, but the straight
access from the nasal cavity makes it accessible. Certain sphenoid sinus lesions can
140
D. B. Spielman and J. M. DelGaudio
be addressed with an ofce-based procedure, especially in patients who have undergone prior ESS.Indications include recurrent polyposis, isolated sphenoid sinus
opacication, mucocele, and fungus ball. Lesions with bony dehiscence of the lateral or posterior sphenoid walls can still be safely performed in the ofce, but if the
surgeon is uncomfortable due to the potential involvement of critical neurovascular
structures, they should be performed in the operating room.
The sphenoid sinus may be accessed via two routes: trans-nasally (medial to the
middle and superior turbinates) or trans-ethmoidally (lateral to the middle turbinate
through the posterior ethmoids). In patients who have not previously undergone
ESS with total ethmoidectomy, the trans-ethmoid approach would require a total or
posterior ethmoidectomy rst, which is more difcult to perform in-ofce. The
trans-nasal approach can be utilized by lateralizing the middle and superior turbinates to nd the sphenoid ostium 1.5cm superior to the choana. Placing additional
pledgets to decongest this area signicantly improves exposure and visualization.
The inferior 1/third of the superior turbinate can be trimmed with straight throughcut forceps to improve visualization of the ostium, although the senior author prefers to preserve the entire superior turbinate. A Freer or Cottle elevator is used to
gently palpate and enlarge the sphenoid ostium, followed by a sphenoid punch to
remove the anterior face of the sphenoid. The sphenoidotomy can be extended
through the posterior ethmoid sinuses to the lateral face of the sphenoid while preserving the superior turbinate, termed the Superior Turbinate Straddling
Sphenoidotomy [12].
In the ofce setting, one should avoid the posterior septal branch of the sphenopalatine artery running inferiorly along the anterior face of the sphenoid in order to
prevent bleeding. If performing an in-ofce sphenoidotomy, it is important to have
the means to perform cauterization of this vessel readily available. Debris or polyps
within the sinus can be removed by suction, forceps, or irrigation, taking care to
avoid contact or injury to the lateral sphenoid walls and surrounding structures. A
microdebrider is not used beyond the face of the sphenoid sinus itself to avoid damage to critical neurovascular structures.
Mucocele Drainage
Mucoceles are obstructed sinus cells or cavities that expand over time, frequently
causing bony erosion and exerting pressure on adjacent structures. Risk factors for
development include chronic rhinosinusitis, prior surgery, facial trauma, and allergy,
and idiopathic mucocele development is also common [8]. The frontal and ethmoid
sinuses are the most likely to develop mucoceles, but they can occur throughout the
sinonasal cavities. When accessible, the vast majority of mucoceles can successfully be drained in the ofce [13]. Obtaining cross-sectional imaging preoperatively
is important for diagnosis and to identify any bony dehiscences of surrounding neurovascular structures. Surgically, the goal is to create as large of a drainage pathway
as safely possible and to marsupialize the entire lesion to minimize the risk of
recurrence.
13 In-Oce Endoscopic Sinus Surgery forRecalcitrant Chronic Rhinosinusitis
141
The frontal sinus is most frequently affected by mucocele formation and may be
the most challenging to address. When there is anterior and inferior extension into
the ethmoid cavity, these lesions are more easily accessed in the ofce under local
anesthesia. The presence of posterior table or orbital roof erosion must be noted,
although they are not necessarily contraindications to an ofce-based procedure.
Although less common, maxillary sinus mucoceles are easily drained in the
ofce setting, even in patients who have not had prior sinus surgery. It is important
to differentiate maxillary sinus mucoceles from mucus retention cysts, which are
incidentally found and rarely expand or cause symptoms. Medial expansion of
mucoceles into the nasal cavity often thins the medial wall of the maxillary sinus,
making entry into the sinus easier than usual via the inferior meatus. If this modality
is employed, it is important to connect the antrostomy with the natural ostium or
keep it sufciently far away to decrease the risk of mucus recirculation. If signicant medial expansion has not occurred, a traditional maxillary antrostomy via the
middle meatus may be performed.
Ethmoid mucoceles can be addressed in the ofce setting when they are sufciently anterior or if the patient has undergone prior surgery, allowing access to the
posterior ethmoid cavity. Ethmoid mucoceles frequently thin the bone of the adjacent orbit or skull base, thus careful review of preoperative imaging is essential.
Sphenoid sinus mucoceles are the least common, but may be addressed with an
ofce-based procedure, especially if the patient has undergone prior surgery. The
trans-nasal or trans-ethmoid approaches to the sphenoid sinus can be employed, as
discussed above.
Balloon Sinus Dilation
Balloon sinus dilation is a useful tool when performing ofce-based procedures for
the treatment of chronic rhinosinusitis. We will cover some aspects of balloon dilation in this section, but more details regarding balloon sinuplasty are available in
Chap. 12 of this text. The minimally invasive nature of balloon dilation as compared
with traditional ESS makes it well tolerated under local anesthesia. Balloon dilation
systems can be used to enlarge the ostia of the maxillary, sphenoid, and frontal
sinuses, but cannot directly address the ethmoid sinus.
Data regarding the use of balloon dilation demonstrates signicant quality of life
improvements in patients with CRS, although the majority of patients studied had
relatively mild disease with a mean preoperative Lund-Mackay score of 7.7, compared with an average of 13 for all-comers undergoing treatment for CRS [14]. The
Clinical Consensus Statement on sinus balloon dilation released by the American
Academy of Otolaryngology—Head and Neck Surgery Foundation states that balloon dilation can improve quality of life in patients with limited CRS without nasal
polyps. However, there was consensus that it should not be used in the absence of a
preoperative CT scan demonstrating ndings consistent with sinusitis [15]. There is
no role for balloon dilation in patients who do not meet the formal diagnostic criteria for CRS or recurrent acute sinusitis.
142
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D. B. Spielman and J. M. DelGaudio
Understanding the appropriate indications for balloon sinus dilation makes it a
valuable tool for ofce-based surgery. Patients with nasal polyps or extensive disease, especially involving the ethmoid sinuses, are more likely to benet from traditional ESS. Patients with relatively mild CRS without nasal polyps who have
symptoms refractory to medical therapy may benet from in-ofce balloon dilation
of the affected sinuses. In the senior author’s experience, balloon dilation serves a
more valuable role in addressing postoperative stenosis of sinus ostia. The frontal
sinus outow tract is narrow and has a propensity to stenose. In patients who develop
recurrent symptoms secondary to frontal sinus stenosis, balloon dilation can be used
to reestablish the drainage pathway while minimizing trauma to the surrounding
mucosa. The same technique can be applied to the maxillary or sphenoid sinuses.
Under direct visualization using a rigid endoscope, the ostium is cannulated with
the guidewire in an atraumatic fashion. When addressing the frontal sinus, transillumination or image navigation can be used to verify appropriate placement. The
balloon is then advanced over the guidewire until it is located at the level of the
ostium, in its most narrow location (Fig. 13.4; see video, Video 13.1). Once
Fig. 13.4 (a) Stenotic R frontal sinus outow tract after prior ESS (b) In-ofce balloon dilation
(c) Steroid eluting stent placement (d) Patent frontal sinus outow tract 6months postoperatively
13 In-Oce Endoscopic Sinus Surgery forRecalcitrant Chronic Rhinosinusitis
143
appropriate placement is conrmed, the balloon is inated for several seconds
according to manufacturer instructions. If the outow tract remains stenotic, the
balloon can be advanced and a second dilation can be performed. Providers who
utilize sinonasal balloons must understand the manufacturer and FDA regulations
regarding reuse of the devices.
Outcomes
While there is extensive evidence to support the benets of ESS for patients with
CRS refractory to medical therapy, there is a paucity of data isolated to ofce-based
surgical procedures. Goyal and Hwang report the outcomes of 52 ofce-based procedures performed by a single surgeon under local anesthesia, which were well
tolerated without complication [16]. The majority of these procedures were performed for recurrent disease following traditional ESS for CRS.
Ofce-based revision ESS has been demonstrated to have encouraging outcomes
in a pilot study of ve CF patients who previously underwent full-house ESS.All
were noted to have signicant improvements in quality of life and Lund-Mackay
scores [7]. Drainage of mucoceles in-ofce is well tolerated with excellent outcomes. Barrow and DelGaudio reported on the ofce-based drainage of 36 mucoceles. All were successfully accessed under local anesthesia except for one. Five
patients (14%) required additional future surgery to address septated mucoceles or
recurrence [13]. These results are similar to those reported for operating room drainage of mucoceles.
Ofce-based balloon dilation has been demonstrated to improve sinonasal quality of life in patients with CRS refractory to medical therapy after one-year follow up [17–19]. While balloon sinus dilation has been associated with clinically
signicant improvements in quality of life metrics, these studies lack a wide distribution of CRS patients or those with more severe forms of disease [14]. Proper
patient selection for appropriate use of the balloon sinuplasty technique is essential,
as patients with signicant sinonasal disease are likely to benet more from traditional ESS.In the authors’ experience, balloon sinus dilation is most useful as an
adjunct for patients with CRS who have mucosal scarring and a narrowed ostium
following traditional ESS.In two pilot studies, this has been demonstrated to be a
safe and effective technique following frontal sinusotomy in the operating room
[20, 21].
Increasing competition to secure time in the operating room and the increased
cost of operating room services makes the performance of in-ofce procedures
highly palatable for both patients and physicians. Members of the rhinology community have already demonstrated that they regularly perform ofce-based procedures. The prevalence of ofce-based endoscopic sinus surgery is likely to increase
with time because it is cost effective and improves the patient experience. An
emphasis should be placed on proper patient selection and safe technique.
144
D. B. Spielman and J. M. DelGaudio
Tips and Pearls
• Patient selection and realistic expectations are essential.
• Anxious patients with a low pain tolerance or those who require signicant bone
removal are better suited for procedures in the operating room.
• Decongestion of the nasal mucosa and delivery of both topical and injected local
anesthetic must be used.
• Ideal candidates for ofce-based procedures are those with symptomatic inam-
matory disease, but minimal residual bony septations, often after primary ESS.
• The most common indications for ofce-based surgery include recurrent nasal
polyposis, maxillary/frontal sinus ostium stenosis, mucocele, and maxillary
sinus recirculation syndrome.
• Pediatric endoscopes and instruments may allow for improved access with less
patient discomfort.
• Balloon sinus dilation and steroid eluting stents are valuable tools that can easily
be used in the ofce for patients with ostial stenosis and residual symptoms after
initial surgery.
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In-Office Navigation forRecalcitrant
Chronic Rhinosinusitis
NoraW.Perkins
Key Points
• Advances in endoscopic sinus surgery have allowed surgeons to apply rhinologic
procedures to the ofce setting.
• Image guidance is a useful adjunct that can be applied to patients in-ofce to
allow more thorough in-ofce dissection.
Background
The advances in endoscopic sinus technologies in the twentieth and twenty-rst
centuries have allowed sinus surgeons to skillfully visualize and access all of the
paranasal sinuses and generally avoid the need for open surgical sinus procedures
[1]. Angled endoscopes of various sizes with large monitor video systems, a plethora of instrumentation choices, powered shavers, and navigation systems that allow
those instruments and shavers to be tracked throughout the surgical procedure have
become customary in the operating suite [1–3]. As these endoscopic sinus surgery
technologies advanced, several factors directed surgeons to bring sinus procedures
from the operating room into the ofce, including economic drivers like lower overall healthcare cost and direct to patient cost, ease and timeliness of procedure scheduling, access to operating room block time, patient preference to avoid general
anesthesia and recover/return to work more quickly, surgeon preference, and
improved surgical efciency during and between procedures [2, 4–7].
14
N. W. Perkins (*)
Albany ENT & Allergy Services, Albany, NY, USA
e-mail: nperkins@albanyent.com
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
J. T. Lee et al. (eds.), Advances in Surgical and Medical Interventions for
Recalcitrant Chronic Rhinosinusitis,
https://doi.org/10.1007/978-3-031-89191-5_14
147