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4 Endoscopic Denker’s Approach
Fig. 4.3 A suction freer
elevator is used to elevate
the anterior maxillary soft
tissues off of the anterior
wall of the maxillary sinus
in a subperiosteal plane
Fig. 4.4 An anterior
maxillotomy is performed
taking care to avoid trauma
to infraorbital
neurovascular bundle
41
subjective ndings, recurrent polyposis was noted in 80% of patients. The authors
report that all patients were treated with nasal saline irrigations, but do not comment
on the use of intranasal corticosteroids post-operatively.
Wreesman et al [13] reviewed their series of 82 patients who underwent the
Denker’s procedure over a 10-year period. Sixty-three patients (77%) completed
and returned surveys exploring their sinonasal symptoms prior to, and after, the
Denker’s procedure. Prior to surgery, the majority of patients complained of nasal
obstruction, reduced olfaction, headache, and facial fullness despite prior medical
and surgical therapy. After the Denker’s surgery, patients reported nearly a 50%
reduction in nasal obstruction, rhinorrhea, and facial fullness, but contrary to the
prior study, olfaction was not signicantly restored. Subgroup analysis of patients
42
Fig. 4.5 The pyriform
aperture is drilled out to
allow for wide exposure of
the entire maxillary sinus
Fig. 4.6 At the conclusion
of the procedure the
nasolacrimal duct (NLD) is
identied and sharply
transected
J. P. McCormick and J. T. Lee
with asthma demonstrated signicant reduction of lower airway symptoms as well
after the Denker’s surgery.
In 2006, the same group conducted a prospective survey-based study on a group
of refractory CRS patients who underwent the Denker’s procedure [14]. The
included patients had undergone three prior ESS procedures, in addition to medical
therapy including topical saline irrigations, antibiotics, and topical and/or oral corticosteroids. Similar to the prior study, patients reported severe congestion, nasal
obstruction, rhinorrhea, and olfactory disturbance prior to surgery. After the
4 Endoscopic Denker’s Approach
43
Denker’s surgery, a majority of patients reported signicant improvement in nasal
congestion (73%), rhinorrhea (70%), and nasal obstruction (60%). Again, there was
no signicant change in olfactory function. Over a 2-year follow-up period of this
cohort, no patient required revision surgery after the Denker’s procedure. A follow up to this study was published in 2007, reporting on the effect of radical surgery on
general quality of life and pain in CRS patients [15]. The results of this study suggest that after the Denker’s procedure, patients have less impairment in work and
other daily activities as a result of their physical health problems. Additionally,
patients tend to experience less pain after radical surgery based on results of the
McGill pain questionnaire. Table 4.2 summarizes the included studies and their
ndings.
Table 4.2 Studies investigated the Denker’s approach for refractory maxillary sinusitis
Number
Author
Date
Kerrebijn
etal. 1996
Wreesman
etal. 2001
of
patients
56 Recurrent
82 Refractory
Indication for
surgery Outcomes
Complete resolution of
sinusitis and nasal
polyposis
Failure of prior
surgery to resolve
symptoms
chronic
rhinosinusitis and/
or nasal polyposis
Failure of
established
functional sinus
surgery
nasal discharge (n=46,
82%)
Restored olfaction
(n=50, 89%)
Recurrent polyposis
(n=45, 80%) patients.
Authors note recurrent
polyposis was typically
small and along the
ethmoid roof
84% reported overall
reduction in sinonasal
symptoms
50% reduction in feeling
of fullness
47% reduction in nasal
obstruction
47% reduction in
rhinorrhea
Olfaction did not improve
signicantly
34% required revision
after the Denker’s
procedure, most
commonly for recurrent
polyps
Complications
Nasolacrimal duct
stenosis requiring
DCR (n=6, 11%)
Dacryocystitis
treated with
antibiotics (n=2)
Meningitis (n=1)
*Did not report
complications
(continued)
44
J. P. McCormick and J. T. Lee
Table 4.2
Author
Date
Videler
etal. 2006
Videler
etal. 2007
(continued)
Number
of
patients
23 Refractory
23 Refractory
Indication for
surgery Outcomes
70% reported overall
chronic
rhinosinusitis
+/− nasal
polyposis
Failure of at least
3 prior
endoscopic sinus
surgeries
chronic
rhinosinusitis
+/− nasal
polyposis
Failure of at least
3 prior
endoscopic sinus
surgeries
reduction in sinonasal
symptoms
74% reported improved
congestion
70% reported improved
post nasal drip
60% reported improved
nasal obstruction
Olfaction did not improve
signicantly
No revision surgery
required in 2year follow
up period
Improvement in 7 of 8
SF-36 domains at 2years,
though only role
limitations due
tophysicalproblems is
signicant
Signicant reduction in
sensory pain and total
pain based on McGill
pain questionnaire
Complications
Oroantral stula
without clinical
symptoms (n=1)
*Did not report
complications
Reported Outcomes
The introduction of the modied endoscopic Denker’s approach (MED) permits
similar access and visualization of the maxillary sinus as the standard Denker’s
approach, without the need for a sublabial incision. Within the literature, the MED
has been primarily used for management of maxillary sinus and infratemporal fossa
tumors [11]. However, the MED may prove valuable in the management of refractory maxillary sinus CRS.
Nasalization or radical ethmoidectomy has been described for patients with
extensive polyposis in order to decrease the likelihood of early recurrence.
Nasalization entails removing all ethmoid bony lamellae and mucosa, in addition to
the middle turbinate, and making a wide maxillary antrostomy and sphenoidotomy.
Surgeons have reported a lower incidence of polyp recurrence, greater symptom
improvement, and less need for revision surgery after nasalization [16]. Patients
undergoing the so-called full-reboot procedure which involves clearance of all polyps and mucosa, as well as a Draf III frontal sinusotomy, were noted to have signicantly reduced polyp recurrence rate, and symptom scores were also signicantly
reduced based on the SNOT-22 questionnaire [17]. The MED is a means by which
full clearance of disease within the maxillary sinus may be achieved. Opponents of
4 Endoscopic Denker’s Approach
45
radical surgery express valid concern for delayed wound healing, potential for
increased scar formation, and increased complications as a result of more aggressive surgery. In patients who underwent the reboot procedure however, there was no
evidence of abnormal scarring. and biopsy of the new mucosa at 28months post-op
showed normal ciliated respiratory epithelium.
With the exception of Kerrebijn etal [12], most studies reporting on outcomes of
the Denker’s approach for CRS did not comment on complications associated with
this procedure. However, more recent studies investigating the MED for maxillary
sinus tumors more thoroughly described potential complications (Table4.3) [18,
19]. Reported complications of the MED include the standard complications of
endoscopic sinus surgery, as well as temporary numbness of the cheek or palate,
epiphora, and alar collapse. These complications tend to be self-resolving, with
epiphora being the complication to most likely need secondary intervention [11].
The MED was utilized successfully in 22 patients with maxillary sinus inverted
papilloma [18]. Across a mean follow-up of 2years, only 1 patient recurred, with
the recurrence developing along the infraorbital nerve after prior conservative resection to maintain facial sensation. Three patients in this series developed epiphora;
however, only one required dacryocystorhinostomy (DCR), while the others
resolved spontaneously within 3months after surgery. Additionally, only one patient
Table 4.3 Studies investigating the modied endoscopic Denker’s approach for maxillary
sinus tumors
Author
Date
Lee etal.
2020
McCormick
etal. 20225835 benign
Number
of patients
22 Maxillary sinus
23
malignant
Indication for
surgery Outcomes
4.5% recurrence rate
inverted
papilloma
attached to
anterior or
lateral
maxillary sinus
wall
Maxillary sinus
tumors, both
benign and
malignant
(n=1), tumor
attachment at
infraorbital nerve.
Bony canal was
preserved at initial
resection to avoid
risk of facial
numbness
19% overall
recurrence rate
(n=11).
5.7% local
recurrence rate for
benign tumors
(n=2)
26.1% local
recurrence rate for
malignant tumors
(n=6)
Complications
4.5% epiphora rate
requiring DCR (n=1).
Two other patients had
spontaneous resolution
of post-operative
epiphora within
3months post-op
1 patient with transient
parethesia of the lip
13.8% overall
complication rate
6.9% epiphora rate
requiring DCR (n=4).
Spontaneous resolution
of post-op epiphora
occurred in 57% of
cases
5.2% with long-term
facial numbness/
paresthesia
1 patient with nasal
vestibular stenosis
following adjuvant
radiation therapy
46
J. P. McCormick and J. T. Lee
had transient upper lip numbness that resolved within 3months of surgery. A larger,
multicenter study evaluated outcomes following the MED for management of both
benign and malignant maxillary sinus tumors [19]. Similar to the prior study, the
recurrence rate for benign tumors was 5.7%. Malignant tumors, however, had a
recurrence rate of 26.1%. The overall complication rate in this series was 13.8%.
The most common reported complications were facial numbness and epiphora.
Facial numbness was noted to be more likely to resolve spontaneously, as 78% of
patients who initially reported facial numbness ultimately recovered full sensation.
Epiphora seems to be less likely to resolve spontaneously, as four out of seven
patients who initially reported epiphora at follow-up visits ultimately required
DCR. The overall rate of epiphora requiring DCR in this tumor series (6.9%) is less
than what Kerrebijn etal [12] reported in their refractory CRS series (11%), which
may be related to advanced technology and renement of surgical techniques
throughout the modern endoscopic age.
As the indications for endoscopic surgery continue to expand and evolve,
modications of previously described open approaches may enhance access and
visualization from an endoscopic standpoint. While further research will need to
be conducted to validate the utility of these approaches, it is useful for the endoscopic surgeon to have a vast armamentarium of techniques to adequately manage the subset of patients with refractory disease. The MED is yet another method
by which surgeons may access and treat the maxillary sinus in these difcult cases.
References
1. Orlandi RR, Kingdom TT, Smith TL, etal. International consensus statement on allergy and
rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol. 2021;11:213–739.
2. Young LC, Stow NW, Zhou L, Douglas RG. Efcacy of medical therapy in treatment of
chronic rhinosinusitis. Allergy Rhinol (Providence). 2012;3:e8–e12.
3. Subramanian HN, Schechtman KB, Hamilos DL.A retrospective analysis of treatment outcomes and time to relapse after intensive medical treatment for chronic sinusitis. Am J Rhinol.
2002;16:303–12.
4. Kennedy DW, Zinreich SJ, Rosenbaum AE, Johns ME.Functional endoscopic sinus surgery.
Theory and diagnostic evaluation. Arch Otolaryngol. 1985;111:576–82.
5. Hopkins C, Slack R, Lund V, Brown P, Copley L, Browne J.Long-term outcomes from the
English national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis.
Laryngoscope. 2009;119:2459–65.
6. Hunter TD, DeConde AS, Manes RP. Disease-related expenditures and revision rates in
chronic rhinosinusitis patients after endoscopic sinus surgery. J Med Econ. 2018;21:610–5.
7. Smith KA, Orlandi RR, Oakley G, Meeks H, Curtin K, Alt JA.Long-term revision rates for
endoscopic sinus surgery. Int Forum Allergy Rhinol. 2019;9:402–8.
8. McCormick JP, Hicks MD, Grayson JW, Woodworth BA, Cho DY.Endoscopic Management
of Maxillary Sinus Diseases of Dentoalveolar origin. Oral Maxillofac Surg Clin North Am.
2020;32:639–48.
9. Cho DY, Hwang PH.Results of endoscopic maxillary mega-antrostomy in recalcitrant maxillary sinusitis. Am J Rhinol. 2008;22:658–62.
4 Endoscopic Denker’s Approach
10. Kim E, Duncavage J. Caldwell-Luc procedure. Oper Tech Otolaryngol Head Neck Surg.
2010;21:163–5.
11. Lee JT, Suh JD, Carrau RL, Chu MW, Chiu AG.Endoscopic Denker's approach for resection
of lesions involving the anteroinferior maxillary sinus and infratemporal fossa. Laryngoscope.
2017;127:556–60.
12. Kerrebijn JD, Drost HE, Spoelstra HA, Knegt PP.If functional sinus surgery fails: a radical
approach to sinus surgery. Otolaryngol Head Neck Surg. 1996;114:745–7.
13. Wreesmann VB, Fokkens WJ, Knegt PP.Refractory chronic sinusitis: evaluation of symptom
improvement after Denker's procedure. Otolaryngol Head Neck Surg. 2001;125:495–500.
14. Videler WJ, Wreesmann VB, van der Meulen FW, Knegt PP, Fokkens WJ. Repetitive
endoscopic sinus surgery failure: a role for radical surgery? Otolaryngol Head Neck Surg.
2006;134:586–91.
15. Videler WJ, van Drunen CM, van der Meulen FW, Fokkens WJ.Radical surgery: effect on quality of life and pain in chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2007;136:261–7.
16. Jankowski R, Pigret D, Decroocq F, Blum A, Gillet P.Comparison of radical (nasalisation) and
functional ethmoidectomy in patients with severe sinonasal polyposis. A retrospective study.
Rev Laryngol Otol Rhinol (Bord). 2006;127:131–40.
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surgery for Type-2 CRS wNP: an Endotype-based retrospective study. Laryngoscope.
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management of inverted papilloma of the anterior maxillary sinus. Int Forum Allergy Rhinol.
2020;10:533–8.
19. McCormick JP, Suh JD, Wang EW, et al. Modied endoscopic Denker's approach for
Management of Anterior Maxillary Sinus Tumors: multicenter series of 58 cases. Am J Rhinol
Allergy. 2022;36:763.
47
The Reboot Procedure forSevere
Chronic Rhinosinusitis withNasal Polyps
ClausBachert , ZhangNan, PhilippeGevaert,
andThibautvan Zele
Key Points
• Chronic rhinosinusitis with nasal polyps (CRSwNP) is characterized by persis-
tent mucosal disease that is multifactorial in nature and may persist despite surgical and medical therapy.
• There is evidence that some patients demonstrate long-term immunologic mem-
ory that may lead to persistent type 2 inammation and recurrent or recalcitrant
sinonasal disease.
C. Bachert (*)
Department of Oto-Rhino-Laryngology, Münster University, Münster, Germany
First Afliated Hospital, Sun Yat-sen University, International Airway Research Center,
Guangzhou, China
Upper Airways Research Laboratory, Department of Oto-Rhino-Laryngology, Head and Skin,
Ghent University, Ghent, Belgium
e-mail: Claus.Bachert@Ugent.be; Claus.Bachert@ukmuenster.de
Z. Nan
First Afliated Hospital, Sun Yat-sen University, International Airway Research Center,
Guangzhou, China
Upper Airways Research Laboratory, Department of Oto-Rhino-Laryngology, Head and Skin,
Ghent University, Ghent, Belgium
e-mail: Nan.Zhang@Ugent.be
P. Gevaert · T. van Zele
Department of Oto-Rhino-Laryngology, Münster University, Münster, Germany
Upper Airways Research Laboratory, Department of Oto-Rhino-Laryngology, Head and Skin,
Ghent University, Ghent, Belgium
e-mail: Philippe.Gevaert@Ugent.be; Thibaut.VanZele@Ugent.be
5
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
J. T. Lee etal. (eds.), Advances in Surgical and Medical Interventions for
Recalcitrant Chronic Rhinosinusitis,
https://doi.org/10.1007/978-3-031-89191-5_5
49
50
• The reboot procedure seeks to provide broad access to the paranasal sinuses and
remove dysfunctional sinonasal mucosa and polypoid tissue to allow the regrowth
of functional mucosa.
C. Bachert etal.
Background
Chronic rhinosinusitis with nasal polyposis (CRSwNP) is classically considered a
type 2 inammatory disease process of the paranasal sinuses characterized by nasal
polyp growth that may be refractory to medical and/or surgical management [1, 2].
Although nasal polyps are called “nasal,” they typically originate from the sinuses
and are secondarily prolapsing into the nose. Nasal polyps in the majority of cases
are derived from the ethmoidal and maxillary sinus mucosa, but also may grow out
from frontal and sphenoid sinus mucosa. They very rarely develop from nasal
mucosa including the turbinates. I personally have seen nasal polyps originating in
the nose only in specic cases such as patients with Woakes syndrome (massive
polyp grow from the nose, sinuses and middle ear mucosa, leading to the broadening of the midface in younger subjects caused by the polyp pressure [3].
The reboot procedure aims to remove the sinus mucosa from the maxillary, ethmoidal, frontal and (if necessary) sphenoidal sinuses bilaterally. The goal is to allow
for the complete re-epithelialization of the paranasal sinuses by nasal mucosa which
has a low potential of developing nasal polyps [4].
The Role ofType 2 Inflammation inCRSwNP, Diagnosis,
andOutcomes
Chronic rhinosinusitis (CRS), affecting up to 15% of the adult population in Europe
and the USA, may be differentiated in two large groups, CRS with and without
(Latin: sine) nasal polyps (CRSw/sNP) [5]. The differentiation is based on nasal
endoscopy and CT scanning, which also allows for estimations regarding the extent
of paranasal sinus disease. However, these clinical techniques do not allow providers to differentiate the underlying pathogenesis of the patient’s inammation.
Approximately 80% of CRSwNP and 50% of CRSsNP are type 2 “eosinophilic”
inammatory reactions. Type 2 inammation has been associated with comorbid
asthma, increased disease recurrence after treatment including surgery, and more
severe symptoms, and a differentiation of inammatory types therefore is considered important [6, 7]. Furthermore, modern biologic approaches for CRSwNP primarily target type 2 cytokines and may have limited efcacy in the non-type 2
population [8–11].
Traditionally, CRSwNP is considered the more difcult to treat subgroup on a
long-term basis. Polyp recurrence is common, impacting as many as 78% of patients
according to one 12year postoperative control study of CRSwNP patients treated
surgically [12]. However, recurrence rates vary based on the inammatory type and
severity of inammation at the time of surgery, the surgical technique, the
5 The Reboot Procedure forSevere Chronic Rhinosinusitis withNasal Polyps
51
post- operative care, and the length of the observation period. These factors are
strongly interrelated and should be considered to correctly understand the situation
of the individual patient (Fig.5.1).
In this chapter, we focus on type 2 inammatory CRSwNP with the aim of
achieving long-term control with the rst or a subsequent surgical procedure (in
those patients who already had unsuccessful former surgery) without the primary
intention to use biologic agents. This implies several questions for further decisions:
1. Is the patient suffering from type 2 disease?
2. Is the patient surgery-naïve or did she/he had former sinus surgery?
3. Has the patient received repeated oral/systemic (glucocorticoids) GCS treat-
ments over the past year?
4. Would a biologic treatment be an option to consider, and if so, as single treat-
ment or combined with surgery?
These questions are interrelated and each may dictate different approaches in patient
management. Surgical intervention and/or biopsy of polyp tissue can provide clear
signs of the presence of type 2 inammation, e.g., through the description of eosinophils in the tissue. The authors recommend routine histologic evaluation of nasal
polyp tissues obtained either in clinic or intra-operatively as it provides valuable
information that may guide future treatment. In the authors’ experience, a once
proven type 2 inammation remains type 2, whenever polyps should recur. Should
even a small polyp regrow, it will be characterized by type 2 inammation again. In
these patients, a reboot procedure may be an option to break the cycle of repetitive
inammation related to type 2 inammation and provide an opportunity for fresh
mucosalization that may not undergo this same inammatory pathway. If pathology
is unavailable, clinical signs may also indicate the presence of type 2 disease. These
signs are included in Table5.1.
Recalcitrant CRSwNP can be dened based on the nasal polyposis score (0–8
bilaterally) and on subjective symptom severity scales [5]. Severe CRSwNP is
dened as bilateral chronic rhinosinusitis with nasal polyps (CRSwNP) with a
nasal polyp score (NPS) of ≥4 points and persistent symptoms including loss of
Fig. 5.1 Nasal endoscopy
in a patient with nasal
polyps (CRSwNP) medial
and lateral to the middle
turbinate