Complications of endonasal paranasal sinus surgery--diagnostic and therapeutic consequences

BACKGROUND: Functional endoscopic sinus surgery has been proven the therapeutic method of choice in surgical therapy of chronic sinusitis. On the other hand, endonasal sinus surgery may cause severe complications even when performed by a skilled surgeon. This is easily explained by the close vicinity of many functionally important structures to the operative site. CASE REPORTS: Three histories are reported that involve possible complications even in apparently simple cases. Diagnostic and therapeutic consequences are discussed. In a case previously diagnosed histologically as chronic unspecific sinusitis, an endonasal biopsy resulted in endocranial bleeding requiring neurosurgical intervention. Midline granuloma was found to be the correct diagnosis. Another patient was seen with a normal X-ray of the sinuses and solitary polypoid structure in his left nose. Polypectomy was planned and a CT scan was performed, which demonstrated a meningocele. Transfacial surgery was then performed to remove the meningocele. Another patient presented with a traumatic impression of the frontal sinus, and open reposition by transfacial surgery of the frontal and ethmoid sinus was planned. When CT scans revealed an uncovered optic nerve in the sphenoid sinus of the fractured side, we abandoned ethmodectomy and performed reposition of the frontal sinus as the only surgical procedure. RESULTS AND CONCLUSIONS: In this paper, we show typical complications of endonasal sinus surgery and strategies for avoiding them. If any complication occur, prompt treatment is required. Three groups of complications can be defined: perforation of frontobasal dura resulting in cerebrospinal fluid (CSF) fistula, severe bleeding, and orbital or optic nerve injury. When the surgeon discovers an intraoperative complication, possible consequences must be considered immediately to minimize side effects for the patient. A CSF fistula should be closed in the same procedure, and transfacial surgery may be necessary. Hemorrhage resulting from an ethmoidal artery may require frontoorbital surgery and ligation of this vessel. If retrobulbar hemorrhage caused by retraction of an ethmoid artery occurs, immediate intervention is necessary. Usually a transfacial approach, resection of the medial orbital wall and retrobulbar decompression are performed. In some cases lateral canthotomy may be the best way to drain haematoma and decompress the optic nerve. Subsequently, orbital revision and ligation of the retracted artery must be performed. Any delay can result in persistent visual loss. We conclude that the extranasal frontoorbital approach should be part of the residency training program in ENT departments. Any surgeon performing endonasal sinus surgery must be trained in transfacial emergency procedures, which should be part of anatomic preparations in teaching courses, thus avoiding severe damage in case of intraoperative complication.     

Endonasal frontal sinus surgery with permanent implantation of a place holder

BACKGROUND: Endonasal frontal sinus surgery is well established. It is not yet clear what degree of enlargement of the frontal sinus neoostium is required to achieve permanent drainage or whether stenting improves the results. PATIENTS AND METHODS: Prospective survey with two groups: Group 1. included 10 patients (15 operations) who underwent endonasal sinus surgery because of chronic polypoid sinusitis with stenting of the frontal sinus neoostium for 6 months. Group 2. included 11 patients (21 operations) without stenting. INTERVENTION: Endonasal frontal sinus surgery with extended drainage Draf Type II (NFA II according to May) with (group 1) and without (group 2) long-term stenting of the neoostium for 5 months using a silicone stent. MAIN OUTCOME MEASURE: 12-16 months postoperatively: flexible endoscopy of nose and frontal sinus; computed tomography; magnetic resonance tomography; Wilcoxon-Mann Withney-Test. RESULTS: With stenting: neoostium endoscopically patent in 80% (including 20% with edematous swelling only at the opening to the frontal sinus), occluded by scar tissue in 6.7%, occluded by polyps in 13.3%. Endoscopy and CT/MRT together: normal mucosa and aeration in 93.3%, complete opacification in 6.7%. Without stenting: neoostium endoscopically patent in 33%, occluded by scar tissue in 48%, occluded by polyps in 19%. Endoscopy and CT together: normal mucosa and aeration in 71.4%, aeration and mucosal swelling in 14.3%, complete opacification in 14.3%. With stenting of the frontal sinus neoostium for six months endoscopic evaluation of the frontal sinus was possible in a significantly higher proportion of cases (p = 0.0416). CONCLUSION: Long-term stenting of the frontal sinus significantly reduces the rate of recurrent stenosis of the frontal neoostium and is recommended in all cases where an extended frontal sinus drainage is necessary. The optimal design for such a stent has not yet been clearly defined.     

Fungal sinusitis: progression of disease in immunosuppression--a case report

Fungal sinusitis is a disease which can be grouped into invasive and noninvasive forms. The invasive entities include the acute/fulminant and chronic/indolent forms. The noninvasive entities include the fungus ball and allergic forms. The noninvasive forms, however, can develop into invasive disease under certain immunosuppressive states. The patient in this case report had the fungus ball form of fungal sinusitis which evolved into chronic, and then the acute/fulminant form approximately two weeks after undergoing cadaver-donor kidney transplantation. Due to the patient's immunosuppressed state, the fungus spread beyond the sinus region and eventually lead to fulminant disseminated disease. The severity of the fungal disease corresponded directly to the severity of the patient's immunosuppression.     

Report of the first case of invasive fungal sinusitis caused by Scopulariopsis acremonium: review of scopulariopsis infections

Scopulariopsis acremonium is a species of saprophytic fungus not previously reported to cause invasive disease in humans, although invasive infections from other species of Scopulariopsis have been reported and are reviewed. Deep infection with this fungus is associated with a high mortality rate. Invasive fungal sinusitis, in general, is a potentially fatal disease that typically affects immunocompromised patients, such as those receiving intensive chemotherapy or undergoing bone marrow transplantation. We report a case of invasive fungal sinusitis caused by Scopulariopsis acremonium in a patient with leukemia, who was successfully treated with amphotericin B, itraconazole, endoscopic sinus surgery, and granulocyte colony-stimulating factor.     

Allergic fungal sinusitis: clinicopathological characteristics

Allergic fungal sinusitis is a comparatively new disease entity in paranasal sinus mycoses. It is not a very rare condition, but diagnosis is difficult to establish. Of 28 consecutive cases of allergic nasal polyposis during a 2-year period, 11 patients had allergic fungal sinusitis and the diagnosis was based on the presence of type I hypersensitivity, eosinophilic mucus without tissue invasion of fungi on histopathology and detection of septate hyphae on direct microscopy. On culture, Aspergillus flavus was isolated from nine patients and A. fumigatus and A. niger from one patient each. Among patients with allergic fungal sinusitis, five had asthma, four had proptosis, of whom two had impaired vision, and all 11 patients had nasal obstruction. Eight patients described a history of recurrence. All patients underwent surgical clearance of the diseased sinuses and were given post-operative topical steroids to prevent recurrence.     

Giant extra-axial cerebellopontine angle/cavernous sinus ependymoma: case report

Metarrhizium anisopliae is a common pathogen of insects and has even been used to control insect populations. It is rarely isolated from human or animal sources, but recently, there have been three reported cases of disease, two in humans and one in a cat. We present our experience with five isolates from human sources, including two that were the apparent causes of two cases of sinusitis in immunocompetent hosts. The first patient was a 36-year-old male with frontal and ethmoid sinusitis, and the second was a 79-year-old female with chronic sinusitis. Both patients underwent surgery, and pathology of the surgical specimens revealed branching hyphae. Cultures grew only Metarrhizium species. Neither patient received antifungal therapy, and both did well postoperatively. The other three isolates were cultured from bronchoalveolar lavage specimens but were not felt to be clinically significant. Antifungal susceptibility testing using the National Committee for Clinical Laboratory Standards macrobroth method revealed that all isolates were resistant to amphotericin B, 5-flucytosine, and fluconazole. Itraconazole and newer azole compounds were more active. Metarrhizium species may cause disease in humans, even those without evidence of immunosuppression, and are apparently highly resistant to amphotericin B in vitro.     

The role of powered instrumentation in the surgical treatment of allergic fungal sinusitis

Allergic fungal sinusitis is a chronic disorder that is being more frequently recognized by otolaryngologists. It is a recurrent illness characterized by frequent exacerbations, and requires aggressive medical and surgical treatment. When surgical therapy is employed, it is necessary to ensure adequate debridement and removal of edematous tissue. We have been using powered dissection as our primary method in sinus surgery over the past three year. We have treated 11 patients with allergic fungal sinusitis, and find powered instrumentation to be very effective in removing the polypoid tissue from the nose and sinuses, and in providing a clear surgical field. The procedure can be performed safely with minimal trauma to normal tissue. We believe that the use of powered dissection greatly enhances the comprehensive treatment of allergic fungal sinusitis.     

Invasive mold sinusitis: 17 cases in immunocompromised patients and review of the literature

A 10-year retrospective analysis of invasive mold infections in hospitalized patients was performed to characterize the epidemiology and clinical features of invasive fungal sinusitis. Seventeen cases of invasive mold sinusitis were identified. Eleven cases were caused by Aspergillus flavus, three were caused by unspecified species, and one each was caused by Aspergillus fumigatus, Rhizopus species, and Alternaria species, respectively. Fifteen patients had hematologic malignancies, and two had end-stage liver disease. The most common presenting symptom was periorbital swelling (seven patients). Sinusitis was diagnosed a median of 19 days after admission. Eight patients (47%) survived; six of these patients were treated with both amphotericin B and surgery. Postmortem examination of six patients showed evidence of disseminated disease; the brain was the most common extrapulmonary site (four patients). To our knowledge, this is the largest currently reported series on invasive mold sinusitis; our report extends the information on invasive mold sinusitis and shows that aggressive therapeutic and surgical interventions are needed to prevent rapid progression of disease in immunocompromised patients.     

Endoscopic sinus surgery for chronic sinusitis in children

Anatomical features show maxillary sinus to be most commonly involved during childhood chronic sinusitis. Fifty-one cases who failed to respond to medications and irrigation were selected to undergo the middle meatal antrostomy under endoscopy. The majority of them had maxillary sinusitis. 10 cases had middle turbinate edema and polyps. 6 had ethmoiditis. After operations, signs of headache eliminated in 20 cases, nasal obstruction in 43 cases and yellowish discharge in 37 cases. The operative results were satisfactory. It is demonstrated that endoscopic sinus surgery is an ideal therapy for the treatment of childhood chronic maxillary sinusitis at present.     

Revision endoscopic sinus surgery: the Thomas Jefferson University experience

Since its introduction, functional endoscopic sinus surgery (FESS) has demonstrated success rates of 76% to 98%. A small group of the patients in whom initial FESS and optimal medical therapy fail require revision endoscopic sinus surgery (RESS). This group has recently been studied by several authors, and we have evaluated a group of 90 RESS patients selected from 753 consecutive primary FESS patients. Patients were followed for a mean of 22.8 months. Extent of disease, history of polyps, allergy, previous traditional endonasal sinus surgery, male gender, chronic steroid use, and the presence of a deviated septum all appeared to adversely affect RESS outcome. The surgeon's knowledge of the sinus anatomy is critical, especially in revision sinus cases in which landmarks are distorted or absent. In our review, RESS was associated with a 1% major complication rate and was successful in 67% of patients. Computer-assisted endoscopic sinus surgery integrates preoperative imaging with realtime endoscopic visualization, augments the surgeon's knowledge of anatomy, and helps to minimize patient risk.     

Value of B-image ultrasound in diagnosis of paranasal sinus diseases in comparison with computerized tomography

BACKGROUND: In diagnostic imaging of the paranasal sinuses, the A-mode technique is increasingly being substituted by B-mode ultrasonography. To assess the value of B-mode sonography we compared in a double-blind study computed tomography with our ultrasound findings. PATIENTS AND METHODS: Seventy-eight patients were examined by CT and subsequently by ultrasound, two-thirds before endonasal surgery and one-third for diagnosis of serious facial pain and swelling. RESULTS: Among 114 pathological maxillary sinus tomograms, 83 findings could also be diagnosed by ultrasound (sensitivity 72.8%). In the frontal sinuses only 12 of 52 of pathological findings could be detected (23.1%) and only 9 of 80 in the frontal ethmoid (11.3%). Except for circumscribed polyps and moderate general swelling of the mucosa, the detection rate by sonography was 97.4% for the maxillary sinuses, 31.5% for the frontal and 18% for the ethmoid sinuses. CONCLUSIONS: Ultrasound usually only demonstrates the presence of absence or unspecific findings. Differential diagnosis between tumors and sinusitis is generally difficult. The healthy individual is correctly assessed as healthy due to the total reflection of the air-filled healthy sinus. According to our findings ultrasound has a certain value in the diagnosis of maxillary sinuses. It can be used to obtain a preliminary diagnosis and as a screening method although a negative result never excludes a disease of the sinuses. As it does not involve radiation exposure, ultrasonography can be recommended as first step in diagnosis for children, pregnant women, and young women especially in acute sinusitis, because in acute sinusitis the maxillary sinuses are generally affected.     

Coronal CT of the paranasal sinuses before and after functional endoscopic sinus surgery

Coronal CT of the paranasal sinuses and the ostiomeatal complex (OMC) was performed before and 12 months after bilateral functional endoscopic sinus surgery (FESS) in 30 patients with sinusitis and 12 patients with nasal polyposis. The extent of sinus mucosal thickening was graded, and the patency of the OMC was evaluated. After FESS, the percentage of open OMCs had increased from 42% to 83% in the sinusitis group, and from 8% to 45% in the polyposis group. There was only a small improvement in mucosal score in sinuses with opened OMC, so that the overall extent of sinus opacification before and after FESS was almost the same. Despite this, 91% of the patients reported clinical relief of symptoms. Preoperative coronal CT of the paranasal sinuses serves as an anatomical map for the surgeon, but there is no benefit of routine postoperative CT.     

Variation in labial shoulder geometry of metal ceramic crown preparations: a finite element analysis

BACKGROUND: The anatomic variation of the frontal sinus and frontal recess can create both a diagnostic and therapeutic challenge. Most cases of frontal sinus disease can now be treated by endoscopic approaches. For refractory cases or those with severe pathology, the microscopically controlled drainage (MCD) operation has at times been successful and spared the patient the morbidity of an external approach. The aim of this study was to evaluate microscopically controlled frontal sinus surgery in these difficult cases. MATERIAL AND METHODS: Prospective analysis was performed on the efficacy of MCD in patients for whom endoscopic sinus surgery had failed or in primary cases with severe pathology or unfavorable anatomy. The technique employs a self-retaining endonasal retractor and a diamond bur under microscopic visualization to remove solid bone (frontal spine) obstructing the sinus drainage and allow a wide opening of the frontal recess while causing minimal mucosal damage. Unilateral drainage (extended frontal sinus drainage operation), and in some cases bilateral drainage (median drainage procedure) is employed. RESULTS: With an average of 23 months of follow-up, over 90% of patients were either free of symptoms or substantially improved after the MCD procedure. Three patients required revision surgery (extend the opening into a median drainage procedure) for adequate relief of symptoms. CONCLUSIONS: The MCD procedure is highly successful in the treatment of frontal recess disease, particularly in those cases of severe pathology or difficult anatomy. It may be used in those cases refractory to standard endoscopic sinus surgery where an external approach and frontal sinus obliteration are contemplated. As with endoscopic sinus surgery, precise knowledge of the frontal recess and neighboring landmarks is critical, and adequate drainage with minimal mucosal disruption should be the goal.     

Treatment of pancreatic stones with extracorporeal lithotripsy with sonographic localization

BACKGROUND: Pancreatic stones may be treated by endoscopic extraction or by surgery. Extracorporeal shock wave lithotripsy increased possibility of noninvasive steps to their elimination. The aim of this study was to describe our first experience with this method. METHOD AND RESULTS: 10 patients (6 men and 4 women) in average age 47 years (between 19 to 72 years) were treated. The lithotriptor MEDILIT with sonographic targeting was used for fragmentation of pancreatic stones. Fragmentation was achieved in 8 patients, in 4 cases we observed spontaneous disappearnace, in 3 cases an endoscopic extraction of fragments was necessary. In one case good fragmentation was observed at control ECRP, but the repeated Wirsungography showed a big pseudocyst which had not been diagnosed at the first examination and surgery was necessary. In 2 cases no fragmentation was achieved and in these cases surgery was also indicated. No serious side effects were observed, nor elevation of amylase values compared with the situation before the shock wave treatment. CONCLUSIONS: Extracorporeal shock wave lithotripsy of pancreatic stones revealed good fragmentation and disappearance stone from ductus Wirsungi without serious side effects on clinical course and surrounding soft tissues.     

Chronic sinusitis: characterization of cellular influx and inflammatory mediators in sinus lavage fluid

Chronic sinusitis is a recurrent disorder commonly found in atopic individuals, yet few studies have explored the role of inflammatory mediators in sinusitis. Sinus lavage fluid from ten patients with chronic sinusitis obtained during endoscopic surgery was analyzed for total cell counts and then assayed for histamine, immunoreactive leukotriene C4/D4/E4 (LTC4/D4/E4), and prostaglandin D2 (PGD2). All ten patients had been unresponsive to medical treatment, including oral corticosteroids in most cases. High concentrations of histamine, LTC4/D4/E4 and PGD2 were found in sinus fluid and were comparable to levels seen in nasal secretions of allergic rhinitis patients following allergen challenge. In the sinus fluid, inflammatory cells were predominantly neutrophils with only low percentages of mast cells, basophils or eosinophils. On the basis of the histamine and PGD2 concentrations in sinus fluid, we conclude that mast cell/basophil activation does occur in chronic sinusitis and may contribute to the persistent inflammation present in sinusitis.     

Good results of endoscopic paranasal sinus surgery for chronic or recurrent sinusitis and for nasal polyps

Endoscopic sinus surgery is being applied increasingly for chronic or recurrent sinusitis and nasal polyps. We investigated the results, which we classified as subjective results (i.e. the opinion of the patient) and objective results (i.e. the result as seen with nasal endoscopy). The subjective result was 'good' in 85% of 92 patients with chronic or recurrent sinusitis, the objective result in 77% of the treated sides, with a median follow-up of 46 months. In 90 patients with nasal polyps the percentages were 90% and 65% respectively, with a follow-up of 24 months. In 63% of 30 patients with chronic obstructive lung disease and nasal polyps the pulmonary function increased postoperatively (FEV1). In 4.2% of 1235 operated sides in 593 patients local complications were seen. These were mainly minor complications. Only in 0.3% serious complications as a orbital hematoma or a CSF leak were seen. Endoscopic sinus surgery has good results and little morbidity.     

Aspergilus nasal sinusitis endoscopic surgery

Five cases of non-invasive fungal sinusitis were reported. Among them were 2 cases of maxillary, 2 of maxillo-ethmoid and sphenoid sinus. All the patients were operated under endoscopic intranasal approach. The pathological diagnosis of all 5 cases was aspergills infection. The pathogenesis were conditional such as unclean working situation, deviation of nasal septum, polyposis and infection. The disease was easily confused with common infectious disease. The pathogenic factor, diagnosis and treatment were discussed.     

How traumatising is mechanical mucous membrane care after interventions on paranasal sinuses? A histological immunohistochemical study

OBJECTIVE: Endonasal sinus surgery lead to more or less circumscribed mucosa defects exposing the underlying bone. Healing of these wounds is accompanied by crust formation, which may be subjected to mechanical debridement. It is not known whether this wound care impaires or facilitates wound healing. METHODS: Following sinus surgery, 72 crusts were removed from the operative site after having taken endoscopic photographs choosing different postoperative intervals. Mucosal biopsies were taken from beneath the crusts. All specimen were submitted to routine histological serial sections as well as immunohistochemical staining of epithelium. RESULTS: Local debridement of crusts avulsed parts of epithelium in 23% of cases during the first postoperative week. There was no histological evidence of avulsed epithelium with crusts removed the second week. This figure later increased to 16%. Possible trauma to regenerating mucosa cannot be predicted solely by the appearance of crusts. CONCLUSION: In principle, large crusts may disturb ventilation and drainage, causing secondary mucositis. Local care is mandatory in these cases. According to our examinations, mechanical debridement of wounds must respect the time-dependent irritability of the healing wound. There is little risk of impairing epithelization during the second week after surgery and the chance of sustaining the healing process is best.     

The use of small intestine in bladder reconstruction

OBJECTIVE: This study was conducted to determine the efficacy of FESS (functional endoscopic sinus surgery) on sinus and asthma symptoms. METHOD: Seventy-nine patients with asthma and medically unresponsive sinusitis were evaluated. Maximal medical therapy was attempted to relieve both sinus and asthma symptoms. The surgical procedures involved standard FESS techniques. Fifty-six percent of patients had undergone a sinus procedure prior to the FESS. Nasal polyposis was noted in 73% of the group. The majority of patients had pansinusitis. RESULTS: Eighty-six percent of patients stated that FESS improved their sinusitis. Nine of 11 sinus symptoms recorded preoperatively diminished significantly (p < .05) following surgery. Eighty percent of patients noted improvement of their asthma following FESS. The factors associated with treatment failure and the unique characteristics of this disease process were evaluated. CONCLUSIONS: FESS is a viable option in the treatment of asthma when medical therapy fails.     

MR-guided endoscopic sinus surgery

We describe an interactive, intraoperative imaging-guided method for performing endoscopic sinus surgery (ESS) within a vertically open MR system. The procedure was performed with intraoperative imaging using a 0.5-T magnet with a 56-cm vertical gap. Interactive control of imaging planes was accomplished by optical tracking with two infrared light-emitting diodes mounted on an aspirator probe. The probe's position defined the location of the orthogonal imaging planes. Twelve patients with varying degrees of sinus disease underwent ESS with MR imaging guidance. Patients had acute and chronic sinusitis, nasal polyposis causing airway obstruction, or tumor requiring tissue biopsy. All procedures were performed with the patients under general anesthesia. The integration of endoscopy with optical tracking and intraoperative interactive imaging allowed localization of anatomic landmarks during ESS. No complications were encountered.