Acute rhinosinusitis (<4 weeks duration)
Bacterial
Viral
Invasive fungal (immunocompromised patients)
Recurrent acute rhinosinusitis (each episode <4 weeks)
Subacute rhinosinusitis (4–12 weeks duration)
Chronic rhinosinusitis (can be a combination of the following)
Bacterial
With polyposis or without
Allergic fungal
Eosinophilic mucin
Fungal ball/mycetoma/aspergilloma
Chronic fungal/saprophytic
Aspirin sensitivity and/or asthma
Mucocele formation
As a clinician, it is important to elicit the symptoms that accompany the disease process as this will help determine the diagnosis as well as the subsequent course of action.
For rhinitis, symptoms generally include nasal airway congestion, postnasal drip, and allergy-like symptoms including sneezing, clear nasal discharge/nose blowing, and pruritus.
Symptoms of sinusitis include those listed earlier for rhinitis, in addition to the following: mucopurulent/purulent nasal or postnasal drainage, facial pressure/pain, hyposmia, fevers, headaches, halitosis, dental pain, cough, ear pain, and malaise/fatigue. Multiple sets of criteria have been proposed to help distinguish true sinusitis from various clinical imitators such as migraines, dental pains, headache syndromes, allergies, etc. A basic understanding of the algorithms used to define sinusitis and the ability to differentiate it from other diagnoses can help physicians other than otolaryngologists who may encounter these symptoms while working up a patient for a DCR or other combined procedure (Table 28.2).
Table 28.2
Major and minor criteria for the diagnosis of rhinosinusitisa
Major symptoms | Minor symptoms |
|---|---|
Purulent anterior nasal discharge | Headache |
Purulent or discolored posterior nasal discharge | Ear pain, pressure, or fullness |
Nasal congestion or obstruction | Halitosis |
Facial congestion or fullness | Dental pain |
Facial pain or pressure | Cough |
Hyposmia or anosmia | Fever (for subacute or chronic sinusitis) |
Fever (for acute sinusitis only) | Fatigue |
Patients will often have a preconceived notion that they suffer from “sinus headaches.” The most common misdiagnosis of sinusitis is migraine headaches. An alarm should go off in the clinician’s mind when intermittent unilateral facial pain exists with no other accompanying symptoms in addition to a negative physical exam or negative CT scan. Multiple studies emphasize the risks of misdiagnosing migraines as sinusitis and many have even recommended a trial of anti-migraine medication prior to a trial of antibiotics in such cases [2–4].
Once a thorough history has been obtained, physical exam can help narrow the differential diagnosis. Upon anterior rhinoscopy with an otoscope, the clinician can assess the anterior nasal airway for septal deviation and turbinate hypertrophy (Fig. 28.1). Significant purulence as well as polyposis or other nasal masses may also be picked up with this initial evaluation (Fig. 28.2). The next step is to assess deeper within the nasal passage, using nasal endoscopy. In-office nasal decongestant spray and topical anesthetic allows for a rigid endoscope to gently be passed into the anterior nasal cavity, the middle meatus under the axilla of the middle turbinate, and medial to the middle turbinate to assess the posterior nasal cavity. During this inspection, the various diseases of the nose can be more readily seen, such as polypoid changes, purulence, mucosal edema, nasal masses, or other conditions.
Fig 28.1
Left nasal endoscopy showing significant septal deviation as well as mild turbinate hypertrophy narrowing the nasal airway
Fig 28.2
Classic view of severe but benign appearing nasal polyps
Over the past few decades, the use of CT scans for diagnostic purposes and surgical planning has become increasingly utilized. If findings such as a nasal mass or polyposis are found during the initial physical exam, imaging is generally accepted as part of the primary workup. However, most other nasal diseases warrant a trial of medical therapy prior to obtaining further diagnostics.
If septal deviation or turbinate hypertrophy is encountered during endoscopy and they account for the patient’s symptoms, then radiologic confirmation is unlikely to be necessary. However, if criteria of rhinosinusitis are met and symptoms persist despite medical therapy, then a CT scan of the sinuses is generally obtained prior to further intervention (Fig. 28.3).
Fig 28.3
Patient with mild mucosal thickening of the right maxillary sinus but otherwise normal appearing sinuses on that side. Contrast this to the patient’s left side, where pan-sinusitis is seen as opacification of the sinuses and will require surgical intervention to correct
Surgical Techniques of Adjunctive Procedures
If the decision is made to proceed with an endonasal procedure in addition to a dacryocystorhinostomy, the order of the surgeries becomes relevant. In general, surgeries done for access and anatomical obstruction such as a septoplasty are performed first to allow the surgeon proper visualization of the nasolacrimal system. If bilateral DCRs are to be performed, the DCR on the nonobstructed side can be performed prior to a septoplasty. In the rare case that a septal deviation requiring surgical intervention protrudes to the opposite side of the nasolacrimal duct obstruction, the DCR can be performed first followed by the septoplasty. Inferior turbinate reduction can be performed after a DCR as this procedure generally does not influence the work done on the nasolacrimal system. Middle turbinate work is usually performed before the DCR to allow improved access and can include anterior partial turbinectomy or concha bullosa excision. If an axillary mucosal flap is going to be utilized for the DCR as described by Wormald [5], and a middle turbinate procedure is required, the mucosal flap must be raised prior to the middle turbinate procedure to prevent its loss during the preceding interventions. If functional endoscopic sinus surgery (FESS) is going to be performed with the DCR, then the DCR is performed first. This is done because during DCR one removes the anterior wall of the agger and exposes it; this makes the first step in FESS easy as the agger is exposed and ready to be taken down. Again, if the axillary flap is to be utilized, this is to be performed as the first part of the DCR and can be later trimmed as needed for a mucosal graft to promote healing.
Septoplasty
One of the keys to a successful endoscopic DCR is adequate surgical access during the surgery and ample space surrounding the surgical bed in the postoperative period. Therefore, it is recommended to have a low threshold in performing an adjunctive septoplasty. By straightening such a deflection (Figs. 28.4, 28.5, and 28.6), the surgeon gains improved access to the axilla of the middle turbinate and the area surrounding the proposed neo-ostium of the DCR. Considering the surgeon has all required instrumentation already set up including endoscopes, suction, lighting, etc., our recommendation is to perform an endoscopic septoplasty rather than an open version.
Fig 28.4
Endoscopic view of right deviated nasal septum narrowing the nasal cavity
Fig 28.5
Endoscopic submucoperichondrial view showing the septal deviation
Fig 28.6
External view of right caudal deviation
To be able to perform an endoscopic septoplasty, certain instruments are necessary. A suction Freer elevator helps keep a clear surgical field while allowing the surgeon to continue to elevate the flaps. The endoscopic lens cleaner can remove blood without reinsertion of the endoscope repeatedly throughout the procedure and facilitates surgical progress.
The initial incision is made either in the location of a Killian incision or, if there is caudal dislocation of the cartilaginous septum, in the more anterior location of a hemitransfixion incision (Fig. 28.7). The subperichondrial plane is exposed using a scalpel, iris scissors, or other sharp instrumentation, and then further elevated using the suction Freer (Fig. 28.8).
Fig 28.7
Right hemitransfixation incision
Fig 28.8
Submucoperichondrial elevation of the flap
In order to preserve the septal flap during elevation of the flap off the maxillary crest, it is best to raise the flap as far posterior as possible prior and then to dissect toward the floor in the posterior region and bring this plane progressively anteriorly releasing the flap from the crest (Fig. 28.8). This helps prevent perforation of the mucosa as it thins out over the junction of the cartilage and nasal crest. This is best done by starting on the side of the septum without a spur or significant deviation to ensure at least one septal flap is preserved. In most cases, if there is a significant spur or deviation it can be very difficult to maintain the integrity of the flap, so preserving the nondeviated side flap becomes critically important in avoiding a septal perforation.
Often, if the cartilaginous septum is elongated and dislocated off the crest, and an inferior strip of cartilage needs to be removed just above the maxillary crest, rather than attempting to elevate all the way to the floor in this circumstance, the flap can be raised down to the presenting edge of the spur. The flap is not raised over the entire deflection, as it is likely to tear. Rather, using the sharp end of a regular Freer elevator, a horizontal incision is made above the spur through the cartilage onto the crest. This allows for removal of the cartilaginous insertion into the crest from anterior to posterior. If the bony crest is found to contribute significantly, this can be removed using an osteotomy chisel. In general, patients should be counseled preoperatively that numbness of the central incisors can be common, but most often dissipates after several weeks. Ideally, only half of the crest that is protruding into the nasal cavity is removed because damage to the nerves is more common when the whole maxillary crest is removed.
As the septoplasty proceeds, occasional glances with the endoscope into the bilateral nasal cavities will allow the surgeon to correct the areas of greatest concern. The posterior bony deflections can be addressed by disarticulating the bony and cartilaginous junction (Fig. 28.9) followed by bilateral subperiosteal planes. A sharp Freer elevator is used to incise the cartilage leaving a good strut anterior and above (Fig. 28.10) and disarticulate the portion to be removed (Fig. 28.11). The bony spur is then exposed (Fig. 28.12) and can be removed superiorly using a through-biting instrument such as an open Jansen–Middleton to prevent torqueing on the roof and thus preventing a skull base damage and CSF leak (Fig. 28.13). A good space is thus created within the nasal cavity (Fig. 28.14).
