Outcomes in Sinus Surgery—Management Parameters
CHAPTER 17
Sinusitis affects approximately 35 million Americans. Nasal inflammation and sinus disease cause patient discomfort and loss of productivity and have a negative impact on the quality of life of those affected. The cost of treating this disease surpasses $2 billion per year.1 Most people who experience sinus infections can be treated medically without entertaining surgical intervention. However, deciding which patients require surgical intervention can be difficult.
Most patients will respond to medical therapy. Adequate medical therapy may include the use of saline irrigation, topical and/or systemic decongestants, topical nasal steroids, systemic corticosteroids, mucolytic agents, appropriate antihistamine use, and the appropriate use of oral antibiotics for an appropriate treatment duration. The evaluation and treatment of systemic disease such as allergy (inhalant or food), immunodeficiency, cystic fibrosis, diabetes mellitus, and the evaluation of environmental factors (e.g., smoke, inhaled irritants, drug use) may increase the number of patients who will be successfully treated without surgery. It is not uncommon to treat a patient for 6 to 10 weeks before an infection resolves. Medical failures can often be traced to patient noncompliance, but if a compliant patient fails maximal therapy for 12 weeks or more, surgery should be considered.
The development and acceptance of functional endoscopic sinus surgery2 have offered a variety of treatment options for patients who fail medical therapy and continue with debilitating sinus conditions. Functional endoscopic sinus surgery provides a method of excellent visualization that aids in the precise and meticulous eradication of paranasal sinus disease. Most patients receive surgery on an outpatient basis, have a minimal recovery time, and have excellent long-term results.3, 4
The evaluation of a patient for sinus surgery begins with the assurance that all other treatment options have been used, and the patient continues with unrelenting disease. There are obvious cases for which sinus surgery is indicated, including unilateral nasal masses, invasive fungal disease, obstruction with nasal polyps, and complications such as subperiosteal, orbital, or intracranial extension of infection. Patients who are immuno-compromised and have sinusitis should be considered eligible for surgery at a much earlier point, as they tend to respond poorly to medical management and have an increased propensity to develop orbital or intracranial complications. These patients comprise a minority of surgical candidates; the usual candidate requires a more careful evaluation. In addition, many patients undergoing sinus surgery will require ongoing treatment for underlying systemic or recalcitrant disease.
The decision to operate must be based on clear historical, clinical, and radiographic evidence. If the patient is a child, the decision becomes even more complicated. The major anatomic differences between adult and pediatric paranasal sinuses are smaller sinus size and lesser degree of pneumatization. In evaluating a child who is considered a possible candidate for sinus surgery, an immature but still developing immune system, the role of tonsils and adenoids, and other factors must be considered. Support for aggressive medical therapy before surgery has been well established;5 however, certain conditions do benefit from surgical intervention. Most cystic fibrosis patients are within the pediatric age group and experience sinusitis. Sinusitis may progress to a life-threatening condition in this population. Sinus inflammation leads to congestion and stasis of secretions and forms a reservoir for pathogen growth. Sinus pathogens seed the lower respiratory tract and can lead to pneumonia, particularly in those who have lung transplants.6 A decreased ability to clear secretions, the propensity to develop polyps, common colonization with Pseudomonas organisms, and progressive general deterioration of the patient are reasons sinus surgery is performed. Surgery is directed toward removing disease, relieving obstruction, ventilating the paranasal sinuses, and eradicating pathogenic organisms. Sinus surgery serves to mediate, not cure, the sinus disease or pulmonary involvement. The creation of widely patent middle meatus with large maxillary sinus antrostomies or “mega-antrostomies” is advocated. The “mega-antrostomy” involves opening the maxillary ostia both posteriorly and inferiorly with the removal of the posterior inferior turbinate and inferior meatus, to allow secretions to drain toward the floor of the nose and nasopharynx. Surgery often provides drastic and prolonged improvement in these patients.7 Revision sinus surgery is not uncommon, as sinus surgery improves the general health of cystic fibrosis patients but does not cure the underlying disease. Tenacious secretions associated with cystic fibrosis are difficult to expel, and impair the function of cilia within the nasal cavity. The resultant stasis will continue to cause recurrent episodes of sinusitis, but the severity of the infection and the potential for life-threatening sequelae are most often lessened.