• Preoperative imaging must be carefully evaluated in order to identify possible dangerous areas that may lead to adverse outcomes. It is highly recommended to evaluate the patient’s individual anatomy in coronal, axial, and sagittal image sets.
• Patients with unrealistic surgical expectations and symptoms that do not correlate well with endoscopic and CT scan findings may not be good candidates for desired symptom improvement via ESS.
Postsurgical Care and Treatment
• Comprehensive postsurgical care—with directed debridement, sinonasal irrigations, and appropriate postoperative medical therapy—is critical to achieve the desired results.
• Surgeons should attempt to maintain wide patency of the middle meatal area, avoiding lateralization of the middle turbinate in order to achieve better delivery of topical treatments as well as improved surveillance and postoperative debridements.
• The postoperative period is almost as critical to the success of surgery as the surgery itself; optimize the postoperative period by delivering topical treatments and enough debridements to allow postoperative patency of the surgically created sinusotomies.
• In the vast majority of patients with CRS, surgery alone is unlikely to completely resolve their symptoms. Patients need to be aware of the need for continuing medical (topical) treatment in order to achieve the best outcomes possible.
• Chronic Rhinosinusitis (with or without nasal polyps), recalcitrant to medical treatment
• Fungal Rhinosinusitis (invasive and noninvasive forms): see Chapter 17
• Recurrent acute rhinosinusitis
• Complications of rhinosinusitis (mucoceles, orbital/subperiostial infections, intracranial complications): see Chapter 19
• Antrochoanal polyp
(with or without skull base compromise)
• Benign tumors: see Chapter 25
• Malignant tumors: see Chapter 26
• Silent sinus syndrome: used to describe an acquired maxillary atelectasis with complete or partial opacification of the sinus; could be associated with enophthalmos and infrequently, diplopia; surgical intervention to restore sinus ventilation, with or without orbital floor reconstruction, is the mainstay treatment for this condition
• CSF leak and meningoencephalocele: see Chapter 37
• Choanal atresia repair
• Recurrent epistaxis: see Chapter 11
• Sinus foreign body removal
Mucosa Preservation
• Regardless of the technique used, the single most important concept that needs to be kept in the surgeon’s mind is mucosal preservation.
• Removal of mucosa from any bony surface that is going to remain in place at the conclusion of surgery (eg, lamina papyracea, skull base) should be avoided at every step of the sinus dissection; denuded bone leads to crusting formation, scarring, hyperostosis, pain, and, ultimately, undesirable outcomes in ESS.
• Preservation of this lining aids with rapid healing (limits osteitis and crust formation), limits synechiae formation, and minimizes ostial stenosis; furthermore, this native lining is essential to maintaining mucociliary clearance.
Adequate Superficial Exposure to Safely Dissect Deeper Structures
• It is highly recommended to avoid working in narrow spaces whenever possible.
• Often, widening the exposure superficially is avoided to prevent against injury to the orbit and/or skull base; a better strategy for safe dissection that avoids restricted visualization deeper within the ethmoids is early identification of the lamina papyracea +/− skull base.
Sinusotomies Should Include the Natural Ostia
• The natural ostium of each sinus should always be included in all sinusotomies since the mucociliary clearance patterns propel mucus toward the natural ostia.
• Failure to include natural ostium may lead to recirculation and potentially recalcitrant CRS.
Prevention of Middle Turbinate Lateralization
• Surgeons should be particularly interested in minimizing postoperative scarring in all areas that will lead to obstruction of the surgically created sinus drainage pathways and subsequent suboptimal postsurgical results.
• Patency of the middle meatus/ostiomeatal complex is key to maintaining adequate long-term ventilation and drainage of the maxillary, ethmoid, and frontal sinuses.
• A variety of techniques have been described to prevent middle turbinate lateralization; these include suture techniques, Bolgerization, partial resection of the middle turbinate, and various forms of stents.
Intraoperative Use of Intraoperative Navigation Systems (Image-Guided ESS)
• These systems are designed for real-time localization of surgical instruments within the surgical field, based on preoperative thin-cut CT scans.
• They provide assistance in identifying critical (eg, orbit, skull base) structures surrounding the paranasal sinuses, and potentially aid in minimizing complications.
• Navigation systems are not a substitute for a thorough understanding of the patient’s anatomy; these systems should not be used to undertake a case that the surgeon would not otherwise be comfortable completing.
• The American Academy of Otolaryngology–Head and Neck Surgery (AAOHNS) endorses use of these systems to assist the surgeon, in selected cases, to clarify complex anatomy during sinus and skull base surgery.
• Indications in which use of computer-aided surgery may be deemed appropriate according to AAOHNS include (1) revision sinus surgery; (2) distorted sinus anatomy of developmental, postoperative, or traumatic origin; (3) extensive sinonasal polyposis; (4) pathology that involves the frontal, posterior ethmoid, and sphenoid sinuses; (5) disease that abuts the skull base, orbit, optic nerve, or ICA; (6) CSF rhinorrhea or conditions in which there is a skull base defect; and (7) benign and malignant sinonasal neoplasms.
Powered Instrumentation
• Powered microdebriders are very useful to debulk hypertrophic sinonasal mucosal lining, sinonasal polyps, or tumors. They should be used in such a way to cut the desired mucosa sharply and minimize mucosal stripping.
• Microdebrider blades angulated at 15°, 40°, 60°, and 90° are available to address different areas in the nasal cavity/sinuses.
• A suction trap attached to the microdebrider may be used to collect tissue for histopathology.
• Drills (diamond and cutting burrs) with different angulations have been crucial for bone removal in complex ESS cases and in patients with sinonasal and skull base tumors.
Balloon Sinusotomy
• Balloons may be used with the goal of atraumatically dilating the sinus ostia (frontal, maxillary, or sphenoid) to widen the sinus ventilation passageway and restore normal drainage/function.
• These balloons can be used alone or in conjunction with other instruments and techniques.
• Mild to moderate inflammatory disease is likely most amenable to solo treatment by balloon sinusotomy.
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