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In the mid-1980s, sinus surgery shifted to a more physiological basis as attention was directed to the osteomeatal complex through the introduction and popularization of functional endoscopic sinus surgery (FESS).1,² Since that time, FESS has emerged as the preferred surgical modality for the treatment of chronic rhinosinusitis (CRS) that has proven refractory to aggressive medical treatment. Numerous technological advances over the past 2 decades have served to facilitate the implementation of FESS principles, but the emphasis upon restoration of mucociliary clearance and preservation of sinus mucosa has only grown stronger.

This chapter will focus on the surgical management of CRS after medical treatment has failed. Because FESS alone will not provide optimal results, special consideration will be given to perioperative management, which optimizes the surgical results.

Over the past 10 to 15 years, endoscopic techniques have been developed for septoplasty, cerebrospinal fluid (CSF) leak repair, orbital decompression, optic nerve decompression, dacryocystorhinostomy, hypophysectomy, and tumor resection. Discussion of the procedures is beyond the scope of this chapter.

♦ Preoperative Care and Decision Making

Chronic Rhinosinusitis Diagnosis

Although complaints of nasal and sinus symptoms rank among the most common health complaints, considerable controversy persists about the definition of chronic rhinosinusitis. In its most general sense, CRS represents a long-standing inflammatory process involving the contiguous mucous membranes of the nose and paranasal sinuses. Rather than a disease with a single pathophysiology, CRS is a syndrome of various specific diseases, including but not limited to sinonasal polyposis, sinus mucocele, chronic suppurative bacterial infection, eosinophilic rhinosinusitis, aspirin (ASA) triad (also known as Sampter’s triad), and allergic fungal rhinosinusitis (AFRS). From a practical standpoint, confirmation of a specific pathophysiology is problematic; fortunately, an operational approach for CRS diagnosis may be used.

This strategy for CRS diagnosis relies on the major and minor diagnostic factors summarized in the 2003 Sinus and Allergy Health Partnership consensus statement (Table 2–1).³ The presence of two major factors for more than 12 weeks constitutes a history that is strongly supportive of the clinical diagnosis of CRS. Two minor factors and a single major factor for an equivalent time period provides similar evidence for CRS. It must be remembered that clinical symptoms alone may be a poor marker of CRS; therefore, CRS diagnosis in patients with a strong clinical history must be confirmed by the objective means of nasal endoscopy and/or sinus computed tomography (CT).

Nasal endoscopy is an important tool for CRS diagnosis because it provides visualization that simple anterior rhinoscopy cannot duplicate. Relatively subtle changes, such as polypoid mucosal changes, mucosal edema, and purulent drainage, may be easily appreciated during routine office-based endoscopic examinations. Furthermore, nasal endoscopy provides access for direct sampling of purulent nasal secretions for culture. Admittedly, endoscopic visualization may be limited in some patients with unfavorable nasal anatomy, even with the application of topical decongestants and anesthetics. In addition, the endoscopic examination may be relatively normal in patients with quite extensive paranasal sinus opacification on sinus CT. Therefore, one must not overly rely upon nasal endoscopy for CRS diagnosis.

Sinus CT is certainly a sensitive method for assessing paranasal sinus aeration; however, even relatively minor upper respiratory illnesses may be associated with extensive but reversible paranasal sinus opacification. For this reason, the clinician must interpret sinus CTs in a framework defined by the clinical history of the patient at the time of CT scan acquisition.

Recurrent acute rhinosinusitis is characterized by frequent episodes (more than four to six episodes per year in adults) of purulent acute rhinosinusitis, with symptomatic resolution between episodes. Because symptoms are a poor marker of inflammatory paranasal sinus disease, confirmation of this diagnosis includes nasal endoscopy and/or sinus CT during an active episode. Recurrent acute rhinosinusitis may mimic frequent episodes of viral rhinitis. In general, viral rhinitis symptoms are much less severe and more self-limiting (Table 2–2). Most episodes of acute rhinosinusitis are preceded by viral rhinitis, and most attacks (>95%) of viral rhinitis resolve without specific intervention within 7 to 10 days of onset. Persistent or worsening symptoms beyond 10 to 14 days suggest the presence of an acute bacterial sinus infection.

Some patients with CRS may experience acute exacerbations that are characterized by a symptomatic flare-up of their baseline symptoms. During an acute exacerbation of chronic rhinosinusitis, a patient’s characteristic symptoms grow acutely worse, but with appropriate treatment, symptoms return to baseline.

Chronic Rhinosinusitis Treatment

• CRS medical therapy focuses on the two underlying themes in CRS pathophysiology, which is felt to represent an underlying inflammatory process and an infectious process.
  
• Because CRS is a long-standing illness, aggressive treatment is often prolonged, and some patients require treatment indefinitely.
  
• The microbiology of CRS differs from acute rhinosinusitis, in which the primary organisms are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.4 In particular, some studies seem to indicate that anaerobes play a much larger role in CRS.⁵ The primary pathogens for CRS include coagulasenegative staphylococcal species, Staphylococcus aureus, Streptococcus species Pseudomonas aeruginosa, and enteric gram-negative bacteria, as well as the more common pathogens associated with acute rhinosinusitis.⁶
  
• Empiric antimicrobial therapy should provide coverage for the likely organisms. Amoxicillin/clavulanate, respiratory quinolones (levofloxacin, moxifloxacin, temafloxacin, etc.), second-generation cephalosporins, and macrolides (clarithromycin, rather than azithromycin and erythromycin) all may be used for empiric treatment. If empiric treatment fails, switching to another antimicrobial class should be considered.
  
• Adequate antimicrobial treatment should last for at least 4 weeks and possibly longer.
  
• Ideally, antibiotics selection is based on cultures obtained under endoscopic visualization.
  
• Nasal endoscopy provides a means for both establishing the diagnosis of CRS and gauging its response to therapy.
  
• Important adjuvant medications in CRS treatment include mucolytics (guaifenesin 600–1200 mg po bid) and topical nasal steroids (budesonide, flunisolide, fluticasone, mometasone, and triamcinolone). Often topical nasal steroids are used at doses 2 or 3 times the standard dosing for allergic rhinitis.
  
• Concomitant inhalant allergies require appropriate medications, including systemic antihistamines (cetirizine, desloratadine, fexofenadine, etc.) and topical antihistamines (azelastine). Older, first-generation systemic antihistamines may have a significant drying effect on the sinonasal lining and probably should be avoided.
  
• Many CRS patients also have asthma. Because of the relationship between CRS and asthma, comprehensive CRS treatment includes coordination with the patient’s other physicians who are actively managing the reactive lower airway disease.
  
• Many patients also benefit from the administration of systemic corticosteroids. In particular, patients with sinonasal polyposis and/or ASA triad are candidates for systemic steroid treatment. Short bursts of steroids (i.e., methylprednisolone dose pack) may be used, but more severe sinonasal inflammation will require longer treatment courses (i.e., prednisone 40 mg po daily × 3 days, then 30 mg po daily × 3 days, then 20 mg po daily × 3 days, then 10 mg daily × 3–6 weeks, with a final taper adjusted based on response, side effects, etc.) Unfortunately, systemic corticosteroids carry significant morbidity (including weight gain, mood changes/swings, diabetes, hypertension, osteopenia/osteoporosis, glaucoma, cataracts, rare avascular necrosis of a major joint, etc.); patients must be counseled about these issues. Furthermore, physicians should perform a risk assessment before commencing systemic steroids. In particular, ophthalmological evaluations for glaucoma and cataracts as well as bone densitometry should be considered.

Indications

• Symptomatic, refractory CRS The diagnosis should be confirmed by CT obtained after aggressive medical treatment (administered during a 6–8 week period).
  
• Recurrent acute rhinosinusitis This diagnosis must be confirmed by an abnormal CT or nasal endoscopic examination performed approximately 7 to 10 days after the onset of symptoms. The minimal frequency should be at least four to six episodes per year.
  
• Frontal sinus and/or sphenoid mucocele Complete opacification of the frontal or sphenoid sinus, especially when associated with bony remodeling and expansion of the sinus, suggests the presence of a mucocele. If medical treatment does not produce at least partial aeration, endoscopic marsupialization is warranted to prevent delayed complications even in the absence of symptoms. The presence of bony erosion, even if such erosion brings sinus mucosa into contact with the dura, requires a functional, endoscopic approach.7
  
• Acute suppurative complications of rhinosinusitis In these instances of secondary orbital infection (subperiosteal abscess, orbital cellulitis) and intracranial complications (meningitis, extradural abscess, etc.), the functional endoscopic technique may be substituted for the traditional, nonendoscopic techniques. Of course, the management of these complications requires coordination of care with neurosurgery, ophthalmology, infectious disease, neuroradiology and other allied disciplines.
  
• Noninvasive fungal sinusitis Both mycetoma and AFRS require operative intervention for confirmation of diagnosis and treatment. For mycetoma, such a procedure is likely to be curative; for AFRS, a nondestructive, functional approach is warranted because multiple procedures over many years may be necessary.
  
• Invasive fungal sinusitis Initial surgical management of invasive fungal rhinosinusitis may rely on FESS principles; however, the surgical objective of complete debridement will likely require nonfunctional tissue resection, which still can be performed under endoscopic visualization.

Preoperative Considerations

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