13 Historical Overview
Current endoscopic surgery of the nasal sinuses derives its stimulus from two sources: intranasal surgery extending back to the nineteenth century, and sinuscopy, which was originally used only for diagnosis. A historical review must therefore encompass the early stages of both components. Furthermore, it must not only chronicle the past but should also point the way to future developments.
Not every reference can be analyzed, because of lack of time and space, and it has therefore not always been possible to establish the priority of reporting of a technique. Moreover, new ideas and practical innovations are often not published at all, or are only reported long after they have been presented at meetings and operative courses and taken up by other surgeons. It seems more important to name the paramount contributions to anatomy, pathophysiology, diagnosis, and treatment that have infl uenced this author’s ideas.
Beginnings of Intranasal Sinus Surgery
The first intranasal antral operation is usually ascribed to von Mikulicz, who reported opening of the antral cavity through the middle meatus in 1886. In 1886 Ziem stated that Schaeffer had also used this method often to simplify irrigation for the treatment of a chronic antral infection. Claoué used antrostomy for the same indication, and published his 10-year personal experience in 1912.
Dahmer (1909) created a large inferior meatal antrostomy by resecting the anterior end of the inferior turbinate. He curetted the mucosa from the floor of the antrum itself, and claimed that the resulting ease of irrigation was the actual purpose of his operation. Indeed, the patient could carry out the regular irrigations himself.
Other European rhinologists such as Boenninghaus and Hajek who had adopted the method of wide inferior meatal antrostomy, sometimes with resection of the head of the inferior turbinate, had declared themselves satisfied with the rapid decrease of purulent secretion after the operation (cited by Claoué 1912). In America in 1897, Lothrop carried out a wide inferior meatal antrostomy leading to resolution of suppuration due to various causes, but the antrostomy was regarded merely as a means of irrigation to control the suppuration.
Middle meatus antrostomy described by Siebenmann in 1899 and 1900 had the same purpose, that is, the creation of an easily accessible nasoantral opening for longterm irrigation of the antral cavity by patients themselves. He proposed resection of the head of the middle turbinate, and breaking down the fontanelle with the little finger. Zuckerkandl’s (1882) statement that this window generally remained fully patent deserves mention: it was already known at that time that the inferior meatal antrostomy easily closed again (Lothrop 1897). Kubo in 1912 expressed a preference for a middle meatal antrostomy and Onodi designed a perforator for this purpose in 1902. Gerber (1905), like Onodi, favored middle meatal antrostomy; he created the window in the middle meatus after transoral antral procedures.
Others had different preferences: for example McBride (1900) stated that an antrostomy lying as deeply as possible in the inferior meatus was more correct on surgical principles (for example Halle 1906). A milestone on the route of the development of modern sinus surgery aiming at the recovery of chronically inflamed mucosa was the recommendation of Eckert-Möbius (1934) to get away from the transoral radical curettage of the maxillary cavity and to confine an antrostomy to a simple edonasal infraturbinal fenestration. A year later King (1935) stated that even hyperplastic sinusitis could heal after a simple antrostomy in the inferior meatus, although the radiographic contrast medium was mainly transported to the natural ostium. Thus Lavelle and Harrison in 1971 compared two series and found a higher rate of healing of chronic maxillary sinusitis with fewer complications after a middle meatal antrostomy. A list of advantages of this procedure was presented by Bryant in 1960. Halle in 1906 thought that this route of access was impractical because it lay close to the orbit.
Those who prefer middle meatal antrostomy emphasize that the physiological transport pathways of the antral cavity lead to the maxillary ostium. The credit for the photographic recording of their corkscrew course should be given to Hilding (1932, 1941), who also showed that carbon particles bypassed an inferior meatal antrostomy, and could leave the antral cavity and reenter it again before finally leaving through the natural ostium. Accurate descriptions were given by Proetz (1941). Messerklinger and Stammberger have provided an impressive film demonstrating this process.
The combination of two antrostomies was described by McKenzie (1921, 1927) and the removal of the entire medial antral wall by Sluder (1927), who preserved only the inferior turbinate. In 1903 Réthi recommended a large bimeatal perforation and removed the anterior twothirds of the inferior turbinate.
More recently, Straatman and Buiter (1981) resurrected the old principle of fontanellotomy which had been in disuse for many decades. They have developed a precise operative technique using the endoscope, and fenestrate the posterior fontanelle under vision using a special instrument.
It is difficult to establish who was the first to go beyond simple intranasal antrostomy, and who was the first to carry out transnasal manipulations within the antral cavity without an angled telescope.
In 1909 Dahmer removed chronic hyperplastic mucosa partially or subtotally based on the concept of radical surgery. He resected the anterior third of the middle turbinate and created a wide opening from the floor of the nose up to the middle meatus, and turned a mucosal flap from the nasal wall into the opening. Réthi (1903) excised all the suspect tissue from the antral cavity using a sharp curette after removing the anterior two-thirds of the inferior turbinate and creating a large bimeatal window. The intracavity manipulations described by Sturmann (1910) are not included under this heading, although his was an intranasal procedure. He used an approach through the piriform aperture, and also resected the anterior wall of the antrum.
It can be assumed that gross lesions of the antral mucosa were removed intranasally by other surgeons through a wide antrostomy created with a punch, as Unterberger emphasized in 1932. However, Schickedanz in 1959 was the first to mention that isolated mucosal cysts could be removed via the inferior meatus. Davison (1969) removed polyps from the antrum using forceps and curettes, but he used the Caldwell–Luc procedure for longstanding disease. All intranasal procedures without endoscopic monitoring should be regarded as modifi ed antrostomy, but they do not meet the criteria of mucosal microsurgery.
Intranasal ethmoid surgery with the unaided eye is also subject to the same limitations, and it is uncertain how complete, precise, and safe it has been. This is doubtless why the method, indications, results, and operative dangers of intranasal ethmoidectomy rema8n controversial.
Killian described his technique of resection of the uncinate process with widening of the neighboring ostium in 1900 see Fig. 1.8). Halle was probably the first surgeon with extensive personal experience of intranasal ethmoidectomy and frontal and sphenoidal sinusotomy. The important points, such as uniting all individual cells into a common cavity, difficulties with the most anterior cells, indications for chronic empyema, prevention of blind dissection, the topical use of epinephrine, and the use of special curved instruments were all described in his work which appeared in 1906. In the English-speaking world, Mosher (1912) initiated intranasal ethmoidectomy for chronic ethmoiditis, centered upon the fine structure of the ethmoid labyrinth. He resected the middle turbinate widely, thus improving the view of the sphenoid and posterior ethmoid sinuses and making the operation safer. Numerous authors adopted the same view including Lederer (1953), Weille (1959), Yankauer (1921), Kidder et al. (1974) and Friedman et al. (1982). It is interesting that Grünwald had recommended radical amputation in 1896 and warned against a faint-hearted approach. Others such as Pratt (1925), Davison (1969), Eichel (1972), Guggenheim (1972), Freedman and Kern (1979) and Dixon (1983) emphasized the value of preservation of the middle turbinate to prevent the symptoms of dryness because the nasal cavity would otherwise become too large.
A similar divergence of opinions and results appears in statements about the completeness of ethmoidectomy. Eichel (1972) confirmed that many rhinologists term a limited opening of a few middle ethmoid cells an ethmoidectomy. Many understand the term total ethmoidectomy to include opening of the sphenoid sinus (Dixon 1983, Wigand 1981c, Eichel 1972, Friedman et al. 1982) and an antrostomy as well (Davison 1969, Ashikawa et al. 1982, Wigand 1981b). Others usually leave the sphenoid sinus unopened. Messerklinger (1987) and Stammberger (1985) open the antral cavity if indicated by the individual radiological findings. Many of these aspects can only be submitted to a comparison of treatment modalilities if intranasal sinus surgery is raised to the status of precise endoscopic sinus surgery.
Early Stages of Endoscopic Sinus Surgery
The start of endoscopic sinus surgery cannot be ascribed to one date or one person. It began with endoscopic diagnosis that could be combined with the removal of tissue for histology. From this step, endoscopic surgical treatment of sinus disease slowly emerged.
Draf in his monograph of 1978 reviewed the literature on endoscopic diagnosis. Hirschmann (1903) was the first to use a reflector, a speculum, and the true endoscope for the inspection of the nose and sinuses. His endoscope was made by the firm of Reiniger, Gebbert, and Schall in Berlin, based on the cystoscope designed by Nitze in 1897. Early Stages of Endoscopic Sinus Surgery 213 214 13 Historical Overview Other pioneers of this new method refined it for endoscopic diagnosis of the nasal passages, the antrum, and the nasopharynx. However, Reichert, Valentin, and Sargnon rapidly extended its use to minor procedures such as cautery, opening of cysts, irrigation (Reichert 1902), measurement of tubal opening (Valentin 1903), and removal of foreign bodies (Sargnon 1908; Imhofer 1910). Until that time, the endoscope had only been introduced into the antral cavity through an open dental socket or via the anterior antral wall (Sargnon), but it is suspected that Spielberg (1922) in the USA was the first to use the intranasal route through the inferior meatus. He used the nasopharyngoscope described by Holmes for inspection of the antral cavity. He named the procedure antroscopy, and used it for work-up before a radical antrostomy or conservative treatment with irrigation. In 1925, Maltz described the sinuscope made for him by the firm of Wolf in Berlin. He also used an approach through the inferior meatus or through the anterior antral wall. In the succeeding years these and other almost exclusively rigid telescopes with proximal illumination by a very small bulb were used, almost always for diagnosis, including the removal of specimens for biopsy (Portmann 1925; Watson-Williams 1930; Slobodnik 1930; Lüdecke 1932; Christensen 1946; Hahn 1955; von Riccabona 1955; Bauer and Wodak 1958). The details were summarized by Draf in 1978.
Reports of techniques allowing excision of biopsy specimens and more precise removal of tissue such as cysts followed rapidly: small grasping forceps were integrated into the endoscope (Draf 1973), and a two-channel instrument, the bimeatal antral endoscope, was described by Hellmich and Herberhold.
The improved diagnostic capability of nasal and sinus endoscopy was also taken up in other European countries: Illum and Jeppesen (1972) and Draf (1978), compared the reliability of radiographywith sinuscopy. Buiter (1976) and Terrier (1973, 1975) demonstrated its value in recording mucosal lesions.
Reynolds and Brandow in 1975 reported intranasal antrostomy for chronic sinusitis: they drilled a small opening into the antral cavity in front of the head of the inferior turbinate under an operating microscope. They introduced a sinuscope through the anteromedial antral window, and were able to inspect the antrum, to carry out irrigation and biopsy, and to insert a Tefl on button.
Terrier and Baumann (1976) reviewed the validity of endoscopic assessment of mucosal lesions using histomorphology, and established a classification of sinusitis. The value of this diagnostic procedure is also recognized by maxillofacial surgeons (Schmidseder and Lambrecht 1977). Draf (1975) has extended endoscopy to the frontal and sphenoid sinuses.
Flexible fiberoptic endoscopes have been developed for the investigation of the nose and the nasal sinuses. They include the ENF-P2 rhinolaryngoscope made by the Olympus Company with an external diameter of only 3.4 mm, an 85° angle of vision, and a 230° arc of the visual field. This can be used for pain-free endoscopy in children and adults, but has not yet replaced the widespread use of the rigid sinus endoscope because of the poorer light output and the necessary bimanual manipulation. Its place is in diagnostic nasopharyngolaryngoscopy (Yamashita et al. 1984; Lancer and Jones 1986).
Endoscopic surgery of the nasal sinuses is defined as a range of procedures based on the use of endoscopes with an angled telescope or the microscope. The history of its development is relatively short, and coincides with the renaissance of older intranasal operative techniques that it has influenced continuously in recent times.
The beginning can be dated from 1958 when H. Heermann reported intranasal surgery with the use of a binocular microscope, designed especially for more precise clearance of the middle and posterior ethmoid cells and the sphenoid cavity; it also facilitated the removal of polyps from the olfactory cleft (Heermann J. 1982). The microscopic view into the antral cavity through the inferior meatus for removal of antral mucosa had previously been mentioned by J. Heermann in 1974. Bagatella and Mazzoni (1980) reported the advantages of the microscope using a lens of 250 or 300 mm focal length for ethmoidectomy for polyposis of the middle and posterior ethmoid cells. Draf (1982) also used the microscope but combined it with an angled telescope. In 1983 Dixon emphasized the increased safety achieved by the microscope for ethmosphenoidectomy, but had to admit that not all regions were visible with this technique.
Transseptal transsphenoidal microsurgery under optical control can be regarded as intranasal sinus surgery, and is the standard procedure for pituitary adenomas.
The rigid endoscope with an angular optical axis offers clear advantages in viewing the sinuses and their recesses compared with the straight field of vision provided by the operating microscope, but it has disadvantages including the tendency to misting and soiling by the warm and bleeding operative field. A much-needed technical improvement was the suction-irrigation surgical endoscope with a rotary and interchangeable angled telescope that could remain in situ for a long time (Wigand 1981a). With its help, the intranasal technique of antral surgery could be extended to all forms of chronic maxillary sinusitis (Wigand and Steiner 1978) and to the intranasal surgery of all nasal sinuses (Wigand 1981b, c, e).
The passage of fine instruments alongside the endoscope is preferable to transendoscopic instrumentation. The working channels that need to be integrated in the telescope are very small, allowing only thin forceps or drills to pass (Bumm et al. 2005). The options for instruments introduced alongside the observation tube are much wider.
Besides other advances of endoscopic sinus surgery such as the terrific expansion of indications for the treatment of trauma, malformation, complications, and neoplasia, three technical innovations have broadened the spectrum of its applications: the introduction of lasers, of powered instruments, and of computer-assisted surgery (CAS).
The surgical laser has attracted interest from its start as a perforator (Lenz et al. 1977; Buiter 1985) and bloodless destructor of polyps and cysts (Wigand 1981d; Simpson et al 1982), especially for their recurrence (Rouvier and Peynegre 2000), to its use in radical excision of papillomas and other tumors (Heermann and Heermann 2000) and in dacryocystorhinostomy (Metson et al. 1994). Its advantage for the latter indication was questioned, however (Riveros-Castillo and Campos 2000), and for experimental wound healing the argon laser was shown to have disadvantages (von Glass and Hauenstein 1988). While the depth of penetration of the carbon dioxide laser (Simpson et al. 1982) can be utilized near sensitive structures, other lasers (argon, Nd:YAG, etc.), though preferable because of the possibility to transfer their power through fl exible fibers, have restricted application close to the orbit and skull base. Their necrotizing effect below their focus is difficult to predict. Hosemann et al. (2000) has reviewed various laser types.
Learning from the orthopedic arthroscopic resection technique, the removal of soft and hard tissues with a rotating debrider, the shaver, was adapted to endoscopic sinus surgery (Setliff and Parsons 1994; Grevers 1995; Hawke and McCombe 1995; Gross and Becker 1996). This method has become popular in particular for the one-day treatment of obstructing nasal polyposis. Its promoters praise its almost blood-free, easy to survey ablation mode, while more critical comments point to considerable recurrence rates, originating from imprecise dissection in narrow compartments in the ethmoids and turbinates.
Modern imaging technology such as computerized tomography (CT) and magnetic resonance imaging (MRI) had in the 1980 s already revolutionized both the rhinosurgical indications and the safety of endoscopic procedures. An unfilled gap in the capabilities of both CT and MRI–targeting of hidden objects in the vicinity of vital structures–was almost perfectly closed by the introduction of computer-assisted surgery (Mösges and Schlöndorff 1988; Schlöndorff et al. 1989). Various attempts have been made to simplify the previously complicated fixation of fixpoints screwed to the patient’s skull and to improve the handling of the detector during dissection (Freysinger et al. 1997; Hauser et al. 1997; Fried and Morrison 1998). The cardinal problem, a reliable, constant minimum resolution during the intervention to allow socalled navigation or piloting of the surgeon, has not yet been definitively solved by the various systems. A comparison of different modules competing for the highest precision has recently been published by Strauß et al. (2006).
The abundance of new proposals appearing every year illustrates a fascinating chapter of nasal surgery in which technical developments and biological knowledge supplement each other in achieving the aim of the perfection of medical treatment.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
