Nasal obstruction (88%) and rhinorrhea, mostly combined with an unpleasant postnasal drip (72%) were the most frequent complaints of this group. Table 12.1 gives the data on the presenting symptoms.

Tables 12.2 and 12.3 give an overview on the postoperative improvement rates of 98 first interventions and 14 revision operations. The mean observation period was 3.7 years (1–6 years). The age of the individuals varied from 12.8 to 72.6 years; 78 were male, 34 were females. One hundred and twelve answered questionnaires were evaluated.

Table 12.4 reports answers of responding patients concerning the long-term necessity of consulting an ENT doctor after surgery.

A more objective evaluation of partial ethmoidectomies as treatment of limited CRS through endoscopic inspection performed by a physician who was not involved in the diagnosis and treatment of this patient concerned the form and placement of the nasal septum and turbinates, the supraturbinal antrostomy, and the aspect of the lining mucosa. Since the inner ethmoidal texture was not directly visible, the findings listed in Table 12.5 apply predominantly to the maxillary antrum. The figures do not highlight that in some cases the postoperative check-up disclosed more severe changes than were observed during surgery!

The nasal septum was in a good medial position (46.6%) or somewhat lateralized (44%), with bridging scar formation in 12.5%. There was no case of intraoperative or postoperative complications (see Chapter 9) in this series. A small symptomless septum perforation had developed in two cases, neither requiring repair.

Total Ethmoidectomy/Pansinus Operation for Disseminated and Diffuse CRS (n = 208)

These subcategories can be grouped together because this procedure was executed for nearly identical indications. The main pathological finding in a preoperative CT series was the complete or near-complete opacifi cation of the ethmoids combined with various degrees of marginal or convex intracavitary shadows (see Chapter 3) in the maxillary, frontal, and/or sphenoidal sinuses. Together with a total ethmoidectomy, the interventions included, at least, a moderate fenestration of these cavities for their endoscopic evaluation and, in some cases, a broader ouverture for intracavitary excisions. Sharp bone resection with preservation of the lining mucosa of opened cells and cavities was a leading characteristic of these procedures, which were mostly combined with sculpting of the middle turbinate and adequate septal correction.

The re-examined material comprised 208 primary cases and 77 revisional cases: 63% male/37% female among first interventions and 71% male/29% female in the group of revisions at an age of 5–79 years with an average of 47 years. Only six patients were younger than 20 years.

While first partial resections of the ethmoid were carried out bilaterally in 96% of the 163 registered patients, bilateral total ethmoidectomies/pansinus operations amounted to 95% (91% in revisions) of the 320 registered candidates. It must be stressed that more than 50% of the secondary attempts concerned individuals who had undergone partial ethmoidectomies before, as functional endoscopic sinus surgery (FESS) in the manner of Messerklinger/Stammberger.

Tables 12.6 and 12.7 indicate the subjective evaluation of both groups after pansinus operation regarding the prevailing symptoms as percentage of the affected individuals. The mean observation period was 3.1 years (1–7 years) and 320 answered questionnaires were evaluated.

One can recognize a general trend to complete elimination or marked improvement in the majority of complaints. No change was noted for few symptoms, at a rate of about 20%, and worsening was exceptional. The figures for reoperations were lower but showed remarkable success rates, with only few exceptions such as smell, crusting, and headache. Particular attention should be paid to the high percentages of normalization or major improvement of olfaction as judged by the patients, and to the fact that in no case was deterioration reported for either side. This means that no injury of the olfactory rim had occurred.

The sense of smell before and after ethmoidectomy is a yardstick of the severity of the disease, the effi cacy of treatment, and also the precision of the mucosa-sparing technique. The patients themselves often regard the recovery of a long-absent olfactory function as being more important than the improved nasal respiration and relief from headache. Tables 12.6 and 12.7 present the author’s experience with a consecutive series: The sense of smell was regained in a large proportion of cases, whereas olfactory deterioration was exceptional.

An illuminating example of the pathological mechanism of dysosmia in nasal and ethmoid polyps may be of interest. After a septal correction done elsewhere, a 45-year-old patient complained of loss of the sense of smell due to mechanical occlusion of the olfactory cleft by mucosal swelling and polyps. At the first investigation he was found to have hyposmia (Fig. 12.1a) . When he presented for operation a few months later, he had become anosmic. The entrance to both olfactory clefts was found to be narrowed by scar tissue at follow-up several months after ethmoidectomy (Fig. 12.1b) . At this time the sense of smell was relatively poor, but improved greatly after division of synechiae. A follow-up osmogram (Fig. 12.1c) indicated a return to normal on one side and improvement on the opposite side.

Fig. 12.1 a–c Mechanical obstruction of the right olfactory cleft by bridges of scar tissue.

a   Olfactogram of anosmia in chronic polypoid pansinusitis.

b   Five months after ethmoidectomy, the olfactory cleft is again partially closed by synechiae (arrow) and the patient again complains of severe hyposmia (70° telescope).

c   The sense of smell returned almost completely to normal after endoscopic division of the scar tissue.

Scar formation in the olfactory rim is most detrimental to olfaction. Its most frequent cause is nasal polypectomy with snares tearing valuable mucosa from the middle turbinate and superior septum. Endoscopy often cannot locate the injured area. Undisturbed smell, on the other hand, can remain possible with small remnants of olfactory mucosa (Fig. 12.2)

Table 12.8 shows the answers of 170 patients about the long-range necessity of consulting an ENT doctor after pansinus operations. If one takes into account that all of these persons had been permanent outpatients before surgery, one may estimate the increase in quality of life and the cost reduction by an active surgical treatment of CRS, almost approaching the figures for partial ethmoidectomies in Table 12.4.

Considering that the nasal and paranasal mucosa is only part of the extensive system of mucociliary epithelium reaching from the nasal entrance into the bronchi and middle ear, some other results concerning allergy and bronchial asthma deserve attention. Figure 12.3 reflects related information from 208 responding patients. It shows high benefits independently of the type of surgical procedure. A clear gain of health was found in more than two-thirds of patients suffering from chronic bronchitis and asthma, whereas approximately 50% of this group still needed some medical help. Similarly, seasonal and perennial allergy as well as respiratory infections decreased by marked percentages.

Cases with intolerance to analgesics (Widal disease) were included in the preceding cohorts but, because of their specific mucosal hyperreactivity, were also subjected as a special group of 41 patients to a separate evaluation. Table 12.9 gives the related figures for their postsurgical scales of complaints. Comparing these data with those in Fig. 12.3, which included the Widal patients, a marked reduction of expectations can be read from Table 12.9 for this special condition. Unfortunately, the analysis for the year 2000 did not exclude this unfavorable subgroup, otherwise higher success rates would have been evidenced for the entire population.

Fig. 12.2 a, b Mechanical stenosis by scar formation in the olfactory rim.

a   A flat remnant of the right middle turbinate with a scarred surface on both sides narrows the sensitive area. The enlarged nasofrontal duct stays open (*).

b   Normal sense of smell despite the marked reduction of the olfactory epithelium documented in the olfactogram.

Fig. 12.3 The preoperative total of coexisting factors and treatments for chronic rhinosinusitis is shown as white bars; there are four white bars for each parameter, each representing a specific surgical subgroup. Black bars integrated into the white bars represent the number of patients with no change or worsening of these parameters postoperatively. I (n = 52), II (n = 49), III (n = 79), IV (n = 28).

Some comment should be made on the subjective extramedical outcome of ESS for chronic rhinosinusitis. Repeatedly, persons in intellectual/artistic professions such as teachers or writers have spontaneously mentioned their satisfaction with an unexpected increase in mental capacity, power to concentrate, or comfort in reading. Some singers expressed happiness with improvement of their voice and articulation, and others mentioned improvement of vision.

The more objective long-term findings by endoscopic survey of the operated compartments are listed in Table 12.10. This summary of the effects of endoscopic cleansing of the mucosal covering in the paranasal sinuses in advanced chronic-hyperplastic and polypous sinusitis confirms our earlier findings of potential full recovery of severely diseased and structurally altered mucosa (Wigand and Goede 1995), making an absurdity of the earlier notion of its biologically inferior quality (Albrecht; Wittmaack 1918). Taking into account that the loss of vital mucosa from preceding ethmoidectomies with production of extensive scar tissue does not exclude extensive regeneration into a normal-looking mucosal texture (Fig. 12.4a, b) , one must judge the underlying idea of surgery aiming at reventilation and drainage as a fruitful biomechanical interpretation of the pathogenesis. To these observations must also be added that sometimes late pathological efflorescences, absent during surgery, must have developed despite or due to the altered microanatomical conditions.

It must finally be stressed that no case of severe complications was on record; in particular no visual defi cits, injury of the skull base, or tearing of olfactory fibers became evident for the period 1986–1991. Fifty years ago, it was the high proportion of visual defects, blindness, CSF fistulas, and meningitis that brought intranasal ethmoidectomy into disrepute, rather than the poor results. The importance of the introduction of endoscopy thus cannot be overestimated.

The complications in the author’s series for these years were relatively minor, with no permanent injury (Table 12.11). One fatality, however, must be admitted for an earlier period due to an unexpected malformation of the internal carotid artery channel within the sphenoid cavity. This case was described in Chapter 9. Probing of the sphenoid cavitywith a blunt suction tube led to a massive hemorrhage with a critical drop in blood pressure despite packing of the posterior ethmoid area. The patient died 5 days later of bilateral cerebral edema despite immediate anesthesiological support and rapid transfusion. The autopsy showed that the internal carotid artery was protruding deep into the lumen of the sphenoid sinus, and had almost no protective bony covering.

A similarly sized series of operations carried out by more than thirty full-time academic staff and assistants in training in the author’s department included one case of meningitis and brain abscess with fatal outcome, and one case of blindness due to postoperative intraorbital bleeding. The brain abscess presented 2 weeks after the operation, and it was unclear whether it was already present before the operation or was caused by the operation itself. In conclusion, one must admit that even with well-organized training programs a certain learning curve applies and exacts some penalty.

Fig. 12.4 a, b Full recovery of a hyperplastic polypoid mucosa after endoscopic pansinus operation.

a   Endoscopic aspect after 2 years.

b   A coronal CT image shows the clear ethmoid on the operated left side (*) and opacification in the unoperated right ethmoid.

Table 12.11 Complications after complete ethmoidectomy for diffuse ethmoid polyposis (n = 220)

^a After pain medication in patients with undiagnosed sensitivity to analgesics.