Functional endoscopic sinus surgery--II (A preliminary study).
Seventy-eight patients of chronic sinusitis were subjected to functional endoscopic sinus surgery by the technique described in the previous paper. The clinical features, findings at surgery and the results of this technique are described here.
The rationale for considering the ostiomeatal complex as the primary focus responsible for development and persistence of chronic inflammatory sinus disease, has been explained in the previous paper.
On the basis of this concept, we decided to study patients of chronic sinusitis, especially maxillary and frontal, and to investigate and operate thcm endoscopically to find out the presence and role of disease of the ostiomeatal complex in such infections. We also regularly followed up these patients to evaluate the results of functional endoscopy as regards relief of symptoms after having removed disease from the ostiomeatal region.
Over a period of 16 months, we examined 78 patients of chronic sinusitis with various nasal complaints and subjected thcm to functional endoscopic sinus surgery (FESS). Of these 48 were males and 30 were females and their ages ranged from 12 to 57 years.
(11-20 yr: n = 27; 21-30: n = 28; 31-40: n = 13; 41-50: n = 8 and 51-60: n = 2)
All the patients except three were operated under local anaesthesia.
All the patients went through a definite protocol of investigations and were subjected to FESS (as described in the previous paper).
Of the 78 patients studied for various nasal complaints, the commonest complaint was nasal discharge. This was followed by headache and nasal obstruction, which occurred with equal frequency. The details of these symptoms are given in [Table - 1].
Fifteen patients complained of severe sneezing, while another 7 had hyposmia. Fourteen complained of anosmia and another 4 of cacosmia while 3 had crusting.
The duration of symptoms ranged between 3 months and 1 year in 38 patients, between 1 and 5 yrs. in 16, between 5 and 10 years in 12, between 10 and 20 yrs. in 9 and in 3 patients it was found to be more than 20 yrs. (< 20-30 yrs). The patients usually complained of recurrent bouts of acute exacerbation over this period.
All the patients coming to us had taken some form of medication for their complaints without satisfactory relief. Twenty-seven patients had undergone some form of surgical procedure without any relief as shown in [Table - 2].
[Table - 3] illustrates the findings revealed at the clinical examination carried out at the time of presentation. Twenty-seven patients had a deviated nasal septum.
In the X-ray paranasal sinuses, we looked for haziness, fluid levels, rounded shadows suggestive of polyps, cysts, etc. and thickened mucosa. These findings are given in [Table - 4]. In 9 patients, there was no sinus pathology detected on plain X-rays.
A bilateral nasal endoscopic examination was done in all the patients. However ' functional endoscopic sinus surgery was done unilaterally in 48 patients and bilaterally in 30 patients. The findings at functional endoscopic sinus surgery are as in [Table - 5].
In our series no major complications occurred. Seven patients required an anterior nasal packing immediately after surgery, 6 patients revealed synechiae and 6 patients revealed recurrent polypi during routine follow-up. There was not a single case of CSF rhinorrhoea or orbital complications. The patients were evaluated for relief of symptoms, especially nasal discharge, headache and nasal obstruction, and were asked to grade the relief of symptoms experienced by thcm as total, partial or none. Forty-seven patients had total relief of symptoms, 12 had partial relief of symptoms, with no relief in 7 patients. Twelve patients were lost to follow-up.
Six patients who had total relief of symptoms after surgery showed recurrence of small ethmoidal polypi during routine follow up, which were again removed by the same procedure but without any sedation. It should be noted that in spite of the recurrence of polypi the patients had no recurrent symptoms.
It has long been recognised that nasal obstruction can contribute to persistent infection in the paranasal sinuses. Septum surgery is often advised for such sinus infections. However, it has been convincingly shown by Messerklinger and others,,,, that a diseased ostiomeatal complex plays a vital role in the pathogenesis and persistence of chronic infections of the maxillary and frontal sinuses. The focal point of the ostiomeatal complex is the anterior ethomoidal air cells.
It has been shown that mucocillary clearance of the paranasal sinuses occurs along well-defined pathways leading to the natural ostium of the sinus,,,,. Any blockage of the natural ostium leads to disturbed mucociliary clearance into the middle meatus. Their openings in the middle meatus are surrounded by the frontal recess and the ethmoidal infundibulum respectively, both of which form a part of the anterior ethmoid complex. Thus, in effect, these sinuses drain into the middle meatus via the anterior ethmoid. This anatomical feature explains why disease of the anterior ethmoids leads to persistent infection of the dependent sinuses.
What makes the anterior ethmoid more prone to disease? There are several factors, which contribute to it e.g.
1. The anterior ethmoid complex consists of clefts and fissures where mucosal areas are in contact with each other. In a normal healthy mucosa, the mucociliary beat from opposing mucosal surfaces works on mucus from two sides and hence provides efficient mucociliary drainage. If mucosal edema occurs in these areas, the mucosal surfaces may come firmly in contact with each other and prevent drainage of mucus leading to a vicious cycle of stasis, infection, further edema and resultant blockage of the ostia of the larger dependent sinuses.
2. The anterior end of the middle turbinate bears the brunt of atmospheric pollutants, allergens etc. and is therefore very prone to edema and hypertrophy.
3. There are certain other anatomical factors which may further contribute to infection in this area, viz., a paradoxically curved middle turbinate, a concha bullosa, a laterally curved uncinate process and an enlarged bulla ethmoidalls. All these in effect block the space of the middle meatus.
FESS aims at this primary focus of inflammation, viz., the diseased ethmoid, clearing its stenotic blocked fissures and diseased cell and re-establishing ventilation and drainage of the dependent larger sinuses through their natural ostia, usually without touching these sinuses themselves. The principle of this therapy concept aims at attacking diseased mucosa alone, leaving the normal mucosa and structures untouched.
We had been routinely using the operative microscope for sinus surgery for several years. The introduction of nasal endoscopy has shown us that there are certain distinct advantages of this procedure over microsurgical techniques.
Endoscopy provides us with improved illumination and depth of field and hence has great diagnostic potentials. Small sinus pathologies like early malignancy, and other tumours of the sinuses can be easily visualised and biopsied.
Because of the deflected angles of view, the technique enables recognition and rcmoval of disease from recesses that could not be seen with the routine intranasal approach and hence reduces the need for wide exposure and an external approach in several cases. It is a minor procedure where the patient does not require to be hospitalised except when anterior nasal packing is necessary (only 7 of our cases required packing). Anterior nasal packing is done with Merocel, thus making the procedure much less traumatic than when using gauze.
The relief of symptoms (total and partial) seen in our series has been 76% while there have been no 5 major complications like CSF rhinorrhoea, or orbital complications.
FESS, however, is not a panacea for all sinus pathologies. It cannot be used in complicated sinusitis where the disease has spread intracranially, or where the disease has eroded the bony walls of the sinus. The surgical technique itself needs to be practised and mastered by virtue of the relations of this area to important anatomical landmarks. External operations and Caldwell- Luc have their role to play in irreversible disease while allergy must be treated entirely on its own merit.
Thanks are due to the Dean, King Edward Memorial Hospital and Seth GS Medical College, Mumbai, for permitting us to use hospital data.