What are best medical practices?
What is the structure of the sinuses?
Best medical practices seek to apply the best available scientific evidence to clinical decision making. In utilizing evidence-based medicine, one seeks to assess the strength of medical evidence to guide the diagnosis and treatment of disorders. Evidence of clinical efficacy is ranked double-blind, placebo-controlled clinical trials to clinical wisdom. The former is the most likely to yield a consistent result whereas the latter may be dependent on a skilled expert, but not necessarily reproducible. In addition, the skilled clinician recognizes that not all treatments may be solely evaluable by vigorous statistical analysis.
What are the causes and classifications of sinusitis?
Each side of the facial skeleton has four sinuses, named by the facial bone in which they occur. The frontal sinuses are located within the frontal bone, or forehead. The ethmoid sinuses develop within the ethmoid bones, which are between the nose and eyes. The maxillary sinuses form within the maxillary bones, or upper jaw, and the sphenoid sinuses are within the sphenoid bone.
LEGEND: The sinuses are cavities within the facial skeleton. The ethmoid (2) and maxillary (3) sinuses are seen in this image, which overlays a coronal CT on a photograph of the face. Other structures labeled are the nasal septum (1) which divides the nose into approximately two equal cavities and roof of the ethmoid sinus (4) which forms the floor of the anterior cranial fossa. The frontal lobe of the brain rests on the latter which also separates the nose and sinuses from the intracranial cavity.
Arising from the wall of the nose, are three mucus membrane covered bony appendages known as turbinates, or cochae. These three sinuses drain into a space bounded by the middle turbinate and the wall of the nose referred to as the osteomeatal complex, or middle meatus. The osteomeatal complex drains into the nose and then into the nasopharynx (the space behind the nose). Mucus passes from the nasopharnyx into the throat and potentially into the trachea and lungs. Consequently, sinusitis exacerbates asthma and bronchitis.
The fourth sinus is within the sphenoid bone and the sphenoid sinus drains
directly into the nasopharynx.
What is the history of the study of sinus anatomy?
Legend: IT = inferior turbinate, MT = middle turbinate, ST = superior turbinate, SS = sphenoid sinus and *osteomeatal complex.
LEGEND: This sagittal cadaver section shows the anatomy of the nasal wall and the sinuses after removal of the middle and superior turbinates. The frontal sinuses (FS) are paired cavities which drain into the osteomeatal complex. The ethmoid sinus is a labyrinth of cells, much like a honeycomb. The cells of the front or anterior ethmoid are smaller and more numerous than the posterior ethmoid (PE). Cells within the anterior ethmoid sinus expand to form of bulla ethmoidalis (BE).The nose drains into the throat via the nasopharynx (NP) and the Eustachian tubes communicate from the middle ear to the back or posterior wall of the anatomic site.
The proximity of the sinuses to important structures and organs within the facial skeleton predispose patients to specific complications. As early as 3,600 years ago, the Egyptians recorded surgical drainage of brain and sinus abscesses. As such infections today are often secondary to sinus or ear infection, it is reasonable to attribute the earliest recorded treatment of such complications to the Egyptians.
The Edwin Smith papyrus, circa 1600 BCE is the oldest known medical text. This papyrus makes reference to older works and may be the product of the great Egyptian priest, architect and physician, Imhotep from the Old Kingdom, circa 3000-2500 BCE. Aside from its age, it is unique because of the analytic and rational approach to treating disorders and injuries. For example, the physician is instructed on how to care for a simple scalp laceration; whereas, fatal injuries are described and treatment is directed towards making the victim comfortable. Thousands of years would pass before physicians again would be instructed in the value of careful observation and application of scientific principles to treatment of disorders.
LEGEND: Edwin Smith Papyrus, c. 1600 BCE.
During the Middle Ages, anatomic dissection of the human body was prohibited in Europe. As Europe emerged from the Dark Ages, scientist-artists, such as Leonardo da Vinci (1452-1519), resumed the study of human body which had remained a science in the Middle East and Asia. An example of da Vinci’s skill and intellectual curiosity is his drawings of the human skull from his 1489 Folio. These drawings illustrate the human sinuses.
LEGEND: Leonardo da Vinci illustration of the skull, including the paranasal sinuses (c. 1489).
Although da Vinci had also included the maxillary sinus in his 1489 Folio, the sinus would later be also known as the antrum of Highmore. Nathaniel Highmore (1613-1685) was an English physician and anatomist who describes this sinus in his Corpus humanidisquisito anatomica. The practice of naming sinuses or regions within the sinuses after individuals rather their anatomic location or origins would continue and is confusing to both patients and physicians.
LEGEND: Illustration of the maxillary sinus from Nathaniel Highmore’s Corpus humanidisquisito anatomica.
What is mucociliary transport and what is its role in the maintenance of the sinuses?
Viruses are the most common cause of acute sinusitis and may lead to secondary bacterial infections. Other causes of sinusitis are allergies, which can cause swelling or obstruction of the sinus drainage pathways into the nose, and genetic disorders such as cystic fibrosis. The latter leads to an impairment of the cilia, or hair cells which direct the transport of mucous produced within the sinuses into the nose. This physiologic process is known as mucociliary transport and is essential for the normal cleansing of the sinuses of infectious agents and air pollutants.
LEGEND: Mucociliary transport within the right maxillary sinus is illustrated. The arrows show the direction of mucus movement within the sinus by the cilia towards the opening of the sinus into the nose (upper right corner of the illustration).
Bacterial sinusitis follows viral sinusitis because the viruses injure the lining of the sinuses and respiratory tract, leading to thickening of this mucous membrane. The swollen membranes impair the ability of the sinuses to drain. The hallmark of bacterial sinusitis is purulent rhinorrhea, yellow or green mucous draining from the nose. Facial pain or tenderness over the sinuses and productive cough are other important symptoms. Aside from infection, other causes of sinusitis include chronic obstruction of the drainage pathways, polyps, focal obstruction of drainage pathways within a sinus and severe deviation of the nasal septum.
LEGEND: Various forms of obstruction of the sinus drainage pathways is illustrated. These include diseased or swollen mucus membrane within the sinus (A), deviation of the nasal septum compressing the middle turbinate against the ethmoid sinus (B), enlarged or bullous middle turbinate (aka, concha bullosa, [C]), deviated nasal septum compressing the middle turbinate against the ethmoid sinus with contralateral enlargement of the middle turbinate (D), swollen mucus membrane or focal obstruction of the ethmoid infundibulum (E), and obstruction of ethmoid infundibulum secondary to enlarged or diseased ethmoid sinus cells (F). From Rice DH and Schaefer SD. Endoscopic Paranasal Sinus Surgery, 3rd Ed, Lippincott, 2004.
Sinusitis is further classified by the duration of the illness and whether or not disease recurs. As a generalization, sinusitis lasting more than twelve weeks is referred to as chronic; less than twelve weeks as acute; and when there is an exacerbation of acute symptoms with underlying chronic sinusitis, this condition is classified as acute-chronic sinusitis. The symptoms and etiology of acute and chronic sinusitis are frequently different. Acute sinusitis tends to have a rapid onset of facial pain or tenderness, low grade fever less than 100.4 degrees Fahrenheit and musculoskeletal discomfort. Common bacterial organisms in acute infections are Streptococcus pneumoniae, Haemophilusinfluenzae and Moraxella catarrhalis. These microorganisms tend to be sensitive to penicillin or sulfamethoxazole-based antibiotics. Chronic sinusitis symptoms differ by their duration and intensity. For example, the cause of longstanding pain or headache over a sinus may be chronic infection. Such infections are more likely to be caused by Staphylococcus aureus or anaerobic bacteria. These microorganisms require more aggressive antibiotic therapy than those seen in acute infections.
A third form of sinusitis is fungal sinusitis. Fungal sinusitis ranges from highly invasive and often fatal forms to the benign presence of fungus within a sinus. The former microorganisms are most often seen in individuals with disorders of their immune system, poorly controlled diabetes and other generalized diseases which prevent an appropriate response of the normal defense mechanisms of the body. The most lethal of these infections is mucormycosis, which is caused by fungi from in the genus Mucorales.
These fungi are commonly found in the soil and harmless to healthy individuals. In the compromised individual, the fungi enter the body through the respiratory tract and progressively compromise the vessels supplying the face, sinuses, brain and lungs. Early in the course of such illnesses the effected structures appear black or necrotic because the fungi have caused thrombosis and death of these organs. The treatment for invasive fungal sinusitis is surgical removal of all involved tissue and fungi, and intravenous anti-fungal agents.
Allergic fungal sinusitis is caused by fungi found within the Dematiaceous, or soil-born, family. These fungi occupy the sinuses and as they grow the bony borders of the sinuses are thinned, recontoured or lost due to the pressure exerted on the bone. The fungi expand, but do not invade adjacent organs. On imaging, these changes are potentially dramatic. Many patients also have significant nasal polyps due to the inflammatory response to the fungi. Treatment consists of surgical removal of the fungus and nasal polyps via endoscopic surgical approaches with preservation of normal sinuses, facial and adjacent structures. Additional treatment often includes systemic and topical steroids, and in severe cases, anti-fungal medications.
LEGEND: Intraoperative image of allergic fungal sinusitis within the sphenoid sinus. These organisms form a dense, mucoid mixture of fungus, antibodies against the fungus and white blood cells.
LEGEND: Axial CT scan showing bilateral opacification of the maxillary sinus. The image of the patient has been digitally processed to highlight an opaque mass within the left maxillary sinus. This hyper-dense appearance of a mass or fungal debris is a typical radiographic finding for allergic fungal sinusitis.
What roles do facial x-rays and CT scans have in the diagnosis of sinusitis when a physical examination is not conclusive?
Mucociliary transport describes the process by which the mucous membrane lining the entire respiratory tract from the lungs to the sinuses expels microorganisms and pollutants. The surface cells of the respiratory tract have hair-like appendages, or cilia. The cilia are surrounded by a thin layer of mucus, upon which a second viscous layer of mucus rests. The viscous layer traps microorganisms and pollutants. This self-cleaning mechanism of the respiratory is both temperature and humidity dependent. It is most efficient at normal body temperature of 98.6 degrees Fahrenheit and a relative humidity of 100 percent. Clinically, a "happy respiratory tract" is one which is both moist and a normal body temperature. The cilia move, or beat, in specific directions. In the sinuses, they move microorganisms and pollutants towards openings of these cavities into the nose. Alterations in temperature, humidity and various air pollutants, including smoking, reduce the beat frequency of the cilia and facilitate infection.
Legend: Coronal section through the facial skeleton showing the frontal (FS), upper cavity above the ethmoid sinus, ethmoid (ES) sinus with its subunit bulla being the bulla ethmoidalis. Mucus produced within the frontal, ethmoid or maxillary sinuses passes via the ethmoid infundibulum (latin = funnel) through the hiatus semilunaris (hs) into the nose. Collectively these structures constitute the osteomeatal complex. The anterior or the front of this complex is the uncinate process.
What role does nasal endoscopy play in the diagnosis of sinusitis?
When the diagnosis of sinusitis cannot be made by the history and physical examination and the patient is clinically ill, or if impending complications are suspected, radiographic imaging of the sinuses is considered. Imaging can delineate infection within the sinuses and spread of infection to adjacent structures, such as the eye.
The choice of radiographic imaging varies with the physician’s training, availability of imaging machines and the severity of the infection. As a generalization, more physicians (including our Center physicians) prefer computed tomography (CT) imaging over plain film x-rays because of the superior resolution of images and the three-dimensional projections, or views, of the sinuses. However, the cost of such studies requires judicious use of this technology. Most specialists reserve CT imaging for patients refractive to prolonged medical treatment and those considered for surgery. These physicians employ nasal endoscopy and the history as their primary mode of diagnosing sinusitis, and reserve CT imaging as stated above.
Facial x-rays, or plain films, provide images that show the facial bones, air containing sinuses and adjacent bony or soft tissue structures. The resolution and detail of such studies is relatively poor compared to CT imaging. In contrast to plain films, CT involves simultaneously passing multiple beams of x-rays through the object of interest to an array of detectors that convert the energy of the photons to an electric current. The current undergoes a complex form of signal processing which compares the energy of the photons striking each detector to each other and converts the resultant signal to a grey scale. The grey scale mirrors plain films in that the denser an object, the darker it appears on the CT. Unlike two-dimensional plain films, CT scanning provides three-dimensional high resolution images revealing less than one percent difference in density between structures or tissues. The combination of these attributes makes CT scanning the radiological study of choice for evaluating the sinuses.
LEGEND: Coronal CT of frontal (FS), ethmoid (ES) and maxillary (MS) sinuses (mt = middle turbinate, it = middle turbinate).
LEGEND: Axial CT of ethmoid (ES) and sphenoid (SS) sinuses.
LEGEND: Sagittal CT of frontal (FS), ethmoid (ES) and sphenoid (SS) sinuses (ACF = anterior cranial fossa floor, mt – middle turbinate, it = inferior turbinate, pg = pituitary gland).
The radiation dose of CT scanning has recently received attention. The dose of a modern scanner depends on the volume of tissue scanned, the size of the patient, the number of scans performed, the current of the x-ray tube and the resolution of the images. Overall CT imaging of the sinuses is a low risk technology which provides necessary information in the care of sinusitis. As is true of many modern technologies, CT requires judicious application.
MRI as an Alternative or Complementary Technology to CT Imaging.
As described above, CT scans use x-rays passed through the object of interest, such as the sinuses, to produce radiographic images. The denser an object, the whiter it appears on the resultant image. Bone is the densest and appears white, and air is the least dense and appears black. Magnetic resonance imaging (MRI) utilizes the radiofrequency bands, similar to FM radio waves, of the electromagnetic spectrum to produce images. These images resemble CT images because both technologies use a grey scale to quantify the energy produced during the study. As MRI involves exciting the hydrogen ions within the water in tissues to release energy, this form of imaging is superior to CT scanning for evaluating soft tissues. Therefore, MRI compliments CT imaging when evaluating structures adjacent to the sinuses such as the eye and brain.
Mucopyocele (*) or infected mucus membrane arising from the left frontal sinus and extending into the left orbit. The left eye (arrows) is displaced inferiorly by the mucopyocele. Due to previous trauma, the right eye had been removed.
LEGEND: MRI of same patient illustrates the preferential and complimentary imaging of soft tissue when compared to CT.
LEGEND: Intraoperative photograph of same patient showing mucopyocle exposed in the upper inner quadrant of left orbit. The eyebrow is seen above the surgical field and the eyelids are below. Patient did well after surgical drainage and treatment of their sinusitis.
How are saline nose sprays and nasal decongestant sprays used in the medical treatment of sinusitis?
Rigid endoscopes provide superior illumination and visualization, and permit the physician to manipulate instruments within the nose. Given these benefits, our Center physicians prefer the use of rigid endoscopes. Flexible endoscopes are also available, which may be easier to guide to examine all regions of the nose.
Needs for nasal endoscopy include:
- Differentiation of viral versus bacterial sinusitis by identification of purulent secretions arising from the nose or sinus drainage pathways into the nose.
- Obtaining endoscopic-directed cultures of the purulent secretions within the osteomeatal complex. Using this culture technique avoids the normal contamination of the specimen by normal nasal bacterial flora which normally invalidates nasal cultures.
- Evaluation of the nasal airway for a deviated septum, polyps, tumors or foreign bodies.
- Biopsy of masses or tumors within the nose.
- Identification of sites of bleeding within the nose or from the sinuses into the nose. Control of epistaxis (that is, nose bleeds) by cauterization or selective packing of the bleeding site.
- Cleaning or debriding dried secretions, blood, fungus and foreign bodies within the nasal cavity and sinuses after surgery.
LEGEND: Endoscopic view of left nose. A curved probe is seen resting between the uncinate process (up) and the bulla ethmoidalis. The nasal septum (S) has a small septum spur (*) or deviation pressing against middle turbinate (mt). The inferior turbinate (it) arises from the lateral nasal wall and is seen in the lower right-hand side of the image.
When would a NYHNI physician diagnose a condition as bacterial sinusitis and how would this be treated?
Saline nose spray, or lavage of the nasal cavity with normal saline (i.e., 0.9% salt [NaCl], which can be prepared by dissolving one level teaspoon of sea salt in one pint of clean water), is universally beneficial and probably under appreciated. When employing saline lavage, the head should be tilted forward to avoid the water draining to the back of the nose and into the throat. As normal saline is by definition the same concentration of salt as in our blood, this solution should not raise most patients’ blood pressure. However, if in doubt about such treatment due to the risk of raised blood pressure, it is always best to consult one’s primary care physician.
Evacuating nasal mucus can also be promoted by using mucolytic agents, which liquefy the secretions. Guaifenesin is such an agent and is sold either separately or as a component in various over-the-counter preparations. One should be aware the guaifenesin is also an emetic and in high doses causes gastrointestinal discomfort.
Another useful adjuvant treatment is humidification of air using cool water vapor or steam, or simply taking a warm shower. This simple treatment also requires judicious application because the nose is a sensitive organ and functions best in a body temperature, slightly humid environment. That is, very hot steam or dry environments like a sauna are not happy places for the nose.
Nasal decongestant sprays, such as oxymetazaline (Afrin®) or phenyl epinephrine, are useful to constrict the swollen nasal turbinates and drainage pathways of the sinuses. Such agents should not be used longer than three days because the nasal membranes become refractive to the drug and require increasing dosages to obtain the same benefit. This rebound effect is known as rhinitis medicamentosa and may persist as long as the patient uses the decongestant spray. In some individuals, the inability to breathe through the nose without using the decongestant spray is so profound, and addicting, that the patient must seek medical care.
LEGEND: Saline lavage of the nose using a bulb syringe. The head should be titled forward over a sink and the lavage directed towards the eye on the same side of the face (arrow). Some patients experience pain during lavaging and this can be minimized by not occluding the nostril with the syringe or other nasal irrigation devices. After rinsing, allow the water to freely drain from the nose rather than forceful blowing.
What is endoscopic sinus surgery (ESS)/FESS?
Bacterial sinusitis should be considered when symptoms and abnormal physical findings, particularly purulent nasal secretions, last beyond seven days. Initial treatment of acute bacterial sinusitis includes all of the above recommendations for viral sinusitis and antibiotics. First-line antibiotics include amoxicillin, trimethoprim-sulfamethoxazole (e.g., Bactrum DS®) and macrolides (e.g., Erythromycin, Clarithromycin, Azithromycin). Second-line antibiotics should be considered in patients with a history of prior infections, repeated use of antibiotics, suspected drug resistance to first-line antibiotics, serious or complicated infections and in immunologically-compromised patients. Second-line antibiotics include amoxicillin/clavulanic acid (i.e., Augmentin®), quinolones (e.g., Cipro®, Levaquin® or Avelox®) or cephalosporins (e.g., Ceftin®). Recommended average length of treatment is seven to ten days, with shorter courses of therapy questionable. When second-line therapy is indicated, 14 days of antibiotics should be considered. Intranasal steroid sprays during the course of the illness reduce swelling within the nose and promote patency of the sinus drainage pathways.
Treatment of chronic sinusitis should include the same recommendations used for viral sinusitis, longer courses and more targeted use of antibiotics, allergy evaluation and use of anti-inflammatory treatments. Acute bacterial infections in the presence of chronic sinusitis are characterized by exacerbations of facial pain and purulent nasal secretions. In such episodes, antibiotic treatment should utilize second-line antibiotics and consist of three to four weeks of therapy. Targeted antibiotic therapy against specific bacteria causing acute exacerbations of chronic sinusitis is optimized by isolation of the bacteria causing the infections. Such isolates require endoscopically-directed culturing secretions within the osteomeatal complex of the effected sinuses or antral punctures (i.e., passing a needle through the nose or above the gums into the maxillary sinus). Swabbing the nose for bacteria is not efficacious because the nose is a highly contaminated site and such cultures are nearly uniformly poor predictors of the bacteria causing sinusitis. Adjuvant treatment of chronic sinusitis should also include allergy and immunological evaluation, particularly in the presence of nasal polyps, nasal steroids and anti-inflammatory agents ranging from oral steroids to specific drugs interfering with the metabolic pathways leading to inflammation.
What are the different types of sinus surgery?
With the simultaneous introduction of computed tomographic imaging (CT scan) and optical instruments, the diagnosis and treatment of sinus diseases rapidly expanded. Concurrently, the concept of minimally invasive surgery; that is, the preservation of form and function would alter the entire surgical treatment of sinus disease.
Our understanding of sinus structure or form would evolve from the careful anatomic studies of the European anatomist, Emile Zucherkandl (1849-1910), and the American anatomist, J. Parsons Schaeffer (1878-1970).
LEGEND: Emile Zucherkandl
In the twentieth century, American anatomists and surgeons began a century of intense studying of the intricate anatomy and physiology of the nose and sinuses, and application of their knowledge to surgical treatment. These efforts evolved into surgical approaches to the sinuses through the nose and face. The latter was practiceds by relatively few surgeons until the introduction of surgical endoscopes (endo = within + scope = to see) in the 1980’s.
Our understanding of the physiology of the sinuses is best attributed to the decades of research by Professor Walter Messerklinger at the University of Graz. Surgical treatment would become the removal of areas of obstruction to the drainage pathways of the sinuses into the nose utilizing endoscopes. Unlike prior surgical methods, the illumination and magnification provided by endoscopes permitted surgery entirely through the nose while fulfilling the precepts of minimally invasive surgery. These procedures would be known as Endoscopic Sinus Surgery (ESS), and the concept of minimally invasive surgery performed using such techniques is now known as Functional Endoscopic Sinus Surgery (FESS).
LEGEND: Illustration courtesy of Professor Malte Wigand, showing the concept of functional or minimally invasive surgery for sinusitis. Upper left-hand drawing represents a normal sinus cavity with air entering the sinus and mucus draining to the nose. Lower-right shows diseased mucus membrane preventing normal ventilation and drainage of the sinus. Upper-right illustration demonstrates initial re-ventilation sinus function by selective removal of the narrowest area of the obstruction or isthmus in the drainage pathway. The remaining illustrations demonstrate return of both normal function and appearance of the post-operative sinus.
What should I do after undergoing sinus surgery?
Intranasal (aka, endonasal) approaches to the sinuses have been utilized for more than a century. With the advent of optical endoscopes and refinements in minimally invasive surgical techniques, Endoscopic Sinus Surgery (ESS) procedures have evolved to focus on the drainage pathways of the sinuses. The most common procedures are:
Ethmoidectomy and Antrostomy:
Ethmoidectomy is the surgical removal of the labyrinth of mucus membrane lined cells which fill the ethmoid bone to restore the normal drainage pathways of this sinus. Ethmoidectomy and antrostomy can be performed under local or general anesthesia, depending on the patient’s preference, the surgeon’s experience, the health of the patient and the severity of sinus problems. In all cases, the mucous membranes of the nose are anesthetized and vasoconstricted (i.e., to diminish the size of blood vessels) by the application of drugs to the nose at beginning of surgery to minimized blood loss and to improve visualization of the operative field.
Surgery begins with careful inspection of the nose. Key landmarks are the three turbinates, or conchae, arising from the lateral nasal wall and the ostiomeatal complex. The most anterior, or nearest to the front structure within the ostiomeatal complex, is the uncinate process. This semilunar ridge of bone projects in front of the ostium of the maxillary sinus. Behind or posterior to the uncinate process, is a group of ethmoid cells known as the bulla ethmoidalis. The first step in ethmoidectomy is the careful and atraumatic removal of the uncinate process to visualize the ethmoid sinus and maxillary ostium. In our experience, incomplete removal of the uncinate process is a significant factor in leading to revision surgery. We believe that the uncinate should be removed at its attachment to the lateral nasal wall.
LEGEND: Endoscopic view of right nose showing uncinate process (up) and middle turbinate (mt). Ethmoidectomy begins with probing the space between the uncinate process and bulla ethmoidalis known as the ethmoid infundibulum (infundibulum = funnel-like).
Often, complete removal of the uncinate process reveals the natural ostium, or drainage pathway of the maxillary sinus into the nose. Various instruments have been designed to enlarge the maxillary ostium and remove the uncinate process. How much to enlarge the natural ostium of the maxillary sinus, also known as an antrostomy (to drain or make a permanent opening in the maxillary sinus to the nose), remains the subject of debate. Some surgeons prefer to only expose the natural ostium, while others routinely remove much of the maxillary sinus wall as part of this step of the procedure. All agree that the antrostomy must include the natural ostium of the sinus because mucocilliary flow is directed to the ostium and mucous may re-enter the sinus through the antrostomy. This so-called “circus effect,” which leads to reinfection of this sinus, is avoided by incorporating the natural ostium in the antrostomy.
Confining maxillary sinus surgery to primarily restoring the drainage pathway of the sinus into the nose is a significant departure from the pre-minimally invasive or functional sinus surgery era. Traditionally, the Caldwell Luc procedure was an integral part of maxillary and ethmoid sinus surgery. However, the American anatomist J. Parsons Schaeffer recognized that the “maxillary sinus is often the cesspool for infectious material from the sinus frontalis and certain anterior group of cellulae ethmoidalis.” That is, Schaeffer was implying that the maxillary sinusitis was often the result of infected drainage from the ethmoid and frontal sinuses, and not the cause of infection in these sinuses. In the modern era of sinus surgery, Caldwell Luc is reserved for disease processes or tumors which cannot be treated through an endoscopic transnasal approach.
: Endoscopic image of the right nose showing completion of removal of the uncinate process by a debrider exposing the natural ostium of the maxillary sinus (mt
= middle turbinate). Following the antrostomy, the maxillary sinus is inspected and polyps, fungus or infected secretion are removed.
LEGEND: An uncommon complication of antrostomy is to injure the nasolacrimal duct (arrows) which drains tears into the nose. When such injuries do occur, the patient may have no problems because the tears drain directly into the nose at the site of injury. Less often the patient experiences epiphoria or tears flowing onto the cheek. In such individuals, a dacryocystorhinotomy (DCR) reestablishes the normal drainage into the nose.
LEGEND: Axial cadaver section through the ethmoid sinus. Enlargement outlines the infundibulum (infundibulum = funnel-like) drainage pathway of the ethmoid (yellow) which is bounded anteriorly by the uncinate process (yellow arrow) and posteriorly by the cells of the bulla ethmoidalis. After the uncinate process is removed, ethmoidectomy consist of exenteration of the ethmoid cells. From Schaefer SD et al. The combined anterior-to-posterior and posterior-to-anterior approach to ethmoidectomy: An update. Laryngoscope 116:509-513, 2006.
Exenteration or removal of the cells of the ethmoid sinus has several approaches. Since the 1990’s two separate approaches to the removal of the ethmoid cells have been combined into one procedure. The anterior-to-posterior approach adapted from an earlier technique described by Halle was initially utilized by Professors Walter Messerklinger and Heinz Stammberger. This adaptation began with removal of the uncinate process and antrostomy followed by progressive removal of only diseased ethmoid cells. If indicated, the ethmoidectomy was extended into the posterior ethmoid cells. Sphenoidotomy was performed when the patient had sphenoid sinusitis, mucoceles or tumors of this sinus. The advantage of this technique was that surgery was limited to the diseased sinuses. The disadvantage was that the removal of the superior ethmoid cells required the surgeon to rotate inferiorly their dissection away from the skull base to avoid causing cerebral spinal fluid rhinorrhea or injuring the brain.
The anterior-to-posterior approach was subsequently combined with a posterior-to-anterior adaptation of intranasal sphenoethmoidectomy by Professor Malte Wigand to endoscopes. As originally described, sphenoethmoidectomy began with partial resection of the middle turbinate to expose the anterior or front wall of the sphenoid sinus.
LEGEND: Sagittal cadaver section through the ethmoid sinus. The anterior-to-posterior approach initially includes removal of the uncinate process and ethmoid cells encompassed by the dotted lines (FR = frontal recess, SS = sphenoid sinus and SER = sphenoethmoid recess). The ethmoid cells above or superior to the dotted lines are exenterated in a retrograde or posterior-to-anterior technique in which the surgical instruments are directed away from the skull base. From Schaefer SD et al. The combined anterior-to-posterior and posterior-to-anterior approach to ethmoidectomy: An update. Laryngoscope 116:509-513, 2006.
The anterior wall of the sphenoid was then removed and the procedure consisted of removing the posterior and then anterior ethmoid cells. This approach permits the surgeon to direct the removal of ethmoid cells away from the skull base and thus lessen the likelihood of injury to this site. The disadvantage of the posterior-to-anterior approach is the extensive nature of the procedure in patients who have minimal sinus disease. In the combined approach, surgery begins in the anterior nose with removal of the uncinate process and antrostomy. Following antrostomy, the anterior ethmoid cells are removed. Partial or total ethmoidectomy is dictated by the extent of sinus disease.
After completing the anterior to posterior dissection, the superior ethmoid cells are removed retrograde under direct endoscopic vision. The ethmoidectomy is completed with visualization of the frontal sinus drainage pathway or frontal recess. This pathway is not disturbed unless the patient has frontal sinusitis and requires a frontal sinusotomy.
LEGEND: Sagittal cadaver section through the ethmoid sinus illustrating retrograde exenteration of the superior ethmoid cells in the combined approach to ethmoidectomy. Enlargement shows the superior ethmoid cells (A) along the skull or roof of the ethmoid sinus prior to their removal. Image B shows removal of the bony partitions between the superior cells with preservation of the skull base. The arrowheads indicate the direction of the surgery which is primarily away from the skull base. From Schaefer SD et al. The combined anterior-to-posterior and posterior-to-anterior approach to ethmoidectomy: An update. Laryngoscope 116:509-513, 2006.
Sphenoidotomy is to make an opening into or to remove the anterior, or front, wall of the sphenoid sinus. The roof, walls and floor of this sinus contain the major nerves to the face and eyes, and arterial supply and venous drainage of the brain. Similarly to ethmoidectomy, various surgical approaches have evolved into an intranasal minimally invasive endoscopic procedure.
LEGEND: Sagittal cadaver section showing the central location of the sphenoid sinus relative to the brain, major nerves, pituitary glands and blood vessels.
LEGEND: MRI of patient with acute left sphenoid sinusitis. Typical of such infection, this patient complained of intense mid face and vertex pain. As is seen in this image, the sphenoid sinus may extend beyond the body of the sphenoid bone to pneumatize or involve the adjacent regions. In this case, a lateral recess has been formed within the greater wing of the sphenoid sinus. This MRI illustrates the close proximity of important brain, eye and blood vessels to the sphenoid sinus.
Frontal sinusotomy is a broad term which encompasses both external and intranasal approaches to open and/or create a permanent communication from the sinus to the nose. Endoscopic frontal sinusotomy is the restoration of the drainage of this sinus into the nose via an endoscopic approach. Included in this approach is a range to relatively simple to highly complex procedures. The complexity of endoscopic frontal sinusotomy is determined by the site of obstruction to the outflow tract or disease within the sinus, and variations in frontal and ethmoid sinus anatomy.
LEGEND: Left-Coronal CT scan showing frontal sinusitis secondary to obstruction the drainage pathways of both frontal sinuses ethmoid cells (EC) also known as frontal cells. Center-Illustration of ethmoid cell (green ellipse), filling the drainage pathway known as the frontal recess of the frontal sinus. Left- Diagram of type 1 frontal sinusotomy showing the removal of the ethmoid cells within the frontal recess (FR) restore the drainage pathway of the frontal sinus into the nose.
Historical and less widely used surgical techniques include:
Caldwell-Luc is the fenestration of the anterior wall of the maxillary sinus and the surgical drainage of this sinus into the nose via an antrostomy. This procedure has become the “work horse” of much of sinus surgery (Macbeth, 1968). With the introduction of endoscopic sinus surgery, Caldwell-Luc is much more selectively employed as intranasal approaches often permit excellent access to the maxillary sinus. Caldwell-Luc has been used for treatment of chronic sinusitis, removal of polyps, cysts or foreign bodies, reduction of facial fractures, closure of dental fistulas into the maxillary sinus and as a route to the ethmoid and sphenoid sinuses. Other applications of Caldwell-Luc include visualization of the orbital floor for decompression, various forms of tumor surgery and access to the pterygomaxillary fossa (the space behind the maxillary sinus).
LEGEND: Caldwell-Luc begins with an incision beneath the cheek above the gums. The cavity of the maxillary sinus is entered through a fenestration of the frontal wall known as an antrotomy (i.e., to make an opening into the antrum). After completing the surgery within the maxillary sinus, a permanent drainage opening to the nose or antrostomy is made beneath the inferior turbinate.
Osteoplastic Frontal Sinusotomy with Fat Obliteration:
Osteoplastic frontal sinusotomy was first described in the American literature by Hoffman in 1904 and begins most commonly with a coronal scalp incision to enter the frontal sinus. Next, an incision into the anterior bony wall of the frontal sinus is performed and the sinus is entered while preserving the periosteal blood supply the bone. As this procedure predates antibiotics, surgeons realized that preservation of the tissues carrying blood to bone was essential to minimizing infection. For this reason, this procedure was named osteoplastic frontal sinusotomy because the periosteum of the anterior frontal wall is preserved. Fifty years later, Goodale and Montgomery would modify this operation to obliterate the frontal sinus by filling it with fat.
LEGEND: Illustration of various incisions utilized during sinus surgery via external approaches (1 = modified lateral rhinotomy provides exposure of the maxillary and ethmoid sinuses and is primarily used for tumor surgery. 2 = coronal scalp incision provides exposure of the frontal bone and is both for osteoplastic frontal sinusotomy and cranial facial surgery. 3 = modified lateral rhinotomy skin incision to approach the medial wall of the maxillary sinus.)
LEGEND: Intraoperative photograph of osteoplastic frontal sinusotomy. A coronal scalp flap (4) exposes the anterior wall of the frontal sinus and the periosteum (1) remains attached to this bone. An incision or osteotomy (2) into the frontal bone is outlined and the remaining periosteum (3) remains intact.
What are the potential complications of sinusitis?
Post-surgery instructions vary with each procedures and case, the patient’s underlying health and the surgeon. The following are general day-by-day patient instructions. Always follow your physician’s guidance for the most personalized instructions following your surgery.
DAY OF SURGERY:
- Activity: Avoid driving, any activity which raises your blood pressure, showering and nose blowing (open your mouth if you sneeze).
- Concerns: Contact your physician if you develop a fever greater than 100.4 degrees Fahrenheit, chills, stiff neck or back, unusual or severe facial or eye pain, or clear water-like fluid (not mucous or blood) dripping from the nose. Clear water will normally drain from the nose after saline lavage. Minor nasal bleeding is normal, persistent loss of several tablespoons of blood per minute should be reported.
- Diet: If you have had local anesthesia you may resume a light meal. If you have had general anesthesia, limit your diet to clear liquids, such as soup and Jello.
- Ice: Keep an ice pack or plastic bag over the center of the upper nose as much as possible. If the ice is uncomfortable, place a wash cloth between the ice and your face.
- Medications: Resume your pre-operative medications except those which are blood thinners and cause bleeding; such as Coumadin®, aspirin and Plavix®. Resume these drugs seven or ten days after surgery. Begin medication prescribed by your doctor the night of surgery. Delay taking these medications if you have nausea from the general anesthesia.
Days After Surgery –Post-Operative Days 1 and 2:
- Activity: You may resume limited driving and showering. Avoid any activity which raises your blood pressure, and nose blowing (open your mouth if you sneeze). Avoid nose blowing for ten days. If you need to clear mucous or blood from your nose, gently sniff.
- Diet: Slowly resume your normal pre-surgery diet with the exception of hot liquids, which may cause nasal bleeding.
- Ice: Continue an ice pack or plastic bag with ice over the center of the upper nose as much as possible. If the ice is uncomfortable, place a wash cloth between the ice and your face.
- Medications: Continue your pre-operative medications except those which are blood thinners and cause bleeding; such as Coumadin®, aspirin and Plavix®. Take the medication prescribed by your physician.
Days After Surgery –Post-Operative Days 3 and 4:
- Activities, Diet, Ice and Medications as stated above.
- Nasal Lavage: Begin lavaging, or irrigating the nose with salt water. We recommend purchasing Neilmed Saline Rinse® at your pharmacy, which consists of an eight ounce plastic bottle and packets of sea salt. Place the bottle against your nostril, without forming a seal, and gently squeeze the salt water into the nose. Flex your head downward over the sink. If this hurts, move the bottle further away from the nostril as you are causing too much pressure within the nose. Although the sinus rinse instructions recommend vigorously forcing the saline into the nose, we strongly suggest avoiding such practices. Allow the water to spontaneously drain from your nose and do not blow the nose. If rinsing the nose with saline causes vigorous bleeding, delay irrigating for a day. Use eight ounces of saline twice daily or more each day. Continue to lavage your nose after surgery because it significantly improves your quality of life. Adding one drop of baby shampoo to each eight ounces of saline lavage improves the ability to clean the nose and may be performed indefinitely. To sterilize the bottle, place the empty plastic bottle weekly in the microwave for one minute at high. Change the bottle monthly.
- Patients with significant polyps or inflammatory sinus disease may benefit by adding one half to one milligram respule of Pulmacort® (which requires a prescription) to each eight ounces of saline lavage twice daily.
Days After Surgery –Post-Operative Days 7 through 10:
- Activity: Resume light exercise advancing to normal activities. Flying should be delayed until ten days after surgery. When flying, we suggest taking a decongestant, such as Sudafed, prior to flying and spraying the nose with Afrin 30 to 60 minutes prior to the airplane landing. Remember to continue to lavage your nose with saline while traveling.
Most patients are seen the week after surgery, two to three weeks after surgery and at six to eight weeks post-surgery. Call for post-surgery office visits.
What other disorders are treated by the physicians of the Center for Sinus and Allergy?
The orbit or eye socket borders the maxillary sinus, and infection may spread from this sinus to the eye. Further spread of infection can lead to blindness and brain abscess. The proximity of the ethmoid and frontal sinuses to the eye and brain permit microorganisms to infect these organs. As the sphenoid sinus lies adjacent to the brain and is bounded by the nerves that control vision, and eye and facial movements, infections of this site are particularly significant. Facial pain, severe headache, tenderness over a sinus, fever, double vision and altered consciousness are all signs of a progressively worsening sinus infection.
Provided sinusitis is properly treated, complications are relatively rare today. However, if not treated, potential complications include:
- Orbit (eye) complications: Infection may spread from all four sinuses into the orbit. Swelling of the eyelids and redness of the eye may be the first sign of infection. As the infection progresses within the orbit, bulging of the eye and double vision become evident. Orbital cellulitis or abscess are a potential cause of such symptoms and require immediate attention. Our physicians utilize CT scans or MRIs for diagnosing these complications. Loss of vision implies the optic nerve is impaired. As this process ascends the arteries and veins to the eye, infections can involve the internal carotid artery and a major venous drainage pathway of the brain known as the cavernous sinus. Such infections are life threatening and heralded by altered consciousness and impaired vision and eye movements in the opposite eye.
LEGEND: Orbital cellulitis secondary to ethmoid sinusitis.
LEGEND: Extension of infection from the frontal sinus beneath the skin of the right orbit. Known as a Potts’ puffy tumor (arrow), such infections may also involve the intracranial cavity.
Intracranial (within the cranium or skull) complications:
Ethmoid, frontal or sphenoid infections may spread directly to between the skull and the fibrous tissue adhering to the cranium known as the dura. Infections involving the covering tissues of the brain known as the meninges and the cerebral spinal fluid surrounding the brain are referred to as meningitis. Infections from the sinuses may also spread via the blood supply to the brain and cause a brain abscess. All of these potential complications require immediate treatment.
LEGEND: Right-Coronal MRI of mucopyocele (arrows) or infected mucus containing cyst arising within the right frontal sinus and extending into the epidural space (between the dura and the skull). Left- Sagittal CT of patient after endoscopically placed drain (arrows) within the frontal sinus (FS) and epidural space.
As the eyes and lacrimal apparatus are both located within the facial skeleton and intimately involved with the sinuses and nose, our physicians surgically treat certain disorders of these sites. Further, benign, intermediate grade (i.e., inverting papillomas) and selective malignant neoplasms are often surgically treated via an endoscopic procedure.
Orbital and Optic Nerve Decompression
: The most common indication for orbital decompression is thyroid eye disease or Graves’s disease. In this disorder, antibodies are made against the eye muscles and fat within the orbit. As the disorder progresses, the patients develop exophthalmos (i.e., a bulging of the eyes from their sockets), experience double vision and occasionally loss of vision. Patients who cannot be managed by medication significantly benefit by surgically removing the walls of the orbits, which are common to the ethmoid and maxillary sinuses.
LEGEND: Axial CT scan showing typical enlargement of the eye muscles and exophthalmos. As the muscles enlarge, the optic nerves are compressed and vision deteriorates.
: Inability of the nasolacrimal apparatus to drain tears into the nose causes excessive tearing onto the cheek. This condition is known as epiphoria and is most often due to an obstruction of the nasolacrimal duct draining into the nose. DCR re-establishes normal drainage by creating a permanent passageway from the lacrimal sac into the nose. Endoscopic DCR avoids facial incision and provides an excellent drainage pathway for tears.
Endoscopic Resection of Nasal and Sinus Neoplasms
LEGEND: Right eye with lacrimal drainage apparatus. Tears are produced by the lacrimal gland located in the outer upper quadrant of the eye and wash across the eye ball to drain into the lacrimal apparatus. Tears enter the lacrimal punctum (up = upper punctum) to drain into the lacrimal sac (ls) via the lacrimal superior (sc) and inferior lacrimal canaliculi. These canniculi join to empty into the common canniculus which directs tears into the lacrimal sac and from there into the nose via the nasolacrimal duct (nld). Illustration modified from Weber R, Keerl R, Schaefer SD and Della Rocca R: Atlas of Lacrimal Surgery. Springer, 2007.
: An array of neoplasms of nasal and sinus origin arises from the mucus membrane lining these sites. This lining is unique to these sites and is also referred to as Schneiderian epithelium. One common benign, but locally aggressive neoplasm arising from this epithelium is inverting or Schneiderian papilloma. Other elements of the lining of the nose and sinuses include glands, blood vessels and nerves. All of these tissues can give rise to both benign and malignant neoplasms. The surgical management of such neoplasms is governed by their site of origin, benign or malignant characteristics and extension into adjacent organs.
LEGEND: CT and MRI of inverting papilloma arising from the right nasal wall to involve the maxillary (MS) and ethmoid (ES) sinuses. The CT scan on the right shows that the bony walls of the maxillary sinus are largely intact, including the floor of the orbit which is also the roof of the maxillary sinus. The right medial rectus muscle (mr; the muscle which turns the eye inward) is not compromised by tumor and eye (E) and orbit appear normal. The MRI confirms the findings on the CT and is consistent inverting papilloma. Such tumors on MRI have a very heterogeneous appearance which accounts for the light and dark areas within the tumor.