INVITED EDITORIAL

A TAILOR MADE APPROACH TO ENDOSCOPIC SINUS SURGERY FOR

CHRONIC RHINOSINUSITIS
*Dipak Ranjan Nayak

Vol.-9, Issue-II, July-Dec. - 2015

ABSTRACT
Chronic sinusitis is a major health hazard that affects the quality of life of an individual significantly. A comprehensive
medical and surgical management is required to treat such cases. Various surgical options are now available to manage such
cases that include FESS, FENS, MIST, MISS and balloon assisted sinuplasty etc. The author proposes a tailor made approach
to tackle such problems based on the extent of disease, past surgical treatment, associated local and systemic factors. The tailor
made surgery ranges from a minimally invasive approach to a complete fronto-maxillo-spheno-ethmoidectomy with uncinate
preservation as required.
Key words: Ultra conservative Endoscopic sinus surgery, Chronic sinusitis, Tailor made approach.
INTRODUCTION
Hirschmann 1901 had performed endoscopic
examination using a cystoscope to examine maxillary sinus
for visualization of oro-antral fistula.1 Reichert used a 7mm
endoscope to perform first transnasal endoscopic surgery for
closure of oro-antral fistula. Speilberg (1922) described the
antroscopy of maxillary sinus via an inferior meatal
approach.3 Maltz(1925) used the term sinuscopy. Evolution
of functional endoscopic sinus surgery started with
Messerklinger in 1978 and took a concrete shape around mid
1980s with the pioneering work of Stamberger and Kennedy46
. Kennedy(1985) is the first sinus surgeon to coin the term
Functional endoscopic sinus surgery.5 It is now the gold
standard in the management of chronic and reccurent sinus
disease. It facilitates ventilation and drainage of the paranasal
sinuses involved and allows the return of adequate functioning
of the mucociliary movements of the nasal mucosa while
providing several benefits when compared to traditional open
procedures.7, 8 Introduction of coronal CT played a pivotal
role in preoperative evaluation, diagnosis, planning and
management of inflammatory paranasal sinus diseases.9
Kennedy found a strong relationship between the surgical
outcome and extent of disease and proposed a staging system
for all inflammatory sinus disease. Several factors including
aspirin intolerance, asthma, allergic fungal sinusitis, systemic
factors can affect the outcome of surgical treatment. In spite
of aggressive treatment modality, many patients can have
residual disease.10 Combined input of CT evaluation, clinical
features and diagnostic endoscopic finding can determine the
accurate extent of the disease and the functional outcome
after treatment and may help in preventing complications11.
Classical functional endoscopic sinus surgery in its early days
still raises some issues and inherent limitations, mainly ending
up in removing the nasal mucosa and osseous tissue, that can
cause pain, bleeding, and physiological changes of the nasosinus mucosa, especially of the mucociliary movements and
local cicatricial fibrosis7, 8. Mucosal preservation during
surgery, precise and safe removal of tissues forms the
cornerstone for a successful surgical outcome[Fig-1]. It has lead
6

to the technological advances in the form of thru cut forceps,

Microdebridor and navigation system etc.12,13
A small sinus ostium is often found at the time of surgery

Fig1. Image guided endoscopic sinus surgery

with healthy sinus clinically and CT suggesting small size

ostium is sufficient to maintain functional sinus. A technique
for opening the transition space of maxillary sinus with no
instrumentation of its ostium obviates the necessity for more
traumatic large hole procedure.14 Uncinate process probably
has a protective role in preventing deposition of bacteriae
and allergens in the sinuses during the inspiratory phase.
Inoculation of new pathogenic bacteriae in the open
ethmoid cavities can probably be prevented by concealing it
from the inspired air. This can be achieved by preserving the
uncinate process and the anterior end of the middle turbinate15.
Nayak et al (2001) coined the term Functional endoscopic
naso-sinus surgery (FENS) where in, a comprehensive sinonasal surgery was performed with preservation of uncinate
process and selective ethmoidal clearance through a
transbullar approach. In case of isolated maxillary sinus
Affiliations:
Professor, Department of ENT-HNS, Kasturba Medical College,Manipal
University,Manipal
Address of Correspondence:
Prof. Deepak Ranjan Nayak
Professor, Department of ENT-HNS,
Kasturba Medical College,
Manipal University,Manipal, Karnatak.

Isolated sinusitis: Often we find isolated sinusitis

involving major sinuses with no involvement of ethmoids after
maximizing the medical treatment. The best option to manage
such cases is to adopt a balloon assisted endoscopic sinuplasty.
Balloon sinuplasty is a surgical technique where dilation of
the ostium of a major sinus is performed by using a balloon
catheter. The technique involves passing of a balloon dilation
catheter over a fiberoptic luma guide wire that has been
positioned within the involved paranasal sinus under the
endoscopic supervision. The positioned balloon in the
targeted sinus ostium is inflated by an inflation device to dilate
the ostium[Fig2].
Fig2. Showing
balloon assisted
sinuplasty of
frontal sinus (a)
passage of ballon
cathter through
Luma guide wire
(b)
Ballon
dilatation
of
lower segmnt of
frontal recess (c)
Further passage
and dilatation of
upper segment
and
frontal
ostium (c) After
dilatation.

Since balloon device is quite expensive in developing

countries like India, the author adopted an ultraconservative
approach where in the maxillary and frontal ostia are enlarged
without disturbing the drainage pathway[Fig-3]. In case of
isolated disease in frontal sinus with limited disease in frontal
recess, an intact uncinate and bulla technique is adopted with

Fig-3. Showing enlargement of maxillary ostium with intact drainage pathway

Fig-4.
Showing
frontal disease with
very
limited
e t h m o i d a l
invovement
on
C T ( a , b & c ) ,
undergone a draff-I
procedure
with
preservation
of
uncinate and bulla via
trans
Axillary
suprabullar approach.

Fig-5. Showing
foleys catheter
assisted balloon
sinuplasty in a
revision case of
frontal
sinus
disease.

Fig-6. Showing
Modified
endoscopic
Lothrop(DraffIII)
with
u n c i n a t e
preservation.
resection of the posterior wall of the agar nasi along with
exenteration of frontal cell through trans-axillary suprabullar
approach[Fig-4]. Considering the poor economic status, a infant
foleys catheter[Fig.5] assisted balloon sinuplasty was carried
out with good results. In case of extensive disease involving
frontal sinus like allergic fungal sinusitis and polyposis, a
Draf-II procedure is done for unilateral disease and Draf-III
surgery for bilateral disease[Fig 6].
If ethmoidal disease is present, the maxillary sinus is
dealt with as described under isolated maxillary sinusitis and
for the ethmoids, a trans-bullar approach is adopted with
uncinate process preservation. The bulla is opened inferomedially as described by Stammberger. The upper anterior
part of the bulla is preserved till frontal sinus is identified.
The anterior ethmoidal artery is identified and confirmed as
per the imaging study. A ball probe is passed between the
remnant of the bulla and posterior wall of the agger nasi gently
without applying pressure to localize the frontal sinus
drainage pathway. The agger nasi is opened inferiorly after
doing an axillotomy with the help of a back biting forceps.
The posterior wall of the agger nasi is removed with an up
turned tru-cut forceps/ microdebrider. The frontal cell type
as per imaging study is identified and removed. The ground
7

Vol.-9, Issue-II, July-Dec. - 2015

disease, a maxillary sinusostomy was carried out while

preserving the uncinate process and bulla ethmoidalis.7 The
author proposes a tailor made approach from minimal
invasive to complete fronto-maxilla-spheno-ethmoidectomy
with uncinate preservation to tackle chronic sinus disease
based on extent of disease and other associated local and
systemic factors that can hamper the outcome of surgery.
Surgical indication & Technique for a tailor made approach:

lamella is again opened infero-medially. The remnant of the

upper anterior attachment of the bulla is removed carefully
from its attachment. The author preserves the upper
attachment of the bulla if the frontal recess is not cleared.
The posterior ethmoidectomy is done in the
conventional way with the help of a microdebrider or
mushroom punch forceps based on the imaging finding.
Sphenoid ostium is identified medial to superior turbinate
and lateral to septum. Ostium is enlarged infero-medially
using a sphenoidal mushroom punch forceps of different sizes
if required.
In invasive fungal sinusitis, one needs to be aggressive in
approach with an endoscopic medial maxillectomy and skull
base clearance.

1.

J. Woodham: History of the development of surgery for

sinusitis P.J. Donald, J.L. Gluckman, D.H. Rice (Eds.),
The sinuses, Raven, New York (1995), pp. 314

2.

M. Reichert: ber eine neue Unterscuhungsmethode

der Oberkieferhhle mittels des Antroskops Berl klin
Wochenschr, 401 (1902), p. 478 [in German]

3.

W. Spielberg: Antroscopy of the maxillary sinus;

Laryngoscope, 32 (1922), pp. 441444

4.

Messerklinger W: Endoscopy of the Nose. Baltimore,

MD, Urban and Schwarzenberg, 1978

5.

Kennedy DW (Oct 1985). Functional endoscopic sinus

surgery. Technique. Arch Otolaryngol 111 (10): 6439

6.

Stammberger H: Endoscopic endonasal surgery

Concepts in treatment of recurring rhinosinusitis. Part
II. Surgical technique. Otolaryngol Head Neck Surg
94:147-156, 1986.

7.

Nayak etal : Endoscopic physiological approach to

allergy associated chronic rhinosinusitis; Ear Nose
Throat J. 2001, 80:390-403.

8.

Friedman & Schalch; Op Tech Otolaryngol Head Neck

Surg. 2006, 17:126-34.

9.

Zinreich SJ, Kennedy DW, Rosenbaum AE. Paranasal

sinuses: CT imaging requirements for endoscopic
surgery. Radiology 1987; 163:769-775.

10.

Kennedy DW: Prognostic factors, outcomes and staging

in ethmoid sinus surgery; Laryngoscope,1992 Dec;102(12
Pt 2 Suppl 57):1-18.

11.

Lund VJ, Kennedy DW: Staging for Rhinosinusitis; 1997

Sep; Otolaryngol Head Neck Surg;117(3 Pt 2):S35-40.

12.

Setliff RC, Parsons DS:The Hummer: new

instrumentation for functional endoscopic sinus surgery.
Am J Rhinol 1994; 8:275278.

13.

Kennedy DW: Technical innovations and the evolution

of endoscopic sinus surgery; Ann Otol Rhinol Laryngol
Suppl. 2006 Sep;196:3-12.

14.

Setliff Reuben: Minimally invasive sinus surgery: the

rationale and the technique1996; OCNA vol-29(1). P115-129

CONCLUSION:

15.

A Tailor made ultraconservative sinus surgery with

mucosal preservation is the gold standard for treating
Sinonasal infections. It facilitates early mucociliary recovery
with minimal hospitalization/day care procedure thus
reducing the cost and postoperative morbidity. However
extensive diseases like allergic fungal sinusitis, polyposis, and
invasive fungal sinusitis require more aggressive approach.

Nayak D R & Balakrishnan R : De novo bacterial

reinfections after endoscopic sinus surgery: can uncinate
process preservation surgeries prevent it? Laryngoscope
115(5), p 928; May 2005.

16.

Yogesh M. Seth W, Peter C: Management of early nasal

Polyposis using a steroid impregnated nasal dressing;
international forum of allergy & rhinology, Vol.I, No.5,
P-401-404,, Sept.-Oct. 2011.

A Resorbable nasal dressing available as Nasopore can

be used as a nasal dressing to prevent synechia. The Nasopore
piece was cut into appropriate size and was soaked with
triamcinolone and antibiotic. Each Nasopore piece was then
placed at the maxillary ostium, frontal ostium and frontal
recess and ethmoidal cavity. The author uses this for his recent
cases. Use of Nasopore soaked steroids can be used effectively as
a nasal dressing and can reduced the need for systemic steroid
in the presence of polyposis.16
RESULTS:

Vol.-9, Issue-II, July-Dec. - 2015

REFERRENCES:

The author has followed the above described surgical

protocol in a series of 1211 cases over a period of six years
from 2007 to 2012. The cases were ranging from isolated sinus
disease to extensive pan sinusitis. These cases were advised
regular follow up for a minimum period of one year. The
subjective analysis was carried out using visual analogue scale
for four common symptoms encountered among patients, i.e.
nasal obstruction, headache, anterior/ posterior nasal
discharge and anosmia/ hyposmia. It was observed that 64.9%
of subjects had complete relief from nasal obstruction, 68.4%
from headache, 61.35% from anterior/ posterior nasal
discharge and 51.8% from anosmia/ hyposmia at 6 months
after surgery. Nasal endoscopy at 6 months post operatively
was carried out for 639 cases and revealed persistent nasal
discharge in 36.7%, nasal synechia in 24.9% and recurrence of
polyps in 27.8% (These patients are also a part of an ongoing
study for assessment of long term benefits of surgery).