Endoscopic Sinus Surgery: A Practical Approach
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Arch Otolaryngol Head Neck Surg. The authors have no relevant financial interest in this article. Second-look endoscopy was indicated for selected cases to ensure the extirpation of residual disease and the patency of ostiomeatal complex and sinus ostia. Chronic rhinosinusitis CRS is defined as signs and symptoms of inflammation of the sinuses persisting more than 8 to 12 weeks. Surgery may be considered in patients with failed medical treatment. Traditional sinus surgery for pediatric rhinosinusitis, including the nasal antral window, Caldwell-Luc procedure, ethmoidectomy, and adenoidectomy, often has unsatisfactory outcomes and high morbidity.
Messerklinger developed the concept of the ostiomeatal complex and radically altered the understanding and management of CRS. Second-look endoscopy SLE was indicated in selected cases. More than patients have been treated with FESS in our institution, of whom 5. Our literature review did not reveal any other large series of such cases in the Asian population.
We reviewed the medical charts of all patients younger than 18 years who underwent FESS between January and September There were patients. Thirty patients with asthma, immunodeficiency, or antrochoanal polyps were excluded from this study, leaving patients who met the selection criteria for the study. All of these patients were regularly monitored and had complete medical records. Assessment of the disease included a full history and physical examination. Patients were considered to have CRS if they met the criteria of 1 12 weeks of persistent symptoms and signs or 2 6 times per year of recurrent episodes of acute rhinosinusitis, each lasting at least 10 days.
If poor response to the initial 2-week medical treatment was noted, antibiotics such as amoxicillin—clavulanate potassium, cefaclor, or cefixime were given instead.
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Computed tomography CT with a bone window of the sinuses was obtained to document the extent of their disease if the symptoms and signs persisted after more than 4 weeks of medical therapy. The CT scans of all our patients indicated Levine and May stage 3 or 4 disease.
Our surgical technique, the limited approach, was modified from the Messerklinger technique for FESS.
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- Endoscopic Sinus Surgery: A Practical Approach!
This operation was conservative and directed to the originating site of the disease. Sinonasal mucosa and soft tissue were handled very gently. Frontal recess was the superior-anterior boundary of surgical dissection. Opening of the maxillary sinuses was regularly performed.
However, dilation of the ostia was not necessary unless ostial obliteration was found. If ostial dilation was indicated, dilation in the anterior direction after the excision of the uncinate process was the principal management. The superior, inferior, and posterior margins of the maxillary ostium were not manipulated. Partial removal of the ethmoid bulla inferior medial portion was performed. Instead of "wide excision," a small window on the basal lamella was created to facilitate the drainage of the posterior ethmoid sinus. Evacuation of the anterior ethmoid sinus was reserved for the extensive disease.
Whether posterior ethmoidectomy was performed or not was related solely to the extent of the disease. If sinus lateralis existed, the enlargement of the basal lamellar window and posterior ethmoid sinusotomy were mandatory to minimize the possibility of residual disease. Patients were monitored weekly for the first month, biweekly for the second month, and monthly thereafter, if necessary. Second-look endoscopy under general anesthesia was indicated in selected patients 3 to 6 weeks after surgery for examination and cleaning of the operative site.
Patients were considered for SLE if they met the following criteria: 1 recurrence was strongly suspected during follow-up, 2 diffuse sinonasal polyposis was present before operation, or 3 extensive disease required revision. The SLE procedures comprised 1 general examination of the surgical wound; 2 release of synechiae, removal of debris, extirpation of polypoid tissue, and debridement of granulation tissue; 3 reventilation of the sinus; and 4 thorough irrigation of the sinus antrum if mucopus stasis existed. A questionnaire designed to compare preoperative and postoperative signs and symptoms was administered at least 6 months after surgery.
This comparison included nasal obstruction, purulent rhinorrhea, postnasal drip, headache, hyposmia smell dysfunction , and chronic cough.
The questionnaires were answered in conjunction with patients' parents, and were evaluated along with patients' medical records. Parents were asked to select a word from the following that best described the improvement of the symptoms and signs after surgery: worse, no change, better, or resolved. At the conclusion of the questionnaire, parents were asked whether they were satisfied with the outcomes of the FESS procedures.
The mean age of the patients at the time of surgery was The male-female ratio was 1. The average postoperative follow-up period at the time of the study was Preoperative and postoperative evaluations of symptoms and signs were calculated on a percentage basis, and the actual numbers of children affected are shown in Table 1.
All of the patients who underwent pediatric FESS also underwent preoperative sinus noncontrast CT with bone window , and all of them had Levine and May stage 3 or 4 disease. All patients exhibited diverse preoperative symptoms and signs. Chronic nasal obstruction was the most common preoperative complaint 97 patients. This course is an attempt to teach Smell and Taste in a most practical and interesting way, meaning that the meeting is not only defined by lectures, but through practical courses and demonstrations. As in previous years this unique course will showcase the expertise and knowledge of world renowned surgeons in the field of rhinoplasty and facial plastic surgery.
This 3 day highly supervised course offers the opportunity to learn and enhance skills in a range of Septorhinoplasty and Facial Plastic Surgery techniques on Fresh Frozen Cadavers. Main topics Surgery of the infratemporal fossa, frontal sinus surgery, endoscopic orbital surgery, surgery of the pterygoid fossa, surgery of the cavernous sinus and the sellar region, infrasellar and transcival approach, CSF leakage Read More.
ERS Read More. Apart from those limitations, a maximal medicamentous therapy of CRS currently consists of nasal steroids in higher doses, accompanying nasal rinsing with saline solution, antibiotic therapy for 2—3 weeks, and systemic steroids [ 19 ], [ 20 ], [ 21 ], [ 22 ], [ 23 ] [ 24 ].
Endoscopic Sinus Surgery
The direct application in the paranasal sinuses is more effective than the mere nasal application [ 28 ]. Nasal rinsing with saline solution is effective as accompanying therapy in all types of CRS, allergic rhinitis, acute rhinosinusitis, and for prophylaxis of frequent upper airway infections [ 29 ], [ 30 ], [ 31 ]. Irrespective to the high acceptance of antibiotic therapy in CRS as part of the recommended maximum [ 19 ], [ 32 ], the evidence of the respective treatment effectiveness is limited.
In CRSwNP the application of doxycycline over 3 weeks leads to a little reduction of the polyposis; after 3 months, however, the symptoms were the same as at the beginning [ 33 ]. Antibiotic therapy is currently considered as an option [ 35 ].
Endoscopic Sinus Surgery: A Practical Approach - Shashikant K. Kaluskar - Google книги
It should be applied in all types of CRS revealing obvious purulent secretion — the choice of the specific drug, however, should be made after taking endoscopically guided swabs [ 6 ]. Macrolides seem to be effective due to their anti-inflammatory properties which is true especially for the subgroup of patients with low IgE. However, the actual range of effectiveness is limited and is often considered as clinically not relevant [ 36 ].
The long-term effectiveness of systemic steroids in CRSsNP as single therapeutic modality has not been evaluated or adequately proven up to now. Systemic steroids have always been part of a multimodal concept together with antibiotics and topical steroids. In most cases 10—60 mg are applied for 10—12 days. This is why they are only regarded as an option [ 19 ], [ 37 ], [ 38 ], [ 39 ] are recommended in individual cases only [ 6 ], [ 19 ], [ 37 ], [ 40 ], [ 41 ], [ 42 ].
Systemic steroids in CRSwNP are effective, but the duration of this effect is very limited [ 33 ], [ 42 ], [ 43 ]. Regularily, the short-term application is recommended [ 44 ]. In AFS, systemic steroids are effective but the duration of the treatment must inevitably be prolonged and thus often side effects must be expected [ 42 ]. The relevant incidence of different side effects of systemic steroids must be weighed up against their temporary effectiveness so that dose minimization is always aimed at and a specific informed consent should be taken prior to starting the therapy [ 42 ], [ 45 ], [ 46 ].
There is no consensus about an optimal cortisone dosage and duration of therapy. The applied dose is frequently determined by the packaging of the tablets at disposition. The following pharmaceuticals have been applied: e.