Endoscopic Sinus Surgery Failure Explained

**** EMBARGOED UNTIL APRIL 29, 2004, AT 0:000 EST *****

April 28, 2004

Kenneth Satterfield 1-(480)-293-3619 (from 4/28 to 5/4) 1-(703) -519-1563 [email protected]

ENDOSCOPIC SINUS SURGERY FAILURE EXPLAINED Recurrent frontal sinus failure is linked to inherent mucosal disease and technical shortcomings of the previous surgical procedures.

Phoenix, AZ " Each year, more than 30 million are diagnosed with acute or chronic rhinosinusitis. This disorder can be highly debilitating, resulting in a significant decline in quality of life. For most cases of sinusitis, antibiotics offer effective treatment; but there are circumstances where surgery is necessary for preventing symptom recurrence and leading to a disease-free state. Endoscopic surgery has been reported to be highly successful in treating the more persistent sinusitis cases with success rates reported as high as 97.5 percent. However, experts still debate treatment for the frontal sinuses; how to effectively deal with surgery, medical management, and surgical failures.

A new study set out to document the causes of those failures in patients who had undergone surgical treatment for sinus disorders. The authors of "Causes of Frontal Sinus Failure after Endoscopic Sinus Surgery" are John M. DelGaudio MD, and Kristen J. Otto MD, both from the Department of Otolaryngology-Head and Neck Surgery, The Emory Clinic, Atlanta, GA. Their findings at the Spring Meeting of the American Rhinologic Society being held April 30, 2004, at the JW Marriott Desert Ridge Resort & Spa, Phoenix, AZ.

Methodology: The charts and records of all patients requiring revision or repeat endoscopic frontal sinus procedures between May 1997 and October 2003 were reviewed. Patients were evaluated both by in-office endoscopic exam under topical anesthesia and non-contrast CT scan with multiplanar reformatting. Patients were offered revision endoscopic surgery based on recurrence of symptoms, endoscopic and CT findings of sinus disease, and resistance to medical therapy. Patients included in the study were those patients whose frontal sinuses were addressed during the repeat operation.

The researchers analyzed 149 cases for reoperative findings contributing to disease in the frontal sinuses. Data on sex, associated conditions, and associated disease states (i.e. Samter's triad, cystic fibrosis, allergic fungal sinusitis) were also collected and entered into a database. The second surgeries were all performed using computer image guidance under general anesthesia. Procedures performed were tailored to each patient's underlying cause for failure and included release of scarring and adhesions, opening of residual anterior ethmoid air cells, polypectomy, and takedown of neoosteogenic bone within the frontal recess. Concurrent maxillary antrostomy, ethmoidectomy, and sphenoid sinusotomy were performed when necessary.

A total of 298 frontal sinuses from 149 cases of revision endoscopic frontal sinus surgery were reviewed. With exclusions, the study group was comprised of the remaining 289 frontal sinuses requiring revision endoscopic surgery for symptoms and physical and radiologic findings of frontal sinus disease.

Results: The researchers examined 149 cases comprising 127 [127 patients) 61 (48 percent) male and 66 (52 percent) female). Twelve patients required multiple revision procedures during the study dates. The number of revision procedures within this group ranged from two to seven. Key findings were:

"¢ Seven major factors were identified as causes for frontal sinus failure after previous endoscopic sinus surgery with persistent mucosal disease, including the presence of polyps, the most common finding. Mucosal disease causing obstruction of the frontal recess was evident in 193 (67 percent) revisions of frontal sinuses.

"¢ Retained anterior ethmoid cells were also found to contribute significantly to frontal sinus failure. A total of 190 (66 percent) frontal sinuses were obstructed by retained ethmoid cells. Of these, 37 were agger nasi cells, and 153 were unnamed anterior ethmoid air cells, representing 13 percent and 53 percent of the total 289 sinuses, respectively.

"¢ Another common intraoperative finding was a middle turbinate that had become scarred laterally as a result of previous surgery, causing obstruction of the natural frontal sinus outflow tract. Lateralized middle turbinates were found in 88 (30 percent) frontal recesses.

"¢ The other factors were scar in the frontal recess in 34 (12 percent) sinuses, retained frontal cells in 23 (eight percent) sinuses and neoosteogenesis, or new, osteitic, bone formation in 19 (seven percent) sinuses.

"¢ There were 12 (four percent) frontal sinuses that were felt to have disease by preoperative evaluation, but on exploration, no pathology was found in the frontal recess, and an open frontal sinus ostium was noted.

"¢ In the group of patients requiring multiple revisions, there were three patients with allergic fungal sinusitis, one patient with Samter's triad, one patient with cystic fibrosis, one patient with Wegener's granulomatosis, one patient with sarcoidosis, and five with chronic rhinosinusitis.

Conclusions: Frontal sinus disease is present in 48-63 percent of all recurring sinus cases suggesting that frontal sinusitis is a significant factor in overall failures. A review of the patients presenting for revision frontal sinus surgery at our institution revealed seven reproducible causes for failure. Recurrent mucosal disease, retained ethmoid air cells, and lateralized middle turbinates were the most common factors, while missed frontal cells, scarring, and neoosteogenesis were also found to contribute. One of the issues not addressed in this study was the type of operation performed either initially, or at the time of revision. This information has the potential to explain which procedures may lead to certain causes for failure. While the best approach to the frontal sinus is still the subject of debate, there is no question that a comprehensive approach including aggressive medical management, meticulous technique with mucosal preservation and minimal mucosal trauma, complete removal of all diseased cells, and thorough postoperative care, can lead to improved outcomes and fewer technical failures.