NOSE AND SINUS
Dr Martin Forer
The nasal septum is a midline structure which divides the nose into two nasal cavities. The septum may deviate to one and or other side thus occluding one or both nasal passages.Septal deflection is usually related to trauma or is congenital. The main indication for surgery is nasal obstruction however it also needs correction if it impairs access to other areas during nasal surgery.
This procedure involves correction or realignment of the bone and cartilage into the midline. The mucosa of the septum is elevated via a small incision at the front of the septum. The deflected bone or cartilage is then realigned or in some cases resected .The mucosa is then sutured back onto the cartilage. Splints and packs are then used as required. This procedure is performed under general anaesthetic and is often performed as day surgery.
Septoplasty is a safe procedure and complications are uncommon. Complications include septal perforation which may result in crusting and whistling. Septal haematoma which is a collection of blood in the septum and needs drainage. Adhesions (scar tissue ) may occur which results in residual nasal blockage.
The turbinates are mucosal covered bony processes protruding into the nasal cavities. The two most important are the middle and inferior turbinates. These structures may require to be reduced in size so as to improve nasal airflow and sinus ventilation. The inferior turbinate is reduced to improve nasal airflow which is impeded by a large swollen turbinate. A large middle turbinate obstructs airflow , occludes sinus ventilation and impedes access to the middle meatus during surgery. The middle turbinate requires reduction to overcome any of these situations.
The inferior turbinates are best assessed clinically using an endoscope. The middle turbinates are also assessed with a scope but also using a CT scan of sinuses. Good information aids with obtaining optimal outcomes.
Surgery on the inferior turbinate can reduce the soft tissue and or bony component. The techniques include mucosal surface cautery, submucosal diathermy , cryotherapy, laser and the use of the microdebrider. Resection of the bone of the inferior turbinate is called submucosal resection of the turbinate.
The main complication of turbinectomy is bleeding. This can be severe when total resection is performed. Longer term problems include adhesions (scarring ) and dry nasal mucosa (atrophic rhinitis ). Fortunately these complications are rare.
This procedure is required when there has been trauma to the nose. One or both nasal bones may be fractured and need to be reduced. The fracture often results in the nose being deviated to one side or the other. Reducing the fracture usually results in the nose straightening. The fracture may displace inward or outward. The septum may also be fractured at the same time. The indication for reduction is therefor to reduce displaced nasal bones. The procedure should be done within 14 days of the fracture having occurred.
Clinical assessment is critical to exclude septal haematoma which needs urgent drainage. Xray will document the fracture however the decision on surgery is best made by clinical assessment. Sometimes surgery is needed even in the absence of an obvious fracture on Xray. Significant deformity can occur even in the absence of a fracture on Xray. The patient needs to be seen by the specialist within one week so that the procedure can be performed within the 14 day period.
The nasal bones are reduced by elevating the depressed bones and realigning the displaced bones. A plaster of paris cast is put on for about a week. If the septum is deviated due to fracture it will need formal septoplasty. Attempts at simple reduction is usually not effective.
Bleeding from the procedure - this is rare. Failure to achieve total reduction. Persistent nasal blockage Nasal collapse if a septal haematoma is left untreated and becomes a septal abscess which erodes the septal cartilage and results in saddling of the nose.
DACROCYSTORHINOSTOMY ( DCR )
This procedure is required when there is obstruction of the nasolacrimal drainage system. The obstruction results in excessive tearing and a watery eye. This is known as epiphora. The canaliculi which drain from the eye into the lacrimal sac must be functioning in order for this procedure to work. The cause of failed drainage may be due to dacrocystitis ( infection in the sac ) , a dacrolith ( duct stone ) a fungal collection or trauma to the duct or sac. Sometimes no specific cause can be found and the obstruction is known as functional.
Ophthalmology consultation - Jones test to determine patency of nasolacrimal system.
CT scan of sinuses and nasolacrimal system.
Endoscopic nasal examination.
Dacrocystogram - dye is put into the system and then an xray performed. This outlines patency as well as anatomy of the nasolacrimal system.
The procedure can be done via an endoscopic technique or an external method. The principle of both methods is removal of bone over the inner aspect of the lacrimal sac and duct. The sac is then opened and marsupialised into the nose. A stent is placed through the canaliculi into the nose and secured in place. It is left in situ for 6 weeks and removed in the office as a simple procedure. Both endoscopic and external techniques have similar results in primary cases. In cases of revision surgery the endoscopic method has superior results. The advantage of the endoscopic method is that no external incision is required and therefor no scar. Nasal problems which may cause failure of the DCR can be assessed and dealt with at the time of the surgery
EXTERNAL SINUS PROCEEDURES
The surgical management of sinus disease in today's world should be primarily by using the FUNCTIONAL ENDOSCOPIC SINUS SURGERY techniques. There are a few occasions when external methods of surgery are required. These techniques are used when endoscopic methods cannot reach the area or when endoscopic methods have failed. These methods are often used for dealing with tumors or complications of sinusitis.
1.Caldwell Luc procedure and radical antrostomy which is to enter the maxillary sinus via an incision under the lip. May result in numbness of the upper lip and dental damage.
2.External ethmoidectomy via incision on inner side of eye.
3.External fronto-ethmoidectomy which deals with frontal and ethmoid sinuses.
4.Frontal sinus trephine which makes a small hole in front wall of frontal sinus and the frontal sinus can then be irrigated therapeutically or to locate the frontal recess endoscopically. This is done via a small incision in the eyebrow.
5.Osteoplastic flap raises a large forehead skin flap from ear to ear and down to eyebrows. The front wall of the frontal sinus is removed and then replaced at the end of the procedure. Disease may be removed or the sinus obliterated.
6.Antral washout or aspiration which is for obtaining material for culture or therapeutic washout.
Simple nasal polyps are benign swellings of the nasal mucosa which may fill the nasal cavity and sinus cavities. Polyps are associated with nasal obstruction sinus obstruction and associated sinusitis. After optimal medical therapy which is failing to control nasal polyps, surgery is considered. The presence of polyps on only one side of the nose or unusual looking polyps require to be removed and sent for histological assessment. Tumors can present like this. Malignancy needs to be excluded.
Full endoscopic nasal assessment. CT scans of the sinuses. Allergy assessment.
Modern techniques of polyp removal are performed using powered instrumentation. The instrument is known as a microdebrider. This allows very extensive removal of polyps with good visualisation and reduced bleeding. The ethmoid sinuses also need to be cleared of polyps so as to lessen the recurrence of the polyps. The polyps need to be submitted for pathological assessment.
Complications are uncommon but do occur from time to time. The main complications to be aware of include bleeding damage to the eye ( double vision , reduced vision , blindness )skull base penetration resulting in csf leak or meningitis adhesions It is critical to know that there is a very high incidence of polyp recurrence after surgery. Polyps are generally a medical rather than surgical disease. Even after surgery most patients require ongoing medical treatment. This includes mainly sprays but at times systemic medication as well.
FUNCTIONAL ENDOSCOPIC SINUS SURGERY ( FESS )
This procedure is done predominantly for patients with significant sinus disease. The underlying problem in most patients with sinus disease is obstruction of the sinus drainage openings (ostia ). This results in sinusitis involving the maxillary , ethmoid ,frontal and sphenoid sinuses. When medical treatment fails to cure the problem FESS is needed. The surgery is indicated to correct anatomical anomalies , remove nasal polyps , widen sinus ostia and remove pus and fungal debris from the sinuses.
The procedure is generally done under general anaesthetic. The bony plate called the uncinate process is removed in order to expose the natural ostium of the maxillary sinus. The ostium can then be widened. Variable amounts of ethmoid cells are then uncapped depending on the extent of the disease. The recess into which the frontal sinus drains is then cleared to allow good frontal sinus drainage. The frontal sinus itself rarely needs to be operated on. The sphenoid sinus ostium can also be located and widened if required. The average time for bilateral uncomplicated FESS would be approximately one hour. CT scans are critical and no FESS should be done without a CT scan.
Bleeding at the time of surgery or later. Bleeding during the operation may impair ability to safely complete the procedure. It is better to stop if vision is inadequate due to bleeding as this may save complications occurring. Orbital penetration. This is rare but may occur. It may result in bleeding into the eye with resultant double vision ,vision deterioration and in extreme cases blindness. Penetration of the skull base with dural tear. This may result in CSF leak or meningitis. Adhesions which compromise the final result. Recurrence of disease if the underlying problem is related to the lining and not an anatomical anomaly. Surgery will not cure a mucosal disease and ongoing medical treatment will be required.