Combined Approach to Paranasal Sinuses

Summary of article: Combined anterior-to-posterior and posterior-to-anterior approach to paranasal sinus surgery: an update. Schaefer SD, Li JC, Chan EK, Wu ZB, Branovan DI.Laryngoscope. 2006 Apr;116(4):509-13

This article first reviews the historical development of FESS, from Wigand's postero-anterior approach (expose posterior ethmoids, open face of spehnoid, and retrograde ethmoidectomy) to the antero-posterior approach of Messerklinger & Stammberger (anterior ethmoidectomy followed by antegrade dissection posteriorly, extent determined by disease.) Kennedy's FESS is built on these antecedent techniques with the aim of 'reestablishing sinus drainage & mucosal recovery through restoration of obstructing sinus ostium and removal of devitalised mucous membrane or bone.'

The obvious advantage and disadvantage of the P-A approach is that
1. it avoids the skull base
2. surgery is excessive in cases of limited disease

As for the A-P approach:
1. surgery is selective and limited to pathologic sinus
2. there is potential for penetrating the posterio-inferiorly sloping skull base

The author's (Schaeffer) CAPS (combined approach to paranasal sinuses) is introduced and discussed. It is claimed that CAPS aims to 'bring together the salient features of the AP and PA approaches while observing the concept of functional endoscopic sinus surgery' and is therefore a 'minimally invasive surgery.. seeking the least disruption of form and function of the paranasal sinuses'

Key tenets of the combined approach are :
1. It is a 'disease-and-anatomy-oriented surgical approach'
2. It's goal is to 'conserve sinus anatomy'
3. Surgical principles utilizes 'anatomic relationships'

(It is disease-oriented in that surgery is targeted to 'relieve medically irreversibly obstruction of sinus outflow tracts' and it is anatomy-oriented in that anterior and posterior ethmoid sinuses are approached separately, in view that they are 'embryologically distinct structures... separated by the basal lamella of the middle turbinate.')

The key surgical principles include:
1. Complete uncinectomy necessary for anterior ethmoidectomy and prevent recurrence
2. Identification of MSO necessary to find plane of lamina papyracea
3. Anterograde (AP) dissection of anterior ethmoid cells up to basal lamella, retrograde (PA) dissection of posterior ethmoid cells

The authors' experience indicates that CAPS can be performed under local or general anesthesia, as permitted or tolerated. In this review of 2,344 patients, 'the overall complication rate was 3.4%. The minor complication rate was 2.6% (6 of 2,344 patients), and the major complication rate was 0.8% (2 of 2,344 patients).' Evidence that underscores how this 'hybrid technique' succesfully combines 'the conservation goals of the AP approach and anatomic virtues of the PA approach to ethmoidectomy.'

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