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.'

PubMed link

AAAAI Urges Seasonal Allergy Sufferers to Consider Immunotherapy

from An AAAAI News Release
'For seasonal allergy sufferers, the cold winter weather brings much needed relief from watery eyes and runny noses. But with the peak allergy season around the corner, few allergy sufferers find time to relax. Rather than dreading the months ahead, a technique called immunotherapy, or allergy shots, may rid their suffering once and for all.'

Rhinitis news

FDA MedWatch: ZyPREXA (olanzapine) and ZYRTEC (cetirizine HCI)
PharmaLive.com (press release) - Newtown,PA,USA. Eli Lilly and Company has received reports of medication dispensing or prescribing errors between our atypical antipsychotic ZyPREXA (olanzapine) and the antihistamine ZYRTEC (cetirizine HCI) marketed by Pfizer. These reports include instances where Zyprexa was incorrectly dispensed for Zyrtec and vice versa, leading to various adverse events in some instances. These errors could result in unnecessary adverse events or potential relapse in patients suffering from schizophrenia or bipolar disorder.

MOLD Allergies
allergies.about.com - USA
Molds may be a major contributor to seasonal and perennial allergic rhinitis, as well as other health problems. Although thousands of molds exist, only a few dozen different types are significant allergens. Mold spores can easily become airborne and can be found almost anywhere. Because they are so small, mold spores may invade the protective mechanisms of the nose and upper respiratory tract.

Chronic Sinusitis Breakthrough

Two 1999 scientific breakthroughs may lead to long-term relief for allergy and chronic sinusitis sufferers.

The most startling announcement was published in the 1999 Mayo Clinic Proceedings. Researchers found that chronic sinusitis, a condition that affects about 37 million people in the United States, is apparently caused by an immune response to fungus.

Up until then the cause of chronic sinusitis was unknown, but it was suspected to be an allergic response. This research indicates that the condition is not caused by an allergic reaction, but by an immune reaction.

Full article at Allergies.About.Com

Anti-Fungus Drug Useful for Sinus Problem

NEW YORK (Reuters Health) - Treatment with a nasal spray containing the anti-fungal drug amphotericin B reduces the swelling and inflammation that occurs with chronic rhinosinusitis, a common cause of stuffy nose and facial pain, new research shows.

Amphotericin B is an old drug that can cause serious side effects, particularly to the kidneys. However, when given as a nasal spray, the drug does not get absorbed, effectively avoiding these effects, researchers report in the Journal of Allergy and Clinical Immunology.

Rhinosinusitis - Review of January 2005

by Y.Y.Yap, MD

Our understanding of rhinosinusitis and how we can best treat this ambiguous condition is in rapid evolution.

Fungal etiology for RSS
First off we have Gosepath J and Mann WJ. take a closer look at the role of fungi role in initiating and maintaining CRSS. While fungi are ubiquitously present in ALL, an immunologic sensitization in RSS patients is evidenced by specific cytokine production in blood-derived lymphocytes not found in controls. Sasama J, et.al also supports this theory showing from literature that eosinophilic inflammation in the nasal mucosa seems to be a specific reaction to certain molds in the nasal and paranasal cavities. Hence the shift from a bacteria-driven etiology to a fungal based one for RSS. It's implications for research and treatment is pressing and is reviewed in these articles. As though to dispel all doubt, Ponikau JU, et.al boldy instituted a clinical trial and showed that intranasal amphotericin B reduces inflammatory mucosal thickening on both CT scan and nasal endoscopy and decreases the levels of intranasal markers for eosinophilic inflammation in patients with CRS.

Recurrent Rhinosinusitis - something different?
Bhattacharyya N, Lee KH. try to distinguish Chronic Recurrent (CRRSS) from Chronic Persistent Rhinosinusitis (CPRSS) by looking at a distinct group of patients who have symptom free periods between at least 4 episodes of RSS symptoms a year. Interestingly the chronic recurrents (CRRSS) seem to suffer more, require more antibiotics and miss work more than the chronic persistents.

FESS for children?
Lieser JD, Derkay CS review the role of FESS in children. Present consensus for FESS in children are 'when maximal medical therapy, adenoidectomy, and culture-directed systemic antibiotics have all failed with persistence of sinonasal disease, when anatomic abnormalities predispose to chronic rhinosinusitis by obstructing normal sinonasal drainage pathways, in sinonasal polyposis to facilitate application of topical steroids', among others. The debate for the best timing for surgery and the fine balance between interfering with facial growth vs. quality of life continues.

No limits!
The greats have spoken! Cohen NA and Kennedy DW. have come forward to defend a larger role for the endoscopic surgeon, stating: 'Endoscopic sinus surgery is no longer exclusively for the management of chronic rhinosinusitis and nasal polyposis. Sinonasal malignancies, as well as anterior skull base lesions have become part of the rhinologist's responsibility. Furthermore, selective lesions managed through traditional craniotomies may now be accessed via trans-sinonasal transcranial endoscopic routes.' They attribute this increased scope, safety and efficacy to advancements in imaging technology including image acquisition, three-dimensional reconstruction, stereotactic navigation, and CT-MRI fusion.

Rapid steps forward are being made on the basic science, pharmacotherapeutics and surgical fronts in rhinology. The future is bright!