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Powered Instrumentation in Sinus Treatment

Question: Tell me about powered instrumentation in endoscopic sinus surgery.
Powered instrumentation, also known as microdebriders or soft tissue shavers, represent a relatively recent advance in endoscopic sinus surgery. The powered instruments have a clear role for fine soft tissue work in sinus surgery.

The use of powered instrumentation has become almost standard in sinus surgery because they offer the endoscopic surgeon the opportunity for greater technical precision. The powered instrument consists of the power source and a handpiece with a disposable shaving cannula. Each shaving cannula has a blunt tip and a side opening near the tip. The shaver sucks soft tissue into the lateral opening and subsequently cuts or "shaves" it with a rotating or oscillating inner blade. Because the blade is guarded, the instrument provides excellent control for precise resection of soft tissue without damaging surrounding tissues.

Newer blades enable surgeons to resect both soft tissue and bone. Built-in suction continuously removes blood, secretions and debris and maintains a clear surgical field. Newer modifications of the shaving cannulas enable a combination of soft tissue and thin bone resection known as micro-excision. Furthermore, the cannulas have become available in a variety of pre-bent angles and bendable types for work in difficult areas such as the frontal recess or the maxillary sinus. The powered instruments offer the potential advantages of less trauma, decreased bleeding, shorter surgical time, greater comfort, improved recovery and more rapid healing.

The most dramatic advantage of powered instrumentation has been seen in nasal polyps. Traditionally nasal polyp surgery was performed with manual instruments that work by avulsion of the polyps. This caused tearing of the tissues which often included adjacent normal mucosa. As a result, the field was often obscured by blood, thereby increasing the potential to damage important structures. For these reasons, it was not uncommon for the surgeon to abort the procedure before all the polyps had been removed. These patients also almost invariably required nasal packing for at least 24 hours.

The soft tissue shaver helps make this procedure routine. The shaver allows for excellent visualization of the anatomy while the polyps are precisely and quickly removed. The continuous suction allows relatively uninterrupted dissection in a clear field. Packing is usually not required. Overall, a more complete removal is possible with less bleeding and greater comfort.

Question: How did this technology develop?
The first revolutionary change in the modern history of sinus surgery was the introduction and refinement of endoscopic techniques. The second important development in the modern history of rhinology was the introduction of powered instrumentation. The first powered instrument (microdebrider, or soft tissue shaver) was designed and patented by an Otolaryngologist, Dr. J.C. Urban, in 1969, for use in microscopic ear surgery. Powered instruments became very useful in orthopedic arthroscopic surgery in the 1970s, but were not used in Otolaryngology-Head & Neck Surgery until the 1990s -- after the introduction of endoscopic techniques made the use of powered instrumentation more practical.

Question: What advantages are offered by powered instrumentation?
The precision of powered istruments has led to a re-emphasis on a minimally invasive approach. FESS is a physiologic operation and not an exenterative operation. The goal is not to perform a total ethmoidectomy in all cases, for instance, but instead to open irreversibly diseased areas and allow the reversible disease to recover normal function. Now that the instrumentation allows us to more easily perform functional surgery, we are seeing a renewed emphasis on this approach. This translates into quicker recovery.

Clearly though, manual through-cutting instruments remain an extremely useful part of the surgeon's armamentarium. The powered instruments are, after all, nothing more than a useful surgical tool. Ultimately, the surgical result relies on surgeons' knowledge of anatomy, experience and judgment, and surgical ability.

Question: What are some other uses of powered instruments in nasal and sinus surgery?
Powered instrumentation has found many uses in rhinologic surgery. In addition to endoscopic surgery in adults, it has proven useful in pediatric FESS. Also, it has been described as useful in adenoidectomy, choanal atresia, sphenoidotomy, complex frontal sinus surgery, and other applications.

Question: What about use of powered instrumentation for children?
Powered instrumentation has been widely described for rhinologic surgery in children. The small confines of the pediatric nasal cavity make this precise instrumentation, with combined suction and cutting action, particularly useful.

Powered instrumentation has been described as useful not only in pediatric endoscopic sinus surgery, but more specifically in pediatric sphenoidotomy. Also, some surgeons have described its utility in endoscopic adenoidectomy.

The bone-cutting suction drills have been useful for treatment of choanal atresia. Many cases that would otherwise have been done through an open or transpalatal approach can now be done endoscopically.

Qustion: What about application to the frontal sinuses?
Most frontal sinus problems can be addressed with conservative, minimally invasive approaches. When conservative measures have failed, bone-cutting suction drills have provided utility in frontal sinus drillout (modified Lothrop procedure), also known as Draf I, II, and III procedures.

Beginning in the early 1990s, there has been a re-focus on the treatment of frontal sinus problems using an endoscopic approach. At the University of Virginia in Charlottesville, Dr. Charles W. Gross -- along with a team of doctors including Dr. Becker -- was frustrated by the current approaches, and found endoscopic approaches to be unsuccessful in certain cases. In these difficult revision cases, osteoplastic frontal sinus procedures with frontal obliteration were often required. Drs. Gross and Becker presented a report to the American Academy of Otolaryngology National Meeting during which they speculated at that time on the use of a frontal sinus drill. Subsequent research that they performed demonstrated the utility of a modified Lothrop procedure for achieving opening of the frontal recess when more conservative endoscopic measures have failed.

Frontal Sinus Before

Frontal Sinus After

And of course, other surgeons around the world were also performing important research in this area. They included Dr. Wolfgang Draf, Dr. Wigand, and Dr. Mark May, and also Dr. Lanny Close and his colleagues.

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