Question: Tell me about powered instrumentation in
endoscopic sinus surgery.
Answer: 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
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
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
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.