contains:
Image Guidance
Quality of Life
Fungus
Powered Instrumentation
Question: Tell me about powered instrumentation in
endoscopic sinus surgery.
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?
Question: What advantages are offered by powered instrumentation?
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?
Question: What about use of powered instrumentation for children?
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?
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.
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.
Answer:
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.
Answer:
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.
Answer:
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.
Answer:
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.
Answer:
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.
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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.
Question: Tell me about computer-assisted or
image-guided endoscopic sinus surgery.
Answer: Computer-assisted surgery was initially developed for accurate
localization during neurosurgical procedures. The application of this technique in endoscopic
sinus surgery is available in many major centers. This system allows the surgeon to localize the
tip of the surgical instrument in the paranasal sinuses, generally within 2 mm of accuracy on
coronal, axial, and sagittal CT images. Computer-assisted endoscopic sinus surgery can
potentially aid the surgeon, especially when working in or near difficult areas such as the frontal
sinuses, sphenoid sinus, skull base and orbit.
These systems are not universally available. While they are helpful in specific cases, they are
not always necessary for an experienced, skillful surgeon to perform difficult procedures. While
they do
provide potential advantage in specific situations. They are not, at this stage, associated
with decreased surgical risk.
Question: Is image guidance surgery an important advance?
Answer:
The first revolutionary change in the surgical treatment of the sinuses was the introduction and refinement of
endoscopic techniques. The second important development in the modern
history of rhinology was the introduction of powered instrumentation.
Now we are seeing a third turning point, which is the use of intraoperative
image guidance in endoscopic sinus surgery.
Question: What devices are used?
Answer:
There are a number of companies making image-guidance systems, and the basic
elements are the same in all of them. All of these devices have a tracking
system, a head set, and a computer with hardware and software that
interprets the information it receives from an instrument that is used
inside the nose that has been registered with the system.
There are two types of image guidance surgery devices: optical and electomagnetic.
- In optical devices, a direct and uninterrupted line-of-sight between the patient and the image guidance system is necessary. The headset does not need to be present when the patient has a CT scan. Registration of fiducials, or positioning points, is required when the patient is in the operating room before the image guidance system may be used.
- The electromagnetic devices require that the patient wear a headset during the CT scan, and then this headset must be used at the time of surgery. The problems with line-of-site that are present in the optical systems is not an issue in the electromagnetic systems. Also the fiducials are on the headset, so markers or registration of fiducials is not required.
Question: Any summary thoughts about new technology in sinus surgery?
Answer:
There have been a number of advances in rhinology in the 21st
century. As we celebrate these advances and use them to the benefit of
our patients, we must always remember the basic principles that
always take priority over technology: anatomic knowledge, surgical ability,
and clinical judgement.
Question: Tell me about how sinusitis affects the quality of life.
Answer: If you have sinusitis, you already know sinusitis has a NEGATIVE
impact on your quality of life. But did you know there is specific scientific proof?
To analyze quality of life, questionnaires have been developed to produce reliable Health Related Quality of Life (HRQL) data.
In an important study by Doctors Glicklick and Metson, patients with chronic sinusitis were found to have significant decreases in quality of life measures. The areas that were most affected were bodily pain, general health, vitality and social functioning. Such decrements in quality of life for chronic sinus patients were similar to those seen in other chronic diseases such as chronic obstructive pulmonary disease, congestive heart failure, and chest pain or angina pectoris.
A subsequent study by Drs. Winston and Barnet, also in patients with chronic sinusitis, found that these patients had significant decrements in multiple areas of health-related quality of life. The most affected areas were physical bodily pain, social functioning and vitality.
Drs. Gliklick and Metson reported on the effect of sinus surgery on quality of life in 1997. In this study, 82% of patients who underwent surgery for chronic sinusitis demonstrated statistically significant clinical improvement in their sinusitis-specific measures of life quality. Patients who underwent surgery for chronic sinusitis demonstrated significant improvement in 6 of the 8 sub-scales of general health one year after surgery.
Question: Everyone is talking about the paper from
the MAYO clinic. What is it all about?
Answer: The article published in the MAYO proceedings of September
1999 reported that using specialized techniques, fungal growth was found in 96% of patients
with chronic sinusitis. Fungal growth was found in 100% of normal healthy volunteers,
people without sinusitis.
Why is this interesting? Well, the researchers have found evidence that the sinus patients appear to have an abnormal inflammatory reaction to the fungus, while normal subjects do not. These researchers speculate that treating fungus in these patients may improve their symptoms.
The discovery that fungus is present in healthy people and in patients with chronic sinusitis was a surprise. The apparent difference in the way these two groups react to fungus provides some hope for new treatments.
There is no published evidence that anti-fungal therapy routinely relieves sinus symptoms. Anecdotal reports do suggest that selected patients show improvement.
Question: What is itraconazole?
Answer:
Itraconazole, or Sporonox, is a medication that is used by doctors to treat fungal infection. When
doctors suspect fungal cause of sinusitis, they may discuss treatment with a course of
Sporonox. The doctor will then order blood tests to check your liver function before treatment,
and then several weeks into treatment, to be sure that it is not adversely affecting your liver. If it is,
you may have to discontinue this therapy.
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