Centripetal endoscopic sinus surgery in chronic rhinosinusitis: A 6-year experience Guillermo Sanjuan de Moreta, M.D., Isabel Cardoso-Lo´pez, M.D., and Daniel Poletti-Serafini, M.D.

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ABSTRACT

Background: Despite technical advances in the tools designed to facilitate endoscopic nasosinusal surgery, the approach used, functional endoscopic sinus surgery, has not undergone major modifications since it was first described in the late 1980s. Centripetal endoscopic sinus surgery (CESS) is a new approach based on taking the medial wall of the orbit and the anterior cranial base as constant dissection landmarks. The aim of this study was to evaluate the long-term outcome of CESS in chronic rhinosinusitis (CRS) by measuring clinical and objective improvement, the need for revision surgery, and the complication rate. Methods: We reviewed 114 patients with CRS with or without polyps who underwent CESS at our center between May 2006 and December 2011. CRS was assessed using the Lund-Mackay staging system. The follow-up period ranged from 18 to 84 months (May 2013). Results: Of 114 patients, 83 presented CRS with nasal polyposis, 12 had CRS without nasal polyposis, 17 had Samter’s triad, and 2 had antrochoanal polyps. Postoperative evaluation of nasal obstruction and olfaction showed a significant and lasting improvement in these symptoms. Only four patients (3.5%) have required revision surgery, to date. Conclusion: CESS provided a lasting improvement in patients with CRS, by dramatically reducing the number of reinterventions. This approach is especially indicated in difficult cases, such as recurrent nasal polyposis and massive polyposis, because the dissection is based on constant borders and not influenced by previous surgery or disease extension. (Am J Rhinol Allergy 28, 349 –352, 2014; doi: 10.2500/ajra.2014.28.4062)

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hronic rhinosinusitis (CRS) with or without polyposis is a benign disease of the nasal epithelium that affects 1% to 4% of the general population.1,2 Nasosinusal endoscopic surgery has proven to be an excellent tool for improving perception of nasal patency and disease control. Conventional endoscopic sinus surgery, which was described and developed in the mid-1980s by Kennedy3 and Stammberger4 and is used worldwide, is very successful. In the present article, we ask whether the conventional approach can be improved on. Further development of current techniques can ensure long-term improvement in symptoms and a reduction in the number of interventions that patients undergo. In the mid-1980s, Felippu5 developed a new approach for ethmoidectomy, starting with a vertical incision in the lateral wall of the nasal cavity anterior to the uncinate process to identify the lamina papyracea and proceeding to the dissection of the medial wall of the orbit in a posterosuperior direction toward the ethmoid roof. Identification of the frontal sinus makes it possible to situate the anterior ethmoidal artery (immediately posterior and inferior to the frontal sinus), which we can use as a reference (Figs. 1–3). The medial limit of our dissection is the vertical insertion of the middle turbinate to the lateral edge of the cribriform plate. The dissection continues posteriorly along the floor of the anterior cranial fossa (frontal bone), thus displacing the polyp into the middle turbinate, until we reach the anterior wall of the sphenoid sinus, which is opened in such a way as to protect the critical structures behind its lateral and posterior walls. Only when the dissection is complete and all the paranasal sinuses are wide open can we remove the polyp. Because we system-

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From the Department of Otolaryngology, Hospital General Universitario Gregorio Maran˜o´n, Madrid, Spain Pressented at “Chirurgia Endoscopica Nasosinusale Centripeta Nella Rinosinusite Cronica Un’alternativa Alla Fess: 6 Anni Di Sperienza,” 100° Congresso Nazionale della Societa` Italiana di Otorinolaringoiatria e Chirurgia Cervico-Facciale, Rome, Italy, May 28 –31, 2013 The authors have no conflicts of interest to declare pertaining to this article Address correspondence to Guillermo Sanjuan, M.D., Department of Otolaryngology, Hospital General Universitario Gregorio Maran˜o´n, Calle Doctor Esquerdo, 46, Madrid 28007, Spain E-mail address: [email protected] Published online May 28, 2014 Copyright © 2014, OceanSide Publications, Inc., U.S.A.

atically remove middle turbinate attachments to the agger nasi cell and the orbit (ground lamella), it is highly recommended to perform partial resection of the middle turbinate to prevent closure of the osteomeatal complex by a flaccid turbinate. In other words, because functional endoscopic sinus surgery (FESS) is based on an inferior and medial approach in a centrifugal resection of the ethmoidal cells and the polyp inside, centripetal endoscopic sinus surgery (CESS), as described by Felippu,5 is based on centripetal dissection after the edges of the ethmoidal bone, en bloc resection of the polyp, and partial resection of the middle turbinate. The aim of this study was to evaluate the outcome of CESS after a long-term follow-up period by measuring clinical and patient-reported improvement and comparing revision surgery rates with those reported in the literature.

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MATERIALS AND METHODS We retrospectively reviewed the cases of 114 patients with CRS who underwent CESS performed at our center between May 2006 and December 2011. All patients gave their signed informed consent for the surgical procedure and for the retrospective review of the data. The criteria for inclusion in the study were age ⱖ18 years, CRS with or without polyps, availability of clinical reports, and failed medical treatment. Patients had to have undergone a presurgical computed tomography scan and complete ethmoidectomy by CESS. In addition, informed consent had to be provided and at least 18 months of follow-up completed. Patients who failed to meet any of the inclusion criteria or refused to provide consent were excluded. To assess disease severity, patients were asked to assess the level of nasal obstruction using a visual analog scale (VAS), which was scored from 0 to 10. Subjective perception of olfaction was also scored from 0 to 10, considering 0 as complete anosmia and 10 as normal olfaction. These data were recorded before surgery and at each follow-up visit to determine the outcome of surgery. All patients underwent preoperative computed tomography scans of the sinuses. Disease was staged according to the Lund-Mackay score.6 No postoperative computed tomography scans were acquired, except in the case of patients who required revision surgery. All patients underwent endoscopic monitoring and cleaning every 15 days during the 1st month after surgery and once per month at months 3, 6, and 12 after surgery. Endoscopic monitoring was annual from the end of the 1st year after surgery onward.

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Figure 1. Once the uncinate process has been dissected, the ethmoidal bulla is visible. The arrows indicate the line of dissection on the orbital wall.

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Figure 3. Complete dissection of the medial orbital wall and the floor of the anterior fossa. The posterior wall of the sphenoid sinus and the major anatomical structures are visible (center back of image). AEA, anterior ethmoidal artery; PEA, posterior ethmoidal artery; ON, optic nerve; GL, ground lamella; ICA, internal carotid artery.25

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Table 1 Main symptoms

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Figure 2. The white arrows indicate the line of dissection on the medial orbital wall. The immediately underlying structure (after the ethmoid bulla) is the ground lamella. EB indicates ethmoid bulla.

Patients were advised to perform nasal irrigation with saline solution at least three times a day for the 1st month after surgery to prevent the formation of crusts. They were also advised to use inhaled corticosteroids at standard doses indefinitely to control the development of new inflammatory signs and to improve clinical outcome, as described by Rowe-Jones et al.7 (level of evidence, Ib). All patients were given oral corticosteroids during the 1st month after surgery (deflazacort, 30 mg/day for 15 days and 15 mg/day for the following 15 days). Patients with mucosal hyperactivity with polyps blocking the ostium after 3–6 months were given oral corticosteroids for 1 month (30 mg/day for 15 days and 15 mg/day for the following 15 days). The data collected included demographic data, presence of asthma, allergies, smoking habits, main symptoms, extent of surgery, history of previous surgery, disease stage, clinical outcome, recurrence, need for revision surgery, and complications. Data were entered into a standard spreadsheet program (Microsoft Excel; Microsoft Corp., Redmond, WA).

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No. of Patients (%)

Nasal obstruction Hyposmia/anosmia Headache/facial pain Rhinorrhea

112 (96) 74 (65) 48 (42) 63 (55)

We conducted a literature search in PubMed (2003–2013) to determine revision surgery rates during FESS using the following MeSH terms (CRS, recurrent nasal polyposis, endoscopic sinus surgery, and long-term results).

RESULTS We report data for 114 patients (80 men and 34 women) with CRS who underwent CESS. The mean age was 49.8 years (range, 21–77 years). Of the 114 patients in the sample, 83 presented CRS with nasal polyposis, 12 had CRS without nasal polyposis, 17 had Samter’s triad, and 2 had antrochoanal polyps with ethmoidal involvement. Table 1 shows the main symptoms recorded. All patients underwent complete ethmoidectomy by CESS. Nearly all of the procedures were bilateral (four were unilateral). Septoplasty or inferior turbinoplasty was performed when necessary. Nineteen patients had undergone previous sinus surgery by conventional FESS (16 patients), Caldwell-Luc approach (2 patients), and external frontoplasty (1 patient). The average number of previous interventions was 1.7 (range, 1–7). The mean time from previous surgery to CESS was 31.2 months. As for disease stage, 56% of patients had a Lund-Mackay score of ⬎15, and 24% had a Lund-Mackay score of ⬎20. Follow-up ranged from 18 to 84 months, with a mean follow-up of 51.8 months: ⬎36 months in 84 cases (74%), ⬎48 months in 57 cases (50%), and ⬎60 months in 32 cases (28%). Figure 4 presents the subjective perception of symptoms according to the VAS score for nasal obstruction:

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Table 2 General medical history in our series No. of Patients (%) Samter’s syndrome Asthma Environmental allergies Smoking

17 (14.9) 32 (28.0) 32 (28.0) 55 (48.2)

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Figure 4. Subjective perception of preoperative nasal obstruction according to the VAS score. VAS, visual analog scale.

The mean time from the first centripetal approach to revision surgery was 38.5 months. Only one patient underwent revision surgery before 36 months of follow-up. If we focus only on patients with CRS and massive polyposis (Lund-Mackay score ⬎15), the revision surgery rate was 4.7%. Minor complications were recorded in 11 patients as follows: orbital emphysema in 2 patients; nasal bleeding stopped with nasal packing in 2 patients, and uncomplicated leak of cerebrospinal fluid, which was observed and repaired intraoperatively without sequelae, in 7 patients. Major complications were recorded in three patients, as follows: orbital hematoma that required endoscopic orbital decompression in one patient and nasal bleeding due to sphenopalatine pedicle injury that required endoscopic coagulation in two patients. No sequelae were detected in these patients. The Lund-Mackay score was ⬎15 in all three patients. Almost all complications occurred within the first 2 years of training in the centripetal technique.

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DISCUSSION

Figure 5. Subjective perception of postoperative nasal obstruction according to the VAS score after 36 months of follow-up. VAS, visual analog scale.

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Preoperative nasal obstruction—of the 114 patients, 102 (87.7%) had a VAS score of ⬎5. The most repeated value (mode) was 8 points of nasal breathing difficulty. Nasal obstruction beyond 36 months of follow-up—all of 84 patients (100%) had a VAS score of ⱕ5, and 91% had a score of ⱕ3 (mode, 0; Fig. 5).

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Nasal obstruction after at least 60 months of follow-up—all patients (100%) had a VAS score of ⱕ5. The score was ⱖ3 (mode, 0) in 26 of 32 patients (81%).

As for preoperative olfaction, 93 of 114 patients (81.5%) had a high level of hyposmia (range, 0–5 points), and 54 (47%) had complete anosmia. The postoperative olfaction questionnaire administered at least 36 months after surgery showed that the previous level of olfaction was maintained in 19% of patients, decreased in 13% of patients (mean loss of 3.4 points), and increased in 68% of patients (mean improvement of 5.3 points). If we take into account only those patients who had undergone CESS before FESS, 12 of 19 reported an improvement in olfaction; only 1 patient reported a loss of olfaction, with a mean improvement of 3.3 points in the VAS score. In most cases, the objective signs of CRS were observed to have resolved at the regular endoscopic follow-up visits. Fewer than 15% required oral corticosteroids to control mucosal hyperactivity, with a mean time of 45 months since the surgical procedure. During followup, none of those patients required more than two cycles of salvage therapy with systemic corticosteroids. To date, only four patients (3.5% (CI, 0.96–8.74%)) have required revision surgery. All four patients had a Lund-Mackay score of ⱖ15, and three had Samter’s syndrome.

The association between CRS and asthma, allergy, and aspirin intolerance reflected in our series (Table 2) has been well described elsewhere.8 A direct relationship has been established between increased severity of polyposis and the rate of recurrence.9–12 In developed countries, CRS is a highly prevalent disease that generates a significant cost burden through absenteeism.13 Consequently, strategies to control the disease in the long term are necessary. In our study, CESS led to a significant and lasting improvement in the main symptoms and signs of CRS with or without polyps. Hopkins et al.14 reported on ⬎3000 patients with CRS who underwent endoscopic sinus surgery. The revision rate was 3.6% after 12 months of follow-up and 11.8% after 36 months. We report rates of 0 and 3.5% after 12 and 36 months of follow-up. The global revision rate was summarized in the 2007 European Position Paper on Rhinosinusitis and Nasal Polyps,15 which reported ⬎10% after a minimum postoperative period of 36 months. Four patients in our study (3.5%) required revision surgery. All four had a Lund-Mackay score of ⱖ15, which is considered to indicate severe diffuse polyposis16; three of the four patients had Samter’s syndrome. The risk of recurrence is closely related to the extent of involvement, but it is not well documented. Wynn and Har-El16 studied 118 patients (Lund-Mackay score, ⬎15) who underwent conventional sinus surgery. Of these, 27% underwent revision surgery, with a median time to recurrence of 12 months. In our series, we report 63 patients (Lund-Mackay score, ⬎15), of whom 4.7% underwent revision surgery, with a median time to recurrence of 39.5 months. Partial resection of the middle turbinate is well documented. Some authors consider the procedure a means of reducing the revision rate.17 In a randomized trial (n ⫽ 1106), Havas and Lowinger18 showed that partial resection of the middle turbinate was associated with reduced frequency of synechia and fewer revision procedures (level of evidence, Ib). The disadvantage of resection of the middle turbinate is that it removes an important landmark that may be needed in revision surgery.19 In CESS, the orbit and the floor of the anterior cranial fossa (frontal bone) are used as landmarks. Both anatomic structures are easily identified, even in patients undergoing revision surgery.

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Long-term follow-up did not reveal a significant reduction in subjective olfaction after partial resection of the middle turbinate. In fact, 85% of our patients preserved or improved their sense of smell: the mean improvement was 3.15 of 10 points, which is comparable with that reported by Briner et al.,20 who reported a mean improvement in olfaction of 30.1 of 100 points 5 years after surgery. This improvement was also reported in patients who underwent revision endoscopic sinus surgery.21 Although olfactometry is considered the gold standard for evaluating olfactory symptoms, we think that a subjective assessment is mandatory in CRS, because subjective perception of smell and nasal obstruction are the most important criteria for performing surgery. Despite the high number of studies on CRS in the literature, few focus on the complications of endoscopic sinus surgery. The 2007 European Position Paper on Rhinosinusitis and Nasal Polyps15 reported a global rate of 4% for minor complications and ⬍1% for major complications. In revision surgery, the rates of major complications could rise to 7%.22,23 We observed a rate of 2% for major complications, even taking 19 cases of revision surgery into account. The minor complication rates reported in the literature are much lower than those we report, although every case in our series was resolved intraoperatively without sequelae and only required 24–48 extra hours of hospitalization. Our study is limited by its retrospective design, which may have led us to underestimate the number of minor complications. In our opinion, the general trend is to disregard complications that are resolved with no need for further action. However, Asaka et al.24 reported a direct relationship between the polyp score and the complication rate. In addition, omission of the stage of polyposis in most studies hampers evaluation and management of the polyp and comparison of the outcome of surgery. Our study reveals an increased rate of minor complications that may be related to the learning curve of the surgeon. This rate can be reduced by means of careful training based on cadaveric dissection. Furthermore, exposure of anatomic structures during CESS means that iatrogenic injury, which could go unnoticed with classic techniques, is clearly visualized. Damage can therefore be repaired without delay and major complications avoided.

CONCLUSIONS

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CESS seems to be successful not only in terms of clinical improvement, but also in terms of duration of the improvement. It considerably reduces the number of revision procedures and, thus, of the likelihood of surgical or anesthetic complications. The surgical complication rate seems to be closely correlated with disease extension. In fact, CESS is especially indicated for surgeons handling difficult cases, because dissection is based on constant borders that are affected neither by previous surgery nor disease extension.

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Centripetal endoscopic sinus surgery in chronic rhinosinusitis: a 6-year experience.

Despite technical advances in the tools designed to facilitate endoscopic nasosinusal surgery, the approach used, functional endoscopic sinus surgery,...
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