ORIGINAL ARTICLE

Causes of failure in endoscopic frontal sinus surgery in chronic rhinosinusitis patients Constanza J. Valdes, MD1 , Mariana Bogado, MD1 and Mark Samaha, MD, MSc, FRCSC2

Background: The frontal sinus is the most challenging area to address in endoscopic sinus surgery (ESS). Incomplete surgery or iatrogenic injury in the narrow space of the frontal recess with synechia formation can lead to recurrence or persistence of disease. The goal of this study was to identify causes of failure of endoscopic frontal sinus surgery and to determine complication rates. Methods: A cross-sectional retrospective study was conducted. Charts and preoperative sinus computed tomography (CT) scans of patients who underwent revision frontal ESS for chronic frontal rhinosinusitis, between 2006 and 2012 were reviewed.

trophic mucosa (92.7%); retained agger nasi cell (73.4%); neo-osteogenesis within the frontal recess (45.9%); lateral scarring of the middle turbinate (47.7%); residual anterior ethmoid air cell (32.1.%); and residual frontal cells (24.8%). Conclusion: With the exception of mucosal disease and neo-osteogenesis, all identified causes of failure of frontal sinus surgery are a result of surgical technique. Careful preoperative planning and meticulous and complete surgical execution are therefore critical for a successful surgiC 2014 ARScal outcome in primary frontal sinus surgery.  AAOA, LLC.

Key Words: Results: Of 829 patients who underwent ESS during the study period, 740 had the frontal recess dissected and frontal sinus opened. Of these, 66 patients had revision surgery of the frontal sinus, with a total of 109 frontal sinuses. The mean ± standard deviation (SD) age was 52 ± 12.9 years. Forty patients were male (59.1%). The most common findings were the following: edematous or hyper-

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hronic rhinosinusitis (CRS) has an estimated prevalence of 5% in the Canadian population and greatly influences quality of life.1 Endoscopic sinus surgery (ESS) has been demonstrated to improve symptom scores and quality of life2, 3 with success rates for primary ESS as high as 97.5%.4, 5 However, patients commonly have persistent disease despite surgical treatment, with as many as 10% requiring revision surgery within 3 years.6

1 Department

of Otolaryngology—Head and Neck Surgery, Hospital del Salvador, Universidad de Chile, Santiago, Chile; 2 Department of Otolaryngology—Head and Neck Surgery, McGill University, Montreal, Quebec, Canada

Correspondence to: Mark Samaha, MD, MSc, FRCSC, Royal Victoria Hospital, 687 Ave. Des Pins Ouest, Rm E4.41. Montreal, QC. H3A 1A1, Canada; e-mail: [email protected] Potential conflict of interest: None provided. Received: 11 August 2013; Revised: 31 December 2013; Accepted: 21 January 2014 DOI: 10.1002/alr.21307 View this article online at wileyonlinelibrary.com.

frontal sinus surgery; endoscopic sinus surgery; revision surgery; recalcitrant frontal sinusitis; chronic rhinosinusitis How to Cite this Article: Valdes CJ, Bogado M, Samaha M. Causes of failure in endoscopic frontal sinus surgery in chronic rhinosinusitis patients. Int Forum Allergy Rhinol. 2014;4:502–506.

The frontal sinus deserves particular consideration owing to the technical challenge of its surgical treatment and the nature of its anatomical drainage pathways: the narrow frontal recess. Although the incidence of recurrent or persistent frontal sinusitis following ESS is not exactly known, it is suspected to be higher than other sinuses. Published reports over the last decade quote a 2% to 11% rate of persistent symptoms attributable to frontal sinusitis following ESS.7–10 This challenge is compounded by a decreased success rate of revision ESS of 69.8%11 compared to primary surgery. Persistent or recurrent disease in the frontal sinus may be due to incomplete surgery, recurrent disease following a successful procedure, or iatrogenic injury. In the case of incomplete surgery or recurrent mucosal disease, the inflammatory process leading to mucosal edema or hypertrophy causes obstruction of the frontal recess. Obstruction can also be caused by iatrogenic injury or inflammatory disease causing stenosis of the natural ostium or synechiae in the frontal recess.12 Few studies have investigated the causes

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TABLE 1. Harvard computed tomography staging system

TABLE 2. Demographics for patients who underwent

for chronic rhinosinusitis

endoscopic revision frontal sinus surgery*

Stage

Description

Characteristics

0

Less than 2 mm of mucosa thickening on any sinus wall

Age (years), mean

I

Unilateral disease or anatomical abnormality

Gender

II

Bilateral ethmoid and/or maxillary sinus disease

Male

27 (40.9)

III

Bilateral disease with sphenoid and/or frontal sinus involvement

Female

39 (59.1)

IV

Pansinus disease

of recurrence or persistence of frontal sinusitis symptoms following surgical treatment.13 The purpose of this study was to elucidate the causes of failure of primary endoscopic frontal sinus surgery and determine the rate of intraoperative complications of revision surgery by evaluating the findings in the frontal recess in revision frontal sinus surgery cases.

Patients and methods A cross-sectional retrospective study was performed after obtaining Institutional Review Board approval from McGill University. The study population consisted of patients who underwent revision frontal ESS for chronic frontal rhinosinusitis, operated by the senior author (M.S.), at the McGill University Health Center between 2006 and 2012. Patients included were patients that failed maximal medical treatment (culture-directed antibiotics for 21 days, 3 weeks of a prednisone taper, saline irrigations, and topical corticosteroids). After treatment patients were evaluated according to their symptoms. No second computed tomography (CT) scan was performed following medical therapy. If symptoms attributable to frontal sinusitis persisted in patients whose initial CT showed pathology in the frontal sinus or recess, the recess was addressed surgically. Charts (clinic notes and operative reports) and preoperative CT scans were reviewed. Clinical data collected included patient demographics: sex, age, preoperative diagnosis, and associated conditions (ie, Samter’s triad, cystic fibrosis, allergic fungal sinusitis). Preoperative CT scans were reviewed to evaluate Harvard CT staging system (Table 1),14 presence of residual agger nasi cells, residual frontal cells, edematous soft tissue in the frontal sinus or frontal recess, neo-osteogenesis within the frontal recess, and lateral scarring of the middle turbinate. All operative reports were dictated by the senior surgeon (M.S.). These were reviewed for the surgical approach, presence of synechiae, and intraoperative complications, such as cerebrospinal fluid (CSF) leak or breach of the lamina papyracea. Patients with masses or tumors, such as antrochoanal polyps, inverting papilloma, or malignant tumors were excluded. Statistical analysis was performed using SPSS 13.0 (SPSS Inc, Chicago, Illinois). Studied variables were analyzed in absolute and percentage values. Categorical variables were

503

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Diagnosis CRSwNP

56 (84.8)

CRSsNP

9 (13.6)

AFRS

1 (1.5)

Previous sinus surgeries 1

47 (71.2)

2

8 (12.1)

3

4 (6)

4

4 (6)

ࣙ5

2 (3)

Osteoplastic flap

1 (1.5)

Associated medical conditions None

50 (75.7)

Samter’s triad

7 (10.6)

Cystic fibrosis

1 (1.5)

Asthma

7 (10.6)

Churg-Strauss syndrome

1 (1.5)

*Values are n (%) unless otherwise indicated. AFRS = allergic fungal rhinosinusitis; CRSsNP = chronic rhinosinusitis without nasal polyps; CRSwNP = chronic rhinosinusitis with nasal polyps.

compared with chi-square and Fisher’s exact test; continuous variables were compared with Student t test.

Results Patient demographics During the study period, 829 patients underwent ESS, with 740 patients having the frontal recess dissected and frontal sinus opened. Of these patients 66 were cases of revision surgery of the frontal sinus, with 10 patients (15%) being revision surgeries of the senior author. Thirty-nine were male (59.1%) with a mean age of 52.39 (range, 25–85) years. CRS with nasal polyposis was the most frequent diagnosis, found in 56 patients (84.8%); CRS without nasal polyps in 9 (13.6%); and 1 patient (1.5%) with proven allergic fungal rhinosinusitis. The median time between surgeries was 5.2 years (range, 0.67–42.8; 95% confidence interval [CI], 5.7–9.4). Forty-seven patients had 1 previous surgery, 8 patients had 2 previous surgeries, 4 patients had

Valdes et al.

FIGURE 1. CT scan of a patient with chronic sinusitis and nasal polyposis with pansinus mucosal disease. CT = computed tomography;

FIGURE 2. CT scan showing retained agger nasi and lateralized middle turbinate secondary to severe polypoid disease medial to the middle turbinates. CT = computed tomography;

FIGURE 3. CT scan showing neo-osteogenesis with right-sided recurrent disease due to a lateralized MT and retained agger nasi. CT = computed tomography; MT = middle turbinate.

3 previous surgeries, 4 patients had 4 previous surgeries, 1 patient had 7 previous surgeries, 1 patient had 10 previous surgeries, and 1 patient had a previous osteoplastic flap (Table 2).

Comorbidities Forty-nine patients did not have any associated medical condition (75.7%). Seven patients had been diagnosed with asthma and 7 with Samter’s triad. Patients with these comorbidities presented less time between the first surgery and revision surgery, as compared with patients who had chronic sinusitis with no associated conditions (mean time 6.46 vs 7.48 years, p = 0.012).

Radiological and surgical findings Preoperative sinus CT scans were graded using the Harvard CT staging system14 (Table 1). Four patients (6.1%)

were stage I, 16 patients (24.3%) were stage III, and 46 patients (69.7%) were Stage IV, which is defined as pansinus disease. A total of 109 frontal sinuses were included in the analysis because 23 patients had unilateral frontal sinus surgery. The most common CT findings were edematous or hypertrophic mucosa (92.7%) (Fig. 1) and retained agger nasi cell (73.4%) (Fig. 2). Soft tissue density in the frontal recess was noted on CT in 47.7%; whether it was associated with scarring or mucosal disease was determined intraoperatively. In the operative report, 18 patients (16.5%) showed scarring and adhesions in the frontal recess. Neo-osteogenic bone within the frontal recess (45.8%) was also a frequent finding (Fig. 3). Less frequent were retained ethmoid cells (32.2%), of which the bulla ethmoidalis was the most frequent (21.1%) (Table 3). Most of the patients had more than 2 possible etiologies for surgical failure (Table 4). There were no intraoperative complications.

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TABLE 3. Computed tomography findings of patients who

underwent revision frontal sinus surgery Computed tomography findings

n (%)

Residual agger nasi

80 (73.4)

Residual ethmoid cells no agger nasi

35 (32.19)

Bulla ethmoidalis

23 (21.1)

Suprabullar cells

10 (9.2)

Frontobullar cells

3 (2.7)

Residual frontal cells

27 (24.8)

Edematous mucosa

101 (92.7)

Neo-osteogenic bone within the frontal recess

50 (45.9)

Middle turbinate scarred lateral

52 (47.7)

TABLE 4. Number of findings in computed tomography of

patients who underwent revision frontal sinus surgery* Number of findings

n (%)

0

1 (0.9)

1

3 (2.8)

2

28 (25.7)

3

38 (34.9)

4

25 (22.9)

5

14 (12.8)

6

0 (0.0)

*Computed tomography findings: residual agger nasi; residual ethmoid cells no agger nasi; residual frontal cells; edematous mucosa; neo-osteogenic bone within the frontal recess; middle turbinate scarred lateral.

ation. This reemphasizes the need for complete dissection in the area of the frontal recess and sinus for adequate ventilation and drainage at the time of primary surgery. Given that only 15% of the cases were revision surgeries of the senior author, operative reports of the remaining patients’ prior surgeries were not available for review. In addition to surgical factors, the chronic and recurrent nature of the mucosal disease is another principal cause of failure. Continued postoperative medical therapy is, of course, essential for disease control. However, inadequate primary surgery not only causes persistence of symptoms, but also impedes adequate access of topical pharmacotherapy to the frontal recess and allows the disease process to continue unchecked. The importance of complete dissection is therefore dual. The retrospective review did not extend prior to 2006 because charts are unavailable prior to that date; local regulations mandate maintenance of patient charts for a period of 5 years. Also, because it is a retrospective review followup data was unavailable. The high proportion of ESS cases in which the frontal recess and sinus were dissected in our series is related to the tertiary nature of the practice and the senior surgeon’s (M.S.) indications for surgery, resulting in a high proportion of cases with advanced disease and some degree of frontal sinus involvement. Additionally, in our community, most general otolaryngologists do not perform frontal recess surgery at the time of ESS. As a result, most cases of failure of the frontal sinus that were revised in this series were due to incomplete dissection of the frontal recess, in addition to recurrent or evolving frontal sinus mucosal disease. Consequently, there were no frontal sinus drillout procedures or frontal sinus obliteration, which, in our practice, are usually performed for tumor resection, mucoceles, or other pathologies.

Discussion

Conclusion

The importance of opening the frontal sinus and recess is two-fold. Symptom resolution as well as providing access for topical medical therapy for the long-term treatment of the chronic mucosal disease are equally important goals. The findings of this study demonstrate a large percentage of incomplete resection of the frontal recess at the time of primary surgery. The presence of agger nasi cells in 73% of patients indicates that adequate dissection to clear the frontal recess and open the frontal sinus was not performed. There are certainly a number of cases in which such a dissection may not have been indicated by the disease extent at the time of primary surgery. The failures resulting from incomplete primary surgery are high despite this consider-

The importance of performing complete dissection of the frontal recess and sinus where indicated should not undermine the importance of caution, particularly for novice or inexperienced surgeons. Indeed, the narrow space of the frontal recess, angle of access, and intricate anatomy make the frontal sinus technically demanding. This may require the surgeon to obtain additional training or attend courses to attain the necessary expertise. Alternatively, referral to a more experienced endoscopist may be necessary.

Acknowledgment We acknowledge Ms. Lisette Versailles for administrative assistance.

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International Forum of Allergy & Rhinology, Vol. 4, No. 6, June 2014

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Causes of failure in endoscopic frontal sinus surgery in chronic rhinosinusitis patients.

The frontal sinus is the most challenging area to address in endoscopic sinus surgery (ESS). Incomplete surgery or iatrogenic injury in the narrow spa...
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