ORIGINAL ARTICLE
Office surgery for paranasal sinus recirculation John M. DelGaudio, MD1 and Matthew C. Ochsner, BS2
Background: Circular flow of mucus between adjacent openings of a single paranasal sinus is known as recirculation, and can cause persistent sinonasal symptoms. Removing the bridging tissues allows the surgical ostium to connect to the natural ostium. This procedure prevents the circular flow between the 2 ostia, and allows the mucociliary system to provide for physiologic drainage of the sinuses. Traditionally this has taken place in the operating room; however, performing this procedure in the office is possible, even when there is significant intervening bone. Here we report a series patients with recirculation successfully treated in the office.
turbinate bone between ostia in the inferior and middle meatus, and 1 involving bone of the face of the sphenoid sinus.
Methods: A prospective study of 10 patients endoscopically diagnosed with recirculation, 9 involving the maxillary sinus and 1 involving the sphenoid. Symptoms included facial pressure, mucus stasis, congestion, and recurrent sinusitis. All patients had previous sinus surgery. All patients were treated in the office under topical ± local anesthesia. The bridging tissues between ostia were removed, 6 of which consisted of mucosal bands within the middle meatus, 1 with mucosa and intervening bone within the middle meatus, 2 with mucosa and inferior
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M
ucus recirculation syndrome (MRS) is a phenomenon that was first reported by Messerklinger1 in 1978, and a cause of chronic rhinosinusitis (CRS). The normal physiological paths of mucoid secretions from the various sinuses flow through the natural sinus ostia to the nasopharynx through propulsion by ciliary clearance where the secretions can be subsequently swallowed.2 In contrast, when an additional opening is present in a sinus wall, the
1 Department
of Otolaryngology–Head and Neck Surgery, Emory Sinus, Nasal, and Allergy Center, Emory University Hospital Midtown, Atlanta, GA; 2 Emory University School of Medicine, Atlanta, GA
Correspondence to: Matthew C. Ochsner, BS, Emory University School of Medicine, 1648 Pierce Dr. NW, Atlanta, GA 30322; e-mail: [email protected] Potential conflict of interest: None provided. Presented as a poster at the Annual ARS Meeting on September 20, 2014, Orlando, FL. Received: 1 September 2014; Revised: 13 October 2014; Accepted: 7 November 2014 DOI: 10.1002/alr.21466 View this article online at wileyonlinelibrary.com.
Results: All 10 patients had significant improvement or resolution of the symptoms associated with recirculation, with no further endoscopic evidence of mucus recirculation. Conclusion: This case series demonstrates that mucus recirculation can be successfully treated in the office seing, even across bony structures. This leads to significant savings to the healthcare system and less missed work/school C 2015 ARScompared to an operating room procedure.
Key Words: Sinus recirculation; mucus recirculation; chronic sinusitis; office sinus surgery; sinus surgery; recirculation How to Cite this Article: DelGaudio JM, Ochsner MC. Office surgery for paranasal sinus recirculation. Int Forum Allergy Rhinol. 2015;5:326– 328.
secretions can deviate from the normal pathway, and reenter the sinus through the unnatural surgical ostium.3 Mucus recirculation leads to an impaired ability to clear sinus secretions and increases the risk of CRS. This may result from the repeated presentation of bacteria and viruses contained in the mucous within the sinuses, which under normal physiologic conditions should be eliminated.4 The prevalence of MRS is poorly studied; however, 1 study did find that 4% of the population have an additional ostium.5 A study conducted by Mladina et al.6 showed that patients suffering from CRS had a higher prevalence (19.3%) of posterior fontanel defects when compared to healthy controls (0.5%), suggesting that additional ostia and CRS are linked. Another study by the same group found that 57.3% of patients with complaints of postnasal drip had a posterior fontanel defect, in comparison to 2.2% of healthy controls.7 Additionally, these studies showed that a portion of patients with additional ostia suffered from MRS, which resulted in CRS. MRS is readily treated with a procedure that removes the bridging tissues between the 2 ostia, resulting in a
International Forum of Allergy & Rhinology, Vol. 5, No. 4, April 2015
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Office recirculation surgery
single ostium.8 This procedure prevents the circular flow, and allows the mucociliary system to provide physiologic drainage of the sinuses. If MRS is responsible for a patient’s sinus pathology, the patient should have improvement or resolution of their condition after the procedure. Traditionally, this procedure has taken place in the operating room (OR), which requires valuable time, money, and resources. To the authors’ knowledge, there have not been any studies reported on treating this condition in the office setting on awake patients.
Patients and methods The study was conducted at the Emory Sinus, Nasal, and Allergy center from 2009 to 2014. Institutional Review Board approval was obtained. Ten patients were treated, ages 24 to 76 years old, including 4 males and 6 females. All patients had undergone previous sinus surgery at outside hospitals prior to initial presentation. Nine of the 10 patients underwent endoscopic sinus surgery for CRS, 7 of 9 without nasal polyposis, and 2 of 9 with nasal polyposis, ranging from unilateral maxillary antrostomy to bilateral complete sinus surgery. Three of these 9 patients had revision surgery at our institution prior to the office recirculation procedure. One additional patient presented with a posterior nasal septal chondrosarcoma, which had been previously partially resected at an outside hospital. The patient underwent an endoscopic resection of residual tumor, bilateral sphenoidotomies, and partial resection of the sphenoid rostrum at our institution. Symptoms of recirculation were elicited from the patient, including pressure in the area of the maxillary sinus, facial pain, headache, sensation of excessive mucus in the affected side, nasal drainage or discharge, congestion, and recurrent infections. All patients were diagnosed endoscopically with MRS, identifying mucus circulating between the 2 ostia, with 9 involving the maxillary sinus and 1 involving the sphenoid sinus. Additionally, many patients had inflammatory disease involving other sinuses. All patients were treated under topical anesthesia; the 4 patients with a bone component also received local anesthesia injections. The bridging tissues between ostia was removed using throughcutting forceps, 6 of which were mucosal bands between ostia in the middle meatus (Fig. 1), 1 consisted of mucosal tissue and intervening bone within the middle meatus, 2 consisted of mucosa and inferior turbinate bone between ostia in the inferior and middle meatus (Figs. 2 and 3), and 1 involved the bone of the sphenoid face (Fig. 4). All patients tolerated the procedure well with only minimal discomfort, with 1 patient complaining of transient light-headedness. There was little to no bleeding observed during and directly after the treatment. No packing was placed and no cautery was used. The procedures lasted from 5 to 10 minutes. No complications occurred. Patients were asked to follow up in the clinic at 4 weeks, or earlier if needed, to check on the progress of their disease.
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International Forum of Allergy & Rhinology, Vol. 5, No. 4, April 2015
FIGURE 1. Endoscopic view of a tissue band between ostia in the middle meatus before (left) and after (right) surgically connecting the ostia to form a common ostium.
FIGURE 2. Endoscopic view of mucus recirculation between inferior and middle meatus around inferior turbinate before (left) and after (right) removal of intervening structures.
FIGURE 3. Endoscopic view of recirculation between ostia in the inferior and middle meatus before (left) and after (right) removal of inferior turbinate.
FIGURE 4. Endoscopic view of recirculation of mucus between ostia along the face of the right sphenoid sinus before (left) and after (right) removal of intervening bone and mucosa. Left sphenoid face had been previously resected as part of tumor resection.
DelGaudio and Ochsner
Results All patients reported significant improvement of the symptoms related to the MRS at their next visit. All patients were examined endoscopically, and no signs of recirculation were present and all mucosa was well healed. Followup ranged from 3 months (2 recent patients) to 5 years. One patient required an additional office procedure unrelated to the presenting sinusitis complaint due to nasal congestion from inferior turbinate hypertrophy. An inferior turbinate radiofrequency reduction was performed with subsequent complete relief of her symptoms.
Discussion MRS is a result of misdirected flow of mucus due to the presence of additional openings in a sinus separate from the natural ostium. Cilia within a sinus are programmed to beat toward the natural ostium. If an additional ostium is present and separated from the natural ostium by a bridge of tissue, whether it be a surgical ostium or a natural accessory ostium, the normal beating of the cilia may draw mucus in from the nasal cavity and the normal mucociliary clearance then direct it to the natural ostium. This can result in recirculation. Although the sinus itself may be otherwise clear, this can result in symptoms of sinus pressure, nasal congestion, and recurrent sinusitis. Connection of the multiple ostia to create a common ostium allows the mucus to flow in a single direction since all cilia are beating toward the common ostium, thereby eliminating ingress of mucus. To date, there has been no report in the literature of office-based surgical treatment of MRS. This study documents successful identification and treatment of MRS in the office, with patients endorsing significant improvement in
their symptoms, and with no sign of MRS on subsequent endoscopic evaluation. These procedures involved removing both mucosal tissue and intervening bone, but were still accomplished safely in the office with minimal patient discomfort. Our results demonstrate that office surgery for mucus recirculation is both feasible and effective, and offers a time-efficient solution to patients presenting with this condition. As with other office-based sinus surgeries, conducting this procedure in the office eliminates the additional risk, cost, and time commitment of an OR procedure.9 Performing this procedure in the office could lead to significant savings to the healthcare system in expense, and reduced societal impact from missed work compared to an OR procedure.
Conclusion The trend toward office-based procedures continues. As endoscopic technology continues to advance, the ability to perform minimally invasive office-based procedures continues to grow, and an emphasis must be placed on those procedures that can be safely and effectively performed in the office setting. The ability to perform surgeries without the use of the OR saves time for both the patient and physician, along with a decrease in cost and use of resources. Treatment of MRS through removal of bridging tissue is an excellent example of a procedure typically performed in the OR that can be accomplished in the office setting with excellent results and patient satisfaction, even when there is significant intervening bone. Patients can benefit from treatment on the same day they receive their diagnosis, and without the need for preoperative clearance, general anesthesia, and the additional time and cost of the OR.
References 1. Messerklinger W. Endoscopy of the Nose. Baltimore, MD: Urban Schwartzenberg; 1978:123. 2. Stammberger H. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Philadelphia, PA: B.C. Decker; 1991:17–37. 3. Yanagisawa E, Weaver EM. Endoscopic view of recirculation phenomena of sphenoid sinus drainage. Ear Nose Throat J. 1996;75:68–70.
4. Matthews BL, Burke AJC. Recirculation of mucus via accessory ostia causing chronic maxillary sinus disease. Otolaryngol Head Neck Surg. 1997;117:422–423. 5. Jog M, McGarry GW. How frequent are accessory sinus ostia? J Laryngol Otol. 2003;117:270–272. 6. Mladina R, Vukovic K, Poje G. Two holes syndrome. Am J Rhinol. 2009;23:602–604. 7. Mladina R, Skitareli´c N, Casale M. Two holes syndrome (THS) is present in more than half of
the postnasal drip patients? Acta Oto Laryngol. 2010;130:1274–1277. 8. Coleman JR, Duncavage JA. Extended middle meatal antrostomy: the treatment of circular flow. Laryngoscope. 1996;106:1214–1217. 9. Prickett K, Wise S, DelGaudio J. Cost analysis of officebased and operating room procedures in rhinology. Int Forum Allergy Rhinol. 2012;2:207–211.
International Forum of Allergy & Rhinology, Vol. 5, No. 4, April 2015
328
Office surgery for paranasal sinus recirculation John M. DelGaudio, MD1 and Matthew C. Ochsner, BS2
Background: Circular flow of mucus between adjacent openings of a single paranasal sinus is known as recirculation, and can cause persistent sinonasal symptoms. Removing the bridging tissues allows the surgical ostium to connect to the natural ostium. This procedure prevents the circular flow between the 2 ostia, and allows the mucociliary system to provide for physiologic drainage of the sinuses. Traditionally this has taken place in the operating room; however, performing this procedure in the office is possible, even when there is significant intervening bone. Here we report a series patients with recirculation successfully treated in the office.
turbinate bone between ostia in the inferior and middle meatus, and 1 involving bone of the face of the sphenoid sinus.
Methods: A prospective study of 10 patients endoscopically diagnosed with recirculation, 9 involving the maxillary sinus and 1 involving the sphenoid. Symptoms included facial pressure, mucus stasis, congestion, and recurrent sinusitis. All patients had previous sinus surgery. All patients were treated in the office under topical ± local anesthesia. The bridging tissues between ostia were removed, 6 of which consisted of mucosal bands within the middle meatus, 1 with mucosa and intervening bone within the middle meatus, 2 with mucosa and inferior
AAOA, LLC.
M
ucus recirculation syndrome (MRS) is a phenomenon that was first reported by Messerklinger1 in 1978, and a cause of chronic rhinosinusitis (CRS). The normal physiological paths of mucoid secretions from the various sinuses flow through the natural sinus ostia to the nasopharynx through propulsion by ciliary clearance where the secretions can be subsequently swallowed.2 In contrast, when an additional opening is present in a sinus wall, the
1 Department
of Otolaryngology–Head and Neck Surgery, Emory Sinus, Nasal, and Allergy Center, Emory University Hospital Midtown, Atlanta, GA; 2 Emory University School of Medicine, Atlanta, GA
Correspondence to: Matthew C. Ochsner, BS, Emory University School of Medicine, 1648 Pierce Dr. NW, Atlanta, GA 30322; e-mail: [email protected] Potential conflict of interest: None provided. Presented as a poster at the Annual ARS Meeting on September 20, 2014, Orlando, FL. Received: 1 September 2014; Revised: 13 October 2014; Accepted: 7 November 2014 DOI: 10.1002/alr.21466 View this article online at wileyonlinelibrary.com.
Results: All 10 patients had significant improvement or resolution of the symptoms associated with recirculation, with no further endoscopic evidence of mucus recirculation. Conclusion: This case series demonstrates that mucus recirculation can be successfully treated in the office seing, even across bony structures. This leads to significant savings to the healthcare system and less missed work/school C 2015 ARScompared to an operating room procedure.
Key Words: Sinus recirculation; mucus recirculation; chronic sinusitis; office sinus surgery; sinus surgery; recirculation How to Cite this Article: DelGaudio JM, Ochsner MC. Office surgery for paranasal sinus recirculation. Int Forum Allergy Rhinol. 2015;5:326– 328.
secretions can deviate from the normal pathway, and reenter the sinus through the unnatural surgical ostium.3 Mucus recirculation leads to an impaired ability to clear sinus secretions and increases the risk of CRS. This may result from the repeated presentation of bacteria and viruses contained in the mucous within the sinuses, which under normal physiologic conditions should be eliminated.4 The prevalence of MRS is poorly studied; however, 1 study did find that 4% of the population have an additional ostium.5 A study conducted by Mladina et al.6 showed that patients suffering from CRS had a higher prevalence (19.3%) of posterior fontanel defects when compared to healthy controls (0.5%), suggesting that additional ostia and CRS are linked. Another study by the same group found that 57.3% of patients with complaints of postnasal drip had a posterior fontanel defect, in comparison to 2.2% of healthy controls.7 Additionally, these studies showed that a portion of patients with additional ostia suffered from MRS, which resulted in CRS. MRS is readily treated with a procedure that removes the bridging tissues between the 2 ostia, resulting in a
International Forum of Allergy & Rhinology, Vol. 5, No. 4, April 2015
326
Office recirculation surgery
single ostium.8 This procedure prevents the circular flow, and allows the mucociliary system to provide physiologic drainage of the sinuses. If MRS is responsible for a patient’s sinus pathology, the patient should have improvement or resolution of their condition after the procedure. Traditionally, this procedure has taken place in the operating room (OR), which requires valuable time, money, and resources. To the authors’ knowledge, there have not been any studies reported on treating this condition in the office setting on awake patients.
Patients and methods The study was conducted at the Emory Sinus, Nasal, and Allergy center from 2009 to 2014. Institutional Review Board approval was obtained. Ten patients were treated, ages 24 to 76 years old, including 4 males and 6 females. All patients had undergone previous sinus surgery at outside hospitals prior to initial presentation. Nine of the 10 patients underwent endoscopic sinus surgery for CRS, 7 of 9 without nasal polyposis, and 2 of 9 with nasal polyposis, ranging from unilateral maxillary antrostomy to bilateral complete sinus surgery. Three of these 9 patients had revision surgery at our institution prior to the office recirculation procedure. One additional patient presented with a posterior nasal septal chondrosarcoma, which had been previously partially resected at an outside hospital. The patient underwent an endoscopic resection of residual tumor, bilateral sphenoidotomies, and partial resection of the sphenoid rostrum at our institution. Symptoms of recirculation were elicited from the patient, including pressure in the area of the maxillary sinus, facial pain, headache, sensation of excessive mucus in the affected side, nasal drainage or discharge, congestion, and recurrent infections. All patients were diagnosed endoscopically with MRS, identifying mucus circulating between the 2 ostia, with 9 involving the maxillary sinus and 1 involving the sphenoid sinus. Additionally, many patients had inflammatory disease involving other sinuses. All patients were treated under topical anesthesia; the 4 patients with a bone component also received local anesthesia injections. The bridging tissues between ostia was removed using throughcutting forceps, 6 of which were mucosal bands between ostia in the middle meatus (Fig. 1), 1 consisted of mucosal tissue and intervening bone within the middle meatus, 2 consisted of mucosa and inferior turbinate bone between ostia in the inferior and middle meatus (Figs. 2 and 3), and 1 involved the bone of the sphenoid face (Fig. 4). All patients tolerated the procedure well with only minimal discomfort, with 1 patient complaining of transient light-headedness. There was little to no bleeding observed during and directly after the treatment. No packing was placed and no cautery was used. The procedures lasted from 5 to 10 minutes. No complications occurred. Patients were asked to follow up in the clinic at 4 weeks, or earlier if needed, to check on the progress of their disease.
327
International Forum of Allergy & Rhinology, Vol. 5, No. 4, April 2015
FIGURE 1. Endoscopic view of a tissue band between ostia in the middle meatus before (left) and after (right) surgically connecting the ostia to form a common ostium.
FIGURE 2. Endoscopic view of mucus recirculation between inferior and middle meatus around inferior turbinate before (left) and after (right) removal of intervening structures.
FIGURE 3. Endoscopic view of recirculation between ostia in the inferior and middle meatus before (left) and after (right) removal of inferior turbinate.
FIGURE 4. Endoscopic view of recirculation of mucus between ostia along the face of the right sphenoid sinus before (left) and after (right) removal of intervening bone and mucosa. Left sphenoid face had been previously resected as part of tumor resection.
DelGaudio and Ochsner
Results All patients reported significant improvement of the symptoms related to the MRS at their next visit. All patients were examined endoscopically, and no signs of recirculation were present and all mucosa was well healed. Followup ranged from 3 months (2 recent patients) to 5 years. One patient required an additional office procedure unrelated to the presenting sinusitis complaint due to nasal congestion from inferior turbinate hypertrophy. An inferior turbinate radiofrequency reduction was performed with subsequent complete relief of her symptoms.
Discussion MRS is a result of misdirected flow of mucus due to the presence of additional openings in a sinus separate from the natural ostium. Cilia within a sinus are programmed to beat toward the natural ostium. If an additional ostium is present and separated from the natural ostium by a bridge of tissue, whether it be a surgical ostium or a natural accessory ostium, the normal beating of the cilia may draw mucus in from the nasal cavity and the normal mucociliary clearance then direct it to the natural ostium. This can result in recirculation. Although the sinus itself may be otherwise clear, this can result in symptoms of sinus pressure, nasal congestion, and recurrent sinusitis. Connection of the multiple ostia to create a common ostium allows the mucus to flow in a single direction since all cilia are beating toward the common ostium, thereby eliminating ingress of mucus. To date, there has been no report in the literature of office-based surgical treatment of MRS. This study documents successful identification and treatment of MRS in the office, with patients endorsing significant improvement in
their symptoms, and with no sign of MRS on subsequent endoscopic evaluation. These procedures involved removing both mucosal tissue and intervening bone, but were still accomplished safely in the office with minimal patient discomfort. Our results demonstrate that office surgery for mucus recirculation is both feasible and effective, and offers a time-efficient solution to patients presenting with this condition. As with other office-based sinus surgeries, conducting this procedure in the office eliminates the additional risk, cost, and time commitment of an OR procedure.9 Performing this procedure in the office could lead to significant savings to the healthcare system in expense, and reduced societal impact from missed work compared to an OR procedure.
Conclusion The trend toward office-based procedures continues. As endoscopic technology continues to advance, the ability to perform minimally invasive office-based procedures continues to grow, and an emphasis must be placed on those procedures that can be safely and effectively performed in the office setting. The ability to perform surgeries without the use of the OR saves time for both the patient and physician, along with a decrease in cost and use of resources. Treatment of MRS through removal of bridging tissue is an excellent example of a procedure typically performed in the OR that can be accomplished in the office setting with excellent results and patient satisfaction, even when there is significant intervening bone. Patients can benefit from treatment on the same day they receive their diagnosis, and without the need for preoperative clearance, general anesthesia, and the additional time and cost of the OR.
References 1. Messerklinger W. Endoscopy of the Nose. Baltimore, MD: Urban Schwartzenberg; 1978:123. 2. Stammberger H. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Philadelphia, PA: B.C. Decker; 1991:17–37. 3. Yanagisawa E, Weaver EM. Endoscopic view of recirculation phenomena of sphenoid sinus drainage. Ear Nose Throat J. 1996;75:68–70.
4. Matthews BL, Burke AJC. Recirculation of mucus via accessory ostia causing chronic maxillary sinus disease. Otolaryngol Head Neck Surg. 1997;117:422–423. 5. Jog M, McGarry GW. How frequent are accessory sinus ostia? J Laryngol Otol. 2003;117:270–272. 6. Mladina R, Vukovic K, Poje G. Two holes syndrome. Am J Rhinol. 2009;23:602–604. 7. Mladina R, Skitareli´c N, Casale M. Two holes syndrome (THS) is present in more than half of
the postnasal drip patients? Acta Oto Laryngol. 2010;130:1274–1277. 8. Coleman JR, Duncavage JA. Extended middle meatal antrostomy: the treatment of circular flow. Laryngoscope. 1996;106:1214–1217. 9. Prickett K, Wise S, DelGaudio J. Cost analysis of officebased and operating room procedures in rhinology. Int Forum Allergy Rhinol. 2012;2:207–211.
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