CONVENTIONAL NASAL AND SINUS SURGERY
J T Shah
Honorary E.N.T. Surgeon, Sir Hurkisondas N. Hospital, Raja Rammohan Roy Road, Mumbai 400 004.
Conventional surgery still holds a place in certain problems of the nose. For any surgery to survive, it should have consistently good and long lasting results, should be safe and easy to carry out and have minimum complications. Conventional surgery includes cautery of the inferior turbinates, submucous resection of the septum polypectomy, intranasal antrostomy, Caldwell- Luc operation, intra-nasal ethmoidectomy, external frontoethmoidectomy and external frontal operations. Whilst septoplasty remains a commonly done surgery for deviated nasal septums, Caldwell-Luc operation was and is still done for certain maxillary sinus problems. Its indications include chronic maxillary sinusitis, maxillary tumours and cysts, antro-choanal polyps, removal of foreign bodies in the sinus, dentigerous cysts, orbital decompression, and treatment of maxillo-facial trauma. The use of this surgical procedure is also rational in cases of very serious mycotic or septic factors, or when a surgical approach to the pterygo-maxillary fossa is necessary. Polypectomy and intranasal ethmoidectomy have been replaced by functional endoscopic sinus surgery (FESS). The external frontoethmoidectomy may still be done for severe chronic ethmoidal and frontal sinusitis, recurrent polyposis, ethmoiditis complicated by orbital or periorbital abscess and in cases of cerebrospinal fluid (CSF) rhinorrhea. These operations have been reviewed and their role in sinus disease discussed.
Nasal surgery has progressed by leaps and bounds. However, conventional surgery still holds a place in certain problems of the nose. For any surgery to survive, it should have consistently good and long lasting results, should be safe and easy to carry out and have minimum complications. The very fact that these conventional and standard operations have been done for so many years and are still being done today, show that they have fulfilled the above mentioned criteria.
Conventional surgery includes cautery of the inferior turbinates, submucous resection of the septum, polypectomy, intranasal antrostomy, Caldwell- Luc, intra-nasal ethmoidectomy, external frontoethmoidectomy and external frontal operations. These were normally carried out with a good and powerful focussing head light, self retaining nasal specula and specially designed long nasal instruments.
Modern surgery includes endoscopic sinus surgery (ESS) and the use of endonasal laser. The main advantages of ESS are the ability to do the surgery under vision with magnification, reduced bleeding, capability to tackle disease at the source and the ability to look around corners.
Microscopic endonasal surgery (MES) uses the operating microscope with a 300 mm lens, which allows improved surgical precision and reduces morbidity. It also enhances preservation of normal tissues. Intra-operative haemorrhage that presents a formidable problem in endoscopic surgery is easily controlled by the use of bipolar cautery. The other advantages of MES include the wide stereoscopic vision to the surgeon and the ability to use both hands, which helps in keeping the field of vision clear. The main disadvantage is its inability to assess the frontal sinus and its recess for which the telescopes have a definite edge.
Cautery of the inferior turbinates is still being done in a lot of centres, in cases of vasomotor and allergic rhinitis. However, discrimination and experience play an important part in its management. Direct cautery of the mucous membrane of the turbinates would affect the mucociliary function of the nose resulting in thickened mucus and crust formation. Moreover the chances of developing synechia are increased. Therefore, it is being replaced by submucous cautery of the turbinates, in which the submucous tissues are cauterised without affecting the mucociliary function of the nose. Results of this operation are quite gratifying. However one should be careful to avoid cauterizing the conchal bone which could lead to osteitis and sequestrum formation. It would also be beneficial to cauterize as much stromal tissue as possible through each entrance point to avoid excessive crusting and exudation.
Laser destruction of the mucous membrane of the turbinates has the same disadvantage as direct cautery of the mucous membrane resulting in reducing the mucociliary function of the nose and has no added advantage over it. Moreover due care has to be taken to prevent any laser mishaps. The cost factor also increases and this has to be taken into account.
Inferior turbinate resection is another well-known procedure for treating nasal obstruction caused by hypertrophied inferior turbinates. This may be done by removal of the inferior conchal bone by submucous resection of the concha (turbinate) or by partial removal of soft tissues only. Alternately, it can be done by a combination of soft tissue and conchal bone removal.
The technique of submucous resection of the concha involves incision of the anterior tip of the inferior turbinate and carrying out a submucous resection through it, avulsion and removal of the conchal bone and allowing the soft tissues to collapse over it. The main advantage of the procedure is the preservation of the soft tissues. Some surgeons prefer a partial removal of the turbinate whilst some prefer a complete removal. Removal of the soft tissues or combination of soft tissues and the concha has few followers as it may lead to haemorrhage, crusting, adhesions and atrophic rhinitis. Also, a significant number of patients who undergo inferior turbinectomy, may develop sinusitis.  Current thought prefers that the resection should be sufficient enough to remove the obstruction.
Polyps are formed by retention of fluid in the submucous tissues and are the result of a prolapse of the lining of the ethmoid sinuses The factors responsible are: mucosal reactions, poorly developed blood supply and the complex anatomy of the ethmoidal sinuses. They are usually allergic in nature or occasionally due to infection. The treatment in early cases is medical therapy with topical corticosteroids whilst in advanced cases, it is always surgical. In cases where they are pedunculated, they can be easily removed by using ordinary nasal instruments and a headlight. The technique involves dilating the nasal cavity with a nasal speculum and following the polyp to its base or source of origin. The pedicle is then nipped off with an ethmoidal or Tilley’s forceps or with a nasal snare. There is very little bleeding and either no pack or a small vaseline pack or piece of gelfoam may be used to prevent further bleeding. Results are quite gratifying though recurrences are fairly common.
Antrochoanal polyps arise from the mucosa of the lateral wall or the floor of the maxillary sinus and prolapse into the nose through the ostium in the middle meatus. It keeps growing till it presents itself at the nostrils or in the oropharynx. In children where the dentition is still incomplete a simple polypectomy would suffice temporarily though if a recurrence occurs, a Caldwell Luc (CWL) operation will be required at a later age. It still remains a standard operation in adults. However, creation of an antrostomy still remains a debatable point.
The endoscopists have now started removing the maxillary portion of the polyp through the natural orifice of the sinus with gratifying results. Most surgeons now prefer removal of antrochoanal polyps by endoscopic methods to the CWL operation.
Submucous resection of the septum or SMR done for a deviated nasal septum causing nasal obstruction was the standard operation for the last many years till the advent of septoplasty which is gradually replacing it. The conventional SMR operation involved removal of most of the cartilaginous and bony septum leaving a little support in the anterior, caudal and dorsal parts of the septum. The results of this operation have always been good and long lasting. However, in few cases, where very little or no support was left in the dorsal or caudal parts of the septum, a slight depression on the dorsum or a partial collapse of the tip of the nose have resulted. In cases where the flaps have been torn on both the sides at the same site inadvertently, a perforation of the septum has resulted.
With these complications in mind, septoplasty was invented in which the cartilage is realigned to the centre by breaking its spring and a minimum of the cartilage that is maximally deviated is removed. The technique consists of taking a unilateral hemitransfixation incision at the lower end of the septum and separating the mucopericondrium and the periosteum of the septum on one side of the cartilage only. Vertical or horizontal strips of the septum which are most deviated are removed after elevating the flaps in these regions only. The rest of the septum is realigned into a straight position if necessary by multiple small vertical incisions, which go through three fourths of the cartilage. At these sites, the cartilage is fractured and realigned to bring it to the centre. A strip of cartilage 3 to 4 mm wide along the lower border of the septum may have to be trimmed out if the height of the septum has to be reduced to allow it to remain in the centre. The premaxillary crest and the vomer are also fractured medially if required, to bring them to the centre after creating the inferior tunnels. The posteriorly deviated septum is removed by elevating the mucoperiosteal flap on both the sides. Results of septoplasty have been gratifying in experienced hands but the recurrence rate has increased, as a lot of novice surgeons do not have the adequate experience required for this operation. Technically, septoplasty is a more difficult operation that the SMR as it is a preservative surgery in which most of the cartilage is preserved but at the same time enough must be removed to eliminate all the obstruction. Much more training is required in this operation than the SMR to get the balance between removal and preservation. Therefore, for amateur surgeons or those who are doing this operation only occasionally, it would be advisable to do the SMR instead of septoplasty. The complications mentioned earlier can easily be avoided by preserving enough support. Though septal perforation can occur in both the operations, it is less likely in septoplasty, and can easily be avoided by taking adequate care during elevation of the flaps, especially if a tear has already occurred on one side.
Subacute and chronic maxillary sinusitis is an infection of the maxillary sinus most often as a result of repeated attacks of rhinitis, which have often been neglected (Fig. 1).
Fig 1 Coronal CT scan showing maxillary sinusitis.
Antral puncture is still being done in a number of centres as a routine procedure for washing out the sinuses. It is normally done under local anaesthesia as an outpatient procedure. It involves pushing a Lichwitz trocar and cannula through the inferior meatus into the maxillary sinus after which the trocar is removed. The Higginson’s rubber syringe is then attached to the cannula and the antrum washed out with normal saline, following which the cannula is removed. In cases where some pus has to be collected for culture and antibiotic sensitivity test, a sterile test tube may be connected between the suction and the cannula and the pus aspirated into the tube. At the end of the wash, an antibiotic drug can be installed into the sinus through the cannula prior to its removal. The procedure may be repeated every five days till the return wash becomes clear. In cases where the return wash remains purulent even after three or four washes, surgery will be required to cure the patient. Results from antral washes, which have been done over a large number of years, have been encouraging. However certain number of patients do have a recurrence of disease after a few years. The protagonists of endoscopic surgery advise opening up the normal maxillary opening in the middle meatus instead of doing antral punctures.
Hartog B et al compare the efficacy of sinus irrigation with that of sinus irrigation followed by FESS in 89 patients.  In their series, they found that sinus irrigation alone prevented surgery in 58% of all patients for 1 year. However, they found significantly favourable results for sinus irrigation followed by FESS especially for loss of smell and purulent rhinitis. They concluded that a good option for treatment of chronic maxillary sinusitis seems to be sinus irrigation in combination with a broad-spectrum antibiotic followed by FESS. I believe that this could be the right approach and FESS as a follow up step could be done in the best interests of the patient. In cases where FESS fails, or in cases where the antral wash reveals thick foul smelling pus in spite of repeated washes, a CWL operation should be done.
Caldwell-Luc operation was and is still a commonly done operation for certain maxillary sinus problems. Its indications include chronic maxillary sinusitis, maxillary tumours and cysts, antro-choanal polyps, removal of foreign bodies in the sinus, dentigerous cysts, orbital decompression, and treatment of maxillo-facial trauma. It has also been done as an approach to ethmoid and sphenoidal sinusitis. The use of this surgical procedure is also rational in cases of very serious mycotic or septic factors, or when a surgical approach to the pterygo-maxillary fossa is necessary. 
The majority of these indications still remain, though for problems related to the ethmoids and the sphenoid, FESS has taken over. For taking biopsies in suspected cases of malignancy where the lesion is clearly seen on endoscopic examination, the latter method would be preferable as the chances of seeding in the overlying soft tissues of the face would be eliminated. However if the biopsy is negative, it would still be advisable to open the sinus and take direct multiple biopsies under vision. Moreover the Caldwell-Luc operation is a simple and safe operation associated with little morbidity. With the endoscopic method it is still not possible to see the complete sinus unless it is combined with a sinusotomy.
The technique involves taking an incision in the gingivo-labial fold from the canine to the first molar, right down to the bone (Fig. 2). The muco-periosteum is elevated from the anterior surface of the maxilla and a hole is made in the anterior wall of the maxillary antrum with a gouge and hammer. The hole is enlarged with a maxillary punch till an adequate view of the interior of the sinus is obtained. All the diseased mucosa of the sinus along with all the polypi are removed. An antrostomy is made in the inferior meatus of the nose and the wound sutured up, after packing the sinus and the nose. In cases of antrochoanal polyps, all the mucosa need not be removed and the antrum need not be packed.
Fig 2 : Sublabial incision for the Caldwell-Luc operation.
Intranasal ethmoidectomy done for chronic ethmoidal sinusitis associated with polyposis has been done for a number of years with the use of the head light and standard self retaining nasal specula, special ethmoid forceps and good suction cannulas. The surgical microscope has provided magnification and improved the illumination. The main principle is to exteriorize the ethmoidal sinuses so as to restore normal function and prevent intra-cranial complications.
The ethmoidal sinuses are entered just lateral to the anterior end of the middle turbinate after infracturing the first one centimeter of the middle turbinate. The ethmoidal cells are then cleared by remaining lateral to the medial wall of the nose, medial to the lamina papyracea and below the fovea ethmoidalis to avoid damage to the orbital contents and the dura. Posteriorly one should take care not to damage the optic nerve.
This operation has given good results though the recurrence rate has been high. Functional Endoscopic sinus surgery (FESS) has now gradually replaced the conventional method of operating with the headlight due its excellent vision and accessibility. It is now possible to remove disease from practically every nook and corner of the ethmoids with the endoscopic or telescopic method. Moreover with the diagnostic endoscopy it is possible to catch early disease and remove it endoscopically at its root. As the trouble site is usually the ostiomeatal complex where most of the sinuses open, any obstruction at this site can hinder the drainage of the sinuses. With the endoscope it is possible to diagnose this in its infancy and treat it immediately instead of waiting for it to become a full-fledged disease. However one must remember that endoscopic surgery requires a lot of expertise and should not be taken lightly, as serious complications including damage to the orbital contents, optic nerve and the dura can occur.
Fig 3 Lynch-Howarth incision for external ethmoidectomy..
The external frontoethmoidectomy or the Lynch-Howarth has been done for extensive disease of the frontal and ethmoid sinuses. These include severe chronic ethmoidal and frontal sinusitis, mucocoeles of these sinuses, recurrent polyposis, ethmoiditis complicated by orbital or periorbital abscess and in cases of cerebrospinal fluid (CSF) rhinorrhoea. The incision is taken just medial to the inner canthus of the eye (Fig. 3) and the lacrimal sac displaced laterally. It may be extended laterally under the eyebrow to facilitate excess to the frontal sinuses. After exposure and ligation of the anterior and the posterior ethmoidal arteries the ethmoidal sinuses are entered into through the medial thin wall of the orbit. All the diseased ethmoidal cells are then exenterated in an anterior to posterior direction extending upward upto the fovea ethmoidalis only and preventing damage to the optic nerve posteriorly. The sphenoid sinus is also cleared of all disease.
The frontal sinus is entered through the anterior ethmoidal cells and all diseased mucosa removed and the patency of the nasofrontal duct maintained by a fenestrated silastic tube kept from the frontal sinus through the ethmoidal region into the nose for a few months. The results of these operations have been poor because of the post-operative closure of the newly constructed naso-frontal duct and the occurrence of mucocoeles. Newer operations aimed at maintaining the patency of the duct by lining them with mucoperiosteal flaps and by stenting it have been described with varying amounts of success.
The endoscopic techniques that aim at the drainage area of the ethmoidal and frontal sinuses have given good results and are now being gradually extended to treat ethmoidal and frontal mucocoeles with extremely good results. These endoscopic operations may reduce the necessity of carrying out the conventional extensive operations required for severe hyperplastic disease of the ethmoid and frontal sinuses.
The intra-nasal route can today tackle most of the indications of frontoethmoidectomy. The results of repair of CSF rhinorrhoea by the endoscopic method have given excellent results in experienced hands. The main advantage of this approach is avoidance of a major neurological operation to repair the leak.
If FESS fails to cure a patient of chronic frontal sinusitis, then the frontal osteoplastic flap operation with obliteration of the sinus still remains the procedure of choice.
The procedure involves taking a coronal incision just behind the hairline and elevating an osteoplastic flap. All diseased mucosa of the sinus is removed and the vestiges inverted into the opening of the sinus. The sinus is then obliterated with fat removed from the abdominal wall and the flap is then replaced.
I personally believe that for simple problems of the nose and the sinuses, the conventional operations using a simple head light and special ENT instruments should suffice. However, in more complicated cases, either MES or FESS should be done depending on which technique one has been trained in. In cases where the endoscopic method fails, it may be combined with the conventional method, which in a majority of cases has resulted in a cure.
It is important to move onwards and progress with time and to keep oneself updated with the current trends and newer technology, so as to give the best available treatment to the patient.
- Berenholz L, Kessler A, Sarfati S, Eviatar E, Segal S. Chronic sinusitis: a sequela of inferior turbinectomy. Am J Rhinol 1998 Jul-Aug;12(4):257-61.
- Hartog B, van Benthem PP, Prins LC, Hordijk GJ. Efficacy of sinus irrigation versus sinus irrigation followed by functional endoscopic sinus surgery. Ann Otol Rhinol Laryngol 1997 Sep;106(9):759-66.
- Romagnoli R, Aimetti M, Secco F, Brucoli M. The Caldwell-Luc procedure in the management of maxillary sinusitis. Long-term results. Minerva Stomatol 1998 Apr;47(4):143-7.
- Bertran Mendizabal JM, Perez Martinez C, Martinez Vidal A. Osteoplastic frontal sinus flap. Study of 47 cases. Acta Otorrhinolaryngol Esp 1998 Jun-Jul;49(5):380-4