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Sinus Surgery Information
Functional
endoscopic sinus surgery (FESS) has
revolutionized the surgical approach
to sinus disease. However, FESS is not
without its limitations or complications.
The most important goal of the surgery
is to regain ventilation of the obstructed
sinuses and to reestablish physiologic
mucociliary flow. The increased bleeding
that has been associated with the removal
of sinonasal polyps is frequently the
limiting factor in the ability to completely
remove diseased tissue. Inadequate polyp
removal leads to a higher recurrence
rate, while a more complete removal
allows for better reepithelialization.
Although techniques have evolved to
reduce bleeding, it is still problematic
in many cases, including extensive polyposis
patients, AAP patients (aspirin sensitivity,
asthma and polyps), revision surgeries,
etc. Recent advances in instrumentation,
such as through-cutting instruments
and powered tissue debriders, remove
tissue in a less avulsive manner than
previously, but still do not prevent
bleeding and, in the case of the debrider,
provide utility primarily in the nasal
passage and not in the deep sinus recesses.
The Sinu-Clear technique was developed
to optimize visualization and control
of bleeding in sinonasal surgery, with
atraumatic removal of diseased tissue
and sparing of non-diseased tissue,
thus enabling a safe and complete procedure
with enhanced rather than compromised
visualization. The procedure utilizes
a combination of warmed water and a
unique controlled laser energy delivery
system to enhance the surgeon's operating
environment. The warmed water provides
vasoconstriction, eliminating the need
for pharmaceutical vasoconstricting
agents. The water also lavages the sinonasal
areas and magnifies the optical field,
enhancing visualization. The laser,
specifically the SLT Contact Nd:YAG
Laser with the DF 2 diffuser flat probe,
gently and controllably coagulates tissue.
Hemostatic tissue removal is more gently
accomplished as the diseased tissue
is weakened by the coagulation process.
This system enables the surgeon to prevent
bleeding rather than attempting to address
it if and when it occurs.
Technique
Light
general anesthesia is employed throughout
the procedure to allow for gentle emergence
from anesthesia. This avoids any bucking,
coughing or vomiting which can cause
bleeding from the nose and sinuses.
A cuffed endotracheal tube is used to
prevent aspiration of liquids during
the procedure. The patient is placed
in a semi-Fowler's (25-30) position,
draped and protected from the laser
as usual. A small disposable, flexible
dental suction is placed into the nasopharynx
to serve as outflow for the irrigating
solution. No sprays, injections, or
vasoconstrictor-soaked pledgets are
used prior to, during, or after the
procedure.
Pre-operative
CT scans are utilized and referred to
throughout the procedure. Sinuscopy
is then performed using a Wolf Hydrascope
with a 25 Panoview telescope and a video
monitor. The Hydrascope handle provides
suction via a trumpet-valve button and
irrigation via a finger-controlled stopcock
valve. The irrigation is warmed to approximately
41C by a SIMS Level 1 fluid warmer system.
All suction and irrigation tubing, as
well as laser accessories, are provided
in the SLT Sinu-Clear kit which is pre-labeled
for easy set-up.
Liberal warm irrigation during initial
sinuscopy lavages the sinonasal spaces,
displacing secretions that may be stagnant
in the nose or sinuses, and provides
mucosal vasoconstriction. Landmarks
can be identified while viewing the
path and turbulence of the irrigating
stream, which simulates the inspired
air column. Hydrogen peroxide-soaked
pledgets will blanch areas of mucosal
damage caused by irritation to assist
in surgical planning to restore adequate
ventilation.
The laser utilized is an SLT CL MD Contact
Nd:YAG laser, although other Nd:YAG
or diode lasers with SMA 905 interfaces
can be used with the SLT fiber and probe
system. The laser energy is delivered
through a reusable SLT LAH / LAW 0 hand piece
with a Frazier-type proximal bend. In
cases where there is a need to improve
the posterior ventilation, an SLT GRP
6 scalpel tip is used at a power setting
of typically 12-18 watts to partially
excise posterior mulberry tips or impacted
and hypertrophied turbinates. More anterior
hypertrophy can be treated with intramural
photo coagulation by placing the GRP
6 tip submucosally and applying laser
energy of typically 12-16 watts for
approximately 7 to 10 seconds at a time.
Then the SLT DF 2 diffuser flat probe
is placed between the polyps and energy
applied at typically 8-14 watts with
simultaneous warm irrigation. The polyps
are coagulated at their base as observed
by mucosal blanching. Whenever utilizing
laser energy, it is recommended to begin
at a lower power setting, then increase
the power setting if required to achieve
the desired tissue effect.
The DF 2 probe incorporates a proprietary
surface treatment that absorbs a portion
of the Nd:YAG wavelength, heating the
probe surface on the front and sides.
The laser energy provides a combined
thermal heating effect of diffused Nd:YAG
absorption in tissue and thermal conduction
from the heated DF 2 tip, tempered by
the heat sink effect of the irrigation.
Due to the diffuse and slow thermal
effect of this laser delivery system,
coagulation can be observed and ceased
when desired, providing optimal control
of depth and area of thermal tissue
effect, thus ensuring enhanced safety.
This is notable in its contrast to the
deep thermal effect of native free-beam
Nd:YAG laser energy. It is also preferable
to other laser wavelengths which will
provide a very rapid tissue effect,
possibly unintended, with the inherent
risk of complication.
A vertical lateral partial hemiturbinectomy
may need to be performed to improve
access and/or ventilation to the middle
meatus, or to remove the lateral half
of a concha bullosa. In less severe
cases it may be possible to leave the
middle turbinate undisturbed. An osteomucosal
flap of middle turbinate is constructed
for later use or as a landmark. Attention
and care must be paid posteriorly in
the area of the sphenopalatine artery
during the partial turbinectomy. The
posterior edge of the lacrimal/maxillary
bone is identified, serving as a constant
landmark even in cases of severe polyposis,
scarred mucosa, or previous surgery.
The DF 2 probe is used to blanch the
mucosa over the uncinate process, ethmoid
bulla, and the area of the natural maxillary
sinus ostium and fontanelles. A maxillary
antrostomy is made through the fontanelle
and the retrograde dissector (a backbiter
is used to dissect and elevate mucosa
and not used as a biter) is utilized
to dissect the mucosa off the bony lateral
nasal wall. The uncinate process is
rotated and removed in a posterior direction
and then is followed toward its superior
attachment and carefully excised. The
maxillary sinus mucosa/polyps are removed
with warm irrigation and gentle suction
curettage. The ethmoid bullae are entered
using the DF 2 probe and irrigation
continued. Polyps are coagulated. The
sphenoid sinus ostium is irrigated and
enlarged if needed. Sphenoid polyps
are coagulated with the DF 2 probe if
required. The lamina papyracea is identified
anteriorly and superiorly in the area
of the upper attachment of the uncinate
and followed into the frontal recess.
The base of the skull is similarly identified,
taking care not to injure the ethmoidal
neurovascular canals. Polyps here are
also dissected with warm irrigation
and carefully removed with gentle suction
curettage.
The frontal sinus ostium is identified
and copiously irrigated. If present,
diseased tissue is removed. A "frontal
duct" canalplasty may need to be
performed if indicated to maintain patency.
Care is to be taken medially where the
middle turbinate attaches to the skull
base in the area of the lateral wall
of the olfactory fossa. This may be
the area encountered during the procedure
that is most thin. The sphenoid sinus
ostium is irrigated and enlarged if
needed. Sphenoid polyps are coagulated
with the DF 2 probe if required. A small
elliptical stent is may be placed into
the frontal ostium if it was widened.
Gelfilm® and hydrophilic antiseptic
nasal gelpaste are applied in the sinus,
as well as a septal wafer to prevent
synechia formation. An eye pad is used
as a "moustache" dressing.
Patients are able to resume many day-to-day
activities with minimal limitations
within a few days.
Results
The
Sinu-Clear procedure has evolved and
been refined to its current state over
the last five years with over 500 patients.
I have had no major complications using
this technique, and no ill effects to
intracranial or orbital structures,
even though dissection of the lamina
papyracea and anterior skull base is
performed routinely if needed. With
respect to symptom improvement and polyp
recurrence rates, the results have been
gratifying and are attributed to the
completeness of surgery achieved with
this procedure, as well as patient adherence
to the post-operative nasal hygiene
protocol.
The Sinu-Clear procedure supplies numerous
advantages. The laser coagulation denatures
protein, weakening diseased tissue and
its adherence to underlying structures,
allowing gentle, safe and hemostatic
tissue removal. Thermal effects with
the DF 2 probe and irrigation are minimal
and do not penetrate deeply for the
durations applied. Because the atraumatically
shaped DF 2 probe works on contact,
the surgeon has tactile feedback and
is able to feel whether the tissue being
contacted is soft or hard. The Sinu-Clear
procedure provides exquisite visualization
and control of bleeding, a necessity
for safe and complete microsurgery of
the paranasal sinuses, nasal passages
and the anterior base of skull.
Selected
References:
1
Schuman, DM, et. al., Functional Aqualaser®
Sinuscopy: A Safe Technique for the
Treatment of Severe Nasal Polyposis,
Journal of Clinical Laser Medicine and
Surgery, Vol. 12, No. 6, 1994.Daniel
M. Schuman, MD, FACS - America's National
Medical & Research Institute - Department
of Rhinology and Neurorhinology - West
Boca Medical Center - Boca Raton, Florida
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