Jack B. Anon

THE MEDICAL MANAGEMENT OF RHINOSINUSITIS

The management of rhinosinusitis depends on a number of variables related to the duration and severity of symptoms in the individual patient. Furthermore acute rhinosinusitis is managed differently than chronic rhinosinusitis. Because a variety of conservative and pharmacologic interventions are available, the physician can find it difficult to develop a cohesive and logical approach to treatment. An understanding of the pathophysiology, microbiology, and natural history of rhinosinusitis is necessary to formulate the best treatment plan for the individual patient.

Bacteriologic Findings from the Nose, Ethmoid, and Bloodstream during Endoscopic Surgery for Chronic Rhinosinusitis: Implications for Antibiotic Therapy:

This study addresses the bacterial flora of chronic rhinosinusitis at the time of endoscopic sinus surgery. We used the consensus definition of chronic rhinosinusitis as the presence of paranasal sinus inflammation present for greater than 12 weeks. In our patient study group, all cases of chronic rhinosinusitis had failed to respond to antibiotic therapy and had not been treated previously with surgery. By microscopic examination, chronic inflammatory changes were confirmed in the resected sinus lining of all study patients. Intraoperative cultures were obtained from the nasal vestibule, the middle meatus, ethmoid lining, and peripheral blood during and after the endoscopic procedure. We found approximately 30% of the patients with sterile sinuses, 50% with coagulase-negative staphylococci, and the remainder with a mixed group of “nonpathogenic” organisms. Anaerobes were conspicuously rare. The blood cultures were positive in 7% of cases and were consistent with an organism of the operative site. This is the first time bacteremia has been reported in association with endoscopic sinus surgery. The results suggest that chronic rhinosinusitis is not a bacterial disease, but rather the result of chronic inflammation produced by a previous acute inflammation. The incidence of positive blood cultures, while relatively low and cleared quickly, should alert the physician for the possible need for prophylactic antibiotics in patients with cardiac, prosthetic, or systemic conditions that could lead to metastatic infection.

Computer-assisted endoscopic sinus surgery—Current experience and future developments

Computer-assisted image guidance during endoscopic sinus surgery allows for safer and more thorough sinus surgery. We have previously reviewed our experience with the ISG Intraoperative Viewing Wand system. This article describes our current technique and indications for use of the system. Several new technological advances, including the development of a curved operative probe for use in the frontal recess, as well as the introduction of a free-hand infrared localizer, are also described.

Computer assisted endoscopic sinus surgery: Clinical applications

In patients with sinonasal disease, recognition of anatomic landmarks may be difficult. The ISG Viewing Wand is an intraoperative navigational device that allows the surgeon to correlate the anatomy of the patient with a computerized display of the reformatted image of preoperative computed tomographic or magnetic resonance scans. We have found the ISG Viewing Wand to be a valuable tool for surgery of the paranasal sinuses. Representative cases are presented that illustrate the application of this device. An intraoperative navigational device enhances the surgeons ability to safely identify anatomic structures.

Rhinology and paranasal sinus disease committee: Powered endoscopic sinus surgery (PESS)

The use of powered instrumentation in functional endoscopic sinus surgery (FESS) has been shown to be a safe and reliable technique. Although initially thought to be just a soft tissue dissector, the microdebrider has been shown to be an excellent surgical instrument for performing all FESS procedures. It is clear that the evolution and expansion of powered techniques in FESS has been one of the most exciting developments in rhinology in this decade. This panel will be presenting the history and development of powered endoscopic sinus surgery (PESS) and will be comparing PESS with traditional FESS techniques. Pertinent anatomy will be presented together with the powered techniques involved for sphenoethmoidectomy, frontal sinus surgery, and maxillary sinusotomy in adults and in the pediatric population. The use of PESS with computer-aided navigation will also be presented.

Anatomy of the Paranasal Sinuses and Its Variations

Educational objectives: To understand the adult normal paranasal sinus anatomy and the embryology that led to the development of these structures to understand the variations in the normal anatomy through a developmental approach.

Computer-Assisted Endoscopic Sinus Surgery

Educational objectives: To introduce the participant to the new technique of computer-assisted endoscopic sinus surgery and to review important anatomic areas, with special attention to potential “danger areas.”