Endoscopic physiologic approach to allergy-associated chronic rhinosinusitis: A preliminary study.

Abstract

Patients with allergy-associated chronic rhinosinusitis respond poorly to functional endoscopic sinus surgery (FESS), probably because of the altered nasosinus ventilatory physiology and the increased contamination of the nasosinus mucosa by the offending allergens. With this in mind, we describe the concept and technique of functional endoscopic nasosinus surgery (FENS) in such cases. The advantages of this technique are that it preserves the uncinate process, it limits ethmoidal exenteration via a transbullar approach, and it simultaneously corrects both septal and lateral wall pathologies. The aim of our randomized prospective study was to subjectively and objectively compare the efficacy of FESS and FENS in 64 patients with allergy-associated chronic rhinosinusitis. Subjective assessment was ascertained by visual analog scores, and objective assessment was made by nasal endoscopy. In this preliminary study, we found that FENS was superior to FESS in treating chronic sinusitis associated with nasal allergy .

Introduction

The evolution of nasosinus endoscopes and an improvement in our understanding of nasosinus pathophysiology in chronic sinusitis have revolutionized the treatment of sinus disease. Stammberger [1] in Europe and Kennedy [2] in the United States have standardized and popularized the Messerklinger technique described in 1978, which is now accepted worldwide. Although functional endoscopic sinus surgery (FESS) provides good results in cases of chronic nonallergic rhinosinusitis, its results are poor in patients with allergy-associated chronic sinusitis.

According to Stammberger and Posawetz, allergic disease of the upper airway is not a primary indication for FESS. [3] They advocate FESS as an adjuvant therapy in patients who do not respond to hyposensitization and antiallergic therapy. In such cases, they stress the need for a limited surgical procedure to treat the stenosis in the middle meatus and ethmoid complex.

Nishioka et al found that the polyp recurrence rate was higher following FESS in allergic patients. [4] Levine reported better results in cases of chronic sinusitis than in cases of polyposis. [5] Our own experience with FESS in chronic sinusitis reveals that nasal allergy heralds a poor prognosis. A second look into the nasosinus ventilatory physiology, which is considerably altered in post-FESS cases, explains the reason for its failure. Removal of the uncinate process hypothetically exposes the operated ethmoid cavity and the major sinuses to allergens and bacteria-contaminated inspiratory airflow. This leads to allergen exposure to a larger surface area, which causes increased or persistent mucosal disease.

In this article, we stress the need for a proper case selection for FESS, and we emphasize the need to view cases of chronic sinusitis associated with nasal allergy more cautiously and skeptically. We advocate functional endoscopic nasosinus surgery (FENS) as an adjuvant modality of treatment in cases that are refractory to pharmaco- and immunotherapeutic measures. FENS involves the simultaneous endoscopic treatment of the turbinates and septum to relieve the nasal obstruction associated with allergy and a limited sinus surgery that preserves the uncinate process. This modified endoscopic surgery protects the mucosa of the sinuses from allergen exposure during inspiration without compromising the clearance of ethmoidal disease. This technique perhaps favors better ventilation of the sinuses in the more sterile and allergen-free expiratory phase than in the more contaminated and allergen-carrying inspiratory phase.

Rationale for FENS

The vertical jet of inspired air spreads in a wide and gentle curve from the internal nasal valve toward the choanae. During quiet inspiration, the flow becomes laminar at the valve area, and the direction becomes horizontal. Most of the airflow occurs along the middle meatus and floor of the nose, with less turbulence. The conformity of the lateral wall to the shape of the septum tends to keep the passage narrow and of uniform width, thereby promoting laminar flow. This thin laminar flow facilitates the exchange of temperature and humidity between the turbinates and the inspired air. [6] The expired air is more turbulent and flows throughout the nasal cavity. The sinuses are ventilated in the expiratory rather than inspiratory phase. [7]

The accompanying diagrammatic representation of airflow during the two phases of respiration in the nasal cavity and sinuses clearly shows the role of the uncinate process in directing the inspired air away from the sinuses, thus protecting them (figure 1). The uncinate process probably also directs the expired air into the infundibulum and the maxillary ostium. Inspired air carries allergens and bacteria. Expired air is more sterile and allergen-free because it is "pretreated" by the respiratory mucosa. Thus, the sinuses are normally ventilated by a more sterile and allergen-free air. Moreover, an important and hitherto unrecognized function of the paranasal sinuses is that they provide a continual supply of fresh, uncontaminated mucus to the middle meatus so that mucociliary activity is preserved. [8]

Removal of the anterior part of the middle turbinate, as suggested by LaMear et al, [9] and the uncinate process exposes the sinuses to the rather contaminated inspired air. This is what hypothetically occurs in post-FESS patients, in whom the area of allergen deposition is greatly enhanced, extending into the sinuses. This might be the reason for the persistent postnasal drip and the increase in respiratory symptoms in post-FESS patients.

Keeping this in mind, the aims of FENS are (1) to preserve the uncinate process and anterior end of the middle turbinate, thereby protecting the sinuses from the contaminated inspired air; (2) to allow better ventilation of the sinuses in the expiratory phase by resecting the inferolateral part of the middle and inferior turbinates, which does not disrupt the laminar inspiratory flow because the conformity between the septum and lateral wall is preserved; (3) to treat sinus disease with a limited resection; and (4) to concomitantly treat the septal deformity via an ultraconservative approach aided by endoscopes.

FENS operative technique

In our study, all but seven FENS patients received local anesthesia. For vasoconstriction and topical anesthesia, each patient's nose was sprayed with 4% lidocaine with 1:25,000 epinephrine. Cottonoid packs soaked in 4% lidocaine with 1:25,000 epinephrine were also placed. The surgical target sites were infiltrated with 2% lidocaine with 1:100,000 epinephrine. In all procedures, 4-mm, 0[degrees] and 30[degrees] nasal telescopes were used. The surgical procedure involved the simultaneous treatment of the pathologic septa, turbinates, and sinuses endoscopically.

Septal correction. After infiltration, a hemitransfixation incision was made. Septal deviations were corrected endoscopically. A hemitransfixation incision was made on the concave side in an S-shaped deviation. However, for a posterior deviation, a C-shaped spur was made on the convex side. The septal flap was elevated. Ultraconservative resection of the septal pathology was performed whenever indicated. Alignment of the septum was achieved by wedge resection, trimming, or crisscross incisions. [10]

After surgical treatment of the turbinates and the sinuses, the septal flaps were kept apposed and splinted with dental wax plates, which had been sterilized in glutaraldehyde and cut to fit the nasal cavity. [11] These splints were anchored together to the septum by a through-and-through stitch with 2-0 catgut or silk approximately 1.5 to 2 cm posterior to the caudal end of the septum.

Turbinoplasty. In all cases, the inferior turbinate was trimmed inferolaterally, and the end that projected toward the nasopharynx was amputated as described by Nayak et al. [10] The inferolateral portion of the middle turbinate was also resected in the middle and posterior areas (figure 2).

The concha bullosa was resected laterally. Submucous diathermy was performed at the anterior end of the inferior turbinate--at times even to a polypoidal middle turbinate. Diathermy of the raw stump of the trimmed turbinates helped achieve hemostasis. Too much resection of the middle turbinate was avoided to maintain its stability.

Sinus surgery. Unlike FESS, FENS allows the surgeon to preserve the uncinate process. The anterior ethmoid cells were exenterated to the extent possible by a curved curette and upturned forceps. The maxillary ostium was visualized with a 30[degrees] endoscope, usually anteroinferiorly to the bulla ethmoidalis in the hiatus semilunaris. When it was found, it was widened posteriorly and inferiorly. When the maxillary ostium could not be found, a curved spoon or fine cannula was used to palpate and probe the ostium just lateral to the inferior attachment of the uncinate process and inferior to the bulla. If the maxillary ostium still could not be located, the posterior aspect of the uncinate process was partially trimmed with a backward-cutting forceps to expose the natural ostium area (figure 3).

The posterior fontanelle was opened with a sickle knife, and the backward-cutting forceps were reintroduced to enlarge the antrostomy to join the natural ostium. A large middle meatal antrostomy was created until the roof of the antrum was well visualized (figure 4). Care was taken to preserve the uncinate process. When an accessory ostium was also found, the bridge of tissue between it and the natural ostium was removed. (An accessory ostium seen through a 0[degrees] scope itself should not be confused with the true ostium, which opens near the roof of the antrum.)

When computed tomography (CT) and diagnostic nasal endoscopy found no disease, the ethmoid sinuses were not exenterated. When indicated, exenteration was performed via a transbullar approach with a 30[degrees] scope. This is unlike the Messerklinger and Wigand techniques, which are anteroposterior and posteroanterior approaches, respectively. [12] The bulla was found to be the most constant ethmoidal cell and the key area for approaching either the anterior or the posterior group of air cells. The bulla was first punctured inferomedially and later exenterated with caution after the surgeon identified the lamina papyracea and the roof of the ethmoids. Identification of these structures was very easy via the transbullar approach. Using the fovea, lamina papyracea, and the middle meatal antrostomy as landmarks, the remainder of the ethmoids and sphenoids were exenterated when indicated (figure 5). A diseased frontal sinus and/or recess necessitated exenteration of even a normal bulla for proper access. A 30[deg rees] scope and an upturned forceps were used between the middle turbinate and lateral wall just posterior to the uncinate process to open the frontal recess and then the frontal sinus. It was not difficult to clear the frontal recess disease and create a frontal sinusotomy despite the uncinate process preservation. Occasionally, a 90[degrees] scope was used to visualize the frontal recess better. The posterior ethmoids and sphenoids were exenterated only when indicated.

Dental wax plates were used as a spacer between the middle turbinate and the lateral wall, in the manner described by Nayak et al, [13] whenever the development of synechiae was anticipated. Packing of the nasal cavity was not necessary except in three patients, who exhibited an ooze from the resected stump of the inferior turbinate. This was controlled by placing a cottonoid soaked in bismuth iodoform paraffin paste, which was removed after 8 to 12 hours.

Materials and methods

We identified 120 patients with allergy-associated chronic rhinosinusitis who had been treated between January 1993 and December 1996 at Kasturba Hospital in Manipal, India. These patients had not responded to medical treatment. They were prospectively randomized into one of two groups (60 patients in each); one group underwent FESS as described by Stammberger, [1] and the other underwent FENS.

Sixty-four of these patients were available for a followup of 6 months or more--30 in the FESS group and 34 in the FENS group. Each patient was evaluated by a detailed history, clinical examination, nasal endoscopy, and radiology of the paranasal sinuses. None of them had a history suggestive of food allergy. In each case, sinus disease was confirmed by CT. Every patient had a positive allergic skin test, and each either had undergone or were undergoing hyposensitization and other antiallergic therapy. Patients who had frank nasal polyposis on anterior rhinoscopy were excluded from this study.

The two groups were age- and sex-matched. All patients were subjectively evaluated pre- and postoperatively with a visual analog scale. Objective evaluation was performed by nasal endoscopy. A topical budesonide nasal spray was advised for all patients postoperatively for a minimum of 3 months. Maintenance therapy with cromolyn sodium nasal spray or a systemic antihistamine was advocated in most cases, depending on the response. A few patients required intermittent short courses of systemic steroids.

Results

Of the 120 patients, 64 were available for a followup of at least 6 months (range: 6 mo to 6 yr)--30 patients in the FESS group and 34 in the FENS group. All of these patients had symptoms of perennial allergy and chronic sinusitis, and most had headache, anterior nasal discharge, nasal obstruction, postnasal drip, and sneezing spells (table I). A few patients also had hyposmia and wheezing.

Six of the FESS patients underwent septoplasty during a different sitting, while three underwent septal surgery concurrently. The conventional Messerklinger technique was used for all FESS patients, and the extent of ethmoid exenteration was guided by CT. Twenty-four patients underwent middle meatal antrostomy, and six patients underwent a total sphenoethmoidectomy.

All 34 of the FENS patients underwent turbinoplasty, and 22 had a septal correction. All 34 had a middle meatal antrostomy--28 with an ethmoidectomy and 6 without. Of the 28 patients who underwent an ethmoidectomy, 22 had an anterior ethmoidectomy, 4 had an anterior and posterior ethmoidectomy, and 2 others had an anterior and posterior ethmoidectomy in addition to a sphenoidotomy.

Subjective evaluation. The criteria for surgical cure in the literature differ widely, from symptomatic improvement to complete resolution. Therefore, the statistical significance of success rates in different studies cannot be compared. We categorized our subjective postoperative results as either resolved, improved, unchanged, or worse (table 2). Our subjective evaluations were aided and documented by comparisons with each patient's pre- and postoperative visual analog scores. The statistical significance of the differences between the numbers of patients whose symptoms had resolved and those whose symptoms had not resolved was calculated according to the [[chi].sup.2] tests with Yates' correction.

The resolution rates for headache, nasal obstruction, and postnasal drip were significantly greater in the post-FENS group than in the post-FESS group. Anterior nasal discharge, sneezing spells, hyposmia, and wheezing were not significantly resolved by either surgery. However, there was a significant difference in favor of FENS in patients with sneezing and wheezing when the percentage of those whose symptoms resolved was combined with the percentage of those whose symptoms improved (p[less than or equal to]0.05).

Objective evaluation. Postoperative followup evaluation by nasal endoscopy documented the outcomes of both surgeries, and it showed that FENS was clearly superior to FESS (table 3). However, the poor response in the FESS group might have been attributable to a much worse underlying allergy and to the greater extensiveness of the surgery. No orbital complication or cerebrospinal fluid rhinorrhea was encountered during or after either surgery.

Discussion

Messerklinger's endoscopic approach to the nasal sinuses is well established. [14, 15] This procedure involves the removal of the uncinate process, clearance of the ethmoid disease, and the creation of frontal and maxillary sinusotomies. Although this technique is quite suitable and effective in cases of nonallergic chronic sinusitis, its efficacy in allergy-associated chronic rhinosinusitis is questionable.

Allergic rhinitis is one of the most common coexisting conditions in patients with chronic sinusitis, and it is also seen in some patients with bronchial asthma. [16,17] In a review of published results of endoscopic sinus surgery, Terris and Davidson documented the presence of allergies in 14 to 58% (mean: 40%) of patients with chronic sinusitis. [18]

All patients with allergy-associated chronic sinusitis should be given an adequate course of treatment with pharmaco- and immunotherapy, which are the mainstays of treatment. In patients who do not respond to immunotherapy, the probability of an IgG-mediated food and/or mold allergy should be considered.

Surgical treatment is indicated in refractory cases as the last resort to relieve obstruction and infection. [19] Stammberger and Posawetz advocated a limited endoscopic sinus surgery as an adjuvant treatment. [3] Such an operation helps to modify minor obstructive anatomic variants, but it has no effect on the allergy. [16,17] Shambaugh viewed the new sinus operations for allergic rhinitis with great skepticism. [20] Indeed, the efficacy of FESS in allergy-associated chronic rhinosinusitis is not impressive in the literature. Davis et al observed extended postoperative recovery times and decreased antrostomy patencies in patients operated on during a period of high antigen exposure. [21] In a significant study, Nishioka et al found that a higher incidence of polyp recurrence occurred in allergic cases following FESS. [4] It has also been reported that patients with diffuse rhinosinopathy and primary eosinophilic infiltration are more likely to develop recurrent disease following endoscopic sinus surgery. [17 ]

Allergy associated with chronic rhinosinusitis is seen frequently in our center. Earlier treatment modalities included submucosal diathermy, partial or total inferior turbinectomy, and intraturbinal corticosteroid injections as an adjunct to pharmaco- and immunotherapy. Refractory sinus disease in such cases was treated by conventional intra- and/or extranasal procedures. Our results, unfortunately, never showed that patients experienced a complete relief of symptoms.

When FESS came into vogue, it was overenthusiastically performed, even in cases of allergy-associated chronic rhinosinusitis. Although FESS produced good results in patients with nonallergic rhinosinusitis, it was disappointing in those with allergy-associated chronic rhinosinusitis. (In fact, the senior author [D.R.N.] is one such patient.) The poor post-FESS outcomes prompted us to rethink the pathophysiology of allergy-associated chronic rhinosinusitis, the rationale for FESS in such cases, and the reasons for its failure. As a result of this reconsideration, we began to combine modified conventional surgical techniques (submucosal diathermy and/or a partial inferior turbinectomy) with a judicious use of modified endoscopic sinus surgery to treat such cases. This technique eventually gave rise to the evolution of FENS.

Nasal turbinate hypertrophy is often associated with allergy, more so in patients who also have bronchial asthma. Septoturbinal compression is associated with middle turbinate syndrome, and middle turbinate hypertrophy results in an obstruction that alters the normal flow of air and mucus. [22] The inferior turbinates in the allergic nose are the primary shock organs that cause nasal obstruction. [19] To deal with such turbinates, many techniques have been advocated: intraturbinal steroid injections, submucosal diathermy, surface cautery of the inferior turbinate, bipolar cautery of the turbinate, chemical cautery with agents such as silver nitrate, outfracture of the turbinate, submucosal resection of the inferior turbinate, partial inferior turbinectomy, and endoscopic partial inferior turbinectomy with a powered microcutting instrument. [10] Some surgeons perform partial endoscopic middle turbinectomy in all cases as a standard component of FESS. [9] LaMear et al, in discussing the impact of middle turbine ctomy on the normal nasal physiology, wrote that this procedure is safe and does not cause postoperative atrophic rhinitis. [9] A concha bullosa is trimmed by a partial resection of its lateral aspect. [1]

In our series, we performed an inferolateral partial resection and amputation of the posterior end of the inferior turbinate to facilitate the flow of inspiratory air in the inferiormost part of the nasal cavity and to allow for the passage of allergen-free expired air through the middle meatus. The inferolateral trimming of the middle turbinate with preservation of the anterior end helps provide better ventilation of the sinuses during the expiratory phase.

The success of FENS in allergy-associated chronic rhinosinusitis might be explained by the protection of the sinuses from allergen exposure during the inspiratory phase and the better ventilation of the sinuses in the allergen-free sterile expiratory phase. Long-term success depends on control of the primary cause (i.e., the allergy) rather than repeated surgeries to treat pathologic changes. Thus, short courses of systemic steroids and maintenance treatment with nasal steroid sprays, cromolyn sprays, mucolytics, anticholinergics, and/or suitable antihistamines help provide long-term relief. Local and systemic decongestants also provide immediate relief of symptoms, but they cannot be used on a long-term basis because of their side effects. [19] Immunotherapy is promising because it provides long-term symptomatic relief, but it does not statistically influence middle meatotomy patency, synechiae formation, or recurrence of polyps following FESS. [4] Although our preliminary findings are encouraging, a larger series over a longer duration is required to determine its efficacy accurately.

In conclusion, FESS is not the panacea for all sinus disorders, and its role has been overemphasized. In allergy-associated chronic rhinosinusitis, FESS actually aggravates allergic symptoms. We found FESS to be more troublesome than beneficial because of the incidence of persistent or even increased postnasal drip. This was probably the result of the increase in mucosal surface area that became available for allergen exposure plus the drying effect of the increased volume of air as a result of overzealous turbinate resection and total ethmoidectomy.

FENS, on the other hand, provides a safe and efficient method of relieving obstruction in the nasal passage and osteomeatal complex. At the same time, it protects the sinuses from allergen exposure, ventilating them during an allergen-free expiratory phase. It is not merely a viable alternative in the management of allergy-associated chronic rhinosinusitis, it is a superior alternative.

Acknowledgments

The authors thank Dr. Ramdas Pai, medical director at Kasturba Hospital, and Prof. P. Hazarika, professor and head of the Department of ENT at the Kasturba Medical College, for their contributions to this study. We also thank Mrs. A. Thulasi for her secretarial assistance.

From the Department of ENT-Head and Neck Surgery, Kasturba Medical College, Manipal, Karnataka, India.

References

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Table 1. Preoperative symptoms in 30 FESS and 34 FENS patients
                            FESS       FENS       Total
                            n (%)      n (%)      n (%)
Headache                  28 (93.3)  31 (91.2)  59 (92.2)
Anterior nasal discharge  26 (86.7)  32 (94.1)  58 (90.6)
Nasal obstruction         28 (93.3)  25 (73.5)  53 (82.8)
Postnasal drip            24 (80.0)  21 (61.8)  45 (70.3)
Sneezing spells           17 (56.7)  27 (79.4)  44 (68.8)
Hyposmia                  13 (43.3)  15 (44.1)  28 (43.8)
Wheezing                  11 (36.7)  12 (35.3)  23 (35.9)
Table 2. Subjective postoperative evaluation: Number of patients
and the degree of change in symptoms
                          FESS (n = 30)
Symptoms                        R *       I   U  W  Total
Headache                        7        13   6  2   28
Anterior nasal discharge        6        14   5  1   26
Nasal obstruction               4         7  16  1   28
Postnasal drip                  3         5  12  4   24
Sneezing spells                 0         2  14  1   17
Hyposmia                        2         2   9  0   13
Wheezing                        0         2   6  3   11
                          FENS (n = 34)
Symptoms                        R         I   U  W  Total
Headache                       17         8   6  0   31
Anterior nasal discharge       11        16   4  1   32
Nasal obstruction              13         9   3  0   25
Postnasal drip                 12         7   1  1   21
Sneezing spells                 5         9  13  0   27
Hyposmia                        3         4   8  0   15
Wheezing                        2         7   3  0   12
Symptoms                     p value+
Headache                  [less than]0.05
Anterior nasal discharge             NS
Nasal obstruction         [less than]0.01
Postnasal drip            [less than]0.01
Sneezing spells                      NS
Hyposmia                             NS
Wheezing                             NS
(*)R = resolved
I = improved
U = unchanged
W = worse
(+)p value is calculated according to the [[chi].sup.2] test with Yates'
correction and applies to the difference between those patients
who resolved and those who did not.
Table 3. Objective postoperative evaluation: Adverse endoscopic
findings in 30 FESS and 34 FENS patients
                            FESS       FENS
                            n (%)      n (%)
Residual disease
 Discharge                25 (83.3)  15 (44.1)
 Polypoidal musosa        13 (43.3)    3 (8.8)
 Polyp formation           8 (26.7)    1 (5.9)
synechiae between the      6 (20.0)    2 (5.9)
 MT * and lateral well
Persistent contact areas   6 (20.0)    2 (5.9)
Sinusotomy closure          2 (6.7)      0
(*)MT = middle turbinate.