Endoscopic view of the powered removal of middle meatal adhesions.

A 44-year-old man presented with an ongoing history of recurrent sinus infections that were characterized by purulent nasal discharge, periorbital pain, and pain in both cheeks. During his previous active infections, his symptoms would resolve with antibiotic therapy, but they returned every 2 or 3 months. An important aspect of his history was that he had undergone bilateral endoscopic sinus surgery for similar problems 3 years earlier.

Nasal endoscopy identified adhesions in both the left and right middle meatus between the middle turbinates and the lateral nasal wall (figure, A and D). Computed tomography of the sinuses confirmed the presence of bilateral chronic ethmoid and maxillary sinusitis with extensive mucosal thickening.

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The patient elected to undergo revision endoscopic sinus surgery with a microdebrider to remove the adhesions and widen both middle meatus. The middle meatus were opened widely, and revision ethmoidectomy was performed (figure, B and E). Rolled Gelfilm splints were then placed between the middle turbinate and the lateral nasal wall on both sides (figure, C and F). The splints were removed 1 week postoperatively, by which time the patient's symptoms had abated. At follow-up 2 years later, both middle meatus remained patent and without adhesions.

Functional endoscopic sinus surgery as described by Kennedy (1) is frequently performed to treat persistent or recurrent symptoms of chronic sinusitis. Meticulous surgical technique is essential. Proper technique includes good hemostasis (2) and mucosal preservation; the latter can be effectively accomplished by using powered instrumentation (3) or through-biting instruments. Meticulous technique decreases the likelihood that fibrous adhesions will form between opposing mucosal surfaces. The development of middle meatal scarring and adhesions can lead to persistent or recurrent disease. To prevent opposition of wound surfaces within the middle meatus, a variety of spacers is available. (4) Gelfilm can be rolled to form a multilayered stent and be placed within the middle meatus. A small laminated Merocel sponge (e.g., a Kennedy intraoperative surgical sponge (4)), which swells upon exposure to moisture, can secure and stabilize the position of the Gelfilm.

The case described here illustrates the value of an effective microdebrider technique for removing nasal adhesions and obstructions.

References

(1.) Kennedy DW. Functional endoscopic sinus surgery. Technique. Arch Otolaryngol 1985; 111:643-9.

(2.) Yanagisawa E, Mirante JP, Christmas DA. Endoscopic view of a hemostatic technique for endoscopic sinus surgery. Ear Nose Throat J 2003;82:749-50.

(3.) Christmas DA, Jr, Krouse JH. Powered instrumentation in functional endoscopic sinus surgery. 1: Surgical technique. Ear Nose Throat J 1996;75:33-6, 39-40.

(4.) Yanagisawa E, Joe JK. The use of spacers to prevent postoperative middle meatal adhesions. Ear Nose Throat J 1999;78:530-2.

From the Department of Otolaryngology, University of South Florida College of Medicine, Tampa and the Halifax Medical Center, Daytona Beach, Fla. (Dr. Christmas and Dr. Mirante); and the Southern New England Ear, Nose, Throat, and Facial plastic Surgery Group; the Section of Otolaryngology, Hospital of St. Rafael; and the Section of Otolaryngology, Yale University School of Medicine, New Haven, Conn. (Dr. Yanagisawa).