ORIGINAL ARTICLE. Toru Kikawada, MD; Takeo Nonoda, MD; Mariko Matsumoto, MD; Mikino Kikura, MD; Keiko Kikawada, MD

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1 ORIGINAL ARTILE Treatment of Intractable iseased Tissue in the Maxillary Sinus After Endoscopic Sinus Surgery With High-Pressure Water Jet and Preservation of the Periosteum Toru Kikawada, M; Takeo Nonoda, M; Mariko Matsumoto, M; Mikino Kikura, M; Keiko Kikawada, M Objective: To describe a new high-pressure water jet (HPWJ) treatment to remove intractable diseased mucosa persisting in the maxillary sinus several months after endoscopic sinus surgery (ESS) while preserving the periosteum. esign: A retrospective review of HPWJ treatment in 45 consecutive patients with at least 12 months follow-up. Setting: A private surgicenter in Japan. Patients: Patients (25 male and 20 female) ranged in age from 8 to 59 years. All patients had diffuse intractable lesions in the opened maxillary sinus after the initial ESS, with or without disease of the ethmoid and other major sinuses. Main Outcome Measures: Resolution of diffuse intractable disease in the maxillary sinus and postoperative change in the size of the cavity were evaluated using nasal endoscopy and computed tomographic scan. Results: Twenty-six (81%) of 32 sides in 25 patients with isolated persistent maxillary sinus disease were restored after HPWJ procedures; 25 (93%) of 27 sides in 20 patients who also had ethmoiditis also were restored. In the latter group, ethmoiditis recurred in 5 sides, which also included 2 sides of unrestored maxillary sinuses. Of the 51 restored sides, 33 (65%) were restored within 3 months after HPWJ treatment under endoscopic observation. No complications were seen during the surgery. Except for 1 side in 1 patient from which all diseased mucosa was removed almost completely, along with the periosteum, no reduction of the cavity by scar tissue formation was observed. This method did not affect the development of the maxillary bone in children. onclusion: Removing diffuse intractable diseased mucosa in the maxillary sinus while preserving the periosteum with HPWJ treatment is an effective surgical therapy that fulfills the ultimate purpose of ESS. Arch Otolaryngol Head Neck Surg. 2000;126:55-61 From the Hamamatsu Ear, Nose and Throat Surgicenter, Hamamatsu, Japan. SINE THE AVENT of the endoscope, there has been a dramatic change from radical to functional endonasal procedures for the operative treatment of chronic sinusitis. The aim of endoscopic sinus surgery (ESS) is to cure inflammation in all the sinuses by restoring ventilation and drainage without total removal of the mucosa from the major sinuses. However, not all patients can be completely cured using ESS alone. NumerousstudieshavereportedtheresultsofESSandrevisionsurgery Reasons indicated for revision surgery are recurrent polyps in the ethmoid and/or frontal recess, middle meatus adhesion, maxillary ostium stenosis, and frontal sinus obstruction due to postoperative scarring. To date, the only reported problem of the maxillary sinus for which revision surgery has been indicated is maxillary ostium stenosis. In our experience, however, the maxillary sinus was not restored to normal in any of the patients, although ESS succeeded in achieving a stable maxillary ostium for ventilation and drainage and in restoring the ethmoid and other major paranasal sinuses. In some patients, diffuse intractable disease in the maxillary sinus that caused purulent rhinorrhea and continued growth into the nasal cavity were observed for several months to several years after ESS. Of these patients, many were completely cured after the diseased mucosa was surgically removed, but the periosteum was left intact (Figure 1). Our aim is to describe our experience with intractable disease of the maxillary sinus, our method of surgical treatment using high-pressure water jet (HPWJ), and the results. RESULTS Resolution of diffuse intractably diseased mucosal tissue in the maxillary sinus and postoperative change in the size of the cavity were evaluated using nasal endoscopy and T scan at a minimum of 12 months 55

2 PATIENTS, EQUIPMENT, AN METHOS PATIENTS From January 1, 1991, to September 30, 1997, 59 sides of 45 patients underwent the procedure using HPWJ treatment of intractable disease such as a persistent diffuse lesion or growing polyp in the opened maxillary sinus after initial ESS. In 32 of the 59 sides, all sinuses except the maxillary sinus had been confirmed as healthy by normal endoscopic findings and computed tomographic (T) scans. In the remaining 27 sides, intractable disease in the maxillary sinus accompanied by disease of the ethmoid and other major sinuses was confirmed. efore surgery, informed consent was obtained from all patients, whose ages ranged from 8 to 59 years (Figure 2). Each patient had intractably diseased tissue that did not respond to early postoperative medical treatment (erythromycin stearate, 400 mg/d, for 2 to 4 weeks, with prednisolone, 10 to 20 mg/d, for several days in some cases) and persisted for more than several months after the initial ESS, as seen in the following tabulation: No. of Months From Initial ESS to HPWJ No. of Patients EQUIPMENT A machine that shoots isotonic sodium chloride solution at a high static pressure has been developed for this treatment (Aquasurgery; ALOKA ompany, Tokyo, Japan). Physiologic isotonic sodium chloride solution is pressurized up to approximately 3 MPa in the machine, while resistance reduces the kinetic energy of the isotonic sodium chloride solution to about 1 MPa by the time it reaches the tip of the curved cannula (Figure 3). SURGIAL TEHNIQUE All patients arrived at our surgicenter on the morning of their procedure and underwent general anesthesia. Each patient was positioned supinely on the operating table with the head slightlyloweredandturnedfacingthesurgeon, whowasseated to the right of the patient. The tip of the cannula of the HPWJ system was inserted into the maxillary sinus through the previously widened antrostomy using a 70 endoscopic observation. The HPWJ was shot intermittently from the cannula at the lesions of the maxillary sinus. Using differently curved cannulas, most lesions of the maxillary sinus could be removed while preserving the periosteum (Figure 4 and Figure 5). ecause of the risk of injecting water into the orbitthroughthethininferiororbitalwall, shootingthestream directly at the inferior orbital wall was avoided. Small, highly curved forceps specially designed for the maxillary sinus were used to remove the separated mucosal epithelium and hard lesions, as necessary. No packing was used in the maxillary sinus. In patients who also had ethmoiditis and/or disease in other sinuses, the lesions were treated using the standard ESS procedure simultaneously. All patients stayed in the hospital for 2 to 3 days. Nasal packings were removed on discharge if they had been used in the ethmoid and the nasal cavity. All patients were seen approximately once a week for cleaning of the operative cavity during the early postoperative period. after the operation, with additional follow-up of up to 6 years (mean, 36 months). Procedures that restored the maxillary sinuses sinuses that showed neither inflammatory changes on endoscopic evaluation nor abnormal mucosal thickening on the T scan were considered operative successes. The results were evaluated separately in the following 2 groups: 1 group had no inflammation outside the maxillary sinus at the time of this treatment (n = 25), and the other had preoperative ethmoiditis with or without another sinus disease (n = 20). In the first group, 26 (81%) of 32 sides with isolated persistent maxillary sinus disease were restored following HPWJ procedures. In the second group, 25 (93%) of 27 sides with ethmoiditis were restored (Figure 6). In the latter group, ethmoiditis recurred in 5 sides, which also included 2 sides with unrestored maxillary sinus. The time required for restoration after HPWJ under endoscopic evaluation was as follows. In the first group, 18 sides were restored within 3 months; 7 sides, within 4 to 12months;and1side,after12months.Inthesecondgroup, 15 sides were restored within 3 months; 7 sides, within 4 to 12 months; and 3 sides, after 12 months (Figure 7). OMPLIATIONS AN SEQUELAE There were no complications (eg, orbital or bleeding) during the operations. In some patients, the periosteum was partially separated from the bone or the bone was partially denuded, probably because the water pressure used was too high. However, no thickening of the maxillary wall or reduction of the cavity was found using T scan. One patient whose unilaterally diseased mucosa was almost completely removed along with the periosteum with the HPWJ showed marked reduction of the maxillary sinus, in contrast to the opposite side in which the periosteum was preserved. No effect on sinus or facial growth was observed in 13 patients younger than 15 years who underwent a unilateral HPWJ procedure, during a follow-up period ranging from 12 to 67 months (Figure 8). MUOILIARY LEARANE In 5 patients, the mucociliary clearance of the regenerated mucosa on the preserved periosteum was estimated using coffee particles. Within 30 minutes, almost all the particles had been removed from the maxillary 56

3 A Figure 1. A, Preoperative computed tomographic (T) scan of a 16-year-old girl before the initial endscopic sinus surgery (ESS) show bilateral pansinusitis (stage III as reported by Kennedy 2 )., Postoperative endoscopic findings of ESS show intractably diseased mucosa persisting in the maxillary sinuses even after making patent the maxillary orifice and restoring the ethmoid at 5 months., Preoperative T scan before high-pressure water jet (HPWJ) procedure at 7 months after the initial ESS., Postoperative endoscopic findings show rapid restoration of the intractable disease in the maxillary sinus at 5 months after the HPWJ procedure. R indicates right; L, left; RM, right maxillary sinus; LM, left maxillary sinus; RE, right ethmoid sinus; and LE, left ethmoid sinus No. of Patients Age at Surgery, y A Figure 2. istribution of patients by age (n = 45). Tank Accumulator Valve Pump Hand Piece Nozzle Figure 3. A, Photograph of the high-pressure water jet (HPWJ) machine., iagrammatic representation of the HPWJ machine. Physiologic isotonic sodium chloride solution at a static pressure of 3 MPa in the tank is transmitted to the cannula and spout with a dynamic pressure of 1 MPa at the tip of the cannula. Motor Pressure Gauge Pressure Regulator 57

4 Figure 4. Intraoperative 70 endoscopic view of the high-pressure water jet procedure on a 44-year-old woman with diffuse intractable lesions in the maxillary sinus 24 months after the initial endoscopic sinus surgery. A, Preoperative persistent diffuse disease filled the sinus., Physiologic isotonic sodium chloride solution shot from the cannula., Immediate postoperative view showing preserved periosteum covering almost the entire bony surface., Partially separated periosteum elevated from the bony surface (asterisk) by the suction catheter. A 3 µm Figure 5. Scanning electron microscopic photograph of the periosteum taken immediately after the high-pressure water jet procedure in Figure 4 shows meshlike fibrous structures Restoration, % Group 1 (32 Sides) Group 2 (27 Sides) Figure 6. Results of the high-pressure water jet procedure. No. of Sides Group 1 (n = 26 Sides) Group 2 (n = 25 Sides) % >12 Months Figure 7. Time required for restoration after the high-pressure water jet procedure as evaluated using endoscopic observation. sinus through the widened orifice. In typical cases, the particles that were scattered in the sinus were gathered and transferred in a row toward the widened natural orifice, as in the nondiseased sinus (Figure 9). In 1 patient, regenerated mucosal specimens taken from the posterior wall of the maxillary sinus 4 years after the HPWJ procedure were evaluated using scanning electron microscopy. The regenerated mucosa was 58

5 R L A R L E F Figure 8. The long postoperative course of a 13-year-old patient who underwent the high-pressure water jet (HPWJ) procedure on 1 side. A and, Preoperative view of the initial endoscopic sinus surgery (ESS) shows a huge polyp in the right anterior nares (25 endoscope) and pansinusitis (by coronal computed tomographic [T] scan)., Preoperative view of the HPWJ procedure shows diffuse intractably diseased mucosa in the right maxillary sinus 6 months after the initial ESS., Immediate postoperative view after the HPWJ procedure shows the preserved periosteum and the partially denuded bone (asterisk). E, Status 2 years later. F, oronal T scan shows the restored right maxillary sinus 3 years after the HPWJ procedure. No scar tissue deformity of the right maxillary sinus is seen compared with the left maxillary sinus, which had been restored after the initial ESS, and equal development of the maxillary bone is seen on both sides. R indicates right; L, left. 59

6 A E F Figure 9. The mucociliary clearance function of the regenerated mucosa after the high-pressure water jet (HPWJ) procedure. A, Preoperative view, via a 70 endoscope, before the HPWJ procedure on an 18-year-old patient, 6 months after the initial endoscopic sinus surgery (ESS) shows diffuse intractable lesions in the right maxillary sinus., Immediate postoperative view after the HPWJ procedure shows the preserved periosteum, the partially denuded bone (at the tip of the suction catheter), and the separation of the mucosal epithelium (arrows) from the periosteum. through F, Transfer of coffee particles over the regenerated mucosa 20 months after the HPWJ procedure immediately after scattering and 5, 10, and 20 minutes later, respectively. The particles are transferred over regenerated mucosa in the direction of the original natural orifice. 60

7 5 µm Figure 10. Scanning electron microscopic photograph of regenerated mucosa taken from the posterior wall of the maxillary sinus, 4 years after the high-pressure water jet procedure, shows numerous cilia with a normal appearance. considered healthy with numerous ciliated cells (Figure 10). OMMENT The HPWJ procedure is based on the assumption that, if the periosteum could be preserved on the surface of the bone, normal mucosa could regenerate over the periosteum without formation of granulation or scar tissue and without reducing the size of the cavity, unlike so-called radical surgery (eg, aldwell-luc operation). Half of the diseased tissue in the maxillary sinus can be removed with forceps. However, it is difficult to completely remove the diseased tissue intranasally through a surgical ostium created in the middle meatus. The HPWJ has been developed to wash out almost all mucosal lesions that are difficult to remove intranasally, even with well-curved forceps, while preserving the periosteum. Although it is difficult to show the preserved periosteum in a photograph, we can confirm preservation, including many capillary vessels, by touching or moving it slightly with the tip of a suction catheter during surgery. Although the purpose of ESS is to restore diseased mucosa, localized diseased mucosa in the major sinus may be removed at the time of ESS. However, in the initial ESS, it is difficult to judge whether any certain lesion is irreversible. Therefore, we believe that any lesions except large polyps that might impede ventilation and drainage through the opened ostium should be preserved in the initial ESS. In determining whether the disease is irreversible, May et al 5 reported that, after ESS, almost all postoperative conditions become apparent within 6 months, with the exception of obstructive frontal sinusitis caused by scarring, and polyps, which recur within 3 to 4 years. In our experience, disease that persisted in the maxillary sinus for more than several months after ESS was less likely to be restored spontaneously. Therefore, if patients have persistent disease in the maxillary sinus for more than 6 months and show persistent or progressive symptoms such as purulent rhinorrhea or nasal obstruction caused by the disease, we consider that the condition is irreversible and that additional surgery is required. However, if the patient has no such symptoms, we generally wait at least 1 year before performing such surgery. The time required for restoration after HPWJ treatment differed from side to side and patient to patient, and was probably affected by the extent of damage to the periosteum and the condition of the ethmoid, among other factors. In cases that required more than several months for restoration after the HPWJ procedure, it cannot be said readily that the surgery was effective. However, the 33 sides that were restored within 3 months of the HPWJ procedure (65% of 51 total restored sides) can be considered successful. Furthermore, owing to the rapid recovery of a number of patients within 1 month of the HPWJ procedure, we estimated that we could achieve better results if the periosteum were left even more intact. Use of a microdebrider system could be an ideal method to avoid damage to the periosteum. However, there is no method to remove entirely the diseased mucosa intranasally other than the HPWJ. ONLUSIONS Although most mucosal tissue is removed by this operation, our method differs from radical surgery because the periosteum is preserved so that regeneration of normal mucosa over the periosteum can occur without granulation on denuded bone; there is no risk for reduction of the size of the cavity by scar formation; and there is no risk for disturbance of the development of the maxillary bone in children. Rather than revision surgery, surgery based on this principle can be called a second-step operation for intractably disease to fulfill the aim of ESS. The HPWJ is an effective functional method for treating diffuse intractably diseased tissue in the maxillary sinus as a secondstep procedure after ESS. Accepted for publication July 23, We thank Tomoyuki Hoshino, M, and Isao Kosugi, M, Hamamatsu University School of Medicine, Hamamatsu, Japan, for the photographic work. 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