ENDOSCOPIC LASER SURGERY OF THE MIDDLE MEATUS FOR CHRONIC PARANASAL SINUSITIS Yosaku Shiomi, Nobuya Fujiki*, Kyosuke Kurata* Department of Otolaryngology, Matsue Municipal Hospital, Shimane *Department of Otolaryngology, Kyoto University Hospital, Kyoto This paper assesses the effectiveness of our laser surgical technique for chronic paranasal sinusitis retrospectively. Forty-one adult with chronic paranasal sinusitis and bilateral nasal polyposis underwent laser surgery. After local anesthesia was administered, nasal polyps were resected and the diseased mucous membrane of the middle and middle turbinate were vaporized with a CO2 laser, without opening the paranasal sinuses. Relief or improvement of symptoms was achieved in with nasal obstruction (100%), amount of nasal discharge (97.4%), and anosmia (85.8%). The degree of opacity of the maxillary and ethmoid sinuses on x-ray films improved in 95% and 93.8% of sinuses, respectively. The laser surgical technique that we have developed for chronic paranasal sinusitis is noninvasive and appears to be a good alternative to the Caldwell-Luc operation or endoscopic sinus surgery. Key words: chronic paranasal sinusitis, CO2 laser, endoscope Introduction Recently functional endoscopic sinus surgery (FESS) was developed1-3) as a result of the endoscopic finding4,5) that the pathogenic origin of paranasal sinusitis is in the middle -anterior ethmoid complex (osteomeatal complex). And it was demonstrated that during postoperative recuperation of paranasal sinuses after FESS, once aeration of the sinuses was restored, even severe mucosal diseasewhich was assumed to be irreversible-returned to normal1). FESS is aimed at the fenestration of anterior ethmoidal cells to widen the osteomeatal complex and improve ventilation of paranasal sinuses. Therefore, if opening the osteomeatal complex resulted in improvement of aeration of paranasal sinuses, it seemed that a less invasive procedure to keep the middle open might be adopted to improve the ventilation of paranasal sinuses. We attempted laser surgery of the nasal mucosa to keep the middle open using CO2 laser without changing the architecture of the osteomeatal complex. Materials and Methods Surgical Procedure Surgery was performed under local anesthesia. The nasal cavities were packed with 4%Xylocaine-and epinephrine-soaked gauze preoperatively, and during the operation 0.5%Xylocaine(R) with 1:100,000 epinephrine was also applied. Nasal polyps were transected with a nasal polyp snare a grasping forceps. The polypoid mucous membranes of the middle turbinate, ethmoid bulla and semilunar hiatus were also removed as much as possible using a grasping cutting forceps without fenestrating the ethmoidal sinuses (Figure 1). The architecture of the osteomeatal complex and orifices of paranasal sinuses were left untouched. Next, all residual polypoid mucous membranes of the
日 鼻 middle and the middle turbinate were vapor- propionate (200 micrograms ized with CO, LASER (MEDILASER 30-S, Mochida, propionate (200 micrograms Tokyo, delivery). intranasally in an aqueous Japan; procedures 1-3W, continuous were performed All under a rigid sinus endos- cope (Olympus(R),Tokyo, Japan; optical axis of 0 and until the mucous or fluticasone bid) was also applied spray for several membrane 1999 months of the middle became normal. 30). Before and three months after surgery, the Patients and Method Forty-one were asked to rate their nasal symptoms: adult age 12-76 years and bilateral underwent (24 men and 17 women, (47.6+17.0 with allergic rhinitis) years), eleven of them with severe paranasal nasal polyposis the laser surgery. were not performed bid) 誌38(4), resistant to medication Concurrent septoplasties in any of the subjects. had been treated preoperatively or longer with medication (RXM) (150mg dipropionate ment. All the before the operation to evaluate The The duration aqueous 2: moderate; between the effectiveness 150mg per day) and tranilast of symptoms of the treat- by comparing the opacity of maxillary and ethmoidal sinuses on x-ray also determined Operative (roxithromycin, Beclometasone technique 1. Nasal polyps 2. All morbid observation In every patient, of the nasal cavity a crust was observed in the middle middle turbinate, but the nasal vaporized sive proliferation di- of the laser surgery. were resected mucous soon after cavity of the middle with CO2 laser. -(437) 49- Orifices of paranasal while and paranasal the middle sinuses were sinuses. turbinate the formation findings of the left nasal cavity are shown. the turbinates to As no exces- of tissue was observed in the nasal cavity. on the returned wound was healing, there was no synechia while preserving membrane CT films Results laser surgery (300mg per day) were postoperatively. the two was normal about one month after surgery. antibiotics 3: effectiveness radiologically but ranged from 6 months to 40 years macrolide scale between before and one year after surgery. (9.7+10.4 years). Figure 1 1: slight; aqueous nasal spray bid in our center, on a 4-point The scores were compared occasions for 3 months bid or fluticasone propionate showed no improvement. administered asymptomatic; severe). consisting of roxithromycin nasal spray 200 micrograms Low-dose (0: 3) anosmia, per day) and lysozyme chloride, and with beclometasone 200 micrograms sinusitis tion, 2) rhinorrhea, 1) obstruc- was
日 鼻 誌38(4), 1999 Figure 2-A, B findings of the nasal cavity A 40-year-old female was free of symptoms es; (A) and CT before laser surgery with severe nasal one year no recurrence obstruction, following laser surgery. of polyp can be observed. Table 1 Symptoms purulent following rhinorrhea, Nasal No opacity laser surgery endoscopy in 30.7%. and no recurrence recovered regained it partially. tative case; Figure 2-A shows a represen- after surgery, blockage The degree of the middle and swelling of the middle turbinates com- ethmoidal shows normal Concerning their of opacity Figure 2-B shows chronological laser surgery. of the charge Nasal obstruction and decreased were relieved disappeared disappeared in 14.6%, that of this symptom. is, all Nasal in 66.7% of the of the sinuses, respectively observed on CT, in a representative in 85.4% atively. dis- and de- -(438) 50- of smell, of 42.9% and the sinuses on x-ray films improved in 95% and Clinical Results There middle 42.9% of the maxillary 93.8% changes 3 months after anosmia, full sense pletely disappeared. Table 1 shows symptomatic (B) patient (n=41) creased the course of recovery. and anosmia.the of the sinuses can be seen on CT. observed to be opened under endoscopic examination, of polyps was observed throughout and 1 year after surgery were no complications (Table changes 2). in opacity case. peri-and postoper-
Table 2 X-ray findings following laser surgery (n=number of sinuses) Discussion During the past decade, several authors attempted to establish a clinical staging system for hyperplastic rhinosinusitis by findings on the radiographic studies6), the presence or absence of nasal polyposis7) the effectiveness of conservative medical therapiese8). According to these papers, surgical intervention is the rational way to handle the chronic rhinosinusitis concurring with nasal polyposis and being resistant to medication. Cumulative endoscopic investigations have demonstrated that in most cases paranasal sinusitis originates in the nasal cavity4,5). Obstruction of the inf undibular area prevents mucus transport from the paranasal sinuses. FESS was developed by Messerklinger4,5) to correct that condition. Two techniques of improving infundibular obstruction2,3) are now in use. While, both of them fenestrate paranasal sinuses. Our laser surgical technique is a less invasive method for removing the pathologic mucous membrane and polyps from the nasal cavity without touching paranasal sinuses. Nasal polyps are prone to recur after simple polypectomy with snare forceps and the middle is apt to be obstructed again9), while laser irradiation inhibits excessive proliferation of tissue during the wound healing process and prevents regrowth of polyps10). Therefore, vaporization of polypoid mucous membrane with laser in the middle and middle turbinate can open the middle for a long time, help to ventilate the osteomeatal complex and normalize nasal and paranasal aeration. In our series, neither regrowth of polyps, nor development of granulation has been observed during follow-up (maximum: for 4 years). The improvement of paranasal opacity detected by radiographical examination indicated that surgery was effective in opening not only the middle but also the orifice of paranasal sinuses, restoring thereby normal ventilation. One or two months after surgery, secretion and crust in the middle disappeared, which suggested recovery of normal mucociliary function. Macrolide antibiotics, which are reported to normalize hypersecretion11), might assist mucociliary clearance. Postoperatively, we also applied tranilast, which has been reported to suppress collagen synthesis by fibroblasts12), expecting to inhibit excessive proliferation of tissue and thus keep the osteomeatal complex open. In some, the procedure had to be performed twice to attain complete alleviation of symptoms. Conclusion Forty-one with chronic paranasal sinusitis underwent laser surgery dealing with only the diseased nasal mucosa to open the middle. Most were cured or experienced improvement simply by removing middle meatal obstruction, which brought about better aeration and improved mucociliary transport of the osteomeatal complex. These results imply that it is not always necessary to open the paranasal sinuses to achieve physiological reversal of sinus disease and that this procedure can be a good alternative to the Caldwell-Luc operation or endoscopic sinus surgery. References 1) Kennedy DW, Zinreich SJ, Rosenbaum AE, et al: Functional endoscopic sinus surgery: theory and diagnostic evaluation. Arch Otolaryngol Head Neck Surg 111: 576-582, 1985. 2) Kennedy DW: Functional endoscopic sinus surgery: technique. Arch Otolaryngol Head Neck Surg 111: 643-649, 1985. 3) Wigand ME, Steiner W, Jaumann MP: Endonasal sinus surgery with endoscopic control: from radical operation to rehabilitation of the mucosa. Endoscopy 10: 255-260, 1978. 4) Messerklinger W: Die Rolle der lateralen
Nasenwand in der Pathogenese, Diagnose and Therapie der rezidivierenden and chronischen Rhinosinusitis. Laryngol Rhinol Otol (Stuttg) 66: 293-299, 1978. 5) Messerklinger W: Endoscopy of the nose. Urban s Schwarzenberg, Baltimore.: 49-60, 1978. 6) Friedman WH, Katsantonis GP, Sivore M, et al: Computed tomography staging of the paranasal sinuses in chronic hyperplastic rhinosinusitis. Laryngoscope 100: 1161-1165, 1990. 7) Eichel BS: A proposal for a staging system for hyperplastic rhinosinusitis based on the presence of intranasal polyposis. Ear Nose Throat J 78: 262-265, 1999. 8) Eichel BS: Simplified method of staging hyperplastic rhinosinusitis. Arch Otolaryngol Head Neck Surg 121: 725-728, 1995. 9) Larsen K, Tos M: A long-term follow-up study of nasal polyp after simple polypectomies. Eur Arch Otorhinolaryngol Suppl: 1: S85-88, 1997. 10) Ohyama M: Laser Polypectomy. Rhinology Suppl 8: 35-43, 1989. 11) Goswami SK, Kivity S, Marom Z: Erythromycin inhibitss respiratory glucoconjugate secretion from human airways in vitro. Am Rev Respir Dis 141: 72-78, 1990. 12) Suzawa H, Kikuchi S, Arai N, et al: The mechanism involved in the inhibitory action of tranilast on collagen biosynthesis of keroid fibroblasts. Jpn J Pharmacol 60: 91-96, 1992. e-mail: yshiomiaby3.so-net.ne.jp