Case Studies in Endoscopic Sinus Surgery

Different scopes revealed different details. Initial endoscopic exam using a 30-degree scope revealed a patent maxillary antrostomy and seemingly normal antral mucosa. However, when a 45-degree rigid scope was used in this case, the remnants of a fungal ball could be seen at the inferiormost aspect of the maxillary sinus. With a flexible scope, the full extent of the remnant fungus could be appreciated, and it was found to extend to the anterior wall of the sinus.

The patient underwent revision maxillary antrostomy and the remaining fungus was removed. The symptoms resolved and the patient was still fungus-free after three months.

The message here is that 45-degree and flexible scopes are the key to diagnosing maxillary sinus pathology in a seemingly normal postsurgical maxillary sinus cavity. Occult disease may lie anteriorly and inferiorly within the sinus, beyond the view of 0-degree or 30-degree scopes, Dr. Hwang said.

Another case where fungus was a factor was presented by James Stankiewicz, MD, Professor and Chair of Otolaryngology-Head and Neck Surgery at the Loyola University Medical Center. Here, a 40-year-old male presented with fungal sinusitis. He had had previous ESS but continued to have significant edema and infection. The patient had failed various sorts of treatments, although there was some success with oral steroids.

A physical exam revealed large, swollen maxillary turbinates (MTs) blocking the ethmoid, frontal and maxillary sinuses. CT showed that the MTs obstructed sinus drainage.

To treat the patient, revision surgery was performed. This was a case in which the middle turbinate needed to be cut back significantly, in part to allow for topical therapy to get in better, Dr. Stankiewicz said. The MTs were cut back significantly.

But panelists agreed that for most patients the middle turbinates shouldn’t be removed-and not just for exposure. There is not always a clear answer and the physcian’s best clinical judgment needs to be used, he said.

Papilloma

Dr. Kennedy presented a case of a 70-year-old man who presented with left-sided nasal congestion with a prior history of endoscopic treatment for multiply recurrent inverted papilloma.

The patient had been informed by doctors overseas that he was free of the tumor, but presented with synchiae between the septum and lateral nasal wall on the left, a small antrostomy and inferior meatal window, plus polyps in the ethmoid sinus.

An office biopsy of the area in the maxillary sinus showed there was persistent papilloma, Dr. Kennedy said. There was also extensive residual tumor present on the medial orbit wall, skull base, supraorbital ethmoid, and maxillary sinus, he said.