Nonstandard Thinking Required to Meet the Challenge of Complex Sinus Conditions

“I would consent him as if I was going to do a traditional endoscopic sinus surgery,” said Michael Stewart, MD, Professor and Chair of Otorhinolaryngology at Weill Medical College of Cornell University in New York, NY, and ENToday Board Member. But, if another etiology was present, such as a potential lymphoma or squamous cell carcinoma, then a biopsy should be done. The course of action depends on the findings.

Generally, the panelists agreed they would ask for consent for a wide variety of investigations and procedures.

In pediatrics, the consent process is extensive, said Dr. Parikh. However, with kids there is an advantage in that parents can be asked for consent at almost any point, even during a procedure.

Endoscopic or Open Surgery for Carcinoma?

Further work on the patient revealed a friable mass filling the right ethmoid sinus extending to the face of the sphenoid, and it was squamous cell carcinoma. Panelists had different opinions on what the next step should be.

“I would consider removing it endoscopically,” especially if the mass had a small pedicle, said Dr. Palmer.

In Dr. Witterick’s office, only a biopsy would be done. A metastatic work-up would follow if squamous cell carcinoma was present. “Our primary treatment modality is usually radiation therapy or chemo-radiation. The vast majority of these people will not need any surgical resection,” he said. A traditional craniofacial resection would be performed if there was persistent disease or recurrence.

Dr. Fried reported that in this case, the mass had a small pedicle, was removed and multiple biopsies taken. The patient then underwent radiation therapy for any residual disease.

“I think it’s interesting we have this debate about endoscopic versus open, as if they are mutually exclusive… People get hot and bothered about which one, but in fact you don’t have to declare one side or the other. Endoscopy is a wonderful way to facilitate an open resection,” said Dr. Stewart.

Saline versus Debridement

Panelists then discussed how to proceed with a 55-year old woman with progressive diplopia, bilateral nasal obstruction, left epiphora and forehead pain. She had standard nasal polyposis, had a large left frontal mucopyocele, and had undergone surgery. The question was whether or not post-operative debridement should be done.

“I rely more on saline solution…you have a scab, let it heal and once it falls off it falls off. Have them use a saline rinse,” said Dr. Witterick.