Panel Debates when to Use an Endoscopic Approach to Sinus Surgery

Recurrent acute rhinosinusitis (RARS) is one such disease. “Many of these cases are asymptomatic,” explained Dr. Hwang. “They can require multiple onsets.” CT scans done between exacerbations may be negative; this does not exclude a diagnosis of RARS. Establishing a diagnosis in these cases can take months or even years. “There is very limited data available for outcomes” in cases of RARS, said Dr. Hwang. Unanswered questions on RARS include: What is the optimal medical therapy? Is there a threshold number of episodes per year that would justify surgery? What is the optimal timing of radiologic evaluation? and, perhaps most importantly, Who benefits from surgery?

“Surgery for minimal disease is a controversial area. It’s driven by anecdotal experience and personal opinion.” – Peter H. Hwang, MD

Barosinusitis is another minimal disease, often but not always found in patients with chronic sinusitis. “There is a potential role for surgery in negative CT barosinusitis,” said Dr. Hwang. There are very limited case reports available, all reporting surgical success.

Controversy over Headaches

Contact point headache is more controversial; “Is it real or mythical?” asked Dr. Hwang. “The International Headache Society doesn’t believe in it.” However, there is a theory that mucosal contact leads to elaboration of substance P, which may lead to stimulation of afferent c pain fibers and local mucosal inflammation with exacerbation of the contact area. Contact point headache presents as self-diagnosed sinusitis that is unresponsive to antibiotics. It typically has a negative CT scan and can be partially relieved with decongestants and steroids.

“For your patients, I encourage you to proceed with caution and rule out other causes of headache,” said Dr. Hwang. “The majority of these patients will benefit from medical therapy.”

Finally, Dr. Hwang addressed CT-negative chronic sinusitis. “This is the most controversial area,” he said. “Some wonder if this entity really exists. And if so, is it surgically amenable? I’m not here to argue the point of its existence…” He went on to say that he found only one study where patients were treated with a normal CT scan and normal endoscopy.

Dr. Hwang concluded, “For patients who have ‘minimal disease,’ we need to make sure we make the correct diagnosis. We have to understand that a CT scan may not show the whole picture of health.” He stressed, “Surgery should be a rare event.”

Surgery for Advanced Disease

Roy R. Casiano, MD, Associate Professor of Otolaryngology at the University of Miami School of Medicine (Fla.), then covered indications for endoscopic sinus surgery in advanced disease, asking, “How much surgery is enough?”