Dr. DelGaudio agreed. If the obstruction is not adequately relieved, the sinuses inadequately opened, and the underlying disease not addressed by the surgery, the likelihood of failure is increased, Dr. DelGaudio said. One of the most frequent reasons for frontal sinus surgery failure is inadequate control of disease in the frontal recess.
Explore This IssueAugust 2008
The challenge is to preserve as much of the healthy mucosa as possible to prevent stenosis or scarring while performing a complete surgery to allow adequate ventilation of the sinuses.
Failures can also occur in people who were appropriate candidates and had persistent symptoms afterward. Such symptoms may be due to disease factors such as significant nasal polyps with aspirin sensitivity, allergic fungal sinusitis, advanced radiological disease according to Lund-McKay scores, or cigarette smoking.
The surgeon should also be alert to problems that become known intraoperatively, such as fungal rhinosinusitis, said Dr. Kountakis. Such patients are less likely to have satisfying outcomes, as are patients with high sinus tissue eosinophil counts. In his practice, the pathologist counts the number of eosinophils per higher power field for at least five different fields, and then averages them. Fewer than five per higher power field are associated with better outcomes than those with larger counts, he said.
Dr. Kountakis and his colleagues use intraoperative pathological findings to stage patients into one of four prognostic categories and treat them accordingly postoperatively.1 The first category consists of patients with polyps that have a high number of tissue eosinophils. Such patients will probably have recurrence and require more surgeries in the future, he said. They require more aggressive therapy, with longer steroid tapers, as well as additional intranasal and oral anti-inflammatory medications.
In the second group, patients have polyps but without high tissue eosinophilia; these patients receive shorter courses of medical therapy. The third group has mucosal involvement but no polyps, and does not require prolonged oral steroids. In the last group, which is most likely to have a good outcome after surgery, patients have no polyps, no mucosal involvement, and no sinus tissue eosinophilia. Their long-term postoperative management is typically limited to intranasal corticosteroid spray medication.
Individualize Postoperative Care
The postoperative regimen is not one size fits all, Dr. Senior said. Different patients will need different types of medications, and sometimes you have to test several medications on a patient to find what works best. This may involve the right antibiotic, steroids, an antihistamine, a leukotriene inhibitor, or combination therapy.