The Evolution of Endoscopic Sinus Surgery

We now know that it is unwise to open up virgin mucosa to the same environmental factors that caused the inflammation to develop in the first place, unless those environmental factors have been removed or their effects medically controlled. Additionally, we have demonstrated conclusively that improvement in symptoms does not correlate with resolution of disease and that the latter typically requires prolonged medical therapy and careful endoscopic follow up. Indeed, it appears that in many cases surgery alone does not create a long-term resolution, and prolonged medical therapy is typically required for control of this chronic disorder.

Current Advances

Whereas, 20 years ago, the surgery itself was limited, quick, and frequently involved some stripping of mucosa from the ethmoid sinuses, it is now a much more meticulous procedure, with the surgeon taking care to preserve the mucoperiosteum and to avoid exposed bone. At the same time, significantly greater attention is given to completely removing the bony partitions in the areas of disease, because we now believe that this inflamed bone may lead to persistent inflammation and scarring. This surgical evolution has been aided by the development of through-cutting forceps and the microdebrider. As microdebrider technology has improved, so has the potential to remove disease rapidly with excellent mucoperiosteal preservation. However, with the use of powered instrumentation, there has also some suggestion that the degree of severity of complications may have again risen, because of the potential for microdebriders to rapidly remove either orbital contents or brain should the surgeon stray out of the normal surgical field.

A number of other technological advancements have had a significant impact on our ability to improve endoscopic sinus surgery. The ability of the Endoscrub™ to maintain clear visualization in the presence of bleeding, improved charge-coupled device (CCD) camera technology, and the development of suction irrigation drills have all enhanced our ability to completely remove disease and to extend the surgery beyond just the treatment of rhinosinusitis and beyond the boundaries of the nose. Although there is very limited evidence to suggest that the use of computer-assisted surgical navigation reduces complications, it clearly improves the surgeon’s ability to perform a complete surgical procedure and is a superb teaching tool. However, perhaps most important, scrolling through the images in a triplanar display preoperatively enables the surgeon to gain 3-D conceptualization of the anatomy, which is difficult to achieve with static images, even when they are available for review in all three planes. A significant limitation of computer-assisted surgical navigation, however, is its reliance on the preoperative scans. An exciting new development in this field is the introduction of portable low-radiation-dosage intraoperative CT with the ability to update the information in the image-guidance computer with real-time intraoperative images. Our preliminary work with such intraoperative CT scans suggests that they will be of significant benefit in ensuring the completeness of surgery.