The Evolution of Endoscopic Sinus Surgery

Surgical precision continues to improve. With dramatic improvements in anesthetic safety, surgical time is no longer as critical an issue as it was previously, enabling the prudent surgeon to further reduce mucosal trauma, while at the same time performing a more complete procedure. The recent introduction of high-pressure dilation balloons (balloon sinuplasty) may further reduce mucosal trauma in highly selected cases. However, the positioning of this device as an alternative to surgery in many of the patients currently undergoing surgery would appear to be an unfortunate deception imparted on the patient population that we are trying to serve.

What the Future Holds

The demonstrated ability of rhinologists to close skull base defects and cerebrospinal fluid leaks with greater success rate than by craniotomy has already significantly extended the potential for endoscopic transnasal approaches. Benign, and even selected malignant, skull base tumors can now be approached by skilled endoscopic surgeons with major reductions in patient morbidity and improved surgical visualization. Yet we may have barely begun to scratch the surface of what is possible through an endoscopic approach. Although currently still too large for transnasal use, the surgical robot has demonstrated excellent utility for transoral surgery and carries the potential to dramatically enlarge the type of surgery that can be performed at the skull base and intracranially via the intranasal route. When small enough to be utilized intranasally, this device caries the potential to allow intracranial manipulation without tremor and with a level of dexterity not available even to the most skilled skull base surgeons. Additionally, it caries the potential to use vascular clipping or bipolar cauterization of intracranial blood vessels which cannot be reached with currently available technology significantly expanding the intracranial horizons for this type of surgery, while at the same time also reducing postoperative complications by allowing direct suture closure of dural patches.

The past 20 years have been an exciting period for rhinology, and evidence would suggest that the rapid advancements which have occurred to date will continue in the years ahead. The primary advances in terms of chronic rhinosinusitis will likely occur in the realm of further improvements in the understanding of the inflammatory pathways and their pharmacological control. However, surgery will likely continue to play a significant role for a minority of patients whose quality of life is impacted by this disorder. Since current estimates place the number of affected individuals at approximately 32 million people in the United States, it is likely that there will still be a sizeable population requiring surgical intervention, even as our medical therapies continue to improve. The sinus surgery is likely to be considerably more meticulous and less traumatic than it frequently is today. Additionally, the potential for advancements in skull base surgery remains large.