Over the past several decades, endoscopic sinus surgery has grown to include a series of advanced, minimally invasive procedures. This is in large part due to the work of the experts in the field creating new techniques to access complex anatomy while minimizing morbidity to the patient. Despite these advances, some sinus problems on occasion require a more aggressive approach. In this article, we describe five techniques that have fallen out of favor in recent years. We mean to show that they are useful adjuncts in treating some patients with sinus disease.
ENDOSCOPIC PARTIAL MIDDLE TURBINECTOMY
Ever since the introduction of the endoscopic antrostomy in 1987 by Kennedy, the question of removing the middle turbinate has been marked by controversy. To date, there has been little compelling information about the function of the middle turbinate in the nasal cavity. However, in the senior authors’ practice over the last 26 years many patients undergoing revision endoscopic sinus surgery have benefited from the removal of the middle turbinate.
In some instances, preservation of the middle turbinate may result in poor outcomes. The middle turbinate can scar laterally resulting in blockage of the middle meatus and subsequent maxillary and frontal sinusitis. When revising this type of scar tissue, we recommend partial endoscopic removal as described by Nurse and Duncavage . In some instances, a preserved middle turbinate can make postoperative access to the maxillary sinus difficult. Similarly, the preservation of the middle turbinate in an isolated endoscopic sphenoidotomy may lead the original surgeon to miss a scarred sphenoidotomy.
In patients with a large concha bullosa and contralateral nasal septal deviation, if the medial aspect of the concha is preserved, persistent septal deviation may result. This occurs when the medial aspect of the concha, still attached to its vertical attachment superiorly, bulges into the septum causing it to deviate to the contralateral side. If the medial concha attachment is not removed, it may result in persistent septal deviation.
The current endoscopic surgical concept for managing nasal polyps with chronic rhinosinusitis is to nasalize the sinus cavities. This allows for topical medications to reach further into the nose and sinuses and thereby minimize polyp regrowth. Soler et al.  studied outcomes after middle turbinate resection. The middle turbinate resection group was statistically more likely to have asthma, aspirin intolerance, nasal polyposis and prior sinus surgery. This group also had more extensive surgery. Their findings showed a higher improvement in postoperative endoscopy and sense of smell testing compared with the middle turbinate preservation group.
We suggest that when performing endoscopic sinus surgery, the surgeon evaluates the role of the middle turbinate and whether its removal may benefit the patient's long-term outcomes.
MAXILLARY SINOSCOPY (CANINE FOSSA PUNCTURE) AND THE CALDWELL-LUC PROCEDURES
In the treatment of maxillary sinus disease, two issues have challenged the conventional wisdom that endoscopic surgery alone is sufficient. First, views of the most anterior, inferior portion of the maxillary sinus can be difficult with standard endoscopes, and even with 70 or 120° telescopes. Inferior turbinate anatomy and anterior–posterior distance from nare to posterior border of the nasolacrimal duct may be sufficiently large to prevent the surgeon from positioning the endoscope to visualize the inferior mucosa of the sinus. And in patients with recalcitrant maxillary disease despite aggressive medical and endoscopic surgical therapy, mucosal abnormalities in this difficult-to-view area may be the cause.
Second, the severity of the disease process may not be sufficiently addressed with even advanced endoscopic techniques. Recent literature challenges the idea that endoscopic maxillary antrostomy, either standard or mega-antrostomy, is sufficient to treat severe disease [3,4▪]. The mucosa in severe cases of chronic rhinosinusitis with or without nasal polyps may be overwhelmingly edematous and covered with thick eosinophilic mucin, and thus may be resistant to medical treatments even in the presence of a sufficient middle meatus antrostomy. Anecdotal evidence exists that complete removal of the diseased mucosa, or at least a significant debulking, results in significantly improved postoperative course and lower revision surgery rates [5▪]. However, the ability to remove that mucosa is limited in endoscopic techniques because of visualization and instrument rigidity. Access to that mucosa requires a more radical approach through the front wall of the sinus. To address these issues, the sinus surgeon must look back to more traditional sinus surgery techniques including maxillary sinoscopy via canine fossa puncture and the Caldwell-Luc/canine fossa trephine approach.
One option for investigation of the mucosa is maxillary sinoscopy through a sublabial, canine fossa puncture approach. For the sinoscopy, the surgeon uses an endoscopic trocar to traverse the canine fossa into the maxillary sinus. This trocar should be short, between 5 and 7 cm, so that the endoscope and/or instruments can be passed and the most anterior/inferior aspects of the sinus can be addressed. Robinson and Wormald [6,7] described an ideal point of anterior entry into the sinus at the intersection of the mid-pupillary line and the horizontal line through the floor of the nasal vestibule. Figure 1 depicts this point. Once this landmark is identified, a trocar is twisted to puncture the bone of the anterior wall of the maxillary sinus. When the disease process is severe enough, endoscopic instruments may not be sufficient to remove the diseased mucosa. To extend the sinoscopy approach into a Caldwell-Luc, the puncture site is expanded using biting instruments, such as Kerrison rongeurs. One must carefully elevate the periosteum overlying the bone to not injure the nerves. Primary closure of the puncture site is rarely indicated if the mucosal incision is no larger than the trocar itself. For the Caldwell-Luc, interrupted sutures with vicryl or chromic are sufficient.
In both procedures, the trocar should not be hammered into the sinus because of the possibility of fracture of the anterior wall through the branches of the infraorbital nerve and anterior–superior alveolar nerve (ASAN) with resultant facial numbness. Also, injury to the posterior wall of the sinus is a possibility. One must be mindful of the tooth roots, and stay above them with the puncture. With concomitant use of surgical navigation, the placement and trajectory of the puncture can be carefully chosen. Careful attention to these guidelines will diminish the risk for dental numbness, facial hypoesthesia and dentition injury. In general, published rates of complications from this procedure are less than 1–3% [8,9].
The opposition to these procedure stems in large part to the concern for the associated morbidity [10▪]; however, the data have shown that complications are minimal in experienced hands [8,9,11–13]. In addition, evidence is building that it is successful in addressing severe disease. Cutler et al.  reviewed 133 Caldwell-Luc procedures with a follow-up of 1–6 years. They found a 92% success rate with an average follow-up of 23.5 months. The most common risk for the Caldwell-Luc procedure is the failure of the surgery to cure the infection. Eight percent (n of 53) of patients in this review did not respond to the surgery. In two of these three cases, failure was caused by trapped mucosa and these cases were successfully salvaged with a repeat Caldwell-Luc procedure. Other evidence demonstrates the utility of canine fossa trephine/puncture in recalcitrant disease [3,4▪,14]. Sieberling et al.  demonstrated that in 67 patients with an average of 2.83 previous endoscopic sinus surgeries, the Caldwell-Luc trephine procedure resulted in clearance of disease. This is contrary to evidence by Lee et al.  that showed no difference in outcomes in a randomized control trial comparing Caldwell-Luc procedure and endoscopic maxillary antrostomy. But as Sieberling et al.  point out, the variability in severity of disease across these studies makes definitive conclusions difficult.
Maxillary sinoscopy and the Caldwell-Luc procedure are important tools for otolaryngologists to consider in difficult-to-treat patients with maxillary sinus disease, as they allow the surgeon to access and address potentially disease-altering tissue. Although the evidence is not definitive, these procedures should not be forgotten or condemned.
INJECTION OF STEROIDS INTO SINONASAL INFLAMMATORY POLYPS
Intranasal steroid injections have been used for the treatment of allergic rhinitis and nasal polyps for more than 60 years [15,16]. Reports about transient and permanent visual loss emerged shortly after their introduction and their use has subsequently declined . This rare complication is believed to be secondary to the injection of large-particle sized corticosteroids directly into the mucosa of the inferior turbinate and nasal septum. There has been one published case of transient blindness after steroid injection into a sinonasal polyp . It is believed that steroid particles travel in a retrograde fashion through the ethmoidal circulation to enter the central retinal artery causing embolization and/or vasospasm. To diminish the likelihood of visual complications from intranasal steroid injections, Mabry recommended using a small particle size steroid, a small-gauge needle, and adequate preinjection topical vasoconstriction .
The authors use intrapolyp injection of steroids in an attempt to avoid further surgery for patients with recurrent polyposis whose symptoms are only marginally controlled with medical therapy. The authors apply an aerosolized mixture of topical anesthetic and decongestant prior to the intranasal injection of Kenalog-40 mg (Bristol-Myers Squibb, New York, New York, USA). 0.5–1 ml are drawn into a syringe and then slowly injected directly into the central portion of the nasal polyp. If multiple polyps are present, every effort is made to inject each polyp. The authors use a 25-gauge spinal needle under endoscopic visualization and not more than 0.5 ml of steroid is injected per side. The use of a rigid nasal endoscope is strongly recommended to avoid injection into the nasal mucosa. The most common complication in our patient population is short lasting epistaxis and failure to improve. Patients often require another injection in 8–12 weeks.
Most studies about intrapolyp injection of steroids are retrospective, or anecdotal, and report favorable results. Becker found a statistically significant decrease in the mean monthly rate of surgery for patients that underwent surgery and injection when compared with patients who underwent surgery alone. He also found that 19% of patients with difficult to control symptoms on medical therapy avoided the need for surgery when triamcinolone injections were instituted . Kapucu et al. [20▪] demonstrated a significant increase in the apoptotic index of nasal polyps after being treated with triamcinolone injection when compared with a nonmedication control group and a similar apoptotic index when compared with topical and systemic steroids.
The risk of visual complications from an intrapolyp injection of steroid is extremely rare, but is serious enough to deter practicing otolaryngologists from engaging in its practice. Recent studies resulting in thousands of injections of steroids into nasal polyps have shown no visual or systemic complications [19,20▪,21]. Despite their safety profile in the use for nasal polyps, their use remains controversial and off-label. Further studies are needed to demonstrate their efficacy when compared with standard therapy.
FRONTAL SINUS TREPHINATION
The endoscopic approach to the frontal sinus is considered the standard for the surgical treatment of frontal sinus disease. The frontal recess contains a complex anatomy that requires great understanding in order to manage chronic frontal sinusitis and other pathology. Despite extensive training on the anatomy, physiology and management, the frontal sinus remains one of the most challenging areas to treat surgically . Scarring of the frontal recess after surgery, air cells within the sinus, disease at the far lateral aspect of the sinus, and the presence of tumors are reasons for persistent frontal sinusitis and the need for frontal sinus surgery. A frontal sinus trephine allows the manipulation of hard-to-reach areas in the frontal sinus by allowing scopes and instruments, that otherwise would not have reached via standard endoscopic approaches, to be passed into the sinus. It is also useful as an adjunct to standard endoscopic frontal sinus surgery to find the recess when the anatomy is severely distorted from previous surgery, scarring, ossification or infection [23,24▪,25].
The authors perform a frontal sinus trephine as an adjunct to endonasal techniques only if the target region is not accessible via standard endoscopic approaches. The forehead is prepped and the medial brow is injected with 1% lidocaine with epinephrine 1 : 100 000. A 0.5 cm incision is made approximately 1–1.5 cm from the midline at the inferomedial margin of the brow or within the brow. If the incision is placed within the brow, the blade should be beveled parallel to the hair follicles to avoid eyebrow alopecia and a better cosmetic result. The soft tissues are gently dissected sparing the supratrochlear and supraorbital neurovascular bundles until the frontal bone is exposed. The periosteum is dissected off the bone and the location for the trephine marked.
The ideal location of the frontal sinus trephine has not been formally established. Traditional teaching recommends performing it close to the floor of the sinus about 1–1.5 cm from the midline wherein the depth of the frontal sinus is the greatest thus minimizing the risk of posterior table penetration. Lee et al.  recently measured the depth of the frontal sinus at 0.5, 1.0 and 1.5 cm from the midline and found no statistically significant difference in measurements. Lee did find an increased risk of cross trephination when performed 0.5 cm from midline because of the variable location of the intersinus septum. Image-guided surgery is commonly used when addressing the frontal sinus endoscopically, but it can also be used to locate the safest area for the trephine. Image guidance trephination offers several advantages over ‘blind entry’ in that it can specifically localize the target lesion, minimizes the size of the skin incision and trephination and lowers the risk of intracranial entry .
The authors prefer to use image guidance to localize the site for the trephine. Once localized, a 4 mm burr is used to drill the anterior table and enter the frontal sinus in an area that is strategic and will provide the greatest access to the disease. Bone-cutting instruments can be used to enlarge the opening if desired. Endoscopes are introduced through the trephine and the sinus cavity and drainage pathways are evaluated. Instruments are inserted through the trephine and the pathology is removed. If the frontal recess anatomy is distorted, cannulating or irrigating through the trephine while visualizing the recess endonasally may find the opening to the frontal sinus. A frontal sinus stent may be placed through the trephine or endoscopically. The periosteum is approximated with absorbable sutures and the skin incision sutured.
The combined used of a frontal sinus trephine with endoscopic frontal sinus surgery often spares the patient the need for more invasive procedures. Benoit and Duncavage  found no statistically significant difference in symptom improvement and patency rate after a combined approach versus an endoscopic Lothrop procedure. They found a patency rate of 79 and 82% for the combined approach and the endoscopic Lothrop, respectively . A trephine also allows for preservation of natural frontal outflow drainage pathway, facilitates endoscopic and radiographic surveillance postoperatively and is cosmetically appealing .
A disadvantage of the frontal sinus trephination is external scar formation. There should be gentle soft tissue manipulation and the trephine should not be larger than 0.5 cm to avoid soft tissue prolapse and poor cosmetic results . Minor complications have been reported like facial cellulitis and wound infection . Other rare but potential complications are penetration of the posterior table, cerebrospinal fluid leak and ophthalmologic injury.
Frontal trephination as an adjunct to standard endoscopic frontal sinus surgery is a useful mode of treatment for frontal sinus pathology in patients with unfavorable endoscopic anatomy. It allows greater manipulation of the sinus contents and spares the patient more invasive and potentially riskier procedures.
The above procedures are useful adjuncts to endoscopic sinus surgery. Sinusitis is an inflammatory disease, and in many cases direct visualization and surgical treatment of the diseased mucosa is required. To access difficult to reach areas and to maximize medical treatment to those areas, the surgeon will find these techniques useful.
Conflicts of interest
J.S.S. has nothing to disclose.
J.A.D. has nothing to disclose.
A.A. has nothing to disclose.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 88–89).
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An excellent article describing how the canine fossa trephine can benefit patients with recalcitrant disease.
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Interesting article about how the Caldwell-Luc procedure accesses often missed pathology in the maxillary sinus.
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Important article on how the maxillary antrostomy's importance should not be minimized in surgery despite its seemingly simple approach.
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Important article comparing the effect of the different modes of steroid delivery on nasal polyps.
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A good article describing how certain pathology in the frontal sinus may require nonendoscopic approaches.
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