Pansinus surgery is a surgical therapeutic procedure in otolaryngology that can be used to treat simultaneous inflammation of all sinuses. The pansinus operation represents a minimally invasive surgical procedure, so that there is relatively little stress for the patient peri- and postoperatively (during and after the operation). Because of this, the recovery period after surgery is relatively short. The sinuses include the frontal sinus, the maxillary sinus, the sphenoid sinus and the ethmoid sinus. In addition to a classic infection spreading in the sinuses, pansinus surgery is also used for anatomical malformations in the sinus area. Anatomical malformations can significantly increase the risk of chronic inflammation in the sinus area. In addition to these malformations, constrictions caused, for example, by polyps (visible change or proliferation of tissue that can be benign or malignant) or neoplasms (benign or malignant neoplasms with variable disease progression) predispose to the development of an inflammatory process. In this inflammation, an increase in volume of the tissue is basically detectable. In acute inflammations this is caused by a swelling of the tissue, in chronic processes the body’s defense reaction leads to a long-term adaptation reaction. Depending on the reason for the development of pansinusitis, it may be inevitable to prefer surgical treatment to conservative treatment with antibiotics. However, before surgical intervention is undertaken, it should be ensured that available nonsurgical measures to eliminate the inflammatory process have been exhausted. In addition to antibiotic therapy, antiphlogistics (anti-inflammatory drugs) and cortisone nasal sprays should be used by the patient as therapeutic measures. However, if surgical therapy is used too late when conservative measures are ineffective, secondary diseases may already occur in the larynxareal (laryngeal area) and bronchi.
Indications (areas of application)
- Complications of acute inflammation – if sinusitis (inflammation of the paranasal sinuses) spreads to the other sinus areas, this is not necessarily an indication for surgery, because the possibility of conservative treatment exists. However, if the inflammatory process is accompanied by complications of inflammation, there is a need for immediate surgery.
- Chronic sinus infection – if there is a permanent inflammation of the sinus areas, which can no longer be controlled with medication and may lead to chronic inflammation or secondary diseases of the larynx and bronchi, an early pansinus operation must be initiated.
- Mucocele or pyocele – if there is a formation of mucous or pus cysts, this is an indication for pansinus surgery.
- Expansion of the inflammatory area – if the present inflammation spreads to the orbit (eye socket) or the brain, then a rapid operation must be performed to avoid subsequent damage.
- Injuries to the base of the skull with cerebrospinal fluid (cerebrospinal fluid discharge).
- Polyp formation – due to the development of so-called polyps, the occurrence of ventilation disorders is relatively common, so that the polyps must be removed by sinus surgery to improve nasal breathing. In addition to this respiratory impairment, the polyps can also lead to olfactory disorders (dysosmia) or cause a tendency to ear trumpet catarrh (inflammation of the mucous membranes associated with increased fluid secretion) or otitis media (inflammation of the middle ear).
- Nosebleeds (epistaxis) – for unstoppable nosebleeds from the posterior ethmoid region, pansinus surgery is the first-line treatment option.
Contraindications
- Bleeding tendency – a congenital bleeding tendency, which may be due to hemophilia (hereditary blood clotting disorder), for example, requires special precautions to avoid serious peri- or postoperative complications. If there is still a risk, the operation must be canceled.
- Reduced general condition – since general anesthesia is performed during pansinus surgery, the patient must be physically able to compensate.
Before surgery
- Discontinuation of blood-thinning medications such as acetylsalicylic acid (ASA) or Marcumar should be done in consultation with the treating physician. Discontinuing medication for a short time significantly minimizes the risk of rebleeding without a significant increase in risk to the patient.
- Medications taken for symptom relief prior to surgical intervention should not be continued without consultation with the treating physician. It is possible that medications used for postoperative treatment and medications taken before surgery may adversely affect each other. During follow-up treatment, further medicinal measures are taken to prevent reinfection.
The surgical procedure
Anatomical characteristics and physiological function of the paranasal sinuses.
- The paranasal sinuses represent air-containing cavities lined with mucosa and connected to the nose by a system of passages. Due to this, there is a risk of inflammatory processes from the nose spreading throughout the network of cavities in the paranasal sinuses.
- However, because the excretory ducts have only a small circumference, pathogens (disease-causing agents) can easily implant and thus lead to permanent inflammation. The nidation (implantation of the germs) and the resulting inflammation can lead to obstructed nasal breathing, chronic rhinitis (rhinitis), tendency to infection, headaches and additionally to a disturbance of the sense of smell.
- With the help of surgery, the goal is to widen existing constrictions in the nasal respiratory tract and to remove mucous membranes altered due to inflammation.
Procedure
In the absence of success of non-surgical measures, there is an indication (indication) for the implementation of minimally invasive ablation of all existing ethmoid cells. However, during surgical removal, it is important to note that especially the vertical lamellae (anatomical support structure) of the middle and upper turbinates are spared. To achieve adequate protection of the lamellae, the procedure is performed using an endoscope, which may or may not be equipped with a microscope. At the beginning of the procedure, an anterior ethmoidectomy (removal of the ethmoid cells) is first performed with identification of the skull base so that a frontal sinus opening is possible. Removal of the ethmoid cells is usually followed by fenestration (windowed tissue removal) and, in some cases, total reconstruction of both the maxillary and frontal sinuses and the sphenoid sinus. Following the surgery performed, a nasal tamponade is often inserted and usually left in place for 48 hours. However, there are now also study results that advise against the use of nasal tamponade. In addition to the pansinus operation, it is possible to add other surgical measures to the surgical procedure. An example of such an additional measure is septal correction, which involves surgical reconstruction of the nasal septum, leading to remediation of the disease foci in case of respiratory problems on the one hand, or to improved visibility and instrument movement during the surgical procedure on the other hand. In addition, nasal turbinate reduction and tonsillectomy can be integrated into the surgery to better combat inflammatory processes or improve ventilation. However, it should be noted in this surgery that complications such as bleeding are very common even if the pansinus surgery is performed in a standard manner. If this complication occurs, immediate coagulation (obliteration) of the blood vessels is indicated. In addition to post-operative bleeding or infection, in rare cases there may be congestion of secretions or hematomas on the eye. Furthermore, the patient must accept a mostly temporary disturbance of the sense of smell.
After the operation
In the case of pansinus surgery, postoperative care represents an elementary part of the overall treatment concept, as otherwise adequate healing of the surgical site cannot be guaranteed.In particular, reventilation and restoration of mucociliary clearance (tiny hairs serve to transport mucus and pathogenic substances) as a defense mechanism of the mucosal areas are of great importance in the treatment scheme. Furthermore, the existing adhesion and encrustation must be loosened in order to reduce the probability of later recurrence. For optimal follow-up treatment, it is necessary that this is done either by the treating surgeon or by a resident ear, nose and throat specialist under endoscopic control. However, depending on the clinic, the methods of using nasal tamponade differ. Often, a rubber fingerling tamponade is inserted after surgery and must be removed a few days after the procedure. Once the removal is done, it is necessary to follow up with decongestant nasal drops for several days. Also, suction of the wound secretion is performed, as this can reduce later complications. In addition to suction, crusts and bark are removed and mucosal care is performed using nasal oil and ointment. In order to perform the removal of crusts and borks, the patient must inhale three times a day before suctioning so that the structures can soften. However, antibiotic administration is usually avoided so as to prevent resistance.
Possible complications
- Endonasal hemorrhage – bleeding may occur within the nose, the sources of which are generally the sphenopalatine artery or a vascular branch over the inferior (posterior) anterior wall of the sphenoid sinus.
- Intraorbital hemorrhage – surgery may cause injury to the lateral (side) anterior ethmoidal artery, resulting in retraction (pulling back) of the bleeding artery into the orbit. This poses a massive risk of a threatening orbital hematoma (hematoma into the orbit).
- Injury to the ductus nasolacrimalis (anatomical structure of the nose) – as a rule, this injury is often inconsequential, however, the tear flow can be affected to such an extent that damage to the eye can occur.
- Perforation of the skull base – injuries to the skull base are accompanied by cerebrospinal fluid (CSF) flow, which must be interpreted as a sign of immediate care. A computed tomography (CT) scan should be performed to check for this.
- Ocular muscle damage – due to the proximity of the surgical site to the eye muscles, lesions on the ausgen muscles may result. Depending on the extent, certain eye movements can thus not be performed or only to a limited extent.