Imaging for functional endoscopic sinus surgery

Practical recommendations for managing severe chronic rhinosinusitis with nasal polyps in the era of biologics

Objective

We conducted a national survey to understand how rhinology practice has changed with the advent of biologics and how this affected patients with uncontrolled, severe chronic rhinosinusitis with nasal polyps (CRSwNP). We aimed to analyse the results of the survey and infer practical recommendations for clinical practice.

Methods

A group of ear, nose, and throat specialists (ENTs) experienced in the management of CRSwNP developed a 74-question survey. ENTs from rhinology centres authorised to prescribe biologics in the context of the national health system were invited to answer it between 01/05/2022 and 31/07/2022. The responses underwent descriptive analyses, and the authors discussed the results and derived practical recommendations for clinical practice.

Results

ENTs working in rhinology centres changed their practices coinciding with the advent of biologics. CRSwNP evaluations have become more complex because they involve diagnostic confirmation, determining the patients' immunologic profile, and other factors. We observed heterogenous behaviours in practice that may be conditioned by the novelty of the topic. The results of the survey were used to develop practical recommendations for ENTs and are summarised herein.

Conclusions

Clinical practice in rhinology outpatient clinics has changed profoundly in the era of biologics. Our practical recommendations for clinicians working in rhinology centres are expected to help standardise practice and improve care.

Comparison of Diagnostic Accuracy of Panoramic Radiography to CBCT in Maxillary Sinus Diseases

We aimed to compare the effectiveness of panoramic radiography (PR) and cone beam computed tomography (CBCT) in radiographic diagnosis of maxillary sinus (MS) diseases. MS diseases (mucosal thickening, mucus retention cyst, polyp sinusitis, mucocele and tumoral formations) was carried out on both PR and CBCT images belonging to 625 patients. Analyzes were performed separately for right and left maxillary sinus, and total of 1250 PR and CBCT images. While a diagnosis of disease was made in 42.96% of a total of 1250 MS according to CBCT. According to PR, diagnosis was made in 58.72%. The 537 diagnoses where lesion presence was determined on CBCT in our study were compared over PR, and it was observed that, there was the right diagnosis (true positive) in 106 (19.73%) of these including respectively mucus retention cyst (n = 88), polyp (n = 16), 1 sinusitis and 1 tumor, and there was an incorrect diagnosis (false positive) in 221 (41.15%). In 42.92% of the MS that were identified as healthy based on CBCT, the correct diagnosis was also made on PR (true negative). The use of CBCT instead of PR in the diagnosis of pathological or inflammatory diseases contributes to a more accurate radiographic differential diagnosis.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Into the septum I go, a case of bilateral ectopic infraorbital nerves: a not-to-miss preoperative sinonasal CT variant

An ectopic course of the infraorbital nerve is a very rare anatomical variant of the sinonasal anatomy that carries the risk of inadvertent nerve injury during functional endoscopic sinus surgery. We describe herein a case of bilateral ectopic course of the infraorbital nerve into a maxillary sinus septum detected on computed tomography in a patient complaining of chronic headache and facial pain.

Sinus imaging for diagnosis of chronic rhinosinusitis in children

Chronic rhinosinusitis (CRS) is a relatively common disease in children but is often overlooked because at times the clinical symptoms are subtle and nonspecific. This makes imaging very important in the diagnosis. Among the different techniques, plain radiography has limited utility,whereas CT scan and MRI have a major role in evaluating the modifications caused by the disease. In particular, a CT scan provides higher resolution of bone and soft tissue and removes the overlapping structures that are present in conventional radiography. CT is recommended in isolated sphenoid sinusitis, is essential in diagnosing fungal sinusitis, and is the technique of choice when orbital complications are suspected. MRI allows investigation of not only the morphology of structures, but their intrinsic biophysical and biochemical properties, such as water content, cellular density, lipid or blood product deposits, and fibrosis. MRI allows better soft tissue differentiation and high spatial resolution images depicting fine details. When indicated, MRI with contrast gadolinium-based agents may better characterize the local disease extension or its diffusion beyond paranasal and nasal cavities and has excellent contrast resolution. A combination of CT and MRI is useful in cases of diagnostic difficulties,especially when complications are involved.

Endoscopic vs Transfacial Resection of Sinonasal Adenocarcinomas

Objectives. Compare the survival and the complication rates of 2 comparable groups of patients who underwent either endoscopic or transfacial resection of a sinonasal adenocarcinoma.

Study Design. Historical cohort study.

Setting. Tertiary referral center.

Subjects and Methods. Twenty-four patients with sinonasal adenocarcinomas who recently underwent an endoscopy (the ENDO group, 1999-2009) were compared with 24 patients who underwent a lateral rhinotomy procedure (the LR group, 1993-2007). The present retrospective study included patients who would have had an endoscopic resection in 2011.

Results. The groups were comparable in terms of age and sex ( P = .49), as well as tumor stages; 43 of the 48 patients had undergone postoperative radiotherapy. There were 13 T1-T2 and 11 T3-T4 tumors in the ENDO group compared with 12 T1-T2 and 12 T3-T4 tumors in the LR group ( P = .77). The mean length of follow-up was 38 months for the ENDO group and 89 for the LR group. The overall survival and recurrence-free rates were not significantly different ( P = .3 and P = .87, respectively). The median duration of hospitalization was significantly shorter in the ENDO group than in the LR group (4 vs 8 days, P < .0001). The rate of early complications was identical in both groups (12.5%).

Conclusion. The endoscopic approach is a safe and effective treatment in selected sinonasal adenocarcinoma cases. The early oncological outcome and morbidity associated with the endoscopic approach were comparable with a transfacial approach. Hospitalization was significantly reduced by the endoscopic approach. Although the endoscopic approach is less invasive, it requires an optimal preoperative imaging protocol and an experienced surgical team.

Tomografia computadorizada das células etmoidais intra e extramurais: ensaio iconográfico

O desenvolvimento dos seios paranasais é um processo intricado que se inicia na vida intrauterina e termina na idade adulta. Dos seios da face, as células etmoidais são provavelmente as estruturas mais complexas e as que estão associadas com o maior número de variantes da normalidade. Variações no padrão de pneumatização das células etmoidais podem ser divididas em intra ou extramurais. Intramurais são aquelas que ao se desenvolverem mantêm contato com o labirinto etmoidal, e extramurais as que se desenvolvem isoladamente. A tomografia computadorizada é a ferramenta mais útil na avaliação de processos inflamatórios dos seios paranasais. De igual modo, ela é importante para o planejamento pré-operatório e controle pós-operatório, pois possibilita grande detalhe anatômico das estruturas normais e detecção precisa de suas variantes. Neste ensaio iconográfico os autores descrevem as principais variantes da normalidade do labirinto etmoidal e suas relações com estruturas adjacentes. Cirurgias endoscópicas para o tratamento de afecções dos seios paranasais têm-se tornado cada vez menos invasivas, o que certamente aumentará a demanda por relatórios de imagem cada vez mais ricos em detalhes desta região.

Computed tomography scans of paranasal sinuses before functional endoscopic sinus surgery

This review aims to familiarize the radiologist with the common types of sinus surgery including their indications and techniques. We also illustrate how surgeons interpret 3D sinus anatomy when evaluating computed tomography (CT) studies. Preoperative evaluation by CT is mandatory for all patients undergoing functional endoscopic sinus surgery (FESS). In the past decade in particular, CT of the paranasal sinuses has become a roadmap for FESS. The radiologist’s goal is to report on five key points: the extent of sinus opacification, opacification of sinus drainage pathways, anatomical variants, critical variants, and condition of surrounding soft tissues of the neck, brain and orbits. We present a systematic approach to the use of coronal, axial, and sagittal images in CT evaluation before FESS.

Perioperative and intraoperative maneuvers to optimize surgical outcomes in skull base surgery

There are many approaches to obtaining a workable endoscopic surgical field in sinus surgery. With extended sinus and transdural endoscopic surgery, a more rigid approach must be taken. There are 3 main factors that invariably lead to poor surgical outcomes in endoscopic sinus and skull base surgery: bleeding, inadequate access, and unidentified anatomic anomalies. Bleeding is arguably the most common reason for incomplete resection. An understanding of microvascular and macrovascular bleeding allows a more structured approach to improve the surgical field in extended endoscopic surgery. The endoscopic surgeon should always be comfortable in performing the same procedure as an open operation. However, converting or abandoning an endoscopic procedure should rarely occur because much of this decision making should take place preoperatively. Along with poor hemostasis, inadequate access is an important cause of poor outcome. Evaluation of the anatomy involved by pathology but also the anatomy that must be removed to allow adequate exposure is important. This article reviews the current techniques used to ensure optimal surgical conditions and outcomes.

Radiologic Appearances in Fungal Rhinosinusitis

Radiological diagnosis forms an important tool in the armamentarium to diagnose and classify fungal rhinosinusitis. However, many times, the appearances may be deceptive; while on one hand in Allergic Fungal Rhinosinusitis the appearance is classical and considered one of the clinchers in the diagnosis of the condition, in invasive fungal rhinosinusitis (especially in the early phases), the appearances may range from a nonspecific sinusitis to even a ‘apparently normal’ scan! CT scan as well as MRI may at times complement each other, in order to aid the clinician arrive at a diagnosis. Nevertheless, despite the best radiologic modalities, a clinicoradiological correlation is a must to accurately diagnose this often deceptive condition called fungal rhinosinusitis.

Paranasal sinus imaging

Endonasal surgery is currently extending its application beyond inflammatory sinonasal lesions to successfully treat both benign and malignant neoplasms. This progression has been possible by the detailed information provided by imaging techniques (CT, MRI and PET). Inflammatory diseases are the "domain" of CT. CT provides excellent details about the thin bony sinonasal walls separating the ethmoid from the anterior skull base and the orbit. Benign and malignant neoplasms are the "domain" of MRI because the tumor is more easily separated from adjacent structures, the periosteal linings (periorbita, dura mater) and perineural spread can be accurately shown. Whereas MRI precisely assess pre-treatment tumor extent, early submucosal local recurrences are difficult to demonstrate because of post-treatment changes of the anatomy and of the signal of treated tissues. Though diffusion-weighted imaging and dynamic contrast-enhanced techniques are promising developments, PET-CT may overcome the limits of morphological MRI.