Preoperative Evaluation

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Preoperative evaluation of the sinus patient begins with a complete otolaryngologic history and physical examination [20]. The typical complaints that a patient with hyperplastic rhinosinusitis presents with polyposis are nasal obstruction and anosmia [24]. A significant number of patients will have a history of repeated sinus infections, headache, and may have a medical history significant for asthma and aspirin sensitivity [11]. Environmental allergy may also be prevalent [1]. Since the major complaint associated with hyperplastic rhinosinusitis and nasal polypo-sis is subjective in nature, many institutions advocate the use a preoperative sinonasal questionnaire. Many different questionnaires exist in the literature and all are focused on defining the baseline symptomatology of the disease as well as the level of exacerbation of the disease process [13].

Important in establishing the history of hyperplas-tic rhinosinusitis and nasal polyposis is the establishment of previous therapy for the condition [50]. The use of nasal inhaled steroids, oral steroids, prolonged periods of antibiotic use, and history of previous nasal or sinus surgery provide important information and establish the failure of medical therapy for the disease process [9]. In many instances, medical therapy including an oral steroid and 4-8 weeks of antibiotics provided intermittent relief of symptoms, but rapid return to the baseline upon cessation of therapy [14].

A history of nasal trauma, midface trauma, or previous surgery is an important consideration of preoperative planning. Patients with such histories can pose a variety of problems. Dehiscence of the lamina papyracea, or other intranasal anatomic alterations may occur in such traumas [36]. In addition, nasal trauma with severe deviation may necessitate septoplasty in order for surgical resection of nasal polyposis to be performed [23].

As with all patients, a thorough medical history to assess the risk of anesthesia, a propensity for bleeding, and the use of both prescribed anticoagulants as well as herbal supplements which may influence clotting ability is necessary [47]. It is important to establish a social history with emphasis on tobacco use and exposure as well as environmental exposures that may contribute to nasal irritation. A complete review of systems with attention to endocrine disorders such as diabetes, immunologic disorders such as HIV and y-globulin deficiencies, as well as systemic disorders such as Wegener's granulomatosis provides significant diagnostic information.

A complete head and neck examination is routine in preoperative evaluation [20]. Special attention is taken during the assessment of the nose and nasal structures. Nasal polyposis can rarely lead to visible nasal or facial deformity [28]. Anterior rhinoscopy can demonstrate the extent of polyposis (Fig. 10.1) and the percentage of airway blockage. In addition to visible polyposis, evaluation of the turbinate structures and nasal septum help determine other potential causes for airway obstruction. Evaluation of the

Fig. 10.1. Obstructing nasal polyp (arrow)

response of the nasal mucosa of the inferior turbinates to a vasoconstrictive agent such as neosyneph-rine may also aid in isolating the pathogenesis of nasal obstruction [39].

Nasal endoscopy is very important in the preoperative evaluation of the hyperplastic rhinosinusitis patient [40]. Determination of the extent of disease and visibility of normal anatomic structures such as the uncinate process and middle turbinate are essential. The presence of pus, indicative of active infection, or allergic mucin, thick mucus with a peanut-butter-like appearance and consistency, may be visible [46] (Fig. 10.2).

Laboratory evaluation for hyperplastic rhinosinusitis patients:

■ Begins with an allergy screening [17]. Many different allergy-screening tests exist; from the radioal-lergosorbent test (RAST) to the Multi-Test II skin prick tests. Determining if atopy plays a role in the hyperplastic rhinosinusitis patient is important for postoperative prevention of nasal polyp recurrence [12].

■ Evaluation of the total immunoglobulin E level may be indicative of allergic fungal disease, with or without polyposis [38].

■ Other laboratory tests that may be beneficial but that are cost-inhibitive include screening for y-globulin deficiencies [37, 48]. Such tests may be more beneficial in the recalcitrant patient [8].

■ The chloride sweat test is a necessary adjunct to the evaluation of the pediatric patient, but is generally not necessary in the adult population [2].

Computed tomography (CT) evaluation is essential in preoperative planning. A screening coronal sinus CT scan (5-mm coronal images) provides essential input into the extent of disease as well as the anatomic structure of the patient [25]. Identification of the level of the skull base and the status of the lamina papy-racea is essential prior to operative intervention and prevention of complications [42] (Fig. 10.3). Other important information that can be obtained includes the status of the nasal septum as well as the presence of a concha bullosa that may be contributing to sinona-sal obstruction. Heterogenicity of an opacified sinus may be indicative of a fungal ball, whereas bowing of boney structures may be more indicative of mucocele formation [4].

Tips and Pearls

Preoperative CT evaluation:

■ Determine the extent of involvement

■ Identify the lamina papyracea

■ Identify the level of skull base/cribiform plate

■ Identify the presence of a concha bullosa

While the screening sinus CT scan provides a cost-efficient evaluation of important bony anatomy, a three-dimensional CT scan such as those used for computerized guidance during surgery may provide additional information in significant detail [44]. While the computer-guided three-dimensional imagery can be an effective adjunct to surgical intervention, it is

Risks of surgery include [45]:

Fig. 10.3. Sinus computed tomography scan showing the lamina papyracea (white arrow), medial rectus (red arrow), relation of the skull base to the medial rectus (red line) and lateral lamella (black arrow)

Risks of surgery include [45]:

Orbital abscess secondary to acute infection Frontal lobe abscess/meningitis secondary to acute infection Mucocele Fungal mycetoma 2. Relative

(a) Chronic rhinosinusitis failing medical therapy

(b) Headaches Facial pain

Recurrent acute sinusitis Obstructive nasal polyposis Asthma exacerbations in patients with Samter's triad

Recurrent disease requiring repeat or revision surgery

Entrance into the orbit resulting in blindness Double vision

Violation of the skull base resulting in CSF leak

Meningitis Brain damage Death

An understanding that surgical resection of nasal polyps and maintenance of the sinonasal cavity will require continued postoperative medical therapy is also essential.

Fig. 10.3. Sinus computed tomography scan showing the lamina papyracea (white arrow), medial rectus (red arrow), relation of the skull base to the medial rectus (red line) and lateral lamella (black arrow)

not the standard of care for primary nasal polyp surgery, nor should it be used in lieu of an understanding of the sinonasal anatomy as viewed through an endoscope [33]. Magnetic resonance imaging provides little useful adjunctive information with respect to surgical planning [32].

Indications for sinus surgery for hyperplastic rhi-nosinusitis/nasal polyposis are as follows: 1. Absolute

Tips and Pearls

Surgical goals:

■ Define normal anatomy first

■ Use maxillary antrostomy to establish the level of the sphenoid ostium and lamina papyracea

■ Identify the level of the skull base posteriorly at the sphenoid and proceed from posterior, superior to anterior superior through the ethmoids

■ Avoid disruption of the frontal recess if unnecessary

■ Preserve normal mucosa

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