Minimally invasive nasal endoscopic technique for the treatment of chronic sinusitis
Zhang Liqiang
Department of Otolaryngology, Qilu Hospital, Shandong University, No. 107, West Culture Road, Jinan, 250012, China
Abstract In recent years, a comprehensive treatment plan centered on minimally invasive nasal endoscopic surgery has become an important method for the treatment of chronic sinusitis. Minimally invasive techniques in the treatment of chronic sinusitis are not only reflected in the surgical procedure, but also highlighted in the perioperative management, good surgical instruments and treatment concepts. The mucosal protection technique has received more and more attention from rhinologists as the top priority of nasal endoscopic surgery. The measures of perioperative management in the treatment of chronic sinusitis have been described in the literature, and this paper focuses on the minimally invasive techniques in surgical operation. Minimally invasive nasal endoscopic techniques are introduced in terms of the selection of the timing of surgery, the selection of anesthesia and position, the selection of the surgical sequence, the method of nasal mucosa astringency, the removal of nasal polyps, the treatment of middle turbinates, the removal of hooks, the opening of maxillary sinus, the opening of frontal sinus, the opening of anterior and posterior sieve, the opening of olfactory fissure, the opening of pterygoid sinus, the treatment of nasal septum, the general principles of nasal endoscopic operation and the postoperative dressing change. Minimally invasive nasal endoscopic surgery is carried out based on a full understanding of the physiological function of the sinus mucosa, and the updating of treatment concepts is as important as the improvement of surgical skills. In some cases, it is not the surgical technique but the management principles and surgical protocols that determine the regression of the lesion. Therefore, there is still a long way to go to improve the effectiveness of minimally invasive nasal endoscopic surgery for chronic sinusitis. Zhang Liqiang, Department of Otolaryngology, Qilu Hospital, Shandong University
Keywords: nasal endoscopy, chronic sinusitis, minimally invasive surgery
In recent years, a comprehensive treatment plan centered on minimally invasive nasal endoscopic surgery has become an important method for the treatment of chronic sinusitis. Minimally invasive techniques in the treatment of chronic sinusitis are not only reflected in the surgical procedure, but also highlighted in the perioperative management, good surgical instruments and treatment concepts. The mucosal protection technique has received more and more attention from rhinologists as the top priority of nasal endoscopic surgery. The measures of perioperative management in the treatment of chronic rhinosinusitis have been introduced in the literature, and this paper focuses on the minimally invasive techniques in surgical operation.
I. Selection of surgical timing
The core of minimally invasive nasal endoscopic surgery is the technique of mucosal and structural protection. The complex and delicate anatomy of the lateral wall of the nasal cavity has been studied in detail, and these structures have been selected and preserved during the long-term evolution of human beings and must have important physiological functions, but little is known about them so far. Therefore, without this knowledge, a single excision of these structures may lead to undesirable results that we do not fully recognize. It should be the quest of the rhinologists to obtain the best treatment results with the least damage. Some scholars in China have begun to notice this problem and have made useful attempts. Preliminary results show that, under the premise of reasonable selection of indications, preserving the hooked sinus opening can achieve better therapeutic results. Although more in-depth basic research is needed to elucidate the effect of preserved or unpreserved leptomeninges on nasal sinus function, this study suggests that we should not take for granted the arbitrary removal of nasal anatomical structures that we do not yet understand in depth. The results of modern physiological studies have identified the sinus-oral-nasal tract complex as a breakthrough point in the surgical treatment of chronic sinusitis, and maximum efforts are taken to preserve the sinus mucosa with the aim of obtaining the best outcome for functional recovery. Clinical practice has shown that it is unwise to perform surgery when inflammation is not effectively controlled and may force the removal of excessive mucosa and bring about avoidable structural damage. The timing of surgery is very important. In the case of a patient with a multi-year history of chronic sinusitis, the severity of the disease varies from season to season, and the patient can usually clearly inform the surgeon when the lesions are least severe in general. Our advice to these patients is to choose the time when the lesions are least severe for surgery or to come back after systematic treatment when the lesions have reached the maximum possible control. The patient’s sinuses have recovered optimally under the effect of environmental factors individual factors or medical interventions, when the sinuses and associated anatomical structures that still have lesions can be selected out, while allowing the surgeon to easily grasp the main contradictions in treatment. The advantage of this is that there is less intraoperative bleeding, less mucosal damage, fine anatomy, and the structures that want to be preserved can be easily preserved intact, and the structures that need to be removed will not be removed with omission.
II. Choice of anesthesia and body position
In most cases, general anesthesia is appropriate. Local anesthesia is suitable for milder lesions and simpler operations. The disadvantage of local anesthesia is that if the pain relief is not effective, the patient’s reaction to pain will prevent the surgeon from treating the lesion accurately and thoroughly. Controlled hypotension can be used during general anesthesia to reduce bleeding and allow the surgeon to treat the delicate structures more delicately without regard to the patient’s pain response. During general anesthesia, if bleeding is high, a mixture of lidocaine and paid renin can be injected into the palatine foramen magnum to constrict the pterygopalatine fossa segment of the internal maxillary artery, thereby reducing bleeding. The appropriate position is also quite important to reduce bleeding. Generally, a head-high-foot-low position can be used to make the blood pool to the lower body as much as possible, but the head should not be overly flexed forward, otherwise it will bring inconvenience to the processing of the frontal sinus.
Third, the choice of surgical sequence
In our surgical treatment of chronic sinusitis cases more than 70% of patients need to deal with the nasal septum at the same time. The experience can be drawn from: sinus surgery on the spacious side of the nasal cavity first, then septal correction, followed by sinus surgery on the narrow side of the nasal cavity. If the inferior turbinate is excessively enlarged and insensitive to contraction, a submucosal partial resection of the inferior turbinate bone or fracture displacement may be performed before sinus surgery on that side. In this way, the nasal cavity is spacious during the entire surgical operation, which is conducive to the entry and exit of instruments and reduces the frictional damage to the mucosa caused by repeated entry and exit of instruments.
Fourth, the application method of instruments
When entering the mirror, the endoscope can be placed at the top of the anterior nostril with slight force forward, so that the side of the anterior nostril is enlarged, leaving more operating space for the entry and exit of the instruments. However, when dealing with the frontal sinuses, it is sometimes necessary to place the 70-degree endoscope in the lower part of the nasal cavity, with the instruments reaching the frontal crypt above the endoscope. When the middle turbinate is enlarged or the septal sinus is narrower, blood can easily contaminate the lens when entering the mirror, then the instruments can be placed in front and the endoscope in the back, and the endoscope can be placed into the septal sinus after the middle turbinate is pushed inward with the instruments under the endoscopic surveillance, so that the contamination of the lens by blood can be reduced. When opening the septal sinus, if there is more bleeding, the assistant can be made to continuously aspirate blood. If you can cooperate tacitly, it will greatly accelerate the surgical process.
V. Method of nasal mucosa astringency
Local anesthetic astringency of the nasal mucosa is necessary even in patients under general anesthesia. Patients with general anesthesia do not effectively inhibit the transmission of nociceptive stimuli to the center, and the physiological reflex of nociception still exists during general anesthesia, such as shallow anesthesia, patients may experience increased blood pressure, increased nasal bleeding and other reactions. When placing a cotton pad in the nasal cavity, it should be done so that the cotton pad is not bloodied when it is removed. Therefore, when placing the cotton piece, it should be operated gently. When the nasal cavity is narrow, the cotton piece should not be inserted into the nasal cavity by force, but the head end of the cotton piece should be placed in place first, and then the rear part of the cotton piece should be rotated back and forth and up and down alternately and gently inserted into the rear part of the nasal cavity. Since most of the nasal blood supply comes from the pterygopalatine artery, special attention should be paid to the astringency of the mucosa of the pterygopalatine foramen, which can have unexpected effects on reducing intraoperative bleeding.
Sixth, the removal of nasal polyps
In cases of multiple nasal polyps, excision of nasal polyps is required before sinus surgery. The polyp is first palpated with a stripper to find the location of the middle turbinate and the barbels, and then the superficial polyp is removed with a cutting suction device to reveal the contours of the nasal structures. Since the olfactory fissure is mostly narrow, the polyps in this area can be left untreated until the septal sinus is opened and the middle turbinate can be mildly displaced before treating the olfactory fissure. The polyps should not be traced to the deep septal sinus with a cutting suction device, which may damage the turbinates and mucosal structures of the sinus opening. Since the anatomical judgment of nasal endoscopy is based on the relative positions of the structures under the endoscope, not removing large polyps and clearing a clearer operative field may cause the operator to make a mistake in identifying the anatomical position, and the instruments may enter the orbit or the skull without being aware of it.
VII. Treatment of middle turbinate
The middle turbinate is the gateway to the middle nasal tract, and a good treatment of the middle turbinate can widen the space for the subsequent operation and reduce the frictional damage to the mucosa. If the middle turbinate is too thick, the lateral part of the turbinate can be removed without shape. If the middle turbinate is excessively anterior, coronal excision of the middle turbinate is feasible to the slightly posterior part of the maxillary line to prevent the postoperative adnexation of the middle turbinate with the anterior cut edge of the hook. If the middle turbinate is excessively long and touches the inferior turbinate, the lower part of the middle turbinate needs to be resected horizontally to prevent postoperative blockage of the maxillary sinus opening after the external migration of the middle turbinate. The timing of treatment of the middle turbinate needs to be chosen according to different needs. If the treatment is to widen the surgical space, it should be performed immediately between the treatment of the septal sinus to facilitate the subsequent surgery. If to prevent postoperative cavity adhesions or to reduce mucosal contact points for the treatment of rhinogenic headache, treatment should be done before the end of surgery to protect the unresected portion of the middle turbinate from frictional damage by excessive instruments.
VIII. Hook excision
There are many ways of hook excision. The main methods are: 1. The hooked process is turned forward with the mucosa at its maxillary line as the axis by using the backbite forceps to bite the two mouths above and below the hooked process, and then the part between the two incisions is removed with the bite forceps. In this procedure, the hooks are removed completely without damaging the mucosa and cardboard of the maxillary sinus opening.2 Submucosal resection The hooks are first injected with local drug infiltration to make the mucosal swelling and bone easy to separate. The mucosa on both sides of the hooked bone piece is separated by cutting the anterior edge of the hooked process with a stripper or sickle knife, and the mucosa on both sides of the hooked process is separated by submucosal resection of the inferior turbinate as far as possible along the hooked process downward and posteriorly to the attachment of the hooked process to the inferior turbinate, and the hooked process bone piece is completely extracted from between the mucosa on both sides. In this way, the base of the hooks can be removed cleanly and the integrity of the mucosa of the natural sinus opening of the maxillary sinus can be preserved.3 Removal of the hooks with difficult localization The middle turbinate is moved moderately inward, and the medial mucosa of the hooks is removed with a cutting suction device to expose the bones of the hooks, and then the anterior edge of the hooks is carefully separated along the bones to find the anterior edge of the hooks, and the lateral mucosa of the hooks is removed with a cutting suction device after removing the bony pieces of the hooks.4 Conventional method A striker or sickle knife is used to find the lateral mucosa of the hooks along the After the maxilla is touched backward to find the anterior edge of the hooked process, insert the striker outward at the upper edge of the inferior turbinate, taking care not to insert it too deeply to prevent damage to the anterior wall of the sieve vesicle, separate the hooked process inward, and after the opening of the maxillary sinus is seen, stroke the striker up and down to free the hooked process, cut the hooked process across the top and bottom with scissors, remove the hooked process with a clamp, and then remove the caudal end of the hooked process by separating it with a sickle knife. This method is located near the opening of the maxillary sinus because of the low position of the incision, even if the angle is too large, at most it enters the maxillary sinus without damaging the cardboard. The main points of hook excision are: not to damage the mucosa of the maxillary sinus mouth, complete excision of the caudal part of the hook, retaining part of the upper end of the hook, preventing damage to the mucosa of the frontal saphenous fossa, in short, not to damage other structures except the hook.
9.Maxillary sinus opening
If the hooks are properly removed, the maxillary sinus opening can be seen immediately. If the mucosa of the natural sinus opening is smooth and opens well, it is not necessary to open the maxillary sinus. Otherwise, the mucosa of the posterior chimney is pulled inward by reaching into the maxillary sinus opening with an elbow suction device, and the posterior chimney is removed with a mucosal bite forceps, and then the mucosa of the anterior part of the maxillary sinus opening is removed with a reverse bite forceps. If the maxillary sinus opening is more deviated, mostly caused by excessive inferior turbinate adduction, the maxillary sinus opening can be opened with an elbow cutting suction device. After the maxillary sinus opening, the position of the cardboard can be positioned to facilitate the opening of the septal sinus. When the hooked process is ossified and excessively displaced, the maxillary sinus opening can be closed by bony or tougher fibrous tissue, and blindly searching for the sinus opening can sometimes damage the cardboard. Patience is required to remove the hooked process before accessing the maxillary sinus.
X. Frontal sinus opening
The posterior wall of the frontal crypt is bounded by the anterior wall of the sieve vesicle attached upward to the base of the skull. Therefore, opening the frontal saphenous fossa before opening the sieve vesicle can prevent access to the anterior skull base. According to the way of hook attachment shown in CT, the position of frontal saphenous fossa opening can be judged, and the opening of frontal saphenous fossa can be found by removing the upper part of the hook and the upper posterior wall of the nasal mound. At present, CT three-dimensional reconstruction technology allows the surgeon to construct the three-dimensional anatomical structure of the frontal saphenous fossa before surgery, and the skillful CT reading technique and the accurate interpretation of each structure during surgery are the basic skills of frontal sinus opening. The most important thing in opening the frontal saphenous fossa is to preserve the mucosa, any exposed bone can cause postoperative scar growth and narrowing. If bleeding is high and mucosal edema is heavy, intraoperative untreated, conservative treatment or treatment during postoperative dressing changes is better than aggressive intraoperative treatment in most cases. The development of frontal sinus opening depends on the improvement of surgical instruments, which is still a difficult procedure for most rhinologists.Wormald proposed a transcallosal approach to frontal sinus opening, in which a mucosal flap is separated at the attachment of the anterior middle turbinate to the lateral wall of the nasal cavity, and then some of the bone of the middle turbinate fornix is removed, so that the airspace of the turbinate can be viewed directly, and after removal of the airspace of the turbinate, the frontal sinus can be opened with a 0-degree mirror [ 4].
XI. Opening the sieve bubble
Generally, biting forceps can be used to open the sieve bubble, and if the sieve bubble bone is thin, a cutting suction device can be used to open the sieve bubble. A sharp knife can also be used to cut the lateral part of the anterior wall of the sieve vesicle longitudinally, so that the sieve vesicle cut edge is neat and avoids repeated trimming of the cut edge. If the posterior sieve does not need to be opened, the cardboard can be dissected out at the beginning, noting that there are many infraorbital air spaces above the opening of the maxillary sinus, the cardboard itself is lateralized in the lower part, and small air spaces are often left in the lower part of the cardboard. These air spaces should be completely opened. If the posterior sieve is to be opened, this part of the small air space near the cardboard can be left untreated. Because of the operation in the posterior sieve, the instrument to repeatedly through the front sieve in and out. The sieve bubble is not continuous with the middle turbinate, and once the sieve bubble is removed, the lateral aspect of the middle turbinate can be exposed to the operative field, and the frictional damage of the mucosa of the lateral aspect of the middle turbinate is often unavoidable, so that some of the airspaces and septa close to the cardboard can protect the mucosa on the cardboard surface, so that they will not be damaged when the instruments enter and exit the posterior sieve. After the posterior sieve is processed, these air chambers are then opened to remove these bony septa. When removing these air chambers and septa close to the cardboard, first palpate with an elbow suction device to confirm the presence of cardboard bone or press on the eye to confirm that the cardboard is not damaged, then use a cutting suction device or an occlusal forceps to treat the cardboard. When applying the cutting suction device, it should not be pressed against the cardboard, otherwise the medial rectus muscle will be sucked out without the surgeon being aware of it. As long as the cardboard is identified in advance, there will be no intraorbital complications.
12. Opening of the posterior sieve
After the opening of the anterior sieve, the middle turbinate substrate can be seen. When the bleeding is more anatomically unclear, the way to identify the middle turbinate substrate is that the middle turbinate substrate is the only structure that connects the middle turbinate and the cardboard at the same time. The middle turbinate substrate is removed with a cutting suction or mucosal occlusion forceps, preserving a small portion of the lower part to support the middle turbinate to prevent its outward migration. The middle turbinate base should not be retained too high, otherwise it will affect the observation of the posterior sieve during postoperative dressing changes and will not facilitate the drainage of the operative cavity. If there is no inflammation in the posterior sieve, keeping the turbinate substrate intact can confine the inflammation to the anterior sieve. If the posterior sieve is not inflamed, preserving the integrity of the middle turbinate substrate can limit the inflammation to the anterior sieve. The posterior sieve airspace is mostly thin and wide, and in most cases a cutting suction device is sufficient to open the posterior sieve. Note that the lower part of the posterior sieve can have a larger and more pneumatized airspace below the orbital apex, where the lower part of the cardboard slopes outward and downward, making sure not to miss the airspace below the orbital apex. Sometimes there are more posterior sieve air spaces, and to avoid missing air spaces, the distribution and level of posterior sieve air spaces should be determined from CT before surgery. The central posterior septal airspace can be opened with heavy instruments because the septum and mucosa of these airspaces will eventually be removed, but the airspaces near the margins must be operated gently, and the airspaces should not be opened roughly with the suction device. The suction device should not touch the mucosa when suctioning, but only allow the blood to be suspended and aspirated through the cotton pad if necessary. In addition, the root of the middle turbinate is attached to the base of the skull because it is prone to cerebrospinal fluid nasal leakage, and the small air space is often missed when dealing with this area. As long as the location of the operation is known, the skull base will not be damaged. Sometimes the posterior sieve is better gasified forward and there are more small air spaces near the skull base, which are often left unopened for fear of damaging the skull base. At this time, it is possible to open these air spaces near the skull base without any residue by switching to a 70-degree mirror along the posterior sieve roof forward or along the posterior wall of the frontal saphenous fossa backward. If too much of the middle turbinate substrate is retained, there may be air spaces left behind the middle turbinate substrate, which should be opened by occluding the middle turbinate substrate. A fully open septal sinus should be narrowed superiorly and wide anteriorly and posteriorly, and a well open septal sinus should have no bony exposure. The septum should be occluded as flat as possible and the septal sinuses should be contoured and mucosal. The smaller air spaces should be as completely open as possible; if only a small portion is opened, the small air spaces may be atretic due to postoperative mucosal edema. Once the middle turbinate substrate is opened, the superior turbinate substrate can be seen. It is usually necessary to keep the superior nasal tract open and the olfactory fissure open. Two measures can be taken, one is to remove part of the free edge of the superior turbinate so that the pterygoid sinus can be easily treated. After removal of the root of the superior turbinate, the opening of the pterygoid sinus can almost certainly be found medial to its residual bony crest. The other is to remove the posterior edge of the vertical middle turbinate with a backbite forceps or cutting suction, so that the posterior sieve can still be well drained through the superior nasal tract even when the anterior sieve mucosa is edematous and poorly drained. When the posterior sieve is sclerotic, the septal sinus forceps can be used to gently fracture the septum and the mucosa on its surface, at which time the mucosa can still maintain continuity, but the fracture piece can be separated and clamped out, and then the excess mucosa can be removed with a cutting suction device. The airspace near the cardboard must be handled with care, first confirm the cardboard is intact with the elbow suction before opening the airspace with the cutting suction, sometimes the cardboard has congenital defect, blind application of cutting suction may seriously damage the orbital content. In order to prevent damage to the cardboard, when opening the posterior sieve, the medial part of the septal sinus can be opened first, and the contours of the middle turbinate and the lateral surface of the superior turbinate can be dissected clearly before dissecting the cardboard and the air chamber at the orbital apex; otherwise, there is a risk of misdirection into the orbital apex due to the wrong direction, causing serious complications.
XIII. Opening the olfactory fissure
After opening the septal sinus, the middle turbinate can be moderately moved outward, at this time the olfactory fissure can be easily explored, polyps and part of the superior turbinate in this area can be removed and the superior nasal tract can be opened.
XIV. Opening the pterygoid sinus
In most cases, the pterygoid sinus can be opened via the olfactory fissure by using a blunt-tipped suction device to cut into the natural opening of the pterygoid sinus along the upper edge of the posterior nostril near the nasal septum and upward. The pterygoid sinus is then opened with a cutting aspirator and pterygoid bite forceps. In cases with better pneumatization of the pterygoid sinus, the pterygoid sinus can be opened via the septal sinus, and the incidence of complications of pterygoid sinus surgery is instead lower because of sufficient knowledge of the dangers of pterygoid sinus opening. In fungal pterygoid sinusitis, the opening of the pterygoid sinus needs to be opened as wide as possible and, if necessary, part of the posterior nasal septum can be removed to prevent atresia. It is usually safer to open the pterygoid sinus inferiorly, but when opening it downward, pulsatile bleeding can sometimes occur due to encountering the nasal septal branch of the pterygopalatine artery, which can be controlled very easily and effectively by using electrocoagulation. If the pterygoid sinus is not easy to open, a bone chisel can be used to chisel backward along the nasal septum and then expand the opening to the surrounding area.
XV. Nasal septum treatment
The mucosal incision of the nasal septum can be flexible and varied. In the classical submucosal resection of the nasal septum, for example, the incision is mostly chosen on the side where it is difficult to separate the operation, and the incision needs to be extended toward the nasal floor, and upward it can be slightly extended backward at the upper end of the incision, so that the mucosal pocket is spacious and the damage to the mucosa of the nasal septum by instruments and endoscope is smaller when separating the mucosa. The difficult separation is mostly at the joint of the bone suture near the nasal base. The better method is to first separate the layers from the nasal floor bone, then separate the lower and posterior part of the bone crest along the nasal floor bone, and finally separate the upper part of the bone crest mucosa. If the bone crest is not obvious, the upper part of the mucous membrane can be separated first, and when it is separated to the vertical plate of the sieve bone and the plow bone, it is easier to separate the mucous membrane from the level and keep separating to the nasal base, and then use the cartilage knife to separate the mucous membrane along the separated level of the bone from the back to the front, and the adhesions at the intersection of the nasal cartilage of the nasal septum and the nasal spine of the maxilla can be easily separated out. The bone or cartilage is removed in as large a piece as possible, which reduces the operating time in the mucosal pocket, reduces damage to the mucosa, and allows the use of large pieces of cartilage or bone to repair the perforation. Deviation of nasal septum mostly occurs at the junction of nasal septal cartilage and maxillary nasal spine. The mucoperiosteal membrane can be separated on one side first, and then the connection between nasal septal cartilage and sieve vertical plate and cartilage and maxillary nasal spine can be separated, and part of sieve vertical plate and maxillary nasal spine can be removed, and most of nasal septal cartilage can be retained.
Principles of operation in nasal endoscopic surgery
Care for the mucosa should be paid attention to at all times during nasal endoscopic surgery. Any rough action should be prohibited. The operation should be planned, targeted and effective, and the operation should be done in one step to reduce unnecessary and redundant movements. Strengthening the training of basic operation skills, familiarizing with various anatomical variants, and minimizing the operation time are also important measures to reduce mucosal injury. In the case of high bleeding, the ability to handle the lesion in the case of bleeding should be strengthened, keeping the assistant continuously aspirating blood, passing the instruments to be able to work tacitly with the operator, and striving for continuous operation without taking the operator’s eyes off the monitor are important methods to speed up the surgical process. When there is a lot of bleeding, make sure to see the structure before operating, which is the most important principle to avoid complications.
XVII. Postoperative cavity exchange
Good postoperative management is important for the recovery of the lesion. Although postoperative drug exchange occupies a very important position in the comprehensive treatment. However, the operator should put the main focus on the correct and in place treatment of the lesion during surgery. Failure to treat intraoperatively can make postoperative dressing changes difficult, and do not attempt to leave lesions that have not been treated intraoperatively for postoperative dressing changes. In most cases, if the intraoperative management is thoughtful and comprehensive, the postoperative dressing change will be very easy and the lesion will recover quickly. After 24 to 48 hours of postoperative extraction of the nasal filling, if there is no significant bleeding or other complications, the patient can be discharged and have a nasal washout for about 1 week, followed by the first nasal endoscopic drug change, focusing on removing the clots in the sinuses to stop the hemorrhaging aya and so on. Thereafter, the next drug change will be decided according to the condition of the operative cavity. The focus of the change is to apply suction to remove the clots and crusts and to separate the adhesions without suctioning and manipulating the mucosa as much as possible, leaving the crusts that cannot be removed for the nasal rinse and the next change. It is best to achieve a bloodless surgical cavity. It is not better to have more dressing changes. Excessive dressing changes can also damage the mucosa and prolong its healing time. Delayed mucosal healing is usually seen in the following conditions: incomplete and inadequate lesion management, long-term postoperative sepsis irritation of the mucosa of the operative cavity, and ineffective control of inflammation. Insufficient resection of the tracheal septum, narrowing of the left and right diameters of the operative cavity, and slight swelling of the mucosa can cause serious drainage obstruction or even the formation of atresia of the trachea. In some cases, the treatment effect is poor because of the patient’s physical factors, which can be seen in some adolescents, hooked or middle turbinate polyp-like changes, due to the long history of disease, septal sinus osteosclerosis, more intraoperative bleeding, heavy injury, and incomplete opening of the air space. Some patients have epithelialized the surgical cavity, but after stopping nasal hormone for 1 year, mucosal swelling and thickening can be seen again on re-examination, and then using nasal hormone, some patients can epithelialize again soon. Therefore, the so-called epithelialization does not mean a cure. Chronic sinusitis is a long-term disease that requires lifelong care of the sinus mucosa.
Minimally invasive nasal endoscopic surgery is carried out based on a full understanding of the physiological function of the sinus mucosa, and the updating of treatment concepts is as important as the improvement of surgical skills. In some cases, it is not the surgical technique but the treatment principles and surgical protocols that determine the regression of the lesion. Therefore, there is still quite a long way to go to improve the results of minimally invasive nasal endoscopic surgery for chronic sinusitis. Nowadays, it seems that inflammatory sinus disease is essentially a medical disease, where comprehensive treatment is particularly important and surgical procedures are not a panacea. Perhaps with the development of pharmacotherapeutics, surgery will be withdrawn from the treatment of sinusitis at some point in the future.