Due to the widespread use of minimally invasive nasal endoscopic techniques, the efficacy of chronic diseases of the nasal cavity and sinuses has been greatly improved, and most cases are even cured. However, due to differences in endoscopic surgical techniques, local and systemic factors of the patient’s nasal cavity and sinuses, etc., some cases are recurrent. Revision endoscopic minimally invasive surgery is mainly for reoperation or multiple operations after failed endoscopic nasal and sinus surgery or traditional surgery. We combined with clinical practice, and summarize the strategy of corrective endoscopic minimally invasive surgery mainly for recurrent nasal and sinus diseases as follows.
I. Analysis of the main reasons leading to recurrence
1., local factors
1.1 The presence of sinus mucus circulation and natural sinus opening is not handled properly
Practice has proved that even if the maxillary sinus opening window (via the inferior or middle nasal tract) is wide and open during surgery, if the natural mouth is not connected to the maxillary sinus opening window and the mucus cilia removal direction is still toward the natural mouth, there will be a continuous mucus circulation, resulting in the lesion not being completely cleared. Occasionally, there is mucus circulation between the natural orifice of the maxillary sinus and the paracavity.
1.2 Inadequate treatment of the middle turbinate and the presence of nasal adhesions
The most common causes of recurrence observed through follow-up were inadequate management of the middle turbinate during previous surgery and the presence of nasal cavity adhesions. Due to inappropriate treatment of the middle turbinate itself (polyps, etc.) or anatomical abnormalities (reversed or too long, etc.), or even complete removal, the natural barrier effect was lost, leading to adhesions and occlusion of the surgical cavity. Postoperative adhesions of the middle turbinate to the lateral wall of the nasal cavity are not released in place in time is also an important reason.
1.3 Residual sinus lesions
Due to the problem of surgical technique, the existence of residual lesions in the anterior sieve leads to the obstruction of the frontal sinus opening, which is also one of the reasons for the failure of endoscopic surgery.
1.4 Presence of deviated nasal septum
The correlation between nasal septal deviation and the development of CRS is well known, especially the high deviation, if not effectively treated, will definitely affect the nasal cavity and sinus ventilation and drainage, which in turn will prolong the healing time of the surgical cavity after endoscopic surgery and more easily cause complications such as adhesions.
1.5 Recurrent nasal polyps
Regardless of the recurrence of nasal polyps, or the proliferation of polyps on the basis of the original migratory inflammation, will lead to sinus mouth obstruction, resulting in nasal cavity, sinus ventilation and drainage and mucus cilia removal system dysfunction, and ultimately surgical failure.
2.Systemic factors
2.1 The presence of abnormal immune function
Such as the persistence of allergic factors, coupled with the combination of asthma in some patients, which in turn affects the function of the mucus cilia clearance system, is also one of the important reasons for poor healing. Other abnormalities such as abnormal immune function (abnormal immunoglobulins, abnormal T-cell subsets), in addition to AIDS disease combined with sinusitis, are also associated with poor surgical results.
2.2 Presence of certain congenital hereditary basic
such as the combined presence of immobile cilia syndrome and cystic fibrosis, lead to surgical failure [1].
3.Too poor compliance
Patients cannot adhere to the regular follow-up and medication change in strict accordance with medical advice for such and such reasons, especially within 10-14 weeks after surgery is the key, adhesions, vesicles, edema, etc. cannot be dealt with in time, it will lead to recurrence.
Second, the main preoperative treatment strategy
A considerable number of doctors and patients are not sufficiently aware of the preoperative preparation period, and the patient factor may be a little more. During this period (about 7 days), the main goal is to create conditions for a smooth surgery, especially for patients undergoing revision surgery, which appears to be more important. Practice has shown that preoperative patients who can properly control the congestion and edema of the nasal and sinus mucosa caused by local inflammation and metaplasia will effectively reduce intraoperative bleeding, enabling complete clearance of the lesion and more delicate surgery, while reducing complications. The specific practices are as follows.
1. Grasp the indications for corrective surgery
If the patient’s symptoms are not relieved or aggravated after surgery, if there are obvious hyperplastic polyps, sinus stenosis or even occlusion, and infection in the operative cavity by endoscopy, and if CT scan suggests residual lesions, and if active conservative treatment is ineffective, then consider revision surgery again.
2.Drug preparation (note contraindications)
2.1 Systemic antibiotics: We usually choose cephalosporins or macrolides for routine oral administration, which are suitable for all patients.
2.2 Local glucocorticoids: they have potent anti-inflammatory and anti-edema effects and are suitable for all patients. If patients have clear allergic factors present, systemic hormones (prednisone, etc.) or systemic antihistamines for at least 2 months postoperatively are also given.
2.3 Mucus pro-discharge agents: usually Gireotone is used orally. It is indicated for all patients.
2.4 Local astringent: nasal spray of hydroxymethylphenidate, twice daily, for all patients [2].
3. The role of sinus CT scan in corrective surgery must be emphasized
Anterior surgery, whether endoscopic or conventional, can lead to structural changes, scarring or fibrosis, and conventional radiographs do not accurately indicate the extent and scope of recurrent lesions. Many studies have demonstrated that CT can accurately visualize sinus lesions, and although it does not distinguish between fibrosis and hyperplasia, it does provide a clear indication of the site and extent of the lesion, the site of previous surgical failure, and the site of the proposed secondary surgical treatment, especially for some injuries caused by previous surgery or lesions (e.g., orbital cardboard). CT is an indispensable imaging tool for the diagnosis and treatment of recurrent chronic sinusitis, and is extremely important for corrective surgery.
4. Pay attention to the importance of nasal irrigation
Recent studies have shown that hypertonic saline has a better effect on rinsing the nasal cavity than physiological saline. Warm saline plays an important role in cleaning nasal secretions after surgery, wetting the nasal cavity and improving nasal and sinus ventilation and drainage, but saline has no anti-infection and anti-metamorphosis effects. Therefore, there are still some defects in using saline alone to rinse the nasal cavity. In recent years, various literature reported the use of a variety of drug-containing rinses for surgical cavity irrigation, and certain efficacy has been achieved. Clinical practice proves that nasal irrigation has a good auxiliary therapeutic effect regardless of preoperative and postoperative applications.
5.Choose a good anesthesia method
Choose the anesthesia method according to the comprehensive situation of the patient (with or without basic diseases, psychological, economic conditions, etc.). Generally, for patients undergoing revision surgery again, it is best to choose controlled low-pressure general anesthesia with tracheal intubation, and local anesthesia can be chosen only for lesions confined to the nasal cavity and tolerated by the patient. Improper choice of anesthesia leads to cases where the surgery cannot be adhered to.
6.Do a good job of doctor-patient communication
Provide detailed information to the patient and family members about the condition, the purpose and basic procedure of surgery, expected efficacy, possible accidents and ways to deal with them, and the need for long-term follow-up and uninterrupted comprehensive treatment after surgery. In particular, the expected outcome should be left open, which symptoms can be solved by reoperation and which cannot, and the patient’s compliance. Clinical experience proves that a significant portion of doctor-patient disputes are caused by poor communication between doctors and patients.
Main strategies in surgery
Four basic principles must be grasped for corrective reoperation: first, to grasp the key positioning markers for reoperation; second, to thoroughly remove residual lesions and recurrent polyps; third, to ensure that the sinus openings are fully opened and enlarged to ensure adequate patency and drainage. Fourth, use minimally invasive methods (application of electric suction cutter, etc.) to deal with lesions as much as possible and try not to expand the scope of surgery.
1. Grasp the key positioning mark for re-operation
The key to re-operation is to confirm the intraoperative anatomical reference mark, which has caused great difficulties in re-operation due to the destruction or even absence of some positioning marks (middle turbinate) as a result of previous operations. Our clinical practice is a six-point localization method with six anatomical reference marker points available for intraoperative application. Accurate localization is a reliable guarantee of successful reoperation and reduces complications. These marker points are common and easy to find intraoperatively.
1.1 Anterior vault of the middle nasal passage (anterior arch): The first locating point is the anterior arch, which is actually the anterior vault of the middle nasal passage, located between the posterior superior lacrimal bone and the anterior superior attachment margin of the middle turbinate. Even if all of the middle turbinates are removed in some patients due to rough surgery, this bony arch is always present and it is the anterior border and entrance of the septal sinus. Grasping this point and avoiding inward access to the lateral plate of the sieve plate; outward, always operating along the orbital cardboard, can avoid the risk of penetrating the sieve roof into the skull. The anterior arch must be found during the operation in order to enter the septal sinus and frontal sinus for the operation.
1.2 Maxillary sinus opening window (maxillary sinus opening): In clinical practice, it is found that even if the maxillary sinus opening window in the middle nasal tract is open and wide, some cases still have persistent sinus inflammation, and endoscopic examination reveals residual sieve funnel or hooked remnants, and the above residual lesion scarification can obstruct the natural mouth area of the maxillary sinus. Two methods of positioning are available intraoperatively. One test pressure on the posterior fontanelle area, centered on the place where bubbles appear for opening, can enlarge the maxillary sinus opening; the second, the posterior fontanelle is a soft and movable membrane, located above the inferior turbinate, which is also easy to locate. The maxillary sinus opening window is enlarged sufficiently after access and must include the natural opening. The maxillary sinus opening is one of the most meaningful landmarks for positioning in endoscopic surgery, its position is certainly constant and it has an important reference role for the lateral wall of the nasal cavity (the outermost part of the sagittal plane).
1.3 Orbital cardboard: Careful reading of the CT scan of the sinus before reoperation can identify clearly the cardboard damage due to previous surgery or lesions. The orbital cardboard is located above the maxillary sinus opening window and can be found inward along the orbital floor wall. The orbital plate is viewed microscopically as a flat bone plate with a yellowish color due to the orbital fat behind it.
1.4 Infraorbital ridge: The orbital plate forms a bony elevation between the lower maxillary sinus opening and the plate above it, the “infraorbital ridge”. Microscopically, the posterior sieve is located above the infraorbital ridge and the pterygoid sinus is located below it. Therefore, the infraorbital ridge and the opening window itself allow the surgeon to confirm whether the posterior sieve or the pterygoid sinus is being entered, which is an extremely useful anatomical reference for positioning.
1.5 Posterior nasal arch: In endoscopic surgery, identification of the posterior nasal arch is particularly useful for localizing the anterior wall of the pterygoid sinus, especially during revision surgery or when the pterygoid septal crypt is extensively diseased and the natural opening of the pterygoid sinus is difficult to find. The anterior mucosa of the pterygoid sinus is locally electrocoagulated or bitten off downward, and the branches of the pterygopalatine artery are treated. The pterygoid sinus is entered through the proximal septum, 1 cm above the arch, by biting open with straight forceps, noting that the inner lower portion of the pterygoid sinus is a safe site for entry. The opening must include the natural sinus opening of the pterygoid sinus to avoid recirculation of mucus.
1.6 Pterygoid sinus parietal wall and pterygoid sinus opening: the parietal wall of the pterygoid sinus and septal sinus is continuous and consistent, which is clear from the sagittal image. The mouth of the pterygoid sinus can be found based on the posterior nasal arch, and sometimes, the residual superior turbinate is of great help in locating the mouth of the pterygoid sinus, and the endoscopic view of the medial inferior turbinate is usually the mouth of the pterygoid sinus. The pterygoid sinus opening can suggest the deepest part of the sinus, and the position is also constant, and it is also one of the most meaningful signs of positioning in endoscopic surgery.
2.Handle the focus of reoperation
2.1 Treatment of middle and inferior turbinates: middle turbinate scar adhesions blocking the middle nasal tract can be partially excised. Since middle turbinates have an important role in maintaining the physiological function of the nasal cavity and sinuses, they cannot be routinely excised and need to be completely excised rarely. If the middle turbinate lesion (vesicular, polypoid, reverse deviation, etc.) obstructs drainage, it can be partially excised or trimmed. The middle turbinate treatment is to keep the middle nasal tract and the olfactory groove open to drainage as the mastery scale. If the maxillary sinus opening window of the middle nasal tract exists, it is necessary to check whether it is connected with the natural opening, if not, the two openings must be connected endoscopically. Treatment of inferior turbinate is mostly done by minimally invasive methods, such as external displacement of inferior turbinate fracture or submucosal resection and reduction, partial excision, etc. It is rare that the inferior turbinates are relatively small and mucus circulation is formed between the middle nasal tract and the maxillary sinus opening window of the inferior nasal tract. At this time, partial resection of the medial wall of the maxillary sinus can be performed to connect the windows of the middle and inferior nasal tract.
2.2 The key to the presence of maxillary sinusitis despite the opening window of the inferior nasal tract is the obstruction of the natural mouth of the maxillary sinus, and the corrective surgery must be performed with an adequate maxillary sinus opening of the middle nasal tract. The residual hooked scar is bound to obstruct the natural opening of the maxillary sinus and must be completely removed endoscopically, while ensuring that the natural opening and the open window are connected. If mucus circulation is found between the maxillary sinus opening window and the natural orifice, the same treatment is performed.
2.3 In patients who have not been relieved by performing conventional Kirk-Luk procedure, the role of residual respiratory epithelium in the natural orifice area of the maxillary sinus is considered, such as edema and polyp growth causing sinus orifice obstruction, then a maxillary sinus opening window in the middle nasal tract is required. In cases where all abnormalities are ruled out and after treatment with antibiotics that are sensitive to the causative organism, the Cole-Lu pathway can be considered for resection of all maxillary sinus mucosa and, at the same time, endoscopic maxillary sinus opening of the middle nasal tract via the Cole-Lu pathway.
2.4 Revision surgery for nasal septal deviation: nasal septal deviation requires reoperation, which is usually seen when previous surgery is incomplete or when the deviation is formed again by developmental effects. Our experience is to do limited corrective resection mainly, where the deviation affects the ventilation and drainage, where the incision changes with the site of the deviation, without sutures, and generally heal after keeping the edges aligned and filled. Another attention to the deviation of the side of more filling, if necessary, with high expansion sponge coated with erythromycin ointment again filling to ensure the correction effect.
Fourth, the main postoperative treatment strategy
After surgery, we must grasp the principle of comprehensive treatment, which is the following points: local treatment is the main treatment, and systemic treatment is supplemented; operative cavity cleaning and local drug treatment are equally important; timely and standardized follow-up can ensure the efficacy.
1. Surgical cavity irrigation.
After removal of the plug, use saline with antimicrobial and hormone to flush once a day. If possible, hypertonic saline can be used.
2.Operative cavity dressing change.
The scabs and blood clots in the operative cavity should be cleaned under frontoscopic illumination and mucous secretions should be aspirated daily within 7 days after surgery. The first endoscopic cleanup and drug change can be 7-10 days postoperatively, and the endoscopic drug change cycle for stages 1 and 2 [3] can vary from 10 days to three weeks, mainly depending on the condition seen in the endoscopic review at that time, and too frequent endoscopic cleanup is instead prone to cause new opportunities for injury. We put great emphasis on the endoscopic drug exchange technique, should pay attention to protect the new epithelium of the trauma, mainly to remove blood scabs, snot scabs, aspirate the mucous secretions for the purpose, for some vesicles, edema, do not clamp, only aspirate it to break, discharge the fluid can be; for the granulation, small polyps can be used in Shandong Texas New Direction Medical Equipment Co. The other is the treatment of nasal adhesions, especially the adhesions caused by external or internal displacement of middle turbinate, if necessary, local placement of high expansion sea sponge or tin foil to separate the adhesions. We have specially designed a post-endoscopic health care handbook for patients to clearly inform them when they should come for medication change, and each medication change is recorded, which is very popular among patients, and the efficiency of endoscopic surgery or revision surgery is greatly improved.
3. Medication use (note contraindications).
The use of antibiotics generally does not exceed one week, corticosteroids can be intravenous drip within 7 days after surgery, later can be changed to prednisone 30-40mg/day (0.5-1.0/kg/day), once a day in the morning dose. Oral mucus thinning and drainage drugs should be administered in all 3 phases. In cases of combined allergic rhinitis, oral antihistamines should also be given. In principle, the use of decongestants is not recommended for local use, but glucocorticosteroid nasal spray should be applied continuously during the 3 stages of wound healing in the surgical cavity.
Recurrent nasal polyps and sinus inflammation is a relatively long and comprehensive treatment process, which can never be solved by a single corrective surgery. Both doctors and patients should have a full understanding before surgery, and must go through a complex treatment process before and after surgery, and have full recognition and confidence in this process, so that both doctors and patients can be more satisfied in the end.