The European guidelines for the treatment of chronic rhinosinusitis, published in 2007, endorse cortisone nasal sprays as the first-line treatment that is best supported by the medical literature. The use of systemic antibiotics is less favorably evaluated, but the studies provide conflicting data. Second-line approaches include nasal lavage, antihistamines, and immunomodulatory agents.
We have used for years the combination of cortisone nasal sprays and salt water nasal lavage for a period of four weeks. If marked improvement occurs during this time, the treatment is continued but with a reduced strength of cortisone sprays. In the early stages of chronic rhinosinusitis, there is a realistic chance that a medical approach will produce a cure, avoiding the need for an operation.
In more chronic cases, the conservative approach often does not bring sufficient improvement, so that the only reasonable approach is surgical. Before the operation, we always perform computerized tomography (CT scan) of the sinuses; the information obtained contributes greatly to the safety of the operation.
Although in the past a variety of radical surgical measures were popular, in the past two decades minimally-invasive endoscopic surgery has become the preferred surgical approach to chronic rhinosinusitis. The goal is to establish a patent connection between the sinuses and the main nasal cavity in order to insure both proper drainage and adequate air exchange (Fig. 1).
The same therapeutic approach is used to treat nasal polyps (Fig. 2). Often as an accompanying measure a septoplasty (correction of septal deviation) as well as trimming of the turbinates with laser or radio frequency ablation may be needed. The nose is then packed for one night to control possible post-operative bleeding.
The surgical approach is individually adjusted for each patient, tailored to their history and clinical findings. We always consider previous and accompanying illnesses, sequelae of previous operative attempts and the status of the nasal mucosa. Each of these parameters can affect the course and duration of healing, as well as the success of the procedure.
MINIMALLY-INVASIVE ENDOSCOPIC SURGERY
We have been involved with chronic rhinosinusitis and polyps for a quarter-century, initially in the Department of Otorhinolaryngology of the Ludwig Maximilian University, Munich, and since 2001 in our private clinic in Starnberg. In addition to research and clinical studies on the causes and diagnostic approach, we have been active in developing minimally-invasive endoscopic surgery of the nose and sinuses since its early days in Germany, and helped refine this approach for nasal polyps, initiating the now well-established shaver technique and navigation surgery.
In the Nasen-Zentrum-Starnberg, we have performed annually since 2001 several hundred minimally-invasive operations on the sinuses. Our success rate ranges between 85 and 95%. Such an accomplishment is only possible when the indications are carefully weighed and the surgical approach carefully customized for each patient.
We must re-emphasize that minimally-invasive endoscopic surgery of the nose and sinuses is not a trivial procedure. Working through a keyhole, the surgeon moves in close proximity to both the optic nerve and frontal lobe of the brain. The procedures are challenging, even for the most experienced surgeon, especially when the inflammation is chronic or a previous surgical attempt has been made. Thus the indications have to be carefully weighed when considering a surgical procedure.
If we decide to recommend surgery after exhausting non-surgical therapeutic measures, then the patient is counseled in detail by the treating surgeon himself. Using a model, the planned operation is described in detail, demonstrating the potential problems and the proximity to the eye and brain.
Just as in many other professions, in surgery experience is a key factor in determining outcomes. There is a close relationship between the number of times an operation is performed annually and the quality of the surgical results. Long-term studies on thousands of patients have documented that in centers concentrating on minimally-invasive endoscopic surgery, all parameters are more favorable shorter period of treatment, shorter operation time, fewer complications and higher success rates.
Another important requirement for a surgical success is an individualized post-operative therapy. Depending on the history and previous therapy, the post-operative problems and the length of time required to manage them can vary considerably (patient information for post-operative period). Important factors in healing include not only the extent of the surgery but also the pre-operative condition of the mucosa. For example scarring and adhesions after previous surgery, duration of pre-operative inflammation, and long-term decongestant nose drop use may all delay healing.