HEAD AND NECK

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The use of the endoscopes in diagnostics and surgery of nose diseases almost a decade ago, changed radically our ideas and practices in this field. The anatomy of the nose and the areas around it acquired a new meaning. New anatomic elements, that in the past were simply described, obtained a particular clinical importance as significant surgery points.

In parallel, the increasing sensitivity of imaging methods, especially of CT and of MRI, helped in the diagnostics of nose diseases but firstly in the preoperative study and planning of the cases that require surgical treatment. The increasing use of navigator systems during the last five years, helped nose and paranasal sinuses surgery became safer and more radical. It also made possible the design and implementation of operations in anatomical areas beyond the bounds of the nose and the paranasal sinuses, giving a new prospective to the collaboration with other specialties such as Neurosurgery, Ophthalmology and Oral and Maxillofacial surgery.

We believe that the endoscopic surgery of the nose and the paranasal sinuses will be a reference in the history of Otorhinolaryngology similar to the introduction of the microscope in ear surgery and the laser in laryngeal cancer surgery. It is a real privilege for us to participate in its really fast and exciting development.

Nose and paranasal sinuses disorders are a large part of Otorhinolaryngology. Nasal polyps afflict much of the Greek population. The term polyp is descriptive and does not reflect its clinical meaning. Thus, nasal polyp has a different clinical importance than ear, laryngeal or intestinal polyp. Nasal polyps are benign lesions of inflammatory etiology. The inflammation may be an allergic or vasomotor rhinitis or rhinitis of fungal or bacterial origin. Polyps of inflammatory etiology involve both nostrils. The presence of alterations and masses affecting one nostril only, should make us cautious in the diagnostic investigation. Less commonly, polyps are observed only in the one nasal chamber and they come from one paranasal sinus, usually the maxillary sinus. Such polyps are called choanal polyps, are benign, may reach a considerable size and they are of unknown etiology. They are considered as a predisposition of the organism.

The usual polyps are caused by inflammation and at the same time they also sustain the inflammation. They often coexist with chronic paranasal sinusitis. Chronic paranasal sinusitis afflicts much of the population and may be due to either incompletely healed acute paranasal sinusitis or to anatomical problems of the orifices of the paranasal sinuses.

If we imagine paranasal sinuses such as maxillary sinuses as reservoirs, these are ventilated and they discharge their contents through small orifices. When, their orifices are narrow for anatomic reasons, or they are obstructed by polyps or because of tissues oedema resulting from an incompletely healed chronic sinusitis, then the alteration process of chronic paranasal sinusitis begins.

The patient goes to the doctor during an episode of inflammation of the paranasal sinuses complaining about difficulty of nasal breathing, catarrh, or purulent rhinorrhea. The patient is likely to report feeling of weight or pain on the face and also headache. This kind of symptoms may have recently occurred or may have been repeated several times in the past. In case of chronic symptoms, the patient is usually aware of the problem and visits the doctor seeking a radical solution.

Clinical examination, with endoscope, enables us to make a diagnosis in most cases. We can easily notice the presence and extension of polyps, or the presence of a choanal polyp and the group of paranasal cells from which it stems.

In other cases, pus discharge into the nose can guide us to the cell group which suffers the inflammation. Furthermore, more lesions of different nature compared to those of simple polyps can be detected. Lastly, anatomic conditions predisposing to the narrowing of the orifices of the paranasal sinuses that will make difficult the access to certain areas in case of surgery are revealed.

Imaging examinations, such as simple sinus x-ray or the CT and the MRI are necessary only in selected cases. For patients with isolated episodes of acute inflammation of the paranasal sinuses, diagnosis and monitoring of the response to treatment are made with nasal endoscopy. For patients with relapsed episodes, chronic paranasal sinusitis or nasal polyps, where there is evidence that renders surgery necessary, a CT may have to be done, however, not during the acute phase of the disease or during a seasonal symptom increase.

Surgical intervention is performed in cases of chronic alterations that do not improve after sufficient medication. By performing the CT we actually try to locate this kind of alteration. MRI aims at determining alterations extended beyond the nose and the paranasal sinuses, to the ocular orbit, or the brain or behind the maxillary sinuses in the infratemporal fossa.

The CT must meet specific standards concerning the precision of the cuts and the possibility of three-dimensional reconstruction. The CT will help us make a detailed study of the paranasal sinuses anatomy and detect deficits in bone walls which are in contact with the ocular orbit and the brain. The CT is also a requirement for the use of navigation system in possible surgery. MRI must meet similar standards. Moreover, in specific cases, both tests may be used in a combination.

For some patients, we may have to seek specific syndromes related to the disorder, or predisposing factors for inflammations, or to study the hyperactivity or possible suppression of the immune system. In other cases, taking material for biopsy may be the last act before final diagnosis and therefore, before deciding on treatment. As mentioned before, polyps of inflammatory etiology are benign. There are, however, malign tumors whose outer texture resembles that of simple polyps or tumors which present polypoid degeneration at their borders. That is why, any kind of material after surgery is sent for histological examination.

After completing as many of these actions are necessary, it is time to inform the patient about the proposed treatment. In most cases, conservative medication is enough. Antibiotics treatment and additional decongestant (to be inhaled through the nose), as well as antihistamines or cortisone (in local or systematic form) are administered. The medication is not only the solution for acute situations, but also the preparation process preceding a scheduled surgery and an additional treatment after certain operations.

If the recommended treatment is surgical, our first concern is to distinguish patients to whom we can promise a radical solution to the problem from those for whom surgery would be only an episode in the long course of the disease. Thus, in the case of paranasal sinusitis which are due to anatomic and microbial factors or choanal polyps we can promise a radical solution to the problem.

In cases, however, of polyps resulting from the particularity of nasal mucosa, it is generally recognized that the tendency for recurrence is high. Many of our patients have already been operated for the same reason and it is very likely that we will not be the last to perform the same kind of medical intervention. Our efforts will not be judged by whether and how long it will take for the polyps to appear again but by how sincere was our preoperative discussion, how radical was our intervention by opening up all areas and cells affected and by how systematic our postoperative attendance was.

The patient has completed the preoperative treatment, he / she has undergone a specific CT and has been examined by the anesthesiologist in order for the latter to detect possible coexisting respiratory or other problems that are usual in such cases. For most patients general anesthesia is preferred. In certain cases, surgery will be performed under local anesthesia, and therefore, a radical solution is not guaranteed. The operation usually lasts two to three hours depending on the extent of the pathology or anatomic difficulties. Despite the scale of the dissection of tissues, postoperative bleeding is rare and the patient is transferred to his room without tamponade. He / she stays overnight in hospital and is discharged the next day. The navigation system (navigator), is our guide through the nose during surgery. Thus, it ensures that our operations are both radical and safe. The navigator is a tool of latest technology. It is used as a supplement during surgery like the nerve stimulator in thyroid or parotid surgery. It may be necessary only in certain surgeries however we ensure that it will be available in every endoscopic surgery.

Postoperative care lasts about a month or more and it includes administration of antibiotics, washing with hypertonic saline solution and nose cleaning. Postoperative monitoring of patients with high probability of disease recurrence, lasts indefinitely, or at least till we calculate the frequency of administration of the medication capable of preventing the recurrence of polyps. This treatment will include frequent washing with hypertonic saline solution and, at intervals, cortisone for local administration into the nose.

Recently, in 2013, we published our technique for the treatment of recurrent polyposis. Our technique is called modified dermoplasty and consists in the replacement of the mucosa of the nasal vault with skin from the patient. The skin graft exhibits great capacity for take and survival in its new position and great resistance in the growth of polyps. For more details you can visit our website nasalpolyps.gr.