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News -> April, 2002 News
Peter H. Hwang, MD
Oregon Health & Science University
Portland, OR
RK is a 55 year-old man with cystic fibrosis, advanced bronchiectasis, and chronic sinusitis. He underwent endoscopic sinus surgery over ten years ago. Most recently, he presented to his pulmonologist with chief complaints of progressive severe left-sided headache, nasal obstruction, and post-nasal drip exacerbating his respiratory failure. A CT scan revealed two large expansile cystic masses in the left frontal and maxillary sinuses; there was also secondary erosion of the medial orbital wall (See Figures 1 & 2). On referral to the rhinology service, endoscopic examination confirmed the presence of purulent discharge and a protruding mass of polypoid tissue filling the middle meatus. The patient's pulmonary status was significantly impaired due to his cystic fibrosis and bronchiectasis, and he required supplemental oxygen by nasal cannula.
Figure 1
Figure 2
Because of his fragile respiratory status, the patient was not a candidate for surgery under general anesthesia. Similarly, he was deemed by his pulmonologist to be unsuitable for any procedure involving intravenous sedation. Given these constraints, the patient ultimately underwent a procedure under local anesthesia without sedation in the clinic setting. Anesthesia was achieved using topical 4% lidocaine, topical 4% cocaine, and submucosal 1% lidocaine with 1:100,000 epinephrine. The patient was positioned sitting upright to minimize aspiration risk and he was not sedated. A 40-degree curved microdebrider was used to clear polyps from the ethmoid, and to marsupialize and drain large mucopyoceles in the frontal and maxillary sinuses. Blood loss was less than 10cc. The patient tolerated the procedure very well, with minimal discomfort and without any compromise of his pulmonary status. He experienced immediate relief of symptoms. His sinuses remain patent and clear at 3 months post-procedure.
Discussion:
Just as local anesthesia can be an attractive and viable option for certain patients undergoing sinus surgery in the operating room, office procedures performed under local anesthesia can be a valuable adjunct to the practice of the rhinologic surgeon. Armed with a basic set of instruments (backbiter, through-cutting Blakesley forceps, frontal curets) and a microdebrider, the rhinologic surgeon can perform a variety of procedures in the office: maxillary sinus revision (removal of retained uncinate, correction of recirculation); polypectomy; turbinate reduction; and selective ethmoid, sphenoid, or frontal revisions. As for any procedure, careful patient selection is of utmost importance. Typically, the best candidates are motivated patients needing minor revision surgical procedures. Anesthesia should be provided meticulously, using topical lidocaine and/or cocaine, augmented by lidocaine injections to the lateral nasal wall and/or greater palatine foramen as needed. Placement of a nasopharyngeal sponge may minimize the risk of aspiration of blood in more extensive cases (Kennedy Intranasal Surgical Sponge, Medtronic-Xomed, Jacksonville, FL). The surgeon should have CT images readily available for reference just as one would in the operating room.
The above patient represents a more complex and higher risk case that should be undertaken only after extensive experience has been gained in office rhinologic procedures. However, for more straightforward cases, office procedures under local anesthesia can provide an effective treatment alternative to the operating room, offering a minimum of morbidity and a high degree of patient satisfaction.
References
- Thaler ER, Gottschalk A, Samaranayake R, Lanza DC, Kennedy DW.
Anesthesia in endoscopic sinus surgery. Am J Rhinol. 1997 Nov-Dec;11(6):409-13.
- Lee WC, Kapur TR, Ramsden WN. Local and regional anesthesia for functional endoscopic sinus surgery. Ann Otol Rhinol Laryngol. 1997 Sep;106(9):767-9.
- Rontal M, Rontal E, Anon JB. An anatomic approach to local anesthesia for surgery of the nose and paranasal sinuses. Otolaryngol Clin North Am. 1997 Jun;30(3):403-20.
- Jorissen M, Heulens H, Peters M, Feenstra L. Functional endoscopic sinus surgery under local anaesthesia: possibilities and limitations. Acta Otorhinolaryngol Belg. 1996;50(1):1-12.
- Moriyama H. The technique of endoscopic surgery and diagnosis of frontal recess and sinus disease under local anesthesia. J Otolaryngol. 1991 Dec;20(6):382-4.
- Kennedy DW, Josephson JS, Zinreich SJ, Mattox DE, Goldsmith MM. Endoscopic sinus surgery for mucoceles: a viable alternative. Laryngoscope. 1989 Sep;99(9):885-95.
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