eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Nasal & Sinus Diseases
Sinusitis, Ethmoid, Acute, Surgical Treatment: Treatment
Updated: Aug 28, 2009
Treatment
Medical Therapy
Medical therapy for acute ethmoid sinusitis is geared toward eradicating the infection, opening the ostium, restoring the mucociliary function, and relief of pain.
Treatment is often empiric, with the use of antibacterial agents most often directed against gram-positive organisms. Antimicrobial agents such as ampicillin, amoxicillin, amoxicillin/clavulanate, erythromycin, clarithromycin, cefaclor, cefuroxime, and trimethoprim/sulfamethoxazole can be used, usually for 10 days. If dental extraction is implicated, consideration should be given to using metronidazole. Decongesting of the mucosa using topical oxymetazoline or oral decongestants can be helpful in shrinking the mucosa. Pain is managed as needed.
If the patient does not respond to treatment, the results of cultures can be used to guide further therapy. Investigations for atypical pathogens or immunocompromised status must be undertaken in an otherwise healthy patient who develops ethmoiditis that is not responsive to therapy and progresses. If Pseudomonas or fungal sinusitis may be present, it must be identified, and therapy must be altered to treat the offending agents.
Medical treatment may not be enough to resolve the ethmoiditis. In those cases that resolve but are not eradicated, chronic sinusitis may develop. Further antibiotic treatment and ultimately surgical therapy may be warranted for chronic ethmoidal sinusitis, but such matters are beyond the scope of this article.
When acute ethmoidal sinusitis is rapidly progressing, threatening to involve or involving contiguous areas such as the orbit, and not responding to aggressive antimicrobial therapy, surgical intervention is warranted. These patients are often hospitalized, and medical treatment consists of broad antibiotic coverage with more than one agent. In addition to the agents mentioned previously, these include ceftriaxone, vancomycin, ticarcillin/clavulanate, ampicillin/sulbactam, and ceftazidime. If improvement is not observed within 24 hours, surgical intervention is usually undertaken.
Surgical Therapy
An ethmoidectomy is performed using one of 3 major approaches, the external ethmoidectomy, the intranasal (endoscopic) ethmoidectomy, and the transantral ethmoidectomy. Each approach offers advantages and has disadvantages. The ultimate decision of which approach to use will depend on the surgeon's preference and the extent of the disease. However, the transantral approach is the least used for isolated ethmoidal sinusitis. Depending on the extent of the disease, more than one approach may be combined during the surgical intervention.
External approach
This surgery can be performed under monitored anesthesia care or general anesthesia. General anesthesia may be preferred because manipulating the globe can be uncomfortable to the patient. An incision is made in a curvilinear fashion approximately 2.5-3 cm in length. It is positioned at the midpoint between the medial canthus and the middle of the anterior nasal bone. The skin is incised, and the dissection is carried down to the periosteum. If the angular artery is transected, it is cauterized or ligated. Dissection is carried subperiosteally to the posterior lacrimal crest, avoiding damage to the lacrimal excretory structures.
The medial canthal tendon may need to be released to allow for easier access to this area, and, if this is done, care must be taken to reposition it correctly. The posterior crest may need to be removed. Care must be taken not to extend the dissection superiorly to the frontoethmoidal suture as this demarcates the cranial fossa. The anterior ethmoidal artery lies at the level of this suture 20 mm posterior to the posterior lacrimal crest. The posterior ethmoidal artery is also at this level another 10 mm posterior, and the optic nerve is found 5 mm further back from the posterior ethmoidal artery. If needed, the anterior ethmoidal artery can be ligated.
The anterior cells are removed. The posterior cells can also be approached and treated as needed with ligation of the posterior ethmoidal artery if required. A drain is often placed and can be used in the postoperative period for lavage of the sinus. The medial canthal tendon is repositioned if needed, the periosteum can be closed or left open, and the skin is closed in layers.
Intranasal approach
This surgery can be performed with the patient under monitored anesthesia care or general anesthesia. Pledgets soaked in 4% cocaine or a combination of 4% lidocaine and 0.25% oxymetazoline are passed into the nasal cavity to anesthetize and decongest the mucosa. A local anesthetic containing 1% lidocaine and 1:100,000 epinephrine is injected into the mucosa of the middle turbinate, septum, and lateral wall. Hand instruments or powered instrumentation is used. If present, polyps are resected.
If the middle turbinate is obstructing the ostial area, such as with a concha bullosa, it can be partially resected. When manipulating the middle turbinate, care must be taken not to fracture the cribriform plate, which is just medial to the attachment of the turbinate, because this will cause a cerebrospinal fluid (CSF) leak.
The uncinate process and infundibulum are approached. An incision is made in the infundibulum and the uncinate process is resected. The mucosa can be incised with a sickle blade and removed with forceps. A loop curette or other noncutting instrument can be used to gently break into the anterior cells of the sinus. The cells are opened with biting instruments. Posteriorly, the dissection ends at the sphenoid sinus. Dissecting this far posterior in isolated anterior disease may not be necessary.
If the sphenoid sinus is involved, it must also be surgically addressed. The frontoethmoidal suture lies at approximately the level of the pupils, but this can be less reliable with a patient under general anesthesia. Complications from improper dissection of the sphenoid sinus can involve the optic nerve and carotid artery with disastrous consequences.
Culture can be obtained and material sent for pathologic examination as warranted. The nasal area is then packed with antibiotic ointment–coated gauze.
Transantral approach
This surgery can be performed under monitored anesthesia sedation or general anesthesia. A Caldwell-Luc approach is used. Once the maxillary sinus has been entered, the medial and superior walls of the maxillary sinus are identified. At the midpoint of the medial wall, the bulla ethmoidalis may be seen bulging into the maxillary sinus. A curette is used to enter this area, which is enlarged with a Kerrison rongeur or other bone cutting instruments. This allows access to most of the anterior cells, but the most anterior cells may be difficult to reach. The posterior cells off the ethmoid sinus can also be reached.
Preoperative Details
CT scans should be obtained to determine the extent of the ethmoidectomy needed. The degree of surgery required is determined by the extent of the disease and not by a simple categorization or technique, such as limiting the surgery to only the anterior ethmoidal air cells as in the Messerklinger technique or a complete sphenoethmoidectomy as in the Wigand approach.9
Intraoperative Details
Regardless of the approach used, the surgeon must be familiar with the anatomy and aware of all pertinent landmarks to reduce the risk of complications. Attention must be paid to avoid violating the cribriform plate or inadvertently entering the orbit. Avoiding injury to the septal mucosa, especially if the endoscopic approach is used, will diminish bleeding that otherwise would obscure the view. If bleeding is a problem it must be controlled, with cautery; thrombin; Gelfilm; Gelfoam; Surgicel; Merocel; or packing containing cocaine, adrenaline, phenylephrine, or oxymetazoline.
Postoperative Details
The postoperative course and care of the patient will to some extent depend on the approach used. All patients are maintained on antibiotic therapy and pain medication. Culture results can be used to adjust the antimicrobial regime as needed. Once the prognosis is improved, steroid usage can be considered. Patients are instructed to avoid nose blowing for up to 1 week.
In the external approach, the drain is usually removed in 48-72 hours. It can also be used to lavage the sinus; however, the authors do not do this. The skin sutures are removed in approximately 7 days. Topical nasal decongestants are used for 3 days after surgery and then discontinued. The patient then uses nasal saline mist for 1 week.
In the endoscopic approach, the packing is removed within 48-72 hours. Topical nasal decongestants are used for 3 days after surgery and then discontinued. The patient then uses nasal saline mist for 1 week. Repeat nasal endoscopic examination and debridement in the postoperative period are usually necessary.
In the transantral approach, the patient rinses with an antiseptic mouthwash after each meal and at bedtime to maintain the hygiene of the mouth. The sutures are dissolvable. Topical nasal decongestants are used for 3 days after surgery and then discontinued. The patient then uses nasal saline mist for 1 week.
Follow-up
All patients have a follow-up visit the first day after surgery. Further follow-up visits are scheduled according to the surgical approach used and the degree of illness of the patient.
Complications
Complications of sinusitis
Ethmoidal sinusitis can spread outside of the borders of the sinus and cause an orbital cellulitis, orbital subperiosteal abscess, orbital abscess, superior orbital fissure syndrome, or cavernous sinus thrombosis. Cavernous sinus thrombosis can be life threatening and result in limited ocular motility, proptosis, and loss of vision. Intracranial complications are fortunately rare from sinusitis but can have a high morbidity and mortality and include meningitis, thrombophlebitis of the superior sagittal sinus, and abscess formation. Osteitis and osteomyelitis have also been observed. Mucoceles and pyoceles can occur.
Complications of ethmoid sinus surgery
Overall, the complication rate for ethmoid sinus surgery has been reported to be from 2-17%.5
The transantral approach does allow for access through the maxillary sinus and is a unilateral approach, but it provides restricted access to the most anterior ethmoidal air cells. In the transantral approach, damage to the dentition, oral-antral fistula formation, paresthesias in the distribution of the infraorbital nerve, and paresthesias in the gingivobuccal sulcus and alveolar ridge can also occur.
The external approach allows for visualization of the orbital contents and is a unilateral approach that will result in a cutaneous scar that could lead to medial canthal webbing, telecanthus, and medial canthal dystopia, especially if the medial canthal tendon is released and not properly repositioned. In the external approach, periorbital edema, injury to the extraocular muscles with diplopia, paresthesias in the distribution of the supraorbital, supratrochlear and infratrochlear nerve distributions, and blepharoptosis can also occur. The globe also can be injured. Blindness can occur from either a hematoma or excessive pressure on the globe occluding the central retinal artery during the surgery.
This endoscopic approach allows for access to both ethmoid sinuses, but it requires that the surgeon be facile with an endoscope. This approach can also cause an orbital hematoma and blindness. Diplopia can occur if an extraocular muscle, usually the medial rectus, is injured. Atrophic rhinitis has also been reported.12 More worrisome are the rare, but unfortunate, reports of blindness due to resecting the optic nerve. CSF leaks can also occur. Most will resolve with conservative treatment, but, if extensive and noted at the time of surgery, a leak should be addressed and repaired with dura, fat, mucosa, and/or fibrin glue. Synechia and ostial closure can also occur. Often, the synechia can occur between the turbinate and the septum. If it occurs between the turbinate and the lateral wall, blockage of the ostium can occur.13
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References
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Further Reading
Keywords
ethmoid sinusitis, ethmoid infection, ethmoiditis, ethmoidectomy, external ethmoidectomy, intranasal ethmoidectomy, endoscopic ethmoidectomy, transantral ethmoidectomy
