Revision Endoscopic Sinus Surgery for Maxillary Recirculation

Chronic sinusitis is, as the name implies, a chronic disease. There is no permanent cure for chronic sinusitis, but there are many treatments that can improve patients’ symptoms. The first step in treatment of chronic sinusitis is using a topical nasal steroid, like Flonase (now over the counter) and a saline rinses. If patients continue to have symptoms despite medical therapy, and they have an abnormal sinus CT (available in our office) then endoscopic sinus surgery is an option. Unfortunately patients may require more than one operation. A large part of my practice is revision sinus surgery. This can be due to polyp regrowth with symptom recurrence or due to scar tissue or incomplete prior surgery.

A unique indication for revision endoscopic sinus surgery is maxillary recirculation. This occurs when the natural ostium (hole) of the maxillary (cheek) sinus is not connected to the surgical opening that was made at the previous sinus surgery. The cilia in the sinus beats the mucus out of the natural ostium, and it falls back into the surgical opening in the maxillary. Then it goes around and around from maxillary sinus to the nasal cavity. Eventually it falls out into the nasal cavity, and patients describe usually unilateral thick post nasal drainage. It can be a source of recurrent infections as well, since bacteria frequently infect the thick mucus that resides in the maxillary. Nasal steroids and rinses can decrease symptoms, however definitive repair requires revision surgery.

By connecting the two openings in the maxillary sinus the recirculation ceases. I have had many patients that had decades of “allergies” resolve after the revision surgery. Convincing patients that had previous endoscopic sinus surgery in the 1980s or 90s is challenging, but fortunately the techniques have improved that do not require packing anymore. Without packing there is minimal pain.

I encourage you to visit https://www.doctor.com/Dr-Josh-Meier where dozens of patients have described their experiences after revision endoscopic sinus surgery for chronic sinusitis.

If you had endoscopic sinus surgery in the past and you have symptoms similar to those list above, please make an appointment; with a few diagnostic tests I can ascertain if your would benefit from revision surgery.

Josh Meier, M.D. F.A.R.S.

Director Reno Tahoe Sinus Center

Dr. Meier lectured at Renown Regional Medical Center Grand Rounds on August 10th, 2017 on “Chronic Sinusitis and Other Nasal Complaints”.

In addition to the audience present in the Mack Auditorium, there were remote attendees from Ely and Bishop.

Dr. Meier was happy to meet his referring doctors, and to answer everyone’s questions about nasal health.

Dr. Meier lectured on “Advances in Endoscopic Sinus Surgery” at Plumas District Hospital in Quincy, CA on July 31st.

He was pleased to meet many of his referring providers, and educate the staff on cutting edge treatments for chronic sinusitis.

Nevada ENT was proud to sponsor “Outrunning 50” – the winner of the Senior Women Division of the Reno Tahoe Odyssey.

Congratulations to Dr. Van Duyne who participated.

Chronic sinusitis (CRS) is defined as 12 weeks or more of two or more of the following signs and symptoms:

• Mucopurulent drainage (anterior or posterior)
• Nasal obstruction
• Facial pressure or pain or fullness
• Decreased smell

In addition, inflammation must be documented by one or more of the following findings:

• Purulent mucus or edema in the middle meatus or anterior ethmoid
• Polyps in the nasal cavity
• Radiographic imaging showing inflammation in the sinuses

Traditionally chronic sinusitis is managed first with saline rinses and a topical nasal steroid. For patients that continue to have a decrement in their quality of life despite medical therapy, then endoscopic sinus surgery can be considered as an option.

Endoscopic sinus surgery is surgery that is performed using cameras through the nostrils to open up and drain the sinuses. There are no external incisions. Since its inception in the 1980s, it has advanced in leaps and bounds, allowing more extensive surgery with less complications and easier recovery. One of the keys to this advancement has been the use of “image guidance” or computer assisted surgery.

At the beginning of endoscopic sinus surgery, the surgeon will trace the outline of the patients’ face and the computer will align and fuse it with the patient’s sinus CAT scan.   There are two ways that the computer can track where the instruments are during the operation, using magnets or an infrared system. We use the Medtronic Fusion® system at both St. Mary’s and Renown. Once it has been registered, the computer screen will show the surgeon where the tip of the suction or probe is during the operation on the computer screen. This enables the surgeon to confirm his or her location within the sinuses and allow the surgeon to access more complicated structures such as the frontal sinus, the sphenoid sinus and orbital or skull base lesions.

The American Academy of Otolaryngology – Head and Neck Surgery and the American Rhinologic Society endorses the use of image guidance in endoscopic sinus surgery in following situations:

• Revision sinus surgery.
• Distorted sinus anatomy of development, postoperative, or traumatic origin.
• Extensive sino-nasal polyposis.
• Pathology involving the frontal, posterior ethmoid and sphenoid sinuses.
• Disease abutting the skull base, orbit, optic nerve or carotid artery.
• CSF rhinorrhea or conditions where there is a skull base defect.
• Benign and malignant sino-nasal neoplasms.

Dr. Meier uses this technology commonly, and it enables him to address more disease safely. In the past extensive frontal sinus disease would require an external approach that has increased morbidity, however now with improved visualization, techniques and instrumentation in conjunction with image guidance, Dr. Meier is able to endoscopically treat the majority of frontal sinus disorders without incisions.

Josh Meier, M.D. F.A.R.S.

Rhinology is one of the newest medical specialties with many exciting technological advances occurring in recent years. Endoscopic sinus surgery began in the 1980s, and has progressed in leaps and bounds over the ensuing decades. Dr. Meier attends multiple courses annually to stay up to date on the newest technologies employed in the medical and surgical management of chronic sinusitis and diseases of the anterior skull base.

Dr. Meier uses a combination of old and new products to ensure proper healing after endoscopic sinus surgery. He uses a new product, Posisep X, which is a dissolvable dressing made from Chitosan, a naturally occurring molecule that has hemostatic and anti-inflammatory properties. Most of the Posisep will rinse out in the week after sinus surgery.

Another product Dr. Meier uses is the Propel stent in specific cases. This is a degradable steroid-eluting stent that stays in the ethmoid cavity for one month after surgery. By delivering mometasone, it can decrease inflammation after endoscopic sinus surgery.

Dr. Meier does not use splints or non-absorbable packing after endoscopic sinus surgery and septoplasty. This is because of the mucosal-preserving techniques he uses, which reduce bleeding, and speeds up healing and recovery. When packing is not used, there is minimal pain after nasal surgery.

Under Dr. Meier’s guidance, both Renown and St. Mary’s have upgraded their endoscopy camera and tower to the Karl Storz Image One system. Video examples of this technology can be seen at the Karl Storz website. This advanced, high-definition technology has enabled Dr. Meier to perform more complicated endoscopic sinus surgery involving the skull base, the frontal and sphenoid sinuses.

Josh Meier, M.D. F.A.R.S.