I wonder if you still have an infection.

this article  was posted here before. may be relevnce to post it
again. Don't hold your breath for fen either, it is also invasive and
damaging:

Ear, Nose & Throat Journal
June, 2001

Endoscopic physiologic approach to allergy-associated chronic
rhinosinusitis: A preliminary study.

Author/s: Dipak Ranjan Nayak

Abstract

Patients with allergy-associated chronic rhinosinusitis respond poorly
to functional endoscopic sinus surgery (FESS), probably because of the
altered nasosinus ventilatory physiology and the increased
contamination of the nasosinus mucosa by the offending allergens. With
this in mind, we describe the concept and technique of functional
endoscopic nasosinus surgery (FENS) in such cases. The advantages of
this technique are that it preserves the uncinate process, it limits
ethmoidal exenteration via a transbullar approach, and it
simultaneously corrects both septal and lateral wall pathologies. The
aim of our randomized prospective study was to subjectively and
objectively compare the efficacy of FESS and FENS in 64 patients with
allergy-associated chronic rhinosinusitis. Subjective assessment was
ascertained by visual analog scores, and objective assessment was made
by nasal endoscopy. In this preliminary study, we found that FENS was
superior to FESS in treating chronic sinusitis associated with nasal
allergy .

Introduction

The evolution of nasosinus endoscopes and an improvement in our
understanding of nasosinus pathophysiology in chronic sinusitis have
revolutionized the treatment of sinus disease. Stammberger [1] in
Europe and Kennedy [2] in the United States have standardized and
popularized the Messerklinger technique described in 1978, which is
now accepted worldwide. Although functional endoscopic sinus surgery
(FESS) provides good results in cases of chronic nonallergic
rhinosinusitis, its results are poor in patients with
allergy-associated chronic sinusitis.

According to Stammberger and Posawetz, allergic disease of the upper
airway is not a primary indication for FESS. [3] They advocate FESS as
an adjuvant therapy in patients who do not respond to
hyposensitization and antiallergic therapy. In such cases, they stress
the need for a limited surgical procedure to treat the stenosis in the
middle meatus and ethmoid complex.

Nishioka et al found that the polyp recurrence rate was higher
following FESS in allergic patients. [4] Levine reported better
results in cases of chronic sinusitis than in cases of polyposis. [5]
Our own experience with FESS in chronic sinusitis reveals that nasal
allergy heralds a poor prognosis. A second look into the nasosinus
ventilatory physiology, which is considerably altered in post-FESS
cases, explains the reason for its failure. Removal of the uncinate
process hypothetically exposes the operated ethmoid cavity and the
major sinuses to allergens and bacteria-contaminated inspiratory
airflow. This leads to allergen exposure to a larger surface area,
which causes increased or persistent mucosal disease.

In this article, we stress the need for a proper case selection for
FESS, and we emphasize the need to view cases of chronic sinusitis
associated with nasal allergy more cautiously and skeptically. We
advocate functional endoscopic nasosinus surgery (FENS) as an adjuvant
modality of treatment in cases that are refractory to pharmaco- and
immunotherapeutic measures. FENS involves the simultaneous endoscopic
treatment of the turbinates and septum to relieve the nasal
obstruction associated with allergy and a limited sinus surgery that
preserves the uncinate process. This modified endoscopic surgery
protects the mucosa of the sinuses from allergen exposure during
inspiration without compromising the clearance of ethmoidal disease.
This technique perhaps favors better ventilation of the sinuses in the
more sterile and allergen-free expiratory phase than in the more
contaminated and allergen-carrying inspiratory phase.



Rationale for FENS

The vertical jet of inspired air spreads in a wide and gentle curve
from the internal nasal valve toward the choanae. During quiet
inspiration, the flow becomes laminar at the valve area, and the
direction becomes horizontal. Most of the airflow occurs along the
middle meatus and floor of the nose, with less turbulence. The
conformity of the lateral wall to the shape of the septum tends to
keep the passage narrow and of uniform width, thereby promoting
laminar flow. This thin laminar flow facilitates the exchange of
temperature and humidity between the turbinates and the inspired air.
[6] The expired air is more turbulent and flows throughout the nasal
cavity. The sinuses are ventilated in the expiratory rather than
inspiratory phase. [7]

The accompanying diagrammatic representation of airflow during the two
phases of respiration in the nasal cavity and sinuses clearly shows
the role of the uncinate process in directing the inspired air away
from the sinuses, thus protecting them (figure 1). The uncinate
process probably also directs the expired air into the infundibulum
and the maxillary ostium. Inspired air carries allergens and bacteria.
Expired air is more sterile and allergen-free because it is
"pretreated" by the respiratory mucosa. Thus, the sinuses are normally
ventilated by a more sterile and allergen-free air. Moreover, an
important and hitherto unrecognized function of the paranasal sinuses
is that they provide a continual supply of fresh, uncontaminated mucus
to the middle meatus so that mucociliary activity is preserved. [8]

Removal of the anterior part of the middle turbinate, as suggested by
LaMear et al, [9] and the uncinate process exposes the sinuses to the
rather contaminated inspired air. This is what hypothetically occurs
in post-FESS patients, in whom the area of allergen deposition is
greatly enhanced, extending into the sinuses. This might be the reason
for the persistent postnasal drip and the increase in respiratory
symptoms in post-FESS patients.

Keeping this in mind, the aims of FENS are (1) to preserve the
uncinate process and anterior end of the middle turbinate, thereby
protecting the sinuses from the contaminated inspired air; (2) to
allow better ventilation of the sinuses in the expiratory phase by
resecting the inferolateral part of the middle and inferior
turbinates, which does not disrupt the laminar inspiratory flow
because the conformity between the septum and lateral wall is
preserved; (3) to treat sinus disease with a limited resection; and
(4) to concomitantly treat the septal deformity via an
ultraconservative approach aided by endoscopes.

FENS operative technique

In our study, all but seven FENS patients received local anesthesia.
For vasoconstriction and topical anesthesia, each patient's nose was
sprayed with 4% lidocaine with 1:25,000 epinephrine. Cottonoid packs
soaked in 4% lidocaine with 1:25,000 epinephrine were also placed. The
surgical target sites were infiltrated with 2% lidocaine with
1:100,000 epinephrine. In all procedures, 4-mm, 0[degrees] and
30[degrees] nasal telescopes were used. The surgical procedure
involved the simultaneous treatment of the pathologic septa,
turbinates, and sinuses endoscopically.



Septal correction. After infiltration, a hemitransfixation incision
was made. Septal deviations were corrected endoscopically. A
hemitransfixation incision was made on the concave side in an S-shaped
deviation. However, for a posterior deviation, a C-shaped spur was
made on the convex side. The septal flap was elevated.
Ultraconservative resection of the septal pathology was performed
whenever indicated. Alignment of the septum was achieved by wedge
resection, trimming, or crisscross incisions. [10]

After surgical treatment of the turbinates and the sinuses, the septal
flaps were kept apposed and splinted with dental wax plates, which had
been sterilized in glutaraldehyde and cut to fit the nasal cavity.
[11] These splints were anchored together to the septum by a
through-and-through stitch with 2-0 catgut or silk approximately 1.5
to 2 cm posterior to the caudal end of the septum.

Turbinoplasty. In all cases, the inferior turbinate was trimmed
inferolaterally, and the end that projected toward the nasopharynx was
amputated as described by Nayak et al. [10] The inferolateral portion
of the middle turbinate was also resected in the middle and posterior
areas (figure 2).

The concha bullosa was resected laterally. Submucous diathermy was
performed at the anterior end of the inferior turbinate--at times even
to a polypoidal middle turbinate. Diathermy of the raw stump of the
trimmed turbinates helped achieve hemostasis. Too much resection of
the middle turbinate was avoided to maintain its stability.

Sinus surgery. Unlike FESS, FENS allows the surgeon to preserve the
uncinate process. The anterior ethmoid cells were exenterated to the
extent possible by a curved curette and upturned forceps. The
maxillary ostium was visualized with a 30[degrees] endoscope, usually
anteroinferiorly to the bulla ethmoidalis in the hiatus semilunaris.
When it was found, it was widened posteriorly and inferiorly. When the
maxillary ostium could not be found, a curved spoon or fine cannula
was used to palpate and probe the ostium just lateral to the inferior
attachment of the uncinate process and inferior to the bulla. If the
maxillary ostium still could not be located, the posterior aspect of
the uncinate process was partially trimmed with a backward-cutting
forceps to expose the natural ostium area (figure 3).

The posterior fontanelle was opened with a sickle knife, and the
backward-cutting forceps were reintroduced to enlarge the antrostomy
to join the natural ostium. A large middle meatal antrostomy was
created until the roof of the antrum was well visualized (figure 4).
Care was taken to preserve the uncinate process. When an accessory
ostium was also found, the bridge of tissue between it and the natural
ostium was removed. (An accessory ostium seen through a 0[degrees]
scope itself should not be confused with the true ostium, which opens
near the roof of the antrum.)

When computed tomography (CT) and diagnostic nasal endoscopy found no
disease, the ethmoid sinuses were not exenterated. When indicated,
exenteration was performed via a transbullar approach with a
30[degrees] scope. This is unlike the Messerklinger and Wigand
techniques, which are anteroposterior and posteroanterior approaches,
respectively. [12] The bulla was found to be the most constant
ethmoidal cell and the key area for approaching either the anterior or
the posterior group of air cells. The bulla was first punctured
inferomedially and later exenterated with caution after the surgeon
identified the lamina papyracea and the roof of the ethmoids.
Identification of these structures was very easy via the transbullar
approach. Using the fovea, lamina papyracea, and the middle meatal
antrostomy as landmarks, the remainder of the ethmoids and sphenoids
were exenterated when indicated (figure 5). A diseased frontal sinus
and/or recess necessitated exenteration of even a normal bulla for
proper access. A 30[deg rees] scope and an upturned forceps were used
between the middle turbinate and lateral wall just posterior to the
uncinate process to open the frontal recess and then the frontal
sinus. It was not difficult to clear the frontal recess disease and
create a frontal sinusotomy despite the uncinate process preservation.
Occasionally, a 90[degrees] scope was used to visualize the frontal
recess better. The posterior ethmoids and sphenoids were exenterated
only when indicated.



Dental wax plates were used as a spacer between the middle turbinate
and the lateral wall, in the manner described by Nayak et al, [13]
whenever the development of synechiae was anticipated. Packing of the
nasal cavity was not necessary except in three patients, who exhibited
an ooze from the resected stump of the inferior turbinate. This was
controlled by placing a cottonoid soaked in bismuth iodoform paraffin
paste, which was removed after 8 to 12 hours.

Materials and methods

We identified 120 patients with allergy-associated chronic
rhinosinusitis who had been treated between January 1993 and December
1996 at Kasturba Hospital in Manipal, India. These patients had not
responded to medical treatment. They were prospectively randomized
into one of two groups (60 patients in each); one group underwent FESS
as described by Stammberger, [1] and the other underwent FENS.

Sixty-four of these patients were available for a followup of 6 months
or more--30 in the FESS group and 34 in the FENS group. Each patient
was evaluated by a detailed history, clinical examination, nasal
endoscopy, and radiology of the paranasal sinuses. None of them had a
history suggestive of food allergy. In each case, sinus disease was
confirmed by CT. Every patient had a positive allergic skin test, and
each either had undergone or were undergoing hyposensitization and
other antiallergic therapy. Patients who had frank nasal polyposis on
anterior rhinoscopy were excluded from this study.

The two groups were age- and sex-matched. All patients were
subjectively evaluated pre- and postoperatively with a visual analog
scale. Objective evaluation was performed by nasal endoscopy. A
topical budesonide nasal spray was advised for all patients
postoperatively for a minimum of 3 months. Maintenance therapy with
cromolyn sodium nasal spray or a systemic antihistamine was advocated
in most cases, depending on the response. A few patients required
intermittent short courses of systemic steroids.

Results

Of the 120 patients, 64 were available for a followup of at least 6
months (range: 6 mo to 6 yr)--30 patients in the FESS group and 34 in
the FENS group. All of these patients had symptoms of perennial
allergy and chronic sinusitis, and most had headache, anterior nasal
discharge, nasal obstruction, postnasal drip, and sneezing spells
(table I). A few patients also had hyposmia and wheezing.

Six of the FESS patients underwent septoplasty during a different
sitting, while three underwent septal surgery concurrently. The
conventional Messerklinger technique was used for all FESS patients,
and the extent of ethmoid exenteration was guided by CT. Twenty-four
patients underwent middle meatal antrostomy, and six patients
underwent a total sphenoethmoidectomy.

All 34 of the FENS patients underwent turbinoplasty, and 22 had a
septal correction. All 34 had a middle meatal antrostomy--28 with an
ethmoidectomy and 6 without. Of the 28 patients who underwent an
ethmoidectomy, 22 had an anterior ethmoidectomy, 4 had an anterior and
posterior ethmoidectomy, and 2 others had an anterior and posterior
ethmoidectomy in addition to a sphenoidotomy.



Subjective evaluation. The criteria for surgical cure in the
literature differ widely, from symptomatic improvement to complete
resolution. Therefore, the statistical significance of success rates
in different studies cannot be compared. We categorized our subjective
postoperative results as either resolved, improved, unchanged, or
worse (table 2). Our subjective evaluations were aided and documented
by comparisons with each patient's pre- and postoperative visual
analog scores. The statistical significance of the differences between
the numbers of patients whose symptoms had resolved and those whose
symptoms had not resolved was calculated according to the
[[chi].sup.2] tests with Yates' correction.

The resolution rates for headache, nasal obstruction, and postnasal
drip were significantly greater in the post-FENS group than in the
post-FESS group. Anterior nasal discharge, sneezing spells, hyposmia,
and wheezing were not significantly resolved by either surgery.
However, there was a significant difference in favor of FENS in
patients with sneezing and wheezing when the percentage of those whose
symptoms resolved was combined with the percentage of those whose
symptoms improved (p[less than or equal to]0.05).

Objective evaluation. Postoperative followup evaluation by nasal
endoscopy documented the outcomes of both surgeries, and it showed
that FENS was clearly superior to FESS (table 3). However, the poor
response in the FESS group might have been attributable to a much
worse underlying allergy and to the greater extensiveness of the
surgery. No orbital complication or cerebrospinal fluid rhinorrhea was
encountered during or after either surgery.

Discussion

Messerklinger's endoscopic approach to the nasal sinuses is well
established. [14, 15] This procedure involves the removal of the
uncinate process, clearance of the ethmoid disease, and the creation
of frontal and maxillary sinusotomies. Although this technique is
quite suitable and effective in cases of nonallergic chronic
sinusitis, its efficacy in allergy-associated chronic rhinosinusitis
is questionable.

Allergic rhinitis is one of the most common coexisting conditions in
patients with chronic sinusitis, and it is also seen in some patients
with bronchial asthma. [16,17] In a review of published results of
endoscopic sinus surgery, Terris and Davidson documented the presence
of allergies in 14 to 58% (mean: 40%) of patients with chronic
sinusitis. [18]

All patients with allergy-associated chronic sinusitis should be given
an adequate course of treatment with pharmaco- and immunotherapy,
which are the mainstays of treatment. In patients who do not respond
to immunotherapy, the probability of an IgG-mediated food and/or mold
allergy should be considered.

Surgical treatment is indicated in refractory cases as the last resort
to relieve obstruction and infection. [19] Stammberger and Posawetz
advocated a limited endoscopic sinus surgery as an adjuvant treatment.
[3] Such an operation helps to modify minor obstructive anatomic
variants, but it has no effect on the allergy. [16,17] Shambaugh
viewed the new sinus operations for allergic rhinitis with great
skepticism. [20] Indeed, the efficacy of FESS in allergy-associated
chronic rhinosinusitis is not impressive in the literature. Davis et
al observed extended postoperative recovery times and decreased
antrostomy patencies in patients operated on during a period of high
antigen exposure. [21] In a significant study, Nishioka et al found
that a higher incidence of polyp recurrence occurred in allergic cases
following FESS. [4] It has also been reported that patients with
diffuse rhinosinopathy and primary eosinophilic infiltration are more
likely to develop recurrent disease following endoscopic sinus
surgery. [17 ]



Allergy associated with chronic rhinosinusitis is seen frequently in
our center. Earlier treatment modalities included submucosal
diathermy, partial or total inferior turbinectomy, and intraturbinal
corticosteroid injections as an adjunct to pharmaco- and
immunotherapy. Refractory sinus disease in such cases was treated by
conventional intra- and/or extranasal procedures. Our results,
unfortunately, never showed that patients experienced a complete
relief of symptoms.

When FESS came into vogue, it was overenthusiastically performed, even
in cases of allergy-associated chronic rhinosinusitis. Although FESS
produced good results in patients with nonallergic rhinosinusitis, it
was disappointing in those with allergy-associated chronic
rhinosinusitis. (In fact, the senior author [D.R.N.] is one such
patient.) The poor post-FESS outcomes prompted us to rethink the
pathophysiology of allergy-associated chronic rhinosinusitis, the
rationale for FESS in such cases, and the reasons for its failure. As
a result of this reconsideration, we began to combine modified
conventional surgical techniques (submucosal diathermy and/or a
partial inferior turbinectomy) with a judicious use of modified
endoscopic sinus surgery to treat such cases. This technique
eventually gave rise to the evolution of FENS.

Nasal turbinate hypertrophy is often associated with allergy, more so
in patients who also have bronchial asthma. Septoturbinal compression
is associated with middle turbinate syndrome, and middle turbinate
hypertrophy results in an obstruction that alters the normal flow of
air and mucus. [22] The inferior turbinates in the allergic nose are
the primary shock organs that cause nasal obstruction. [19] To deal
with such turbinates, many techniques have been advocated:
intraturbinal steroid injections, submucosal diathermy, surface
cautery of the inferior turbinate, bipolar cautery of the turbinate,
chemical cautery with agents such as silver nitrate, outfracture of
the turbinate, submucosal resection of the inferior turbinate, partial
inferior turbinectomy, and endoscopic partial inferior turbinectomy
with a powered microcutting instrument. [10] Some surgeons perform
partial endoscopic middle turbinectomy in all cases as a standard
component of FESS. [9] LaMear et al, in discussing the impact of
middle turbine ctomy on the normal nasal physiology, wrote that this
procedure is safe and does not cause postoperative atrophic rhinitis.
[9] A concha bullosa is trimmed by a partial resection of its lateral
aspect. [1]

In our series, we performed an inferolateral partial resection and
amputation of the posterior end of the inferior turbinate to
facilitate the flow of inspiratory air in the inferiormost part of the
nasal cavity and to allow for the passage of allergen-free expired air
through the middle meatus. The inferolateral trimming of the middle
turbinate with preservation of the anterior end helps provide better
ventilation of the sinuses during the expiratory phase.



The success of FENS in allergy-associated chronic rhinosinusitis might
be explained by the protection of the sinuses from allergen exposure
during the inspiratory phase and the better ventilation of the sinuses
in the allergen-free sterile expiratory phase. Long-term success
depends on control of the primary cause (i.e., the allergy) rather
than repeated surgeries to treat pathologic changes. Thus, short
courses of systemic steroids and maintenance treatment with nasal
steroid sprays, cromolyn sprays, mucolytics, anticholinergics, and/or
suitable antihistamines help provide long-term relief. Local and
systemic decongestants also provide immediate relief of symptoms, but
they cannot be used on a long-term basis because of their side
effects. [19] Immunotherapy is promising because it provides long-term
symptomatic relief, but it does not statistically influence middle
meatotomy patency, synechiae formation, or recurrence of polyps
following FESS. [4] Although our preliminary findings are encouraging,
a larger series over a longer duration is required to determine its
efficacy accurately.

In conclusion, FESS is not the panacea for all sinus disorders, and
its role has been overemphasized. In allergy-associated chronic
rhinosinusitis, FESS actually aggravates allergic symptoms. We found
FESS to be more troublesome than beneficial because of the incidence
of persistent or even increased postnasal drip. This was probably the
result of the increase in mucosal surface area that became available
for allergen exposure plus the drying effect of the increased volume
of air as a result of overzealous turbinate resection and total
ethmoidectomy.

FENS, on the other hand, provides a safe and efficient method of
relieving obstruction in the nasal passage and osteomeatal complex. At
the same time, it protects the sinuses from allergen exposure,
ventilating them during an allergen-free expiratory phase. It is not
merely a viable alternative in the management of allergy-associated
chronic rhinosinusitis, it is a superior alternative.

Acknowledgments

The authors thank Dr. Ramdas Pai, medical director at Kasturba
Hospital, and Prof. P. Hazarika, professor and head of the Department
of ENT at the Kasturba Medical College, for their contributions to
this study. We also thank Mrs. A. Thulasi for her secretarial
assistance.

From the Department of ENT-Head and Neck Surgery, Kasturba Medical
College, Manipal, Karnataka, India.

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Table 1. Preoperative symptoms in 30 FESS and 34 FENS patients
                           FESS       FENS       Total
                           n (%)      n (%)      n (%)
Headache                  28 (93.3)  31 (91.2)  59 (92.2)
Anterior nasal discharge  26 (86.7)  32 (94.1)  58 (90.6)
Nasal obstruction         28 (93.3)  25 (73.5)  53 (82.8)
Postnasal drip            24 (80.0)  21 (61.8)  45 (70.3)
Sneezing spells           17 (56.7)  27 (79.4)  44 (68.8)
Hyposmia                  13 (43.3)  15 (44.1)  28 (43.8)
Wheezing                  11 (36.7)  12 (35.3)  23 (35.9)
Table 2. Subjective postoperative evaluation: Number of patients
and the degree of change in symptoms
                         FESS (n = 30)
Symptoms                        R *       I   U  W  Total
Headache                        7        13   6  2   28
Anterior nasal discharge        6        14   5  1   26
Nasal obstruction               4         7  16  1   28
Postnasal drip                  3         5  12  4   24
Sneezing spells                 0         2  14  1   17
Hyposmia                        2         2   9  0   13
Wheezing                        0         2   6  3   11
                         FENS (n = 34)
Symptoms                        R         I   U  W  Total
Headache                       17         8   6  0   31
Anterior nasal discharge       11        16   4  1   32
Nasal obstruction              13         9   3  0   25
Postnasal drip                 12         7   1  1   21
Sneezing spells                 5         9  13  0   27
Hyposmia                        3         4   8  0   15
Wheezing                        2         7   3  0   12
Symptoms                     p value+
Headache                  [less than]0.05
Anterior nasal discharge             NS
Nasal obstruction         [less than]0.01
Postnasal drip            [less than]0.01
Sneezing spells                      NS
Hyposmia                             NS
Wheezing                             NS
(*)R = resolved
I = improved
U = unchanged
W = worse
(+)p value is calculated according to the [[chi].sup.2] test with
Yates'
correction and applies to the difference between those patients
who resolved and those who did not.
Table 3. Objective postoperative evaluation: Adverse endoscopic
findings in 30 FESS and 34 FENS patients
                           FESS       FENS
                           n (%)      n (%)
Residual disease
Discharge                25 (83.3)  15 (44.1)
Polypoidal musosa        13 (43.3)    3 (8.8)
Polyp formation           8 (26.7)    1 (5.9)
synechiae between the      6 (20.0)    2 (5.9)
MT * and lateral well
Persistent contact areas   6 (20.0)    2 (5.9)
Sinusotomy closure          2 (6.7)      0
(*)MT = middle turbinate.