Contemporary indications for external approaches to the paranasal sinuses

The term minimally invasive functional endoscopic sinus surgery is surely a misnomer. First, the surgery is not minimally invasive. Extensive surgery, even skull base tumor resection, can be accomplished through the approach. In fact, because of the improved visualization provided by the adaptation of the endoscope to this technique, it can be argued that the surgery is now more invasive than it has ever been historically. More correctly, the technique is "minimal incision" surgery, and this term more accurately reflects the philosophy. External incisions, however, can be cleverly minimized or cosmetically acceptable. Second, the term "functional" is relative. There is no doubt that the greatest advance that the endoscope has afforded is the ability to assess disease in the clinic or office with far more accuracy. Endoscopic assessment has added to the general appreciation of the physiologic function of the sinuses as part of the respiratory tract in general. Certain endoscopic procedures, however, are not entirely directed at improving the physiology of sinuses. The endoscopic Lothrop procedure, for example, does not have a sensible physiologic basis. It does maintain the frontal sinus as an aerated space: this preservation is often, but not always and automatically, an advantage. One of the key factors in successfully disseminating surgical technology is the ability to teach the technique to the physician in clinical practice. This process requires constant research and development in instrument technology and the constant sharing of information and technology at courses and meetings. The types of instruments used to conduct endoscopic surgery have advanced dramatically in the last 10 years. The advent and distribution of image guidance and microdebriders and drills is an important adjunct to endoscopic techniques. Perhaps more important is the refinement that has occurred in the development of angled instruments, micro-throughcutting forceps, and 45 degrees endoscopes that will allow advanced endoscopic technology to be disseminated throughout the otolaryngology community. Nevertheless, many of the external approaches use commonly available instrumentation that is available in every operating room in the United States. This availability is certainly an advantage under certain circumstances. The wastebasket of history sometimes contains procedures that can afford efficient and effective treatment. Ignoring the past will result in a need to rediscover it. A broad perspective and the ability to think creatively about clinical problems will probably result in the occasional need to employ the techniques described in this article.