Endoscopic surgery for mycotic and chronic recurring sinusitis

Chronic sinusitis and its complications are often caused or perpetuated by fungi. In Europe and North America Aspergillus species are the most common contaminants of the sinuses, with relatively few cases of mycoses caused by Mucor, Candida, Penicillium, Cladosporium, and Fusarium reported in the literature. Although Aspergillus and Mucor are mainly saprophytic, they may cause severe, potentially lethal complications. Consequently, therapy should include complete removal of the mycotic masses and prevention of reinfection. In nearly all cases in our experience, fungal diseases of the maxillary sinuses are secondary diseases, the pathologic conditions for which are created by chronic recurring sinusitis. Nasal endoscopy has shown that in most cases of recurring sinusitis, infection spreads from the nose into the larger sinuses, mostly from an infected anterior ethmoid. Maxillary and frontal sinuses are fully dependent on the pathophysiologic conditions in the anterior ethmoid because their ventilation and drainage pass through its complicated system of fissures and clefts into the middle nasal meatus. Endoscopic endonasal surgery of the diseased ethmoid is therefore an important element in our treatment schedule. Stenotic and/or chronically infected areas of the anterior ethmoid are identified by conventional or computed tomography. These areas then undergo endonasal operation under the guidance of rigid endoscopes. Diseased mucosa is removed, narrow or stenotic areas are widened, and the natural maxillary sinus ostium is enlarged. In many cases it is possible to remove all mycotic masses through this new window. Fenestration into the inferior nasal meatus is unnecessary with this method, and the sinus mucosa is usually left untouched. For follow-up treatment, instillations of antimycotic or antibiotic ointments are used. Even in cases of massive mucosal changes, the dependent sinuses, such as the frontal or maxillary sinuses, usually heal spontaneously after this procedure without having been treated directly. More than 140 patients with mycotic sinusitis, 48 of whom were studied and followed up for this paper, were treated by us during the last 8 years. The endoscopic surgical technique we have developed is described in detail.