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Procedure
Sinu-Clear Laser Microsurgery of the Paranasal Sinuses – Clinical Procedures Review
Daniel M. Schuman, M.D., F.A.C.S.
America’s National Medical and Research Institute
Department of Rhinology and Neurorhinology
West Boca Medical Center
Boca Raton, Florida
February 1997
Functional Endoscopic Sinus Surgery (FESS) has revolutionized the surgical
approach to sinus disease. However, FESS is not without its limitations
or complications. The most important goal of the surgery is to regain ventilation
of the obstructed sinuses and to reestablish physiologic mucociliary flow.
The increased bleeding that has been associated with the removal of sinonasal
polyps is frequently the limiting factor in the ability to completely remove
diseased tissue. Inadequate polyp removal leads to a higher recurrence
rate, while a more complete removal allows for better reepithelialization.
Although techniques have evolved to reduce bleeding, it is still problematic
in many cases, including extensive polyposis patients, AAP patients (aspirin
sensitivity, asthma and polyps), revision surgeries, etc. Recent advances
in instrumentation, such as through-cutting instruments and powered tissue
debriders, remove tissue in a less avulsive manner than previously, but
still do not prevent bleeding and, in the case of the debrider, provide
utility primarily in the nasal passage and not in the deep sinus recesses.
The Sinu-Clear ™ technique was developed to optimize visualization and
control of bleeding in sinonasal surgery, with atraumatic removal of diseased
tissue and sparing of non-diseased tissue, thus enabling a safe and complete
procedure with enhanced rather than compromised visualization. The procedure
utilizes a combination of warmed water and a unique controlled laser energy
delivery system to enhance the surgeon’s operating environment. The warmed
water provides vasoconstriction, eliminating the need for pharmaceutical
vasoconstricting agents. The water also lavages the sinonasal areas and
magnifies the optical field, enhancing visualization. The laser, specifically
the SLT Contact Nd:YAG Laser with the DF 2 diffuser flat probe, gently
and controllably coagulates tissue. Hemostatic tissue removal is more gently
accomplished as the diseased tissue is weakened by the coagulation process.
This system enables the surgeon to prevent bleeding rather than attempting
to address it if and when it occurs.
Technique
Light general anesthesia is employed throughout the procedure to allow
for gentle emergence from anesthesia. This avoids any bucking, coughing
or vomiting which can cause bleeding from the nose and sinuses. A cuffed
endotracheal tube is used to prevent aspiration of liquids during the procedure.
The patient is placed in a semi-Fowler’s (25-30º) position, draped and
protected from the laser as usual. A small disposable, flexible dental
suction is placed into the nasopharnyx to serve as outflow for the irrigating
solution. No sprays, injections, or vasoconstrictor-soaked pledgets are
used prior to, during, or after the procedure.
Pre-operative CT scans are utilized and referred to throughout the procedure.
Sinuscopy is then performed using a Wolf Hydrascope with a 25º Panoview
telescope and a video monitor. The Hydrascope handle provides suction via
a trumpet-valve button and irrigation via a finger-controlled stopcock
valve. The irrigation is warmed to approximately 41º C by a SIMS Level
1 fluid warmer system. All suction and irrigation tubing, as well as laser
accessories, are provided in the SLT Sinu-Clear kit which is pre-labeled
for easy set-up.
Liberal warm irrigation during initial sinuscopy lavages the sinonasal
spaces, displacing secretions that may be stagnant in the nose or sinuses,
and provides mucosal vasoconstriction. Landmarks can be identified while
viewing the path and turbulence of the irrigating stream, which simulates
the inspired air column. Hydrogen peroxide-soaked pledgets will blanch
areas of mucosal damage cause by irritation to assist in surgical planning
to restore adequate ventilation.
The laser utilized is an SLT CL MD Contact Nd:YAG laser, although other
Nd:YAG or diode lasers with SMA 905 interfaces can be used with the SLT
fiber and probe system. The laser energy is delivered through a reusable
SLT LAH/LAW 0 handpiece with a Frazier-type proximal bend. In cases where
there is a need to improve the posterior ventilation, an SLT GRP 6 scalpel
tip is used at a power setting of typically 12-18 watts to partially excise
posterior mulberry tips or impacted and hypertrophied turbinates. More
anterior hypertrophy can be treated with intramural photocoagulation by
placing the GRP 6 tip submucosally and applying laser energy of typically
12-16 watts for approximately 7 to 10 seconds at a time. Then the SLT DF
2 diffuser flat probe is placed between the polyps and energy applied at
typically 8-14 watts with simultaneous warm irrigation. The polyps are
coagulated at their base as observed by mucosal blanching. Whenever utilizing
laser energy, it is recommended to begin at a lower power setting, then
increase the power setting if required to achieve the desired tissue effect.
The DF 2 probe incorporates a proprietary surface treatment that absorbs
a portion of the Nd:YAG wavelength, heating the probe surface on the front
and sides. The laser energy provides a combined thermal heating effect
of diffused Nd:YAG absorption in tissue and thermal conduction from the
heated DF 2 tip, tempered by the heat sink effect of the irrigation. Due
to the diffuse and slow thermal effect of this laser delivery system, coagulation
can be observed and ceased when desired, providing optimal control of depth
and area of thermal tissue effect, thus ensuring enhanced safety. This
is notable in its contrast to the deep thermal effect of native free-beam
Nd:YAG laser energy. It is also preferable to other laser wavelengths which
will precede a very rapid tissue effect, possibly unintended, with the
inherent risk of complication.
A vertical lateral partial hemiturbinectomy may need to be performed to
improve access and/or ventilation to the middle meatus, or to remove the
lateral half of a concha bullosa. In less severe cases it may be possible
to leave the middle turbinate undisturbed. An osteomucosal flap of middle
turbinate is constructed for later use or as a landmark. Attention and
care must be paid posteriorly in the area of the sphenopalatine artery
during the partial turbinectomy. The posterior edge of the lacrimal/maxillary
bone is identified, serving as a constant landmark even in cases of severe
polyposis, scarred mucosa, or previous surgery. The DF 2 probe is used
to blanch the mucosa over the uncinate process, ethmoid bulla, and the
area of the natural maxillary sinus ostium and fontanelles. A maxillary
antrostomy is made through the fontanelle and the retrograde dissector
(a backbiter is used to dissect and elevate mucosa and not used as a biter)
is utilized to dissect the mucosa off the bony lateral nasal wall. The
uncinate process is rotated and removed in a posterior direction and then
is followed toward its superior attachment and carefully excised. The maxillary
sinus mucosa/polyps are removed with warm irrigation and gentle suction
curettage. The ethmoid bullae are entered using the DF 2 probe and irrigation
continued. Polyps are coagulated. The sphenoid sinus ostium is irrigated
and enlarged if needed. Sphenoid polyps are coagulated with the DF 2 probe
if required. The lamina papyracea is identified anteriorly anauperiorly
in the area of the upper attachment of the uncinate and followed into the
frontal recess. The base of the skull is similarly identified, taking care
not to injure the ethmoidal neurovascular canals. Polyps here are also
dissected with warm irrigation and carefully removed with gentle suction
curettage.
The frontal sinus ostium is identified and copiously irrigated. If present,
diseased tissue is removed. A “frontal duct” canalplasty may need to be
performed if indicated to maintain potency. Care is to be taken medially
where the middle turbinate attaches to the skull base in the area of the
lateral wall of the olfactory fossa. This may be the area encountered during
the procedure that is most thin. The sphenoid sinus ostium is irrigated
and enlarged if needed. Sphenoid polyps are coagulated with the DF 2 probe
if required. A small elliptical stent may be placed into the frontal ostium
if it was widened. Gelfilm® and hydrophilic antiseptic nasal gelpaste are
applied in the sinus, as well as a septal wafer to prevent synechia formation.
An eye pad is used as a “moustache” dressing. Patients are able to resume
many day-to-day activities with minimal limitations within a few days.
RESULTS
The Sinu-Clear™ procedure has evolved and been refined to its current state
over the last 5 years with over 500 patients. I have had no major complications
using this technique and no ill effects to intracranial or orbital structures,
even though dissection of the lamina papyracea and anterior skull base
is performed routinely if needed. With respect to symptom improvement and
polyp recurrence rates, the results have been gratifying and are attributed
to the completeness of surgery achieved with this procedure, as well as
patient adherence to the post-operative nasal hygiene protocol.
The Sinu-Clear procedure supplies numerous advantages. The laser coagulation
denatures protein, weakening diseased tissue and its adherence to underlying
structures, allowing gentle, safe and hemostatic tissue removal. Thermal
effects with the DF 2 probe and irrigation are minimal and do not penetrate
deeply for the durations applied. Because the atraumatically shaped DF
2 probe works on contact, the surgeon has tactile feedback and is able
to feel whether the tissue being contacted is soft or hard. The Sinu-Clear
procedure provides exquisite visualization and control of bleeding, a necessity
for safe and complete microsurgery of the paranasal sinuses, nasal passages
and the anterior base of skull |
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