Fungal rhinosinusitis (FRS) is categorized as being either invasive or non-invasive based on the histopathological evidence of tissue invasion by fungi. Endoscopic sinus surgery (ESS) has become the gold standard treatment for non-invasive FRS including sinus fungal ball. It is considered to be an effective and safe procedure. It is important to keep a sufficient field of view in order to remove the fungal debris completely. ESS should also prevent damage to the nasal cavity structures including the inferior turbinate. This report mainly describes the endoscopic surgical procedures for fungal ball of the maxillary sinus (sinus mycelia) based on our methods and review of the literature, including written articles in Japanese. ESS procedures include the middle meatus approach for the maxillary sinus, the combined approach (both middle and inferior meatal antrostomy) for the maxillary sinus, and endoscopic modified medial maxillectomy (EMMM).
Fungal rhinosinusitis (FRS) is categorized as either invasive or non-invasive based on the histopathological evidence of tissue invasion by fungi [
In contrast, the non-invasive type grows slowly and in some cases, there are no symptoms [
Endoscopic sinus surgery (ESS) has become the gold standard of treatment or chronic rhinosinusitis, including non-invasive fungal sinusitis. It is considered as an effectiveness and safe procedure, and the recurrence rate is about 5% (0% - 22.5%) [
To treat fungal ball of the maxillary sinus, all of the fungus must be completely removed. To verify complete removal of the fungal ball, it is important to achieve sufficient visualization of the sinus. In addition, the use of not only a 0˚ endoscope but also angled endoscopes (30˚, 45˚, 70˚) are required to achieve this. How to ensure the sufficient visualization? It is sometimes difficult to see the anterior inferior or medial inferior wall of the maxillary sinus even when a 70˚ endoscope is used, when the maxillary sinus is observed from a middle meatus window. If 70˚ endoscope does not allow sufficient visualization afterwards, then a flexible scope deployed into the maxillary sinus may avoid any unnecessary surgery. Although the surgery involves a large opening of the sinus, including removal of part of the inferior turbinate in some cases, the surgery should also prevent damage to the nasal cavity structures. It is not necessary to make an additional mucosal incision at the canine fossa. It is better to perform the septoplasty prior to ESS in order to achieve sufficient visualization of the sinus in cases with nasal septal deviation. The biopsy of the fungal debris and its surrounding mucosa is necessary to confirm non-invasive FRS when the fungal debris is removed. Nasal and sinus saline irrigation is performed at the end of the surgery.
Surgical procedures | Methods |
---|---|
Middle meatus approach | uncinectomy and middle meatal antrostomy (standard procure of ESS) |
Combined approach | both middle and inferior meatal antrostomy with preserved inferior turbinate |
Endoscopic modified medial maxillectomy (EMMM) | medial maxillectomy with preserved inferior turbinate and nasolacrimal duct |
Endoscopic middle meatal approach is one of the most commonly performed functional ESS procedures. The nasal cavity is decongested using a gauze with lidocaine and epinephrine. The lidocaine with epinephrine is injected at the level of the middle turbinate root and uncinate process. The uncinate process is removed in case of middle meatal antrostomy. Complete removal of fungal debris by ESS through an uncinectomy and a sufficiently wide meatal antrostomy is performed. The large or wide antrostomy means that we have a good visualization of the maxillary sinus and surgical instruments can be inserted easily. There are varying opinions on what the size of the antrostomy should be. If the ethmoid bulla is severely blocked, the ethmoidectomy has to be performed. After widening of the antrostomy for the maxillary sinus, the fungal ball is extracted using curved suctions, forceps, and curved microdebrider blades.
The “Gauze technique” is a simple and quick method used to be removed the fungal ball in the maxillary sinus [
When fugal debris can be removed completely, it is not necessary to have a large opening in the middle meatus for sufficient access to the maxillary sinus cavity. Although the mucosa should be preserved, it must be biopsied to exclude any possibility of microscopic invasion by fungi. Infected granulation tissue should be removed using curved forceps and microdebrider blades, but the periosteum of the sinus must be preserved in such cases. When the fungal ball is located near the ostiomeatal complex, it is a good indication for a middle meat us approach (
It is impractical to make a new window at the inferior meatus for these cases. On the other hand, it is sometimes difficult to see the anterior inferior or medial inferior wall of the maxillary sinus even when a 70˚ endoscope is used, when the maxillary sinus is observed from a middle meatus window. The insufficient visualization of the entire maxillary sinus means that removal of the fungal ball will be incomplete. Thus, it is possible that fungal debris removal will be incomplete from a middle meatus window, and only when the fungus ball is not located in the anterior inferior and medial inferior wall of the maxillary sinus, will complete removal be achieved.
Our department recently published a study that combined both middle and inferior meatal antrostomy. This combination was shown to be effective for the treatment of FRS [
and removal of the fungal ball [
Even if the inferior meatal antrostomy is closed after the surgery, which is not a major problem, we usually perform the meatal mucosal flap procedure to avoid closure or stenosis of the inferior meatal antrostomy (
meatal mucosal flap procedure after ESS [
To remove the fungal ball, a gauze which has a size of either 3 cm × 15 cm or 3 cm × 30 cm is generally used. The gauze is soaked with normal saline or saline which includes epinephrine. The gauze is introduced into the maxillary sinus from the inferior meatal window using curved forceps (
Okanoue et al. described the combined approach using a Foley catheter instead of the gauze-assisted technique [
Endoscopic medial maxillectomy with medial sift of preserved inferior turbinate
is a procedure for FRS that was introduced in 2008 (Japanese article) [
[
An electrically powered, cylindrical shaver (vacuum-powered microdebrider) can use continuous suction to remove fungal debris and the related granulation as well as polypoid tissue [
A powered saline sinus irrigation system (for example, Hydrodebrider System) will help the removal of the fungal ball or bacterial colonies from the paranasal sinuses [
As with any endoscopic surgery procedure, ESS has associated risks. Although the risk of a complication of ESS for FRS is low, it is important to understand the potential complications. In most studies, complications of ESS for FRS were the same as those described of Functional ESS for sinusitis [
Post-operative care is similar to that used after functional ESS for sinusitis. Previous studies have shown that non-invasive FRS does not require adjuvant local or systemic antimycotic chemotherapy after ESS. The patients require nasal and sinus saline irrigation using a bulb syringe after ESS [
ESS is the standard treatment for non-invasive FRS including sinus fungal ball. All of the fungus must be completely removed. To verify complete removal of the fungal ball, it is important that there is sufficient visualization of the sinus. We have considered useful approaches such as, the middle meatal approach, combined middle and inferior meatal approach, and endoscopic medial maxillectomy, endoscopic modified medial maxillectomy (EMMM) for fungal maxillary sinusitis (
I would like to thank Editage (http://www.editage.jp) for their English language editing.
The author declares no conflicts of interest regarding the publication of this paper.
Sawatsubashi, M. (2018) Endoscopic Surgical Procedures for Fungal Maxillary Sinusitis: How to Do It, a Review. International Journal of Otolaryngology and Head & Neck Surgery, 7, 287-297. https://doi.org/10.4236/ijohns.2018.75029