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Original research article/Artykuł oryginalny

Unilateral pathological lesions of paranasal sinuses

removed by endoscopic surgery

Jednostronne zmiany patologiczne z zatok przynosowychusunięte metodą chirurgii endoskopowej

Jarosław Miłoński, Piotr Pietkiewicz, Joanna Urbaniak, Jurek Olszewski *

Department of Otolaryngology and Laryngological Oncology, 2nd Chair of Otolaryngology, Medical University of Lodz,Head: Jurek Olszewski, MD, PhD, Lodz, Poland

a r t i c l e i n f o

Article history:

Received: 19.06.2013

Accepted: 03.07.2013

Available online: 05.07.2013

Keywords:� Pathological lesions� Paranasal sinuses� Endoscopic surgery

Słowa kluczowe:� zmiany patologiczne� zatoki przynosowe� chirurgia endoskopowa

a b s t r a c t

Introduction: The aim of this study was to analyze the incidence and nature of unilateral

pathological lesions of paranasal sinuses in patients who had endoscopic sinus surgery

performed in ENT. Materials and methods: In the years 2006–2011 endoscopic sinus sur-

gery for unilateral pathological lesions of paranasal sinuses was performed in 1847

patients (838 women and 1009 men). The enrollment of patients was based on the fin-

dings of otolaryngological clinical and subjective examinations, assessment of the para-

nasal sinuses on three-dimensional CT scans, and laboratory examinations. Based on the

analysis of medical history data, including gender, age, the type of surgical procedure

performed, and histopathological findings the cases were finally analyzed. Results:

Pathological lesions of the paranasal sinuses were localized on the left side in 132 (57%)

patients, and on the right side in 100 (43%) patients. Of the 232 patients with unilateral

pathological changes, 41.8% subjects underwent endoscopic sinus surgery for polypotic

changes in the ethmoid and maxillary sinuses; 28.4% for the maxillary sinus; 10.8% for

the ethmoid, maxillary and frontal sinuses; and 8.6% patients for all paranasal sinuses

on one side. The number of operations of only one sinus was considerably lower: sphe-

noid sinus, 4.7%; ethmoid sinus, 2.2%; and frontal sinus, 1.7% patients. The histopatholo-

gical analysis of unilateral pathological lesions removed by endoscopic surgery showed

chronic paranasal sinusitis with polyps in 56.5% patients; chronic paranasal sinusitis in

22.8% patients; and maxillary sinus cyst was confirmed in 11.6% patients. In 5.1%

patients inverted papilloma was diagnosed and in 2.2% patients the presence of osteoma

was found. Conclusions: Unilateral paranasal pathological lesions, leaving aside rather

typical maxillary sinus cysts, require a particularly thorough pre-operative diagnosis and

a precise histopathological assessment.

Otorhinolaryngology - Head and Neck Surgery Society. Published by

Elsevier Urban & Partner Sp. z o.o. All rights reserved.

© 2014 Polish

* Corresponding author at: Klinika Otolaryngologii i Onkologii Laryngologicznej II Katedry Otolaryngologii UM, ul. Żeromskiego 113,90-549 Łódź, Poland. Tel.: +48 426393580; fax: +48 426393580.

E-mail address: jurek.olszewski@umed.lodz.pl (J. Olszewski).0030-6657/$ – see front matter © 2014 Polish Otorhinolaryngology - Head and Neck Surgery Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

http://dx.doi.org/10.1016/j.otpol.2013.07.002

Table I – Incidence of unilateral and bilateral pathologicallesions in patients who underwent endoscopic paranasalsinus surgery

Pathological lesionsof paranasal sinuses

Women Men Total

n % n % n

Bilateral lesions 741 45.9 874 54.1 1615Unilateral lesions 97 41.8 135 58.2 232

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Introduction

Endoscopic nasal and paranasal sinus surgery is a safeand effective method that allows removal of pathologicallesions in the nasal cavity and paranasal sinuses. Thecommonly held preference for conservative treatment forchronic inflammatory lesions, as well as for nasal andparanasal sinus polyps does not diminish the importanceof surgical treatment. Deciding on surgery depends on theprogress of the inflammatory lesions, the extent to whichopenings into paranasal sinus and nasal cavity are bloc-ked or the patient's response to conservative management[1–3].

The development of endoscopic sinus techniques stemsfrom the progress of new technologies, especially fromscientific advances in the area of the pathophysiology ofparanasal sinuses and the development of a new conceptof the basic pathomechanism responsible for the develop-ment of paranasal sinusitis. The development of chronicparanasal sinusitis depends on a number of differentfactors, of which viral and bacterial infections, allergies,the environmental impact of irritating agents (exhaustfumes, tobacco smoke), anatomical variations in theseptum or nasal lateral wall, and gastro-oesophagealreflux disease appear to be the most important. They leadto persistent swelling of the ostium of the paranasalsinus, making ventilation and drainage difficult, thusfacilitating the penetration of bacteria into the sinuslumen. Nasal polyps present chronic inflammatory diseaseof the nasal mucosa, manifested by swelling, interstitiallesions and infiltrations of specific inflammatory cells[4–6].

The number of publications on the role of disorders withan immunological basis in the etiology of chronic paranasalsinusitis has recently been growing. It is thought that theeffect of exogenous environmental factors may lead to thedevelopment of this disease for those who are geneticallypredisposed [7]. There have been numerous studies aimedat finding genetic markers for risk. Such markers in thiscase may be polymorphisms of gene coding proteinsresponsible for the development of inflammatory proces-ses. Paranasal sinusitis is probably induced by the activa-tion of the immune system through mobilization andproliferation of T cells, synthesis of cytokines and activa-tion of chronic and destructive inflammatory processes inthe mucosa.

The large number of general factors affecting the mucousmembrane and leading to this pathology means that thedevelopment of bilateral lesions seems to be a naturalprocess. On the other hand, if the major pathomechanismby which inflammation develops is regarded as the ostium-ductal complex, the unilateral appearance of changes ofinflammatory etiology in the paranasal sinuses is logicaland understandable [8–11].

The aim of this study was to analyze the incidence andnature of unilateral pathological lesions of paranasal sinu-ses in patients who had endoscopic sinus surgery performedin the Department of Otolaryngology and LaryngologicalOncology, Medical University of Lodz.

Materials and methods

In the years 2006–2011 endoscopic sinus surgery for unilate-ral pathological lesions of paranasal sinuses was performedin 1847 patients (838 [45.4%] women, aged 15–82 and 1009[54.6%] men, aged 17–87; mean, 48.6 years) admitted to theDepartment of Otolaryngology and Laryngological Oncology,Medical University of Lodz.

The patients were enrolled on the basis of the findingsof otolaryngological clinical and subjective examinations,assessment of the paranasal sinuses on three-dimensionalCT scans, and laboratory examinations. All surgically remo-ved tissues were referred to the pathological laboratory forhistopathological examination. Based on the analysis ofmedical history data, including gender, age, the type ofsurgical procedure performed, and histopathological findingsthe cases were finally analyzed. Prior to the operation eachpatient had a seton saturated with 2% solution of xylocaineand ephedrine (1:1) placed in the nose. The 0, 30, 45 and 70degrees endoscopes with visual trajectory and debrider wereused in endoscopic sinus surgery. Each time the paranasalsinuses in which CT imaging documented the presence ofunilateral pathological lesions were qualified for surgicaltreatment. The type of surgical treatment, as regards indivi-dual sinuses, was modified intra-surgically, depending onthe changes in the lumen inside the affected sinuses.Tamponade was adopted to the extent of the incision, usingsetons in rubber gloves, merocel dressings 8–10 cm long forthe tamponade of the whole nasal duct and 4–5 cm long forthe tamponade of the middle nasal meatus or the spaceafter removal of the cells of the ethmoid sinus. The post-operative management involved the application of mucosaldecongestants for 7–10 days and targeted antibiotic therapywhen necessary. After mucosal healing nasal glycocorticos-teroids were being administered for three months. Thepatients in whom pathological lesions were diagnosed inone or in all unilateral paranasal sinuses were selected forthe analysis.

Results

Pathological lesions of paranasal sinuses on either side werediagnosed in 232 patients, constituting 12.6% of all thepatients who underwent endoscopic sinus surgery (Table I).

Pathological lesions of paranasal sinuses localized on theleft side were found in 132 (57%) patients, including 58(43.9%) women and 74 (56.1%) men, and on the right side in

[(Fig._1)TD$FIG]

Fig. 1 – Study group analysis by the localization ofpathological lesions and gender

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100 (43%) patients, including 39 (39%) women and 61 (61%)men (Fig. 1).

Of the 232 patients with unilateral lesions 97 (41.8%)patients were operated for polypotic changes of the ethmoidand maxillary sinuses. This was followed by 66 (28.4%)patients who underwent endoscopic maxillary sinus sur-gery. In 25 (10.8%) patients the maxillary, athmoid andfrontal sinuses; and in 20 (8.6%) patients all the paranasalsinuses on one side were operated. A much lower numberof patients had only one sinus operated; sphenoid, 11 (4.7%);ethmoid, 5 (2.2%); and frontal, 4 (1.7%) patients (Fig. 2).

Histopathological analyses of the surgically removedpathological tissues localized unilaterally revealed chronicparanasal sinusitis with polyps in 131 (56.5%) patients andchronic paranasal sinusitis without polyps in 53 (22.8%)patients; the maxillary sinus cyst was confirmed in 27[(Fig._2)TD$FIG]

Fig. 2 – Frequency of pathological lesio

(11.6%) patients; inverted papilloma was diagnosed in 12(5.1%) patients; osteoma in 5 (2.2%) patients; and squamousepithelial carcinoma was found in 4 (1.7%) patients (Fig. 3).

Chronic unilateral inflammatory lesions were also analy-zed in the patients in whom nasal septum surgery wasperformed at the same time. Of the 131 patients operatedfor chronic unilateral sinusitis with polyps, 77 (57.1%)patients had the nasal septum operated, whereas of the 53patients with chronic unilateral paranasal sinusitis, 37(69.8%) had the nasal septum operated at the same time(Fig. 4).

Discussion

Although unilateral pathological lesions of paranasal sinu-ses are intuitively treated more fearfully by patients, morethoroughly diagnosed by the otolaryngologist prior andduring the operation and emphasized in selective histologi-cal referrals, in our study group tumors were infrequentlydiagnosed, occurring in 6.4% of cases. These includedpapillary changes (4.7%) and malignant tumors (1.7%).However, in the whole group of patients operated forhypertrophic changes in paranasal sinuses neoplasms werefound in 0.8% of cases, including papillary changes (0.6%)and malignant tumors (0.2%), which gives almost a tenfoldhigher incidence of neoplastic changes in the unilateralpathological lesions of sinuses [12–15].

Based on the histopathological examination of surgicallyremoved tissues squamous epithelial carcinoma was diag-nosed in 4 patients. In all these cases lesions were found inthe maxillary and ethmoid sinuses, however, there were noclinical or radiological indications suggesting the develop-ment of a malignant tumor. Endoscopic surgical techniquewas not applied as a surgical method for malignant tumorsdiagnosed earlier. As regards the papillary changes observedin 12 (2.2%) patients, in some cases radiological imaging or

ns in individual paranasal sinuses

[(Fig._3)TD$FIG]

Fig. 3 – Findings of histopathological examination of surgically removed pathological lesions

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macroscopic pictures of intra-operationally removed tissuesuggested a hypertrophic lesion, which was later confirmedby histopathological examination. We regarded the histopa-thological findings in some of these cases as surprising.Thus it seems that radiological imaging and even extensivesurgical experience cannot substitute for the histopathologi-cal examination of tissues removed [16–19].

Many studies provide evidence that the coexistence ofchronic paranasal sinusitis and septal deviation or anoma-lies of the lateral nasal wall is quite frequent. We placedifferent weight on septal deviation in chronic rhinitis andparanasal sinusitis with and without polyps despite the factthat both qualify for surgery. As regards chronic rhinitis and

[(Fig._4)TD$FIG]

Fig. 4 – Frequency of the co-occurrence of nasal sep

paranasal sinusitis with polyps, the fact of their coexistenceis not regarded as a major cause of inflammation [20, 21].The primary objective of surgical treatment is to obtaina better nasal flow patency and good conditions for intrana-sal drug distribution as an element of the further conserva-tive treatment regarded as essential. The confirmation ofthe coexistence of anatomical abnormalities of the septumor lateral nasal wall with chronic paranasal sinusitiswithout polyps presents quite a different situation. In suchcases it seems that they exert a much greater effect on thedevelopment of chronic inflammatory changes in paranasalsinuses [22–24]. In our own cases of chronic unilateralparanasal sinusitis without polyps, nasal septum surgery

tum deviation and chronic paranasal sinusitis

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was performed in 69% of cases, while in chronic unilateralparanasal sinusitis with polyps in 57.1% of cases.

Many studies, including our own [25–29] find that inflam-matory changes in the paranasal sinuses occur mostfrequently on both sides of the maxillary and ethmoidsinuses. In the frontal and sphenoid sinuses unilateralinflammatory lesions are much more common, but theyoccur parallel to bilateral lesions of remaining sinuses.These observations confirm the results of the study presen-ted here, where isolated inflammation of the frontal andsphenoid sinuses was operated in only 15 patients, withsphenoid sinus constituting 4.7% and frontal sinus 1.7%.

The mechanisms by which unilateral nasal polypsemerge and develop have not as yet been elucidated. Someauthors postulate that another disease somewhat differentfrom bilateral polypotic lesions may be responsible. Allergiccatarrh and asthma were statistically more frequent inbilateral than in unilateral polypotic lesions. Further clinicalinvestigations are required. Other authors have also obser-ved less successful surgical outcomes in chronic unilateralthan in bilateral inflammatory lesions [29, 30]. It is not easyto document this observation reliably, bearing in mind thatit is not easy to assess the additional impact of such factorsas adequate post-operative treatment, coexisting metabolicdiseases and those of immune background, tobacco smo-king, conditions at work and many others. On the otherhand, in none of the cases of chronic unilateral inflamma-tory lesions with or without polyps did we find indicationsfor further surgery.

Conclusions

Unilateral pathological lesions of paranasal sinuses, leavingaside rather typical maxillary sinus cysts, requirea particularly thorough pre-operative diagnosis and a pre-cise histopathological assessment.

Authors' contributions/Wkład autorów

JM – study design, data collection, statistical analysis. JO –

statistical analysis, acceptance of final manuscript version.PP – data interpretation. JU – literature search.

Conflict of interest/Konflikt interesu

None declared.

Financial support/Finansowanie

None declared.

Ethics/Etyka

The work described in this article has been carried out inaccordance with The Code of Ethics of the World Medical

Association (Declaration of Helsinki) for experiments invol-ving humans; EU Directive 2010/63/EU for animal experi-ments; Uniform Requirements for manuscripts submitted toBiomedical journals.

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