original article

Functional endoscopic sinus surgery (FESS)

in unilateral sinus disease
Authors’ Contribution:
A – Study Design Daniela Mielcarek-KuchtaACDEF, Karolina SimonBDF, Dawid KondratowiczBDE, Zofia ŁukomskaD,
B – Data Collection
C – Statistical Analysis Aleksandra Rybak-KorytowskaD
D – Data Interpretation
E – Manuscript Preparation
F – Literature Search Department of Otolaryngology, Provincial Hospital, Poznań, Poland; Head:A.Rybak-Korytowska MD, PhD, Poland
G – Funds Collection

Article history: Received: 23.02.2017  Accepted: 23.06.2017  Published: 31.10.2017

ABSTRACT: Background: Unilateral sinus disease (USD) occurs in 23 % of all cases. It is believed that it is mainly associated with
cancer development. Retrospective data from large rhinological centers show that the most common USD is chronic
rhinosinusitis (CRS), followed by mycosis, inverted papilloma and finally cancer, but only in a small percent of cases.
Aim of the study: The analysis of USD in the group of patients who underwent FESS at the secondary referral center.
 aterial and Method: The retrospective study of patients treated for USD in the Department of Otolaryngology in
M
the Provincial Hospital in Poznan between June 2014 and June 2016. The analysis includes age, sex, the localization of
lesions, histopathological and microbiological results, extension of the surgery and treatment results.
 esults: Over the analyzed period of time, 415 FESS for chronic sinusitis were performed. In this group, 83 patients underwent
R
surgery for USD. There were 35 women and 48 men.CRS was found in 48 cases, mycosis in nine cases, 12 patients were operat-
ed for non-malignant tumors, such as inverted papilloma (9), osteoma (2) and fibrosis tumor(1); seven patients had a choanal
polip and two of them had a foreign body in maxillary sinus – a tooth root lying loose. Four patients were diagnosed with hy-
poplastic maxillary sinus and one patient suffered from frontal sinus pyocele. One side endoscopic opening of all sinuses was
performed in the group with CRS, endoscopic medial maxillectomy was conducted in patients with inverted papilloma, and an
isolated opening of the affected sinus was performed in the cases with mycosis.
Conclusions: USD must be always suspected of malignant degeneration until proven otherwise. Endoscopic sinus
surgery with the use of angled scopes allows for the removal of even very extensive lesions. In our opinion, the extent
of operation is determined by the nature of pathology. While extensive surgery is recommended in patients with in-
verted papilloma, a limited procedure should be performed in those with isolated mycosis.
KEYWORDS: unilateral sinus disease, FESS, chronic rhinosinusitis, inverted papilloma, mycosis

Rhinological examination must always be complemented by endo-

INTRODUCTION
Unilateral sinus disease (USD) represents about 23% of all cases [1].
The symptoms of USD include nasal obstruction, facial pain and
pressure, unilateral rhinorrhea or postnasal drip, headache, less
frequently visual problems or epistaxis on the affected side. Retro-
spective data from large American centers [2] show that the most
common USD is chronic rhinosinusitis (CRS), followed by mycosis,
inverted papilloma and finally cancer, but only in a small percent of
cases. Therefore, a significant algorithm has been developed to fa-
cilitate proper therapeutic and diagnostic procedure (Table 1). It is
believed that USD is mainly associated with cancer development.
This process is generally accompanied by unilateral obstruction,
paresthesia and dysesthesia, followed by epistaxis and eventually
cheek and palate deformities and various neurological deficits [3].
scopic evaluation. Polyps detected during examination are typical
of CRS or inverted papilloma (IP). No change in the endoscop-
ic assessment occurs in mycosis or isolated maxillary sinusitis of
odontogenic origin. The aim of this study was to analyze USD in
patients undergoing FESS in the secondary referral center. There
is only one study of this problem in Polish literature [4], so this
analysis seems to be justified.
MATERIAL AND METHODS
The retrospective study involved patients with USD hospi-
talized in the Department of Otolaryngology of the Provin-
cial Hospital in Poznan, Poland, from June 2014 to June 2016.
Medical histories, the results of computed tomography (CT),

OTOLARYNGOL POL 2017; 71 (5): 29-36 DOI: 10.5604/01.3001.0010.5314 31

 original article

magnetic resonance tomography and surgery reports were

analyzed. The study included age, sex, localization of the le-
sions, as well as histopathological and microbiological results.
This article presents the scope and type of surgical procedure,
as well as the treatment outcomes. Patients underwent endo-
scopic examination using 0 and 45 degree angled scopes dur-
ing follow-up visits.

RESULTS
During the observation period from June 2014 to June 2016,
415 FESS for chronic sinusitis were performed. In this group,
83 patients were treated for USD including 35 women and 48
men, aged from 14 to 76 years. CRS was found in 48 cases,
mycosis in nine cases, 12 patients were operated for non-ma- Fig. 1. P
 olyps in the common meatus observed during endoscopy.
lignant tumors, such as inverted papilloma (9), osteoma (2)
and fibrosis tumor(1); seven patients had a choanal polip and
two of them had a foreign body in maxillary sinus – a tooth
root lying loose. Four patients were diagnosed with hypo-
plastic maxillary sinus and one patient suffered from fron-
tal sinus pyocele. Most patients with CRS had polyps in the
common meatus or the middle meatus, which were observed
during endoscopy (Fig.1). Histopathological examination di-
agnosed CRS, and the dominant cells were eosinophils and
plasma cells. In these patients, all sinuses were opened uni-
laterally and polyps were removed in order to obtain good
drainage and ventilation. In this case it is important to en-
sure that medication can easily reach the affected area and
the nasal cavity can be rinsed effectively (Fig. 2). The same
procedure was used in patients with a choanal polip. In pa-
tients with inverted papilloma, polypoid lesions with warty
Fig. 2. CT after unilateral FESS (on the left side).
surface were located mainly in the middle meatus. In this
group, in all patients, CT showed that the place of origin of
papilloma was within the lateral wall of the nasal cavity and
part of the maxillary sinus. The material for histological ex- infections. No recurrence was found in any of the patients
amination was collected prior to surgery. Intraoperative sam- during follow-up visits. In this group, three cases of fungal
ples were sent to determine the scope of the surgery. These lesions were accompanied by chronic ethmoid sinusitis. An
patients underwent endoscopic medial maxillectomy, and at opening of the ethmoid sinus was performed in these cases
the end of the surgery a diamond bur removed only a thin (Figure 4). In patients with hypoplastic maxillary sinus, an
layer of the periosteum to prevent recurrence. In our study, isolated opening of the sinus was performed, its natural nar-
patients remain without evidence of local recurrence (Fig- row ostium was widened and the contents, i.e. thick mucus
ure 3). In the case of fungal lesions, an isolated opening and secretions, were sucked out (Figure 5). Before surgery, pa-
eradication of the affected cavity was performed. Mycosis tients reported facial pain and pressure and periodic swell-
was located within the maxillary sinus in seven patients and ing of the lower eyelid or both eyelids.
the sphenoid sinus was affected in two patients. The diagno-
sis was made on the basis of CT scan findings that showed
excessive calcification or a shadow imitating a foreign body DISCUSSION
[5]. The material was sent for both mycological and histo-
pathological examination. Most common fungal infections Unilateral sinus lesions are observed less frequently than bilat-
were caused by aspergilla. They were non-invasive fungal eral lesions. This has also been confirmed by our study. While

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Fig. 3. Preoperative CT scan and postoperative endoscopic examination in a patient with inverted papilloma localized in the right maxillary sinus.

Ryc. 4. Preoperative CT scan and intraoperative endoscopic examination showing fungus ball in the right maxillary sinus and then the state after the removal of the
changes.

polyps in the nasal meatuses are the most common lesions,
changes located only within the sinuses are less often observed.
Their unilateral nature raises suspicion of tumor growth. How-
ever, reports based on extensive clinical material clearly show
that tumors are rarely observed. Paz Silva et al. [2] performed
a 15-year retrospective analysis of patients with USD. They
found that CRS was the most commonly recognized disease
and tumors were observed in a small percent of cases. How-
ever, among patients diagnosed with polyps or exophytic mass
during endoscopic examination, 66.7% had CRS, 2% - myco-

OTOLARYNGOL POL 2017; 71 (5): 29-36 33

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Ryc. 5. CT scan showing hypoplastic right maxillary sinus and intraoperative picture presenting removal of thick mucus discharge from the sinus.
sis, 15.7% - inverted papilloma and 13.7% - malignant tumors.
Shin [6] analyzed a group of 640 patients with unilateral CRS
and showed that USD was more common in males than in fe-
males, and that nasal polyps were present in 11.1% of cases.
The maxillary sinus was most often affected by the disease. In
Polish literature, Miłoński et al [4] found that the most com-
mon lesions were CRS with polyps (56.5%), followed by CRS
without polyps (22.8%), cysts of the maxillary sinus (11.6 %),
inverted papilloma (5.1%), osteoma(2.2%) and squamous cell
carcinoma (1.7%). In our study, the most common disease was
also CRS (58%), followed by benign tumors, such as inverted
papilloma, osteoma and fibrous tumor (14%), and finally my-
cosis (10%). Two patients were diagnosed with cancer, but they
were not operated in our unit, so they have not been included
in the statistics.
Generally, CRS occurred in all sinus cavities. It was found in
48 patients. Endoscopically, they were polyps within the com-
mon and middle meatuses. Patients underwent extensive sinus
fenestration and remain under control. None of the patients
were diagnosed with allergic fungal sinusitis. Tritt et al. [7] in-
dicate that in their material, allergic fungal sinusitis occurred
in 34% of cases. The increased incidence of this disease is ex-
34
plained mainly by climatic conditions, and surgical treatment
is complemented by aggressive steroid therapy.
Inverted papilloma was found in nine patients. This benign
tumor is the most common of unilateral lesions [8-11]. It oc-
curs in between 0.5 and 4% of cases, between the fifth and
seventh decade of life [12]. Clinically, this is a polypoid mass
with a warty surface. The mass is brittle and easily bleed-
ing, and it comes out of the lateral wall of the nasal cavity,
i.e. the middle meatus and extends mostly towards the an-
trum. It is reported that between 50 and 80% of tumors oc-
cur in the ethmoid sinus and maxillary sinus and are rarely
located within the sphenoid sinus or frontal sinus [13, 14].
Endoscopic medial maxillectomy is the method of choice in
the treatment of this type of pathology [15-22]. It should be
stressed that the most important thing is to radically remove
the lesions, because about 8% recur in the malignant form
[23]. If radical removal cannot be achieved with endoscop-
ic procedure, double approach and even external approach
are recommended, such as osteoplastic frontal sinus surgery
[11]. In this study, endoscopic medial maxillectomy was per-
formed in all patients because the lesions were located in the
maxillary sinus. Patients remain under control.
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Tab. I. Diagnostic algorithm for the workup and managment of USD ( from Paz Silva at all (2) )

OTOLARYNGOL POL 2017; 71 (5): 29-36 35

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Fungal sinusitis is most often non-invasive aspergillosis of od-
ontogenic origin [24-26]. We have confirmed this in our group
of patients, because most of the lesions were located within the
maxillary sinus. Infection occurs primarily through the treated
root canal, which has a direct contact with the sinus [27-30]. It
is also noted that dental materials containing zinc contribute to
the development of aspergillus [31]. Therapeutic procedure in-
volves eradication of the fungal masses from the sinus, preceded
by dental treatment. This procedure was performed in all of our
patients and no recurrence has been found.
Hypoplastic maxillary sinus is rarely discussed in the literature.
It occurs in between 1.73% and 10.4% cases [32]. Symptoms re-
ported by patients are mainly: facial pain and pressure, postna-
sal drip and swelling of the eyelids. Attention should be paid to
asymptomatic patients in whom the diagnosis is determined
based on radiological examination (i.e. silent sinus syndrome)
[33]. In Polish medical literature the issue has been addressed
by Burduk et al. and Babinski et al. [34, 35]. Bolger et al. classi-
fied hypoplastic maxillary sinus into three types based on the
structure of hypoplastic uncinate process [34]. Our material
consisted of four patients with this ailment. The main problem
during the procedure is to avoid damage to the lamina papyra-
cea because of its proximity to the natural ostium and its nat-
ural anatomical structure. After surgery, patients experience a
marked improvement.
Our study has shown the distribution of pathology in USD. We
have demonstrated that our observations are compatible with
the findings of other authors. We are aware that data from ter-
tiary referral centers are certainly different from those from
secondary referral centers represented by our research group.
These differences may also result from the current contracts
concerning oncological procedures. In high referral centers,
the percentage of patients with cancer will be higher.
CONCLUSIONS
USD must always be suspected of neoplastic proliferation. En-
doscopic sinus surgery with the use of angled scopes allows for
the removal of even very large sinus lesions. In our opinion,
the extent of operation is determined by the nature of pathol-
ogy. While extensive surgery is recommended in patients with
inverted papilloma, a limited procedure should be performed
in those with isolated mycosis.

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Access the article online:  DOI: 10.5604/01.3001.0010.5314  Table of content: https://otolaryngologypl.com/resources/html/articlesList?issueId=10369

Corresponding author: Daniela Mielcarek-Kuchta; Department of Otolaryngology, Provincial Hospital, ul.Juraszów 7-19; Poznań, Poland;
e-mail: dkuchta2001@yahoo.de

Copyright © 2017 Polish Society of Otorhinolaryngologists Head and Neck Surgeons. Published by Index Copernicus Sp. z o.o. All rights reserved. 

Competing interests: The authors declare that they have no competing interests.

Cite this article as: Mielcarek-Kuchta D., Simon K., Kondratowicz D., Łukomska Z., Rybak-Korytowska A.: Functional endoscopic sinus surgery (FESS) in unilateral sinus disease;
Otolaryngol Pol 2017; 71 (5): 29-36

OTOLARYNGOL POL 2017; 71 (5): 29-36 37