Endoscopic surgical approaches to the paranasal sinuses are becoming increasingly preferred to traditional open craniofacial resection techniques for the surgical management of inverted papilloma. Endoscopic procedures have been observed to significantly shorten postoperative hospital admissions when compared with open surgery, while not increasing either the operative time or blood loss.1 Furthermore, provided the tumor site of attachment can be adequately visualized and reached using endoscopic instruments, an endoscopic technique does not increase the risk of disease recurrence.2 Where the tumor cannot be reached endoscopically, the surgeon will convert to an open surgical procedure, such as a radical maxillary antrostomy (Caudwell-Luc), to achieve complete tumor clearance. For this reason, the ability of surgeons to use endoscopic surgery to remove inverted papilloma is limited by the instruments available to reach and completely excise the tumor.
TECHNIQUE AND DISCUSSION
We present a case of a 40-year-old male in whom suction diathermy was used to ablate inverted papilloma from the maxillary sinus. His case history illustrates how the haemostatic properties and malleable tip of the suction diathermy instrument can be used to extend the applications of a minimally invasive endoscopic surgical approach to the paranasal sinuses. Our patient had histologically confirmed inverted papilloma in the right maxillary sinus; residual disease from a previous operation was present in the anterior medial wall of the sinus, lying immediately above the inferior meatus. The lesion could be visualized endoscopically using a 30° Hopkins' rod endoscope passed through a middle meatal antrostomy. Due to the tumor's position within the maxillary sinus, however, it could not be reached and excised using standard endoscopic equipment, including curved biopsy forceps, curette, or angled microdebriders passed through either a middle or inferior meatal antrostomy.
At this point in the operation, it would be usual to consider removing the medial wall of the sinus or converting to open surgery. Suction diathermy has in recent years become a popular technique for adenoidectomy, especially in children, due to its ability to effect complete tissue ablation and maintain haemostasis.3–5 In our case, during endoscopic sinus surgery, the shape of the malleable suction diathermy instrument (Vallylab, Boulder, CO; E2505-10FR) was modified so that when passed through the inferior meatal antrostomy its tip reached the tumor (Figs. 1 and 2). When the tip was sucking on the tissue, continuous diathermy was applied at 38W. By using this technique, all residual inverted papilloma was removed. Complete macroscopic clearance of the tumor was confirmed by direct observation intra-operatively and subsequently by endoscopic examination of the maxillary sinus at 3, 6, and 12 months postoperatively. To our knowledge, this is the first report in the literature of suction diathermy being used during endoscopic sinus surgery. For our patient, the only alternative would have been to convert to open surgery or to excise the medial wall of the maxillary sinus. We concede that 12 months is not a sufficient follow-up to be confident that the inverted papilloma will not recur in this patient. Nonetheless, the absence of recurrence after 12 months confirms that suction diathermy at the very least achieved complete macroscopic tumor clearance intra-operatively. As with other surgical instruments used to excise inverted papilloma, further research is required to determine how long-term recurrence rate following this technique compares with more destructive surgical approaches.
An obvious advantage of using suction diathermy during endoscopic sinus surgery is that it does not avulse the mucosa and therefore causes less bleeding. Where bleeding occurs, the combined functions of suction and coagulation provide a bloodless operative field, without the need to change instruments, which has the potential to reduce operating time. It is possible that computed tomography-assisted surgical navigation would have helped us in locating the base of the papilloma. As is the case in the majority of hospitals performing paranasal sinus surgery, this technology is not yet available to us at our institution.
Suction diathermy is an instrument that is inexpensive to buy and readily available to most otolaryngologists. We would therefore recommend that the use of suction diathermy be considered prior to converting to open surgery or destruction of the medial sinus wall when one is faced with needing to remove any appropriate lesion in the maxillary sinus that cannot be reached with conventional endoscopic sinus surgery instruments. An important limitation of this technique is that it does not allow tissue samples to be collected for histologic analysis. For this reason, we would recommend that it be used with caution when histologic diagnosis is not already available, especially if biopsies cannot be taken at the time of surgery. Arguably, another limitation of using suction diathermy is that it does not enable bone to be removed from the sinus wall by burring. Provided that the site of tumor attachment can be adequately visualized and excised, it is not our practice to burr the sinus wall following surgical excision of inverted papilloma. Although this approach is consistent with those of other large centers treating inverted papilloma,6 otolaryngologists who are proponents of bone burring may not be inclined to use suction diathermy.