The intranasal ethmoidectomy procedure: Historical, technical and clinical considerations.

Abstract

Abstract The intranasal ethmoidectomy procedure is in questionable repute at this time. The reasoning behind its waning popularity is historical and primarily due to the poor results obtained in the pre‐antibiotic era. Two schools of thought regarding the procedure were present in this earlier era: one dedicated to the preservation of the middle turbinate and the other concerned with its entire removal. 5,6,7 Shortly before the emergence of antibiotics, a third school developed, led by some of the leaders of the more destructive procedure, showing preference for an external approach. 10 Descendants of the more conservative school, namely those dedicated to the preservation of the middle turbinate, are the only ones still actively and enthusiastically endorsing the intranasal method. 1,2 An intranasal approach is described which attempts to leave intact the medial wall of the middle turbinate. It is this structure that is felt to be the crucial landmark necessary to perform a safe and effective procedure. Several steps that are felt to be essential to this technique are outlined in detail. Avoiding the sphenoid sinus, especially in reference to opening up the ostium of the sphenoid sinus, is advocated. It is felt that the normal nasal anatomy can be restored by the proper application of this technique. The need for more effective and intensive measures, corticosteroids, antibiotics, and antihistamine‐decongestant medication, is stressed, especially in the postoperative state. It is recognized that it is impossible to treat an underlying allergy with a knife or forceps. The indications for utilization of this procedure are many and are listed. When a space expanding lesion, such as a neoplasm, mucocele, mucopyocele, or osteoma is encountered, then a primary external approach is advocated; likewise, when an isolated sphenoid sinus problem is suspected, then external, a transantral, or a transseptal approach is preferred. In the remaining problems, especially in the more difficult ones, involving the paranasal sinuses, either in the acute or chronic state, with or without complications, the intranasal ethmoidectomy technique is felt to be the key procedure in the initial approach to these problems. If this method of approach appears to be ineffective, then one can resort to the more elaborate external techniques that are commonly being performed. Five cases are reported in detail, illustrating some of the areas where this procedure is effective. The most common utilization is for the alleviation of obstructive nasal polyposis, with or without concommitant sinusitis. Radiographic improvement in many of these cases may prove to be an objective perimeter to gauge the type of surgery. This procedure also supplies an important link in the development of a more standardized or uniform approach to the more difficult problems involving the paranasal sinuses.