Transnasal endoscopic piezoelectric-assisted removal of frontal sinus osteoma

The LaryngoscopeVC 2013 The American Laryngological,Rhinological and Otological Society, Inc.

How I Do It

Transnasal Endoscopic Piezoelectric-Assisted Removal of FrontalSinus Osteoma

Tomasz Gotlib, MD, PhD; Kazimierz Niemczyk, MD, PhD

Key Words: Frontal sinus, osteoma, piezosurgery.Laryngoscope, 123:588–590, 2013

INTRODUCTIONPiezosurgery, a method of bone cutting utilizing

ultrasound vibrations, widely used in oral and maxillofa-cial surgery, is being used in a growing number of newclinical applications. Its main advantages are preserva-tion of soft tissues, precise bone cutting, and thepossibility of use in narrow spaces. Over the past 5years, several authors have presented their experiencewith the use of this tool in ENT including antromastoi-dectomy, stapedectomy, osteoplastic flap procedure,removal of osteomas of the frontal bone, and revisionendoscopic sinus surgery.1–4

Osteomas of the paranasal sinuses are benign,slow-growing, usually asymptomatic tumors. The frontalsinus and recess are the most commonly affected sites.In most cases, surgery is not required, and radiologicalfollow-up is performed.5 Indications for removal includefrontal pain, rapid tumor growth, blockage of sinusdrainage, involvement of more than half of the sinus vol-ume, and intracranial or intraorbital complications.5,6

Endonasal endoscopic surgery of frontal sinus osteo-mas became possible due to the development of extendedapproaches to the frontal sinus.7 Draf IIb, IIb/III, andIII procedures are limited mainly by individual anatomicconditions such as narrow anterior-posterior dimensionof the frontal recess, not allowing the scope and burr topass.5 The most common late complication of these pro-

cedures is scaring of the created ostium, which dependson the amount of removed mucosa created by the use ofthe burr.8 The use of mucosa-sparing, slim-shapedinstruments allows for better visualization of the opera-tive field, minimizes trauma, and improves lateoutcomes.

Removal of large osteomas with currently availableequipment (irrigated curved burrs) is rather time con-suming.9 Cavitation of the lesion with burrs and thenfracturing and piecemeal removal of eggshell remnantsis the method of choice.10 The use of saw-like cuttinginstruments allows for creation of narrow gaps throughthe tumor, decreasing resection time. Another advantageof the use of piezoelectric systems is decreased risk ofcerebrospinal fluid (CSF) leak and bleeding due to pres-ervation of the dura and vessels. For these reasons, it isa promising tool for use in endonasal surgery of bonytumors of the paranasal sinuses. The purpose of this ar-ticle was to present our initial experience with the useof piezosurgery for transnasal endoscopic frontal sinusosteoma removal.

The patient was a 50-year-old, obese, asthmaticfemale complaining of severe frontal pain/headaches.She had previously undergone endoscopic sinus surgeryfor chronic rhinosinusitis with polyps 6 months priorwith no improvement in headaches. Computerized to-mography revealed osteoma type IV, according to Chiuand Kennedy classification, in her hypoplastic right fron-tal sinus, relatively thick frontal beak, and lowerintersinus septum (Fig. 1). The maximum dimension ofthe tumor was 2.2 cm.

EQUIPMENT AND SURGICAL TECHNIQUE

Piezoelectric EffectThe equipment utilizes piezoelectric effect. This

effect results from the passage of an electric currentthrough ceramic material, making it contract and

From the Department of Otolaryngology, Medical University ofWarsaw, Warsaw, Poland.

Editor’s Note: This Manuscript was accepted for publicationAugust 16, 2012.

The authors have no funding, financial relationships, or conflictsof interest to disclose.

Send correspondence to Tomasz Gotlib, MD, Department of Otolar-yngology, Medical University of Warsaw, ul. Banacha 1 a, 02-097, War-saw, Poland. E-mail: tgotlib@wum.edu.pl

DOI: 10.1002/lary.23728

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expand. The vibrations created are amplified and trans-ferred to the blade of the piezoelectric tool. In this way,a mechanical cutting effect exclusively on mineralizedtissues is achieved. The equipment consists of a controlunit, foot switch, hand piece, and exchangeable bladescalled tips (Fig. 2). A built-in peristaltic pump enablescooling of the tip with physiological saline.

ProcedureThe surgical procedure was performed under gen-

eral anesthesia. In the initial phase, standardfunctional endoscopic sinus surgery instruments and30� and 45� rigid scopes were used to widen the frontalrecess and trim the anterior-upper parts of the middleturbinates. Draf IIb procedure was then performedwith an irrigated curved burr (5.0 mm, 15� burr, Uni-drive motor system, Drill-Cut X handpiece [Karl Storz,Tuttlingen, Germany]) on both sides. The posterior wallof the frontal sinus was then traced. After creating per-foration of the upper nasal septum, the remnants of thefrontal beak and intersinus septum were removed withthe use of the burr and piezoelectric system (piezoelec-tric system 05.001.400 with 05.001.4001 handpiece[DePuy Synthes, West Chester, PA]) using two curvedcutting tips of 10.6 cm in length: a horizontally oriented

flat tip (03.000.421 S) and a vertically oriented saw tip(03.000.412 S).

The osteoma was detached from the anterior tableand intersinus septum, exposed with the piezoelectriccurved flat tip, mobilized with a frontal sinus curette,then reduced in size with both piezoelectric tips andremoved (Fig. 3). The last phase of the procedure wasperformed exclusively with the use of the piezoelectricsystem. There were no intraoperative complications (noCSF leak, severe bleeding, orbital hematoma).

The patient was discharged home on the secondpostoperative day. Postoperative follow-up wasuneventful.

DISCUSSIONWe found the piezoelectric system effective both in

widening of the median drainage pathway and duringosteoma removal. A cutting, curved, flat tip was usefulfor detaching the tumor from the anterior table due toits slim shape (flat tip of 3 mm of width) and appropriatecurvature (Fig. 2). Compared to a curved 70� diamondburr (3.5 mm in diameter), it was easier to reach narrowspaces, maneuver inside of the sinus, and did notobstruct vision.

Fig. 1. Computed tomography ofthe osteoma before the surgery.

Fig. 2. Piezoelectric system: hand-piece with the tip attached. [Colorfigure can be viewed in the onlineissue, which is available atwileyonlinelibrary.com.]

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On the other hand, the piezoelectric system causedthe endoscopic image to blur due to the sprinkling ofwater over the cutting tip. Slight withdrawal of thescope and stopping the system regularly for several sec-onds made control of the operative field satisfactory.Another inconvenience was the limited choice of tips.There were only two tips of appropriate length available.Tips with less curvature would be more suitable fordetaching the tumor from the posterior wall of the fron-tal sinus. Our impression was that the piezoelectricsystem removed the bone with the same speed orslightly slower than the diamond burr. This is consistentwith the estimations of other authors, indicating

that the time needed to complete the procedure with pie-zoelectric devices is longer compared to othermechanical devices.2,3

As mentioned above, soft tissue sparing is one ofthe advantages of piezoelectric surgery. Due to specificanatomic conditions of the presented patient and thelarge amount of bone that had to be removed, our opin-ion was that preservation of the mucosa would havebeen difficult with any surgical technique.

It is worth mentioning that piezosurgery devicesrequire a different technique of handling compared tosinus burrs. Opposite of burrs, no pressure should beapplied on the bone when using piezoelectric devices, asit decreases the microvibrations, and the energy istransferred to heat. This could lead to thermal injury ofthe nasal vestibule.

CONCLUSIONPiezoelectric surgery is a valuable tool that can

improve the performance of endoscopic transnasal sur-gery of bony tumors of the frontal sinus.

AcknowledgmentThe authors thank Peter Richards for help with lan-

guage corrections, and Aleksandra Szurgoci�nska for helpwith the equipment.

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Fig. 3. Curved flat cutting tip inside of the frontal sinus duringwidening of the median drainage pathway (above) and the mediandrainage at the end of the procedure (below). Endoscopic view in45� scope.

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