Endonasal ethmoidectomy
Endonasal ethmoidectomy is the removal of the ethmoidal cells, the cavities of the ethmoidal sinuses located between the eyes behind the nose. Nasosinusal polyposis, which affects between 1% and 4% of the white population and up to 15% of asthmatics, creates polyps that grow in the sinuses, mainly the ethmoid, and fill the nasal cavities. Nasosinus polyposis is the main indication for ethmoidectomy, but it may also be required in cases of benign or malignant tumors of the ethmoidal, frontal, sphenoidal or maxillary sinuses, in cases of bacterial infections resistant to medical treatment, and in cases of sinus mycosis.
Find out more about endonasal ethmoidectomy from Dr. Delagranda, ENT and cervico-facial surgeon in La Roche sur Yon, France.
Indications and target audience for endonasal ethmoidectomy
Who is concerned by endonasal ethmoidectomy?
- Adults with polyps for which medical treatment is no longer sufficient and who do not wish a simple polypectomy.
- Adults with a benign or malignant tumor of the ethmoid.
- Adults with bacterial ethmoiditis resistant to several lines of usually effective antibiotics.
- Adults with fungal sinusitis (exceptional in the ethmoid or frontal sinuses).
- Very exceptionally, children with cystic fibrosis or Woakes syndrome.
When should an endonasal ethmoidectomy be performed?
Endonasal ethmoidectomy should be performed in cases of:
- Disabling nasosinusal polyposis despite well-administered medical treatment: blocked nose that constantly runs down the nostrils and into the throat (nasal obstruction, anterior and posterior rhinorrhea), reduced or absent sense of smell (hyposmia, anosmia), repeated sneezing, sinusitis pain at the top of the skull, forehead, cheekbones, between or behind the eyes.
- Benign tumor such as inverted papilloma.
- Malignant tumors such as ethmoid adenocarcinoma or squamous cell carcinoma.
Ethmoid and endonasal polyps
The ethmoid is a single, complex bone with 2 parts called lateral masses, which are hollowed out by cavities called ethmoidal cells, analogous to the cells of monks in monasteries. This bone is located between the 2 eyes and under the anterior part of the brain, making surgery a delicate operation.
Bilateral endonasal polyps are the expression of nasosinusal polyposis, a chronic inflammatory disease with multi-factorial causes. In the vast majority of cases, there is no precise explanation for nasosinusal polyposis, but it may reflect a more general underlying disease such as cystic fibrosis, primary ciliary dyskinesia, or immune deficiency such as naked lymphocyte syndrome or Wegener’s disease. Diagnosis of naso-sinusal polyposis is clinical, based on the presence of polyps in both nasal cavities. When associated with asthma and/or intolerance to aspirin and non-steroidal anti-inflammatory drugs, this is known as Widal’s syndrome.Intolerance to sulfites, which are used in preserves and certain wines, notably champagne, can increase symptoms. If the nose is deformed by the polyps with a “tapir” snout appearance, this is known as Woakes syndrome.
Classification of polyps:
- Stage 0: no visible polyps.
- Stage 1: polyps located in the upper middle meatus.
- Stage 2: polyps located in the lower middle meatus.
- Stage 3: polyps reaching the back of the inferior cornet.
- Stage 4: polyps reaching the body of the inferior turbinate.
Treatment of nasosinusal polyposis is primarily medical, based on daily saline nosewashes, long-term inhaled corticosteroids and short courses of corticosteroids by mouth (maximum 2-3 per year, lasting 5-10 days). Dietary and medical adjustments are recommended.
- For patients with nasosinusal polyposis, it may be effective to limit intakes of food additives such as SULFITES (E150 and E220 to 228 and list of foods concerned below) and BENZOATES (E210 to E213 in soft drinks). GLUTAMATES E620 to E625, commonly found in Asian foods, are not involved.
- For patients suffering from Widal’s disease, you should also avoid taking aspirin or non-steroidal anti-inflammatory drugs, and modify your diet by favoring foods rich in omega-3 fatty acids (linseed oil, rapeseed oil, fish: anchovies, sardines, herring, salmon, tuna) to the detriment of those rich in omega-6 fatty acids (corn oil, peanuts, red meats, industrial eggs, dairy products).
Sulfite intolerance? Have you ever had a headache, a blocked or runny nose, or a small flush on the face after drinking just one or two glasses of sparkling or still white wine? If so, you are probably intolerant to sulfites: see the list of foods to avoid.
Objectives of endonasal ethmoidectomy
- Improve the sensation of a blocked nose.
- Reduce anterior and posterior rhinorrhea and their consequences (asthma attacks).
- Reduce sneezing.
- Improve the sense of smell, which is the most difficult to achieve.
- Remove benign or malignant tumors.
The different stages of the intervention
The surgical procedure
Under general anaesthetic in the operating room, the nasal cavities are cleaned with an anaesthetic, then the polyps are cut and aspirated using a protected suction blade or suitable forceps, under visual control via a rigid optic inserted into the nose. Once the nasal cavity polyps have been removed, the surgeon removes the bony partitions of the ethmoidal cells, preserving the walls in contact with the noble organs such as the eyes and brain. If necessary, the surgeon can also open the frontal and sphenoidal sinuses (the maxillary sinuses are automatically opened in the case of a complete ethmoidectomy). A healing foam gel is then placed in the 2 operated nostrils.
Post-surgery recovery period
In the case of outpatient surgery, the patient usually returns home the same day.
After hospitalization, you’ll need to rest at home for 7 days, and check that there’s no bleeding from the nose or throat.
If necessary, the surgeon will give you a 14-day medical leave.
Sport is not recommended for the first 15 days, and should be resumed gradually.
Pain is moderate. It is controlled by Class I analgesics.
Post-operative care at home: nosewash with saline solution, more intense than for polyposis alone, analgesics, antibiotics if required by your doctor.
Scarring: no visible scarring.
Complications liées l’ethmoïdectomie endonasale
In addition to the risks inherent in any surgery involving general anaesthesia, endonasal ethmoidectomy presents rare complications:
- Nasal haemorrhage (epistaxis) after the procedure, which is very minor and rapidly subsides with nose-blowing and nose-washing.
- Infection.
- Tearing.
- Bridles responsible for limiting nasal flow.
Exceptional complications add to the difficulty of this operation, but they can be controlled with experience and technical instruments such as neuronavigation:
- Compressive intra-orbital hematoma.
- Double vision (diplopia).
- Blindness.
- Cerebrospinal fluid discharge.
- Meningitis.
- Facial paralysis.
For further explanations, please consult the College of ENT’s fact sheet on endonasal ethmoidectomy:
Frequently asked questions
Here is a selection of questions frequently asked by Dr Delagranda’s patients during consultations for endonasal ethmoidectomy in La Roche-sur-Yon.
Is the operation obligatory?
No, it’s a comfort operation. The surgeon advises and the patient decides.
Is the effect guaranteed?
Yes, on nasal obstruction and rhinorrhea, less so on olfaction.
Is the effect long-lasting?
Yes, but it varies from case to case and cannot be predicted. However, it can last for years, and is longer-lasting than a simple polypectomy.
Is it painful?
No.
Does the operation mean I can stop using nosewash and inhaled corticosteroids?
No. In fact, treatment of polyposis is never etiological (we don’t treat the cause because it’s not possible, as with diabetes, for example), whether medically or surgically. You must therefore continue to treat yourself with nosewashes and inhaled corticosteroids on a daily basis at the very least, to limit the risk of recurrence of polyp regrowth, despite the operation.
Fees and coverage of the procedure
Endonasal ethmoidectomy is covered by health insurance. Contact your mutual insurance company to find out whether any extra fees will be covered.
Do you have a question? Need more information?
Dr. Antoine Delagranda is available to answer any questions you may have about endonasal ethmoidectomy. Dr. Delagranda is a specialist in ENT surgery at clinique St-Charles (La Roche sur Yon, France).
ENT consultation for endonasal ethmoidectomy in Vendée
Dr Antoine Delagranda will be happy to answer any questions you may have about endonasal ethmoidectomy. Dr Delagranda is a specialist in ENT surgery at the Clinique Saint Charles in La Roche-sur-Yon in the Vendée.