Transition Spaces. LJ Mariotti, DO Associate Professor of Surgery The Commonwealth Medical College Scranton, PA

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1 Transition Spaces LJ Mariotti, DO Associate Professor of Surgery The Commonwealth Medical College Scranton, PA

2 Messerklinger considered these the spaces between the sinus proper and the nose He called these spaces Pre- Chambers He felt that these narrow spaces were vulnerable to inflammation and therefore obstruction of mucus flow

3 Messerklinger theorized that surgery on the pre-chamber might preclude surgery on the sinus itself

4 Setliff should be credited with coining the term, Transition Space, and illustrating the contrast between a direct entry sinus and a transition space entry sinus.

5 Direct Entry vs Transition Space Entry Understanding this concept Which sinuses have direct entry into the nose Which have transitional entry into the nose

6 Sphenoid sinus is a direct entry sinus, it s ostia drain directly into the nose at the face of the sinus

7 Posterior ethmoid sinus drains directly into the superior meatus, also a direct entry sinus

8 Maxillary sinus ostia drain into the ethmoidal infundibulum. Mucocillary transport thru the infundibulum transitions mucus from the sinus to the nose.

9 Anterior ethmoid sinus ostia drain into the hiatus semilunaris, where mucocillary transport transitions mucous into the nose.

10 Frontal sinus drains into the frontal recess, and retro-agger space before transitioning to the nose

11 Transition Space Intervention These spaces represent the bottleneck in development of CRS Is targeting the transition space the best approach to the surgical treatment of CRS?

12 Options for Transition Space Intervention MIST Balloon Sinuplasty

13 Setliff should MIST also be credited for describing the first surgical model for Transition Space intervention in This model was later termed MIST by Catalano in Ethmoidal Infundibulum Hiatus semilunaris superior

14 MIST Ethmoidal infundibulum Retro agger space / naso-frontal rescess Hiatus semilunaris superior

15 Balloons Ethmoidal Infundibulum Retro-agger space / naso-frontal recess

16 Headache/CRS Case Report 23 y/o female with a history of headaches and CRS for many years 4 infections per year Headaches are non-migraine, based on IHS criteria

17 8 headaches per month, lasting 24 hrs, 6 out of 10 pain intensity Right sided headache, behind right eye Headache improved with topical intranasal anethesia

18 Past History Mild asthma Allergies as a child Non-smoker School teacher

19 Initial Exam Non-obstructing right septal deviation Mild boggy congestion Otherwise unremarkable

20 Follow up visit, normal CT scan. Complaining of pain, pressure, congestion

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23 Exam at Follow Up Bilateral purulent drainage from middle meatus

24 Is anatomic intervention indicated? FESS vs MIST vs Balloon Sinuplasty

25 Pansinusitis How much is possible in an office setting?

26 39 y/o OMF surgeon with 6 week history of facial pain, low grade fever, congestion; Tx with Augmentin, Biaxin, Avelox, Nasonex, Sudafed, ONS, Allegra unremarkable PMH / PSH / SH Presented for 2nd opinion

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28 Anesthesia QuickTime and a decompressor are needed to see this picture.

29 Maxillary QuickTime and a decompressor are needed to see this picture.

30 Frontal QuickTime and a decompressor are needed to see this picture.

31 Sphenoid QuickTime and a decompressor are needed to see this picture.

32 Frontal Sinusitis 39 y/o male with a long history of CRS and allergic rhinitis, first presented in 06 Intake CT showed complete right frontal opacification and moderate mucosal edema through out the other sinuses

33 He responded to medical management Right frontal clear in post treatment CT He remained symptomatically stable for 5 years on immunotherapy and occasionally required antibiotics for acute infection

34 Past History Allergic Rhinitis Ex-smoker, quit 2006

35 Exam Non-obstructing right septal deviation Boggy congestion of varying degrees over the years. Occasionally has polypoid changes of middle turbinate Purulence is not seen

36 MIST was offered on several occasions Patient preferred to be treated w/o surgery

37 He presented increasing right frontal pressure in Nov,2011 All other chronic sinus symptoms are very tolerable to him

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40 In office right balloon sinuplasty 1/25/12

41 Follow up CT March 21, 2011

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44 Chronic Acute CRS 28 y/o female with Hx of CRS for last 8-10 years Septoplasty with excision of Concha Bullosa, done 2002, some improvement Still gets 3-4 sinus infections per year requiring Abx

45 Symptoms Frontal headache, facial pressure Nasal congestion Nasal discharge

46 Initial Physical Exam Septum midline Bilateral purulent drainage from middle meatus

47 Initial CT

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50 Initial Treatment Augmentin for one month 2 week prednisone taper Saline irrigation Flonase spray

51 Overall improvement in symptoms Still c/o headache, R > L Some nasal congestion

52 Post-Treatment CT

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55 Is anatomic intervention an option?

56 Options Traditional FESS vs Transition Space Intervention MIST vs Balloon vs Traditional ESS