Current otolaryngology literature would have the patient believe that high tech, expensive endoscopic sinus window surgery will resolve nasal obstruction, sinus pressure headaches, repeated (bacterial) sinus infections and post nasal drip. However, this is not the case! And health insurance companies reinforce this misconception by rewarding ENT surgeons for doing "high tech"endoscopic sinus surgery. And by penalizing these same surgeons if they approach this same group of patients by doing conventional, "low tech" septal straightening and manicure of the (intra-) nasal side wall structures (inferior turbinates). However, if these proven "low tech" procedures are correctly done, a number of good clinical trials (Mabry, Meredith, Pollock, Courtiss, Fry, Sheen, Spector, Saunders, etc.) have shown, conclusively, that nasal obstruction, (vacuum) sinus pressure headaches, repeated (bacterial) sinus infections and post nasal drip are all resolved. By using this combination of septal straightening and inferior turbinate trim. The opposite is so, based on this authors' extensive clinical experience and based on a critical literature review, vis a' vis "high tech" endoscopic sinus surgery. Let the buyer beware... All that is old is not bad... and all that is new and high tech is not necessarily good.

    Conventional wisdom would cause ENT surgeons and patients alike to believe that recurring episodes of (bacterial) sinusitis can be corrected by using high tech rigid fiberoptic nasal endoscopes, precision delicate endoscopic forceps, sickle knives, snares and (now) even power assisted devices... all designed to create windows between the sphenoid, frontal, and especially the maxillary sinuses and the nasal vault.

    These techniques and instruments, in the hands of a knowledgeable, experienced nasal surgeon, can in fact, be used effectively to remove tumor masses and inflammatory polyps from the nasal vault and ethmoid bloc. And, rarely, to perform dacryocystorhinostomies (draining blocked tear ducts). And, also rarely, to repair some spinal fluid leaks. However, "high tech" windows placed in "diseased" frontal, sphenoid, and particularly, maxillary sinuses have, actually, in this observers experience, made that patient's symptom complex worse rather than better. Furthermore, careful reconstruction of these patients medical history indicated, in most of these cases, that the patient's primary concerns were not addressed by endoscopic sinus "window" placement. In the majority of these failed endoscopic sinus surgery cases, the patient's initial complaint, if a careful, meaningful history was taken, was not repeated sinus infections (these are relatively rare)... instead the primary reason that these patients consulted the ENT physician was, in fact, nasal obstruction. And frontal (above the eyes), ethmoid (between the eyes) and, infrequently, maxillary (below the eyes) negative pressure sinus headaches and abnormal sinus CAT scans... and infrequently related bacterial sinus infections (which were, in fact, secondary to underlying nasal obstruction).

    In other words, if the surgeon directs his attention to the nasal blockage and secondary sinus pressure headaches... if the surgeon directs his attention to these items by using relatively "low tech" (and thus low paying) methods to straighten the nasal septum, to manicure the inferior turbinates to the proper size...then most, if not all, of the patient's symptom complex will be corrected.

    This investigator studied a group of nasal patients and found, on careful questioning, that they came to the ENT surgeon because of:

    Simply by using older techniques for straightening the nasal septum and for trimming the inferior turbinates, these symptoms were corrected in the vast majority of these patients. As was found in this author's long term follow up studies...

    Relief of symptoms following nasal septal straightening combined with manicure of the inferior turbinates:

• Nasal obstruction 86% were relieved
• Negative sinus pressure headaches 85% were relieved
• Dry throat 81% were relieved
• Repeated bacterial sinus infections! 73% were relieved of this symptom complex long term
• Postnasal drip 55% were relieved

    Despite a careful literature review, this investigator was unable to find concrete long term follow up statistics vis a' vis "sinus windows" and repeated (bacterial) sinus infections. However, this editors experience with more than three dozen "redo cases", drawn from a large geographic area, indicates that expensive, "high tech" endoscopic sinus window (and infundibulum) surgery, at least in this group of patients, made these patient's symptoms worse rather than better. Crusting, bleeding, thick Ducocement like secretions, nasal halitosis and persistent nasal obstruction were frequent long term complaints following high tech endoscopic sinus window surgery.

    Many times, with the exception of nasal polyp removal and removal of the occasional nasal tumor, endoscopic sinus surgery creates more problems than it corrects. Extensive "high tech" endoscopic windows into the frontal, maxillary and sphenoid sinuses are to be particularly avoided. It is this investigator's firm belief that once nasal obstruction is corrected, then mucociliary transport through the formerly obstructed natural ostium (window) of each of these sinuses results in a decrease in mucous membrane swelling and a return to normal function of that sinus's thin mucous membrane lining and natural ostium (window).

    In other words, although much of the otolaryngology literature, over the last five years, supports the thesis that sinus window surgery, done endoscopically, improves mucociliary clearance and reduces the instance and severity of repeated episodes of bacterial maxillary, frontal, and ethmoid sinus infections, a vocal minority of us disagree. We feel that the small ostia of the maxillary sinus with the delicately oriented cilia beating towards this small natural ostium (hiatus semilunaris) can not be duplicated by "natural" antrostomies regardless of the precision of the endoscopic surgeon. Likewise, endoscopic resection of most or all of the middle turbinate hinders, rather than helps, mucociliary clearance, humidification, and warming. In general, we, the vocal minority, feel that at least 80% of each middle turbinate should be preserved in most cases of turbinate and ethmoid bloc surgery

    Original articles by Pollock, Murray, and Meredith, all indicate that partial resection of the inferior turbinates (one-third would be fine!), reduces the interstitial edema (swelling) of the lateral nasal wall (swelling of the side wall of the nasal cavity). This, in turn, allows for decompression of the hiatus semilunaris and all the ethmoid air cells. Obviously, ethmoid bloc polyps have to be removed if they exist. Use of corticosteroids and antibiotics, in the perioperative period, combined with irrigation of the maxillary sinus with saline and then with high-dose steroids, intraoperatively, we feel offers the best chance for resolution of a chronically opacified maxillary sinus. The same holds true for the sphenoids and frontal air cell systems, all things being equal.

    Relatively inexpensive, traditional septal and inferior turbinate surgery have proven, in well documented, long term studies by Spector, Fry, Sheen, Pollock, Meredith, Saunders, Mabry and Courtiss, to produce lasting relief of nasal obstruction, sinus pressure headaches, dry throat, repeated sinus (bacterial) sinus infections and post nasal drip.

    The difference between these two philosophies is exaggerated by near do well health insurance companies whose physician advisors do not understand that new, "high tech" is not nearly as effective as traditional, well thought out, well documented surgical techniques for correcting frontal and ethmoid (vacuum) sinusitis, nasal obstruction and secondary bacterial sinusitis. It is these poorly informed health insurance companies that have denied patients "low tech" yet proven nasal surgery, and defacto, caused them to undergo ill conceived, endoscopic sinus window and infundibulum surgery.

    Buyer beware! Know the established, germane medical literature before undergoing "high tech endoscopic sinus window surgery." There are less expensive, vastly superior alternatives... even though your health insurance company would financially persuade your ENT surgeon to choose otherwise!