Lund, VJ

Rowe-Jones, JM

English

UCL Discovery

Journal of Laryngology &amp; Otologyhttp://journals.cambridge.org/JLOAdditional services for Journal of Laryngology &amp; Otology:Email alerts: Click hereSubscriptions: Click hereCommercial reprints: Click hereTerms of use : Click hereThe Future of ORL­HNS and Associated Specialties Series: The future of rhinology, anterior skull base and facial plastic surgeryJulian M. Rowe­Jones and Valerie J. LundJournal of Laryngology & Otology / Volume 114 / Issue 04 / April 2000, pp 245 ­ 247DOI: 10.1258/0022215001905346, Published online: Link to this article: http://journals.cambridge.org/abstract_S002221510000075XHow to cite this article:Julian M. Rowe­Jones and Valerie J. Lund (2000). The Future of ORL­HNS and Associated Specialties Series: The future of rhinology, anterior skull base and facial plastic surgery. Journal of Laryngology & Otology, 114, pp 245­247 doi:10.1258/0022215001905346Request Permissions : Click hereDownloaded from http://journals.cambridge.org/JLO, IP address: 144.82.107.84 on 09 Oct 2012The Journal of Laryngology and OtologyApril 2000, Vol. 114, pp. 245–247The Futureof ORL-HNSand Associated SpecialtiesSeriesThe future of rhinology, anterior skull base and facialplastic surgeryJulian M. Rowe-Jones, F.R.C.S. (orl), Valerie J. Lund, M.S., F.R.C.S., F.R.C.S.(ed)‘Future n. That period of time in which our affairsprosper, our friend are true and our happiness isassured.’The Devil’s Dictionary, Ambrose Gwinnett Bierce(1842–1914).RhinologyAdvances in the treatmentof in￿ammatory sinonasaldisease will follow upon increased understanding ofthe molecular biology involved in pathogenesis.Patients with rhinosinusitis that is allergic in originare perhaps most easily described for study and theallergic process is now well described.1,2 Morerecently cytokine pro￿les have been described forrhinosinusitis with, and without, polyposis.3 Pro-posed mechanisms for polyp formation based uponcellular interaction, particularly involving the eosi-nophil have been proposed.4 Similar cells may alsobe important in non-polypoid rhinosinusitis.5 TheMayo Clinic group have proposed that eosinophiliain cases with, and without, polyps is related to fungalcolonization6 and there is likelyto be a move for theuse of anti-fungal therapy in many cases of chronicrhinosinusitis.Understanding of in￿ammation at the cellular andmediator level creates potential for new therapeuticagents. Leukotriene pathway modi￿ers are beingused in the treatment of asthma and may have aplace in chronic rhinosinusitis, particularly foraspirin-sensitive cases but disappointingly a recentstudy in patients with seasonal allergic rhinitis failedto demonstrate any bene￿t.7 Other mediators arealso potential targets such as antagonists to adhesionmolecules, inter-leukin 5 or immunoglobulin E.Autoantibodies may also be developed to keyorchestrating cells such as T lymphocytes that areCD23 positive. New generation anti-histamines withgreater speci￿city, wider anti-in￿ammatory activityand fewer side-effects may be discovered andhydrolysable steroids may be engineered that haveno systemic availability.As the molecular nature of chronic in￿ammatoryairway disease is better understood it is possible thataetiological gene sequences may be discovered.Mucin messenger RNA in nasal polyps has recentlybeen described as having a characteristic pattern,distinct from normal nasal mucosa.8 Since theidenti￿cation of the cystic ￿brosis gene, the samegene has been found in some cases of severe nasalpolyposis unassociated with cystic ￿brosis, althoughthere is no consistent link.9 Nasal delivery genetherapy for cystic ￿brosis has demonstrated correc-tion of basal nasal potential10 so the future may seenasal delivery gene transfer for chronic polypoidrhinosinusitis.Nasal delivery of drugs generally is likely to seefurther development.11 Application of topical nasalcorticosteroids may see improved mechanisms forintranasal distribution of the drug.12Some cases ful￿lling the clinical criteria for‘rhinitis’ may be neurogenic in origin rather thanin￿ammatory. Success with neuropeptide nerveablation therapy involving topical application ofcapsaicin has been reported13 which may lead tothe development of tachykinin and neurokininantagonists in the treatment of these patients.Bacterial antibiotic resistance patterns will con-tinue to evolve and so the choice of antibiotics forinfective rhinosinusitis will be modi￿ed. Viral andbacterial immunization therapy will also change thespectrum of pathogens that result in infectiverhinosinusitis. There is a developing trend toconsider bacterial infection less important in thepathogenesis of chronic rhinosinusitis than wastraditionally the case.14 The use of antibiotics inthis condition is likely to be re￿ned and should infuture also be less prevalent for acute cases.15From the Department of Otolaryngology, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey and the ProfessorialUnit* Royal National Throat Nose & Ear Hospital, London, UK.245Intranasal and sinus surgery instrumentation andtechniques will continue to develop and systems thatimprove accuracy and safety and that minimizetrauma to normal tissues will be re￿ned. Pre-operative imaging with software data manipulationcan now provide triplanar views and 3D reconstruc-tions. These views may act as considerableperceptional aids to the understanding of involvedanatomy in more dif￿cult cases and morphologicalareas such as the frontoethmoidal recess andpituitary fossa, particularly in revision cases. Theseimages can also be linked to real-time computer-aided navigation systems for use during surgery.16The debate continuesin relationto the routine use offacial nerve monitoring during tympanomastoidsurgery and a similar argument will develop regard-ing endoscopic sinus surgery and routine use ofperi-operative image navigation. The possibledisadvantages of monocular endoscopic vision willbe addressed and the use of 3-D dimensionalsystemsmay bring bene￿ts in depth perception as have beendescribed in laparoscopic surgery.17 Computed-assisted surgery should also bring advances thatcan be applied to surgical training. Virtual realitysimulation systems of increasing complexity will helpsurgeons practise procedures and enablemesurements of competence (Ota and Loftin,http://www.vetl.uh.edu/surgery.vrse.html:).Health purchasers will increasingly require evi-dence of the level of effectiveness of present andfuture treatments. Clinical audits, such as thatcurrently being carried out by the Royal College ofSurgeons of England on sinonasal surgery, willdemonstrate the results of current practice, forgeneric groups of patients, and research, hopefullyconducted through multi-centre trials, will assess therelative merits of new developments. This shouldcomplement the long-term results on large numbersof cases of chronic rhinosinusitis who have now beentreated by this approach. It is also likely that theextended applications of endoscopic surgery such asligation of the spheno-palatine artery,18 dacryo-crystorhinostomy and orbital decompression willbecome routine as their track record is established.There is certainly an increasing shift towardsendonasal repair of CSF leaks resulting fromcongenital dehiscence or trauma to the anteriorskull base. Again this may become a more routineundertaking with results that rival those of formalcraniotomy and it is likelythat the interface betweenour ophthalmic and neurosurgical colleagues willcontinue to develop in a very positive way.Increased understanding of immunopathology andneurophysiology of sinonasal disease will eventuallyenable us to reach the gold standard of accuratelyde￿ning disease for individual patients. With thisknowledge individual treatments can be appropri-ately determined rather than relying on results fromlarge trials usually involving a heterogenous popula-tion. As the disease process is better understoodnasal and sinus symptoms such as congestion andblockage will be better explained. Objective mea-surements that relate to these symptoms will bedeveloped and these may then be used to quantifydisease and assess interventions. For example,current interest is directed at nasal nitric oxidelevels.19Facial plastic surgeryComputer-assisted surgery will develop in facialplastic surgery as in rhinology. Its role is most clearlyseen in craniofacial surgery (Robb and Camp,http://www.mayo.edu/bir/home.html:). It will ￿ndapplicationin 3-D surface rendering and quantitativeanalysis prior to surgery. This enables accurateplanning. Similar analysis after surgery will alsoprovide data for statistical analysis. 3-D digitalsurface photogrammetry, which allows instantimage capture will also be applicable to rhinoplasty.Computed tomography (CT) image-guided surgeryhas now been described in conjunction with facialskeleton surgery.20 Facial and pro￿le analysis is thekey stone to successful aesthetic surgery. A surgicalplan based on these analyses relates to a concept ofwhat constitutes beauty. The future will see changesin the fashion of beauty as society evolves andsurgical trends will re￿ect these changes.Biomedical technology will advance. Bioresorb-able skeletal ￿xation plates will perhaps becomeroutinely used and current trends have seen theutilization of alloplastic implant materials withosteogenic proteins as bone substitutes. The idealalloimplant material may eventually be developedbut it is likely to compete with tissue-engineeredcartilage and bone cultured in vivo.21Grafts, particularly autogenous cartilage, havefound increasing use in rhinoplasty. This hasparticularly followed the increasing application ofopen-structure rhinoplasty, where the emphasis is onreconstruction and re-orientation rather than resec-tion.22 We will be in a better position to judge thelong-term aesthetic results of tip grafting. A grad-uated approach to the use of structural and tipgrafting rather than routine application is alreadybeing advocated. Nasal reconstructive surgery hasimproved dramatically over the last decade and thedescribed techniques should become more available.Attention is now paid to three layer reconstruction,including mucosal lining ￿aps, a structural frame-work and external tissue coverage. Dramatic resultsfor total nasal reconstruction have been presented.23New materials are being developed for the nasalframework such as vitallium or titanium mesh.24Facial reconstruction and rehabilitation willencompass techniques looking to improve facialnerve repair. Nerve guidance conduits enrichedwith growth factors and Schwann cells are underinvestigation as are the effects on regeneration oflocal electrical stimulation.25The endoscope has seen application in facialplastic surgery particularly with regard to foreheadlift. Greater experience has now been gained inmidface and orbital complex endoscopic surgery andthe technique may gain increasingly widespreadacceptance.26246 j. m. rowe-jones, v. j. lundDespite the oucome of most facial plastic surgeryhaving a dominant aesthetic component this branchof surgery will need to develop standard outcomemeasures and assessment techniques. This willenable new procedures and all of us as individualsurgeons to stand up to critical scrunity andcomparison in the future.Anterior skull baseThe surgical ‘gold standard’ for malignant and someextensive benign tumours affecting the anterior skullbase is likelyto remain the cranio-facialresection forthe foreseeable future.27 However, the way in whichthis is undertaken may change in an effort to avoidfacial scarring. At present this can be done bycombining a bi-coronal and mid-facial deglovingapproach but endoscopic resection may be possiblefor the intranasal component. It is dif￿cult to seehow an entirely endoscopic approach, as is beingadvocated by some European centres, will comparefavourably with the actuarial survival provided bycraniofacial resection for tumours such as olfactoryneuroblastoma and adenocarcinoma given theirnatural history. Unfortunately with tumours thatoccur relatively infrequently and which may recuranything up to 15 to 20 years after the originalintervention it will be dif￿cult to make any mean-ingful comparisons for some time to come. However,it is possible for benign lesions such as invertedpapilloma to be excised by an experienced endo-scopic surgeon, even when it involves the skull baseand large series may be accrued in the future tosupport this contention.28Confucius said: ‘if you would de￿ne the future,study the past’. It is interesting to re￿ect that manyimportant advances in understanding nose and sinusproblems were made in the 1890s and that a centurylaterwe have seen a second renaissance in rhinology.It is probably beyond our imagination to predictwhat the next hundred years will bring but it seems areasonably safe bet that interest in this area willcontinueunabated and patients will seek our help forthe foreseeable future.References1 Howarth P. The cellular basis for allergic rhinitis. Clin ExpAllergy 1995;50(suppl 23):6–102 Howarth PH. Mediators of nasal blockage in allergicrhinitis. Allergy 1997;52(suppl 40):12–83 Rudack C, Stoll W, Bachert C. Cytokines in nasalpolyposis, acute and chronic sinusitis. Am J Rhinol1998;12:383–84 Jordana M, Dolovich J. Eosinophilsin Nasal Polyps. NasalPolyps, Epidemiology,Pathogenesis and Treatment. RhodeIsland: OceanSide, 19975 Rowe-Jones J, Mackay I. Management of nasal polyps.Curr Opin Otolaryngol Head Neck Surg 1998;6:42–66 Ponikau JU, Sherris D, Kern E, Homburger H, Frigas E,Gaffey T, et al. The diagnosis and incidence of allergicfungal sinusitis. Mayo Clin Proc 1999;74:877–847 Pullerits T, Praks I, Skoogh B-E, Lotvall J. Randomizedplacebo-controlledstudy comparing a leukotriene receptorantagonist and a nasal glucocorticoid in seasonal allergicrhinitis. Am J Resp Crit Care Med 1999;59:1814–88 Wood SJ, Bloxam R, Stark R, Birchall M, Cor￿eld A. Theexpression of mucin genes by nasal polyps. Clin Otolar-yngol 1999;24:375–69 Irving RM, McMahon R, Clark R, Jones N. Cystic ￿brosistransmembrane conductance regulator gene mutations insevere nasal polyposis. Clin Otolaryngol 1997;22:519–2110 Graham SM. Gene therapy for cystic ￿brosis. ClinOtolaryngol 1998;23:481–311 Quraishi MS, Jones N, Mason J. The nasal delivery ofdrugs. Clin Otolaryngol 1997;22:289–30112 Weber R, Keerl R, Schick B, Jaspersen D, Dshambazov K,Mlynski G, et al. Videoendoscopicanalysis of nasal steroiddistribution. Rhinology 1999;37:69–7313 Blom H, van Rijswijk J, Garrelds I, Mulder P, Gerth vanWijk R. The effect of capsaicin on nasal complaints andin￿ammatory mediators in the nasal mucosa of patientswith VMR. A placebo-controlled study. Second Sympo-sium on Experimental Rhinology and Immunology of theNose 1996;(abstract)14 Rontal M, Bernstein J, Rontal E, Anon J. Bacteriological￿ndings from the nose, ethmoid, and bloodstream duringendoscopic surgery for chronic rhinosinusitis: implicationsfor antibiotic therapy. Am J Rhinol 1999;13:91–615 Dinis PB. Antibiotics in sinus tissue. Rhinosinusitis:Current Issues in Diagnosis and Management. London:Royal Society of Medicine Press, 199916 Gunkel A, Freysinger W, Thumfart W. Computer-assistedsurgery in the frontal and maxillary sinus. Laryngoscope1997;107:631–317 Tendick F, Mori T, Way L. Futureof laparoscopic surgery.Fundamentals of Laparoscopic Surgery. New York:Churchill Livingstone, 199518 Sharp H, Rowe-Jones JM, Biring G, Mackay IS. Endo-scopic ligation ordiathermy ofthe sphenopalatineartery inpersistent epistaxis. J Laryngol Otol 1997;111:1047–5019 Silkoff PE, Chatkin J, Qian W, Chakravorty S, GutierrezC, Furlott H, et al. Nasal nitric oxide: a comparison ofmeasurement techniques. Am J Rhinol 1999;13:169–7820 Frodel J, Pacheco E. The use of intraoperative image-guided surgical techniquesfor reconstruction oforbitalandzygomatic deformities. Facial Plast Surg 1999;15:83–921 Hadlock T, Vacanti J, Cheney M. Tissue engineering infacial plastic and reconstructive surgery. Facial Plastic Surg1998;14: 197–20422 Johnson C, Torium D. Open Structure Rhinoplasty.Philadelphia: WB Saunders, 199023 Burget B, Menick F. Aesthetic Reconstruction of the Nose.Missouri: Mosby, 199424 Ahn M, Monhian N, Mass C, Bikhazi N. Total nasalreconstruction with alloplastic and autogenous grafts.Facial Plast Surg 1999;14:145–5025 Hadlock T, Cheney M. Update on facial nerve repair.Facial Plastic Surg 1999;14: 179–8426 Ramirez OM. Endoscopic subperiosteal browlift andfacelift. Clin Plast Surg 1995;22:639–4427 Lund VJ, Howard DJ, Wei WI, Cheesman AD. Cranio-facial resection for tumours of the nasal cavity andparanasal sinuses – a 17-year experience. Head Neck1998;20:97–10528 Stankiewicz JA, Girgis SJ. Endoscopic surgical treatmentof nasal and paranasal sinus inverted papilloma. Otolar-yngol Head Neck Surg 1993;109:988–95Address for correspondence:Professor V. J. Lund,Professorial Unit,Royal National Throat, Nose and Ear Hospital,330–332 Gray’s Inn Road,London WC1X 8DA, UK.the future of rhinology, anterior skull base and facial plastic surgery 247

The Future of ORLHNS and Associated Specialties Series: The future of rhinology, anterior skull base and facial plastic surgery

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