Division of Rhinology, Allergy, and Endoscopic Skull Base Surgery

Sinusitis and allergy are two of the most common diseases occurring in the United States with millions of new cases being diagnosed every year. With a tradition dating back to 1979 with W. Paul Biggers, MD, and Libby Drake, RN, the Division of Rhinology, Allergy, and Endoscopic Skull Base Surgery provides a complete range of services for medical and surgical management of sinusitis and allergy, in addition to cutting edge management of tumors and other complex processes and diseases affecting the sinuses and skull base.

The Division is led by Brent A. Senior, MD, Immediate Past President of the American Rhinologic Society, with other members including Adam M. Zanation, MD; Charles S. Ebert, MD; Peter Chikes, MD; and Harold C. Pillsbury, MD, current President of the American Academy of Otolaryngic Allergy. Together, they perform the full range of allergy, medical, as well as minimally invasive endoscopic surgical management of diseases of the nose and paranasal sinuses. , including Functional Endoscopic Sinus Surgery (FESS), a minimally invasive technique used to restore normal sinus ventilation and function in the setting of chronic inflammation and infection. Recent advances in these minimally invasive techniques developed by UNC surgeons now allow for performance of endoscopic surgery for cancerous and non-cancerous tumors of the nose and sinuses and skull base, including, tumors extending into the eye and brain. Technological innovations, including the latest in powered instrumentation and drills, computer image guidance, and balloon sinus dilation, aid in these advanced techniques and provide significant advantages over traditional approaches. In addition, the division was among the first in the world to obtain and utilize intraoperative CT imaging for real-time surgical use.

As a leader in the field, the Division is proud to treat extremely complicated sinonasal inflammatory disorders such as allergic fungal rhinosinusitis. Allergic Fungal Sinusitis (AFS) is a refractory subtype of chronic rhinosinusitis, and is noted for its difficulty to manage through typical medical regimens. Almost universally, a diagnosis of AFS requires operative intervention, with the goals of removing anatomic obstruction, clearing infection and inflammatory debris from the sinus cavities, creating patent sinus outflow tracts, and preserving the mucociliary function of healthy sinonasal mucosa. Our Division has become a leading innovator of postoperative adjuvant medical therapy for AFS. This treatment may include the use of systemic and topical corticosteroids in irrigation solution or gels, immunotherapy directed at fungal-specific antigens, and/or systemic and topical antibiotics. The efficacy of these regimens is variable and the goal is to lengthen the time to recurrence rather than to cure the underlying disease. Therefore, long-term follow-up with serial physical and endoscopic examination is necessary to monitor for disease progression.

Gina Stoffel, RN and Robin Gunter RN at our new Carolina Crossing facility provide full allergy service including allergy shots to over 400 patients a month. The Carolina Pointe satellite clinic providedes unparalleled walk-up convenience and free parking right at the front door. New testing methods including immunocap blood testing as well as the multi-test 11skin test screen, have opened doors for diagnosis in younger children, while the imminent initiation of sublingual immunotherapy (SLIT), allowing shots to be given as drops under the tongue, will allow for painless treatment of children and adults who are apprehensive about traditional allergy injection therapy.

UNC physicians in the Division of Rhinology, Allergy , and Endoscopic Skull Base Surgery are pioneers in the use of in-office minimally invasive surgical treatments for sinusitis. One such technology is balloon catheter dilation of the sinus openings. This technology allows for a thin balloon catheter (similar to an angioplasty catheter for the heart) to be placed into the opening of a sinus and inflated. When the sinus balloon catheter is inflated, it gently restructures and dilates the opening of the passageway while maintaining the integrity of the sinus mucosal lining. In selected patients, this technology may allow some to avoid general anesthesia while experiencing quicker recovery times.

A major activity of the Division is co-sponsorship of educational programs in rhinology, sinus and endoscopic skull base surgery. One such effort, now in it’s tenth year is the Southern States Rhinology Course held each spring on Kiawah Island, South Carolina. Jointly sponsored by the Medical University of South Carolina, Georgia Health Sciences University, Emory University, and the Georgia Nasal and Sinus Institute, the course attracts annually over 80 participants from around the world in addition to over 30 residents. It provides an opportunity to participate in laboratory dissections while hearing renowned rhinologists over the course of this three-day meeting. The next course will take place May 2-4, 2013; more information on this annual course can be found at www.southernstatesrhinology.org.

The Division also sponsors the 360 Degree UNC Skull Base Surgery Course. This course brings together senior otolaryngology and neurosurgery residents and fellows from all over the nation, pairing them in a novel team approach to learning and dissections. The course encompasses both endoscopic and transcranial approaches.
The new home of this course is the Harold C. Pillsbury Sinus and Temporal Bone Training facility, highlight for the division for 2012. Offering the latest in endoscopic technology and videoconferencing technology, this 1300 square foot, 16 station facility allows for full training in all aspects of sinus, skull base, and temporal bone surgery. As a joint facility with colleagues in the departments of ophthalmology, neurosurgery, and thoracic surgery, the lab also offers the latest in surgical simulation technology as well as several full size operating room tables for more extensive dissection training. Starting in 2013, this lab will be the new home of the 360 Degree UNC Skull Base Surgery Course.

Research remains a major focus for the Division. This year, numerous residents and medical students participated in Division research activities resulting in several presentations at major national and international otolaryngology meetings including the Annual Meeting of the AAO/HNS, the Annual Meeting of the American
Rhinologic Society, the Annual Meeting of the North American Skull Base Society, as well as the Combined Otolaryngology Section Meeting. A highlight of this year’s research activity is the completion of a very important, high impact study on the use of topical steroid rinses in treatment of polyp disease, currently in press in the International Forum of Allergy and Rhinology.

Julie Kimbell, PhD who joined the Division in 2010 as a basic science researcher with a background in mathematics, has developed several cutting edge projects in the realm of computer modeling of airflow through the nasal cavity and paranasal sinuses in healthy noses and in the presence of sinus and nasal disease. This cutting edge work has helped us to understand how medications are distributed in the nose and sinuses as well as the potential impact of airflow on disease development or progression of sinusitis. Ongoing work in this area is also leading to new understanding of the impact of different aspects of sinus surgery on the progression or resolution of sinusitis.

The Division collaborates with several departments in the UNC School of Medicine including exciting work with the Division of Pulmonary Medicine yielding new insights into the molecular basis of inflammatory diseases of the nose and paranasal sinuses and the Division of Nephrology examining involvement of the upper airway in vasculitis. While, outside the UNC School of Medicine, the Division has an ongoing collaborative project with the UNC Gillings School of Public Health, Department of Biostatistics to specifically characterize the genetic expression profiles of patients with Allergic Fungal Rhinosinusitis through a comparative analysis of healthy and diseased specimens of sinonasal mucosa. Through both of these collaborations, we have received funding through the North Carolina Translational and Clinical Sciences Institute funded through Clinical and Translational Science Awards.

Other recent topics of division research have included investigations in the use of image guidance during endoscopic sinus and skull base surgery, cost effective analyses of endonasal, endoscopic surgical approaches to the skull base versus traditional open approaches, andquantification of the impact of Functional Endoscopic Sinus Surgery and endoscopic skull base surgery via patient-rated quality of life (QOL) measures All of these efforts haveled to numerous grants, presentations and publications in peer-reviewed journals.

As a result of the Division of Rhinology, Allergy, and Endsocopic Skull Base Surgery’s leadership in the realm of nasal, sinus, and skull base disease, UNC Otolaryngology/Head and Neck Surgery was named the first recipient of a National Center of ENT Excellence Award in 2004 by BrainLAB, AG, of Munich, Germany, one of the world’s leading image guidance technology companies.

Pioneering Minimally Invasive Skull Base Tumor Treatments: Minimally Invasive Pituitary Surgery and Expanded Endoscopic Approaches to the Skull Base

Endoscopic Skull Base Surgery

In March 2000, Brent Senior, MD, along with Matthew Ewend, MD of the Department of Neurosurgery, became the first team in North Carolina to perform Minimally Invasive Pituitary Surgery (MIPS) using an endoscopic approach entirely through the nose to treat pituitary adenomas. In contrast to traditional open approaches, in this procedure the nose is used as a corridor to the tumor, so no facial or oral incisions are involved, dramatically reducing the overall morbidity of the procedure. Sinus endoscopes are used to directly access and open the sphenoid sinus. The scope is held in position and the sella is then accessed using a typical two-handed technique. The tumor is removed using only the endoscopes, allowing for visualization at angles deep in the sella for removal of residual tumor that may otherwise be missed using microscopic approaches. Recovery is rapid and no packing is typically used. Tumor removal is potentially more complete given the ability of the angled endoscopes to see behind and under otherwise obstructing structures.

“Hydroscopy,” a technique developed by Drs. Senior and Ewend, is then performed in order to assess for residual tumor. Members of the Division along with collaborators in Neurosurgery have become recognized experts in this exciting area, lecturing nationally and internationally on the topic, in addition to authoring publications in several books and journals. They have performed over 600 of these procedures, placing the University of North Carolina at the forefront of minimally invasive approaches to skull base tumors.

In 2008, Dr. Adam Zanation joined Dr. Senior in the Division of Rhinology following his fellowship in Minimally Invasive Skull Base Surgery at the University of Pittsburgh. Teaming up with Dr. Deanna Sasaki-Adams in the Department of Neurosurgery, they are advancing minimally invasive skull base surgery to new and exciting levels for patients with a variety of skull base, brain, spine, orbital tumors, and even certain brain anuerysms.

With the role of expanded endonasal skull base surgery continuously growing, ever more advanced benign and cancerous skull base tumors are being successfully managed with these techniques. Some of these tumors include sinonasal cancers, meningiomas, craniopharyngiomas, optic nerve and orbital tumors, and petrous apex lesions. Indeed, in the last year, UNC performed over 100 expanded endoscopic tumor surgeries. In a very special case in 2008, Drs. Zanation and Germanwala performed one of the first endoscopic endonasal clippings of a ruptured aneurysm in the world. The one year follow up of this patient revealed complete obliteration of the aneurysm and the manuscript describing this novel approach has been published in the prestigious journal Neurosurgery in the last year. This case illustrates the potential of the minimally invasive endoscopic approach and shows how UNC is expanding the limits in this new field.

As techniques and experience lead us to utilize the endoscopic corridor for more complex skull base lesions, the natural progression is to utilize this approach for pediatric skull base tumors. Drs. Zanation and Senior along with our Pediatric Otolaryngology Attendings (Drs. Austin Rose and Carlton Zdanski) have successfully performed numerous pediatric skull base surgeries together. Dr. Zanation’s lab has recently published one of the first papers on endoscopic pediatric skull base surgery and reconstruction in Laryngoscope 2009, which illustrates the hurdles and offers solutions that these pediatric cases present. Two additional follow-up manuscripts in pediatric endonasal and skull base surgery have been accepted for publication this past year. What is clear is that all pieces of this multidisciplinary puzzle are integral and needed to optimize patient care. Drs. Rose and Carlton Zdanski and the UNC Skull Base Surgery Program are all currently working together to provide the most advanced pediatric tumor care and advance the research in pediatric skull base tumor surgery.

Treatment of Snoring and Obstructive

Sleep Apnea

Snoring is a ubiquitous problem in the United States, affecting more than 50% of middle aged men and 40% of middle aged women. Obtrusive snoring can be associated with more severe medical conditions, including obstructive sleep apnea, or upper airway resistance syndrome (UARS), and treatments for these disorders of sleep are needed to prevent long-term problems with heart and lung disease. (Click here for an informative infographic on sleep apnea.)

For simple snoring, not associated with OSA or UARS, the division offers radiofrequency treatment of the palate as our procedure of choice. Now available in the United States for over 10 years, it is a time tested office-based procedure that is fast, with little pain, and rapid recovery. The procedure involves the placement of a tiny needle electrode into the palate, delivering radiofrequency energy in the form of heat energy to the surrounding tissue. Research performed in the Department has resulted in an alteration of the technique yielding fewer treatment sessions and improved outcomes. Indeed 70% of patients will be significantly improved after two treatment sessions using our technique, while the side effects of this procedure are minimal. The relatively minor amount of post-procedure pain is the major advantage of this technique over other snoring therapies. And as opposed to other minimally invasive treatments, no implants are required with no risk of implant extrusion.

Obstructive Sleep Apnea Treatments

Nearly one-fourth of middle-aged men and one-tenth of middle-aged women have more severe problems with sleep disordered breathing including obstructive sleep apnea.

In addition to excessive daytime sleepiness, obstructive sleep apnea has been associated with increased risk of several serious medical problems including hypertension, heart attack, stroke, and even premature death, mandating diagnosis and treatment. For diagnosis, surgeons in the Department of Otolaryngology/Head and Neck Surgery perform a careful upper airway evaluation, including an upper airway endoscopic exam, while working with a multi-disciplinary team of sleep medicine specialists in the Departments of Neurology and the Division of Pulmonary Medicine, as well as dentists from the University of North Carolina School of Dentistry, and surgical colleagues in the Department of Oral and Maxillofacial Surgery, work to develop a personalized treatment plan for patients with sleep apnea, as there is not one simple treatment for all patientsOptions for treatment and services provided include the full range of “multi-level” surgery. This treatment philosophy recognizes that the obstruction occurring in OSA occurs at several levels in the upper airway, requiring a variety of procedures to treat, including manipulation of soft tissues from the nose to the back of the throat, in addition to bony facial surgery involving primarily the jaw. Some of these options include:

Septoplasty

Septoplasty consists of manipulation of the bone and cartilage of the center wall of the nose, allowing for the repair of deviations causing nasal obstruction. Avoiding the need for packing of the nose or placement of splints makes this outpatient operation a remarkably painless procedure with rapid recovery. In some cases the procedure may be combined with turbinate reduction allowing for the reduction of the bulky tissues on the side wall of the nose contributing to nasal blockage, performed either in the office or in the operating room.

Uvulopalatopharyngoplasty

For over thirty years, this procedure has been widely applied to individuals with OSA. It involves removing the uvula and portions of the palate and is frequently combined with tonsillectomy. This surgical procedure is usually performed with an overnight hospital stay and results in significant improvement in obstructive sleep apnea (OSA) in about half of all individuals undergoing the surgery.

Radiofrequency Tongue Base Reduction

Radiofrequency tongue base reduction is a minimally invasive procedure utilizing radiofrequency energy to heat tissue surrounding a small needle which is inserted into the tongue base. The heated tissue is resorbed by the body, creating a small area of scar, thereby reducing the size of the tongue base. This procedure has proven safe with few complications, as well as effective by several studies, in properly selected individuals.

Genioglossus Advancement and Hyoid Repositioning

Working with colleagues in the Department of Oral and Maxillofacial Surgery, genioglossus advancement is a procedure frequently performed for obstructive sleep apnea in the presence of blockage in the upper airway caused by the position of the back of the tongue. The procedure requires making an incision between the lower lip and the gum in the mouth. A small window of bone in the jaw is then cut and advanced slightly, thereby pulling the tongue forward and increasing the space in the breathing passage in the back of the throat. Repositioning of the hyoid bone over the front of the neck is frequently performed at the same time as genioglossus advancement in order to augment its effect.