Medicine is defined by a continuous stream of innovation and evolution. As such, change, often for better, at times for worse, is a fundamental feature of its history. In reviewing our collective understanding of the nose and paranasal sinuses from ancient times to the present, several general themes emerge. Advances throughout history have often reflected the cultural and disease-related needs of the civilization at that time. For example, detailed descriptions of treatment for syphilis-related ozena are prominent throughout the preantibiotic history of medicine. An additional theme is the propagation of concepts that are ultimately disproven by divergent thinkers including seminal concepts in physiology and anatomy. Further, the major diagnostic and treatment advances in medicine have had successful application to nasal and paranasal sinus disorders. This includes microscopy, anesthesia, radiography, and antimicrobial therapy. Finally, technology has been a major force in the development of rhinologic surgeries, especially over the past century. The adage that in order to know where you are going, you must first know where you came from has truth in the field of rhinology whose history is colored with innovation, misdirection, and evolution.
ANCIENT HISTORY
Interest in the nose and the diseases that affect it has puzzled human civilizations throughout history. Ancient Persian writings note that male noses with a “hawk type” appearance resembling that of King Cyrus were admired. The Huns during the age of Attila routinely used bandages to flatten the noses of their infants. The Old Testament comments on prejudices against “flat-nosed people.”1 Conditions such as nasal polyps, ozena, and epistaxis have plagued people of all civilizations since the first medical documents were written. Our knowledge about the anatomy and pathology of the nose has progressed over the centuries resulting in the current field of modern rhinology.
The ancient Egyptians were the first to demonstrate an understanding of the nasal anatomy and its surrounding structures. Egyptian papyri from 3500 bc shows that specially trained priests in charge of the embalming process were the first to access the brain through a transnasal technique; the brains of the deceased were removed through the nasal cavity using specially designed instruments. This precursor to the transnasal approach to the intracranial cavity shows the detailed anatomic knowledge of the ancient Egyptians. This civilization also provides information on the earliest historical figure who performed the role of a physician in approximately 3500 bc. Engraving on the pharaoh Sahura's tomb states that an attendant named Sekhet’ enanch “healed the King's nostils.”2–4
While the Egyptians were using the nose as a means of accessing the brain, the Hindus were also investigating the function and physiology of the nose. The Hindu document Sushruta Samhita provides the first detailed description of a nasal exam. It was written before the sixth century BC and notes a nasal speculum made of bamboo tree.3,5 The Hindus developed multiple treatments for diseases of the head and neck and noted their findings in a document known as the Sanskrit Atharvaveda. In this document, they describe surgeries to remove nasal polyps and reconstructive techniques for nasal injury and 4amputation, a common form of punishment at the time. Surgeons used local flaps from the cheek and forehead to reconstruct these defects and in doing so were the first to describe several important aspects of rhinoplasty and reconstruction still in use today.3,4
The ancient Chinese civilizations were using traditional eastern medical practices such as acupuncture to treat many nasal conditions. The Chinese also used their pharmacologic knowledge to provide relief to individuals with nasal congestion with a small shrub endemic to their area known as ma huang. This herb was documented to be an effective stimulant and nasal decongestant during the Han Dynasty in the second century AD.1,6 It was not until the 19th century that the active chemical in ma huang, ephedrine, was discovered and produced commercially.
Nasal ailments are even described in religious texts including the Bible. In 2 Kings 4:35, the phenomenon of sneezing is described. Treatment of epistaxis using hemlock or other plant remedies is also detailed. “Lord God formed man of the dust of the ground and breathed into his nostrils the breath of life” (Genesis 2:7) represents one of the first documented references to the respiratory function of the nose.7
ANCIENT GREECE AND ROME
The “Father of Medicine,” Hippocrates, wrote extensively about nasal disorders in the 5th century BC including management of nasal fractures, polyps, and epistaxis. Nasal trauma was commonplace during the time of Hippocrates in both Greek athletes and soldiers. For mildly displaced fractures, Hippocrates recommended lifting the fragments of bone and cartilage back into place within the first 24–36 hours after injury and using bandages and internal stents made of leather to keep the reduced fragments in the proper position. He detailed the use of a large external splint made of olive tree branches or a leather thong that would be tied around the head and kept in place using glue in order to reduce severely displaced nasal fractures. Hippocrates also wrote detailed descriptions of his methods of removing nasal polyps. This technique consisted of tying several sponges along a string, placing them deep into the nose or nasopharynx and slowly pulling them out in the hopes of removing the polyps along with the sponges. He was also the first to describe polyp removal using a snare.4,8 These techniques were revolutionary for their time and were practiced well into the 19th century.
The Romans played a large role in advancing medical knowledge and the study of rhinology. A Roman nobleman by the name of Aulus Cornelius Celsus is believed to have documented the extent of Roman medical knowledge during the first century AD in his eight volume encyclopedia, De Medicina. These eight volumes are all that survived from a much larger collection. They were discovered in the papal library in the early 15th century AD and published in 1478. His work details information regarding diet, pharmacology, and surgery practiced in the Roman Empire. Celsus is the first to note the four cardinal signs of inflammation: dolor, calor, rubor, and tumor. He translated the work of his Greek predecessor Hippocrates and became the first person to use the Latin term cancer to refer to a malignant lesion.4 It is unclear whether he was a practicing physician himself, but he documented medical treatments and often provided his opinion on the subject. In his works, he described the, “two nasal passages separated by an intermediate bone.” Like many other physicians or anatomists of the time, Celsus believed that, “these passages break up into two branches, one for respiration and one leading to the brain through which we get our sense of smell.” His treatment for nasal polyposis involved both the use of caustic material and surgical removal. Using specially designed instruments including a spatula shaped rod and a sickle knife or hook, he located and severed the stalk of the polyp prior to removal. Celsus also made the first note of a unified airway when he discussed lung infections possibly originating from the contents of the nasal cavities.9
Approximately two centuries after Celsus, another Roman played a large role in the advancement of medicine and rhinology. Claudius Galenus was a physician in the 2nd century AD who advanced medical knowledge and anatomy in such a major way that many of his theories were taught in medical schools until the 18th century (Fig. 1.1). His dissections of pigs and monkeys provided detailed information regarding many areas in anatomy, in particular the upper respiratory tract. He provided anatomic descriptions of the external and internal portions of the nose and continued the theory of the nose acting as the beginning of the respiratory tract. Galen divided nasal disease into two general categories: polyps and ozena. He noted the proximity of the nose and sinuses to the brain and believed that the sinuses contained fluid and mucus produced by the brain and pituitary gland. These fluids were thought to be waste products excreted by the brain. The work of these Greek and Roman physicians provided the basis for the study of medicine and rhinology for the next 1000 years.4,105
Fig. 1.1: Second century AD physician, Claudius Galenus, played a large role in advancing the medical and anatomic knowledge of the nose and paranasal sinuses.Courtesy: National Library of Medicine.
THE ITALIAN RENAISSANCE
Progress in the study of rhinology, and in medicine in general, slowed during the early Middle Ages. During this period, most physicians believed that the function of the paranasal sinuses was to store oils used to lubricate the eyes or to function as drainage space for malignant spirits. As late as the 16th century, names such as “la cloaca del cerebro” were given to the sinuses demonstrating the continuation of this belief. Although not discovered until 1901, Leonardo da Vinci drew the nasal conchae and paranasal sinuses in detail in 1489.1 Andreas Vesalius described the anatomy of the nasal bones, nasal cartilage, choanae and maxillary, sphenoid, and frontal sinuses in his landmark publication De humani corporis fabrica in 1543.11 He also notes that these sinuses are air filled and not full of humor or spirits. Bartholomeus Eustachius, another anatomist of the time, played a large role in advancing rhinology and otolaryngology by describing most of the structures within the middle ear. In his 1562 treatise Epistola de auditus organis (Examination of the Organ of Hearing), he described a tube that “originates at the anterior portion of the base of the skull, and takes an anterior course towards the pterygoid process of the sphenoid bone.”12 Although the function of the Eustachian tube was not completely understood at the time, the renewed emphasis on the study of medicine and the human body during the Renaissance laid the groundwork for advancements that would take place in medicine in the years to come.
Gaspare Tagliacozzi (1545–1599) made an impact during this time period through the publication of his book Treaty on Rhinoplasty. In it, he detailed the “Italian method” of rhinoplasty that differed from the “Indian method” that was detailed in Sushruta Samhita years earlier. Tagliacozzi developed pedicled flaps from the upper extremities and shaped them to cover the nasal defects. The upper extremity was then bandaged in an elevated position for approximately 20 days before the pedicle was transected and the transferred skin was trimmed to its final shape (Fig. 1.2).13
Other important European anatomists and physicians of the time also played a role in advancing the treatment of diseases affecting the nose. Gabriel Fallopius wrote in detail regarding his use of a wire snare to remove nasal polyps.14 Petrus Forestus, known as the “Hollandic Hippocrates” claims in his 1591 text Observationum et Curationum Medicinalium Libri to have cured a girl of ozena by copious nasal douching “with perfumed white wine in which were dissolved cypress, roses and myrrh.” In this same text, Forestus also treats ozena with silver nitrate and alum rubbed up with honey and applied with a probe. He was one of the first physicians to detail the findings in patients with nasal syphilis and notes that they should be treated differently than lesions of other etiologies.15 Another European physician practicing at the same time as Forestus was Hieronymus Fabricius. He described treatment of intranasal ulcers secondary to ozena using cautery by a “glowing hot instrument.” The cautery was to be continued until the area “was thoroughly cleansed of crusts.”1
EUROPE 17TH–19TH CENTURIES
During the 17th century, physicians and anatomists made major strides in describing the function of the nose and paranasal sinuses.6
Fig. 1.2: Italian surgeon Gaspare Tagliacozzi designed pedicled flaps from the upper extremities for use in reconstruction of the nose.Courtesy: National Library of Medicine.
Until this time, the belief that nasal mucus and secretions were actually “purgings of the brain” dominated most medical teachings. These secretions were believed to percolate through the bony foramina of the anterior skull base to enter the nasal cavity. Conditions such as halitosis or facial acne were associated with the nose and paranasal sinuses. The recommended treatment of such conditions was total or partial middle turbinectomy.4
In 1651, the British surgeon and anatomist Nathaniel Highmore published his treatise Corporis Humani Disquisitio Anatomica in which he described and illustrated the antrum of the maxillary sinus, a structure that later became known as Highmore's antrum (Fig. 1.3). Highmore also became the first person to use the term ostomy to refer to an opening made to permanently drain an organ.16 Ten years after Highmore published his work, a German physician named Conrad Victor Schneider made the assertion that nasal secretions did not come from the cranial cavity. In his published treatise on the membranes of the nose, De Catarrhis, Schneider stated that nasal secretions actually originated from the mucous membranes of the nose and sinuses.17 This change of belief would have important implications for future rhinologists.
Fig. 1.3: An engraving from the British surgeon and anatomist Nathaniel Highmore's treatise Corporis Humani Disquisitio Anatomica detailing the anatomy of the maxillary sinus and antrum.Courtesy: New York Academy of Medicine.
In 1707, two English physicians named James Drake and William Cowper published a medical treatise Antropologica Nova in which they described multiple cases of halitosis caused by suppuration of the maxillary sinus. This suppuration was relieved by removal of maxillary teeth creating an oral antral fistula that allowed drainage of the sinus through the alveolus.18 In 1768, French surgeon Louis Lamorier described a similar method of 7draining the maxillary sinuses. After its description, Lamorier's transalveolar technique remained the procedure of choice for the treatment of maxillary sinus suppuration for nearly a century.19 An 1889 paper by Dr. Joseph H Bryam, one of the four founding physicians of the Episcopal Eye, Ear and Throat Hospital of Washington DC, notes that the best surgical method to drain an abscess of the maxillary sinus is to remove a molar tooth and perforate into the antrum through the alveolus.20
A new technique of accessing the maxillary sinus was developed by Charles Joseph Heath of London in 1889 and William Robertson of Newcastle–on-Tyne in 1892. It involved trephination of the anterior maxillary wall and removal of all sinus contents.21 In 1893, George Walter Caldwell, a physician in New York, published his method of opening the maxillary sinus using trephination of the anterior maxillary wall. However, Caldwell also created an inferior antrostomy through the lateral nasal wall.22 At roughly the same time as Caldwell described his technique, the French physician Luc independently reported his technique for opening the maxillary sinus using a nearly identical technique to Caldwell's.23 This surgical technique became known as the Caldwell–Luc operation and remains in practice to this day.24,25
In addition to surgical developments in rhinology, the 19th century also heralded vast leaps in our understanding of the histology, physiology, and anatomy of the nose and sinuses. The development of the microscope in the 1830s allowed individuals like Rudolph Virchow and Friedrich Henle of Germany along with J.F.L Deschamps of France to study the epithelia of the nose and sinuses. Henle provided detailed descriptions of the different types of epithelia. He also first noted the function of the ciliated epithelium found throughout the upper respiratory tract.4,26 In 1870, Emil Zuckerkandl of Austria published an extremely detailed anatomic and pathologic descriptions of the paranasal sinuses. Other anatomists such as L. Grunwald of Munich, M. Hajek of Austria, Adolf Onodi of Hungary, and Harris Mosher of Boston also contributed to the rapidly growing fund on rhinology knowledge.4
Technology was also developing rapidly during this era. The rhinologic exam became much more informative and accurate following German physician Phillip Bozzini's creation of endoscopy in 1806 (Fig. 1.4).27 In addition to developing laryngoscopy, Czech physician Johann Czermak further improved the nasal exam by promoting the use of the nasal speculum, head mirror with reflected light, and endoscope in 1879.28 Following the discovery of the analgesic properties of cocaine by Carl Koller of Austria in 1884, these tools contributed greatly to the surgical and anatomic teachings of physicians.4
Fig. 1.4: The endoscopic light source developed by German physician Philip Bozzini involved candle light reflected by a mirror into the endoscope.Courtesy: National Library of Medicine.
With these new tools in hand, surgeons began to develop new treatments for old ailments. In 1893, Charles Henry Burnett of Philadelphia detailed a number of conditions that he believed were due to hypertrophy of the inferior turbinates and recommended inferior turbinectomy as an effective treatment. These conditions all related to “nasal stenosis” and consisted of habitual mouth breathing, rhinorrhea, excessive nasal mucous, serous otitis media, obstruction of the lacrimal duct, nasopharyngitis, laryngeal hyperemia, laryngitis, and secondary lung disease.29 Others such as D. Braden Kyle30 and Chevalier Jackson31 of Philadelphia along with William Jarvis of New York supported this procedure and its benefits. As a result of the popularity of inferior turbinectomies, investigators in the United States and Europe evaluated nasal 8airflow patterns and developed anterior and posterior rhinomanometric methods still in use today.32–36
The understanding and treatment of nasal polyps improved during the 19th century as well. As far back as the times of Galen (200 ad), nasal polyps were believed to be “a constitutional disease due to the state of the humors of the body.” They were treated with knotted thread, caustic agents, and snare ligation.37–39 Deschamps was one of the first people to describe nasal polyps as a local disease of the nasal and sinus mucosa. He developed a classification system for nasal polyps consisting of “fungous and vascular, mucous and lymphatic, scirrhous, and sarcomatous.”26 The Austrian surgeon Theodore Billroth later described nasal polyps as adenomatous in nature while Virchow called them myxomata. Treatment of these lesions improved due to the use of the endoscope, nasal speculum, and topical anesthetics such as cocaine. Due to its effectiveness, the primary method of polyp removal remained the wire snare. While the design of this instrument improved during the 19th century, it still relied on principles present for hundreds of years.4
In 1881, Dr. Francke Bosworth of New York City published one of the first otolaryngology textbooks, A Text-book of Diseases of the Nose and Throat. In it, he details a multitude of pathologies affecting the nose and discusses how these can affect the entire body. He provides descriptions of thorough nasal exams and demonstrates an impressive understanding of nasal and sinus anatomy. Dr. Bosworth is often referred to as the “Father of Rhinology” in North America due to his extensive work on the subject.40,41
Besides Dr. Bosworth, many other American physicians of the 19th century advanced the field of rhinology. Drs. Morris Asch,41 Fletcher Ingals,42 Robert Weir44, and John Rowe43 played large roles in the development of new nasal surgery techniques. These “early rhinologists” were all part of the American Laryngological Association, a group formed in 1878 to promote knowledge “in all that pertains to the diseases of the upper air passages.” This interest in rhinology as well as laryngology and otology grew to such an extent that specialty eye and ear hospitals opened in New York (1820) followed by hospitals in Philadelphia and Boston.4
THE 20TH CENTURY
The beginning of the 20th century continued the rapid progression of rhinology seen in the previous century. This progression was largely due to advancements in surgical techniques that allowed for more effective treatment of nasal ailments. Drs. Otto “Tiger” Freer and Gustav Kilian built on septal surgery techniques taught by Ephraim Ingals of Chicago 20 years earlier and developed the submucous resection of the nasal septum.45 To aid in this procedure, Freer produced new surgical instruments including new nasal speculae, rasps, scissors, knives, forceps and elevators. He published extensively on this procedure and described the areas of the septum that can be safely resected, proper postoperative follow up, the proper use of cocaine, and post-operative packing. It is noteworthy that Freer's surgical teachings and instruments remain in use today.46–48 At the same time that Freer was publishing his works in Chicago, Killian of Germany developed a similar method of submucous septal resection that yielded comparable results. Freer and Kilian's work quickly turned septal surgery into a popular procedure performed by rhinologists throughout North America and Europe.49–51 This popularity lead others to further refine the technique, develop new instruments and decrease the operative time. During this time, most nasal surgeries were performed under local anesthesia using cocaine or epinephrine that did not allow for long procedures. Freer claimed to require 45 minutes to complete his procedure.52 William Ballenger's invention of the swivel knife and John Mackenty's technique for application of local anesthetic reduced to average operative time for a submucous nasal septal resection to 20–30 minutes by 1908.53
Septal surgery was not the only rhinologic procedure that took leaps forward during this century. Surgery on the ethmoid and sphenoid sinuses was developed in the early 20th century by Albert Jansen. His transantral route to the ethmoid and sphenoid sinuses relied on the widely taught Caldwell-Luc procedure to provide access to the lateral nasal wall. Mosher, a prominent anatomist and physician in Boston, noted that this route was effective in treating “combined empyema of the antrum, ethmoid region and the sphenoid.”54 However, Jansen's procedure required removal of the majority of the lateral nasal wall including the middle and inferior turbinates that likely resulted in significant atrophic rhinitis. This led to the procedure falling out of favor among many rhinologists.55,56
In 1912, Mosher published one of the first descriptions of an intranasal method of performing an ethmoidectomy. The procedure required wide exenteration of the labyrinth and complete removal of the middle turbinate. This wide dissection performed through a small nasal cavity lead 9others to question the safety of this method of ethmoidectomy.57 Mosher eventually became disenchanted with this procedure and in 1929 noted that “it has proved to be one of the easiest operations with which to kill a patient.”58 In response to the poor success rate of intranasal and transantral access to the ethmoid sinuses, Robert Lynch of New Orleans59 and W. Howarth of London60 described external approaches to these sinuses that did not leave unsightly scars or bony deformities. The Lynch frontoethmoidectomy provided a safe and relatively effective method of opening and treating the anterior ethmoid and frontal sinuses. Mucosal flaps and stents were also developed in the hopes of improving the patency of the frontoethmoid recess but none of them were used with any success.61
In order to treat patients who did not receive relief from their frontal sinus disease after a Lynch procedure, rhinologists of the time developed external approaches to this sinus. Originally, these procedures led to defects in the anterior table and left unsightly scars. However, a new technique developed by Howard Lothrop of Boston in 1917 allowed for treatment of frontal sinus disease with minimal aesthetic impact. Lothrop developed a method to bypass the nonfunctional frontal sinus by removing the inter-sinus septum and frontal floor to allow sinus contents to drain through the opposite side.62,63 In 1964, Robert Goodale and William Montgomery of Boston combined the osteoplastic flap with fat obliteration of the frontal sinuses to treat chronic frontal sinus disease.64 This technique became the treatment of choice for chronic frontal sinus disease for many years afterwards.
Another common surgical technique that developed in the early 20th century was the inferior meatus antrostomy. This procedure was promoted by Jan Mikulicz-Radecki of Austria and Lothrop for the treatment of chronic maxillary sinusitis.65 Critics of the time did not like that it did not remove the diseased mucosa of the sinus. However, poorly controlled rabbit model studies conducted by A. C. Hilding suggested that the natural ostium of the maxillary sinus should not be surgically altered.66 This misinformation influenced the rhinology community for over 40 years until it was finally disproven by Messerklinger.67–70
In addition to surgical advancements, the 20th century let to technologic advancements that benefitted the field of rhinology. The first of these was radiography. Cornelius Coakley of New York City was the first otolaryngologist to report using this new equipment. He described how he was able to diagnose frontal sinus disease using a posterior-anterior view with an exposure time of 3.5 minutes.71 The Waters, Caldwell, and lateral views were all in use by 1915 and played a major role in the diagnosis of sinus disease before computed tomography was developed.72,73 According to Stammberger, the lack of detail found in these early radiographs likely delayed the understanding of the complex surgical sinus anatomy.4
In addition to radiology, advancements in nasal endoscopy were coming about during the mid-20th century. Although the first endoscope had been invented in 1801 by Bozzini, it was not frequently used by physicians due to poor visualization and illumination. Endoscopic examinations were limited to the peritoneum and bladder. In 1853, French physician Antonin D'Esormeux demonstrated an alcohol illuminated urethroscope. Following the development of electricity, distal illumination improved significantly that led Max Nitze of Germany and Joseph Leiter of Austria to develop the Nitze–Leiter cystoscope. Using a modified version of this instrument, E. Zaufal examined the Eustachian tube orifice during the 1880s. Twenty years later, Alfred Hirschmann of Germany described the first nasal endoscopy using a special 4.0 mm diameter endoscope. He examined the middle meatus and maxillary sinus ostia through the nose as well as via the molar tooth socket. Roughly at this same time, M Reichert, also of Germany, described minor manipulation of sinus tissue using endoscopy. However, Hirschmann's and Reichert's advancements and their possible applications to the field of rhinology were ignored for the next six decades. Harold Hopkins of England designed the modern endoscope 1948. He drew influence from the work of John Baird earlier in the century who patented the transmission of images through glass fibers. Over the next two decades, Hopkins and German manufacturers improved endoscope technology to provide a precise, detailed picture. Using Hopkin's new technology, surgeons of the day slowly began performing more endoscopic examinations and eventually surgical procedures.74–77
Important figures in rhinology were plentiful early in the century. Arthur Proetz, an otolaryngology professor at Washington University, wrote his thesis entitled “The Displacement Method of Sinus Diagnosis and Treatment.” In this thesis Proetz describes using sophisticated equipment and head positions to diagnose and treat an array of sinus conditions. For his work, Proetz was awarded the Castlebury Prize from the American Laryngological Association in 1931.78–81 Ten years later, Professor Van Alyea of Chicago authored a legendary textbook entitled “Nasal Sinuses.”10
Fig. 1.5: Maurice Cottle was a founding member and the first president of the American Rhinologic Society. His teaching and leadership in the field of rhinology spurred its growth that led to his nickname “the father of rhinology.”
In the book, he details information about nasal anatomy and physiology as well as the role that allergy may play in sinus disease. The book discusses newer concepts such as the mucociliary blanket, mucosal information and the role of new medications known as antibiotics in the treatment of sinusitis.82
Maurice Cottle of Chicago is often referred to as the “rhinologist of the century” for his work in this field and his dedication to its advancement (Fig. 1.5). He is considered to have restored rhinology to the same prominence as laryngology and otology. Dr. Cottle is known as a great educator who taught his functional approach to nasal and sinus surgery at his lecture series beginning in 1944. The series became known as “Cottle courses” and soon attracted specialists from around the country.4 It was at one of these courses at Johns Hopkins Hospital in 1954 that the American Rhinologic Society (ARS) was formed and Dr. Cottle was elected the first president of the group. His leadership and mentoring helped the ARS flourish and grow from a somewhat small group of practitioners to a robust academic society with a strong presence in the otolaryngology community. Although the interests of the ARS originally concerned the structure and function of the nose, the advent of nasal endoscopy and surgery shifted its focus towards disease of the paranasal sinuses and skull base. The development of the ARS spurred the academic study of diseases affecting the paranasal sinuses and aided in the dissemination of effective endoscopic surgical techniques for the treatment of these conditions.83
In the latter half of the 20th century, pioneers such as Walter Messerklinger of Austria entered the field of rhinology and embraced the new technology and concepts introduced earlier in the century. Endoscopes developed by Hopkins were refined by German manufactures and provided significantly better visualization of the nasal cavity and sinuses than previous versions. Messerklinger was the first person to use these endoscopes to examine and treat sinus disorders.84 He provided detailed endoscopic anatomy using this new technology and opened the gates for other pioneers to follow. David Kennedy from Johns Hopkins,85 Heinz Stammberger of Austria,70 and Wolfgang Draf of Germany4 built on these concepts and further developed modern endoscopic sinus surgery. Their work showed the importance of mucociliary function and detailed the need for proper antrostomies in the treatment of chronic rhinosinusitis.
The rapid evolution of endoscopic sinus surgery also required development of new surgical instruments and other supportive technologies. The removal of only diseased mucosa and sparring of normal tissue required through cutting and power instrumentation. These instruments allowed for precise cutting of mucosal edges in order to avoid stripping mucosa and exposing the underlying bone.86 Computed tomography, developed by Geoffrey Hounsfield in 1969 allowed for improved pre-operative visualization of complex sinus anatomy and aided in the diagnosis and treatment of sinusitis. Improvements in computed tomography lead to the development of intraoperative image guidance navigation. These systems were developed to satisfy a clinical need for better intraoperative orientation and localization. Modern navigation technologies are based on stereotactic systems developed for neurosurgery.87
As endoscopic surgery progressed, rhinologists began pushing the boundaries of indications and pathologies for transnasal surgery. Endoscopic septoplasty and endoscopic ligation of the sphenopalatine artery for refractory epistaxis became commonly performed procedures. Transnasal endoscopic orbital procedures such as endoscopic dacryocystorhinostomy and orbital decompressions for optic neuropathy and Graves’ disease were developed. Based on the work of Draf and others, frontal sinus surgery evolved from primarily an open procedure 11into one with multiple methods of endoscopic treatment.4 The increase in endoscopic sinonasal surgery naturally lead some rhinologists and neurosurgeons to begin to explore the application of this new technology to the field of neurosurgery. Gerard Guiot of France with Karl Bushe and E. Halves of Germany reported the first use of a transnasal endoscope to access a pituitary lesion in 1970.88 Over two decades later, Hae-Dong Jho and Ricardo Carrau from Pittsburgh published their first series using strictly endonasal transsphenoidal approach to resect pituitary tumors.89 Their success led others to develop methods of accessing and treating anterior skull base, clival, and infratemporal fossa lesions.
Mirroring the paradigm shifts that have occurred throughout the history of rhinology, the past quarter of a century has refined our understanding of the pathophysiology of sinusitis. The disease began to be viewed not just as an infectious process but also the result of an inflammatory process within the mucosa itself. Mediators of inflammation such as cytokines and interleukins became targets of research and potential intervention.90–92 The role of eosinophils in chronic sinusitis and the destructive inflammatory contents that they release became better understood.93 Bent et al. detailed the pathogenesis of allergic fungal sinusitis.94 Multiple research groups described the bacteriostatic role nitrous oxide plays within the paranasal sinuses.95 Others showed that this substance that is naturally found in high concentrations within the sinuses also has antiviral properties and upregulates mucociliary activity.
The end of the 20th century and the beginning of the 21st century saw many changes in the medical management of sinusitis due to the improved understanding of its pathophysiology. Evidence supporting a polymicrobial etiology of chronic rhinosinusitis became more prevalent and the role of bacterial biofilms began to be investigated.96 Antimicrobial therapy remained the mainstay of treatment for both acute and chronic sinus disease. However, treatment methods directed at inflammation took on a larger role in the management of chronic sinusitis.97
In addition to improved basic science research into the pathophysiology of chronic sinusitis, the 21st century also witnessed an emphasis on patient-centered quality of life measures in defining treatment outcomes in rhinosinusitis. Using psychometrically validated questionnaires and large patient databases, a more robust measure of treatment intervention and impact of comorbidities has become available.98,99 As patient databases grow and researchers abilities to analyze information improve, rhinologists are sure to refine their treatments methods even further to the benefit of the millions of patients with sinus disease.
The history of rhinology can be traced back to the earliest cultures on earth. Our understanding of the anatomy and pathologies in this field has advanced steadily over the past 3 millennia leading to the fevered pace of study that has taken place in the last four decades. As more information is discovered, more questions arise. Research directed at the pathophysiology and treatment of sinus disease, collaborative dissemination of information, and technological advances will continue to advance the field of rhinology.
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