Functional endoscopic sinus surgery for chronic rhinosinusitis

The safe gate to the posterior paranasal sinuses: reassessing the role of the superior turbinate

Surgery of the posterior ethmoid and sphenoid sinuses can be challenging. In 1999, a technique was described for identification of the superior turbinate and utilizing it as a landmark in endoscopic posterior ethmoidectomy and sphenoidotomy. Although this was more than a decade ago, it has not been supported by further studies. In our practice, we have routinely adopted this technique, and have modified it to allow further orientation during endoscopic surgery of the posterior sinuses. To describe a review of our technique, and to prospectively assess the value of the superior turbinate as a useful landmark during endoscopic posterior ethmoidectomy and sphenoidotomy. Fifty patients listed for endoscopic posterior ethmoidectomy with or without sphenoidotomy were included in a prospective study utilising our surgical technique. Data were collated for the success or failure of identification of the landmarks, and for any complications during the surgery. A total of 93 sides of endoscopic posterior ethmoidectomy and 73 sides of endoscopic sphenoidotomy were performed. The superior turbinate was identified in 100% of the cases. The coronal part of the superior turbinate basal lamella was identified in 60.22% of the cases, and the axial part in 88.17% of the cases. The natural sphenoid ostium was identified medial to the posterior part of the superior turbinate in 98.63% of the cases. The axial part of the superior turbinate basal lamella was a constant landmark for the level of the sphenoid ostium. The number of transverse septae between the axial part of the superior turbinate basal lamella and the skull base was studied, and was found never to exceed one septum. No major complications were recorded. One case of small posterior septal perforation was detected with no post-operative effects. Our study represents the first report of identifying the two parts of the superior turbinate basal lamella intra-operatively. It also represents the first report of using the axial basal lamella of the superior turbinate as a landmark for the level of the sphenoid sinus ostium, as well as a landmark for the level of the skull base. The superior turbinate represents a constant landmark for performing a safe posterior ethmoidectomy and sphenoidotomy.

Extracts from The Cochrane Library

The “Cochrane Corner” is a quarterly section in the Journal that highlights systematic reviews relevant to otolaryngology–head and neck surgery, with invited commentary to aid clinical decision making. This installment features a Cochrane Review, titled “Functional Endoscopic Balloon Dilation of Sinus Ostia for Chronic Rhinosinusitis,” that finds no convincing evidence supporting balloon dilation compared to conventional surgical modalities for managing refractory disease.

Functional endoscopic balloon dilation of sinus ostia for chronic rhinosinusitis

BACKGROUND

Dilation of sinus ostia using a high-pressure balloon has been introduced as a treatment for chronic rhinosinusitis (CRS) refractory to medical treatment. The efficacy of this technology, however, has not been systematically reviewed.

OBJECTIVES

To assess the effectiveness of balloon sinus ostial dilation as a treatment for patients suffering with CRS refractory to medical treatment.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 20 December 2010.

SELECTION CRITERIA

Randomised controlled trials in patients of any age with rhinosinusitis lasting longer than 12 weeks who have failed a prolonged course of medical treatment. Studies compared either balloon sinus ostial dilation or a hybrid procedure (balloon dilation in conjunction with functional endoscopic sinus surgery (FESS)) versus conventional surgery (e.g. FESS) or a waiting list control.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed risk of bias.

MAIN RESULTS

One study (34 patients) met our inclusion criteria although it was not yet a peer reviewed publication. The study randomised patients with chronic frontal sinusitis who had failed a prolonged course of medical treatment into two groups: balloon dilatation of the frontal recess (plus conventional FESS of other involved sinuses) versus conventional FESS (Draf type 1/2a procedures on the frontal sinuses). At 12 months follow up there was no statistically significant difference in radiological resolution of frontal sinuses between the two groups. The percentages of directly observed patent frontal recesses at 12 months were 75% in the balloon dilation group versus 63% in the FESS-only group. The authors state that this was statistically significant but details of the analysis were not presented. Indeed the study as a whole suffers from a bias in the way its outcome measures were reported.No major complications were reported. Three patients in the FESS-only group required further revision frontal sinus surgery compared to one in the balloon dilation group, although synechiae were more common in the latter.

AUTHORS' CONCLUSIONS

At present there is no convincing evidence supporting the use of endoscopic balloon sinus ostial dilation compared to conventional surgical modalities in the management of CRS refractory to medical treatment. With the escalating use of balloon sinuplasty, there is an urgent need for more randomised controlled trials to determine its efficacy over conventional surgical treatment modalities.

Maxillary sinus disease: diagnosis and treatment

The maxillary sinus is the paranasal sinus that impacts most on the work of the dentist as they will often be required to make a diagnosis in relation to orofacial pain that may be sinogenic in origin. Maxillary sinus disease is often coincidentally observed on radiographs, and dentists often have to make a diagnosis and plan treatment based on the interpretation of the image. This paper aims to guide the dental professional through some of the disease processes involving the paranasal sinuses and in particular the maxillary sinus. The outcome is to encourage comprehensive history taking and examination of the patient to facilitate an accurate diagnosis that will enable successful treatment.

Systemic antibiotics for chronic rhinosinusitis without nasal polyps in adults

BACKGROUND

Chronic rhinosinusitis (CRS) is a common health problem which significantly affects quality of life. A wide range of medical and surgical therapies have been used to treat CRS. Both systemic and topical antibiotics are used with the aim of eliminating infection and inflammation, altering bacterial biofilm formation, reversing ostial occlusion and improving symptoms. Various groups of systemic antibiotics have been studied; clinical cure rates reported are inconsistent and range from 50% to 95%.

OBJECTIVES

To determine the effectiveness and adverse reactions associated with systemic antibiotic therapy for CRS in adults.

SEARCH STRATEGY

We searched the Cochrane ENT Group Trials Register; CENTRAL (2010, Issue 2); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 10 June 2010.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing systemic antibiotics with placebo for chronic rhinosinusitis in adults.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently, compared results and resolved disagreements by discussion. We assessed treatment effect by calculating the risk ratio (RR) and 95% confidence intervals (CI) of cure at a specific time point for each trial. We used mean difference (MD) and 95% CI for continuous variables (severity scores, duration of symptoms, etc.).

MAIN RESULTS

We included one study involving 64 patients. We assessed the overall risk of bias in this study as high. The study reported that roxithromycin could reduce the mean response score of patients by 0.73 points on a 1 to 6-point scale (95% CI 0.32 to 1.14, P = 0.0005) compared to those on placebo at three months after the start of treatment. This study also used sinonasal outcome test-20 (SNOT-20) comparing between pre and post-treatment at six, 12 and 24 weeks. The mean change in SNOT-20 from baseline at 24 weeks in the roxithromycin group was not significantly more than in the placebo group, at 0.27 points (95% CI -0.24 to 0.78, P = 0.30) on a 0 to 5-point scale.

AUTHORS' CONCLUSIONS

There is limited evidence from one small study to support the use of systemic antibiotics for the curative treatment of chronic rhinosinusitis in adults. Further good quality trials, with large sample sizes, are needed to evaluate the use of antibiotics in chronic rhinosinusitis.

Radiological findings in patients undergoing revision endoscopic sinus surgery: a retrospective case series study

Background

Functional endoscopic sinus surgery (FESS) is now a well-established strategy for the treatment of chronic rhinosinusitis which has not responded to medical treatment. There is a wide variation in the practice of FESS by various surgeons within the UK and in other countries.

Objectives

To identify anatomic factors that may predispose to persistent or recurrent disease in patients undergoing revision FESS.

Methods

Retrospective review of axial and coronal CT scans of patients undergoing revision FESS between January 2005 and November 2008 in a tertiary referral centre in South West of England.

Results

The CT scans of 63 patients undergoing revision FESS were reviewed. Among the patients studied, 15.9% had significant deviation of the nasal septum. Lateralised middle turbinates were present in 11.1% of the studied sides, and residual uncinate processes were identified in 57.1% of the studied sides. There were residual cells in the frontal recess in 96% of the studied sides. There were persistent other anterior and posterior ethmoidal cells in 92.1% and 96% of the studied sides respectively.

Conclusions

Analysis of CT scans of patients undergoing revision FESS shows persistent structures and non-dissected cells that may be responsible for persistence or recurrence of rhinosinusitis symptoms. Trials comparing the outcome of conservative FESS techniques with more radical sinus dissections are required.

Canadian clinical practice guidelines for acute and chronic rhinosinusitis

This document provides healthcare practitioners with information regarding the management of acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) to enable them to better meet the needs of this patient population. These guidelines describe controversies in the management of acute bacterial rhinosinusitis (ABRS) and include recommendations that take into account changes in the bacteriologic landscape. Recent guidelines in ABRS have been released by American and European groups as recently as 2007, but these are either limited in their coverage of the subject of CRS, do not follow an evidence-based strategy, or omit relevant stakeholders in guidelines development, and do not address the particulars of the Canadian healthcare environment.

Advances in understanding the pathophysiology of CRS, along with the development of appropriate therapeutic strategies, have improved outcomes for patients with CRS. CRS now affects large numbers of patients globally and primary care practitioners are confronted by this disease on a daily basis. Although initially considered a chronic bacterial infection, CRS is now recognized as having multiple distinct components (eg, infection, inflammation), which have led to changes in therapeutic approaches (eg, increased use of corticosteroids). The role of bacteria in the persistence of chronic infections, and the roles of surgical and medical management are evolving. Although evidence is limited, guidance for managing patients with CRS would help practitioners less experienced in this area offer rational care. It is no longer reasonable to manage CRS as a prolonged version of ARS, but rather, specific therapeutic strategies adapted to pathogenesis must be developed and diffused.

Guidelines must take into account all available evidence and incorporate these in an unbiased fashion into management recommendations based on the quality of evidence, therapeutic benefit, and risks incurred. This document is focused on readability rather than completeness, yet covers relevant information, offers summaries of areas where considerable evidence exists, and provides recommendations with an assessment of strength of the evidence base and degree of endorsement by the multidisciplinary expert group preparing the document.

These guidelines have been copublished in both Allergy, Asthma & Clinical Immunology and the Journal of Otolaryngology-Head and Neck Surgery.

Article Commentary: Chronic rhinosinusitis: An education and treatment model

Research into chronic rhinosinusitis (CRS) has rapidly expanded over the last decade, resulting in a plethora of proposed etiologic and disease-modifying factors. Potentially, advancement of knowledge in this field has developed more than any other disease in otolaryngologic science. However, the teaching and education of this complex and still evolving process has lagged behind. Trainees, students, and residents may find the heterogeneous group of pathophysiologic mechanisms difficult to learn and apply to treatment decision making. Identification of the propagating factor and subsequent microbial, inflammatory, or mucociliary disease-modifying effects for a specific patient allows individual tailoring of treatment to address these factors. This facilitates a logical strategic process, rather than using one broad, ill-defined approach for each and every CRS patient. A model of CRS is presented as a teaching aid for residents and those learning about the etiology and directed treatment of this complex problem.

Quality of life outcomes after functional endoscopic sinus surgery

Most patients with chronic rhinosinusitis seek medical treatment when the burden of symptoms negatively impacts their quality of life. The degree to which quality of life improves after sinus surgery is a critical indicator of surgical success. This article reviews quality of life outcomes after functional endoscopic sinus surgery, including relevant clinical factors, weaknesses in the current literature, and future research directions.

Trends in endoscopic sinus surgery rates in the Medicare population

OBJECTIVE

To examine the trends in rates of endoscopic sinus surgery, open sinus procedures (open sinus surgery), and the prevalence of diagnosis of chronic rhinosinusitis in the Medicare population from 1998 to 2006.

DESIGN

Retrospective cohort analysis.

PATIENTS

Twenty-percent sample of Medicare beneficiaries aged 65 to 99 years for the years 1998 to 2006.

MAIN OUTCOME MEASURES

Change in per capita annual rates of endoscopic sinus surgery, open sinus surgery, and chronic rhinosinusitis diagnosis among Medicare beneficiaries.

RESULTS

From 1998 to 2006, the rate of patients undergoing endoscopic sinus surgery per 1000 Medicare beneficiaries increased by 20%, from 0.72 (95% confidence interval [CI], 0.70-0.74) to 0.92 (95% CI, 0.89-0.95). Over the same period, the rate of open sinus surgery declined 40%, from 0.20 (95% CI, 0.19-0.21) to 0.11 (95% CI, 0.10-0.12). However, the per capita rate of beneficiaries diagnosed as having chronic rhinosinusitis declined by 1.4% over the study period. Further analysis by age cohort revealed significantly higher rates of surgery and diagnosis rates in the 65- to 69-year-old beneficiaries relative to older age groups. Over the study period, the per capita rate of diagnosis of chronic rhinosinusitis declined or remained stable across age groups. Despite this, all age groups showed increases in endoscopic sinus surgery rates.

CONCLUSIONS

Our findings indicate that endoscopic sinus surgery is increasingly becoming the mainstay of chronic rhinosinusitis management in the Medicare population. Because of the uncertainty regarding the outcomes of surgical vs medical management, the root causes of the observed increase in endoscopic sinus surgery rates need to be investigated. Given that sinusitis is a common diagnosis necessitating physician visits, comparative effectiveness studies examining medical vs surgical management would be warranted.

Benefit from the minimally invasive sinus technique

INTRODUCTION

Sinus drainage is impeded by the transition spaces that the anterior paranasal sinuses drain into, not the ostia themselves. Addressing the transition spaces and leaving the ostia intact, using the minimally invasive sinus technique, should reverse chronic rhinosinusitis.

AIM

To assess patient benefit following use of the minimally invasive sinus technique for chronic rhinosinusitis.

METHOD

One hundred and forty-three consecutive patients underwent the minimally invasive sinus technique for chronic rhinosinusitis. Symptoms (i.e. blocked nose, poor sense of smell, rhinorrhoea, post-nasal drip, facial pain and sneezing) were recorded using a visual analogue scale, pre-operatively and at six and 12 weeks post-operatively. Patients were also surveyed using the Glasgow benefit inventory, one and three years post-operatively.

RESULTS

We found a significant reduction in all nasal symptom scores at six and 12 weeks post-operatively, and increased total quality of life scores at one and three years post-operatively (25.2 and 14.8, respectively).

CONCLUSION

The patient benefits of treatment with the minimally invasive sinus technique compare with the published patient benefits for functional endoscopic sinus surgery.

The Cochrane Collaboration and the Cochrane Library

The Cochrane Collaboration (www.cochrane.org) is an international, independent, not-for-profit organization dedicated to making up-to-date, accurate information about the effects of health care readily available worldwide. I review the origins, development, and structure of the organization and describe the important components of its output, The Cochrane Library.