Radiographic Stage Fails to Predict Symptom Outcomes after Endoscopic Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVE

To determine whether preoperative computed tomography (CT) stage predicts degree of symptom improvement after endoscopic sinus surgery (ESS).

METHODS

A series of adult patients undergoing ESS was prospectively evaluated with CT and the rhinosinusitis symptom inventory (RSI) preoperatively and at a minimum of 12 months postoperatively. Symptom domains (nasal, facial, oropharyngeal, systemic, and total) were computed and both absolute change and percentage change in symptom domain scores before and after ESS were correlated with the preoperative CT scan stage according to three staging systems: Lund-MacKay, Kennedy, and Harvard.

RESULTS

One-hundred sixty-one patients (mean age, 40.2 years) completed the study with a mean follow-up of 19.4 months. Overall, statistically significant decreases in RSI symptom domains were noted for the nasal (net change -30.1 [range -100 to +100]), facial (-26.1), oropharyngeal (-13.4), systemic (-17.0), and total (-20.8) symptom scores (all P < .001). For the absolute change in total symptom score, no statistically significant correlation with CT stage was demonstrated for any of the staging systems (Lund: Spearman rho = -0.004, P = .962; Kennedy: rho = -0.008, P = .918; Harvard: rho = -0.011, P= .891). Similarly, no significant correlation with CT stage was demonstrated with the other symptom domains. Additionally, no significant correlation was identified between preoperative CT stage and percentage change in symptom domain scores.

CONCLUSIONS

Although CT scan is widely accepted as an accurate diagnostic tool for chronic rhinosinusitis, CT scan stage alone does not significantly predict symptom outcomes after chronic rhinosinusitis, regardless of staging system utilized.

Symptom and disease severity differences between nasal septal deviation and chronic rhinosinusitis

OBJECTIVE

To determine whether patients with chronic rhinosinusitis (CRS) exhibit more severe sinonasal symptom scores as compared with patients with nasal septal deviation (NSD) alone.

METHODS

Two patient cohorts were prospectively identified: patients undergoing surgery for NSD alone and those undergoing endoscopic sinus surgery for CRS without NSD. Patients in the NSD group were required to have normal paranasal sinus CT scans, whereas patients in the CRS group were required to have radiographic evidence of CRS. All patients completed the Rhinosinusitis Symptom Inventory (RSI). Statistical comparisons were conducted between cohorts with respect to RSI symptom domains and medical resource utilization.

RESULTS

A total of 42 patients were identified in the NSD group (mean age, 40.8 years) and 155 patients were identified in the CRS group (mean age, 44.9). Patients with CRS demonstrated higher severity scores for the nasal symptom domains (60.3 [CRS] versus 53.9 [NSD], P = 0.037). Oropharyngeal symptoms and total symptoms were also worse for the CRS group versus the NSD group (29.8 versus 23.1, P = 0.014 and 43.0 versus 37.0, P = 0.030). Facial and systemic symptom scores did not differ between groups. Patients with CRS demonstrated significantly higher utilization rates for topical nasal steroids (21.2 versus 12.2 weeks, P = 0.006) and oral antibiotics (7.9 weeks versus 2.1 weeks, P < 0.001), but not for oral antihistamines (P = 0.420).

CONCLUSIONS

Although patients with CRS manifest higher sinonasal symptom scores than patients with NSD alone, differentiating these 2 diagnoses on the basis of symptoms alone is difficult. These data suggest that as a disease process, CRS confers a significant disease burden with more significant negative symptom impact.

Chronic Recurrent Rhinosinusitis: Disease Severity and Clinical Characterization

OBJECTIVES/HYPOTHESIS

The objective was to clinically characterize and determine disease severity parameters for chronic recurrent rhinosinusitis (CRRS).

STUDY DESIGN

Prospective.

METHODS

A consecutive series of adult patients undergoing evaluation for CRRS was prospectively evaluated. Patients with four or more acute rhinosinusitis episodes in the previous calendar year with an absence of symptoms between episodes were considered as manifesting CRRS. Symptom severity and disease data from the Rhinosinusitis Symptom Inventory was obtained, as well as Lund staging information from the paranasal sinus CT scan. The Lund staging scores for patients with CRRS were compared with a control group of patients without CRRS. Symptom domain scores and disease severity parameters were compared between the CRRS group and a third group of patients with chronic persistent rhinosinusitis.

RESULTS

In all, 30 patients met inclusion criteria for the diagnosis of CRRS. Mean age was 40.9 years with a 3:1 female preponderance. The mean Lund score for patients with CRRS was 3.79. Patients with CRRS failed to demonstrate a statistically different Lund score from control patients (mean Lund score, 4.26 [P = .538]). Symptom severity scores according to Rhinosinusitis Symptom Inventory domains were largely similar for the nasal, facial, and total symptom domains between patients with CRRS versus chronic persistent rhinosinusitis. However, patients with CRRS demonstrated statistically significant increases in oropharyngeal and systemic symptom domain scores. Patients with CRRS also had significant increases in number of antibiotic courses (4.8 vs. 2.9 [P < .001]) and number of missed workdays (8.8 vs. 4.6 d [P = .046]) attributable to rhinosinusitis.

CONCLUSION

Chronic recurrent rhinosinusitis is a distinct form of chronic rhinosinusitis differing somewhat from chronic persistent rhinosinusitis. However, patients with CRRS still experience significant symptoms associated with this diagnosis, which results in significant medication usage and workplace impact.

Rhinosinusitis: establishing definitions for clinical research and patient care

Background

There is a need for more research on all forms of rhinosinusitis. Progress in this area has been hampered by a lack of consensus definitions and the limited number of published clinical trials.

Objectives

To develop consensus definitions for rhinosinusitis and outline strategies useful in clinical trials.

Methods

Five national societies, The American Academy of Allergy, Asthma and Immunology; The American Academy of Otolaryngic Allergy; The American Academy of Otolaryngology Head and Neck Surgery; The American College of Allergy, Asthma and Immunology; and the American Rhinologic Society formed an expert panel from multiple disciplines. Over two days, the panel developed definitions for rhinosinusitis and outlined strategies for design of clinical trials.

Results

Committee members agreed to adopt the term “rhinosinusitis” and reached consensus on definitions and strategies for clinical research on acute presumed bacterial rhinosinusitis, chronic rhinosinusitis without polyposis, chronic rhinosinusitis with polyposis, and classic allergic fungal rhinosinusitis. Symptom and objective criteria, measures for monitoring research progress, and use of symptom scoring tools, quality-of-life instruments, radiologic studies, and rhinoscopic assessment were outlined for each condition.

Conclusion

The recommendations from this conference should improve accuracy of clinical diagnosis and serve as a starting point for design of rhinosinusitis clinical trials.

Rhinosinusitis: Establishing definitions for clinical research and patient care

Background

There is a need for more research on all forms of rhinosinusitis. Progress in this area has been hampered by a lack of consensus definitions and the limited number of published clinical trials.

Objectives

To develop consensus definitions for rhinosinusitis and outline strategies useful in clinical trials.

Study design

Five national societies, The American Academy of Allergy, Asthma and Immunology; The American Academy of Otolaryngic Allergy; The American Academy of Otolaryngology Head and Neck Surgery; The American College of Allergy, Asthma and Immunology; and the American Rhinologic Society formed an expert panel from multiple disciplines. Over two days, the panel developed definitions for rhinosinusitis and outlined strategies for design of clinical trials.

Results

Committee members agreed to adopt the term “rhinosinusitis” and reached consensus on definitions and strategies for clinical research on acute presumed bacterial rhinosinusitis, chronic rhinosinusitis without polyposis, chronic rhinosinusitis with polyposis, and classic allergic fungal rhinosinusitis. Symptom and objective criteria, measures for monitoring research progress, and use of symptom scoring tools, quality-of-life instruments, radiologic studies, and rhinoscopic assessment were outlined for each condition.

Conclusions

The recommendations from this conference should improve accuracy of clinical diagnosis and serve as a starting point for design of rhinosinusitis clinical trials.

Pediatric chronic rhinosinusitis

PURPOSE OF REVIEW

Pediatric sinusitis is prevalent, and the debate continues regarding how best to care for these children. Although acute sinusitis is commonly associated with an upper respiratory infection, the focus of this paper is on chronic rhinosinusitis in children. Research is often more difficult in children than adults, so many times one can learn from the adult literature and determine whether there can be application to the childhood population.

RECENT FINDINGS

This paper looks at both medical and surgical treatment of chronic rhinosinusitis. "Maximal medical management" is often cited in the literature, but what this should consist of has never been clearly proved in the literature. Alternative medicine approaches as well as irrigation as an adjunct to care are discussed. Biomaterials are also be discussed. Recent outcome data are put in perspective.

SUMMARY

Hopefully the reader will find the presentation stimulating. The paper does not promote surgery as a "cure all," and in the end, analysis will hopefully leave the reader more cautious but with a better understanding of this complex disease.