Functional endoscopic sinus surgery for chronic rhinosinusitis

Comparison of intranasal medication delivery devices before and after functional endoscopic sinus surgery using Phacon sinus surgery models

OBJECTIVE

Functional endoscopic sinus surgery for chronic rhinosinusitis improves sinus drainage and intranasal medication delivery. This study compares medication delivery with commonly used devices in normal and altered anatomy (post functional endoscopic sinus surgery) using sinus surgery models (Phacon).

METHODS

Medication delivery was simulated via nasal drops, nasal spray and an irrigation device (Neilmed Sinus Rinse). Coverage was then calculated from endoscopic pictures taken at various anatomical sites in the normal nose and post functional endoscopic sinus surgery.

RESULTS

In the normal nose, nasal spray did not penetrate the sphenoid sinus, and drops bypassed the vestibule anteriorly. Neilmed Sinus Rinse provided superior coverage at the sphenoid site following sphenoidectomy and the frontal site following Draf III. After ethmoidectomy, nasal drops overall provided less coverage than the other methods.

CONCLUSION

Neilmed Sinus Rinse generally provided the best distribution, followed by the nasal spray and then nasal drops. The type and extent of surgery also affects medication delivery.

Outcomes of Functional Endoscopic Sinus Surgery in Chronic Rhinosinusitis: A Systematic Review and Meta-Analysis

Chronic rhinosinusitis (CRS) is a prevalent health problem that affects many people around the world and can require surgical intervention if conservative therapy fails. Functional endoscopic sinus surgery (FESS) is a minimally invasive surgical procedure commonly used to manage CRS. The success of FESS depends on various factors, and larger studies are necessary to determine its efficacy in managing CRS in this population. This systematic review and meta-analysis of the available literature aims to provide a comprehensive assessment of the effectiveness of FESS in the Middle East. We followed the standards outlined by PRISMA and the Cochrane Handbook for systematic reviews. The primary outcome of interest was the quality of life (QOL), and the secondary outcome was the recurrence of CRS. This systematic review and meta-analysis was conducted, and sensitivity analysis was performed to examine the robustness of the results. Six studies were included. The review found that the QOL significantly improved (p < 0.001). Two studies reported recurrence of CRS after FESS, and data showed that the recurrence of CRS after surgery was 6%. FESS is an effective intervention for CRS, but further research is needed on recurrence rates.

Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews and meta-analyses

OBJECTIVES

This study aims to examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons and whether surgery or the drug intervention was favoured.

DESIGN

Systematic review of systematic reviews (umbrella review).

DATA SOURCES

Cochrane Database of Systematic Reviews.

ELIGIBILITY CRITERIA

Systematic reviews attempt to compare surgical to drug interventions.

DATA EXTRACTION

We extracted whether the review found any randomised controlled trials (RCTs) for eligible comparisons. Individual trial results were extracted directly from the systematic review.

SYNTHESIS

The outcomes of each meta-analysis were resynthesised into random-effects meta-analyses. Egger's test and excess significance were assessed.

RESULTS

Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% CIs, the surgical intervention was favoured in 38/103 (37%), and the drugs were favoured in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority in our reanalysis (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favour of surgery and 2 (9%) were in favour of drugs. There was no evidence of excess significance.

CONCLUSIONS

Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomised evidence is rare. More randomised trials comparing surgery to drug interventions are needed.

Surgery for nasal polyposis in cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is a life-shortening, autosomal recessive disease that leads to abnormal electrolyte concentration in exocrine secretions. Secretion stasis in paranasal sinuses determines chronic rhinosinusitis (CRS) and nasal polyposis. Endoscopic sinus surgery is used to open the sinuses and allow medical treatment to work properly.

OBJECTIVES

To determine the effects of sinus surgery alone or in combination with medical treatment (non-surgical) compared to medical treatment (non-surgical) alone on both nasal and pulmonary function in people with CF diagnosed with CRS with nasal polyposis. Further, to evaluate the impact of sinus surgery (with or without medical treatment) on hospitalization rates, use of antibiotics and pulmonary exacerbation rates.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and hand searching of journals and conference abstract books. Date of last search: 4 July 2022. We also searched other databases (Pubmed, Embase, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Virtual Health Library and ClinicalTrials.gov). Date of last search: 18 September 2022.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing groups who underwent endoscopic sinus surgery and groups with medical treatment alone.

DATA COLLECTION AND ANALYSIS

The review authors independently selected studies, extracted data, assessed the risk of bias and evaluated the certainty of the evidence using GRADE. They contacted the authors of the included study for additional information.

MAIN RESULTS

We identified 66 publications relating to 50 studies from electronic searches. Only one study fulfilled the inclusion criteria, and only limited information was available. In this study, 28 participants aged 19 to 28 years were randomized in equal numbers to either nasal irrigation alone or nasal irrigation with surgery (endoscopic polypectomy with extended sinusotomy). The certainty of the evidence was very low according to the GRADE approach. We are uncertain whether, compared to medical treatment alone, the addition of surgical intervention improves nasal symptoms, or reduces bacterial colonization, the use of antibiotics and pulmonary exacerbations. We are also uncertain whether the addition of surgery to medical treatment leads to changes in pulmonary function. There was one episode of bleeding during surgery that was corrected during the procedure with no further consequences. The study did not report on survival.

AUTHORS' CONCLUSIONS

Very low-certainty evidence means we are not certain if endoscopic sinus surgery to treat chronic rhinosinusitis with nasal polyposis in cystic fibrosis is effective. Future research should be multicentric to increase the number of participants and increase statistical power. Adequate randomization and allocation concealment are important to guarantee that the groups are similar. Blinding, however, may not be possible in an ethical trial; even without blinding, results can achieve high-level evidence if the outcomes used are objective parameters. Future research should follow participants of all ages for at least 12 months to evaluate the evolution of nasal polyposis, its recurrence and how symptoms may return. We also consider mortality an important outcome to be assessed. Future clinical research should consider the effects of cystic fibrosis transmembrane conductance regulators, a new group of drugs that may affect the development of nasal polyps.

Advancements in acoustic drug delivery for paranasal sinuses: A comprehensive review

Chronic rhinosinusitis (CRS) impacts patients' quality of life and healthcare costs. Traditional methods of drug delivery, such as nasal sprays and irrigation, have limited effectiveness. Acoustic Drug Delivery (ADD) using a nebulizer offers targeted delivery of drug to the sinuses, which may improve the treatment of CRS. This review examines the influence of aerosol particle characteristics, aero-acoustic parameters, inlet flow conditions, and acoustic waves on sinus drug delivery. Key findings reveal that smaller particles improve the ADD efficiency, whereas larger sizes or increased density impair it. The oscillation amplitude of the air plug in the ostium is crucial for the ADD efficiency. Introducing acoustic waves at the NC-sinus system's resonance frequency improves aerosol deposition within sinuses. Future research should address advanced models, optimizing particle characteristics, investigating novel acoustic waveforms, incorporating patient-specific anatomy, and evaluating long-term safety and efficacy. Tackling these challenges, ADD could offer more effective and targeted treatments for sinus-related conditions such as CRS.

Risk Factors for Recalcitrant Chronic Rhinosinusitis in Non-Solid and Solid Transplant Recipients

OBJECTIVES

Transplant patients are high risk for surgery due to their immunocompromised state. There is a paucity of evidence concerning the differences in incidence of chronic rhinosinusitis (CRS) in solid versus non-solid organ transplant. Our aim is to analyze the difference in incidence of CRS requiring endoscopic sinus surgery (ESS) between non-solid and solid transplant populations and determine if certain risk factors are associated with increased incidence of recalcitrant CRS in non-solid versus solid transplants.

STUDY DESIGN

Retrospective cohort.

SETTING

Multisite tertiary academic center.

METHODS

This is a retrospective chart review of 1303 transplant recipients who were seen in our rhinologic clinic for CRS between 2017 and 2022. A total of 224 patients underwent ESS and were further analyzed for risk factors associated with recalcitrant disease requiring sinus surgery. Subgroup analysis based on solid and non-solid organ transplant was performed.

RESULTS

Of the 224 patients in the study, 171/224 (76.3%) had solid transplants while 53/224 (23.6%) had non-solid transplants. 17.19% of all transplant recipients required ESS. The incidence of ESS in non-solid transplants was 28.2% versus 57% in solid transplant. The risk of recalcitrant CRS in solid transplant recipients was almost 1.78 times greater than those with non-solid organ transplant (95% CI, 1.27-2.54, p  =  0.0005). Individual factors such as certain immunotherapy drugs, pancytopenia, and rejection appear to correlate with the risk of ESS in both non-solid and solid organ transplant.

CONCLUSION

Risk of ESS was greater in the solid transplant recipients compared to those who received non-solid organ transplant.

Availability of evidence and comparative effectiveness for surgical versus drug interventions: an overview of systematic reviews

Objectives

To examine the prevalence of comparisons of surgery to drug regimens, the strength of evidence of such comparisons, and whether surgery or the drug intervention was favored.

Design

Systematic review of systematic reviews (umbrella review).

Data sources

Cochrane Database of Systematic Reviews (CDSR).

Eligibility criteria and synthesis of results

Using the search term "surg*" in CDSR, we retrieved systematic reviews of surgical interventions. Abstracts were subsequently screened to find systematic reviews that aimed to compare surgical to drug interventions; and then, among them, those that included any randomized controlled trials (RCTs) for such comparisons. Trial results data were extracted manually and synthesized into random-effects meta-analyses.

Results

Overall, 188 systematic reviews intended to compare surgery versus drugs. Only 41 included data from at least one RCT (total, 165 RCTs with data) and covered a total of 103 different outcomes of various comparisons of surgery versus drugs. A GRADE assessment was performed by the Cochrane reviewers for 87 (83%) outcomes in the reviews, indicating the strength of evidence was high in 4 outcomes (4%), moderate in 22 (21%), low in 27 (26%) and very low in 33 (32%). Based on 95% confidence intervals, the surgical intervention was favored in 38/103 (37%), and the drugs were favored in 13/103 (13%) outcomes. Of the outcomes with high GRADE rating, only one showed conclusive superiority (sphincterotomy was better than medical therapy for anal fissure). Of the 22 outcomes with moderate GRADE rating, 6 (27%) were inconclusive, 14 (64%) were in favor of surgery, and 2 (9%) were in favor of drugs.

Conclusions

Though the relative merits of surgical versus drug interventions are important to know for many diseases, high strength randomized evidence is rare. More randomized trials comparing surgery to drug interventions are needed.

Protocol registration

https://osf.io/p9x3j.

Surgery for nasal polyposis in cystic fibrosis

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To determine the effects of sinus surgery alone or in combination with medical treatment (non‐surgical) compared to medical treatment (non‐surgical) alone on both nasal and pulmonary function in people with cystic fibrosis diagnosed with CRS with nasal polyposis. Further, to evaluate the impact of sinus surgery (with or without medical treatment) on hospitalization rates, use of antibiotics and pulmonary exacerbation rates.

Clearance of Bone Substitute in Gel Form Accidentally Dispersed into the Sinus Cavity during Transcrestal Maxillary Sinus Floor Elevation: Two-Case Report

Sinus membrane perforation is the most frequent intraoperative complication occurring during maxillary sinus floor elevation. Although numerous techniques for perforation management are present, grafting material dissemination may still occur, representing a potential trigger factor leading to acute or chronic sinusitis. This case report describes two cases of xenogeneic bone substitute in gel form accidentally dispersed into the sinus cavity during maxillary sinus floor elevation with a transcrestal approach. In both cases, immediately postoperative radiographic imaging showed an important amount of gel graft dislodged into the sinus cavity as a consequence of hidden perforations that remained undetected during surgery. Patients were monitored for 6 months after surgery and reported no signs or symptoms related to possible sinus disease. Control radiographs showed no sinus membrane hypertrophy and/or presence of residual disseminated gel, confirming complete clearance of the accidentally dispersed graft through the ostiomeatal complex. In order to minimize postoperative complications, bone substitutes in gel form could represent an interesting alternative to granular grafts for their easier clearance from the maxillary sinus cavity in case of accidental dissemination during sinus augmentation procedures.

Influence of the Microbiome on Chronic Rhinosinusitis With and Without Polyps: An Evolving Discussion

Chronic rhinosinusitis (CRS) is widely prevalent within the population and often leads to decreased quality of life, among other related health complications. CRS has classically been stratified by the presence of nasal polyps (CRSwNP) or the absence nasal polyps (CRSsNP). Management of these conditions remains a challenge as investigators continue to uncover potential etiologies and therapeutic targets. Recently, attention has been given to the sinunasal microbiota as both an inciting and protective influence of CRS development. The healthy sinunasal microbiologic environment is largely composed of bacteria, with the most frequent strains including Staphylococcus aureus, Streptococcus epidermidis, and Corynebacterium genera. Disruptions in this milieu, particularly increases in S. aureus concentration, have been hypothesized to perpetuate both Th1 and Th2 inflammatory changes within the nasal mucosa, leading to CRS exacerbation and potential polyp formation. Other contributors to the sinunasal microbiota include fungi, viruses, and bacteriophages which may directly contribute to underlying inflammation or impact bacterial prevalence. Modifiable risk factors, such as smoking, have also been linked to microbiota alterations. Research interest in CRS continues to expand, and thus the goal of this review is to provide clinicians and investigators alike with a current discussion on the microbiologic influence on CRS development, particularly with respect to the expression of various phenotypes. Although this subject is rapidly evolving, a greater understanding of these potential factors may lead to novel research and targeted therapies for this often difficult to treat condition.

Older Age Is Associated With Better Compliance With Follow-up in Taiwan After Functional Endoscopic Sinus Surgery

BACKGROUND/AIM

Functional endoscopic sinus surgery (FESS) is frequently conducted for restoring sinus ventilation and function. Postoperative care is critical for success. However, loss to follow-up is disturbing. The specific aim of this study was to identify critical factors contributing to loss of patients to follow-up and how to improve it.

PATIENTS AND METHODS

A total of 221 patients with chronic rhinosinusitis undergoing FESS were enrolled. Patients were divided into three groups according to their follow-up after surgery: Less than 1 month (short-term), 1-3 months (medium-term) and more than 3 months (long-term). The gender, age, smoking status, comorbidities, laterality, Lund-Mackay score, 22-question Sinonasal Outcome Test, nasal obstruction Visual Analogue Scale and mucociliary clearance were evaluated for their contribution to better compliance in follow-up.

RESULTS

The results revealed that older patients had better compliance in follow-up compared with younger ones (p=0.0093). Other factors were not contributory (p>0.05).

CONCLUSION

In contrast to the US, older patients in Taiwan have better compliance in postoperative follow-up, while younger ones require more education on the importance of follow-up.

Patient perspectives on endoscopic sinus surgery for chronic rhinosinusitis

Background

Through shared decision-making, physicians and patients can elect endoscopic sinus surgery (ESS) when maximal medical therapy fails in patients with chronic rhinosinusitis (CRS). In this study, we aim to explore the most important themes with regards to patients’ perspectives on ESS. Our objective was to define the patient experience and ensure that we have congruent physician and patient goals for obtaining success.

Methods

Semi-structured face-to-face interviews were conducted with 22 patients at a tertiary-care institution in Montreal. Three themes were established a priori: living with CRS, objectives and expectations and criteria for success. This thematic approach allowed the identification, analysis and reporting of patterns found across the data set. A phenomenological methodological orientation was used. Interviews were audio-recorded and transcribed verbatim for continuous analysis. These were coded by hand by a single coder who read the transcripts multiple times and relistened to the recordings.

Results

Exploration of themes on patients’ perspectives on ESS for CRS yielded multiple anecdotal findings, and some recurring patterns. There is a tendency for patients to focus on one principal symptom that drives their decrease in QoL. Headaches and nasal congestion seemed to impact patients’ QoL the most amongst rhinologic symptoms. Hyposmia was rarely spontaneously by patients but was often a significant source of distress when prompted during interviews. Objectives and expectations seemed to be inversely proportional to number of previous surgeries and severity of symptoms preoperatively. There was a clear association between preoperative expectations and postoperative satisfaction. There was no clear pattern in the improvement magnitude or time improved postoperatively for patients to consider the surgery a success.

Conclusions

Patients’ level of satisfaction postoperatively and with their care in general is multifactorial. We believe the topic of goals and expectations regarding ESS should be discussed preoperatively for every patient with CRS. This includes patients with seemingly minor disease and patients naive to surgery, as can sometimes have exceedingly high expectations. Preoperative counselling must also include an assessment of what symptom is the most cumbersome to that particular patient, as patients tend to focus a lot on one or two symptoms. Postoperatively, we encourage clinicians to be attentive to the change in each patient’s principal complaints within the context of a personalized approach and to refer back to patients’ preoperative goals in their assessment of operative success.

Graphical abstract

Evaluation of selected parameters of the coagulation system during the perioperative period in patients undergoing endoscopic surgery of the paranasal sinuses

INTRODUCTION

The aim of the study was to evaluate selected parameters of the coagulation system during the perioperative period in patients undergoing endoscopic sinus surgery.

MATERIAL AND METHODS

The study involved 121 patients: group I - 42 patients who did not receive anticoagulatory or antiplatelet medications, qualified for endoscopic sinus surgery under total intravenous anaesthesia (TIVA); group II - 40 patients who received in the perioperative period low-molecular-weight heparins, qualified for endoscopic sinus surgery under TIVA; group III - 39 patients diagnosed according to a schedule, due to vertigo or loss of hearing. All the patients received a full laryngological examination and detailed audiological and otoneurological diagnostics, and examination of selected haemostatic parameters before the surgery/diagnostics.

RESULTS

The analysis of concentrations of coagulation parameters in groups I and II revealed a statistically significantly higher international normalized ratio value before surgery (I - 1.11; II - 1.08) and 48 h following surgery (I - 1.15; II - 1.10) in group I. The concentration of coagulation factor VII in the study patients was considerably higher in group I for all three measurements (481.93; 443.13; 486.02). The concentration of fibrinogen (coagulation factor I) was significantly lower in group I before surgery (3.2) and at 6 h after surgery (2.84). A significantly lower level of von Willebrand factor was found in group I before surgery (2.94). Comparing test results of groups I and III, who did not receive antiaggregants, statistically significant differences were observed in both tests for factors VII and VIII.

CONCLUSIONS

Concentrations of von Willebrand factor and prothrombin revealed statistically significant differences in between groups.

Maxillary Antrostomy Patency Following Intraoperative Use of Spray Cryotherapy

Objectives/Hypothesis: Stenosis of the middle meatus antrostomy (MMA) represents a major cause of recurrent disease following endoscopic sinus surgery (ESS). Various strategies have been developed to prevent the occurrence of MMA stenosis. The aim of the present study was to evaluate the effects of spray cryotherapy (SC) on nasal wound healing following ESS. Methods: This is a prospective within-subject, randomized, and controlled trial. Twenty-six patients submitted to bilateral ESS with chronic rhinosinusitis without polyps were included. Following surgery, patients were randomized to receive SC on one side and saline contralaterally. Outcomes were represented by MMA diameter and area, histology of nasal mucosa, and nasal symptoms. Variables were assessed at 3 and 12 months postoperatively. Results: The MMA size in the SC group at 3 and 12 months (area-0.578 ± 0.1025 cm², diameter-0.645 ± 0.1024 cm; 0.605 ± 0.1891 cm², 0.624 ± 0.0961 cm, respectively) was significantly larger (p = 0.000) than in the control group. Histology established that cell infiltration, goblet cells, edema, and epithelial hyperplasia were prominent and persistent in the control side compared to the SC side. Nasal obstruction and discharge were significantly improved in the SC group compared to the control group. Conclusion: SC is a promising therapy following ESS, since it precludes MMA stenosis and decreases inflammation, edema, and goblet cell hyperplasia.

The Effects of Postoperative Astaxanthin Administration on Nasal Mucosa Wound Healing

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BACKGROUND

Wound healing of the nasal mucosa after endoscopic sinus surgery (ESS) is frequently complicated by scaring and consequently recurrences are encountered. Methods of optimizing results have been sought. In the present study we evaluated the effects of a powerful antioxidant, astaxanthin, on nasal mucosa healing after surgery, comparing it to the extensively studied properties of dexamethasone.

MATERIALS AND METHODS

63 Wistar rats were used. The nasal mucosa from one side was damaged employing the brushing method. They were randomly divided into three experimental groups, one treated with astaxanthin, the second treated with dexamethasone and the third one acted as the control and was given normal saline. The rats were killed on days 5, 14 and 28 following injury. We observed the temporal evolution of the wound healing process and quantified the results by assessing four parameters: the epithelial thickness index (ETI), the subepithelial thickness index (STI), the goblet cell count and the subepithelial fibrosis index (SFI).

RESULTS

At 28 days, the ETI was significantly lower in the astaxanthin group (p < 0.05) compared to the other two groups. The STI was also lower in the astaxanthin group (p < 0.05), but comparable to the dexamethasone group at 28 days. The goblet cell count was higher in the astaxanthin group. The SFI had similar results in both dexamethasone and astaxanthin groups, with lower values compared to the control group. In the astaxanthin group there was no synechia formation.

CONCLUSION

Astaxanthin given in the post injury period significantly decreases fibrosis, inhibits synechia development and significantly decreases subepithelial fibrosis. Moreover, it has no general or local toxic effects.

A structured histopathology-based analysis of surgical outcomes in chronic rhinosinusitis with and without nasal polyps

Objectives

Structured histopathology reporting has been recently described for detailing immunopathological characteristics of chronic rhinosinusitis (CRS), and can be utilized for subtyping CRS and personalizing management. This study scrutinized elements of structured histopathology to identify characteristics that prognosticate outcomes following endoscopic sinus surgery (ESS) for CRS patients with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP).

Methods

Outcomes following ESS were measured using the patient‐reported 22‐item sinonasal outcome test (SNOT‐22). Changes in total SNOT‐22 scores at 6 and 12 months postoperatively were analyzed. Thirteen parameters reported in structured histopathology of sinus surgical tissue were studied for association with outcomes postsurgery. The overall cohort of all CRS patients was studied, along with subgroup analyses of CRSwNP and CRSsNP patients.

Results

In the entire CRS cohort (n = 171), eosinophil count >10 per high power field (HPF) was associated with greater improvement in SNOT‐22 scores at 6 months post‐ESS (P = .039). At 12 months follow‐up, no histopathological characteristic was associated with change in total SNOT‐22 score. In the CRSwNP (n = 66) subgroup, the presence of fibrosis (P = .006) and eosinophil count ≤10 per HPF (P = .025) were associated with less favorable changes in SNOT‐22 scores at 12 months follow‐up. Fibrosis remained statistically significant in multivariable analysis (P = .007).

Conclusions

At 6 months post‐ESS, tissue eosinophilia is associated with significantly higher improvement in SNOT‐22 scores, but this difference is diluted by 12 months. Fibrosis was associated with less favorable outcomes in SNOT‐22 scores for CRSwNP patients at 12 months and may be a prognosticator for poorer long‐term outcomes.

Level of Evidence

4

Health Care Disparities in Patients Undergoing Endoscopic Sinus Surgery for Chronic Rhinosinusitis: Differences in Disease Presentation and Access to Care

OBJECTIVES

Data on health care disparities by socioeconomic status for chronic rhinosinusitis (CRS) are lacking, and the available literature shows mixed results. The aim of this study was to evaluate several indicators of disease complexity in patients with CRS undergoing endoscopic sinus surgery between a private and a public hospital to determine if there are any disparities in the severity of disease presentation or in access to care.

METHODS

Two hundred patients with CRS who underwent endoscopic sinus surgery from 2015 to 2017 were retrospectively reviewed. Demographics, disease-specific data, and pre- and postoperative management were collected.

RESULTS

Public hospital patients (n = 100) were significantly more likely to be non-Caucasian (73.0% vs 25.0%, P < .0001) and to have Medicaid or no insurance (86.0% vs 4.0%, P < .0001). Patients from the public hospital were more likely to have CRS with nasal polyposis (85.0% vs 60.0%, P < .0001) and to have longer wait times for surgery (68 vs 45 days, P < .0001) and were more likely to be lost to follow-up (26.0% vs 16.0%, P = .031). Patients at the public hospital had CRS symptoms 21% longer ( P = .0206), and if a patient carried a diagnosis of asthma, he or she had on average more severe asthma ( P = .0021).

CONCLUSIONS

This study suggests that patients of lower socioeconomic status had a longer duration of disease prior to surgery, more often had nasal polyposis, and had decreased access to care, as indicated by increased surgical wait times and being lost to follow-up. Acting as a foundation for further investigation, the ultimate intent of this study is to improve care for all patients.

Real-World Database Examining the Association between Sjögren's Syndrome and Chronic Rhinosinusitis

Objective: To investigate the risk of chronic rhinosinusitis (CRS) among patients with Sjögren’s syndrome (SS). Method: A total of 18,723 patients diagnosed with SS between 1997 and 2011 were retrospectively analyzed. Moreover, 59,568 patients without SS were matched to patients with SS at a 1:4 ratio on the basis of sex, age, urbanization level, income level, and the comorbidities of rhinitis and nasal sepal deviation. Patients were followed up until death or the end of the study period (31 December, 2013). The primary outcome was the occurrence of CRS. Results: The cumulative incidence of CRS was significantly higher in patients with SS than in those without SS (p < 0.001). The adjusted Cox proportional hazard model showed that patients with SS had a significantly higher incidence of CRS (hazard ratio, 2.51; 95% confidence interval, 2.22–2.84; p < 0.001). Sensitivity and subgroup analyses demonstrated SS was an independent risk factor for CRS. The dosage of intranasal corticosteroid spray used was not different between the SS and non-SS groups. Fewer patients with CRS in the SS group underwent sinus surgery (82/407 (20.2%)) than those in the non-SS group (179/667 (26.8%)) and this finding was statistically significant (p = 0.013). The number of operations did not differ significantly between patients with CRS in the SS and non-SS groups. Conclusions: SS is an independent risk factor for CRS. Our study extends the disease spectrum and prompts physicians to be aware of potential CRS occurrence after SS.

Effect of Sphenopalatine Ganglion Block With Bupivacaine on Postoperative Pain in Patients Undergoing Endoscopic Sinus Surgery

Background

Postoperative pain is one of the most complications in endoscopic sinus surgery. We aimed to evaluate the effect of the sphenopalatine ganglion block (SPGB) with bupivacaine on postoperative pain in patients undergoing endoscopic sinus surgery.Methods and Materials: In this clinical trial, 40 patients who indicated functional endoscopic sinus surgery were selected and then divided into 2 parallel groups as intervention and control. The intervention group was received 1.5 mL of bupivacaine 0.5% (injected to sphenopalatine ganglion) and while control was injected 1.5 mL of normal saline at the same injection site. Also, the visual analogue scale (VAS) was recorded immediately after anesthesia, along with 6, 12, 24, 48 h, 7 days, and 21 days after the operation for all patients.

Results

Immediately after anesthesia, as well as 6, 12, and 24 h after the operation, VAS in the intervention group was significantly lower than in the control group (P < .05, for all). However, there were no significant differences between the 2 groups regarding VAS 48 h as well as 7 and 21 days after surgery (P > .05, for both). Also, the rescue analgesia in the intervention group was significantly lower than in the control group (P = .01).

Conclusion

SPGB with bupivacaine 0.5% (1.5 mL) was a simple, effective, safe, and noninvasive method for the management of postoperative pain in the patients undergoing endoscopic sinus surgery.

Comparison of Metoprolol and Tramadol with Remifentanil in Endoscopic Sinus Surgery: A Randomised Controlled Trial

Objective

Controlled hypotension is commonly induced during functional endoscopic sinus surgery to limit mucosal bleeding. This may be detrimental to elderly patients and patients with arterial stenosis. The aim of this pilot study was to determine if a normotensive anaesthetic technique with sufficient analgesia and without profound vasodilation may reduce intraoperative bleeding and incidence of adverse haemodynamic effects associated with vasodilation and variable rate continuous infusions.

Methods

In this double-blind randomised controlled trial in a tertiary care centre, a total of 88 patients were randomised to receive intravenously either 0.1 mg kg^-1 metoprolol and 1 mg kg^-1 tramadol following anaesthesia induction (MT group) or a bolus dose of 0.5 μg kg^-1 remifentanil following anaesthesia induction, followed by 0.25-0.5 μg kg^-1 min^-1 remifentanil infusion (R group). The primary outcome was quality of surgical field and incidence of adverse haemodynamic effects. The secondary outcomes were time to achieve intraoperative bleeding score <3, bleeding rate and changes in cerebral regional oximetry.

Results

A total of 105 patients were recruited, in which 88 were randomised. The median intraoperative bleeding score was similar (1, interquartile range: 1-1, p=0.69). The mean bleeding rate was lower in the MT group, although the difference was not significant (p=0.052, 95% CI 0 to 8.8). Hypotension, bradycardia and cerebral desaturation in the MT group were not observed compared to hypotension in 3 (7%), bradycardia in 18 (41%) and cerebral desaturation in 2 (5%) patients in the R group (p=0.241, p<0.001, p=0.474, respectively).

Conclusion

Providing sufficient analgesia and eliminating stress response can provide stable heart rate and good surgical field with no need for additional hypotension. This normotensive technique may be useful in patients with stenotic arteries or ischaemic organ diseases.

Chronic Rhinosinusitis: Potential Role of Microbial Dysbiosis and Recommendations for Sampling Sites

Chronic rhinosinusitis (CRS) is an inflammatory condition that affects up to 12% of the human population in developed countries. Previous studies examining the potential role of the sinus bacterial microbiota within CRS infections have found inconsistent results, possibly because of inconsistencies in sampling strategies. The aim of this study was to determine whether the sinus microbiome is altered in CRS and additionally if the middle meatus is a suitable representative site for sampling the sinus microbiome. Swab samples were collected from 12 healthy controls and 21 CRS patients, including all eight sinuses for CRS patients and between one and five sinuses for control subjects. The left and right middle meatus and nostril swabs were also collected. Significant differences in the sinus microbiomes between CRS and control samples were revealed using high-throughput 16S rRNA gene sequencing. The genus Escherichia was over-represented in CRS sinuses, and associations between control patients and Corynebacterium and Dolosigranulum were also identified. Comparisons of the middle meatuses between groups did not reflect these differences, and the abundance of the genus Escherichia was significantly lower at this location. Additionally, intra-patient variation was lower between sinuses than between sinus and middle meatus, which together with the above results suggests that the middle meatus is not an effective representative sampling site.

Chronic Rhinosinusitis without Nasal Polyps

Chronic rhinosinusitis without nasal polyps (CRSsNP) is more prevalent than chronic rhinosinusitis with nasal polyps (CRSwNP). Certain diseases predispose to whereas others are associated with CRSsNP. Predisposing diseases include allergic and nonallergic upper and lower airway diseases, epithelial cell disorders, immunodeficiencies, autoimmune diseases, and some infectious diseases. In addition, environmental and host factors, examples of which include smoking, a higher incidence of abnormal biofilms, and innate immune defects, play a role in the pathogenesis of this disease. CRSsNP is characterized by histologic abnormalities, including basement membrane thickening (fibrosis) and goblet cell hyperplasia. Neutrophils and several chemokines, TGF-β and C-X-C motif chemokine ligand (CXCL)-8, play a role in CRSsNP remodeling. However, there are conflicting data about CRSsNP endotypes, for example, whether it is characterized by neutrophilia or eosinophilia or both. In spite of advancements and the understanding of the pathogenesis of this disease, additional study is necessary to better comprehend its underlying mechanisms, endotypes, and evidence-based treatment strategies.

Developing a core outcome set for chronic rhinosinusitis: a systematic review of outcomes utilised in the current literature

BACKGROUND

A core outcome set (COS) is an agreed standardised collection of outcomes that should be measured and reported by all trials for a specific clinical area, in this case chronic rhinosinusitis. These are not restrictive and researchers may continue to explore other outcomes alongside these that they feel are relevant to their intervention. The aim of this systematic review was to identify the need for a COS for chronic rhinosinusitis.

METHODS

A sensitive search strategy was used to identify all published Cochrane systematic reviews and randomised control trials of intervention for adult patients with chronic rhinosinusitis. Two independent authors reviewed these to obtain a list of outcomes and outcome measures reported by each clinical trial.

RESULTS

Sixty-nine randomised control trials and eight Cochrane systematic reviews were included in this study. They reported 68 individual outcomes and outcome measures, with an average of four to ten outcomes per clinical trial. These outcomes were mapped to 23 subcategories belonging to eight core categories.

CONCLUSIONS

The key finding of this review was the heterogeneity of outcomes reported and measured by clinical trials of patients with chronic rhinosinusitis, precluding meaningful meta-analysis of data. This review supports the need for development of a COS, to be used in future trials on adult patients with chronic rhinosinusitis.

Yellow nail syndrome: a review

Yellow nail syndrome (YNS; OMIM 153300, ORPHA662) is a very rare disorder that almost always occurs after 50 years of age but a juvenile or familial form has also been observed. YNS is diagnosed based on a triad associating yellow nail discoloration, pulmonary manifestations (chronic cough, bronchiectasia, pleural effusion) and lower limb lymphedema. Chronic sinusitis is frequently associated with the triad. YNS etiology remains unknown but a role of lymphatic impairment is usually evoked. YNS is more frequently isolated but may be associated in rare cases with autoimmune diseases, other clinical manifestations implicating lymphatic functions or cancer and, hence, is also considered a paraneoplastic syndrome. YNS management is symptomatic and not codified. YNS can resolve spontaneously. Oral vitamin E alone or even better when associated with triazole antifungals may achieve partial or total disappearance of nail discoloration. Pleural effusion can be treated surgically, with decortication/pleurectomy or pleurodesis. Antibiotic prophylaxis is prescribed for bronchiectasia with chronic sputum production. Lymphedema treatment is based on low-stretch bandages and the wearing of elastic compression garments combined with skin care, exercises and, as needed, manual lymph drainage.

Endoscopic sinus surgery in adult patients with chronic rhinosinusitis with nasal polyps (PolypESS): study protocol for a randomised controlled trial

BACKGROUND

Chronic rhinosinusitis with nasal polyps is a chronic disease frequently seen in otorhinolaryngological practice. Along with its chronic disease burden it creates high societal costs. Therapy consists of long-term use of medication and, if insufficient, endoscopic sinus surgery. No consensus exists on the right timing and extent of disease that warrants surgery. Furthermore, there is lack of clinical knowledge about the benefit of surgery over medication only. The current trial evaluates the clinical effectiveness and cost-effectiveness of endoscopic sinus surgery in addition to drug treatment versus medication exclusively in the adult patient group with nasal polyps.

METHODS

A prospective, multicentre, superiority, randomised controlled (PolypESS) trial in 238 patients aged 18 years or older selected for primary or revision endoscopic sinus surgery by the otorhinolaryngologist was designed. Patients will be randomised to either endoscopic sinus surgery in addition to medication or medical therapy only. Relevant data will be collected prior to randomisation, at baseline and 3, 6, 12, 18 and 24 months after start of treatment. Complete follow-up will be 24 months. Primary outcome is disease-specific Health-related Quality of Life quantified by the SNOT-22 after 12-month follow-up. Secondary outcomes are generic Health-related Quality of Life, cost-effectiveness, objective signs of disease and adverse effects of treatment. Subgroup analyses will be performed to verify whether treatment effects differ among patient phenotypes.

DISCUSSION

The PolypESS trial will investigate tailored care in adult patients with chronic rhinosinusitis with nasal polyps and will result in improved clinical pathways to help to determine in which circumstances to perform surgery.

TRIAL REGISTRATION

Dutch Trial Register, NTR4978 . Registered on 27 November 2014.

Deliberate hypotension with propofol under anaesthesia for functional endoscopic sinus surgery (FESS)

BACKGROUND

Functional endoscopic sinus surgery (FESS) is a minimally invasive technique that is used to treat chronic sinusitis. Small bleeding areas can reduce operative visibility and result in destruction of surrounding structures. Deliberate hypotension (lowering the mean arterial blood pressure to between 50 and 65 mm Hg in normotensive patients) using a range of pharmacological agents during general anaesthesia reduces blood loss in many operations. This review was originally published in 2013 and updated in February 2016.

OBJECTIVES

We aimed to compare the use of propofol versus other techniques for achieving deliberate intraoperative hypotension during FESS procedures with regard to blood loss and operative conditions.

SEARCH METHODS

We searched the following databases in the updated review: the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE (1950 to February 2016), Embase (1980 to February 2016), LILACS (1982 to February 2016), and ISI Web of Science (1946 to February 2016). We also searched the reference lists of relevant articles and conference proceedings and contacted the authors of included trials.

SELECTION CRITERIA

We sought all randomized controlled trials comparing propofol with other techniques for deliberate hypotension during FESS with regard to blood loss and operative conditions in both adults and children. Our primary outcome was total blood loss (TBL). Other outcomes included surgical field quality, operation time, mortality within 24 hours, complications, and failure to reach target blood pressure.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently extracted details of trial methodology and outcome data from the reports of all trials considered eligible for inclusion. We made all analyses on an intention-to-treat basis where possible. When I2 was less than 40% and the P value from the Chi2 test was higher than 0.10, we pooled data using the fixed-effect model. Otherwise, we pooled data using the random-effects model.

MAIN RESULTS

We found no new studies. This updated review therefore includes four studies with 278 participants. Most analyses were based on data from few participants and low-quality evidence, so our results should be interpreted with caution. Deliberate hypotension with propofol did not decrease TBL (millilitres) when compared with inhalation anaesthetics in either children (1 study; 70 participants; very low-quality evidence), or adults (1 study; 88 participants; moderate-quality evidence). Propofol improved the quality of the surgical field by less than one category on a scale from 0 (no bleeding) to 5 (severe bleeding) (mean difference -0.64, 95% CI -0.91 to -0.37; 4 studies; 277 participants; low-quality evidence), but no difference in operation time was reported (3 studies; 214 participants; low-quality evidence). Failure to lower blood pressure to target was less common in the propofol group (risk ratio of failure with propofol 0.24, 95% CI 0.09 to 0.66; 1 study; 88 participants; moderate-quality evidence).

AUTHORS' CONCLUSIONS

Using propofol to achieve deliberate hypotension probably improves the surgical field, but the effect is small. Deliberate hypotension with propofol did not decrease TBL and the operation time. However, due to the very low quality of the evidence, this conclusion is not definitive. Randomized controlled trials with good-quality methodology and large sample size are required to investigate the effectiveness of deliberate hypotension with propofol for FESS.

Olfactory Outcomes after Endoscopic Sinus Surgery for Chronic Rhinosinusitis

Objective

To use combined pre- and postsurgical olfactory outcomes to assess the impact of endoscopic sinus surgery on chronic rhinosinusitis−related olfactory impairment.

Data Sources

CINAHL, Cochrane, OVID, EMBASE, PubMed, and SCOPUS. Each database was searched from inception up to October 2015.

Review Methods

Studies were included that reported subjective or objective olfactory data in chronic rhinosinusitis patients before and after endoscopic sinus surgery.

Results

Thirty-one studies were used in the meta-analysis. Weighted mean differences of olfactory measures demonstrated significant improvement in mixed CRS patients (those with and without polyps) through visual analog scales (−0.83, P = .001), altered taste/smell item on Sinonasal Outcome Test (−1.32, P < .00001), 40-item Smell Identification Test (3.49, P = .0010), and Sniffin’ Sticks identification (0.34, P = .03). Chronic rhinosinusitis mixed patients demonstrated nonsignificant improvements via Sniffin’ Sticks threshold (1.60, P = .16) and Brief Smell Identification Test (0.20, P = .32). When separated, polyp patients and dysosmic patients experienced the highest levels of olfactory improvement. Polyp patients improved by 7.87 ( P = .006) on the 40-item Smell Identification test, 11.54 ( P < .0001) with the Sniffin’ Sticks total score, and 2.57 ( P < .00001) through Sniffin’ Sticks identification. Dysosmic patients improved by 5.75 via the 40-item Smell Identification Test ( P = .0001).

Conclusion

Endoscopic sinus surgery improves nearly all subjective and objective measures of olfaction in chronic rhinosinusitis patients. Patients with nasal polyposis or preoperative olfactory dysfunction improve to a greater degree.

Review article: outcomes in endoscopic sinus surgery

Chronic rhinosinusitis has a significant impact on health-related and generic quality-of-life, has a high cost burden to both society and patients, and may be associated with absenteeism, loss of productivity and poor respiratory function. Though there is a paucity of level 1 evidence, endoscopic sinus surgery may be considered in medically refractory patients and a variety of objective and subjective outcome measures exist to assess the effectiveness of intervention. We outline the outcome measurements available and review in-depth the published outcomes to date. Furthermore we discuss the literature that indicates that endoscopic sinus surgery can have a positive effect on respiratory function in asthma. How patient selection, timing and extent of surgery, and post-operative care interventions may optimise surgical outcomes is explored.

Diagnosis and Management of Rhinosinusitis: Highlights from the 2015 Practice Parameter

Rhinosinusitis is a commonly diagnosed disease in the USA. Rhinosinusitis is classified as acute, recurrent, or chronic (with or without nasal polyps). While acute rhinosinusitis is diagnosed by history and physical examination, chronic rhinosinusitis and recurrent acute rhinosinusitis are diagnosed based on symptoms and the presence of disease on either a sinus CT scan and/or endoscopy. Management of uncomplicated acute rhinosinusitis includes analgesics, saline irrigation, and/or intranasal steroids. Antibiotics and intranasal steroids are recommended for acute bacterial rhinosinusitis. Intranasal and oral steroids with antibiotics are recommended to treat chronic rhinosinusitis although the evidence for antibiotics is weak. Biologics such as omalizumab and mepolizumab are being investigated for the treatment of chronic rhinosinusitis with nasal polyps. Surgery may be indicated in management of refractory chronic rhinosinusitis and rarely for acute bacterial rhinosinusitis. This review discusses highlights of the updated 2014 practice parameter and up-to-date evidence from other literature sources.

Factors affecting revision rate of chronic rhinosinusitis

Objective

Chronic rhinosinusitis (CRS) is a variable multifactorial disease. It can be divided into forms with nasal polyps (CRSwNP) and without (CRSsNP). Sinus and/or nasal polypectomy surgery are considered if maximal conservative treatment is insufficient. The predictive factors of the need of revision surgery comprise mostly the CRSwNP phenotype and are not fully understood.

Study Design

The aim of this follow‐up study was to evaluate the factors associated with the revision surgery rate in CRS patients with variable extent of disease.

Methods

Data of CRS patients (N = 178) undergoing sinus surgery and/or nasal polypectomy in 2001 to 2010 were used. Patient characteristics and follow‐up data were collected from patient records and questionnaires. Associations were analyzed by Fisher's exact, Mann Whitney U, and the Kaplan‐Meier method with log‐rank test. Unadjusted Cox's proportional hazard models were used for 12 variables and were fitted for the need for revision sinus surgery and/or nasal polypectomy during follow‐up of in average 9 years.

Results

The proportion of CRS patients who had undergone revision in 5 years was 9.6%. After adjustment, the following factors associated significantly with the need for recurrent CRS surgery: allergic rhinitis, corticosteroid treatment, previous surgery of CRS, and recurrent NP.

Conclusion

Increased risk of progressive CRS phenotypes with the need for revision surgery would putatively be recognized by relatively simple clinical questions. Further studies with increased sample size are needed to evaluate whether these predictive factors would be relevant for developing better detection and management of progressive CRS.

Level of Evidence

2b.

WITHDRAWN: Systemic antibiotics for chronic rhinosinusitis without nasal polyps in adults

Review withdrawn from Issue 4, 2016. Review replaced by 'Systemic and topical antibiotics for chronic rhinosinusitis' (Head 2016).

The editorial group responsible for this previously published document have withdrawn it from publication.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

The burden of revision sinonasal surgery in the UK-data from the Chronic Rhinosinusitis Epidemiology Study (CRES): a cross-sectional study

OBJECTIVES

The aim of this study was to investigate the surgical revision rate in patients with chronic rhinosinusitis (CRS) in the UK CRS Epidemiology Study (CRES). Previous evidence from National Sinonasal Audit showed that 1459 patients with CRS demonstrated a surgical revision rate 19.1% at 5 years, with highest rates seen in those with polyps (20.6%).

SETTING

Thirty secondary care centres around the UK.

PARTICIPANTS

A total of 221 controls and 1249 patients with CRS were recruited to the study including those with polyps (CRSwNPs), without polyps (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS).

INTERVENTIONS

Self-administered questionnaire.

PRIMARY OUTCOME MEASURE

The need for previous sinonasal surgery.

RESULTS

A total of 651 patients with CRSwNPs, 553 with CRSsNPs and 45 with AFRS were included. A total of 396 (57%) patients with CRSwNPs/AFRS reported having undergone previous endoscopic nasal polypectomy (ENP), of which 182 of the 396 (46%) reported having received more than one operation. The mean number of previous surgeries per patient in the revision group was 3.3 (range 2-30) and a mean duration of time of 10 years since the last procedure. The average length of time since their first operation up to inclusion in the study was 15.5 years (range 0-74). Only 27.9% of all patients reporting a prior ENP had received concurrent endoscopic sinus surgery (ESS; n=102). For comparison, surgical rates in patients with CRSsNPs were significantly lower; 13% of cases specifically reported ESS, and of those only 30% reported multiple procedures (χ(2) p<0.001).

CONCLUSIONS

This study demonstrated that there is a high burden of both primary and revision surgery in patients with CRS, worst in those with AFRS and least in those with CRSsNPs. The burden of revision surgery appears unchanged in the decade since the Sinonasal Audit.

Image-guided sphenoidotomy in revision functional endoscopic sinus surgery

The application of image-guided systems to sinus surgery is gaining in popularity. This study tried to evaluate the efficacy of image-guided surgery (IGS) in the fenestration of the sphenoid sinus in patients with chronic rhinosinusitis (CRS) who received revision functional endoscopic sinus surgery (FESS). A total of 51 CRS patients who received revision FESS incorporating IGS between January 2010 and August 2011 by two surgeons were enrolled in this study. A group of 30 CRS patients who underwent revision FESS by the senior surgeon without incorporating IGS was chosen for comparison. The penetration rates for the sphenoid sinus were 91.2% when performed by the senior surgeon with IGS and 91.3% when done by the other surgeon with IGS. The penetration rate for the sphenoid sinus was 68.6% for revision FESS without IGS. The fenestration rate for the sphenoid sinus in revision FESS without IGS was significantly lower than that in revision FESS with IGS (p = .004). Our results showed that IGS was a beneficial procedure for opening the sphenoid sinus in the revision cases.

Prospective, randomised, controlled trial comparing delivery of patient information for functional endoscopic sinus surgery via website versus printed leaflet

OBJECTIVE

To compare the efficacy of two modes of delivery of information for patients undergoing functional endoscopic sinus surgery: website and printed leaflet.

METHODS

A two-centre, prospective, single-blinded, randomised, controlled trial was conducted, comparing mode of information delivery. Adult patients were randomly allocated to receive pre-operative information regarding functional endoscopic sinus surgery, either via a website or a printed leaflet. Primary outcomes, measured by questionnaire, were: readability, usability and recall of complications.

RESULTS

Fifty-eight patients were recruited. Fifty met the inclusion criteria, of which 40 were analysed in the study (20 patients per group), meeting the power criteria set. There were 18 male and 22 female patients, ranging in age from 21 to 76 years (mean, 47 years). Patients found both the printed leaflet and the website readable, and were satisfied with the usability of both modes. There were similar rates for recall of complications in both study arms.

CONCLUSION

Patient information on functional endoscopic sinus surgery can be provided either as a printed leaflet or a website, with similar rates for usability, readability and recall of complications. These findings could help tailor the provision of pre-operative information for patients undergoing functional endoscopic sinus surgery, based on patient preference.

ICON: chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a public health problem that has a significant socio-economic impact. Moreover, the complexity of this disease due to its heterogeneous nature based on the underlying pathophysiology - leading to different disease variants - further complicates our understanding and directions for the most appropriate targeted treatment strategies. Several International/national guidelines/position papers and/or consensus documents are available that present the current knowledge and treatment strategies for CRS. Yet there are many challenges to the management of CRS especially in the case of the more severe and refractory forms of disease. Therefore, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), a collaboration between EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus (ICON) on Chronic Rhinosinusitis. The purpose of this ICON on CRS is to highlight the key common messages from the existing guidelines, the differences in recommendations as well as the gaps in our current knowledge of CRS, thus providing a concise reference. In this document we discuss the definition of the disease, its relevance, pharmacoeconomics, pathophysiology, phenotypes and endotypes, genetics and risk factors, natural history and co-morbidities as well as clinical manifestations and treatment options in both adults and children comprising pharmacotherapy, surgical interventions and more recent biological approaches. Finally, we have also highlighted the unmet needs that wait to be addressed through future research.

Rhinosinusitis

Although sinusitis is common, controversy exists regarding terminology, diagnostic criteria, indications for imaging, and treatment guidelines. Patients who are diagnosed with bacterial sinusitis should be started on amoxicillin-clavulanate unless an allergy to penicillin is reported, in which case doxycycline or a respiratory fluoroquinolone is indicated for non-pregnant patients. Patients who fail to respond to antibiotic therapy should be suspected of having chronic sinusitis, which may requirea dditional therapy, including endoscopic surgery. Referral of these patients to an otolaryngologist for further evaluation is recommended. Patients with severe systemic symptoms including altered mental status or severe headaches should be suspected of having fungal sinusitis and to an otolaryngologist acutely because this condition has high mortality if not treated emergently.

Endoscopic sinus surgery compared to continued medical therapy for patients with refractory chronic rhinosinusitis

BACKGROUND

The decision to continue medical therapy or recommend endoscopic sinus surgery (ESS) can be challenging in patients with refractory chronic rhinosinusitis (CRS). The objective of this study was to evaluate continued medical therapy vs ESS for patients with refractory CRS who have severe reductions in baseline disease-specific quality of life (QoL).

METHODS

This was a prospective longitudinal crossover study between August 2011 and June 2013. All patients were >18 years old, diagnosed with CRS based on guideline recommendations, failed initial medical therapy and elected ESS. While waiting for ESS, all patients received continued medical therapy. The preoperative waiting period outcomes (continued medical therapy) were compared to the postoperative outcomes. The primary outcome was change in disease-specific QoL (22-item Sinonasal Outcome Test [SNOT-22]). Secondary outcomes were change in endoscopic grading (Lund-Kennedy score), medication consumption, and work days missed in the preceding 90 days.

RESULTS

Thirty-one patients were enrolled. Mean baseline SNOT-22 score was 57.6. After a mean of 7.1 months of continued medical therapy, there was a worsening in SNOT-22 score (57.6 to 66.1; p = 0.006). After ESS, with a mean postoperative follow-up of 14.6 months, there was a significant improvement in SNOT-22 score (66.1 to 16.0; p < 0.001). There was also a significant improvement in endoscopic grading (p < 0.001) coupled with a reduction in both work days lost (p < 0.001) and medication consumption (p < 0.01).

CONCLUSION

Results from the study suggest that ESS is a more effective intervention compared to continued medical therapy for patients with refractory CRS who have severe reductions in their baseline disease-specific QoL.

Evidence-based surgery for chronic rhinosinusitis with and without nasal polyps

Meta-analysis of both large outcome studies as well as cohort studies support the safety and efficacy of Endoscopic Sinus Surgery for Chronic Rhinosinusitis. The efficacy of endoscopic sinus surgery is demonstrated in the improvement of both disease-specific and generic QOL as well as objective measures. However, this must be interpreted together with a well-recognized long-term 15-20 % revision rate, seen more often in patients with ASA trias and cystic fibrosis as well as osteitis and previous surgery. The effect of surgery is higher in managing nasal obstruction (effect size 1.7) and less so hyposmia (effect size 0.8). Allergy has an additive role on the symptomatology of CRS; however, its role if any on the outcome of ESS for CRS is unclear. The concurrent presence of aspiring sensitivity and asthma is associated with increased disease burden and more revision surgeries. Improved phenotyping of CRS may lead in the future to better tailoring of surgical treatments.

Bacterial sinusitis can be a focus for initial lung colonisation and chronic lung infection in patients with cystic fibrosis

A major purpose of treating patients with cystic fibrosis (CF) is to prevent or delay chronic lung infections with CF-pathogenic Gram-negative bacteria. In the intermittent stage, bacteria can usually be eradicated from the lungs with antibiotics, but following eradication, the next lung colonisations often occur with bacteria of identical genotype. This may be due to re-colonisation from the patient's paranasal sinuses. In our study, we found that approximately two-thirds of CF patients having sinus surgery (FESS) had growth of CF-lung-pathogenic Gram-negative bacteria in their sinuses (Pseudomonas aeruginosa, Achromobacter xylosoxidans, Burkholderia cepacia complex). The environment in the sinuses is in many ways similar to that of the lower respiratory tract, e.g. low oxygen concentration in secretions. Sinus bacteria are more difficult to eradicate than in the lungs, thus, having good conditions for adapting to the environment in the lungs. In the presence of bacteria, the environment of the sinuses differs from that of the lower respiratory tract by having a higher immunoglobulin A (IgA): IgG ratio, and reduced inflammation. We found a significant correlation between the concentration of IgA against P. aeruginosa (standard antigen and alginate) in nasal secretions and saliva and CF patients' infection status (not lung colonised, intermittently colonised or chronically lung-infected with P. aeruginosa). This supports the hypothesis that infections often originate in the sinuses and can be a focus for initial lung colonisation or for maintaining lung infections in CF patients. We are confident that anti-P. aeruginosa IgA can be used as an early supplementary tool to diagnose P. aeruginosa colonisation; P. aeruginosa being the microorganism causing most morbidity and mortality in CF patients. This is important since urgent treatment reduces morbidity when CF patients are early colonised with P. aeruginosa, however, there is a lack of diagnostic tools for detecting the early colonisation in the lungs and in the sinuses. We initiated a treatment strategy for CF patients to prevent sino-nasal bacteria being seeded into the lower airways: we recommended extensive functional endoscopic FESS with creation of sufficient drainage from all involved sinuses with subsequent i.v. antibiotics and at least 6 months of twice daily nasal irrigation with saline and antibiotics. By this strategy, sinus bacteria could be eradicated in a large proportion of patients. Essentially, growth of CF-pathogenic bacteria from the lower respiratory tract was decreased following the treatment. Furthermore, a number of patients have been free from CF-pathogenic bacteria for more than one year after FESS, and thus re-classified as "not lung colonised". We also corroborated that CF patients obtain an improved quality of life and reduction in their symptoms of chronic rhinosinusitis after FESS. It is primarily intermittently lung colonised CF patients with CF-pathogenic bacteria in their sinuses that seem to benefit from the treatment strategy. This is in accordance with the fact that we did not see a significant increase in lung function and only a small decrease in specific antibodies after FESS; a high systemic immune and inflammatory response and a decreasing lung function is generally not present in patients who primarily have sinus CF-pathogenic bacteria. It is important that guidelines are created for how CF patients with CF-pathogenic bacteria in the sinuses are to be treated, including criteria for who may likely benefit from FESS, and who may be treated exclusively with conservative therapy, e.g. saline and antibiotic irrigations.

Chronic rhinosinusitis and emerging treatment options

This review describes the epidemiology and various treatments in chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). Evidence for short-term use of systemic corticosteroids has been shown to be favorable in CRSwNP, but still limited in CRSsNP. Topical corticosteroids improve symptom scores in both CRS subgroups. The role of microbes in CRS is still controversial. Culture-directed antibiotics are recommended for CRSsNP with exacerbation. Long-term use of low dosage antibiotics is recommended for CRSsNP for their anti-inflammatory effects. Other emerging treatment options are also discussed.

Deliberate hypotension with propofol under anaesthesia for functional endoscopic sinus surgery (FESS)

BACKGROUND

Functional endoscopic sinus surgery (FESS) is a minimally invasive technique that is used to treat chronic sinusitis. Small bleeding areas can reduce operative visibility and result in destruction of surrounding structures. Deliberate hypotension (lowering the mean arterial blood pressure to between 50 and 65 mm Hg in normotensive patients) using a range of pharmacological agents during general anaesthesia reduces blood loss in many operations.

OBJECTIVES

We aimed to compare the use of the intravenous anaesthetic agent propofol versus other techniques for deliberate hypotension during FESS with regard to blood loss and operative conditions.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE (1950 to April 2012), EMBASE (1980 to April 2012), LILACS (1982 to April 2012) and ISI Web of Science (1946 to April 2012). We also searched the reference lists of relevant articles and conference proceedings and contacted the authors of included trials.

SELECTION CRITERIA

We sought all randomized controlled trials (RCTs) conducted to compare propofol with other techniques. Our primary outcome was total blood loss (TBL). Other outcomes included surgical field quality, operation time, mortality within 24 hour, complications and failure to reach target blood pressure.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted details of trial methodology and outcome data from reports of all trials considered eligible for inclusion. All analyses were made on an intention-to-treat basis where possible. When I(2) was < 40% and the P value from the Chi(2) test was > 0.10, we pooled data by using the fixed-effect model. Otherwise we pooled data by using the random-effects model.

MAIN RESULTS

We included four studies with 278 participants in the review. Deliberate hypotension with propofol did not decrease TBL (millilitres) when compared with inhalation anaesthetics in either children or adults. Propofol improved the quality of the surgical field by less than one category on a scale from 0 (no bleeding) to 5 (severe bleeding) (mean difference (MD) 0.64 better with propofol, 95% confidence interval (CI) 0.37 to 0.91 better), but no difference in operation time was reported. Failure to lower blood pressure to target was less common in the propofol group (relative risk of failure with propofol (RR) 0.24, 95% CI 0.09 to 0.66).

AUTHORS' CONCLUSIONS

Using propofol to achieve deliberate hypotension may improve the surgical field, but the effect is small. Deliberate hypotension with propofol did not decrease TBL and operation time. RCTs with good quality methodology and large sample size are required to investigate the effectiveness of deliberate hypotension with propofol for FESS.

Long-term successes of various sinus surgeries: a comprehensive analysis

Outcome studies often examine the efficacy of sinus surgery with 1 year of follow-up data, while longer-term postoperative data is less easily available. This article reviews long-term outcomes of various endoscopic techniques to further delineate risk factors for surgical failure. A systematic review of the literature was performed and studies were stratified based on surgical technique and recognized risk factors of postoperative failure. A total of 126 abstracts were identified, 82 articles were retrieved for full review, and 56 were included in this report. A total of 30 studies had longer than 1 year of follow-up data and the longest follow-up period was 10 years. Based on the available evidence, endoscopic sinus surgery has a high success rate, but with well-recognized risk factors for failure. Aggressive postoperative local care and medical therapy should be tailored to each patient's particular disease process, and form an integral part of surgical management.

Do rhinology care pathways in primary care influence the quality of referrals to secondary care?

Background:

Chronic sinusitis is the most common routine presentation for a general ENT surgeon. The 2007 ‘Primary Care Guidelines: European Position Paper on the Primary Care Diagnosis and Management of Rhinosinusitis and Nasal Polyps’ aimed to deliver evidence-based guidelines for the diagnosis and management of rhinosinusitis in specialist and primary care.

Objective:

The aim of this audit was to assess the information provided in the referral letters to the ENT department regarding patients with potential rhinosinusitis, and compare this to the information required for the rhinology care pathways.

Method:

We evaluated one month of referrals to the ENT department.

Results:

The quality of information in the referral letters was poor. Only 22 per cent of patient referrals included basic information about symptoms, duration and treatment.

Conclusion:

We plan to investigate why general practitioners are not complying with the pathway. In addition, the pathways will be more widely disseminated via the ‘Map of Medicine’ (an online resource for general practitioners). This should facilitate the receipt of the best evidence-based treatment for patients prior to referral to secondary care.

Efficacy of a marine bacterial nuclease against biofilm forming microorganisms isolated from chronic rhinosinusitis

Background

The persistent colonization of paranasal sinus mucosa by microbial biofilms is a major factor in the pathogenesis of chronic rhinosinusitis (CRS). Control of microorganisms within biofilms is hampered by the presence of viscous extracellular polymers of host or microbial origin, including nucleic acids. The aim of this study was to investigate the role of extracellular DNA in biofilm formation by bacteria associated with CRS.

Methods/Principal Findings

Obstructive mucin was collected from patients during functional endoscopic sinus surgery. Examination of the mucous by transmission electron microscopy revealed an acellular matrix punctuated occasionally with host cells in varying states of degradation. Bacteria were observed in biofilms on mucosal biopsies, and between two and six different species were isolated from each of 20 different patient samples. In total, 16 different bacterial genera were isolated, of which the most commonly identified organisms were coagulase-negative staphylococci, Staphylococcus aureus and α-haemolytic streptococci. Twenty-four fresh clinical isolates were selected for investigation of biofilm formation in vitro using a microplate model system. Biofilms formed by 14 strains, including all 9 extracellular nuclease-producing bacteria, were significantly disrupted by treatment with a novel bacterial deoxyribonuclease, NucB, isolated from a marine strain of Bacillus licheniformis. Extracellular biofilm matrix was observed in untreated samples but not in those treated with NucB and extracellular DNA was purified from in vitro biofilms.

Conclusion/Significance

Our data demonstrate that bacteria associated with CRS form robust biofilms which can be reduced by treatment with matrix-degrading enzymes such as NucB. The dispersal of bacterial biofilms with NucB may offer an additional therapeutic target for CRS sufferers.

Surfactant improves irrigant penetration into unoperated sinuses

BACKGROUND

Saline irrigations are proving to be a valuable intervention in the treatment of chronic sinusitis. The use of surfactants is a well established additive to topical treatments known to reduce surface tension and may prove to be a simple, nonoperative intervention to improve intrasinus douching penetration.

METHODS

Six 30-mL, flat-bottomed medicine cups with circular holes cut through the bottom center and varying in diameter from 1 to 6 mm were created with punch biopsies. Water, saline, saline/dye, and saline/dye/surfactant were compared for maximum holding pressure via these modeled ostia. Holding pressures also were determined for cups with septal mucosa fused to the bottom with holes ranging from 1 to 6 mm. In addition, analysis was carried out with blood and blood/surfactant. Finally, five thawed, fresh-frozen cadaver heads were evaluated before any sinus surgery with water/dye and water/dye/surfactant for intrasinus penetration.

RESULTS

Surfactant significantly improved the ability of all solutions to penetrate ostia in both the plastic cup and fused septal mucosa model. All nonsurfactant-containing solutions were not statistically different from one another, nor did surfactant change the ostial penetration of blood. Surfactant significantly improved the ability of sinus irrigant to penetrate unoperated sinus cavities (3.12 vs 3.5, p = .021).

CONCLUSIONS

The addition of surfactant to saline irrigation improves ostial penetration in undissected and undiseased cadavers. This has practical implications for unoperated patients seeking care for sinus-related symptoms in that we have now described a method for improving topical treatment of target sinus mucosa prior to surgical intervention.