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Shrestha K, Salati H, Fletcher D, Singh N, Inthavong K. Effects of head tilt on squeeze-bottle nasal irrigation - A computational fluid dynamics study. J Biomech 2021; 123:110490. [PMID: 34022532 DOI: 10.1016/j.jbiomech.2021.110490] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 11/28/2022]
Abstract
Nasal irrigation is a widely recognized treatment for several sinonasal diseases. However, there is a lack of clear evidence-based guidelines for optimal irrigation delivery to improve lavage and topical drug delivery. This study uses computational fluid dynamics (CFD) to assess the effects of different head tilt positions on sinonasal coverage, residence time and shear stresses in squeeze-bottle nasal irrigation. A sinonasal cavity computational model was constructed from a high-resolution CT scan of a healthy, 25-year-old Asian female. The Volume of Fluid method was used to track the interface between the two immiscible fluids (air and water). The direction of gravity was varied to simulate different head tilt-positions (0° Straight, 45° Forward, 45° Left, 45° Right and 45° Backward) during nasal irrigation with 150 mL liquid via a squeeze bottle through the left nostril for 2 s with a 0.1 s acceleration/deceleration time. The results showed that the 45° backward head tilt position was the most effective in delivering irrigation to the ethmoid, frontal and sphenoid sinuses. Altering head tilt had minimal impact on irrigation delivery to the maxillary sinuses. Maximum wall shear stresses seen in localized areas of the sinus mucosa varied significantly with different head tilt angles. However, the difference in mean wall shear stress on the sinus surfaces was marginal with changing head tilt position. The findings suggest that an optimized head tilt position can be identified to improve liquid irrigation to targeted sinuses, as per treatment requirements (lavage and topical drug delivery).
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Affiliation(s)
- Kendra Shrestha
- Mechanical & Automotive Engineering, RMIT University, Bundoora, Victoria 3083, Australia
| | - Hana Salati
- Mechanical & Automotive Engineering, RMIT University, Bundoora, Victoria 3083, Australia
| | - David Fletcher
- School of Chemical and Biomolecular Engineering, The University of Sydney, Australia
| | - Narinder Singh
- Dept of Otolaryngology, Head and Neck Surgery, Westmead Hospital, Australia; School of Medicine, The University of Sydney, NSW 2006, Australia
| | - Kiao Inthavong
- Mechanical & Automotive Engineering, RMIT University, Bundoora, Victoria 3083, Australia.
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Effect of surgery, delivery device and head position on sinus irrigant penetration in a cadaver model. The Journal of Laryngology & Otology 2021; 135:234-240. [PMID: 33682652 DOI: 10.1017/s0022215120002662] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The extent of surgery, the type of device used and head position may influence nasal irrigation. The aim of this study was to determine the effectiveness of topical irrigant delivery to the paranasal sinuses according to these factors. METHOD Four cadaveric heads underwent four stepwise endoscopic dissections. Irrigations were evaluated after every stage using different delivery devices (squeeze-bottle, gravity-dependent device and syringe) in two head positions (nose-to-sink and vertex down). Irrigant penetration into each sinus was estimated using a four-point scale. RESULTS A significant positive effect of surgery was demonstrated for each sinus as well as for the delivery device. High-volume irrigant devices are more effective, and the head position plays a significant role in irrigant distribution to the frontal sinus. CONCLUSION This study further confirms the efficacy of high-volume irrigant devices. A vertex down position during the irrigation could improve delivery to the frontal sinus, and the widening of the ostia increases irrigant access to the sinuses.
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Martinez-Paredes JF, Karatayli-Ozgursoy S, Gonzalez V, Olomu O, Donaldson AM. Effect of Partial Uncinectomy After Balloon Sinuplasty on Maxillary Sinus Irrigant Penetration: A Cadaveric Study. OTO Open 2021; 5:2473974X21989583. [PMID: 33598598 PMCID: PMC7863165 DOI: 10.1177/2473974x21989583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/23/2020] [Indexed: 11/15/2022] Open
Abstract
Objective The uncinate process may play a role in the amount of irrigation penetrance. In this cadaver study, we aimed to investigate if the addition of partial uncinectomy provides better maxillary sinus irrigation penetrance than balloon sinuplasty (BSP) alone. Study Design Cadaveric study. Setting Simulation laboratory at the Mayo Clinic in Florida. Methods Five fresh-frozen human cadaveric heads (10 sides) were used to assess maxillary sinus irrigation penetration after 3 interventions performed sequentially: irrigation penetrance with no intervention, irrigation after BSP, and irrigation after BSP and partial removal of the uncinate. Penetrance was recorded with intrasinus endoscopy and scored by 4 blinded observers using a scale from 0 (no irrigation) to 5 (fully irrigated). The diameter of the maxillary ostium was measured before and after BSP. Internal consistency was evaluated with Cronbach’s alpha. Results Mean ostium size increased from 4.1 to 6.8 mm after BSP (P = .013). Cronbach’s alpha was 0.93. The median scores of irrigation penetration after no intervention, BSP, and BSP and partial uncinectomy were 2.5, 3, and 4, respectively. We found a significantly higher penetrance following partial uncinectomy plus BSP versus BSP alone (P = .008). Both interventions had a statistically significant difference in irrigation penetrance as compared with no intervention (P = .0001). Conclusion Maxillary sinus irrigation penetration increased from baseline after BSP. The addition of a partial uncinectomy to the balloon dilation of the maxillary sinus was associated with a statistically significant increase in irrigation penetrance scores as compared with BSP alone.
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Affiliation(s)
- Jhon F Martinez-Paredes
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Selmin Karatayli-Ozgursoy
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Valeria Gonzalez
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Osarenoma Olomu
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Angela M Donaldson
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic in Florida, Jacksonville, Florida, USA
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Seiberling KA, Kidd SC, Kim GH, Church CA. Efficacy of Dexamethasone Versus Fluticasone Nasal Sprays in Postoperative Patients With Chronic Rhinosinusitis With Nasal Polyps. Am J Rhinol Allergy 2019; 33:478-482. [DOI: 10.1177/1945892419841355] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Topical nasal steroids are commonly prescribed to patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) following endoscopic sinus surgery (ESS). They are found to be effective in improving symptoms and quality of life as well as reducing the incidence of nasal polyps recurrence. Objective We sought to determine whether a higher concentration of topical nasal steroid spray is more effective than the standard nasal steroid spray in controlling symptoms and preventing recurrence of polyps in patients with CRSwNP who underwent ESS. Method A double-blind randomized controlled trial was performed on patients with CRSwNP after ESS. Patients were randomized into 2 treatment groups: one received topical nasal dexamethasone 0.032% and the other, fluticasone proprionate. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Lund-Kennedy nasal endoscopy scores were measured at the initiation of topical nasal steroid treatment and then at approximately 4-, 8-, and 12-week intervals. Results Thirty-nine patients were enrolled in the study. Eighteen patients continued using the medications prescribed to them for the duration of the study. There were 8 patients in the dexamethasone group and 10 patients in the fluticasone group. Both groups saw significant improvements in postoperative SNOT-22 and Lund-Kenney scores over time. There was no significant difference in improvement between the groups. Conclusion There is no significant increased benefit in using a higher dose nasal steroid spray compared to the standard dose nasal steroid spray after ESS.
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Affiliation(s)
- Kristin A. Seiberling
- Department of Otolaryngology Head and Neck Surgery, Loma Linda University, Loma Linda, California
| | - Stephanie C. Kidd
- Department of Otolaryngology Head and Neck Surgery, Loma Linda University, Loma Linda, California
| | | | - Christopher A. Church
- Department of Otolaryngology Head and Neck Surgery, Loma Linda University, Loma Linda, California
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Jensen BT, Holbrook EH, Chen PG, Luong AU, Marino MJ, Yao WC. The intraoperative accuracy of maxillary balloon dilation: a blinded trial. Int Forum Allergy Rhinol 2019; 9:452-457. [PMID: 30629822 DOI: 10.1002/alr.22286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/31/2018] [Accepted: 12/11/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND Balloon sinus dilation (BSD) is a commonly performed sinus procedure in the United States. Several cadaveric studies have evaluated BSD accuracy and the maxillary sinus has consistently been shown to be the most challenging to cannulate. We designed an independent study to evaluate the intraoperative accuracy of maxillary sinus BSD. METHODS A prospective, single-blinded trial evaluating the accuracy of maxillary sinus BSD was performed using 2 commercially available BSD systems (guidewire- and probe-based systems) randomly assigned to patients undergoing endoscopic surgery for chronic rhinosinusitus without nasal polyps (CRSsNP) or a skullbase approach in patients without sinus disease. All patients underwent maxillary BSD followed by uncinectomy to reveal dilation of the natural maxillary sinus ostia. The recorded procedures were reviewed by 3 fellowship-trained rhinologists from different institutions blinded to the BSD system utilized. The primary endpoint compared accuracy of maxillary BSD attempts. The secondary endpoint compared accuracy between the 2 systems. RESULTS Twenty-nine maxillary BSD procedures were performed in 18 patients (age range, 20-79 years; mean, 51 years) without nasal polyposis undergoing maxillary antrostomy as part of a more extensive procedure. BSD was successful in 18 of 29 (62%) attempts and unsuccessful in 9 of 29 (31%) attempts, with statistically "almost perfect" interrater agreement (kappa = 0.86). There was no statistical difference between the 2 BSD systems (p = 0.81). CONCLUSION Maxillary BSD appeared to be less accurate in living patients when compared with findings from previously published cadaver studies. There were no differences in accuracy between the probe- and guidewire-based systems. This is the first non-industry-sponsored study evaluating maxillary sinus BSD in living patients. Further studies are needed to investigate the clinical implications of our findings.
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Affiliation(s)
- Brett T Jensen
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Eric H Holbrook
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
| | - Philip G Chen
- Department of Otolaryngology, University of Texas Health Science Center, San Antonio, TX
| | - Amber U Luong
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | | | - William C Yao
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
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Kohanski MA, Toskala E, Kennedy DW. Evolution in the surgical management of chronic rhinosinusitis: Current indications and pitfalls. J Allergy Clin Immunol 2018; 141:1561-1569. [DOI: 10.1016/j.jaci.2018.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/20/2018] [Accepted: 03/26/2018] [Indexed: 11/16/2022]
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Laury AM, Chen PG, McMains KC. Randomized Controlled Trial Examining the Effects of Balloon Catheter Dilation on "Sinus Pressure" / Barometric Headaches. Otolaryngol Head Neck Surg 2018; 159:178-184. [PMID: 29688826 DOI: 10.1177/0194599818772818] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objective To determine if balloon catheter dilation of sinus ostia affects the severity or frequency of headache among patients who have barometric pressure-related "sinus" headache. Study Design Prospective single-blinded randomized controlled trial. Setting Tertiary care medical center. Subjects and Methods Subjects with a diagnosis of sinus pressure headache without evidence of mucosal thickening on computed tomography were recruited. Subjects were blinded and randomized to undergo balloon dilation of affected sinus ostia (active treatment) or balloon dilation in the nasal cavity (placebo). Two balloon devices were utilized (Acclarent and Entellus) and outcomes compared. Subjects were followed with pre- and postprocedure SNOT-22 scores (Sinonasal Outcome Test-22), HIT-6 scores (Headache Impact Test-6), and medication utilization logs for 6 months. Results There was no statistically significant difference in SNOT-22 or HIT-6 scores between the arms at any time point. However, both arms experienced statistically and clinically significant decreases in SNOT-22 and HIT-6 scores from preprocedure to 6 months postprocedure. There was no statistically significant difference in SNOT-22 or HIT-6 score reductions between the Entellus and Acclarent devices. There was no statistically significant difference in medication utilization between the groups at any time point. Conclusions Subjects with sinus pressure headache without evidence of mucosal thickening on computed tomography had no significant difference in outcomes between active treatment (balloon dilation of sinus ostia) and placebo (nasal dilation). Further study on the etiology and effective treatment of barometric pressure / "sinus" headache is needed.
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Affiliation(s)
- Adrienne M Laury
- 1 Department of Otolaryngology-Head and Neck Surgery, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Philip G Chen
- 2 Department of Otolaryngology-Head and Neck Surgery, University of Texas Health at San Antonio, San Antonio, Texas, USA
| | - Kevin C McMains
- 1 Department of Otolaryngology-Head and Neck Surgery, San Antonio Military Medical Center, San Antonio, Texas, USA
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Kidwai SM, Parasher AK, Khan MN, Eloy JA, Del Signore A, Iloreta AM, Govindaraj S. Improved delivery of sinus irrigations after middle turbinate resection during endoscopic sinus surgery. Int Forum Allergy Rhinol 2016; 7:338-342. [DOI: 10.1002/alr.21894] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 10/24/2016] [Accepted: 11/08/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Sarah M. Kidwai
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center; New York NY
| | - Arjun K. Parasher
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center; New York NY
| | - Mohemmed N. Khan
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center; New York NY
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery; Rutgers New Jersey Medical School; Newark NJ
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey; Rutgers New Jersey Medical School; Newark NJ
- Department of Neurological Surgery; Rutgers New Jersey Medical School; Newark NJ
- Department of Ophthalmology and Visual Science; Rutgers New Jersey Medical School; Newark NJ
| | - Anthony Del Signore
- Department of Otolaryngology, Head and Neck Surgery; Beth Israel Hospital; New York NY
| | - Alfred Marc Iloreta
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center; New York NY
| | - Satish Govindaraj
- Department of Otolaryngology-Head and Neck Surgery; Mount Sinai Medical Center; New York NY
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Weber RK, Hosemann W. Comprehensive review on endonasal endoscopic sinus surgery. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 14:Doc08. [PMID: 26770282 PMCID: PMC4702057 DOI: 10.3205/cto000123] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Rainer K. Weber
- Division of Paranasal Sinus and Skull Base Surgery, Traumatology, Department of Otorhinolaryngology, Municipal Hospital of Karlsruhe, Germany
- I-Sinus International Sinus Institute, Karlsruhe, Germany
| | - Werner Hosemann
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Greifswald, Germany
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Doellman M, Chen PG, McMains KC, Sarber KM, Weitzel EK. Sinus penetration of saline solution irrigation and atomizer in a cadaveric polyp and allergic fungal sinusitis model. ALLERGY & RHINOLOGY 2015; 6:8-11. [PMID: 25860165 PMCID: PMC4388882 DOI: 10.2500/ar.2015.6.0115] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Allergic fungal sinusitis (AFS) is a stubborn disease requiring surgical and medical management. Delivery of topical medication is paramount in these patients, but the most difficult to accomplish. We investigated heavy irrigation (nasal douche) and atomized medication delivery potential in a cadaveric sinus model of polypoid AFS disease. Three disease models were created: a control that involved unoperated sinuses and no simulated disease; an unoperated AFS with type II polyposis mode; and an operated model with recurrent allergic fungal sinusitis with type II polyposis. The maxillary sinus showed the best irrigation and overall the heavy irrigator was more efficient than the atomizer.
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Affiliation(s)
- Mary Doellman
- Department of Otolaryngology - Head and Neck Surgery, San Antonio Military Medical Center, Fort Sam, Houston, Texas, USA
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Snidvongs K, Kalish L, Sacks R, Sivasubramaniam R, Cope D, Harvey RJ. Sinus surgery and delivery method influence the effectiveness of topical corticosteroids for chronic rhinosinusitis: systematic review and meta-analysis. Am J Rhinol Allergy 2013; 27:221-33. [PMID: 23710959 DOI: 10.2500/ajra.2013.27.3880] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Published randomized controlled trials (RCTs) on the efficacy of intranasal corticosteroid (INCS) in chronic rhinosinusitis (CRS) use either nasal delivery (nasal drop or nasal spray) or sinus delivery (sinus catheter or sinus irrigation) in patients with or without sinus surgery. This influences topical drug delivery and distribution. The effect of these factors on the published results of RCTs is assessed. This systematic review explores the strength of evidence supporting the influence of sinus surgery and delivery methods on the effectiveness of topical steroids in studies for CRS with meta-analyses. METHODS A systematic review was conducted of RCTs comparing INCS with either placebo or no intervention for treating CRS. Data were extracted for meta-analysis and subgroup analyses by sinus surgery status and topical delivery methods. RESULTS Forty-eight studies (3961 patients) met the inclusion criteria. INCS improved overall symptoms (standardized mean difference [SMD], -0.49; p < 0.00001) and the proportion of responders (risk ratio [RR], 0.59; p < 0.00001) compared with placebo. It decreased nasal polyp size with a greater proportion of responders (RR, 0.48; p < 0.00001) and prevented polyp recurrence (RR, 0.59; p = 0.0004) compared with placebo. Reduction of polyp size was greater in patients with sinus surgery (RR, 0.31; 95% confidence interval [CI], 0.20, 0.48) than those without (RR, 0.61; 95% CI, 0.46, 0.81; p = 0.009). Greater symptom improvement occurred when sinus delivery methods (SMD, -1.32; 95% CI, -2.26, -0.38) were compared with nasal delivery methods (SMD, -0.38; 95% CI, -0.55, -0.22; p < 0.00001). CONCLUSION INCS is effective for CRS. Prior sinus surgery and direct sinus delivery enhance the effectiveness of INCS in CRS.
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Affiliation(s)
- Kornkiat Snidvongs
- Australian School of Advanced Medicine, Macquarie University, Sydney, Australia.
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In-office functional endoscopic sinus surgery for chronic rhinosinusitis utilizing balloon catheter dilation technology. Curr Opin Otolaryngol Head Neck Surg 2013; 21:17-22. [PMID: 23222121 DOI: 10.1097/moo.0b013e32835c05e1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Balloon catheter dilation (BCD) technology was introduced in 2005 as a device employed to dilate maxillary, sphenoid, and frontal sinus outflow tracts in patients with chronic sinus disease. With the evolution of the technology, BCD has been utilized in the office setting. The purpose of this review is to discuss the safety, tolerability, and technical success of this change of venue and to consider the possible significant cost savings in the current healthcare environment. RECENT FINDINGS Recent studies have shown that BCD technology can be safely and successfully used in the office setting with high patient satisfaction and symptom improvement similar to that achieved in the operating room. SUMMARY In select patients with chronic sinus disease, BCD can be safely and effectively utilized to open compromised outflow tracts from the peripheral sinuses including the maxillary, sphenoid, and frontal sinuses. This has the potential to reduce the overall costs related to the surgical treatment of medically refractory sinus disease.
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Nasal polyposis: an inflammatory condition requiring effective anti-inflammatory treatment. Curr Opin Otolaryngol Head Neck Surg 2013; 21:23-30. [PMID: 23172039 DOI: 10.1097/moo.0b013e32835bc3f9] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW Recent literature in chronic rhinosinusitis with nasal polyps (CRSwNP) has focussed on inflammatory mechanisms underlying the disease. Endotyping the histopathological features of the disease, rather than simple clinical phenotypes, reflects a change in our understanding of the disease and approach to management. This is paralleled by renewed evidence for the need for wide postsurgical access and topical anti-inflammatory therapy. RECENT FINDINGS Recent research into patterns of dysfunction in innate immunity suggests a crucial role of respiratory epithelium in mediating the inflammatory response. Elevated interleukins, IL-25 and IL-33, from sinus mucosa in CRSwNP and their interaction via innate lymphoid cells may represent the link between the host-environment interface and T-helper 2 dominated inflammation that characterizes CRSwNP. While thorough immunological profiling of CRSwNP is not routinely available, classification of CRS as eosinophilic (ECRS) or noneosinophilic is practical and correlates with disease severity and prognosis. The practice and utility of endoscopic sinus surgery to create a single neosinus for topical corticosteroid delivery is a logical conclusion founded on the inflammatory basis of CRSwNP/ECRS. SUMMARY There is mounting evidence for CRSwNP as a predominantly inflammatory disease. Even simple histopathological classification on the basis of degrees of tissue eosinophilia reflects the underlying pathogenic mechanisms with diagnostic and prognostic implications. Optimal treatment involves topical anti-inflammatory therapy delivered locally via a wide, postsurgical corridor.
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Thomas WW, Harvey RJ, Rudmik L, Hwang PH, Schlosser RJ. Distribution of topical agents to the paranasal sinuses: an evidence-based review with recommendations. Int Forum Allergy Rhinol 2013; 3:691-703. [DOI: 10.1002/alr.21172] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 01/28/2013] [Accepted: 03/12/2013] [Indexed: 11/09/2022]
Affiliation(s)
- W. Walsh Thomas
- Ralph H. Johnson VA Medical Center and Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston SC
| | - Richard J. Harvey
- Division of Rhinology and Endoscopic Skull Base Surgery; University of New South Wales and St. Vincent's Hospital; Sydney Australia
| | - Luke Rudmik
- Division of Otolaryngology-Head and Neck Surgery; University of Calgary; Alberta Canada
| | - Peter H. Hwang
- Department of Otolaryngology-Head and Neck Surgery; Stanford University Hospital; Palo Alto CA
| | - Rodney J. Schlosser
- Ralph H. Johnson VA Medical Center and Department of Otolaryngology-Head and Neck Surgery; Medical University of South Carolina; Charleston SC
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Long-term successes of various sinus surgeries: a comprehensive analysis. Curr Allergy Asthma Rep 2013; 13:244-9. [PMID: 23338607 DOI: 10.1007/s11882-012-0336-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Snidvongs K, Chin D, Sacks R, Earls P, Harvey RJ. Eosinophilic rhinosinusitis is not a disease of ostiomeatal occlusion. Laryngoscope 2013; 123:1070-4. [DOI: 10.1002/lary.23721] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 07/18/2012] [Accepted: 08/13/2012] [Indexed: 01/04/2023]
Affiliation(s)
| | - David Chin
- Department of Otolaryngology-Head and Neck, Skull Base Surgery; St. Vincent's Hospital; Sydney; Australia
| | | | - Peter Earls
- Department of Anatomical Pathology; St. Vincent's Hospital; Sydney; Australia
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Brodner D, Alexander I, Chandler S, Cutler J, Saigal K. Accuracy of transnasal cannulation and dilation of the maxillary ostium in cadavers with intact uncinates. Am J Rhinol Allergy 2012; 27:58-61. [PMID: 23265308 DOI: 10.2500/ajra.2012.26.3852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Transnasal cannulation of the natural ostium in patients with an intact uncinate process is complicated by the lack of direct visualization of the ostium. Accuracy of transnasal dilation of the maxillary ostium was evaluated for a malleable-tipped balloon device that was bent to specific angles for avoiding the fontanelle during cannulation. METHODS Transnasal cannulation and dilation of 42 cadaver maxillary sinus ostia was attempted by 6 surgeons including 3 with very limited clinical experience using the study device. All physicians received procedure training including the technique to shape the balloon device into the recommended 135° maxillary configuration. Tissue dissection was prohibited. Canine fossa trephination and transantral endoscopy were used to evaluate cannulation and dilation outcomes. Physician operators were blinded to transantral images and results were documented by two observers. RESULTS Appropriate transnasal cannulation and dilation of natural maxillary sinus ostia occurred in 92.9% (39/42) of attempts. Two failures emanated from procedural deviations. In one deviation, the bend angle was changed to 90° and the device tip did not cannulate the ostium. In the second, the device was passed through a preexisting hole in the uncinate and cannulated the natural ostium. A third failure occurred when the device was passed through the fontanelle creating a false lumen. CONCLUSION Using recommended procedural techniques and a malleable-tipped balloon device, newly trained and experienced physicians alike can perform uncinate-preserving transnasal cannulation and dilation of the maxillary ostium with a high rate of success.
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Affiliation(s)
- David Brodner
- Center for Sinus, Allergy and Sleep Wellness, Boynton Beach, FL 33472, USA.
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