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Tran T, Staibano P, Snidvongs K, Nguyen TBV, Sommer DD. Extent of Endoscopic Sinus Surgery in Chronic Rhinosinusitis: A Systematic Review and Meta-Analysis. Curr Allergy Asthma Rep 2024:10.1007/s11882-024-01175-5. [PMID: 39249643 DOI: 10.1007/s11882-024-01175-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2024] [Indexed: 09/10/2024]
Abstract
PURPOSE OF REVIEW There is an incomplete understanding regarding the extent of endoscopic sinus surgery (ESS) in managing chronic rhinosinusitis (CRS) and its effect on outcomes. This study aimed to assess and compare limited sinus surgery, full-house, extended and radical ESS for optimizing CRS outcomes. RECENT FINDINGS An online search in adherence with PRISMA guidelines was performed. Data were pooled for meta-analysis. Forty-six articles met inclusion criteria. Full-house ESS yielded greater improvements in SNOT-22 and endoscopy scores over limited ESS. Radical ESS improved nasal symptoms and reduced disease recurrence more than full house ESS, while extended ESS decreased revision ESS rates when compared to full-house ESS. Total ethmoidectomy reduced SNOT-22 scores more than limited ethmoidectomy. There was no difference in perioperative complications for all extents of ESS. When compared to limited ESS, full-house ESS yielded better patient symptom outcomes. Radical ESS demonstrated even greater reductions in nasal symptoms, while extended ESS additionally decreased revision surgery rates. Thus, in general, greater extent of ESS leads to better outcomes, while all extents of ESS are relatively safe.
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Affiliation(s)
- Thinh Tran
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Department of Otolaryngology, Head and Neck Surgery, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Phillip Staibano
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
- Department of Health Methodology, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Kornkiat Snidvongs
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
- Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
| | - Thomas B V Nguyen
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Doron D Sommer
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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Chiari F, Guarino P, Caporale CD, Orsini K, Trevisi G, Presutti L, Molteni G. Clinical features, operative management and surgical results of first Draf III procedure, revision Draf III approach and the use of mucosal flaps and stents: a systematic review. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08957-7. [PMID: 39237772 DOI: 10.1007/s00405-024-08957-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 08/27/2024] [Indexed: 09/07/2024]
Abstract
OBJECTIVES Draf III procedure is a challenging endoscopic technique, which has gradually gained an increasing popularity in treating frontal sinus pathologies. The main aim of this systematic review is to offer a comprehensive overview on clinical indications, pre-operative evaluation, surgical techniques, post-operative management and complications of the Draf III procedure. As a step forward, such issues have been comparatively evaluated as referred to patients who underwent primary Draf III procedure and revision DRAF III one). Finally, surgical outcomes related to mucosal flaps and stents to prevent re-stenosis are analyzed. METHODS A systematic literature review has been performed following PRISMA 2020 checklist statement. An automated search has been carried out by applying an extensive set of queries on the Embase/PubMed, Scopus and Cochrane databases, relating to papers published from 2000 to 2021. RESULTS Frontal chronic refractory sinusitis is the most frequent indication to Draf III procedure (72%), followed by mucoceles (11%) and skull base or paranasal tumors (10%). The success rate of primary and revision Draf III are 83.5% and 71%, respectively. The re-stenosis phenomenon seems to depend on allergic mechanism and polyposis). The use of mucosal flaps could improve the Draf III efficacy, better than the use of stents (87 vs 72% of neo-ostium patency). CONCLUSION Draf III is a safe and highly effective surgical technique. However, some limited clinical conditions require some careful technical features, such as the use of mucosal flap, in order to prevent re-stenosis.
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Affiliation(s)
- Francesco Chiari
- Otolaryngology and Audiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pierre Guarino
- Otolaryngology Head and Neck Unit, "Santo Spirito" Hospital, Pescara, Italy.
| | | | - Klizia Orsini
- Neurosurgical Unit, "G. Mazzini" Hospital, Teramo, Italy
| | - Gianluca Trevisi
- Neurosurgical Unit, "Santo Spirito" Hospital, Pescara, Italy
- Department of Neurosciences, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Livio Presutti
- Otolaryngology and Audiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gabriele Molteni
- Otolaryngology and Audiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum di Bologna, Bologna, Italy
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Lv C, Li C, Qu J, Dong Y, Huang Z, Sun Y, Cui S, Huang Q, Wang B, Huo M, Zhou B. The Impact of the Nasal Mucosal Flap on Tissue Remodeling After Sinus Bone Drilling in Rabbit Models. Am J Rhinol Allergy 2024; 38:23-30. [PMID: 37936308 DOI: 10.1177/19458924231207547] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND Frontal sinus surgery remained a challenge of restenosis or obliteration of the drainage pathway caused by the scarring and neo-osteogenesis after mucosal stripping and bone drill-out. The pedicled or free nasal mucosal flap is typically used to repair the exposed bone surface to avoid or reduce recurrence. OBJECTIVE This study aimed to explore the histopathological mechanism of mucosal flaps repairing bare bone after mucosal resection and bone drill-out in the rabbit model. METHODS Thirty New Zealand white rabbits were used. Sixteen rabbits were selected as the experimental group, and Staphylococcus aureus was used to establish the CRS model (CRS group). Fourteen healthy rabbits were allocated to the control group (NCRS group). Each group was divided into two subgroups with or without mucosal flap repair (CRS-FLAP, CRS-NFLAP, NCRS-FLAP, and NCRS-NFLAP, respectively). The bony anterior and lateral walls of the maxillary sinus of each rabbit were abraded by the drill. The bare bone was then covered with a flap in FLAP subgroups. Bone remodeling and mucosal morphological changes were observed and compared by histopathological hematoxylin and eosin and Masson staining. RESULTS In the CRS-NFLAP subgroup, the regenerated epithelium lacked typical structure, accompanied by numerous inflammatory cell infiltration and collagen deposition. Conversely, the inflammatory reaction was mild in the CRS-FLAP subgroup, and there was less collagen deposition. The restored mucosal structure was like the normal mucosa. The epithelium in the NCRS-NFLAP subgroup was partially exfoliated, with few cilia, goblet cells, and glandular structures. Compared with the NCRS-NFLAP subgroup, the CRS-NFLAP subgroup showed significant bone remodeling with enhanced activity of osteoblast and osteoclast cells. CONCLUSIONS Pedicled mucosal flap repair could significantly reduce local mucosal and bone remodeling in a rabbit model of CRS.
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Affiliation(s)
- Cao Lv
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
- Department of Otolaryngology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Cheng Li
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Jing Qu
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
- Department of Otolaryngology, Beijing Huaxin Hospital, First Hospital of Tsinghua University, Beijing, China
| | - Yi Dong
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Zhenxiao Huang
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Yan Sun
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Shunjiu Cui
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Qian Huang
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Bin Wang
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Mingrui Huo
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
| | - Bing Zhou
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology-Head and Neck Surgery, Ministry of Education, Beijing, China
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Abstract
BACKGROUND Chronic rhinosinusitis with nasal polyps (CRSwNP) is comprised of a diverse group of endotypes that cause significant morbidity for afflicted patients. While endoscopic sinus surgery helps ameliorate the disease, polyps frequently recur. Newer strategies are intended to provide access for topical steroid irrigations in attempts to improve the disease process and quality of life, and decrease overall recurrence of polyps. OBJECTIVE To review the current literature examining the latest surgical approaches for CRSwNP. METHODS Review article. RESULTS In dealing with the recalcitrant nature of CRSwNP, surgical techniques have simultaneously become more nuanced and aggressive. Bony resection in anatomically unfavorable areas such as the frontal, maxillary, and sphenoid outflow regions, replacing diseased or denuded mucosa with healthy grafts or flaps at the neo-ostia, and introducing drug-eluting biomaterials to newly opened sinus outflow tracts are highlights in the recent advancements in sinus surgery for CRSwNP. The Draf 3 or modified endoscopic Lothrop procedure has become a standard technique and demonstrated to improve quality of life and decrease polyp recurrence. A number of mucosal grafting or mucosal flap techniques have been described that cover exposed bone of the neo-ostium and evidence shows that this improves healing and diameter of the Draf 3. Partial middle turbinectomy, while controversial, appears to help decrease polyp recurrence in long-term follow-up studies. Modified endoscopic medial maxillectomy improves access to the maxillary sinus mucosa, facilitates debridement and, particularly, in the cystic fibrosis nasal polyp patient, improves overall management of the disease. Sphenoid drill-out procedure provides wider access for topical steroid irrigations and also may improve management of CRSwNP. CONCLUSION Surgical intervention remains a mainstay of therapy for CRSwNP. Newer techniques revolve around improving access for topical steroid therapy.
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Affiliation(s)
- T Graham Norwood
- Department of Otolaryngology/Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jessica W Grayson
- Department of Otolaryngology/Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bradford A Woodworth
- Department of Otolaryngology/Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Klimenko KE, Kryukov AI, Rusetsky YY, Tovmasyan AS, Kudryashov SE. [History of frontal sinus surgery and current view of the problem. Part 2]. Vestn Otorinolaringol 2023; 88:76-81. [PMID: 37970774 DOI: 10.17116/otorino20238805176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Surgical treatment of inflammatory diseases of the frontal sinus is one of the biggest challenges of modern otorhinolaryngology. Close proximity of the frontal sinus and frontal sinus drainage pathways to the skull base, the orbit and the anterior ethmoid artery, great limitations with its visualization and instrumentation, and high risk of the frontal recess scarring cause difficulties in either endoscopic or external approaches to the frontal sinus. At the same time endoscopic approach to the frontal sinus is considered as preferred method of frontal sinusitis surgical treatment by majority of peers nowadays. The introduction of extended approaches to the frontal sinus pathology treatment with frontal sinus floor and interfrontal sinus septum drill-out as well as superior septectomy with common drainage pathway formation gave an opportunity to greatly decrease a rate of indications for external frontal sinus procedures. In this paper historical backgrounds of endonasal approaches to frontal sinuses are presented, current controversies in proper selection of extent and methods of the frontal sinus surgery are analyzed and endoscopic as well as external approaches to frontal sinuses are summarized.
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Affiliation(s)
- K E Klimenko
- Central Clinical Hospital with Polyclinic of Administrative Directorate of the President of the Russian Federation, Moscow, Russia
- Central State Medical Academy of Administrative Directorate of the President of the Russian Federation, Moscow, Russia
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
| | - A I Kryukov
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
| | - Yu Yu Rusetsky
- Central Clinical Hospital with Polyclinic of Administrative Directorate of the President of the Russian Federation, Moscow, Russia
- Central State Medical Academy of Administrative Directorate of the President of the Russian Federation, Moscow, Russia
| | - A S Tovmasyan
- Sverzhevsky Research Clinical Institute of Otorhinolaryngology, Moscow, Russia
| | - S E Kudryashov
- Central Clinical Hospital with Polyclinic of Administrative Directorate of the President of the Russian Federation, Moscow, Russia
- Central State Medical Academy of Administrative Directorate of the President of the Russian Federation, Moscow, Russia
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Aspirin-Exacerbated Respiratory Disease and the Unified Airway. Otolaryngol Clin North Am 2022; 56:107-124. [DOI: 10.1016/j.otc.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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He C, Zhen HT. Value of a lateral inferior pedicle flap in Draf IIb for recurrent frontal sinus diseases: a prospective study. Eur Arch Otorhinolaryngol 2022; 279:4935-4942. [PMID: 35220482 PMCID: PMC9474523 DOI: 10.1007/s00405-022-07302-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 02/07/2022] [Indexed: 11/29/2022]
Abstract
Purpose The Draf IIb procedure allows the widest unilateral access to the frontal sinus in a minimally invasive fashion, with efficiency and safety comparable to the Draf III. However, this technique is still associated with a high postoperative stenosis rate. The exposure of drilled bone induces osteitis predisposing to scarring and neo-osteogenesis causing ostium restenosis. We developed a novel lateral inferior pedicle flap (LIPF) to cover the exposed bone and prevent restenosis during Draf IIb. We aimed to describe our technique. Methods Adult patients requiring a Draf IIb for unilateral recurrent frontal sinus disease were prospectively enrolled. A LIPF technique was systematically performed. Demographics and complications were recorded. The primary outcome measure was neo-ostium patency at 12 months. In patients with chronic rhinosinusitis (CRS), the clinical control rate was evaluated at 12 months. Results 59 patients underwent the Draf IIb with LIPF technique from 2013 to 2021. 49 patients (20 women/29 men, median age of 48.0 years) completed at least 12 months of follow-up (median 41.0 months, range 12–100 months). Indications included recalcitrant CRS (n = 32), inverted papilloma (n = 9) and frontal mucocele (n = 8). Overall, the neo-ostium remained patent at 12 months in all patients, and the clinical control rate of 32 patients with recalcitrant CRS at 12 months was 100%. No main complications were recorded. Conclusion The LIPF technique was associated with a high rate of success for a Draf IIb.
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Affiliation(s)
- Chao He
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030 People’s Republic of China
| | - Hong-Tao Zhen
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, 430030 People’s Republic of China
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Haddad R, Khoueir N, Smaily H, Rassi S, Abou Hamad W. Safety and Efficacy of the Draf IIb Procedure: A Systematic Review. Otolaryngol Head Neck Surg 2021; 165:784-790. [PMID: 33820467 DOI: 10.1177/01945998211004237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To systematically review the literature to evaluate the indications, safety, and efficacy of the Draf IIb procedure and to evaluate the added advantages of technical factors such as stents and flaps. DATA SOURCES Articles published until July 2019 on Medline and Cochrane databases. REVIEW METHODS After a systematic review based on the 2018 PRISMA guidelines was conducted, 26 of 1533 articles were included and reviewed for indications of Draf IIb; surgical technique; use of flaps, stents, grafts, or mitomycin; complications during and after surgery; and success or recurrence rate. RESULTS The main indication for Draf IIb was chronic frontal rhinosinusitis (61.82%). The postoperative patency rate was 87.85%. When flaps/grafts were applied, the rate was 93.5%, but their added value was not statistically significant. Stents could be an alternative for revision surgery. Treating frontal pathologies other than chronic rhinosinusitis was also satisfying. Safety was comparable to Draf III: no perioperative complications were reported, only a few postoperative ones (eyelid ecchymosis and periorbital cellulitis in 0.2% of the cases, hyposmia in 1.55%). CONCLUSION When properly indicated, Draf IIb frontal drilling is a safe and highly effective surgical technique for frontal pathology treatment, with efficiency and safety comparable to the Draf III, making it a valid option when a bilateral approach is not needed. More studies are required to confirm the added values of flaps, grafts, and stents.
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Affiliation(s)
- Ralph Haddad
- Department of Otolaryngology-Head and Neck Surgery, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Nadim Khoueir
- Department of Otolaryngology-Head and Neck Surgery, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Hussein Smaily
- Department of Otolaryngology-Head and Neck Surgery, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Simon Rassi
- Department of Otolaryngology-Head and Neck Surgery, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
| | - Walid Abou Hamad
- Department of Otolaryngology-Head and Neck Surgery, Hotel Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
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Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 408] [Impact Index Per Article: 136.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
I. EXECUTIVE SUMMARY BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. METHODS ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. CONCLUSION This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
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Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
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Appropriate extent of surgery for aspirin-exacerbated respiratory disease. World J Otorhinolaryngol Head Neck Surg 2020; 6:235-240. [PMID: 33336179 PMCID: PMC7729211 DOI: 10.1016/j.wjorl.2020.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/19/2020] [Accepted: 07/24/2020] [Indexed: 11/20/2022] Open
Abstract
The current literature lacks strong guidelines regarding surgical management of patients with aspirin-exacerbated respiratory disease (AERD), who present with the clinical triad of chronic rhinosinusitis with nasal polyposis (CRSwNP), bronchial asthma, and aspirin/nonsteroidal anti-inflammatory drug intolerance. To further define the effectiveness of sinus surgery in treating AERD patients, this review article discusses current evidence regarding outcomes associated with more extensive surgery, the benefits of frontal sinus surgery on polyposis, and the role of Draf III intervention. Numerous studies suggest that Draf III frontal sinusotomy may be an efficacious early intervention due to increased neo-ostial patency and subsequent distribution of topical therapies. Future studies that further investigate the efficacy and safety of extensive surgery in AERD patients are warranted.
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Quality of Life Outcomes in Frontal Sinus Surgery. J Clin Med 2020; 9:jcm9072145. [PMID: 32650386 PMCID: PMC7408842 DOI: 10.3390/jcm9072145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/03/2020] [Indexed: 12/31/2022] Open
Abstract
Introduction: Although significant experience has been gained in the technical nuances of endoscopic sinus surgery procedures, the patient-reported outcomes of frontal endoscopic sinus surgery procedures are still poorly understood. In this study we used the validated patient outcome measure Sino Nasal Outcome Test-22 (SNOT-22) to assess the preoperative and postoperative quality of life in patients undergoing extended endoscopic frontal sinus surgery (Draf type 2 and Draf type 3 procedures). Methods: Out of a total of 680 patients undergoing endoscopic sinus and skull base surgery and 186 patients undergoing frontal sinus surgery, 99 chronic rhinosinusitis patients with (CRSwNP) or without (CRSnNP) nasal polyps undergoing Draf 2 or Draf 3 were assessed. Results: The mean preoperative SNOT-22 was 45.6 points for patients undergoing Draf 2 and 59 for patients undergoing Draf 3, while the mean radiological Lund–Mackay Score was 14.3 and 14.5, respectively. Mean SNOT 22 improvement was 22.9 points for Draf 2 and 37 points for Draf 3 respectively and remained significant in all time intervals, including at 4 years after surgery. With the exception of loss of smell/taste, all symptoms improved by a far bigger extent in Draf 3 group, despite the considerably worse starting point. Effect size (Cohen / Standard Deviations) of Draf 3 was greatest in the following symptoms: “being frustrated/restless/irritable” (1.63), “nasal blockage” (1.43), “reduced concentration” (1.35), “fatigue” (1.29) “runny nose” (1.26) and “need to blow nose” (1.17). Frontal sinus (neo) ostium was patent (fully or partly) at last follow up in 98% of Draf 2 patients and in 88% of patients following Draf 3. Patients with non-patent frontal (neo-) ostium however had a mean postoperative SNOT 22 score of 43 compared to 20 of those with patent frontal sinus (neo-) ostium, although the difference was not statistically significant. Conclusion: Patients undergoing Draf 3 have a greater burden of disease, including both nasal and emotional/general symptoms compared to Draf 2 patients; surgery results in improvement in both groups, although Draf 3 patients have the greatest benefit, especially in emotional / general symptons. In this way both groups achieve similar postoperative quality of life, despite the different starting points.
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Barham HP, Hall CA, Hernandez SC, Zylicz HE, Stevenson MM, Zito BA, Harvey RJ. Impact of Draf III, Draf IIb, and Draf IIa frontal sinus surgery on nasal irrigation distribution. Int Forum Allergy Rhinol 2019; 10:49-52. [PMID: 31826329 DOI: 10.1002/alr.22447] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/20/2019] [Accepted: 09/06/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Delivery of topical pharmacotherapy to the paranasal sinuses remains integral to the management of chronic rhinosinusitis. The frontal sinus remains a difficult access site for irrigations, often limited by its position relative to the nostril and ethmoid sinus. In view of the previous demonstration of improved frontal sinus irrigation with Draf III vs Draf IIa, in this work we sought to evaluate topical access of Draf IIb relative to Draf IIa and Draf III modification of the frontal sinus outflow tract. METHODS Unfixed human cadaver heads were dissected using Draf IIa, Draf IIb, and Draf III frontal sinusotomies. Draf IIa, Draf IIb, and Draf III frontal sinusotomies were performed in progressive sequence on each cadaver head. Nasal irrigation fluid access to the frontal sinus was tested after each successive frontal sinus intervention. Irrigations were performed using Frankfort horizontal and vertex positioning. Blinded reviewers were then asked to evaluate nasal irrigation access based on an ordinal scale. RESULTS Eight cadaveric specimens (age, 78 ± 12.3 years; 62.5% female) were assessed. The greatest distribution scores were recorded by Draf III, then IIb, and then IIa (90.7% vs 81.3% vs 50.1%; p < 0.001). Similarly, the rate of lavage was greatest with Draf III (50% vs 12.5% vs 12.5%). Vertex positioning and increasing volume trended toward improved distribution but did not reach statistical significance. CONCLUSION Adequate delivery of topical therapy to the paranasal sinuses by nasal irrigation remains critical in the postoperative state. Although increasing the dimensions of the frontal recess improves nasal irrigation delivery, the Draf III procedure provides the optimal delivery of pharmacotherapy in those with frontal sinus disease.
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Affiliation(s)
- Henry P Barham
- Sinus and Nasal Specialists of Louisiana, Baton Rouge, LA.,Rhinology and Skull Base Research Group, Baton Rouge General Medical Center, Baton Rouge, LA
| | - Christian A Hall
- Sinus and Nasal Specialists of Louisiana, Baton Rouge, LA.,Rhinology and Skull Base Research Group, Baton Rouge General Medical Center, Baton Rouge, LA
| | - Stephen C Hernandez
- Department of Otolaryngology, Lousiana State University Health Sciences Center-New Orleans, New Orleans, LA
| | - Harry E Zylicz
- Sinus and Nasal Specialists of Louisiana, Baton Rouge, LA.,Rhinology and Skull Base Research Group, Baton Rouge General Medical Center, Baton Rouge, LA
| | - Megan M Stevenson
- Sinus and Nasal Specialists of Louisiana, Baton Rouge, LA.,Rhinology and Skull Base Research Group, Baton Rouge General Medical Center, Baton Rouge, LA
| | - Brittany A Zito
- Sinus and Nasal Specialists of Louisiana, Baton Rouge, LA.,Rhinology and Skull Base Research Group, Baton Rouge General Medical Center, Baton Rouge, LA
| | - Richard J Harvey
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research University of New South Wales, Sydney, NSW, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
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13
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Varghese G, Sahadevan A. Comparison of the Modified Version of DRAF III to the Conventional DRAF III: A 5 Year Study. Indian J Otolaryngol Head Neck Surg 2019; 71:334-340. [PMID: 31559200 PMCID: PMC6737146 DOI: 10.1007/s12070-019-01628-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 02/25/2019] [Indexed: 11/30/2022] Open
Abstract
A modification is made to the conventional way of doing Draf III by completely avoiding burrs by using only gouges and punches to reduce the postoperative narrowing followed by local instillation of budesonide solution. The results are compared. The comparison was made in terms of surgical duration, frontal ostium size, and recurrence of pathology. This is a prospective non-randomised comparative study in a private practice setting. 25 patients (15 males and 10 females) who underwent Draf III surgery between April 2012 and March 2017 were included in the study. Among them, 14 patients were assigned surgery only with punches and gouges. All the patients were given budesonide nasal instillation postoperatively. Outcomes measured included surgical duration, frontal neo-ostium size and, recurrence of pathology. They were followed up for a period of 14 months. The Student's independent t test and χ2 test for independence of attributes were used for statistical analysis. The mean surgical duration for modified Draf III was significantly shorter than conventional Draf III (p value < 0.01). The frontal ostium remained patent in modified Draf III than the Draf III using burrs with a statistical significance (p value < 0.01). The number of cases reporting the absence of recurrence was significantly higher (p value < 0.001) in modified Draf III. Modified Draf III technique, which completely avoids the burr, takes only lesser surgical duration, keeps the frontal ostium patent and drastically reduces recurrence of pathology. Combining postoperative budesonide instillation after modified Draf III helps in achieving promising results.
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14
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A prospective, feasibility study to evaluate the efficacy and usability of a novel drivable endoscope in patients with chronic rhinosinusitis. Eur Arch Otorhinolaryngol 2019; 276:2499-2505. [PMID: 31278497 DOI: 10.1007/s00405-019-05535-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To carry out a pilot study to evaluate the efficacy of a novel, drivable endoscope (the Peregrine™ Drivable ENT Scope), compared to standard rigid endoscopes in the access, visualization, and irrigation of the paranasal sinus anatomy. METHODS A prospective, multi-center, feasibility study was conducted on seventeen subjects who underwent primary functional endoscopic sinus surgery and were evaluated with the drivable endoscope and standard, rigid endoscopes (0°, 30° and 70°, as applicable). A CT scan was available for image guidance, as needed. The primary efficacy endpoint was the ability to access and visualize sinonasal anatomic landmarks. Secondary endpoints included device usability, as measured by a usability questionnaire given to surgeons postoperatively; the device's ability to irrigate the sinuses and patient reports of tolerability and pain during postoperative procedures. RESULTS The drivable endoscope success rate in visualizing all paranasal sinus anatomic landmarks was 55.6% better than the standard rigid endoscopes: 98.3% (178/181) versus 42.7% (76/178); p < 0.001. Surgeons rated scores of over 4 (on a 1-5 scale) for the usability of the drivable endoscope to enter the maxillary, frontal and sphenoid sinuses. The ability to irrigate the sinuses using the drivable endoscope was given a mean score of 4.3, and image quality was given a mean score of 3.4. The three patients evaluated postoperatively reported low pain and high tolerability scores with the drivable endoscope. CONCLUSIONS These preliminary results indicate that the drivable endoscope is effective, easy to use and highly tolerable in sinonasal endoscopy.
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15
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Huang Z, Huang Q, Zhou B, Ma J, Wang M, Dong Y. Bioabsorbable steroid-eluting sinus stents for patients with refractory frontal diseases undergoing a revision Draf 3 procedure: a case series. Acta Otolaryngol 2019; 139:636-642. [PMID: 31124718 DOI: 10.1080/00016489.2019.1592222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Bioabsorbable steroid-eluting sinus stents are safe and effective in maintaining the patency of the frontal sinus ostium. Aims/objectives: To assess the efficacy of steroid-eluting sinus stents in improving postoperative outcomes following revision and re-revision Draf 3 procedures in patients with frontal diseases. Material and methods: Patients with recalcitrant chronic frontal rhinosinusitis (FRS) and mucocele who underwent revision and re-revision Draf 3 procedures from 2015 to 2017 were included. Preoperative disease parameters, demographics, and endoscopic and radiographic images were recorded. Results: Seven patients undergoing the Draf 3 procedure for recalcitrant chronic FRS (43%) and mucocele after complete resection of benign tumours in the frontal sinus (57%) were followed up for a mean of 16.5 months. At the end of follow-up, seven (100%) patients were asymptomatic and all patients (100%) had patent neo-ostia. Conclusions and significance: The use of bioabsorbable steroid-eluting sinus stents had no unanticipated consequences, and the drainage pathways of the frontal neo-ostium remained patent. Steroid-eluting sinus stents may decrease recurrence rates in revision cases where patients have extensive scarring or neo-osteogenesis of the operative field from prior Draf 2 or 3 procedures. Further follow-up of the current cases and studies with larger cohorts are needed.
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Affiliation(s)
- Zhenxiao Huang
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Qian Huang
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Bing Zhou
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Jingying Ma
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Mingjie Wang
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yi Dong
- Department of Otolaryngology-Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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16
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Won TB, Cho SW, Sung MW, Paek SH, Chan S, Salisbury K, Blevins NH, Vaisbuch Y, Hwang P. Validation of a rhinologic virtual surgical simulator for performing a Draf 3 endoscopic frontal sinusotomy. Int Forum Allergy Rhinol 2019; 9:910-917. [PMID: 31012526 DOI: 10.1002/alr.22333] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 02/17/2019] [Accepted: 02/24/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND We recently introduced a patient-specific rhinologic virtual surgical environment (VSE) that has shown potential for surgical rehearsal of various skull base lesions. Our aim in this study was to validate the usefulness of the rhinology VSE in performing the Draf 3 procedure. METHODS An outside-in Draf 3 procedure was performed on 4 cadaver heads. Computed tomography (CT) scans were obtained before and after cadaver dissection (CD). Pre-dissection CT scans were used to construct a cadaver-specific VSE. A virtual Draf 3 dissection (VD) was performed using the same technique. Validation was conducted by comparing the final common frontal outflow tract. A subjective comparison of the post-dissection endoscopic findings (CD vs VD) and an objective measurement using the post-dissection CT scan for the CD and the reconstructed CT scan obtained from the data after the VD was performed. RESULTS Subjective overall resemblance of the 2 dissections (CD vs VD) assessed by the 4-point Likert scale (0-3) was 2.5 (median interquartile range [IQR], 0.25) for the 4 cadavers. The median difference for the anteroposterior dimension of the frontal neo-ostium (CD vs VD) assessed in the midsagittal view was 0.11 mm, whereas the median difference for the lateral dimension assessed in the coronal view was 2.71 mm. Thus, no statistical difference was observed. CONCLUSION VD showed nearly matching results with the actual cadaver dissection. With further validation, our rhinologic VSE may be used for presurgical planning and rehearsal before the actual Draf 3 procedure is performed in the operating room.
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Affiliation(s)
- Tae-Bin Won
- Department of Otorhinolaryngology-Head & Neck Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Center for Minimally Invasive Skull Base Surgery, Seoul National University Hospital, Seoul, Korea
| | - Sung-Woo Cho
- Department of Otorhinolaryngology-Head & Neck Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Myung-Whun Sung
- Department of Otorhinolaryngology-Head & Neck Surgery, Seoul National University Hospital, Seoul, Korea
| | - Sun Ha Paek
- Center for Minimally Invasive Skull Base Surgery, Seoul National University Hospital, Seoul, Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea
| | - Sonny Chan
- Department of Computer Science, University of Calgary, Calgary, AB, Canada
| | | | - Nikolas H Blevins
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, CA
| | - Yona Vaisbuch
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, CA
| | - Peter Hwang
- Department of Otolaryngology-Head & Neck Surgery, Stanford University, Stanford, CA
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17
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Bhalla V, Sykes KJ, Villwock JA, Beahm DD, McClurg SW, Chiu AG. Draf IIB with superior septectomy: finding the "middle ground". Int Forum Allergy Rhinol 2018; 9:281-285. [PMID: 30548455 DOI: 10.1002/alr.22228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 09/10/2018] [Accepted: 10/02/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previous studies have demonstrated a high failure rate of endoscopic sinus surgery (ESS) with Draf IIa in patients with diffuse polyposis, asthma, and aspirin-exacerbated respiratory disease. A high percentage of these patients progress to endoscopic modified Lothrop procedure (EMLP). We describe a modification of the Draf IIb with a superior septectomy (IIb+SS), which may provide similar therapeutic benefit as demonstrated by the distribution of sinus irrigations in the sinus cavity with ESS with IIb+SS vs ESS with EMLP. METHODS ESS with IIb+SS was performed on 6 cadaver heads. Fluorescein-dyed irrigations were performed on each head and penetration was recorded using video endoscopy. EMLP was subsequently performed on each head with repeat dye-irrigation and video endoscopy. The videos were reviewed by 4 blinded fellowship-trained rhinologists, and irrigant penetration of the maxillary, ethmoid, frontal, sphenoid sinuses, and olfactory cleft was graded 0 to 3 (3 implying complete staining). RESULTS The mean scores when comparing IIb+SS to EMLP were as follows: overall 1.99 vs 1.97 (p = 0.816), maxillary sinus 2.67 vs 2.38 (p = 0.128), ethmoid sinus 1.88 vs 1.98 (p = 0.536), sphenoid sinus 2.58 vs 2.50 (p = 0.467), frontal sinus 1.13 vs 1.38 (p = 0.073), and olfactory cleft 1.71 vs 1.63 (p = 0.529). There was no significant difference between subsites. Interrater reliability was good (Cronbach's alpha = 0.781). CONCLUSION Performing ESS with IIb+SS provides similar irrigation delivery benefits to ESS with EMLP, without the need for altering natural sinus outflow and creating circumferential scarring. Further studies evaluating its use in patients that are high risk for revision surgery are needed.
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Affiliation(s)
- Vidur Bhalla
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, KS.,Saint Luke's Hospital of Kansas City, Kansas City, MO
| | - Kevin J Sykes
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Jennifer A Villwock
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, KS
| | - D David Beahm
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, KS
| | | | - Alexander G Chiu
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, KS
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18
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Wong EH, Do TQ, Harvey RJ, Orgain CA, Sacks R, Kalish L. Patient-reported olfaction improves following outside-in Draf III frontal sinus surgery for chronic rhinosinusitis. Laryngoscope 2018; 129:25-30. [DOI: 10.1002/lary.27352] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 05/01/2018] [Accepted: 05/22/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Eugene H. Wong
- Rhinology and Skull Base Research Group, Applied Medical Research Centre; University of New South Wales; Sydney Australia
| | - Timothy Q. Do
- Rhinology and Skull Base Research Group, Applied Medical Research Centre; University of New South Wales; Sydney Australia
| | - Richard J. Harvey
- Rhinology and Skull Base Research Group, Applied Medical Research Centre; University of New South Wales; Sydney Australia
- Faculty of Medicine and Health Sciences; Macquarie University; Sydney Australia
| | - Carolyn A. Orgain
- Rhinology and Skull Base Research Group, Applied Medical Research Centre; University of New South Wales; Sydney Australia
| | - Raymond Sacks
- Rhinology and Skull Base Research Group, Applied Medical Research Centre; University of New South Wales; Sydney Australia
- Faculty of Medicine and Health Sciences; Macquarie University; Sydney Australia
| | - Larry Kalish
- Rhinology and Skull Base Research Group, Applied Medical Research Centre; University of New South Wales; Sydney Australia
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19
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Al-Salman R, Thamboo A. Advances in Surgery for Chronic Rhinosinusitis. CURRENT OTORHINOLARYNGOLOGY REPORTS 2018. [DOI: 10.1007/s40136-018-0210-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Welch KC. Medical and surgical rhinology-outcomes matter. Int Forum Allergy Rhinol 2017; 8:5-7. [PMID: 29266855 DOI: 10.1002/alr.22075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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