Low-stage computed tomography chronic rhinosinusitis: what is the role of endoscopic sinus surgery?

Minimal Radiographic Mucosal Thickness or Opacification Criterion for Sinus-Specific Endoscopic Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVE

Primary chronic rhinosinusitis (CRS) is typically a diffuse process and the extent of endoscopic sinus surgery (ESS) performed for medically recalcitrant CRS is impacted by many factors. However, some third-party payors have implemented policies to authorize coverage for ESS in a sinus-by-sinus manner based on a minimal measurement of millimeters of mucosal thickening or sinus opacification in the corresponding sinus that is being surgically addressed. Our objective was to determine whether such policies are based on scientific evidence that in patients with medically recalcitrant CRS, a minimum measurement of mucosal thickening or sinus opacification is a predictor of CRS in that sinus or improved outcomes after ESS on a sinus-by-sinus basis.

DATA SOURCES

Medline, Embase, Scopus, and Web of Science databases, from inception through May 2022.

REVIEW METHODS

A systematic review was performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.

RESULTS

We identified 6070 abstracts which were screened and from which 112 studies ultimately underwent a full-text review. From these studies, we found that none investigated (or provided evidence of) whether any minimal degree of radiographic mucosal thickening or sinus opacification predicted CRS or better outcomes after ESS in a sinus-specific manner.

CONCLUSION

We were unable to find evidence supporting a minimum millimeter measurement of mucosal thickening or sinus opacification as predictors of CRS or better post-ESS outcomes in a sinus-specific manner in patients with medically recalcitrant CRS. The extent of ESS for CRS should be determined through personalized medical decision-making that considers all patient-specific factors.

Nasal Septal Deviation and Incidental Paranasal Sinus Opacification: A Role of Computed Tomography

Background and Objectives: The purpose of this study was to investigate the prevalence of incidental paranasal sinus (PNS) opacification in nasal septal deviation (NSD) using computed tomography (CT) and to identify contributing factors.Subjects and Method: We analyzed 216 patients who underwent septoplasty for the correction of NSD and who underwent preoperative PNS CT. We assessed the prevalence of incidental PNS opacification in these patients and determined the type of NSD according to Mladina classification. We also evaluated whether the direction of NSD affected the presence of PNS opacification on CT, and whether the presence of PNS opacification was associated with other rhinologic symptoms.Results: Of 216 patients with NSD, 86 showed opacified PNS on CT. According to Mladina classification, NSD patients were classified as type I (24.1%), type II (36.1%), type III (20.8%), type IV (5.6%), type V (9.7%), type VI (2.3%), or type VII (1.4%). Patients with type II NSD showed a significantly higher incidence of PNS opacification compared with other types of NSD (p=0.001). However, the direction of NSD did not significantly influence the presence of incidental PNS opacification. Furthermore, regardless of the presence of PNS opacification, there was no significant difference in rhinologic symptoms such as olfactory dysfunction, among others.Conclusion: We found that incidental PNS opacification on CT was common in NSD patients, especially in patients with type II NSD. Thus, we suggest that CT evaluation of patients with NSD may be helpful for assessing comorbid PNS pathologies as well as objectively identifying nasal septal deformities.

Long-term outcomes of endoscopic sinus surgery in the management of adult chronic rhinosinusitis

BACKGROUND

There is a striking lack of long-term, prospective outcomes data for endoscopic sinus surgery (ESS) in chronic rhinosinusitis (CRS) using validated instruments. Our primary objective in this study was to report long-term outcomes (>10 years) after ESS for CRS obtained by prospective data collection.

METHODS

An observational cohort (n = 59) of adult patients with CRS electing ESS was enrolled between 2004 and 2008. Long-term, disease-specific quality-of-life (QOL) outcomes, health utility values (HUV), revision surgery rate, development of asthma, and patient expectations/satisfaction with outcomes of ESS were examined using descriptive statistics and simple fixed-effects linear modeling.

RESULTS

Fifty-nine adult patients were followed for 10.9 years (±13.8 months), on average. Mean QOL significantly improved between baseline and 6 months and remained durable to 10 years. HUV improved to normal. A 17% revision surgery rate within the 10-year follow-up period was observed with a 25% revision rate in CRS with polyposis. New-onset asthma after ESS occurred at a rate of 0.8%/year. Patient satisfaction with ESS outcomes was generally high.

CONCLUSIONS

Ten-year prospective outcomes of ESS for CRS demonstrate that the initial clinically significant improvements in QOL seen 6 months postoperatively are durable over the long term. Over 75% of patients reported clinically significant long-term QOL and HUV improvement. HUV returned to normal. Revision surgery rate was 17% and worse postoperative endoscopy scores within 18 months of initial ESS were associated with higher likelihood of revision surgery. Most patients would pursue ESS again and recommend the procedure to other patients considering this treatment option.

Asymptomatic radiographic sinonasal inflammation does not affect pituitary surgery outcomes

OBJECTIVE

Chronic rhinosinusitis (CRS) is a proposed risk factor for meningitis and other intracranial complications following the endoscopic endonasal transsphenoidal approach (TSA). Some have recommended staging TSA following surgery for CRS; however, delaying TSA has important ramifications. The objective of this study is to determine whether asymptomatic sinonasal inflammation (RSNI) on preoperative computed tomography scans, without clinical CRS, is associated with postoperative complications following TSA.

METHODS

All consecutive TSA cases performed at a single tertiary care institution from January 1, 2009, to December 31, 2017, were reviewed for patient demographics, prior surgery, presence of RSNI on preoperative computed tomography scan based on Lund-Mackay (LM) score, intraoperative cerebrospinal fluid (CSF) leak, and postoperative complications (postoperative CSF leak, bleeding, infection). The association between preoperative RSNI and postoperative complications was analyzed via multivariate logistic regression.

RESULTS

One hundred seventy-one cases of TSA were included with mean patient age of 52.6 years, 42.7% males, 18.1% revision cases, and mean LM score of 1.9 ± 2.7. Complications were identified in 9.9% of patients at the following rates: 5.3% postoperative CSF leak, 2.9% bleeding, and 1.8% infection (all sinusitis, no episodes of meningitis). Neither total LM score nor LM score > 5 (representative of clinically significant radiographic CRS) were predictors of any postoperative complication (both P > 0.05). Age, sex, revision status, intraoperative CSF leak, and total LM score were not independent predictors of any postoperative complication on multivariate analysis (all P > 0.05).

CONCLUSION

In asymptomatic patients, radiographic evidence of sinonasal inflammation is not associated with increased risk of complications following TSA.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1545-1548, 2019.

Accessory maxillary ostium repair using middle turbinate flap: a case series of 116 patients with chronic rhinosinusitis

BACKGROUND

The ostiomeatal complex (OMC), comprising a small natural maxillary sinus ostium and narrow infundibulum, transmits the air diffusion into the antrum and mucociliary transport from the antrum, and is considered a key area in chronic rhinosinusitis (CRS). Thin membranous anterior and posterior fontanelle areas below the OMC can rupture forming a perforation, accessory maxillary ostium (AMO), that increases antral airflow changing the anatomy and function of the sinus. The purpose of this study was to report the first case series of CRS patients who had undergone repair of fontanelle defects aiming to reconstruct normal structures.

METHODS

Between 2011 and 2017, a total of 157 perforations were diagnosed and repaired in 121 of 525 consecutive endoscopic sinus operations performed by the author. Defects were 3 mm to 4 mm in size (range, 1 mm to 7 mm). A flap cut from the undersurface of the middle turbinate was used. In total, 101 patients received concurrent balloon catheter dilation (BCD), while 15 patients had only an AMO repair. The mean endoscopic follow-up time was 16 weeks (range, 1 to 188 weeks).

RESULTS

Overall, 101 perforations were closed, 21 open, and 17 partially open. A history of earlier endoscopic sinus surgery (ESS) or BCD surgery, presence of nasal polyposis or whether the repair was made without simultaneous BCD did not influence the closure rate. Postoperative febrile sinusitis occurred in 26 patients.

CONCLUSION

Repair of AMO is in theory a beneficial and technically feasible office procedure with only transient side effects. Three out of 4 perforations were closed after repair.

Effectiveness of extensive sinus surgery with post-operative medical management for chronic rhinosinusitis

OBJECTIVE

To prospectively assess treatment outcomes of chronic rhinosinusitis patients undergoing functional endoscopic sinus surgery and post-operative medical treatment over a prolonged follow-up period.

METHODS

Patients undergoing functional endoscopic sinus surgery in the tertiary referral practice of a single surgeon were studied prospectively. Symptoms were scored by patients pre-operatively and over a minimum follow-up period of 12 months.

RESULTS

The study comprised 200 non-consecutive patients. The median pre-operative symptom score was 16 (out of a maximum of 25) (95 per cent confidence interval = 15 to 17). Symptom scores reduced to a median of 7 (95 per cent confidence interval = 6 to 8) after 12 months of follow up (p < 0.0001). The median symptom score improved for all symptoms and across all patient subgroups.

CONCLUSION

Extensive functional endoscopic sinus surgery offers significant and durable symptom improvement in patients with chronic rhinosinusitis refractory to medical treatment. This improvement extends to all patient subgroups. Prolonged medical therapy is recommended after functional endoscopic sinus surgery.

Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study

BACKGROUND

Appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) are currently poorly defined. The lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates and contributes to reduced quality of care. The objective of this study was to define appropriateness criteria for ESS during management of adult patients with uncomplicated CRS.

METHODS

The RAND/UCLA appropriateness methodology was performed. An international, multidisciplinary panel of 10 experts in CRS was formed and completed 2 rounds of a modified Delphi ranking process along with a face-to-face meeting.

RESULTS

A total of 624 clinical scenarios were ranked, 312 scenarios each for CRS with and CRS without nasal polyps. For adult patients with uncomplicated CRS with nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus a short-course of systemic corticosteroid with a post-treatment total SNOT-22 score ≥ 20. For adult patients with uncomplicated CRS without nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus either a short-course of a broad spectrum/culture-directed systemic antibiotic or the use of a prolonged course of systemic low-dose anti-inflammatory antibiotic with a post-treatment total SNOT-22 score ≥ 20.

CONCLUSION

This study has developed and reported of list of appropriateness criteria to offer ESS as a treatment "option" during management of uncomplicated adult CRS. The extent or technique of ESS was not addressed in this study and will depend on surgeon and patient factors. Furthermore, these criteria are the minimal threshold to make ESS a treatment "option" and do not imply that all patients meeting these criteria require surgery. The decision to perform ESS should be made after an informed patient makes a preference-sensitive decision to proceed with surgery. Applying these appropriateness criteria for ESS may optimize patient selection, reduce the incidence of unwarranted surgery, and assist clinicians in providing high-quality, patient-centered care to patients with CRS.

When are we operating for chronic rhinosinusitis? A systematic review of maximal medical therapy protocols prior to endoscopic sinus surgery

BACKGROUND

Endoscopic sinus surgery (ESS) is considered a therapeutic option after failure of maximal medical therapy (MMT) for chronic rhinosinusitis (CRS). There is currently no consensus on the definition of MMT. The objective of this systematic review is to describe the various MMT criteria employed prior to considering ESS.

METHODS

A systematic review was performed using the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were adults with CRS based on guideline diagnostic criteria, enrolled to undergo ESS, and study publication within the last 5 years (January 1, 2009, to December 30, 2014). Studies were excluded if the study population included non-CRS indications for ESS. Primary outcome was the MMT criteria employed prior to considering a patient a candidate for ESS. A subgroup analysis was performed based on polyp status.

RESULTS

Of 387 reviewed studies, 21% reported MMT criteria. When reported, criteria included topical nasal corticosteroids (91% of studies) for a mean of 8 ± 8 weeks, oral antibiotics (89%) for 23 ± 8 days, systemic corticosteroids (61%) for 18 ± 12 days, saline irrigations (39%), oral antihistamines (11%), oral mucolytics (10%), and topical/oral decongestants (10%).

CONCLUSION

A minority of studies report MMT criteria used as the indication for ESS. When reported, the majority included an 8-week course of topical intranasal corticosteroids and 3-week course of oral antibiotics. Use of systemic corticosteroids did not differ based on polyp status. Because of variation in current MMT criteria, there is a need to develop standardized indications for ESS that will work to improve the appropriateness of care for patients with.

Patients electing medical vs surgical treatment: emotional domain of the Rhinosinusitis Disability Index associates with treatment selection

BACKGROUND

The Rhinosinusitis Disability Index (RSDI) consists of multiple subdomains shown to be useful in studying chronic rhinosinusitis (CRS). The objective of this study was to determine if RSDI subdomain scores are associated with selection of treatment modality (endoscopic sinus surgery [ESS] or continued medical management [CMM]) in subjects with CRS.

METHODS

Patients with CRS were prospectively enrolled into a multi-institutional cohort study. Following an initial period of medical management, patients elected to undergo treatment with either ESS or CMM. Baseline RSDI total and subdomain scores were compared between patients electing different treatment modalities.

RESULTS

A total of 684 subjects were enrolled with 122 (17.8%) electing CMM and 562 (82.2%) electing ESS. When compared to patients undergoing CMM, patients electing ESS exhibited significantly higher mean baseline RSDI total scores (mean ± standard deviation [SD]: 48.1 ± 24.9 vs 40.1 ± 24.1; p = 0.001) and subdomain scores (emotional: 13.2 ± 9.1 vs 10.4 ± 8.3; p = 0.001; functional: 15.3 ± 8.9 vs 12.6 ± 8.4; p = 0.002; and physical: 19.6 ± 9.3 vs 17.1 ± 9.6; p = 0.007). Emotional subdomain scores were found to be the most associated with choice of treatment modality.

CONCLUSION

Patients with CRS electing ESS had worse baseline RSDI total and subdomain scores compared to those electing CMM. Although both rhinologic and nonrhinologic symptoms contributed to the selection of treatment modality, emotional symptoms appeared to exhibit the greatest influence on patient-centered treatment decisions.

In-office, multisinus balloon dilation: 1-Year outcomes from a prospective, multicenter, open label trial

BACKGROUND

The objective of this prospective, multicenter study was to assess 1-year changes in sinonasal symptoms and health care use after office-based multisinus balloon dilation.

METHODS

Adults diagnosed with chronic or recurrent acute rhinosinusitis per the 2007 adult sinusitis guidelines were enrolled in this Institutional Review Board-approved study. Balloon dilation of the maxillary sinuses/ethmoid infundibula with or without frontal or sphenoid ostial dilation was performed in the physician's office under local anesthesia. Intraoperative procedure technical success and subject procedure tolerance were recorded. Efficacy was assessed using the patient-reported 20-item Sino-Nasal Outcome Test (SNOT-20) and Rhinosinusitis Symptom Inventory (RSI). Complications and revision surgeries were also recorded.

RESULTS

A total of 313 ostial dilations were attempted and 307 were successfully completed (98.1%) in 81 subjects. Mean procedure tolerance was 2.8 ± 2.2 (0 = no pain; 10 = severe pain). Clinically meaningful and statistically significant (p < 0.0001) mean SNOT-20 symptom improvement was observed at 1 and 6 months and sustained through 1 year. The RSI treatment effect for all major rhinosinusitis symptoms was "large" and improvement in each was significant (p < 0.0001). Compared with the previous 1-year period, patients reported an average of 2.3 fewer acute sinus infections (p < 0.0001), 2.4 fewer antibiotic courses taken (p < 0.0001), and 3.0 fewer sinus-related physician visits (p < 0.0001) after balloon dilation. No serious device or procedure-related adverse events occurred. One subject (1.3%) underwent revision surgery.

CONCLUSION

In-office, multisinus balloon dilation is safe, effective, and well tolerated. Patients reported significant reductions in both sinonasal symptoms and health care use after balloon dilation. Efficacy observed at 1 and 6 month follow-up was sustained through 1 year with a very low rate of revision surgery. This study was a part of the clinical trial NCT01612780 registered at www.clinicaltrials.gov.

Patient-centered decision making in the treatment of chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

To explore possible factors that might impact a patient's choice to pursue endoscopic sinus surgery (ESS) or continue with medical management for treatment of refractory chronic rhinosinusitis (CRS).

STUDY DESIGN

Cross-sectional evaluation of a multicenter prospective cohort.

METHODS

Two hundred forty-two subjects with CRS were prospectively enrolled within four academic tertiary care centers across North America with ongoing symptoms despite prior medical treatment. Subjects either self-selected continued medical management (n = 62) or ESS (n = 180) for treatment of sinonasal symptoms. Differences in demographics, comorbid conditions, and clinical measures of disease severity between subject groups were compared. Validated metrics of social support, personality, risk aversion, and physician-patient relationships were compared using bivariate analyses, predicted probabilities, and receiver operating characteristic curves at the 0.05 alpha level.

RESULTS

No significant differences were found between treatment groups for any demographic characteristic, clinical cofactor, or measure of social support, personality, or the physician-patient relationship. Subjects electing to pursue sinus surgery did report significantly worse average quality-of-life (QOL) scores on the 22-item Sinonasal Outcome Test (SNOT-22; P < .001) compared to those electing continued medical therapy (54.6 ± 18.9 vs. 39.4 ± 17.7), regardless of surgical history or polyp status. SNOT-22 score significantly predicted treatment selection (odds ratio, 1.046; 95% confidence interval, 1.028-1.065; P < .001) and was found to accurately discriminate between subjects choosing endoscopic sinus surgery and those electing medical management 72% of the time.

CONCLUSIONS

Worse patient-reported disease severity, as measured by the SNOT-22, was significantly associated with the treatment choice for CRS. Strong consideration should be given for incorporating CRS-specific QOL measures into routine clinical practice.

LEVEL OF EVIDENCE

2b.

Two-year results: transantral balloon dilation of the ethmoid infundibulum

BACKGROUND

Multiple prospective and retrospective studies have reported results from balloon-only procedures and hybrid balloon sinus surgeries through intermediate follow-up periods of up to 1 year. Long-term durability results beyond 2 years are limited.

METHODS

One-year results from the original study of standalone transantral balloon dilation in patients with computed tomography (CT) evidence of chronic inflammation in the maxillary sinuses alone or maxillary and anterior ethmoid sinuses combined were previously reported. Revision rate, symptom improvement, and productivity improvement were prospectively evaluated after a minimum follow-up of 2 years.

RESULTS

Fifty-nine patients (107 maxillary ostia) underwent balloon dilation of the maxillary sinus outflow tract and completed postprocedure follow-up assessment at 27.0 ± 3.6 months. Patient 20-item Sino-Nasal Outcome Test (SNOT-20) score improved from 2.65 ± 0.97 at baseline to 0.79 ± 0.71 at long-term follow-up (p < 0.0001). Improvement in work productivity and activity due to sinus-related health issues for all patients was statistically significant across all survey instrument characteristics (p range, <0.0001 to 0.02). An analysis of the outcomes in a subgroup of patients with maxillary and anterior ethmoid disease (20; 34%) showed similar significant improvement in symptoms (SNOT-20 decrease = -2.1; p < 0.0001). Approximately 92% of all patients reported satisfaction with the balloon procedure. Four (6.8%) patients underwent revision sinus surgery at 11.1 ± 7.3 months after treatment.

CONCLUSION

Patients with chronic rhinosinusitis and radiographic evidence of isolated maxillary disease with or without anterior ethmoid disease have reported clinically meaningful and statistically significant improvement in symptoms, productivity, and activity through a minimum of 2 years following standalone balloon dilation.

Concurrent septoplasty during endoscopic sinus surgery for chronic rhinosinusitis: does it confound outcomes assessment?

OBJECTIVES/HYPOTHESIS

To determine if chronic rhinosinusitis (CRS)-specific health-related quality-of-life (HRQoL) outcomes are affected by concurrent septoplasty performed during endoscopic sinus surgery (ESS) for medically refractory CRS.

STUDY DESIGN

Prospective, multicenter cohort study.

METHODS

A total of 221 patients with medically refractory CRS without nasal polyposis who elected primary ESS were included in this study. Patients were dichotomized into two cohorts: concurrent septoplasty (n = 108) or no septoplasty (n = 113) during ESS. The main outcomes of interest included two CRS-specific HRQoL instruments: the Rhinosinusitis Disability Index (RSDI) and the Chronic Sinusitis Survey (CSS). Symptom presentation was assessed using eight sinonasal visual analog scale (VAS) symptom scores.

RESULTS

There were no differences in CRS-specific HRQoL improvements on all RSDI and CSS measures following ESS between cohorts with or without septoplasty (all P > .05). In patients with medically refractory CRS, the presence of septal deviation did not result in a different CRS-specific symptom presentation compared to patients without septal deviation (all baseline VAS symptom score comparisons P > .295).

CONCLUSIONS

To optimize nasal patency and improve surgical access, septoplasty is commonly performed during ESS. Based on the results of this study, concurrent septoplasty does not appear to affect CRS-specific HRQoL or symptom outcomes and does not function as a confounding factor in HRQoL improvement.