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

American Rhinologic Society Expert Practice Statement: Indications and Recommendations for Septoplasty in Children

The goal of this American Rhinologic Society Expert Practice Statement (EPS) is to provide recommendations and guidance through evidence-based consensus statements regarding pediatric septoplasty. This EPS was developed following the previously published methodology and approval process. The topics of interest included appropriate indications, safety and efficacy, timing, relevant quality of life instruments, and surgical techniques. Following a modified Delphi approach, six statements were developed, five of which reached consensus and one that did not. These statements and accompanying evidence are summarized along with an assessment of future needs.

Headache and Facial Pain/Pressure in the Chronic Rhinosinusitis Population: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the severity and prevalence of headache and facial pain/pressurere in the chronic rhinosinusitis (CRS) population.

DATA SOURCES

CINAHL, PubMed, Scopus.

REVIEW METHODS

The literature was searched from inception through June 2023 for English language articles documenting "headache" or "facial pain/pressure" and "chronic rhinosinusitis." Data collected included Lund-MacKay computed tomography score, Lund-Kennedy endoscopy score, sinonasal outcome test, and visual analog scale. Meta-analyses were performed on continuous measures (mean), proportions (%), and regression.

RESULTS

A total of 69 studies were included with 8643 CRS patients and 703 control patients. The CRS group had a mean age of 44.1 (range: 16-82; 95% confidence interval [CI]: 40.3-48) and 86.1% [95% CI: 76.4-93.5] with nasal polyposis. The control group had a mean age of 39.2 (range: 17-88; 95% CI: 28.7-49.8). All CRS subgroups had significantly more severe headache and facial pain/pressure when compared to the control (P < .0001). Patients without polyps had significantly more severe facial pain/pressure and headache when compared to patients with polyps (P < .0001). Facial pain/pressure is a moderate problem or worse in 29.8% of polypoid patients versus 56.4% of nonpolypoid patients; Δ26.6% [95% CI: 0.7-50; P = .045].

CONCLUSIONS

Across all outcome metrics, CRS patients experience significantly more severe headache and facial pain/pressure when compared to a control population. Nonpolypoid patients experience significantly more severe facial pain/pressure and headache when compared to polypoid patients. The majority of nonpolypoid patients experience facial pain/pressure that is moderate in severity or worse.

Work productivity and activity impairment in patients with chronic rhinosinusitis undergoing endoscopic sinus surgery-A prospective, multi-institutional study

BACKGROUND

Productivity loss and activity limitations due to chronic rhinosinusitis (CRS) are known to contribute to the significant economic and personal burden of disease. The purpose of this study was to assess productivity and activity impairment before and after endoscopic sinus surgery (ESS) for medically refractory CRS.

METHODS

This investigation was a prospective, multi-institutional, observational cohort study. Patients diagnosed with medically refractory CRS completed the Work Productivity and Activity Impairment-Specific Health Problem (WPAI-SHP) questionnaire before surgery and approximately 6 months after the procedure. Factors associated with minimal clinical important differences (MCIDs) for productivity and activity impairment were identified.

RESULTS

A total of 279 study participants were screened for inclusion, of whom 176 (63.1%) with postoperative follow-up were included in the final cohort. Preoperative productivity and activity impairment were observed in 63.2% and 69.8% of the patients, respectively. Among these patients, postoperative improvement equaling at least 1 MCID was reported in both productivity (76.1%) and activity (76.4%) impairments. Multivariate regression identified sphenoidotomy (odds ratio [OR], 4.18; 95% confidence interval [CI], 1.03-17.02) as the only factor associated with increased likelihood of productivity improvement, whereas septoplasty during ESS (OR, 8.45; 95% CI, 2.33-30.68) and migraine (OR, 0.35; 95% CI, 0.12-0.96) were associated with differential odds of activity improvement.

CONCLUSION

CRS is associated with a substantial burden on productivity and activity that significantly improves after treatment with ESS. These data may facilitate improved patient counseling and shared decision-making regarding surgical management for CRS.

Predictors of Surgical Outcomes After Functional Endoscopic Sinus Surgery in Chronic Rhinosinusitis

Chronic rhinosinusitis has an incidence of 15% in India. Functional endoscopic sinus surgery (FESS), in case of failed medical management, is the current treatment protocol in Chronic rhinosinusitis. This study aims to assess the outcome of FESS as measured by subjective quality of life indices; Rhinosinusitis Disability Index (RSDI) and Sinonasal Outcome Test (SNOT-22. It also assesses the predictive factors which influence the outcome after FESS. The study was conducted among 100 patients with Chronic Rhinosinusitis who underwent FESS, after failure of medical management. Immunocompromised or pregnant patients and patients with history of previous sinus surgery or malignancy were excluded from the study. The evaluation was done using Lund Kennedy endoscopy scores, Lund Mackay CT scan scores and RSDI and SNOT-22 questionnaires (baseline and 3 months post-op). Statistical analysis was done using Wilcoxon signed-rank test, Kruskall Wallis test, Mann Whitney test and Chi-square test. p < 0.05 was considered significant. RSDI and SNOTT 22 scores showed a mean change 34.78 and 33.04 respectively after FESS, with a p value of < 0.001, which was highly significant. The pre-operative factors which predicted a poor quality of life after FESS were smoking, Allergy and Asthma. Higher pre-operative Endoscopic and CT scores resulted in an improved quality of life after FESS. Gender, concurrent septoplasty and sinonasal polyposis did not influence the quality of life outcomes after FESS. The study determines the quality of life after FESS and also analyses the factors responsible for poor prognosis after functional endoscopic sinus surgery. This study will enable the ENT surgeons to adequately counsel the patients before surgery.

Comparison of the Type and Severity of Nasal Septal Deviation between Chronic Rhinosinusitis Patients Undergoing Functional Endoscopic Sinus Surgery and Controls

Objectives

Some correlations have been proposed between chronic rhinosinusitis (CRS) and type and severity of nasal septal deviation. This study sought to compare the type and severity of nasal septal deviation between CRS patients undergoing functional endoscopic sinus surgery (FESS) and asymptomatic controls using cone-beam computed tomography (CBCT).

Materials and Methods

This prospective case-control study evaluated 49 CRS patients who did not respond to pharmaceutical therapy and were candidates for FESS and 49 asymptomatic controls. All participants underwent CBCT and were inspected for septal deviation type and severity. Data were analyzed by the independent t-test and chi-square test.

Results

The study population comprised of 58.25% males and 41.8% females, with a mean age of 33.74 ± 11.78 years. Significant correlations were noted between the presence of CRS and severity of septal deviation (P=0.007). Type of septal deviation had no significant correlation with the presence of CRS (P=0.443).

Conclusion

Patients with CRS have significantly more severe nasal septal deviation. However, type of septal deviation is not correlated with CRS.

Efficacy of Povidone-Iodine Nasal Irrigation Solution After Sinonasal Surgery: A Randomized Controlled Study

OBJECTIVES/HYPOTHESIS

To evaluate the efficacy of postoperative nasal irrigation with povidone-iodine (PVP-I) solution in patients undergoing sinonasal surgery.

STUDY DESIGN

Single-blind, randomized controlled study.

METHODS

This is a prospective, single-blind, randomized controlled study. Patients with chronic rhinosinusitis (CRS) and hypertrophic inferior turbinates who underwent endoscopic sinus surgery (ESS) and inferior turbinate reduction were enrolled in the study. Patients were evaluated using the Taiwanese version of the 22-item Sino-Nasal Outcome Test (TWSNOT-22), rhinomanometry, endoscopic examination, and bacterial cultures. One week after the operation, patients were randomly assigned to either a 0.1% PVP-I nasal irrigation group or a control (normal saline) irrigation group. We then compared the two groups' results to illustrate the effects of nasal irrigation with PVP-I solution following sinonasal surgery.

RESULTS

Of the 55 patients that completed the study, 27 patients were in the PVP-I group and 28 were in the control group. In both groups, the TWSNOT-22 scores, Lund-Kennedy endoscopic scores, and total nasal resistance (TNR) all revealed significant improvements at 3 months postoperatively compared with preoperative measurements (all, P < .05). However, there were no significant differences between the two groups in TWSNOT-22, endoscopic, or TNR scores 3 months after the operation (all, P > .05).

CONCLUSIONS

A dilute 0.1% PVP-I nasal irrigation as a postoperative care modality after sinonasal surgery did not provide additional benefit compared with normal saline irrigation.

LEVEL OF EVIDENCE

2 Laryngoscope, 2021.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

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.

Lack of impact of radiologic septal measurements upon patient symptoms and performance of septoplasty during endoscopic sinus surgery

BACKGROUND

Recent literature suggests that concurrent septoplasty during endoscopic sinus surgery (ESS) improves patient outcomes, however, the underlying indications for performing concurrent septoplasty are unknown. The objective of this study was to investigate the relationship between objective radiologic measures of nasal septal deviation with preoperative patient symptomatology and measures of CRS disease severity. We also sought to understand the association of objective radiologic measurements with surgeon performance of concurrent septoplasty during ESS.

METHODOLOGY

Seventy-four patients with CRS undergoing ESS were prospectively enrolled. Angles of septal deviation, intranasal areas and volumes were assessed on preoperative computed tomography (CT) scans and correlated with a robust battery of patient reported outcomes measures (PROMs), objective measures of CRS severity including olfaction scores, radiologic and endoscopic staging, and performance of septoplasty.

RESULTS

Intranasal areas and volumes demonstrated only weak linear associations with patient-reported nasal congestion, however, angles of septal deviation alone did not correlate with congestion or any other PROM measure. Meanwhile, radiologic septal-related measurements did not correlate with objective measures of CRS disease severity or the performance of a concurrent septoplasty.

CONCLUSIONS

Though prior studies demonstrate improved patient outcomes in the setting of concurrent septoplasty during ESS, this study failed to establish an association between preoperative radiologic septal-related measurements and patient symptomatology or surgeon decision to perform septoplasty. Although objective factors to identify patients most likely to benefit from concurrent septoplasty remain unidentified, the potential improvement of surgical recommendations and patient outcomes makes this an important area of continued investigation.

A prediction modeling based on SNOT-22 score for endoscopic nasal septoplasty: a retrospective study

Background

To create a nomogram prediction model for the efficacy of endoscopic nasal septoplasty, and the likelihood of patient benefiting from the operation.

Methods

A retrospective analysis of 155 patients with nasal septum deviation (NSD) was performed to develop a predictive model for the efficacy of endoscopic nasal septoplasty. Quality of life (QoL) data was collected before and after surgery using Sinonasal Outcome Test-22 (SNOT-22) scores to evaluate the surgical outcome. An effective surgical outcome was defined as a SNOT-22 score change ≥ 9 points after surgery. Multivariate logistic regression analysis was then used to establish a predictive model for the NSD treatment. The predictive quality and clinical utility of the predictive model were assessed by C-index, calibration plots, and decision curve analysis.

Results

The identified risk factors for inclusion in the predictive model were included. The model had a good predictive power, with a AUC of 0.920 in the training group and a C index of 0.911 in the overall sample. Decision curve analysis revealed that the prediction model had a good clinical applicability.

Conclusions

Our prediction model is efficient in predicting the efficacy of endoscopic surgery for NSD through evaluation of factors including: history of nasal surgery, preoperative SNOT-22 score, sinusitis, middle turbinate plasty, BMI, smoking, follow-up time, seasonal allergies, and advanced age. Therefore, it can be cost-effective for individualized preoperative assessment.

An Uncommon Presentation of the Common Sinusitis

A nine-year-old child was brought to the emergency room by her mother because of an upper respiratory infection symptoms and forehead swelling. The patient was seen by the emergency department physician and diagnosed with an upper respiratory infection; the forehead swelling was felt to be related to forceful coughing. The patient and patient’s mother returned on a second visit because the forehead swelling had not improved. A CT scan of the head was subsequently done which demonstrated pansinusitis.

A new technique of revision septoplasty using semi-penetrating straight and circular incisions of the nasal septum

OBJECTIVE

This study aimed to investigate endoscopic revision septoplasty with semi-penetrating straight and circular incisions in patients for whom septoplasty was unsuccessful.

METHOD

Patients in this study (n = 14) had a deviation of the nasal septum after septoplasty. Pre-operative and post-operative assessments were performed using a visual analogue scale and nasal endoscope. Semi-penetrating straight and circular incisions in front of the caudal septum and at the margin of the nasal septal cartilage-bone defect, respectively, were made. The mucoperichondrium and mucoperiosteum were bilaterally dissected until interlinkage with the cartilage-bone defect was achieved. Mucous membranes within the circular incision as well as the right mucoperichondrium and mucoperiosteal flaps were protected by pushing them to the right. This exposed the osteocartilaginous framework and allowed correction of the residual deviation. The patients were followed up for 30-71 months.

RESULTS

For nasal obstruction and headaches, a significant improvement was noted in post-operative compared to pre-operative visual analogue scale scores. No patients had septal deviations, saddle nose, false hump nose or contracture of the nasal columella.

CONCLUSION

The technique allowed exposure of the septal osteocartilaginous framework and a broad operational vision, which enabled successful correction of various deformities of the nasal septum.

Impact of Septal Deviation on Recurrent Chronic Rhinosinusitis after Primary Surgery: A Matched Case-Control Study

OBJECTIVE

To evaluate the impact of untreated deviated nasal septum (DNS) on recalcitrant chronic rhinosinusitis (CRS) among patients undergoing revision endoscopic sinus surgery (ESS).

STUDY DESIGN

Case-control study.

SETTING

Tertiary academic center.

SUBJECTS AND METHODS

We performed a retrospective review of 489 patients undergoing revision ESS for CRS at a tertiary academic center. Patients undergoing septoplasty were matched to nonseptoplasty controls based on age and sex. Preoperative Lund-Mackay score (LMS) was compared between cohorts. Linear regression was used to identify predictors of LMS and ostiomeatal complex (OMC) obstruction.

RESULTS

Thirty-six matched pairs (72 patients) were selected for analysis: 36 undergoing septoplasty and revision ESS and 36 undergoing revision ESS alone. Compared with nonseptoplasty controls, the septoplasty group had a significantly higher average LMS (17.8 vs 14.6, P = .02) and a greater rate of OMC obstruction (89% vs 61%, P < .01). The septoplasty group also had significantly higher opacification scores in the maxillary (1.5 vs 1.2, P = .03) and posterior ethmoid (1.8 vs 1.4, P = .02) sinuses. On multivariable analysis, DNS was an independent predictor of LMS ( P = .02) and OMC obstruction ( P < .01).

CONCLUSION

Untreated DNS is associated with radiographic markers of CRS severity among patients undergoing revision ESS and may contribute to the multifactorial pathogenesis of persistent CRS.

Operative time and cost variability for functional endoscopic sinus surgery

BACKGROUND

Understanding the variation in costs of endoscopic sinus surgery (ESS) is critical to defining value. Current published costs of ESS have not identified potential sources of variation. Our objective was to analyze ESS costs to identify sources of variance that could guide value-improving decisions.

METHODS

ESS cases (n = 1739) performed between 2008 and 2016 were identified from a database of 22 rural to tertiary facilities. Cost and time data were extracted from the database. Medical records were reviewed to confirm procedures. Three bilateral groupings were examined (n = 895 cases from 13 facilities): (1) full ESS (all sinuses); (2) intermediate ESS (total ethmoid, maxillary); and (3) anterior ESS (anterior ethmoid, maxillary). Cost and operative time were analyzed using multivariable gamma regression.

RESULTS

Median costs for full, intermediate, and anterior ESS were $4281, $3716, and $2549 U.S. dollars (p < 0.001). Median durations were 87, 60, and 58 minutes (p < 0.001). Among patients with no additional procedures, those with full ESS had operative duration, total cost, and supply costs that were 1.37 (95% confidence interval [CI], 1.17 to 1.61), 1.52 (95% CI, 1.32 to 1.75), and 2.40 (95% CI, 1.76 to 3.25) times greater than anterior ESS, respectively (all p < 0.001). Intermediate ESS duration at community urban facilities was 1.87 (95% CI, 1.74 to 2.02) times that of community rural facilities (p < 0.001).

CONCLUSION

Duration of surgery, extent of surgery, and location of surgery are sources of significant variation in the cost of ESS. These findings will assist healthcare policy makers, hospitals, and surgeons in optimizing the value of ESS.

Nasal Septal Deviation and Concha Bullosa - Do They Have an Impact on Maxillary Sinus Volumes and Prevalence of Maxillary Sinusitis?

Background

The aim of the study was to assess if the presence of nasal septal deviation and concha bullosa is connected with the development of sinuses and the incidence of inflammation within them.

Material/Methods

We retrospectively analysed 214 patients who underwent paranasal sinus computed tomography. There were 125 females and 89 males, the mean age being 47.67±16.74 years (range 18–97). Exclusion criteria included: age under 18 years, prior sinonasal surgery and S-shaped septum.

Results

Mean volume of the right maxillary sinus was 17.794 cm³, while for the left one it was 17.713 cm³. Nasal septal deviation was found in 79.9% of computed tomography examinations and concha bullosa was observed in 42.1% of the patients’ examinations. There was an association between the presence of unilateral or dominant concha bullosa and contralateral direction of septal deviation [right-sided (p=0.039), left-sided (p=0.003)]. There was higher incidence of bilateral maxillary sinusitis in patients with septal deviation (p=0.007). Bilateral concha bullosa did not influence the incidence of bilateral maxillary sinusitis (p=0.495). Neither septal deviation (right sided: p=0.962; left-sided: p=0.731), nor unilateral/dominant concha bullosa (right: p=0.512; left: p=0,430) affected the asymmetry in volumes of maxillary sinuses. Bilateral concha bullosa was connected with larger volume of maxillary sinuses (right sinus: p=0.005; left sinus: p=0.048).

Conclusions

Nasal septal deviation, contrary to concha bullosa, has influence on the development of maxillary sinusitis. There is a connection between the presence of concha bullosa and direction of septal deviation. Only bilateral concha bullosa affects maxillary sinus volumes.

Comparing surgeon outcomes in endoscopic sinus surgery for chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The objective of this investigation was to evaluate endoscopic sinus surgery (ESS) outcomes for chronic rhinosinusitis (CRS) between medical centers to determine if differences in quality-of-life outcomes were detectable. In addition, we sought to identify significant, independent cofactors toward the development of an ESS-specific risk-adjustment model so that ESS outcomes may be appropriately compared between institutions and healthcare providers.

STUDY DESIGN

Prospective, multicenter, observational cohort.

METHODS

Study participants electing ESS for CRS were enrolled and randomly selected in equal numbers from three academic clinical practices in North America between April 2011 and May 2015. The magnitude of average 6-month postoperative improvement in patient-related outcome measures (PROMs) was compared between enrollment sites using multivariate linear regression modeling.

RESULTS

A total of 228 participants met inclusion criteria and were included for final analyses (n = 76 per site). The prevalence of septal deviation/septoplasty and oral corticosteroid-dependent conditions was significantly different between enrollment sites (P ≤ 0.004). Each enrollment site generated significant within-subject improvement across all PROMs after ESS (P < 0.001); however, average unadjusted magnitudes of improvement were significantly different between sites for the primary outcome measure. After controlling for baseline PROMs, septal deviation, steroid-dependent conditions, and medication use variables, enrollment site was no longer associated with significant outcome differences (P = 0.535).

CONCLUSION

Comparison of surgeon outcomes of ESS is feasible and must take into account a number of baseline patient characteristics. Further studies will be critical toward developing an ESS-specific risk-adjustment model and enabling a robust comparison of surgeon outcomes.

LEVEL OF EVIDENCE

2c. Laryngoscope, 127:14-21, 2017.

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.

Is preoperative paranasal sinus computed tomography necessary for every patient undergoing septoplasty?

BACKGROUND

The aim of this study was to determine whether anterior rhinoscopy (AR), nasal endoscopy (NE) and paranasal sinus computed tomography (PNS CT) can predict other sinonasal obstructive pathologies in the setting of nasal septal deviation (NSD), and to evaluate the impact of preoperative PNS CT on the decision for a surgical procedure in patients with NSD.

METHODS

A total of 262 patients with NSD were evaluated using AR, NE, PNS CT, and the visual analogue scale (VAS) for nasal obstruction. The diagnostic values of AR, NE, and PNS CT for sinonasal obstructive pathologies, and the impact of preoperative PNS CT on the decision for a surgical procedure in patients with NSD were evaluated.

RESULTS

PNS CT showed concomitant nasal pathologies in the 62 of 262 patients (23.6%) with NSD. Positive predictive value (PPV) and negative predictive value (NPV) of NE for concomitant nasal pathologies were 0.75 and 0.069, respectively. The sensitivity of NE for sinonasal pathologies was significantly higher in the patients with mild NSD than in the patients with moderate-severe NSD. The decision for a surgical procedure was changed in 22 of 262 (8.3%) patients after a PNS CT.

CONCLUSION

We recommend performing preoperative PNS CTs on patients in whom septoplasty is planned, if they have obstructive middle turbinate hypertrophy, if one is unable to evaluate the middle meatus and posterior nasal cavity because of an anteriorly severe deviation or a nasal polyp, and in patients with chronic sinusitis based on clinical and endoscopic findings.

Relationship between nasal septal deformity, symptoms and disease severity in chronic rhinosinusitis

The objective of this study was to evaluate the interaction of nasal septal deformity (NSD), including the contribution of septal spurs, with the severity of subjective symptoms, impairment of health-related quality of life (HRQoL) and sinus mucosal hyperplasia in patients with chronic rhinosinusitis (CRS). One hundred seventeen patients with CRS were assigned to three groups with mild, moderate or severe NSD, according to the measured nasal septal angle, including the presence of contact septal spurs. All CRS patients completed the visual analog scale (VAS) symptom severity score and the Sino-Nasal Outcome Test (SNOT-22) questionnaire. Symptoms scores, SNOT-22 and Lund-Mackay (LM) scores among the three NSD groups were compared. Related anatomy from the study group was compared with 100 control patients. VAS score for postnasal discharge in CRS patients was significantly higher in patients with mild NSD. There was a significantly higher LM score in CRS patients with severe NSD, compared to those with mild (P = 0.001) or moderate NSD (P = 0.005). CRS patients with a contact spur demonstrated a significantly higher LM score (P = 0.006) compared to those without a contact spur, and no differences in VAS symptom scores or HRQoL scores. There was a similar prevalence of septal deformities in CRS patients and in the non-ENT population. Our results support the conclusion that in patients with CRS, associated NSD or contact septal spur do not contribute significantly to CRS symptom severity or HRQoL impairment, but may have an impact on sinus mucosal hyperplasia.

Using preoperative SNOT-22 score to inform patient decision for Endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

The purpose of this study is to improve patient understanding of surgical outcomes while they make a preference-sensitive decision regarding electing endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS).

STUDY DESIGN

Prospective observational cohort study.

METHODS

Patients with CRS who elected ESS were prospectively enrolled into a multi-institutional, observational cohort study. Patients' were categorized into 10 preoperative Sino-Nasal Outcome Test (SNOT-22) groups based on 10-point increments beginning with a score of 10 and ending at 110. The proportion of patients achieving a SNOT-22 minimal clinically important difference (MCID) (9 points) and the percentage of relative improvement (%) for each preoperative SNOT-22 group were calculated. A subgroup analysis based on polyp status was performed.

RESULTS

A total of 327 patients were included in this study. Patients with a SNOT-22 score between 10 and 19 had the lowest chance of achieving an MCID (37.5%) and received a relative mean worsening of their quality of life (QoL) after ESS (+18.8%). Patients with a SNOT-22 score greater than 30 obtained a greater than 75% chance of achieving an MCID, and there was a relative improvement of 45% in QoL (all < -44.9%) after ESS. Outcomes from the polyp status subgroup analysis were similar to the findings from the overall cohort.

CONCLUSION

Outcomes from this study suggest that patients with a preoperative SNOT-22 score higher than 30 points receive a greater than 75% chance of achieving an MCID and on average obtain a 45% relative improvement in their QoL after ESS. Patients with SNOT-22 score of less than 20 did not experience improved QoL from ESS.

Can FESS combined with submucosal resection (SMR)/septoplasty reduce revision rate?

OBJECTIVES

Our study was designed to ascertain the outcomes of functional endoscopic sinus surgery (FESS) combined with submucosal resection (SMR)/septoplasty in reducing FESS revision rates.

STUDY DESIGN

Retrospective population-based study.

SETTING

Academic tertiary medical center.

SUBJECTS AND METHODS

By using the Taiwan Longitudinal Health Insurance Database, we obtained the patients who underwent FESS for chronic rhinosinusitis. These patients were divided into 2 groups: the control group (FESS alone) and the study group (FESS combined with SMR). The primary outcome was the revision operative rate.

RESULTS

In total, 4484 patients who had undergone FESS were recruited into this study. The number of patients who underwent revision FESS was 528 (11.78%). In our sample, 80.45% of patients received FESS alone, whereas 19.54% of the patients underwent concurrent SMR/septoplasty during FESS. There are more female patients and older patients in the control group than in the study group. The revision rates of these 2 groups were significantly different (12.36% vs 9.36%, respectively; P = .016). Moreover, logistic regression analysis came out that patients in the control group had a higher revision rates than those in the study group. Male patients and younger patients were found to have higher revision rates. In addition, patients with asthma or allergic rhinitis had higher revision rates compared with those patients without these 2 comorbidities.

CONCLUSIONS

This study showed an association between FESS combined with concurrent SMR/septoplasty and less incidence of revision rate of FESS. Patients with asthma or allergic rhinitis have an increased risk of requiring more revision surgeries after FESS.

The role of immediate postoperative systemic corticosteroids when utilizing a steroid-eluting spacer following sinus surgery

OBJECTIVE

Steroid-eluting spacers can improve local drug delivery immediately following endoscopic sinus surgery and reduce the recurrence of inflammation warranting systemic corticosteroids. For chronic rhinosinusitis with nasal polyposis, the need for systemic corticosteroids immediately following endoscopic sinus surgery when using a steroid-eluting spacer has not been studied.

STUDY DESIGN

A randomized, double-blind, placebo-controlled trial.

SETTING

Academic rhinology practice.

SUBJECTS AND METHODS

Chronic rhinosinusitis patients with nasal polyposis who failed medical therapy and elected endoscopic sinus surgery were enrolled. Patients were randomized into either the treatment arm (postoperative prednisone 30 mg daily × 7 days; n = 18) or placebo arm (postoperative placebo pill daily × 7 days; n = 18). Outcomes were evaluated at 1 week, 3 weeks, and 2 months postoperatively. Primary outcome was endoscopic grading at postoperative month 2 using the Lund-Kennedy system. Secondary outcome included disease-specific quality of life using the Sinonasal Outcome Test (SNOT-22) survey. Patient enrollment occurred from January 2012 through February 2013 (NCT01564355).

RESULTS

Both arms received significant improvement in endoscopic grading and disease-specific quality of life from baseline compared to 2-month follow-up (P < .001). There were no significant differences in mean endoscopic scores between the postoperative prednisone and control groups at 1 week (P = .715), 3 weeks (P = .883), or 2 months (P = .343). There were no significant differences in SNOT-22 scores between groups at all follow-up points (all P > .119).

CONCLUSION

Minimizing systemic corticosteroid use in patients with chronic rhinosinusitis with nasal polyposis may avoid adverse events. Results from this study suggest that postoperative systemic corticosteroids immediately following endoscopic sinus surgery may not provide improved outcomes when utilizing a steroid-eluting spacer.

Impact of synechiae after endoscopic sinus surgery on long-term outcomes in chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

Synechiae are one of the most common unwanted outcomes after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). However, there has been scant investigation into the true significance of synechiae formation after ESS. The aim of this study was to evaluate the impact of synechiae formation on health-related quality of life (HRQoL) outcomes after ESS in patients with CRS.

STUDY DESIGN

Prospective, multi-institutional cohort.

METHODS

Rhinosinusitis Disability Index (RSDI) and Chronic Sinusitis Survey (CSS) scores were measured in adult patients before and after undergoing ESS for CRS. Differences in HRQoL were evaluated between those who developed sinonasal synechiae and those who did not, controlling for demographic factors, medical comorbidities, and measures of disease severity at baseline.

RESULTS

A total of 286 patients underwent ESS, with 55 (19.2%) developing synechiae in the follow-up period. Patients developing synechiae reported significantly less improvement on the RSDI total scores (13.5 vs. 21.4, P = 0.008), RSDI physical subscores (5.3 vs. 8.3, P = 0.007), RSDI emotional subscores (2.9 vs. 5.8, P = 0.008), CSS total scores (14.5 vs. 21.2, P = 0.093), and CSS symptom subscores (19.9 vs 30.3, P = 0.069) compared to those who did not develop synechiae postoperatively. These differences persisted even after controlling for baseline differences in disease severity.

CONCLUSIONS

Synechiae of the sinonasal cavity commonly occurs following ESS, particularly in those undergoing revision surgeries. Although both groups improve, the degree of HRQoL improvement appears to be less in those who form postoperative synechiae after surgery compared to those who do not.