Endoscopic endonasal sinus surgery: a review of 18 years of practice and long-term follow-up

Long-Term Clinical Follow-Up of Patients With Chronic Rhinosinusitis

Objective:

This study comprised a long-term follow-up of a cohort of patients with chronic rhinosinusitis (CRS) regarding clinical features and symptomatology.

Methods:

Data from 42 patients with CRS were available from a previous study. Forty of these patients were alive and were contacted for inclusion after approximately 10 years. Patients completed a questionnaire about disease and symptoms, and underwent a clinical examination.

Results:

Thirty-four patients (85%) responded and could be included and evaluated. For the participants in this follow-up study median length of time between initial inclusion (C1) and follow-up (C2) was 11 years (range: 8-15). In some patients the CRS shifted phenotype over time, from CRS with nasal polyposis to CRS without nasal polyposis or vice versa. The median total visual analogue score for combined sinonasal symptoms for all patients was statistically significantly reduced at follow-up. For individual patients, scores for nasal congestion, nasal discharge, facial pressure, and hyposmia were also statistically significantly reduced. The most frequently reported symptom-relieving treatments were nasal steroids and saline rinsing of the nose. Self-reported general quality of life was statistically significantly improved at C2 compared to C1.

Conclusion:

At long-term follow-up, symptoms were generally reduced and patients reported an improved quality of life. Patients can be given hope for eventual symptom relief. CRS is a chronic condition that seems to harbor the ability to alter its phenotype after several years. Topical corticosteroids and saline rinsing of the nose should be emphasized, since patients consider these treatments to be of high value.

Healthcare utilisation, follow-up of guidelines and practice variation on rhinosinusitis in adults: A healthcare reimbursement claims study in The Netherlands

Objectives

To provide insight into healthcare utilisation of rhinosinusitis, compare data with clinical practice guideline recommendations and assess practice variation.

Design

Anonymised data from claims reimbursement registries of healthcare insurers were analysed, from 1 January 2016 until 31 December 2016.

Setting

Secondary and tertiary care in the Netherlands.

Participants

Patients ≥18 years with diagnostic code “sinusitis.”

Main outcome measures

Healthcare utilisation (prevalence, co‐morbidity, diagnostic testing, surgery), costs, comparison with guideline recommendation, practice variation.

Results

We identified 56 825 patients, prevalence was 0.4%. Costs were € 45 979 554—that is 0.2% of total hospital‐related care costs (€21 831.3 × 10⁶). Most patients were <75 years, with a slight female preponderance. 29% had comorbidities (usually COPD/asthma). 9% underwent skin prick testing, 61% nasal endoscopy, 2% X‐ray and 51% CT. Surgery rate was 16%, mostly in daycare. Nearly, all surgical procedures were performed endonasally and concerned the maxillary and/or ethmoid sinus. Seven recommendations (25%) could be (partially) compared to the distribution of claims data. Except for endoscopy, healthcare utilisation patterns were in line with guideline recommendations. We compared results for three geographical regions and found generally corresponding rates of diagnostic testing and surgery.

Conclusion

Prevalence was lower than reported previously. Within the boundaries of guideline recommendations, we encountered acceptable variation in healthcare utilisation in Dutch hospitals. Health reimbursement claims data can provide insight into healthcare utilisation, but they do not allow evaluation of the quality and outcomes of care, and therefore, results should be interpreted with caution.

[Orbital complications]

A disease or symptom of disease spreading from the vicinity of the orbit to the internal structures of the orbit is referred to as an orbital complication. Orbital complications can have a traumatic, inflammatory, allergic, or autoimmunologic cause. They are more frequent in children than adults. The present review aims to provide a description of orbital complications, their etiology, pathogenesis, and treatment. Recent literature in the field is acknowledged and discussed, and results from the authors' own patient groups are analyzed. Particular attention is paid to orbital complications due to acute sinusitis and those caused by acute hemorrhage. The term "orbital phlegmon" frequently used for orbital complications with inflammatory causes is confusing and should be replaced by differentiated grading. Diagnosis and treatment of orbital complications requires interdisciplinary collaboration, whereby inclusion of ophthalmologists is particularly important. Treatment of orbital complications depends on their cause. In inflammatory cases affecting only the preseptal tissues and compartment, conservative therapy is indicated. If clinical findings worsen within 24 h of conservative therapy, or if the patient presents with a high-grade orbital complication with loss of visual acuity or impairment of globe mobility, surgery is required. In cases of acute hemorrhage into the orbit, a procedure for decreasing intra-orbital pressure is mandatory (i. e., canthotomy, cantholysis, orbital decompression).

The Preoperative Sinus CT: Avoiding a "CLOSE" Call with Surgical Complications

Although functional endoscopic sinus surgery is an effective means of treating patients with recurrent and refractory sinusitis, the procedure is not without risk of serious surgical complications. Preoperative computed tomography (CT) affords radiologists the opportunity to prospectively identify anatomic variants that predispose patients to major surgical complications; however, these critical variants are not consistently evaluated or documented on preoperative imaging reports. The purpose of this review is to illustrate important anatomic variants and landmarks on the preoperative sinus CT with a focus on those that predispose patients to surgical complications. These critical variants and landmarks can be quickly recalled and incorporated into the preoperative imaging report through the use of the mnemonic "CLOSE": Cribriform plate, Lamina papyracea, Onodi cell, Sphenoid sinus pneumatization, and (anterior) Ethmoidal artery. This approach will greatly enhance the value of the preoperative imaging report for referring otolaryngologists and help reduce the risk of surgical complications. (©) RSNA, 2016 Online supplemental material is available for this article.

The effect of blood pressure and cardiac output on the quality of the surgical field and middle cerebral artery blood flow during endoscopic sinus surgery

BACKGROUND

A clear surgical field is critical during endoscopic sinus surgery (ESS). Hypotensive anesthesia and cardiac output (CO) may optimize the surgical field; however, evidence of their effect on bleeding and cerebral blood flow is conflicting. The aim of this study was to evaluate the effect of blood pressure (BP) and CO on intraoperative bleeding and middle cerebral artery blood flow velocity (Vmca ) during ESS.

METHODS

This was a prospective randomized controlled trial. Patients undergoing ESS for chronic rhinosinusitis at a tertiary institution in 2013 were randomized to receive BP manipulation using target-controlled noradrenaline infusion during surgery to either their left or right sinuses. The contralateral side in each patient served as control. Bleeding was scored using a 0 to 10 point bleeding assessment scale (BAS, 0-10) and Vmca was measured using transcranial Doppler ultrasonography every 10 minutes or when surgically opportune, and time-matched with BP and CO. Data was analyzed using Bland-Altman methods.

RESULTS

A total of 105 time points were collected across a mean arterial pressure (MAP) range of 32 to 118 mmHg. Significant correlations were demonstrated between MAP and Vmca (r = 0.7, p < 0.0001), MAP and BAS (r = 0.50, p < 0.0001), CO and Vmca (r = 0.57, p < 0.0001), and CO and BAS (r = 0.42, p < 0.0001). The best surgical fields were seen at 40 to 59 mmHg MAP. However, MAP below 60 mmHg produced >50% reduction in Vmca in more than 10% of time points.

CONCLUSION

Balancing surgical visibility with organ perfusion remains a challenge. The results of this study show that moderate hypotension significantly improves the surgical field; however reducing BP below 60 mmHg may risk cerebral hypoperfusion.

Imaging of the Paranasal Sinuses: Mitigation, Identification, and Workup of Functional Endoscopic Surgery Complications

The purpose of this article is to identify and define the appropriate imaging techniques in the evaluation of post-functional endoscopic surgery (FESS) complications. Although most complications encountered during FESS are identified readily during surgery, some are less conspicuous and require postoperative imaging. As illustrated in this article, these include cerebrospinal fluid leak, vascular injury, brain injury, orbital injury, and infectious complications of the brain and meninges. Some of the common anatomic variants of the paranasal sinuses are identified, and how these may predispose to surgical complications is discussed.

Variations of lamina papyracea position from the endoscopic view: a retrospective computed tomography analysis

BACKGROUND

Accidental injury of lamina papyracea (LP) remains one of the most common complications reported in endoscopic sinus surgery (ESS) even in most recent studies. The purpose of this study was to categorize the LP position radiologically and from an endoscopic perspective.

METHODS

A total of 207 computed tomography (CT) scans (414 sides) including both diseased and control groups were retrospectively reviewed by 2 examiners. Inferior turbinate attachment to the lateral nasal wall and the inferior margin of the planned middle meatal antrostomy (MMA) were identified anteriorly. Position of LP in relation to the vertical line passing through MMA inferior margin was reported. LP was categorized to lie either within 2 mm on either side of the MMA inferior margin (type I), more than 2 mm medial to the MMA line (type IIa: 2 to 4 mm; type IIb: >4 mm), or more than 2 mm lateral to the MMA line (type IIIa: 2 to 4 mm; type IIIb: >4 mm).

RESULTS

Of the 221 sides in the control group, 69.7% were classified as type I, 24.9% as type II, and 5.5% as type III. Among the 193 diseased operated sides examined, 60.1% were classified as type I, 20.2% as type II, and 13.5% as type III. Weighted kappa coefficient showed good interexaminer reliability. Five sides (2.6%) in the case group had accidental LP penetration intraoperatively, 4 of them were type II and type III LP.

CONCLUSION

This study improves surgeons' awareness of LP variations in the endoscopic field and can be of help for residents in training.

Endoscopic sinus surgery: a safe procedure among the less experienced surgeons?

OBJECTIVES

To determine the incidence of complications in endoscopic sinus surgery (ESS), in a surgical centre with 20 years of experience, and whether or not the surgeon's experience can be a predisposing factor for them to happen.

METHODS

The clinical data of the 667 patients who were submitted to EES between January of 2006 and December 2009, was reviewed, and the perioperative and postoperative complications were evaluated, with a minimum follow up period of 3 months. For each surgery, the surgeon's experience as well as surgery particularities, were correlated with the presence of complications.

RESULTS

In the 677 surgeries, the incidence of complications was of 7.39% (5.91% minor and 1.48% major). There was no correlation between surgery complications and the years of experience of the main surgeon. When comparing the complication rate between residents and specialists, there were no statistically significant differences between them. Extensive surgeries, revision surgeries and the presence and grade of polyposis, were associated with a higher rate of complications.

CONCLUSIONS

ESS is not a risk free procedure. Complications can happen regardless of the surgeońs experience. Patients who are submitted to surgery by residents, under the supervision of a senior doctor, are not at greater risks of complications.

Neuro-ophthalmic complications of endoscopic sinus surgery

PURPOSE OF REVIEW

This review aims to provide an overview of powered endoscopic sinus surgery and raise awareness of the possible neuro-ophthalmic complications associated with the procedure.

RECENT FINDINGS

The neuro-ophthalmic complications of endoscopic sinus surgery can be categorized into five anatomic sites: eye, orbit, optic nerve, extraocular muscle, and lacrimal drainage system. Double vision may be caused by various ocular motility abnormalities. Visual loss may be the result of orbital hemorrhage or direct optic nerve trauma.

SUMMARY

A wide range of neuro-ophthalmic complications may occur during endoscopic sinus surgery. The use of powered cutting instruments has been a recent advance in endoscopic sinus surgery, but it has also been implicated in rapid, irreversible, and devasting complications. Multiple preoperative and intraoperative factors appear to be involved in the adverse events associated with endoscopic sinus surgery. Ophthalmologists may be asked to evaluate and manage ocular damage in patients who have undergone endoscopic sinus surgery, and in some cases emergent intervention may be required in an attempt to avoid permanent visual loss.