Advances in the surgical management of chronic sinusitis and nasal polyps

The Development of Dry Eye Disease After Surgery-Indicated Chronic Rhinosinusitis: A Population-Based Cohort Study

We aim to evaluate the risk of dry eye disease (DED) occurrence in patients with surgery-indicated chronic rhinosinusitis (CRS) via the national health insurance research database in Taiwan. After exclusion, patients with a diagnostic code of CRS and had received functional endoscopic sinus surgery (FESS) were regarded as having surgery-indicated CRS and enrolled in the study group, then each patient in the study group was age- and gender-matched to four non-CRS patients that served as the control group. The outcome was considered as the development of DED and Cox proportional hazard regression was used for the statistical analysis, which involved multiple potential risk factors of DED. A total of 6076 patients with surgery-indicated CRS that received FESS and another 24,304 non-CRS individuals were enrolled after exclusion. There were 317 and 770 DED events in the study group and the control group during the 16-year follow-up interval, and the study group demonstrated a significantly higher adjusted hazard ratio (1490, 95% confidence intervals (CI): 1.303-1.702) of DED development compared to the control group in the multivariable analysis. In addition, the cumulative probability analysis illustrated a positive correlation of DED occurrence and the disease period of surgery-indicated CRS (p < 0.0001). In the subgroup analysis, both genders revealed a higher but not significant incidence of developing DED in the study group. In conclusion, the existence of surgery-indicated CRS will increase the risk of developing DED, which correlated to the disease interval.

The Development of Glaucoma after Surgery-Indicated Chronic Rhinosinusitis: A Population-Based Cohort Study

This study investigates the development of glaucoma in subjects with surgery-indicated chronic rhinosinusitis (CRS) by the use of the National Health Insurance Research Database in Taiwan. Individuals that received the functional endoscopic sinus surgery (FESS) with a diagnostic code of CRS were regarded as surgery-indicated CRS and enrolled in the study group. Four non-CRS patients were age- and gender-matched to each patient in the study group. The exclusion criteria included legal blindness, ocular tumor, history of eyeball removal, and previous glaucoma. The outcome was regarded as the development of glaucoma, and conditional logistic regression was used for the statistical analysis, which involved multiple potential risk factors in the multivariate model. A total of 6506 patients with surgery-indicated CRS that received FESS and another 26,024 non-CRS individuals were enrolled after exclusion. The age and gender distributions were identical between the two groups due to matching. There were 108 and 294 glaucoma events in the study group and control group, respectively, during the follow-up period, and the study group had a significantly higher adjusted hazard ratio (1.291, 95% confidential interval: 1.031–1.615). The cumulative probability analysis also revealed a correlation between the occurrence of glaucoma and the CRS disease interval. In the subgroup analysis, the chance of developing open-angle glaucoma and normal-tension glaucoma was significantly higher in the study group than in the control group. In conclusion, the existence of surgery-indicated CRS is a significant risk factor for the development of glaucoma, which correlated with the disease interval.

The development of optic neuropathy after chronic rhinosinusitis: A population-based cohort study

Background

To evaluate the risk of developing optic neuropathy (ON) in patient with both non-surgery and surgery-indicated chronic rhinosinusitis (CRS) via the national health insurance research database in Taiwan.

Methodology/Principal findings

44,176 Patients with a diagnostic code of CRS was selected, which included 6,678 received functional endoscopic sinus surgery (FESS) regarded as the surgery-indicated CRS. Each individual in the study group was matched to two non-CRS patients by age and gender. The outcome was set as the occurrence of ON according to the diagnostic codes occurred after the index date. Poisson regression was used to calculate the adjusted relative risk (aRR) and conditional Cox proportional model was used to estimate the adjusted hazard ratio (aHR). There were 131 and 144 events of ON occurred in the study group and the control group respectively during the follow-up period. The whole study group, whether received FESS or not, demonstrated both significant aRR and aHR compared to the control group after adjusting demographic data, prominent ocular diseases, and systemic co-morbidities. In addition, both the aRR and aHR were higher in CRS patient received FESS than those with CRS but without FESS management.

Conclusion

The existence of CRS, especially the surgery-indicated CRS is a significant risk factor for the following ON using multivariable analysis.

The Development of Keratopathy after Surgery-Indicated Chronic Rhinosinusitis: A Population-Based Cohort Study

The aim of the present study was to evaluate the risk of developing keratopathy in patients with surgery-indicated chronic rhinosinusitis (CRS) via the National Health Insurance Research Database in Taiwan. Patients with a diagnostic code of CRS and who received functional endoscopic sinus surgery (FESS) were considered to have surgery-indicated CRS. The exclusion criteria were legal blindness, an ocular tumor, eyeball removal or previous keratopathy, and each individual in the study group was matched to four non-CRS patients by age and sex. The outcome was set as the occurrence of keratopathy according to the diagnostic codes after the index date. Cox proportional hazard regression was used for statistical analysis. A total of 6053 patients with surgery-indicated CRS and another 24,212 non-CRS individuals were enrolled after exclusions. The age and sex distributions were identical between the two groups due to matching, while comorbidities, including hypertension, diabetes mellitus, and other cardiovascular disorders, were significantly higher in the study group. There were 231 episodes of keratopathy in the study group, and 695 episodes of keratopathy in the control group after the index date, for which study group showed a significantly higher rate of developing keratopathy with an adjusted hazard ratio of 1.208 and a higher cumulative probability. In subgroup analysis, female sex with surgery-indicated CRS showed a significantly greater risk of developing keratopathy. In conclusion, surgery-indicated CRS that needs FESS to relieve symptoms is a potential risk factor for keratopathy.

Evaluation of a new and simple classification for endoscopic sinus surgery

OBJECTIVE

In 2013, the Japanese Rhinologic Society proposed a simple classification for endoscopic sinus surgery (ESS). This classification consists of five procedures (type I, fenestration of the ostiomeatal complex, with uncinectomy and widening of the natural ostium; type II, single-sinus procedure, with manipulating the inside of the sinus; type III, polysinus procedure; type IV, pansinus procedure; type V, extended procedure beyond the sinus wall). The clinical relevance of this classification in chronic rhinosinusitis (CRS) and paranasal sinus cyst was evaluated.

STUDY DESIGN

A retrospective validation study.

METHODS

A total of 122 patients (195 sinuses) who underwent ESS in Okayama University Hospital in 2012 were enrolled. The relationships between the ESS classification and the clinical course, including the operation time, bleeding amounts during surgery and postoperative changes of olfaction, the computed tomography (CT) score, and nasal airway resistance were analyzed.

RESULTS

A total of 195 ESS procedures were classified into type I (n = 3), type II (n = 17), type III (n = 91), type IV (n = 82), and type V (n = 2). The major phenotypes of type II, III, and IV ESS were paranasal sinus cyst (68%), CRS without nasal polyps (77%), and CRS with nasal polyps (55%), respectively, and the difference was significant. The degree of ESS based on this classification was positively and significantly correlated with the operation time and bleeding amounts. As a whole, olfaction, CT score, and nasal airway resistance were significantly improved after surgery. The degree of improvement was similar between type III and type IV ESS.

CONCLUSION

This simple classification for ESS reflected the perioperative burden of the disease.

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.

Association of the -33C/G OSF-2 and the 140A/G LF gene polymorphisms with the risk of chronic rhinosinusitis with nasal polyps in a Polish population

Nasal polyps are strongly associated with a risk of chronic rhinosinusitis development as well as other obstruction including asthma and allergy. The following study tested the association of the 140A/G polymorphism of lactoferine (LF) encoding gene and the -33C/G polymorphism of osteoblast-specific factor-2 (OSF-2) encoding gene with a risk of chronic rhinosinusitis with nasal polyps in a Polish population. One hundred ninety five patients of chronic rhinosinusitis with nasal polyps as well as 200 sex, age and ethnicity matched control subjects without chronic sinusitis and nasal polyps were enrolled in this study. Among the group of patients 63 subjects were diagnosed with allergy and 65 subjects with asthma, respectively. DNA was isolated from peripheral blood lymphocytes of patients as well as controls and gene polymorphisms were analyzed by restriction fragments length polymorphism polymerase chain reaction (RFLP-PCR). We reported that the 140A/G LF (OR 4.78; 95% CI 3.07-7.24), the -33C/G OSF-2 OR 3.48; 95% CI 2.19-5.52) and the -33G/G OSF-2 (OR 16.45; 95% CI 6.71-40.30) genotypes were associated with an increased risk of chronic rhinosinusitis with nasal polyps among analyzed group of patients. Moreover, the group of patients without allergy or asthma indicated the association of the -33C/G (OR 3.72; 95% CI 2.24-6.19 and OR 15.11; 95% CI 5.91-38.6) and -33G/G (OR 3.73; 95% CI 2.24-6.19 and OR 14.07; 95% CI 5.47-36.16) genotypes of the OSF-2 as wells as 140A/G (OR 3.89; 95% CI 2.40-6.31 and OR 3.62; 95% CI 2.45-5.34) genotype of OSF-2 with an increased risk of chronic rhinosinusitis with nasal polyps. Finally, it was also found that the selected group of patients with allergy or asthma indicated a very strong association of the -33C/G (OR 2.40; 95% CI 1.23-4.69 and OR 2.40; 95% CI 1.23-4.69, respectively) and -33G/G (OR 16.01; 95% CI 5.77-44.41 and OR 17.90; 95% CI 6.53-49.05, respectively) genotypes of the OSF-2 as wells as 140A/G (OR 3.22; 95% CI 1.74-6.11 and OR 3.25; 95% CI 1.75-6.04, respectively) genotypes with an increased risk of chronic rhinosinusitis with nasal polyps. Thus, our results suggest that LF and OSF-2 gene polymorphisms may have deep impact on the risk of rhinosinusitis nasal polyps' formation which may also depend on asthma or allergy. Our results showed that the 140A/G polymorphism of LF gene and the -33C/G polymorphism of the OSF-2 gene may be associated with the risk of chronic rhinosinusitis with nasal polyps in a Polish population.