Correlation between computed tomography scores and symptomatic improvement after endoscopic sinus surgery

Which is Better in Predicting CT Scores in Patients with Chronic Rhinosinusitis after Medical treatment-Baseline Rhinosinusitis Disability Index (RSDI) or Endoscopic Score?

Introduction

Rhinosinusitis disability index (RSDI) questionnaire is used to assess the severity of chronic rhinosinusitis (CRS) from the patient's perspective. The severity of CRS can be measured objectively with the endoscope and computed tomogram (CT) using the Lund-Kennedy endoscopic score and Mackay-Lund scores respectively. The objective of the study is to evaluate whether baseline RSDI and Lund-Kennedy (LK) endoscopy scoring can help predict the Mackay-Lund CT (MKLCT) scores after medical treatment in patients with CRS.

Methodology

This is a prospective, observational study, carried out from 1st October 2017 to 30th September 2019 in the ENT out- patient department at a tertiary hospital in Northern India. 90 patients diagnosed with CRS were enrolled consecutively in the study. RSDI questionnaire was filled out for all the participants. They all underwent a diagnostic endoscopy and CRS was graded according to the Lund-Kennedy endoscopic scores. All participants were given medical treatment. Patients underwent CT of the paranasal sinuses after medical treatment and the MLKCT scores were calculated. The baseline RSDI and Lund-Kennedy scores were correlated with the MKLCT scores using Spearman's Rank correlation tests. The diagnostic ability of the RSDI and LK endoscopy scores to predict the least MKLCT scores was compared using the receiver operator characteristics curves (ROC).

Results

A statistically significant correlation was seen with LK endoscopy scores and MKLCT scores (r = 0.396, p < 0.001) Among the individual parameters of the LK endoscopy scores only the polyp score had a statistically significant correlation with MKLCT scores (r = 0.593, p < 0.001). A weak negative correlation (r = - 0.058, p = 0.586) was seen between the RSDI scores and MKLCT scores. AUC in ROC curves for a LK endoscopy scores and RSDI scores were 0.690 and 0.462 respectively. Cut-off for predicting a MKLCT score of one or more for RSDI score was 25, with a sensitivity of 61% and specificity of 38.5%. Similarly, the cut-off for LK endoscopic score was 4.5, with a sensitivity of 68.8% and specificity of 61.5%.

Conclusion

Statistically significant (p < 0.001) association was found between baseline Lund-Kennedy endoscopic scores and Mackay-Lund CT scores post medical treatment. No significant association was found between RSDI scores and Mackay-Lund CT scores. ROC analysis indicated that Lund- Kennedy endoscopy score is a more accurate tool than RSDI score to predict a Mackay-Lund CT scores after medical treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04708-6.

Association of Sinonasal Computed Tomography Scores to Patient-Reported Outcome Measures: A Systematic Review and Meta-analysis

OBJECTIVE

To perform a systematic review of proposed sinus computed tomography (CT) scoring systems and determine their association with patient-reported outcome measures (PROMs).

DATA SOURCES

PubMed, CINAHL, Scopus, and Cochrane Library.

REVIEW METHODS

A systematic search was conducted following the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) for studies describing CT scores and PROMs in patients with chronic rhinosinusitis.

RESULTS

A total of 144 studies were included. Out of 20,741 patients, 53.6% were male and 55.5% had nasal polyposis. A meta-analysis of correlations revealed a moderate correlation between Lund-McKay (LM) and the 22-item Sinonasal Outcome Test (SNOT-22; r = 0.434, P < .001) and a weaker correlation between LM and the 20-item Sinonasal Outcome Test (SNOT-20; r = 0.257, P = .039). Meta-regression also revealed a weak association between LM and SNOT-20 (n = 25 studies) but no significant associations between Zinreich score and SNOT-22 or LM scores and PROMs, including SNOT-22 (n = 94 studies), Rhinosinusitis Disability Index (n = 25), nasal obstruction visual analog scale (n = 15), Chronic Sinusitis Survey (n = 12), Total Nasal Symptom Score (n = 4), Total Symptom Score (n = 3), and 12-Item Short Form Health Survey (n = 3).

CONCLUSION

There is essentially little association between radiologic grade and PROMs. CT grading systems with improved clinical utility are needed.

Quality of life in CRSwNP: evaluation of ACCESS and Lund-Mackay computed tomography scores versus the QoL questionnaire

PURPOSE

Recently, a new CT scan classification of the extent of previous endoscopic sinus surgery called The Amsterdam Classification of Completness of Endoscopic Sinus Surgery (ACCESS) was published. The aim of this study was to investigate possible associations between traditionally used Lund-Mackay CT score and ACCESS score and their possible relationship to pre- and postoperative quality of life in a narrowly defined group of patients with recurrent CRSwNP.

METHODS

Forty-nine patients who underwent a revision ESS for CRSwNP were enrolled in a retrospective study. CT imaging scans were evaluated, LM and ACCESS scores determined. All patients completed the validated Czech version of the SNOT-22 questionnaire before and 6 months after surgery. The correlation between the two CT scores and the QoL questionnaire was tested using Pearson's correlation tests.

RESULTS

No correlation was demonstrated between LM scores and patient-based SNOT-22 scores neither preopratively nor postoperatively (r = - 0.0580; p = 0.918 and r = 0.0252; p = 0.8634, respectively. Similarly, no correlation was found between the ACCESS score and SNOT-22 before and after surgery (r = - 0.1988; p = 0.1708 and r = - 0.943; p = 0.5193, respectively). No linear relationship was demonstrated between the LM score and the ACCESS score (r = 0.075; p = 0.6053).

CONCLUSIONS

The results show that even the CT score evaluating the completeness of previous procedures has no linear relationship to the quality of life preoperatively and cannot serve as a predictor for the outcomes of surgical treatment. This study also confirms that ACCESS evaluates a different aspect of the radiological finding than the traditionally used LM score.

Correlation of Clinical Symptoms With Nasal Endoscopy and Radiological Findings in the Diagnosis of Chronic Rhinosinusitis: A Prospective Observational Study

INTRODUCTION

In the diagnosis of chronic rhinosinusitis (CRS), computed tomography (CT) of the nose and paranasal sinuses (PNS) remains the gold standard investigation. Though the diagnostic nasal endoscopy (DNE) is an equally effective and easily available investigation for diagnosis of CRS, its reliability and clinical significance to that of patient's symptoms have to be proven.

OBJECTIVE

The purpose of this study is to determine the correlations between the symptom severity score, radiological score, and the endoscopic score in the diagnosis of CRS.  Methods: This prospective observational study included 70 patients with CRS. It was conducted in a tertiary care institute from January 2019 to June 2020. All patients were subjected to DNE and CT nose and PNS. Symptom score was assessed using Visual Analogue Scale (VAS) score of 0-10. DNE and CT scores were calculated using the Lund-Kennedy endoscopic scoring system and the Lund-Mackay CT scoring system, respectively. The correlation between these scores were done using Pearson's correlation coefficient (p-value).

RESULTS

The mean and standard deviation of the symptom score by VAS was 7 ± 1.7; the Lund-Kennedy score was 7.6 ± 2.3, and the Lund-Mackay score was 14.3 ± 6.5, respectively. The symptom score had moderate correlation with the Lund-Kennedy Score (r = 0.643, p < 0.001) and high degree of correlation with the Lund-Mackay Score (r = 0.835, p < 0.001). The Lund-Kennedy score had a positive correlation with The Lund-Mackay score.

CONCLUSION

DNE can be utilized as an early diagnostic tool in the clinical evaluation of CRS and is equally effective as CT in diagnosing the same. At the same time, a CT scan can be done in patients with positive symptoms and can be reserved as a second-level investigation for those patients with negative endoscopic findings but who become symptomatic on follow-up.

A systematic review to examine the relationship between objective and patient-reported outcome measures in sinonasal disorders: recommendations for use in research and clinical practice

BACKGROUND

Common sinonasal disorders include chronic rhinosinusitis (CRS), allergic rhinitis (AR), and a deviated nasal septum (DNS), which often coexist with shared common symptoms including nasal obstruction, olfactory dysfunction, and rhinorrhea. Various objective outcome measures and patient-reported outcome measures (PROMs) are used to assess disease severity; however, there is limited evidence in the literature on the correlation between them. This systematic review aims to examine the relationship between them and provide recommendations.

METHODS

A search of MEDLINE and EMBASE identified studies quantifying correlations between objective outcome measures and PROMs for the sinonasal conditions using a narrative synthesis.

RESULTS

In total, 59 studies met inclusion criteria. For nasal obstruction, rhinomanometry shows a lack of correlation whereas peak nasal inspiratory flow (PNIF) shows the strongest correlation with PROMs (r > 0.5). The Sniffin' Stick test shows a stronger correlation with PROMs (r > 0.5) than the University of Pennsylvania Smell Identification Test (UPSIT) (r < 0.5). Computed tomography (CT) sinus scores show little evidence of correlation with PROMs and nasal endoscopic ratings (weak correlation, r < 0.5).

CONCLUSION

Overall, objective outcome measures and PROMs assessing sinonasal symptoms are poorly correlated, and we recommend that objective outcome measures be used with validated PROMs depending on the setting. PNIF should be used in routine clinical practice for nasal obstruction; rhinomanometry and acoustic rhinometry may be useful in research. The Sniffin' Sticks test is recommended for olfactory dysfunction with UPSIT as an alternative. CT scores should be excluded as a routine CRS outcome measure, and endoscopic scores should be used in combination with PROMs until further research is conducted.

Sinonasal Outcome Scores and Imaging: A Concurrent Assessment of Factors Influencing Their Association

OBJECTIVE

The overall discriminatory ability of validated instrument scores for computed tomography (CT) findings of chronic rhinosinusitis has limitations and may be modified by multiple factors. To support optimal methods for assessment, we studied which factors could influence this relationship, including the concurrent impact of multiple discrete CT scoring mechanisms, colocalized imaging findings, and nasal comorbid conditions.

STUDY DESIGN

Observational outcomes study.

SETTING

Academic medical center.

METHODS

Patients with sinonasal complaints who completed the 22-item Sinonasal Outcome Test (SNOT-22) and underwent CT were included. Multivariate ordinal regression was utilized to assess associations. CT data were quantified with the Lund-Mackay system, Zinreich system, and a direct measure of maximal mucosal thickness. The impact of incidental findings (mucous retention cysts, periapical dental disease) and nasal comorbid conditions was also assessed.

RESULTS

A total of 233 patients were included. SNOT-22 nasal scores were significantly associated with CT results when those with incidental findings were excluded, regardless of the radiologic scoring mechanism utilized: Lund-Mackay regression coefficient, 0.321 (P = .046); Zinreich, 0.340 (P = .033); and maximum mucosal thickness, 0.316 (P = .040). This relationship subsided when incidental findings were present. SNOT-22 overall scores, sleep scores, and psychological domain scores had no significant association with imaging results, regardless of radiologic scoring system utilized. Nasal comorbid conditions had inconsistent associations.

CONCLUSIONS

SNOT-22 nasal domain scores were associated with all 3 radiologic scoring systems when incidental findings were absent but not when they were present. Delineating the presence or absence of these colocalized findings affected the relationship between SNOT-22 scores and radiological results, beyond other concurrent factors.

The role of sinus CT in surgical treatment decisions for chronic rhinosinusitis

AIMS & OBJECTIVES

To define a predictive role of Lund Mackay CT scan [LM] score in treatment of chronic rhinosinusitis [CRS] by functional endoscopic sinus surgery [FESS].

MATERIALS & METHODS

A prospective study was done on the cited subject in a sample size of 30 patients suffering from CRS failing maximal medical treatment. All the patients underwent FESS under general anaesthesia. CT scan with Lund Mackey scoring was done preoperatively and postoperatively. The symptomatic improvement was analysed using SNOT-22 score over a time period of one year. The SNOT-22 scores were statistically analysed with pre-op Lund Mackey scores to draw judicious conclusions.

RESULTS

A mean Lund Mackey pre-operative score [LM] of 13.1 was recorded in the patients undergoing FESS for CRS. Further, the patients were divided into two groups: one with LM score less than 13.1 [Group-A] and the other with LM score of more than 13.1 [Group B]. A statistically significant improvement in symptoms with good long-term prognosis was recorded in Group-B only. In addition, a direct correlation between Lund Mackay score and extent of surgery was also seen, greater the score more extensive the FESS.

CONCLUSION

There is a predictive value of LM score in prognosis of FESS. We believe that a minimum LM score of 13.1 gives good clinical outcomes in patients with CRS who undergo FESS and thus can be used as a threshold for recruiting CRS patients for FESS.

The Sinonasal Outcome Test-22 or European Position Paper: Which Is More Indicative of Imaging Results?

Objective

The 22-item Sinonasal Outcome Test (SNOT-22) is a trusted measure of symptom severity in chronic rhinosinusitis. The European Position Paper on Rhinosinusitis (EPOS) provides widely accepted diagnostic criteria, which include sinonasal symptoms, their duration, and imaging results. Our objective was to compare these approaches to assessing symptoms to determine if either was more indicative of radiologic findings, to support decisions in telehealth.

Study Design

Observational outcomes study.

Setting

Tertiary care center.

Methods

In total, 162 consecutive patients provided a structured sinonasal history, completed the SNOT-22, and underwent sinus computed tomography (CT) within 1 month. SNOT-22 scores, EPOS-defined symptom sets, and Lund-Mackay results were assessed. To facilitate direct comparisons, we performed stepwise evaluations of sinonasal symptoms alone and combined with duration. The discriminatory capacity for imaging results was determined through areas under the receiver operating characteristic curves (ROC-AUC) for dichotomous outcomes and ordinal regression for multilevel outcomes.

Results

In ROC-AUC analyses, SNOT-22 and EPOS-defined symptoms had similar discriminatory capacity for Lund-Mackay scores, regardless of duration. Within ordinal regression analyses, SNOT-22 nasal scores were significantly associated with Lund-Mackay scores, while EPOS-defined nasal symptoms were not statistically significantly related.

Conclusions

SNOT-22 nasal scores and EPOS-defined nasal symptoms may have similar associations with imaging results when assessed via ROC-AUC, while SNOT-22 may have more association within ordinal data. Understanding the implications of discrete patterns of symptoms may confer benefit, particularly when in-person and fiberoptic exams are limited.

Are objective 'findings' the same as subjective 'severity'? A study of the relationship between computed tomography findings and subjective severity in preoperative CRSwNP patients

In pre-surgical patients with chronic rhinosinusitis with nasal polyps (CRSwNPs), positive findings on computed tomography (CT) scans and an exacerbation of symptoms are two possible factors that indicate surgery. However, the relationship between these factors remains unclear. Confirmed CRSwNP patients ready for sinus surgery were consecutively enrolled. The Sino-Nasal Outcome Test 22 (SNOT-22) and visual analog scale (VAS) scoring were completed by these patients, and scores were subjected to factor analysis using a principal component analysis (PCA) to evaluate subjective symptom components related to CRS. Patient CT scores, measured by the Lund-Mackay score (LMS), together with their demographics, medical treatment, and atopy status, were collected and analyzed. A total of 288 patients who met the criteria for CRSwNP and underwent CT scanning prior to surgery in the Eye, Ear, Nose, and Throat Hospital of Fudan University were enrolled. Five components were identified from the PCA of the SNOT-22 results and VAS scores related to subjective symptoms. More severe ‘nasal’ symptoms (P=0.03; 95% CI, 0.092-1.824), loss of smell and taste (P<0.001; 95% CI, 0.961-1.767) and lower facial pain (P=0.001; 95% CI 1.811 to -0.475), derived from the SNOT-22, were significantly associated with total CT score. For the VAS PCA components, less severe ‘ocular’ symptoms (P=0.004; 95% CI -1.852 to -0.352), a reduced ‘pain’ component (P<0.001; 95% CI -2.133 to -0.715), a higher ‘nasal’ symptom component (P<0.001; 95% CI 0.752-2.257) and, again, loss of smell and taste (P<0.001; 95% CI 0.437-0.811) showed an association with total CT score. ‘Allergy-associated symptoms’ in both the SNOT-22 and VAS scores and ‘loss of smell or taste’ and ‘hyposmia’ were significantly more severe in patients with ethmoid sinus/maxillary sinus (E/M) ratios of >2.59 compared with patients with E/M ratios <2.59. Loss of smell and taste alone was correlated with the LMS in patients with highly positive CT scores. The present study demonstrated associations between several subjective symptoms and objective severity in preoperative CRSwNP patients. Nasal symptoms, including olfaction loss, were correlated positively with CT scores, while ocular- and pain-related symptoms showed an opposite pattern. However, this relationship was not confirmed in patients with highly positive CT scores. A subset analysis confirmed, in terms of symptoms, the value of the E/M ratio for indicating eosinophilic chronic rhinosinusitis.

Psychological Status as an Effect Modifier of the Association Between Sinonasal Instrument and Imaging Results

OBJECTIVE

To determine whether psychological status is an effect modifier of the previously observed low discriminatory capacity of Sinonasal Outcome Test-22 (SNOT-22) scores for Lund-Mackay computed tomography (CT) results.

STUDY DESIGN

Observational outcomes study.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

We assessed patients presenting with chronic sinonasal complaints who underwent CT of the sinuses within 1 month of completing the SNOT-22 instrument. SNOT-22 overall and domain scores were calculated, as were Lund-Mackay CT scores. The discriminatory capacity of SNOT-22 scores for CT results was determined using the receiver-operator characteristic area under the curve (ROC-AUC). Patient-Reported Outcome Measurement Information System (PROMIS) mental health T-scores were assessed, and stratified analyses were used to test for effect modification by psychological status.

RESULTS

In stratified analyses, patients with better PROMIS mental health scores had SNOT-22 overall (ROC-AUC 0.96) and nasal domain scores (ROC-AUC 0.97-0.98) that were highly discriminatory for Lund-Mackay scores, while those with worse mental health scores did not (ROC-AUC 0.42-0.55, P < .007). Patients with better SNOT-22 psychological domain scores also had nasal scores that discriminated among CT results significantly better than those with worse psychological domain scores (ROC-AUC 0.65-0.69 and 0.34-0.35, respectively, P < .013).

CONCLUSIONS

Psychological status is an effect modifier of the relationship between SNOT-22 and Lund-Mackay scores. SNOT-22 scores were discriminatory for Lund-Mackay CT results in patients with better psychological status, while they were nondiscriminatory in those with worse psychological status. When assessing the relationship between subjective and objective measures of chronic rhinosinusitis, accounting for effect modification may have practical utility.

The Utility and Feasibility of Extending Beyond Traditional Patient Descriptions in Daily Practice

OBJECTIVES/HYPOTHESIS

Institutional and national programs have endorsed the use of validated instruments in daily practice, but their utility for frontline clinicians is unknown. Our first objective was thus to determine if routinely obtained patient descriptions accurately predict disease-specific validated instrument results. Our second objective was to assess the feasibility of deploying an electronic system to obtain and document patient-reported descriptions of health status.

STUDY DESIGN

Prospective assessment of consecutive eligible ambulatory care patients.

METHODS

For the first objective, patients presenting with the same chief complaint at consecutive visits provided concurrent routine symptom descriptions and validated instrument responses. To determine whether patients' routine descriptions predicted scores from disease-specific instruments, receiver operator characteristic (ROC) curves, sensitivity/specificity, Spearman ρ correlation, and regression models were utilized. For the second objective, feasibility assessment focused on percent with successful response capture, time to questionnaire completion, and impact on physician time needed to obtain and document patient histories.

RESULTS

For the first objective, among patients with hearing loss, eustachian tube dysfunction, nasal obstruction, and chronic rhinosinusitis, the areas under the ROC curves were 0.38 to 0.83. Spearman ρ coefficients were 0.25 to 0.46. Sensitivity and specificity ranged from 15.9% to 87.8%, with correct classification in 42.3% to 55.2% of cases. For the second objective, there was a 91% completion rate. Completion times were 7:18 to 12:37 for new patients and 3:23 to 6:41 for established patients. Physician time savings were estimated at 11 minutes per patient.

CONCLUSIONS

Using validated instruments and electronic data collection systems in daily practice has practical and clinical implications. These topics warrant further study.

LEVEL OF EVIDENCE

2c Laryngoscope, 130:S1-S13, 2020.

Antibiotics, steroids, and combination therapy in chronic rhinosinusitis without nasal polyps in adults

Despite a lack of robust data regarding their efficacy, oral antibiotics and steroids remain two of the most common treatments for chronic rhinosinusitis without nasal polyps (CRSsNP). We sought to objectively compare the efficacy of antibiotics and steroids, independently and in combination, for the initial treatment of CRSsNP. To that end, we conducted a retrospective chart review of 100 patients-51 men and 49 women, age 20 to 85 years (mean: 50)-who were treated for CRSsNP from January 2010 through January 2015. Of this group, 17 patients were treated with an antibiotic only, 28 with a steroid only, and 55 with both agents. All patients underwent computed tomography (CT) before and after treatment, and we compared the three groups' pre- and post-treatment Lund-Mackay CT scores, symptom scores, and rates of surgery. The average time between the pre- and post-treatment visits was 4.4 weeks. The mean Lund-Mackay CT score for the entire study population was significantly lower after treatment than at baseline (6.3 vs. 9.1; p < 0.001); however, there were no significant differences among the three groups in either pre- or post-treatment scores. Symptom scores were significantly better in the combination therapy group than in the two monotherapy groups (p < 0.001). In all, 40 of the 100 patients underwent surgery; the difference in surgery rates among the three groups was not statistically significant (p = 0.884). Surgery was performed on 9 of the 52 (17.3%) patients who either were followed for at least 1 year or who had had surgery within the first year postoperatively; again, there were no significant differences among the three groups (p = 0.578). We conclude that although the Lund-Mackay CT scores decreased significantly in the antibiotic, steroid, and combination therapy groups, no one regimen was superior to any other for treating CRSsNP in our study.

Preoperative Lund-Mackay computed tomography score is associated with preoperative symptom severity and predicts quality-of-life outcome trajectories after sinus surgery

BACKGROUND

Disagreement exists about the relationship between Lund-Mackay CT scores (LMCTS) and quality-of-life outcome (QoL) measures. We investigated whether preoperative LMCTS are associated with preoperative QoL, and whether LMCTS is predictive of postoperative QoL outcomes in chronic rhinosinusitis (CRS) patients.

METHODS

Adult patients with medically recalcitrant CRS (n = 665) were enrolled in a prospective, observational cohort study. Preoperative LMCTS and pre- and postoperative self-reported QoL outcomes (22-item Sino-Nasal Outcomes Test [SNOT-22]) were collected and evaluated over 12 months. Five hundred sixty-eight patients met the inclusion criteria. Longitudinal linear mixed-effects modeling was used to investigate the effect of LMCTS on QoL after functional endoscopic sinus surgery (FESS).

RESULTS

Preoperative LMCTS were significantly associated with preoperative SNOT-22 scores (p < 0.01) and postoperative SNOT-22 scores (p < 0.001), driven by Extranasal and Rhinologic subdomains of the QoL questionaire. Patients in the lowest preoperative LMCTS quartile had the lowest mean change in SNOT-22 scores at 12 months (16.8 points; 95% confidence interval [CI], 12.2-21.3). Patients in the second and third lowest preoperative LMCTS quartiles had mean changes at 12 months of 21.1 points (95% CI, 16.7-25.4) and 23.1 points (95% CI, 18.3-27.9). Patients in the highest preoperative LMCTS quartile had the greatest improvement in SNOT-22 scores after FESS (29.9 points; 95% CI, 24.9-34.8). The difference in QoL change at 12 months between the highest and lowest preoperative LMCTS quartiles was 13.1 points (95% CI, 6.0-20.2; p < 0.001).

CONCLUSION

Our study demonstrates that preoperative LMCTS correlate with preoperative extranasal and rhinologic symptom severity and that the LMCTS is an indicator of postsurgical QoL outcomes for medically recalcitrant chronic rhinosinusitis patients in a large tertiary otolaryngology setting.

Imaging of Asthma

Asthma is one of the most common diseases of the lung. Asthma manifests with common, although often subjective and nonspecific, imaging features at radiography and high-resolution computed tomography. The primary role of imaging is not to make a diagnosis of asthma but to identify complications, such as allergic bronchopulmonary aspergillosis, or mimics of asthma, such as hypersensitivity pneumonitis. This article reviews the imaging features of asthma as well as common complications and mimics.

Paranasal Sinus Anatomic Variations Accompanying Maxillary Sinus Retention Cysts: A Radiological Analysis

Objective

The risk factors for the development of retention cysts of the maxillary sinuses (RCMs) are not clear, although RCMs are common findings on radiographic images. This study was conducted to evaluate the correlation between RCMs and other nasal-paranasal anomalies and to demonstrate the possible effects of these anomalies on the development of RCMs.

Methods

In the study, paranasal sinus computerized tomography (PNsCT) images from 5166 patients were retrospectively reviewed. Correlations between RCMs and osteomeatal complex obstruction, accessory ostium presence, abnormalities of the middle turbinate, and nasal septal deviation were analyzed in the PNsCT images. The paranasal sinus anomalies on the side of the RCMs were compared to the contralateral side.

Results

A total of 1880 RCMs were detected in 1429 (27.6%) of 5166 patients. At least one nasal-paranasal sinus anomaly was associated with 88.7% of the RCMs. In the descending order, accessory ostium presence, accessory ostium, middle turbinate anomalies, and nasal septal deviation are pathologies that accompany RCMs. When unilateral RCMs were compared with the normal side, significant correlations were observed between RCMs and osteomeatal complex obstruction, accessory ostium, and middle turbinate anomalies (p=0.001, p=0.016, and p=0.03, respectively). RCMs were commonly found on the same side as osteomeatal complex obstruction (p=0.001), middle turbinate anomalies (p=0.001), and accessory ostium (p=0.052).

Conclusions

In this study, the coexistence of osteomeatal complex obstruction, accessory ostium, middle turbinate anomalies, and nasal septum deviation with RCMs was analyzed by investigating PNsCT findings in 5166 patients. The results show that RCMs are associated with pathologies that increase paranasal inflammation, such as osteomeatal complex obstruction, and are good markers for nasal-paranasal sinus anomalies. The presence of incidental RCMs should be a warning sign of nasal-paranasal sinus anomalies.

Diagnostic Accuracy of Nasal Endoscopy as Compared to Computed Tomography in Chronic Rhinosinusitis

The study was done with the aims to evaluate the accuracy of nasal endoscopy as compared to computed tomography (CT) in diagnosing chronic rhinosinusitis (CRS) and to evaluate the correlation between Endoscopy Score and CT Score. It was a cross sectional study. Every consecutive, symptomatic patient of CRS who fulfilled the criteria of American Academy of Otolaryngology-Head and Neck Surgery Task Force were included in the study. Rigid diagnostic nasal endoscopy (DNE) was done and Lund-Kennedy scoring system was used. Plain CT of paranasal sinuses was done on the same day and severity was assessed using Lund-Mackay scoring system. Results were analysed considering CT as a gold standard. Out of 54 study patients, 45 (83.33%) had abnormal endoscopic examination while 50 (92.59%) were showing positive CT scan. Sensitivity and specificity of DNE against CT scan were 94% (95% CI 81.43-98.33%) and 75% (95% CI 42-99.24%), respectively. The positive predictive value was 98% and negative predictive value was 67%. Correlation between Lund-Mackay overall CT and Lund-Kennedy Endoscopy Score was high [Pearson's correlation coefficient (r) = 0.881, p value < 0.0001]. The conclusion was drawn that, endoscopy is valuable in individuals with symptoms consistent with CRS and can be used to confirm the diagnosis and to know the severity of the disease. CT scan can be advised in those with high clinical suspicion of CRS but negative endoscopy and in those having persistent symptoms after optimum medical management requiring Functional Endoscopic Sinus Surgery.

Preoperative chronic sinusitis as significant cause of postoperative infection and implant loss after sinus augmentation from a lateral approach

OBJECTIVES

Among intra/postoperative complications of sinus augmentation from a lateral approach, postoperative infection and implant loss are particularly important because they have irreversible consequences. The purpose of this study was to determine the causes of postoperative infection and implant loss after a lateral approach and to determine the appropriate prophylaxis and therapy.

MATERIALS AND METHODS

In total, 109 patients (121 sinuses, 252 implants) were included in this study. The correlation between postoperative infection and implant loss and clinical variables was assessed using logistic regression analyses.

RESULTS

Postoperative infection and implant loss occurred in 8/121 sinuses (6.6%). Infection had the strongest correlation to preoperative chronic sinusitis (p = 0.007), followed by timing of implant insertion. Implant loss had the strongest correlation to preoperative chronic sinusitis (p = 0.007), followed by sex, diabetes, postoperative use of dentures, and intraoperative perforation of the sinus membrane.

CONCLUSIONS

Preoperative chronic sinusitis could be a significant cause of postoperative infection and implant loss when using sinus augmentation from a lateral approach. For appropriate prophylaxis and therapy, it is necessary to diagnose the presence of chronic sinusitis that should be treated with proper methods prior to sinus augmentation.

Clustering of chronic rhinosinusitis symptomatology reveals novel associations with objective clinical and demographic characteristics

BACKGROUND

Chronic rhinosinusitis (CRS) is associated with varied head and neck symptomatology and quality-of-life impairments that are not necessarily correlated with each other or with objective measures of disease.

OBJECTIVE

To determine how clustering patterns of CRS symptoms associate with objective clinical findings.

METHODS

Symptom scores from 193 Sinonasal Outcomes Test-22 (SNOT-22) questionnaires, from 177 consecutive CRS patients, were analyzed by principal component analysis (PCA) to uncover fewer and physiologically understandable latent components. Univariate and multivariate regressions were made with patients' demographic characteristics, nasal polyposis, comorbid allergic rhinitis, asthma, gastro-esophageal reflux disease (GERD) or depression, and Lund-Mackay scoring of sinus computed tomography (CT) results.

RESULTS

Four principal components (PCs), heavily weighted on sleep symptoms, nasal symptoms, otologic symptoms, and emotional function symptoms, respectively, are found to primarily describe the variability in patients' SNOT-22 scores. SNOT-22 subset scores reflecting sleep, nasal, otologic, and emotional function symptoms were constructed from corresponding PCs. Only female gender associated with the total SNOT-22 score (p = 0.004), whereas only Lund-Mackay score associated with the nasal subset score (p = 0.015). Allergic rhinitis only associated with the otologic subset score (p = 0.005), whereas only asthma associated with the emotional function subset score (p = 0.027). None of the measured covariates were associated with the sleep subset score.

CONCLUSION

Variability in SNOT-22 scores from CRS patients may be explained by the independent presence of sleep, nasal, otologic, and emotional function symptoms, with which we find novel clinical and demographic associations. These findings may represent clinical evidence for distinct pathophysiologic processes that differentially cause specific CRS symptomatology.

Comparison by objective parameters in patients with chronic rhinosinusitis managed medically and surgically (with and without powered instruments)

Objective:

To compare mucociliary clearance time and quality of life in patients who underwent sinus surgery using conventional and powered instruments, and in patients who were treated nonsurgically.

Methods:

A total of 151 patients with chronic rhinosinusitis were included. Fifty-four patients were treated conservatively, 48 patients were managed surgically by using conventional instruments and 49 patients were managed by using a microdebrider. Kupferberg nasal endoscopy grades, 20-item Sino-Nasal Outcome Test scores, Lund-Mackay scores, and mucociliary clearance time were analyzed.

Results:

On comparison among the groups, it was found that there was a significant difference between group A (nonsurgically treated) compared with group B (surgery by conventional means) or group C (surgery with microdebrider) in nasal endoscopic grades, Lund-Mackay scores, 20-item Sino-Nasal Outcome Test scores, and mucociliary clearance time. However, in comparison between groups B and C, there was no statistically significant difference.

Conclusion:

Mucociliary clearance time tended to recover after starting treatment for chronic rhinosinusitis both after conservative treatment and after surgical treatment. Surgery provided better improvement in different objective scores in chronic rhinosinusitis. There exists no statistical difference in parameters independent of the instrument used for surgery.

Standalone Balloon Dilation versus Sinus Surgery for Chronic Rhinosinusitis: A Prospective, Multicenter, Randomized, Controlled Trial with 1-year Follow-up

Background

The objective of this prospective, multicenter, randomized trial was to evaluate and compare 1-year outcomes from the REMODEL study between office balloon dilation and functional endoscopic sinus surgery (FESS).

Methods

Adults with maxillary chronic rhinosinusitis (CRS), including those with anterior ethmoid disease, who failed medical management and were surgical candidates for FESS, underwent either standalone balloon dilation or FESS in a 1:1 randomization scheme and were followed through a minimum of 1 year. Sinonasal symptom improvement was assessed using the validated 20-item Sino-Nasal Outcome Test (SNOT-20) survey. Standardized effect sizes were computed to further assess clinical significance. Ostial patency rate, rhinosinusitis episode frequency, impact of sinus disease on activity and work productivity using the validated Work Productivity and Activity Impairment survey, complications, and revision rate were also compared between the two groups.

Results

Ninety-two patients (50 balloon dilation; 42 FESS) were treated and 89 (96 %) completed 1-year follow-up. Both groups showed clinically meaningful and statistically significant (p < 0.0001) improvement in mean overall SNOT-20 scores and in all four SNOT-20 subscales. The 1-year mean change in SNOT-20 after balloon dilation (-1.64) was noninferior to FESS (-1.65; p < 0.001). The standardized effect size was large, showing clinically significant improvement for both interventions. Ostial patency was 96.7 and 98.7% after balloon dilation and FESS, respectively, and each group reported significant reductions (p < 0.0001) in rhinosinusitis episodes (mean decrease, 4.2 for balloon dilation and 3.5 for FESS). Overall work productivity and daily activity impairment due to chronic sinusitis were significantly improved (p < 0.001) in both groups. There were no complications and revision surgery rate was 2% in each arm through 1 year.

Conclusion

With 1-year follow-up, standalone balloon dilation is as effect as FESS in the treatment of CRS in patients with maxillary sinus disease with or without anterior ethmoid disease who failed medical therapy and met the criteria for medically necessary FESS.

Diagnosis of adult chronic rhinosinusitis: can nasal endoscopy predict intrasinus disease?

OBJECTIVES

To define the role of endoscopic evaluation of middle meatus in adult patients clinically diagnosed to have chronic rhino-sinusitis and its ability to predict intra-sinus mucosal involvement as compared to CT scan.

METHODS

This prospective analytical study was conducted on consecutive patients with diagnosis of chronic rhino-sinusitis who were symptomatic and fulfilled the American Academy of Otolaryngology - Head and Neck Surgery Task Force criteria. The patients were enrolled prospectively and were subjected to rigid diagnostic nasal endoscopy and classified as defined by the revised Sinus Allergy Health Partnership Task Force criteria. The patients then underwent non contrast CT sinuses on the same day. Results were analyzed as a diagnostic test evaluation using CT as a gold standard.

RESULTS

Among the 75 study patients with symptom based chronic rhino-sinusitis, nasal endoscopy was abnormal in 65 patients (87%). Of these patients, 60/65 (92%) showed positive findings on CT scan. Ten patients had normal endoscopy, of these 6/10 (60%) had abnormal CT scan. Sensitivity and specificity of diagnostic nasal endoscopy against CT scan were 91% (95% CI: 81-97) and 44% (95% CI: 14-79), respectively. The likelihood ratio for positive nasal endoscopy to diagnose chronic rhino-sinusitis was 1.6 and the likelihood ratio to rule out chronic rhino-sinusitis when endoscopy was negative was 0.2.

CONCLUSION

Nasal endoscopy is a valid and objective diagnostic tool in the work up of patients with symptomatic chronic rhino-sinusitis. When clinical suspicion is low (<50%) and endoscopy is negative, the probability of rhino-sinusitis is very low (<17%) and there is no need to perform a CT scan to reconfirm this finding routinely. Endoscopy alone is able to diagnose chronic rhino-sinusitis in >90% of patients when clinical suspicion is high (88%) as defined in this study by AAO-HNS Task Force criteria. Negative endoscopy, however, does not totally exclude the sinus disease in patients fulfilling task force criteria. CT scan may be needed on follow-up if there is clinical suspicion in 10% of these patients who are negative on endoscopy if symptoms persists. It is thus possible to reduce the number of CT scans if patients are carefully selected based on clinical criteria and endoscopy is done initially as part of their evaluation.

Endoscopic sinus surgery with antrostomy has better early endoscopic recovery in comparison to the ostium-preserving technique

Background. Endoscopic sinus surgery (ESS) is considered for chronic rhinosinusitis (CRS) after failure of conservative therapy. Objective. The aim of this study was to evaluate endoscopically ostium patency and mucosal recovery after ESS, with either maxillary sinus ostium-preserving or -enlarging techniques. Materials and Methods. Thirty patients with non-polypous CRS were enrolled. Uncinectomy-only and additional middle meatal antrostomy were randomly and single-blindly performed for each side. Pre- and postoperative endoscopic scores were semi-quantitatively determined according to findings in the ostiomeatal complex area. Adhesions, maxillary sinus mucosal swelling, secretions, and ostium obstruction were also endoscopically evaluated. In addition, symptoms were asked and computed tomography scans were taken preoperatively and 9 months postoperatively. Results. At 16 days postoperatively, a better endoscopic score and a less obstructed ostium were found with antrosomy. At 9 months postoperatively the endoscopic score improved significantly and identically with both procedures, however, obstructed ostia and sinus mucosal swelling/secretions were insignificantly more frequently found on the uncinectomy-only side. Endoscopic and radiologic findings of the maxillary sinus mucosa and ostium correlated significantly 9 months postoperatively. Conclusion. There was a good long-term mucosal recovery with both surgical procedures. In terms of early mucosal recovery and ostium patency, antrostomy might be slighly superior.

Predictive factors for a good outcome following endoscopic sinus surgery

The aim of this study was to establish if there are any symptoms which can predict increased patient satisfaction following Endoscopic Sinus Surgery (ESS) and whether these symptoms correlate with Lund-Mackay score on Computerised Tomography (CT). A prospective observational study was performed. Ninety-three consecutive patients who were offered ESS were recruited from an otolaryngology department in a UK Teaching Hospital. All patients had failed medical therapies for chronic rhinosinusitis (CRS), recurrent acute sinusitis and/or nasal polyposis. Patients were asked to complete a questionnaire pre-operatively and 12 months after surgery. Symptoms were assessed using a visual analogue scale. Endoscopic examination of the nose was performed pre and post-operatively. Lund-Mackay score was recorded for the pre-operative CT scan. Results were analysed using linear regression analysis and Pearson correlation coefficient. All symptoms improved after ESS (P < 0.001). However, a high pre-operative score for nasal discharge and olfactory disturbance were predictive of lesser improvement in symptom scoring (P < 0.001). Patients undergoing polypectomy with ESS demonstrated greater improvement in symptom score than those undergoing ESS with septoplasty or turbinate reduction surgery. There was no correlation between symptom score improvement and pre-operative Lund-Mackay score (r = 0.09). Patients who have high pre-operative symptom scores for nasal discharge and olfactory disturbance may gain less benefit from ESS, whilst those with nasal polyposis appear to perceive the greatest benefit. Increasing pre-operative Lund-Mackay score is not a predictor of a favourable operative outcome.

Outcome of endoscopic sinus surgery in patients with symptomatic chronic rhinosinusitis with minimal changes on computerised tomography

This study was designed to assess the efficacy of functional endoscopic sinus surgery (FESS) in chronic rhinosinusitis (CRS) patients with minimal radiological findings, and based on one centre, prospective randomized controlled study, conducted in the Department of Otorhinolaryngology, Lady Hardinge Medical College, New Delhi. All the CRS out-patients (>18 years) refractory to 3 weeks of medical therapy were radiologically evaluated with computerised tomographic scan (CT) of nose and paranasal sinuses. These patients were grouped based on CT scoring (Lund Mackay staging system): group A (CT score 0-6) and group B (CT score 7-24); with 35 patients in each group. All the patients underwent FESS using Messerklinger technique. Symptom scoring of all the patients was done using visual analog scale preoperatively and postoperatively at 1-, 3-, 6- and 12-month follow-up. CRS patients with minimal evidence of disease on CT showed statistically significant improvement in symptom scores after FESS. There was no significant difference noted in the overall symptom score improvement as well as for improvement in specific symptoms in both the groups. Further, there was no correlation between the pre-operative symptoms and CT scores. A good subjective outcome in terms of symptom improvement can be obtained with FESS in patients with CRS with minimal evidence of disease on CT.

Role of measurement of nasal mucociliary clearance by saccharine test as a yard stick of success of functional endoscopic sinus surgery

AIM

The present study was done to establish normal nasal mucociliary clearance time (NMCT) in people of our region, study variations in NMCT in patients of chronic rhinosinusitis, to see change in NMCT after functional endoscopic sinus surgery (FESS) and to see whether saccharine test can be used as a yard stick of success of FESS.

MATERIALS AND METHODS

NMCT of 100 normal individual was measured twice to establish control value. Fourtythree patients of chronic rhinosinusitis were divided into polypoidal and non-polypoidal. Their symptom score, endoscopic appearance score, CT scan score and NMCT was measured preoperatively and postoperatively.

RESULTS

NMCT in control group was 6.61 ± 0.84 minutes, in unilateral (u/l) polypoidal sinusitis 13.45 ± 2.07 minutes, in bilateral (b/l) polypoidal sinusitis 21.31 ± 0.76 minutes, u/l non-polypoidal sinusitis 9.54 ± 1.00 minutes and in b/l non-polypoidal sinusitis 11.34 ± 0.93 minutes. Linear relationship was seen between preoperative NMCT and preoperative symptom score, endoscopic appearance score, CT scan score. NMCT improved significantly after FESS.

CONCLUSION

NMCT measurement helps in selection of appropriate patients for surgery. It can be used as preoperative indicator of success of FESS.

Reliability and validity assessments of a Japanese version of QOL 20-Item Sino-Nasal Outcome Test for chronic rhinosinusitis

OBJECTIVE

The objective of this study was to assess the reliability and validity of a Japanese version of the 20-Item Sino-Nasal Outcome Test SNOT-20, which is one of the quality-of-life (QOL) evaluation sheets for chronic rhinosinusitis (CRS), and assess its reliability and validity.

METHODS

The SNOT-20 was conducted in patients with CRS and in healthy volunteers. The response rate was evaluated as the feasibility of this test, and reliability and internal consistency were assessed as reliability. In addition, concurrent validity and discriminant validity were assessed as validity.

RESULTS

Regarding the feasibility of this test, the response rate for each question item in the SNOT-20 was nearly 100% for all 20 items. For reliability, test-retest reliability was r=0.890 and the internal consistency was alpha=0.903. For validity, the concurrent validity was r=0.162 when compared with objective findings in the nasal cavity, and was r=0.431 when compared with the score for general physical condition, which evaluate the patient's general condition. Discriminant validity was significantly higher in patients with CRS than in healthy volunteers (p<0.001). Moreover, when the discriminant validity was assessed using an ROC (receiver operating characteristic) curve, it was found that ROC-AUC (the area under the curve)=0.775.

CONCLUSION

The reliability and validity of a Japanese version of the SNOT-20 were assessed in this study. It is thought that the SNOT-20 serves as a useful QOL evaluation sheet for CRS.

Assessing the Additional Disease Burden of Polyps in Chronic Rhinosinusitis

Objectives:

This study was undertaken to determine the differential disease burden between chronic rhinosinusitis (CRS) cases with and without nasal polyposis (NP).

Methods:

A consecutive series of adult patients who met clinical and radiographic criteria for CRS was assessed with the Rhinosinusitis Symptom Inventory, nasal endoscopy, and computed tomography. Three clinical groups were examined: 1) CRS without NP, 2) CRS with primary NP (no prior surgery), and 3) CRS with recurrent NP (prior surgery). The groups were compared with respect to symptom presentation, medical resource utilization, and medication costs.

Results:

Two hundred eighty-six CRS cases without NP, 131 CRS cases with primary NP, and 45 CRS cases with recurrent NP were studied; their mean Lund scores were 8.8, 13.2, and 16.3, respectively (p < 0.001). Statistically significant differences in severity for nasal (p = 0.002), facial (p = 0.025), oropharyngeal (p = 0.017), and systemic symptoms (p = 0.042) between groups were noted, whereas total symptoms did not differ between groups (p = 0.339). Medication use and physician visits were similar between groups (p = 0.335 and p = 0.951, respectively). The aggregate yearly medication costs were significantly greater for the recurrent polyp group ($866) than for either the non-polyp group ($570; p = 0.013) or the primary polyp group ($565; p = 0.020).

Conclusions:

Patients with non-polyp CRS and those with primary polyp CRS present with different symptom phenotypes, but exhibit similar total symptom burdens and medical resource consumption. The presence of polyps does not necessarily confer a dramatic additional disease burden in CRS.

Important Clinical Symptoms in Patients Undergoing Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVE

To evaluate the prevalence and severity of individual Rhinosinusitis Task Force (RSTF) symptoms in patients with chronic rhinosinusitis (CRS) undergoing functional endoscopic sinus surgery (FESS).

METHODS

Retrospective analysis of prospectively collected data in 201 patients treated with FESS. The prevalence and severity of individual RSTF major and minor symptom scores graded on a visual analogue scale (VAS) were compared. Correlation between absolute improvement in individual symptom scores at 1-year postoperative was performed.

RESULTS

One-hundred fifty-eight of 201 patients met inclusion criteria giving a response rate of 78%. The average age was 49.4 (range 18-80) with a male-to-female ratio of 1.1:1. The preoperative leading mean symptom scores were postnasal drip (5.8 +/- 0.3), nasal obstruction (5.7 +/- 0.3), and facial congestion (5.1 +/- 0.3). These symptoms were also the most prevalent with 82%, 84%, and 79% of patients reporting these symptoms, respectively. Postoperative symptom improvements were significant (P < .0001) across all RSTF domains except fever. The highest percentage improvement was seen with facial congestion (93%), nasal obstruction (92%), and postnasal drip (85%). Multivariate analysis revealed significant (P < .0001) high correlation between improvements of facial pain/pressure with facial congestion (R = 0.72), facial congestion with nasal obstruction (R = 0.65), and facial pain/pressure with headache (R = 0.72).

CONCLUSION

The top three RSTF symptoms were postnasal drip, nasal obstruction, and facial congestion in terms of prevalence and severity. Symptom scores improved after FESS. Of these symptoms, the degree of improvement of facial pain/pressure, facial congestion, nasal obstruction, and headache are highly correlated.

Evidence-based recommendations regarding the differential diagnosis and assessment of nasal congestion: using the new GRADE system

Nasal congestion is an important symptom in nasal pathology and can be defined as an objective restriction of nasal cavity airflow because of mucosal pathology and/or increased mucus secretion (excluding anatomical variants). Using the new Grading Recommendations Assessment, Development and Evaluation system, evidence-based recommendations are made that will encompass different clinical questions regarding diagnostic modalities of nasal congestion: (i) their usefulness in assessment of presence and severity of congestion; (ii) their usefulness in assessment of etiological pathology responsible for congestion; and (iii) their usefulness in follow up and treatment effectiveness evaluation of nasal congestion.

Blood and sputum eosinophil levels in asthma and their relationship to sinus computed tomographic findings

OBJECTIVE

To investigate the relationship among blood and sputum eosinophil levels, sinus mucosal thickening, and osteitis in patients with asthma.

PATIENTS AND METHODS

We conducted an observational study of 201 patients with asthma who underwent sinus computed tomographic (CT) imaging and induced sputum analysis at Mayo Clinic's site in Rochester, MN, from November 1, 2000, through December 31, 2005. Sinus CT scans were reviewed by an investigator blinded to patients' identity and chart information (J.B.H.) to assess for mucosal thickening. Each scan was assigned a CT score based on the Lund-Mackay staging scale. Approximately 20% of the scans were reviewed at random by a radiologist (N.G.C.) to ensure quality control. Bone changes consistent with osteitis were ascertained from radiology reports. Lung function was measured, and sputum was analyzed by conventional methods.

RESULTS

Sinus CT scans revealed abnormalities in 136 (68%) of the 201 study patients. Severe mucosal thickening (CT score, > or = 12) was found in 60 patients (30%) and osteitis in 18 patients (9%). There was a positive correlation between CT scores and eosinophil levels in both peripheral blood (rho=0.45; 95% confidence interval, 0.33-0.56; P<.001) and induced sputum (rho=0.46; 95% confidence interval, 0.34-0.57; P<.001). Further, elevated blood and sputum eosinophil levels were associated with the presence of osteitis on CT scan and previous sinus surgery.

CONCLUSION

Blood and sputum eosinophil levels in patients with asthma are directly correlated with sinus mucosal thickening and are associated with osteitis, lending further support to the hypothesis that asthma and chronic rhinosinusitis are mediated by similar inflammatory processes.

Evaluation of combined medical and surgical treatment in nasal polyposis - III. Correlation between symptoms and CT scores before and after surgery for nasal polyposis

CONCLUSION

Computed tomography (CT) in nasal polyposis (NP) patients has three functions before any treatment. CT provides objective evidence of the disease and precise topography of the disease, and is an indicator of the disease severity. After functional endoscopic sinus surgery (FESS), CT is an indicator of the residual disease severity and permits detection of asymptomatic mucoceles.

OBJECTIVE

NP affects nearly 4% of the population. CT has become the examination of choice for the exploration of NP. FESS is accepted for NP treatment in the setting of failure of medical management. The aim of this study was to find out whether any correlation exists between symptom severity and CT scan score before and after FESS.

PATIENTS AND METHODS

A total of 114 CT scans were performed in NP patients without contrast medium before and after FESS (mean follow-up 5 years), and were scored according to the Lund-MacKay system.

RESULTS

Lund-MacKay scores before treatment ranged from 8 to 24. There was a correlation between symptom and CT scores before any treatment. Postoperative Lund-MacKay scores ranged from 0 to 24. There was a correlation between symptom and CT scores after surgery. There was no correlation between postoperative symptom and baseline CT scores. Eleven asymptomatic mucoceles were found.

The Lund-Mackay staging system for chronic rhinosinusitis: how is it used and what does it predict?

OBJECTIVES

The Lund-Mackay score is widely used in assessment of chronic rhinosinusitis. We aimed to describe its relationship to other measures of pre- and post-treatment health status.

STUDY DESIGN

Multicenter prospective study of 1840 patients undergoing surgery for chronic rhinosinusitis in the UK.

RESULTS

There was no absolute threshold for surgery, but patients with higher Lund-Mackay scores underwent more extensive surgery. There was no correlation between Lund-Mackay and SNOT-22 scores. The Lund-Mackay increased with increasing grade of polyposis. The Lund-Mackay score was associated with symptom reduction (coefficient = 0.24, P = 0.02) complication rates (odds ratio, 1.08, 95%CI 1.06 to 1.1), and revision rates (odds ratio, 1.03, 95% CI 1.001 to 1.06).

CONCLUSIONS

The Lund-Mackay score measures a different aspect of disease to "subjective" symptom scores. However, it correlates well with other markers of disease severity, the nature of surgery offered, and its outcome.

SIGNIFICANCE

This demonstrates the strengths and limitations of a commonly used staging system.

Rhinosinusitis Task Force symptoms versus the Sinonasal Outcomes Test in patients evaluated for chronic rhinosinusitis

BACKGROUND

The aim of this study was to compare Rhinosinusitis Task Force (RSTF) symptom scores with Sinonasal Outcome Test 20 (SNOT-20) in patients with chronic rhinosinusitis (CRS) and controls.

METHODS

An analysis was performed of prospectively collected data in patients with CRS (n=201) and controls (n=100). The severity of individual RSTF major and minor symptom scores graded on a visual analog scale and total symptom scores were compared between the two groups. Correlation of the RSTF symptoms with the SNOT-20 was performed using data collected from the CRS group at baseline and at 1 year postoperatively.

RESULTS

CRS patients had higher RSTF symptom scores compared with control patients when asked to rate the severity of nasal obstruction, facial pain/pressure, facial congestion, alteration of smell, nasal discharge, postnasal drip, headache, halitosis, fatigue, cough, and ear pain (p < 0.005). No statistically significant difference was seen for the symptoms of dental pain and fever. Total RSTF scores were 54.5 +/- 1.9 in CRS patients versus 23.4 +/- 3.0 in controls. Total SNOT-20 scores were 28.7 +/- 0.8 in CRS patients versus 15.2 +/- 0.6 in controls. In CRS patients, total RSTF scores correlated with total SNOT-20 scores at baseline (r = 0.36; p < 0.0001) and 1-year postoperatively (r = 0.37; p < 0.0001).

CONCLUSION

Total RSTF symptom scores are significantly different in patients with chronic rhinosinusitis compared with those without this disease. The total RSTF symptom scores also correlate with a validated outcome measures instrument.

Impact of nasal polyps on quality of life of chronic sinusitis patients

OBJECTIVE

To study the significance of nasal polyps on the symptoms of chronic rhinosinusitis (CRS) and their influence on surgical outcomes.

METHODS

Retrospective analysis of prospectively collected data comparing two groups of patients diagnosed with CRS with and without polyps who underwent surgery with a minimum of 3 month follow up period. Subjective scoring was performed using the Sino-nasal Outcome Test (SNOT-20) questionnaire. Computed tomography (CT) scans were compared using the Lund-Mackay scoring system. Endoscopic findings were graded according to Lanza and Kennedy staging system. The two groups were analyzed for the need of revision surgery.

RESULTS

30 patients underwent surgical management of CRS over a period of one year. 20 were male, 10 were female and the average age was 26 years (range 15-55years). Polyps were present in 15 patients with CRS while, the other 15 did not have polyps. The average CT score was 10.13 for the polyp group and 9.79 for patients without polyp.The Polyp group SNOT-20 preoperative scores averaged 20.27 with improvement to 3.80 at 2 weeks, 2.67 at 1 month and 2.93 at 3 months (86.21% improvement p=0.001). Non-polyp group SNOT-20 scores were 18.80 preoperatively with improvement to 4.67 at 2 weeks, 3.40 at 1 month and 3.27 at 3 months (81.83% improvement). Preop diagnostic endoscopy on polyp group was 5.27 which improved to 2.13 in 2 weeks, 1.33 in 1 month and 1.53 in 3 months (73% improvement). In the non polyp group it was 4.53 pre-operatively which improved to 1.20 in 2 weeks, 0.93 in 1 month and to 1.13 in 3months (69% improvement). 6 patients required revision surgery (20%), 3 (10%) belonging to polyp group and 3 (10%) who did not have polyps.

CONCLUSION

Nasal Polyp has a significant negative impact on the patients with CRS. Patients with polyps have higher symptom scores, worse objective findings compared with patients without polyp, but patients with polyp show more improvement after surgical intervention and need for revision surgery is equal in both groups.

Comparative outcomes of endoscopic sinus surgery in patients with chronic sinusitis and nasal polyps

This study was carried out to compare the outcomes of endoscopic sinus surgery in patients with chronic sinusitis without nasal polyps (CRS) and those with nasal polyps (NP). We also sought to determine the correlation between preoperative computed tomography (CT) findings and postoperative endoscopy and symptom score improvement. Data were collected from two groups of patients diagnosed as CRS with and without nasal polyps that underwent functional endoscopic sinus surgery with a 1-year postoperative follow up. Preoperative symptoms, CT scores, and endoscopic scores were recorded. Postoperative symptom and endoscopic scores were recorded at 1, 6, and 12 months. Assessment of symptoms was performed subjectively using visual analogue scoring (VAS). CT scan findings were scored using the Lund-Mackay system. Endoscopic examination findings were scored according to the staging system proposed by Lanza and Kennedy. The correlations between the CT score, endoscopic scores and VAS scores were calculated. There was a statistically significant correlation between the preoperative CT, symptom, and endoscopic scores. Postoperative symptom and endoscopic scores also showed a significant correlation. Total CT scores of the CRS group were significantly lower than the scores of the NP group. Also preoperative endoscopy and symptom scores were statistically lower in CRS group compared to NP group. Endoscopy total scores and symptom total scores of both groups were significantly decreased at postoperative 12th month. Statistically significant difference was observed between the preoperative and postoperative symptom and endoscopy scores. The patients with polyps had higher symptom scores and worse objective findings compared to the patients with CRS. In all patients groups, objective and subjective scores seemed to correlate well preoperatively and postoperatively. These data suggest that endoscopic sinus surgery provides significant symptomatic relief and endoscopic healing in patients with CRS and NP.

Relationship between matrix metalloproteinases MMP-2, MMP-9, tissue inhibitor of matrix metalloproteinases-1 and IL-5, IL-8 in nasal polyps

BACKGROUND

Nasal polyps (NP), a subgroup of chronic rhinosinusitis, are characterized by interleukin 5 (IL-5) mediated infiltration of eosinophils in sinus mucosa, leading to pseudostratified ciliated columnar epithelium, thickening of the epithelial basement membrane and tissue edema. Matrix metalloproteinases (MMP) constitute a large group of Zn2+ dependent endopeptidases with the ability to degrade extracellular matrix and are possibly responsible for the development of tissue edema in chronic sinusitis.

OBJECTIVE

The aim of this study was to determine the expression of MMP-2, MMP-9 and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) mRNA and to locate the distribution of MMP-2, MMP-9 and TIMP-1 by immunohistochemistry in ethmoid sinus mucosa in NP. Furthermore the correlation between IL-5 or IL-8 and MMP-2, MMP-9 or TIMP-1 is examined.

METHODS

Nasal polyps of 33 patients and 18 specimens of inferior turbinate mucosa were examined by real time RT-PCR for MMP-2, MMP-9, TIMP-1, IL-5 and IL-8 mRNA expression. Immunohistochemical labeling for MMP-2, MMP-9 and TIMP-1 was performed.

RESULTS

Differences between both locations were detectable for MMP-9 (P < 0.001) and IL-5 (P=0.003) but not for MMP-2 (P=0.278), TIMP-1 (P=0.515) and IL-8 (P=0.386). Correlation was detected only between TIMP-1 and IL-5 (r=0.422, P =0.014). Cytoplasmic staining of MMP-2 was present in the apical part of the ciliated cells, submucosal glands and in smooth muscle cells. Matrix metalloproteinase-9 was expressed in surface epithelium, in seromucous glands and in polymorphonuclear cells.

CONCLUSIONS

Expression of MMP-9 and IL-5 mRNA are associated with NP. The correlation between IL-5 and TIMP-1 indicates the role of TIMP-1 in maintaining the homeostasis in NP.

Bibliography. Current world literature. Nose and paranasal sinuses

PURPOSE OF REVIEW

Patients with advanced head and neck cancer are being treated with chemo-radiotherapy, and life is being prolonged, with or without persistent disease, for longer than was previously. Hypercalcaemia may present in patients with advanced or disseminated head and neck cancer, and, as such, these patients may present to a larger variety of clinicians for advice concerning their symptoms and illness. Modes of presentation of hypercalcaemia and treatment strategies are reviewed.

RECENT FINDINGS

There were previously few large series of head and neck cancer patients diagnosed with hypercalcaemia, which may or may not have been related to their cancer being treated. Investigations, by way of blood/serum calcium level, may identify such patients. Patients with cancer-related hypercalcaemia have a poor prognosis, but many may respond temporarily to treatment when offered, with an improvement of their quality of life and death.

SUMMARY

Hypercalcaemia should and must be considered in all patients who have or possibly have a diagnosis of a head and neck cancer and who present unwell with symptoms of fatigue, lethargy and somnolence. Investigation must include serum calcium (corrected for serum albumin binding) and parathyroid hormone level. Patients may be treated by a combination of rehydration and bisulphonate therapy until the serum calcium is reduced to a level below 3 mmol/l. The majority of patients diagnosed with hypercalcaemia due to head and neck malignancy die of their diseases in the short term, but some may enjoy a prolongation of life with reasonable quality if diagnosed and treated aggressively.

Clinical outcomes after endoscopic sinus surgery

PURPOSE OF REVIEW

Chronic rhinosinusitis continues to present diagnostic and therapeutic challenges for clinicians. Recently, attention has been focused on reliable and valid measures of outcomes for many sinonasal diseases. As a significant fraction of patients with chronic rhinosinusitis will come to endoscopic sinus surgery, there has been a dedicated focus on determining objective clinical outcomes after medical and surgical treatment for CRS. This has been aided by validated instruments for measuring both symptom outcomes and quality of life after endoscopic sinus surgery.

RECENT FINDINGS

Recent studies have demonstrated that endoscopic sinus surgery provides statistically and clinically significant improvements in most sinonasal symptoms. These benefits are maintained more than 1 year after surgery. In addition, the significant adverse effects of chronic rhinosinusitis on quality of life can be reversed with appropriate endoscopic sinus surgery. Certain sub-populations do not fare as well with endoscopic sinus surgery, however; adjunctive medical management is required to maintain symptomatic and quality-of-life improvements for patients with nasal polyposis. Unfortunately, paranasal sinus computed tomography scan findings do not predict symptomatic or quality-of-life improvements after endoscopic sinus surgery.

SUMMARY

With reliable objective evidence of the health benefits of endoscopic sinus surgery, patients should be considered for such surgery after failure of medical management. Further work is required to characterize outcomes for sub-populations, and to stage and select patients who will derive appropriate benefit from endoscopic sinus surgery.

Pathogenesis of nasal polyps: an update

The cause of nasal polyp formation is still unknown. Genetic predisposition has been suggested, but there are scanty data to support such theories. Activated epithelial cells may be the major source of mediators inducing influx of inflammatory cells (mostly eosinophils) and proliferation and activation of fibroblasts leading to nasal polyp formation. Infectious agents (including viruses, bacteria, or fungi) may be potential primary factors activating nasal epithelial cells. Proinflammatory cytokines and growth factors play important roles in the persistence of mucosal inflammation associated with nasal polyps. Arachidonic acid metabolites seem to be particularly important in the pathogenesis of nasal polyps in patients with aspirin hypersensitivity rhinosinusitis/asthma syndrome.