Symptom outcomes following endoscopic sinus surgery

[Short-term quality of life assessment after sinus surgery for chronic rhinosinusitis]

BACKGROUND

Chronic rhinosinusitis (CRS) has a negative impact on health-related quality of life (HRQoL). Functional endoscopic sinus surgery (FESS) is the treatment of choice for those not responding to medical treatments. To date, the short-term effects of FESS on HRQoL are still unclear.

OBJECTIVE

Evaluation of the short-term effects of FESS on HRQoL in CRS patients using the SNOT-22 questionnaire.

METHODS

The results of the validated German version of the Sino-Nasal Outcome Test-22 (SNOT-22) questionnaire were analysed from 89 patients with CRS before surgery and 10-14 days (n = 77), four (n = 77), six weeks (n = 76) and 6 months (n = 71) after FESS, and compared with those of 1,000 healthy controls selected using a non-probability quota sample in accordance to the distribution of the German Microcensus.

RESULTS

Compared to the preoperative mean SNOT-22 score (47.35), CRS patients significantly improved in HRQoL 10-14 days (31.75, p < 0.01), 4 weeks (25.84, p < 0.01), 6 weeks (24.16, p < 0.01) and 6 months after FESS (27.16, p < 0.01). Pre- and 6 months postoperatively, the five most important SNOT-22 items were nasal obstruction, smell and taste reduction, thick, mucous nasal secretions, need to blow the nose and postnasal drip. At the 2, 4 and 6-week follow-up, the reduction in smell and taste was most frequently perceived as limiting the HRQoL.

CONCLUSIONS

This follow-up study shows for the first time that the reduction in smell and taste should be treated and controlled concervatively in the short term after FESS.

The Effect of Nasoseptal Flap Elevation on Post-Operative Olfaction and Sinonasal Quality of Life: A Prospective Double-Blinded Randomized Controlled Trial

BACKGROUND

The use of nasoseptal flaps (NSF) for defect reconstruction in endoscopic endonasal approaches (EEA) to cranial base pathology has markedly reduced rates of cerebrospinal fluid leak. However, the effect of NSF use on post-operative olfaction remains unclear.

OBJECTIVE

To evaluate the impact of NSF use during EEA on binarial and uninarial olfaction, and sinonasal quality of life (QOL).

METHODS

This was a prospective double-blinded randomized controlled trial. Patients undergoing EEA for sellar pathology were recruited from the University of Pittsburgh Medical Center from December 2014 to May 2017. Subjects were randomized pre-operatively to a side of NSF harvest. Olfaction and QOL were assessed pre-operatively and 6 to 12 months post-operatively using the University of Pennsylvania Smell Identification Test, "Sniffin' Sticks," and Sinonasal Outcomes Test 22. The side of dominant uninarial olfaction was determined using "Sniffin' Sticks."

RESULTS

Thirty-one patients were enrolled. Sixteen underwent EEA without NSF (control group) and 15 with NSF. A dominant side of olfaction was identified in 14 patients with NSF; 8 patients were randomized to NSF harvest on the dominant side and the remaining 6 on the non-dominant side. NSF elevation resulted in a 4% decrease in University of Pennsylvania Smell Identification Test scores, but was not statistically significant compared to controls. Similarly, NSF elevation on the side of dominant olfaction resulted in a 6% decrease, but was not statistically significant when compared to the non-dominant elevation group. Change in rhinologic QOL as determined by the Sinonasal Outcomes Test 22 was not significantly different between any of the groups.

CONCLUSIONS

The use of NSF during EEA for sellar pathology does not have a significant effect on olfaction or rhinologic QOL. The presence of a dominant side of olfaction is not a primary consideration when deciding the side of NSF harvest.

Comparison of Quality of Life Before and After Septoplasty With Short Form-36

The authors aimed to evaluate quality of life after septal surgery with Short Form-36 survey, and the effectiveness of the survey. Nasal symptoms (nasal obstruction, facial pain, catarrh), and general quality of life (using the Turkish version of the Short Form-36 questionnaire) were assessed preoperatively and at 1st and 6th postoperative months. Acoustic rhinometry and rhinomanometry were assessed preoperatively and at 6th postoperative month. Data from 78 patients were analyzed. This prospective clinical study was conducted on patients complaining of nasal obstruction with nasal septal deviation. Seventy-eight patients were included in the study. Fourty-two patients (53.8%) were male and 36 patients (46.2%) were female. At 1st postoperative month, nasal obstruction, facial pain and catarrh scores significantly improved in all, 46, 18 patients, respectively (P < 0.0001). At 6th postoperative month, scores nonsignificantly worsened by 1 point in 12, 6, 12 patients, respectively. Nasal volume significantly increased and total resistance significantly decreased at 6th month (P < 0.0001). Compared to preoperative values, all items except social function and bodily pain significantly increased at 1st postoperative month. Compared to values at 1st postoperative month, only bodily pain score decreased at 6th postoperative month. One patient presented with septal perforation. Septoplasty is a well-established technique to reduce nasal obstruction and improve quality of life. SF-36 may be used as a reliable measure of changes in quality of life after septal surgery.

Role of inferior turbinate reduction in the quality of life of patients undergoing endoscopic sinus surgery for chronic rhinosinusitis

BACKGROUND

The impact on quality of life (QoL) of bilateral inferior turbinate reduction (BITR) performed in the setting of endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) has been a point of controversy. The aim of this study was to determine whether addition of BITR to ESS is associated with improved QoL when compared with ESS alone.

METHODS

This study presented findings a multi-institutional, retrospective analysis of a prospective open cohort of patients electing ESS for failed medical management of CRS. QoL parameters were compared between patients who underwent ESS alone vs those who underwent ESS with BITR.

RESULTS

A total of 571 patients with CRS who elected to undergo ESS were identified. Sixty-one of these patients also underwent concurrent BITR, whereas 510 patients underwent ESS without BITR. Mean length of follow-up was 15.1 months. Comparison between baseline and last postoperative QoL, olfaction, and endoscopic scores revealed significant improvement in both groups. Overall, BITR surgery was not significantly associated with clinically significant incremental improvement in QoL in either the polyp or non-polyp group. Nevertheless, statistically significant improvement was noted for the nasal congestion/blockage symptom in polyp patients (p = 0.006) and in primary surgery patients (p = 0.027) who underwent BITR.

CONCLUSION

BITR in the setting of ESS for CRS is not associated with significant incremental improvement in overall QoL vs ESS alone. However, BITR in polyp and primary surgery patients undergoing ESS appears to offer a significant incremental improvement in nasal congestion/blockage symptoms compared with ESS alone. Future studies are warranted to better corroborate these findings.

[Depression and anxiety : Prevalence among ENT outpatients]

BACKGROUND

Few data exist on the prevalence of comorbid mental disorders among ENT patients. This investigation aimed to assess the prevalence of two disorders frequent in our society, namely depression and anxiety, in patients of an ENT outpatient clinic.

PATIENTS AND METHODS

During a 2‑week period, 101 consecutive patients were interviewed with the Beck Depression Inventory-II (BDI II) and Beck Anxiety Inventory (BAI) screening aids.

RESULTS

Of 97 evaluated tests, 38% contained indications of a psychiatric problem or mental comorbidity. The proportion of moderate and severe depressive syndromes, anxiety disorders, and combined disorders was only 11.3%. There were no significant differences between genders or in terms of acute vs. chronic ENT diseases. The highest frequency of pathological test results was observed in the group of patients with cochleovestibular disorders. An astoundingly high number of conspicuous test results were seen in patients with trivial diseases and disorders, as well as among those with chronic obstructive disorders of the nose and sinuses.

CONCLUSION

The finding of a considerable prevalence of psychiatric comorbidities among ENT patients represents important information for the treating physician. BDI II and BAI were found to be reliable and easy to apply in the outpatient clinic.

Diseases of the nasal cavity

Despite garnering minimal attention from the medical community overall, olfaction is indisputably critical in the manner in which we as humans interact with our surrounding environment. As the initial anatomical structure in the olfactory pathway, the nasal airway plays a crucial role in the transmission and perception of olfactory stimuli. The goal of this chapter is to provide a comprehensive overview of olfactory disturbances as it pertains to the sinonasal airway. This comprises an in-depth discussion of clinically relevant nasal olfactory anatomy and physiology, classification systems of olfactory disturbance, as well as the various etiologies and pathophysiologic mechanisms giving rise to this important disease entity. A systematic clinical approach to the diagnosis and clinical workup of olfactory disturbances is also provided in addition to an extensive review of the medical and surgical therapeutic modalities currently available.

Risk of depression in patients with chronic rhinosinusitis: A nationwide population-based retrospective cohort study

BACKGROUND

Depression is prevalent in patients with chronic rhinosinusitis (CRS). However, no population-based study has ever investigated this relationship. We used nationwide population insurance data to conduct a retrospective cohort study to evaluate the subsequent risk of depression among patients with CRS.

METHODS

We used the National Health Insurance Research Database (NHIRD) of Taiwan identified 15,371 CRS patients diagnosed during 2000-2010. The non-CRS group consisted of 61,484 individuals without CRS frequency matched by sex, age, and the year of diagnosis. The occurrence of depression was monitored until the end of 2011. The hazard ratios (HRs) of depression were estimated using the Cox proportional hazards model after adjusting for demographic characteristics and comorbidities.

RESULTS

The overall incidence of depression was 77% higher in the CRS group than in the non-CRS group (8.25 vs. 4.66/1000 person-years, p<0.001), with an adjusted HR of 1.56 (95% confidence interval=1.43-1.70). Further data analyses revealed that the adjusted HRs of depression in the CRS group compared with the non-CRS group by sex, age, urbanization level, monthly income, occupation category, and comorbidity were all significant. However, there was no difference in incidences of depression between CRS patients with and without surgical treatment (8.31 vs. 8.24/1000 person-years).

CONCLUSION

The present study suggests that patients with CRS are at an increased risk of depression, compared with those without CRS. Therefore, we should pay attention to the psychiatric status of these patients and provide adequate support for them.

A survey on chronic rhinosinusitis: opinions from experts of 50 countries

Chronic rhinosinusitis (CRS) is a very prevalent inflammatory disease. Treatments vary in different countries. In the present study, we explored the approaches of physicians in 50 countries. In this cross-sectional study, a rhinosinusitis survey (RSS) was completed by Honorary and Corresponding Members (otorhinolaryngologists) of the Italian Society of Rhinology. In 79.1 % of the 50 countries, the proportion of patients suffering from CRS was 15 %. Nasal symptoms were more intense in winter (46 % of countries), and spring and autumn (22 %). The most common symptoms were nasal obstruction (86 %), postnasal drip (82 %) and headache (52 %). The most common investigative modalities in the assessment of CRS are paranasal sinus CT, fiberoptic endoscopy, and anterior rhinoscopy. CRS patients were principally treated by otorhinolaryngologists (70 %). Medical treatments included nasal corticosteroids (90 %), nasal washes (68 %), and nasal decongestants (32 %). In 88 % of countries, more than 50 %, or "about 50 %", of all patients reported subjective symptom improvement after treatment. In most of the countries, surgery was required by 20-35 % of all CRS patients. During post-surgery follow-up, nasal washes (90 %), nasal corticosteroids (76 %), and systemic antibiotics (32 %) were prescribed. In 20-40 % of all patients, CRS was associated with nasal polyps. In such patients, the medical treatment options were nasal corticosteroids (90 %), systemic corticosteroids (50 %), nasal washes (46 %), and systemic antibiotics (34 %). Treatment of CRS patients varies in different countries. Paranasal sinus CT is the most common investigative modality in the assessment of CRS, and nasal corticosteroids are the first-line treatment, in the absence or presence of nasal polyps.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

The role of flow limitation as an important diagnostic tool and clinical finding in mild sleep-disordered breathing

Obstructive sleep apnea (OSA) is defined by quantifying apneas and hypopneas along with symptoms suggesting sleep disruption. Subtler forms of sleep-disordered breathing can be missed when this criteria is used. Newer technologies allow for non-invasive detection of flow limitation, however consensus classification is needed. Subjects with flow limitation demonstrate electroencephalogram changes and clinical symptoms indicating sleep fragmentation. Flow limitation may be increased in special populations and treatment with nasal continuous positive airway pressure (CPAP) has been shown to improve outcomes. Titrating CPAP to eliminate flow limitation may be associated with improved clinical outcomes compared to treating apneas and hypopneas.

Patient-reported nasal morbidity following endoscopic endonasal skull base surgery

OBJECTIVE

To quantify the frequency and severity of nasal morbidity following endoscopic endonasal skull base surgery using patient-reported outcome measures.

METHODS

Retrospective review and follow-up of all patients who underwent endoscopic endonasal skull base surgery at University Hospital Southampton between January 2007 and December 2011. Demographic data were collated from case notes and patients were asked a standardised questionnaire by telephone interview. Statistical sub-analysis of pituitary and other anterior skull base pathology groups was performed using SPSS 1.8.

RESULTS

Out of 151 included patients, 85 had a pituitary pathology and the remaining had other anterior skull base pathologies. The mean age was 55.2 years, with 75 male and 76 female patients. Totally 124 patients were interviewed with a median follow-up of 15 months. Mild or no nasal crusting was reported by 77% of patients. In those experiencing crusting, more than 50% resolved within 4 weeks. The majority of patients reported no nasal blockage (52%), pain (83%) or nasal discharge (57%) post-operatively. Totally 71% reported no change in sense of smell post-operatively. The only statistically significant difference between the two pathology groups was that surgery on other anterior skull base pathology was associated with an increased rate of developing anosmia (p = 0.02).

CONCLUSION

Endoscopic endonasal skull base surgery is associated with a low level of patient-reported post-operative nasal morbidity. There is no significant difference in frequency of crusting, blockage, pain or discharge between pituitary and other anterior skull base pathology groups. However, anterior skull base surgery would appear to be associated with an increased rate of anosmia post-operatively.

A randomized trial of mupirocin sinonasal rinses versus saline in surgically recalcitrant staphylococcal chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

Chronic rhinosinusitis (CRS) recalcitrant to surgery is a frustrating clinical entity. Recently, mupirocin sinonasal rinses have been suggested as an efficacious treatment alternative in these patients where Staphylococcus aureus infection is demonstrated. To our knowledge, how best to treat this S aureus reservoir has not been previously evaluated in a double-blinded, randomized, placebo-controlled trial.

STUDY DESIGN

Prospective, double-blinded, placebo-controlled study.

METHODS

Twenty-five S aureus-positive CRS patients with persistent sinonasal infection despite endoscopic sinus surgery received either a 1-month, twice-daily treatment course of mupirocin sinonasal rinses (MUP) or saline rinses (CON). The primary outcome was S aureus-culture negativity at the conclusion of treatment; secondary rhinological outcomes included subjective and objective measures of rhinosinusitis.

RESULTS

Twenty-two patients satisfactorily completed the treatment period. Of CON patients, 0/13 (0.0%) returned an S aureus-negative sinonasal culture at 1 month, compared to 8/9 (88.9%) of MUP patients (P < .01). Improvements in rhinological outcomes observed in MUP patients following treatment were not subsequently evident when these patients were followed up at a delayed assessment 2 to 6 months after completing treatment.

CONCLUSIONS

Mupirocin sinonasal rinses are an effective short-term anti-S aureus treatment in surgically recalcitrant CRS as assessed by microbiological and selected rhinological outcomes, although the latter improvements may not be durable with time.

Retrospective study of full-house functional endoscopic sinus surgery for revision endoscopic sinus surgery

BACKGROUND

Outcomes for revision endoscopic sinus surgery (RESS) are rarely reported in relation to technique. Our goal was to document the outcome of full-house functional endoscopic sinus surgery (FESS) (FHF) (complete sphenoethmoidectomy with Draf IIA frontal sinusotomy) for treatment of this recalcitrant group.

METHODS

Twenty-one patients with chronic sinusitis having had at least 1 previous sinus surgery (mean, 2.14) underwent FHF, followed by postoperative nasal douching and oral antibiotics for 12 weeks. After a minimum 6 months of follow-up, patients were asked to complete a 5-item Patient Response Score (PRS) (graded on a 6-point scale from 1 = completely improved to 6 = much worse). Objective measures collected included computed tomography (CT) Lund MacKay score (L-M score, LMS), and endoscopic findings: mucosal swelling (MS) and mucopus (MP) (graded on a 4-point scale from 0 = none to 3 = severe).

RESULTS

Patients were divided into 3 subgroups based on months of follow up from surgery: 6-12, 12-18, and 18-24. There was no statistical difference in any outcome based on length of follow up. Mean symptom outcome was reported as much improved (PRS = 1.9 ± 0.1). Both mucosal swelling and mucopus improved dramatically (2.48 vs 0.29, p < 0.001; 2.52 vs 0.29, p < 0.001, respectively). LMS also improved dramatically (11.52 vs 2.1, p < 0.001). Presence of nasal polyps did not affect any subjective or objective outcome.

CONCLUSION

Marked improvements in symptoms and mucosal findings were consistently obtained with FHF between 6 and 24 months postoperatively.

Effects of microelectrical current on migration of nasal fibroblasts

BACKGROUND

Migration of fibroblasts is critical in wound healing. The question of how wounded electric fields guide migration of nasal fibroblasts remains to be elucidated. This study was designed to determine morphology, directedness, and migration rate of nasal fibroblasts during microcurrent application, which is simulated by an endogenous electric field at the vicinity of the wound.

METHODS

Nasal fibroblasts were exposed to a microelectric field at 50, 100, and 250 mV/mm for 3 hours at 37°C. In this experiment, the field polarity was reversed for an additional 3 hours. During in vitro testing, the cells were incubated in a newly developed miniature, microcurrent generating chamber system, with 5% CO(2), at 37°C; the media was circulated by a pump system. A wound was created by scratching a cell-free area (∼150 μm wide) into a confluent monolayer. The average migration speed was calculated as the distance traveled by the cell divided by time.

RESULTS

A microelectric field of 100 mV/mm or more induced significant cell migration in the direction of the cathode. Trajectory speeds at 50, 100, and 250 mV/mm were 9.8 ± 0.3, 11.8 ± 0.3, and 13.5 ± 0.9 μm/mm, respectively. A significant difference was observed between migratory rate of controls and that of 50 mV/mm (p < 0.05).

CONCLUSION

Microelectric fields appear to have a crucial role in control of nasal fibroblast activity in the process of wound healing.

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

OBJECTIVES/HYPOTHESIS

To measure the change in quality-of-life (QoL) after endoscopic sinus surgery (ESS) in patients with medically recalcitrant chronic rhinosinusitis (CRS) and minimally affected computed tomography (CT) scans of the paranasal sinuses.

STUDY DESIGN

Prospective, multicenter cohort study at three academic, tertiary care centers.

METHODS

A total of 778 patients with CRS were enrolled between January 2001 and April 2009 after electing ESS. For the purposes of this analysis, patients with nasal polyposis, history of prior sinus surgery, or follow-up <6 months were excluded. Final study patients were categorized as low-stage CT CRS (Lund-Mackay ≤3; n = 17) and high-stage CT CRS (Lund-Mackay >3; n = 207). Primary outcome measures included two disease-specific QoL instruments: the Rhinosinusitis Disability Index and the Chronic Sinusitis Survey.

RESULTS

In patients with low-stage CT CRS, a statistically significant improvement was found across all disease-specific QoL scores (all P ≤ .012), with the exception of the CSS medication usage subscale (P = .073). These QoL improvements were comparable to those in patients with high-stage CT CRS.

CONCLUSIONS

Some patients will present with CRS that is refractory to medical therapy even though their CT demonstrates relatively minimal disease. Based on the results of this study, ESS is associated with improved QoL in patients with low-stage CT CRS and can provide significant benefit to carefully selected patients with minimally affected CT scans.

Functional somatic syndromes, anxiety disorders and the upper airway: a matter of paradigms

The relationship between the functional somatic syndromes, anxiety disorders and the upper airway (particularly, sleep disordered breathing) remains ambiguous. This ambiguity, despite a growing body of research supporting a relationship, may result from the absence of a paradigm to explain how upper airway dysfunction can promote disorders commonly associated with one's mental health. This review models the functional somatic syndromes and anxiety disorders as consequences of chronically increased hypothalamic-pituitary-adrenal axis activity. It then examines the literature supporting a relationship between these disorders and upper airway dysfunction during wakefulness and sleep. Finally, building upon an existing paradigm of neural sensitization, sleep disordered breathing is linked to functional somatic syndromes and anxiety disorders through chronic activation of the hypothalamic-pituitary-adrenal axis.

Nasal morbidity following endoscopic skull base surgery: a prospective cohort study

BACKGROUND

Nasal morbidity following skull base surgery necessitates follow-up for postoperative care. We describe nasal morbidity following endoscopic skull base surgery.

METHODS

Patient and operative data and postoperative subjective and objective measures of morbidity were prospectively collected for 1 year. Time to absence of crusting and remucosalization were determined. Risk factor analyses for crusting and nasal discharge were performed.

RESULTS

Nasal crusting (98%) and discharge (46%) were the most common postoperative symptoms. Median time to absence of crusting was 101.0 days, with longer times for complex cases (p = .033) but not for patients with septal flaps or fat grafts. Median time to remucosalization after nasoseptal flap was 89.0 days. There were no risk factors for crusting, although surgical complexity was a risk factor for postoperative discharge (odds ratio [OR] = 5.17).

CONCLUSIONS

Nasal morbidity following endoscopic skull base surgery is common and may be affected by surgical complexity and use of the nasoseptal flap.

Quality of life following nasal surgery

OBJECTIVES/HYPOTHESIS

This prospective study aimed to investigate changes in quality of life (QOL) after nasal surgery.

STUDY DESIGN

Prospective study.

METHODS

A total of 788 patients (492 men and 296 women; age range, 9-81 years; mean age, 41 years) were included in this prospective study. Three hundred thirty-six patients received sinus surgery, 358 received septum surgery, and 94 additional patients received sinus surgery involving the septum. QOL was assessed with a standardized questionnaire for general health and well-being (36-Item Short Form Health Survey [SF-36]). Additionally, subjective sinonasal impairment was collected using the Rhinosinusitis Disability Index (RSBI). QOL and subjective sinonasal impairment were retested 4 months after surgery (63-339 days after surgery; mean, 128 days) in 361 patients.

RESULTS

In the RSBI severity scale, 29.5% of the patients rated their sinonasal problems presurgery to be of high severity, 61.2% rated them as medium, and 9.3% as minor. Postsurgery, 2.8% of the patients rated the severity of their sinonasal problems high, 35% medium, and 62.2% minor. Subjective improvement of symptoms was found in more than 80% of the patients. Presurgery, general QOL (SF-36) was impaired in sinus patients and improved significantly after surgery. For most septum patients we found relatively little impact of sinonasal disease on general QOL (SF-36) compared to the German normative sample.

CONCLUSIONS

Functional endoscopic surgery seems to be a good technique for reducing sinonasal symptomatology in the majority of patients. It appears to enhance QOL in those patients who were severely affected beforehand. Long-term investigations are currently underway to further explore the patients' subjective QOL following nasal surgery.