Management of chronic rhinosinusitis

Experimental and numerical investigation of pressure distribution in human upper airway passage before and after maxillary sinus surgery

Sinusitis, a common disease of the maxillary sinus, is initially managed with saline solution and medication, resulting in the resolution of symptoms within a few days in most cases. However, Functional Endoscopic Sinus Surgeries are recommended if pharmacological treatments prove ineffective. This research aims to investigate the effects of maxillary sinus surgery on the airflow field, pressure distribution within the nasal cavity, and overall ventilation. This study utilized a three-dimensional realistic nasal cavity model constructed from CT images of a healthy adult. Virtual surgery including uncinectomy with Middle Meatal Antrostomy, two standard procedures performed during such surgeries, was performed on the model under the supervision of a clinical specialist. Two replicas representing pre- and post-operative cases were created using 3D printing for experimental purposes. Various breathing rates ranging from 3.8 to 42.6 L/min were examined through experimental and numerical simulations. To ensure the accuracy of the numerical simulations, the results were compared to measured pressure data, showing a reasonable agreement between the two. The findings demonstrate that uncinectomy and Middle Meatal Antrostomy significantly enhance the ventilation of the maxillary sinuses. Furthermore, increasing inspiratory rates leads to further improvements in ventilation. The static pressure distribution within the maxillary sinuses remains relatively uniform, except in regions close to the sinus ostium, even after surgical intervention.

Functional Endoscopic Sinus Surgery and Recurrence of Post-COVID Mucormycosis

Purpose

To evaluate the value and limitation of functional endoscopic sinus surgery alone for the management of post-COVID mucormycosis and need for adjunctive invasive procedure.

Materials and Methods

This is a clinical observational study that included a total of 17 patients who underwent FESS for post-COVID mucormycosis from April 2021 to May 2021. These patients reported to our institute with no improvement in their symptoms post-FESS from June 2021 to July 2021. Aggressive Surgical debridement of the involved sinuses, removal of surrounding necrotic bone and orbital exenteration (wherever necessary) was done in these patients. A regular follow-up till six months was done for every patient. Sixteen out of 17 patients did not report with any fresh complaint or recurrence.

Results

The study included male and female in ratio of 12:5, with a mean age of 62.5 ± 7.7 years (range: 50-75 years). These patients underwent functional endoscopic sinus surgery, one to two months before reporting to our institute. Post-FESS, there was no improvement in the symptoms. All these patients were given systemic antifungal treatment post-operatively. The specimen was sent for histopathological as well as microbiological examination. All the FESS operated patients required a secondary more aggressive surgical intervention.

Conclusion

Post-COVID mucormycosis is an aggressive fungal infection, for which FESS proves inadequate. It requires an aggressive surgical debridement of the necrotic bone along with the debridement of the sinuses.

Effectiveness of pediatric nasal irrigation solution with or without xylitol

OBJECTIVES

/Hypothesis: The aim of this study was to compare the efficacy and outcome of daily hypertonic saline irrigation versus saline/xylitol for treating pediatric chronic rhinosinusitis (CRS).

STUDY DESIGN

This was a prospective, randomized, single-blinded study.

METHODS

One hundred and twenty-five children diagnosed with CRS were enrolled in this study. The patients were randomized to twice-daily hypertonic irrigations with saline or saline/xylitol for 6 weeks. The treatment outcomes were measured using: Sinonasal Quality of Life Survey (SN-5) completed at baseline and after 6 weeks of irrigation.

RESULTS

There were statistically significant improvements in the hypertonic nasal saline group's (reduction in SN-5 domain scores) four domains and an increase in the overall QoL score within each group after 6 weeks of treatment compared to baseline; however, there were no differences in the activity limitation (p = 0.1803). The xylitol solution groups had no differences between the two groups in the SN-5 scores in any of the domains or the overall score at baseline, and post irrigation treatment.

CONCLUSIONS

Due to low tolerance, compliance, and the side effects, xylitol irrigation is not recommended as a first-line treatment for pediatric CRS. The use of a large volume of low pressure, twice-daily intranasal hypertonic irrigation for 6 weeks is safe and effective in the treatment of pediatric CRS; therefore, it can be used as a baseline treatment for pediatric CRS before considering surgical interventions.

Nasal Polyps in Children: The Early Origins of a Challenging Adulthood Condition

Nasal polyps (NPs) are benign inflammatory masses causing chronic nasal obstruction, usually associated with underlying chronic rhinosinusitis (CRS), which are rarely reported in childhood. The interest in NPs has recently increased due to new therapeutic options, namely biological agents, such as dupilumab, and an update of the European position paper on this topic was released in 2020, providing a detailed classification for these lesions and also discussing diagnostic and therapeutic approaches also in children. In childhood, NPs usually represent red flags for systemic diseases, such as cystic fibrosis and immunodeficiencies. This review outlines the recent data on NPs in childhood, focusing on predisposing factors for CRS as well as on the potential endotypes in this particular age group, for which further studies are required in order to better clarify their pathogenesis and to identify molecular biomarkers that could help achieve more personalized treatments.

Numerical simulation of unsteady airflow in a nasal cavity for various sizes of maxillary sinus opening in a virtual endoscopic surgery

Functional endoscopic sinus surgery (FESS) is performed to treat sinusitis when treatment with medication fails. In the present study, three different virtual maxillary sinus endoscopic surgeries were performed on a realistic 3-D computational model of the nasal cavity of an adult male under the supervision of a specialist. They included only uncinectomy, uncinectomy + 8mm Middle Meatal Antrostomy (MMA) and uncinectomy + 18 mm MMA. Simulations were performed for two human activity respiratory rates, including rest and moderate activities, and effects of different surgeries and respiratory rates on maxillary sinus were investigated. It was found that after endoscopic sinus surgery, the volume of air entering the maxillary sinus increased significantly, and as the size of the MMA increased, or the breathing condition changed from rest to moderate activity, this volume of air increased. For the rest condition, on average for both nasal passages, for uncinectomy +8 mm MMA, around 15 % of the inhaled flow and 7 % of the exhaled flow enter the maxillary sinuses. For uncinectomy +18 mm MMA, these values are 24 % and 14 %, respectively. As human activity increases, a lower portion of inhaled and exhaled air enters the maxillary sinuses. For the moderate activity condition, on average for both nasal passages, for uncinectomy +8 mm MMA, around 11 % of the inhaled flow and 6 % of the exhaled flow rate enters the maxillary sinus. For uncinectomy +18 mm MMA, these values are 16 % and 8%, respectively. Comparing the steady and unsteady simulation results showed that the quasi-steady flow assumption could predict the flow in the maxillary sinus and the volume of air entering the sinuses, almost at any moment of respiration, with acceptable accuracy.

Efficacy and safety of paranasal sinus balloon catheter dilation in pediatric chronic rhinosinusitis: a systematic review

Objective

Chronic rhinosinusitis (CRS) negatively affects quality of life (QoL), and balloon catheter sinuplasty (BCS) has shown good outcomes in adult patients. However, there has not been much research on the effects of BCS on pediatric patients. The objective of this review is to systematically assess the literature for studies demonstrating the effectiveness and safety of BCS in pediatric CRS patients.

Data sources

PubMed, Embase and Cochrane Library.

Study selection

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations (PRISMA) to conduct our study. Observational- and interventional-based studies reporting efficacy and/or side effects of BCS among pediatric populations were included. Efficacy was evaluated by clinically reliable measures including Sino-Nasal 5 (SN-5) QoL scale. Antibiotic usage and revision surgery were also evaluated.

Data extraction

Articles were screened, and data were obtained. Study design, sample size and demographics, treated sinuses, criteria of inclusion, adjunct procedure(s), follow-up time, and outcomes measured were reported.

Main findings

Out of 112 articles identified, 10 articles were included: two interventional controlled trials and eight observational studies. All studies evaluating QoL by SN-5 showed a remarkable reduction in SN-5 score postoperatively. Improvement in the computed tomography (CT) and endoscopic findings for up to 1 year after operation was reported. Furthermore, the majority of patinets treated with BCS did not recieve any course of sinusitis-indicated antibiotics during long-term follow-up, and they had low surgical revision rates. Minor side effects were reported, most commonly synechia.

Conclusion

Available evidence suggests that BCS is safe and effective for the treatment of CRS in pediatric patients. Future randomized controlled studies with large sample size are warranted. Such studies can further determine the efficacy of BCS in managing children with CRS.

3-year follow-up after balloon sinuplasty in children with chronic rhinosinusitis

OBJECTIVE

Balloon sinuplasty could restore nasal sinus drainage and airflow, limiting the damages and lowering the risks. This study aimed to assess the 3-year clinical efficacy, safety, and satisfactory degree of balloon sinuplasty through multiple aspects. Also the experience about treatment for postoperative adhesion was described.

MATERIALS AND METHODS

A study was performed in 30 children who had failed medical therapy, and received Balloon sinuplasty of selected sinuses. Data in 3-year follow-up including questionnaire, VAS, CT, and nasal endoscopy findings were collected. Also postoperative nose-related medications or auxiliary therapies, revision surgery, and incidence of complications were collected. The satisfactory degree of children and parents were assessed.

RESULTS

Compared to preoperative, the VAS scores, questionnaire (SN-5 or SNOT-22) scores and Lund-Mackay scores were significantly lower. In the 3-year follow-up, most of them did not require nose-related medications or auxiliary therapies, and were free of symptoms, or the symptoms did not affect their daily activities. None of the 30 children had complications of facial pain, teeth numbness, facial deformity, and dysosmia. However, nasal cavity adhesion still remained the most frequent. The satisfactory degree was relatively high.

CONCLUSION

The 3-year follow-up demonstrated that balloon sinuplasty had high clinical efficacy and safety, the satisfactory degree of children and parents remained relatively high. Improved the upper respiratory infection and increased the immunity, which were considered effective methods to reduce the risk of recurrence. Nasal spraying of steroids and nasal irrigation in three months after surgery cold help prevent the nasal cavity adhesion.

Clinical curative effect and safety of balloon sinuplasty in children with chronic rhinosinusitis

OBJECTIVE

Balloon Sinuplasty for the management of paranasal sinus inflammatory diseases was introduced in otolaryngology in 2005. Over the past decade, evidence strongly supports its safety and efficacy for the treatment of chronic rhinosinusitis (CRS) in adults. Because it requires no bone or tissue removal, this procedure could be suitable in children. We present our initial experience of its use for the treatment of CRS in children.

MATERIALS AND METHODS

A prospective study was performed of 30 children with failed medical therapy, who were scheduled for surgery. They underwent treatment by balloon sinuplasty of selected sinuses. Data were collected, including age, VAS score, CT score, and nasal endoscopy findings.

RESULTS

The procedure was successful in 61/65 sinuses (93.84%). Balloon sinuplasty improved sinus-related quality of life scores as well as computed tomography (CT) and endoscopic findings for up to 1 year after operation (p < 0.05).

CONCLUSION

In this initial study, balloon sinuplasty showed a clinical curative effect in the treatment of children with refractory CRS, and was relatively safe. Structural abnormalities in sinus ostia and hypoplastic sinuses may not be amenable to balloon catheter sinuplasty.

Post-adenoidectomy quality of life in children with refractory chronic rhinosinusitis

Objective:

This study aimed to evaluate post-adenoidectomy quality of life in children with refractory chronic rhinosinusitis.

Methods:

A prospective interventional study of children aged 4–12 years with chronic refractory rhinosinusitis was conducted. A total of 60 children completed follow up. Nasal endoscopy and non-contrast computed tomography of the paranasal sinuses were performed, and both symptoms and their effects on patient quality of life pre- and post-adenoidectomy were evaluated.

Results:

The most frequent symptoms were nasal obstruction, cough, fever and fatigue, which were experienced by 100 per cent, 90 per cent, 85 per cent and 81.7 per cent of children, respectively. Nasal endoscopy showed oedema and discharge were present in all children. A statistically significant post-operative improvement in sinus and nasal quality of life was seen in 53 children (88.3 per cent).

Conclusion:

Adenoidectomy is a simple, first-line surgical procedure for managing paediatric chronic rhinosinusitis refractory to maximal medical therapy and leads to an improved quality of life.

Effect of sodium hyaluronate added to topical corticosteroids in chronic rhinosinusitis with nasal polyposis

BACKGROUND

Available medical treatments for chronic rhinosinusitis (CRS) with nasal polyposis (CRSwNP) comprise systemic and topical therapies. Although topical corticosteroids are effective in the treatment of CRS, they are not completely devoid of adverse effects. Thus, care has to be taken when long-term treatments are prescribed. There is recent evidence that sodium hyaluronate (SH), the major component of many extracellular matrices, promotes tissue healing, including activation and moderation of the inflammatory responses, cell proliferation, migration, and angiogenesis.

OBJECTIVE

The aim of the study was to evaluate clinical outcomes and quality of life in two groups of patients with CRSwNP treated with topical corticosteroids alone or in combination with 9 mg of high-molecular-weight SH.

METHODS

The impact of treatments was determined by using nasal endoscopy and validated quality of life questionnaires (Short Form-36, 22-item Sino-Nasal Outcome Test, visual analog scale [VAS]). Eighty subjects who had CRS with grade IV nasal polyposis: 40 diagnosed with allergic rhinitis (AR) and 40 with non-allergic-eosinophilic rhinitis (NARES) based on skin-prick test and nasal cytology results, were divided in two groups. Group I comprised 40 subjects (20 AR and 20 NARES), who received mometasone furoate plus SH; group II comprised 40 subjects (20 AR and 20 NARES), who received mometasone furoate plus saline solution alone. All the patients were followed up for 3 months.

RESULTS

At baseline, no statistically significant differences were observed between the groups and the VAS score showed a moderate-to-severe degree of disease. After treatments, Lund and Kennedy, Short Form-36, 22-item Sino-Nasal Outcome Test, and VAS scores were statistically significant in both groups but slightly in favor of the group I and in the subjects with allergic CRSwNP.

CONCLUSION

Analysis of our data indicated that an SH supplement to standard corticosteroid seems to play an important role in improving the severity of symptoms, the endoscopic appearance, and discomfort associated with CRSwNP. This effect seems to be strongest in patients with allergic CRSwNP.

Fifty Years of Chronic Rhinosinusitis in Children: The Accepted, the Unknown, and Thoughts for the Future

Chronic sinusitis is an often-used term in both lay and medical circumstances. In children, it has significant but largely undefined healthcare costs. Chronic rhinosinusitis (CRS) in children has well demarcated time periods and symptoms, although the actual pathway from normal sinus to CRS is not well understood. There is reasonable consensus as to the standards for diagnosis, the selection of a first-round antibiotic, and length of treatment. However, no recent prospective studies of antibiotics are available. Areas of continued speculation include the following: the microbiome of pediatric CRS, the best use of standard imaging, alternative antibiotic selection, ancillary therapy, and treatment of refractory CRS. In addition, older adolescents can present with a more adult-oriented CRS with or without polyps, suggesting a broader spectrum of disease than is commonly recognized. An accounting of the accepted elements of pediatric rhinosinusitis, as well as areas for future research, is emphasized in this review and, where appropriate, suggestions for potential investigations are offered.

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.

Clinical characteristics associated with conjunctival inflammation in allergic rhinoconjunctivitis

BACKGROUND

Allergic rhinitis affects up to 30% of the general population worldwide and is increasing in prevalence. Among several comorbidities, conjunctivitis is probably the most common and occurs so frequently with allergic rhinitis that the term allergic rhinoconjunctivitis (ARC) has been coined.

OBJECTIVES

The cytological characteristics of conjunctival inflammation in patients with ARC were assessed and then correlated to clinical characteristics.

METHODS

Fifty-one patients with clinically diagnosed ARC (23 men; 32.4 ± 13.5 years old) underwent a detailed clinical history and standard diagnostic allergy workup as well as nasal and conjunctival scraping for cytological analysis. Patients were subdivided into 3 groups on the basis of cytological phenotype: (1) nasal and conjunctival inflammation, (2) nasal inflammation only, and (3) no mucosal inflammation.

RESULTS

Group 1 patients reported significantly higher eye itching scores (5.8 ± 2.9 on a 0-10 scale) than did patients in group 2 (3.8 ± 2.8; P = .06) or 3 (2.6 ± 2.9; P = .018) and were mostly men (81.8%). Male sex (odds ratio, 8.4; P = .005) and eye itching (odds ratio, 1.3; P = .019) significantly correlated with conjunctival inflammation. The odds of exhibiting conjunctival inflammation, at multivariate analysis, increased 13-fold for men and 1.5-fold for each point on the eye itching scale. A cutoff value of 3 or more for eye itching effectively identified patients with conjunctival inflammation.

CONCLUSIONS

Our study demonstrates that some clinical manifestations of ARC correlate well with conjunctival inflammation.

Pediatric chronic rhinosinusitis: when should we operate?

PURPOSE OF REVIEW

The timing and role of surgery in the management of pediatric chronic rhinosinusitis (pCRS) remains unclear. This review attempts to summarize the existing literature regarding this topic.

RECENT FINDINGS

pCRS is a complex clinical syndrome that results from multiple potential causes. Multimodal medical therapy is the accepted primary treatment. Adenoidectomy continues to be the appropriate first-line surgical therapy, and the addition of antral lavage or balloon dilation to this procedure may improve outcomes. Functional endoscopic sinus surgery (FESS) in children is safe and effective in relieving symptoms in the majority of patients. Failure to respond to maximal medical therapy continues to be a commonly cited, although poorly defined, requisite for proceeding to surgery. Recent literature has been focused on the outcomes after FESS rather than specifically defining when this intervention should be considered. Nevertheless, the literature seems to continue to support FESS in children with persistent symptoms despite adenoidectomy and appropriate medical treatment for pCRS. As the symptoms of chronic rhinosinusitis (CRS) may result from multiple underlying causes, clinicians must understand that the role and timing of surgery may vary with particular patients' disease.

SUMMARY

Surgical management of CRS in children continues to be a frequent topic of study in the otolaryngology literature. As recent research tends to be focused on outcomes after surgery, further prospective studies comparing surgical versus nonsurgical treatment of CRS will likely be required to better define indications for proceeding to surgery at all.

Pediatric chronic rhinosinusitis

Pediatric chronic rhinosinusitis is a multifactorial inflammatory and infectious disorder. It likely reflects a dysfunction at the site of the interaction between host and environmental factors in the nose and sinuses. Our limited understanding of this common childhood disease makes it difficult to diagnose and to treat effectively. This review focuses on the scope of manifestations particular to the pediatric form of the disease, diagnostic challenges, and epidemiologic data. The normal development of sinuses in children, the role of inflammation, and biofilm and immune responses in the pathophysiology of chronic rhinosinusitis in pediatric patients are discussed. Predisposing and comorbid factors contributing to this disorder or associated with it are described. The current investigational and therapeutic approaches are presented, including recommendations for imaging and medical and surgical therapy. Various aspects of the disease that are still subject of controversy are underscored. Advice for what constitutes a reason to involve a multidisciplinary collaboration in the care of a child with chronic rhinosinusitis is provided.

Impact of intranasal sodium hyaluronate on the short-term quality of life of patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis

BACKGROUND

Functional endoscopic sinus surgery (FESS) has become the treatment of choice for patients with medically resistant chronic rhinosinusitis (CRS) and nasal polyps. Despite the consolidated use of different treatments, the postoperative period is often very painful and uncomfortable, especially during the first month. Although evidence on the effectiveness of sodium hyaluronate (SH) on postoperative care following FESS is available, data on the quality of life (QoL) from the patients' perspective are still lacking. This study aimed to evaluate for the first time the effectiveness of nasal douche with SH in reducing patients' discomfort during the first month following FESS.

METHODS

A double-blind randomized controlled study was carried out on 124 subjects undergoing FESS for CRS with nasal polyposis. They were divided into 2 groups: group I was treated with nasal douche containing 9 mg of high molecular weight SH plus saline solution and group II was treated with saline solution alone. To assess QoL in CRS patients, the Short Form-36 (SF-36) test, the Sino-Nasal Outcome Test-22 (SNOT-22), and the visual analogue scale (VAS) questionnaires were administered.

RESULTS

At baseline, there were no statistically significant differences between the 2 groups. However, after 30 days of long postoperative treatments, we found clinically significant improvements in QoL of subjects treated with SH, as evidenced by all QoL scales.

CONCLUSION

Our data indicate that SH significantly improves patients' short-term QoL following FESS in terms of both general health and specific sinonasal status.