Effect of recombinant human acidic fibroblast growth factor on nasal mucosal healing after endoscopic sinus surgery

BACKGROUND

Postoperative nasal treatment is an important factor affecting the outcomes of endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS). This study aimed to determine the effect of recombinant human acidic fibroblast growth factor (rh-aFGF) on nasal mucosal healing after ESS.

METHODS

This study is a prospective, single-blind, and randomized controlled clinical study. Fifty-eight CRS patients with nasal polyps (CRSwNP) with bilateral ESS were enrolled and randomly given 1 mL of budesonide nasal spray and 2 mL of rh-aFGF solution (rh-aFGF group) or 1 mL of budesonide nasal spray and 2 mL of rh-aFGF solvent (budesonide group)-infiltrated Nasopore nasal packing after ESS. Preoperative and postoperative scores for Sino-Nasal Outcome Test (SNOT-22), Visual Analogue Scale (VAS), and Lund-Kennedy were collected and analyzed.

RESULTS

Forty-two patients completed the 12-week follow-up. Postoperative SNOT-22 scores and VAS scores showed no significant differences between the two groups. In terms of the Lund-Kennedy scores, there was a statistically significant difference between the two groups at the 2-, 4-, 8-, and 12-week postoperative visits, but not at the 1-week visit. Twelve weeks after surgery, the nasal mucosa had completely epithelialized in 18 patients in the rh-aFGF group and in 12 patients in the budesonide group (χ² = 4.200, P = 0.040).

CONCLUSION

The combined application of rh-aFGF and budesonide significantly improved postoperative endoscopic appearance in the nasal mucosal healing process.

Revision of endoscopic sinus surgery in adults: A population-based study in Taiwan

OBJECTIVE

This study aimed to elucidate the revision rate, time to revision, and factors associated with revision of endoscopic sinus surgery (ESS) in Taiwan.

DESIGN

Retrospective study.

SETTING

Population-based analysis.

PARTICIPANT

We identified all in-hospital patients, aged >20 years, who underwent ESS between 2000 and 2008 from the Taiwan National Health Insurance Research Database, and followed up with them until 2018.

MAIN OUTCOME MEASURES

Factors associated with revision surgery were analyzed using multivariable Cox proportional hazard model.

RESULTS

Overall, 66 592 patients were identified (mean age, 46.3 years; 62% males). The revision rate was 14.5% (9644/66 592) and time to revision surgery was 5.9 years. Multivariable Cox proportional hazard model showed that young age, male gender (hazard ratio [HR] = 1.18; 95% confidence interval [CI], 1.13-1.23), having nasal polyposis (HR = 1.17; 95% CI, 1.12-1.22), having allergic rhinitis (HR = 1.08; 95% CI, 1.04-1.13), having asthma (HR = 1.26; 95% CI, 1.14-1.39), and surgical time of >4 h (HR = 1.11; 95% CI, 1.06-1.16) were associated with increased risk of revision surgery. Concurrent septal surgery (HR = 0.81; 95% CI, 0.76-0.87), turbinate surgery (HR = 0.91; 95% CI, 0.85-0.97), or septal and turbinate surgery (HR = 0.68; 95% CI, 0.64-0.73) were associated with decreased risks of revision surgery.

CONCLUSION

In Taiwan, risk factors for revision ESS are young age, male gender, having nasal polyposis, having allergic rhinitis, having asthma, and long surgical times. Concurrent septal or turbinate surgery decreases the risk of revision.

Biomechanical characteristics of self-expanding sinus stents during crimping and deployment_A comparison between different biomaterials

Self-expanding sinus stents are often used in functional endoscopic sinus surgery to treat inflamed sinuses. The PROPEL self-expanding sinus stent offers mechanical support to the sinus cavity to prevent restenosis. The stent is made of a bioabsorbable material (PLGA) that disappears after wound healing. However, complications such as foreign body sensation and severe stent migration/expulsion have been reported after implantation. Little is known about the contact characteristics of self-expanding sinus stents from when the stent is crimped into the insertion device through to deployment into the sinus cavity. This current study developed a test platform to analyze the biomechanical behavior of the stent during this process. Three common bioabsorbable materials, PLGA, PCL and Mg alloy, were evaluated to understand how the choice of material affects the biomechanical characteristics of self-expanding sinus stents. The results showed that the material can have a considerable influence on the contact characteristics during crimping and deployment. When crimped, the PLGA and Mg alloy stents showed much higher plastic strain and contact stress than the PCL stent. When deployed, the PCL stent had the largest contact area (4.3 mm²) and the lowest contact pressure (0.1 MPa) on the inner surface of the sinus canal. The results indicate that PCL could be a suitable choice for self-expanding sinus stents. This current study provides a method for observing the biomechanical characteristics of sinus stents during stent crimping and deployment.

Harms reporting by systematic reviews for functional endoscopic sinus surgery: a cross-sectional analysis

OBJECTIVES

To evaluate the completeness of harms reporting in systematic reviews (SRs) pertaining to functional endoscopic sinus surgery (FESS).

METHODS

Using a cross-sectional study design, we performed a comprehensive search using MEDLINE (PubMed and Ovid), EMBASE, Epistemonikos, and the Cochrane Database of Systematic Reviews databases for SRs regarding FESS on May 15th, 2022. Returns were screened and data were extracted in a masked, duplicate manner. Following established methodology, we extracted general study characteristics, harms items, and overall methodological quality for each SR in our sample. Corrected covered area (CCA) was calculated for SR dyads. For data analysis, using Stata 16.1 we performed a bivariate analysis between variables.

RESULTS

Fifty-five SR's were included in our sample after excluding 375 studies that did not meet our inclusion criteria. Of the included SRs, 19 (19/55, 34.5%) did not report harms and 39 (39/55, 70.9%) reported half of the harms items or fewer. Our study found that 23 (23/55, 41.8%) of SRs demonstrated a method of harms data collection, 26 (26/55, 47.3%) of SRs had patients available for harms analysis in their results, and 25 (25/55, 45.5%) of SRs had a balanced discussion of harms and benefits of FESS. Fifty-two SRs were appraised as "critically low" quality using AMSTAR-2. A significant association was found between completeness of harms reporting (Mahady) and whether harms were listed as a primary outcome. No other associations were statistically significant. Two SR dyads had CCAs between 20% and 50% overlap and were compared for unique and shared harms.

CONCLUSIONS

Our study demonstrates gaps in harms reporting regarding FESS in SRs. We recommend future studies implement guidelines such as the STROCCS guidelines or the harms extension of the PRISMA guidelines to improve harms reporting. Accurate harms reporting may advance patient safety and promote a more objective risk-benefit analysis for physicians and patients.

Clinical Outcomes of Endonasal Sphenopalatine Artery Cauterization in Endoscopic Sinus Surgery

Endoscopic sinus surgery (ESS) is one of the common ENT surgeries performed. Various techniques are available for reducing the blood loss during ESS. The efficacy of cauterization of the SPA in reducing the per-operative blood loss has not been explored in the literature. This study evaluates the efficacy of SPA cauterization prior to sinus surgery and its per-operative and post-operative outcomes. To study the outcomes of endonasal SPA cauterization in patients undergoing ESS. This is a prospective observational study conducted in a tertiary care centre from October 2018 to October 2020. 30 patients underwent ESS where SPA was cauterized by bipolar diathermy in one side of the nasal cavity and in the contralateral side, SPA was not cauterized. The results were tabulated and compared between the cauterized and non cauterized side. p value < 0.05 was considered as statistically significant. Mean blood loss (p value = 0.20), operating time (p value = 0.19), surgical field grade, post operative Lund Kennedy Score at 1st, 4th and 12th week were compared and the difference between cauterized and non cauterized was found to be statistically insignificant. In this study, endonasal SPA cauterization did not significantly reduce the intra operative bleeding and surgical field grade in patients undergoing ESS. SPA cauterization did not adversely affect the per operative and post operative outcome and hence authors highlight the fact that it can be safely performed in cases where severe intra operative bleeding is expected and its effectiveness can be studied better in such cases.

Efficacy of Absorbable Steroid-Impregnated Nasal Packing in Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis: A Systematic Review

OBJECTIVE

To evaluate the efficacy of absorbable steroid-impregnated nasal packing on postoperative outcomes following functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis (CRS).

METHODS

A systematic review of the literature was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve databases (including Journals@Ovid, Embase®, Medline®, EBM Reviews and Joanna Briggs Institute EBP Database) were searched using relevant keywords and expanded with corresponding MeSH/Emtree terms. Results were narrowed to English articles assessing the efficacy of absorbable packing impregnated with steroids post-production placed at time of surgery under general anesthetic, with hollow-lumen devices and devices inserted in-office excluded.

RESULTS

Eight studies met criteria and were included in this review. Five evaluated the efficacy of the intervention in only CRS with nasal polyposis (CRSwNP) patients, two included all subtypes of CRS, and one included only CRS without nasal polyposis (CRSsNP). Of the eight studies, four studied the efficacy of Nasopore®, three studied bioabsorbable gels, and one studied bioabsorbable calcium alginate. Four studies applied triamcinolone as the operative steroid, with the other studies utilizing betamethasone, budesonide, mometasone, and dexamethasone. Seven studies demonstrated statistically significant improvements in endoscopic outcomes using validated scoring scales, albeit at differing timepoints. The one study which included only CRSsNP patients failed to find a significant difference.

CONCLUSION

Steroid-impregnated nasal packing appears to have positive effects on postoperative endoscopic outcomes in CRSwNP patients undergoing FESS. Additional research is needed to evaluate the efficacy of these interventions in more recently defined subtypes of CRS, and whether these interventions differ in their efficacy in eosinophilic and non-eosinophilic CRS. Laryngoscope, 131:1704-1714, 2021.

The Effects of Postoperative Astaxanthin Administration on Nasal Mucosa Wound Healing

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BACKGROUND

Wound healing of the nasal mucosa after endoscopic sinus surgery (ESS) is frequently complicated by scaring and consequently recurrences are encountered. Methods of optimizing results have been sought. In the present study we evaluated the effects of a powerful antioxidant, astaxanthin, on nasal mucosa healing after surgery, comparing it to the extensively studied properties of dexamethasone.

MATERIALS AND METHODS

63 Wistar rats were used. The nasal mucosa from one side was damaged employing the brushing method. They were randomly divided into three experimental groups, one treated with astaxanthin, the second treated with dexamethasone and the third one acted as the control and was given normal saline. The rats were killed on days 5, 14 and 28 following injury. We observed the temporal evolution of the wound healing process and quantified the results by assessing four parameters: the epithelial thickness index (ETI), the subepithelial thickness index (STI), the goblet cell count and the subepithelial fibrosis index (SFI).

RESULTS

At 28 days, the ETI was significantly lower in the astaxanthin group (p < 0.05) compared to the other two groups. The STI was also lower in the astaxanthin group (p < 0.05), but comparable to the dexamethasone group at 28 days. The goblet cell count was higher in the astaxanthin group. The SFI had similar results in both dexamethasone and astaxanthin groups, with lower values compared to the control group. In the astaxanthin group there was no synechia formation.

CONCLUSION

Astaxanthin given in the post injury period significantly decreases fibrosis, inhibits synechia development and significantly decreases subepithelial fibrosis. Moreover, it has no general or local toxic effects.

"In-Office Balloon Sinus Ostial Dilation with Concurrent Antiplatelet and Anticoagulant Therapy for Chronic Rhinosinusitis without Nasal Polyps"

OBJECTIVE

Functional endoscopic sinus surgery (FESS) and balloon sinus ostial dilation (BSD) are well-recognized minimally invasive surgical treatments for chronic rhinosinusitis without nasal polyps (CRSsNP) refractory symptoms to medical therapy. Patients on antiplatelet and anticoagulant therapies (AAT) usually are recommended to discontinue their medications around the period of endoscopic sinus surgery. The goal of this study is to assess the clinical experience of BSD in CRSsNP patients with concurrent anticoagulant or antiplatelet therapy.

METHODS

A review of prospectively-collected clinical data from October 2012 to March 2017 were used to perform a cohort study of subjects with CRSsNP who met criteria for surgical intervention while on antiplatelet and anticoagulant therapy. Data were collected on demographics, details of the procedures, type of AAT used, pre- and postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores, and complications.

RESULTS

Thirty-five patients underwent in-office BSD while on antiplatelet and/or anticoagulant therapy. The mean difference in pre- and postoperative SNOT-22 scores of 9.9 (SD 14.4, P < .001) was both statistically significant and exceeded the minimal clinically important difference of 8.9. Absorbable nasal packing was used for persistent bleeding immediately post-procedure in two patients. Intraoperative bleeding was associated with aspirin 325 mg and warfarin. FESS was required for further management of chronic sinusitis in four patients after anticoagulant/antiplatelet therapy could be discontinued. There were no systemic complications. None of the patients experienced significant bleeding events postoperatively after leaving the office.

CONCLUSION

In-office BSD appears to be a safe alternative to endoscopic sinus surgery in select patients who cannot discontinue antiplatelet and anticoagulant therapy.

LEVELS OF EVIDENCE

IV.

Impact of age on outcomes following endoscopic sinus surgery for chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a common condition that affects people of all ages and negatively impacts quality of life. The goal of this study was to identify differences in outcomes by age following endoscopic sinus surgery (ESS) for CRS utilizing 22-item Sino-Nasal Outcome Test (SNOT-22) scores.

METHODS

Data from 1252 adult CRS patients electing to undergo ESS (2007-2018) were collected retrospectively. The median age of 50 years was used to divide the data into 2 groups for comparison of the impact of age on SNOT-22 scores at 0, 3, and 6 months after surgery. Changes in SNOT-22 scores were analyzed using a mixed models analysis.

RESULTS

After adjusting for gender, race, polyp status, and number of prior ESSs, patients younger than 50 years had a higher mean pre-ESS SNOT-22 score (44.0) compared to those of at least 50 years of age (38.9). Among patients younger than 50 years, SNOT-22 scores declined by 20.7 points at 3 months post-ESS and 16.1 points at 6 months post-ESS. The rate of change between the dichotomized age groups was not significantly different at 3 and 6 months post-ESS (p = 0.7952 and p = 0.1057, respectively).

CONCLUSION

Both age groups showed significant and durable improvement in SNOT-22 scores after ESS. Patients younger than 50 years of age have higher pre-ESS SNOT-22 scores, but converge to the same SNOT-22 scores by 3 months post-ESS. The rate of change of SNOT-22 scores is not different between those younger than 50 years and those of at least 50 years.

Effect on Quality Of Life of Patients Before and After Functional Endoscopic Sinus Surgery

Rhinosinusitis is defined as an inflammatory process involving the mucosa of the nose and one or more of the paranasal sinuses. Rhinosinusitis is not associated with increased mortality, but may have an impact on the quality of life (QOL). Current study is aimed at investigating the role of FESS in the enhancement of QOL of the patients with rhinosinusitis. Several instruments have been designed to assess the QOL, among which Glasgow Benefit Inventory (GBI) questionnaire, has been used in this study. This cross sectional study of duration of 1 year and 6 months was conducted on 30 patients between the age group 18-60 years in the Department of Otorhinolaryngology at Safdarjung Hospital in New Delhi. Our results showed that FESS was associated with improved QOL in patients with Chronic Sinusitis. Observations were made on the basis of the GBI questionnaire which is designed to measure outcomes of the surgical procedures in form of 4 different scores. Mean total score before surgery was (-) 65.28 ± 7.39 and after surgery was 21.22 ± 11.24. Mean general Subscale Score before surgery was (-) 60.56 ± 9.14 and after surgery was 25.28 ± 13.40. Mean Social Support Score before surgery was (-) 79.44 ± 14.31 and after surgery was 17.78 ± 16.34. Mean Physical Health score before surgery was (-) 70.00 ± 10.17 and after surgery 10.00 ± 14.25. A statistically significant improvement was observed in all the four scores before and after surgery. The present study demonstrates that radical surgery has led to improvement in the QOL of chronic rhinosinusitis.

Medical Therapy Versus Balloon Sinus Dilation in Adults With Chronic Rhinosinusitis (MERLOT): 12-Month Follow-up

Background Chronic rhinosinusitis (CRS) is a devastating disease affecting nearly 30 million people in the United States. An interim analysis of data from the present study suggested that, in patients who had previously failed medical therapy, balloon sinus dilation (BSD) plus medical management (MM) provides a significant improvement in the quality of life (QOL) at 24 weeks postprocedure compared to MM alone. Objective The primary objective of this final analysis was to evaluate the durability of treatment effects through the 52-week follow-up. Methods Adults aged 19 and older with CRS who had failed MM elected either BSD plus MM or continued MM. Patients were evaluated at 2 (BSD arm only), 12, 24, and 52 weeks posttreatment. Balloon dilations were performed either as an office-based procedure under local anesthesia or in the operating room per physicians' and patients' discretion. The primary end point was change in patient-reported QOL as measured by Chronic Sinusitis Survey (CSS) total score from baseline to the 24-week follow-up. Secondary outcomes including changes in CSS, Rhinosinusitis Disability Index (RSDI), and Sino-Nasal Outcome Test (SNOT) total and subscores, sinus medication usage, missed days of work/school, number of medical care visits, and sinus infections from baseline to the 52-week follow-up are reported here within. Results BSD led to sustained greater improvements in self-reported QOL using the CSS and RSDI total scores with a trend toward improvement in the SNOT-20 total score from baseline to the 52-week follow-up compared to continued MM. There were no changes in medication usage apart from nasal steroid usage for which the MM cohort had an increase in usage. There were no device-related serious adverse events. Conclusion The current analysis highlights the safety, effectiveness, and durability of BSD in CRS patients aged 19 and older who had previously failed MM.

Systematic Review and Meta-analysis of SNOT-22 Outcomes after Surgery for Chronic Rhinosinusitis with Nasal Polyposis

Objective Wide variation exists regarding reported outcomes after endoscopic sinus surgery (ESS) for chronic rhinosinusitis with nasal polyps (CRSwNP). This study seeks to combine data across studies to generate a summary measure and explore factors that might lead to variation. Data Sources OVID Medline, Scopus, EbscoHost, Database of Abstracts and Reviews of Effects, Health Technology Assessment, and National Health Service Economic Evaluation Database. Review Methods A search was performed following the PRISMA guidelines. Two independent researchers conducted a search using the mentioned data sources. Studies published before August 29, 2016, that involved ESS to treat CRSwNP were included. Mean changes in Sinonasal Outcome Test-22 (SNOT-22) scores were determined through metaregression of the following independent variables: publication year, sex, age, allergy status, asthma, tobacco use, prior surgery, follow-up length, and preoperative SNOT-22. Results Fifteen articles with 3048 patients treated with ESS met inclusion criteria. Pooled analyses of SNOT-22 scores revealed a mean change of 23.0 points (95% CI, 20.2-25.8; P < .001). A metaregression of patient factor effects on the mean change of SNOT-22 scores demonstrated that age ( r = 0.71, P = .01), asthma ( r = 0.21, P = .01), prior ESS ( r = 0.29, P = .01), and preoperative SNOT-22 score ( r = 0.4, P < .01) correlated with greater improvement in SNOT-22 scores. Tobacco use ( r = -0.91, P = .01) and longer lengths of follow-up ( r = -0.45, P < .01) were associated with less improvement in SNOT-22 scores. Conclusions Quality-of-life outcomes are significantly improved after ESS among patients with CRSwNP. Patient-specific factors may affect the degree of SNOT-22 change after surgery.

Topical Steroid Drops for the Treatment of Sinus Ostia Stenosis in the Postoperative Period

Background

Chronic oral steroid use causes significant morbidity, including osteoporosis, immunosuppression, and adrenal insufficiency. Refractory chronic rhinosinusitis patients often take repeated oral steroid courses to treat polypoid disease or sinus ostia stenosis. This study evaluated topical steroid drop efficacy in treating recurrent sinus ostia stenosis in the postoperative period.

Methods

The 5-year single institution experience with topical steroid drop use after endoscopic sinus surgery (ESS) was evaluated by retrospective review. Patients were included if they began topical dexamethasone ophthalmic, prednisolone ophthalmic, or ciprofloxacin/dexamethasone otic intranasally (used off-label) within 3 months after ESS. Outcomes (i.e., ostia patency, oral steroid use, revision surgery, and complications) were assessed for a 6-month period after steroid drop initiation.

Results

Thirty-six patients met inclusion criteria. Forty-four surgeries were performed during the study period; 67 sides were treated postoperatively with topical steroid drops. In 86.6% of cases, steroid drops were used to treat frontal ostium stenosis or frontal recess edema; 93.2% of surgeries were revision procedures. Sixty-four percent of sinuses were treated successfully with topical steroid drops, 14.9% remained stable, and 20.9% failed. Reasons for failure included persistent/worsening edema, scarring, or noncompliance. Ten patients (27.8%) required oral steroids and 4 patients (6%) underwent revision surgery during the study period. One case of adrenal suppression occurred.

Conclusion

Topical steroid drops are beneficial in preventing sinus ostia stenosis in the postoperative period and may decrease the propensity toward repeated oral steroid therapy. This is particularly noteworthy in this challenging cohort, largely composed of revision frontal sinus surgery patients.

Enhanced Irrigant Delivery to the Ethmoid Sinuses Directly Following Ethmoid Punch Sinusotomy

OBJECTIVES

Ethmoid punch sinusotomy (EPS) is a feasible treatment for ethmoid sinusitis in a subset of chronic rhinosinusitis (CRS) patients per a recent report. This adjunctive work investigates the technical characteristics of EPS and determines if EPS measurably alters the topical delivery of irrigant into the ethmoid sinuses in a cadaveric model.

METHODS

The sinonasal cavities of 10 human cadaver heads were irrigated with a solution containing methylene blue and radio-opaque contrast prior to and following EPS. Procedural characteristics and irrigant distribution were assessed by endoscopy and computed tomography.

RESULTS

Forty EPS procedures were performed through the ethmoid bulla and basal lamella. Compared to controls, EPS enhanced dye distribution into the anterior (90% vs 35%, P < .004) and posterior (90% vs 35%, P < .002) ethmoid sinuses, representing a 157% increase for each of these sites. Contrast was detected in a higher proportion of anterior (65% vs 5%, P < .001) and posterior (60% vs 0%, P < .001) ethmoid sinuses. Endoscopically guided catheter instillation of contrast through the EPS sites achieved radiotracer distribution throughout the ethmoid complex.

CONCLUSIONS

Ethmoid punch sinusotomy sites can be reliably created via micro-minimally invasive procedures. Ethmoid punch sinusotomy improves irrigant delivery to the ethmoid sinuses, providing mechanistic understanding for the clinical outcomes observed in CRS patients.

THE 2017 13TH ANNUAL DAVID W. KENNEDY, MD, LECTURE The evolution of outcomes in sinus surgery for chronic rhinosinusitis: past, present, and future

This is an edited transcript from the 2017 13th Annual David W. Kennedy, MD, Lecture, presented to the American Rhinologic Society during the 63rd Annual Meeting.

Randomized controlled trial of steroid-soaked absorbable calcium alginate nasal packing following endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

To evaluate the potential efficacy of steroid-soaked, absorbable calcium alginate nasal packing following endoscopic sinus surgery.

STUDY DESIGN

Prospective, randomized, single-blinded, placebo-controlled trial.

METHODS

Twenty-two patients (44 nostrils) who had chronic rhinosinusitis with polyps underwent bilateral endoscopic sinus surgery. Only those with an intersinus difference in Lund-Mackay severity score of 1 or less were included. In each patient, one randomly selected nostril was packed with calcium alginate soaked with 2 mL of triamcinolone (40 mg/mL) (triamcinolone group), whereas the contralateral nostril received an identical packing soaked in 2 mL of normal saline (saline group). Two independent investigators blinded to the packing allocation scored the surgical field using the validated Perioperative Sinus Endoscopy (POSE) scores 1, 4, and 8 weeks after surgery.

RESULTS

All 44 nostrils were analyzed; the Lund-Mackay scores did not differ significantly between the groups before surgery. Eight weeks after surgery, the total POSE scores were significantly lower in the triamcinolone group (P = .014). The POSE scoring parameters were then compared between groups, and the following variables were significantly different: middle turbinate synechiae with the lateral wall (P = .037), polypoid degeneration of the ethmoid cavity (P = .006), and sphenoid sinus severity (P = .036).

CONCLUSIONS

This study demonstrated that steroid-soaked, absorbable nasal packing can be used to enhance wound healing after endoscopic sinus surgery and to prevent polypoid changes in the nasal mucosa.

LEVEL OF EVIDENCE

1b. Laryngoscope, 128:311-316, 2018.

Asthma quality of life and control after sinus surgery in patients with chronic rhinosinusitis

BACKGROUND

Patients with chronic rhinosinusitis (CRS) often have comorbid asthma. Prior studies have not examined the impact of CRS or endoscopic sinus surgery (ESS) upon asthma quality of life (QOL) and asthma control using validated outcome metrics.

METHODS

Patients with CRS, both with and without polyps, and comorbid asthma completed the Mini Asthma QOL Questionnaire (miniAQLQ) and Asthma Control Test (ACT) at baseline and 6 months postoperatively as part of a multi-institutional, prospective study.

RESULTS

Baseline metrics were available on 86 patients. Patients undergoing ESS reported improved miniAQLQ [0.5 (SD ±1.1), 95% CI: 0.2-0.7; P = 0.002] and ACT scores [1.3 (±4.1), 95% CI: 0.2-2.4; P = 0.025]. Uncontrolled baseline asthma (ACT < 20) was present in 51% of patients undergoing ESS. In uncontrolled patients, ESS resulted in a minimal clinically important difference 57% of the time for miniAQLQ scores (≥0.5 points) and 50% of the time for ACT scores (≥3.0 points). After adjustment with linear regression, baseline miniAQLQ scores were worse in patients with comorbid allergy (P = 0.045) and chronic obstructive pulmonary disease (COPD; P = 0.015). Adjusted baseline ACT scores were worse in patients with COPD (P = 0.004). Covariates associated with changes in miniAQLQ scores after ESS were pre-operative corticosteroid dependency (P = 0.011) and change in total SNOT-22 score (P = 0.010). Covariate associated with significantly less improvement in ACT scores was obstructive sleep apnea (P = 0.016).

CONCLUSIONS

Patients with CRS often present with uncontrolled asthma, and ESS improves both miniAQLQ and ACT. Approximately half of patients with uncontrolled asthma improve after ESS, yet there are few CRS-specific factors associated with asthma QOL or control or ESS outcomes.

CHEER National Study of Chronic Rhinosinusitis Practice Patterns: Disease Comorbidities and Factors Associated with Surgery

Objectives (1) Describe national patterns of chronic rhinosinusitis (CRS) care across academic and community practices. (2) Determine the prevalence of comorbid disorders in CRS patients, including nasal polyposis, allergic rhinitis, asthma, and cystic fibrosis. (3) Identify demographic, clinical, and practice type factors associated with endoscopic sinus surgery (ESS). Study Design Multisite cross-sectional study. Setting Otolaryngology's national research network CHEER (Creating Healthcare Excellence through Education and Research). Subjects and Methods A total of 17,828 adult patients with CRS were identified, of which 10,434 were seen at community practices (59%, n = 8 sites) and 7394 at academic practices (41%, n = 10 sites). Multivariate logistic regression was used to evaluate the association between demographic, practice type, and clinical factors and the odds of a patient undergoing ESS. Results The average age was 50.4 years; 59.5% of patients were female; and 88.3% were Caucasian. The prevalence of comorbid diseases was as follows: allergic rhinitis (35.1%), nasal polyposis (13.3%), asthma (4.4%), and cystic fibrosis (0.2%). In addition, 24.8% of patients at academic centers underwent ESS, as compared with 12.3% at community sites. In multivariate analyses, nasal polyposis (odds ratio [OR], 4.28), cystic fibrosis (OR, 2.42), and academic site type (OR, 1.86) were associated with ESS ( P < .001), while adjusting for other factors. Conclusions We describe practice patterns of CRS care, as well as demographic and clinical factors associated with ESS. This is the first study of practice patterns in CRS utilizing the CHEER network and may be used to guide future research.

Safe treatment of ethmoid sinusitis utilizing minimally invasive ethmoid punch sinusotomy in chronic rhinosinusitis without polyposis patients

OBJECTIVES/HYPOTHESIS

Current rhinologic practice is devoid of minimally invasive procedures dedicated to the treatment of ethmoid sinusitis to improve ventilation and topical drug delivery. We have recently described a handheld spiral punch to create minimally invasive ethmoid punch sinusotomy (EPS) sites into the ethmoid bulla and basal lamella, which significantly increased irrigant access to the ethmoid sinuses in cadaver models. Here, we conducted a clinical feasibility study to determine the initial safety evaluation of EPS in chronic rhinosinusitis without polyposis (CRSsNP) patients with active ethmoid disease.

STUDY DESIGN

Single-arm, institutional review board-approved observational study.

METHODS

This study was performed in CRSsNP patients who failed medical management; were candidates for standard, traditional functional endoscopic sinus surgery; and were offered the option of EPS. EPS characteristics (patency, remucosalization) and complications (closure, mucus recirculation) were collected. Alterations in radiographic disease and symptoms after EPS were determined by Lund Mackay (LM) scoring and 22-item Sinonasal Outcome Test (SNOT-22) scoring, which was collected up to 6 months post-procedure.

RESULTS

Thirty-two of 40 possible ethmoid compartments (17 of 20 anterior, 15 of 20 posterior) underwent EPS. Twenty-nine of 32 EPS sites remained patent (n = 29, 90.6%), with a minority displaying evidence of restenosis (n = 9, 28.1%) or closure (n = 3, 9.3%). All patent EPS sites had complete remucosalization (n = 29, 100%) with no evidence of mucus recirculation (n = 0, 0%) or other complications secondary to healing or device use. Ethmoid sinus cavities with a pre-EPS LM score of 1 or 2 universally improved to an LM score of 0 following EPS (n = 30 of 30, 100%). SNOT-22 scores significantly improved, with a mean reduction of 33.1 (49.6 ± 7.5 pre-EPS vs 16.5 ± 7.7 post-EPS, p < .0001).

CONCLUSIONS

This feasibility study demonstrates that EPS appears to be a safe, minimally invasive procedure to treat ethmoid sinusitis in CRSsNP patients unresponsive to medical therapy that establishes ethmoid ventilation, and likely improves effective sinus irrigation. Conducting a clinical trial would be appropriate in assessing a potential role for EPS in the management of this condition.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1268-1275, 2017.

Management and Outcome of Rhinosinusitis in Nigeria

OBJECTIVE

The aim of this study is to present the management and outcome of treatment of rhinosinusitis in Nigeria.

STUDY DESIGN

A retrospective review of the case notes of patients with rhinosinusitis between January 2009 and December 2014.

SETTING

Study at the University of Ilorin Teaching Hospital, Nigeria, using retrieved case notes after ethical approval was received.

SUBJECTS AND METHODS

The information retrieved included sociodemographic data, clinical presentation, duration, endoscopic examination, and other clinical management protocols with follow-up. All information was entered into SPSS version 20 and analyzed descriptively, and results are presented in tables and figure.

RESULTS

A total of 5618 patients were seen in the ear, nose, and throat clinic over the 6-year period. Of the patients, 445 had rhinosinusitis, and only 410 had complete data for analysis. Patient age ranged from 2 to 75 years (mean ± SD, 31.8 ± 1.2 years). The male to female ratio was 1.2:1. The duration of symptoms varied from 3 days to 10 years, with 78.7% having symptoms between 3 and 120 months. About 82.4% had nasal discharge, 51.3% had sneezing, 78.9% had alternating nasal obstruction, and 49.3% had nasal itch. Of the patients, 61.4% had a predisposition, of which 30.9% were allergic, 23.3% were infective, and 7.2% were vasomotor. Ethmoidal-maxillary sinuses were commonly affected radiologically. About 63% of patients had medical treatment, and only 28.7% had surgical intervention, of which 37% were scheduled for surgical treatment and 7.3% refused. Improved symptoms were noticed in 72.6% of patients, and 1.4% reported no improvement.

CONCLUSION

Rhinosinusitis is still common, affecting active males economically with more chronic cases and more allergic predisposition. Early medical management is still effective, and endoscopic sinus surgery is now a better surgical option with better outcome in 72.6%.

Prospective, multicenter evaluation of balloon sinus dilation for treatment of pediatric chronic rhinosinusitis

Background

Although balloon sinus dilation is a treatment option for adults with chronic rhinosinusitis (CRS), there have been few studies performed in pediatric patients.

Methods

This study was designed as a prospective, multicenter, single‐arm investigation. Children (2 to 21 years old) with CRS who had failed medical management were treated with balloon sinus dilation and followed to 6 months postprocedure.

Results

Fifty children were treated at 4 centers; 33 participants were 2 to 12 years old (mean ± standard deviation age: 6.6 ± 2.2 years) and 17 participants were >12 to 21 years (mean age: 15.7 ± 2.5 years). A total of 157 sinus dilations were attempted (98 maxillary, 30 frontal, and 29 sphenoid sinuses) and all were successful with no complications. Significant improvement in the Sinus and Nasal Quality of Life Survey (SN‐5) was seen for all children between baseline and 6 months (4.6 ± 1.2 vs 1.7 ± 0.8; p < 0.0001) and 92% improved by a minimal clinically important difference (MCID) of 1.0 or more. Those children aged 2 to 12 years with standalone balloon dilation also showed significant SN‐5 improvements between baseline and follow‐up (4.5 ± 1.0 vs 1.9 ± 0.8; p < 0.0001). Multivariate regression analysis showed no differences or associations of SN‐5 improvement at 6 months with the presence of allergy, asthma, or concomitant procedures. For adolescents, overall 22‐item Sino‐Nasal Outcome Test (SNOT‐22) mean scores were also significantly improved at 6 months (42.2 ± 19.2 vs 10.4 ± 9.7; p < 0.0001).

Conclusion

Balloon sinus dilation is safe and appears effective for children with CRS aged 2 years and older.

Surgical therapy vs continued medical therapy for medically refractory chronic rhinosinusitis: a systematic review and meta-analysis

BACKGROUND

The currently accepted treatment paradigm of treating chronic rhinosinusitis (CRS) first with appropriate medical therapy (AMT) and then with surgery if patients are refractory to AMT, has been criticized for lack of evidence. The objective of this study was to reassess the literature and establish the highest level of evidence possible regarding further management of CRS patients refractory to AMT.

METHODS

This study was a systematic review (SR) with meta-analysis (MA). Adult CRS patients who received AMT and then underwent either medical or surgical therapy in moderate to high level prospective studies were included. Outcomes assessed were disease-specific quality of life (QOL), nasal endoscopy, health-state utility, missed work days, change in cardinal symptoms of CRS, economic impact, and adverse events.

RESULTS

A total of 970 manuscripts were identified; 6 studies were ultimately included in the SR with 5 included in the MA. Compared to continued medical therapy, endoscopic sinus surgery (ESS) significantly improved patient-based QOL scores (p < 0.00001) and nasal endoscopy scores (p < 0.00001). Difference in missed work days depended heavily on patient choice of intervention. Unpooled analysis showed improvements in olfaction, health utility scores, and cost-effectiveness.

CONCLUSION

On meta-analysis, for CRS patients refractory to AMT, ESS significantly improves objective endoscopic scoring outcomes vs continued medical therapy alone. In patients with refractory CRS who have significant reductions in baseline QOL, ESS results in significant improvements. Continued medical therapy appears to maintain outcomes in patients with less severe baseline QOL. Unpooled analysis demonstrates improvement in health utility, olfaction, and cost-effectiveness following ESS compared to continued medical therapy alone, in medically refractory CRS.

Recent advances in the surgical management of rhinosinusitis

Rhinosinusitis affects a significant portion of the US population, and its management imposes a substantial burden on the healthcare system. The treatment of chronic rhinosinusitis includes initial medical management prior to consideration of surgical intervention. However, if surgery does become necessary, several factors must be considered in order to optimize outcomes. This review evaluates surgical patient selection, perioperative medical management, and the extent of operative intervention, with the goal of improving surgical results, decreasing the need for revision surgery, and enhancing the patient's quality of life. Specific variations in patient genotypes and phenotypes will be further explored with regard to their implications on surgical outcomes. Additionally, the evidence behind pre- and post-operative antibiotic and steroid use will be evaluated. Finally, we will review evolving surgical tools and techniques that are currently being utilized for the treatment of specific subsets of rhinosinusitis.

Can we use the questionnaire SNOT-22 as a predictor for the indication of surgical treatment in chronic rhinosinusitis?

Introduction

Chronic rhinosinusitis is a prevalent disease that has a negative impact on the lives of sufferers. SNOT-22 is considered the most appropriate questionnaire for assessing the quality of life of these patients and a very effective method of evaluating therapeutic interventions; however it is not used as a tool for decision-making.

Objective

To test the hypothesis that the SNOT-22 score can predict the outcome of surgical treatment.

Methods

A retrospective, longitudinal and analytical study. We evaluated the medical records of patients with chronic rhinosinusitis that completed the SNOT-22 at the time of diagnosis. All the patients were consecutively receiving care at an otolaryngology service in Salvador, Bahia from August 2011 to June 2012. The outcomes of the surgical treatment of these patients were obtained from their medical records. The initial score was compared to a group of patients who were not referred for surgery. All the patients completed and signed a consent form.

Results

Of the 88 patients with chronic rhinosinusitis, 26 had evolved to surgery over the last 3 years. The groups were homogeneous regarding gender and respiratory and medication allergies. The patients of the surgical group were 44.8 + 13.8 years old and the patients of the clinical group were 38.2 + 12.5 years old (p = 0.517). The average SNOT-22 score of the case group was 49 + 19 and the average score of the control group was 49 + 27 (p = 0.927).

Conclusion

The SNOT-22 was unable to predict the outcome of surgical patients with chronic rhinosinusitis.

Exploring the psychological morbidity of waiting for sinus surgery using a mixed methods approach

BACKGROUND

Patients with chronic rhinosinusitis (CRS) often have to endure significant wait times for endoscopic sinus surgery (ESS). The pyschiatric impact of placement on a waitlist for ESS has not been explored.

METHODS

Questionnaires measuring CRS symptom severity and health-related anxiety and stress (SNOT-22, HADS, WPAI-GH) were sent to patients diagnosed with CRS and currently on a waitlist for ESS. Fifteen representative waitlisted patients participated in one-on-one semi-structured interviews discussing their experience with their wait for ESS. A deductive thematic analysis was used to interpret the interview data using a quantitative driven mixed methods analysis.

RESULTS

Participants waiting for ESS reported worsening clinical symptomatology during their waiting period. Participants reported waitlist and CRS impact on both work and social aspects of their lives. The HADS scale showed no overall significant level of depression or anxiety in the HADS screening questionnaire. The qualitative data describe the effects of the symptom burden of CRS.

CONCLUSIONS

Patients waitlisted for ESS did not demonstrate any significant level of psychiatric distress, however variability exists. The qualitative arm of this study elucidates how patients cope with their wait.

Safety and Outcomes of Balloon Catheter Sinusotomy: A Multicenter 24-Week Analysis in 115 Patients

OBJECTIVE: The aim of this study was to further evaluate the safety and effectiveness of balloon catheter devices to dilate obstructed sinus ostia/perform sinusotomy.

METHODS: Through a prospective, multicenter evaluation, safety was assessed by rate of adverse events, patency was determined by endoscopic examination, and sinus symptoms were determined by the Sino-Nasal Outcome Test (SNOT 20).

RESULTS: At the conclusion of the 24-week analysis, endoscopy determined that the sinusotomy was patent in 80.5% (247 of 307) sinuses and nonpatent in 1.6% (5 of 307), and could not determine ostial patency status in 17.9% (55 of 307). Of the ostia visualized on endoscopy, 98% were patent (247 of 252), while 2% (5 of 252) were considered nonpatent. SNOT 20 scores showed consistent symptomatic improvement over baseline. Revision treatment was required in 3 sinuses (3 of 307 sinuses, 0.98%) in 3 patients (3 of 109 patients, 2.75%).

CONCLUSION: Balloon catheter technology appears safe and effective in relieving ostial obstruction. Patients were pleased and indicated that they experienced symptomatic improvement.

WITHDRAWN: Nasal saline irrigations for the symptoms of chronic rhinosinusitis

Review withdrawn from Issue 4, 2016. Review replaced by 'Saline irrigation for chronic rhinosinusitis' (Chong 2016).

The editorial group responsible for this previously published document have withdrawn it from publication.

Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study

BACKGROUND

Appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) are currently poorly defined. The lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates and contributes to reduced quality of care. The objective of this study was to define appropriateness criteria for ESS during management of adult patients with uncomplicated CRS.

METHODS

The RAND/UCLA appropriateness methodology was performed. An international, multidisciplinary panel of 10 experts in CRS was formed and completed 2 rounds of a modified Delphi ranking process along with a face-to-face meeting.

RESULTS

A total of 624 clinical scenarios were ranked, 312 scenarios each for CRS with and CRS without nasal polyps. For adult patients with uncomplicated CRS with nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus a short-course of systemic corticosteroid with a post-treatment total SNOT-22 score ≥ 20. For adult patients with uncomplicated CRS without nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus either a short-course of a broad spectrum/culture-directed systemic antibiotic or the use of a prolonged course of systemic low-dose anti-inflammatory antibiotic with a post-treatment total SNOT-22 score ≥ 20.

CONCLUSION

This study has developed and reported of list of appropriateness criteria to offer ESS as a treatment "option" during management of uncomplicated adult CRS. The extent or technique of ESS was not addressed in this study and will depend on surgeon and patient factors. Furthermore, these criteria are the minimal threshold to make ESS a treatment "option" and do not imply that all patients meeting these criteria require surgery. The decision to perform ESS should be made after an informed patient makes a preference-sensitive decision to proceed with surgery. Applying these appropriateness criteria for ESS may optimize patient selection, reduce the incidence of unwarranted surgery, and assist clinicians in providing high-quality, patient-centered care to patients with CRS.

Single seventh day debridement compared to frequent debridement after endoscopic sinus surgery: a randomized controlled trial

The aim of this study was to evaluate the postoperative debridement frequency following endoscopic sinus surgery. Individual randomized controlled trial. Sixty-two adult patients with a diagnosis of chronic rhino sinusitis (CRS) with nasal polyps (NP) and CRS without NP meeting the inclusion criteria were enrolled in this prospective study. The patients were randomized equally to frequent debridement (FD; at postoperative weeks 1, 2 and 4) or to a single debridement (SD; at postoperative week 1) after surgery. The outcomes were assessed with visual analog scale (VAS) for nine main symptoms concerning patient discomfort within the first 4 weeks, with the modified Lund-Kennedy endoscopic score (MLKES) at weeks 4 and 24 and with the sino-nasal outcome test-20 (SNOT-20) at week 24. Thirty-seven of the patients were male, and twenty-five were female. The mean age was 36.1 ± 13.5 in FD group and 39.2 ± 14.7 in SD group. In the SD group, the VAS scores at postoperative week four showed significantly less discomfort at visits (p = 0.004) and less negative effects on their work (p = 0.013). There was no statistically significant difference between the two groups in the week 4 and 24 MLKES and in the week 24 SNOT-20 scores (p > 0.05). The endoscopic findings did not show significant differences between the groups. Our data indicate that FD causes more discomfort at the required visits, more facial pain and more negative effects on patients' work; this method is not superior to postoperative single seventh day debridement in terms of the 24-week quality of life and endoscopic scores.

LEVEL OF EVIDENCE

1b.

The impact of endoscopic sinus surgery on total direct healthcare costs among patients with chronic rhinosinusitis

BACKGROUND

This study investigates how endoscopic sinus surgery (ESS) impacts total direct healthcare costs, medication usage, and frequency of imaging among patients with chronic rhinosinusitis (CRS).

METHODS

Data were obtained from the MarketScan® Commercial Claims and Encounters databases (Truven Health Analytics); patients who underwent ESS for CRS in 2008 were identified. Healthcare costs, days of antibiotic and oral steroid usage, and number of computed tomography (CT) and magnetic resonance imaging (MRI) studies were collected for 12 months prior to and 36 months after surgery and compared in 1-year intervals.

RESULTS

A total of 8963 surgical patients were included. Median total direct costs fell from $4750 at preoperative baseline (95% confidence interval [CI], $4661 to $4838) to $4212 by year 3 after surgery (95% CI, $4078 to $4346). Disease-specific costs related to conditions commonly associated with CRS-asthma, allergy, depression, and headache-all decreased in the years after surgery; the reduction was significant for all conditions but asthma. Mean days of antibiotic usage per year decreased from 28.2 days before surgery to 15.9 days by year 3 after surgery, p value <0.001. Days of oral corticosteroid usage remained stable at just over 7 days. Mean number of imaging studies fell from an average of 1.6 in the year before surgery to 0.2 by year 3 after surgery, p value <0.001.

CONCLUSION

Among patients who underwent ESS for CRS, total direct healthcare costs, antibiotic usage, and number of imaging studies decreased after surgery, and remained below preoperative levels throughout all 3 years of follow-up. Oral corticosteroid usage remained stable.

Quality of life outcomes after functional endoscopic sinus surgery for nasal polyposis

PURPOSE

The objective of this study is to determine the results of functional endoscopic sinus surgeries (FESS) for chronic rhinosinusitis with polyps and assess the association between surgery and specific quality of life outcomes.

MATERIALS AND METHODS

A prospective study was performed in a tertiary referral center. Fifty-eight patients affected by chronic rhinosinusitis with nasal polyposis underwent endoscopic sinus surgery from January 2011 to April 2013 and followed for 1 year. The rhinosinusitis disability index (RSDI), a validated disease-specific instrument, was used to quantify the patient's symptoms before and 12 months after surgery.

RESULTS

A strongly statistically significant reduction was seen between the mean scores on RSDI before and after FESS [86.43 (IQR=16.10) versus 51.16 (IQR=18.95), Wilcoxon signed-rank test, p<0.0001]. In multiple regression model, only four preoperative characteristics predicted the outcomes. The high mucosal eosinophilia density was the most important preoperative predictor.

CONCLUSIONS

There is evidence which supports the efficacy of FESS to improve long-term QOL outcomes in patients with CRS. The mucosal eosinophilia density and prior sinus surgery appeared to be the most predictive factors of surgical outcomes.

Effect of topical ofloxacin on bacterial biofilms in refractory post-sinus surgery rhino-sinusitis

Bacterial biofilms have been shown to play a major role in many chronic infections, in addition, there is growing evidence that bacterial biofilms may play a role in some forms of refractory CRS that persists despite proper surgery and culture directed antibiotic therapy. The objective is to determine the effect of application of topical ofloxacin on nasal and sinus mucosa in patients with proven existence of bacterial biofilms and persistent chronic sinusitis after FESS. The study design is a prospective controlled study. The study included a total of 12 patients who had refractory CRS in spite of undergoing FESS for that specific reason (study group), and control group (involved 25 patients), for whom FESS was done, with complete improvement postoperatively in 15 of them, and persistence of symptoms in the other ten. Topical ofloxacin eye drops (0.3 %) tds for 12 weeks were prescribed for (study group), culture and sensitivity and scanning electron microscopy were done for middle meatal mucosal specimens for all patients and controls, all of them were followed up for a minimum of 9 months (range 9-18 months). Of the study group, 80 % showed marked improvement in the structure of the mucosa, with the regaining of normal respiratory epithelium, with complete disappearance of the biofilm surface, and the remaining 20 % showed only reduction in the number of inflammatory cells and regaining cilia with scattered patches of very thin biofilm. Biofilms formation plays an active role in perpetuating inflammation in CRS patients and enhanced the recurrence and resistance in those patients, we found a statistically significant improvement in patients' group (P < 0.001), after 12 weeks of topical ofloxacin (without any evidence of any side effects). So, we concluded that topical ofloxacin seems to be an effective, tolerable, convenient, cheap and even safe mode of treatment of refractory CRS after FESS due to biofilms' formation. Thus, we recommend such modality of treatment postoperatively especially in refractory cases of CRS.

ICON: chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a public health problem that has a significant socio-economic impact. Moreover, the complexity of this disease due to its heterogeneous nature based on the underlying pathophysiology - leading to different disease variants - further complicates our understanding and directions for the most appropriate targeted treatment strategies. Several International/national guidelines/position papers and/or consensus documents are available that present the current knowledge and treatment strategies for CRS. Yet there are many challenges to the management of CRS especially in the case of the more severe and refractory forms of disease. Therefore, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), a collaboration between EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus (ICON) on Chronic Rhinosinusitis. The purpose of this ICON on CRS is to highlight the key common messages from the existing guidelines, the differences in recommendations as well as the gaps in our current knowledge of CRS, thus providing a concise reference. In this document we discuss the definition of the disease, its relevance, pharmacoeconomics, pathophysiology, phenotypes and endotypes, genetics and risk factors, natural history and co-morbidities as well as clinical manifestations and treatment options in both adults and children comprising pharmacotherapy, surgical interventions and more recent biological approaches. Finally, we have also highlighted the unmet needs that wait to be addressed through future research.

Effects of Endoscopic Sinus Surgery and Nasal Surgery in Patients with Obstructive Sleep Apnea

OBJECTIVES

To evaluate the impact of combined nasal surgery and endoscopic sinus surgery on the objective measurements of obstructive sleep apnea (OSA) and sleep architecture by comparing polysomnographic data before and after combined surgery in patients with OSA.

STUDY DESIGN

Case series with chart review.

SETTING

A single clinical site.

SUBJECTS AND METHODS

Patients with OSA and chronic rhinosinusitis who underwent combined nasal surgery and endoscopic sinus surgery and preoperative and postoperative polysomnography were identified. Patient charts were reviewed and preoperative and postoperative body mass index, apnea-hypopnea index (AHI), mean and minimum oxygen saturation, sleep efficiency, and sleep staging were compared.

RESULTS

Fifty-six patients were included in our study. Patients were divided into 3 groups on the basis of the severity of OSA: those with mild OSA (n = 9), those with moderate OSA (n = 23), and those with severe OSA (n = 24). After combined nasal and sinus surgery, the mean AHI significantly decreased from 33.5 ± 22.0 to 29.4 ± 20.8 (P = .009) in our overall population. Specifically, AHI improved significantly in patients with moderate OSA (from 22.3 ± 4.8 to 20.7 ± 8.2, P = .023) and severe OSA (from 52.3 ± 21.4 to 43.6 ± 23.9, P = .034), while patients with mild OSA did not have significant changes in AHI. Successful surgical procedures were achieved in only 2 of 56 patients.

CONCLUSION

Although combined nasal and sinus surgery may slightly improve AHI in a certain group of patients, it does not cure OSA or have a significant clinical impact.

Chapter 12: Surgery for sinonasal disease

Surgery for chronic rhinosinusitis is an effective complement to a well-designed medical regimen. Functional endoscopic sinus surgery is among the most common surgeries performed for sinonasal disease refractory to maximal medical therapy. Nasal surgery techniques, such as septoplasty and inferior turbinate surgery, may assist in both relieving the symptom of nasal obstruction and providing access for sinus surgery. Although rare, open sinus techniques are occasionally required.

The role of immediate postoperative systemic corticosteroids when utilizing a steroid-eluting spacer following sinus surgery

OBJECTIVE

Steroid-eluting spacers can improve local drug delivery immediately following endoscopic sinus surgery and reduce the recurrence of inflammation warranting systemic corticosteroids. For chronic rhinosinusitis with nasal polyposis, the need for systemic corticosteroids immediately following endoscopic sinus surgery when using a steroid-eluting spacer has not been studied.

STUDY DESIGN

A randomized, double-blind, placebo-controlled trial.

SETTING

Academic rhinology practice.

SUBJECTS AND METHODS

Chronic rhinosinusitis patients with nasal polyposis who failed medical therapy and elected endoscopic sinus surgery were enrolled. Patients were randomized into either the treatment arm (postoperative prednisone 30 mg daily × 7 days; n = 18) or placebo arm (postoperative placebo pill daily × 7 days; n = 18). Outcomes were evaluated at 1 week, 3 weeks, and 2 months postoperatively. Primary outcome was endoscopic grading at postoperative month 2 using the Lund-Kennedy system. Secondary outcome included disease-specific quality of life using the Sinonasal Outcome Test (SNOT-22) survey. Patient enrollment occurred from January 2012 through February 2013 (NCT01564355).

RESULTS

Both arms received significant improvement in endoscopic grading and disease-specific quality of life from baseline compared to 2-month follow-up (P < .001). There were no significant differences in mean endoscopic scores between the postoperative prednisone and control groups at 1 week (P = .715), 3 weeks (P = .883), or 2 months (P = .343). There were no significant differences in SNOT-22 scores between groups at all follow-up points (all P > .119).

CONCLUSION

Minimizing systemic corticosteroid use in patients with chronic rhinosinusitis with nasal polyposis may avoid adverse events. Results from this study suggest that postoperative systemic corticosteroids immediately following endoscopic sinus surgery may not provide improved outcomes when utilizing a steroid-eluting spacer.

Etiology, diagnosis and management of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a common health care problem, yet many aspects of this diagnosis remain poorly understood. Its etiology is often debated and remains a significant area of research. The diagnosis of CRS is based on subjective symptoms, duration of symptoms and objective evidence of inflammation. Each of these criteria must be met to make a diagnosis of CRS. Management of CRS often involves a combination of systemic and topical therapies with surgery reserved for patients who fail medical therapy. This review provides a comprehensive view of the etiology, diagnosis and management of CRS.

Quantification of airflow into the maxillary sinuses before and after functional endoscopic sinus surgery

BACKGROUND

The effects of increases in maxillary sinus (MS) airflow following functional endoscopic sinus surgery (FESS) are unknown. The goal of this study was to quantify the effects of FESS on airflow into the MS in a cohort of patients with chronic rhinosinusitis, and compare MS flow rate with patient-reported outcome measures.

METHODS

A pilot study was conducted in which preoperative and postoperative computed tomography scans of 4 patients undergoing bilateral or unilateral FESS were used to create 3-dimensional (3D) reconstructions of the nasal airway and paranasal sinuses using Mimics™ (Materialise, Inc.). The size of the maxillary antrostomies post-FESS ranged from 107 to 160 mm(2). Computational meshes were generated from the 3D reconstructions, and steady-state, laminar, inspiratory airflow was simulated in each mesh using the computational fluid dynamics (CFD) software Fluent™ (ANSYS, Inc.) under physiologic, pressure-driven conditions. Airflow into the MS was estimated from the simulations and was compared preoperatively and postoperatively. In addition, patients completed preoperative and postoperative Rhinosinusitis Outcome Measure-31 (RSOM-31) questionnaires and scores were compared with MS airflow rates.

RESULTS

CFD simulations predicted that average airflow rate into post-FESS MS increased by 18.5 mL/second, and that average flow velocity into the MS more than quadrupled. Simulation results also showed that MS flow rate trended with total RSOM-31 and all domain scores.

CONCLUSION

CFD simulations showed that the healed maxillary antrostomy after FESS can greatly enhance airflow into the MS. Our pilot study suggests that to some extent, increasing airflow into the MS may potentially improve chronic rhinosinusitis patients' quality of life pre-FESS and post-FESS.

Complementary and integrative treatments: rhinosinusitis

Rhinosinusitis is characterized by inflammation of the mucosa involving the paranasal sinuses and the nasal cavity and is one of the most common health care problems, with significant impairment of quality of life. There is a growing amount of interest in the use of complementary and integrative medicine for the treatment of rhinosinusitis. This article focuses on an integrative approach to rhinosinusitis.

Improvement of olfactory function for quality of life recovery

OBJECTIVES/HYPOTHESIS

To explore quality of life (QoL) improvement after treatment of patients with chronic olfactory disorders; and to correlate QoL with olfactory rehabilitation and evaluate olfactory improvement values over which QoL outcomes are significantly recovered.

STUDY DESIGN

Prospective clinical study.

METHODS

Eighty-nine patients following endoscopic sinus surgery for chronic rhinosinusitis (CRS) and immunotherapy for allergic rhinitis (AR) were studied. Olfactory function was evaluated using Sniffin' Sticks test pre-and 12 months after treatment. All patients completed six validated QoL questionnaires either specific for olfaction (Questionnaire of Olfactory Deficits-QOD) and for assessing mental health (Zung Anxiety Scale, State-Trait Anxiety Inventory, Zung Depression Scale, Beck Depression Inventory), or generic one (Short Form-36).

RESULTS

Significant improvement (all P < 0.001) of olfactory function by 27.4% in total cohort (AR: 10.4%, P = 0.004; CRS: 39.9%, P < 0.001), expressed by the combined Threshold-Discrimination-Identification (TDI) score-and of all QoL questionnaires scores (all P < 0.01) as well, was observed after treatment. There was a positive correlation between olfactory recovery and improvement of patients' QoL. ROC analysis revealed that an increase in the TDI score by 3.50 points in AR and 4.75 points in CRS was necessary for a clinically significant improvement in all QoL questionnaires results.

CONCLUSIONS

QoL and mental health of patients suffering from chronic sinonasal diseases are totally recovered after treatment, presenting a direct positive relationship with smell improvement. An increase of olfactory function by 3.50 points for AR and 4.75 points for CRS might be considered the cutoff point for patients' QoL significant recovery.

Long-term successes of various sinus surgeries: a comprehensive analysis

Outcome studies often examine the efficacy of sinus surgery with 1 year of follow-up data, while longer-term postoperative data is less easily available. This article reviews long-term outcomes of various endoscopic techniques to further delineate risk factors for surgical failure. A systematic review of the literature was performed and studies were stratified based on surgical technique and recognized risk factors of postoperative failure. A total of 126 abstracts were identified, 82 articles were retrieved for full review, and 56 were included in this report. A total of 30 studies had longer than 1 year of follow-up data and the longest follow-up period was 10 years. Based on the available evidence, endoscopic sinus surgery has a high success rate, but with well-recognized risk factors for failure. Aggressive postoperative local care and medical therapy should be tailored to each patient's particular disease process, and form an integral part of surgical management.

[Treatment of chronic rhinosinusitis using balloon sinuplasty. A quality of life analysis]

BACKGROUND

Balloon sinuplasty (functional endoscopic dilation surgery, FEDS) has become established as a safe therapeutic procedure for treatment of chronic rhinosinusitis. Our goal was to assess the effect on quality of life (QoL) using validated tools and identify predictive factors.

MATERIALS AND METHODS

A consecutive cohort of 14 patients was evaluated using the disease-specific QoL questionnaire Sino-Nasal Outcome Test 20 (SNOT-20). The measured postoperative changes were then correlated to the results of preoperative CT scan analyses performed according to Lund.

RESULTS

Both the overall SNOT-20 scores and those corresponding to subsections regarding primary nasal symptoms (PNS) and secondary rhinogenic symptoms (SRS) showed a highly significant improvement (p < 0.01). Changes in PNS but not in SRS correlated with the CT scan analyses (p < 0.05). Eighty five percent of patients said that they would choose to undergo FEDS again.

CONCLUSIONS

FEDS is an effective technique that can alleviate symptoms and improve QoL. Patient selection should not be based on CT data alone but a CT scan can be used to determine whether or not the FEDS technique is applicable to the individual patient.