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Kim K, Otto BA, Farag AA, Zhao K. Topical irrigation against gravity may lead to better sinus penetration. Int Forum Allergy Rhinol 2020; 11:198-200. [PMID: 33145957 DOI: 10.1002/alr.22711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Kanghyun Kim
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH.,Department of Biomedical Engineering, The Ohio State University, Columbus, OH
| | - Bradley A Otto
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH
| | - Alexander A Farag
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH
| | - Kai Zhao
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH.,Department of Biomedical Engineering, The Ohio State University, Columbus, OH
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Zhao K, Kim K, Craig JR, Palmer JN. Using 3D printed sinonasal models to visualize and optimize personalized sinonasal sinus irrigation strategies. Rhinology 2020; 58:266-272. [PMID: 32441708 DOI: 10.4193/rhin19.314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Topical sinus irrigations (neti-pot, squeeze bottles) play a critical role in the management of sinonasal disease. However, due to intricate nasal anatomy, penetration of topical irrigations to targeted sinus regions may be highly variable, and difficult to objectively predict. Variables, including head positions, injection angles, flow rates, etc. may vary significantly depending on the individual's anatomy. OBJECTIVE The purpose of this study was to propose a novel idea: using a 3D printed model of sinonasal cavities to visualize and develop a patient-specific irrigation strategy. METHODS As a proof of concept, 3D replicas of one patient's sinonasal cavities pre- and post-surgery were printed with a Form2 SLA 3D printer based on their CT scans. The setup included rubber/silicon seals attached to the model's nostrils to create a watertight seal with the irrigation device and food color dye added for better visualization of irrigation results. RESULTS Irrigations were performed on the 3D models with various head positions, injection angles, and flow rates, and were successful to determine the optimal strategy to targeted sinuses. Significant differences were observed between different targeted sinuses and between pre and post-surgery models. CONCLUSION With more affordable 3D printing, this technology may potentially improve patient care and patient education, allowing clinicians and patients to develop a personalized irrigation strategy and have visual confirmation.
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Affiliation(s)
- K Zhao
- Department of Otolaryngology- Head and Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - K Kim
- Department of Otolaryngology- Head and Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - J R Craig
- Department of Otolaryngology- Head and Neck Surgery, Henry Ford Health System, Detroit, MI, USA
| | - J N Palmer
- Department of Otolaryngology- Head and Neck Surgery, Perelmann School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
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Medikeri G, Javer A. Optimal Management of Allergic Fungal Rhinosinusitis. J Asthma Allergy 2020; 13:323-332. [PMID: 32982320 PMCID: PMC7494399 DOI: 10.2147/jaa.s217658] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/13/2020] [Indexed: 01/02/2023] Open
Abstract
Introduction Allergic fungal rhinosinusitis (AFRS) is a chronic disorder with significant morbidity and a high recurrence rate needing long-term follow-up. Even after its first description many decades ago, there is still considerable uncertainty about the management of this condition. Description In this chapter, we breakdown the topic “Optimal management of allergic fungal rhinosinusitis” into sub-headings in order to discuss the latest research and available literature under each topic in great detail. Every attempt has been made to incorporate the highest level of evidence that was available at the time of writing. Summary Pre-operative diagnosis and further management prior to surgery is important. Steroids help in reducing inflammation and help improve the surgical field. Surgery remains the mainstay in the management of this condition along with long-term medical management. Oral steroids are reserved for acute flare-ups in the background of associated lung concerns. Oral and topical antifungal agents have no role in the control of the disease. Biological agents are being prescribed predominantly by respiratory physician colleagues, mainly for the control of the chest-related issues rather than for sinus disease. Immunotherapy as an adjunct with surgery is promising. Conclusion AFRS is a disease with many variables and a wide range of symptomatic presentation. It takes a keen clinician to identify the disease and subsequently manage the condition. Treatment involves long-term follow-up with early detection of recurrence or flare-ups. Any of the mentioned modalities of management may be employed to effectively control the condition, and treatment protocols will have to be tailor-made to suit each individual patient. Various medications and drugs such as Manuka honey, antimicrobial photodynamic therapy, hydrogen peroxide and betadine rinses appear to be promising. More robust studies need to be undertaken to ascertain their routine use in clinical practice.
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Affiliation(s)
| | - Amin Javer
- Rhinology & Skull Base Surgery, St. Paul's Sinus Center, Vancouver, BC, Canada
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Govindaraju R, Cherian L, Macias-Valle L, Murphy J, Gouzos M, Vreugde S, Wormald PJ, Bassiouni A, Psaltis AJ. Extent of maxillary sinus surgery and its effect on instrument access, irrigation penetration, and disease clearance. Int Forum Allergy Rhinol 2019; 9:1097-1104. [PMID: 31343852 DOI: 10.1002/alr.22397] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/04/2019] [Accepted: 07/10/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Middle meatal antrostomy (MMA) provides limited access to the anteromedial and inferior aspect of the maxillary sinus (MS) often resulting in residual disease and inflammatory burden. Newer extended procedures, such as mega-antrostomy (Mega-A) and extended modified mega-antrostomy (EMMA), have been developed to address this limitation. This study assesses the effect of varying extent of MS surgery on irrigation penetration and access of instrumentation. METHODS The MS of 5 fresh-frozen cadavers were sequentially dissected. Irrigation was evaluated with a squeeze bottle (SB) in different head positions and using different volumes of fluid. Surgical reach and visualization were examined using common sinus instruments and different angled endoscopes. A disease simulation was also performed to check for residual debris after instrumentation and irrigations. RESULTS Irrigation penetration improved as antrostomy size increased (p < 0.0001), with a significant difference observed between the extended procedures and MMA. The effect of the volume was significant for SB (p < 0.0001) but head positions appeared irrelevant (p = 0.613). Overall visualization improved for Mega-A and EMMA. A similar trend was seen for the reach of the instruments to all sinus wall subsites. EMMA facilitated the most removal of "sinus disease" in the disease simulation model when compared with both MMA and Mega-A, due to its reach of the anteroinferior aspects of the maxillary sinus. CONCLUSIONS High-volume irrigation using SB achieved good sinus penetration, irrespective of head position. Extended MS procedures appear to further increase irrigation penetration as well as surgical access.
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Affiliation(s)
- Revadi Govindaraju
- Department of Otorhinolaryngology-Head & Neck Surgery, The Queen Elizabeth Hospital, Woodville South, SA, Australia.,Department of Otorhinolaryngology-Head & Neck Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Lisa Cherian
- Department of Otorhinolaryngology-Head & Neck Surgery, The Queen Elizabeth Hospital, Woodville South, SA, Australia
| | - Luis Macias-Valle
- Department of Otorhinolaryngology-Head & Neck Surgery, The Queen Elizabeth Hospital, Woodville South, SA, Australia
| | - Jae Murphy
- Department of Otorhinolaryngology-Head & Neck Surgery, The Queen Elizabeth Hospital, Woodville South, SA, Australia
| | - Michael Gouzos
- Department of Otorhinolaryngology-Head & Neck Surgery, The Queen Elizabeth Hospital, Woodville South, SA, Australia
| | - Sarah Vreugde
- Department of Otorhinolaryngology-Head & Neck Surgery, The Queen Elizabeth Hospital, Woodville South, SA, Australia
| | - Peter John Wormald
- Department of Otorhinolaryngology-Head & Neck Surgery, The Queen Elizabeth Hospital, Woodville South, SA, Australia
| | - Ahmed Bassiouni
- Department of Otorhinolaryngology-Head & Neck Surgery, The Queen Elizabeth Hospital, Woodville South, SA, Australia
| | - Alkis James Psaltis
- Department of Otorhinolaryngology-Head & Neck Surgery, The Queen Elizabeth Hospital, Woodville South, SA, Australia
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Griggs ZH, M Williams A, Craig JR. Head and Bottle Angles Achieved by Patients During High-Volume Sinonasal Irrigations. Am J Rhinol Allergy 2019; 33:302-309. [PMID: 30674198 DOI: 10.1177/1945892419825612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Certain head positions can optimize topical irrigation distribution to specific sinuses. No studies have assessed whether patients attain these positions when irrigating. OBJECTIVE The purpose of this study was to assess head and bottle angles achieved when patients irrigate based on instructions from an irrigation device or from a Rhinologist. METHODS Study approval was obtained from Henry Ford Health System's Institutional Review Board (10604). Forty-two patients with various rhinologic conditions were equally divided into groups based on irrigation instruction type: pictoral instructions from an irrigation device or written/verbal instructions from a Rhinologist. Both groups' instructions directed nose-to-floor head positioning. Simulating home irrigations, patients irrigated 120 mL of saline into each naris using 240 mL squeeze bottles. Frontal and lateral views were captured using video cameras. On frontal view, angles were measured between (1) nasal dorsum (ND) and bottle tip (BT; n = 84) and (2) ND and vertical (V; n = 84). On lateral view, angles were measured between (1) line from nasion-to-pogonion (NTP) and horizontal (H) (n = 73) and (2) NTP and BT (n = 73). RESULTS On lateral view, average angle between NTP and H was 20.0° (standard deviation [SD] = 13.1, 95% confidence interval [CI] = 17.0-23.0) and between NTP and BT was 59.4° (SD = 15.8, 95% CI = 55.8-63.1). On frontal view, average angle between ND and V was 9.5° (SD = 19.5, 95% CI = 5.3-13.6) and between ND and BT was 24.5° (SD = 12.0, 95% CI = 21.9-27.0). There were no significant angle differences between sides or instruction types. CONCLUSION When instructed to irrigate in the nose-to-floor head position, patients achieved a head position uprotated 20° on lateral view and vertex rotated 10° away from the side of irrigation on frontal view.
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Affiliation(s)
- Zachary H Griggs
- 1 Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan
| | - Amy M Williams
- 1 Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan
| | - John R Craig
- 1 Department of Otolaryngology, Henry Ford Health System, Detroit, Michigan
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Chen PG, Murphy J, Alloju LM, Boase S, Wormald PJ. Sinus Penetration of a Pulsating Device Versus the Classic Squeeze Bottle in Cadavers Undergoing Sinus Surgery. Ann Otol Rhinol Laryngol 2016; 126:9-13. [DOI: 10.1177/0003489416671532] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: Nasal irrigation is standard in the management of chronic rhinosinusitis both before and after surgical intervention. Numerous irrigation devices are commercially available. The aim of this study was to compare the efficacy of a handheld pulse irrigation device against the gold standard manual squeeze bottle after endoscopic sinus surgery (ESS). Methods: Five cadaveric specimens were prepared with video visualization ports into each sinus. Endoscopic sinus surgery was performed on each cadaver from minimal to maximal dissection. Sinuses were irrigated with fluorescein solution using both devices following each dissection. The irrigations were video recorded. A blinded independent observer scored each irrigation according to a defined scale. Results: Comparison of the 2 devices using an intraclass correlation coefficient (ICC = 0.39) showed the 2 systems differed. Observation of individual sinuses showed the squeeze bottle consistently provided greater irrigation in the maxillary ( P < .006), frontal ( P < .0001), and sphenoid ( P < .0001) sinuses. Pulse irrigation improved only in the maxillary sinus following ESS. Conclusion: The squeeze bottle consistently demonstrated superior irrigation in both native and operated conditions. Interestingly, saline penetration was not significantly improved after opening of the frontal and sphenoid sinuses. This is likely due to decreased backpressure in the nasal passage after opening the sinus cavities.
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Affiliation(s)
- Philip G. Chen
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Jae Murphy
- Department of Surgery-Otorhinolaryngology, Head & Neck Surgery, University of Adelaide, South Australia, Australia
| | - Les M. Alloju
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Sam Boase
- Department of Surgery-Otorhinolaryngology, Head & Neck Surgery, University of Adelaide, South Australia, Australia
| | - Peter-John Wormald
- Department of Surgery-Otorhinolaryngology, Head & Neck Surgery, University of Adelaide, South Australia, Australia
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Zhao K, Craig JR, Cohen NA, Adappa ND, Khalili S, Palmer JN. Sinus irrigations before and after surgery-Visualization through computational fluid dynamics simulations. Laryngoscope 2015; 126:E90-6. [PMID: 26467934 DOI: 10.1002/lary.25666] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 08/05/2015] [Accepted: 08/18/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Topical sinus irrigations play a critical role in the management of sinonasal disease, and the improvement in irrigant penetration into the sinuses postoperatively greatly contributes to the success of endoscopic sinus surgery. Prior investigations on postoperative sinus irrigations have been mostly limited to cadaver studies, which are labor intensive and do not capture the full dynamics of the flows. A pilot study was conducted to investigate the impact of surgery on sinus irrigation through computational fluid dynamics (CFD) simulations. STUDY DESIGN Retrospective computational study. METHODS Pre- and postoperative computed tomography (CT) scans were obtained on a patient who underwent standard endoscopic surgeries for all sinuses, including a Draf III frontal sinusotomy. CT-based pre- and postoperative CFD models then simulated irrigations of 120 mL saline per nostril at 12 mL/s (typical of Sinugator) and 60 mL/s (SinusRinse Bottle), in two head positions: face parallel and at a 45° angle to the ground. RESULTS Overall, surgery most significantly improved frontal sinus irrigation, but surprisingly resulted in less maxillary and ethmoid sinuses penetration. This may due to the partial removal of the septum during the Draf III, causing most fluid to exit prematurely across the resected septum. Higher flow rate slightly improved ethmoid sinus irrigation, but resulted in less preoperative contralateral maxillary sinus penetration. CONCLUSIONS CFD modeling of sinonasal irrigations is a novel technique for evaluating irrigant penetration of individual sinus cavities. It may prove useful in determining the optimal degree of surgery or the ideal irrigation strategy to allow for maximal and targeted sinus irrigant penetration. LEVEL OF EVIDENCE NA Laryngoscope, 126:E90-E96, 2016.
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Affiliation(s)
- Kai Zhao
- Department of Otolaryngology-Head & Neck Surgery, Ohio State University, Columbus, OH
| | - John R Craig
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noam A Cohen
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania.,Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, U.S.A
| | - Nithin D Adappa
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sammy Khalili
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James N Palmer
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania
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