Patienten mit chronischer Rhinosinusitis

Machine-Learning Points at Endoscopic, Quality of Life, and Olfactory Parameters as Outcome Criteria for Endoscopic Paranasal Sinus Surgery in Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is often treated by functional endoscopic paranasal sinus surgery, which improves endoscopic parameters and quality of life, while olfactory function was suggested as a further criterion of treatment success. In a prospective cohort study, 37 parameters from four categories were recorded from 60 men and 98 women before and four months after endoscopic sinus surgery, including endoscopic measures of nasal anatomy/pathology, assessments of olfactory function, quality of life, and socio-demographic or concomitant conditions. Parameters containing relevant information about changes associated with surgery were examined using unsupervised and supervised methods, including machine-learning techniques for feature selection. The analyzed cohort included 52 men and 38 women. Changes in the endoscopic Lildholdt score allowed separation of baseline from postoperative data with a cross-validated accuracy of 85%. Further relevant information included primary nasal symptoms from SNOT-20 assessments, and self-assessments of olfactory function. Overall improvement in these relevant parameters was observed in 95% of patients. A ranked list of criteria was developed as a proposal to assess the outcome of functional endoscopic sinus surgery in CRS patients with nasal polyposis. Three different facets were captured, including the Lildholdt score as an endoscopic measure and, in addition, disease-specific quality of life and subjectively perceived olfactory function.

Predictive markers of long-term recurrence in chronic rhinosinusitis with nasal polyps

BACKGROUND

In last years, many attempts were made to recognize chronic rhinosinusitis with nasal polyps (CRSwNP) phenotypes focusing on identifying relevant key pathogenic molecules. Polyps recurrence rate ranges from 4% to 60%, so it's clear that not all clinical and immunologic factors associated with recurrence are known.

OBJECTIVE

We investigate the inflammatory profile in patients with long term recurrent and non-recurrent CRSwNPs and if a specific profile is associated with recurrence, comparing eosinophilic, neutrophilic and lymphocytic infiltration, as well as IL-5 and IL-8 expression to long term recurrence rate.

METHODS

This prospective study included 44 adult patients with CRSwNP treated with endoscopic sinus surgery between 2008 and 2010. Long term follow-up data (8-10 years) indicated that among 44 patients, 18 (40.1%) experienced long term recurrence of nasal polyposis needing maximal medical treatment or revision surgery. We realized two groups: one with patients who didn't present long term recurrence (26 patients) and another with patients who presented long term recurrence (18 patients) and in both groups eosinophilic, neutrophilic and lymphocytic infiltration and IL-5 and IL-8 expression were measured.

RESULTS

The parameters that reached statistical significance (p < 0.05) comparing the two groups were eosinophilic infiltration and IL-5 expression, whereas neutrophilic and lymphocytic infiltration, as IL-8 expression didn't show any significant difference. Asthma and aspirin intolerance seemed significantly more frequent in patients with recurrence, while allergy presented not statistically significant difference between two groups.

CONCLUSIONS

We can conclude that high eosinophilic infiltration and high IL-5 expression in CRSwNP correlate with higher rate of long term recurrence, while neutrophilic and lymphocytic infiltration, and IL-8 expression don't correlate with it. These findings provide the opportunity to improve our ability to predict the prognosis of surgical intervention, although it is still needed to explore the optimal predictor of outcome in CRSwNP.

Cytokine patterns in nasal secretion of non-atopic patients distinguish between chronic rhinosinusitis with or without nasal polys

BACKGROUND

Being one of the most common nasal diseases, chronic rhinosinusitis (CRS) is subdivided into CRS with nasal polyps (NP) and CRS without nasal polyps (CRSsNP). CRSsNP presents itself with a TH1 milieu and neutrophil infiltration, while NP is characterised by a mixed TH1/TH2 profile and an influx of predominantly eosinophils, plasma cells and mast cells. For the purpose of discovering disease-specific cytokine profiles, the present study compares levels of mediators and cytokines in nasal secretions between CRSsNP, NP, and healthy controls.

METHODS

The study included 45 participants suffering from NP, 48 suffering from CRSsNP and 48 healthy controls. Allergic rhinitis constituted an exclusion criterion. Nasal secretions, sampled using the cotton wool method, were analysed for IL-4, IL-5, IL-10, IL-12, IL-13, IL-17, IL-8, GM-CSF, G-CSF, IFN-γ, MCP-1, MIP-1α, MIP-1β, eotaxin, and RANTES, and for ECP and tryptase, using Bio-Plex Cytokine assay or ELISA, respectively.

RESULTS

Elevated levels of IL-5, IL-17, G-CSF, MCP-1, MIP-1α, MIP-1β, ECP, and tryptase, as well as decreased levels of IL-10, IL-12, IL-13, and IFN-γ were detected in NP. CRSsNP presented increased levels of RANTES and MIP-1β while IL-13 was decreased. No differences between the three groups were found for IL-4, IL-8, GM-CSF, and eotaxin.

CONCLUSIONS

The present work suggests a disequilibrium of TH1 and TH2, together with a down-regulation of regulatory T lymphocytes and up-regulated TH17 in NP. Moreover, elevated levels of diverse mediators represent the activation of various inflammatory cells in this disease entity. The inflammation in CRSsNP, however, is only weakly depicted in nasal secretions. Therefore, cytokines in nasal secretions may provide helpful information for differential diagnosis.

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.

Changes of Proteases, Antiproteases, and Pathogens in Cystic Fibrosis Patients' Upper and Lower Airways after IV-Antibiotic Therapy

BACKGROUND

In cystic fibrosis (CF) the upper (UAW) and lower airways (LAW) are reservoirs for pathogens like Pseudomonas aeruginosa. The consecutive hosts' release of proteolytic enzymes contributes to inflammation and progressive pulmonary destruction. Objectives were to assess dynamics of protease : antiprotease ratios and pathogens in CF-UAW and LAW sampled by nasal lavage (NL) and sputum before and after intravenous- (IV-) antibiotic therapy.

METHODS

From 19 IV-antibiotic courses of 17 CF patients NL (10 mL/nostril) and sputum were collected before and after treatment. Microbiological colonization and concentrations of NE/SLPI/CTSS (ELISA) and MMP-9/TIMP-1 (multiplex bead array) were determined. Additionally, changes of sinonasal symptoms were assessed (SNOT-20).

RESULTS

IV-antibiotic treatment had more pronounced effects on inflammatory markers in LAW, whereas trends to decrease were also found in UAW. Ratios of MMP-9/TIMP-1 were higher in sputum, and ratios of NE/SLPI were higher in NL. Remarkably, NE/SLPI ratio was 10-fold higher in NL compared to healthy controls. SNOT-20 scores decreased significantly during therapy (P = 0.001).

CONCLUSION

For the first time, changes in microbiological patterns in UAW and LAW after IV-antibiotic treatments were assessed, together with changes of protease/antiprotease imbalances. Delayed responses of proteases and antiproteases to IV-antibiotic therapy were found in UAW compared to LAW.

A technique with manipulator-assisted endoscope guidance for functional endoscopic sinus surgery: proof of concept

OBJECTIVE

The goal of this study was to examine the theoretical feasibility of a new manipulator system for endoscope guidance in functional endoscopic sinus surgery.

STUDY DESIGN

The accuracy of endoscope positioning and time of endoscope movement with an endoscope manipulator system were determined with an artificial sinus model.

SETTING

A laboratory trial was performed. The time for 60 repetitions of manual compared to manipulator-assisted endoscope movements directed at 3 different target positions was evaluated. In addition, the alignment of the position vector for each endoscope movement was examined.

SUBJECTS AND METHODS

A zero-degree Hopkins II telescope with a camera was used to head for the target positions. First, the endoscope movements were done manually, and afterward the endoscope manipulator system was used for endoscope guidance. The alignment of the position vector of the endoscope was measured with a portable measuring arm.

RESULTS

There was no statistical difference between the time for manual and manipulator-assisted endoscope movements for all target positions. The alignment of the position vector of the endoscope was statistically different at 2 target positions: anterior ethmoid left side and ostium of maxillary sinus left side. There was no statistical difference at all other positions.

CONCLUSION

The endoscope manipulator system has the potential to be integrated into the operating workflow without extending the time for endoscope guidance. The surgeon will be able to use both hands for the manipulation of the instruments. Less frequent endoscope movements and instrument changes may be expected after technical modification.

Quality of life before and after septoplasty and rhinoplasty

Subjective assessment of quality of life (QOL) as an important aspect of outcomes research has received increasing importance during the past decades. QOL is measured with standardized questionnaires which had been tested with regard to reliability, validity, and sensitivity. Surgical procedures of the nasal septum (septoplasty) and the external nose (rhinoplasty) are frequently performed. Since many years subjectively assessed results of these operations have been reported in the literature. However, validated QOL instruments were applied only for one decade. Beforehand, measurements were performed using retrospective assessment of satisfaction or visual analogue scales. Prospective application of validated disease-specific and general measuring instruments has to be demanded for future studies.Most of the septoplasty patients as well as most of the rhinoplasty patients evaluate the operation being successful. However, a relevant number of patients is not satisfied with the result of surgery. In this context, QOL instruments have the potential to identify further factors influencing the outcome. Especially in rhinoplasty patients, special attention has to be drawn on potential psychosocial effects of the operation.

Systematic review of change in bodily pain after sinus surgery

OBJECTIVES

To determine whether bodily pain is increased in patients with chronic rhinosinusitis (CRS) and if bodily pain improves following endoscopic sinus surgery (ESS).

METHODS

All studies reporting results of more than 10 adult patients analyzing the response of bodily pain to ESS were retrieved by searching MEDLINE, EMBASE, Web of Science, Cochrane databases, and additional web-based sources (from January 1, 1980, to May 1, 2008); by examining bibliographies of retrieved articles; and by contacting investigators in the field.

RESULTS

Of 279 ESS symptom outcome studies, only studies measuring results using the 36-Item Short Form Health Survey (SF-36) quality-of-life survey instrument measured bodily pain. Eleven observational ESS studies (1019 patients) reported mean preoperative SF-36 bodily pain scores at 0.89 SD below general population norms (24% more severe bodily pain than general population norms) and significantly below norms for a population 25 years older. Using a repeated-measures design, nine of 11 studies noted significant improvement in SF-36 bodily pain domain scores following ESS, with a moderate-sized combined effect of 0.55 (95% confidence interval, 0.45-0.64; I(2) = 44%) using the fixed-effects model. This pooled effect corresponded to a mean improvement of 11.8 U on the SF-36 bodily pain domain scale.

CONCLUSIONS

Bodily pain is increased in patients with CRS awaiting ESS, exceeding the normative bodily pain scores of a general normative population 25 years older. Using within-subject comparisons, a clinically and statistically significant improvement in bodily pain is noted after ESS, an improvement similar to that previously described for fatigue.

[Update: catheter-based balloon dilatation of the sinuses without fluoroscopy. Dilation technique with an illumination system]

BACKGROUND

Catheter-based balloon dilation of the sinus ostia follows the general guidelines for functional endoscopic sinus surgery with the goal of reopening the sinus ostium to restore ventilation and drainage of the sinus and reestablish normal mucosal function, while maintaining normal mucosal tissue and avoiding scar tissue formation. A main criticism of this procedure questions the necessity of fluoroscopy with the C-arm since its use exposes patients and medical personnel to radiation and the C-arm is not available in every ENT operating room.

MATERIAL AND METHODS

Catheter-based balloon dilation of the sinus ostia was performed with the Relieva Luma Sinus Illumination System (Acclarent, Inc.) without fluoroscopy.

RESULTS

Using this method of illumination, it was possible to localize the device tip transcutaneously in the maxillary and frontal sinus cavities, making radiological exposure unnecessary.

CONCLUSION

The advantages of catheter-based balloon dilation without fluoroscopy lie in the elimination of radiation exposure to the patient and personnel as well as the cost savings. Randomized controlled trials should be planned to further evaluate this technique.

[Development of a grading scale for the Sino-Nasal Outcome Test-20 German Adapted Version (SNOT-20 GAV)]

INTRODUCTION

Quality of life measurements with the Sino-Nasal Outcome Test-20 German Adapted Version (SNOT-20 GAV) in chronic rhinosinusitis (CRS) patients require normative values measured in a comparison group taken from the normal population. These will make it possible to reach conclusions on correlations between scores and severity of symptoms and also on how close such patients' scores can get to those scores recorded in healthy subjects after surgical treatment.

PATIENTS AND METHODS

We collected SNOT-20 GAV data and data on the presence of CRS from 778 subjects via a web-based survey of employees of the University Hospital in Heidelberg. For comparison we used data collected before surgery and at 3 months and 1 year after surgery from 163 CRS patients who had undergone endonasal sinus surgery (ESS).

RESULTS

Gender and age had no clinically significant impact on the SNOT-20 GAV scores. We defined an assessment scale with four classes of symptom intensity. Surgically treated patients with CRS showed a persisting small disadvantage in the scales of the SNOT-20 GAV compared with the reference subgroup without CRS. When surgically treated CRS patients were compared with the entire reference group these disadvantages were only obvious in the Primary Nasal Symptoms (PNS) scale and not in the other scales measuring quality of life.

CONCLUSION

Patients with CRS benefit from ESS and subsequently reach scores similar to those recorded in the reference group. The newly developed four-level assessment scale is easy to use and gives the attending physician additional information about the severity of the patients' illness and its effects on their subjective wellbeing.

Fatigue improvement following endoscopic sinus surgery: a systematic review and meta-analysis

BACKGROUND

Fatigue is a common symptom of chronic rhinosinusitis (CRS), yet the response of fatigue to endoscopic sinus surgery (ESS) has not been systematically evaluated.

METHODS

Studies published in any language were retrieved by searching MEDLINE, EMBASE, Web of Science, Cochrane databases, and additional Web-based sources (from 1980-2007); by examining bibliographies of retrieved articles; and by contacting investigators in the field. Studies consisting of more than 10 adult patients analyzing the response of fatigue, vitality, energy, or malaise following ESS were included. Two authors independently evaluated studies for inclusion, rated the methods, and summarized relevant data using a standardized protocol.

RESULTS

Using within-subject comparisons, 28 identified observational studies noted substantial improvement in fatigue after ESS. A subgroup analysis of 11 studies measuring outcomes using the 36-Item Short Form Health Survey (SF-36) demonstrated a moderate-sized combined effect of 0.47 (95% confidence interval, 0.38-0.56; I = 0%), corresponding to a mean +/- standard deviation improvement of 9.7 +/- 3.4 units on the SF-36 vitality domain scores. In studies measuring outcomes using symptom rating scores, the preoperative severity scores and improvement after surgery for fatigue were similar to the respective values for other pooled CRS symptoms.

CONCLUSIONS

All 28 studies described substantial improvement in fatigue following ESS based on presurgery and postsurgery comparisons. A subgroup analysis of 11 studies reporting results by the SF-36 vitality domain scores demonstrated a moderate-sized combined effect. Preoperative fatigue severity scores and improvement noted after surgery were similar to the respective values for other pooled CRS symptoms.

[Chronic rhinosinusitis. Subjective assessment of benefit 1 year after functional endonasal sinus surgery]

BACKGROUND

Against the background of constantly intensifying economic pressure in the healthcare sector, in the future confirmation of subjective and economic benefit of different forms of therapy will be the criterion applied by the health insurance companies to decide whether to reimburse the costs they involve. The aim of this study was to provide confirmation that patients with chronic rhinosinusitis (CRS) do benefit from functional endonasal sinus surgery (FESS).

PATIENTS AND METHODS

One year after undergoing FESS for the treatment of CRS, 82 patients completed various questionnaires. The Glasgow Benefit Inventory (GBI) was used, as it is a validated instrument for the assessment of benefit. In addition, the patients were asked to complete questionnaires relating to pre- and postoperative use of resources (use of antibiotics, visits to their doctors and time unfit for work) and also to give an overall rating of their satisfaction with the outcome, the difference in their symptoms after FESS and the likelihood that they would recommend this treatment to friends or relatives.

RESULTS

Three out of four GBI scales [total score (+22.6), general benefit (+26.8), physical functioning (+23.7)] indicated that patients experienced significant benefit. The frequency of visiting their doctors, their intake of antibiotics and the amount of time off work were all significantly reduced. The vast majority of patients were satisfied with the overall result and the level of symptom relief achieved and would recommend FESS to friends and relatives.

CONCLUSION

The vast majority of these patients with CRS experienced FESS as highly beneficial. A significant reduction of resource usage was reported after the operation.

Chronisch polypöse Rhinosinusitis

BACKGROUND

The prevalence of chronic polypous rhinosinusitis is high at 1-2%. In the present study, the predisposing factors for this condition, the clinical symptomatology, results of surgical interventions, significance of computed tomography diagnosis, as well as histology and post-operative therapy with steroids were investigated.

METHODS AND RESULTS

A 15% stratified sample, made up of 194 post-paranasal sinus surgery patients of 5 surgical years was investigated. Above all, the eosinophil dominated type led to the formation of polyps. In the diagnosis of chronic polypous rhinosinusitis computed tomography is only sufficiently sensitive for the ethmoid bone. The complication rate was, with 4.6%, in the lower range of comparable pre-examinations. In addition, the 18% relapse rate in the patient population, of whom 49% had already been operated on once or several times, corresponds to a good result when compared at an international level.

CONCLUSIONS

These data confirm that surgical experience and a consistent post-surgical treatment can reduce the relapse frequency of chronic polypous rhinosinusitis. This is indicated by the on average late occurrence of a relapse.