Chronic rhinosinusitis and endoscopic sinus surgery

Endoscopic Sinus Surgery in Older Patients With Chronic Rhinosinusitis: Meta-Analysis of Surgical Outcomes

BackgroundChronic rhinosinusitis (CRS) is a common condition that significantly impacts quality of life. While endoscopic sinus surgery (ESS) has proven effective in the general adult population, its specific effectiveness in older patients remains understudied.ObjectiveThis meta-analysis assessed the therapeutic effect and safety of ESS in patients aged 55 years and older with CRS.MethodsFive electronic databases were queried: PubMed, Embase, Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials. Therapeutic effectiveness of ESS was quantitatively assessed using random-effects meta-analysis, in which mean changes of pre- versus postoperative scores of the Sino-Nasal Outcome Test-22 (SNOT-22) were pooled. Meta-regression was conducted to predict the variability in SNOT-22 changes. Comparative meta-analyses evaluating surgical complications between older and younger adult patients were conducted.ResultsA total of 12 studies were synthesized. Both short- and long-term follow-up data demonstrated significant improvement by reference to baseline. Our analysis demonstrated statistically significant mean reduction in the SNOT-22 score by 21.4 points (95% confidence interval [CI], -26.9 to -15.9) at an average follow-up of approximately 9 months. This improvement exceeds the minimal clinically important difference for SNOT-22. The presence of nasal polyposis was a favorable prognostic indicator of SNOT-22 improvement (β = -0.21; P = .002). The rates of surgical adverse events among older patients were 4.2% for significant bleeding, 0.6% for orbital injury, and 0.2% for skull base injury. A significant difference between the two age groups was observed only in skull base injury (odds ratio = 2.98; 95% CI, 1.53-5.80; P < .001).ConclusionESS offers clinically significant benefits for older individuals, particularly those with nasal polyposis. It is a safe treatment option for CRS in the older patients, with outcomes largely comparable to those in younger adults, though certain risks, such as skull base injury, may be slightly higher in older populations.

Significant Underreporting of Preoperative Hyposmia in Patients Undergoing Endoscopic Skull Base Surgery: Discrepancies Between Subjective and Objective Measurements

Objective  The assessment of baseline olfactory function before endoscopic skull base surgery (ESBS) has been relatively limited compared with analysis before functional endoscopic sinus surgery (FESS). Our study addresses this knowledge gap, assessing preoperative olfactory function in ESBS and FESS and elucidating any differences. Study Design  We conducted a retrospective review of patients undergoing anterior ESBS or FESS at a single institution between 2021 and 2022. We included 171 patients and compared their reported and measured preoperative olfactory function using the Sino-Nasal Outcome Test questionnaire and the 40-item University of Pennsylvania Smell Identification Test. Results  Of the 171 patients included in this study, 30% of patients underwent ESBS and 70% underwent FESS. Of all patients, only 57% correctly reported their objective preoperative olfactory function. Of the 36 ESBS patients with measured preoperative hyposmia, only 31% correctly reported hyposmia, while 69% incorrectly reported normosmia. This distribution significantly differs ( p  < 0.0001) from the FESS subset (89 patients), with 64% correctly reporting hyposmia and 36% incorrectly reporting normosmia. Conclusion  Our analysis demonstrates higher than anticipated underreporting of preoperative hyposmia in patients undergoing ESBS as well as discrepancies between subjective and objective olfactory functions in the FESS population. The results highlight several gaps in knowledge regarding perioperative olfactory function that would be best examined with more thorough pre- and postoperative objective olfactory testing. This analysis demonstrates significant prognostic uncertainty for patients and providers and creates significant medicolegal uncertainty regarding the appropriate attribution of postoperative olfactory loss in cases without objective preoperative testing.

Polyps' Extension and Recurrence in Different Endotypes of Chronic Rhinosinusitis: A Series of 449 Consecutive Patients

Different inflammatory endotypes reflect the heterogeneity of chronic rhinosinusitis with nasal polyps' (CRSwNPs) clinical presentation. This retrospective study aimed to analyze the distribution of polyps in nasal cavities and paranasal sinuses to establish a possible association between CRSwNP endotypes, prognosis, and polyps' extension. This study included 449 adult patients who underwent endoscopic sinus surgery for CRSwNPs between 2009 and 2022. Patients were categorized based on the number of paranasal sinuses involved by polyps. Statistical analyses, including Cox regression, were performed to identify associations between demographic, clinical, and histopathological factors and disease recurrence. CRSwNP patients were stratified into four groups based on the extent of polyp involvement. Asthma and acetylsalicylic acid (ASA) sensitivity were associated with more sinuses involved (p-values = 0.0003 and 0.0037, respectively). Blood eosinophil counts increased with the number of sinuses affected (p-value < 0.0001). The distribution of eosinophilic and non-eosinophilic histotypes varied significantly among these groups (p-value < 0.0001). The risk of CRSwNP recurrence was higher in patients with asthma, higher basophil percentages, and eosinophilic histotype (p-value 0.0104, 0.0001, 0.0118, and 0.0104, respectively). This study suggests a positive association between the number of paranasal sinuses involved by polyps and the severity of CRSwNPs, particularly in patients with eosinophilic histotype, asthma, and ASA sensitivity.

Transnasal endoscopic skull base surgery in the COVID-19 era: Recommendations for increasing the safety of the method

Transnasal endoscopic skull base surgery (eSBS) has been adopted in recent years, in great part to replace the extended procedures required by external approaches. Though sometimes perceived as "minimally invasive", eSBS still necessitates extensive manipulations within the nose/paranasal sinuses. Furthermore, exposure of susceptible cerebral structures to light and heat emanated by the telescope should be considered to comprehensively evaluate the safety of the method. While the number of studies specifically targeting eSBS safety still remains scarce, the problem has recently expanded with the SARS-CoV-2 pandemic, which also has implications for the safety of the surgical personnel. It must be stressed that eSBS may directly expose the surgeon to potentially high volumes of virus-contaminated aerosol. Thus, the anxiety of both the patient and the surgeon must be taken into account. Consequently, safety requirements must follow the highest standards. This paper summarizes current knowledge on SARS-CoV-2 biology and the peculiarities of human immunology in respect of the host-virus relationship, taking into account the latest information concerning the SARS-CoV-2 worrisome affinity for the nervous system. Based on this information, a workflow proposal is offered for consideration. This could be useful not only for the duration of the pandemic, but also during the unpredictable timeline involving our coexistence with the virus. Recommendations include technical modifications to the operating theatre, personal protective equipment, standards of testing for SARS-CoV-2 infection, prophylactic pretreatment with interferon, anti-IL6 treatment and, last but not least, psychological support for the patient.

Improved perioperative quality of life in endoscopic sinus surgery by application of enhanced recovery after surgery

Background: Endoscopic sinus surgery (ESS) has been the definitive treatment for chronic rhinosinusitis (CRS), but the complications caused perioperatively may affect patients’ quality of life (QoL). This study aims to evaluate the effects of enhanced recovery after surgery (ERAS) on improving perioperative QoL in ESS.

Materials and methods: Seventy-four patients with chronic rhinosinusitis with nasal polyps (CRSwNP) met the criteria for inclusion. Participants undergoing ESS were randomly divided into an ERAS group and a control group, and QoL assessment was performed using the Chinese version of the 22-item Sinonasal Outcomes Test (SNOT-22). Measurements were administered at baseline, and on postoperative day 1 (POD1), POD3 and POD6. Complications such as nausea/emesis, hemorrhage, aspiration and dizziness were also recorded.

Results: The preoperative global SNOT-22 scores (mean ± SD) were 39.89±4.86 in the ERAS group and 40.52±3.61 in the control group (t=0.643, P=0.522). On POD1, the global SNOT-22 scores increased significantly to 51.77±5.59 and 62.02±3.86 (t=9.218, P<0.01), and on POD3 they increased to 48.22±6.22 and 51.11±5.14, respectively (t=2.179, P<0.05). However, the scores recovered to 39.39±4.73 and 40.13±3.31 in the respective groups on POD6, which were lower than but not statistically significant different from the baseline (t=0.786, P=0.434). There were statistically significant improvements across all subdomains of SNOT-22 for patients in the two groups only in POD1 (all P<0.05). The ERAS group did not have an increased incidence of complications such as nausea/emesis (χ²=0.223, P>0.05), hemorrhage, aspiration and dizziness compared to the control group.

Conclusion: ERAS could improve perioperative QoL in patients with CRSwNP undergoing ESS, and SNOT-22 can be used for ERAS evaluation as a patients’ outcome report.