Long-term outcome analysis of functional endoscopic sinus surgery: correlation of symptoms with endoscopic examination findings and potential prognostic variables

Causal association of gastroesophageal reflux disease with chronic sinusitis and chronic disease of the tonsils and adenoids

BACKGROUND

Exploring bidirectional causal associations between gastroesophageal reflux disease (GERD) and chronic disease of the tonsils and adenoids and chronic sinusitis, respectively.

METHODS

We first conducted a TSMR (two-sample mendelian randomization) study using the results of the inverse variance weighting method as the primary basis and bidirectional MR to rule out reverse causation. Subsequently, MVMR (multivariate MR) analysis was performed to identify phenotypes associated with SNPs and to explore the independent effect of GERD on two outcomes. Finally, we calculated MR-Egger intercepts to assess horizontal polytropy and Cochran's Q statistic to assess heterogeneity and ensure the robustness of the study.

RESULTS

For each standard deviation increase in genetically predicted GERD rate, there was an increased risk of chronic disease of the tonsils and adenoids (OR 1.162, 95% CI 1.036-1.304, P: 1.06E-02) and of developing chronic sinusitis (OR 1.365, 95% CI 1.185-1.572, P: 1.52E-05), and there was no reverse causality. Causality for TSMR was obtained on the basis of IVW (inverse variance weighting) and appeared to be reliable in almost all sensitivity analyses, whereas body mass index may be a potential mediator of causality between GERD and chronic sinusitis.

CONCLUSION

There is a causal association between GERD and chronic disease of the tonsils and adenoids and chronic sinusitis, respectively, and the occurrence of GERD increases the risk of developing chronic disease of the tonsils and adenoids and chronic sinusitis.

Association Between Chronic Rhinosinusitis and Reflux Diseases in Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Over the last few decades, reflux diseases, such as laryngopharyngeal reflux (LPR) and gastroesophageal reflux disease (GERD), have been identified as significant contributors to inflammatory upper aerodigestive tract diseases. Establishing a direct relationship between reflux disease and chronic rhinosinusitis (CRS) is challenging due to the high prevalence of both diseases and their potential for independent coexistence.

OBJECTIVE

The purpose of this study is to review the existing literature and evaluate the evidence of an association between reflux diseases and CRS.

METHODS

A comprehensive electronic search was conducted across multiple databases to identify all studies that investigated the relationship between LPR, GERD, and CRS from January 1, 1950, to June 16, 2022. Only studies with English manuscripts involving adult populations were included, while case series, case reports, and in vitro studies were excluded. The risk of bias was evaluated using The Newcastle-Ottawa Scale for case-control studies and the NIH quality assessment tool for observational cohort and cross-sectional studies.

RESULTS

The search strategy yielded a total of 427 articles, out of which 25 studies examined the correlation between reflux diseases and CRS. The meta-analysis indicated a significant association between the presence of GERD and CRS compared to control groups (P < .001; CI 3.56 [2.25, 5.65]), as well as significantly higher pH values and pepsin detection in CRS patients when compared to healthy individuals (P = .003). Furthermore, all studies that evaluated proton pump inhibitor (PPI) therapy in CRS patients reported positive outcomes, with 93% of CRS patients showing improvement on PPIs.

CONCLUSION

The existing literature provides suggestive evidence of an association between reflux diseases and CRS, with regards to both prevalence and treatment. Nonetheless, further studies are required to confirm this relationship.

Anatomical findings in patients with chronic rhinosinusitis without nasal polyps requiring revision surgery

OBJECTIVES

For the treatment of chronic rhinosinusitis functional endoscopic sinus surgery is a well-established therapy with high initial success rates. However, a significant proportion of patients have persistent disease requiring revision surgery. To date, studies including data of large patient collectives are missing. In this study, we aimed to identify anatomic factors increasing the need for revision surgery in a large patient collective with chronic rhinosinusitis without nasal polyps.

METHODS

Data were collected retrospectively on patients with recurrent or persistent chronic rhinosinusitis without nasal polyps requiring revision surgery. The patients' symptomatology, endoscopic and radiographic findings were analyzed. Preoperatively, patients were evaluated with endoscopic examination of the nose and paranasal sinuses. In all individuals computed tomography of the sinuses was performed. Images were evaluated according to the Lund-Mackay system. Information was also collected intraoperatively.

RESULTS

253 patients were included. The most common anatomic factor was incomplete anterior ethmoidectomy (51%), followed by residual uncinated process (37%), middle turbinate lateralization (25%), incomplete posterior ethmoidectomy (20%), frontal recess scarring (19%), and middle meatal stenosis (9%). Other factors such as persistent sphenoid pathology was less frequent.

CONCLUSION

Iatrogenic causes with inadequate resection of obstructing structures seem to be a principal risk factor for recurrent chronic rhinosinusitis and the need for revision sinus surgery. Meticulous attention in the area of the ostiomeatal complex during surgery with ventilation of obstructed anatomy as well as avoidance of scarring and turbinate destabilization may reduce the failure rate after primary endoscopic sinus surgery.

LEVEL OF EVIDENCE

2b.

Host and Surgical Factors Affecting the Frequency and Duration of Revision Endoscopic Sinus Surgery

Background

Endoscopic sinus surgery is accepted as an effective surgical approach in the management of chronic rhinosinusitis. Different clinical pictures can be observed in chronic rhinosinusitis with nasal polyps (CRSwNP). Unfortunately, the eradication of the disease is impossible in all cases even if it is performed by experienced surgeons. In a significant number of patients, the polyps may regenerate and symptoms may reappear more or less in different durations. Due to the complex pathophysiology of the disease, revision sinus surgery is accepted as a multifactorial problem. We investigated the possible host and surgical factors which are related to increased frequency and earlier revision surgeries in CRSwNP.

Methodology

Patients operated on two or more times between 2010 and 2020 were retrospectively identified. A total of 49 patients with CRSwNP (38 male, 11 female) were statistically analyzed. The effects of host and surgical factors on the frequency and duration of revision surgery in CRSwNP were assessed.

Results

Samter’s syndrome was noted to be a significant host factor affecting recurrence and revision surgeries. In addition, we observed significantly more frequent scarring and adhesions in patients with a higher number of operations.

Conclusions

Patients with Samter’s syndrome should be informed of possible revision surgeries. The soft and mucosa-preserving technique is important for less scarring and good postoperative results.

The association between chronic rhinosinusitis and proton pump inhibitor use: a nested case-control study using a health screening cohort

This study aimed to evaluate the relationship between chronic rhinosinusitis (CRS) and proton pump inhibitor (PPI) use in a Korean population. The Korea National Health Insurance Service-National Sample Cohort was assessed from 2002 to 2013. Patients with CRS (n = 7194) and control participants (n = 28,776) were matched by random order at a 1:4 ratio for age, sex, income group, region of residence, and index date. We analyzed PPI use by patients with and without CRS. ICD-10 codes defined CRS, and claim codes defined previous PPI use. Conditional logistic regression analyzed the crude and adjusted odds ratios (ORs) with 95% confidence intervals (CI). Subgroup analyses were performed according to age and sex. There was a difference in PPI prescription history and prescription duration between the CRS and control groups. The rate of CRS was higher in current (33.8% [263/778]) and past (26.3% [713/2708]) PPI users than PPI non-users (19.1% [6218/32,484], P < 0.001). The adjusted OR (aOR) of CRS with/without nasal polyps was 1.71 (95% CI 1.46–2.02, P < 0.001) and 1.28 (95% CI 1.16–1.41, P < 0.001) in current and past PPI users, respectively. Irrespective of PPI prescription days, PPI use was associated with higher CRS occurrence (aOR 1.46; 95% CI 1.26–1.69, P < 0.001) in the 30–89-day PPI user group. The subgroup analyses results were consistent. The ORs of CRS were higher in PPI users than in the controls, and consistently so in all age and sex groups.

Association of gastro-oesophageal reflux disease and quality of life in patients with chronic rhinosinusitis

Objective

We determined the influence of gastro-oesophageal reflux disease (GERD) on quality of life (QOL) before and after functional-endoscopic-sinus-surgery (FESS) for chronic rhinosinusitis (CRS).

Methods

Medically-recalcitrant CRS patients were recruited prior to FESS. GERD was diagnosed endoscopically. QOL was compared between patients with vs without GERD at baseline and one-year post-FESS.

Results

Of 187 CRS patients receiving FESS, 40 had GERD. Pre-operative QOL was significantly worse in CRS patients with vs without GERD. Pre-operative GERD health-related QOL (GERD-HRQL) and reflux symptom index (RSI) scores were both correlated with pre-operative SNOT-22 scores. Compared with non-GERD CRS patients, GERD patients demonstrated larger SNOT-22 improvements after FESS, such that post-operative SNOT-22 values were no longer significantly different between GERD and non-GERD groups. However, post-FESS, in patients with CRS without nasal polyps (unlike those with nasal polyps), the GERD (vs non-GERD) group suffered from greater sleep dysfunction and otologic/facial symptoms.

Conclusions

Compared to CRS patients without GERD, those with GERD experienced poorer pre-operative QOL and greater QOL improvement after FESS.

Management of nasal synechiae with Kshara Sutra - A case report

Nasal synechiae or nasal adhesions are among the most common unwanted outcomes following functional endoscopic sinus surgery (FESS) with an incidence rate of 10%-40%. Approximately 500,000 patients per year undergo FESS for the treatment of chronic rhinosinusitis (CRS). A wide number of research studies support the utility of endoscopic sinus surgery to improve health-related quality of life (HRQoL) in patients with CRS. However, failures are still reported at a rate up to 26%. About 50% who present with synechiae in the middle meatus require revision endoscopic sinus surgery. A case report of a 48-year old-male has been presented here with complaints of nasal blockage and difficulty in breathing, diagnosed as nasal synechiae after anterior rhinoscopy and endoscopic examination and managed with Ayurvedic intervention. Kshara karma with Apamarga Kshara is the choice of management in case of nasal polyp and turbinate hypertrophy [1]. But in nasal synechiae, since we have to cut open the adhesion precisely, Kshara Sutra, which is meant for cutting open the tract in case of fistula-in-ano was chosen. Nasal synechiae which was managed only with electrocautery or other surgical procedures where there is a chance of recurrence can be successfully managed with an Ayurvedic intervention viz., KsharaSutra which is strictly new to this site of occurrence (nose).

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Gastritis and gastroesophageal reflux disease are strongly associated with non-allergic nasal disorders

Background

Gastroesophageal reflux disease (GERD) has been reported to be significantly associated with chronic rhinosinusitis, but the strength of the association is still debated.

Aims

To evaluate the strength of the association between gastritis/GERD and non-allergic rhinitis (NAR)/allergic rhinitis (AR)/sinusitis.

Methods

We investigated 2887 subjects aged 20–84 years, who underwent a clinical visit in seven Italian centres (Ancona, Palermo, Pavia, Terni, Sassari, Torino, Verona) within the study on Gene Environment Interactions in Respiratory Diseases, a population-based multicase-control study between 2008 and 2014. Subjects were asked if they had doctor-diagnosed “gastritis or stomach ulcer (confirmed by gastroscopy)” or “gastroesophageal reflux disease, hiatal hernia or esophagitis”. The association between NAR/AR/sinusitis and either gastritis or GERD was evaluated through relative risk ratios (RRR) by multinomial logistic regression.

Results

The prevalence of gastritis/GERD increased from subjects without nasal disturbances (22.8% = 323/1414) to subjects with AR (25.8% = 152/590) and further to subjects with NAR (36.7% = 69/188) or sinusitis (39.9% = 276/691). When adjusting for centre, sex, age, education level, BMI, smoking habits and alcohol intake, the combination of gastritis and GERD was associated with a four-fold increase in the risk of NAR (RRR = 3.80, 95% CI 2.56–5.62) and sinusitis (RRR = 3.70, 2.62–5.23) with respect to controls, and with a much smaller increase in the risk of AR (RRR = 1.79, 1.37–2.35)..

Conclusion

The study confirmed the association between gastritis/GERD and nasal disturbances, which is stronger for NAR and sinusitis than for AR.

Gender as a Predictor of Complications in Endoscopic Sinus Surgery

BACKGROUND

Understanding patient-specific risk factors for complications of functional endoscopic sinus surgery (ESS) is critical. Previous work has investigated such risk factors, but a population-based analysis has not been performed to date.

OBJECTIVES

This study analyzes the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to identify patient-specific risk factors associated with complications following ESS.

METHODS

A retrospective cohort study of patients who underwent ESS was conducted using the NSQIP database from 2011 to 2017. Patients were identified using CPT-codes for ESS procedures. The primary outcome analyzed was any postoperative complication. Simultaneous procedures with ESS were controlled for with regression analysis. Post-operative complications and 30-day readmission were evaluated using multivariate logistic regression controlling for age, gender, race, comorbidities (diabetes mellitus, hypertension, chronic obstructive pulmonary disease, congestive heart failure, renal failure, steroid use, and cancer history), smoking history, and intraoperative factors.

RESULTS

A total of 1279 patients who underwent ESS were identified. The average age of patients was 46.1 (SD = 16.8). Most patients (58.2%) had no major comorbidities. 594 (46.4%) patients had a tonsillectomy, adenoidectomy, or uvulopharyngoplasty at the same time as ESS. 101 (7.9%) patients experienced a complication post-operatively. 46 (3.6%) patients experienced a readmission postoperatively. The most common complication was reoperation (N = 40, 3.1%). Regression analysis revealed that gender was the only demographic factor associated with risk of post-operative complications, with women having a significantly lower risk than men (OR = 0.61, 95% CI 0.37-0.99, P = .046).

CONCLUSIONS

ESS is typically performed on a relatively young and healthy population. Women have a significantly lower risk of complications after controlling for comorbidities. Further analysis of gender-specific differences in surgical outcomes should be evaluated to understand this phenomenon.

Assessing effects of modification of middle meatal silastic splint after endoscopic sinus surgery for nasal polyps: A randomized controlled study

Purpose

To investigate the efficacy of middle meatal silastic splint in preventing adhesions after bilateral endoscopic sinus surgery (ESS) for chronic rhinosinusitis with nasal polyps (CRSwNP), and to assess nasal symptoms and endoscopic findings in splinted and non-splinted sides.

Methods

After completion of ESS, silicon silastic splints were randomly inserted in the middle meatus of one nasal side, while no stent in the other side (control). The surgeon was blinded to the side selection, and splint insertion until removal after 1 week. Patients were followed -up after 1 week, 1 and 6 months. Each side of the nasal cavity was assessed for adhesions, crusting, pus, pain, nasal obstruction, and nasal discharge by endoscopic examination and visual analogue scale.

Results

Forty-nine patients (98 nasal sides) were included. At the 1st week visit, there was no significant difference between the splinted and non-splinted sides for all investigated parameters.After 1- month, adhesions were seen in 10% of the splinted sides, while it was in 26% of the non-splinted sides (P = 0.037).At the 6 -month follow-up visit, the adhesions rate remained 10% in the splinted sides, however the rate increased to 32% in the non-splinted sides (P = 0.007). All other examined parameters remained statistically insignificant between both sides throughout the follow -up visits.

Conclusions

Middle meatal silastic splint is significantly reducing middle meatal adhesions with low complication rate in CRSwNP patients undergoing ESS. Our results support its usage when the middle turbinate is unstable or traumatized during surgery.

Correlation of salivary and nasal lavage pepsin with MII-pH testing

OBJECTIVES

Laryngopharyngeal reflux (LPR) is a common upper airway disease. Salivary pepsin is a proposed marker for LPR; however, the optimal time for collection of specimens for pepsin detection and pepsin's presence in the oral and nasal secretions relative to concurrent multichannel intraluminal impedance-pH (MII-pH) monitoring are unknown.

STUDY DESIGN

Prospective case-control study with an experimental design.

METHODS

Patients undergoing MII-pH testing for evaluation of LPR and asymptomatic control subjects were selected. Nasal lavage and saliva samples were collected in the clinic prior to MII-pH probe placement. Additional saliva samples were obtained an hour after each meal and upon waking the following morning. Nasal lavage and salivary pepsin were measured by ELISA.

RESULTS

Twenty-six patients undergoing MII-pH testing and 13 reflux-free control patients were enrolled. Salivary pepsin was detected in 11 of 26 patients with suspected LPR and 0 of 13 controls. Pepsin was most frequently detected in the specimen provided upon waking at an average concentration of 186.9 ng/mL. A significant correlation was observed between salivary pepsin in waking samples to MII-pH measurements, including reflux bolus duration, and proximal and distal recumbent reflux episodes (P < 0.05). A significant correlation was also observed between salivary pepsin upon waking or sinus lavage and reflux symptom index (P < 0.05).

CONCLUSION

Pepsin in salivary and nasal lavage samples demonstrated an association with MII-pH-documented LPR. Pepsin detection was most frequent in morning samples, supporting use of morning salivary pepsin levels as a potential noninvasive technique for LPR diagnosis.

LEVEL OF EVIDENCE

2 Laryngoscope, 130:961-966, 2020.

Autonomic nervous system dysfunction and sinonasal symptoms

Background

The autonomic nervous system (ANS) richly innervates the nose and paranasal sinuses, and has a significant role in lower airway diseases, e.g., asthma. Nonetheless, its contribution to sinonasal symptoms is poorly understood. This review aimed to explore the complex relationship between the ANS and sinonasal symptoms, with reference to systemic diseases and triggers of ANS dysfunction.

Methods

A review of articles published in English was conducted by searching medical literature databases with the key words “autonomic nervous system” and (“sinusitis” or “nose” or “otolaryngology”). All identified abstracts were reviewed, and, from these, relevant published whole articles were selected.

Results

The ANS has a significant role in the pathophysiologic mechanisms that produce sinonasal symptoms. There was limited evidence that describes the relationship of the ANS in sinonasal disease with systemic conditions, e.g. hypertension. There was some evidence to support mechanisms related to physical and psychological stressors in this relationship.

Conclusion

The role of ANS dysfunction in sinonasal disease is highly complex. The ANS sits within a web of multiple factors, including personality and psychological distress, that contribute to sinonasal symptoms. Further research will help to clarify the etiology of ANS dysfunction and its contribution to common systemic conditions.

Assessment of Predictive Prognostic Factors for Functional Endoscopic Sinus Surgery in a 5-Year Prospective Outcome Study

Background

Among numerous studies in the literature regarding prognostic factors that might determine outcome in functional endoscopic sinus surgery (FESS), very few have dealt with assessment of their predictive potential regarding outcome, and none have tried to find out the extent of such a prediction. We have developed a composite model to find out the predictive values of various prognostic factors, using an outcome measure based on the need for postoperative medical intervention.

Methods

One hundred nine patients were recruited for FESS and followed up at regular intervals for 5 years. Ten prognostic factors were identified and were correlated with prospectively recorded outcome measures. A discriminant analysis using SPSS software was performed to identify the prognostic factors that could “predict” the outcome.

Results

CT scan scores and polyp scores were the strongest predictors. Using our model, the probability to predict correctly the need for postoperative systemic medication was found to be 81.7%.

Conclusion

We have generated a model to predict the outcome of FESS, with a 5-year follow-up. CT scan scores and polyp scores were found to be the strongest predictors of the need for postoperative systemic medication.

The Role of Mitomycin C in Preventing Synechia and Stenosis after Endoscopic Sinus Surgery

Background

Synechia and stenosis formation after endoscopic sinus surgery (ESS) represents a potential source of surgical failure. Mitomycin C (MMC) has been used successfully in other fields to decrease postoperative scar formation. We hypothesize that the topical application of MMC reduces the incidence of stenosis and synechia formation after ESS.

Methods

This study is a randomized, controlled, single-blinded study based in a tertiary care teaching hospital. After routine ESS, a pledget soaked in MMC (0.5%) was randomly placed into the middle meatus of one nasal cavity for 5 minutes and a pledget soaked in saline was placed in the contralateral side in each patient. A blinded observer followed the patients for any evidence of stenosis or synechia formation. The medical records of enrolled patients were reviewed for demographics, diagnosis, prior surgery, type of sinus surgery, complications, incidence of stenosis/synechia, and need for further procedures.

Results

Twenty-nine patients were included in the final analysis. The mean follow-up period was 15 months (range, 3–32 months). There were no complications in this series. Eight patients experienced 10 episodes of synechia formation and one patient experienced 1 episode of synechia formation and 1 episode of stenosis of the maxillary sinus ostium. Seven of the 12 episodes of synechia/stenosis occurred on the side of the MMC application and the remaining 5 episodes occurred on the side opposite to the MMC application. This difference was not statistically significant.

Conclusion

The topical application of MMC did not decrease the incidence of stenosis and synechia formation after ESS. (American Journal of Rhinology 18, 311–314, 2004)

Evidence Supporting Endoscopic Sinus Surgery in the Management of Adult Chronic Rhinosinusitis: A Systematic Review

Background

Evidence-based medicine calls for a critical evaluation of the scientific evidence for treatments of disease. This report synthesizes the available evidence on the use of endoscopic sinus surgery (ESS) in the management of adult chronic rhinosinusitis (CRS) examining the clinical question: “In adults with CRS who have failed medical management, does ESS improve symptoms and/or quality of life (QOL)?”

Methods

The American Rhinologic Society and the American Academy of Otolaryngology–Head and Neck Surgery convened a steering committee composed of the authors. Primary research articles evaluated for this report were identified using appropriate search terms and a Medline search. Two authors independently reviewed each article. Articles were assigned an evidence level based on accepted guidelines (level 1 = randomized trials; level 2 = prospective cohort studies with comparison group; level 3 = case-control studies; level 4 = retrospective case series; level 5 = expert opinion).

Results

We identified 886 abstracts to review, retrieved 75 articles for full review, and included 45 articles in our report. The vast majority of articles represented level 4 evidence (n = 42) and two articles represented level 5 evidence. One article was identified that qualified for level 2 evidence. All of these articles generally supported the finding that ESS improves symptoms and/or QOL in adult patients with CRS.

Conclusion

There is substantial level 4 evidence with supporting level 2 evidence that ESS is effective in improving symptoms and/or QOL in adult patients with CRS. Future research efforts should focus on prospective studies that include appropriate comparison groups in their design.

Significance of undissected retromaxillary air cells as a risk factor for revision endoscopic sinus surgery

BACKGROUND

Retromaxillary air cells (RMC) are posterior ethmoid cells that separate the maxillary and ethmoid sinuses. The clinical significance of these cells in contributing to revision functional endoscopic sinus surgery (FESS) is unknown.

OBJECTIVES

To investigate the prevalence, anatomic dimensions, and radiographic characteristics of RMC in patients with recalcitrant chronic rhinosinusitis after previous FESS.

METHODS

A retrospective review of patients who underwent revision FESS at a tertiary medical center between January 1, 2012, and December 31, 2014. Computed tomographies of patients who underwent revision FESS, including posterior ethmoidectomies, were reviewed. Each side of the scan was assessed for residual RMCs. The radiographic dimensions and Lund-Mackay (LM) scores of these cells were recorded.

RESULTS

Sixty-nine patients who underwent revision FESS were identified. The median age of the patient population was 51 years (range, 21-79 years). Forty-two percent of the patients had nasal polyps. The mean number of previous FESS was 2 (range, 1-10). Incompletely dissected RMCs were identified in 101 of 138 analyzed sides (73%), despite documented previous posterior ethmoidectomies. Sixty-five percent of RMCs had an LM score of ≥1; RMCs of patients with polyps were more likely to have an LM score of 2 (p = 0.049). There was a significant correlation between the number of previous FESS procedures and whether the RMCs had been dissected (p = 0.010). There also was a significant correlation between RMC height and the number of previous FESS procedures (p = 0.015).

CONCLUSION

RMCs seemed to often be undissected during primary FESS and, thus, were commonly encountered in revision FESS. The majority of analyzed cells in this cohort demonstrated an LM score of ≥1, which indicated that these cells frequently harbor residual diseased mucosa that may contribute to the need for revision surgery.

Relation between chronic rhinosinusitis and gastroesophageal reflux in adults: systematic review

Introduction

The relationship between gastroesophageal reflux disease (GERD) and chronic rhinosinusitis (CRS) is still a controversial issue in literature.

Objective

A systematic review of the association between these two diseases in adult patients.

Methods

Systematic review in PubMed and Cochrane Database with articles published between 1951 and 2015. We included all articles that specifically studied the relationship between CRS and GERD.

Results

Of the 436 articles found, only 12 met the inclusion criteria. Eight cross-sectional articles suggest a relation between CRS and GERD, especially on CRS that is refractory to clinical or surgical treatment. However, the groups are small and methodologies are different. Four other longitudinal studies have assessed the effect of treatment with proton pump inhibitors (PPIs) on the improvement of symptoms of CRS, but the results were conflicting.

Conclusions

There seems to be relative prevalence of reflux with intractable CRS. There is still a lack of controlled studies with a significant number of patients to confirm this hypothesis. Few studies specifically assess the impact of treatment of reflux on symptom improvement in patients with CRS.

Prevalence of allergic rhinitis and asthma in patients with chronic rhinosinusitis and gastroesophageal reflux disease

BACKGROUND

An association between chronic rhinosinusitis (CRS) and gastroesophageal reflux disease (GERD) has been previously reported; however, the underlying factors linking CRS and GERD remain to be elucidated.

OBJECTIVE

To assess the association of GERD and CRS using prospective and retrospective approaches.

METHODS

The retrospective study comprised a large cohort of CRS cases, whereas the prospective arm evaluated a series of CRS cases and controls.

RESULTS

In the retrospective arm of the study, of the 1066 patients with CRS, 112 (10.5%) had GERD. Among patients with CRS, GERD was associated with higher body mass index, older age, and female sex. The odds ratios (ORs) for asthma and allergic rhinitis in the CRS group with GERD compared with the CRS group without GERD were 2.89 (95% confidence interval [CI], 1.905-4.389) and 2.021 (95% CI, 1.035-3.947). Furthermore, GERD was associated with a greater duration of CRS. Ninety patients with CRS and 81 controls were enrolled in the prospective arm of the study. In the CRS group, GERD was associated with asthma (OR, 4.77; 95% CI, 1.27-18.01). Patients with CRS and GERD had a longer duration and a younger age at onset of CRS. In controls, no association was found between GERD and asthma (OR, 0.67; 95% CI, 0.09-5.19) or allergic rhinitis (OR, 0.35; 95% CI, 0.05-2.59).

CONCLUSION

Patients with CRS and GERD are more likely to have atopic conditions and asthma when compared with patients with CRS but without GERD. One of the potential explanations of this link is that comorbid GERD and atopic disease are potential risk factors for development of CRS.

Helicobacter Pylori and Laryngopharyngeal Reflux in Chronic Rhinosinusitis

OBJECTIVES: Investigation of the potential role of several laryngopharyngeal reflux contents in sinus disease.

STUDY DESIGN AND SETTING: A controlled cohort analysis of Helicobacter pylori, pepsin and pepsinogen I in inflamed and non-inflamed sinonasal tissue. Fifteen patients, selected for surgery due to chronic medically refractory rhinosinusitis, had their pathologic sinus tissue analyzed for polymerase chain reaction detection of H. pylori DNA and assayed for pepsin and pepsinogen I tissue concentration levels. A control group of 5 patients undergoing surgery for anatomic sinonasal abnormalities provided non-inflammatory mucosa specimens for comparison.

RESULTS: H. pylori was found scattered in inflamed and non-inflamed mucosa, whereas sinonasal tissue pepsin/pepsinogen never rose above blood levels in both groups.

CONCLUSIONS: Evidence of intra-operative peptic reflux into the sinuses was not found. As H. pylori was similarly encountered in healthy and diseased sinus mucosa, it seemingly fails to support a pathogenic role for this organism in the sinuses.

EBM rating: B-2b

Nasal polyps in patients with asthma: prevalence, impact, and management challenges

Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) often have coexisting asthma under the concept of “United Airway Disease”, being the combination of both diseases, which is one of the most challenging phenotypes to treat. Although clinicians have recognized this difficult-to-treat phenotype for many years, it remained poorly characterized. There is increasing epidemiological evidence linking chronic rhinosinusitis and asthma, but a good understanding of the pathophysiology and the combined management is still lacking. Bronchial asthma is more prevalent in patients who suffer chronic rhinosinusitis, while asthmatic patients have a greater prevalence of CRSwNP than patients without asthma. The effect of CRSwNP treatment, whether medical or surgical, in asthma is today less controversial after some studies have shown improvement of asthma after medical and/or surgical treatment of CRSwNP. However, direct comparisons between surgical and medical treatments are limited. Further randomized clinical trials are, however, still needed to better understand the management when both asthma and CRSwNP occur together. This review aims at summarizing the prevalence, impact, and management challenges regarding both asthma and CRSwNP.

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.

The influence of spray cryotherapy on wound healing following endoscopic sinus surgery in chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The aim of this study was to assess the influence of spray cryotherapy on wound healing following endoscopic sinus surgery (ESS).

STUDY DESIGN

A prospective, randomized, double-blinded, controlled trial.

METHODS

The study included 22 consecutive adult patients with chronic rhinosinusitis with and without polyps scheduled for bilateral ESS. At the end of the surgical procedure, patients were randomized to the distribution of spray cryotherapy in one middle meatus and saline contralaterally. Outcomes were only measured for endoscopy scores. Thus, postoperative healing and the amount of edema, crusting, secretions, and scarring were assessed using the validated Lund-Kennedy and Perioperative Sinus Endoscopy (POSE) scores.

RESULTS

There were no baseline differences concerning POSE and Lund-Kennedy scores between the two groups. Nevertheless, a significant difference was recorded at one, 2, 4, 8, and 12 weeks in both POSE (P = .001, P = .012, P = .02, P = .006, P = .001) and Lund-Kennedy (P = .002, P = .005, P = .02, P = .02, P = .03) scores.

CONCLUSIONS

These preliminary results reveal an improvement in postoperative scores, demonstrating enhanced healing following spray cryotherapy. However, without patient subjective outcomes, the study is limited. Additional studies with longer follow-up and larger samples are needed to describe the effects of cryotherapy on wound healing.

Management of chronic rhinosinusitis in asthma patients: is there still a debate?

The united airway concept in which upper and lower respiratory conditions are present in one patient requires special consideration. There is some evidence linking chronic rhinosinusitis and asthma, but a good understanding of the pathophysiology and combined management is still lacking, a fact that leads to discussion. Bronchial asthma is more prevalent in patients who suffer chronic rhinosinusitis. On the other hand, patients with asthma have a greater prevalence of rhinosinusitis than patients without asthma. The effect of chronic rhinosinusitis in patients with or without nasal polyps on asthma treatment, whether medical or surgical, is controversial. Some studies show worsening, other trials improvement, and others no effect. Direct comparisons between surgical and medical treatments are few. Most of the current literature available about this intriguing combination does not provide a good level of evidence. Thus, randomized clinical trials should be performed to better understand the management when asthma and CRS occur together. This review aims to summarize the current state of this association regarding the effects of different types of treatment.

The impact of comorbid gastroesophageal reflux disease on endoscopic sinus surgery quality-of-life outcomes

BACKGROUND

Chronic rhinosinusitis (CRS) and gastroesophageal reflux disease (GERD) are common entities that overlap in patient demographics. The pathophysiologic role of GERD has yet to be elucidated, but it is postulated that extraesophageal reflux may contribute to worsening symptoms of CRS. This study seeks to investigate whether patients with CRS with and without a history of GERD experience comparable quality-of-life (QOL) improvement after endoscopic sinus surgery (ESS).

METHODS

An adult cohort (n = 229) with medically refractory CRS was prospectively assessed following ESS using 3 disease-specific QOL constructs. A patient subset with a history of comorbid GERD was retrospectively identified (n = 72) and preoperative and postoperative QOL were compared to patients without GERD (n = 157).

RESULTS

Patients with comorbid GERD and CRS were comparable across all baseline patient characteristics (p > 0.050) with the exception of patients with a history of GERD; those patients were less likely to have undergone allergy testing (p < 0.002) and were older (53.8 years vs 47.6; p < 0.002). Similarly, baseline objective and subjective measures of disease were comparable between patients with CRS with and without GERD (p > 0.050). Both groups experienced significant QOL improvement across all QOL constructs (p ≤ 0.021), and no difference was detected in the magnitude of that improvement between patients with and without a history of GERD (p > 0.050). Similarly, patients on active medical therapy for GERD (n = 49) had QOL gains comparable to patients not reporting GERD medical therapy (p > 0.050).

CONCLUSION

Patients electing ESS for CRS with and without comorbid GERD have comparable baseline characteristics and QOL outcomes following surgery.

Outcome prediction in endoscopic surgery for chronic rhinosinusitis - a multidimensional model

PURPOSE

Chronic rhinosinusitis (CRS) is one of the most common diseases in the modern society. In recent years endoscopic sinus surgery (ESS) has become the treatment of choice for patients with CRS refractory to medical therapy. ESS proved to be successful in most, but not all patients with CRS. Currently there is no direct method available to distinguish between patients who are likely to benefit from ESS and those who are not. The aim of this study was to build multidimensional models (artificial neural networks) to predict early outcomes of ESS in individual patients.

MATERIAL/METHODS

The study group comprised of 115 patients operated for CRS in the Department of Otolaryngology, Jagiellonian University Collegium Medicum, Cracow. The neural models were created using the Statistica Neural Network computer software package. The models required only information easily achievable for every patient before surgery. Consequently, the models could be readily applicable in everyday clinical practice. To define the results of surgery three different mathematical descriptions were compared. The models' predictions were compared with the actual results of surgery 3-6 months postoperatively.

RESULTS

The models were able to predict the early outcome of surgery in 90% of the patients but their quality depended on mathematical representation of the surgery result. The best models were characterized by 93% sensitivity and 86% specificity.

CONCLUSIONS

The results of ESS depend on many factors, so reliable outcome prognoses can be produced only by multidimensional models. Artificial neural networks are a promising multidimensional tool facilitating clinical decision making in patients with CRS.

A Randomized, Multi-Center, Single Blind, Active-Controlled, Matched Pairs Clinical Study to Evaluate Prevention of Adhesion Formation and Safety of HyFence in Patients After Endoscopic Sinus Surgery

Objectives

Recurrent mucosal disease and anatomic obstruction are commonly cited causes of failed endoscopic sinus surgery (ESS). Hyaluronic acid (HA) has been reported to reduce scarring and to promote wound healing in sinonasal surgery. HyFence is HA stabilized by 1, 4-butandiol diglycidyl ether, which makes it less-water-soluble and highly viscoelastic. The purpose of this study is to examine the anti-adhesion effect of HyFence after ESS compared to that of HA-CMC (Guardix-Sol).

Methods

Seventy-four patients with chronic rhinosinusitis who underwent ESS were included in the study. After the ESS procedure, Merocel was placed in the ethmoidectomized areas of the both sides. Five milliliters of Guardix-Sol was then applied to the Merocel of one side and HyFence LV was applied to the other side. The effect of the agents was evaluated at one, two, and four weeks after surgery by endoscopic examination. The severity of adhesion, edema, infection and complications were evaluated.

Results

There was no significant difference in the incidence of postoperative adhesion between the HyFence group and the Guardix-Sol group (P>0.05). Mean postoperative grades of edema and infection showed no significant difference between groups (P>0.05). There was no significant postoperative complications associated with either anti-adhesion agent (P>0.05).

Conclusion

HyFence has equivalent anti-adhesion effect compared to Guardix-Sol following ESS.

Incidence of gastroesophageal reflux disease and positive maxillary antral cultures in children with symptoms of chronic rhinosinusitis

OBJECTIVES

Studies have shown that gastroesophageal reflux disease occurs more frequently than expected in children with chronic rhinosinusitis. The objective of this study is to further understand the relationship of pediatric chronic rhinosinusitis and gastroesophageal reflux disease in children with symptoms of rhinorrhea, nasal congestion, and chronic cough.

METHODS

A retrospective chart review of 63 children, ages 6 months to 10 years old with rhinorrhea, nasal congestion, and chronic cough. The patients underwent maxillary cultures, adenoidectomy, and distal third esophageal biopsies. Children with esophageal biopsies showing esophagitis were classified as positive for gastroesophageal reflux disease, and maxillary antral swabs growing a high density of bacteria were classified as positive for chronic rhinosinusitis.

RESULTS

Six months to 5 years old children (n=43), 6 (14%) had simultaneous positive maxillary antral cultures and positive esophageal biopsies, 11 (26%) had positive esophageal biopsies alone, 23 (53%) had positive maxillary antral cultures alone, and 3 (7%) had neither. Six to 10 years old children (n=20), 9 (45%) had simultaneous positive maxillary antral cultures and positive esophageal biopsies, 1 (5%) patient had positive esophageal biopsies alone, 3 (15%) patients had positive maxillary antral cultures alone, and 7 (35%) patients had neither. Twenty-seven (42%) of the patients from the whole study had gastroesophageal reflux positive biopsies. The younger children were statistically likely to have chronic rhinosinusitis and gastroesophageal reflux disease independently of each other (p=0.0002). A direct group comparison found the younger group to have independent chronic rhinosinusitis and gastroesophageal reflux disease and the older group to have simultaneous chronic rhinosinusitis and gastroesophageal reflux disease (p=0.0006).

CONCLUSION

In children with the presenting symptoms of rhinorrhea, nasal congestion, and chronic cough, younger children tend to have either chronic rhinosinusitis or gastroesophageal reflux disease, whereas older children tend to have a more complicated etiology of chronic rhinosinusitis and gastroesophageal reflux disease or other. In all of these patients gastroesophageal reflux disease plays an important role, as over 40% of all patients had gastroesophageal positive biopsies.

Impact of synechiae after endoscopic sinus surgery on long-term outcomes in chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

Synechiae are one of the most common unwanted outcomes after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). However, there has been scant investigation into the true significance of synechiae formation after ESS. The aim of this study was to evaluate the impact of synechiae formation on health-related quality of life (HRQoL) outcomes after ESS in patients with CRS.

STUDY DESIGN

Prospective, multi-institutional cohort.

METHODS

Rhinosinusitis Disability Index (RSDI) and Chronic Sinusitis Survey (CSS) scores were measured in adult patients before and after undergoing ESS for CRS. Differences in HRQoL were evaluated between those who developed sinonasal synechiae and those who did not, controlling for demographic factors, medical comorbidities, and measures of disease severity at baseline.

RESULTS

A total of 286 patients underwent ESS, with 55 (19.2%) developing synechiae in the follow-up period. Patients developing synechiae reported significantly less improvement on the RSDI total scores (13.5 vs. 21.4, P = 0.008), RSDI physical subscores (5.3 vs. 8.3, P = 0.007), RSDI emotional subscores (2.9 vs. 5.8, P = 0.008), CSS total scores (14.5 vs. 21.2, P = 0.093), and CSS symptom subscores (19.9 vs 30.3, P = 0.069) compared to those who did not develop synechiae postoperatively. These differences persisted even after controlling for baseline differences in disease severity.

CONCLUSIONS

Synechiae of the sinonasal cavity commonly occurs following ESS, particularly in those undergoing revision surgeries. Although both groups improve, the degree of HRQoL improvement appears to be less in those who form postoperative synechiae after surgery compared to those who do not.

The use of Mitomycin-C to reduce synechia in middle meatus in sinus surgery: preliminary results

Synechia is the most frequent complication after sinus surgery and has been reported in up to 36% of cases. Several types of materials have been used to reduce the incidence of synechia, including Mitomycin C (MMC).

Objective

This prospective study aimed to assess the effectiveness of topical MMC in the prevention of synechia after sinus surgery in humans.

Methods

At the end of surgery, MMC solution (1.0 mg/ml) was topically applied randomly to one of the middle meatuses (MMC group) of 14 patients while saline solution was applied to the contralateral meatus (control group). The author remained blind to the medicated side. Synechiae were classified as partial or total.

Results

Three patients had middle meatus synechia in the MMC group (21.43%) versus nine (64.29%) in the control group (p = 0.054). In the MMC group, all three middle meatus synechia were partial, while in the control group there were four partial (28.57%) and five total (35.71%) cases of synechia (p = 0.025).

Conclusions

Mitomycin C was not effective in preventing middle meatus synechia, but reduced the probability of total synechia formation.

Gastroesophageal reflux and rhinosinusitis

Gastro-esophageal reflux disease (GERD) and chronic rhino-sinusitis (CRS) are prevalent disorders. Coexistence by chance is to be expected in a number of patients. Coexistence due to shared pathogenic mechanisms is controversial. In this paper, we have described the characteristics of GERD and CRS epidemiologically, diagnostically, and pathophysiologically, and reviewed the existing data about a potential role of gastro-esophageal reflux (GER) in the pathogenesis of CRS. A causal link between GERD and CRS has so far not been sufficiently documented. However, some studies do indicate a correlation. Hence, anti-reflux measures should be considered as an option in CRS, particularly in patients where conventional medical and surgical treatment is insufficient.

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.

Gastroesophageal reflux and chronic rhinosinusitis

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) and gastroesophageal reflux disease (GERD) are two common conditions which have been reported to occur together more frequently than expected. It has, therefore, been proposed that GERD may have an aetiologic role in CRS. This study reviews the results of research into the possible reflux and reflex mechanisms that may link CRS and GERD.

RECENT FINDINGS

Robust assessment of gastric reflux into the nasopharynx using circumferential pH probes which are less subject to artefact have demonstrated that direct reflux into the nasopharynx is a rare event. Pepsinogen has only been found in the nasal cavity in one study which had unexpected results, raising doubts about the validity of the methodology. A reflex increase in nasal congestion and mucus secretion has been demonstrated experimentally, but in a small number of patients, which precluded statistical significance. The relationship between reflux and mucus secretion is supported, though, by randomized controlled trials showing decreased postnasal drip with proton-pump inhibitor therapy.

SUMMARY

Recent evidence suggests that GERD does not play a causative role in CRS. However, there is evidence of an oesophageal-nasal reflex, particularly in regard to mucus secretion and symptoms of postnasal drip. The presence of GERD would, therefore, be expected to worsen nasal symptom scores.

Chronic rhinosinusitis, race, and ethnicity

BACKGROUND

Little is known regarding the epidemiology of chronic rhinosinusitis (CRS) in racial and ethnic minorities in the United States. This study was designed to comprehensively evaluate the current prevalence of CRS across various treatment settings to identify possible disparities in health care access and use between racial and ethnic populations.

METHODS

The National Health Interview Survey (NHIS), National Ambulatory Medical Care Survey (NAMCS), and National Hospital Ambulatory Medical Care Survey (NHAMCS) database registries were extracted to identify the national prevalence of CRS in race/ethnic populations and resource use in ambulatory care settings. Systematic literature review identified studies reporting treatment outcomes in minority patients electing endoscopic sinus surgery (ESS). Data were supplemented using a multi-institutional cohort of patients undergoing surgical treatment.

RESULTS

National survey data suggest CRS is a significant health condition for all major race/ethnic groups in the United States, accounting for a sizable portion of office, emergency, and outpatient visits. Differences in insurance status, work absenteeism, and resource use were found between race/ethnic groups. Despite its prevalence, few published studies include information regarding minority patients with CRS. Most (90%) cohort studies did not provide details of race/ethnicity for ESS outcomes. Prospective cohort analysis indicated that minority surgical patients accounted for only 18%, when compared with national census estimates (35%).

CONCLUSION

CRS is an important health condition for all major race/ethnic groups in the United States. Significant differences may exist across racial and ethnic categories with regard to CRS health status and health care use. Given current demographic shifts in the United States, specific attention should be given to understanding CRS within the context of racial and ethnic populations. Public clinical trial registration (www.clinicaltrials.gov) I.D. No. NCT00799097.

Staphylococcus aureus biofilms: Nemesis of endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

Chronic rhinosinusitis (CRS) patients with biofilms have persistent postoperative symptoms, ongoing mucosal inflammation, and recurrent infections. Recent evidence suggests that biofilms of differing species confer varying disease profiles in CRS patients. We aimed to prospectively investigate the effects of Staphylococcus aureus, Pseudomonas aeruginosa, Haemophilus influenzae, and fungal biofilms on outcomes following endoscopic sinus surgery (ESS).

STUDY DESIGN

Prospective blinded study.

METHODS

In this prospective blinded study, 39 patients undergoing ESS for CRS assessed their symptoms preoperatively using internationally accepted standardized symptom scoring systems and quality-of-life measures (10-point visual analog scale, Sino-Nasal Outcome Test-20, global severity of CRS). Their sinonasal mucosa was graded (Lund-Kennedy scale) and extent of radiologic disease on computed tomography scans scored (Lund-McKay scale). Random sinonasal tissue samples were assessed for different bacterial species forming biofilms by using fluorescent in-situ hybridization and confocal laser microscopy. For 12 months after surgery, CRS symptoms, quality of life, and objective evidence of persisting disease were assessed by using the preoperative tools.

RESULTS

Different bacterial species combinations were found in 30 of 39 patients; 60% of these 30 biofilms were polymicrobial biofilms and 70% had S aureus biofilms. Preoperative nasendoscopy and radiologic disease severity were significantly worse in patients with multiple biofilms (P = .02 and P = .01, respectively), and they had worse postsurgery mucosal outcomes on endoscopy (P = .01) requiring significantly more postoperative visits (P = .04). Those with S aureus biofilms progressed poorly with their symptom scores and quality-of-life outcomes, with significant differences in nasendoscopy scores (P = .007).

CONCLUSIONS

S. aureus biofilms play a dominant role in negatively affecting outcomes of ESS with persisting postoperative symptoms, ongoing mucosal inflammation, and infections.

Gastroesophageal reflux disease and chronic sinusitis: in search of an esophageal-nasal reflex

BACKGROUND

This study was performed to explore whether or not a neural reflex linking the esophagus and the nasal airway exists, as a pathogenic mechanism accounting for the association between gastroesophageal reflux (GER) disease and chronic rhinosinusitis (CRS). A prospective trial of healthy human volunteers was performed.

METHODS

Ten healthy volunteers without GER or sinonasal disease were investigated using an acid infusion challenge test. Normal saline and hydrochloric acid were infused into the lower esophagus through an esophageal manometry catheter. Nasal responses in symptom score, nasal inspiratory peak flow, and mucus production were analyzed after the esophageal challenge.

RESULTS

A tendency for an increase in nasal mucus production was observed after esophageal stimulation with both normal saline and HCl. This returned to baseline level 45 minutes after the acid infusion. A similar trend was also observed with the measurements of nasal symptom scores and, to a lesser extent, nasal inspiratory peak flow.

CONCLUSION

These results support the possibility that a neural reflex exists between the esophagus and the paranasal sinuses via the vagus nerve. If indeed present, the reflex-mediated rhinitis derived from this neuropathic inflammation may contribute to the development of CRS in patients with GER. Further study is required to define the relationship between GER and CRS.

Simultaneous inferior and middle meatus antrostomies in the treatment of the severely diseased maxillary sinus

BACKGROUND

Although the majority of the maxillary pathology can be eradicated through the enlarged middle meatus antrostomy (MMA), some patients have extensive disease that is difficult to cope with. The aim of this study was to estimate the usefulness of simultaneous middle and inferior meatal antrostomies (MIMAs) in cases with severely diseased maxillary sinus by comparing the subjective and objective outcomes between patients that underwent MIMA and those who experienced maxillary clearance through conventional MMA.

METHODS

A prospective study was performed on patients with nasal polyps and severely diseased maxillary sinus (Lund-Mackay CT score = 2). All diseased sinuses were addressed with the same endoscopic sinus surgery technique; the only difference consisted of the management of the maxillary sinus: 34 patients underwent MIMAs and in 38 cases maxillary sinus was approached solely through the MMA. After 12 months of follow-up, outcomes consisted of the visual analog scale (VAS) for the main symptoms, the Lund-Mackay and maxillary sinus endoscopic scores, and the percent of airspace occluded by inflammatory mucosal thickening on CT.

RESULTS

Subjective improvement in VAS scores for nasal obstruction, facial pain, and nasal discharge/retronasal drip was significantly better in the MIMA group. The mucosal thickening as expressed by the CT scan and maxillary endoscopic score was significantly reduced in the MIMA group.

CONCLUSION

The MIMA technique is useful for removing severe disease that can not be reached through the MMA and yields both better subjective and better objective outcomes. The additional inferior antrostomy most likely improves drainage and ventilation in the postoperative period.

Does reflux have an effect on nasal mucociliary transport?

CONCLUSION

Gastroesophageal and laryngopharyngeal reflux were found to have no effect on nasal mucociliary transport.

OBJECTIVE

Gastroesophageal and laryngopharyngeal reflux have been recognized as causative factors for chronic rhinosinusitis but no definite mechanism has been described yet. We aimed to determine whether gastroesophageal and laryngopharyngeal reflux impair nasal mucociliary transport.

METHODS

This was a prospective cohort study in a tertiary referral center. Fifty patients with both laryngopharyngeal and gastroesophageal reflux comprised the study group. Reflux syndrome index and reflux finding score were calculated for each patient before and after treatment. Antireflux medication was given for 12 weeks. The control group consisted of 30 healthy volunteers. Nasal mucociliary transport was assessed by means of the saccharine test. It was performed before and after the treatment. Statistical analysis was performed using the saccharine test results of the study and control groups.

RESULTS

No statistical difference was found between the saccharine test results of the study group and control group before treatment. The differences between the pretreatment and post-treatment reflux symptom index and reflux finding scores were statistically significant. The difference between the post-treatment saccharine test results of the patients in whom reflux scores returned to normal and those with remaining high scores was not statistically significant.

Different biofilms, different disease? A clinical outcomes study

OBJECTIVES/HYPOTHESIS

A potential role for biofilms in Chronic Rhinosinusitis (CRS) has been proposed, and the adverse impact they have on disease severity and postoperative outcomes has also been well described. Recent advances have allowed the species within the biofilms of CRS patients to be clearly characterized. This study investigates whether different biofilm species have different disease outcomes.

STUDY DESIGN

Retrospective review.

METHODS

Twenty-four patients with medically recalcitrant CRS undergoing Endoscopic Sinus Surgery (ESS), in whom we had previously characterized their biofilms using fluorescence in situ hybridization (FISH), were reviewed a median of 11 months after their surgery. They were evaluated for preoperative disease markers and evidence of on-going disease in the postoperative period.

RESULTS

Thirty-seven biofilms were identified in the 24 patients. Almost half had polymicrobial biofilms. The presence of polymicrobial, rather than single-species biofilms adversely affected preoperative disease severity but did not alter postsurgical outcome. Patients with single organism Haemophilus influenzae biofilms presented with mild disease symptomatically and radiologically and achieved normal mucosa a short time after their surgery. Conversely, patients with Staphlococcus aureus in their biofilm makeup had more severe disease and a more complicated postoperative course. The effect of Pseudomonas aeruginosa and fungal biofilms is less clear.

CONCLUSIONS

Different biofilm species are associated with different disease phenotypes. H. influenzae biofilms are typically found in patients with mild disease, whereas S. aureus is associated with a more severe, surgically recalcitrant pattern.

Failures in endoscopic surgery of the maxillary sinus

OBJECTIVE

To assess the prognostic factors of recurrence after endoscopic sinus surgery for maxillary chronic rhinosinusitis without nasal polyps.

STUDY DESIGN

Prospective.

SETTING

Tertiary referral center.

METHODS

A total of 411 patients were operated on for maxillary chronic rhinosinusitis without nasal polyps (307 rhinogenic rhinosinusitis, 74 odontogenic rhinosinusitis, and 30 oroantral fistula cases) in a single institution between 2002 and 2007. Ten parameters were analyzed to study their relationship with recurrence: etiology of rhinosinusitis, partial resection of middle turbinate, smoking history, allergy, asthma, gastroesophageal reflux, preoperative endoscopic score, CT stage, maxillary sinus mucosa score, and bleeding score. Preoperative characteristics and recurrence rates were compared with the analysis of variance test. Failure was analyzed as a time-dependent variable by the Kaplan-Meier method. Variables identified on univariate analysis were entered into a multivariate Cox proportional hazards model.

RESULTS

Recurrent rhinosinusitis developed in 28 (6.8%) cases. In the univariate analysis, preoperative endoscopic score, CT stage, and bleeding score were associated with recidivism. However, the multivariate analysis suggested that only bleeding is an independent predictive factor of recurrence (P = 0.034, 95% confidence interval for odds ratio 0.92-7.21).

CONCLUSION

Intraoperative bleeding may be a risk factor for failure in endoscopic surgery of maxillary rhinosinusitis, but there is substantial uncertainty and future research is needed.

Fungal exposure endocrinopathy in sinusitis with growth hormone deficiency: Dennis-Robertson syndrome

A retrospective study was carried out on 79 patients with a history of mold exposure, fatigue, and chronic rhinosinusitis (CRS) to determine whether there is a causal relationship between fungal exposure and chronic sinusitis, fatigue, and anterior hypopituitarism, especially growth hormone deficiency (GHD). Of the patients, 94% had a history of CRS, endoscopically and/or computed tomography (CT) confirmed; 100% had chronic fatigue and 100% had either significant history of indoor mold exposure and/or positive mold plate testing as measured by settle plates, with an average colony count of 21 (0-4 normal). A total of 62 had positive mold plate testing and 17 had positive history of mold exposure. Of 75, 73 (97.3%) had positive serum immunoglobulin G (IgG)-specific antibodies to fungal antigens. Out of 8, 7 were positive for urinary trichothecenes. Resting levels of insulin-like growth factor 1 (IGF-1) averaged 123 ng/mL (range 43-285, normal 88-249 ng/mL). Despite normal resting levels of IGF-1, significant deficiency of serum human growth hormone (GH) was confirmed by insulin tolerance test (ITT) in 40 of 50 tested. In all, 51% (40/79) were GH deficient. Primary or secondary hypothyroidism in T3 and/or T4 was seen in 81% (64/79) patients; 75% (59/79) had adrenocorticotrophic hormone (ACTH) deficiency. Fungal exposure endocrinopathy likely represents the major cause of GHD, affecting approximately 4.8 million people compared to approximately known 60,000 cases from all other causes. A literature review indicates a possible mechanism of GHD in fungal exposure is that the fungal glucan receptors in the lenticulostellate cells of the anterior pituitary bind to fungal cells wall glucans and activate the innate immune system, which activates macrophages that destroy the fungus and lenticulostellate tissue. Treatment of patients included normal saline nasal irrigations, antifungal and antibiotic nasal sprays, appropriate use of oral antibiotics and antifungals, facial steamer with CitriDrops. Thymate and/or Intramax vitamin supplements, hormone replacement, and reduction of indoor mold levels. Resolution of rhinosinusitis was seen in 93% (41 of 45) of the patients who achieved a mold count by settling plates of 0-4 colonies. Thirty patients were unable to lower their mold counts below four colonies and had various degrees of mucosal disease and fatigue remaining. Fatigue was improved in all 37 patients who received GH and cortisol and/or thyroid hormone, which were deficient. Fatigue was partially relieved in 7 of the 37 who did not achieve mold counts of fewer than four colonies.

Endoscopic sinus surgery in the management of nasal obstruction

Nasal obstruction is the leading symptom observed among patients who have chronic rhinosinusitis (CRS) with or without nasal polyposis. After failure of medical therapy, functional endoscopic sinus surgery (FESS) has emerged as the preferred treatment of CRS. Interestingly, although patient-reported outcomes show unequivocal relief of nasal obstruction after FESS, studies measuring nasal airflow and resistance demonstrate more modest improvements. This article provides an overview of the physiology of nasal airflow sensation, the burden of nasal obstruction in patients who have CRS, and the efficacy of FESS in addressing nasal obstruction in this population. Additionally, advances in airflow modeling that may enable improved preoperative planning for the relief of nasal obstruction after FESS are discussed.

Symptom-specific outcomes of endoscopic sinus surgery: A systematic review

Background: Although multiple studies have demonstrated that symptoms of chronic rhinosinusitis (CRS) improve after endoscopic sinus surgery (ESS), a systematic large-scale evaluation of specific symptom response has not been performed.

Objective: To analyze the relative effectiveness of surgery in the improvement of individual CRS symptoms.

Study Design: A literature search of MEDLINE, EMBASE, Web of Science, Cochrane databases, and other Web-based sources from January 1, 1980 through June 1, 2008 was performed. Studies of 20 or more adult patients with CRS that used symptom severity scores to analyze at least 3 major CRS criteria (facial pressure, nasal obstruction, postnasal discharge, and hyposmia) or 2 major CRS criteria plus headache were included.

Subjects and Methods: Inclusion criteria were met by 21 of 289 ESS studies reviewed. Meta-analysis was conducted for each symptom separately with the standardized difference between the preoperative and postoperative severity scores as the effect size (ES).

Results: A total of 2070 patients with CRS were studied a mean of 13.9 months after ESS. All symptoms demonstrated improvement compared with their respective preoperative severity scores by an overall ES of 1.19 (95% confidence interval, 0.96 to 1.41; I2 = 81.7%) using the random-effects model. Nasal obstruction (ES, 1.73) improved the most, with facial pain (ES, 1.13) and postnasal discharge (ES, 1.19) demonstrating moderate improvements. Hyposmia (ES, 0.97) and headache (ES, 0.98) improved the least.

Conclusion: The relative improvements in major CRS symptoms and headache after surgery are similar, with the exception of nasal obstruction, which improves most.