Medical management in functional endoscopic sinus surgery failures

Systematic review of patient-reported outcomes after revision endoscopic sinus surgery

BACKGROUND

Revision endoscopic sinus surgery (RESS) may be required for partially controlled or uncontrolled chronic rhinosinusitis. Studies that reported technical success, e.g., sinus ostia patency after RESS, do not address whether the patient's symptoms and quality of life (QOL) improve after surgery. However, patient-reported outcome measures (PROM) are useful to assess the impact of sinus surgery on a patient's symptoms and QOL.

OBJECTIVE

This systematic review was undertaken to evaluate the impact of RESS on PROMs.

METHODS

Medical literature databases were searched for studies in English. References from retrieved articles and relevant reviews were examined for additional studies. Those studies that reported QOL outcome tools in patients who underwent RESS and with a minimum follow-up of 6 months were included.

RESULTS

A search of the sources yielded 1856 citations. There were 72 articles after abstract review and exclusion, identified for full-text review, with 12 studies (which contained data from 1308 patients) that met the inclusion criteria for this systematic review. There were four "good" and eight "fair" studies. Three studies used the Rhinosinusitis Disability Index and Chronic Sinusitis Survey in tandem; two each used the 20-item Sino-Nasal Outcome Test and the 22-item Sino-Nasal Outcome Test; the remaining studies used either the Adelaide Disease Severity Score, Patient Response Score (PRS), Rhinosinusitis Symptom Inventory, Rhinosinusitis Outcome Measure 31, or the Chinese version of the University of Pennsylvania Smell Identification Test. All studies used validated PROMs apart from the study that used PRS. Studies consistently reported improvement in the five key symptoms of nasal obstruction, rhinorrhea, postnasal drip, facial pain, and anosmia, although improvement in halitosis, fever, dental pain, and cough were modest.

CONCLUSION

Several PROMs demonstrated that RESS improves patient's QOL symptoms. Future studies that examine QOL should use a consistent PROM to allow a meta-analysis.

Prevalence and pattern of humoral immunodeficiency in chronic refractory sinusitis

The purpose of this study is to readdress the issue of primary humoral immunodeficiency frequency and pattern in medically resistant chronic rhinosinusitis (CRS) based on the new guidelines for CRS diagnosis and management. Two hundred and fifty-seven consecutive patients with refractory CRS were included in this study. The results of their IgA, IgM, IgG, and IgG subclasses were analyzed and compared with 75 age- and gender-matched control groups. The average age of CRS patients was 34 years (SD ± 13). In the refractory CRS group, there was no significant difference between patients with or without humoral immunodeficiency based on age, gender and status of allergy, polyps and revision. Low level of one of the major immunoglobulin isotypes was found in 15 patients (6 %). Six patients had low IgG, two had low IgA, and seven had low IgM. IgG subclasses were low in 37 patients (14 %), and IgG4 was the most common deficient subclass. Multiple immunoglobulins deficiencies were found in eight patients. Compared with the control group, CRS patients had a significant higher prevalence of major immunoglobulins as well as total major immunoglobulins and IgG subclasses deficiency. Because of high prevalence of subtle humoral immunodeficiency in medically resistant CRS and inability to find unique clinical and demographic characteristic of these patients, we recommend routine screening of major immunoglobulins and IgG subclasses on the group of CRS patients who failed medical treatment.

The role of balloon sinuplasty in the treatment of sinus headache

INTRODUCTION

Headache attributed to rhinosinusitis, commonly called sinus headache (SH), is probably one of the most prevalent secondary headaches. The purpose of our study was to examine further sinus headache comparing the effect of conventional functional endoscopic sinus surgery and the balloon sinuplasty.

MATERIAL AND METHODS

Eighty-three consecutive patients were enrolled from 2009 to 2012, who were diagnosed sinus headache according the diagnostic criteria of AAO-HNS and of HIS. 40 patients were randomized to Conventional Endoscopy Sinus Surgery for frontal sinus (ESS Group), 35 to balloon sinuplasty of frontal sinus (BS Group).

RESULTS

The mean operative time was 65 ± 15 min for ESS group patients and 32 ± 7 min for 23 patients (BS1 Group) and 55 ± 18 min for 12 treated with hybrid technique (BS2 Group). The preoperative mean of SNOT-22 scores improved from 28.6 ± 1.2 in ESS group and 27.3 ± 0.8 in BS group to a 1-month postoperative scores of 14.5 ± 0.6 in ESS group and 10.3 ± 0.5 in BS group and to a 6-month postoperative scores of 7.8 ± 0.6 and 5.3 ± 0.3, respectively (p<0.0001). The headache scores base on analog visual scale improved from a preoperative mean of 6.5 ± 0.3 in ESS group and 7.1 ± 0.4 in Bs group to a 1-month postoperative scores of 5.4 ± 0.4 in ESS group and 5.5 ± 0.4 in BS group and to a 6-month postoperative scores of 2.7 ± 0.5 and 1.2 ± 0.1, respectively, representing a statistically significant reduction in headache score in both group.

CONCLUSION

Our data prove that improvement in headache can be expected in patients treated with balloon catheter.

Long-term outcomes of endoscopic sinus surgery for chronic rhinosinusitis with and without nasal polyps

Chronic rhinosinusitis (CRS) significantly affects patient quality of life. Medical and surgical treatments aim to clinically manage the condition.

Objective

To assess the long-term quality of life and clinical management of CRS in patients submitted to endoscopic sinus surgery.

Method

This prospective cross-sectional cohort study enrolled 38 patients and looked into the follow-up data of subjects diagnosed with CRS before surgery, three months after surgery, and at least two years after surgery. The Sinonasal Outcome Test 22 (SNOT-22) was used to assess response to treatment and long-term clinical management of the disease.

Results

Significant improvements in the SNOT-22 scores were seen between the preoperative (61.3) and postoperative assessments with three (16.9) and 24 (32.3) months. No statistically significant differences were seen when patients with polyps were compared to polyp-free subjects. Few patients were controlled in both groups, and 7.89% of the subjects had revision surgery during the study.

Conclusion

Endoscopic sinus surgery significantly improved the quality of life of patients with chronic rhinosinusitis. Clinical control of the condition was acceptable, with few patients requiring re-operation within two years of the first surgery.

Topical gel therapy for sinonasal polyposis in Samter's triad: preliminary report

OBJECTIVES

Rhinosinusitis and polyposis are difficult to treat in patients with Samter's triad; they commonly recur despite sinus surgery, antibiotics, and/or nasal steroids. The present study assesses the efficacy of a multimodal regimen that includes topical corticosteroids and antibiotics delivered through a hydroxyethyl cellulose gel and by nebulization.

METHODS

Eleven patients with Samter's triad who had polyposis and rhinosinusitis that recurred despite endoscopic sinus surgery were treated with a 6-week course of multimodal topical therapy consisting of a hydroxyethyl cellulose gel that releases corticosteroids and antibiotics, topical nebulization of corticosteroids and antibiotics, saline solution rinses, and sinus debridement. Clinical outcomes were evaluated by Lund-Kennedy endoscopic and symptom scores. Histologic assessment was evaluated by hematoxylin and eosin staining before and after treatment.

RESULTS

Both Lund-Kennedy symptom and endoscopic scores showed.a progressive and statistically significant decline throughout the course of treatment, reaching at 6 weeks 42% of the pretreatment values (p = 0.005) for the Lund-Kennedy symptom score and 34% (p = 0.002) for the endoscopic score, respectively; however, the significance of the improvement was lost with time.

CONCLUSIONS

Topical gel therapy improves clinical symptoms, endoscopic findings, and sinus membrane histologic features in patients with refractory Samter's triad, but the improvement is transient, suggesting that a longer therapeutic period might be needed.

Phototherapy for chronic rhinosinusitis

OBJECTIVES

Near-infrared laser illumination (NILI), with or without photo-activated (PA) agents, has bactericidal and wound healing promoting effects. NILI may have a potential role managing chronic rhinosinusitis (CRS).

METHODS

A prospective randomized study with 23 symptomatic post-surgical CRS patients with positive cultures was conducted. Two groups (GR1 and GR2) were treated with NILI. Objective nasal endoscopic scoring (NES) was elaborated. GR1 was treated with a 940 nm laser, while GR2 was treated with a topical PA agent, indocyanine-green, followed with 810 nm laser. SNOT20 scores, NES, and cultures were obtained prior to illumination. Saccharin test was performed 1 week following treatment.

RESULTS

Some cultures remained positive through treatment, with Staph. aureus predominating. Both therapy arms demonstrated clinical efficacy. The SNOT20 score change was 0.9, 0.8 for GR1 and GR2, respectively (P < 0.05). Improvement (P < 0.05) was observed based on NES. No significant difference was observed between two treatment groups. All passed the saccharin test. Therapeutic effect was sustained for a minimum of 2 months. Side effects were minimal.

CONCLUSIONS

NILI was objectively and subjectively beneficial in managing CRS, safe, reproducible, sustained and appeared not to interfere with ciliary motility. CRS exacerbation was avoided without using antibiotics or steroids.

High Prevalence of Humoral Immunodeficiency Patients with Refractory Chronic Rhinosinusitis

Background

The purpose of this study was to investigate the prevalence and contribution of humoral immunodeficiency in refractory chronic rhinosinusitis (RCRS). This study was performed at a tertiary care academic referral center.

Methods

RCRS patients who had at least three episodes of documented sinusitis in the previous year despite antibiotic therapy, who had endoscopic sinus surgery performed at University of Iowa Health Care (UIHC), and who were evaluated by the UIHC Adult Immune Disorder Clinic were included. Exclusion criteria included allergic fungal sinusitis, human immunodeficiency virus, and other causes of secondary immunodeficiency. Sixty-seven patients fulfilled the inclusion and exclusion criteria. The results of their immunologic evaluation for atopy and humoral immune function were examined.

Results

The average age of these patients was 50 years (±11.6 years). Twenty-eight (42%) patients had at least one positive result on allergy skin testing. Determination of quantitative immunoglobulins showed low IgG in 9%, low IgA in 3%, and low IgM in 12% of patients. Common variable immunodeficiency was diagnosed in one case. Immunoglobulin G subclasses were tested in 31 cases and found low in 6 patients. Fifty-one patients underwent a dynamic assessment of their antibody response by examining the increase in antibody titer to an unconjugated pneumococcal polysaccharide vaccine. Sixty-seven percent of patients failed to produce more than a fourfold increase in postimmunization antibody titer for >7 of 14 serotypes being tested and were considered to have functional antibody deficiency.

Conclusion

This retrospective review shows an unexpectedly high prevalence of humoral immune dysfunction in patients with RCRS. These findings suggest that assessment of immune function should be undertaken routinely in RCRS. Immune assessment should first include measurement of serum immunoglobulin levels; if these are normal, then functional antibody responses should be evaluated.

Use of computational fluid dynamics to study the influence of the uncinate process on nasal airflow

BACKGROUND

Chronic rhinosinusitis is commonly treated by functional endoscopic sinus surgery involving excision of the uncinate process and opening of the osteomeatal complex.

METHODS

Computational fluid dynamics were used to compare nasal airflow after two different surgical interventions which involved opening the paranasal sinuses, excising the ethmoid sinus, and excising or preserving the uncinate process, in a cadaveric head model. Cross-sectional computed tomography images were obtained before and after the interventions. Imaging data were used to prepare computer simulations, which were used to assess the airflow characteristics of the nasal cavities and paranasal sinuses during inspiration and expiration, before and after intervention.

RESULTS

Significantly larger nasal cavity airflow velocity changes were apparent following the uncinate process excising procedure. Nasal cavity airflow distribution remained relatively unchanged following the uncinate process preserving procedure. There was a significantly greater increase in airflow volume following the uncinate process excising procedure, compared with the uncinate process preserving procedure.

CONCLUSION

Preservation of the uncinate process may significantly reduce the alteration of nasal cavity airflow dynamics occurring after functional endoscopic sinus surgery for chronic rhinosinusitis.

Revision endoscopic sinus surgery in children: surgical causes of failure

OBJECTIVES/HYPOTHESIS

Revision endoscopic sinus surgery (ESS) in children is uncommon. Causes of failure, however, are not very well delineated. The purpose of this study was to evaluate surgical causes of failure in children after ESS.

STUDY DESIGN

A retrospective review of children who had ESS at a tertiary children's referral center between 1993 and 2005 for chronic rhinosinusitis.

METHODS

ESS was performed on 243 children. Children with cystic fibrosis, immune deficiency/suppression, and ciliary abnormalities were excluded because the reasons of failure in those children are well known. Data were available on 176 children with at least one year of follow-up.

RESULTS

Twenty-three (13%) children required revision. The most common finding was adhesions in 57%, followed by maxillary sinus ostium stenosis or missed maxillary sinus ostium in 52% of the cases. In 39% of the cases, there was recurrent disease in the sinuses that were operated on initially. Interestingly, however, we found that in 26% surgery was needed because of disease that was present in nonoperated sinuses during the primary ESS. A deviated septum and a mucocele were the cause of failure in 17% and 13% of the patients, respectively. Presence of asthma and younger age contributed to the failure in some of these children.

CONCLUSIONS

Adhesions and a scarred, narrow maxillary sinus ostium were the most common cause of failure in children after ESS. Steps taken during surgery may be required to help reduce the need for revision in particular for younger asthmatic children. Laryngoscope, 2009.

Systemic treatment of rhinosinusitis in children

Systemic acute rhinosinusitis therapy consists mostly of antibiotic treatment because pathogens play a major role. Amoxicillin is the drug of choice for treatment of acute rhinosinusitis, with second- and third- generation cephalosporins, azythromycin, clarithromycin, and telithromycin as possible options, especially in the case of allergy to amoxicillin. If the clinical course suggests that an anaerobic pathogen is more likely, clindamycin or metronidazole can be considered in combination with a broad-spectrum drug. In antimicrobial treatment of chronic sinusitis there is no consensus on treatment length, organism coverage, or which antibiotics are most effective because the bacteriology is variable with polymicrobial anaerobic and aerobic organisms present. Adjuvant therapies need to be proven by additional studies. Chronic rhinosinusitis is heterogeneous and treatment should vary according to the causative factor involved. Short courses of systemic steroids have been found very useful to decrease mucosal swelling and inflammation in chronic rhinosinusitis. However, no randomized controlled studies have been performed to validate their efficacy in children. A variety of other agents are used in the treatment of chronic rhinosinusitis including antihistamines, decongestants, and leukotriene modifiers. To date, there is no good evidence from randomized controlled studies to support the use of any of these agents in the treatment of this disease in either children or adults.

Hyperostosis may affect prognosis after primary endoscopic sinus surgery for chronic rhinosinusitis

OBJECTIVE

To investigate the independent effect of hyperostosis on outcome after endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS).

STUDY DESIGN AND SETTING

The medical records of 81 consecutive patients who had undergone primary ESS for CRS were reviewed retrospectively. Sinus CT scans were evaluated for the presence of hyperostosis to investigate the association with postoperative outcomes. The independent effect of hyperostosis on surgical outcome was analyzed, controlling for possible confounding factors with a multiple logistic regression model.

RESULTS

Sixty percent of the patients showed hyperostosis, and there was a statistically significant association between the hyperostosis and postoperative outcome (P = 0.035, chi(2) test), which was confirmed after adjustment for the possible confounding factors (P = 0.048, odds ratio [OR] = 3.19, logistic regression analysis).

CONCLUSIONS

Our study suggests that patients with CRS who have hyperostosis may have a poorer surgical outcome than those without hyperostosis.

EBM RATING

B-2b.

Therapeutic options in the management of headache attributed to rhinosinusitis

Sinus headache is a common diagnosis when patients have facial pain and pressure accompanying their headache. However, acute sinus headache is in fact rare, and the headache must accompany acute bacterial rhinosinusitis (ABRS), a diagnosis which is based both on clinical and radiological evidence. In fact, sinus headache is a misnomer. The only headache related to sinus disease, as recognised by the International Headache Society (IHS), is headache attributed to rhinosinusitis (HARS; section 11.5 of IHS criteria). Many patients who are diagnosed with sinus headache and treated with antibiotics have a primary headache, usually migraine. This is an important distinction and the treatment is very different. This review covers the most recent definitions, epidemiology, pathophysiology, diagnostics and treatment of ABRS and the resulting headache as defined by the IHS.