The effect of endoscopic olfactory cleft polyp removal on olfaction

BACKGROUND

The presence of olfactory cleft polyps in chronic rhinosinusitis with nasal polyposis is well documented, but the effect of endoscopic olfactory cleft polyp surgery on olfaction, versus observation, has not been well studied. This analysis assessed if microdebridement of olfactory cleft polyps yields significant objective smell improvements in those with anosmia or hyposmia.

METHODS

A randomized prospective single-blinded study was performed on patients undergoing bilateral endoscopic sinus surgery with profound bilateral nasal polyposis, excluding those younger than 18 years or without olfactory polyps. A preoperative University of Pennsylvania Smell Identification Test (UPSIT), visual analog scale (VAS), and sinonasal outcomes 20 score (SNOT-20), and a follow-up at 6 months was performed. Two cohorts were created, including one with cleft polyp removal (group A) and one with cleft polyps left in place (group B).

RESULTS

There were 10 patients in group A and 7 in group B. By using the Wilcoxon signed rank test, the two groups were individually analyzed for changes in the preoperative UPSIT, VAS, and SNOT-20 versus the 6-month test results. In group A, the improvement in the UPSIT, VAS, and SNOT-20 were statistically significant at p < 0.05. For group B only the improvement in the VAS was statistically significant, at p < 0.05. There was a statistically significant difference in clinical smell improvement between group A and B at 6 months (p = 0.00512).

CONCLUSIONS

Evidence exists that olfactory cleft polyp surgery improves olfactory function outcomes. Long-term data beyond 6 months is needed to further validate these early promising outcomes.

Conductive olfactory losses in chronic rhinosinusitis? A computational fluid dynamics study of 29 patients

BACKGROUND

Besides sensorineural factors, conductive impediments likely contribute to olfactory losses in chronic rhinosinusitis (CRS) patients, yet no conclusive evidence exists. We aimed to examine possible conductive factors using computational fluid dynamics (CFD) models.

METHODS

A total of 29 CRS patients were assessed via odorant detection thresholds (ODTs), rhinomanometry (nasal resistance [NR]), acoustic rhinometry (minimum-cross-sectional area [MCA]) and computed tomography (CT) staging. CFD simulations of nasal airflow and odorant absorption to olfactory region were carried out based on individual CTs. Biopsies of olfactory epithelium (OE) were collected, cryosectioned, stained, and scored for erosion.

RESULTS

Significant correlations to ODTs were found for 3 variables: odor absorption in the olfactory region (r = -0.60, p < 0.01), MCA (r = -0.40, p < 0.05), and CT staging (r = 0.42, p < 0.05). However, significant findings were limited to ODTs of the highly soluble l-carvone. Multiple regression analysis revealed that these variables combined, with the addition of NR, can account for 65% of the total variance in ODTs. CT staging correlated significantly with OE erosion (r = 0.77, p < 0.01) and can replace the latter in the regression with comparable outcomes. Partial correlations suggest the contributions of both conductive and sensorineural variables are more prominent if adjusted for the effects of the other. Olfactory loss and inflammatory factors have strong bilateral involvement, whereas conductive factors are independent between sides. As validation, CFD-simulated NRs significantly correlated with rhinomanometrically assessed NRs (r = 0.60, p < 0.01).

CONCLUSION

Both conductive and sensorineural mechanisms can contribute to olfactory losses in CRS. CFD modeling provides critical guidance in understanding the role of conductive impediments in olfactory dysfunction in CRS.

Effect of greater palatine canal injection on estimated blood loss during endoscopic sinus surgery

PURPOSE

We compare estimated blood loss (EBL) during endoscopic sinus surgery (ESS) between patients receiving transoral greater palatine canal (GPC) and transnasal infiltration (combined group) to patients receiving only transnasal infiltration (control group). CT stage, endoscopic stage, revision surgery, presence of polyps, degree of resident involvement, and operative time (OT) are also evaluated.

METHODS

Injection with 1% lidocaine with 1:100,000 epinephrine was performed through the GPC and transnasally in the "combined" study group (20 patients) and only transnasally in the control group (22 patients). Charts, operative reports, and CT scans were reviewed and demographic data as well as pertinent information collected. Data analysis was performed using SPSS Version 16 (SPSS Inc., Chicago, Illinois).

RESULTS

Twelve females and 8 males underwent combined injections and 16 males and 6 females received transnasal injections only. Average ratio of EBL to OT was 2.9 mL/min for the combined group and 4.1 mL/min for the control group (p=0.05). Presence of polyps and revision surgery lead to a statistically significantly higher EBL (p<0.05). Increased EBL and OT were noted with higher endoscopic and CT stages. No complications were reported.

CONCLUSIONS

Increased endoscopic and CT stages, presence of polyps, and revision surgery may all lead to greater EBL in ESS. Although there was a trend towards decreased EBL in the combined group, this however did not reach statistical significance. Combined injection through the GPC and nasal cavity appears to be a safe method to decrease EBL during ESS.

Neuropathology of the olfactory mucosa in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a complex heterogeneous inflammatory disease that affects the nasal cavity, but the pathological examination of the olfactory mucosa (OM) in this disease has been limited.

METHODS

Nasal biopsy specimens were obtained from 20 control subjects and 50 CRS patients in conjunction with clinical assessments. Histopathology of these nasal biopsy specimens was performed and immunohistochemistry was used to characterize nonneuronal, neuronal, and inflammatory cells in the OM. These OM characteristics were then evaluated to determine the degree to which pathological features may be related to smell loss in CRS.

RESULTS

Histopathological examination of control and CRS OM revealed changes in the normal pseudostratified olfactory epithelium (OE): intermixing of goblet cells, metaplasia to squamous-like cells, and erosion of the OE. Lower percentages of normal epithelium and olfactory sensory neurons were found in CRS OE compared with controls. Relative to other CRS patients, those with anosmia had the greatest amount of OE erosion, the highest density of eosinophils infiltrating the OE, and exhibited the most extensive abnormalities on CT and endoscopic examination, including being significantly more likely to exhibit nasal polyposis.

CONCLUSION

Our results suggest that OM pathology observed in nasal biopsy specimens can assist in understanding the degree of epithelial change and sensorineural damage in CRS and the potential for olfactory loss.

Effect of coblation polypectomy on estimated blood loss in endoscopic sinus surgery

BACKGROUND

We conducted a pilot study comparing estimated blood loss (EBL) using coblation-assisted endoscopic sinus surgery (CAESS) where coblation is used to debulk nasal polyps before microdebridement with a traditional microdebrider technique in chronic rhinosinusitis (CRS) patients with sinonasal polyps undergoing endoscopic sinus surgery (ESS).

METHODS

A retrospective analysis was performed at a tertiary care center on patients with nasal polyposis undergoing ESS between January 2008 and July 2008. The University of Miami CT staging system was used preoperatively to evaluate the extent of sinonasal disease. The duration of surgery, blood loss per minute, total EBL, and demographic data were collected.

RESULTS

Twenty-one patients underwent nasal polypectomy/ESS using CAESS and 16 patients underwent nasal polypectomy/ESS using microdebridement. The two groups had comparable University of Miami CT staging scores (p>0.05). The average EBL was 307.1+/-169.8 mL using coblation compared with 627.8+/-424.2 mL using microdebridement (p<0.05). The average duration of surgery using coblation was 116.2+/-41.7 minutes, compared with 125.3+/-48.4 minutes using microdebridement (p>0.05). The average blood loss per minute was 2.8+/-1.7 mL in the coblation group compared with 4.8+/-2.1 mL in the microdebridement group (p<0.05). Subgroup analyses showed a significant decrease in average EBL and EBL/minute to be only significant for revision cases (p<0.05) and not for primary cases (p>0.05).

CONCLUSION

Coblation-assisted nasal polypectomy/ESS is associated with a statistically significant lower EBL and blood loss per minute when compared with traditional microdebridement technique. Coblation represents a new device that can reduce blood loss in patients with nasal polyposis undergoing traditional revision ESS. Further prospective randomized trials are needed to validate these findings.

Probiotics as adjunctive treatment for chronic rhinosinusitis: A randomized controlled trial

Objective: To determine if oral probiotics as adjunctive treatment are more effective than placebo in improving quality of life in patients with chronic inflammatory rhinosinusitis.

Design: Prospective, randomized, double-blind, placebo-controlled trial.

Methods: A total of 77 patients with chronic inflammatory rhinosinusitis were randomly assigned to receive oral probiotic Lactobacillus rhamnosus R0011 strain (500 million active cells/tablet twice daily) (n = 39) or oral placebo treatment (n = 38) for 4 weeks.

Results: In the probiotic group, the mean change from baseline in the SNOT-20 scores was significant at 4 weeks ( P = 0.002) but not at 8 weeks ( P = 0.37). Rhinological domain improved by 9.3 percent ( P = 0.004) in probiotics group but returned to baseline level at 8 weeks. No significant differences were found between the probiotic and placebo groups in mean changes from baseline to 4 weeks ( P = 0.79) or from baseline to 8 weeks ( P = 0.23). No changes in symptom frequency were noted, either within each group or between treatment groups at 4 and 8 weeks. There was no difference in medication use or side effects between the two study groups.

Conclusion: Oral use of the probiotic strain L rhamnosus R0011 did not improve sinonasal quality-of-life scores in patients with chronic inflammatory rhinosinusitis compared with placebo.