Orbital Complications of Chronic Rhinosinusitis: Two Years' Experience in a Tertiary Referral Hospital

PURPOSE

To investigate the different clinical manifestations in Egyptian patients with orbital complications of rhinosinusitis (RS) according to the pathology within the paranasal sinuses.

METHODS

The medical records of patients presented with chronic RS between August 2018 and December 2020 were retrospectively reviewed.

RESULTS

This study included 64 patients: 28 patients with subperiosteal abscess (SPA), 10 with allergic fungal RS, 6 with isolated fungal RS, 6 with invasive fungal RS, and 14 with mucocele. The most common manifestation was proptosis, limitation of ocular motility, periorbital swelling, and pain. A relative afferent pupillary defect was present in all cases of invasive fungal sinusitis. Surgical interventions were performed in 63 out of 64 cases. All the ophthalmological manifestations were reversible except for patients with invasive fungal rhinosinusitis.

CONCLUSION

Orbital complications of RS may require early surgical intervention with multidisciplinary counseling between ophthalmologists, otorhinolaryngologists, radiologists, and neurologists.

A modified form of the St Thomas' Hospital (STH) classification to improve cochlear implantation outcomes

OBJECTIVES

re-evaluation and modification of the St Thomas' Hospital (STH) classification to improve cochlear implantation outcomes. STUDY DEIGN: a prospective cohort study.

PATIENTS

children (n = 20) between 2 to 8 years old who received a unilateral cochlear implant, all had difficult round window visibility and/or accessibility for electrode insertion. 10 had a round window insertion through the endoscopic assisted cochlear implantation and the remaining 10 had the same insertion using the retro-facial approach. THE SURGERY: two alternative techniques were used to overcome the difficult cases of round window electrode insertion: 1Endoscopic assisted cochlear implantation 2Transmastoid retro-facial approach RESULTS: both techniques proved to be effective and practical to overcome cases with difficult round window visibility and/or accessibility for electrode insertion.

CONCLUSION

Round window insertion is associated with superior cochlear implantation outcomes, so we recommend a new modification to the STH classification to bypass the cochleostomy insertion.

Orbital Complications of Acute Invasive Fungal Rhinosinusitis: A New Challenge in the COVID-19 Convalescent Patients

Purpose

Increased incidence of acute invasive fungal rhinosinusitis (AIFR) in the setting of COVID-19 is undeniable. This can be attributed to its effect on innate immunity and extensive use of corticosteroids. The goal of our study was to assess the orbital complications of AIFR and its management in the COVID-19 convalescent patients.

Methods

Our longitudinal prospective study included 45 patients with orbital complications of AIFR in recently recovered COVID-19 patients. We performed otorhinolaryngological, ophthalmological, and neurological examinations to monitor the manifestations of the disease. Computed tomography and contrast enhanced magnetic resonance imaging were performed to detect the extent of infection. Antifungal medications, surgical intervention, and general condition management were all provided to all the patients.

Results

We reported pre-septal cellulitis, orbital cellulitis, and orbital apex syndrome in 18, 13, and 10 patients, respectively. Four patients had cavernous sinus thrombosis. Mucormycosis and Aspergillus species were detected in 80% and 11.11% of our patients, respectively, while the mixed infection was found in 8.88% of our patients. Diabetes mellitus was the most common cause of immunocompromise (95.55% of our patients). Orbital pain and ophthalmoplegia were the most common ocular manifestations, followed by proptosis and relative afferent pupillary defect. All patients underwent surgical intervention, except for one patient who was unfit for surgery. One patient had orbital exenteration. The ophthalmological manifestations were reversible in cases of orbital and pre-septal cellulitis. The overall survival rate was 66.67%.

Conclusion

Early diagnosis and treatment of AIFR can decrease the morbidity and mortality rate of affected patients.

Anterior part middle turbinoplasty in endoscopic sinus surgery: a randomized controlled study

OBJECTIVE

Resection of middle turbinate in the setting of endoscopic sinus surgery is a controversial procedure. Our aim is to assess the impact of the anterior part middle turbinoplasty on the outcome of endoscopic sinus surgery, incidence of synechia between the middle turbinate and the lateral nasal wall, intra- and post-operative accessibility to the paranasal sinuses.

METHODS

Single blinded randomized controlled study of 120 patients with chronic rhinosinusitis without polyps, they were allocated into two groups, we performed anterior part middle turbinoplasty in the group one "60 patients", and we preserved the middle turbinate in the group two "60 patients". We assessed the patients pre-operatively by Sino-nasal outcome Test (SNOT-22), intra-operatively by Likert scale score for the sinuses accessibility. At least 6 months post-operatively, we assessed the patients by SNOT-22, and Likert scale score for sinus accessibility.

RESULTS

During and after surgery, the Likert scale score in the group one showed statistically significant better sinuses accessibility than in the group two. We noticed synechia between the MT and the lateral nasal wall in 9.2% and 18.2% of the operated sides in group one and group two, respectively. SNOT-22 and its smell item improved significantly in both groups with no statistically significant differences between them. No major complications were reported.

CONCLUSION

Anterior part middle turbinoplasty is a safe and effective technique during endoscopic sinus surgery to improve the intra- and post-operative sinus accessibility, and decrease the incidence of post-operative synechia, with no adverse effect on olfaction or bleeding.

Effectiveness of chondrofascial 'cigar' graft in contouring the nasal dorsum

Irregularities of the nasal dorsum after rhinoplasty are frustrating for the patient and the surgeon. Different grafts and implants have been adopted to camouflage this nasal imperfection. This study was performed to assess the outcome of a composite chondrofascial 'cigar' graft for contouring an irregular nasal dorsum. Thirty-six patients who underwent rhinoplasty between May 2014 and October 2016 were studied prospectively. The cartilaginous core of the graft was obtained from the septal or conchal cartilage, while the graft outer sleeve was harvested from the right lateral thigh fascia lata. The graft was secured over the nasal dorsum through an external rhinoplasty approach. The patients were followed up for at least 18 months postoperative. All participants were evaluated objectively by two independent rhinoplasty surgeons and subjectively by Rhinoplasty Outcome Evaluation (ROE) score. Donor site morbidity was also assessed. All patients had satisfactory aesthetic results with no apparent irregularities detected over the nasal dorsum. The ROE score improved, from a mean of 20.94±8.67 (range 8-58) preoperatively to a mean of 79.56±10.65 (range 50-96) postoperatively. Insignificant donor site morbidity was encountered, with inconsequential effects. The chondrofascial cigar graft is a reliable method for contouring dorsal irregularities, particularly in patients with thin nasal skin.

Self-reported anxiety and depression unchanged after endoscopic sinus surgery for chronic rhinosinusitis

BACKGROUND

Prior research has established that anxiety and depression, as measured by the Hospital Anxiety Depression Score (HADS), are strongly correlated with disease-specific quality of life (Rhinosinusitis Disability Index - RSDI) in chronic rhinosinusitis (CRS). We hypothesized that anxiety and depression would decrease after functional endoscopic sinus surgery (FESS), and furthermore that HADS would predict improvement in RSDI following surgery.

METHODOLOGY

The study cohort from 2014 consisted of 99 CRS patients who underwent nasal endoscopy, RSDI, and HADS evaluation. The cohort was segregated by whether or not they underwent FESS and an updated HADS was administered. For 44 surgical patients, pre- and post-operative RSDI (n=38), Lund-Kennedy (LK) (n=34) and HADS (n=18) scores were compared. Delta RSDI was compared between patients with varying levels of anxiety and depression.

RESULTS

Lund-Kennedy scores improved from 5.8 ± 4.1 to 3.2 ± 2.6 following surgery, as did total RSDI (39.3 ± 26.8 to 24.6 ± 29.2). Total HADS (9.8 ± 6.4 to 11.3 ± 7.4) and depression and anxiety subscores were unchanged. Linear regression did not reveal a correlation between HADS and change in RSDI following FESS. Delta RSDI was not significantly different between patients with varying levels of anxiety and depression.

CONCLUSIONS

Despite improvements in objective evidence of sinonasal inflammation (LK) and disease-specific quality of life (RSDI), neither depression nor anxiety improved after FESS, nor did the magnitude of psychological comorbidity predict post-operative improvement in quality of life. Improvement in RSDI was not different among patients with varying levels of anxiety and depression. Levels of depression and anxiety may be hard-wired, and therefore not influenced by changes in objective or perceived sinonasal disease burden.

Long-term follow-up of repair of external nasal deformities in rhinoscleroma patients

INTRODUCTION

Rhinoscleroma (RS) is a chronic, progressive, granulomatous infectious disease endemic in Egypt and the Middle East, affecting the nose in 95-100% of cases, and resulting in functional and esthetic sequelae. The aim of the study was to investigate the feasibility of performing reconstructive procedures to improve external deformities in RS patients, with long-term follow up.

PATIENTS & METHODS

This prospective, controlled cohort study included 25 patients who were seeking rhinoplasty to improve their esthetic appearance, with evident clinical and histopathological history of RS. Another 25 patients seeking esthetic augmentation rhinoplasty in the same period formed the control group. All the participants were evaluated objectively by two independent rhinoplasty surgeons, and subjectively with ROE 2 years postoperatively.

RESULTS

All the participants showed significant improvement in esthetic facial evaluation postoperatively, with a correlative rise in ROE score. There was an insignificant difference between the studied groups. Inconsequential complications were encountered throughout the follow-up period, but with insignificant incidence in both groups.

CONCLUSION

Rhinoplasty for correction of RS external deformities is both safe and beneficial, with no risks of flaring up or increased complications.

LEVEL OF EVIDENCE

Level 2b.

Olfactory bulb neuroplasticity: A prospective cohort study in patients with chronic rhinosinusitis with nasal polyps

OBJECTIVES

To compare the olfactory bulb volumes (OBVs) in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) to healthy individuals, and to assess the changes of the OBVs in patients with CRSwNP before and after the endoscopic sinus surgery (ESS) utilising magnetic resonance imaging (MRI) with specialised software.

DESIGN

This is a prospective cohort study.

SETTING

Tanta University hospital (tertiary referral hospital), Egypt.

PARTICIPANTS

Thirty patients with CRSwNP (Group A) were compared with thirty healthy individuals (Group B) as regards the OBVs. Patients with CRSwNP underwent ESS where the Smell Identification Test-40 (SIT-40) and the OBVs were assessed pre-operatively and at least 6 months postoperatively. Assessment of the OBVs was carried out using MRI with specialised software.

MAIN OUTCOME MEASURES

Assessment of the volumetric changes of the olfactory bulbs in patients with CRSwNP before and after endoscopic sinus surgery utilise magnetic resonance imaging.

RESULTS

The OBVs were significantly smaller in Group A (58.94 ± 7.96 mm³ and 60.79 ± 8.14 mm³ on the right and left sides, respectively) as compared with the Group B (73.46 ± 8.54 mm³ and 72.96 ± 9.74 mm³ on the right and left sides, respectively). There was also a significant increase in the olfactory bulb volumes as well as improvement of the SIT-40 6 months postoperatively in the Group A.

CONCLUSIONS

The olfactory bulb is characterised by neural plasticity, and its volume may be affected by the peripheral olfactory function.

Standardized letters of recommendation and successful match into otolaryngology

OBJECTIVES/HYPOTHESIS

Historically, narrative letters of recommendation have been utilized in the selection of applicants for otolaryngology residency programs. In the last two application cycles, our specialty adopted a standardized letter of recommendation (SLOR). The intent was to decrease time burden for letter writers and to provide readers with an objective evaluation of applicants. The objective of this study was to determine attributes in the SLOR that correlate with matching into a residency program.

STUDY DESIGN

We performed a retrospective study using SLOR, United States Medical Licensing Examination (USMLE) step 1 scores, and matched outcomes of applicants who applied to our institution for the 2013 and 2014 match cycle.

METHODS

We included the following variables from the SLOR in the statistical analysis to determine which ones were associated with matching: patient care, medical knowledge, communication skills, procedural skills, research, initiative and drive, commitment to otolaryngology, commitment to academic medicine, match potential, and USMLE1 scores.

RESULTS

We identified 532 applicants and 963 SLOR. In successful applicants, scores for patient care, medical knowledge, communication skills, initiative and drive, and match potential were statistically higher (P < 0.05). Scores for professionalism, procedural skills, research, commitment to otolaryngology, commitment to academic medicine, and USMLE step 1 scores were not higher among successfully matched applicants.

CONCLUSION

Although SLOR can save time for letter writers and provide an objective description of applicants, the utility of individual domains within the SLOR is questionable. Additionally, it is concerning that applicants' professionalism and procedural skills are not correlated with matching in our specialty.

LEVEL OF EVIDENCE

NA. Laryngoscope, 126:1071-1076, 2016.

Depression and anxiety in chronic rhinosinusitis

BACKGROUND

Both depression and anxiety have been suspected to impact quality of life adversely in patients with chronic rhinosinusitis (CRS). The objective of this work was to assess for the presence of anxiety and/or depression in the setting of CRS and to assess their impact on disease-related quality of life by analyzing the correlation between the Rhinosinusitis Disability Index (RSDI) and the Hospital Anxiety and Depression score (HADS), as well as the Lund-Kennedy nasal endoscopic scores.

METHODS

A total of 124 patients with CRS were prospectively evaluated in the outpatient setting using the RSDI and HADS questionnaires as well as the Lund-Kennedy nasal endoscopy scoring system.

RESULTS

The total RSDI and its subscale scores had moderate to very strong correlation with the HADS total score and each of its subscale scores in comparison to their poor correlation with Lund-Kennedy endoscopic score. CRS patients with depression or anxiety scores 8 to 10 (possible case of clinically significant depression or anxiety) and 11 to 21 (probable case) reported worse total RSDI and subscale scores when compared with those with normal scores (0 to 7). There was no significant difference in the Lund-Kennedy endoscopic scores between the different groups of anxiety and depression scores.

CONCLUSION

Depression and anxiety are prevalent in CRS. The total RSDI and its different subscale scores exhibit moderate to very strong correlation with depression/anxiety scores as determined by HADS, whereas poor correlation was seen with the Lund-Kennedy endoscopic score.

Endoscopic Management of Chronic Frontal Sinusitis: Prospective Quality of Life Analysis

BACKGROUND

Previous studies of endoscopic frontal sinus surgery have been primarily retrospective and focused on symptom relief only.

OBJECTIVES

To prospectively assess the impact of endoscopic frontal sinus surgery on frontal sinus ostium patency and disease-specific quality of life as measured by the Rhinosinusitis Disability Index (RSDI).

STUDY DESIGN

A 60-patient cohort with chronic frontal sinusitis (100 diseased frontal sinuses) was prospectively evaluated using the RSDI, computed tomography (CT) imaging, and endoscopic examination. Image-guided endoscopic frontal sinusotomy (Draf 2a) was performed in each case. Patients were assessed with RSDI and endoscopic assessment at least 6 months postoperatively.

RESULTS

At a mean follow-up of 10 months, endoscopic assessment revealed patent frontal recesses in 90 of 100 frontal sinuses (90%), with significant improvement in the total RSDI score (41.98 ± 26.48 preoperatively to 17.15 ± 15.66 postoperatively) as well as each of its physical, emotional, and functional subscales from 16.3 ± 9.03, 12.23 ± 10.55, 13.45 ± 9.59 preoperatively to 5.95 ± 5.71, 5.55 ± 5.66, 5.65 ± 5.72 postoperatively, respectively. Similar improvement was seen in patients with asthma, polyps, and those undergoing revision sinus surgeries.

CONCLUSIONS

With frontal recess mucosal preservation and meticulous postoperative endoscopic surveillance, endoscopic frontal sinusotomy results in high rates of frontal sinus ostium patency with significant improvement in quality of life.

Use of a Foley catheter balloon as a tool during endoscopic frontal sinus surgery in a resource-poor environment

OBJECTIVE

This study aimed to evaluate the non-Food and Drug Administration-approved off-label use of a 10F Foley catheter as a tool during endoscopic frontal sinus surgery.

METHOD

A cohort of 40 patients with chronic frontal rhinosinusitis was prospectively evaluated using the Sino-Nasal Outcome Test (SNOT-22), computed tomography (CT) imaging, and endoscopic examination. Endoscopic sinus surgery (ESS) was performed in the usual fashion, however, when approaching the frontal sinus, a 10F Foley catheter was inserted and the balloon inflated in the frontal outflow. Patients were assessed postoperatively with SNOT-22, CT imaging, and endoscopic assessment at 6 months.

RESULTS

Successful intraoperative dilation of the frontal recess was achieved in 62 of 69 frontal sinuses (90%). No cerebrospinal fluid leak or orbital entry occurred. Six months postoperative, SNOT-22 scores showed significant improvement, whereas endoscopic assessment revealed patent frontal recess in 55 of 62 (89%) frontal sinuses. Computed tomography imaging was completed in 25 patients comprising 41 operated frontal sinuses with no mucosal thickening seen in 37 of 41 (90%).

CONCLUSION

The 10F Foley catheter is an effective tool to dilate the frontal recess by compression of edema during ESS. It may be a safe and cost-effective alternative to high-cost commercially available sinus balloons, especially in resource-poor environments.