Nationwide survey on the use of image-guided functional endoscopic sinus surgery.

OBJECTIVE: To evaluate impressions and usage of sinus surgery image-guided surgical (IGS) systems by ENT surgeons in the United States. STUDY DESIGN AND SETTING: A survey was mailed to selected practicing ENT physicians, investigating regional information, practice type, IGS usage patterns, perceived benefits and limitations, and usage of the 61795 surgery code. RESULTS: Seventy-three percent of respondents use IGS. Nonusers respond that it provides no benefit or is too expensive. Eighty percent of respondents replied that IGS may allow for increased safety in certain procedures. Most users attempt reimbursement with the 61795 code. CONCLUSION: IGS usage is increasing but appears to be perceived as expensive and nonbeneficial in certain situations. Most respondents, however, felt that IGS may lead to safer surgery in certain situations, including revision and frontal procedures. Several factors appear to limit routine use including ease of use, technical setup, code reimbursement, and initial purchase costs. SIGNIFICANCE: IGS use appears to be increasing. The most frequent users appear to agree with the previously issued AAO-HNS guidelines regarding appropriate indications. Expanded use may depend on ease of use, reimbursement, and affordability. EBM rating: D-5.     

Patient expectations and recovery following endoscopic sinus surgery.

OBJECTIVES: Studies examining the early postoperative period after endoscopic sinus surgery (ESS) are lacking. The objectives were to determine patient expectations of recovery following ESS and compare these expectations to actual outcomes. STUDY DESIGN: A prospective study. An 11-item survey regarding recovery from anesthesia and sinonasal outcomes was administered after ESS over postoperative days (POD) #1, #7, and #14. Preoperative surveys established baseline levels and explored patient expectations of POD #1 outcomes. RESULTS: Forty-six patients participated. Individual expectations generally did not correlate with POD #1 outcomes. Sinonasal symptoms, narcotic usage, and activity level (P < 0.05) demonstrated significant improvement over the postoperative period. Within one week, 75% of patients returned to work. By POD #14, nasal obstruction, discharge, fatigue, and overall health (P < 0.05) had improved over preoperative levels. Patients undergoing concomitant septoplasty had a more difficult postoperative course. CONCLUSION: Patient expectations of ESS vary widely, although this surgery is generally well tolerated with a brief recovery period. EBM rating: C-4.     

Airway complication following functional endoscopic sinus surgery

Difficulty breathing after upper airway surgery requires immediate evaluation and treatment. We present a case of airway compromise after sinus surgery due to edema of the uvula. The patient was admitted for observation overnight and discharged the next day. A discussion of potential airway changes after sinonasal surgery is presented.     

Ocular motility complications after endoscopic sinus surgery with powered cutting instruments.

OBJECTIVE: The purpose of this study was to describe 2 unique cases of ocular motility dysfunction after powered endoscopic sinus surgery and identify potential risk factors for extraocular muscle injury. STUDY DESIGN: Interventional case series. RESULTS: Patient 1 developed a restrictive global ophthalmoplegia after inadvertent entry into the medial orbit during powered endoscopic sinus surgery. Patient 2 had complete loss of adduction of the left eye as a result of transection of the medial rectus muscle by a powered cutting instrument. CONCLUSIONS: Despite advances in endoscopic sinus surgery technique and instrumentation, serious ophthalmic complications may still occur. Inadvertent entry into the medial orbital wall can result in ocular motility complications. Furthermore, it is possible that attraction of orbital contents into the tip of a powered cutting instrument may occur without significant entry into the orbital cavity. SIGNIFICANCE: It is important for endoscopic sinus surgeons to be aware of the intimate anatomical relationship between the orbit and sinuses, as well as the potential risks of the current instruments used in endoscopic sinus surgery.     

Image-guided functional endoscopic sinus surgery.

INTRODUCTION: Computer-aided surgery (CAS) technology in functional endoscopic sinus surgery (FESS) has engendered considerable discussion. OBJECTIVE: The goals of this study were to describe CAS preoperative planning (software-based CT image analysis) and to develop intraoperative CAS strategies for endoscopic sinus surgery. Study Design: Between October 1, 1997, and December 31, 1998, the StealthStation (Sofamor Danek, Memphis, TN) was used in 61 FESS cases, and a retrospective review of the findings was performed. The indication for surgery in all instances was chronic rhinosinusitis refractory to medical management. The StealthStation was used to review all CT scans before surgery. Anatomic fiducial registration supplemented by contour mapping was used. RESULTS: Localization accuracy was estimated to be within 2 mm or better. The StealthStation was used for both CT image review and intraoperative localization. CAS was useful in the frontal recess, sphenoethmoid region, posterior ethmoid system, and skull base area. CAS was deemed helpful in situations where the surgical anatomy was altered by previous surgery and extensive inflammatory disease (polyposis, fungal sinusitis, and pansinusitis). CONCLUSION: The paradigm of image-guided FESS surgery, which integrates CAS into FESS, will serve to increase surgical effectiveness and decrease surgical morbidity.     

Outcome predictors for endoscopic sinus surgery.

OBJECTIVE: The outcomes management of endoscopic sinus surgery (ESS) is a major effort to improve the quality of chronic sinusitis treatment. The objective of this study was to investigate the factors that may predict a variety of outcomes of ESS. STUDY DESIGN AND SETTING: Two hundred and thirty consecutive patients who underwent ESS were prospectively evaluated by computerized axial tomography scan of the sinus and a validated chronic sinusitis survey (CSS) before surgery. The effects of prognostic factors were then investigated. RESULTS: Extent of disease was a consistent predictor (P < 0.05) for bleeding, complication occurrence, medical resource utilization, subjective sinus-specific health status, and physicians' objective evaluation of surgical outcomes. The preoperative CSS total score and extent of disease significantly (P < 0.05) predicted the postoperative CSS total score. Subjective and objective outcomes were significantly correlated (r = 0.58, P = 0.0001). These findings suggested the necessity of disease severity stratification when reporting ESS outcomes. CONCLUSION: Operation-related events, medical resource utilization, physician evaluation, and sinus-specific health status of patients are all integral parts of reporting outcomes of ESS. We have concluded that computerized axial tomography scan of the sinuses and CSS are efficient ways of providing reliable baseline information before ESS.     

Measuring competence in endoscopic sinus surgery.

BACKGROUND: Competence based education is currently being introduced into higher surgical training in the UK. Valid and reliable performance assessment tools are essential to ensure competencies are achieved. No such tools have yet been reported in the UK literature. OBJECTIVE: We sought to develop and pilot test an Endoscopic Sinus Surgery Competence Assessment Tool (ESSCAT). The ESSCAT was designed for in-theatre assessment of higher surgical trainees in the UK. METHODS: The ESSCAT rating matrix was developed through task analysis of ESS procedures. All otolaryngology consultants and specialist registrars in Scotland were given the opportunity to contribute to its refinement. Two cycles of in-theatre testing were used to ensure utility and gather quantitative data on validity and reliability. Videos of trainees performing surgery were used in establishing inter-rater reliability. RESULTS: National consultation, the consensus derived minimum standard of performance, Cronbach's alpha = 0.89 and demonstration of trainee learning (p = 0.027) during the in vivo application of the ESSCAT suggest a high level of validity. Inter-rater reliability was moderate for competence decisions (Cohen's Kappa = 0.5) and good for total scores (Intra-Class Correlation Co-efficient = 0.63). Intra-rater reliability was good for both competence decisions (Kappa = 0.67) and total scores (Kendall's Tau-b = 0.73). CONCLUSION: The ESSCAT generates a valid and reliable assessment of trainees' in-theatre performance of endoscopic sinus surgery. In conjunction with ongoing evaluation of the instrument we recommend the use of the ESSCAT in higher specialist training in otolaryngology in the UK.     

Cost-utility analysis for endoscopic sinus surgery.

OBJECTIVE: To undertake cost-utility analysis for endoscopic sinus surgery (ESS) in order to analyze the cost-effectiveness of different chronic sinusitis severity groups. METHODS: One hundred ninety-two patients with chronic sinusitis were evaluated with a Chronic Sinusitis Survey (CSS) before and 1-year after ESS. Direct health care cost data during the first year after operation were retrieved. The utility gain is defined as change in the CSS total score. The cost-utility ratio was defined as cost per utility gain. Patients are stratified by disease severity using the Harvard Staging System. RESULTS: The average total direct cost attributable to ESS is 40,829 NT dollars in the first postoperative year and the average cost-utility ratio is 2194.42 NT dollars. The high cost-utility ratio of 3246.45 NT dollars for pansinusitis cases is due to the higher cost and limited utility gain. CONCLUSIONS: Treating mild and moderate chronic sinusitis are most cost-effective because of their favorable utility gain and relatively reasonable cost. However, there is no proportional linear relationship between disease severity and cost-utility ratio.     

Partial endoscopic middle turbinectomy augmenting functional endoscopic sinus surgery.

Endoscopic sinus surgery has gained acceptance in the otolaryngologic community as an effective and safe method of treating inflammatory disease of the paranasal sinuses. At our institution, partial endoscopic middle turbinectomy has become a standard component of the procedure and our experience is reported. Middle turbinectomy enhances surgical exposure, specific anatomic anomalies are more completely corrected, and subpopulations of patients at risk for failure because of their underlying disease enjoy decreased rates of synechiae formation and closure of the middle meatus antrostomy when followed over time. Photodocumentation of the surgical technique and a discussion regarding the impact of middle turbinectomy on normal nasal physiology are presented. It is reported that the procedure is safe, and no complications directly attributable to middle turbinectomy (including atrophic rhinitis) are reported in a series of 298 patients.     

Quality of life following lung cancer surgery

BACKGROUND: Patients with non-small cell bronchogenic carcinoma have a limited survival. Quality of life (QoL) is therefore an issue of importance in this group of patients. The aim of the present study was to evaluate QoL in lung cancer patients after open surgery. METHODS: During a 4 year period (1997-2000) 194 patients with primary bronchogenic carcinoma of the lung underwent surgery at the Department of Thoracic and Cardiovascular Surgery in Uppsala, Sweden; 132 patients were alive on 1 April 2001. These patients received the Short Form-36 (SF-36) health questionnaire, Hospital Anxiety and Depression (HAD) scale, and special questions related to pulmonary symptoms (response rate 85%). Patients who underwent coronary bypass surgery (CABG) served as a comparison group (response rate 91%). Corresponding estimates of QoL in healthy controls were obtained from the SF-36 manual for the Swedish population. RESULTS: Lung cancer patients differed from CABG patients in only one subgroup of the SF-36 (role physical), but had poorer QoL than healthy controls. No difference in anxiety was found between the lung cancer patients and the CABG patients, but the latter were more likely to suffer from depression (5.0% v 3.0%). Current smokers scored lower in the mental health dimension assessment. CONCLUSION: Lung cancer patients who undergo open traditional surgical resection have a QoL comparable to that of CABG patients. Lung cancer patients have poorer physical function because of reduced pulmonary function, but show no sign of increased anxiety or depression. Those who continued to smoke after surgery had impaired mental health.     

Quality of life following surgery for abdominal aortic aneurysm.

Repair of abdominal aortic aneurysm (AAA) carries a considerable rate of morbidity and mortality, but little information exists on the quality of life following this procedure. During 1988 and 1989, in two hospitals, 211 patients (186 men and 25 women; median age 74 (range 48-87) years) underwent surgery for AAA. There were 77 ruptured aneurysms and 134 electively repaired. Of these, 38 patients died in hospital (27 ruptured, 11 elective); by the time of review a further eight (one ruptured, seven elective) had died from unrelated causes. Of the 165 survivors, 131 (45 ruptured, 86 elective) were reviewed and questioned as to their physical and mental state before and after surgery. Using the Rosser index, a value for quality of life before and after surgery was calculated (1.0, good; 0, dead). The value for the elective group was 0.94 before operation and 0.96 after, but in the ruptured group fell from 0.98 before surgery to 0.87 afterwards. This study shows that patients undergoing elective surgery for repair of AAA retain good quality of life. By contrast, patients surviving emergency surgery following this procedure seem to suffer a deterioration in life quality, which must be endured for the same expected lifetime as that for the elective group. These results support the need for a national AAA ultrasonographic screening programme.     

Combined open septorhinoplasty and functional endoscopic sinus surgery.

OBJECTIVE: To compare perioperative and early postoperative complication rates of performing open septorhinoplasty (OSR) and functional endoscopic sinus surgery (FESS) concomitantly or individually. STUDY DESIGN AND SETTING: Retrospective chart review of 55 patients treated at an academic referral center who had undergone combined OSR and FESS. Complication rates for the combined procedures were compared with published complication rates for the individual procedures. RESULTS: Patients' ages ranged from 14 to 77 years (average, 43 years). Among the 55 cases, there were no major complications and 6 (11%) minor complications: 4 cases of cellulitis (7%; previously published risk, 1%-3%) and 2 cases of postoperative epistaxis (4%). CONCLUSION: OSR and FESS may be performed safely in combination without a clinically significant increased risk of complications. SIGNIFICANCE: The slightly increased risk of cellulitis may warrant the use of intraoperative sinus irrigation and postoperative antibiotic prophylaxis after combined OSR and FESS.     

Anaesthesia for endoscopic sinus surgery

Endoscopic sinus surgery is commonly performed and has a low risk of major complications. Intraoperative bleeding impairs surgical conditions and increases the risk of complications. Remifentanil appears to produce better surgical conditions than other opioid analgesics, and total intravenous anaesthesia with propofol may provide superior conditions to a volatile‐based technique. Moderate hypotension with intraoperative β blockade is associated with better operating conditions than when vasodilating agents are used. Tight control of CO₂ does not affect the surgical view. The use of a laryngeal mask may be associated with improved surgical conditions and a smoother emergence. It provides airway protection equivalent to that provided by an endotracheal tube in well‐selected patients, but offers less protection from gastric regurgitation. Post‐operatively, multimodal oral analgesia provides good pain relief, while long‐acting local anaesthetics have been shown not to improve analgesia.     

New endoscopic instruments for paranasal sinus surgery.

BACKGROUND: Minimally invasive endoscopic and microscopic procedures represent state of the art paranasal sinus surgery techniques in both diagnostic and surgical fields. To combine favorable aspects of both techniques, we evaluated the clinical applicability and effectiveness of multifunctional microendoscopes, providing multiple features to ensure highest accuracy and surveillance when performing crucial steps in paranasal sinus surgery. METHODS: The study included both anatomic experiments on cadaveric heads and clinical tests on patients undergoing routine paranasal surgery. The systems applicability was evaluated in procedures approaching the frontal and sphenoid sinus. Three different endoscopes, 2 straight and the other 1 with a 90 degrees angle, were tested. They integrate canals for flushing and suction and a working canal for either drilling or obtaining biopsies with a miniaturized forceps. For stereotactic feedback, the applicability in combination with a computer-navigation system was evaluated. RESULTS: Anatomic tests were performed to optimize illumination and to test drilling features and forceps biopsies. In all cases, the frontal sinus ostium and the sphenoid sinus anterior wall was easily identified and enlarged by drilling under visual and stereotactic control. Continuous suction and irrigation ensured a constant visual surveillance by removing drilling debris and blood. Best suited for multifunctional endoscopic surgery were drill heads with a cylinder shape, for placing bore holes along the Z axis, and spherical drill heads, for furbishing and enlarging drill holes. CONCLUSION: These new instruments have proven their applicability in paranasal sinus surgery. Multifunctional endoscopic procedures were deemed best suited for maneuvers requiring highest precision, such as the surgery of the frontal and sphenoid sinus.     

Hemorrhagic vascular complications of endoscopic transsphenoidal surgery.

Two hundred and fifty consecutive patients operated on by an endoscopic endonasal transsphenoidal approach were retrospectively analyzed in order to evaluate hemorrhagic vascular complications occurring during or after the surgical procedure and their appropriate management. Vascular complications of endoscopic transsphenoidal surgery are identical to those of a microsurgical transsphenoidal approach. Damage to the sphenopalatine artery and to the internal carotid artery (ICA), which are the most frequent vascular troubles, may require technical tricks because of some aspects connected to the approach itself and of the physical properties of the endoscope. Furthermore, the progress in interventional neuroradiology in the last decades offers new solutions in respect to the past, where the use of the surgical microscope was already a tremendous progress. The anatomic substrate of each complication is discussed, along with the peculiar surgical details related to it.