Prognostic factors of pediatric endoscopic sinus surgery

OBJECTIVE: Pediatric endoscopic sinus surgery (ESS) is performed for refractory cases of rhinosinusitis that do not respond to medical management. However, few studies have been reported for the prognostic factors affecting the outcomes of pediatric ESS. The aim of this study was to investigate the prognostic factors affecting the outcomes of pediatric ESS. MATERIALS AND METHOD: Medical records of 97 pediatric patients who had undergone ESS from February 1995 to October 2003 were reviewed retrospectively. We classified the patients into two groups based on outcome, i.e., either good or poor, according to the postoperative endoscopic findings. Then univariate and multivariate analyses were performed to compare the following nine characteristics between the good and poor outcome groups: the presence of allergy, bronchial asthma, adenotonsillar hypertrophy, history of previous sinus surgery, presence of a smoker in the family, degree of polyposis, preoperative disease extent scored by CT scan findings, blood eosinophil count, and eosinophil infiltration in the nasal mucosa. RESULT: The overall success rate was 70% based on the objective postoperative endoscopic finding. Statistical differences were found between the good and poor groups in terms of the degree of preoperative polyposis and CT staging in univariate analysis, whilst in multivariate logistic regression analysis severe polyposis and indirect smoking predicted poor outcome after pediatric ESS. CONCLUSION: Pediatric ESS with severe polyposis, high CT rhinosinusitis staging, or indirect smoking predisposes to a poorer outcome. This needs to be taken into consideration when performing ESS for children.     

The role of endoscopic sinus surgery in chronic sinonasal sarcoidosis

The aim of this study was to define a role for endoscopic sinus surgery (ESS) in the treatment of chronic sinonasal sarcoidosis. All patients seen for sinonasal sarcoidosis in an otolaryngology practice in a tertiary care center from 1991 to 2000 were reviewed. Of 86 patients, 6 were treated with ESS for an operative rate of 7%. Surgeries were performed on those patients with significant sinonasal anatomic blockage. This included nasal obstruction from nasal polyposis and chronic and recurrent acute sinusitis from granulomatous lesions of the ostiomeatal complex. Patients remained symptom free for years after surgery on a nasal steroid regimen. Endoscopic sinus surgery is a viable treatment for those few patients with nasal obstruction or chronic sinusitis due to anatomic blockage from sinonasal sarcoidosis. Although it does not eradicate the disease or prevent recurrence, it does markedly improve quality of life by relieving severe symptoms and reducing the need for systemic steroids. This is the first study to advocate a role for surgery in sinonasal sarcoidosis beyond biopsy and management of complications. Although it may not be the appropriate approach for every patient, ESS certainly should be considered in the treatment options.     

Outcomes of endoscopic sinus surgery for chronic rhinosinusitis associated with sinonasal polyposis

BACKGROUND: The aim of this study was is to investigate the outcomes of endoscopic sinus surgery (ESS) when performed for chronic rhinosinusitis associated with sinonasal polyps. METHODS: Forty-three patients with polyps were compared with 76 patients without polyps before and after ESS. Mean follow-up was 1.5 years. Patients were analyzed prospectively based on computed tomography (CT), endoscopy, quality-of-life (QOL) assessment, and visual analog scales (VASs). Univariate analyses were performed to evaluate whether the presence of polyps was predictive of outcome. RESULTS: Patients with polyps had worse CT and endoscopy scores both pre- and postoperatively when compared with patients without polyps (p < 0.0001 for each). All patients, regardless of polyps, improved on endoscopic exam; however, patients with polyps showed a greater degree of improvement (p = 0.002). Despite this, postoperative endoscopic scores in patients with polyps were worse than those without polyps (p < 0.0001). Patients with polyps had better QOL as measured by the Chronic Sinusitis Survey (CSS) both pre- and postoperatively (p = 0.001 and 0.044, respectively). The preoperative VAS indicated that patients with polyps had increased nasal obstruction compared with patients without polyps (p = 0.002) while having less facial pain and headache (p = 0.002 and 0.005, respectively). Patients with polyps showed a greater postoperative improvement in nasal congestion (p = 0.003) but no difference in level of improvement in postoperative headache or pressure. CONCLUSION: Despite significantly worse objective testing scores, patients with polyps report significantly better QOL as measured by the CSS and less facial pain/headache as measured by VAS scores pre- and postoperatively. Polyps were not found to be predictive of QOL or endoscopic outcome.     

Role of intraoperative CT-updates during image-guided endoscopic sinus surgery for sinonasal fibro-osseous lesions

Fibrous dysplasia, ossifying fibroma and osteomas are collectively known as fibro-osseous lesions. Occurrence in the sinonasal region is rare, and its management can be technically challenging. We report a case of an 8-year-old female with cemento-ossifying fibroma of the ethmoid sinus who underwent a two-staged, endoscopically assisted, transfacial resection of the lesion and a 31-year-old male with fibrous dysplasia of the ethmoid sinus who underwent endoscopic removal of the tumor. Both cases utilized intraoperative computed tomography (CT)-updated image-guided systems (IGS) to improve surgical precision. In the second patient, further resection was undertaken after CT-update in the same surgery. The postoperative courses were uneventful, and at 1-year follow-up no tumor recurrence was observed in either patient. Our experience suggested that the use of intraoperative CT-updated IGS in endoscopic or endoscopically assisted surgeries for sinonasal fibro-osseous lesions will lead to more optimal tumor control, which can translate into greater patient safety.     

Endoscopic sinus surgery for sinonasal haemangiopericytomas

Haemangiopericytomas are rare peri-vascular tumours with variable malignant potential. The nasal cavity and the paranasal sinuses are most often involved in the head and neck. Five cases of haemangiopericytomas treated by a strict endonasal endoscopic approach are presented. Bleeding and nasal obstruction are the most frequent symptoms. Computed tomography (CT) scan and magnetic resonance imaging (MRI) allowed pre-operative assessment. Angiography with embolization was needed in two of the five cases. None of our patients presented with malignant histology. Our five cases were operated on, and a total tumour excision was performed through the endoscopic endonasal approach. We had one recurrence with a mean follow-up of 4.5 years. We suggest that when the tumour is purely intranasal or strictly located in the ethmoid or sphenoid sinus, it can be removed via an endonasal approach under endoscopic guidance in experienced hands.     

Sleep quality after endoscopic sinus surgery in patients with sinonasal polyposis

ObjectivesEvaluate the effect of functional endoscopic sinus surgery (FESS) for nasal polyposis on sleep efficiency and polysomnographic parameters.Subjects and methodsThis clinical trial was conducted on 15 patients with bilateral massive sinonasal polyposis who underwent FESS between August 2012 and September 2013. All participants were evaluated subjectively by employing the Pittsburgh Sleep Quality Index (PSQI) questionnaire and objectively (provided by polysomnographic parameters) before and 2 months after surgery.ResultsThe evaluation of subjective criteria of sleep quality assessed by PSQI showed significant improvement, particularly in nocturnal awakening (P = 0.002). However, Apnea Hypopnea Index (AHI) was not reduced significantly after surgery (P = 0.233). Among patients who had suffered from obstructive sleep apnea, AHI was improved in 7 patients, deteriorated in 3 patients, and did not change in 1 patient. Although the mean duration of REM sleep stage increased from 15.2 ± 10.7 to 18.9 ± 7.9, this change was not statistically significant. Furthermore, arousal index decreased dramatically from 31.6 to 17.1 (P = 0.02) and sleep efficiency index was improved after the surgery (P = 0.008).ConclusionsThis study documented the effect of resuming nasal cavity patency on improvement of sleep efficiency after FESS. In spite of insignificant effect of FESS on apnea index, alteration of other sleep parameters like arousal index following surgery may have a positive effect on sleep quality.     

Powered versus conventional endoscopic sinus surgery instruments in management of sinonasal polyposis

To conduct a prospective randomized controlled trial investigating the efficacy and safety of powered versus conventional endoscopic sinus surgery instruments in the management of sinonasal polyposis. Two hundred patients with sinonasal polyposis who failed conservative therapy were included in the study. They were equally randomized into powered and conventional instruments groups. A subjective visual analogue scale (VAS), endoscopic examination, saccharine clearance time and coronal CT were done preoperatively. Intraoperatively, the operative time, the surgical conditions and degrees of dryness of the operative field were carefully rated and recorded. Postoperatively, VAS, polyp grades, saccharine clearance time, the number of endoscopic debridement and time to mucosalization were recorded. Complications, smoothness of postoperative course were reported. Both groups experienced a significant improvement in the VAS with no statistically significant difference in symptom improvement between the two groups except for olfaction where there was significant improvement in the powered group. Similarly, the two groups demonstrated a significant improvement in the objective parameters including polyp grade and saccharine clearance time changes, but no significant difference between the two groups was found. The operative time as well as the surgical conditions and dryness of the operative field score were significantly better in the powered group. There was a tendency for improvement in the number of endoscopic debridement and time to mucosalization in powered group when compared to conventional instruments group, but this did not reach statistical significance. The incidence of postoperative synechiae was significantly lower in powered endoscopic group. Powered endoscopic sinus surgery offers a better therapeutic approach for patients with sinonasal polyposis when compared to endoscopic surgery with the conventional instruments. It provides a bloodless dry operative field with better visualization for a more precise, less traumatic procedure with minimal intraoperative complications and shorter operative time. Additionally, patients have a smoother postoperative course, less incidence of synechiae, with a tendency for a faster healing.     

鼻内镜鼻窦手术中鼻腔鼻窦解剖变异与慢性鼻窦炎的关系

目的 探讨鼻内镜鼻窦手术中鼻腔鼻窦解剖变异与慢性鼻窦炎的关系。 方法 选取慢性鼻窦炎患者206例,根据是否患有慢性鼻窦炎分为观察组85例与对照组121例。记录两组患者是否存在鼻中隔偏曲、泡状中鼻甲、下鼻甲及鼻丘气房肥大、中鼻甲反向偏曲及钩突气化等鼻腔鼻窦解剖变异现象。 结果 观察组鼻中隔偏曲、下鼻甲及鼻丘气房肥大、泡状中鼻甲发生率均显著高于对照组(P<0.05),而中鼻甲反向偏曲及钩突气化发生率比较无显著差异(P>0.05)。两组鼻中隔偏曲均以高位偏曲为主,但观察组鼻中隔高位偏曲发生率显著高于对照组(P<0.05)。 结论 鼻中隔偏曲、泡状中鼻甲、鼻丘气房及下鼻甲肥大均为慢性鼻窦炎发展中的重要结构变异,与慢性鼻窦炎的发生密切相关。     

内镜鼻窦手术后Rhino凝胶填塞效果的观察

目的 前瞻性比较新型鼻腔填塞材料Rhino凝胶与传统填塞物用于内镜鼻窦手术后填塞的效果.方法 对双侧病变基本对称,手术范围基本相同的24例慢性鼻窦炎患者行内镜鼻窦手术,术后右侧鼻腔以Rhino凝胶填塞(观察组),左侧鼻腔以藻酸钙+油纱条填塞(对照组).术后1日抽取对照侧填充物,观察侧凝胶保留至术后1周第1次内镜复查时清理,鼻腔冲洗、鼻喷糖皮质激素等其他局部处理双侧鼻腔相同.采用视觉模拟量表(visual analog scale,VAS)记录两侧鼻腔术后当天(填塞期)、术后第1天(抽取左侧填充物时)、术后第2天(抽取左侧填充物后)患者鼻痛、鼻堵程度,分泌物、渗血、流泪量,以及术后内镜复查术腔恢复情况(干痂、分泌物、反应膜、黏膜水肿、囊泡、窦口阻塞),并对两组上述11项观察项目评分和上皮化时间进行比较.结果 苏醒时因血压过高,凝胶侧鼻腔出血改用纱条填塞1例;外地患者失访2例.余21例完成2～20个月的随访.术后当天、术后第1天鼻痛,术后当天流泪评分,Rhino组<对照组(Z值分别为-3.575、-3.546、-2.736,P值均<0.05);术后第1天渗血评分,Rhino组<对照组(Z=-3.075,P<0.05);术后1周术腔干痂评分,Rhino组<对照组(Z=-2.103,P<0.05);其余各项评分差异无统计学意义;凝胶侧术腔平均上皮化时间为(10.7±2.6)周,对照侧为(10.6±2.9)周,两组差异无统计学意义(t=-0.146,P=0.886).结论 Rhino凝胶可减轻患者鼻腔填塞期的不适,并可避免专门撤除填充物造成的痛苦和出血,较传统方法有明显的优越性.在促进术腔恢复方面与传统方式相当.     

Improvement of sinonasal mucociliary function by endoscopic sinus surgery in patients with chronic rhinosinusitis

Objectives

Mucociliary clearance is an important defense mechanism for upper and lower airway. Chronic rhinosinusitis has been frequently associated with mucociliary dysfunction. Endoscopic sinus surgery (ESS) is recommended for treatment-resistant sinusitis in order to improve mucociliary function. The present study investigated the effect of ESS on the saccharin time (mucociliary clearance time) in relation to symptom profile assessed by the Sino-nasal Outcome Test (SNOT)-22, and disease severity based on the Lund-Kennedy endoscopic scores and Lund-Mackay computed tomographic (CT) scores.

Anatomy for endoscopic sinus surgery

An understanding of the anatomy of the paranasal sinuses is essential for successful endoscopic sinus surgery. The anatomy of the sinuses is carefully described and illustrated.     

Image-guidance for endoscopic sinus surgery

Objectives/Hypothesis: Image‐guided surgery (IGS) is a critical tool. However, its clinical validity remains controversial. A review of indications and a consensus based on literature are presented. Methods: Literature review. Results: Traditional indications remain valid. Novel applications have emerged, and the reliability of IGS has been consistently endorsed. Although evidence is based on scattered reports and expert opinions, the use of IGS in approved instances is regarded as the state of the art. Conclusions: IGS is reliable, and a scientific validation of outcomes would entail unethical strategies. An expanding spectrum of indications is anticipated, although IGS does not replace proper training.     

Nonsurgical versus endoscopic sinonasal surgery for rhinogenic headache

Headaches of sinonasal origin have been described lately. Terms such as middle turbinate syndrome have been used to describe this entity. The true incidence of this headache is unknown. A concha bullosa or a hypertrophied middle turbinate have been associated with these cases. Mucosal contact between the middle turbinate and the nasal septum or the lateral wall of the nose have been attributed as the cause of referred pain in the face. We present data on 23 individuals with refractory primary headache in the absence of any significant sinus symptoms. The duration of the symptoms of these individuals ranged between 4 and 13 years with a mean of 7.2 years. Fifteen patients agreed to undergo surgery, whereas eight refused surgery. After a mean of 23 months of follow-up, all those who did not have surgery continued to have pain that required excessive medications, whereas 60% of those who had surgery reported marked relief of their headaches. Those who had symptoms for less than 7 years had a greater chance of success (OR = 2). Sinonasal surgery seems to be helpful in alleviating primary headaches, especially in individuals whose duration of symptoms is less than 7 years.     

Partial middle turbinectomy during endoscopic sinus surgery for extended sinonasal polyposis: short- and mid-term outcomes

Conclusions. The 23 patients with extensive sinonasal polyposis who had undergone partial resection of the middle turbinate during functional endoscopic sinus surgery (FESS) showed no differences in nasal airway resistance and in postoperative complication rate (1-year follow-up period) in comparison with the 25 patients who had FESS with middle turbinate preservation. Objective. The aim of the study was to investigate the outcomes of partial middle turbinectomy during FESS in patients with sinonasal polyposis. Patients and methods. A retrospective analysis of 48 consecutive patients who had undergone surgery for extended sinonasal polyposis was performed. Twenty-three patients underwent FESS with middle turbinate head resection; 25 patients underwent FESS with preservation of middle turbinate. We endoscopically scored polyposis extension and evaluated nasal airflow resistance (NAR) preoperatively and postoperatively. Results. We found an improvement of endoscopic score (high to low grade of polyposis extension) and a statistically significant reduction of NAR after both surgical techniques. There was no statistically significant difference in the mean NAR values before and after the two techniques.     

Partial middle turbinectomy during endoscopic sinus surgery for extended sinonasal polyposis: short- and mid-term outcomes

CONCLUSIONS: The 23 patients with extensive sinonasal polyposis who had undergone partial resection of the middle turbinate during functional endoscopic sinus surgery (FESS) showed no differences in nasal airway resistance and in postoperative complication rate (1-year follow-up period) in comparison with the 25 patients who had FESS with middle turbinate preservation. OBJECTIVE: The aim of the study was to investigate the outcomes of partial middle turbinectomy during FESS in patients with sinonasal polyposis. PATIENTS AND METHODS: A retrospective analysis of 48 consecutive patients who had undergone surgery for extended sinonasal polyposis was performed. Twenty-three patients underwent FESS with middle turbinate head resection; 25 patients underwent FESS with preservation of middle turbinate. We endoscopically scored polyposis extension and evaluated nasal airflow resistance (NAR) preoperatively and postoperatively. RESULTS: We found an improvement of endoscopic score (high to low grade of polyposis extension) and a statistically significant reduction of NAR after both surgical techniques. There was no statistically significant difference in the mean NAR values before and after the two techniques.     

鼻内镜或鼻内镜辅助下鼻腔鼻窦恶性肿瘤切除术的初步分析

目的：探讨鼻内镜或鼻内镜辅助下切除鼻腔鼻窦恶性肿瘤的可行性和疗效。方法：回顾性分析我院收治的40例鼻腔鼻窦恶性肿瘤患者的临床资料。病理类型为内翻性乳头状瘤恶变5例,上颌窦癌2例,筛窦癌3例,恶性黑色素瘤11例,嗅神经母细胞瘤7例,神经内分泌癌2例,肌上皮癌4例,鼻腔软骨肉瘤2例,腺样囊性癌3例,恶性血管外皮细胞瘤1例。所有患者均行鼻内镜或鼻内镜辅助下肿瘤切除术,其中32例术后采用放化疗。结果：所有患者随访1～5年,其中22例随访1～3年,随访3年以上者18例。4例患者术后6个月～2年症状复发,再次行鼻内镜手术后疗效满意;3例术后出现颈淋巴结转移,其中2例行颈淋巴结清扫术,1例因无手术指征而行放、化疗;4例出现远处转移;8例死亡;其余21例在随访期间未见复发及转移。结论：鼻内镜或鼻内镜辅助下手术切除鼻腔鼻窦恶性肿瘤切实可行,但必须严格选择适应证,辅以术后综合治疗,可取得满意的疗效。     

Platelet gel for endoscopic sinus surgery

OBJECTIVES: New techniques are being utilized to improve outcomes for endoscopic sinus surgery, including newer forms of packing. Platelet gel is an innovative technique that holds many advantages, including comfort, hemostasis, and growth factors that may improve wound healing. This report discusses the theoretical advantages of this packing material and describes the initial results in a cohort of patients who underwent endoscopic sinus surgery. METHODS: A cohort of patients who underwent endoscopic sinus surgery were interviewed and evaluated after the placement of platelet gel. A quality of life study was also administered for further understanding. RESULTS: None of the patients in the study had postoperative epistaxis that required additional packing, and there were no instances of synechia formation or exuberant granulation tissue. Although not statistically significant because of a small population, the quality of life scores did show improvement over the control group. CONCLUSIONS: Platelet gel used as a packing material after endoscopic sinus surgery offers efficient hemostatic properties, as well as growth factors that can advance the healing process. The quality of life of the patient may be improved by the use of platelet gel packing.