Chronic recurrent rhinosinusitis: disease severity and clinical characterization

OBJECTIVES/HYPOTHESIS: The objective was to clinically characterize and determine disease severity parameters for chronic recurrent rhinosinusitis (CRRS). STUDY DESIGN: Prospective. METHODS: A consecutive series of adult patients undergoing evaluation for CRRS was prospectively evaluated. Patients with four or more acute rhinosinusitis episodes in the previous calendar year with an absence of symptoms between episodes were considered as manifesting CRRS. Symptom severity and disease data from the Rhinosinusitis Symptom Inventory was obtained, as well as Lund staging information from the paranasal sinus CT scan. The Lund staging scores for patients with CRRS were compared with a control group of patients without CRRS. Symptom domain scores and disease severity parameters were compared between the CRRS group and a third group of patients with chronic persistent rhinosinusitis. RESULTS: In all, 30 patients met inclusion criteria for the diagnosis of CRRS. Mean age was 40.9 years with a 3:1 female preponderance. The mean Lund score for patients with CRRS was 3.79. Patients with CRRS failed to demonstrate a statistically different Lund score from control patients (mean Lund score, 4.26 [P = .538]). Symptom severity scores according to Rhinosinusitis Symptom Inventory domains were largely similar for the nasal, facial, and total symptom domains between patients with CRRS versus chronic persistent rhinosinusitis. However, patients with CRRS demonstrated statistically significant increases in oropharyngeal and systemic symptom domain scores. Patients with CRRS also had significant increases in number of antibiotic courses (4.8 vs. 2.9 [P < .001]) and number of missed workdays (8.8 vs. 4.6 d [P = .046]) attributable to rhinosinusitis. CONCLUSION: Chronic recurrent rhinosinusitis is a distinct form of chronic rhinosinusitis differing somewhat from chronic persistent rhinosinusitis. However, patients with CRRS still experience significant symptoms associated with this diagnosis, which results in significant medication usage and workplace impact.     

A comparison of symptom scores and radiographic staging systems in chronic rhinosinusitis

BACKGROUND: The aim of this study was to determine if one of the popular computed tomography (CT) scan staging systems exhibits better correlation with sinonasal symptom severity in chronic rhinosinusitis (CRS). METHODS: Adult patients meeting diagnostic criteria for CRS were prospectively studied with the Rhinosinusitis Symptom Inventory and their paranasal sinus CT scan was staged according to the Kennedy, Harvard, and Lund staging systems. From the Rhinosinusitis Symptom Inventory, Likert symptom severity scores were obtained and the nasal, facial, oropharyngeal, systemic, and total symptom scores were computed. Correlation analysis was conducted between symptom scores and CT scan stage for each of the three staging systems. RESULTS: Two hundred patients met inclusion criteria (mean age, 41.1 years; 42% men). The mean Lund score for the entire cohort was 10.0 (SD, 5.3). The Kennedy stage distributions were 40, 42, 84, and 34 patients for stages 1-4, respectively. The Harvard stage distributions were 17, 53, 85, and 45 patients for stages 1-4, respectively. All three staging systems exhibited statistically significant Pearson correlation (all p < 0.001) for the nasal symptom domain (nasal obstruction, rhinorrhea, and hyposmia), although the magnitude of the correlation coefficient generally was small (range of Pearson's r, 0.242-0.345). The Kennedy and Harvard systems exhibited significant but negative correlation with the oropharyngeal symptom domain. All three staging systems failed to significantly correlate CT stage with facial symptoms, systemic symptoms, and total symptom scores. CONCLUSION: The Lund staging system exhibited the best correlation between nasal symptom scores and CT stage in CRS, but the degree of correlation remained small. All three systems were lacking in staging value for nonnasal sinonasal symptoms.     

Influence of polyps on outcomes after endoscopic sinus surgery

OBJECTIVE: To determine clinical and comparative outcomes for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) with polyposis. METHODS: Two cohorts of adult patients with refractory CRS with and without nasal polyps were prospectively studied before and after ESS (minimum follow-up, 12 months) with the Rhinosinusitis Symptom Inventory (RSI). For the non-polyp and polyp cohorts, RSI symptom domains and medical resource utilization were compared in the preoperative and postoperative states. Corresponding effect sizes were computed and compared between cohorts to determine the effect of polyps on prognosis after ESS. RESULTS: A total of 165 non-polyp and 86 polyp patients were enrolled. Polyps were more common in female patients (2:1, P = .025); age (mean, 42.9 years) and follow-up (18.5 months) were similar between groups. Lund scores were significantly higher for polyp patients (13.7, SD 4.8) vs. non-polyp patients (8.1, SD 5.3, P < .001). At baseline, polyp patients reported lower symptom scores for facial, oropharyngeal, and systemic RSI symptom domains (all P < .012); nasal and total symptom domains were similar between groups. Both non-polyp and polyp groups obtained significant symptomatic benefit from ESS with effect sizes for RSI symptom domain improvements ranging from 0.89 to 1.38 and 0.43 to 1.19, respectively (all P < .001). There were no significant differences between groups in symptomatic improvement, excepting oropharyngeal symptoms (better improvement in non-polyp group, P = .024). Non-polyp patients decreased medical resource consumption more significantly than did polyp patients. CONCLUSIONS: Both non-polyp and polyp patients derive similar clinically significant symptomatic improvement after ESS. These similarities suggest that polyp patients do not necessarily have a poorer symptomatic outcome after ESS.     

Radiographic stage fails to predict symptom outcomes after endoscopic sinus surgery for chronic rhinosinusitis

OBJECTIVE: To determine whether preoperative computed tomography (CT) stage predicts degree of symptom improvement after endoscopic sinus surgery (ESS). METHODS: A series of adult patients undergoing ESS was prospectively evaluated with CT and the rhinosinusitis symptom inventory (RSI) preoperatively and at a minimum of 12 months postoperatively. Symptom domains (nasal, facial, oropharyngeal, systemic, and total) were computed and both absolute change and percentage change in symptom domain scores before and after ESS were correlated with the preoperative CT scan stage according to three staging systems: Lund-MacKay, Kennedy, and Harvard. RESULTS: One-hundred sixty-one patients (mean age, 40.2 years) completed the study with a mean follow-up of 19.4 months. Overall, statistically significant decreases in RSI symptom domains were noted for the nasal (net change -30.1 [range -100 to +100]), facial (-26.1), oropharyngeal (-13.4), systemic (-17.0), and total (-20.8) symptom scores (all P < .001). For the absolute change in total symptom score, no statistically significant correlation with CT stage was demonstrated for any of the staging systems (Lund: Spearman rho = -0.004, P = .962; Kennedy: rho = -0.008, P = .918; Harvard: rho = -0.011, P= .891). Similarly, no significant correlation with CT stage was demonstrated with the other symptom domains. Additionally, no significant correlation was identified between preoperative CT stage and percentage change in symptom domain scores. CONCLUSIONS: Although CT scan is widely accepted as an accurate diagnostic tool for chronic rhinosinusitis, CT scan stage alone does not significantly predict symptom outcomes after chronic rhinosinusitis, regardless of staging system utilized.     

Do anxiety and depression confound symptom reporting and diagnostic accuracy in chronic rhinosinusitis?

OBJECTIVES: We sought to determine the impact of psychiatric comorbidity on symptom reporting and diagnostic accuracy in chronic rhinosinusitis (CRS). METHODS: A prospective cohort of patients presenting for evaluation of CRS was studied with the Rhinosinusitis Symptom Inventory and the Hospital Anxiety and Depression Scale. Data concerning symptom scores, symptom domains, and psychiatric comorbidity were analyzed with respect to paranasal sinus computed tomography (CT) Lund score. The degree of correlation between sinonasal symptoms and CT scan stage adjusting for anxiety and depression was determined. The relationships between symptoms, psychiatric comorbidity, and the presence of radiographic CRS were determined with multivariate logistic regression. RESULTS: There were 230 patients (mean age, 43.4 years) enrolled. High levels of anxiety and depression were noted in 23.5% and 13.0%, respectively. According to CT criteria, 61.3% to 71.3% of patients had true CRS. Even adjusting for anxiety and depression, only the nasal symptom domain severity had a statistically significant correlation with Lund score (r = 0.240; p = .001); facial, oropharyngeal, systemic, and total symptoms did not correlate with CT score. Similarly, multivariate analysis revealed that even with adjustment for anxiety and depression, sinus symptom domains failed to predict radiographic positivity. Individually, only dysosmia, dental pain, and fatigue were predictive for CRS (odds ratios, 1.29 [p = .032], 1.69 [p = .001], and 0.70 [p = .023], respectively). CONCLUSIONS: Although anxiety and depression are prevalent in patients with CRS, they do not influence the correlation between nasal symptoms and CT findings. Markers of psychiatric comorbidity do not correlate with CRS symptoms. The presence of anxiety or depression does not cloud symptom reporting in CRS and should not bias clinical decision-making.     

Relationship between mucosal inflammation, computed tomography, and symptomatology in chronic rhinosinusitis without polyposis

OBJECTIVES: This study was an attempt to determine whether sinus mucosal inflammation is related to computed tomographic findings and patients' reported symptoms in chronic rhinosinusitis (CRS) without polyposis. METHODS: I retrospectively reviewed the clinical symptom scores according to the Rhinosinusitis Symptom Inventory (RSI), the radiographic findings, and the histopathologic findings in the paranasal sinus mucosa for a consecutive series of adult patients who underwent endoscopic sinus surgery for CRS. Linear regression analysis was conducted for the relationship between tissue pathology inflammatory severity score graded on a 5-point Likert scale and the RSI symptom domains. A similar analysis was conducted for the relationship between the pathology inflammatory score and the total Lund score. RESULTS: The study cohort consisted of 115 adult patients (mean age, 40.2 years). The mean Lund score for the cohort was 8.8 (95% confidence interval, 7.9 to 9.7), and the mean pathology severity score was 2.1 (median, 2.0). The mean total symptom score for the overall cohort was 41.3; the mean total symptom scores for pathology severity grades 0, 1, 2, 3, and 4 were 25.0, 43.8, 41.8, 42.4, and 32.8, respectively. No significant association could be identified between pathology severity and any of the 5 RSI symptom domains (nasal, facial, oropharyngeal, systemic, and total symptoms; all p > .436, linear regression). A statistically significant relationship between total Lund score and pathology severity was identified (p < .001). CONCLUSIONS: Poor correlation exists between the histopathologic severity of sinonasal inflammation and self-reported symptom scores in CRS. Histopathologic inflammatory grade alone fails to stratify CRS cases according to disease symptom severity. Histopathologic inflammation and computed tomographic findings correlate strongly.     

Endoscopic and quality-of-life outcomes after revision endoscopic sinus surgery

OBJECTIVES: First, to examine the impact of endoscopic sinus surgery (ESS) on endoscopic and quality-of-life (QOL) outcomes after revision ESS as compared to primary ESS. Second, to evaluate whether or not other risk factors and/or co-morbidities influence the relationship between revision surgery status and outcomes of ESS. STUDY DESIGN: Prospective observational study with an internal comparison group. METHODS: Preoperative computed tomography scores, pre and postoperative endoscopy scores, and two validated disease-specific QOL instruments, the Rhinosinusitis Disability Index (RSDI) and Chronic Sinusitis Survey (CSS), were collected on a prospective cohort of patients undergoing ESS for chronic rhinosinusitis. Data were analyzed using Pearson's chi and multiple logistic regression models. RESULTS: Mean preoperative Lund-Mackay computed tomography scan scores were similar in primary and revision surgery patients. In patients without polyps, revision ESS patients were 3.88 times more likely to improve on endoscopy scores than primary ESS patients (95% confidence interval 1.70, 8.83; P = .001). In nasal polyp patients, there was no difference by revision status (odds ratio 0.48; 95% confidence interval 0.15, 1.59; P = .23). The odds of improving on the RSDI (odds ratio 0.51, 95% confidence interval 0.25, 1.04, P = .065) and CSS (odds ratio 0.98, 95% confidence interval 0.51, 1.89, P = .950) were not significantly different by revision status. CONCLUSIONS: Both revision and primary ESS patients improved after ESS with regard to endoscopy, RSDI, and CSS scores. In non-polyp patients, revision ESS patients were more likely to improve on endoscopy scores than primary ESS patients; there was no difference in polyp patients by revision status. Revision ESS patients and primary ESS patients were equally as likely to improve on two QOL instruments.     

Surgical treatment of chronic recurrent rhinosinusitis: a preliminary report

OBJECTIVE: The objective of this study was to determine if endoscopic sinus surgery (ESS) is effective in the management of chronic recurrent rhinosinusitis (CRRS). METHODS: A consecutive series of patients with CRRS diagnosed according to stringent criteria was prospectively examined before and at least 1 year after ESS. Paranasal sinus computed tomography scans were staged and ESS was performed targeting radiographic disease and the ostiomeatal complex. Preoperative and postoperative disease severities in terms of symptom scores, medicine utilization, and resource factors were assessed using the rhinosinusitis symptom inventory (RSI). Improvements in RSI symptom domains, medical and economic resource factors were determined using effect sizes and statistical comparison before and after ESS. RESULTS: Nineteen patients (mean age, 42.3 years) completed the study with a mean follow up of 19.1 months. The mean Lund score was 3.42 (standard deviation, 4.09). Statistically significant decreases in nasal (-36.1), facial (-28.4), oropharyngeal (-34.6), systemic (-24.7), and total (-31.9) RSI symptom domain scores were observed (all P < .003) with effect sizes ranging from 0.87 to 1.63 (strong surgical effect). Statistically significant decreases in antihistamine use (-30%, P = .031), number of workdays missed as a result of CRRS (-1.9, P = .035), and number of acute infectious episodes (-2.5, P = .006) were also observed. However, declines in weeks of antibiotic use (-2.8 weeks, P = .293) and number of antibiotic courses (-1.7, P = .118) were not significant. CONCLUSIONS: Patients with CRRS may substantially benefit both symptomatically and medically from ESS. Although surgery should be used cautiously in treating CRRS, further trials of ESS for CRRS are warranted.     

Symptom outcomes in endoscopic sinus surgery: a systematic review of measurement methods

OBJECTIVE: To determine the type and prevalence of measurement methods used to analyze symptom outcomes after endoscopic sinus surgery (ESS). DATA SOURCES: Data were derived from PubMed, MEDLINE, EMBASE, Web of Science, Cochrane databases, Google Scholar, and manual searches. STUDY SELECTION: All English-language studies consisting of more than 10 adult patients from January 1980 to December 2006 reporting ESS symptom outcome results were reviewed. Studies of radical surgery and studies involving patients with significant comorbidities were excluded. RESULTS: The ESS symptom outcome results of 29,333 patients were reported in 204 studies. Symptom outcome was determined by survey instruments in 47 (23.0%) studies and individual symptom scoring in 63 (31%) studies. Of 18 validated instruments used, almost two thirds of studies that reported results by survey measures used the following three instruments: Chronic Sinusitis Survey (12 studies), Sinonasal Outcome Test-20 (11 studies), and Medical Outcomes study 36-Item Short-Form Health Survey (10 studies). The percentages of studies that reported specific results of the 1997 American Academy of Otolaryngology-Head Neck Surgery Rhinosinusitis Task Force (RSTF) chronic rhinosinusitis symptom criteria varied as follows: facial pain/pressure, 35%; facial congestion/fullness, 10%; nasal obstruction/blockage, 42%; nasal discharge/purulence/discolored postnasal discharge, 47%; hyposmia/anosmia, 35%; fever, 2%; halitosis, 4%; fatigue, 11%; dental pain, 3%; cough, 10%; and ear pain/pressure/fullness, 6%. CONCLUSIONS: ESS symptom outcome is assessed inconsistently by numerous measures. Individual report- ing of all RSTF chronic rhinosinusitis symptom criteria, as recommended by the RSTF and by subsequent consensus conferences, is rarely noted. Many RSTF symptom criteria are seldom studied.     

Endoscopic sinus surgery: its subjective medium-term outcome in chronic rhinosinusitis

OBJECTIVE: The subjective success of endoscopic sinus surgery (ESS) for chronic rhinosinusitis has been reported mainly after short-term follow-up studies, but may change with increasing time after surgery. We assessed in a retrospective study the medium-term clinical outcome of ESS as complete ethmoidectomy or pansinus surgery in 208 patients with chronic rhinosinusitis. PATIENTS AND METHODS: The senior author performed the surgeries according to his techniques. We used a questionnaire focusing on nasal obstruction, rhinorrhea, nasal dryness/crusts, sneezing, headache, smell, numbness in cheeks and lips, ear pressure, epiphora, and sore throat. Additionally the subjective influence of sinus surgery on asthma, bronchitis and allergic diseases was evaluated. The mean follow-up was 3.1 years. RESULTS: Overall success was reported by 92% of all patients. Forty-one percent of all patients with complete ethmoidectomy and 32% of all patients with pansinus surgery described complete resolution of complaints. No differences in clinical success rates were noted when comparing primary surgery or revision. A favorable effect was also reported for asthma, bronchitis and allergic diseases. CONCLUSION: Improvements for nasal symptoms and coexisting complaints are demonstrated with a mean observation period of more than 3 years. The value of ESS is underlinedfor the treatment of patients with chronic rhinosinusitis.     

Effect of asthma on sinus computed tomography grade and symptom scores in patients undergoing revision functional endoscopic sinus surgery

BACKGROUND: The aim of this study was to determine the influence of asthma on sinus computed tomography (CT) grade, endoscopic appearance, and symptom scores in patients undergoing revision functional endoscopic sinus surgery (FESS). METHODS: Prospective data was collected of patients undergoing revision FESS at a tertiary medical center over a 2-year period. CT scans were graded as per the Lund and Mackay system. Patient symptom scores were recorded from the Sino-Nasal Outcome Test (SNOT 20) inventory and individual symptoms from the Rhinosinusitis Task Force major and minor symptom list were graded on a visual analog scale. RESULTS: Eighty patients underwent revision FESS and 20 of those patients had asthma. The average CT grade in asthmatic patients was 18.6 compared with 11.7 in patients who were nonasthmatic (p = 0.000006). The average SNOT 20 symptom score in patients with asthma was 49.6 and in nonasthmatic patients it was 44.9 (p = 0.238). Both asthmatic and nonasthmatic patients experienced a reduction in SNOT 20 symptom scores at 1 year with reductions of 70% (p = 0.0000) versus 72.6% (p = 0.0000), respectively. CONCLUSION: Patients with asthma undergoing revision FESS had higher sinus CT grades compared with patients without asthma. Asthmatic and nonasthmatic patients had statistically significant reductions in symptoms scores after revision FESS. Asthmatic patients had similar symptomatic relief scores after revision FESS as compared with nonasthmatic patients.     

The relationship between atopy and chronic rhinosinusitis

BACKGROUND: The aim of this study was to determine whether atopy influences either clinical and radiological severity or surgical revision rates in patients with chronic rhinosinusitis (CRS). METHODS: Patients who had been scheduled for endoscopic sinus surgery were classified as having CRS or nasal polyposis. Their atopic status was determined by ImmunoCAP testing. Disease severity was assessed clinically by the Lund symptom and Sino-Nasal Outcome Test 20 (SNOT-20) quality-of-life scores and radiologically by the Lund-Mackay CT score. RESULTS: One hundred ninety-three consecutive patients with rhinosinusitis were included in the study. The prevalence of atopy in this group was found to be 30%. No association was found between atopic status and Lund symptom scores. Analysis of the SNOT-20 scores indicated that atopic patients had higher sneezing scores (p < 0.03), reduced productivity (p < 0.01), and reduced concentration (p < 0.01). The mean CT score was significantly higher in the atopic patients than in nonatopic patients overall (14.2+/-1.6 versus 12.2+/-1.3; p = 0.05), although within each of the clinical subgroups no statistically significant relationship was observed between a patients' atopic status and their CT scores. The rate of revision surgery was not significantly different between atopic and nonatopic patients. CONCLUSION: These results suggest that atopic status has minimal impact on the severity of CRS.     

Clinical symptomatology and paranasal sinus involvement with nasal septal perforation

OBJECTIVE: Determine the symptom manifestations, clinical impact, and incidence of chronic rhinosinusitis (CRS) in patients with newly diagnosed nasal septal perforation. METHODS: A consecutive series of adult patients with nasal septal perforation were prospectively studied at the time of endoscopic diagnosis with the rhinosinusitis symptom inventory (RSI) and sinus computed tomography (CT). Patients' symptoms in the RSI symptom domains were computed. From the CT scan, septal perforation size and Lund scores were obtained. A separate (control) cohort of patients with CRS without septal perforation was matched to these patients for age, sex, and Lund score. RSI symptom domain comparisons were conducted between groups to determine the additional symptom burden conferred by septal perforation. RESULTS: Thirty-three patients with septal perforation were enrolled (mean age, 48.2 yr; 69.7% female). Mean perforation size was 1.9 (SD, 2.1) cm. The mean Lund score was 5.8 (SD, 5.3); 16 (57.1%) patients met radiographic criteria for a concurrent diagnoses of CRS. Patients with septal perforation reported significant nasal and facial symptom domain scores (56.8 and 47.0, respectively [range, 0-100]). Oropharyngeal and systemic symptoms were less severe (29.7 and 34.7, respectively). However, after comparison with the matched control patients, no statistically significant differences were identified in sinonasal symptoms between patients with and without septal perforation (all P > .131). CONCLUSIONS: Concurrent CRS may frequently accompany nasal septal perforation and may require appropriate treatment along with the perforation itself. The presence of septal perforation does not appear to significantly augment symptom severity in CRS.     

The effect of endoscopic sinus surgery on symptoms of eustachian tube dysfunction

BACKGROUND: The symptom of eustachian tube dysfunction has been categorized as a "minor" symptom in chronic rhinosinusitis. The aim of this pilot study was to determine the frequency of otologic symptoms in patients with confirmed rhinosinusitis and the likelihood of its resolution in those patients undergoing endoscopic sinus surgery (ESS). METHODS: Questionnaires were obtained from 168 patients who had undergone prior ESS over a 5-year period. Patients were asked to evaluate if they suffered from several different potential symptoms of eustachian tube dysfunction before ESS and whether that symptom changed postoperatively. RESULTS: Using the binomial test, 95% confidence intervals were determined for the following otologic symptoms of tubal dysfunction: "earfullness and congestion," "ear cracking and popping," "dizziness," and "ear pain. "ESS was found to have a significant treatment effect for the indicated otologic symptoms of tubal dysfunction. CONCLUSION: Tubal dysfunction, as manifested by otologic symptoms, is common in patients with chronic rhinosinusitis undergoing ESS. The classification of this as a "minor" symptom of rhinosinusitis needs to be reevaluated. These symptoms improve or resolve in the majority of patients undergoing ESS.     

The Completely Opacified Frontal or Sphenoid Sinus: A Marker of More Severe Disease in Chronic Rhinosinusitis?

OBJECTIVE: Determine whether complete opacification of the sphenoid or frontal sinus is associated with increased clinical severity of chronic rhinosinusitis (CRS). METHODS: Adult patients undergoing evaluation for CRS prospectively completed the rhinosinusitis symptom inventory (RSI) and underwent computed tomography of the paranasal sinuses. A cohort with at least one completely opacified frontal sinus was identified. To each patient in this opacified cohort, a control patient without complete frontal sinus opacification was matched with corresponding Lund score. Symptom scores for headache, facial pressure, RSI symptom domains, and medical resource consumption were statistically compared. Similar analysis was conducted for patients with complete sphenoid sinus opacification. RESULTS: Fifty-four patients with at least one completely opacified frontal sinus were matched for Lund score to the control group (mean Lund score 17.1). There was no statistically significant difference in headache (2.1 vs. 2.8) or pressure scores (2.0 vs. 2.3) or in the RSI symptom domains between those patients with completely opacified frontal sinuses and controls, respectively. Although completely opacified patients received more antibiotic treatment and missed more workdays, only the increased numbers of physicians visits (4.0 vs. 2.1, P = .02) was significant. Thirty-four of 35 completely opacified sphenoid patients were matched to control patients (mean Lund score 16.7). Again, differences in symptom scores for headache (2.5 vs. 2.5), facial pressure (2.3 vs. 2.3), and RSI symptom domains were not statistically significant. Increased use of antibiotics (9.6 vs. 3.9, P = .036) and physician visits (5.8 vs. 1.8, P = .024) for sphenoid opacification patients was statistically significant. CONCLUSIONS: Patients with a completely opacified sphenoid or frontal sinus do not necessarily manifest more severe clinical symptoms of CRS. Thus, a higher radiographic stage should not be automatically assigned to patients with a completely opacified sphenoid of frontal sinus in CRS.     

Impact of age on presentation of chronic rhinosinusitis and outcomes of endoscopic sinus surgery

BACKGROUND: As the population ages, the mean age of patients with chronic rhinosinusitis (CRS) likely will increase as will the frequency of endoscopic sinus surgery (ESS) in the older population. The purpose of this study was to compare symptom presentation, CT scores, endoscopy scores, and quality of life (QOL) measures in patients >60 years of age as compared with younger patients. METHODS: A prospective cohort of 18 patients >60 years and 121 patients < or =60 years undergoing ESS for CRS were studied. Patient factors, symptom severity, and CT scores were examined preoperatively. Endoscopy and QOL scores were compared pre- and postoperatively between the two groups. RESULTS: The prevalence of allergies, polyps, asthma, aspirin sensitivity, and revision surgery was similar in each age group. There was no statistically significant difference in the visual analog scale scores of symptom severity in each age group. Older patients had scores that were similar to younger patients with regard to CT (13.11 versus 11.63; p = 0.419), preoperative endoscopy (8.22 versus 7.96; p = 0.828), postoperative endoscopy (3.06 versus 4.82; p = 0.100), and change in endoscopy (-5.17 versus -3.15; p = 0.083). Older patients had similar preoperative, postoperative, and change scores when compared with younger patients on the Rhinosinusitis Disability Index (-15.33 versus -20.63; p = 0.318) and Chronic Sinusitis Survey (14.35 versus 23.11; p = 0.126). CONCLUSION: Older patients with CRS present with symptoms and patient factors that are comparable with younger patients and have a similar degree of improvement on endoscopy scores and QOL measures after ESS.     

Molecular and cellular staging for the severity of chronic rhinosinusitis

OBJECTIVES: To correlate objective and subjective clinical parameters with molecular, cellular, and histologic markers and to acknowledge the importance of these basic science parameters in a severity classification system for chronic rhinosinusitis (CRS). STUDY DESIGN: Retrospective analysis of prospectively collected data of consecutive patients undergoing endoscopic sinus surgery for CRS in an academic institution. METHODS: The preoperative computed tomography (CT) scans of all patients with CRS scheduled for surgery were graded according to Lund and Mackay. The patients completed a Sino-Nasal Outcome Test (SNOT)-20 questionnaire and had a preoperative nasal endoscopy performed, which was graded by assigning an endoscopy score according to Lanza and Kennedy. Subjects had a medical questionnaire regarding presence of aspirin sensitivity, allergic rhinitis, asthma, and medication usage. Subjects also underwent pulmonary function testing and had skin tests for allergies. At the time of surgery, blood was drawn to determine the level of peripheral eosinophilia and the degree of polymorphisms of the leukotriene C4 synthase gene. Sinus mucosal and polyp tissue was examined pathologically for the number of eosinophils per high-powered filed (HPF) and was stained for EG2 to determine the portion of activated eosinophils. Leukotriene C4 levels (pg/g of tissue) were determined using a sensitive competitive enzyme immunoassay. Endoscopy and SNOT-20 scores were reevaluated 1 year after surgery. Data were analyzed for disease-severity correlation to recommend a severity classification system for CRS that incorporates the contribution of clinical, molecular, cellular, and histologic parameters. RESULTS: The presence of polyps resulted in higher preoperative CT scores and higher preoperative and postoperative symptom scores. Average preoperative CT scores were significantly higher in asthmatics and allergy patients and correlated with endoscopy scores. Patients with more than five eosinophils/HPF of sinus tissue had higher frequency of polyps and asthma and higher CT and endoscopy scores than patients without sinus tissue eosinophilia (less than or equal to 5 cells/HPF sinus tissue). The subgroup of patients with eosinophilic nasal polyps (eosinophilic hyperplastic rhinosinusitis) had more severe disease by CT and endoscopy than the subgroup of patients with nasal polyps (hyperplastic rhinosinusitis) but without eosinophilia. Similarly, patients without polyps but with tissue eosinophilia had more severe disease than patients without polyps and without eosinophilia. Leukotriene C4 levels were elevated in all patient groups. Symptom scores did not correlate with any of the parameters. CONCLUSION: We suggest the following severity classification system for CRS: 1) eosinophilic chronic hyperplastic rhinosinusitis (ECHRS): patients with polyps and sinus tissue eosinophilia; 2) noneosinophilic chronic hyperplastic rhinosinusitis (NECHRS): patients with polyps but without sinus tissue eosinophilia; 3) eosinophilic chronic rhinosinusitis (ECRS): patients without polyps but with sinus tissue eosinophilia; 4) noneosinophilic chronic rhinosinusitis (NECRS): patients without polyps and without sinus tissue eosinophilia.     

Important clinical symptoms in patients undergoing functional endoscopic sinus surgery for chronic rhinosinusitis

OBJECTIVE: To evaluate the prevalence and severity of individual Rhinosinusitis Task Force (RSTF) symptoms in patients with chronic rhinosinusitis (CRS) undergoing functional endoscopic sinus surgery (FESS). METHODS: Retrospective analysis of prospectively collected data in 201 patients treated with FESS. The prevalence and severity of individual RSTF major and minor symptom scores graded on a visual analogue scale (VAS) were compared. Correlation between absolute improvement in individual symptom scores at 1-year postoperative was performed. RESULTS: One-hundred fifty-eight of 201 patients met inclusion criteria giving a response rate of 78%. The average age was 49.4 (range 18-80) with a male-to-female ratio of 1.1:1. The preoperative leading mean symptom scores were postnasal drip (5.8 +/- 0.3), nasal obstruction (5.7 +/- 0.3), and facial congestion (5.1 +/- 0.3). These symptoms were also the most prevalent with 82%, 84%, and 79% of patients reporting these symptoms, respectively. Postoperative symptom improvements were significant (P < .0001) across all RSTF domains except fever. The highest percentage improvement was seen with facial congestion (93%), nasal obstruction (92%), and postnasal drip (85%). Multivariate analysis revealed significant (P < .0001) high correlation between improvements of facial pain/pressure with facial congestion (R = 0.72), facial congestion with nasal obstruction (R = 0.65), and facial pain/pressure with headache (R = 0.72). CONCLUSION: The top three RSTF symptoms were postnasal drip, nasal obstruction, and facial congestion in terms of prevalence and severity. Symptom scores improved after FESS. Of these symptoms, the degree of improvement of facial pain/pressure, facial congestion, nasal obstruction, and headache are highly correlated.