Incidence of chronic hyperostotic rhinosinusitis in patients undergoing primary sinus surgery compared to revision surgery

HYPOTHESIS: The incidence of chronic hyperostotic rhinosinusitis has been underreported due to poor recognition of the disease process. The surgical management of chronic hyperostotic rhinosinusitis with prolonged pre and post-operative antibiotic therapy can alter clinical course of the disease process. STUDY DESIGN: A prospective study of 40 patients based at two teaching tertiary care institutions. MATERIAL AND METHODS: CT scans of twenty patients (ten undergoing primary sinus surgery and ten undergoing revision sinus surgery) were randomly selected from each institution and reviewed by an independent radiologist for evidence of hyperostosis and compared to original reading of the CT scans. RESULTS: The finding of sinus hyperostosis is rarely reported by the radiologist on the sinus CT scan where the focus is always on mucosal disease. The incidence of sinus hyperostosis is higher, in patients undergoing revision sinus surgery than patients undergoing primary sinus surgery. CONCLUSION: Sinus hyperostosis is not an uncommon finding in chronic refractory sinusitis which may require long term intravenous antibiotic therapy in conjunction with surgery to provide symptomatic relief.     

The role of computed tomography scans in evaluating sinus disease in pediatric patients

OBJECTIVES: To determine the incidence and severity of sinus abnormalities in children undergoing computed tomography (CT) of the sinuses for suspected chronic sinusitis. To compare these findings with abnormalities noted on random CT scans. METHODS: Sixty CT scans, performed for evaluation of sinus disease in symptomatic children aged 2-12, were compared with 50 CT scans of children aged 2-12 of the orbits or sinuses obtained for indications other than sinusitis. A staging system was applied to assess the severity of abnormalities. RESULTS: Mucoperiosteal thickening was present in 60% of symptomatic and 46%, of random CT scans (logistic regression, P = 0.144). Children aged 2-4 and 9-12 had an increased prevalence of abnormalities in both groups, although these findings were not statistically significant (logistic regression, P = 0.817). Early stage sinus disease was present in the majority of random (96%) and symptomatic (85%) children. CONCLUSIONS: There is a high incidence of mucoperiosteal thickening in the paranasal sinuses of children. CT scans of the sinuses should be obtained from children who are being considered for sinus surgery after failing the appropriate medical therapy. Decisions regarding the need for sinus surgery should not be solely based on imaging abnormalities.     

Endoscopic sinus surgery for unilateral chronic sinusitis]

Functional endoscopic sinus surgery has become an increasingly popular treatment for chronic sinusitis. This approach is aimed at re-establishment of ventilation and mucociliary clearance of the sinuses. However, some otolaryngologists believe that the Caldwell-Luc procedure should be routinely used for unilateral chronic sinusitis, because it is often associated with the maxillary sinus carcinomas. To evaluate the state of endoscopic sinus surgery for the diagnosis and treatment of unilateral chronic sinusitis, we analyzed the cases of 39 patients with unilateral chronic sinusitis who underwent endoscopic sinus procedures. These patients were unresponsive to appropriate antibiotic management for more than 6 months. Generally, endoscopic ethmoidectomy and antrostomy were performed with preservation of the middle turbinate. After the ostium was enlarged, the maxillary sinus was cleaned and carefully inspected for the presence of associated neoplasms using 30 and 70 degree endoscopes. Preoperative computed tomography (CT), postoperatve pathologic diagnosis, fiberscopic findings of the maxillary sinus, and symptomatic improvement were evaluated. Three patients had CT evidence of bone destruction of the lateral nasal wall. Pathological diagnosis demonstrated that three patients had maxillary sinus mycoses caused by Aspergillus species, one patient had inverted papilloma, and the other 35 patients had chronic sinusits. No associated malignancy was found. Eighty-one percent of the patients had almost normal endoscopic findings of the maxillary sinus by postoperative fiberscopic examination 4 to 8 months following surgery. With an average follow-up of 26 months, 88% of the patients were judged as having significantly improved in their presenting complaints of mucopurulent rhinorrhea, nasal obstruction, and facial pain. The results of this series suggest that endoscopic sinus surgery is an effective procedure for the diagnosis and treatment of unilateral chronic sinusitis.     

The role of endoscopic sinus surgery in patients with acquired immune deficiency syndrome

Purpose: Increasingly, otolaryngologists are treating patients with acquired immunodeficiency syndrome (AIDS) who suffer from associated sinusitis refractory to medical therapy. Despite this trend, few reports in the literature detail the mode of surgical therapy, pathogens, and outcome in this patient population. Our aim in this study was to describe our experience in treating these patients, with particular attention to surgical outcome and pathogens.Patients and Methods: We reviewed our experience with performing sinus surgery in 33 AIDS patients. Endoscopic sinus procedures were performed in 24 patients, while the remaining nine patients underwent nasal antral windows and/or Caldwell-Luc operations. Follow-up information was obtained in 16 of the 24 patients who underwent endoscopic sinus surgery.Results: At an average follow-up time of 16 months, 14 of the endoscopic sinus surgery patients reported improvement from their preoperative condition. Thirty-seven pathogens were identified in 23 patients. A larger percentage of nontraditional pathogens was found in these patients, which suggests a larger role for microbiologic diagnosis and treatment versus empiric therapy.Conclusion: Patients with AIDS and chronic sinusitis may benefit from endoscopic sinus procedures.     

Initial surgical treatment for chronic frontal sinusitis: a pilot study

OBJECTIVES: The initial surgical treatment for chronic frontal sinusitis is not well defined. Our objective was to determine the effectiveness of anterior ethmoidectomy for chronic frontal sinusitis. METHODS: Patients with chronic frontal sinusitis who underwent anterior ethmoidectomy as initial surgical treatment were reviewed. Data were collected from computed tomography scans with use of the Lund-Mackay scale. Data on demographics, comorbidities, management, postoperative recovery, and follow-up were collected. RESULTS: Seventy-seven patients representing 121 diseased frontal sinuses met the inclusion criteria. The respiratory comorbidities were asthma alone (8.3%), asthma and polyps (6.6%), aspirin triad (5.8%), and cystic fibrosis (0.8%). Nineteen of 121 frontal sinuses (15.7%) belonged to smokers. Fourteen of 121 frontal sinuses (11.5%) exhibited postoperative evidence of disease. Of these 14 frontal sinuses, 10 (8.3%) underwent revision surgery. Frontal sinuses of patients with aspirin triad, with both nasal polyposis and asthma, or with inter-frontal sinus septal cells were more likely to fail Draf I surgery (p < .05). CONCLUSIONS: Anterior ethmoidectomy for drainage of frontal sinuses appears to be effective initial surgical treatment for chronic frontal sinusitis. Patients with aspirin triad, both asthma and polyposis, or inter-frontal sinus septal cells are more likely to fail this procedure.     

Sphenoid marsupialization for chronic sphenoidal sinusitis

OBJECTIVES: To review experience with sphenoid marsupialization and describe the technique using new instrumentation. STUDY DESIGN: Retrospective review of five cases of chronic sphenoid sinusitis that were resistant to standard medical and surgical methods, which were treated by sphenoid marsupialization. METHODS: Charts were reviewed and patients were interviewed regarding postoperative resolution of symptoms. RESULTS: Five cases of recalcitrant sphenoid sinusitis were reviewed. All patients had headache before surgery, and two had visual disturbance. In follow-up ranging from 1 to 87 months, all were free of symptoms related to the sphenoid sinus. CONCLUSIONS: Marsupialization is an effective method of exteriorizing a chronically infected sphenoid sinus. The use of functional endoscopic sinus surgery instruments and the TAC attachment of the Midas Rex drill make this surgery possible.     

Prevalence of noninvasive fungal sinusitis in South Australia

BACKGROUND: The aim of this study was to document the prevalence of noninvasive fungal sinusitis in patients with chronic sinusitis and thick viscous secretions in South Australia. METHODS: We studied of 349 patients with chronic rhinosinusitis undergoing endoscopic sinus surgery in a specialized rhinology practice. Patients with nasal polyposis and thick fungal-like sinus mucin had operative samples sent for microscopy and fungal culture. Evidence of atopy was taken as positive radioallergosorbent or skin-prick tests to fungi. RESULTS: One hundred and thirty-four (38%) patients were noted to have thick, viscid sinus mucin, raising suspicion of fungal disease. Ninety-three patients had positive fungal cultures or microscopy (26.6%). It was possible to classify 95.5% of the patients into subgroups of noninvasive fungal sinusitis or nonfungal sinusitis: 8.6% of patients with allergic fungal sinusitis, 1.7% of patients with allergic fungal sinusitis-like sinusitis, 15.2% of patients with chronic fungal sinusitis, one patient with a fungal ball, and the remaining 69% of patients with nonfungal chronic sinusitis. CONCLUSION: This is the first prospective study to evaluate the prevalence of these increasingly widely recognized conditions. It highlights the need for otolaryngologists to be alert to these not uncommon diagnoses in order for early, appropriate medical and surgical management to be instituted.     

Risk assessment in coronal computed tomography scans of the paranasal sinuses

Computed tomography (CT) is a prerequisite to planning and performing FESS procedures. No standards exist for assessing the risk to the anatomical structures in the proximity of the nose and sinuses associated with surgery. The aim is to assess the agreement of surgeons in identifying key areas related to the anterior skull base and the orbit on coronal CT scans. A cross-sectional study involving five otolaryngologists from three centres related the scans. Two scoring systems were used to rate each film; the Lund-MacKay system and a risk assessment system. The latter system was compiled and agreed upon by the authors. κ analysis was used for measurement of inter-observer agreement. A consecutive series of patients undergoing CT scanning in advance of paranasal sinus surgery formed the study population. Patients who had previous surgery, anterior skull base trauma or were suspected of malignant disease were excluded. Twenty-nine scans were reviewed. There was moderate agreement using the Lund-MacKay system (median value 0.5) values. The risk assessment system showed moderate agreement in two of 11 parameters (pneumatized ethmoid roof 0.58 and uncinate process variations 0.43), poor agreement on the other parameters assessed (range ?0.06–0.21). The difficulties encountered in judging vulnerability or anatomical structures on coronal CT of sinuses may relate to a lack of clear definitions of structures, subtle degree of variation or technical aspects of scanning.     

Correlation between bacteriology and computed tomography staging for chronic sinusitis

In this study we report on the correlation between bacteriology and disease severity staging by computed tomography (CT) for chronic sinusitis. When patients with chronic sinusitis underwent functional endoscopic sinus surgery (FESS), swab specimens were taken from the ipsilateral middle meati and ethmoid sinuses under endoscope guidance. The severity of chronic sinusitis was evaluated by pre-operative CT scans. The CT scans were staged by the Lund and Mackay system. The scores for the frontal, anterior ethmoid and maxillary sinuses and for the ostiomeatal complex were added.The culture rates were correlated with the added scores. Between November 1998 and January 2003, 79 pairs of specimens were collected from 79 patients whose CT scans were done within a day before FESS. The culture rates of middle-meatus specimens were moderately correlated with the scores, but those of ethmoid sinus specimens were negatively correlated with the scores. If Staphylococcus epidermidis and corynebacteria were considered normal flora, the bacteriology of the middle meatus was highly correlated with the CT scores. This study shows that culture rates of middle-meatal specimens tended to increase with the severity of chronic sinusitis.     

鼻内窥镜术上颌窦自然开口的处理

探讨内窥镜鼻窦手术治疗慢性鼻窦炎，鼻息肉的上颌窦中鼻道开口的重要性及处理方法。方法 配对研究５６例双侧鼻窦炎，鼻息肉患者，比较同一患者术中扩大或不扩大上颌窦自然开口的术后情况。结果 窦口的开放率在不扩大和扩大上颌窦自然开口的术侧中分分别为９２．９％和８０．４％。     

12 minute consultation: Evidence based management of a patient with facial pain

Clin. Otolaryngol. 2012, 37 , 207–212 Background: There is a common misconception that facial pain and headache are mainly caused by sinusitis. The findings of nasal endoscopy, computer tomography (CT) and the results of observational studies reveal that this is not the case. Moreover, when sinus surgery is performed in patients where headache/facial pain has been a feature, it has been found that these symptoms persist after sinus surgery, particularly where there had been no nasal symptoms or endoscopic signs of paranasal sinusitis. Methods: This review was based on a literature search performed on 30 November 2011. The MEDLINE, EMBASE and Cochrane databases were searched using the subject heading of facial pain, that is, rhinosinusitis, migraine, cluster headaches, midsegment facial pain, trigeminal neuralgia, paroxysmal hemicrania, hemicrania continua and drug‐dependent headache. The search was limited to English language articles. Relevant references from selected articles were reviewed after reading the abstract. Results: A review of the literature shows that headaches are rarely caused by sinusitis. Similarly, only a small proportion of patients with facial pain have sinusitis, and these patients have either acute sinusitis or an acute exacerbation of chronic purulent sinusitis. Importantly, most patients with chronic rhinosinusitis rarely have facial pain unless they develop an acute infection or suffer barotrauma. CT scans should not routinely be performed for facial pain because of the prevalence of incidental changes in asymptomatic patients. Surgery is very rarely indicated in the treatment for chronic facial pain. Conclusion: A structured history of the pain and its associated symptoms, nasendoscopy and relevant targeted investigations should lead to a correct diagnosis and the appropriate treatment.     

Single intraoperative intravenous Co-Amoxiclav versus postoperative full oral course in prevention of postadenotonsillectomy morbidity: a randomised clinical trial

Background

Functional endoscopic sinus surgery (FESS) is now a well-established strategy for the treatment of chronic rhinosinusitis which has not responded to medical treatment. There is a wide variation in the practice of FESS by various surgeons within the UK and in other countries.

Objectives

To identify anatomic factors that may predispose to persistent or recurrent disease in patients undergoing revision FESS.

Methods

Retrospective review of axial and coronal CT scans of patients undergoing revision FESS between January 2005 and November 2008 in a tertiary referral centre in South West of England.

Results

The CT scans of 63 patients undergoing revision FESS were reviewed. Among the patients studied, 15.9% had significant deviation of the nasal septum. Lateralised middle turbinates were present in 11.1% of the studied sides, and residual uncinate processes were identified in 57.1% of the studied sides. There were residual cells in the frontal recess in 96% of the studied sides. There were persistent other anterior and posterior ethmoidal cells in 92.1% and 96% of the studied sides respectively.

Conclusions

Analysis of CT scans of patients undergoing revision FESS shows persistent structures and non-dissected cells that may be responsible for persistence or recurrence of rhinosinusitis symptoms. Trials comparing the outcome of conservative FESS techniques with more radical sinus dissections are required.     

CT扫描对上颌窦骨间隔畸形的诊断价值

目的：探讨ＣＴ扫描对上颌窦骨间隔畸形的诊断价值。方法：对８例经ＣＴ扫描确诊、手术证实的上颌窦骨间隔畸形患者的临床资料进行分析。结果：８例中，垂直冠状分隔者５例，水平分隔者２例，垂直矢状分隔者１例，双侧者３例，单侧者５例。     

鼻窦球囊导管扩张术的远期疗效分析

目的 评估鼻窦球囊导管扩张术的安全性和有效性.方法 应用鼻窦球囊导管扩张术治疗48例(94侧)慢性鼻窦炎伴或不伴鼻息肉以及霉菌性鼻窦炎和鼻窦囊肿患者,随访1年、2年,分析手术前后鼻内镜检查、冠状位鼻窦CT检查结果,用Lund-Kennedy内镜和Lund-Mackay鼻窦CT评分系统评分观察手术效果,以SNOT-20调查表评价预后.结果 患者主观症状均有不同程度改善,SNOT-20评分表中各项与术前比较差异有统计学意义(P＜0.01).鼻内镜检查见窦口通畅,与术前比较差异有统计学意义(P＜0.01),7例(8侧)窦口肿胀、狭窄可在术后随访过程重新扩大处理.1例出现眶周淤斑,无颅底和眼眶等严重并发症.结论 鼻窦球囊导管扩张术操作简便,能有效解除窦口阻塞,同时能够保留鼻腔鼻窦的正常结构,手术微创,出血少,安全有效.鼻内镜检查和鼻窦CT客观上反映了手术的良好转归.对合适的伴或不伴鼻息肉的鼻窦炎病例,可单独应用鼻窦球囊导管扩张术或联合标准的鼻内镜鼻窦手术.     

Endoscopic paranasal sinus surgery: indications and considerations

Recently, American otolaryngologists have become increasingly interested in endoscopic paranasal sinus surgery. This trend has been beneficial, because it has enhanced the understanding of the anatomy and pathophysiology of the sinuses. However, as with the introduction of any new surgical technique, it takes both time and experience to acquired the skills necessary to perform this procedure. To evaluate the state of endoscopic sinus surgery, we analyzed the experience of one of the authors with 100 consecutive patients undergoing therapeutic endoscopic sinus surgery over 23 months. With an average follow-up of 5 months (range: less than 1 month to 20 months), 14 patients had minor complications. The most common complication was synechia between the middle turbinate and the lateral nasal wall (six patients), resulting in revision surgery in four patients. Eighty-three patients were judged as having significantly improved after surgery, while ten were improved but had one episode of sinusitis postoperatively. The results of this series suggest that endoscopic paranasal sinus surgery is an efficacious advance in the treatment of sinusitis, given the limitations discussed in this report.     

43例真菌球型鼻窦炎诊疗分析

摘要：目的探讨真菌球型鼻窦炎的病因、临床特点、手术方式及疗效。方法回顾分析北京仁和医院耳鼻咽喉头颈外科2013年11月~2017年4月收治的43例真菌球型鼻窦炎患者的临床资料。全部患者均在全身麻醉下行鼻内镜手术治疗。结果术后随访6个月至1年，1例真菌球型蝶窦炎患者术后6个月复发，再次手术后随访6个月未见无复发。结论真菌球型鼻窦炎根据临床表现，结合鼻窦CT检查可初步诊断，鼻内镜手术是治疗的主要方法，预后良好。     

Significance of computed tomography pathology in chronic rhinosinusitis.

OBJECTIVES/HYPOTHESIS: Multiple reports show that the extent of disease on computer tomography (CT) of the sinuses does not correlate with patients' subjective sinus symptom scores. In the current study, sinus symptom scores of patients with normal findings on sinus CT scans are compared with sinus symptom scores of patients with chronic rhinosinusitis and with disease on CT of the sinuses. The objective is to determine the significance of CT disease in patients with chronic rhinosinusitis. STUDY DESIGN: Prospective collection of data of consecutive patients seen for possible sinusitis. METHODS: Prospective data at a tertiary medical center were collected over an 8-month period. Computed tomography scans were graded according to Lund and MacKay, and patients were asked to grade each of the major and minor rhinosinusitis symptoms listed by the Rhinosinusitis Task Force from 0 to 10. A score of 0 was given for no symptom at all, and 10 indicated the most severe extent of a symptom. RESULTS: Twenty-seven patients with sinus complaints had normal findings on sinus CT scans. The average scores for major and minor rhinosinusitis symptoms were 18.6 and 15, respectively. Twenty-six patients with sinus complaints had disease on CT of their sinuses. The average scores for major and minor rhinosinusitis symptoms for these patients were 42.9 and 22, respectively. Higher symptom scores were seen in the patients with CT disease, and the differences between these two groups were statistically significant (major symptom, P = .000001; minor symptom, P = .02). Patient symptom scores did not correlate with extent of disease on CT as previously reported (r = 0.16). CONCLUSION: The presence of CT disease translates to higher patient symptom scores compared with symptom scores of patients without CT disease.     

电磁影像导航在内镜鼻窦、颅底手术中的应用

目的：探讨电磁影像导航系统在内镜鼻窦、颅底手术中的优缺点。方法：12例患者,其中慢性鼻窦炎、鼻息肉5例,脑脊液鼻漏2例,慢性鼻窦炎合并脑脊液鼻漏1例,筛窦异物1例,垂体瘤1例,额、筛侵袭性丛状神经纤维瘤病1例,鼻咽、斜坡韦格纳肉芽肿1例,均应用Insta Trak电磁导航系统行鼻内镜手术。结果：术前准备平均15min,手术均顺利完成,术中、术后未出现并发症。结论：电磁导航系统能帮助术者确定术区周围重要解剖结构,减少并发症。尤其是在既往手术或病变破坏了鼻腔、鼻窦解剖标志的情况下,导航系统对术者的帮助更大。     

Is there a correlation between radiographic and histologic findings in chronic sinusitis?

OBJECTIVE: To determine if the degree of radiologic changes noted on computed tomography (CT) scan correlate with the severity of histologic changes. DESIGN: Retrospective analysis. SETTING: Academic tertiary care centre. METHODS: Sixty consecutive patients undergoing endoscopic sinus surgery for chronic sinusitis, with complete data obtained for 131 sinuses. MAIN OUTCOME MEASURES: Paranasal sinus CT scans and pathologic reports were examined. Respective findings were graded as mild, moderate, or severe, and the results were analyzed for agreement. CT scan grading was based on the extent of sinus opacification and pathologic grading was determined by the number of inflammatory cells found in the sinus mucosa. RESULTS: Of the 51 ethmoid sinuses, agreement between the radiographic and histologic grading occurred in 32 or 62.7%. In the maxillary group, a 57.1% (24 of 42) correlation was noted. Of the 20 frontal sinuses, agreement occurred in 8 or 40%, whereas a 22.2% (4 of 18) correlation was present in the sphenoid group. CONCLUSION: This study suggests that the severity of sinus disease based on preoperative CT scan does not correlate with the histologic degree of disease.     

慢性鼻窦炎、鼻息肉的修正性鼻内窥镜手术治疗

目的 :探讨修正性内窥镜鼻窦手术治疗复发性鼻窦炎、鼻息肉的临床意义。方法 :采用内窥镜鼻窦手术对 112例复发性鼻窦炎、鼻息肉患者进行了修正性治疗 ,术中采用 Messerklinger技术、Stryker切削器 ,并辅以控制性降压。结果 :病变清除满意 89例 (79.5 % ) ,手术欠满意 17例 (15 .2 % ) ,6例失败。并发脑脊液鼻漏 1例、眼眶血肿 4例、术后溢泪 3例 ,大出血 12例。结论 :修正性手术适用于鼻窦内窥镜手术后出现的术腔随访清理难以控制的鼻窦炎病变。但该术对于堵塞、粘连性病变效果较好 ,鼻息肉病效果欠佳。中鼻甲残根和后鼻孔上穹窿为手术重要的安全标志 ,术前 CT扫描可以减少并发症的发生。