Concurrent Endoscopic Sinus Surgery Research Articles

Role of Endoscopic Sinus Surgery and Dental Treatment in the Management of Odontogenic Sinusitis Due to Endodontic Disease and Oroantral Fistula.

Background: Odontogenic sinusitis (ODS) is frequently encountered in ENT practice; however, there are no guidelines regarding its management. This study aims to analyse the results of endoscopic sinus surgery versus dental treatment in ODS. Additionally, we aim to demonstrate the benefit of associating endoscopic sinus surgery (ESS) to surgical closure of chronic oroantral fistulas (OAF) by comparing mean time to healing in patients who opted or not for concurrent ESS. Methods: Records of patients with ODS were reviewed. Group one consisted of patients with ODS caused by periapical pathology undergoing either endoscopic sinus surgery (ESS) or dental treatment. Resolution of ODS was considered treatment success and was compared between the two treatment strategies. Group two included patients with ODS and associated chronic oroantral communication. Time to healing was compared between patients undergoing OAF closure alone versus patients receiving associated ESS, using the Log-Rank test to correlate Kaplan–Meier curves. Results: 25 patients from a total of 45 in group one underwent dental treatment alone, and 20 opted for exclusive ESS treatment. The failure rate was 40% for patients treated with ESS compared to 4% (one patient) for dental treatment. ODS resolved in all patients in the second group, but the mean time to healing was half (10 days) when ESS was complementary to OAF closure. Conclusion: The present study represents the first estimator of the role ESS plays in OAF treatment. Nonetheless, it provides proof of the importance of first addressing dental problems in odontogenic sinusitis.

Outcomes of Septal Perforation Repair With Concurrent Endoscopic Sinus Surgery

This study reviews a cohort of patients in whom septal perforation repair was performed concurrently with endoscopic sinus surgery. We present an endonasal perforation repair technique using bilateral mucosal flaps with an autogenous interposition graft. Intraoperative and postoperative management of the combined surgical patient is discussed and perforation closure outcomes are reported. Case series. Tertiary care center. In this institutional review board-approved retrospective chart review, adult patients who underwent concurrent bilateral mucosal flap septal perforation repair and endoscopic sinus surgery from March 1992 to March 2020 were identified. Data on demographics, clinical presentations, perforation size, surgical techniques, and outcomes were extracted and analyzed for patients with a minimum of 3 months of follow-up. Fifty-six patients met study inclusion criteria. Nasal obstruction/congestion was the most frequent symptom reported (80.4%), followed by crusting and epistaxis. Mean perforation size measured at the time of surgery was 14.7 (range, 3-41) mm in length by 9.3 (range, 2-23) mm in height. Temporalis fascia was the most frequent (57.9%) interposition graft material used. Complete perforation closure at the time of the last follow-up was noted in 51 (91.1%) patients. Only 1 failure was noted in the last 48 attempted repairs. Patients with a perforated septum may have coexistent chronic sinusitis. The feasibility of attempting concurrent sinus surgery and perforation repair has been questioned. Our review demonstrates a high perforation closure rate when a bilateral mucosal flap procedure is performed after sinus surgery is performed at the same setting.

Validation of Simultaneous Endoscopic Sinus Surgery and Transsphenoidal Surgery in Patients with Chronic Rhinosinusitis and Pituitary Tumors

Background and Objectives Transsphenoidal (TS) surgery for removal of pituitary lesions has become popular with improvements in diagnostic and treatment modalities, as well as endonasal and endoscopic methods, resulting in reduced complications. Rhinosinusitis (RS) is considered a risk factor for postoperative intracranial infections. Previously, we showed that concurrent TS surgery and endoscopic sinus surgery (ESS) yielded a favorable outcome in cases with pituitary lesions and RS. However, there seems to be a lack of consensus in performing simultaneous TS and ESS for patients with a pituitary lesion and RS. We would like to validate the feasibility of performing two operations concurrently.Subjects and Method We reviewed the medical records of 13 patients who underwent simultaneous TS surgery and ESS between 2007 and 2016. One patient underwent concurrent TS surgery and ESS twice due to the regrowth of pituitary macroadenoma and recurrence of RS.Results There were only four minor nasal complications during the postoperative period, which were controlled with conservative treatment. Only one patient exhibited postoperative cerebrospinal fluid leakage and no patients experienced intracranial complications.Conclusion This study shows that it might be better to treat patients with pituitary lesion and RS simultaneously. Also, further studies with large cases would be necessary to manage these patients without intracranial complications.

Infection After Endoscopic Dacryocystorhinostomy: Incidence and Implications

Endoscopic dacryocystorhinostomy (EN-DCR) is an increasingly common procedure performed by otolaryngologists. While EN-DCR has a high rate of success at relieving blockage of the lacrimal system, little is known regarding associated postoperative infection (POI) rates and risk factors. The purpose of this study was to identify factors associated with the occurrence of postoperative orbital and rhinologic infection in a large cohort of patients undergoing EN-DCR. A retrospective review of 582 patients who underwent EN-DCR was performed. All patients received antibiotic prophylaxis as a single intraoperative intravenous administration and a ten-day postoperative oral course. Clinical and demographic information was reviewed, including the occurrence of acute orbital or rhinologic infection within 30 days of surgery. Multivariable analysis was performed to identify risk factors associated with POI. Fifteen of 582 patients (2.6%) developed POI following EN-DCR. The most common POI was acute rhinosinusitis (10/15, 66.7%), followed by acute dacryocystitis (2/15, 13.3%), preseptal cellulitis (2/15,13.3%), and acute bacterial conjunctivitis (1/15, 6.7%). The majority of patients (464/582, 79.7%) underwent concurrent endoscopic sinus surgery (ESS). In most cases (302/464, 65.1%), ESS was performed to address comorbid rhinosinusitis, whereas 7.8% (36/464) of patients underwent surgery to enhance surgical access to the lacrimal sac. Patients who underwent concurrent ESS were less likely to develop POI (OR: 0.17, CI: 0.04-0.80, p < 0.05). Evidence of mucopurulence at surgery increased the likelihood of POI (OR: 6.24, CI: 1.51-25.84, p < 0.05). Mucopurulence at the time of surgery significantly increased the risk of POI, whereas concurrent ESS, performed most commonly to address comorbid rhinosinusitis, significantly decreased the risk of POI. Awareness of risk factors for POI and appropriate surgical management of concurrent rhinosinusitis can lead to reduced infectious complications after EN-DCR.

Coronavirus disease 2019 (COVID-19): challenges and management of aerosol-generating procedures in dentistry.

Data sources Experimental investigation.Study design A retrospective review to evaluate the use of a negative-pressure otolaryngology viral isolation drape (NOVID) system to reduce cross-infection through aerosol. The apparatus consists of a plastic drape suspended over the surgical field in the head and neck region with a smoke evacuator suction placed inside the chamber with an ultra-low penetrating air (ULPA) efficiency rating and a fluid suction high-efficiency particulate air (HEPA) filter compartment. Spread of patient secretions and droplet formation was evaluated using 1% fluorescein dye in 10 ml of normal saline and ultraviolet light. The dye was applied topically in the nasal cavity and nasopharynx preoperatively and intraoperatively prior to the use of instruments such as micro-debrider, electrocautery and high-speed drilling. Following completion of the surgical procedure, an ultraviolet Wood's lamp was used to evaluate the presence of droplets on the surgical drapes and surgical gowns of the operating team.Results The study sample consisted of four patients who underwent endonasal endoscopic surgical procedures; two of these patients required concurrent endoscopic sinus surgery. A micro-debrider was used in three cases; electrocautery in three cases, while a high-speed drilling was employed in two cases. Presence of fluorescein was identified around the patients' nares; on the chest wipe and instrument tray in all four patients. Dye contamination was noted on the gauze placed over the smoke evacuator (two cases of skull base surgery); no fluid droplets were identified beyond the nares or the smoke evacuator (two cases of sinus surgery). However, fluid contamination was identified underneath barrier several centimetres away from the nares (one case of trans-sphenoidal surgery). Droplets were also identified on the surgeon's gown in the abdominal region in all cases and on the arm region in one case. In one case, droplets were also identified on the abdominal region of the nurse, but this was attributed to cross contamination from surgical gauze and instruments. Conclusions This retrospective study provides preliminary data on aerosol and droplet contamination during endonasal and transoral surgery performed under a negative pressure isolation drape system. Although the authors did not screen patients for SARS-CoV-2, they propose smoke evacuator ULPA filter attachment is appropriate to capture particles down to 0.1 microns including SARS-CoV-2 which is 0.125 microns. It would be helpful to see direct evidence to support this claim in future studies. The authors have not provided details regarding set-up time and training requirements for effective application of the isolation drape apparatus or the associated costs etc. It would have also been helpful if the authors could comment on any potential difficulties in undertaking the surgical procedure with the isolation system in place. The sample size is limited to four patients and variations in the magnitude and extent of aerosol contamination needs to be investigated further before drawing any conclusions. Although unlikely, this study design did not capture the presence of aerosol/droplets in the air within the operating room which may follow removal of the isolation drape system or from exposed surgical instruments. Notwithstanding the limitations of the design, negative-pressure aspiration of air under a chamber barrier is likely to minimise the contamination from aerosol and droplet during endonasal and transoral surgery.

Factors of success of low-dose macrolides in chronic sinusitis: Systematic review and meta-analysis.

To assess the prognostic factors that predict favorable outcomes of low-dose macrolides (LDMs) in treating chronic rhinosinusitis (CRS). Randomized controlled trials studying the effects of LDMs in treating CRS were included. Data were pooled for meta-analysis. Primary outcome was Sino-Nasal Outcome Test (SNOT). Six prognostic factors: CRS subtypes, serum immunoglobulin (Ig)E level, membered lactone ring of macrolides, concurrent endoscopic sinus surgery (ESS), and dosage and duration of the LDMs were assessed by subgroup analyses. Ten studies (608 patients) met the inclusion criteria. LDMs and placebo were not different in SNOT improvement (standardized mean difference [SMD] = -0.23, 95% confidence interval [CI]: -0.69 to 0.24). Subgroup analyses showed that the effects favored LDMs in the patients with CRS without polyps (SMD = -0.64, 95% CI: -1.01 to -0.27) compared to CRS with polyps, and the patients receiving a half dose (SMD = -0.64, 95% CI: -1.01 to -0.27) compared to a very low dose. There was no difference in SNOT improvement between LDMs plus standard treatment compared to standard treatment (SMD = -0.52, 95% CI: -1.57 to 0.53). Subgroup analyses showed that the effects favored LDMs in the patients receiving LDMs for a duration of 24 weeks (SMD = -1.68, 95% CI: -2.40 to -0.95) compared to 8 and 12 weeks. There was no difference between the 14-membered and 15-membered ring LDMs. Assessment of concurrent ESS found mixed results. Serum IgE level could not be assessed. LDMs provided favorable outcomes in patients with CRS without polyps. A half dose of macrolides should be given for a duration of 24 weeks. 1a Laryngoscope, 129:1510-1519, 2019.

Endoscopic Sinus Surgery Associated with Rhinoseptoplasty: A Case-control Study.

Objective:To examine the difference between outcomes in the administration of concurrent endoscopic sinus surgery (ESS), septoplasty (SP), and rhinoplasty (RP) and concurrent ESS and SP in 1 single surgical session.Methods:Patients who underwent concurrent ESS and SP from September 2004 to July 2015 were identified. Furthermore, patients among them who underwent functional primary RP were selected. Subjects who had been administered concurrent ESS, SP, and RP (primary RP) were matched for sex, age, sinonasal surgical procedures for treatment of chronic rhinosinusitis with patients underwent concurrent ESS and SP, used as control subjects. A literature review was performed to find previous articles describing results of concurrent procedures among ESS, SP, and RP.Results:Twenty subjects, who underwent concurrent ESS, SP, and RP, were compared with a matched control group made of 20 patients who underwent concurrent ESS and SP, evaluating different postoperative outcomes (postoperative complications, postoperative improvement of respiratory symptoms, persistence of chronic rhinosinusitis symptoms 6 months to 1 year postoperative, need of revision surgery, satisfaction of the patient). Obtained P values showed that there was no statistically significant difference (P > 0.05) as regards the different outcomes, except for postoperative complications, increased because of the invasiveness proper of RP (P < 0.05).Conclusions:Therefore, execution of concurrent ESS, SP, and RP seems to be safe and effective, and additional RP does not modify postoperative outcomes of concurrent ESS and SP except for a little increase of postoperative complications, even if most of them had low impact on result of procedures.

Contemporary considerations in concurrent endoscopic sinus surgery and rhinoplasty.

Characterize indications, perioperative considerations, clinical outcomes and complications for concurrent endoscopic sinus surgery (ESS) and rhinoplasty. Chronic rhinosinusitis and septal deviation with or without inferior turbinate hypertrophy independently impair patient-reported quality of life. Guidelines implore surgeons to include endoscopy to accurately evaluate patient symptoms. Complication rates parallel those of either surgery (ESS and rhinoplasty) alone and are not increased when performed concurrently. Operative time is generally longer for joint surgeries. Patient satisfaction rates are high. Concurrent functional and/or cosmetic rhinoplasty and ESS is a safe endeavor to perform in a single operative setting and most outcomes data suggest excellent patient outcomes. Additional studies that include patient-reported outcome measures are needed.

Intracranial complications of acute sinusitis in children: The role of endoscopic sinus surgery

ObjectiveTo study the role of endoscopic sinus surgery (ESS) in the management of intracranial complications of children with acute rhinosinusitis MethodsRetrospective chart review at a tertiary care pediatric hospital Main outcomesDemographics, intracranial complications, length of hospital stay (LOS), neurological sequelae, ESS, neurosurgical procedures ResultsTwenty-four children with a mean age (SD) of 12.9 years (+/-3.2) with an intracranial complication(s) of acute rhinosinusitis were identified between 2005-2016. A total of 22 were included and 15 (68%) of these were males. The most common complications were: subdural abscess (n=10), epidural abscess (n=10), meningitis (n=5), intraparenchymal abscess (n=5), and cavernous sinus thrombosis (n= 2). Neurologic symptoms included headache (n=12), hemiparesis (n=5) and aphasia (n=3). Average length of stay was 16 (+/- 9.2) days. Average follow up was 7 (+/-5.6) months. One patient had residual seizures and 1 had recurrent rhinosinusitis. Aphasia and hemiparesis resolved in all patients within 1 year. Nineteen (86%) patients had ESS within 4 days of admission. Fourteen patients (63%) had a neurosurgical procedure, 6 (27%) required more than 1 neurosurgical procedure. Six patients (27%) had concurrent neurosurgical drainage and ESS. Four patients (17%) had neurosurgical procedure followed by ESS and 3 patients (13%) were treated only by a neurosurgical procedure. Patients who underwent ESS prior to a neurosurgical procedure had significantly less risk of needing a neurosurgical intervention (OR = .02, p < .01). There was a significantly higher proportion of neurosurgical patients with positive Strep anginosus cultures compared to the ESS only group (85.7% vs 37.5%, p = .02). Studies with larger patient populations are needed to determine the role of ESS in the management of intracranial complications of children with acute rhinosinusitis. DiscussionEarly ESS may be associated with less need for neurosurgical procedures.

The burden of revision sinonasal surgery in the UK—data from the Chronic Rhinosinusitis Epidemiology Study (CRES): a cross-sectional study

ObjectivesThe aim of this study was to investigate the surgical revision rate in patients with chronic rhinosinusitis (CRS) in the UK CRS Epidemiology Study (CRES). Previous evidence from National Sinonasal...

Odontogenic sinusitis: a case series studying diagnosis and management.

Odontogenic sinusitis is a well-recognized, but understudied form of sinusitis. Odontogenic sinusitis requires unique diagnostic criteria and a treatment regimen that differs from non-odontogenic sinusitis. The purpose of this article is to present a case series of patients with odontogenic sinusitis in order to clarify key disease characteristics and management techniques. Retrospective case series of 55 patients with odontogenic sinusitis. Each patient underwent chart and imaging review to analyze demographic factors, diagnostic criteria, clinical course, and management. Fifty-five patients were identified retrospectively. Forty-four were diagnosed at initial visit. Twenty-eight (64%) of these patients were diagnosed by computed tomography (CT) scan showing dental pathology, 11 (25%) by known temporal relationship to a dental procedure, and 5 (11%) by presentation with oral-antral fistula. Only 65% of radiology reports for all patients mentioned dental pathology. Overall, 21 (38%) patients had disease resolution. Of these, 7 (33%) resolved with endoscopic sinus surgery (ESS) alone, 7 (33%) resolved with concurrent ESS and dental surgery, 2 (10%) resolved with dental surgery alone, 2 (10%) resolved with ESS after failing dental surgery, 2 (10%) resolved with medical management alone, and 1 (5%) resolved with medical management after failing dental surgery. Forty-six (84%) patients had unilateral odontogenic sinusitis. The Lund-Mackay score for all patients was (mean ± standard deviation [SD]) 4.0 ± 3.2. Odontogenic sinusitis is often misdiagnosed. Radiology reports commonly do not mention dental pathology. Management of odontogenic sinusitis needs to be tailored to each individual patient and involves varying combinations of medical management, dental surgery, and ESS.

Surgical management of rhinosinusitis in endoscopic-endonasal skull-base surgery.

Endoscopic-endonasal skull base surgery (ESBS) provides an important approach to select pathologies. There remains a paucity of data, however, regarding morbidity in patients undergoing ESBS with comorbid acute rhinosinusitis (ARS), a fungal ball (FB), or chronic rhinosinusitis (CRS). A retrospective database review between January 2008 and January 2013 identified 35 patients with concurrent skull-base pathology and refractory ARS, FB, CRS, and CRS with nasal polyposis (CRSP) who underwent endoscopic sinus surgery (ESS) and ESBS. Two of 35 (5.7%) had an FB, 3 of 35 (8.6%) had ARS, 19 of 35 (54.2%) had CRSP, and 11 of 35 (31.4%) had CRS. Five of 35 (14.3%) were staged procedures whereas 30 of 35 (85.7%) underwent concurrent ESS and ESBS. Four patients (80%) who were staged carried diagnoses of an FB and ARS. Two patients in the concurrent group required revision ESS for recurrent polyposis. There were no cases of intraorbital or intracranial infectious complications. Management of the paranasal sinuses is paramount to maintain healthy sinonasal function in patients undergoing ESBS. In our experience, most cases of CRS and CRSP can be surgically managed at the time of ESBS without increased risk of intracranial infection. Patients with ARS at the time of surgery or an FB should be staged to avoid postoperative ESBS morbidity.

Management of CRSwNPs Surgically

Objectives: Long-term follow-up of 1045 patients with chronic rhinosinusitis with nasal polyposis (CRSwNPs) in the national Sinonasal Audit demonstrated that at 5 years 20.6% of patients had undergone revision surgery. The aim of this study was to see if the Chronic Rhinosinusitis Epidemiology Study (CRES) data reflected a continued burden of revision surgery in patients with CRSwNPs. Methods: A prospective questionnaire-based study at 30 sites around the UK of patients with CRS presenting to secondary care between October 2007 and September 2013. This paper presents a specific analysis of patients with CRS who reported undergoing sinus surgery. Results: A total of 651 patients with CRSwNPs, 553 with CRSsNPs, and 45 with AFRS were included in the CRES. 365 (57%) of patients with CRSwNPs/AFRS reported undergoing endoscopic nasal polypectomy (ENP) in which 175 (25% or 48% of surgical cases) reported having received more than one ENP. The mean number of ENPs per patient in the revision group was 3.3 with a range of 2 to 30. Only 27.9% of patients reported concurrent endoscopic sinus surgery (n = 102). For comparison, patients with CRSsNPs reported ESS in 13% of cases with only 17% of those surgical cases reporting multiple procedures (chi-squared P &lt; .001). Conclusions: This study demonstrated a significantly higher burden of both primary and revision surgery to the health care system for patients with CRSwNPs. Extrapolation of these findings to the HES data for 2011 and 2012 would suggest a bill of approximately £5.3 million per year spent on revision surgery.

The Effects of Endoscopic Sinus Surgery on the Postoperative Outcomes of Open Rhinoplasty

Several studies have advocated concurrent endoscopic sinus surgery and rhinoplasty. However, concerns about increased surgical risk, complications, and unsuccessful cosmetic outcomes following the concurrent procedures have been reported. The aim of this study was to investigate the overall safety of concurrent endoscopic sinus surgery and rhinoplasty and to specifically examine the effect of endoscopic sinus surgery on cosmetic outcomes. We retrospectively reviewed 57 patients who underwent concurrent open rhinoplasty and endoscopic sinus surgery (ESS). We then selected a control group of patients, who underwent rhinoplasty only and were matched with a study group for age, sex, external nose deformity, and implant graft material. The postoperative outcomes of the 2 groups were compared. Fifty-seven patients underwent concurrent open rhinoplasty and ESS. Postoperative assessment showed that a successful outcome was achieved in 82.5% of the patients who underwent concurrent procedures and in 87.7% of the patients who underwent rhinoplasty only (P = .56). The rate of revision due to a dissatisfied outcome was 5 patients (8.7%) in the concurrent surgery group and 3 patients (5.3%) in the rhinoplasty-only group (P = .36). Minor complications occurred in 6 patients (10.5%) from the group who underwent the concurrent procedures and 5 patients (8.8%) from the rhinoplasty-only group (P = .76). Combined rhinoplasty and endoscopic sinus surgery achieves a similar aesthetic outcome to rhinoplasty only, with no significant increase in rates of revision or complication.

Combined Endoscopic Sinus Surgery and Rhinoplasty: Efficacy and Limitation

Received April 5, 2014 Revised May 22, 2014 Accepted May 23, 2014 Address for correspondence Hong-Ryul Jin, MD, PhD Department of OtorhinolaryngologyHead and Neck Surgery, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 156-707, Korea Tel +82-2-870-2441 Fax +82-2-870-3866 E-mail doctorjin@daum.net Background and ObjectivesZZCombined endoscopic sinus surgery (ESS) and rhinoplasty may benefit patients but can pose a considerable task to the surgeon at the same time. The aim of this study is to analyze the surgical outcomes of the concurrent ESS and rhinoplasty with emphasis on the efficacy and limitation. Subjects and MethodZZConsecutive 21 patients who underwent concurrent ESS and rhinoplasty (combined group) were identified. For comparison, rhinoplasty group who had only rhinoplasty and ESS group who had only ESS over the same period were selected. Medical records, endoscopic findings, and CT scans were reviewed. A telephone survey was done to evaluate subjective outcomes of the surgery. Objective aesthetic outcomes of rhinoplasty were evaluated by comparing the preoperative and postoperative photos by two rhinoplasty surgeons. ResultsZZIn the combined group, ten patients (24%) had ESS-related complications and one patient (5%) had rhinoplasty-associated complications. On the other hand, only one patient (5%) had recurred rhinosinusitis in the ESS group but three patients (14%) had complications including revision surgery in rhinoplasty group. Subjective functional satisfaction score after ESS and subjective aesthetic satisfaction score after rhinoplasty did not show any significant difference between the combined group and each matching group. Objective aesthetic evaluation did not show any difference either. ConclusionZZConcurrent ESS and rhinoplasty have similar subjective functional improvement and objective surgical outcome compared with ESS alone or rhinoplasty alone. However, concurrent surgery had a tendency to show poorer surgical outcome in ESS than in rhinoplasty warranting a cautious approach with patient selection. Korean J Otorhinolaryngol-Head Neck Surg 2014;57(7):460-5

Triological thesis: concurrent endoscopic sinus surgery and cosmetic rhinoplasty: Rationale, risks, rewards, and reality

To examine the effect of concurrent endoscopic sinus surgery (ESS) on the postoperative course of cosmetic rhinoplasty (CR), identify any specific contraindications, and to develop more useful treatment regimen in patients undergoing concurrent ESS and CR. Retrospective case-control study. Consecutive patients undergoing CR (performed by the principal investigator (PI) in a tertiary care academic practice) at the same operative setting as ESS from June 2004-June 2007 were identified. Additionally, patients undergoing CR (also by the PI) without ESS over the same time period (matched for gender, age, and rhinoplasty approach and techniques) were identified and used as control subjects. The office and hospital charts of these patients were reviewed for details of pre-, intra-, peri-, and postoperative care, preoperative CT scans as well as for patient and physician observations. Specifically noted were details regarding the type of cosmetic changes sought, course of symptoms of chronic sinusitis, prior treatment, surgical techniques used for both ESS and CR, and postoperative treatment with antibiotics and corticosteroids. Additionally, a literature review of articles describing concurrent CR and ESS was performed. Thirteen patients were identified who underwent ESS at the same time as CR. There were no cases of cerebrospinal fluid leak, epistaxis, orbital complications, septal perforation, cellulitis or saddle nose deformity. No correlation was found between sinus surgery performed and need for revision surgery (CR or ESS) or postoperative infections. However, the time to patient reported resolution of postoperative nasal swelling was significantly higher in patients undergoing concurrent ESS/CR compared to CR only (dorsal swelling: 9.62 +/- 6.18 (ESS/CR) vs. 5.85 +/- 1.95 (CR) weeks, P = .0469; nasal tip swelling: 19.31 +/- 13.02 (ESS/CR) vs. 10.38 +/- 2.96 (CR) weeks, P = .0240, unpaired t test). The same relation held true for doctor noted postoperative edema (nasal dorsal edema: 10.62 +/- 7.32 (ESS/CR) vs. 6.31 +/- 2.72 (CR) weeks, P = .0582; nasal tip edema: 21.46 +/- 15.66 (ESS/CR) vs. 12.23 +/- 4.10 (CR) weeks, P = .0508, unpaired t test). Among patients who underwent concurrent ESS and CR, this time was highly correlated with the severity of sinus disease on preoperative CT scanning (r(2) = 0.8573, P < .0001). A greater need for postoperative corticosteroid injections in the ESS/CR group was suggestive but not statistically significant (30.8% vs. 0%, P = .0957). While our data supports concurrent ESS and CR as safe, our findings suggest that the presence and treatment of concurrent sinonasal disease prolongs the patients' recovery from CR. This may be due to the effects of sinus pathology and manipulation of sinonasal venous and lymphatic drainage patterns or could be due to subclinical infectious soiling of rhinoplasty tissue planes. We recommend a two-team approach to promote excellent surgical technique, avoid surgeon fatigue, and enhance patient care. We recommend adequate medical management of chronic sinusitis prior to surgery, pre, intra and postoperative antibiotic coverage, appropriate postoperative sinus toilet beginning 1 week after surgery and careful and close patient follow-up to optimize results. Most importantly, we advocate close coordination of sinonasal and rhinoplastic care in a two-team approach to maximize care.

Rhinologic Outcomes of Concurrent Operation for Pituitary Adenoma and Chronic Rhinosinusitis: An Early Experience

The transsphenoidal approach (TSA) is the procedure of choice for the vast majority of pituitary neoplasms. Sinusitis is considered a contraindication to TSA because of possible transcranial spread of infection. This study was performed to determine if TSA for pituitary tumors could be extended to patients with pituitary adenoma and chronic rhinosinusitis (CRS). Medical records, including rhinologic outcomes, were retrospectively assessed in 11 consecutive patients who underwent concurrent TSA and endoscopic sinus surgery (ESS) because of pituitary adenoma and CRS between May 2004 and October 2007. The 11 patients consisted of 5 men and 6 women, with a mean age of 55 years (range, 31-69 years) and average follow-up of 24.4 months (range, 6-44 months). Preoperatively, all patients had symptoms of CRS, but none had acute exacerbation of rhinosinusitis. All patients had CRS and two had nasal polyps. TSA was via the transcolumellar transseptal approach in seven patients and the transnasal approach in four patients. No postoperative complications due to ESS were observed. Two patients, including one with sphenoid aspergillosis, had preoperative unilateral sphenoid sinusitis, which was managed by ESS on the involved side, with TSA performed concurrently through the contralateral healthy sphenoid sinus. There was one case of postoperative sphenoid sinusitis and one case of septal perforation due to TSA. There were no postoperative intracranial complications, including meningitis and brain abscess. Concurrent TSA and ESS can be performed in selected patients with CRS and pituitary adenoma. Future studies should involve more patients and longer follow-ups.

Concurrent Endoscopic Sinus Surgery and Rhinoplasty

Concerns over increased surgical risk and associated complications have been reported regarding concurrent endoscopic sinus surgery (ESS) and rhinoplasty procedures. The aim of this study was to evaluate the overall safety of these concurrent procedures in our experience. A chart review was performed on 48 consecutive patients undergoing concurrent ESS and rhinoplasty between January 1998 and January 2005 with a mean follow-up of 12 months. The extent of surgical procedures, revisions required, and postoperative complications were documented. Thirty-one (65%) women and 17 (35%) men ranging in age from 16 to 56 years with a mean age of 37 years were included in this study. Forty-five patients (93.7%) underwent a primary rhinoplasty procedure, whereas the other three (6.3%) underwent a revision rhinoplasty. Four patients required minor rhinoplasty revision procedures for a rhinoplasty revision rate of 4/48 or 8.3%. Complications noted in three separate cases included partial nasal obstruction, pain near osteotomy site, and localized infection for a complication rate of 3/48 or 6.3%. In this study, rhinoplasty revisions did not appear to be related to the fact that ESS was performed at the same time as rhinoplasty. In addition, the only complication possibly attributed to a combined approach was a postoperative infection that developed in an insulin-dependent diabetic patient who underwent a rhinoplasty for functional reasons. Consequently, we recommend screening patients with poor wound healing factors in addition to those with acute exacerbations of chronic rhinosinusitis or severe chronic rhinosinusitis before performing concurrent ESS and rhinoplasty. In our experience, complications noted during concurrent ESS and rhinoplasty were minor, indicating the overall safe nature of this combined procedure when performed in appropriate patients.