Endoscopic Sinus Surgery Research Articles

Allergic fungal rhinosinusitis (AFRS) is a highly recurrent form of chronic allergic rhinosinusitis in immunocompetent patients. This study aims to compare the recurrence rates of AFRS between patients who received nasal steroid spray alone and patients who received a combination of nasal and oral steroids after endoscopic sinus surgery. This was a retrospective chart review of patients who underwent endoscopic sinus surgery for AFRS. The selection of the 39 participants has followed the 5 aspects of Bent and Kuhn criteria. Patients were divided into 2 groups: those discharged on both nasal and oral steroids (combination group) and those discharged on nasal steroids alone (local therapy group). All patients were followed for 3 years post operatively, and multiple assessments done for disease recurrence. One patient from 13 patients in the combination therapy group (7.7 %) and 9 patients from the 26 patients in the local therapy group (34.6 %) had recurrence of the condition and underwent functional endoscopic sinus surgery revision surgery (Fisher Exact Test = 3.30, P = .069). AFRS has recurred more frequently among patients who had bilateral disease (33.3%) compared to those who had unilateral disease (0%) (Fisher Exact Test = 4.03, P value = .045). In the postoperative medical management in ARFS, the combination of a short course of oral prednisolone and nasal steroid spray maybe effective to lower the recurrence rate of the disease when compared to nasal steroid spray alone.

Background & objective: Functional endoscopic sinus surgery (FESS) is a minimally invasive surgical technique used in some nasal conditions, refractory to medical treatment, for example chronic rhinosinusitis. The pain after the procedure is usually addressed with non-steroidal anti-inflammatory drugs (NDAIDs) or opioids, which are not without side effects. We conducted this study to assess the effect of bilateral sphenopalatine ganglion block with 0.5% bupivacaine injection at the end of the surgery in controlling postoperative pain. Methodology: We performed a double blinded randomized clinical trial on 70 patients undergoing FESS under general anesthesia. Sample size was calculated using PASS software version 15. Based on the findings of a previous study, using a two-sided two- sample equal-variance t-test with the population effect size at 0.7, the significance level (alpha) at 0.05 and the power (1- β) at 0.8, a sample size of at least 70 patients (35 per group) was produced. The patients were randomly assigned to one of the two groups; a control group, where normal saline was injected in the greater palatine foramen transorally, and the study group (SPG block group), where 0.5% bupivacaine was injected. Pain was then assessed postoperatively by the visual analogue scale (VAS); and the time to first need of inj. fentanyl as rescue analgesia and the total amount used were recorded. Results: Maximum intensity of the pain was at 2 hours post-operatively in the control group and 6 hours in the SPG block group, and pain intensity was lower in the SPG block group at 2, 6 and 12 hours post- operatively. In the SPG block group, less patients required rescue analgesia, time needed for the first dose of rescue analgesia was more, and the total 24-hour fentanyl consumption was lower. Conclusions: Sphenopalatine ganglion block using 0.5% bupivacaine results in better postoperative pain management, and a reduced need for analgesics in patients undergoing functional endoscopic sinus surgery. Keywords: Bupivacaine; Endoscopic Sinus Surgery; Fentanyl; Sphenopalatine Ganglion Block Citation: Albadry YAB, Saleh SHET, El-said AM, Naseef JN. The effect of sphenopalatine ganglion block with 0.5% bupivacaine on postoperative pain after functional endoscopic sinus surgery (FESS) under general anesthesia. Anaesth. pain intensive care 2025;29(4):356-62. DOI: 10.35975/apic.v29i4.2820 Received: April 02, 2025; Revised: June 06/ June 12, 2025; Accepted: June 12, 2025

We aimed to compare revision surgery risk and postoperative healthcare utilization between patients with chronic rhinosinusitis (CRS) who undergo balloon sinuplasty (BSP) versus endoscopic sinus surgery (ESS). Using the TriNetX US database, patients 18 years or older with CRS were retrospectively followed for five years, excluding those with a history of cystic fibrosis or sinonasal malignancy. The cohort was stratified into patients who underwent BSP versus ESS, and subsequently propensity score matched by age, sex, race, ethnicity, history of asthma, allergic rhinitis, nicotine dependence, and nasal polyposis. The primary outcome was revision ESS or BSP. Secondary outcomes included postoperative oral antibiotic and steroid utilization. Of the 4,632 patients included, 26.0% had nasal polyps. Within five years of initial surgery, 215 (9.70%) BSP patients underwent either revision BSP or ESS compared to 160 (7.22%) patients with initial ESS (p=0.0004). Initial BSP was associated with a greater risk of undergoing revision BSP at one year [OR 2.70; 95%CI (1.49,4.90)], three years [OR 2.41; 95%CI (1.49,3.90)], and five years [OR 3.02; 95%CI (1.87,4.86)] postoperatively. Notably, after one year of initial surgery, there was no difference in postoperative antibiotic or steroid utilization between patients who underwent ESS or BSP. Patients with CRS who undergo BSP are at a greater five-year-risk for revision ESS or BSP, as compared to patients who undergo ESS. However, long-term postoperative healthcare utilization does not vary significantly between patients who undergo either procedure.

Various factors affect the immunopathogenesis of chronic rhinosinusitis (CRS). Although the relationship between allergies and CRS has attracted considerable attention, it remains controversial. Notably, little is known about whether the clinical characteristics and immunological profiles differ based on allergic sensitization status among patients with CRS. This study included 209 patients with CRS with nasal polyps (CRSwNP) who underwent endoscopic sinus surgery, and their nasal polyp tissues were obtained. Patients were divided into two groups according to allergic sensitization status: "allergic" and "non-allergic" groups. The clinical characteristics and immunological profiles were compared between the two groups. Ex vivo phenotypes of nasal CD4+ T cells were analyzed using flow cytometry. Compared to the non-allergic group, the allergic group exhibited a significantly higher prevalence of comorbid asthma, serum total IgE levels, SNOT-22 scores, JESREC scores, blood/ tissue eosinophil counts, the proportion of eosinophilic histologic type, and lower gustatory function test scores. Additionally, the frequencies of nasal T helper 2 (TH2) and proallergic TH2 (TH2A) cells were significantly higher in the allergic group than in both the non-allergic and the control groups, and these frequencies were significantly correlated with eosinophilic inflammation. Our study demonstrates that allergic sensitization is closely associated with eosinophilic inflammation, as indicated by elevated levels of blood/tissue eosinophils and nasal TH2A cells, and by worse symptom scores in CRSwNP. Given the distinct immunological features of allergic patients, considering allergic sensitization within nasal tissue when managing CRSwNP is crucial.

Chronic maxillary atelectasis (CMA) describes the loss of maxillary sinus volume and has been well-described in the literature under many different names, creating inconsistency in reporting. A recent proposal has standardized the nomenclature but does not include disease of other paranasal sinuses. We describe a unique case of chronic ethmoid atelectasis, briefly review literature associated with CMA, and propose an expanded classification of chronic sinus atelectasis. A 70-year-old man presented to the emergency department with transient vision loss and was incidentally found to have sinus opacification on MRI. At his otolaryngology follow-up, he did not have any signs of sinonasal symptoms, hypoglobus, or enophthalmos. CT confirmed sinus opacification which was correlated with lateralized left middle turbinate and uncinate process. The patient underwent functional endoscopic sinus surgery to correct the anatomical changes. The spectrum of atelectasis affecting the ethmoids mirrors what has been described for CMA, potentially indicating a similar disease process affecting different areas. If this falls along the same spectrum of disease, the grading system applied to CMA may be applied to other paranasal sinuses.

Chronic rhinosinusitis (CRS) may require endoscopic sinus surgery (ESS) as a complement to medical therapies. Type 2 dominant inflammation underlies nasal polyposis (CRSwNP), and is characterized by eosinophilic inflammation, poor therapeutic response, and high recurrence risk. Type 2 inflammation was defined as eosinophilic CRS (ECRS) based on clinical presentation and laboratory findings. Unfavorable wound healing, associated with elevated levels of matrix metalloproteinase 9 (MMP-9), can lead to failure of ESS. Doxycycline with its antibiotic, anti-inflammatory, and anti-protease (including MMP-9) properties may improve postoperative healing. Thirty-three adult CRS patients scheduled for ESS were randomly assigned to receive either doxycycline or placebo for 56 days postoperative and were followed up until 48 weeks post-ESS. Postoperative wound healing was assessed endoscopically. Nasal secretions, serum, and patient-reported outcome measures were collected throughout the study. Nasal secretions were analyzed to monitor local myeloperoxidase (MPO), MMP-9, eosinophilic cationic protein (ECP), and IgE levels from baseline until 48 weeks post-ESS. Proteomics analysis, using LC-MS/MS, of nasal secretions was performed at baseline, 2- and 8-weeks post-ESS to investigate wound healing mechanisms. Postoperative doxycycline significantly improved wound healing quality in patients with CRSwNP or ECRS. Increased local MMP-9, neutrophilic (MPO), and eosinophilic (ECP) inflammation post-ESS was dampened by doxycycline. Wound healing and extracellular matrix remodeling processes were upregulated by doxycycline treatment. In contrast, the placebo group showed increased neutrophilic inflammation and delayed healing. Postoperative doxycycline therapy facilitated wound healing in CRSwNP and ECRS patients and suppressed local mucosal inflammation.

Xylitol, a low-permeability sugar alcohol, is recommended for treating chronic rhinosinusitis (CRS) due to its ability to decrease liquid salt concentration at the airway surface. This study investigated the efficacy of xylitol nasal irrigation for the management of CRS and its postoperative care. We analysed 7 studies with 263 participants after reviewing the studies that were retrieved from PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases up to December 2024. Those comparing changes in endoscopic score, Sinonasal Outcome Test (SNOT), Nasal Obstruction Symptom Evaluation (NOSE), olfactory dysfunction, and CRS-related visual analogue scale from baseline to post-treatment between xylitol and normal saline nasal irrigation groups were analysed. Nasal irrigation with xylitol significantly improved sinonasal well-being in CRS patients compared to irrigation with saline (SMD 0.6253, 95% CI [0.0067; 1.2438]; I2 = 0.0%). Patients who underwent endoscopic sinus surgery showed substantial SNOT improvement (SMD 3.1284, 95% CI [0.5229; 5.7338]; I2 = 86.1%), while no significant changes were observed in non-ESS patients (SMD 0.2571, 95% CI [-0.4872; 1.0014]). The xylitol group also showed significant improvements in NOSE (SMD 0.5976, 95% CI [0.2297; 0.9656]; I2 = 49.3%) and SNOT scores (SMD 0.3608, 95% CI [0.0724; 0.6493]; I2 = 49.1%). However, there were no significant changes in endoscopic scoring (SMD 0.1309, 95% CI [-0.1777; 0.4396]; I2 = 0.0%), olfaction (SMD -0.0292, 95% CI [-0.3633; 0.3050]; I2 = 0.0%), or saccharine clearance time (SMD 0.3816, 95% CI [-0.3816; 1.1449]; I2 = 61.6%). Xylitol irrigation was well tolerated, with minimal, transient side effects and no significant adverse events. Nasal irrigation with xylitol significantly improves the subjective management of CRS and postoperative care compared to saline irrigation but does not alter objective outcomes.

Comparison of three different loading doses of dexmedetomidine for controlled hypotension during functional endoscopic sinus surgery under general anaesthesia- A randomised controlled study

This case report describes a male patient with chronic invasive fungal sinusitis, mainly characterised by swelling of the eye. After a definitive diagnosis was made based on clinical symptoms and imaging studies, the patient received timely antimicrobial and symptomatic treatment, followed by functional endoscopic sinus surgery and orbital abscess drainage. The foci of infection in the sinuses were completely removed and adequate drainage of the sinuses was achieved, resulting in significant relief of the patient's symptoms. The follow-up examination 1 month after discharge showed a good recovery.

BackgroundNasal septum deviation (NSD) plays a vital role in paranasal sinus development, influencing sinonasal structures and maxillary sinus volume (MSV). This study aims to identify the NSD types and ascertain their impact on sinonasal variants, MSV, and morphometry of the infundibulum using three-dimensional (3D) computed tomography (CT) scans.MethodsCT images of 300 patients (150 females and 150 males), aged between 18 and 70 years, were retrospectively analyzed. The prevalences of NSD types, NS pneumatization (NSP), middle concha bullosa (MCB), paradoxical middle turbinate (PMT), MS mucosal thickening (MSMT), accessory maxillary ostium (AMO), uncinate process (UP) variants, and inferior turbinate hypertrophy (ITH) were evaluated. Also, MSV, MO width (MOW), infundibulum length (IL) and angle (IA) were measured. Statistical analyses of data was done taking into account gender, laterality, and age.ResultsThe greater the degree of NSD, the greater the likelihood of MCB, PMT and ITH occurring on the opposite side. Conversely, AMO, hypoplastic MS, MSMT, and hook-shaped UP were more prevalent on the same side of the deviation. The strongest associations with ipsilateral hyperplastic MS and being a young male were exhibited by PMT and MCB. Moderate and severe NSD, AMO, hook-shaped UP, hypoplastic MS and MSMT were more prevalent in older subjects, while younger subjects had more NSP, extensive MCB, PMT with a significant difference. The mean MSV, MOW and IL were found to be lower in MS on the same side of NSD, while the largest IA was observed in MS with severe NSD, as well as larger IA on the ipsilateral side of deviation, with a significant difference. However, we found that, as the degree of NSDA increased, the mean IL decreased and the mean MOW increased. The mean MOW and IL values indicated a positive correlation with ageing, whereas the MSV and IA values decreased with increasing age.ConclusionsDespite their significance, our understanding of how sinonasal structures, MSV, and infundibulum morphometry vary and covary with NSD remains limited, a crucial aspect in the planning of dental implantology and endoscopic sinus surgery.

Pott’s Puffy Tumor (PPT) is a rare but potentially life-threatening complication of frontal sinusitis, characterized by subperiosteal abscess formation and frontal bone osteomyelitis. Although predominantly seen in adolescents, adult cases are increasingly recognized. Early diagnosis is essential to prevent severe orbital and intracranial sequelae. We present two patients with distinct clinical features: a 31-year-old female with chronic frontal sinusitis complicated by sequestrated bone extrusion through a cutaneous fistula, and a 16-year-old male with an acute presentation of subperiosteal abscess, nasal polyp-related obstruction of the osteomeatal complex (OMC), and orbital cellulitis. Both patients underwent combined surgical and medical management, including broad-spectrum intravenous antibiotics, functional endoscopic sinus surgery, and external drainage. In the adult, necrotic bone was excised, and the anterior frontal wall was reconstructed with titanium mesh to restore sinus anatomy and drainage, while in the adolescent, early abscess drainage and polyp removal ensured frontal recess patency and prevented osteomyelitis. Postoperative follow-up demonstrated complete resolution without recurrence. These cases highlight that PPT can occur in both acute and chronic settings of chronic rhinosinusitis with nasal polyps, emphasizing the importance of prompt imaging, multidisciplinary evaluation, and individualized surgical strategies to optimize outcomes and minimize life-threatening complications.

Endoscopic endonasal transsphenoidal surgery in children: Necker - Enfants Malades Hospital experience.

Telementoring shows promise as a supportive tool to enhance confidence and comfort in endoscopic sinus surgery training. This study’s remote guidance model demonstrates the potential of a scalable, low-barrier solution to expand access to expert mentor- ship in surgical education, particularly in resource-limited or geographically remote settings.

ABSTRACTGranulomatosis with polyangiitis (GPA) is a rare disease of unknown aetiology with variable severity and a relapsing course. We report a case emphasizing the importance of the airway status and management of patients with a history of GPA. The patient was a candidate for emergency endoscopic sinus surgery and general anaesthesia to control bleeding. After induction of anaesthesia, the patient was placed under general anaesthesia for endoscopic sinus examination, and mask ventilation was initiated. On laryngoscopy, porous granulomatous tissue and a web‐like membrane were observed in the subglottic area near the vocal cords, involving extensive portions of the glottis and subglottis. Consequently, endotracheal intubation was not attempted. Given the urgency of the surgery, an emergency tracheostomy was performed, followed by the planned procedure. Subglottic stenosis (SGS) is one of the most difficult‐to‐treat organ involvements in patients with GPA. Screening for respiratory distress should be done even in asymptomatic patients at the time of diagnosis of GPA. Early diagnosis and management of tracheobronchial involvement in GPA significantly improve the prognosis of patients.

Examination of opioid prescribing guidelines on sinus surgery opioid prescription trends.

ABSTRACTBackgroundChronic rhinosinusitis with nasal polyps (CRSwNP) significantly impairs the quality of life, and disease control is now considered the primary treatment goal. Although patient‐reported outcome measures (PROMs) such as the 22‐item Sinonasal Outcome Test (SNOT‐22) and CRS‐PRO are widely used, their utility in predicting long‐term postoperative disease control remains limited.MethodsThis prospective follow‐up study aimed to evaluate postoperative recovery and identify the predictors of suboptimal disease control in patients with CRSwNP by integrating preoperative PROMs with objective clinical features. A total of 102 patients with CRSwNP undergoing functional endoscopic sinus surgery (FESS) were enrolled, of whom 89 completed at least 12 months of follow‐up. Preoperative and postoperative PROMs were compared across disease control groups classified based on the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 criteria. Least absolute shrinkage and selection operator regression was applied to select objective clinical predictors, which were then combined with either CRS‐PRO or SNOT‐22 item scores to develop and compare the nine machine learning models. Model performance was assessed using area under the curve (AUC), decision curve analysis, sensitivity, specificity, and other metrics.ResultsEosinophil and neutrophil counts were identified as key objective predictors of suboptimal disease control after FESS. Among all models, logistic regression incorporating CRS‐PRO scores and selected clinical features achieved the best performance, yielding an AUC of 0.866, accuracy of 83.3%, sensitivity of 72.7%, specificity of 89.5%, and F1‐score of 76.2%. This model demonstrated a strong discriminatory ability and potential utility in individualized clinical decision‐making.ConclusionIntegrating preoperative CRS‐PRO item scores with selected objective clinical parameters enables the accurate prediction of suboptimal disease control in patients with CRSwNP following FESS. This approach supports personalized risk stratification and postoperative management strategies.

Tailored Reconstruction of Low- and High-Flow Cerebrospinal Fluid Leaks: A Single-Center, 1-Year Analysis Following 656 Endoscopic Endonasal Surgeries.

Background: Computed tomography (CT)-based image-guided surgery (IGS) is of great importance in functional endoscopic sinus surgery (FESS) and requires IGS-specific imaging protocols to ensure high intraoperative accuracy. This study aimed to compare photon-counting CT (PCCT), dual-energy dual-source CT (DECT), and spectral detector CT (SDCT) of the paranasal sinuses with respect to image quality, IGS accuracy and radiation dose. Methods: A formalin-fixed cadaver skull was examined using PCCT, DECT and SDCT at 100 kV tube voltage with descending tube currents (mAs). The setup of electromagnetic IGS was evaluated using a visual analog scale. Accuracy was analyzed endoscopically using defined anatomical landmarks. Diagnostic image quality as well as bone and soft tissue noise were assessed qualitatively using a 5-point Likert scale and quantitatively by determination of signal-to-noise ratio. Radiation dose was evaluated using the dose length product. Results: While PCCT datasets could be registered and navigated accurately down to 10 mAs (1.5 mm error at 10 mAs), both DECT and SDCT exhibited significantly increased inaccuracies below 40 mAs (4.35/5.15 mm for DECT/SDCT at 25 mAs). Using PCCT therefore enabled a 45% radiation dose reduction at the minimally required dose length product using PCCT. Quantitative and qualitative image quality were superior for PCCT compared to DECT and SDCT. Conclusions: PCCT provides excellent accuracy of anatomical landmarks in IGS with superior image quality of the paranasal sinuses in low-mA scans and substantially reduced radiation exposure.

Low-value care occurs when the harms or costs of care exceed the benefits. Such care includes when medical device-based procedures are favored over medical management, such as invasive coronary angiography (ICA) and percutaneous coronary intervention (PCI) for stable coronary artery disease; endovascular intervention for lower extremity peripheral arterial disease with intermittent claudication; and nasal endoscopy with balloon ostial dilation and functional endoscopic sinus surgeries (collectively, sinus procedures) for chronic rhinosinusitis. To evaluate the association of enacting evidence-based clinical coverage policies for these low-value procedures with their use in Louisiana's Medicaid program. Louisiana Medicaid partnered with academic investigators to develop and enact evidence-based policies between December 2021 and February 2022. This study used an interrupted time series approach to evaluate use of the 4 identified procedures 12 months before and 18 months after policy enactment. For each procedure, best-fit curves were constructed of prepolicy utilization trends, which were used to generate expected postpolicy trends. These expected trends were then compared to observed postpolicy utilization. Three-way analysis (time × intervention period [pre or post] × procedure) was used to assess changes in utilization slope for each procedure relative to colonoscopy (which had no policy changes and was expected to show baseline use of procedures in Louisiana Medicaid). Final follow-up was in September 2023. Monthly outpatient procedural utilization per 100 000 Louisiana Medicaid members of ICA, PCI, endovascular intervention, and sinus procedures. There were 1 396 629 Louisiana Medicaid members with data at 1 year before any policy enactment and 1 548 265 at final follow-up. Overall, 14 940 individuals (mean [SD] age, 43.5 [13.7] years; 53.0% female) underwent one of these procedures before policy enactment, and 20 882 (mean [SD] age, 43.3 [13.7] years; 52.6% female) after enactment. Differences in monthly outpatient procedure rates in the postenactment compared with the preenactment period per 100 000 members were as follows: ICA, 0.65 (95% CI, 0.06 to 1.23); PCI, 0.15 (95% CI, -0.01 to 0.31); endovascular intervention, -0.01 (95% CI, -0.12 to 0.10); and sinus procedures, -0.23 (95% CI, -1.61 to 1.15). There was no significant change in the 3-way time × intervention period × procedure vs colonoscopy interaction for any procedure. In this quality improvement study, enactment of evidence-based clinical coverage policies for 4 common medical device-based procedures was not associated with a reduction in their use in Louisiana Medicaid. These findings suggest a need for more comprehensive strategies to improve evidence-based care for Medicaid through multipronged efforts that include education, policymaking, and value-based coverage implementation.

Malignant neoplasms of the paranasal sinuses and skullbase are rare. They account for 3—5% of malignant tumors of the head and neck and less than 1% of all malignant neoplasms. The main method of surgical treatment of these tumors is transfacial operations. Such operations lead to serious complications: cosmetic defects and scars on the face, wound infections, long recovery time, which leads to an increase in the duration of hospitalization and a delay in adjuvant treatment. Endoscopic endonasal surgery has significantly advanced, expanding the indications for use over the past 20 years. This technical progress has made this treatment method a real alternative to transfacial approaches in surgery for malignant neoplasms of the paranasal sinuses and skull base. Numerous studies have shown that survival outcomes with the endoscopic endonasal approach are comparable, and in some cases even better, than with the open approach. However, given the rarity of this disease, personalized choice of treatment tactics remains a priority today.