Evaluation Of Chronic Rhinosinusitis Research Articles

Correlation between Lund-Mackay CT scan score and Sinonasal Outcome Test-20 symptoms score in the evaluation of chronic rhinosinusitis

Background: Computed tomographic (CT) scan is important in the evaluation of chronic rhinosinusitis (CRS). The usefulness of CT scan in predicting the severity of symptoms is still debatable. The aim of this study is to determine the correlation between a CT scan scoring and the severity of clinical symptoms in patients with CRS. Methods: A cross-sectional study of patients with clinically diagnosed CRS. Their symptoms severity was assessed using the Sinonasal Outcome Test-20 (SNOT-20) scoring system. All eligible patients had CT scans using BrightSpeed (GE) computed tomographic scanner. The CT scan findings of each subject were scored according to the Lund-Mackay scoring system. The correlation between the CT score and the SNOT-20 symptom score was determined. Results: There were 120 participants comprised 70 (58.3%) males and 50 (41.7%) females with male: female ratio of 1.4:1. The mean and standard deviation of SNOT-20 were 38.9 ± 17.5 (range: 6–81) and that of Lund-Mackay score were 9.8 ± 5.5 (range: 0–24). There was statistical significant correlation between Lund-Mackay score and SNOT-20 score (r = 0.653 P = 0.000). The correlation was strongest in relation to nasal symptom domain (r = 0.746, P = 0.000), but it was weak with the facial symptom domain (r = 0.225, P = 0.013). Conclusion: This study found a strong positive correlation between the Lund-Mackay score and SNOT-20 symptoms score among patients with CRS.

Nasal Endoscopy Billing Patterns: A Survey of the American Rhinologic Society.

Introduction Nasal endoscopy (NE) is an essential element of office-based clinical rhinology, including the evaluation of chronic rhinosinusitis. Despite the presence of guidelines, variability exists regarding coding and billing for NE especially with regard to inclusion of evaluation and management (E&M) codes and use of the 25 modifier. The goal of this survey was to assess the billing patterns for NE among American Rhinologic Society (ARS) members. Methods An invitation to participate in a web-based survey was electronically sent to all ARS members. Survey participants were queried regarding demographics and billing patterns for NE in several different clinical scenarios using a 5-point Likert-type scale, with a score of 5 representing "always" and a score of 1 representing "never" for billing E&M. Results A total of 93 respondents successfully completed the survey with a range of the number of years since completing training, practice type (50.5% private, 44.1% academic) and completion of a rhinology fellowship (40.9%). Variable responses for billing patterns for distinct clinical scenarios were noted. Higher scores for billing both E&M and NE for the queried clinical scenarios were noted for new patients (mean 4.50) compared to established patients (mean 3.81) and postoperative patients (mean 3.04). Inclusion of a septoplasty as part of the surgery impacted billing an E&M code 28% of the time. Practice type and history of performing a fellowship did not significantly influence billing patterns for NE. Conclusions Significant variability exists among ARS respondents with regard to billing patterns for NE, despite the presence of coding guidelines. Additional teaching of standard coding practices for NE may limit variability among otolaryngologists.

Diagnostic Accuracy of Cone-Beam Computed Tomography in the Evaluation of Chronic Rhinosinusitis

Introduction: This study assessed the agreement of cone-beam computed tomography (CBCT) scan and sinus endoscopy findings and attempted to find a diagnostic accuracy of CBCT in patients with chronic rhinosinusitis (CRS). Methods: Forty-two patients with CRS referred to the Aria and 22 Bahman Hospitals in Mashhad, Iran, during the year 2011 were included in this cross-sectional study. Paranasal sinus CBCT scanning and endoscopy were performed in all patients. The sensitivity, specificity, positive and negative predictive values (PPV and NPV), and accuracy of CBCT were determined, and the agreement between CBCT and endoscopy findings was evaluated. Results: In most of our findings, except for infundibulum thickening, there was a strong agreement between CBCT and paranasal sinus endoscopy, with a kappa coefficient >0.80 (p < 0.05). The sensitivity, specificity, PPV, NPV, and accuracy of CBCT were >80% for most of the findings, except for infundibulum thickening and septal deviation. Conclusion: CBCT has nearly the same diagnostic accuracy as sinus endoscopy. The accuracy of CBCT scanning is high, and CBCT findings are well correlated with sinus endoscopy findings. Considering its high accuracy and lower costs and radiation doses, CBCT may be a proper alternative method for diagnostic sinus endoscopy in the assessment of CRS in patients with a contraindication for sinus endoscopy.

Predicting Positive CT Findings in Non-Polypoid Para-Nasal Sinus Disease

Objective: Chronic rhinosinusitis affects significant portion of the population and is one of the most common reasons for Otolaryngology visits. In recent years, Computed Tomography (CT) has become the main modality of investigation in sinus disease. However, significant paucity in evidence exists in correlating symptoms and laboratory findings with positive CT findings. Given the associated radiation exposure and significant cost on the healthcare system, clinical guidelines in determining the appropriateness of CT investigation are needed. Study Design: Eighty-three consecutive patients referred to a single rhinologist for evaluation for chronic rhinosinusitis without nasal polyposis were retrospectively reviewed. Setting: The study involved two McGill University associated hospitals in a 13 month period. Subjects and Methods: Patients were evaluated for presence of six subjective symptoms and two objective signs. Complete blood count and CT sinuses were then ordered. CT sinuses were subsequently graded using the Lund-McKay scoring system. Results: No single symptom, sign or combinations were predictive of positive CT finding. No laboratory markers were able to predict a positive scan. Interestingly inflammatory markers were lower in positive scan group compared to the negative scan population. Conclusion: Clinical diagnosis of chronic rhinosinusitis in nonpolypoid patients presents a challenge. CT imaging is a fundamental component in diagnosing those patients, yet clinical experience is important in preventing unnecessary radiation exposure.

一酸化窒素 （NO） と副鼻腔炎病態

一酸化窒素 （NO） と副鼻腔炎病態

What is the role of nasal endoscopy in the diagnosis of chronic rhinosinusitis?

BACKGROUND Chronic rhinosinusitis (CRS) is one of the most common chronic conditions in the United States, but clinical diagnostic criteria remain controversial. Nasal endoscopy is frequently employed by otolaryngologists in cases of suspected CRS. Although endoscopy allows visualization of pathology that may provide objective evidence for the diagnosis of CRS in the posterior nasal cavity, nasopharynx, and the middle and superior meati that would not be visible on anterior rhinoscopy, its appropriate role in the evaluation of CRS has been the subject of controversy. In 2007, the American Academy of Otolaryngology– Head and Neck Surgery (AAO-HNS) published guidelines for diagnosis of CRS that utilize a combination of symptom criteria and objective findings. A positive diagnosis was defined as 12 weeks or longer of two or more of the following signs and symptoms: mucopurulent drainage; nasal obstruction; facial pain, pressure, or fullness; or decreased sense of smell. In addition, an objective measure, such as evidence on nasal endoscopy of nasal polyps or purulent mucus in the middle meatus or ethmoid region, or radiographic evidence of paranasal sinus inflammation are also recommended. Given the high utilization rate and availability of computed tomography (CT) for CRS diagnosis, these guideline criteria designated nasal endoscopy as an optional diagnostic measure. Although endoscopic findings are frequently used to support a diagnosis of CRS, the true diagnostic value of nasal endoscopy in diagnosing CRS has not been clearly defined. LITERATURE REVIEW The diagnostic utility of nasal endoscopy, in relation to common clinical and radiologic criteria, has been assessed in relatively few clinical studies. A 1997 study by Benninger evaluated the role of nasal endoscopy in the diagnosis and treatment planning in 100 consecutive new clinic patients with sinonasal complaints. Of those, only 28 patients were diagnosed with CRS, and all diagnoses were made based on history and physical examination that included anterior rhinoscopy. The role of endoscopy in this study was to determine if the endoscopic findings contradict the established diagnosis. The study did not compare the results of endoscopy with CT scans. Although the addition of endoscopy did not change any of the diagnoses of CRS, the study concluded that it was useful in evaluating patients in whom anterior rhinoscopy is limited by anatomic abnormalities or in whom the diagnosis is otherwise unclear. A 1998 study by Rosbe et al. prospectively compared results of nasal endoscopy, CT scanning, and a symptom questionnaire, with a goal of determining whether a combination of patient symptoms and nasal endoscopy could accurately predict CRS on CT in 92 consecutive patients referred for sinonasal symptoms. The study obtained CT scans on all patients with endoscopic findings positive or equivocal for CRS. They found that 91% of patients with positive findings on endoscopy had CT scans consistent with CRS. Of the patients with a chief complaint of nasal obstruction who had a positive finding on nasal endoscopy, 100% had CT findings consistent with CRS. This study did calculate positive predictive values (PPVs) or negative predictive values (NPVs) for endoscopy as compared with CT results. The study concluded that combined with a symptom history, nasal endoscopy can be a highly specific technique for predicting positive CT findings of CRS. In a 2002 study of 78 patients meeting the current symptom-based definition of CRS, Stankiewicz and Chow evaluated the relationship between symptom history, nasal endoscopy, and CT findings. Nasal endoscopy was considered positive for CRS if it demonstrated purulence, nasal polyps, or watery congested From the Massachusetts Eye and Ear Infirmary (J.S.), Department of Otolaryngology–Head and Neck Surgery, Boston; the Division of Otolaryngology (N.B.), Brigham and Women’s Hospital, Boston, Department of Otology and Laryngology (J.S., N.B.), Harvard Medical School, Boston, Massachusetts, U.S.A. Editor’s Note: This Manuscript was accepted for publication April 5, 2012. Neil Bhattacharyya, MD, is a consultant for Intersect-ENT, Inc. and Entellus, Inc. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Neil Bhattacharyya, MD, Division of Otolaryngology, 45 Francis St., Boston, MA 02115. E-mail: neiloy@massmed.org

Interrater agreement of nasal endoscopy for chronic rhinosinusitis

Nasal endoscopy is a routine, important diagnostic tool in the evaluation of chronic rhinosinusitis (CRS). Although the procedure is ideally "objective," the subjective nature of endoscopy interpretation and lack of standardization are potential limitations. The goal of this study was to examine the interrater agreement of various categories of nasal endoscopy findings in patients undergoing evaluation for CRS. Fourteen patients (28 sides) with CRS underwent clinical evaluation, SNOT-22, sinus computed tomography (CT), and digital video nasal endoscopy. Five academic rhinologists blindly reviewed the endoscopies for structural anatomic issues, inflammatory rhinosinusitis findings, and atypical lesions. Statistical comparison of the endoscopy interpretations was performed using the unweighted Fleiss' kappa statistic (K(f) ). The mean Lund-Mackay CT scan score was 7.8 (standard deviation [SD] 4.9) and the mean SNOT-22 score was 35.8 (SD 22.7). Significant variability was noted among the raters with respect to the various categories of nasal endoscopy findings. The overall levels of interrater agreement for the various categories were as follows: "almost perfect" for atypical lesions (K(f) = 0.912); "substantial" for nasal polyps (K(f) = 0.693); "moderate" for nasal discharge (K(f) = 0.422) and mucosal inflammatory changes of the middle turbinate (K(f) = 0.413); and "fair" for edema of the middle meatus (K(f) = 0.214), obstruction by nasal septum deviation (K(f) = 0.240), and obstruction by the middle turbinate (K(f) = 0.276). Significant variability was noted in the interrater agreement for nasal endoscopy findings in this study, with relatively limited agreement on some of the key findings of the procedure. Additional investigation and standardization of nasal endoscopy interpretation is required to improve the clinical utility of the procedure.

Advancements in Computed Tomography Management of Chronic Rhinosinusitis

Advances in cone beam computed tomography (CBCT) technology have allowed for reduction in radiation dosages as well as the miniaturization of CT scanner units. This has given rise to new applications for CT scanning, including point-of-care (POC) in-office and intraoperative applications. A review of recent changes to radiological modalities as applied to otolaryngology-head and neck surgery was performed. A discussion of the physics, applications, and role of diagnostic imaging in the evaluation of chronic rhinosinusitis (CRS) is conducted. The adaptation of cone beam technology has allowed for the practical implementation of CT scanning at the bedside, be it in the clinic or operating room setting. Given their relative low cost, ease of storage, and low-dose radiation exposure, POC-CT scanners have become an indispensable tool in the diagnosis and treatment of CRS. In the setting of increasing antibiotic costs, overtreatment with antibiotics, and fewer required return visits, POC-CT challenges the conventional role of empiric medical therapy before progression to imaging for the diagnosis of CRS.

Global Osteitis Scoring Scale and chronic rhinosinusitis: a marker of revision surgery

Determine the incidence and severity of osteitis in patients with chronic rhinosinusitis using a new Global Osteitis Scoring Scale. Validation and prospective case-control study. Academic Tertiary Otolaryngology Department (Academic Medical Centre, Amsterdam). A prospective series of 102 patients undergoing a computed tomography (CT) sinuses as part of their evaluation for chronic rhinosinusitis between January and May 2008 (study group) and an age- and gender-matched control group of 68 non-rhinosinusitis patients. Seventy-eight of the chronic rhinosinusitis patients completed the nasal subset of the RhinoSinusitis Outcome Measure (RSOM-31) and visual analogue scales. Their CT scans were assessed for osteitis using a newly developed Global Osteitis Scoring Scale. A subsample of 35 scans were additionally scored by a second otolaryngologist and a radiologist. Global Osteitis Scoring Scale. The interrater variability of Global Osteitis Scoring Scale was low (average intraclass correlation coefficient: 0.94). Forty per cent of the chronic rhinosinusitis group and none of the control group had evidence of clinically significant osteitis. In the chronic rhinosinusitis group (102 patients), the severity of osteitis was correlated with Lund-Mackay (L-M) score (P<0.001), duration of symptoms (P<0.01) and previous surgery (P<0.001), rising in incidence with increasing number of previous operations. There was no association between osteitis and age, gender, smoking, co-existing asthma, allergy or Sumpter's triad. Additionally, there was no correlation between osteitis and symptom burden including headache, facial pain and nasal subset score of the RhinoSinusitis Outcome Measure. In patients with recalcitrant chronic rhinosinusitis who have undergone multiple surgeries in the past, the incidence of osteitis can be as high as 64%. It does not seem to be associated with more troublesome symptoms; however, it is strongly associated with previous sinus surgery, which may be a manifestation of a shared endpoint (underlying recalcitrant disease).

Clinical Predictors of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is diagnosed by the presence of signs and symptoms of CRS in conjunction with physical evidence of mucosal inflammation. We sought to identify symptoms that predict CRS. We performed a retrospective review of patients referred to a tertiary care rhinology clinic for evaluation of CRS. Symptom survey data and diagnoses were reviewed. Of 187 patients who met inclusion criteria, 112 (60%) were diagnosed with CRS and 75 (40%) were not. Chronic purulent rhinorrhea (odds ratio [OR], 2.2) and hyposmia (OR, 2.3) individually and in combination (OR, 3.8) were significant predictors of CRS. The major criteria of the 1997 Task Force in Rhinology (TFR) also predicted CRS (OR, 1.9) but the minor criteria did not (OR, 0.3). In this preliminary study, purulent rhinorrhea and hyposmia are strong predictors of CRS. The major criteria of the TFR also predict CRS but the minor criteria do not.