FESS Procedures Research Articles

Modelling the effects of post-FESS middle turbinate synechiae on sinonasal physiology: A computational fluid dynamics study

Objective(s)Chronic rhinosinusitis (CRS) is common and often requires surgical intervention. Surgical failure may lead to persistent symptoms and recalcitrant disease, often secondary to synechiae between the middle turbinate (MT) and lateral nasal wall. Synechiae prevention techniques have been extensively investigated, however evidence for the effect of synechiae on sinonasal physiology is lacking. We aimed to model the effects of MT synechiae on a post-functional endoscopic sinus surgery (FESS) sinonasal cavity using computational fluid dynamics (CFD). MethodsDICOM data from a CT-sinus of a healthy 25-year-old female was segmented to create a three-dimensional model. Virtual surgery was performed to simulate a “full-house” FESS procedure. Multiple models were created, each with a single unilateral virtual MT synechia of varying extent. CFD analysis was performed on each model and compared with a post-FESS control model without synechiae. Airflow velocity, humidity and mucosal surface and air temperature values were calculated. ResultsAll synechiae models demonstrated aberrant downstream sinonasal airflow. There was reduced ventilation of the ipsilateral frontal, ethmoid and sphenoid sinuses, with a concentrated central “jet” in the middle meatus region. Effects were proportionate to the size of synechiae. The impact on bulk inspired airflow was negligible. ConclusionPost-FESS synechiae between the MT and lateral nasal wall significantly disrupt local downstream sinus ventilation and nasal airflow. These findings may explain the persistent symptoms seen in post-FESS CRS patients with MT synechiae, reinforcing the importance of prevention and adhesiolysis. Larger cohort studies with multiple models of actual post-FESS patients with synechiae are required to validate these findings.

Relationship between the Severity of Inflammatory Changes in Chronic Sinusitis and the Level of Vitamin D before and after the FESS Procedure.

There have been a few reports confirming that vitamin D (VD3) deficiency increases inflammation in the paranasal sinuses. The work brings new information that, despite the presence of inflammation before surgery, patients with higher vitamin D levels had less inflammation, and this has been proven on three levels. We show that vitamin D levels clearly correlate with the severity of the disease in chronic sinusitis. These results have been confirmed in imaging studies (Lund MacKay scale), endoscopy (Lund-Kennedy scale) and in the SNOT 20 questionnaire. 40 patients suffering from chronic sinusitis were divided into two equal groups: group 1: with less severe radiological changes (10 or less points on the Lund-Mackay scale), group 2: with a more advanced form (>10 points). The relationship between VD3 and the severity of the disease (clinical and nasal endoscopy) was assessed. The mean VD3 level in patients in group 2 before surgery was lower (23.01 ng/mL) than in group 1 (28.02 ng/mL) (p < 0.05). They presented a higher degree of advanced changes in all the above scales, i.e., before the SNOT 20 procedure, the mean was: group 1: 30.33, group 2: 31.80 (p < NS); Lund-Kennedy: group 1: 3.21, group 2: 6.30 (p < 0.05). After surgery an increase in VD3 levels was observed in both study groups: in group 1 to the value of 37.98 ng/mL (p < 0.002) and in group 2 to 27.67 ng/mL (p < 0.004). Lower VD3 levels were found in patients with a higher stage of the disease. Reduction of inflammation increases the level of VD3 and reduces subjective and objective symptoms of chronic inflammation.

3D endoscopy shows enhanced anatomical details and depth perception vs 2D: a multicentre study

PurposeThe current standard endoscopic technique is a high resolution visualisation up to Full HD and even 4 K. A recent development are 3D endoscopes providing a 3-dimensional picture, which supposedly gives additional information of depth, anatomical details and orientation in the surgical field. Since the 3D-endoscopic technique is new, little scientific evidence is known whether the new technique provides advantages for the surgeon compared to the 2D-endoscopic standard technique in FESS. This study compares the standard 2D-endoscopic surgical technique with the new commercially available 3D-endoscopic technique.MethodsThe prospective randomized interventional multicenter study included a total of 80 referred patients with chronic rhinosinusitis with and without polyps without prior surgery. A bilateral FESS procedure was performed, one side with the 2D-endoscopic technique, the other side with the 3D-endoscopic technique. The time of duration was measured. Additionally, a questionnaire containing 20 items was completed by 4 different surgeons judging subjective impression of visualisation and handling.Results2D imaging was superior to 3D apart from “recognition of details”, “depth perception” and “3D effect”. For usability properties 2D was superior to 3D apart from “weight of endoscopes”. Mean duration for surgery was 26.1 min for 2D and 27.4 min. for 3D without statistical significance (P = 0.219).ConclusionThree-dimensional endoscopy features improved depth perception and recognition of anatomic details but worse overall picture quality. It is useful for teaching purposes, yet 2D techniques provide a better outcome in terms of feasibility for routine endoscopic approaches.

Mitomycin-C Prevents Post-Operative Adhesions after Endoscopic Nasal Surgery

Purpose: To assess the role of mitomycin-c (MMC) in preventing synechia formation and ostial stenosis following endoscopic nasal surgery.Patients and methods: This is a prospective comparative study on a total of thirty patients of different ages including both sexes. Patients were divided in two groups (A and B, 15 each). Group (A) had FESS operation and group (B) had partial inferior turbinectomy. In Group (A) 15 primary FESS procedures were performed in 15 patients: nine patients had bilateral pansinusitis, and six cases had bilateral nasal polyposis. MMC was applied at the site of middle meatal antrostomy on one side and the contra-lateral side served as the control. In Group (B), 15 endoscopic bilateral partial inferior turbinectomy was performed in 15 patients. MMC was applied between residual of right inferior turbinate and the septum, while the contra-lateral side served as a control. The data were analyzed after two months of follow up.Results: One patient (6.7%) had adhesion at Rt. Side and seven patients (46.7%) had adhesions at Lt. Side, while 14 patients (93.3%) had no adhesion at Rt. Side and eight patients (53.3%) had no adhesion on Lt. Side (P=0.013). In Group (B), three patients (20%) had adhesion at Rt. Side and nine patients (60%) had adhesions at Lt. Side, while 12 patients (80%) had no adhesion at Rt. Side and 6 patients (40%) had no adhesion on Lt. Side (P=0.025).Conclusion: Topical use of MMC is safe and beneficial in decreasing adhesion formation after endoscopic nasal surgery.

Sinus augmentation with simultaneous removal of antral polyp

Antral polyps are the most common pathologies found in maxillary sinus. If asymptomatic, it can be left untreated but if symptomatic and is encountered during posterior maxillary rehabilitation procedures like sinus augmentation procedures, it has to be treated preoperatively through FESS procedure by otolaryngologist or may be treated intra operatively during sinus elevation procedure as the case presented here.

Effects of functional endoscopic sinus surgery on the acoustics of the sinonasal tract

Nasal and paranasal cavities are supposed to contribute substantially to the vocal tract resonator properties. However, their acoustical effects as well as the effects of sinus surgery on the voice remain unclear. In this work we investigate resonance phenomena of paranasal sinuses prior to and after various rhinosurgical procedures in cadaveric human sinonasal tracts and corresponding 3D casts. Nasal and paranasal cavities of formalin-preserved cadavers and corresponding 3D replicas were excited by sine-tone sweeps from an earphone placed in the epipharynx. The response was picked up by a microphone at the nostrils. Different FESS procedures were performed and the acoustical responses following excitation were recorded. The measured acoustical changes in the obtained transfer functions were then evaluated. Marked low frequency dips were detected in the transfer functions when sinus cavities were included in the nasal resonator system. These dips showed a significant correlation with sinus volumes. Following FESS procedures they moved upwards in frequency depending on the extent of the surgical intervention. The transfer functions obtained in cadaveric situs and 3D replicas showed dips at the resonance frequencies of the paranasal cavities. Marked acoustic effects in terms of increase in dip frequency following FESS procedures were reproducibly documented.

Functional Endoscopic sinus surgery &amp; conventional sinus surgery in Inflammatory Sinonasal diseases

Background: Functional endoscopic sinus surgery is a minimally invasive technique used to restore sinus ventilation and normal function. The most suitable candidates for this procedure have recurrent acute or chronic infective sinusitis, and an improvement in symptoms of up to 90 per cent may be expected following the procedure. Objective: The study has been designed to compare the clinical outcome of functional endoscopic sinus surgery and conventional surgery in the management of inflammatory sinonasal diseases. Study design: This was a prospective study. A combine of both quantitative and qualitative methods was used in conducting the study. Method: Here, a survey method was used to obtain quantitative data from the patients and complication of the operation was observed to obtain qualitative data. Data was collected from a sample that was determined through a semi-purposive method. Results: In the series 9% had synaechia during post operative period and it was 3.3% for FESS and 26.7% for conventional surgery. FESS procedure shows better relief of obstruction, better pain relief and quicker relief of clot than Conventional surgery. In FESS, 56.7% patients reported complete recovery and 43.3% were found symptoms free while in conventional surgery only very few of the patients reported complete recovery. and rest of the patients (93.3%) were symptoms free. Conclusion: The study had shown significant benefits from FESS over conventional surgery. DOI: http://dx.doi.org/10.3329/bjo.v20i1.22011 Bangladesh J Otorhinolaryngol; April 2014; 20(1): 8-14

From Inpatient Notes to Outpatient Followup: Enhancing the Rhinology Service in a Tertiary Centre through Student Led Projects.

Introduction. Medical students can use systems to help improve the quality of care in a unit. Following the review of care within the ENT department at a tertiary centre a number of quality improvement projects were put in place. Methods. The following interventions were established: (1) creation of an outpatient telephone enquiry clinic, (2) development of a rhinology database, (3) introduction of operative note templates, and (4) construction of electronic discharge summary templates (eDSTs). Discussion and Outcomes. (1) Consultant telephone inquiry clinics were successfully organised and showed high levels of patient satisfaction. (2) A database to collect patient reported outcome measures was piloted within rhinology outpatients; the results suggest that such a database would be simple to introduce and yield benefits for patients and the department. (3) Operative note templates for FESS procedures were implemented with a view to improving the continuity of care onto the ward; these have become well established and further steps to integrate these into routine care are being taken. (4) eDSTs specific to FESS and septorhinoplasty procedures were introduced with a view to increasing completion speed of templates and adherence to Royal College of Physician Guidance.

Mental distress and effort to engage an image-guided navigation system in the surgical training of endoscopic sinus surgery: a prospective, randomised clinical trial.

The use of image-guided navigation systems in the training of FESS is discussed controversy. Many experienced sinus surgeons report a better spatial orientation and an improved situational awareness intraoperatively. But many fear that the navigation system could be a disadvantage in the surgical training because of a higher mental demand and a possible loss of surgical skills. This clinical field study investigates mental and physical demands during transnasal surgery with and without the aid of a navigation system at an early stage in FESS training. Thirty-two endonasal sinus surgeries done by eight different trainee surgeons were included. After randomization, one side of each patient was operated by use of a navigation system, the other side without. During the whole surgery, the surgeons were connected to a biofeedback device measuring the heart rate, the heart rate variability, the respiratory frequency and the masticator EMG. Stress situations could be identified by an increase of the heart rate frequency and a decrease of the heart rate variability. The mental workload during a FESS procedure is high compared to the baseline before and after surgery. The mental workload level when using the navigation did not significantly differ from the side without using the navigation. Residents with more than 30 FESS procedures already done, showed a slightly decreased mental workload when using the navigation. An additional workload shift toward the navigation system could not be observed in any surgeon. Remarkable other stressors could be identified during this study: the behavior of the supervisor or the use of the 45° endoscope, other colleagues or students entering the theatre, poor vision due to bleeding and the preoperative waiting when measuring the baseline. The mental load of young surgeons in FESS surgery is tremendous. The application of a navigation system did not cause a higher mental workload or distress. The device showed a positive effort to engage for the trainees with more than 30 FESS procedures done. In this subgroup it even leads to decreased mental workload.

Specific stressors in endonasal skull base surgery with and without navigation.

The goal of modern organizational psychology is to recognize, anticipate and finally avoid stress situations. The aim of this study was to measure objectively the mental and physical demands during transnasal surgery with and without the aid of a navigation system. Forty endonasal surgeries (20 with and 20 without navigation, not blinded and not randomized) done by four different experienced rhinosurgeons (>250 FESS procedures done) were included. The heart rate, the heart rate variability, the respiratory frequency and the masseter tone were monitored as biometrical parameters by the surgeons during the whole surgery for the quantification of mental demand. Stress situations could be identified during the procedures by an increase in the heart rate and a decrease in the heart rate variability. Stress level in procedures with navigation did not significantly differ from procedures without navigation. Interestingly, in 10 % of the cases a navigation system would have been helpful, although the surgeon stated before the procedure that such a system would not be necessary. Other stressors could be identified like time pressure, students or colleagues speaking with the surgeon or chatting in the OR and system failure of medical devices, i.e. navigation, sinus drill, electrocautery or shaver. Surgical stressors blurred vision due to diffuse bleeding and drill out procedures in the sphenoid sinus. Calming situations were a quiet atmosphere in the OR (i.e. closed doors) and the participation of another experienced colleague, especially a neurosurgeon. Stress situations occur when complex medical devices like the navigation do not work. For their proper function it is important that the whole OR-team is trained with it. Unqualified or unmotivated OR personnel create stress for the surgeon and disharmony in the team, which then ends in inadequate behaviour.

PRS58 - Balloon Catheter Dilation For Chronic Rhinosinusitis Does Not Increase The Frequency Of Sinus Surgeries In The United States

Balloon catheter dilation (BCD) of sinus ostia performed by surgeons to treat patients suffering from chronic rhinosinusitis (CRS) refractory to medical management has recently been shown to be safe and effective as an in-office procedure. This approach thus provides physicians with the opportunity to treat patients in a low-acuity care setting, whereas traditional endoscopic surgery is performed in the operating room. Recent publications have raised concerns about the potential for this technology to increase the number of patients surgically treated through supplier-induced or normal, patient-driven demand. This study was therefore conducted to evaluate the total volume of sinus surgeries (including BCD procedures) from 2006 to 2011, to determine whether the introduction of BCD in 2005 increased sinus surgery volumes in the United States. The Marketscan databases were queried from 2006 to 2011 using CPT codes associated with functional endoscopic sinus surgery (FESS: CPT 31254 - 31288) and BCD (CPT 31295 - 31297). Total surgery and procedures counts were analyzed separately, as each surgery could include one or multiple FESS or BCD procedures (ie, one or multiple sinuses treated per patient). A projection methodology developed by Marketscan was applied to estimate US-wide frequencies. Procedural case-mix and total average payment per surgical event were also analyzed for each year of interest. Total individual procedural volume growth reached an average compounded annual growth rate (CAGR) of 1.4% from 2006 to 2011. The number of surgeries, however, only grew by a CAGR of 0.9% during that timeframe, a rate comparable to that of the overall US population (0.8%). BCD did not result in significant growth of procedures or surgeries, thus suggesting that the criteria for selecting patients for surgery did not change with the introduction of BCD. The growth in procedures slightly outpaced that of surgeries, suggesting a potentially larger number of procedures per surgery.

Zum Erinnerungsvermögen an das präoperative Aufklärungsgespräch bei HNO-Patienten

More than one third of all lawsuits against surgeons include statements of insufficient or lacking preoperative informed consent which is mandatory in the german jurisprudence. Almost nothing is known about the postoperative patient's memory of risk factors which were explained prior to typical surgical procedures in ENT. The objectives of this prospective study in 201 patients were to elucidate the actual clinical routine of obtaining informed consent for tympanoplasty (n=105) and FESS procedures (n=89), collect information on active and passive recall 6 weeks, 6 months and 1 year post-operatively, and to investigate whether patient age, sex, education, the time from obtaining consent to interview, recurrent vs. non-recurrent procedures, would influence the patient's recall capabilities. In clinical routine, obtaining informed consent included 5 main items for tympanoplasty and 5 for FESS procedures made by the physician. Of the patients, 18.9% recalled actively and 65.3% passively. They named 1.5 items on average, with "deafness" as the leading complication in tympanoplasty and "amaurosis" in FESS procedures. Patient's memory was depending on the time from obtaining consent to interview and education exclusively. In conclusion, the quantity of patient/physician interaction does not guarantee an increased effect on patient's recall. Improving patient interaction may reduce the probability of imminent accusations.

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.