Functional Endoscopic Sinus Surgery Procedures Research Articles

Controlled Hypotension for Functional Endoscopic Sinus Surgery With Two Different Doses of Fentanyl.

Background and Objectives Functional endoscopic sinus surgery (FESS) is a type of minimally invasive surgery done for acute and chronic sinus diseases or paranasal illnesses. The idea of FESS is to preserve the normal anatomy, which is non-obstructing and mucous membranewhile removing tissue obstructing OMC (osteo metal complex) and facilitating drainage. The critical structures, including the brain, orbit, and carotid veins, the lack of adequate operating room, and bleeding that obscures endoscopic vision throughout the procedure may increase the likelihood of unfavorable surgical results.This study seeks to examine the hemodynamic effects of intubation and extubation as well as the impact of fentanyl infusion on lowering blood pressure during FESS procedures. Materials and Methods Sixty-eight patients from the American Society of Anesthesiologistsclasses 1 and 2 who were planned for functional endoscopic sinus operations were randomly split into two groups for this randomized prospective trial. Group 1 patient belonging to the fentanyl 2 mcg per kg bolus 30 minutes before induction followed by 2 mcg per kg per hr infusion for 90 minutes of surgery, and Group 2 patient belonging to fentanyl 1 mcg per kg bolus 30 minutes before induction followed by 1 mcg per kg per hr infusion for 90 minutes of surgery. The significance of the difference in quantitative measures was measured using the student-t test, and the Chi-square test was used to measure upthe difference in proportion. Statistically significant was set at P<0.05. Results Mean systolic blood pressure was higher in members of Group 2 than in Group 1. In contrast to Group 2, Group 1 had considerably better surgical field conditions, surgeon satisfaction on the AONO'S scale, post-operative nausea and vomiting, and a post-operative VAS Score during the first 24 hours. Conclusion Pre-induction Fentanyl with infusion can effectively control hypotension during functional endoscopic sinus surgery.

A retrospective study on variations of uncinate process of ethmoid bone using cone-beam computed tomography

Background: Uncinate process (UP) is a key landmark in the lateral wall of the nose which plays a vital role in the ventilation of paranasal sinuses and is also the first structure to be resected during functional endoscopic sinus surgery (FESS). The variations in this structure can lead to intraoperative and postsurgical complications during the FESS procedure. Aim: The aim of this study was to evaluate the variations of UP of ethmoid bone using cone-beam computed tomography (CBCT). Materials and Methods: Retrospective data of 100 cone-beam computed radiographic CBCT images of paranasal sinuses were evaluated using CS 3D version 3.10.12 software for variations in the superior attachment of UP (SAUP) using Landsberg and Friedman and the presence of pneumatization of UP. Out of 100 CBCT images, 56 were of males and 44 were of females. Statistical Analysis Used: Chi-square test was used for statistical analysis. Results: In our study, a total of 200 sides in 100 CBCT images were studied and Type I SAUP (51%) was observed as the most common type, followed by Type II (17%), Type IV (11.5%), Type III (10%), Type V (6.5%), and Type VI (4%) is the least common type observed. No statistically significant difference was observed among gender regarding SAUP. Pneumatization of UP was seen in 7% of cases, out of which 4% were in males and 3% were in females. Conclusion: Preoperative analysis of UP variations using CBCT can reduce intraoperative and postoperative complications during FESS with less radiation exposure.

Functional endoscopic sinus surgery outcome in chronic rhinosinusitis patients with hypoplastic maxillary sinus.

To review the clinical characteristics, prevalence and outcomes of chronic rhinosinusitis patients with a hypoplastic maxillary sinus who underwent functional endoscopic sinus surgery. A retrospective review was performed for the 814 consecutive, elective functional endoscopic sinus surgery procedures performed at an academic centre from 2010 to 2020, to identify patients with a hypoplastic maxillary sinus. A total of 56 hypoplastic maxillary sinus cases were detected. Maxillary sinus hypoplasia presented unilaterally in 20 cases and bilaterally in 18 cases. Of the maxillary sinus hypoplasia cases, 38 were type I, 17 were type II and 1 was type III. The average Lund-McKay score was 8.6. No major post-operative complications were reported. Four patients had minor complications and one had persistent post-nasal drip. Functional endoscopic sinus surgery is a safe and effective procedure for improving the clinical condition of patients with a hypoplastic maxillary sinus; however, careful pre-operative radiological evaluation, identification of intra-operative endoscopic landmarks and use of additional techniques may be essential to achieve satisfactory results and avoid possible serious complications.

ENT Residents Benefit from a Structured Operation Planning Approach in the Training of Functional Endoscopic Sinus Surgery.

Background and Objectives: Preoperative planning utilizing computed tomographies (CT) is of utmost importance in functional endoscopic sinus surgery (FESS). Frequently, no uniform documentation and planning structures are available to residents in training. Consequently, overall completeness and quality of operation planning may vary greatly. The objective of the present study was to evaluate the impact of a structured operation planning (SOP) approach on the report quality and user convenience during a 4-day sinus surgery course. Materials and Methods: Fifteen participant were requested to plan a FESS procedure based on a CT scan of the paranasal sinuses that exhibited common pathological features, in a conventional manner, using a free text. Afterwards, the participants reevaluated the same scans by means of a specifically designed structured reporting template. Two experienced ENT surgeons assessed the collected conventional operation planning (COP) and SOP methods independently with regard to time requirements, overall quality, and legibility. User convenience data were collected by utilizing visual analogue scales. Results: A significantly greater time expenditure was associated with SOPs (183 s vs. 297 s, p = 0.0003). Yet, legibility (100% vs. 72%, p < 0.0001) and overall completeness (61.3% vs. 22.7%, p < 0.0001) of SOPs was significantly superior to COPs. Additionally, description of highly relevant variants in anatomy and pathologies were outlined in greater detail. User convenience data delineated a significant preference for SOPs (VAS 7.9 vs. 6.9, p = 0.0185). Conclusions: CT-based planning of FESS procedures by residents in training using a structured approach is more time-consuming while producing a superior report quality in terms of detailedness and readability. Consequently, SOP can be considered as a valuable tool in the process of preoperative evaluations, especially within residency.

Use of triamcinolone-soaked absorbable gelatin foam (gelfoam) as a treatment for recurrent sinonasal polyposis after FESS in poor candidates for revision surgery

BackgroundChronic rhinosinusitis with nasal polyps recurs frequently after functional endoscopic sinus surgery (FESS), with resultant poor quality of life with persistence of nasal obstruction, sinus aches, and discharge as well anosmia and dysgysia; revision FESS is usually the treatment of choice referred to relief patients’ suffering, yet it is not always the case, patients preference as well as fitness for general hypotensive anesthesia, patients age, cardiopulmonary status, and concurrent bronchial asthma might render unfit for an elective procedure. The aim of this study was to evaluate the efficacy of triamcinolone-soaked absorbable gelatin foam (gelfoam) as a treatment for recurrent sinonasal polyposis after FESS in poor candidates for revision surgery.ResultsThirty patients suffering from recurrent sinonasal polyposis after single or multiple FESS procedures were selected; all patients were subjected to intranasal application of gelfoam soaked with triamcinolone as a conservative medical office procedure using triamcinolone-soaked absorbable gelatin foam (gelfoam) weekly for a period of 8 weeks followed by intranasal steroid nasal spray for maintenance and as anti-recurrence measure. Patients were followed up for 4 months post-intervention; Meltzer Clinical Scoring System was used to analyze the patients’ pre- and post-intervention via office endoscopy (0° 4-mm Hopkins endoscope). All patients tolerated the procedure well. The study group showed no statistical significance pre-intervention which comprised 17 (56.7%) patients with grade 4 sinonasal polyposis extent and 13 (43.3%) patients with grade 3 sinonasal polyposis extent (P=0.795), denoting no difference between patients pending treatment option. Post-treatment, both groups showed a significant reduction in the extent of polyposis (P<0.001) where post-treatment showed 21 (70%) patients with grades 0 no polyps and 9 (30%) patients with grade 1 sinonasal polyposis extent.ConclusionTriamcinolone-soaked gelfoam packing is an effective and safe method for managing recurrent sinonasal polyposis after FESS. Intervention contributed to a successful result, decreased the need for surgery in poor candidates for hypotensive anesthesia, and could be used as a sole treatment of recurrent sinonasal polypsis in elderly patients whose general condition could not tolerate invasive procedures.

Correlation between Radiological Staging of Chronic Rhinosinusitis and Revision of Endoscopic Sinus Surgery

Introduction: Chronic rhinosinusitis (CRS) is an inflammatory condition affecting the sinonasal mucosa with duration of more than 12 weeks. Multifactorial aetiology contributes to its refractoriness. Functional endoscopic sinus surgery (FESS) is the most common surgical technique preferred in CRS not responding to medical management, showing high success rates. However, some failure has been noted, requiring revision FESS. CT (Computed Tomography) is a diagnostic tool for CRS, and aids in improving surgical outcomes. Combined with the Lund-Mackay scoring system, CT can help stage the CRS, predicting the need for revision surgery. Methods: In our paper, we aimed to study the relationship between severity of CRS using radiological staging and revision of functional endoscopic sinus surgery, assessing outcome after at least 1 year of follow-up. There was a single centre retrospective study involving 150 patients selected by random sampling, to study the correlation between the severity of chronic rhinosinusitis and revision of functional endoscopic sinus surgery (FESS). The study was conducted in the ENT department of King Hamad University Hospital, Bahrain for a time period of 6 months. Records were scanned and scored using Lund-Mackay system. Lund Mackay score of 10 and above was considered severe. The relation between increased severity with Lund Mackay score on the CT scan and the need for revision sinus surgeries was then determined. Results and Conclusion: This study concludes that LMS score in CT scans can be used to predict the outcomes of primary FESS procedure and the need for revision surgery in the management of CRS.

The surgical management of recurrent acute and chronic barosinusitis in sports self-contained underwater breathing apparatus (scuba) divers

The aim of this retrospective study is to evaluate the feasibility of functional endoscopic sinus surgery (FESS) with supplementary surgical procedures in scuba divers with recurrent acute barosinusitis (RABS) and chronic barosinusitis (CBS). In this retrospective study, 25 divers were classified into RABS (n:11) and CBS (n:14) groups. The presentation of divers have been reviewed. The PNS CT images were scored according to Lund-Mackay (L-M) system. A score has been assigned to the extent of endoscopic procedures performed. The outcome of surgery and life quality were determined by SNOT-22 and dive-related questions (DRQ) tests. The average L-M score was 3.8 ± 2 for RABS and 12.2 ± 3.4 for CBS groups. L-M score of CBS group was found to be statistically higher than RBS group (p < 0.05). The FESS score of CBS group (8.7 ± 2.4) was higher than RABS group (5.6 ± 2) which showed that the endoscopic sinus procedures were performed more extensively in CBS group (p < 0.05). The difference between the preoperative and postoperative SNOT-22 scores indicates that the degree of sinus symptoms improved better in RABS group than CBS group (p < 0.05). When DRQ test was evaluated, RABS group showed a better improvement in diving performance symptoms than the CBS group (p < 0.05). Our study demonstrated that divers with RABS and CBS can be managed successfully with FESS and supplementary surgical procedures. The improvement in the RABS group was superior to the CBS group, a difference attributed to the severity of chronic inflammation in CBS.

Analysis of Lamina Papyracea Area and Ethmoid Sinus Volume in Indonesian Patients Undergoing Paranasal Sinus CT Scan

Of the rhinosinusitis (CRS) patients, half of whom require surgical intervention. Functional endoscopic sinus surgery (FESS) is a standard treatment of CRS and sinonasal polyposis. Orbito-ocular complications can occur during FESS. The lamina papyracea (LP) is the weakest point of the medial wall of the orbit. The variability in the size and shape of the paranasal sinuses is important in the FESS procedure. The ethmoid sinus is the most complex paranasal sinuses. Preoperative evaluation using computed tomography (CT) is mandatory for all patients undergoing FESS. This study aimed to determine the lamina papyracea area and ethmoid sinuses volume in patients who underwent a CT scan of paranasal sinuses. This study was a descriptive study on 103 patients who underwent a CT scan of paranasal sinuses in the Radiology Department of Hasanuddin University General Hospital, Makassar, from January to August 2019. The lamina papyracea area and ethmoid sinus volume were measured based on age and gender. The results showed that the average of lamina papyracea size and ethmoid sinus volume was greater in males than in females. There was a correlation between age and posterior height of left lamina papyracea (p=0.02), but no correlation between ethmoid sinuses volume and age.

The efficacy of esmolol, remifentanil and nitroglycerin in controlled hypotension for functional endoscopic sinus surgery

IntroductionControlled hypotension is a reversible procedure in which the patient’s baseline mean arterial blood pressure is reduced by 30% and sustained at 60–70 mmHg during the procedure. It decreases blood loss and provides clear surgical field during the procedures. ObjectivesThe purpose of this study was to compare the efficacy of controlled hypotension agents esmolol, remifentanil, and nitroglycerin in functional endoscopic sinus surgery, in terms of hemodynamic changes and impact on the surgical efficiency. MethodsThe research was carried out as a cohort study. Patients who underwent functional endoscopic sinus surgery were randomized into 3 groups. Controlled hypotension was achieved with remifentanil (Group R), esmolol (Group E) and nitroglycerin (Group N). The efficacy of the drugs was tested by comparing the length of time with the targeted mean arterial pressure, the amount of anesthetics used, surgical field bleeding score and surgeon’s satisfaction. ResultsBetween May to December 2015, 60 patients were included and randomized equally into 3 different study groups. The median of the length of time with the targeted mean arterial pressure was shorter in the Group R when compared with Group E (p = 0.01) and Group N (p = 0.14). The amount of volatile anesthetics used was 25.0 mL (15–51), 43.0 mL (21–105) and 40.0 mL (26–97) in Groups R, E and N, respectively (p < 0.001). While there was more bleeding with nitroglycerin, surgical field bleeding scores were lower in Group R when compared with esmolol (p = 0.001) and nitroglycerin (p < 0.001). The analysis of surgeon’s satisfaction scores concluded that surgeons were more satisfied with the group R (100%), when compared with group E (60%) and group N (30%) (p < 0.001). ConclusionLess volatile agent, short time to achieve controlled hypotension, stable blood pressure, lower surgical field bleeding scores and larger length of time with the targeted mean arterial pressure were found as the advantages of Remifentanil. Less costly, efficiency of achieving the targeted median arterial pressure and less postoperative complications were the advantages of nitroglycerin. In functional endoscopic sinus surgery procedures, appropriate controlled hypotensive agents should be selected according to the patients’ characteristics and advantages/disadvantages of the drugs.

Occurrence of occult CSF leaks during standard FESS procedures.

To determine the incidence of occult cerebrospinal fluid leaks (CSF) after functional endoscopic sinus surgery (FESS) and to evaluate the diagnostic performance of beta2-transferrin in blood-contaminated conditions. Prospective cohort study. An analysis of 57 intraoperative samples using hydrogel 6 beta2-transferrin assay after FESS was undertaken. In case of CSF positive samples and continuing rhinorrhea, reanalysis after more than 1 year was conducted. In-vivo analysis of a primary spontaneous CSF leak sample took place to verify difficulties in detecting beta2-transferrin in blood-contaminated settings. Own titrations were performed to evaluate detection limits of CSF by beta2-transferrin and beta-trace protein assays in these settings. An incidence of 13% for occult CSF leaks after FESS was found. In blood-contaminated conditions, routine beta2-transferrin assays showed low sensitivity. In over 1 year follow-up, all samples were negative for CSF and none of them developed clinical relevant CSF leaks or meningitis. Occult and clinically irrelevant CSF leaks do occur in a significant proportion of patients during and shortly after FESS. Intra- and postoperatively, routine beta2-transferrin assays show low sensitivity. They should not be used in these settings. The clinical course of patients with occult CSF leaks indicated possibility of an uneventful follow-up.

The application of surgical procedure manager (SPM): first experience with FESS.

In our hypothesis, the newly developed program SPM (surgical procedure manager) will ensure successful standardization and efficiency of the FESS (functional endoscopic sinus surgery) and therefore make a decisive contribution in terms of economization and improvement of intraoperative quality. Between 27th March 2015 and 8th October 2015, data from 259 FESS procedures were collected using the SPM. The study took place at the surgical desk, an operating room in the ACQUA clinic in Leipzig, Germany. 233 FESS (90%) of the total FESS (n=259, 100%) were conducted entirely with SPM. 26 SPM terminations (10%) of 259 FESS remain, which are classified as actual SPM terminations-when the surgeon intentionally stops the SPM. The maximum time slot decreased clearly from 1h39min (period A) to 1h10min (period B). A time reduction can also be seen with the minimum duration of 13.5min compared to 11min. The variability of the time slot also decreases since the standard deviation is reduced by 4.5min. On the basis of available recordings it can be postulated that the application of SPM is suitable for standardization for FESS. Standardization by means of SPM and minimal development can be recognized over a period of time. The SPM makes it possible to transfer the general advantages of mechanization on a concrete FESS and do not influence the medical processes nor even restrict the medical freedom. The users are still entirely free in the implementation of the respective procedure.

Robot-assisted endoscope guidance versus manual endoscope guidance in functional endonasal sinus surgery (FESS)

Background: Having one hand occupied with the endoscope is the major disadvantage for the surgeon when it comes to functional endoscopic sinus surgery (FESS). Only the other hand is free to use the surgical instruments. Tiredness or frequent instrument changes can thus lead to shaky endoscopic images.Methods: We collected the pose data (position and orientation) of the rigid 0° endoscope and all the instruments used in 16 FESS procedures with manual endoscope guidance as well as robot-assisted endoscope guidance. In combination with the DICOM CT data, we tracked the endoscope poses and workspaces using self-developed tracking markers.Results: All surgeries were performed once with the robot and once with the surgeon holding the endoscope. Looking at the durations required, we observed a decrease in the operating time because one surgeon doing all the procedures and so a learning curve occurred what we expected. The visual inspection of the specimens showed no damages to any of the structures outside the paranasal sinuses.Conclusion: Robot-assisted endoscope guidance in sinus surgery is possible. Further CT data, however, are desirable for the surgical analysis of a tracker-based navigation within the anatomic borders. Our marker-based tracking of the endoscope as well as the instruments makes an automated endoscope guidance feasible. On the subjective side, we see that RASS brings a relief for the surgeon.

Significance of undissected retromaxillary air cells as a risk factor for revision endoscopic sinus surgery.

Retromaxillary air cells (RMC) are posterior ethmoid cells that separate the maxillary and ethmoid sinuses. The clinical significance of these cells in contributing to revision functional endoscopic sinus surgery (FESS) is unknown. To investigate the prevalence, anatomic dimensions, and radiographic characteristics of RMC in patients with recalcitrant chronic rhinosinusitis after previous FESS. A retrospective review of patients who underwent revision FESS at a tertiary medical center between January 1, 2012, and December 31, 2014. Computed tomographies of patients who underwent revision FESS, including posterior ethmoidectomies, were reviewed. Each side of the scan was assessed for residual RMCs. The radiographic dimensions and Lund-Mackay (LM) scores of these cells were recorded. Sixty-nine patients who underwent revision FESS were identified. The median age of the patient population was 51 years (range, 21-79 years). Forty-two percent of the patients had nasal polyps. The mean number of previous FESS was 2 (range, 1-10). Incompletely dissected RMCs were identified in 101 of 138 analyzed sides (73%), despite documented previous posterior ethmoidectomies. Sixty-five percent of RMCs had an LM score of ≥1; RMCs of patients with polyps were more likely to have an LM score of 2 (p = 0.049). There was a significant correlation between the number of previous FESS procedures and whether the RMCs had been dissected (p = 0.010). There also was a significant correlation between RMC height and the number of previous FESS procedures (p = 0.015). RMCs seemed to often be undissected during primary FESS and, thus, were commonly encountered in revision FESS. The majority of analyzed cells in this cohort demonstrated an LM score of ≥1, which indicated that these cells frequently harbor residual diseased mucosa that may contribute to the need for revision surgery.

Evaluation of resident's training for endoscopic sinus surgery using a sheep's head.

Training in functional endoscopic sinus surgery (FESS) is an essential part of each ENT resident and it takes place on a very fragile area. This study focus on showing the learning curve of FESS, using an anatomical model such as the sheep's head. Four residents in our centre performed dissections. Each of these residents operated eight sheep's head. They performed an endoscopic septoplasty followed by maxillary antrostomy, total ethmoidectomy and frontal sinusotomy on every head. A staff member guided all procedures and checked for the appropriate dissection and complications occurred. Analysis was made upon the residents' performance of their first four septoplasties and eight nasal sides against their subsequent performance of the same. Final procedures presented better outcomes than the initial ones on every step of them. Results were measured by means of decrease of time (P<0.0001) and complications, showing no major complications on the latest ones. Sheep's head is a suitable substitute for the cadaveric human head, to obtain the surgical skills needed for FESS procedures. Sheep's nasal cavity allows gaining dexterity and it is an easy model to obtain.

Functional endoscopic sinus surgery in treating pediatric chronic rhinosinusitis: The Aseer Region experience

Objectives: This study aimed to investigate the clinical outcomes of functional endoscopic sinus surgery (FESS) in treating chronic rhinosinusitis (CRS) in Aseer Region children, and to look at the most likely etiologies that might be attributed to the need of surgical intervention in these children. Methods: Hospital charts for 47 children underwent FESS for CRS were retrospectively reviewed. We looked at the demographic information, clinical presentation, preoperative CT-scan reports and indications for the surgical procedure. Exclusion criteria include cases of FESS done by other surgeons, children below 4years and above 15 years, allergic fungal sinusitis, cystic fibrosis, mucocele and cases of antro-choanal polyps. Results: The majority of patients 38 (81%) presented with CRS were under the age of 8 years. The mean age was 6.5 years at presentation. There were 31 (66 %) males and 16 (34)% females. The persistent nasal discharge was the main symptom in 38 (81%) of the children. Eight (17%) children only presented with an associated nasal obstruction that was attributed directly to adenoid hypertrophy. Nineteen (40.4%) patients had obstructive anatomical variants and 28 (59.6%) patients were diagnosed having allergic rhinitis. Forty- one (87.2%) patient improved and required no further treatment and the remaining 6 (12.8%) patients required revision. Conclusions: Results of the present study are commensurate with findings from prior research in that they confirm that the FESS procedure is recommended to those who fail medical therapy and continue to have bothersome symptoms. Congenital anatomical obstruction (concha bullosa and Haller cells) followed by allergic rhinosinusitis havebeen found to be the most common etiological factors among the experimental group of children treated surgically.

Induced hypotension in ambulatory functional endoscopic sinus surgery: A comparison between dexmedetomidine and clonidine as premedication. A prospective, double-blind, and randomized study.

Background:Functional endoscopic sinus surgery (FESS) is the mainstay of a therapeutic technique for nasal pathologies. This study is to compare the ability of preoperative dexmedetomidine versus clonidine for producing controlled hypotensive anesthesia during FESS in adults in an ambulatory care setting.Materials and Methods:Sixty patients (25-50 years) posted for ambulatory FESS procedures under general anesthesia were randomly divided into Group C and D (n = 33 each) receiving dexmedetomidine 1 μg/kg and clonidine 1.5 μg/kg, respectively; both diluted in 100 ml saline solution 15 min before anesthetic induction. Nasal bleeding and surgeon's satisfaction score; amount and number of patients receiving fentanyl and nitroglycerine for analgesia and deliberate hypotension, duration of hypotension, post anesthesia care unit (PACU) and hospital stay; hemodynamic parameters and side effects were recorded for each patient.Results:Number and dosage of nitroglycerine used was significantly (P = 0.034 and 0.0001 respectively) lower in Group D compared to that in Group C. Similarly, number of patients requiring fentanyl and dosage of same was significantly lower in Group D. But, the duration of controlled hypotension was almost similar in both the groups. Group D patients suffered from significantly less nasal bleeding and surgeon's satisfaction score was also high in this group. Discharge from PACU was significantly earlier in Group D, but hospital discharge timing was quite comparable among two groups. Intraoperative hemodynamics was significantly lower in Group D (P < 0.05) without any appreciable side effects.Conclusion:Dexmedetomidine found to be providing more effectively controlled hypotension and analgesia, and thus, allowing less nasal bleeding as well as more surgeons’ satisfaction score.

Frontal sinus obliteration with autologous calvarial bone graft: indications and results

Despite increasing advances in endonasal frontal sinus surgery, frontal sinus obliteration (FSO) is sometimes necessary after failure of other surgical techniques. This procedure has been reported with autologous tissue or synthetic material, but few studies have reported results with autologous calvarial bone graft. The aim of this study was to report our experience with osteoplastic FSO calvarial bone graft. A retrospective review was performed on 11 patients operated upon for FSO with autologous calvarial bone graft from 2005 to 2011. Obliteration was indicated for chronic symptomatic frontal sinusitis with nasofrontal duct stenosis in five cases of nasal polyposis with a history of endoscopic sinus surgery, two cases of frontal trauma, two of surgery for frontal inverted papilloma and two of chronic frontal purulent sinusitis. Ten patients had a history of one or two previous functional endoscopic sinus surgery (FESS) procedures. On outcome assessment, eight patients had no residual complaints after FSO and all patients showed improvement in symptoms. Frontal sinus obliteration with autologous calvarial bone graft showed low donor site morbidity and good aesthetic results. This procedure should be considered in severe frontal sinusitis after repeated FESS procedures have failed.

Preemptive analgesic efficacy of gabapentin and nimesulide in the functional endoscopic sinus surgery

Preemptive analgesia is an important factor in controlling the postoperative pain and avoiding the stress response caused by the surgery. We aim to compare impact of gabapentin and nimesulide on postoperative analgesic consumption on the visual analog scale (VAS) as well as any potential side effects, to those of the placebo group. Ninety patients aged 18-70 under ASA I-II risk, who were to undergo Functional Endoscopic Sinus Surgery (FESS), were included in the study. Patients were randomized into three groups. One hour before the surgery, oral placebo capsules were administered to Group I patients, Gabapentin 1200 mg to Group II patients and Nimesulide 100 mg to Group III patients. Perioperative hemodynamic parameters were measured for all patients. During the first 24 hours of the postoperative period, side effects such as nausea, vomiting, hypotension, hypertension, bradycardia, tachycardia were noted, and the time from end of the surgery to the first diclofenac need was recorded in addition to VAS scores. In all of the follow-ups for 24 hours of the postoperative period, time from end of the surgery until the first diclofenac requirement; Group 2 > Group 3 > Group 1. Total diclofenac consumption of group 2 was found to be significantly lower than Group 1 and Group 3 on a statistical basis. Postoperative VAS score in Group 2 was lower than Group 1 and Group 3. To conclude, we believe that gabapentin or nimesulide may be safely used preemptively for the purposes of postoperative analgesia after FESS procedures.

Endocranial Complications of Endoscopic Sinus Surgery: Learning from Experience

Objectives: We critically reviewed our experiences in endocranial complications with Functional Endoscopic Sinus Surgery, and investigated the causes, prevention strategies and management. Methods: We conducted a retrospective study of endocranial complications with Functional Endoscopic Sinus Surgery performed during last 10 years in our ENT department. We analyzed endocranial complications, their causes, consequences, treatments and outcomes. Management was performed in collaboration with neurosurgeons and infectious diseases specialists. Results: Of 763 Functional Endoscopic Sinus Surgery procedures, we identified three cases with endocranial complications (0.393%). These complications included: a case of postoperative severe cerebrospinal fluid leak in a patient treated for severe polyposis; a case of cerebral-frontal abscess with delayed clinical manifestation (4 weeks post-surgery) in a patient treated for chronic pansinusitis who experienced difficult surgery for septal spur; and a case of pneumocephalus in a patient treated for allergic fungal sinusitis. The clinical outcome was favorable in all cases. Conclusions: Intra-operative cerebrospinal fluid leak, anatomical deformities (even minimal deformities) and massive inflammatory sinus disease are predisposing factors for endocranial complications with Functional Endoscopic Sinus Surgery. Prognosis can be favorable when therapeutic management is carried out in collaboration with neurosurgeons and infectious disease specialists.

Modified Lothrop procedure in cystic fibrosis patients: does it have a role?

The management of frontal sinus disease in cystic fibrosis patients represents a challenge for many surgeons. Procedures can vary from the minimally invasive to those involving extensive open surgery. This study describes the outcomes of the endoscopic modified Lothrop procedure, in terms of safety and morbidity, for cystic fibrosis patients with frontal sinus disease who did not improve following traditional functional endoscopic sinus surgery. The study setting was a tertiary referral unit in a London teaching hospital, the largest national base for adult cystic fibrosis patients. Two patients diagnosed in childhood with cystic fibrosis presented with histories of recurrent, severe frontal sinusitis; both had previously undergone multiple endoscopic sinus surgical procedures. The modified Lothrop procedure was performed on both patients. The outcome measures were symptom resolution and post-operative complications. The endoscopic modified Lothrop procedure was beneficial in the cystic fibrosis patients with frontal sinus disease who failed to respond to standard functional endoscopic sinus surgery procedures.