Post-endoscopic Sinus Surgery Research Articles

Factors influencing residual plus moist HS-W calcium alginate packing material after endoscopic sinus surgery

ObjectiveThis study aims to evaluate the presence of residual Plus Moist HS-W (PM), a novel calcium alginate packing material, during the initial postoperative visit following endoscopic sinus surgery. The research aims to identify factors that influence the quantity of remaining PM. MethodsA retrospective review of medical records was conducted for patients who underwent middle meatus packing with PM. ResultsA total of fifty-two patients (representing 92 sides of paranasal sinuses) were included in the analysis. The remaining PM was classified as follows: absent (0) in 41 out of 92 cases, minimal (1) in 22 out of 92 cases, moderate (2) in 15 out of 92 cases, and substantial (3) in 14 out of 92 cases. Notably, all three patients who underwent Draf III surgery exhibited a significant amount of PM during their initial visit, with two patients classified as grade 2 and one patient as grade 3. Other factors investigated were found to be unrelated to the persistence of PM. Removal of all PM was achieved effortlessly using suction under flexible endoscopy. ConclusionThis study highlights the efficacy of PM in post-endoscopic sinus surgery care. It is important to limit an amount of PM, particularly in Draf III procedures.

Chitogel with deferiprone following endoscopic sinus surgery: improved wound healing and microbiome.

Adhesion formation, sinus ostial narrowing, and presence of pathogenic bacteria are associated with poor outcomes following endoscopic sinus surgery (ESS) for chronic rhinosinusitis. Chitogel has been shown to improve wound healing, restore a healthier microbiome, and reduce post-operative infections post ESS. Deferiprone has antibacterial properties and has been shown to reduce adhesion formation. The aim of the study was to assess whether the addition of low concentration deferiprone to Chitogel further improves surgical outcomes following ESS compared with Chitogel alone. In this double-blinded trial, 45 patients undergoing ESS were prospectively recruited. At the end of the surgery, patients were randomised to receive Chitogel alone, Chitogel with 1 mM of deferiprone, or Chitogel with 5 mM of deferiprone to one side of the sinuses (allowing the other side to serve as control). Patients underwent routine follow-ups with symptom questionnaires and nasoendoscopies performed at 2, 6, and 12 weeks post-operatively. Sinus ostial measurements, microbiology, and microbiome swabs from bilateral middle meatuses were collected intraoperatively and at 12 weeks post-operatively. A significant improvement in the endoscopic appearance of the sinuses and frontal ostial patency was noted at 12 weeks post-operatively (p < 0.05) in all three treatment groups compared with the control. There was no significant difference noted between patients who received Chitogel alone and those who received Chitogel with 1 or 5 mM deferiprone. Chitogel alone, Chitogel with 1 mM deferiprone, and Chitogel with 5 mM deferiprone used following ESS led to a significant improvement in endoscopic appearance of the sinuses and frontal ostial preservation at 12 weeks post-operatively. No significant difference was found with the addition of deferiprone to Chitogel.

Endoscopic outcomes in patients with AERD treated with topical antibiotics and intranasal corticosteroids.

BackgroundIdentifying effective therapy for recalcitrant chronic rhinosinusitis with nasal polyposis (CRSwNP) is a major challenge; and subtypes such as aspirin-exacerbated respiratory disease (AERD) are even more difficult to treat. Evidence on topical antibiotics use in (CRSwNP) is lacking. Current consensus guidelines recommend against its routine use, but recent reviews show some benefit when managing recalcitrant disease after endoscopic sinus surgery (ESS).ObjectiveEvaluate the effect of culture-directed topical antibiotics on sinonasal outcomes in AERD patients with a positive perioperative sinonasal bacterial culture who have undergone ESS.MethodsA retrospective cohort study of AERD patients with positive sinonasal culture, who underwent ESS from 2016 to 2021 was performed. Forty-four patients were identified and stratified based on their postoperative medical treatment. Twenty-six underwent postoperative intranasal corticosteroids (INCS) alone, while eighteen underwent INCS plus a 4-weeks treatment with topical antibiotics. SNOT-22 and Lund-Kennedy score (LKS) were assessed preoperatively and at 4-weeks and 4-6 months after ESS.ResultsA statistically significant improvement in the 4-weeks and 4-6 months postoperative SNOT-22 and LKS were noted within both groups (p<0.05). However, only a statistically significant difference was found in the 4-weeks postoperative LKS when comparing between treatment groups (p=0.01). Our linear regression model demonstrated a relationship between the use of combined therapy with INCS and topical antibiotics and the LKS 4-weeks post ESS (p=0.015).ConclusionIn AERD patients with a confirmed sinus infection, the combination of culture-directed topical antibiotics and intranasal corticosteroid irrigations in the postoperative period can provide a short-term improvement in endoscopic scores.

Evaluation of quality of life using Sinonasal Outcome Test-22 among patients with chronic rhinosinusitis postendoscopic sinus surgery

BACKGROUND: The background of this study was to assess the quality of life (QoL) of patients with chronic rhinosinusitis (CRS) before and after endoscopic sinus surgery Sinonasal Outcome Test-22 (SNOT-22). MATERIALS AND METHODS: This was an observational prospective cohort study carried out at the Ear, Nose and Throat Department of Kogi State Specialist Hospital, Lokoja, and University of Ilorin Teaching Hospital, Ilorin. Both of which are tertiary-level hospitals in North-Central Nigeria offering advanced rhinology services after ethical approval was obtained. The total score for each subject was derived from the 22-item psychometrically validated self-administered SNOT-22 questionnaire. Lower scores postoperatively represent better health-related QoL (HRQOL). RESULTS: A preliminary report of 40 consecutive patients with rhinosinusitis were enrolled. There were 19 males and 21 females aged between 16 and 80 years (mean age: 34.95 ± 2.69 years). There was a significant improvement in SNOT-22 scores from the preoperative period: 37–88 (mean: 67.45 ± 15.10) to 22–43 (mean: 31.73 ± 5.61) 6 weeks after surgery, giving a percentage improvement of 52.97% (P = 0.0002), thus statistically significant. CONCLUSION: SNOT-22 tool is a valuable tool to evaluate the HRQOL of patients with CRS and endoscopic sinus surgery as surgical intervention improves the HRQOL of patients with reduction in the mean score of all items in the SNOT-22 in the postoperative state compared to the preoperative state.

Comparison of Sinus Deposition from an Aqueous Nasal Spray and Pressurised MDI in a Post-Endoscopic Sinus Surgery Nasal Replica

BackgroundOptimising intranasal distribution and retention of topical therapy is essential for effectively managing patients with chronic rhinosinusitis, including those that have had functional endoscopic sinus surgery (FESS). This study presents a new technique for quantifying in vitro experiments of fluticasone propionate deposition within the sinuses of a 3D-printed model from a post-FESS patient.MethodsCircular filter papers were placed on the sinus surfaces of the model. Deposition of fluticasone on the filter paper was quantified using high-performance liquid chromatography (HPLC) assay-based techniques. The deposition patterns of two nasal drug delivery devices, an aqueous nasal spray (Flixonase) and metered dose inhaler (Flixotide), were compared. The effects of airflow (0 L/min vs. 12 L/min) and administration angle (30° vs. and 45°) were evaluated.ResultsInhaled airflow made little difference to sinus deposition for either device. A 45° administration angle improved frontal sinus deposition with the nasal spray and both ethmoidal and sphenoidal deposition with the inhaler. The inhaler provided significantly better deposition within the ethmoid sinuses (8.5x) and within the maxillary sinuses (3.9x) compared with the nasal spray under the same conditions.ConclusionIn the post-FESS model analysed, the inhaler produced better sinus deposition overall compared with the nasal spray. The techniques described can be used and adapted for in vitro performance testing of different drug formulations and intranasal devices under different experimental conditions. They can also help validate computational fluid dynamics modelling and in vivo studies.

A comparative study on the effectiveness of budesonide nasal irrigation versus normal saline nasal irrigation in post endoscopic sinus surgery patients

: Comparative studies evaluating budesonide and saline nasal irrigations for patients with polyposis/ rhinosinusitis are deficient in the current literature. This study aimed to evaluate the effectiveness of budesonide nasal irrigations compared with saline irrigations during postoperative care of patients with rhinosinusitis.: A total of 100 patients who underwent functional Endoscopic Sinus SurgeryESS) were randomly divided into two groups (A and B) of 50 participants each (normal saline [NS] + budesonide irrigation and NS irrigation alone, respectively). Pre- and post operative evaluation was done with a 22-item sinonasal outcomes test (SNOT-22), and Lund Kennedy endoscopic (LKE scores) in second and sixth week. : The condition of the patients significantly improved in both intervention arms related to SNOT-22 and LKE score at each postoperative visit (Group A: p&amp;#60;0.001, Group B: p&amp;#60;0.001). The reduction of SNOT 22 score was higher in budesonide group by 10% (mean SNOT 22 score from 33.31 to 15.84) compared to normal saline group (mean SNOT 22 score from 37.49 to 22.24). The reduction of LKEscore was higher in budesonide group by 18.69% (mean LKE score from 4.49 to 2.71) compared to normal saline group (mean LKE score from 5.02 to 4). : Steroid nasal irrigation is a good option in postoperative EES patients. The difference of reduction of both SNOT 22 score and LKEscore was statistically significant (p &amp;#60;0.05 and p&amp;#60;0.01 respectively) by repeated contrast test. This study is one of the few comparative studies evaluating budesonide and saline nasal irrigations in post-ESS patients.

Mucormycosis an avoidable complication of COVID-19: a case report

Mucormycosis is caused by the fungi belonging to the order Mucorales. There has been an increasing trend of rising fungal infection during the second wave of COVID in India, seen among patients recovering from COVID-19. A 37-years-old middle-aged adult, with the diagnosis of left paranasal sinus mucormycosis, left side pneumothorax (intercostal drainage tube in-situ) with COVID pneumonia reported to the emergency department (ED) during the COVID-19 pandemic in our hospital in India. The patient presented in the ED on oxygen support via a non-rebreathing mask at rate of 10 l/min with a history of progressive left eye redness, pain, and tenderness, periorbital swelling, sudden onset, and mild shortness of breath from 8 days. The patient had a history of taking steroids during the management of COVID-19, also had left intercostal drainage tube (ICD) in-situ, and underwent post endoscopic sinus surgery in the private hospital. The patient was clinically examined by multispeciality experts and subjected to laboratory investigations. The patient was diagnosed with left PNS mucormycosis and planned for debridement. The patient developed renal failure secondary to antifungal therapy had sudden deterioration and could not be saved. The mortality rate of mucormycosis is very high due to delayed presentation, toxicity associated with the antifungal therapy, etc. There is a need to identify risk factors, perform specific laboratory tests, and initiation of prompt treatment. Monitoring and competent nursing care are required during antifungal therapy and prolonged hospital stay.

Efficacy of Topical High Volume Budesonide Nasal Irrigation in Post FESS Patients of Chronic Rhinosinusitis With or Without Nasal Polyposis.

Chronic rhinosinusitis (CRS) is a chronic inflammatory process of nasal mucosa and paranasal sinuses, lasting more than 12weeks, without complete resolution of symptoms. CRS is treated medically, followed by Endoscopic sinus surgery (ESS) if necessary, and supplemented by post-operative topical treatment with highly variable clinical outcomes. However, till date there is no consensus on the composition and duration of maximal medical treatment. Despite proven role of topical steroids, the mode of delivery, dose and duration of topical intranasal corticosteroids still remains debatable. Studies found that high volume sinonasal irrigation (> 50ml) using budesonide is most efficient method but still there is not sufficient data to prove this and results are variable with multiple modifiable factors therefore, this study has been conducted. (1) To determine the difference in mean decrease in Lund-Kennedy endoscopic scores and SNOT-22 scores among post ESS patients with high volume budesonide nasal irrigation nasal cavity and control nasal cavity of chronic rhinosinusitis patients. (2) To determine safety by measuring serum cortisol levels and intra ocular pressure. This is hospital based interventional, randomised, double blind, control trial study. A total of 66 patients of CRS with previous failed medical therapy were included. Same patients nasal cavities were divided into control and case nasal cavities, to avoid demographic bias. All subjects had a baseline SNOT-22 scores (Sino Nasal Outcome Test scores), Lund Kennedy endoscopy score, NCCT PNS score. All patients were undergone ESS procedure. After nasal pack removal, nasal cavities were randomly assigned 1:1 to receive normal saline irrigation (control group) or 1mg of budesonide irrigation (case group) for transnasal irrigation twice daily for 12weeks. A total of 66 patients with 132 nasal cavities were included in the study. Out of which 16 were female and 50 were male with mean age 33year and mean duration of symptoms was 38.19months. Mean duration of follow up was for 3months. Mean decrement in SNOT-22 score in control nasal cavity from 52.54(16.309) to 30.06 (18.16) and in endoscopic score from 6.53 (1.33) to 3.93 (1.6) which is statically significant (p value < 0.05) in both scores. Mean decrement in SNOT-22 score in case nasal cavity from 53.73 (15.75) to 21.15 (13.52) and in endoscopic score from 6.74 (1.8) to 2.77 (1.4) which is statically significant (p value < 0.05) in both scores. Decrement in SNOT-22 scores and endoscopy scores in case nasal cavity in comparision to control nasal cavity were compared by student 't' test and found to be statically significant (p value equals to 0.0001). In subjective outcomes 57.57% shows total improvement in control nasal cavities while 72.73% case nasal cavities shows total improvement. Our study shows high volume budesonide irrigation is safe and superior over normal saline irrigation and results were statistically comparable. Still further studies with larger sample size and longer duration of irrigation needed.Based on available evidence, high volume budesonide irrigation is statically safe and superior over normal saline irrigation.

Assessment of Olfaction Following Endoscopic Sinus Surgery.

To assess the olfactory outcomes following Endoscopic Sinus Surgery (ESS) in patients diagnosed with Chronic Rhinosinusitis (CRS) and Sinonasal polyposis (SNP). To assess and compare the pre-operative and post-operative olfactory scores of patients undergoing ESS/ ESS + polypectomy/ESS + Septoplasty by subjective and objective methods. This is a prospective, cohort study which included a total of 60 patients. Subjective assessment was done using a Questionnaire. Preoperative olfactory assessment was performed with Sniffing Sticks. Olfactory assessment was done at 1st,3rd, 6th and 12th week following surgery. The preoperative and postoperative scores were statistically analysed and compared. In patients who underwent ESS, there was a significant reduction in olfactory scores in the immediate few weeks after surgery which improved over time by the end of 3months. In patients who underwent ESS with polypectomy, there was a significant improvement in olfactory scores from the third week following surgery which was sustained over 3rd month follow-up. In patients who underwent ESS with Septoplasy, there was a significant decrease in olfactory scores during the initial few weeks with a marginal improvement during 3months follow-up. At the end of 12weeks post ESS, no patient was found to be anosmic. Patients with pre-existing hyposmia did not show statistically significant change post surgery.However patients with anosmia showed statistically significant improvement in olfactory function, but did not become normosmic at 12th post-operative week. Majority of normosmics did not have alteration in their olfactory perception at 12th post-operative week.

Tualang honey versus steroid impregnated nasal dressing following endoscopic sinus surgery: a randomized controlled trial.

Recurrence rate of nasal polyps is high following endoscopic sinus surgery. To improve the surgical outcome, steroid impregnated nasal dressing is used postoperatively We aimed to compare the effect of Tualang honey impregnated nasal dressing with steroid impregnated nasal dressing on wound healing and surgical outcomes in post endoscopic sinus surgery patients. A prospective, randomized, controlled trial was carried out at two tertiary hospitals. 32 patients diagnosed with chronic rhinosinusitis and had underwent endoscopic sinus surgery were enrolled. The study group received 2mL of Tualang honey nasal dressing and the control group received nasal dressing with 2mL of triamcinolone 20mg/mL as positive control. A 2cm nasal dressing was placed longitudinally into the middle meatuses of both nasal cavities. Postoperative healing assessments of edema, crusting, secretions, scarring and symptoms were performed at postoperative day 7, 14, 28 and at 3months using Sinonasal Outcome Test 22 questionnaire and modified Lund-Kennedy scoring system. There were no significant differences noted in the scores of Sinonasal Outcome Test 22 and modified Lund-Kennedy at Day 7, 14 and 28 (p>0.05) for both groups. At 3rdmonth, patients in the triamcinolone group had lesser symptoms and better endoscopic findings (p<0.05). Tualang honey is not as effective as steroid in achieving good wound healing and surgical outcomes in post endoscopic sinus surgery patients. Thus, it is not suitable as a substitute for steroid to reduce symptoms and prevent recurrence of disease.

Postoperative evaluation of olfactory dysfunction in eosinophilic chronic rhinosinusitis – comparison of histopathological and clinical findings

Background: Olfactory dysfunction in eosinophilic chronic rhinosinusitis (ECRS) is poorly understood.Objective: To compare olfactory mucosal injury due to eosinophil infiltration in ECRS with postoperative olfactory function.Methods: Seventeen ECRS patients (ECRS group) and 18 bilateral rhinosinusitis (non-ECRS group) patients were compared. At 3 and 12 months post-endoscopic sinus surgery (ESS), all patients were evaluated for subjective symptoms (nasal obstruction, nasal discharge and olfactory dysfunction), endoscopic nasal findings, CT score and T&T olfactometer recognition threshold test. The eosinophil count, OMP-positive cells and epithelial erosion in olfactory mucosa collected during ESS were compared with the postoperative olfactory function.Results: The non-ECRS group showed significant improvement in all clinical findings at 3 and 12 months, but the ECRS group showed worsening of the olfactory dysfunction symptoms and T&T olfactometer recognition threshold at 12 months because of recurrence of sinusitis. The groups differed significantly in the ΔT&T value (i.e. pre-ESS T&T recognition threshold – post-ESS T&T recognition threshold) at both 3 and 12 months, and the degree of olfactory improvement differed. Histologically, the ECRS group showed significantly more eosinophils, fewer OMP-positive cells and greater epithelial erosion than the non-ECRS group.Conclusions: Eosinophilic inflammation was thought to cause olfactory mucosal injury/dysfunction.

Successful management of central retinal artery occlusion and optic nerve injury postendoscopic sinus surgery with combined hyperbaric oxygen and intravenous steroids

Successful management of central retinal artery occlusion and optic nerve injury postendoscopic sinus surgery with combined hyperbaric oxygen and intravenous steroids

Characteristics of macrolide responders in persistent post-surgical rhinosinusitis.

The anti-inflammatory effects of long term low dose macrolide therapy have shown benefit in the management of diffuse panbronchiolitis. Dramatic responses to macrolide in the upper airway are seen but our understanding of the patient phenotype predisposing to macrolide response in chronic rhinosinusitis (CRS) is poor. A case control study was performed in a tertiary level rhinology practice of consecutive chronic rhinosinusitis patients placed on a 3-month low dose macrolide therapy after failing at least 3 months of corticosteroid irrigation therapy post-endoscopic sinus surgery. Patients were defined as a macrolide responder when having near normal endoscopy after a 3-month period of clarithromycin treatment. Patient characteristics of smoking, asthma, atopy status, revision surgery, symptom severity (SNOT-22) along with biomarkers from serum and tissue histopathology results were compared between groups. Of twenty-eight consecutive macrolide treated patients, 19 responders were compared to 9 non-responders. The groups were similar in age, female gender, non-smoking, asthma, and atopy. Macrolide response was associated with a lack of tissue eosinophilia (more than 10/HPF) and lower serum eosinophilia. Neutrophil expression was similar in tissue and serum. Squamous metaplasia was overexpressed in non-responders. Low tissue and serum eosinophilia, and absence of tissue squamous metaplasia may predict a CRS phenotype suitable to a trial of long-term macrolide therapy when surgery and topical therapy has failed.

Randomized controlled trial of a bioabsorbable steroid-releasing implant in the frontal sinus opening.

To assess safety and efficacy of a steroid-releasing implant in improving surgical outcomes when placed in the frontal sinus opening (FSO) following endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS). Prospective, multicenter, randomized, blinded trial using an intrapatient control design. Eighty adult (≥ 18 years) CRS patients who underwent successful bilateral frontal sinusotomy were randomized to receive a steroid-releasing implant in one FSO, whereas the contralateral control side received no implant. All patients received standard postoperative care. Endoscopic evaluations recorded at 30-days postendoscopic sinus surgery (ESS) were graded real time by clinical investigators and by an independent, blinded sinus surgeon to assess the need for postoperative interventions in the FSO. Implants were successfully placed in all 80 frontal sinuses, resulting in 100% implant delivery success. At 30-days post-ESS, steroid-releasing implants provided a statistically significant (P = 0.0070) reduction in the need for postoperative interventions compared to surgery alone by an independent reviewer, representing 38% relative reduction. Clinical investigators reported statistically significant reduction in this measure at 30 days (P < 0.0001) and 90 days (P = 0.0129). Clinical investigators also reported a 55.6% reduction in the need for oral steroid interventions (P = 0.0015), 75% reduction in the need for surgical interventions (P = 0.0225), 16.7% reduction in inflammation score, 54.3% reduction in restenosis rate (P = 0.0002), and 32.2% greater diameter of FSO (P < 0.0001) on treated sides compared to control at 30 days. No implant-related adverse events were reported. This study demonstrates the efficacy of steroid-releasing implants in improving outcomes of frontal sinus surgery. 1b. Laryngoscope, 126:2659-2664, 2016.

Safety analysis of long-term budesonide nasal irrigations in patients with chronic rhinosinusitis post endoscopic sinus surgery.

Although the safety of topical nasal steroids is well established for nasal spray forms, data regarding the safety of steroid irrigations is limited. We studied the effect of long-term budesonide nasal irrigations (>6 months) on hypothalamic-pituitary-adrenal axis (HPAA) function and intraocular pressure (IOP) in patients post-endoscopic sinus surgery. This was retrospective case series. Adrenal function was assessed by using the high-dose cosyntropin stimulation test. A total of 48 patients were assessed, with a mean duration of budesonide irrigations of 22 months. Stimulated cortisol levels were abnormally low in 11 patients (23%). None reported to have symptoms of adrenal suppression. Three of 4 patients who repeated the study being off budesonide for at least 1 month returned to near normal levels. Logistic regression analysis revealed that concomitant use of both nasal steroid sprays and pulmonary steroid inhalers was significantly associated with HPAA suppression (p = 0.024). Patients with low stimulated cortisol levels were able to continue budesonide irrigations under the supervision of an endocrinologist without frank clinical manifestations of adrenal insufficiency. IOP was within normal limits in all patients. Long-term use of budesonide nasal irrigations is generally safe, but asymptomatic HPAA suppression may occur in selected patients. Concomitant use of both nasal steroid sprays and pulmonary steroid inhalers while using daily budesonide nasal irrigations is associated with an increased risk. Rhinologists should be alerted to the potential risks of long-term use of budesonide nasal irrigations, and monitoring for HPAA suppression may be warranted in patients receiving long-term budesonide irrigation therapy.

Post-sinus surgery insertion of steroid-eluting bioabsorbable intranasal devices: A systematic review.

Postendoscopic sinus surgery corticosteroid administration reduces polyp formation, inflammation, and adhesions. Steroid-eluting bioabsorbable intranasal devices (SEBID) are novel interventions thought to improve local drug delivery while minimizing systemic side effects. The primary aim of this systematic review is to evaluate the efficacy and safety of bioabsorbable SEBIDs. The secondary aim is to inform clinical recommendations and to introduce clinicians to this novel technology. MEDLINE, PubMed, Embase, and Cochrane Database were searched according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Original articles assessing the efficacy of SEBIDs inserted after endoscopic sinus surgery. For each study, we recorded the efficacy endpoints and safety outcomes. Seven studies met the inclusion criteria from 737 initial articles identified, including five prospective randomized controlled trials and two prospective single-cohort studies involving 394 sinuses within treatment arms. Patients were followed up for 2 to 6 months. Six studies demonstrated SEBID efficacy with statistical significance (P < 0.05). Steroid-eluting bioabsorbable intranasal devices were effective in reducing adhesion formation, polyp formation, inflammation, Lund-Kennedy scores, and perioperative sinus endoscopy scores. The devices improved patient-reported outcomes and olfaction while reducing postoperative interventions. They were not associated with adverse events and pose no ocular safety risk. Complications in three SEBID applications were reported. There is limited data available on SEBIDS; further studies are required to determine whether they are safe and effective adjuncts postendoscopic sinus surgery. Future studies are needed to optimize the dosing regimen, compare devices, and provide long-term outcomes. Steroid-eluting bioabsorbable intranasal devices may tentatively be incorporated into future evidence-based practice.

Clinical significance of middle turbinate lateralization after endoscopic sinus surgery.

To investigate the clinical significance of middle turbinate lateralization (MTL) occurrence postendoscopic sinus surgery (ESS) for chronic rhinosinusitis, namely, association with postoperative symptoms and eventual need for undergoing revision surgery. Retrospective chart review of consecutive postoperative follow-up appointments (November 2009-May 2011) for patients who had had full-house ESS (post hoc analysis). Endoscopic video recordings were reviewed by a blinded reviewer to determine occurrence of MTL (any portion of the middle turbinate touching the lateral nasal wall). Postoperative symptom questionnaires using the Adelaide scoring system were collected. Records were reviewed to determine the need for revision surgeries during follow-up. A total of 151 patients had follow-up with video endoscopy from 2009 to 2011. No statistically significant association between MTL and symptoms was found (P > .05). Of the patients with MTL, 21% required revision versus 9% in those who had no MTL (P = .07). Log-rank test showed that there was a statistically significant difference between the revision surgery survival curves for the MTL and no-MTL groups (P = .03). Controlling for the inability to examine the frontal sinus, the difference between the two survival functions increased (P = .005). MTL was not associated with patient-reported symptoms, but may be associated with a more rapid need for future revision surgery. We hypothesize that this effect is related to interference with the frontal sinus.

The effect of intranasal fluticasone propionate irrigations on salivary cortisol, intraocular pressure, and posterior subcapsular cataracts in postsurgical chronic rhinosinusitis patients

Intranasal corticosteroid irrigations, especially budesonide, are used increasingly in the management of chronic rhinosinusitis. In post-endoscopic sinus surgery patients, irrigations may offer improved delivery at higher doses to the paranasal sinuses than intranasal spray preparations. Fluticasone propionate may have higher potency and lower systemic bioavailability than budesonide, but there is little data on its effects as an intranasal irrigation on the hypothalamic-pituitary-adrenal axis or on ocular findings. Adult patients who had previously undergone bilateral endoscopic sinus surgery and had not taken systemic corticosteroids in the last 6 months were prospectively enrolled. Subjects irrigated with 3 mg of fluticasone propionate in 240 mL saline solution twice daily. Salivary cortisol, intraocular pressure, and the presence of posterior subcapsular cataracts were measured before drug administration and after 6 weeks of continuous use. Twenty-three subjects completed the study. No subjects had salivary cortisol levels below the normal range before or after therapy, and there was no statistical difference in mean salivary cortisol levels pretreatment and posttreatment (0.294 vs 0.392 μg/dL; p = 0.27). There was no clinical or statistical difference in mean intraocular pressure before or after therapy (13.3 vs 13.3 mmHg; p = 0.86). No subjects developed a posterior subcapsular cataract. Fluticasone propionate irrigations did not suppress salivary cortisol levels or result in ocular changes. Irrigation with fluticasone propionate 3 mg in 240 mL saline twice daily may be a safe alternative to other intranasal or systemic corticosteroid treatments for chronic rhinosinusitis patients.

Efficacy of Targeted Middle Meatal Antibiotics and Endoscopic Sinus Surgery

Postoperative infection remains a significant comorbidity of endoscopic sinus surgery (ESS) delayed healing, synechia formation, etc. The objective of this study was to compare the incidence of postoperative infection after ESS in patients receiving conventional postoperative oral antibiotic prophylaxis versus a synthetic bioabsorbable antibiotic-soaked nasal sponge used in the middle meatus (MM) in lieu of oral antibiotics. A prospective randomized multicenter trial included 321 chronic rhinosinusitis patients undergoing minimally invasive ESS who received either 1 week of oral antibiotics and a saline-soaked bioabsorbable MM sponge (control group) or no oral antibiotics and the placement of a bacitracin-soaked bioabsorbable sponge in the MM (study group). Evaluations performed at baseline, 3-weeks, and 3-months postoperatively included the 20-item Sino-Nasal Outcome Test and nasal endoscopic examination. The 3-week postoperative infection rate was not significantly different between the study (n = 165) and control groups (n = 156): 5.4% versus 3.8%; p > 0.05. In addition, there was no significant difference between the two patient groups on evaluation of MM granulations, synechia, middle turbinate lateralization, or sponge retention. Antibiotic-soaked synthetic bioabsorbable MM sponges show equivalent efficacy in controlling post ESS infections compared with conventional postoperative oral antibiotics. Topical antibiotic delivery to the MM via bioabsorbable sponges may reduce the need for postoperative systemic antibiotics and provide a cost-effective alternative that eliminates the issues of antibiotic side effects, drug-drug interactions, and medication compliance in the postoperative setting.

Comparison of endoscopically‐guided swab vs aspirate culture techniques in post–endoscopic sinus surgery patients: blinded, prospective analysis

Culture-directed antibiotic therapy remains imperative in the management paradigm of chronic rhinosinusitis (CRS). The objective of this study was to conduct a prospective, blinded comparison of endoscopically-guided swab and aspirate cultures from the same sinonasal site in patients presenting with acute infectious exacerbations post-sinus surgery. Forty-nine CRS patients were prospectively enrolled in a tertiary care rhinology clinic. At the conclusion of the study, all cultures were unblinded to determine mean culture yield, most common pathogens, potential contaminants, and therapeutic correlation. The mean patient age was 49 years and 40.8% were males. All patients had evidence of symptomatic exacerbation with purulence on endoscopy at the time of presentation. There was a mean of 1.367 pathogens assayed per aspirate culture vs a mean of 1.102 per swab culture (p = 0.0032). The prevalence of Pseudomonas aeruginosa was 42% for aspirate vs 30% for swab cultures, respectively. The prevalence of Staphylococcus aureus was 49% for suction cultures vs 45% for swab cultures. There were 9 and 11 likely contaminants using aspirate and swab cultures, respectively. Therapeutic correlation was strong in 67%, moderate in 18%, and weak in 14% of patients. This prospective analysis demonstrated higher culture yield, particularly with Pseudomonas, with aspirate vs swab cultures in postoperative patients. There is a strong clinical correlation between the 2 methods, and both aspirate and swab techniques serve as acceptable alternatives for endoscopic-guided cultures in patients with post-functional endoscopic sinus surgery infectious exacerbations.