Prior Endoscopic Sinus Surgery Research Articles

Exostoses of the paranasal sinuses

While bony exostoses of the external auditory canal have long been recognized as a complication of cold-water swimming, bony exostoses of the paranasal sinuses have not been previously reported. We present an unusual case of multiple exostoses of the paranasal sinuses, which began coincident with nasal irrigation with cold gentamicin solution. The patient had had prior endoscopic sinus surgery. Topical antibiotic gentamicin irrigation lessened recurrence of bacterial sinus episodes. He admitted to using the irrigation directly from the refrigerator daily for two years. A biopsy was consistent with exostosis. Patients should be counseled to avoid irrigating their paranasal sinuses with cold irrigants. Laryngoscope, 2010.

Unrecognized Odontogenic Maxillary Sinusitis: A Cause of Endoscopic Sinus Surgery Failure

Endoscopic sinus surgery (ESS) is reported to improve symptoms in approximately 85% of patients. Reasons for failure include misdiagnosis, technical inadequacies, underlying severe hyperplastic disease, biofilm, and immunodeficiency. Only one previous case of unrecognized odontogenic maxillary sinusitis has been cited in the literature as a reason for failure to improve with sinus surgery. This study was designed to characterize clinical and radiographic findings in patients who fail to improve with ESS because of an unrecognized dental etiology. Five patients, with odontogenic maxillary sinusitis with prior unsuccessful ESS, were prospectively enrolled. Demographics and clinical aspects including duration of illness, prior sinus surgeries and therapies, and radiographic data were assessed. Five adults underwent an average of 2.8 sinus surgeries with persistence of disease and symptoms until their dental infection was treated. Duration of symptoms ranged from 3 to 15 years. In four of five patients, the periapical abscess was not noted on the original CT report but could be seen in retrospect. Three of five patients had been seen by their dentists and told they had no dental pathology. All five patients underwent dental extractions and one patient underwent an additional ESS after dental extraction. These procedures led to a resolution of sinusitis symptoms in all five patients. Unrecognized periapical abscess is a cause of ESS failure and the radiological report frequently will fail to note the periapical infection. Dentists are unable to recognize periapical abscesses reliably with dental x-rays and exam. In patients with maxillary sinus disease, the teeth should be specifically examined as part of the radiological workup.

Predictors of Olfactory Dysfunction in Patients With Chronic Rhinosinusitis

To measure the prevalence of and identify clinical characteristics associated with poor olfactory function in a large cohort of patients with chronic rhinosinusitis (CRS). Multi-institutional, cross sectional analysis. An objective measure of olfactory dysfunction, the Smell Identification Test, demographic data, clinical factors, and comorbidity data were collected from a cohort of 367 patients who presented with CRS at three tertiary care centers. Data were analyzed using univariate and multivariate analyses. Sixty-four percent of men and women aged 18 to 64 had olfactory dysfunction whereas 95% of patients older than or equal to 65 years had olfactory dysfunction (P < .001); no significant difference was noted by gender. By multivariate logistic regression analysis, patients with nasal polyposis [Odds ratio (OR) 2.4, 95% confidence interval (CI) 1.3-4.2, P = .003] and patients older than or equal to 65 years (OR 10.0, 95% CI 2.3-43.7, P = .002) were at increased risk of hyposmia. Patients with nasal polyposis (OR 13.2, 95% CI 5.7-30.7, P < .001), asthma (OR 4.2, 95% CI 1.8-9.8, P = .001), older than or equal to 65 years (OR 15.6, 95% CI 2.3-104.9, P = .005), and smokers (OR 7.6, 95% CI 1.8-31.6, P = .005) were at increased risk of anosmia. Poor olfactory function is common in patients with CRS. Age, nasal polyposis, smoking, and asthma were significantly associated with olfactory dysfunction in patients with CRS. Neither prior endoscopic sinus surgery nor a history of allergic rhinitis was associated with olfactory dysfunction. Septal deviation and inferior turbinate hypertrophy were associated with normal olfactory function.

Comprehensive Management of Failed Frontal Sinus Obliteration

Treatment of patients with failed frontal sinus (FS) obliteration (FSO) remains an important challenge in the endoscopic era. Advances in endoscopic techniques have facilitated the application of minimally invasive approaches for clinical scenarios that previously required open procedures. A retrospective chart review of patients presenting with failed FSO from January 1, 2001 to June 30, 2007 was performed. Seventeen patients (mean age, 52.8 years; 10 men and 7 women) presented at an average of 9.7 years from initial FSO. The most common primary presenting symptoms included headache (41.2%) and forehead swelling (23.5%). Seven patients had prior craniotomies and 10 patients had prior endoscopic sinus surgery. All patients underwent surgical exploration; revision procedures were required in 5 patients. Definitive procedures included endoscopic frontal sinusotomy (EFS; 10 patients), endoscopic frontal drill-out (3 patients), revision osteoplastic frontal sinusotomy with obliteration reversal (2 patients), and repeat FSO (2 patients). One patient required revision EFS twice. Initial intraoperative findings included mucocele (13 cases), bone wax (3 cases), fibrous tissue (2 cases), and polypoid mucosa (1 case). All patients had resolution or improvement of their primary presenting signs/symptoms. All FSO reversal patients achieved functional FS patency documented by endoscopy and/or CT scan with mean follow-up of 9.5 months (range, 1.5-30.8 months). Operative exploration should be considered in all patients with persistent or recurrent symptoms and/or signs of failed FSO. In most instances, repeat FSO can be avoided, and a minimally invasive endoscopic strategy can be used successfully.

The Effect of Endoscopic Sinus Surgery on Symptoms of Eustachian Tube Dysfunction

The symptom of eustachian tube dysfunction has been categorized as a "minor" symptom in chronic rhinosinusitis. The aim of this pilot study was to determine the frequency of otologic symptoms in patients with confirmed rhinosinusitis and the likelihood of its resolution in those patients undergoing endoscopic sinus surgery (ESS). Questionnaires were obtained from 168 patients who had undergone prior ESS over a 5-year period. Patients were asked to evaluate if they suffered from several different potential symptoms of eustachian tube dysfunction before ESS and whether that symptom changed postoperatively. Using the binomial test, 95% confidence intervals were determined for the following otologic symptoms of tubal dysfunction: "earfullness and congestion," "ear cracking and popping," "dizziness," and "ear pain. "ESS was found to have a significant treatment effect for the indicated otologic symptoms of tubal dysfunction. Tubal dysfunction, as manifested by otologic symptoms, is common in patients with chronic rhinosinusitis undergoing ESS. The classification of this as a "minor" symptom of rhinosinusitis needs to be reevaluated. These symptoms improve or resolve in the majority of patients undergoing ESS.

Endoscopic management of cerebrospinal fluid rhinorrhea.

Most anterior skull base defects causing cerebrospinal fluid (CSF) rhinorrhea can be readily approached using endoscopic techniques when surgical repair is necessary. We present our data from endoscopic repair of CSF rhinorrhea with long-term follow-up. Retrospective data analysis of patients that were diagnosed with anterior skull base CSF rhinorrhea and underwent endoscopic repair at a tertiary institution. Data were analyzed to determine the etiology and location of CSF leaks. Diagnostic techniques, surgical techniques, and surgical outcomes were reviewed. Ninety-two patients were diagnosed with CSF rhinorrhea and underwent endoscopic repair over a 12-year period. Forty-eight were males, and 44 were females. The average age was 49 (range 6-81) years. Average follow-up was 25 months, with a range of 12 to 82 months. The etiology of CSF leak was prior endoscopic sinus surgery in 23 patients (25%), idiopathic in 19 (21%), neurosurgery in 17 (18%), trauma in 18 (20%), and the presence of meningocele/encephalocele in 11 patients (12%). The most common location of the defect was the sphenoid sinus (n = 36, 39%), followed by ethmoid roof (n-27, 29%), and cribriform plate (n = 24, 26%). Endoscopic repair was initially successful in 78 (85%) patients. Seven additional patients underwent successful revision endoscopic repair for an overall success rate of 92% (n = 85). Five (6%) large skull base defects were eventually repaired by neurosurgery using open intracranial techniques. No major complications were encountered. The intranasal endoscopic approach is an effective and safe technique in the surgical management of anterior skull base CSF rhinorrhea. Long-term success rate in our patient population was 92%.

The microbiology and antimicrobial resistance patterns in chronic rhinosinusitis

Objectives The purpose of this study was to review the microbiology of chronic rhinosinusitis (CRS) in patients undergoing endoscopic sinus surgery (ESS) and comment on antimicrobial resistance trends. Methods A retrospective review of 101 patients undergoing ESS during the period of 1997 to 2001 was performed. Patients were divided into groups based on their surgical history. Fifty-five patients without prior ESS history were placed in the primary group; 46 patients who had undergone prior ESS were placed in the revision group. Intraoperative microbiology culture data were reviewed and antimicrobial resistance data analyzed. Results Data on 101 patients were analyzed. There were 182 total cultures sent, yielding 257 isolates. The most common isolates were coagulase-negative Staphylococcus (SCN) (45% of cultures), gram-negative rods (25% of cultures), and Staphylococcus aureus (24% of cultures). Pseudomonas aeruginosa was isolated in 9% of cultures. When comparing the 2 patient groups, we did not find consistent trends in the differences in the prevalence of these isolates. Antimicrobial resistance for SCN ( P = .01) and S aureus ( P < .001) was greater in the revision surgery. Overall, 62% of patients were found to have at least 1 isolate with decreased antibiotic sensitivity. Conclusion The most prevalent microorganisms in patients with CRS are SCN, S aureus, and gram-negative rods. Perhaps more importantly, the antimicrobial sensitivities of these microorganisms appear to be a growing problem. These findings suggest increased antimicrobial resistance in patients undergoing revision ESS when compared with patients undergoing surgery for the first time.

Smoking in chronic rhinosinusitis: a predictor of poor long-term outcome after endoscopic sinus surgery.

This study was designed to determine whether smoking patients have poorer outcomes after endoscopic sinus surgery (ESS) based on a reliable validated rhinosinusitis-specific quality-of-life outcomes test. Retrospective chart and computed tomography (CT) review with telephone and letter questionnaire. Charts of 230 adult patients undergoing ESS for chronic rhinosinusitis between January 1995 and December 1998 were reviewed. Each participating patient completed a detailed questionnaire, including the Sino-Nasal Outcome Test-16 (SNOT-16), at an average of 52 months after surgery. Preoperative CT scans were reviewed and the findings used to stage the patients' conditions. Multivariate analysis was used to assess these data. Eighty-two patients completed the questionnaire, with 26 who smoked at the time of surgery and continued to smoke at the time of answering the questionnaire (Smokers). Average SNOT-16 score in Smokers was 27.5, versus 18.2 in those who did not smoke at the time of surgery (Non-Smokers). There was a statistically significant correlation between elevated SNOT-16 scores and smoking (P <.001) and antibiotic use within the past year (P <.001). There was an association between high SNOT-16 scores and both prior smoking and passive smoke exposure that did not reach statistical significance (P =.055 and P =.267, respectively). CT staging scores and prior ESS were not statistically correlated with SNOT-16 scores. Smoking is associated with statistically worse outcomes after ESS based on average SNOT-16 scores. Although no investigator has proved that the effects of smoking on sinonasal health are reversible, we counsel smoking patients considering ESS about the desirability of smoking cessation (for this and many health reasons), and the possibility of a poorer postsurgery outcome should they continue smoking.

Safety of Steroid Injections in the Treatment of Nasofrontal Recess Obstruction

A retrospective review was undertaken to determine if steroid injection is a safe and effective intervention in the management of chronic nasofrontal recess obstruction. Seventy-four patients were identified who had undergone prior endoscopic sinus surgery and subsequently developed nasofrontal recess obstruction that was treated with injection of Kenalog 20 mg/mL (Bristol-Myers Squibb Co., Princeton, NJ) directly into the polyps or fibrosis. The study included 38 men and 36 women with a mean age of 45.4 years. These patients collectively underwent 687 injections, an average of 9.3 injections per patient. The indication was polyposis in 70 patients and fibrosis in 17 patients, with 13 sharing both indications. These patients also required 112 office procedures to maintain nasofrontal recess patency, an average of 1.5 procedures per patient. Three patients eventually required frontal sinus obliteration. The mean follow-up period from the initial injection was 50.1 months, and no complications were reported. Therefore, nasofrontal steroid injection appears to be safe and effective in the treatment of nasofrontal recess obstruction.

Persistent rhinosinusitis in children after endoscopic sinus surgery

The efficacy of endoscopic sinus surgery (ESS) in children is insufficiently addressed in the medical literature. We report a cohort of 14 children (mean age 7.7 years, median age 5.1 years) seen at our multidisciplinary clinic for refractory rhinosinusitis during a 30-month period who continued to have rhinosinusitis despite previous ESS. Prior ESS procedures were performed by 11 surgeons in 3 states. The first ESS was performed when the children were a mean age of 4.6 years, and in 10 of 14, it was performed when they were younger than 4.8 years. This cohort required a disproportionately high rate of subsequent surgical intervention, 50%, versus a 9% surgical rate in the remaining clinic population ( P = 0.0002). Osteomeatal scarring was the single most difficult surgical complication. Significant morbidity, in the form of persistent disease, is encountered after ESS in young children. Although chronic rhinosinusitis after ESS, to a certain degree, can still be managed by medical therapy, judicial use of ESS, especially in the very young, is recommended. (Otolaryngol Head Neck Surg 1999;121:577-80.)