Sinus Surgery Research Articles

EDS-FLU efficacy in patients with chronic rhinosinusitis with or without prior sinus surgery in ReOpen1 and ReOpen2 randomized controlled trials.

The inability of topical medications to reach sinus cavities is a potential reason for lack of efficacy in chronic rhinosinusitis (CRS). One purpose of endoscopic sinus surgery (ESS) is to enable delivery of medications into the sinus cavities. The exhalation delivery system with fluticasone (EDS-FLU; XHANCE) creates unique biomechanics that enable deposition of intranasal corticosteroid into sinuses and sinus drainage pathways but may have differing efficacy in operated versus unoperated sinuses. Two 24-week randomized trials (ReOpen1/2) evaluated EDS-FLU versus EDS-placebo in patients with CRS, stratified by surgical status. Surgery-naive (n=332) and prior-surgery (n=215) patient groups were analyzed as pooled data from ReOpen1/2. Outcome measures (least-squares mean change from baseline) included combined symptom score (CSS) and congestion score at weeks 4, 8, and 12 and average of percentages of opacified volume (APOV) of ethmoid/maxillary sinuses on CT and Sinonasal Outcome Test 22 (SNOT-22) total score at week 24. Baseline scores suggested moderate-severe disease: mean CSS=5.8; APOV=67.2%. EDS-FLU produced significant improvement versus placebo (p<0.05): CSS (surgery-naive, -0.68vs. -1.42; prior ESS, -0.70vs. -1.87); congestion (surgery-naive, -0.24vs. -0.59; prior ESS, -0.24vs. -0.69); and SNOT-22 (surgery-naive, -7.56vs. -18.30; prior ESS, -10.72vs. -18.74). Similar results were observed for APOV (p<0.05). No statistically significant difference was observed between surgery subgroups with either EDS-FLU dose. EDS-FLU improved symptoms, sinus opacification, and quality of life in patients with CRS with or without prior ESS, suggesting a role for EDS-FLU in both populations.

Residual Cyst Mimicking an Aggressive Neoplasm—A Life-Threatening Condition

Odontogenic cysts are frequently encountered in clinical practice. However, residual cysts, a specific type of inflammatory odontogenic cyst, are relatively rare. These cysts may slowly expand over time, damaging surrounding soft tissues and bone, typically without posing a threat to life. We report the case of a 67-year-old man with liver failure and a cystic tumor in his right maxilla that had invaded his oral cavity and cheek, causing nasal obstruction and severe bleeding following an incisional biopsy. A computed tomography (CT) scan of the mass was nonspecific, and an initial histopathological analysis of the tissues was inconclusive due to chronic inflammation and hemorrhagic alterations, complicating the diagnostic pathway. The suspicion of a potentially aggressive malignant neoplasm and the need for immediate intervention due to bleeding necessitated a tracheotomy, tumor removal, percutaneous endoscopic gastrostomy, and transfusions of red blood cells. A subsequent histopathological examination revealed features indicative of a residual cyst. The entire lesion was excised through functional endoscopic sinus surgery. The surgical treatment was performed safely and effectively. Follow-up CT confirmed complete removal of the lesion. This case highlights a rare yet possible complication of odontogenic cysts and underscores the necessity of early diagnosis and comprehensive prophylaxis to prevent severe complications.

Predictors for Development of Chronic Rhinosinusitis in Transplant Recipients.

Studies suggest that transplant patients are at a higher risk of developing chronic rhinosinusitis (CRS). However, there is a dearth of studies describing the factors that may be linked to the development of CRS in this population. Our objective is to identify the risk factors associated with the development of CRS in transplant recipients. Retrospective cohort. Tertiary care center. This cohort included 3347 transplant recipients seen between 2017 and 2022. Of these, 2128 patients met the inclusion criteria and were grouped according to whether they were diagnosed with CRS during the post-transplant period. The analysis included both univariate and multivariate analysis to ascertain the odds ratio (OR) and predictive factors. Of the 2128 patients, 649/2128 (30.4%) had CRS. CRS patients had an increased prevalence of previous endoscopic sinus surgery, allergic rhinitis, and recurrent acute rhinosinusitis in the pre-transplant period compared to the non-CRS group. According to the multivariate analysis, patients with primary immunodeficiency and additional transplant were 1.9 and 3.1 times more likely to develop CRS during the posttransplant period (95% CI: 1.3-2.6, p < .0001), (95% CI: 1.3 -7.3, p = .01), respectively. Sirolimus use was also associated with the development of CRS (OR = 1.4, 95% CI: 1.1-1.9, p = .01). This study is the largest cohort aimed at determining the predictive factors associated with the development of CRS. Patients with pretransplant rhinologic conditions, hematologic deficiencies, and the utilization of specific immunosuppressants were found to have a higher likelihood of developing CRS following transplantation.

Evaluation of CNPase and TGFβ1/Smad Signalling Pathway Molecule Expression in Sinus Epithelial Tissues of Patients with Chronic Rhinosinusitis with (CRSwNP) and without Nasal Polyps (CRSsNP).

Chronic rhinosinusitis with and without nasal polyps (CRSwNP and CRSsNP, respectively) is a chronic inflammatory disease affecting almost 5 to 12% of the population and exhibiting high recurrence rates after functional endoscopic sinus surgery (FESS). TGFβ1-related pathways contribute to tissue remodelling, which is one of the key aspects of CRS pathogenesis. Additionally, adenosine signalling participates in inflammatory processes, and CNPase was shown to elevate adenosine levels by metabolizing cyclic monophosphates. Thus, the aim of this study was to assess the expression levels of Smad2, pSmad3, TGFβ1, and CNPase protein via immunohistochemistry in sinus epithelial tissues from patients with CRSwNP (n = 20), CRSsNP (n = 23), and non-CRS patients (n = 8). The expression of Smad2, pSmad3, TGFβ1, and CNPase was observed in the sinus epithelium and subepithelial area of all three groups of patients, and their expression correlated with several clinical symptoms of CRS. Smad2 expression was increased in CRSsNP patients compared to CRSwNP patients and controls (p = 0.001 and p < 0.001, respectively), pSmad3 expression was elevated in CRSwNP patients compared to controls (p = 0.007), TGFβ1 expression was elevated in CRSwNP patients compared to controls (p = 0.009), and CNPase was decreased in CRSsNP patients compared to controls (p = 0.03). To the best of our knowledge, we are the first to demonstrate CNPase expression in the upper airway epithelium of CRSwNP, CRSsNP, and non-CRS patients and point out a putative synergy between CNPase and TGFβ1/Smad signalling in CRS pathogenesis that emerges as a novel still undiscovered aspect of CRS pathogenesis; further studies are needed to explore its function in the course of the chronic inflammation of the upper airways.

Mucosal LTE4, PGD2 and 15(S)-HETE as potential prognostic markers for polyp recurrence in chronic rhinosinusitis

BackgroundAltered biosynthesis of eicosanoids is linked to type 2 inflammation in chronic rhinosinusitis with nasal polyps (CRSwNP), but their role in recalcitrant NPs is unclear. ObjectivesWe sought to identify endotypes that are linked to recalcitrant CRSwNP, based on eicosanoids, their biosynthetic enzymes, and receptors as well as cytokines and the presence of eosinophils and mast cells in recurrent NPs. MethodsMucosal tissue collected at the time of sinus surgery from 54 patients with CRSwNP and 12 non-CRS controls were analysed for leukotriene (LT) E4, prostaglandin (PG) D2, 15(S)-hydroxyeicosatetraenoic acid (15(S)-HETE) and 17 cytokines with ELISAs and Bio-Plex immunoassays. Patient subgroups were identified by cluster analysis and the probability of NP recurrence were tested with logistic regression analyses. Gene expressions were analysed with qPCR. Tryptase and eosinophil-derived neurotoxin (EDN) were measured with ELISAs as indications of the presence of mast cells and eosinophils, respectively. ResultsClustering of patients showed that an inflammatory signature characterised by elevated LTE4, PGD2, 15(S)-HETE and IL-13 was associated with NP recurrence. Previous NP surgery as well as aspirin-exacerbated respiratory disease were significantly more common among these patients. Expression of cyclooxygenase 1 was the only gene associated with NP recurrence. Levels of EDN, but not tryptase, were significantly higher in patients with recurrent NPs. ConclusionDistinguishing endotypes that include LTE4, PGD2, 15HETE and conventional biomarkers of type 2 inflammation could help predict recurrent nasal polyposis and thus identify cases of recalcitrant CRSwNP.

Comparative Effectiveness of Dupilumab Versus Sinus Surgery for Chronic Rhinosinusitis With Polyps: Systematic Review and a Meta-Analysis.

Current treatment paradigms recommend surgical intervention when conventional medical management proves ineffective in resolving chronic rhinosinusitis with nasal polyposis. To assess and compare the efficacy of dupilumab and functional endoscopic sinus surgery (FESS) for the treatment of chronic rhinosinusitis with nasal polyp (CRSwNP) over time. Studies comparing CRSwNP patients who received dupilumab with those who underwent FESS were included. Outcome measures included the nasal congestion score (NCS), Sino-nasal Outcome Test-22 (SNOT-22), University of Pennsylvania Smell Identification Test-40 (UPSIT-40), and nasal polyp score (NPS). The risk of bias was evaluated using the Newcastle-Ottawa Scale. A total of 4 studies with 724 participants were included. The dupilumab group had a superior NCS, but an inferior NPS, compared to the FESS group during the follow-up period. The SNOT-22 score of the dupilumab group was inferior to that of the FESS group until 6 months posttreatment, but the scores were similar at around 1 year. A similar trend was observed for the UPSIT-40 score, but the score of the dupilumab group was higher at around 1 year. Functional endoscopic sinus surgery was more effective than dupilumab for several months after treatment. However, at 1 year after treatment, the effects of the 2 treatments became similar, with greater olfactory improvement seen in the dupilumab group.

Comparative evaluation of oral premedication with clonidine and metoprolol on surgical field conditions and intraoperative hemodynamics during functional endoscopic sinus surgery

Abstract Background and Aims: Bloodless surgical field during functional endoscopic sinus surgery (FESS) is an essential part, and research continues to find simple and effective regime for it. This study was aimed to compare the efficacy of oral clonidine versus oral metoprolol as premedicants regarding surgical field condition and controlled hypotension in patients undergoing FESS. Material and Methods: Sixty-eight patients of American Society of Anesthesiologists (ASA) physical status (PS) I and II aged 18–60 years, of both genders, scheduled for FESS under general anesthesia were randomly allocated in two groups. Group C (n = 34) received oral clonidine 300 μg and group M (n = 34) received oral metoprolol 50 mg, 2 h before surgery. Controlled hypotension (mean arterial pressure [MAP] 65–75 mmHg) was achieved by titrating sevoflurane (1%–3%). Primary outcome measured was surgical field visualization by Average Category Scale (ACS 0–5), and the secondary outcomes measured were hemodynamic parameters, sevoflurane requirement, recovery, and side effects. Categorical, continuous, and ordinal data were compared using Chi-square test, t-test, and Mann–Whitney test, respectively. P &lt; 0.05 was considered as statistically significant. Results: ACS was significantly less in group C compared to group M up to 60 min, (P &lt; 0.05). Mean systolic blood pressure (SBP), diastolic blood pressure (DBP), and MAP were significantly less in group C compared to group M at all time intervals (P &lt; 0.05) Intraoperative sevoflurane requirement (vol %) was significantly less in group C (1.21 ± 0.42) compared to group M (1.68 ± 0.53) (P = 0.000). Conclusions: Premedication with oral clonidine was found to be superior to oral metoprolol as it provided significantly better surgical field condition during FESS with much efficient controlled hypotension and anesthetic-sparing effect. Standardized Study Reporting Requirements: CONSORT: http://www.consort-statement.org/.

Correction to: Early Endoscopic Sinus Surgery after Medical Failure Improves Postoperative Inflammation Control in Chronic Rhinosinusitis without Nasal Polyps

Correction to: Early Endoscopic Sinus Surgery after Medical Failure Improves Postoperative Inflammation Control in Chronic Rhinosinusitis without Nasal Polyps

Orbital Apex Syndrome Caused by Invasive Fungal Sinusitis due to Candida glabrata: A Case Report

Purpose: To report a case of orbital apex syndrome resulting from invasive fungal sinusitis attributed to the unusual &lt;i&gt;Candida glabrata&lt;/i&gt; species.Case summary: A 76-year-old patient presented with persistent left-sided orbital pain, headaches, and blurred vision for 3 weeks. The patient had a history of uncontrolled diabetes, chronic kidney failure, and angina, and was treated for a COVID-19 infection 1 month prior to admission. Contrast-enhanced computed tomography scans revealed extensive bilateral sinusitis affecting the left optic nerve. The patient underwent endoscopic sinus surgery, which included nasal cavity biopsy, conducted by an otorhinolaryngologist. Histopathological analysis using Gömöri methenamine silver stains identified &lt;i&gt;Candida&lt;/i&gt;. Cultures from sinus specimens later grew &lt;i&gt;Candida glabrata&lt;/i&gt;. Treatment involved daily IV amphotericin B followed by oral itraconazole. After 6 months, the patient fully recovered from fungal sinusitis but continued to experience negative light perception in the left eye and progressed to complete ophthalmoplegia, consistent with orbital apex syndrome.Conclusions: Reports of invasive fungal sinusitis caused by &lt;i&gt;Candida&lt;/i&gt; infections are rare globally. This report marks the first occurrence in this country. Effective management requires careful assessment and appropriate treatment tailored to the specific species, especially considering the risk of orbital extension of the inflammatory lesion.

Analgesic efficacy of ultrasound-guided bilateral sphenopalatine ganglion block as a sole analgesic in fess surgeries and reconstructive nasal surgeries

: Severe postoperative pain is the most common complaint following Functional endoscopic sinus surgeries (FESS) and reconstructive nasal surgeries. Sensory, autonomic nerves supplying paranasal sinuses, nasal cavity, and palate relay in sphenopalatine ganglion. Bilateral Sphenopalatine ganglion block can be an effective regional anaesthetic technique for post-operative analgesia. We conducted a study with ultrasound-guided bilateral sphenopalatine ganglion block as the sole analgesic compared to Fentanyl in patients undergoing FESS &amp; reconstructive nasal surgeries performed under general anaesthesia. The primary objective of our study was to assess the analgesic effect, quality, and duration of analgesia of ultrasound guided bilateral sphenopalatine ganglion block as a sole analgesic. In addition, the secondary aim was to further evaluate the adverse effects.With Institutional ethical committee approval and written informed consent, we conducted this study with two groups of 30 patients each. The surgical procedure was performed under general anaesthesia. At the end of the surgery and before the reversal of neuromuscular blockade, bilateral sphenopalatine plexus block was performed under ultrasound guidance in interventional Group (A) with a mixture of 0.25% Ropivacaine, Dexamethasone 4mg 7.5ml each side, whereas the control Group (B) received fentanyl 2ug/kg intraoperatively. Visual analogue scale (VAS) scores were evaluated soon after extubating (0hrs) and up to 48 hrs postoperatively in all patients.There was no significant difference in VAS scores at 0hrs, 2hrs between both groups. Interventional group(A) had statistically significant lower scores (P &amp;#60;0.00) 4hrs onwards till 48hrs than in control group(B). No adverse events were noted with minimal postoperative analgesic requirement in group(A) (P &amp;#60;0.000).: We conclude, that ultrasound-guided bilateral sphenopalatine block is a safe and effective procedure that provides sustained and superior quality of analgesia when compared to fentanyl

Technical Quality of Contemporary Endoscopic Sinus Surgery: An Assessment by Study of Anatomical Features Needing Attention at Revision Surgery

Although technical causes of endoscopic sinus surgery (ESS) failure have long been reported, we were curious about the quality of contemporary sinus surgery. The electronic health database of Mayo Clinic, Arizona was scrutinized to identify adult patients with diffuse chronic rhinosinusitis (CRS) who underwent revision ESS between January 2019 and September 2023 with a history of bilateral full-house ESS. Anatomical features on preoperative radiology and intraoperative endoscopy were cataloged: residual uncinate tissue, maxillary antrostomy with a non-incorporated natural os, residual ethmoidal septations (three septations &gt; 3 mm), and inadequate sphenoid osteotomy (os size &lt; 6 mm). Sixty-nine subjects were identified. A deviated nasal septum was present in 53.6%. Residual uncinate tissue was noted in 50.7% of patients associated with missed natural maxillary os in 39.13% of antrostomies. An inadequate os diameter was noted in 63.8% of sphenoidotomies. Significant residual septations were seen in posterior ethmoidal cells in 66.7% and anterior ethmoidal cells in 62.3% of patients. Residual frontoethmoidal cells were noted in 72.4% of patients. Although the extent of ESS must be individualized, a high prevalence of features reflecting suboptimal surgery that could limit the success of ESS was identified. These findings merit further consideration for focused training during residency and continuous professional development activities.

Transanal circumferential pouch advancement for treatment of pouch vaginal fistulae

BackgroundIleal pouch anal anastomosis (IPAA) circumferential pouch advancement (CPA) involves full-thickness transanal 180–360° dissection of the distal pouch, allowing the advancement of healthy bowel to cover the internal opening of a vaginal fistula. We aimed to describe the long-term outcomes of this rare procedure.MethodsPatients with IPAA who underwent transanal pouch advancement for any indication between 2009 and 2021 were included. Demographics, operative details, and outcomes were reviewed. An early fistula was defined as occurring within 1 year of IPAA construction. Clinical success was defined as resolution of symptoms necessitating CPA, pouch retention, and no stoma at the time of follow-up. Figures represent the median (interquartile range) or frequency (%).ResultsOver a 12-year period, nine patients were identified; the median age at CPA was 41 (36–44) years. Four patients developed early fistula after index IPAA, and five developed late fistulae. The median number of fistula repair procedures prior to CPA was 2 (1–2). All patients were diagnosed with ulcerative colitis at the time of IPAA and all late patients were re-diagnosed with Crohn’s disease. Four (44.4%) patients had ileostomies present at the time of surgery, three (33.3%) had one constructed during surgery, and two (22.2%) never had a stoma. The median follow-up time was 11 (6–24) months. Clinical success was achieved in four of the nine (44.4%) patients at the time of the last follow-up.ConclusionsTransanal circumferential pouch advancement was an effective treatment for refractory pouch vaginal fistulas and may be offered to patients who have had previous attempts at repair.

Shifting paradigms in endoscopic sinus surgery: a comprehensive analysis from Japan’s national database

Background In 2013, Japan established a standardized classification system for categorizing endoscopic sinus surgery (ESS) into types I–V, yet no evaluation has been conducted thereof. Objective We assessed the ESS trends and status in Japan, focusing on outpatient and inpatient surgeries. Material and Methods This descriptive retrospective cohort study used Japan’s National Database of Health Insurance Claims and Specific Health Checkups between 2014 and 2021. The distribution of ESS types I–V and outpatient and inpatient surgeries was analysed, along with age groups and regional differences, focusing on ESS type III. Results Overall, 427,813 ESS procedures were performed, with types III and IV being most common. Outpatient ESS type III increased substantially compared to inpatient surgeries. Younger individuals favoured outpatient ESS type III over inpatient surgeries, with substantial regional variations across prefectures. Conclusions and Significance The adoption of a standardized ESS classification in Japan has facilitated a detailed understanding of surgical trends. The shift toward outpatient surgeries, especially for type III ESS, aligns with global trends toward minimally invasive procedures and reflects changing patient preferences and healthcare delivery practices. Consequently, continuous monitoring and research are crucial for adapting surgical practices to the evolving healthcare needs and patient expectations.

Endoscopic endonasal drainage of a middle fossa epidural abscess in conjunction with endoscopic sinus surgery: illustrative case.

Recent anatomical studies have reported the feasibility of the endoscopic endonasal approach to the middle fossa. However, its clinical applicability has been discussed in only a few cases. This article describes the case of a middle fossa epidural abscess successfully drained through a fully endoscopic endonasal corridor and discusses the key technical points. The authors describe an 8-year-old boy who presented with worsening headache, fatigue, emesis, and fever and was diagnosed with a left middle fossa epidural abscess associated with sphenoid sinusitis. Following endoscopic sinus surgery performed by a rhinologist, the middle fossa was accessed by removing the maxillary strut through the transmaxillary transpterygoid corridor. Complete drainage of the abscess was confirmed on postoperative magnetic resonance imaging. The patient tolerated the surgery without neurological deficit and demonstrated prompt symptom improvement. He was discharged home after completing a 6-week course of antibiotic therapy and remained free from recurrence at 1 year following surgery. The endoscopic endonasal approach may be applicable to a middle fossa epidural abscess, resulting in prompt clinical improvement. The maxillary strut is a key structure for entering the middle fossa. https://thejns.org/doi/10.3171/CASE24288.

Virtually Augmented Surgical Navigation in Endoscopic Sinus Surgery Simulation Training: A Prospective Trial of Repeated Measures.

The objective of this study was to explore the educational utility of virtually augmented surgical navigation (VASN) in simulation training for endoscopic sinus surgery. Prospective trial using within-subjects design. Single academic institution. Otolaryngology trainees (n = 15) were enrolled in a prospective trial of repeated measures. Participants performed unilateral functional endoscopic sinus surgery (FESS) on a 3-dimensional-printed sinus model without instruction. Participants then underwent educational intervention incorporating VASNtools-featuring anatomic overlay delineations, virtual planning points, proximity alerts, digital measurements, as well as artificial intelligence-generated endoscopic viewpoints. With the VASN tools activated, participants then performed FESS on the contralateral side of the model. Primary outcomes of interest included number of major complications, time to complete anterior fess, steps completed, and technical skills score. Descriptive statistics were performed to describe participant characteristics and bivariate analysis were used to evaluate differences in subjective and objective outcome measures. A majority (93%) of residents strongly agreed that simulation intervention improved their confidence in surgical skills related to FESS. Complications decreased from 13 instances to 3 following interventions. Initial technical skills score of 45.2 increased to 54.4 postintervention (P < .0001) and global score also improved by 4.6 points on average (P < .001). Time to anterior FESS decreased from 1356 to 915seconds (P = .006) and average number of completed surgical steps increased from 3.3 to 4.6 (P < .001). This simulation study contributes to growing evidence supporting utility of advanced technology in surgical education. Results suggest that VASN serves as a beneficial adjunct in FESS simulation training.

Nasal Dermoid - A Series of Ten Cases and Review of Literature.

Congenital nasal swellings are commonly encountered in pediatric practice. Differential diagnosis includes dermoid cyst, meningoencephalocele, glioma, benign tumors. Here we discuss 10 cases of nasal dermoid which were studied between January 2022 - December 2022 to obtain clinical data for diagnosis and treatment in pediatric population. In total 10 patients in the age group of 1-10 years were included, patients presented either with a swelling on nose or sinus opening on nose or a combination of the two. After radiological investigation, each patient was taken up for excision of sinus/cyst and 1year follow up was done for each. The objective of this article is to present few cases of nasal dermoid cyst sinus in pediatric patients and to discuss the embryology, clinical presentation, diagnosis and surgical approach of such lesions.

Tomographic classification proposal for safe endoscopic surgery of the sphenoid sinus

Tomographic classification proposal for safe endoscopic surgery of the sphenoid sinus

Dexmedetomidine versus labetalol for induced hypotension during functional endoscopic sinus surgery: a randomized, double-blind study

Background &amp; Objective: Functional endoscopic sinus surgery (FESS) is a surgical procedure for treating sinus diseases. Bleeding is a common concern during FESS, so maintaining hemodynamic stability and ensuring quality surgical field visibility is crucial for achieving the best outcomes. The present study compared the time taken to achieve target mean arterial pressure (MAP) when using dexmedetomidine or labetalol during FESS and assessed the quality of the surgical field to establish the better choice of the two. Methodology: The study was conducted as a prospective, randomized, double-blinded clinical study. Sixty patients classified as American Society of Anesthesiologists grade I or II, undergoing FESS under general anesthesia, were divided into two groups, each with 30 patients. Group D patients received dexmedetomidine and Group L received labetalol. The study aimed to maintain the mean arterial pressure (MAP) between 60-70 mmHg. The operative field visibility was assessed using the Fromme and Boezaart scoring system. Emergence time and postoperative first analgesic request time were also recorded. Results: The time taken to achieve target MAP (60-70 mmHg) was less in Group D (15.1 ± 0.2 min) than in Group L (18.2 ± 0.5 min), and it was statistically significant (P &lt; 0.05). Although insignificant, lower MAP were observed in the Group D than Group L. A significantly lower heart rate was observed at defined intervals in Group D than in Group L. The visibility of the surgical field in both groups has comparable results. The first analgesic request time was considerably longer in Group D (52.2 ± 1.9) compared to Group L (10.2 ± 2.1) (P &lt; 0.05). Conclusion: Dexmedetomidine provided better hemodynamic stability and operative field visibility than Labetalol during FESS. Abbreviations: FESS - Functional endoscopic sinus surgery; MAP - Mean arterial pressure; EtCO2 - end-tidal carbon dioxide Keywords: Dexmedetomidine; Labetalol; Controlled Hypotension; Mean Arterial Pressure Citation: Gupta S, Yadav I, Saxena A, Bagla RK, Nazir N. Dexmedetomidine versus labetalol for induced hypotension during functional endoscopic sinus surgery: a randomized, double-blind study. Anaesth. pain intensive care 2024;28(4):652−657; DOI: 10.35975/apic.v28i4.2507 Received: May 19, 2024; Reviewed: June 08, 2024; Accepted: June 08, 2024

Clinical analysis of 50 patients with abnormal pulsatile tinnitus in sigmoid sinus

Objective: To analyze the disease characteristics, diagnosis and treatment methods of venous pulsatile tinnitus treated by intervention of sigmoid sinus. Methods: Fifty patients (from Shandong Provincial ENT Hospital, Shandong University between February 2014 and July 2020) with venous pulsatile tinnitus treated by sigmoid sinus surgery were analyzed retrospectively. The tinnitus characteristics, imaging findings, surgical methods, intraoperative findings and postoperative tinnitus changes were recorded. The patients were followed up for 6-12 months. The sign rank sum test was used to analyze the difference in tinnitus grading before and after surgery. There were 50 patients with unilateral venous pulsatile tinnitus, including 49 females and 1 male. The age ranged from 17 to 67 years, with a median age of 44 years. There were 45 cases of right tinnitus and 5 cases of left tinnitus. The degree of tinnitus before operation was grade Ⅱ or above, including 4 cases of gradeⅡ, 11 cases of grade Ⅲ, 22 cases of grade Ⅳ and 13 cases of grade Ⅴ. Results: Thirty-seven cases were cured, 8 cases were ineffective (no change in tinnitus), 3 cases were markedly effective (tinnitus grade decreased by 3 in 2 cases, 4 in 1 case), and 2 cases were effective (tinnitus grade decreased by 1). The difference of tinnitus grade before and after operation was statistically significant (Z=-5.70,P<0.05). Temporal bone CT showed 36 cases of sigmoid diverticulum (including 17 cases with sigmoid sinus dehiscence), 12 cases of sigmoid sinus dehiscence and 2 cases of absence of the temporal bone cortex abutting to sigmoid sinus. Thirty-five cases were performed with closure of sigmoid sinus diverticulum, 4 cases were performed with resurfacing of the sigmoid plate, 5 cases were performed with narrowing of sigmoid sinus, 4 cases were performed with simple opening of pre sigmoid mastoid air chamber, 1 case of opening was performed with pre sigmoid mastoid air chamber combined with narrowing of sigmoid sinus, and 1 case was performed with opening of pre sigmoid mastoid air chamber combined with closure of sigmoid sinus diverticulum. Conclusions: Venous pulsatile tinnitus is common in women. The common causes may be sigmoid sinus wall abnormalities such as sigmoid sinus diverticulum and perisigmoid bone defect. Imaging examinations are helpful for diagnosis. Venous pulsatile tinnitus can be treated with surgery.

Rate of dupilumab use and symptom severity of patients with chronic rhinosinusitis with nasal polyposis after Draf 3 frontal sinusotomy.

The indications for endoscopic modified Lothrop procedure (Draf 3) in patients with refractory chronic rhinosinusitis with nasal polyposis (CRSwNP) remain unclear. This study evaluates the effectiveness of Draf 3 for refractory CRSwNP focusing on improvements in disease severity and need for subsequent dupilumab rescue therapy. Retrospective review of patients with CRSwNP undergoing Draf 3 surgery at a tertiary center between 2012 and 2022. Clinicodemographic variables were compared across those who did versus did not require rescue with postoperative dupilumab. Time to postoperative dupilumab rescue was analyzed and longitudinal disease-specific outcomes were measured using the sinonasal outcomes test (SNOT-22). Within 87 patients with CRSwNP, 24.1% had aspirin-exacerbated respiratory disease (AERD). Significant improvement in SNOT-22 score was found in CRSwNP with AERD (p<0.001) and without AERD (p=0.01) up to 24 months postoperative. 14.9% eventually required rescue with a dupilumab. More specifically, of 21 patients with AERD, 24.1% eventually required rescue with dupilumab. Dupilumab rescue was associated with a greater number of prior sinus surgeries (p=0.02), prior aspirin desensitization (p=0.02), and worse preoperative Lund-MacKay scores (p<0.001). No association between biologic rescue and frontal recess antero-posterior diameter was found (p=0.20). Draf 3 surgery in CRSwNP was associated with significant improvement in SNOT-22 score at 24 months. Furthermore, only 14.9% of patients required dupilumab rescue. Patients with AERD were more likely to require rescue with dupilumab even though 75.1% avoided treatment with the biologic over the study period.