Time Of Endoscopic Sinus Surgery Research Articles

The Impact of Acute Peri-operative Particulate Matter Exposure on Endoscopic Sinus Surgery Outcomes: A Preliminary Multi-site Investigation.

Environmental exposures have been postulated to play an important role in the pathophysiology of chronic rhinosinusitis (CRS). Particulate matter (PM) is one of the most widely studied ambient air pollutants, but its peri-operative impact on CRS is unknown. To determine the effect of acute, peri-operative PM exposure on outcomes after endoscopic sinus surgery (ESS). Participants with CRS who self-selected ESS were prospectively enrolled. The 22-item SinoNasal Outcome Test (SNOT-22) and Medical Outcomes Study Questionnaire Short-Form 6-D (SF-6D) health utility values scores were recorded. Using residence zip codes, a secondary analysis of patient exposure to PM <2.5 μm and <10 μm (PM2.5 and PM10, respectively) was performed for the month of surgery utilizing data from Environmental Protection Agency air quality monitors. Spearman's correlation coefficients (ρ), 95% confidence intervals (CIs), and effect estimates (β) were used to determine the magnitudes of association. Simple, multivariate regression analysis was also completed. One hundred and seven patients from four geographically unique institutions across the US were enrolled with a follow-up of 6 months. Patients with higher peri-operative PM2.5 exposure had less improvement in their SNOT-22 scores after ESS compared to those with less exposure using both univariate analysis (ρ = 0.26, 95% CI: 0.08, 0.43; P = .01) and after covariate adjustment with multivariate analysis (B = 1.06, 95% CI: 0.001, 2.14, P = .05). Similar associations were not found with SF-6D outcomes or with PM10 as an exposure of interest. No significant correlations were found between peri-operative PM levels and Lund-Kennedy endoscopy scores post-operatively. Preliminary data from this pilot study reveal that PM exposure at the time of ESS may negatively associate with post-operative improvement in sinonasal quality-of-life. Larger, population-based studies with more standardized PM exposure windows are needed to confirm the clinical significance of the present findings.

Optimal timing of endoscopic sinus surgery for the retention cyst of maxillary sinus.

The optimal timing of functional endoscopic sinus surgery for odontogenic infections precipitated by retention cysts of the maxillary sinus was investigated. Five adults who underwent functional endoscopic sinus surgery were examined. The root apexes of all teeth that had odontogenic infection protruded into the maxillary sinus. All teeth with odontogenic infections precipitated by the retention cysts had percussion pain, indicating they had periodontitis and pulpitis around the root apex. They were vital teeth, indicating they did not have pulp necrosis. The small area of cyst wall attached to the floor of the maxillary sinus and root apex were left intact. The teeth that had odontogenic infections precipitated by retention cysts continued to be vital with no symptoms. Functional endoscopic sinus surgery should be performed before periodontitis and pulpitis of the root apex progress to ascending pulpitis and pulp necrosis. In other words, functional endoscopic sinus surgery should be performed while the affected tooth is still vital.

Prognostic factors for polyp recurrence in chronic rhinosinusitis with nasal polyps

Chronic rhinosinusitis with nasal polyps is frequently managed with endoscopic sinus surgery (ESS). Prior studies describe individual clinical variables and eosinophil density measures as prognostic for polyp recurrence (PR). However, the relative prognostic significance of these have not been extensively investigated. We sought to evaluate the impact of PR on measures of disease severity post-ESS and quantify the prognostic value of various clinical variables and biomarkers. Ninety-four patients with chronic rhinosinusitis with nasal polyps and prospectively biobanked polyp homogenates at the time of ESS were recruited 2 to 5 years post-ESS. Patients were evaluated with patient-reported outcome measures and endoscopic and radiographic scoring pre- and post-ESS. Biomarkers in polyp homogenates were measured with ELISA and Luminex. Relaxed least absolute shrinkage and selection operator regression optimized predictive clinical, biomarker, and combined models. Model performance was assessed using receiver-operating characteristic curve and random forest analysis. PR was found in 39.4% of patients, despite significant improvements in modified Lund-Mackay (MLM) radiographic and 22-item Sinonasal Outcomes Test scores (both P< .0001). PR was significantly associated with worse post-ESS MLM, modified Lund-Kennedy, and 22-item Sinonasal Outcomes Test scores. Relaxed least absolute shrinkage and selection operator identified 2 clinical predictors (area under the curve= 0.79) and 3 biomarkers (area under the curve= 0.78) that were prognostic for PR. When combined, the model incorporating these pre-ESS factors: MLM, asthma, eosinophil cationic protein, anti-double-stranded DNA IgG, and IL-5 improved PR predictive accuracy to area under the curve of 0.89. Random forest analysis identified and validated each of the 5 variables as the strongest predictors of PR. PR had strong associations with patient-reported outcome measures, endoscopic and radiographic severity. Acombined model comprised of eosinophil cationic protein, IL-5, pre-ESS MLM, asthma, and anti-double-stranded DNA IgG could accurately predict PR.

Comparative Viral Sampling in the Sinonasal Passages; Different Viruses at Different Sites.

Background: With the emergence of the microbiome as an important factor in health and disease in the respiratory tract standardised, validated techniques are required for its accurate characterisation. No standardised technique has been reported specifically for viral sampling in the sinonasal passages.Aim: To optimise viral sampling techniques from the sinonasal cavity.Methods: Sterile cytology brushes were used under endoscopic guidance to sample the sinonasal mucosa at time of endoscopic sinus surgery at both the middle and inferior meatuses (MM and IM). DNA and RNA were extracted from the samples and underwent PCR or RT-PCR testing, respectively, for a panel of 15 common upper respiratory tract viruses.Results: Twenty-four adult patients were recruited for this study. 18/24 (75%) patients were positive for virus in at least one site, while 8/24 (33%) were positive for virus at both sites. The mean number of viruses identified at the two sites were similar (0.875 ± 0.899 at the MM vs. 0.750 ± 1.032 at the IM). 6/24 (25%) of patients showed no virus at either site, while 3/24 (12.5%) demonstrated the same viral species at both sites.Conclusion: Although the number of viruses present at different sites with the nasal cavity are similar, discord exists in the viral species between sites. It is therefore recommended that both sites are sampled in the clinical and research setting better to characterise the viral species within the nasal cavity.

Partial resection of the middle turbinate during endoscopic sinus surgery for chronic rhinosinusitis does not lead to an increased risk of empty nose syndrome: a cohort study of a tertiary practice.

The treatment of the middle turbinate (MT) during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) remains a contentious issue with arguments both for and against its resection. The purpose of this study was to examine the clinical impact of partial MT resection (PMTR) during ESS, paying particular attention to the risk of developing empty nose syndrome (ENS) and alteration to olfaction. This cohort study was performed on prospectively collected data. A total of 177 patients underwent ESS for CRS; 93 had PMTR and 84 MT preservation (MTP). Preoperative data collection included subjective symptom scores as per the Adelaide Disease Severity Score (ADSS), Lund-Mackay scores, and nasal polyp status. The Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) was administered by telephone consultation and analyzed alongside postoperative symptom scores. There was no difference in ENS6Q scores in patients who underwent PMTR vs those who had MTP. Patients who underwent PMTR had a higher baseline disease on Lund-Mackay scoring, and were more likely to be nasal polyp patients and be undergoing revision surgery. ADSS scores demonstrated significant improvements in all rhinologic symptoms, with no difference between the cohorts. PMTR is an adjunctive procedure to ESS. This study has established that PMTR as performed by the senior author carries no additional risk of developing ENS symptoms as defined by the ENS6Q, and that it carries no additional risk to olfaction or other rhinologic symptoms. PMTR can be safely considered at time of ESS, especially in patients at risk of lateralization of the MT.

T regulatory and Th17 cells in chronic rhinosinusitis with polyps.

Chronic rhinosinusitis (CRS) is categorized into 2 types based on the absence (CRSsNP) and presence of nasal polyps (CRSwNP). Although CRSsNP patients lack nasal polyps, the mucosa may show variable degrees of polypoid change. This raises the question of whether or not the classification system is an over simplification and that CRSsNP and CRSwNP only represent 2 phenotypic extremes along a broader spectrum of immunologically different disease processes. To investigate this, adaptive and innate immune cells were compared in the different tissue types within CRSsNP and CRSwNP patients. Tissue from 15 CRSwNP, 6 CRSsNP, and 8 healthy control patients was obtained prospectively. Nonpolypoid mucosa, polypoid tissues, and polyps were obtained at the time of endoscopic sinus surgery and analyzed using flow cytometry for various adaptive and innate immune cell subsets. In the polyps from CRSwNP patients there were significantly more T regulatory (Treg) cells (12.86 ± 12.60 vs 2.83 ± 4.68) and Th17 cells (16.12 ± 11.75 vs 2.31 ± 2.13) compared to the polypoid tissue from CRSsNP patients. Cellular infiltrates in the nonpolypoid or polypoid mucosa of the different patient categories showed no difference in CRSwNP, CRSsNP and control groups. This observational study identified an increase in Treg and Th17 cells in CRSwNP patients implying that these cells may be implicated in polyp development. Importantly it also identified a similar inflammatory infiltrate in nonpolyp or polypoid mucosa across control, CRSsNP, and CRSwNP groups inferring that polyps should be sampled when studying CRSwNP.

Extending borders

The last 20 years of the last century, that sounds long ago but was actually the time that many of us already practiced in Rhinology or received their training, was I think the time of endoscopic sinus surgery. We learned all the possibilities of the endoscope, first mainly in limited inflammatory disease but later also because of the development of new technical possibilities like debriders, lens cleaners and probably most important curved drills more extensive surgery (1-4). Since the beginning of the 21ste century it is the time of endoscopic treatment of skull base tumours. In 2010 this Journal already produced an extensive overview in the European position paper on endoscopic management of tumours of the nose, paranasal sinuses and skull base (5). In the mean time a number of papers on skull base surgery has been published in Rhinology (3, 6-11). With the rhinologist involvement in more and more complex benign and malignant sinus and skull base tumours we became part of endoscopic skull base teams.

Extending borders

The last 20 years of the last century, that sounds long ago but was actually the time that many of us already practiced in Rhinology or received their training, was I think the time of endoscopic sinus surgery. We learned all the possibilities of the endoscope, first mainly in limited inflammatory disease but later also because of the development of new technical possibilities like debriders, lens cleaners and probably most important curved drills more extensive surgery (1-4). Since the beginning of the 21ste century it is the time of endoscopic treatment of skull base tumours. In 2010 this Journal already produced an extensive overview in the European position paper on endoscopic management of tumours of the nose, paranasal sinuses and skull base (5). In the mean time a number of papers on skull base surgery has been published in Rhinology (3, 6-11). With the rhinologist involvement in more and more complex benign and malignant sinus and skull base tumours we became part of endoscopic skull base teams.

Advance II

Endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) may be compromised by postoperative inflammation, polyposis, and adhesions, often requiring subsequent intervention. To address this issue, the authors investigated the safety and effectiveness of controlled delivery of mometasone furoate to the sinus mucosa via bioabsorbable implants deployed at the time of ESS. Prospective, multicenter, randomized, controlled, double-blind trial using an intrapatient control design. Otolaryngology-head and neck surgery centers; both academic and private practices. The study enrolled 105 patients with CRS undergoing bilateral ethmoidectomy to compare the effect of drug-releasing to non-drug-releasing implants using an intrapatient control design. Postoperative interventions, polyposis, and adhesions were assessed postoperatively. Efficacy was determined through independent analysis of randomized video-endoscopies by 3 blinded sinus surgeons. Safety assessments included ocular examinations. Implants were successfully deployed in all 210 ethmoid sinuses. Compared with control sinuses with non-drug-releasing implants, the drug-releasing implant provided a 29.0% relative reduction in postoperative interventions (P = .028) and a 52% (P = .005) decrease in lysis of adhesions. The relative reduction in frank polyposis was 44.9% (P = .002). Similar reductions were observed in real-time grading performed by the clinical investigators. No clinically significant changes from baseline in intraocular pressure or cataracts were observed. This study provides a high level of evidence that use of steroid-releasing implants that apply a sustained release of corticosteroid improves surgical outcomes by reducing synechiae formation, polyposis, and the need for postoperative interventions, with no observable ocular safety risk.

The ADVANCE II Study: A Prospective, Randomized, Multi‐center Study to Assess the Safety and Efficacy of a Bioabsorbable Steroid‐Eluting Sinus Implant

Objective: Endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) may be compromised by postoperative inflammation, polyposis, and adhesions, often requiring subsequent intervention. To address this issue, we investigated the safety and effectiveness of controlled delivery of mometasone furoate to the sinus mucosa via bioabsorbable implants deployed at the time of ESS. Method: A prospective, multicenter, randomized, double-blind trial was performed on 105 patients with CRS under-going ESS, comparing the effect of drug-eluting to non-drug-eluting stents. Postoperative interventions, polyposis, and adhesions were assessed postoperatively. Efficacy was determined through independent analysis of randomized video-endoscopies by 3 blinded sinus surgeons. Safety assessments included ocular exams. Results: Implants were successfully deployed in all 210 sinuses. Compared with control sinuses, the drug-eluting stent provided a 29% relative reduction in postoperative interventions ( P = .0280), a 52% ( P = .0053) decrease in lysis of adhesions, and a 29% ( P = .0881) decrease in oral steroid prescriptions. The relative reduction in frank polyposis was 45% ( P = .0023). Similar reductions were observed in real-time grading performed by the clinical investigators. No clinically significant changes from baseline in intraocular pressure or cataracts were observed. Conclusion: Continual postoperative application of topical corticosteroids applied via drug-eluting stent deployed at surgery was studied to assess its impact upon ESS outcomes. This study strongly suggests that steroid-eluting implants are effective at improving surgical outcomes by reducing the need for postoperative interventions, with negligible ocular safety risk.

Impaired Mucosal Healing and Infection Associated with Staphylococcus Aureus After Endoscopic Sinus Surgery

Differentiating normal nasal discharge and postoperative crust from infection after endoscopic sinus surgery (ESS) can be difficult. We investigated whether bacteria cultured at operation was predictive for postoperative mucosal infection-defined as frank pus, thick mucus, and/or abnormal crusting seen on endoscopic examination associated with positive microbiology. The records of 48 patients with chronic rhinosinusitis (CRS) with infection at the time of ESS were retrospectively reviewed. Results of intraoperative cultures were compared with those taken at the time of postoperative mucosal infection. Fourteen of 16 patients (87.5%) with intraoperative infection with Staphylococcus aureus progressed to postoperative mucosal infection with S. aureus, whereas patients who cultured "other" bacteria intraoperatively progressed to postoperative mucosal infection in 6/19 cases (31.6%), with S. aureus cultured in only 3/19 cases (15.8%; p=0.0001). S. aureus infection at ESS predicts for abnormal, S. aureus-associated mucosal healing and infection post-ESS. Although a prospective trial is warranted, these findings suggest a future role for aggressive anti-S. aureus therapy peri- and/or postoperatively in patients who culture positive for this organism to improve postsurgical outcomes.

Cost-effective airway cultures in the cystic fibrosis patient

Background Cystic fibrosis (CF) patients have a high incidence of multidrug-resistant infections, rendering CF patients a treatment challenge. Objective To evaluate culture protocols for CF patients and develop a cost-effective culture regimen that identifies clinically relevant pathogens. Study design Retrospective review. Methods At the time of endoscopic sinus surgery, CF patients underwent both sinus and bronchial lavage cultures. Medical records from 2002 to 2006 were reviewed. Results Twenty-four cases were identified; 12 had complete sets of cultures. Seven of 12 had sinus aerobic bacteria that were also present in bronchial culture. Anaerobic cultures from both sites were all negative (42%) or nondiagnostic (58%). Thirty-three percent of sinus fungal cultures and 91.6% of bronchial fungal cultures were positive. Sinus acid fast bacillus cultures were all negative. Conclusion CF culture protocols may be streamlined by eliminating all anaerobic cultures, as well as sinus acid fast bacillus and fungal cultures for a 52% reduction in cost.

Various causes for frontal sinus obstruction

Purpose A variety of inflammatory and structural conditions can cause frontal sinusitis. The present study was conducted as pilot study to determine the primary cause of frontal sinusitis at the time of endoscopic sinus surgery. Materials and methods Retrospective chart review was performed from 1997 to 2004 of patients who underwent endoscopic frontal sinus surgery at the University of Virginia. Demographic data, intraoperative frontal recess findings, and history of prior sinus procedures were collected. Results There were 102 patients, and 176 endoscopic frontal sinus surgeries were performed with mean follow-up of 29 months. The major causes for frontal sinusitis were polyp (53%), frontal recess synechia (21%), agger nasi cell (12%), and narrow osteomeatal complex (5%). Frontal recess synechia was present only in patients who had prior surgery. Conclusions Inflammatory polyps, followed by synechia, were the most common causes of chronic frontal sinusitis requiring frontal sinus surgery. Further investigation is warranted to identify the sources of frontal recess synechia and to develop preventative strategies of this iatrogenic problem.

Intranasal corticosteroid use is associated with lower rates of bacterial recovery in chronic rhinosinusitis

To determine whether use of a topical intranasal corticosteroid (INCS) preoperatively had an effect on the bacterial recovery rate and flora recovered at endoscopic sinus surgery (ESS). A prospective, multicenter, observational study from academic-based rhinology practices. Consecutive, unselected patients undergoing ESS had protected sinus cultures done at the time of ESS. 157 patients were assessed. Overall growth rate was 45.5%. INCS users had a positive culture rate of 35.4% vs 61.7% in nonusers (P = 0.0001). This effect was most pronounced in the subgroup undergoing revision surgeries (bacterial recovery rate INCS: 40.0%, no INCS: 82.6%, P = 0.001) and most marked for S. aureus (INCS: 12.5%, no INCS: 40.0%, P = 0.04) and CNS (INCS: 12.5%, no INCS: 30.4%, P = 0.05). While the rate of nasal polyposis was higher in both revision and the INCS-treated groups, rate of bacterial recovery was not influenced by a diagnosis of nasal polyposis. INCS use preoperatively is associated with a lesser rate of bacterial recovery at the time of ESS, especially in individuals with previous ESS. The results suggest a possible role of INCS in the management of post-ESS disease.

Microbiology of chronic ethmoid sinusitis: Is this a bacterial disease?

Purpose Review the microbiology of chronic rhinosinusitis and test the hypothesis that bacterial infections are not the predominant etiology for chronic rhinosinusitis. Materials and methods Tissue cultures were prospectively collected from the ethmoid mucosa of 179 patients (94 had chronic rhinosinusitis and 85 had chronic rhinosinusitis with polyposis) at the time of endoscopic sinus surgery. All patients were off antibiotics for at least 1 week at the time of surgery. Both aerobic and anaerobic cultures were obtained for each specimen. Results A total of 263 isolates were identified (average: 1.5 isolates per specimen). Coagulase-negative Staphylococcus, a likely contaminant, was the most common isolate and was identified in 51% of patients. Forty percent of patients (72/179) grew pathogenic aerobic bacteria, the most common was Staphylococcus aureus (18%). Six percent of patients (10/179) grew pathogenic anaerobic bacteria. The microbiology of patients with and without nasal polyposis was not significantly different. Conclusion These findings suggest that factors other than bacterial infection may play an integral role in the pathogenesis of chronic rhinosinusitis.

Electron Microscopy Assessment of the Recovery of Sinus Mucosa after Sinus Surgery

Objectives—To determine the level of injury to the maxillary sinus mucosa due to chronic infection and the capacity of sinus mucosa to recover after sinus surgery.Material and Methods—Scanning and transmission electron microscopy (SEM and TEM, respectively) were used for examination of maxillary sinus mucosa at the time of endoscopic sinus surgery and 6 months postoperatively.Results—SEM showed non-ciliated cells, metaplasia, ciliary disorientation, abundant goblet cells, microvilli and compound cilia perioperatively. Six months postoperatively the numbers of non-ciliated cells and microvilli had increased but the degree of metaplasia and disorientation and the number of compound cilia had decreased. Perioperative TEM revealed metaplasia, disorientation, tubulus anomalies, compound cilia and one patient with short dynein arms.Conclusions—As a result of this study we conclude that sinus mucosa repairs slowly after surgery. There are still many pathological findings in the mucosa 6 months postoperatively and some of these findings may even be irreversible. Patients need frequent follow-up after their operation and we suggest that a follow-up time for sinus surgery patients of at least 1 year should be allowed before final evaluation of the operation and its outcomes is made.

Eosinophils in nasal polyps and nasal mucosa: An immunohistochemical study

Immunohistochemical staining was performed at the time of endoscopic sinus surgery (ESS), after 6 months, and after 1 year on nasal polyps and biopsy specimens of the macroscopically unaffected mucosa of the middle and inferior turbinate bones of 46 patients with nasal polyps. During the follow-up period the patients were treated with topical corticosteroids. At time of ESS significantly more BMK13 + and EGI + (pan eosinophil markers) and EG2 + (activation marker) eosinophils were found in the polyps than in the macroscopically unaffected mucosa of the middle and inferior turbinate bones of the patients. In the middle and inferior turbinate bones of 10 healthy subjects no EG2+ (activated) eosinophils were detected, whereas low-to-moderate numbers of BMK13 + and EGl + eosinophils were seen in these specimens. This emphasizes that eosinophils play a role in the pathogenesis of nasal polyps. Compared with numbers at ESS, after 6 months and 1 year of follow-up, lower numbers of BMK13 +, EGl +, and especially of EG2 + eosinophils were found in recurrences of polyps and in the macroscopically unaffected mucosa of the middle and inferior turbinate bones of the patients. The decrease in number of EG2+ (activated) eosinophils is an indication of a reduced local inflammatory reaction, and could be an important factor in postponement of recurrences of nasal polyps.

Clinical aspects and distribution of immunologically active cells in the nasal mucosa of patients with nasal polyps after endoscopic sinus surgery and treatment with topical corticosteroids.

Clinical parameters of 72 patients who were operated upon for nasal polyps were evaluated as well as biopsy specimens of the mucosa of the middle and inferior turbinates of 41 of these patients. Biopsies were taken at the time of endoscopic sinus surgery (ESS), after 6 months and after 1 year in 23 patients. During the follow-up period the patients were treated with topical corticosteroids (budesonide). At the time of ESS significantly more CD8+ (suppressor/cytotoxic) cells than CD4+ (helper/inducer) cells were found in the middle and inferior turbinates. At 6 months significantly more CD4+ cells were found than at the time of ESS, whereas at 1 year the number of CD4+ cells had decreased and was lower than at 6 months. These data support the theory that the occurrence of nasal polyps is associated with T-cell-dependent disturbances. Clinical evaluation revealed that most of the patients with chronic airway obstruction had better pulmonary functions postoperatively or required less medication for lung disease. These findings show that ESS combined with topical corticosteroids has a positive effect on upper and lower respiratory tract pathology.