Rhinosinusitis

Balloon sinus dilation in the office setting

August 27, 2014     Joseph P. Mirante, MD, FACS; Michael A. Munier, MD, FACS; Dewey A. Christmas Jr., MD; Eiji Yanagisawa, MD, FACS
article

The ability to complete operative procedures in the office setting avoids the time and cost of working in a hospital or outpatient surgical center operating room.

Rhinotopic therapy for refractory chronic rhinosinusitis: A study of 20 cases

May 7, 2014     Alan H. Shikani, MD, FACS; Karim A. Chahine, MD; Mohannad A. Alqudah, MD
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Abstract

The management of refractory chronic rhinosinusitis (CRS) after endoscopic sinus surgery is complex and challenging. We conducted a prospective clinical pilot study to evaluate the effectiveness of a rhinotopic protocol for the treatment of refractory CRS. Our study population was made up of 20 patients-8 men and 12 women, aged 31 to 76 years (mean: 50.1)-who were treated in our tertiary care rhinology fellowship training program. The rhinotopic protocol consisted of twice-daily saline rinses, each of which was followed by the administration of a nebulized corticosteroid and then a nebulized antibiotic. This regimen was administered for 6 weeks. Thereafter, patients underwent a once-weekly endoscopic sinus debridement followed by topical intrasinus installation of a corticosteroid and antibiotic. The duration of follow-up was 24 weeks, and thus the total study duration was 30 weeks. Treatment outcomes were based on Lund-Kennedy symptom scores and Lund-Kennedy endoscopic appearance scores. We found a 56% improvement in the mean symptom score after 3 weeks of therapy and 77% after 6 weeks. Subsequent follow-up revealed 90% improvement 4 weeks following the completion of therapy and 95% at 8 weeks post-therapy. Thereafter, we saw a small decrease in improvement: 73% at 16 weeks of follow-up and 65% at 24 weeks. Analysis of endoscopic appearance scores revealed a 55% improvement at 3 weeks of therapy and 84% at 6 weeks. The same general pattern emerged during follow-up, with 94% improvement 4 weeks after the cessation of therapy, 96% at 8 weeks, 76% at 16 weeks, and 75% at 24 weeks. Sinus cultures performed 4 weeks after the cessation of therapy found no growth in 13 patients (65%), normal respiratory flora in 5 patients (25%), a persistent pathogen in 1 patient (5%), and the emergence of a new pathogen in another (5%). Analysis of symptom scores and endoscopic appearance scores revealed that the rhinotopic protocol resulted in statistically significant improvement (p < 0.001) throughout the treatment period and follow-up period, although the improvement gradually declined over time. We therefore conclude that a rhinotopic protocol can be an effective treatment for refractory CRS.

Extensive pneumatization of the ethmoid sinus in a case of velocardiofacial syndrome

December 20, 2013     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS
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Endoscopic view of the sphenoid sinus seen through the posterior ethmoid sinus

October 23, 2013     Joseph P. Mirante, MD, FACS; Dewey A. Christmas, MD; Eiji Yanagisawa, MD, FACS
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Care must be taken when entering the sphenoid sinus, to dissect inferiorly and medially to avoid injury to the vital structures of the lateral wall of the sphenoid sinus.

How closely related are allergic rhinitis, asthma, and chronic sinusitis?

September 18, 2013     Mahmoud Ghaderi, DO, FAOCO
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Various triggers may have different presentations and thus create a clinically known diverse group of diseases that we have classically grouped as chronic rhinosinusitis.

Endoscopic view of the drainage pathway of a pneumatized uncinate process

August 21, 2013     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; and Eiji Yanagisawa, MD, FACS
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Pneumatized structures of the nose and sinuses have a mucosal lining whose mucociliary clearance will be associated with a drainage pathway into the nose.

Bipolar microdebrider may reduce intraoperative blood loss and operating time during nasal polyp surgery

August 10, 2012     Nishant Kumar, MD; Raj Sindwani, MD, FACS
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Abstract

Bleeding during endoscopic sinus surgery (ESS) can interrupt the flow of the procedure and increase the risk of complications. Advances in microdebrider design now allow for bleeding to be controlled by bipolar energy during the suctioning and shaving of polyps. We conducted a retrospective study to examine the effects of this technology on blood loss and operating times during ESS for chronic rhinosinusitis with nasal polyps (CRS+P). Our patient population was made up of 80 patients who had undergone ESS for CRS+P by the same surgeon from January 2007 through May 2008. All surgeries were performed with either the PK diego bipolar microdebrider (Gyrus ACMI, ENT Division; Bartlett, Tenn.) or a standard microdebrider. There were 40 patients in each group. The PK group was made up of 23 males and 17 females, aged 14 to 66 years (mean: 43.1), and the control group included 21 males and 19 females, aged 17 to 71 years (mean: 43.1); there were no statistically significant differences between the two groups in terms of sex and age. In addition to demographic data, the charts were reviewed for comorbidities and operative variables; the latter included blood loss, operating room (OR) time, and complications. The preoperative treatment and anesthesia protocols were similar for all patients, and all patients demonstrated a similar disease burden on imaging (mean Harvard CT stage: 3.12 for the PK group and 3.15 for the controls; p > 0.05). We found that during ESS, the PK group experienced significantly less intraoperative blood loss than did the controls (means: 86.0 and 123.0 ml, respectively; p = 0.015). In addition, the PK device was associated with significantly shorter OR times (means: 88.9 and 101.4 min, respectively; p = 0.026). There were no complications in either group. We conclude that using a microdebrider with bipolar capabilities during ESS may offer the advantages of less blood loss and shorter operating times in patients with nasal polyps.

Allergic fungal rhinosinusitis in children

July 5, 2012     Ross Shockley, MD; Soham Roy, MD
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Allergic fungal rhinosinusitis most often occurs in adolescents or young adults who exhibit nasal obstruction, congestion, purulent or clear rhinorrhea, anosmia, and headache--classic manifestations of chronic sinusitis.

The role of point-of-care CT in the management of chronic rhinosinusitis: A case-control study

August 15, 2011     David Conley, MD, Aaron Pearlman, MD, Kali Zhou, MD, Rakesh Chandra, MD, and Robert Kern, MD
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Abstract

Point-of-care computed tomography (POC-CT) has become more feasible since the introduction of smaller imaging devices that deliver lower radiation doses. As the availability of this modality continues to increase, its impact on diagnostic and therapeutic algorithms in patients with chronic rhinosinusitis (CRS) must be evaluated. We conducted a study of 40 consecutively presenting new patients who (1) met the symptom criteria for CRS but whose endoscopy results were negative (i.e., no pus, polyps, or edema), (2) had not undergone any previous CT scanning or sinus surgery, and (3) had undergone POC-CT during their initial evaluation. A comparison group was made up of 40 patients from the pre-POC-CT era whose initial treatment had been based on the history alone; these patients underwent CT after their medical therapy had been completed. In the pre-POC-CT group, follow-up CT showed evidence of inflammatory disease in 24 patients (60%), 13 of whom (54.2%) had received an antibiotic at their initial visit, including 2 who had received an oral steroid, as well; among the 16 patients whose follow-up CT was negative, only 2 (12.5%) had received an antibiotic, neither of whom received an oral steroid. In the POC-CT group, 27 of 40 patients (67.5%) had positive findings at the initial visit, and 14 of them (51.9%) received an antibiotic and an oral steroid; none of the 13 patients in whom POC-CT was negative was prescribed either agent. Thus, the incidence of scan positivity and antibiotic use was similar in the two cohorts. Also, patients who met the symptomatic definition of CRS but who were lacking in objective endoscopic findings were more likely to have received an oral steroid when POC-CT was part of the initial assessment; these patients were also less likely to be lost to follow-up. Ongoing prospective studies will better characterize the magnitude of these effects on long-term outcomes, antibiotic resistance, healthcare costs, and overall quality of care.

The role of antifungal therapy in the prevention of recurrent allergic fungal rhinosinusitis after functional endoscopic sinus surgery: A randomized, controlled study

August 15, 2011     Yaser Khalil, MD, Adel Tharwat, MD, Asmaa Gaber Abdou, MD, Enas Essa, MD, Abdel Hamid Elsawy, MD, Osama Elnakib, MD, and Nada Farag Elnaidany, PhD
article

Abstract

Allergic fungal rhinosinusitis (AFRS) is the most common form of fungal sinus disease. Its recurrence rate is high despite numerous strategies to prevent it. We conducted a study to assess the effect of systemic and topical antifungal agents-both separately and in combination-in preventing recurrence of AFRS following functional endoscopic sinus surgery (FESS). Our initial study population was made up of 50 adults who were diagnosed with AFRS by clinical, radiologic, histopathologic, and laboratory workup and who subsequently underwent FESS. Postoperatively, these patients were randomized into 5 different treatment groups matched for sex, age, and socioeconomic status. Four of the groups received a different antifungal regimen in addition to convenient medical treatment (CMT), while a fifth group served as a control. The antifungal regimens included oral itraconazole (group A), fluconazole nasal spray (group B), combined oral itraconazole and nasal fluconazole (group C), and irrigation with a fluconazole solution through the nasal fossa (group D); the group of 10 controls (group E) received CMT only. A total of 41 patients were available for follow-up (9 mo maximum). Recurrence rates in the 5 groups were 66.7, 10.0, 14.3, 28.6, and 75.0%, respectively. Based on our findings, we conclude that treatment with topical fluconazole as either a nasal spray or an irrigation solution can significantly reduce the rate of recurrence of AFRS after FESS.

Comparison of maxillary sinus specimens removed during Caldwell-Luc procedures and traditional maxillary sinus antrostomies

June 13, 2011     Samuel S. Becker, MD, Deanne M. Roberts, MD, Peter A. Beddow, MA, Paul T. Russell, MD, and James A. Duncavage, MD
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Abstract

The cases of 80 patients who underwent Caldwell-Luc surgery for the treatment of chronic rhinosinusitis between 2002 and 2007 at Vanderbilt University Medical Center's Department of Otolaryngology were reviewed. Data on demographics, comorbidities, details of surgery, surgical pathology, and histology were collected. These data were compared with those of 40 patients who underwent standard functional endoscopic sinus surgery in 2007. Statistically significant differences were found in terms of mean patient age, sex, mean number of sinuses surgically addressed, number of prior surgeries, and tissue eosinophil counts. Microscopic examination revealed the presence of “necrotic bone” in 2 Caldwell-Luc specimens, and “necrotic debris” in 2 other Caldwell-Luc specimens. No similar finding was seen in the control group. Caldwell-Luc is a surgery of last resort for patients who fail aggressive interventions for maxillary sinus disease. The mucosal lining of this small group of patients appears to be different from that of patients who respond favorably to functional endoscopic sinus surgery.

The internist's literature on chronic rhinosinusitis: An evaluation of the amount and quality of published information

July 31, 2010     Alexander C. Chester, MD, FACP
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Abstract

Most patients with chronic rhinosinusitis (CRS) are treated by internists, yet the information available to internists about CRS is rarely assessed. The author undertook a study to evaluate the amount and quality of information about CRS that is available to internists. Four information sources were analyzed: (1) five journals routinely read by internists, published over a 10-year period and searched on PubMed for the “exploded” terms chronic and sinusitis; (2) seven representative general and outpatient medicine texts, searched on MD Consult and STAT!Ref; (3) the 14th edition of the Medical Knowledge Self-Assessment Program (MKSAP 14), a review of internal medicine; and (4) four commonly used Internet databases. The five journals contained a total of 37,250 cited articles of various types over the study period; CRS was mentioned in only 19 of them. The standard medical texts offered little information about CRS, and MKSAP 14 did not mention CRS at all in the text, although it included some information in the questions and answers. Finally, among the online sources, UpToDate, a proprietary Internet database, offered an excellent discourse on CRS; in contrast, the Physicians' Information and Education Resource, maintained by the American College of Physicians, contained no information about CRS in its 436 subject modules. The author concludes that, with few exceptions, the literature routinely available to internists offers little information about CRS.

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