Comparison of radical (nasalisation) and functional ethmoidectomy in patients with severe sinonasal polyposis. A retrospective study.

OBJECTIVE: To compare the 5-year outcomes of two endoscopic surgical approaches for diffuse and severe nasal polyposis. STUDY DESIGN: A natural experimental situation gave us the opportunity to compare the results 5 years after radical ethmoidectomy (nasalisation) (n= 39), and functional ethmoidectomy (n= 37). The two surgical procedures were performed by two different surgeons on 76 consecutive patients. There was no random assignment for this retrospective study. METHODS: Five years after surgery, the criteria for comparison were 1) functional results based on a questionnaire using visual analogue scales in patients free of revision surgery; 2) endoscopic and CT-scan assessments of anatomical results. The CT-scans were blinded and randomized, and opacities were measured using a computerized model; 3) the recurrence rate of nasal polyps. RESULTS: Five years after surgery, the overall nasal functional benefit was scored 8.41 +/- 0.40 (mean +/- SEM) after nasalisation, and 5.69 +/- 0.83 after ethmoidectomy P= 0.002) in patients free of revision surgery. The endoscopic appearance of the mucosa was methodically scored according to a pre-defined scale. Results were significantly better in the nasalisation group (6.03 +/- 0.7 versus 3.27 +/- 1.0, P= 0.02). A good correlation was found between the endoscopic and CT-scan scores (r= -0.78, P= 0.0001 for nasalisation, and r= -0.65, P= 0.001 for ethmoidectomy). The total recurrence rate was 22.7% in the nasalisation group, and 58.3% in the ethmoidectomy group (chi2= 10.41, P< 0.01). CONCLUSION: Our study suggests that in the treatment of nasal polyposis complete ethmoidectomy leads to better long term results than incomplete ethmoidectomy.

Comparison of functional results after ethmoidectomy and nasalization for diffuse and severe nasal polyposis.

Taking advantage of a natural experimental situation, we compared, retrospectively, functional results after nasalization and ethmoidectomy for diffuse nasal polyposis. Nasalization was a radical ethmoidectomy systematically removing all the bony lamellae and mucosa within the labyrinth, with large antrostomy, sphenoidotomy, frontotomy, and middle turbinectomy (Surgeon 1, 39 consecutive patients operated on between March and September 1991). Ethmoidectomy was a less systematic procedure, that was adapted to the extent of the pathology (Surgeon 2, 37 consecutive patients, operated on between October 1991 and November 1994). In May 1994, a third physician mailed a questionnaire simultaneously to all patients including 10-point visual analog scales 34/39 patients in the nasalization group (age: 28-71 years: 20 asthmatics; follow-up: 32-36 months), and 29/37 patients in the ethmoidectomy group (age: 26-65 years: 9 asthmatics: follow-up: 18-31 months) participated in the study. The overall nasal improvement was 8.8 +/- 0.2 (mean +/- SEM) after nasalization and 5.9 +/- 0.6 after ethmoidectomy (p = 0.0001). Olfaction improvement was similar in both groups 6 months after surgery, remained at the same level 36 months after nasalization (6.9 +/- 0.7), but decreased to 4.2 +/- 1 points 24 months after ethmoidectomy (p = 0.02). Asthma improvement remained significantly better after nasalization (p = 0.05), and the need for systemic steroids was also lower (p = 0.03). Results of this study suggest that when dealing with nasal polyposis, the more radical the surgery, the better the functional results.

Management of post-ethmoidectomy crust formation: randomized single-blind clinical trial comparing pressurized seawater versus antiseptic/mucolytic saline.

This study compared the efficacy of mechanical nasal lavages with pressurized seawater versus nasal irrigations with saline plus benzododecinium (antiseptic) plus oleosorbate (mucolytic). Twenty patients agreed to participate in a randomized, single-blind clinical trial. All patients underwent endoscopic endonasal ethmoidectomy for nasal polyps. The packing was removed after 48 h and patients were asked to start the same day nasal lavages three times a day. Clinical evaluations were performed: (1) by weighing residual nasal crusts and secretions after 21 +/- 2 days; and (2) by using visual analogue scales to daily record symptom scores. Data are presented as mean +/- SEM. T-test statistics for two independent groups were applied. The mean residual crust and secretion weights were 1,756 +/- 688 mg and 1,033 +/- 422 mg in the pressurized seawater group, 932 +/- 414 mg and 1,222 +/- 435 mg in the antiseptic-mucolytic saline group. No statistical differences were found. Sample size calculations showed that 100 subjects in each group would be necessary to confirm a 700-mg reduction in residual crusts in the antiseptic/mucolytic saline group (power = 0.80; two-sided type-I error = 0.05). Daily symptom score curves were similar in both groups and allowed us to give a description of post-operative complaints. The role of antiseptic, mucolytic and mechanical lavages in preventing post-ethmoidectomy crust formation is discussed.

[Undifferentiated osteogenic carcinoma of the thyroid]. / Carcinome indifférencié ostéogénique de la thyroïde.

A case of osteogenic thyroid carcinoma in a 68 years old male patient is reported. The WHO histopathological classification of such exceptional tumor is reminded. A review of the literature and the treatment modalities are discussed. Several etiological hypotheses are discussed.