Tissue eosinophilia in chronic sinusitis: quantification techniques.

OBJECTIVE: To ascertain the reliability of a proposed method for quantifying tissue eosinophilia in sinus mucosa. DESIGN: Prospective cohort study. INTERVENTIONS AND OUTCOME MEASURES: Pathology slides from patients undergoing endoscopic sinus surgery for chronic rhinosinusitis were independently assessed by 2 reviewers. Using a proposed systematic counting method, the degree of tissue eosinophilia was quantified. Disease severity was assessed by computed tomographic (CT) staging. Intrarater, interrater, and intrapatient reliability was determined using correlational reliability analysis. The degree of correlation between tissue eosinophilia and CT stage was determined. RESULTS: One hundred thirty-two slides from 65 patients were reviewed. The mean (SD) eosinophil density was 23.4 (37.2) eosinophils per high-power field. Only 12 patients (18%) had no eosinophils on histopathologic analysis. Strong intrarater (r> or =0.91 for each rater, P<.001) and interrater reliability (r> or =0.82 between raters, P<.001) was noted for the quantification method. A moderate degree of correlation was found between CT scan stage and degree of tissue eosinophilia (Spearman rho = 0.62, P<.001). CONCLUSIONS: The proposed method for quantifying tissue eosinophilia in sinus mucosa is reliable and valid. A relatively strong correlation exists between CT scan stage and tissue eosinophilia in chronic rhinosinusitis.

Validation of a patient-graded instrument for facial nerve paralysis: the FaCE scale.

OBJECTIVE: To develop and validate a patient-based instrument to measure both facial impairment and disability, the Facial Clinimetric Evaluation (FaCE) Scale. STUDY DESIGN: Prospective instrument validation. METHODS: Eighty-six patients with a documented history of facial paralysis completed a preliminary, 51-item instrument (alpha FaCE Scale), as well as the previously developed Facial Disability Index (FDI) and the Medical Outcomes Study Short Form 36 Item Questionnaire (SF-36). Two weeks after completing these instruments, 76 patients again completed the alpha FaCE Scale. Forty-one of the patients were also evaluated using the House-Brackmann Grading System (HBGS) and the Facial Grading System (FGS). RESULTS: Exploratory principal component factor analysis grouped 15 FaCE Scale items into 6 impairment and disability categories (domains), forming the beta FaCE Scale. Overall, the test-retest reliability of the FaCE Scale was high (Spearman's correlation coefficient (r) = 0.88, P <.01), as were the reliability coefficients of the individual domains (r = 0.81-0.92, P <.01). The FaCE Scale domains showed appropriate correlation to global visual analogue scale questions posed on the original alpha FaCE Scale (r = 0.65-0.81, P <.01). Overall, the FaCE Scale showed significant correlation with HBGS and FGS scores (r = -0.55 and 0.57, respectively; P <.01). However, not all FaCE Scale domains correlated with the HBGS and FGS scores. CONCLUSIONS: A reliable and valid patient-based system to measure impairment and disability in facial paralysis has been developed. This system appears to be better than traditional, physician-graded scales for evaluating quality-of-life issues affected by facial disability.

Physician experience with an optical image guidance system for sinus surgery.

OBJECTIVES/HYPOTHESIS: Intraoperative guidance systems have been developed which use infrared tracking technology to assist with anatomical localization during sinus surgery. Although the introduction of this technology is intended to increase the safety and efficacy of sinus surgery, little is known about its actual impact in the clinical setting. The objective of this report was to study the application and utilization of an image guidance system shared by multiple sinus surgeons in a specialty hospital. STUDY DESIGN: Combined prospective case study and retrospective analysis of physician surveys. METHODS: An optical-based image guidance system (LandmarX, Xomed, Inc., Jacksonville, FL) was used by 34 physicians to perform 754 sinonasal surgeries over a 2.5-year period at Massachusetts Eye and Ear Infirmary. In 19 cases, system registration was repeated during surgery to measure the effect of fiducial placement on system accuracy. RESULTS: The measured accuracy of anatomical localization at the start of surgery (mean value, 1.69 +/- 0.38 mm) was comparable to the perceived accuracy of 1 to 3 mm that was reported by 79% of surgeons surveyed. Operating room time (mean period, 130.6 +/- 41.1 min) correlated with the surgical procedure performed (P < .05), but not with the disease stage or revision rate. According to a majority of surgeons, use of the image guidance equipment increased operating room time by 15 to 30 minutes during initial cases and by 5 to 15 minutes once experience with the equipment had been acquired. More than 90% of surgeons anticipated their continued use of the image guidance equipment for sinus surgery at a similar or greater level in the future. CONCLUSION: An optical-based image guidance system can be successfully integrated into a multisurgeon operating room environment. Use of the system provides accurate anatomical localization during sinus surgery and results in a relatively high level of physician satisfaction.

Delayed orbital infection after endoscopic orbital decompression for dysthyroid orbitopathy.

OBJECTIVE: To present a delayed complication of endoscopic orbital decompression that has not been reported previously in the literature. DESIGN: Retrospective non-comparative small case series. PARTICIPANTS: Three patients with dysthyroid orbitopathy. INTERVENTION: The medical records of patients with dysthyroid orbitopathy who underwent endoscopic orbital decompression and subsequently developed orbital infection were reviewed. RESULTS: Three patients with dysthyroid orbitopathy developed orbital infection (cellulitis or abscess) originating from the frontal sinus more than 2 years after their endoscopic orbital decompression surgery. Management required drainage of the abscess, administration of antibiotics, and creation of adequate frontal sinus drainage. CONCLUSIONS: Delayed orbital infection can occur after endoscopic orbital decompression for dysthyroid orbitopathy when the frontal sinus ostium is obstructed by orbital fat or scar tissue. Infection within the frontal sinus can cause secondary orbital cellulitis or abscess. Early signs and symptoms of a frontal sinus infection can be easily misdiagnosed as progression of the patient's thyroid eye disease. Awareness of this possible complication followed by appropriate early intervention will prevent a potentially blinding condition. Furthermore, ever since this complication was observed, the authors' surgical technique of endoscopic decompression has been modified to leave the most anterosuperior portion of the lamina papyracea to prevent fat prolapse and scar formation into the region of the frontal recess.

Clinical outcomes in patients with chronic sinusitis.

Although sinusitis is one of the most common chronic illnesses in this country, relatively little is known about the effect of this disease or its treatment on quality of life. In a series of studies utilizing both disease-specific and general health instruments, patients with chronic sinusitis were found to have significant decrements in several subscales of general health, including bodily pain and social functioning (P<.05), compared with the general US population. Surgery for sinus disease was shown to result in significant reduction in both symptoms and medication usage (P<.05) after 12 months. These same outcome instruments can be used by health care providers to document clinical outcomes in similar populations of patients with chronic sinusitis.

The role of image-guidance systems for head and neck surgery.

BACKGROUND: Although image-guidance systems have gained widespread acceptance for neurosurgical procedures, their role for extracranial surgery of the head and neck is yet to be defined. OBJECTIVES: To describe the authors' experience with image-guidance systems and to measure the effects of image-guided technology on the performance of minimally invasive otolaryngological procedures. DESIGN: Prospective cohort study. METHODS: Optical- and electromagnetic-based image-guidance systems were used during the performance of endoscopic surgery on patients with disease of the paranasal sinuses, orbit, skull base, and temporal bone (n = 79). Results were compared with those in control patients who underwent similar surgery without image guidance during the same period (n = 42). RESULTS: Intraoperative anatomical localization was accurate to within 2 mm at the start of surgery in all cases. Accuracy degraded by 0.89 +/- 0.20 mm (mean +/- SE) during the operative procedure. The use of an image-guidance system increased operating room time by a mean of 17.4 minutes per case (image-guidance group, 137.3 +/- 6.0 minutes [mean +/- SE]; control group, 119.9 +/- 5.7 minutes; P=.006) and increased hospital charges by approximately $496 per case. Intraoperative blood loss (image-guidance group, 178.4 +/- 18.0 mL [mean +/- SE]; control group, 149.4 +/- 20.1 mL) and complication rates (image-guidance group, 2.7%; control group, 4.7%) did not differ significantly between groups. CONCLUSIONS: Image-guidance systems can provide the head and neck surgeon with accurate information regarding anatomical localization in cases with poor surgical landmarks caused by extensive disease or prior surgery; however, the use of such systems is associated with increased operative time and expense.

Clinical outcome of endoscopic surgery for frontal sinusitis.

OBJECTIVE: To determine the efficacy of endoscopic surgery for chronic frontal sinusitis. DESIGN: A prospective analysis of established measures of clinical outcome (Chronic Sinusitis Survey and Short Form 36) that was administered to patients before frontal sinus surgery and at intervals of 3 months, 6 months, and 1 year after surgery. INTERVENTIONS: For limited disease, the frontal recess was opened and the frontal ostium probed or enlarged. For more severe cases, a drill was used to resect the frontal sinus floor and interfrontal septum. SETTING: Private and institutional-based practices at an academic medical center. SUBJECTS: Eighty-seven patients who underwent endoscopic surgery for frontal sinusitis, including 24 patients with severe disease who underwent a frontal sinus drillout procedure. MAIN OUTCOME MEASURES: Scores on the Chronic Sinusitis Survey, Short Form 36, and surgical revision rate. RESULTS: Significant improvement in facial pain, nasal drainage, and congestion was observed 1 year after surgery (P<.01). Medication use was also significantly reduced during this period (P<.01). Quality-of-life measures showed greatest improvement in the domain of social functioning (P<.05). Three (12.5%) of 24 patients who underwent a frontal sinus drillout procedure did not respond to surgery secondary to restenosis of the frontal ostium. CONCLUSIONS: Although the long-term results of endoscopic surgery for frontal sinusitis are unknown, this approach appears to be effective for most patients and may provide a reasonable alternative to frontal sinus obliteration surgery in selected cases.

A comparison of image guidance systems for sinus surgery.

OBJECTIVE: Intraoperative computed tomographic guidance systems are available which utilize either electromagnetic (radiofrequency) or optical (infrared) signals to localize instruments within the surgical field. The objective of this study was to compare the use of these two different image guidance technologies for sinus surgery. STUDY DESIGN: Prospective cohort study. METHODS: The electromagnetic-based InstaTrak system (n = 24) and the optical-based Stealth-Station (n = 49) were compared in a series of 73 consecutive sinus series which utilized image guidance technology. RESULTS: Both the electromagnetic and optical systems provided anatomic localization to within 2 mm during surgery. Intraoperative reregistration was effective in correcting for any anatomic drift. There were no intraoperative complications. Mean operative times were 156.3 +/- 8.9 minutes for the electromagnetic and 139.2 +/- 17.7 minutes for the optical system (P < .05). The average intraoperative blood loss did not differ significantly between groups (electromagnetic, 190.6 +/- 28.7 mL; optical, 172.4 +/- 23.0 mL). Each system was noted to have limitations. The presence of metallic objects in the operative field interfered with functioning of the electromagnetic system, whereas the optical system required a clear line of sight to be maintained between the infrared camera and surgical handpiece. Both systems required specialized headsets to be worn by patients during surgery to monitor head position. The electromagnetic system also required these headsets to be worn during the preoperative computed tomography scan. CONCLUSION: Although these two image guidance systems both proved valuable for anatomic localization during sinus surgery, individual preferences can be based on distinct differences in their design and operation.

Economic implications of chronic sinusitis.

An approach to cost analysis useful in understanding the economic implications of surgical intervention on chronic sinusitis is break-even time analysis. The break-even time is the time until cost savings associated with improved health status after surgery equal the up-front costs of the operation itself. Data from 100 consecutive patients undergoing sinus operation were obtained by survey before surgery and at quarterly intervals for 1 year with statistically validated outcome measures (Medical Outcome Study Short Form 36-Item Health Survey, Chronic Sinusitis Survey). Direct and indirect costs were obtained or derived for this cohort. The cost of sinus medications, including over-the-counter remedies, nasal steroid sprays, and antibiotics, averaged $1220 per patient per year before surgery and $629 after surgery (p < 0.0001), which is a 48% reduction. Surgical costs averaged $6490 per patient. Economic modeling predicted a break-even time of approximately 7 years assuming a 3% surgical revision rate per year, a 3% decrease in sickness-related disability, and a 5% discount rate. The model was sensitive to changes in the total cost of operation, the surgical revision rate, and the anticipated disability benefit. We conclude that significant direct and indirect medical cost savings may be achieved after surgical intervention for chronic sinusitis and these savings eventually break even with the total cost of surgery itself.

Comparison of sinus computed tomography staging systems.

In an attempt to establish a standardized rating system for CT of the paranasal sinuses, the Committee on Rhinology and Paranasal Sinus Disease of the American Academy of Otolaryngology-Head and Neck Surgery instituted a protocol for the review of sinus CT scans at six international sites. Fifty identical scans were rated by four otolaryngologists at each site according to five established sinus CT staging systems. Twenty of 24 reviewers repeated the rating session at least 1 week later to determine intrarater variability. The number of CT scans that could not be classified by a particular rating system ranged from 1.3% to 5.5%. The range of intrarater agreement (kappa = 0.39 to 0.74) exceeded that of interrater agreement (kappa = 0.18 to 0.49). A skewed distribution of CT scans resulted in a system with high rater agreement but poor ability to differentiate among disease states. The use of a numeric rating system to assign a score to each scan produced a comprehensive and disease-sensitive system, but one with low rater agreement. A precise definition of mucosal thickening in terms of millimeters appeared to enhance the raters' ability to assign stage and improve a system's comprehensiveness and reproducibility. On the basis of these findings, recommendations are made for the use of CT rating systems to study clinical outcomes in patients with chronic sinusitis.

Effects of sinus surgery on speech.

OBJECTIVE: To determine the effects of sinus surgery on the production and perception of speech. DESIGN: Vocal recordings were performed before, 1 week after, and at least 1 month after sinus surgery. Acoustic spectra were analyzed for nasal consonants /m/ and /n/, nasalized vowels, and nonnasalized vowels. Results for nasal consonants were compared with similar recordings obtained from a group of normal subjects with no history of sinus disease. Perceptual analysis of nasalized vowels was conducted by trained phoneticians. SETTING: Private practice at an academic medical center. SUBJECTS: Five patients who underwent endoscopic sinus surgery and 3 normal subjects. MAIN OUTCOME MEASURES: The spectral characteristics and perceptual attributes of nasal sounds. RESULTS: Significant differences in spectral properties were observed for the consonants and nasalized vowels recorded before and after surgery (P < .001). Perceptual experiments for nasalized vowels demonstrated a postoperative decrease in nasality for the high vowel /i/, as in "beep," and an increase in nasality for the non-high vowel /ae/, as in "bad." These perceived changes correlated well with acoustic measures of nasal peak amplitudes and the lowest resonance peak amplitude of the vocal tract. CONCLUSIONS: Sinus surgery results in measurable effects on the produced acoustic signal and the perceived nasality of a patient's speech. The identified acoustic correlates may be useful for preoperative counseling of patients concerning expected changes in speech quality following surgery.

Effect of sinus surgery on quality of life.

Although sinus surgery may reduce the incidence of recurrent infection in patients with chronic sinusitis, little is known about the effect of such surgery on a patient's quality of life. One hundred eight patients undergoing ethmoid sinus surgery were prospectively evaluated with statistically validated measures of sinusitis-specific and general health-related quality of life. Twelve months after surgery significant improvements were found in sinus-specific health status, including a reduction in symptoms (p < 0.001) and medication usage (p < 0.001). An overall improvement was found in 82% of patients, whereas 11% were worse, and 7% remained unchanged. Measures of general health status demonstrated preoperative decrements in five of eight subscales as compared with the normal population. Six months after surgery significant improvements were noted in six categories (p < 0.05), and most attained near-normative levels. Individuals with asthma demonstrated greater overall improvement in general health status than did other cohorts (p < 0.05). We conclude that patients with chronic sinusitis achieve large improvements in sinusitis-specific quality-of-life measures 12 months after sinus surgery, as well as improvements in general health status.

New developments in the diagnosis of Kartagener's syndrome.

Kartagener's syndrome is characterized by the clinical triad of bronchitis, sinusitis, and situs inversus. An inherited ultrastructural defect results in ciliary immotility with impaired mucociliary clearance throughout the pulmonary and sinonasal passages. Until recently, the diagnosis of Kartagener's syndrome was made on the basis of a qualitative decrease in the number of dynein arms and subjective abnormalities in other ciliary components on electron microscopy. New investigations, however, have defined objective methods of diagnosis on the basis of quantitative ciliary measurements. The use of these methods in a series of 17 cases of suspected ciliary immotility resulted in a reversal of diagnosis in 6 cases (35%) that previously were considered normal. These results suggest that the prevalence of inherited ciliary dyskinesias is much greater than currently is recognized. The early identification and treatment of individuals with these disorders could lead to a reduction in irreversible sinus and pulmonary pathologic conditions with improved long-term survival.

Transnasal endoscopic approach to expose the medial rectus from the annulus of Zinn to the penetration of Tenon's capsule.

Conventional strabismus surgery employs a conjunctival incision to gain access to Tenon's space where a wide variety of procedures are routinely performed on the tendon and anterior aspect of the extraocular muscles. Recently, transnasal endoscopic surgical techniques have gained acceptance as effective means of decompressing the medial wall and floor of the orbit in patients with thyroid-related orbitopathy. The orbital surface of the medial rectus and inferior rectus are exposed from the annulus of Zinn to a position close to where the muscles penetrate Tenon's capsule. In theory, this technique also provides the exposure necessary to locate and retrieve a "lost" medial rectus when the usual sub-Tenon's approach fails to recover the muscle. Cadaver studies demonstrate the feasibility of exposure and suture placement in the stump of a lost medial rectus with passage of the suture through Tenon's capsule to transmit the force of the muscle to the globe, provided that the lost muscle is retrieved before severe contracture develops.

Endoscopic treatment of sphenoid sinusitis.

Juxtaposed between the posterior nasal cavity and skull base, the diseased sphenoid sinus presents unique challenges when surgical drainage is required. Endoscopic techniques have gained widespread popularity for the treatment of sphenoid sinusitis, yet the efficacy of such treatment remains largely unknown. Thirty-four patients who underwent endoscopic sphenoidotomy were monitored over a period of 6 months to 5 years. Surgery was performed with the superior turbinate used as the key landmark for identification and enlargement of the natural sphenoid ostium. Surgical access was through either a transnasal or transethmoid approach, depending on whether disease was limited to the sphenoid sinus. Prospective analysis of 26 patients with established outcome measures demonstrated a significant reduction in facial pain, nasal drainage, and congestion 6 months after surgery (p < 0.0001). Medication use was also reduced but to a lesser extent (p < 0.05). Endoscopic sphenoidotomy appears to be a safe technique that effectively reduces patient morbidity associated with sphenoid sinusitis.

Holmium:YAG laser endoscopic sinus surgery: a randomized, controlled study.

Although surgical lasers were introduced to the field of otolaryngology more than 20 years ago, their use in rhinologic surgery has remained relatively limited. With the development of the holmium:yttrium-aluminum-garnet (YAG) laser, a device is now available that offers those features necessary for effective sinus surgery:precise bone ablation, efficient soft tissue coagulation, and fiberoptic transmission. This solid-state laser of 2.1-microns wavelength can be coupled with endoscopic instrumentation for the surgical treatment of sinus disease. This study was conducted to determine the clinical efficacy of the holmium:YAG laser for endoscopic sinus surgery. A microscopic analysis of laser-treated sinus tissue was also performed in an attempt to determine the histologic basis of the observed clinical findings. In a prospective, randomized, controlled, single-blinded study, 32 consecutive patients underwent endoscopic sinus surgery using the holmium:YAG laser on one side of the nose and conventional endoscopic instrumentation on the other side. Patients rated symptoms for each side of the nose at 1 week, 1 month, 3 months, 6 months, and 2 years after surgery. Healing parameters were similarly rated by the surgeon. Until the study was completed, patients were not told which side of the nose had been treated with laser surgery. No intraoperative complications occurred. The mean intraoperative blood loss was 24.6 mL less on the laser-treated side of the nose than on conventionally treated side (P < .001). At 1 week after surgery, there was increased mucosal edema on the laser-treated side (P < .01). Crust formation was greater on the conventionally treated side at 1 week and was greater on the laser-treated side at 1 mouth (P < .01). Improvements in symptoms of pain, congestion, and drainage were equivalent for both treatment modalities (P < .001). Microscopic analysis demonstrated the ability of the holmium:YAG laser to remove tissue in relatively thin layers with ablation depths of 260 +/- 8.2 microns, 286 +/- 9.4 microns, and 341 +/- 20.4 microns per pulse at energy levels of 0.5, 1.0, and 1.5 J, respectively. A zone of thermal necrosis extending up to 1 mm beyond the site of laser impact was thought to correlate with the increased postoperative edema observed on the laser-treated side. Endoscopic sinus surgery with the holmium:YAG laser is as effective as nonlaser techniques in relieving the symptoms of chronic sinusitis. Laser surgery offers improved intraoperative hemostasis, but it causes increased postoperative tissue edema. The holmium:YAG laser provides the surgeon with an additional tool for the performance of safe, effective sinus surgery.

Endoscopic orbital decompression under local anesthesia.

Orbital decompression for Graves' disease has traditionally been performed with the patient under general anesthesia. Endoscopic instrumentation allows for removal of the medial orbital wall and floor through an intranasal approach with local anesthetic techniques. Twelve endoscopic orbital decompressions were performed on awake patients with uncovered eyes so that vision could be monitored throughout the procedure. Simultaneous lateral decompressions were performed in 11 cases. No intraoperative or postoperative complications occurred. Visual acuity remained stable or improved in all cases. Proptosis was reduced an average of 5.5 +/- 1.6 mm. In a comparable series of 29 endoscopic decompressions performed with patients under general anesthesia, proptosis was reduced an average of 4.8 +/- 2.0 mm. Endoscopic orbital decompression with patients under local anesthesia appears to be an effective technique that may provide an additional margin of safety in prevention of injury to the optic nerve.

The health impact of chronic sinusitis in patients seeking otolaryngologic care.

Although chronic sinusitis is an increasingly common diagnosis in the United States, the health burden of this disorder relative to the general population and to other chronic diseases has not been previously evaluated. One hundred fifty-eight patients with chronic sinusitis and no prior surgery underwent cross-sectional evaluation by use of the Medical Outcome Study Short-form 36-Item Health Survey. These patients were all referred for otolaryngologic care, and more than 80% subsequently underwent sinus surgery. Mean scores were compared from the eight subscales of general health assessment with similarly derived data for the United States general population. Significant differences (p < 0.05) were seen in several domains, including bodily pain, general health, vitality, and social functioning. Comparisons with other chronic diseases revealed significantly lower scores (p < 0.05) in measures of bodily pain and social functioning for sinusitis patients than in patients with congestive heart failure, angina, chronic obstructive pulmonary disease, and back pain. These findings suggest that the national health impact of chronic sinusitis is far greater than is currently appreciated.