Multidisciplinary approaches to identifying and managing global airways disease: Expert recommendations based on qualitative discussions.

Background: Chronic rhinosinusitis with nasal polyps (CRSwNP) and asthma frequently co-exist and share pathologic features. Taking a "global" treatment approach benefits diagnosis and treatment of both, but care is often siloed by specialty: joined-up clinics are uncommon. Our objectives were to explore expert opinion to give practical suggestions to identify adults needing global airways care; enhance cross-specialty working; and widen knowledge to support diagnosis and management, integrate with existing care pathways, and supplement existing guidelines. Methods: Sixteen practicing physicians from northern Europe were invited for their national and/or international standing in treating asthma and/or chronic rhinosinusitis. Appreciative Inquiry techniques were used to guide their discussions. Results: Key themes arising were screening and referral, collaboration on management, awareness and education, and research. Provided are screening criteria and suggestions for specialist referrals, and pointers for physicians to optimize their knowledge of global airways disease. Collaborative working is underscored, and practical suggestions are given for multidisciplinary teamworking within global airways clinics. Research gaps are identified. Conclusion: This initiative provides practical suggestions for optimizing the care of adults with CRSwNP and asthma. Discussion of the role of allergy and drug exacerbations on these conditions, and care for patients with other global airways diseases were beyond scope; however, we expect some principles of our discussion will likely benefit patients with related conditions. The suggestions bridge asthma and CRSwNP management guidelines, envisioning interdisciplinary, global airway clinics relevant to various clinical settings. They highlight the value of joint screening for early recognition and referral of patients.

Long-term follow-up of patients with thyroid eye disease treated with endoscopic orbital decompression.

PURPOSE: To evaluate the outcome of endoscopic decompression in a series of patients with thyroid eye disease. METHODS: All 46 patients operated at our institution in the period 2001 to 2011 were invited for re-examination. Thirty-seven patients were included in the study and underwent a general otorhinolaryngological and ophthalmological examination. Nasal endoscopy, autoperimetry and a CT scan of the orbits and paranasal sinuses were performed. Preoperative and early postoperative data were obtained from hospital records. Re-examination was performed from 12 months to 9 years postoperatively. Paired t-test was used to evaluate the change in pre- and postoperative data. Image-guided surgery was used in two patients. RESULTS: Visual acuity improved from a median value (range) of 0.8 (0.05-1.25) to 1.0 (0.4-1.25) (p=0.006). Intra-ocular pressure (IOP) was reduced from a median value (range) of 18 mmHg (10-27 mmHg) to 14 mmHg (8-24 mmHg) (p<0.001). Median (range) Hertel values were 22.5 mm (14-29 mm) preoperatively and 19 mm (11-26 mm) postoperatively (p<0.001). Mean reduction in proptosis was 4.0 mm. At follow-up, visual fields were normal in 16/37 patients (43%) and with small defects in 12/37 patients (32%). Seventeen patients (46%) had diplopia preoperatively in one or more directions of gaze while 9 (24%) suffered from constant diplopia. After endoscopic decompression, new onset diplopia was seen in seven (19%) individuals, while worsening of diplopia occurred in eight (22%). Impaired motility in abduction and/or elevation was seen in 20 (54%) individuals before decompression and in 23 (62%) after. Strabismus surgery was performed in 22 patients. On final examination 85% of the study population were totally free of diplopia or experienced diplopia only in the peripheral field of gaze. Three patients developed sinusitis. Of these, endoscopic sinus surgery was performed in two patients, and one patient was conservatively treated. Symptoms resolved in all three patients. CONCLUSION: Endoscopic medial orbital decompression including removal of the medial floor of the orbit is a safe and effective procedure for treatment of thyroid eye disease. Navigation can be of valuable help to ensure complete resection of the bony walls. However, the majority of patients will need subsequent strabismus surgery, mainly due to significant increase of esotropia.

Endoscopic endonasal sinus surgery: a review of 18 years of practice and long-term follow-up.

A study of 1,915 patients operated on with a total of 4,285 endoscopic endonasal ethmoidal procedures during a period of 18 years is presented. The study comprises five groups of patients with (1) acute recurrent and chronic sinusitis--long-standing symptoms >3 months--(n = 733), (2) nasal/paranasal polyposis (n = 710), (3) sinogenic headache (n = 325), (4) mucoceles (n = 59) and (5) other nasal/paranasal disorders (n = 88). This group includes acute sinus infection with complications (n = 38), acute trauma/injury (n = 22), Grave's disease with exophthalmus (n = 12) and olfactory dysfunction (n = 16). The need for a thorough examination leading to a final diagnosis is emphasized. Endoscopy and CT/MRI are standard tools in the diagnostic and postoperative process. Close cooperation and educational teaching of the patient are necessary to obtain highest compliance. Long-standing medical treatment of inflammatory diseases is important to the long-term outcome and is of utmost importance to surgical success. Surgery is recommended to be performed under general anesthesia (total intravenous anesthesia or laryngeal mask anesthesia) with additional local, topical anesthetics, and can be easily performed on a day-case out-patient basis. The surgery is based upon the Messerklinger technique (MT). Peroperative complications are reduced by a skilled and meticulous surgical conduct and an adequate medication preoperatively. During this period of time, necessary controls within the first postoperative month were reduced from 3-4 to only one. Long-term follow-up secures a long-standing optimal result. Endoscopic surgery for more rare conditions, such as orbital decompression, CSF leaks and meningoceles, is recommended to be performed in specialized centers with adequate trained staff and necessary equipment. The possibilities of the picture archiving communication system, giving a number of different projections and angles and video-guided imaging peroperatively, facilitates safe surgical performances in areas usually associated with great risks and hazards. The long-term results are very good during the above circumstances. Reoperations are few and the patient satisfaction is very high.

The role of computed tomography in endoscopic sinus surgery: a review of 10 years' practice.

CT scans from 100 patients undergoing endoscopic sinus surgery (ESS) were primarily re-examined in order to assess the quality of the radiological examinations and the information it could provide years later. The material comprised the cases of patients who had undergone ESS by one surgeon (AD) in the 1990s. The indications for surgery were acute recurrent or chronic sinus infections, polyposis of the nasal and paranasal cavities, mucoceles and sinogenic headache. All examinations were described using a scheme modified according to Stoney et al., evaluating the opacity/mucosal thickening, drainage/pathways, the lateral nasal walls, septum and other bony walls. This study has been re-evaluated and an additional group of 20 patients consecutively operated on in 2002/2003 has been added. The initial radiological examinations often proved incomplete, with insufficient descriptions of either the drainage/pathways, the lateral nasal wall or the septum and bony walls, which all are structures of great value to evaluate preoperatively for the endoscopic surgeon. The operative findings correlated well with the CT if taken between 4-6 weeks before the operation. The structural pathology correlated with preoperative endoscopic findings independently of the time lapse between the scans taken and the date of surgery. The development and the gradual implementation of the picture archiving and communication system (PACS) certainly represent huge advantages in radiological assessment. The need for CT scans to be available in the operating room calls for specific computer installations to make PACS readily available peroperatively and in an easily workable way for the surgeon.

Interleukin 5, IL6, IL12, IFN-gamma, RANTES and Fractalkine in human nasal polyps, turbinate mucosa and serum.

Polyps are considered to develop as an end result of an inflammatory process. Cytokines and chemokines in the respiratory mucosa may be a key to polyp pathophysiology. The main objective was to identify IL-5, IL-6, IL-12, RANTES, IFN-gamma and Fractalkine in humans on the protein level in nasal polyps and mucosa from the inferior turbinate (IT). Furthermore, the cytokines and chemokines RANTES and Fractalkine were analyzed in plasma. Tissue homogenates and plasma from 13 patients were analyzed by the ELISA technique. All the patients had longstanding nasal/paranasal polyposis. Fractalkine was detected in polyps and IT in two different patients. IL-5 was expressed in polyps and IT. IL-6 was expressed in all patients with a higher level in polyps than IT. IL-12 was present in plasma, polyps and IT, though at an increased level in polyps. RANTES was present at a higher level in plasma than in polyps and IT. IFN-gamma was detectable in polyps and IT. Fractalkine is detected in nasal polyps, which is a new observation. The overall results indicate a mixed T(H)1/T(H)2 cytokine profile in nasal polyps. RANTES and IL-12 are strongly present in plasma, suggesting an ongoing inflammatory "drive". IL-6 and IL-12 are up-regulated in polyps versus the IT. Up-regulation of IL-6 may be explained by increased fibroblast activity dependant on an ongoing local inflammation possibly initiated by an infection. IL-5, RANTES and IFN-gamma are equally represented in polyps and IT, indicating equilibrium between the nasal polyps and surrounding tissue, and that an up-regulation of cytokines in the polyp indicates a potential for polyp growth.

Anaesthesia in endoscopic sinus surgery.

The aim of this study was to evaluate the methods of anaesthesia used in 1,460 patients (677 females and 783 males), aged 4 to 79 years, who were consecutively operated on with a functional endonasal endoscopic approach (FESS) or by an endoscopic endonasal approach (ESS) by one surgeon (AD) in the period from 1987-2001. The included patients presented a variety of disorders within the nose and sinuses. Many of the patients had sinonasal polypoid disease, which had gradually expanded over years and was causing pressure to neighbouring structures. Several had undergone previous multiple surgical procedures altering the original anatomy. However, the majority of the patients had been treated surgically for acute recurrent and/or chronic infections, others for sinogenic headache, benign tumours/mucoceles and smell disorders. The intention of looking into the anaesthetic procedures being used was to clarify the needs for a differentiated anaesthetic approach to different surgical tasks. It is of crucial importance for an optimal surgical result that both the patient and surgeon feel absolutely comfortable during the operation. Local anaesthesia can be used in minor surgery on selected patients and is definitely suitable even for residents in training. General anaesthesia is preferred in most cases by both patients and surgeons. The conclusion of this paper is that total intravenous anaesthesia (TIVA) in addition to oxygen-enriched air through a laryngeal mask airway (LMA) should be the anaesthetic procedure of choice, at least in our experience.