A comparison of radiographic evidence of frontal sinusitis in middle-turbinate sacrificing versus middle-turbinate sparing approaches to the sella.

BACKGROUND: Initial descriptions of endoscopic approaches to the sella and pituitary involved resecting the middle turbinate (MT) to help improve access and visualization. Modifications of these procedures to preserve the MT have since been described, one rationale being to reduce the incidence of frontal sinusitis. The objective of this study was to establish the incidence of postoperative frontal sinusitis in MT sparing (MTsp) and MT sacrificing (MTsc) approaches to the sella. OBJECTIVE: A retrospective cohort study that compared radiographic evidence of frontal rhinosinusitis or frontal recess obstruction after skull base surgery in patients who underwent MTsc and MTsp endonasal approaches to the sella. METHODS: Consecutive retrospective review of pre- and postoperative magnetic resonance imaging from two institutions in geographic proximity but with different approaches to the sella. Mucosal thickening in the frontal sinus was measured and graded by a radiologist blinded to patient cohorts. RESULTS: Seventy-five patients, based on sample size calculations, were included at each site. Baseline demographics and indications for surgery were not significantly different between the groups. No difference was seen between the groups in the overall grade of radiographic frontal sinusitis seen on postoperative imaging. A total of 8 patients (10%) in the MTsc group had measured mucosal thickening, which was increased from their preoperative scan versus 15 in the MTsp group (20%) (p = 0.10). New mucosal thickening of >1 mm was found in three patients in the MTsc group and eight patients in the MTsp group (p = 0.21); the only patient with postoperative complete frontal sinus opacification was in the MTsp group. CONCLUSIONS: The choice of MTsc versus MTsp in endonasal endoscopic approach to the sella does not seem to make a difference in the incidence of postoperative radiographic frontal sinusitis.

The role of immediate postoperative systemic corticosteroids when utilizing a steroid-eluting spacer following sinus surgery.

OBJECTIVE: Steroid-eluting spacers can improve local drug delivery immediately following endoscopic sinus surgery and reduce the recurrence of inflammation warranting systemic corticosteroids. For chronic rhinosinusitis with nasal polyposis, the need for systemic corticosteroids immediately following endoscopic sinus surgery when using a steroid-eluting spacer has not been studied. STUDY DESIGN: A randomized, double-blind, placebo-controlled trial. SETTING: Academic rhinology practice. SUBJECTS AND METHODS: Chronic rhinosinusitis patients with nasal polyposis who failed medical therapy and elected endoscopic sinus surgery were enrolled. Patients were randomized into either the treatment arm (postoperative prednisone 30 mg daily × 7 days; n = 18) or placebo arm (postoperative placebo pill daily × 7 days; n = 18). Outcomes were evaluated at 1 week, 3 weeks, and 2 months postoperatively. Primary outcome was endoscopic grading at postoperative month 2 using the Lund-Kennedy system. Secondary outcome included disease-specific quality of life using the Sinonasal Outcome Test (SNOT-22) survey. Patient enrollment occurred from January 2012 through February 2013 (NCT01564355). RESULTS: Both arms received significant improvement in endoscopic grading and disease-specific quality of life from baseline compared to 2-month follow-up (P < .001). There were no significant differences in mean endoscopic scores between the postoperative prednisone and control groups at 1 week (P = .715), 3 weeks (P = .883), or 2 months (P = .343). There were no significant differences in SNOT-22 scores between groups at all follow-up points (all P > .119). CONCLUSION: Minimizing systemic corticosteroid use in patients with chronic rhinosinusitis with nasal polyposis may avoid adverse events. Results from this study suggest that postoperative systemic corticosteroids immediately following endoscopic sinus surgery may not provide improved outcomes when utilizing a steroid-eluting spacer.

Effect of a dexamethasone Sinu-Foam™ middle meatal spacer on endoscopic sinus surgery outcomes: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Off-label drug eluting middle-meatal spacers have shown promising results for improving clinical outcomes following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). This study evaluates a dexamethasone Sinu-Foam™ spacer following ESS for CRS without nasal polyposis (CRSsNP). METHODS: Patients with CRSsNP (n = 36) were enrolled into a double-blind, placebo-controlled trial and randomized into either a treatment arm (dexamethasone Sinu-Foam™ mixture; n = 18) or placebo arm (Sinu-Foam™ alone; n = 18). Therapeutic outcomes were evaluated at 1 week, 4 weeks, and 3 months using sinonasal endoscopy and graded using the Lund-Kennedy scoring system. Postoperative care included nasal saline irrigations and a short course of systemic steroids. RESULTS: All patients completed the study follow-up period. Both study arms experienced significant improvement in endoscopic grading over the study duration (p < 0.001). There was no difference in average endoscopic scores between the treatment and placebo groups at 1 week, 4 weeks, and 3 months (all p > 0.489). CONCLUSION: This study demonstrated that an off-label drug-eluting middle-meatal spacer of dexamethasone and Sinu-Foam™ does not improve endoscopic outcomes in the early postoperative period following ESS when combined with postoperative saline irrigations and a short course of systemic steroids.

Identification of bacterial contaminants in sinus irrigation bottles from chronic rhinosinusitis patients.

OBJECTIVE: To determine if sinus irrigation bottles from patients with chronic rhinosinusitis (CRS) harbour bacterial contaminants. DESIGN: Patients with symptoms of CRS who showed no mucopurulent infection and had no history of surgery were enrolled in the study. Patients were instructed on the proper use and cleaning of sinus irrigation bottles and were asked to return their rinse bottle during follow-up visits. METHODS: Bacterial contaminants were cultured from the inner surface of the sinus irrigation bottles obtained from patients. Genomic deoxyribonucleic acid (DNA) was isolated from purified colonies and used to polymerase chain reaction (PCR) amplify the 16S ribosomal ribonucleic acid (rRNA) genes. PCR products were sequenced and analyzed in the Human Oral Microbiome Database (HOMD) for genus and species identification based on 16S ribosomal DNA (rDNA) sequence comparisons. MAIN OUTCOME MEASURES: The outcomes included the recovery of bacterial contaminants and their subsequent identification. RESULTS: In total, 142 bacterial isolates were cultured and identified. The organisms included known oral flora bacteria, as well as pathogens of the upper respiratory tract and sinuses. Thirty-two different bacterial species were identified from 11 patients. There was no correlation between the length of bottle use and the degree of contamination. CONCLUSION: This study highlights the risk of bacterial contamination of sinus irrigation bottles and the potential for patient reinoculation.

Training, practice, and referral patterns in rhinologic surgery: survey of otolaryngologists.

OBJECTIVES: Rhinology, which encompasses clinical and surgical treatment of the nasal cavity and paranasal sinuses, is a growing subspecialty with advances in the surgical, clinical, and research realms. The advancement of this subspecialty and its impact on the practice of otolaryngology, in both academic and nonacademic institutions, is not yet understood. METHODS: A novel survey created by our research team was mailed out to 150 randomly selected otolaryngology staff and 8 fellowship-trained rhinologists throughout Canada asking questions related to demographics, training, referral patterns, technique, and adequacy of training. RESULTS: One hundred respondents completed the survey, yielding a response rate of 63%. The average age of rhinologists who responded (38 years) was younger than those who were nonrhinologists (50 years). Compared with fellowship-trained rhinologists, nonrhinologists felt less comfortable with cerebrospinal leak repairs, skull base surgery, frontal sinus surgery, paranasal sinus neoplasm removal, and sphenopalatine artery ligation. CONCLUSIONS: Rhinology is a distinct subspecialty with new fellowship opportunities combined with advances in surgical technique, clinical treatments, and research opportunities. There are procedures that can be performed by both rhinologists and nonrhinologists; however, there is a subset of procedures that nonrhinologists do not feel comfortable performing. These procedures should be referred to fellowship-trained rhinologists who practice out of academic centres.

Chinook wind barosinusitis: an anatomic evaluation.

BACKGROUND: Chinook, or föhn, is a weather phenomenon characterized by a rapid influx of warm, high-pressured winds into a specific location. Pressure changes associated with chinook winds induce facial pain similar to acute sinusitis. The purpose of this study was to determine the relationship between sinonasal anatomy and chinook headaches. METHODS: Retrospective computed tomography (CT) sinonasal anatomy analysis of 38 patients with chinook headaches and 27 controls (no chinook headaches). The chinook headache status was blinded from the CT reviewer. Forty-one sinonasal anatomy variants, Lund-Mackay status, and sinus size (cm(3)) were recorded. RESULTS: There were three statistically significant sinonasal anatomy differences between patients with and without chinook headaches. The presence of a concha bullosa and sphenoethmoidal cell (Onodi cell) appeared to predispose to chinook headaches (p = 0.004). Chinook headache patients had larger maxillary sinus size (right, p = 0.015, and left, p = 0.002). The Lund-Mackay score was higher in the control patients (p = 0.003) indicating that chronic sinusitis does not play a role in chinook headaches. CONCLUSION: Chinook winds are a common source of facial pain and pressure. This is the first study to show that sinonasal anatomic variations may be a predisposing factor. Anatomic variants may induce facial pain by blocking the natural sinus ostia, thus preventing adequate pressure equilibrium.

Effect of intraoperative injection of 0.25% bupivacaine with 1:200,000 epinephrine on intraoperative blood loss in FESS.

BACKGROUND: This study was designed to compare differences in intraoperative blood loss, mean arterial blood pressure (MABP), and duration of surgery when 0.25% bupivacaine with 1:200000 epinephrine is injected, preoperatively, versus normal saline (NS), during functional endoscopic sinus surgery (FESS). METHODS: A prospective, double-blind randomized placebo-controlled study was performed. Part I involved 46 patients who were infiltrated with 0.25% bupivacaine with 1:200000 epinephrine on one side of the nose and sterile NS on the other (control). Part II involved 30 patients infiltrated with 0.25% bupivacaine with 1:200000 epinephrine bilaterally and 30 patients with NS bilaterally (control). Patient demographics, preoperative MABP, intraoperative MABP, duration of surgery, and total estimated blood loss (EBL) were recorded for each side (Part I) and case (Part II). RESULTS: For part I, there were 46 patients (mean age, 49 years), 24 women and 22 men. MABP was 72 mmHg for each side (p = 0.97). Preoperative MABP was 93 mmHg. Duration of surgery was 48 minutes for epinephrine side and 45 minutes for control (p = 0.17). Total EBL was 185 mL for the epinephrine side and 197 mL for control (p = 0.53). For Part II, there were 60 patients (mean age, 56 years), 28 women and 32 men. The MABP was 77 mmHg for the epinephrine group and 72 mmHg for control (p = 0.048). Preoperative MABP was 100 mmHg for the epinephrine group and 97 mmHg for control (p = 0.37). Duration of surgery was 2.25 hours for the epinephrine group and 2.08 hours for control (p = 0.17). Total EBL was 589 mL for the epinephrine group and 538 mL for control (p = 0.64). CONCLUSION: There was no significant reduction in intraoperative blood loss during FESS when local anesthetic containing epinephrine was used compared with infiltration with NS. More importantly, Part II shows a significantly higher MABP associated with infiltration of epinephrine. Parts I and II did not show a significant difference in preoperative MABP or duration of surgery.

A comparison of two sphenoidotomy approaches using a novel computerized tomography grading system.

BACKGROUND: Endoscopic management of sphenoid sinus disease has great potential for surgical complications. A variety of endoscopic surgical techniques have been described for entering the sphenoid sinus. The utility of these surgical techniques is based on the position of the superior turbinate attachment to the sphenoid face (Parson's ridge). We introduce a novel computerized tomography (CT) grading system for the attachment of the superior turbinate to the sphenoid face. Using this new grading system, we recommend a safer systematic approach for entry into the sphenoid sinus. METHODS: A grading based on the attachment of the superior turbinate to the sphenoid face at the level of the natural sphenoid ostium was developed. A total of 53 patients were enrolled. Types A, B, and C refer to the superior turbinate attachment at the medial, middle, or lateral third of the anterior sphenoid face, respectively, and type D refers to orbital attachment of the superior turbinate. The surgical approach used (superior turbinate intact [STI] or superior turbinate resection [STR]) was recorded and correlated to the type of superior turbinate attachment. RESULTS: The overall incidence of the various superior turbinate attachments were 40% (41) for type A, 41% (42) for type B, 18% (19) for type C, and 1% (1) for type D. STR was used in 38 sides (44%) and STI was used in 48 sides (56%). Spearman correlation study showed that the closer the superior turbinate attachment was to the orbit the more likely STR was used as the choice of entry into the sphenoid (p < 0.001). CONCLUSION: To perform a safe sphenoid entry it is pertinent to evaluate the superior turbinate attachment to the sphenoid face before making a decision on the method of entry.

Comparison of drain versus no drain thyroidectomy: randomized prospective clinical trial.

OBJECTIVE: To evaluate the use of surgical drains in thyroid surgery. DESIGN: Randomized, prospective, clinical trial. METHODS: Patients were randomized into drain and no drain groups by a blinded observer. Inclusion criteria included all patients presenting for total, hemi-, or completion thyroidectomies. Those with massive goitres or nodules greater than 6 cm were excluded. Fifty-five patients were enrolled in the study. Complications, length of hospital stay, and overall cost were evaluated. RESULTS: In the no drain group, there was a 1.12-day reduction in hospital stay (p < .01), with no increase in postoperative complications. This translated into a cost savings of $2177 per patient. CONCLUSIONS: Thyroid surgery without the use of a drain decreases the length of hospital stay, with no increase in patient morbidity. The overall cost is significantly reduced.

Lansoprazole in globus pharyngeus: double-blind, randomized, placebo-controlled trial.

OBJECTIVE: To evaluate the effectiveness of once-daily lansoprazole in the typical globus pharyngeus patient, who presents with a normal head and neck examination and without other sinister otolaryngologic complaints. STUDY DESIGN: Prospective, randomized, double-blind, placebo-controlled trial. SETTING: Outpatient otolaryngology office practice. METHODS: After meeting the inclusion criteria, patients were randomized to a 3-month course of either treatment (30 mg lansoprazole daily) or placebo (lactose). All patients were given a medication diary and instructed to take the medication daily on waking. During the office visit, counseling regarding lifestyle modifications for gastroesophageal reflux disease was provided to all patients. MAIN OUTCOME MEASURE: The Glasgow-Edinburgh Throat Scale questionnaire was given prior to treatment and at 1- and 3-month intervals during treatment. RESULTS: Forty patients were enrolled between June 2005 and December 2006. Nineteen patients were randomized to the lansoprazole treatment arm, whereas 21 were enrolled in the placebo arm. Both groups were similar with regard to age, sex, and smoking history. The globus symptom score improved an average of 6.7 of 70 points in the treatment group and 2.9 points in the placebo group. There was no clinically or statistically significant difference between the two groups at any time point. CONCLUSION: The globus pharyngeus patient who presents with a normal head and neck examination and without sinister otolaryngologic complaints does not benefit from once-daily lansoprazole therapy.

Revision endoscopic sinus surgery: the St. Paul's Sinus Centre experience.

OBJECTIVE: To determine the most common findings in patients undergoing revision endoscopic sinus surgery (ESS) presenting to a tertiary rhinology centre. It is our aim that by identifying these findings, the common pitfalls in primary ESS can be avoided to prevent the necessity for revision ESS. METHODS: The findings of 73 cases of revision ESS from July 2006 to March 2007 presenting to the St. Paul's Sinus Centre were recorded and then presented. RESULTS: There are many common findings at revision ESS, including residual uncinate process, persistent septal deviation, nonphysiologic maxillary antrostomies, incomplete ethmoidectomy, and partial or total resection of the middle and superior turbinate, resulting in the formation of the "uniturbinate." CONCLUSION: Many common findings in revision ESS can be avoided with proper primary surgery.