A Randomized Single-Blinded Trial of Ibuprofen- versus Opioid-Based Primary Analgesic Therapy in Outpatient Otolaryngology Surgery.

OBJECTIVE: To compare the efficacy of pain control and opioid consumption between patients who receive opioid as primary analgesic therapy and those who receive ibuprofen. STUDY DESIGN: Prospective randomized trial. SETTING: Tertiary care academic hospital. SUBJECT AND METHODS: Adult patients undergoing outpatient otolaryngology surgery were assigned to take hydrocodone/acetaminophen or ibuprofen for postoperative analgesia. Patient-recorded pain scores and analgesic consumption were analyzed. RESULTS: Out of 185 recruits, 108 (58%) completed responses. Fifty-six patients (52%) received opioid medication for primary analgesic treatment versus 52 (48%) who received ibuprofen. There was no difference in reported pain scores between the treatment groups. Those who received ibuprofen as primary therapy reported a significantly lower consumption of opioid medication at 2.04 tablets/pills (95% CI, 0.9-3.1) versus 4.86 (3.6-6.1; P = .001). Based on multivariate analysis, male sex and older age exhibited lower reported pain scores, while older age and use of ibuprofen as primary therapy exhibited lower opioid requirements. CONCLUSION: For postoperative pain management in outpatient otolaryngology procedures, ibuprofen as primary therapy can provide equally effective pain control as compared with hydrocodone/acetaminophen while decreasing overall opioid requirement. Prescription pill counts are further described to help guide physician practices in the era of an opioid epidemic.

Antibiotics, steroids, and combination therapy in chronic rhinosinusitis without nasal polyps in adults.

Despite a lack of robust data regarding their efficacy, oral antibiotics and steroids remain two of the most common treatments for chronic rhinosinusitis without nasal polyps (CRSsNP). We sought to objectively compare the efficacy of antibiotics and steroids, independently and in combination, for the initial treatment of CRSsNP. To that end, we conducted a retrospective chart review of 100 patients-51 men and 49 women, age 20 to 85 years (mean: 50)-who were treated for CRSsNP from January 2010 through January 2015. Of this group, 17 patients were treated with an antibiotic only, 28 with a steroid only, and 55 with both agents. All patients underwent computed tomography (CT) before and after treatment, and we compared the three groups' pre- and post-treatment Lund-Mackay CT scores, symptom scores, and rates of surgery. The average time between the pre- and post-treatment visits was 4.4 weeks. The mean Lund-Mackay CT score for the entire study population was significantly lower after treatment than at baseline (6.3 vs. 9.1; p < 0.001); however, there were no significant differences among the three groups in either pre- or post-treatment scores. Symptom scores were significantly better in the combination therapy group than in the two monotherapy groups (p < 0.001). In all, 40 of the 100 patients underwent surgery; the difference in surgery rates among the three groups was not statistically significant (p = 0.884). Surgery was performed on 9 of the 52 (17.3%) patients who either were followed for at least 1 year or who had had surgery within the first year postoperatively; again, there were no significant differences among the three groups (p = 0.578). We conclude that although the Lund-Mackay CT scores decreased significantly in the antibiotic, steroid, and combination therapy groups, no one regimen was superior to any other for treating CRSsNP in our study.

Effect of intranasal dexamethasone on endogenous cortisol level and intraocular pressure.

BACKGROUND: Medical treatment of chronic rhinosinusitis with nasal polyposis (CRSwNP) centers on the administration of steroids. High-dose topical nasal steroids (HDTNS) have shown promising results with less systemic effects than oral steroids. One promising HDTNS is 0.132% dexamethasone nasal spray. We investigated whether intranasal dexamethasone was associated with changes in serum cortisol and/or intraocular pressure (IOP). METHODS: Patients with CRSwNP were treated with dexamethasone sodium phosphate 0.132% nasal spray twice daily. Morning serum cortisol and IOP were checked after at least 6 weeks of therapy. RESULTS: Twenty-eight patients met study criteria. The average serum cortisol level after at least 6 weeks of therapy (average duration of 38.3 weeks) was 9.8 µg/dL (normal range, 4 to 22 µg/dL). Ten patients had suppressed cortisol levels (average, 2.5 µg/dL). Ten patients underwent IOP measurements and none revealed ocular hypertension on tonometry. CONCLUSION: High-dose dexamethasone nasal spray given for a period of at least 6 weeks does appear to have the potential to cause a decrease in serum cortisol levels; however, future studies with greater power are necessary to support this claim. Additionally, similar administration of high-dose dexamethasone nasal spray did not reveal IOP diagnostic of ocular hypertension on single-measurement tonometry readings.

Effect of intranasal budesonide irrigations on intraocular pressure.

BACKGROUND: Intranasal and oral corticosteroids are widely used in the management of chronic rhinosinusitis with nasal polyps (CRSwNP). Higher-dose topical nasal steroids (HDTNS) such as budesonide irrigations are increasingly used for long-term maintenance in these patients. Oral steroids have the potential to cause increased intraocular pressure (IOP) and glaucoma. It is unclear whether HDTNS have the same potential. The objective of this study was to determine the effect of intranasal budesonide irrigations on IOP. METHODS: Two groups of patients with CRSwNP treated with budesonide irrigations were prospectively enrolled. Patients with history of elevated IOP or glaucoma were excluded. Patients in group 1 had been using budesonide for at least 1 month and had IOP measured once at the time of enrollment. Group 2 consisted of patients who were placed on budesonide at the time of enrollment and had IOP measured both before and after at least 4 weeks of therapy. RESULTS: Ten patients in group 1 and 8 patients in group 2 completed the study. In group 1, the average duration of therapy at enrollment was 6.3 months (1-22 months). Only 1 patient had a single eye pressure above 21 mmHg. None of the patients in group 2 had a significant change in IOP or IOP over 21 mmHg. CONCLUSION: Intranasal budesonide irrigations given for a period of at least 1 month do not appear to increase IOP.

The effect of intraoperative mupirocin irrigation on Staphylococcus aureus within the maxillary sinus.

BACKGROUND: Antibiotic irrigations are occasionally used during endoscopic sinus surgery when gross mucosal infection is present. These irrigations are thought to flush out pathogenic bacteria and decrease the bacterial load within the mucosal surfaces. This treatment, however, has not been studied in vivo and it is unknown whether antibiotic rinses produce a quantitative reduction in pathologic bacteria within the sinus mucosa. The objective of this study was to determine the relative abundance of Staphylococcus aureus within the maxillary sinus and to evaluate the impact of intraoperative mupirocin irrigation on bacterial burden. METHODS: Sixteen patients with symmetric maxillary chronic rhinosinusitis were prospectively enrolled. After bilateral maxillary antrostomies, biopsies were taken of the maxillary sinus mucosa on both sides. In each patient, the right side was irrigated with 240 mL of normal saline (NS) and the left side was irrigated with 240 mL of NS mixed with 60 mg mupirocin. Repeat maxillary sinus mucosal biopsies were taken from each side 7 to 10 days postsurgery. Each biopsy was analyzed using quantitative polymerase chain reaction to determine the presence and relative amount of S. aureus. RESULTS: Mupirocin irrigations were found to significantly reduce the amount of S. aureus found within the maxillary sinus mucosa compared to NS alone. The average fold change between the pre- and posttreatment biopsies on the right and left was 9.05 and 97.42, respectively (p < 0.01). CONCLUSION: Intraoperative mupirocin irrigations significantly reduce the amount of S. aureus detected within the diseased sinus mucosa at up to 10 days postoperatively.

The incidence of maxillary sinus membrane perforation during endoscopically assessed crestal sinus floor elevation: a pilot study.

Transcrestal sinus membrane elevation is a surgical procedure performed to increase the bone volume in the maxillary sinus cavity. Because of visual limitations, the potential for maxillary sinus membrane perforations may be greater than with the lateral approach technique. The aim of this study was to macroscopically investigate ex vivo the occurrence of sinus membrane perforation during surgery using 3 transcrestal sinus floor elevation methods. Twenty fresh human cadaver heads, with 40 intact sinuses, were used for simultaneous sinus membrane elevation, placement of graft material, and dental implants. Real-time sinus endoscopy, periapical digital radiographs, and cone-beam computerized tomography (CBCT) images were subsequently used to evaluate the outcome of each surgical procedure. Perforation rates for each of the 3 techniques were then compared using a significance level of P < .05. No statistically significant differences in the perforation rate (P = .79) were found among the 3 surgical techniques. Although the sinus endoscope noted a higher frequency of perforations at the time of implant placement as compared with instrumentation or graft insertion, the difference was not statistically significant (P = .04). The CBCT readings were judged to be more accurate for identifying evidence of sinus perforations than the periapical radiographs when compared with the direct visualization with the endoscope. This pilot study demonstrated that a sinus membrane perforation can occur at any time during the sinus lift procedure, independent of the surgical method used.

Canine fossa trephine is a beneficial procedure in patients with Samter`s triad.

BACKGROUND: Canine fossa trephine (CFT) is an adjunctive technique to sinus surgery in patients with recalcitrant maxillary sinusitis. CFT allows for disease clearance in areas of the maxillary sinus that are hard to reach with standard endoscopic techniques. The objective of this study was to compare the surgical outcome of CFT to standard middle meatal antrostomy (MMA) in matched patients with the severely diseased maxillary sinus. STUDY DESIGN: Prospective clinical study METHODS: Patients undergoing sinus surgery were enrolled in either the CFT or MMA group. All patients had nasal polyps, Lund Mackay score of 2 in the maxillary sinus, and nasal endoscopy showing the maxillary sinus full of polyps. The patients were followed and the maxillary sinus was graded endoscopically at 3, 6 and 12 months after the surgery. Length of surgery, disease recurrence and need for revision surgery was documented. RESULTS: Forty-two CFTs and MMA were performed in each group. At 6 and 12 months the CFT group demonstrated statistically significant improvement in nasal endoscopy scores. Six patients recurred by the one year mark in the MMA group, 4 of which underwent revision surgery. In the CFT group 2 patients recurred, one who underwent a unilateral revision CFT. Furthermore the CFT did not prolong the surgical time and was often faster than performing a MMA. CONCLUSION: CFT allows for clearance of all gross disease in the maxillary sinus and appears to improve postoperative outcome at 6 and 12 months and decrease the need for revision surgery.

Epigenetics of chronic rhinosinusitis and the role of the eosinophil.

BACKGROUND: One theory for the pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP) involves aberration in the expression of genes that maintain the sinonasal innate immune system. We propose that the alteration in gene expression seen in CRSwNP is a result of oxidative byproducts of eosinophils. Activated eosinophils and neutrophils may lead to the production of hypobromous acid (HOBr) and hypochlorous acid (HOCL) and the posttranslational modification products 5-bromocytosine (5BrC) and 5-chlorocytosine (5ClC), respectively. 5BrC and 5ClC may cause aberrant methylation of cytosine during DNA replication and mimic the endogenous methylation signal associated with gene silencing. We propose to use gas chromatography-mass spectrometry (GC-MS) to identify the presence of 5BrC and 5ClC in CRSwNP patients. METHODS: Patients with CRSwNP undergoing endoscopic sinus surgery were prospectively recruited into this study. Using GC-MS, tissue specimens were analyzed for the presence of 5BrC, 5ClC, and methylated cytosine. RESULTS: Tissue specimens from 14 patients with CRSwNP and 3 normal controls were processed using GC-MS. CRSwNP specimens demonstrate elevated levels of 5BrC and 5ClC compared to normal controls. CONCLUSION: Eosinophils, which are predominantly found in CRSwNP, may lead to DNA modification and gene silencing via 5BrC and aberrant methylation patterns and may help explain the pathogenesis of CRSwNP.

The impact of intraoperative saline irrigations on bacterial load within the maxillary sinus.

BACKGROUND: Saline irrigations are routinely employed during endoscopic sinus surgery to remove mucous and debris from the sinus cavities. What is unknown is whether this results in a quantitative reduction in pathologic bacteria within the sinus mucosa. The objectives of this study were to quantify the amount of 5 different bacteria (Staphylococcus aureus, Haemophilus influenzae, Pseudomonas aeruginosa, coagulase-negative Staphylococcus (CNS), and Streptococcus pneumoniae) within the maxillary sinus and to determine the impact of saline irrigations on bacterial counts. METHODS: Twenty patients with chronic rhinosinusitis were prospectively enrolled. After bilateral maxillary antrostomies, biopsies were taken of the maxillary sinus mucosa prior to any irrigation. In each patient, the left maxillary sinus was then irrigated with 250 cc of normal saline (NS) with a pressurized pulse-irrigation device and the right side was irrigated with 250 cc of NS using a 30-cc syringe attached to a curved suction tip. Repeat maxillary sinus mucosal biopsies were then taken from each side. Each biopsy was analyzed using quantitative polymerase chain reaction to determine the presence and amount of each of the bacteria. RESULTS: Saline irrigations were found to significantly reduce the amount of S. aureus, P. aeruginosa, and S. pneumoniae found within the maxillary sinus mucosa. No difference was found for H. influenzae or CNS. No difference in bacterial load reduction was able to be shown between the pressurized saline flushes and manual saline rinse methods. CONCLUSION: Intraoperative saline irrigations are able to significantly reduce the amount of potentially pathogenic bacteria within the diseased sinus mucosa.

Informed consent process and patient communication after complications in sinus surgery.

Sinonasal surgery has always been a potential source of complications. Most legal suits involving endoscopic sinus surgery alleged lack of informed consent. In this article, the authors discuss what informed consent means, to the physician and the patient, and how it is relevant in the case of complications. They also explain that patient communication is important and helps to develop a positive physician-patient relationship.

Balloon catheter sinusotomy: one-year follow-up--outcomes and role in functional endoscopic sinus surgery.

OBJECTIVE: The primary objective was to assess the long-term effectiveness of balloon catheter sinusotomy. METHODS: Patients who had sinus ostia dilated with balloon catheters were prospectively evaluated 1 year after surgery with nasal endoscopy, a CT scan, and the Sino-Nasal Outcome Test (SNOT-20). RESULTS: Sixty-six patients (202 sinuses) were examined. One hundred seventy-two of 202 sinus ostia (85%) were endoscopically patent, 1 percent (2/202) were nonpatent, and ostial patency could not be determined by endoscopy in 28 of 202 (14%). In these "indeterminate" sinuses, the CT scans were normal in 13, implying functional patency in 91.6 percent of sinuses (185/202). Sinus CT scan scores were 1.95 at 1 year versus 8.89 at baseline (P < 0.001), and 1-year SNOT-20 scores (0.91) were significantly improved from baseline (2.14, P < 0.0001). CONCLUSION: Balloon catheter sinusotomy results were durable over the study period, showing long-term effectiveness.

Long-term outcome analysis of balloon catheter sinusotomy: two-year follow-up.

OBJECTIVE: Assess two-year postoperative clinical outcomes for patients receiving balloon catheter sinusotomy. METHODS: Patients who had sinus ostia dilated with balloon catheters were prospectively evaluated two years after surgery by Sinonasal Outcome Test (SNOT-20) and computed tomographic (CT) scan. RESULTS: Sixty-five patients (195 ballooned sinuses) were followed for two years after surgery, including 34 "balloon-only" patients and 31 "hybrid" patients. SNOT-20 symptom scores were significantly improved from baseline (0.87 vs 2.17 baseline, P < 0.001) and stable compared to six months and one year; this was the case for both balloon-only (1.09 vs 2.09, P < 0.001) and hybrid (0.64 vs 2.26, P < 0.001) patients. Lund-MacKay CT scores were significantly improved from baseline (2.69 vs 9.66, P < 0.001) and stable compared to one year, confirmed for both balloon-only (1.75 vs 5.67, P < 0.015) and hybrid (3.25 vs 12.05, P < 0.001) subsets of patients. A total of 85% of patients reported improvement of their sinus symptoms, with 15% same and 0% worsened. Revision treatment was required in seven of 195 sinuses (3.6%) in six of 65 patients (9.2%). CONCLUSION: Patients who receive balloon catheter sinusotomy in endoscopic sinus surgery have significant improvement in symptoms two years after surgery. Radiographic evidence also confirms resolution of disease after two years. This demonstrates durability of clinical results previously reported at 24 weeks and one year after surgery.

Patient and surgeon radiation exposure in balloon catheter sinus ostial dilation.

OBJECTIVE: The aim of this study was to determine the extent of radiation exposure to the patient and the surgeon in balloon catheter dilation. METHODS: Dosimeters were used to record radiation exposure to both patients and surgeons. The mean radiation dose per sinus treated and per patient treated was calculated for each dosimeter location. RESULTS: The mean patient dose (108 sinuses treated in 34 patients), was 0.32 mSv per sinus and 1.02 mSv per patient over the eye and 1.33 mSv per sinus and 4.22 mSv per patient over the temple. The average total fluoroscopy time was 3.6 minutes per patient. The average number of sinuses treated was 3.2. The mean surgeon dose at the chest (254 sinuses in 89 patients) was 0.025 mSv per sinus and 0.072 mSv per patient. The mean surgeon dose at the hand (182 sinuses in 68 patients) was 0.009 mSv per sinus and 0.023 mSv per patient. CONCLUSIONS: The use of fluoroscopy in balloon catheter dilation exposes both the patient and surgeon to very low doses of radiation.

The effect of deliberate hypercapnia and hypocapnia on intraoperative blood loss and quality of surgical field during functional endoscopic sinus surgery.

BACKGROUND: Anesthetic management during functional endoscopic sinus surgery is aimed at minimizing bleeding and establishing a near-perfect surgical field. We investigated whether deliberate intraoperative hypercapnia and hypocapnia may affect blood loss and quality of surgical field through a proposed modulating effect of different carbon dioxide (CO2) tension levels on nasal vasculature. METHODS: One hundred and eighty patients were randomly assigned to normocapnia (end-tidal CO2 [ETco2] 37 +/- 2 mm Hg), hypercapnia (ETco2 60 +/- 2 mm Hg), and hypocapnia (ETco2 27 +/- 2 mm Hg) groups. Anesthetic management was with propofol and remifentanil infusions, nitrous oxide, and moderate controlled hypotension. Blood loss and operating conditions were assessed by the surgeon who was blinded to group assignment. Differences among the study groups, the effect of the study group and time on ETco2 levels and hemodynamic variables, and the association of blood loss with surgical covariates were analyzed. RESULTS: There were no differences in blood loss and quality of surgical field among the study groups. Patients in the hypocapnia group demonstrated the highest, and in the hypercapnia group, the lowest, requirements for remifentanil, labetalol, and administration of the antihypertensive medications in general. The computed tomography-graded severity of sinonasal disease and duration of surgery were the only independent predictors of intraoperative blood loss. CONCLUSIONS: CO2 management during functional endoscopic sinus surgery does not influence operating conditions or blood loss.

Safety and outcomes of balloon catheter sinusotomy: a multicenter 24-week analysis in 115 patients.

OBJECTIVE: The aim of this study was to further evaluate the safety and effectiveness of balloon catheter devices to dilate obstructed sinus ostia/perform sinusotomy. METHODS: Through a prospective, multicenter evaluation, safety was assessed by rate of adverse events, patency was determined by endoscopic examination, and sinus symptoms were determined by the Sino-Nasal Outcome Test (SNOT 20). RESULTS: At the conclusion of the 24-week analysis, endoscopy determined that the sinusotomy was patent in 80.5% (247 of 307) sinuses and nonpatent in 1.6% (5 of 307), and could not determine ostial patency status in 17.9% (55 of 307). Of the ostia visualized on endoscopy, 98% were patent (247 of 252), while 2% (5 of 252) were considered nonpatent. SNOT 20 scores showed consistent symptomatic improvement over baseline. Revision treatment was required in 3 sinuses (3 of 307 sinuses, 0.98%) in 3 patients (3 of 109 patients, 2.75%). CONCLUSION: Balloon catheter technology appears safe and effective in relieving ostial obstruction. Patients were pleased and indicated that they experienced symptomatic improvement.

Rofecoxib versus hydrocodone/acetaminophen for postoperative analgesia in functional endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: Functional endoscopic sinus surgery (FESS) is less invasive and more tissue sparing than extirpative techniques, with an assumed benefit of diminished postoperative pain. Oral opioids are commonly prescribed after sinus surgery but are associated with adverse effects, including gastrointestinal and neurologic symptoms. Nonopioid analgesics have been suggested to offer similar pain control efficacy with fewer adverse effects. STUDY DESIGN: To investigate postoperative analgesia in FESS, a prospective randomized, double-blinded comparison of hydrocodone/acetaminophen 7.5/750 mg (an opioidderivative) with rofecoxib 50 mg (a cyclooxygenase-2 inhibitor) was performed. METHODS: Forty subjects were enrolled, of which 28 successfully completed the study. Subjects recorded peak pain levels and requirement for rescue analgesia on the day of surgery and for 4 days thereafter. On postoperative day 5, subjects completed an exit survey in which adverse effects and overall satisfaction with pain control were recorded. RESULTS: In this study, there were no statistical differences in peak pain levels between the groups at any point in the postoperative period, regardless of extent of surgery. Adverse effect profiles were also similar for the two groups. CONCLUSIONS: The use of nonopioid analgesics after FESS may provide similar pain control to oral opioids.

Fluoroquinolone-induced arthralgia and myalgia in the treatment of sinusitis.

BACKGROUND: Because of their broad-spectrum coverage, fluoroquinolone antibiotics are widely used in the treatment of acute sinusitis and acute exacerbations of chronic sinusitis. Generally, they are well tolerated, and adverse effects are usually mild. In our experience with quinolones, patients have frequently complained of arthralgias and/or myalgias. Although tendon rupture has been described as one of the more severe side effects, there are few published reports of arthralgias and/or myalgias associated with these drugs. METHODS: A retrospective review of fluoroquinolone prescriptions in a tertiary rhinology clinic was completed. Patients treated with oral levofloxacin for sinusitis over a 12-month period were contacted by mail and asked to complete an anonymous survey regarding adverse effects. Of 81 patients identified, 36 responses were received. RESULTS: Among respondents, the incidence of arthralgias and/or myalgias was 25%, which was more than twice the incidence of any other adverse effect reported. Occurrence of arthralgias and/or myalgias did not appear to be influenced by respondent age, course length, concurrent use of oral steroids, or a history of arthritis. Among those reporting arthralgia or myalgia, symptoms began after an average of 3 days of therapy and resolved an average of 7.5 days after cessation of treatment. Fourteen percent of respondents were unable to complete their course of therapy because of arthralgias and/or myalgias. CONCLUSION: Although effective and generally well tolerated in the treatment of sinusitis, fluoroquinolone antibiotics may produce adverse effects of arthralgia and/or myalgia.

Informed consent in functional endoscopic sinus surgery: the patient's perspective.

OBJECTIVE: Informed consent is essential prior to functional endoscopic sinus surgery (FESS). The content of this discussion is often determined by each surgeon. Many doctors discuss all potential complications. This may provoke anxiety or deter from beneficial surgery. Our goal was to examine the process from the patient's perspective. Study design A list of potential complications was reviewed with FESS patients. Patients were asked questions concerning their consent and the potential complications before and after FESS. RESULTS: Both before and after surgery, patients felt that discussion of most potential complications was important. Vision changes and cerebrospinal fluid leak (CSF) received the highest scores. No significant differences were found between primary and revision cases. CONCLUSION: Patients wanted most potential FESS complications to be discussed. Even though this triggered anxiety, they felt it was important to have a thorough disclosure. Findings presented may impact how surgeons counsel patients prior to FESS.

Pigmented villonodular synovitis of the temporomandibular joint: a report of two cases.

Pigmented villonodular synovitis is a benign but locally destructive disease that originates in the synovial membranes of the joints. It is a proliferative disorder of unknown etiology, and it is usually monarthric. Approximately 80% of cases involve the knee; the hip, ankle, foot, hand, elbow, and shoulder account for most other cases. Pigmented villonodular synovitis in the temporomandibular joint is rare. When it does occur, its features include preauricular swelling, trismus, and symptoms of temporomandibular joint dysfunction. It can be diagnosed by a combination of the history, clinical examination, characteristic radiologic findings, and fine-needle aspiration or biopsy results. Wide local excision, including the involved bone, and a total synovectomy are advocated because the lesion can recur if it is not adequately excised. We report two new cases of pigmented villonodular synovitis of the temporomandibular joint, and we review the literature on this subject.