Preoperative risk assessment for ambulatory sinonasal surgery.

OBJECTIVES: An increasing proportion of patients who are candidates for endoscopic sinus surgery can be treated as an outpatient. A preoperative risk assessment is needed to evaluate eligibility for day surgery. This study analyses the effectiveness of a risk assessment scoring system which examines medical, procedure-related, and socioeconomic factors. DESIGN: Prospective multicenter study. SETTING: Three center study including Klinik Hirslanden, Zurich, Switzerland, Luzerner Kantonsspital, Lucerne, Switzerland and HNO-Klinik München-Bogenhausen, Munich, Germany. PARTICIPANTS: Patients with endoscopic sinus procedures between January 1st, 2017 and December 31st, 2018. MAIN OUTCOME MEASURES: The "day surgery risk score" consisted of three subgroups with medical, procedure-related and socioeconomic risk factors were assessed to determine if these predicted the severity of postoperative complications. RESULTS: Three-hundred and one patients who underwent endoscopic sinus surgery were included. The score resulted in a median value of 5 [5, 5]. In the Receiver-Operating Curve (ROC-the true-positive rate against the false-positive rate), the Area Under the Curve (AUC) was 0.59 with 95% confidence interval from 0.49 to 0.69, indicating that the "day surgery risk score" may be no better at predicting the likelihood of a complication than a random classification model. CONCLUSIONS: The "day surgery risk score" is a straightforward risk assessment which combines medical, procedure-related, and socioeconomic factors. The score is easy to use but in trying to decide whether a patient is eligible for ambulatory endoscopic sinus surgery it did not predict whether a complication was more likely to occur.

3D endoscopy shows enhanced anatomical details and depth perception vs 2D: a multicentre study.

PURPOSE: The current standard endoscopic technique is a high resolution visualisation up to Full HD and even 4 K. A recent development are 3D endoscopes providing a 3-dimensional picture, which supposedly gives additional information of depth, anatomical details and orientation in the surgical field. Since the 3D-endoscopic technique is new, little scientific evidence is known whether the new technique provides advantages for the surgeon compared to the 2D-endoscopic standard technique in FESS. This study compares the standard 2D-endoscopic surgical technique with the new commercially available 3D-endoscopic technique. METHODS: The prospective randomized interventional multicenter study included a total of 80 referred patients with chronic rhinosinusitis with and without polyps without prior surgery. A bilateral FESS procedure was performed, one side with the 2D-endoscopic technique, the other side with the 3D-endoscopic technique. The time of duration was measured. Additionally, a questionnaire containing 20 items was completed by 4 different surgeons judging subjective impression of visualisation and handling. RESULTS: 2D imaging was superior to 3D apart from "recognition of details", "depth perception" and "3D effect". For usability properties 2D was superior to 3D apart from "weight of endoscopes". Mean duration for surgery was 26.1 min for 2D and 27.4 min. for 3D without statistical significance (P = 0.219). CONCLUSION: Three-dimensional endoscopy features improved depth perception and recognition of anatomic details but worse overall picture quality. It is useful for teaching purposes, yet 2D techniques provide a better outcome in terms of feasibility for routine endoscopic approaches.

Real-life assessment of chronic rhinosinusitis patients using mobile technology: The mySinusitisCoach project by EUFOREA.

BACKGROUND: Chronic rhinosinusitis (CRS) is a chronic inflammatory disease associated with a substantial personal and socioeconomic burden. Monitoring of patient-reported outcomes by mobile technology offers the possibility to better understand real-life burden of CRS. METHODS: This study reports on the cross-sectional evaluation of data of 626 users of mySinusitisCoach (mSC), a mobile application for CRS patients. Patient characteristics of mSC users were analysed as well as the level of disease control based on VAS global rhinosinusitis symptom score and adapted EPOS criteria. RESULTS: The mSC cohort represents a heterogeneous group of CRS patients with a diverse pattern of major symptoms. Approximately half of patients reported nasal polyps. 47.3% of all CRS patients were uncontrolled based on evaluation of VAS global rhinosinusitis symptom score compared to 40.9% based on adapted EPOS criteria. The impact of CRS on sleep quality and daily life activities was significantly higher in uncontrolled versus well-controlled patients. Half of patients had a history of FESS (functional endoscopic sinus surgery) and reported lower symptom severity compared to patients without a history of FESS, except for patients with a history of more than 3 procedures. Patients with a history of FESS reported higher VAS levels for impaired smell. CONCLUSION: Real-life data confirm the high disease burden in uncontrolled CRS patients, clearly impacting quality of life. Sinus surgery improves patient-reported outcomes, but not in patients with a history of more than 3 procedures. Mobile technology opens a new era of real-life monitoring, supporting the evolution of care towards precision medicine.

Incidence of anatomical variations according to the International Frontal Sinus Anatomy Classification (IFAC) and their coincidence with radiological sings of opacification.

BACKGROUND: The endonasal access to the frontal recess and sinus may be complicated by a variety of anatomical variations. Previous classifications of these variants were characterized by proper names or position information without anatomical reference. The IFAC is intended to simplify the classification of anatomical variations of the frontoethmoidal complex. The aim of this study was to analyse a representative number of sinus CT scans to assess the incidence of anatomical variations according to the IFAC and to compare the results with previous classifications. In addition, the coincidence of complex anatomical variations and radiological sings of opacification was investigated. METHODOLOGY/PRINCIPAL: Two hundred and forty-nine sinus CT scans were analysed in multiplanar reconstructions. Exclusion criteria were previous operations on the paranasal sinuses, malignant diseases, and an insufficient image quality. All anatomical variants were analysed according to the IFAC criteria. In addition, the coincidence of radiological sings of opacification and the presence of anatomical variations of the frontal recess and sinus were investigated. RESULTS: The analysis revealed Agger nasi cells in 95% of the CT scans. Supra agger cells (SACs) were detected in 49% and Supra agger frontal cells (SAFCs) in 25% of the data sets. Suprabulla cells (SBCs) were detected in 89% and Supra bulla frontal cells (SBFCs) in 27% of the scans. Supraorbital ethmoid cells (SECs) were detectable in 9% and interfrontal septal cells in 28% of the scans. Despite a partially strong narrowing of the frontal recess, no increased occurrence of radiological sings of opacification could be detected (p > 0.05). CONCLUSIONS: Anatomical variations in the frontoethmoidal area are very common. According to the IFAC criteria, in 43% of the patients, cells could be detected with pneumatization to or into the frontal sinus. The IFAC is structured more clearly compared to previous classifications due to the anatomical aspect. It represents the most consistent classification regarding surgical planning. Further studies will demonstrate the scientific and clinical value of this classification.

Spontaneous nasal cerebrospinal fluid leaks: management of 24 patients over 11 years.

PURPOSE: Most cases of non-traumatic nasal cerebrospinal fluid (CSF) leaks occur spontaneously without any obvious reason. Severe and life-threatening complications are possible consequences. Endoscopic repair is considered the gold standard; however, diagnosis and therapy of these CSF leaks stay challenging. METHODS: In this retrospective analysis, patients who presented with spontaneous nasal CSF leaks from 2006 to 2017 were included. Symptoms, diagnostics, localization of the skull base defect, surgical method, outcome, and postoperative treatment were recorded. RESULTS: Twenty four patients were included. 8 patients presented with symptoms of meningitis. The skull base defects were most commonly located in the anterior ethmoid roof-especially in the cribriform plate-and in the lateral part of the sphenoid sinus. 21 patients had a BMI above 25. In only 13 cases the defect could be detected preoperatively via computed tomography or additional magnetic resonance imaging. In all patients intraoperative visualization of the CSF leak was possible using intrathecal application of sodium-fluorescein. Endoscopic repair was the initial surgical method for all patients and proved to be successful in 80% of the cases. In most cases surgical revision was performed endoscopically; however, in two patients an open transpterygoidal approach was necessary. CONCLUSIONS: Spontaneous nasal CSF leaks often initially present with symptomatic meningitis. Imaging does not always clearly identify the skull base defect. Common localizations are the anterior ethmoid roof and the lateral sphenoid sinus. Obesity seems to be a predisposing factor. In most cases, endoscopic repair with low morbidity is possible; however, an individualized approach is necessary.

Diode laser-induced tissue effects: in vitro tissue model study and in vivo evaluation of wound healing following non-contact application.

INTRODUCTION: The basic difference between the various common medical laser systems is the wavelength of the emitted light, leading to altered light-tissue interactions due to the optical parameters of the tissue. This study examines laser induced tissue effects in an in vitro tissue model using 1,470 nm diode laser compared to our standard practice for endonasal applications (940 nm diode laser) under standardised and reproducible conditions. Additionally, in vivo induced tissue effects following non-contact application with focus on mucosal healing were investigated in a controlled intra-individual design in patients treated for hypertrophy of nasal turbinate. METHODS: A certified diode laser system emitting the light of λ = 1470 nm was evaluated with regards to its tissue effects (ablation, coagulation) in an in vitro setup on porcine liver and turkey muscle tissue model. To achieve comparable macroscopic tissue effects the laser fibres (600 µm core diameter) were fixed to a computer controlled stepper motor and the laser light was applied in a reproducible procedure under constant conditions. For the in vivo evaluation, 20 patients with nasal obstruction due to hyperplasia of inferior nasal turbinates were included in this prospective randomised double-blinded comparative trial. The endoscopic controlled endonasal application of λ = 1470 nm on the one and λ = 940 nm on the other side, both in 'non-contact' mode, was carried out as an outpatient procedure under local anaesthesia. The postoperative wound healing process (mucosal swelling, scab formation, bleeding, infection) was endoscopically documented and assessed by an independent physician. RESULTS: In the experimental setup, the 1,470 nm laser diode system proved to be efficient in inducing tissue effects in non-contact mode with a reduced energy factor of 5-10 for highly perfused liver tissue to 10-20 for muscle tissue as compared to the 940 nm diode laser system. In the in vivo evaluation scab formation following laser surgery as assessed clinically on endonasal endoscopy was significantly reduced on 1,470 nm treated site compared to 940 nm diode laser treated site. CONCLUSIONS: Diode laser system (1,470 nm) induces efficient tissue effects compared to 940 nm diode laser system as shown in the tissue model experiment. From the clinical point of view, the healing process following non-contact diode laser application revealed to be improved using 1,470 nm diode laser compared to our standard diode laser practise with 940 nm.

Influence of laser light on bioimplants used in otorhinolaryngology.

In otorhinolaryngology, dermatology and reconstructive surgery biomaterials as implants and a variety of lasers are used. Laser light applied near to an implant could have the risk to damage these materials. Therefore, their resistance exposed to laser light is of interest. A diode laser emitting at 940 nm and a CO2 laser were used to investigate its effects to the biomaterials Bioverit®, Medpor® and Palacos®, and in addition, an excised implant containing Medpor® and nasal turbinate tissue, excised and fixed in formalin. The macro- and microscopic changes of the material, temperature development during laser energy application in dependency to distance of fibre and material, time of exposure and applied power were investigated. Interaction of diode laser light with Bioverit® (0 mm distance, 360 s, 10 W, 3,600 J) resulted in minimal microscopic effects in direct contact of with the fibre. Using Medpor® (1 mm, 10s, 10 W, 100 J) resulted in melting and perforation. In the case of Palacos® (0.6 mm, 10s, 10 W, 100 J), melting occurred creating a flat excavation. The effect to Medpor® in nasal turbinate (1-2 mm, 10s, 10 W, 100 J) showed tissue denaturation and carbonisation and creation of a hole. The interaction of the CO2 laser with Bioverit® (3 cm, 0.5, 1 and 5 s, 2, 10 or 20 W) induced melting and discolouring resulting finally in a perforating hole. Depending on the material, first damage starts 10 s after an impact of 100 J (threshold value). So interaction between laser energy and biomaterials occurs. This should be carefully considered during clinical laser treatments especially nearby implants.

Sinonasal outcome under aspirin desensitization following functional endoscopic sinus surgery in patients with aspirin triad.

Recalcitrant forms of recurrent nasal polyposis are problematic for patients as for rhinosurgeons. In aspirin-sensitive patients, aspirin desensitization is supposed to prevent recurrence by targeting the metabolism of arachidonic acid. Aspirin-sensitive patients (n = 65) following aspirin desensitization after functional endoscopic sinus surgery (FESS) for recurrent nasal polyposis under daily intake of 500-mg aspirin were compared to a post-FESS group (n = 81) of aspirin-sensitive individuals using exclusively topical mometasone. Quality of life (QoL) scores including sinonasal, pulmonal and general QoL items as well as endoscopic endonasal examination findings were evaluated during the postoperative follow-up period. After a follow-up period of minimum 18 months, a significant improvement in nasal obstruction, rhinorrhea, post nasal drip, sense of smell, facial pain, sleep quality and further general QoL items in desensitized patients was found compared to aspirin-sensitive controls. Improvement in sinonasal symptoms was evident, whereas the severity of asthmatic symptoms showed no significant changes. Although the pathophysiology of aspirin sensitivity is still not fully understood and the therapy is not sufficiently investigated, aspirin desensitization seems to have a positive effect on QoL scores concerning sinonasal symptoms and should be regarded as a possible postoperative treatment modality for recurrent nasal polyposis in aspirin-sensitive individuals.

Intraindividual comparison of 1,470 nm diode laser versus carbon dioxide laser for tonsillotomy: a prospective, randomized, double blind, controlled feasibility trial.

INTRODUCTION: The need for reduction of post-tonsillectomy hemorrhage has led to promotion of tonsillotomy techniques for tonsil tissue reduction in obstructive tonsillar hypertrophy. This trial compares ablative tissue effects using 1,470 nm diode laser and carbon dioxide laser for tonsillotomy in an intraindividual design. METHODS: 21 children aged 3-13 years (mean age 6.3 years) underwent laser tonsillotomy for obstructive tonsillar hypertrophy in this double blind, prospective, randomized, clinical feasibility trial. In each of the blinded patients, tonsillotomy was performed using fiber guided 1,470 nm diode laser (contact mode, 15 W power) on the one side and carbon dioxide laser (12 W power) on the other side. An independent, blinded physician documented clinical presentation and patients' symptoms preoperatively and on Days 1, 3, 7, 14, and 21 post-operatively using standardized questionnaire including VAS for each side separately. RESULTS: The mean duration of operative treatment was 2.7 min using 1,470 nm laser and 4.9 min using carbon dioxide laser respectively. Intraoperative bleeding and the frequency of bipolar forceps use for intraoperative bleeding control was significantly less using 1,470 nm diode laser system. There was no difference in post-operative pain scores between the carbon dioxide laser treated and the 1,470 nm fiber guided diode laser treated side. No infections, hemorrhages or other complications occurred in the course of the 3 weeks post-operative period. CONCLUSIONS: A fiber-guided 1,470 nm diode laser system offers an efficient and safe method for tonsillotomy as treatment of obstructive tonsillar hypertrophy. Compared to our standard practice (carbon dioxide laser), 1,470 nm laser application provides comparable tissue ablation effects with less intraoperative bleeding and shorter operation time.

Functional endoscopic surgery of paranasal fungus ball: clinical outcome, patient benefit and health-related quality of life.

Paranasal fungus ball can cause chronic rhinosinusitis. Removal via functional endoscopic sinus surgery is usually performed; however objective data on the overall benefit and patient satisfaction are very scarce. The study focuses on the clinical outcome and the quality of life following endoscopic surgery due to fungus ball sinusitis. Forty patients diagnosed with fungus ball sinusitis who underwent functional endoscopic surgery were included. Epidemiologic data, pre-, intra- and postoperative findings were recorded. Surgical success, the detailed benefit and the health-related quality of life were objectively assessed 1 year after the surgery based on a standardized questionnaire (modified SNOT 20) and the Glasgow Benefit Inventory. Health-related quality of life improved significantly in >90% of patients (p < 0.05). There were no serious complications or recurrences. As the treatment of choice functional endoscopic sinus surgery of paranasal fungus ball sinusitis is associated with exceptionally high patient satisfaction.

A double-blind, randomized, intra-individual controlled feasibility trial comparing the use of 1,470 and 940 nm diode laser for the treatment of hyperplastic inferior nasal turbinates.

INTRODUCTION: Various laser systems have been used for volume reduction of hyperplastic nasal turbinates. For endonasal application, fiber controlled diode lasers are preferred over conventional laser systems for reasons of cost and practicability. This study compares coagulative tissue effects using λ = 1,470 nm and λ = 940 nm lasers in treatment of hyperplastic inferior nasal turbinates in an intraindividual manner. METHODS: Twenty patients underwent laser coagulation for hyperplastic inferior nasal turbinates in this prospective, randomized, double-blind, clinical feasibility trial. In each case, one nasal cavity was treated using 1,470 nm laser (4-5 W power), the other one with 940 nm laser (12 W power), endoscopically controlled in noncontact mode. Clinical presentation and patients symptoms were documented preoperatively and on day 1, 3, 7, 14, and 21 postoperatively using rhinomanometry, standardized questionnaires including SNOT 20 GAV (German adapted version), and separate endoscopic examination, respectively. RESULTS: No infections, hemorrhages, or other complications occurred intra- or postoperatively. The mean operation time was significantly shorter using the 1,470 nm diode laser as compared to the 940 nm laser. There was a significant reduction of nasal obstruction on day 21 postoperatively compared to the preoperative condition on both sides regardless of the laser system used. Evaluation of the SNOT-Scores as assessed before and 3 weeks after surgery showed significant subjective improvements. CONCLUSIONS: 1,470 nm diode laser system offers an efficient method for tissue reduction in hyperplasia of inferior nasal turbinate. Compared with our standard practice (940 nm diode laser), 1,470 nm diode laser application provides an equivalent tissue reduction in shorter operation time using less total energy and a comparable relief of nasal obstruction postoperatively.

Surgical management of osteomas of the frontal recess and sinus: extending the limits of the endoscopic approach.

Osteomas are among the most common benign tumors of the paranasal sinuses. Symptomatic osteomas are most often found in the frontal recess and the frontal sinus. While the extranasal approach is still a part of the treatment concept for removing osteomas at this localization, over the last years the endoscopically controlled endonasal approach has greatly gained in importance due to the improved surgical equipment. We retrospectively analyzed the surgical indication, surgical approach and outcome of the removal of osteomas of the frontal recess and the frontal sinus performed at our hospital between 1996 and 2010. The exact surgical technique, intra- and postoperative complications, the duration of the hospital stay and the follow-up and subjective contentment of the patients were evaluated. With a total of 24 patients being included, the study comprises one of the largest groups of patients with osteomas of the frontal recess and sinus. Over the study period, the frequency of the endoscopic approach clearly increased. Previously suggested guidelines for the endoscopic resection of a frontal sinus osteoma turned out to be superseded. Endoscopically controlled resection even of large, adversely located osteomas of the frontal recess and the frontal sinus is becoming increasingly possible, but is still naturally limited by the individual anatomic conditions and the need for experienced surgeons.

Paranasal ossifying fibroma: endoscopic resection or wait and scan?

The ossifying fibroma is a fibro-osseous lesion that rarely occurs in the paranasal sinuses. Due to its tendency to behave locally aggressively, complete resection is generally recommended. A subdivision into the aggressive juvenile ossifying fibroma (JOF) and the less aggressive cemento-ossifying fibroma of the adult (COF) is clinically reasonable. The objective of the study was to retrospectively analyze the management and follow-up of the patients diagnosed with ossifying fibroma at our ENT-department from 2006 to 2010. A total of five patients were included, thereby comprising one of the largest case series of paranasal ossifying fibromas. In three patients an exclusively endoscopically controlled resection was performed. Two patients with asymptomatic COF declined surgery. Within the 2-year follow-up, no progression was detected. While the JOF should always be surgically treated, for the asymptomatic paranasal ossifying fibroma of the adult (COF) a wait-and-scan strategy, similar to that recommended for osteomas or fibrous dysplasia, could be an option in selected cases.

Control of bleeding following functional endoscopic sinus surgery using carboxy-methylated cellulose packing.

The aim of this study is to evaluate the haemostatic effect of carboxy-methylated cellulose (CMC) nasal packing following functional endoscopic sinus surgery (FESS). The design includes an investigator-initiated, randomized, single-blinded, controlled, prospective clinical study. A bilateral FESS procedure was performed on 41 patients. At the end of the operation, one side was randomly filled with CMC nasal packing, the other side remained without packing. The patients were blinded to the side of nasal packing and were postoperatively examined on the 1st day, after 2 and 4 weeks and the extent of the postoperative bleeding was quantified with a clinical grading system. Even though there were slightly more postoperative bleedings reported for the non-packed sides as compared to the CMC-packed sides, these differences were at no point statistically significant within the monitored postoperative period of 4 weeks. In the examined collective, the CMC packing investigated did not statistically prove to have an effect on bleeding control in this study design.

CMC packing in functional endoscopic sinus surgery: does it affect patient comfort?

BACKGROUND: Functional endoscopic sinus surgery (FESS) has become the treatment of choice for patients with medically resistant chronic rhinosinusitis (CRS and nasal polyposis). Nasal packing is usually placed after the surgery to minimize mucosal bleeding and support the wound healing process. Both the packing itself and its removal are often associated with pain and discomfort. OBJECTIVE: To evaluate the effect of carboxymethylcellulose (CMC) nasal packing on patient comfort following FESS. METHODS: Forty consecutive patients underwent bilateral FESS. One side of the nasal cavity was packed with CMC (mesh or gel) and the opposite side was not packed, the sides having been randomly selected. Postoperatively, patients were given visual analog scales to rate nasal airway obstruction and headache/pressure separately for the right and left sides. They also rated sleep disturbance and general well-being. RESULTS: No significant differences were found between the CMC-packed side and the unpacked side with regard to patient comfort. No significant differences were found between CMC mesh and CMC gel. CONCLUSION: Based on the presented data concerning patient comfort, CMC appears to be an ideal packing material following FESS. However, there is no other study revealing an identical study design focusing on other resorbable packing material. As a consequence, other available resorbable packing material should be investigated to find the ideal packing material following FESS, if packing is required.

Surface laser registration in ENT-surgery: accuracy in the paranasal sinuses--a cadaveric study.

Over the past decade, surgical navigation systems have found widespread use in ENT-surgery. Navigational accuracy highly depends on the registration process. The objective of this study was to assess the accuracy in the paranasal sinuses and lateral skull base after surface laser registration using the navigation system VectorVisionCompact (BrainLab, Heimstetten, Germany). Repeated measurements were performed on two cadaver heads. Sixteen titanium screw fiducials per head were placed in facial bones, the paranasal sinuses and the lateral skull base, thereby serving as exactly identifiable measurement points. The respective influence on measurement accuracy depending on the localization and conformation of the registration area was evaluated by performing symmetrically bilateral as well as strictly unilateral registrations. The resulting overall accuracy for a symmetrically bilateral surface laser registration was 1.13 +/- 0.53 mm, ranging from 0.77 (sinus frontalis) to 1.76 (petrous bone) mm, and thus proved to be clinically sufficient. Increasing distance between target point and registration area went along with a decline in accuracy. Navigational accuracy was significantly influenced by the choice of the registration area. Best accuracy was detected after symmetrically bilateral registration.

Treatment of essential palatal myoclonus in a 10-year-old girl with botulinum neurotoxin.

Palatal myoclonus (PM) is a rare neurotological disorder but is being reported with increasing frequency. Two forms, symptomatic and essential PM, have been identified as separate clinical entities and probably also have separate etiologies. In essential PM, brain imaging is unremarkable and a clicking noise caused by peritubal muscle contractions and often audible by the examiner usually is the patients' chief complaint. The treatment of essential PM with systemic application of anticonvulsants and related substances as well as by destructive surgical means has yielded unsatisfactory results. Recently, the use of botulinum neurotoxin has emerged as a new treatment option that seems particularly attractive due to its safety, complete reversibility, very few side effects, and minimal invasiveness. We report the case of essential PM in a 10-year-old girl who was successfully treated with botulinum toxin injections under eletromyographic guidance and we review the literature on the use of botulinum toxin in PM.