The EUFOREA pocket guide for chronic rhinosinusitis.

Chronic rhinosinusitis (CRS) is known to affect around 5 % of the total population, with major impact on the quality of life of those severely affected (1). Despite a substantial burden on individuals, society and health economies, CRS often remains underdiagnosed, under-estimated and under-treated (2). International guidelines like the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) (3) and the International Consensus statement on Allergy and Rhinology: Rhinosinusitis 2021 (ICAR) (4) offer physicians insight into the recommended treatment options for CRS, with an overview of effective strategies and guidance of diagnosis and care throughout the disease journey of CRS.

Rhinology Future Debates 2018, a EUFOREA Report.

The third Rhinology Future Debates was organized by the European Forum for Research and Education in Allergy and Airways diseases (EUFOREA) in 2018 in Brussels. Experts from different specialties and countries, alongside patients, health policy makers and industry representatives discussed relevant topics in Rhinology, in an attempt to improve current clinical practices, through implementation of precision medicine, by empowering patients' participation and the use of eHealth tools. The debates which are available on-line (www.rhinology-future.com) dealt with 5 topics in Rhinology: the adoption of allergen-specific immunotherapy (AIT) by implementing change management strategies, the needs and obstacles in care delivery in respiratory diseases, 3D technology in nose and sinus surgery, ambulatory nasal surgery, and clinical evidence for efficacy of biologicals in CRSwNP and asthma. This report summarizes the outcomes of the brainstorming sessions highlighting novel approaches and unmet needs in the field of respiratory diseases by focusing on integrated care pathways.

CHronic Rhinosinusitis Outcome MEasures (CHROME), developing a core outcome set for trials of interventions in chronic rhinosinusitis.

STATEMENT OF PROBLEM: Evaluating the effectiveness of treatments in chronic rhinosinusitis (CRS) have been limited by both a paucity of high quality randomised trials, and the heterogeneity of outcomes in those that have been reported. Core outcome sets (COS) are an agreed, standardized set of outcomes that should be measured and reported by future trials as a minimum and will facilitate future meta-analysis of trial results in systematic reviews (SRs). We set out to develop a core outcome set for interventions for adults with CRS. METHOD(S) OF STUDY: A long-list of potential outcomes was identified by a steering group utilising a literature review, thematic analysis of a wide range of stakeholders' views and systematic analysis of currently available Patient Reported Outcome Measures (PROMs). A subsequent e-Delphi process allowed 110 patients and healthcare practitioners to individually rate the outcomes in terms of importance, on a Likert scale. MAIN RESULTS: After 2 rounds of the iterative Delphi process, the 54 initial outcomes were distilled down to a final core-outcome set of 15 items, over 4 domains. PRINCIPAL CONCLUSIONS: The authors hope inclusion of these core outcomes in future trials will increase the value of research on interventions for CRS in adults. It was felt important to make recommendations regarding how these outcomes should be measured, although additional work is now required to further develop and revalidate existing outcome measures.

mySinusitisCoach: patient empowerment in chronic rhinosinusitis using mobile technology.

Mobile health technology is emerging to take a prominent position in the management of chronic diseases. These technologies aim at enhancing patient empowerment via education and self-management. To date, of all the different apps available for patients with sinus disease, none were developed by medical experts dealing with chronic rhinosinusitis (CRS). The European Forum for Research and Education in Allergy and Airway diseases (EUFOREA) has undertaken a multi-stakeholder approach for designing, developing and implementing a tool to support CRS patients in monitoring their symptoms and to provide patients with a digital support platform containing reliable medical information about their disease and treatment options. mySinusitisCoach has been developed by medical experts dealing with CRS in close collaboration with patients, primary care physicians and community pharmacists, meeting the needs of both patients and health care providers. From a research perspective, the generation of real life data will help to validate clinical studies, patient stratification and improve understanding of the socio-economic impact of CRS, thereby paving the way for better treatment strategies.

Rhinology Future Debates, an EUFOREA Report.

The first Rhinology Future Debates was held in Brussels in December 2016, organized by EUFOREA (European Forum for Research and Education in Allergy and Airways diseases). The purpose of these debates is to bring novel developments in the field of Rhinology to the attention of the medical, paramedical and patient community, in a highly credible and balanced context. For the first time in Rhinology, a peer to peer scientific exchange with key experts in the field of rhinology and key medical colleagues from leading industries let to a brainstorming and discussion event on a number of hot issues in Rhinology. Novel developments are presented by key experts from industry and/or key thought leaders in Rhinology, and then followed by a lively debate on the potential positioning of new developments in care pathways, the strengths and weaknesses of the novel development(s), and comparisons with existing and/or competing products, devices, and/or molecules. As all debates are recorded and distributed on-line with limited editing (www.rhinology-future.com), EUFOREA aims at maximizing the education of the target groups on novel developments, allowing a critical appraisal of the future and a more rapid implementation of promising novel tools, techniques and/or molecules in clinical practise in Europe. The next Rhinology Future debate will be held in Brussels in December 2017.

Surgical management of recurrent sinonasal mucosal melanoma: endoscopic or transfacial resection.

Sinonasal mucosal melanoma (SNMM) is associated with poor prognosis. Local recurrence is common and represents a major problem in the therapy. Wide resection surgery is usually applied. However, given the almost futile prognosis, optimal symptom control may be preferable to wide resection at all costs. The aim of our study was to analyze the outcome in patients with recurrent SNMM treated by transfacial radical surgery or by a less invasive endoscopically controlled approach. Patients with recurrent grade III or IV staged SNMM who presented to our ENT department between 2000 and 2010 were either treated by transfacial (n = 10) or endoscopically controlled surgery (n = 12). The patients' charts were reviewed for clinical symptoms, relapse-free time and survival time. Clinical symptoms improved after surgery. The morbidity after endoscopic surgery was significantly lower than after transfacial surgery. The chosen surgical technique did neither affect relapse-free nor survival time. When treating recurrent SNMM, the comparatively gentle and less mutilating endoscopic approach proved to be a sufficient surgical procedure, being not inferior to aggressive surgery with respect to recurrence and survival rate.

Mental distress and effort to engage an image-guided navigation system in the surgical training of endoscopic sinus surgery: a prospective, randomised clinical trial.

The use of image-guided navigation systems in the training of FESS is discussed controversy. Many experienced sinus surgeons report a better spatial orientation and an improved situational awareness intraoperatively. But many fear that the navigation system could be a disadvantage in the surgical training because of a higher mental demand and a possible loss of surgical skills. This clinical field study investigates mental and physical demands during transnasal surgery with and without the aid of a navigation system at an early stage in FESS training. Thirty-two endonasal sinus surgeries done by eight different trainee surgeons were included. After randomization, one side of each patient was operated by use of a navigation system, the other side without. During the whole surgery, the surgeons were connected to a biofeedback device measuring the heart rate, the heart rate variability, the respiratory frequency and the masticator EMG. Stress situations could be identified by an increase of the heart rate frequency and a decrease of the heart rate variability. The mental workload during a FESS procedure is high compared to the baseline before and after surgery. The mental workload level when using the navigation did not significantly differ from the side without using the navigation. Residents with more than 30 FESS procedures already done, showed a slightly decreased mental workload when using the navigation. An additional workload shift toward the navigation system could not be observed in any surgeon. Remarkable other stressors could be identified during this study: the behavior of the supervisor or the use of the 45° endoscope, other colleagues or students entering the theatre, poor vision due to bleeding and the preoperative waiting when measuring the baseline. The mental load of young surgeons in FESS surgery is tremendous. The application of a navigation system did not cause a higher mental workload or distress. The device showed a positive effort to engage for the trainees with more than 30 FESS procedures done. In this subgroup it even leads to decreased mental workload.

Patient comfort following FESS and Nasopore® packing, a double blind, prospective, randomized trial.

BACKGROUND: The use of nasal packing after functional endoscopic sinus surgery (FESS) is often associated with pain and a feeling of pressure for patients. The aim of the present work was to investigate a modern wound dressing made of polyurethane (Nasopore®) that makes removal of the nasal packing unnecessary and is focussed on patient comfort. METHODOLOGY: Following bilateral FESS, after randomisation, one side was packed with Nasopore® while the other side was without packing as a control. The following parameters from 47 patients were determined daily in two centres from post-operative day 1 for the duration of the inpatient stay in a double-blinded setting: side-specific post-operative bleeding, nasal breathing and feeling of pressure as well as the general parameters sleep disturbance, headaches and general well-being. Which side patients considered subjectively the better was also recorded. RESULTS: No significant differences were determined between the two sides in terms of the rates of post-operative bleeding and nasal breathing. The feeling of pressure was slightly less on the side packed with Nasopore® on post-operative days 2 and 3. No trend could be observed regarding which side patients described as being subjectively better. CONCLUSION: There were only slight differences in patient comfort between the Nasopore® side and the control. Because the feeling of pressure in the midface was significantly less and there were no complications, this suggests there is greater patient comfort when using Nasopore® compared to using no nasal packing.

Complications in endonasal sinus surgery: a 5-year retrospective study of 2,596 patients.

Recent developments should have aided to reduce postoperative complications of endoscopic sinonasal surgery: Computerised tomography (CT) and magnetic resonance imaging (MRI) allow a more precise preoperative view of the anatomic situation and possible variations. The Lund-MacKay-Index provides a tool to assess the extent of the disease, and by introducing microscopic-endonasal and computer-assisted sinunasal surgery (CAS) as well as providing the corresponding training technical progress has been made. We analysed the data of 2,596 patients with acute or chronic rhinosinusitis who underwent surgery between 2000 and 2005 using the procedure of Stammberger. We saw 3.1 % minor complications (minor bleedings, perforation of the lamina papyracea), 0.9 % major complications (severe bleedings, cerebrospinal fluid (CSF) leaks, lesion of the ductus lacrimalis), and one (0.04 %) serious complication (meningitis). When we compared these figures with those of reports from the late 90 s by correlating opacification, type of operation, the surgeon's experience and employing CAS with the outcome we did not find a distinct improvement in the rate of postoperative complications. Serious complications and those resulting in permanent harm such as carotid artery injury, cerebral deficit or death have, however, become very rare. A grading into I (minor), II (major) and III (serious) complications is proposed, to point out this critical grade-III proportion, which should not exceed 0.1 %.

Endoscopic sinus surgery training courses: benefit and problems - a multicentre evaluation to systematically improve surgical training.

BACKGROUND: The aim of this multicentre study was to systematically analyse the strengths and weaknesses in the surgical training for endoscopic sinus surgery (ESS) and identify measures that may improve training. METHODOLOGY: Using a structured questionnaire, 133 participants of ESS courses in seven centres in Germany, Switzerland and Australia were asked about their experiences during their dissection courses and how they perceived their course could be improved. RESULTS: Gaining confidence in handling of instruments and endoscopes was only a problem for participants with little experience in ESS. The majority of the participants, independent from their level of training, considered infundibulotomy and anterior ethmoidectomy as the easiest dissection steps, whilst surgery of the frontal sinus posed a considerable challenge for many surgeons even those with a higher level of training. Participants with and without ESS experience thought that emphasis on anatomy was the most important improvement that could be made during their surgical training. Virtually all participants stated that the course improved their anatomical knowledge, their surgical skills and their confidence when performing ESS. CONCLUSIONS: ESS dissection courses are considered beneficial by surgical trainees. Participants felt that more emphasis on sinus anatomy in conjunction with private study is essential to maximize their skills in surgical dissection. For beginners with ESS, an infundibulotomy and anterior ethmoidectomy were thought to be the best initial procedures to help develop endoscopic surgical skills.

Limitations of balloon sinuplasty in frontal sinus surgery.

Balloon sinuplasty is a tool that is used to treat selected patients with paranasal sinus pathologies. No studies have investigated the aetiology of failed access to the frontal sinus. The aim of our study was to specify the intraoperative technical failure rate and to analyse the aetiology of the failed access to predict potential technical difficulties before surgery. We retrospectively analysed the charts of patients who underwent balloon sinuplasty from November 2007 to July 2010 at three different ENT-Centres. CT-analysis of the patients with failed access was performed. Of the 104 frontal sinuses, dilation of 12 (12%) sinuses failed. The anatomy of all failed cases revealed variations in the frontal recess (frontoethmoidal-cell, frontal-bulla-cell or agger-nasi-cell) or osteoneogenesis. In one patient, a lymphoma was overlooked during a balloon only procedure. The lymphoma was diagnosed 6 months later with a biopsy during functional endoscopic sinus surgery. In complex anatomical situations of the frontal recess, balloon sinuplasty may be challenging or impossible. In these situations, it is essential to have knowledge of classical functional endoscopic sinus surgery of the frontal recess area. The drawbacks of not including a histopathologic exam should be considered in balloon only procedures.

Evaluation of an image-guided navigation system in the training of functional endoscopic sinus surgeons. A prospective, randomised clinical study.

INTRODUCTION: Many sinus surgeons report improved spatial orientation after using a navigation system. This study investigates the surgical, ergonomic and economic aspects of using a navigation system in training and teaching. MATERIALS AND METHODS: Eight rhino-surgeons in training and 32 patients with bilateral diseases of the paranasal sinus system were included. After randomisation, one patient`s side was operated on with a navigation system while the other side was operated on without navigation. It was monitored how often the surgeon used the navigation pointer and then changed the procedures. A standardised and validated interview recorded the cognitive load when using the navigation system and the application efficiency. RESULTS: The operations lasted on average 16 minutes longer with the navigation. Five paranasal sinuses could not be found in the control group without navigation. In only 10-13% of cases did the surgical procedure change after the use of the pointer. Most of the surgeons admitted that particular steps of the operation were more reliable and safer to carry out with the navigation system. The general trust in the system rose in proportion to intraoperative accuracy and repeated use. CONCLUSION: Overall, there was an overwhelming level of trust in the navigation system. Trainee sinus surgeons seeing their more experienced colleagues using a navigation device tend to overestimate the possibilities of the system and to underestimate the risks. The assistance system was used particularly effectively in the group of slightly more experienced surgeons. In this group, the additional expenditure of time was less and the navigation substantially contributed to reinforcing the anatomical sense of direction.

[Cystic lesion with a displaced tooth in the maxillary sinus]. / Zystischer Kieferhöhlenprozess mit verlagertem Zahn.

Ameloblastomas are epithelial odontogenic tumors in the mandibula or maxilla with potential local infiltrating growth; therefore, relapses can occur after incomplete resection. Among the different histological subtypes, the following are of clinical importance: The so-called unicystic ameloblastoma, radiologically presenting as a common dentigerous cyst, and the so-called extraosseous ameloblastoma. This case report describes the rare combination of a unicystic ameloblastoma with extraosseous localization in the maxillary sinus and association with a displaced tooth. This unusual constellation can cause major diagnostic problems.

[FESS and surgical training: what are the problems?]. / FESS und Ausbildung: Wo liegen die Probleme?

BACKGROUND: The literature lacks studies analyzing the specific problems of colleagues in the surgical training for FESS. The presented date can help to systematically improve the training. METHODS: The participants of the 11 (th) Munich FESS Course were asked about problems occurring during dissection and about their opinion how the training could be improved. RESULTS: Handling of instruments and endocopes was only a problem for participants without any experience in FESS. The majority of the participants, independently from their training level, considered infundibulotomy and anterior ethmoidectomy the easiest dissection steps. Participants with and without FESS experience regarded a more extensive study of anatomy in the forefront as the most important toehold in the improvement of the surgical training. Virtually all participants stated that the course improved their anatomical knowledge, their confidence on the patient, and their surgical skills. CONCLUSIONS: FESS dissection courses are well accepted and considered as beneficial by surgical trainees. An exhaustive private study of anatomy is essential. For beginners with FESS, infundibulotomies and anterior ethmoidectomies should preferentially be chosen.

[Symptoms and treatment of choanal atresia--stenting remains controversial]. / Symptome und Therapie der Choanalatresie--Stents weiterhin umstritten.

Congenital choanal atresia is a rare malformation of the upper airways occurring sole or within the scope of syndromes. The controversy regarding standardized surgical approach and optimal technique preventing re-stenosis as well as the proceeding in case of a unilateral malformation persists. To address these issues, a retrospective analysis of patients presenting with choanal atresia in our department within the last 10 years was performed. 15 infants aged 3 days to 13 years (mean 42 months) who presented with unilateral (10 cases) and bilateral (5 cases) choanal atresia underwent surgical repair. 4 patients failed previous surgeries. All interventions were performed in transnasal endoscopic technique. 7 patients were intraoperatively stented for 6 weeks, 4 patients for 1 week. In 73% (11 out of 15 children) further congenital anomalies were identified. In 7 cases a re-stenosis requiring treatment occurred, predominantly in long-term stented patients. No intra- or postoperative hemorrhages or infections occurred. To provide an adequate work-up of affected patient including a screening for further congenital anomalies, a multidisciplinary approach is required. Endonasal endoscopic approach represents a safe technique for surgical repair of choanal atresia. The indication for surgical repair in case of a unilateral atresia is based on the severity of clinical symptoms. The use of stents, especially of long term, remains controversial and needs further evaluation.

Management of orbital complications due to rhinosinusitis.

Emergencies in sinusitis are in 60-75% orbital complications defined by blepharedema (stage I), periostitis (stage II), subperiostal abscesses (SPA) (stage III) and orbital cellulites (stage IV). Ophthalmic complications such as diplopia, exophthalmia and reduced visual acuity are seen in stages III and IV. There is a consensus for primary conservative treatment in stage I or II and until recently for surgery in stages III and IV. The discussion concerns the decision for surgery versus conservative therapy in stage III in children. Another question is the definitive outcome of ophthalmic symptoms. The charts of 127 patients with orbital complications of sinusitis from 1995 until 2003 were analyzed. A follow-up questionnaire was sent to all asking for general quality of life, ophthalmic symptoms, and symptoms of sinusitis, further surgery or other treatments. The ratio of male to female was 2.3:1; 32 of the patients (25.2%) were ≤ 16 years and 37% had chronic rhinosinusitis. Of the adult patients, 37.9% had blepharedema, 45.3% periostitis, 4.2% SPA and 12.6% orbital cellulitis (children: 31.3, 40.6, 12.5 and 15.6%). Children with orbital cellulites were significantly (P < 0.01) older than those with SPA. Motility disorders, e.g., diplopia, were seen in 11%, exophthalmia in 12% and reduced visual acuity in 5.5%. As much as 51.2% were treated conservatively. Intervention was endoscopic sinus surgery in 81% and a combined intervention in 19%. After a mean of 40.5 months, 6 of 55 patients who had returned the questionnaire still had ophthalmic symptoms. Treatment of stages I and II are conservative, but if it fails surgery is required within 24-28 h. There is a trend for a more conservative therapy in children with stage III. However, we plead for a flexible approach to therapy in stage III and for primary surgery in patients with recurrent chronic sinusitis.

Surgical anatomy of the frontal recess--is there a benefit in multiplanar CT-reconstruction?

Anatomical variations in the sinus region are not necessarily pathological, but they may complicate the anatomy of the lateral nasal wall and contribute to the occurrence or persistence of chronic inflammatory diseases. In this study the interpretations of initial coronal CT scans were significantly altered following multiplanar CT-reconstruction. Assuming that a multiplanar analysis includes coronal views, we may conclude that imaging in three planes yields more information and provides a substantial benefit in the planning and performance of a surgical procedure on the paranasal sinuses.

Frontal sinus obliteration--a successful treatment option in patients with endoscopically inaccessible frontal mucoceles.

OBJECTIVE: This study evaluates non-standardized subjective patient satisfaction- and clinical outcome variables following frontal sinus obliteration with abdominal fat in endoscopically inaccessible mucoceles. METHODS: In a retrospective chart review, all patients who underwent frontal sinus obliteration for endoscopically inaccessible mucoceles at the Ludwig Maximilian University in Munich between 1996 and 2006 were identified and the postoperative outcomes were evaluated by a non-standardized patient questionnaire rating the degree of symptoms before and after surgery. Additionally, the postoperative clinical status and MRI-scans were analysed in a subgroup of patients. RESULTS: Nine out of 10 patients were generally satisfied with the obliteration. Most had a significant improvement in their main symptoms and reported a decrease in annual days of missed work and a reduced use of disease-specific drugs. The sense of smell and the intensity of postnasal dripping remained subjectively unchanged. Seventy percent of patients complained about temporary pain at the abdominal donor side. CONCLUSIONS: Based on these results, osteoplastic frontal sinus obliteration using abdominal fat seems to be a successful treatment option in patients in whom mucoceles of the frontal sinus are not endoscopically accessible.

[Laryngeal papillomatosis: etiology, diagnostics and therapy]. / Larynxpapillomatose : Atiologie, Diagnostik und Therapie.

Papillomas are rare tumors that originate from the mucosa. They may appear in the nose, paranasal sinuses, oral cavity, larynx, trachea, or the skin. Papillomas are mainly asymptomatic and are therefore mostly diagnosed coincidentally. In contrast, laryngeal papillomatosis may cause stridor, dyspnoea, and hoarseness. A viral cause of the disease seems likely, especially human papilloma virus. Mechanical irritation is also a possible reason when the nose, oral cavity, or oropharynx is affected. All papillomas, independent of their origin, may recur, and have the possibility of malignant degeneration in common. The therapy of choice is complete surgical excision. Regarding laryngeal papillomatosis, laser vaporisation or excision using the CO(2)laser is recommended. Because retreatments using conventional modalities are frequently necessary, especially in the case of laryngeal papillomatosis, adjuvant therapies are applied with the aim of reducing the recurrence rate and prolonging the interval between treatments.