Extent of Endoscopic Sinus Surgery in Chronic Rhinosinusitis: A Systematic Review and Meta-Analysis.

PURPOSE OF REVIEW: There is an incomplete understanding regarding the extent of endoscopic sinus surgery (ESS) in managing chronic rhinosinusitis (CRS) and its effect on outcomes. This study aimed to assess and compare limited sinus surgery, full-house, extended and radical ESS for optimizing CRS outcomes. RECENT FINDINGS: An online search in adherence with PRISMA guidelines was performed. Data were pooled for meta-analysis. Forty-six articles met inclusion criteria. Full-house ESS yielded greater improvements in SNOT-22 and endoscopy scores over limited ESS. Radical ESS improved nasal symptoms and reduced disease recurrence more than full house ESS, while extended ESS decreased revision ESS rates when compared to full-house ESS. Total ethmoidectomy reduced SNOT-22 scores more than limited ethmoidectomy. There was no difference in perioperative complications for all extents of ESS. When compared to limited ESS, full-house ESS yielded better patient symptom outcomes. Radical ESS demonstrated even greater reductions in nasal symptoms, while extended ESS additionally decreased revision surgery rates. Thus, in general, greater extent of ESS leads to better outcomes, while all extents of ESS are relatively safe.

Systematic Review of Long Term Sinonasal Outcomes in CRSwNP after Endoscopic Sinus Surgery: A call for Unified and Standardized Criteria and Terms.

PURPOSE OF REVIEW: To present current evidence in long-term (> 5 years) results after endoscopic sinus surgery (ESS) focusing on Patients Reported Outcome Measures (PROMs) and other sinonasal outcomes while assessing the role of ESS in the treatment of CRSwNP, and identifying outcomes which affect the results of ESS and defining recommendations for future studies. RECENT FINDINGS: Long-term results of ESS in CRSwNP can be branched in PROMs and other objective measurements. Despite the heterogeneity of reported outcomes make it difficult to perform comparisons and meta-analysis, ESS improves PROMs, including symptoms, QOL and olfaction. Objectives outcomes such as NPS, LMS, type of surgery, or recurrence and revision surgery don't have a clear role in long-term results. Clustering patients suggest asthma, N-ERD, allergy, eosinophil count and IL-5 could have a role in predicting recurrence and severe disease. Long-term studies of CRSwNP treated with ESS are scarce. There is a significant need to standardize the report of results. The use of tools as SNOT-22, NPS, validated smell tests, defined criteria for disease recurrence and control and ESS extension in a unified systematic way could allow better comparisons between treatments in the new era of biologics.

Anteriorly Tilted Coronal CT of Paranasal Sinuses for Endoscopic Sinus Surgery.

Conventional coronal CT scans of paranasal sinuses, aligned perpendicularly to the nasal floor, often deviate significantly from the endoscopic view during sinus surgery. This discrepancy complicates the interpretation of anatomical structures. In response, we propose the utilization of anteriorly tilted coronal CT slices to enhance anatomical understanding. These slices align more closely with the endoscopic view, fostering an intuitive grasp of paranasal sinus anatomy. This study aims to quantify the tilt of the endoscope to the nasal floor during endoscopic sinus surgery. To figure out the tilt of the endoscopically true coronal slices, we calculated the tilt of the endoscope to the nasal floor in the operative setting by taking pictures of the operation and measuring the image and sagittal CT. Fourteen patients (25 sides of paranasal sinuses) were analyzed. Endoscope tilts to the nasal floor were measured at different anatomical landmarks: 16.2 ± 9.7 degrees (lower edge of ground lamella), 29.8 ± 7.9 degrees (central ground lamella), 62.3 ± 10.1 degrees (most superior part), and 25.6 ± 7.0 degrees (optic canal). In conclusion, we showed the actual tilt of the endoscope to the nasal floor during endoscopic sinus surgery. A 30-degree anteriorly tilted coronal scan for frontal recess and sphenoid sinus is more intuitive than a traditional coronal scan, which helps surgeons understand the complex sinus anatomy.

Endoscopic resection of primary sinonasal mucosal melanoma with orbital invasion: How I do it.

Primary sinonasal mucosal melanoma is a rare aggressive malignancy. In this video, a case of a 68-year-old female who presented with diplopia for 2 weeks is described. The present video reports the endoscopic endonasal surgical excision of a primary sinonasal mucosal melanoma. The video contains patient's medical history, preoperative radiological evaluations and step-by-step description of surgical steps of the procedure with the utilization of computer-assisted navigation system.

Centripetal endoscopic sinus surgery in rhinogenic headache.

OBJECTIVES: The aim of this manuscript is to analyse a diagnostic protocol to select correctly patients with Rhinogenic Headache Contact Point (RH) and to investigate the effect of surgical treatment and medical therapy in pain relief. METHODS: A prospective no-randomized study selected adult patients with headache and nasal alteration at CT exam or endoscopic vision with positive response to test with nasal spray with corticosteroids and antihistamine or/and local anesthesia test to the contact points. MIDAS score, intensity score, daily duration of symptoms, frequency of headache in the last month were collected in patients who performed surgery and in patients who performed medical therapy. RESULTS: Following the inclusion, 415 patients were selected for this study. 302 patients performed nasal surgery (septoplasty, turbinoplasty and/or endoscopic surgery with centripetal technique), 113 performed medical therapy. There was a statistically significant improvement in MIDAS score, intensity score, daily duration of symptoms, frequency of headache in the last month in patients who performed surgery and in patients who performed medical therapy. Regarding the comparison between patients who performed surgery (Group A) and patients who performed only medical therapy for RH (Group B), better outcomes were obtained by Group A. Considering the daily life handicap index, the lowest handicap was obtained in Group A. CONCLUSION: This study demonstrates that surgery, using in some cases centripetal technique, gives an improvement statistically significant than medical therapy in RH. The use of nasal spray with corticosteroids and with anti-histamine is a good method in the diagnosis of RH, especially in patients with anatomical variants such as concha bullosa, agger nasi cells and Haller cells.

Orbital preservation in the treatment of acute invasive fungal sinusitis.

Acute invasive fungal sinusitis (AIFS) is an aggressive disease with significant mortality and morbidity. Surgical debridement is a mainstay of treatment. However, orbital involvement may limit its efficacy and is an independent risk factor for mortality. Traditionally, orbital exenteration has been utilized in cases with orbital invasion and ophthalmoplegia or vision loss. Retrobulbar liposomal amphotericin B injection may improve disease control and has the potential to spare the morbidity associated with exenteration. In this video article, we document the use of serial endonasal debridement with retrobulbar injections to salvage the eye in a patient with significant orbital involvement. A 28-year-old immunocompromised female patient presented with acute onset restricted right extraocular movement, progressive orbital pain, V2 trigeminal numbness, and 20/40 vision. The patient underwent recurrent debridement and retrobulbar injections of liposomal amphotericin B. Her serial exams, including changes in extraocular muscle appearance and gradual improvement in extraocular movement, were documented. The exam six months after initial presentation demonstrated 20/20 vision, minimal extraocular movement restriction, and proper healing of the orbit and ethmoid. The salvage of the patient's orbit suggests that liposomal amphotericin B injections with debridement may be a viable treatment alternative in patients with acute invasive fungal sinusitis and orbital involvement.

Chronic invasive fungal rhinosinusitis and granulomatous invasive fungal sinusitis: A systematic review of symptomatology and outcomes.

INTRODUCTION: Chronic invasive fungal rhinosinusitis (CIFRS) and granulomatous invasive fungal sinusitis are two uncommon diseases differentiated primarily by the pathologic finding of non-caseating granulomas in GIFRS. Both share many similarities in presentation. We aim to characterize the symptomatology and outcomes of these diseases. METHODS: A comprehensive search strategy was designed to identify studies in the Cochrane, EMBASE and PubMed databases from database inception to January 2022. Inclusion criteria included all patients with a diagnosis of either CIFRS or GIFRS. All studies were screened by two reviewers. Chi-square analyses were used where appropriate. RESULTS: 51 studies were included totaling 513 patients. The majority were diagnosed with CIFRS (389, 75.8 %) compared to GIFRS (124, 24.4 %). CIFRS was more common in immunocompromised or diabetic patients (p < 0.0001; p = 0.02). Patients with CIFRS were more likely to exhibit nasal symptoms including discharge (p = 0.0001), obstruction (p = 0.03) and congestion (p = 0.001) as well as systemic symptoms including fever, which no GIFRS patient exhibited, facial pain (p = 0.007), headache (p = 0.004). Aspergillus was the most common organism identified in both groups with a slight predominance among GIFRS patients (p = 0.01). GIFRS patients were also more likely to present with no identifiable organisms (p = 0.0006). CIFRS patients were more likely to die of disease (p = 0.0008). CONCLUSIONS: CIFRS generally presents with more symptoms and is associated with poorer outcomes primarily occurring in an immunocompromised population. GIFRS likely follows a more insidious course in immunocompetent patients. Understanding the key differences in symptomatology and outcomes for these two populations is critical for appropriate diagnosis and prognostication.

Indocyanine green fluorescence visualizes landmark arteries for endoscopic sinus and skull base surgery.

OBJECTIVE: Landmark arteries during endoscopic sinus surgery are currently identified on the basis of anatomy, CT imaging and navigation, and Doppler flowmetry. However, the advantage of intraoperative fluorescence imaging during endoscopic sinus surgery has not been demonstrated. This study aimed to investigate whether Indocyanine Green (ICG) is useful for visualizing landmark arteries during endoscopic sinus and skull base surgery. METHODS: Eight patients who underwent endoscopic sinus and pituitary surgeries and consented to study participation were included. After planned procedures were performed as usual, landmark arteries were examined by ICG endoscope. Recorded video and preoperative CT images were analyzed for identification of five landmark arteries: anterior ethmoidal artery (AEA), posterior ethmoidal artery (PEA), internal carotid artery (ICA), sphenopalatine artery (SPA), and postnasal artery (PNA). Identification of arteries was evaluated three grades: identifiable, locatable, unrecognizable. RESULTS: Eight patients and eleven sides were evaluated. The ICG dose was 2.5 mg/body and a single shot was sufficient for evaluation. 100 % of AEA was identified (9/9 sides), 86 % of PNA (6/7 sides), 56 % of ICA (5/9 sides), and 25 % of PEA and SPA (2/8 sides). CONCLUSION: ICG could visualize landmark arteries, even thin arteries like AEA, during endoscopic sinus and skull base surgeries. Visualization was affected by thickness of bone or soft tissue above arteries, blood clots, sensitivity setting, and angle and distance of near-infrared light irradiation. ICG visualization of landmark arteries may help avoid vascular injuries during endoscopic sinus and skull base surgeries, particularly of AEA, PNA and ICA.

Multidisciplinary approach to severe intracranial, intraorbital allergic fungal sinusitis.

BACKGROUND: Allergic fungal sinusitis (AFS) is a form of paranasal mycosis that often involves bone destruction and can extend into the orbit and anterior skull base. Intracranial and intraorbital involvement are published but not both in each included patient of a series. The purpose of the present study was to review cases of extensive AFS with orbital or/and skull base erosion, including the presenting symptoms, patient socioeconomic background, imaging features, surgical technique, and post-operative outcomes. METHODS: The records of 30 patients with the histological diagnosis of AFS and both intracranial and intraorbital involvement were reviewed. RESULTS: The average age of the patients was 25.2 years. 83 % of patients were male. 70 % were African American. 66 % of patients had Medicaid or were uninsured. Presenting symptoms were headaches (80 %), nasal obstruction (33 %), proptosis (40 %), vision change (23 %), facial pressure (10 %), and decreased sense of smell (7 %). 100 % of patients had bone erosion observed on computerized tomography scans with disease extending intracranially through the anterior skull base or posterior wall of the frontal sinus along with disease that eroded through the lamina papyracea. All patients had failed medical management. All patients underwent surgery by Otolaryngology, Ophthalmology, and Neurosurgery with transnasal endoscopic approaches and orbitotomy. 80 % also underwent a bifrontal craniotomy for removal of intracranial extradural disease with cranialization. 53 % of patients had orbital implants remaining after surgery; 23 % had nasal stents. There were no postoperative cerebrospinal fluid leaks. Average hospital stay was 4.8 days. Preoperatively, 13 % of patients underwent allergy testing. 94 % saw an Allergist postoperatively. 21 % required follow up surgery. CONCLUSIONS: A team approach of Otolaryngologists, Ophthalmologists, and Neurosurgeons is recommended for this slowly growing but locally destructive disease. Most patients with AFS will present with headaches and nasal obstruction. While most cases of AFS can be successfully managed with transnasal endoscopic techniques, orbitotomy and craniotomy represents an effective treatment for severe AFS cases with extensive intracranial and intraorbital involvement. This disease is found most commonly in young African American males and in the underinsured.

Biologics versus endoscopic sinus surgery: Acute rhinosinusitis episodes and antibiotic use in chronic rhinosinusitis.

BACKGROUND: We sought to determine if chronic rhinosinusitis patients treated with endoscopic sinus surgery have fewer episodes of acute rhinosinusitis (ARS) post treatment compared to CRS patients treated with biologics alone. METHODS: We analyzed the electronic medical records of 213 adults with CRS who initiated treatment with either dupilumab or mepolizumab in calendar years 2016-2021 (CRS-biologics) group and a matched group with tissue eosinophilia who had undergone endoscopic sinus surgery (CRS-ESS) group. For each cohort, the medical record was reviewed to determine the number of ARS episodes for 12 months before and after treatment. Similarly, the number of antibiotic prescriptions was determined for each cohort in the 12 months after initiation of biologic therapy or ESS. RESULTS: There was no statistically significant difference in ARS episodes before initiation of between the CRS-biologic and CRS-ESS cohorts (0.38 versus 0.44 episodes per year, respectively; p = 0.323). In contrast, after initiation of therapy, the CRS-biologics group had a significantly reduced frequency of acute rhinosinusitis episodes versus the CRS-ESS group (0.11 versus 0.25 episodes per year; p = 0.001). Finally, the utilization of oral antibiotics in the 12 months after among those treated with biologics versus those treated with ESS was not significantly different (0.04 versus 0.08, respectively; p = 0.109). CONCLUSION: For CRS patients, treatment with dupilumab or mepolizumab significantly reduced the number of ARS episodes compared to CRS treated with ESS. Biologics appear to work as well as ESS in the control of ARS episodes after treatment for CRS.

Preoperative laboratory measurements as a predictor for nasal steroid irrigations after sinus surgery for chronic rhinosinusitis with nasal polyps.

PURPOSE: To assess whether preoperative C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), immunoglobulin E (IgE), and blood eosinophil percentage (EOS) can predict need for steroid irrigations after FESS. MATERIALS AND METHODS: Adult patients at BIDMC from inception until September 8, 2023 with chronic rhinosinusitis with nasal polyps who underwent FESS and had preoperative CRP (n = 129), ESR (n = 79), IgE (n = 107), or EOS (n = 125) were included. Labs were divided into normal (CRP: 0-5.0 mg/L; ESR: 0-15 mm/h; IgE: 150-300Ul/mL; EOS: 1-7 %) and high groups (CRP: >5.0 mg/L; ESR: >15 mm/h; IgE: >300Ul/mL; EOS: >7 %). The primary outcome was need for intranasal steroid irrigations after FESS (≤4 weeks, 4-12 weeks, 12-26 weeks, 26-52 weeks, 1-3 years, 3-5 years, and > 5 years). Receiver operating characteristic curves were created to determine thresholds for predicting postoperative steroid irrigations. RESULTS: Elevated IgE required intranasal steroid irrigation at 1-3 years (normal 34 %, high 62 %, p = 0.02), 3-5 years (normal 24 %, high 48 %, p = 0.04), and > 5 years (normal 19 %, high 43 %, p = 0.02). Elevated EOS required intranasal steroid irrigation at 26-52 weeks (normal 7 %, high 25 %, p = 0.009) and > 5 years (normal 19 %, high 46 %, p = 0.005). The area under the curve for IgE at 1-3 years was 0.696 (95 % CI: 0.597-0.795) with cutoff at 144-148 Ul/mL. CRP and ESR were not predictive of postoperative intranasal steroid treatment. CONCLUSIONS: Elevated IgE and EOS (but not CRP or ESR) may predict need for intranasal steroid treatment after FESS.

Pediatric chronic rhinosinusitis.

PURPOSE: An up-to-date overview of diagnosis, differential diagnosis, comorbidities, and current medical and surgical management of pediatric chronic rhinosinusitis (PCRS). METHODS: Review of current evidence-based literature on PCRS. RESULTS: Diagnosis of PCRS seems to be improving based on recent evidence using nasal endoscopy as well as computed tomography scanning. Recent literature supports the fact that chronic adenoiditis can be an independent etiology of symptoms of chronic sinusitis, that are very similar to chronic adenoiditis. Allergic rhinitis and immune deficiency play important roles in the management of PCRS. Surgery for PCRS has evolved significantly in the last 15-20 years to include adenoidectomy as well as endoscopic sinus surgery. CONCLUSIONS: PCRS is very common in children causing poor QOL for these children. Medical management remains the main stay of treatment with attention to management of co-morbidities that may contribute to the disease severity. Making the correct diagnosis will help with the choice of surgical intervention if medical management fails.

Effect of hot saline irrigation on the operative field during endoscopic sinus surgery: a randomized controlled trial.

BACKGROUND: Control of bleeding is very important during endoscopic sinus surgery. Saline heated up to 50 °C causes dilatation of vessels and edema without nasal mucosa necrosis. It also promotes the clotting cascade so helps in having a bloodless procedure. METHODS AND MATERIALS: This randomized controlled trial was conducted on 60 patients divided into two groups (30 each). Group A was the interventional group in which patients were irrigated with saline of 50 °C during surgery. Group B was the control group where room-temperature saline was used. The operative field was assessed using the Boezaart score, duration of surgery, and bleeding in ml. RESULTS: The Boezaart score in group A came out to be 2.23 ± 0.72 whereas it was 3.43 ± 0.72 in group B. Most of the patients who were in the interventional group had their surgery completed within 60 min with comparatively less bleeding (mean bleeding = 221.83 ml). Patients of the control group had increased duration of surgery mostly and bleeding (mean = 265.67 ml). Our study showed a strong correlation amongst the Boezaart score, duration of surgery, and bleeding in ml with a p value of < 0.001 where all three variables significantly improved in the interventional group due to a good operative field provided by warm saline heated up to 50 °C. CONCLUSION: Normal saline heated up to 50 °C is a cost-effective way to achieve a bloodless operative field during endoscopic sinus surgery. Reduced bleeding also decreases the duration of surgery.

The impact of submucosal PRP injection on wound healing after endoscopic sinus surgery: a randomized clinical trial.

PURPOSE: Chronic rhinosinusitis (CRS) is a prevalent chronic disease observed on a global scale. The utilization of endoscopic sinus surgery (ESS) has gained significant recognition as an effective intervention for individuals with CRS and nasal polyps who have not responded to conventional treatments. The need (or not) for revision surgery frequently relies on the promotion of optimal wound healing. The impact of platelet-rich plasma (PRP) on tissue healing has been extensively examined in various surgical fields. METHODS: The present prospective study involved 30 patients suffering with nasal polyposis who underwent endoscopic sinus surgery. 15 patients were assigned to the PRP group, and 15 patients to the control group. The clinical follow-up of the patients took place at specific intervals, at weeks 1, 2, 3, 4, 8, and 12 after the surgical procedure. The evaluator identified the existence of adhesions, crusting, bleeding, granulation and infection using a visual analogue scale score. The patients also completed the SNOT 22 questionnaire prior to surgery and at each postoperative visit. RESULTS: The present study observed a lower incidence of adhesion, infection, hemorrhage and granulation in the PRP group. Furthermore, a statistically significant difference was detected between the groups. CONCLUSION: Based on the findings of the present investigation, it seems that platelet-rich plasma (PRP) is beneficial on wound healing during the early stages following the surgical procedure. The technique is characterized by its limited invasiveness, which contributes to its low risk profile and the achievement of clinically good outcomes.

A novel technique with butterfly splint for middle turbinate stabilization in sinus surgery.

OBJECTIVE: To assess the efficacy of newly designed butterfly splint with special technique for middle turbinate stabilization in preventing adhesion following bilateral endoscopic sinus surgery (ESS) for chronic rhinosinusitis with nasal polyps (CRSwNP). STUDY DESIGN: Prospective, double-blind, randomized controlled. SETTING: University hospitals. METHODS: Following ESS, in cases of traumatized and/or unstable middle turbinates, newly designed butterfly plastic splint was randomly inserted in the middle meatus of one nasal side, while no splint was inserted in the other (control). Patients were followed up on after 1 week, 1 month, and 6 months. Endoscopic examination and a visual analog scale were used to evaluate each side of the nasal cavity for adhesion, crusting, pus, pain, nasal obstruction, and nasal discharge. RESULTS: Thirty patients (60 nasal sides) were included. For all investigated parameters, there was no significant difference between the splinted and non-splinted sides at the first week visit. Adhesion was found significantly less in the splinted sides (3%) than the non-splinted sides (27%) after 1 month (P = 0.038). The adhesion rate in the splinted sides remained 3% at the 3 month follow-up visit, however, in the non-splinted sides, the rate increased up to 30% (P = 0.007). Throughout the follow-up visits, all other investigated parameters remained statistically insignificant between both sides. CONCLUSIONS: The newly designed butterfly plastic splints to avoid middle turbinate adhesion is safe and effective in both reducing middle meatal adhesion with low complication rate in CRSwNP patients undergoing ESS and middle turbinate stabilization in its intermediate position.

A clinical comparative study of an outpatient treatment group and an endoscopic sinus surgery group for maxillary sinus fungus ball.

PURPOSE: This study aimed to clarify the differences in the pathophysiology of maxillary sinus fungus balls (FB) among different case groups and to identify which patients with maxillary sinus FB would be suitable for outpatient procedures. METHODS: Thirty-four patients diagnosed with maxillary sinus FB between January 2017 and December 2021 were divided into two groups (O and S). We retrospectively compared the clinical and imaging characteristics, and the treatment outcomes between the groups. Group O comprised 12 patients (13 sides) treated in an outpatient clinic and Group S comprised 15 patients (16 sides) treated with endoscopic sinus surgery (ESS). RESULTS: Compared to Group S, Group O had more patients with an enlarged maxillary sinus membranous portion, and shadows indicative of fungal masses (P < 0.01 and P < 0.05, respectively). In particular, the anteroposterior ratio of the open maxillary sinus membranous area was 0.68 ± 0.16 in Group O and 0.5 ± 0.12 in Group S. After surgery, Group O exhibited greater anteroposterior expansion of the maxillary sinus membranous portion compared to Group S (P < 0.01). Additionally, Group O had more patients with shadows in sinuses other than the maxillary sinus (P < 0.01) and medial displacement of the uncinate process (P < 0.01) than Group S. In addition, Group O required fewer procedures and hospital visits than Group S (P < 0.001 and P < 0.01, respectively). CONCLUSIONS: Determining the indications for outpatient procedures while considering the pathophysiology of maxillary sinus FB can significantly benefit patients and medical professionals in terms of safety and medical costs.

Evaluating the efficacy of nasal irrigation in postoperative functional endoscopic sinus surgery patients: a systematic review and meta-analysis.

PURPOSE: Functional endoscopic sinus surgery (FESS) is a mainstay surgical intervention for chronic rhinosinusitis with nasal polyposis (CRSwNP). Nasal irrigation, particularly with normal saline, is a widely recommended postoperative care modality. This systematic review and meta-analysis aimed to assess the efficacy of various nasal irrigation solutions in postoperative FESS patients. METHODS: A comprehensive search was conducted in multiple databases for randomized controlled trials investigating normal saline and various substances for nasal irrigation post-FESS. The systematic review followed PRISMA guidelines, and the meta-analysis used R software for data synthesis. Outcome measures included SNOT-22 and LKES scores. The Cochrane tool was employed to evaluate the potential for bias. RESULTS: Results from 14 studies, focusing on six each for SNOT-22 and LKES, revealed a significant reduction in symptoms and endoscopic scores with various solutions compared to normal saline. The meta-analysis using the random-effects model indicated a negative standardized mean difference (SMD) of - 0.69(95% CI [- 1.64; 0.27], p = 0.157) for symptoms and endoscopic scores (SMD = - 0.48, 95% CI [- 1.32; 0.36], z = - 1.12, p = 0.264). Subgroup analyses highlighted budesonide's efficacy over normal saline, but substantial heterogeneity and potential publication bias were noted. CONCLUSION: Nasal irrigation with various solutions postoperative FESS patients demonstrated significant improvements in patient-reported symptoms and endoscopic scores compared to normal saline. Budesonide appeared particularly effective. However, high heterogeneity and potential publication bias warrant cautious interpretation. Standardized outcome measures and further research are needed to strengthen the evidence.

Assessing the safety and tolerability of rhinologic surgery under local anesthetic: an 8-year retrospective analysis.

PURPOSE: Office-based rhinologic procedures (OBRP) have become widely available in North America due to technological advances and appropriate patient selection. Nevertheless, the literature exploring the safety of these procedures remains limited. The objective of this study was to further evaluate the safety, tolerability and efficacy of these procedures with a more robust sample size to allow for capture of rare events. METHODS: A retrospective chart review of all patients who underwent OBRP from May 2015 to March 2023. Information regarding patient demographics, the indication for surgery, wait time, tolerability, intra- and postoperative complications, need for revisions, and type of revision (if applicable) was recorded. RESULTS: 1208 patients underwent OBRP during the study period. No patients were excluded. These included turbinoplasties (35%), endoscopic sinus surgeries (ESS) (26%), septoplasties (15%), nasal fracture reductions (7%), and a variety of other procedures. For ESS procedures, the anterior ethmoids and the maxillary sinuses were the most common sinuses treated. 1.1% of procedures were aborted prior to completion. The post-operative complication rate was 3.2%, with 2 major complications (significant bleeding and sepsis) encountered. The mean follow-up overall was 11 months and for ESS it was 15.8 months. CONCLUSION: Office-based rhinologic procedures are well tolerated and safe for the appropriate patient and associated with shorter wait-times as well as avoidance of general anesthesia. The complication rates are similar to or lower than previously reported rates for rhinologic surgeries done in the operating room. The low rates of revision surgery also demonstrate the efficacy of these procedures.

Efficacy of perioperative lidocaine infusion on surgical field quality during functional endoscopic sinus surgery: a systematic review and meta-analysis with trial sequential analysis.

PURPOSE: To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) that assessed the efficacy of perioperative intravenous lidocaine versus placebo in improving the quality of surgical field during functional endoscopic sinus surgery (FESS). METHODS: PubMed, Scopus, Web of Science, and CENTRAL were thoroughly searched from inception until June 2023. The included RCTs were evaluated via RoB-2 tool. Our primary endpoint included intraoperative surgical field quality, and secondary endpoints involved operative duration, estimated blood loss, time for post-anesthesia care unit (PACU) discharge, postoperative pain, mean difference in heart rate (HR), and mean difference in mean arterial pressure (MAP). Continuous data were pooled as mean difference (MD) or standardized mean difference (SMD) via RevMan software. Also, the certainty of evidence for each outcome were assessed according to the GRADE system. RESULTS: Four RCTs with total of 267 patients were included. Regarding the intraoperative quality of surgical field, the results indicated a significant difference in favor of the lidocaine group compared to the placebo group (n = 3 RCTs, MD - 0.80, 95% CI [- 0.98, - 0.61], p < 0.001, moderate certainty of evidence). The trial sequential analysis showed there is a substantial and conclusive evidence. Regarding time for PACU discharge, there was a significant difference that favor lidocaine group (p < 0.05). On the contrary, there was no significant difference between lidocaine and placebo groups in terms of operative duration, estimated blood loss, postoperative pain, mean change in MAP and HR, (p > 0.05). CONCLUSION: Our review revealed that lidocaine infusion, compared with a placebo, significantly improved the surgical field and shortened the time required for PACU discharge. However, lidocaine did not reduce surgery time, estimated blood loss, postoperative pain, MAP, or HR.

Plus moist HS-W®: a new nasal packing material for the middle meatus in endoscopic sinus surgery.

PURPOSE: Removal of the current calcium alginate packing materials to the middle meatus in endoscopic sinus surgery (ESS) is usually accompanied by discomfort or pain owing to the hard and brittle nature of these materials. Plus moist HS-W® is a new calcium alginate packing material released in 2022 developed to overcome this issue by changing the uronic acid component. We aimed to compare the discomfort/pain during the removal of Plus moist HS-W® with Kaltostat®, as well as their suitability as packing materials in ESS. METHODS: Kaltostat® and Plus moist HS-W® were used as packing materials in 22 and 21 patients who underwent ESS in 2021 and 2022, respectively. Patients were asked to rate the pain during the packing removal 10 days after ESS using the Numerical Rating Scale (NRS). The ratio of residual packing materials, number of suctions (insertions/extractions of the suction cannula), and time required to remove packing materials were measured. Postoperative complications such as hemorrhage, local infection, lateralization of the middle turbinate, and synechia of the middle meatus were also evaluated. RESULTS: The Plus moist HS-W® group exhibited significantly lower NRS pain scores, a lower ratio of residual packing materials, a reduced number of suctions, and a shorter time required to remove the packing. No obvious postoperative complications occurred in both groups except for one suspicious case of a slight infection in the Kaltostat® group. CONCLUSION: Compared with Kaltostat®, Plus moist HS-W®, characterized by better gelatinization than Kaltostat®, benefits patients by minimizing discomfort/pain during removal. LEVEL OF EVIDENCE: Level 3.