Development and validation of the Sinonasal Endoscopic Score (SiNES) for chronic rhinosinusitis.

BACKGROUND: Although there are several endoscopic grading systems for chronic rhinosinusitis (CRS), they are limited in their range and applicability. We developed a SiNonasal Endoscopic Score (SiNES) that builds upon the strengths of previous systems while addressing their limitations. METHODS: The SiNES system was developed by consensus after multiple rounds of guided discussions. Face, content, and convergent validity were investigated. It was validated using an independent sample of 79 CRS individuals from two referral centres from September 2021 to February 2022. Each patient underwent a sinonasal endoscopy and filled PROM questionnaires. Three independent rhinologists graded endoscopic videos using the SiNES and modified Lund-Kennedy (MLK) scores. Inter-rater and test-retest reliability were assessed via the intraclass correlation coefficient (ICC). SiNES and MLK scores were correlated with PROMs using a Spearman correlation and canonical correlation analysis (CCA). RESULTS: The SiNES system evaluates five anatomical spaces regarding edema, discharge, and scarring. Face, content, and convergent validity were deemed satisfactory by the study authors and an independent panel of Otolaryngologists. Inter-rater reliability was excellent for the SiNES and good for the MLK score. Test-retest reliability was excellent for both systems. Total SiNES was correlated with self-reported smell loss. CONCLUSIONS: The SiNES system is an accurate and reliable grading framework applicable to all CRS subtypes. It can be utilized in clinical and research settings and improves upon previously published systems.

Canadian Rhinology Working Group consensus statement: biologic therapies for chronic rhinosinusitis.

BACKGROUND: Recent evidence suggests that biologic therapy with targeted activity within the Type 2 inflammatory pathway can improve the clinical signs and symptoms of chronic rhinosinusitis with nasal polyposis (CRSwNP). There remains a population in CRSwNP that despite medical therapy and endoscopic sinus surgery have persistent signs and symptoms of disease. Therefore, biologics, monoclonal antibody agents, could be beneficial therapeutic treatments for these patients. There have been eight randomized, double-blind, placebo-controlled trails performed for CRSwNP targeted components of the Type 2 inflammatory pathway, notably interleukin (IL)-4, IL-5 and IL-13, IL-5R, IL-33, and immunoglobulin (Ig)E. However, there are no formal recommendations for the optimal use of biologics in managing Chronic Rhinosinusitis (CRS) within the Canadian health care environment. METHODS: A Delphi Method process was utilized involving three rounds of questionnaires in which the first two were completed individually online and the third was discussed on a virtual platform with all the panelists. 17 fellowship trained rhinologists across Canada evaluated the 28 original statements on a scale of 1-10 and provided comments. A rating within 1-3 indicated disagreement, 8-10 demonstrated agreement and 4-7 represented being neutral towards a statement. All ratings were quantitively reviewed by mean, median, mode, range and standard deviation. Consensus was defined by removing the highest and lowest of the scores and using the "3 point relaxed system". RESULTS: After three rounds, a total of 11 statements achieved consensus. This white paper only contains the final agreed upon statements and clear rationale and support for the statements regarding the use of biologics in patients with CRS. CONCLUSION: This white paper provides guidance to Canadian physicians on the use of biologic therapy for the management of patients with CRS, but the medical and surgical regimen should ultimately be individualized to the patient. As more biologics become available and additional trials are published we will provide updated versions of this white paper every few years.

Sinonasal inverted papilloma recurrence rates and evaluation of current staging systems.

BACKGROUND: Sinonasal inverted papillomas (SNIPs) are benign epithelial growths with high recurrence rates after surgical management. This study aims to evaluate SNIP recurrence rates after endoscopic surgery and to provide a comparison of published staging systems. METHODS: This chart review evaluated primary and revision SNIP cases from January 2008 to December 2016 at a tertiary sinus centre. Data was collected on patient demographics, origin site, surgical approaches, follow-up duration, recurrence, and smoking history. Each case was staged using Krouse, Oikawa, Cannady, Han, and Kamel systems. RESULTS: 52 primary and 22 revision SNIP patients had a mean follow-up of 42.3 (range:3-55) months. 11 primary cases (21.1%) and 5 revision cases (22.7%) had recurrences. Primary and revision cases had a mean time to recurrence of 24.0 (range:3-55) and 14.6 (range:10-20) months respectively. Smoking history had an OR of 0.63 (CI 95%: 0.18-2.22) for recurrence. The age group of 20-39 years featured the highest rates of recurrence. Patient groups defined by each staging system were compared by Kaplan-Meier survival analyses and logrank tests. Chi-squared values for Krouse, Oikawa, Cannady, Han, and Kamel systems were 6.73, 7.02, 6.19, 8.23 and 3.29, respectively. CONCLUSION: Recurrence rates found in this study are comparable to published literature. No statistical significance was found to associate smoking with recurrence. Han and Cannady staging systems were found to define patient groups that correlated well with recurrence. Staging systems should play a role in the management of SNIPs, especially to identify patients requiring additional post-surgical monitoring.

Squeeze bottle versus saline spray after endoscopic sinus surgery for chronic rhinosinusitis: a pilot multicentre trial.

BACKGROUND: There is a need for controlled trials to guide the perioperative management of patients undergoing endoscopic sinus surgery (ESS). The authors performed a pilot multicenter trial to compare two types of saline delivery devices in this population. METHODS: Patients were randomized to high volume saline irrigation with a squeeze bottle and low volume saline spray after ESS in patients with chronic rhinosinusitis (CRS). Surgeons were blinded to treatment, and one-month postoperative scores for sinonasal outcomes [Sinonasal Outcome Test-22 (SNOT-22)] scale, nasal and sinus symptom score (NSS), and perioperative sinus endoscopy (POSE) scale were compared with preoperative scores. RESULTS: Nine centers provided data for 86 patients. All three outcomes measures improved significantly for both groups. Saline spray: SNOT-22 48.8 versus. 23.7, treatment effect 25.1 (95% confidence interval [CI], 17.9-32.2), POSE 21.1 versus. 8.4, treatment effect 12.7 (95% CI, 9.2-16.1), and NSS 8.2 versus 5.0, treatment effect 3.1 (95% CI, 1.4-4.9) pre- and postoperatively, respectively (all p < 0.0001). Squeeze bottle: SNOT-22 49.5 versus 23.6, treatment effect 25.9 (95% CI, 20.3-31.6), POSE 18.6 versus 9.2, treatment effect 9.3, (95% CI 6.7-12.0), and NSS 9.0 versus 5.7, treatment effect 3.3 (95% CI, 2.3-4.3) pre- and postoperatively, respectively (all p < 0.0001). Analysis of variance did not identify a difference between the two treatment groups. Subgroup analysis based on preoperative disease severity did not change the nonassociation of saline bottle with outcome measures. Post hoc sample size calculation determined that 176 patients is required to detect an 8.9-point difference in SNOT-22 scores. CONCLUSION: In this pilot multicenter trial examining patients with chronic rhinosinusitis undergoing ESS, both squeeze bottle and saline spray showed significant improvement in SNOT-22, POSE, and NSS scores at one-month postoperatively. Because the study was nonpowered, we cannot rule out a potential difference between the two treatment groups.

The effect of two sphenoidotomy approaches on the sense of smell: trans-ethmoidal versus trans-sphenoethmoidal.

BACKGROUND: There are generally two methods to access the sphenoid sinus: either through the natural ostium {trans-sphenoethmoidalor via sphenoethmoidal recess), or by creating a second opening through the posterior ethmoids (trans-ethmoidal).This study psychophysically and subjectively evaluates the effect of the trans-sphenoethmoidal technique to the trans-ethmoidal technique for sphenoid sinusotomy on olfactory function. METHODS: Prospective cohort analysis of 48 patients with comparable sinus disease underwent primary sphenoidotomy via transsphenoethmoidal(n = 24) versus trans-ethmiodal (n = 24) technique between September 2011 and February 2012. The patients had their olfaction measured psychophysically with "Sniffin' Sticks" and subjectively with a visual analogue scale (VAS) pre-operatively and at 5 weeks post-operatively. RESULTS: Psychophysical scores from the Sniffin' sticks provide a Threshold, Discrimination and Identification (TDI) score out of 48.The TDI change (post-operative TDI score minus pre-operative score) as well as VAS change (post-operative VAS minus pre-operativeVAS) were analyzed using t-test analysis, which showed no significant difference between the two measurements. CONCLUSION: If the trans-sphenoethmoidal technique is done meticulously, patients have the same olfactory relief, psychophysically and subjectively, as those undergoing the trans-ethmoidal technique.

A label-free microfluidic assay to quantitatively study antibiotic diffusion through lipid membranes.

With the rise in antibiotic resistance amongst pathogenic bacteria, the study of antibiotic activity and transport across cell membranes is gaining widespread importance. We present a novel, label-free microfluidic assay that quantifies the permeability coefficient of a broad spectrum fluoroquinolone antibiotic, norfloxacin, across lipid membranes using the UV autofluorescence of the drug. We use giant lipid vesicles as highly controlled model systems to study the diffusion through lipid membranes. Our technique directly determines the permeability coefficient without requiring the measurement of the partition coefficient of the antibiotic.

Computer or not? Use of image guidance during endoscopic sinus surgery for chronic rhinosinusitis at St Paul's Hospital, Vancouver, and meta-analysis.

BACKGROUND: The advantages and limitations of image guidance systems for endoscopic sinus surgery are unclear. We report our experience and present a meta-analysis of the evidence. METHODS: We performed a retrospective analysis of endoscopic sinus surgery procedures performed with versus without image guidance. A total of 355 cases was included. Primary outcomes included complication rates and time to revision surgery. A literature search was conducted to enable identification and analysis of studies of similar comparisons. RESULTS: Within 1.5 years of the index sinus surgical procedure, the risk of revision surgery was significantly higher for patients treated with non-assisted versus computer-assisted endoscopic sinus surgery (p = 0.001). Meta-analysis did not indicate a reduction in complications or revision surgery procedures with the use of image guidance systems, although the majority of included studies showed a non-significant reduction in revision surgery. CONCLUSION: Our study offers some evidence that computer-assisted endoscopic sinus surgery may delay residual disease and reduce the requirement for revision surgery. Although this finding was not borne out in the meta-analysis, the majority of identified studies demonstrated a trend towards fewer revision procedures after computer-assisted endoscopic sinus surgery. This type of surgery may offer other advantages that are not easily measurable.

Development of a tool for Global Rating of Endoscopic Surgical Skills (GRESS) for assessment of otolaryngology residents.

OBJECTIVE: To develop a valid and reliable assessment tool for endoscopic sinus surgery (ESS). MATERIAL AND METHODS: Data were collected prospectively in an observational study through evaluations at two tertiary academic institutions, i.e. St. Paul's Sinus Centre, St. Paul's Hospital, Vancouver, British Columbia, Canada, and King Fahd Medical City, Riyadh, Saudi Arabia, from December 2006 to December 2009. A 2-page evaluation form was developed in conjunction with the Objective Assessment of Technical Skills Surgery (OSATS) evaluation form developed by Reznick et al in Toronto to assess residents' surgical skills. A Likert scale (1-5 where 5 = excellent) was used for evaluations. The Global Rating of Endoscopic Surgical Skills (GRESS) evaluation instrument was designed with input from academic otolaryngologists, fellowship-trained rhinologists, and experts in medical education. The experts' comments were incorporated, establishing face and content validity. Residents from various levels of training were assessed objectively using this instrument. Internal consistency was evaluated using Cronbach's alpha. Test-retest and inter-rater reliability was measured using intra-class correlation. RESULTS: A total of 31 assessments were completed by 15 residents. GRESS showed high reliability in the context of internal consistency (alpha = 0.99), test-retest (0.95, CI = 0.83-0.98), and inter-rater reliability (0.86, CI = 0.31-0.98). CONCLUSIONS: This pilot study demonstrated that GRESS is a valid and reliable assessment tool for operating room performance.

A double-blind randomised controlled trial of gloved versus ungloved merocel middle meatal spacers for endoscopic sinus surgery.

BACKGROUND: Middle meatal spacers are commonly used following endoscopic sinus surgery to prevent post-operative bleeding and lateralization of the middle turbinates. The effects of nasal packing on post-operative sinonasal mucosal healing remain unknown in humans. OBJECTIVE: This study aims to compare the histopathalogical effects of Merocel and Merocel covered with a finger glove on mucosal healing, and patients` discomfort immediately post-operatively after endoscopic sinus surgery and at removal of the nasal packing. METHODS: Thirty-seven patients with chronic rhinosinusitis undergoing bilateral endoscopic sinus surgery were enrolled in a prospective study. Patients were randomized and blinded to receive Merocel middle meatal spacer (MMMS) in one nostril and finger glove Merocel middle meatal spacer (FGMMS) in the contra lateral side. Patients were seen on post-operative day 6, and completed a visual analogue score reporting the post-operative discomfort from nasal packing on each side. Following the removal of nasal packing, patients indicated which side caused more discomfort on removal. Biopsies were taken from the middle turbinates and sent to a blinded pathologist who scored the level of mucosal inflammation from 0 - 4. RESULTS: There was no statistically significant difference between MMMS and FGMMS in regards to their effect on sinonasal mucosal inflammation and discomfort post-operatively. A statistically significant difference was noted with respect to discomfort at removal with the uncovered Merocel more likely to cause discomfort when compared to the Merocel covered in a glove finger. CONCLUSION: MMMS and FGMMS are equivalent in the amount of sinonasal mucosal inflammation and discomfort post endoscopic sinus surgery. However, the main advantage of the FGMMS was a significant reduction in pain on removal when compared with the MMMS.

Allergic fungal rhinosinusitis - a new staging system.

BACKGROUND: The existing Kupferberg post-operative endoscopic staging system for allergic fungal rhinosinusitis (AFRS) has 4 stages (0-3) based on the `global` appearance of one side of the nose. Patients may however show visual improvement and yet remain at the same stage due to persistence in one sinus cavity, thus making the staging system ineffective. The aim of this study was to validate a new system that allows greater sensitivity in characterising the inflammation seen endoscopically. METHODOLOGY: A series of endoscopy videos of 50 patients with AFRS were retrospectively staged using a new ten-grade system, scoring each sinus cavity (maxillary, ethmoid, frontal and sphenoid) from 0-9 for increasing mucosal oedema and 1 point for the presence of fungal mucin giving a maximum score of 40 for each side of the nose. To assess reliability, 4 independent rhinologists were also asked to score the videos using the new system. RESULTS: A greater variety in the spectrum of mucosal disease was demonstrated with the new system allowing for a more descriptive analysis of its severity and its response, or lack of, to treatment. The inter-class correlation between the 6 total observers was 0.86 (95% CI: 0.83, 0.92). CONCLUSION: Use of the new staging system provides a more sensitive tool for following patients` progress post-operatively in allergic fungal rhinosinusitis and in determining their response to treatment.

Tumefactive fibroinflammatory lesion of the frontal sinus.

OBJECTIVE: A 65-year-old man presented with a nine-month history of swelling in the midline of the forehead. After surgical intervention, this lesion was found to be a tumefactive fibroinflammatory lesion of the frontal sinus. This case report and review aims to report this new location for tumefactive fibroinflammatory lesion, and to discuss whether, in retrospect, there would have been alternative options to surgery. METHODS: Case report and literature review. RESULTS: Tumefactive fibroinflammatory lesions are rare. Although cases in the sinonasal tract have been described, none involving the frontal sinus have previously been reported. A review of the literature suggests that these lesions have an association with other fibroinflammatory lesions, and may be amenable to systemic steroid therapy. CONCLUSION: Each case should be managed on its merits, and a biopsy taken followed by subsequent screening for associated fibroinflammatory lesions. In the case of an isolated lesion, a surgical approach is probably favoured in a patient suitable for general anaesthesia.

Primary endoscopic management of the frontal sinus.

Surgical treatment of the frontal sinus continues to be an area of much interest and controversy. The complex anatomy and confined space of this region require the endoscopic surgeon to be knowledgeable and delicate to obtain a positive result. Proper instrumentation is crucial and continues to evolve over time. Postoperative endoscopic care is integral to the success of endoscopic frontal sinusotomy and the availability of proper office equipment to perform this care is critical. In most instances, the intranasal endoscopic approach can be accomplished successfully without the need for an external procedure.

Revision endoscopic frontal sinusotomy with mucoperiosteal flap advancement: the frontal sinus rescue procedure.

Frontal sinusitis after middle turbinate resection occurs because of stenosis of the frontal ostium by soft tissue scarring or residual bony fragments (which are pulled to the medial orbital wall by scar contracture). Standard endoscopic techniques cannot address this problem; however, revision endoscopic frontal sinusotomy with mucoperiosteal flap advancement (the frontal sinus rescue procedure) relieves this bony stenosis and incorporates a mucosal flap that minimizes postoperative stenosis.

The frontal sinus unobliteration procedure.

Although intranasal frontal sinusotomy can now be performed for most cases of chronic frontal sinusitis, the osteoplastic frontal sinus procedure with obliteration, unfortunately, still is considered by many to be the standard for chronic frontal sinusitis against that which other frontal sinus procedures are judged. Unobliterating the previously obliterated sinus is indicated for patients with evidence of frontal sinus pathology on CT or MR images and for patients with chronic symptoms with equivocal radiologic results. The reopened frontal sinus can be reventilated and remucosalized, or reobliterated with the placement of a new fat graft. Complete or partial auto-obliteration by new bone formation or fibrosis is another possible endpoint that can result when unobliteration is attempted.

The frontal sinus rescue procedure: early experience and three-year follow-up.

The frontal sinus rescue (FSR), first described in 1997, has now been performed on 24 patients (32 sides) over a period of three years. It is a functional endoscopic surgical approach to correct an iatrogenically scarred and obstructed frontal recess, which cannot be successfully opened via a normal endoscopic frontal sinusotomy approach. It is utilized primarily for patients whose only remaining option is either a Draf-type drill-out (modified intranasal Lothrop) procedure or frontal sinus obliteration. The FSR is a technically challenging procedure, but faster, less difficult, and less destructive for the patient than a "drill-out" or frontal sinus obliteration. Once learned, it can save the patient from undergoing the more radical drill-out or obliterative procedure. The early experience and three-year follow-up with this new endoscopic procedure is presented in our first 24 patients (32 sides).

Allergic fungal sinusitis: a four-year follow-up.

Allergic fungal sinusitis (AFS), first described over 18 years ago and subsequently identified using established criteria, remains a challenge to treat. Our protocol has included complete functional endoscopic sinus surgery to remove the fungal load and restore physiologic mucous clearance. The patient is treated with prednisone for several months and followed monthly with total serum IgE levels and an established endoscopic mucosal staging system. A group of 11 patients first treated in 1994 and presented at the 1995 American Rhinology Society Spring meeting are being presented again to provide an update on their progress over the past four years. A great deal of experience has been gained from their treatment and has continued to modify our postoperative medical management. An overview of AFS, our evolving and current treatment protocol, and possible future trends are discussed in this paper.

The endoscopic management of chronic frontal sinusitis associated with frontal sinus posterior table erosion.

Expansile inflammatory diseases of the frontal sinuses may produce erosion of the posterior table of the frontal sinus. In these instances, the bone between sinus mucosa and intracranial dura is absent. Over the past decade, endoscopic frontal sinusotomy has emerged as the preferred technique for the treatment of refractory chronic frontal sinusitis. Endoscopic approaches also have a role in the most advanced instances of frontal sinusitis. A retrospective chart review of patients who were treated for frontal sinusitis with erosion of the frontal sinus posterior table was performed. Eight patients were identified. All patients underwent endoscopic frontal sinusotomy; some patients required multiple endoscopic procedures. Complete frontal recess dissection with identification of the frontal ostium was achieved for all involved frontal sinuses. In all cases, this postoperative result was monitored by CT scans (where indicated) and serial nasal endoscopy, which demonstrated good frontal sinus aeration and normal mucociliary clearance. Antibiotics were administered for culture-documented bacterial exacerbations, and systemic steroids were given for management of allergic fungal sinusitis and sinonasal polyposis associated with asthma. No patient underwent frontal sinus obliteration or cranialization. No suppurative intracranial complications were noted during the postoperative period. Endoscopic frontal sinusotomy can be used safely for the definitive management of frontal sinusitis associated with posterior table erosion. In fact, endoscopic techniques may represent the preferred approach for the treatment of this problem. Such an approach avoids the morbidity of more destructive alternatives (such as obliteration), and serves to create a frontal sinus with normal mucociliary clearance.

Allergic fungal rhinosinusitis: perioperative management, prevention of recurrence, and role of steroids and antifungal agents.

Allergic fungal sinusitis can best be thought of as chronic fungal affectation (not an infection) of the sinuses to which the body's immune system hyperreacts, thereby creating significant inflammation, edema, obstruction, and polyposis. Currently it is felt that allergic fungal sinusitis requires both surgical and medical management. The effectiveness and required duration of the various medical treatments remain unknown and are under active investigation. Both surgical intervention and the use of systemic steroids are recommended in the treatment of allergic fungal sinusitis. Experience with surgical and medical management, follow-up of patients, and proposed treatment protocols are discussed.