Endoscopic treatment of inverted papilloma: safety and efficacy.

PURPOSE: Inverted papillomas of the nose and paranasal sinuses are uncommon neoplasms, characterized by their tendency to recur and by their association with malignancy. Over the past 25 years, the standard surgical treatment of inverted papillomas has involved extranasal, en bloc resections because of high recurrence rates with less extensive surgery. The past decade has witnessed an increasing number of reports documenting the successful treatment of inverted papilloma with endoscopic approaches. This investigation examines the role of endoscopic procedures in treating inverted papilloma. MATERIALS AND METHODS: The present article presents a thorough review of the literature relating to the history, pathology, diagnosis, and treatment of inverted papillomas of the nose and paranasal sinuses. It also provides a systematic review of the pertinent medical literature with pooled statistical analysis of data from 33 studies involving 1,426 patients. RESULTS AND CONCLUSIONS: The findings suggest that many cases of inverted papilloma can be treated successfully with low recurrence rates and less morbidity through endoscopic surgery, with results comparable to extranasal procedures. Less aggressive approaches to the sinuses and nonendoscopic intranasal procedures, such as the Caldwell-Luc, have unacceptable rates of recurrence and should be abandoned. A staging system for inverted papilloma and a logical approach to treatment are presented.

Computed tomography stage, allergy testing, and quality of life in patients with sinusitis.

BACKGROUND: Chronic rhinosinusitis is a common disease associated with significant morbidity. CT has been a poor predictor of the extent of symptoms among these patients. Allergic rhinitis is frequently associated with chronic rhinosinusitis. This study examines CT stage, allergic sensitivity, and sinus-related symptoms. METHODS: Forty-eight patients with chronic rhinosinusitis underwent CT scanning and skin end-point titration (SET). They also completed the Rhinosinusitis Disability Index (RSDI), a measure of sinus-related disability. RESULTS: No association was noted between CT stage and severity of sinus-related symptoms. There was a significant correlation between CT stage and SET mean end point and between SET mean end point and RSDI physical scale score, as well as between significance on the RSDI emotional scale score and overall score. CONCLUSION: The degree of allergic disease is a better indicator of symptom severity and impairment in quality of life among patients with chronic rhinosinusitis than CT stage. Careful evaluation and treatment of allergic disease is critical in the treatment of chronic rhinosinusitis.

Efficacy of immunotherapy based on skin end-point titration.

OBJECTIVE: The purpose of this study is to examine the efficacy of skin end-point titration (SET) as a method of assessing skin responsiveness, selecting antigens, and initiating treatment for successful inhalant immunotherapy. STUDY DESIGN: This study is a prospective, randomized, controlled, double-blind investigation. Eighteen patients were randomly assigned to 1 of 2 groups: an experimental group treated for all positive antigens, and a control group treated for all positive antigens, with the exception of the study antigens. Quality of life was assessed with 3 dependent measures, and response to nasal challenge and nasal endoscopic evaluations were conducted. Ten patients completed the 6-month study. RESULTS: There were significant improvements in the emotional component of sinus-related disability, in response to nasal challenge, and in the endoscopic appearance of the mucosa, regardless of patient group. There was a trend toward improved quality of life among experimental subjects. CONCLUSIONS: SET-based immunotherapy reduces self-rated disability over time. In addition, SET-based immunotherapy allows decrease in nasal reactivity and normalizes the endoscopic appearance of the nose.

Development of a staging system for inverted papilloma.

OBJECTIVES: Inverted papillomas of the nose and sinuses are uncommon neoplasms. In the past decade there has been a trend toward the use of endoscopic surgical techniques in the management of these tumors, in contrast to the extensive open procedures recommended previously. This trend has not been without controversy, given the association of inverted papillomas with malignancy. It has been difficult to compare surgical approaches to these neoplasms, because of the absence of a uniformly applied staging system representing the extent of disease. It was the purpose of this study to develop such a system that could be easily applied in outcomes research. STUDY DESIGN: This study involved an integrated literature review and a synthesis of findings from a number of studies. METHODS: Previous and current clinical studies examining the treatment of inverted papilloma were reviewed. Findings were organized, and a staging system was framed based on this review. RESULTS: A simple, easily applied staging system was developed based on the extent of tumor involvement noted on endoscopic examination of the nasal cavity and computed tomography (CT) scan evaluation. CONCLUSIONS: Stage I disease is limited to the nasal cavity alone. Stage II disease is limited to the ethmoid sinuses and medial and superior portions of the maxillary sinuses. Stage III disease involves the lateral or inferior aspects of the maxillary sinuses or extension into the frontal or sphenoid sinuses. Stage IV disease involves tumor spread outside the confines of the nose and sinuses, as well as any malignancy.

Geographic variation in allergic fungal rhinosinusitis.

Allergic fungal rhinosinusitis (AFRS) has a worldwide distribution. This survey of 20 otolaryngologic practices throughout the United States confirmed a variation in the frequency of AFRS relative to endoscopic sinus procedures performed for all other diagnoses. The highest incidence occurred in Memphis, Tennessee at 23%, with three other southern practices reporting a frequency of at least 10%. In the northern locations the frequency ranged from 0 to 4%. No correlation with mould counts was demonstrated, possibly because of incomplete mould data relative to most of the surgical locations.

Endoscopic-powered rhinoplasty.

OBJECTIVE: To present a new method for sculpting the bony nasal dorsum in rhinoplasty surgery. MATERIALS AND METHODS: Fifteen patients underwent powered dissection of the nasal dorsum during cosmetic and reconstructive rhinoplasty. The precise technique is described and its benefits are discussed. RESULTS: All patients had acceptable postoperative results using this technique. Intraoperative bleeding and postoperative ecchymosis appeared to be reduced. No complications were noted. CONCLUSIONS: Endoscopic-powered rhinoplasty provides an excellent approach to the bony dorsum. It allows sculpting to be completed under direct vision, permitting precise contouring and easy visualization by associates. It can be completed easily and safely with standard microdebrider equipment. Its use should be considered in situations requiring precise contouring of the bony nasal dorsum.

Patient use of traditional and complementary therapies in treating rhinosinusitis before consulting an otolaryngologist.

OBJECTIVES: It has been estimated that 50 million Americans are bothered with symptoms of allergic disease and sinusitis. Patients treat these symptoms with a variety of traditional and complementary therapies. This study examined the use of these therapies by patients before consulting an otolaryngologist. STUDY DESIGN: This investigation involved a prospective clinical survey. METHODS: The sample consisted of 120 adult patients seen in a community-based otolaryngology practice, who presented with complaints of sinusitis and rhinitis. Patients completed a set of questionnaires at their initial office visit to assess the various traditional and complementary therapies they had used. In addition, they completed a questionnaire evaluating the various symptoms with which they presented to the physician. All data were analyzed with descriptive statistics. RESULTS: The results demonstrated that patients had been symptomatic for a mean length of 3.5 years before seeking therapy from the otolaryngologist. In addition, 87% of patients had previously seen a primary care provider, and 42% of patients had previously consulted an otolaryngologist. While traditional therapies including medications were commonly used, many patients also attempted a variety of complementary treatments, including dietary management, herbal therapy, exercise, and chiropractic. Patients who had previously seen an otolaryngologist were commonly treated with surgery. CONCLUSIONS: These findings demonstrate that patients employ both traditional and complementary therapies before seeking the care of an otolaryngologist. In addition, findings suggest that, despite aggressive medical and surgical therapy, many patients continue to remain symptomatic.

Introduction to sinus disease: I. Anatomy and physiology.

Chronic rhinosinusitis is the most common chronic illness in the United States. An understanding of the anatomy of the paranasal sinuses, their functioning in health and in disease, and the contributing factors that are critical to the pathogenesis of rhinosinusitis is essential for nurses caring for patients with this prevalent disease. This paper will provide the otorhinolaryngology (ORL) nurse with an overview of the scientific principles important in rhinosinusitis, as well as presenting a framework for the understanding of rhinosinusitis and its treatment. (This paper is the first in a series of two articles. The second part will review the diagnosis and treatment of chronic rhinosinusitis.)

Complementary therapeutic practices in patients with chronic sinusitis.

Understanding patient use of alternative and complementary modalities to treat chronic health conditions is an important component to providing holistic care. This study sought to identify traditional and complementary therapies used by patients with chronic sinusitis. Eighty-one percent of patients with chronic sinusitis engaged in physical exercise to relieve symptoms. Additional complementary therapies utilized included herbal therapy (32%), chiropractic therapy (16%), biofeedback (13%), acupuncture (11%), and chelation therapy (7%). Medications were commonly used by patients (60%), especially those with severe symptoms. By recognizing and incorporating effective complementary therapies into care for chronic sinusitis, nurse practitioners may help patients to improve their clinical outcomes.

The role of powered instrumentation in the surgical treatment of allergic fungal sinusitis.

Allergic fungal sinusitis is a chronic disorder that is being more frequently recognized by otolaryngologists. It is a recurrent illness characterized by frequent exacerbations, and requires aggressive medical and surgical treatment. When surgical therapy is employed, it is necessary to ensure adequate debridement and removal of edematous tissue. We have been using powered dissection as our primary method in sinus surgery over the past three year. We have treated 11 patients with allergic fungal sinusitis, and find powered instrumentation to be very effective in removing the polypoid tissue from the nose and sinuses, and in providing a clear surgical field. The procedure can be performed safely with minimal trauma to normal tissue. We believe that the use of powered dissection greatly enhances the comprehensive treatment of allergic fungal sinusitis.

Powered functional endoscopic sinus surgery.

The use of powered instrumentation in functional endoscopic sinus surgery has been a revolutionary development in the surgical treatment of chronic sinusitis. Several studies have demonstrated the safety, efficacy, and ease of use of this new technique. To provide support and coordinate the surgical process in powered functional endoscopic sinus surgery procedures, perioperative nurses must have an appreciation for its specific equipment handling and for appropriate patient care. This article describes a specific protocol that perioperative nurses can use to facilitate efficient and safe surgical environments for patients who undergo powered endoscopic sinus surgery procedures.

Endoscopic sinus surgery in otorhinolaryngology nursing using powered instrumentation.

Powered instrumentation has gained increased popularity in otolaryngology because of its safety and effectiveness in sinus surgery. An understanding of the principles and techniques of powered dissection of the sinuses, setup and handling of instrumentation, and pre- and postoperative care is necessary for otolaryngology nurses in management of patients undergoing these procedures.

Powered nasal polypectomy in the office setting.

The use of powered instrumentation has revolutionized the practice of functional endoscopic sinus surgery. We have expanded the role of the instrument to the treatment of polypoid disease of the nose within the office setting. We have found the technique to be both safe and effective, and to allow thorough exenteration of nasal polyps with minimal bleeding and discomfort. We recommend the use of the powered device as the primary tool in the surgical treatment of nasal polyps in the office.

Powered instrumentation in dissection of the frontal recess.

The use of powered instrumentation in functional endoscopic sinus surgery has become very popular due to its safety and thoroughness. An area which has been more problematic in the use of this technique has been the frontal recess, due to its anatomic location and associated risk of serious complications. We have done a number of powered dissections of the frontal recess as a surgical treatment of refractory frontal sinusitis, and find that it is extremely safe and effective. The ability of the powered devices to preserve normal mucosa allows an adequate surgical approach while significantly decreasing the postoperative risk of frontal recess stenosis and reocclusion. We feel that powered dissection of the frontal recess offers a significant advantage over standard techniques in this anatomic location.

Powered instrumentation in functional endoscopic sinus surgery. I: Surgical technique.

The use of the microdebrider provides an excellent, safe and thorough technique in functional endoscopic sinus surgery. It provides atraumatic dissection with minimal bleeding which enables decreased surgical time and faster postoperative healing. It is easily learned and requires minimal supplemental instrumentation. We feel that it is a superior technique in the practice of functional endoscopic sinus surgery.

Powered instrumentation in functional endoscopic sinus surgery. II: A comparative study.

The present paper compares the use of the microdebrider as a form of powered instrumentation for endoscopic sinus surgery with traditional endoscopic surgical techniques. A group of 250 patients undergoing surgery with the microdebrider was compared with a group of 225 patients undergoing traditional procedures in order to evaluate their postoperative recovery, healing, and incidence of complications. The use of the microdebrider demonstrated faster healing with less crusting than standard techniques, as well as decreased bleeding, synechia formation, lateralization of the middle turbinate, and ostial reocclusion. The microdebrider offers excellent surgical results with fewer complications and faster healing than traditional techniques in functional endoscopic sinus surgery.

Tympanostomy tubes: experience with removal.

Whereas the clinical indications for tympanostomy tube placement are well-established, the indications for operative tympanostomy tube removal remain unspecified. A 1-year retrospective review done at the Massachusetts Eye and Ear Infirmary revealed 131 tympanostomy tubes to have been removed under general anesthesia. Chronic otorrhea, granuloma formation, tube nonfunction due to blockage, and migration of the tube into the middle ear constituted the surgical indications in 75 cases. The remaining 56 tubes were removed on the physicians' judgment that artificial ventilation was no longer required. Selected cases are presented. While the vast majority of tubes spontaneously extrude uneventfully, a comparatively small number of patients do require operative tube removal. Practice guidelines for surgical tube removal are suggested.

Barium swallow is a predictor of salivary fistula following laryngectomy.

Pharyngocutaneous salivary fistula after laryngectomy is a serious complication that can lead to prolonged hospitalization and increased patient morbidity. A postoperative barium swallow provides the surgeon with information regarding the integrity of the pharyngeal suture line. In an attempt to determine whether this information can be used to predict or prevent salivary fistula, we reviewed the records of 109 patients who underwent total laryngectomy, including 51 who had a barium swallow before they began oral intake. Ten patients (20%) demonstrated a sinus tract originating from the pharyngeal suture line. A clinical salivary fistula developed in all four patients with a sinus tract 2 cm or longer, but in only one of six patients with a tract shorter than 2 cm. Other factors predictive of salivary fistula included tumor stage, previous radiation therapy, and the presence of concurrent postoperative complications. A single fistula developed in the 58 patients not studied with barium. Information provided by postlaryngectomy barium swallow appeared to predict, but not prevent salivary fistula formation.