Consensus criteria for chronic rhinosinusitis disease control: an international Delphi Study.

BACKGROUND: Chronic rhinosinusitis (CRS) disease control is a global metric of disease status for CRS. While there is broad acceptance that it is an important treatment goal, there has been inconsistency in the criteria used to define CRS control. The objective of this study was to identify and develop consensus around essential criteria for assessment of CRS disease control. METHODS: Modified Delphi methodology consisting of three rounds to review a list of 24 possible CRS control criteria developed by a 12-person steering committee. The core authorship of the multidisciplinary EPOS 2020 guidelines was invited to participate. RESULTS: Thirty-two individuals accepted the invitation to participate and there was no dropout of participants throughout the entire study (3 rounds). Consensus essential criteria for assessment of CRS control were: overall symptom severity, need for CRS-related systemic corticosteroids in the prior 6 months, severity of nasal obstruction, and patient-reported CRS control. Near-consensus items were: nasal endoscopy findings, severity of smell loss, overall quality of life, impairment of normal activities and severity of nasal discharge. Participants’ comments provided insights into caveats of, and disagreements related to, near-consensus items. CONCLUSIONS: Overall symptom severity, use of CRS-related systemic corticosteroids, severity of nasal obstruction, and patient-reported CRS control are widely agreed upon essential criteria for assessment of CRS disease control. Consideration of near-consensus items to assess CRS control should be implemented with their intrinsic caveats in mind. These identified consensus CRS control criteria, together with evidence-based support, will provide a foundation upon which CRS control criteria with wide-spread acceptance can be developed.

EPOS/EUFOREA update on indication and evaluation of Biologics in Chronic Rhinosinusitis with Nasal Polyps 2023.

Severe chronic rhinosinusitis with nasal polyps (CRSwNP) is a debilitating disease with a significant impact on the quality of life (QoL). It is typically characterized by a type 2 inflammatory reaction and by comorbidities such as asthma, allergies and NSAID-Exacerbated Respiratory Disease (N-ERD). Here, the European Forum for Research and Education in Allergy and Airway diseases discusses practical guidelines for patients on biologic treatment. Criteria for the selection of patients who would benefit from biologics were updated. Guidelines are proposed concerning the monitoring of the drug effects that provide recognition of responders to the therapy and, subsequently, the decision about continuation, switching or discontinuation of a biologic. Furthermore, gaps in the current knowledge and unmet needs were discussed.

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.

A computational fluid dynamics analysis of the effects of size and shape of anterior nasal septal perforations.

BACKGROUND: Nasal septal perforations (NSPs) often cause bleeding, crusting, obstruction, and/or whistling. The objective was to analyze the impact of anterior NSP size and shape on nasal physiology using computational fluid dynamics (CFD). METHODS: A 3-dimensional model of the nasal cavity was constructed from a radiologically normal CT scan using imaging software. Anterior NSPs (ovoid (ONSP): 0.5, 1, 2, and 3 cm long anterior-to-posteriorly and round (RNSP, 0.5 and 1 cm)) were virtually created in the model and divided into ventral, dorsal, anterior, and posterior regions. Steady-state inspiratory airflow, heat, and water vapor transport were simulated using Fluent CFD software. Air crossover through the perforation, wall shear, heat flux, water vapor flux, resistance, and humidification were analyzed. RESULTS: Air crossover and wall shear increased with perforation size. Regionally, wall shear and heat and water vapor flux were highest posteriorly and lowest anteriorly, generally increasing with size in those regions. RNSPs had greater heat and water vapor flux compared to corresponding size ONSPs. Resistance decreased by 10% or more from normal only in the 3 cm ONSP. Maximum water content was achieved more posteriorly in larger NSP nasal cavities. CONCLUSIONS: High wall shear and heat and water vapor flux in posterior perforation regions may explain the crusting most commonly noted on posterior NSP edges. This preliminary study suggests that larger NSPs have a greater effect on nasal resistance and water content. Decrease in resistance with larger NSP size may be implicated in reported symptomatic improvement following enlargement of NSPs for treatment.

Self-reported anxiety and depression unchanged after endoscopic sinus surgery for chronic rhinosinusitis.

BACKGROUND: Prior research has established that anxiety and depression, as measured by the Hospital Anxiety Depression Score (HADS), are strongly correlated with disease-specific quality of life (Rhinosinusitis Disability Index - RSDI) in chronic rhinosinusitis (CRS). We hypothesized that anxiety and depression would decrease after functional endoscopic sinus surgery (FESS), and furthermore that HADS would predict improvement in RSDI following surgery. METHODOLOGY: The study cohort from 2014 consisted of 99 CRS patients who underwent nasal endoscopy, RSDI, and HADS evaluation. The cohort was segregated by whether or not they underwent FESS and an updated HADS was administered. For 44 surgical patients, pre- and post-operative RSDI (n=38), Lund-Kennedy (LK) (n=34) and HADS (n=18) scores were compared. Delta RSDI was compared between patients with varying levels of anxiety and depression. RESULTS: Lund-Kennedy scores improved from 5.8 ± 4.1 to 3.2 ± 2.6 following surgery, as did total RSDI (39.3 ± 26.8 to 24.6 ± 29.2). Total HADS (9.8 ± 6.4 to 11.3 ± 7.4) and depression and anxiety subscores were unchanged. Linear regression did not reveal a correlation between HADS and change in RSDI following FESS. Delta RSDI was not significantly different between patients with varying levels of anxiety and depression. CONCLUSIONS: Despite improvements in objective evidence of sinonasal inflammation (LK) and disease-specific quality of life (RSDI), neither depression nor anxiety improved after FESS, nor did the magnitude of psychological comorbidity predict post-operative improvement in quality of life. Improvement in RSDI was not different among patients with varying levels of anxiety and depression. Levels of depression and anxiety may be hard-wired, and therefore not influenced by changes in objective or perceived sinonasal disease burden.

A computational study of functional endoscopic sinus surgery and maxillary sinus drug delivery.

BACKGROUND: Topical medication is increasingly used following functional endoscopic sinus surgery (FESS). Information on particle sizes that maximise maxillary sinus (MS) delivery is conflicting, and the effect of antrostomy size on delivery is unclear. The purpose of this study was to estimate antrostomy and particle size effects on topical MS drug delivery. METHODOLOGY: Sinonasal reconstructions were created from a pre- and a post-FESS CT scan in each of four chronic rhinosinusitis patients. Additional models were created from each post-FESS reconstruction representing four alternative antrostomy sizes. Airflow and particle deposition were simulated in each reconstruction using computational fluid dynamics for nebulised and sprayed delivery. RESULTS: MS ventilation and drug delivery increased following FESS, the largest virtual antrostomy led to greatest delivery, and MS delivery was sensitive to particle size. Particles within a 5-18 µm and 5-20 µm size range led to peak MS deposition for nebulised and sprayed particles, respectively. Post-FESS increases in drug delivery varied across individuals and within individuals by the type of antrostomy created. CONCLUSION: Our findings suggest that FESS, particularly with larger antrostomies, improves topical drug delivery, and that certain particle sizes improve this delivery. Further research is needed to contextualise these findings with other post-surgical effects.

Benign lesions of the frontal sinus.

Benign tumors of the frontal sinus including fibro-osseous lesions and inverted papillomata present unique problems for the rhinologist. Because of the bony cavity surrounding the frontal sinus and relatively small portal into the nose, conventional techniques including the osteoplastic flap, frontal trephination, and lynch procedure have provided useful approaches to these tumors. The advent of endoscopic techniques in the management of chronic inflammatory disease of the paranasal and, specifically, frontal sinuses, has led to these traditional techniques being augmented successfully, and, in some cases, surpassed by newer endoscopic techniques. This article reviews the diagnosis and management of the two most common types of benign tumors of the frontal sinus, bony tumors and inverted papillomata, with emphasis on the usefulness of the endoscope in managing such lesions.

Use of the Rhinosinusitis Disability Index (RSDI) in rhinologic disease.

Chronic rhinosinusitis has been shown to have an adverse impact on the quality of life in those afflicted as determined by a number of standardized outcome tools. We have utilized a standardized, statistically validated, disease-specific tool, the Rhinosinusitis Disability Index (RSDI), to investigate the disability suffered by 292 consecutive patients with nine unique rhinologic diagnoses, including chronic rhinosinusitis. Physical, functional, and emotional domains were assessed. We have found that individuals with rhinologic disease in general have lower physical scores, followed by functional scores and emotional scores. Individuals with chronic rhinosinusitis and allergic rhinitis have the greatest level of disability, while those with aspirin triad are least affected.

Safety and efficacy of endoscopic repair of CSF leaks and encephaloceles: a survey of the members of the American Rhinologic Society.

The purpose of this article is to review the endoscopic management of cerebrospinal fluid (CSF) leaks and encephaloceles, with particular emphasis on safety and efficacy, by retrospective assessment utilizing the results of a mailed questionnaire. Surveys were mailed to members of the American Rhinologic Society with practices in both academic centers and/or private settings. Survey results were then assessed and tabulated. There were 635 mailings, with 197 responses (31%). Seventy-two (36% of respondents) indicated that they performed endoscopic management of CSF leaks and encephaloceles, while 125 (64% of respondents) did not. Respondents reported approximately 522 cases of CSF leaks and approximately 128 cases of encephaloceles managed by endoscopy. Success rates after a single procedure were estimated at 90% for CSF leaks and 93% for encephaloceles. Success rates after a secondary procedure were estimated at 86% and 97%, respectively; 29% of respondents have, at some point, made a referral to neurosurgery. A total of 13 complications related to endoscopic repairs were reported (2.5%). For CSF leak repair, complications included seizures, 0.2%; meningitis, 1.1%; and one reported case each of cavernous sinus thrombosis, temporary visual problems, sinusitis, and intracranial hypertension/bleed. There was only one reported death in the approximately 522 cases. Eleven complications following encephalocele repairs (8.5%) included seizures, 3.1%; meningitis, 2.3%; and one reported case each of brain abscess, sinusitis, false aneurysm of middle cerebral artery, and mild dizziness. No deaths following encephalocele repair were reported. The endoscopic management of CSF leaks and encephaloceles has become increasingly popular and has proven to have low morbidity and mortality with high success. Overall, our results confirm that in the hands of the skilled endoscopist, endoscopic management of CSF leaks and encephaloceles is highly efficacious and has a very low incidence of significant complication.

Gastroesophageal reflux and obstructive sleep apnea.

OBJECTIVE: To determine the extent to which gastroesophageal reflux (GER)-initiated laryngeal chemoreflexes contribute to obstructive sleep apnea (OSA). METHODS: Prospective, nonrandomized clinical trial of an antireflux treatment protocol as a means of reducing the severity of OSA. Population consisted of 10 males aged 20 to 64 years with confirmed OSA (by overnight polysomnography) and GER (by ambulatory pH probe monitoring). Patients were treated with omeprazole and standard antireflux protocol for 30 days and pre- and posttreatment polysomnography variables were compared. RESULTS: Mean apnea index declined 31% (45-31, P = .04); mean respiratory disturbance index declined 25% (62-46, P = .06). Three patients (30%) are "treatment responders" as defined by traditional OSA treatment definitions. CONCLUSIONS: These results suggest a potential relationship between OSA and GER, the treatment of which may be an effective adjunctive in those with both disorders. Treatment of GER may significantly impact OSA in select individuals.

Efficacy of uvulopalatopharyngoplasty in unselected patients with mild obstructive sleep apnea.

OBJECTIVES: Uvulopalatopharyngoplasty (UPPP) is widely used as a first-step procedure for the surgical management of obstructive sleep apnea (OSA) syndrome but best manages obstruction occurring at the level of the oropharynx alone and not the hypopharynx. Previous publications have noted mediocre results with use of this procedure in unselected patients with OSA, but less clear is the effectiveness of this procedure in the unselected patient with mild OSA (respiratory event index [REI] 5-25). Using objective and subjective criteria, we retrospectively analyzed the results of UPPP in patients with mild OSA. METHODS: We examined 37 patients with mild OSA (REI 13.5 +/- 5.1, range 5.6-23.1) who had been operated on during 1996 with UPPP with or without tonsillectomy and/or septoplasty. Follow-up polysomnography was obtained in 25 (68%) an average of 40.5 weeks after surgery and compared with findings before surgery. Subjective assessment of sleepiness was performed with the Sleep-Wake Activity Inventory. RESULTS: Ten patients (40%) had a postoperative reduction in the REI of more than 50%, comparable with the improvements reported in those with more severe apnea. Those who did not have a reduction in REI after surgery actually saw an increase in average REI from 16.6 +/- 5 to 26.7 +/- 18.4. Similarly, subjective assessment of sleepiness with the Sleep-Wake Activity Inventory showed no statistically significant improvement after surgery. CONCLUSION: Overall, these results indicate that UPPP alone in the unselected patient provides little benefit in the management of mild OSA, similar to findings for more severe OSA. Surgeons must use great care in discerning the level of obstruction in the patient with mild OSA to tailor the appropriate retropalatal and/or retrolingual procedures and thereby achieve excellent surgical outcomes.

Applications of in situ hybridization techniques in the diagnosis of chronic sinusitis.

The clinical significance of positive bacterial cultures in chronic sinusitis is often difficult to assess. Contaminants from surface colonization of the sinus mucosa may be difficult to distinguish from true intramucosal or bone involvement. Furthermore, tissue Gram stains are frequently unable to demonstrate the presence of bacteria in tissue despite endoscopic evidence of active sinusitis. In situ hybridization (ISH) techniques using bacterial rRNA probes were applied to evaluate the presence of intramucosal and intraosseous bacteria in chronic sinusitis surgical specimens. A total of 22 specimens of chronically inflamed human ethmoid bone were evaluated by ISH and by Gram stain. In three specimens, ISH identified bacterial rRNA within sinus mucosa and mucin. Notably, in these three ISH-positive specimens, Gram stain was negative in two. No specimen showed evidence of bacterial rRNA within bone. These preliminary results suggest that in situ hybridization may be a useful adjunct to current methods of detecting microorganisms within chronically infected sinus tissue.

Long-term impact of functional endoscopic sinus surgery on asthma.

Using objective and subjective criteria, we performed a study to assess the long-term impact of functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis and asthma at an average follow-up of 6.5 years. One hundred twenty patients who underwent FESS for chronic rhinosinusitis were followed up for an average of 6.5 years (range 6.0 to 10.6 years). Seventy-two (60%) patients responded to a follow-up questionnaire, and 30 (42%) of them reported a history of asthma. Subjective levels of improvement and assessments of medication need were evaluated and statistically assessed with parametric and nonparametric methods. Of these 30 patients, 27 (90%) reported that their asthma was better than it had been before FESS, 6.5 years ago. Average reported improvement increased from 49% at 1.1 years after surgery to 65% at 6.5 years after surgery. Asthma attacks declined in 20 of 27 (74.1%). Medication use for asthma showed similar improvement, with approximately half reporting less inhaler usage and nearly two thirds reporting less oral steroid use. This study demonstrates that a combination of FESS, careful postoperative care, and appropriate medical therapy for chronic rhinosinusitis has a favorable long-term effect on asthma in patients with symptomatic chronic sinusitis. In this study asthma severity, frequency of attacks, and medication need were all improved.

Effect of uvulopalatopharyngoplasty and genial and hyoid advancement on swallowing in patients with obstructive sleep apnea syndrome.

OBJECTIVE: Uvulopalatopharyngoplasty (UPPP) and genial and hyoid advancement (GHA) are surgical techniques for the treatment of obstructive sleep apnea. These techniques enlarge the oropharyngeal and hypopharyngeal airway, reducing collapse at these levels. This study evaluated the effect of these procedures on swallowing. METHODS: Fifteen patients who had undergone UPPP and GHA were evaluated with a modified barium swallow to assess biomechanical changes in swallowing. Specifically, velopharyngeal insufficiency; changes in tongue-base movement, laryngeal elevation, and closure; epiglottic movement; and pharyngoesophageal opening were examined. A brief swallowing questionnaire was administered to assess for subjective changes in swallowing. RESULTS: Nine of 15 patients demonstrated abnormal objective swallow, of whom 5 reported normal subjective swallowing. Six of 15 demonstrated normal objective swallowing. Of these, 5 reported subjective change. CONCLUSION: UPPP with GHA may alter biomechanical events during deglutition. However, little correlation exists between subjective symptoms and objective findings. Further studies that include preoperative and postoperative modified barium swallows are needed to identify a cause-and-effect relationship.

Histology and histomorphometry of ethmoid bone in chronic rhinosinusitis.

Mucosal changes have been well described in chronic sinusitis, yet little is known about the underlying bone, despite clinical and experimental evidence suggesting that bone may be involved in chronic sinusitis. Techniques of undecalcified bone analysis were used for detailed histologic examination of ethmoid bone in chronic sinusitis compared with controls. Bone synthesis, resorption, and inflammatory cell presence were specifically assessed. Additionally, histomorphometry techniques were used to determine ethmoid bone physiology in individuals undergoing surgery for chronic sinusitis. Overall, individuals undergoing surgery for chronic sinusitis were found to have evidence of marked acceleration in bone physiology with histologic changes including new bone formation, fibrosis, and presence of inflammatory cells. These findings are compared with osteomyelitis in long bone and the jaw. The suggestion that underlying bone may serve as a catalyst for chronic sinusitis is supported and implications for therapy are discussed.

Long-term results of functional endoscopic sinus surgery.

Although much has been reported on the short-term outcomes of functional endoscopic sinus surgery (FESS), little has been reported with regard to its long-term impact on chronic sinusitis. The senior author (D.W.K.) previously reported detailed subjective and endoscopic follow-up on 120 patients at a mean of 18 months following surgery. This current study represents a long-term follow-up (average, 7.8 years) of 72 patients (60%) from the same cohort. Of patients responding to a question about overall symptoms, 98.4% (n = 66) reported improvement compared with before surgery. There was a trend toward continued subjective improvement in symptom scores with longer follow-up, but the changes did not reach statistical significance. Thirteen patients (18%) required subsequent surgical procedures. Preoperative stage, prior surgery, and other factors that might affect outcome were evaluated. The study demonstrates that excellent subjective results following FESS can be maintained in the long term with appropriate postoperative management. The study also validates the concept that patients in whom the cavity can be normalized following surgery are unlikely to require further surgery.

The development of the Rhinosinusitis Disability Index.

Assessment of patient perception of disability and outcomes from treatment has become an integral part of medical care. General quality-of-life measurement tools have led to the development of disease-specific quality instruments. Conventional methods for evaluating nasal-sinus disease are inadequate to assess the impact of these disorders on everyday life. Therefore, using methods that are well established and validated for creating instruments, the Rhinosinusitis Disability. Index was created to evaluate the self-perceived impact of disease-specific head and neck disorders. The development of the preliminary and final versions (30 items) of the Rhinosinusitis Disability Index is described. Content-related validity using Cronbach's alpha measurement and construct-related validity were accomplished. A comparison of the responses between patients with and without documented nasal or sinus disease was used to verify that the Rhinosinusitis Disability Index is a valid measuring instrument for patients with sinus disease, and test-retest validity reveals reliability over time.

Computer-assisted resection of benign sinonasal tumors with skull base and orbital extension.

OBJECTIVE: To use freehand, real-time, intraoperative, 3-dimensional computed tomography (3-D CT) localization to assist with resection of sinonasal lesions with skull-base and/or orbital extension. DESIGN: The 3-D CT is computer-assisted technology using the preoperative CT scan as a road map for resection of lesions. Previous technology, while resulting in little intraoperative error, required use of a somewhat cumbersome rigid articulated arm and attached probe, limiting mobility and requiring rigid fixation of the head to maintain system reference. A new freehand version of this technology, eliminating these limitations, has been used for resection of benign sinonasal lesions with skull-base and/or orbital extension. SETTING: Tertiary care, university-based practice. PATIENTS: Seven patients prospectively selected with benign lesions involving the sinonasal cavity and orbit and/or skull base. INTERVENTION: All patients underwent surgical resection of their tumors using endoscopic, open, or combined procedures with the assistance of freehand 3-D CT localization. MAIN OUTCOME ASSESSMENTS: Surgeon assessment of usefulness. RESULTS: In several cases, the device assisted the operator in determining the exact location of a displaced optic nerve, ensuring vision preservation, while in other cases, the location and depth of skull-base penetration was clearly determined, allowing resection via a transnasal endoscopic approach. In addition, the device was useful for determining the depth of necessary resection for optimal cosmetic result. In all cases, system accuracy was within less than 2 mm at the operative site. System limitations included need for an additional preoperative CT and time required at the beginning of the case for system setup and registration. CONCLUSIONS: Freehand 3-D CT, while still with limitations, offers the advantage of increased surgical safety, aiding anatomic understanding in distorted surgical fields for resection of benign sinonasal tumors with orbital and skull-base extension.

Endoscopic sinus surgery. A review.

Endoscopic sinus surgery has progressed from a limited surgical intervention for chronic sinus disease to a viable approach for diffuse sinonasal polyposis, benign tumors, skull base defects, and orbital lesions. Some aspects of endoscopic diagnosis and treatment, however, remain controversial and are poorly understood. Controversies in endoscopic sinus surgery are reviewed and the primary critical issues with regard to the more recently developed instrumentation and the newer extended approaches are presented.

Management of sinusitis in the asthmatic patient.

OBJECTIVE: To describe pathophysiologic links between sinusitis and asthma; to identify means of diagnosing sinusitis in the asthmatic; to discuss the management of asthmatic patients with sinusitis, both medical and surgical; to examine the outcome of managing the asthmatic patient with sinusitis. DATA SOURCES: Prospective and retrospective data from the author's experience was evaluated. Medline database was searched from January 1, 1984, using the keywords "asthma" and "sinusitis" without restriction to species or language; 48 articles identified. Relevant articles referenced in retrieved sources, current texts in otorhinolaryngology and sinus disease were also utilized. STUDY SELECTION: From data source abstracts, pertinent articles (33) and book chapters meeting the objectives of our paper were intensively reviewed. RESULTS: Clinical and experimental studies indicate that sinonasal inflammation can result in worsening of lower airway disease, while the exact nature of this relationship remains debated. Regardless of mechanism, identification of the asthmatic patient with chronic sinusitis using the techniques of nasal endoscopy and CT scanning can lead to treatment of sinusitis with overall sinus and asthmatic disease improvement. Proper management is first medical, while surgical approaches are reserved for persistent cases. Traditional, more radical, surgical approaches have shown good results overall, while newer techniques of functional endoscopic sinus surgery which respect anatomy and mucosal function are less studied but expected to result in similar or better long-term outcome. CONCLUSIONS: Sinusitis and asthma coexist and impact on one another at many different levels. Proper identification of the asthmatic patient with chronic sinusitis can be readily discerned by an accurate and thorough history and physical examination including nasal endoscopy and CT scanning. Proper medical and surgical management of sinusitis in the asthmatic patient can result in both improved sinonasal and asthmatic symptoms with fewer physician visits and decreased need for medication.