Alexander C. Chester

Symptom-specific outcomes of endoscopic sinus surgery: A systematic review

Background: Although multiple studies have demonstrated that symptoms of chronic rhinosinusitis (CRS) improve after endoscopic sinus surgery (ESS), a systematic large-scale evaluation of specific symptom response has not been performed. Objective: To analyze the relative effectiveness of surgery in the improvement of individual CRS symptoms. Study Design: A literature search of MEDLINE, EMBASE, Web of Science, Cochrane databases, and other Web-based sources from January 1, 1980 through June 1, 2008 was performed. Studies of 20 or more adult patients with CRS that used symptom severity scores to analyze at least 3 major CRS criteria (facial pressure, nasal obstruction, postnasal discharge, and hyposmia) or 2 major CRS criteria plus headache were included. Subjects and Methods: Inclusion criteria were met by 21 of 289 ESS studies reviewed. Meta-analysis was conducted for each symptom separately with the standardized difference between the preoperative and postoperative severity scores as the effect size (ES). Results: A total of 2070 patients with CRS were studied a mean of 13.9 months after ESS. All symptoms demonstrated improvement compared with their respective preoperative severity scores by an overall ES of 1.19 (95% confidence interval, 0.96 to 1.41; I 2 = 81.7%) using the random-effects model. Nasal obstruction (ES, 1.73) improved the most, with facial pain (ES, 1.13) and postnasal discharge (ES, 1.19) demonstrating moderate improvements. Hyposmia (ES, 0.97) and headache (ES, 0.98) improved the least. Conclusion: The relative improvements in major CRS symptoms and headache after surgery are similar, with the exception of nasal obstruction, which improves most.

Tubular Function in Adult Polycystic Kidney Disease

Various tubular functions were assessed in 10 patients with polycystic kidney disease (PKD). Three relatively unique abnormalities were apparent in many of these patients -- an inability to maximally concentrate urine, a decrease in ability to lower urine pH after acute acid challenge, and an inability to excrete adequate amounts of ammonium during persistent acid challenge. The defects in urinary acidification and ammonium excretion in PKD have not been previously described.

Fatigue Improvement Following Endoscopic Sinus Surgery: A Systematic Review and Meta‐Analysis

Background: Fatigue is a common symptom of chronic rhinosinusitis (CRS), yet the response of fatigue to endoscopic sinus surgery (ESS) has not been systematically evaluated.

Symptom Outcomes in Endoscopic Sinus Surgery: A Systematic Review of Measurement Methods†

Objective: To determine the type and prevalence of measurement methods used to analyze symptom outcomes after endoscopic sinus surgery (ESS).

Giardiasis as a chronic disease

In an effort to better describe the incidence and characteristics of chronic giardiasis in an urban private practice outpatient setting, we reviewed our experience of 65 cases. In the entire group, the mean duration of symptoms was 1.9 years. A history of foreign travel was described by 45%. No association with homosexuality was noted. Chronic giardiasis, defined as that population symptomatic for six months or longer, constituted 58% of the entire group (38 cases). For these patients the mean duration of symptoms was 3.3 years. When compared to acute giardiasis, an increased frequency of constipation and upper gastrointestinal complaints was noted in the chronic population. Symptomatic cure was obtained in 71% of chronic cases and 93% of acute. Palliative results were noted in 18% of chronic cases and 4% of acute. We conclude that giardiasis is frequently a chronic disease in our population with symptoms lasting years. The incidence is similar in both sexes and a history of foreign travel is often absent. A disproportionate incidence in male homosexuals was not noted in our study.

Systematic review of change in bodily pain after sinus surgery

Objectives To determine whether bodily pain is increased in patients with chronic rhinosinusitis (CRS) and if bodily pain improves following endoscopic sinus surgery (ESS). Methods All studies reporting results of more than 10 adult patients analyzing the response of bodily pain to ESS were retrieved by searching MEDLINE, EMBASE, Web of Science, Cochrane databases, and additional web-based sources (from January 1, 1980, to May 1, 2008); by examining bibliographies of retrieved articles; and by contacting investigators in the field. Results Of 279 ESS symptom outcome studies, only studies measuring results using the 36-Item Short Form Health Survey (SF-36) quality-of-life survey instrument measured bodily pain. Eleven observational ESS studies (1019 patients) reported mean preoperative SF-36 bodily pain scores at 0.89 SD below general population norms (24% more severe bodily pain than general population norms) and significantly below norms for a population 25 years older. Using a repeated-measures design, nine of 11 studies noted significant improvement in SF-36 bodily pain domain scores following ESS, with a moderate-sized combined effect of 0.55 (95% confidence interval, 0.45–0.64; I 2 = 44%) using the fixed-effects model. This pooled effect corresponded to a mean improvement of 11.8 U on the SF-36 bodily pain domain scale. Conclusions Bodily pain is increased in patients with CRS awaiting ESS, exceeding the normative bodily pain scores of a general normative population 25 years older. Using within-subject comparisons, a clinically and statistically significant improvement in bodily pain is noted after ESS, an improvement similar to that previously described for fatigue.

Hypersensitivity to salicylazosulfapyridine: renal and hepatic toxic reactions.

Salicylazosulfapyridine has been used for a number of years as therapy for ulcerative colitis. Reported toxicities are usually minor. This case report represents an acute allergic reaction to the drug. Characterized by fever, rash, eosinophilia, nephritis, and hepatitis. Resolution occurred with discontinuation of salicylazosulfapyridine. Although similar reactions have been reported with the antimicrobial sulfonamides, none has been fully described with salicylazosulfapyridine, a combination of a sulfonamide and salicylate.

The effects of endoscopic sinus surgery on level of fatigue in patients with chronic rhinosinusitis.

Background Fatigue is a common symptom of chronic rhinosinusitis (CRS), but the response of fatigue to endoscopic sinus surgery (ESS) is rarely studied. Methods A prospective, open cohort of adult patients undergoing ESS for CRS was studied using 10-cm fatigue visual analog scales (VASs), Lund-MacKay computed tomography (CT), and Lund-Kennedy nasal endoscopy scoring. Results Two hundred seventy-two patients, followed for a mean (±SD) of 16.5 ± 8.5 months after ESS, noted significant fatigue improvement with an effect size defined as large by Cohen (0.8 [95% CI, 0.5–1.3]). Neither preoperative CT scores nor preoperative endoscopy scores correlated with preoperative fatigue severity. Compared with the mean preoperative fatigue score (6.1 ± 2.9 cm), preoperative fatigue was more severe in women (6.9 ± 2.6 cm; p < 0.001) patients with depression (7.7 ± 2.4 cm; p < 0.001) and patients with fibromyalgia (7.9 ± 2.2 cm; p = 0.013), but less severe in patients with nasal polyposis (5.4 ± 3.2 cm; p = 0.009). Significantly greater postoperative reduction in fatigue was noted in patients with fibromyalgia when compared with study patients without fibromyalgia (effect size = 1.8 [95% CI, 1.6–2.2]; p > 0.001) with final fatigue severity scores similar to the entire study group. Similarly, patients with severe fatigue (n = 112; mean VAS score, 8.8 ± 0.8 cm) showed a more pronounced improvement than patients less severely fatigued (n = 160; mean VAS score 4.2 ± 2.4 cm; effect size = 2.2 [95% CI, 2.0–2.9]; p > 0.001). Conclusion Fatigue improves after ESS, with significantly greater improvement in patients with fibromyalgia and in patients that are more severely fatigued at presentation.

Case report: Peripheral polyneuropathy and mefloquine prophylaxis.

We describe a case of a woman who developed a peripheral polyneuropathy shortly after completing 4 weekly doses of mefloquine hydrochloride (250 mg) malaria prophylaxis. Although mefloquine-related central nervous system neuropathy is well described in the literature, peripheral polyneuropathy similar to this case has been documented only once before, to our knowledge.

Endoscopic sinus surgery and evidence-based medicine: The gold standard requires gold

The need to establish efficacy of chronic rhinosinusitis treatments using evidence-based medicine (EBM) was well described in a recent Otolaryngology–Head and Neck Surgery supplement issue. The power of these evaluations by the Cochrane Library, in particular, to influence patients, practitioners, and policy is hard to overstate. Despite substantial efforts to select and synthesize appropriate studies for EBM analysis, the conclusions are occasionally problematic. For instance, the Cochrane Library’s systematic review of endoscopic sinus surgery (ESS) concludes that the procedure “does not confer additional benefit to that obtained by medical treatment” in relieving the symptoms of chronic rhinosinusitis based on the studies selected. This conclusion stands as the only EBM assessment of ESS efficacy that I am aware of and is based on limited evidence. Although approximately 200 observational studies generally describe a success rate greater than 85%, findings of the three randomized controlled trials selected for analysis by the Cochrane Library suggest, according to the reviewers, no advantage for ESS over medical treatment. However, the studies miss the mark. The first study reported no differences in medical and surgical outcomes among groups not receiving initial medical therapy that included antibiotics, a generally accepted prerequisite for ESS. The second study compared symptom improvement in isolated maxillary sinusitis noted after ESS vs after saline rinses among patients randomized before antibiotics were administered. The third study (a thesis) compared 12 patients receiving functional endoscopic middle meatal antrostomy vs 17 patients receiving conventional intranasal inferior meatal antrostomy, noting symptom improvement in both groups but no differences between groups; 1-year follow-up data were available for 11 patients vs 9 patients, a sample size the author acknowledges as being too small to exclude a type II error. There is insufficient evidence for any comment about the worth of ESS compared with medical treatment based on these three studies. One study does not compare ESS with medical treatment, and the other two studies do not analyze ESS results among patients who failed medical treatment, including antibiotic therapy. The reluctance of practitioners to quickly integrate EBM into medical practice reflects, in part, a concern that some conclusions are not justified by the data. Furthermore, many believe in this case that the results of numerous carefully designed observational studies of ESS efficacy should have some relevance in the assessment of the procedure when the