Amin R. Javer

Canadian clinical practice guidelines for acute and chronic rhinosinusitis

This document provides healthcare practitioners with information regarding the management of acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) to enable them to better meet the needs of this patient population. These guidelines describe controversies in the management of acute bacterial rhinosinusitis (ABRS) and include recommendations that take into account changes in the bacteriologic landscape. Recent guidelines in ABRS have been released by American and European groups as recently as 2007, but these are either limited in their coverage of the subject of CRS, do not follow an evidence-based strategy, or omit relevant stakeholders in guidelines development, and do not address the particulars of the Canadian healthcare environment.Advances in understanding the pathophysiology of CRS, along with the development of appropriate therapeutic strategies, have improved outcomes for patients with CRS. CRS now affects large numbers of patients globally and primary care practitioners are confronted by this disease on a daily basis. Although initially considered a chronic bacterial infection, CRS is now recognized as having multiple distinct components (eg, infection, inflammation), which have led to changes in therapeutic approaches (eg, increased use of corticosteroids). The role of bacteria in the persistence of chronic infections, and the roles of surgical and medical management are evolving. Although evidence is limited, guidance for managing patients with CRS would help practitioners less experienced in this area offer rational care. It is no longer reasonable to manage CRS as a prolonged version of ARS, but rather, specific therapeutic strategies adapted to pathogenesis must be developed and diffused.Guidelines must take into account all available evidence and incorporate these in an unbiased fashion into management recommendations based on the quality of evidence, therapeutic benefit, and risks incurred. This document is focused on readability rather than completeness, yet covers relevant information, offers summaries of areas where considerable evidence exists, and provides recommendations with an assessment of strength of the evidence base and degree of endorsement by the multidisciplinary expert group preparing the document.These guidelines have been copublished in both Allergy, Asthma & Clinical Immunology and the Journal of Otolaryngology-Head and Neck Surgery.

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.

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.

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis

Isam Alobid, MD, PhD1, Nithin D. Adappa, MD2, Henry P. Barham, MD3, Thiago Bezerra, MD4, Nadieska Caballero, MD5, Eugene G. Chang, MD6, Gaurav Chawdhary, MD7, Philip Chen, MD8, John P. Dahl, MD, PhD9, Anthony Del Signore, MD10, Carrie Flanagan, MD11, Daniel N. Frank, PhD12, Kai Fruth, MD, PhD13, Anne Getz, MD14, Samuel Greig, MD15, Elisa A. Illing, MD16, David W. Jang, MD17, Yong Gi Jung, MD18, Sammy Khalili, MD, MSc19, Cristobal Langdon, MD20, Kent Lam, MD21, Stella Lee, MD22, Seth Lieberman, MD23, Patricia Loftus, MD24, Luis Macias‐Valle, MD25, R. Peter Manes, MD26, Jill Mazza, MD27, Leandra Mfuna, MD28, David Morrissey, MD29, Sue Jean Mun, MD30, Jonathan B. Overdevest, MD, PhD31, Jayant M. Pinto, MD32, Jain Ravi, MD33, Douglas Reh, MD34, Peta L. Sacks, MD35, Michael H. Saste, MD36, John Schneider, MD, MA37, Ahmad R. Sedaghat, MD, PhD38, Zachary M. Soler, MD39, Neville Teo, MD40, Kota Wada, MD41, Kevin Welch, MD42, Troy D. Woodard, MD43, Alan Workman44, Yi Chen Zhao, MD45, David Zopf, MD46

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.

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).

Medical management of allergic fungal rhinosinusitis following endoscopic sinus surgery: an evidence‐based review and recommendations

Allergic fungal rhinosinusitis (AFRS) is a subset of polypoid chronic rhinosinusitis that is characterized by the presence of eosinophilic mucin with fungal hyphae within the sinuses and a Type I hypersensitivity to fungi. The treatment of AFRS usually involves surgery in combination with medical therapies to keep the disease in a dormant state. However, what constitutes an optimal medical regimen is still controversial. Hence, the purpose of this article is to provide an evidence‐based approach for the medical management of AFRS.

A systematic review of factors associated with health-related quality of life in adolescents and adults with cystic fibrosis.

RATIONALE As the life expectancy for individuals with cystic fibrosis (CF) continues to improve, an emphasis on optimizing health-related quality of life (HRQoL) has become increasingly important. The Cystic Fibrosis Questionnaire-Revised (CFQ-R 14+) is the most widely accepted method to quantify HRQoL in this patient population. OBJECTIVES Our objective was to systematically review the literature to identify sociodemographic and clinical factors associated with HRQoL among adolescents and adults with CF. METHODS Five major literature databases were searched (MEDLINE, EMBASE, CENTRAL, CINAHL, psychINFO) to identify studies published from January 1989 to April 2014 (n=1,921). We included all full-text studies that: (1) focused on individuals 14 years of age or older, and (2) examined the relationship between sociodemographic (age, sex, body-mass index [BMI], socioeconomic status, and employment) and clinical (FEV1 % predicted, pulmonary exacerbation, comorbidities) factors with the CFQ-R 14+. Effect estimates and levels of statistical significance in the association between sociodemographic and clinical factors with each of the 12 CFQ-R 14+ domains were analyzed, if examined in at least two studies. MEASUREMENTS AND MAIN RESULTS Twenty-eight articles met our inclusion/exclusion criteria, but 5 studies were excluded at the data synthesis stage, leaving 23 articles for analysis. In relation to the CFQ-R 14+, 10 candidate factors were examined in at least two studies. The five most commonly studied factors were FEV1 % predicted (57.1% of 28 studies), sex (32.1%), BMI (28.6%), age (17.6%), and pulmonary exacerbations (13%). In studies incorporating multivariable methods, FEV1 % predicted was positively associated with all CFQ-R 14+ domains with the exception of Digestion, Social Functioning, and Emotional Functioning. Male subjects reported higher Physical Functioning and lower Body Image scores than female subjects, BMI was positively correlated with Body Image and Weight, and age was negatively correlated with Treatment Burden. Pulmonary exacerbations were negatively associated with multiple domains, including Respiratory Symptoms, Physical, and Role Functioning. CONCLUSIONS Although several factors have been found to be associated with the CFQ-R in adolescents and adults with CF, FEV1 % predicted and pulmonary exacerbations have the broadest impact on HRQoL. Further research is required to investigate the impact of age-related comorbidities, psychosocial factors, and treatment-related factors on HRQoL in adolescents/adults with cystic fibrosis.

Patient quality of life improvements with and without computer assistance in sinus surgery: outcomes study.

BACKGROUND Chronic rhinosinusitis affects millions of North Americans and has been increasing annually since 1991. This study aimed to evaluate the effectiveness of functional endoscopic sinus surgery (FESS) done with the use of computer assistance (CASS) and without the use of computer assistance on patient quality of life. As of this writing, there is no published study that measures the difference in patient quality of life with and without image guidance in endoscopic sinus surgery. METHODS A nonrandomized prospective study was performed on 95 patients. A 31-item quality of life (Rhinosinusitis Outcome Measures Form [RSOM-31]) questionnaire was administered to patients prior to surgery and 6 months following surgery during a 3-year enrollment period. Patients assessed both rhinologic and nonrhinologic symptoms using a statistically validated scoring system. Statistical analysis was performed using both equal and unequal variance sample t-tests when appropriate. RESULTS Statistically significant improvement in mean score analysis between preoperative and postoperative results for all symptom subgroups was reported when the entire study population was included. When the improvement in quality of life was compared between the CASS and FESS surgical groups, the CASS group demonstrated an overall greater improvement in quality of life. CONCLUSION Quality of life restrictions in patients with chronic rhinosinusitis were greatest in the areas of nasal symptoms and sleep deprivation, which were significantly improved by endoscopic sinus surgery. Although the long-term effect of CASS as measured by patient quality of life remains relatively unknown, there appears to be a significant trend indicating greater quality of life improvement in the short- term over non-computer-assisted FESS techniques.

Effectiveness of intraoperative mitomycin C in maintaining the patency of a frontal sinusotomy: a preliminary report of a double-blind randomized placebo-controlled trial.

Background Postoperative scarring in the frontal recess is the most common cause of iatrogenic frontal sinusitis. Topical mitomycin-C (MMC) is an antifibroblastic agent that has been shown to reduce clinical scarring. This is a preliminary report of a double-blind, randomized, placebo-controlled trial using MMC to determine its effectiveness in reducing frontal recess stenosis after frontal sinusotomy. Methods All patients with chronic rhinosinusitis undergoing primary or revision bilateral image-guided endoscopic sinus surgery were enrolled. Patients requiring frontal sinus stents and those with allergic fungal sinusitis were excluded. After completion of the frontal sinusotomy, dimensions of the frontal recess were measured using curved Frazer suction diameters. A neuropattie soaked in 0.5 mg/mL of MMC was then placed into one frontal recess for 4 minutes in a randomized manner. A saline control was used for the other side. The primary surgeon was blinded to the medicated side intraoperatively and throughout the follow-up period. Measurements of the frontal recess were repeated at 1, 3, and 6 months. Results There was no difference in the degree of frontal recess stenosis between the MMC and control sides at 1, 3, and 6 months postoperatively for both primary and revision cases. Conclusion One-time intraoperative topical MMC is not effective in reducing postoperative frontal recess stenosis in both primary and revision cases.