Donald C. Lanza

Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology.

Abstract Chronic rhinosinusitis Chronic rhinosinusitis (CRS) is a term that has been used to describe a number of entities characterized by chronic symptoms of nasal and sinus inflammation or infection. There has been a lack of consensus regarding definitions and treatments because CRS may be a spectrum of diseases with a range of appropriate treatments. The absence of widely accepted definitions for CRS has resulted in a paucity of research directed at understanding its pathophysiology and has hampered efforts to improve treatment. A Task Force was convened by the Sinus and Allergy Health Partnership to summarize much of the current and important information available regarding the prevalence, economic impact, pathophysiology, common inflammatory mediators, and the role of infectious microbes such as bacteria and fungi in CRS. The goal is to establish a standard and usable definition. Through this thorough review of the literature and the expert input from Task Force members, a definition was developed that serves to create a consistent baseline so that many of the currently debated or unanswered questions may be addressed. The new and more-specific Task Force definition is that “ Chronic rhinosinusitis is a group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses of at least 12 weeks duration.” Recommended criteria for making the diagnosis of CRS for both clinical care and research were also outlined.

Rhinosinusitis: Establishing definitions for clinical research and patient care

Background There is a need for more research on all forms of rhinosinusitis. Progress in this area has been hampered by a lack of consensus definitions and the limited number of published clinical trials. Objectives To develop consensus definitions for rhinosinusitis and outline strategies useful in clinical trials. Methods Five national societies, The American Academy of Allergy, Asthma and Immunology; The American Academy of Otolaryngic Allergy; The American Academy of Otolaryngology Head and Neck Surgery; The American College of Allergy, Asthma and Immunology; and the American Rhinologic Society formed an expert panel from multiple disciplines. Over two days, the panel developed definitions for rhinosinusitis and outlined strategies for design of clinical trials. Results Committee members agreed to adopt the term “rhinosinusitis” and reached consensus on definitions and strategies for clinical research on acute presumed bacterial rhinosinusitis, chronic rhinosinusitis without polyposis, chronic rhinosinusitis with polyposis, and classic allergic fungal rhinosinusitis. Symptom and objective criteria, measures for monitoring research progress, and use of symptom scoring tools, quality-of-life instruments, radiologic studies, and rhinoscopic assessment were outlined for each condition. Conclusion The recommendations from this conference should improve accuracy of clinical diagnosis and serve as a starting point for design of rhinosinusitis clinical trials.

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

Endoscopic repair of cerebrospinal fluid fistulae and encephaloceles

The authors review their experience with endoscopic repair of skull base defects associated with cerebrospinal fluid (CSF) rhinorrhea and/or encephaloceles involving the paranasal sinuses. Between January 1991 and December 1995, 51 patients were evaluated for anterior and middle cranial fossa defects at a tertiary care facility. Of these patients, 36 underwent endoscopic repair of skull base defects.

Endoscopically Guided Cultures in Chronic Sinusitis

In chronic sinusitis, culture-directed antibiotics are often recommended as a cornerstone of treatment. The significance of Gram-negative rods (GNRs), coagulase-negative Staphylococci (SCN), and Staphylococcus aureus has been controversial. In an effort to determine host factors which correlate with culture results, 507 endoscopically-guided cultures are reviewed from 265 patients. A history of asthma, allergic rhinitis, prior sinus surgery, and the concurrent use of antibiotics, steroids, and irrigations were some of the host factors compared by X2. The results were compared to a control group of 50 cultures from healthy volunteers. SCN, S. aureus, P. aeruginosa, and Streptococcus were the most common isolates. GNRs were present in 27% of cultures and were more common in patients who had prior sinus surgery or were using irrigations. P. aeruginosa was more common in patients taking systemic steroids. SCN occurred with the same incidence in patients and control subjects but was more prevalent in cultures obtained intraoperatively and in patients taking systemic steroids. No identifiable host factor was associated with S. aureus. S. aureus occurred at similar rates in patients and control subjects but grew heavily in patients and exhibited only light growth in controls. Topical nasal steroids appear to have no statistically significant effect on bacterial cultures. Findings from this study further our understanding of chronic sinusitis and may help guide practitioners in the treatment of this disease.

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.

Endoscopically assisted anterior cranial skull base resection of sinonasal tumors.

The traditional approach to sinonasal tumors involving the base of skull has been the anterior craniofacial resection. Endoscopic techniques have created the potential to approach the intranasal aspect of skull base lesions without external incisions and still develop an en bloc resection when removed. We report our initial experience with skull base neoplasms in which the otolaryngic portion of the standard resection was accomplished instead through an endoscopic approach. The nature of lesions favorable for this approach and associated technical issues are discussed. Although we do not consider this approach a replacement for the traditional anterior craniofacial resection, it is an important adjunct in the skull base surgeons armamentarium.

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.

Clinically relevant frontal sinus anatomy and physiology

Management of frontal sinus disease has evolved considerably with the advent of endoscopic paranasal sinus instrumentation. With this evolution has come the increased demand for anatomic competence among otolaryngologists. Armed with a better understanding of the complex frontal sinus and anterior ethmoid complex anatomy, the otolaryngologist can target the anatomic abnormalities that predispose an individual to frontal sinus disease and limit the effectiveness of medical and surgical management.

Endoscopic Management of Sinonasal Inverted Papilloma

Since 1992, 42 patients at the University of Pennsylvania have been treated for inverted papilloma (IP). Thirty-three patients were managed endoscopically with or without a Caldwell Luc approach (CLA) and retrospectively analyzed. The CLA, which involves a gingivobuccal incision for access to the maxillary sinus, is distinguished from a formal Caldwell Luc procedure. These 33 patients with histologically confirmed IP were without evidence of malignancy. They also did not have evidence of intracranial, orbital, or frontal sinus IP. Seventeen of 33 patients (17/33) were without prior treatment (primary). Sixteen of 33 (16/33) presented from an outside institution with recurrent IP (secondary). The recurrence rate using this method to treat primary IP was 6% (1/17), and for secondary IP was 25% (4/16). Scheduled postoperative endoscopic surveillance permitted early detection of recurrence and continued endoscopic control of IP. All 33 patients were endoscopically free of disease at the end of the study. These preliminary data are encouraging for the use of intranasal endoscopy with and without CLA as a means of managing and controlling IP in selected cases.