Eng Cern Gan

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.

Five-degree, 10-degree, and 20-degree reverse Trendelenburg position during functional endoscopic sinus surgery: a double-blind randomized controlled trial

Using the reverse Trendelenburg position (RTP) during functional endoscopic sinus surgery (FESS) is a safe, simple, and cost‐free method that has been found to reduce intraoperative blood loss. However, the critical angle of RTP that produces the least amount of bleeding without compromising surgical technique and safety remains unanswered. The objective of this study was to assess the effects of 5‐degree, 10‐degree, and 20‐degree RTP (5‐RTP, 10‐RTP, and 20‐RTP, respectively) on intraoperative bleeding during FESS.

The safety and efficacy of short-term budesonide delivered via mucosal atomization device for chronic rhinosinusitis without nasal polyposis

Budesonide is a potent corticosteroid commonly prescribed for management of inflammation in chronic rhinosinusitis (CRS). The standard for prescribing budesonide is via impregnated nasal saline irrigation (INSI), although recently the mucosal atomization device (MAD) has emerged as a theoretically superior method of distributing medication into the sinuses. The MAD atomizes medication into small droplets and this is thought to enhance absorption and improve bioavailability. However, no studies have shown whether enhanced absorption and improved bioavailability of budesonide via MAD causes adrenal suppression. The objective of this study is to determine whether budesonide via MAD affects the hypothalamic‐pituitary‐adrenal (HPA) axis.

The effect of head position on the distribution of topical nasal medication using the Mucosal Atomization Device: a cadaver study.

The Mucosal Atomization Device (MAD) distributes medication throughout the paranasal sinuses for patients with chronic rhinosinusitis (CRS). Determining the optimal head position is important to ensure maximal delivery of medication to the sinus cavities. The objective of this work was to determine the effect of the lying‐head‐back (LHB) and head‐down and forward (HDF) position, on the distribution of topical nasal medication via MAD in cadaver specimens.

The efficacy and safety of an office‐based polypectomy with a vacuum‐powered microdebrider

The waiting time for functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) in the Canadian public healthcare system can be lengthy. Many such patients have significant nasal obstruction resulting in a poor quality of life. A simple and safe office‐based polypectomy device to debulk nasal polyps allows immediate alleviation of nasal obstruction and better access for topical medications. The aim of this study is to assess the efficacy, safety, and patient tolerability of a vacuum‐powered microdebrider in the outpatient clinic setting.

Hemostatic effect of hot saline irrigation during functional endoscopic sinus surgery: a randomized controlled trial.

The endoscopically magnified operative field in functional endoscopic sinus surgery (FESS) makes even a small amount of bleeding a potentially significant hindrance. It is thought that irrigation with hot saline during surgery may improve surgical field of view by producing a hemostatic effect. Our objective was to assess the effectiveness of hot saline irrigation (HSI) compared to room temperature saline irrigation (RTSI) in the control of intraoperative bleeding during FESS.

Omalizumab therapy for refractory allergic fungal rhinosinusitis patients with moderate or severe asthma

PURPOSE 1. To assess the efficacy of omalizumab therapy in improving sinonasal outcomes in refractory allergic fungal rhinosinusitis (AFRS) patients with moderate or severe asthma. 2. To determine if omalizumab therapy reduces the usage of corticosteroids or antifungal therapy in AFRS patients METHOD DESIGN The clinical charts of patients with AFRS with moderate or severe asthma who received at least three subcutaneous injections of omalizumab therapy between 1st January 2012 and 1st May 2014 were retrospectively reviewed. These patients had undergone bilateral functional endoscopic sinus surgery (FESS) and failed adjunct medical treatments (oral or topical corticosteroids and/or antifungal therapy) prior to omalizumab therapy. RESULTS Seven patients met the inclusion criteria and were included in this study. The mean age of the patients was 48.14. The average number of subcutaneous omalizumab injections was 7.57 (range 6-11) with a mean dosage of 287mg (range 225-375mg). The mean pre-omalizumab treatment Sino-Nasal Outcome Test-22 (SNOT-22) score was 52.14 while the mean post-omalizumab treatment SNOT-22 score was 35.86 (31% improvement). The mean pre-omalizumab therapy Phillpott-Javer endoscopic score (over the last one year before omalizumab therapy) was 36 while the mean post-omalizumab therapy endoscopic score (from the last clinic visit) was 14 (61% improvement). Omalizumab therapy reduced the dependence of AFRS patients on corticosteroid and antifungal treatments. CONCLUSION Omalizumab therapy can be considered as a potential adjunct for the treatment for patients with refractory AFRS with moderate or severe asthma. However, larger prospective studies to confirm the findings of this study will be required.

The interrater and intrarater reliability of the Philpott-Javer staging system based on level of training.

Objective The Philpott-Javer postoperative endoscopic mucosal staging system for allergic fungal rhinosinusitis has previously demonstrated acceptable interrater reliability among rhinologists. There are, however, numerous learners involved in patient care at tertiary centers. This study aims to analyze the interrater and intrarater reliability of this system among learners in otolaryngology at different stages in training. Study Design A prospective analysis of retrospectively collected endoscopic photographs. Setting A tertiary care teaching hospital (January 2013). Subjects Fifty patients undergoing routine follow-up. Method Three photographs from each of 50 patients undergoing routine postsurgical nasoendoscopy were reviewed. Images were played twice, 1 week apart, in 2 differently randomized cycles and scored according to Philpott-Javer criteria by a rhinologist, a rhinology fellow, a senior otolaryngology resident, a junior otolaryngology resident, and a medical student. Interobserver reliability was assessed using the intraclass correlation coefficient, while intrarater reliability was assessed by Shrout-Fleiss κ values. Agreement between each learner and the rhinologist was also assessed using κ values. Results The interclass correlation among the 5 raters was 0.7600 (95% confidence interval, 0.6917-0.8161) for the Philpott-Javer scoring system, suggesting substantial reliability. Intrarater data showed substantial to almost-perfect reliability (κ values between 0.668 and 0.815) among all raters using this system. There was also moderate to substantial agreement between the learners and the rhinologist (κ values between 0.534 and 0.710). Conclusion Results suggest that the Philpott-Javer staging system has acceptable intrarater and interrater reliability among learners of differing levels of clinical experience and is suitable for evaluating progress following surgery.

Interrater and Intrarater Reliability of Philpott-Javer and Kupferberg Staging following Sinus Surgery Based on Training

Objectives: The Philpott-Javer and Kupferberg endoscopic mucosal staging systems for allergic fungal rhinosinusitis have previously demonstrated acceptable inter-rater reliability among rhinologists. There are, however, numerous learners involved in patient care at tertiary centers. This study aims to 1) Analyze the inter-rater and intra-rater reliability of the Philpott-Javer and Kupferberg scoring systems among otorhinolaryngology learners at different stages in training; 2) Analyze whether the Philpott-Javer scoring system can be used reliably by learners compared to an experienced rhinologist. Methods: This retrospective study examined the endoscopic photographs of patients who had undergone post-surgical endoscopy at a tertiary sinus center in January 2013. 150 Images (3 images randomly selected from 50 patients) were played twice, one week apart, in a randomized loop and scored according to Philpott-Javer and Kupferberg criteria by a staff rhinologist, a rhinology fellow, a senior otorhinolaryngology resident, a junior otorhinolaryngology resident, and a medical student. Results: The inter-class correlation between the 5 raters was 0.7600 (95% CI: 0.6917, 0.8161) and 0.6679 (95% CI: 0.5997, 0.7312) for the Philpott-Javer and Kupferberg scoring systems respectively, suggesting substantial reliability. Intra-rater data showed substantial reliability (kappa values between 0.588 and 0.844) among all raters using both systems. There was also moderate to substantial agreement between the learners and the staff rhinologist (kappa values between 0.534 and 0.710). Conclusions: Results suggest that both the Philpott-Javer and Kupferberg staging systems have acceptable intra-rater and inter-rater reliability among learners of differing levels of clinical experience and are suitable for evaluating progress following endoscopic surgery.

Impact of Increased Postoperative Debridement Frequency following Functional Endoscopic Sinus Surgery

Objectives: 1) Compare sinonasal-specific quality of life between patients receiving an additional postoperative visit at 14 days compared to a standard of care control group receiving debridements at one, four, and twelve weeks post–functional endoscopic sinus surgery (FESS). 2) Compare endoscopically assessed mucosal edema between the two groups at one and three months post-FESS to determine if the additional postoperative debridement had an impact on sinus health. Methods: Adult chronic rhinosinusitis patients receiving FESS at a tertiary-level rhinology center between January 2011 and 2012 were included. Records were retrospectively evaluated for sinonasal outcome test (SNOT-22) and mucosal edema scores (Philpott-Javer) at one and three months post-FESS. Treatment subjects receiving additional debridement fourteen days post-FESS were compared to control subjects receiving the standard of care. Subjects were matched in terms of baseline disease severity and extent of surgery. Results: The cohort consisted of 48 subjects equally distributed between study groups. SNOT-22 scores did not differ between the two groups at one and three months post-FESS. These findings were not statistically significant (p=0.67, 95% confidence interval [CI]: -10.05, 15.47; p=0.63, 95% CI: -14.54, 8.96). The treatment group presented with greater reduction in mucosal edema between 1 and 3 months, although this was not statistically significant (3.29 vs. -0.26; p=0.40, 95% CI: -4.83, 11.93). Conclusions: Additional postoperative debridement within the first month following FESS did not provide a significant improvement in quality of life and mucosal edema. However, a clinically significant improvement in mucosal edema was observed with the additional debridement.