Frederick A. Kuhn

Safety and outcomes of balloon catheter sinusotomy: A multicenter 24-week analysis in 115 patients

OBJECTIVE: The aim of this study was to further evaluate the safety and effectiveness of balloon catheter devices to dilate obstructed sinus ostia/perform sinusotomy. METHODS: Through a prospective, multicenter evaluation, safety was assessed by rate of adverse events, patency was determined by endoscopic examination, and sinus symptoms were determined by the Sino-Nasal Outcome Test (SNOT 20). RESULTS: At the conclusion of the 24-week analysis, endoscopy determined that the sinusotomy was patent in 80.5% (247 of 307) sinuses and nonpatent in 1.6% (5 of 307), and could not determine ostial patency status in 17.9% (55 of 307). Of the ostia visualized on endoscopy, 98% were patent (247 of 252), while 2% (5 of 252) were considered nonpatent. SNOT 20 scores showed consistent symptomatic improvement over baseline. Revision treatment was required in 3 sinuses (3 of 307 sinuses, 0.98%) in 3 patients (3 of 109 patients, 2.75%). CONCLUSION: Balloon catheter technology appears safe and effective in relieving ostial obstruction. Patients were pleased and indicated that they experienced symptomatic improvement.

Endoscopic middle meatal antrostomy: theory, technique, and patency.

Ostial obstruction is a major factor in the pathogenesis of sinusitis. Detailed diagnostic evaluation in patients with maxillary sinusitis demonstrates the prominence of disease in the ethmoidal infundibulum and in adjacent ethmoid cells. Surgical procedures performed to improve maxillary sinusitis by inferior meatal antrostomy leave residual disease in the ostiomeatal area and may result in persistent mucociliary obstruction.

PROGNOSIS FOR ALLERGIC FUNGAL SINUSITIS

Allergic fungal sinusitis is a recently described clinical entity that has gained increased attention as a cause of chronic sinusitis. The diagnosis can be established by demonstrating (1) type I hypersensitivity confirmed by history, skin tests, or serology; (2) nasal polyposis; (3) characteristic CT scan; (4) eosinophilic mucus without fungal invasion into sinus tissue; and (5) positive fungal stain of sinus contents removed intraoperatively or during office endoscopy. The exact pathogenesis of allergic fungal sinusitis remains controversial, and no treatment modality has proved to be consistently effective. Several reports during the last decade have suggested that allergic fungal sinusitis recurs more frequently than chronic bacterial sinusitis, but no studies have specifically addressed the prognosis of allergic fungal sinusitis. During the past two and a half years, we have treated 26 patients with allergic fungal sinusitis. The treatment always included functional endoscopic sinus surgery, topical nasal steroids, postoperative nasal saline irrigations, and endoscopic cleaning in the office. Adjuvant medical therapy included systemic steroids, oral antifungals, a combination of systemic steroids and oral antifungals, or in some cases, no additional treatment. Outcome was graded subjectively as improved, unchanged, or worse. Mean follow-up was 14.5 months. Twenty-two of 26 patients were improved. In reviewing postoperative outcomes, we observed endoscopic recurrent disease that generally preceded patient symptoms. Consequently, we developed an endoscopic staging system to record postoperative clinical status. Use of this staging system allowed evaluation of various treatments and enabled classification of patient outcome. Nineteen of 24 patients examined with extensive follow-up had objective signs of recurrent disease. It appears that this is a chronic disease characterized by physical signs that appear before the return of subjective clinical symptoms.

Long-term outcome analysis of balloon catheter sinusotomy: Two-year follow-up

Objective Assess two-year postoperative clinical outcomes for patients receiving balloon catheter sinusotomy. Methods Patients who had sinus ostia dilated with balloon catheters were prospectively evaluated two years after surgery by Sinonasal Outcome Test (SNOT-20) and computed tomographic (CT) scan. Results Sixty-five patients (195 ballooned sinuses) were followed for two years after surgery, including 34 “balloon-only” patients and 31 “hybrid” patients. SNOT-20 symptom scores were significantly improved from baseline (0.87 vs 2.17 baseline, P < 0.001) and stable compared to six months and one year; this was the case for both balloon-only (1.09 vs 2.09, P < 0.001) and hybrid (0.64 vs 2.26, P < 0.001) patients. Lund-MacKay CT scores were significantly improved from baseline (2.69 vs 9.66, P < 0.001) and stable compared to one year, confirmed for both balloon-only (1.75 vs 5.67, P < 0.015) and hybrid (3.25 vs 12.05, P < 0.001) subsets of patients. A total of 85% of patients reported improvement of their sinus symptoms, with 15% same and 0% worsened. Revision treatment was required in seven of 195 sinuses (3.6%) in six of 65 patients (9.2%). Conclusion Patients who receive balloon catheter sinusotomy in endoscopic sinus surgery have significant improvement in symptoms two years after surgery. Radiographic evidence also confirms resolution of disease after two years. This demonstrates durability of clinical results previously reported at 24 weeks and one year after surgery.

Antifungal Activity Against Allergic Fungal Sinusitis Organisms

A review of more than 50 allergic fungal sinusitis (AFS) patients indicates that most patients experience postoperative recurrences once weaned from oral steroids, leaving a glaring need for improved treatment. Topical antifungal therapy has not been described for AFS, but it could potentially lower fungal antigen loads via postoperative irrigations. No information exists to direct the choice of antifungal agent. The purpose of this study was to identify the appropriate drug to use for postoperative irrigations in AFS patients.

Balloon catheter sinusotomy: one-year follow-up--outcomes and role in functional endoscopic sinus surgery.

Objective The primary objective was to assess the long-term effectiveness of balloon catheter sinusotomy. Methods Patients who had sinus ostia dilated with balloon catheters were prospectively evaluated 1 year after surgery with nasal endoscopy, a CT scan, and the Sino-Nasal Outcome Test (SNOT-20). Results Sixty-six patients (202 sinuses) were examined. One hundred seventy-two of 202 sinus ostia (85%) were endoscopically patent, 1 percent (2/202) were nonpatent, and ostial patency could not be determined by endoscopy in 28 of 202 (14%). In these “indeterminate” sinuses, the CT scans were normal in 13, implying functional patency in 91.6 percent of sinuses (185/202). Sinus CT scan scores were 1.95 at 1 year versus 8.89 at baseline (P < 0.001), and 1-year SNOT-20 scores (0.91) were significantly improved from baseline (2.14, P < 0.0001). Conclusion Balloon catheter sinusotomy results were durable over the study period, showing long-term effectiveness.

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.

Middle turbinate stabilization after functional endoscopic sinus surgery: the controlled synechiae technique.

INTRODUCTION Lateralization of the middle turbinate is a possible complication of functional endoscopic sinus surgery that can lead to iatrogenic sinusitis or mucocele formation. To avoid these sequelae, turbinate resection has been advocated, but many rhinologists are hesitant to resect the middle turbinate. The middle turbinate is an important surgical landmark in revision endoscopic procedures that is largely lost with resection. Because the normal function of the middle turbinate is not fully appreciated, the long-term effects of resection are unknown. Additionally, some reports have associated frontal sinus obstruction with middle turbinate resection.1 We present a simple method to prevent turbinate lateralization that saves the turbinate as a future surgical landmark and preserves turbinate function.

An update on the classifications, diagnosis, and treatment of rhinosinusitis.

Purpose of reviewThis review is timely and relevant because rhinosinusitis is a disease process that is heterogeneous in its clinical and pathologic manifestations. Therefore, no one causative factor has been identified that fully accounts for all rhinosinusitis. The purpose of this review is to provide a succinct update of rhinosinusitis classification, pathophysiology, and management given the new movement toward evidence-based guidelines. Recent findingsThe term rhinosinusitis reflects the concurrent inflammatory and infectious processes that affect the nasal passages and the contiguous paranasal sinuses. The most recent classification scheme is intended primarily to guide clinical research and divides rhinosinusitis into four categories: acute bacterial rhinosinusitis, chronic sinusitis with nasal polyposis, chronic rhinosinusitis with nasal polyposis, and allergic fungal rhinosinusitis. The goals of treatment include reduction of mucosal edema, reestablishment of sinus ventilation, and eradication of infecting pathogens. Multiple therapies are available for the management of chronic rhinosinusitis, including antibiotics, hypertonic and isotonic saline irrigations or sprays, topical and systemic glucocorticords, antileukotriene agents, and endoscopic sinus surgery. SummaryRhinosinusitis is a common medical problem that interferes with patient quality of life and loss of work productivity. Because of the heterogeneity that underlies its pathology, no one treatment regimen exists for the management of rhinosinusitis.

Allergic fungal sinusitis: diagnosis and treatment.

Since allergic fungal sinusitis was initially described by Millar et al. in 1981, many have tried to define and explain the disorder. It has been labeled as the sinonasal equivalent of allergic bronchopulmonary aspergillosis; however, allergic fungal sinusitis cannot be categorized so easily. According to the literature at this time, there are five major criteria and six associated characteristics or minor criteria of patients with allergic fungal sinusitis. In reality, patients may not develop all five major criteria or have any of the associated criteria for years. Allergic fungal sinusitis is not only difficult to diagnose, but it is one of the most complicated conditions rhinologists must manage. Endoscopic sinus surgery must be used in conjunction with long-term medical therapy, ie, oral and nasal corticosteroids, immunotherapy, antifungal therapy, and antimicrobial agents to effectively control the problem. Allergic fungal sinusitis is most likely the endpoint in a spectrum of sinonasal disease, driven by the presence of fungus and eosinophils with their inflammatory mediators. The affected nasal mucosa no longer functions properly, and a cycle of chronic edema, stasis, and bacterial superinfection results. Therapy entails disrupting the inflammatory process to allow normal mucosal function to resume.