James A. Duncavage

Prospective analysis of sinus symptoms and correlation with paranasal computed tomography scan.

OBJECTIVES: We designed a prospective study to determine whether there is a correlation between the severity of sinus symptoms and the severity of computed tomography (CT) scan evidence of rhinosinusitis. METHODS: Acute and chronic rhinosinusitis patients rated their symptoms and had a CT scan of the sinuses taken the same day. A Likert severity scale and standardized CT scoring system were used. Data were analyzed by nonparametric methods with Kendalls rank correlation coefficient. RESULTS: The severity of 5 symptoms correlated with severity of disease on CT scan. Headache and facial pain or pressure had no correlation. CONCLUSION: The certainty of a clinical diagnosis of rhinosinusitis requiring treatment is enhanced in patients with high symptom severity scores for fatigue, sleep disturbance, nasal discharge, nasal blockage, or decreased sense of smell. Isolated headache and facial pain or pressure are less reliable predictors of CT scan findings supporting the diagnosis rhinosinusitis.

Contemporary indications for the Caldwell-Luc procedure.

The Caldwell-Luc operation was first described in the late 19th century as a technique to remove infection and diseased mucosa from the maxillary sinus via the canine fossa, while creating intranasal counterdrainage through the inferior meatus. This operation has been performed countless times over the past century, but it has come under increased scrutiny within the past 20 years. This criticism is multifactorial. Medical management of allergic and infectious sinus disease has continued to improve, and endoscopic sinus surgery techniques have proven to be safe and effective in the vast majority of patients requiring surgical management. Additionally, several retrospective studies have shown high complication rates with the operation. Recent studies have illustrated both the histologic benefit of complete removal of diseased mucosa, as well as better patient outcomes with minimal morbidity when a safer operative technique is used. Overall, the Caldwell-Luc procedure is safe and effective as described, and should remain in the repertoire of surgeons managing the maxillary sinus.

Osteoplastic Flap for Obliteration of the Frontal Sinus: Five years’ Experience

The objective of this retrospective study was to evaluate the osteoplastic flap (OPF) for the obliteration of the frontal sinus in this current era of endoscopic management of frontal sinus disease. A review of consecutive OPF procedures (n = 43) performed by the senior author (J.A.D.) from 1992 to 1997 was carried out. Data were gathered regarding chief symptom, medical history, previous sinus surgery, endoscopic findings in the office and at surgery, CT scan findings, and follow-up results (mean 19.4 months). Previous endoscopic management of frontal sinus disease had failed in 24% of patients; 97% had eventual resolution of frontal sinusitis with OPF. After OPF, 63% also had improvement or resolution of disease in other paranasal sinuses. Statistically significant, Positive correlations (P < 0.05) were noted between the resolution of frontal sinusitis and improved or resolved pain, as well as the resolution of frontal sinusitis and improved or resolved infections in other paranasal sinuses. In 1998 OPF remains the standard for treating frontal sinus disease refractory to other methods. OPF can decrease the pain associated with frontal sinus infections and has a Positive impact on inflammatory disease in other paranasal sinuses.

Surgery of the inferior and middle turbinates.

For over a century, surgical management of the inferior and middle turbinates has been an ongoing topic of discourse and disagreement. Treatment, either medical or surgical, of the inferior turbinate is required in cases of turbinate hypertrophy where the goals of therapy are to maximize the nasal airway, to preserve nasal mucosal function, and to minimize complications. Middle turbinate management, more controversial than inferior turbinate management, still lacks definitive consensus. This article reviews the anatomy, physiology, and pathology involving these two structures. Advantages, disadvantages, complications, and controversies surrounding the surgical management of the turbinates are discussed.

Combined External and Endoscopic Frontal Sinusotomy With Stent Placement: A Retrospective Review

Objectives To examine the long‐term results of combined external and endoscopic frontal sinusotomy using frontal sinus stents and to compare our results with those reported for the endoscopic Lothrop procedure.

Proton Pump Inhibitor Therapy Improves Symptoms in Postnasal Drainage

BACKGROUND & AIMS Gastroesophageal reflux is common among patients with postnasal drainage. We investigated whether proton pump inhibitor therapy improved symptoms in patients with postnasal drainage without sinusitis or allergies. METHODS In a parallel-group, double-blind, multi-specialty trial, we randomly assigned 75 participants with continued symptoms of chronic postnasal drainage to groups that were given 30 mg of lansoprazole twice daily or placebo. Participants were followed up for 16 weeks. Symptoms were assessed at baseline and after 8 and 16 weeks. Ambulatory pH and impedance monitoring assessed presence of baseline reflux. The primary objective of the study was to determine if acid suppressive therapy improved postnasal drainage symptoms. The secondary objective was to assess if pH and impedance monitoring at baseline predicted response to treatment. RESULTS Postnasal drainage symptoms improved significantly among patients given lansoprazole compared with placebo. After 8 and 16 weeks, participants given lansoprazole were 3.12-fold (1.28-7.59) and 3.50-fold (1.41-8.67) more likely to respond, respectively, than participants given placebo. After 16 weeks, median (interquartile) percent symptom improvements were 50.0% (10.0%-72.0%) for participants given lansoprazole and 5.0% (0.0%-40.0%) for participants given placebo (P = .006). Neither baseline presence of typical reflux symptoms nor esophageal physiologic parameters predicted response to therapy. CONCLUSIONS Among participants with chronic postnasal drainage without evidence of sinusitis and allergies, twice-daily therapy with proton pump inhibitors significantly improved symptoms after 8 and 16 weeks. The presence of heartburn, regurgitation, abnormal levels of esophageal acid, or nonacid reflux did not predict response to therapy.

Impact of chronic rhinosinusitis on work productivity through one-year follow-up after balloon dilation of the ethmoid infundibulum.

Although multiple clinical trials have demonstrated that balloon dilation of sinus ostia in patients diagnosed with chronic rhinosinusitis (CRS) results in sustained symptomatic improvement, less data are available to measure the effects of sinusitis on worker productivity. The objective of our research was to analyze work and activity impairment before and after transantral, endoscopically‐guided balloon dilation of the maxillary sinus ostia and ethmoid infundibulum.

Revisiting the interpretation of positive sinus CT findings: a radiological and symptom-based review.

Objective: It is widely believed that a high percentage of normal, healthy patients without sinusitis symptoms have abnormal findings on sinus CT. Experiences of the authors of this study suggest otherwise. Study Design: Cross-sectional survey. Subjects and Methods: Head/sinus CT scans of 50 consecutive patients from each of three study groups were reviewed. Group 1 consisted of patients without any sinus symptoms. Group 2 consisted of patients with acute headache symptoms. Group 3 consisted of patients with complaints consistent with chronic sinusitis. CT scans were evaluated with the Lund-Mackay scoring system. Results: In the asymptomatic patient group (group 1), six (3%) patients had positive sinus CT scan findings, compared with 11 (5.5%) in the acutely symptomatic group (group 2), and 32 (64%) in the chronically symptomatic group (group 3). In the chronically symptomatic group (group 3), 64 percent of patients were allergic compared with 18% of the acute headache group (group 2) and 8 percent of the asymptomatic patient group (group 1). Conclusion: Results of this study suggest that symptomatic sinus patients are much more likely to have positive sinus CT scan findings than asymptomatic patients. Conversely, normal healthy patients should not be expected to have abnormal sinus CT scans.

Extended Middle Meatal Antrostomy: The Treatment of Circular Flow†

Intranasal surgery has changed significantly over the years. The inferior meatal antrostomy has lost favor to the more physiologic middle meatal antrostomy which includes the natural ostium. Difficult‐to‐cure patients may exhibit mucous stasis due to circular flow between ostomies. Kennedy described circular flow in both the experimental model and the clinical arena. We have enlarged his definition of circular flow to include the flow of mucus from the natural ostium or a surgically created ostium to any accessory ostium, either natural or surgically created. We present the extended middle meatal antrostomy, a technique which prevents circular flow and allows the mucociliary system to provide for physiologic drainage of the maxillary sinus. This technique is demonstrated in this report to be safe and effective in the treatment of chronic maxillary sinusitis.

A review of malpractice cases after tonsillectomy and adenoidectomy

OBJECTIVE To examine sources of litigation following tonsillectomy and/or adenoidectomy. STUDY DESIGN Analysis of malpractice claims filed after tonsillectomy or adenoidectomy provided by 16 medical liability insurance companies. SETTING Not applicable. SUBJECTS AND METHODS Data was obtained from 16 members of the Physician Insurers Association of America. All claims were either filed or closed between 1985 and 2006. Claims were evaluated and categorized according to the type of complication. RESULTS One hundred and fifty-four claims were identified between 1985 and 2006. Six categories were created based on frequency of claims (bleeding complication n=27 [17.5%], airway fire n=2 [1.5%], burns n=28 [18.2%], consent related n=9 [5.8%], medication related n=9 [5.8%] and residual tissue/recurrence n=9 [5.8%]). Other less frequent claims were grouped as miscellaneous n=70 [45.5%]. CONCLUSIONS A significant portion of malpractice claims following tonsillectomy or adenoidectomy are related to complications not commonly discussed in the literature.