James A. Stankiewicz

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.

Complications in endoscopic intranasal ethmoidectomy: An update

A previous publication by this author discussing complications of endoscopic intranasal ethmoidectomy indicated an overall complication rate of 29% in 90 patients (17% in 150 ethmoidectomies). Compared to published complications rates for traditional intranasal ethmoidectomy (2.7% to 3.7%), 17% is alarming and of concern.

Complications of endoscopic intranasal ethmoidectomy

A consecutive series of 90 patients undergoing endoscopic intranasal ethmoidectomy was reviewed. There were 26 complications (29%) in 19 patients in this group. Eight complications (8%) including CSF leak, temporary blindness, and hemorrhage were considered major with the latter occurring most commonly. Synechiae were the most commonly occurring minor complications.

The Endoscopic Repair of Choanal Atresia

Since 1755, when choanal atresia was first described by Roederer, more than 300 papers have appeared in the literature dealing with various aspects of choanal atresia. Todays preferred methods of repair are transnasal and transpalatal. Each method has its advantages, disadvantages, proponents, and opponents. The main disadvantage of the transnasal procedure is limited vision, even with a microscope, especially in newborn infants, and the inability to adequately remove enough vomerine septal bone to prevent restenosis. Endoscopic transnasal repair of choanal atresia provides excellent visualization and the ability to perform exact surgery on patients of all ages. Described are four patients who underwent endoscopic repair of choanal atresia. Three of the four have patent nares, one patient after revision surgery. The technique is discussed along with its advantages and disadvantages relative to other surgical treatment modalities.

Cerebrospinal fluid fistula and endoscopic sinus surgery

Seven cases of cerebrospinal fluid fistulae occurring as a result of endoscopic sinus surgery in a total of 800 ethmoidectomies are discussed, along with 1 case referred for consultation. One cerebrospinal fluid fistula was intrasphenoid, 4 were posterior ethmoid/base of skull, 2 were anterior ethmoid, and 1 was ethmoid cribriform. Six of 8 fistulae were closed endoscopically. The sphenoid sinus cerebrospinal fluid fistula was closed successfully with fibrin glue and Gelfoam. Five cerebrospinal fluid fistulae were closed successfully using fascia, muscle, and Gel-foam. Two cerebrospinal fluid fistulae were treated conservatively, and only 1 stopped. Anatomic and technical aspects related to the occurrence of cerebrospinal fluid fistulae are discussed. Management and treatment of cerebrospinal fluid fistulae occurring during and after endoscopic sinus surgery is emphasized. When identified intraoperatively or delayed, cerebrospinal fluid fistulae can be managed successfully by endoscopic technique.

Nasal Endoscopy and the Definition and Diagnosis of Chronic Rhinosinusitis

OBJECTIVES: Although endoscopy has been shown by a few authors to be a valuable tool for the diagnosis of chronic rhinosinusitis, its true role in the evaluation of the patient with chronic rhinosinusitis has not been elucidated. The current definition of chronic rhinosinusitis is a symptom-based definition, and objective testing such as endoscopy or computed tomography (CT) is not included. However, the current treatment paradigm for chronic rhinosinusitis is dependent on the definition for diagnosis. Patients are treated with 4 weeks of antibiotics and decongestant/antihistamines/steroids based on the definition. This study aims to evaluate in a prospective fashion the place of endoscopy in the diagnosis of chronic rhinosinusitis. STUDY DESIGN: A group of 78 patients meeting the definition of chronic rhinosinusitis were subjected to same-day endoscopy and CT scanning. RESULTS: Seventeen (22%) of 78 patients had positive endoscopic and CT results. There were 20 (26%) of 78 patients with negative endoscopic and positive CT results. Six (8%) patients had positive endoscopic and negative CT results, and 35 (45%) had negative endoscopic and negative CT results. Overall, 37 (47%) patients had positive CT results, and 41 (53%) patients had negative CT results. Endoscopy showing the presence of purulence, nasal polyps, or watery congested mucosa correlated well with CT results. Negative endoscopy correlated with CT results in 65% of patients. CONCLUSION: The use of endoscopy to corroborate the diagnosis in nonpolypoid or nonpurulent rhinosinusitis in previously unoperated patients is questioned. Patients who meet the subjective definition of chronic rhinosinusitis should have a high degree of sensitivity and specificity with endoscopy or CT. The fact this is not the case questions the accuracy of the definition and the treatment paradigm. SIGNIFICANCE: According to this study, positive endoscopic results correlated well with CT, and negative endoscopic results correlated in 71% of patients with negative CT results.

Complications in endoscopic sinus surgery for chronic rhinosinusitis: a 25-year experience.

The aim of this study was to review complications occurring as a result of endoscopic sinus surgery by one surgeon in an academic practice during a 25‐year period.

Medical therapy vs surgery for chronic rhinosinusitis: a prospective, multi‐institutional study with 1‐year follow‐up

This study evaluated 1‐year outcomes in patients with chronic rhinosinusitis (CRS) who were considered surgical candidates by study criteria and elected either medical management or endoscopic sinus surgery (ESS). In addition, some patients initially enrolled in the medical treatment arm crossed over to the surgery arm during the study period and their respective outcomes are evaluated.

A diagnostic dilemma for chronic rhinosinusitis: definition accuracy and validity.

Background The current definition of chronic rhinosinusitis is a symptom-based definition with minimal reliance on objective information. Based on this definition, patients are diagnosed and treated with medical therapy. A computed tomography (CT) scan is obtained only if the patient is not improved after medical therapy. No study is available evaluating in an evidence-based manner the accuracy of the current definition and its impact on diagnosis and treatment. Methods This study represents 78 patients evaluated in a prospective fashion who met the subjective criteria for the definition of chronic rhinosinusitis. All patients underwent a complete history with a questionnaire evaluating symptom severity, a physical exam including anterior rhinoscopy and endoscopy, and a CT scan obtained on the day of their initial visit. Objective CT scan findings were compared with the subjective findings and related to the ultimate diagnosis of chronic sinusitis. Results Only 37/78 (47%) had a positive (1) CT scan, indicating demonstrable sinusitis. There also was no real difference in symptom severity between patients with positive (1) and negative (2) CT scanning. Conclusion The current symptom-based definition of chronic sinusitis poorly predicts whether a patient truly has chronic sinusitis and needs reevaluation.

Surgical Experience and Complications During Endonasal Sinus Surgery

Objective/Hypothesis: The introduction of optical aids for endonasal sinus surgery has not produced the expected drop in the rate of serious intraoperative complications.