Jastin L. Antisdel

Symptom-specific outcomes of endoscopic sinus surgery: A systematic review

Background: Although multiple studies have demonstrated that symptoms of chronic rhinosinusitis (CRS) improve after endoscopic sinus surgery (ESS), a systematic large-scale evaluation of specific symptom response has not been performed. Objective: To analyze the relative effectiveness of surgery in the improvement of individual CRS symptoms. Study Design: A literature search of MEDLINE, EMBASE, Web of Science, Cochrane databases, and other Web-based sources from January 1, 1980 through June 1, 2008 was performed. Studies of 20 or more adult patients with CRS that used symptom severity scores to analyze at least 3 major CRS criteria (facial pressure, nasal obstruction, postnasal discharge, and hyposmia) or 2 major CRS criteria plus headache were included. Subjects and Methods: Inclusion criteria were met by 21 of 289 ESS studies reviewed. Meta-analysis was conducted for each symptom separately with the standardized difference between the preoperative and postoperative severity scores as the effect size (ES). Results: A total of 2070 patients with CRS were studied a mean of 13.9 months after ESS. All symptoms demonstrated improvement compared with their respective preoperative severity scores by an overall ES of 1.19 (95% confidence interval, 0.96 to 1.41; I 2 = 81.7%) using the random-effects model. Nasal obstruction (ES, 1.73) improved the most, with facial pain (ES, 1.13) and postnasal discharge (ES, 1.19) demonstrating moderate improvements. Hyposmia (ES, 0.97) and headache (ES, 0.98) improved the least. Conclusion: The relative improvements in major CRS symptoms and headache after surgery are similar, with the exception of nasal obstruction, which improves most.

Effect of Microporous Polysaccharide Hemospheres (MPH) on Bleeding after Endoscopic Sinus Surgery: Randomized Controlled Study

OBJECTIVES: Absorbable hemostatic agents are commonly used after endoscopic sinus surgery (ESS). MPH (microporous polysaccharide hemospheres) is a novel hemostatic powder that is rapidly absorbed. The goal of this study was to examine the effects of MPH on bleeding after ESS. STUDY DESIGN: Randomized, controlled, single-blinded. SETTING: Tertiary university hospital. SUBJECTS AND METHODS: Patients undergoing bilateral (symmetric) ESS for CRS by the same surgeon were randomized to unilateral treatment with MPH at surgical conclusion. The untreated opposite side served as a control. All patients received standard postoperative management. Patients completed symptom diaries using visual analog scales (VAS, scored out of 100) at baseline and through postoperative day (POD) 30. Outcomes including bleeding, pain, obstruction, and nasal discharge were recorded separately for left and right sides. RESULTS: Forty patients (19 men, 21 women) with an average age of 48.3 years were included. There were no complications, and all patients were discharged home the same day. The mean bleeding score on POD one for MPH-treated sides was 22.5 vs 39.0 for untreated controls (mean reduction 16.5, P < 0.0001, 95% CI −23.2 to −9.7). The scores for bleeding at baseline and at all other post-treatment days were not significantly different (P > 0.05). There were no other significant differences between MPH-treated and control sides in any other variables measured. CONCLUSION: The use of MPH after ESS results in significantly less bleeding in the early postoperative period with no increase in pain, obstruction, or nasal discharge. Patients treated with MPH follow a normal postoperative recovery otherwise.

Hemostatic agent microporous polysaccharide hemospheres (MPH) does not affect healing or intact sinus mucosa.

Objectives/Hypothesis: Absorbable hemostatic agents are used routinely following sinus surgery. Recent studies suggest that current biomaterials, such as FloSeal Matrix Hemostatic Sealant (Fusion Medical Technologies, Mountain View, CA) may interfere with mucosal regeneration. This study was designed to evaluate the effects of Microporous Polysaccharide Hemospheres (MPH, Medafor, Inc., Minneapolis, MN), a novel rapidly‐absorbing hemostatic powder, on healing and intact sinus mucosa.

Application of ultrasonic aspirators to endoscopic dacryocystorhinostomy.

Endoscopic dacryocystorhinostomy (E-DCR) offers success rates equivalent to those of traditional external approaches, for relief of nasolacrimal duct obstruction (NLDO). The removal of the thick bone overlying the lacrimal sac, a critical step in the operation, may be accomplished by using a variety of instruments including powered (drills, microdebriders, and lasers) or nonpowered (curettes, rongeurs, hammer and chisel). All of these conventional tools risk injury to adjacent mucosal surfaces and deeper elements of the lacrimal apparatus. Because bone removal occurs in the narrow confines of the axilla of the middle turbinate, even minor mucosal trauma can often lead to unwanted scarification and contribute to surgical failures. Advances in ultrasonic aspirator technology now permit in situ bone emulsification, which is respectful of nearby soft tissues. The objectives of this study were to report our preliminary experience with this technology in E-DCR surgery and to evaluate its affect on adjacent nasal mucosa.

Microporous polysaccharide hemospheres do not increase synechiae after sinus surgery: randomized controlled study.

Background Many surgeons use absorbable packing materials after endoscopic sinus surgery (ESS). Despite their popularity, some of these agents have been shown to contribute to synechiae formation. Microporous polysaccharide hemospheres (MPH) is a plant-based hemostatic powder that does not interfere with regenerating sinus mucosa in the animal model. The goal of this study was to examine the impact of MPH on healing and synechiae formation after ESS in human subjects. Methods A prospective, randomized, controlled, double-blind study was performed. Forty consenting adult patients with chronic sinusitis requiring symmetric ESS were randomized to receive MPH unilaterally at the conclusion of surgery. The opposite side was untreated. Standard postoperative care was performed bilaterally. Outcomes measured included blinded observer ratings for synechiae formation, edema, and infection. Each side was examined endoscopically and scored at postoperative days 7, 14, and 30. Results Twenty men and 20 women with an average age of 48.2 years were included. There were no complications and all patients were discharged home the same day. There was no significant difference in synechiae formation at any point postoperatively. The rate of synechiae formation was determined to be 10% (4/40) on the MPH-treated side versus 7.5% (3/40) on the untreated side (p = 0.7639). In addition, there were no significant differences observed in edema (p = 0.7480) or infection (p = 0.5533). Conclusion The use of MPH after sinus surgery does not increase synechiae formation and does not appear to deleteriously affect the healing of postoperative sinus cavities.

Histopathological and clinical analysis of chronic rhinosinusitis by subtype.

Chronic rhinosinusitis (CRS) encompasses diverse phenotypic expression. Clinical and histological differences suggest 4 CRS subtypes: eosinophilic CRS with and without nasal polyps (eCRSwNP, eCRSsNP, respectively) and non‐eosinophilic CRS with and without nasal polyps (neCRSwNP, neCRSsNP, respectively). The mucosal basement membrane (BM) and cilia are believed to play roles in CRS pathogenesis by impacting mucociliary clearance and immune barriers. This study aimed to identify clinical, surgical, and histopathological subtype differences to further elucidate disease mechanisms.

Anatomic evaluation of endoscopic transnasal transorbital approach to the lateral orbital apex.

Background This anatomic study investigates the feasibility of an endoscopic transnasal transorbital approach to the lateral orbital apex. Methods Five cadavers with no prior history of sinus surgery were studied bilaterally. Standard techniques and instrumentation for functional endoscopic sinus surgery were used to perform dissections and delineate anatomy of sinuses and orbits. Results With resection of the inferior aspect of the lamina papyracea and the medial portion of the orbital floor, followed by incision of the periorbita along the inferomedial aspect of the orbit and removal of minimal orbital fat, a satisfactory view of the surgical field is achieved. The medial and inferior rectus muscles are dissected and retracted to allow visualization of the optic nerve. By dissecting inferior to the optic nerve and using 0 and 30° endoscopes, the lateral orbital apex could be accessed without damage to the optic nerve. Conclusion In patients whose vision is irreparably damaged, one might consider an endoscopic approach to lesions of the lateral orbital apex. Approach in patients with intact vision should be handled with caution because of possible traction of the optic nerve.

Product comparison model in otolaryngology: Equivalency analysis of absorbable hemostatic agents after endoscopic sinus surgery

Evidence‐based medicine in otolaryngology literature continues to be lacking, especially with regard to new products brought to market. The marketing of products often includes statements of benefit that have limited objective support in research or literature. To address this, and to adequately determine product equivalency/superiority, careful evaluation must be made. In order to establish standards for this process in rhinology products, we directly compare three different absorbable hemostatic agents in patients with chronic rhinosinusitis (CRS) after undergoing endoscopic sinus surgery (ESS), using both objective and subjective outcomes.

Societal and physician perspectives on sinonasal diagnosis and treatment.

Background Sinusitis is diagnosed in 31 million individuals annually and has a significant impact on health care expenditures. Otolaryngologists understand that patient expectations, health knowledge, and the use of therapeutic options by patients and primary care physicians (PCPs) vary greatly. The intent of this study was to elucidate differences in the perspectives of patients, PCPs and otolaryngologists regarding the diagnosis and treatment of sinonasal disease. Methods Three surveys were developed with questions targeting sinonasal infections: specifically, prevalence, diagnosis, physician prescribing patterns, treatment alternatives, and referral patterns to tertiary level physicians. Surveys were distributed to adult patients (n = 113) at general health fairs, whereas surveys for PCPs (n = 54) and otolaryngologists (n = 40) were obtained from teaching conferences and professional networking events. Results In a description of viral upper respiratory tract infections (URIs), 43% of patients attributed symptoms to allergic rhinitis, 28% to URIs, and 28% to sinus infections. Despite this, 37% of patients still expected anti-bacterial agents. In patients with acute rhinosinusitis (ARS), 44% of patients would wait <1 week to see a physician whereas 82% of otolaryngologists and 57% of PCPs felt waiting 1 week or more was appropriate. In an ambulatory care setting, 45% of PCPs would chose to treat patients with 5 days of ARS symptoms whereas 32% of otolaryngologists would treat patients (p = .22). For ARS, 70% of patients expected antibiotics. Seventy percent of PCPs stated that they would refer a patient to an otolaryngologist after a single episode of sinusitis. Conclusion Patients with sinonasal symptoms confuse URIs for sinusitis and expect unnecessary treatment with antibiotics. PCPs and otolaryngologists vary regarding indications for presentation to a physician, approaches to therapy, and indications for referral to a tertiary provider in their respective practices.

40-year incidence trends for oropharyngeal squamous cell carcinoma in the United States

OBJECTIVES To determine differences in oropharyngeal squamous cell carcinoma (OPSCC) incidence between 1975 and 2014 stratified by race, sex, and age. MATERIALS AND METHODS We obtained age-adjusted OPSCC incidence rates for race and sex groups from 1975 to 2014 using the Surveillance, Epidemiology, and End Results 9 database. We defined OPSCC as cancers of the base of tongue, lingual/palatine tonsil, oropharynx, soft palate, uvula, and Waldeyers ring. We used Joinpoint analyses to determine incidence trends for race/sex/age groupings. RESULTS There were 38,624 oropharyngeal primary tumors in the analyses. Males accounted for 74% of sample population, and whites accounted for 84% of tumors. Overall, there was a 57.3% increase in incidence of oropharyngeal between 1975 and 2014. For blacks and whites, average incidence was lower for females than males. Rates for black males aged ≥50years was highest for most of the follow-up time but decreased sharply around 1988 and were surpassed by the significant increase in incidence in white males aged 50-59 (1995-2014 APC=4.07, p<0.001) and ≥60years (2002-2014 APC=4.25, p<0.001). For males aged ≥60, whites had higher rates than blacks starting in 2010. OPSCC incidence in White males (10.99 per 100,000 person-years) surpassed rates in Blacks (10.14 per 100,000 person-years) beginning in 2008. CONCLUSION OPSCC has significantly increased in the United States in the last 40 years. This overall increase in OPSCC can primarily be attributed to white males. OPSCC prevention and early detection efforts could target these demographic factors to decrease rising OPSCC incidence.