John M. DelGaudio

Gastroesophageal reflux and laryngopharyngeal reflux in patients with sleep-disordered breathing

Objective To assess the relationship of gastroesophageal reflux (GER) and laryngopharyngeal reflux (LPR) with obstructive sleep apnea (OSA). Patients and Methods Thirty-seven sleep-disordered breathing (SDB) patients underwent polysomnography (PSG) and dual-channel pH probe testing. LPR was defined as greater than 6.9 proximal reflux episodes or reflux area index (RAI) greater than 6.3. GER was defined as greater than 4% of time below pH 4.0. Results OSA was present in 28 patients. Twenty-three patients had LPR (66.7% of snorers, 60.7% of OSA patients). Twenty-one patients had GER (33.3% of snorers, 64.3% of OSA patients). Body mass index (BMI) correlated positively with respiratory disturbance index (RDI) (r = 0.67, P < 0.001). BMI did not correlate with pH probe parameters. OSA presence/severity did not correlate with LPR or GER. Supine LPR and GER events did not correlate with OSA presence/severity. Conclusion Gastric acid reflux is prevalent in SDB patients. Direct correlations between reflux and PSG parameters were not identified. EBM rating: B-2b

Association of nasopharyngeal and laryngopharyngeal reflux with postnasal drip symptomatology in patients with and without rhinosinusitis.

Background Patients often report postnasal drip (PND), but objective rhinosinusitis and allergy findings are frequently absent. In this study, we evaluate the association between PND and pharyngeal reflux. Methods Sixty-eight participants underwent 24-hour pH testing, including chronic rhinosinusitis (CRS) patients persistently symptomatic after endoscopic sinus surgery, CRS patients successfully treated by endoscopic sinus surgery, and volunteers without a CRS history. The pH probes contained nasopharyngeal (NP), laryngopharyngeal (LP), and distal esophageal sensors. Participants completed the Sinonasal Outcome Test-20 (SNOT-20) and Modified Reflux Symptom Index (MRSI) questionnaires. Survey items addressing PND symptomatology were compared with NP reflux (NPR) below pH 4 and pH 5 (defined as ≥1 event), and LP reflux (LPR; defined as ≥7 events or reflux area index <6.3). Results Pearson analyses revealed a positive correlation of r = 0.87 between SNOT-20 and MRSI PND items. For NPR < pH 4, no significant difference existed between participants with and without reflux on the SNOT-20 or MRSI (p < 0.05). However, for NPR < pH 5, reflux-positive participants exhibited significantly more PND symptoms on the SNOT-20 (p = 0.030) and the MRSI (p = 0.018) compared with participants without reflux. Finally, participants with LPR had significantly more PND symptomatology on the SNOT-20 (p = 0.010) versus those without LPR. A borderline significant difference existed on the MRSI PND item between participants positive and negative for LPR (p = 0.055). Conclusion Objective evidence of NPR and LPR exists in patients reporting PND. Reflux treatment may reduce PND complaints.

Topical steroid drops for the treatment of sinus ostia stenosis in the postoperative period.

Background Chronic oral steroid use causes significant morbidity, including osteoporosis, immunosuppression, and adrenal insufficiency. Refractory chronic rhinosinusitis patients often take repeated oral steroid courses to treat polypoid disease or sinus ostia stenosis. This study evaluated topical steroid drop efficacy in treating recurrent sinus ostia stenosis in the postoperative period. Methods The 5-year single institution experience with topical steroid drop use after endoscopic sinus surgery (ESS) was evaluated by retrospective review. Patients were included if they began topical dexamethasone ophthalmic, prednisolone ophthalmic, or ciprofloxacin/dexamethasone otic intranasally (used off-label) within 3 months after ESS. Outcomes (i.e., ostia patency, oral steroid use, revision surgery, and complications) were assessed for a 6-month period after steroid drop initiation. Results Thirty-six patients met inclusion criteria. Forty-four surgeries were performed during the study period; 67 sides were treated postoperatively with topical steroid drops. In 86.6% of cases, steroid drops were used to treat frontal ostium stenosis or frontal recess edema; 93.2% of surgeries were revision procedures. Sixty-four percent of sinuses were treated successfully with topical steroid drops, 14.9% remained stable, and 20.9% failed. Reasons for failure included persistent/worsening edema, scarring, or noncompliance. Ten patients (27.8%) required oral steroids and 4 patients (6%) underwent revision surgery during the study period. One case of adrenal suppression occurred. Conclusion Topical steroid drops are beneficial in preventing sinus ostia stenosis in the postoperative period and may decrease the propensity toward repeated oral steroid therapy. This is particularly noteworthy in this challenging cohort, largely composed of revision frontal sinus surgery patients.

Operative findings in the frontal recess at time of revision surgery

OBJECTIVE Endoscopic sinus surgery is the gold standard for the treatment of medically refractory chronic rhinosinusitis. There is, however, a population of patients for whom persistent disease is a problem. Of all the sinuses, the frontal sinus is the most likely to have recurrent obstruction. We evaluated the findings causing frontal recess obstruction at the time of revision surgery. STUDY DESIGN AND SETTING A retrospective review was performed in a tertiary care academic otolaryngology department. RESULTS Findings obstructing the frontal recess at the time of revision sinus surgery were reviewed. Two hundred eighty-nine frontal sinuses were included. Seven findings were identified: mucosal disease (67%), retained ethmoid cells (53%), lateralized middle turbinates (30%), retained agger nasi cells (13%), scar (12%), retained frontal cells (8%), and neoosteogenesis (7%). Most frontal recesses had multiple etiologies for failure listed above, with an average of 1.6. CONCLUSIONS Multiple findings can be identified that contribute to frontal recess obstruction requiring revision sinus surgery. A comprehensive approach to address all factors is necessary to prevent surgical failure among patients presenting for endoscopic frontal sinus surgery.

Computer-aided surgery of the paranasal sinuses and skull base

Endoscopic sinus surgery is one of the most common surgical procedures in otolaryngology. However, the location of the orbit and intracranial contents in close proximity to the paranasal sinuses makes endoscopic sinus surgery potentially hazardous. Otolaryngologists have employed computer-aided surgery, or image-guided surgery, over the past two decades to enhance surgeon confidence, allow more thorough surgical dissections and possibly reduce the complication rate of endoscopic sinus surgery. Computer-aided surgery utilizes preoperative imaging to provide real-time localization of surgical instruments in the surgical field. Although computer-aided surgery originated in the neurosurgical realm, otolaryngologists soon appreciated that this technology could assist in identifying critical orbital or intracranial structures surrounding the paranasal sinuses, and potentially aid in decreasing complications. In this article, the history of image-guidance systems and their application to surgery of the paranasal sinuses and skull base will be reviewed. The components of computer-aided surgery systems and the currently available technologies for surgical instrument tracking are discussed, as well as the advantages and disadvantages of each of the tracking technologies. In addition, issues relating to the accuracy of image-guidance systems are examined. A number of institutional series noting surgeon experience with computer-aided surgery in the domain of paranasal sinus surgery are reviewed. Furthermore, the authors evaluate the utility of image-guidance technology beyond the paranasal sinuses and skull base, such as its use in surgery of the pituitary gland and pterygopalatine fossa, research and resident education. Finally, potential future applications of computer-aided surgery technology are discussed.

Ethnic and gender differences in bone erosion in allergic fungal sinusitis.

Background Erosion of the bony sinus walls in allergic fungal sinusitis (AFS) is an established phenomenon. Reports of the incidence of bone erosion in AFS vary widely, and definitions of bone erosion lack uniformity. Differences in bone erosion among ethnic and gender groups have not been examined previously in the literature. Methods At our institution we reviewed 47 cases of AFS for ethnic and gender differences in presentation and presence of bone erosion. Results Caucasians presented at a mean 12 years later than African-Americans (p = 0.002); however, this difference was largely carried by Caucasian females. African-Americans presented with a greater incidence of bone erosion than Caucasians (p = 0.028). In addition, there are statistically significant differences in the individual paranasal sinuses affected by bone erosion in AFS. Conclusions We examine the potential implications of ethnic and gender differences in presentation and bone erosion in AFS.

Presence of fungus in sinus cultures of cystic fibrosis patients.

Background Sinonasal pathology is nearly universal in the cystic fibrosis (CF) population. The bacteriology of sinus cultures from CF patients and the implications of sinus bacterial pathogens in this group have been studied; however, sinus fungal isolates from CF patients have not been examined in the literature. Methods We reviewed 30 consecutive CF patients undergoing endoscopic sinus surgery at our institution for the presence of fungal isolates obtained from the sinuses at the time of surgery. Results Thirty-three percent of fungal cultures were positive in this sample; in addition, two patients were newly diagnosed with allergic fungal sinusitis. Conclusion We examine the possible implications of positive fungal sinus cultures in the CF population.

Evaluation of postoperative pain after sinonasal surgery

Background Pain after sinonasal surgery concerns both patients and surgeons. Factors affecting sinonasal postoperative pain have not been examined extensively. Methods Using a prospective survey design, sinonasal surgery patients evaluated postoperative pain (on a scale of 0–10), pain location, and medication use. Results One hundred twenty-seven patients consented to participate. One hundred fifteen patients returned surveys, with 100 patients appropriate for analysis over the 6-day postoperative period. Pain score and medication use were evaluated with respect to sex, primary/revision case, nasal packing, and other factors. Repeated measures analysis of variance and chi-square analysis were conducted (p < 0.05). Pain ratings and analgesic use declined significantly over the postoperative period (p < 0.05). Mean pain score on postoperative day (POD) 1 was 3.61 and on POD 6 was 1.72. Mean medication use was 1.37 tablets on POD 1 and 0.55 tablets on POD 6. Additionally, a significant interaction existed, such that narcotic medication use declined from 1.91 tablets on POD 1 to 0.52 tablets on POD 6, whereas nonnarcotic medication use remained steady (p < 0.05). Periorbital pain was most frequent (46.3%), with unilateral facial pain reported least (4.1%). A significant difference existed for distribution of pain location (p < 0.05). Finally, the difference in pain rating between primary and revision procedure for women (0.65) was less than for men (1.12); this interaction was significant (p < 0.05). Conclusion Multiple patient and operative factors affect pain rating and medication use after sinonasal surgery. Generally, pain level should be low with little analgesic use postoperatively.

Association of radiological evidence of frontal sinus disease with the presence of frontal pain.

Background Rhinosinusitis is a common cause of frontal pain. We evaluated the relationship between frontal pain and the type and degree of frontal sinus disease in chronic rhinosinusitis (CRS) patients. Methods Inclusion criteria were presence of frontal sinusitis or frontal recess obstruction on computed tomography scan. Office notes and operative reports were reviewed to determine the presence and location of frontal pain and categorization of sinus disease. Results Two-hundred seven patients were identified with frontal recess obstruction and/or frontal sinus disease. Thirty-one of 37 frontal mucocele patients (84%) had frontal pain. Twenty of 70 polyp patients (29%) had frontal pain, with only 7 of 38 patients (18%) with complete frontal opacification having pain. In patients with CRS without polyps or mucocele, 59 of 100 (59%) had frontal pain, with 21 of 38 (55%) with complete opacification having pain. This difference between the distribution of frontal pain was significant (p < 0.005) among the mucocele, polyp, and nonpolypoid CRS groups. Additionally, among nonmucocele CRS groups exhibiting complete opacification, there was a significant difference in proportion of patients exhibiting frontal pain (p < 0.005). When the nonmucocele groups (i.e., polypoid and nonpolypoid CRS patients) were combined and stratified for disease extent, a difference in the distribution of frontal pain was found (p < 0.025), with the mild-to-moderate thickening group showing the highest proportion of pain. Conclusion Frontal pain was more common in nonpolypoid CRS patients than in polyp patients. Furthermore, in nonmucocele CRS, patients with mild-to-moderate thickening exhibited more frontal pain.

Silent sinus syndrome: lack of orbital findings in early presentation.

Background Silent sinus syndrome (SSS) is an uncommon disease process, classically described as unilateral maxillary sinus opacification that presents with enophthalmos and atelectasis of bony sinus walls from chronic negative pressure. Patients are largely free of characteristic rhinosinusitis symptoms. Methods Operative reports, clinic notes, and radiological studies were reviewed for cases of SSS treated in a tertiary care institution over a 7-year period. Presenting symptoms, radiological features, and surgical findings were evaluated. Results Seventeen cases of SSS were identified. Presentation ranged from incidental computed tomography (CT) scan findings to unilateral enophthalmos with altered midface anatomy. Facial pain ipsilateral to the disease process occurred in 30% of cases. Vision changes were uncommon. Radiological studies universally revealed an opacified maxillary sinus on the affected side. Maxillary sinus walls were contracted and demineralized with significant orbital floor depression in 11 advanced cases. Four early cases revealed only lateralized uncinate process on CT scan without increased orbital volume, and two moderate cases showed increased orbital volumes on CT scan without clinical enophthalmos. All patients had a significantly lateralized uncinate process at surgery, often closely apposed to demineralized orbital walls. Conclusion Some authors maintain that SSS presentation must include enophthalmos. However, our series shows cases of lateralized uncinate processes and increased orbital volumes on CT scan, as would be seen in classic SSS, but lacking clinical enophthalmos. Such cases should be considered as potentially representing early SSS, before the development of clinical orbital findings.