Matti Penttilä

Otoscopic diagnosis of middle ear effusion in acute and non-acute otitis media. I. The value of different otoscopic findings

To determine the value of different pneumotoscopic findings in diagnosing the middle ear effusion (MEE) of acute (AOM) and non-acute otitis media, 11,804 ear-related visits of 2,911 unselected children at ages 0.5-2.5 years were analysed. About half of these were examined by an otolaryngologist in one, and half by a pediatrician in another, urban area. Myringotomy was always performed when MEE was suspected, and it confirmed the presence of MEE in 85% (otolaryngologist) and 82% (pediatrician) of altogether 5,462 acute and in 69% (both doctors) of 1,092 non-acute cases suspected. Redness of the tympanic membrane (TM) was found in only 18% and 27% of the visits with AOM, and it predicted MEE with only 60% and 51% probability, if seen in acute visits. Cloudiness of the TM was noticed in 81% and 67% of the visits with AOM; its specificity and the other calculated variables were good in regard to the diagnosing of MEE, especially in acute cases in both groups. Distinctly impaired mobility of the TM was of about the same diagnostic value, but its position reliably indicated MEE only when bulging. In AOM the colour or mobility of the TM was normal very rarely, but the position was normal in a third of the cases. Thus, although there were differences in the incidences of different otoscopic findings in the two study groups, the diagnostic value of certain pneumatic otoscopic findings, especially cloudiness and distinct hypomobility of the TM, seemed to be good in both groups.

Functional vs. Radical Maxillary Surgery. Failures after Functional Endoscopic Sinus Surgery

Randomized FES or Caldwell-Luc (C-L) operations were performed in 150 patients suffering from chronic maxillary sinusitis during 1987-1989. Follow-up examination was done for 143 patients (95%) 1 year postoperatively. Although 15 patients had already deceased, questionnaires were obtained from 128 patients (85%) 5-9 years after operation. One year after surgery 51% of the C-L patients and 77% of the FES patients reported no symptoms or distinct improvement in their global symptoms, whereas 5-9 years postoperatively 82% of the C-L and 76% of the FES patients reported this outcome, respectively. Thirteen C-L operated patients (18%) and 14 FES patients (20%) have been reoperated during 7-9 years follow-up. In most cases revision surgery was done for polyposis or maxillary sinusitis. In the long term, altogether 21 patients (28%), including 14 reoperated patients, were failures after FES. These included also 4 patients with global symptoms unchanged at late inquiry and 3 other patients, though getting better, reported unwillingness for FES operation if they had known the result beforehand.

Endoscopic sinus surgery might reduce exacerbations and symptoms more than balloon sinuplasty.

Background Endoscopic sinus surgery (ESS) is considered after medical therapy failure of chronic rhinosinusitis (CRS). The balloon sinuplasty dilates the natural ostium without moving mucosa or bone. It still lacks evidence from randomized controlled trials. The aim of this retrospective controlled study was to compare the symptom outcomes after maxillary sinus surgery with either the ESS or the balloon sinuplasty technique. No previous or additional sinonasal operations were accepted. Methods Two hundred eight patients with CRS without nasal polyps underwent either balloon sinuplasty or ESS. The patients who met with the inclusion criteria (n = 45 in ESS group and n = 40 in balloon group) replied to a questionnaire of history factors, exacerbations, and a visual analog scale (VAS) scoring of the change in symptoms, on average 28 ± 6 (mean ± SD) months postoperatively. Results The groups were identical in the response rate (64%), patient characteristics, and the improvement in all of the asked symptoms. Patients with CRS-related comorbidity and/or present occupational exposure had a statistically significantly better symptom reduction after ESS than after balloon sinusotomy. Moreover, the balloon sinusotomy group reported a statistically significant higher number of maxillary sinus punctures and antibiotic courses during the last 12 months. Conclusion ESS might be superior to balloon sinuplasty, especially in patients with risk factors. There is a need to perform more controlled studies on the treatment choices of CRS.

Endoscopic Findings After Functional and Radical Sinus Surgery: A Prospective Randomized Study

Functional endoscopic (FES) and radical Caldwell-Luc (C-L) surgical approaches were compared in a prospective randomized trial of 150 consecutive patients (aged 14–88 years) suffering from chronic maxillary sinusitis over 3 months’ duration refractory to medical and repeated antral irrigation therapy. A total of 143 patients with 109 operated antra in the C-L group and 127 antra in the FES group were available for the follow-up nasal and antral endoscopic examination median 12 months postoperatively. Both modalities proved effective in relieving subjective symptoms. Postoperatively, FES antra contained markedly fewer secretions, although the endoscopically enlarged natural antral ostium was closed in 18.6% of the sinuses. The inferior meatal antrostomies of the C-L operation were markedly stenosed or closed in 31.4% of the sinuses. Antral mucosal thickness and antral polyps diminished significantly after both operations, but large polyps were found more often after FES.

Local anesthesia with EMLA cream for maxillary sinus puncture.

Maxillary sinus puncture is traditionally carried out through the lateral wall of the inferior nasal meatus under local anesthesia. One problem with it is that the insertion of a cotton-tipped applicator soaked in local anesthetic is painful. Patients also dislike waiting for the anesthetic effect with the metallic applicators in the nose. In this study, we present a new, well-tolerated method of topical anesthesia for maxillary sinus puncture via the inferior meatus of the nose. Twenty adult patients with maxillary sinus infection who were undergoing bilateral maxillary sinus puncture were studied. One side of each patients nose was anesthetized with a cotton-tipped applicator moistened with a lidocaine-adrenaline solution (LA), and the other side was anesthetized with EMLA cream instilled with a suction needle and syringe; the sides were chosen randomly. The mean “application of anesthesia” pain score on a 100-mm visual analog scale was 39.2 for the LA side and 9.1 for the EMLA side (p <.01). The anesthesia required for puncture was reached more quickly on the EMLA side than on the LA side (p =.02). The mean puncture pain score was 25.1 with LA and 8.6 with EMLA (p =.01). Fourteen patients out of the 20 (70%) found EMLA more tolerable, 3 patients (15%) found no difference, and 3 patients (15%) preferred LA (p <.01). We conclude that EMLA is better-tolerated and quicker-acting than LA for local anesthesia in maxillary sinus puncture.

Comparison of intra-operative characteristics and early post-operative outcomes between endoscopic sinus surgery and balloon sinuplasty

Abstract Conclusion: In terms of operation time, anesthesia method, and low complication rate, ESS and balloon sinuplasty seemed comparable. The advantages of balloon sinuplasty were shown to be shortness of sick leave, possibility to be performed as an in-office procedure, and lower adhesion formation. Background: Endoscopic sinus surgery (ESS) has been considered as a treatment of choice for persistent chronic rhinosinusitis (CRS). During the last decade balloon sinuplasty has been introduced as an alternative technique to dilate the ostium. Although balloon sinuplasty is considered relatively safe and efficient, comparative evidence of its putative intra-operative and post-operative advantages remain limited. Objectives: The aim of this retrospective controlled study was to evaluate intra-operative factors and early post-operative outcomes among CRS patients who had undergone maxillary sinus operation with either balloon sinuplasty or ESS technique. Materials and methods: Data were collected from 208 patients with CRS treated either with ESS or balloon sinuplasty during the years 2008–2010. Intra- and peri-operative factors were collected from patient records of the patients who met the inclusion criteria (n = 39 in ESS group and n = 36 in balloon sinuplasty group). Results: There was no significant difference in operation time and anesthesia method between the two groups. No complications occurred with either technique. All ESS procedures and 67% of the balloon sinuplasty procedures were done in the hospital setting, whereas 33% of the balloon sinuplasty procedures were done in the office setting. The duration of sick leave and the number of patients with adhesions were significantly higher in the ESS group compared to the balloon sinuplasty group.

Long-term follow-up after ESS and balloon sinuplasty: Comparison of symptom reduction and patient satisfaction.

Abstract Conclusion This is the first controlled study of balloon sinuplasty’s long-term efficacy with the follow-up time over 5 years. The results are in accordance with a previous 2-year-follow-up study. Both techniques retained the efficacy and patient satisfaction on average 6 years after the surgery. Background Endoscopic sinus surgery (ESS) and balloon sinuplasty are considered as a treatment for chronic rhinosinusitis (CRS) after a failure of conservative therapy. High cost and lack of long-term follow-up studies restrain the use of balloon sinuplasty. Objective The aim of this study was to compare long-term efficacy and satisfaction in CRS patients who had undergone maxillary sinus operation with either balloon sinuplasty or ESS technique. Previous or additional sinonasal operations were exclusion criteria. Materials and methods Study patients were recruited from 208 CRS-patients who underwent either ESS or balloon sinuplasty. Patients with nasal polyposis (gradus ≥ 2), previous sinonasal surgery, unilateral disease, or immune deficiency were excluded. Altogether 45 patients in the ESS group and 40 patients in the balloon group were included. Of these, 30 and 28, respectively, answered to a phone interview held on average 6 years after primary surgery. Symptom reduction and long-term satisfaction were evaluated by using symptom scores of 19 parameters altogether. Results Both groups experienced improvement in symptoms and were equally satisfied with the operation. The number of patient-reported acute exacerbations was higher among the balloon dilated patients. Also, the reduction of thick nasal discharge was less evident in the balloon sinuplasty group. Four patients in the balloon sinuplasty group underwent revision surgery. There were no revisions in the ESS group.

Factors affecting revision rate of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a variable multifactorial disease. It can be divided into forms with nasal polyps (CRSwNP) and without (CRSsNP). Sinus and/or nasal polypectomy surgery are considered if maximal conservative treatment is insufficient. The predictive factors of the need of revision surgery comprise mostly the CRSwNP phenotype and are not fully understood.

In Reference to Reformation of Concha Bullosa Following Treatment by Crushing Surgical Technique: Implication for Balloon Sinuplasty

In the December 2009 issue, authors David A. Kieff, MD and Nicolas Y. Busaba, MD, FACS, published their article titled ‘‘Reformation of Concha Bullosa Following Treatment by Crushing Surgical Technique: Implication for Balloon Sinuplasty.’’ This is a retrospective case series of 10 patients, in which the authors claim that middle turbinate concha bullosa reforms after previous crushing, causing chronic maxillary sinusitis and nasal obstruction. In addition, the authors use this observation to relate their findings and imply the possibility of restenosis of the sinuses when balloon catheter dilation techniques are used. The authors make a great leap of reasoning to relate these two claims, which is ill-founded and illogical based on the data they present and the data in the published literature. I have had experience in both of these areas and have not found this to occur; therefore, I disagree with their conclusion. I have performed endoscopic sinus surgery since 1986, and for most of my career have used a crushing technique to diminish both middle and superior bullous turbinates. I believe that crushing has advantages over resection for several reasons:

Mucociliary Clearance of the Maxillary Sinuses in Patients With Recurrent or Chronic Sinusitis

This is one of the first human studies of maxillary sinus mucociliary activity using human serum albumin labelled with 99m-technetium (99mTc-HSA) as a tracer in patients suffering from recurrent or chronic maxillary sinusitis. The tracer was injected into both maxillary sinuses through small sinus irrigation catheters. Nasal endoscopy and computed tomography were performed in all patients shortly before the injection. The clearance rates of four case report patients with different endoscopic and radiographic findings showed great individual variation. The technique proved to have viability for clinical use when evaluating sinusitis treatment options and results.