Nicholas W. Stow

Efficacy of medical therapy in treatment of chronic rhinosinusitis

Uncomplicated chronic rhinosinusitis (CRS) is generally treated with medical therapy initially and surgery is contemplated only after medical therapy has failed. However, there is considerable variation in the medical treatment regimens used and studies defining their efficacy are few. The aim of this study was to determine the proportion of patients treated medically who responded sufficiently well so that surgery was not required. Subgroup analysis to identify clinical features that predicted a favorable response to medical therapy was also performed. Eighty patients referred to the Otorhinolaryngology Clinic at North Shore Hospital were treated with a standardized medical therapy protocol (oral prednisone for 3 weeks, oral antibiotics and ongoing saline lavage and intranasal budesonide spray). Symptom scores were collected before and after medical therapy. Clinical features such as presence of polyps, asthma, and aspirin hypersensitivity were recorded. Failure of medical therapy was defined as the persistence of significant CRS symptoms, and those patients who failed medical therapy were offered surgery. Follow-up data were available for 72 (90%) patients. Of this group, 52.5%, (95% CI, 42.7%, 62.2%) failed to respond adequately to medical therapy and were offered surgery. The remaining patients (37.5%) were successfully treated with medical therapy and did not require surgery at the time of follow-up. The premedical therapy symptom scores were significantly higher than the postmedical therapy symptom scores (p < 0.01). The symptom scores of those patients postmedical therapy who proceeded to have surgery were significantly higher than the group who responded well to maximum medical therapy (MMT) and did not require surgery (p < 0.0001). There were no significant differences in the proportion of patients with asthma, aspirin sensitivity, or polyps between the groups failing or not failing MMT. In approximately one-third of patients with CRS, medical therapy improved symptoms sufficiently so that surgical therapy was avoided. Patients with more severe symptoms tended not to respond as well as those with less severe symptoms. Long-term follow-up is required for the group of responders to determine how many will eventually relapse.

Minimal clinically important differences in nasal peak inspiratory flow.

INTRODUCTION Acoustic Rhinometry, Rhinomanometry, Nasal Spirometry and Nasal Peak Inspiratory flow (NPIF) all measure subtly different constructs of nasal function. All have limitations but NPIF is simple and quick to integrate into clinical practice. The minimum clinically important difference (MCID) for an outcome measure is an estimate of the smallest change that is experienced by a patient or group as being significant. Studies, particularly with large samples, may generate results that while statistically significant, have limited clinical effect. Defining MCID allows an assessment of the clinical impact of an intervention. This study defines the MCID for NPIF. METHODS Prospective study of patients from a tertiary clinic undergoing open septorhinoplasty. Nasal obstruction scores and NPIF were recorded before and after surgery. Global function and nasal obstruction scores were used to assess subjective change. Statistical based and patient anchored techniques were used to define MCID. RESULTS 51 patients with a mean age 36 +- 13 yrs (75% female) were recruited. All had open rhinoplasty, septal reconstruction, spreader grafts and turbinate reduction. Baseline NPIF was 101 +- 35 L/min. The statistically derived MCID (half standard deviation) was 18 L/min, the patient anchored approaches were 20 L/min and 20-25 L/min. DISCUSSION Although NPIF is effort dependant with the potential for poor test-retest reliability, it is simple, quick and a reliable technique can be quickly learnt. An MCID of 20L/min is recommended when NPIF is used as an outcome tool. Understanding the MCID is critical for assessing the impact of nasal surgery.

Silastic Splints Reduce Middle Meatal Adhesions after Endoscopic Sinus Surgery

Background Adhesions frequently form between the middle turbinate and lateral nasal wall after endoscopic sinus surgery (ESS) and are a possible cause for surgical failure. Many absorbable and nonabsorbable spacers have been tried to improve healing. This study was designed to ascertain whether placement of a thin silastic splint into the middle meatus after sinus surgery for 2 weeks reduces adhesion formation and whether a reduction in the adhesion rate improves patient outcomes in the early postoperative phase. Methods Forty-two patients who were scheduled to undergo ESS for chronic rhinosinusitis were randomized to have a silastic splint placed into the middle meatus on one side of the nose but not the other at the completion of surgery. Splints were removed 2 weeks postoperatively. Symptom scores were recorded for each side of the nose up to 12 weeks after surgery and ethmoid cavities were graded at the 6- and 12-week visits along with assessment of adhesions. Patients were blinded to which side was splinted as was the surgeon assessing ethmoid cavities at 6 and 12 weeks. Results Thirty-three patients completed 12 weeks of follow-up. Nasal obstruction and facial pain/discomfort were significantly higher on splinted sides for the first 2 weeks. More interventions were performed to debride adhesions in nonsplinted sides. Endoscopy revealed no adhesions at 12 weeks for sides treated with a splint whereas 9 of 33 nonsplinted sides had persistent adhesions. There were no significant differences in symptom or ethmoid cavity scores at 6 or 12 weeks between sides treated with splints versus sides treated without splints or between sides with adhesions versus without adhesions. Conclusion Middle meatal silastic splints reduce adhesions after ESS but increase early nasal obstruction and discomfort. Their use did not significantly change symptom or ethmoid cavity scores at 12 weeks.

Functional Outcomes of Structured Nasal Tip Refinement

OBJECTIVE To describe a technique to refine the nasal tip and supratip while preserving structure; traditional attempts to reduce nasal tip bulbosity involve maneuvers that may result in loss of support, leading to poor functional and cosmetic outcomes. METHODS A prospective study of patients undergoing open structure nasal tip refinement using scroll joint excision with a septal-lateral crural suture to flatten the lateral crus. Outcomes assessed were nasal peak inspiratory flow (NPIF), nasal obstruction scores, 22-item Sinonasal Outcome Test (SNOT-22), 36-item Short-Form questionnaires (SF-36), and anchor scores for breathing and cosmesis. RESULTS The mean NPIF improved from 100 L/min to 139 L/min, nasal obstruction improved, and the mean (SD) SNOT-22 scores improved from 1.45 (0.86) to 0.63 (0.65) (P< .01 for all comparisons). All patients had improved cosmesis, and 2.2% had both subjectively and objectively impaired nasal breathing. CONCLUSIONS A technique is described allowing refinement of the nasal tip while maintaining or improving the nasal airway and providing a high level of patient satisfaction with the aesthetic outcome. Even in patients seen for cosmetic rhinoplasty, there may be a degree of preoperative nasal obstruction that should be recognized and addressed.

Simultaneous Tonsillectomy and Nasal Surgery in Adult Obstructive Sleep Apnea A Pilot Study

Objective Although adenotonsillectomy is the accepted treatment for obstructive sleep apnea (OSA) in the pediatric population, tonsillectomy has not been widely adopted in adults, and its success in this group has not been well reported. Despite the lack of current evidence, there may be an important role for tonsillectomy in selected adult cases, and further study is required. This is a pilot study from a larger group of subjects currently enrolled and awaiting surgery and repeat polysomnography. Study Design Retrospective series with chart review. Setting Tertiary referral teaching hospitals. Subjects and Methods Thirteen consecutive eligible subjects with tonsillar hypertrophy and OSA were identified after treatment. These patients had undergone pre- and postoperative polysomnography for assessment of the severity of sleep-disordered breathing. Post hoc analysis of key parameters was performed by Wilcoxon signed rank and paired t tests. Tonsillectomy was performed on all subjects, using the diathermy dissection technique. Nasal surgery was performed simultaneously in 11 subjects for symptomatic nasal blockage unresponsive to medical treatment. Results There was a statistically significant improvement in the severity of OSA after surgery. The total Respiratory Disturbance Index (RDI) was significantly decreased from median values of 31.7 to 5.5 (P = .0002). The RDI in rapid eye movement and non–rapid eye movement sleep and the arousal index were also significantly decreased. Conclusion In selected adult subjects, tonsillectomy with intercurrent nasal surgery should be considered an effective treatment for OSA and may reduce the requirement for continuous positive airway pressure, oral appliances, or further therapeutic intervention.

Technique of temporoparietal fascia flap in ear and lateral skull base surgery.

Objectives: The temporoparietal fascia (TPF) is a distinct anatomic layer of the lateral scalp with a defined blood supply. The TPF flap has desirable properties for otologic surgery: high malleability, distinct vascularity, and close proximity to the temporal bone. This article describes our technique for preserving the TPF in approaches to the temporal bone and its subsequent use in otologic reconstructive surgery. Interventions: A retrospective review of the senior authors personal database was undertaken over a 6-year period where a TPF flap was used. Main Outcome Measures: The indication for surgery, type of surgery, time taken for cavity healing, complications, and length of follow-up were recorded. Results: Sixty-five TPF flaps were performed for ear and lateral skull base reconstructive operations. Indications for surgery included cholesteatoma, chronic otitis media, cerebrospinal fluid fistula, and meningoencephalocele. Cholesteatoma and chronic otitis media accounted for 88% of the cases (n = 57). Most (98%, n = 50) of the mastoidectomy cases underwent a posterior based flap. All mastoid cases were epithelialized at 6 weeks. Complications encountered and discussed were a mastoid-cutaneous fistula, mastoid hematoma, and canal stenosis (5%; n = 3). Conclusion: With appropriate technique and indications, the TPF flap is an important reconstructive option after ear and lateral skull base surgery.

Functional and cosmetic outcomes of external approach septoplasty.

Background The external approach for septoplasty is an important surgical technique to manage severe septal deviations, caudal deformities, and mid-dorsal abnormalities when a simple endonasal approach may not suffice. The procedure is longer in duration and draws on more resources than endonasal septoplasty. The outcome reporting of the external approach for septoplasty is important to provide evidence of benefit for both patients and health care providers. This study was designed to describe functional and cosmetic outcomes of the external approach for septoplasty. Methods A prospective assessment of consecutive patients undergoing the external approach for septoplasty at a tertiary center was performed. Pre- and postoperative nasal peak inspiratory flow (NPIF), symptom scores, 22-Item Sinonasal Outcome Test (SNOT-22), Nasal Obstruction Score, and Short Form 36 (SF-36) quality-of-life scores were assessed. A global Likert change scale was also used for both function and cosmesis. Results Thirty patients (mean age, 40 ± 15.9 years; 40% women) were assessed with a mean follow-up of 12.2 ± 9.5 months. Mean NPIF improved significantly from 93.3 ± 34.7 to 143.0 ± 44.3 (p < 0.001). Nasal obstruction score improved significantly from 3.6 ± 1.3 to 0.69 ± 1.2 (p < 0.001). SNOT-22 improved significantly from 34.1 ± 17.2 to 12.7 ± 14.9 (p < 0.001). Ninety-six percent had subjective improvement in nasal function, and 96% had no change or improvement in cosmesis. Seventy percent improved by the minimal clinically important difference for NPIF. Conclusion The external approach for septoplasty is an operation that produces significant improvements in subjective and objective nasal health measures. Although requiring greater training and operative time, it is an appropriate approach for the severely deviated nasal septum.

Laryngeal cryptococcosis: clinical presentation and treatment of a rare cause of hoarseness.

Objective: Laryngeal cryptococcosis is rare, with few reported cases in the literature. We present current investigation and treatment recommendations for this disease. Study Design: A structured literature review; additional cases and expert opinion are presented. Results: Localized laryngeal cryptococcal infection most commonly presents with persisting hoarseness. Clinical suspicion of the disease is required for accurate diagnosis, with treatment based on the patients immune status. Early microbiological advice and adequate follow-up is recommended to ensure disease resolution. Conclusion: Isolated laryngeal cryptococcosis is a rare presentation of fungal infection. It is easily treated and should be considered in the differential diagnosis of patients with persisting hoarseness.

Bacterial Communities Vary between Sinuses in Chronic Rhinosinusitis Patients.

Chronic rhinosinusitis (CRS) is a common and potentially debilitating disease characterized by inflammation of the sinus mucosa for longer than 12 weeks. Bacterial colonization of the sinuses and its role in the pathogenesis of this disease is an ongoing area of research. Recent advances in culture-independent molecular techniques for bacterial identification have the potential to provide a more accurate and complete assessment of the sinus microbiome, however there is little concordance in results between studies, possibly due to differences in the sampling location and techniques. This study aimed to determine whether the microbial communities from one sinus could be considered representative of all sinuses, and examine differences between two commonly used methods for sample collection, swabs, and tissue biopsies. High-throughput DNA sequencing of the bacterial 16S rRNA gene was applied to both swab and tissue samples from multiple sinuses of 19 patients undergoing surgery for treatment of CRS. Results from swabs and tissue biopsies showed a high degree of similarity, indicating that swabbing is sufficient to recover the microbial community from the sinuses. Microbial communities from different sinuses within individual patients differed to varying degrees, demonstrating that it is possible for distinct microbiomes to exist simultaneously in different sinuses of the same patient. The sequencing results correlated well with culture-based pathogen identification conducted in parallel, although the culturing missed many species detected by sequencing. This finding has implications for future research into the sinus microbiome, which should take this heterogeneity into account by sampling patients from more than one sinus.

Novel approach of medialization thyroplasty with arytenoid adduction performed under general anesthesia with a laryngeal mask.

Objective. To objectively assess the voice outcomes of patients with unilateral vocal fold paralysis treated with medialization thyroplasty and arytenoid adduction suture. Study Design. Case series of patients who underwent medialization thyroplasty and arytenoid adduction suture. Preoperative and postoperative voice testing was performed and the data were compared by statistical analysis. Setting. Tertiary referral teaching hospital in Sydney, Australia. Subjects. All patients had a unilateral vocal fold paralysis, with a large posterior glottic gap and vocal symptoms affecting their quality of life. Methods. Thirteen patients with a diagnosis of a unilateral vocal fold paralysis with a large posterior glottic gap, vocal symptoms, and total denervation of the vocal fold underwent medialization thyroplasty and arytenoid adduction suture. The surgery was performed in a novel method under a general anesthetic using a laryngeal mask and with direct intraoperative endoscopic feedback. Preoperative and postoperative measures of voice performance were compared, including acoustic analysis (fundamental frequency, speech intensity against quiet and loud background noise, speech rate) and aerodynamic assessment (airflow, maximum phonation time). Results. Medialization thyroplasty with arytenoid adduction suture significantly improved aerodynamic assessment and phonation duration for both male and female subjects overall. There were 2 of 13 treatment failures. Median follow-up time was 6 months. Conclusion. Preliminary results indicate that in selected patients with vocal fold paralysis, medialization thyroplasty with arytenoid adduction suture leads to significant improvements in objective voice measures. Longer follow-up data are required to further quantify the voice outcomes after this procedure.