Paul R. Cook

Long-term outcome analysis of functional endoscopic sinus surgery: Correlation of symptoms with endoscopic examination findings and potential prognostic variables

One hundred eighty‐two patients were evaluated after functional endoscopic sinus surgery. The goal was to establish whether any anatomical finding correlated with symptoms and to find any historical predictors of symptomatic failure. Of all physical findings reviewed, only scarring of middle meatal antrostomy and scarring of the ethmoids approached significance in predicting poor outcome. Surprisingly, of the historical factors reviewed, only gastroesophageal reflux disease was statistically significant as a predictor of poor symptomatic outcome.

Immunotherapy in Patients Undergoing Functional Endoscopic Sinus Surgery

A total of 283 consecutive patients with chronic sinusitis underwent functional endoscopic sinus surgery. There were 72 allergic patients and 211 nonallergic patients. Data were collected on the effect of immunotherapy on middle meatotomy patency, synechiae formation, and recurrent polyps in allergic patients. Data supported the following conclusions: (1) Immunotherapy given either before or after surgery does not statistically influence middle meatotomy patency, synechiae formation, or recurrence of polyps after functional endoscopic sinus surgery. However, the data do suggest, for all three outcome parameters, that allergic patients who undergo immunotherapy do better than those who do not undergo immunotherapy and, with the exception of recurrent polyps, do as well as nonallergic patients. (2) The prevalence of preoperative polyps is the same for allergic and nonallergic patients in this study, but polyp recurrence is higher in allergic patients. (3) Approximately 40% of allergic patients who began preoperative immunotherapy stopped immunotherapy after surgery because their allergic symptoms resolved or were minimal. A comment regarding this observation is provided.

Functional endoscopic sinus surgery in patients with chronic sinusitis and asthma.

Twenty asthma patients who underwent functional endoscopic sinus surgery for chronic sinusitis were studied. Medical records and questionnaire data for these 20 patients were studied regarding the Impact of sinus disease and functional endoscopic sinus surgery on their asthma. We found that 95% reported that their asthma was worsened by their sinus disease (95% confidence interval, 0.74 to 0.99+), and 85% reported that functional endoscopic sinus surgery improved their asthma (0.60 to 0.97). Of the 13 patients who used both inhalers and systemic medication, 53.8% were able to eliminate some of their medication (0.21 to 0.79). Furthermore, 61.5% of these patients had a concomitant reduction in their inhaler use (0.28 to 0.85). All patients (six) who used only inhalers experienced a reduction in their inhaler use (0.54 to 1.00), and two patients were able to eliminate their inhalers completely. One of two patients who were steroid dependent was able to discontinue steroids after surgery. Of patients who used steroids intermittently (13), 53.8% were able to eliminate the use of steroids after surgery (0.21 to 0.79). Patients who required preoperative hospital admissions (4) and emergency room or urgent physician office visits (18) had a 75.0% and 81.3% (p < 0.001) reduction in visits, respectively, after surgery. Because 43% of the cost of asthma is the result of hospitalizations and emergency department/urgent physician office visits, a significant Impact on health care costs can be realized with functional endoscopic sinus surgery in this patient population.

Symptom outcome after functional endoscopic sinus surgery in patients with cystic fibrosis: A prospective study ☆ ☆☆ ★ ★★

Twenty-nine consecutive patients with cystic fibrosis were offered functional endoscopic sinus surgery. Twenty-six of these patients underwent surgery. A symptom questionnaire was obtained from the patient or parent before surgery. At the end of the study this symptom questionnaire was again administered to the same individual, and 21 completed it. There were 14 male and 7 female patients, with a mean age of 12.3 years and a median age of 8.7 years. Mean follow-up was 34.3 months. Results for the following symptoms were significant: nasal airway obstruction was improved (p < 0.0002), olfactory function was improved (p < 0.0037), purulent nasal discharge was decreased (p < 0.001), and activity level was increased (p < 0.001). Other parameters are also reported in the text. In summary, this study prospectively studies the effects of functional endoscopic sinus surgery on symptoms in patients with cystic fibrosis. The study points out several significant areas of symptom improvement and supports the selective use of functional endoscopic sinus surgery in patients with cystic fibrosis. Indications for surgery are provided.

Effect of partial middle turbinectomy on nasal airflow and resistance.

We report the first prospective study of the effect of partial middle turbinectomy on nasal airflow and resistance as measured objectively by active anterior rhinomanometry. Our study group consisted of 31 consecutive patients who underwent functional endoscopic sinus surgery with simultaneous partial middle turbinate resections. We found that all patients had significant improvement in nasal airflow (p < 0.001) and significant decrease in nasal resistance (p < 0.001). Thus we found no deleterious effect on nasal function. Additionally, we reviewed the literature on retrospective series in which patients had received partial middle turbinectomies and found no evidence that nasal function was impaired after surgery. We conclude that partial middle turbinectomy may be performed without adversely altering nasal function, as measured by active anterior rhinomanometry.

Endoscopic partial inferior turbinoplasty.

Endoscopic partial inferior turbinoplasty with a microdebrider has been introduced as an alternative to other inferior turbinectomy techniques for the treatment of nasal airway obstruction. Between June 1994 and December 1997, 100 patients underwent endoscopic partial inferior turbinoplasty. Concurrent septoplasty was performed in 81 patients, and functional endoscopic sinus surgery was performed in 43 patients. Synechiae formation in 12 patients was the most common complication and resolved in nearly all cases. Postoperative improvement in nasal patency occurred in 93% of the patients. In the 48 patients for whom preoperative subjective scores were available, a significant difference was noted when comparing preoperative and postoperative subjective and outcome scores of nasal patency (P < 0.0001). Patients with underlying allergy and chronic sinusitis tended to have lower outcome scores. Postoperative rhinomanometry was obtained in 21 patients and revealed a normalized mean total nasal resistance of 0.23 Pa/mL/second. This improved to 0.17 Pa/mL/second with topical decongestion (P = 0.0029), revealing the retention of the turbinate mucosas vasoactive capability. We conclude that endoscopic partial inferior turbinoplasty provides a good alternative to other inferior turbinectomy techniques and is associated with excellent outcomes and minimal morbidity.

Paranasal Sinus Computed Tomography Scan Findings in Patients with Cystic Fibrosis

Seventy paranasal sinus computed tomography scans of patients with cystic fibrosis were compared with those of age-matched control groups of randomly selected chronic sinusitis patients without cystic fibrosis to determine whether differences in disease patterns existed. In patients older than 10 years, frontal sinus agenesis and maxilloethmoid sinus opacification were significantly more prevalent in patients with cystic fibrosis than in chronic sinusitis patients without cystic fibrosis. Medial bulging of the lateral nasal wall was significantly greater in patients with cystic fibrosis than in chronic sinusitis patients without cystic fibrosis in patients older than 5 years. On the basis of these findings, a diagnostic triad of radiologic findings for cystic fibrosis detection is presented, as well as its clinical implications.

Functional endoscopic sinus surgery in patients with normal computed tomography scans.

Eighteen patients were operated on by functional endoscopic sinus surgery who had no ostiomeatal unit obstruction on computed tomography scan and had unremarkable paranasal sinuses. These patients also had no apparent ostiomeatal unit obstruction on diagnostic nasal endoscopy. Data were collected on these patients regarding the impact of very limited functional endoscopic sinus surgery on their principal complaint of recurrent sinusitis with facial pain/headache thought to be of sinogenic origin. Sixteen patients (88.9%) had a reduction in the number of sinus infections requiring antibiotic therapy. This reduction was significant at p < 0.0001. Twelve of 14 patients whose facial pain/headache was believed to be of sinogenic origin had a significant reduction in severity (95% confidence interval, 49.2% to 95.3%). We discuss the role of reversible nasal mucosal disease in the pathophysiology of recurrent rhinosinusifts in this patient population. This was a very small, select group of patients who had specific complaints and had had medical treatment failures. This therapy Is not recommended for every patient, but only a select few with classic complaints of sinus headaches or recurrent sinusitis and negative computed tomography scans.

Systemic reactions to immunotherapy: the American Academy of Otolaryngic Allergy morbidity and mortality survey.

Anaphylaxis may be defined as a systemic, Immunoglobulin E-mediated (Gell-Coombs type I) hypersensitivity reaction triggered by exposure to an antigen in a previously sensitized patient. Anaphylaxis may occur in a varlety of circumstances: however, when it occurs as the result of Immunotherapy, it is of great concern to the practicing allergist. When describing or reporting anaphylaxis relating to Immunotherapy, most allergists speak in terms of the types of reactions, local vs. systemic. Germane to this discussion is the use of the term systemic reaction, which can mean anything from mild allergy symptoms resulting from an allergy injection to bradycardia and hypotension (shock). In this article we report serious or significant systemic reactions, which are characterized by any of the following symptoms: urticaria, sneezing or nasal obstruction, throat tightness or congestion, wheezing, and shock (bradycardta or hypotension). There were no fatalities reported from the survey group. The overall reaction rate was 0.3%.

Botryomycosis: improved therapy for a difficult infection

Botryomycosis is a chronic bacterial granulomatous disease often involving the skin and subcutaneous tissue. Head and neck involvement is rare. Botryomycosis presents with clinical and histological features similar to actinomycosis or mycetoma, but the causative organism is usually Staphylococcus aureus. Microscopically the organisms appear to be encapsulated in granules, which are thought to protect them from the effects of standard courses of antibiotics. Botryomycosis usually requires surgical intervention for cure. Major debilitating surgery has been required for most patients, because the infection has been unresponsive to seemingly appropriate medical therapy. We present an 8-month-old male with periorbital botryomycosis. Surgical specimens for diagnosis were obtained, but complete resection would have created debilitating functional and cosmetic defects. The lesion failed to respond to nafcillin alone or combination therapy with hyperbaric oxygen, but showed slow, steady improvement with long-term clindamycin. The patient has been disease free for more than 4 years, with minimal scarring and no functional impairment. Prolonged medical therapy for botryomycosis may be a viable alternative to the traditionally recommended surgical resection, thereby reducing cosmetic and functional morbidity.