Pete S. Batra

Outcome analysis of endoscopic sinus surgery in patients with nasal polyps and asthma

Objective: To investigate the efficacy of endoscopic sinus surgery (ESS) in the management of chronic sinusitis and asthma in patients with nasal polyps and steroid‐dependent asthma. Study Design: Retrospective chart review. Methods: The study included 17 patients who underwent ESS with nasal polyps, steroid‐dependent asthma with or without aspirin sensitivity and a minimum of 1 year postoperative follow‐up. Nine patients were ASA sensitive, and eight patients were ASA tolerant. Chronic sinusitis and asthma were evaluated using subjective (patient complaints) and objective (computed tomography scans, pulmonary function tests, steroid doses) criteria. Preoperative data were compared with data obtained 12 to 18 months postESS. Tissue samples were graded for degree of inflammation and edema. Results: Thirteen of the 17 (76.5%) patients reported improved clinical symptoms postESS. The postoperative Lund‐Mackay scores were statistically lower for the 17 patients (P < .0001). The group experienced improvement in postoperative forced expiratory volume at 1 second (FEV1) (P < .014). Twelve of 17 (70.6%) experienced reduction in systemic steroid usage (P < .048). The ASA sensitive patients did not have a statistical improvement in postoperative FEV1 (P > .08) and sinonasal symptoms (P > .16) compared with the ASA tolerant group. Polyp tissue from the ASA sensitive patients demonstrated more edema and more inflammation on average than ASA tolerant polyps, but the results were not statistically significant. Conclusion: ESS demonstrates a beneficial effect on the sinonasal and asthma symptomatology in patients with nasal polyps and asthma using objective measures. Subset of aspirin‐tolerant patients have statistically better outcome for sinonasal symptoms and pulmonary function testing than aspirin‐sensitive patients.

Resection of anterior skull base tumors: Comparison of combined traditional and endoscopic techniques

Background Traditional craniofacial resection (tCFR) has been used successfully for resection of anterior skull base (ASB) tumors. Minimally invasive endoscopic resection (MIER) also has been used recently; this strategy facilitates superior visualization, avoids facial incisions, and preserves local structures. The goal of this study was to compare the outcome for these two approaches. Methods Retrospective chart analysis was conducted to identify patients undergoing resection of ASB tumors between January 1995 and January 2003. Demographic data, tumor characteristics, and the surgical approach used were determined. The mean operative time, estimated blood loss, hospital stay, and complications were analyzed. Recurrence and mortality rates were calculated. Results Nine patients were managed with the MIER approach, and 16 patients were treated with the traditional open approach. No significant difference was observed between groups on operative time, estimated blood loss, or hospital stay. Major complications were encountered in 2/9 (22%) and 7/16 (44%) patients in the MIER and tCFR groups, respectively. Recurrence was observed in 3/9 (33%) and 5/14 (36%) of the patients in the MIER and tCFR groups, respectively. Mortality rates in the MIER and tCFR groups were 0/9 (0%) and 4/15 (27%), respectively. Conclusion In this preliminary study, MIER of ASB neoplasia did not differ significantly from tCFR in operative time, estimated blood loss, hospital stay, or complication rate. Survival and recurrence rates were similar also. This early experience suggests that MIER is a viable alternative for the surgical management of ASB lesions in appropriately selected patients.

Evidence supporting endoscopic sinus surgery in the management of adult chronic rhinosinusitis : A systematic review

Background Evidence-based medicine calls for a critical evaluation of the scientific evidence for treatments of disease. This report synthesizes the available evidence on the use of endoscopic sinus surgery (ESS) in the management of adult chronic rhinosinusitis (CRS) examining the clinical question: “In adults with CRS who have failed medical management, does ESS improve symptoms and/or quality of life (QOL)?” Methods The American Rhinologic Society and the American Academy of Otolaryngology–Head and Neck Surgery convened a steering committee composed of the authors. Primary research articles evaluated for this report were identified using appropriate search terms and a Medline search. Two authors independently reviewed each article. Articles were assigned an evidence level based on accepted guidelines (level 1 = randomized trials; level 2 = prospective cohort studies with comparison group; level 3 = case-control studies; level 4 = retrospective case series; level 5 = expert opinion). Results We identified 886 abstracts to review, retrieved 75 articles for full review, and included 45 articles in our report. The vast majority of articles represented level 4 evidence (n = 42) and two articles represented level 5 evidence. One article was identified that qualified for level 2 evidence. All of these articles generally supported the finding that ESS improves symptoms and/or QOL in adult patients with CRS. Conclusion There is substantial level 4 evidence with supporting level 2 evidence that ESS is effective in improving symptoms and/or QOL in adult patients with CRS. Future research efforts should focus on prospective studies that include appropriate comparison groups in their design.

Esthesioneuroblastoma: 25-year experience at a single institution

Objectives To evaluate outcomes for patients with esthesioneuroblastoma treated at a single institution during a 25-year period. Design Eighteen patients with pathologic diagnosis of esthesioneuroblastoma between 1980 and 2004 were retrospectively identified. Results Two patients had Kadish A, seven had Kadish B, and nine had Kadish C disease. The mean follow-up was 71 months. Treatment regimens consisted of surgery alone (four patients), surgery followed by postoperative radiation (six patients), surgery followed by postoperative chemoradiotherapy (three patients), preoperative radiotherapy (two patients), preoperative chemoradiotherapy (one patient), chemoradiotherapy (one patient), and surgery plus chemotherapy (one patient). Surgical approaches (n = 17) consisted of 13 traditional craniofacial resections, one endoscopic-assisted cranionasal resection, and three minimally invasive endoscopic resections. The 10-year disease-specific survival was 80%. The overall recurrence-free survival at five and 10 years was 62% and 46%, respectively. Positive surgical margins and TNM staging predicted survival. Conclusion Both endoscopic and open surgical approaches have been successful in treating a small number of esthesioneuroblastoma patients with high survival and low rate of surgical complications.

Sinonasal Wegener granulomatosis: A single-institution experience with 120 cases

Wegener granulomatosis (WG) is intimately associated with the sinonasal tract, with involvement reported in 85% of patients during the course of the disease process. The objectives of the study were: 1) to describe sinonasal symptoms and signs at the time of initial otolaryngologic evaluation; and 2) to review indications and outcomes for rhinologic surgery in WG at our institution.

Functional Endoscopic Sinus Surgical Outcomes for Contact Point Headaches

Headaches secondary to sinonasal anatomic abnormalities continue to remain a difficult entity to diagnose and to manage. This retrospective study analyzed the outcome of care for 34 patients who presented with headaches as one of their primary sinonasal complaints and were subsequently found to have contact points between the nasal septum and one or more turbinates on nasal endoscopy and/or computed tomography scan. Following functional endoscopic sinus surgery to relieve the contact points, these patients were interviewed regarding preoperative and postoperative intensity and frequency of the headaches and the overall response of the chronic sinusitis and headaches to surgery, after a mean follow‐up period of 13.9 months. After surgery, reduction in intensity and frequency of headaches was experienced in 91% and 85% of the patients, respectively. This investigation demonstrates that surgical management of contact point headaches can make a significant impact on the headache symptomatology in children and adults.

Isolated sphenoid sinus disease : Etiology and management

OBJECTIVE: To evaluate the diagnosis and management of isolated sphenoid sinus disease by using the current rhinologic standard of care. STUDY DESIGN: Retrospective chart review. RESULTS: Fifty sequential, symptomatic patients were studied. Presenting symptoms included headache or facial pain (88%), rhinorrhea (46%), and nasal congestion (26%). All patients underwent CT imaging, demonstrating bony changes or dehiscences (42%), a mass (24%), or complete opacification of the sphenoid sinus (22%). Eighty percent required surgical intervention. The most frequent diagnoses were as follows: sinusitis (38%), fungal ball (20%), neoplasm (16%), and mucocele (12%). Treatment resulted in clinical or endoscopic improvement or resolution in 87% of the patients. CONCLUSION: The presenting symptoms of isolated sphenoid sinus disease can be nonspecific and may result in an inordinate delay in diagnosis. Nasal endoscopy and radiologic imaging are central to making an accurate and timely diagnosis. Medical treatment or minimally invasive surgical techniques can successfully manage the majority of patients with persistent or refractory symptoms.

Intraoperative surgical navigation for endoscopic sinus surgery: Rationale and indications

Purpose of reviewThe present review discusses the rationale and indications for image-guided surgery through a critical discussion of registration concepts as well as clinical reports. Recent findingsThe surgical navigation accuracy achieved by commercially available image-guided surgery systems is best reported as target registration error. Clinically achievable target registration error is probably in the 1.5–2.0 mm range. Dry lab studies of registration serve to highlight the principles of registration, the process through which image-guided surgery systems calculate the one-to-one mapping relationship between the preoperative imaging data and the intraoperative surgical volume. Reports on image-guided surgery have highlighted its usefulness in primary and revision endoscopic sinus surgery, osteoplastic frontal sinusotomy, transsphenoidal hypophysectomy, endoscopic cerebrospinal fluid leak repair and endoscopic pterygomaxillary fossa biopsy. Both three-dimensional computed tomography angiography and computed tomography–magnetic resonance fusion images have been incorporated into IGS for advanced minimally invasive endoscopic skull base procedures. The American Academy of Otolaryngology–Head and Neck Surgery policy statement accurately summarizes the current consensus for image-guided surgery applications. SummaryImage-guided surgery has emerged as an important technology, which both general otolaryngologists and subspecialty rhinologists can employ for a wide variety of procedures.

New staging system for sinonasal inverted papilloma in the endoscopic era.

Objectives: Advanced endoscopic techniques have emerged as the preferred treatment modality for sinonasal inverted papilloma (IP); however, a staging system that provides prognostic information has not yet been developed. This study aims to develop a clinically relevant staging system for IP managed with the endoscopic approach as the primary surgical modality.

Endoscopic resection of sinonasal malignancies: a preliminary report.

Background A minimally invasive endoscopic approach for the management of sinonasal malignancy offers several advantages including excellent illumination, maximal preservation of uninvolved vital structures, and sparing of facial incisions. The purpose of this study was to evaluate the outcome and morbidity of endoscopic resection with or without combined radiotherapy and/or chemotherapy. Methods Forty-seven patients with sinonasal malignancy were diagnosed and/or treated with an endoscopic approach at The Cleveland Clinic Foundation and The University of Pennsylvania Medical Center from 1996 to 2003. Nineteen patients fulfilled the study criteria and had a minimally invasive endoscopic resection. Fifteen patients were treated with curative intent and four patients underwent palliative resection. Results The mean age was 56.9 (9–78 years) years and the mean follow-up period was 26.4 months. Combined radiation with or without chemotherapy pre- or postoperatively was given to 15 of 19 (78.9%) patients. Thirteen patients were resected strictly with an endoscopic approach and six patients were resected in combination with neurosurgery. There were no peri- and postoperative deaths. The local recurrence (LR) rate was 26.3% (5/19) and the distant metastasis rate was 15.8% (3/19). Overall survival rate (OS) was 78.9% (15/19) at a mean follow-up duration of 32.1 (4–74 months) months. The disease-free survival (DFS) rate was 68.4% (13/19) by clinical, endoscopic, and radiographic surveillance at a mean follow-up duration of 33.1 months. Patients treated with curative intent had LR, OS, and DFS rates of 21.4, 85.7, and 85.7%, respectively, and the patients treated for palliation had LR, OS, and DFS rates of 40, 60, and 15%, respectively. Conclusion Minimally invasive endoscopic resection of sinonasal malignancy in combination with adjunctive therapies reduces treatment morbidity and yields LR, OS, and DFS rates that are comparable with traditional anterior craniofacial approaches.