Ralph Metson

The Health Impact of Chronic Sinusitis in Patients Seeking Otolaryngologic Care

Although chronic sinusitis is an increasingly common diagnosis in the United States, the health burden of this disorder relative to the general population and to other chronic diseases has not been previously evaluated. One hundred fifty-eight patients with chronic sinusitis and no prior surgery underwent cross-sectional evaluation by use of the Medical Outcome Study Short-form 36-Item Health Survey. These patients were all referred for otolaryngologic care, and more than 80% subsequently underwent sinus surgery. Mean scores were compared from the eight subscales of general health assessment with similarly derived data for the United States general population. Significant differences (p < 0.05) were seen in several domains, including bodily pain, general health, vitality, and social functioning. Comparisons with other chronic diseases revealed significantly lower scores (p < 0.05) in measures of bodily pain and social functioning for sinusitis patients than in patients with congestive heart failure, angina, chronic obstructive pulmonary disease, and back pain. These findings suggest that the national health impact of chronic sinusitis is far greater than is currently appreciated.

Holmium: YAG Endonasal Laser Dacryocystorhinostomy

Previously described techniques of endonasal laser-assisted dacryocystorhinostomy appear to offer several advantages over conventional external dacryocystorhinostomy, including the following: (1) decreased disruption of medial canthal anatomy, (2) enhanced hemostasis, and (3) avoidance of a cutaneous scar. Although good results were achieved, several limitations of early laser-assisted techniques have been noted, including difficulty in removal of the thick bone of the anterior lacrimal crest and inability to obtain specimens of lacrimal sac mucosa for biopsy purposes. In a series of 40 consecutive, primary endonasal dacryocystorhinostomy procedures, we used the holmium:YAG (Ho:YAG) laser for bone removal and endoscopic sinus surgical instrumentation to obtain lacrimal sac biopsy specimens. Intraoperative hemostasis was excellent and medial canthal scarring was avoided in all patients. The overall long-term ostium patency rate in our series was 82%. Several technical modifications adopted in the latter part of our series, including use of a small drill for supplemental bone removal, extensive removal of lacrimal sac mucosa, and use of a double stent, appeared to enhance this success rate.

EFFECT OF SINUS SURGERY ON QUALITY OF LIFE

Although sinus surgery may reduce the incidence of recurrent infection in patients with chronic sinusitis, little is known about the effect of such surgery on a patients quality of life. One hundred eight patients undergoing ethmoid sinus surgery were prospectively evaluated with statistically validated measures of sinusitis-specific and general health-related quality of life. Twelve months after surgery significant improvements were found in sinus-specific health status, including a reduction in symptoms (p < 0.001) and medication usage (p < 0.001). An overall improvement was found in 82% of patients, whereas 11% were worse, and 7% remained unchanged. Measures of general health status demonstrated preoperative decrements in five of eight subscales as compared with the normal population. Six months after surgery significant improvements were noted in six categories (p < 0.05), and most attained near-normative levels. Individuals with asthma demonstrated greater overall improvement in general health status than did other cohorts (p < 0.05). We conclude that patients with chronic sinusitis achieve large improvements in sinusitis-specific quality-of-life measures 12 months after sinus surgery, as well as improvements in general health status.

Endoscopic laser dacryocystorhinostomy

Endoscopic laser dacryocystorhinostomy (DCR) enables an obstructed lacrimal sac to be opened through an intranasal approach, avoiding the need for a skin incision. The holmiumtyttrium aluminum garnet (holmium:YAG) laser is well‐suited for this procedure because of its properties of fiberoptic delivery, effective bone cutting, and precise soft‐tissue coagulation. Efficient bone ablation is particularly important for primary DCR which requires removal of relatively thick bone along the lateral nasal wall to expose the lacrimal sac. Forty‐six endoscopic laser DCRs were performed on 40 patients. There were no intraoperative or postoperative complications. The surgery successfully relieved lacrimal obstruction in 85% of patients. Endoscopic instrumentation allowed for the rapid identification and correction of intranasal causes of DCR failure, including ethmoid sinus disease and middle turbinate hypertrophy. Endoscopic laser DCR appears to be a safe and effective procedure which should be considered as an alternative to external DCR for the surgical treatment of nasolacrimal duct obstruction.

Validation of a Patient‐Graded Instrument for Facial Nerve Paralysis: The FaCE Scale

Objective To develop and validate a patient‐based instrument to measure both facial impairment and disability, the Facial Clinimetric Evaluation (FaCE) Scale.

A comparison of image guidance systems for sinus surgery

Objective: Intraoperative computed tomographic guidance systems are available which utilize either electromagnetic (radiofrequency) or optical (infrared) signals to localize instruments within the surgical field. The objective of this study was to compare the use of these two different image guidance technologies for sinus surgery. Study Design: Prospective cohort study. Methods: The electromagnetic‐based InstaTrak system (n = 24) and the optical‐based Stealth‐Station (n = 49) were compared in a series of 73 consecutive sinus series which utilized image guidance technology. Results: Both the electromagnetic and optical systems provided anatomic localization to within 2 mm during surgery. Intraoperative reregistration was effective in correcting for any anatomic drift. There were no intraoperative complications. Mean operative times were 156.3 ± 8.9 minutes for the electromagnetic and 139.2 ± 17.7 minutes for the optical system (P < .05). The average intraoperative blood loss did not differ significantly between groups (electromagnetic, 190.6 ± 28.7 mL; optical, 172.4 ± 23.0 mL). Each system was noted to have limitations. The presence of metallic objects in the operative field interfered with functioning of the electromagnetic system, whereas the optical system required a clear line of sight to be maintained between the infrared camera and surgical handpiece. Both systems required specialized headsets to be worn by patients during surgery to monitor head position. The electromagnetic system also required these headsets to be worn during the preoperative computed tomography scan. Conclusion: Although these two image guidance systems both proved valuable for anatomic localization during sinus surgery, individual preferences can be based on distinct differences in their design and operation.

Techniques for outcomes research in chronic sinusitis

Accurate assessment of patient outcome after sinus surgery requires the collection of valid and reliable data. Symptom-based surveys were administered in a prospective manner to 104 patients with chronic sinusitis. Test-retest reliability for the Chronic Sinusitis Survey based on duration of symptoms (0.86, P<.0001) was superior to that for a similar survey based on severity of symptoms (0.57, P<.0001). Results of the Chronic Sinusitis Survey also correlated significantly with subscales of a general health assessment in the extent to which chronic sinusitis limits physical activity (0.40, P<.01), interferes with work or other activities (0.36, P<.01), and affects patient perception of bodily pain (0.46, P<.001). The Chronic Sinusitis Survey is an efficient and reliable method to follow health status and health-related quality of life outcomes in patients with chronic sinusitis

Endoscopic surgery for lacrimal obstruction.

Intranasal access to the lacrimal drainage system has been greatly enhanced with the advent of endoscopic nasal surgery. This technique has been used for the treatment of recurrent lacrimal obstruction after failed external dacryocystorhinostomy (DCR) in 12 patients. Improved intranasal visualization with the endoscope allowed easy identification and opening of the lacrimal sac, with no need for a skin incision. Obstructing intranasal pathology, including adhesions from previous DCR, an enlarged middle turbinate, and ethmoid sinus disease, was readily identified and corrected. There were no intraoperative complications. Lacrimal obstruction was completely relieved in nine of 12 patients (75%), with a followup of 7 to 25 months. Endoscopic revision DCR should be considered in patients with recurrent epiphora after external DCR.

Mitomycin C for the prevention of adhesion formation after endoscopic sinus surgery: A randomized, controlled study

OBJECTIVE: Mitomycin C (MMC) is an antineoplastic agent that has been shown to decrease scar tissue after ophthalmologic surgery. Our goal was to determine whether the application of MMC at the conclusion of sinus surgery decreases the incidence of postoperative adhesion formation. METHODS: At the completion of endoscopic sinus surgery in 55 patients, a cotton pledget saturated with 1 mL of 0.4 mg/mL MMC was placed for 4 minutes in the right or left middle meatus and a similar saline-soaked pledget was placed on the opposite side. Patients were examined postoperatively by a masked observer for the presence of synechiae and mucosal changes. RESULTS: Postoperative adhesions were observed in 16 patients (29%) with a mean follow-up of 4.1 months. These adhesions were bilateral in 6 patients (10.9%) and unilateral in 10 patients (18%). Unilateral adhesions were observed on only 2 sides (3.6%) treated with MMC and 8 controls (14.5%) (P = 0.058). No adverse effects were observed. CONCLUSIONS: MMC was found to be safe to use during sinus surgery, and it may reduce the incidence of postoperative adhesions at the dosage used in this study. SIGNIFICANCE: Because of the observed trend toward decreased synechiae formation with MMC application, further trials using higher concentrations and application times are warranted.

Clinical Outcomes in Patients With Chronic Sinusitis

Although sinusitis is one of the most common chronic illnesses in this country, relatively little is known about the effect of this disease or its treatment on quality of life. In a series of studies utilizing both disease‐specific and general health instruments, patients with chronic sinusitis were found to have significant decrements in several subscales of general health, including bodily pain and social functioning (P < .05), compared with the general US population. Surgery for sinus disease was shown to result in significant reduction in both symptoms and medication usage (P < .05) after 12 months. These same outcome instruments can be used by health care providers to document clinical outcomes in similar populations of patients with chronic sinusitis.