Raymond Sacks

Endoscopic skull base reconstruction of large dural defects: A Systematic Review of Published Evidence

Systematically review the outcomes of endoscopic endonasal techniques to reconstruct large skull base defects (ESBR). Such surgical innovation is likely to be reported in case series, retrospective cohorts, or case‐control studies rather than higher level evidence.

Structured histopathology profiling of chronic rhinosinusitis in routine practice

Tissue eosinophilia in chronic rhinosinusitis (CRS) is a marker of inflammatory disorders recalcitrant to surgical intervention. Eosinophilic chronic rhinosinusitis (ECRS) is traditionally associated with asthma, polyps, aspirin sensitivity, high serum eosinophilia, and elevated immunoglobulin E (IgE). However, patients with ECRS may not present with these associations and there is a need to establish other surrogate markers. The objective of the study was to determine the associations between the histopathology, serology, and clinical characteristics in CRS patients.

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis

Isam Alobid, MD, PhD1, Nithin D. Adappa, MD2, Henry P. Barham, MD3, Thiago Bezerra, MD4, Nadieska Caballero, MD5, Eugene G. Chang, MD6, Gaurav Chawdhary, MD7, Philip Chen, MD8, John P. Dahl, MD, PhD9, Anthony Del Signore, MD10, Carrie Flanagan, MD11, Daniel N. Frank, PhD12, Kai Fruth, MD, PhD13, Anne Getz, MD14, Samuel Greig, MD15, Elisa A. Illing, MD16, David W. Jang, MD17, Yong Gi Jung, MD18, Sammy Khalili, MD, MSc19, Cristobal Langdon, MD20, Kent Lam, MD21, Stella Lee, MD22, Seth Lieberman, MD23, Patricia Loftus, MD24, Luis Macias‐Valle, MD25, R. Peter Manes, MD26, Jill Mazza, MD27, Leandra Mfuna, MD28, David Morrissey, MD29, Sue Jean Mun, MD30, Jonathan B. Overdevest, MD, PhD31, Jayant M. Pinto, MD32, Jain Ravi, MD33, Douglas Reh, MD34, Peta L. Sacks, MD35, Michael H. Saste, MD36, John Schneider, MD, MA37, Ahmad R. Sedaghat, MD, PhD38, Zachary M. Soler, MD39, Neville Teo, MD40, Kota Wada, MD41, Kevin Welch, MD42, Troy D. Woodard, MD43, Alan Workman44, Yi Chen Zhao, MD45, David Zopf, MD46

Corticosteroid nasal irrigations after endoscopic sinus surgery in the management of chronic rhinosinusitis

Inflammatory dysfunction is considered an important part of chronic rhinosinusitis (CRS). Corticosteroid therapy has been widely used in CRS. Effective topical delivery has been previously problematic. The post–endoscopic sinus surgery (ESS) corridor is essential for adequate topical drug access. Devices delivering large volume with positive pressure allow better distribution to sinus mucosa. The objective of this study is to evaluate the efficacy of postoperative topical sinonasal steroid irrigations for CRS.

Topical Steroids in Chronic Rhinosinusitis Without Polyps: A Systematic Review and Meta-Analysis

OBJECTIVE: To evaluate whether topical steroids provide symptomatic relief in patients with chronic rhinosinusitis without polyps. DATA SOURCES: MEDLINE, EMBASE, and Cochrane CENTRAL databases. REVIEW METHODS: Systematic review and meta-analysis was performed of the articles identified by two independent reviewers of all randomized controlled trials that had evaluated intranasal corticosteroids in patients with chronic rhinosinusitis (CRS) without polyps. The quality of included studies was evaluated, and results synthesized using standard random-effects meta-analytical methods. RESULTS: Of 424 potential studies, only nine randomized trials involving 657 patients in total were eligible. Quality of design and reporting was suboptimal, with only one trial adhering to accepted standards for reporting. Five trials combined outcome measures and reported on overall response of CRS without polyps to topical steroids. The summary estimate for overall response to treatment showed no significant benefit and substantial variability among studies (5 trials: RR 0.75, 95% CI 0.50–1.10, P = 0.14, χ2 = 13.78, I2 = 66.2%). Total symptom score was reported in three trials with a standardized mean difference favoring topical steroids (RR 0.63, 95% CI 0.16–1.09, P = 0.009), with no evidence of heterogeneity (χ2 = 3.03, P = 0.22). Although the data were limited, there were no reports of increased adverse effects with topical steroids. CONCLUSION: There is insufficient evidence to demonstrate a clear overall benefit for topical steroids in CRS without polyps; however, their use appears safe and may show some symptomatic benefit. A class effect among different topical steroids cannot be assumed, and further trials are required.

Image-guided surgery influences perioperative morbidity from endoscopic sinus surgery: a systematic review and meta-analysis

Objective Although image-guided surgery (IGS) is considered a valuable tool, its impact on perioperative morbidity for endoscopic sinus surgery (ESS) remains unclear. The evidence from reported literature is systematically reviewed with meta-analysis. Data Sources MEDLINE (1946 to September 14, 2012, week 2) and EMBASE (1974 to September 14, 2012, week 37). Review Methods MEDLINE and EMBASE were searched using a search strategy for publications on IGS during ESS that reported original data on perioperative morbidity. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed. Both comparative cohort studies with non-IGS cases and case series were included. Primary outcome was major and total complications. Secondary outcomes were specific orbital and intracranial injury, major hemorrhage, ability to complete the operation, and revision surgery. The incidence of these events was defined as dichotomous variables and expressed as a risk ratio (RR) in a fixed-effects model. Results In total, 2586 articles fulfilled the search, producing 55 included studies. Fourteen were comparative cohorts of IGS and non-IGS sinus surgical patient populations used for meta-analysis. Among the cohorts, major complications were more common in the non-IGS group (RR = 0.48; 95% confidence interval [CI], 0.28-0.82; P = .007). Total complications were greater in the non-IGS group (RR = 0.66; 95% CI, 0.47-0.94; P = .02). All other outcomes did not reach significance on meta-analysis. Conclusion Contrary to current review articles on the topic of IGS use during ESS, there is evidence from published studies that the use of IGS for sinus surgery, within selected populations, is associated with a lower risk of major and total complications compared with non-IGS sinus surgery.

Sinus surgery and delivery method influence the effectiveness of topical corticosteroids for chronic rhinosinusitis: systematic review and meta-analysis.

Background Published randomized controlled trials (RCTs) on the efficacy of intranasal corticosteroid (INCS) in chronic rhinosinusitis (CRS) use either nasal delivery (nasal drop or nasal spray) or sinus delivery (sinus catheter or sinus irrigation) in patients with or without sinus surgery. This influences topical drug delivery and distribution. The effect of these factors on the published results of RCTs is assessed. This systematic review explores the strength of evidence supporting the influence of sinus surgery and delivery methods on the effectiveness of topical steroids in studies for CRS with meta-analyses. Methods A systematic review was conducted of RCTs comparing INCS with either placebo or no intervention for treating CRS. Data were extracted for meta-analysis and subgroup analyses by sinus surgery status and topical delivery methods. Results Forty-eight studies (3961 patients) met the inclusion criteria. INCS improved overall symptoms (standardized mean difference [SMD], −0.49; p < 0.00001) and the proportion of responders (risk ratio [RR], 0.59; p < 0.00001) compared with placebo. It decreased nasal polyp size with a greater proportion of responders (RR, 0.48; p < 0.00001) and prevented polyp recurrence (RR, 0.59; p = 0.0004) compared with placebo. Reduction of polyp size was greater in patients with sinus surgery (RR, 0.31; 95% confidence interval [CI], 0.20, 0.48) than those without (RR, 0.61; 95% CI, 0.46, 0.81; p = 0.009). Greater symptom improvement occurred when sinus delivery methods (SMD, −1.32; 95% CI, −2.26, −0.38) were compared with nasal delivery methods (SMD, −0.38; 95% CI, −0.55, −0.22; p < 0.00001). Conclusion INCS is effective for CRS. Prior sinus surgery and direct sinus delivery enhance the effectiveness of INCS in CRS.

Nasal allergies in the Asian-Pacific population : results from the Allergies in Asia-Pacific Survey

Background The Allergies in Asia–Pacific Survey describes the symptoms, impact, and treatment of allergic rhinitis (AR) across Australia, China, Hong Kong, Malaysia, Singapore, Taiwan, Vietnam, and the Philippines. The Allergies in Asia–Pacific Survey was undertaken to further clarify the prevalence of physician-diagnosed nasal allergies (NAs), impact on quality-of-life (QOL), existing treatment paradigms and gaps, and NA medications currently used in treatment. Methods Thirty-three thousand three hundred seventy-eight households were screened for individuals, ≥4 years old, with a physician diagnosis of AR or NA and either symptoms or treatment in the past 12 months. Standardized questionnaires were used to make comparisons across regions. A total of 1043 adults and 192 children were included in the survey. Results Nine percent of participants were diagnosed with AR with two of three responding that their NAs were seasonal in nature. Nasal congestion was the most common and bothersome symptom of AR. Most participants reported that AR impacted their QOL with nearly one-half citing impairments in school/work performance/productivity. Sleep disturbances, secondary to AR, were also shown to be appreciable. Two-thirds of patients took medication for their AR. Less than one-quarter of survey respondents reported taking an intranasal corticosteroid and the satisfaction rate was similar to that of over-the-counter medications. The most common reasons cited for dissatisfaction were related to inadequate efficacy and bothersome side effects. Conclusion AR appears to be extremely common across Asia–Pacific nations. Many individuals with AR suffer from symptoms that reduce QOL and treatment gaps exist with current therapies. Through identification of disease impact and highlighting treatment gaps, clinicians may better understand and treat AR, leading to improvements in overall patient satisfaction and QOL.BACKGROUND The Allergies in Asia-Pacific Survey describes the symptoms, impact, and treatment of allergic rhinitis (AR) across Australia, China, Hong Kong, Malaysia, Singapore, Taiwan, Vietnam, and the Philippines. The Allergies in Asia-Pacific Survey was undertaken to further clarify the prevalence of physician-diagnosed nasal allergies (NAs), impact on quality-of-life (QOL), existing treatment paradigms and gaps, and NA medications currently used in treatment. METHODS Thirty-three thousand three hundred seventy-eight households were screened for individuals, ≥ 4 years old, with a physician diagnosis of AR or NA and either symptoms or treatment in the past 12 months. Standardized questionnaires were used to make comparisons across regions. A total of 1043 adults and 192 children were included in the survey. RESULTS Nine percent of participants were diagnosed with AR with two of three responding that their NAs were seasonal in nature. Nasal congestion was the most common and bothersome symptom of AR. Most participants reported that AR impacted their QOL with nearly one-half citing impairments in school/work performance/productivity. Sleep disturbances, secondary to AR, were also shown to be appreciable. Two-thirds of patients took medication for their AR. Less than one-quarter of survey respondents reported taking an intranasal corticosteroid and the satisfaction rate was similar to that of over-the-counter medications. The most common reasons cited for dissatisfaction were related to inadequate efficacy and bothersome side effects. CONCLUSION AR appears to be extremely common across Asia-Pacific nations. Many individuals with AR suffer from symptoms that reduce QOL and treatment gaps exist with current therapies. Through identification of disease impact and highlighting treatment gaps, clinicians may better understand and treat AR, leading to improvements in overall patient satisfaction and QOL.

Antifungal therapy in the treatment of chronic rhinosinusitis : a meta-analysis

Background Chronic rhinosinusitis (CRS) is an inflammatory disorder of the nose and sinuses. Because fungi were postulated as a potential cause of CRS in the late 1990s, contrasting articles have advocated and refuted the use of antifungal agents in its management. Although good research shows an interaction of the immune system with fungus in CRS, e.g., allergic fungal sinusitis (AFS), this does not imply that fungi are the cause of CRS or that antifungals will be effective in management. This study was designed to assess the potential advantage of either topical or systemic antifungal therapy in the symptomatic treatment of CRS to aid physicians in making informed decisions about treating patients with CRS. Methods A systematic review of the literature was performed with meta-analysis. All studies obtained from searches were reviewed and trials meeting the eligibility criteria were selected. CRS was defined using either the European Position Paper on Rhinosinusitis and Nasal Polyps or American Academy of Otolaryngology–Head and Neck Surgery criteria. Authors were contacted and original data were used for data analysis. Results Five studies investigating topical antifungals and one investigating systemic antifungals met the inclusion criteria. All trials were double blinded and randomized. Pooled meta-analysis showed no statistically significant benefit of topical or systemic antifungals over placebo. Symptoms scores statistically favored the placebo group for this outcome. Adverse event reporting was higher in the antifungal group. Conclusion Reported side-effects of antifungal therapies may outweigh any potential benefits of treatment based on this meta-analysis and the authors therefore do not advocate the use antifungal treatment in the management of CRS.

Silent sinus syndrome: dynamic changes in the position of the orbital floor after restoration of normal sinus pressure.

BACKGROUND Silent sinus syndrome is characterised by spontaneous enophthalmos and hypoglobus, in association with chronic atelectasis of the maxillary sinus, and in the absence of signs or symptoms of intrinsic sinonasal inflammatory disease. Traditionally, correction of the enophthalmos involved reconstruction of the orbital floor, which was performed simultaneously with sinus surgery. Recently, there has been increasing evidence to support the performance of uncinectomy and antrostomy alone, then orbital floor reconstruction as a second-stage procedure if needed. METHODS We performed a retrospective review of 23 cases of chronic maxillary atelectasis managed in our unit with endoscopic uncinectomy and antrostomy alone. All patients were operated upon by the same surgeon. RESULTS Twenty-two of the 23 patients had either complete or partial resolution. One patient had ongoing enophthalmos, and was considered for an orbital floor reconstruction as a second-stage procedure. CONCLUSION Our case series demonstrates that dynamic changes in orbital floor position can occur after sinus re-ventilation. These findings support the approach of delaying orbital floor reconstruction in cases of silent sinus syndrome treated with sinus re-ventilation, as such reconstruction may prove unnecessary over time.