Sarah K. Wise

Gastroesophageal reflux and laryngopharyngeal reflux in patients with sleep-disordered breathing

Objective To assess the relationship of gastroesophageal reflux (GER) and laryngopharyngeal reflux (LPR) with obstructive sleep apnea (OSA). Patients and Methods Thirty-seven sleep-disordered breathing (SDB) patients underwent polysomnography (PSG) and dual-channel pH probe testing. LPR was defined as greater than 6.9 proximal reflux episodes or reflux area index (RAI) greater than 6.3. GER was defined as greater than 4% of time below pH 4.0. Results OSA was present in 28 patients. Twenty-three patients had LPR (66.7% of snorers, 60.7% of OSA patients). Twenty-one patients had GER (33.3% of snorers, 64.3% of OSA patients). Body mass index (BMI) correlated positively with respiratory disturbance index (RDI) (r = 0.67, P < 0.001). BMI did not correlate with pH probe parameters. OSA presence/severity did not correlate with LPR or GER. Supine LPR and GER events did not correlate with OSA presence/severity. Conclusion Gastric acid reflux is prevalent in SDB patients. Direct correlations between reflux and PSG parameters were not identified. EBM rating: B-2b

Intracranial complications before and after endoscopic skull base reconstruction.

Background Endoscopic skull base reconstruction (ESBR) has been widely accepted in the management of cerebrospinal fluid (CSF) leaks. However, it is not the CSF leak itselfbut the potential for life-threatening intracranial complications (ICCs) that is of primary clinical concern. The risk of developing complications, such as meningitis, in a skull base defect is unknown. Many ESBR are multilayered soft tissue repairs, and long-term prevention of ICCs is not well described. Methods Retrospective chart review and telephone consultation was used to assess patients who had an ESBR from 2002 to 2008. The incidence of an ICCs (meningitis, cerebral abscess, and pneumocephalus) and associated risk factors were assessed before and after surgery. Results One hundred six patients underwent ESBR (mean age (∓SD), 47.7 ∓ 18.5 years; range, 2–78 years) with 95.3% long-term follow-up (mean, 19.9 ∓ 16.3 months). ICCs occurred in 21.7% of patients at presentation, in 2.8% of patients during the perioperative period (<2 weeks), and in one patient (0.9%) during the postoperative period. Risk factors for presenting with an ICC and meningitis were revision cases performed elsewhere (χ2 = 9.10; p = 0.007) and leaking encephaloceles (χ2 = 5.98; p = 0.014). Factors not associated with increased ICC were an active CSF leak at presentation (χ2 = 3.03; p = 0.082) and previous radiotherapy. Conclusion ESBR offers an excellent long-term option in preventing subsequent ICC with low perioperative complications. ESBR is robust with delayed (>2weeks) CSF leakage occurring in only 1.9% regardless of etiology. The presence of identifiable risk factors for ICC may guide the surgeon in determining the urgency of ESBR.

Socioeconomic factors in the diagnosis of allergic fungal rhinosinusitis.

Objectives 1) To investigate socioeconomic and demographic factors differentiating allergic fungal rhinosinusitis (AFRS) from other chronic rhinosinusitis (CRS) diagnostic groups. 2) To consider the potential impact of epidemiological differences on AFRS disease course. Study Design Retrospective review. Study Methods Retrospective review of AFRS patients, CRS patients with nasal polyps (CRSwNP) without AFRS, and CRS patients without polyps (CRSsNP). Analysis of group differences was performed for age at presentation, gender, ethnicity, insurance status, and socioeconomic measures with the use of medical records and a South Carolina demographic database. Results AFRS presentation age was lower than CRSwNP and CRSsNP (P < 0.001). The AFRS group had more African Americans (P < 0.001) and uninsured or Medicaid patients (P < 0.001) than expected. AFRS patients resided in counties with higher poverty percentage (P = 0.011), lower median income (P = 0.048), and more African American residents (P = 0.020) than CRSsNP patients. No group differences existed for gender or physicians per 1000 county residents. Conclusion Demographic and socioeconomic factors may affect AFRS presentation and treatment.

Association of nasopharyngeal and laryngopharyngeal reflux with postnasal drip symptomatology in patients with and without rhinosinusitis.

Background Patients often report postnasal drip (PND), but objective rhinosinusitis and allergy findings are frequently absent. In this study, we evaluate the association between PND and pharyngeal reflux. Methods Sixty-eight participants underwent 24-hour pH testing, including chronic rhinosinusitis (CRS) patients persistently symptomatic after endoscopic sinus surgery, CRS patients successfully treated by endoscopic sinus surgery, and volunteers without a CRS history. The pH probes contained nasopharyngeal (NP), laryngopharyngeal (LP), and distal esophageal sensors. Participants completed the Sinonasal Outcome Test-20 (SNOT-20) and Modified Reflux Symptom Index (MRSI) questionnaires. Survey items addressing PND symptomatology were compared with NP reflux (NPR) below pH 4 and pH 5 (defined as ≥1 event), and LP reflux (LPR; defined as ≥7 events or reflux area index <6.3). Results Pearson analyses revealed a positive correlation of r = 0.87 between SNOT-20 and MRSI PND items. For NPR < pH 4, no significant difference existed between participants with and without reflux on the SNOT-20 or MRSI (p < 0.05). However, for NPR < pH 5, reflux-positive participants exhibited significantly more PND symptoms on the SNOT-20 (p = 0.030) and the MRSI (p = 0.018) compared with participants without reflux. Finally, participants with LPR had significantly more PND symptomatology on the SNOT-20 (p = 0.010) versus those without LPR. A borderline significant difference existed on the MRSI PND item between participants positive and negative for LPR (p = 0.055). Conclusion Objective evidence of NPR and LPR exists in patients reporting PND. Reflux treatment may reduce PND complaints.

Topical steroid drops for the treatment of sinus ostia stenosis in the postoperative period.

Background Chronic oral steroid use causes significant morbidity, including osteoporosis, immunosuppression, and adrenal insufficiency. Refractory chronic rhinosinusitis patients often take repeated oral steroid courses to treat polypoid disease or sinus ostia stenosis. This study evaluated topical steroid drop efficacy in treating recurrent sinus ostia stenosis in the postoperative period. Methods The 5-year single institution experience with topical steroid drop use after endoscopic sinus surgery (ESS) was evaluated by retrospective review. Patients were included if they began topical dexamethasone ophthalmic, prednisolone ophthalmic, or ciprofloxacin/dexamethasone otic intranasally (used off-label) within 3 months after ESS. Outcomes (i.e., ostia patency, oral steroid use, revision surgery, and complications) were assessed for a 6-month period after steroid drop initiation. Results Thirty-six patients met inclusion criteria. Forty-four surgeries were performed during the study period; 67 sides were treated postoperatively with topical steroid drops. In 86.6% of cases, steroid drops were used to treat frontal ostium stenosis or frontal recess edema; 93.2% of surgeries were revision procedures. Sixty-four percent of sinuses were treated successfully with topical steroid drops, 14.9% remained stable, and 20.9% failed. Reasons for failure included persistent/worsening edema, scarring, or noncompliance. Ten patients (27.8%) required oral steroids and 4 patients (6%) underwent revision surgery during the study period. One case of adrenal suppression occurred. Conclusion Topical steroid drops are beneficial in preventing sinus ostia stenosis in the postoperative period and may decrease the propensity toward repeated oral steroid therapy. This is particularly noteworthy in this challenging cohort, largely composed of revision frontal sinus surgery patients.

Computer-aided surgery of the paranasal sinuses and skull base

Endoscopic sinus surgery is one of the most common surgical procedures in otolaryngology. However, the location of the orbit and intracranial contents in close proximity to the paranasal sinuses makes endoscopic sinus surgery potentially hazardous. Otolaryngologists have employed computer-aided surgery, or image-guided surgery, over the past two decades to enhance surgeon confidence, allow more thorough surgical dissections and possibly reduce the complication rate of endoscopic sinus surgery. Computer-aided surgery utilizes preoperative imaging to provide real-time localization of surgical instruments in the surgical field. Although computer-aided surgery originated in the neurosurgical realm, otolaryngologists soon appreciated that this technology could assist in identifying critical orbital or intracranial structures surrounding the paranasal sinuses, and potentially aid in decreasing complications. In this article, the history of image-guidance systems and their application to surgery of the paranasal sinuses and skull base will be reviewed. The components of computer-aided surgery systems and the currently available technologies for surgical instrument tracking are discussed, as well as the advantages and disadvantages of each of the tracking technologies. In addition, issues relating to the accuracy of image-guidance systems are examined. A number of institutional series noting surgeon experience with computer-aided surgery in the domain of paranasal sinus surgery are reviewed. Furthermore, the authors evaluate the utility of image-guidance technology beyond the paranasal sinuses and skull base, such as its use in surgery of the pituitary gland and pterygopalatine fossa, research and resident education. Finally, potential future applications of computer-aided surgery technology are discussed.

Ethnic and gender differences in bone erosion in allergic fungal sinusitis.

Background Erosion of the bony sinus walls in allergic fungal sinusitis (AFS) is an established phenomenon. Reports of the incidence of bone erosion in AFS vary widely, and definitions of bone erosion lack uniformity. Differences in bone erosion among ethnic and gender groups have not been examined previously in the literature. Methods At our institution we reviewed 47 cases of AFS for ethnic and gender differences in presentation and presence of bone erosion. Results Caucasians presented at a mean 12 years later than African-Americans (p = 0.002); however, this difference was largely carried by Caucasian females. African-Americans presented with a greater incidence of bone erosion than Caucasians (p = 0.028). In addition, there are statistically significant differences in the individual paranasal sinuses affected by bone erosion in AFS. Conclusions We examine the potential implications of ethnic and gender differences in presentation and bone erosion in AFS.

Presence of fungus in sinus cultures of cystic fibrosis patients.

Background Sinonasal pathology is nearly universal in the cystic fibrosis (CF) population. The bacteriology of sinus cultures from CF patients and the implications of sinus bacterial pathogens in this group have been studied; however, sinus fungal isolates from CF patients have not been examined in the literature. Methods We reviewed 30 consecutive CF patients undergoing endoscopic sinus surgery at our institution for the presence of fungal isolates obtained from the sinuses at the time of surgery. Results Thirty-three percent of fungal cultures were positive in this sample; in addition, two patients were newly diagnosed with allergic fungal sinusitis. Conclusion We examine the possible implications of positive fungal sinus cultures in the CF population.

Socioeconomic factors in allergic fungal rhinosinusitis with bone erosion

Background Previous studies have shown an increase in the incidence of orbital and skull base erosion in African Americans and males diagnosed with allergic fungal rhinosinusitis (AFRS). However, underlying reasons for the advanced presentation of AFRS in certain ethnic and gender groups are currently unknown. We evaluated several socioeconomic and demographic factors for their possible contribution to advanced presentation of AFRS in our patient population. Such factors have not been examined previously in the literature. The aim of this study was to evaluate the contribution of race, ethnicity, and various socioeconomic factors to the advanced presentation of AFRS with orbital and skull base bone erosion. Methods Retrospective review of medical records and radiological studies were performed for 54 consecutive AFRS patients presenting to a tertiary care rhinology practice. Presence of radiological evidence of bone erosion was compared with demographic data and insurance status, as indicated in the medical record. Bone erosion status was evaluated also against state demographic data, divided by county. Results Males were significantly more likely to present with bone erosion than females (p = 0.009). In this analysis, age and race were not statistically associated with the presence of bone erosion. Additionally, no statistically significant correlations were identified between bone erosion and several socioeconomic factors listed from the patients county of residence (percentage below the poverty level, median household income, population percentage of African Americans, or number of physicians per 1000 residents). Conclusion No socioeconomic factors were identified that correlated with the incidence of bone erosion in patients diagnosed with AFRS. Factors other than socioeconomic status and access to health care appear to play a role in the advanced presentation of AFRS.

Factors contributing to failure in endoscopic skull base defect repair.

Background Endoscopic repair of skull base (SB) defects is successful in over 90% of cases. Certain factors may contribute to failure of SB repair techniques or need for secondary repair. Methods Five-year retrospective review of endoscopic SB defect repairs performed by a single surgeon. Results Eighty-nine patients undergoing 110 procedures to repair 97 SB defects were evaluated. Etiology of defects included surgical/iatrogenic (64%), spontaneous (17%), traumatic (12%), congenital (6%), and idiopathic (1%). Defects occurred in the sella (41%), sphenoid sinus (18%), ethmoid roof (17%), olfactory cleft (16%), frontal sinus/recess (6%), and middle cranial fossa (2%). Sixty-three patients (71%) underwent primary SB defect repair and 26 patients underwent secondary repair (29%). In revision cases, mean number of prior repair attempts was 1.5 (range, 1-4). Factors potentially contributing to need for secondary SB defect repair included inability to localize SB defect (p =0 008), development of new SB defect, prior sinus or SB surgery (p < 0.001), prior craniotomy (p < 0.001), prior radiation therapy (p = 0.002), and intracranial infection (p = 0.023). SB defects were successfully closed in 83 patients overall (93%), with success achieved in 97% of primary patients and 85% of secondary patients. Of failures, 3 patients required craniotomy for defect closure, 2 patients underwent permanent cerebrospinal fluid (CSF) diversion, and 1 patient has persistent CSF rhinorrhea. Conclusion Although endoscopic repair of SB defect remains largely successful, certain factors should alert the surgeon to the potential for failure of repair or need for secondary SB defect repair.