Tetsushi Okushi

Mucosal eosinophilia and recurrence of nasal polyps - new classification of chronic rhinosinusitis.

BACKGROUND Eosinophils and nasal polyps are believed to affect the surgical outcome of chronic rhinosinusitis (CRS). CRS is classified based on the presence of nasal polyps in western countries. The majority of patients with CRS with nasal polyps (CRS with NP) are characterized by predominantly eosinophilic inflammation. However, Asian patients with CRS with NP show characteristics indicative of neutrophilic inflammation. Therefore, are eosinophils or nasal polyps more important for the classification of CRS? METHODS A prospective cohort study conducted from April 2007 to March 2008 classified patients with CRS based on the presence of nasal polyps and mucosal eosinophilia. The recurrence rate of nasal polyps was compared between the groups. Recurrence rate was analysed as a time-dependent variable by the Kaplan-Meier method. RESULTS Eosinophilic inflammation was found in 59.6% of patients with CRS with NP. Patients with mucosal eosinophilia had higher polyp recurrence rate than patients without mucosal eosinophilia, whereas patients with nasal polyps did not have higher polyp recurrence rate than patients without nasal polyps. CONCLUSIONS Presence of mucosal eosinophilia is a more important factor than nasal polyps for classifying CRS in terms of the surgical outcome.

Identification of chronic rhinosinusitis phenotypes using cluster analysis.

Background The pathophysiology of chronic rhinosinusitis (CRS) is not fully understood. In Europe and the United States, major subsets of CRS classification are based on the presence or absence of polyps. Although nasal polyps (NPs) are a critical factor, many other factors also contribute to the pathogenesis of CRS. The aim of this study was to investigate diverse CRS phenotypes using cluster analysis. Methods This was a multicenter study examining clinical data from CRS patients treated at five hospitals. The study design was a retrospective analysis of prospectively collected data. Complete data were available for 425/496 patients. Data were subjected to k-means cluster analysis in an attempt to identify the different phenotypes involved in CRS. Results CRS was divided into four clusters. Cluster 1 (n = 180) and cluster 2 (n = 129) comprised patients with low peripheral eosinophil and mucosal eosinophil counts. However, polyp scores in cluster 2 were higher than cluster 1. Cluster 3 (n = 50) comprised patients with very high mucosal eosinophil counts but low polyp and symptom scores. Finally, subjects in cluster 4 (n = 66) showed severe polyposis. Polyp score and mucosal eosinophil count were the strongest predictors of clustering by discriminant analysis. Conclusion The results of this study identified distinct clinical CRS phenotypes. CRS was classified into four phenotypes based on NPs and mucosal eosinophil counts. Cutoff points for these factors were identified by tree analysis. Additional studies are needed to establish clinical significance of the phenotypes.

Endoscopic medial maxillectomy with preservation of inferior turbinate and nasolacrimal duct.

Background Endoscopic medial maxillectomy (EMM) is a safe and effective procedure for treatment of inverted papilloma (IP) originating from the maxillary sinus. However, EMM usually removes the inferior turbinate and nasolacrimal duct. The inferior turbinate has a critical function in conditioning of the nasal airflow, and resection of the nasolacrimal ducts has a risk of epiphora. We developed a newly derived surgical technique, endoscopic modified medial maxillectomy (EMMM), which enables preservation of the inferior turbinate and nasolacrimal duct. Methods A retrospective case series of six patients with IP and nine patients with mucoceles of the maxillary sinus after a Caldwell-Luc operation, who underwent surgery using the EMMM technique, were reviewed. Results In patients with IP, there were no recurrences for a mean follow-up of 16.7 months. Eight of nine patients with mucoceles of the maxillary sinus showed patency. All patients showed preservation of the inferior turbinate. One patient with mucocele was referred for dacryocystorhinostomy because of epiphora. Conclusion EMMM produces access to the maxillary sinus identically to conventional EMM, despite preservation of the inferior turbinate and nasolacrimal duct.

Risk factors for complications of endoscopic sinus surgery for chronic rhinosinusitis.

Background Patients undergoing endoscopic sinus surgery (ESS) are at risk of complications because of the close proximity of the sinuses to the orbit and anterior skull base. The aim of this study was to evaluate the complications of ESS and to identify patient characteristics that were risk factors for the complications. Methods We conducted a prospective study of 706 patients who underwent ESS for chronic rhinosinusitis. Patients completed preoperative examinations that included computed tomography, endoscopic observation for nasal polyps, and tests for comorbidities including asthma and vascular disease. Perioperative complications were evaluated based on information provided by the surgeons. Multivariate analysis was performed to identify patient characteristics that were risk factors for complications. Results Overall, perioperative complications occurred in 41 patients (5.8%). A major complication, cerebrospinal fluid leakage, occurred in one patient (0.1%). Minor complications occurred in 40 patients (5.7%), with the most common being intraoperative hemorrhage (n = 18). Multivariate analysis indicated that presence of asthma and the total polyp score correlated significantly with the occurrence of complications. Conclusion The risk factors for perioperative complications were asthma and the polyp score. We conclude that the surgeon should confirm whether the patient has lower airway disease, especially asthma, before operating. The surgeon should also determine the grade of nasal polyps.

Evaluation of symptoms and QOL with calcium alginate versus chitin-coated gauze for middle meatus packing after endoscopic sinus surgery

OBJECTIVE Nasal packing is used to control postoperative bleeding and wound healing, and it also exerts a very strong influence on the comfort of the patient. Sorbsan(®) (calcium alginate) is an absorbent packing that shows a potent hemostatic effect and is able to maintain wound surfaces in a moist environment by absorbing and gelling the wound exudate. The aim of this study was to evaluate the early symptoms and QOL with Sorbsan(®) versus Beschitin-F(®) (chitin-coated gauze) for middle meatus packing after endoscopic sinus surgery (ESS). METHODS We performed a cohort study of 40 patients who underwent ESS. Following ESS, the patients were randomly allocated into two groups of 20 patients each who underwent insertion of either Sorbsan(®) or Beschitin-F(®) into the middle meatus. A daily diary was used to record the symptoms and QOL, measured using visual analogue scales, before the ESS and on each day thereafter. Postoperative bleeding and local infection were also recorded. RESULTS The scores for each of the symptoms of nasal pain, headache, nasal bleeding and postnasal drip were statistically significantly lower in the Sorbsan(®) group. The scores for each of the QOL parameters, including the effect on their stay in the hospital and sleep disturbance, were also significantly lower in the Sorbsan(®) group. There were no findings of postoperative hemorrhage or local infection in either group. CONCLUSION Sorbsan(®) packing did not cause any major complications and has the potential to reduce nasal pain and suffering in post ESS patients compared with gauze packing.

Effect of Maxillomandibular Advancement on Morphology of Velopharyngeal Space

PURPOSE The objectives of the present study were to assess the changes in upper airway morphology and function in response to advancement of the maxilla and mandible. PATIENTS AND METHODS Orthognathic surgery was performed. During the surgery, the maxilla and mandible were each advanced as a maxillomandibular advancement simulation. A total of 18 patients with a chief complaint of malocclusion were studied. The distance in jaw advancement and the anteroposterior and left-right diameters of the velopharyngeal space before and after jaw advancement were measured. After the anteroposterior and left-right dilation rates and area enlargement rates were calculated, we compared advancement of the maxilla with that of the mandible. RESULTS Each of the jaw advancements resulted in statistically significant increases in the anteroposterior and left-right diameters of the velopharyngeal space, and the area was significantly enlarged. The anteroposterior dilation rate was significantly greater after advancement of the maxilla, and the left-right dilation rate was significantly greater after advancement of the mandible. The velopharyngeal space area enlargement rate was significantly greater with advancement of the maxilla. CONCLUSIONS These data suggest that the mode of dilation of the velopharyngeal space differs between maxillary advancement and mandibular advancement. Jaw advancement affects the soft palate muscles, and the velopharyngeal space is expanded 3-dimensionally by each of those muscles. The difference in the pattern of expansion of the velopharyngeal space was related to differences in the functions of the soft palate muscles.

Nasal splinting using silicone plates without gauze packing following septoplasty combined with inferior turbinate surgery

OBJECTIVE Nasal packing after septoplasty is uncomfortable and painful for patients. The aim of this study was to determine the efficacy of nasal splinting using silicone plates to prevent complications and decrease the pain after septoplasty compared with the conventional gauze packing. MATERIALS AND METHODS Thirty-five adult patients who had undergone septoplasty were included in this study. The patients were allocated into two groups: Group S, silicone plates were used (13 males, 2 females); and Group G, gauze packing smeared with an antibiotic ointment was used (19 males, 1 female). We evaluated and compared the postoperative pain, pain due to postoperative cleaning, nasal bleeding, postnasal drip, body temperature, effect on stay in the hospital, effect on food intake and sleep disturbance using visual analogue scale (VAS) scores. RESULTS The postoperative pain score in Group S was significantly lower than in Group G on days 1 and 2 after the septoplasty. And the pain due to postoperative cleaning score was significantly lower than in Group G on days 2 and 3 after operation. No statistically significant differences were found between the two groups in regard to nasal bleeding, postnasal drip, body temperature, effect on stay in the hospital, effect on food intake or sleep disturbance. Objective evaluation performed at 4 weeks postoperatively revealed that nasal crusting occurred at a significantly higher incidence in Group G compared with Group S. CONCLUSION The use of silicone plates in lieu of conventional gauze packing decreased post-septoplasty nasal pain and pain due to postoperative cleaning of the nasal cavity. We conclude that nasal splinting using silicone plates after septoplasty is an effective method for managing pain and preventing complications.

Sinus Fungus Ball in the Japanese Population: Clinical and Imaging Characteristics of 104 Cases

Sinus fungus ball is defined as noninvasive chronic fungal rhinosinusitis occurring in immunocompetent patients with regional characteristics. The clinical and imaging characteristics of paranasal sinus fungus ball were retrospectively investigated in 104 Japanese patients. All patients underwent endoscopic sinus surgery. Preoperative computed tomography (CT), magnetic resonance (MR) imaging, age, sex, chief complaint, causative fungus, and clinical outcome were analyzed. Patients were aged from 25 to 79 years (mean 58.8 years). Female predominance was noted (58.7%). Most common symptoms were nasal discharge and facial pain. CT showed high density area in 82.0% of the cases (82/100), whereas T2-weighted MR imaging showed low intensity area in 100% of the cases (32/32). Histological examination showed that most causative agents were Aspergillus species (94.2% (98/104)). Culture test was positive for 16.7% (11/66). Recurrence was found in 3.2% (3/94). Older age and female predominance were consistent with previous reports. MR imaging is recommended to confirm the diagnosis.

A modified Lund-Mackay system for radiological evaluation of chronic rhinosinusitis

OBJECTIVE The Lund-Mackay system (L-M system) is widely used for computed tomography (CT) evaluation of chronic rhinosinusitis (CRS). However, a major drawback of the L-M system is its insufficiency of gradation. To avoid this deficiency, a new staging system proposed by American societies and the Zinreich system were reported as modifications of the L-M system. The aim of this study was to investigate the efficiency of gradation and the accuracy of the visual quantification of these modified staging systems. METHODS Preoperative CT scanning was performed on 20 adult patients with CRS. A computer workstation was used to measure the volume of each sinus and the volume of inflammatory disease in each sinus. Then the soft tissue density rate (STDR) and objective scores, which were adapted to each system, were calculated. Visual evaluation of the CT images was performed using these systems. The visual score with each staging system and STDR value were evaluated for a correlation, and the rate of agreement was determined between the visual and objective scores obtained with each staging system. RESULTS The correlation between the visual scores and the STDR values was shown with all staging system including L-M system. The coefficients of correlation between the visual scores and the STDR values with these modified systems were higher than with the L-M system. While the agreement rates with these modified systems were significantly lower than with the L-M system, differences of 2 or greater between the subjective and objective scores were rare. CONCLUSION We cannot conclude that one of these three staging systems is superior to the other. With this study, the simple grading system such L-M staging score was considered easy and accurate method to use the clinical level. The modified staging systems showed more efficient ability to gradate in evaluating rhinosinusitis inflammation compared with the L-M system and also showed acceptable accuracy.

Impact of residual ethmoid cells on postoperative course after endoscopic sinus surgery for chronic rhinosinusitis

OBJECTIVE Endoscopic sinus surgery (ESS) is a worldwide standard surgical procedure for chronic rhinosinusitis (CRS). Residual ethmoid cells (RECs), which result from failure to completely remove them, have been thought to be a cause of recurrence of CRS. Our objective was to investigate the relationship between the REC score and post ESS recurrence of CRS. METHODS From January 2002 through December 2003, a total of 138 consecutive CRS patients (86 men and 52 women; mean age: 44 years) underwent ESS at the Department of Otorhinolaryngology, Ota General Hospital. CT was performed at 6 or more months post ESS for all patients. The left and right ethmoid sinuses were each divided into superior-anterior, inferior-anterior and posterior parts. The extent of RECs in each part was assessed using a 3-grade scoring system. The outcome of CRS was classified into a satisfactory outcome group and a poor outcome group based on the improvement rate determined from the pre ESS and post ESS CT image findings. The two groups were then compared for the age, gender, presence/absence of nasal polyps, presence/absence of allergic rhinitis, presence/absence of asthma, the peripheral eosinophil count (%) and the total REC score. In addition, the individual correlations between the above variables and the poor outcome group were analyzed by logistic regression analysis. RESULTS The total REC score was 0 in only 35 (25.4%) of the total patients. The most common total REC scores were 1-6 in 85 (61.6%) patients. The superior-anterior part had the largest number of patients with an REC score of 1 or more. The satisfactory outcome group comprised 97 patients (70.3%), while the poor outcome group comprised 41 patients (29.7%). Comparison of these two groups found that the peripheral eosinophil count, the prevalence rate of asthma and the total REC score were each significantly higher in the poor outcome group than in the satisfactory outcome group. Logistic regression analysis identified a peripheral eosinophil count of ≥9.5%, the presence of asthma and a total REC score of ≥4 as factors that correlated significantly with a poor outcome. CONCLUSION The findings of this study indicate that RECs are involved in the recurrence of CRS following ESS. It can be thought that how to achieve full opening of the superior-anterior part of the ethmoid sinus, which includes the frontal recess, will be an issue in the future.