Future Directions

Meticulous postoperative debridement and medical therapy are the best manner in which to achieve a successful objective and subjective outcome in the long-term. However, the cost-effectiveness of such a management strategy has never been demonstrated. Intuitively, avoidance of revision surgery with its associated costs and risks would seem advantageous. However, aggressive postoperative follow-up and the use of prolonged systemic steroid therapy and antibiotics are not without risk and cost. It is our strong clinical impression that maintaining a patent cavity and minimizing inflammation and persistent/recurrent disease permit the inflammation and mucosal hyperreactivity to slowly resolve during the years after surgical intervention. Thus, these patients slowly continue to improve clinically and require fewer medications. However, this observation requires further longitudinal documentation. If not validated, it is possible that periodic revision surgery could be more cost-effective and appealing for patients with chronic rhinosinusitis. It is hoped that future studies will serve to resolve such issues.

REFERENCES

Kennedy and Wright—CHAPTER 16

1. Kennedy DW. Prognostic factors, outcomes and staging in ethmoid sinus surgery. Laryngoscope 1992;102(suppl):1-18

2. Vleming M, De Vries N. Endoscopic paranasal sinus surgery: results. Am J Rhinol 1990;4:13-17

3. Leopold D, Ferguson BJ, Piccirillo JF. Outcomes assessment. OOtolaryngolHead Neck Surg 1997;117(suppl 3):S58-S68

4. Lund VJ, MacKay IS. Staging in rhinosinusitis. Rhinology 1993;107:183-184

5. Lund VJ, Kennedy DW. Quantification for staging sinusitis. In: Kennedy DW, ed. International conference on Sinus Disease: Terminology, Staging Therapy. Ann Otorhinol Laryngol 1995;104(suppl 167):17-21

6. Lund VJ, Kennedy DW. Staging for rhinosinusitis. Otolaryngol Head Neck Surg 1997;117(suppl 3):S35-S40

7. Ware JE, Sherbourne CD. The MOS 36 item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30:473-483

8. Gliklich RE, Metson R. Techniques for outcomes research in chronic sinusitis. Laryngoscope 1995;105:387-390

9. Gliklich RE, Metson R. Effect of sinus surgery on quality of life. OOtolaryngolHead Neck Surg 1997;117:12-17

10. Piccirillo JF, Edwards D, Haiduk A, et al. Psychometric and clinimetric validity of the 31-item rhinosinusitis outcome measure (RSOM-31). Am J Rhinol 1995;9:297-306

11. Benninger MS. The development of the rhinosinusitis disability index. Arch Otolaryngol Head Neck Surg 1997;123: 1175-1179

12. Hoffman SR, Mahoney MG, Chmiel JF, et al. Symptom relief after endoscopic sinus surgery: an outcomes-based study. Ear Nose Throat J 1993;72:413-414, 419-420

13. Lawson W. The intranasal ethmoidectomy: an experience with 1077 procedures. Laryngoscope 1991;101:367-371

14. Sogg A. Long-term results of ethmoid surgery. Ann Otorhinol Laryngol 1989;98:699-701

15. Rice D. Endoscopic sinus surgery: results at 2-year follow-up. Otolaryngol Head Neck Surg 1989;101:467-479

16. Levine H. Functional endoscopic sinus surgery: evaluation, surgery, and follow-up of 250 patients. Laryngoscope 1990; 100:79-84

17. Senior BA, Kennedy DW, Tanabodee J, et al. Long-term results of functional endoscopic sinus surgery. Laryngoscope 1998;108:151-157

Outcomes in Sinus Surgery—Management Parameters

Charles W. Gross and Scott E. Harrison

CHAPTER 17

Sinusitis affects approximately 35 million Americans. Nasal inflammation and sinus disease cause patient discomfort and loss of productivity and have a negative impact on the quality of life of those affected. The cost of treating this disease surpasses $2 billion per year.1 Most people who experience sinus infections can be treated medically without entertaining surgical intervention. However, deciding which patients require surgical intervention can be difficult.

Most patients will respond to medical therapy. Adequate medical therapy may include the use of saline irrigation, topical and/or systemic decongestants, topical nasal steroids, systemic corticosteroids, mucolytic agents, appropriate antihistamine use, and the appropriate use of oral antibiotics for an appropriate treatment duration. The evaluation and treatment of systemic disease such as allergy (inhalant or food), immunodeficiency, cystic fibrosis, diabetes mellitus, and the evaluation of environmental factors (e.g., smoke, inhaled irritants, drug use) may increase the number of patients who will be successfully treated without surgery. It is not uncommon to treat a patient for 6 to 10 weeks before an infection resolves. Medical failures can often be traced to patient noncompliance, but if a compliant patient fails maximal therapy for 12 weeks or more, surgery should be considered.

The development and acceptance of functional endoscopic sinus surgery2 have offered a variety of treatment options for patients who fail medical therapy and continue with debilitating sinus conditions. Functional endoscopic sinus surgery provides a method of excellent visualization that aids in the precise and meticulous eradication of paranasal sinus disease. Most patients receive surgery on an outpatient basis, have a minimal recovery time, and have excellent long-term results.3,4

The evaluation of a patient for sinus surgery begins with the assurance that all other treatment options have been used, and the patient continues with unrelenting disease. There are obvious cases for which sinus surgery is indicated, including unilateral nasal masses, invasive fungal disease, obstruction with nasal polyps, and complications such as subperiosteal, orbital, or intracranial extension of infection. Patients who are immunocompromised and have sinusitis should be considered eligible for surgery at a much earlier point, as they tend to respond poorly to medical management and have an increased propensity to develop orbital or intracranial complications. These patients comprise a minority of surgical candidates; the usual candidate requires a more careful evaluation. In addition, many patients undergoing sinus surgery will require ongoing treatment for underlying systemic or recalcitrant disease.

The decision to operate must be based on clear historical, clinical, and radiographic evidence. If the patient is a child, the decision becomes even more complicated. The major anatomic differences between adult and pediatric paranasal sinuses are smaller sinus size and lesser degree of pneumatization. In evaluating a child who is considered a possible candidate for sinus surgery, an immature but still developing immune system, the role of tonsils and adenoids, and other factors must be considered. Support for aggressive medical therapy before surgery has been well established;5 however, certain conditions do benefit from surgical intervention. Most cystic fibrosis patients are within the pediatric age group and experience sinusitis. Sinusitis may progress to a life-threatening condition in this population. Sinus inflammation leads to congestion and stasis of secretions and forms a reservoir for pathogen growth. Sinus pathogens seed the lower respiratory tract and can lead to pneumonia, particularly in those who have lung transplants.6 A decreased ability to clear secretions, the propensity to develop polyps, common colonization with Pseudomonas organisms, and progressive general deterioration of the patient are reasons sinus surgery is performed. Surgery is directed toward removing disease, relieving obstruction, ventilating the paranasal sinuses, and eradicating pathogenic organisms. Sinus surgery serves to mediate, not cure, the sinus disease or pulmonary involvement. The creation of widely patent middle meatus with large maxillary sinus antrostomies or "mega-antrostomies" is advocated. The "mega-antrostomy" involves opening the maxillary ostia both posteriorly and inferiorly with the removal of the posterior inferior turbinate and inferior meatus, to allow secretions to drain toward the floor of the nose and nasopharynx. Surgery often provides drastic and prolonged improvement in these patients.7 Revision sinus surgery is not uncommon, as sinus surgery improves the general health of cystic fibrosis patients but does not cure the underlying disease. Tenacious secretions associated with cystic fibrosis are difficult to expel, and impair the function of cilia within the nasal cavity. The resultant stasis will continue to cause recurrent episodes of sinusitis, but the severity of the infection and the potential for life-threatening sequelae are most often lessened.

Ciliary dyskinesia may result from different causes. As described, cystic fibrosis causes altered secretions that commonly leads to ciliary failure. Bacterial and viral infections damage ciliated epithelium; however, most patients regain mucociliary clearance after the infection has cleared and the cilia regenerate. Cilia regeneration occurs over approximately 10 weeks. Patients with Kartagener's syndrome have congenital dysfunction of cilia. Patients with suspected primary ciliary disorders require a mucosal biopsy to establish the diagnosis. Often this will be followed by functional surgery to widen areas of constriction to improve ventilation and mucus clearance.

Any cause of ciliary dysfunction causes ineffective mucus transport, resulting in stagnation and ultimately infection.

There is a well-established relationship between sinusitis and asthma;8 and convincing clinical evidence indicates that sinusitis may play a part in the pathogenesis of bronchial asthma.9 Clearing disease from the paranasal sinuses with removal of offensive bacterial organisms often results in improvement of asthma.10 Therefore, applying the principles of functional sinus surgery to medically resistant sinusitis has proved helpful in the well-being of these patients. Asthmatics are at higher risk of postoperative pulmonary complications, and this should be considered before surgery begins.

Allergic or nonallergic rhinitis has been sited as one of the most common causes of chronic or recurrent sinusitis.11 Rhinitis is differentiated from sinusitis by the presence of sneezing, itching, and clear rhinorrhea. Surgery in itself will not cure allergic rhinitis, but allergies can lead to such severe mucosal edema and chronic inflammation that the sinus mucosa becomes permanently damaged, leading to mucosal changes and polyp formation. If such a condition exists, surgical removal of sinus obstruction and opening of sinus ostia relieves the discomfort associated with disease; improved ventilation provides access for topical steroids that further improve the patient's overall condition. Allergic rhinitis may also be due to noninvasive fungal sinusitis. Patients with allergic fungal sinusitis typically have carried the diagnosis of chronic sinusitis and have had multiple sinus surgeries before the correct diagnosis was discovered.12 The allergic response to the fungus may initiate massive polypoid growth with significant mass effect. The diagnosis requires demonstration of allergic mucin containing fungal elements. Surgery is indicated to remove polyps and allergic mucin and restore the patency of the paranasal sinuses.

Invasive fungal sinusitis usually presents in patients who are immunocompromised. Patients who have received an organ transplant, been treated for malignancy, or have allergies or asthma should be considered at risk. The diagnosis requires a surgical biopsy with evidence of mucosal penetration that may include blood vessel or bone involvement.13 Acute fulminate invasive fungal sinusitis (usually mucormycosis) is a medical and surgical emergency. It is characterized by rapid spread of fungus via vascular routes into the orbits or brain with the presentation of fever, headache, mental status changes, epistaxis, and a characteristic dark rust-colored or black eschar within the nasal cavity. Therapy involves aggressive surgical debridement of nonviable tissue until healthy tissue is discovered. Systemic amphotericin B is also indicated.

There are situations in which chronic or recurrent sinusitis is the result of anatomic abnormalities within the nasal cavity. Most of the structures within the nasal cavities can have deformities that lead to functional obstruction of the sinus outflow tracts, particularly the anatomically narrow osteomeatal complex. Deflection of the nasal septum (either cartilaginous, bony, or both) can result in a significant narrowing of the nasal cavity. Abnormalities of the middle turbinate including a paradoxical curvature or pneumatization (concha bullosa) can impinge on the region of the hiatus semilunaris resulting in compromise of the osteomeatal complex. An enlarged inferior turbinate can obstruct nasal airflow and sinus drainage. Anatomic variation within the ethmoid system including large agger nasi cells, hypertrophy of the anterior or posterior ethmoid air cells, infraorbital ethmoid cells (Haller's cells), or sphenoethmoid cells (Onodi's cells) can functionally impair the outflow tracts. Abnormal deflection of the uncinate process due to development or trauma can occlude the osteomeatal complex leading to obstruction. When these anatomic variations are present, even the most minor cause of inflammation can lead to obstruction, stasis of secretions, and the creation of an environment suitable for the proliferation of bacterial pathogens. The focus of functional endoscopic sinus surgery is on the restoration of ventilation and mucociliary clearance of the paranasal sinuses. Correcting the anatomic abnormalities and providing improved ventilation and drainage of the paranasal sinuses can minimize the effects of mucosal edema, obstruction, and subsequent infection. In turn, this provides for a cured or significantly improved patient.

The frontal sinus is a paranasal sinus that requires particular attention. Infection of the frontal sinus does not respond quickly to antibiotic therapy and therefore can lead to central nervous system infection. The posterior table of the frontal sinus can be traversed by infection and allow access to the frontal lobe area causing an intracranial abscess or meningitis. Frontal sinusitis requiring surgery may be approached either externally or internally. External trephination or osteoplastic flaps with frontal sinus obliteration are the more common external methods. An intranasal approach is now frequently advocated as the frontal recess can often be opened widely with the complete eradication of disease using endoscopic methods. The patency of the frontal recess can be maintained indefinitely. This prevents the patients from acquiring external signs of surgery such as unsightly scar formation. Frontal sinus trephination has historically involved a Lynch incision with access gained through the medial supraorbital frontal bone. A much smaller version or mini-trephination system is now available that allows access to the frontal sinus by making a minimal incision directly over the anterior table of the frontal sinus and provides a means of obtaining cultures and irrigation. Experience has shown that this sort of trephination and endoscopic frontal sinus surgery results in the resolution of frontal sinus disease.

Consideration of all these factors can lead to the development of a treatment algorithm. The first consideration is to ensure the patient has undergone a thorough evaluation concerning the possibility of systemic influence or other causes (environmental) and adequate medical therapy for an appropriate length of time. If the sinus condition persists for 12 weeks or more, surgical intervention may be indicated. The patient's overall medical condition must also be considered. Patients with systemic illness may be predisposed for sinusitis-related complications and surgical intervention may be warranted at an earlier point in time. The treatment protocol begins with a careful history followed by a physical examination, including nasal endoscopy. Attention to anatomic factors that could cause sinus outflow obstruction, or signs of acute or chronic infection are carefully assessed. It may be difficult to perform an adequate examination on an uncooperative child; for these cases, a computed tomography (CT) study of the sinuses is extremely helpful. Many rhinologists consider CT an essential part of the preoperative evaluation, as well as a diagnostic aid for the existence, severity, and extent of chronic inflammation. It can provide anatomic information that can direct the surgical procedure and add an element of safety in cases of difficult or unusual anatomy. Once all factors have been analyzed, appropriate counsel can be offered to the patient. Counseling patients with pre-existing medical conditions, such as cystic fibrosis, ciliary disorders, immunodefi ciency, and diabetes, must be provided in order to maximize the benefit of endoscopic surgery. It is not unusual for some patients to require more than one surgical procedure; revision sinus surgery is not uncommon in these patients. Revisions are at times advised in those with chronic recurrent sinusitis in spite of previous surgery, appropriate medical therapy and CT studies that show no other sign of abnormality.14

Functional endoscopic sinus surgery has been established as an effective and safe method of treating patients who have chronic sinusitis and have not benefited from medical therapy. It is effective in treating adults and children as long as careful attention has been given to concomitant medical conditions and a careful anatomic evaluation has been performed.

REFERENCES

Gross and Harrison—CHAPTER 17

1. Kaliner MA, Osguthorpe JD, Fireman P, et al. Sinusitis: bench to bedside. J Allergy Clin Immunol 1997;99:S829-S848

2. Kennedy DW, Zinreich SJ, Rosenbaum A, et al. Functional endoscopic sinus surgery: theory and diagnosis. Arch Otolaryngol 1985;111:576-582

3. Senior BA, Kennedy DW, Tanabodee J, et al. Long-term results of functional endoscopic sinus surgery. Laryngoscope 1998;108:151-157

4. Danielson A, Olofsson J. Endoscopic endonasal sinus surgery: a long-term follow-up study. Acta Otolaryngol 1996;116:611-619

5. Parsons DS. Chronic sinusitis: a medical or surgical disease? Otolaryngol Clin of North Am 1996;29:1-9

6. Davidson TM, Murphy C, Mitchell M, et al. Management of chronic sinusitis in cystic fibrosis. Laryngoscope 1995;105:354-358

7. Gentile VG, Isaacson G. Patterns of sinusitis in cystic fibrosis. Laryngoscope 1996;106:1005-1009

8. Marney SR. Pathophysiology of reactive airway disease and sinusitis. Ann OtolRhinolLaryngol 1996;105:98-100

9. Slavin RG. Complications of allergic rhinitis: implications for sinusitis and asthma. J Allergy Clin Immunol 1998;101: S357-S360

10. Bucca C, Rolla G, Scappaticci E, et al. Extrathoracic and intrathoracic airway responsiveness in sinusitis. J Allergy Clin Immunol 1995;95:52-59

11. Kaliner M. Medical management of sinusitis. Am J Med 1998; 316:21-28

12. deShazo RD, Swain RE. Diagnostic criteria for allergic fungal sinusitis. J Allergy Clin Immunol 1995;96:24-35

13. deShazo RD. Fungal sinusitis. Am J Med Sci 1998;316: 39-45

14. Lazar RH, Younis RT, Long TE, Gross CW. Revision endoscopic sinus surgery. Ear Nose Throat J 1992;71:131-133

Outcomes in Sinus Surgery—Management Parameters

CHAPTER 18

Richard E. Gliklich

Outcomes assessment refers to the measurement of health and medical results toward the goal of improving care. Although outcomes assessment in itself is not controversial, controversy arises when attempts are made to standardize methodology. There are several valid ways to approach outcomes assessment and management in sinus surgery. The best means to eliminate controversy is for the reader to understand that the relevant criteria for choosing an outcomes management system should be based on the individual needs of a particular practice or a particular study and the performance characteristics (e.g., type of measure, reliability, ease of use) of the available measures and staging systems.

Sinusitis is an increasingly common cause for patient visits to the doctor in the United States and is the prinicipal diagnosis in nearly 2% of all patient visits. Surgery for the treatment of chronic sinusitis is performed more than 200,000 times per year in the United States alone, making sinusitis both a common and, in aggregate, an expensive illness.

Sinusitis is a predominantly ambulatory disease that afflicts a working-age population. In many ways, sinusitis is a model to explain the practical steps necessary in developing outcomes management systems for chronic ambulatory diseases as well as the information that can be obtained and used from an effective program. The elements of an outcomes management system for sinus surgery include staging and stratification, process measurement, outcomes measures, and feedback.

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