Surgical Management of Chronic Rhinosinusitis in Cystic Fibrosis

Cystic fibrosis patients frequently develop chronic rhinosinusitis as a result of their propensity to form inspissated mucus and impairment of mucociliary clearance. They exhibit variable symptom burden even in the setting of positive radiographic and endoscopic findings. Current evidence suggests a positive effect of managing sinonasal disease on pulmonary health. Topical antimicrobial and mucolytic therapies are frequently required to manage the disease with surgery reserved for refractory cases. Endoscopic sinus surgery has been demonstrated to be safe and efficacious in controlling symptoms of chronic rhinosinusitis in patients with comorbid cystic fibrosis. However, the impact of surgery on pulmonary health remains an active area of investigation. In addition, a growing body of research has suggested a more extended surgical approach creating large sinonasal cavities with gravity-dependent drainage pathways, followed by adjuvant medical therapies, as an ideal strategy to optimally control disease and prevent pulmonary exacerbations. In this manuscript, we provide an up-to-date review of current evidence in the surgical management of chronic rhinosinusitis in cystic fibrosis patients.

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Does time to endoscopic sinus surgery impact outcomes in Chronic Rhinosinusitis? Prospective findings from the National Comparative Audit of Surgery for Nasal Polyposis and Chronic Rhinosinusitis

Rhinology Journal ◽

10.4193/rhino13.217 ◽

2015 ◽

Vol 53 (1) ◽

pp. 10-17

Author(s):

C. Hopkins ◽

J. Rimmer ◽

V.J. Lund

Keyword(s):

Chronic Rhinosinusitis ◽

Nasal Polyposis ◽

Surgical Intervention ◽

Elective Surgery ◽

Symptom Burden ◽

Sinus Surgery ◽

Time Points ◽

Comparative Audit ◽

The Impact ◽

Snot 22

Objectives: Patients with chronic rhinosinusitis refractory to medical management undergo elective surgery. The time from initial diagnosis to surgery varies considerably. The impact of this delay on surgical success has never previously been evaluated. Design: First-time patients within the National Comparative Audit of Surgery for Nasal Polyposis and Chronic Rhinosinusitis were grouped based on time to surgery: 1) Early cohort: %lt; 12 months; 2) Mid cohort: 12-60 months; and 3) Late cohort: > 60 months. Co-morbidities and preoperative CT scores were analysed for all patients. Main outcome measures: The 22-item Sino-Nasal Outcome Test scores (SNOT-22) were collected at 0, 3, 12 and 60-months. Absolute and relative SNOT-22 changes from baseline were evaluated. Results: Asthma and allergies were significantly more prevalent in the Late versus the Early and Mid-cohorts. In addition, patients in the Late cohort had greater symptom burden on the SNOT-22 and more extensive preoperative radiographic disease as determined by Lund-Mackay (LM) scores. SNOT-22 scores demonstrated greater percentage improvements in the Early versus the Mid- and Late cohorts, at all time points after surgery. At 12 and 60 months after surgery, significantly more patients in the Early group achieved a clinically important change in SNOT-22 scores compared with the other groups. These differences were maintained when cohorts were matched for preoperative co-morbidities. Conclusion: Patients with asthma and/or allergies are more likely to experience delayed surgical intervention versus other patients. Overall, patients with delayed surgery reported less improvement in SNOT-22 scores than patients treated at earlier time points, regardless of co-morbid status. Delaying surgical intervention may worsen long term clinical outcomes.

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Impact of Septal Deviation on Recurrent Chronic Rhinosinusitis after Primary Surgery: A Matched Case-Control Study

Otolaryngology ◽

10.1177/0194599818815106 ◽

2018 ◽

Vol 160 (5) ◽

pp. 922-927

Author(s):

Terence Fu ◽

Daniel Lee ◽

Jonathan Yip ◽

Alisha Jamal ◽

John M. Lee

Keyword(s):

Chronic Rhinosinusitis ◽

Case Control Study ◽

Multivariable Analysis ◽

Case Control ◽

Sinus Surgery ◽

Deviated Nasal Septum ◽

Primary Surgery ◽

Academic Center ◽

The Impact ◽

Control Study

Objective To evaluate the impact of untreated deviated nasal septum (DNS) on recalcitrant chronic rhinosinusitis (CRS) among patients undergoing revision endoscopic sinus surgery (ESS). Study Design Case-control study. Setting Tertiary academic center. Subjects and Methods We performed a retrospective review of 489 patients undergoing revision ESS for CRS at a tertiary academic center. Patients undergoing septoplasty were matched to nonseptoplasty controls based on age and sex. Preoperative Lund-Mackay score (LMS) was compared between cohorts. Linear regression was used to identify predictors of LMS and ostiomeatal complex (OMC) obstruction. Results Thirty-six matched pairs (72 patients) were selected for analysis: 36 undergoing septoplasty and revision ESS and 36 undergoing revision ESS alone. Compared with nonseptoplasty controls, the septoplasty group had a significantly higher average LMS (17.8 vs 14.6, P = .02) and a greater rate of OMC obstruction (89% vs 61%, P < .01). The septoplasty group also had significantly higher opacification scores in the maxillary (1.5 vs 1.2, P = .03) and posterior ethmoid (1.8 vs 1.4, P = .02) sinuses. On multivariable analysis, DNS was an independent predictor of LMS ( P = .02) and OMC obstruction ( P < .01). Conclusion Untreated DNS is associated with radiographic markers of CRS severity among patients undergoing revision ESS and may contribute to the multifactorial pathogenesis of persistent CRS.

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Chronic rhinosinusitis in adult patients with cystic fibrosis: clinical manifestation and therapeutic approaches

Russian Pulmonology ◽

10.18093/0869-0189-2019-29-3-311-320 ◽

2019 ◽

Vol 29 (3) ◽

pp. 311-320

Author(s):

G. L. Shumkova ◽

E. L. Amelina ◽

V. M. Svistushkin ◽

E. V. Sin’kov ◽

S. A. Krasovskiy ◽

...

Keyword(s):

Cystic Fibrosis ◽

Surgical Treatment ◽

Treatment Group ◽

Chronic Rhinosinusitis ◽

Paranasal Sinuses ◽

Endoscopic Sinus Surgery ◽

Nasal Polyps ◽

Adult Patients ◽

Sinus Surgery ◽

Markers Of Inflammation

The aim of this study was to evaluate prevalence of chronic rhinosinusitis (CRS) and nasal polyps in adult patients with cystic fibrosis (CF) in Russian Federation. Additionally, we investigated the clinical course of CRS and developed the optimal therapeutic strategy.Methods. Three hundred and forty eight CF patients were involved in the study. Physical examination, computed tomography (CT) of paranasal sinuses and audiometry, if needed, were used. CRS and bilateral nasal polyps were diagnosed in 28 patients. Nasal endoscopy, SNOT-20 questionnaire, rhinomanometry, micro - biological examination of sputum and mucus from paranasal sinuses (obtained during puncture or surgery), spirometry, and measurement of serum markers of inflammation were used. Endoscopic sinus surgery was used in 14 patients (the group 1) and others were treated non-surgically (the group 2). Both group were treated during 6 months using intranasal mometasone, mucolytics and antibiotics via PARI SINUSTM nebulizer.Results. An improvement in symptoms, CT signs, rhinomanometry parameters and endoscopic signs was seen in both groups after treatment and was more prominent in the surgical treatment group compared to the non-surgical treatment group. Bacterial load reduction in nasal sinuses, decrease in the rate of pulmonary disease exacerbations, and an improvement in oxygen blood saturation were found in the surgical treatment group only. Treatment of CRS did not affect lung function, sputum microbiology and serum inflammatory markers.Conclusion. Endoscopic sinus surgery followed by intranasal mucolytics and antibacterials is an effective and well-tolerated treatment in adult CF patients with CRS.

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The impact of chronic rhinosinusitis on sleep-disordered breathing

Rhinology Journal ◽

10.4193/rhino15.204 ◽

2016 ◽

Vol 54 (1) ◽

pp. 75-79

Author(s):

Rong-San Jiang ◽

Kai-Li Liang ◽

Chung-Han Hsin ◽

Mao-Chang Sun

Keyword(s):

Sleep Quality ◽

Chronic Rhinosinusitis ◽

Nasal Obstruction ◽

Sleep Disordered Breathing ◽

Sleep Problems ◽

Sleep Apnea Syndrome ◽

Sinus Surgery ◽

Obstructive Sleep ◽

The Impact ◽

Disordered Breathing

Background: The nose plays an important role in sleep quality. Very little is known about sleep problems in patients with chronic rhinosinusitis (CRS). The aim of this study was to investigate the impact of CRS on sleep-disordered breathing. Methodology: CRS patients who underwent functional endoscopic sinus surgery were collected between July 2010 and May 2015. Before surgery, they filled 20-item Sino-Nasal Outcome Test and Epworth Sleepiness Scale questionnaires, were asked about the severity of nasal obstruction, and received acoustic rhinometry, smell test, an endoscopic examination, sinus computed tomography, and a one-night polysomnography. Sleep quality was evaluated in these patients and was correlated with the severity of rhinosinusitis. Results: One hundred and thirty-nine CRS patients were enrolled in the study. Among them, 38.1% complained of daytime sleepiness, and this sleep problem was correlated with the symptom of nasal obstruction. Obstructive sleep apnea syndrome (OSAS) was diagnosed in 64.7% of the patients, but there was no correlation with the severity of rhinosinusitis. Nasal polyps did not worsen sleep problems in the CRS patients. Conclusions: This study showed that CRS patents had a high prevalence of OSAS, and worse OSAS in CRS patients was not correlated with the severity of rhinosinusitis.

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Real-world evidence analysis of the impact of steroid-eluting implants on healthcare resource use among chronic rhinosinusitis patients undergoing sinus surgery

Current Medical Research and Opinion ◽

10.1080/03007995.2021.2022874 ◽

2021 ◽

pp. 1-12

Author(s):

Veena Hoffman ◽

Kathleen M. Mortimer ◽

Kyra Mulder ◽

Ia Topuria ◽

Richard Gliklich ◽

...

Keyword(s):

Chronic Rhinosinusitis ◽

Resource Use ◽

Real World ◽

Healthcare Resource ◽

Sinus Surgery ◽

Healthcare Resource Use ◽

Real World Evidence ◽

Evidence Analysis ◽

The Impact

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A 10-Year Follow-Up of a Randomized Prospective Study of 2 Treatments for Chronic Rhinosinusitis Without Nasal Polyps and Investigation of the Impact of Gastroeosophageal Reflux Disease in the Resistance to Treatment

Ear Nose & Throat Journal ◽

10.1177/0145561319892460 ◽

2019 ◽

pp. 014556131989246

Author(s):

Jerome R. Lechien ◽

Gersende Debie ◽

Virginie Mahillon ◽

Marie-Paule Thill ◽

Alexandra Rodriguez ◽

...

Keyword(s):

Gastroesophageal Reflux Disease ◽

Gastroesophageal Reflux ◽

Chronic Rhinosinusitis ◽

Reflux Disease ◽

Nasal Polyps ◽

Sinus Surgery ◽

Amoxicillin Clavulanate ◽

The Impact

Objectives: To compare the 2 long-term medical strategies in chronic rhinosinusitis without nasal polyps (CRSnNP) and to identify the role of gastroesophageal reflux disease (GERD) and Helicobacter pylori as factors of treatment failure. Material and Methods: Fifty-seven patients with CRSnNP were randomized into 2 therapeutic groups. The first group was treated with 4 weeks of amoxicillin/clavulanate and a short course of oral steroids. The second group received 8 weeks of clarithromycin. Sinonasal Outcome Test-20 (SNOT-20) and Lund and Mackay scores were assessed at baseline and after treatment, and GERD Health-Related Quality of Life (GERD-HRQL) questionnaire was evaluated in all patients. Patients with a GERD-HRQL score >8 received esogastroscopy and H pylori detection. Patients were followed during a 10-year period for clinical course and GERD evolution. The 10-year evolution of patients was described in terms of recurrence, medical, and surgical treatments. Results: Thirty-seven patients completed the study; SNOT-20 and Lund and Mackay scores similarly improved in both groups. Amoxicillin/clavulanate group had significantly more adverse reactions than the clarithromycin group (P = .03). After the therapeutic course, 35% (amoxicillin/clavulanate) and 41% (clarithromycin) of patients needed functional endoscopic sinus surgery (FESS). During the long-term follow-up, 54% (amoxicillin/clavulanate) and 40% (clarithromycin) of patients had late CRSnNP recurrence; FESS was performed in less than 15% of cases of recurrence. Gastroesophageal reflux disease complaint’s severity was associated with late recurrence of CRSnNP. Conclusion: Amoxicillin/clavulanate and clarithromycin would be competitive treatments for CRSnNP. Gastroesophageal reflux disease seems to be a negative factor for treatment response and recurrence.

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Office-Based Sinus Surgery for Cystic Fibrosis Chronic Rhinosinusitis

ORL ◽

10.1159/000512495 ◽

2020 ◽

pp. 1-4

Author(s):

Daniel B. Spielman ◽

David A. Gudis

Keyword(s):

Cystic Fibrosis ◽

Mechanical Ventilation ◽

Chronic Rhinosinusitis ◽

Local Anesthesia ◽

Endoscopic Sinus Surgery ◽

Care Center ◽

Academic Medical Center ◽

Tertiary Care ◽

Sinus Surgery ◽

Office Setting

Objective: Chronic rhinosinusitis (CRS) is nearly ubiquitous in the cystic fibrosis (CF) population, and many patients require multiple endoscopic sinus surgeries throughout their lifetime. Recent studies have demonstrated the profound pulmonary and systemic health benefits of comprehensive CRS treatment. Both endotracheal intubation with mechanical ventilation and inpatient hospital care represent significant risks for CF patients. The goal of this study is to evaluate the safety and feasibility of performing revision endoscopic sinus surgery for CF patients in the outpatient office setting using only local anesthesia to decrease the need for mechanical ventilation and inpatient hospitalization. Methods: This is a prospective cohort study conducted at a tertiary care academic medical center with a CF Foundation-accredited care center. Patients with CF and refractory CRS despite prior surgery and medical therapy were eligible for inclusion. Comprehensive revision ESS was performed in the office using only local anesthesia. Results: Five patients were enrolled and underwent revision endoscopic sinus surgery without complication. The average preoperative Sinonasal-Outcome Test-22 score was 52.0 ± 12.1 and the average preoperative Lund-Mackay score was 15.2 ± 3.8. No patients requested aborting the procedure early due to pain, discomfort, or any other reason. No subjects required prolonged observation or postoperative hospital admission. Conclusion: This prospective pilot study is the first to demonstrate the safety and feasibility of performing comprehensive revision endoscopic sinus surgery for CF patients in the outpatient office setting using only local anesthesia.

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