Lal, Devyani

Background Women electing endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) report higher symptom burden but have lower computed tomography (CT) scores. Gender‐specific analysis of outcomes from ESS therefore merits further study. The objective of this work was to study gender‐specific differences in outcomes from ESS for CRS by analyzing preoperative and postoperative 22‐item Sino‐Nasal Outcome Test (SNOT‐22) scores. Methods Data from adult CRS patients electing ESS (2011‐2013) were retrospectively collected. SNOT‐22 total, rhinologic/nonrhinologic subdomain, and individual item scores were analyzed for gender‐specific differences. Results Two hundred and forty‐eight patients met study criteria (mean age 55.4 years; 49.6% female). Preoperatively, mean Lund‐Mackay CT score was 11.1; average total SNOT‐22 score was 41.9. Compared to men, women had lower CT score (10.2 vs 12.0; p = 0.004) but higher total SNOT‐22 score (44.7 vs 39.1; p = 0.02). Both genders showed significant improvement in total SNOT‐22 scores at 3, 6, 12, and 24 months following ESS ( p < 0.001), with largely similar slopes of improvement. The greatest improvement occurred at 3 months (SNOT‐22 decreased by 25.4 points), with stable improvement after 12 months (SNOT‐22 decreased by 21.3 points). Higher total SNOT‐22 scores in females were noted preoperatively and until 6 months post‐ESS; these were driven by rhinologic and nonrhinologic‐otolaryngic subdomain items. No gender differences in anxiety/depression prevalence or psychological subdomain scores were noted preoperatively or postoperatively. Conclusion Both male and female CRS patients showed significant and durable symptom relief following ESS. Women reported higher symptom burden prior to surgery, and in the early postoperative period. However, after 1‐year post‐ESS, both genders showed similar symptom scores. The trend and magnitude of improvement were similar in both genders.

BackgroundThe objective of this work was to describe the association between baseline clinical characteristics and attendance at follow‐up visits after endoscopic sinus surgery (ESS).MethodsA retrospective review of chronic rhinosinusitis (CRS) patients electing ESS at a tertiary‐care center (2011‐2013) was conducted. Baseline characteristics were studied for association with clinic attendance at 3, 6, 12, and 24 months post‐ESS.ResultsWe identified 268 patients. Significant decline occurred in the number of patients following up after ESS (3 months: 246 patients [92%]; 6 months: 145 [54%]; 12 months: 94 [35%]; and 24 months: 90 [34%]). Older patients were more likely to follow up at 3 months (mean age 55.7 vs 48.4 years, p = 0.04) and 6 months (57.5 vs 52.3 years; p = 0.01) post‐ESS. Those with higher preoperative sinus computed tomography (CT) (Lund‐Mackay) scores were more likely to follow at 6 months (11.8 vs 10.3, p = 0.01), 12 months (12.6 vs 10.3, p < 0.001), and 24 months (12.2 vs 10.5, p = 0.01). At 12 months having asthma (p = 0.03), previous ESS (p = 0.04), nasal polyps (p < 0.0001), allergic fungal sinusitis (AFS) (p = 0.002), and granulomatosis with polyangiitis (GPA) (p = 0.01) were associated with clinic attendance. At 24 months asthma status (p = 0.003), previous ESS (p = 0.002), AFS (p = 0.04), GPA (p = 0.001), and aspirin‐exacerbated respiratory disease (AERD) (p = 0.006) were associated with higher attendance. Geographical proximity did not impact attendance.ConclusionThe sharpest decline in patient follow‐up occurred between 3–6 months after ESS. Higher preoperative sinus CT scores, previous ESS, presence of asthma, and diagnosis of recalcitrant CRS subtype (nasal polyps, AERD, AFS, GPA) were factors associated with increased long‐term attendance.

Background Sinus computed tomography (CT) is performed for the diagnosis of paranasal sinus disease and to assess response to medical therapy. In addition, sinus CT is used for intraoperative imaging guidance. Multiple CTs increase cost and radiation exposure. Objective To determine potential cost savings and radiation dose reduction that result from the use of a single universal sinus CT protocol for diagnostic imaging and intraoperative navigation. Materials and Methods For sinus CT at the authors' institution, a single imaging protocol was begun and deemed acceptable by neuroradiologists and surgeons for diagnostic imaging and intraoperative guidance. The electronic medical record was queried over a 4-year period to determine the number of sinus CTs performed, dose-length products, referring providers' specialties, percentage of CTs used for intraoperative navigation, and the elapsed time between CT and surgery. Results A total of 6187 sinus CTs were performed by using a 64-detector scanner during the study period (2759 women and 3428 men; 53.6 ± 16.7 years [mean ± SD]), and 596 endoscopic sinus surgery cases used imaging guidance, for which all the CTs were deemed technically adequate. The mean dose-length product for the CTs was 338.4 ± 31.9 mGy-cm (mean ± SD). Of the 3702 sinus CTs ordered by nonotolaryngology providers, 167 surgeries with intraoperative navigation (4.5%) were performed. A higher percentage of CT referrals from sinus surgeons (23.9%) and other otolaryngology providers (11.4%) was used for imaging guidance (p < 0.0001). The time interval between sinus CT and surgery was greatest for nonotolaryngology providers (63.1 days, p < 0.01). Based on Medicare reimbursement, the total estimated saving was $147,628. Conclusions Adopting a single universal sinus CT protocol for diagnostic imaging and intraoperative navigation can be an effective means of decreasing cost and radiation exposure. However, successful implementation must take into account multiple practice-based considerations.

BackgroundThe objective of this study was to investigate gender‐specific differences in chronic rhinosinusitis (CRS) patients electing endoscopic sinus surgery (ESS).MethodsThis study was a retrospective review of CRS patients electing ESS (2011–2013) at a tertiary‐care center.ResultsESS was elected by 272 patients (mean age 54.6 years; 48.5% female). Mean Lund‐Mackay computed tomography (CT) score was 10.9; total 22‐item Sino‐Nasal Outcome Test (SNOT‐22) score was 41.8. Compared to men, women electing ESS had lower CT score (10.1 vs 11.7; p = 0.01) but higher total SNOT‐22 score (44.9 vs 39; p = 0.02). Women reported significantly worse postnasal drainage (p < 0.0001) and embarrassment (p = 0.0021). SNOT‐22 scores declined with advancing age (women, p = 0.003; men, p = 0.0005). Reduction in CT scores with age was seen only in males (p = 0.03). Stratifying by age, females aged 61 to 80 years had higher SNOT‐22 scores compared to male counterparts (p = 0.04), whereas CT scores were similar. More women underwent surgery for CRS without nasal polyps (CRSsNP) (54.9%) whereas more men underwent surgery for CRS with nasal polyps (CRSwNP) (57.4%), but this difference missed statistical significance (p = 0.052). Women with CRSwNP had higher SNOT‐22 scores than men (p = 0.02) for similar CT scores. Men electing ESS for CRSsNP had higher CT scores than women (p = 0.02). Women with CRSsNP aged 18 to 40 years reported higher SNOT‐22 scores than men (p = 0.003), even though CT scores were lower (p = 0.005).ConclusionEquivalent numbers of men and women underwent ESS for CRS. Overall, women electing ESS had higher total SNOT‐22 scores and lower Lund‐Mackay CT scores than men. Women reported more problems with postnasal drainage (CRS overall, CRSsNP, and CRSwNP), embarrassment (CRS overall and CRSwNP), and facial pain (CRSwNP). Gender differences in CRS are poorly understood and merit further study.

BackgroundThe objective of this work was to study patient and 22‐item Sino‐Nasal Outcome Test (SNOT‐22) characteristics in primary headache disorders (PHDs).MethodsRetrospective chart review of “sinus” headache/pressure/pain patients was conducted. Patients that had rhinosinusitis excluded (negative endoscopy/computed tomography [CT]), and neurologist‐confirmed PHD were studied. Patterns in symptom and SNOT‐22 items were analyzed by network visualization and cluster analysis.ResultsForty‐six patients met study criteria. Forty‐three (93.5%) reported “need to blow nose” and 40 (86.9%) reported postnasal drainage. Sneezing was reported by 37 (80.4%) patients, “blockage/congestion of nose” by 33 (71.8%), and “runny nose by 32 (69.6%) patients. The median SNOT‐22 score was 54 (interquartile range [IQR], 40 to 63). Past history included neurological diagnoses (60%), rhinologic disease (39%; chronic rhinosinusitis [CRS], rhinitis, recurrent acute sinusitis), asthma (28%), and allergen‐sensitivity (26%). Previous sinonasal surgery had been performed in 41%. Network layout and cluster analysis identified 2 patient clusters and 2 symptom clusters. Two‐thirds (31) of patients formed a tight cluster (cluster 1) linking to a symptom cluster of psychosocial items wrapped tightly with “facial pain/pressure.” The remaining one‐third of patients (cluster 2) linked to rhinologic symptoms loosely grouped away from “facial pressure/pain.” In contrast to patients in cluster 2, patients in cluster 1 were predominantly female (p < 0.04), had significantly higher (p < 0.0001) median SNOT‐22 scores (60 vs 34; IQR, 53 to 67 vs 17 to 42), were more likely to have migraine history (p = 0.058), and reported being “sad” (p < 0.0001) or “embarrassed” (p < 0.006).ConclusionProminent rhinologic symptoms can be present in PHD patients in the absence of rhinosinusitis. In particular, high symptom‐burden/SNOT‐22 scores and high psychosocial symptoms should raise suspicion of PHD when endoscopy and/or CT results do not correlate with symptoms.

Our objective was to perform a systematic review of the literature on contemporary indications and outcomes for frontal sinus trephination and present an illustrative case of an endoscopically assisted repair of a subcutaneous frontal sinus fistula by trephination technique. PubMed and Ovid databases were used as data sources. A systematic review of the English literature was completed to review reports of frontal trephination from 1980 to 2014. Articles meeting inclusion criteria for inflammatory and noninflammatory indications were reviewed. Articles were systematically reviewed and graded by evidence‐based medicine level. An illustrative case from our institution is then presented. The systematic review identified 2,621 published studies. Thirty‐eight studies were identified for inclusion. The indications, techniques, outcomes, safety, and complications were reviewed for noninflammatory and inflammatory conditions. There were 32 retrospective case series, reports, or cohort studies (level 4), four systematic reviews (level 3), one prospective analysis (level 3), and one meta‐analysis (level 2). Due to the heterogeneity of study cases and inclusion criteria, a meta‐analysis was not feasible. We also present a novel closure of an anterior skull base defect resulting in a subcutaneous fistula with use of a frontal trephination approach. The frontal sinus trephination should not be regarded as a procedure of the past, as it useful in the armamentarium of the modern sinus and skull base surgeon. This approach provides access for instrumentation for hard‐to‐reach frontal sinus disease either purely through a trephination approach or as a supplementation to the transnasal endoscopic approach. Evidence supporting frontal sinus trephination is of levels 2, 3, and 4.Level of EvidenceNALaryngoscope, 125:2046–2053, 2015