AORXXX10.1177/0003489415573959Annals of Otology, Rhinology & LaryngologyAskar et al
Endoscopic Management of Chronic Frontal Sinusitis: Prospective Quality of Life Analysis
Annals of Otology, Rhinology & Laryngology 1–11 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0003489415573959 aor.sagepub.com
Mohamed H. Askar, MD1, Ahmed Gamea, MD1, Mohamed O. Tomoum, MSc1,2, Hossam S. Elsherif, MD1, Charles Ebert, MD2, and Brent A. Senior, MD2
Abstract Background: Previous studies of endoscopic frontal sinus surgery have been primarily retrospective and focused on symptom relief only. Objectives: To prospectively assess the impact of endoscopic frontal sinus surgery on frontal sinus ostium patency and disease-specific quality of life as measured by the Rhinosinusitis Disability Index (RSDI). Study Design: A 60-patient cohort with chronic frontal sinusitis (100 diseased frontal sinuses) was prospectively evaluated using the RSDI, computed tomography (CT) imaging, and endoscopic examination. Image-guided endoscopic frontal sinusotomy (Draf 2a) was performed in each case. Patients were assessed with RSDI and endoscopic assessment at least 6 months postoperatively. Results: At a mean follow-up of 10 months, endoscopic assessment revealed patent frontal recesses in 90 of 100 frontal sinuses (90%), with significant improvement in the total RSDI score (41.98 ± 26.48 preoperatively to 17.15 ± 15.66 postoperatively) as well as each of its physical, emotional, and functional subscales from 16.3 ± 9.03, 12.23 ± 10.55, 13.45 ± 9.59 preoperatively to 5.95 ± 5.71, 5.55 ± 5.66, 5.65 ± 5.72 postoperatively, respectively. Similar improvement was seen in patients with asthma, polyps, and those undergoing revision sinus surgeries. Conclusions: With frontal recess mucosal preservation and meticulous postoperative endoscopic surveillance, endoscopic frontal sinusotomy results in high rates of frontal sinus ostium patency with significant improvement in quality of life.
Keywords chronic rhinosinusitis, endoscopic frontal sinusotomy, frontal sinus ostium patency, quality of life, rhinosinusitis disability index
Introduction Chronic rhinosinusitis (CRS) is a common disease with a significant impact on the quality of life (QOL) of affected patients. Due to its increasing prevalence, CRS is associated with a significant socioeconomic burden.1,2 In cases of CRS with chronic frontal sinusitis, anatomical studies demonstrate that the underlying problem is rarely limited to the frontal sinus itself, but rather its drainage pathway through and around a labyrinth of anterior ethmoid cells termed the frontal recess.3 The frontal sinus is the most challenging of the 4 major paranasal sinuses to obtain good endoscopic surgical results due to complex and varied anatomy, acute angle of access, and proximity to critical structures (olfactory fossa, skull base, and orbit) as well as a tendency to postoperative scarring with subsequent stenosis.4
Frontal sinus surgery has evolved from radical, morbid procedures to minimally invasive endoscopic mucosal preserving techniques. There is still controversy regarding the most appropriate surgical approach because multiple endoscopic approaches have been described and longterm efficacy of these approaches is debated.3,5 In an attempt to improve healing and subsequent postoperative 1
Tanta University, Otolaryngology/Head and Neck Surgery, Tanta, ElGharbiya, Egypt 2 University of North Carolina at Chapel Hill, Otolaryngology/Head and Neck Surgery, Chapel Hill, NC, USA Corresponding Author: Mohamed O. Tomoum, MSc, University of North Carolina at Chapel Hill, Department of Otolaryngology/Head and Neck Surgery, CB 7070, Chapel Hill, NC 27599-7070, USA. Email: [email protected]
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Annals of Otology, Rhinology & Laryngology
results, surgeons today try to preserve the mucosa in the sinuses by using through-cutting instruments, powered microdebriders, and balloon dilation technology.6 Clinicians have traditionally focused on objective findings to assess response after a given treatment; however, for many disease processes, including chronic rhinosinusitis, objective measures fail to capture the full burden of the disease experienced by the patients.7 Today, multiple diseasespecific QOL instruments exist for the evaluation of CRS, for example, Rhinosinusitis Disability Index (RSDI)8 and Sinonasal Outcome Test-22 (SNOT-22).9,10 In our study we used the RSDI, which is a 30-item survey consisting of physical, emotional, and functional subscales.10 Although a number of retrospective studies have reported the symptom outcomes of endoscopic frontal sinusotomy, there is a surprising paucity of prospective literature on its effect on different aspects of quality of life utilizing statistically validated disease-specific QOL instruments. The purpose of this study is to evaluate the results of endoscopic frontal sinusotomy with regard to objective frontal sinus patency as well as the disease-specific quality of life using the RSDI with its physical, emotional, and functional subscales.
Materials and Method A prospective cohort of 60 patients with chronic frontal sinusitis (100 diseased frontal sinuses) who underwent endoscopic frontal sinus surgery between March 2013 and January 2014 from the senior author’s practice at the University of North Carolina, Chapel Hill was performed. The diagnostic criteria for CRS used in our study are derived from the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS).11 Computed tomographic (CT) scans of the sinuses were obtained in coronal, sagittal, and axial views following medical treatment with a minimum of 3 weeks of antibiotic therapy. Indications for endoscopic frontal sinus surgery included chronic frontal sinusitis not responding to medical treatment (including a minimum of 3 weeks of antibiotic, combined with 4 weeks of nasal steroids, nasal saline irrigations, and in the case of chronic rhinosinusitis with nasal polyposis, oral steroids ) in the presence of radiological and endoscopic evidence of chronic frontal sinusitis. Patients undergoing surgery for benign and malignant paranasal sinus tumors, trauma, as well as cystic fibrosis, Kartagner syndrome, or other primary mucociliary abnormalities were excluded. All patients were prospectively evaluated in an unblinded fashion preoperatively and at least 6 months postoperatively using the RSDI and endoscopic examination. The RSDI is a validated 30-item survey consisting of physical, functional, and emotional subscales with total scores ranging from 0 to 120. Higher RSDI total and subscale scores
imply greater impact on the quality of life related to the disease.10 The advantage of the RSDI lies in its measurement of more general QOL domains related to functional and emotional functioning, thereby reducing the need for an additional general health tool.8 We chose to have a minimum follow-up of 6 months in light of multi-institutional longitudinal study from 3 medical centers conducted by Smith and Solar,12 which suggested that clinical trial designs incorporating QOL outcomes after endoscopic sinus surgery should consider the 6-month time frame as an appropriate primary end point. Our study was approved by the University of North Carolina Institutional Review Board.
Operative Technique Under general anesthesia, using 4 mm Hopkins rod telescopes at angles of 0°, 45°, and 70°, image-guided endoscopic sinus surgery was performed using standard technique: the uncinate process was resected, middle meatal antrostomy, anterior and posterior ethmoidectomy and sphenoidotomy were all done according to the extent of the disease as determined by clinical and radiological studies. For diseased frontal sinuses, endoscopic frontal sinusotomy technique was done involving removal of any obstructing ethmoidal air cells to access the frontal recess. The extent of endoscopic frontal sinusotomy was determined by reference to preoperative CT scans and intraoperative findings but typically consisted of Draf 2a, opening the sinus medially to the level of the middle turbinate but not beyond it. All frontal sinuses with evidence of mucosal inflammation, infection, or polyposis were opened endoscopically, and any diseased mucosa was debrided carefully without stripping or exposing underlying bone. The surgical technique focused on mucosal preservation by using microdebrider and through-cutting instrumentation for reestablishment of the natural frontal sinus drainage pathway. No stents or packing were used. An aggressive period of postoperative endoscopic surveillance and debridement and postoperative antibiotics followed each of these operations. Endoscopic debridement was performed in the office setting 1 week postoperatively. Following this, patients were followed up according to endoscopic findings. Mucus, blood, and crust were removed; polyps were resected; and synechiae were lysed. All patients received antibiotics for at least 2 weeks postoperatively, after which antibiotic use was individualized. Patients with chronic rhinosinusitis with polyposis were treated with a steroid taper, begun 4 days preoperatively; the length of steroid use postoperatively was individualized. All patients were encouraged to start saline douching of the nose on the first postoperative day. Postoperative assessment was done at least 6 months postoperatively with the RSDI and endoscopic evaluation.
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Askar et al Table 1. Rhinosinusitis Disability Index (RSDI) Pre- and Postoperative Mean Total, Physical, Emotional, and Functional Subscale Scores for All Patients.
Preoperative, Mean ± SD
Postoperative, Mean ± SD
Postoperative –Preoperative Score, Mean ± SD
Total Physical Emotional Functional
41.98 ± 26.48 16.30 ± 9.03 12.23 ± 10.55 13.45 ± 9.59
17.15 ± 15.66 5.95 ± 5.71 5.55 ± 5.66 5.65 ± 5.72
−24.83 ± 18.51 −10.35 ± 6.79 −6.68 ± 7.26 −7.80 ± 7.00
−855.5 −850.5 −653.5 −765.0