The Journal of Laryngology and Otology October 1991, Vol. 105, pp. 832-835
Functional endoscopic sinus surgery in the management of chronic rhinosinusitis. An objective assessment VALERIE J. LUND M.S., F.R.C.S.,* M.R.C.P.t (London)
MATS HOLMSTROM
M.D., Ph.D.,t
GLENIS
K.
SCADDING,
M.D.,
Abstract Considerable clinical success has been claimed for functional endoscopic sinus surgery but objective assessment of prospective series is lacking in the literature. Twenty-four patients with chronic rhino-sinusitis underwent assessment of symptoms by visual analogue scoring, nasomucociliary function by ciliary beat frequency, olfaction by qualitative olfactometry and nasal airway resistance by anterior rhinomanometry pre- and post-operatively. This demonstrated a significant improvement in all symptoms examined and in ciliary beat frequency. Quantitative olfaction and anterior rhinomanometry were not improved despite diminished symptoms. These results offer quantitative evidence of clinical improvement following functional endoscopic sinus surgery which supports the pathophysiological concepts on which the technique is based.
Introduction Although a number of papers have been written on underlying pathophysiological aspects, diagnosis and technique of functional endoscopic sinus surgery, the evaluation of results has largely relied upon subjective assessment. This has led to criticism of the successes claimed. To obtain a more objective measure of operative outcome, a prospective study was performed on a small series of patients undergoing functional endoscopic sinus surgery (FESS) for chronic rhino-sinusitis, using sequential physiological tests in addition to visual analogue scoring of symptoms.
All patients included had failed appropriate conservative medication. Patients with congenital defects of muco-ciliary function or gross immunodeficiency were not included. However, three patients had individual IgG subclass levels at the lower limit of normal and one of these also had a low salivary IgA. The symptoms were assessed subjectively on a 0-10 visual analogue scale (VAS) which considered nasal obstruction, problems with the sense of smell, anterior rhinorrhoea, post-nasal discharge, headache and facial pain. The quality of the discharge was noted and was in all cases mucopurulent.
Method Patients Twenty-four patients attending the Rhinology Research Clinic with symptoms of chronic rhinosinusitis for three months or longer were entered in the study. There were 12 men and 12 women, their ages ranging from 19 to 77 years (mean 46 years). The majority were non-smokers (82 per cent). In addition to chronic rhinosinusitis, six patients had gross polyp formation extruding into the nasal cavity from the middle meatus and six patients had asthma. Forty-two per cent had one or more positive skin tests. Seventy-three per cent had had previous surgery, with between one and six procedures (mean number 2.6, SD 1.4), which included inferior meatal antrostomy (46 per cent), intranasal polypectomy (25 per cent), septal surgery (25 per cent) and inferior turbinectomy (21 per cent).
Objective assessment Mucociliary function was assessed by the measurement of ciliary beat frequency using the technique described by Rutland and Cole (1980), in which a brushing is taken from approximately 1 cm behind the anterior end of the inferior turbinate using a bronchoscopic cytology brush. The measurement was done using a photometric technique employing a Leitz Dialux 20 microscope to which a Leitz MPV compact microscope photometer was connected. The readings were done at x320 magnification. A rectangular light (1.5 X 5 (xm) from the photometer was positioned in the long axis of the cilia so that it was interrupted by ciliary beating. The change in light intensity was transformed into an electrical signal which was then converted to a reading in Hertz (beats/sec) by a ciliary frequency processor unit (Greenstone etal. 1984). Ten readings were made on each speci-
*Senior Lecturer in Rhinology, Institute of Laryngology and Otology, London. tClinical Research Fellow, Institute of Laryngology and Otology, and Department of Oto-Rhino-Laryngology, Karolinska Institute, Huddinge University, Sweden. ^Consultant Medical Rhinologist, Royal National Throat Nose and Ear Hospital, London. Accepted for publication: 24 June 1991 832
833
FUNCTIONAL ENDOSCOPIC SINUS SURGERY IN CHRONIC RHINOSINUSITIS
men within one hour of the specimen being taken and the mean calculated. All readings were done without prior knowledge of the surgical status of the patient. Olfaction was evaluated with a forced choice 'scratch and sniff University of Pennsylvania Smell Identification Test (UPSIT) using the full 40 item test. All patients had skin prick tests performed to 10 common allergens and haematological tests to exclude relevant systemic disease and immune deficiency. Upper and lower respiratory tract function were assessed by oral-pulmonary peak flow meter and anterior active rhinomanometry (Mercury NR6D) respectively. The latter was performed using a standardized technique after the method of Jones etal. (1987). All patients underwent rigid endoscopy of the nasal cavity and computerized tomography was performed prior to surgery. The radiological extent of opacification in the individual sinus cavities was evaluated using a scale of 0-3. Thus a maximum score of 30 was possible when the right and left maxilla, frontal, sphenoid and anterior and posterior ethmoids were considered. The mean CT scan score was 15.2 (range 1-30).
revision surgery during the follow-up period to eradicate residual disease in the agger nasi region and/or adhesions. The results of the visual analogue symptom scores are shown in Table I. All symptoms were significantly improved following surgery and it appeared that nasal obstruction, headache and facial pain were most affected (/>
Functional endoscopic sinus surgery in the management of chronic rhinosinusitis. An objective assessment VALERIE J. LUND M.S., F.R.C.S.,* M.R.C.P.t (London)
MATS HOLMSTROM
M.D., Ph.D.,t
GLENIS
K.
SCADDING,
M.D.,
Abstract Considerable clinical success has been claimed for functional endoscopic sinus surgery but objective assessment of prospective series is lacking in the literature. Twenty-four patients with chronic rhino-sinusitis underwent assessment of symptoms by visual analogue scoring, nasomucociliary function by ciliary beat frequency, olfaction by qualitative olfactometry and nasal airway resistance by anterior rhinomanometry pre- and post-operatively. This demonstrated a significant improvement in all symptoms examined and in ciliary beat frequency. Quantitative olfaction and anterior rhinomanometry were not improved despite diminished symptoms. These results offer quantitative evidence of clinical improvement following functional endoscopic sinus surgery which supports the pathophysiological concepts on which the technique is based.
Introduction Although a number of papers have been written on underlying pathophysiological aspects, diagnosis and technique of functional endoscopic sinus surgery, the evaluation of results has largely relied upon subjective assessment. This has led to criticism of the successes claimed. To obtain a more objective measure of operative outcome, a prospective study was performed on a small series of patients undergoing functional endoscopic sinus surgery (FESS) for chronic rhino-sinusitis, using sequential physiological tests in addition to visual analogue scoring of symptoms.
All patients included had failed appropriate conservative medication. Patients with congenital defects of muco-ciliary function or gross immunodeficiency were not included. However, three patients had individual IgG subclass levels at the lower limit of normal and one of these also had a low salivary IgA. The symptoms were assessed subjectively on a 0-10 visual analogue scale (VAS) which considered nasal obstruction, problems with the sense of smell, anterior rhinorrhoea, post-nasal discharge, headache and facial pain. The quality of the discharge was noted and was in all cases mucopurulent.
Method Patients Twenty-four patients attending the Rhinology Research Clinic with symptoms of chronic rhinosinusitis for three months or longer were entered in the study. There were 12 men and 12 women, their ages ranging from 19 to 77 years (mean 46 years). The majority were non-smokers (82 per cent). In addition to chronic rhinosinusitis, six patients had gross polyp formation extruding into the nasal cavity from the middle meatus and six patients had asthma. Forty-two per cent had one or more positive skin tests. Seventy-three per cent had had previous surgery, with between one and six procedures (mean number 2.6, SD 1.4), which included inferior meatal antrostomy (46 per cent), intranasal polypectomy (25 per cent), septal surgery (25 per cent) and inferior turbinectomy (21 per cent).
Objective assessment Mucociliary function was assessed by the measurement of ciliary beat frequency using the technique described by Rutland and Cole (1980), in which a brushing is taken from approximately 1 cm behind the anterior end of the inferior turbinate using a bronchoscopic cytology brush. The measurement was done using a photometric technique employing a Leitz Dialux 20 microscope to which a Leitz MPV compact microscope photometer was connected. The readings were done at x320 magnification. A rectangular light (1.5 X 5 (xm) from the photometer was positioned in the long axis of the cilia so that it was interrupted by ciliary beating. The change in light intensity was transformed into an electrical signal which was then converted to a reading in Hertz (beats/sec) by a ciliary frequency processor unit (Greenstone etal. 1984). Ten readings were made on each speci-
*Senior Lecturer in Rhinology, Institute of Laryngology and Otology, London. tClinical Research Fellow, Institute of Laryngology and Otology, and Department of Oto-Rhino-Laryngology, Karolinska Institute, Huddinge University, Sweden. ^Consultant Medical Rhinologist, Royal National Throat Nose and Ear Hospital, London. Accepted for publication: 24 June 1991 832
833
FUNCTIONAL ENDOSCOPIC SINUS SURGERY IN CHRONIC RHINOSINUSITIS
men within one hour of the specimen being taken and the mean calculated. All readings were done without prior knowledge of the surgical status of the patient. Olfaction was evaluated with a forced choice 'scratch and sniff University of Pennsylvania Smell Identification Test (UPSIT) using the full 40 item test. All patients had skin prick tests performed to 10 common allergens and haematological tests to exclude relevant systemic disease and immune deficiency. Upper and lower respiratory tract function were assessed by oral-pulmonary peak flow meter and anterior active rhinomanometry (Mercury NR6D) respectively. The latter was performed using a standardized technique after the method of Jones etal. (1987). All patients underwent rigid endoscopy of the nasal cavity and computerized tomography was performed prior to surgery. The radiological extent of opacification in the individual sinus cavities was evaluated using a scale of 0-3. Thus a maximum score of 30 was possible when the right and left maxilla, frontal, sphenoid and anterior and posterior ethmoids were considered. The mean CT scan score was 15.2 (range 1-30).
revision surgery during the follow-up period to eradicate residual disease in the agger nasi region and/or adhesions. The results of the visual analogue symptom scores are shown in Table I. All symptoms were significantly improved following surgery and it appeared that nasal obstruction, headache and facial pain were most affected (/>
