xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

mean diameter of 16 mm. Difference in ostial size was not found to impact symptomatic improvement in facial pain, nasal obstruction or rhinorrhea. 1978 Although most stud ies of MIST have been related to maxillary ostium size, in a more recent retrospective study of minimally invasive eth moid surgery, a simple punch sinusotomy led to improve ment of symptomatology as well as radiographic resolution of ethmoid disease. 1979 The necessary extent of ESS has also been addressed through study of balloon dilation for RS. In 2 prospective randomized trials, 1800,1980 patients with mild CRS (such as chronic maxillary sinusitis with or without concomi tant anterior ethmoid sinus disease but excluding poste rior ethmoid, frontal or sphenoid sinus disease) received either balloon sinus dilation or ESS. For those patients with mild disease, similar levels of sinonasal symptom improve ment, sinus ostium patency, reduction in RS episodes, and improvement in work productivity and daily activity were seen. In a separate non-randomized prospective study of patients with CRS without polyps undergoing ESS or bal loon sinus dilation, balloon sinus dilation was associated with a greater frequency of acute exacerbations of CRS and less improvement of nasal drainage symptoms at up to 6 years post-operatively. 1981 Thus, balloon sinus dilation appears to be effective for patients with mild sinus disease. Extended surgery of the maxillary, frontal and sphenoid sinuses to enlarge the openings of those sinuses beyond traditional ESS principles includes mega-antrostomy, frontal sinus drill out, and sphenoid drill out, respectively. Extended surgeries are generally reserved for recalcitrant disease and most frequently performed in the setting of revision ESS. Clinical studies have shown that a mega antrostomy and modified endoscopic medial maxillectomy (MEMM) for recalcitrant chronic maxillary sinusitis are effective in reducing sinonasal symptomatology, objective endoscopic and radiographic evidence of CRS, and the need for corticosteroid and antibiotic use. 1982–1988 Arecent systematic review reported that MEMM is safe with a low complication rate and may reduce symptoms of recalcitrant chronic maxillary sinusitis in up to 80%. 1989 Presently, the relative efficacies of various extended frontal and sphenoid sinus surgeries are less clear. 1990,1991 Post-operative distribution of topical medications to the paranasal sinuses may be limited by more conservative ESS techniques, such as MIST or balloon dilation. Studies have suggested that maxillary antrum size correlates with intra sinus delivery of topical medications. 1992,1993 Evidence sug gests that unoperated sinuses receive little topical ther apy compared to sinuses that have been surgically opened. More extensive enlargement of the maxillary, frontal and sphenoid sinuses has been associated increased penetra tion of irrigations. 1993–1995

Currently available data suggest that MIST and balloon sinus dilation may be a reasonable alternative to ESS for select CRS patients, particularly those with limited disease burden. In comparison, surgeries aimed at creating larger openings may be better suited for patients with more severe disease or nasal polyposis who require greater penetration of topical medications. The current evidence does not sup port the routine application of limited or extended tech niques for all CRS patients, but they may be considered on a case by case basis. Ostium Size in ESS Aggregate Grade of Evidence: B (Level 2, 6 studies; level 3, 4 studies; level 4, 1 study; level 5, 4 studies; Table XII-14). Benefit: Although no studies have demonstrated a direct benefit of more conservative (less extensive) surgical approaches for treatment of CRS com pared to traditional ESS, reduced manipulation of sinonasal tissues with these limited approaches, including MIST or balloon dilation, has the poten tial to reduce surgical time. Harm: Potential harm of more conservative tech niques includes insufficient removal of obstruct ing sinonasal disease, leading to persistent inflam mation, reduced postoperative delivery of topical medications, less access for postoperative care, and potentially faster relapse of symptoms. Cost: Although no studies have examined the issue of cost related to modified ESS techniques, shorter operative time could translate to lower costs in some circumstances. In contrast, balloon-dilation technology is associated with increased equipment costs per case. Benefits-Harm Assessment: Over the short-term (up to 1 year post-operatively), conservative approaches do not appear to increase harm from recurrence of inflammatory sinus disease, particularly in patients with limited sinus disease. Value Judgments: Conservative approaches (MIST or balloon dilation) appear to provide short-term clinical outcomes that are comparable to tra ditional ESS in patients with limited disease. For patients with moderate-to-severe CRS, tradi tional ESS or extended ESS approaches have the potential for improved long-term sinus ventila tion and delivery of topical medications. There is no strong evidence for or against the use of less extensive sinus procedures. All studies to date have suggested equivalent short-term outcomes as