xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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International consensus statement on rhinosinusitis

XII.D.2 Concurrent Septoplasty with Sinus Surgery Rhinologic surgeons commonly perform septoplasty as an adjunctive procedure in patients undergoing ESS. Sep tal surgery may be performed to provide access to the paranasal sinuses, or to address nasal obstruction due to septal deviation. Because the 2 procedures are often per formed together, it may difficult to separate the benefits of the concurrent procedures. Similarly, while some risks are clearly related to the septoplasty (eg, septal perforation), attributing other outcomes, such as postoperative pain or epistaxis, may be problematic. Descriptions of conventional septoplasty (CS) per formed in conjunction with ESS are sparse, although the procedure combination seems quite common. Cantrell described the technique and rationale for “limited” sep toplasty, presumably performed with traditional headlight illumination. 2024 Most authors describe techniques for endoscopic septoplasty (ES) and report limited outcomes data in case series. 2025–2028 Giles et al. compared cohorts of patients undergoing ESS alone, ESS and CS, and ESS and ES and noted good outcomes in the ESS/ES group. 2029 Bothra and Mathur performed a similar comparison of ES and CS in patients undergoing ESS and noted no differ ences between groups. 2030 In a prospective, multi-institutional study, Rudmik et al. compared ESS with septoplasty to ESS without septo plasty, and noted no differences in various quality-of-life measures for CRS. 2031 Based upon these data, the authors conclude that patients undergoing concurrent septoplasty should not be excluded from studies evaluating the impact of ESS on CRS. In a large retrospective case series, Chang et al. com pared ESS with septoplasty and ESS without septoplasty and noted a lower revision rate in patients who underwent both procedures. 2032 Similarly, Rudmik et al. noted that ESS with septoplasty was associated with a lower revision ESS rate in retrospective review. 2033 These studies demon strate a clear benefit of performing septoplasty and ESS concurrently, at least for patient with both CRS and sep tal deviation. Data on opioid usage among patients undergoing ESS and septoplasty vs ESS alone are inconsistent. One study noted that ESS with septoplasty patients did not request narcotics refills at a higher rate, 2034 while another study did show that concurrent ESS and septoplasty associ ated with greater opioid usage. 2035 Patients undergoing concurrent ESS and septoplasty have a longer period to pain relief than those patients undergoing septoplasty alone. 2036

sinus penetration with irrigation with Draf III cavities when compared to IIb. 1262 In the presence of co-morbid conditions such as asthma and nasal polyposis, the extent of surgery may influence rates of polyp recurrence. In patients with asthma and nasal polyposis, Zhang et al. found that the addition of a Draf III frontal sinusotomy improved polyp recurrence rates in the first year after surgery compared to standard ESS (59% vs 89%); however, by year 3 there were no differences in polyp recurrence rate, with a 96% rate of polyp recurrence in both groups. 2020 Newer intermediate hybrid procedures between Draf IIb and III have also been described. 1263,2021–2023 When com pared to Draf III surgery, these procedures demonstrated similar rates of frontal patency rates 2022,2023 and compara ble patterns of irrigation distribution. 1263 In summary, a graded approach to frontal sinusotomy is generally supported by evidence for safety and efficacy. High level evidence for the selection of extent of frontal sinus surgery in any given patient is lacking. Extent of Frontal Surgery Aggregate Grade of Evidence: C (Level 2: 1 study; level 3: 1 study; level 4: 7 studies; Table XII-17). Evidence is based on mostly uncontrolled studies. Benefit: Frontal sinusotomy is an effective and safe operation for chronic frontal sinusitis. Harm: Surgeries are associated with potential complications, but the rates are comparable between the extended, Draf IIb and III, frontal sinus operations. Cost: There is Level 4 evidence to demonstrate Draf III patients requiring more frequent clinic vis its and debridement procedures in the early post operative period, when compared to less extensive frontal sinus operations. Benefits-Harm Assessment: Balance of benefit and harm for performing extended frontal sinus surgery for chronic frontal sinusitis. Value Judgments: Patient selection is crucial for advising and performing various extents of frontal sinus surgery. Policy level. Options for extent of frontal sinuso tomy. Intervention: Frontal sinusotomy is likely benefi cial for recalcitrant frontal sinusitis, but in decid ing the extent, various patient, surgeon expertise and illness factors need to be taken into consider ation.