Role Of Endoscopic Sinus Surgery In Chronic.pptx

Role of Endoscopic Sinus Surgery in Chronic Rhinosinusitis

Contents Chronic Rhinosinusitis Diagnostic Criteria  Etiology Investigations Treatment Options Endoscopic Sinus Surgery  Indications & Contraindications  Goals  Role of ESS in Chronic Rhinosinusitis Case Study

Chronic Rhinosinusitis •

Persistent sinonasal mucosal inflammation producing both symptomatic and objective evidence of inflammation.

Diagnostic Criteria According to American Academy of Otolaryngology Twelve weeks or longer of two or more of the following signs and symptoms:  Mucopurulent drainage (anterior, posterior, or both),  Nasal obstruction (congestion),  Facial pain-pressure-fullness, or decreased sense of smell.  Inflammation is documented by one or more of the following findings: • Purulent (not clear) mucus or edema in the middle meatus or anterior ethmoid region, • Polyps in nasal cavity or the middle meatus, and/or • Radiographic imaging showing inflammation of the paranasal sinuses

Etiology

Investigations Computed tomographic (CT) scan, performed in a coronal plane with cuts of 4 mm or less, is considered the gold standard radiographic delineation of sinus disease .

Treatment Options Medical Treatment

Surgery Treatment

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• Reserved for patients who fail medical management. • However, in selected patient populations, up to 50% of patients with CRS (not acute sinusitis) will ultimately require surgical intervention. • The most common reasons for surgical intervention are CRS that does not respond to medical intervention. • Many other medical problems may require surgical intervention, including complicated acute sinusitis, allergic fungal sinusitis, and mucoceles .

Topical Nasal Steroids Systemic Steroids Nasal Irrigation Antibiotics : Antibiotics play a role in the management of CRS to decrease bacterial load and to treat acute bacterial exacerbations of CRS.

Endoscopic Sinus Surgery Endoscopic sinus surgery is a surgical procedure used to remove blockages in the sinuses. These blockages can cause sinusitis, in which the sinus mucous membranes swell and become blocked, causing pain, drainage and impaired breathing.

Indications & Contraindications INDICATIONS • Sinusitis o Recurrent acute bacterial sinusitis o Chronic bacterial sinusitis unresponsive to adequate medical treatment o Fungal sinusitis • Nasal Polyps • Septal Deviations and Hyperthropy

CONTRAINDICATIONS • • • •

Lack of proper instrumentation Inexperience Osteomyelitis Threatened intracranial or intraorbital complications

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Goals

Endoscopic sinus surgery goals include:  Reduction of the number and severity of sinus infections  Improvement in symptoms associated with sinusitis  Improvement of airflow through the nose  Improvement in a patient’s sense of smell

Role of ESS in Chronic Rhinosinusitis Most otolaryngologists have encountered patients with symptoms and endoscopic findings suggestive of CRS, however CT evaluation demonstrates minimal mucosal disease. Despite failure of medical therapy and elimination of non-rhinologic etiologies, there is often a reluctance to perform ESS in the setting of a low-stage CT scan. • LOW STAGE CT low-stage CT was defined as having a Lund-Mackay score of 3 or less. • HIGH STAGE CT High-stage CT was defined as having a CT score of 4 or more.

Lund Mackay Staging System • Lund Mackay staging system is a measure of the degree of opacification in the maxillary, sphenoid, ethmoid, osteomeatal complex, and frontal sinus regions (score range: 0–24)

Case Study A prospective,multi center cohort study was conducted to measure the change in quality-of-life (QoL) after endoscopic sinus surgery (ESS) in patients with medically recalcitrant chronic rhinosinusitis (CRS) and also minimally affected computed tomography (CT) scans of the paranasal sinuses.

Methodology A total of 778 patients with medically recalcitrant CRS were initially enrolled between Jan, 2001 and April, 2009. After the appropriate exclusion criteria were applied, a total of 17 patients with low-stage CT CRS and 207 patients with high-grade CT CRS were included in this study.

Total baseline enrollment and exclusion criteria for low and high stage CT CRS

Surgeries performed in selected patients • Patients in the low-stage CT CRS cohort commonly underwent bilateral surgery (64.7%), and maxillary antrostomy and partial ethmoidectomy were the most common procedures. • For the high-stage CT CRS cohort, the majority underwent bilateral surgery (76.3%), and maxillary antrostomy and total ethmoidectomy were the most common procedures

QoL Evaluation All study patients were asked to complete two disease-specific QoL surveys pre-operatively and at each post-operative visit for the duration of the study.

RHINOSINUSITIS DISABILITY SURVEY The Rhinosinusitis Disability Index (RSDI) is a 30question survey comprised of three individual subscales to measure the impact of sinus disease on the physical, functional, and emotional domains on a continuum (score range: 0–120). Higher RSDI total and subscale scores represent a higher impact of disease.

CHRONIC SINUSITIS SURVEY The Chronic Sinusitis Survey (CSS) is a 6-question survey designed to measure sinusitis-specific symptoms and medication use within the preceding 8-week period (score range: 0–100). Lower total and subscale scores indicate a greater impact of CRS.

Results & Conclusion Low stage CT CRS preop and postoperatively mean score for total RSDI and CSS when were compared, shows significant disease specific QoL improvement after ESS Comparing mean QoL differences in post-operative improvement for both RSDI and CSS total scores, there was no difference between low and high-stage CT cohorts (p=0.201 and p=0.178, respectively. So this study shows that similar to patients with high grade CT CRS , carefully selected patients with low stage CT CRS , who have failed medical therapy and exclusion of other potential etiologies, also experience a significant QoL benefit following ESS

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