expressed about such minimally invasive surgery, during the intervening 4 years there has beenarapid rise in the number of British ENT (ear, nose and throat) ...
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Journal of the Royal Society of Medicine Volume 87 February 1994
Outcome assessment of endoscopic sinus
Valerie J Lund MS FRCS1
Ian S MacKay FRCS2
surgery
'Reader in Rhinology,
Institute of Laryngology & Otology, University College London, London and 2Consultant ENT Surgeon, Royal Brompton Hospital & Charing Cross Hospital; London, UK
Keywords: endoscopic surgery; chronic sinusitis; polyposis
Introduction In 1989 a presentation on surgery of the ethmoids was given to the then Section of Laryngology', at a time when few people in the UK had great expertise in the technique of endoscopic sinus surgery. Although reservations, both economic and philosophical have been expressed about such minimally invasive surgery, during the intervening 4 years there has been a rapid rise in the number of British ENT (ear, nose and throat) surgeons adopting this approach. A recent survey of British ENT surgeons revealed that 37% (146 of 391 respondents) are now performing endoscopic sinus surgery, and this represents an exponential rise since 1985. Any new surgical technique, particularly one which gains rapid popularity, requires careful evaluation to assess its place in the existing surgical armamentarium. However, one of the difficulties in evaluating success in any operation is whether to rely on the subjective criteria of how patients feel or to apply objective measures, each with their own intrinsic inaccuracies. Although the rationale for surgery in the ostiomeatal complex is well-established2 4, there are still few large long-term studies of clinical efficacy in the literature. Methods and materials Six hundred and fifty patients, aged between 7-76 years, who had undergone endoscopic sinus surgery were included in the study. All underwent preoperative symptomatic assessment and were available for similar evaluation at 6 months. Diagnostic criteria for inclusion were chronic rhinosinusitis, acute recurrent rhinosinusitis and diffuse gross polyposis, based on clinical history, endoscopic findings and computerized tomography (CT) appearances. Any systemic medical conditions which might affect the respiratory tract and potentially adversely affect clinical response were noted. The patients were asked to place their three most significant preoperative symptoms first, second or third, in order of importance. At the end of 6 months they were asked to decide whether these symptoms had been cured, improved, remained the same or had been made worse by surgery and to give an overall impression of surgical success in the same terms. The surgery was performed under general anaesthesia in the majority of patients (97%) and under local anaesthetic in 3%. The extent of the surgery was determined by the extent of the disease but included uncinectomy, anterior ethmoidectomy and perforation of the ground lamella of the middle turbinate in all Correspondence to: Valerie J Lund
cases, with posterior ethmoidectomy, sphenoidotomy, clearance of the fronto-nasal recess and enlargement of the maxillary ostium as required. (Ninety-five per cent underwent middle meatal antrostomy at the site of the natural ostium.) All patients had failed adequate medical treatment which included combinations of intranasal steroids, anti-histamines, antibiotics and oral steroids, the latter being used predominantly in patients with gross polyposis with and without asthma. CT scanning was performed in all cases, usually at the point when medical treatment had failed and surgical intervention was contemplated. Patients continued with intranasal steroid therapy up to the time of surgery and for at least three months post-operatively. Antibiotics were given after surgery if the purulent secretion was present and all patients with polyps received a sliding regime of oral steroids if there was no medical contraindication. All patients were reviewed regularly following surgery to undergo endoscopic cleaning of their ethmoidal cavities. This was performed initially between 5 and 10 days and thereafter at 1 to 2 weekly intervals until the cavity was satisfactorily healed. All patients were available for outpatient assessment at 6 months. Three per cent underwent revision endoscopic surgery during this period.
Results The patients consisted of 331 cases of chronic rhinosinusitis (51%), 305 cases of gross polyposis (47%) and 14 cases of acute recurrent rhinosinusitis. Thus, whilst all patients had undergone an endoscopic procedure, a 'functional' approach could only be applied to the chronic and acute sinusitics. The distribution of the preoperative symptoms as a whole with each broken down into flrst, second and third, according to their importance is shown in Figure 1. Discharge (which included both anterior rhinorrhoea and post-nasal drip) (72%) and blockage Percentage * First Sympeom
80
I
m
U l
Second Symptom
al Third Symptom
60 40
20 0
uDscnarge
Block
Headache
Facial Pain
Smell
Sneeze
Figure 1. Histogram showing frequency of preoperative symptoms, divided into first, second and third in importance
Paper read to Sections of Laryngology & Rhinology, 5 February 1993
Journal of the Royal Society of Medicine Volume 87 February 1994
(70%) were the commonest symptoms, of which blockage was the commonest first symptom (41%). At the end of 6 months, 87% of patients regarded themselves as improved (78%) or cured (9%), 11% felt that they were clinically unchanged, and 2% felt worse. When these results are considered separately for the two main diagnostic sub-groups, there was no apparent difference in results between the patients with chronic rhinosinusitis and those with diffuse polyposis. Twenty-one per cent of patients had a systemic diagnosis which might predispose them to upper respiratory tract problems. This included asthma (81 patients), with and without aspirin sensitivity, cystic fibrosis, including a sub-group who had undergone heart/lung transplantation, primary immune deficiency and bronchiectasis. When these groups are considered separately, the cystic fibrosis patients did considerably worse than the group as a whole and than any of the other groups (Table 1). These patients all suffered from aggressive diffuse polyposis which recurred particularly in those individuals immunosuppressed with cyclosporin for transplantation. For the majority of patients, each symptom considered demonstrated an overall improvement (Table 2). The sensation of blockage improved in 92% (of whom 23% regarded the symptom as cured) and facial pain improved in 86% (cured in 17%). The frequency of symptom improvement in order of importance was also considered but it was not possible to demonstrate any differences irrespective of the relative importance of the symptom (Table 3). This is in contradistinction to a small group of 12 patients whose only symptom was facial pain, only five of whom had any symptomatic improvement following surgery. Table 1. Systemic diagnosis in patients undergoing endoscopic sinus surgery (21% of series with contributory systemic
diagnosis) Improved Same Worse
Complaint
No.
(%O)
(%o)
Asthma Asthma/ASA Cystic fibrosis CF/HLT Immune deficiency (primary+secondary) Bronchiectasis Myeloma Wegener's Sarcoid
81 (19) 28 (10) 14
94
6
0
54
46
0
79
14
7
85
15
0
13 1 1 2
(%o)
ASA=asthma and aspirin sensitivity; CF/HLT=cystic fibrosis/heart lung transplantation
Table 2. Overall results of endoscopic sinus surgery (n=650)
Discharge Block Headache Facial pain Smell Overall
Improved (to)
Cured (to)
Same (to)
Worse (So)
78 92 83 86 79
(10) (23) (15) (17) (12) (9)
17 6 15 12 21
5 2 2 2 0
11
2
87
Table 3. Frequency of symptom improvement by severity following endoscopic sinus surgery (n=650)
Discharge Block Headache Facial pain Smell
First (%o)
Second (o)
Third (o)
80 94 80 82 80
77 93 85 90 84
78 83 85 87 84
In this group of 650 consecutive patients, one patient developed a CSF leak on the 3rd postoperative day after he sneezed. This was managed endoscopically with a free mucoperichondrial graft from the opposite side of the septum. One further case required an external ethmoidectomy at the time of surgery due to an orbital haematoma resulting from bleeding from the anterior ethmoidal artery which retracted into the orbit. Both cases underwent an otherwise satisfactory and uneventful postoperative recovery, with no further sequelae. There were no cases of diplopia, blindness, meningitis or death.
Discussion The pathophysiological principles on which functional endoscopic sinus surgery is based have been well described2-4 and several series have now been published considering the subjective clinical benefits of the technique5-8. There is a considerable learning curve in the execution of this surgery. Stankiewcz reported a 9.3% complication rate, 7.1% of which occurred in the first 90 cases9. As experience with the surgical technique has been gained by both authors since 1987, the prospective consecutive series herein presented could be regarded as having undergone surgery performed with acceptable and comparable expertise and as being representative of our clinical practice. The preoperative frequency of symptoms are similar to other studies in similar patient populations6'8. In a previous study of patients with chronic rhinosinusitis undergoing endoscopic sinus surgery, obstruction, post-nasal discharge and headache occurred with almost equal frequency but this study excluded patients with gross polyposis10. The overall results compare favourably with the few large published series. Wigand considered 220 patients with unknown follow-up, mainly suffering from polyposis who responded to a questionnaire8. Overall 82% regarded their disease as healed or improved, with pain in the head and face and nasal obstruction responding best (93% healing/improvement for each). At 6 months our patients with diffuse polyposis did not show any significant difference in subjective improvement from those with chronic rhinosinusitis but clearly this could alter with longer follow-up. Stammberger reported similar subjective results in a more heterogenous group of 500 patients with rhinosinusitis of various forms with follow-up of 8 months to 10 years3. Overall evaluation was very good or good in 85%, moderate to fair in 10% and unchanged or poor in 5%. Although results for individual symptoms are not given, pain and the sensation of pressure or fullness were noted to improve immediately following surgery. In a detailed study by Kennedy7 of 120 patients with 3-51 months follow-up (mean 18 months),
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Journal of the Royal Society of Medicine Volume 87 February 1994
Table 4. Percentage of symptoms remaining the same or becoming worse after endoscopic sinus surgery (ESS) and inferior meatal antrostomy (IMA)
Discharge Block Headache Facial pain
ESS (n=650)
IMA (n=65)
22 8 17 14
62 20 42 38
85% reported a marked amelioration, 12.5% minor improvement and 2.5% were unchanged or worse. These results were correlated with a number of prognostic factors, including systemic conditions and extent of disease. The apparently detrimental effect of previous surgery, asthma and aspirin sensitivity (ASA) did not prove to be significant when stratified for extent of disease. Interestingly with the exception of the cystic fibrosis patients, the patients in our study with other systemic diagnoses did not appear to fare worse than the group as a whole though this again may alter with time. Immunosuppression with cyclosporin during heartllung transplantation appears to exacerbate polypoid disease though the mechanism by which it does this remains unknown. However, as these patients are already on systemic steroids and do derive some benefit from the procedure, albeit short-lived, this should not in itself preclude endoscopic surgery. In Wigand's group, there was also an apparent adverse effect on subjective improvement in those patients with asthma, polyps and asthma and aspirin sensitivity compared to those without analgesic sensitivity or asthma but this was not correlated with extent of disease8. It is notable that whilst the majority of patients regarded the operation as a success and derived benefit for each symptom considered, cure is a more difficult commodity to achieve. Conversely, very few patients felt worse following endoscopic surgery and a minority remained the same. In the absence of a prospective randomized trial, an historical comparison can be made with a previous prospective study on 65 patients undergoing inferior meatal antrostomies for chronic rhinosinusitis'1. If the percentage of patients whose symptoms were the same or worse following surgery are compared for the two procedures, there are striking differences, notwithstanding the different number of patients in each group (Table 4). This is particularly evident for the sensation of obstruction and it would seem likely that it is inflammatory disease within the ostiomeatal complex which is primarily responsible for this symptom in chronic rhinosinusitis. This would explain why endoscopic surgery in this area is effective in its alleviation in patients who have previously undergone unsuccessful septal and turbinate surgery.
Eighty-four per cent of patients undergoing inferior meatal antrostomy regarded it as a success which compares well with 87% success rate for patients in the present study. However, this must be set against the effect on these individual symptoms such as post-nasal discharge which was more frequently adversely affected by inferior meatal surgery (28%) than by a middle meatal approach (2%). A cynic might suggest that one could at least assure patients undergoing endoscopic surgery that they were unlikely to be worse afterwards. Difficulties will always exist in the assessment of a disease, which unlike cancer, does not have a finite endpoint. Caldwell12 recognized the need for a staging system in sinusitis yet after 100 years and several attempts7'13 we seem no closer to a coherent solution. Only with the development of such a system will it be possible to correlate results over time and distance, to achieve further corroboration of studies such as this with the expectation that for endoscopic sinus surgery at least 'cynicism is merely humour in ill-health' (HG Wells, The Last Trump). References 1 Lund VJ. Surgery of the ethmoids - past, present and future. J R Soc Med 1990;83:451-5 2 Messerklinger W. Endoscopy of the Nose. Baltimore: Urban & Schwartzenberg, 1978 3 Stammberger H. Functional Endoscopic Sinus Surgery. Philadelphia: Decker, 1991 4 Kennedy DW. Functional endoscopic sinus surgery: technique. Arch Otolaryngol 1985;111:643-9 5 Levine HL. Functional endoscopic sinus surgery: evaluation, surgery and follow-up of 250 patients. Laryngoscope 1990;100:79-84 6 Stammberger H, Posawetz W. Functional endoscopic sinus surgery: concept, indications and results of the Messerklinger technique. Eur Arch Otolaryngol 1990;247:63-76 7 Kennedy DW. Prognostic factors, outcomes and staging in ethmoid sinus surgery. Laryngoscope 1992;102(suppl No. 57):1-18 8 Wigand ME. Endoscopic Surgery of the Paranasal Sinuses and Anterior Skull Base. Stuttgart, New York: Thieme, 1990 9 Stankiewicz JA. Complications of endoscopic sinus nasal surgery: occurrence and treatment. Am J Rhinol 1987;1:45-9 10 Lund VJ, Holmstrom M, Scadding GK. Functional endoscopic sinus surgery in the management of chronic rhinosinusitis: an objective assessment. J Laryngol Otol 1991;105:832-5 11 Lund VJ. Inferior meatal antrostomy. J Laryngol Otol 1988;102(suppl 15):1-18 12 Caldwell GW. Diseases of the accessory sinuses of the nose and an improved method of treatment for suppuration of the maxillary antrum. N Y Med J 1893;58:526-8 13 Gaskins RE. A surgical staging system for chronic sinusitis. Am J Rhinol 1992;6:5-12
(Accepted 12 July 1993)
