|Year : 2020 | Volume
| Issue : 1 | Page : 1-6
Indication and outcome of endoscopic sinus surgery among patients with chronic rhinosinusitis with or without nasal polyps in the national ear care centre, Kaduna
Abdulrahman O Afolabi1, Garba Mainasara Mohammed2, Mustapha Yaro Abubakar3, Hassan Dadi3, Tsamiya B Gazali3, Rashida Sanni3, Mohammed Sani3, Saheed Nasir3
1 Department of Ear, Nose and Throat, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Nigeria
2 Department of Ear, Nose and Throat, Kaduna State University/ Barau Dikko Teaching Hospital, Kaduna, Nigeria
3 Department of Ear, Nose and Throat, National Ear Care Centre, Kaduna, Nigeria
|Date of Submission||23-Jan-2020|
|Date of Acceptance||23-Mar-2020|
|Date of Web Publication||30-May-2020|
Dr. Garba Mainasara Mohammed
Department of Ear, Nose and Throat, Kaduna State University/Barau Dikko Teaching Hospital, Kaduna
Source of Support: None, Conflict of Interest: None
Context: Endoscopic sinus surgery is a minimally invasive and currently the treatment of choice for acute/intermittent and chronic/persistent rhinosinusitis (RS) unresponsive to conservative medical treatment. Aims: To evaluate the indications and outcomes of treatment of RS with or without nasal polyps. Methods and Material: This was a retrospective review of all cases of endoscopic sinus surgery done at the National Ear Care Centre. The information extracted from the case notes of patients included the demographic profile, clinical radiologic and endoscopic findings, the surgery offered and outcome of surgery. Statistical analysis used: All information was entered into SPSS version 20.0. Results: Out of 116 patients had endoscopic sinus surgery, only 107 (92%) had complete information for the analysis. Their age ranged from 9 to 72 years with a mean age of 35.9 ± 1.9 years. Up to 105 of the patients presented nasal discharge alternating with nasal obstruction while 65% (70) of them had bilateral disease. Computed tomography scan revealed abnormalities in 66.4% (71) patients. The preoperative diagnosis of chronic RS (CRS) with simple nasal polyp was made in 66 patients, had functional endoscopic sinus surgery with polypectomy in 64.5% (69) patients and intraoperative findings revealed a mixture of mucosal diseases with sinonasal polyps in 73.8% and fungal sinus diseases in 18 (16.8). Majority of the patients (53.3%) were discharged home on the 2nd postoperative day. About 71% of the patients had resolution of their disease after months of followup. Conclusion: Endoscopic sinus surgery is higher among young adult in third and fourth decades of life. There is female preponderance and preoperative radiology assessment and the intraoperative findings revealed strong relationship. The outcome of treatment revealed recurrent disease in 10.5% with nasal adhesion, epistaxis and excessive nasal crust formation.
Keywords: Endoscopic sinus surgery, indication, nasal polyp, outcome, rhinosinusitis
|How to cite this article:|
Afolabi AO, Mohammed GM, Abubakar MY, Dadi H, Gazali TB, Sanni R, Sani M, Nasir S. Indication and outcome of endoscopic sinus surgery among patients with chronic rhinosinusitis with or without nasal polyps in the national ear care centre, Kaduna. Niger J Basic Clin Sci 2020;17:1-6
|How to cite this URL:|
Afolabi AO, Mohammed GM, Abubakar MY, Dadi H, Gazali TB, Sanni R, Sani M, Nasir S. Indication and outcome of endoscopic sinus surgery among patients with chronic rhinosinusitis with or without nasal polyps in the national ear care centre, Kaduna. Niger J Basic Clin Sci [serial online] 2020 [cited 2020 Jul 7];17:1-6. Available from: http://www.njbcs.net/text.asp?2020/17/1/1/285472
| Introduction|| |
Rhinosinusitis (RS) is an inflammatory process involving the mucosa of the nose and paranasal sinuses. Chronic RS (CRS) defined by the European Position Paper on Rhinosinusitis and Nasal Polyps (EP  OS) as inflammation of the nose and paranasal sinuses, characterised by two or more of the following symptoms, persisting for more than 12 weeks: nasal blockage/congestion; nasal discharge; facial pain/pressure; reduction in smell and either endoscopic signs of polyps, mucopurulent discharge from the middle meatus; oedema/mucosal obstruction primarily in the middle meatus and/or mucosal changes within the osteomeatal complex and/or sinuses on computed tomography (CT).,,, It can be acute or chronic based on duration of symptoms. RS has been classified into various forms by various guidelines which include EPOS, Clinical Practice Guideline; Adult Sinusitis (CPG; AS), RS Initiatives (RI), Joint Task for Practice Parameters (JTFPP) and British Society for Allergy and Clinical Immunology (BSACI).
It is one of the most frequent otorhinolaryngology diseases encountered in everyday practice worldwide that affect productivity, quality of life and finances. It is thus a common medical condition in which the diagnosis and prognosis depend on symptoms, signs, clinical diagnosis and radiological evaluation. Western literatures have reported RS to be more prevalent than arthritis or hypertension, affecting between 5% and 15% of studied populations, while in Nigeria, it is found to have a prevalence of 7.92% from a study carried out in Ilorin.
Medical therapy forms the mainstay of management in CRS without nasal polyps; however, the failure of the medical treatment, the presence of nasal polyps that do not respond to steroids or in the presence of actual or impending complications, usually necessitates the surgical interventions.,
Endoscopic sinus surgery is a minimally invasive surgery and is currently the treatment of choice for acute/intermittent RS and chronic/persistent RS un-responsive to conservative medical treatment or where there are complications associated with these conditions. The concept of functional endoscopic sinus surgery (FESS), the Messerklinger technique, spreads worldwide by the efforts of Stammberger and Kennedy in the 1980's. This functional approach to RS hypothesised recovery of the diseased sinus mucosa by enabling the sinus ventilation through the natural ostia and restoring mucociliary clearance achieved by minimally invasive endoscopic technique.,
The aim of the study was to evaluate the various indications for endoscopic sinus surgery in our centre among patients with RS with or without nasal polyps, the type offered, the outcome and complications.
| Methodology|| |
This was a retrospective review of all cases of endoscopic sinus surgery done over a 5-year period at the National Ear Care Centre between January 2014 and December 2018. Using the theatre register, all cases of endoscopic sinus surgery were extracted and their case files were retrieved from the medical record of the hospital and information extracted from the file included the demographic profile, clinical presentation, the examination findings including the nasal endoscopy, the diagnosis, pre-operative assessment which included the radiologic findings, the operative technique, postoperative assessment which included outcome of surgery, complications and follow-up. Ethical approval was sought from the ethical review committee of the hospital_(NECC/ADM/214/IV/104).
The clinical diagnosis of RS is based on the major and minor criteria set by the EPOS, CPG: AS, RI, JTFPP  and BSACI  guidelines as stated above. All the information were entered into the Statistical Packages for the Social Sciences (SPSS) version 20.0 produced by IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp and analysed and the results are presented in tables and figures.
| Results|| |
A total number of 116 patients had endoscopic sinus surgery in the National Ear Care Centre, Kaduna, of which only 107 cases had complete information and were included in the study. This constituted 92% of the cases. The age range from the study was 9–72 years, with a mean age of 35.9 ± 1.9 years (standard deviation [SD]), and the modal age group was between 21 and 40 years in 55 patients (51.4%), while the least was among those above 70 years age group which is 1 (0.9%) [Table 1]. There were 60 females and 47 males with a male-to-female ratio of 1:1.3. About 98.1% (105 patients) presented with nasal discharge alternating with nasal obstruction, about 72% (77Patients) presented with nasal growth, while the least clinical presentation was facial swelling in 9 patients (8.3%) [Table 2]. About 65% (70.0 patients) had bilateral lesions, 20% (21) had lesions on the left side and about 15% (16) had the disease on the right side [Figure 1]. The pre-operative diagnosis was CRS with a nasal polyp in 66 patients (61.7%) and the least preoperative diagnosis was CRS with cerebrospinal leak and chronic granulomatous disease in 1 patient each (0.9%) [Table 3].
|Figure 1: Site of lesion frequency table Figure 1 Site of lesion frequency table|
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All the patients had radiological investigation (computerised tomographic scan) which revealed mixed densities in multiple sinuses suggestive sinus diseases with nasal polyps in 71 patients (66.4%), while mucosal thickening with air-fluid levels was seen in 21 patients (19.6%), the least finding was found in others which consisted of one suggestive of antrochoanal polyps and one with increased density within the nasal cavity suggestive of engorged turbinates [Figure 2].
All the patients had endoscopic sinus surgery technique using cold instruments using various surgical approaches such as FESS with polypectomy in 69 patients (64.5%), followed by FESS alone and the least was FESS with sphenopalatine artery ligation following epistaxis [Table 4], and intraoperative findings included sinus diseases with sinonasal mass such as polyps constituted the largest percentage of 73.8% (79 patients) followed by mucosal disease alone involving the osteomeatal complex without any mass and the least were turbinal engorgements causing obstruction and antrochoanal polyps who had turbinectomy with middle meatal antrostomy and polypectomy with middle meatal antrostomy [Table 4].
|Table 4: Frequency table of type of surgery offered and intraoperative findings (n=107)|
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Postoperatively, majority of the patients 57 (53.3%) were discharged home on the 2nd post-operative day, while the least were between 6 and 9th post-operative day for 1 patient (0.9%) each as in [Figure 3]; however, the mean duration post-operative day was 2.78 ± 0.6 days (SD).
Inflammatory polyp was the most common histologic diagnosis found in our review in 47 patients (43.9%) [Table 5].
The outcome of the surgery revealed that about 26.28% (28 patients) had complications and these were nasal adhesion in 11 (10.3%), excessive crust formation in 10 (9.3%), bleeding in 3 (2.8%), infection in 2 (1.9%), oroantral fistula in 1 (0.9%) and orbital abscess in 1 (0.9%), one of the patients died.
Other outcome measures revealed complete resolution of symptoms in 76 patients (71%), about 10.5% (11 patients) had partial improvement in symptoms, while about 6.7% (7 patients) had residual disease after surgery with an unsatisfactory outcome; another 10.5% (11 patients) had a recurrence of symptoms of which 9 patients (8.94)% had revision endoscopic sinus surgery.
The correlation of the pre-operative radiology assessment and the intraoperative findings revealed a good relation between the two parameters, but statistically, it was not significant as the P = 0.2323 (P > 0.05). The correlation study also revealed no relationship between allergy and the general outcome of the surgery as well as between allergy and recurrent of the disease after surgical intervention with P = 0.81 and 0.94, respectively [Table 6].
|Table 6: Correlation between Allergy, recurrence and outcome, Radiology and intra-operative findings|
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| Discussion|| |
RS is an inflammatory process involving the mucosa of the nose and one or more sinuses. It is a multifactorial disease of the mucosa of the nose and sinuses that forms a continuum thus any inflammatory response in one spreads to the other.,
Our study revealed a higher female preponderance which is at variance with earlier study from the Northwestern region by Iseh and Makusidi  in Sokoto as well as Afolabi et al. in Ilorin North Central Nigeria, the variation may be due to the fact that those studies were epidemiology study, while our study is on the outcome surgical intervention, thus, the male may be more but more females presented for surgical intervention. From our study, the mean age of 35.9 ± 1.9 years (SD) was similar to other studies around the world , and about 51.4% of the patients were in their third and fourth decades of life which inferred that the diseases affect the highly productive group which is similar to most findings by the previous researchers,,, while the least presentations were recorded among the extreme of ages similar to findings reported earlier.
From our study, the most common presentations were nasal discharge and nasal obstruction similar to an earlier reports;, which were the major symptoms according to the guidelines on the diagnosis of RS. This was accompanied by a nasal growth in 77% of cases which is mostly nasal polyp. Thus, supporting the further classification of the disease into RS with or without nasal polyps based on outpatient endoscopy done for the patient., A large percentage also presented with hyposmia/anosmia in facial pain and facial numbness which are also major and minor symptoms for the diagnosis of the diseases.,, Majority of the patients had bilateral disease which depicts the severity of the diseases and the grade of inflammation, which are the most important predictors of longterm outcomes of the disease intervention as well as the level or degree of intervention that is required;, while about onethird had unilateral diseases with a higher percentage on the left side compared to the right.
The most common pre-operative diagnosis and indications for surgery in our study were CRS with nasal polyp which does not correlate statistically with the intraoperative findings similar to the earlier report  as we found the radiological studies to be helpful, as its finding is related with the clinical findings.,, However, some studies have found radiological studies to be unhelpful in unravelling the mucosal abnormalities  thus the need for interpretation with caution,,,, as the CT scan with increased density suggestive of mucosal thickening may mimic a normal cyclical changes in the nasal mucosal volume as documented in some literature.
Considering the extent of the disease based on the Kennedy staging system and Lund and Mackay staging  on the basis of the CT finding about two-third of our patients had endoscopic sinus surgery with polypectomy (defined as Stages III and IV by the Kennedy system or as a score >6 by the Lund–Mackay system) which was the most common surgery done for our patients similar to findings by other workers,, while about 16.6% had functional endoscopic sinus surgery alone.
The average duration of hospital stay postoperatively was 2.78 days approximately 3 days during which the nasal bolster applications were removed and patients were asked to return to the clinic for nasal toileting and antral washout.
Postoperatively, surgical specimens were sent for histological assessment to enhance if there is need for further treatment or not, The result revealed that almost half of the patients had inflammatory as histological diagnosis, while a few were inverted papilloma and the least histological diagnosis were olfactory neuroblastoma, plexiform ameloblastoma, rhabdomyosarcoma and fibromatoses similar to other reports.
The surgical complications were both nasal and extranasal, the nasal complications were nasal adhesions, excessive nasal crust formation, secondary epistaxis and nasal and Paranasal sinus infection with copious purulent nasal discharge then extranasal complication such as oroantral fistula and orbital infections specifically orbital abscess as seen in other reports. Only one death was reported in a patient with other comorbid conditions (diabetes mellitus and uncontrolled hypertension), the cause of which was unknown.
On the treatment outcome of our review more than two-third of operated cases had resolution of symptoms following surgical intervention and reported very good result, while some had partial improvement in symptoms, while some had residual disease after surgery and had an unsatisfactory outcome [Figure 4] which still falls within the range reported by the European Position Paper on Rhinosinusitis  and the review by Terris and Davidson in 1994.
From a systematic review on the clinical effectiveness of ESS with nasal polypectomy conducted at University of Exeter in 2002, it revealed that the disease recurrence was between 8% and 35%; however, in our study, a recurrence of about 10.5% was recorded which still falls within the reported range; however, there is still room for improvement in view of the continuous advancement in the surgical intervention.
The correlation of the pre-operative radiology assessment and the intraoperative findings revealed good relation between the two parameters, but statistically, it was not significant.
The study also found out no correlation between allergy and surgical outcome neither there was a relationship between allergy and disease recurrence and is not statistically significant.
| Conclusion|| |
Endoscopic sinus surgery is one of the treatment modalities of CRS, there is a higher female preponderance, most operated patients are the young adult in third and fourth decade of life, CRS with nasal polyp was found to be the most common indication for the intervention and pre-operative radiology assessment and the intraoperative findings revealed good relationship but no correlation statistically. The surgical outcome of treatment revealed recurrent disease in 10.5% with nasal adhesion, epistaxis, excessive nasal crust formation and oroantral fistula in only one patient.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Fokkens W, Lund V, Mullol J. European Position Paper on Rhinosinusitis and Nasal Polyps Group. European position paper on rhinosinusitis and nasal polyps 2007. Rhinol Suppl 2007;20:1-36.
Deepthi NV, Menon UK, Madhumita K. Chronic Rhinosinusitis – An Overview. Amrita J Med 2012;8:1-44.
Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, et al
. Clinical practice guideline: Adult sinusitis. Otolaryngol Head Neck Surg 2007;137:S1-31.
Meltzer EO, Hamilos DL, Hadley JA, Lanza DC, Marple BF, Nicklas RA, et al
. Rhinosinusitis: Establishing definitions for clinical research and patient care. J Allergy Clin Immunol 2004;114:155-212.
Slavin RG, Spector SL, Bernstein IL, Kaliner MA, Kennedy DW, Virant FS, et al
. The diagnosis and management of sinusitis: A practice parameter update. J Allergy Clin Immunol 2005;116:S13-47.
Scadding GK, Durham SR, Mirakian R, Jones NS, Drake-Lee AB, Ryan D, et al
. BSACI guidelines for the management of rhinosinusitis and nasal polyposis. Clin Exp Allergy 2008;38:260-75.
Yip J, Vescan AD, Witterick IJ, Monteiro E. The personal financial burden of chronic rhinosinusitis: A Canadian perspective. Am J Rhinol Allergy 2017;31:216-21.
Hopkins C, Browne JP, SlackR, Lund V, Topham J, Reeves B, et al
. The national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis. Clinical Otolaryngology, 2006;31:390–8. doi:10.1111/j.1749-4486.2006.01275.x.
Afolabi OA, Alabi BS, Omokanye HK, Ayodele SO, Segun-Busari S, Dunmade AD, et al
. Management and Outcome of Rhinosinusitis in Nigeria. OTO Open 2017;1:2473974x16685545.
Mascarenhas JG, da Fonseca VM, Chen VG, Itamoto CH, Silva CA, Gregório LC, et al
. Long-term outcomes of endoscopic sinus surgery for chronic rhinosinusitis with and without nasal polyps. Braz J Otorhinolaryngol 2013;79:306-11.
Stammberger H. Endoscopic endonasal surgery–oncepts in treatment of recurring rhinosinusitis. Part II. Surgical technique. Otolaryngol Head Neck Surg 1986;94:147-56.
Kennedy DW, Zinreich SJ, Shaalan H, Kuhn F, Naclerio R, Loch E. Endoscopic middle meatal antrostomy: Theory, technique, and patency. Laryngoscope 1987;97:1-9.
El Ghonemy MM, Shehata W, Abd El Atti RM. Predictive outcomes of functional endoscopic sinus surgery in patients with chronic rhinosinusitis. Egypt J Otolaryngol 2013;29:80-5.
Iseh KR, Makusidi M. Rhinosinusitis: A retrospective analysis of clinical pattern and outcome in north western Nigeria. Ann Afr Med 2010;9:20-6.
] [Full text]
Schlosser RJ, Storck K, Smith TL, Mace JC, Rudmik L, Shahangian A, et al
. Impact of postoperative endoscopy upon clinical outcomes a_er endoscopic sinus surgery. Int Forum Allergy Rhinol 2016;6:115-23.
Bassiouni A, Naidoo Y, Wormald PJ. When FESS fails: The inflammatory load hypothesis in refractory chronic rhinosinusitis. Laryngoscope 2012;122:460-6.
Naclerio RM, deTineo ML, Baroody FM. Ragweed allergic rhinitis and the paranasal sinuses. A computed tomographic study. Arch Otolaryngol Head Neck Surg 1997;123:193-6.
Jiang RS, Hsu CY. Revision functional endoscopic sinus surgery. Ann Otol rhino Laryngol 2002;111:155-9.
Moser FG, Panush D, Rubin JS, Honigsberg RM, Sprayregen S, Eisig SB. Incidental paranasal sinus abnormalities on MRI of the brain. Clin Radiol 1991;43:252-4.
Havas TE, Motbey JA, Gullane PJ. Prevalence of incidental abnormalities on computed tomographic scans of the paranasal sinuses. Arch Otolaryngol Head Neck Surg 1988;114:856-9.
Patel K, Chavda SV, Violaris N, Pahor AL. Incidental paranasal sinus inflammatory changes in a British population. J Laryngol Otol 1996;110:649-51.
Weaver EM, Kapur V, Yueh B. Polysomnography vs self-reported measures in patients with sleep apnea. Arch Otolaryngol Head Neck Surg 2004;130:453-8.
Lund VJ, Kennedy DW. Staging forrhinosinusitis. Otolaryngol Head Neck Surg 1997;117:S35-40.
Lang EE, Curran AJ, Patil N, Walsh RM, Rawluk D, Walsh MA. Intracranial complications of acute frontal sinusitis. Clin Otolaryngol Allied Sci 2001;26:452-7.
Terris MH, Davidson TM. Review of published results for endoscopic sinus surgery. Ear Nose Throat J 1994;73:574-80.
Dalziel K, Stein K, Round A, Garside R, Royle P. Systematic review of endoscopic sinus surgery for nasal polyps. Health Technol Assess 2003;7:iii, 1-159.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]