Impact of residual ethmoid cells on postoperative course after endoscopic sinus surgery for chronic rhinosinusitis
Introduction
Chronic rhinosinusitis (CRS) is recognized as a disease that seriously affects the quality of life of patients. CRS causes pain and adversely impacts various aspects of the general health, including social functioning. Surgery is often recommended for alleviation of these problems [1].
Endoscopic sinus surgery (ESS) is a worldwide standard surgical procedure for CRS that does not respond to conservative therapy. The success rate of ESS has been variously reported to range from 67% to 97.5% [2], [3]. However, CRS has been reported to recur in some patients post-ESS, and even as a conservative estimate 7–15% of cases were reported to require a second surgery [4], [5]. Patient factors suggested to be associated with CRS recurrence include eosinophil infiltration of the nasal mucosa, asthma, allergic complications, nasal polyps, a high preoperative CT score, etc [6], [7], [8], [9], [10]. On the other hand, surgical factors, such as failure to completely remove the ethmoid cells, etc., have also been reported to be causes of CRS recurrence [4], [11], [12]. Those authors reported that such failure to completely remove the cells results in residual ethmoid cells (RECs), which prevent full enlargement of the paranasal sinus ostium and lead to recurrence of the CRS. It is thus thought that various factors are involved in CRS recurrence, including the noted operative technique factors, but there is still no consensus regarding the reason for postoperative CRS recurrence.
We divided each of the bilateral ethmoid sinuses into three parts and assigned an REC score to each part. We then investigated the relationship between the REC score and post-ESS recurrence of CRS.
Section snippets
Subjects
From January 2002 through December 2003, a total of 138 consecutive patients (86 men and 52 women, with a mean age of 44 years) were diagnosed with CRS at the Department of Otorhinolaryngology, Ota General Hospital, and underwent ESS. All patients underwent a computed tomographic (CT) scan on a Siemens SOMATOM Sensation 16 (Siemens, Berlin, Germany) pre-ESS and at 6 or more months post-ESS. Multi-slice helical CT scans were obtained in the coronal and axial planes. The diagnosis of CRS was made
Preoperative data
Data were recorded for the following background factors for each patient prior to the ESS: age, gender, presence/absence of nasal polyps, presence/absence of allergic rhinitis, presence/absence of asthma and the peripheral eosinophil count (%). The presence/absence of nasal polyps was determined using a rigid endoscope. The presence/absence of allergic rhinitis and asthma was determined on the basis of a questionnaire that was completed by each patient preoperatively and included the values for
Data analysis
The total REC score and the REC scores for the three parts of the ethmoid sinus were analyzed.
The Mann–Whitney U test was used to compare the following variables between the satisfactory outcome group and the poor outcome group: age, gender, presence/absence of nasal polyps, presence/absence of allergic rhinitis, presence/absence of asthma, pre-ESS CT score, the peripheral eosinophil count (%), the total REC score and the surgeon's experience (number of operations performed). In addition, the
REC score after ESS
The total REC score was 0 in only 35 (25.4%) of the total patients. The most common total REC scores were 1–6, recorded in 85 (61.6%) patients. A score of ≧7 was recorded in 18 (13.0%) patients (Fig. 3). For each of the right and left three ethmoid sinus parts, the superior-anterior part had the largest number of sinuses with an REC score of 1 or more (i.e., 0, 48.2%; 1, 22.8%; 2, 18.5%; 3, 10.5%), followed by the posterior part (i.e., 0, 64.1%; 1, 21.0%; 2, 10.5%; 3, 4.4%). The
Discussion
Our logistic regression analyses found that a peripheral eosinophil count of ≥9.5%, presence of asthma and a total REC score of ≥4 were factors that correlated significantly with a poor outcome following performance of ESS for CRS. Earlier reports had identified the peripheral eosinophil count and a complication of asthma as factors associated with postoperative recurrence of CRS [6], [7], [8], [14], [15], [16], [17], [18], [19]. However, our present study also showed that incomplete removal of
Conclusion
The findings of this study indicate that RECs are involved in the recurrence of CRS following ESS. Surgical factors, such as failure to completely remove the ethmoid cells, lead to RECs and are thus involved in that recurrence. In particular, it can be thought that how to achieve full opening of the superior-anterior part of the ethmoid sinus that includes the frontal recess will be an issue in the future. It can also be thought that incomplete removal of the ethmoid cells is potentially
References (26)
- et al.
Anatomic findings in patients undergoing revision endoscopic sinus surgery
Am J Otolaryngol
(2004) - et al.
Factors associated with failure of frontal sinusotomy in the early follow-up period
Otolaryngol Head Neck Surg
(2004) - et al.
Eosinophils in nasal polyps and nasal mucosa: an immunohistochemical study
J Allergy Clin Immunol
(1993) - et al.
A clinical and pathologic study of chronic sinusitis: the role of the eosinophil
J Allergy Clin Immunol
(1988) - et al.
The role of agger nasi air cells in patients requiring revision endoscopic frontal sinus surgery
Otolaryngol Head Neck Surg
(2004) - et al.
Rhinosinusitis: establishing definitions for clinical research and patient care
J Allergy Clin Immunol
(2004) - et al.
Impact of mucosal eosinophilia and nasal polyposis on quality-of-life outcomes after sinus surgery
Otolaryngol Head Neck Surg
(2010) The agger nasi cell: the key to understanding the anatomy of the frontal recess
Otolaryngol Head Neck Surg
(2003)- et al.
The eosinophil as a mediator of damage to respiratory epithelium: a model for bronchial hyperreactivity
J Allergy Clin Immunol
(1988) - et al.
Clinical outcomes in patients with chronic sinusitis
Laryngoscope
(2000)