Elsevier

Auris Nasus Larynx

Volume 39, Issue 5, October 2012, Pages 484-489
Auris Nasus Larynx

Impact of residual ethmoid cells on postoperative course after endoscopic sinus surgery for chronic rhinosinusitis

https://doi.org/10.1016/j.anl.2011.09.001Get rights and content

Abstract

Objective

Endoscopic sinus surgery (ESS) is a worldwide standard surgical procedure for chronic rhinosinusitis (CRS). Residual ethmoid cells (RECs), which result from failure to completely remove them, have been thought to be a cause of recurrence of CRS. Our objective was to investigate the relationship between the REC score and post ESS recurrence of CRS.

Methods

From January 2002 through December 2003, a total of 138 consecutive CRS patients (86 men and 52 women; mean age: 44 years) underwent ESS at the Department of Otorhinolaryngology, Ota General Hospital. CT was performed at 6 or more months post ESS for all patients. The left and right ethmoid sinuses were each divided into superior-anterior, inferior-anterior and posterior parts. The extent of RECs in each part was assessed using a 3-grade scoring system. The outcome of CRS was classified into a satisfactory outcome group and a poor outcome group based on the improvement rate determined from the pre ESS and post ESS CT image findings. The two groups were then compared for the age, gender, presence/absence of nasal polyps, presence/absence of allergic rhinitis, presence/absence of asthma, the peripheral eosinophil count (%) and the total REC score. In addition, the individual correlations between the above variables and the poor outcome group were analyzed by logistic regression analysis.

Results

The total REC score was 0 in only 35 (25.4%) of the total patients. The most common total REC scores were 1–6 in 85 (61.6%) patients. The superior-anterior part had the largest number of patients with an REC score of 1 or more. The satisfactory outcome group comprised 97 patients (70.3%), while the poor outcome group comprised 41 patients (29.7%). Comparison of these two groups found that the peripheral eosinophil count, the prevalence rate of asthma and the total REC score were each significantly higher in the poor outcome group than in the satisfactory outcome group. Logistic regression analysis identified a peripheral eosinophil count of ≥9.5%, the presence of asthma and a total REC score of ≥4 as factors that correlated significantly with a poor outcome.

Conclusion

The findings of this study indicate that RECs are involved in the recurrence of CRS following ESS. It can be thought that how to achieve full opening of the superior-anterior part of the ethmoid sinus, which includes the frontal recess, will be an issue in the future.

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

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