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11:40: Efficacy of Paranasal Sinus Irrigation in Chronic Sinusitis
Scientific Sessions—Monday
11:24 Sinus Surgery in Patients with Previously Repaired CSF Leaks Douglas David Reh, MD (presenter); Ralph B Metson, MD; Raj Sindwani, MD, FRCS OBJECTIVES: 1. Understand how to perform safe and effective revision sinus surgery in patients who have sustained a previous skull base injury and CSF leak. 2. Learn why a history of previous skull base injury is not a contraindication for revision sinus surgery. METHODS: The study population consisted of 12 patients with previously repaired iatrogenic CSF leaks who underwent revision endoscopic surgery for recurrent sinus disease. A retrospective review of the preoperative workup, intraoperative findings, and postoperative outcomes was conducted to determine the optimal surgical management of these patients. RESULTS: There were 7 men and 5 women with a mean age of 44.3 (⫾14.8) years. Indications for revision surgery included chronic rhinosinusitis (CRS) without polyps (67%), CRS with polyps (25%) and allergic fungal sinusitis (8%). Intrathecal fluorescein dye was not administered before any of the procedures; however, surgical navigation was utilized in all cases. At time of surgery, dissection near the area of previously reported CSF leak repair was carefully performed as needed. In one case, the surgeon observed pulsations at the ethmoid roof repair site; however, in no instance was an active pre-existing CSF leak identified or a new leak created. All patients were discharged home within 24 hours. The average follow-up was 13.3 (⫾7.3) months. CONCLUSIONS: Previous skull base injury with CSF leak is not a contraindication to revision sinus surgery. Surgery in this setting can be performed safely and efficaciously, and may be
recommended to patients with symptomatic recurrence of their sinus disease.
11:32 Socioeconomic Factors in Allergic Fungal Rhinosinusitis Sarah K Wise, MD (presenter); Mark D Ghegan, MD; Edward D Gorham, PhD; Rodney J Schlosser, MD OBJECTIVES: Prior studies demonstrate increased incidence of allergic fungal rhinosinusitis (AFRS) in African Americans (AAs) and males, but the etiology of this ethnic and gender predilection remains unknown. Objectives are (1) to investigate the socioeconomic and demographic factors differentiating AFRS from other chronic rhinosinusitis (CRS) diagnostic groups, and (2) to consider the role that epidemiologic differences may have on disease progression and treatment. METHODS: Retrospective four-year review of 54 AFRS patients, 58 CRS patients with nasal polyps (CRSwNP) who did not meet classic AFRS diagnostic criteria, and 57 non-polyp CRS patients (CRSsNP) in a tertiary care rhinology practice. Group differences were evaluated for presentation age, gender, ethnicity, and insurance status. Using a state demographic database, group differences were assessed for county poverty level, mean county income, physicians per 1,000 county residents, and county percentage of AAs. Statistical analyses included ANOVA and Chi square tests. RESULTS: Presentation age for AFRS was significantly lower than CRSwNP and CRSsNP (p ⬍ 0.001). The AFRS group had more AAs (p ⬍ 0.001) and uninsured or Medicaid patients (p ⬍ 0.001) than expected, resided in counties with higher percentages of residents below the poverty level (p ⬍ 0.01), lower mean income (p ⬍ 0.05), and higher percentage of AAs (p ⬍ 0.05) than CRSsNP. No significant differences were found between diagnostic groups for gender, physicians per 1,000 county residents, or geographic region of patient residence. CONCLUSIONS: Multiple demographic, socioeconomic, and genetic factors appear to affect AFRS presentation and treatment. The impact of these factors remains to be elucidated.
11:40 Efficacy of Paranasal Sinus Irrigation in Chronic Sinusitis Kornkiat Snidvongs, MD (presenter); Pattraporn Chaowanapanja, MD; Songklot Aeumjaturapat, MD; Supinda Saengpanich, MD; Puangmali Praweswararat, MD OBJECTIVES: 1. Assess the efficacy of nasal douche and nasal spray to deliver solution into paranasal sinus cavities in chronic rhinosinusitis. 2. Compare the two techniques.
MONDAY
of follow-up, surgical success, and method used to assess surgical outcome were collected. RESULTS: The study designs were retrospective case series without control (8 papers), retrospective with internal control (4 papers), and prospective case series without control (6 papers). Seventy-eight percent of the published papers provide an evidence level of 4 while the remaining 22% provide an evidence level of 3. The surgical technique was described as frontal sinusotomy (n⫽6), modified Lothrop (n⫽7), Draf types II or III (n⫽3), transseptal frontal sinusotomy (n⫽1), and frontal sinus rescue (n⫽1). The median number of subjects was 20. The median duration of follow-up was 15 months. The diagnosis of frontal sinus disease was made by CT only (n⫽4), CT and MRI (n⫽2), CT and symptoms (n⫽5), and CT and nasal endoscopy (n⫽7). Surgical success rate ranged between 77% and 100%. The surgical outcome was based on nasal endoscopy (n⫽18), CT (n⫽3), symptoms (n⫽10), and outcome measure (n⫽2). CONCLUSIONS: The majority of the published papers that report on the efficacy of endoscopic approaches to treat frontal sinus disease had a small sample size, short follow-up duration, and provide a low evidence level.
P75
P76
Otolaryngology-Head and Neck Surgery, Vol 137, No 2S, August 2007
METHODS: This was a prospective study. Fourteen patients presenting with bilateral chronic rhinosinusitis from October 2005 to June 2006 were enrolled. They underwent nasal irrigation with iodinated contrast solution at an ionic strength of 140 mgI/ml by douching solution 40ml through irrigation syringe into one side of nose and spraying solution 10 ml into the other side. The method of delivery to each side of nose was randomized. Immediately after nasal irrigation, coronal computed tomography was undertaken to determine the volume and distribution in nasal and paranasal sinus cavities of the irrigated contrast media. The efficacy of each method was analyzed by use of the Paired T test. The difference between the two irrigation techniques was analyzed by
use of the McNemar test. All values of p⬍0.05 were considered to be significant. RESULTS: Two patients had little staining in three sides of the maxillary sinus cavities (0.01ml, 0.04ml, 0.13ml). There was no more staining in other paranasal sinus cavities. The mean volume of paranasal sinuses staining was 0.0093ml by nasal douche and 0.01 by nasal spray. Compared with the irrigation volume, this was very little (both techniques: p⬍0.001). There was no statistical difference between the efficacy of the two methods (p⫽1.00). CONCLUSIONS: Neither nasal douche nor spray could effectively deliver nasal irrigation solution into paranasal sinuses cavities in chronic rhinosinusitis.
10:00 AM to 10:20 AM RESEARCH FORUM WCC 208AB
RESULTS: All flaps survived the initial 2-hour primary ischemic time. The mean ⫹/- SD percentage survival for the flaps among the groups 7 days following pedicle ligation was 28.1 ⫹/- 12.4 for the control group, 71.6 ⫹/- 16.2 for the VEGF protein group, and 77.5 ⫹/- 12.7 for the plasmid DNA group. ANOVA with a post-hoc test for significance revealed a statistically significant difference between the control group and the other experiment groups (p ⬍ 0.001). No differences were observed between the VEGF protein and VEGF plasmid DNA groups. CONCLUSION: Locally administered VEGF protein or plasmid DNA expressing VEGF enhanced the survival of fasciocutaneous flaps as compared to a control group. This observation was associated with an improvement in flap revascularization. SIGNIFICANCE: This study demonstrates the potential of gene therapy in promoting revascularization of the flap.
䡲
Research Forum: Facial Plastic and Reconstructive Surgery Moderators: David B. Hom, MD; John S. Rhee, MD, MPH
10:00 Plasmid VEGF Gene Therapy Enhances Survival of Rat Fascial Colin McNight, MD (presenter); Mark K Wax, MD; Xi Gong, MD; Shelley Winn, PhD PROBLEM: Fasciocutaneous tissue transfer is a common procedure performed in head and neck reconstructive surgery. Revascularization of flap tissue is an important component of tissue transfer procedures. Successful transfer depends on a patent vascular pedicle until revascularization from the periphery of the surgical bed can occur. If pedicle blood flow is compromised during this initial period, flap failure may occur. Gene therapy offers one promising avenue through which the period of pedicle vascular dependency can be reduced and overall flap survival can be improved. METHODS: A rat fasciocutatneous flap model was used. The study assessed revascularization potential of three groups: control group; vascular endothelial growth factor (VEGF) protein; and plasmid DNA expressing VEGF. All groups were mixed with (1) a polycation complex, jet PEI, and (2) human fibrin sealant CROSSEAL®. During a primary ischemic time (2 hours), the various treatment groups were applied. Vascular pedicles were ligated on postoperative day 5 and the subsequent percentage of flap survival relative to 100% was evaluated 7 days later.
10:10 Capillary Blood Gas Assessment of Free Flap Tissue Perfusion Gregory T Lesnik, MD (presenter); Aaron Kyle Remenschneider, BS, BA; Douglas A Ross, MD PROBLEM: To demonstrate that Capillary Blood Gas measurements may represent a reliable, accessible and easy new method of identifying failing free tissue flaps secondary to venous occlusion, when compared to implantable oxygen microelectrodes, a currently accepted monitoring modality. METHODS: Rat groin fasciocutaneous flaps were elevated and following arterial or venous occlusion, oxygen microelectrode measurements (pO2 and flow) and Capillary Blood Gas measurements (pO2, pCO2, pH, HCO3) were obtained at 0, 10 and 20 minutes. RESULTS: Steady, statistically significant declines in Capil-
11:24 Sinus Surgery in Patients with Previously Repaired CSF Leaks Douglas David Reh, MD (presenter); Ralph B Metson, MD; Raj Sindwani, MD, FRCS OBJECTIVES: 1. Understand how to perform safe and effective revision sinus surgery in patients who have sustained a previous skull base injury and CSF leak. 2. Learn why a history of previous skull base injury is not a contraindication for revision sinus surgery. METHODS: The study population consisted of 12 patients with previously repaired iatrogenic CSF leaks who underwent revision endoscopic surgery for recurrent sinus disease. A retrospective review of the preoperative workup, intraoperative findings, and postoperative outcomes was conducted to determine the optimal surgical management of these patients. RESULTS: There were 7 men and 5 women with a mean age of 44.3 (⫾14.8) years. Indications for revision surgery included chronic rhinosinusitis (CRS) without polyps (67%), CRS with polyps (25%) and allergic fungal sinusitis (8%). Intrathecal fluorescein dye was not administered before any of the procedures; however, surgical navigation was utilized in all cases. At time of surgery, dissection near the area of previously reported CSF leak repair was carefully performed as needed. In one case, the surgeon observed pulsations at the ethmoid roof repair site; however, in no instance was an active pre-existing CSF leak identified or a new leak created. All patients were discharged home within 24 hours. The average follow-up was 13.3 (⫾7.3) months. CONCLUSIONS: Previous skull base injury with CSF leak is not a contraindication to revision sinus surgery. Surgery in this setting can be performed safely and efficaciously, and may be
recommended to patients with symptomatic recurrence of their sinus disease.
11:32 Socioeconomic Factors in Allergic Fungal Rhinosinusitis Sarah K Wise, MD (presenter); Mark D Ghegan, MD; Edward D Gorham, PhD; Rodney J Schlosser, MD OBJECTIVES: Prior studies demonstrate increased incidence of allergic fungal rhinosinusitis (AFRS) in African Americans (AAs) and males, but the etiology of this ethnic and gender predilection remains unknown. Objectives are (1) to investigate the socioeconomic and demographic factors differentiating AFRS from other chronic rhinosinusitis (CRS) diagnostic groups, and (2) to consider the role that epidemiologic differences may have on disease progression and treatment. METHODS: Retrospective four-year review of 54 AFRS patients, 58 CRS patients with nasal polyps (CRSwNP) who did not meet classic AFRS diagnostic criteria, and 57 non-polyp CRS patients (CRSsNP) in a tertiary care rhinology practice. Group differences were evaluated for presentation age, gender, ethnicity, and insurance status. Using a state demographic database, group differences were assessed for county poverty level, mean county income, physicians per 1,000 county residents, and county percentage of AAs. Statistical analyses included ANOVA and Chi square tests. RESULTS: Presentation age for AFRS was significantly lower than CRSwNP and CRSsNP (p ⬍ 0.001). The AFRS group had more AAs (p ⬍ 0.001) and uninsured or Medicaid patients (p ⬍ 0.001) than expected, resided in counties with higher percentages of residents below the poverty level (p ⬍ 0.01), lower mean income (p ⬍ 0.05), and higher percentage of AAs (p ⬍ 0.05) than CRSsNP. No significant differences were found between diagnostic groups for gender, physicians per 1,000 county residents, or geographic region of patient residence. CONCLUSIONS: Multiple demographic, socioeconomic, and genetic factors appear to affect AFRS presentation and treatment. The impact of these factors remains to be elucidated.
11:40 Efficacy of Paranasal Sinus Irrigation in Chronic Sinusitis Kornkiat Snidvongs, MD (presenter); Pattraporn Chaowanapanja, MD; Songklot Aeumjaturapat, MD; Supinda Saengpanich, MD; Puangmali Praweswararat, MD OBJECTIVES: 1. Assess the efficacy of nasal douche and nasal spray to deliver solution into paranasal sinus cavities in chronic rhinosinusitis. 2. Compare the two techniques.
MONDAY
of follow-up, surgical success, and method used to assess surgical outcome were collected. RESULTS: The study designs were retrospective case series without control (8 papers), retrospective with internal control (4 papers), and prospective case series without control (6 papers). Seventy-eight percent of the published papers provide an evidence level of 4 while the remaining 22% provide an evidence level of 3. The surgical technique was described as frontal sinusotomy (n⫽6), modified Lothrop (n⫽7), Draf types II or III (n⫽3), transseptal frontal sinusotomy (n⫽1), and frontal sinus rescue (n⫽1). The median number of subjects was 20. The median duration of follow-up was 15 months. The diagnosis of frontal sinus disease was made by CT only (n⫽4), CT and MRI (n⫽2), CT and symptoms (n⫽5), and CT and nasal endoscopy (n⫽7). Surgical success rate ranged between 77% and 100%. The surgical outcome was based on nasal endoscopy (n⫽18), CT (n⫽3), symptoms (n⫽10), and outcome measure (n⫽2). CONCLUSIONS: The majority of the published papers that report on the efficacy of endoscopic approaches to treat frontal sinus disease had a small sample size, short follow-up duration, and provide a low evidence level.
P75
P76
Otolaryngology-Head and Neck Surgery, Vol 137, No 2S, August 2007
METHODS: This was a prospective study. Fourteen patients presenting with bilateral chronic rhinosinusitis from October 2005 to June 2006 were enrolled. They underwent nasal irrigation with iodinated contrast solution at an ionic strength of 140 mgI/ml by douching solution 40ml through irrigation syringe into one side of nose and spraying solution 10 ml into the other side. The method of delivery to each side of nose was randomized. Immediately after nasal irrigation, coronal computed tomography was undertaken to determine the volume and distribution in nasal and paranasal sinus cavities of the irrigated contrast media. The efficacy of each method was analyzed by use of the Paired T test. The difference between the two irrigation techniques was analyzed by
use of the McNemar test. All values of p⬍0.05 were considered to be significant. RESULTS: Two patients had little staining in three sides of the maxillary sinus cavities (0.01ml, 0.04ml, 0.13ml). There was no more staining in other paranasal sinus cavities. The mean volume of paranasal sinuses staining was 0.0093ml by nasal douche and 0.01 by nasal spray. Compared with the irrigation volume, this was very little (both techniques: p⬍0.001). There was no statistical difference between the efficacy of the two methods (p⫽1.00). CONCLUSIONS: Neither nasal douche nor spray could effectively deliver nasal irrigation solution into paranasal sinuses cavities in chronic rhinosinusitis.
10:00 AM to 10:20 AM RESEARCH FORUM WCC 208AB
RESULTS: All flaps survived the initial 2-hour primary ischemic time. The mean ⫹/- SD percentage survival for the flaps among the groups 7 days following pedicle ligation was 28.1 ⫹/- 12.4 for the control group, 71.6 ⫹/- 16.2 for the VEGF protein group, and 77.5 ⫹/- 12.7 for the plasmid DNA group. ANOVA with a post-hoc test for significance revealed a statistically significant difference between the control group and the other experiment groups (p ⬍ 0.001). No differences were observed between the VEGF protein and VEGF plasmid DNA groups. CONCLUSION: Locally administered VEGF protein or plasmid DNA expressing VEGF enhanced the survival of fasciocutaneous flaps as compared to a control group. This observation was associated with an improvement in flap revascularization. SIGNIFICANCE: This study demonstrates the potential of gene therapy in promoting revascularization of the flap.
䡲
Research Forum: Facial Plastic and Reconstructive Surgery Moderators: David B. Hom, MD; John S. Rhee, MD, MPH
10:00 Plasmid VEGF Gene Therapy Enhances Survival of Rat Fascial Colin McNight, MD (presenter); Mark K Wax, MD; Xi Gong, MD; Shelley Winn, PhD PROBLEM: Fasciocutaneous tissue transfer is a common procedure performed in head and neck reconstructive surgery. Revascularization of flap tissue is an important component of tissue transfer procedures. Successful transfer depends on a patent vascular pedicle until revascularization from the periphery of the surgical bed can occur. If pedicle blood flow is compromised during this initial period, flap failure may occur. Gene therapy offers one promising avenue through which the period of pedicle vascular dependency can be reduced and overall flap survival can be improved. METHODS: A rat fasciocutatneous flap model was used. The study assessed revascularization potential of three groups: control group; vascular endothelial growth factor (VEGF) protein; and plasmid DNA expressing VEGF. All groups were mixed with (1) a polycation complex, jet PEI, and (2) human fibrin sealant CROSSEAL®. During a primary ischemic time (2 hours), the various treatment groups were applied. Vascular pedicles were ligated on postoperative day 5 and the subsequent percentage of flap survival relative to 100% was evaluated 7 days later.
10:10 Capillary Blood Gas Assessment of Free Flap Tissue Perfusion Gregory T Lesnik, MD (presenter); Aaron Kyle Remenschneider, BS, BA; Douglas A Ross, MD PROBLEM: To demonstrate that Capillary Blood Gas measurements may represent a reliable, accessible and easy new method of identifying failing free tissue flaps secondary to venous occlusion, when compared to implantable oxygen microelectrodes, a currently accepted monitoring modality. METHODS: Rat groin fasciocutaneous flaps were elevated and following arterial or venous occlusion, oxygen microelectrode measurements (pO2 and flow) and Capillary Blood Gas measurements (pO2, pCO2, pH, HCO3) were obtained at 0, 10 and 20 minutes. RESULTS: Steady, statistically significant declines in Capil-