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Outcome variation following surgery for nasal polyposis
Otolaryngology– Head and Neck Surgery Volume 131 Number 2
Conclusion: Cell viability in electroformed cartilage can be optimized with prudent selection of electrode geometry, voltage, and application time. Significance: CLSM provides a means of studying chondrocyte viability and insight into how electromechanical cartilage reshaping can be optimized. Support: National Institute of Health, the Air Force Office of Scientific Research, and the American Society of Lasers in Surgery and Medicine.
Research Forum—Tuesday P121
Support: The study was funded by a standard contribution from each participating hospital. Funding was also received from the British Association of Otorhinolaryngologists-Head and Neck Surgeons and from GlaxoSmithKline Ltd. 8:56 AM Outcome Variation Following Surgery for Nasal Polyposis Claire L Hopkins (presenter); John P Browne, PhD; Robert Slack, FRCS
Patient Outcome after Sino-Nasal Surgery: A Large Prospective Cohort Study John P Browne, PhD (presenter); Claire L Hopkins; Robert Slack, FRCS
London United Kingdom; Orpington United Kingdom; Bristol United Kingdom
Problem: This study estimated the safety and effectiveness of surgery to relieve the symptoms associated with rhinosinusitis and nasal polyposis. Methods: For this study 3128 consecutive patients undergoing surgery for nasal polyposis or rhinosinusitis at 87 hospitals were prospectively enrolled. Data on patient prognostic factors were collected at the time of surgery. Outcomes data were collected at 3, 12, and 36 months postsurgery. A patient-centered outcome instrument, the SNOT-22, was used as the main outcome measure. Data on patient satisfaction, revision surgery, and adverse events were also collected. Results: There were no adverse events reported in 93.4% of procedures. The CSF leak rate was 0.064% and the periorbital haematoma rate was 0.2% with no long-term visual problems. There is a statistically significant decrease in patient-reported symptomatology as measured by the SNOT-22 from the preoperative period to both 3 and 12 months. The average effect size at 12 months was 0.7 SD. Asthma, previous surgery, and less extensive polyposis were the strongest independent predictors of higher postoperative symptomatology in a multivariate analysis. Nearly one third of patients undergoing sinus surgery had Lund-Mackay scores less than 4, lower than the normal population. In 3.9% of the patients surgery was performed in the virtual absence of symptoms, and 8.6% of the patients had had or were awaiting revision surgery at 12 months. Full results for the 36-month follow-up period are currently being analyzed and will be presented. Conclusion: Sino-nasal surgery is generally safe and effective. Greatest symptom reduction is seen with primary surgery for patients with extensive nasal polyposis. Greater attention should be paid to patient-reported symptoms when selecting patients for surgery. Significance: This is the largest study of its kind to date and provides a unique estimate of the safety and effectiveness of sino-nasal surgery from the perspective of the patient.
Orpington United Kingdom; London United Kingdom; Bristol United Kingdom
Problem: Using data from a large prospective cohort study, we evaluated whether the extent of surgery undertaken, use of endoscope and powered instrumentation, or grade of surgeon are independent predictors of outcome following surgery for nasal polyposis. Methods: Two thousand thirty-nine patients undergoing surgery for nasal polyposis in 87 participating UK hospitals were prospectively entered into the study. Information on patient prognostic factors, operative interventions, instrumentation, and surgeon grade was collected at the time of surgery and outcomes data were collected over the next 36 months. The main outcome measures used were the SNOT-22, a patient-based outcome instrument, and revision rates. Robust multivariate and logistic regressions were performed to identify factors associated with improved outcome. Results: There is a clinically (0.81 SD) and statistically significant symptomatic improvement 36 months following surgery for polyposis. However, 11.2% of patients have required revision surgery. The most common procedure undertaken is simple polypectomy (34.3%). Multivariate regression demonstrates that revision rates are significantly lower for more extensive surgery compared with simple polypectomy alone (odds ratio for revision following anterior ethmoidectomy versus simple polypectomy ⫽ 0.26, P ⫽ 0.017). Symptomatic improvement does not differ significantly. Use of the microdebrider has an additional independent effect on revision rates, without a significant increase in adverse events. Endoscopic surgery, compared with conventional illumination, does not confer an independent advantage in terms of revision rates or symptomatic improvement, but facilitates more extensive surgery to be undertaken in a safe manner. Appropriate case-selection ensures that there is no detrimental outcome effect when nonconsultant surgeons undertake sinonasal surgery. Conclusion: Surgery is effective for symptomatic relief in nasal polyposis. We may reduce the high revision rates associated with this condition by undertaking endoscopic surgery extending into the sinuses, combined with judicious use of powered instrumentation. Significance: Polyposis is a common problem with excep-
TUESDAY
8:48 AM
Research Forum—Tuesday
tionally high recurrence rates after surgery, which may be reduced by modern surgical techniques. Support: None reported. 9:04 AM Psychiatric Distress Amplifies Symptoms after Surgery for Chronic Rhinosinusitis Greg Davis, MD (presenter); Bevan Yueh, MD MPH; Edward A Walker, MD; Wayne Katon, MD; Thomas D Koepsell, MD MPH; Ernest A Weymuller, Jr, MD Seattle WA; Seattle WA; Seattle WA; Seattle WA; Seattle WA; Seattle WA
Problem: Psychiatric disorders are associated with increased symptom burden when combined with chronic medical conditions. However, there are no reports of how psychiatric distress influences outcomes with surgical treatment for chronic rhinosinusitis (CRS). We hypothesized that subjects with psychiatric distress (somatization, anxiety, and depression) would report more severe long-term sinus symptoms and worse quality of life (QOL) than subjects without psychiatric distress. Methods: This is a community-based, prospective, observational cohort study of patients diagnosed with CRS presenting for surgery. Patients were interviewed prior to surgery; their CT scans were reviewed; and they completed questionnaires about sinusitis-related symptoms (SNOT-16), general health status and QOL (SF-36), and psychiatric distress (BSI and PHQ). Outcomes were also assessed 1, 3, 6, and 12 months postoperatively. Results: Ninety-five patients had complete records for analysis. Psychiatric distress was prevalent, with 31% screening positive for somatization, 17% positive for anxiety, and 25% positive for depressive disorders. Subjects with somatization had significantly worse SNOT-16 scores at each time point compared to those without somatization (P ⬍ 0.05). Subjects with depression reported more severe symptoms at 6 and 12 months after surgery than those without depression (P ⬍ 0.05). The presence of somatization preoperatively was also independently associated with symptom severity 12 months after surgery, even after adjusting for prior sinus surgery, CT stage, Charlson Index, and deviated septum. Additionally, subjects with psychiatric distress reported significantly worse SF-36 physical and mental component summary scores 12 months after surgery than subjects without psychiatric distress. Conclusion: Psychiatric distress is associated with worse reported sinus symptoms and lower QOL throughout surgical management of chronic rhinosinusitis. Despite this, subjects with psychiatric distress report a similar degree of improvement in sinus symptoms after surgery compared to those without distress. Significance: Psychiatric distress should be considered in
patients with persistent symptoms following surgery. Psychiatric distress should also be considered in efforts to design a chronic sinusitis staging system. Support: Dr Davis was supported by an NIH Training Grant (DC-00018) during this project. Dr Bevan Yueh is supported by a Career Development Award (CD-98318) from the Department of Veterans Affairs. This project was funded, in part, by a Resident Research Gran 9:12 AM Study of Lubricant-Induced Changes in Chronic Snorers Rohan C Wijewickrama, BA (presenter); P David Blalock, CCC SLP; James W Mims, MD Winston-Salem NC; Winston Salem NC; Winston Salem NC
MA
Problem: The efficacy of many of the noninvasive treatments for snoring has not been evaluated in controlled trials. This study seeks to evaluate the efficacy of an oil-based spray in the treatment of snoring, in a double-blinded, placebocontrolled, cross-over trial using objective acoustic analysis and subjective questionnaires. Methods: Participants were randomized to use both oilbased oral spray (treatment) and water-based oral spray (placebo) during a 2-night in-home study period. Questionnaires were completed by the participant and his/her bed-partner; these were evaluated along with audiotape recordings, which were analyzed for frequency, duration, and mean energy of snoring. Results: Greatest snoring rate demonstrated 30% ⫽ benefit; 40% ⫽ no change; 30% ⫽ adverse effect (n ⫽ 20). percent time snoring yielded: 30% ⫽ benefit; 15% ⫽ no change; 55% ⫽ adverse effect (n ⫽ 20). Study data results for mean energy were (n ⫽ 12): 17% ⫽ benefit; 33% ⫽ no change; 50% ⫽ adverse effect. Bed-partner observations (n ⫽ 17) demonstrated 37% ⫽ benefit; 38% ⫽ no change, 25% ⫽ adverse effect. Conclusion: Objective and subjective evaluation of the performance of the oil-based Snoreless spray in comparison to placebo demonstrated a lack of efficacy in snoring reduction. Significance: Study findings indicate that oil-based oral sprays are not effective in the treatment of snoring. Support: None reported. 9:20 AM Acceptance of Treatment Suggestions for SleepDisordered Breathing Thomas Verse, MD (presenter); Kerstin Wiesmiller; Wolfgang Pirsig, MD; Boris A Stuck, MD; Joachim T Maurer, MD; Karl Hoermann, MD Mannheim Germany; Ulm Germany; Ulm Germany; Mannheim Germany; Mannheim Germany; Mannheim Germany
TUESDAY
P122
Otolaryngology– Head and Neck Surgery August 2004
Conclusion: Cell viability in electroformed cartilage can be optimized with prudent selection of electrode geometry, voltage, and application time. Significance: CLSM provides a means of studying chondrocyte viability and insight into how electromechanical cartilage reshaping can be optimized. Support: National Institute of Health, the Air Force Office of Scientific Research, and the American Society of Lasers in Surgery and Medicine.
Research Forum—Tuesday P121
Support: The study was funded by a standard contribution from each participating hospital. Funding was also received from the British Association of Otorhinolaryngologists-Head and Neck Surgeons and from GlaxoSmithKline Ltd. 8:56 AM Outcome Variation Following Surgery for Nasal Polyposis Claire L Hopkins (presenter); John P Browne, PhD; Robert Slack, FRCS
Patient Outcome after Sino-Nasal Surgery: A Large Prospective Cohort Study John P Browne, PhD (presenter); Claire L Hopkins; Robert Slack, FRCS
London United Kingdom; Orpington United Kingdom; Bristol United Kingdom
Problem: This study estimated the safety and effectiveness of surgery to relieve the symptoms associated with rhinosinusitis and nasal polyposis. Methods: For this study 3128 consecutive patients undergoing surgery for nasal polyposis or rhinosinusitis at 87 hospitals were prospectively enrolled. Data on patient prognostic factors were collected at the time of surgery. Outcomes data were collected at 3, 12, and 36 months postsurgery. A patient-centered outcome instrument, the SNOT-22, was used as the main outcome measure. Data on patient satisfaction, revision surgery, and adverse events were also collected. Results: There were no adverse events reported in 93.4% of procedures. The CSF leak rate was 0.064% and the periorbital haematoma rate was 0.2% with no long-term visual problems. There is a statistically significant decrease in patient-reported symptomatology as measured by the SNOT-22 from the preoperative period to both 3 and 12 months. The average effect size at 12 months was 0.7 SD. Asthma, previous surgery, and less extensive polyposis were the strongest independent predictors of higher postoperative symptomatology in a multivariate analysis. Nearly one third of patients undergoing sinus surgery had Lund-Mackay scores less than 4, lower than the normal population. In 3.9% of the patients surgery was performed in the virtual absence of symptoms, and 8.6% of the patients had had or were awaiting revision surgery at 12 months. Full results for the 36-month follow-up period are currently being analyzed and will be presented. Conclusion: Sino-nasal surgery is generally safe and effective. Greatest symptom reduction is seen with primary surgery for patients with extensive nasal polyposis. Greater attention should be paid to patient-reported symptoms when selecting patients for surgery. Significance: This is the largest study of its kind to date and provides a unique estimate of the safety and effectiveness of sino-nasal surgery from the perspective of the patient.
Orpington United Kingdom; London United Kingdom; Bristol United Kingdom
Problem: Using data from a large prospective cohort study, we evaluated whether the extent of surgery undertaken, use of endoscope and powered instrumentation, or grade of surgeon are independent predictors of outcome following surgery for nasal polyposis. Methods: Two thousand thirty-nine patients undergoing surgery for nasal polyposis in 87 participating UK hospitals were prospectively entered into the study. Information on patient prognostic factors, operative interventions, instrumentation, and surgeon grade was collected at the time of surgery and outcomes data were collected over the next 36 months. The main outcome measures used were the SNOT-22, a patient-based outcome instrument, and revision rates. Robust multivariate and logistic regressions were performed to identify factors associated with improved outcome. Results: There is a clinically (0.81 SD) and statistically significant symptomatic improvement 36 months following surgery for polyposis. However, 11.2% of patients have required revision surgery. The most common procedure undertaken is simple polypectomy (34.3%). Multivariate regression demonstrates that revision rates are significantly lower for more extensive surgery compared with simple polypectomy alone (odds ratio for revision following anterior ethmoidectomy versus simple polypectomy ⫽ 0.26, P ⫽ 0.017). Symptomatic improvement does not differ significantly. Use of the microdebrider has an additional independent effect on revision rates, without a significant increase in adverse events. Endoscopic surgery, compared with conventional illumination, does not confer an independent advantage in terms of revision rates or symptomatic improvement, but facilitates more extensive surgery to be undertaken in a safe manner. Appropriate case-selection ensures that there is no detrimental outcome effect when nonconsultant surgeons undertake sinonasal surgery. Conclusion: Surgery is effective for symptomatic relief in nasal polyposis. We may reduce the high revision rates associated with this condition by undertaking endoscopic surgery extending into the sinuses, combined with judicious use of powered instrumentation. Significance: Polyposis is a common problem with excep-
TUESDAY
8:48 AM
Research Forum—Tuesday
tionally high recurrence rates after surgery, which may be reduced by modern surgical techniques. Support: None reported. 9:04 AM Psychiatric Distress Amplifies Symptoms after Surgery for Chronic Rhinosinusitis Greg Davis, MD (presenter); Bevan Yueh, MD MPH; Edward A Walker, MD; Wayne Katon, MD; Thomas D Koepsell, MD MPH; Ernest A Weymuller, Jr, MD Seattle WA; Seattle WA; Seattle WA; Seattle WA; Seattle WA; Seattle WA
Problem: Psychiatric disorders are associated with increased symptom burden when combined with chronic medical conditions. However, there are no reports of how psychiatric distress influences outcomes with surgical treatment for chronic rhinosinusitis (CRS). We hypothesized that subjects with psychiatric distress (somatization, anxiety, and depression) would report more severe long-term sinus symptoms and worse quality of life (QOL) than subjects without psychiatric distress. Methods: This is a community-based, prospective, observational cohort study of patients diagnosed with CRS presenting for surgery. Patients were interviewed prior to surgery; their CT scans were reviewed; and they completed questionnaires about sinusitis-related symptoms (SNOT-16), general health status and QOL (SF-36), and psychiatric distress (BSI and PHQ). Outcomes were also assessed 1, 3, 6, and 12 months postoperatively. Results: Ninety-five patients had complete records for analysis. Psychiatric distress was prevalent, with 31% screening positive for somatization, 17% positive for anxiety, and 25% positive for depressive disorders. Subjects with somatization had significantly worse SNOT-16 scores at each time point compared to those without somatization (P ⬍ 0.05). Subjects with depression reported more severe symptoms at 6 and 12 months after surgery than those without depression (P ⬍ 0.05). The presence of somatization preoperatively was also independently associated with symptom severity 12 months after surgery, even after adjusting for prior sinus surgery, CT stage, Charlson Index, and deviated septum. Additionally, subjects with psychiatric distress reported significantly worse SF-36 physical and mental component summary scores 12 months after surgery than subjects without psychiatric distress. Conclusion: Psychiatric distress is associated with worse reported sinus symptoms and lower QOL throughout surgical management of chronic rhinosinusitis. Despite this, subjects with psychiatric distress report a similar degree of improvement in sinus symptoms after surgery compared to those without distress. Significance: Psychiatric distress should be considered in
patients with persistent symptoms following surgery. Psychiatric distress should also be considered in efforts to design a chronic sinusitis staging system. Support: Dr Davis was supported by an NIH Training Grant (DC-00018) during this project. Dr Bevan Yueh is supported by a Career Development Award (CD-98318) from the Department of Veterans Affairs. This project was funded, in part, by a Resident Research Gran 9:12 AM Study of Lubricant-Induced Changes in Chronic Snorers Rohan C Wijewickrama, BA (presenter); P David Blalock, CCC SLP; James W Mims, MD Winston-Salem NC; Winston Salem NC; Winston Salem NC
MA
Problem: The efficacy of many of the noninvasive treatments for snoring has not been evaluated in controlled trials. This study seeks to evaluate the efficacy of an oil-based spray in the treatment of snoring, in a double-blinded, placebocontrolled, cross-over trial using objective acoustic analysis and subjective questionnaires. Methods: Participants were randomized to use both oilbased oral spray (treatment) and water-based oral spray (placebo) during a 2-night in-home study period. Questionnaires were completed by the participant and his/her bed-partner; these were evaluated along with audiotape recordings, which were analyzed for frequency, duration, and mean energy of snoring. Results: Greatest snoring rate demonstrated 30% ⫽ benefit; 40% ⫽ no change; 30% ⫽ adverse effect (n ⫽ 20). percent time snoring yielded: 30% ⫽ benefit; 15% ⫽ no change; 55% ⫽ adverse effect (n ⫽ 20). Study data results for mean energy were (n ⫽ 12): 17% ⫽ benefit; 33% ⫽ no change; 50% ⫽ adverse effect. Bed-partner observations (n ⫽ 17) demonstrated 37% ⫽ benefit; 38% ⫽ no change, 25% ⫽ adverse effect. Conclusion: Objective and subjective evaluation of the performance of the oil-based Snoreless spray in comparison to placebo demonstrated a lack of efficacy in snoring reduction. Significance: Study findings indicate that oil-based oral sprays are not effective in the treatment of snoring. Support: None reported. 9:20 AM Acceptance of Treatment Suggestions for SleepDisordered Breathing Thomas Verse, MD (presenter); Kerstin Wiesmiller; Wolfgang Pirsig, MD; Boris A Stuck, MD; Joachim T Maurer, MD; Karl Hoermann, MD Mannheim Germany; Ulm Germany; Ulm Germany; Mannheim Germany; Mannheim Germany; Mannheim Germany
TUESDAY
P122
Otolaryngology– Head and Neck Surgery August 2004