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Surgical outcomes in rhinosinusitis: What we know
Otolaryngology– Head and Neck Surgery APRIL 1999
VOLUME 120
NUMBER 4
COMMENTARY Surgical outcomes in rhinosinusitis: What we know J. DAVID OSGUTHORPE, MD, Charleston, South Carolina
R
hinosinusitis is a common self-reported health problem in the United States, with an incidence of 135 per 1000 of population, and it was the reason for 11,898,000 physician office visits in 1995.1,2 It has been the topic of more than 3700 articles in the world literature since 1985, of which at least 820 were surgical. A preponderance of these surgical articles emphasized transnasal approaches, which were elucidated earlier this century by Mosher,3 Yankauer,4 Hajek,5 and others6,7; however, not until the 1970s and after were longer term results on substantial numbers of patients reported by Eichel, 8 Friedman, 9 Sogg, 10 Freedman and Kern,11 Lawson,12 and others.13 The endoscopic (ESS) variation of the transnasal approach has dominated the otolaryngology literature since promulgation of the Messerklinger14 technique by Stammberger and Posawetz15 and Senior and Kennedy,16 and other variations by Wigand and Hosemann17 and others18,19 from the mid-1980s. Most early publications dealt with technical aspects and complications of the procedure; it was not until 1989 that 1-year postoperative results on 100 consecutive patients were reported by Rice.20 Even today, there is a dearth of prospective, long-term reports on the outcomes of medical or surgical management of recurrent acute or chronic rhinosinusitis, for which From the Department of Otolaryngology and Communicative Sciences, Medical University of South Carolina, Charleston. Reprint requests: J. David Osguthorpe, MD, Professor, Department of Otolaryngology and Communicative Sciences, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425. Otolaryngol Head Neck Surg 1999;120:451-3. Copyright © 1999 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/99/$8.00 + 0 23/10/95228
approximately 200,000 sinus procedures were performed in the United States last year.1,2,13,21 Assessment of treatments of recurrent acute or chronic rhinosinusitis is hampered by the lack of a universally accepted sinus disease staging system and standards for reporting results. Just this past year a task force of the American Academy of Otolaryngology– Head and Neck Surgery (AAO-HNS), with input from the American Rhinologic Society and the American Academy of Otolaryngic Allergy, assembled definitions for the various types of rhinosinusitis, the essential elements of clinical and radiographic evaluations, and the reasons for operative interventions.2,22,23 At the time 6 outcomes measures for rhinosinusitis had been promulgated in the recent English language literature, with another added since. What is clear is that both recurrent acute rhinosinusitis and chronic rhinosinusitis have an impact on individuals’ assessments of their health, and as such their self-assessments significantly depressed 5 of 8 subscales of the most common health-related outcomes measure, the MOS-SF36.21,24-26 Postoperative freedom from sinus disease as assessed by subjective or objective measures diminishes with time. Of objective tests CT, rhinomanometry, and olfactory testing are not consistently reliable as followup measures.2,13 Reports suggest that abnormalities detected by nasal endoscopy are the best early postoperative indicators of recurring disease (although the abnormalities produce symptoms in less than half of patients) and that subjective quality-of-life measures do not deteriorate until months to even years later.15,16 The length of any particular study’s follow-up is a major issue. Lawson12 noted “follow-up of 1 year is meaningless, with 2 years the very minimal interval,” 451
452
Otolaryngology– Head and Neck Surgery April 1999
OSGUTHORPE
and Schaitkin et al18 observed that “symptoms may not recur for up 3 years.” Their recommendations were subsequently confirmed by Maran,24 Drake-Lee,27 and Penttila et al.28 The literature indicates that the greatest percentage of recurrent disease becomes evident within 18 months after surgery, with lesser decrements in the symptom-free group for at least 18 further months (excluding frontal sinus disease, which requires much longer follow-up). However, a review by Terris and Davidson13 of the 10 largest series reported as of 1994 noted that 7 included patients with less than a year of follow-up. Most surgical series have involved single institutions or surgical groups, have been retrospective, and have involved modest numbers of patients (or have many lost to follow-up); few have had medical therapy and/or comorbidity controls. However, some conclusions can be drawn from the few dozen reports that contain sufficient numbers of subjects, follow-up, and technical details to draw meaningful, if incomplete, conclusions. Pooling of data from these studies seems reasonable, given the report by Pentilla et al28 of 150 adults matched and randomized between an ESS or CaldwellLuc approach to chronic sinusitis. Their report followed up 128 patients for 5 to 7 years and found no significant differences except that the ESS patients, when queried whether they would repeat the surgery, were more likely to accept than those subjected to the more painful transbuccal approach. Aside from the aforementioned study and a comparison of middle and inferior meatal antrostomies by Arnes et al,29 few studies compare the various surgical techniques (eg, transantral ethmoidectomy and transnasal approaches with an endoscope, microscope, or loupes). Common preoperative predictors of disease recurrence include, in approximate order of severity, Samter’s triad, failure of prior surgery, polyps, asthma (without polyps), inhalant sensitivities, and smoking. Substantial or total resolution of symptoms 2 or more years after sinus surgery, as estimated from my review of the literature since 1985, is 76% to 98% (some report higher or lower percentages), with subgroups of at least 93% success in patients with “uncomplicated” chronic or recurrent acute rhinosinusitis, 82% to 90% in those with coexisting polyps, about 70% in those having had prior sinus surgery, and 39% in those with Samter’s triad. Most patients receiving medication for asthma or inhalant sensitivities continue to require medication after surgery (52% to 73%16,21), although patients with asthma usually have improvement in the severity/frequency of bronchospastic events and can diminish medication levels. Immune deficiencies, cystic fibrosis, allergic fungal sinusitis, and the like are associated with
a high incidence of recurrent rhinosinusitis, regardless of medical or surgical interventions, but the numbers of patients in reports to date are insufficient for analysis. Part of the problem in analyzing long-term results is that the follow-up of patients in most studies is usually not provided for those requiring revisions (indeed, many consider the procedure successful if the patient is symptom free for an undefined period after revision). Surgical revision rates range from 18% to 25% and are needed to address, in order of frequency, synechiae, ostial stenosis (commonly maxillary followed by frontal), and obstructing polyps. Serious complications of sinus surgery range from 0.3% to 1.1% (some authors include all epistaxis, whereas others count only major bleeds; all include orbital hematoma or cerebrospinal fluid leak), and minor complications range from 2% to 8.3%, depending on whether the author counts early lysis of synechiae or removal of granulations. Government agencies and health maintenance organizations place increasing emphasis on outcomes studies (eg, coronary bypass surgery vs angioplasty or pharmacotherapy for angina) and the costs of interventions compared with changes in quality-of-life measures.21,25,30 Indeed, otitis media in children has recently been studied, as acute rhinosinusitis is currently, by the federal Agency for Health Care Policy and Research; scrutiny of chronic rhinosinusitis is imminent. An expectation of complete and permanent resolution of nasal/sinus symptoms after sinus surgery is unrealistic, given the underlying significant diseases in some (eg, cystic fibrosis, immune deficiencies); the continued mucosal stimulation by allergies, tobacco smoke, and the like in many; and the occasional viral infections in all (ie, a single episode of rhinosinusitis associated with influenza should not mean prior sinus surgery was unsuccessful). The AAO-HNS has embarked on a 3-year outcomes study of the medical and surgical managements of chronic rhinosinusitis. Parameters from disease classification to quality-of-life measures have been standardized, as have endoscopic and radiographic findings.2 Participation is open to any AAO-HNS fellow and is encouraged by both the American Rhinologic Society and the American Academy of Otolaryngic Allergy. REFERENCES 1. Kaliner M, Osguthorpe J, Fireman P, et al. Sinusitis: bench to bedside—current findings, future directions. Otolaryngol 1997; 116(Suppl):S1-20. 2. Anon J. Report of the Rhinosinusitis Task Force committee meeting. Otolaryngol Head Neck Surg 1997;117(Suppl):S1-68. 3. Mosher HP. The applied anatomy in the intranasal surgery of the ethmoidal labyrinth. Trans Am Laryngeal Assoc 1912;34:25-39.
Otolaryngology– Head and Neck Surgery Volume 120 Number 4
4. Yankauer S. Demonstration of intra-nasal surgery on wet specimen. Laryngoscope 1930;40:642-5. 5. Hajek M. Pathology and treatment of the inflammatory diseases of the nasal accessory sinuses. 1st ed. Mosby: St Louis; 1926. 6. Kubo I. Supraturbinale eroffnung bei der sinusitis maxillaris chronica. Arch Laryngol Rhinol 1912;26:351-6. 7. Siebenmann E, Beitr Z, von Lehre D. Entstehung und heilung rombinierter nebenhohleneiterungen der nase. Monatcsh Ohren 1912;46:656-71. 8. Eichel B. Intranasal ethmoidectomy: a 12 year perspective. Otolaryngol Head Neck Surg 1982;90:540-3. 9. Friedman W, Katsantonis G. Intranasal and transantral ethmoidectomy: a twenty year experience. Laryngoscope 1990;100: 343-8. 10. Sogg A. Long term results of ethmoid surgery. Ann Otol Rhinol Laryngol 1989;98:699-701. 11. Freedman H, Kern E. Complications of intranasal ethmoidectomy: a review of 1000 consecutive patients. Laryngoscope 1979; 89:421-34. 12. Lawson W: The intranasal ethmoidectomy: evaluation and assessment of the procedure. Laryngoscope 1994;104(suppl 64): S1-S49. 13. Terris M, Davidson T. Review of published results for endoscopic sinus surgery. Ear Nose Throat J 1994;73:574-80. 14. Messerklinger W. Endoscopy of the nose. 1st ed. Urban and Schwarzenberg: Baltimore; 1978. 15. Stammberger H, Posawetz W. Functional endoscopic sinus surgery: concept, indications and results of the Messerklinger technique. Eur Arch Otorhinolaryngol 1990;247:63-7. 16. Senior B, Kennedy D, Tanabodee J, et al. Long-term results of functional endoscopic sinus surgery. Laryngoscope 1998;108: 151-7. 17. Wigand M, Hosemann W. Results of endoscopic surgery of the
OSGUTHORPE
18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.
453
paranasal sinuses and anterior skull base. J Otolaryngol 1991;20: 385-90. Schaitkin B, May M, Shapiro A, et al. Endoscopic sinus surgery: 4-year follow-up on the first 100 patients. Laryngoscope 1993; 103:1117-20. Levine H. Functional endoscopic sinus surgery: evaluation, surgery and follow-up of 250 patients. Laryngoscope 1990;100:79-84. Rice D. Endoscopic sinus surgery: results at 2 year follow-up. Otolaryngol Head Neck Surg 1989;101:476-9. Gliklich R, Metson R. Economic implications of chronic sinusitis. Otolaryngol Head Neck Surg 1998;118:344-9. Anand V, Osguthorpe J, Rice D. Surgical management of adult rhinosinusitis. Otolaryngol Head Neck Surg 1997;117(Suppl): S50-52. Lusk R, Stankiewicz J. Pediatric rhinosinusitis. Otolaryngol Head Neck Surg 1997;117(Suppl):S53-7. Maran AG. Endoscopic sinus surgery. Eur Arch Otorhinolaryngol 1994;251:309-18. Gliklich R, Metson R. The effect of sinus surgery on quality of life. Otolaryngol Head Neck Surg 1997;117:12-6. Leopold D, Ferguson BJ, Piccirillo JF. Outcomes assessment. Otolaryngol Head Neck Surg 1997;117(Suppl):S58-S68. Drake-Lee A. Magical numbers and the treatment of nasal polyps. Clin Otolaryngol 1996;21:193-7. Penttila M, Rautiainen M, Pukander J, et al. Functional vs. radical maxillary surgery: failures after functional endoscopic sinus surgery. Acta Otolaryngol Suppl (Stockh) 1997;529:173-6. Arnes E, Anke I, Mair I. A comparison between middle and inferior meatal antrostomy in the treatment of chronic maxillary sinus infections. Rhinology 1985;23:65-9. Gliklich R, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg 1995;113:104-9.
Maxillofacial Courses
AO/ASIF Maxillofacial courses will be held June 12-13, 1999, in Atlanta, GA; July 17-18, 1999, in Montreal, Quebec, Canada; and August 7-8, 1999, in East Elmhurst, NY. These courses are intended for instructional training in the operative treatment of fractures, nonunions, osteotomies, and facial reconstructions involving the mandible, maxilla, and midface, according to AO/ASIF principles and techniques. Chairmen are Thomas Dodson, DMD, MPH; Daniel Buchbinder, DMD, Pierre Lavertu, MD; and Norman Clark, DMD, MD, and it is accredited by the AO North America. Credit: 14 AMA category 1 CME credits. For further information, contact the AO/ASIF Continuing Education Office, 1690 Russell Rd, PO Box 1766, Paoli, PA 19301; phone, 800-769-1391; fax, 610-251-5039.
VOLUME 120
NUMBER 4
COMMENTARY Surgical outcomes in rhinosinusitis: What we know J. DAVID OSGUTHORPE, MD, Charleston, South Carolina
R
hinosinusitis is a common self-reported health problem in the United States, with an incidence of 135 per 1000 of population, and it was the reason for 11,898,000 physician office visits in 1995.1,2 It has been the topic of more than 3700 articles in the world literature since 1985, of which at least 820 were surgical. A preponderance of these surgical articles emphasized transnasal approaches, which were elucidated earlier this century by Mosher,3 Yankauer,4 Hajek,5 and others6,7; however, not until the 1970s and after were longer term results on substantial numbers of patients reported by Eichel, 8 Friedman, 9 Sogg, 10 Freedman and Kern,11 Lawson,12 and others.13 The endoscopic (ESS) variation of the transnasal approach has dominated the otolaryngology literature since promulgation of the Messerklinger14 technique by Stammberger and Posawetz15 and Senior and Kennedy,16 and other variations by Wigand and Hosemann17 and others18,19 from the mid-1980s. Most early publications dealt with technical aspects and complications of the procedure; it was not until 1989 that 1-year postoperative results on 100 consecutive patients were reported by Rice.20 Even today, there is a dearth of prospective, long-term reports on the outcomes of medical or surgical management of recurrent acute or chronic rhinosinusitis, for which From the Department of Otolaryngology and Communicative Sciences, Medical University of South Carolina, Charleston. Reprint requests: J. David Osguthorpe, MD, Professor, Department of Otolaryngology and Communicative Sciences, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425. Otolaryngol Head Neck Surg 1999;120:451-3. Copyright © 1999 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/99/$8.00 + 0 23/10/95228
approximately 200,000 sinus procedures were performed in the United States last year.1,2,13,21 Assessment of treatments of recurrent acute or chronic rhinosinusitis is hampered by the lack of a universally accepted sinus disease staging system and standards for reporting results. Just this past year a task force of the American Academy of Otolaryngology– Head and Neck Surgery (AAO-HNS), with input from the American Rhinologic Society and the American Academy of Otolaryngic Allergy, assembled definitions for the various types of rhinosinusitis, the essential elements of clinical and radiographic evaluations, and the reasons for operative interventions.2,22,23 At the time 6 outcomes measures for rhinosinusitis had been promulgated in the recent English language literature, with another added since. What is clear is that both recurrent acute rhinosinusitis and chronic rhinosinusitis have an impact on individuals’ assessments of their health, and as such their self-assessments significantly depressed 5 of 8 subscales of the most common health-related outcomes measure, the MOS-SF36.21,24-26 Postoperative freedom from sinus disease as assessed by subjective or objective measures diminishes with time. Of objective tests CT, rhinomanometry, and olfactory testing are not consistently reliable as followup measures.2,13 Reports suggest that abnormalities detected by nasal endoscopy are the best early postoperative indicators of recurring disease (although the abnormalities produce symptoms in less than half of patients) and that subjective quality-of-life measures do not deteriorate until months to even years later.15,16 The length of any particular study’s follow-up is a major issue. Lawson12 noted “follow-up of 1 year is meaningless, with 2 years the very minimal interval,” 451
452
Otolaryngology– Head and Neck Surgery April 1999
OSGUTHORPE
and Schaitkin et al18 observed that “symptoms may not recur for up 3 years.” Their recommendations were subsequently confirmed by Maran,24 Drake-Lee,27 and Penttila et al.28 The literature indicates that the greatest percentage of recurrent disease becomes evident within 18 months after surgery, with lesser decrements in the symptom-free group for at least 18 further months (excluding frontal sinus disease, which requires much longer follow-up). However, a review by Terris and Davidson13 of the 10 largest series reported as of 1994 noted that 7 included patients with less than a year of follow-up. Most surgical series have involved single institutions or surgical groups, have been retrospective, and have involved modest numbers of patients (or have many lost to follow-up); few have had medical therapy and/or comorbidity controls. However, some conclusions can be drawn from the few dozen reports that contain sufficient numbers of subjects, follow-up, and technical details to draw meaningful, if incomplete, conclusions. Pooling of data from these studies seems reasonable, given the report by Pentilla et al28 of 150 adults matched and randomized between an ESS or CaldwellLuc approach to chronic sinusitis. Their report followed up 128 patients for 5 to 7 years and found no significant differences except that the ESS patients, when queried whether they would repeat the surgery, were more likely to accept than those subjected to the more painful transbuccal approach. Aside from the aforementioned study and a comparison of middle and inferior meatal antrostomies by Arnes et al,29 few studies compare the various surgical techniques (eg, transantral ethmoidectomy and transnasal approaches with an endoscope, microscope, or loupes). Common preoperative predictors of disease recurrence include, in approximate order of severity, Samter’s triad, failure of prior surgery, polyps, asthma (without polyps), inhalant sensitivities, and smoking. Substantial or total resolution of symptoms 2 or more years after sinus surgery, as estimated from my review of the literature since 1985, is 76% to 98% (some report higher or lower percentages), with subgroups of at least 93% success in patients with “uncomplicated” chronic or recurrent acute rhinosinusitis, 82% to 90% in those with coexisting polyps, about 70% in those having had prior sinus surgery, and 39% in those with Samter’s triad. Most patients receiving medication for asthma or inhalant sensitivities continue to require medication after surgery (52% to 73%16,21), although patients with asthma usually have improvement in the severity/frequency of bronchospastic events and can diminish medication levels. Immune deficiencies, cystic fibrosis, allergic fungal sinusitis, and the like are associated with
a high incidence of recurrent rhinosinusitis, regardless of medical or surgical interventions, but the numbers of patients in reports to date are insufficient for analysis. Part of the problem in analyzing long-term results is that the follow-up of patients in most studies is usually not provided for those requiring revisions (indeed, many consider the procedure successful if the patient is symptom free for an undefined period after revision). Surgical revision rates range from 18% to 25% and are needed to address, in order of frequency, synechiae, ostial stenosis (commonly maxillary followed by frontal), and obstructing polyps. Serious complications of sinus surgery range from 0.3% to 1.1% (some authors include all epistaxis, whereas others count only major bleeds; all include orbital hematoma or cerebrospinal fluid leak), and minor complications range from 2% to 8.3%, depending on whether the author counts early lysis of synechiae or removal of granulations. Government agencies and health maintenance organizations place increasing emphasis on outcomes studies (eg, coronary bypass surgery vs angioplasty or pharmacotherapy for angina) and the costs of interventions compared with changes in quality-of-life measures.21,25,30 Indeed, otitis media in children has recently been studied, as acute rhinosinusitis is currently, by the federal Agency for Health Care Policy and Research; scrutiny of chronic rhinosinusitis is imminent. An expectation of complete and permanent resolution of nasal/sinus symptoms after sinus surgery is unrealistic, given the underlying significant diseases in some (eg, cystic fibrosis, immune deficiencies); the continued mucosal stimulation by allergies, tobacco smoke, and the like in many; and the occasional viral infections in all (ie, a single episode of rhinosinusitis associated with influenza should not mean prior sinus surgery was unsuccessful). The AAO-HNS has embarked on a 3-year outcomes study of the medical and surgical managements of chronic rhinosinusitis. Parameters from disease classification to quality-of-life measures have been standardized, as have endoscopic and radiographic findings.2 Participation is open to any AAO-HNS fellow and is encouraged by both the American Rhinologic Society and the American Academy of Otolaryngic Allergy. REFERENCES 1. Kaliner M, Osguthorpe J, Fireman P, et al. Sinusitis: bench to bedside—current findings, future directions. Otolaryngol 1997; 116(Suppl):S1-20. 2. Anon J. Report of the Rhinosinusitis Task Force committee meeting. Otolaryngol Head Neck Surg 1997;117(Suppl):S1-68. 3. Mosher HP. The applied anatomy in the intranasal surgery of the ethmoidal labyrinth. Trans Am Laryngeal Assoc 1912;34:25-39.
Otolaryngology– Head and Neck Surgery Volume 120 Number 4
4. Yankauer S. Demonstration of intra-nasal surgery on wet specimen. Laryngoscope 1930;40:642-5. 5. Hajek M. Pathology and treatment of the inflammatory diseases of the nasal accessory sinuses. 1st ed. Mosby: St Louis; 1926. 6. Kubo I. Supraturbinale eroffnung bei der sinusitis maxillaris chronica. Arch Laryngol Rhinol 1912;26:351-6. 7. Siebenmann E, Beitr Z, von Lehre D. Entstehung und heilung rombinierter nebenhohleneiterungen der nase. Monatcsh Ohren 1912;46:656-71. 8. Eichel B. Intranasal ethmoidectomy: a 12 year perspective. Otolaryngol Head Neck Surg 1982;90:540-3. 9. Friedman W, Katsantonis G. Intranasal and transantral ethmoidectomy: a twenty year experience. Laryngoscope 1990;100: 343-8. 10. Sogg A. Long term results of ethmoid surgery. Ann Otol Rhinol Laryngol 1989;98:699-701. 11. Freedman H, Kern E. Complications of intranasal ethmoidectomy: a review of 1000 consecutive patients. Laryngoscope 1979; 89:421-34. 12. Lawson W: The intranasal ethmoidectomy: evaluation and assessment of the procedure. Laryngoscope 1994;104(suppl 64): S1-S49. 13. Terris M, Davidson T. Review of published results for endoscopic sinus surgery. Ear Nose Throat J 1994;73:574-80. 14. Messerklinger W. Endoscopy of the nose. 1st ed. Urban and Schwarzenberg: Baltimore; 1978. 15. Stammberger H, Posawetz W. Functional endoscopic sinus surgery: concept, indications and results of the Messerklinger technique. Eur Arch Otorhinolaryngol 1990;247:63-7. 16. Senior B, Kennedy D, Tanabodee J, et al. Long-term results of functional endoscopic sinus surgery. Laryngoscope 1998;108: 151-7. 17. Wigand M, Hosemann W. Results of endoscopic surgery of the
OSGUTHORPE
18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.
453
paranasal sinuses and anterior skull base. J Otolaryngol 1991;20: 385-90. Schaitkin B, May M, Shapiro A, et al. Endoscopic sinus surgery: 4-year follow-up on the first 100 patients. Laryngoscope 1993; 103:1117-20. Levine H. Functional endoscopic sinus surgery: evaluation, surgery and follow-up of 250 patients. Laryngoscope 1990;100:79-84. Rice D. Endoscopic sinus surgery: results at 2 year follow-up. Otolaryngol Head Neck Surg 1989;101:476-9. Gliklich R, Metson R. Economic implications of chronic sinusitis. Otolaryngol Head Neck Surg 1998;118:344-9. Anand V, Osguthorpe J, Rice D. Surgical management of adult rhinosinusitis. Otolaryngol Head Neck Surg 1997;117(Suppl): S50-52. Lusk R, Stankiewicz J. Pediatric rhinosinusitis. Otolaryngol Head Neck Surg 1997;117(Suppl):S53-7. Maran AG. Endoscopic sinus surgery. Eur Arch Otorhinolaryngol 1994;251:309-18. Gliklich R, Metson R. The effect of sinus surgery on quality of life. Otolaryngol Head Neck Surg 1997;117:12-6. Leopold D, Ferguson BJ, Piccirillo JF. Outcomes assessment. Otolaryngol Head Neck Surg 1997;117(Suppl):S58-S68. Drake-Lee A. Magical numbers and the treatment of nasal polyps. Clin Otolaryngol 1996;21:193-7. Penttila M, Rautiainen M, Pukander J, et al. Functional vs. radical maxillary surgery: failures after functional endoscopic sinus surgery. Acta Otolaryngol Suppl (Stockh) 1997;529:173-6. Arnes E, Anke I, Mair I. A comparison between middle and inferior meatal antrostomy in the treatment of chronic maxillary sinus infections. Rhinology 1985;23:65-9. Gliklich R, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg 1995;113:104-9.
Maxillofacial Courses
AO/ASIF Maxillofacial courses will be held June 12-13, 1999, in Atlanta, GA; July 17-18, 1999, in Montreal, Quebec, Canada; and August 7-8, 1999, in East Elmhurst, NY. These courses are intended for instructional training in the operative treatment of fractures, nonunions, osteotomies, and facial reconstructions involving the mandible, maxilla, and midface, according to AO/ASIF principles and techniques. Chairmen are Thomas Dodson, DMD, MPH; Daniel Buchbinder, DMD, Pierre Lavertu, MD; and Norman Clark, DMD, MD, and it is accredited by the AO North America. Credit: 14 AMA category 1 CME credits. For further information, contact the AO/ASIF Continuing Education Office, 1690 Russell Rd, PO Box 1766, Paoli, PA 19301; phone, 800-769-1391; fax, 610-251-5039.