Extensive surgical and comprehensive postoperative medical management for cystic fibrosis chronic rhinosinusitis

Abstract

Background: Chronic rhinosinusitis has a major impact on the quality of life of patients with cystic fibrosis (CF) and may contribute to progression of chronic lung disease. Despite multiple sinus surgeries, maxillary sinus involvement is a recurrent problem. The modified endoscopic medial maxillectomy (MEMM) permits debridement in the clinic, improves mucus clearance with nasal irrigations, and increases access for topical delivery of therapeutics. However, clinical outcomes of aggressive sinus surgery with regimented postoperative medical treatment have not been systematically evaluated.

Methods: CF patients completed the 22-Item Sinonasal Outcome Test questionnaires before sinus surgery (and bilateral MEMM) and at sequential postoperative visits. Objective measures included Lund-Kennedy endoscopic score and pulmonary function tests (forced expiratory volume at 1 second percent [FEV(1)%] predicted). Culture-directed antibiotic therapy, prednisone, and topical irrigations were initiated postoperatively.

Results: Twenty-two patients (mean age, 26.5 years; 4.9 prior sinus operations) underwent MEMM and sinus surgery. Symptom scores were significantly reduced at 60 days (primary outcome, 64.7 ± 18.4 presurgery versus 27.5 ± 15.3 postsurgery; p < 0.0001) and up to a year postoperatively (27.6 ± 12.6; p < 0.0001). Endoscopic scores were also reduced after surgery (10.4 ± 1.1 presurgery versus 5.7 ± 2.4 [30 days], 5.7 ± 1.4 [60 days], 5.8 ± 1.3 [120 days], and 6.0 ± 1.1 [1 year]; p < 0.0001)]. There were no differences in FEV(1)% predicted up to 1 year postoperatively, but hospital admissions secondary to pulmonary exacerbations significantly decreased (2.0 ± 1.4 versus 3.2 ± 2.4, respectively; p < 0.05).

Conclusion: Prospective evaluation indicates sinus surgery with MEMM is associated with marked improvement in sinus disease outcomes. Additional studies are necessary to confirm whether this treatment paradigm is associated with improved CF pulmonary disease.

Figure 1.

(A) Coronal CT scans showing the preoperative appearance of a patient with cystic fibrosis (CF) after traditional maxillary antrostomies with completely opacified maxillary sinuses (left, white arrow) and postoperative appearance after bilateral modified endoscopic medial maxillectomies and revision sinus surgery (right). (B) Transnasal endoscopic view of a left maxillary sinus after modified endoscopic medial maxillectomy. A 30° endoscope is inserted past the anterior ⅓ of the inferior turbinate revealing a well-healed maxillary cavity with no secretions retained in the floor of the sinus (arrow).

Figure 2.

Twenty-two Item Sinonasal Outcomes Test (SNOT-22) scores before and after aggressive sinus surgery with modified endoscopic medial maxillectomies and ordered postoperative medical management. (*p < 0.0001; n = 20).

Figure 3.

Total Twenty-two Item Sinonasal Outcomes Test (SNOT-22) score preoperatively and at each postoperative visit (*p < 0.0001). No significant difference in total SNOT-22 scores were observed among postoperativie visits (p = 0.89).

Figure 4.

Lund-Kennedy endoscopic score preoperatively and at each postoperative visit (*p < 0.0001).

Figure 5.

Forced expiratory volume at 1 second percent (FEV₁%) predicted preoperative and at each postoperative visit. FEV₁]% at 60 and 120 days were combined (p = 0.48).

Figure 6.

The number of hospital admissions per year before and after sinus surgery (*p < 0.05).