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. 2022 Feb;42(1):63-74.
doi: 10.14639/0392-100X-N1561.

Radiological score of computed tomography scans predicts revision surgery for chronic rhinosinusitis

Markus Lilja  1   2 , Anni Koskinen  1   2 , Anna Julkunen-Iivari  3 , Antti Mäkitie  2 , Jura Numminen  4 , Markus Rautiainen  4   5 , Jyri P Myller  6 , Antti Markkola  7 , Mikko Suvinen  8 , Mika Mäkelä  1 , Risto Renkonen  3   9 , Juha Pekkanen  10 , Sanna K Toppila-Salmi  1   3
Affiliations

Radiological score of computed tomography scans predicts revision surgery for chronic rhinosinusitis

Markus Lilja et al. Acta Otorhinolaryngol Ital. 2022 Feb.

Abstract
in English, Italian

Objective: Evaluate computed tomography (CT) signs that predict need for revision endoscopic sinus surgery (ESS) of chronic rhinosinusitis (CRS).

Methods: CRS patients (n = 48) underwent routine sinus CT scans and baseline ESS in 2006-2011. Lund-Mackay (LM) scores and 43 other CT signs were analysed blinded from both sides. Patients filled in a questionnaire during the day of CT scanning. Follow-up data were collected from hospital records until January 2018. Associations were analysed by Fisher's exact, Mann Whitney U, Kaplan-Meier method with logrank test and Cox's proportional hazard model.

Results: Total LM score was not significantly associated with the need for revision ESS. The best predictive model was a sum of CT signs of non-detectable anatomy of inferior/middle turbinates, obstructed frontal recess, and previous sinus surgery. Using these CT findings, we formed a Radiological Score (RS) (min-max, 0-3 points). Having at least one RS point was significantly associated with the need for revision ESS during the average follow-up of 10.7 years (p = 0.008, Logrank test).

Conclusion: We identified a radiologic score that was able to predict the need for revision ESS, which is probably useful in predicting CRS outcomes.

Score radiologico della Tac in grado di predire la revisione chirurgica nei pazienti affetti da rinosinusite cronica.

Obiettivo: Valutare i segni della tomografia computerizzata (TC) predittivi della necessità di un intervento di revisione endoscopica dei seni paranasali (ESS) nella rinosinusite cronica (CRS).

Metodi: I pazienti con CRS (n = 48) sono stati sottoposti a TC dei seni paranasali e ESS dal 2006 al 2011. I punteggi di Lund-Mackay (LM) e altri 43 segni TC sono stati analizzati in cieco. I pazienti hanno compilato un questionario di valutazione al momento dell’esecuzione della TC. Sono stati revisionati i dati di follow-up dei registri ospedalieri fino a Gennaio 2018. Le analisi sono state effettuate mediante test di Fisher, Mann Whitney U, Kaplan-Meier con il test di logrank e il modello di rischio proporzionale di Cox.

Risultati: Il punteggio LM totale non era significativamente associato alla necessità di revisione mediante ESS. Il miglior modello predittivo è risultato la somma dei seguenti reperti TC: turbinati inferiori/medi non rilevabili, recesso frontale ostruito ed esiti di precedenti interventi chirurgici nasosinusali. Utilizzando questi risultati TC, abbiamo creato un punteggio radiologico (RS) (min-max, 0-3 punti). Un punteggio RS minimo di uno, è significativamente associato alla necessità di revisione ESS durante il follow-up medio di 10,7 anni (p = 0,008, test di Logrank).

Conclusioni: Abbiamo identificato un punteggio radiologico in grado di prevedere la necessità di revisione ESS e quindi probabilmente utile nel predire gli esiti della CRS.

Keywords: CRSsNP; CRSwNP; computed tomography; prediction; rhinosinusitis.

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Figures

Figure 1.
Figure 1.
Examples of radiologic signs that were evaluated from sinus computed tomography (CT) scans, which were routinely performed due to clinical purposes. (A) Anatomical fine structures of middle turbinates are not detectable. (B) Middle and inferior turbinates are not detectable. (C) Obstructed frontal recess on both sides. (D) Signs of previous operation (middle meatal antrostomy on both sides) and undetectable left middle turbinate. The reasons for “not detectable” responses were poor visualisation of middle turbinate due to polypoid change or operative modification of turbinate. (E-G) Example of a patient with RS 0 score. (H-J) Example of a patient with RS 1 score. (K-L) Example of a patient with RS 2 score. (M-O) Example of a patient with RS 3 score.
Figure 2.
Figure 2.
Comparison of (A). Total VAS score of symptoms (nasal obstruction, facial pain/pressure, postnasal drip, sense of smell) (B). Total Lund-Mackay scores of sinus computed tomography (CT) scans in the chronic rhinosinusitis (CRS) patient groups who did or did not undergo revision ESS. All patients underwent baseline ESS performed within one year after the CT scans. P-values by Mann Whitney U test.
Figure 3.
Figure 3.
The receiver operating characteristic (ROC) curve plots for predictor models of baseline factors, in order to show how the radiological score was formed from the variables. The figure summarises the overall picture of different variables, and provides the possibility to compare predication potential of different variables. Area under the ROC curve (AUC) was used to obtain a model of probability that an individual will have uncontrolled chronic rhinosinusitis (CRS) after surgery. Several individual and combined variables were tested. The number of subjects was 38 in each curve. The dark blue line indicates the sum model of “signs of surgery + obstructed frontal recess + undetectable anatomy of inferior/middle turbinate” (e.g. “Radiological Score (RS)”) was showing to have good predictive potential and to contain easily identifiable variables, and thus it was selected for further analyses. * p value < 0.05.
Figure 4.
Figure 4.
The proportion of different signs (Y-axis) in sinus computed tomography (CT) scans in chronic rhinosinusitis (CRS) patients with or without a revision ESS in 5 years. (A) Paradoxical inferior/middle turbinate on both sides. (B) Pooled score of other structural/mucosal turbinate abnormalities than paradoxical inferior/middle turbinate on both sides. (C) Obstruction of at least one frontal recess. (D) Signs of at least one previous surgery. (E) Pooled score of the questions A and B of inferior turbinates on both sides. Difficulty in detecting the anatomy of inferior turbinate on at least one side (no, yes)? (F) Pooled score of the questions A and B of middle turbinates on both sides. Difficulty in detecting the anatomy of middle turbinate on at least one side (no, yes)? (G) Radiological Score (RS) that was assessed from scores (C-F) as follows; C) = 1 point, D) = 1 point, E-F) at least one “yes” = 1 point. RS is ranging between 0-3 H) Pooled RS 0 point; 1-3 points. P-values by Fisher’s exact test.
Figure 5.
Figure 5.
Predictive effect of radiological score (RS) of baseline sinus computed tomography (CT) scans to the time until the revision ESS was performed. All patients underwent baseline ESS within one year after the CT scans. Eight patients underwent revision ESS. The predictive effect was analysed according to the Kaplan-Meier method and p-values by log rank test. ESS = endoscopic sinus surgery.
Table II.
Table II.
Fifty variables, including 49 sinonasal structures, evaluated from sinus CT scans. All structures had 2-5 different choices. All potential variables of the Radiological Score (RS) are displayed in blue or red. All variables that ended in the RS are displayed in red.
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