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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 21  |  Issue : 2  |  Page : 33-36

Risk factors of recurrent chronic rhinosinusitis after functional endoscopic sinus surgery


1 College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 College of Medicine, Majmaah University, Riyadh, Saudi Arabia
3 Department of Otolaryngology and Surgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia

Date of Submission14-Apr-2019
Date of Decision15-May-2019
Date of Acceptance22-Jun-2019
Date of Web Publication22-Oct-2019

Correspondence Address:
Dr. Waleed Abdullah Mohsenh
College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJOH.SJOH_4_19

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  Abstract 


Background: Chronic rhinosinusitis (CRS) is one of the most common chronic diseases, which is defined as an inflammation of the nose and paranasal sinuses. Computed tomography (CT) scan of paranasal sinuses has become mandatory for all patients undergoing functional endoscopic sinus surgery (FESS), which is, nowadays, regarded as the gold standard for treatment of CRS after a trial of medical treatment. Our aim in this study is to explore the risk factors and anatomical findings on CT scan of CRS patients who had recurrence after FESS in King Abdulaziz Medical City, Riyadh, Saudi Arabia. Methods: A retrospective chart review study was conducted in the section of otolaryngology head and neck surgery to assess the risk factors of patients with recurrent CRS after FESS. The study included all patients, who were adults 16 years of age and above of both genders that had FESS after a diagnosis of CRS between 2016 and 2018. Results: The study identified 257 patients with CRS, of which 38 (14.79%) patients had recurrence after FESS. Various risk factors were taken into consideration such as age, gender, airway and inflammatory autoimmune diseases, smoking, type of sinusitis, and anatomical variations and findings on CT scan. However, only fungal type of sinusitis was found to be a significant risk factor of a recurrent CRS. Anatomical findings on CT scan postoperatively were mucosal thickening, nasal polyps, nasal septum deviation, and obliterated osteomeatal complex. Conclusion: CRS patients were assessed for various risk factors of recurrent CRS. The overall incidence of recurrent CRS was 14.79%. Fungal rhinosinusitis was found to be a significant risk factor. The most common anatomical findings on CT scan postoperatively were mucosal thickening in paranasal sinuses followed by nasal polyps.

Keywords: Chronic rhinosinusitis, computed tomography scan, functional endoscopic sinus surgery, recurrence


How to cite this article:
Mohsenh WA, Aljthalin RA, Aljthalin RA, Al-Bahkaly S. Risk factors of recurrent chronic rhinosinusitis after functional endoscopic sinus surgery. Saudi J Otorhinolaryngol Head Neck Surg 2019;21:33-6

How to cite this URL:
Mohsenh WA, Aljthalin RA, Aljthalin RA, Al-Bahkaly S. Risk factors of recurrent chronic rhinosinusitis after functional endoscopic sinus surgery. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2019 [cited 2019 Dec 12];21:33-6. Available from: http://www.sjohns.org/text.asp?2019/21/2/33/269711




  Introduction Top


Chronic rhinosinusitis (CRS) is one of the most common chronic diseases which is defined as an inflammation of the nose and paranasal sinuses that persists for 12 weeks or longer with two or more of the following symptoms: nasal congestion or blockade, anterior or posterior nasal discharge, facial pain or pressure, reduction or loss of smell (anosmia), complementary endoscopic signs, and computed tomography (CT) changes.[1] CRS may manifest as one of three major clinical presentations: CRS without nasal polyps, CRS with nasal polyps, or allergic fungal rhinosinusitis. These classifications possess a great deal of therapeutic significance.[2]

Nowadays, functional endoscopic sinus surgery (FESS) is regarded as the gold standard for the treatment of CRS, with or without nasal polyposis refractory to optimal medical treatment. This surgery is based on the principles of improved function and patency of the complex bone-meat, through interventions in the sidewall of the nose.[3]

The following conditions and risk factors have been identified in different studies that predispose patients to the development of CRS: anatomic abnormalities of the ostiomeatal complex (e.g., septal deviation, concha bullosa, deviation of uncinate process, and Haller cells), allergic rhinitis, aspirin sensitivity, asthma, nasal polyps, obstruction by tumor, immunologic disorders (e.g., common variable immunodeficiency, immunoglobulin [Ig] A deficiency, IgG subclass deficiency, and AIDS), cystic fibrosis, primary ciliary dyskinesia, kartagener syndrome, repeated viral upper respiratory tract infections, smoking, environmental irritants and pollutants, gastroesophageal reflux disease, and systemic diseases (e.g., granulomatosis with polyangiitis [Wegener granulomatosis], Churg-Strauss vasculitis, and sarcoidosis).[2],[3],[4]

It is estimated that the total recurrence rate of CRS resides in a spectrum of percentages between 9% and 16%. A study was done in the Department of Otolaryngology, Taichung Veterans General Hospital, showed 9.18% of all patients with CRS have undergone revision of FESS within 1 year of the failure of primary FESS.[4] Even a higher incidence of 16.1% was reported by the Department of Otorhinolaryngology, Jikei University School of Medicine, Tokyo.[5]

Moreover, our review of literature did not reveal any similar studies done in Saudi Arabia or Arabic countries that studied the recurrence rate, and risk factors associated with CRS except one, that was conducted in 1988 in Saudi children, revealed a prevalence rate for sinusitis of 8.5% among new patients of total number of 74 cases occurred in 69 patients, with five recurrences and patients age ranged from 7 months to 14 years.[6] Hence, our research will specify the number of adult CRS patients who had recurrence and determine the risk factors associated with such an event. Based on the findings of this study, we will identify a group of patients who are under the risk of developing the recurrence and estimate the success rates of their primary FESS.


  Methods Top


A retrospective chart review study was conducted to assess the risk factors of patients with recurrent CRS after FESS and to evaluate the anatomical findings on CT scan postoperatively. Ethical approval was obtained from King Abdullah International Medical Research Center, and consents were not needed from patients. The list of patients was provided from the department of otolaryngology head and neck surgery after obtaining the institutional review board approval. The research team took the responsibility of collecting the data from the patients' file.

Study settings

The study conducted at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. KAMC is a governmental hospital with a bed capacity of 690 beds, provides all types of care to all National Guard employees and their families, and it also accepts patients from different nationalities, starting from primary care up to tertiary specialized care. The section of otolaryngology head and neck surgery comprises eight consultants, four associate consultants. The section offers a wide range of services ranging from pediatric airway reconstruction, cochlear implant, and endoscopic sinus surgeries to major head and neck surgeries.

Study subjects

The study included 258 patients who are all adults, 16 years of age and above, from both genders and from all nationalities who were admitted to do FESS after a diagnosis of CRS between 2016 and 2018.

Data collection

A chart review study was done, and the data were collected by Excel datasheet that includes different variables and risk factors. The variables and risk factors include: anatomical findings on CT scan after FESS, airway diseases, inflammatory autoimmune diseases, presenting symptoms, history of paranasal sinus surgery, type of sinusitis and the organism found, age, and gender. The outcome variable is a recurrence of CRS after FESS or not.

Statistical analysis

Data were analyzed by using SPSS software (IBM Corp, Released 2013. IBM statistics for windows, Version 22.0. Armonk, New York, USA). Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as percentages. The Chi-square test was used for categorical variables. T-test and one-way analysis of variance were used for continuous variables. Logistic regression was used to assess the risk factors. P < 0.05 was considered statistically significant.


  Results Top


The study identified 257 patients, of which 38 patients (14.79%) had recurrence of CRS after FESS. All patients with recurrence had CT scan postoperatively. Twenty patients had a revision of FESS, yet symptoms improved after that. However, four patients improved with a medical treatment without a revision of FESS, but only fourteen patients did not show an improvement even after a revision of FESS. Various risk factors were taken into consideration such as age, gender, airway and inflammatory autoimmune diseases, smoking, type of sinusitis, and anatomical variations and findings on CT scan. [Table 1] shows the characteristics of patients by recurrent CRS after FESS. However, only fungal type of sinusitis was found to be a significant risk factor of recurrent CRS. [Table 2] shows univariate logistic regression for risk factors of patients with recurrent CRS after FESS.
Table 1: Characteristics of patients by recurrent chronic rhinosinusitis after functional endoscopic sinus surgery

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Table 2: Univariate logistic regression for risk factors of patients with recurrent chronic rhinosinusitis after functional endoscopic sinus surgery

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Anatomical findings on CT scan postoperatively were mucosal thickening that was found in 13 patients, followed by osseous defect or skull base defect that was found in eight patients. Deviated nasal septum was found in seven patients only, whereas nasal polyp or progression of polypoidal disease was found in eight patients and only two of them had the sinonasal polyposis protruding to the orbit. Adenoid hypertrophy was not common and was found only in one patient. [Figure 1] shows Computed tomography (CT) scan of a patient with fungal chronic rhinosinusitis that had recurrence after functional endoscopic sinus surgery.
Figure 1: Computed tomography scan of a patient with fungal chronic rhinosinusitis that had recurrence after functional endoscopic sinus surgery, (a) represents the CT scan preoperatively in 2015, and (b) represents the CT scan postoperatively in 2017 which shows interval worsening of the previously noted polypoid mucosal thickening involves the right maxillary antrum with near total opacification of the rest of the paranasal sinuses after 2 years of the operation

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The majority of patients that were diagnosed with CRS and admitted for FESS had a nasal obstruction alone or accompanied with anosmia or postnasal drip. Facial pain that is considered to be one of the major criteria was not common. [Table 3] shows the clinical presentation of CRS of all patients.
Table 3: Clinical presentation of chronic rhinosinusitis

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  Discussion Top


As one of the most common chronic diseases, a controversy among various studies of the incidence of recurrent CRS leads us to the need of multiple studies to identify more of risk factors to develop recurrent CRS after a successful FESS. The variability of the prevalence and incidence among different studies can be related to different genetic and environmental factors. In this study, the prevalence of recurrent CRS is 14.79%, which is considered to be within the average of different studies.[4],[5],[7]

However, patients of CRS presented to our institute in different presentations. Some patients had all the major symptoms in the diagnosis criteria of CRS and some had only minor symptoms with CT changes. Nasal obstruction alone was the most common presentation among 73 patients in 28%, followed by nasal obstruction with anosmia in 25% of 66 patients. As many previous papers agreed with our result in which nasal obstruction was the major Complaint, except Rafii study, who identified cough in 54% as the most common presenting symptom.[6]

Various risk factors were taken into consideration; fungal rhinosinusitis was found to be a significant risk factor in 82%. On the other hand, other risk factors presented as airway disease in 55%, inflammatory diseases 7%, smoking 15.8%, and anatomical variation 13.2%. This association supports the study of Musy and Kountakis, when they explained a significant number of patients had systemic illnesses, including asthma in 18 (26%).[8] Similarly, Matsuwaki et al. found that the recurrence rate of CRS and asthma, peripheral eosinic count, and mucosal eosinic count were significant risk factors for the recurrence. In opposite to our study, fungal infection was high in recurrence group but not significant.[5] Same Kim et al. were investigated the prevalence of CRS in Korea which present in 6.95% and among these population, persistent/moderate to severe allergic rhinitis was proven to be the most significant risk factor.[9] In opposite to our study, fungal infection was high in recurrence group but not significant.

CT scan of the paranasal sinuses has become mandatoryfor all patients undergoing FESS as Jiang RS et al. studied the anatomical change on CT scan postoperatively in patients undergone revision of FESS within 1 year of failure of primary FESS, the most common cause of revision of FESS was adhesion in osteomeatal complexes, stenosis of middle meatus and recurrent polypoidal disease.[10] Furthermore, Pierre Y et al. found on CT the most common findings was lateralized middle turbinates in 78% but who had retained agger nasi cell were in 49% while recurrent polyposis found in 37% and undiagnosed allergic fungal sinusitis in 1% of patients.[8] Our study found mucosal thickening followed by osseous defect or skull base defect as the most common anatomical findings on CT scan postoperatively while adenoid hypertrophy was not common and found only in one patient. Different results, high percentage of patient required FESS revision was due to postoperative nasal polyposis, Kuan et al. and Bassiouni and Wormald.[11],[12]

There are multiple limitations of this study. The retrospective study design did not allow us to collect a full data from the medical records regarding the details of each case as well as other missing data that can be easily completed if we conducted the study prospectively. Furthermore, patients who had FESS operation in the last months of 2018, we could not follow them afterward to see whom of them have a recurrence of CRS.


  Conclusion Top


The prevalence of CRS was higher among males with a mean age of 37 years, and nasal obstruction alone was the major presentation. In conclusion, the prevalence of recurrent CRS is within the average that found in the literature (14.79%). This study suggests a significant association between fungal infection with recurrent CRS. The most common anatomical findings on CT scan postoperatively was mucosal thickening in paranasal sinuses followed by nasal polyps. A prospective multicentric chart review study taking into consideration more risk factors would make the relationship of risk factors and recurrent CRS patients more clear.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abualnasr SA, Alattas AM, Abualnasr AA, Alsrisri HA, Aljeraisi T. Prevalence of chronic rhino sinusitis and IT\'s recurrent after treatment compare to its recurrent after surgery at Saudi Arabia, 2016. Int J Adv Res 2017;5:2310-8.  Back to cited text no. 1
    
2.
Brook I. Department of Pediatrics, Georgetown University School of Medicine, Chronic Sinusitis. Medscape; 2018.  Back to cited text no. 2
    
3.
Basílio FM, Arantes MC, Ballin AC, Dallagnol MR, Bornhausen MB, Szkudlarek DC, et al. Efficacy of endoscopic sinus surgery in the treatment of chronic rhinosinusitis. Int Arch Otorhinolaryngol 2010;14:433-7.  Back to cited text no. 3
    
4.
Wide K, Suonpää J, Laippala P. Recurrent and prolonged frontal sinusitis. Clin Otolaryngol Allied Sci 2004;29:59-65.  Back to cited text no. 4
    
5.
Matsuwaki Y, Ookushi T, Asaka D, Mori E, Nakajima T, Yoshida T, et al. Chronic rhinosinusitis: Risk factors for the recurrence of chronic rhinosinusitis based on 5-year follow-up after endoscopic sinus surgery. Int Arch Allergy Immunol 2008;146 Suppl 1:77-81.  Back to cited text no. 5
    
6.
Rafii ZS. Sinusitis in Saudi children. Ann Saudi Med 1990;10:504-7.  Back to cited text no. 6
    
7.
Huang BY, Lloyd KM, DelGaudio JM, Jablonowski E, Hudgins PA. Failed endoscopic sinus surgery: Spectrum of CT findings in the frontal recess. Radiographics 2009;29:177-95.  Back to cited text no. 7
    
8.
Musy PY, Kountakis SE. Anatomic findings in patients undergoing revision endoscopic sinus surgery. Am J Otolaryngol 2004;25:418-22.  Back to cited text no. 8
    
9.
Kim YS, Kim NH, Seong SY, Kim KR, Lee GB, Kim KS, et al. Prevalence and risk factors of chronic rhinosinusitis in Korea. Am J Rhinol Allergy 2011;25:117-21.  Back to cited text no. 9
    
10.
Jiang RS, Hsu CY. Functional endoscopic sinus surgery in children and adults. Ann Otol Rhinol Laryngol 2000;109:1113-6.  Back to cited text no. 10
    
11.
Kuan EC, Mallen-St Clair J, Frederick JW, Tajudeen BA, Wang MB, Harvey RJ, et al. Significance of undissected retromaxillary air cells as a risk factor for revision endoscopic sinus surgery. Am J Rhinol Allergy 2016;30:448-52.  Back to cited text no. 11
    
12.
Bassiouni A, Wormald PJ. Role of frontal sinus surgery in nasal polyp recurrence. Laryngoscope 2013;123:36-41.  Back to cited text no. 12
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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