10.14639/0392-100X-N1545
Objective. Stenosed sphenoid sinus ostia are among the most common findings in revision endoscopic sinus surgery. This study sought to identify the optimal intraoperative sphenoidotomy size for prevention of postoperative stenosis. Methods. 32 patients affected by chronic rhinosinusitis not associated with nasal polyps (CRSsNP) underwent 52 sphenoidotomies. Sphenoidotomy size was assessed using a ruler intraoperatively and at the first, third and sixth months postoperatively. Ostia sizes, SNOT- 22 questionnaire findings, episodes of recurrent sinusitis and need for revision surgery were recorded. Results. All sphenoidotomies exhibited a significant size reduction (mean 43.4 ± 6.8%) at the first month postoperatively, with a tendency to enlarge at 3 months and stabilise at 6 months. Ostia larger than 61.3 mm2 did not exhibit stenoses postoperatively. Stenosis was observed in 11 sphenoidotomies (21.2%); however, only five presented with recurrent symptoms (9.6%), while three required revision sphenoid surgery (5.8%). Conclusions. Sphenoidotomy size significantly reduced during the first postoperative month and then stabilised. A baseline sphenoidotomy size of 61.3 mm2 at the time of the operation seemed sufficient to prevent ostium stenosis. Half of stenosed ostia presented with recurrent symptoms.
text/xml
1827-675X
1545
en
Iordanis Konstantinidis
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
curette
Sphenoidotomy kinetics in patients with chronic rhinosinusitis without nasal polyps
Text.Serial.Journal
https://www.actaitalica.it/
42
Rhinology
2022-02-07
2021-03-06
2022-03-07
2022-03-07
55-62
1
Iordanis Konstantinidis
2022/02/07
10.14639/0392-100X-N1545
55
2nd Academic ORL Department, Papageorgiou Hospital, Aristotle University, Thessaloniki, Greece
1827-675X
curette
62
Sphenoidotomy kinetics in patients with chronic rhinosinusitis without nasal polyps
https://www.actaitalica.it/article/download/1545/731
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:55-62; doi: 10.14639/0392-100X-N1545




Rhinology


Sphenoidotomy kinetics in patients with chronic
rhinosinusitis without nasal polyps
Cinetica della sfenoidotomia nei pazienti affetti da rinosinusite cronica non associata
a poliposi nasale
Panagiotis D. Pyriochos1, Konstantinos Markou1, Jannis Constantinidis2, Iordanis Konstantinidis1
1
 2nd Academic ORL Department, Papageorgiou Hospital, Aristotle University, Thessaloniki, Greece; 2 1st Academic ORL Department,
AHEPA Hospital, Aristotle University, Thessaloniki, Greece


SUMMARY
Objective. Stenosed sphenoid sinus ostia are among the most common findings in revision
endoscopic sinus surgery. This study sought to identify the optimal intraoperative sphenoi-
dotomy size for prevention of postoperative stenosis.
Methods. 32 patients affected by chronic rhinosinusitis not associated with nasal polyps
(CRSsNP) underwent 52 sphenoidotomies. Sphenoidotomy size was assessed using a ruler
intraoperatively and at the first, third and sixth months postoperatively. Ostia sizes, SNOT-
22 questionnaire findings, episodes of recurrent sinusitis and need for revision surgery were
recorded.
Results. All sphenoidotomies exhibited a significant size reduction (mean 43.4 ± 6.8%)
at the first month postoperatively, with a tendency to enlarge at 3 months and stabilise at
6 months. Ostia larger than 61.3 mm2 did not exhibit stenoses postoperatively. Stenosis
was observed in 11 sphenoidotomies (21.2%); however, only five presented with recurrent
symptoms (9.6%), while three required revision sphenoid surgery (5.8%).
Conclusions. Sphenoidotomy size significantly reduced during the first postoperative
month and then stabilised. A baseline sphenoidotomy size of 61.3 mm2 at the time of the
operation seemed sufficient to prevent ostium stenosis. Half of stenosed ostia presented
with recurrent symptoms.                                                                         Received: March 6, 2021
                                                                                                 Accepted: September 14, 2021
KEY WORDS: sphenoidotomy, stenosis, kinetics, CRSsNP, curette                                    Published online: February 7, 2022

                                                                                                 Correspondence
RIASSUNTO                                                                                        Iordanis Konstantinidis
Obiettivo. Le stenosi degli osti sfenoidali sono tra i reperti più comuni nelle revisioni chi-   3A Kapetan Kotta str, Panorama, Thessaloniki,
rurgiche endoscopiche a carico di questo seno paranasale. Questo studio ha cercato di            Greece
identificare la dimensione ottimale della sfenoidotomia, misurata intraoperatoriamente,          Tel. +30 6973229525
per prevenire la stenosi postoperatoria.                                                         E-mail: jordan_orl@hotmail.com
Metodi. Trentadue pazienti affetti da rinosinusite cronica non associata a poliposi nasale
(CRSsNP) sono stati sottoposti a sfenoidotomia (52 sfenoidotomie). La dimensione della             How to cite this article: Pyriochos PD,
sfenoidotomia è stata valutata utilizzando un righello intraoperatoriamente, al primo, ter-        Markou K, Constantinidis J, et al. Sphenoi-
zo e sesto mese dopo l’intervento. Sono state registrate le dimensioni degli osti, i risultati     dotomy kinetics in patients with chronic rhi-
del questionario SNOT-22, gli eventi di recidiva di sinusite e la necessità di un intervento       nosinusitis without nasal polyps. Acta Otorhi-
chirurgico di revisione.                                                                           nolaryngol Ital 2022;42:55-62. https://doi.
Risultati. Tutte le sfenoidotomie (n = 52) hanno mostrato una significativa riduzione delle        org/10.14639/0392-100X-N1545
dimensioni (media 43,4 ± 6,8%) al primo mese dopo l’intervento, con una tendenza ad al-
largarsi a tre mesi e stabilizzarsi a sei mesi. Gli osti più grandi di 61,3 mm2 non hanno mo-    © Società Italiana di Otorinolaringoiatria
                                                                                                 e Chirurgia Cervico-Facciale
strato stenosi dopo l’intervento. La stenosi è stata osservata in 11 sfenoidotomie (21,2%);
tuttavia, solo cinque erano associati a sintomi ostruttivi (9,6%), mentre in tre casi è stato
                                                                                                                OPEN ACCESS
necessario un intervento di revisione dello sfenoide (5,8%).
Conclusioni. La dimensione della sfenoidotomia si è ridotta significativamente durante           This is an open access article distributed in accordance with
                                                                                                 the CC-BY-NC-ND (Creative Commons Attribution-Non-
il primo mese postoperatorio, e successivamente si è stabilizzata. Una dimensione della          Commercial-NoDerivatives 4.0 International) license. The
sfenoidotomia al basale di 61,3 mm2 sembra prevenire la stenosi dell’ostio. La metà delle        article can be used by giving appropriate credit and mentio-
stenosi degli osti sfenoidali sembrerebbe associarsi a sintomi disventilativi.                   ning the license, but only for non-commercial purposes and
                                                                                                 only in the original version. For further information: https://
PAROLE CHIAVE: sfenoidotomia, stenosi, cinetica, CRSsNP, curette                                 creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                           55
P.D. Pyriochos et al.




Introduction                                                    cluded from the study (compliance rate: 88.9%, 32 of 36
                                                                patients).
Endoscopic sphenoidotomy, which can be performed tran-
                                                                In terms of preoperative computed tomography (CT) scans,
sethmoidally or transnasally, is the preferred surgical ap-
                                                                all patients exhibited at least partial opacification of one
proach for the treatment of sphenoid sinus diseases, largely
                                                                sphenoid sinus. Each sinus was categorised according to
due to its excellent outcomes and low morbidity rate 1.
                                                                the Lund-Mackay (LM) system, a well-validated staging
The long-term outcomes of endoscopic sphenoidotomy in
                                                                system for CRS, and graded between zero and two (zero:
the context of isolated sphenoid sinus diseases have been
                                                                no abnormality, one: partial opacification, two: total opaci-
found to have patency rates greater than 90% 1. However,
                                                                fication) 6.
chronic rhinosinusitis (CRS) with sphenoid involvement
                                                                Patients had been referred for ESS after failure of maximal
is more challenging to treat. In fact, although CRS is the
                                                                medical treatment to control symptoms. Thus, the criterion
least common sinus disease, additional surgery is required
                                                                for surgery was the severity of symptoms, as reported using
in 34%-65% of revision cases due to persistent or recurrent
                                                                the Sino-Nasal Outcome Test-22 (SNOT-22) questionnaire
disease and stenosis 1.
                                                                (score > 20), accompanied by imaging findings with an LM
The main causes of persistent sphenoid disease are scar-
                                                                score of ≥ 1 7.
ring and/or thick neo-osteogenic bone in the ostium area,
failure to open the sphenoid sinus (e.g. mistaking the Onodi
                                                                Surgery
cell for the sphenoid sinus) and recirculation in the tran-
                                                                All surgical procedures were performed under general an-
sethmoidal approaches 2. Given that blocked or significant-
                                                                aesthesia by the same surgeon over a 2.5-year period. The
ly stenosed sphenoid sinus ostia are identified in 65.9% of
                                                                extent of sinus surgery performed for each patient was de-
patients who undergo revision endoscopic sinus surgery
                                                                termined by the amount and location of their sinus disease.
(ESS), the postoperative assessment of the patency and size
                                                                Thus, in accordance with the Messerklinger principles, all
of the ostium is highly important 3. Yet, despite advances in
                                                                the patients in the study group underwent at least middle
our understanding of the pathophysiology of CRS, the opti-
                                                                meatal antrostomy, anterior ethmoidectomy and transnasal
mal sphenoidotomy size at the time of the surgery remains
unclear 4,5.                                                    sphenoidotomy. The additional surgery, which was per-
This prospective study sought to evaluate the size of the       formed when necessary, included frontal sinusotomy and
sphenoidotomy within the first six months after surgery as      posterior ethmoidectomy. However, patients who required
well as to determine whether the identified intraoperative      posterior ethmoidectomy were excluded from the present
sinus ostium size predisposes patients with CRS without         study, whether or not they underwent transnasal or tran-
polyps (CRSsNP) to recurrence of disease.                       sethmoidal sphenoidotomy.
                                                                Each patient in the study group underwent at least one
                                                                transnasal sphenoidotomy with a minimum diameter of
Materials and methods                                           5 mm (19.625 mm2 area), with this size area being con-
Patients                                                        sidered the criterion for stenosis. To minimise the risk of
Patients between 18 and 75 years who were undergoing            bias, each sphenoidotomy was performed using only con-
functional ESS for CRSsNP were included in the present          ventional instrumentation (e.g. Kerrison forceps). In some
study. Patients with nasal polyps, allergic fungal sinusitis,   cases, once the appropriate structures had been identified,
isolated sphenoid sinusitis, a history of previous sinus sur-   the inferior third of the superior turbinate was resected to
gery (including sphenoid sinus surgery), tumours or who         allow for identification of the sphenoid sinus natural os-
were undergoing trans-sphenoidal neurosurgical proce-           tium medial to it. The ostium was then widened medially
dures were excluded. Initially, 50 patients were included.      towards the septum and inferiorly towards the posterior
Later, patients who underwent transethmoidal sphenoidot-        septal branch of the sphenopalatine artery. This was done
omies (five patients), who needed posterior ethmoidectomy       without further manipulation of the superior turbinate
(four patients) and who developed postoperative recurrent       to reduce the risk of skull base injury. In all cases, the
ethmoid sinusitis (three patients), which all complicated       sphenoidotomy was performed while protecting the sur-
the healing process of the sphenoid ostium, were excluded       rounding mucosa, meaning that the operation resulted in
from the study. Among the remaining 38 patients, two did        an ostium without any uncovered bony edges. At the end
not complete the follow-up assessment. Finally, another         of each surgical procedure, the sphenoidotomy size was
four patients who exhibited poor compliance with their          assessed by using a curved ear curette (90°, 5 mm internal
postoperative care, including failing to perform the daily      diameter) as a ruler (Fig. 1A).
nasal rinsing for a period of over a week, were also ex-        Endoscopic images were taken and stored in a computer.



56
                                                                                                                 Sphenoidotomy kinetics in CRSsNP patients




Figure 1. (A) The curved 90° ear curette with an internal diameter of 5 mm used as a ruler. (B) Endoscopic image of a left sphenoidotomy. (C) Endoscopic image
of the same sphenoidotomy, as measured in Adobe Acrobat.


After each procedure, both nasal cavities were packed for                        of the sphenoid ostium. More specifically, the measure-
24 hours.                                                                        ments were performed using Adobe Acrobat Pro Docu-
                                                                                 ment Cloud software (version 2018.009.20050) (Adobe
Postoperative care                                                               Inc., San Jose, California, United States [US]), while the
All patients were discharged with a 10-day course of oral                        areas of interest were manually marked. Using Adobe
doxycycline, nasal steroids (budesonide, total daily dose                        tools for area measurements, the sphenoidotomy size
of 400 mcg) and nasal saline irrigation, which was to be                         was automatically calculated after adjusting the meas-
performed at least twice daily for up to eight weeks. The                        urements for the known curette diameter (embedded
postoperative removal of clots and crusts was performed                          scale ratio) (Fig. 1B). The curette area could easily be
endoscopically on a weekly basis for a period of four to six                     found using the formula A = πr2, where A is the area and
weeks if required. Follow-up appointments were scheduled                         r is the radius (2.5 mm): 19.625 mm2. Every sphenoi-
at one, three and six months postoperatively.                                    dotomy with an area measurement ≤ 19.625 mm2 was
                                                                                 considered stenotic.
Measurements                                                                     The SNOT-22 questionnaire was used to assess patients’
The sphenoidotomy size was assessed intraoperatively and                         subjective symptoms at baseline and during follow-up ap-
at the three follow-up appointments (first, third and sixth                      pointments 9. We also assessed the number of patients who
postoperative months) using a curved ear curette with a 5                        had changes in their SNOT-22 scores above the minimal
mm internal diameter. All the intraoperative and postop-                         clinically important difference (MCID) for surgically treat-
erative endoscopic images were captured using the same                           ed CRS patients (9.0 points), as suggested by Hopkins et
0o, 3.5 mm nasal endoscope (Karl Storz Co., Tuttlingen,                          al. 10. The patients’ medical records were also reviewed for
Germany). We placed the probe in the same vertical plane                         episodes of postoperative recurrent sinusitis and the need
as the sphenoidotomy and close to the centre of the endo-                        for revision surgery.
scope’s field in order to minimise the visuospatial distor-                      The patients were defined as being symptomatic postopera-
tion.                                                                            tively if their SNOT-22 scores remained > 20 at their last
The stenosis assessment was performed when the endo-                             follow-up appointment and pus or thick secretions from
scopic image of the probe most closely resembled a cir-                          their sphenoid sinus ostium were observed (with no evi-
cle. Under these conditions, the endoscopic images can be                        dence of ethmoidal cavity inflammation). No further imag-
measured accurately and in a reproducible manner, as the                         ing studies were performed postoperatively.
visuospatial error fell below 5% 8. In borderline cases, to
achieve precise measurements, the probe should occupy                            Statistical analysis
more than 40% of the endoscopic field.                                           The results were analysed using Statistical Package for the
The stored endoscopic images were measured by a                                  Social Sciences (SPSS) version 16.0 for Windows (SPSS
blinded observer (the last author) to determine the size                         Inc., Chicago, Illinois, US).



                                                                                                                                                          57
P.D. Pyriochos et al.




The sample size calculation was based on the following                 The presence of sphenoidotomy stenosis did not correlate
parameters: an acceptable error alpha of 0.05; an accept-              with gender, age, comorbidities or ostium shape (all r < 0.2,
able error beta of 0.10; and a clinical difference of 3 mm in          p > 0.05). The correlations are presented in Table II.
diameter and a standard deviation (SD) ± 1.1, which corre-             The mean sphenoidotomy area in our cohort during base-
sponds to an area of 28.26 mm2 and a SD ± 3.8. According               line assessments (end of the operation) was 67.5 ± 14.6
to Douglas Altman’s nomogram, the adequate minimum                     mm2. A significant decrease in this size (mean size: 38.2
number of patients for a study with 85% power equates to               ± 11.3 mm2, p < 0.001) was observed during the first post-
28 sphenoidotomies 11.                                                 operative month (percentage decrease: 43.4% ± 6.8), with
All descriptive statistics are presented in the text as the            a slight enlargement being seen at three months (9.1% ±
mean values ± SD of the means. The comparisons among                   2.7) and stabilisation being noted at six months (Fig. 2).
the ostium areas during the follow-up period were per-                 Figure 3 presents an example of the aforementioned sphe-
formed using a paired t-test, while the correlations between           noidotomy kinetics in a patient from our cohort.
the measurements and descriptive statistics were deter-                The stenotic sphenoidotomies had a mean baseline size of
mined using the Spearman rank correlation coefficients.                38.8 ± 8.8 mm2, which was significantly smaller than the
The statistical significance level was set at 0.05.
                                                                       mean baseline size of the sphenoidotomies that did not de-
                                                                       velop stenosis (76 ± 14.7 mm2, p < 0.001). Notably, at the
Results                                                                end of the surgery, all the sphenoidotomies were greater
Patient characteristics                                                than 19.625 mm2 in area, which was the criterion for ste-
Thirty-two CRSsNP patients (18 males and 14 females)                   nosis.
with a mean age of 46.1 years (range: 22-73 years) who un-             A comparison of the kinetics between the stenotic and non-
derwent ESS at a tertiary centre were included in this pro-            stenotic sphenoidotomies postoperatively (Fig. 4) revealed
spective, non-controlled study, which was conducted over a             initially similar patterns, with a significant decrease be-
period of 2.5 years. Demographic statistics concerning the             ing seen in the first month for both groups. However, the
patients are presented in Table I.                                     stenotic sphenoidotomies exhibited a slight worsening in
                                                                       size between the one-month (18 ± 5.1 mm2), three-month
Sphenoidotomy kinetics                                                 (16.6 ± 5.5 mm2) and six-month postoperative follow-up
In total, 52 nasal cavities (20 bilateral and 12 unilateral sphe-      appointments (12.6 ± 4.5 mm2). The non-stenotic sphenoi-
noidotomies) were assessed at the first, third and sixth months        dotomies exhibited an increase in size at the three-month
postoperatively. The shape of each patient’s ostia at the end of       follow-up appointment (9.92% ± 2.1) and no change at the
the operation was either oval (n = 27) or round (n = 25).              six-month appointment. All 24 patients with non-stenotic
During the final postoperative follow-up appointments,                 sphenoidotomy remained asymptomatic during the follow-
11 of the 52 sphenoidotomies were found to be stenotic                 up period.
(21.2%), which related to eight of the 32 operated patients
(25%). Five of those patients had unilateral stenosis, while
three had bilateral stenosis.


Table I. Demographic statistics of the CRSsNP patient cohort.
 Total group (n)                                              50
 Included                                                    32
 Male                                                    18 (56%)
 Female                                                  14 (44%)
 Mean age (age range)                                   46.1 (22-73)
 Asthma                                                    1 (3%)
 Diabetes                                                  2 (6%)
 Smoking                                                  6 (18%)
 Transnasal sphenoidotomy                                    32
                                                                       Figure 2. Sphenoidotomy size kinetics of the study group. Asterisks indi-
    i) Bilateral                                             20
                                                                       cate the statistically significant size differences between the intraoperative and
    ii) Unilateral                                           12        follow-up measurements. Polynomial trendline represents the measurement
n: number of patients.                                                 fluctuation.



58
                                                                                                                          Sphenoidotomy kinetics in CRSsNP patients




Table II. Correlations between the patient characteristics and stenosis (Spearman correlation test).
                                  Age                   Gender           Shape of ostium        Comorbidities                  Preop LM CT             Stenosis
                                                                                                                                  score
 Age                                                        p = 0.92                 p = 0.81                p = 0.13            p = 0.65              p = 0.57
                                                            r = 0.17                 r = 0.11                 r = 0.1            r = 0.18              r = 0.12
 Gender                             p = 0.92                                         p = 0.71                p = 0.97            p = 0.94              p = 0.43
                                    r = 0.17                                         r = 0.13                r = 0.11            r = 0.08               r = 0.1
 Shape of ostium                    p = 0.81                p = 0.71                                         p = 0.53            p = 0.68              p = 0.78
                                    r = 0.11                r = 0.13                                         r = 0.16            r = 0.15              r = 0.13
 Comorbidities                      p = 0.13                p = 0.97                 p = 0.53                                    p = 0.47              p = 0.11
                                     r = 0.1                r = 0.11                 r = 0.16                                    r = 0.19              r = 0.17
 Preop LM CT score                  p = 0,65                p = 0.94                 p = 0.68                p = 0.47                                  p = 0.78
                                    r = 0,18                r = 0.08                 r = 0.15                r = 0.19                                  r = 0.19
 Stenosis                           p = 0.57                p = 0.43                 p = 0.78                p = 0.11            p = 0.78
                                    r = 0.12                 r = 0.1                 r = 0.13                r = 0.17            r = 0.19
p: p value; r: correlation coefficient; Preop LM CT score: Preoperative Lund-Mackay computed tomography score.




                                                                                          Figure 4. Comparison of the mean areas between stenotic and non-stenotic
                                                                                          sphenoidotomies during the six-month follow-up period. Asterisks indicate the
                                                                                          significant decrease in the sphenoidotomy sizes of both groups at the one-
                                                                                          month postoperative assessment (p < 0.001).


                                                                                          day] for ten weeks). However, the remaining three sympto-
                                                                                          matic patients with stenosis required further sphenoid sinus
Figure 3. Endoscopic images of a non-stenotic left sphenoidotomy in a male                surgery due to the nearly complete blockage of the ostium
patient from our cohort. The changes in size at every stage of the follow-up pe-
riod are made clear by the ruler. (A) Sphenoidotomy at the end of the operation.
                                                                                          and persistent sinusitis symptoms (the patients’ ostium areas
(B) One month later. (C) Three months later. (D) Six months later.                        were 8 mm2, 10 mm2 and 12 mm2, respectively). Thus, the
                                                                                          revision surgery rate in our cohort was 5.8% (or three of 52
                                                                                          sphenoid sinuses). Revision surgery was planned for these
Outcomes of patients with stenosis                                                        three patients after the six-month follow-up period.
The eight patients with stenosis were divided as follows:                                 The mean baseline sphenoidotomy size of the five sympto-
three asymptomatic and five with recurrent symptoms of                                    matic patients was lower (36.9 ± 6.9 mm2) than that of the
sinusitis (SNOT-22 score > 20). The three asymptomatic                                    three asymptomatic patients (41.9 ± 5.3 mm2, p = 0.11),
patients with stenosis were provided with close follow-up                                 albeit without statistical significance. All sphenoidotomy
in accordance with a “wait and see” policy. Two of the five                               area measurements are presented in Table III.
symptomatic patients with stenosis were successfully man-
aged by further medical treatment (nasal steroids for an ad-                              SNOT-22
ditional two months and a low dose of doxycycline [100 mg/                                The assessment of the SNOT-22 questionnaire findings



                                                                                                                                                                   59
P.D. Pyriochos et al.




Table III. Sphenoidotomy area (mm2) measurements intraoperatively and at the first, third and sixth postoperative months.
                                      Intraoperatively                 First month                       Third month          Sixth month
 Study cohort                                   67.5 ± 14.6               38.2 ± 11.3                    41.6 ± 10.9          41.4 ± 9.8
 Non-stenotic                                   76.0 ± 14.7               45.6 ± 12.3                     50.2 ± 11           50.2 ± 12.2
 Stenotic                                        38.8 ± 8.8                18.0 ± 5.1                     16.6 ± 5.5           12.6 ± 4.5
    i) Symptomatic                               36.9 ± 6.9                16.1 ± 3.2                     15.1 ± 4.0           11.0 ± 2.9
    ii) Asymptomatic                             41.9 ± 5.3                21.3 ± 1.8                     18.6 ± 3.5           15.1 ± 2.0
Data are expressed as Mean ± Sd; Sd: standard deviation.



revealed a significant improvement in patients’ symp-                            plications in terms of nasal lavage than smaller ones, sug-
tom scores from a mean of 35.7 ± 11.2 preoperatively to                          gesting that better saline penetration was obtained at an
a mean of 9.3 ± 4.2 at the sixth postoperative month. All                        ostial diameter of 4.7 mm 15. However, other studies have
the asymptomatic (stenotic and non-stenotic) patients had                        suggested that a wider sinus ostium does not necessarily
changes in their SNOT-22 symptom scores greater than a                           ensure appropriate drug application 17,18.
MCID of 9.0, without correlation between the postopera-                          Given that blocked sphenoid sinus ostia are identified in
tive SNOT-22 scores and the final sphenoidotomy sizes 10.                        65.9% of patients who undergo revision surgery, this study
The three patients who required revision surgery had no                          sought to assess the kinetics of the sphenoidotomy size and
significant improvement of their SNOT-22 scores, with                            determine its effect on the course of the disease 3. The pre-
their mean score being 23.5 ± 5.8 at the final follow-up                         sent study had two major findings. First, the sphenoidoto-
appointment. The latter score mainly included symptoms                           my area decreased significantly (by 43.4%) within the first
from the nasal subdomain of the SNOT-22 questionnaire,                           postoperative month, with a small improvement in size and
including postnasal drip, thick secretions and stuffed nose,                     then stabilisation occurring during the next five months.
with a mean score of 18.3 ± 2.4 12.                                              Second, stenosis did not develop in patients with a large
                                                                                 sphenoidotomy area at baseline (> 61.3 mm2, approximate-
LM CT score                                                                      ly three times the ruler’s size). This criterion represents the
A comparison of the LM CT scores between the stenotic                            mean sphenoidotomy size in non-stenotic patients minus
and non-stenotic cases did not reveal a significant differ-                      its SD (76 – 14.7 mm2).
ence (stenotic mean LM score of 12.3 ± 1.8 vs non-stenotic                       Wound healing following ESS represents a prolonged and
mean LM score of 11.8 ± 1.6, p = 0.821). The presence of                         complex process 19. Limited data are available regarding
stenosis was not correlated with the extent of the disease,                      alterations in the antrostomy size during the healing pro-
as seen in relation to the preoperative LM CT score (r =                         cess 20. However, the first six postoperative months are con-
0.19, p = 0.78).                                                                 sidered the most important in relation to the development
                                                                                 of ostium stenosis 19.
                                                                                 The finding of an initial rapid decrease in size during the
Discussion
                                                                                 follow-up period in the present study corresponds to the
Revision endoscopic surgery is required when medical                             blood-crusting and obstructive-lymphedema phases of the
treatment fails to manage persistent disease due to issues                       wound-healing process. The subsequent increase in size
such as postoperative abnormal mucociliary transport, in-                        during the third month and the stabilisation of the ostium
complete surgery, lateralised middle turbinate, synechiae                        size in the sixth month mainly reflect the phases involving
and stenosed or blocked sinus ostium 3. A blocked antros-                        mesenchymal growth and scar-tissue formation 19. The sig-
tomy is the most common anatomical finding in revision                           nificant decrease in the ostium size within the first month
maxillary sinus surgery, as reported by Musy and Kounta-                         may indicate the importance of early postoperative care
kis (39% of their series) 13. Although several studies have                      concerning the nasal cavity, such as nasal rinsing and me-
previously investigated the optimal antrostomy size for the                      ticulous debridement. Further studies are required to clarify
maxillary sinus, finding that an ostium of at least 5 mm in                      the optimal medical treatment during this postoperative pe-
diameter is necessary, the same is not true for the sphe-                        riod, focusing on medications that could act in the early
noid sinus, as only a very limited body of literature is avail-                  phases of wound healing. In addition, taking into account
able 14-16.                                                                      this early ostium shrinkage, surgeons may prefer to create
In a cadaveric study, Singhal et al. found that larger maxil-                    larger ostia during surgery.
lary and sphenoid sinus ostia had significantly better ap-                       The use of a simple ear curette to assess the sphenoidotomy



60
                                                                                            Sphenoidotomy kinetics in CRSsNP patients




size, despite being quick and easily applicable in an op-          It must be recognised that the present study had several
erating room/clinical setting, remains an imprecise means          limitations. First, it included only patients with CRSsNP,
of assessing the size of a sinus ostium. Ideally, software         meaning that the results do not provide information about
should be developed to facilitate the calculation of the si-       patients with higher inflammatory loads, such as nasal poly-
nusotomy size on site.                                             posis or cystic fibrosis. In addition, patients with extended
Based on the present results, it is difficult to suggest an op-    sinusitis involving the posterior ethmoids that required
timal sphenoidotomy size due to the limited number of pa-          posterior ethmoidectomy, a procedure that can complicate
tients and the multifactorial nature of both the disease and       the healing process of the sphenoid ostium, were excluded.
wound-healing process. However, the data on non-stenotic           Although isolated sphenoid sinusitis appears to be the ideal
patients (mean: 76 ± 14.7 mm2) indicate that larger ostia          model for such a study, the disorder is rare and represents
may be safer when it comes to avoiding recurrent symp-             only a small proportion of CRS patients 24. Given the afore-
toms and the need for revision surgery.                            mentioned reasons, we limited our cohort to CRSsNP.
The patients’ subjective symptoms, measured using the              Further research is required to assess the other factors,
SNOT-22 questionnaire, showed a significant improvement            besides the initial size, that contribute to ostium stenosis,
postoperatively in non-stenosed and asymptomatic sten-             including osteitis in revision cases or other underlying dis-
otic cases, regardless of the postoperative sphenoidotomy          orders (e.g., Wegener’s disease). Additionally, mucociliary
size. On the contrary, significantly higher SNOT-22 scores         function, especially around the neo-ostium, may require
(> 20) were found at the last follow-up appointment in the         special attention, as the sphenoid sinus works partially
stenosed cases requiring surgery. These results may indi-          against gravity. Bearing in mind that the volume of the si-
cate that stenosis is not the only factor that contributes to      nus and the size of the ostium clearly affect the pressure
persistent disease and, furthermore, that additional medical       gradient between the nasal cavity and sinus, thereby play-
treatment may help to ensure a healthy sphenoid sinus de-          ing an important role in the transport of gas and drugs, fur-
spite the presence of a stenosed ostium.                           ther studies are required to assess these factors 25.
A number of prior studies have explored techniques that            Although the method used for the ostium measurements is
may serve to prevent postoperative stenosis of the sphenoi-        applicable for research purposes, it should be noted that
dotomy, albeit without performing measurements of the ac-          it is difficult to apply in an operating room setting, where
tual area size. Yu et al. suggested that powered instrumen-        it is not possible to obtain accurate measurements without
tation is more effective than conventional instruments in          simultaneous software-based calculations.
terms of treatment of isolated sphenoid sinus 21. Our study
cannot support this suggestion, as we used only conven-
                                                                   Conclusions
tional instruments; however, the use of powered instrumen-
tation may cause osteitis, a factor known to contribute to         The findings of the present study demonstrated that sphe-
the closure of the ostium. This issue remains controversial        noidotomy in CRSsNP patients following transnasal sphe-
and further studies are required to provide clarification.         noidotomy significantly reduces in size (43.4%) within the
Another prior study proposed the use of the adjacent nasal         first postoperative month, with a small improvement in size
mucosa as rotational tissue ﬂaps covering the exposed bone         and then stabilisation occurring over the next five months.
of the neo-ostium, thereby minimising ﬁbrosis and prevent-         In our cohort, a baseline sphenoidotomy size of 61.3 mm2
ing the closure of the sinus 22. The extent and size of the ini-   (approx. three times the area of a 5 mm ear curette) did not
tial ostium were not reported, and the outcome was only ap-        result in ostium stenosis. About 50% of postoperative sten-
proximately measured using suction tips of different widths.       osed ostia experienced recurrent symptoms.
Similarly, Thompson et al. used a mini-nasoseptal ﬂap to
prevent ostium restenosis in a cohort of 9 patients with high-     Conflict of interest statement
ly inflammatory sphenoid sinus pathologies, although they          The authors declare no conflict of interest.
did not calculate the initial sphenoidotomy size 23.
To the best of our knowledge, this is the first study to meas-     Funding
ure the sphenoid ostium size at the time of surgery and dur-       This research did not receive any specific grant from fund-
ing the healing process. Despite the final sample size of          ing agencies in the public, commercial, or not-for-profit
the population requiring revision surgery being too small to       sectors.
make a meaningful comparison, the nearly complete block-
age of the sphenoid ostium represented their main charac-          Authors’ contributions
teristic.                                                          PP processed the experimental data, took the measurements



                                                                                                                                 61
P.D. Pyriochos et al.




and wrote the article. KM and JC gave final approval for the                      endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope
                                                                                  2015;125:1779-1784. https://doi.org/10.1002/lary.25318
article. IK conceived the study, performed the operations
                                                                             11
                                                                                  O’Hara J. How I do it: sample size calculations. Clin Otolaryngol
and processed the experimental data.
                                                                                  2008;33:145-149. https://doi.org/10.1111/j.1749-4486.2008.01668.x
                                                                             12
                                                                                  Feng AL, Wesely NC, Hoehle LP, et al. A validated model for the
Ethical consideration                                                             22-item Sino-Nasal Outcome Test subdomain structure in chronic rhi-
The investigations were performed according to the Guide-                         nosinusitis. Int Forum Allergy Rhinol 2017;7:1140-1148. https://doi.
lines for Biomedical Studies Involving Human Subjects                             org/10.1002/alr.22025
(“Helsinki Declaration”). The study protocol was approved
                                                                             13
                                                                                  Musy PY, Kountakis SE. Anatomic findings in patients undergoing re-
                                                                                  vision endoscopic sinus surgery. Am J Otolaryngol - Head Neck Med
by the Ethics Committee of Aristotle University of Thes-                          Surg 2004;25:418-422. https://doi.org/10.1016/j.amjoto.2004.06.002
saloniki, Greece (Δ3β/49441/17-12-2018). All the subjects                    14
                                                                                  Aust R, Stierna P, Drettner B. Basic experimental studies of ostial pa-
provided written informed consent.                                                tency and local metabolic environment of the maxillary sinus. Acta Oto-
                                                                                  laryngol 1994;114:7-11. https://doi.org/10.3109/00016489409124315
                                                                             15
                                                                                  Singhal D, Weitzel EK, Lin E, et al. Effect of head position and surgi-
References                                                                        cal dissection on sinus irrigant penetration in cadavers. Laryngoscope
1
     Lee JM, Yip J. Extended sphenoid sinus antrostomy and radical sphe-          2010;120:2528-2531. https://doi.org/10.1002/lary.21092
     noidectomy. In: Adappa N, Palmer J, Chiu Al, editors. Atlas of endo-    16
                                                                                  Konstantinidis I, Tsakiropoulou E, Vital I, et al. Intra- and post-
     scopic sinus and skull base surgery. Philadelphia, PA: Elsevier Inc.;        operative application of Mitomycin C in the middle meatus re-
     2019. p. 133. https://doi.org/10.1016/C2015-0-01193-5                        duces adhesions and antrostomy stenosis after FESS. Rhinology
2
     Stankiewicz JA, Donzelli JJ, Chow JM. Failures of functional endo-           2008;46:107-111.
     scopic sinus surgery and their surgical correction. Oper Tech Otolar-   17
                                                                                  Thomas WW, Harvey RJ, Rudmik L, et al. Distribution of topical
     yngol - Head Neck Surg 1996;7:297-304. https://doi.org/10.1016/              agents to the paranasal sinuses: an evidence-based review with rec-
     S1043-1810(96)80051-0                                                        ommendations. Int Forum Allergy Rhinol 2013;3:691-703. https://
3
     Khalil HS, Eweiss AZ, Clifton N. Radiological findings in patients           doi.org/10.1002/alr.21172
     undergoing revision endoscopic sinus surgery: a retrospective case      18
                                                                                  Schuschnig U, Keller M, Klopfer E, et al. Drug delivery to the nasal
     series study. BMC Ear, Nose Throat Disord 2011;11:2-7. https://doi.          and paranasal cavities - critical cast dimensions and aerosol dynam-
     org/10.1186/1472-6815-11-4                                                   ics. Respiratory Drug Delivery 2008;1:227-238.
4
     Richtsmeier WJ. Top 10 reasons for endoscopic maxillary sinus           19
                                                                                  Hosemann W, Wigand ME, Dunker I. Normal wound healing of the
     surgery failure. Laryngoscope 2001;111:1952-1956. https://doi.               paranasal sinuses: clinical and experimental investigations. Eur Arch
     org/10.1097/00005537-200111000-00015                                         Oto-Rhino-Laryngology 1991;248:390-394. https://doi.org/10.1007/
5
     Snidvongs K, Pratt E, Chin D, et al. Corticosteroid nasal irrigations        BF01463560
     after endoscopic sinus surgery in the management of chronic rhi-        20
                                                                                  Thompson CF, Conley DB. What is the optimal maxillary antrostomy
     nosinusitis. Int Forum Allergy Rhinol 2012;2:415-421. https://doi.           size during sinus surgery? Curr Opin Otolaryngol Head Neck Surg
     org/10.1002/alr.21047                                                        2015;23:34-38. https://doi.org/10.1097/MOO.0000000000000128
6
     Lund VJ, Kennedy DW. Staging for rhinosinusitis. Otolaryn-              21
                                                                                  Yu H, Li H, Chi F, et al. Endoscopic surgery with powered instru-
     gol Head Neck Surg 1997;117:35-40. https://doi.org/10.1016/                  mentation for isolated sphenoid sinus disease. ORL 2006;68:129-134.
     S0194-5998(97)70005-6                                                        https://doi.org/10.1159/000091269
7
     Rudmik L, Soler ZM, Hopkins C, et al. Defining appropriateness          22
                                                                                  Nada I, El-Sharnouby M, Abo-El-Ezz T. The role of local rotational
     criteria for endoscopic sinus surgery during management of uncom-            flaps in minimizing sphenoidal and maxillary sinuses ostium steno-
     plicated adult chronic rhinosinusitis: a RAND/UCLA appropriate-              sis. Egypt J Ear, Nose, Throat Allied Sci 2014;15:93-97. https://doi.
     ness study. Int Forum Allergy Rhinol 2016;6:557-567. https://doi.            org/10.1016/j.ejenta.2014.03.001
     org/10.1002/alr.21769                                                   23
                                                                                  Thompson CF, DeConde AS, Chiu AG, et al. Mini-nasoseptal flap
8
     Nouraei SAR, Hajioff D, Almeyda J, et al. Measurement of absolute            for recalcitrant sphenoid sinusitis. Am J Rhinol Allergy 2013;27:144-
     dimensions in endoscopic sinus surgery. Laryngoscope 2005;115:889-           157. https://doi.org/10.2500/ajra.2013.27.3860
     893. https://doi.org/10.1097/01.MLG.0000161450.81557.6D                 24
                                                                                  Charakorn N, Snidvongs K. Chronic sphenoid rhinosinusitis: man-
9
     Drahaman AMP, Henney SE. Using SNOT – 22 as a decision making                agement challenge. J Asthma Allergy 2016;9:199-205. https://doi.
     tool in performing nasal surgery. Ceylon Journal of Otolaryngology           org/10.2147/JAA.S93023
     2015;4:26-29. http://doi.org/10.4038/cjo.v4i1.5226                      25
                                                                                  Möller W, Schuschnig U, Meyer G, et al. Ventilation and drug deliv-
10
     Hopkins C, Oxon MA, Orlhns F, et al. The predictive value of the             ery to the paranasal sinuses: studies in a nasal cast using pulsating
     preoperative Sinonasal Outcome Test-22 score in patients undergoing          airflow. Rhinology 2008;46:213-220.




62
