Achieving Optimal Patient Outcomes After Frontal Sinus Endoscopy

Background The frontal sinus is among the most anatomically complex regions to manage in endoscopic sinus surgery, with high risks of postoperative restenosis. This study aimed to evaluate the safety and efficacy of biodegradable, drug-eluting stents (Propel) compared to traditional non-drug-eluting stents (Merocel and Rains) in maintaining frontal sinus ostium patency following functional endoscopic sinus surgery (FESS). Methods A prospective comparative study was conducted at Helwan University Hospital (Badr Hospital), enrolling 34 adult patients with various frontal sinus pathologies at high risk of restenosis. Participants were randomized into two groups: the study group ( n = 17) received the Propel stent, while the control group ( n = 17) received either Merocel or Rains stents. Patients were followed for 6 months postoperatively with clinical, endoscopic, and radiological assessments. Primary outcomes included frontal ostium patency, while secondary outcomes assessed complications such as stenosis, obstruction, adhesions, polyp formation, mucosal healing, and inflammation. Results Baseline characteristics and surgical indications were comparable between groups. At 6 months, the Propel group demonstrated significantly higher ostium patency (100% vs. 41.18%, p = 0.001), a complete absence of adhesions (0% vs. 58.82%, p = 0.001), and lower rates of polyp formation (0% vs. 23.53%, p = 0.033). Sinonasal mucosal healing was higher in the Propel group (94.12% vs. 76.47%, p = 0.168), though not statistically significant. Trends toward reduced inflammation and retained secretions favored the Propel group. All Propel stents were entirely absorbed by 6 months without the need for removal. Conclusion Biodegradable drug-eluting Propel stents significantly improve postoperative outcomes in frontal sinus surgery by enhancing ostium patency, reducing adhesions and polyp recurrence, and promoting mucosal healing. These findings support the selective use of drug-eluting stents in high-risk patients; however, larger multicenter trials with longer follow-up are needed to confirm the long-term benefits.

Management of chronic frontal sinusitis can be challenging due to the complicated anatomic relationships in the anterior skull base. Frontal sinus surgery itself is one of the most common causes of iatrogenic or refractory frontal sinus disease requiring revision surgery. Frontal sinus disease usually results from obstruction of the frontal recess (drainage pathway) rather than an intrinsic problem with the frontal sinus itself. The often variable drainage pathway of the frontal recess resembles an hourglass with the internal frontal sinus ostium being the neck of the hourglass. A simple nasofrontal “duct” does not exist. Proper diagnostic evaluation of the frontal sinus includes a fine-cut CT scan (including coronal and sagittal views) and a well-decongested nasal endoscopy using angled nasal endoscopes. The spectrum of microorganisms typically found in chronic frontal sinusitis is different from that of acute frontal sinusitis. Medical management with a prolonged course of antibiotics, frequently coupled with systemic corticosteroids, is the first line of therapy for chronic frontal sinusitis. In the absence of impending complications, surgery of the frontal sinuses is generally reserved for patients with symptomatic disease that has failed to respond to adequate medical therapy. Endoscopic frontal sinusotomy is the current standard of care for frontal sinus surgery, supplemented by extended endoscopic techniques or external approaches as needed for complex anatomy or tumors. Meticulous postoperative care is an important element for ensuring long-term patency of the frontal sinus outflow tract following endoscopic surgery. External approaches to the frontal sinus are very rarely utilized in the primary surgical management of inflammatory frontal sinus disease. The complications associated with untreated chronic frontal sinusitis are associated with superimposed acute infections and include orbital and intracranial infections.

Chronic rhinosinusitis (CRS) causes severe symptoms that lead to poor quality of life. When optimal medical therapy does not improve CRS symptoms, then endoscopic sinus surgery (ESS) can be used in patients with persistent symptoms and radiographic evidence of CRS to improve patients' symptoms and quality of life. Despite appropriate and complete sinus surgery, there can be issues after sinus surgery such as synechiae formation and recurrence of polyps in certain CRS patients that can decrease long-term outcomes. Corticosteroids are used to decrease postoperative scarring and edema as well as prevent recurrence of nasal polyp formation after sinus surgery. However, the use of oral or systemic steroid can lead to serious short-term and long-term complications. Therefore, a safer alternative would be the topical delivery of steroid via steroid-eluting sinus implants. A literature review was performed to identify clinical studies evaluating steroid-eluting implants. Two forms of steroid-eluting implants were identified, Propel family products and Sinuva. The research findings from clinical studies using various steroid-eluting sinus implants are reviewed and discussed. Four prospective randomized clinical studies were identified for the Propel family products. Two prospective randomized clinical studies were identified for Sinuva. The results from the clinical studies showed that the use of the various steroid-eluting sinus implants can improve postoperative results after ESS as well as treat the recurrence of nasal polyps after sinus surgery without the need for additional sinus surgery. The novel steroid-eluting implants appear to be beneficial for CRS patients immediately post-operatively as well as for nasal polyps patients. Interestingly, these implants could be used as a substitute for the beneficial effect of systemic steroid use for CRS patients.

Long-term results of endoscopic frontal sinus surgery

Incidence of Odontogenic Disease in Patients With Pott's Puffy Tumor

In the modern age of endoscopic sinus surgery (ESS), there is an undefined role for external approaches in the treatment of inflammatory disease. This study examines the frontal sinus surgery practices of three experienced rhinologists with a focus on those who underwent an external approach. Our goal was to characterize these patients and propose indications for the use of an external approach alone or in combination with functional ESS (FESS) for frontal sinus inflammatory disease. A retrospective review was performed of frontal sinus procedures performed for inflammatory disease at one institution from 2004 to 2007. Seven hundred seventeen procedures were performed, 38 (5.3%) of which were external alone (14 procedures) or in combination with FESS (24 procedures). Osteoplastic flap with obliteration (12/14) made up the majority of external alone procedures and the most common indication was neo-osteogenesis of the frontal recess. Trephination was the most common external adjunct to FESS (12/24), and often was performed for type 3 frontal recess cells or in the initial management of acute frontal bone osteomyelitis (FOM). Twenty-eight of 38 (74%) patients had a history of previous surgery. Of the 10 patients with no history of previous surgery, 6 (60%) had an external adjunct for frontal recess neo-osteogenesis. There were no major complications but 9/38 (23.7%) patients required revision surgery for persistent/recurrent symptoms. External approaches alone and in combination with FESS are predominantly secondary to neo-osteogenesis of the frontal recess. Factors associated with neo-osteogenesis include previous trauma, endoscopic surgery, and FOM. External frontal sinus surgery provides adequate management of inflammatory disease but has a high revision rate.

Can sinus anatomy predict quality of life outcomes and operative times of endoscopic frontal sinus surgery?

BackgroundFibro-osseous (FO) lesions are slow-growing benign lesions in the paranasal sinuses. They include osteomas, fibrous dysplasia (FD), and ossifying fibro­ma (OF). Fibro-osseous (FO) lesions are frequently asymptomatic, and they are incidentally found on imaging. They are characterized by different histological, radiological, and clinical variants. Depending on symptoms, size, location, and extension, the treatment strategy varies significantly for these lesions.ObjectiveWe aim to compare the age, onset, gender, clinical presentation, postoperative improvement, and complications of a fibro-osseous lesion in the paranasal sinuses.MethodsA retrospective analysis was done targeting patients diagnosed with benign fibro-osseous (FO) lesions, and the incidence among 403 patients who underwent functional endoscopic sinus surgery (FESS) at Aseer Central Hospital, Kingdom of Saudi Arabia, was reviewed from January 2013 to January 2022.ResultsA total of seven patients were found; five patients were diagnosed with osteoma, and two were diagnosed with fibrous dysplasia. There were no ossifying fibroma cases. The patients’ mean age was 25.5 ± 12.9 years old. Four (57.1%) patients were males, and three (42.9%) were females, with a male/female ratio of 1.25:1. The most common locations were the frontal sinus and ethmoid sinus, and the two cases of fibrous dysplasia involved almost all facial bones. The endonasal endoscopic approach was chosen to treat all seven patients.ConclusionsThere are differences in the onset age, location, and complications postoperatively among osteoma and fibrous dysplasia patients. Osteoma most commonly occurs in the frontal sinus, while fibrous dysplasia involved all facial bones in our study. Endoscopic surgery is currently the primary strategy for treatment.

Aberrant Course of the Internal Carotid Artery in Surgery of Adenoids and Tonsils

About 810 women died every day in 2017 from preventable causes related to pregnancy and childbirth. To reduce the risks of maternal and fetal complications during pregnancy, knowledge about preconception care must be increased. Preconception care is closely linked to maternal and infant health. This study aimed to examine the level of knowledge, attitudes, and utilization of preconception care among women in Al Ahsa, Saudi Arabia. A cross- sectional study was conducted between June 27 and September 30, 2021, in three governmental hospitals and three private hospitals from the outpatient department of Al Ahsa, Saudi Arabia. In this study, the participants were recruited using a simple randomization technique. The estimated sample size is 386. Data were collected by using a modified structured questionnaire adapted from similar studies. The questionnaire contains three sections. The validity and reliability of the tool were accomplished. This study was approved by the Institutional Review Board (IRB) of the KFHH, and a letter of informed participation, along with the purposes of the study, was provided with the administered questionnaire. Near to half of the study participants, 166 (43%) had good knowledge, and 186 (48.2%) had fair knowledge on preconception care whereas 34 (8.8%) had poor knowledge on preconception care. Regarding the utilization, most participants 170 (44%) did not receive complete preconception care. The majority of participants (73.6%) said that women don't undertake complete preconception care due to a lack of knowledge. The level of education of participants is strongly correlated with preconception care awareness. The findings concluded that fewer than half of Saudi women in Al Ahsa were aware about preconception care. In general, responders do not use preconception care services due to a lack of knowledge about how these services may affect maternal and neonatal health.

Background: The level of knowledge about ischemic heart disease (IHD) and stroke symptoms varies between different studies. Early recognition of symptoms is crucial for timely receipt of care and to improve outcomes. This study aims to assess the level of knowledge of IHD and stroke symptoms among diabetic and hypertensive patients in Al Ahsa, Saudi Arabia. Methods: A questionnaire-based cross-sectional survey conducted in outpatient clinics in several hospitals and primary care centers. We enrolled 339 participants who had diabetes, hypertension or both. Data were collected between October 2020 and June 2021. A score of 1 was given for each correct answer. A total score of 5 was considered excellent, between 2-4 adequate, and 1 poor. Results: Poor knowledge score of IHD symptoms showed in 24.8% of participants and 26.3% had poor knowledge score of stroke symptoms. Chest pain was recognized as the most common symptom of IHD by 31%. When facing an emergency situation, 42% responded by taking the patient to the hospital and 45% by calling the emergency phone numberA higher degree of education, higher income, and previously received information were correlated with a higher knowledge score, while history of IHD in the participants was not correlated with a better score. Conclusions: Knowledge of IHD and stroke symptoms was poor in a quarter of at-risk patients in Al Ahsa, Saudi Arabia. The history of IHD in the participants did not correlate with a better knowledge score. Our findings call for more efforts to establish and expand the awareness campaign. Keywords: Awareness, knowledge, stroke symptoms, ischemic heart disease symptoms, diabetes, hypertension.

ABSTRACTBACKGROUND: Endoscopic transnasal surgery has gained rapid global acceptance over the last two decades. The growing literature and understanding of anterior skull base endoscopic anatomy, in addition to new dedicated endoscopic instruments and tools, have helped to expand the use of the transnasal route in skull base surgery.OBJECTIVE: Report our early experience in expanded endoscopic transnasal surgery (EETS) and approach to skull base neoplasms.DESIGN: Descriptive, retrospective case series.SETTING: Major tertiary care center.PATIENTS AND METHODS: A retrospective case review was conducted at King Saud University Medical City between December 2014 and August 2019. Cases with skull base neoplasms that underwent EETS were included. EETS was defined as endoscopic surgical exposure that extended beyond the sellar margins (prechiasmatic sulcus superiorly, clival recess inferiorly, cavernous carotid lines laterally). Routine transsphenoidal pituitary neoplasms, neoplasms of sinonasal origin and meningoencephaloceles were excluded.MAIN OUTCOME MEASURES: Preoperative clinical assessment, imaging results, surgical approach, and hospital course were all retrieved from the patient electronic charts. Clinical follow-up, perioperative complications, and gross residual tumor rates were documented and reviewed.SAMPLE SIZE AND CHARACTERISTICS: 45 cases of EETS, 13 males and 32 females with mean age of 39.0 (17.7) years (range 2–70 years).RESULTS: The series comprised a wide range of pathologies, including giant pituitary adenoma (8 cases), meningioma (23 cases), craniopharyngioma (4 cases), chordoma (4 cases), optic pathway glioma (2 cases), epidermoid neoplasms (2 cases), astrocytoma (1 case), and teratoma (1 case). For the entire series, gross total resection was achieved in 25/45 operations (55.5%). Postoperative cerebrospinal fluid leak was the most common complication observed in 9 patients (20%) which were all managed endoscopically. Major vascular complications occurred in 2 patients (4.4%) and are described. Other complications are outlined as well. No mortality was observed.CONCLUSIONS: EETS to the skull base can be done with results comparable to traditional approaches. More work is needed to expand our experience, improve outcomes, and educate the public and medical community in our region about the usefulness of this approach.LIMITATIONS: Sample size and study design.CONFLICT OF INTEREST: None.

Balloon sinuplasty is a tool that is used to treat selected patients with paranasal sinus pathologies. No studies have investigated the aetiology of failed access to the frontal sinus. The aim of our study was to specify the intraoperative technical failure rate and to analyse the aetiology of the failed access to predict potential technical difficulties before surgery. We retrospectively analysed the charts of patients who underwent balloon sinuplasty from November 2007 to July 2010 at three different ENT-Centres. CT-analysis of the patients with failed access was performed. Of the 104 frontal sinuses, dilation of 12 (12%) sinuses failed. The anatomy of all failed cases revealed variations in the frontal recess (frontoethmoidal-cell, frontal-bulla-cell or agger-nasi-cell) or osteoneogenesis. In one patient, a lymphoma was overlooked during a balloon only procedure. The lymphoma was diagnosed 6months later with a biopsy during functional endoscopic sinus surgery. In complex anatomical situations of the frontal recess, balloon sinuplasty may be challenging or impossible. In these situations, it is essential to have knowledge of classical functional endoscopic sinus surgery of the frontal recess area. The drawbacks of not including a histopathologic exam should be considered in balloon only procedures.

Image-guided sinus surgery (IGSS) is a type of computer-assisted surgical navigation technique. It is also termed computer-aided surgery (CAS) as well as computer-assisted navigation (CAN). Compared to its first description in the 1990s, it is now widely applied by the rhinologists worldwide. While it is not a substitute for surgical expertise or a thorough anatomical knowledge for endoscopic sinus surgery (ESS), it is a valuable aid during any challenging ESS procedure, including surgery for chronic rhinosinusitis, benign sinonasal tumors, CSF rhinorrhea, etc. IGSS is especially helpful in cases of revision ESS, frontal or sphenoid sinus surgery, and ethmoid surgery approaching the ethmoid roof. However, there are also disadvantages including increased cost and increased time in the operating room, particularly early on in the user’s experience as they learn the nuances of system registration. A typical system localizes the tip of a probe, suction, or instrument in three different planes on the patient’s preoperative computed tomographic (CT) images viewed on an attached monitor, while a fourth panel on the screen will frequently contain an endoscopic view. The tip of the instrument is depicted by crosshairs on the abovementioned orthogonal images. Accuracy of the tip localization on the CT images is recognized to be 2 mm or better, thereby providing the surgeon with greater confidence when working in more vulnerable areas such as frontal sinus, optic nerve, base of skull, etc. during ESS. In this chapter, we aim to provide the reader with an understanding of the technology and technique of IGSS and its clinical use in standard and complex cases of ESS.

Background: Injuries caused by road traffic are a significant public health concern. In the 0-12-year age group, among the leading causes of death, unintentional injuries are considered the second and main cause of morbidity due to the safety of children in cars. According to statistics, approximately 4.7% of deaths in Saudi Arabia are caused by road traffic, while fatalities from road traffic do not exceed 1.7% in Australia, the United Kingdom, or the United States. Road traffic injuries killed more people in Saudi Arabia than in any other country with a high income. Aim: In this study, parents' knowledge, attitudes, and practices were evaluated regarding child safety regarding child car seats in Al Ahsa community. Methods: A cross?sectional descriptive study was done from November 10 to December 31, 2022. The data were collected using a 19-question survey. A convenience sampling of 379 samples was conducted. Results: In one-quarter of the participants, (24.8%) had the wrong answer when we asked them whether it is safer to hold a newborn baby in their arms than placing them in baby car safety seats, while (5.8%) did not know what is safe. Regarding the knowledge about the right way to put the car safety seat for children aged 2-4 years, near to one quarter (23%) answered wrong answer, while (11.1%) did not know how to fix it in the car. In relation to fixing the car safety seat for children aged below 2 years, only half the participants (54.6%) knew the right way. The mean score of knowledge was 3.37/5 with Std dev. ±1.52.in relation to practices and attitudes, (11.9%) said that the child is afraid to sit in the back seats, while (68.3%) said they do. (92.9%) of respondents believe that child safety seats are important. (14%) reported not using the seatbelt for children while (18.7%) reported using it sometimes. (67.3%) of those surveyed reported using seatbelts for all their children under the age of eight. There were (66.6%) of participants with acceptable knowledge and attitude scores, while (31.4%) had low scores. Parents' education level and their knowledge level were found to be significantly correlated. Parents' knowledge about care safety increased with the number of children, but there was no significant correlation between knowledge level and gender or number of children. Conclusion: According to the study, car safety seat noncompliance includes multiple variables that can be modified. The study could raise awareness by focusing on a major public health issue and providing outreach on child safety in cars. Residents of Al Ahsa generally had a positive attitude and good knowledge of car safety seats.