Improving CT Sinus Reporting for Endoscopic Sinus Surgery Using the CLOSE Criteria: A Quality Improvement Project

Background: Chronic rhinosinusitis with sinonasal polyps (CRSwNP) is a prevalent condition associated with olfactory dysfunction, nasal obstruction, and facial pain. Endoscopic sinus surgery (ESS) is a common treatment option for patients with CRSwNP, but the effect of ESS on olfactory function remains under debate. Objective: This study aims to evaluate the changes in olfactory function before and after ESS in patients with CRSwNP and sinonasal polyps. Methods: This Descriptive case series was conducted in the department of ENT, Lahore General Hospital, Lahore, from September 2024 to January 2025. Data were collected through the Non-probability consecutive sampling technique. The participant was admitted to the ENT ward for surgery. Functional endoscopic sinus surgery was performed under GA in each case with the standard anterior-to-posterior approach. Post-operative follow-up was carried out at the 3rd month. Results: A total of 69 patients were added in the study and the mean age was 45.2 ± 9.3 years, with 52% males and 48% females. The duration of symptoms ranged from 12.5 ± 6.4 months on average, with no significant gender differences. 25% of the patients were smokers, and 40% had a history of allergies. All patients included in the study had a preoperative olfactory score of 0, indicating complete anosmia before undergoing functional endoscopic sinus surgery (FESS). At the three-month follow-up, 68.1% of patients demonstrated improvement in olfactory function, scoring 1 on the olfactory test, indicating the ability to identify phenyl ethyl alcohol (50%). However, 31.9% of patients remained anosmic, unable to distinguish between the odorless substance and the test solution. Conclusion: ESS significantly improves olfactory function and alleviates other sinonasal symptoms in patients with CRSwNP. The degree of polyp removal correlates with olfactory recovery, and ESS enhances overall quality of life.

Direct carotid-cavernous fistula after functional endoscopic sinus surgery – A case report

Functional endoscopic sinus surgery (FESS) has been the most common surgery for chronic rhinosinusitis (CRS), and to accomplish surgical goals such as facilitate adequate visualization and allow room for endoscopic instrumentation, the correction of the minimally deviated septum has been advocated. Objective: To ascertain the role of limited septoplasty during functional endoscopic sinus surgery (FESS) in reducing the recurrence of the rhinosinusitis. Patients and methods:A prospective descriptive study conducted at the department of Otorhinolaryngology–Head & Neck surgery (Sulaymaniyah Teaching Hospital - College of Medicine - University of Sulaymaniyah). Patients were presented with refractory CRS, with concomitant septal deviation, and prepared for FESS were randomly divided into two groups; group A (10 patients) underwent FESS without septoplasty and group B (10 patients) underwent FESS with limited septoplasty. To determine the effectiveness of the septoplasty in concomitant with FESS, a comparison of the outcomes of FESS in both groups been done throughout utilizing the Sino-Nasal outcome test (SNOT-22) and Lund –Kennedy (LK) endoscopic score preoperatively and 6 months postoperatively. Results: Among the twenty patients included in this study, (40%) of patients in the group A and (30%) of patients in the group B had polyp extending to nasal cavity with (two score), which diminished to 0% at 6 months postoperatively. Need to blow nose, Sneezing, Runny nose, cough, postnasal discharge, ear fullness, dizziness, ear pain, facial pain/pressure, fatigue, sad, embarrassed symptoms had improved in patients undergone FESS with limited septoplasty. Conclusions: Limited septoplasty is primarily used when the septal deviation is located opposite the work area for endoscopic sinus surgery--namely, opposite the middle turbinate and/or the osteomeatal unit.

To quantify and analyze the concurrent performance of rhinoplasty (RP) (with or without septoplasty) and functional endoscopic sinus surgery (FESS). Cross-sectional analysis. Current Procedural Terminology codes were used to extract cases of RP (n = 22,360), FESS (n = 99,173), and concurrent RP with FESS (RP + FESS) (n = 1,321) within the State Ambulatory Surgery Databases of California, Florida, Maryland, and New York from 2009 to 2011. Patient demographics, surgeon volume, charge, concurrent nasal procedures, and operating room (OR) time were compared. Among the 1,321 RP + FESS combination cases, a majority involved primary rhinoplasty (n = 697, 52.8%), followed by nasal valve repair (n = 563, 42.6%) and revision rhinoplasty (n = 61, 4.6%). High-volume (n > 30), medium-volume (n = 10-30), and low-volume rhinoplasty surgeons (n ≤ 9) were observed to perform a similar number of FESS + RP combination surgeries (153, 152, and 155, respectively). A majority of RP + FESS involved two or fewer sinuses (65%). Mean OR time for RP + FESS was 189.4 ± 4.2 minutes, approximately 50 minutes shorter than the sum of standalone RP performed individually (138.8 ± 1.0 minutes) and standalone FESS (102.9 ± 0.4 minutes). RP + FESS more frequently involved fewer sinuses (compared with FESS alone) and was also less likely to involve revision rhinoplasty (compared with rhinoplasty alone); therefore, these cases may be selected for lower sinus disease burden and less complex rhinoplasty compared to standalone procedures. Procedures combining rhinoplasty and sinus surgery had a reduction in OR time compared to the hypothetical sum of two standalone procedures. NA Laryngoscope, 130:E311-E319, 2020.

Background Functional endoscopic sinus surgery (FESS) is considered one of the most common ENT procedures. The main obstacle is impaired vision owing to excessive bleeding. Many drugs have been used to control such issues. Dexmedetomidine has a great affinity to α2-adrenergic receptors. This research evaluated the hypotensive effect of intravenous against the intranasal dexmedetomidine in FESS. Materials and methods Patients randomized into 2 equal groups:Dexmedetomidine intravenous group (IV group) (n = 35): IV dexmedetomidine 1 μg/kg in 100 ml of normal saline (0.9%) was infused 15 min before starting anesthesia, followed by 0.5 μg/kg/h. At the same time, intranasal saline was given as a placebo.Dexmedetomidine intranasal group (IN group) (n = 35):IN dexmedetomidine (2 μg/kg) was given 15 min before induction, 1 ml in each nostril. At the same time, the patient received 100 ml of saline (0.9%)15 min before anesthesia, followed by IV saline as a placebo. The primary outcome was Boezaart’s grading scale. Other outcomes were the recorded hemodynamics, surgical satisfaction, sedation score, and adverse events. Results The calculated blood loss and Boezaart’s scale were lower in the IV group (p value < 0.001). Also, the IV group’s mean arterial blood pressure (MAP) and heart rate were significantly lower. The total intraoperative fentanyl dose was lower in the IV group. Surgeon satisfaction and sedation scores were significantly higher in the IV group. Conclusions Intravenous dexmedetomidine provides a better surgical field, more surgeon satisfaction, and lower blood loss for FESS.

This review aims to highlight the ocular complications related to Functional Endoscopic Sinus Surgery (FESS) and provide insight for ophthalmologists and also otorhinolaryngologists. A literature search was conducted on ophthalmic complications associated with FESS in the PubMed and Google Scholar databases. The keywords "endoscopic sinus surgery", "functional endoscopic sinus surgery", "paranasal sinuses", "orbita", "orbital complications", "orbital hemorrhage", "epiphora", "visual loss", "double vision", "optic nerve", "diplopia", "hematoma", "blindness", "oculomotor nerve", "lamina papyracea", "lacrimal drainage system", "ciliary ganglion", "extraocular muscles" were used. Major complications include extraocular muscle injury, nasolacrimal duct injury, orbital hemorrhage, optic nerve injury, permanent vision loss, and injuries to the vascular and neural structures of the orbit. Orbital hemorrhage is among the most frequent ophthalmic complications of FESS and poses a potential threat to vision. It typically occurs due to penetration of the lamina papyracea into the orbit. Direct or indirect trauma to the optic nerve is one of the most devastating complications, resulting in irreversible vision loss, and there is currently no established treatment. Other complications include injuries to extraocular muscle, which must be managed on a case-by-case basis, and epiphora, which, although not vision-threatening, significantly reduces quality of life. FESS has provided a new perspective on the surgical management of sinus diseases. While it is generally regarded as a safe procedure, the potential for complications should always be considered. The orbit and, therefore, the ocular tissues are susceptible to complications due to their critical anatomical relationships with the paranasal sinuses and skull base.

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.

BackgroundContinuous quality improvement (CQI) has become an important aspect of healthcare organizations. The objective of this study was to identify contributing factors for implementing continuous quality improvement projects in health facilities for the better delivery of healthcare service in the region of South Nation and Nationalities Peoples Region (SNNPR), Ethiopia.MethodsA cross-sectional study was conducted from April to May 2018 in health facilities within two districts (woredas) located in SNNPR. Descriptive, bivariate, and multivariate analyses were used. During the analysis, a P-value less than 0.05 and 95% confidence interval (CI) were used to assess the significance of the associations.ResultsA total of 144 health professionals participated in the study. The majority of the respondents (75%) were male and 35% reported that their respective health facilities have implemented continuous quality improvement projects. More than half of the leaders (51.4%) were not receptive to new ideas and the majority of leaders were not encouraging learning (62.5%) or engaged in the quality improvement project implementation process (66%). Multivariate logistic regression analysis revealed that 84% of the health facilities were implementing a continuous quality improvement project (AOR=0.138 (0.029−0.652)). Similarly, client satisfaction was 90% (AOR=0.101 (0.019−0.522)) and the percentage of staff who believe that the quality improvement project contributed to the improvement of work at their respective health facility was 80% (AOR=0.181 (0.047−0.696)).ConclusionThe following variables, “Leaders receptiveness to new ideas”, “Leaders share information/data about health facility service delivery status”, “Health facility has a quality improvement project plan”, “Staff know using indicators to tell progress about service delivery”, and “Health facility assess client satisfaction level” were found to be independent predictors of continuous quality improvement (CQI) project implementation.

Improving data quality control in quality improvement projects

e18733 Background: Participation in quality improvement (QI) projects allows medical trainees to develop an essential skillset to systematically analyze practice and implement changes with the goal of practice improvement. The ACGME designates QI education and participation as a core competency for all fellows. Training programs and institutions can vary significantly in QI educational format, participation, and direct support for project design and implementation. Here we present a description of the Resident Quality, Experience, and Safety Team (RQUEST) committee, which is being utilized by Hematology and Oncology fellows for QI project design and implementation at our institution. Methods: The first RQUEST committee was convened in August of 2021. RQUEST holds formal monthly meetings from August to June of each academic year. At the initial meetings, committee members are introduced to quality, safety, and patient experience structures and receive introductory training in QI tools and techniques. RQUEST members are then split into smaller project groups and work to select a QI project, perform current state analysis and baseline data collection, design and implement improvement interventions, and re-measure to determine the impact of the chosen interventions. The year concludes with each team presenting their project at a joint session to a larger audience of program directors, quality officers, service line directors, department chairs, graduate medical education staff, and hospital leadership RQUEST participation provides fellows with direct access to a multidisciplinary team and resources throughout project design and implementation. The timeline of monthly meetings provides both accountability and productive feedback. This facilitates the identification of system-specific opportunities for improvement and the most practical points of contact within the hospital, clinic, or EMR to design and apply quality interventions promptly and effectively. Results: We sent a voluntary survey to RQUEST participants, and 40% of participants responded to the survey. 100% of those who responded said participating in RQUEST has been beneficial in developing and implementing a QI project, and 100% said they would recommend participating in RQUEST to other medical trainees. The most common benefits listed were: · Structured approach/guidance · Institutional support and resources · A collaborative environment with a team of members from various departments, including IT. Conclusions: Fellow participation in a multidisciplinary QI committee at our institution has improved fellow QI education, participation, and project implementation. This engagement model has proven valuable to fellows and faculty in enhancing QI competency and clinical practice.

Functional endoscopic sinus surgery (FESS) is a standard treatment modality for patients with chronic rhinosinusitis (CRS) who have failed appropriate medical therapy. However, FESS entails modification of the upper airway tract that may alter phonatory resonance and produce voice changes. The effects of FESS on postoperative voice characteristics in patients with CRS have yet to be quantitatively assessed. Patients with severe CRS who underwent FESS at a tertiary care referral center between May and October 2017 were prospectively enrolled. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and the Voice Handicap Index (VHI) were used to quantitatively evaluate voice characteristics and quality of life, respectively. Preoperative and postoperative CAPE-V and VHI scores were compared with postoperative scores for each patient. Sino-Nasal Outcome Test (SNOT-22) scores were also obtained to assess changes in patient symptoms. 18 CRS patients undergoing FESS were enrolled. The average preoperative Lund-Mackay score was 14, indicating baseline severe CRS. Postoperative assessments demonstrated a statistically significant decrease in CAPE-V (45-27, p = .005) and VHI (10-4.7, p < .001) scores. These correlated with a statistically significant decrease in SNOT-22 scores (42-13, p < .001). Patients with CRS experience a significant improvement in voice characteristics and vocal quality of life following FESS. Furthermore, this appears to correlate with a significant decrease in self-reported disease severity. These findings may augment the discussion of potential benefits of FESS to a new potential domain for voice quality.

Background:There is preliminary evidence that patients with chronic rhinosinusitis (CRS) and comorbid obstructive sleep apnea (OSA) have reduced quality-of-life (QOL) improvements after functional endoscopic sinus surgery (FESS) compared with patients without OSA. The effect of OSA severity on QOL improvement after FESS is unknown.Objectives:To better characterize the QOL improvement after FESS for patients with comorbid OSA and to assess whether QOL improvement is dependent on OSA severity.Methods:This multi-institution, retrospective cohort study evaluated adult patients with CRS who underwent FESS between 2007 and 2015. Preoperative, 1-month, 3-month, 6-month, and 1-year postoperative 22-Item Sino-Nasal Outcome Test scores were used to evaluate QOL. We compared patients without OSA with patients with stratified OSA based on the preoperative apnea-hypopnea index. A multilevel, mixed-effects linear regression model was used for the analysis.Results:Of 480 participants, 83 (17%) had OSA, and 47 of these patients had polysomnography results available for review. Both patients with OSA and patients without OSA reported significant QOL improvement after surgery (p < 0.0001) relative to baseline. In the unadjusted model, the subjects with OSA demonstrated a statistically worse outcome in 22-Item Sino-Nasal Outcome Test scores at each time point (2.4 points higher per time point, p = 0.006). When controlling for covariates, the adjusted model showed no difference in QOL outcome based on OSA status (p = 0.114). When stratified by OSA disease severity, the adjusted model showed no difference in the QOL outcome.Conclusions:Patients with CRS and comorbid OSA had worse QOL outcomes after FESS; however, when controlling for patient factors, there was no difference in QOL outcome. OSA disease severity did not seem to predict QOL improvement after FESS.

Objectives: To determine the effect of a single intravenous dose of tranexamic acid on intraoperative bleeding, duration of surgery, and surgical field visualization during endoscopic sinus surgery.&#x0D; &#x0D; Methods:&#x0D; Study Design: Double-blind, randomized, placebo-controlled trial.&#x0D; Setting: Tertiary Government Hospital in Quezon City&#x0D; Participants: 10 patients aged 18-75 years old diagnosed with chronic rhinosinusitis with or without nasal polyposis and unresponsive to medical treatment, who underwent endoscopic sinus surgery from September 2016 to August 2017, were randomly allocated to treatment group and control group respectively. The “odd” numbers were assigned to the treatment group (intravenous Tranexamic acid) given 1 dose of 100mg/ml (500mg tranexamic acid per 5 ml) tranexamic acid slow intravenous drip 1 hour prior to the procedure, while the “even” numbers assigned to the control group received the same amount of normal saline solution.&#x0D; &#x0D; Results: The mean duration of surgery of the tranexamic group was 185 minutes (standard deviation, SD 55.23) and the control group was 122.6 minutes (SD 42.03) showing no significant difference (p=.08). The mean blood loss of the tranexamic group was less at 240ml (SD 108.39) compared with the control group at 290ml (SD 74.16), although there was no statistically significant difference (p=.42). Intraoperative surgical field assessed by the surgeon based on the Boezart grading scale showed that 2 (40%) of the tranexamic group had higher bleeding score compared with the placebo group. However, this was not found to be statistically significant (p=.460). Due to the small sample size, a type II error occurred with alpha level of 0.05 and estimated power of 0.0885, with not enough basis to refute that a single dose of intravenous tranexamic acid has no effect in improving surgical field visualization during endoscopic sinus surgery. No drug side effects were noted after administration until after surgery.&#x0D; &#x0D; Conclusion: Single dose intravenous tranexamic acid in functional endoscopic sinus surgery decreased mean intraoperative blood loss (but this was statistically insignificant), but its effect on surgical field visualization cannot totally be assessed due to small sample size. There was also no change in the observed duration of surgery. No untoward side effects associated were noted from administration of the drug until after the surgery finished.&#x0D; &#x0D; Keywords: Functional endoscopic sinus surgery, intravenous tranexamic acid, chronic rhinosinusitis

Context: Endoscopic sinus surgery is a minimally invasive and currently the treatment of choice for acute/intermittent and chronic/persistent rhinosinusitis (RS) unresponsive to conservative medical treatment. Aims: To evaluate the indications and outcomes of treatment of RS with or without nasal polyps. Methods and Material: This was a retrospective review of all cases of endoscopic sinus surgery done at the National Ear Care Centre. The information extracted from the case notes of patients included the demographic profile, clinical radiologic and endoscopic findings, the surgery offered and outcome of surgery. Statistical analysis used: All information was entered into SPSS version 20.0. Results: Out of 116 patients had endoscopic sinus surgery, only 107 (92%) had complete information for the analysis. Their age ranged from 9 to 72 years with a mean age of 35.9 ± 1.9 years. Up to 105 of the patients presented nasal discharge alternating with nasal obstruction while 65% (70) of them had bilateral disease. Computed tomography scan revealed abnormalities in 66.4% (71) patients. The preoperative diagnosis of chronic RS (CRS) with simple nasal polyp was made in 66 patients, had functional endoscopic sinus surgery with polypectomy in 64.5% (69) patients and intraoperative findings revealed a mixture of mucosal diseases with sinonasal polyps in 73.8% and fungal sinus diseases in 18 (16.8). Majority of the patients (53.3%) were discharged home on the 2nd postoperative day. About 71% of the patients had resolution of their disease after months of followup. Conclusion: Endoscopic sinus surgery is higher among young adult in third and fourth decades of life. There is female preponderance and preoperative radiology assessment and the intraoperative findings revealed strong relationship. The outcome of treatment revealed recurrent disease in 10.5% with nasal adhesion, epistaxis and excessive nasal crust formation.

Introduction: "Quality improvement (QI) is an approach to enhancing service systems and processes through the routine use of health and program data to meet patient and program needs". 1 Pregnancy and prenatal care follow-ups require frequent care visits.Problems that decrease the efficiency in caring for high volumes of patients can occur at any time.Furthermore, studies show that excessive wait time can be a source of patient and employee dissatisfaction, 2-4 and are associated with lower patient satisfaction (p<0.05). Objective:The purpose of this QI project was to improve patient visit efficiency. 5Our goal was to decrease the lead time (entrance to exit) for the initial maternity visit that included ancillary services (e.g.Women, Infants and Children (WIC), Pregnancy Care Management) to 30 minutes or less by December 1, 2016 from the current baseline of 2 hours 49 minutes.This decrease in lead time is a critical component of our efforts to improve patient and staff satisfaction, increase our capacity for patient care, provide multiple same-day services, enhance time management, and increase "word of mouth" patient referral. 6Furthermore, an additional goal of this study was to evaluate and improve the delay time (i.e.days until next available appointment) in scheduling clinic appointments.