Outcomes of Endoscopic Sinus Surgery in Geriatric Patients: An Institutional Study

Abstract

The aim of this study was to investigate the efficacy and safety of Endoscopic Sinus Surgery (ESS) as a treatment modality for chronic rhinosinusitis refractory to maximal medical therapy in the elderly population. ESS has gained importance over the past 2–3 decades. A prospective review of outcome was done in fifty seven patients over age of 60 years who underwent ESS. They were evaluated preoperatively and postoperatively at 3, 6, and 12 months with a rigid nasal endoscopy scoring system, and the Sino Nasal Outcome Test-20 questionnaire. Data analysis was performed using the Student’s t test to compare mean scores. All complications were noted. All of the patients in the study reported postoperative symptomatic improvement. And it was concluded that ESS in the geriatric population is a safe and effective treatment modality for rhinosinusitis which is refractory to medical therapy.

Introduction

As the size of the geriatric population has increased in developing countries, the illnesses of older people have become more important. A previous survey data ranked sinusitis as the sixth most common chronic condition of elderly persons, occurring more frequently than cataract, diabetes, and general visual impairment [1].

The most common clinical manifestations of chronic sinusitis in older persons are nasal congestion, postnasal drip, impaired olfactory function, sore throat and pyrexia of unknown origin [2]. Adequate antibiotic therapy with other auxiliary treatments is the first step in the management of geriatric sinusitis [2]. If the patient fails to respond to medical management, surgical treatment might be indicated [3].

Predisposing factors in elderly include nasal and paranasal mucosal changes such as atrophy of the nasal mucosa, decreased mucus production, excessive crusting and a decreased mucociliary clearance. The supporting fibro-fatty tissues of the nose can atrophy, with a potential loss of support of nasal structures (i.e. narrowed nasal valve) and associated nasal obstruction. There is also an increased incidence of epistaxis and olfactory impairment in the elderly [4–6].

Over the last 30 years a functional endoscopic operative approach to chronic sinus disease has developed and it has become a widely accepted treatment modality. Endoscopic sinus surgical techniques focus on minimizing removal of normal mucous membrane and critical paranasal sinus structures, thereby minimizing trauma and preserving the mucociliary function [7].

There are very few studies regarding endoscopic sinus surgery in geriatric patients. In the current study, nasal endoscopic exam scores and sinus symptom scores were obtained preoperatively in geriatric patients undergoing endoscopic sinus surgery (ESS) or functional endoscopic sinus surgery (FESS) and compared to the follow up postoperative scores. The objective was to determine the safety and effectiveness of ESS in elderly patients with sinus disorder.

Review of Literature

The safety and effectiveness of ESS for treatment of chronic sinusitis in adults has been shown and well documented. In their review of the literature, Terris and Davidson showed that in 1713 patients undergoing FESS, 63% experienced very good results, 28% experienced good results, and 9% had poor results. They reported CSF leaks in 0.6% of patients, postoperative epistaxis in 1.5% of patients, and minor complications in 2% of patients [8]. Using symptom questionnaires, Senior et al. [9] followed 66 patients that had undergone FESS over 7.8 years. They noted that 98.4% noted improvement postoperatively. These authors also noted that the degree of improvement per patient increased over time from 68% (average improvement at 1.5 years) to 71% (average improvement at 7.8 years); however, this was not statistically significant [9] Damm et al. utilized quality-of-life (QOL) assessment questionnaires to evaluate their postoperative results in patients followed an average of 31.7 months. They noted an amelioration of QOL in 85% of patients, no change in 12%, and a decline in 3%. They did not report the degree of improvement of QOL scores in this patient population [10]. Vleming et al. [11] studied complications of FESS in 593 patients of which 2 had CSF rhinorrhea, 2 had orbital complications and 15 had haemorrhage.

In this study postoperative outcomes were analyzed in patients over the age of 60 who underwent ESS. The Sino-Nasal Outcomes Test questionnaires and nasal endoscopy scores were used to analyze postoperative outcomes. The postoperative degrees of improvement noted over the 3, 6 and 12-month time periods for each of the scoring systems are all statistically significant (P 0.001). Patients evaluated by the Sino Nasal Outcome Test-20 (SNOT-20) scoring system experienced a 65% of improvement of symptom scores at 3 months, 75% improvement at 6 months and 75% improvement at 12 months. The SNOT-20 questionnaire system is a statistically valid as a quality-of-life and rhinosinusitis health status assessment tool as shown by Piccirillo et al. [12]. Therefore, the degree of improvement noted in this study by the SNOT-20 evaluation method is statistically significant and a valid outcome measure in this population. Studies suggest that postoperative follow-up with nasal endoscopic examination provides prognostic in-formation with regard to potential future episodes of sinusitis and need for revision FESS [13]. Rigid nasal endoscopy scores improved by 77% at 3 months, 66% at 6 months, and 78% at 12 months, respectively, as compared to preoperative scores elderly population accounted for 15.6% of all endoscopic surgeries in their population, which included children (9.9%) and adults. Although they reported a slightly increased complication rate as compared to their adult and pediatric group, they noted a greater improvement rate with FESS in the elderly as compared to non-elderly adults. In this series of 57 patients there were 6 very minor complications and no major complications.

Materials and Methods

Data was collected prospectively in patients presenting to a tertiary care hospital in Odisha with complaints of chronic rhinosinusitis.

Inclusion criteria:

• Patients over 60 years of age.

• Diagnosed with chronic rhinosinusitis without nasal polyposis or nasal growths.

• Had not undergone previous surgery and had failed maximal medical therapy.

• Patients giving written informed consent.

Exclusion criteria:

• Patients less than 60 years of age.

• Patients with uncontrolled diabetes and uncontrolled hypertension.

• Rhinosinusitis with polyposis.

• Patients unfit for surgery.

• Associated with other sino nasal malignancies.

• Patients who did not give written informed consent.

Fifty seven such patients with sinus disease who underwent primary ESS presenting from August 2016 to January 2019, were prospectively included in the study. At the time of presentation, a careful history and physical examination, including a rigid nasal endoscopy, were performed. Patients were identified with persistent sinus disease by history, physical exam and CT scan. These patients had persistent symptoms like headache, heaviness of head, recurrent rhinorrhea, post nasal drip and nasal blockage despite at least 3–4 weeks of medical therapy for rhinosinusitis. Therapy included nasal steroid spray and mucolytic agents. At least 10 days of broad-spectrum antibiotics were prescribed when there was evidence of purulent discharge on endoscopy. All patients had their CT scans done for diagnosis.

Those who failed this medical therapeutic regimen and had evidence of radiologic rhinosinusitis underwent ESS. For the surgery, under all aseptic precautions, uncinectomy was done using Swing Door technique. Blunt instrument was used for the uncinectomy instead of conventional sharp instruments to prevent injury to lamina papyracea as elderly patients tend to have osteoporotic bones. This was followed by middle meatal antrostomy to facilitate adequate sinus drainage. Then anterior and posterior ethmoidectomy were done. Sphenoid and frontal sinuses ostia were opened in all patients except in 15 patients who had radiologically normal findings in the sphenoid and frontal sinuses. Tissue was sent for biopsy in all cases which came out to be inflammatory. Patients were followed up postoperatively at intervals of 3, 6, and 12 months.

The study population was composed of 32 males and 25 females with an average age of 67 years. The subjects were evaluated with the Sino-Nasal Outcome Test-20 (SNOT-20) [12]. These test forms were completed preoperatively, and also at 3, 6, and 12 months postoperatively.

Nasal endoscopic exam scores were obtained at the same time intervals [14]. The nasal endoscopy was graded for presence of any discharge, scarring, edema, polyposis and crusting. For nasal polyps, 0 was given for absence of polyps, 1 for polyps present within the middle meatus and 2 for polyps beyond the middle meatus. For edema, scarring and crusting, 0 was given if the corresponding finding was absent, 1 if it was mild and 2 if it was severe in extent.

For discharge, 0 for no discharge, 1 for clear thin discharge and 2 for thick purulent discharge. Each side was graded separately and the scores from each side were added to the overall endoscopic score.

Data analysis was performed using the Student’s t test to compare mean postoperative scores at 3, 6 and 12 months to the preoperative scores. Statistical significance is said to be achieved when P value is less than or equal to 0.05.

Results

Fifty seven consecutive patients over the age of 60 were evaluated by history and physical examination, including rigid nasal endoscopy. The average age was 67 years (range, 61–75). Thirty two patients in our study were male and twenty five were female. Patients with findings consistent with chronic rhinosinusitis were initially treated with maximal medical therapy and a CT scan was done after 4 weeks of treatment. Those who failed maximal medical management underwent ESS and were included in the study.

All of the patients in the study had benign inflammatory biopsy reports. All of them reported postoperative symptomatic improvement. Sino Nasal Outcome Test-20 (SNOT-20) scores were obtained preoperatively and at 3, 6, and 12 months postoperatively. The mean preoperative SNOT-20 symptom score was 29.6. Mean postoperative symptom scores at 3, 6, and 12 months were 10.7 (P 0.001), 8.1 (P 0.001), and 7.3 (P 0.001), respectively (Fig. 1).

Fig. 1.

Preoperative and postoperative SNOT-20 outcomes in outpatient population. SNOT-20, Sinonasal outcomes test

Endoscopic exam scores were obtained preoperatively, and at 3, 6, and 12 months postoperatively. The mean preoperative endoscopic score was 4.8. The mean postoperative scores at 3, 6, and 12 months were 1.3 (P 0.001), 1.7 (P 0.001), and 1.2 (P 0.001), respectively (Fig. 2) (Table 1).

Fig. 2.

Preoperative and postoperative rigid nasal endoscopy scores

Table 1.

Comparison between pre-operative post-operative results at 3, 6 and 12 months with P value

	SNOT-20 score	Endoscopic score
Pre operative	29.6	4.8
Post operative	10.7	1.3
P value	0.001	0.001
3 months post operative	10.7	1.3
6 months post operative	8.1	1.7
1 year post operative	7.3	1.2
P value	0.001	0.001

The patient did well symptomatically. There were no episodes of postoperative epistaxis, orbital complications, or cerebrospinal fluid (CSF) leaks. No revision ESS has been necessary to date

Postoperative complications included three patients having intranasal crusting seen by follow-up endoscopic exam. This was controlled using aggressive nasal saline irrigations. One patient experienced lateralization of the anterior portion of the middle turbinate without associated symptoms of obstruction of the osteomeatal complex. Follow-up rigid nasal endoscopic exams revealed healthy appearing nasal mucosa.

Discussion

Within this rising percentage of elderly persons there will also be an increase in the average age. The portion of those 85 years of age is growing. Thus, a greater understanding of otolaryngologic physiology and disorders of the elderly is needed [15].

Rhinosinusitis is the sixth most common chronic condition of those aged 65 and older [1]. Physiologic changes related to mucus membrane function, nasal structure, and immune function likely have a role in the high prevalence of sinus disease in the elderly [4–6].Medical and precise surgical approaches to treating rhinosinusitis in this population must address these factors. Also, the surgeon should be aware of the higher rates of iatrogenic injury in geriatric patients that have been ascribed to the increased rates of comorbid illnesses and longer lengths of hospitalization [1]. While the majority of geriatric patients do well during surgery and postoperatively, higher rates of adverse postoperative complications have been reported. A thorough history and physical examination with particular attention to neurologic and cardiopulmonary preoperative status is imperative [16]. The surgeon should also pay particular attention to the increased use of anticoagulants in this patient population. Discontinuation of anticoagulant therapy should be performed carefully, taking into account the patient’s relative risk for a thromboembolic event [17]. In our practice we endeavor to ensure proper communication among the surgeon, anesthesia, and the primary and secondary physicians to ensure proper perioperative management of the patient’s surgical and comorbid medical issues.

Conclusion

Rhinitis and sinusitis are troublesome and often unrecognized medical conditions in the geriatric population. Changes in anatomy and physiology associated with ageing potentiate the occurrence and severity of these entities. With advancing age, the mucociliary motility decreases, predisposing the patient to sinus diseases. This adds to other comorbidities that geriatric patients inadvertently face. This in turn leads to a poorer quality of life in the patient. The patients and their families face extra added burden of disease. Sinus disease in elderly leads to increased episodes and severity of symptoms such as headache and post nasal drip; which can further lead to aspiration. Patients have to undergo recurrent hospital visits for the same. Thus relieving the patients from the symptoms and complications and to improving the quality of life is paramount.

The purpose of this study was to investigate functional endoscopic sinus surgery in the geriatric population. The statistically valid SNOT-20 scoring method and an endoscopic scoring method were used to evaluate patients preoperatively and postoperatively at 3, 6, and 12 months, respectively. There was symptomatic improvement in our geriatric population after FESS and this result is comparable to that of other age groups presented in the literature [9]. Also, the complication rate in geriatric FESS was very low in this series and comparable to that of nongeriatric FESS. To date, our experience with FESS in those over the age of 60 reveals that it is a safe and effective treatment method to address chronic rhinosinusitis that is refractory to medical therapy.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

The ethical clearance is approved by Institutional Ethical Committee, KIMS Hospital, Bhubaneswar (KIIT/KIMS/IEC/07/2016).