Abstract
Chronic inflammatory disorders of the upper airways are extremely prevalent and they have a major impact on public health.To assess the change in pulmonary function tests in patients of chronic rhinosinusitis undergoing functional endoscopic sinus surgery pre operatively and post operatively.To evaluate the difference in mean of FEV1, FEV1%, FVC, FVC%, FEV1/FVC in patients of chronic rhinosinusitis undergoing functional endoscopic sinus surgery.Prospective observational study.From July 2019 to September 2020 in Department of ENT and Head & Neck surgery, SMS Medical College, Jaipur.There was a significant improvement in the mean FEV1, FEV1%, FVC, and FVC% values post-surgically (p < 0.05). In our study, there was also a significant improvement in the FEV1/FVC value at one month postoperatively, reflecting the effect of FESS on relieving the symptomatic lower airway obstruction.Our study concludes that following Functional Endoscopic Sinus Surgery there is significant improvement in pulmonary function tests reflecting the improvement of asymptomatic lower airway disease in cases of chronic rhinosinusitis.
Keywords: Pulmonary function tests, Chronic rhinosinusitis, Functional endoscopic sinus surgery
Introduction
The human respiratory tract is divided into the upper and lower respiratory tracts which share a close relationship with respect to coexistence of diseases [1].Chronic rhinosinusitis (CRS) is an inflammatory disease of the mucosa of the nasal cavity and paranasal sinuses, with symptoms lasting > 12 weeks or > 3 months [2]. The global prevalence of CRS according to EPOS( European Position Paper on rhinosinusitis) criteria is 10.9% [3]. Although clinical evidence is accumulating that chronic sinusitis exacerbates lower airway disease, more direct and objective studies are needed to assess the importance of CRS in lower airway disease. Direct evidence of an association can be obtained by examining the effect of treatment of chronic rhinosinusitis on pulmonary function.
Functional endoscopic sinus surgery (FESS) is a minimally invasive technique in which sinus air cells and sinus ostia are opened under direct visualization.The goal of this procedure is to restore ventilation and normal function of paranasal sinuses [4]. Both epidemiological and physiological data suggest that the respiratory tract from the middle ear mucosa, through the nose and sinuses,and into the pulmonary tree behave as an integrated unit [5]. It has been found in the patients of nasal polyposis that 30% of those referred to ENT department and in more than 70% of those referred to allergy department had asthma [6].It has also been suggested that medical management of CRS helps in improvement of asthma or lower airway diseases. Typical histopathological findings seen in asthma, like airway remodeling(epithelial shedding and basement membrane thickening), eosinophilic infiltration, T-helper cell involvement, and IL-5 production are present in both asthma and CRS with nasal polyposis (CRSwNP), suggesting similar pathophysiological processes [7].
Hence, the present study focuses on improvement of pulmonary function in patients with chronic rhinosinusitis undergoing endoscopic sinus surgery.
Material and Method
This hospital based,descriptive observational,prospective study was conducted in Department of ENT and Head &Neck Surgery of SMS Medical College, Jaipur from July 2019 to September 2020.The aim of the study was to evaluate the effect of functional endoscopic sinus surgery on pulmonary function of patients with chronic rhinosinusitis.
The combination of functional endoscopic sinus surgery and medical management remains the treatment of choice in patients of chronic rhinosinusitis.
Total 30 patients of age group 18–55 years,who fulfilled the clinical criteria for chronic rhinosinusitis according to the chronic rhinosinusitis criteria[EPOS],who had taken medical management of 4 to 6 weeks,who gave consent and were found to be fit for surgery were included in our study.
Patients with any of the following conditions were excluded: pregnant women,coexistent systemic diseases like diabetes, hypertension,malignancy, with known psychiatric illness or prior paranasal sinus, nose or throat surgery,bronchial asthma and chronic obstructive pulmonary disease.
Sample Size
It was calculated at 80% study power and alpha error of 0.05, assuming standard deviation 11.51% of FVC% in pulmonary functions of chronic rhinosinusitis patients. For minimum detectable mean difference, 6.6% of FVC minimum 26 Chronic rhinosinusitis patients were required as sample size which was further enhanced to 30 patients as final sample size expecting 10% attrition/ dropout.
Methodology
CRS Assessment
Subjective symptoms and findings of CRS were based on the CRS criteria [8] and were divided into major and minor factors (Table 1). A diagnosis of CRS requires presence of at least 2 major factors or one major factor with 2 or more minor factors, or nasal purulence on examination. Facial pain is not considered to be a symptom of CRS without other nasal signs and symptoms. The signs and symptoms must persist for at least 12 weeks to qualify as chronic rhinosinusitis.
Table 1.
Chronic rhinosinusitis criteria
| Major factors | Minor factors |
|---|---|
| Facial pain/pressure | Headache |
| Facial congestion/fullness | Fever |
| Nasal obstruction/blockage | Halitosis |
| Nasal discharge/purulence/discoloured | Fatigue |
| Postnasal discharge | Dental pain |
| Hyposmia/Anosmia | Cough |
| Purulence in the nasal cavity | Ear pain/pressure/fullness |
The Lund-Mackay CT scoring system was used to separately assess the extent of involvement of the individual sinuses and osteomeatal complex, and a score of 2, 1, or 0 was respectively assigned if there was complete, partial,or no opacification. During the study, NCCT scans of paranasal sinuses were done and assessed on the basis of Lund and Mackay criteria for each sinus with a maximum score of 24.
Lower Airway Assessment
Reversibility was tested with short-acting bronchodilators,and,when the forced expiratory volume in 1 s (FEV1) was < 60%, with corticosteroids, to establish the diagnosis and to differentiate between asthma and chronic obstructive pulmonary disease.Reversibly was a diagnostic potential for bronchial asthma.
Pulmonary Function Tests
PFT were assessed using Spirometer model 6800 (vitalographPneumotac)one week prior to surgery. In a Normal case, FVC and FEV1 should be greater than or equal to 80% of predicted, and the FEV1 to FVC ratio should be normal. The PFT values were considered to indicate significant airway obstruction when FEV1/ FVC is less than 0.7 and FEV1 less than80% of the predicted value for a patient’s age, height and weight.
An obstructive ventilatory defect was defined as a decrease in FEV1 out of proportion to any decrease in FVC (i.e., a decrease in the FEV1/ FVC ratio). The severity of lower airway obstruction was assessed as follows: an FEV1/FVC ratio from 71 to 79% was regarded as mild obstruction; 61% to 70%, moderate; and < 60%, severe [9]. After obtaining written and informed consent from the patients before FESS (by Messerklinger technique) and then providing them with a an information sheet which included details of the disease, the procedure and risks involved and possible outcomes, pulmonary function test was done pre-FESS 1 week which was followed by FESS.
Surgery
FESS was performed under general anaesthesia by the Messerklinger technique.After administration of general anesthesia,nasal packing was done. An infundibulectomy was performed by incising the anterior attachment of the uncinate process; then, the ethmoidal bulla was opened and removed. The decision to open the maxillary antrum and explore the frontal recess, the posterior ethmoids, and the sphenoid depended on the extent of the disease as evidenced by the CT scan and operative findings.
Follow Up
Packs were removed after 48 h and patients were discharged on antibiotics for 7 to 10 days with alkaline nasal douching and intranasal corticosteroid spray for one month postoperatively. Systemic corticosteroids were not administered to the patients throughout the study period. Pulmonary function tests were re-evaluated after 1 month of surgery.
The outcomes of different variables were seen as follows: FEV1,FEV1%,FVC,FVC%,FEV1/FVC.
For the quantitative data, to see the significance between the means, paired t test was used.
Observation and Results
The present study was conducted at department of ENT and Head and Neck Surgery, Sawai Man Singh Medical College, Jaipur from July 2019 to September 2020.The aim of the study was to find out the efficacy of pulmonary function following endoscopic sinus surgery.The study consisted of 30 patients suffering from CRS who had undergone FESS. Preoperative and postoperative PFT values were measured at one week preoperatively and one month postoperatively and the results were analysed.
Age and Sex
The age of patients involved in the study ranged from 18 to 55 years with a mean of 35.43 ± 10.47 years. The maximum number of patients (10 cases) were in the age group 31–40 years representing 33.3% of the total. The percentage of male and female was 60% & 40% respectively. So in the study population majority of patients were males.
CT Scoring
Scoring of the CT findings as per the Lund and Mackay classification revealed that the maximum number of cases had the score of 5–8 (50% cases) followed by 9–12 (36.66%cases).Overall mean score was 9.10 with standard deviation of 2.683 (Table 2).
Table 2.
Lund-Mackay Score distribution
| Lund-Mackay Score | |||||
|---|---|---|---|---|---|
| N | Mean | SD | Median | Minimum | Maximum |
| 30 | 9.1 | 2.683 | 8.5 | 5 | 14 |
Preoperative PFT Values
The preoperative FEV1 values ranged from 1.75 to 3.58 with the mean of 2.61 ± 0.54.
Preoperative FVC values varied from 2.26 to 4.02 with the mean of 3.08 ± 0.53. The mean FEV1/FVC was 0.85 ± 0.06 with no values below 0.7 (Table 3).
Table 3.
Preoperative FEV1,FEV1%FVC,FVC%and FEV1/FVC values
| Pre-op | N | Minimum | Maximum | Mean | SD |
|---|---|---|---|---|---|
| FVC | 30 | 2.26 | 4.02 | 3.08 | 0.53 |
| FVC % | 30 | 73.40 | 95.60 | 86.45 | 5.34 |
| FEV1 | 30 | 1.75 | 3.58 | 2.61 | 0.54 |
| FEV1% | 30 | 71.20 | 93.40 | 85.02 | 5.11 |
| FEV1/FVC | 30 | 0.70 | 0.93 | 0.85 | 0.06 |
Postoperative PFT Values at 1 Month
The postoperative FEV1 values at 1 month ranged from 1.84 to 3.60 with a mean of 2.67 ± 0.54. Postoperative FVC values varied from 2.29 to 4.00 with a mean of 3.09 ± 0.52. The mean postoperative FEV1/FVC was 0.87 ± 0.06 with none of the value below 0.71 (Table 4).
Table 4.
PostoperativeFEV1, FEV1%,FVC,FVC%andFEV1/FVC values at the end of 1 month
| Post-operative | N | Minimum | Maximum | Mean | SD |
|---|---|---|---|---|---|
| FVC | 30 | 2.29 | 4.00 | 3.09 | 0.52 |
| FVC % | 30 | 76.40 | 95.40 | 88.00 | 4.74 |
| FEV1 | 30 | 1.84 | 3.60 | 2.67 | 0.54 |
| FEV1% | 30 | 73.30 | 94.20 | 86.22 | 4.93 |
| FEV1/FVC | 30 | 0.71 | 0.95 | 0.87 | 0.06 |
Comparison Between Pre and Postoperative 1 month FEV1 and FEV1% Values
The difference between mean pre-operative and post-operative FEV1 was 0.06 and the p-value was 0.009 which indicates that there was a significant improvement in FEV1 following surgery (Table 5, Fig. 1).
Table 5.
Comparison between pre and postoperative FEV1,FEV1%,FVC,FVC% and FEV1/FVC at 1 month paired t test
| N | Mean | SD | Differences | P value* | ||
|---|---|---|---|---|---|---|
| FEV1 | Pre-Operative | 30 | 2.61 | 0.54 | 0.06 | 0.009 |
| Post-Operative | 30 | 2.67 | 0.54 | |||
| FEV1% | Pre-Operative | – | – | 5.11 | 1.20 | 0.001 |
| Post-Operative | 30 | 86.22 | 4.93 | |||
| FVC | Pre-Operative | 30 | 3.08 | 0.53 | 0.28 | 0.043 |
| Post-Operative | 30 | 3.36 | 0.52 | |||
| FVC % | Pre-Operative | 30 | 86.45 | 5.34 | 1.55 | < 0.0001 |
| Post-Operative | 30 | 88.00 | 4.74 | |||
| FEV1/FVC | Pre-Operative | 30 | 0.85 | 0.06 | 0.02 | 0.001 |
| Post-Operative | 30 | 0.87 | 0.06 | |||
Fig. 1.
Showing mean pre and post operative FEV1
Similarly, the difference between mean pre-operative and post-operative FEV1% was 1.20 and the p-value was 0.001 which indicates that there was also a significant improvement in FEV1% after the surgery (Table 5, Fig. 2).
Fig. 2.
Showing mean pre and post operative FEV1%
Comparison Between Pre and Postoperative 1 month FVC and FVC% Values
The difference between mean pre-operative and post-operative FVC was 0.28 and the p-value was 0.043 (Fig. 3) which indicates that there was a significant improvement in FVC after the surgery (Tables 3, 5).
Fig. 3.
Showing mean pre and post operative FVC
The mean pre-operative and post-operative FVC% showed a difference of 1.55 and the p-value was < 0.0001 which indicates that there was also a significant improvement in FVC% after the surgery (Table 5, Fig. 4).
Fig. 4.
Showing pre and post operative FVC%
Comparison Between Pre and Postoperative 1 month FEV1/FVC Values
The difference between mean pre-operative and post-operative FVC% was 1.55 and the p-value was < 0.0001 which indicates that there was a significant improvement in FEV1% after the surgery (Table 5, Fig. 5).
Fig. 5.
Showing mean pre and post operative FEV1/FVC
The cases included in the present study comprised of 30 patients who fulfilled the CRS criteria. Pre-operatively five of the patients had abnormal FEV1 values and this improved in three of them after one month. There was a significant improvement in the mean FEV1 values post-surgically (p < 0.05).Out of the three patients who had abnormal FVC values pre-operatively,only one showed improvement. There was a significant improvement in the mean FVC values post operatively.(p < 0.05). The FEV1/FVC values were initially abnormal in three of the patients and this improved in two. It was observed that there was a significant improvement in the FEV1/FVC ratio (p < 0.05) post-operatively after one month.
Discussion
The role of pulmonary function test in evaluating the outcomes of FESS for airway improvement and ventilation is well established.The possible mechanisms explaining the link between chronic sinusitis and lower airway diseases include:
A: Sino nasal bronchial reflex which states that stimulation of neural receptors in the nose and sinuses activates trigeminal afferent pathways and produces bronchoconstriction through a vagal efferent [10].
B: Direct passage of inflammatory mediators (postnasal drip) produced by activated inflammatory cells from the sinuses into the lungs exert a significant effect on bronchial hyperresponsiveness [11].
C: Persistent mouth breathing due to nasal obstruction where air is not warmed and filtered through the nasal passages before it enters the lungs [12].
D: Cytokines and chemotactic factors released by inflamed sinus tissue into circulation promoting inflammation and recruiting eosinophils into upper and lower airway [13].
E: Chronic sinusitis and asthma are characterized by the same inflammatory process that is marked histologically by tissue eosinophils which contribute to inflammation and injury of epithelium of nose, sinuses and lungs. Eosinophilic inflammation, epithelial damage and basement membrane thickening which are present in chronic sinusitis are also present in asthma suggesting a common process underlying at least some types of chronic sinusitis and asthma [14].
With such an association, it is expected that the treatment of upper airway would improve the lower airway. Whether Functional endoscopic sinus surgery (FESS.) has a positive effect on the clinical course of bronchial asthma in patients with chronic sinusitis remains controversial.
Some studies have shown significant improvement in pulmonary function following FESS in asthmatic patients and others have shown no significant difference.
Dhong et al. found there was no significant change in pulmonary function [15]. According to Goldstein et al. there was no statistically significant change in group mean asthma symptom scores, asthma medication use scores, pulmonary function test results, and the number of emergency department visits or hospital admissions following FESS. Only a few patients demonstrated statistically significant improvement after FESS in asthma symptom scores (1 patient), medication use scores (1 patient), or pulmonary function test results (2 patients) [16]
On the other side, Ragab et al. found that the 6- and 12-month postoperative FEV1 percent (% of predicted) showed significant improvement [17]. Nakamura et al. found an important correlation between the preoperative and postoperative FEV1 scores and asthma severity [18].Study by Ikeda et al. [19] and Batra et al. [20] found significant improvement (p < 0.05) in pulmonary function tests following FESS in patients with asthma.
Hence, the present study was conducted at department of ENT and Head and Neck Surgery, Sawai Man Singh Medical College, Jaipur from July 2019 to September 2020 with the aim to find out the effect on pulmonary function following endoscopic sinus surgery in patients of chronic rhinosinusitis.We enrolled 30 patients suffering from CRS who had undergone FESS. Preoperative and postoperative PFT values were measured at one week preoperatively and one month postoperatively and the results were analysed.
The commonest age group affected in our study belonged to the age group 31–40 years (33.3%) with the mean age of 35.43 ± 10.47 years which was similar to the studies conducted by Winsted et al. [21] and Ogunleye et al. [22].
According to modified Lund scoring system, in the present study, 15 (50%)cases had the score in the range of 5–8. Similar findings were noted by Bhattacharya et al. [23]
In our study, it was noted that there was an increase in mean postoperative FEV1 (1 month–2.67) from the preoperative value (2.61) The difference between mean pre-operative and post-operative FEV1 was 0.06 and the p-value was 0.009 which indicates that there was a significant change in FEV1 after the surgery.
The difference between mean pre-operative and post-operative FEV1% was1.20 and the p-value was 0.001 which indicates that there was also a significant change in FEV1% after the surgery.
It was also observed that there was increase in mean postoperative FVC (1 month–3.36) from the preoperative value (3.08). The difference between mean pre-operative and post-operative FVC was 0.28 and the p-value was 0.043 which indicates that there was a significant improvement in FVC after the surgery.
The difference between mean pre-operative and post-operative FVC% was 1.55 and the p-value was < 0.0001 which indicates that there was a significant change in FEV1% after the surgery.
The difference between mean pre-operative and post-operative FEV1/ FVC was 0.02 and the p-value was 0.001 which indicates that there was a significant change in FEV1/FVC after the surgery.
Therefore, in our study,it was noted that there was a significant increase in mean postoperative FEV1,FEV1%.FVC,FVC%,FEV1/FVC at the end of one month compared to preoperative finding of one week before endoscopic sinus surgery. This improvement can be attributed mainly to the surgery with steroid sprays and antibiotics also playing a role.
Our study depicted significant improvement in efficacy of pulmonary function following FESS.
Thus it is evident from our study that in patients with CRS, some amount of lower airway disease is evident; which however, remains asymptomatic in most patients in this study.This non symptomatic nature of the lower airway involvement in patients with CRS can be explained by the dysfunction and inflammation of the small airways (i.e. terminal and respiratory bronchioles- 2–3 mm in diameter),or what is otherwise called as small airway disease resulting in bronchial hypereactivity.
Nasal obstruction on CRS can induce a blockage of the sinus ostia, with a reduction in the availability of nitric oxide in the upper and lower airways, as reported for patients with chronic sinus disease as a result of which it affects pulmonary function test [24].
Conclusion
Our study concludes that following Functional Endoscopic Sinus Surgery there is significant improvement in pulmonary function tests reflecting the improvement of asymptomatic lower airway disease.
The probable cause of this seems to be the removal of the trigger areas in the nose and sinuses that can cause release of leukotrienes, prostaglandins, and other inflammatory mediators that may affect the lower airways, which in turn causes improvement in pulmonary function post-operatively.
Limitations
The study did not take into consideration the possible role of different antibiotics and steam inhalation.For considering these factor further studies are required.
Funding
No financial funding received. Patients were treated free of cost under ‘MNDY (Mukhyamantri Nishulk Dava Yojana) scheme’ sponsored by Government of Rajasthan.
Availability of data and material
Pro-forma of the data taken is filled for every patient and is available with the first author for review.
Declaration
Ethical approval
“All procedures performed in the presented study involving human participants were in accordance with the ethical standards of the institutional ethical committee of SMS Medical College Jaipur (Letter no. 460/MC/EC/2020) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.”
Informed consent statement
Written informed consent was obtained from all individual participants included in the study in native language.
Consent for publication
Written Informed Consent was taken.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Data Availability Statement
Pro-forma of the data taken is filled for every patient and is available with the first author for review.