Impact of FESS on the Pulmonary Function of Patients with Chronic Rhinosinusitis

Abstract

Background and Aims

There is interdependence between the upper and lower airway has led to the concept of a unified airway. Here we aim to study the impact of functional endoscopic sinus surgery (FESS) on the pulmonary function (PFT) of patients with chronic rhinosinusitis (CRS).

Methods

The proposed study is undertaken in the department of ENT, PGIMER & Dr. RML Hospital, New Delhi. It is a prospective study of 34 patients fulfilling the clinical criteria for (CRS) from the study period of Oct 2015 to Dec 2017 not responding to medical management and taken up for fess and follow up done with (PFT).

Results

The maximum incidence of cases was seen in the age group > 40 years. Chronic rhinosinusitis predominantly affected the male population. Nasal discharge was the commonest presenting complaint. A marked reduction is seen in the frequency of symptoms post-surgery.

Conclusion

CRS affected persons of adult age with maximum number in the age group of > 40 years, with a male:female ratio of approximately 2:1. Percentage improvement in FEV1 and FVC is more in age group > 40 years while percentage improvement in FEV1/FVC ratio is more in age group 31–40 years. Percentage increase in FEV1 and FVC is more in males while percentage increase in FEV1/FVC is more in females. Percentage increase in FEV1 and FVC is more in males and FEV1/FVC is more in females. Percentage increase in FEV1, FVC and FEV1/FVC ratio is more in cases of bilateral diseases then those with unilateral disease.

Introduction

Chronic rhinosinusitis (CRS) and asthma are among the most important health-related conditions with evident socio-economic effects. The relationship between asthma and CRS has been considered in medical references for centuries. The disease processes of these two conditions are very similar, and in some cases, even the clinical manifestations and pathophysiology of these diseases are the same.Coexistence of upper and lower respiratory diseases is common. The nasal airways and their closely associated paranasal sinuses are an integral part of the respiratory tract. In the second century, Claudius Galenus, one of the fathers of modern respiratory physiology, defined the nose as a respiratory instrument in his work “De usupartium” [1–5].

Both the upper and lower respiratory tracts are continually exposed to gases and airborne particles. The importance of host defence mechanisms is vital. Physical barriers, mucociliary clearance systems and cellular or humoral immune processes combine to protect the lung from damage. Where abnormalities of these mechanisms occur, the patient may first present to the otolaryngologist before serious bronchopulmonary involvement occurs. Mucociliary clearance is the predominant clearance mechanism for both upper and lower airways. The two component of mucociliary clearance are the cilia and the secretions above them. The cilia beat in a coordinated fashion with a ciliary beat frequency of 12–14 beats per second. Two layers of mucus are present over the ciliated cell; an outer thick, viscoelastic, semisolid mucus layer, which the cilia do not directly strike, and an inner layer of watery serous fluid.

Because of the low viscosity of the layer of watery serous fluid, the cilia can beat normally and move the watery lower layer, affecting movement of the upper thick layer. Changes in these properties affect movement of the mucus blanket and play a major role in pulmonary and sinus disease. In the upper respiratory tract, cilia propel mucus, bacteria, and the particles trapped in mucus to the nasopharynx, where the mucus drops to the hypopharynx and is swallowed. In the lower respiratory tract, the cilia that line the trachea and bronchial treesimilarly move the mucus blanket up the trachea and into the hypopharynx for swallowing [6].

Chronic rhinosinusitis is one of the most commonly diagnosed chronic medical conditions in present time due to change in life style. According to Scott brown’s textbook of otorhinolaryngology latest edition, the term sinusitis refers to group of disorders characterized by inflammation of mucosa of the paranasal sinuses. Because the inflammation always also involves the nose, it is now generally accepted that Rhinosinusitis is the preffered term to describe this inflammation of nose and paranasal sinuses [7]. In consultation with other medical disciplines, the American Academy of Otolaryngology and Head and Neck Surgery established baseline parameters in 1996 for discerning the subtypes of rhinosinusitis (acute, recurrent acute, subacute and chronic). It is defined as chronic rhinosinusitis if the symptoms persists for more than 12 weeks.

Subjective symptoms and findings of CRS were based on the CRS criteria and were divided into major and minor factors. CRS diagnosis requires presence of at least 2 major factors or one major factor with 2 or more minor factors. The signs and symptoms must persist for at least 12 weeks to qualify as CRS.

Major symptoms are facial pain, facial congestion,nasal obstruction, nasal discharge/purulence, hyposmia/anosmia.

Minor symptoms are headache,fever,halitosis,fatigue,dental pain,cough,ear pain /pressure/fullness [7].

Before starting any management of the patient, proper history and examination of the patient is done. Examination of the patient of chronic rhinosinusitis includes anterior rhinoscopy and nasal endoscopy. With the introduction of CT scanning in the 1970s, accurately pinpointing the location and extent of the sinus pathology has become possible. Treatment of sinusitis includes medical and surgical management. A course of medical management comprises antibiotics, antihistaminic, antiallergics, decongestants and topical and systemic steroids. This medical management is generally given for 3 weeks. If refractory to this medical management,patient is taken up for surgery Functional endoscopic sinus surgery (FESS) has now become a wellestablished strategy for chronic rhinosinusitis refractory to medical treatment. It is based on principle that diseased mucosa gets reverted if ventilation and drainage are improved, thus restoring mucociliary clearance.

Functional endoscopic sinus surgery can be performed through two techniques—Mesenklinger’s approach-anterior to posterior approach [8].

Wigand’s approach—posterior to anterior approach [9].

A close association has been suggested between sinusitis and lower respiratory disorders like bronchial asthma. It is well known that chronic sinusitis coexists in as many as 40–75% of patients with asthma. Study done by Shaabanet al. [10] had shown that allergic rhinitis was associated with increased onset of bronchial hyperresponsiveness, and less chance for remission except in those treated for rhinitis.

So to check for the lower respiratory tract functioning, pulmonary function tests for the patient is done.

Pulmonary Function Tests

In a nnormal case, FVC and FEV1 should be greater than or equal to 80% of predicted, and the FEV1 to FVC ratio should be no more than 8–9 absolute percentage points below thepredicted ratio. The PFT values were considered to indicate significant airway obstruction when FEV1/FVC < 0.7 and FEV1 < 80% of the predicted value for a patient’s age, height and weight.[11].

The objective of this study is to assess the extent of improvement of chronic sinusitis following surgical treatment in the form of FESS and also if it can bring about a significantimprovement in the pulmonary function tests of patients (see Figs. 1 and 2).

Fig. 1.

Nasal findings pre and post op

Fig. 2.

Spirometer used for pulmonary function testing

Materials and Methods

• The proposed study was undertaken in the department of ENT, PGIMER & Dr. RML Hospital, and New Delhi.

Study Design Prospective study.

Study Period October 2015–December 2017.

Inclusion Criteria

• Diagnosed cases of Chronic rhinosinusitis with or without nasal polyposis not responding to maximum medical management.

• The patients belong to the age group 18–60 years.

Exclusion Criteria

• Revision endoscopic sinus surgery

• Patients medically unfit for surgery

• Smokers

• Coexisting lung diseases like bronchial asthma, cystic fibrosis, immunodeficiency, lung neoplasms etc.

Methodology

The study included 34 patients, who fulfill the clinical criteria for chronic rhinosinusitis according to CRS criteria (who do not respond to maximum medical management of at least 3 weeks duration).

Plan of Action

• For diagnosis of patients, chronic rhinosinusitis criteria (major and minor criteria) was used.

• Maximum medical management was given. It included antibiotic (amoxyclav) for 3 weeks, antihistamines (cetrizine) for 3 weeks, decongestents for 3 weeks, local and systemic steroids for 3 weeks.

• Patient not responding to this medical management was taken up for surgery.

• To know the extent of disease, NCCT nose and paranasal sinus (axial, coronal, saggital sections 3 mm cut) was done (see Fig. 3).

• Routine blood investigations of the patients were done and preanaesthetic clearance was taken.

• PFT was done for the patients who were planned for surgery.(not responding to medical management).

Fig. 3.

PFT graph

FESS

• FESS was performed under local or general anesthesia by the Messerklinger technique or Wigand’s technique.

• Patient was laid supine on OT table, postioned for FESS. Then patient nasal cavity was properly decongested.

• Endoscopes used in the procedure were 0°, 30°, 70° and 90°.

• Surgery was performed according to extent of disease and sinus involvement.

• Merocel pack or antibiotic soaked gauze pack was placed in the surgical cavity after the operation.

Followup

• Pack removal after 48 h.

• Broad spectrum antibiotics for 10 days.

• Saline irrigation for 10 days.

• Diagnostic Nasal Endoscopy was done at 3 weeks interval till 3 months.

• Post operative CT scan was done at 3 monts

• Patients was reassesed every 3 weeks and post operative PFT was done at 3 months.

Pulmonary Function Tests

• The purpose and method of the test was explained to the patient (correct posture with head slightly elevated). The test involves maximal rapid inspiration, followed by forced exhalation of air through the mouthpiece sealed by mouth.

• Preparation of the patient (patient was asked about smoking, recent illness, medication use and weight, height and age was recorded).

• A clean, disposable mouthpiece was attached to the spirometer (a fresh one for each patient)

• Patient was comfortably seated. A clean nose clip was attached, a mouth piece was placed in the mouth and patient will be advised to close lips around this. The patient was asked to inhale completely and rapidly with a pause of no longer than 1 s at full inspiration and then to exhale maximally until no more air can be expelled while maintaining an upright posture.

• The patient was encouraged to keep blowing out. It was ensured that patient has exhaled for at least 6 s; the blow was continued until a volume plateau was reached. The flow volume curve was assessed for evidence of poor effort and hesitation.

• The procedure was repeated until three reading of which at least two of the FVC and FEV1 components are reproducible, i.e., within 0.15 L of each other. Ideally, the expiratory volume-time graph should be free from irregularities.

Following parameters were checked in pulmonary function test

1. FEV1/FVC

2. FEV1%

3. FVC

The PFT values was considered to indicate significant airway obstruction when FEV1/FVC < 0.8 and FEV1 < 80% of the predicted value for a patient’s age, height and weight.

Observations and Results

The study consisted of 34 patients suffering from chronic rhinosinusitis with or without polyposis who had undergone FESS. Preoperative PFT and postoperative PFT (after 3 months) were measured and the results were analysed.

Categorical variables were presented in number and percentage (%) and continuous variableswere presented as mean ± SD and median. Normality of data was tested by Kolmogorov–Smirnov test. If the normality was rejected then non parametric test was used. Quantitative variables were compared using paired t-test/Wilcoxon rank sum Test (when the data sets were not normally distributed) across follow up and Independent T test/ Mann whitney test was used to compare between two groups and ANOVA/Kruskal Wallis test was used for comparison of more than two groups.Qualitative variables were compared using Chi square test/Fisher exact test. A p value of < 0.05 was considered statistically significant. The data was entered in MS EXCEL spreadsheet and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0.

Age Distribution of Cases

The age of the patient involved in the study ranged from 21 to 53 years with a mean of 39.12 ± 8.22. The maximum number of patients (15) were in the age group > 40 years representing 44.12%of the total. The age distribution is given in the Table 1.

Table 1.

Percentage change in pulmonary function tests according to age group/sex/laterality of disease

	Age group				Sex group			Laterality of disease
	(1) ≤ 30	(2) 31–40	(3) > 40	p value	F	M	p value	b/l	u/l	p value
Per change in FEV1
Sample size	5	14	15	0.248	11	23	0.919	21	13	0.18
Mean ± SD	8.95 ± 15.19	41.18 ± 56.36	45.75 ± 31.22		37.35 ± 31.08	38.98 ± 48.35		46.31 ± 48.1	25.76 ± 30.87
Median	5.26	23.88	39.34		19.34	28.69		36.44	13.92
Min–max	− 11.11 to 28.06	− 11.23 to 204.92	5.75 to 91.3		3.18–90	− 11.23 to 204.92		− 11.11 to 204.92	− 11.23 to 87.39
Inter quartile range	− 0.389–21.522	2.198–60.465	15.944–73.439		15.944–59.269	5.384–67.848		16.950–71.803	2.938–46.107
Per change in FEV1/FVC
Sample size	5	14	15	0.613	11	23	0.509	21	13	0.072
Mean ± SD	14.14 ± 7.11	14.54 ± 16.51	10.05 ± 9.6		14.59 ± 15.39	11.5 ± 11.2		15.54 ± 13.06	7.59 ± 10.33
Median	14.6	8.16	11.04		11.9	10.98		12.86	3
Min–max	4.93–23.68	− 7.1 to 52.38	− 2.04 to 24.68		− 2.04 to 52.38	− 7.1 to 38.15		− 1.5 to 52.38	− 7.1 to 24.68
Inter quartile range	8.828–18.917	3.444–26.675	0.913–20.040		4.862–22.095	2.093–21.422		5.208–22.548	0.593–17.630
Per change in fvc
Sample size	5	14	15	0.109			0.874	21	13	0.414
Mean ± SD	− 4.07 ± 16.63	22.83 ± 40.15	34.18 ± 31.46					27.86 ± 39.06	17.45 ± 28.94
Median	− 8.71	18.13	41.29					26.8	11.8
Min–max	− 19.18 to 22.04	− 28.14 to 120.19	− 13.58 to 93.04					− 28.14 to 120.19	− 25 to 63.82
Inter quartile range	− 16.839–6.674	− 8.025–49.286	5.336–59.547					− 1.441–49.376	− 2.190–43.121

Percentage increase in FEV1 and FVC is maximum in age group of more than 40 years while percentage increase in FEV1/FVC is maximum in age group of 31–40 years.

Sex Wise Distribution of Cases

Male constituted the majority of the 34 patients who were studied accounting for 67.65% of total. So the male to female ratio in this study came out to be approximately 2:1 (see Table 1).

Percentage increase in FEV1 and FVC is more in males while percentage increase in FEV1/FVC is more in females.

Symptomatology of Cases and Endoscopy Findings

Out of the 34 patients included in the study, 21 patientshae bilateral disease constituting 61.76% of the total patients (see Table 1).

Percentage improvement in FEV1, FVC and FEV1/FVC is more in cases of bilateral disease than those with unilateral disease.

Nasal Findings

On anterior rhinoscopy and endoscopy, nasal discharge is the commonest finding present in 85.29% cases followed by nasal congestion/edema in 76.47% cases. Nasal polyps were present in 70.59% cases and nasal crusts in 35.29% cases. In post operative stage these findings were considerably reduced (see Fig. 4).

Fig. 4.

NCCT of patients coronal cuts and axial cuts

Distribution of Post Operative Complications

The most common post operative complication seen was synechaeformation (23.53%) followed by bleeding (14.71%). Recurrence was seen in 4 cases (11.76%) (see Table 2).

Table 2.

Distribution of post-operative complications

	Frequency	Percentage
Post operative complications
No	21	61.76
Yes	13	38.24
Total	34	100.00
Bleeding
No	29	85.29
Yes	5	14.71
Total	34	100.00
Syneche
No	26	76.47
Yes	8	23.53
Total	34	100.00
Recurrence
No	30	88.24
Yes	4	11.76
Total	34	100.00

Pulmonary Function Tests

FEV1 Values (Pre and Post OP)

The preoperative FEV1 values ranged from 0.86 to 3.69 with a mean of 2.31 ± 0.75 while the post operative FEV1 values ranged from 1.37 to 4.06 with a mean of 3 ± 0.73. Comparison of both the values is done, mean difference is 3 − 2.31 ie 0.69, was found to be statistically significant (p value < 0.0001) (see Table 3).

Table 3.

Comparison between the pre and post-operative PFT values

	Mean	N	SD	SE mean	p value
Pair 1
PRE OP  FEV1	2.3124	34	.75297	.12913
Post OP  FEV1	2.9947	34	.72665	.12462	< 0.001
Pair 2
Pre OP  FVC	3.0174	34	.90988	.15604
Post OP  FVC	3.5444	34	.89455	.15341	< 0.002
Pair 3
Pre OP  FEV1/FVC	.75962	34	.083319	.014289
Post OP  FEV1/FVC	.84897	34	.085806	.014716	< .0001

VC Values (Pre and Post OP)

The preoperative FVC values ranged from 1.4 to 4.86 with a mean of 3.02 ± 0.91 while the post operative FVC values ranged from 1.89 to 5.01 with a mean of 3.54 ± 0.89. Comparison of both the values is done, mean difference is 3.54 − 3.02 ie 0.52, was found to be statistically significant (p value < 0.0001) (see Table 3).

FEV1/FVC Values (Pre and Post OP)

The preoperative FEV1/FVC values ranged from 0.57–0.98 with a mean of 0.76 ± 0.08 while the post operative FEV1/FVC values ranged from 0.65 to 0.98 with a mean of 0.85 ± 0.09. Comparison of both the values is done, mean difference is 0.85 − 0.76 ie 0.09, was found to be statistically significant (p value < 0.0001) (see Table 3).

Discussion

The present work was undertaken in the Department of Otorhinolaryngology & Head and Neck surgery, PGIMER and Dr. RML Hospital, New Delhi to study the impact of FESS on the pulmonary function of 34 patients suffering from chronic rhinosinusitis with or without polyposis. The clinical and laboratory data from the study cases were recorded as per the proforma. The study included patients of varied age groups, of varied socio-economic status, of both sexes. The results were then compared with available literature.

Age Distribution

The commonest age group affected in this study belonged to the age group> 40 years (44.12%). The age ranged from 21 to 53 years with the mean age of 39.12 ± 8.22 years.

In a study carried out by Chaudhary et al. [12] age ranged from 14 to 66 years. Similarly Winsted et al. [13] also found the mean age to be 34 years. In a 5-year study of 63 nasal polyposis patients was conducted by Ogunleye et al. [14] the mean age was 34 years.

Dursum et al. [15] found mean age of 34 years and range was 9–76 years. Batra et al. found the mean age of 51 years and the range was 31–80 years [16]. similarly mean age was 45 years in a study conducted by Defour et al. [17]. Giger et al. [18] found the mean age of 42.7 years and the age range was 12–75 years. Similarly the mean age was 44.1 years in a study conducted by Wynn et al. The average age was 45.7 years in a study done by Jacobsen et al. [19].

Sex Distribution

This study showed that males (67.65%) are more commonly affected as compared to the females (32.35%).Male to female ratio approximately came out to be 2:1 in this study. Many studies have found a male preponderance. In a 5-year study of 63 nasal polyposis patients was conducted by Ogunleye et al. [14] the male:female ratio was 1.6:1.

Symptomatology and Nasal Findings of the Patients

In the present study, On anterior rhinoscopy and endoscopy, nasal discharge is the commonest finding present in 85.29% cases followed by nasal congestion/edema in 76.47% cases.

Ling et al. [20] in their study found that nasal discharge was seen in 82% of the total cases while Nayak et al. [21] in 1991 found it in 78.2% of the total cases. Winsted and Barnett [13] in their study had 87% of total cases with nasal discharge which is very close to our study.

In the present study, Nasal polyps were present in 70.59% of the total number of cases In a study by Damm et al. [22], they found that nasal polyps were present in 38% cases while Deal et al. [23] found polyps in 38.8% cases. Pradhan et al. [24] found polyps in 85% of total cases in their study.

Also chaudharyet al. [12] in their study in 2000 found mucopurulent nasal discharge in 37.7% cases. Ethmoidal polyps were present in 26% and antrochoanal polyps in 13% of total cases. Out of the 34 patients included in our study, 21 patients have bilateral disease constituting 61.76% of the total patients.

Post Operative Complications

The most common post operative complication seen in this study was synechae formation (23.53%) followed by bleeding (14.71%). Recurrence was seen in 4 cases (11.76%).

Chaudhaury et al. [12] noticed bleeding in 13% cases, value quite similar to our study.

As far as synechie formation is concerned, Nayak et al. [21] noted that in 9% cases, Chaudhary et al. [12] in 5.7% cases and Pradhan et al. [24] in 15.9% cases.

CT Scan Comparison

In this study post operative CT scan of all the patients were done at 3 months and was compared with pre operative CT scan. It was found to improve significantly. Out of 34 patients,30 patients were found clear of disease at 3 months. All sinuses were free of disease. Only 4 patients had recurrence but PFT values for even these patients showed improvement.

CT scans of few patients had been compared in this picture (Fig. 5).

Fig. 5.

Comparison of CT scans of few patients PRE and POST OP

Pulmonary Function Tests

In the present study, it was noted that there was increase in FEV1, FVC, FEV1/FVC ratio values post operatively than the preoperative values. All were found to be significant by the 2 tailed t test (p value< 0.0001).

In a study done by Ragab et al. it was found that 6 month post-operative FEV1 percent showed significant increase. In a similar study by Nakamura et al. [25] on the effects of sinus surgery on asthma in aspirin triad patients, an important correlation was found between the preoperative and post-operative FEV1 scores and asthma severity. In another study by Ikeda et al. [6], the average peak expiratory flow 6 months following surgery improved in FESS patients significantly. The study by Batra et al. [16] found significant improvement in post-operative FEV1 and a reduction in systemic steroid usage. In a study by Dhong et al. [26] there was no significant change in pulmonary function.

Conclusions

The cases included in the present study cases comprised of 34 patients who fulfilled the CRS criteria.The patients refractory to medical management are taken up for surgery. The pre-operative PFTs were compared with the post-operative values. The following conclusions can be drawn from the present study.

• CRS affected persons of adult age with maximum number of patients in the age group of more tan 40 years.

• CRS of this region showed a male predominance with a male:female ratio of approximately 2:1.

• Percentage improvement in FEV1 and FVC is more in age group> 40 years while percentage improvement in FEV1/FVC ratio is more in age group 31–40 years.

• Percentage increase in FEV1 and FVC is more in males while percentage increase in FEV1/FVC is more in females.

• Percentage improvement in FEV1, FVC and FEV1/FVC ratio is more in cases of bilateral disease than those with unilateral disease.

All the three values FEV1, FVC and FEV1/FVC ratio significantly improves 3 month post operatively than their preoperative values. The improvement in the PFT values signifies a decrease in the bronchial hyperresponsiveness as compared to the pre-operative condition.

Funding

None.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.