Revision Sinus Surgery

not between CT score and quality of life (QoL) as measured with the Chronic Sinusitis Score [61].

Bhattacharyya compared three staging systems with the Rhinosinusitis Symptom Inventory [7] and found the Lund-MacKay score to correlate best with nasal scores, but the degree of correlation remained low.

It has been suggested that an attempt to quantify the percentage of the sinus occupied by inflammatory disease might improve its sensitivity [46], although it would not necessarily be easy to reproduce or indeed apply to the post-operative situation. The extent of sinus opacification is calculated from the sum of the scores of the five major sinuses (frontal, maxillary, anterior and posterior ethmoid, and sphenoid), each scored on a five-point opacification scale, where 0 = 0%; 1 = 1–25%; 2 = 26–50%; 3 = 51– 75%; 4 = 76–99%; 5 = 100%. Alternatively, both CT [52] and magnetic resonance imaging (MRI) might be used to assess the volume of inflamed mucosa, but interpretation could be difficult due to the reproducibility of the scans, and in the case of MRI, the effect of the nasal cycle and the high incidence of incidental changes renders it oversensitive. As with CT, there is a similar lack of correlation between rhinological symptoms and MRI changes [44].

The University of Miami staging system, which includes CT and endoscopic assessment, has also been assessed by its creators for inter-rater reliability [36]. In- ter-rater reliability for the CT and endoscopic arms were good for patients undergoing either primary or revision surgery. The correlation between endoscopic findings and CT staging was also high, again in both primary and revision cases.

In a study from Switzerland [21], the Kennedy CT Staging system I–III was used in 77 patients with CRS without polyps, and showed that the likelihood of revision was greatest in those with higher-staged disease.

Bhattacharyya has considered the role of the predictive value of symptoms and extent of disease on CT in both primary and revision endoscopic sinus surgery (ESS) for CRS [7, 8], again confirming that extent of disease using the Lund-MacKay, Kennedy or Harvard systems correlates poorly with symptoms either preor post-opera- tively. However, he was able to show that a scoring system such the Lund-MacKay could be applied to the revision patient, with similar scores before the primary and secondary procedure (10.5 vs. 9.7, p = 0.38) [5].

In a study considering clinical outcomes after revision ESS, the Lund-MacKay CT score confirmed the presence of disease (mean score 12.6) and allowed a comparison of results with patients undergoing primary surgery to be matched according to the extent of their inflammatory change on imaging [6]. Results were similar in this group of refractory CRS patients to that found in the primary population.

Other Methods of Assessment

A range of investigative tools have been applied to the CRS/NP patient, including measures of mucociliary clearance, olfaction and airway, but these are not universally available and may be subject to intra-individual variation. Consequently, these have generally not featured

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in most staging systems. However, an increasing number of studies have used validated questionnaires, considering QoL and quantification of symptoms. Kountakis and colleagues attempted a correlation of the level of tissue and systemic eosinophilia and degree of polymorphisms of the leukotriene C4 synthase gene with endoscopy, CT and a validated sinonasal questionnaire [35]. As expected, tissue eosinophilia was associated with polyps, asthma, allergy, and higher CT and symptom scores. Stratification was proposed, with those with polyps, tissue and blood eosinophilia representing the most severe, and those without these features being the least severe. It is probable that this would apply to patients irrespective of their surgical status, but has not been used widely in clinical practice.

General (generic) measurements such as the Medical Outcomes Study Short Form 36 [63] enable the comparison of patients suffering from CRS with other patient groups, but have not been used to any degree in the stratification of CRS, especially not in recurrent problems. In addition, there are several disease-specific questionnaires for CRS that may be more sensitive than general health status instruments, but again have not generally been utilised in staging the extent of disease [3, 4, 33, 51, 54].

Use of Staging in Outcome Research

Any attempt at staging, particularly after the anatomy has been distorted by previous surgery, is open to criticism. Both the endoscopic appearances and particularly the scan represent a snapshot at a particular moment and may be influenced by the medical treatment that patients receive. It is difficult enough to devise schemes to stage primary disease [18, 46] that few have grappled with the complexities of staging recurrent disease, although they may have considered studies to prevent disease recurrence in chronic disease.

Requirements of a staging system [45]:

1.Provide an objective means of quantifying the volume of inflammatory mucosa and opacification.

2.Be easy to use and require no formal training.

3.Have high reproducibility, as demonstrated by interobserver and intra-observer studies.

4.Be able to quantify the patency of the ostiomeatal pas-

24 sageways.

This does not mention a relationship to outcome, but also does not address the issue of revision surgery in recurrent disease.

Validated questionnaires that cover some health-re- lated QoL aspects, such as the 20-item Sino-Nasal Out-

Valerie J. Lund

come Test (SNOT-20 and SNOT-22) have been used in several studies to assess outcome, but have not been used specifically as part of a stratification or staging process, nor in general focused on a revision population [9, 27]. Nonetheless, this approach might reward further investigation, particularly in those patients likely to relapse (e.g. CRS+polyps), and the SNOT-20 is regarded as one of the most useful [47].

One of the few studies to consider staging instruments in revision ESS by McMains and Kountakis [43] utilised the Lund-MacKay CT score, endoscopic score, VAS and SNOT-20. CT scores in this group were similar to those seen in patients undergoing primary surgery (13.4±0.7), and the score served principally to quantify disease, whereas the other measures could be used to quantify outcome and confirmed overall improvement. Those patients with polyps, not surprisingly, constituted the majority of failures.

In a study by Smith et al. [57] concerning predictive factors in ESS for CRS, 119 patients with CRS and a mean follow-up of 1.4 years were evaluated prospectively. This group included patients who had undergone surgery. Contributory medical conditions, CT and endoscopy scores as well as QoL were considered. As usual, CT scores were worse in the presence of polyps, but interestingly the CT score was not affected by prior sinus surgery, whereas endoscopic scores were significantly worse. Nonetheless, these patients had the greatest improvement in endoscopy score, and CT scores approached significance in predicting worse outcome. However, other factors such as aspirin sensitivity and depression were associated with worse outcome, suggesting that this information needs to be factored into any staging in both primary and revision surgery.

If staging based on CT does not correlate well with symptoms, does it assist in determining other outcomes, such as complication rates? The Sino-Nasal Audit undertaken by the Royal College of Surgeons of England on 3128 consecutive patients undergoing all forms of sinonasal surgery for CRS ± NP confirmed by multivariate analysis that the complication rate was linked to extent of disease measured in terms of CT score (Lund-MacKay) as well as symptom severity, health-related QoL, extent of polyposis and the presence of co-morbidity, but interestingly not on extent of surgery. However, this group was a heterogeneous mix of those having primary and revision surgery [28].

Virtually all of the systems have been developed for an adult population, possibly recognising the changing development of the sinus system in the paediatric population and the high frequency of opacification due to common upper-respiratory-tract infections [15].

Staging of Disease after Sinus Surgery Failure

Staging for Neoplasia

Even in the area of neoplasia, staging in the nose and sinuses has proved problematic. A variety of systems has been devised for malignant tumours, but these systems are generally of less prognostic use than elsewhere in the head and neck. The nose and sinuses represent an area of great histological diversity, each with a unique natural history, which undermines the value of 5-year survival rates as malignant tumours can recur many years, even decades later. This combined with late presentation, the complexity of the anatomy and proximity to skull base and orbit means that most patients present with advanced local disease, but rather less often with dissemination, so staging is of much less relevance in determining prognosis. The standard systems such as TNM [23] are relatively crude and do not take into account the many different histopathologies; nor are they based on the findings of modern imaging and histology. Cantu et al. compared the 1997 and 2002 American Joint Committee on Can- cer–Union Internationale Contre le Cancer systems and their own classification system, perhaps not surprisingly, finding their own to be superior [13].

There have been several attempts to classify according to extent (e.g. Kadish et al. [32], staging for olfactory neuroblastoma), but again these have been relatively crude. Histological classification based on degree of differentiation may be of some help in predicting prognosis (e.g. in adenocarcinoma). With the increasing use of endoscopic resection of skull-base tumours, this situation will need to be addressed, as not only can the origin of the tumour be more accurately determined, but the subtleties of dural and orbital periosteal invasion assessed. Unfortunately, a significant proportion of these patients will relapse and require revision surgery. To date, none of the staging systems have addressed this aspect.

There have been several studies based on large personal series that have considered some of the more common benign tumours, such as inverted papilloma and juvenile angiofibroma. Inverted papilloma is associated with a recurrence rate that varies in the literature from 0 to 75%. However, virtually all “recurrence” actually represents residual disease and requires further surgical intervention. Attempts at staging have utilised CT, MRI and endoscopic findings [12, 49, 55, 58] to stratify according to site of involvement, but as usual they focus on initial presentation and treatment rather than considering those with recurrence/residual papilloma.

Juvenile angiofibroma has been previously crudely staged using systems such as those of Chandler et al. [14] or Fisch [17] into stage I–III, which overlooked one of the most essential determinants of “recurrence”, invasion of the basisphenoid. Since this issue has been fully

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realised through careful analysis of imaging studies and addressed surgically, the “recurrence” rate and need for revision surgery has dropped dramatically from ~25% to <2% [29].

Conclusion

Staging in inflammatory disease is helpful in confirming its presence and extent, corroborating the endoscopic findings and clinical diagnosis and serving as inclusion criteria and for case matching in clinical research. Few systems have considered the situation when recurrent disease is present or revision surgery contemplated. In contrast to neoplastic disease, conventional staging does not serve as a strong indicator of prognosis, as symptoms correlate poorly with extent of disease in both primary and recurrent CRS/nasal polyposis. Perhaps it is simply useful to confirm one’s own prejudice and bias!

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34.Kennedy DW (1992) Prognostic factors, outcomes and staging in ethmoid sinus surgery. Laryngoscope 57: 1–18

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 Core Messages

■Headache is a common symptom in patients diagnosed with chronic rhinosinusitis.

■The diagnosis of primary and secondary headache disorders is important to avoid unnecessary revision surgery.

■Headache symptoms attributable to persistent or recurrent rhinologic disease may be addressed surgically if medical therapy has failed.

■Headache symptoms secondary to rhinologic disease have shown significant improvement following endoscopic sinus surgery.

Introduction

Headache is a common symptom in patients diagnosed with chronic rhinosinusitis (CRS), being present in up to 83% of patients [1]. The severity of headaches has been reported to be one of the highest among the most common symptoms associated with CRS [2]. Persistent headache symptoms after primary functional endoscopic sinus surgery (FESS) for CRS may create an unhappy patient and a frustrated physician. An appropriate understanding of the differential diagnoses of headache is important for treating patients presenting to a rhinology practice.

In 1997, the American Academy of Otolaryngology – Head and Neck Surgery Rhinosinusitis Task Force published recommendations for symptom-based criteria for the accurate diagnosis of CRS [8, 20]. Headache is considered a minor diagnostic symptom using these criteria.

■The Rhinosinusitis Task Force suggests that headache alone should not constitute a suggestive history for rhinosinusitis without major nasal symptoms or signs.

Summary  . . . . . . . . . . . . . . . . . . .   221

The Rhinosinusitis Initiative, consisting of five national societies, created a guideline for evidence-based research of rhinosinusitis in 2004 [11]. This guideline included headache as a relevant symptom of CRS and recommended its severity documentation for treatment assessment. Accordingly, the Rhinosinusitis Initiative has recommended including headache as one of the 11 symptoms scored for efficacy assessment in clinical trials studying CRS [11,12].

The treatment of headache associated with CRS is challenging, as its underlying cause is unknown and its severity associated with multiple factors. Concomitant headache, inappropriately associated with CRS, will not improve following FESS. As such, a rhinologist should rely on a comprehensive history and physical examination, along with objective endoscopic and radiologic findings, to ensure appropriate headache management.

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Differential Diagnosis

Understanding nonrhinologic headache is important, as patients may be referred to otolaryngologists for presumed rhinosinusitis without subjective or objective findings to support the diagnosis.

■Primary headache disorders include:

1.Migraine.

2.Tension-type headache.

3.Cluster headaches.

4.Other less common entities, including primary thunderclap headache and hemicrania continua.

Secondary headache disorders are associated with underlying central nervous system pathology [6,15].

Primary Headache Disorders

Migraine Headaches

Migraine headaches are common and underdiagnosed [9]. Approximately 28 million Americans are affected, with the 1-year prevalence of 18% in women and 6% in men [9, 24]. Migraine is an episodic neurovascular headache disorder involving moderate to severe attacks lasting 4–72 h, with a pulsating quality [6].

■Migraine headaches are:

1.Usually associated with nausea.

2.Associated with sensitivity to light, sound, or movement.

3.Often unilateral.

4.With pain described over the frontal and temporal regions.

5.Pain can also be described in the parietal, occipital, and high cervical regions [5].

The pathogenesis of pain in migraine is not completely understood; however, it is thought to be a neurovascular disorder resulting in nerve activation from vascular dilation. The diagnostic criteria defined by the International Headache Society (IHS) in 2004 are presented in Table 25.1 [6].

Migraine headaches are divided into two major subtypes, migraine with and without aura. Aura is defined as a reversible focal neurological symptom that usually

25 develops gradually over 5–20 min and lasts for less than 60 min [6]. The aura occurs at the onset or just prior to a migraine headache. Auras may include visual symptoms, including flickering lights, sensory symptoms, which may involve numbness or sensation of pins and needles, or dysphasic speech disturbance.

William H. Moretz III and Stilianos E. Kountakis

A recent analysis by Perry et al. [17] was performed on patients with headaches presenting to a tertiary rhinology practice without evidence of rhinosinusitis on CT or endoscopic evaluation.

■The majority of patients with headache as a chief complaint were diagnosed with migraine upon further evaluation by a neurologist [17].

Other studies have shown similar findings in patients seeking treatment for “sinus headaches.” Schreiber et al. reported that 80% of 2991 patients with “sinus headaches” presenting to primary care physicians fulfilled IHS migraine criteria [21].

Tension-Type Headaches

■Tension-type headaches are the most common type of primary headache, affecting up to 78% of the general population [6].

The etiology of tension-type headaches is unknown. Subtypes of tension-type headache have been described, dividing the headaches into episodic or chronic, and with or without pericranial tenderness on manual palpation. Pericranial tenderness is a distinguishing characteristic of tension-type headaches, but does not necessarily need to be present for its diagnosis.

Diagnostic criteria for episodic tension-type headaches have been outlined by the IHS. Episodic tensiontype headaches last from 30 min to 7 days, are usually bilateral, and have a pressing/tightening quality. These headaches occur for at least 3 months, averaging less than 15 days out of the month, and are not aggravated by routine physical activity. Chronic tension-type headaches typically last hours or may be continuous, occur for at least 3 months, averaging 15 or more days per month, and have the same characteristics of episodic tensiontype headaches [6].

■Perry et al. [17] found that 6% of patients with nonrhinologic headache presenting to their rhinology practice with a chief complaint of headache were diagnosed with tension-type headache upon subsequent evaluation by a neurologist.

Cluster Headaches

The IHS describes the cluster headache as a severe, unilateral pain located at the orbital, supraorbital, or temporal areas, lasting 15–180 min and occurring from once every other day to eight times a day. Cluster headaches typically