Endoscopic sinus surgery for the treatment of chronic sinusitis in geriatric patients.

Abstract

Although endoscopic sinus surgery is a well-documented procedure for the treatment of chronic sinusitis in children and adults, no study has been conducted to specifically investigate its application in a geriatric population. We undertook to fill this void by analyzing the records of 1,112 patients who had undergone endoscopic sinus surgery for chronic sinusitis in our department between April 1988 and March 1998. We categorized these patients by age. There were 171 patients (15.4%) in the geriatric group (age: [greater than or equal to]65yr), 837 patients (75.3%) in the adult group (age: l7 to 64), and 104 patients (9.4%) in the pediatric group (age: [less than or equal to]l6yr). We found that the geriatric group experienced a disproportionately larger share of operative complications, but most of them were minor. Outcomes were similar in all three groups. We conclude that endoscopic sinus surgery is a safe and effective treatment for older patients with chronic sinusitis.

Introduction

As the size of the geriatric population has grown in developed countries, [1] the illnesses of older people have become a more important part of medicine. [2] Sinusitis has been ranked as the sixth most common chronic disease in the geriatric population. [3] One reason for the high incidence might be that mucus production is decreased in older people. [4]

The most common clinical manifestations of chronic sinusitis in older persons are nasal stuffiness, postnasal drip, cough, impaired olfactory function, sore throat, and fever of unknown origin. [3] Chronic sinusitis can also cause hallucinations, cognitive impairment, and delirium. Adequate antibiotic therapy with other auxiliary treatment is the first step in the management of geriatric sinusitis. [3] If the patient fails to respond to medical management, surgical treatment might be indicated. [4]

Since the late 1970s, functional endoscopic sinus surgery (FESS) has become a common procedure for treating chronic sinusitis in adults. [5] More recently, it has been used to treat chronic sinusitis in pediatric patients with promising results. [6-9] Because there might be differences between ordinary FESS performed in adults and children, Poole coined the term pediatric endoscopic sinus surgery (PESS) to differentiate the latter from the former. [10]

To our knowledge, no study has thus far reported the experience of FESS performed on geriatric patients. To fill this void, we analyzed the results of what we call geriatric endoscopic sinus surgery (GESS) at our institution and compared them with the results of ordinary FESS performed in adults and PESS performed in children.

Materials and methods

In our department, FESS has been used to treat chronic sinusitis with or without polyps since 1988. FESS is indicated when medical treatment has failed--failure being defined as an unsatisfactory result after repeated and appropriate antibiotic therapy and adequate auxiliary treatment. Repeated and appropriate antibiotic therapy means either continuous long-term antibiotic management or several intermittent courses of antibiotics based on the results of bacterial cultures. Depending on the clinical course and findings, auxiliary treatment can be added. This auxiliary treatment includes mucolytic agents, antihistamines, nasal steroids, and nasal douches. The indications for revision FESS are the same as those for primary surgeries--that is, another failure of medical management.

We included in this study all patients who underwent endoscopic sinus surgery for chronic sinusitis in our department between April 1988 and March 1998. We categorized these patients into three groups according to their age at the time of surgery. The GESS group was made up of all patients 65 years or older. Patients between 17 and 64 years of age were included in the ordinary FESS group, and patients aged 16 years or younger were included in the PESS group.

A chart review was used to evaluate operative procedures and complications, and questionnaires were mailed to all patients to assess the effectiveness of their surgery and the incidence of postoperative symptoms. Patients were given a choice of indicating whether their symptoms had disappeared, were improved, were unchanged, or were worse. Patients were considered to have improved if their symptoms had disappeared or were alleviated to some degree.

Results

Patients. We identified 1,112 patients who were eligible for analysis: 171 (15.4%) in the GESS group, 837 (75.3%) in the FESS group, and 104(9.4%) in the PESS group.

The GESS group included 146 men and 25 women, aged 65 to 84 years (mean: 70.3); 153 were between 65 and 74 years old, and 18 were 75 or older. The FESS group included 494 men and 343 women, aged 17 to 64 years (mean age: 37.9), while the PESS group was made up of 55 boys and 49 girls, aged 5 to 16 years (mean: 12.6).

Procedures. The 1,112 patients underwent a total of 1,227 endoscopic sinus surgeries: 191 GESS, 915 FESS, and 121 PESS. The indications for GESS were chronic sinusitis without polyps (n = 91 operations), with nasal polyps (n = 97), and with antrochoanal polyps (n = 3). The corresponding figures in the FESS group were 474, 418, and 23, and in the PESS group they were 63, 47, and 11. The percentage of patients with antrochoanal polyps was significantly higher in the PESS group than in the FESS and GESS groups (p[less than]0.01). Most procedures were bilateral and primary, and except for the PESS group, most were performed with local anesthesia (table 1).

Complications. Operative complications occurred during or after 29 GESS (15.2%), 87 FESS (9.5%), and 5 PESS (4.1%) procedures (table 2). The difference in complication rates was statistically significant between the GESS group and both the FESS (p 0.02) and the PESS groups (p = 0.002).

The 29 complications in the GESS group occurred in 13 patients without polyps, 16 with nasal polyps, and 0 with antrochoanal polyps. The corresponding figures in the FESS group were 40, 44, and 3. In the PESS patients, these figures were 2, 2, and 1.

Outcomes. Followup questionnaires yielded 547 usable responses. In the GESS group, 83 of 97 patients (85.6%) reported improvement, as did 300 of 400 FESS patients (75.0%) and 42 of 50 (84.0%) PESS patients.

There was a statistically significant difference in improvement rates between the GESS and FESS groups (p = 0.027), but not between the GESS and FESS groups (p = 0.081) or the FESS and PESS groups (p = 0.161).

Among GESS patients without polyps, 7 reported no symptoms at all, 31 had improved, 6 were unchanged, and 3 had worsened. Among the GESS patients with nasal polyps, the corresponding figures were 14, 29, 3, and 2. The 2 GESS patients with antrochoanal polyps who answered the survey both indicated that their symptoms had improved. This followup period ranged from 7 months to 8 years and 4 months (mean: 3 yr, 6 mo).

Among PESS patients without polyps, 18 had no symptoms, 129 had improved, 50 were unchanged, and 17 were worse. Among those with nasal polyps, the corresponding figures were 16, 129, 25, and 7. Among those with antrochoanal polyps who responded to the questionnaire, 2 reported no symptoms at all, 6 had improved, and 1 had worsened. This followup period ranged from 7 months to 10 years and 6 months (mean: 3 yr, 9 mo).

Among PESS patients without polyps, 4 had no symptoms, 13 had improved, 3 were the same, and 2 had worsened. The corresponding figures for those with nasal polyps were 3, 16, 2, and 1. Among the 7 patients with antrochoanal polyps who answered, I reported no symptoms and 5 had improved. This followup period ranged from 7 months to 9 years and 2 months (mean: 3 yr, 7 mo).

Discussion

Although chronic sinusitis is quite common in older people, the role of aging in the pathophysiology of geriatric sinusitis is not clear. Decreased mucus production in the noses of older persons might be one responsible factor. [4] Furthermore, it is not clear whether aging has any unique effect on the management of chronic sinusitis in the geriatric population. Therefore , geriatric sinusitis is usually included with adult sinusitis, and the principles of management are essentially the same. [4,5,9]

FESS was introduced to treat chronic sinusitis in adults in the late 1970s, [5] and it has been effective. [11] Although pediatric sinusitis has been considered to be a different disease entity from adult sinusitis, endoscopic sinus surgery is just as successful in children. [6,12,13] However, it has not yet been clearly demonstrated that endoscopic sinus surgery can be effectively applied in the geriatric age group. Moreover, although geriatric sinusitis is present in 17% of older persons, [4] the frequency of GESS has not been mentioned in the literature. [5,9]

In our study, GESS accounted for 15.6% of all endoscopic sinus surgeries for chronic sinusitis. Because GESS was performed more often than PESS (9.9%) in our department, it seems that geriatric sinusitis is quite common--or at least that it requires surgical treatment more often than does pediatric sinusitis. Therefore, we believe that geriatric sinusitis deserves more attention than it is currently given in the literature.

In our study, the techniques for GESS were similar to those for FESS. The fact that unilateral surgery was more common in GESS operations (30.4%) than in FESS (21.1%) implies that geriatric sinusitis might be somewhat different from adult sinusitis.

Although the operative techniques were similar, complications occurred more often in the GESS group (15.2%) than in the FESS (9.5%) and PESS (4.1%) groups.

Despite its higher complication rate, the GESS group had a better improvement rate: 85.6% after a mean followup of 3 years and 6 months. Therefore, we conclude that it is an effective treatment for chronic sinusitis in geriatric patients who fail to respond to medical treatment.

References

(1.) Abrams WB, Beers MH, Berkow R. Epidemiology and demographics. In: Abrams WB, Beers MH, Berkow R, eds. The Merck Manual of Geriatrics. 2nd ed. Whitehouse Station, N.J.: Merck Research Laboratories, 1995:1351-65.

(2.) Abrams WB, Beers MH, Berkow R. Introduction. In: Abrams WB, Beers MH, Berkow R, eds. The Merck Manual of Geriatrics. 2nd ed. Whitehouse Station, N.J.: Merck Research Laboratories, 1995:5-7.

(3.) Reddy U, Thadepalli H. Respiratory infections. In: Yoshikawa TT, Cobbs EL, Brummel-Smith K, eds. Practical Ambulatory Geriatrics. 2nd ed. St. Louis: Mosby, 1998:445-52.

(4.) Yoder MG. Geriatric ear, nose, and throat problems. In: Reichel W, ed. Care of the Elderly: Clinical Aspects of Aging. 4th ed. Williams and Wilkins, 1995:441-50.

(5.) Lazar RH, Younis RT, Long TE, Gross CW. Revision functional endonasal sinus surgery. Ear Nose Throat J 1992;71:131-3.

(6.) Gross CW, Gurucharri MJ, Lazar RH, Long TE. Functional endonasal sinus surgery (FESS) in the pediatric age group. Laryngoscope 1989;99:272-5.

(7.) Lazar RH, Younis RT, Gross CW. Pediatric functional endonasal sinus surgery: Review of 210 cases. Head Neck 1992;14:92-8.

(8.) Parsons DS, Phillips SE. Functional endoscopic surgery in children: A retrospective analysis of results. Laryngoscope 1993; 103:899-903.

(9.) Lazar RH, Younis RT, Long TE. Functional endonasal sinus surgery in adults and children. Laryngoscope 1993;103:1-5.

(10.) Poole MD. Pediatric endoscopic sinus surgery: The conservative view. Ear Nose Throat J 1994;73:221-7.

(11.) Senior BA, Kennedy DW, Tanabodee J, et al. Long-term results of functional endoscopic sinus surgery. Laryngoscope 1998;108:151-7.

(12.) Poole MD. Pediatric sinusitis is not a surgical disease. Ear Nose Throat J 1992;71:622-3.

(13.) Mair EA. Pediatric functional endoscopic sinus surgery: Postoperative care. Otolaryngol Clin North Am 1996;29:207-19.

                  Comparison of the characteristics of
                     191 geriatric endoscopic sinus
                   surgeries (GESS) with those of 915
                   ordinary functional (FESS) and 121
                      pediatric (PESS) procedures
                             GESS        FESS        PESS
                             n(%)        n(%)        n(%)
Bilateral surgery         133 (69.6)  722 (78.9)  102 (84.3)
Unilateral surgery         58 (30.4)  193 (21.1)   19 (15.7)
Primary surgery           172 (90.1)  808 (88.3)  105 (86.8)
Revision surgery           19 (9.9)   107 (11.7)   16 (13.2)
Under local anesthesia    121 (63.4)  572 (62.5)   36 (29.8)
Under general anesthesia   70 (36.6)  343 (37.5)   85 (70.2)
Complications              29 (15.2)   87 (9.5)     5 (4.1)
                    Comparison of complications that
                 occurred during or after 29 geriatric
                 endoscopic sinus surgeries (GESS) with
                   those occurring during or after 87
                    ordinary functional (FESS) and 5
                      pediatric (PESS) procedures
                                  GESS      FESS       PESS
                                  n(%)      n(%)       n(%)
Orbital fax extrusion           7 (24.1)  28 (32.2)  2 (40.0)
Blood transfusion               7 (24.1)  19 (21.8)  1 (20.0)
Epistaxis                       3 (10.3)  21 (24.1)  1 (20.0)
Surgery halted because of pain  3 (10.3)   5 (5.7)      0
Nasolacrimal duct injury        3 (10.3)   3 (3.4)      0
Periorbital exposure            2 (6.9)    5 (5.7)      0
Dural exposure                     0       2 (2.3)      0
Readmission for epistaxis       1 (3.4)       0         0
Cerebrospinal fluid leak        1 (3.4)    2 (2.3)      0
Diplopia                        1 (3.4)    1 (1.1)   1 (20.0)
Atrophic rhinitis               1 (3.4)       0         0
Unremoved nasal packs              0       1 (1.1)      0