Delivered by Ingenta to: Economics Dept IP: 46.161.56.124 On: Tue, 28 Jun 2016 17:04:46 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm The effect of anatomically directed topical steroid drops on frontal recess patency after endoscopic sinus surgery: A prospective randomized single blind study Sang Duk Hong, M.D., Jeon Yeob Jang, M.D., Joon Ho Kim, M.D., Seong Yun Jang, M.D., Hyo Yeol Kim, M.D., Ph.D., Hun-Jong Dhong, M.D., Ph.D., and Seung-Kyu Chung, M.D., Ph.D. ABSTRACT Background: The failure rate for frontal sinusotomy is higher than that of overall endoscopic sinus surgery (ESS). To prevent frontal sinus obstruction, systemic or topical steroids are commonly used, but systemic steroid therapy can cause significant morbidity and topical sprays can not be distributed to the frontal ostium. This study was designed to determine the efficacy of anatomically directed topical steroid drops in reducing frontal ostium stenosis compared with topical steroid sprays after ESS. Methods: A prospective, randomized, single-blind study was conducted in 43 patients (77 nasal cavities) who had undergone ESS, including frontal sinusotomy. Twenty-one patients (39 nasal cavities) used steroid drops applied with the Mygind technique, and 22 patients (38 nasal cavities) used steroid sprays for 8 weeks postoperatively. The patency of the frontal ostium was evaluated endoscopically 3 months postoperatively. Results: The study included 29 men and 14 women (mean age, 48.2 years; range, 19 – 62 years). Endoscopic scores in terms of polypoid change, edema, and scar in the middle meatus and frontal recess were not significantly different between the groups, although the drop group showed a tendency to superior scores when compared with the spray group (p  0.05). The frontal sinus patency of the drop group was significantly higher than of the spray group (p  0.05). Conclusion: Topical steroid drops using the Mygind technique led to a 16% improvement in frontal sinus patency rates in 3 month after ESS in this study compared with postoperative topical steroid use. (Am J Rhinol Allergy 26, 209 –212, 2012; doi: 10.2500/ajra.2012.26.3758) E ndoscopic sinus surgery (ESS) yields excellent results in the treat- ment of chronic rhinosinusitis, with large series and literature reviews reporting 90% success rates. 1 However, patients undergoing frontal sinus surgery, especially those with polypoid mucosa, tend to have difficulties maintaining adequate sinus ostia patency postoper- atively, because of the narrow diameter of the frontal sinus and propensity for circumferential scarring. Jacobs et al. 2 performed 105 frontal sinusotomies and reported 70.5% of cases had abnormal frontal recess findings. Kennedy et al., 3 in 1992, reported that the stenosis rate of the maxillary sinus ostia was 2%, but that the stenosis rate of the frontal sinus ostia was 11.9% (27.3% in patients with polyposis). Treatment options for preventing frontal ostium stenosis after ESS include systemic and topical ste- roids, application of mitomycin C, packing absorbable material into the frontal ostium, prolonged stenting, and steroid eluting stenting (in an animal model). 4–7 None of these treatment options are considered definitive. Short-term systemic steroid therapy has played an impor- tant role in many sinonasal diseases, including allergic rhinitis, nasal polyposis, and the reduction of postoperative reactive edema. Some studies found that systemic steroids were effective for mucosal le- sions of the frontal recess. 8 However, because of the untoward effects of chronic oral steroid use, topical nasal steroid therapy, which has minimal systemic effects, is preferred. Topical nasal steroids are most commonly dispensed as sprays, and these sprays are widely used postoperatively. However, some studies reported that particles from topical nasal sprays reach only as far as the inferior turbinate, anterior surface of middle turbinate, and nasal floor rather than the middle meatus or frontal recess after ESS. 9,10 Alternatively, significantly larger amounts of particles from topical nasal drops, with anatomic positioning, such as the Mygind 11 (supine and head extended) position, reached the middle meatus, including the frontal recess. 9,10 A retrospective study using topical nasal drops with Mygind positioning showed benefits in preventing maxillary and frontal sinus ostia stenosis. 12 Many studies have investigated the use of topical nasal steroids in the treatment of chronic rhinosinusitis after ESS. However, the effectiveness of topical nasal steroid drops compared with sprays for frontal ostium patency after ESS still has not been determined. The objective of this study was to determine the effectiveness of intranasal steroid drops with anatomically directed positioning, com- pared with spray forms, after endoscopic frontal sinusotomy. MATERIALS AND METHODS A prospective, randomized, single-blind case-control study was conducted. The Institutional Review Board of Samsung Medical Cen- ter granted approval for this study. The indications for ESS included (1) symptoms meeting the criteria of the American Academy of Oto- laryngology Task Force on Rhinosinusitis guideline 13 and (2) radio- logical confirmation with computed tomography (CT). Among the candidates for ESS, patients who underwent frontal sinusotomy with a neofrontal ostium of 4 mm–-confirmed with 4-mm-diameter long curved suction tips—were offered an opportunity to volunteer for recruitment into this study. All subjects provided informed consent. The exclusion criteria of this study included (1) history of using the systemic steroids within the 4 weeks before the surgery, (2) poor overall health, (3) fungal sinusitis or the presence of a tumor, and (4) an age of 18 years. Preoperative data were collected regarding smoking, allergy status, asthma status, preoperative Lund-Mackay CT scores, presence of polyps, and history of previous sinus operations. A single surgeon (S.K.C.) conducted all operations. During frontal sinusotomy, meticulous dissection was performed and care was taken to not detach the mucosa around the neo-ostium. All frontal neo-ostia were large, as much as 4 mm in diameter, confirmed with 4-mm-long From the Department of Otorhinolaryngology–Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea The authors have no conflicts of interest to declare pertaining to this article Address correspondence and reprint requests to Seung-Kyu Chung, M.D., Ph.D., Department of Otorhinolaryngology– Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Korea E-mail address: rhinochung@skku.edu Copyright © 2012, OceanSide Publications, Inc., U.S.A. American Journal of Rhinology & Allergy 209 DO NOT COPY