<= /p>

3D"Text <= /td>

<= /p>

An Audit of Endoscopic Sinus Surgery at a Tertiary

Hospital in Tanzania

*Aveline Aloyce Kahinga¹, Isaac John Batule¹, Zephania Saitabau Abraham ²,� <= /span>

Elimath Martin Mushi³.

¹Department of Otorhinolaryngology, Muhimb= ili University of Health and Allied Sciences, Dar es Salaam, Tanzania2Department of Su= rgery, School of Medicine and Dentistry, University of Dodoma, Dodoma, Tanzania. <= sup>3Department of Otorhinolaryngology, Muhimbili National Hospital, Dar es Salaam, Tanzania.=

<= /p>

Background= : Being a frequently used approach by otorhinolaryngologists, Endoscop= ic sinus surgery (ESS) has been useful in the surgical management of different sinonasal conditions in this era. Although ESS is most commonly performed for inflammatory and infect= ious sinus diseases since its introduc= tion in the 1960s by Prof. Messserklinger and Wigand= , the current advancement in instrumentation has led to an increase in its indications. This study therefore aimed at auditing the ESS done at a terti= ary hospital in our settings.

This was a retrospective descriptive cross-sectional study which was conducted a= t Muhimbili National Hospital. It involved all patients who underwent ESS in the department of otorhinolaryngology. Information was extracted from patients� files, ledger, and admission books. The obtained data were analyzed using a statistical package for social sciences (SPSS) version 22. Descriptive statistics were performed to present the frequency distribution of the demographic characteristics, indications for ESS, and mean for the length of hospital stay.

Out of 1261 surgeries done during the study period, 6.7% (84/1261) were endosco= pic sinus surgeries. Of patients who underwent ESS, an almost equal proportion = of males and females was found and ages ranged from 8 to 71 years with a mean = age of 32 .2 �16 .9 years.� The commone= st indication for ESS was sinonasal polyposis at 50.0% (42/84) followed by chr= onic rhinosinusitis at 20.4% (17/84). The majority of patients 52.4% (44/84) had= a hospital stay of 1- 3 days. The mean length of postoperative hospital stay following ESS in this study was found to be 2.8 days.

Endoscopic sinus surgeries accounted for 6.7% of all surgeries with sinonasal polyposis being the commonest indication and the estimated mean length of postoperati= ve hospital stay being 3 days.

: Endoscopic Sinus Surgery, Chronic Sinusitis, Indications for ESS.

=

��*Correspondence: Dr. Aveline A= . Kahinga Muhimbili Univers= ity of Health and Allied Sciences, P. O. Box 65001, Dar es Salaam, Tanzania E-mail<= /span>: avelynek@yahoo.co.uk

This is an open access journal, and articles are distributed und= er the terms of the Creative Commons Attribution-Non-Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creati= ons are licensed under the identical terms.

How to cite this article<= b>= : Kahinga= AA, Batule IJ, Abraham ZS, Mu= shi EM. An Audit of Endoscopic Sinus Surgery at a Tertiary Hospital in Tanzania Nig= er Med J 2023; 63(4):563-568 Accepted: August 29, 2023. Published: September 2= 1, 2023.

Introduction

Endoscopic sinus surgery (ESS) has been a frequently used approach by otorhinolaryngologists and has been useful in the surgical management of different sinonasal conditions in this era.^[1]Prior advent of ESS, open surgery predominated despite its pitfalls such as increased morbidity to patients a= nd cosmetic implications. Due to frequent failures of Caldwell-Luc surgery, the morbidity of frontal sinus osteoplast= y, and difficulties of performing headlight intranasal ethmoidectomy, such encountered challenges led to a strong rationale for the improvement of surgical techniques for chronic sinusitis.^=
[2] In 1903 Hi= rchman visualized endoscopically the nasal cavity and maxillary sinus via a tooth socket by using a modified Nitzecystoscope. ESS= was then introduced by Prof. Messerklinger and Wiga= nd in the 1960s and later on, it was popularized in Europe and North America by <= span class=3DSpellE>Stammbeger and Kennedy respectively.^[2,3]Kennedy studied the pathophysio= logy of sinusitis and came to discover that, the disease was due to blockage of = the osteo meatal unit (OMU) which is the key area for the proper drainage of the sinuses hence once this obstruction is removed the mucosal changes that occurred in the sinuses resolve and ventilation is restored. He then coined= the term function endoscopic sinus surgery (FESS) in 1985.^[1�3]FESS is hence referred to as t= he removal of tissue obstructing the Osteo-Matal Complex (OMC) and the facilitation of drainage while conserving the normal non-obstructing anatomy and mucous membrane.^[4,5]

Although ESS is most commonly performed for inflammatory and infectio= us sinus diseases, the current advancement in instrumentation has led to an increase in the indications for ESS.^[2]The most common indications for ESS are as follows; Chronic sinusitis refractory to medical treatment, recurrent sinusitis, nasal polyps, antrocho= anal polyp, sinus mucocele, resection of selected tumours, cerebrospinal fluid leak closure, orbital decompression in graves ophthalmopathy, optic nerve decompression, dacryocystor= hinostomy, foreign body removal from sinuses and control of epistaxis.^[1,2,4�25]Aim of this study was thu= s to audit ESS at the largest tertiary hospital in our settings.

<= /o:p>

Study design=

This was a hospital-based retrospective cross-sectional study.

Study popula= tion and duration

The study involved all patients who underwent ESS in the Department o= f Otorhinolaryngology (ORL) at Muhimbili National Hospital for a peri= od of one year from August 2017 to August 2018.

Data collect= ion method and analysis

Data was collected using data collecting sheets from ledger books, discharge summaries, and patient files. Information such as age and sex, indications,= and length of postoperative hospital stay were collected. Obtained data were co= ded and then entered into a computer database. It was cleaned, verified, and analyzed using a statistical package for social scie= nces (SPSS) version 22.

The proportion of ESS procedures was obtained by calculating the ratio of the number of patients who underwent ESS to overall surgeries done in the ORL department in 12 months. Indications for ESS were obtained by running the frequency of each indication and the length of postoperative hospital stay = was obtained by finding the mean length of hospitalization in days.<= /span>

Ethical clea= rance

Ethical clearance was obtained from the Research and Publication Committee of Muhimbili University of Health and Allied Sciences. Permission to conduct the study was sought from the Traini= ng, Research, and Consultancy unit of Muhimbili Nat= ional Hospital.� The information obtained= was kept confidential as no names were recorded.

��= ��= ��

Results

Out of 1261 surgeries done during the study period, 6.7% (84/1261) were endoscopic sinus surgeries (ESS). Of patients w= ho underwent ESS, an almost equal proportion of males and females was found (m= ale to female ratio being 1.04:1) and ages ranged from 8 to 71 years with a mean age of 32 .2 �16 .9 years. The age group of 16 � 25 years had the highest proportion accounting for 26.2% (22/84) of the cases, with a slight female preponderance. (Table 1)

Table = 1: Age and sex distribution of patients who underwent ESS.

AGE GROUP

(YEARS)

SEX

TOTAL (%)

MALE (%)

FEMALE (%)

≤15

8 (57.1)

6(42.9)

14(16.7)

16-25=

10(45.5)

12(54.5)

22(26.2)

26-35=

7(41.2)

10(58.8)

17(20.2)

36-45=

6(40.0)

9(60.0)

15(17.9)

46-55=

3(50.0)

3(50.0)

6(7.1)

56-65=

5(71.4)

2(28.6)

7(8.3)

66-75=

2(66.7)

1(33.3)

3(3.6)

TOTAL

41(48.8)

43(51.2)

84(100)

The commonest indication for ESS in this s= tudy was sinonasal polyposis 50.0 % (42/84) followed by chronic rhinosinusitis 2= 0.2 % (17/84) while the least indications were excision of sinonasal inverted papilloma, control of epistaxis and choanal atresia release each contributi= ng 1.2 % (1/84).

<= /o:p>

(Figur= e 1)

The majority of patients 52.4% (44/84) had= a hospital stay of 3 days and below and a few 6% (5/84) had more than 6 days hospital stay after operation. The mean length of postoperative hospital st= ay following ESS in this study was found to be 2.8 days with days ranging from= 1 to 7 days. <= /p>
&= nbsp;

Table = 2: Length of hospital stay postoperatively <= o:p>

LENGTH OF HOSPIT= AL STAY

(DAYS)

FREQUENCY (%)

1 to 3 days

44 (52.4)

4 to 6 days

35(41.7)

7 days

5 (6.0)

Total

84(100)

Discussion

Before the adaptation of= the endoscopic approach to sinonasal pathologies, they were managed by open sur= gery which had its pitfalls, including cosmetic issues. Currently, with advancem= ents in instrumentation, the indications for endoscopic sinus surgeries have increased. ^[2,7]

=

In this study, a total of 1261 surgeries were performed in the ORL department where= ESS accounted for 6.7 % of all surgeries with an almost equal proportion of fem= ales and males. The mean age is 32 years.� The proportion of ESS done in our setting for 12 months was higher compared to several other studies whereby�� 94 = ESS were performed over� 26 months in N= epal,^[7] 78 ESS were performed over�� 36 months in Iraq,^[3]�� and 69� ESS were performed over� 17 = months in China.^[22]The almost equal proportion of males and females in our study appears to be different from what was observed in Nepal, China, and Iraq where males predominated ^[3,7,22]� but the study that was conducted in Ira= q had a� mean age of 32 years similar to = our study findings.^[3]The commonest indication for ESS in our study was sinonasal polyposis where ethmoidal pol= yps predominated compared to antrochoanal polyps, 3= 0 and 12 respectively followed by chronic sinusitis. These findings are congruent with those from other studies which also found nasal polyposis to be the ma= jor indication for ESS.^{[3,4,9,12,15,17,18,20,22,26,27]}�� Other indications for ESS included fun= gal sinusitis, sinus mucocele, pyogenic granuloma, intracranial tumour biopsy and the least were sinonasal inverted papilloma, epistaxis, and choa= nal atresia release.� The least indicat= ion such as inverted papilloma appears consistent with the observed find= ings from the study that was done in Nepal.^[7]

Moreover, the majority of patients had a hospital stay of 1 to 3 days followed by 4- 6 da= ys stay and few had a hospital stay of 7 days. The mean length of postoperative hospital stay following ESS was found to be 2.8 days. Such findings appear = to be different from those depicted in other countries where the mean length of postoperative hospital stay was estimated to be 2.3 days. The reason for the existing differences may be the indications for surgery.^[7,16,]

Conclusion

Though endos= copic surgeries including ESS in this developing country seem not to be one the routine surgeries because of lack of expertise ESS accounted for 6.7% of all surgeries done in the Otorhinolaryngology Department of this tertiary hospi= tal and sinonasal polyposis was found to be the commonest indication for ESS.

References

1.&= nbsp;     Basilio F, Arantes M, Ballin A, Da= llanol M, Bornhausen MB, Szkudla= rek D, Santos M, et al. Efficacy of Endoscopic Sinus Surgery in the Treatment = of Chronic Rhinosinusitis. Intl Arch Otorhinolaryngol, S�o Paulo - Brazil. 2010;14(4):433�7. <= b>

2.&= nbsp;     Tajudeen BA, Kennedy DW. Thirty years of endoscopic sin= us surgery: What have we learned? Wor= ld J Otorhinolaryngol Head Neck Surg. 2017;3(2):115�21. <= /p>
3.&= nbsp;     Alnori HAM. Endoscopic Sinus Surgery: Indications and Complications Tikrit Medical Journal. 2013;19(= 1):89�94.

4.&= nbsp;     Al-Mujaini A, Wali U, Al-Khabori M. Functional endoscopic sinus surgery: Indications and complications in ophthalmic field. Oman Med J. 2009;24(2):70�80.

5.&= nbsp;     Gosepath J, Pogods= ky T, Mann WJ. Characteristics of recurrent chronic rhinosinusitis after prev= ious surgical therapy.ActaOtolaryngol. 2008 128(7):778�84=

6.&= nbsp;     House W. Text book of ear nose and throat diseases. Vol. Seventh ed, Jitendar P Vi= jJaypee Brothers Medical Publishers (P) Ltd. 2007. Pp 431.

7.&= nbsp;     Pradhan, B &Thapa N. Functional Endoscopic Sinus Surgery (FESS). Journal of Nepal M= edical Association. 2006;45(164)= :337�41

8.&= nbsp;     Tajudeen BA, Brooks SG, Yan CH, Kuan EC, Schwartz JS, S= uh JD, et al. Quality-of-life Improvement after Endoscopic Sinus Surgery in Patients with Obstructive Sleep Apnea. Allergy and Rhinology. 2017;8(1):25�31.
9.&= nbsp;     Rahman T, Alam MM, Ahmed S, Karim MA, Rahman M, Wahiduzzaman M. Outcome of Endoscopic Sinus Surgery = in the Treatment of Chronic Rhinosinusitis. Mymensingh Med J. 2016;25(2):261�70.=

10.= Staffieri A, Marino F, Staffier= i C, Giacomelli L, D�Alessandro E, Maria Ferraro S, et al. The effects of sulfurous-arsenical-ferruginous thermal water nasal irrigation in wound healing after functional endoscopic sinus surgery for chronic rhinosinusitis: a prospective randomized study. American Journal of Otolaryngology - Head and Neck Medicine and Surgery. 2008;29(4):223�9= .

11.= Mierzwiński J, Dalke K, Laz P, Olijewski J, Piziewicz A= , Burduk PK. Functional endoscopic sinus surgery in children--our experience. OtolaryngolPol . 2006;60(4):517�20
12.= Bugten V, Nordg�rd S, Steinsv�g S. Long-term effects of postoperative meas= ures after sinus surgery. European Arch= ives of Oto-Rhino-Laryngology. 2008 May;265(5):531�7.

13.= Fernandes SV. Postoperative car= e in functional endoscopic sinus surge= ry?Laryngoscope .1999 ;109(6):945�8/

14.= Rudmik L, Soler = ZM, Orlandi RR, Stewart MG, Bhattacharyya N, Kennedy DW, et al. Early postoperative care following endoscopic sinus surgery: An evidence-based review with recommendations. Int F= orum Allergy Rhinol. 2011;1(6):417�30.

15.= Wu XF, Kong WF, Wang WH, Yuan L= X, Xu HQ, Qi M, et al. Enhanced recovery after surgery protocols in functional endoscopic sinus surgery for patients with chronic rhinosinusitis with nas= al polyps: A randomized clinical trial. Chin Med J (Engl) 2019 ;132(3)= :253�8.

16.= Casler JD, Doolittle AM, Mair E= A. Endoscopic surgery of the anterior skull base. Laryngoscope 2005;115= (1 I):16�24

17.= Karaku#= 1; MF, �zcan KM, �zcan M, Karakurt SE, �etin MA, �olak M, et al. Does the Change in the Indicati= ons of Endoscopic Sinonasal Surgery Continue? Data between 1994-2018. Turk Arch Otorhi= nolaryngol 2020;58(1):5�9.

18.= Zhang Z, Adappa ND, Doghramji LJ, Chiu AG, Lautenbach E, Cohen NA, et al. Quality of life improvement from sinus surgery in chronic rhinosinusitis patients with asthma and nasal polyps. Int Forum Allergy Rhinol. 2014;4(11):885�92.

19.= Khalil HS, Nunez DA. Functional endoscopic sinus surgery for chronic rhinosinusitis. Cochrane Database Syst Rev. 2006 Jul 19;(3)

20.= Rudmik L, Soler = ZM, Hopkins C, Schlosser RJ, Peters A, White AA, et al. Defining appropriatene= ss criteria for endoscopic sinus surgery during management of uncomplicated a= dult chronic rhinosinusitis: a RAND/UCLA appropriateness study. Int Forum Allergy Rhinol. 2016;6(6):557�67.

21.= Han D, Zhou B, Liu H. Effects of endoscopic sinus surgery and relative factors. ZhonghuaEr Bi Yan HouKeZaZhi. 1996;31(1):12�5.
22.= Sun H, Tan G, Xiao J. Endoscopic sinus surgery, clinical aspect with 69 cases. ZhonghuaEr Bi Yan HouKeZaZhi .1996 ;31(1):18�9.
23.= Tan BK, Lane AP. Endoscopic Sin= us Surgery in the Management of Nasal Obstruction. OtolaryngolClin North Am. 2009;42(2):227�40.

24.   <= ![endif]>Ranga RK and Yadav SPS. Endoscopic Management of Foreign Body Nose Removal with = Self Fabricated Blunt Hooks: An Experience of 1156 Cases. = Otolaryngol Open Access J 2021, = 6(1): 000210

25.= Khan MA, Akram S, Khan M, Usman= HB. Comparison of efficacy and postoperative complications between unipolar electrocautery and bipolar electrocautery in cases of anterior epistaxis: a randomized control trial. Journal = of Postgraduate Medical Institute. 2017 Aug 10;31(3).

26.= Al-Abbasi, A., Al-Uraibi, S., A= tshan, S. Functional endoscopic sinus surgery. Basrah Journal of Surgery, 2020; 26(2): 12-18.

27.= Smith LF, Brindley PC. Indicati= ons, evaluation, complications, and results of functional endoscopic sinus surg= ery in 200 patients.Otolaryngology-Head and Neck Surgery. 1993;108(6):688�96.

<= /span>

AGE GROUP (YEARS)	SEX	TOTAL (%)
MALE (%)	FEMALE (%)
≤15	8 (57.1)	6(42.9)	14(16.7)
16-25=	10(45.5)	12(54.5)	22(26.2)
26-35=	7(41.2)	10(58.8)	17(20.2)
36-45=	6(40.0)	9(60.0)	15(17.9)
46-55=	3(50.0)	3(50.0)	6(7.1)
56-65=	5(71.4)	2(28.6)	7(8.3)
66-75=	2(66.7)	1(33.3)	3(3.6)
TOTAL	41(48.8)	43(51.2)	84(100)

LENGTH OF HOSPIT= AL STAY (DAYS)	FREQUENCY (%)
1 to 3 days	44 (52.4)
4 to 6 days	35(41.7)
7 days	5 (6.0)
Total	84(100)