Abstract
Objectives
The position of human maxillary ostia is high on their superomedial walls, which may be suboptimal for natural drainage. Human maxillary sinuses exhibit better passive drainage through their ostia when tilted anteriorly to mimic a quadrupedal head position. We all know that sufficient drainage is very important for the treatment of chronic rhinosinusitis (CRS). Chronic maxillary sinusitis (CMS) is the high incidence of CRS. The aim of this study was to investigate the efficacy of quadrupedal head position in patients with CMS.
Methods
One hundred six patients diagnosed with CMS were enrolled. Patients were randomized to quadrupedal head position group and non-quadrupedal head position group for 6 weeks of treatment. Treatment outcomes were measured using 1) Lund-Mackay scoring system of pre-and post-treatment computer tomography (CT); and 2) Sinonasal Quality-of-Life (QoL) Survey completed at baseline and 6 weeks of therapy.
Results
There were statistically significant differences in QoL scores and CT scores between quadrupedal head position group and non-quadrupedal head position group. The quadrupedal head position group had much more improvements in QoL scores and CT scores than that of non-quadrupedal head position group. One patient in the quadrupedal head position group required functional endoscopic sinus surgery (ESS) due to persistent symptoms, and nine patients in non-quadrupedal head position group needed ESS. There were less patients that required ESS in the quadrupedal head position group than in the non-quadrupedal head position group.
Conclusions
The improvements of QoL scores and CT scores were significantly better in the quadrupedal head position group than that in the non-quadrupedal head position group. Quadrupedal head position can be valuable adjuvant therapy for patients with CMS.
1
Introduction
Rhinosinusitis is a disease with a sudden onset of two or more symptoms, one of which should be either nasal blockage or nasal discharge (anterior or posterior nasal drip). Other symptoms are facial pain or pressure, headache, impairment or loss of smell, and cough with resultant sleep disturbance. When symptoms are present for more than 12 weeks, this is defined as chronic rhinosinusitis (CRS). The etiology of CRS is a subject of very complex and ongoing research. The current opinion is that of a multifactorial pathogenesis. The paranasal sinuses are aerated cavities that drain into the nasal cavity via the sinus ostia. The ability for paranasal sinuses to clear normal mucous secretions depends on three major factors: ostial patency, ciliary function, and mucous consistency . Any pathological factors may damage the sinus mucosa leading to inflammation, edema, bacterial proliferation, outflow obstruction, and mucociliary dysfunction. Allergic conditions, specifically rhinitis, is certain factor for cause of CRS . Viral and bacterial infections are also factors for CRS . In addition, predisposing factors for CRS include some systemic factors, such as cystic fibrosis and primary ciliary dyskinesia . Thickened nasal walls, engorged turbinates, and ostial occlusion characterize CRS. Swollen tissue blocks ostial drainage, airflow becomes insufficient, intrasinus pressure increases and blood flow to the tissues is significantly decreased . In order to maintain the balance of gas exchange, the sinus ostia must be large enough. Excessive constriction leads to pain as increasing sinus pressure stimulates sensory receptors. In CRS, mucin composition significantly changes, resulting in increased viscosity and the inability to successfully drain fluid from the sinus . Ostial occlusion or excessive constriction is another important factor for insufficient drainage. Poor drainage conditions make CRS difficult to be cured. Functional endoscopic sinus surgery (ESS) has greatly improved the cure rate for CRS through improving drainage condition by expanding the natural ostial. It demonstrated that sufficient drainage is very important for the treatment of CRS.
Chronic maxillary sinusitis (CMS) is the high incidence of CRS. The reason is that the position of maxillary ostia is high on their superomedial walls, which may be suboptimal for natural drainage. Human maxillary sinuses exhibit better passive drainage through their ostia when tilted anteriorly to mimic a quadrupedal head position . In this study we investigated the effect of quadrupedal head position as adjunctive therapy on the recovery from CMS.
2
Materials and methods
2.1
Study design
This prospective, randomized, double-blinded study was performed at the department of otolaryngology of Guangzhou General Hospital of Guangzhou Military Command. The study was approved by the Institutional Review Board of Guangzhou General Hospital of Guangzhou Military Command. One hundred six patients were enrolled between May 2006 and July 2011, and follow-up was completed by September 2011. All 106 patients were randomized into two treatment groups, quadrupedal head position group and non quadrupedal head position group, each group contained 53 patients. All patients were strictly instructed to medical scheme.
Both quadrupedal head position group and non-quadrupedal head position group were treated with erythromycin, mometasone furoate aqueous nasal spray, myrtol standardized enteric coated soft capsules and desloratadine tablets. Additionally, all the patients were asked to give up smoking and alcohol during the treatment.
The quadrupedal head position group received the same basic treatment as the non-quadrupedal head position group, with the addition of quadrupedal head position therapy. The quadrupedal head position group took quadrupedal head position ( Fig. 1 ) for 20 minutes in every morning and afternoon respectively.
2.2
Study procedures
Patients referred to the principal author (otolaryngologist in the outpatient department) for evaluation of chronic maxillary sinusitis were screened for eligibility for enrollment. After clinical history and a thorough physical exam were obtained, pretreatment CT scans were reviewed. Positive screening was determined based on a positive clinical history as well as a positive CT scan within 2 months of the evaluation by the outpatient otolaryngology appointment. Once a patient was determined to be a candidate for enrollment, the patient was given a full explanation of the research protocol, and enrollment into trial was offered.
2.3
Inclusion criteria
Criteria for inclusion in the study were: healthy person age 18–38 years and a history of recurrent or chronic maxillary sinusitis (history must include > 3 months of any or a combination of the following symptoms: nasal congestion/nasal airway obstruction, rhinorrhea/nasal discharge, persistent cough, postnasal drip, headache, facial pain, etc); has had at least a total of 21 days of oral antibiotic therapy for above symptoms in the previous 3 months; and patient has had a CT scan of the paranasal sinuses within 2 months prior to visit date, which demonstrates opacification of at least single or two maxillary sinus. All females in this study were not in gestation period. In addition, the patient should be able to accept follow up.
2.4
Exclusion criteria
Exclusion criteria included: history of cystic fibrosis; history of immotile cilia syndrome; history of immune suppression/immune compromise; CT scan within the past 4 weeks available for review at time of clinic visit that is entirely negative for evidence of sinus disease plus complete absence of any of the above symptoms; history of endoscopic sinus surgery; history of presence of nasal polyposis; severe nasal septum deviation; combined with frontal sinusitis, ethmoiditis or sphenoiditis.
All patients were asked to complete the Quality of Life (QoL) survey at the time of enrollment, after 3 weeks of treatment via telephone, and at the follow-up visit after 6 weeks of treatment. To determine if quadrupedal head position resulted in improvement of chronic maxillary sinusitis, each patient was scheduled for a follow-up CT scan within 2 weeks of completion of the 6-week treatment. A follow-up appointment was made as immediately as possible following the post-treatment CT scan. And patients were asked during that appointment to fill out the final QoL survey. Results of the post-treatment CT scan were discussed with the patients, and our research group decided whether further treatments was necessary. To determine objective improvement based on CT findings, pretreatment and post-treatment CT scans for each patient were scored by a radiologist using the Lund-Mackay scoring system. The CT scores were documented for each maxillary sinus and ostiomeatal complex on each side. The CT scans were reviewed and scored in random order with all identifying information concealed. The radiologist was blinded to all CT scans. All otolaryngologists in this research were not involved in the scoring of the CT scans. Subjective improvement of chronic maxillary sinusitis for each patient was determined using the QoL surveys.
2.5
Statistical analysis
χ 2 and t tests were performed using a commercial statistical software package (SPSS 19.0).
2
Materials and methods
2.1
Study design
This prospective, randomized, double-blinded study was performed at the department of otolaryngology of Guangzhou General Hospital of Guangzhou Military Command. The study was approved by the Institutional Review Board of Guangzhou General Hospital of Guangzhou Military Command. One hundred six patients were enrolled between May 2006 and July 2011, and follow-up was completed by September 2011. All 106 patients were randomized into two treatment groups, quadrupedal head position group and non quadrupedal head position group, each group contained 53 patients. All patients were strictly instructed to medical scheme.
Both quadrupedal head position group and non-quadrupedal head position group were treated with erythromycin, mometasone furoate aqueous nasal spray, myrtol standardized enteric coated soft capsules and desloratadine tablets. Additionally, all the patients were asked to give up smoking and alcohol during the treatment.
The quadrupedal head position group received the same basic treatment as the non-quadrupedal head position group, with the addition of quadrupedal head position therapy. The quadrupedal head position group took quadrupedal head position ( Fig. 1 ) for 20 minutes in every morning and afternoon respectively.
2.2
Study procedures
Patients referred to the principal author (otolaryngologist in the outpatient department) for evaluation of chronic maxillary sinusitis were screened for eligibility for enrollment. After clinical history and a thorough physical exam were obtained, pretreatment CT scans were reviewed. Positive screening was determined based on a positive clinical history as well as a positive CT scan within 2 months of the evaluation by the outpatient otolaryngology appointment. Once a patient was determined to be a candidate for enrollment, the patient was given a full explanation of the research protocol, and enrollment into trial was offered.
2.3
Inclusion criteria
Criteria for inclusion in the study were: healthy person age 18–38 years and a history of recurrent or chronic maxillary sinusitis (history must include > 3 months of any or a combination of the following symptoms: nasal congestion/nasal airway obstruction, rhinorrhea/nasal discharge, persistent cough, postnasal drip, headache, facial pain, etc); has had at least a total of 21 days of oral antibiotic therapy for above symptoms in the previous 3 months; and patient has had a CT scan of the paranasal sinuses within 2 months prior to visit date, which demonstrates opacification of at least single or two maxillary sinus. All females in this study were not in gestation period. In addition, the patient should be able to accept follow up.
2.4
Exclusion criteria
Exclusion criteria included: history of cystic fibrosis; history of immotile cilia syndrome; history of immune suppression/immune compromise; CT scan within the past 4 weeks available for review at time of clinic visit that is entirely negative for evidence of sinus disease plus complete absence of any of the above symptoms; history of endoscopic sinus surgery; history of presence of nasal polyposis; severe nasal septum deviation; combined with frontal sinusitis, ethmoiditis or sphenoiditis.
All patients were asked to complete the Quality of Life (QoL) survey at the time of enrollment, after 3 weeks of treatment via telephone, and at the follow-up visit after 6 weeks of treatment. To determine if quadrupedal head position resulted in improvement of chronic maxillary sinusitis, each patient was scheduled for a follow-up CT scan within 2 weeks of completion of the 6-week treatment. A follow-up appointment was made as immediately as possible following the post-treatment CT scan. And patients were asked during that appointment to fill out the final QoL survey. Results of the post-treatment CT scan were discussed with the patients, and our research group decided whether further treatments was necessary. To determine objective improvement based on CT findings, pretreatment and post-treatment CT scans for each patient were scored by a radiologist using the Lund-Mackay scoring system. The CT scores were documented for each maxillary sinus and ostiomeatal complex on each side. The CT scans were reviewed and scored in random order with all identifying information concealed. The radiologist was blinded to all CT scans. All otolaryngologists in this research were not involved in the scoring of the CT scans. Subjective improvement of chronic maxillary sinusitis for each patient was determined using the QoL surveys.
2.5
Statistical analysis
χ 2 and t tests were performed using a commercial statistical software package (SPSS 19.0).
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