**4.2 Hematologic examination**

There was no statistically significant difference in hematologic examination results between groups (unpaired *t*-test, *p* > 0.05). The absolute peripheral eosinophil counts in Group A were significantly higher than in Group D (**Table 2**).

## **4.3 L-M score and sinus wall thickness**

The average L-M score of Group A was 16.7 ± 8.0 and of Group C was 12.9 ± 5.1; there was no significant difference between these groups (unpaired *t*-test, *p* > 0.05, **Table 3**).

The assessments of sinus wall thickness between the independent otolaryngologists were very close. The average intraclass correlation coefficient between two assessors was 0.833 (95% confidence interval, 0.782–0.872). In terms of individual sinuses, the closest interrater agreement was found for sphenoid sinuses (0.821,


*Group A: Revision group (same surgeon). Group B: Revision group (different surgeons). Group C: Primary FESS group. Group D: Normal control group.*

*\* p < 0.05 (Kruskal-Wallis test).*

*# Other than normal flora, there are Staphylococcus aureus (n = 5), MRSA (n = 1), Citrobacter koseri (n = 1), and Haemophilus influenzae (n = 1).*

**79**

*Refractory Rhinosinusitis*

*group. Group D: Normal control group.*

*group. Group D: Normal control group.*

*p < 0.05, compared with group A.*

*p < 0.05, compared with group B.*

*With primary CT; n = 8.*

*Hematologic examination result in different groups.*

*p < 0.05, compared with group D.*

*\**

*¶*

*#*

*\$*

**Table 3.**

**Table 2.**

*DOI: http://dx.doi.org/10.5772/intechopen.84714*

**Group Hematologic exam**

**Hemoglobin WBC count (k/μl) Eos. (%) Peripheral eos.** 

**Group L-M score Sinus wall thickness (mm)**

A 16.7 ± 8.0 4.25 ± 1.66 1.83 ± 0.37 1.89 ± 0.66 B 12.9 ± 6.6\$ 2.43 ± 0.83 1.49 ± 0.28 1.49 ± 0.59 C 12.9 ± 5.1 2.06 ± 0.49¶ 1.46 ± 0.24¶ 1.34 ± 0.28¶ D 0.23 ± 0.43 1.97 ± 0.42¶, # 1.44 ± 0.33¶ 1.39 ± 0.34¶ *Group A: Revision group (same surgeon). Group B: Revision group (different surgeons). Group C: Primary FESS* 

A 14.58 ± 0.67 6333.3 ± 1494.5 4.48 ± 3.82 303.09 ± 297.48\* 91.2 ± 8.3 B 14.34 ± 1.29 6119.4 ± 1781.6 2.91 ± 2.03 181.45 ± 179.31 93.1 ± 14.3 C 14.29 ± 1.53 6994.3 ± 1637.0 3.66 ± 3.03 249.48 ± 240.49 90.1 ± 9.2 D 14.00 ± 1.23 6146.7 ± 1598.4 3.50 ± 2.51 164.29 ± 204.15 96.4 ± 21.6 *Group A: Revision group (same surgeon). Group B: Revision group (different surgeons). Group C: Primary FESS* 

**count (k/μl)**

**Maxillary Ethmoid Sphenoid**

**Sugar (g/dL)**

0.932), followed by the ethmoid sinuses (0.631, 0.851) and the maxillary sinuses (0.576, 0.825). In Group A, the mean sinus wall thickness of the maxillary, ethmoid, and sphenoid sinuses were 4.25 ± 1.66 mm, 1.83 ± 0.37 mm, and 1.89 ± 0.66 mm, respectively. Group B had a mean thickness of 2.43 ± 0.83 mm, 1.49 ± 0.28 mm, and 1.49 ± 0.59 mm in the maxillary, ethmoid, and sphenoid sinuses. In Group C, the sinus wall thickness was as follows: maxillary sinus, 2.06 ± 0.49 mm; ethmoid sinus, 1.46 ± 0.24 mm; and sphenoid sinus, 1.34 ± 0.28 mm. In Group D, the measured sinus wall mean thickness of the maxillary, ethmoid, and sphenoid sinuses were

The sinus wall thickness of Group A was significantly higher than Groups C and D; in Group B, only the maxillary sinus wall thickness was significantly different compared to Group D (unpaired *t*-test, *p* < 0.05; **Table 3**). Multiple logistic regression analysis was performed between Groups A and C against various parameters including age, gender and maxillary sinus wall thickness, LM score, Hb, and eosinophil count. Eventually, maxillary sinus wall thickness was an independent

Average recurrence time of Group A was 28.7 ± 13.9 months. There was no significant correlation between the mean recurrence time and preoperative L-M score

(**Figure 3**) or sinus wall thickness (linear regression, *p* > 0.05; **Figure 4**).

1.97 ± 0.42 mm, 1.44 ± 0.33 mm, and 1.39 ± 0.34 mm, respectively.

significant factor noted (*p* = 0.037; **Table 4**).

*L-M score and sinus wall thickness result in different groups.*

**4.4 Mean recurrence time**

*\$ Average eosinophil count >10/high power field in ten randomly selected fields (X 400) under H&E staining13. &Number of patient with positive ImmunoCAP test.*

#### **Table 1.** *Patients' demographic data.*

#### *Refractory Rhinosinusitis DOI: http://dx.doi.org/10.5772/intechopen.84714*


*Group A: Revision group (same surgeon). Group B: Revision group (different surgeons). Group C: Primary FESS group. Group D: Normal control group.*

*\* p < 0.05, compared with group D.*

#### **Table 2.**

*Rhinosinusitis*

**4.1 Patient demographics**

**4. Clinical features associated with the severity of CRS**

(only one case in Groups A and C, respectively).

**4.2 Hematologic examination**

*group. Group D: Normal control group.*

*&Number of patient with positive ImmunoCAP test.*

*p < 0.05 (Kruskal-Wallis test).*

*Haemophilus influenzae (n = 1).*

*Patients' demographic data.*

**Table 3**).

**4.3 L-M score and sinus wall thickness**

Group A included 8 males and 1 female (mean age, 49.1 ± 15.1 years), Group B included 11 males and 6 females (mean age, 47.8 ± 15.6 years), Group C included 23 males and 7 females (mean age, 41.9 ± 11.3 years), and Group D included 10 males and 20 females (mean age, 50 ± 14.9 years). There was no significantly difference across age (unpaired *t*-test, *p* > 0.05). The gender distribution was significantly different with obvious male preponderance in Groups A, B, and C (Kruskal-Wallis test, *p* < 0.05; **Table 1**). The information including bacteriology, eosinophilic rhinosinusitis, asthma, or ImmunoCAP Specific IgE blood test were shown in **Table 1**. The bacteriological data indicated *Staphylococcus aureus* was the major bacterial species found. The main infiltrative inflammatory cells according to pathologic slides were lymphoplasma cells and, occasionally, neutrophil infiltration. Eosinophilic rhinosinusitis was defined as average eosinophil count >10/high power field in ten randomly selected fields (X 400) under H&E staining from our previous publication [13]. Aspirin intolerance and bronchial asthma were very scarce

There was no statistically significant difference in hematologic examination results between groups (unpaired *t*-test, *p* > 0.05). The absolute peripheral eosinophil counts in Group A were significantly higher than in Group D (**Table 2**).

The average L-M score of Group A was 16.7 ± 8.0 and of Group C was 12.9 ± 5.1; there was no significant difference between these groups (unpaired *t*-test, *p* > 0.05,

The assessments of sinus wall thickness between the independent otolaryngologists were very close. The average intraclass correlation coefficient between two assessors was 0.833 (95% confidence interval, 0.782–0.872). In terms of individual sinuses, the closest interrater agreement was found for sphenoid sinuses (0.821,

A 9 49.1 ± 15.1 8M1F (1)& 3 1 1 B 17 47.8 ± 15.6 11M6F (3) 3 1 1 C 30 41.9 ± 11.3 23M7F (4) 2 1 0 D 30 44.7 ± 13.6 10M20F NA NA NA *Group A: Revision group (same surgeon). Group B: Revision group (different surgeons). Group C: Primary FESS* 

*Other than normal flora, there are Staphylococcus aureus (n = 5), MRSA (n = 1), Citrobacter koseri (n = 1), and* 

*Average eosinophil count >10/high power field in ten randomly selected fields (X 400) under H&E staining13.*

**rhinosinusitis\$**

**Aspirin intolerance or asthma**

**Group N= Age Gender\* Bacteriology# Eosinophilic** 

**78**

**Table 1.**

*\**

*#*

*\$*

*Hematologic examination result in different groups.*


*Group A: Revision group (same surgeon). Group B: Revision group (different surgeons). Group C: Primary FESS group. Group D: Normal control group.*

*¶ p < 0.05, compared with group A.*

*# p < 0.05, compared with group B.*

*\$ With primary CT; n = 8.*

#### **Table 3.**

*L-M score and sinus wall thickness result in different groups.*

0.932), followed by the ethmoid sinuses (0.631, 0.851) and the maxillary sinuses (0.576, 0.825). In Group A, the mean sinus wall thickness of the maxillary, ethmoid, and sphenoid sinuses were 4.25 ± 1.66 mm, 1.83 ± 0.37 mm, and 1.89 ± 0.66 mm, respectively. Group B had a mean thickness of 2.43 ± 0.83 mm, 1.49 ± 0.28 mm, and 1.49 ± 0.59 mm in the maxillary, ethmoid, and sphenoid sinuses. In Group C, the sinus wall thickness was as follows: maxillary sinus, 2.06 ± 0.49 mm; ethmoid sinus, 1.46 ± 0.24 mm; and sphenoid sinus, 1.34 ± 0.28 mm. In Group D, the measured sinus wall mean thickness of the maxillary, ethmoid, and sphenoid sinuses were 1.97 ± 0.42 mm, 1.44 ± 0.33 mm, and 1.39 ± 0.34 mm, respectively.

The sinus wall thickness of Group A was significantly higher than Groups C and D; in Group B, only the maxillary sinus wall thickness was significantly different compared to Group D (unpaired *t*-test, *p* < 0.05; **Table 3**). Multiple logistic regression analysis was performed between Groups A and C against various parameters including age, gender and maxillary sinus wall thickness, LM score, Hb, and eosinophil count. Eventually, maxillary sinus wall thickness was an independent significant factor noted (*p* = 0.037; **Table 4**).

#### **4.4 Mean recurrence time**

Average recurrence time of Group A was 28.7 ± 13.9 months. There was no significant correlation between the mean recurrence time and preoperative L-M score (**Figure 3**) or sinus wall thickness (linear regression, *p* > 0.05; **Figure 4**).

#### *Rhinosinusitis*


#### **Table 4.**

*Multiple logistic regression between Groups A and C.*

#### **Figure 3.**

*Linear regression between the mean recurrence period and L-M score in Group A showed no significant relationship (p > 0.05).*

**Figure 4.**

*Mean recurrence period showed no significant relationship compared to the maxillary, ethmoid, and sphenoid sinus wall thickness (linear regression, p > 0.05).*

#### **4.5 The cutoff values of sinus wall thickness for the prediction of recalcitrant CRS**

The cutoff value of sinus wall thickness in prediction of refractory CRS who needs revision surgery differed across sinuses. The sensitivity and specificity for prediction also varied. Using 3.03 mm as a cutoff value for the maxillary sinus, the sensitivity was 88.9% and the specificity was 90%. Using 1.63 mm as cutoff value for ethmoid sinus, the sensitivity and specificity were 77.8 and 80.0%, respectively. Using 1.75 mm as a cutoff value for the sphenoid sinus, the sensitivity was 44.4% and the specificity was 80.0%.

**81**

*Refractory Rhinosinusitis*

*p* < 0.05; **Figure 5**).

**Figure 5.**

**revision surgeries**

*maximal area under a curve (AUC) of 0.94.*

in order to evaluate its severity.

*DOI: http://dx.doi.org/10.5772/intechopen.84714*

Different sinus wall thicknesses showed areas under ROC curve (AUC) of 0.94, 0.72, and 0.63, for maxillary, ethmoid, and sphenoid sinuses, respectively. The AUC of maxillary sinus wall thickness reached statistical significance (ROC curve,

*and 1.75 mm in maxillary, ethmoid, and sphenoid sinus, respectively. The ROC curve of maxillary sinus has* 

**5. Sinus wall thickness and blood eosinophilia as the indicators for** 

*ROC curve shows the cutoff values for the best sensitivity and specificity of each sinus: 3.03, 1.63,* 

The success of FESS for CRS is still variable, ranging from 76 to 98% [4]. Although the exact predictive factors are still controversial, several risk factors, such as nasal polyps, allergic rhinitis, aspirin intolerance, and bacterial resistance, can result in unfavorable treatment outcomes for CRS patients. In this study, we found that the presence of thickened maxillary sinus walls of more than 3.03 mm and increased peripheral blood eosinophil count are good predictors of unfavorable outcomes from FESS. In addition to the classical L-M scoring system, a twodimensional parameter, we suggest that these two factors may represent another three-dimensional parameter that may indicate the depth of inflammation in CRS

The sinonasal organ is an expanding air-filled space that grows in a random pattern proven by using a simple computerized equation [14]. The sinus pneumatization process may be considered as using limited material ballooning to occupy the space among the eyeballs, brain, and mouth. This expanding process creates one frontal, maxillary, and sphenoid sinus cell on each side and, more importantly, the complexity of the ethmoid cell system. The bony sinus wall, which confines this sinonasal cavity, represents the boundary and most peripheral lining of this organ. If it is involved in the inflammatory process, it might be considered as one of the dimensions of the depth of disease extent, indicating a more severe form of sinonasal disease. One study showed that CRS patients had smaller maxillary sinuses than normal controls. These authors proposed that the increased bone thickness in the maxillary sinus itself might be related to the size of the sinus [15]. Accordingly, we demonstrated that maxillary

sinus wall thickness is an indicator of poor surgical outcome.

#### **Figure 5.**

*Rhinosinusitis*

**Table 4.**

**Figure 3.**

**Figure 4.**

*relationship (p > 0.05).*

**80**

**recalcitrant CRS**

and the specificity was 80.0%.

**4.5 The cutoff values of sinus wall thickness for the prediction of** 

*and sphenoid sinus wall thickness (linear regression, p > 0.05).*

*Mean recurrence period showed no significant relationship compared to the maxillary, ethmoid,* 

The cutoff value of sinus wall thickness in prediction of refractory CRS who needs revision surgery differed across sinuses. The sensitivity and specificity for prediction also varied. Using 3.03 mm as a cutoff value for the maxillary sinus, the sensitivity was 88.9% and the specificity was 90%. Using 1.63 mm as cutoff value for ethmoid sinus, the sensitivity and specificity were 77.8 and 80.0%, respectively. Using 1.75 mm as a cutoff value for the sphenoid sinus, the sensitivity was 44.4%

*Linear regression between the mean recurrence period and L-M score in Group A showed no significant* 

*P* **value Odds ratio 95% CI**

Age 0.648 1.039 0.881–1.226 Gender 0.711 0.001 0.026–8.020 Maxillary thickness 0.037 19.442 1.192–317.181 L-M score 0.958 0.994 0.800–1.235 Hb 0.648 1.400 0.330–5.951 Eosinophil count 0.827 0.999 0.989–1.009

*Group A: Revision group (same surgeon). Group C: Primary FESS group.*

*Multiple logistic regression between Groups A and C.*

*ROC curve shows the cutoff values for the best sensitivity and specificity of each sinus: 3.03, 1.63, and 1.75 mm in maxillary, ethmoid, and sphenoid sinus, respectively. The ROC curve of maxillary sinus has maximal area under a curve (AUC) of 0.94.*

Different sinus wall thicknesses showed areas under ROC curve (AUC) of 0.94, 0.72, and 0.63, for maxillary, ethmoid, and sphenoid sinuses, respectively. The AUC of maxillary sinus wall thickness reached statistical significance (ROC curve, *p* < 0.05; **Figure 5**).
