Alexander C. Chester

We describe a case of a woman who developed a peripheral polyneuropathy shortly after completing 4 weekly doses of mefloquine hydrochloride (250 mg) malaria prophylaxis. Although mefloquine-related central nervous system neuropathy is well described in the literature, peripheral polyneuropathy similar to this case has been documented only once before, to our knowledge.

Most patients with chronicrhinosinusitis (CRS) are treated by internists, yet the information available to internists about CRS is rarely assessed. The author undertook a study to evaluate the amount and quality of information about CRS that is available to internists. Four information sources were analyzed: (1) five journals routinely read by internists, published over a 10-year period and searched on PubMed for the “exploded” terms chronic and sinusitis; (2) seven representative general and outpatient medicine texts, searched on MD Consult and STAT!Ref; (3) the 14th edition of the Medical Knowledge Self-Assessment Program (MKSAP 14), a review of internal medicine; and (4) four commonly used Internet databases. The five journals contained a total of 37,250 cited articles of various types over the study period; CRS was mentioned in only 19 of them. The standard medical texts offered little information about CRS, and MKSAP 14 did not mention CRS at all in the text, although it included some information in the questions and answers. Finally, among the online sources, UpToDate, a proprietary Internet database, offered an excellent discourse on CRS; in contrast, the Physicians’ Information and Education Resource, maintained by the American College of Physicians, contained no information about CRS in its 436 subject modules. The author concludes that, with few exceptions, the literature routinely available to internists offers little information about CRS.

Background: Although multiple studies have demonstrated that symptoms of chronic rhinosinusitis (CRS) improve after endoscopic sinus surgery (ESS), a systematic large‐scale evaluation of specific symptom response has not been performed.Objective: To analyze the relative effectiveness of surgery in the improvement of individual CRS symptoms.Study Design: A literature search of MEDLINE, EMBASE, Web of Science, Cochrane databases, and other Web‐based sources from January 1, 1980 through June 1, 2008 was performed. Studies of 20 or more adult patients with CRS that used symptom severity scores to analyze at least 3 major CRS criteria (facial pressure, nasal obstruction, postnasal discharge, and hyposmia) or 2 major CRS criteria plus headache were included.Subjects and Methods: Inclusion criteria were met by 21 of 289 ESS studies reviewed. Meta‐analysis was conducted for each symptom separately with the standardized difference between the preoperative and postoperative severity scores as the effect size (ES).Results: A total of 2070 patients with CRS were studied a mean of 13.9 months after ESS. All symptoms demonstrated improvement compared with their respective preoperative severity scores by an overall ES of 1.19 (95% confidence interval, 0.96 to 1.41; I ² = 81.7%) using the random‐effects model. Nasal obstruction (ES, 1.73) improved the most, with facial pain (ES, 1.13) and postnasal discharge (ES, 1.19) demonstrating moderate improvements. Hyposmia (ES, 0.97) and headache (ES, 0.98) improved the least.Conclusion: The relative improvements in major CRS symptoms and headache after surgery are similar, with the exception of nasal obstruction, which improves most.

To summarize recent studies exploring the response of chronic rhinosinusitis (CRS) symptoms to endoscopic sinus surgery (ESS). ESS symptom outcomes were reported using various symptom scoring systems and more than 18 survey instruments. When individual symptom scores were pooled by meta-analysis, most major CRS symptoms improved to a similar degree following surgery, with an overall effect size of 1.19 (95% confidence interval, 0.96-1.41; I(2) = 82%). Headache (effect size, 0.98) and hyposmia (effect size, 0.97) improved less than nasal obstruction (effect size, 1.73). Fatigue and bodily pain were more severe than general population normative values and improved following ESS by an effect size of approximately 0.5 SD, a change usually regarded as a minimally important clinical difference. Similarly, quality-of-life score in fibromyalgia improved after surgery. Neither anxiety nor depression confounded CRS symptom reporting, and neither correlated with computed tomography score; however, depression was associated with lower quality-of-life scores before and after ESS. Following ESS, most major CRS symptoms usually improve to a similar degree. Bodily pain and fatigue are associated with CRS and improve after ESS. Anxiety and depression do not confound symptom reporting, although depression is associated with poorer preoperative and postoperative quality-of-life scores.

Objectives: To determine whether bodily pain is increased in patients with chronic rhinosinusitis (CRS) and if bodily pain improves following endoscopic sinus surgery (ESS).Methods: All studies reporting results of more than 10 adult patients analyzing the response of bodily pain to ESS were retrieved by searching MEDLINE, EMBASE, Web of Science, Cochrane databases, and additional web‐based sources (from January 1, 1980, to May 1, 2008); by examining bibliographies of retrieved articles; and by contacting investigators in the field.Results: Of 279 ESS symptom outcome studies, only studies measuring results using the 36‐Item Short Form Health Survey (SF‐36) quality‐of‐life survey instrument measured bodily pain. Eleven observational ESS studies (1019 patients) reported mean preoperative SF‐36 bodily pain scores at 0.89 SD below general population norms (24% more severe bodily pain than general population norms) and significantly below norms for a population 25 years older. Using a repeated‐measures design, nine of 11 studies noted significant improvement in SF‐36 bodily pain domain scores following ESS, with a moderate‐sized combined effect of 0.55 (95% confidence interval, 0.45–0.64; I² = 44%) using the fixed‐effects model. This pooled effect corresponded to a mean improvement of 11.8 U on the SF‐36 bodily pain domain scale.Conclusions: Bodily pain is increased in patients with CRS awaiting ESS, exceeding the normative bodily pain scores of a general normative population 25 years older. Using within‐subject comparisons, a clinically and statistically significant improvement in bodily pain is noted after ESS, an improvement similar to that previously described for fatigue.

Background: Fatigue is a common symptom of chronic rhinosinusitis (CRS), yet the response of fatigue to endoscopic sinus surgery (ESS) has not been systematically evaluated.Methods: Studies published in any language were retrieved by searching MEDLINE, EMBASE, Web of Science, Cochrane databases, and additional Web‐based sources (from 1980–2007); by examining bibliographies of retrieved articles; and by contacting investigators in the field. Studies consisting of more than 10 adult patients analyzing the response of fatigue, vitality, energy, or malaise following ESS were included. Two authors independently evaluated studies for inclusion, rated the methods, and summarized relevant data using a standardized protocol.Results: Using within‐subject comparisons, 28 identified observational studies noted substantial improvement in fatigue after ESS. A subgroup analysis of 11 studies measuring outcomes using the 36‐Item Short Form Health Survey (SF‐36) demonstrated a moderate‐sized combined effect of 0.47 (95% confidence interval, 0.38–0.56; I² = 0%), corresponding to a mean ± standard deviation improvement of 9.7 ± 3.4 units on the SF‐36 vitality domain scores. In studies measuring outcomes using symptom rating scores, the preoperative severity scores and improvement after surgery for fatigue were similar to the respective values for other pooled CRS symptoms.Conclusions: All 28 studies described substantial improvement in fatigue following ESS based on presurgery and postsurgery comparisons. A subgroup analysis of 11 studies reporting results by the SF‐36 vitality domain scores demonstrated a moderate‐sized combined effect. Preoperative fatigue severity scores and improvement noted after surgery were similar to the respective values for other pooled CRS symptoms.

To determine the type and prevalence of measurement methods used to analyze symptom outcomes after endoscopic sinus surgery (ESS). Data were derived from PubMed, MEDLINE, EMBASE, Web of Science, Cochrane databases, Google Scholar, and manual searches. All English-language studies consisting of more than 10 adult patients from January 1980 to December 2006 reporting ESS symptom outcome results were reviewed. Studies of radical surgery and studies involving patients with significant comorbidities were excluded. The ESS symptom outcome results of 29,333 patients were reported in 204 studies. Symptom outcome was determined by survey instruments in 47 (23.0%) studies and individual symptom scoring in 63 (31%) studies. Of 18 validated instruments used, almost two thirds of studies that reported results by survey measures used the following three instruments: Chronic Sinusitis Survey (12 studies), Sinonasal Outcome Test-20 (11 studies), and Medical Outcomes study 36-Item Short-Form Health Survey (10 studies). The percentages of studies that reported specific results of the 1997 American Academy of Otolaryngology-Head Neck Surgery Rhinosinusitis Task Force (RSTF) chronic rhinosinusitis symptom criteria varied as follows: facial pain/pressure, 35%; facial congestion/fullness, 10%; nasal obstruction/blockage, 42%; nasal discharge/purulence/discolored postnasal discharge, 47%; hyposmia/anosmia, 35%; fever, 2%; halitosis, 4%; fatigue, 11%; dental pain, 3%; cough, 10%; and ear pain/pressure/fullness, 6%. ESS symptom outcome is assessed inconsistently by numerous measures. Individual report- ing of all RSTF chronic rhinosinusitis symptom criteria, as recommended by the RSTF and by subsequent consensus conferences, is rarely noted. Many RSTF symptom criteria are seldom studied.