Quality-of-life and olfaction changes observed with short-term medical management of chronic rhinosinusitis

BACKGROUND

Patients with chronic rhinosinusitis (CRS) commonly experience both reduced quality of life (QOL) and olfactory dysfunction (OD). Literature on the impacts of appropriate medical therapy (AMT) for CRS on QOL and OD is limited, and the focused design of these studies may limit their applicability to usual clinical practice.

METHODS

Adults with symptomatic CRS were prospectively enrolled (November 2016 to October 2018) into an observational, multi-institutional study. Individualized AMT was initiated using standard practice according to evidence-based guidelines. Endoscopy examination (Lund-Kennedy), olfactory function (Sniffin' Sticks) testing, and QOL survey responses (22-item Sino-Nasal Outcome Test [SNOT-22], Questionnaire of Olfactory Disorders-Negative Statements [QOD-NS]) were obtained at enrollment and follow-up.

RESULTS

Baseline measures demonstrated heterogeneity of QOL and OD. After an average of 7.8 weeks, within-subject median SNOT-22 total improved by 39.5% (n = 39, p < 0.001) relative to baseline, including 50% (p = 0.014) improvement for item #21, "Sense of smell/taste." QOD-NS improvement was also statistically significant (p = 0.044). Sniffin' Sticks score relative improvement of 10.9% (n = 33, p = 0.109) was not statistically significant and lacked correlation with SNOT-22 total scores (R = -0.247, p = 0.165) or QOD-NS total scores (R = -0.016, p = 0.930), but correlated moderately with endoscopy score (R = -0.436, p = 0.018).

CONCLUSIONS

Participants with varied impacts of CRS, treated with individualized short-term AMT, demonstrated significant improvements in CRS- and olfactory-specific QOL measures, without corresponding improvement in clinically measured olfactory function. Olfactory function changes moderately correlated with endoscopy score changes, but lacked an association with QOL measurements.

Association Between Smell, Taste, and Depression in Nationally Representative Sample of Older Adults in the United States

Objectives

To characterize the association between quantitative olfactory dysfunction (OD) and gustatory dysfunction and depression in older adults.

Methods

The 2013–2014 National Health and Nutrition Examination Survey (NHANES) data were used to investigate the relationship between smell and taste dysfunction and depression. Adults aged 65 years and older were included in the analysis. For smell status, subjects were divided into hyposmia, anosmia, and OD (hyposmia + anosmia) using the Pocket Smell Test. For taste status, subjects were evaluated using quinine, 1M NaCl, and 0.32M NaCl solutions. Indicator variables were made for subjects with both smell and taste dysfunction to determine whether a combination of symptoms could predict depression. Depression status was evaluated by the 9-item Patient Health Questionnaire using accepted cutoff values. Relevant demographic, socioeconomic, and comorbid factors were included in multivariate logistic regression models, which accounted for the complex survey design of NHANES.

Results

A total of 931 subjects aged 65 years or older were included in the weighted analysis. Anosmia significantly predicted depressive symptoms in multivariate analysis (odds ratio [OR] = 2.484, P = .032) but not univariate. In univariate analysis, hyposmia + anosmia (OR = 2.193, P = .006) and hyposmia (OR = 2.512, P < .001) significantly predicted depression. Significance was lost in multivariate analysis.

Conclusions

Smell dysfunction is an independent predictor of depressive symptoms in a representative sample of older adults in the United States after adjusting for relevant demographic factors and comorbidities.

Correlation of mucus inflammatory proteins and olfaction in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is one of the most common causes of olfactory loss, but the pathophysiology underlying olfactory dysfunction in CRS has not been fully elucidated. Previous studies found correlations between olfactory cleft (OC) inflammatory cytokines/chemokines and olfaction in CRS. The purpose of this study was to evaluate the relationship between OC mucus inflammatory proteins and olfaction in a multi-institutional cohort.

METHODS

Adults with CRS were prospectively recruited. Demographics, comorbidities, olfactory assessment (Sniffin' Sticks), computed tomography (CT), and OC mucus for protein analysis were collected. Statistical analysis was performed to determine associations between olfactory function, OC mucus protein concentrations, and CT opacification.

RESULTS

Sixty-two patients were enrolled in the study, with an average age of 48.2 (standard deviation, 16.2) years, and 56.5% were female and 59.7% were classified as CRS with nasal polyps (CRSwNP). Ten of 26 OC mucus proteins were significantly correlated with threshold, discrimination, and identification (TDI) scores and OC opacification. Subgroup analysis by polyp status revealed that, within the CRSwNP group, C-C motif ligand 2 (CCL2), interleukin-5 (IL-5), IL-6, IL-13, IL-10, IL-9, tumor necrosis factor-α (TNF-α), CCL5, and CCL11 were significantly correlated with olfaction. For CRS without nasal polyps (CRSsNP), only C-X-C ligand 5 (CXCL5) showed a correlation. In CRSwNP, IL-6, IL-10, vascular endothelial growth factor-A, and immunoglobulin E (IgE) correlated with OC opacification, whereas, in CRSsNP, only CXCL5 showed a correlation. OC mucus proteins and Lund-Mackay score correlated only in the CRSsNP group (CXCL5, IL-5, IL-13, IgE).

CONCLUSION

Several OC mucus proteins have been found to correlate with olfactory function and OC opacification. The profile of OC mucus proteins differs between CRSsNP and CRSwNP subgroups, suggesting different mechanisms between groups, but further study is required.

Olfactory cleft and sinus opacification differentially impact olfaction in chronic rhinosinusitis

OBJECTIVES

Prior studies have indicated that olfactory cleft (OC) opacification correlates with olfaction in patients with chronic rhinosinusitis (CRS). However, the results have been unclear in patients without polyps. The purpose of this study was to further explore the relationship between OC opacification, sinus opacification, and olfactory function in patients with CRS.

METHODS

One hundred and forty-eight patients with CRS were prospectively enrolled across five institutions. Olfactory function was evaluated using the Sniffin' Sticks tests (Burghardt, Wedel, Germany) and the 17-item Questionnaire of Olfactory Disorders (QOD-NS). Computed tomography (CT) scans for each patient were acquired and Lund-Mackay scores recorded. Opacification of the OC was determined using OsiriX MD (Pixmeo, Bernex, Switzerland) and correlated with olfaction scores.

RESULTS

A total of 148 CRS patients, 73 CRS without nasal polyps (CRSsNP) and 75 CRS with nasal polyps (CRSwNP), as well as 30 control subjects were enrolled. Overall OC opacification averaged 63.7% in CRS patients and 47.1% in control subjects (P < 0.001). In the overall cohort, OC opacification significantly correlated with threshold, discrimination, and identification (TDI) (r = -0.520; P < 0.001) and QOD-NS scores (r = 0.374; P < 0.001). CRSwNP patients demonstrated a significant correlation between OC opacification and TDI scores (r = -0.464; P < 0.001) but not the CRSsNP group (r = -0.143; P = 0.229). Lund-Mackay score correlated with TDI in both the CRSsNP (r = -0.300; P = 0.010) and CRSwNP (r = -0.271; P = 0.019) groups.

CONCLUSION

CT opacification is associated with olfactory dysfunction differentially based on nasal polyp status. Smell loss in CRSwNP correlated with both OC opacification and Lund-Mackay score, whereas CRSsNP correlated only with Lund-Mackay score, indicating different relationships between olfactory function and local inflammatory processes in these disorders.

LEVEL OF EVIDENCE

2 Laryngoscope, 130:2311-2318, 2020.

A brief version of the questionnaire of olfactory disorders in patients with chronic rhinosinusitis

BACKGROUND

The Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS) is a valuable instrument in the measurement of olfactory-specific quality of life (QOL). In the clinical setting, patients can be overwhelmed with the time required to complete questionnaires. Our objective was to develop a brief version of the QOD-NS to streamline clinical care and research.

METHODS

QOD-NS scores from 221 subjects were used to determine which subset of the 17 QOD-NS questions best correlated with total and subdomain QOD-NS scores. An initial pool of 11 questions was made by removing items with ρ < 0.80 to their respective subdomain scores. Next, 500 bootstrapped samples were taken. On each sampe, an all-subsets regression was performed with total QOD-NS scores and QOD-NS subdomain scores as the outcomes. From this, our "top" and "bottom" 10 subsets were identified based on mean r2 value, representation in bootstrap analysis, and number of items.

RESULTS

All of our top subsets had excellent correlation with total and subdomain QOD-NS scores (mean r2 > 0.90). Our top choice has 7 total questions, is representative of all subdomains, has a mean r2 = 0.92, and was represented in 323 of our 500 bootstrapped samples. The worst-performing subset has 5 items, mean r2 = 0.81, and was represented in only 1 bootstrapped sample.

CONCLUSIONS

Using less than half of the questions in the QOD-NS, excellent correlations with both total and domain-specific scores are achieved. A brief version of the QOD-NS may prove useful in future clinical and research settings.

Long-term outcomes of endoscopic sinus surgery in the management of adult chronic rhinosinusitis

BACKGROUND

There is a striking lack of long-term, prospective outcomes data for endoscopic sinus surgery (ESS) in chronic rhinosinusitis (CRS) using validated instruments. Our primary objective in this study was to report long-term outcomes (>10 years) after ESS for CRS obtained by prospective data collection.

METHODS

An observational cohort (n = 59) of adult patients with CRS electing ESS was enrolled between 2004 and 2008. Long-term, disease-specific quality-of-life (QOL) outcomes, health utility values (HUV), revision surgery rate, development of asthma, and patient expectations/satisfaction with outcomes of ESS were examined using descriptive statistics and simple fixed-effects linear modeling.

RESULTS

Fifty-nine adult patients were followed for 10.9 years (±13.8 months), on average. Mean QOL significantly improved between baseline and 6 months and remained durable to 10 years. HUV improved to normal. A 17% revision surgery rate within the 10-year follow-up period was observed with a 25% revision rate in CRS with polyposis. New-onset asthma after ESS occurred at a rate of 0.8%/year. Patient satisfaction with ESS outcomes was generally high.

CONCLUSIONS

Ten-year prospective outcomes of ESS for CRS demonstrate that the initial clinically significant improvements in QOL seen 6 months postoperatively are durable over the long term. Over 75% of patients reported clinically significant long-term QOL and HUV improvement. HUV returned to normal. Revision surgery rate was 17% and worse postoperative endoscopy scores within 18 months of initial ESS were associated with higher likelihood of revision surgery. Most patients would pursue ESS again and recommend the procedure to other patients considering this treatment option.

A Prospective Study of Outcomes of Septoplasty with Turbinate Reductions in Patients with Allergic Rhinitis

OBJECTIVE

Examine outcomes of septoplasty with turbinate reductions in patients with allergic rhinitis as compared to patients without allergic rhinitis using validated outcome and quality-of-life (QOL) instruments.

STUDY DESIGN

Prospective observational cohort study.

SETTING

Single surgeon, university hospital.

SUBJECTS AND METHODS

Consecutive study-eligible patients with a symptomatic nasal septal deviation, with (n = 30) or without (n = 30) documented allergic rhinitis, were enrolled from March 2014 to February 2017. All patients subsequently underwent nasal septoplasty and inferior turbinate reductions. Outcomes were studied using the Nasal Obstruction Symptom Evaluation (NOSE) scale, mini-Rhinoconjunctivitis Quality of Life Questionnaire (mini-RQLQ), and Ease-of-Breathing (EOB) Likert scores completed preoperatively and, together with a patient satisfaction Likert, at 3 and 6 months postoperatively.

RESULTS

NOSE scores, EOB scores, and mini-RQLQ scores improved significantly in both groups at 3 and 6 months postoperatively. Results were sustained from 3 to 6 months. Although mini-RQLQ scores in allergic patients were higher at all intervals, the magnitude of change in scores in both groups was comparable.

CONCLUSION

Although patients with allergic rhinitis report greater allergy-related QOL impairment (mini-RQLQ) on a day-to-day basis than nonallergic patients, this does not appear to attenuate the benefit they might experience from septoplasty and turbinate reductions when indicated for nasal obstruction. Furthermore, the symptomatic relief of their structural nasal obstruction appears to significantly improve their overall allergy-related quality of life. If appropriate expectations are set pre-operatively, allergic rhinitis is neither a contraindication nor a deterrent to septoplasty and turbinate reductions and these patients can reasonably expect a high degree of satisfaction post-operatively.

Symptom importance, patient expectations, and satisfaction in chronic rhinosinusitis

BACKGROUND

Sinonasal symptoms and poor quality of life (QOL) prompt chronic rhinosinusitis (CRS) patients to undergo sinus surgery (ESS). However, little is known regarding the symptoms most important to patients and how these impact expectations and postoperative satisfaction.

METHODS

A prospective, multi-institutional cohort study of 100 CRS patients undergoing ESS completed a novel adaptation of the 22-item Sino-Nasal Outcome Test (SNOT-22) wherein they rated how important it was for specific symptoms to improve after surgery, along with preoperative expectations and postoperative satisfaction. The primary satisfaction measure was whether a patient would choose to undergo endoscopic sinus surgery (ESS) again. A multivariate, logistic regression model was built using demographics, objective measures, and the adapted SNOT-22 data. Spearman correlation analysis was also performed.

RESULTS

Nasal obstruction was rated as "extremely" or "very" important by 93% of patients, followed by smell/taste, thick nasal discharge, need to blow nose, postnasal discharge, and sleep symptoms (range, 61-72%). Symptoms like sadness and embarrassment were not considered important by preoperative patients (≤28%). In multivariate logistic regression, postoperative satisfaction depended on preoperative expectations being met and ESS improving their most important symptoms (odds rato, 19.6-27.5; p < 0.005). Postoperative satisfaction was not correlated with achieving a minimal clinically important difference, but it was correlated with magnitude of change in SNOT-22 (r = 0.35; p < 0.05).

CONCLUSIONS

Nasal, smell, and sleep-related symptoms were consdidered most important by this cohort. Meeting of preoperative expectations, improvement of the most important symptoms, and the magnitude of change in the SNOT-22 may drive postoperative satisfaction.

Association Between Olfactory and Gustatory Dysfunction and Cognition in Older Adults

Background

The association between olfactory dysfunction (OD) and cognitive decline is becoming apparent in the emerging literature. However, the literature demonstrating a similar effect between gustatory dysfunction (GD) and cognition is not well established.

Objective

To determine whether OD and GD are independently associated with cognitive impairment.

Methods

The 2013–2014 National Health and Nutrition Examination Survey was queried for 1376 older adults, corresponding to a weighted population sample of 50 816 529, to assess olfactory and gustatory status and cognition using univariate and multivariate regression analyses. OD and GD were determined using objective measurements with validated protocols. Participants were stratified as normal or abnormal cognition status using accepted cutoff values as indicated for the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) neuropsychological test, Animal Fluency Test (AFT), and Digit Symbol Substitution Test (DSST).

Results

OD was associated with both mild cognitive impairment (odds ratio [OR] 1.809, P = .004) and dementia (OR 3.173, P < .001) with CERAD testing, abnormal AFT (OR 2.424, P < .001), and abnormal DSST (OR 4.028, P < .001). GD based on 1M NaCl whole mouth taste testing was associated with dementia on CERAD testing (OR 2.217, P = .004). When smell and taste parameters were included together in the regression model, both OD and GD remained significant independent predictors of dementia status based on CERAD testing (OR 3.133, P < .001, OR 1.904, P = .015).

Conclusions

OD and severe GD represent independent predictors of cognitive impairment in a nationally representative sample of older adults.

Factor analysis of the questionnaire of olfactory disorders in patients with chronic rhinosinusitis

BACKGROUND

Olfactory-specific quality of life (QOL) can be measured using the Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS), which examines various aspects of olfactory dysfunction. It is unknown if certain factors of the QOD-NS differentially impact QOL.

METHODS

Patients with chronic rhinosinusitis (CRS) completed the QOD-NS, 22-item Sino-Nasal Outcome Test (SNOT-22), Medical Outcomes Study Short Form 6-D (SF-6D) health utility measure, and Patient Health Questionnaire-2 (PHQ-2) depression screen. Exploratory factor analysis of the QOD-NS was performed. Associations between QOD-NS factors and other QOL metrics were analyzed before and after endoscopic sinus surgery (ESS).

RESULTS

Outcomes were examined on 132 patients. The QOD-NS contains 4 distinct factors. There was no difference in associations between the different factors and baseline clinical characteristics. ESS had greatest effect size (d) on factors 2 and 4 (d = 0.29 and 0.27, respectively, p < 0.05). Postsurgical changes in the SF-6D and SNOT-22 had the strongest correlation with factor 2 scores (r = 0.29 and 0.34, respectively, p < 0.05), and changes in the PHQ-2 had the strongest correlation to factor 3 (r = 0.24, p < 0.05). Abnormal QOD-NS scores at baseline were associated with effect size increases of 50% to 100% (p < 0.05).

CONCLUSION

The QOD-NS measures 4 distinct factors. Eating-related questions had the greatest improvement after ESS. Health utility and CRS-specific QOL improvement most strongly associated with factor 2, while PHQ-2 changes are most highly associated with factor 3, suggesting a differential impact of the factors of the QOD-NS on varying aspects of QOL.

Establishing the minimal clinically important difference for the Questionnaire of Olfactory Disorders

BACKGROUND

Olfactory-specific quality of life (QOL) can be measured using the Questionnaire of Olfactory Disorders Negative Statements (QOD-NS). Changes in the QOD-NS after treatment can be difficult to interpret since there is no standardized definition of clinically meaningful improvement.

METHODS

Patients with chronic rhinosinusitis (CRS) completed the QOD-NS. Four distribution-based methods were used to calculate the minimal clinically important difference (MCID): (1) one-half standard deviation (SD); (2) standard error of the mean (SEM); (3) Cohen's effect size (d) of the smallest unit of change; and (4) minimal detectable change (MDC). We also averaged all 4 of the scores together. Finally, the likelihood of achieving a MCID after sinus surgery using these methods, as well as average QOD-NS scores, was stratified by normal vs abnormal baseline QOD-NS scores.

RESULTS

Outcomes were examined on 128 patients. The mean ± SD improvement in QOD-NS score after surgery was 4.3 ± 11.0 for the entire cohort and 9.6 ± 12.9 for those with abnormal baseline scores (p < 0.001). The MCID values using the different techniques were: (1) SD = 6.5; (2) SEM = 3.1; (3) d = 2.6; and (4) MDC = 8.6. The MCID score was 5.2 on average. For the total cohort analysis, the likelihood of reporting a MCID ranged from 26% to 51%, and 49% to 70% for patients reporting preoperative abnormal olfaction.

CONCLUSION

Distribution-based MCID values of the QOD-NS range between 2.6 and 8.6 points, with an average of 5.2. When stratified by preoperative QOD-NS scores the majority of patients reporting abnormal preoperative QOD-NS scores achieved a MCID.

Glucocorticoid receptor isoform expression in peripheral blood mononuclear leukocytes of patients with chronic rhinosinusitis

BACKGROUND

In several inflammatory disorders, altered peripheral blood mononuclear leukocyte (PBML) glucocorticoid (GC) receptor isoform expression has been associated with GC resistance and disease severity. However, it is unclear if PBML GC receptor isoforms are expressed differentially and are associated with worsened disease severity in chronic rhinosinusitis (CRS).

METHODS

PBMLs were isolated from control (n = 8), CRS without nasal polyps (CRSsNP) (n = 8), atopic CRS with nasal polyps (CRSwNP) (n = 8), non-atopic CRSwNP (n = 8), and allergic fungal rhinosinusitis (AFRS) (n = 8) patients. Demographics, atopic status, asthmatic status, 22-item Sino-Nasal Outcome Test (SNOT-22) scores, Lund-Kennedy nasal endoscopy scores, Lund-Mackay sinus computed tomography (CT) scores, Kennedy Osteitis scores, and GC utilization 6 months postoperatively were collected. Intracellular immunostaining was then performed for functional GC receptor α (GCRα) and nonfunctional GC receptor β (GCRβ), followed by flow cytometry analysis of geometric mean fluorescent intensity (MFI) and the percentage of cells expressing each GC receptor isoform.

RESULTS

Compared to controls, each CRS subtype had decreased PBML GCRα and GCRα:GCRβ MFI expression, but no difference in GCRβ expression. Decreasing PBML GCRα in AFRS was associated with increasing Lund-Mackay sinus CT scores (r = -0.880, p =0.004). No significant associations were found between GC receptor isoform expression and other clinical measures.

CONCLUSION

CRS patients have reduced functional PBML GCRα expression and decreased GCRα:GCRβ compared to controls. Reductions in GCRα in AFRS are associated with worsening Lund-Mackay sinus CT scores. The clinical implications of decreased functional GC receptor expression merits further investigation.

Systematic Review and Meta-analysis of SNOT-22 Outcomes after Surgery for Chronic Rhinosinusitis with Nasal Polyposis

Objective Wide variation exists regarding reported outcomes after endoscopic sinus surgery (ESS) for chronic rhinosinusitis with nasal polyps (CRSwNP). This study seeks to combine data across studies to generate a summary measure and explore factors that might lead to variation. Data Sources OVID Medline, Scopus, EbscoHost, Database of Abstracts and Reviews of Effects, Health Technology Assessment, and National Health Service Economic Evaluation Database. Review Methods A search was performed following the PRISMA guidelines. Two independent researchers conducted a search using the mentioned data sources. Studies published before August 29, 2016, that involved ESS to treat CRSwNP were included. Mean changes in Sinonasal Outcome Test-22 (SNOT-22) scores were determined through metaregression of the following independent variables: publication year, sex, age, allergy status, asthma, tobacco use, prior surgery, follow-up length, and preoperative SNOT-22. Results Fifteen articles with 3048 patients treated with ESS met inclusion criteria. Pooled analyses of SNOT-22 scores revealed a mean change of 23.0 points (95% CI, 20.2-25.8; P < .001). A metaregression of patient factor effects on the mean change of SNOT-22 scores demonstrated that age ( r = 0.71, P = .01), asthma ( r = 0.21, P = .01), prior ESS ( r = 0.29, P = .01), and preoperative SNOT-22 score ( r = 0.4, P < .01) correlated with greater improvement in SNOT-22 scores. Tobacco use ( r = -0.91, P = .01) and longer lengths of follow-up ( r = -0.45, P < .01) were associated with less improvement in SNOT-22 scores. Conclusions Quality-of-life outcomes are significantly improved after ESS among patients with CRSwNP. Patient-specific factors may affect the degree of SNOT-22 change after surgery.

Novel Radiographic Assessment of the Cribriform Plate

Background The cribriform plate (CP) is a common site of spontaneous cerebrospinal fluid (SCSF) leaks. Radiographic assessment of the anterior and lateral skull base has shown thinner bone in patients with SCSFs; however, prior assessment of the CP has required postmortem cadaver dissection. Objective To develop novel radiographic techniques to assess the anatomy of the CP. Methods Computed tomography (CT) scans were performed on cadaveric specimens. Bone density and anatomy of a predefined volume of interest of the posterior CP were assessed by two independent reviewers. CT assessment of olfactory foramina was also performed and validated using anatomic dissection of cadaver specimens. Results Interclass correlation coefficients (ICCs) for measuring the same volume of each CP was 0.96, confirming reproducible anatomic localization. Cadaver CPs had a mean Hounsfield units of 263, indicating a mix of bone and soft tissue, and ICC was 0.98, confirming reproducible radiographic measurements. Optimal CT estimates of bone composition of CPs averaged 85% (range 76% to 96%) compared to actual anatomic dissection which averaged 84% bone (range 74% to 91%, r = .690, P = .026). Conclusion Our novel, noninvasive CT method for assessing CP anatomy is reproducible and correlates with anatomic dissection assessing bone composition. The clinical implications of anatomic changes in the CP are an area for further study.

Taste impairment in chronic rhinosinusitis

BACKGROUND

Though many patients with chronic rhinosinusitis (CRS) describe disturbances in smell and taste, there have been no studies specifically assessing taste impairment in CRS. This study sought to objectively assess taste dysfunction in CRS patients and determine whether taste impairment correlates with olfactory dysfunction. Additionally, this investigation sought to determine the impact of taste dysfunction on quality of life (QOL) in CRS and identify the clinical factors that influence taste.

METHODS

Sixty-eight CRS patients were prospectively enrolled and completed several QOL surveys in relation to taste, smell, overall sinus-specific QOL, and depression. Validated taste strips were used to determine gustatory dysfunction pertaining to sweet, sour, salty, and bitter. Olfactory testing was assessed using the Sniffin' Sticks Test while both Lund-Kennedy and Olfactory Cleft Endoscopy Scoring (OCES) systems were used for endoscopic evaluation.

RESULTS

The overall prevalence of dysgeusia was 28%, with scores significantly lower for sour compared to other subgroups. No correlation was observed between taste scores and objective olfactory metrics including olfaction tests and OCES. Taste scores were better in younger patients (r = 0.28, p = 0.02), female patients (p = 0.004), and never smokers compared to former smokers (p = 0.01). Taste scores did not correlate with patient-reported outcome measures or CRS disease severity metrics.

CONCLUSION

Taste dysfunction is a common complaint in CRS. This cohort shows prevalence of gustatory loss to be about 28% using ideal normative values. This dysfunction correlated with male gender, smoking history, and older age. Taste dysfunction did not correlate with measured olfactory outcomes.

Sino-Nasal outcome test-22 outcomes after sinus surgery: A systematic review and meta-analysis

OBJECTIVES/HYPOTHESIS

The goal of the study was to perform a systematic review with meta-analysis to determine the mean change in the 22-item Sino-Nasal Outcome Test (SNOT-22) across patients who have had endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) in the literature.

METHODS

A literature search was performed to identify studies that assessed SNOT-22 scores before and after ESS in adult patients with CRS. A random effects model with inverse variance weighting was used to generate the mean change after surgery, along with the forest plot and 95% confidence interval (CI). The impact of patient-specific factors across studies was assessed using a mixed-effects meta-regression.

RESULTS

The final study list included 40 unique patient cohorts published from 2008 to 2016. All studies showed a statistically significant change in mean SNOT-22 scores between baseline and postoperative time points (P < .001), ranging from 12.7 to 44.8, at an average follow-up of 10.6 months. The summary change in mean SNOT-22 across all studies was 24.4 (95% CI: 22.0-26.8). After forward, step-wise multivariate modeling, studies with higher mean preoperative SNOT-22 score and higher asthma prevalence were associated with greater changes in SNOT-22 score after ESS, whereas studies with longer mean follow-up had smaller changes in SNOT-22 score.

CONCLUSIONS

Studies evaluating quality-of-life outcomes after sinus surgery using the SNOT-22 instrument universally show significant improvement after ESS. Across the published literature, the magnitude of change is quite variable and appears to be influenced by a number of factors including baseline SNOT-22 score, asthma prevalence, and length of follow-up. Laryngoscope, 128:581-592, 2018.

Sinonasal T-cell expression of cytotoxic mediators granzyme B and perforin is reduced in patients with chronic rhinosinusitis

BACKGROUND

CD8+ T cells and natural killer (NK) cells are cytotoxic cells that use granzyme B (GrB) and perforin. Defective cytotoxic function is known to play a role in dysregulated immune response as seen in chronic sinusitis, also referred to as chronic rhinosinusitis (CRS). However, to our knowledge, in the United States, neither GrB or perforin expression has been reported in patients with CRS.

OBJECTIVE

The aim of this study was to investigate sinonasal cytotoxic cells, their mediators, and cell-specific distribution of these mediators in patients with CRS with nasal polyp (CRSwNP) and in patients with CRS without nasal polyp (CRSsNP).

METHODS

Blood and sinus tissue samples were taken from patients with CRSsNP (n = 8) and CRSwNP (n = 8) at the time of surgery. Control subjects (n = 8) underwent surgery for cerebrospinal fluid leak repair or to remove non-hormone-secreting pituitary tumors. The cells were analyzed via flow cytometry by using CD8 expression to identify cytotoxic T cells and CD56 expression to identify NK cells. Intracellular GrB and perforin expression were analyzed with flow cytometry.

RESULTS

We observed no significant differences in plasma or peripheral blood immune cell numbers or specific levels of GrB or perforin among the groups. In the sinonasal mucosa of the patients with CRSsNP and the patients with CRSwNP, there was a significant decrease in GrB and perforin levels (p < 0.05) despite similar or increased numbers of cytotoxic cells when compared with the controls. The overall decrease in GrB and perforin in the sinonasal mucosa of the patients with CRSsNP and the patients with CRSwNP was due to decreased T cell production. There was no difference in total NK cell count or expression of perforin or GrB among all the groups.

CONCLUSION

Total levels of sinonasal GrB and perforin were decreased in the sinonasal mucosa of both the patients with CRSwNP and the patients with CRSsNP compared with the controls, whereas sinonasal CD8+ T cells, (but not NK cells,), intracellular stores of GrB and perforin were reduced in the patients with CRSwNP compared with the controls.

Rhinology-specific priority setting for quality improvement: a modified Delphi study from the Quality Improvement Committee of the American Rhinologic Society

BACKGROUND

Improving the quality of healthcare is a complex and resource intensive process. To optimize the allocation of scarce resources, quality improvement (QI) should focus on high-value diseases that will produce the largest improvement in health system performance. Given the breadth and multidisciplinary nature of sinonasal disease management, the purpose of this study was to transparently develop a prioritized list of sinonasal diseases for QI from the perspective of the specialty of rhinology and the American Rhinologic Society (ARS).

METHODS

The RAND modified Delphi methodology was used to rank the priority of nine sinonasal disease categories from 1 (lowest priority) to 9 (highest priority). Two rounds of ranking along with a teleconference meeting was performed by a panel of 9 experts from the ARS Quality Improvement Committee.

RESULTS

The final QI-prioritized list of sinonasal diseases are as follows: chronic rhinosinusitis (CRS) (mean score = 8.9), recurrent acute rhinosinusitis (RARS) (mean score = 7.9), sinonasal neoplasms (mean score = 7.0), anatomic nasal obstruction (mean score = 5.9), refractory epistaxis (mean score = 5.2), complicated acute rhinosinusitis (mean score = 5.2), chronic nonallergic rhinitis (mean score = 4.4), orbital disease (mean score = 4.3), uncomplicated acute rhinosinusitis (mean score = 4.1), and allergy/allergic rhinitis (mean score = 3.7).

CONCLUSION

The three most important disease categories for QI from the perspective of the specialty of rhinology were CRS, RARS, and sinonasal neoplasms. Future studies need to define and validate quality metrics for each of these important disease categories in order to facilitate appropriate measurement and improvement initiatives.

Understanding the relationship between olfactory-specific quality of life, objective olfactory loss, and patient factors in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) significantly impacts olfaction. However, the relationship between objective olfaction and patient-reported olfactory-specific quality of life (QOL) is not well understood. Furthermore, objective olfactory testing can be time consuming, so we sought to determine if patient-reported olfactory QOL can be used as screening tool for olfactory dysfunction.

METHODS

Olfactory dysfunction was evaluated in 109 patients with CRS using the Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS) and the Sniffin' Sticks Test, assessing for olfactory threshold, discrimination, identification, and overall composite scores (TDI; composite score of threshold, discrimination, and identification). Regression analysis was performed to correlate olfactory metrics and patient and disease-specific factors with QOD-NS scores. Optimal QOD-NS scores to classify patients based upon objective olfactory function were established.

RESULTS

Bivariate and multivariate regression analyses of QOD-NS and CRS-associated comorbidities, objective measures of disease, demographics, and CRS-specific QOL were performed. Non-white race, depression, and worse 22-item Sino-Nasal Outcome Test (SNOT-22) scores correlated with worse QOD-NS scores (p < 0.005). Worse TDI scores correlated with worse QOD-NS scores, and discrimination had the strongest correlation (p < 0.001). Mean ± standard deviation (SD) QOD-NS scores for normosmia, hyposmia, and anosmia were 44 ± 7.2, 35.7 ± 12.8, and 31.6 ± 10.7, respectively. Receiver operating characteristic curve analysis revealed an area under the curve of 0.770 (p < 0.001), and a QOD-NS cutoff of 38.5 to have maximal Youden's index to define normal vs abnormal TDI score.

CONCLUSION

In CRS, QOD-NS correlates with non-white race, depression, SNOT-22, and TDI score, with discrimination having the strongest correlation. The QOD-NS also appears to be a feasible tool for olfaction screening.

Impact of quality improvement measures on the delivery of allergy immunotherapy: a 2-year follow-up

BACKGROUND

Anaphylaxis is the most serious potential complication from allergy treatment with subcutaneous immunotherapy (SCIT). Quality measures were developed with the goal to decrease the incidence of complications resulting from SCIT and improve the safety of care provided.

METHODS

The incidence and characteristics of anaphylaxis episodes resulting from SCIT was measured between 2008 and 2012 prior to implementation of quality measures including vial verification, vial testing, and standardized training across 6 allergy delivery sites. Errors and anaphylaxis rates were then tracked prospectively over a 2-year period after implementation of these process measures.

RESULTS

From 2008 to 2012 there were 9 episodes of anaphylaxis or 0.02% of injections/year. Eight patients had sufficient information from which to derive meaningful data. Patient identification error led to anaphylaxis in 2 patients, dosing error in 2, and compounding error in 1 patient. In 2 patients, anaphylaxis occurred with advancement during pollen season, and in 1 patient no clear reason could be identified although she had asthma as a risk factor. After implementation of quality improvement measures the anaphylaxis rate fell to 0 of 8948 injections for years 2013 and 2014.

CONCLUSION

Errors in the mixing and administration of allergy serum comprised the majority of identifiable factors that led to anaphylaxis. Implementation of quality measures, including vial verification and vial testing, can improve safety and decrease anaphylaxis rates in the delivery of allergy immunotherapy.

Delayed nasoseptal flaps for endoscopic skull base reconstruction: proof of concept and evaluation of outcomes

OBJECTIVES

To assess delayed nasoseptal flaps as a viable reconstructive option for sellar defects, evaluate postoperative vascularity of delayed nasoseptal flaps, and compare cerebrospinal fluid leak and surgery-specific complication rates of primary to delayed nasoseptal flaps.

STUDY DESIGN

Case series with chart review.

SETTING

University of Pittsburgh Medical Center.

SUBJECTS AND METHODS

All patients undergoing transsellar approaches for skull base tumors from 2009 to 2013 were evaluated. In cases where the necessity of a vascularized reconstructive flap was made evident only after tumor resection, the nasoseptal flap was raised after tumor resection and/or cerebrospinal fluid leak development, thus constituting a delayed nasoseptal flap. Outcome measures include postoperative magnetic resonance imaging (MRI) findings, cerebrospinal leak rates, and complication rates.

RESULTS

During this timeframe, 437 patients underwent transsellar approaches. Primary nasoseptal flaps were used to reconstruct 179 patients while 32 patients had delayed flaps. All available postoperative MRI scans of delayed nasoseptal flap patients maintained vascularity on examination of T1 postcontrast images. There was no significant difference in cerebrospinal fluid leak rate between primary (3.4%) and delayed flaps (3.1%) (P = .95). There was no significant difference in surgery-specific complication rates between primary flaps (10.6%) and delayed flaps (3.1%; P = .14). Logistic regression analysis demonstrated no significant effect of flap type, age, or sex on cerebrospinal fluid leak rates.

CONCLUSION

Delayed nasoseptal flaps are a viable reconstructive option for sellar skull base defects. They maintain vascularity as evidenced on postoperative MRI and are comparable to primary nasoseptal flaps with regard to cerebrospinal fluid leak rates and complication rates.

Intratemporal and intracranial complications of acute otitis media in a pediatric population

OBJECTIVE

To review all cases intratemporal and intracranial complications of acute otitis media (AOM) in infants and children from 1998 to 2013.

METHODS

Retrospective chart review of 109 consecutive patients admitted for complications of AOM during a 15-year period at a tertiary-care children's hospital. The main outcomes are: (1) complications of AOM, (2) bacteriology, (3) management strategies.

RESULTS

In our population, complications included mastoiditis (86.1%), subperiosteal abscess (38%), facial nerve palsy (16.7%), sigmoid sinus thrombosis (8.3%) and epidural abscess (7.4%). Other complications included post-auricular cellulitis, otic hydrocephalus and elevated intracranial pressure, internal jugular thrombosis, cranial nerve VI palsy and Gradenigo's syndrome, labyrinthine fistula, sensorineural hearing loss, and cerebellar infarct. Sixty-one patients (56%) received antibiotics prior to presentation. Cultures revealed Streptococcus pneumoniae in 36 patients (33.3%), other bacteria in 30 patients (27.8%), and "no growth" in 33 patients (30.5%). Nine patients (8.3%) did not undergo culture. Of the patients with S. pneumoniae, 20 cultures (55%) were found to be multidrug-resistant. Eleven patients (10.2%) were treated non-surgically, 31 (31%) were treated with myringotomy and intravenous antibiotics. Forty patients (97.5%) presenting with subperiosteal abscess required mastoid surgery. Thirteen of 18 (72.2%) patients with facial paralysis had full recovery. Eight of 10 (80%) patients with epidural abscess empyema required mastoid surgery and incision and drainage of the abscess.

CONCLUSION

Complications of AOM are uncommon, yet continue to have potentially serious consequences. The bacteriology in this population reveals an increasing trend of multi-drug resistant S. pneumoniae as the causative organism.