Rhinology Future Debates, an EUFOREA Report

The first Rhinology Future Debates was held in Brussels in December 2016, organized by EUFOREA (European Forum for Research and Education in Allergy and Airways diseases). The purpose of these debates is to bring novel developments in the field of Rhinology to the attention of the medical, paramedical and patient community, in a highly credible and balanced context. For the first time in Rhinology, a peer to peer scientific exchange with key experts in the field of rhinology and key medical colleagues from leading industries let to a brainstorming and discussion event on a number of hot issues in Rhinology. Novel developments are presented by key experts from industry and/or key thought leaders in Rhinology, and then followed by a lively debate on the potential positioning of new developments in care pathways, the strengths and weaknesses of the novel development(s), and comparisons with existing and/or competing products, devices, and/or molecules. As all debates are recorded and distributed on-line with limited editing (www.rhinology-future.com), EUFOREA aims at maximizing the education of the target groups on novel developments, allowing a critical appraisal of the future and a more rapid implementation of promising novel tools, techniques and/or molecules in clinical practise in Europe. The next Rhinology Future debate will be held in Brussels in December 2017.

International survey and consensus (ICON) on ambulatory surgery in rhinology

OBJECTIVES

Day-case surgery is the gold standard to several surgical procedures in Rhinology. However, few data and guidelines have been published except in the Anglo-Saxon countries and France. The aim of this survey was to propose a list of issues arising during day-case surgery in order to analyze the different constraints encountered around the world.

MATERIAL AND METHOD

It was a prospective multicenter international email survey. The method was based on the formalized expert consensus methodology. A list of 11 issues was based on literature data and was sent by e-mail to 265 key opinion leaders (KOL) who attended the IFOS congress.

RESULTS

The response rate was 20% from 27 countries without statistical difference between continents concerning the score on each item. The mean age of KOL was 50±10 years. Their mean length of experience was 21±10 years. Issues in relation with technical resources and experience showed that the last time at which ambulatory surgery in the day is possible was 4:00 PM but responses varied depending the availability of technical resources. Bleeding or hematoma occurred most frequently between the third and fourth postoperative day whatever the surgical procedure. A strong agreement and consensus was obtained concerning the nasal packing, septal contention and their schedule of removal which were not a contraindication of day-case. Also 75% of participants were agreeing with a therapeutic education program to improve the performance of postoperative care and decrease readmission rates. A relative agreement without consensus were obtained for the distance between the day-case unit and home, the role of surgery duration and the impact of anticoagulant and/or antiplatelet drugs in overnight admission and readmission rates.

CONCLUSION

Practice varies widely owing to local organization constraints and the availability of a dedicated day-case unit seems to be the main limiting factor.

Finite difference time domain modelling of a point-excited elastic plate radiating into an acoustic cavity

Finite difference time domain (FDTD) models are developed to solve the vibroacoustic problem of a thin elastic plate undergoing point force excitation and radiating into an acoustic cavity. Vibroacoustic modelling using FDTD can be computationally expensive because structure-borne sound wavespeeds are relatively high and a fine spatial resolution is often required. In this paper a scaling approach is proposed and validated to overcome this problem through modifications to the geometry and physical properties. This allows much larger time steps to be used in the model which significantly reduces the computation time. Additional reductions in computation time are achieved by introducing an alternative approach to model the boundaries between the air and the solid media. Experimental validation is carried out using a thin metal plate inside a small reverberant room. The agreement between FDTD and measurements confirms the validity of both approaches as well as the FDTD implementation of a thin plate as a three-dimensional solid that can support multiple wave types. Below the lowest room mode, there are large spatial variations in the sound field within the cavity due to the radiating plate; this indicates the importance of having a validated FDTD model for low-frequency vibroacoustic problems.

EUFOREA Rhinology Research Forum 2016: report of the brainstorming sessions on needs and priorities in rhinitis and rhinosinusitis

The first European Rhinology Research Forum organized by the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) was held in the Royal Academy of Medicine in Brussels on 17th and 18th November 2016, in collaboration with the European Rhinologic Society (ERS) and the Global Allergy and Asthma European Network (GA2LEN). One hundred and thirty participants (medical doctors from different specialties, researchers, as well as patients and industry representatives) from 27 countries took part in the multiple perspective discussions including brainstorming sessions on care pathways and research needs in rhinitis and rhinosinusitis. The debates started with an overview of the current state of the art, including weaknesses and strengths of the current practices, followed by the identification of essential research needs, thoroughly integrated in the context of Precision Medicine (PM), with personalized care, prediction of success of treatment, participation of the patient and prevention of disease as key principles for improving current clinical practices. This report provides a concise summary of the outcomes of the brainstorming sessions of the European Rhinology Research Forum 2016.

The effect of endoscopic sinus surgery on quality of life and absenteeism in patients with chronic rhinosinuitis - a multi-centre study

BACKGROUND

Chronic rhinosinusitis with and without nasal polyps (CRSw/sNP) are common conditions decreasing health-related quality of life (HRQOL). Individual symptoms capable of predicting outcome after endoscopic sinus surgery (ESS) are poorly defined, and the indirect costs of CRS is rarely reported in Europe.

METHODOLOGY

Patients with CRSw/sNP admitted for ESS were prospectively enrolled. Patients completed the 22 Sinonasal Outcome Test (SNOT-22), the short-form 36-item questionnaire (SF-36), a Visual Analogue Scale (VAS) and reported CRS-related absenteeism pre- and post-operatively.

RESULTS

181 patients were included. The SNOT-22 score diminished from 51.8 (48.7-55.0) pre-operatively to 33.0 (29.2-36.8) at 6 months. 64% achieved a clinically important improvement in the SNOT-22. SF-36 scores improved statistically significantly in all domains except Role Emotional. The VAS score halved from 68 (65-71) to 34 (29-39) at 6 months post-operatively. A pre-operative SNOT-22 score over 20 implied a greater chance of score improvement after 6 months. A multivariate model identified individual items associated with SNOT-22. Further, patients that had lees than 12 months of sinus disease derived greatest benefit. CRS-related absenteeism dropped from 8-14 days to 1-7 days 12 months after ESS.

CONCLUSIONS

This prospective study showed that ESS significantly improved the HRQOL and decreased absenteeism of patients with CRSw/sNP. Shorter duration of disease and Need to blow nose and Blockage/congestion of nose of SNOT-22 were identified as predictive factors for good surgical outcome.

Chronic rhinosinusitis and mood disturbance

BACKGROUND

This study is part of the Chronic Rhinosinusitis Epidemiology Study (CRES). The overarching aim is to determine factors that influence the onset and severity of chronic rhinosinusitis (CRS). The aim of this analysis is to determine whether those with CRS are more likely to report psychiatric morbidity and in particular mood disturbance compared with healthy controls.

METHODS

CRES consists of a study-specific questionnaire regarding demographic and socioeconomic factors and past medical history as well as a nasal symptom score (SNOT-22) and SF-36 (QoL - quality of life tool). Both of these tools contain mental health or emotional well-being domains. Participants were specifically asked whether they had ever consulted with their General Practitioner for anxiety or depression. Questionnaires were distributed to patients with CRS attending ENT outpatient clinics at 30 centres across the United Kingdom from 2007-2013. Controls were also recruited at these sites. Patients were divided into subgroups of CRS according to the absence/presence of polyps (CRSsNPs/CRSwNPs) or allergic fungal rhinosinusitis (AFRS).

RESULTS

Consultations with a family physician for depression or anxiety were higher amongst those with CRS than controls, but this was only significant for those with CRSsNPs. Odds ratio (OR) for CRSsNPs vs controls: 1.89; OR for CRSwNPs: 1.40. Patients with CRS showed significantly higher mental health morbidity than controls across the mental health and emotional wellbeing domains of the SF-36 and SNOT-22. Mean difference in the mental health domain of SF-36 was 8.3 for CRSsNPs and 5.3 for CRSwNPs. For the emotional domain of SNOT-22, differences were 7.7 and 6.3 respectively.

CONCLUSIONS

Depression and anxiety are significantly more common in patients with CRS compared to healthy controls, especially in those with CRSsNPs. This added mental health morbidity needs consideration when managing these patients in primary and secondary care settings.

Health utility reporting in chronic rhinosinusitis patients

OBJECTIVES

Direct comparison of different diseases allows clinicians and researchers to place the burden of symptoms and impact on quality of life of each condition in context. Generic health-related quality-of-life assessment tools allow such analysis, and limited data are available for British patients with chronic rhinosinusitis.

DESIGN

As part of a larger feasibility study, patients underwent baseline assessment using the SNOT-22, SF-12 and EQ-5D-5L tools. Data were analysed using Microsoft Excel and algorithms available for the analysis of the later two tools. We plotted EQ-5D-5L VAS and utility scores and SF-12 MCS and PCS scores separately against SNOT-22 scores and quantified associations using bivariate ordinary least squares regression analysis.

SETTING

Patients were prospectively recruited from six UK outpatient clinics.

PARTICIPANTS

Adult patients with chronic rhinosinusitis without nasal polyps (CRSsNPs).

MAIN OUTCOME MEASURES

Baseline SNOT-22, SF-12 and EQ-5D-5L scores.

RESULTS

Fifty-two adults were recruited with a mean age of 55 years, 51% were male. The mean SNOT-22 score was 43.82. Mental and physical component scores of the SF-12 were 46.53 and 46, respectively. Mean index score computed form the EQ-5D-5L was 0.75. Worse (higher) SNOT-22 scores were associated with lower EQ-5D-5L VAS and utility scores and SF-12 MCS and PCS scores.

CONCLUSION

The EQ-5D-5L suggests that British CRSsNPs patients are negatively impacted with regards to quality of life. We found the SF-12 to be less sensitive and conclude that the EQ-5D-5L tool is a quick and accessible method for assessing QOL in order it can be compared with other disease states.

A cross sectional analysis of a case-control study about quality of life in CRS in the UK; a comparison between CRS subtypes

BACKGROUND

The Sinonasal Outcome Test (SNOT-22) has been used as a patient reported outcome measure to grade symptom severity before and after treatment for chronic rhinosinusitis (CRS).

METHODOLOGY

This analysis uses data from the CRS Epidemiology Study (CRES). The overarching aim of CRES was to determine factors that influence the onset and severity of CRS. A study-specific questionnaire including SNOT-22 was distributed to patients with CRS attending ENT clinics across 30 centres in the United Kingdom. The aim of this analysis was to compare SNOT-22 scores between those with different types of CRS to determine any differences present in the total score or the subdomains and to assess whether any differences varied according to gender.

RESULTS

There were a total of 1249 CRS participants in the following subgroups: CRS without nasal polyps (CRSsNPs) (n=553), CRS with nasal polyps (CRSwNPs) (n=651), allergic fungal rhinosinusitis (AFRS) (n=45). Since there were differing gender ratios in each subgroup, males and females were analysed separately. The mean and standard deviation for SNOT-22 was: males CRSsNP 41.1 (21.0), CRSwNP 41.7 (20.5); females CRSsNP 49.6 (19.7), CRSwNP 49.5 (22.9). In the nasal domain, those with CRSwNP scored more highly than those with CRSsNP; for males 18.1 (8.1) vs. 15.9 (7.9); for females 19.6 (8.0) vs 16.7 (7.5).

CONCLUSIONS

Patients with CRSwNPs report higher symptom scores in the nasal domain of SNOT-22 than those with CRSsNPs with women in both subgroups reporting higher total scores than men.

The impact of commissioning for rhinosinusitis in England

OBJECTIVES

To assess the compliance of clinical commissioning groups (CCGs) in England with the ENT-UK rhinosinusitis commissioning guide produced in collaboration with the Royal College of Surgeons England and the National Institute of Clinical Excellence. We also aimed to assess the ease of accessibility of data from CCGs.

DESIGN

Audit of compliance of English CCGs with the ENT-UK rhinosinusitis commissioning guide.

SETTING

CCGs in England

PARTICIPANTS

A total of 58 of the 221 CCGs in England were included and chosen because they were the first CCGs authorised by NHS England, or alternately, the CCGs forecasted to have a deficit in their first year of operation. Their websites were reviewed; when information was not easily accessible, a freedom of information request was submitted to the relevant CCG.

MAIN OUTCOME MEASURES

Compliance with commissioning guidelines for rhinosinusitis.

RESULTS

Thirteen percent of CCGs had restrictive referral criteria in place, largely unrelated to published evidence-based guidance. The routine use of multiple courses of oral steroids, prescription of antibiotics, CT scanning within primary care, and delaying referral for a year, prior to referral to a specialist were recommended against published advice.

CONCLUSIONS

Restricting access to surgery may contribute to poorer outcomes and a decrease in the patient's quality of life. This is against the NHS constitution and is open to legal challenge. We encourage all ENT surgeons to review policies of their local CCG and engage with commissioners to ensure that their patients have evidence-based care.

Bending, longitudinal and torsional wave transmission on Euler-Bernoulli and Timoshenko beams with high propagation losses

Advanced Statistical Energy Analysis (ASEA) is used to predict vibration transmission across coupled beams which support multiple wave types up to high frequencies where Timoshenko theory is valid. Bending-longitudinal and bending-torsional models are considered for an L-junction and rectangular beam frame. Comparisons are made with measurements, Finite Element Methods (FEM) and Statistical Energy Analysis (SEA). When beams support at least two local modes for each wave type in a frequency band and the modal overlap factor is at least 0.1, measurements and FEM have relatively smooth curves. Agreement between measurements, FEM, and ASEA demonstrates that ASEA is able to predict high propagation losses which are not accounted for with SEA. These propagation losses tend to become more important at high frequencies with relatively high internal loss factors and can occur when there is more than one wave type. At such high frequencies, Timoshenko theory, rather than Euler-Bernoulli theory, is often required. Timoshenko theory is incorporated in ASEA and SEA using wave theory transmission coefficients derived assuming Euler-Bernoulli theory, but using Timoshenko group velocity when calculating coupling loss factors. The changeover between theories is appropriate above the frequency where there is a 26% difference between Euler-Bernoulli and Timoshenko group velocities.

The value of a feasibility study into long-term macrolide therapy in chronic rhinosinusitis

OBJECTIVES

There is currently conflicting level 1 evidence in the use of long-term antibiotics for chronic rhinosinusitis without nasal polyps. The primary aim of this feasibility study was to optimise future randomised trial design by assessing recruitment and retention of patients alongside providing preliminary data on symptomatic control.

DESIGN

Prospective, multicentre feasibility (cohort) study with all patients receiving macrolide therapy for 12 weeks and a further subsequent 12-week follow-up. Participants received a 12-week course of clarithromycin 250 mg alongside twice daily topical mometasone and nasal douching. Primary outcomes focused on recruitment, retention and compliance. Clinical and quality-of-life outcomes measures were also recorded.

SETTING

Patients were prospectively recruited from six UK outpatient clinics.

PARTICIPANTS

Adult patients with chronic rhinosinusitis without nasal polyps and no prior endoscopic sinus surgery underwent baseline assessment and then follow-up at 3 and 6 months.

MAIN OUTCOME MEASURES

Six-month recruitment and retention data.

RESULTS

Over 13 months, 55 adults were recruited from five centres. Four patients declined participation. 75% of patients were retained within the study. Dropouts included one medication contraindication, three unable to tolerate medication and 10 not attending full follow-up. Sino Nasal Outcome Test-22 and endoscopic scores showed statistically significant improvement. No other clinical or quality-of-life assessment improvements were seen.

CONCLUSION

Retention and recruitment to a trial using long-term clarithromycin to treat chronic rhinosinusitis without nasal polyps is achievable and this data will support a future randomised controlled trial. The study provides vital insight into trial design, thus informing UK research networks and rhinology researchers internationally.