Total intravenous anesthesia improves intraoperative visualization during surgery for high-grade chronic rhinosinusitis: a double-blind randomized controlled trial

BACKGROUND

Total intravenous anesthesia (TIVA) has been proposed as a method to reduce blood loss during endoscopic sinus surgery (ESS). Impaired sinonasal visualization due to mucosal bleeding may be burdensome in cases of chronic rhinosinusitis (CRS) with high-grade inflammatory disease, suggesting a role for TIVA in that disease subgroup.

METHODS

A double-blind, randomized controlled trial was conducted of adults undergoing ESS at a tertiary medical center. Patients considered for inclusion had high-grade CRS defined as either sinonasal polyposis or a preoperative Lund-Mackay score of ≥12. Subjects were randomized to receive either TIVA or inhaled anesthesia (IA) during ESS. The primary outcome measure was intraoperative visibility as rated by 3 blinded reviewers utilizing the 10-point Wormald Surgical Field Grading Scale. Secondary outcomes included operative blood loss, complications, and change in quality of life evaluated by the 22-item Sino-Nasal Outcome Test (SNOT-22).

RESULTS

A total of 72 patients were randomized into TIVA (n = 37) and IA (n = 35) study arms. Aggregate median (interquartile range) Wormald scores across all reviewers demonstrated a more favorable visual field with TIVA compared to IA (3.5 [2.4-3.9] vs IA 4.1[3.0-5.8], p = 0.0089). There was significantly less blood loss in the TIVA group compared to the IA group (200 mL [100-450] vs 300 mL [200-500], p = 0.046). Baseline patient characteristics were comparable between cohorts with no significant postoperative complications. No significant changes were detected between postoperative SNOT-22 scores at 3 months (p = 0.278) and at 6 months (p = 0.396) following ESS.

CONCLUSION

TIVA contributes to improved intraoperative visualization and decreased blood loss in patients undergoing ESS for high-grade inflammatory sinus disease.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Intranasal tissue necrosis associated with opioid abuse: Case report and systematic review

OBJECTIVE

Opioid abuse is a common disorder affecting over 2 million Americans. Intranasal tissue necrosis is a previously described sequela of nasal opioid inhalation, with a similar presentation to invasive fungal rhinosinusitis (IFRS). The goal of this case report and systematic review is to evaluate the evidence supporting this uncommon disease, with qualitative analysis of the presentation, management and treatment outcomes.

DATA SOURCES

MEDLINE, EMBASE, Google Scholar, Scopus, and Web of Science.

REVIEW METHODS

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were utilized to identify English-language studies reporting intranasal mucosal injury associated with prescription opioid abuse. Primary outcomes included clinical presentation, treatment strategies, and outcomes.

RESULTS

Systematic review identified 61 patients for qualitative analysis. Common clinical features include facial pain without a history of chronic sinusitis or known immunodeficiency. Diagnostic nasal endoscopy revealed superficial debris with underlying tissue necrosis, consistent with a preliminary diagnosis of IFRS. Characteristic pathologic findings include mucosal ulceration with an overlying acellular substrate, often with polarizable material. Fungal colonization is often reported, with several accounts of angiocentric invasion in immunocompetent patients. Complete symptom resolution is expected following surgical debridement with cessation of intranasal opioid inhalation, with 89% of identified patients experiencing a complete resolution of disease.

CONCLUSION

Intranasal opioid abuse is a prevalent condition associated with chronic pain and tissue necrosis that is clinically concerning for invasive fungal disease. Whereas IFRS must be excluded, even in patients without known immunodeficiency, complete resolution of symptoms can be expected following surgical debridement with cessation of opioid abuse. Laryngoscope, 1767-1771, 2018.

Investigating the minimal clinically important difference for SNOT-22 symptom domains in surgically managed chronic rhinosinusitis

BACKGROUND

Prior work has described 5 domains within the 22-item Sino-Nasal Outcomes Test (SNOT-22) that allow for stratification of symptoms into similar clusters and that can be used to direct therapy. Although the outcomes of various interventions on these symptom domains have been reported, minimal clinically important difference (MCID) values have not been investigated, which has limited clinical interpretation of these results.

METHODS

This study was designed as a secondary analysis of a prospective, multi-institutional, observational cohort. A total of 276 patients with medically refractory CRS who underwent surgical management were enrolled. Distribution-based methods (half-standard deviation, standard error of measurement, Cohen's d, and the minimum detectable change) were used to compute MCID values for both SNOT-22 total and domain scores. The Medical Outcomes Study Short Form 6D (SF-6D) health utility score was used to operationalize anchor-based associations using receiver-operating characteristic (ROC) curves.

RESULTS

The mean MCID of several distribution-based methods for total SNOT-22 scores was 9.0, in agreement with previously published metrics. Average MCID values for the rhinologic, extranasal rhinologic, ear/facial, psychological, and sleep domain scores were 3.8, 2.4, 3.2, 3.9, and 2.9, respectively. Anchor-based approaches with the SF-6D did not have strong predictive accuracy across total SNOT-22 scores or domains (ROC areas under-the-curve ≤ 0.71), indicating weak associations between improvement in SNOT-22 scores and health utility as measured by the SF-6D.

CONCLUSION

This estimation of MCID values for the SNOT-22 symptom domains allows for improved clinical interpretation of results from past, present, and future rhinologic outcomes research.

Trends in sinusitis research: a systematic review of extramural funding

BACKGROUND

Innovation represents a core value of the American Rhinologic Society (ARS), with multiple efforts to promote research in the advancement rhinologic care. We therefore sought to identify trends in extramural sinusitis funding and underutilized sources of support to facilitate future efforts.

METHODS

A systematic review of the National Institutes of Health (NIH) Research Portfolio Online Tools (RePORTER) database (fiscal year 1993 to 2017) was completed with the search strategy: ("chronic sinusitis" OR rhinosinusitis). All identified studies were accepted for review, with comparison to ARS membership rolls to identify studies supported by ARS investigators. Foundation awards were surveyed to identify and characterize additional sources of support.

RESULTS

The systematic review identified 958 projects receiving NIH funding, of which 120 remain active. The percentage of sinusitis-related awards and total funding relative to all NIH awards increased over the past 10 years (2006 to 2016) from 0.06% (8 / 9128) and 0.09% ($2,151,152 / $3,358,338,602) to 0.87% (86 / 9540) and 0.90% ($37,201,095 / $4,300,145,614). Among active studies, 9 investigators maintain membership in the ARS and serve as principal investigator or project leader in 12 (10%) studies. ARS investigators received the greatest number of awards from the National Institute on Deafness and Other Communication Disrders (n = 8,66.7%), while only receiving 2.2% of awarded funding from the National Institute of Allergy and Infectious Diseases ($607,500/$26,873,022), the largest source of awards for sinusitis research.

CONCLUSION

Support for sinusitis research is significantly growing, with the largest source of active funding not being fully utilized by members of the ARS. Further efforts to promote funding priorities among extramural sources is necessary to facilitate increased funding for ARS member initiatives.

Defining the minimal clinically important difference for olfactory outcomes in the surgical treatment of chronic rhinosinusitis

BACKGROUND

Olfactory dysfunction is a common and defining symptom of chronic rhinosinusitis (CRS). Many measures of olfactory dysfunction in CRS are limited by scoring criteria defined within general populations with interpretations of statistical significance to infer clinically meaningful improvement. In this investigation we define a minimal clinically important difference (MCID) for the Brief Smell Identification Test (BSIT) in CRS patients electing endoscopic sinus surgery (ESS).

METHODS

A multicenter cohort of 290 adult patients electing ESS for medically recalcitrant CRS were prospectively enrolled between March 2011 and June 2015 and completed BSIT evaluations before and after ESS. Distribution and anchor-based analytic approaches were utilized to define MCID values of the BSIT across patient cofactors.

RESULTS

A total of 92 (∽32%) patients were found to have preoperative olfactory dysfunction (BSIT <9), significantly associated with nasal polyposis (χ² = 35.0; p < 0.001). The effect-size distribution-based approach identified 1.0 as a MCID criterion value between "small" and "medium" effect (range, 0.61-1.52) overall. Significant mean postoperative change (ΔM) was reported for patients with olfactory dysfunction (ΔM = 2.28; p < 0.001), both with (n = 54; ΔM = 2.52; p < 0.001) and without (n = 38; ΔM = 1.95; p < 0.001) nasal polyposis, significantly exceeding the MCID criterion. Anchor-based approaches with regression modeling confirmed associations between MCID values and postoperative changes to olfactory-specific survey responses (p < 0.001).

CONCLUSION

Clinically meaningful change in BSIT scores may be defined as an absolute value difference of at least 1.0 unit for heterogeneous patients electing ESS for CRS. Significantly exceeding this criterion may be restricted to CRS patients with baseline olfactory dysfunction, regardless of nasal polyposis.

Influence of interpersonal traits on patient outcomes in the treatment of chronic rhinosinusitis

BACKGROUND

Patient-reported outcome measures (PROMs) measure health states in chronic rhinosinusitis (CRS) and have become the dominant metrics of treatment outcomes. Interpersonal traits (IPTs) are patient-specific factors that include personality type, perceived social support, and trust in physicians. The association of IPTs on treatment outcomes among patients with CRS has not been described previously, and IPTs may represent major clinical factors influencing treatment outcomes.

METHODS

Adult patients electing medical or surgical treatment for recalcitrant CRS were prospectively enrolled into a multi-institutional, observational outcomes study. Validated measures of IPTs, including the Big Five Inventory-10 Short Version (BFI-10), Multidimensional Scale of Perceived Social Support (MSPSS), and the Trust in Physician Scale (TPS), were completed and compared with PROMs, which included the 22-item SinoNasal Outcome Test (SNOT-22), the Medical Outcomes Study Short Form-6D (SF-6D), and the Patient Health Questionnaire-2 (PHQ-2).

RESULTS

Three hundred fifty-four participants were included and followed for an average (± standard deviation) of 16.3 (±4.8) months. Significant within-subject improvement in mean PROM scores was reported (all p <0.001). No association was detected between PROM score improvement and baseline BFI-10 or MSPSS scores (p > 0.050). Significant, but weak, absolute correlations were reported between baseline TPS scores and improvement in SNOT-22, SF-6D, and PHQ-2 total scores (p < 0.050; r ≤ 0.138).

CONCLUSION

Personality type and perceived social support do not associate with improvement after treatment for CRS. However, increased trust in physicians is weakly associated with greater posttreatment improvement. Further study is needed to examine the relationship between physician trust, patient satisfaction, and treatment outcomes among patients with CRS.

The US Experience with Local Economic Development

In this paper the increasing intensity of intermunicipal and interstate economic competition in the USA is noted. It is argued that the federal structure of the USA, the present political climate, and the mobility of capital combine to produce a situation of positive feedback leading to everincreasing subsidies. The situation constitutes a classic prisoner's dilemma. Decreased competition would be in the interests of all units of government. However, there is no way that a state or local government can opt out of the competition unilaterally and no mechanism by which collective action can be taken to reduce the intensity of competition. Also considered in this paper are the aggregate effects of local economic development programs in terms of taxes and public expenditures, efficiency, and equity, and several less commonly discussed considerations.

Prevalence of polyp recurrence after endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis

OBJECTIVES/HYPOTHESIS

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a disease process that is driven, in part, by intrinsic mucosal inflammation. Surgery plus continued medical therapy is commonly elected by medically recalcitrant, symptomatic patients. The objective was to evaluate the prevalence of nasal polyp recurrence up to 18 months after endoscopic sinus surgery (ESS) with congruent continuing medical management.

STUDY DESIGN

Prospective, multicenter cohort of adult patients undergoing ESS for medically recalcitrant CRSwNP performed between August 2004 and February 2015.

METHODS

All patients received baseline nasal endoscopy quantified using Lund-Kennedy grading. All patients included for final analysis provided at least 6 months of postoperative endoscopy examinations. Multivariate analysis was used to identify risk factors for polyp recurrence.

RESULTS

Three hundred sixty-three CRSwNP patients having undergone ESS involving polypectomy were enrolled. A total of 244 (67%) participants had graded postoperative endoscopies with average of follow-up of 14.3 ± 7.0 months. Surgery plus postoperative medical management significantly improved endoscopy total scores at 6 months (P < .001). The recurrence of nasal polyposis 6 months after ESS was 35% (68/197), compared to 38% (48/125) after 12 months, and 40% (52/129) after 18 months. Multivariate analysis identified both prior ESS (odds ratio [OR]: 2.6, 95% confidence interval [CI]: 1.5-4.6; P = .001) and worse preoperative polyposis severity (OR: 1.4, 95% CI: 1.1-1.8; P = .016) as risk factors for recurrent polyposis.

CONCLUSIONS

Polyp recurrence is common after ESS with control of polyps up to 18 months found in approximately 60% to 70% of patients. Investigation into both surgical and medical management strategies is warranted to improve upon the observed prevalence of recurrence.

LEVEL OF EVIDENCE

2c. Laryngoscope, 127:550-555, 2017.

Contemporary management of chronic rhinosinusitis with nasal polyposis in aspirin-exacerbated respiratory disease: an evidence-based review with recommendations

BACKGROUND

Chronic rhinosinusitis (CRS) in aspirin-exacerbated respiratory disease (AERD) represents a recalcitrant form of sinonasal inflammation for which a multidisciplinary consensus on patient management has not been reached. Several medical interventions have been investigated, but a formal comprehensive evaluation of the evidence has never been performed. The purpose of this article is to provide an evidence-based approach for the multidisciplinary management of CRS in AERD.

METHODS

A systematic review of the literature was performed and the guidelines for development of an evidence-based review with recommendations were followed. Study inclusion criteria included: adult population >18 years old; CRS based on published diagnostic criteria, and a presumptive diagnosis of AERD. We focused on reporting higher-quality studies (level 2 or higher) when available, but reported lower-quality studies if the topic contained insufficient evidence. Treatment recommendations were based on American Academy of Otolaryngology (AAO) guidelines, with defined grades of evidence and evaluation of research quality and risk/benefits associated with each treatment.

RESULTS

This review identified and evaluated the literature on 3 treatment strategies for CRS in AERD: dietary salicylate avoidance, leukotriene modification, and desensitization with daily aspirin therapy.

CONCLUSION

Based on the available evidence, dietary salicylate avoidance and leukotriene-modifying drugs are options following appropriate treatment with nasal corticosteroids and saline irrigation. Desensitization with daily aspirin therapy is recommended following revision endoscopic sinus surgery (ESS).

Low 22-item sinonasal outcome test scores in chronic rhinosinusitis: Why do patients seek treatment?

OBJECTIVES/HYPOTHESIS

Patients with chronic rhinosinusitis (CRS) who experience minimal reductions in quality of life (QoL) may present for treatment despite QoL scores comparable to controls without CRS. This study seeks to identify cofactors influencing patients with CRS and low 22-item Sinonasal Outcome Test (SNOT-22) scores to seek care.

STUDY DESIGN

Prospective, multicenter, observational cohort.

METHODS

Patients with CRS were enrolled between April 2011 and September 2015. Patients with sinonasal mucocele or unilateral sinus opacification were excluded. Control subjects without CRS were enrolled for comparison. Low-SNOT CRS was defined as a SNOT-22 score < 20.

RESULTS

A total of 774 subjects (low-SNOT CRS, n = 38; high-SNOT CRS, SNOT-22 ≥ 20, n = 641; controls without CRS, n = 95) were enrolled. Low SNOT scores were identified in 6% of subjects with CRS. After adjustment, low-SNOT CRS and control groups without CRS reported similar baseline average SNOT-22 total scores (P = .879). Unexpectedly, compared to controls, low-SNOT CRS patients had significantly better average psychological (2.1 ± 2.3 vs. 5.8 ± 6.0; P = .030) and sleep dysfunction (2.7 ± 3.4 vs. 6.0 ± 5.2; P = .016) scores. Fourteen of 38 (37%) low-SNOT patients elected to undergo endoscopic sinus surgery (ESS), with a significantly lower likelihood of reporting a minimal clinically important difference (MCID) when compared to high-SNOT patients (43% vs. 82%; P < .001) after a mean follow-up of ∼15 months.

CONCLUSIONS

Low-SNOT CRS patients represent an outlier population for which measures of QoL fail to identify factors influencing the decision to seek treatment. Low-SNOT CRS patients electing ESS have a decreased likelihood of reporting MCIDs following ESS. Further study is required to identify novel factors associated with treatment-seeking behavior in this population.

LEVEL OF EVIDENCE

3B Laryngoscope, 127:22-28, 2017.

Longitudinal improvement and stability of olfactory function in the evaluation of surgical management for chronic rhinosinusitis

BACKGROUND

Abnormal olfaction is common with chronic rhinosinusitis (CRS) and associates with various measures of sinonasal inflammation. The Brief Smell Identification Test (BSIT) has demonstrated improvements in abnormal olfactory detection following endoscopic sinus surgery (ESS), but olfaction remains understudied using this instrument. Discerning longitudinal, postoperative durability in olfaction is critical for patient counseling.

METHODS

Adult participants with medically recalcitrant CRS were prospectively enrolled into a multi-institutional cohort study and observed for 18 months after ESS. Olfaction was operationalized using BSIT scores collected at baseline, 6 months, 12 months, and 18 months postoperatively and compared using repeated measures analysis of variance (ANOVA).

RESULTS

A total of 122 participants met inclusion criteria and were recruited between March 2011 and February 2014. Improvement in mean BSIT scores at 6-month follow-up were reported for all participants (p = 0.014) with greatest improvement in subjects with nasal polyposis (p = 0.001). No differences in mean BSIT scores were found between 6 months and 18 months overall; however, subjects with comorbid asthma (F₍₂₎ = 5.29; p = 0.010) and nasal polyposis (F₍₂₎ = 3.99; p = 0.033) reported significant mean worsening. Prevalence of abnormal olfaction decreased from 28% preoperatively to 17% at 6 months (p = 0.015), for all subjects, without significant change at 12 months (19%; p = 0.791) or at 18 months (21%; p = 0.581) postoperatively.

CONCLUSION

Postoperative improvement in olfaction was reported 6 months after ESS using BSIT scores, with greatest improvements in patients undergoing polypectomy. Overall improvement persisted between 6 months and 18 months after ESS for most patient subgroups; however, dysosmia worsened after initial improvement in patients with asthma and nasal polyps, highlighting the need for further identification of prognostic factors associated with abnormal olfaction in CRS.

Improvements in psychological dysfunction after endoscopic sinus surgery for patients with chronic rhinosinusitis

BACKGROUND

Psychological dysfunction is highly prevalent among patients with chronic rhinosinusitis (CRS). Previous study has identified various measures of anxiety and depression as predictors of quality-of-life outcomes following endoscopic sinus surgery (ESS). Psychological dysfunction scores, as measured by the 22-item Sino-Nasal Outcome Test (SNOT-22), have been found to influence treatment decision making in CRS. This study aims to further elucidate improvement in discrete psychological symptoms following ESS for CRS.

METHODS

Adult patients with medically recalcitrant CRS electing to undergo ESS were prospectively enrolled into a multi-institutional, observational cohort. Psychological-related symptom severity and postoperative outcomes were assessed using psychological domain items of the SNOT-22, including subgroup analysis of patients with and without comorbid depression.

RESULTS

A total of 374 participants met inclusion criteria and were followed postoperatively for a mean ± standard deviation (SD) of 14.6 ± 5.0 months. Total mean psychological domain scores improved from 15.9 ± 8.2 to 8.5 ± 8.4 (p < 0.001). Significant relative mean improvements were reported in "waking up tired" (23%; p < 0.001), "fatigue" (25%; p < 0.001), "reduced productivity" (28%; p < 0.001), "reduced concentration" (27%; p < 0.001), " frustrated/restless/irritable" (27%; p < 0.001), "sad" (15%; p < 0.001), and "embarrassed" (8%; p < 0.001) scores. A total of 64% to 66% of participants reported improvement in "reduced productivity," "waking up tired," "fatigue," and "frustrated/restless/irritable," compared to 46% and 38% reporting improvement in "sad" and "embarrassed," respectively.

CONCLUSION

Patients with CRS report significant improvement in common mental health-related symptoms following ESS. Despite these improvements, some degree of persistent postoperative psychological dysfunction was reported. Further study is necessary to determine which factors are associated with persistent psychological dysfunction after ESS in order to optimize treatment outcomes.

Medications to Assist in Tobacco Cessation for Dental Patients

Smoking is the leading cause of preventable illness in the United States. Without assistance, only 3% to 6% of smokers successfully quit after 1 year. Nicotine replacement therapy (NRT), buproprion, and varenicline are first-line pharmacologic therapies. These medications function by reducing nicotine withdrawal symptoms and the desire to smoke. When first-line therapy does not lead to successful smoking cessation, combinations of varenicline with NRT, buproprion with NRT, and varenicline with buproprion may be efficacious. Behavioral therapy also plays a role in smoking cessation and the combination of pharmacologic therapy with behavioral therapy is more effective than either therapy alone.

Initial Experience of a Patient Navigation Model for Head and Neck Cancer

IMPORTANCE

Specific temporal goals for treatment of head and neck cancer (HNC) are common in Europe but not in the United States. We implemented a patient-centric navigation model with an aspirational goal that all patients will receive treatment recommendations within 2 weeks of presentation as a means to improve outcomes in our patients with HNC.

OBJECTIVE

To assess the temporal impact of using an aspirational goal in a patient-centric navigation system on the time from presentation to formulation of treatment planning for patients with HNC.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective review of 100 consecutive patients treated for squamous cell carcinoma of the head and neck at a tertiary referral center between 2011 and 2014. Patients were assessed to determine the efficiency of a patient-centric navigational model in delivering cancer treatment recommendations. This model was designed with an aspirational goal of providing treatment recommendations within a 2-week period.

EXPOSURE

Starting in 2011, patient-centric navigation model including the assignment of a nurse who acts as a patient navigator.

MAIN OUTCOMES AND MEASURES

The time interval between presentation to clinic and definitive treatment recommendations, as well as factors associated with delay.

RESULTS

Of the 93 patients who met inclusion requirements, most were white (81 [87%]) males (74 [80%]) with a mean (SD) age of 63.4 (10.8) years insured by Medicare or Medicaid (64 [69%]). Forty-seven (51%) received treatment recommendations within the 2-week period, with median and mode values of 15 and 14 days, respectively. The mean (SD) interval was 18.8 (18.6) days. Outliers included 2 patients with synchronous lung nodules (72 and 85 days) and 2 patients with psychosocial barriers (107 and 86 days). There were no significant differences seen for the mean (SD) time interval with respect to patient race (blacks, 17.6 [15.7] vs whites, 22.5 [30.0]; P = .20), sex (males, 18.3 [18.1] vs females, 20.4 [19.7]; P = .13), insurance status (insured, 16.3 [10.2] vs uninsured, 19.8 [21.0]; P = .24), and stage at presentation (stage I, 14.4 [17.0] vs stage II, 11.0 [5.3] vs stage III, 14.7 [8.6] vs stage IV, 21.2 [20.2]; P = .40).

CONCLUSIONS AND RELEVANCE

The goal of treatment recommendations for HNC within 2 weeks was shown to be reasonable and attainable. Further research should address the delays encountered by patients with psychosocial barriers and those with synchronous lung nodules.

Paranasal Sinus Balloon Catheter Dilation for Treatment of Chronic Rhinosinusitis: A Systematic Review and Meta-analysis

OBJECTIVE

Paranasal sinus balloon catheter dilation (BCD) represents a commonly used tool in the management of chronic rhinosinusitis (CRS) for which the indications, utilization, and outcomes have not been well established. A systematic review and meta-analysis were undertaken to evaluate change in quality of life and sinus opacification following paranasal sinus BCD in the treatment of CRS.

DATA SOURCES

MEDLINE and EMBASE databases.

REVIEW METHODS

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were utilized to identify English-language studies reporting patient outcomes following BCD for CRS. Primary outcomes included the impact of BCD on validated measures of quality of life and sinonasal opacification.

RESULTS

Systematic review identified 17 studies for qualitative analysis. Studies generally included cases with limited disease based on radiographic opacification. Five studies contained extractable data for change in 20-Item Sinonasal Outcome Test (SNOT-20) 1 year following BCD, with significant improvement in self-reported quality of life (P = .04). Five studies reported a significant change in paranasal sinus opacification following BCD (P < .001). Two studies directly compared change in SNOT-20 between BCD and endoscopic sinus surgery, without demonstration of significant difference in outcome (P = .07). Subgroup analysis found that change in SNOT-20 score was greater after BCD in the operating room than in the office (P = .004).

CONCLUSION

Current evidence supporting the role of BCD in CRS remains incomplete. Long-term within-group improvements in quality-of-life and sinus opacification scores are demonstrated among a restricted adult population with CRS. Additional study is needed to further evaluate the role for BCD in specific settings and patient subgroups.

Memory bias in the temporal bisection point

The ability to time intervals confers organisms, including humans, with many remarkable capabilities. A common method for studying interval timing is classification, in which a subject must indicate whether a given probe duration is nearer a previously learned short or long reference interval. This task is designed to reveal the probe duration that is equally likely to be labeled as short or long, known as the temporal bisection point. Studies have found that this bisection point is influenced by a variety of factors including the ratio of the target intervals, the spacing of the probe durations, the modalities of the stimuli, the attentional load, and the inter-trial duration. While several of these factors are thought to be mediated by memory effects, the prototypical classification task affords no opportunity to measure these memory effects directly. Here, we present a novel bisection task, termed the “Bisection by Classification and Production” (BiCaP) task, in which classification trials are interleaved with trials in which subjects must produce either the short or long referents or their midpoint. Using this method, we found a significant correlation between the means of the remembered referents and the bisection points for both classification and production trials. We then cross-validated the bisection points for production and classification trials by showing that they were not statistically differentiable. In addition to these population-level effects, we found within-subject evidence for co-variation across a session between the production bisection points and the means of the remembered referents. Finally, by using two sets of referent durations, we showed that only memory bias-corrected measures were consistent with a previously reported effect in which the ratio of the referents affects the location of the bisection point. These results suggest that memory effects should be considered in temporal tasks.

An unusual presentation of Gaucher disease in an infant with progressive dyspnea

BACKGROUND

The most common lysosomal storage disorder, Gaucher disease, represents a collection of 3 clinical syndromes associated with disrupted glucocerebroside catabolism. Despite the common occurrence of dyspnea in advanced Gaucher, dyspnea is rarely reported as a presenting symptom of the disease.

CASE REPORT

A 10-month-old male was referred to the Otolaryngology Clinic for evaluation of progressive dyspnea. Physical examination was significant for cervical adenopathy, inspiratory stridor, and developmental delay. A complete evaluation for failure to thrive and lymphadenopathy was performed, with subsequent lymph node biopsy and enzyme assay confirming the presence of Gaucher disease.

CONCLUSION

A high level of suspicion is required to make an early diagnosis of Gaucher disease, but it should be considered in patients presenting with failure to thrive, generalized lymphadenopathy, and respiratory or neurologic findings. Initiation of early treatment is paramount for the prevention of irreversible disease.

Indication of electron neutrino appearance from an accelerator-produced off-axis muon neutrino beam

The T2K experiment observes indications of ν(μ) → ν(e) appearance in data accumulated with 1.43×10(20) protons on target. Six events pass all selection criteria at the far detector. In a three-flavor neutrino oscillation scenario with |Δm(23)(2)| = 2.4×10(-3)  eV(2), sin(2)2θ(23) = 1 and sin(2)2θ(13) = 0, the expected number of such events is 1.5±0.3(syst). Under this hypothesis, the probability to observe six or more candidate events is 7×10(-3), equivalent to 2.5σ significance. At 90% C.L., the data are consistent with 0.03(0.04) < sin(2)2θ(13) < 0.28(0.34) for δ(CP) = 0 and a normal (inverted) hierarchy.