Clinical practice guideline (update): adult sinusitis

Synthesis, characterization and evaluation of hyaluronic acid-based polymers for nasal delivery

Epidemiological research has found that between 5 and 12 percent of the population suffers from chronic rhinosinusitis. Patients are dealing with local side effects such as nasal dryness, sporadic sneezing, and nasal pain in addition to the inflammation. The aim of this study was to synthesize a polymer based on hyaluronic acid in order to provide lubrication combined with a ligand leading to a covalent binding on the nasal mucosa. Hyaluronic acid (HA) was modified with L-cysteine ethyl ester hydrochloride (CYS) via amid bond formation. Ellman's assay, together with spectroscopic techniques like IR and ¹H NMR, confirmed that HACys had been successfully synthesized. It was demonstrated that HACys is safe for administration on the nasal mucosa. The mucoadhesive potential was determined by 3.26-fold with the rotating cylinder assay and 1.4-fold in terms of bioadhesive examination, respectively. Further, the stability of the modified polymer was improved by 7.6-fold compared to the unmodified polymer. Spraying the formulation on the nasal mucosa, the residence time of a model drug was 1.74-fold prolonged at the site of action compared to unmodified polymer. In light of these findings, modified hyaluronic acid (HACys) displayed compelling properties such as lubricity, targeted application, long-lasting effect, and safety and therefore could be an excellent candidate for nasal application.

[Possibilities of usage of modern herbal medicinal product in the treatment of patients with acute viral rhinosinusitis]

INTRODUCTION

The issues of epidemiology, etiopathogenesis, diagnostics and clinic of acute catarrhal rhinosinusitis are considered, the possibility of using the herbal medicinal product Sinupret extract in the treatment of patients with acute viral rhinosinusitis is substantiated.

OBJECTIVE

To evaluate the efficacy and safety of using the drug Sinupret extract in patients with acute viral rhinosinusitis.

MATERIAL AND METHODS

A comparative study of the efficacy and safety of clinical use in patients of the drug Sinupret extract in patients with acute viral rhinosinusitis was carried out in comparison with symptomatic treatment.

RESULTS AND DISCUSSION

After analyzing and processing the results obtained using statistical methods for the main group, a faster rate of decrease in the severity of complaints (data with the use of the MSS visual analogue scale), the severity of inflammation in the nasal cavity and nasopharynx, the amount of discharge from the nose and its viscosity were confirmed. Restoration of respiratory function according to rhinomanometry and mucociliary transport according to the results of the saccharin test also occurred more quickly in patients of the main group compared to the control group. The effectiveness of using Sinupret extract is also confirmed by the results of photoplethysmography.

CONCLUSIONS

The use of the drug Sinupret extract not only contributes to a more rapid improvement in the general well-being of patients and a decrease in the severity of complaints, but also leads to an improvement in the objective picture of the disease (rhinoscopy, the results of anterior active rhinomanometry, saccharin test) compared with the control group, favorably affects the quality life of patients, causes a decrease in economic and social costs against the background of the development of acute viral rhinosinusitis.

Association of cytokine profile with prior treatment failure and revision surgery in chronic rhinosinusitis

BACKGROUND

Inflammatory patterns in chronic rhinosinusitis (CRS) may predict disease severity, need for multiple sinus surgeries, and treatment response. This study analyzes nasal mucus inflammatory cytokine patterns in patients with (CRSwNP) and without (CRSsNP) nasal polyposis and their association with revision sinus surgery.

METHODS

A total of 319 CRS patients who underwent sinus surgery were included. Cytokines were quantified in intraoperative mucus specimens using a multiplex flow cytometric bead assay. Cytokine expression patterns in patients with 0, 1, and ≥2 previous surgeries were analyzed using Kruskal-Wallis and principal component (PC) regression analyses.

RESULTS

There were 122 (38%) patients with CRSsNP and 197 (62%) with CRSwNP. On univariate analysis, interleukin (IL)-1β, IL-6, IL-8, and IL-21 were associated with increasing number of sinus surgeries in CRSsNP, as were IL-2, IL-4, IL-5, IL-6, IL-9, IL-17A, and tumor necrosis factor (TNF)-α in CRSwNP. PC analysis with continuous Poisson regression in CRSwNP demonstrated that high IL-5 and IL-13 and low IL-1β, IL-12, and IL-21 were associated with more prior surgeries. In CRSsNP low IL-13 and high IL-5 and regulated-on-activation, normal T-cell-expressed and secreted (RANTES) were associated with more prior surgeries. Age remained a significant covariate in the full regression model for CRSsNP, but was nonsignificant in CRSwNP.

CONCLUSION

In CRSwNP, elevated IL-5 and IL-13 levels were higher at time of surgery in patients with more prior surgeries. Type 2 cytokines in CRSsNP demonstrated mixed associations with revision surgery. For both phenotypes, IL-10, IL-12, and IL-21 were consistently lower as number of prior surgeries increased, suggesting that treatment-resistant disease may be modulated by impairment in these signaling pathways.

Olfaction and Gustation in Children With Primary Ciliary Dyskinesia

Objective

Primary ciliary dyskinesia (PCD) is a rare autosomal recessive disorder whereby abnormal cilia cause a wide array of respiratory tract manifestations including chronic rhinosinusitis. The purpose of this study was to determine whether olfaction and gustation are impaired in children with PCD.

Study Design

Cross-sectional study.

Setting

Tertiary pediatric academic hospital.

Methods

Children with confirmed PCD based on having at least 1 of 3 approved diagnostic criteria as per The American Thoracic Society guidelines were recruited from The PCD Clinic in our tertiary care pediatric hospital. Odor identification ability was tested using the Universal Sniff (U-Sniff) test and taste threshold was measured using an electrogustometer. The main outcome of this study is to determine the incidence of olfactory dysfunction in children with PCD and investigate if there is an associated gustatory dysfunction.

Results

Twenty-five children participated (14 male, 11 female), The median age was 10.8 years (range: 4.1-17.9 years). Only 4/25 (16%) complained of olfactory dysfunction prior to testing. None of the patients complained of dysgeusia. However, 48% (12/25) scored less than 7 on the U-Sniff, signifying hyposmia or anosmia. In contrast, scores obtained by electrogustometry were in the normal range. There was no correlation between performance on the U-Sniff and electrogustometry testing.

Conclusion

Olfactory impairment in children with PCD is common but underrecognized by patients. This is not associated with abnormal gustation. Among other, this places children with PCD at an increased risk with respect to smelling a fire or detecting spoiled or poisonous food.

Use of low-level laser therapy for patients with chronic rhinosinusitis: a single-blind, sham-controlled clinical trial

Chronic rhinosinusitis (CRS) is one of the most common conditions all over the world. The purpose of this study was to investigate the effects of low-level laser therapy (LLLT) in patients with CRS. Fourteen adult patients with CRS participated in this single-blind, sham-controlled clinical trial (12 male, mean age 40 years). Patients received five successive sessions of sham laser followed by five successive sessions of real laser after 2 days. Ga-Al-As laser of 830 nm in a continuous mode at a power output of 30 mW and energy dose of 1 J was applied on the cheeks and the forehead for the maxillary and frontal sinuses, respectively. Laser was delivered on six points over each sinus, each point for 33 s. Four measurements were taken. The total symptom score (TSS) was calculated as the primary outcome measure. The effects of LLLT on TSS were evaluated by using repeated measure ANOVA. The percentage improvement of real laser and sham laser was compared by Wilcoxon signed ranked test. Cohen's d was used to calculate the effect size. Total symptom score significantly improved after real laser (p = 0.015, Cohen's d = 0.69). The percentage improvement for real laser (34.12 ± 46.43) was significantly better than the sham laser (5.02 ± 37.34, Z =  - 2.23, p = 0.026). No significant improvements were observed after sham laser. This study indicates that five-session active LLLT when compared with sham is effective in the treatment of CRS symptoms.

Sinonasal Outcomes Using Oral Corticosteroids in Patients with Chronic Rhinosinusitis with Nasal Polyps and Positive Sinonasal Cultures

Introduction Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) and positive sinonasal bacterial cultures may be recalcitrant to topical therapy alone due to the additional local inflammatory burden associated with bacterial infection/colonization.

Objective To evaluate sinonasal outcomes in CRSwNP patients with a positive perioperative bacterial culture, who were treated with postoperative intranasal corticosteroids (INCS) alone versus INCS in combination with a short-term course of oral corticosteroids (OCS).

Methods This is a retrospective chart review of CRSwNP patients. A total of 59 patients met inclusion criteria, including positive perioperative bacterial culture and treatment with INCS with or without concomitant use of OCS. Two cohorts were formed based on the chosen postoperative medical treatment; 32 patients underwent postoperative INCS alone, while 27 underwent INCS plus a ≤ 2-week course of OCS. The 22-item sinonasal outcome test (SNOT-22) scores and Lund-Kennedy scores (LKS) were assessed preoperatively, and at 2-week, 4-week, and 4 to 6 months after endoscopic sinus surgery (ESS).

Results There were no statistically significant differences in postoperative sinonasal symptoms or endoscopic scores between the cohorts treated with INCS plus OCS versus those prescribed INCS alone (p > 0.05). Our regression model failed to demonstrate a relationship between the use of OCS and better sinonasal outcomes at 2-week, 4-week, and 4 to 6 months after ESS (p > 0.05).

Conclusion Our study suggests that in a cohort of CRSwNP patients with recent bacterial infections, the postoperative use of combined OCS and INCS did not result in a statistical improvement of endoscopic and symptomatic outcomes over INCS irrigation alone. However, both treatment groups had a clinically significant improvement based on the Minimal Clinically Important Difference.

Chinese herbal therapy in the management of rhinosinusitis-A systematic review and meta-analysis

This systematic review aims to assess the effects and safety of Chinese herbal medicines (CHMs) in the management of rhinosinusitis (RS); inform clinicians of the current state of the evidence; identify the best available evidence; and suggest further directions for research. Five English and four Chinese language databases, and four clinical trial registries were searched. Eligible studies were randomised controlled trials (RCTs). Participants were diagnosed with RS based on established criteria. Test interventions were CHMs administered orally and/or nasally, excluding injections and displacement techniques. Control interventions included placebos, no additional treatment, and conventional non-invasive treatments including pharmacotherapies and/or nasal irrigation, and/or inhalations. Polyposis and post-surgical recovery were excluded. Outcomes were Sino-Nasal Outcome Test (SNOT), visual analogue scales (VAS), Lund-Mackay computed tomography score (LM), Lund-Kennedy Endoscopic score (LK), Mucociliary transport time (MTT), Mucociliary transport rate (MTR), quality of life and adverse events (AEs). Risk of bias used the Cochrane tool. Meta-analysis in Review Manager 5.4.1 used random effects for mean difference (MD) or risk ratio (RR) with 95% confidence intervals. Heterogeneity was assessed as I2. Thirty-four RCTs were included, 30 of chronic RS (CRS) and four of acute RS (ARS). These enrolled 3,752 participants. Five RCTs blinded participants. For CRS, comparisons with placebo showed greater improvements in the CHM groups for SNOT-20 and VAS-TNS (total nasal symptoms). Blinded comparisons with pharmacotherapies showed no differences between groups in the degree of improvement for SNOT-20, VAS-TNS, and LM, suggesting these CHMs had similar effects, at least in the short term. In ARS, pooled results found improved scores on VAS-TNS and LK suggesting a benefit for combining these CHMs with pharmacotherapies. Limitations included inadequacies in study design and methodological reporting, and insufficient reporting of AEs. Heterogeneity in some pooled results precluded strong conclusions. Further well-designed studies are needed to test whether the results are replicable. Systematic review registration number: PROSPERO (CRD42019119586).

"Fizz Sign" in Acute Sinusitis-A CT Scan Finding

To study the Computerized Tomography (CT) Paranasal Sinus findings in patients with acute bacterial sinusitis and the clinical symptom associated with it. 120 patients were examined over 2 years with coronal CT images of paranasal sinus with clinical symptoms of acute sinusitis of 2 weeks duration from the onset. Patients with symptoms of more than 2 weeks and patients with chronic sinusitis, immunocompromised status were excluded. Air mixed with fluid is seen like a Fizz of cola drink within the maxillary, frontal or sphenoid sinus, mucosal thickening of more than 5 mm, fluid level and presence of opacifications were used as evidence of acute sinusitis. 28 patients (23.3%) had Fizz sign (Air mixed with fluid seen as bubbles) coronal CT images of the paranasal sinus. The study demonstrated great variation in the CT paranasal findings amongst patients with suspected acute sinusitis. More than one sinus subsite was affected amongst patients in whom acute sinusitis was confirmed by CT Paranasal sinus imaging. We hereby highlight a new sign of air mixed with fluid which the senior author had named as Fizz Sign because of its resemblance to the fizz of dark cola drink.

Prevalence of Antibiotic Prescription in Patients with Acute Rhinosinusitis Treated by General Practitioners and Otolaryngologists in Germany-A Retrospective Cohort Study

(1) Background: The goal of this retrospective cohort study, based on real-world data and conducted in Germany, was to investigate the prevalence of antibiotic (AB) prescription in patients with acute rhinosinusitis (ARS). (2) Methods: Data from the Disease Analyzer database were used for this cross-sectional study. Patients aged ≥18 years diagnosed with acute sinusitis by general practitioners (GPs) and ear, nose, throat (ENT) specialists between January 2012 and December 2020 were included. The main outcome of the study was the proportion of patients with ARS who received an AB prescription on the day of diagnosis or within three days afterwards. The proportion was estimated separately for patients treated by GPs and ENTs, and also for five age groups, as well as women and men. (3) Results: In total, 308,095 patients were diagnosed with ARS (187,838 by GPs and 120,257 by ENTs). 50.9% of patients treated by GPs and 50.0% treated by ENTs received an AB prescription. AB prevalence increased with age from 46.9% in the age group 18−30 years to 55.5% in the age group > 60 years. (4) Conclusions: We have shown a high prevalence of potentially inappropriate AB prescription for adult patients with ARS in both GP and ENT practices and also among both women and men and in several age groups. There is an urgent need for interventions to reduce inappropriate AB use.

Comparing the severity of chronic rhinosinusitis symptoms before versus during the COVID-19 pandemic

Background

COVID-19 measures such as masking, social distancing, and staying indoors may mitigate chronic rhinosinusitis (CRS) symptoms. We evaluate whether these measures correlated with improved symptoms in patients with CRS.

Methods

This retrospective study compared SNOT-22 survey data from the Northwestern CRS Registry at the time of enrollment and at years 1-5 of follow-up. The final sample consisted of 1826 SNOT-22 surveys for 598 patients. April 10, 2020 to December 31, 2021 was considered "during the pandemic" and prior to March 11, 2020 was considered "pre-pandemic." Wilcoxon test was used to compare SNOT22 at enrollment pre-pandemic versus during pandemic. Separate linear mixed models were performed to estimate SNOT22 at 1 to 5 years after enrollment pre-pandemic versus during pandemic.

Results

Subjects enrolled during the pandemic had worse SNOT22 scores than those enrolled pre-pandemic (53 vs. 42, p = .0024). Total SNOT-22 scores were improved during the pandemic than before the pandemic at 1 year follow-up (18.17 vs. 12.22, p = .001). This effect persists when evaluating the nasal (7.33 vs. 5.13, p = .003), sleep (2.63 vs. 1.39, p = .008), function (1.40 vs. 0.72, p = .015), and emotion (0.77 vs. 0.17, p < .001) domains individually. There was no statistically significant difference in total SNOT-22 score at Years 2-5 of follow-up.

Conclusions

Patients with CRS experience a greater reduction in symptom severity in their first year of treatment during the pandemic than before the pandemic, plausibly from measures such as masking and staying indoors.

Level of Evidence

4.

Cone Beam Computed Tomography in the Assessment of the Effectiveness of Physical Therapy with the Use of the Electromagnetic Field Combined with Light Radiation Emitted by LEDs in the Treatment of Inflammation of the Paranasal Sinuses-A Case Study

Modern high-resolution volumetric tomography, commonly known as cone beam computed tomography (CBCT), is one of the most innovative imaging techniques which can provide views of anatomical structures not attainable by conventional techniques. Magnetic field LED therapy is a physical therapy method, combining the effects of the Extremely Low Frequency-Electromagnetic Field (ELF-EMF) and high-power light radiation emitted by Light Emitting Diodes (LEDs). The method has been widely applied in the treatment and rehabilitation of complications of many medical conditions, including in dentistry. The aim of this study was to use CBCT to assess the effectiveness of the simultaneous use of electromagnetic field and LED light in the physical therapy of paranasal sinusitis. Treatments employing the electromagnetic field combined with LED light were administered to a 39-year-old female outpatient of the physiotherapy ward for rehabilitation therapy of paranasal sinusitis. Normal sinus pneumatization was restored almost completely. Reduction in the swelling of the sinus mucosa was so significant that even the pneumatization of the ethmoid bulla was restored. Physical therapy with the simultaneous use of ELF-EMF and LED light was found to be effective in the rehabilitation of the patient with paranasal sinusitis. Positive effects of the treatment were confirmed by CBCT findings.

Deviated Nasal Septum a Risk Factor for the Occurrence of Chronic Rhinosinusitis

The aim of this review article is to determine whether a deviated nasal septum (DNS) is a potential risk factor for the occurrence of chronic rhinosinusitis (CRS). Nasal septal deformities include spur, deviated nasal septum, thickening, and dislocation. Deformities of the nose tip and columella are examples of external deformities, together with the deviated part of either cartilage or both the bony and cartilage part of the dorsum of the nose. Various symptoms of chronic rhinosinusitis include nasal obstruction, nasal or post-nasal drainage, facial pain and pressure, and smell disturbances. For a long time, the deviation of the nasal septum is related to the pathogenesis, progression, and severity of chronic rhinosinusitis. Mechanisms involving mechanical and aerodynamics theory may be used to explain this relationship. Etiology in the occurrence of CRS are allergy, asthma, tooth Infection, immunodeficiency, mucociliary disorders, anatomical irregularities like DNS, concha bullosa, septum spurring, or an expanded cystic middle turbinate or prominent agger nasi cells that compromise the osteomeatal complex. The computed tomography (CT) scan imaging of the nasal cavity and paranasal sinuses has dramatically improved especially since the use of coronary CT scans. These scans make it simple to find even minute changes and abnormalities in bony structures and mucosal pathologies. An increase in the angle of DNS is significantly linked to specific disease patterns in the osteomeatal complex. This review shows that not all subtypes of DNS always result in the development of CRS. Only extremely severe DNS appears to contribute to the etiology of CRS.

Assessing Stakeholder Engagement for Outcomes-Based Research Among Patients With Chronic Rhinosinusitis and Asthma: A Survey-Based Investigation

BACKGROUND

Despite significant morbidity, there remains a critical need for prospective analyses to investigate the impact of comorbid chronic rhinosinusitis (CRS) with asthma (CRSwA) on patient centered outcomes. The objective of this study was to ascertain critical stakeholder feedback from patients that could inform future study design based on patient preferences, in an effort to optimize patient enrollment.

METHODS

A prospective, descriptive study was performed in order to determine the importance of various factors on CRSwA treatment among critical stakeholders. A Likert-scale survey highlighting various aspects of treatment of CRSwA and elucidating patient enthusiasm for clinical enrollment was constructed and prospectively administered to patients with CRSwA. A univariate analysis was instituted to understand the significance of the different trial design preferences.

RESULTS

Survey responses were collected from a total of 17 patients with CRSwA. With Likert scores >4/5, responses indicated significant stakeholder interest in research focused on understanding symptom triggers, including the impact of air quality and allergens. Importantly, the highest mean scores noted were for studies focused on improving (1) overall quality of life (4.8/5) and (2) lung function (4.8/5). Patients appeared least interested in participation in a randomized trial, whereas the greatest support was communicated for a purely observational trial (P = .08).

CONCLUSION

Patients with CRSwA demonstrate enthusiasm for participation in research that focuses on improving patient centered outcomes-specifically quality of life and lung function. Stakeholder feedback also indicates a preference for observational study design over randomized control trials.

Assessment of Olfaction Following Endoscopic Sinus Surgery

To assess the olfactory outcomes following Endoscopic Sinus Surgery (ESS) in patients diagnosed with Chronic Rhinosinusitis (CRS) and Sinonasal polyposis (SNP). To assess and compare the pre-operative and post-operative olfactory scores of patients undergoing ESS/ ESS + polypectomy/ESS + Septoplasty by subjective and objective methods. This is a prospective, cohort study which included a total of 60 patients. Subjective assessment was done using a Questionnaire. Preoperative olfactory assessment was performed with Sniffing Sticks. Olfactory assessment was done at 1st,3rd, 6th and 12th week following surgery. The preoperative and postoperative scores were statistically analysed and compared. In patients who underwent ESS, there was a significant reduction in olfactory scores in the immediate few weeks after surgery which improved over time by the end of 3 months. In patients who underwent ESS with polypectomy, there was a significant improvement in olfactory scores from the third week following surgery which was sustained over 3rd month follow-up. In patients who underwent ESS with Septoplasy, there was a significant decrease in olfactory scores during the initial few weeks with a marginal improvement during 3 months follow-up. At the end of 12 weeks post ESS, no patient was found to be anosmic. Patients with pre-existing hyposmia did not show statistically significant change post surgery.However patients with anosmia showed statistically significant improvement in olfactory function, but did not become normosmic at 12th post-operative week. Majority of normosmics did not have alteration in their olfactory perception at 12th post-operative week.

Country data on AMR in Türkiye in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome

BACKGROUND

Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.

OBJECTIVES

To review AMR in Türkiye and initiatives addressing it. Identifying any areas where more information is required will provide a call to action to minimize any further rise in AMR within Türkiye and to improve patient outcomes.

METHODS

National AMR initiatives, antibiotic use and prescribing, and availability of susceptibility data, particularly for the key community-acquired respiratory tract infection (CA-RTI) pathogens Streptococcus pneumoniae and Haemophilus influenzae, were identified. National and international antibiotic prescribing guidelines commonly used locally for specific CA-RTIs (community-acquired pneumonia, acute otitis media, acute bacterial rhinosinusitis) were also reviewed, plus local antibiotic availability. Insights from both a local clinician and local clinical microbiologist were sought to contextualize this information.

CONCLUSIONS

Türkiye developed an antibiotic stewardship programme, The Rational Drug Use National Action Plan 2014-2017, prioritizing appropriate antibiotic prescription in the community. Public campaigns discouraging inappropriate antibiotic use were also initiated. Türkiye has a high level of antibiotic resistance and a high level of consumption, however, in 2015 over-the-counter antibiotic sales were prohibited, resulting in a declining trend in overall consumption. There is still a need for physician education on current developments in antibiotic use. Several ongoing global surveillance studies provide antibiotic susceptibility data in Türkiye. Clinicians in Türkiye use several country-specific guidelines for common CA-RTIs plus a range of international guidelines. A more standardized inclusive approach in developing local guidelines, using up-to-date surveillance data on isolates from community-acquired infections in Türkiye, could make guideline use more relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve patient outcome.

Cystic Fibrosis Foundation otolaryngology care multidisciplinary consensus recommendations

BACKGROUND

Cystic fibrosis (CF) is a multisystem disease that often requires otolaryngology care. Individuals with CF commonly have chronic rhinosinusitis but also present with hearing loss and dysphonia. Given these manifestations of CF, otolaryngologists are frequently involved in the care of patients with CF; however, there is limited consensus on optimal management of sinonasal, otologic, and laryngologic symptoms.

METHODS

The Cystic Fibrosis Foundation convened a multidisciplinary team of otolaryngologists, pulmonologists, audiologists, pharmacists, a social worker, a nurse coordinator, a respiratory therapist, two adults with CF, and a caregiver of a child with CF to develop consensus recommendations. Workgroups developed draft recommendation statements based on a systematic literature review, and a ≥80% consensus was required for acceptance of each recommendation statement.

RESULTS

The committee voted on 25 statements. Eleven statements were adopted recommending a treatment or intervention, while five statements were formulated recommending against a specific treatment or intervention. The committee recommended eight statements as an option for select patients in certain circumstances, and one statement did not reach consensus.

CONCLUSION

These multidisciplinary consensus recommendations will help providers navigate decisions related to otolaryngology consultation, medical and surgical management of CF-CRS, hearing, and voice in individuals with CF. A collaborative and multidisciplinary approach is advocated to best care for our patients with CF. Future clinical research is needed utilizing standardized, validated outcomes with comprehensive reporting of patient outcome, effects of modulator therapies, and genetic characteristics to help continue to advance care, decrease morbidity, and improve the quality of life for individuals with CF.

Acupuncture for the Treatment of Chronic Rhinosinusitis: A PRISMA-Compliant Systematic Review and Meta-Analysis

Background. Chronic rhinosinusitis (CRS) is a highly prevalent disease associated with poor quality of life. In this paper, we appraised the role of acupuncture in the treatment of CRS. Methods. Electronic databases were searched for randomized controlled clinical trials (RCTs) that examined the role of acupuncture in CRS. The primary outcome measures included posttreatment CRS severity, as measured by the Visual Analogue Scale (VAS) and Total Effective Rate (TER). The risk of bias and quality of evidence were evaluated according to the Cochrane Collaboration’s risk-of-bias tool and GRADE tool, respectively. Results. Evidence from the RCTs (n = 10) suggested that acupuncture as a monotherapy or adjunctive therapy to conventional treatment was associated with significant improvements in VAS, TER, and quality of life when compared with conventional treatments for CRS. However, there was a similar incidence of adverse events. The risk of bias was unclear and the quality of evidence for each finding was generally moderate to low. Conclusions. Acupuncture as a stand-alone or adjunctive treatment for CRS was associated with clinical symptom improvement and better quality of life, without any risk for serious adverse events. However, the high clinical heterogeneity of the included RCTs and overall moderate-to-low quality of evidence necessitates rigorous, well-designed trials to confirm these findings. Trial Registrations. This trial is registered with PROSPERO (no. CRD42021292135).

Discordance of chronic rhinosinusitis disease control between EPOS guidelines and patient perspectives identifies utility of patient-rated control assessment

Background: The objective of this study was to determine concordance of patient-reported chronic rhinosinusitis (CRS) disease control with CRS disease control assessed according to European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) criteria. Methods: In 421 participants, CRS disease control was determined using EPOS criteria which include the burden of 5 symptoms measured on a binary scale, use of rescue medications in the prior 6 months and presence of diseased mucosa on nasal endoscopy. Symptom severity was also assessed using a visual analogue scale (VAS). Participants rated their CRS disease control as “controlled”, “partly controlled” or “uncontrolled”. Results: Patient-reported and EPOS-based CRS disease control ratings agreed for 49.6% of participants. Amongst cases of disagreement, EPOS guidelines assessed worse CRS disease control relative to 92.9% of patients. Facial pain/pressure and impaired sense of smell distinctly associated with patient agreement with EPOS guidelines on having “uncontrolled” CRS. Higher VAS symptom scores were associated with worse patient-reported CRS disease control (i.e., agreeing with EPOS guidelines). Removal of the nasal endoscopy criterion improved agreement between patients’ and EPOS control assessments, and replacement of this criterion with patient-reported control further aligned EPOS guidelines with patient perspectives. Conclusions: EPOS guidelines regularly assess worse CRS control than assessed by patients. The lack of more gradated symptom severity criteria and inclusion of nasal endoscopy may contribute to discordance of EPOS guidelines with patient-reported CRS control. Replacement of nasal endoscopy findings with a measure of patient-reported CRS disease control better aligns EPOS CRS disease control guidelines with patients’ perspectives.

Benefits of nasal saline treatment in acute rhinosinusitis: Systematic review and meta-analysis

BACKGROUND

Although nasal saline treatments are widely used in treating acute rhinosinusitis (ARS), the evidence in adult patients is inconclusive. Our objective was to assess the add-on benefits of saline treatment in adults with ARS.

METHODS

Literature searches were performed (updated May 9, 2021). Randomized, controlled trials studying the effects of nasal saline treatment in adults with ARS were included. Data were pooled for meta-analysis. Outcomes were composite symptoms score (CSS), disease-specific quality-of-life (DS-QoL) score, individual symptom score, endoscopy score, saccharin transit time, cure rate, days to resolution, and adverse events.

RESULTS

Eleven studies (718 patients) were included in our investigation. Nasal discharge was the only symptom improved (standardized mean difference [SMD], -0.36; 95% confidence interval [CI], -0.66 to -0.05]. Saline as an add-on treatment brought no benefit to CSS and DS-QoL score at both time-points (3-10 days and at the end of the study). Other outcomes also showed no benefits with use of saline, including endoscopy score, saccharin transit time, cure rate, days to resolution, and adverse events. Subgroup analyses showed improvement in viral ARS patients for CSS (SMD, -0.60; 95% CI, -1.12 to -0.08) and DS-QoL score (mean difference, -15.90; 95% CI, -31.78 to -0.02), and also in patients using high-volume saline (SMD, -0.42; 95% CI, -0.78 to -0.06).

CONCLUSION

Nasal saline as an add-on treatment improved rhinorrhea. There was no improvement in CSS and DS-QoL, except among the subgroup of viral ARS patients using high-volume saline. There were no differences in adverse events between the saline and non-saline treatments.

Efficacy and safety of traditional Chinese medicine nasal irrigation on chronic rhinosinusitis recovery after endoscopic sinus surgery: A protocol for a systematic review and meta-analysis

Background

Continuous comprehensive treatment is still needed after endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) to promote the recovery of sinus mucosal morphology and function. Traditional Chinese medicine (TCM) nasal irrigation is a promising external treatment of TCM, but at present, the application of TCM nasal irrigation after ESS for CRS has not been recommended by the guidelines. Therefore, this article aims to develop a systematic overview and meta-analysis protocol to assess the effectiveness and safety of Chinese herbal nasal rinse for CRS recovery after ESS.

Methods

Seven databases shall be retrieved from their inception until December 2021. Eligible randomized controlled trials will be covered in the study. The outcome indicators of the survey will consist of efficacy, visual analogue scale score, Lund-Kennedy score for nasal endoscopy, Lund-Mackay score for sinus computed tomography and other secondary outcome indicators. The selection of literature, extraction of data, and methodological quality evaluation of literature shall be conducted by two researchers separately. If there is any dispute, it can be discussed and solved by a third researcher. Review Manager 5.3 software will be applied to data analysis.

Results

The article will make a detailed research programme to explore the efficacy and safety of TCM nasal irrigation on CRS recovery after ESS.

Conclusion

This protocol is suitable for evaluating the effectiveness and safety of TCM nasal rinse for CRS recovery after ESS, and can provide corresponding evidence-based medical evidence.

Systematic review registration

Open Science Framework Registration DOI: 10.17605/OSF.IO/ZV73Q.

Anterior Pedicled Nasal Flap in Frontal Sinus Drill-Out Patients: A Randomised Controlled Pilot Study

Background: The endoscopic modified Lothrop procedure (EMLP) is a common procedure performed in patients with frontal sinus pathology. While performing this procedure, large segments of bone are exposed, which may lead to the promotion of frontal sinus neo-ostium stenosis. Here we examine the peri-operative differences in time to achieve healing in patients where a mucosal flap is used to cover the exposed bone on one side of the neo-ostium. Design: A randomised pilot study with 12 patients undergoing EMLP surgery participated in this study. Methods: Patients were randomised to undergo a mucosal flap on either the left or right side of the neo-ostium. Prior to surgery, patients completed a SNOT-22 and smell identification test. Patients were reviewed until the neo-ostium had healed on both sides. Once healing had occurred, a post-operative SNOT-22 score and smell identification test were recorded. Results: Average time to healing for the frontal sinus neo-ostium was 4.7 vs. 4.2 (p = 0.3) on the flap vs. non-flap side, respectively. There was an average 24.4 point (range: −75 to +9) decrease in SNOT-22 scores post-surgery. The post-operative USPIT score demonstrated an average increase of 6.6 points (range −13 to +27). Conclusion: We did not detect significant differences in peri-operative time toward healing in neo-ostiums where a single flap is utilised. Further studies are needed to determine whether the usage of a single neo-ostium flap affords any benefit over no flap on either ostium. SNOT-22 and UPSIT scores improved post-surgery.

Improving Pharmacists’ Awareness of Inadequate Antibiotic Use for URTIs through an Educational Intervention: A Pilot Study

The inadequate use of antibiotics led to the development of multi-resistant bacteria that are now causing millions of deaths worldwide. Since most antibiotics are prescribed/dispensed to treat respiratory tract infections, it is important to raise awareness among health professionals to optimize antibiotic use, especially within the primary care context. Thus, this pilot study aimed to evaluate pharmacists’ feedback about the eHealthResp platform, composed by an online course and a mobile application (app) to help in the management of upper respiratory tract infections (URTIs). Ten community pharmacists were invited to participate in this study, exploring the contents of the eHealthResp platforms and answering a content validation questionnaire composed by eight qualitative and thirty-five quantitative questions about the online course and mobile app. The eHealthResp platform is a comprehensive, consistent, and high-quality e-learning tool. Median scores of 5.00 were attributed to the course contents’ and clinical cases’ adequacy and correction. Most qualitative feedback was about completeness and objectivity of the course, and its usefulness for clinical practice. This study showed that eHealthResp has great potential as an e-health tool for the management of URTIs’ symptoms, which may ultimately aid in reducing inappropriate antibiotic use.

Antibiotic Prescribing Practices for Upper Respiratory Tract Infections Among Primary Care Providers: A Descriptive Study

Background

Most antibiotics are prescribed in the ambulatory setting with estimates that up to 50% of use is inappropriate. Understanding factors associated with antibiotic misuse is essential to advancing better stewardship in this setting. We sought to assess the frequency of unnecessary antibiotic use for upper respiratory infections (URIs) among primary care providers and identify patient and provider characteristics associated with misuse.

Methods

Unnecessary antibiotic prescribing was assessed in a descriptive study by using adults ≥18 years seen for common URIs in a large, Upper Midwest, integrated health system, electronic medical records from June 2017 through May 2018. Individual provider rates of unnecessary prescribing were compared for primary care providers practicing in the departments of internal medicine, family medicine, or urgent care. Patient and provider characteristics associated with unnecessary prescribing were identified with a logistic regression model.

Results

A total of 49 463 patient encounters were included. Overall, antibiotics were prescribed unnecessarily for 42.2% (95% confidence interval [CI], 41.7–42.6) of the encounters. Patients with acute bronchitis received unnecessary antibiotics most frequently (74.2%; 95% CI, 73.4–75.0). Males and older patients were more likely to have an unnecessary antibiotic prescription. Provider characteristics associated with higher rates of unnecessary prescribing included being in a rural practice, having more years in practice, and being in higher volume practices such as an urgent care setting. Fifteen percent of providers accounted for half of all unnecessary antibiotic prescriptions.

Conclusions

Although higher-volume practices, a rural setting, or longer time in practice were predictors, unnecessary prescribing was common among all providers.

The protocol of improving safe antibiotic prescribing in telehealth: A randomized trial

BACKGROUND

The CDC estimates that over 40% of Urgent Care visits are for acute respiratory infections (ARI), more than half involving inappropriate antibiotic prescriptions. Previous randomized trials in primary care clinics resulted in reductions in inappropriate antibiotic prescribing, but antibiotic stewardship interventions in telehealth have not been systematically assessed. To better understand how best to decrease inappropriate antibiotic prescribing for ARIs in telehealth, we are conducting a large randomized quality improvement trial testing both patient- and physician-facing feedback and behavioral nudges embedded in the electronic health record.

METHODS

Teladoc® clinicians are assigned to one of 9 arms in a 3 × 3 randomized trial. Each clinician is assigned to one of 3 Commitment groups (Public, Private, Control) and one of 3 Performance Feedback groups (Benchmark Peer Comparison, Trending, Control). After randomly selecting ⅓ of states and associated clinicians required for patient-facing components of the Public Commitment intervention, remaining clinicians are randomized to the Control and Private commitment arms. Clinicians are randomized to the Performance Feedback conditions. The primary outcome is change from baseline in antibiotic prescribing rate for qualifying ARI visits. Secondary outcomes include changes in inappropriate prescribing and revisit rates. Secondary analyses include investigation of heterogeneity of treatment effects. With 1530 clinicians and an intra-clinician correlation in antibiotic prescribing rate of 0.5, we have >80% power to detect 1-7% absolute differences in antibiotic prescribing among groups.

DISCUSSION

Findings from this trial may help inform telehealth stewardship strategies, determine whether significant differences exist between Commitment and Feedback interventions, and provide guidance for clinicians and patients to encourage safe and effective antibiotic use.

CLINICALTRIALS

gov: NCT05138874.

Antibiotic prescribing patterns and guideline-concordant management of acute respiratory tract infections in virtual urgent care settings

BACKGROUND

Antibiotic overprescribing for acute respiratory tract infections (ARTIs) commonly occurs and can lead to higher medical costs, antibiotic resistance, and health complications. Inappropriate prescribing of antibiotics for ARTIs has been shown to occur more frequently in urgent care than other outpatient settings. It is not clear whether antibiotic overprescribing varies between virtual and in-person urgent care.

OBJECTIVES

Summarize published primary scientific literature on antibiotic prescribing patterns for ARTIs among adults in virtual urgent care settings.

DATA SOURCES

We conducted a systematic review to compare antibiotic prescribing for ARTIs between virtual and in-person urgent care. Our review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. We assessed risk of bias using the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) assessment tool. We summarized study results from seven included retrospective cohort studies.

CONCLUSIONS

Antibiotic prescribing frequency may be similar between virtual urgent care and in-person care for adult patients treated for ARTIs. However, variability existed in intervention characteristics, settings, and outcome measures. Additional studies are needed to better understand the conditions in which virtual care may be most effective.

IMPLICATIONS FOR PRACTICE

Evidence suggests that giving providers direct access to evidence-based guidelines and electronic health records within the virtual visit may support diagnosis and management. Furthermore, practices that use telemedicine platforms for virtual urgent care visits should consider how to potentially improve diagnosis and management of conditions through the use of home-based point-of-care testing or accessory "e-tools."

The negative impact of chronic rhinosinusitis on the health-related quality of life among adult patients with cystic fibrosis

BACKGROUND

With improved survival in cystic fibrosis (CF) patients, it is crucial to evaluate the impact of chronic co-morbidities such as chronic rhinosinusitis (CRS). The objectives were 1) To determine the prevalence of CRS with a large series of CF patients 2) To evaluate the impact of CRS on the Health-Related Quality of Life (HRQoL) of CF patients and 3) To compare CRS-specific, CF-specific and general HRQoL instruments.

METHODS

Consecutive CF patients from the Toronto Adult Cystic Fibrosis Centre were recruited between March 2018 and January 2020. Participants completed the 22-Item Nasal Outcome Test (SNOT-22), Cystic Fibrosis Questionnaire-Revised for adolescents and adults over 14 years of age (CFQ-R), Cystic Fibrosis Quality of Life Evaluative Self-administered Test (CF-QUEST) and the 36-Item Short Form Survey (SF-36). HRQoL scores were correlated using Spearman's correlation coefficients.

RESULTS

Out of 195 patients eligible for analysis, the prevalence of CRS with positive endoscopic findings was 42.6% (95% confidence interval: 35.5-49.8%). CRS patients reported significantly lower HRQoL with higher SNOT-22 scores and lower scores in the respiratory domain of CFQ-R and physical health domains of CF-QUEST and SF-36. The physical (ρ= -0.63) and mental (ρ= -0.66) domains of SF-36 and CF-QUEST (ρ= -0.76) had a strong correlation with SNOT-22. Higher scores of SNOT-22 nasal subdomains correlated with lower scores of SF-36, CFQ-R and CF-QUEST.

CONCLUSION

CRS is a prevalent co-morbidity of CF patients, which significantly reduces HRQoL. SNOT-22, CFQ-R, CF-QUEST and SF-36 were strongly correlated. Severity of sinonasal symptoms have a strong correlation with HRQoL in CF patients.

The Efficacy of Functional Endoscopic Sinus Surgery Combined With Triamcinolone Acetonide Aqueous Nasal Spray for the Treatment of Chronic Rhinosinusitis

Objective

We aimed to investigate the efficacy of functional endoscopic sinus surgery (FESS) combined with triamcinolone acetonide aqueous nasal spray (TAA AQ) for the treatment of chronic rhinosinusitis.

Methods

From December 2019 to June 2021, 109 patients with chronic rhinosinusitis were classified into a control group (n = 50) and an experimental group (n = 59) according to the method of treatment. Subjects in the control group were treated with FESS while those in the experimental group were treated with FESS + TAA AQ. We then compared clinical indices, total effective rate, and the clinical symptoms of patients between the two groups. The pre- and postoperative serum levels of inflammatory cytokines were also determined. Before and 12 months after surgery, we analyzed the recovery of the nasal mucosa, olfactory function, and mucociliary transport rate of each patient. Postoperative complications were observed and recorded and the quality-of-life 12 months after surgery was ascertained.

Results

Clinical indices and total effective rate were higher in the experimental group. After treatment, the VAS score and serum levels of inflammatory cytokines in the two groups both decreased, although the experimental group had lower VAS scores and inflammatory cytokine levels. Six months after treatment, olfactory function, and the recovery of nasal mucosa were improved, MTR had increased, and the total incidence of complications had reduced in the experimental group when compared with the control group. No significant difference was found between the two groups in terms of quality-of-life (P > 0.05).

Conclusion

The combination of FESS and TAA AQ exerted a certain therapeutic effect on chronic rhinosinusitis.

Disease control in chronic rhinosinusitis: a qualitative study of patient perspectives

BACKGROUND

The definition of disease control in chronic rhinosinusitis (CRS) is an active area of study. However, investigations have not engaged CRS patients in how they think about disease control. This study seeks to understand the patient perspective on CRS disease control.

METHODS

Qualitative phenomenological study using constant comparative methodology was applied. The research team conducted 10, one-on-one interviews with CRS patients ranging from 22 to 55 minutes in length. The content of the interview protocol was determined through iterative discussion amongst all authors. Two authors served as coders to identify recurrent themes. Themes were analyzed for meaning and conclusions were summarized.

RESULTS

Three recurring themes determined from patients were that (1) use of the terminology "control" adequately represents this phenomenon, (2) components of control could be classified into four main themes relating to CRS symptomatology, exacerbation of comorbid disease, quality of life and acute exacerbations of CRS, and (3) when patients deem their CRS is uncontrolled they are more willing to escalate their treatment to include escalating their daily maintenance regimen, seeking otolaryngology referral, taking rescue medication or undergoing endoscopic sinus surgery.

CONCLUSIONS

CRS patients consider their daily symptoms, the severity and frequency of CRS exacerbations, impact on quality of life as well as exacerbation of comorbid disease when thinking about their disease control. Disease control is a goal of treatment for patients and uncontrolled disease motivates patients to seek further treatment. Physicians should explore all components of CRS control when considering disease status and need for further treatment.

Improving predictability of IgE-high type 2 chronic sinusitis with nasal polyps in the biologic era

BACKGROUND

Chronic rhinosinusitis (CRS) is an inflammatory disease that may require biological therapy. Omalizumab is an anti-IgE biologic that was recently approved by the FDA and Health Canada for use in severe CRS with nasal polyps (CRSwNP) recalcitrant to intranasal corticosteroids. Dosing is based on weight and pre-treatment serum IgE, with elevated levels of the latter being an indication for biologic treatment according to EPOS and EUFOREA guidelines. The goal of this study was to identify variables that predict IgE-high type 2 inflammation and serve as indicators for biologic treatment in CRS.

METHODS

Patients ≥ 19 yo diagnosed with CRS undergoing functional endoscopic sinus surgery were included retrospectively. Demographics, past medical history, preoperative blood work, Lund-Mackay (LM), Lund Kennedy (LK), and SNOT-22 scores were extracted. Descriptive statistics and binary logistic regression analyses were conducted. Model superiority was based on Nagelkerke R2 scores and receiver operating characteristic curves.

RESULTS

Sixty-five patients, average age 49.96 ± 13.59 years, were included. Sixty-one binary logistic regression models for elevated serum IgE were created. Among the top 3 models, the best model had sensitivity, specificity, positive predictive value and negative predictive values of 82.1, 69.2, 80.0, and 72.0. All performance measures except sensitivity exceeded the Canadian Biologics Guideline model. Serum eosinophils ≥ 300 cell/uL, CRSwNP and LM ≥ 17 increased the odds of elevated IgE.

CONCLUSIONS

IgE-high type-2 inflammation can be predicted by a model that includes eosinophil ≥ 300 cell/uL, CRSwNP, LM ≥ 17, asthma diagnosis and SNOT-22 ≥ 40. Patients meeting these parameters have a high pretest probability for elevated IgE and would benefit from IgE serology to determine qualification for omalizumab. This could reduce unwarranted IgE serology in patients with CRSwNP but also target a patient population for further workup that will lead to optimization of resource allocation and improve healthcare equity in rural and remote areas within Canada.

ACR Appropriateness Criteria® Sinonasal Disease: 2021 Update

This article presents guidelines for initial imaging utilization in patients presenting with sinonasal disease, including acute rhinosinusitis without and with suspected orbital and intracranial complications, chronic rhinosinusitis, suspected invasive fungal sinusitis, suspected sinonasal mass, and suspected cerebrospinal fluid leak. CT and MRI are the primary imaging modalities used to evaluate patients with sinonasal disease. Given its detailed depiction of bony anatomy, CT can accurately demonstrate the presence of sinonasal disease, bony erosions, and anatomic variants, and is essential for surgical planning. Given its superior soft tissue contrast, MRI can accurately identify clinically suspected intracranial and intraorbital complications, delineate soft tissue extension of tumor and distinguish mass from obstructed secretions.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Managing Chronic Rhinosinusitis with Nasal Polyps in the Elderly: Challenges and Solutions

The proportion of the population over 65 years old continues to grow. Chronic rhinosinusitis is common in this population and causes a reduction in quality of life and an increase in health care utilization. Diagnosis of chronic rhinosinusitis with nasal polyps follows the same principles for elderly patients as in the general population, but the elderly population presents some diagnostic challenges worth considering. Presbynasalis, the anatomic and functional changes of the nose and paranasal sinuses associated with aging must be accounted for when caring for these patients. In addition, polypharmacy and other medical issues that can cause similar symptoms must be considered. Medical therapy is generally similar to the general population but with additional concerns given the propensity for geriatric patients to be on multiple medications and to suffer from multiple medical issues. Sinus surgery should be considered following the same indications as in the general population. While some authors have found higher complication rates in endoscopic sinus surgery, others have found higher rates of success. As always, the risks of surgery must be considered with the possible benefits on a patient-to-patient basis.

Is there a role for antibiotics in the treatment of chronic rhinosinusitis?

Rhinosinusitis is one of the most common reasons for adult outpatient antibiotic prescriptions, though there is little clinical evidence to support this practice, especially for chronic rhinosinusitis. Despite considerable research, the etiology of chronic rhinosinusitis, including the pathogenic role of microbes, remains poorly understood. Rigorous studies of the efficacy of antibiotic treatment of chronic sinusitis are surprisingly few in number and the results are somewhat conflicting. This review article will review the rationales for and against the treatment of chronic rhinosinusitis with antibiotics, based on current evidence and understanding of pathophysiology, and will also summarize the current guidelines.

The Role of the Otolaryngologist in the Evaluation and Management of Headache

Headaches are a global health problem and are encountered by a variety of specialties, including otolaryngologists. These patients can present as a challenge, but an understanding of primary and secondary headache disorders and the accompanying broad differential diagnosis is critical. For secondary headache disorders, a differential diagnosis categorized by anatomic location can help organize the evaluation of these patients, which can then be narrowed by the history and examination findings. Additional ancillary tests such as laboratories and imaging can further aid in diagnosis but are not always necessary.

Developments and Emerging Trends in the Global Treatment of Chronic Rhinosinusitis From 2001 to 2020: A Systematic Bibliometric Analysis

Background

Research on the treatment of chronic rhinosinusitis (CRS) has increased in recent decades. We undertook a bibliometric and visualization analysis of studies on CRS treatment to track research trends and highlight current research “hotspots”.

Methods

Original publications related to CRS treatment were obtained from the Science Citation Index-Expanded (SCI-E) and Social Sciences Citation Index (SSCI) databases in the Web of Science Core Collection (WoSCC) of Clarivate Analytics between 2001 and 2020. The country/region, institution, author, journal, references, and keywords involved in this topic were extracted using CiteSpace and VOSviewer to identify and analyze the research focus and trends in this field.

Results

In the previous two decades (especially after 2015), the number of publications on CRS treatment has grown markedly. With regard to publications and access to collaborative networks, the leading country was the USA. High-frequency keywords were “CRS,” “endoscopic sinus surgery,” “sinusitis,” “nasal polyps,” “asthma,” “rhinosinusitis,” “management,” “diagnosis,” “outcomes,” and “quality of life.” Inspection of keyword bursts suggested that “clinical practice guideline,” “adult CRS,” “innate lymphoid cell,” “recurrence,” and “mepolizumab” are the emerging research hotspots. The timeline view of the cluster map revealed that biologic agents have become an up-and-coming “hot topic” in CRS treatment in recent years.

Conclusion

Academic understanding of CRS treatment has improved markedly over the past 20 years. We study analyzed the papers objectively, methodically, and comprehensively, and identified hotspots and prospective trends in the field of CRS treatment. These results will aid rhinologists in gaining greater insight into CRS treatment strategies and identifying the changing dynamics of CRS research.

Validity and Reliability Study of Bahasa Malaysia Version of Sino-Nasal Outcome Test 22 in Chronic Rhinosinusitis Patient

Background

Chronic rhinosinusitis (CRS) affects 14% of the general population. The Sino-Nasal Outcome Test 22 (SNOT-22) is a reliable instrument assessing the impact of CRS. This study aimed to examine the reliability and construct validity of the translated Bahasa Malaysia version of SNOT-22.

Methods

This cross-sectional study was conducted in the Otorhinolaryngology clinic in Universiti Sains Malaysia (USM). Seventy CRS respondents and 39 healthy participants were included. The Bahasa Malaysia translated SNOT-22 (bmSNOT-22) was produced using rigorous forward and backward translation. Statistical analyses used included feasibility, Cronbach's alpha, intraclass correlation coefficient, Pearson's correlation coefficient and factor analysis.

Results

The feasibility was 97.2% in the initial test and 100% in the retest. The Cronbach's alpha was 0.89 in the initial test. The average intraclass correlation coefficient (ICC) was 0.90, indicating good test-retest reliability. The bmSNOT-22 discriminated between the control group and patients (t = 15.33; P < 0.001).

Conclusion

The bmSNOT-22 is reliable, and validity established therefore recommended for Malaysia's clinicians and researchers as a measurement tool for the outcome in sino-nasal disorders such as rhinosinusitis and nasal polyps.

Dedicated Olfaction and Taste Items do not Improve Psychometric Performance of the SNOT-22

Objective

Previous work has shown the chemosensory dysfunction item of the 22‐item Sinonasal Outcome Test (SNOT‐22) that assesses problems with “taste/smell” has poor psychometric performance compared with other items on the SNOT‐22, which we have hypothesized is due to the simultaneous assessment of two different senses. Our aim was to determine whether distinct smell and taste items in the SNOT‐22 would improve psychometric performance.

Methods

One hundred and eighty‐one CRS patients were recruited and completed the SNOT‐22. Additional items querying problems with the senses of “smell” and “taste,” using the same response scale and recall period were given to study participants. Item response theory (IRT) was used to determine IRT parameters, including item discrimination, difficulty, and information provided by each SNOT‐22 item.

Results

Confirming previous studies, the chemosensory item of the SNOT‐22 (reflecting “taste/smell”) had poor psychometric performance. Use of a distinct smell or taste item instead of the combined “taste/smell” item did not improve psychometric performance. However, a dedicated smell question resulted in a left shift of threshold parameters, showing that the dedicated smell item better captures moderate CRS disease burden than the original taste/smell item of the SNOT‐22, which by virtue of near‐identical IRT parameters appears to more greatly reflect problems with taste.

Conclusions

A dedicated smell‐ or taste‐specific item, rather than the combined “taste/smell” item currently in the SNOT‐22 does not provide significantly greater psychometric performance. However, a dedicated smell item may better capture moderate CRS disease burden compared with the current chemosensory item on the SNOT‐22. Laryngoscope, 132:1644–1651, 2022

Good versus poor prescribers: the comparison of prescribing competencies in primary care

Aim:

To compare the competencies of primary care physicians (PCPs) with poor and good prescribing performance in frequently encountered indications.

Background:

Primary care centers are one of the mostly visited health facilities by the population for different health issues.

Methods:

In this cross-sectional study, we analyzed 6 125 487 prescriptions generated by 1431 PCPs which were selected by systematic sampling in 2016 in Istanbul. We defined PCPs as poor prescriber (n = 227) or good prescriber (n = 210) in terms of their prescribing performance per WHO/INRUD criteria. We compared solo diagnosis prescriptions of these two groups in ‘percentage of prescriptions in compliance with clinical guidelines’ and also rational prescribing indicators.

Findings:

Poor prescribers and good prescribers significantly differed in each of the prescribing indicators for their all solo diagnosis prescriptions. Hypertension had the highest difference of the average cost per encounter (Δ = 284.2%) between poor prescribers (US$43.99 ± 63.05) and good prescribers (US$11.45 ± 45.0), whereas headache had the highest difference between the groups in the percentage encounters with an antibiotic (14.9% vs. 1.5%). Detailed analysis of the prescribing performances showed significantly higher values of each WHO/INRUD indicators for all examined diagnoses. We found significantly higher percentages of guideline-compliant drugs in good prescribers compared to that in poor prescribers in hypertension (40.8% vs 34.8%), tonsillopharyngitis (57.9% vs 50.7%), and acute sinusitis (46.4% vs 43.6%).

Conclusion:

This study shows that the prescribing performances of PCPs are not rational enough in terms of drug selection and prescription content. Furthermore, even the physicians who have good prescribing practice appear as not satisfactorily rational in compliance with current pharmacotherapy competencies.

Odontogenic sinusitis: A state‐of‐the‐art review

Odontogenic sinusitis (ODS) is more common than historically reported, and is underrepresented in the sinusitis literature. ODS is distinct from rhinosinusitis in that it is infectious sinusitis from an infectious dental source or a complication from dental procedures, and most commonly presents unilaterally. ODS clinical features, microbiology, and diagnostic and treatment paradigms are also distinct from rhinosinusitis. ODS evaluation and management should generally be conducted by both otolaryngologists and dental providers, and clinicians must be able to suspect and confirm the condition. ODS suspicion is driven by certain clinical features like unilateral maxillary sinus opacification on computed tomography, overt maxillary dental pathology on computed tomography, unilateral middle meatal purulence on nasal endoscopy, foul smell, and odontogenic bacteria in sinus cultures. Otolaryngologists should confirm the sinusitis through nasal endoscopy by assessing for middle meatal purulence, edema, or polyps. Dental providers should confirm dental pathology through appropriate examinations and imaging. Once ODS is confirmed, a multidisciplinary shared decision‐making process should ensue to discuss risks and benefits of the timing and different types of dental and sinus surgical interventions. Oral antibiotics are generally ineffective at resolving ODS, especially when there is treatable dental pathology. When both the dental pathology and sinusitis are addressed, resolution can be expected in 90%–100% of cases. For treatable dental pathology, while primary dental treatment may resolve the sinusitis, a significant percentage of patients still require endoscopic sinus surgery. For patients with significant sinusitis symptom burdens, primary endoscopic sinus surgery is an option to resolve symptoms faster, followed by appropriate dental management. More well‐designed studies are necessary across all areas of ODS.

Odontogenic sinusitis (ODS) is one of the most common cause of unilateral maxillary sinus disease, but has been underrepresented in previous sinusitis literature.

Clinicians must be able to suspect ODS based on certain clinical features like unilateral middle meatal purulence on nasal endoscopy, subjective foul smell, and sinus computed tomography demonstrating maxillary sinus opacification with or without overt adjacent dental pathology.

Diagnosing ODS requires confirmation of infectious sinusitis by otolaryngologists ideally with nasal endoscopy, and confirmation of adjacent maxillary dental pathology by dental specialists.

Management centers on multidisciplinary collaboration and shared‐decision making between otolaryngologists, dental specialists, and patients.

Laboratory and imaging findings of necrotizing otitis externa are associated with pathogen type and disease outcome: A retrospective analysis

OBJECTIVE

To examine associations of laboratory and imaging data with diagnostic parameters of necrotizing otitis externa (NOE) and its severity, and to compare between bacterial and fungal infections.

METHODS

Records of patients diagnosed with NOE during 2010-2018 at the Department of Otolaryngology, Head and Neck Surgery were reviewed retrospectively for demographics; disease characteristics; and laboratory, scintigraphy, and imaging results.

RESULTS

Of 48 patients with NOE, the mean age is 73±11.6 years; 32 (67%) were males; 83% had diabetes mellitus. Common pathogens were pseudomonas (49%) and fungi (33%). Sensitivities of the technetium-scan (SPECT ratio ≥1.5), temporal bone computed tomography (CT), and gallium-scan (SPECT ratio ≥1.3) were: 78.7%, 48.8%, and 31.4%, respectively. Gallium-scan results correlated positively with CT bone involvement (p=0.002) and hospital length of stay (p=0.0014). C-reactive protein (CRP) level correlated with hospital length of stay (p=0.028) and positive technetium-scan results (p=0.012). Fungal infection had a higher technetium SPECT ratio (2.16 vs. 1.77, p=0.04), gallium SPECT ratio (1.4 vs. 1.2, p=0.02), longer duration of systemic treatment (87.4 vs. 37.9 days, p=0.014), and longer hospital length of stay (31.6 vs. 15.2 days, p=0.004) compared to non-fungal infection. Eight (17%) patients had responded poorly to treatment. Fungal pathogens, facial nerve paresis, extra-auricular, and bilateral disease were more prevalent among the non-responders.

CONCLUSION

The technetium scan has higher sensitivity than temporal bone CT for diagnosing NOE. The gallium scan and CRP correlated well with hospital length of stay. A high rate of fungal infection was found, with significantly higher technetium and gallium SPECT ratios and worse outcome compared to bacterial infection. Fungal NOE remains therapeutically challenging.

A ready-to-use, thermoresponsive, and extended-release delivery system for the paranasal sinuses

A drug delivery system for the paranasal sinuses consisting of a freeze-dried thermoresponsive hydrogel with degradable microspheres, called FD-TEMPS (Freeze Dried-Thermogel, Extended-release Microsphere-based delivery to the Paranasal Sinuses), was developed. Glass transition temperatures (Tg') of the maximally freeze concentrated solutions consisting of poly(N-isopropylacrylamide) (pNIPAAm) and polyethylene glycol (PEG) were determined by differential scanning calorimetry, which informed optimization of the thermogel formulation. By replacing low molecular weight (MW) PEG (200 Da) with a higher MW PEG (2000 Da), the resulting freeze-dried gel exhibited a brittle texture, porous structure, and low residual moisture (< 3% measured by thermal gravimetric analysis). When combined with poly(lactic-co-glycolic acid) microspheres (PLGA MSs) and freeze dried, the complete system (FD-TEMPS) exhibited enhanced shelf-stability. Specifically, the smooth, spherical morphology of the MSs and initial release kinetics were maintained following 6 weeks of storage under ambient conditions. Furthermore, FD-TEMPS remained in place after application to a simulated mucosal surface, suggesting that it could be more uniformly distributed along the sinonasal mucosa in vivo. Freeze drying enables this delivery system to be stored as a ready-to-use product for better ease of clinical translation without compromising the thermoresponsive or sustained release characteristics that would enable local delivery of therapeutics to the sinonasal mucosa.

Individual symptom visual analogue scale severity scores for determining EPOS guideline-based chronic rhinosinusitis disease control

BACKGROUND

The goal of this study was to determine how to translate visual analogue scale (VAS) symptom scores to the binary, descriptive symptom scales used in the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) criteria for chronic rhinosinusitis (CRS) disease control.

METHODS

309 CRS patients were recruited. All patients rated their burden of 5 symptoms (nasal blockage, rhinorrhea/postnasal drip, facial pain/pressure, smell loss, sleep disturbance or fatigue) using the binary EPOS descriptive symptom scales and a VAS (on a scale of 0 to 10). In addition, participants completed a 22-item Sinonasal Outcome Test (SNOT-22) and rated their overall CRS disease control as "controlled", "partly controlled" or "uncontrolled".

RESULTS

Symptom burdens measured by VAS, binary descriptive EPOS scale and SNOT-22 were associated with worsening CRS disease control reported by participants. Each symptom had a distinct VAS score cut-off that strongly predicted the uncontrolled option on the corresponding binary descriptive EPOS symptom scale. However, the predictive ability of VAS for rhinorrhea/ postnasal drip was disparately worse than the other 4 symptoms. When considering all symptom data simultaneously, a VAS score &gt;3.5 strongly predicted the uncontrolled option on the corresponding binary descriptive EPOS symptom scale for all 5 symptoms.

CONCLUSIONS

A VAS symptom score of &gt;3.5 translates to the uncontrolled option in the binary, descriptive symptom scale of the EPOS control criteria. The rhinorrhea/postnasal drip descriptive symptom scale translates disparately worse to VAS scores and may be considered for revision in future criteria.

Conventional Antifungals for Invasive Infections Delivered by Unconventional Methods; Aerosols, Irrigants, Directed Injections and Impregnated Cement

The administration of approved antifungals via unapproved formulations or administration routes (such as aerosol, direct injection, irrigation, topical formulation and antifungal-impregnated orthopedic beads or cement) may be resorted to in an attempt to optimize drug exposure while minimizing toxicities and/or drug interactions associated with conventional (systemic) administrations. Existing data regarding such administrations are mostly restricted to uncontrolled case reports of patients with diseases refractory to conventional therapies. Attribution of efficacy and tolerability is most often problematic. This review updates prior published summaries, reflecting the most recent data and its application by available prevention and treatment guidelines for invasive fungal infections. Of the various dosage forms and antifungals, perhaps none is more widely reported than the application of amphotericin B-containing aerosols for the prevention of invasive mold infections (notably Aspergillus spp.).

Clinical Practice Guideline: Nasal Irrigation for Chronic Rhinosinusitis in Adults

The Korean Society of Otorhinolaryngology-Head and Neck Surgery and Korean Rhinologic Society appointed a guideline development group (GDG) to establish a clinical practice guideline, and the GDG developed a guideline for nasal irrigation for adult patients with chronic rhinosinusitis (CRS). The guideline focuses on knowledge gaps, practice variations, and clinical concerns associated with nasal irrigation. Nasal irrigation has been recommended as the first-line treatment for CRS in various guidelines, and its clinical effectiveness has been demonstrated through a number of studies with robust evidence. However, no guidelines have presented a consistent nasal irrigation method. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. The committee developed 11 evidence-based recommendations. This guideline focuses on the evidence-based quality improvement opportunities deemed the most important by the GDG. Moreover, the guideline addresses whether nasal lavage helps treat CRS, what type of rinsing solution should be used, and the effectiveness of using additional medications to increase the therapeutic effect.

Facial Natural Killer/T-Cell Lymphoma: A Deadly Sinusitis Mimic

Sinusitis and pre-septal cellulitis are common emergency department (ED) conditions, though rare and lethal mimics can present in a similar manner. We present a case of natural killer (NK)/T-cell lymphoma mimicking sinusitis and pre-septal cellulitis. Diagnosis of this condition may include imaging modalities such as CT and MRI, though definitive diagnosis requires tissue biopsy. Therapeutic interventions involve chemotherapy and radiation, with little role for surgical debridement. Complications in treatment can occur including hemophagocytic lymphohistiocytosis. Despite standard treatments, mortality remains high for cases of facial lymphoma.

The Role of Comorbidities in Difficult-to-Control Asthma in Adults and Children

Assessment of asthma comorbidities, conditions that adversely affect the pathobiology of asthma or impair its response to therapies, is a fundamental step in the evaluation and management of patients with difficult-to-treat asthma. Identifying and effectively treating asthma comorbidities, such as obesity, obstructive sleep apnea, and chronic sinusitis with nasal polyps, may improve asthma control and reduce exacerbations. In addition, identifying comorbid T2 inflammatory conditions may help guide optimal selection of biologic therapies. Here, we describe common comorbid conditions found in adult and pediatric difficult-to-control asthma, discuss evidence for the association with asthma morbidity and treatment benefit, and provide information on how and when to assess comorbidities.

The Impact of Medical Comorbidities on Patient Satisfaction in Chronic Rhinosinusitis

BACKGROUND

Patient satisfaction has a significant bearing on medical therapy compliance and patient outcomes. The purpose of this study was to (1) describe patient satisfaction, as characterized by the Patient Satisfaction Questionnaire-18 (PSQ-18), in the care of patients with chronic rhinosinusitis (CRS) and (2) analyze the impact of comorbidities on satisfaction using the functional comorbidity index (FCI).

METHODS

Patient demographics, disease severity measures, and PSQ-18 scores for patients with CRS presenting to a tertiary rhinology clinic between November 2019 and April 2020 were collected and analyzed. FCI was calculated retrospectively using the electronic medical record; individual comorbidities were tabulated. Spearman's correlations followed by multivariate regression was used to assess the relationship between medical comorbidities and PSQ-18.

RESULTS

Sixty-nine patients met criteria for analysis. There were no significant differences in age, gender, and Sinonasal Outcomes Test-22 scores between CRS patients with (CRSwNP) and without (CRSsNP) nasal polyps. There was no significant difference in the mean FCI for patients with CRSwNP versus CRSsNP (5.1 and 4.3, respectively) (P = .843). Similarly, there was no significant difference in the mean sum PSQ-18 score (78/100 in both) between these cohorts (P = .148). The mean sum PSQ-18 score was not significantly associated with anxiety (P = .728), depression (P = .624), or FCI (P = .282), but was significantly associated with hearing impairment (P < .001).

CONCLUSION

Patient satisfaction in the care of CRS is generally high with a diagnosis of comorbid hearing impairment demonstrating a negative association with satisfaction in this cohort.