Prevalence of asthma, aspirin sensitivity and allergy in chronic rhinosinusitis: data from the UK National Chronic Rhinosinusitis Epidemiology Study

BACKGROUND

Chronic rhinosinusitis (CRS) is a common disorder associated with other respiratory tract diseases such as asthma and inhalant allergy. However, the prevalence of these co-morbidities varies considerably in the existing medical literature and by phenotype of CRS studied. The study objective was to identify the prevalence of asthma, inhalant allergy and aspirin sensitivity in CRS patients referred to secondary care and establish any differences between CRS phenotypes.

METHODS

All participants were diagnosed in secondary care according to international guidelines and invited to complete a questionnaire including details of co-morbidities and allergies. Data were analysed for differences between controls and CRS participants and between phenotypes using chi-squared tests.

RESULTS

The final analysis included 1470 study participants: 221 controls, 553 CRS without nasal polyps (CRSsNPs), 651 CRS with nasal polyps (CRSwNPs) and 45 allergic fungal rhinosinusitis (AFRS). The prevalence of asthma was 9.95, 21.16, 46.9 and 73.3% respectively. The prevalence of self-reported confirmed inhalant allergy was 13.1, 20.3, 31.0 and 33.3% respectively; house dust mite allergy was significantly higher in CRSwNPs (16%) compared to CRSsNPs (9%, p < 0.001). The prevalence of self- reported aspirin sensitivity was 2.26, 3.25, 9.61 and 40% respectively. The odds ratio for aspirin sensitivity amongst those with AFRS was 28.8 (CIs 9.9, 83.8) p < 0.001.

CONCLUSIONS

The prevalence of asthma and allergy in CRS varies by phenoytype, with CRSwNPs and AFRS having a stronger association with both. Aspirin sensitivity has a highly significant association with AFRS. All of these comorbidities are significantly more prevalent than in non-CRS controls and strengthen the need for a more individualised approach to the combined airway.

Atypical presentation of Bezold's and Citelli's abscesses, with recollection following an incomplete postoperative course of antibiotics

Bezold's and Citelli's abscesses are rare complications of otitis media. We present a case of a 44-year-old Eastern European man, with a history of recurrent otitis media, who was admitted to hospital with mastoiditis and initially treated with antibiotics. Despite clinical improvement, a CT scan showed mastoiditis with Bezold's and Citelli's abscesses. The patient underwent a myringotomy and grommet insertion, in addition to a cortical mastoidectomy and curettage of the neck abscesses. After a good recovery, he was discharged home. However, likely due to the language barrier, he did not complete a course of antibiotics as prescribed, and the abscess re-collected, necessitating a re-admission and re-operation. This report illustrates the importance of considering rare features of a common disease in the differential, and of communication in ensuring compliance.

A case-control study of medical, psychological and socio-economic factors influencing the severity of chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a common and debilitating disorder. Little is known about the epidemiology of this disease. The aims of the study were to identify differences in socio-economic variables and quality of life between patients with chronic rhinosinusitis and healthy controls, to identify any significant associations between CRS and other medical co-morbidities, psychiatric disease or environmental exposure and to explore the experience of CRS from the perspective of CRS sufferers.

METHODS

Participants were recruited from ENT clinics from 30 centres across the UK. They completed a study-specific questionnaire considering environmental, medical and socio-economic factors, and SF-36 and SNOT-22 scores. All participants with CRS were diagnosed by a clinician and categorised as having CRS (with polyposis, without polyposis or allergic fungal rhinosinusitis (AFRS)). Controls included family and friends of those attending ENT outpatient clinics and hospital staff who had no diagnosis of nose or sinus problems and had not been admitted to hospital in the previous 12 months.

RESULTS

A total of 1470 study participants (1249 patients and 221 controls) were included in the final analysis. Highly significant differences were seen in generic and disease-specific quality of life scores between CRS sufferers and controls; mean SNOT-22 score 45.0 for CRS compared with 12.1 amongst controls. There were no clear differences in socioeconomic variables including social class, index of multiple deprivation and educational attainment between cases and controls. Common comorbidities with a clear association included respiratory and psychiatric disorders, with a higher frequency of reported upper respiratory tract infections.

CONCLUSIONS

CRS is associated with significant impairment in quality of life and with certain medical co-morbidities. In contrast to other common ENT disorders, no socioeconomic differences were found between patients and controls in this study.

Assessing the safety and efficacy of drugs used in preparing the nose for diagnostic and therapeutic procedures: a systematic review

BACKGROUND

Local anaesthetics and vasoconstrictors are essential for pain control and to aid intra-operative haemostasis in nasal procedures. They also improve access, and reduce discomfort when performing nasal endoscopy. There are no clear guidelines on preparing the nose despite evermore diagnostic and therapeutic procedures utilising the nose as a point of access.

OBJECTIVE OF REVIEW

This review aims to identify nasal preparations used in diagnostic and therapeutic nasal procedures and to examine their safety and efficacy.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

A search was carried out using PubMed, MEDLINE, Ovid EMBASE, the Cochrane library and references from the included articles.

EVALUATION METHOD

The inclusion criteria included: full-text English language articles with regard to nasal preparation for surgery. Case reports, systematic reviews, meta-analysis, double-blind placebo controlled randomised trials (RCTs) and case series were included.

RESULTS

A total of 53 articles were retrieved: 13 articles on nasal preparation for operative procedures, six on functional endoscopic sinus surgery and 22 on nasendoscopy as well as six case reports. Cocaine was the most widely used topical preparation for operative procedures but was associated with more side-effects; thus, topical tetracaine and levobupivacaine infiltration are alternatives with equivalent efficacy but reduced adverse effects. All articles reviewed for functional endoscopic sinus surgery used a mixture containing lidocaine, adrenaline or both. Flexible nasendoscopy causes minimal patient discomfort and preparation is only recommended in selected patients, in contrast to rigid nasendoscopy which requires preparation.

CONCLUSION

For operative procedures, such as septorhinoplasty, a single agent tetracaine or levobupivicaine provides an improved surgical field. In functional endoscopic sinus surgery, lidocaine-adrenaline preparations have resulted in significantly better surgical and patient outcomes. There is little evidence to support the routine use of pre-procedural nasal preparation for flexible nasendoscopy. Those undergoing rigid endoscopy conversely always require the use of a vasoconstrictor and local anaesthetic. Pre-procedure assessment of patients is recommended, with agents being reserved for those with low pain thresholds, high anxiety and small nasal apertures presenting resistance to the insertion of the endoscope.

The burden of revision sinonasal surgery in the UK-data from the Chronic Rhinosinusitis Epidemiology Study (CRES): a cross-sectional study

OBJECTIVES

The aim of this study was to investigate the surgical revision rate in patients with chronic rhinosinusitis (CRS) in the UK CRS Epidemiology Study (CRES). Previous evidence from National Sinonasal Audit showed that 1459 patients with CRS demonstrated a surgical revision rate 19.1% at 5 years, with highest rates seen in those with polyps (20.6%).

SETTING

Thirty secondary care centres around the UK.

PARTICIPANTS

A total of 221 controls and 1249 patients with CRS were recruited to the study including those with polyps (CRSwNPs), without polyps (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS).

INTERVENTIONS

Self-administered questionnaire.

PRIMARY OUTCOME MEASURE

The need for previous sinonasal surgery.

RESULTS

A total of 651 patients with CRSwNPs, 553 with CRSsNPs and 45 with AFRS were included. A total of 396 (57%) patients with CRSwNPs/AFRS reported having undergone previous endoscopic nasal polypectomy (ENP), of which 182 of the 396 (46%) reported having received more than one operation. The mean number of previous surgeries per patient in the revision group was 3.3 (range 2-30) and a mean duration of time of 10 years since the last procedure. The average length of time since their first operation up to inclusion in the study was 15.5 years (range 0-74). Only 27.9% of all patients reporting a prior ENP had received concurrent endoscopic sinus surgery (ESS; n=102). For comparison, surgical rates in patients with CRSsNPs were significantly lower; 13% of cases specifically reported ESS, and of those only 30% reported multiple procedures (χ(2) p<0.001).

CONCLUSIONS

This study demonstrated that there is a high burden of both primary and revision surgery in patients with CRS, worst in those with AFRS and least in those with CRSsNPs. The burden of revision surgery appears unchanged in the decade since the Sinonasal Audit.

Audit of Patients Undergoing Thyroid Surgery in an Attempt to Improve the Standard of Care

Objectives:

Improve the standard of care for patients undergoing thyroid surgery. Recognized complications include hypocalcemia and recurrent laryngeal nerve (RLN) damage. We aimed to review our practice and improve it by adhering to the criteria set out by the National Institute of Clinical Excellence (NICE).

Methods:

Retrospective audit looking at patients undergoing thyroid surgery over a 6-month period (09/2012). Pro forma methods were used to establish the adequacy of documentation including the use of nerve monitoring equipment, identification and stimulation of the RLN, and the recording of pre- and postoperative vocal cord checks (n = 18). Retrospective re-audit after recommendations to complete the loop (n = 8) over a 4-month period.

Results:

The first part of the audit cycle identified haphazard management of calcium levels in the postoperative period, incomplete documentation of vocal cord checks, and RLN identification and testing during surgery. Recommendations and guidance to staff, as well as a revised protocol on calcium management, resulted in improved care overall following re-audit. In part 2 of the audit cycle; only 1 patient became hypocalcemic in the postoperative period and was managed successfully following the protocol. RLN detection, testing, and monitoring were documented in all patients. The 2nd loop showed that all patients were receiving documented RLN identification and stimulation intraoperatively; all patients had documented pre- and postoperative cord checks and use of a nerve monitor (n=10).

Conclusions:

The audit shows we were able to meet the criteria set out by NICE.

Otological Effects of Low-Frequency Noise: Case of Wind Turbine Syndrome from a Successful Plaintiff

Objectives:

Symptoms including tinnitus, otalgia, and vertigo have been reported following exposure to wind turbine noise; a condition termed wind turbine syndrome (WTS). We describe a case of an individual suffering following exposure and analyze the evidence for the detrimental physiologic effects of infrasound and low-frequency noise, thereby questioning the existence of WTS.

Methods:

Case report (2013) and literature analysis on articles published within the past 10 years, conducted using the PubMed database and Google Scholar search engine, which included in their title or abstract the terms “wind turbine,” “infrasound,” or “low frequency noise.”

Results:

In our case the patient suffered with the symptoms of WTS and was able to challenge the wind turbine company in court. There is evidence that infrasound has a physiologic effect on the ear, but the overwhelming opinion emerging is that there is no clear evidence that WTS exists, and that the overriding factor is annoyance and the fiscal implications of living near a turbine or wind farm. The literature lacks any convincing evidence that low frequency noise causes significant physiological effects.

Conclusions:

We present a case of a successful plaintiff with all the symptoms of WTS. Although there is some evidence of symptoms in patients exposed to wind turbine noise, our group feels that the symptoms of WTS are vague and can be attributed to psychosomatic factors and annoyance due to the proximity to low frequency whirring, rather than a true physiological impairment.

Lipoma of the pinnal helix: a very unusual location for a very common tumour

Lipomas are common benign tumours but can present in unusual locations. The authors present the rare case of a pedunculated lipoma of the pinnal helix. The lipoma was excised with good cosmetic result. Lipoma of the cartilaginous pinnal helix is rare and has not been described previously in the literature.

Using a microscope to change a speech valve

Replacing a speech valve can be a difficult procedure to learn and perform. In this letter the authors propose a method using an operating microscope, which their department has found useful in performing this procedure, and in teaching trainees.

Unilateral blindness secondary to acute sphenoid sinusitis

OBJECTIVES

To highlight a rare scenario where a delay in diagnosis caused unilateral blindness.

CASE REPORT

A 45-year-old Aboriginal woman with a history of non-Hodgkin's lymphoma presented with a severe left-sided headache, pyrexia and positive blood cultures. Following admission, the patient rapidly developed unilateral blindness, but did not inform her physician until 21 hours after onset. High-resolution CT scanning of the sinuses showed erosion of the bony covering of the optic nerve. Sinus surgery was performed.

RESULTS

Despite the discovery of pus under considerable pressure, and clearing the sphenoid sinus of pus and debris, vision was not restored, even at 2-month follow-up.

CONCLUSIONS

Two pathological processes are postulated here: that erosion of the bony optic canal allowed the optic nerve to be exposed, allowing the ensuing sinusitis to cause irreversible nerve ischemia, and immunosuppression meant the patient's immune response was inadequate to cope with the sinusitis, with devastating effects.