Medical Management and Diagnosis of Chronic Rhinosinusitis: A Survey of Treatment Patterns by United States Otolaryngologists

Background

This study was performed to identify current patterns of diagnostic criteria and medical treatment for chronic rhinosinusitis (CRS) by otolaryngologists in the United States.

Methods

A 15-item survey was mailed to a random sample of 200 members of the American Academy of Otolaryngology–Head and Neck Surgery; statistical analysis was performed.

Results

The overall response rate was 40.0%. Of respondents, 73% defined CRS as lasting >12 weeks. Seventy-three percent also believed radiological imaging was necessary for definitive diagnosis, but only 30% believed nasal endoscopy was necessary. Regarding treatment, respondents reported use of oral antibiotics (94%) and nasal corticosteroids (94%) as part of maximum medical management; oral decongestants, oral mucoevacuants, and allergy testing were used only by about one-half of the respondents, and less frequently topical decongestants (38%), oral corticosteroids (36%), and oral antihistamines (27%) were used. Oral corticosteroids were more likely to be used by specialists that self-classified as rhinologists than by other otolaryngologists (p = 0.005), but rhinologists were less likely to use radiological imaging (p = 0.04) as a diagnostic criterion. Pediatric otolaryngologists used allergy testing in medical management more frequently than other otolaryngologists (p < 0.001). Overall, the basis for choice of maximal medical management was personal clinical experience (74%), rather than clinical research results or expert recommendations.

Conclusion

We had a fairly small sample of returned surveys; therefore, our findings may not be generalizable to the entire population of U.S. otolaryngologists. Nevertheless, in our survey, U.S. otolaryngologists agree on the use of oral antibiotics and nasal corticosteroids as part of maximal medical management for CRS but do not agree on other adjuvant therapies or on the use of endoscopy as a diagnostic criterion.

S189 – Tracheotomy Tube Occlusion Status and Swallowing Function

Objectives

To compare the effects, if any, various types of tracheotomy occlusion conditions may have upon swallowing during either the videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic exam of the swallow (FEES).

Methods

Prospective, repeated measure design. Patients underwent randomized order of tracheotomy occlusion conditions (open, finger, one-way valve, capped) during selected swallows. Main outcome measures were the presence or absence of aspiration/laryngeal penetration.

Results

39 participants have completed the protocol, 19 males/20 females, mean age of 59.41 years (SD=19.31). 20 underwent the VFSS and 19 underwent FEES. The majority of participants (58.9%, 28/39) were able to safely swallow without any airway invasion under all occlusion conditions. Change in swallow function under 1 or more of the occlusion conditions was present in 25.6% (10/39) of the participants. 4 subjects had increased airway invasion with no occlusion (open), 4 with finger occlusion, and 2 while capped. One subject had less airway invasion with the 1-way valve as compared to the other conditions. One subject aspirated under all occlusion conditions.

Conclusions

No clear patterns for optimal occlusion condition for swallowing were identified. Results of this study suggest that swallowing disorders in patients with a tracheotomy tube is a multifactiorial problem and several factors may be associated with the swallowing dysfunction. Therefore, patients should be evaluated under various occlusion conditions to determine their specific optimal swallowing condition.

Strobovideolaryngoscopy and Laboratory Voice Evaluation

A complete and thorough vocal history and physical examination is the cornerstone of the evaluation of any patient who has a vocal complaint. Continued scientific progress in the understanding of vocal fold vibration and sound production combined with advances in technology have resulted in the availability of numerous supplemental diagnostic laboratory tools for an optimal voice evaluation. This article presents additional clinical tools accessible to the otolaryngologist that may aid in diagnosis and help elucidate difficult vocal tract pathology.

Effect of initial treatment on disease outcome for patients with submandibular gland carcinoma

OBJECTIVE

To elucidate the effect on outcome of initial surgical enucleation with or without definitive surgical resection and radiation therapy for patients with submandibular gland carcinoma.

DESIGN

Retrospective clinicopathological review.

SETTING

Tertiary referral center.

PATIENTS

Eighty-seven consecutive patients (mean follow-up, 8.7 years) with primary submandibular gland carcinoma.

MAIN OUTCOME MEASURES

Review of proven cases of primary carcinomas of the submandibular gland treated at our institution during a 33-year period to determine the effect of the type of biopsy and subsequent treatment on locoregional disease control, disease-specific survival, and overall survival.

RESULTS

There was no statistically significant difference in locoregional disease control, disease-specific survival, or overall survival between patients undergoing enucleation of the gland vs patients undergoing enucleation of the gland followed by definitive surgical resection before any radiation therapy. There were no locoregional recurrences among 28 patients treated with enucleation and radiation therapy, compared with 3 locoregional recurrences (7%) among 42 patients treated with enucleation followed by definitive surgical resection before any radiation therapy. Twenty-nine (69%) of 42 patients undergoing a second surgical procedure had evidence of residual carcinoma in the final surgical specimen.

CONCLUSIONS

En bloc surgical resection followed by radiation therapy remains the standard treatment for patients with submandibular gland carcinoma. Patients without clinical and radiographic evidence of disease after enucleation may be adequately treated with subsequent radiation therapy. Definitive surgical resection remains the treatment of choice for patients with clinical or radiographic evidence of disease after enucleation of the gland.

Medical management and diagnosis of chronic rhinosinusitis: A survey of treatment patterns by United States otolaryngologists

BACKGROUND

This study was performed to identify current patterns of diagnostic criteria and medical treatment for chronic rhinosinusitis (CRS) by otolaryngologists in the United States.

METHODS

A 15-item survey was mailed to a random sample of 200 members of the American Academy of Otolaryngology-Head and Neck Surgery; statistical analysis was performed.

RESULTS

The overall response rate was 40.0%. Of respondents, 73% defined CRS as lasting >12 weeks. Seventy-three percent also believed radiological imaging was necessary for definitive diagnosis, but only 30% believed nasal endoscopy was necessary. Regarding treatment, respondents reported use of oral antibiotics (94%) and nasal corticosteroids (94%) as part of maximum medical management; oral decongestants, oral mucoevacuants, and allergy testing were used only by about one-half of the respondents, and less frequently topical decongestants (38%), oral corticosteroids (36%), and oral antihistamines (27%) were used. Oral corticosteroids were more likely to be used by specialists that self-classified as rhinologists than by other otolaryngologists (p = 0.005), but rhinologists were less likely to use radiological imaging (p = 0.04) as a diagnostic criterion. Pediatric otolaryngologists used allergy testing in medical management more frequently than other otolaryngologists (p < 0.001). Overall, the basis for choice of maximal medical management was personal clinical experience (74%), rather than clinical research results or expert recommendations.

CONCLUSION

We had a fairly small sample of returned surveys; therefore, our findings may not be generalizable to the entire population of U.S. otolaryngologists. Nevertheless, in our survey, U.S. otolaryngologists agree on the use of oral antibiotics and nasal corticosteroids as part of maximal medical management for CRS but do not agree on other adjuvant therapies or on the use of endoscopy as a diagnostic criterion.

Superiority of an intranasal corticosteroid compared with an oral antihistamine in the as-needed treatment of seasonal allergic rhinitis

BACKGROUND

The daily use of either intranasal corticosteroids or histamine(1) (H(1)) receptor antagonists has proved to be efficacious in the treatment of seasonal allergic rhinitis. Most patients, however, use these medications as needed. Our objective was to compare the effectiveness of as-needed use of H(1) receptor antagonists with that of intranasal corticosteroids in the treatment of seasonal allergic rhinitis.

METHODS

We performed a randomized, open-label, parallel-group study comparing the as-needed use of an H(1) receptor antagonist (loratadine) with that of an intranasal corticosteroid (fluticasone propionate) in the management of fall seasonal allergic rhinitis in the fall of 1999. Subjects kept a diary of their daily symptoms and were examined at enrollment into the study and biweekly for 4 weeks during treatment. Outcome measures were the Rhinoconjunctivitis Quality of Life Questionnaire score, daily symptom diary scores, and the number of eosinophils and the levels of eosinophilic cationic protein in nasal lavage samples.

RESULTS

Patients in the fluticasone-treated group reported significantly better scores in the activity, sleep, practical, nasal, and overall domains (P<.05) of the Rhinoconjunctivitis Quality of Life Questionnaire. The median total symptom score in the fluticasone-treated group was significantly lower than that in the loratadine-treated group (4.0 vs 7.0; P<.01). After treatment, the number of eosinophils was significantly smaller in the fluticasone-treated group compared with the loratadine-treated group (P =.001). Eosinophilic cationic protein levels followed the same pattern, with a significant correlation between the levels of eosinophilic cationic protein and the number of eosinophils (r(s) = 0.70, P<.01).

CONCLUSION

As-needed intranasal corticosteroids reduce allergic inflammation and are more effective than as-needed H(1) receptor antagonists in the treatment of seasonal allergic rhinitis.