Optimizing cryopreservation of nasal polyp tissue for cellular functional studies and single-cell RNA sequencing

KEY POINTS

Mast cell numbers were reduced in samples cryopreserved as whole tissue chunks. Thawed epithelial cells had reduced proliferation rates when preserved as dissociated cell suspensions. The right cryopreservation method to choose may depend on the goals and cell-type focus of the project.

Dupilumab prevents nasal epithelial function alteration by IL-4 in vitro: Evidence for its efficacy

BACKGROUND

Chronic rhinosinusitis with nasal polyp (CRSwNP) is a typical type 2 inflammation involving interleukin (IL)-4 and IL-13. Dupilumab is a fully human monoclonal antibody targeting IL-4 receptor α subunit, thereby blocking signaling by both cytokines. Our hypothesis was that IL-4 and IL-13, by inducing a severe epithelial dysregulation, are involved in CRSwNP pathogenesis. This study aimed to evaluate the in vitro direct effect of IL-4, IL-13, and dupilumab on nasal epithelial functions.

METHODS

Nasal polyps and control mucosa from 28 patients, as well as human nasal epithelial cells (HNEC) from 35 patients with CRSwNP were used. Three major epithelial functions were investigated: the epithelial barrier function (characterized by transepithelial electrical resistance measurements and tight junction protein expression), the ciliary motion (characterized by the ciliary beating efficiency index), and wound healing (characterized by the wound repair rate) under various stimulations (IL-4, IL-13, and dupilumab). The main outcome was a significant change in epithelial functions following exposure to IL-4, IL-13, and dupilumab for 48 h in the basal media.

RESULTS

IL-4 (1, 10, and 100 ng/mL) but not IL-13 induced a significant decrease in occludin and zonula-occludens protein expression, ciliary beating efficiency, and wound repair rate in HNEC. Dupilumab (0.04 mg/mL) had no effect on HNEC and specifically restored all epithelial functions altered when cells were exposed to a 48-h IL-4 stimulation.

CONCLUSION

Dupilumab, in vitro, restored epithelial integrity by counteracting the effect of IL-4 on the epithelial barrier (increased epithelial permeability, decreased ciliary beating efficiency, and decreased wound repair rate).

Accessing the Eustachian tube: Conventional nasal spray vs. exhalation delivery system and the impact of targeted endoscopic sinus surgery on topical distribution patterns

BACKGROUND

Eustachian tube dysfunction (ETD) may occur distinct from, or in conjunction with, chronic rhinosinusitis (CRS+ETD). Intranasal corticosteroid sprays are often prescribed for ETD, although ET distribution may be limited. To date, no anatomic studies compare nasopharynx (NP) distribution between conventional nasal sprays (NS) and exhalation delivery systems (EDS) after surgery. This study utilizes a cadaver model to examine topical NP delivery using EDS vs. NS before and after targeted endoscopic sinus surgery (ESS).

METHODS

Sixteen sinonasal cavities were administered fluorescein solution via NS and EDS before and after maxillary antrostomy and anterior ethmoidectomy, followed by nasal endoscopy of the NP and ET orifice. Seven blinded experts submitted staining ratings of endoscopy images on a 0- to 3-point scale, with ratings averaged for analysis.

RESULTS

Interrater reliability was excellent (intraclass correlation, 0.956). EDS was associated with significantly greater NP staining vs. NS in a pooled cohort of nonsurgical and ESS specimens (1.19 ± 0.81 vs. 0.78 ± 1.06; p = 0.043). Using a logistic regression model, EDS significantly outperformed NS in nonsurgical (odds ratio [OR], 3.49; 95% confidence interval [CI], 1.21-10.09; p = 0.021) and post-ESS (OR, 9.00; 95% CI, 1.95-41.5; p = 0.005) specimens, with the greatest relative staining observed for EDS after targeted ESS (OR, 18.99; 95% CI, 3.44-104.85; p = 0.001).

CONCLUSIONS

EDS is more effective than NS in topical delivery to the NP and ET orifices in cadavers. Targeted ESS may facilitate greater NP penetration by EDS compared with NS, with possible synergism after ESS for augmented delivery. These findings suggest a role for EDS delivery methods for ETD management and in CRS+ETD patients undergoing sinus surgery.

Prevalence of type 2 inflammatory signatures and efficacy of dupilumab in patients with chronic rhinosinusitis with nasal polyps from two phase 3 clinical trials: SINUS-24 and SINUS-52

BACKGROUND

This post hoc analysis of the international SINUS-24/-52 trials (NCT02912468/NCT02898454) aimed to assess dupilumab efficacy in patients with severe chronic rhinosinusitis with nasal polyps (CRSwNP) according to different definitions of type 2 inflammatory signature.

METHODS

Six definitions of type 2 inflammation were used: ≥150 eosinophils/μL or total immunoglobulin E (IgE) ≥100 IU/mL with a coexisting type 2 condition; ≥150 eosinophils/μL or total IgE ≥100 IU/mL; ≥150 eosinophils/μL; ≥250 eosinophils/μL or total IgE ≥100 IU/mL; coexisting asthma or ≥300 eosinophils/μL; presence of a coexisting type 2 condition. Odds ratios (ORs; dupilumab vs. placebo) for achieving clinically meaningful improvement (≥1 point) from baseline to week 24 (pooled SINUS-24/-52) and week 52 (SINUS-52) were calculated for nasal polyp score (NPS; range 0-8), nasal congestion/obstruction score (NC; 0-3), and loss of smell score (LoS; 0-3).

RESULTS

At baseline (n = 724), most patients displayed a type 2 inflammatory signature across definitions (64.2%-95.3%). At week 24, ORs for clinically meaningful improvement ranged from 11.9 to 14.9 for NPS across type 2 definitions, 6.5-9.6 for NC, and 12.2-17.8 for LoS (all p < 0.0001). OR ranges were similar or greater at week 52: 19.0-36.6, 7.6-12.1, and 9.2-33.5, respectively (all p < 0.0001).

CONCLUSION

Most patients with CRSwNP in the SINUS study had type 2 inflammation. Dupilumab demonstrated robust efficacy across definitions of type 2 inflammation, consistent with its profile as an inhibitor of Interleukin-4 and Interleukin-13 signaling, key and central drivers of type 2 inflammation in CRSwNP.

KEY POINTS

This study assessed type 2 inflammation prevalence and dupilumab efficacy in chronic rhinosinusitis with nasal polyps according to algorithm-defined type 2 inflammation Dupilumab efficacy was similar across all type 2 definitions.

Three-Dimensional (3D) Printing in the Case of a Concurrent Polyp and an Ectopic Tooth

The removal of an ectopic molar tooth at the pterygomaxillary junction may be challenging. This paper presents the use of three-dimensional (3D) printing of the paranasal sinus for careful planning in a way that reduces the risk and makes surgical procedures more effective. A 26-year-old gentleman presented to the ENT department with a left antrochoanal polyp and an incidental ectopic tooth at the pterygomaxillary junction. Pre-operative 3D reconstruction of the maxillary cavity and subsequent 3D printing were used to guide the surgery and counsel the patient on potential outcomes. Left anterior functional endoscopic sinus surgery was subsequently done, and the antrochoanal polyp was completely removed. The preoperative computed tomography scan allowed for the production of the printed model to the exact size and dimensions of the ectopic molar tooth to facilitate the planning of the surgery and to aid in consenting the patient for the treatment.

Impact of long-term nasal airflow deprivation on sinonasal structures and chronic rhinosinusitis in total laryngectomy patients

Objective

Total laryngectomy (TL) patients are good models in which to evaluate the effects of nasal airflow cessation on the sinonasal tract. Here, we evaluated changes in sinonasal structures and association with sinus opacification in the computed tomography (CT) images 3 years post-TL.

Methods

Patients who underwent TL from 2005 to 2017 in a teaching academic center were reviewed retrospectively. Patients with a final follow-up CT taken less than 3 years after TL, tracheoesophageal puncture, inadequate CT image, or history of sinonasal surgery were excluded. The control group included patients who underwent a partial laryngectomy or hypopharyngectomy without requiring a tracheotomy for more than a month. Altogether, 45 TL patients and 38 controls were selected. The volume of all four paranasal sinuses, inferior turbinate soft tissue volume (ITSTV), maxillary sinus natural ostium (MSNO) mucosal width, and Lund-Mackay scores (LMS) were measured on preoperative and postoperative CT scans.

Results

The mean duration between surgery and the final CT scan was 6.3 ± 2.4 and 5.5 ± 2.3 years for the TL and control groups, respectively. Neither group showed significant changes in the four paranasal sinuses' volume or MSNO mucosa width. The ITSTV decreased significantly, from 4.6 ± 1.3 to 2.8 ± 1.1 mL (p < .001), in the TL group, regardless of the presence of nasal septal deviation, showing ITSTV reduction on both concave and convex sides. By contrast, the control group showed no significant changes in ITSTV. Postoperative LMS changes in both groups were insignificant. The number of patients with LMS aggravation or alleviation was the same in both groups, regardless of preoperative sinus opacification.

Conclusions

Paranasal sinus structures and sinus opacification are not affected significantly by nasal airflow cessation; however, the inferior turbinate mucosa is affected by long-term discontinuation of nasal airflow.

Level of Evidence

4 (case-control study).

Clinical characteristics analysis of sinonasal diffuse large B-cell lymphoma and extranodal NK/T-cell lymphoma

KEYPOINTS

Extranodal NK/T-cell lymphoma (ENKL) was the most common sinonasal lymphoma at our hospital. ENKL occurs at a younger age, and is more prevalent in the nasal cavity. ENKL had a lower Ann Arbor stage, and a better prognosis than diffuse large B-cell lymphoma (DLBLC).

Early increase in eosinophil count may predict long-term hypereosinophilia during dupilumab treatment: a 2-year observational study

KEY POINTS

In a limited subset of patients, dupilumab-induced hypereosinophilia is persistent. Two-month follow-up eosinophil count may predict long-lasting hypereosinophilia.

Carolyn's Window Approach to Unilateral Frontal Sinus Surgery

OBJECTIVES

Due to the complexity and variety of the frontal recess and sinus anatomy, traditional Draf 2a frontal sinus surgery is challenging. The thickness of the nasofrontal beak and anterior-posterior dimensions of the frontal recess contribute to this complexity. Carolyn's window technique eliminates the limitation of anterior-posterior depth to facilitate a Draf 2a frontal sinusotomy. The approach is a 0° endoscope technique and provides an excellent view of the frontal sinus and recess. We describe Carolyn's window approach to frontal sinus surgery and the perioperative outcomes.

METHODS

Consecutive adult patients in whom Carolyn's window technique was applied for frontal sinus dissection as part of the endoscopic management of both inflammatory and neoplastic disease were assessed. The primary outcome was frontal sinus patency. Secondary outcomes were surgical morbidity, defined as early (<90 days) or late (>90 days).

RESULTS

Forty-five patients (49.1 ± 17.9 years, 48.9% Female) were assessed. All patients had successful frontal sinus patency (100% [95CI: 92.1%-100%]). Morbidities were adhesion (4.8%), crusting (2.4%), pain (1.2%), and bleeding (1.2%) in the early postoperative period. There were no other morbidities in the early and late postoperative periods.

CONCLUSION

Carolyn's window approach to frontal sinusotomy is a technique that evolves from previously described approaches. Successful frontal sinus patency with very low morbidities is achieved while still working with a 0° endoscope. The "axillectomy" performed simplifies frontal recess surgery by removing the anteroposterior diameter limitation and the dexterity required in angled endoscopy and instrumentation. The inferior-based lateral wall mucosal flap and free mucosal grafting expedite the mucosal healing process. Laryngoscope, 133:2496-2501, 2023.

Prevalence and Associated Factors of Medication Non-Adherence in CRS Patients following Endoscopic Sinus Surgery

This study aimed to evaluate factors that may predispose patients to not adhere to prescribed medication after endoscopic sinus surgery (ESS) and to compare SNOT-22 scores at 0-12 months post-operatively between adherent and non-adherent patients. CRS patients who underwent ESS between 2012 and 2016 were recruited to this retrospective cohort study. Adherence was assessed through a questionnaire and review of medical notes. Ninety-four participants were included (61% male, mean age 60). Of those, 66% did not adhere to their prescribed post-operative CRS medication timing or dosage. The most common reason for non-adherence was improvement of symptoms (17%), followed by deterioration of symptoms (11%) and side effects (10%). Post-operative SNOT-22 scores were lowest for non-intentionally non-adherent (NINA) participants with a mean of 10.5 [95% CI: 7.47-13.5], compared to 25.0 for intentionally non-adherent (INA) [95% CI: 17.6-32.4] and 17.7 for adherent patients [95% CI: 13.7-21.7], p = 0.01. This study identifies that almost two-thirds of patients are not compliant with CRS medications after ESS. NINA participants reported lower post-operative SNOT-22 scores compared to INA and adherent participants. Future studies should focus on educating patients to continue with medications post-operatively despite an initial improvement in symptoms.

Sinonasal and Orbital Imaging Findings in COVID-Associated Rhino-Orbito-Cerebral Mucormycosis During the Second Wave of COVID-19: A Retrospective Cohort Study in a Tertiary Hospital in Central India

Background Mucormycosis is a consequence of the angioinvasive disease caused by filamentous fungi that belong to the order Mucorales, particularly Mucor, Rhizopus, and Rhizomucor. Rhizopus oryzae is the most prevalent form. The invading hyphae lead to damage of blood vessels leading to thrombosis and consequent tissue necrosis. The incidence of this disease entity witnessed a significant rise during the second wave of the coronavirus disease 2019 (COVID-19) pandemic. Timely diagnosis and prompt treatment are crucial to diminish both the mortality and morbidity associated with this disease. Imaging plays a pivotal role in diagnosing the ailment, evaluating its extent, identifying complications such as thrombosis, and facilitating surgical planning. It demonstrates exceptional sensitivity in detecting the disease at its early stages, often before symptoms manifest. Due to the angioinvasive nature of Mucor, early detection assumes utmost importance as it necessitates intensive antifungal therapy and the removal of devitalized tissue through debridement. Methodology We conducted a retrospective cohort study to analyze computed tomography (CT) imaging findings in patients with COVID-associated rhino-orbito-cerebral mucormycosis (ROCM) confirmed by histopathological examination. We compared these findings with CT findings of the nose and paranasal sinuses in patients without mucor following COVID-19 sinusitis (non-ROCM). Results All 16 cases in the non-ROCM group were in stage 1 disease. In contrast, in the ROCM group, three patients had stage 1 disease, five patients had stage 2 disease, and 10 patients had stage 3 disease (p = 0.0001). The pterygopalatine fossa was significantly affected in 10 of 18 ROCM patients and in none of the non-ROCM patients. Conclusions Imaging plays a crucial role in the early detection of mucormycosis. It assists treating physicians in initiating prompt and aggressive treatment, thereby improving the prognosis of this frequently fatal disease.

Endoscopic-Modified Medial Maxillectomy for the Nonfunctioning Maxillary Sinus

BACKGROUND

Middle meatal antrostomy (MMA) is the traditional intervention for chronic maxillary sinusitis but often fails to correct a nonfunctioning maxillary sinus that has lost its capability for mucociliary clearance. Endoscopic-modified medial maxillectomy (EMMM) can reshape the maxillary sinus and avoid a "sumping" effect, preventing secondary bacterial colonization, encouraging dependent drainage, and promoting effective nasal irrigation.

OBJECTIVES

We describe a modification of the EMMM surgical technique in patients with recalcitrant maxillary sinusitis and perioperative outcomes.

METHODS

Consecutive adult patients with nonfunctioning maxillary sinuses managed with EMMM were assessed. Primary outcomes were the resolution of the presenting symptom and the absence of mucostasis. Secondary outcomes were early (<90 days) and late (>90 days) morbidity.

RESULTS

Fifty-seven patients (51.7  ±  17.5 years, 56.1% female) were assessed. Fifty-two patients had complete resolution of their presenting symptom (91.2% [95% CI: 80.7-97.1]) and 52 patients had an absence of mucostasis (91.2% [95% CI: 80.7-97.1]). Those with persistent crusting were also those with symptoms. Early morbidities included temporary dysesthesia (3.2%), bleeding (1.1%), and pain (3.2%), with no late morbidities.

CONCLUSION

EMMM is a robust approach for salvaging a nonfunctioning maxillary sinus. The procedure enhances nasal irrigation, supplants mucociliary clearance, and discourages dependent mucus retention.

What do we mean when we have a "sinus infection?"

INTRODUCTION

Sinus infections are a common reason patients seek medical care. However, the intended meaning of the term sinus infection among patients and otolaryngologists is incompletely understood.

METHODS

In this multi-institutional cross-sectional study, a semantics-based questionnaire was provided to consecutive patients presenting to otolaryngology clinics at six academic centers from June 2020 until May 2021. The primary outcome was respondent definitions for sinus infection from a list of 28 proposed terms covering six general categories. Secondary outcome measures included differences between geographic regions.

RESULTS

Responses were obtained from 560 patients (54% female, mean age 48.9 years) and 29 otolaryngologists (42% female, mean age 37.4 years). Patients and otolaryngologists selected a median of 10 and 11 terms, respectively, to define a sinus infection. Among patients the most frequently selected symptom categories were mucus (500, 89.3%), pressure/pain (480, 85.7%), and airflow (468, 83.6%). Compared to patients, clinicians selected with greater frequency the symptom categories of pressure/pain (14.3% difference; 95% CI, 7.6% to 22.5%), mucus (10.7% difference; 95% CI, 4.7% to 18.3%) and airflow (13.0% difference; 95% CI, 4.8% to 21.7%). Multiple categories were selected by 96% of patients and 100% of providers.

CONCLUSION

The definition of sinus infection appears variable for both patients and otolaryngologists, though patients appear to apply a broader range of symptoms to the term sinus infection. There were no pronounced geographic differences in the description of a sinus infection in this US sample population. Patients commonly described sinus infection in the context of pain-related symptoms. Appreciation of these semantic differences may enable more effective patient-clinician communication.

Features of Odontogenic Sinusitis Associated With Dental Implants

OBJECTIVES

With the increase in dental implants for tooth loss, odontogenic sinusitis following maxillary dental implants is frequently encountered in otorhinolaryngology practice. The authors aimed to reveal the association between implant extrusion into maxillary sinus, along with implant-related complications in patients diagnosed with implant-related odontogenic sinusitis (IR-ODS).

STUDY DESIGN

Case-control study.

METHODS

This study enrolled 60 patients who received functional endoscopic sinus surgery due to IR-ODS. The preoperative sinus computed tomography was retrospectively reviewed. Among the 120 maxillary sinuses of the 60 patients, 68 sides were diagnosed with IR-ODS sides, whereas 27 sides showed no clinical or radiological evidence of this condition after the implant insertion and were defined as the control sides. Statistical analysis between these two groups was conducted, in addition to odds ratio (OR) calculations for associations with IR-ODS.

RESULTS

The mean age of the IR-ODS subjects was 59.5 ± 19.1, with a male to female ratio of 32/28 (53.3%/46.7%). Implants extruding by more than 4 mm into the maxillary sinus, peri-implantitis, bone graft disruption-extrusion were associated with a significantly higher incidence in the IR-ODS (p = 0.035, p = 0.003, p = 0.011, respectively). The IR-ODS sides showed an adjusted-OR (95% confidence interval) of 27.4 (2.7-276.5) for extrusion length >4 mm, 11.8 (3.0-46.5) for peri-implantitis, and 34.1 (3.3-347.8) for bone graft disruption (p = 0.005, p < 0.001, and p = 0.003, respectively).

CONCLUSION

Maxillary dental implants extruding more than 4 mm into the maxillary sinus, peri-implantitis, and disrupted-extruded bone grafts show significant association with IR-ODS.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:237-243, 2023.

Emergence of Cerebral Mucormycosis in the Post-COVID Period: A Detailed Analysis of Risk Factors, Clinical Progression, and Management of This Opportunistic Fungal Infection

BACKGROUND

An epidemic of Mucorales was reported following the second wave of COVID-19 in India, and intracranial extension of the same was one of the most dreadful complications.

METHODS

A total of 62 patients with cerebral mucormycosis were recruited and followed up till 12 weeks to evaluate the risk factors, incidence, clinical manifestations, management, and prognosis of cerebral mucormycosis.

FINDINGS

A median age of 51.5 years with male predominance (74%) was noted. The majority of subjects reported a history of COVID infection (93.5%) and diabetes mellitus (83.87%). The first symptom of mucormycosis appeared after a mean period of 17.63 ± 8.9 days following COVID. Facial swelling and ptosis were the most common symptoms. Only 55% of patients had neurological presentations, and hemiparesis was the most common neurological sign (30.6%). Radiologically, the involvement of maxillary sinus (90.32%) and ethmoid sinus (87.10%) was commonly noted. Cerebral findings included temporal lobe (50%) and parietal lobe (30.06%) involvement, cavernous sinus thrombosis (30.06%), and internal carotid artery thrombosis (22.58%). Acute cerebral infarction was notable in 37% of subjects (p-value=0.0015, significant association with the outcome). Conventional and liposomal amphotericin B were used in 91.94% and 53.23% of patients, respectively. Retrobulbar amphotericin injections used in 11.3% of subjects significantly affected the outcome (p-value=0.03, significant). Posaconazole step-down therapy was used in 72.5% of subjects (p-value=0.0005, significant). Surgical interventions were performed in 53 (85.48%) subjects (p-value=0.004, significant). Functional endoscopic sinus surgery was the most common (in 64.52% of subjects), followed by maxillectomy (20.97% of subjects) and craniotomy (17.7% of subjects). At the end of 12 weeks, 33.87% of patients died and 59.68% were alive; the rest (6.45%) were lost to follow-up.

INTERPRETATION

The absence or late presentation of neurological symptoms led to a delayed diagnosis of cerebral mucormycosis. The presence of acute cerebral infarction indicated a worse prognosis. However, there was a significant influence of step-down posaconazole therapy, retrobulbar amphotericin injections, and surgical intervention on the prognosis of cerebral mucormycosis.

Pain and Opioid Consumption Following Endoscopic Sinus Surgery: A Prospective Cohort Study

OBJECTIVES/HYPOTHESIS

Surgeons have a critical role in the current opioid epidemic, and there is a need to prospectively understand patterns of pain and opioid use among patients undergoing endoscopic sinus surgery (ESS).

STUDY DESIGN

Prospective observational cohort.

METHODS

This was a prospective, observational cohort study that included patients undergoing ESS from November 2019 to March 2020. Demographic data were collected at baseline, as was respondent information regarding preoperative anxiety, pain, and postoperative pain expectations. Opioid use was converted to milligram morphine equivalents (MME). All patients received 10 tablets of 5 mg oxycodone (75 MME). Patients quantified postoperative pain and opioid consumption via telephone follow-up every 48 hours. The primary outcome was total MME utilized.

RESULTS

There were 91 patients included in the final cohort. Mean opioid use was 35.2 ± 47.3 MME. There were 29 (32%) patients who did not use any opioids after surgery, and six (7%) patients who required opioid refills. Postoperative opioid use was associated with increased preoperative anxiety (r = 0.41, P < .001), preoperative pain (r = 0.28, P = .007), and expectations for postoperative pain (r = 0.36, P < .001). Increased postoperative pain was only associated with increased opioid use on postoperative days 0-2 (r = 0.33, P = .001) and 3-4 (r = 0.59, P < .001). On multivariate regression, former smoking (β = 23.4 MME, SE = 10.1, 95% confidence interval [CI]: 3.3-43.5, P = .023) and anxiety (β = 35.9, SE = 10.2, 95% CI: 15.6-56.3, P < .001) were associated with increased MME.

CONCLUSIONS

The majority of patients have minimal opioid use after ESS, and pain appears to influence opioid use within the first 4 days after surgery. Additionally, patients with anxiety may benefit from alternative pain management strategies to mitigate opioid consumption.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Do Federal Regulations Affect Gender, Racial, and Ethnic Disparities in Chronic Rhinosinusitis Research?

OBJECTIVE

The Food and Drug Administration and the National Institutes of Health (NIH) have asserted that diverse demographic representation in clinical trials is essential. In light of these federal guidelines, the objective of this study is to assess the racial, ethnic, and gender demographics of patients enrolled in clinical trials registered with the NIH that evaluate chronic rhinosinusitis with nasal polyposis (CRSwNP) relative to the demographics of the US population.

STUDY DESIGN

Cross-sectional study.

SETTING

Not applicable.

METHODS

ClinicalTrials.gov was queried to identify all prospective clinical trials for CRSwNP. Individual study and pooled data were compared with national US census data.

RESULTS

Eighteen studies were included comprising 4125 patients and evaluating dupilumab, mepolizumab, omalizumab, fluticasone/OptiNose, MediHoney, mometasone, and SINUVA. Women constituted 42.7% of clinical trial participants. Of the 4125 participants, 69.6% identified as White, 6.6% as Black, 20.8% as Asian, 0.1% as Pacific Islander, 0.4% as American Indian, 8.0% as Hispanic, and 2.4% as other. The racial, ethnic, and gender composition of the pooled study population differs significantly from national US census data, with underrepresentation of Black, Hispanic, Pacific Island, and American Indian individuals, as well as females (P < .05).

CONCLUSION

The racial, ethnic, and gender demographics of patients enrolled in CRSwNP clinical trials registered with the NIH differ significantly from the demographics of the US population, despite federal guidelines advising demographically representative participation. Proactive efforts to enroll participants that better represent anticipated treatment populations should be emphasized by researchers, institutions, and editorial boards.

Photodynamic Therapy as a New Treatment for Chronic Rhinosinusitis - A Systematic Review

This review examines the latest evidence for photodynamic therapy (PDT) in treating chronic rhinosinusitis. MedLine, EMBASE and TRIP Database searches were conducted using the terms: "photodynamic" or "phototherapy" or "photo" and "sinusitis" or "rhinosinusitis," date range January 2000 to May 2020. A total of 192 records were initially identified, after duplicates and exclusions, 9 full papers and 3 abstracts were included. All study types including in-vitro, animal and human studies were evaluated. Whilst there is in-vitro evidence for the efficacy of PDT's bactericidal effect on drug resistant bacteria and biofilm viability, there are few clinical studies. PDT is a promising area of research, but larger, focused studies looking at the safety, delivery, efficacy, and patient selection are required before it can be considered a viable treatment for CRS.

Multiparametric Analysis of Factors Associated With Eosinophilic Chronic Rhinosinusitis With Nasal Polyps

INTRODUCTION

Previous studies have reported a diverse range of threshold values for blood eosinophilia. In addition, a single predictive biomarker for eosinophilic chronic rhinosinusitis (CRS) with nasal polyps (ECRSwNP) has not yet been identified.

OBJECTIVES

The aim of this study is to compare the clinical characteristics of ECRSwNP and non-ECRSwNP to evaluate the preoperative risk of tissue eosinophilia of chronic rhinosinusitis with nasal polyps (CRSwNP) through a multiparametric statistical analysis.

METHODS

One hundred ten patients with evidence of chronic polypoid rhinosinusitis were included in this study and clinical records were retrospectively reviewed. Eosinophilic CRSwNP was diagnosed based on the presence of at least 10 eosinophils per high-power field. The demographic and clinical features of ECRSwNP and non-ECRSwNP are described. The values of blood eosinophilia as predictors of tissue eosinophilia have been identified using receiver operating characteristic curves. As the predictive value of the identified cutoff through regression analysis was low, we evaluated whether other risk factors could be statistically associated with ECRSwNP, and from this, a new predictive model was proposed for the identification of eosinophilic nasal polyps before surgery.

RESULTS

We found that the best method for predicting ECRSwNP is based on a model having asthma, blood eosinophil percentage, posterior ethmoid value in Lund-Mackay score, and modified Lund-Kennedy score as explanatory variables.

CONCLUSIONS

This study provides new data for a better understanding of the polypoid CRS endotypes, and the proposed model allows the endotype to be identified preoperatively.

Effects of povidone-iodine composite on the elimination of bacterial biofilm

BACKGROUND

Povidone-iodine (PVP-I) is well known as an antiseptic and exhibits extensive activity against various pathogens. However, due to its uniquely unpleasant nature, it cannot be used locally to deactivate various sinonasal pathogens. Therefore, we developed a PVP-I composite that blocks the unpleasant odor of PVP-I for use as a local antiseptic in the sinonasal cavity and evaluated its effect on bacterial biofilm's formation and elimination in in vivo and in vitro models.

METHODS

MTT, lactate dehydrogenase, and live/dead staining assay were performed to examine the cellular toxicity of PVP-I composites on the primary human nasal epithelial and RPMI 2650 cells. Crystal violet assay was performed to quantify bacterial biofilm after treating with various agents, including PVP-I and antibiotics. Hematoxylin-and-eosin staining, live/dead staining assay, and scanning electron microscopy were conducted to evaluate the effect of PVP-I on biofilm formation in a mice biofilm model.

RESULTS

It was observed that the PVP-I composite did not have any significant toxic effect on the nasal epithelial cells. Furthermore, the PVP-I composite effectively inhibited the formation of bacterial biomass within a dose-dependent manner after 48 hours of incubation with Pseudomonas aeruginosa and Staphylococcus aureus. In mice, it effectively eliminated biofilm from the mucosa of the nasal cavity and maxillary sinus at the tested concentrations.

CONCLUSION

The results of this study indicate that the PVP-I composite is a promising compound that could be used locally to prevent the formation of biofilms and to eliminate them from the sinonasal cavity.

The management of periorbital cellulitis secondary to sinonasal infection: a multicenter prospective study in the United Kingdom

BACKGROUND

Periorbital cellulitis is a potential sight-threatening complication of sinusitis. The majority of patients improve with medical management. Previous studies have suggested significant variations in practice and lack of evidence regarding the optimal management of this condition.

METHODS

A prospective study was conducted over a 12-month period at 8 centers in the United Kingdom assessing the management of patients requiring inpatient treatment for periorbital cellulitis secondary to sinonasal infections.

RESULTS

A total of 143 patients were recruited, of whom 40 were excluded. Of the remaining 103 patients, 5 (4.9%) were diagnosed with neurosurgical complications. This resulted in 98 patients admitted with periorbital cellulitis secondary to an upper respiratory tract infection/sinusitis. A total of 72 were children, of whom 12 (16.7%) required surgical intervention; and of 26 adults, 5 (19.2%) required surgery: the most common antimicrobial regimes administered were intravenous ceftriaxone (with or without metronidazole), and co-amoxiclav. The use of both ceftriaxone and metronidazole from admission was associated with the shortest duration of inpatient stay (3.8 days) in comparison to ceftriaxone alone (5.8 days) or co-amoxiclav (4.5 days) and a reduction in number of patients requiring surgical intervention. There was also an association between the early use of intranasal decongestants and steroids and reduction in requirement for surgical intervention.

CONCLUSION

For a condition where swab and blood cultures are often negative, this study supports the use of ceftriaxone in combination with metronidazole. The administration of intranasal decongestants and corticosteroids correlated with a smaller percentage of those progressing to surgery in those with and without periorbital abscesses.

Topography of polyp recurrence in eosinophilic chronic rhinosinusitis

BACKGROUND

Eosinophilic chronic rhinosinusitis (eCRS) is an inflammatory endotype of CRS. Contemporary treatment includes creation of a "neo-sinus" cavity and postoperative corticosteroid irrigations. Not all patients gain control with local therapy. This study aims to determine, in patients with polyp recurrence, the most common sinuses involved.

METHODS

A prospective case-series was conducted on consecutive adult (≥18 years) post-FESS eCRS patients followed for a minimum of 12 months. All patients had a neo-sinus cavity created surgically and used corticosteroid irrigations daily for 3-6 months, then tapered to disease control. Sinus cavities were assessed by endoscopy on last follow-up. Polyp recurrence was defined as a score of 5 or 6 in the MLMES in ≥3 sinus cavities. Patient-reported outcomes based on SNOT22 and NSS, frequency of corticosteroid irrigations, and courses of systemic antibiotics and corticosteroid were collected. The pattern of sinus involvement was analyzed.

RESULT

A total of 342 sinus cavities were assessed (mean ± standard deviation, 54.9 ± 13.4 years, 43.2% female). Polyp recurrence occurred in 4.3% (6.4% of patients, n = 7 unilateral) of sinus cavities. Frontal and ethmoid sinus cavities were most affected in those with polyp recurrence, compared to the maxilla and sphenoid (100% vs 100% vs 53% vs 53%, p < 0.01). Although those patients with polyp recurrence utilized more systemic corticosteroids courses per year (0.4 ± 0.4 vs 0.1 ± 0.3, p < 0.01), the use of corticosteroid irrigations was similar (% >4/week; 66.7% vs 48.9%, p = 0.13). Prior surgery was more common in patients with polyp recurrence (86.7% vs 53.5%, p = 0.01).

CONCLUSION

The frontal and ethmoid sinuses were most affected in those patients with polyp recurrence. Whether the disease is more active in this location or topical therapy has limited access requires further evaluation.

How aggressive should resection of inverted papilloma be? Refinement of surgical planning based on the 25-year experience of a single tertiary center

BACKGROUND

The technique for transnasal endoscopic resection of inverted papilloma (IP) has evolved considerably during the last 20 years. The aim of the present study is to retrospectively analyze a single tertiary center series, with special emphasis on assessing the value of an "insertion-driven" technique on local control.

METHODS

Patients undergoing endoscopic resection for IP at the University of Brescia during the period 1991 to 2015 were enrolled. Site of origin and extension of IPs were assessed, together with presence of dysplasia and carcinoma in situ. Patients were divided in 3 cohorts: (1) historical cohort (treated before 2008), (2) contemporary "centripetal" cohort (treated with a traditional technique after 2008), and (3) contemporary "insertion-driven" cohort (treated with insertion-driven resection). Groups were compared considering outcomes and complications.

RESULTS

The series included 210 patients. Mean follow-up was 77.8 months. Thirty-eight (18.1%) patients showed precancerous changes. Maxillary involvement (p = 0.021) and presence of precancerous changes (p = 0.013) were significantly associated with a higher risk of recurrence. Five-year local control rate before and after 2008 was 95.1% and 90.5%, respectively. The insertion-driven cohort was associated with lower disease control when IPs involved the maxillary sinus. The rate of complications was 11.9%. The insertion-driven cohort was associated with a lower rate of major complications (p = 0.098).

CONCLUSION

Preoperative evidence of precancerous changes and/or involvement of maxillary sinus should prompt the surgeon to address the disease more aggressively (centripetal resection). Preoperative imaging and biopsy with abundant material may optimize the chance to stratify patients eligible for less or more conservative approaches.

Topical corticosteroid irrigations in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) has previously been thought to occur secondary to infectious or obstructive etiologies. However, in recent years, primary CRS has been more discretely defined as diffuse airway inflammation, similar to asthma. Adequate medical and surgical therapy are needed to control the inflammation. Our purpose in this study was to evaluate the efficacy and safety of topical corticosteroid treatment.

METHODS

A focused literature review was conducted and we identified 11 original articles from the years 2013-2018 evaluating safety or efficacy of topical corticosteroid irrigations.

RESULTS

Eleven articles were identified. One study found significant benefit between corticosteroid irrigations versus corticosteroid sprays. Two studies found significant benefit between corticosteroid irrigations compared to saline irrigations while two did not. One study found significant improvement in certain patient populations when using corticosteroid irrigations compared to no irrigation. Five studies found no significant increase in risk of adverse side effects with the use of topical corticosteroids.

CONCLUSION

Many factors are associated with efficacious and adequate treatment of primary CRS. The pathology must be correctly diagnosed and be inflammatory in nature. The treatment paradigm should include wide and complete endoscopic sinus surgery for the adequate delivery of topical therapy. Topical therapy should be delivered in large-volume, low-pressure devices with adequate dosing. Although there is some systemic absorption, multiple studies have demonstrated that long-term, daily use of topical corticosteroids does not increase intraocular pressure, suppress the hypothalamic-pituitary-adrenal axis, or increase the risk of subcapsular cataracts. Therefore, topical corticosteroid irrigations should be considered a part of first-line medical treatment in postsurgical CRS patients.

Treatment-related morbidity in patients treated for sinonasal malignancy

BACKGROUND

Sinonasal malignancies are a rare, heterogeneous group of tumors that often present at an advanced stage and require multimodal therapy. The presence of high-grade toxicity and sinonasal complications after treatment can negatively impact quality of life. In this study we aim to describe posttreatment morbidity in patients with sinonasal malignancy.

METHODS

A retrospective analysis of all patients treated for sinonasal malignancy was conducted from 2005 to 2018 at a tertiary referral institution. A total of 129 patients met the inclusion criteria. Primary outcomes were treatment details, pathology, posttreatment complications, and radiation toxicity. Fisher's exact test, chi-square test, and Student t test were used for statistical analysis.

RESULTS

Mean age was 58.4 (median, 61; range, 19-94) years. After diagnosis, 24 patients had surgery alone, 46 had surgery with radiation alone, 47 had surgery with chemoradiation, and 14 received definitive chemoradiation. Overall, 10.4% (n = 12) of patients had postoperative complications, and 21.0% (n = 22) had high-grade (grade 3-5) radiation toxicity. After radiation, 20% (n = 21) of patients had chronic sinusitis requiring functional endoscopic sinus surgery and 20% (n = 21) had symptomatic nasal obstruction requiring operative debridement.

CONCLUSION

Sinonasal complications, including nasal obstruction and chronic sinusitis, occur frequently after definitive treatment of sinonasal malignancy and should be addressed when considering quality of life in survivors. These complications occur more frequently in patients who undergo chemoradiation as opposed to surgery alone.

Systemic Immune Profile in Patients With CRSwNP

The immune pathogenesis of chronic rhinosinusitis with nasal polyps (CRSwNP) remains obscure. Our aim was to compare humoral immunity and white blood cell counts in patients with CRSwNP and controls. A prospective case-control study was carried out in 37 patients with CRSwNP and 34 controls without CRS. Clinical data were gathered through a systematic interview. Computed tomography scan, skin prick test, spirometry, and immunological parameters (leukocyte differential count, immunoglobulin classes, and immunoglobulin [Ig] G subclasses) in serum specimens were obtained. Statistical analysis was performed using SPSS v.23. The prevalence of chronic lower respiratory diseases was greater in the CRSwNP group (P < .001), but atopic disease had no significant difference. A significantly higher eosinophil (P < .001) and basophil relative count (P = .022) and a lower relative neutrophil count (P = .013) were found among CRSwNP group. Patients with CRSwNP had higher IgG1 (P = .022), but lower IgG2 (P = .014) and IgG3 (P = .018) serum levels compared to controls; IgG4, total IgG, IgA, IgM, and IgE serum levels did not differ between groups, as well as the prevalence of immunoglobulin classes or IgG subclasses deficiency. The variation observed in peripheral relative leukocyte count and the systemic IgG1 subclass shift are similar to what is known to happen in nasal polyp tissue. A unique systemic immune profile seems to be present in patients with CRSwNP.

Endoscopic sinus surgery improves aspirin treatment response in aspirin-exacerbated respiratory disease patients

BACKGROUND

Aspirin desensitization and treatment benefits most patients with aspirin-exacerbated respiratory disease (AERD), although some patients fail therapy. Our objective was to assess whether recent endoscopic sinus surgery (ESS) improved aspirin treatment outcomes in AERD patients who initially failed aspirin therapy.

METHODS

Outcomes of aspirin desensitization and treatment in AERD patients prospectively enrolled were assessed preoperatively and at 4, 12, and 24 weeks after ESS by determining changes in Asthma Control Test (ACT) and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) scores and respiratory function. Biomarkers, including fractional excretion of nitric oxide (FeNO), spirometry, nasal inspiratory peak flow (NPF), immunoglobulin E (IgE), and eosinophil count, were measured.

RESULTS

Nineteen patients who benefited (responders) and 21 patients who failed (nonresponders) preoperative aspirin treatment with a distant history of ESS (mean, 48 months) were identified. Nonresponders were more likely to be African American (71%, p < 0.01) and have higher baseline IgE levels (252 kU/L vs 87 kU/L in responders, p < 0.01). 24 of the 40 patients (nine responders and 15 non-responders) required subsequent ESS and underwent another aspirin desensitization 3-4 weeks after ESS. All 24 patients tolerated a second round of aspirin desensitization and treatment. The primary aspirin therapy was associated with a significant increase in IgE in nonresponders, but there was no significant increase in IgE after the second aspirin desensitization and treatment.

CONCLUSION

Antecedent ESS enhances aspirin treatment responses in AERD patients and may convert patients who failed aspirin treatment before surgery to a more responsive phenotype after ESS. Patients with higher baseline serum IgE levels may benefit from ESS performed shortly before aspirin desensitization and therapy.

Intraseptal Mucocele as a Long-term Complication of Revision Septorhinoplasty: A Case Report and Review of a Rare Entity

Paranasal sinus mucoceles are benign, expansive, cystic lesions which arise from retention of mucus secretions. They arise primarily in the setting of cystic degeneration of the sinus mucosa or secondarily in the setting of obstruction of the sinus ostium due to mucosal trauma or chronic inflammation. Septal mucoceles are rare. Only 10 cases to our knowledge have previously been reported. Patients are exclusively male, in their middle years, usually with a history of nasal trauma or nasal surgery. Nasal obstruction followed by headache present for 3 months to a year are the most common presenting symptoms. Here, we present a case of septal mucocele with dystrophic bone formation in a 57-year-old man arising 35 years after open septorhinoplasty treated successfully with total excision via an endoscopic, endoseptal approach. A review of the available literature was conducted to provide a consolidated update on diagnosis and management.

The Efficacy of Yogic Breathing Exercise Bhramari Pranayama in Relieving Symptoms of Chronic Rhinosinusitis

INTRODUCTION

A multitude of modalities are available for the treatment of chronic rhinosinusitis, however, each has its side effects and compliance issues. Bhramari pranayama, which is a breathing exercise in the practice of yoga, offers an inexpensive and free from side effect modality in this regard.

OBJECTIVE

The objective of this study was to evaluate the efficacy of Bhramari pranayama in relieving the symptoms of chronic sinusitis.

METHODOLOGY

A total of 60 patients with chronic sinusitis were randomly divided into two groups, one received conventional treatment of chronic sinusitis and the other group was in addition taught to practice yogic breathing exercise Bhramari pranayama. The patients were advised to practice this breathing exercise twice a day and were followed up at 1, 4, and 12 weeks using the Sino-Nasal Outcome Test (SNOT-22 score).

RESULTS

The mean SNOT-22 score in the group following the Bhramari pranayama breathing exercise using the ANOVA test improved from 39.13 ± 9.10 to 24.79 ± 8.31 (P = 0.0002), this improvement was seen by the end of 4 weeks itself and continued until the 12th week of assessment.

CONCLUSION

Integrating regular practice of Bhramari pranayama along with the conventional management of chronic rhinosinusitis is more effective than conventional management alone.

Mucocele: Clinical Characteristics and Outcomes in 46 Operated Patients

Introduction  Paranasal sinus mucocele is a benign, expansive lesion associated with paranasal sinus obstruction. It affects mostly adults, and is most common in the frontal and ethmoidal sinuses.

Objective  To evaluate outcomes in patients undergoing surgical treatment for paranasal sinus mucocele.

Methods  Retrospective review of medical records of patients treated for paranasal sinus mucocele at the ENT department of a tertiary care hospital between 2005 and 2016.

Results  Forty-six patients underwent surgical treatment of paranasal sinus mucocele. The mean age was 50.1 years, and 56.5% were male. The most prevalent symptom was pain, and the frontal sinus was most commonly affected. The vast majority of patients (89.1%) underwent endoscopic sinus marsupialization; 10.9% required combined open and endoscopic access. Seven recurrences occurred.

Conclusion  Sinus mucocele is an expansive disease that primarily affects the frontal sinus of adult patients. In most cases, endoscopic surgery is an effective treatment modality.

Comparison of Sino-Nasal Outcome Test 22 Symptom Scores in Rhinogenic and Odontogenic Sinusitis

BACKGROUND

Odontogenic maxillary sinusitis (OMS) and rhinogenic sinusitis (RS) are the main types of chronic rhinosinusitis (CRS) and have a significant impact on health-related quality of life (HRQL), but the difference in HRQL and symptom presentation between them has not been specifically evaluated to date. Obejctive: Our aim was to compare patterns of symptoms and HRQL disease-specific domains in patients affected with these 2 types of CRS.

METHODS

A group of 201 patients with CRS (99 with rhinogenic and 102 with odontogenic origin) completed the Sino-Nasal Outcome Test 22 (SNOT-22) questionnaire before treatment. Data sets were analyzed by using principal component analysis (PCA) to identify a set of symptom components together with the items excluded from PCA, which were then analyzed for differences between patients with OMS and RS.

RESULTS

PCA of SNOT-22 items identified 5 components: "rhinologic," "extranasal rhinologic," "ear/facial," "sleep and functional disturbance," and "emotional disturbance." Sneezing was excluded from PCA and treated as separate outcome variable and was significantly worse in RS patients. Patients with OMS scored significantly higher scores with regard to emotional disturbance, while RS patients scored significantly worse in sleep and functional disturbance. The extra symptom "malodor" was the most different symptom and was significantly worse in OMS patients. The total SNOT-22 score was not significantly different between the groups.

CONCLUSION

With controlling of covariates that may influence the severity of the disease, this study showed some significant differences in symptom patterns and HRQL impairment between patients with OMS and RS. Malodor is the most characteristic feature of OMS. Therefore, OMS should always be suspected in patients complaining of bad breath.

[A retrospective analysis of clinical characteristics, diagnosis in patients with unilateral sinus disease]

Objective:The aim of this study is to investigate the clinical features in patients with unilateral sinus disease.Method:A retrospective review of 2 480 patients who had undergone sinus surgery was performed. The clinical data were gathered and analyzed to investigate the features of the unilateral sinus disease. Descriptive and inferential statistics were computed.Result:1 350 patients (54.4%) who had bilateral sinus disease were all diagnosed as chronic rhinosinusitis pathologically confirmed after surgery. Unilateral sinus disease was identified in 1 130 patients (45.6%) and the disease entities were categorized as chronic rhinosinusitis (589 patients, 52.1%), fungal rhinosinusitis (312 patients, 27.6%), inverted papilloma (95 patients, 8.4%), sinus cyst (78 patients, 6.9%), malignant tumor (34 patients, 3%), osteoma including osteodysplasia fibrosa (11 patients, 1%) and others (11 patients, 1%) . Among the patients of malignant tumor, there were 13 cases of squamous cell carcinoma, 6 cases of malignant lymphoma, 4 cases of sarcoma, 4 cases of melanoma, 3 cases of adenocystic carcinoma, 1 case of verrucous carcinoma, 1 case of metastases from liver, 1 case of plasmacytoma,and 1 case of hemangiopericytoma. The number of fungal rhinosinusitis patient increased year by year. The common major presenting symptom for fungal rhinosinusitis was headache (46.8%) and bloody discharge (31.1%). Male accounted for a large part of both inverted papilloma and malignant tumor patients, both of which CT findings that correlated with the presence was the absorption and destruction of the sinus wall. Thirty-one cases (32.6%) of inverted papilloma patients recurred. Bloody discharge (58.8%) was major symptom of the malignant tumor.Conclusion:There were almost a half of unilateral sinus diseases that were not common chronic rhinosinusitis, in which the incidence of fungal rhinosinusitis, inverted papilloma, squamous cell carcinoma and other kinds of benign and malignant tumor was high. A careful history taking and endoscopic examination play a key role as well as imaging examination in identifying unilateral sinus disease, which is important for reaching a correct diagnosis and treatment.

[Clinical analysis of plasma cell granuloma in nasal cavity and nasal sinus]

The plasma cell granuloma occurred in nasal cavity and sinus, which is rarely seen in clinical practice,the common clinical features included nasal congestion,nose bleeding,eye protrusion and olfactory impairment.Its clinical manifestations are similar to the clinical manifestations of malignant tumors, the correct diagnosis depends on histopathology and immunohistochemistry, and surgical treatment is the main method, can be supplemented by hormone therapy, radiotherapy,the prognosis could be better.

Accessory maxillary ostium repair using middle turbinate flap: a case series of 116 patients with chronic rhinosinusitis

BACKGROUND

The ostiomeatal complex (OMC), comprising a small natural maxillary sinus ostium and narrow infundibulum, transmits the air diffusion into the antrum and mucociliary transport from the antrum, and is considered a key area in chronic rhinosinusitis (CRS). Thin membranous anterior and posterior fontanelle areas below the OMC can rupture forming a perforation, accessory maxillary ostium (AMO), that increases antral airflow changing the anatomy and function of the sinus. The purpose of this study was to report the first case series of CRS patients who had undergone repair of fontanelle defects aiming to reconstruct normal structures.

METHODS

Between 2011 and 2017, a total of 157 perforations were diagnosed and repaired in 121 of 525 consecutive endoscopic sinus operations performed by the author. Defects were 3 mm to 4 mm in size (range, 1 mm to 7 mm). A flap cut from the undersurface of the middle turbinate was used. In total, 101 patients received concurrent balloon catheter dilation (BCD), while 15 patients had only an AMO repair. The mean endoscopic follow-up time was 16 weeks (range, 1 to 188 weeks).

RESULTS

Overall, 101 perforations were closed, 21 open, and 17 partially open. A history of earlier endoscopic sinus surgery (ESS) or BCD surgery, presence of nasal polyposis or whether the repair was made without simultaneous BCD did not influence the closure rate. Postoperative febrile sinusitis occurred in 26 patients.

CONCLUSION

Repair of AMO is in theory a beneficial and technically feasible office procedure with only transient side effects. Three out of 4 perforations were closed after repair.

Combat zone exposure and respiratory tract disease

BACKGROUND

The impact of deployment to combat zones on the respiratory and sinonasal health of U.S. soldiers is an emerging public health concern. Retrospective studies have shown a correlation between deployment and development of post-deployment pathology, particularly of the aerodigestive system. Respiratory disease, including sinusitis, allergic rhinitis, and asthma, are commonly reported in soldiers deployed to the Middle East and Southwest Asia.

METHODS

Current literature pertaining to combat zone exposure and development of respiratory disease was retrieved using PubMed, Embase, Web of Science, and Google Scholar.

RESULTS

Several types of combat zone exposures exist that may play an influential role in the development of upper and lower respiratory tract diseases. Exposures including foreign dusts, harsh environments, particulate size, and close living quarters may play a causative role. The effect of combat zone exposures has been better examined for lower respiratory tract diseases; however, with the theory of the unified airway, the upper respiratory tract may also be involved. There is evidence that the upper respiratory tract is susceptible, with an increased risk for development of sinusitis and sinonasal disease; however, the quality of evidence of the present literature is generally low.

CONCLUSION

More research is necessary to determine a pathophysiologic mechanism between combat zone exposure and the development of sinonasal disease. Practicing otolaryngologists should be aware of the possibility of combat zone exposures that could contribute to rhinologic symptomatology.

Three-dimensional image analysis for staging chronic rhinosinusitis

BACKGROUND

Traditional methods of staging chronic rhinosinusitis (CRS) through imaging do not differentiate between degrees of partial mucosal sinus inflammation, thus limiting their utility as imaging biomarkers. We hypothesized that software-aided, quantitative measurement of sinus inflammation would generate a metric of disease burden that would correlate with clinical parameters in patients with suspected sinus disease.

METHODS

Adults with rhinologic complaints undergoing computed tomography imaging were recruited at an urban, academic, tertiary care center (n = 45 with Lund-Mackay [LM] scores ≥4). Three-dimensional (3D) volumetric image analysis was performed using a semiautomated method to obtain a "Chicago-modified Lund-Mackay" (Chicago MLM) score, which provides a continuous scale to quantify extent of opacification. Linear regression was used to test the association of the Chicago MLM score with concurrent symptoms (Total Nasal Symptom Score [TNSS]) and disease-specific quality of life, based on the Sinonasal Outcome Test-22 (SNOT-22).

RESULTS

Chicago MLM scores were significantly associated with both symptoms (p = 0.037) and disease-specific quality of life (p = 0.007). Inflammation in the ethmoid and sphenoid sinuses appeared to influence these associations. These findings were even more robust when analysis was limited to patients with more severe disease (LM >6).

CONCLUSION

The quantitative measurement of sinus inflammation by computer-aided 3D analysis correlates modestly with both symptoms and disease-specific quality of life. Posterior sinuses appear to have the greatest impact on these findings, potentially providing an anatomic target for clinicians to base therapy. The Chicago MLM score is a promising imaging biomarker for clinical and research use.

Assessment of Pulmonary Function before and after Sinus Surgery in Lung Transplant Recipients

Introduction  The association between sinus and lung diseases is well known. However, there are scarce studies regarding the effects of sinus surgery on pulmonary function in lung transplant recipients. The present study describes our experience with sinus surgery in lung transplant recipients with chronic rhinosinusitis. Objectives  To assess the impact of sinus surgery for chronic rhinosinusitis on pulmonary function and on inpatient hospitalization days due to lower respiratory tract infection in lung transplant recipients. Methods  A retrospective study conducted between 2006 and 2012 on a sample of lung transplant recipients undergoing sinus surgery for chronic rhinosinusitis. Pulmonary function, measured by forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1), as well as inpatient hospitalization days due to lower respiratory tract infection, were compared 6 months before and 6 months after sinus surgery. Results  The FEV1 values increased significantly, and the inpatient hospitalization days due to bronchopneumonia decreased significantly 6 months after sinus surgery. The preoperative and postoperative median FEV1 values were 2.35 and 2.68 respectively ( p  =  0.0056 ). The median number of inpatient hospitalization days due to bronchopneumonia 6 months before and 6 months after surgery were 32.82 and 5.41 respectively ( p  =  0.0013 ). Conclusion  In this sample of lung transplant recipients with chronic rhinosinusitis, sinus surgery led to an improvement in pulmonary function and a decrease in inpatient hospitalization days due to bronchopneumonia.

Development of the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire

BACKGROUND

The patients' perspective of health outcomes has become important input for assessing treatment effects. However, existing endoscopic endonasal surgery (EES) instruments are not fully aligned with the concept of health-related quality of life (HRQoL). A prospective cohort study was therefore conducted to develop a suitable quality-of-life tool to assess nasal morbidity after EES: the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire (EES-Q).

METHODS

The study included 300 patients: 207 with sinus pathology and 93 with anterior skull base pathology. The EES-Q was administered prior to surgery and postoperatively (2 weeks, 3 months, and 1 year). Psychometric instrument properties were tested and relevant health domains were formulated. Seventy-two items were generated by the conventional psychometric approach. An exploratory factor analysis was used to test construct validity. The optimal number of factors to retain was determined by using the eigenvalues-greater-than-1 rule and scree plot. Orthogonal varimax rotation was used to enhance interpretability. Internal consistency was assessed using the Cronbach α.

RESULTS

The factor analysis yielded a 3-factor solution, representing physical, psychological, and social functioning. The final version of the instrument consisted of 30 items with a high internal consistency (>0.80) for all 3 HRQoL domains.

CONCLUSIONS

The EES-Q is a comprehensive, multidimensional, disease-specific instrument. A distinguishing characteristic is that, apart from the physical and psychological domains, the EES-Q also encompasses a social domain. Understanding different HRQoL aspects in patients undergoing EES may help caregivers restore, improve, or preserve the patient's health through individualized care, which depends on identifying their specific needs.

Single nucleotide polymorphisms related to cystic fibrosis in chronic rhinositus-a pilot study

BACKGROUND

The clinical association between cystic fibrosis (CF) and chronic rhinosinusitis (CRS) is well known. Studies have identified several non-CF transmembrane conductance regulator single nucleotide polymorphisms (SNPs) associated with disease severity in CF patients. We hypothesized that prevalence of these SNPs would be different between CRS patients and age/gender-matched non-CRS controls.

METHODS

This is a targeted SNP study of 1231 CRS patients identified through a large university hospital database who were compared with 8796 age- and gender-matched controls without a history of rhinitis, sinusitis, allergies, or asthma. Prevalence of 5 relevant SNPs was compared between groups, with p < 0.05 considered significant. Stratification by race and gender was performed among groups when statistically appropriate.

RESULTS

CRS patients exhibited a statistically significant (p = 0.036) lower prevalence of rs12883884 (associated with an ion transporter) compared with controls. This association was lost when patients were stratified by race. CRS patients manifested a greater prevalence of rs1403543 (chromosome 23) in both Caucasian and African American subgroups (p = 0.036 and p = 0.026, respectively). Statistical significance disappeared among Caucasians when stratified by gender, but persisted among African American women (p = 0.047). rs12188164 and rs12793173 were both more prevalent in African Americans with CRS than controls (p = 0.042 and p = 0.020, respectively). A trend was also observed for decreased prevalence of rs12883884 in CRS patients compared with controls in the African American subgroup (p = 0.086).

CONCLUSION

The identified SNPs were differentially prevalent in CRS compared with control groups, with some variability as a function of race and gender. Further research is required to confirm these findings and elucidate clinical significance.

Evaluating metrics of responsiveness using patient-reported outcome measures in chronic rhinosinusitis

BACKGROUND

Responsiveness, or sensitivity to clinical change, is important when selecting patient-reported outcome measures (PROMs) for research and clinical applications. This study compares responsiveness of PROMs used in chronic rhinosinusitis (CRS) to inform the future development of a highly responsive instrument that accurately portrays CRS patients' symptom experiences.

METHODS

Adult CRS patients initiating medical therapy (MT; n = 143) or undergoing endoscopic sinus surgery after failing MT (ESS; n = 123) completed the 22-item Sino-Nasal Outcome Test (SNOT-22), European Position Statement on Rhinosinusitis (EPOS) visual analog scale (VAS), and 29-item Patient-Reported Outcomes Measurement Information System (PROMIS-29) at baseline and 3 months after treatment. Cohen's d and paired t statistics were used to evaluate the responsiveness of each measure.

RESULTS

Fifty-two (36.4%) subjects and 42 (34.1%) subjects in the MT and ESS groups, respectively, completed baseline and 3-month questionnaires. Subjects with and without 3-month data were similar with respect to baseline demographics, VAS scores, and SNOT-22 scores (p > 0.05). In MT patients, CRS-specific measures, like VAS (d = -0.58, p < 0.01; t = -1.81, p > 0.05) and SNOT-22 (d = -0.70, p < 0.01; t = -3.29, p < 0.05) scores, were more responsive than PROMIS-29 general health domains (p > 0.05 for Cohen's d). In ESS patients, VAS (d = -1.97; t = -9.63, both p < 0.01) and SNOT-22 (d = -1.56; t = -9.99, both p < 0.01) scores were similarly more responsive, although changes in PROMIS-29 domains of Fatigue (d = -0.82, p = 0.01; t = -4.63, p < 0.01), Sleep Disturbance (d = -0.83; t = -3.77, both p < 0.01), and Pain Intensity (d = -1.0; t = -5.67, both p < 0.01) were significant. All 22 individual SNOT-22 items differed significantly after surgery, whereas only 8 items were consistently responsive after MT.

CONCLUSIONS

For both MT and ESS patients, CRS-specific PROMs are more responsive to posttreatment clinical changes than general health measures. Still, the SNOT-22 contains items that likely decrease its overall responsiveness. Our findings also indicate that existing PROMs had a greater response to ESS than MT.

Odontogenic and rhinogenic chronic sinusitis: a modern microbiological comparison

BACKGROUND

Odontogenic sinusitis and sinonasal complications of dental disease or treatment (SCDDT) play a relevant, often underappreciated role in paranasal sinus infections. Treating SCDDT patients requires tailored medical and surgical approaches in order to achieve acceptable success rates. These approaches differ from common rhinogenic sinusitis treatment protocols mostly because of the different etiopathogenesis. Our study comprehensively evaluated microbiology and antibiotic resistance in SCDDT patients and compared findings with a control group of patients affected by rhinogenic sinusitis.

METHODS

We performed microbiological sampling during surgery on 28 patients with SCDDT and 16 patients with chronic rhinosinusitis with nasal polyps (CRSwNP). Colonies were isolated, Gram-stained, and the species identified using classic biochemical methods. These results were confirmed by DNA pyrosequencing, and then the resistance profile of each SCDDT isolate to various antibiotics was tested.

RESULTS

Microbial growth was observed in all SCDDT patients, whereas samples from 60% of patients in the control group failed to yield any bacterial growth (p < 0.001). Anaerobes grew in 14% of SCDDT patients as compared to 7% of CRSwNP patients (p = 0.42). Of the isolates from SCDDT patients, 70% were susceptible to amoxicillin/clavulanate, whereas all isolates were susceptible to levofloxacin, teicoplanin, and vancomycin. Of the staphylococci identified, 80% were capable of producing beta-lactamase.

CONCLUSION

Given the extent of microbiological contamination within the maxillary sinus of SCDDT patients, these infections should be regarded as a different class of conditions from rhinogenic sinusitis. Our findings support the need for different approaches in the treatment of SCDDT patients.

Pulmonary function in never-smoker patients with chronic rhinosinusitis

BACKGROUND

A close relationship between upper and lower respiratory tract diseases has been reported. The purpose of this study was to evaluate lung function in patients with chronic rhinosinusitis (CRS) who have never smoked.

METHODS

A total of 208 patients with CRS were enrolled in this study. Of these subjects, 96 patients were ever smokers and 112 patients were never smokers. CRS patients with lower pulmonary diseases including chronic obstructive pulmonary disease (COPD) and asthma were excluded from this study. Age-matched normal control subjects (n = 55) who were never smokers were also recruited. Pulmonary function testing was performed using spirometry. Lund-Mackay computed tomography (CT) score, peripheral blood eosinophil count, and immunoglobulin E (IgE) level in serum samples were examined. Nasal obstruction was evaluated by active anterior rhinomanometry.

RESULTS

CRS patients who were ever smokers have decreased lung function. Never-smoking patients with CRS also showed significant obstructive lung function changes as compared with normal controls. No significant correlation was detected between the clinical parameters (CT score, eosinophil count, IgE level, and nasal resistance) and lung function.

CONCLUSION

Asymptomatic obstructive lung function changes were observed in never-smoking patients with CRS. Our findings suggest that patients with CRS should be followed carefully in order to detect lung diseases.

The association between septal deviation and the presence of a maxillary accessory ostium

BACKGROUND

The etiology and the effects of the maxillary accessory ostium (MAO) are not well understood. The aim of this study is to investigate the association between septal deviation (SD) and the presence of an MAO.

METHODS

Paranasal computed tomography (CT) scans of 1104 adult patients were studied retrospectively. Patients with chronic sinusitis, acute sinusitis, nasal polyposis, allergic rhinitis, paranasal sinus tumors, septal perforation, and unilateral or bilateral maxillary sinus hypoplasia/aplasia, as well as patients who had previously had nasal surgery or a history of nasal trauma, were not included in the study. Eight-hundred and seven patients were found to meet the criteria and were included in the study. CT scans were examined to note the presence of SD and MAO and the side of both diseases.

RESULTS

A total of 807 patients were evaluated. SD and MAO were detected in 572 (70.9%) and 299 (37.1%) patients, respectively. A statistically significant relationship was found between the presence of SD and MAO, regardless of side of the disease (p = 0.002). The side of MAO showed a significant correlation with the direction of SD (p < 0.001).

CONCLUSION

Our results revealed a link between SD and MAO. This relationship was correlated with the side of occurrence of the disease.

Stage II Chronic Maxillary Atelectasis Associated with Subclinical Visual Field Defect

Introduction Chronic maxillary atelectasis (CMA) is characterized by a persistent decrease in the maxillary sinus volume due to inward bowing of its walls. According to its severity, it may be classified into three clinical-radiological stages.

Objective To report a case of stage II CMA associated with subclinical visual field defect.

Case Report A 34-year-old woman presented with a 15-year history of recurrent episodes of sinusitis and intermittent right facial discomfort for the past 5 years. She denied visual complaints, and no facial deformities were observed on physical examination. Paranasal sinus computed tomography (CT) demonstrated a completely opacified right maxillary sinus with inward bowing of its walls, suggesting the diagnosis of stage II CMA. A computerized campimetry (CC) disclosed a scotoma adjacent to the blind spot of the right eye, indicating a possible damage to the optic nerve. The patient was submitted to functional endoscopic sinus surgery, with drainage of a thick mucous fluid from the sinus. She did well after surgery and has been asymptomatic since then. Postoperative CT was satisfactory and CC was normal.

Discussion CMA occurs because of a persistent ostiomeatal obstruction, which creates negative pressure inside the sinus. It is associated with nasosinusal symptoms but had never been described in association with any visual field defect. It can be divided into stage I (membranous deformity), stage II (bony deformity), and stage III (clinical deformity). The silent sinus syndrome is a special form of CMA. This term should only be used to describe those cases with spontaneous enophthalmos, hypoglobus, and/or midfacial deformity in the absence of nasosinusal symptoms.