Quantification of Budesonide Retained in the Sinonasal Cavity After High-Volume Saline Irrigation in Post-Operative Chronic Rhinosinusitis

BACKGROUND

Budesonide high-volume saline irrigations (HVSIs) are routinely used to treat chronic rhinosinusitis (CRS) due to improved sinonasal delivery and efficacy compared to intranasal corticosteroid sprays. The off-label use of budesonide is assumed to be safe, with several studies suggesting the systemically absorbed dose of budesonide HVSI is low. However, the actual budesonide dose retained in the sinonasal cavity following HVSI is unknown. The objective of this study was to quantify the retained dose of budesonide after HVSI.

METHODS

Adult patients diagnosed with CRS who had undergone endoscopic sinus surgery (ESS) and were prescribed budesonide HVSI were enrolled into a prospective, observational cohort study. Patients performed budesonide HVSI (0.5 mg dose) under supervision in an outpatient clinic, and irrigation effluent was collected. High-performance liquid chromatography was employed to determine the dose of budesonide retained after HVSI.

RESULTS

Twenty-four patients met inclusion criteria. The average corrected retained dose of budesonide across the cohort was 0.171 ± 0.087 mg (37.9% of administered budesonide). Increased time from ESS significantly impacted the measured retained dose, with those 3 months post-ESS retaining 27.4% of administered budesonide (P = .0004).

CONCLUSION

The retained dose of budesonide in patients with CRS after HVSI was found to be significantly higher than previously estimated and decreased with time post-ESS. Given that budesonide HVSI is a cornerstone of care in CRS, defining the retained dose and the potential systemic implications is critical to understanding the safety of budesonide HVSI.

Site-Specific Quality of Life Outcomes Following Anterior Skull Base Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

There is a limited understanding of site-specific, quality of life (QOL) outcomes in anterior skull base surgery (ASBS). The objective of the present investigation was to characterize postoperative change in QOL outcomes for anterior skull base lesions following open and endoscopic surgery.

METHODS

A comprehensive review of the literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines using the PubMed, Scopus, Embase, and Cochrane databases for studies reporting pre- and postoperative, site-specific, QOL outcome measures in ASBS using validated questionnaires. Studies utilizing the anterior skull base quality of life (ASBQ) questionnaire or the skull base inventory were included. Investigations focusing on skull base surgery for pituitary lesions, as well as survey validation and non-English studies, were excluded.

RESULTS

A total of 112 studies were screened; 4 studies, comprising a total of 195 patients and focusing exclusively on the ASBQ, were included in the systematic review. Using a fixed effect model for the meta-analysis, the mean ASBQ score was similar at six (3.45, P = 0.312; -0.19, 95% confidence interval: -0.57, 0.18) and 12 months postoperatively (3.6, P = 0.147; 0.3, 95% confidence interval: -0.11, 0.72) compared to baseline (3.53).

CONCLUSIONS

Across a variety of anterior skull base pathologies, skull base-specific QOL demonstrated no improvement at 6 months and 12 months postsurgery. Few studies to date have published pre- and postoperative QOL data for patients undergoing ASBS, highlighting a current shortcoming in the available literature. Long-term follow-up in patients undergoing open and endoscopic approaches will be necessary to better understand and optimize outcomes for patients having ASBS.

The Impact of Acute Peri-operative Particulate Matter Exposure on Endoscopic Sinus Surgery Outcomes: A Preliminary Multi-site Investigation

BACKGROUND

Environmental exposures have been postulated to play an important role in the pathophysiology of chronic rhinosinusitis (CRS). Particulate matter (PM) is one of the most widely studied ambient air pollutants, but its peri-operative impact on CRS is unknown.

OBJECTIVE

To determine the effect of acute, peri-operative PM exposure on outcomes after endoscopic sinus surgery (ESS).

METHODS

Participants with CRS who self-selected ESS were prospectively enrolled. The 22-item SinoNasal Outcome Test (SNOT-22) and Medical Outcomes Study Questionnaire Short-Form 6-D (SF-6D) health utility values scores were recorded. Using residence zip codes, a secondary analysis of patient exposure to PM <2.5 μm and <10 μm (PM2.5 and PM10, respectively) was performed for the month of surgery utilizing data from Environmental Protection Agency air quality monitors. Spearman's correlation coefficients (ρ), 95% confidence intervals (CIs), and effect estimates (β) were used to determine the magnitudes of association. Simple, multivariate regression analysis was also completed.

RESULTS

One hundred and seven patients from four geographically unique institutions across the US were enrolled with a follow-up of 6 months. Patients with higher peri-operative PM2.5 exposure had less improvement in their SNOT-22 scores after ESS compared to those with less exposure using both univariate analysis (ρ = 0.26, 95% CI: 0.08, 0.43; P  =  .01) and after covariate adjustment with multivariate analysis (B  =  1.06, 95% CI: 0.001, 2.14, P  =  .05). Similar associations were not found with SF-6D outcomes or with PM10 as an exposure of interest. No significant correlations were found between peri-operative PM levels and Lund-Kennedy endoscopy scores post-operatively.

CONCLUSION

Preliminary data from this pilot study reveal that PM exposure at the time of ESS may negatively associate with post-operative improvement in sinonasal quality-of-life. Larger, population-based studies with more standardized PM exposure windows are needed to confirm the clinical significance of the present findings.

Does air pollutant exposure impact disease severity or outcomes in chronic rhinosinusitis?

BACKGROUND

Poor air quality increases the risk of developing chronic rhinosinusitis (CRS) and other airway diseases. However, there are limited data on air pollutants and CRS-specific disease severity. We assessed the impact of air pollutants on sinonasal-specific and general quality-of-life (QOL) measures in a multi-institutional cohort of patients with CRS.

METHODS

Participants with CRS were prospectively enrolled in a cross-sectional study and self-selected continued appropriate medical therapy or endoscopic sinus surgery (ESS). The 22-item SinoNasal Outcome Test (SNOT-22) and Medical Outcomes Study Questionnaire Short-Form 6-D (SF-6D) health utility value scores were recorded. Patient exposure to air pollutants was determined using residence zip codes. Unadjusted group differences were compared, and correlation coefficients were evaluated to identify the magnitude of bivariate association.

RESULTS

A total of 486 patients were enrolled and followed for a mean of 6.9 (standard deviation [SD] ± 2.3) months. Pollutant exposure did not significantly correlate with baseline SNOT-22 or SF-6D scores. Revision ESS was associated with higher median fine particulate matter (PM2.5; Δ = 0.12, [95% confidence interval {CI}: 0.003, 0.234]; p = 0.006) compared with primary surgery. PM2.5, PM10, and nitrogen dioxide concentrations (μg/m3) did not correlate with change in total SNOT-22 or SF-6D scores after treatment. Nevertheless, sulfur dioxide (SNOT-22: ρ = -0.121 [95% CI: -0.210, -0.030]; p = 0.007; SF-6D: ρ = 0.095 [95% CI: 0.002, 0.186]; p = 0.04) and carbon monoxide (SNOT-22: ρ = -0.141 [95% CI: -0.230, 0.050]; p = 0.002) exposure did correlate with these outcome measures.

CONCLUSION

Air pollutants may contribute, at least in part, to disease severity in CRS; future investigation is needed to further elucidate the nature of this relationship.

Asthma Management Considerations for the Otolaryngologist: Current Therapies

Asthma is frequently comorbid with chronic rhinosinusitis. First-line pharmacologic intervention for asthma includes combination-inhaled corticosteroids with a long-acting-β-agonist, preferably formoterol. Although short-acting-β-agonists have historically been used as sole rescue option, studies show that this approach can lead to more asthma-related exacerbations and greater mortality. Similarly, oral corticosteroids should be used sparingly due to their significant adverse effect profile. Nonpharmacological interventions for asthma include counseling on modifiable risk factors, such as smoking, physical activity, occupational exposures, and healthy diets. Management of patients with unified airway disease should incorporate a multidisciplinary team consisting of otolaryngologists and asthma specialists.

Characterizing Immune Infiltration in Esthesioneuroblastoma Subtypes Through Gene Expression Deconvolution

BACKGROUND

Esthesioneuroblastoma (ENB) is a rare cancer deriving from the olfactory mucosa. Among the basal or neural genomic subtypes, the basal subtype is associated with poorer survival, poor differentiation, and higher levels of tumor-infiltrating immune cells (TIICs). The immune microenvironment of these ENB subtypes remains unclear. We used an established machine learning algorithm on ENB transcriptomic profiles.

METHODS

The authors characterized 22 immune cell populations using the CIBERSORTx deconvolutional machine learning pipeline on RNA sequencing data from 18 ENB cases. The characterization aimed to elucidate differences in relative proportions and populations of TIICs between basal and neural ENB.

RESULTS

No differences in age, Hyams, Dulguerov, IDH2 mutation, or PD-L1 expression were seen between basal and neural subtypes of ENB (P > 0.05). Also, no difference in median overall survival was appreciated (52.0 ± 13.1 months vs. 50.0 ± 43.2 months, P = 0.5). As a cohort, M2 macrophages were the most abundant subpopulation (14%) followed by naïve B cells (13%) and CD4 memory resting T cells (12%). No gross differences in CD20, CD4, or CD8 cells/mm2 were apparent on gross histology (P > 0.05). However, further analysis showed that activated CD4 memory T cells were significantly increased in the basal ENBs, whereas resting dendritic cells were increased in the neural ENB subtype. The TIIC profiles alone could not differentiate between basal and neural ENB, but did suggest immunoprofile differences.

CONCLUSIONS

Basal and neural subtypes display distinct TIIC involvement, which may impact their difference in outcome. These findings provide the framework for further investigation in novel immunomodulation strategies for ENB.

Health care disparities and chronic rhinosinusitis: Does neighborhood disadvantage impact outcomes in sinonasal disease?

OBJECTIVE

Socioeconomic status (SES) is linked to health outcomes but has not been well studied in patients with chronic rhinosinusitis (CRS). The area deprivation index (ADI) is a comprehensive measure of geographic SES that ranks neighborhood disadvantage. This investigation used ADI to understand the impact of neighborhood disadvantage on CRS treatment outcomes.

METHODS

A total of 642 study participants with CRS were prospectively enrolled and self-selected endoscopic sinus surgery (ESS) or continued appropriate medical therapy as treatment. The 22-item SinoNasal Outcome Test (SNOT-22) and Medical Outcomes Study Questionnaire Short-Form 6-D (SF-6D) health utility value scores were recorded pre- and post-treatment. Using residence zip codes, national ADI scores were retrospectively assigned to patients. Spearman's correlation coefficients (Rs) and Cramer's V effect size (φc ) with 95% confidence interval (CI) were calculated.

RESULTS

A history of ESS was associated with significantly worse ADI scores compared to no history of ESS (φc  = 0.18; 95% CI: 0.10, 0.25; p < 0.001). Baseline total SNOT-22 (Rs = 0.14; 95% CI: 0.06, 0.22; p < 0.001) and SF-6D values (Rs = -0.20; 95% CI: -0.27, -0.12; p < 0.001) were significantly negatively correlated with national ADI rank. No significant correlations between ADI and within-subject improvement, or achievement of >1 minimal clinically important difference, in SNOT-22 or SF-6D scores after treatment were found.

CONCLUSIONS

Geographic socioeconomic deprivation was associated with worse baseline disease severity and history of prior surgical intervention. However, ADI did not correlate with improvement in disease-specific outcomes. The impact of socioeconomic deprivation on outcomes in CRS requires further investigation.

Treatment Outcomes With Conservative Management of Frontal Sinus Outflow Tract Fractures

OBJECTIVE

Historically, early surgical management of frontal sinus outflow tract (FSOT) fractures has been standard practice. There has been a paradigm shift toward nonsurgical or delayed management. Unfortunately, clinical indications and treatment outcomes for this approach are poorly understood. This study evaluates radiologic indicators, as well as sinus reaeration and complication rates for FSOT injuries treated nonsurgically.

STUDY DESIGN

A retrospective cohort study of FSOT injuries between 2005 and 2019.

SETTING

Academic, tertiary care medical center.

METHODS

Radiographic fracture patterns of the frontal ostia (FO) and frontal recess (FR) were recorded as either patent, disrupted, or obstructed. Sinus reaeration, surgical rescue, and complication rates were documented. Patients with follow-up imaging >42 days were included. Patients undergoing immediate surgical intervention were excluded.

RESULTS

One hundred patients were identified and 44 met the criteria (88 sinuses). Among nonobstructed FSOT injuries (ie, patent or disrupted), reaeration occurred in 91% of the FO and 98% of FR injuries. Two sinuses required surgical rescue including 1 Draf IIB (1%), and 1 obliteration (1%). Two sinuses had complications including 1 mucocele (1%) and 1 cerebrospinal fluid leak (1%). FO and FR fracture patterns had no identifiable correlation with long-term reaeration rates or the need for surgical intervention.

CONCLUSION

Among nonobstructive injuries to the FSOT, average reaeration rates in observed patients were high (91%-98%). Rescue surgery (2%) and complication rates (2%) were low, suggesting that nonsurgical management of nonobstructed FSOT is a viable strategy. No radiographic features were clearly identified to be predictive of sinus reaeration.

The Impact of Surgical Posterior Nasal Nerve Cryoablation on Symptoms and Disease-Specific Quality of Life in Patients With Chronic Rhinitis

OBJECTIVE

Preliminary data have demonstrated long-term efficacy of posterior nasal nerve (PNN) cryoablation in reducing rhinitis symptoms for patients with allergic rhinitis (AR) and nonallergic rhinitis (NAR). We sought to evaluate the impact of procedural cryoablation of the PNN on quality of life (QOL) in patients with AR and NAR.

METHODS

Adult patients undergoing PNN cryoablation for AR or NAR after appropriate medical therapy were included for analysis. Demographics, medical therapies, baseline rhinitis symptom (total nasal symptom score [TNSS]), and disease-specific QOL (mini-rhinoconjunctivitis quality of life questionnaire [mini-RQLQ]) were recorded. The Wilcoxon signed-rank test was used to test for significant changes in baseline test scores posttreatment. Absolute and relative improvement in outcomes was determined for each participant. Secondary outcomes were assessed with univariate and multivariate analyses.

RESULTS

Fourteen patients were enrolled with a mean follow-up of 16.5 weeks. The TNSS and mini-RQLQ scores significantly improved after PNN cryoablation (median δs [interquartile range]: -4 [3] and -1.61 [1.08], respectively; both P = .0002). The minimal clinically important difference for the TNSS and mini-RQLQ was obtained in 92.9% of patients in each category. Relative mean percentage (%) improvement after PNN cryoablation in the TNSS and mini-RQLQ was 40.7% and 40.5% (standard deviation = 24.9 and 29.5, respectively), respectively, for all patients. Patients with NAR (n = 10) reported mean improvement of 41.3% (29.1) as measured by the TNSS and 49.6% (25.9) by mini-RQLQ. Patients with AR reported mean percentage improvement in TNSS and mini-RQLQ scores of 39.5% (12.1) and 24.6% (28.5), respectively. Patients who had been prescribed a nasal anticholinergic for management prior to PNN cryoablation had statistically significantly increased improvement in mini-RQLQ scores from pre- to post-procedure (P = .0387).

CONCLUSION

Surgical cryoablation of the PNN significantly improves both symptoms and disease-specific QOL in majority of patients with AR and NAR.

Management paradigms for chronic rhinosinusitis in individuals with asthma: An evidence-based review with recommendations

BACKGROUND

Despite the significant morbidity associated with chronic rhinosinusitis (CRS) in individuals with asthma (CRSwA), there is a paucity of codified, evidence-based management strategies for CRS in this population.

METHODS

Using PubMed, Embase, and Cochrane Review Databases, a systematic review was performed covering management strategies for CRSwA. A total of 5903 articles were screened, and 70 were included for full-text analysis. After application of exclusion criteria, 53 articles comprised the qualitative synthesis. The level of evidence was graded and benefit-harm assessments, as well as value judgment and recommendations, were provided RESULTS: Strong evidence confirms the benefit of oral and topical medications on sinonasal-specific outcomes in individuals with CRSwA; there is low-grade evidence demonstrating that these agents improve lung function and/or asthma control. Moderate to strong evidence suggests that endoscopic sinus surgery (ESS) improves both sinonasal- and asthma-specific quality of life. Although there is insufficient to low evidence to indicate that ESS improves pulmonary function in this population, data indicate a positive impact of this intervention on asthma control. Biologic medications strongly improve both subjective and objective sinonasal- and asthma-specific outcomes.

CONCLUSION

Evidence supports managing CRS in individuals with CRSwA in a stepwise fashion, starting with traditional nonbiologic oral and topical medication, and escalating to second-line treatments, such as ESS and biologics. Optimal treatment of individuals who have CRSwA often requires concurrent, directed management of asthma, as not all CRS interventions impact asthma status.

An eosinophil peroxidase activity assay accurately predicts eosinophilic chronic rhinosinusitis

BACKGROUND

A definitive diagnosis of eosinophilic chronic rhinosinusitis (eCRS) requires invasive surgical tissue sampling and histologic enumeration of intact eosinophils. Eosinophil peroxidase (EPX) is an accurate biomarker of sinonasal tissue eosinophilia in CRS regardless of polyp status. A less invasive and rapid method that accurately identifies tissue eosinophilia would be of great benefit to patients.

OBJECTIVE

We sought to evaluate a new clinical tool that uses a nasal swab and colorimetric EPX activity assay to predict a diagnosis of eCRS.

METHODS

A prospective, observational cohort study was conducted using nasal swabs and sinonasal tissue biopsies obtained from patients with CRS electing endoscopic sinus surgery. Patients were classified as non-eCRS (n = 19) and eCRS (n = 35) on the basis of pathologically determined eosinophil counts of less than 10 or greater than or equal to 10 eosinophils/HPF, respectively. Swab-deposited EPX activity was measured and compared with tissue eosinophil counts, EPX levels, and CRS-specific disease metrics.

RESULTS

EPX activity was significantly increased in patients with eCRS than in patients without eCRS (P < .0001). With a relative absorbance unit cutoff value of greater than or equal to 0.80, the assay demonstrated high sensitivity (85.7%) and moderate specificity (79.0%) for confirming eCRS. Spearman correlations between EPX activity and tissue eosinophil counts (rs = 0.424), EPX levels (rs = 0.503), and Lund-Kennedy endoscopy scores (rs = 0.440) in eCRS were significant (P < .05).

CONCLUSIONS

This investigation evaluates a nasal swab sampling method and EPX activity assay that accurately confirms eCRS. This method could potentially address the unmet need to identify sinonasal tissue eosinophilia at the point-of-care, as well as to longitudinally monitor eosinophil activity and treatment response.

Tobacco use increases the risk of chronic rhinosinusitis among patients undergoing endoscopic sinus surgery

BACKGROUND

Although it has been postulated that tobacco use, as well as other environmental exposures, may contribute to chronic rhinosinusitis (CRS), the data remain limited. Here, we utilised a large state population database to assess the association between tobacco use and CRS prevalence among patients undergoing endoscopic sinus surgery (ESS).

METHODS

Employing a case-control study design, the Utah Population Database was queried for patients age >18 with a diagnosis of CRS and tobacco use who underwent ESS between 1996 and 2018. Smoking status was compared between patients with CRS (n = 34 350) and random population controls matched 5:1 on sex, birth year, birthplace, time residing in Utah, and pedigree (i.e., familial) information (n = 166 020). Conditional logistic regression models were used for comparisons between CRS patients and their matched controls. All analyses were repeated, additionally adjusting for race, ethnicity, tobacco use, asthma history, and interaction between tobacco use and asthma history.

RESULTS

A total of 200 370 patients were included in the final analysis. Patients with CRS were significantly more likely to demonstrate a history of tobacco use than controls (19.6% vs. 15.0%; p < .001), with an adjusted odds ratio (aOR) of 1.42, 95% confidence interval 1.37-1.47; p < .001. More patients with CRS and comorbid asthma used tobacco (19.5%) than controls with asthma (15.0%; p < .001).

CONCLUSION

History of tobacco use may portend increased risk for the development of CRS among patients undergoing ESS compared to healthy controls.

Intraoperative Alcoholization of the Pituitary Gland Does Not Reduce the Recurrence Rate of Growth Hormone Secreting Pituitary Adenomas

Objective  Although the role of intraoperative alcoholization of the pituitary gland has been examined for the management of malignant tumor metastases and Rathke's cleft cysts, no such studies have been conducted relating to growth hormone (GH) secreting pituitary tumors, despite the high rate of recurrence in this cohort of patients. Here, we sought to understand the impact of adjunctive intraoperative alcoholization of the pituitary gland on recurrence rates and perioperative complications associated with resection of GH-secreting tumors. Methods  This is a single-institution retrospective cohort study analyzing recurrence rates and complications among patients with GH-secreting tumors who received intraoperative alcoholization of the pituitary gland postresection versus those that did not. Welch's t -tests and analysis of variance (ANOVA) analyses were employed to compare continuous variables between groups, whereas chi-squared tests for independence or Fisher's exact tests were used for comparing categorical variables. Results  A total of 42 patients ( n  = 22 no alcohol and n  = 20 alcohol) were included in the final analysis. The overall recurrence rates did not significantly differ between the alcohol and no alcohol groups (35 and 22.7%, respectively; p  = 0.59). The average time to recurrence in the alcohol and no alcohol groups was 22.9 and 39 months, respectively ( p  = 0.63), with a mean follow-up of 41.2 and 53.5 months ( p  = 0.34). Complications, including diabetes insipidus, were not significantly different between the alcohol and no alcohol groups (30.0 vs. 27.2%, p  = 0.99). Conclusion  Intraoperative alcoholization of the pituitary gland after resection of GH-secreting pituitary adenomas does not reduce recurrence rates or increase perioperative complications.

Systematic Review of Treatment Options and Therapeutic Responses for Lesions of the Sella and Orbit: Evidence-Based Recommendations

OBJECTIVE

Inflammatory pathologies of the sella and orbit are rare but require prompt diagnosis to initiate effective treatment. Because uniform recommendations for treatment are currently lacking, we performed an evidence-based review to identify recommendations.

METHODS

We performed a literature search of the PubMed, Embase, and Web of Science databases to identify papers evaluating treatment of inflammatory pathologies of the sella and orbit. We used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to define recommendations, specifically examining aggregated sample sizes, disease-specific patient follow-up, and clinical trials focused on inflammatory diseases of the sella and orbit.

RESULTS

A total of 169 studies were included and organized by disease pathology. Treatments for various pathologies were recorded. Treatment options included surgery, radiation, steroids, targeted treatments, immunomodulators, intravenous immune globulin, and plasmapheresis. Steroids were the most often employed treatment, second-line management options and timing varied. Pathological diagnosis was highly associated with treatment used. Most evidence were level 3 without available control groups, except for 13 trials in neuromyelitis optica with level 1 or 2 evidence.

CONCLUSIONS

This is the first evidence-based review to provide recommendations on specific treatments for pathologies of the orbit and sella. The reported data may be useful to help guide randomized clinical trials and provide resource for clinical management decisions based on the available evidence.

Healthcare Provider Feedback Improves Outpatient E/M Billing and Coding in Otolaryngology Clinics

Objective

Discrepancies in medical coding can negatively impact institutional revenue and result in accusations of medical fraud. The objective of the present study was to prospectively assess the utility of a dynamic feedback system for otolaryngology providers in improving the coding/billing accuracy of outpatient clinic encounters.

Methods

A billing audit of outpatient clinic visits was performed. Dynamic billing/coding feedback, consisting of a virtual lecture and targeted e-mails, was provided at distinct intervals by the institutional billing and coding department. χ ² was used for categorical data, and the Wilcoxon test was used to compare changes in accuracy over time.

Results

A total of 176 clinic encounters were reviewed. Prior to feedback, 60% of encounters were inaccurately billed by otolaryngology providers, requiring upcoding and representing a potential 35% work relative value unit (wRVU) loss of E/M generated productivity. After 1 year of feedback, providers significantly increased the accuracy of their billing from 40% to 70% (odds ratio [OR]: 3.55, p < .001, 95% confidence interval [CI]: 1.69, 7.29), with a corresponding decrease in potential wRVU loss from 35% to 10% (OR: 4.87, p < .001, 95% CI: 0.81, 10.51).

Discussion

Dynamic billing feedback significantly improved outpatient E/M coding among otolaryngology healthcare providers in this study.

Implications for Practice

This study demonstrates that educating providers on appropriate medical coding and billing policies, while providing dynamic, intermittent feedback, may improve billing accuracy, translating into appropriate charges and reimbursements for services provided.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Tobacco Use Increases the Adjusted Risk of Revision Endoscopic Sinus Surgery in Patients With Chronic Rhinosinusitis

BACKGROUND

Large epidemiologic studies have suggested that a history of tobacco use may be associated with an increased risk of developing chronic rhinosinusitis (CRS). The impact of tobacco use on revision rates of endoscopic sinus surgery (ESS), however, remains limited.

OBJECTIVE

This study seeks to define the independent risk of tobacco use (active or prior) on revision rates of ESS among a large cohort of patients with CRS.

METHODS

A state population database was queried for patients age ≥18 years with CRS who underwent at least one ESS between 1996 and 2018. Demographic characteristics, history of ESS, and tobacco use status were compared across patients with CRS, using t tests for continuous variables and χ² tests for categorical variables. Unadjusted and adjusted logistic regression models were used to understand the impact of tobacco status on revision surgery.

RESULTS

The final analysis included 34 350 patients (29 916 CRS with no revision surgery and 4434 CRS with revision surgery). Unadjusted regression analysis demonstrated an increased odds of undergoing revision ESS (OR 1.12, 95% CI: 1.00-1.25, P = .05) among males with a history of tobacco use and CRS. Adjusted regression analysis demonstrated that the risk of revision ESS among CRS patients with a history of asthma and tobacco use was 1.72-fold, while the risk among CRS patients who were tobacco users without asthma was 1.11-fold.

CONCLUSION

History of tobacco use is an independent risk factor for revision ESS among patients with CRS.

Evaluating Distance Bias in Chronic Rhinosinusitis Outcomes

Importance

The distance traveled by patients for medical care is associated with patient outcomes (ie, distance bias) and is a limitation in outcomes research. However, to date, distance bias has not been examined in rhinologic studies.

Objective

To evaluate the association of distance traveled by a cohort of patients with chronic rhinosinusitis with baseline disease severity and treatment outcomes.

Design, Setting, and Participants

A total of 505 patients with chronic rhinosinusitis were prospectively enrolled in a multi-institutional, cross-sectional study in academic tertiary care centers between April 2011 and January 2020. Participants self-selected continued appropriate medical therapy or endoscopic sinus surgery. The 22-item Sinonasal Outcome Test (SNOT-22) and Medical Outcomes Study Short Form 6-D (SF-6D) health utility value scores were recorded at enrollment and follow-up. Data on the distances traveled by patients to the medical centers, based on residence zip codes, and medical comorbid conditions were collected.

Exposures

Distance traveled by patient to obtain rhinologic care.

Main Outcomes and Measures

SNOT-22 and SF-6D scores. Scores for SNOT-22 range from 0 to 110; and for SF-6D, from 0.0 to 1.0. Higher SNOT-22 total scores indicate worse overall symptom severity. Higher SF-6D scores indicate better overall health utility; 1.0 represents perfect health and 0.0 represents death.

Results

The median age for the 505 participants was 56.0 years (IQR, 41.0-64.0 years), 261 were men (51.7%), 457 were White (90.5%), and 13 were Hispanic or Latino (2.6%). These categories were collected according to criteria described and required by the National Institutes of Health and therefore do not equal the entire cohort. Patients traveled a median distance of 31.6 miles (50.6 km) (IQR, 12.2-114.5 miles [19.5-183.2 km]). Baseline (r = 0.00; 95% CI, 0.00-0.18) and posttreatment (r = 0.01; 95% CI, -0.07 to 0.10) SNOT-22 scores, as well as baseline (r = -0.12; 95% CI, -0.21 to -0.04) and posttreatment (r = 0.07; 95% CI, -0.02 to 0.16) SF-6D scores, were not associated with distance. There was no clinically meaningful correlation between distance traveled and mean comorbidity burden. Nevertheless, patients with a history of endoscopic sinus surgery were more likely to travel longer distances to obtain care (Cliff delta = 0.28; 95% CI, 0.19-0.38).

Conclusions and Relevance

Although this cross-sectional study found that some patients appear more willing to travel longer distances for chronic rhinosinusitis care, results suggest that distance traveled to academic tertiary care centers was not associated with disease severity, outcomes, or comorbidity burden. These findings argue for greater generalizability of study results across various cohorts independent of distance traveled to obtain rhinologic care.

Trial Registration

ClinicalTrials.gov Identifier: NCT02720653.

Health Literacy and Web-Based Audiovisual Multimedia in Pituitary and Endoscopic Skull Base Surgery

Introduction The internet presents a rich milieu of multimedia options relating to pituitary and endoscopic skull base surgery (ESBS). Misinformation can create discordance between patient and provider expectations. The purpose of this study is to analyze the understandability and actionability of available ESBS and pituitary surgery audiovisual information on YouTube and Google.

Methods The top 50 videos generated by searching “pituitary surgery/transsphenoidal surgery” and “endoscopic skull base surgery” in both YouTube and Google were sorted by relevance. Two independent reviewers evaluated each for understandability and actionability based on the Patient Education Materials Assessment Tool for audiovisual material (PEMAT-A/V). Source, authorship, audience, and education/advertisement variables were collected. Chi-square test followed by univariate and multivariate regression analyses assessed the association between these variables and quality.

Results A total of 85 videos (52 YouTube and 33 Google) met inclusion criteria for analysis. There was no significant difference in the presence of the aforementioned variables between YouTube and Google (p < 0.05). Also, 72% of videos targeted patients and 28% targeted surgeons. Academic institutions uploaded 58% of videos. Surgeon-targeted videos were more educational (p = 0.01) and patient-targeted videos involved more advertisement (p = 0.01). Understandability and actionability scores were below the 70% threshold for both YouTube (65 ± 15, 38 ± 33, p = 0.65) and Google (66 ± 12, 38 ± 26, p = 0.94). Patient-targeted videos (p = 0.002) were more understandable, while surgeon- (p < 0.001) and education-focused videos (p < 0.001) were more actionable.

Conclusion Understandability and actionability of YouTube and Google audiovisual patient information on ESBS and pituitary surgery is poor. Consideration should be given to the formation of a standardized patient information resource.

The Impact of Medical Comorbidities on Patient Satisfaction in Chronic Rhinosinusitis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cumulative comorbidity burden does not worsen outcomes in management of chronic rhinosinusitis

BACKGROUND

The impact of multiple coexisting medical comorbidities on treatment outcomes in chronic rhinosinusitis (CRS) is unknown. In this study we sought to evaluate the effect of comorbidities on sinonasal quality of life (QOL) and general health utility values by utilizing the Functional Comorbidity Index (FCI) in CRS patients.

METHODS

Patients with CRS were prospectively enrolled in a cross-sectional study of medical and surgical therapies. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Medical Outcomes Study Short-Form 6D (SF-6D) scores were recorded at enrollment and 6-month follow-up; Lund-Kennedy endoscopy and Lund-Mackay computed tomography scores were recorded at enrollment. The FCI was calculated using the electronic medical record. The impact of cumulative comorbidity burden on baseline and posttreatment outcomes was assessed using univariate and bivariate correlations.

RESULTS

A total of 428 participants with CRS were included. The average (mean standard ± deviation) FCI score was 3.03 ± 2.28 (range, 0-12). Significant linear correlations were identified between increasing FCI score and baseline SNOT-22 and SF-6D scores (R = 0.166, p = 0.001 and R = -0.245, p < 0.001, respectively). There was no correlation between FCI and change in SNOT-22 or SF-6D scores after CRS treatment (R = 0.066, p = 0.17 and R = -0.087, p = 0.074, respectively). Achievement of a minimally clinically important difference was also independent of FCI.

CONCLUSION

Although cumulative comorbidity burden, as measured by FCI, is associated with worse baseline SNOT-22 and SF-6D scores, it does not appear to limit posttreatment improvement in either outcome measure. On average, patients with high comorbidity burden report substantial improvement in both QOL and health utility after CRS treatment, similar to those with fewer comorbidities.

Vascular permeability in chronic rhinosinusitis enhances accumulation and retention of nanoscale pegylated liposomes

Chronic rhinosinusitis (CRS) is a debilitating inflammatory disorder of the sinonasal mucosa that substantially diminishes patient quality of life. Progress surrounding management of this disease has been crippled by a lack of therapeutic innovation. It has been posited that increased vascularity within the diseased sinuses of patients with CRS may allow for improved systemic drug delivery via nanoscale liposomal carriers. Such a system could enhance drug distribution, accumulation, and retention within the sinuses, ultimately leading to improved patient outcomes. PEGylated liposomes loaded with indocyanine green (ICG) were synthesized, characterized and systemically administered in a mouse model of CRS. Accumulation and retention of ICG in sinonasal tissue were evaluated. Compared to healthy controls, CRS mice showed significant sinonasal tissue accumulation and retention of PEGylated liposomal ICG for up to 21 days (P < 0.001). Conversely, free ICG was eliminated from the body after 24 h in both groups.

Cystic Fibrosis Increases Long-Term Revision Rates of Endoscopic Sinus Surgery in Patients With Comorbid Chronic Rhinosinusitis

Background: Comorbid chronic rhinosinusitis (CRS) of adulthood is increasing among patients with cystic fibrosis (CF) due to improved median survival. However, little is known about the natural history of endoscopic sinus surgery (ESS) in this cohort. The objective of this study was to evaluate the revision rate of ESS and associated risk factors among adults with CRS and CF (CRSwCF). Methods: The Utah Population Database was queried for patients age >18 with CRS who underwent at least one ESS between 1996 and 2018. Demographic information and ESS history were collected and compared for CRSwCF versus CRS without CF (CRSsCF) using chi-square and t-tests. Risk factors for revision were analyzed using Cox proportional hazard models and logistic regression analysis. Results: A total of 34 050 patients (33 639 CRSsCF and 411 CRSwCF) were included in the final analysis. The mean duration of follow-up was 9.3 and 9.3 years, respectively (P = .98). Adult patients with CF were significantly more likely to undergo revision ESS (18.7%) than those without CF (13.4%; P < .01). Logistic regression analysis indicated that a diagnosis of CF independently elevated the risk for revision ESS in the absence of nasal polyps (odds ratio [OR] 2.18, confidence interval [CI] 1.34-3.54), asthma (OR 1.36, CI 0.94-1.98), and allergies (OR 1.29, CI 0.90-1.73). Conclusion: In the era before highly effective modulator therapies, the mean revision rate of ESS among adults with CRSwCF was 18.7%, significantly greater than that of adults with CRSsCF. CF was an independent risk factor for revision ESS in the absence of nasal polyps, asthma, and allergies.

Surgeon education through a surgical cost feedback system reduces supply cost in endoscopic skull base surgery

OBJECTIVE

A large proportion of healthcare expense is operating room (OR) costs. As a means of cost mitigation, several institutions have implemented surgeon education programs to bring awareness about supply costs. This study evaluates the impact of a surgical cost feedback system (surgical receipt) on the supply costs of endoscopic skull base surgery (ESBS) procedures.

METHODS

The supply costs of each ESBS surgical case were prospectively collected and analyzed before and after the implementation of a nonincentivized, automated, and itemized weekly surgical receipt system between January 2017 and December 2019. Supply cost data collected 15 months prior to intervention were compared with cost data 21 months after implementation of the surgical receipt system. Demographics, surgical details, and OR time were collected retrospectively.

RESULTS

Of 105 ESBS procedures analyzed, 36 preceded and 69 followed implementation of cost feedback. There were no significant differences in patient age (p = 0.064), sex (p = 0.489), surgical indication (p = 0.389), or OR anesthesia time (p = 0.51) for patients treated before and after implementation. The mean surgical supply cost decreased from $3824.41 to $3010.35 (p = 0.002) after implementation of receipt feedback. Usage of dural sealants (p = 0.043), microfibrillar collagen hemostat (p = 0.007), and oxidized regenerated cellulose hemostat (p < 0.0001) and reconstructive technique (p = 0.031) significantly affected cost. Mediation analysis confirmed that the overall cost reduction was predominantly driven by reduced use of dural sealant; this cost saving exceeded the incremental cost of greater use of packing materials such as microfibrillar collagen hemostat.

CONCLUSIONS

Education of surgeons regarding surgical supply costs by a surgical receipt feedback system can reduce the supply cost per case of ESBS operations.

Nasal endoscopy, room filtration, and aerosol concentrations during live outpatient encounters: a prospective, case-control study

Background

The coronavirus disease 2019 (COVID‐19) pandemic has highlighted safety concerns surrounding possible aerosol‐generating procedures, but comparative data on the smallest particles capable of transmitting this virus remain limited. We evaluated the effect of nasal endoscopy on aerosol concentration and the role of a high‐efficiency particulate air (HEPA) filter in reducing aerosol concentration.

Methods

Otolaryngology patients were prospectively enrolled in an outpatient, cross‐sectional study. Demographic information and clinic room characteristics were recorded. A scanning mobility particle sizer and GRIMM aerosol monitor measured aerosols 14.3 nm to 34 μm in diameter (i.e., particles smaller than those currently examined in the literature) during (1) nasal endoscopy (± debridement) and (2) no nasal endoscopy encounters. One‐way analysis of variance (ANOVA) and Student's t test were performed to compare aerosol concentrations and impact of HEPA filtration.

Results

Sixty‐two patients met inclusion criteria (25 nasal endoscopy without debridement; 18 nasal endoscopy with debridement; 19 no nasal endoscopy). There was no significant difference in age or gender across cohorts. Aerosol concentration in the nasal endoscopy cohort (± debridement) was not greater than the no nasal endoscopy cohort (p = 0.36; confidence interval [95% CI], −1.76 to 0.17 μg/m³; and p = 0.12; 95% CI, −0.11 to 2.14 μg/m³, respectively). Aerosol concentrations returned to baseline after 8.76 min without a HEPA filter versus 4.75 min with a HEPA filter (p = 0.001; 95% CI, 1.73–6.3 min).

Conclusion

Using advanced instrumentation and a comparative study design, aerosol concentration was shown to be no greater during nasal endoscopy versus no endoscopy encounters. HEPA filter utilization reduced aerosol concentrations significantly faster than no HEPA filter.

Cell Adhesion Molecules are Upregulated and May Drive Inflammation in Chronic Rhinosinusitis with Nasal Polyposis

Purpose

Chronic rhinosinusitis with nasal polyps (CRSwNP) is predominantly characterized by eosinophil- and T helper 2 cell (Th2)-biased inflammation. Integrins and intercellular adhesion molecules (ICAMs) are superfamilies of cell adhesion molecules (CAMs) that facilitate the recruitment and trafficking of immune cells and have been implicated in coordinating eosinophil and Th2 cell adhesion and signaling in asthma. The roles of CAMs in CRSwNP, however, remain poorly understood. The purpose of this study was to characterize the systemic and local expression of CAMs and identify which CAMs are potentially involved in CRSwNP pathology.

Materials and Methods

A prospective observational study was conducted using peripheral blood and anterior ethmoid tissues of patients with CRSwNP (n=32) and controls (n=15). Multiplex gene analysis and Pearson correlations were performed to identify associations between systemically and locally expressed CAMs. Based on the gene expression results, immunohistochemical evaluation and quantification of cells expressing integrins ITGAM, ITGAX, and ITGB2, as well as ICAM-3 in sinonasal tissues were conducted to compare local protein expression patterns.

Results

Integrin and ICAM genes were significantly elevated in the blood (p<0.001 to p<0.05) and sinuses (p<0.0003 to p<0.05) of patients with CRSwNP compared to controls. Strong positive correlations of genes expressed in the blood (p<0.01 to p<0.05) and sinuses (p<0.01) were observed between ITGAM, ITGAX, ITGB2, and ICAM3. ITGAM-, ITGB2-, ICAM-3-, and ICAM-3/ITGB2-positive cell counts were significantly increased in CRSwNP compared to controls (p<0.0001 to p<0.04), and a positive correlation between ICAM-3/ITGB2- and ITGAM-positive cell counts was observed (p<0.02).

Conclusion

The systemic and local expression of ITGAM, ITGB2, and ICAM-3 is significantly upregulated in CRSwNP, suggesting that integrin complex ITGAM/ITGB2 and ICAM-3 serve a potential role in inflammation-mediated signaling in CRSwNP.

Comorbidities Known to Affect Physical Function Negatively Impact Baseline Health-Related Quality-of-Life in Patients With Chronic Rhinosinusitis

BACKGROUND

Medical comorbidities are commonly encountered in chronic rhinosinusitis (CRS) and may impact both physical function and patient reported health-related quality-of-life (HRQOL). The functional comorbidity index (FCI) is designed to elucidate the role of comorbidities on functional prognosis. The objective of this study was to understand the impact of comorbidities known to impact physical function on baseline HRQOL using the FCI.Methodology: Patients meeting diagnostic criteria for CRS were prospectively enrolled in a cross-sectional study. Responses from the Sinonasal Outcomes Test-22 (SNOT-22), a measure of patient HRQOL, as well as the Lund-Kennedy and Lund-Mackay scores were recorded at enrollment. FCI was calculated retrospectively using the electronic medical record. Information was collected and compared for patients without (CRSsNP) and with nasal polyps (CRSwNP) using chi-square and t-tests. Spearman's correlations, followed by multivariate regression analysis, were used to assess the association between FCI and SNOT-22 scores.

RESULTS

One hundred and three patients met inclusion criteria for analysis. There were no significant differences in age, gender, and SNOT-22 scores between patients with CRSsNP and those with CRSwNP. FCI was significantly and independently associated with worse SNOT-22 scores (P = .012). FCI did not correlate with endoscopy and computed tomography scores. The mean FCI for patients with CRSsNP and CRSwNP was 2.02 and 2.24, respectively, and did not differ significantly between the two cohorts (P = .565).

CONCLUSIONS

Major medical comorbidities known to affect physical function are associated with worse SNOT-22 scores in patients with CRS as measured by the FCI.

Transcriptional Changes in Chronic Rhinosinusitis with Asthma Favor a Type 2 Molecular Endotype Independent of Polyp Status

Background

Data regarding the inflammatory profile of patients with asthma and chronic rhinosinusitis (CRS-A) with (CRSwNP-A) and without (CRSsNP-A) nasal polyposis remain limited.

Objective

Define and compare systemic transcriptional changes in patients with CRS-A to those with non-asthma-related CRS with (CRSwNP) and without nasal polyposis (CRSsNP).

Methods

Thirty-four patients with CRS-A (n=19) and CRS (n=15) were prospectively enrolled into an observational study. Demographic information and subjective and objective disease severity measures were recorded. Multiplex gene expression analysis of mRNA extracted from peripheral blood was performed. A total of 594 genes associated with innate/adaptive immunity were analyzed using NanoString technology. Gene expression ratios were reported for genes that were differentially expressed among these cohorts. Linear regression analysis was used to compare the mRNA transcript copy numbers for each gene with disease severity.

Results

There was no significant difference in age, gender, nasal polyposis, or health-related quality of life measures between the two groups (p>0.05). HLA class II histocompatibility antigen, DRB3-1 beta chain (HLA-DRB3) was significantly upregulated in the peripheral blood of patients with CRSsNP-A compared to CRSsNP, whereas chemokine (C-C motif) ligands 4 (CCL4) and zinc finger protein helios (IKZF2) were significantly upregulated in CRSwNP-A compared to CRSwNP (p<0.05).

Conclusion

Patients with CRSsNP-A demonstrate a molecular endotype associated with a Th2-dominant inflammatory profile compared to CRSsNP. Patients with CRSwNP-A similarly demonstrate an overrepresentation of genes associated with Th2-driven inflammation compared to patients with CRSwNP.

Asthma increases long-term revision rates of endoscopic sinus surgery in chronic rhinosinusitis with and without nasal polyposis

BACKGROUND

Chronic rhinosinusitis with asthma (CRS-A) has a significant impact on patient morbidity and quality of life. Nevertheless, little is known about the natural history of endoscopic sinus surgery (ESS) in this cohort. The objective of this study was to evaluate revision rates of ESS in CRS-A and identify risk factors associated with increased likelihood for revision surgery compared to those with CRS without asthma (CRS-alone).

METHODS

The Utah Population Database was queried for patients age >18 years with CRS who underwent at least 1 ESS between 1996 and 2018. Demographic information and history of ESS were collected and compared between CRS-A and CRS-alone using chi-square tests for categorical variables and t tests for continuous variables. Risk factors for revision surgery were analyzed using Cox proportional hazard models.

RESULTS

A total of 33,090 patients (7693 CRS-A and 25,397 CRS-alone) were included in the final analysis. Mean follow up was 9.8 years in CRS-A and 9.1 years in CRS-alone (p < 0.001). The revision rate among patients with CRS-A (21.5%) was twice that of CRS-alone (10.8%) (p < 0.001). Among patients with CRS, a history of allergy (p < 0.001), asthma (p < 0.001), and nasal polyposis (p < 0.001) was independently associated with increased risk of revision ESS. Patients with CRS-A and nasal polyposis were 6 times more likely to require revision surgery than those with CRS-alone (p < 0.010).

CONCLUSION

The rate of revision ESS in CRS-A was twice that of CRS-alone; patients with CRS-A and nasal polyposis were 6 times more likely to require revision than those with CRS-alone. ©2021 ARSAAOA, LLC.

Telemedicine, Patient Satisfaction, and Chronic Rhinosinusitis Care in the Era of COVID-19

BACKGROUND

Telemedicine has become increasingly popular in the care of rhinologic patients during the COVID-19 pandemic. This change in practice patterns may place patients at risk of a perceived lower-quality exchange with their healthcare provider, which may in turn impact satisfaction.

OBJECTIVE

This study compares patient satisfaction scores between in-person clinic visits and telemedicine video visits in patients with chronic rhinosinusitis (CRS).

METHODS

Sixty-nine patients with CRS presenting to an academic rhinology clinic between March to April 2020 were retrospectively divided into video visits (VV) and clinic visits (CV) groups based on mandated state quarantine orders on March 19. Patient demographics, disease severity measures, and Patient Satisfaction Questionnaire-18 (PSQ-18) scores were collected and analyzed. Chi square test and Fisher's exact test were performed.

RESULTS

There were no significant differences in age (p = 0.81), gender (p = 0.55), CRS phenotype (p = 0.16), and disease severity measures (Sinonasal Outcomes Test-22 (SNOT-22) (p = 0.92); Lund-Mackay score (p = 0.96)) between the video and clinic visit groups. There were no significant differences in PSQ-18 total scores (VV PSQ-18 mean score = 78.1, CV PSQ-18 mean score = 78.4; p = 0.67) or the following subdomain scores between the two groups: general satisfaction (p = 0.73), technical quality (p = 0.62), interpersonal manner (p = 0.41), communication (p = 0.31), financial aspects (p = 0.89), time spent with doctor (p = 0.88), and accessibility and convenience (p = 0.47).

CONCLUSION

Patient satisfaction with telemedicine in the COVID-19 pandemic parallels that of traditional in-person visits. Video visits can serve as a viable alternative to clinic visits, while still maintaining high satisfaction.

Abstract B19: Malnutrition evaluation in head and neck cancer patients: Practice patterns among otolaryngologists and radiation oncologists

Purpose: 1. To understand practice patterns among head and neck surgeons and radiation oncologists in the assessment and management of malnutrition in head and neck cancer patients. 2. To identify barriers that prevent the identification of and intervention upon malnutrition.

Background: Among patients who undergo surgery for head and neck cancer, there is a strong association between severe malnutrition and increased postoperative complications, length of stay, and cost of care. We aim to evaluate the association between the type of head and neck cancer provider and their comfort with the diagnosis and management of malnutrition in this patient population.

Methods: A 17-question survey was distributed to 1,392 members of the American Head and Neck Society (AHNS) between 04/01/2018 and 04/18/2018. Chi squared testing was used to perform subgroup analysis by hospital type, fellowship training, clinical experience, and specialty.

Results: The response rate among AHNS members was 9%, with 124 total respondents, including both otolaryngologists and radiation oncologists. There was strong agreement among respondents that malnutrition is important to identify and negatively impacts the quality of life, cost of care, length of hospital stay, mortality, and postoperative complications. The majority of respondents stated that although they were comfortable with screening for malnutrition, they were not familiar with the National Comprehensive Cancer Network (NCCN) guidelines on nutrition screening and intervention. Respondents reported use of various screening tools including serum markers, body mass index (BMI), and weight loss. Subgroup analysis demonstrated that otolaryngologists and academic hospitals were significantly more likely to screen by lab markers compared to radiation oncologists and community hospitals (p&lt;0.05). Furthermore, although familiarity with NCCN guidelines was poor, fellowship-trained head and neck surgeons felt significantly more comfortable in their knowledge of NCCN guidelines than those without additional training (p&lt;0.05). Barriers to screening for malnutrition included lack of training or familiarity with screening tools and guidelines, as well as lack of access to ancillary staff, such as nutritionists and speech therapists.

Conclusion: There was a strong consensus among respondents that identification and management of malnutrition among head and neck cancer patients is important. However, familiarity with guidelines on screening and treating malnutrition was lacking, occasionally leading to practice patterns that deviated from the best available evidence.

Citation Format: Amarbir S. Gill, Michael Kinzinger, Michael G. Moore. Malnutrition evaluation in head and neck cancer patients: Practice patterns among otolaryngologists and radiation oncologists [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; 2019 Apr 29-30; Austin, TX. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(12_Suppl_2):Abstract nr B19.

Surgeon cost feedback through a surgical receipt program reduces cost in sinonasal surgery

BACKGROUND

Operating room (OR) costs are a large portion of healthcare expenses. This study evaluates the impact of a surgeon-targeted surgical receipt cost feedback system on OR supply costs in sinonasal surgery and individual components contributing to procedural cost.

METHODS

Itemized weekly surgical receipts detailing individual case supply costs were analyzed before and after the implementation of a non-incentivized surgeon cost feedback system between January 2017 and June 2019. Supply cost data collected 15 months prior to intervention was compared to cost data 15 months after implementation of the weekly automated receipt dissemination to surgeons. Chi square test was used for categorical data and the Wilcoxon test was used to compare change in cost. Univariate and mediation analyses were performed to assess variables impacting cost.

RESULTS

Of 502 sinonasal procedures analyzed, 239 were before and 264 after cost feedback implementation. There were no significant differences in age/gender, or indication for surgery. The median OR supply cost decreased from $1229.64 to $1097.22 (p = 0.02) after receipt implementation. There were effects of procedure type (p = 0.02), circulating nurse specialization (p < 0.001), steroid eluting stent (p = 0.002), and sinus drill (p < 0.001) on cost. Mediation analysis confirmed full mediation by decreasing use of steroid-eluting stents.

CONCLUSION

Surgeon cost feedback in the form of individualized OR surgical receipts is an effective model to reduce supply cost per case in sinonasal surgery.

Diagnosis and Management of Depression in CRS: A Knowledge, Attitudes and Practices Survey

Introduction  Comorbid major depressive disorder (MDD) is present in up to 25% of chronic rhinosinusitis (CRS) cases and provides prognostic information for patients undergoing endoscopic sinus surgery (ESS). Clinical visits offer an opportunity to identify at-risk patients. Objective  The purpose of the present study is to evaluate practice patterns among members of the American Rhinologic Society (ARS) in screening for/diagnosing MDD. Methods  A 21-question survey was distributed to 1,206 members of the ARS from May 26, 2018 to June 12, 2018. The impact of demographic factors, including hospital setting, fellowship status, and experience were assessed through chi-squared analysis. Results  A total of 80 members of the ARS completed the survey, yielding a response rate of 7%. Half of the respondents worked in academic settings and 43% had completed a rhinology fellowship. Twenty percent of the participants felt comfortable diagnosing or managing MDD, while only 10% of participants screened for MDD in patients with CRS. Respondents cited a lack of training (76%) and unfamiliarity with diagnostic criteria (76%) as barriers to the routine assessment of MDD. Most respondents (95%) considered comorbid psychiatric illness to negatively impact outcomes following ESS. Fellowship-trained respondents were significantly more likely to implement screening tools in their practice ( p  = 0.05), and believe in the negative impact of MDD on postoperative outcomes ( p  = 0.007), cost of care ( p  = 0.04) and quality of life ( p  = 0.047). Conclusion  Amongst ARS members, 95% of the respondents consider comorbid MDD to negatively impact patient outcomes following ESS. Regardless, a large proportion of surgeons neither screen nor feel comfortable diagnosing MDD.

A preliminary report on the effect of gabapentin pretreatment on periprocedural pain during in-office posterior nasal nerve cryoablation

BACKGROUND

Posterior nasal nerve (PNN) cryoablation is a novel surgical technique to address allergic and nonallergic rhinitis. Periprocedural pain has been reported after PNN cryoablation and there are no standardized protocols for optimal in-office local anesthesia. This study sought to evaluate the effect of gabapentin on patient discomfort following in-office PNN cryoablation.

METHODS

Multi-institutional prospective analysis of patients undergoing in-office PNN cryoablation for allergic or nonallergic rhinitis between March 2018 and April 2019. Patients received local anesthesia with or without 600 mg oral gabapentin 1 hour preprocedure. Rhinitis diagnosis, demographics, and baseline disease-specific quality of life (mini-Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ] and Total Nasal Symptom Score [TNSS]) were recorded. Patient discomfort was measured by the pain visual analogue scale (VAS) posttreatment and rated 0 to 10 on an ordinal scale. Fisher's exact and Wilcoxon 2-sample tests were used to evaluate differences between the 2 groups.

RESULTS

A total of 26 patients were enrolled (gabapentin n = 15, control = 11). Baseline TNSS scores in the gabapentin vs control group were median [25th percentile to 75th percentile]) 10 (7.5 to 11.0) and 9 (6.0 to 10.0) (p = 0.35). Baseline Mini-RQLQ scores in gabapentin vs control groups were 3.21 (2.0 to 4.0) and 2.92 (2.78 to 4.35) (p = 0.51). The median VAS pain scores at 5, 20, and 30 minutes in the gabapentin vs control group were 0.0 (0.0 to 2.0) vs 3.0 (1.0 to 4.0), 2.0 (0.0 to 3.0) vs 8.0 (6.0 to 10.0), and 1.0 (0.0 to 1.0) vs 5.0 (4.0 to 6.0) (p = 0.02, p = 0.0043, and p = 0.003, respectively).

CONCLUSION

Preprocedure gabapentin significantly reduces immediate and delayed postprocedural patient discomfort following PNN cryoablation.

Patient-Reported Outcome Measures and Provocative Testing in the Workup of Empty Nose Syndrome-Advances in Diagnosis: A Systematic Review

Background

The last 5 years have seen a surge of both clinical and scientific interest in empty nose syndrome (ENS). Although ENS is still considered a controversial diagnosis plagued by a lack of standardized diagnostic criteria, ENS is increasingly becoming recognized as a legitimate, physiologic disease entity. As such, it is important for clinicians to understand the most up-to-date diagnostic tools to assess ENS, confirm the diagnosis, and create a more standardized means to counsel these complex patients.

Objective

Contemporary literature review to discuss diagnostic modalities in the evaluation of ENS, in order to introduce evidence-based diagnostic criteria.

Methods

A systematic review was conducted in PubMed and Embase (2013–2019) using the search term “empty nose syndrome” to identify peer-reviewed articles on the topic of ENS. Articles advancing contemporary methods of ENS diagnosis and testing were included. A quality assessment was conducted using The Rational Clinical Examination Levels of Evidence.

Results

The novel development of the Empty Nose Syndrome 6 Questionnaire (ENS6Q) offers the clinician a validated patient-reported outcome measure to supplement history and physical examination. The in-office cotton test, performed by placing an endoscopically directed cotton plug in the site of tissue loss, may help to identify patients who may benefit from turbinate augmentation. Tools such as the sinus computed tomography scan, computational fluid dynamics, and intranasal trigeminal nerve function testing currently have insufficient evidence to support routine use in the workup of ENS. Up to 66% of ENS patients present with comorbid anxiety or depression.

Conclusion

The ENS6Q and cotton test assist in creating a standardized approach to the evaluation of patients suspected of ENS. These instruments should be used as an adjunct, rather than the sole criteria, on which to ascertain the presumptive diagnosis. Patients suspected of ENS should be screened for comorbid psychological dysfunction.

Malnutrition evaluation in head and neck cancer patients: Practice patterns among otolaryngologists and radiation oncologists

BACKGROUND

Physician practice patterns regarding diagnosis and management of malnutrition in the head and neck cancer patient population are not well studied.

METHODS

A 17-question survey was distributed to 1392 members of the American Head and Neck Society (AHNS). The impact of hospital type, fellowship training, experience, and specialty was assessed.

RESULTS

Among AHNS members, there were 124 total respondents (9% response rate), including both otolaryngologists and radiation oncologists. Respondents strongly agreed (90%) that malnutrition negatively impacts patient outcomes. The majority (63%) felt comfortable screening for malnutrition, but 13% reported no routine assessment of malnutrition; 57% were unfamiliar with relevant guidelines. Barriers to screening included lack of familiarity with screening tools/guidelines, lack of time, and lack of access to dietitian.

CONCLUSION

Although there was a strong consensus among respondents that the identification and management of malnutrition among head and neck cancer patients is critical, familiarity with relevant guidelines was poor.

Utility of Endoscope-Assisted Orbital Fracture Repair for Atraumatic Reduction of Entrapped Muscle Tissue and Surgical Education

Trapdoor fractures can result in extraocular muscle entrapment with resultant pain, diplopia, bradycardia, nausea, and vomiting. Urgent repair is required to minimize the risk of permanent muscle injury and long-term diplopia. Complete fracture visualization is imperative to ensure adequate reduction of the herniated tissue and accurate implant placement when necessary. Orbital floor angulation and prolapsed orbital fat can make visualization of the posterior orbit challenging. Inadequate reduction can lead to reoperation in up to 18% of cases. Because the narrow field of view makes visualization difficult, teaching the surgical technique can be very challenging. We demonstrate the reduction of an entrapped inferior rectus muscle using an endoscope-assisted transconjunctival approach, highlighting its advantages in fracture visualization and surgical training.

Oncologic outcomes after surgery for locally aggressive basal cell carcinoma of the head and neck

OBJECTIVE

Although basal cell carcinoma (BCC) is the most common skin cancer, locally aggressive BCC of the head and neck is rare and not well studied.

STUDY DESIGN

Retrospective review of patients who underwent primary surgical resection of locally aggressive head and neck BCC at a single tertiary academic center.

RESULTS

Eighty-seven patients with 98 tumors demonstrated a 5-year Kaplan-Meier estimated recurrence-free survival of 64.5%, overall survival of 83.3%, and disease-specific survival of 98.3%. Intraoperative positive frozen section margin was a strong independent predictor of local recurrence (hazard ratio 6.88, P = 0.038) and was more likely to occur in tumors previously treated with radiation (odds ratio 6.47 = 0.05).

CONCLUSION

Locally aggressive BCCs of the head and neck have high rates of local recurrence but low disease-specific mortality when treated with primary surgery and selected use of adjuvant therapy. Intraoperative positive frozen section margin is a strong independent predictor of local recurrence and is more likely in tumors that were previously treated with radiation therapy.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:115-119, 2020.

Importance of FNA Technique for Decreasing Non-diagnostic Rates in Thyroid Nodules

To identify potential interventions that may lower the high non-diagnostic rates associated with ultrasound guided (US) fine needle aspiration (FNA) biopsy of the thyroid nodule. A case series of 164 thyroid nodule US-guided FNA was identified retrospectively. The following variables were analyzed in regards to diagnostic and non-diagnostic sampling: patient age, gender, size of nodule, biopsy technique (capillary vs. aspiration), needle gauge (23 vs. 25), and physician experience. The FNA diagnosis, and final pathology, when applicable, was recorded for each sample using the Bethesda criteria. Data was analyzed using the Fisher's exact test or the chi square test. After multivariate logistic regression, capillary action was independently associated with lower non-diagnostic rates (p = 0.01), while increasing patient age was associated with higher non-diagnostic rates (p = 0.018). Physician experience (p = 0.014) was not independently associated with lower non-diagnostic rates. Nodules that were "cystic >50%" were significantly more likely to yield a non-diagnostic result (p < 0.0001). After taking into account confounding variables, including physician experience, our data reveals a statistically significant decrease in non-diagnostic rates with the use of capillary action vs. aspiration technique in US-guided FNA. A major focus in healthcare today is providing cost-effective and minimally invasive care to the patient. In the setting of a rising incidence of thyroid disease, we believe our study demonstrates the need for a prospective analysis of the relationship between technique and non-diagnostic rates.

Sialendoscopy as a management tool in patients with foreign body impaction of the salivary gland

PURPOSE

It has been long known that sialendoscopy has both diagnostic and therapeutic benefits in the identification and treatment of sialadenitis. Sialendoscopy can also be used to triage patients with traumatic injury or foreign bodies lodged in the parotid gland.

PROCEDURES

We present a case of traumatic insertion a fishbone into the parotid gland parenchyma that was evaluated with sialendoscopy and successfully managed on the basis of stable endoscopy findings that correlated with improving symptomatology.

MAIN FINDINGS

We find that sialendoscopy presents a useful tool to help guide management.

CONCLUSIONS

We demonstrate that in an asymptomatic patient, foreign body impaction with absence of ductal obstruction on endoscopy can successfully be followed with simple observation.

Effects of nicotinic antagonists on ocular growth and experimental myopia

PURPOSE

To learn whether nicotinic cholinergic receptors modulate postnatal eye growth and influence the course of form-deprivation myopia.

METHODS

One-week-old White Leghorn chicks wore a unilateral goggle to induce form-deprivation myopia. Other chicks were never goggled. Nicotinic antagonist drugs were administered by intravitreal injection, usually daily or every other day to the goggled eye or to one eye of never-goggled chicks. After 1 week, the eyes were studied by refractometry, A-scan ultrasonography, and caliper measurements.

RESULTS

The relatively non-subtype-specific channel-blocking nicotinic antagonists chlorisondamine and mecamylamine each inhibited the development of form-deprivation myopia but with complex multiphasic dose responses. Chlorisondamine was the most effective. Mecamylamine, at the lowest tested doses, tended to stimulate the growth response and myopic refractive shift of goggle wearing. Methyllycaconitine competitively inhibits nicotinic receptors containing the alpha7 and alpha8 subunits, which are highly expressed in chick retina. It showed a less dramatic but still significant inhibitory effect on myopia. The effects of dihydro-beta-erythroidine, a competitive antagonist relatively selective for nicotinic receptors with alpha3 or alpha4 subunits and particularly for alpha3beta2-containing receptors, were the weakest and inhibited primarily axial elongation. Chlorisondamine but not mecamylamine also affected nongoggled eyes, inhibiting growth and shifting refraction toward hyperopia, but chlorisondamine also induced degenerative changes to the retinal pigment epithelium (RPE).

CONCLUSIONS

Nicotinic receptors are involved in eye growth control. Nicotinic antagonists affect the development of form-deprivation myopia and perhaps the growth of nongoggled eyes. The differences in drug activity and multiphasic dose-response curves may reflect the complexity of nicotinic receptor subtypes associated with the eye and/or pharmacokinetic differences between the individual drugs. Although another tissue(s) cannot be completely excluded by these data, the site of action of these agents may be neural retina or RPE.

Studies of heterosis, combining ability and inheritance of yield and yield components in a diallel cross of bengal gram (Cicer arietinum L.)

A 5 X 5 diallel cross among well-adapted varieties of gram from different agroclimatic regions was studied for heterosis, combining ability and inheritance of days-to-flowering, primary branches, pods per plant, 100-seed weight and grain yield. A high degree of heterosis over mid-parent and better parent was observed for primary branches, no. of pods and grain yield, whereas very little heterosis was exhibited for days-to-flower and 100-seed weight. Crosses among lines of diverse origin generally gave higher heterosis and over-dominance than lines from the same region. Primary branch number, pod number, and grain yield exhibited positive over-dominance; days-to-flower showed negative over-dominance while 100-seed weight had no dominance. Both general and specific combining ability effects were significant for all the characters studied but g.c.a. effects appeared to be more important for days-to-flower, 100-seed weight and grain yield. Graphical analysis indicated additive effects for all the characters, with complete dominance for days-to-flower, no dominance for 100-seed weight and over-dominance for the other three characters. Dominant genes conditioned earliness, primary branch number and 100-seed weight. The role of various parents and crosses in planning a hybridization programme has been discussed.