Does nasal irrigation enter paranasal sinuses in chronic rhinosinusitis?

BACKGROUND

Nasal irrigation is widely used in treating sinonasal diseases. Not only does it remove static secretions and promote mucociliary clearance, but, in chronic rhinosinusitis, nasal flush is also a potential route for topical drug administration into paranasal sinuses. A clinical study was conducted to investigate how well nasal irrigation could reach paranasal sinuses with the ostiomeatal units blocked in chronic rhinosinusitis. This study was performed to (1) assess the ability of a nasal douche and spray to deliver a solution into the paranasal sinuses in chronic rhinosinusitis and (2) compare the performance of the two techniques.

METHODS

Fourteen patients, with bilateral chronic rhinosinusitis, underwent nasal irrigation with 140 mg/mL of iodinated contrast solution by 40 mL of douching using an irrigation syringe in one side, and 10 mL of spraying in the other side. A computed tomography scan was undertaken for each patient to determine the volume and the distribution of staining in the nose and paranasal sinuses.

RESULTS

Only two patients had any staining, with a small amount present in a total of three maxillary sinuses (0.10 mL, 0.04 mL, and 0.13 mL). The mean volumes of paranasal sinus staining by nasal douche and nasal spray were 0.0093 and 0.01 mL, respectively. We found that the two techniques had a similar performance. Both of them delivered only a small amount of the solution, if any, into the sinuses (with a mean difference of -0.0007 mL; 95% CI, -0.02-0.02 mL; p = 0.94).

CONCLUSION

Nasal douche and spray is not effective in delivering a nasal irrigation solution into paranasal sinuses in chronic rhinosinusitis.

Decontamination and reuse of surgical masks and N95 filtering facepiece respirators during the COVID-19 pandemic: A systematic review

OBJECTIVES

Surgical masks and N95 filtering facepiece respirators (FFRs) prevent the spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and protect medical personnel. Increased demands for surgical masks and N95 FFRs during the coronavirus disease 2019 (COVID-19) pandemic has resulted in the shortage crisis. However, there is no standard protocol for safe reuse of the N95 FFRs. In this systematic review, we aimed to evaluate the effectiveness of existing decontamination methods of surgical masks and N95 FFRs and provide evidence-based recommendations for selecting an appropriate decontamination method.

METHODS

We performed systematic searches of Ovid MEDLINE and Ovid EMBASE electronic databases. The last search was performed April 11, 2020. Any trials studying surgical masks and/or N95 FFRs decontamination were included. Outcomes were disinfections of virus and bacteria, restoration of the filtration efficiency, and maintenance of the physical structure of the mask.

RESULTS

Overall, 15 studies and 14 decontamination methods were identified. A low level of evidence supported 4 decontamination methods: ultraviolet (UV) germicidal irradiation (9 studies), moist heat (5 studies), microwave-generated steam (4 studies), and hydrogen peroxide vapor (4 studies). Therefore, we recommended these 4 methods, and we recommended against use were given for the other 10 methods.

CONCLUSIONS

A low level of evidence supported the use of UV germicidal irradiation, moist heat, microwave-generated steam, and hydrogen peroxide vapor for decontamination and reuse of N95 FFRs. These decontamination methods were effective for viral and bacterial disinfection as well as restoration of the filtration efficiency, and the physical structure of the FFRs.

Smell and taste dysfunction in patients with SARS-CoV-2 infection: A review of epidemiology, pathogenesis, prognosis, and treatment options

During the initial pandemic wave of COVID-19, apart from common presenting symptoms (cough, fever, and fatigue), many countries have reported a sudden increase in the number of smell and taste dysfunction patients. Smell dysfunction has been reported in other viral infections (parainfluenza, rhinovirus, SARS, and others), but the incidence is much lower than SARS-CoV-2 infection. The pathophysiology of post-infectious olfactory loss was hypothesized that viruses may produce an inflammatory reaction of the nasal mucosa or damage the olfactory neuroepithelium directly. However, loss of smell could be presented in COVID-19 patients without other rhinologic symptoms or significant nasal inflammation. This review aims to provide a brief overview of recent evidence for epidemiology, pathological mechanisms for the smell, and taste dysfunction in SARS-CoV-2 infected patients. Furthermore, prognosis and treatments are reviewed with scanty evidence. We also discuss the possibility of using "smell and taste loss" as a screening tool for COVID-19 and treatment options in the post-SARS-CoV-2 infectious olfactory loss.

Olfactory and gustatory dysfunctions in COVID-19 patients: A systematic review and meta-analysis

Olfactory and gustatory dysfunctions (OGD) are pathognomonic symptoms in patients with Coronavirus Disease 2019 (COVID-19). This study reviews the associations of OGD with COVID-19 which will be useful for early diagnosis and self-isolation. Systematic searches of PubMed, Ovid Medline, Scopus, and EMBASE electronic databases were performed. Studies reporting OGD in COVID-19 patients were included. Data were pooled for meta-analysis. The outcomes were odds ratios (OR) of OGD in COVID-19 patients. Proportions of smell and/or taste dysfunctions in the COVID-19 patients were assessed. Fourteen studies (21,515 participants, age 49.12 years, 26% male) were included. The OR of olfactory and/or gustatory dysfunctions in COVID-19 patients were 11.26 (95% confidence interval (CI) 5.41 to 23.4) when compared with acute respiratory infection (ARI) without detectable virus and 6.46 (95% CI 2.79 to 14.97) in patients with other respiratory viruses. The OR of olfactory dysfunction in COVID-19 patients were 11.67 (95% CI 6.43 to 21.17) when compared with the ARI patients without detectable virus and 4.17 (95% CI 1.34 to 12.98) with other respiratory viruses. The OR of gustatory dysfunction in COVID-19 patients were 12.70 (95% CI 7.9 to 20.44) when compared with the ARI patients without detectable virus and 4.94 (95%CI 1.59 to 15.31) with other respiratory viruses. Fifty percent (95% CI 36.7 to 63.3%) of COVID-19 patients had olfactory and/or gustatory dysfunctions. In summary, there are associations between OGD and COVID-19 patients. Patients presenting with ARI should be assessed for olfactory and gustatory functions.

Burden of respiratory disease in Thailand: Results from the APBORD observational study

Asia-Pacific Burden of Respiratory Diseases (APBORD) was a cross-sectional, observational study examining the burden of respiratory disease in adults across 6 Asia-Pacific countries.This article reports symptoms, healthcare resource utilization (HCRU), work impairment and cost burden associated with allergic rhinitis (AR), asthma, chronic obstructive pulmonary disease (COPD), and rhinosinusitis in Thailand.Consecutive participants aged ≥18 years with a primary diagnosis of AR, asthma, COPD, or rhinosinusitis were enrolled at 4 hospitals in Thailand during October 2012 and October 2013. Participants completed a survey detailing respiratory symptoms, HCRU, work productivity, and activity impairment. Locally sourced unit costs were used in the calculation of total costs.The study enrolled 1000 patients. The most frequent primary diagnosis was AR (44.2%), followed by rhinosinusitis (24.1%), asthma (23.7%), and COPD (8.0%). Overall, 316 (31.6%) of patients were diagnosed with some combination of the 4 diseases. Blocked nose or congestion (17%) and cough or coughing up phlegm (16%) were the main reasons for the current medical visit. The mean annual cost for patients with a respiratory disease was US$1495 (SD 3133) per patient. Costs associated with work productivity loss were the principal contributor for AR and rhinosinusitis patients while medication costs were the highest contributor for asthma and COPD patients.The study findings highlight the burden associated with 4 prevalent respiratory diseases in Thailand. Thorough investigation of concomitant conditions and improved disease management may help to reduce the burden of these respiratory diseases.

Does Heating up Saline for Nasal Irrigation Improve Mucociliary Function in Chronic Rhinosinusitis?

Background

Mucociliary function is affected by temperature. Exposure to cold air may impair ciliary beat frequency. While saline nasal irrigation improves in ciliary beat activity, there is no evidence supporting the use of heated saline irrigation in treating patients with chronic rhinosinusitis.

Objective

To compare the effects of heated saline to room-temperature saline nasal irrigation on mucociliary clearance in chronic rhinosinusitis patients.

Methods

Adult patients with chronic rhinosinusitis were randomized into two groups receiving either heated saline or room-temperature saline nasal irrigation. Healthy subjects were included as control. Saccharin transit time was measured before and after nasal irrigation. Nasal patency was assessed by peak nasal inspiratory flow, anterior rhinomanometry, acoustic rhinometry, nasal obstruction score, and breathe-comfort score. Any adverse events were reported.

Results

Twenty-three patients with chronic rhinosinusitis and nine healthy subjects were enrolled. Saccharin transit time was decreased after nasal irrigation in both heated saline subgroup (baseline 12.3 ± 4.5 min vs. postirrigation 8.4 ± 4.9 min, p = 0.05) and room-temperature subgroup (baseline 12.8 ± 5.0 min vs. postirrigation 8.9 ± 4.2 min, p = 0.01). The saccharin transit time improvement was not different between heated saline (3.8 ± 6.2 min) and room-temperature saline (3.8 ± 4.0 min), p = 0.13. Postheated saline irrigation saccharin transit time of chronic rhinosinusitis patients (8.4 ± 4.9 min) was not different to healthy subjects (9.2 ± 3.7 min), p = 0.69. Nasal patency was not different between groups. There was no adverse event reported.

Conclusion

Nasal saline irrigation is beneficial to patients with chronic rhinosinusitis on mucociliary improvement. Warming saline is not necessary and adds no additional benefit to room-temperature saline irrigation.

Intranasal corticosteroids for non-allergic rhinitis

BACKGROUND

Non-allergic rhinitis is defined as dysfunction and non-infectious inflammation of the nasal mucosa that is caused by provoking agents other than allergens or microbes. It is common, with an estimated prevalence of around 10% to 20%. Patients experience symptoms of nasal obstruction, anterior rhinorrhoea/post-nasal drip and sneezing. Several subgroups of non-allergic rhinitis can be distinguished, depending on the trigger responsible for symptoms; these include occupation, cigarette smoke, hormones, medication, food and age. On a cellular molecular level different disease mechanisms can also be identified. People with non-allergic rhinitis often lack an effective treatment as a result of poor understanding and lack of recognition of the underlying disease mechanism. Intranasal corticosteroids are one of the most common types of medication prescribed in patients with rhinitis or rhinosinusitis symptoms, including those with non-allergic rhinitis. However, it is unclear whether intranasal corticosteroids are truly effective in these patients.

OBJECTIVES

To assess the effects of intranasal corticosteroids in the management of non-allergic rhinitis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 7); PubMed; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 1 July 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing intranasal corticosteroids, delivered by any means and in any volume, with (a) placebo/no intervention or (b) other active treatments in adults and children (aged ≥ 12 years).

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. The primary outcomes were patient-reported disease severity and a significant adverse effect - epistaxis. Secondary outcomes were (disease-specific) health-related quality of life, objective measurements of airflow and other adverse events. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 34 studies (4452 participants); however, only 13 studies provided data for our main comparison, intranasal corticosteroids versus placebo. The participants were mainly defined as patients with perennial rhinitis symptoms and negative allergy tests. No distinction between different pheno- and endotypes could be made, although a few studies only included a specific phenotype such as pregnancy rhinitis, vasomotor rhinitis, rhinitis medicamentosa or senile rhinitis. Most studies were conducted in a secondary or tertiary healthcare setting. No studies reported outcomes beyond three months follow-up. Intranasal corticosteroid dosage in the review ranged from 50 µg to 2000 µg daily. Intranasal corticosteroids versus placebo Thirteen studies (2045 participants) provided data for this comparison. These studies used different scoring systems for patient-reported disease severity, so we pooled the data in each analysis using the standardised mean difference (SMD). Intranasal corticosteroid treatment may improve patient-reported disease severity as measured by total nasal symptom score compared with placebo at up to four weeks (SMD -0.74, 95% confidence interval (CI) -1.15 to -0.33; 4 studies; 131 participants; I2 = 22%) (low-certainty evidence). However, between four weeks and three months the evidence is very uncertain (SMD -0.24, 95% CI -0.67 to 0.20; 3 studies; 85 participants; I2 = 0%) (very low-certainty evidence). Intranasal corticosteroid treatment may slightly improve patient-reported disease severity as measured by total nasal symptom score change from baseline when compared with placebo at up to four weeks (SMD -0.15, 95% CI -0.25 to -0.05; 4 studies; 1465 participants; I2 = 35%) (low-certainty evidence). All four studies evaluating the risk of epistaxis showed that there is probably a higher risk in the intranasal corticosteroids group (65 per 1000) compared to placebo (31 per 1000) (risk ratio (RR) 2.10, 95% CI 1.24 to 3.57; 4 studies; 1174 participants; I2 = 0%) (moderate-certainty evidence). The absolute risk difference (RD) was 0.04 with a number needed to treat for an additional harmful outcome (NNTH) of 25 (95% CI 16.7 to 100). Only one study reported numerical data for quality of life. It did report a higher quality of life score in the intranasal corticosteroids group (152.3 versus 145.6; SF-12v2 range 0 to 800); however, this disappeared at longer-term follow-up (148.4 versus 145.6) (low-certainty evidence). Only two studies provided data for the outcome objective measurements of airflow. These data could not be pooled because they used different methods of outcome measurement. Neither found a significant difference between the intranasal corticosteroids and placebo group (rhinomanometry SMD -0.46, 95% CI -1.06 to 0.14; 44 participants; peak expiratory flow rate SMD 0.78, 95% CI -0.47 to 2.03; 11 participants) (very low-certainty evidence). Intranasal corticosteroids probably resulted in little or no difference in the risk of other adverse events compared to placebo (RR 0.99, 95% CI 0.87 to 1.12; 3 studies; 1130 participants; I2 = 0%) (moderate-certainty evidence). Intranasal corticosteroids versus other treatments Only one or a few studies assessed each of the other comparisons (intranasal corticosteroids versus saline irrigation, intranasal antihistamine, capsaicin, cromoglycate sodium, ipratropium bromide, intranasal corticosteroids combined with intranasal antihistamine, intranasal corticosteroids combined with intranasal antihistamine and intranasal corticosteroids with saline compared to saline alone). It is therefore uncertain whether there are differences between intranasal corticosteroids and other active treatments for any of the outcomes reported.

AUTHORS' CONCLUSIONS

Overall, the certainty of the evidence for most outcomes in this review was low or very low. It is unclear whether intranasal corticosteroids reduce patient-reported disease severity in non-allergic rhinitis patients compared with placebo when measured at up to three months. However, intranasal corticosteroids probably have a higher risk of the adverse effect epistaxis. There are very few studies comparing intranasal corticosteroids to other treatment modalities making it difficult to draw conclusions.

The orbital floor is a surgical landmark for the Asian anterior skull base

BACKGROUND

Surgical landmarks for defining the level of the skull base during endoscopic sinus and skull base surgery (ESBS), e.g., the middle turbinate, may be distorted by tumor or previous surgery. The orbital floor is a valid fixed anatomic landmark for the white population, but it is not known if its use is useful for an Asian population.

OBJECTIVES

To define fixed anatomic landmarks for ESBS in an Asian population and to compare the level of the skull base and its relation with anatomic landmarks between Asian and white populations.

METHODS

Computed tomographies performed on paranasal sinuses of Thai patients were retrospectively assessed. The distance between the nasal floor to four structures, the orbital floor, sphenoid planum, cribriform, and ethmoid roof, were measured. The level of skull base related to the orbital floor of an Asian population was compared with data of a white population from a previously published study.

RESULTS

A total of 150 Thai patients (300 paranasal sinus systems) were assessed and compared with 150 white patients. The orbital floor was always below the skull base (600 sides [100%]). When compared with white patients, the Asian patients had significantly higher mean (standard deviation [SD]) values: orbital floor (35.2 ± 3.4 mm versus 33.9 ± 3.0 mm; p < 0.001), ethmoid roof (49.3 ± 3.8 mm versus 48.4 ± 4.5 mm; p = 0.01), cribriform (46.4 ± 3.6 mm versus 44.0 ± 3.7 mm; p < 0.001), and sphenoid roof (45.7 ± 3.7 mm versus 44.9 ± 3.7 mm; p = 0.01). The Asian population had a mean (SD) longer distance from the orbital floor to the cribiform (11.2 ± 2.5 mm versus 10.1 ± 2.7 mm; p < 0.001), a shorter distance to the sphenoid roof (10.5 ± 3.3 mm versus 11.0 ± 2.9 mm; p = 0.03), and a similar distance to the ethmoid roof (14.1 ± 3.1 mm versus 14.5 ± 3.5 mm; p = 0.09).

CONCLUSION

Although a statistical difference exists between racial groups, clinically, the orbital floor is a useful fixed anatomic landmark for ESBS for both Asian and white populations.

House-dust mite nasal provocation: A diagnostic tool in perennial rhinitis

BACKGROUND

In perennial allergic rhinitis (PAR), the skin-prick test (SPT) is a good diagnostic tool to identify the specific allergens. A nasal provocation test (NPT) is used to identify allergens and to confirm the diagnosis. The aim of this study was to determine the optimal cutoff values of symptom and peak nasal inspiratory flow (PNIF) changes after dust-mite NPT for predicting PAR. We also studied the relationship of the changes of symptoms in NPT and the wheal size of SPT.

METHODS

One hundred five patients with perennial rhinitis underwent the NPT to Dermatophagoides pteronyssinus and the SPT. The NPT was assessed by changes in symptoms and PNIF. The optimal cutoff values of the symptoms score and PNIF changes after the NPT for predicting the SPT were determined using a receiver operating characteristic (ROC) curve. The relationship of the wheal sizes of SPT and the changes from the NPT were analyzed.

RESULTS

Forty-eight patients had a positive SPT to D. pteronyssinus, of whom 33 patients had a positive NPT by increases of the symptom score. Twenty patients had a positive NPT by decreases of PNIF. The area under the ROC curve was 0.85 for symptom score changes and it was 0.612 for PNIF changes. There was a significant correlation between the wheal size of the SPT and symptom changes in the NPT.

CONCLUSION

Nasal provocation is a valuable test to confirm the diagnosis of D. pteronyssinus allergy, especially when the wheal from the SPT is small. The symptom change after the house-dust mite NPT is better than the PNIF change for predicting the PAR.

EPOS2012 has better specificity compared to IDSA2012 for diagnosing acute bacterial rhinosinusitis

BACKGROUND

Acute bacterial rhinosinusitis (ABRS) is a subtype of acute rhinosinusitis (ARS). To prevent excessive antibiotic prescribing, clinical criteria for diagnosing ABRS are presented in two major international guidelines from European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS2012) and the Infectious Diseases Society of America (IDSA2012). This study aims to assess accuracy of these criteria.

METHODOLOGY

Patients with ARS were recruited. Clinical features were collected including discolored nasal discharge, facial pain, fever, double sickening, symptoms persisting longer than 10 days, and elevated serum C reactive protein (CRP) and erythrocyte sedimentation rate (ERS). Using middle meatal bacterial culture as a reference, accuracy of EPOS2012 and IDSA2012 criteria were analyzed.

RESULTS

Eighty-eight patients (age 43.2+/-14.5 years, 67% female) with ARS were recruited. Using the two criteria for diagnosing ABRS, EPOS2012 and IDSA2012 have sensitivity of 50% (95%CI: 38%-62%) versus 69% (95%CI: 57%-79%), specificity of 63% (95%CI: 43%-79%) versus 46% (95%CI: 28%-65%), and accuracy of 53% versus 63%, respectively.

CONCLUSION

Both EPOS2012 and IDSA2012 had modest accuracy. EPOS2012 had less sensitivity but a better specificity compared to IDSA2012. This suggests that IDSA2012 diagnostic criteria may contribute to inappropriate use of antibiotics due to poorer specificity.

Nasal Cytology as a Diagnostic Tool for Local Allergic Rhinitis

Background

Local allergic rhinitis (LAR) is characterized by chronic rhinitis with localized nasal allergic response to allergens in the absence of systemic immunoglobulin (IgE)-mediated disease assessed by skin prick test (SPT) or specific serum IgE level. Nasal provocation test (NPT) is the gold standard for the diagnosis of LAR. Nasal eosinophilia is a known inflammatory marker in allergic rhinitis. We hypothesized that nasal eosinophilia can be used as a screening tool for LAR.

Objective

To determine the applicability of nasal eosinophilia as a diagnostic tool for LAR.

Methods

Forty-eight perennial nonallergic rhinitis (NAR) patients with SPT negative were recruited. Nasal cytology analysis was performed. NPTs with 3 allergens (mixed mites, mixed cockroaches, and Bermuda grass) were performed to diagnose LAR. Nasal symptoms combined with nasal patency were used to determine the results of NPT. The sensitivity, specificity, positive predictive value, and negative predictive value of nasal eosinophilia as a diagnostic tool of LAR were calculated.

Results

LAR was diagnosed in 41.6% of the NAR patients. Nasal eosinophilia was found in 58% of the NAR patients. The sensitivity of nasal eosinophilia for diagnosing LAR was 80%, the specificity was 57.14%, the positive predictive value was 57.14%, and the negative predictive value was 80%. The most common allergen of LAR was mixed mites.

Conclusion

Nasal eosinophilia on nasal cytology was a good screening tool for diagnosing LAR because of its high sensitivity and simplicity of the procedure. Unfortunately, the low specificity of nasal eosinophilia makes the NPT necessary for confirmation of LAR.

Assessment of safety and intranasal neutralizing antibodies of HPMC-based human anti-SARS-CoV-2 IgG1 nasal spray in healthy volunteers

An HPMC-based nasal spray solution containing human IgG1 antibodies against SARS-CoV-2 (nasal antibody spray or NAS) was developed to strengthen COVID-19 management. NAS exhibited potent broadly neutralizing activities against SARS-CoV-2 with PVNT50 values ranging from 0.0035 to 3.1997 μg/ml for the following variants of concern (ranked from lowest to highest): Alpha, Beta, Gamma, ancestral, Delta, Omicron BA.1, BA.2, BA.4/5, and BA.2.75. Biocompatibility assessment showed no potential biological risks. Intranasal NAS administration in rats showed no circulatory presence of human IgG1 anti-SARS-CoV-2 antibodies within 120 h. A double-blind, randomized, placebo-controlled trial (NCT05358873) was conducted on 36 healthy volunteers who received either NAS or a normal saline nasal spray. Safety of the thrice-daily intranasal administration for 7 days was assessed using nasal sinuscopy, adverse event recording, and self-reporting questionnaires. NAS was well tolerated, with no significant adverse effects during the 14 days of the study. The SARS-CoV-2 neutralizing antibodies were detected based on the signal inhibition percent (SIP) in nasal fluids pre- and post-administration using a SARS-CoV-2 surrogate virus neutralization test. SIP values in nasal fluids collected immediately or 6 h after NAS application were significantly increased from baseline for all three variants tested, including ancestral, Delta, and Omicron BA.2. In conclusion, NAS was safe for intranasal use in humans to increase neutralizing antibodies in nasal fluids that lasted at least 6 h.

Histopathology of ethmoid mucosa versus polyp tissue in diagnosing eosinophilic mucin rhinosinusitis

BACKGROUND

This study aims to compare histopathology of nasal polyp and ethmoid mucosa for diagnosing eosinophilic mucin rhinosinusitis (EMRS).

METHODOLOGY

Patients with chronic rhinosinusitis with polyps (CRSwNP) were enrolled. Using eosinophilic mucin as a reference, histopathology of polyp apex, polyp pedicle and ethmoid mucosa was compared for density of tissue eosinophil and sensitivity for diagnosing EMRS. Associations with asthma were assessed for each site.

RESULTS

Thirty patients with CRSwNP were enrolled. When polyp apex, polyp pedicle and ethmoid mucosa were assessed for tissue eosinophilia, consistent results were reported in 16 patients (53%). Median tissue eosinophil was greater in polyp apex (58, IQR: 7-100) than ethmoid mucosa (10, IQR: 2-21), but not different from polyp pedicle (22, IQR: 1-96). Sensitivity for diagnosing EMRS were 100% (95%CI: 47.8 - 100) for polyp apex, 60% (95%CI: 14.7 - 94.7) for polyp pedicle, 80% (95%CI: 28.4 â€" 99.5) for ethmoid mucosa. Associations with asthma were significant for polyp pedicle, and ethmoid mucosa but not polyp apex.

CONCLUSION

Density of tissue eosinophil was greater in nasal polyp than in ethmoid mucosa. Histopathology of polyp apex had good sensitivity for diagnosing EMRS. Polyp pedicle and ethmoid mucosal eosinophilia associated with asthma.

Effect of the KTP laser in inferior turbinate surgery on eosinophil influx in allergic rhinitis

OBJECTIVE

Intranasal corticosteroids (INCS) are first-line medications for moderate to severe allergic rhinitis (AR). Patients who have had nasal congestion for many years often develop inferior turbinate (IT) hypertrophy. Some patients are refractory to INCS yet decline to receive allergen-specific immunotherapy. IT reduction is then indicated. There have been very few studies evaluating the allergic biomarker changes after IT reduction in AR. This study aimed to determine the effect of potassium titanyl-phosphate (KTP) laser IT surgery on eosinophil influx after challenge with dust mites.

STUDY DESIGN

A randomized prospective controlled study.

SETTING

Tertiary academic rhinology clinic.

SUBJECTS AND METHODS

Thirty-five house dust mite AR patients were randomly assigned to receive either INCS or KTP laser IT surgery. On the first visit, 2 nasal lavages prior to and 6 hours after challenge with Dermatophagiodes pteronyssinus were performed before receiving treatment. On the second visit, 3 months after treatment, the same procedures were repeated. No antiallergic medications were allowed for 2 weeks before each visit. Net changes in eosinophil numbers in the lavages were compared at baseline and 3 months after treatment and between the 2 treatments.

RESULTS

Treatment with KTP laser IT surgery resulted in a significant reduction in eosinophil influx after nasal challenge (P = .013), whereas such a reduction was not shown in the control. However, the net changes in the percentage of eosinophils were not different between the 2 groups at either visit.

CONCLUSION

KTP laser IT surgery reduces eosinophil influx after nasal challenge in perennial AR.

Risk factors of orbital complications in outpatients presenting with severe rhinosinusitis: A case-control study

OBJECTIVES

We assessed associations of potential factors with orbital complications in acute rhinosinusitis (ARS) patients.

DESIGN

An unmatched case-control study.

SETTING

A tertiary referral hospital in Thailand.

PARTICIPANTS

Consecutive outpatients of any age with severe ARS (visual analog scale ≥ 7) with and without orbital complications.

MAIN OUTCOME MEASURES

Patients were enrolled from January 2013 to December 2018. Forty-three ARS patients (55.8% female, median age 45.6, (range 2.0-93.0) years) were included, with 19 patients in the complicated group and 24 in the uncomplicated group. Patient characteristics (gender, age, diabetes, immune status), symptoms and signs, site of infection and type of pathogenic bacteria were recorded and assessed their associations with orbital complications by univariable and multivariable logistic regression analyses. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

The most common orbital complication was subperiosteal abscess (42.1%), followed by orbital cellulitis (15.8%) and cavernous sinus thrombosis (10.5%). Multivariable logistic regression analysis demonstrated a positive association with orbital complications (pseudo R² 0.4) for ethmoid sinusitis (OR 31.1, 95% CI [2.3-430.6]) and a short duration of symptoms (OR 0.9, 95% CI [0.8-0.9]).

CONCLUSIONS

Orbital complications were associated with ethmoid sinusitis with a short duration of ARS symptoms.

Predictive factors for identifying macrolide responder in treating chronic rhinosinusitis

BACKGROUND

Low-dose macrolides (LDM) are anti-inflammatory agents with antineutrophilic activity, but patient selection for LDM therapy in treating chronic rhinosinusitis (CRS) is controversial. This study aimed to assess factors which predict LDM responders.

METHODOLOGY

A prospective cohort study was performed. Patients with CRS received roxithromycin (150 mg) once daily for 12 weeks. Nasal secretions and serology were collected. Nine predictors for LDM response were assessed: nasal secretion IgE, nasal secretion IL-5, serum IgE, serum eosinophils, serum neutrophils, nasal polyps, asthma, allergy, and aspirin hypersensitivity, using receiver-operating curve analysis and multivariable logistic regression. Macrolide responders were those with sino-nasal outcome test-22 improvement, symptoms visual analogue scale decreased to ≤ ≤ ≤5, and no rescue medication.

RESULTS

One hundred CRS patients (mean age 47.4 +- 14.1 years, 45% male) were enrolled. Univariable logistic regression showed local total IgE less than 5.21; and serum eosinophils less than 2.2% associated with macrolide response. Multivariate models showed local total IgE maintained an independent association with macrolide response, with an ability to discriminate between responders and non-responders of 63%. Serum total IgE, nasal secretion IL-5, serum neutrophil, nasal polyp, asthma, allergy, and aspirin hypersensitivity showed no association with LDM response.

CONCLUSIONS

Low total IgE level in the nasal secretion but not in the serum, predict LDM response.

Expression of mammaglobins A and B in nasal polyps is similar in patients with and without allergic rhinitis

BACKGROUND

The causes of nasal polyposis remain unclear. Mammaglobins have been implicated in its pathogenesis. However, their association with the occurrence of nasal polyps in the presence of allergic rhinitis (AR) has not been explored. The aim of this study was to compare the expression levels of mammaglobins A and B with the nasal polyps of patients with and without AR.

METHODS

Thirty-one patients with bilateral nasal polyposis underwent skin-prick tests to specific aeroallergens. Nasal polyp tissues were obtained from all patients and divided into two groups as nasal polyps with and without AR depending on clinical history and the skin-prick test results. All polyp tissues were analyzed for the levels of mammaglobin A and mammaglobin B by using real-time quantitative polymerase chain reaction technique.

RESULTS

Of the 16 samples from patients having nasal polyps with AR, only 1 sample expressed a detectable level of mammaglobin A (1/16). There was no detectable expression of mammaglobin A in tissues from the group of nasal polyps without AR (0/15). Expression of mammaglobin B was detected in all nasal polyp tissues from both groups. The expression of mammaglobin B was not significantly different between nasal polyps with AR (median, 25th-75th percentiles; 0.023, 0.013-0.046) and nasal polyps without AR (0.032, 0.007-0.16).

CONCLUSION

Expression levels of mammaglobins A and B in nasal polyps are not different between patients with and without AR. Our findings suggest that mammaglobins' implication in the pathogenesis of nasal polyps is independent of an underlying AR.

Efficacy and safety of retrobulbar amphotericin B injection in invasive fungal rhinosinusitis with orbital invasion patients

BACKGROUND

At present, there is no consensus for optimal orbital infection management in invasive fungal rhinosinusitis patients. This is the first retrospective cohort study aimed to determine efficacy and side effects of the retrobulbar amphotericin B injection for orbital management in invasive fungal rhinosinusitis patients.

METHODOLOGY

A retrospective chart review was conducted from 2005 to 2020. Thirty-six patients (forty-two orbits) diagnosed with invasive fungal rhinosinusitis with orbital invasion, treated with or without retrobulbar amphotericin B injection, were included in the study.

RESULTS

There were a total of 36 patients in the study, 12 patients received retrobulbar amphotericin B injection and 24 did not. There was no significant difference in orbital exenteration and death between two groups. Visual acuity change at the 3rd month was significantly better in the exposure group. There was a significant difference in the overall clinical outcome at 3rd month and 12th month. There was no report of severe side effects in all patients.

CONCLUSIONS

Retrobulbar amphotericin B injection showed significant efficacy in stabilizing or even improving visual acuity without any side effects. This procedure should be considered as adjunctive treatment.

Effect of budesonide nasal irrigation on Hypothalamic-Pituitary-Adrenal Axis in patients with chronic rhinosinusitis post endoscopic sinus surgery: A prospective study

BACKGROUND

Corticosteroids added to high volume saline nasal irrigation have been introduced as a more effective method of delivering corticosteroids to the sinuses than nasal sprays. However, information regarding the effect of this intervention on the hypothalamic-pituitary-adrenal (HPA) axis is still limited.

OBJECTIVE

To evaluate the safety of long-term corticosteroid (6 months) nasal irrigation in patients with chronic rhinosinusitis (CRS) post endoscopic sinus surgery.

METHODS

Seventeen patients with CRS were included. After undergoing endoscopic sinus surgery, the patients were prescribed budesonide nasal irrigations (250 ml via squeeze bottle) twice daily (1 mg/day) for six months. The serum morning cortisol levels of these patients were then evaluated at 3 and 6 months post-operatively.

RESULTS

Median serum morning cortisol levels were 10.5 mcg% at pre-operative baseline; 10.3 mcg% at 3 months; and 11.2 mcg% at 6 months on post-operative follow-up. There were no significant changes in the serum morning cortisol levels (P value = 0.71 and 0.63 respectively). Three of 17 patients (17.65%) had mildly abnormal serum morning cortisol levels (4, 4.3 and 4.9 mcg%) at 3 months. However, these levels were within a normal range at 6 months.

CONCLUSIONS

Serum morning cortisol levels were not significantly changed after usage of budesonide nasal irrigation for 6 months.

Overall survival and prognostic factors in diabetic patients with invasive fungal rhinosinusitis

BACKGROUND

Patients with diabetes mellitus (DM) are susceptible to invasive fungal rhinosinusitis (IFRS). The mortality rate of IFRS varies greatly among the patients with DM.

OBJECTIVE

To identify the prognostic factors for the overall survival of patients with DM and IFRS.

METHODS

A retrospective study was conducted in four tertiary hospitals in Thailand, Malaysia and Myanmar. Patients diagnosed with IFRS and DM from 2008 to 2019 were identified. The outcome was the overall survival. Variables analyzed for risk factors were age, HbA1C level, ketoacidosis, white blood cell count, hyperglycemia, duration of DM, current use of diabetic medications, serum creatinine level, and the extensions of IFRS to the orbit, the cavernous sinus and intracranial cavity.

RESULTS

Sixty-five diabetic patients with IFRS (age 57.9 ± 13.4 years, male 60%) were identified. The mortality rate was 21.5%. The extensions of IFRS to the cavernous sinus (hazard ratio 5.1, 95% CI [1.4-18.2], p = 0.01) and intracranial cavity (hazard ratio 3.4, 95% CI [1.1-11.3, p = 0.05) predicted mortality. Current use of diabetic medications decreased the mortality risk (hazard ratio 0.2, 95% CI [0.1-0.9], p = 0.03). The 6-month overall survival of the patients with and without the cavernous sinus extension were 51.4% and 83.6%, (p = 0.001), with and without intracranial extension 53.3% and 88.9%, (p = 0.001), and with and without current diabetic medications 82.3% and 57.5%, respectively (p = 0.045).

CONCLUSIONS

The extensions of IFRS to the cavernous sinus and intracranial cavity increased the risk of death in patients with DM. Survival was primarily related to current use of diabetic medications.

A Predictive Model for Diagnosis of Acute Invasive Fungal Rhinosinusitis Among High-Risk Patients

BackgroundAcute invasive fungal rhinosinusitis (AIFR) is a life-threatening disease mainly affecting immunocompromised patients. Early detection is therefore key to improving patient survival. To date, there are still no standard clinical criteria for AIFR diagnosis.ObjectiveThis study develops a predictive model that utilizes clinical presentation and computed tomography (CT) findings to diagnose AIFR.MethodsA retrospective cohort study was conducted on patients with high risk for AIFR at King Chulalongkorn Memorial Hospital over the past 15 years (2008-2022). We constructed several multivariate logistic regression models for AIFR diagnosis based on different subsets of variables from 3 categories: signs/symptoms, endoscopy, and CT imaging.ResultsThere were 67 AIFR-positive patients and 68 AIFR-negative patients. Combining variables from 3 categories, a 6-variable model (fever, visual loss, mucosal discoloration, crusting, mucosal loss of contrast, retroantral fat stranding) achieved the highest area under the receiver operating characteristic curve of 0.8900 (74.63% sensitivity, 89.71% specificity).ConclusionsWe proposed predictive models for AIFR diagnosis in high-risk patients using clinical variables. The models can be used to guide the decision for further management such as biopsy or surgical intervention.