An algorithmic approach to sinonasal evaluation preceding bone marrow transplantation

<b>Introduction:</b> The authors conducted this study to review the available resources and prepare an algorithmic approach to pre-transplantation sinonasal evaluation.</br></br> <b>Materials and methods:</b> The sources of data were PubMed, Cochrane databases, and Google Scholar. We searched the available database for English-language studies using the keywords rhinosinusitis, transplantation, post -transplant sinusitis. Studies of all designs were included.</br></br> <b>Results:</b> Thirty-five relevant studies were retrieved from a total of 182 articles. The review of references guided us to 5more publications.</br></br> <b>Discussion:</b> We have proposed an algorithmic approach to sinonasal evaluation before transplantation which can provide a brief but comprehensive assessment of the patients. The evaluation begins with a thorough history and physical examination, including nasal endoscopy with careful attention to objective evidence of inflammation. CT scan should not be considered in all of the cases.</br></br> <b>Conclusion:</b> We have suggested an algorithm to provide a comprehensive and cost-effective way for the evaluation of sinonasal diseases before planned immunosuppression in order to assist in reducing post-transplantation morbidity and mortality.

Minimal Radiographic Mucosal Thickness or Opacification Criterion for Sinus-Specific Endoscopic Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVE

Primary chronic rhinosinusitis (CRS) is typically a diffuse process and the extent of endoscopic sinus surgery (ESS) performed for medically recalcitrant CRS is impacted by many factors. However, some third-party payors have implemented policies to authorize coverage for ESS in a sinus-by-sinus manner based on a minimal measurement of millimeters of mucosal thickening or sinus opacification in the corresponding sinus that is being surgically addressed. Our objective was to determine whether such policies are based on scientific evidence that in patients with medically recalcitrant CRS, a minimum measurement of mucosal thickening or sinus opacification is a predictor of CRS in that sinus or improved outcomes after ESS on a sinus-by-sinus basis.

DATA SOURCES

Medline, Embase, Scopus, and Web of Science databases, from inception through May 2022.

REVIEW METHODS

A systematic review was performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.

RESULTS

We identified 6070 abstracts which were screened and from which 112 studies ultimately underwent a full-text review. From these studies, we found that none investigated (or provided evidence of) whether any minimal degree of radiographic mucosal thickening or sinus opacification predicted CRS or better outcomes after ESS in a sinus-specific manner.

CONCLUSION

We were unable to find evidence supporting a minimum millimeter measurement of mucosal thickening or sinus opacification as predictors of CRS or better post-ESS outcomes in a sinus-specific manner in patients with medically recalcitrant CRS. The extent of ESS for CRS should be determined through personalized medical decision-making that considers all patient-specific factors.

Diagnostic usefulness of cone‐beam computed tomography versus multi‐detector computed tomography for sinonasal structure evaluation

Objective

Cone‐beam computed tomography (CBCT) is a promising imaging modality for sinonasal evaluation, with advantages of relatively low radiation dose, low cost, and quick outpatient imaging. Our study aimed to compare the diagnostic performance and image quality of CBCT with those of multi‐detector computed tomography (MDCT) with different slice thickness.

Methods

We retrospectively reviewed 60 consecutive patients who had undergone both CBCT and MDCT. MDCT images was reconstructed with 1 and 3 mm slice thickness. The quantitative image quality parameters (image noise, signal‐to‐noise ratio [SNR], and contrast‐to noise ratio [CNR] were calculated and compared between the two imaging modalities. Two observers (ENT surgeon and neuroradiologist) evaluated the presence of seven sinonasal anatomic variations in each patient and interobserver agreements were analyzed. The diagnostic performance of CBCT (0.3 mm) and MDCT (3 mm) was assessed and compared with that of high resolution MDCT (1 mm), which is considered as the gold standard.

Results

The image noise was significantly higher and SNR and CNR values were lower in the CBCT (0.3 mm) group than in the MDCT groups (1 and 3 mm). The diagnostic performance of CBCT (0.3 mm) was similar to that of MDCT (1 mm) and superior to that of MDCT (3 mm). The highest interobserver agreement was for high resolution MDCT (1 mm), followed by CBCT (0.3 mm), and MDCT (3 mm).

Conclusion

Considering its low radiation dose, low cost, and ease of clinical access, CBCT may be a useful imaging modality for as first line sinonasal evaluation and repeated follow up.

Study design: Retrospective study in a tertiary referral university center.

Level of evidence: NA.

Billing patterns for in-office computerized tomography scans of the face/sinus by otolaryngologists

PURPOSE

To evaluate billing trends, Medicare reimbursement, and practice setting for Medicare-billing otolaryngologists (ORLs) performing in-office face computerized tomography (CT) scans.

METHODS

This retrospective study included data on Medicare-billing ORLs from Medicare Part B: Provider Utilization and Payment Datafiles (2012-2018). Number of Medicare-billing ORLs performing in-office CT scans, and total sums and medians for Medicare reimbursements, services performed, and number of patients were gathered along with geographic and practice-type distributions.

RESULTS

In 2018, roughly 1 in 7 Medicare-billing ORLs was performing in-office CT scans, an increase from 1 in 10 in 2012 (48.2% growth). From 2012 to 2018, there has been near-linear growth in number of in-office CT scans performed (58.2% growth), and number of Medicare fee-for-service (FFS) patients receiving an in-office CT scan (64.8% growth). However, at the median, the number of in-office CT scans performed and number of Medicare FFS patients receiving an in-office CT, per physician, has remained constant, despite a decline of 42.3% (2012: $227.67; 2018: $131.26) in median Medicare reimbursements.

CONCLUSION

Though sharp declines have been seen in Medicare reimbursement, a greater proportion of Medicare-billing ORLs have been performing in-office face CT scans, while median number of in-office CT scans per ORL has remained constant. Although further investigation is certainly warranted, this analysis suggests that ORLs, at least in the case of the Medicare FFS population, are utilizing in-office CT imaging for preoperative planning, pathologic diagnosis, and patient convenience, rather than increased revenue streams. Future studies should focus on observing these billing trends among private insurers.

The Role of Imaging in the Preoperative Assessment of Patients with Nasal Obstruction and Septal Deviation-A Retrospective Cohort Study

Introduction  Isolated nasal obstruction (INO) is a common complaint of multiple etiology. The preoperative evaluation of patients presenting with nasal obstruction and deviated nasal septum (DNS) does not typically include imaging. The benefits of performing computed tomography (CT) in the preoperative setting are inconclusive. Objective  Assessing the contribution of preoperative CT to the surgical treatment of non-sinusitis patients presenting with INO and DNS. Methods  A retrospective cohort study on patients referred to surgery for nasal obstruction due to DNS or turbinate hypertrophy between 2006 and 2015. Data was retrieved from patients' medical charts. The CT scans and clinical data were reassessed by a second surgeon blinded to the patients' clinical course. Results  Seventy of the 843 patients (8.06%) who underwent endoscopic sinonasal procedures during the study period had presented with INO and met the inclusion criteria. Thirty-eight (55.88%) of them underwent CT scans during their preoperative assessment. Modification of the initial preoperative planning based on the radiological findings was required in 32 cases (84.2%). When reassessed by a second blinded surgeon, 58% of cases required surgical modification rather than classical submucosal resection of nasal septum and turbinate reduction ( P  = 0.048). Conclusion  Computed tomography was found beneficial in the preoperative planning for patients with INO. The original surgical plan based upon physical examination findings was modified based on radiological findings in 84.2% of the patients.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Consensus statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS-ES) on Pediatric Benign and Malignant Thyroid Surgery

OBJECTIVES

To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children.

METHODS

A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.).

RESULTS

Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus.

CONCLUSION

Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

Assessing the Clinical Value of Performing CT Scan before Rhinoplasty Surgery

Introduction

The endonasal mucosal or anatomic pathologies could lead to poor functional results and dissatisfaction after rhinoplasty. Although computed tomography (CT) scan has become an integral part of the diagnostic paradigm for patients with pathologies of the paranasal sinuses, the use of CT scan for preoperative evaluation of patients seeking rhinoplasty is up for debate. Our aim in this study was to compare the efficacy of CT scan in diagnosing nasal pathologies with other evaluating tools in patients undergoing rhinoplasty.

Design

In this randomized controlled trial study, 74 consecutive patients seeking cosmetic rhinoplasty referred to otorhinolaryngology clinic were randomly assigned into three groups based on the perioperative evaluation method: the CT group, the nasal endoscopy group, and the control group (anterior rhinoscopy only). Surgical planning was made according to perioperative findings, and the identified endonasal pathologies were corrected during the surgery. The functional and aesthetic outcomes of the rhinoplasty were assessed by Nasal Obstruction Symptom Evaluation (NOSE), Rhinoplasty Outcome Evaluation (ROE), and the Visual Analogue Scale (VAS) tools before surgery and at 12-month follow-up.

Results

All outcome measures improved significantly in either group toward one year after rhinoplasty (all with p value <0.05). Subjects in the CT group demonstrated greater improvement in the NOSE, VAS, and ROE compared to other two groups (NOSE: p value = 0.17; VAS: p value = 0.024; ROE: p value = 0.042).

Conclusions

According to our study, perioperative CT is associated with greater patients' satisfaction and quality of life after rhinoplasty compared to either nasal endoscopy or anterior rhinoscopy. A preoperative CT scan may improve the outcomes of rhinoplasty.

Consensus Statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS) on Pediatric Benign and Malignant Thyroid Surgery

OBJECTIVES

To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children.

METHODS

A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.).

RESULTS

Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus.

CONCLUSION

Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

Immediate and partial neural dysfunction after thyroid and parathyroid surgery: Need for recognition, laryngeal exam, and early treatment

BACKGROUND

Laryngeal dysfunction after thyroid and parathyroid surgery requires early recognition and a standardized approach for patients that present with voice, swallowing, and breathing issues. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to define the terms "immediate vocal fold paralysis" and "partial neural dysfunction" and to provide clinical consensus statements based on review of the literature, integrated with expert opinion of the group.

METHODS

A multidisciplinary expert panel constructed the manuscript and recommendations for laryngeal dysfunction after thyroid and parathyroid surgery. A meta-analysis was performed using the literature and published guidelines. Consensus was achieved using polling and a modified Delphi approach.

RESULTS

Twenty-two panelists achieved consensus on five statements regarding the role of early identification and standardization of evaluation for patients with "immediate vocal fold paralysis" and "partial neural dysfunction" after thyroid and parathyroid surgery.

CONCLUSION

After endorsement by the AHNS Endocrine Section and Quality of Care Committee, it received final approval from the AHNS Council.

Update on the diagnostic considerations for neurogenic nasal and sinus symptoms: A current review suggests adding a possible diagnosis of migraine

BACKGROUND

Treatment of rhinosinusitis (RS) is one of the leading reasons for prescriptions of antibiotics, although they often fail to provide symptomatic relief. Appropriately diagnosing and treating patients presenting with RS for whom antibiotic therapy has failed or who have normal CT findings is a controversial topic. One explanation is that what these patients are experiencing is misinformation from the trigeminal nerve and autonomic nervous system. Midfacial pain and pressure with rhinorrhea and nasal congestion do not represent an infectious, or even inflammatory, condition within the sinus or nasal cavities, but a mirage that is best treated as a migraine variant. Observations Although there is not enough research to definitively prove this alternate etiology, we are reaching a tipping point where the clinical implications, real-world experience, and evolving literature support this possible alternate etiology. Four key factors support a midfacial migraine that mimics RS: 1) Pathophysiology: current pathophysiology literature offers a model of how migraine attacks could replicate clinical presentations of RS; 2) Clinical presentation: patients with infectious RS and midfacial migraine have similar symptomatic presentation, similar demographics, but poorly correlated radiological information; 3) Diagnosis: clinical studies support the proposition that there are alternative diagnostic tools for distinguishing patients with midfacial migraine; and 4) Prognosis: Select RS patients show significant improvement with migraine treatment.

CONCLUSIONS

We encourage medical professionals to consider migraine disease as a form of sensory misinformation and as a possible etiology of RS complaints. Clinicians can ask validated questions to determine if possible migraine could be an underlying cause, and there are standard preventative treatments for migraine that could alleviate patient symptoms. Dysfunctional vasomotor activity may be the root of the disturbances, particularly when antibiotic therapy fails and CT findings are discordant with symptoms. Until there is a diagnostic test for migraine, clinicians need to question a patient's self-diagnosis of rhinosinusitis. More research is needed to definitively answer this important question.

The Role of the Adenoids in Pediatric Chronic Rhinosinusitis

There are several mechanisms by which the adenoids contribute to pediatric chronic rhinosinusitis (PCRS), particularly with children aged 12 years and younger. Understanding the role that the adenoids play in PCRS is crucial when attempting to treat these patients. A literature review was performed to address this problem and provide information surrounding this topic. This review will provide a better understanding of how adenoids contribute to PCRS, and also of the medical and surgical treatment options.

Image quality and dose reduction in sinus computed tomography using iterative reconstruction: a cadaver study

Background

Concerns about radiation dose in computed tomography (CT) imaging have renewed interest in iterative reconstruction (IR), a technique which has the potential to produce images with less noise at lower radiation doses than traditional filtered back projection (FBP). This study aimed to assess whether application of IR could provide comparable quality sinus CT images to FBP at lower kilovolt (kV) and milliamp (mA) settings, and to establish optimal scan settings for sinus imaging.

Methodology/Principal

30 sinus CT scans were performed on 5 cadaver heads at two kV setting and three mA settings. Each scan was reconstructed using FBP and 3 IR settings, yielding a total of 120 images series. Each image set was blinded and randomly reviewed by 3 rhinologists and 2 neuroradiologists. Using a 5-point Likert scale, 16 anatomical landmarks, were graded with respect to image quality. Data were assessed with respect to dose and IR settings using statistical analysis.

Results

Higher kV and mAs settings produced significantly higher quality images for structure identification across all 16 landmarks; however, the suitability for surgery did not increase in a linear fashion and plateaued by a total radiation dose of 0.1201 mSv. IR algorithm did not provide a benefit in the overall score of scans at a fixed kV and mAs.

Conclusions

Identification of structures in sinus CT imaging significantly correlate with the kV and mA and overall dose of radiation; however, IR did not provide additional benefit in the image quality.

Demographics and referral patterns of a university-based oral maxillofacial radiology clinic over a 20 year period

OBJECTIVE

The aim of this study was to review the referral patterns, distribution of interpretations, and type of diagnostic imaging used in a university based oral maxillofacial radiology clinic for patients referred for consultation from both dental and nondental clinicians.

STUDY DESIGN

The database of the Special Procedures clinic in the oral radiology department of the University of Toronto, Faculty of Dentistry, containing over 5000 entries, from 1993 to 2013, was queried. Using descriptive categorical analysis, the results were analyzed to describe patient demographic characteristics, the specialty of the referring clinicians, the imaging modalities used, and the interpretation provided.

RESULTS

Most referrals were from oral and maxillofacial surgeons and general dentists. Approximately 25% of referrals were interpreted as variations of normal anatomic structures. The most common reasons for referral were intraosseous lesions (42%), temporomandibular joints (39%), and sialography. Ten percent of all referrals were for recall examinations. The distribution of image modalities has changed through the years covered by this study.

CONCLUSIONS

This study reflects a lower proportion of referrals reported as normal structures and their variations, than reported in a previous comparable study.

Radiodensity of the Ostiomeatal Complex in Recurrent Acute Rhinosinusitis

Objective Recurrent acute rhinosinusitis (RARS) can be an elusive diagnosis due to the lack of clinical and radiographic findings in between acute episodes. This study aims to identify objective computed tomography (CT) characteristics in RARS. Study Design Case series with chart review. Setting Tertiary academic medical center. Subjects and Methods Patients meeting diagnostic criteria for RARS were identified retrospectively from the senior author's practice. Patients were diagnosed with RARS if they experienced 3 or more episodes of acute sinusitis within the past year with complete resolution of symptoms in between episodes. At least 1 episode was confirmed via CT or endoscopy. CT scans showing prior surgery were excluded. The scans for these patients were compared with those from a normal control group. Bone radiodensity of the entire ostiomeatal complex (OMC), including the ethmoid bulla, middle turbinate, and uncinate, was measured in Hounsfield units. Maximum radiodensity was noted for each side. Results A total of 16 patients meeting inclusion criteria for RARS were compared with 16 healthy patients. The mean Lund-MacKay score was 1.6 in the RARS group and 1.3 in the control group. The maximum radiodensity of the OMC was significantly higher in the RARS group (556) compared with that of the control group (327) ( P < .0001). Conclusion Patients with RARS had significantly greater radiodensity of the OMC compared with those in the control group despite minimal differences in mucosal disease. Radiodensity measurement of the OMC using Hounsfield units may help to identify patients with this elusive diagnosis.

Inefficiencies in Computed Tomography Sinus Imaging for Management of Sinonasal Disease

Objective A subset of patients with sinonasal disease who obtain a diagnostic computed tomography (CT) sinus scan may require repeat preoperative CT due to the inadequacy of diagnostic CT for image-guided sinus surgery (IGSS). This leads to increased CT utilization, health care costs, and patient exposure to ionizing radiation. The objective of this study is to determine the frequencies of diagnostic CT sinus studies that were inadequate for IGSS and repeat CT studies for purposes of IGSS. Study Design A retrospective chart study was performed between May 2012 and August 2013. Setting Tertiary care rhinology practice. Subjects and Methods New patients with any sinonasal diagnosis who presented with CT sinus scans acquired from outside institutions were included. CT scans were considered inadequate for IGSS for any of the following reasons: >1.5-mm slice thickness, oblique axial planes due to gantry tilt, and incompletely defined or missing IGSS anatomic landmarks. Results Of 183 patients, 85 (46%) presented with diagnostic CT sinus scans that were inadequate for IGSS. Seventy-one patients met indications for IGSS, of which 37 (52%) required repeat CT due to an IGSS-inadequate diagnostic scan. Conclusion The frequency of repeat preoperative CT sinus imaging may be high at tertiary care centers where IGSS is performed. A standardized IGSS-adequate CT sinus protocol may avoid the need for repeat preoperative scans. Potential advantages include improved efficiency, decreased health care costs, and reduced ionizing radiation exposure to the patient.

Problem-based learning discussion: Medical treatment of pediatric chronic rhinosinusitis

This problem-based learning case focused on the approach to evaluation and management of a 5-year old girl who was "always sick" with sinus infections. The discussion unfolds in a "real life" scenario, i.e., based on information available to the clinician initially and after the acquisition of laboratory data, and, ultimately, after sinus surgery. Emphasis is placed on the differential diagnosis of the patient's symptoms, discussion of the initial management strategy for chronic rhinosinusitis (CRS), evolution from acute rhinosinusitis to CRS, the prevalence of and differential diagnosis of nasal polyps in children, treatment considerations specific for CRS with nasal polyps, the significance of Pseudomonas aeruginosa sinus infection, the significance of an abnormal sweat chloride test in a young child with nasal polyposis, special considerations in children with CRS who have cystic fibrosis, treatment considerations after endoscopic sinus surgery, and, finally, prognostic factors that impact the outcomes of endoscopic sinus surgery. This problem-based learning case highlights many facets of managing refractory CRS in children.

Current Trends in Sinonasal Imaging

As endoscopic sinus surgery (ESS) has evolved since its introduction to the United States, so has technology for imaging the sinonasal cavities. Although imaging is most frequently performed for evaluating chronic sinusitis refractory to medical therapy, its uses have expanded beyond inflammatory sinus disease. Multidetector Computed Tomography is the current workhorse for both diagnosis and preoperative planning in prospective ESS patients, while MR imaging remains a complementary tool for evaluating suspected tumors or intracranial and orbital complications of rhinosinusitis. In this article, the authors review current trends and potential future directions in the use of these modalities for sinus imaging.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Imaging findings of the orbital and intracranial complications of acute bacterial rhinosinusitis

In patients with acute bacterial rhinosinusitis severe orbital and intracranial complications can occur. This review will illustrate the anatomic relationship between the paranasal sinuses and the orbital and intracranial compartments. Subsequently, the spectrum of orbital and intracranial complications of rhinosinusitis and related imaging findings will be discussed and illustrated by case material from daily practice.

TEACHING POINTS

• Acute bacterial rhinosinusitis can cause severe orbital and intracranial complications. • If orbital or intracranial complications are suspected, cross-sectional imaging is mandatory. • Infection can spread from the ethmoid sinus to the orbit through the lamina papyracea. • Frontal sinusitis can spread intracranially through dehiscences or osteomyelitis. • Radiologists must recognize imaging findings of complications of acute bacterial rhinosinusitis.

Clinical practice guideline (update): adult sinusitis

OBJECTIVE

This update of a 2007 guideline from the American Academy of Otolaryngology--Head and Neck Surgery Foundation provides evidence-based recommendations to manage adult rhinosinusitis, defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. Changes from the prior guideline include a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhinosinusitis (ABRS), and 3 new recommendations for managing chronic rhinosinusitis (CRS).

PURPOSE

The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing adult rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for adult rhinosinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy, which includes radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia.

ACTION STATEMENTS

The update group made strong recommendations that clinicians (1) should distinguish presumed ABRS from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography. The update group made recommendations that clinicians (1) should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS; (2) should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic); (3) should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management; (4) should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms; (5) should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia; (6) should confirm the presence or absence of nasal polyps in a patient with CRS; and (7) should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. The update group stated as options that clinicians may (1) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis; (2) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS; and (3) obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS. The update group made recommendations that clinicians (1) should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected, and (2) should not prescribe topical or systemic antifungal therapy for patients with CRS.

May chronic rhinosinusitis in children be diagnosed by clinical symptoms?

OBJECTIVES

Chronic rhinosinusitis (CRS) is a common disease in childhood but is often underdiagnosed because the symptoms are subtle and similar to other nasal pathologies. No clinical symptom is pathognomonic, and consensus documents suggest nasal fibroendoscopy (NF) or imaging criteria (computed tomography, magnetic resonance imaging) as the gold standards for diagnosis of CRS. However, considering the frequent unavailability of such tools to physicians, we designed this study to evaluate whether combinations of symptoms may achieve a clinical diagnosis of CRS in children as confirmed by NF.

METHODS

The study population consisted of 275 children with a clinical diagnosis of CRS, in 228 of whom diagnosis of CRS was confirmed by NF, while in 47 diagnosis was not confirmed by NF and they served as the control group. The symptoms considered were nasal obstruction, nasal discharge, cough, facial pain, and halitosis, using for statistical analysis multivariate logistic regression, Wald tests, and receiver operating characteristic (ROC) curve.

RESULTS

The multivariate logistic regression for CRS symptoms indicated rhinorrea as the strongest predictor of CRS. With three symptoms the probability of CRS was from 60% to 75% without rhinorrea and 77-91% in the presence of this symptom, with four symptoms the probability was over 93%, and with all the five symptoms the probability of having CRS was virtually 100%.

CONCLUSIONS

These findings suggest that an initial symptoms assessment may help to recognize children with a high probability of CRS, thus reducing the need of NF or imaging techniques.

Clinical consensus statement: pediatric chronic rhinosinusitis

OBJECTIVE

To develop a clinical consensus statement on the optimal diagnosis and management of pediatric chronic rhinosinusitis (PCRS).

METHODS

A representative 9-member panel of otolaryngologists with no relevant conflicts of interest was assembled to consider opportunities to optimize the diagnosis and management of PCRS. A working definition of PCRS and the scope of pertinent otolaryngologic practice were first established. Patients of ages 6 months to 18 years without craniofacial syndromes or immunodeficiency were defined as the targeted population of interest. A modified Delphi method was then used to distill expert opinion into clinical statements that met a standardized definition of consensus.

RESULTS

After 2 iterative Delphi method surveys, 22 statements met the standardized definition of consensus while 12 statements did not. Four statements were omitted due to redundancy. The clinical statements were grouped into 4 categories for presentation and discussion: (1) definition and diagnosis of PCRS, (2) medical treatment of PCRS, (3) adenoiditis/adenoidectomy, and (4) endoscopic sinus surgery (ESS)/turbinoplasty.

CONCLUSION

Expert panel consensus may provide helpful information for the otolaryngologist in the diagnosis and management of PCRS in uncomplicated pediatric patients.

Computed tomography imaging practice patterns in adult chronic rhinosinusitis: survey of the American Academy of Otolaryngology-Head and Neck Surgery and American Rhinologic Society membership

BACKGROUND

The objective of this study was to assess the current practice patterns of computed tomography (CT) imaging for diagnosis and management of adult chronic rhinosinusitis (CRS).

METHODS

A 29-item, electronic, Web-based physician survey was disseminated to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and American Rhinologic Society (ARS) membership from November 2012 to January 2013.

RESULTS

A total of 331 otolaryngologists completed the survey. Seventy-five percent of respondents did not obtain confirmatory CT imaging prior to initiating medical therapy for CRS. A typical diagnostic scan was considered to be a 3-mm coronal CT with or without 3-mm axial images for 50.6% of participants. On average, the respondents obtained 1 (58.8%) or 2 (36.6%) CT scans prior to proceeding with sinus surgery. CT scanning was most commonly performed in a hospital radiology department (76.4%), followed by a free-standing imaging center (44.5%). An in-office CT scanner was owned by 24.5% of the respondents, mostly commonly a cone beam CT (74.0%) scanner. Most respondents (87.1%) did not experience problems with carriers denying ability to image or reimbursing for scans. Overall, 68.4% of the respondents were unaware of the dosage of radiation delivered by the scanner used for CT acquisition.

CONCLUSION

This survey provides a snapshot of the current utility of CT imaging in the management paradigm for CRS. Given that most are unaware of the delivered radiation dose, this clearly represents an important area of improvement in the knowledge gap.

Clinical practice guideline: Allergic rhinitis

OBJECTIVE

Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options.

PURPOSE

The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients.

ACTION STATEMENTS

The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

Radiographic evaluation of nasal septal deviation from computed tomography correlates poorly with physical exam findings

BACKGROUND

Performance of septoplasty is dependent on objective evidence of nasal septal deviation. Although physical examination including anterior rhinoscopy and endoscopic examination is the gold standard for evaluation of septal deviation, third-party payors' reviews of septoplasty claims are often made on computed tomography (CT) findings. However, the correlation between radiographic evaluation of septal deviation with physical examination findings is unknown.

METHODS

Retrospective, blinded, independent evaluation of septal deviation in 39 consecutive patients from physical examination, including anterior rhinoscopy and endoscopic examination, by an otolaryngologist and radiographic evaluation of sinus CT scan by a neuroradiologist. Four distinct septal locations (nasal valve, cartilaginous, inferior/maxillary crest and osseous septum) were evaluated on a 4-point scale representing (1) 0% to 25%, (2) >25% to 50%, (3) >50% to 75%, and (4) >75% obstruction. Correlation between physical examination and radiographic evaluations was made by Pearson's correlation and quantitative agreement assessed by Krippendorf's alpha.

RESULTS

Statistically significant correlation was detected between physical examination including nasal endoscopy and radiographic assessment of septal deviation only at the osseous septum (p = 0.007, r = 0.425) with low quantitative agreement (α = 0.290). No significant correlation was detected at the cartilaginous septum (p = 0.286, r = 0.175), inferior septum (p = 0.117, r = 0.255), or nasal valve (p = 0.174, r = 0.222). Quantitative agreement at the nasal valve suggested a bias in CT to underestimate physical exam findings (α = -0.490).

CONCLUSION

CT is a poor substitute for physical examination, the gold standard, in assessment of septal deviation. Clinical decisions about pursuit of septoplasty or third-party payors' decisions to approve septoplasty should not be made on radiographic evidence.

Management of invasive well-differentiated thyroid cancer: an American Head and Neck Society consensus statement. AHNS consensus statement

BACKGROUND

Invasive differentiated thyroid cancer (DTC) is relatively frequent, yet there is a paucity of specific guidelines devoted to its management. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to provide clinical consensus statements based on review of the literature, synthesized with the expert opinion of the group.

METHODS

An expert panel, selected from membership of the AHNS, constructed the manuscript and recommendations for management of DTC with invasion of recurrent laryngeal nerve, trachea, esophagus, larynx, and major vessels based on current best evidence. A Modified Delphi survey was then constructed by another expert panelist utilizing 9 anchor points, 1 = strongly disagree to 9 = strongly agree. Results of the survey were utilized to determine which statements achieved consensus, near-consensus, or non-consensus.

RESULTS

After endorsement by the AHNS Endocrine Committee and Quality of Care Committee, it received final approval from the AHNS Council.

Chronic rhinosinusitis in children

Chronic rhinosinusitis (CRS) affects nearly 37 million people in the United States each year and accounts for approximately $6 billion in direct and indirect health care costs. Despite its prevalence and significant impact, little is known about its exact cause and pathophysiology, and significant controversy remains regarding appropriate treatment options. Basic science research, however, has shown recent promise toward improving understanding of the innate and environmental factors underlying the pathophysiology of CRS. The hope is that this will also lead to advances in treatment for children adversely affected by this common yet complicated disease.