The validity of nasal endoscopy in patients with chronic rhinosinusitis-An inter-rater agreement study

OBJECTIVES

Nasal endoscopy is a cornerstone in diagnosing sinonasal disease, but different raters might generate different results using the technique. Our study aims to evaluate the agreement between multiple raters to assess the validity of nasal endoscopy.

DESIGN/PARTICIPANTS

Three independent and blinded raters evaluated 28 patients (56 nasal cavities) diagnosed with chronic rhinosinusitis according to the European Position Paper on Rhinosinusitis and Nasal Polyps. The ratings were compared using unweighted Fleiss' kappa coefficients (K_f ) for each objective parameter.

SETTING

The department of Otorhinolaryngology, Odense University Hospital, Denmark.

MAIN OUTCOME MEASURES

The ratings were quantified in a modified Lund-Kennedy endoscopy score and focused on the objective parameters specified in the diagnostic criteria: polyps, oedema and discharge.

RESULTS

The raters agreed on the findings concerning polyps and discharge but not regarding oedema with the inter-rater agreement for the different parameters being: polyps K_f =.66 (SE .07, P<.001), oedema K_f =.05 (SE .07, P=.21), discharge K_f =.35 (SE .08, P<.001), oedema exclusively in middle meatus K_f =-.07 (SE .04, P=.8) and discharge exclusively in middle meatus K_f =.16 (SE .07, P=.01).

CONCLUSION

Using nasal endoscopy, the evaluation of polyps by multiple raters showed sufficient reliability indicating an acceptable objective evaluation. The evaluation of discharge achieved a fair level of agreement while the assessment of oedema could not achieve a sufficient reliability questioning the inclusion of oedema in the criteria for diagnosing sinonasal disease.

Impact of educational intervention on the interrater agreement of nasal endoscopy interpretation

OBJECTIVE

Nasal endoscopy is integral to the evaluation of sinonasal disorders. However, prior studies have shown significant variability in the interrater agreement of nasal endoscopy interpretation among practicing rhinologists. The objective of the current study is to evaluate the interrater agreement of nasal endoscopy among otolaryngology residents from a single training program at baseline and following an educational intervention.

METHODS

Eleven otolaryngology residents completed nasal endoscopy grading forms for eight digitally recorded nasal endoscopic examinations. An instructional lecture reviewing nasal endoscopy interpretation was subsequently provided. The residents then completed grading forms for eight different nasal endoscopic examinations. Interrater agreement among residents for the pre- and postlecture videos was calculated using the unweighted Fleiss' kappa (Kf) statistic and intraclass correlation agreement (ICC).

RESULTS

Interrater agreement improved from a baseline level of fair (Kf range 0.268-0.383) to a posteducational level of moderate (Kf range 0.401-0.547) for nasal endoscopy findings of middle meatus mucosa, middle turbinate mucosa, middle meatus discharge, sphenoethmoid recess mucosa, sphenoethmoid recess discharge, and atypical lesions (ICC, P < 0.001). The baseline level of agreement for evaluation of nasal septum deviation was poor/fair and did not improve following educational intervention.

CONCLUSIONS

This study demonstrates a limited baseline level of interrater agreement of nasal endoscopy interpretation among otolaryngology residents. The interrater agreement for the majority of the characteristics that were evaluated improved after educational intervention. Further study is needed to improve nasal endoscopy interpretation.

LEVEL OF EVIDENCE

N/A.

Azithromycin add-on therapy in high-risk postendoscopic sinus surgery patients failing corticosteroid irrigations: A clinical practice audit

BACKGROUND

Chronic rhinosinusitis (CRS) has a high potential for recurrence after endoscopic sinus surgery (ESS), despite a postoperative therapy of topical corticosteroid irrigations. Azithromycin (AZI) is a macrolide antibiotic with anti-inflammatory properties that may be of benefit in such steroid-unresponsive patients. Follow-up study was performed to (1) review the effectiveness of the management strategy of adding AZI in high-risk post-ESS patients failing standard management and (2) identify predictive factors for steroid nonresponsiveness.

METHODS

A retrospective audit of the postoperative evolution of all patients undergoing ESS for CRS in 2010 by a single surgeon was undertaken. Patients deemed at high risk of recurrence based on preoperative history and/or perioperative findings received nasal irrigation with 0.5 mg of budesonide (BUD) in 240 mL of saline twice daily after ESS. Patients showing signs of endoscopic recurrence at 4 months, despite BUD, had AZI at 250 mg three times a week added to their treatment regimen.

RESULTS

A total of 57 high-risk patients underwent ESS during this period. At 4 months, 63.2% (36/57) had a favorable outcome solely with BUD. Twelve of the 21 nonresponders received AZI, with an additional 66.7% (8/12) subsequently showing a favorable response. Failure of BUD was associated with female gender (p = 0.048), having elevated alpha-1-antitrypsin levels (p = 0.037) and lower recovery rates of Staphylococcus aureus (p = 0.063). Although the AZI subgroup was too small for statistical analysis, female gender was more frequently associated with failure of both BUD and AZI, while IgE was not useful.

CONCLUSION

A significant subgroup of high-risk patients showing disease recurrence after ESS despite topical corticosteroid therapy may respond to the addition of AZI as part of their therapy. These findings suggest that topical steroid-unresponsive CRS may represent a distinct entity and that alternate anti-inflammatory agents may be required for optimal management.

Interrater agreement of nasal endoscopy in patients with a prior history of endoscopic sinus surgery

BACKGROUND

Nasal endoscopy is an important part of the clinical evaluation of patients with chronic rhinosinusitis. However, the objectivity and interrater agreement of the procedure related findings have not been well studied, especially in patients who have previously had sinus surgery.

METHODS

Patients with a history of endoscopic sinus surgery for chronic rhinosinusitis were prospectively enrolled from a tertiary rhinology practice. Fourteen endoscopic nasal examinations were recorded using digital video capture software. Each patient also underwent computed tomography (CT) and completed the Sinonasal Outcome Test (SNOT-22). Blinded review of inflammatory and anatomic findings for each video was independently performed by 5 academic rhinologists at separate institutions. Comparisons were performed using the unweighted Fleiss' kappa statistic (K(f) ) and the prevalence- and bias-adjusted kappa (PABAK).

RESULTS

There were no significant correlations between age, Lund-Mackay score, or SNOT-22 score. Interrater agreement was variable across the characteristics studied. Mean PABAK was excellent for the assessment of polyps (K(f) = 0.886); moderate for the assessments of middle turbinate (MT) integrity (K(f) = 0.543), MT position (K(f) = 0.443), maxillary sinus patency (K(f) = 0.593), and ethmoid sinus patency (K(f) = 0.429); fair for discharge (K(f) = 0.314), synechiae (K(f) = 0.257), and middle meatus patency (K(f) = 0.229); and poor for MT mucosal changes (K(f) = 0.148) and uncinate process (K(f) = 0.126).

CONCLUSION

This study was notable for variability in the interrater agreement among the inflammatory and anatomic attributes that were examined. Further standardization of nasal endoscopy with regard to interpretation may improve the reliability of this procedure in clinical practice.

Interrater agreement of nasal endoscopy for chronic rhinosinusitis

BACKGROUND

Nasal endoscopy is a routine, important diagnostic tool in the evaluation of chronic rhinosinusitis (CRS). Although the procedure is ideally "objective," the subjective nature of endoscopy interpretation and lack of standardization are potential limitations. The goal of this study was to examine the interrater agreement of various categories of nasal endoscopy findings in patients undergoing evaluation for CRS.

METHODS

Fourteen patients (28 sides) with CRS underwent clinical evaluation, SNOT-22, sinus computed tomography (CT), and digital video nasal endoscopy. Five academic rhinologists blindly reviewed the endoscopies for structural anatomic issues, inflammatory rhinosinusitis findings, and atypical lesions. Statistical comparison of the endoscopy interpretations was performed using the unweighted Fleiss' kappa statistic (K(f) ).

RESULTS

The mean Lund-Mackay CT scan score was 7.8 (standard deviation [SD] 4.9) and the mean SNOT-22 score was 35.8 (SD 22.7). Significant variability was noted among the raters with respect to the various categories of nasal endoscopy findings. The overall levels of interrater agreement for the various categories were as follows: "almost perfect" for atypical lesions (K(f) = 0.912); "substantial" for nasal polyps (K(f) = 0.693); "moderate" for nasal discharge (K(f) = 0.422) and mucosal inflammatory changes of the middle turbinate (K(f) = 0.413); and "fair" for edema of the middle meatus (K(f) = 0.214), obstruction by nasal septum deviation (K(f) = 0.240), and obstruction by the middle turbinate (K(f) = 0.276).

CONCLUSION

Significant variability was noted in the interrater agreement for nasal endoscopy findings in this study, with relatively limited agreement on some of the key findings of the procedure. Additional investigation and standardization of nasal endoscopy interpretation is required to improve the clinical utility of the procedure.

Topical budesonide via mucosal atomization device in refractory postoperative chronic rhinosinusitis

BACKGROUND

Nebulized budesonide (Pulmicort Respules, AstraZeneca, Wilmington, DE) provides control of respiratory tract inflammation in asthmatic patients. The Mucosal Atomization Device (MAD; Wolfe-Tory Medical, Salt Lake City, UT) is a novel sinonasal atomization device.

METHODS

Uncontrolled case series of postoperative patients with chronic rhinosinusitis (CRS) who received budesonide via MAD was performed.

RESULTS

A total of 44 patients with a mean age of 53.5 years met inclusion criteria. The average follow-up was 31.5 weeks (SD 17.55; range, 8 to 80 weeks). Overall, patient and physician global assessments demonstrated moderate to significant improvement. Average daily oral prednisone usage among patients who took systemic steroids (n = 27) was reduced from 7.96 to 1.94 mg/day without relapse of polyps, mucosal edema, and nasal discharge. Prednisone use was reduced to zero in 16 patients and reduced or stabilized in 10 other patients.

CONCLUSION

Topical budesonide via MAD may reduce the need for systemic prednisone and improve both physician and patient global assessment scores in postoperative CRS patients. Additional investigation is warranted to exclude placebo effect, spontaneous resolution, and regression to the mean as responsible factors for the reported findings.

Evidence-based recommendations regarding the differential diagnosis and assessment of nasal congestion: using the new GRADE system

Nasal congestion is an important symptom in nasal pathology and can be defined as an objective restriction of nasal cavity airflow because of mucosal pathology and/or increased mucus secretion (excluding anatomical variants). Using the new Grading Recommendations Assessment, Development and Evaluation system, evidence-based recommendations are made that will encompass different clinical questions regarding diagnostic modalities of nasal congestion: (i) their usefulness in assessment of presence and severity of congestion; (ii) their usefulness in assessment of etiological pathology responsible for congestion; and (iii) their usefulness in follow up and treatment effectiveness evaluation of nasal congestion.

Bibliography. Current world literature. Nose and paranasal sinuses

PURPOSE OF REVIEW

Patients with advanced head and neck cancer are being treated with chemo-radiotherapy, and life is being prolonged, with or without persistent disease, for longer than was previously. Hypercalcaemia may present in patients with advanced or disseminated head and neck cancer, and, as such, these patients may present to a larger variety of clinicians for advice concerning their symptoms and illness. Modes of presentation of hypercalcaemia and treatment strategies are reviewed.

RECENT FINDINGS

There were previously few large series of head and neck cancer patients diagnosed with hypercalcaemia, which may or may not have been related to their cancer being treated. Investigations, by way of blood/serum calcium level, may identify such patients. Patients with cancer-related hypercalcaemia have a poor prognosis, but many may respond temporarily to treatment when offered, with an improvement of their quality of life and death.

SUMMARY

Hypercalcaemia should and must be considered in all patients who have or possibly have a diagnosis of a head and neck cancer and who present unwell with symptoms of fatigue, lethargy and somnolence. Investigation must include serum calcium (corrected for serum albumin binding) and parathyroid hormone level. Patients may be treated by a combination of rehydration and bisulphonate therapy until the serum calcium is reduced to a level below 3 mmol/l. The majority of patients diagnosed with hypercalcaemia due to head and neck malignancy die of their diseases in the short term, but some may enjoy a prolongation of life with reasonable quality if diagnosed and treated aggressively.