Patient perspectives on recall period and response options in patient-reported outcome measures for chronic rhinosinusitis symptomatology: An international multi-centered study

BACKGROUND

Existing patient-reported outcome measures (PROMs) for chronic rhinosinusitis (CRS) use a variety of recall periods and response scales to assess CRS symptom burden. Global perspectives of CRS patients regarding optimal recall periods and response scales for CRS PROMs are unknown.

METHODS

This was a multi-center, cross-sectional study recruiting 461 CRS patients from sites across the United States, Saudi Arabia, New Zealand, and Austria. Participants chose which CRS symptom recall period (1 day, 2 weeks, 1 month, >1 month) was most reflective of their current disease state and upon which to best base treatment recommendations (including surgery). Participants also chose which of six response scales (one visual analogue scale and five Likert scales ranging from four to eight items) was easiest to use, understand, and preferred.

RESULTS

A plurality of participants (40.0%) felt their CRS symptoms' current state was best reflected by a 1-month recall period. However, most patients (56.9%) preferred treatment recommendations to be determined by symptoms experienced over a >1 month period. The four- and five-item Likert scales were the easiest to understand (26.0% and 25.4%, respectively) and use (23.4% and 26.7%, respectively). The five-item (26.4% rating it most preferred and 70.9% rating it preferred) and four-item Likert (22.3% rating it most preferred and 56.4% rating it preferred) response scales were most preferred.

CONCLUSION

Future PROMs for CRS should consider assessment of symptoms over a 1-month period and use a four- or five-item Likert response scale to reflect global patient preferences. These findings also inform interpretation of current CRS PROMs.

Early Results With the New Active Bone-Conduction Hearing Implant: A Systematic Review and Meta-Analysis

OBJECTIVE

The bone conduction implant (BCI) 602 is a new transcutaneous BCI with smaller dimensions. However, limited patient numbers restrict the statistical power and generalizability of the current studies. The present systematic review and meta-analysis summarize early audiological and medical outcomes of adult and pediatric patients implanted with the BCI 602 due to mixed or conductive hearing loss.

DATA SOURCE

Following the Preferred Reporting items for Systematic Reviews and Meta-analyses guidelines, 108 studies were reviewed, and 6 (5.6%) were included in the meta-analysis.

REVIEW METHOD

The data on study and patient characteristics, surgical outcomes, and audiological test results were extracted from each article. Meta-analysis employed the fixed-effect and random-effects models to analyze the mean differences (MDs) between pre- and postoperative performances.

RESULTS

In total, 116 patients were evaluated, including 64 (55%) adult and 52 (45%) pediatric patients. No intraoperative adverse events were reported, while postoperative complications were reported in 2 (3.1%) adult and 2 (3.8%) pediatric patients. Studies consistently showed significant improvements in audiological outcomes, quality of life, and sound localization in the aided condition. In the meta-analysis, we observed a significant difference in the unaided compared to the aided condition in sound field thresholds (n = 112; MD, -27.05 dB; P < 0.01), signal-to-noise ratio (n = 96; MD, -6.35 dB; P < 0.01), and word recognition scores (n = 96; MD, 68.89%; P < 0.01).

CONCLUSION

The implantation of the BCI 602 was associated with minimal surgical complications and excellent audiological outcomes for both the pediatric and the adult cohort. Therefore, our analysis indicates a high level of safety and reliability. Further research should focus on direct comparisons with other BCIs and long-term functional outcomes.

Presentation Rates for Acute Pharyngitis in the Emergency Room Are Influenced by Extreme Weather Events

OBJECTIVE

Extreme weather events are becoming more prevalent with the increasing pace of climate change. These events negatively impact human health and put considerable strain on health care resources, including emergency departments. Within otolaryngology, acute pharyngitis is a common reason for emergency room visits (ERV). Therefore, we aimed to investigate the impact of extreme meteorological conditions on ERV rates related to acute pharyngitis.

STUDY DESIGN

Retrospective time-series study.

SETTING

ERVs related to acute pharyngitis (n = 1511) were identified at a tertiary care hospital in Vienna, Austria, between 2015 and 2018.

METHODS

The effects of single-day and prolonged (3-day) extreme weather events on ERVs were analyzed using a distributed lag nonlinear model. Relative risk (RR) and cumulative relative risk (cRR) were calculated over a lag period of 14 days. RR refers to the risk for pharyngitis-related ERV at extreme conditions (1st, 5th, 95th, or 99th percentile) compared to the risk at median conditions.

RESULTS

Same-day RR (lag0) was elevated more than 3-fold after prolonged extremely low mean temperatures (P = .028). Furthermore, same-day RR after single-day and prolonged extremely high relative humidity was elevated by 51% (P = .024) and 46% (P = .036), respectively. Significant delayed effects on cRR were observed for extreme mean temperatures, relative humidity, and mean wind speeds within 8 days and for extreme atmospheric pressure within 14 days.

CONCLUSION

Extreme weather events impact ERV rates for acute pharyngitis. Extremely low temperatures, high relative humidity, high atmospheric pressure, and low and high wind speeds were risk-promoting factors.

A scoping review of Rasch analysis and item response theory in otolaryngology: Implications and future possibilities

Objective

Item response theory (IRT) is a methodological approach to studying the psychometric performance of outcome measures. This study aims to determine and summarize the use of IRT in otolaryngological scientific literature.

Methods

A systematic search of the Medline, Embase, and the Cochrane Library databases was performed for original English-language published studies indexed up to January 28, 2023, per the following search strategy: ("item response theory" OR "irt" OR "rasch" OR "latent trait theory" OR "modern mental test theory") AND ("ent" OR "otorhinolaryngology" OR "ear" OR "nose" OR "throat" OR "otology" OR "audiology" OR "rhinology" OR "laryngology" OR "neurotology" OR "facial plastic surgery").

Results

Fifty-five studies were included in this review. IRT was used across all subspecialties in otolaryngology, and most studies utilizing IRT methodology were published within the last decade. Most studies analyzed polytomous response data, and the most commonly used IRT models were the partial credit and the rating scale model. There was considerable heterogeneity in reporting the main assumptions and results of IRT.

Conclusion

IRT is increasingly being used in the otolaryngological scientific literature. In the otolaryngology literature, IRT is most frequently used in the study of patient-reported outcome measures and many different IRT-based methods have been used. Future IRT-based outcome studies, using standardized reporting guidelines, might improve otolaryngology-outcome research sustainably by improving response rates and reducing patient response burden.

Level of evidence

2.

Treatment adherence to olfactory training: a real-world observational study

BACKGROUND

Olfactory training (OT) is considered an effective intervention for most causes of smell loss and is recommended as a long-term treatment. However, the treatment adherence of OT remains unclear. This study aims to identify the frequency and causalities for lack of adherence to OT.

METHODS

In this prospective study, 53 patients previously diagnosed with olfactory dysfunction (OD), who were recommended to perform OT, were enrolled. Patients underwent olfactory testing using Sniffin' Sticks for threshold, discrimination, and identification (TDI) and a subjective numeric rating scale (NRS) at a baseline and follow-up visit. In addition, patients answered a six-item treatment adherence questionnaire. The primary outcome measures were clinically relevant improvements according to the TDI (>=5.5) and NRS (>=5.5) scores.

RESULTS

Out of 53 patients, 45 performed OT. Among patients who performed OT, 31% discontinued the use of OT on their own due to a self-perceived improvement, while 51% discontinued use due to lack of improvements in olfaction. In these patients, the average duration of OT use was five months. After controlling for baseline duration of OD, baseline TDI score and smell loss aetiologies, discontinuing OT due to a lack of self-perceived improvement remained significantly associated with worse TDI and NRS outcomes at follow-up.

CONCLUSIONS

Our data show that therapeutical adherence to OT is low, regardless of patients' perception of olfactory function. Olfactory improvement leads to decreased training due to satisfaction, while lack of improvement leads to non-adherence based on disappointing subjective outcome. Patients should be advised to perform OT consistently.

Impact of the COVID-19 pandemic on management of surgically treated laryngeal squamous cell carcinoma

The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted the treatment of cancer patients, particularly in terms of treatment choices. This study aimed to assess the effects of the COVID-19 pandemic on the management of surgically treated laryngeal squamous cell carcinoma (LSCC) patients, focusing specifically on changes in treatment modalities. We retrospectively analyzed the data from 102 patients who underwent surgical treatment for LSCC between January 1, 2019, and December 31, 2021, at our tertiary medical center. Patient demographics, histological characteristics, and treatment modalities were extracted from electronic medical records and compared between two time periods: pre-COVID-19 and during COVID-19, marked by the introduction of the hospital entry triage. Of the total patients, 53 (52%) were in the pre-COVID-19 group, and 49 (48%) were in the COVID-19 group. No significant differences in patient characteristics at the initial work-up were observed between the two groups. However, a significant shift in treatment modalities was noted. Fewer patients received postoperative adjuvant therapy in the COVID-19 group (70.5%) compared to the pre-COVID-19 group (95.5%). Importantly, this change did not significantly impact the one-year overall survival (OS) rates. The reduction in the use of postoperative adjuvant therapy during the COVID-19 pandemic may be attributed to efforts to minimize hospital visits due to the risk of COVID-19 infection. Further research is warranted to validate these findings and to investigate the potential effects of such changes in treatment modalities on the long-term survival.

Platelet-to-lymphocyte ratio might predict the response to dupilumab treatment for patients with nasal polyposis

BACKGROUND

Dupilumab is a monoclonal antibody against interleukin 4 receptor alpha and has proven to be clinically effective in treating patients with chronic rhinosinusitis with nasal polyps (CRSwNP). However, a certain number of patients are non- or partial responders. This study aims to investigate the relevance of inflammatory markers with regard to therapy response to dupilumab in CRSwNP patients.

METHODS

All patients with CRSwNP treated with dupilumab at a tertiary healthcare center with available pretreatment inflammatory markers were included. The values of pretreatment neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were associated with the outcome. Patients were stratified according to the respective median value (> median was considered high). The binary logistic regression was performed with regard to total treatment response (post-treatment total nasal polyp score (NPS) 0).

RESULTS

A total of 65 CRSwNP patients with available pretreatment peripheral blood values were included in the study. The mean pre- and post-treatment total NPS values were 4.3 ± 1.9 and 1.2 ± 1.6, respectively. High PLR (> 131.2) was independently associated with a 3.9-fold higher probability of reaching the NPS value of 0 in the multivariable analysis. On the other hand, High NLR (> 1.9) did not significantly associate with the outcome.

CONCLUSIONS

The current study provides insights into the potential positive predictive value of the high PLR (> 131.2) in CRSwNP patients regarding treatment with dupilumab. There is a need for further prospective studies for validation of these results, especially in cohorts of patients with severe CRSwNP.

Low free triiodothyronine and immune-related hyperthyroidism are associated with overall and progression-free survival in head and neck squamous cell carcinoma treated with pembrolizumab

INTRODUCTION

Thyroid function is frequently impaired in recurrent/metastatic head and neck squamous cell carcinoma (R/M HNSCC). In patients treated with pembrolizumab, immune-related adverse events (irAEs) of the thyroid are common. However, the prognostic significance of baseline and on-treatment thyroid dysfunction is currently unclear.

METHODS

This study included 95 patients who received pembrolizumab for R/M HNSCC between 2016 and 2022. Baseline thyroid status, according to serum hormone levels, and irAEs were assessed. Univariable and multivariable Cox regression analyses were performed for overall survival (OS) and progression-free survival (PFS). Furthermore, the best overall response according to the prognostic groups was examined.

RESULTS

Low fT3 (HR: 2.52, p = 0.006), immune-related hyperthyroidism (HR: 0.11, p = 0.038), ECOG performance status ≥2 (HR: 3.72, p = 0.002), and platinum-refractory disease (HR: 3.29, p = 0.020) were independently associated with OS. Furthermore, immune-related hyperthyroidism was associated with longer PFS (HR: 0.13, p = 0.007), a higher objective response rate (83% vs. 31%, p = 0.018), and a higher disease control rate (100% vs. 43%, p = 0.008). Thyroid-related autoantibodies were elevated in 40% of thyroid irAEs cases with available measurements. Out of 16 thyroid irAEs, 15 occurred in patients with fT3 above the lower limit of normal.

CONCLUSION

Low fT3 was associated with worse OS. Immune-related hyperthyroidism was correlated with both improved OS and PFS. Baseline fT3 assessment and close on-treatment monitoring of serum thyroid levels may be valuable for risk stratification in R/M HNSCC patients receiving pembrolizumab.

Early on-treatment C-reactive protein and its kinetics predict survival and response in recurrent and/or metastatic head and neck cancer patients receiving first-line pembrolizumab

PURPOSE

First-line immune checkpoint blockade has improved the prognosis of recurrent and/or metastatic head and neck squamous cell carcinoma (R/M HNSCC), but response rates remain low. In this study, we aimed to investigate the prognostic value of CRP and its early kinetics to predict response and survival in R/M HNSCC.

METHODS

A total of 87 patients who received first-line pembrolizumab for R/M HNSCC were analyzed. Three-fold cross-validation was used to estimate cut-off points of CRP at baseline and on-treatment (day 40 ± 10). Treatment response and survival were analyzed according to early CRP kinetics. The neutrophil-to-lymphocyte ratio (NLR) was used as a benchmark for the prognostic performance of CRP.

RESULTS

On-treatment CRP below 2 mg/dl, 4x the upper limit of normal (ULN), was associated with increased overall survival (OS), while on-treatment CRP below 3 mg/dl (6x ULN) was correlated with a higher disease control rate (DCR) and increased progression-free survival (PFS). CRP flare-responders and CRP responders showed a higher DCR and longer PFS than CRP non-responders. An NLR above 6 was a negative prognosticator for progression. In multivariable analysis, on-treatment CRP prevailed as the only significant prognosticator for OS (HR: 4.97, CI95%: 2.18-11.32, p < 0.001) and PFS (HR: 2.07, CI95%: 1.07-3.99, p = 0.030).

CONCLUSION

On-treatment CRP was identified as a prognostic biomarker for objective response and survival in R/M HNSCC patients receiving first-line pembrolizumab and could be easily incorporated into clinical practice as a widely available and cost-effective biomarker.

The "real life" efficacy of dupilumab is independent of initial polyp size and concomitant steroids in CRSwNP

BACKGROUND

Dupilumab significantly improves symptom control in chronic rhinosinusitis with nasal polyps (CRSwNP). Patients with large polyps at the initiation of treatment (total polyp score (TPS) ≥ 5) have been the focus in published studies. Patients with significant burden of disease but small polyps (TPS ≤ 4) have not yet been evaluated for clinical response. This study set out to evaluate the benefit of dupilumab treatment on cohorts of small (TPS ≤ 4) compared to large polyps (TPS ≥ 5). Furthermore, benefit of concomitant oral and/or nasal steroid therapy has been evaluated.

METHODS

97 patients with CRSwNP, who were begun on dupilumab between January 2020 and October 2021, were included. All patients were followed-up for 6 months. At each visit they underwent nasal endoscopy, smell identification tests and filled out validated patient questionnaires.

RESULTS

Significant drops in TPS were seen in both patient groups after 6 months of therapy, dropping from a median score of 3 to 0 and from 6 to 2 in patients with small and large polyps respectively. Furthermore, a linear mixed model calculated a drop of 22% and 24% in TPS per month in patients with small and large polyps respectively with no significant difference in rate of decline. Finally the model showed that neither oral nor nasal steroids influenced the rate of response to dupilumab therapy.

CONCLUSIONS

Polyp size at the initiation of dupilumab therapy and whether patients continue to take steroid therapy does not appear to influence effectiveness of dupilumab treatment.

Experience With the New Active Transcutaneous Bone-Conduction Implant With Smaller Dimensions

OBJECTIVE

Recently, the Bonebridge 602 implant was introduced. Its smaller dimensions facilitate implantation even in surgically demanding cases. However, in extreme anatomical conditions, implant lifts are still required. We intended to report on the medical and audiological outcomes of all patients implanted with the implant with a secondary focus on the safety, efficacy, and feasibility of the use of 1-mm lifts.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary academic center.

METHODS

We retrospectively analyzed all patients implanted with the Bonebridge 602. Patient demographics and surgically-specific data were collected from the medical charts. Furthermore, audiological results were assessed. Outcomes were compared between implantations with versus without lifts.

RESULTS

Twenty-one devices were implanted during the study period. Satisfactory audiological results were observed, while no intra- or postoperative adverse events occurred. The majority of patients were daily users at the end of the observation period (n = 20/21, 95.2%), and one patient (n = 1/21, 4.8%) was a nonuser after 6 months of use because of subjective dissatisfaction. Due to anatomical considerations, 1-mm lifts were used in 4 implantations (19.0%). The application of lifts did not result in prolonged surgical times, complications, or shorter time of use, nor did it negatively affect audiometric results.

CONCLUSION

Implantations with the new and smaller Bonebridge were associated with gratifying medical and audiological outcomes. Still, in extreme anatomical conditions, 1-mm lifts are necessary. Nonetheless, surgical placement with the help of lifts seems safe, effective, and feasible, and is a viable option in cases with challenging anatomies due to previous surgeries or anomalies.

Meteorological extremes and their impact on tinnitus-related emergency room visits: a time-series analysis

PURPOSE

Extreme weather events are rising due to the accelerating pace of climate change. These events impact human health and increase emergency room visits (EV) for many morbidities. Tinnitus is a common cause of EVs within otolaryngology in Germany and Austria. The effect of extreme weather conditions on tinnitus-related EVs is unknown.

METHODS

A total of 526 tinnitus-related EVs at a tertiary care hospital in Vienna were identified. A distributed lag non-linear model with a maximum lag period of 14 days was fitted to investigate the immediate and delayed effect of single-day and prolonged (three-day) extreme atmospheric pressure, relative humidity, mean temperature, precipitation and mean wind speed on EV rates. Extreme conditions were defined as the 1st, 5th, 95th, and 99th percentile of the meteorological variables. Relative risk (RR) is defined as risk for tinnitus-related EVs at an extreme condition compared to the risk at the median weather condition. Cumulative RR (cRR) is the total cumulated EV risk for a given time period.

RESULTS

High relative humidity increased same-day RR for tinnitus-related EVs to 1.75. Both low and high atmospheric pressure raised cRR as early as three days after an event to a maximum of 3.24. Low temperatures mitigated cRR within 4 days, while high temperatures tended to increase risk. Prolonged precipitation reduced cRR within one day.

CONCLUSION

Extreme meteorological conditions are associated with tinnitus-related EV rates. Further investigation into potential causative links and underlying pathophysiological mechanisms is warranted.

A homozygous AP3D1 missense variant in patients with sensorineural hearing loss as the leading manifestation

Loss-of-function variants in AP3D1 have been linked to Hermansky-Pudlak syndrome (HPS) 10, a severe multisystem disorder characterized by oculocutaneous albinism, immunodeficiency, neurodevelopmental delay, hearing loss (HL), and neurological abnormalities, fatal in early childhood. Here, we report a consanguineous family who presented with presumably isolated autosomal recessive (AR) HL. Whole-exome sequencing was performed on all core family members, and selected patients were screened using array-based copy-number analysis and karyotyping. Candidate variants were validated by Sanger sequencing and assessed in silico. A homozygous, likely pathogenic p.V711I missense variant in AP3D1 segregated with the HL. The family was characterized by thorough medical and laboratory examination. The HL was consistent across patients and accompanied by neurological manifestations in two brothers. The sole female patient was diagnosed with premature ovarian failure. Further findings, including mild neutropenia and reduced NK-cell cytotoxicity in some as well as brain alterations in all homozygous patients, were reminiscent of HPS10, though milder and lacking the characteristic albinism. Previously unrecognized, milder, isolated HL was identified in all heterozygous carriers. A protein model indicates that the variant interferes with protein-protein interactions. These results suggest that a missense variant alters inner-ear-specific functions leading to HL with mild HPS10-like symptoms of variable penetrance. Milder HL in heterozygous carriers may point towards semi-dominant inheritance of this trait. Since all previously reported HPS10 cases were pediatric, it is unknown whether the observed primary ovarian insufficiency recapitulates the subfertility in Ap3d1-deficient mice.

Efficacy and safety of switching between biologics in chronic rhinosinusitis with nasal polyps or N-ERD

BACKGROUND AND OBJECTIVE

The effectiveness of biologics in chronic rhinosinusitis with nasal polyps (CRSwNP) is well-established. However, real-world experience on the effectiveness of transitioning between two monoclonal antibodies is scarce. Therefore, we aimed to analyze the safety and efficacy of antibody switching in treatment of chronic rhinosinusitis.

METHODS

All patients with CRSwNP or nonsteroidal anti-inflammatory drugs-exacerbated respiratory disease (N-ERD) requiring a switch between biologics were retrospectively studied. Analysis included changes in polyp size, quality of life parameters, asthma control, and side effects.

RESULTS

Out of 195 patients treated with biologics for CRSwNP or N-ERD in our center, 23 (11.8%) required transition to a different monoclonal antibody. The majority switched from omalizumab to dupilumab (17/23, 73.9%), mostly due to inadequate symptom control. Nine out of these 17 patients (52.9%) were switched without a washout period. All patients showed significant improvement in nasal polyp score, asthma control test and sino-nasal outcome test-22 after changing to dupilumab. Keratoconjunctivitis sicca was the side-effect (4.3%) reported after the switch from omalizumab to dupilumab, which lead to termination of therapy in one patient. Due to limited sample size, other antibody transitions were reported in a descriptive manner.

CONCLUSION

The transition to dupilumab is an effective option in patients with inadequate treatment response or side-effects of omalizumab in nasal polyposis. Our preliminary results indicate that a wash-out period may not be necessary when switching between biologics, however, these findings require further investigations. Other monoclonal antibody transitions also show promising results, but warrant validations in larger cohorts due to small patient samples in our study.

Fluctuations in emergency department visits related to acute otitis media are associated with extreme meteorological conditions

Background

Climate change has been associated with a higher frequency of extreme weather events, resulting in an overall increase in morbidity and mortality. Acute otitis media (AOM) is one of the most common otolaryngological infections and accounts for 1.5% of emergency department visits. This study aimed to identify associations between extreme weather events and the immediate and delayed risks for AOM-related emergency department visits (EV).

Methods

A total of 1,465 AOM-related EVs were identified in the Vienna General Hospital between 2015 and 2018. A distributed lag non-linear model was applied to evaluate the relationship between extreme weather conditions and the total number of AOM-related EVs per day. The relative risk (RR) and cumulative RR (cRR) of single-day events and extended weather events over three days were analyzed over a lag period of 14 days.

Results

AOM-related EVs showed a pronounced seasonality, with the highest occurrence during winter. Single-day weather events affected AOM-related EVs only at high relative humidity. Prolonged extreme weather conditions over three days, however, significantly increased the cRR for AOM-related EVs to 3.15 [1.26-7.88; p = 0.014] and 2.14 [1.14-4.04; p = 0.018] at mean temperatures of -4°C (1^st-percentile - p₁) and 0°C (p₅) on the same day. Relative humidity of 37% (p₁) decreased RR to 0.94 [0.88-0.99; p = 0.032] on day 7, while extremely high humidity of 89% (p₉₉) led to an increased cRR of 1.43 [1.03-2.00; p = 0.034] on day 7. Heavy prolonged precipitation of 24mm (p₉₅) reduced cRR beginning day 4 up until day 14 to 0.52 [0.31-0.86; p = 0.012]. Prolonged low atmospheric pressure events of 985hPa (p₅) reduced the RR to 0.95 [0.91-1.00; p = 0.03], whereas extremely high atmospheric pressure events of 1013hPa (p₉₉) increased the RR to 1.11 [1.03-1.20; p = 0.008]. Extremely low wind speeds significantly diminished the RR of AOM-related EVs.

Conclusions

While single-day extreme weather events had little impact on the occurrence of AOM-related EVs, extended periods of extreme temperatures, relative humidity, precipitation, wind speeds and atmospheric pressure significantly impacted the RR for AOM-related EVs. These findings could help improve healthcare resource allocation in similar climates and aid in educating patients about the role of environmental factors in AOM.

[Clinical features and CT findings of fibrosing mediastinitis associated pulmonary hypertension]

Objective: To investigate the clinical features and CT findings of pulmonary hypertension (PH) in patients with fibrosing mediastinitis (FM). Methods: Thirteen patients with FM diagnosed between September 2015 and June 2022 were studied retrospectively, including patients with PH (FM-PH group) and patients without PH (FM group) confirmed on right heart catheterization. The t test of two independent samples, Mann-Whitney U rank sum and Fisher's test were used to compare the general information, symptoms, laboratory examination, right ventricular and pulmonary artery measurement data and pulmonary artery CT findings between the two groups, respectively. Results: Compared with the 7 FM patients aged 28-79 (60.00±17.69) years, the 6 patients in the FM-PH group, aged from 60 to 82 (68.83±8.35) years, had more peripheral edema, lower percentage of PaO₂, wider inner diameters of pulmonary artery and right ventricle, a higher ratio of right ventricle and left ventricular transverse diameter, faster tricuspid regurgitation velocity and higher estimated systolic pulmonary artery pressure (P<0.05). There were no differences in BNP levels and tricuspid annular plane systolic excursion between groups (P>0.05). Of the 6 patients with PH, 5 had precapillary PH and 1 had mixed PH. Except that the pulmonary vascular resistance in patients of the FM-PH group was significantly higher than that in the FM group (P<0.05), there were no significant differences in cardiac output, mixed venous oxygen saturation and pulmonary capillary wedge pressure between the two groups. CT pulmonary angiography (CTPA) showed pulmonary artery and vein stenosis. Patients in the FM-PH group had more severe stenosis and occlusion of pulmonary artery and pulmonary vein (P<0.05), and more involvement of multiple pulmonary veins (P<0.05). Conclusions: The clinical manifestation of FM complicated with PH is related to the degree of involvement of pulmonary artery, vein and airway. It is recommended that the disease be evaluated in combination with multiple parameters such as clinical manifestations, cardiac ultrasound, right cardiac catheter and CTPA.

Extreme weather conditions influence the frequency of epistaxis-related emergency room visits

BACKGROUND

Climate change has been associated with an increase in extreme weather conditions. The aim of this study was to identify environmental factors and the effect of extreme weather events (95th percentile) on the risk for epistaxis-related emergency room visits (EV).

METHODS

A total of 2179 epistaxis-related EVs were identified between 2015 and 2018. A distributed lag non-linear model was fitted to investigate the relationship between extreme weather conditions and the total number of epistaxis-related EVs per day. Cumulative relative risk (cRR) is defined as the cumulated daily risk of EV for epistaxis within a stated period after an extreme weather condition compared to the risk of EV at the median value of that weather condition.

RESULTS

At a mean daily temperature of 27°C (P95), cRR for epistaxis-related EV was 2.00. At a relative humidity of 39% (P5), cRR was highest on day 3 at 1.59, while extremely high humidity (92%, P99) led to a decreased cRR of 0.7 on day 1. Intense precipitation of 24mm (P99) reduced the cRR on day 3 to 0.38. For prolonged extreme conditions over three days, extremely low wind speed, as well as both high and low atmospheric pressure events, diminished cRR.

CONCLUSIONS

Extreme temperatures, relative humidity, and precipitation, as well as extended periods of extreme wind speeds and atmospheric pressure, significantly impact cRR for epistaxis-related EVs.

Olfactory Dysfunction: Etiology, Diagnosis, and Treatment

BACKGROUND

Disorders of the sense of smell have received greater attention because of the frequency with which they occur as a symptom of SARS-CoV-2 infection. Olfactory dysfunction can lead to profound reduction in quality of life and may arise from many different causes.

METHODS

A selective literature review was conducted with consideration of the current version of the guideline issued by the Association of the Scientific Medical Societies in Germany.

RESULTS

The cornerstones of diagnosis are the relevant medical history and psychophysical testing of olfactory function using standardized validated tests. Modern treatment strategies are oriented on the cause of the dysfunction. While treatment of the underlying inflammation takes precedence in patients with sinunasal dysosmia, olfactory training is the primary treatment option for other forms of the disorder. The prognosis is determined not only by the cause of the olfactory dysfunction and the patient's age, but also by the olfactory performance as measured at the time of diagnosis.

CONCLUSION

Options for the treatment of olfactory dysfunction are available but limited, depending on the cause. It is therefore important to carry out a detailed diagnostic work-up and keep the patient informed of the expected course and prognosis.

Chronic Rhinosinusitis Outcome Registry (CHRINOSOR): Establishment of an International Outcome Registry Driven by mHealth Technology

BACKGROUND

Real-world evidence (RWE) is a valuable instrument to better understand the patient journey and effectiveness of therapies. RWE on the prevalence of uncontrolled chronic rhinosinusitis (CRS) and CRS natural course of disease across Europe is scarce. In addition, there is limited RWE that enables comparison of the effectiveness of marketed therapies including topical or systemic corticosteroids, sinus surgery, or biologics.

OBJECTIVE

To establish an international CHRonic rhINOSinusitis Outcome Registry (CHRINOSOR) based on real-world data collection enabled by mobile health technology.

METHODOLOGY

A digital platform, Galenus Health, supporting patients and physicians in the management of chronic respiratory diseases, is used to collect data on patient profile, disease history, patient outcomes, and a set of relevant clinical outcomes. Adult patients with a diagnosis of CRS are eligible for inclusion.

RESULTS

A collaborative scientific network of 17 university ear-nose-throat (ENT) clinics from 10 European countries has been established with the aim to collect real-world data in a longitudinal and standardized manner. The Galenus Health digital platform is currently being implemented in these ENT clinics taking into account legal, privacy, and data security aspects. Up to 300 patients have already been included.

CONCLUSIONS

CHRINOSOR is a collaborative effort that aims at improving our understanding of CRS, its comorbidities, and the effectiveness of its treatments. Ultimately, these insights will guide us as scientific community to develop future care pathways informed by RWE.

The nasal microbiome in patients suffering from non-steroidal anti-inflammatory drugs-exacerbated respiratory disease in absence of corticosteroids

Chronic rhinosinusitis (CRS) is a chronic inflammatory disease phenotypically classified by the absence (CRSsNP) or presence of nasal polyps (CRSwNP). The latter may also be associated with asthma and hypersensitivity towards non-steroidal anti-inflammatory drugs (NSAID) as a triad termed NSAID-exacerbated respiratory disease (N-ERD). The role of the microbiome in these different disease entities with regard to the underlying inflammatory process and disease burden is yet not fully understood. To address this question, we measured clinical parameters and collected nasal samples (nasal mucosal fluids, microbiome swabs from middle meatus and anterior naris) of patients suffering from CRSsNP (n=20), CRSwNP (n=20) or N-ERD (n=20) as well as from patients without CRS (=disease controls, n=20). Importantly, all subjects refrained from taking local or systemic corticosteroids or immunosuppressants for at least two weeks prior to sampling. The nasal microbiome was analyzed using 16S rRNA gene amplicon sequencing, and levels of 33 inflammatory cytokines were determined in nasal mucosal fluids using the MSD platform. Patients suffering from N-ERD and CRSwNP showed significantly worse smell perception and significantly higher levels of type 2 associated cytokines IL-5, IL-9, Eotaxin and CCL17. Across all 4 patient groups, Corynebacteria and Staphylococci showed the highest relative abundances. Although no significant difference in alpha and beta diversity was observed between the control and the CRS groups, pairwise testing revealed a higher relative abundance of Staphylococci in the middle meatus in N-ERD patients as compared to CRSwNP (p<0.001), CRSsNP (p<0.01) and disease controls (p<0.05) and of Lawsonella in patients suffering from CRSwNP in middle meatus and anterior naris in comparison to CRSsNP (p<0.0001 for both locations) and disease controls (p<0.01 and p<0.0001). Furthermore, we observed a positive correlation of Staphylococci with IL-5 (Pearson r=0.548) and a negative correlation for Corynebacteria and Eotaxin-3 (r=-0.540). Thus, in patients refraining from oral and nasal corticosteroid therapy for at least two weeks known to alter microbiome composition, we did not observe differences in microbiome alpha or beta diversity between various CRS entities and disease controls. However, our data suggest a close association between increased bacterial colonization with Staphylococci and decreased colonization by Corynebacteria as well as increased type 2 inflammation.

Eating behavior in patients with smell loss

Background

The objective of this study was to determine how clinical characteristics and validated quality of life (QoL)-measures are associated with eating behavior in patients with olfactory dysfunction (OD).

Methods

For this cross-sectional study, 150 OD patients of different causes were retrospectively recruited. Olfactory function was measured using the Sniffin’ Sticks (TDI), while olfactory-related QoL was evaluated with the Questionnaire of OD negative and positive statements (QOD-NS and QOD-PS). The importance of olfaction was measured using the Importance of Olfaction Questionnaire (IOQ). The Dutch Eating Behavior Questionnaire (DEBQ) assessed eating behavior based on emotional, external, and restrained eating. Associations were sought between eating behavior metrics (as dependent variables) with clinical characteristics and olfactory-related outcome measures.

Results

Emotional, external, and restrained eating behavior deviating from normative standards were reported in 54%, 71.3%, and 68% of patients, respectively. Multivariate regression modeling revealed that emotional eating was associated with age (ß = –0.227, p = 0.032), the body mass index (BMI, ß = 0.253, p = 0.005), the TDI (ß = 0.190, p = 0.046), and the QOD-NS (ß = 0.203, p = 0.049). External eating was associated with OD duration (ß = 0.291, p = 0.005), the TDI (ß = 0.225, p = 0.018), the QOD-PS (ß = –0.282, p = 0.008), and the IOQ (ß = 0.277, p = 0.004). Restrained eating was associated with age (ß = 0.216, p = 0.033), the BMI (ß = 0.257, p = 0.003), male gender (ß = –0.263, p = 0.002), and the IOQ (ß = 0.332, p &lt; 0.001).

Conclusion

Clinical characteristics and olfactory outcome measures differentially impact eating styles in OD patients. Our study’s results highlight the importance of considering unfavorable changes in eating behavior during clinical counseling.

Pediatric olfactory home testing using regular household items: A cross-over validation study

OBJECTIVE

To develop an olfactory test that can be conducted by an untrained person using common household items and to introduce a German version of the Chemosensory Pleasure Scale for Children (CPS-C(de)).

METHODOLOGY

This olfactory home test was developed in phases including evaluation of odors for suitability in a home setting. Parents of 50 children (ages 6-17) were then equipped with instruction manuals and participants were tested twice in a cross-over design. A validated pediatric olfactory test (the Universal Sniff test (U-Sniff)) served as the comparative gold standard. Additionally, a Chinese-English-German "back-and-forth" translation was conducted to establish the CPS-C(de) and was tested for empirical validity.

RESULTS

Fourteen items were tested for feasibility, and all were identified on a sufficient rate (≥66%, mean ± SD of 93.3% ± 9.5%). Bland Altman Plot analysis between home testing and the U-Sniff test was nearly identical (bias = 0.04). CPS-C(de) showed similar results to the original Chinese version and a moderate correlation was found between CPS-C(de) scores and Body Mass Index of children (r₃₀ = -0.527, p = 0.003).

CONCLUSIONS

Remote olfactory testing in children using household items is feasible. The CPS-C(de) may be of value for future olfactory studies.

Dedicated Olfaction and Taste Items do not Improve Psychometric Performance of the SNOT-22

Objective

Previous work has shown the chemosensory dysfunction item of the 22‐item Sinonasal Outcome Test (SNOT‐22) that assesses problems with “taste/smell” has poor psychometric performance compared with other items on the SNOT‐22, which we have hypothesized is due to the simultaneous assessment of two different senses. Our aim was to determine whether distinct smell and taste items in the SNOT‐22 would improve psychometric performance.

Methods

One hundred and eighty‐one CRS patients were recruited and completed the SNOT‐22. Additional items querying problems with the senses of “smell” and “taste,” using the same response scale and recall period were given to study participants. Item response theory (IRT) was used to determine IRT parameters, including item discrimination, difficulty, and information provided by each SNOT‐22 item.

Results

Confirming previous studies, the chemosensory item of the SNOT‐22 (reflecting “taste/smell”) had poor psychometric performance. Use of a distinct smell or taste item instead of the combined “taste/smell” item did not improve psychometric performance. However, a dedicated smell question resulted in a left shift of threshold parameters, showing that the dedicated smell item better captures moderate CRS disease burden than the original taste/smell item of the SNOT‐22, which by virtue of near‐identical IRT parameters appears to more greatly reflect problems with taste.

Conclusions

A dedicated smell‐ or taste‐specific item, rather than the combined “taste/smell” item currently in the SNOT‐22 does not provide significantly greater psychometric performance. However, a dedicated smell item may better capture moderate CRS disease burden compared with the current chemosensory item on the SNOT‐22. Laryngoscope, 132:1644–1651, 2022

Depression Symptoms and Olfactory-related Quality of Life

Objectives

Patients with olfactory dysfunction (OD) frequently report symptoms of depression. The objective of this study was to determine how clinical characteristics and olfactory‐related quality of life (QoL) measures associate with the likelihood for major depressive disorders (MDDs).

Methods

A total of 192 OD patients were included. Olfactory function was measured using all three subtests of the Sniffn' Sticks test. Olfactory‐related quality of life (QoL) was evaluated using the Questionnaires of Olfactory Dysfunction (QOD)‐negative (NS) and ‐positive statement (PS). The likelihood for MDD was assessed using the Patients Health Questionnaire‐2 (PHQ‐2). Demographics and disease‐specific variables (etiology and duration of OD) were collected. Univariate and multivariable analyses were used to associate disease‐specific variables and the QOD with the outcome of the PHQ‐2. Additionally, the predictive ability of the QOD‐NS to predict depressive symptoms was calculated.

Results

In univariate analysis, COVID‐19 related smell loss, the QOD‐NS, and the QOD‐PS were significantly associated with the PHQ‐2. In multivariable analyses adjusting for QoL measures, the QOD‐NS (ß = 0.532, p < 0.001) and sinonasal OD (compared with postinfectious OD) were significantly associated with the PHQ‐2 (ß = 0.146, p = 0.047). When omitting QoL measures from multivariable analyses, only COVID‐19 related OD (compared with postinfectious OD) was significantly associated with the PHQ‐2 (ß = 0.287, p = 0.009). A QOD‐NS score > 20.5 had 70.13% sensitivity and 76.32% specificity for detecting symptoms of depression.

Conclusion

Our results suggest that COVID‐19 related OD might be associated with a higher likelihood for MDD. Furthermore, we showed that the QOD‐NS score might be helpful to predict symptoms of depression in OD patients.

Level of Evidence

4 Laryngoscope, 132:1829–1834, 2022

Chronic rhinosinusitis symptoms differentially impact the likelihood of major depressive disorders

OBJECTIVES

The extent to which sinonasal symptoms impact the likelihood of major depressive disorders in chronic rhinosinusitis patients with nasal polyposis (CRSwNP) remains incompletely characterized. In this study, we sought to determine whether individual symptom clusters differentially impact the likelihood of depression in a cohort of CRSwNP patients.

METHODS

We retrospectively included 77 patients with CRSwNP. The severity of sinonasal symptoms was assessed using the 22-item Sino-Nasal Outcome Test (SNOT-22) and grouped according to a previously validated four-subdomain structure: nasal, otologic/facial pain, sleep, and emotional subdomains. The likelihood of major depressive disorders was assessed using the Patient Health Questionnaire-2 (PHQ-2). The clinical characteristic of symptom severity (nasal polyp size) and disease-specific information, such as the number of previous sinonasal surgeries, were also collected.

RESULTS

The sleep subdomain was most strongly associated with the likelihood of major depressive disorders, followed by the otologic/facial pain subdomain, after controlling for demographics and clinical indicators of symptom severity (nasal polyp size). We found a SNOT-22 score ≥ 30.5 to be an accurate indicator of scoring higher than or equal to 2 on the PHQ-2 in CRSwNP patients. This had a sensitivity of 83.33% and a specificity of 75.47%.

CONCLUSION

Distinct sinonasal symptom clusters differentially impact the likelihood of depression in CRSwNP patients. Raising awareness for those with severe sinonasal symptomatology might help identify more patients with a higher probability of comorbid depression.

Level of Evidence: 4.

Progressive Sensorineural Hearing Loss in Vibrant Soundbridge Users Requiring Cochlear Implantation

Less than 20% of patients with sensorineural hearing loss (HL) provided with the Vibrant Soundbridge (VSB) experience a progressive HL and warrant cochlear implantation (CI). The aim of this study was to identify possible predictors of progressive HL prior to VSB implantation. This retrospective study included all consecutive ears with sensorineural HL provided with the VSB between 1998 and 2016. The patient cohort was divided in a study group comprising patients who underwent CI (CI group) after years of VSB usage and those who did not require VSB replacement during the observational time (control group). Pre- and postoperative pure-tone audiometry thresholds were compared among the two groups. Fifteen out of 81 VSB devices (18.5%) required a CI. The CI group had higher preoperative air-conduction (AC) thresholds than the control group (64.3 ± 8.9 dB vs. 56.3 ± 12.9 dB; p = 0.007) at the time of the VSB implantation. On average, the CI group was significantly younger (39.1 ± 12.3 years vs. 52.6 ± 16.2 years; p = 0.003). In conclusion, VSB users with higher preoperative AC thresholds and younger age at the time of VSB implantation might be at risk for progressive HL within the upcoming eight years and need a further CI surgery. Preoperative counseling is particularly advisable in this patient group.

Long-lasting olfactory dysfunction in COVID-19 patients

Objectives

Olfactory dysfunction (OD) is a common symptom of Coronavirus Disease 2019 (COVID-19). Although many patients have been reported to regain olfactory function within the first month, long-term observation reports vary. Therefore, we aimed to assess the course of chemosensory function in patients diagnosed with COVID-19 within 3–15 months after the infection.

Methods

One hundred and two patients (71 females and 31 males; mean age 38.8 years) diagnosed with laboratory-confirmed COVID-19 and subjective OD participated in this single-center study 111–457 days after onset of OD. Patients first performed chemosensory tests at home, followed by psychophysical testing (Sniffin’ Sticks (TDI), 27-item Candy Smell Test (CST), Taste Strips Test (TST)) in the clinic. Questionnaires regarding importance of olfaction (IOQ) and olfactory-specific quality of life (QOD) were applied at both timepoints.

Results

After a mean 216 days (SD 73; range 111–457) between OD onset and follow-up testing, the mean Sniffin’ Sticks (TDI) score was 27.1 points (SD 5.8; range 4.25–38.5): 4.0% were anosmic, 72.5% hyposmic, and 23.5% normosmic. At follow-up testing, 73.5% of patients reported improvement, 5.9% deterioration, and 20.6% no change in OD. Moreover, full recovery of self-perceived smell, flavor, and taste was not observed. According to questionnaires, the individual importance of smell did not change, but participants showed improvement in OD-related quality of life (p < 0.001) and had increased parosmia scores (p = 0.014) at follow-up.

Conclusion

Our results show that long-lasting OD after SARS-CoV-2 infection is a common symptom. The majority of patients had OD in the range of hyposmia, which was confirmed by comprehensive smell tests.

Multi-institutional minimal clinically important difference of the 22-item Sinonasal Outcome Test in medically managed chronic rhinosinusitis

BACKGROUND

With a rapid proliferation of clinical trials to study novel medical treatments for CRS, the objective of this study was to study the minimal clinically important difference (MCID) of the 22-item Sinonasal Outcome Test (SNOT-22) in medically-managed CRS patients.

METHODS

A total of 183 medically-treated CRS patients were recruited. All patients completed a SNOT-22 at enrollment and subsequent follow up visit. Distribution and anchor-based methods were used for MCID calculation. These data were combined with data from a previously published study on SNOT-22 MCID in 247 medically managed CRS patients to determine a final recommended MCID value using the combined cohort of 430 patients.

RESULTS

In our cohort, distribution- and anchor-based methods-using both sinus-specific and general health anchors-provided greatest support for a 12-point SNOT-22 MCID, which had approximately 55% sensitivity but 81% specificity for detecting patients explicitly reporting improvement in their sinus symptoms and general health. In the combined cohort of 430 patients, we also found greatest support for a 12-point SNOT-22 MCID, which had approximately 57% sensitivity and 81% specificity for detecting patients explicitly reporting improvement in their sinus symptoms and general health. We also find evidence that the MCID value may be higher in CRS patients without nasal polyps compared to those with nasal polyps.

CONCLUSIONS

Our results - which include data from patients from two different institutions and regions - confirm a SNOT-22 MCID of 12 in medically managed CRS patients. The SNOT-22 MCID was specific but not sensitive for identifying CRS patients experiencing improvement in symptoms or general health.

Olfactory-related Quality of Life Adjustments in Smell Loss during the Coronavirus-19 Pandemic

BACKGROUND

Previous studies provided the first evidence that the importance of olfaction decreases with the duration of olfactory dysfunction (OD).

OBJECTIVE

To evaluate differences in olfactory-related quality of life (QoL) between patients with new-onset and persistent smell loss (>4 weeks) during the coronavirus-19 (COVID-19) pandemic and patients with persistent postinfectious OD (PIOD) that were recruited before the pandemic.

METHODS

This was a retrospective study that included 149 patients with self-reported OD. The olfactory-related QoL was measured using the questionnaire of OD (QOD). The QOD measures the degree to which patients (i) adjust and cope with smell loss (QOD-positive statement [QOD-PS]), (ii) suffer from distorted odor perceptions (QOD-parosmia [QOD-PAR]), and (iii) suffer from smell loss in general (QOD-negative statement [QOD-NS]). Self-perceived chemosensory function, demographics, olfactory function, and duration of smell loss were evaluated. Analyses of variance were used to depict differences in QoL-outcomes between different OD groups.

RESULTS

All patients included during the COVID-19 pandemic reported an extensive loss of chemosensory functions of smell, taste, and flavor perception. Psychophysical retronasal screening testing showed olfactory impairments in more than half of these patients. One-way analysis of variance and posthoc tests revealed that the QOD-NS was significantly higher in the new-onset OD group than the PIOD group. At the same time, the QOD-PS score was significantly higher in the PIOD and the persistent COVID-19 OD group than in the new-onset OD group.

CONCLUSION

We showed that patients with persistent OD experienced better olfactory-related adjustment and lower QoL-impairment scores than those with recent-onset smell loss, suggesting that the olfactory-related QoL might change as a function of time after symptom onset.

Bitter Taste Disrupts Spatial Discrimination of Piperine-Evoked Burning Sensations: A Pilot Study

Simple Summary

The chemical senses smell, taste, and trigeminal sense enable us to interact with the environment and play an essential role in protecting us from hazardous events. It is theorized that capsaicin and piperine not only elicit burning, but also bitter sensations through bitter taste-responding gustatory receptor cells that possess special channels. Similar psychophysiological responses to capsaicin and piperine suggest that bitter taste might also disrupt the spatial discrimination to piperine-induced burning sensations. Results showed that bitter taste disrupted the spatial discrimination of piperine-evoked burning sensations, providing further evidence for a qualitative similarity between burning and bitter sensations and the usefulness of chemical irritants in spatial discrimination tasks.

Abstract

This study aimed to investigate the perceptual similarity between piperine-induced burning sensations and bitter taste using piperine-impregnated taste strips (PTS). This pilot study included 42 healthy participants. PTS of six ascending concentrations (1 mg, 5 mg, 10 mg, 15 mg, 20 mg, and 25 mg piperine/dL 96% ethanol) were presented at the anterior tongue, and participants rated perceived intensity and duration. Then, participants performed a spatial discrimination task in which they had to report which of the two strips presented to the anterior tongue contained an irritating stimulus when one strip was always a PTS while the other strip was impregnated with either a single taste quality (sweet or bitter) or a blank strip. Repeated measures one-way ANOVA revealed that burning sensations of higher concentrated PTS were perceived more intense and more prolonged compared to lower concentrated PTS. McNemar’s test showed that PTS were identified correctly significantly less often when presented with bitter strips compared to when presented with blank (p = 0.002) or sweet strips (p = 0.017). Our results showed that bitter taste disrupts the spatial discrimination of piperine-evoked burning sensations. PTS might serve as a basis for further studies on disease-specific patterns in chemosensory disorders.

Exploring possibilities for shortening the 22-item Sino-Nasal Outcome Test (SNOT-22) using item response theory

BACKGROUND

Even with a high-quality instrument, such as the 22-item Sino-Nasal Outcome Test (SNOT-22), patients can be overwhelmed by repeated completion of questionnaires, leading to nonadherence and reduced data quality. The aim of this study was to evaluate whether the SNOT-22 could be made more concise without losing the valuable information that it provides.

METHODS

A modern psychometric approach, item response theory (IRT), was used on a sample of 800 patients with chronic rhinosinusitis (CRS). The SNOT-22 was refined based on: (1) the item information criteria, retaining only items with above-average information; and (2) the total test information, retaining only the most discriminating items to cover at least 30% of the information within each subdomain. The preliminary validity and reliability of these refined scales were assessed using Cronbach's alpha and Pearson's correlation.

RESULTS

Using an IRT approach, we find that it may be possible to shorten the SNOT-22 to an 11-item and six-item version based on psychometric properties. Item information functions of the shortened 11-item and six-item scales demonstrate that both versions accurately covered the CRS symptom-severity continuum. Preliminary reliability and validity analysis showed that both refined scales had good to excellent reliability (Cronbach's alpha ≥ 0.80) and were highly associated with the original full-length scale (r ≥ 0.90).

CONCLUSION

IRT provides data-driven opportunities for the continuous development and refinement of the SNOT-22. While patient and provider input must be accounted for too, our results show that future revisions of the SNOT-22 could include significantly fewer items.

Item Response Theory for Psychometric Properties of the SNOT-22 (22-Item Sinonasal Outcome Test)

OBJECTIVE

The SNOT-22 (22-item Sinonasal Outcome Test) is a high-quality outcome measure that assesses chronic rhinosinusitis-specific quality of life. The aim of this study was to gain greater insight into the information provided by the SNOT-22 by determining its item-based psychometric properties.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care academic centers.

METHODS

This study used a previously described data set of the SNOT-22 completed by 800 patients with chronic rhinosinusitis. Item response theory graded response models were used to determine parameters reflecting item discrimination, difficulty, and information provided by each item toward the SNOT-22 subdomain to which it belonged.

RESULTS

The unconstrained graded response model fitted the SNOT-22 data best. Item discrimination parameters and total information provided showed the greatest variability within the nasal subdomain, and the item related to sense of smell/taste demonstrated the lowest discrimination and provided the least amount of information overall. The dizziness item provided disparately lower total information and discrimination in the otologic/facial pain subdomain. Items in the sleep and emotional subdomains generally provided high discrimination. While items in the nasal, sleep, and otologic/facial pain subdomains spanned all levels of difficulty, emotional subdomain items covered higher levels of difficulty, indicating greater information provided at higher levels of disease severity.

CONCLUSION

The item-specific psychometric properties of the SNOT-22 support it as a high-quality instrument. Our results suggest the need and possibility for revision of the smell/taste dysfunction item, for example its wording, to improve its ability to discriminate among the different levels of disease burden.

Biannual Differences in Interest Peaks for Web Inquiries Into Ear Pain and Ear Drops: Infodemiology Study

Background

The data retrieved with the online search engine, Google Trends, can summarize internet inquiries into specified search terms. This engine may be used for analyzing inquiry peaks for different medical conditions and symptoms.

Objective

The aim of this study was to analyze World Wide Web interest peaks for “ear pain,” “ear infection,” and “ear drops.”

Methods

We used Google Trends to assess the public online interest for search terms “ear pain,” “ear infection,” and “ear drops” in 5 English and non–English-speaking countries from both hemispheres based on time series data. We performed our analysis for the time frame between January 1, 2004, and December 31, 2019. First, we assessed whether our search terms were most relevant to the topics of ear pain, ear infection, and ear drops. We then tested the reliability of Google Trends time series data using the intraclass correlation coefficient. In a second step, we computed univariate time series plots to depict peaks in web-based interest. In the last step, we used the cosinor analysis to test the statistical significance of seasonal interest peaks.

Results

In the first part of the study, it was revealed that “ear infection,” “ear pain,” and “ear drops” were the most relevant search terms in the noted time frame. Next, the intraclass correlation analysis showed a moderate to excellent reliability for all 5 countries’ 3 primary search terms. The subsequent analysis revealed winter interest peaks for “ear infection” and “ear pain”. On the other hand, the World Wide Web search for “ear drops” peaked annually during the summer months. All peaks were statistically significant as revealed by the cosinor model (all P values <.001).

Conclusions

It can be concluded that individuals affected by otitis media or externa, possibly the majority, look for medical information online. Therefore, there is a need for accurate and easily accessible information on these conditions in the World Wide Web, particularly on differentiating signs and therapy options. Meeting this need may facilitate timely diagnosis, proper therapy, and eventual circumvention of potentially life-threatening complications.

Portable HEPA Purifiers to Eliminate Airborne SARS-CoV-2: A Systematic Review

OBJECTIVE

Current epidemiologic predictions of COVID-19 suggest that SARS-CoV-2 mitigation strategies must be implemented long-term. In-office aerosol-generating procedures pose a risk to staff and patients while necessitating examination room shutdown to allow aerosol decontamination by indwelling ventilation. This review summarizes the current state of knowledge on portable high-efficiency particulate air (HEPA) purifiers' effectiveness in eliminating airborne SARS-CoV-2 from indoor environments.

DATA SOURCES

Medline, Embase, Cochrane Databases, and the World Health Organization's COVID-19 Global Literature on Coronavirus Disease.

REVIEW METHODS

Data sources were systematically searched for original English-language published studies indexed up to January 14, 2021 per the following search strategy: ("HEPA" OR "High-efficiency" OR "High-efficiency particulate air" OR "Efficiency particulate" OR "Purifier" OR "Filter" OR "Cleaner" OR "Filtration") AND ("COVID" OR "COVID-19" OR "SARS-CoV-2" OR "Coronavirus"). Additional relevant studies were identified by searching the reference lists of included articles.

RESULTS

Eleven published studies have evaluated the effectiveness of portable HEPA purifiers in eliminating airborne SARS-CoV-2 with relevantly sized surrogate particles. Ten studies evaluated aerosols and submicron particles similar in size to SARS-CoV-2 virions. In all studies, portable HEPA purifiers were able to significantly reduce airborne SARS-CoV-2-surrogate particles. The addition of portable HEPA purifiers augmented other decontamination strategies such as ventilation.

CONCLUSION

Experimental studies provide evidence for portable HEPA purifiers' potential to eliminate airborne SARS-CoV-2 and augment primary decontamination strategies such as ventilation. Based on filtration rates, additional air exchanges provided by portable HEPA purifiers may be calculated and room shutdown times potentially reduced after aerosol-generating procedures.

Peaks in online inquiries into pharyngitis-related symptoms correspond with annual incidence rates

OBJECTIVE

To assess whether web-based public inquiries into pharyngitis-related search terms follow annual incidence peaks of acute pharyngitis in various countries from both hemispheres.

METHODS

Google Trends (GT) was utilized for systematic acquisition of pharyngitis-related search terms (sore throat, cough, fever, cold). Six countries from both hemispheres including four English (United Kingdom, United States, Canada, and Australia) and two non-English speaking countries (Austria and Germany) were selected for further analysis. Time series data on relative search interest for pharyngitis-related search terms, covering a timeframe between 2004 and 2019 were extracted. Following reliability analysis using the intra-class correlation coefficient, the cosinor time series analysis was utilized to determine annual peaks in public-inquiries.

RESULTS

The extracted datasets of GT proved to be highly reliable with correlation coefficients ranging from 0.83 to 1.0. Graphical visualization showed annual seasonal peaks for pharyngitis-related search terms in all included countries. The cosinor time series analysis revealed these peaks to be statistically significant during winter months (all p < 0.001).

CONCLUSION

Our study revealed seasonal variations for pharyngitis-related terms which corresponded to winter incidence peaks of acute pharyngitis. These results highlight the need for easily accessible information on diagnosis, therapy, and red-flag symptoms for this common disease. Accurately informed patients might contribute to a reduction of unnecessary clinic visits and potentially cutback the futile antibiotic overuse.

Individual importance of olfaction decreases with duration of smell loss

BACKGROUND

The personal importance of a lost neurologic - motor or sensory - function in several conditions has been shown to decrease as the afflicted patient becomes accustomed to not having that function. It is unknown how the importance of olfaction changes with duration of olfactory dysfunction (OD). The aim of this study was to evaluate the association between duration of smell loss and individual significance of olfaction, and whether this relationship would be modulated by other factors, such as etiology of smell loss.

METHODS

This is a retrospective study including a total 163 subjects with different degrees of olfactory function. Individual significance of olfaction was measured using the Importance of Olfaction Questionnaire (IOQ). Demographics, olfactory function, duration and etiology of OD were evaluated. Group comparisons, bivariate correlations, analyses of variance and multivariate linear regression were applied to detect differences and associations with the outcome measure of IOQ.

RESULTS

A significant negative correlation was found between duration of OD and the IOQ. Other important findings include a significantly higher IOQ in patients with posttraumatic- compared to idiopathic OD and in patients with higher aggravation scores compared to the lower aggravation group. Multivariate regression analysis further confirmed that duration of smell loss was independently associated with IOQ.

CONCLUSIONS

The duration of smell loss is negatively correlated with the individual importance of olfaction, suggesting that patients develop coping mechanisms for adjusting to OD.

Factors associated with relevant olfactory recovery after olfactory training: a retrospective study including 601 participants

OBJECTIVE

Olfactory training (OT) represents a therapeutic option for multiple etiologies of olfactory dysfunction (OD) that also benefits normosmic subjects. In this retrospective study, we report the effectiveness of OT and factors associated with relevant changes in olfactory function (OF) in large groups of normosmic participants and patients with OD, including a control group that performed no training.

METHODS

This was a retrospective pooled analysis including 2 treatment cohorts of 8 previously published studies. Adult participants that either presented with the major complaint of quantitative OD or normosmic volunteers were recruited at various ENT clinics and received OT or no training. The outcome was based on changes in objective olfactory test scores after OT.

RESULTS

A total of 601 patients with OD or normosmic subjects were included. OT was more effective compared to no training. No interaction was found between OT and OF. In multivariate analysis, higher baseline OF (adjusted odds ratio, aOR, 0.93) and posttraumatic (aOR, 0.29) or idiopathic OD (aOR, 0.18) compared to postinfectious causes were significantly associated with lower odds of relevant improvements in patients with OD receiving OT. Subgroup analysis of normosmic participants receiving OT further revealed a significant association of lower age and baseline olfactory function with improvements of overall OF.

CONCLUSIONS

This study demonstrated that OT was more effective than no training in patients with various causes of OD. Additionally, baseline olfactory performance and etiology of OD were identified as important factors associated with relevant improvements after OT.

Parosmia is Associated with Relevant Olfactory Recovery After Olfactory Training

OBJECTIVE/HYPOTHESIS

This study aims to determine the association between parosmia and clinically relevant recovery of olfactory function in patients with post-infectious olfactory dysfunction (PIOD) receiving olfactory training.

STUDY DESIGN

Retrospective cohort study.

METHODS

This was a retrospective cohort study of patients with PIOD that received olfactory training. Adult patients with the major complaint of quantitative smell loss were recruited and treated at several ENT clinics in German between 2008 and 2018. The outcome was based on the association between smell-loss related factors (including parosmia and phantosmia) and clinically relevant changes in overall and subdimension olfactory function of threshold, discrimination, and identification using binary logistic regression analysis.

RESULTS

A total of 153 participants with PIOD were included. Clinically relevant improvements in overall olfactory function were more likely in those that had lower baseline olfactory function. Relevant improvements in discrimination function were more likely in those that had lower baseline olfactory function and those that had parosmia at the initial visit. Similarly, relevant improvements in odor identification were more likely in those that had a lower baseline olfactory function and in those who had parosmia at the first visit. Clinically significant improvements in odor threshold were more likely in those who were older in age.

CONCLUSIONS

This study demonstrated that the presence of parosmia is associated with clinically relevant recovery in olfactory discrimination and identification function in patients with PIOD receiving olfactory training.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:618-623, 2021.

Long-term impact of olfactory dysfunction on daily life

Background

Olfactory dysfunction (OD) is common in the general population, affects the quality of life (QoL), and is suspected to cause depression. Long-term outcome data are lacking and there is a need to improve patient counselling regarding prognosis. We aimed to assess subjective long-term recovery rates, the QoL, and mood disturbance in a group of 65 patients, who were affected with OD.

Methods

Out of 325 patients treated for OD between 2003 and 2009  at a smell and taste clinic, 65 patients were included for a follow-up after an average of 8.6 years. A total of 28 patients answered questionnaires only and 37 patients were provided with an additional smell identification test. Among others, questionnaires included a short form of the World Health Organization quality of life questionnaire (WHOQOL-BREF) and the Beck’s depression inventory.

Results

In the long run, subjective improvement was stated in 33.8% of all patients, with the highest rate of 42.3% in patients with postinfectious OD. The subjective rating of olfactory function on a visual analogue scale was significantly higher at study follow-up compared to first clinical contact (median 1.25 vs. 4.5; U = 469.5, p = 0.001), as were mean identification scores (6.0 ± 3.0 vs. 8.0 ± 4.0, t(18) = 2.51, p = 0.021). The QoL in general was considered reduced in 40% of all patients at follow-up. Furthermore, participants exhibited only minor, if any, depressive symptoms.

Conclusion

Despite negative effects of OD on certain activities in daily life, such as cooking, detecting spoiled food, or personal hygiene, it seems that the patients included in this study adapted to the OD in the long-term. The current findings should aid clinicians in patient counselling.

Electronic supplementary material

The online version of this article (10.1007/s00508-020-01751-5) contains supplementary material, which is available to authorized users.

Differences in men and women suffering from CRSwNP and AERD in quality of life

PURPOSE

While the overall impact of chronic rhinosinusitis (CRS) on patients' health is diverse, many affected individuals have a substantially impaired quality of life (QoL). The aim of this study was to evaluate the impact of sex-associated differences specifically in the subgroups of CRS with nasal polyps (CRSwNP) and aspirin-exacerbated respiratory disease (AERD) by assessing QoL parameters in women and men separately.

METHODS

In a retrospective single-center study, 59 patients with CRSwNP (39 males and 20 females) and 46 patients with AERD (18 males and 28 females) were included. Patient-reported outcome measures (PROM) evaluating QoL via the Sino-Nasal Outcome Test-20 German Adapted Version (SNOT-20 GAV) as well as the total polyp score (TPS) were analysed.

RESULTS

There was no significant difference in TPS (p = 0.5550) and total SNOT-20 GAV scores (p = 0.0726) between male or female patients with CRSwNP or AERD. Furthermore, no significant sex differences were found within disease groups regarding the subcategories of the SNOT-20 GAV items.

CONCLUSION

Thus, quality of life is severely impaired in patients suffering from various forms of CRS regardless of their sex.

Self-perceived Taste and Flavor Perception: Associations With Quality of Life in Patients With Olfactory Loss

OBJECTIVE

To evaluate associations between self-perceived chemosensory functions of smell, taste, and flavor perception with olfactory-specific quality of life (QoL) in patients with olfactory dysfunction (OD) and whether these associations would be influenced by other factors, such as duration or etiology of smell loss.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care, academic center.

METHODS

Olfactory-specific QoL was measured with the Questionnaire of Olfactory Disorders (QOD). The QOD measures the impact of OD on QoL (QOD-negative statements) and the ability of patients to cope with smell loss (QOD-positive statements). Orthonasal olfactory function, patients' demographics, self-perceived chemosensory perception, and duration and etiology of OD were retrospectively collected in a cohort of patients with quantitative OD. Correlations and multivariable linear regression models were computed to determine possible associations with the outcome measure of QOD-negative and QOD-positive statement scores.

RESULTS

A total of 133 patients with OD were included. Analysis revealed a positive correlation between self-perceived taste and flavor perception with QOD-negative statement scores, while self-perceived smell showed no significant correlation. Similarly, longer duration of smell loss and higher age were also correlated with higher QOD-positive statement scores. Multivariable regression models confirmed that self-perceived taste was independently associated with the QOD-negative statement score, while age and duration of OD were independently associated with the QOD-positive statement score.

CONCLUSIONS

These findings suggest that the impact of diminished flavor perception during eating and drinking has a stronger impact on the QoL of patients with OD as compared with decreased orthonasal olfaction.

Factors associated with relevant olfactory recovery after olfactory training: a retrospective study including 601 participants

BACKGROUND

Olfactory training (OT) represents a therapeutic option for multiple etiologies of olfactory dysfunction (OD) that also benefits normosmic subjects. In this retrospective study, we report the effectiveness of OT and factors associated with relevant changes in olfactory function (OF) in large groups of normosmic participants and patients with OD, including a control group that performed no training.

METHODS

This was a retrospective pooled analysis including 2 treatment cohorts of 8 previously published studies. Adult partici- pants that either presented with the major complaint of quantitative OD or normosmic volunteers were recruited at various ENT clinics and received OT or no training. The outcome was based on changes in objective olfactory test scores after OT.

RESULTS

A total of 601 patients with OD or normosmic subjects were included. OT was more effective compared to no training. No interaction was found between OT and OF. In multivariate analysis, higher baseline OF (adjusted odds ratio, aOR, 0.93) and posttraumatic (aOR, 0.29) or idiopathic OD (aOR, 0.18) compared to postinfectious causes were significantly associated with lower odds of relevant improvements in patients with OD receiving OT. Subgroup analysis of normosmic participants receiving OT further revealed a significant association of age and baseline olfactory function with improvements of overall OF.

CONCLUSIONS

This study demonstrated that OT was more effective than no training in patients with various causes of OD. Additi- onally, baseline olfactory performance and etiology of OD were identified as important factors associated with relevant improve- ments after OT.

Ortho- and retronasal olfactory performance in rhinosurgical procedures: a longitudinal comparative study

Purpose

Testing olfaction should be an integral part of a clinical work-up in rhinosurgical procedures. Importantly, intact olfactory experience also includes retronasally perceived odors (retronasal olfaction). This study aimed at comprehensively assessing olfaction in patients undergoing rhinosurgical procedures in a comparative manner and evaluating relations to patient-reported outcome measurements (PROMs).

Methods

Each nostril odor threshold and discrimination, and birhinal identification were tested using Sniffin’ Sticks in 14 subjects assigned for septoplasty (SP), 21 for septorhinoplasty (SRP), and 30 for endoscopic sinus surgery (ESS). The 27-Candy-Smell-Test was used to quantify retronasal abilities. Tests were repeated 3 months after surgery.

Results

Olfactory dysfunction was preoperatively present in 21% of SP, in 47.6% of SRP, and in 80% of ESS patients. Odor threshold side differences were most frequently found in SRP. Frequently, SRP and ESS patients showed severely impaired retronasal olfaction. Half of included subjects re-visited after 3 months, but olfactory function did not improve overall and rarely on an individual basis to a meaningful extent. Subjective ratings on nasal patency and PROMs were not associated with olfaction nor with changes in olfactory scores.

Conclusion

Olfactory function can decisively be impaired a priori not only in patients awaiting sinus surgery, but also in those assigned for functional septorhinoplasty. This impairment may not improve in the short term, which has to be taken into account in patient counseling. This study adds to the current literature on olfaction in rhinosurgery with the extension of retronasal testing.

Plasma VEGF - a candidate biomarker for response to treatment with bevacizumab in HHT patients

BACKGROUND

Recurrent epistaxis is the principal symptom of hereditary hemorrhagic telangiectasia (HHT). Currently, there is no standard therapy for this condition. Bevacizumab (anti-VEGF) treatment has been under intense investigation but treatment effects vary greatly between individuals. There are currently no markers to predict anti-VEGF therapeutic response in HHT patients.

METHODS

We evaluated plasma VEGF levels in 13 HHT patients and correlated values with i) degree of epistaxis, measured by visual analog scale (VAS), epistaxis severity score (ESS), and patient bleeding diaries ii) the prevalence of extranasal manifestations, iii) the HHT subtype and iv) the treatment response to intranasal submucosal bevacizumab.

RESULTS

Plasma VEGF was elevated in all 13 HHT patients compared to reference levels and showed a moderate correlation with VAS and duration of moderate bleeding events. In patients treated with intranasal submucosal bevacizumab plasma VEGF levels showed a strong correlation with the degree of reduction of mild bleeding events and VAS.

CONCLUSIONS

The role of plasma VEGF as a potential predictive biomarker for therapeutic response to bevacizumab treatment warrants further investigation in larger prospective studies.

Association Between Orthonasal Olfaction and Chemosensory Perception in Patients With Smell Loss

Objectives

Self‐ratings seem to be the most effortless strategy for assessment of patients' chemical senses. Notably, although flavor perception strongly relies on olfaction, the relationship between self‐reported flavor perception and orthonasal olfactory tests have hitherto not been considered. The aim of this study was to investigate the relationship between self‐perceived olfactory function (SO), taste (ST), and flavor perception (SF) and smell test results in patients with olfactory dysfunction (OD).

Methods

We included 203 patients with quantitative OD. Group comparison, bivariate correlation, and ordinal logistic regression were employed to quantify the relationships between predictor variables (age, gender, reason for OD, and orthonasal olfaction—summed scores of threshold, discrimination, and identification [TDI]) and outcomes of SO and SF (“impaired,” “average,” or “good”).

Results

Group comparison revealed significant differences between SO and SF (P < .001). Stronger correlations were found between SO and TDI (r = 0.64), compared to SF and TDI (r = 0.27). No relevant correlation was found between ST and TDI (r = 0.10). Higher TDI was associated with odds of higher SO in univariate (odds ratio = 1.25) and multivariable analyses (adjusted odds ratio = 1.23), and both models showed good fit of data. Conversely, regression models on the associations between TDI and changes in SF did not meet the assumption of goodness of fit.

Conclusion

We found that higher orthonasal olfactory performance was associated with odds of higher SO in patients with OD, even after controlling for olfactory‐relevant factors. To the contrary, similar models based on flavor perception failed to describe these relationships. This indicates for SF and ST to be less represented by the TDI compared to SO.

Level of Evidence

4 Laryngoscope, 130:2213–2219, 2020

Reversible obstruction of the olfactory cleft: impact on olfactory perception and nasal patency

BACKGROUND

Temporary disruption of sensory input can be studied relatively easily for vision or hearing by covering the eyes or ears. In contrast, closing the nostrils affects not only the sense of smell, but also the ability to breathe through the nose and humidify and warm inhaled air. We hypothesized that filling the olfactory cleft (OC) with dissolvable nasal dressing (foam) would temporarily block olfaction while respecting nasal airflow.

METHODS

In 30 healthy volunteers, the OC was unilaterally obstructed in a back-to-front fashion. Orthonasal and retronasal olfactory function were tested before and after foam application. Ratings of odors and subjective nasal patency (SNP) were collected. Peak nasal inspiratory flow (PNIF) was used to measure nasal patency.

RESULTS

Foam was safely applied in every case using minimal instruments. No complications were reported. Orthonasal and retronasal test results decreased significantly in overall participants (all p < 0.0008). Indicating temporary anosmia, 3 subjects reached the lowest possible score for odor-threshold testing, with corresponding drops in retronasal test scores. PNIF values before and after foam application were not significantly different (p = 0.11). SNP ratings decreased slightly, but not significantly (p = 0.052). Odor-intensity ratings dropped significantly (all p < 0.05).

CONCLUSION

The OC can be safely obstructed with dissolvable nasal dressing, resulting in a decrease in odor-intensity and orthonasal and retronasal olfactory function test scores. This procedure may serve as a hyposmia model that maintains normal nasal airflow.

Eccrine porocarcinoma of the head and neck: Meta-analysis of 120 cases

BACKGROUND

The aim of the study is to analyze potential prognostic factors and to evaluate therapy strategies regarding clinical outcome in patients with eccrine porocarcinoma (EPC) of the head and neck.

METHODS

One hundred and sixteen EPC cases from ninety studies and four authors' EPC cases were included in the meta-analysis.

RESULTS

At an average follow up of 20.48 months, the 3-year overall survival and regional recurrence rate were 70.3% and 19.0%, respectively. Patients without surgical treatment had a significantly worse 3-year overall survival. Mohs microscopic surgery led to significantly less occurrence of regional recurrences compared to wide excision. An ulcerating lesion, high mitotic activity, and lymphovascular invasion were significant prognostic factors.

CONCLUSION

Surgical resection is the cornerstone in the therapy of EPC and represents the therapeutic modality that offers the best chance of disease-free survival. Due to the high probability of recurrence, close follow-ups are strongly recommended.