Allergy and Asthma Prevalence and Management Across Nasal Polyp Subtypes

Allergy and asthma prevalence vary across different subsets of chronic rhinosinusitis with nasal polyposis. In this article, the authors investigate the management of allergy and asthma within populations of patients with aspirin-exacerbated respiratory disease, allergic fungal rhinosinusitis, and central compartment atopic disease. Topical steroids, nasal rinses, and endoscopic sinus surgery are frequently employed in the management of nasal polyposis. Further, other causes of upper and lower airway inflammation like allergy and asthma should be considered in the overall treatment plan in order to optimize outcomes.

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Inflammatory characteristics of central compartment atopic disease

BACKGROUND

Central compartment atopic disease (CCAD) is an emerging phenotype of chronic rhinosinusitis with nasal polyposis (CRSwNP) characterized by prominent central nasal inflammatory changes. This study compares the inflammatory characteristics of CCAD relative to other phenotypes of CRSwNP.

METHODS

A cross-sectional analysis of data from a prospective clinical study was performed on patients with CRSwNP who were undergoing endoscopic sinus surgery (ESS). Patients with CCAD, aspirin-exacerbated respiratory disease (AERD), allergic fungal rhinosinusitis (AFRS), and non-typed CRSwNP (CRSwNP NOS) were included and mucus cytokine levels and demographic data were analyzed for each group. Chi-squared/Mann-Whitney U tests and partial least squares discriminant analysis (PLS-DA) were performed for comparison and classification.

RESULTS

A total of 253 patients were analyzed (CRSwNP, n = 137; AFRS, n = 50; AERD, n = 42; CCAD, n = 24). Patients with CCAD were the least likely to have comorbid asthma (p = 0.0004). The incidence of allergic rhinitis in CCAD patients did not vary significantly compared to patients with AFRS and AERD, but was higher compared to patients with CRSwNP NOS (p = 0.04). On univariate analysis, CCAD was characterized by less inflammatory burden, with reduced levels of interleukin 6 (IL-6), IL-8, interferon gamma (IFN-γ), and eotaxin relative to other groups and significantly lower type 2 cytokines (IL-5, IL-13) relative to both AERD and AFRS. These findings were supported by multivariate PLS-DA, which clustered CCAD patients into a relatively homogenous low-inflammatory cytokine profile.

CONCLUSIONS

CCAD has unique endotypic features compared to other patients with CRSwNP. The lower inflammatory burden may be reflective of a less severe variant of CRSwNP.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

A Cost-Effective and Reproducible Cadaveric Training Model for Internal Carotid Artery Injury Management During Endoscopic Endonasal Surgery: The Submersible Peristaltic Pump

BACKGROUND

Internal carotid artery injury (ICAI) represents one of the most challenging complications in endoscopic endonasal neurosurgery and its rarity results in limited opportunities for trainees and surgeons to achieve proficiency in its management. Currently, available models for ICAI have employed costly systems that prevent their widespread use. The objective of this study is to validate an affordable submersible peristaltic pump (SPP)-based model as a reproducible and realistic paradigm for ICAI management training.

METHODS

A laceration of the left parasellar internal carotid artery was purposely carried out in 2 human cadaveric heads. A blood substitute was perfused to ensure a perfusion flow of 1 L/min using an affordable SPP. A cohort of 20 neurosurgery and otolaryngology residents, fellows, and attendings were enrolled to evaluate the realism and content validity of the model using a validated 5-grade questionnaire.

RESULTS

The model proved to mimic a real intraoperative scenario of ICAI with an expected output flow of 1 L/min. Questionnaire responses reported a realistic experience and the impact of this model on improving trainee surgical coordination and capability to rehearse the most accepted repair technique. The use of a fixed noninjected head allowed the reproducibility of the training session without the additional cost of new fresh-frozen heads. The affordable SPP allowed an impactful reduction of ICAI model training expenses maintaining high realism.

CONCLUSIONS

The SPP-based ICAI model with noninjected cadaveric specimens is an affordable and cost-effective system that allows reproducibility and realism. These qualities favor greater adoption in neurosurgery and otolaryngology training curricula.

A Prospective Analysis of Systemic and Local Aeroallergen Sensitivity in Central Compartment Atopic Disease

OBJECTIVE

To compare systemic allergen sensitivity and local allergen sensitivity in the sinonasal tissue of patients with a recently identified subtype of chronic rhinosinusitis strongly associated with allergy: central compartment atopic disease (CCAD).

STUDY DESIGN

Prospective cohort study.

SETTING

Academic tertiary care rhinology clinic.

METHODS

Fifteen participants with endoscopic and radiographic evidence of CCAD underwent systemic allergy testing with skin testing and measurement of serum specific immunoglobulin E (sIgE) to 15 regionally common aeroallergens. Local allergen sensitivity was determined by measuring sIgE to these same 15 allergens in their sinonasal tissue. sIgE testing was performed by ImmunoCAP assay.

RESULTS

Of the 15 participants, 14 were sensitive to at least 1 allergen locally in the central compartment and systemically on skin or serum testing. Among all participants, 4 were sensitive to allergens on central compartment sIgE testing that they were not sensitive to on skin and serum sIgE testing (range, 1-8 discordant allergens). Comparisons between local and systemic aeroallergen sensitivity results showed statistically significant correlations (P < .05) ranging from weak to strong.

CONCLUSION

Systemic allergy testing is recommended in the initial workup for CCAD. Local allergen sensitivities may be present in a subset of patients with CCAD. Further study of the clinical significance of these sensitivities should be undertaken in CCAD, with evaluation of the role of medical therapies and allergen immunotherapy in the treatment of CCAD.

Intermediate Invasive Fungal Sinusitis, a Distinct Entity From Acute Fulminant and Chronic Invasive Fungal Sinusitis

BACKGROUND

The current classification system of invasive fungal sinusitis (IFS) includes acute (aIFS) and chronic (cIFS) phenotypes. Both phenotypes display histopathologic evidence of tissue necrosis, but differ by presence of angioinvasion, extent of necrosis, and disease progression. aIFS is defined by a rapid onset of symptoms, while cIFS slowly progresses over ≥12 weeks. However, a subset of IFS patients do not fit into the clinical presentation and histopathologic characteristics of either aIFS or cIFS.

OBJECTIVES

To investigate the demographic, clinical, and histopathologic characteristics of a distinct subset of IFS.

METHODS

Retrospective review of patients with IFS from a single tertiary-care institution (2010-2020). Patients with symptoms for ≤4 weeks were classified as aIFS if they displayed endoscopic evidence of mucosal necrosis or fungal angioinvasion on pathology. Patients with slowly progressive IFS for ≥12 weeks were classified as cIFS. Patients with symptom duration between 4 and 12 weeks with evidence of invasive fungal disease were classified as a new entity and were further investigated.

RESULTS

Of the 8 patients identified, 50% were immunosuppressed at presentation. The mean symptom duration prior to presentation was 50.5 days (SD 16.8), and common symptoms included facial pain (100%), vision change (87.5%), and blindness (37.5%). Two patients (25%) died of their disease. Sites of fungal involvement confirmed by histopathology included sphenoid (62.5%) and ethmoid sinuses (12.5%), orbital apex (25%), optic nerve (12.5%), pterygopalatine fossa (12.5%), and clivus (12.5%). Fungal elements but without obvious angioinvasion, were identified in all specimens, and fungus balls (50%), granulomas (37.5%), and giant cells (25%) were also observed on histopathology. CT and MRI radiographic imaging showed findings consistent with orbital, intracranial, or skull base involvement in all patients.

CONCLUSION

We propose intermediate IFS as a new subgroup of patients with IFS who do not fit into the standard classification of aIFS or cIFS.

Central compartment atopic disease: outcomes compared with other subtypes of chronic rhinosinusitis with nasal polyps

BACKGROUND

Central compartment atopic disease (CCAD) is a variant of chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) characterized by polypoid changes of the superior nasal septum, middle (MT), and/or superior turbinates (ST). This study evaluates surgical outcomes in patients with CCAD compared with other CRSwNP subtypes.

METHODS

Retrospective analysis was performed at Emory University from May 2012 to November 2019. Patients undergoing primary endoscopic sinus surgery (ESS) for CCAD, aspirin-exacerbated respiratory disease (AERD), allergic fungal rhinosinusitis (AFRS), and CRSwNP not otherwise specified (CRSwNP NOS) were included consecutively, beginning with the earliest date of CCAD patient. Outcome measures included polyp recurrence, revision ESS, oral steroid use, and oral antibiotic use. Pearson chi-square and univariate analysis of variance (ANOVA) were performed for group comparisons.

RESULTS

Data was collected for 132 patients (CCAD = 38, AERD = 20, AFRS = 37, CRSwNP NOS = 37; 58 females, mean age 42.9 years [range, 13-85 years]). CCAD patients demonstrated polyp recurrence less frequently than expected, whereas AFRS patients had polyp recurrence more frequently than expected (p = 0.003; phi 0.32). CCAD patients underwent revision ESS less frequently than expected; AFRS and CRSwNP NOS underwent revision ESS more frequently than expected (p = 0.03; phi 0.26). CRSwNP NOS patients received more total antibiotic courses than those with CCAD (p = 0.01; eta-squared 0.09) and more courses of antibiotics per month than those with AFRS (p = 0.03; eta-squared 0.07). There was no significant difference in follow-up measures across groups (number of visits, total months, or visits per month).

CONCLUSION

Rates of polyp recurrence and revision ESS were significantly lower in CCAD patients compared with patients with other CRSwNP subtypes, suggesting durable benefit of ESS and postoperative medical therapy in CCAD patients.

Computed Tomography Findings Can Help Identify Different Chronic Rhinosinusitis With Nasal Polyp Phenotypes

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNPs) has several phenotypes.

OBJECTIVES

The goal of this study was to evaluate computed tomography (CT) findings associated with each CRSwNP phenotype.

METHODS

Patient charts between January 2015 and March 2019 were retrospectively reviewed. Patient groups, including allergic fungal rhinosinusitis (AFRS), aspirin-exacerbated respiratory disease (AERD), central compartment atopic disease (CCAD) and CRSwNP not otherwise specified (CRSwNP NOS), were determined by standard criteria. The oldest CT scan available was reviewed for Lund-Mackay (LM) score, septal involvement of inflammatory disease, opacification of olfactory clefts, nasal cavity opacification, and oblique positioning of the middle turbinates. Nonparametric analyses of variance were performed with correction for multiple comparisons.

RESULTS

A total of 356 patients had scans available for review; 80 (23%) patients were categorized into the AFRS group, 101 (28%) in the AERD group, 43 (12%) in the CCAD group, and 132 (37%) in the CRSwNP NOS group. Septal inflammatory involvement and oblique middle turbinate orientation on CT scans was higher in both AERD patients and CCAD patients as compared to AFRS and CRSwNP NOS patients (P < .05). Olfactory cleft opacification was increased in the AERD group compared to all other diagnoses (P < .05). The CCAD group showed lower LM scores compared to all other groups (P < .05), and the AFRS group revealed the greatest differences between left and right LM grades, representing unilaterality of disease (P < .05).

CONCLUSION

CRSwNP encompasses many subsets of disease, which have varying treatments and intraoperative findings. Preoperative CT findings can be used to differentiate between these groups to improve prediction of diagnoses and patient counseling.

Endoscopic Study of the Distribution of Olfactory Filaments: A Cadaveric Study

Objective

Provide a detailed anatomical description of the olfactory filaments (OF) and their distribution in the nasal cavity through endoscopic endonasal dissection.

Methods

Four cadaveric specimens (8 sides) were used in this study. Nasoseptal (NSM), middle (MTM) and superior turbinate (STM) mucosa dissection was performed to identify the OF and follow them superiorly to the cribriform plate (CP). Measurements of the OF were taken on the NSM, MTM, STM under direct endoscopic visualization. A Student’s T-Test was performed to compare means.

Results

The NSM contained a mean of 11 OF, distributed over surface area (SA) of 173 ± 31 mm2 with the highest density of OF being found at the posterior NSM. The MTM contained a mean 6 OF, covering a mean SA of 77 mm2, with the first OF found 5 mm from the anterior border of the MTM, on average. The STM had a mean 9 OF, with the OF covering a mean SA of 96 mm2. Overall mean OF length was 6 mm. The STM OF were significantly greater in number, with a greater distance from the first OF to last OF (p < 0.05) than the MTM OF.

Summary

The STM and MTM combined were found to have a greater density of OF than the NSM. The STM contains a significantly greater number of OF covering a greater area than the MTM OF. Preservation of the STM and MTM in skull base defect repair, and in routine sinus surgery, can be as beneficial for olfactory function as preservation of the NSM; particularly in CP defect repair. Moreover, our findings indicate that nasoseptal flap harvest performed at least 6 mm from the skull base preserves OF in the NSM. To our knowledge, this is the first anatomical study of the OF through direct endoscopic observation and measurements.

Effect of Omega-3 Supplementation in Patients With Smell Dysfunction Following Endoscopic Sellar and Parasellar Tumor Resection: A Multicenter Prospective Randomized Controlled Trial

BACKGROUND

Endoscopic endonasal approaches pose the potential risk of olfactory loss. Loss of olfaction and potentially taste can be permanent and greatly affect patients' quality of life. Treatments for olfactory loss have had limited success. Omega-3 supplementation may be a therapeutic option with its effect on wound healing and nerve regeneration.

OBJECTIVE

To evaluate the impact on olfaction in patients treated with omega-3 supplementation following endoscopic skull base tumor resection.

METHODS

In this multi-institutional, prospective, randomized controlled trial, 110 patients with sellar or parasellar tumors undergoing endoscopic resection were randomized to nasal saline irrigations or nasal saline irrigations plus omega-3 supplementation. The University of Pennsylvania Smell Identification Test (UPSIT) was administered preoperatively and at 6 wk, 3 mo, and 6 mo postoperatively.

RESULTS

Eighty-seven patients completed all 6 mo of follow-up (41 control arm, 46 omega-3 arm). At 6 wk postoperatively, 25% of patients in both groups experienced a clinically significant loss in olfaction. At 3 and 6 mo, patients receiving omega-3 demonstrated significantly less persistent olfactory loss compared to patients without supplementation (P = .02 and P = .01, respectively). After controlling for multiple confounding variables, omega-3 supplementation was found to be protective against olfactory loss (odds ratio [OR] 0.05, 95% CI 0.003-0.81, P = .03). Tumor functionality was a significant independent predictor for olfactory loss (OR 32.7, 95% CI 1.15-929.5, P = .04).

CONCLUSION

Omega-3 supplementation appears to be protective for the olfactory system during the healing period in patients who undergo endoscopic resection of sellar and parasellar masses.

Spontaneous Skull Base Cerebrospinal Fluid Leaks and Their Relationship to Idiopathic Intracranial Hypertension

Background

The association between spontaneous skull base cerebrospinal fluid (CSF) leaks and idiopathic intracranial hypertension (IIH) has been suggested, but its significance remains unclear.

Objective

To estimate the prevalence of IIH in spontaneous skull base CSF leak patients.

Methods

Systematic collection of demographics, neuro-ophthalmic and magnetic resonance imaging evaluation of spontaneous skull base CSF leak patients seen pre- and post-leak repair in one neuro-ophthalmology service. Patients with preexisting IIH were diagnosed with definite IIH if adequate documentation was provided; otherwise, they were categorized with presumed IIH. Classic radiographic signs of intracranial hypertension and bilateral transverse venous sinus stenosis were recorded.

Results

Thirty six patients were included (age [interquartile range]: 50 [45;54] years; 94% women; body mass index: 36.8 [30.5;39.9] kg/m2), among whom six (16.7%, [95% confidence interval, CI]: [6.4;32.8]) had a preexisting diagnosis of definite or presumed IIH. Of the remaining 30 patients, four (13.3%, 95%CI: [3.8;30.7]) had optic nerve head changes suggesting previously undiagnosed IIH, while one was newly diagnosed with definite IIH at initial consultation. One out of 29 patients with normal findings of the optic nerve head at presentation developed new onset papilledema following surgery (3.4%, 95%CI: [0.1;17.8]) and was ultimately diagnosed with definite IIH. Overall, the prevalence of definite IIH was 19.4% (95%CI: [8.2;36.0]).

Conclusion

Striking demographic overlap exists between IIH patients and those with spontaneous CSF leak. Definite IIH was present in approximately 20% of our patients. However, its true prevalence is likely higher than identified by using classic criteria. We therefore hypothesize that an active CSF leak serves as an auto-diversion for CSF, thereby “treating” the intracranial hypertension and eliminating characteristic signs and symptoms at initial presentation.

Is Respiratory Epithelial Adenomatoid Hamartoma Related to Central Compartment Atopic Disease?

BACKGROUND

Respiratory epithelial adenomatoid hamartoma (REAH) is a benign lesion of the sinonasal tract that may mimic more concerning pathology. Clinical factors associated with REAH have not been well characterized.

OBJECTIVE

To report our findings on patients with this pathologic diagnosis.

METHODS

A retrospective chart review of patients with REAH between September 2006 and November 2019 was conducted. Data collected included clinical allergic rhinitis and asthma history, additional sinonasal diagnoses, prior sinus surgery, and the location of the REAH within the sinonasal cavity.

RESULTS

Twenty-six patients were identified (53.8% male, mean age 62 years [range, 29-93]). Bilateral REAH occurred in 50%. REAH was located at the superior nasal septum in 84.6% cases, with the remainder identified in sinus contents submitted for pathology, making definitive site uncertain. Concurrent sinonasal inflammatory disorders were identified in 18 patients (69.2%), including chronic rhinosinusitis with nasal polyps-not otherwise specified (6), chronic rhinosinusitis without nasal polyps (4), aspirin-exacerbated respiratory disease (2), allergic fungal rhinosinusitis (1), central compartment atopic disease (5), and IgG4-related sclerosing disease (1). Eight patients had isolated REAH. Adequate allergy records were available for 19 patients, of which 18 of 19 (94.7%) had clinical allergic rhinitis.

CONCLUSIONS

REAH is a benign sinonasal lesion commonly located within the central compartment of the nasal cavity, a site of significant allergen exposure. Affected patients have a high incidence of allergy along with chronic inflammatory conditions. The coexistence of REAH within inflammatory nasal mucosa in a consistent anatomic location, suggests REAH may have a similar etiology to central compartment atopic disease, with resultant respiratory glandular ingrowth within long-standing reactive changes of mucosa derived from ethmoid embryologic origin.

Central compartment atopic disease: prevalence of allergy and asthma compared with other subtypes of chronic rhinosinusitis with nasal polyps

BACKGROUND

Central compartment atopic disease (CCAD) is a recently described variant of chronic rhinosinusitis with nasal polyp (CRSwNP) associated with inhalant allergy. An association with asthma was noted to be uncommon within our clinical practice. The purpose of this study was to determine allergy and asthma prevalence in CCAD and other CRSwNP subtypes.

METHODS

A retrospective analysis at a tertiary care institution was performed over the period from 2015 to 2019. CRSwNP was grouped into the following subtypes: allergic fungal rhinosinusitis (AFRS); aspirin-exacerbated respiratory disease (AERD); CCAD; and CRSwNP not otherwise specified (CRSwNP NOS). Patients with sinonasal polyps and concomitant polypoid disease in the central compartment (CRSwNP/CC) were analyzed as a separate cohort for the purpose of this study. Prevalence of allergy and asthma was compared between groups.

RESULTS

Three hundred fifty-six patients were included. CRSwNP NOS was the most common subtype (37.1%) and CRSwNP/CC was the least common (3.7%), with other CRS subtypes ranging between 11.5% and 24.2%. Asthma prevalence was highest in AERD (100%) and CRSwNP NOS (37.1%), but substantially lower in AFRS (19.0%) and CCAD (17.1%). Asthma was significantly more common in AERD and CRSwNP NOS when compared with CCAD (p < 0.001 and p = 0.039, respectively). Prevalence of allergy was significantly higher in AFRS (100%), CCAD (97.6%), CRSwNP/CC (84.6%), and AERD (82.6%) when compared with CRSwNP NOS (56.1%) (p < 0.001).

CONCLUSION

CCAD represents a clinically distinct phenotype of CRSwNP with a high prevalence of allergy and low prevalence of asthma. Patients with both CCAD and diffuse sinonasal polyps had an allergy prevalence approaching that of CCAD and an asthma prevalence approaching CRSwNP NOS.

Treatment practices for aspirin-exacerbated respiratory disease: analysis of a national insurance claims database

BACKGROUND

Aspirin-exacerbated respiratory disease (AERD) is the triad of asthma, nasal polyposis, and sensitivity to cyclooxygenase-1 inhibitors. Treatment options include medical management, surgical intervention, and aspirin desensitization (AsaD).

METHODS

AERD patients were identified using the MarketScan Database from 2009 to 2015. Patients were included using International Classification of Diseases, 9th edition (ICD-9) codes for asthma, nasal polyposis, and drug allergy. Treatments were determined by Current Procedural Terminology (CPT) codes for drug desensitization and endonasal procedures. Geographic trends and timing of interventions between those exposed and not exposed to desensitization were explored.

RESULTS

A total of 5628 patients met inclusion criteria for AERD, with mean age 46 years, 60% female; 395 (7%) underwent AsaD and 2171 (39%) underwent sinus surgery. Among patients who were desensitized, 229 (58%) underwent surgery, of whom 201 (88%) had surgery prior to AsaD (median [quartile 1, quartile 3]; 61 days [30, 208] prior to desensitization). For patients undergoing surgery following AsaD (n = 46), surgery was performed a median of 302 (163, 758) days after AsaD. Nineteen patients had multiple surgeries post-AsaD with median time between surgeries being 734 days (312, 1484); 261 patients were not desensitized to aspirin but did undergo multiple surgeries, with the median of the median time between surgeries being 287 days (15, 617), which is shorter than for patients post-AsaD (p < 0.001).

CONCLUSION

A very small percentage of AERD patients undergo AsaD. Patients who had AsaD underwent surgery approximately 2 months prior to AsaD. Patients who underwent AsaD experienced an increased time between surgeries compared to patients who did not undergo AsaD.

Follow-up Management of Patients After Transsphenoidal Approach for Resection of Pituitary Adenomas

Background

Endoscopic transsphenoidal adenomectomy (eTSA) is widely utilized for resection of pituitary adenoma. eTSA patients undergo healing for weeks to months and are potentially at risk for complications. Multidisciplinary follow-up monitoring is necessary. We hypothesized that patients with deviations from the routine postoperative course, broadly termed complications of interest (COI) in this study, following eTSA would increase the duration of follow-up in the rhinology clinic.

Methods

Retrospective review was performed on patients undergoing eTSA for pituitary adenoma from August 2007 to May 2016 at a single tertiary care center. COIs were reviewed for their influence on follow-up time.

Results

A total of 985 patient records were reviewed (mean age 51.0 ± 15.7 years, 55.2% female), of which, 21.1% of patients had a deviation from the expected postoperative course (7.0% rhinologic, 10.8% surgical, 0.6% perioperative medical, and 2.7% endocrinologic COIs). The most common COI was cerebrospinal fluid leak 5.6% (n = 55) followed by sinusitis 5.0% (n = 49). Moreover, 935 patients (94.9%) attended rhinology follow-up (172 patients with COI). For patients seen postoperatively by the rhinology service, COIs significantly increased the number of rhinologic follow-up visits (median 2 [interquartile range, IQR: 2–3] vs 3 visits [IQR: 2–4], P < .001), duration of rhinologic follow-up (median 54.0 days [IQR: 43.0–104.0] vs 88.0 days [IQR: 54.5–242.0], P < .001), and duration of overall multidisciplinary follow-up (median 354.0 days [IQR: 104.0–789.0] vs 537.0 days [IQR: 171.5–1313.5], P < .001), compared to those without COIs.

Conclusions

Patients who develop postoperative complications after eTSA have significantly extended follow-up with the multidisciplinary team.

Longitudinal progression of aspirin-exacerbated respiratory disease: analysis of a national insurance claims database

BACKGROUND

Aspirin-exacerbated respiratory disease (AERD) is a recalcitrant inflammatory disorder defined by asthma, nasal polyposis, and sensitivity to cyclooxygenase-1 inhibitors. The timeline and course of disease progression is unclear.

METHODS

The Truven MarketScan Database, a large American health insurance claims repository, was queried to identify patients meeting criteria for AERD from 2009 to 2015. Included patients had associated International Classification of Diseases, 9th edition (ICD-9) codes consistent with all 3 components of AERD: asthma, nasal polyposis, and drug allergy. Patterns of disease onset and time to progression were analyzed.

RESULTS

A total of 5628 patients were identified for study inclusion. Of the 3 components of AERD, 3303 patients (59%) were initially diagnosed with asthma, 1408 (25%) were initially diagnosed with nasal polyps, and 917 (16%) were first diagnosed with drug sensitivity. The most common (36%) sequence of diagnoses was asthma, followed by nasal polyps, followed by drug allergy. The median interval between diagnosis of upper or lower airway involvement (ie, nasal polyps and/or asthma) to recognition of drug sensitivity was 259 days (quartiles Q1 to Q3: 92 to 603 days). In patients with both asthma and nasal polyps diagnoses, the risk of developing drug sensitivity during the study time period was 6%.

CONCLUSION

Upper and lower airway disease is often initially recognized in patients with AERD, whereas drug sensitivity presents month to years later. This delay may be due to the pathophysiology of AERD and disease progression or due to practice patterns in diagnostic testing and coding. Further work is warranted to identify these patients at early stages in their disease progression.

Central compartment involvement in aspirin-exacerbated respiratory disease: the role of allergy and previous sinus surgery

BACKGROUND

Evidence for a relationship between allergy and chronic rhinosinusitus with nasal polyps (CRSwNP) is equivocal. Central compartment (CC) atopic disease is a nasal inflammatory condition related to inhalant allergy. CC involvement is common in aspirin-exacerbated respiratory disease (AERD), a subset of CRSwNP, and we hypothesize it is related to allergic status.

METHODS

This study was a retrospective analysis of a single-institution database for the January 2016 to February 2019 time period. Data regarding endoscopic CC findings, clinical allergy history, and results of allergy testing were collected. Statistical analysis was performed, with significance set at p < 0.05.

RESULTS

Seventy-two AERD patients met the inclusion criteria. Fifty-nine patients had CC involvement (53 bilateral, 6 unilateral). For patients with documented allergy status, 100% of patients with endoscopic CC disease had clinical allergic rhinitis (AR), and 45 of 48 (93.8%) had positive allergy testing. Thirteen patients had no CC involvement (4 with clinical AR; 3 of 7 with positive allergy testing). CC endoscopic findings in AERD were significantly associated with clinical allergy (p < 0.0001, phi = 0.771). Overall, patients with CC involvement averaged 3.8 surgeries vs 3.2 for those without CC involvement (p = not statistically significant). However, patients with septal involvement averaged 4.2 surgeries vs 2.0 for those without septal involvement (p = 0.004). As the number of sinus surgeries increases, middle turbinate (MT) resection (r = 0.300, p = 0.022) and septal involvement (r = 0.372, p = 0.004) significantly increase. All patients with MT resection had septal disease, whereas none without CC disease had MT resection.

CONCLUSION

Most AERD patients exhibit AR, and this correlates with CC disease. As the number of surgeries increases, MT resection may predispose to polyposis of the septum.

Middle Turbinate Friendly Technique for Cribriform Cerebrospinal Fluid Leak Repair

OBJECTIVE

To compare surgical outcomes between 2 techniques for cribriform cerebrospinal fluid leak (CSF) repair with middle turbinate preservation (MTP) vs middle turbinate resection (MTR). A secondary outcome is to examine the effectiveness of collagen dura matrix (CDM) as a grafting material for repair of isolated cribriform skull base defects.

STUDY DESIGN

A retrospective chart review was performed of consecutive patients who underwent cribriform CSF repair at Emory University over the past 15 years.

SETTING

Tertiary care rhinology practice.

SUBJECTS

Adult patients with cribriform defects limited to the cribriform plate that did not extend lateral to the middle turbinate (MT) and were reconstructed with a free graft (mucosal or synthetic).

METHODS

Patients were stratified into 2 primary groups by surgical technique: MTP vs MTR. A subset of patients underwent repair with CDM alone and was analyzed separately for CSF repair failure rate.

RESULTS

Of 68 patients identified with cribriform defects, 42 underwent repair with MTP and 26 underwent repair with MTR. Average follow-up time was 495 days. Patients with idiopathic intracranial hypertension were also equally distributed (P = .20). Primary CSF leak repair success was 95.6%, with 100% of leaks ultimately repaired. A subset of 39 patients underwent repair with CDM alone, with a primary repair success rate of 94.9%.

CONCLUSIONS

We present an effective method for repair of cribriform CSF leaks while preserving the MT. CDM can be successfully used as a free graft alone for repair of isolated cribriform CSF leaks.

Chronic Rhinosinusitis: Does Allergy Play a Role?

A few chronic rhinosinusitis (CRS) variants have demonstrated a strong association with environmental allergy, including allergic fungal rhinosinusitis (AFRS) and central compartment atopic disease (CCAD). However, the overall relationship between CRS and allergy remains poorly defined. The goal of this review is to evaluate the relationship between CRS and allergy with a focus on specific CRS variants.

The relationship between allergy and chronic rhinosinusitis

Objective

To summarize the current evidence regarding a relationship between chronic rhinosinusitis (CRS) and allergy.

Methods

Literature review.

Results

Despite frequent assumption of an association between CRS and allergy the relationship between these entities remains poorly defined. Certain CRS entities, however, have demonstrated a strong association with allergy—namely allergic fungal rhinosinusitis and central compartment atopic disease.

Conclusion

Studies are heterogeneous and largely retrospective in design with inconclusive evidence for an association between CRS and allergy. Knowledge of CRS endotypes is important in order to understand which entities may or may not be associated with allergy.

Level of Evidence: 5

Remodeling of the Paradoxical Middle Turbinate: Preserving Function While Gaining Access

Background Endoscopic sinus surgery is performed for many reasons, most commonly for chronic rhinosinusitis refractory to medical treatment. A paradoxical middle turbinate is an anatomic variant that can hinder endoscopic access to the sinuses. No publication has addressed how to surgically treat a paradoxical middle turbinate. Method We present a basic endoscopic surgical approach to conservatively resect a paradoxical middle turbinate in order to improve access to the middle meatus and the sinuses while preserving support and function. Conclusion Conservative remodeling of the paradoxical middle turbinate can provide access to the sinuses while maintaining a significant portion of the middle turbinate.

Endocannabinoid receptor CB2R is significantly expressed in aspirin-exacerbated respiratory disease: a pilot study

BACKGROUND

The endocannabinoid system represents a highly conserved, innate signaling network with direct and indirect control of eicosanoid-mediated inflammation. Activation of the type 2 cannabinoid receptor (CB2R) leads to decreased type 2 inflammation and reduced production of arachidonic acid (AA). Given that altered AA metabolism is associated with aspirin-exacerbated respiratory disease (AERD), we hypothesized that expression of the CB2R gene CNR2 is increased in AERD.

METHODS

Nasal polyps from consecutive patients undergoing endoscopic sinus surgery for AERD or allergic fungal rhinosinusitis (AFRS) were prospectively evaluated. Control sphenoid mucosa was collected from patients undergoing endoscopic skull base procedures. Expression and localization of endocannabinoid receptors were evaluated by quantitative reverse transcript-polymerase chain reaction (qRT-PCR) and immunohistochemistry. A 2-group unpaired t test with unequal variances was used to evaluate group differences.

RESULTS

Thirteen subjects were included in this pilot study, including 5 controls, 5 AFRS patients, and 3 AERD patients. Upregulated expression of CNR2 was detected in subjects with AERD vs both AFRS (p = 0.049) and controls (p = 0.047), with a mean increase of 5.2-fold. No significant differences in expression of the CB1R gene CNR1 were detected between control and AFRS groups. Immunohistochemistry predominantly localized CB1R and CB2R expression to the surface epithelium in all subjects.

CONCLUSION

The endocannabinoid system is an emerging immunomodulatory network that may be involved in AERD. This is the first study of CB2R in sinonasal disease, showing significantly increased transcription in nasal polyps from subjects with AERD. Additional study is warranted to further evaluate the contribution and therapeutic potential of this novel finding in chronic rhinosinusitis.

Central compartment atopic disease

BACKGROUND

Isolated polypoid changes of the middle turbinate were recently reported as having a high association with inhalant allergy. A more advanced manifestation of this association may present as polypoid changes of the entire central sinonasal compartment (i.e., the middle and superior turbinates, and the posterosuperior nasal septum), while the lateral sinus mucosa remains relatively normal.

OBJECTIVE

To introduce and describe this newly recognized variant of chronic rhinosinusitis (CRS), termed central compartment atopic disease (CCAD).

METHODS

A case series of 15 patients from two institutions who presented with sinonasal symptoms and demonstrated central compartment polypoid mucosal changes on computed tomography (CT). The endoscopic appearance of central compartment edema was assessed. Allergy status was determined by skin or serum in vitro testing.

RESULTS

The mean ± standard deviation patient age was 42.4 ± 14.8 years, and 47% of the patients were women. All 15 patients had a diagnosis of allergic rhinitis symptomatically, and those who underwent allergy assessment (14/15) tested positive. All the patients had central compartment polypoid edema on endoscopy and central nasal soft-tissue thickening with peripheral clearing on CT. Even with more severe sinus disease, a central focus of inflammatory change existed.

CONCLUSION

CCAD may represent a local inhalant allergy process that affects the central nasal structures of ethmoid origin. Although inhalant allergy changes mainly appear within the nasal cavity, medial-to-lateral progression to involve the sinuses can occur as a simple obstructive phenomenon. This is a pattern of CRS distinct from the more diffuse sinonasal inflammatory disease and likely requires allergy management as a core component.

Presence of Fungus in Sinus Cultures of Cystic Fibrosis Patients

Background

Sinonasal pathology is nearly universal in the cystic fibrosis (CF) population. The bacteriology of sinus cultures from CF patients and the implications of sinus bacterial pathogens in this group have been studied; however, sinus fungal isolates from CF patients have not been examined in the literature.

Methods

We reviewed 30 consecutive CF patients undergoing endoscopic sinus surgery at our institution for the presence of fungal isolates obtained from the sinuses at the time of surgery.

Results

Thirty-three percent of fungal cultures were positive in this sample; in addition, two patients were newly diagnosed with allergic fungal sinusitis.

Conclusion

We examine the possible implications of positive fungal sinus cultures in the CF population.

Association of Radiological Evidence of Frontal Sinus Disease with the Presence of Frontal Pain

Background

Rhinosinusitis is a common cause of frontal pain. We evaluated the relationship between frontal pain and the type and degree of frontal sinus disease in chronic rhinosinusitis (CRS) patients.

Methods

Inclusion criteria were presence of frontal sinusitis or frontal recess obstruction on computed tomography scan. Office notes and operative reports were reviewed to determine the presence and location of frontal pain and categorization of sinus disease.

Results

Two-hundred seven patients were identified with frontal recess obstruction and/or frontal sinus disease. Thirty-one of 37 frontal mucocele patients (84%) had frontal pain. Twenty of 70 polyp patients (29%) had frontal pain, with only 7 of 38 patients (18%) with complete frontal opacification having pain. In patients with CRS without polyps or mucocele, 59 of 100 (59%) had frontal pain, with 21 of 38 (55%) with complete opacification having pain. This difference between the distribution of frontal pain was significant (p < 0.005) among the mucocele, polyp, and nonpolypoid CRS groups. Additionally, among nonmucocele CRS groups exhibiting complete opacification, there was a significant difference in proportion of patients exhibiting frontal pain (p < 0.005). When the nonmucocele groups (i.e., polypoid and nonpolypoid CRS patients) were combined and stratified for disease extent, a difference in the distribution of frontal pain was found (p < 0.025), with the mild-to-moderate thickening group showing the highest proportion of pain.

Conclusion

Frontal pain was more common in nonpolypoid CRS patients than in polyp patients. Furthermore, in nonmucocele CRS, patients with mild-to-moderate thickening exhibited more frontal pain.

Isolated Inflammatory Sphenoid Sinus Disease: A Revisitation of Computed Tomography Indications based on Presenting Findings

Background

Isolated inflammatory sphenoid sinus disease (IISSD) can be difficult to diagnose. Frequently, history and physical are inadequate in establishing a diagnosis. Computed tomography (CT) is an excellent screening tool; however, it often is obtained late in the disease process because of vague symptoms at presentation. Identifying the most common presenting symptoms of IISSD may allow earlier detection and avoidance of more severe sequelae by determining earlier indications for CT. Presently, headache is not an indication for sinus CT.

Methods

A retrospective chart review of IISSD presentation was performed at our institution. A literature review was performed also to quantitatively document trends in presentation of IISSD, including characterization of headache symptoms by location. Cumulative findings were then compared with current CT indications to determine if presentation patterns warrant a change in indications for CT.

Results

A total of 361 cases were evaluated by our inclusion criteria. Headache was the most common finding (81.7%), particularly peri/retro-orbital, vertex, and frontal headache. Ocular changes (17.5%) and cranial nerve involvement (16.1%) were common also, but headache frequently was a solitary finding (42.6%). Twenty-six IISSD cases were reviewed at our institution over 7 years, with similar results. Under current guidelines, the only IISSD findings that are indications for CT scan are the ophthalmologic and neurological complications.

Conclusion

Not every headache necessitates a CT scan. However, the deep-seated vertex, frontal, and, particularly, peri/ retro-orbital headaches, especially when aggravated by head movement and refractory to analgesics, as is often seen in IISSD, should be an indication for CT evaluation. (American Journal of Rhinology 19, 627–632, 2005)

Evaluation of Postoperative Pain after Sinonasal Surgery

Background

Pain after sinonasal surgery concerns both patients and surgeons. Factors affecting sinonasal postoperative pain have not been examined extensively.

Methods

Using a prospective survey design, sinonasal surgery patients evaluated postoperative pain (on a scale of 0–10), pain location, and medication use.

Results

One hundred twenty-seven patients consented to participate. One hundred fifteen patients returned surveys, with 100 patients appropriate for analysis over the 6-day postoperative period. Pain score and medication use were evaluated with respect to sex, primary/revision case, nasal packing, and other factors. Repeated measures analysis of variance and chi-square analysis were conducted (p < 0.05). Pain ratings and analgesic use declined significantly over the postoperative period (p < 0.05). Mean pain score on postoperative day (POD) 1 was 3.61 and on POD 6 was 1.72. Mean medication use was 1.37 tablets on POD 1 and 0.55 tablets on POD 6. Additionally, a significant interaction existed, such that narcotic medication use declined from 1.91 tablets on POD 1 to 0.52 tablets on POD 6, whereas nonnarcotic medication use remained steady (p < 0.05). Periorbital pain was most frequent (46.3%), with unilateral facial pain reported least (4.1%). A significant difference existed for distribution of pain location (p < 0.05). Finally, the difference in pain rating between primary and revision procedure for women (0.65) was less than for men (1.12); this interaction was significant (p < 0.05).

Conclusion

Multiple patient and operative factors affect pain rating and medication use after sinonasal surgery. Generally, pain level should be low with little analgesic use postoperatively.

Malleable Registration Mask: Application of a Novel Registration Method in Image Guided Sinus Surgery

Image-guided systems are becoming more widely used in endoscopic sinus and skull base surgery. All systems require initial registration to correlate the CT scan images to the patient's anatomy. Multiple registration techniques can be used. The ideal technique is one that is easy, reproducible, and provides the most accurate registration in the least amount of time. This study used an optical-based image-guided system (LandmarX) to test a unique mask registration technique and compared it to a previously used anatomic registration technique. Twenty-one patients were scanned with the mask and underwent surgery. Registration was performed using both the registration mask and the anatomic landmarks. Mean registration error and time were recorded. Results are reported for 20 patients. Mean registration error for the mask technique was 0.96 mm and took a mean of 41 seconds. Anatomic registration error using five or six points resulted in a mean initial error of 2.08 mm and took 31.2 seconds. Mean final anatomic registration error was 1.53 mm, requiring reregistration of a mean of 4.6 points, and took 106 seconds. Statistically significant differences were obtained between the two techniques with regard to registration error and time to final registration. We found that the registration mask technique is a more reliable technique in ease, accuracy, and time of registration. This technique should be especially beneficial to the less experienced image-guided surgeon.

Topical Steroid Drops for the Treatment of Sinus Ostia Stenosis in the Postoperative Period

Background

Chronic oral steroid use causes significant morbidity, including osteoporosis, immunosuppression, and adrenal insufficiency. Refractory chronic rhinosinusitis patients often take repeated oral steroid courses to treat polypoid disease or sinus ostia stenosis. This study evaluated topical steroid drop efficacy in treating recurrent sinus ostia stenosis in the postoperative period.

Methods

The 5-year single institution experience with topical steroid drop use after endoscopic sinus surgery (ESS) was evaluated by retrospective review. Patients were included if they began topical dexamethasone ophthalmic, prednisolone ophthalmic, or ciprofloxacin/dexamethasone otic intranasally (used off-label) within 3 months after ESS. Outcomes (i.e., ostia patency, oral steroid use, revision surgery, and complications) were assessed for a 6-month period after steroid drop initiation.

Results

Thirty-six patients met inclusion criteria. Forty-four surgeries were performed during the study period; 67 sides were treated postoperatively with topical steroid drops. In 86.6% of cases, steroid drops were used to treat frontal ostium stenosis or frontal recess edema; 93.2% of surgeries were revision procedures. Sixty-four percent of sinuses were treated successfully with topical steroid drops, 14.9% remained stable, and 20.9% failed. Reasons for failure included persistent/worsening edema, scarring, or noncompliance. Ten patients (27.8%) required oral steroids and 4 patients (6%) underwent revision surgery during the study period. One case of adrenal suppression occurred.

Conclusion

Topical steroid drops are beneficial in preventing sinus ostia stenosis in the postoperative period and may decrease the propensity toward repeated oral steroid therapy. This is particularly noteworthy in this challenging cohort, largely composed of revision frontal sinus surgery patients.

Association of Nasopharyngeal and Laryngopharyngeal Reflux with Postnasal Drip Symptomatology in Patients with and without Rhinosinusitis

Background

Patients often report postnasal drip (PND), but objective rhinosinusitis and allergy findings are frequently absent. In this study, we evaluate the association between PND and pharyngeal reflux.

Methods

Sixty-eight participants underwent 24-hour pH testing, including chronic rhinosinusitis (CRS) patients persistently symptomatic after endoscopic sinus surgery, CRS patients successfully treated by endoscopic sinus surgery, and volunteers without a CRS history. The pH probes contained nasopharyngeal (NP), laryngopharyngeal (LP), and distal esophageal sensors. Participants completed the Sinonasal Outcome Test-20 (SNOT-20) and Modified Reflux Symptom Index (MRSI) questionnaires. Survey items addressing PND symptomatology were compared with NP reflux (NPR) below pH 4 and pH 5 (defined as ≥1 event), and LP reflux (LPR; defined as ≥7 events or reflux area index <6.3).

Results

Pearson analyses revealed a positive correlation of r = 0.87 between SNOT-20 and MRSI PND items. For NPR < pH 4, no significant difference existed between participants with and without reflux on the SNOT-20 or MRSI (p < 0.05). However, for NPR < pH 5, reflux-positive participants exhibited significantly more PND symptoms on the SNOT-20 (p = 0.030) and the MRSI (p = 0.018) compared with participants without reflux. Finally, participants with LPR had significantly more PND symptomatology on the SNOT-20 (p = 0.010) versus those without LPR. A borderline significant difference existed on the MRSI PND item between participants positive and negative for LPR (p = 0.055).

Conclusion

Objective evidence of NPR and LPR exists in patients reporting PND. Reflux treatment may reduce PND complaints.

Allergic phenotype of chronic rhinosinusitis based on radiologic pattern of disease

OBJECTIVES/HYPOTHESIS

Polypoid edema of the middle turbinate is a marker of inhalant allergy. Extensive edematous changes may result in limited central nasal and sinus disease, which has been called central compartment atopic disease (CCAD). Radiologically, this is seen as soft tissue thickening in the central portion of the sinonasal cavity with or without paranasal sinus involvement. When the sinuses are involved, the soft tissue thickening spares the sinus roof or lateral wall (centrally limited). This centrally limited radiological pattern was assessed among chronic rhinosinusitis (CRS) patients and compared to allergy status.

STUDY DESIGN

Diagnostic cross-sectional study.

METHODS

This study included consecutive CRS patients without prior sinus surgery. Computed tomography (CT) scans of the paranasal sinuses were blindly assessed and allergy status was confirmed by serum or skin testing. Individual sinus cavities were defined as either centrally limited or diffuse disease. The radiological pattern that may predict allergy was determined, and its diagnostic accuracy was calculated.

RESULTS

One hundred twelve patients diagnosed to have CRS, representing 224 sides, were assessed (age 46.31 ± 13.57 years, 38.39% female, 41.07% asthma, Lund-Mackay CT score 15.88 ± 4.35, 56.25% atopic). The radiological pattern defined by centrally limited changes in all of the paranasal sinuses was associated with allergy status (73.53% vs. 53.16%, P = .03). This predicted atopy with 90.82% specificity, 73.53% positive predictive value, likelihood positive ratios of 2.16, and diagnostic odds ratio of 4.59.

CONCLUSIONS

A central radiological pattern of mucosal disease is associated with inhalant allergen sensitization. This group may represent a CCAD subgroup of patients with mainly allergic etiology.

LEVEL OF EVIDENCE

3b Laryngoscope, 128:2015-2021, 2018.

International survey and consensus (ICON) on ambulatory surgery in rhinology

OBJECTIVES

Day-case surgery is the gold standard to several surgical procedures in Rhinology. However, few data and guidelines have been published except in the Anglo-Saxon countries and France. The aim of this survey was to propose a list of issues arising during day-case surgery in order to analyze the different constraints encountered around the world.

MATERIAL AND METHOD

It was a prospective multicenter international email survey. The method was based on the formalized expert consensus methodology. A list of 11 issues was based on literature data and was sent by e-mail to 265 key opinion leaders (KOL) who attended the IFOS congress.

RESULTS

The response rate was 20% from 27 countries without statistical difference between continents concerning the score on each item. The mean age of KOL was 50±10 years. Their mean length of experience was 21±10 years. Issues in relation with technical resources and experience showed that the last time at which ambulatory surgery in the day is possible was 4:00 PM but responses varied depending the availability of technical resources. Bleeding or hematoma occurred most frequently between the third and fourth postoperative day whatever the surgical procedure. A strong agreement and consensus was obtained concerning the nasal packing, septal contention and their schedule of removal which were not a contraindication of day-case. Also 75% of participants were agreeing with a therapeutic education program to improve the performance of postoperative care and decrease readmission rates. A relative agreement without consensus were obtained for the distance between the day-case unit and home, the role of surgery duration and the impact of anticoagulant and/or antiplatelet drugs in overnight admission and readmission rates.

CONCLUSION

Practice varies widely owing to local organization constraints and the availability of a dedicated day-case unit seems to be the main limiting factor.

Clinical Consensus Statement: Balloon Dilation of the Sinuses

Objective

To develop a clinical consensus statement on the use of sinus ostial dilation (SOD) of the paranasal sinuses.

Methods

An expert panel of otolaryngologists was assembled to represent general otolaryngology and relevant subspecialty societies. The target population is adults 18 years or older with chronic or recurrent rhinosinusitis (with or without nasal polyps, with or without prior sinus surgery) for whom SOD is being recommended, defined as endoscopic use of a balloon device to enlarge or open the outflow tracts of the maxillary, frontal, or sphenoid sinuses, as a standalone procedure or with endoscopic surgery. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus.

Results

After 3 iterative Delphi method surveys, 13 statements met the standardized definition of consensus while 45 statements did not. The clinical statements were grouped into 3 categories for presentation and discussion: (1) patient criteria, (2) perioperative considerations, and (3) outcomes. Strong consensus was obtained for not performing SOD in patients without sinonasal symptoms or positive findings on computed tomography (CT) in patients with symptoms only of headache or sleep apnea without criteria for sinusitis. In addition, strong consensus was met that CT scan of the sinuses was necessary before performing SOD and that surgeons need to understand and abide by regulations set forth by the US Food and Drug Administration if they choose to reuse/reprocess devices.

Conclusion

Expert panel consensus may provide helpful information for the otolaryngologist considering the use of SOD for the management of patients with a diagnosis of rhinosinusitis. This panel reached consensus on a number of statements that defined the use of SOD as inappropriate in the management of a variety of symptoms or diseases in the absence of underlying sinusitis. When patients meet the definition of chronic sinusitis as confirmed by CT scan, SOD of the sinuses can be indicated and/or effective in certain scenarios. Additional consensus statements regarding proper setting and safeguards for performing the procedure are described.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Intranasal tissue necrosis associated with opioid abuse: Case report and systematic review

OBJECTIVE

Opioid abuse is a common disorder affecting over 2 million Americans. Intranasal tissue necrosis is a previously described sequela of nasal opioid inhalation, with a similar presentation to invasive fungal rhinosinusitis (IFRS). The goal of this case report and systematic review is to evaluate the evidence supporting this uncommon disease, with qualitative analysis of the presentation, management and treatment outcomes.

DATA SOURCES

MEDLINE, EMBASE, Google Scholar, Scopus, and Web of Science.

REVIEW METHODS

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were utilized to identify English-language studies reporting intranasal mucosal injury associated with prescription opioid abuse. Primary outcomes included clinical presentation, treatment strategies, and outcomes.

RESULTS

Systematic review identified 61 patients for qualitative analysis. Common clinical features include facial pain without a history of chronic sinusitis or known immunodeficiency. Diagnostic nasal endoscopy revealed superficial debris with underlying tissue necrosis, consistent with a preliminary diagnosis of IFRS. Characteristic pathologic findings include mucosal ulceration with an overlying acellular substrate, often with polarizable material. Fungal colonization is often reported, with several accounts of angiocentric invasion in immunocompetent patients. Complete symptom resolution is expected following surgical debridement with cessation of intranasal opioid inhalation, with 89% of identified patients experiencing a complete resolution of disease.

CONCLUSION

Intranasal opioid abuse is a prevalent condition associated with chronic pain and tissue necrosis that is clinically concerning for invasive fungal disease. Whereas IFRS must be excluded, even in patients without known immunodeficiency, complete resolution of symptoms can be expected following surgical debridement with cessation of opioid abuse. Laryngoscope, 1767-1771, 2018.

Excavating Meningoencephaloceles: A Newly Recognized Entity

Background

Spontaneous cerebrospinal fluid (CSF) leaks are largely attributed to idiopathic intracranial hypertension and typically present as skull base defects with or without prolapse of intracranial contents. However, in our practice, we have encountered a distinct type of spontaneous CSF leak that presents in a different manner.

Objective

To discuss a newly-classified, difficult to treat, subset of spontaneous CSF leaks that present as excavation of the bone of the skull base in a tunnel- or canal-like fashion by a meningocele or meningoencephalocele instead of as a localized area of bony dehiscence.

Methods

A retrospective review was performed at a tertiary care rhinology practice to identify a subset of CSF leak patients with an excavating/canal-like skull base defect visualized radiographically on computed tomography (CT) scan or magnetic resonance imaging and/or endoscopically in the operating room.

Results

The cohort of patients consisted of 7 females and 1 male with an average age of 53.6 years and a self-reported race of 4:3:1 African-American: Caucasian-Indian. All patients presented with CSF rhinorrhea. The most common leak site was the cribriform and upper septum. Six of the 8 patients had multiple defects and/or progression of their skull base defects, and 5 patients required multiple and/or repeat repairs in the operating room. Seven of the 8 patients underwent a cisternogram because the excavating nature of the leaks made it difficult to identify the specific leak site on high-resolution CT scan alone.

Conclusion

In spontaneous CSF leaks that are difficult to identify or recur soon after a proper repair, an excavating pattern should be considered. Failure to recognize this type of leak and all of its tributaries, to fully unroof the excavated bone to completely resect the meningocele, and to visualize and close the site of origin will likely result in failure and recurrence of CSF leak.

Association of gastro-oesophageal reflux and chronic rhinosinusitis: systematic review and meta-analysis

INTRODUCTION

Gastro-oesophageal reflux disease (GORD) has been implicated in the development of chronic rhinosinusitis (CRS). The association of GORD with CRS is systematically assessed from the medical literature.

METHODOLOGY

Embase and MEDLINE were searched using a comprehensive strategy limited to English language and Human subjects. Any study with original data on the experimental, diagnostic, treatment or prognostic association of CRS with GORD was included. Studies without a control group, case reports and review articles were excluded.

RESULTS

The search returned 958 records, with an additional 10 found from bibliographic lists; this produced 32 studies. The included studies (n=32) consisted of studies reporting pathogenic factors (n=20), epidemiological association (n=8), prognostic interactions (n=3), and a combination of these outcomes (n=1). Potential pathogenic roles for GORD in CRS were supported; CRS subjects had greater prevalence of intranasal Helicobacter pylori and acid reflux than subjects without CRS. CRS is more prevalent in GORD sufferers than those without GORD. Evidence is conflicting for GORD as a factor in CRS treatment failure.

CONCLUSION

The results support a significant association of GORD with CRS. Physicians should be cognizant of the potential for acid and non-acid reflux as a driving factor in CRS.

Randomized Controlled Trial Demonstrating Cost-Effective Method of Olfactory Training in Clinical Practice: Essential Oils at Uncontrolled Concentration

OBJECTIVES

Published data examining the efficacy of olfactory training (OT) has used standardized concentrations of odorants and the Sniffin' Sticks testing method. Although well-validated, these methods are costly and time-intensive for the average otolaryngology practice. The purpose of our study was to evaluate the efficacy of using essential oils at random concentrations and the University of Pennsylvania Smell Test (UPSIT) for training and testing, and compare this with the existing data on OT.

STUDY DESIGN

Randomized Clinical TrialMethods: Patients presenting to a tertiary care rhinology center with subjective loss of smell and olfactory loss measured by UPSIT were randomized to OT or control for 6 months. Only patients with loss of smell greater than one-year duration, and loss associated with post-infectious and idiopathic etiologies were included. Baseline UPSIT was compared to 6-month UPSIT. An accepted 10% change or better was used to establish a significant improvement on UPSIT.

RESULTS

43 patients were enrolled. Eight patients were lost to follow-up, with a total of 35 completing the study. Age ranged from 39-71 with an average of 56. Of 19 patients in the OT group, 6 showed significant improvement (32%), while only two out of 16 patients (13%) in the control group improved. Increasing age and duration of loss were significantly correlated to lack of improvement.

CONCLUSION

Allowing patients to use random concentrations of essential oils to perform OT is as effective as published data using controlled concentrations of odorants for post-infectious and idiopathic olfactory loss.

LEVEL OF EVIDENCE

1b.