Consensus criteria for chronic rhinosinusitis disease control: an international Delphi Study

BACKGROUND

Chronic rhinosinusitis (CRS) disease control is a global metric of disease status for CRS. While there is broad acceptance that it is an important treatment goal, there has been inconsistency in the criteria used to define CRS control. The objective of this study was to identify and develop consensus around essential criteria for assessment of CRS disease control.

METHODS

Modified Delphi methodology consisting of three rounds to review a list of 24 possible CRS control criteria developed by a 12-person steering committee. The core authorship of the multidisciplinary EPOS 2020 guidelines was invited to participate.

RESULTS

Thirty-two individuals accepted the invitation to participate and there was no dropout of participants throughout the entire study (3 rounds). Consensus essential criteria for assessment of CRS control were: overall symptom severity, need for CRS-related systemic corticosteroids in the prior 6 months, severity of nasal obstruction, and patient-reported CRS control. Near-consensus items were: nasal endoscopy findings, severity of smell loss, overall quality of life, impairment of normal activities and severity of nasal discharge. Participants’ comments provided insights into caveats of, and disagreements related to, near-consensus items.

CONCLUSIONS

Overall symptom severity, use of CRS-related systemic corticosteroids, severity of nasal obstruction, and patient-reported CRS control are widely agreed upon essential criteria for assessment of CRS disease control. Consideration of near-consensus items to assess CRS control should be implemented with their intrinsic caveats in mind. These identified consensus CRS control criteria, together with evidence-based support, will provide a foundation upon which CRS control criteria with wide-spread acceptance can be developed.

Position paper on olfactory dysfunction: 2023

BACKGROUND

Since publication of the original Position Paper on Olfactory Dysfunction in 2017 (PPOD-17), the personal and societal burden of olfactory disorders has come sharply into focus through the lens of the COVID-19 pandemic. Clinicians, scientists and the public are now more aware of the importance of olfaction, and the impact of its dysfunction on quality of life, nutrition, social relationships and mental health. Accordingly, new basic, translational and clinical research has resulted in significant progress since the PPOD-17. In this updated document, we present and discuss currently available evidence for the diagnosis and management of olfactory dysfunction. Major updates to the current version include, amongst others: new recommendations on olfactory related terminology; new imaging recommendations; new sections on qualitative OD and COVID-19 OD; updated management section. Recommendations were agreed by all co-authors using a modified Delphi process.

CONCLUSIONS

We have provided an overview of current evidence and expert-agreed recommendations for the definition, investigation, and management of OD. As for our original Position Paper, we hope that this updated document will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency, and generalisability of work in this field.

The EUFOREA pocket guide for chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is known to affect around 5 % of the total population, with major impact on the quality of life of those severely affected (1). Despite a substantial burden on individuals, society and health economies, CRS often remains underdiagnosed, under-estimated and under-treated (2). International guidelines like the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) (3) and the International Consensus statement on Allergy and Rhinology: Rhinosinusitis 2021 (ICAR) (4) offer physicians insight into the recommended treatment options for CRS, with an overview of effective strategies and guidance of diagnosis and care throughout the disease journey of CRS.

Identification and enjoyment of food items is reduced in dysosmic subjects: a pilot study

BACKGROUND

Although dysosmia affects a significant proportion of the adult population, there are a paucity of studies addressing its impact on flavor perception and food enjoyment. This study aimed to assess flavor perception and food enjoyment in subjects with and without dysosmia, comparing performance of items considered olfactory-dominant or trigeminal-dominant.

METHODS

Adult subjects prospectively underwent Sniffin' Sticks olfactory testing from which threshold, discrimination, and identification (TDI) scores were used to identify dysosmic (TDI over 31) and normosmic subjects (TDI under 31). Forced-choice, blinded flavor identification testing was performed using 8 flavor extracts and 8 real-food purees of either trigeminal- or olfactory-dominant flavor profile. Food enjoyment was quantified using visual analog scales.

RESULTS

Forty-one subjects were enrolled, including 20 dysosmics and 21 normosmics, with no difference in age or gender. Compared with normosmics, dysosmic subjects had significantly lower identification of extracts and purees. Among dysosmics, overall identification of trigeminal-dominant extracts and foods was higher than olfactory-dominant extracts and foods. Compared with normosmics, dysosmic subjects reported significantly reduced enjoyment of olfactory-dominant extracts and foods; however, there was no significant difference in enjoyment of trigeminal-dominant extracts or foods.

CONCLUSIONS

Identification and enjoyment of food items is reduced in dysosmic subjects, with the greatest impact in olfactory items. These findings suggest that diet modification might lead to greater enjoyment in those with dysosmia.

Correlation of polyp grading scales with patient symptom scores and olfaction in chronic rhinosinusitis: a systematic review and meta-analysis

BACKGROUND

Various nasal polyp (NP) scoring systems have been proposed and used in the literature. However, no single system has been identified as superior. Correlations between NP scoring systems and patient symptoms, quality of life (QOL) or olfaction vary widely.

METHODS

A systematic search of PubMed, CINAHL, Scopus, and Cochrane Library was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Any study examining endoscopy scores and symptom, QOL or olfaction measures in cross sectional manner or after therapeutic intervention were included.

RESULTS

This review identified 55 studies for a pooled meta-analysis of Lund-Kennedy (LK-NP) polyp scores (N = 6), Meltzer scores (N = 6), Nasal polyp scores (NPS; N = 19), Total polyp score (TPS; N=8) Lilholdt scores (N = 8), Olfactory cleft endoscopy score (OCES; N =4), Discharge, inflammation, polyp/edema score (DIP; N = 2), and Perioperative sinus endoscopy score (POSE; N = 2). Meta-regression assessed correlations between NP grading systems and SNOT-22, nasal congestion scores, total nasal symptom scores (TNSS), and Smell Identification Test-40 (SIT40). None of the NP grading systems correlated significantly with any symptom, QOL or olfactory metric. In intervention studies of surgery or monoclonal antibody treatment, changes in NPS scores did not correlate with any patient reported outcome measure (PROM) or olfactory outcomes.

CONCLUSION

Current NP endoscopic scoring systems are not associated with PROMs such as SNOT-22, nasal congestion scores, and TNSS as well as objective measures of olfaction. NP grading systems with improved clinical utility are needed.

The Suprasellar Meningioma Patient-Reported Outcome Survey: a disease-specific patient-reported outcome measure for resection of suprasellar meningioma

OBJECTIVE

Suprasellar meningioma resection via either the transcranial approach (TCA) or the endoscopic endonasal approach (EEA) is an area of controversy and active evaluation. Skull base surgeons increasingly consider patient-reported outcomes (PROs) when choosing an approach. No PRO measure currently exists to assess quality of life for suprasellar meningiomas.

METHODS

Adult patients undergoing suprasellar meningioma resection between 2013 and 2019 via EEA (n = 14) or TCA (n = 14) underwent semistructured interviews. Transcripts were coded using a grounded theory approach to identify themes as the basis for a PRO measure that includes all uniquely reported symptoms. To assess content validity, 32 patients and 15 surgeons used a Likert scale to rate the relevance of items on the resulting questionnaire and the general Patient-Reported Outcomes Measurement Information System-29 (PROMIS29). The mean scores were calculated for all items and compared for TCA versus EEA patient cohorts by using unpaired t-tests. Items on either questionnaire with mean scores ≥ 2.0 from patients were considered meaningful and were aggregated to form the novel Suprasellar Meningioma Patient-Reported Outcome Survey (SMPRO) instrument.

RESULTS

Qualitative analyses resulted in 55 candidate items. Relative to patients who underwent the EEA, those who underwent the TCA reported significantly worse future outlook before surgery (p = 0.01), tiredness from medications 2 weeks after surgery (p = 0.001), and word-finding and memory difficulties 3 months after surgery (p = 0.05 and < 0.001, respectively). The items that patients who received a TCA were most concerned about included medication-induced lethargy after surgery (2.9 ± 1.3), blurry vision before surgery (2.7 ± 1.5), and difficulty reading due to blurry vision before surgery (2.7 ± 2.7). Items that patients who received an EEA were most concerned about included blurry vision before surgery (3.5 ± 1.3), difficulty reading due to blurry vision before surgery (2.4 ± 1.3), and problems with smell postsurgery (2.9 ± 1.3). Although surgeons overall overestimated how concerned patients were about questionnaire items (p < 0.0005), the greatest discrepancies between patient and surgeon relevance scores were for blurry vision pre- and postoperatively (p < 0.001 and < 0.001, respectively) and problems with taste postoperatively (p < 0.001). Seventeen meningioma-specific items were considered meaningful, supplementing 8 significant PROMIS29 items to create the novel 25-item SMPRO.

CONCLUSIONS

The authors developed a disease- and approach-specific measure for suprasellar meningiomas to compare quality of life by operative approach. If demonstrated to be reliable and valid in future studies, this instrument may assist patients and providers in choosing a personalized surgical approach.

ABBREVIATIONS

EEA = endoscopic endonasal approach; GTR = gross-total resection; PRO = patient-reported outcome; PROMIS29 = Patient-Reported Outcomes Measurement Information System-29; QOL = quality of life; SMPRO = Suprasellar Meningioma Patient-Reported Outcome Survey; TCA = transcranial approach.

The Olfactory Cleft Endoscopy Scale: a multi-institutional validation study in chronic rhinosinusitis

BACKGROUND

Olfactory dysfunction (OD) associated with chronic rhinosinusitis (CRS) remains quite challenging. Instruments to precisely assess olfactory cleft anatomy and their association with olfaction are needed.

METHODS

The olfactory cleft endoscopy scale (OCES) was used to assess the olfactory cleft in healthy control subjects and a cohort of patients with CRS. Psychophysical and psychosocial olfactory function were assessed and correlations with OCES scores were measured.

RESULTS

Control subjects and subjects with CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP) were enrol- led. OCES correlated with both psychophysical and psychosocial olfaction, as measured by threshold, discrimination and identi- fication (TDI) scores and Questionnaire on Olfactory Disorders (QOD-NS) scores for all case and control subjects combined. OCES improved in both CRS groups postoperatively with the highest correlation seen in postoperative olfaction in CRSwNP patients. CRS patients who achieve near perfect OCES and sinus endoscopy scores after surgery have olfactory metrics that are indistin- guishable from controls regardless of polyp status.

CONCLUSIONS

The OCES is a valid olfactory-specific measure that demonstrates strong validity and provides complimentary infor- mation to traditional sinus endoscopy to aid in our understanding of OD associated with CRS.

Nonpharmacological interventions to reduce respiratory viral transmission: an evidence-based review with recommendations

BACKGROUND

Viral respiratory infections are a leading cause of worldwide mortality and exert the potential to cause global socioeconomic crises. However, inexpensive, efficacious, and rapidly deployable strategies to reduce viral transmission are increasingly important in the setting of an ongoing pandemic, though not entirely understood. This article provides a comprehensive review of commonly employed nonpharmacological interventions to interrupt viral spread and provides evidence-based recommendations for their use.

METHODOLOGY

A systematic review of three databases was performed. Studies with defined endpoints of subjects receiving one of five interventions (nasal washing, gargling, personal protective equipment (PPE), social distancing, and hand hygiene) were included. An evidence-based review of the highest level of evidence, with recommendations, was created in accordance with a previously described, rigorous, iterative process.

RESULTS

Fifty-four primary studies were included. The most commonly studied intervention was hand hygiene, followed by PPE, gargling, saline nasal washing, and social distancing.

CONCLUSIONS

Mask use and hand hygiene are strong recommendations for prevention of viral transmission. Donning gloves, gowns, and eye protection are a recommendation in healthcare settings. Saline nasal washing and gargling are options in selected populations. Although an aggregate level of evidence is not provided, the authors recommend social distancing.

Lack of impact of radiologic septal measurements upon patient symptoms and performance of septoplasty during endoscopic sinus surgery

BACKGROUND

Recent literature suggests that concurrent septoplasty during endoscopic sinus surgery (ESS) improves patient outcomes, however, the underlying indications for performing concurrent septoplasty are unknown. The objective of this study was to investigate the relationship between objective radiologic measures of nasal septal deviation with preoperative patient symptomatology and measures of CRS disease severity. We also sought to understand the association of objective radiologic measurements with surgeon performance of concurrent septoplasty during ESS.

METHODOLOGY

Seventy-four patients with CRS undergoing ESS were prospectively enrolled. Angles of septal deviation, intranasal areas and volumes were assessed on preoperative computed tomography (CT) scans and correlated with a robust battery of patient reported outcomes measures (PROMs), objective measures of CRS severity including olfaction scores, radiologic and endoscopic staging, and performance of septoplasty.

RESULTS

Intranasal areas and volumes demonstrated only weak linear associations with patient-reported nasal congestion, however, angles of septal deviation alone did not correlate with congestion or any other PROM measure. Meanwhile, radiologic septal-related measurements did not correlate with objective measures of CRS disease severity or the performance of a concurrent septoplasty.

CONCLUSIONS

Though prior studies demonstrate improved patient outcomes in the setting of concurrent septoplasty during ESS, this study failed to establish an association between preoperative radiologic septal-related measurements and patient symptomatology or surgeon decision to perform septoplasty. Although objective factors to identify patients most likely to benefit from concurrent septoplasty remain unidentified, the potential improvement of surgical recommendations and patient outcomes makes this an important area of continued investigation.

Responsiveness and reliability of the Sinus Control Test in chronic rhinosinusitis

BACKGROUND

The Sinus Control Test (SCT) is a patient-reported questionnaire designed to help physicians identify sub-optimally controlled chronic rhinosinusitis (CRS). This study measures responsiveness to surgery and reliability of the SCT.

METHODOLOGY

Adults meeting diagnostic criteria for CRS were recruited from rhinology clinics at a tertiary academic institution. To measure responsiveness, the SCT was administered at baseline and at least 3 months after surgery to 62 CRS patients. To measure reliability, the SCT was administered at two clinical encounters a maximum of 14 days apart to 22 CRS patients.

RESULTS

Total SCT scores significantly improved from baseline to post-operative follow-up, and the distribution of patients with total SCT scores falling into the uncontrolled, partially controlled, and controlled categories before and after surgery were significantly different in the direction of improvement. The SCT met minimum standards for reliability and internal consistency as measured by: test-retest reliability coefficient, intra-class correlation coefficients, and item-total correlations. Cronbach alpha; values with each item deleted were lower than the overall Cronbach alpha. The SCT captures the full range of disease control as measured by floor and ceiling effects.

CONCLUSION

The SCT is responsive to surgical intervention and a reliable tool to monitor changes in CRS control levels.

Vitamin D3 correlates inversely with systemic dendritic cell numbers and bone erosion in chronic rhinosinusitis with nasal polyps and allergic fungal rhinosinusitis

Vitamin D(3) (VD(3) ) is a steroid hormone that regulates bone health and numerous aspects of immune function and may play a role in respiratory health. We hypothesized that T helper type 2 (Th2) disorders, chronic rhinosinusitis with nasal polyps (CRSwNP) and allergic fungal rhinosinusitis (AFRS) would have VD(3) deficiencies, resulting in increased mature dendritic cells (DCs) and bone erosion. We conducted a retrospective study examining VD(3) levels in patients with AFRS (n = 14), CRSwNP (n = 9), chronic rhinosinusitis without nasal polyps (CRSsNP) (n = 20) and cerebrospinal fluid leak repair (non-diseased controls) (n = 14) at time of surgery. Circulating immune cell levels were determined by immunostaining and flow cytometric analysis. Plasma VD(3) and immune regulatory factors (granulocyte-macrophage colony-stimulating factor and prostaglandin E(2) ) were measured by enzyme-linked immunosorbent assay. It was observed that CRSwNP and AFRS demonstrated increased circulating DCs, while chronic rhinosinusitis without nasal polyps displayed increased circulating macrophages. CRSwNP and AFRS were to found to have insufficient levels of VD(3) which correlated inversely with circulating numbers of mature DCs, DC regulatory factors and bone erosion. CRSsNP displayed no change in circulating DC numbers or VD(3) status compared to control, but did display increased numbers of circulating macrophages that was independent of VD(3) status. Lastly, VD(3) deficiency was associated with more severe bone erosion. Taken together, these results suggest support a role for VD(3) as a key player in the immunopathology of CRSwNP and AFRS.

Endoscopic repair of frontal sinus cerebrospinal fluid leaks

OBJECTIVE

To describe endoscopic management of frontal sinus cerebrospinal fluid (CSF) leaks.

STUDY DESIGN

Retrospective.

METHODS

We reviewed all frontal sinus CSF leaks treated using an endoscopic approach at our institutions from 1998 to 2003. CSF leaks originated immediately adjacent to or within the frontal recess or frontal sinus proper for inclusion in the study. Data collected included demographics, presenting signs and symptoms, site and size of skull-base defect, surgical approach, repair technique, and clinical follow up.

RESULTS

Seven frontal sinus CSF leaks in six patients were repaired endoscopically. Average age of presentation was 45 years (range 25-65 years). Aetiology was idiopathic (three), congenital (one), accidental trauma (one), and surgical trauma (two). All patients presented with CSF rhinorrhea; two patients presented with meningitis. Four defects originated in the frontal recess, while two others involved the posterior table and frontal sinus outflow tract. Four patients had associated encephaloceles. We performed endoscopic repair in all six patients with one patient requiring an adjuvant osteoplastic flap without obliteration. All repairs were successful at the first attempt with a mean follow up of 13 months. All frontal sinuses remained patent on both post-operative endoscopic and radiographic exam.

CONCLUSIONS

Endoscopic repair of frontal sinus CSF leaks and encephaloceles can be an effective method if meticulous attention is directed toward preservation of the frontal sinus outflow tract, thus avoiding an osteoplastic flap and obliteration. The major limiting factor for an endoscopic approach is extreme extension superiorly or laterally within the posterior table beyond the reach of current instrumentation.

Microbiology of chronic frontal sinusitis

OBJECTIVES

To determine bacterial and fungal organisms that are present in patients undergoing surgery for chronic frontal sinusitis.

STUDY DESIGN

Retrospective, nonrandomized study.

METHODS

Retrospective, nonrandomized bacterial and fungal cultures were performed on 46 sinus aspirates obtained by frontal sinus trephination performed on 30 consecutive patients with chronic frontal sinusitis.

RESULTS

Six patients were having sinus surgery for the first time, 19 patients had undergone prior functional endoscopic sinus surgery without instrumentation of the frontal sinus/recess, and the third group included 5 patients who had undergone prior frontal sinus/recess surgery. Preoperative computed tomography scan of the frontal sinuses revealed complete opacification in 63% (29/46 frontal sinuses) and partial opacification in 22% (10/46), and no data were available for 15% (7/46). Aerobic cultures revealed that 38% (13/35 cultures) had no growth, 21% (7/35) grew Staphylococcus aureus, 21% (7/35) grew coagulase-negative Staphylococcus, 9% (3/35) grew Haemophilus influenzae, and 26% (9/35) grew a variety of other organisms. Anaerobic cultures were positive in 3% (1/32) of sinuses, and fungal cultures were positive in 4% (1/24). Haemophilus influenzae was most common in primary cases, whereas coagulase-negative Staphylococcus was most common in patients undergoing revision frontal sinus surgery. There were no other significant differences between cultures from patients undergoing revision frontal sinus surgery, revision functional endoscopic sinus surgery without prior frontal surgery, and primary surgery.

CONCLUSIONS

This study suggests that organisms involved in chronic inflammatory disease of the frontal sinus may change after previous sinus surgery. The study failed to support a significant role for anaerobes. The role for coagulase-negative Staphylococcus as a potential pathogen or a contaminating agent remains unclear.

Aggressive endoscopic resection of inverted papilloma: an update

OBJECTIVE

Endoscopic resection has been proposed for sinonasal inverted papilloma (IP). Our objective was to determine the efficacy of aggressive endoscopic resection of IP.

METHODS

Retrospective analysis was performed on patients undergoing endoscopic resection of IP at the University of Virginia between 1990 and 1996. Total ethmoidectomies, wide maxillary antrostomies, frontal recess explorations, sphenoidotomies, and turbinate resection were performed as required. Once all visible papilloma was removed, residual mucosa was removed by using a diamond burr to polish bone at the site of origin.

RESULTS

Twenty-one patients were treated with endoscopic resection of IP. Only 1 of 21 patients had an adjunctive external procedure (an osteoplastic flap without obliteration). Average follow-up was 41.9 months after initial aggressive endoscopic resection at the ureterovesical angle. Recurrences occurred in 19% (4/21) of patients. One of the 4 had two recurrences. Recurrences occurred in 16 months or less, except for one noted at 35 months and another at 56 months.

CONCLUSIONS

Aggressive endoscopic resection of IP by experienced rhinologists is an acceptable treatment.

Autologous fibrin sealant reduces pain after tonsillectomy

OBJECTIVES/HYPOTHESIS

Pain is a major cause of morbidity after tonsillectomy. Although various efforts have been made to reduce pain, the use of oral analgesics, which can have adverse side effects, remains the standard of care. It is hypothesized that fibrin sealant, used to achieve hemostasis and enhance healing in many surgical procedures, might help decrease pain after this operation.

STUDY DESIGN

A prospective, randomized, blinded study was performed on 20 children aged 5 to 17 years who were undergoing tonsillectomy, to evaluate the efficacy of FIBRIN SEALANT in reducing postoperative pain.

METHODS

All patients pre-donated 40 mL of blood from which autologous concentrated fibrinogen was prepared by cryoprecipitation. In the fibrin sealant group, fibrinogen and topical bovine thrombin were sprayed onto the surgical site to form fibrin sealant at the conclusion of tonsillectomy. The 10 patients in the control group (C) received no fibrin sealant. Patients rated their level of pain immediately after surgery and at regular intervals for 3 days after surgery using the Wong-Baker Faces Pain Rating Scale (1-6). Emesis, postoperative bleeding, medications, and adverse events were also evaluated.

RESULTS

At 7.00 P.M. on postoperative day (POD) 0, the mean +/- SD fibrin sealant group pain score (2.9+/-0.41 units) was significantly lower than for the C group (4.1+/-0.43 units; P < or = .05). There was also a trend in favor of less pain in the fibrin sealant group at 7:00 P.M. on POD 1, with a mean of 3.5+/-0.43 units versus 2.4+/-0.48 units for C (P = .15). The odds of a patient in C experiencing emesis were 8.16 times higher, (P < or = .05) than for patients in the fibrin sealant group.

CONCLUSIONS

Fibrin sealant significantly reduced pain the evening after pediatric tonsillectomy and also decreased the chance of experiencing emesis. Thus fibrin sealant may be clinically useful as an adjunct to tonsillectomy.

Elevated nitric oxide metabolite levels in chronic sinusitis

Decreased exhaled nitric oxide (NO) is found in chronic sinusitis. NO metabolites (nitrates, nitrites, and S-nitrosothiols) were measured in sinus lavages with a rabbit model of chronic sinusitis. NO metabolite levels (mean +/- SD) were 3.0+/-1.6 micromol/L in uninfected rabbits, 10.7+/-11.4 micromol/L in infected animals, and 7.6+/-5.4 micromol/L in postantrostomy recovering animals. Infected sinuses had elevated levels of NO metabolites that were statistically significant (P<0.01) when compared with uninfected sinuses. Mucociliary transport velocity was measured in uninfected (16.0+/-5.7 mm/minute), infected (5.2+/-1.3 mm/minute), and recovery phases (3.0 mm/minute). Endoscopic appearance, light and electron microscopy, and bacterial cultures improved during recovery. Elevated levels of NO metabolites were found during chronic sinusitis and began to return to normal levels during recovery. The possible link between NO in epithelial autotoxicity and host defense mechanisms warrants further investigation.

Effects of fibrin sealant-containing antibiotics in a rabbit model of chronic sinusitis

Postoperative complications of sinus surgery include bleeding, infection, and synechiae. Improved subjective outcomes in humans treated with fibrin sealant (FS) after endoscopic sinus surgery (ESS) have been reported. Streptococcus pneumoniae was used to initiate chronic sinusitis in occluded rabbit sinuses in order to evaluate the role of FS in mucosal healing. Six weeks later, all animals had maxillary antrostomies. Homologous FS-containing ciprofloxicin (100 mg/mL) and clindamycin (15 mg/mL) was applied topically to treatment rabbits (n = 9). Control rabbits (n = 10) received no antibiotics. Two weeks into the recovery phase after antrostomies, all animals were re-examined. Mucociliary transport velocity (mean +/- standard deviation in mm/minute) was measured in all sinuses (n = 38) during healthy (100% measurable, 13.82 +/- 4.16), infected (18% measurable, 4.74 +/- 0.42), and recovery phases (5% measurable, 6.30 +/- 4.67). In both groups, mucopurulent discharge was present in the majority of sinuses (control group 18/20, FS group 16/18). In addition, there was no significant difference in the recovery phase between the two groups when comparing changes in the size of antrostomies, light microscopy, or culture clearance. Scanning electron microscopy did suggest a possible improvement in ciliary regeneration in the FS group. Application of FS-containing antibiotics did not appear to improve healing after ESS in our rabbit model of chronic sinusitis.

Surgery for the dysfunctional nasal valve. Cadaveric analysis and clinical outcomes

OBJECTIVES

To quantify changes in the cross-sectional area of the nasal valve after placement of spreader grafts and flaring sutures and to review clinical outcomes after nasal valve surgery.

DESIGN

The minimal cross-sectional area of cadaveric nasal valves was measured after placement of spreader grafts and flaring sutures. Clinical outcomes for patients undergoing functional rhinoplasty were retrospectively reviewed.

SETTING

Academic medical center.

SUBJECTS

Six fresh cadaver heads and a review of patients from September 1994 through May 1998.

INTERVENTION

Acoustic rhinometry was performed after placement of spreader grafts, flaring sutures, and the two together. Clinically, a site-specific repair was performed with spreader grafts and flaring sutures for statically narrowed internal nasal valves and cartilaginous battens for dynamic collapse.

MAIN OUTCOME MEASURE

Cross-sectional areas of cadaveric valves. Functional and aesthetic results were determined by nasal patency scores from 1 (complete obstruction) to 10 (complete patency) and a rating of postsurgical cosmetic changes.

RESULTS

Spreader grafts improved the cadaveric minimal cross-sectional areas by 5.4% (P > .05), flaring sutures by 9.1% (P > .05), and spreader grafts combined with flaring sutures by 18.7% (P < .05). Mean nasal patency scores improved from 3.4 to 6.5 (P < .01) with the combination of spreader grafts and flaring sutures. Cartilaginous battens improved scores from 2.7 to 6.3 (P < .01).

CONCLUSIONS

The combination of flaring sutures and spreader grafts has the greatest impact on the cadaveric nasal airway. Either technique alone failed to have a statistically significant impact on the minimal cross-sectional area of the nasal valve. Clinical review confirms significant improvement in nasal function using this combination technique.

Functional nasal surgery

Functional nasal surgery is designed to repair nasal obstruction frequently caused by previous reduction rhinoplasty or blunt nasal trauma. Distinguishing the statically narrowed nasal valve from the weak sidewall with dynamic collapse is an important part of the preoperative evaluation. Our workhorse for repair of static obstruction is the combination of spreader grafts and flaring sutures, which together create a significant increase in the intranasal valve area. Dynamic collapse of the sidewall is corrected with cartilaginous batten grafts designed to increase sidewall rigidity. Less common causes of valve obstruction, such as tip ptosis, facial paralysis, cicatricial stenosis, Mohs reconstruction, and paradoxical lateral crura, are repaired by more individualized techniques.

Signal transduction pathways in modulation of ciliary beat frequency by methacholine

The release of endogenous neurotransmitters plays an important role in the airway mucosal defense system. We studied the in vitro effect of methacholine, a beta-methyl ester of acetylcholine, on the ciliary beat frequency (CBF) of human adenoid explants and its mechanism of action. Tissue explants were cultured at 35 degrees C and covered with 1.0 mL of culture medium: minimum essential Eagle's medium (MEM) containing L-arginine (1.2 x 10(-3) mol/L). Methacholine was added to the cultured tissue at concentrations of 10(-10), 10(-8), and 10(-6) mol/L. The CBF was determined by phase contrast microscopy and microphotometry. Methacholine increased CBF in a dose-dependent manner with a maximum increase of 23.0% +/- 1.8% (p < .001). Atropine (10(-6) mol/L) significantly inhibited the ciliostimulatory effects of methacholine (p < .0007). The role of endogenous prostaglandins in methacholine-induced ciliostimulation was determined by treating specimens with a cyclooxygenase inhibitor (diclofenac sodium). Diclofenac (10(-6) mol/L) significantly inhibited the ciliostimulatory effects of methacholine (p < .0007). To determine if nitric oxide (NO) acts as an intermediary in ciliostimulation by methacholine, endogenous NO production was inhibited by treating specimens with an L-arginine analog, NG-nitro-L-arginine methyl ester (L-NAME), prior to addition of methacholine. L-NAME (10(-6) mol/L) inhibited the effects of methacholine in L-arginine-free MEM (p < .008), and this inhibition was reversed by L-arginine (10(-3) mol/L). To further examine the actions of NO in methacholine-induced ciliostimulation, a cyclic guanosine 3'5'-monophosphate (cGMP) kinase inhibitor (KT-5823) was used, prior to the addition of methacholine. KT-5823 (10(-6) mol/L) significantly inhibited the effects of methacholine (p < .0001). Ciliostimulation by methacholine in human upper airway mucosa involves both prostaglandin and NO second messengers and activation of a cGMP-dependent kinase.

Dual signal transduction mechanisms modulate ciliary beat frequency in upper airway epithelium

This study investigated the effects of methacholine and terbutaline on the ciliary beat frequency (CBF) of upper airway epithelium. The CBF of cultured human adenoid explants was measured using microphotometry. Methacholine (10(-6) M) and terbutaline (10(-6)M) increased CBF a maximum of 23.0 +/- 1.8% (P < 0.001) and 16.5 +/- 2.3% (P < 0.001). Inhibition of endogenous nitric oxide (NO) production by nitro-L-arginine methyl ester (L-NAME) (10(-6) M) abolished the effects of methacholine in L-arginine-free medium (P < 0.008). This inhibition was reversed by addition of L-arginine. There was no inhibition of terbutaline-induced ciliostimulation by L-NAME (P < 0.5). KT-5823 (10(-6)M), a guanosine 3',5'-cyclic monophosphate (cGMP) kinase inhibitor, significantly inhibited the effects of methacholine (P < 0.0001), but not terbutaline (P > 0.15). H-89 (10(-6) M), a cAMP kinase inhibitor, significantly inhibited terbutaline-induced ciliostimulation (P < 0.0001), but not methacholine-induced ciliostimulation (P > 0.05). Diclofenac (10(-6) M), a cyclooxygenase inhibitor, significantly inhibited the effects of methacholine (P < 0.0007) but had no effect on terbutaline-induced ciliostimulation (P > 0.05). These findings suggest that the CBF of upper airway epithelium is modulated through at least two distinct pathways. The beta 2-adrenoceptor produces ciliary stimulation by a pathway involving increased intracellular cAMP levels, while the muscarinic receptor increases CBF by a mechanism involving production of prostaglandins, NO, and cGMP.

Signal transduction mechanisms in substance P-mediated ciliostimulation

Substance P is a neuropeptide released by afferent neurons in the respiratory tract during inflammatory reactions. It produces effects on blood vessels, bronchial smooth muscle, nasal glands, and respiratory cilia. We studied the in vitro effect of substance P on the ciliary beat frequency of human adenoid explants and its mechanism of action. Substance P was added to cultured adenoid at concentrations of 10(-10), 10(-8), 10(-6), and 10(-4) mol/L. Ciliary beat frequency was determined with phase-contrast microscopy and microphotometry. Substance P increased ciliary beat frequency a maximum of 11.9% +/- 3.8% (p < 0.01). Diclofenac (10(-6) mol/L) significantly blocked the ciliostimulatory effects of SP (p < 0.022), indicating that prostaglandin synthesis is an intermediate step in the action of substance P on ciliary beat frequency. The L-arginine analogs, NG-nitro-L-arginine methyl ester and NG-monomethyl-L-arginine, inhibit nitric oxide synthesis from L-arginine. L-Arginine analogs (10(-4) to 10(-2) mol/L) inhibited the effect of substance P (p < 0.02 at the higher concentration). This inhibition was reversed by adding L-arginine, demonstrating that nitric oxide production is a required step in substance P-induced ciliostimulation. Substance P stimulates ciliary activity in human nasal mucosa as a result of secondary production and release of endogenous prostaglandins and nitric oxide. It is likely that inflammatory disease processes that stimulate release of substance P and subsequent prostaglandin and nitric oxide production modify mucociliary transport. Pharmacologic modification of substance P and its second messengers may eventually permit regulation of this important defense mechanism and control of neurogenic inflammation.

Cost containment via expense rationalization in open-heart surgery

Hospital costs and the fees of the surgeon, assistant, anesthesiologist, and cardiologist were reviewed in a community hospital doing 425 cardiac operations in the year 1977. Each item of the bill was analyzed and discussed with each department of the hospital. Changes made in the routine saved approximately $1000 per patient--16% for patients having mitral valves replacement (MVR), 15% for those having aortic valve replacement (AVR), 21% for those having saphenous vein bypass grafts (SVBG), and 23% for pediatric cases. The areas most likely to yield economic reductions without alteration of the quality of care are operating room, patient room, respiratory therapy, and pharmacy. Making the nurses, scrub technicians, surgical assistants, residents, and staff surgeons aware of the cost of each item and periodically discussing the alternatives could yield surprisingly large savings.

Aneurysm of saphenous vein bypass graft to coronary artery

A few cases of aneurysmal dilatation of autogenous vein grafts to peripheral arteries have been reported. However, to our knowledge, no case of this complication in coronary artery vein bypass grafts have been found. We are presenting a case of a vein graft aneurysm which appeared 6 months postoperatively. The patient had had an aortic valve replacement and a vein bypass graft to the right coronary artery.

Cardiac compression due to closure of the median sternotomy in open heart surgery

Following open heart surgery, approximation of the median sternotomy can compress the heart and produce cardiac tamponade. A proposed new technique to eliminate this compression by sternal traction is presented.