Comparison of patient-reported outcomes and clinical characteristics among patients with pituitary macroadenomas and giant adenomas

KEY POINTS

Patients with giant adenomas are more likely to have tumor extension into the paranasal sinuses. Compared to macroadenomas, giant adenomas are not associated with worse preoperative SNOT-22 scores.

Predictors of Sinonasal Improvement After Highly Effective Modulator Therapy in Adults with Cystic Fibrosis

OBJECTIVES

The 22-question SinoNasal Outcome Test (SNOT-22) assesses chronic rhinosinusitis (CRS) severity. We aimed to identify predictors of SNOT-22 score improvement following highly effective modulator therapy (HEMT) initiation and to corroborate the SNOT-22 minimal clinically important difference (MCID) in adults with cystic fibrosis (CF).

METHODS

Prospective observational data was pooled from four studies across 10 US centers investigating people with CF (PwCF) and CRS. Three studies evaluated HEMT's impact on CRS. For participants enrolled prior to HEMT initiation, SNOT-22 scores were obtained at baseline and after 3-6 months of HEMT. Multivariate regression identified predictors of improvement. Cronbach's alpha and four distribution-based methods were used to assess internal consistency and calculate the MCID of the SNOT-22.

RESULTS

A total of 184 PwCF participated with mean baseline SNOT-22 scores ranging from 18.1 to 56.7. Cronbach's alpha was ≥0.90 across sites. Participants at sites with pre- and post-HEMT data reported improvement in SNOT-22 scores after initiating HEMT (all p < 0.05). Worse baseline SNOT-22 score (odds ratio (OR): 1.05, p < 0.001, 95% CI: 1.02-1.08), F508del homozygosity (OR: 4.30, p = 0.040, 95% CI: 1.14-18.99), and absence of prior modulator therapy (OR: 4.99, p = 0.017, 95% CI: 1.39-20.11) were associated with greater SNOT-22 improvement. The mean MCID calculated via distribution-based methods was 8.5.

CONCLUSION

Worse baseline sinonasal symptoms, F508del homozygosity, and absence of prior modulator therapy predicted greater improvement after HEMT initiation. The mean MCID for SNOT-22 in PwCF is 8.5 points, similar to non-CF individuals with CRS, and provides a threshold specifically for PwCF. The SNOT-22 has strong internal consistency in PwCF.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

Factors that predict pursuing sinus surgery in the era of highly effective modulator therapy

BACKGROUND

Comorbid chronic rhinosinusitis (CRS) remains unresolved for many people with cystic fibrosis (PwCF). While highly effective modulator therapy improves quality-of-life and symptom severity, the impact of this intervention and other factors associated with pursuing endoscopic sinus surgery (ESS) remains understudied.

METHODS

Adult PwCF + CRS were enrolled into a prospective, observational, multi-institutional study. Participants completed validated outcome measures to evaluate respiratory symptom severity, depression, headache, and sleep quality, as well as nasal endoscopy, sinus computed tomography (CT), and olfactory testing. Bivariate comparisons and regression modeling evaluated treatment cofactors, disease characteristics, and outcome measures associated with pursuing ESS.

RESULTS

Sixty PwCF were analyzed, including 24 (40%) who elected ESS. Pursuing ESS was associated with worse SinoNasal Outcome Test (SNOT-22) total, rhinologic, psychological, and sleep dysfunction domain scores; worse Patient Health Questionnaire-9-Revised depression scores; worse Pittsburgh Sleep Quality Index total scores; worse weight, role, emotion, and eating domain scores on the Cystic Fibrosis Questionnaire-Revised; more severe disease on nasal endoscopy; and lack of modulator therapy (all p < 0.050). Multivariable regression identified that worse SNOT-22 total score was associated with electing ESS (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.02-1.16, p = 0.015) and elexacaftor/tezacaftor/ivacaftor (ETI) treatment (OR 0.04, 95% CI 0.004-0.34, p = 0.004) was associated with pursing medical therapy.

CONCLUSIONS

Worse sinonasal symptom burden, lack of ETI treatment, sleep quality, depression, and nasal endoscopy scores were associated with electing ESS, while lung disease severity and sinus CT scores were not. ETI use was associated with lower odds of pursuing ESS independent of sinonasal symptom burden.

Predictive factors for decreased baseline quality of life in patients with sinonasal malignancies

BACKGROUND

The impact of sinonasal malignancies (SNMs) on quality of life (QOL) at presentation is poorly understood. The Sinonasal Outcome Test (SNOT-22) and University of Washington Quality of Life (UWQOL) are validated QOL instruments with distinctive subdomains. This study aims to identify factors impacting pretreatment QOL in SNM patients to personalize multidisciplinary management and counseling.

METHODS

Patients with previously untreated SNMs were prospectively enrolled (2015-2022) in a multicenter observational study. Baseline pretreatment QOL instruments (SNOT-22, UWQOL) were obtained along with demographics, comorbidities, histopathology/staging, tumor involvement, and symptoms. Multivariable regression models identified factors associated with reduced baseline QOL.

RESULTS

Among 204 patients, presenting baseline QOL was significantly reduced. Multivariable regression showed worse total SNOT-22 QOL in patients with skull base erosion (p = 0.02). SNOT-rhinologic QOL was worse in women (p = 0.009), patients with epistaxis (p = 0.036), and industrial exposure (p = 0.005). SNOT extranasal QOL was worse in patients with industrial exposure (p = 0.016); worse SNOT ear/facial QOL if perineural invasion (PNI) (p = 0.027). Squamous cell carcinoma pathology (p = 0.037), palate involvement (p = 0.012), and pain (p = 0.017) were associated with worse SNOT sleep QOL scores. SNOT psychological subdomain scores were significantly worse in patients with palate lesions (p = 0.022), skull base erosion (p = 0.025), and T1 staging (p = 0.023). Low QOL was more likely in the presence of PNI on UW health (p = 0.019) and orbital erosion on UW overall (p = 0.03). UW social QOL was worse if palatal involvement (p = 0.023) or PNI (p = 0.005).

CONCLUSIONS

Our findings demonstrate a negative impact on baseline QOL in patients with SNMs and suggest sex-specific and symptom-related lower QOL scores, with minimal histopathology association. Anatomical tumor involvement may be more reflective of QOL than T-staging, as orbital and skull base erosion, PNI, and palate lesions are significantly associated with reduced baseline QOL.

Decreases in Rhinology Care Utilization by People with Cystic Fibrosis on Highly Effective Modulator Therapy

BACKGROUND

Many people with cystic fibrosis (PwCF) have chronic rhinosinusitis (CRS). CRS requires additional management beyond that of pulmonary disease and leads to increased utilization of healthcare resources. Elexacaftor/tezacaftor/ivacaftor (ETI) is a highly effective modulator therapy that has been shown to improve CRS in PwCF. However, the impact of ETI on rhinologic healthcare utilization is understudied.

OBJECTIVE

To compare rates of rhinologic healthcare utilization and procedures among PwCF prior to and after initiating ETI therapy.

METHODS

A single-center, cohort study investigating adult PwCF was performed in January 2023. Demographics, clinical characteristics, and data related to CF treatment were retrospectively abstracted. Characteristics of the cohort were compared over 2 periods: the 12-months prior to ETI initiation and the 12-months after ETI initiation. Post-ETI data were linearly extrapolated if a subject had not yet completed the full 12 months of ETI. Paired t-testing, Wilcoxon signed rank testing, and regression analysis were performed.

RESULTS

Of 126 PwCF, 98 (77.8%) were on ETI therapy and 35 (27.7%) were both on ETI and concurrently followed by the rhinology service (ETI-ENT). Rhinology clinic visits (P = .007) and frequency of obtaining nasal cultures (P = .046) decreased for the ETI-ENT cohort after initiating ETI treatment. There were no significant changes in the number of endoscopic sinus surgeries (P = .452) performed. Beyond ETI use, regression analysis did not identify any factors associated with changes in utilization.

CONCLUSION

Aspects of rhinology healthcare utilization by PwCF decreased after initiation of ETI therapy. Additional studies are needed to determine rhinologic healthcare requirements for PwCF who remain on ETI for the long-term and to evaluate larger cohorts of PwCF on ETI.

Fungal and Bacterial Microbiome in Sinus Mucosa of Patients with and without Chronic Rhinosinusitis

OBJECTIVES

Dysbiosis of the sinonasal microbiome has been implicated in the pathogenesis of chronic rhinosinusitis (CRS). However, the mycobiome remains largely understudied, and microbial alterations associated with specific CRS subtypes have yet to be delineated. The objective of this study is to investigate the fungal and bacterial microbiome of sinus mucosa in CRS patients with and without nasal polyposis (CRSwNP and CRSsNP) versus healthy controls.

METHODS

Sinus mucosa was obtained from 92 patients (31 CRSsNP, 31 CRSwNP, and 30 controls) undergoing endoscopic sinus/skull base surgery. Data regarding demographics, Lund-MacKay scores, and histopathology were collected. Fungal and bacterial microbiome analysis was performed utilizing internal transcribed spacer amplicon and 16S rRNA sequencing.

RESULTS

Beta diversity of the sinonasal mycobiome differed significantly between CRS and controls (p = 0.001) and between CRSwNP and controls (p = 0.049), but not between CRSwNP and CRSsNP (p = 0.32) nor between CRSsNP and controls (p = 0.06). With respect to the bacterial microbiome, significantly lower alpha diversity was observed between CRS and controls (p < 0.001), CRSwNP versus controls (p < 0.001), and CRSsNP versus controls (p < 0.001). Beta diversity was also significantly different at the genus level between CRSwNP and CRSsNP (p = 0.019), CRSwNP and controls (p = 0.002)), and CRSsNP and controls (p < 0.001). However, alpha and beta diversity did not differ significantly between CRS patients with/without eosinophils or correlate with Lund-MacKay scores.

CONCLUSIONS

Differences in mycobiota diversity in CRS patients in comparison with controls suggest that alterations in the mycobiome may contribute to disease pathogenesis. Our findings also confirmed that diminished diversity among bacterial communities is associated with CRS and that significant differences are present in microbial composition between CRSwNP and CRSsNP.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1054-1062, 2024.

SNOT-22 subdomain outcomes following treatment for sinonasal malignancy: A prospective, multicenter study

BACKGROUND

Patients with sinonasal malignancy (SNM) present with significant sinonasal quality of life (QOL) impairment. Global sinonasal QOL as measured by the 22-item Sinonasal Outcomes Test (SNOT-22) has been shown to improve with treatment. This study aims to characterize SNOT-22 subdomain outcomes in SNM.

METHODS

Patients diagnosed with SNM were prospectively enrolled in a multi-center patient registry. SNOT-22 scores were collected at the time of diagnosis and through the post-treatment period for up to 5 years. Multivariable regression analysis was used to identify drivers of variation in SNOT-22 subdomains.

RESULTS

Note that 234 patients were reviewed, with a mean follow-up of 22 months (3 months-64 months). Rhinologic, psychological, and sleep subdomains significantly improved versus baseline (all p < 0.05). Subanalysis of 40 patients with follow-up at all timepoints showed statistically significant improvement in rhinologic, extra-nasal, psychological, and sleep subdomains, with minimal clinically important difference met between 2 and 5 years in sleep and psychological subdomains. Adjuvant chemoradiation was associated with worse outcomes in rhinologic (adjusted odds ratio (5.22 [1.69-8.66])), extra-nasal (2.21 [0.22-4.17]) and ear/facial (5.53 [2.10-8.91]) subdomains. Pterygopalatine fossa involvement was associated with worse outcomes in rhinologic (3.22 [0.54-5.93]) and ear/facial (2.97 [0.32-5.65]) subdomains. Positive margins (5.74 [2.17-9.29]) and surgical approach-combined versus endoscopic (3.41 [0.78-6.05])-were associated with worse psychological outcomes. Adjuvant radiation (2.28 [0.18-4.40]) was associated with worse sleep outcomes.

CONCLUSIONS

Sinonasal QOL improvements associated with treatment of SNM are driven by rhinologic, extra-nasal, psychological, and sleep subdomains.

Risk Factors Associated with Postoperative CSF Leak in Extrasellar Tumors

Objective  While postoperative cerebrospinal fluid (CSF) leak rates of pituitary tumors have been frequently studied, there are fewer studies examining postoperative CSF leak rates for extrasellar tumors. The purpose of this study was to identify risk factors for the development of postoperative CSF leak in patients undergoing endoscopic surgery for extrasellar tumors. Methods  A retrospective chart review was done for patients who underwent endoscopic resection for extrasellar tumors between 2008 and 2020. Age, gender, tumor type, tumor location, tumor size, reconstruction technique, medical comorbidities, and other potential risk factors were identified. Data was analyzed to identify significant risk factors for development of postoperative CSF leak. Results  There were 100 patients with extrasellar tumors who developed intraoperative CSF leaks. Seventeen patients (17%) developed postoperative CSF leaks. Leaks occurred at a median of 2 days following surgery (range 0-34 days). Clival tumors had a significantly higher incidence of postoperative leak than those in other sites ( p  < 0.05). There were no significant differences in other locations, body mass index, tumor size, reconstruction technique, medical comorbidities, or other factors. There were nearly twice as many intraoperative grade III leaks in those who developed postoperative CSF leak, but this was not statistically significant ( p  = 0.12). Conclusion  Extrasellar tumors, particularly clival tumors, have a higher rate of postoperative CSF leak than pituitary tumors. Prophylactic lumbar drains can be considered for patients at high risk for developing postoperative CSF leak.

Determining the minimal clinically important difference for the questionnaire of olfactory disorders in people with cystic fibrosis and factors associated with improvement after highly effective modulator therapy

INTRODUCTION

Olfactory dysfunction (OD) is common among people with cystic fibrosis (PwCF). The Questionnaire of Olfactory Disorders (QOD) is a validated instrument that evaluates olfactory-specific quality-of-life. The QOD minimal clinically important difference (MCID) and factors associated with olfactory improvement after elexacaftor/tezacaftor/ivacaftor have not been determined for PwCF.

METHODS

Prospective observational data were pooled from three studies that enrolled adult PwCF with chronic rhinosinusitis (CRS). QOD scores and disease characteristics were assessed. To evaluate internal consistency and calculate the QOD MCID, Cronbach's alpha and four distribution-based methods were employed. For participants who enrolled prior to elexacaftor/tezacaftor/ivacaftor, QOD scores were obtained at baseline and after elexacaftor/tezacaftor/ivacaftor initiation. Multivariable regression was used to identify factors associated with QOD improvement.

RESULTS

Of 129 PwCF included, 65 had QOD scores before and 3-6 months after starting elexacaftor/tezacaftor/ivacaftor. Mean baseline QOD score was 6.5 ± 7.9. Mean Cronbach's alpha was ≥0.85. The MCID estimates were as follows: Cohen's effect size = 1.6, standard error of measurement = 2.5, ½ baseline standard deviation = 4.0, and minimal detectable change = 6.9. Mean MCID was 3.7. Of those with pre/post elexacaftor/tezacaftor/ivacaftor QOD scores, the mean change in QOD was -1.3 ± 5.4. After elexacaftor/tezacaftor/ivacaftor, QOD improvement surpassed the MCID in 22% of participants (14/65). Worse baseline QOD scores and nasal polyps were associated with improved QOD scores after elexacaftor/tezacaftor/ivacaftor (both p < 0.04).

CONCLUSION

The QOD MCID in PwCF was estimated to be 3.7. Elexacaftor/tezacaftor/ivacaftor led to qualitative but not clinically meaningful improvements in QOD score for most PwCF; PwCF with worse baseline QOD scores and nasal polyps improved in a clinically significant manner.

Recurrence patterns among patients with sinonasal mucosal melanoma: A multi-institutional study

OBJECTIVE

To evaluate recurrence patterns and survival after recurrence among patients with sinonasal mucosal melanoma (SNMM).

METHODS

This was a multi-institutional retrospective review from seven U.S. institutions of patients with SNMM from 1991 to 2022. Recurrence was categorized as local, regional, distant, or multifocal. Kaplan-Meier tests were used to evaluate disease-free survival (DFS), overall survival (OS), and post-recurrence survival (PRS) reported with standard errors (SE) and log-rank testing used for comparison. Cox-regression was further used, with hazard ratios (HR) and 95% confidence intervals (CI) reported.

RESULTS

Among 196 patients with SNMM, there were 146 patients with recurrence (74.5%). Among all patients, 60-month DFS (SE) was 15.5% (2.9%), 60-month OS (SE) was 44.7% (3.7%), mean age ± standard deviation at diagnosis was 69.7 ± 12.5 years, and 54.6% were female. In 26 patients who underwent primary treatment of the neck, 60-month DFS did not differ from no treatment (p > 0.05). Isolated distant recurrence was most common (42.8%), followed by local (28.3%), multifocal (20.7%), and regional recurrence (8.3%). Among patients with regional recurrence in the neck, there was no 60-month PRS benefit for patients undergoing salvage neck dissection or radiation (p > 0.05). Among patients with distant recurrence, only immunotherapy was associated with improved 12-month PRS (HR = 0.32, 95% CI = 0.11-0.92, p = 0.034), and no treatment group was associated with improved 24- or 60-month PRS (p > 0.05).

CONCLUSION

SNMM is associated with a high recurrence rate and poor survival. Primary treatment of the neck was not associated with reduced recurrence, and immunotherapy for treatment of distant recurrence was associated with increased 12-month PRS.

Long-term quality of life after treatment in sinonasal malignancy: A prospective, multicenter study

BACKGROUND

Quality of life (QOL) for individuals with sinonasal malignancy (SNM) is significantly under-studied, yet it is critical for counseling and may impact treatment. In this study we evaluated how patient, treatment, and disease factors impact sinonasal-specific and generalized QOL using validated metrics in a large cohort over a 5-year posttreatment time frame.

METHODS

Patients with SNM who underwent definitive treatment with curative intent were enrolled in a prospective, multisite, longitudinal observational study. QOL was assessed using the 22-item Sino-Nasal Outcome Test (SNOT-22) and University of Washington Quality of Life Questionnaire (UWQOL) instruments at pretreatment baseline and multiple follow-ups through 5 years posttreatment. Multivariable modeling was used to determine demographic, disease, and treatment factors associated with disease-specific and generalized physical and social/emotional function QOL.

RESULTS

One hundred ninety-four patients with SNM were analyzed. All QOL indices were impaired at pretreatment baseline and improved after treatment. SNOT-22 scores improved 3 months and UWQOL scores improved 6 to 9 months posttreatment. Patients who underwent open compared with endoscopic tumor resection had worse generalized QOL (p < 0.001), adjusted for factors including T stage. Pterygopalatine fossa (PPF) involvement was associated with worse QOL (SNOT-22, p < 0.001; UWQOL Physical dimension, p = 0.02). Adjuvant radiation was associated with worse disease-specific QOL (p = 0.03). Neck dissection was associated with worse generalized physical function QOL (p = 0.01). Positive margins were associated with worse generalized social/emotional function QOL (p = 0.01).

CONCLUSION

Disease-specific and generalized QOL is impaired at baseline in patients with SNM and improves after treatment. Endoscopic resection is associated with better QOL. PPF involvement, adjuvant radiation, neck dissection, and positive margins were associated with worse QOL posttreatment.

Residential Proximity to a Commercial Pesticide Application Site and Risk of Chronic Rhinosinusitis

Importance

Environmental and occupational toxicants have been shown to be associated with an increased prevalence of chronic rhinosinusitis (CRS). However, few to no studies have evaluated patients for CRS using objective testing and workup protocols that fulfill guidelines for CRS diagnostic criteria. Furthermore, no study, to our knowledge, has investigated the risks of CRS in the context of residential exposure through proximity to a commercial pesticide application site.

Objectives

To evaluate associations of residential proximity to a commercial pesticide application site and the prevalence of CRS with nasal polyps (CRSwNP) and without nasal polyps (CRSwoNP).

Design, Setting, and Participants

This was a retrospective cohort study of patients who presented to a tertiary care institution for rhinology evaluation between March 1, 2018, and December 31, 2022.

Main Outcomes and Measures

The outcome variable was the clinical diagnosis of CRS (CRSwNP, CRSwoNP, or non-CRS control). Patients' residential addresses were utilized to determine pesticide exposure status based on a validated computational geographic information algorithm based on data from the California Pesticide Use Report System. The dichotomous independent variable of exposure status (exposed or non-exposed) was determined by assessing reports of any pesticide applications within 2000 m of each participant's residence in 2017. Multivariable logistic regressions assessing CRS status and CRS subtypes were conducted with pesticide exposure as the primary covariate of interest. The primary study outcome and measurements as well as study hypothesis were all formulated before data collection.

Results

Among a total of 310 patients (90 CRSwNP, 90 CRSwoNP, and 130 control), the mean (SD) age was 50 (17) years; 164 (53%) were female. Race and ethnicity information was not considered. Controlling for patient demographic information, smoking history, county of residence, and medical comorbidities, pesticide exposure was associated with an approximately 2.5-fold increase in odds of CRS (adjusted odds ratio, 2.41; 95% CI, 1.49-3.90). Pesticide exposure was associated with similar risks for CRSwNP (adjusted relative risk ratio [aRRR], 2.34; 95% CI, 1.31-4.18) and CRSwoNP (aRRR, 2.42; 95% CI, 1.37-4.30).

Conclusions and Relevance

The findings of this retrospective cohort study and analysis revealed that residential exposure to commercial pesticide application within a 2000-m buffer was independently associated with an approximately 2.5-fold increase in odds of being diagnosed with CRS. If validated by additional research, this association would have substantial implications for public health.

Safety of Antibiotic Irrigations for Acute Exacerbations of Chronic Rhinosinusitis in Patients with Identical Drug Allergies or Adverse Reactions: A Pilot Study

Objectives: The use of topical antibiotics in the treatment of acute exacerbation of chronic rhinosinusitis (AECRS) represents a viable option prior to initiation of parenteral antibiotics when no oral antibiotic alternatives are available due to patient allergy or adverse reactions. The main objectives of this pilot study were to determine the safety and efficacy of antibiotic irrigations in the treatment of AECRS in patients with documented adverse reactions to the oral form of the drug. Methods: A retrospective review was performed of patients diagnosed with AECRS treated with antibiotic irrigations. Inclusion criteria included a documented allergy or adverse event to the systemic form of the same antibiotic. Patient demographics, medical history, prior sinus surgery, nasal endoscopy findings, and microbiology results were obtained. Side effects to the antibiotic irrigations were recorded. Results: Six patients met the inclusion criteria resulting in 7 treated cases of AECRS. Four patients with adverse effects to oral trimethoprim/sulfamethoxazole (TMP/SMZ) received TMP/SMZ irrigations, and 1 patient with an adverse reaction to oral ciprofloxacin was treated with ciprofloxacin irrigations. One patient with adverse effects to both oral TMP/SMZ and levofloxacin was treated with TMP/SMZ and levofloxacin irrigations, respectively during 2 separate AECRS episodes. Following treatment, 1 case (14.3%) resulted in complete resolution of infection, 1 (14.3%) had partial improvement, and 5 (71.4%) had minimal to no endoscopic improvement at the subsequent clinic visit. There were no adverse reactions to antibiotic irrigations among the entire cohort. Conclusions: Currently, no prior study has examined whether adverse reactions to a systemic antibiotic also occur when the medication is delivered topically via sinonasal irrigations. Our findings suggest that topical administration of antibiotics may be a safe alternative for patients with adverse effects to the systemic form.

Comparison of body size perception of young women in Korea and the United States

Body size perception among young women in Asian and Western countries is believed to be quite different, however, there are no confirming studies. We analyzed the data from young women aged between 20 and 40 who participated in the National Health and Nutrition Examination Survey (2001-2018) of the United States (US) and Korea. US young women had higher rates of being overweight and obesity than Korean young women, and there was no significant change over 20 years. In both countries, the percentage of properly estimating one's own weight exceeded 70 percent and remained relatively steady. The percentage of overestimating one's own weight was only about 10 percent in Korea in 2001, but increased to 20 percent. In the case of the US, the percentage was about 15 percent in 2001-2002, but has since continued to decline. The percentage of underestimating one's own body weight was about 18 percent in Korea in 2001, but decreased to about 8 percent. In the case of the US, the percentage was very low at about 10 percent in 2001-2002, but gradually increased to about 18 percent in 2017-2018. In conclusion, young women in the US tend to underestimate their body size, and those in Korea tend to overestimate it.

Endoscope-Assisted Pedicled Maxillary Artery to Middle Cerebral Artery Bypass: An Anatomic Feasibility Study

BACKGROUND

Extracranial to intracranial bypass is used to augment and/or replace the intracranial circulation for various pathologies. The superficial temporal artery is the mainstay donor for pedicled bypasses to the anterior circulation but can be limited by its variable size, low native flow rates, and potential scalp complications. Interposition grafts such as the radial artery or greater saphenous vein are alternatives but are sometimes limited by size mismatch, length needed to reach the extracranial circulation, and loss of inherent vascular elasticity. Interposition grafts between the maxillary artery (IMA) and middle cerebral artery (MCA) address these limitations.

OBJECTIVE

To explore the feasibility of harvesting the IMA through an endoscopic transnasal, transmaxillary approach to perform a direct IMA to MCA bypass.

METHODS

Combined transcranial and endoscopic endonasal dissections were performed in embalmed human cadavers to harvest the IMAs for intracranial transposition and direct anastomosis to the MCA. Donor and recipient vessel calibers were measured and recorded.

RESULTS

A total of 8 procedures were performed using the largest and distal-most branches of the IMA (the sphenopalatine branch and the descending palatine branch) as pedicled conduits to second division of middle cerebral artery (M2) recipients. The mean diameter of the IMA donors was 1.89 mm (SD ± 0.42 mm), and the mean diameter of the recipient M2 vessels was 1.90 mm (SD ± 0.46 mm).

CONCLUSION

Endoscopic harvest of the IMA using a transnasal, transmaxillary approach is a technically feasible option offering an excellent size match to the M2 divisions of the MCA and the advantages of a relatively short, pedicled donor vessel.

Economic Burden Associated With Nasal Polyposis Recurrence Among Commercially Insured Patients in the United States

OBJECTIVE

To compare health care resource utilization (HRU) and costs among commercially insured patients with nasal polyposis (NP) with and without recurrence after endoscopic sinus surgery (ESS).

STUDY DESIGN

Retrospective matched cohort study.

SETTING

Adults with initial ESS or an NP excision after a new NP diagnosis were identified in Optum's Clinformatics Data Mart Database (October 1, 2014-December 31, 2019).

METHODS

The index date was the date of NP recurrence, identified with a claims-based algorithm for the recurrent cohort, or a random date for the nonrecurrent cohort. Patients in both cohorts were matched 1:1 on baseline characteristics (12 months preindex) via propensity scores and exact matching factors. Annual HRU and costs (2019 US$) were compared between the matched cohorts at 12 months postindex.

RESULTS

NP recurrence was identified among 3343 of 16,693 patients with initial ESS; after matching, each cohort comprised 1574 patients (median age, 54 years; 40% female) with similar baseline health care costs (recurrent, $34,420; nonrecurrent, $33,737). At 12 months postindex, the recurrent cohort had higher HRU, including 36% and 51% more outpatient and emergency department visits, respectively (all P < .01). Mean health care costs were $9676 higher in the recurrent cohort ($24,039) relative to the nonrecurrent cohort ($14,363, P < .01). The mean cost difference between cohorts was driven by $8211 in additional outpatient costs, as well as $6062 in additional NP-related outpatient costs, in the recurrent cohort (all P < .01).

CONCLUSION

NP recurrence is associated with a substantial economic burden, which appears to be driven by outpatient services.

Clinical Predictors of Symptom Improvement Following Eustachian Tube Balloon Dilation

OBJECTIVE

This study aims to identify clinical predictors of treatment response to Eustachian Tube Balloon Dilation (ETBD) as measured by changes in Eustachian Tube Dysfunction Questionnaire-7 (ETDQ-7) scores.

METHODS

One hundred thirteen patients who underwent ETBD at an institution from 2017 to 2021 completed ETDQ-7 pre- and post-operatively. We conducted multivariable regression analyses with ETDQ-7 normalization (<2.1 post-op), minimum clinically important difference (MCID) (>0.5 pre-op - post-op), and quantitative improvement in ETDQ-7 score as outcome variables. Pre-operative ETDQ-7 score, tympanogram type, chronic otitis media, chronic rhinosinusitis (CRS), inferior turbinate hypertrophy, deviated septum, allergic rhinitis, and rhinorrhea were included as covariates. Models controlled for age, sex, ethnicity, prior ear or sinus surgery, and follow-up duration.

RESULTS

The mean age was 49 years old. 51% were females, and all patients had pre-operative ETDQ-7 above 2.1. After a mean follow-up period of 13 months, 77% achieved MCID and 37% had normalized. Higher pre-operative ETDQ-7 score was associated with greater ETDQ-7 score improvement (B = 0.60, 95% CI = [0.37, 0.83]) and greater odds of achieving MCID (aOR = 1.65; 95% CI = [1.06, 2.59]). A history of CRS improved chances of achieving MCID (aOR = 4.53; 95% CI = [1.11, 18.55]) and a history of chronic otitis media predicted increased odds of ETDQ-7 normalization (aOR = 2.88; 95% CI = [1.09, 7.58]).

CONCLUSIONS

Our findings suggest that ETBD was highly effective among patients with pre-operative ETDQ-7 above 2.1. Furthermore, higher pre-operative ETDQ-7 score, CRS, and chronic otitis media predicted more favorable symptomatic benefit from ETBD. These factors may be important to consider when counseling potential candidates for this procedure.

Endoscopic Management of a Post-Traumatic Internal Maxillary Artery Pseudoaneurysm: Case Report and Review of the Literature

Internal maxillary artery (IMA) pseudoaneurysms are rare, and typically occur following trauma or orthognathic surgery. Pseudoaneurysms are life-threatening conditions, and expeditious workup and treatment is critical. Endoscopic treatment of an IMA pseudoaneurysm is a feasible option and should be considered when IR embolization is not available. The objective of this study is to review the literature on IMA pseudoaneurysms and present the first reported case of an IMA pseudoaneurysm successfully treated endoscopically.

Retained Dental Implant in the Maxillary Sinus

Implant dentistry has become a popularized means of replacing damaged or missing teeth. Although it has become common practice, there are accounts of implants displacing into surrounding structures, commonly the maxillary sinus. We present the case of a 54-year-old man who presented with chronic left sided pain and pressure found to be secondary to a displaced implant obstructing the left maxillary outflow sinus tract. A systematic review was conducted to assess the current management and treatment options for dental implants displaced into the maxillary sinus. Functional endoscopic sinus surgery (FESS) and the lateral window approach were both found to be safe techniques with minimal postoperative complications.

Postoperative Gabapentin's Effect on Opioid Consumption and Pain Control Following Sinonasal Surgery

OBJECTIVE

This study investigates the impact of postoperative gabapentin on opioid consumption and pain control following endoscopic sinus surgery (ESS) and/or septoplasty.

METHODS

Patients who underwent ESS and/or septoplasty at a single institution from 2021 to 2022 were enrolled. All patients received postoperative hydrocodone-acetaminophen for pain control. Half of the patients were also prescribed gabapentin for the first postoperative day in addition to hydrocodone-acetaminophen. Subjects completed the Revised American Pain Society Patient Outcome Questionnaire 24 h and 7 days after surgery. We conducted a multivariable regression analysis to assess opioid consumption and improvement in pain scores in the first week between gabapentin and non-gabapentin groups.

RESULTS

A total of 102 subjects, 51 in each arm, were enrolled. The mean age was 52 years and 53% of participants were female. Controlling for important baseline demographic, clinical, and surgically related variables, the addition of postoperative gabapentin was associated with a 44% (9.5 mg from 21.6 mg) reduction in opioids consumed in the first postoperative week (B = -9.54, 95% C.I. = [-17.84, -1.24], p = 0.025). In addition, patients in both arms exhibited similar improvement in pain severity and sleep interference in the first 7 days (B = -1.59, 95% C.I. = [-5.03, 1.84], p = 0.36).

CONCLUSION

To the best of our knowledge, this is the first study to investigate the impact of postoperative gabapentin on opioid consumption and pain control following ESS and/or septoplasty. Our analysis demonstrated that postoperative gabapentin effectively reduced opioid use during the first postoperative week without compromising pain control.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Modified Endoscopic Denker's Approach for Management of Anterior Maxillary Sinus Tumors: Multicenter Series of 58 Cases

OBJECTIVES

Tumors involving the anterior portion of the maxillary sinus remain technically challenging to access via an endoscopic approach. The modified endoscopic Denker's (MED) procedure was recently introduced to address such lesions. We present a multicenter series of 58 patients with tumors involving the anterior maxillary sinus successfully resected using a MED procedure and present the clinical outcomes and complications.

METHODS

A multi-institution retrospective chart review was performed on patients who underwent the MED approach for the management of tumors involving the anterior maxillary sinus from 2009 to 2020. Demographic data, pathology, surgical outcomes, and complications were reviewed.

RESULTS

Fifty-eight patients were identified, including 34 (58.6%) male and 24 (41.4%) female patients. The most common pathologies included: inverted papilloma (n = 27; 46.6%), adenoid cystic carcinoma (n = 9; 15.5%), and squamous cell carcinoma (n = 8; 13.8%). Thirty-eight patients (65.5%) underwent MED alone, while 20 (34.5%) had combined expanded endonasal approaches for lesions extending beyond the maxillary sinus. All maxillary sinus lesions were successfully accessed with the MED procedure without the need for an additional approach. After a mean follow-up of 30 months (range, 1-127), 8 of 58 (13.8%) patients developed complications related to the MED, including epiphora requiring an additional procedure (n = 4; 6.9%), prolonged facial/palatal numbness (n = 3; 5.2%), severe epistaxis (n = 1; 1.7%), and vestibular stenosis (n = 1; 1.7%), the latter of which occurred following postoperative radiation.

CONCLUSION

The MED procedure is a safe and highly effective approach for benign and malignant tumors involving the anterior maxillary sinus. However, patients should be counseled preoperatively on potential complications including the risk of facial numbness and epiphora.

Sinonasal Symptom Outcomes following Endoscopic Anterior Cranial Base Surgery in the Pediatric Population

Objective This study aimed to evaluate the impact of endoscopic anterior cranial base (ACB) surgery on sinonasal symptoms in the pediatric population utilizing the Sino-Nasal Outcome Test (SNOT)-22 questionnaire.

Design This is a retrospective review.

Setting The study was conducted at a tertiary academic medical center.

Participants Thirty-four consecutive patients, age 6 to 17 years, M:F 14:20, who underwent endoscopic ACB surgery from July 2008 to August 2019. Ten patients had baseline and a minimum of two subsequent postoperative SNOT-22 questionnaires available for analysis.

Main Outcome Measures Baseline and postoperative SNOT-22 scores were compared. The mean change from baseline sinonasal symptom scores in the pediatric and historical adult cohorts was compared.

Results The mean baseline SNOT-22 score for our 10 patient cohort was 0.46 out of 5 for each of the first 10 sinonasal-specific questions. This worsened to 1.69 at 1 month and returned to near baseline, 0.7, at 3 months postoperatively. The mean quality-of-life score improved to 0.91 at 1 month and 0.6 at 3 months postoperatively. The mean change from baseline for the following items: need to blow nose, runny nose, postnasal discharge, thick nasal discharge, wake up at night, reduced concentration, and frustrated/restless/irritable were similar to those in our historical adult cohort at 3 months postoperatively.

Conclusion Endoscopic ACB surgery in the pediatric population results in increased sinonasal symptom morbidity in the early postoperative period; however, symptoms return to near baseline by ∼3 months, and quality-of-life scores progressively improve in the postoperative period. These trends were similar to those seen in our historic adult cohort.

Audit of postoperative readmissions and patient messages following endoscopic transnasal transsphenoidal surgery

Objectives:To identify the reasons for patient messages, phone calls and Emergency Department (ED) visits prior to the first postoperative visit following discharge after endoscopic transnasal transsphenoidal (eTNTS) surgery. Design: Retrospective review of patients at a tertiary care academic center who underwent eTNTS for resection of a sellar region tumor between May 2020-August 2021. Patient, tumor, and surgical characteristics were collected, along with post-operative, post-discharge, and readmission information. Regression analyses were performed to investigate risk factors associated with post-discharge phone calls, messages, ED visits, and readmissions. Main Outcome Measures: Number of and reasons for phone calls, patient messages, and ED visits between hospital discharge and the first postoperative visit. We additionally determined whether these reasons were addressed in each patient’s discharge instructions. Results: A total of 98 patients underwent eTNTS during the study period. Median length of hospital stay was 2-days (Interquartile range [IQR] 1-4days), at which point most patients (82%) were provided with eTNTS-specific discharge instructions. First postoperative visit took place 9-days after discharge (IQR 7-10days). Within that time, 54% of patients made/sent at least one phone call or electronic message and 17% presented to the ED. Most common reasons for call/message were nasal care, appointment scheduling, symptom and medication questions. Conclusions: Through this work, we highlight the most common reasons for resource utilization via patient phone calls, messages, and ED visits among our cohort to better understand any shortfall or gap in the discharge process that may reduce these events.

Triamcinolone impregnated bioabsorbable middle meatus packing following endoscopic sinus surgery: a prospective randomized controlled trial

INTRODUCTION

Topical steroids are a mainstay in the treatment of chronic rhinosinusitis (CRS). Multiple delivery methods of topical steroids following sinus surgery have been investigated. The purpose of this trial is to evaluate the effect of triamcinolone impregnated absorbable nasal packing on healing following endoscopic sinus surgery.

METHODS

This is a prospective, randomized, double-blind, placebo-controlled trial. A total of 22 subjects (14 without polyps and 8 with polyps) were enrolled and were randomized to receive triamcinolone impregnated packing in one sinus cavity and normal saline soaked packing in the contralateral sinus cavity. Endoscopic evaluation was completed at the first two post-operative visits, and Lund-Kennedy (LK) endoscopic scores and perioperative sinus endoscopy (POSE) scores were calculated at each visit.

RESULTS

The results of this study found no significant difference in the appearance of the sinuses at either post-operative visit. Mean LK scores for the triamcinolone and saline groups at the first and second post-op visits were 2.09 ± 1.23 v. 2.18 ± 1.01 (p=0.79) and 1.79 ± 1.08 v. 1.68 ± 1.16 (p = 0.77) respectively. POSE scores were 2.59 ± 1.71 v. 2.68 ± 1.62 (p = 0.86) and 1.74 ± 1.15 v. 1.95 ± 1.22 (p = 0.59).

CONCLUSION

The results of this study demonstrated no significant difference in healing, crusting, polyps, edema, or secretions between the triamcinolone treated and non-triamcinolone treated sinuses. There were no adverse effects from use of triamcinolone impregnated absorbable packing. Further studies will be necessary to determine the impact of triamcinolone impregnated absorbable packing following endoscopic sinus surgery. This article is protected by copyright. All rights reserved.

Dural Bleeding After Endoscopic Sinus Surgery

We present a case of an 80-year-old female patient who had an extensive dural bleed after endoscopic sinus surgery. A review of the literature regarding the surgical tools and materials used to treat dural hemorrhage was performed. We describe our preferred method of using the combination of endoscopic bipolar, DuraGen Plus, and DuraMatrix to stop significant dural bleeding and show effective hemostatic regulation.

Role of High-Risk HPV Detected by PCR in Malignant Sinonasal Inverted Papilloma: A Meta-Analysis

INTRODUCTION

Prior studies suggest that there may be a link between human papillomavirus (HPV) infection and malignant sinonasal inverted papilloma (SNIP). This systematic review and meta-analysis was performed to further evaluate this potential association.

STUDY DESIGN

Systematic review with meta-analysis.

METHODS

The Medline and Embase databases were used to identify case-control studies reporting the risk of malignant SNIP in patients with high-risk HPV subtypes identified by polymerase chain reaction (PCR). Meta-analysis was performed to determine pooled odds ratios (ORs) and 95% confidence intervals (CI).

RESULTS

Twenty-one studies were identified, including a total of 841 subjects with SNIP. Seventeen studies were included in the final analysis, as four studies did not have any HPV-positive tumors in either group. A total of 56 malignant SNIP and 551 benign SNIP were ultimately identified. The pooled log-OR was 1.80 (95% CI: 1.03-2.57) for all high-risk HPV subtypes. Stratification by high-risk HPV subtype showed a log-OR of 1.67 (95% CI: 0.88-2.46) for HPV-16 and log-OR of 2.68 (95% CI: 1.30-4.05) for HPV-18.

CONCLUSION

Infection with high-risk HPV subtypes may be associated with an increased risk of malignant SNIP. HPV-18 showed the greatest overall average effect size of the common high-risk subtypes.

LEVEL OF EVIDENCE

n/a Laryngoscope, 2021.

Surgical approach is associated with complication rate in sinonasal malignancy: A multicenter study

BACKGROUND

Management of sinonasal malignancy (SNM) often includes surgical resection as part of the multimodality treatment. Treatment-related surgical morbidity can occur, yet risk factors associated with complications in this population have not been sufficiently investigated.

METHODS

Adult patients with histologically confirmed SNM whose primary treatment included surgical resection were prospectively enrolled into an observational, multi-institutional cohort study from 2015 to 2020. Sociodemographic, disease, and treatment data were collected. Complications assessed included cerebrospinal fluid leak, orbital injury, intracranial injury, diplopia, meningitis, osteoradionecrosis, hospitalization for neutropenia, and subsequent chronic rhinosinusitis. The surgical approach was categorized as endoscopic resection (ER) or open/combined resection (O/CR). Associations between factors and complications were analyzed using Student's t test, Fisher's exact test, and logistic regression modeling.

RESULTS

Overall, 142 patients met the inclusion criteria. Twenty-three subjects had at least 1 complication (16.2%). On unadjusted analysis, adjuvant radiation therapy was associated with developing a complication (91.3% vs 65.5%, p = 0.013). Compared with the ER group (n = 98), the O/CR group (n = 44) had a greater percentage of higher T-stage lesions (p = 0.004) and more frequently received adjuvant radiation (84.1% vs 64.4%, p = 0.017) and chemotherapy (50.0% vs 30.6%, p = 0.038). Complication rates were similar between the ER and O/CR groups without controlling for other factors. Regression analysis that retained certain factors showed O/CR was associated with increased odds of experiencing a complication (odds ratio, 3.34; 95% confidence interval, 1.06-11.19).

CONCLUSIONS

Prospective, multicenter evaluation of SNM treatment outcomes is feasible. Undergoing O/CR was associated with increased odds of developing a complication after accounting for radiation therapy. Further studies are warranted to build upon these findings.

Racial and ethnic disparities in paranasal sinus malignancies

BACKGROUND

Racial and ethnic disparities in cancer outcomes have been demonstrated for several different malignancies. In this study we aimed to quantify disease-specific survival (DSS) and the 5-year conditional disease-specific survival (CDSS, the change in life expectancy with increasing survivorship) for paranasal sinus cancer by race and ethnicity.

METHODS

Patients with sinus cancer between 1973 and 2015 were extracted from the Surveillance, Epidemiology, End Results (SEER) registry. Kaplan-Meier analysis for DSS was stratified by race and ethnicity. Cox regression models of DSS were generated controlling for stage, age, race, and ethnicity. CDSS was calculated using Cox models. Logistic regression was conducted to identify risk factors for younger age at diagnosis, late-stage at diagnosis, and likelihood of receiving surgical intervention when recommended.

RESULTS

The analysis included a total of 5202 patients. DSS was significantly different when stratified by race (p < 0.01). Compared with White patients, Black patients (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.13-1.45; p < 0.001) and American Indian/Alaskan Natives (HR, 1.94; 95% CI, 1.37-2.74, p < 0.001) exhibited increased mortality when controlling for other factors. Black patients had worse CDSS for regional and distant staged cancer compared with other races; American Indian/Alaskan Native patients had worse CDSS for cancers of all stages. Hispanic patients were more likely to present with advanced disease (odds ratio [OR], 1.47; 95% CI, 1.07-2.07; p = 0.020). American Indian/Alaskan Native patients were less likely than White patients to receive surgical intervention when recommended (OR, 0.42; 95% CI, 0.21-0.04; p = 0.024). Nonwhite patients were more likely to be diagnosed at a younger age. Variations in racial and ethnic disparities were observed over time.

CONCLUSION

Race and ethnicity significantly impact paranasal sinus cancer outcome metrics. Disparities in outcomes are likely multifactorial.

Uvulopalatopharyngoplasty may decrease the incidence of Parkinson's disease associated with obstructive sleep apnea

The purpose of this study was to investigate whether the incidence of Parkinson’s disease (PD) is increased among patients with obstructive sleep apnea (OSA) and whether surgical treatment can prevent such an increase. This was a retrospective cohort study. We analysed the claims data from the Korea National Health Insurance Service. A total of 202,726 patients who were newly diagnosed with OSA between 2007 and 2014 were included. The patients were divided into two groups: patients who underwent uvulopalatopharyngoplasty (surgery group, n = 22,742) and those who did not (conservative group, n = 179,984). The control group (n = 1,013,630) was selected by propensity score matching. They were tracked until 31^st December 2015. The hazard ratio of PD diagnosis (95% confidence interval) in the OSA group with respect to the control group was calculated using the Cox proportional hazard model. In the conservative group, the incidence of PD (hazard ratio 2.57 [2.32–2.85]) was significantly higher than that in the control group, while the incidence of PD in the surgery group was similar to that in the control group (hazard ratio 1.45 [0.89–2.22]). Patients with OSA are at an increased risk of developing PD, and uvulopalatopharyngoplasty may mitigate this risk.

Assessment of Biomarker Heterogeneity in Sinus Versus Inferior Turbinate Tissue in Patients Without Chronic Rhinosinusitis

BACKGROUND

Currently, no consensus exists on the appropriate control specimen site to utilize in studies evaluating for biomarkers in chronic rhinosinusitis (CRS). Studies thus far have utilized tissue from various anatomic sites despite regional heterogeneity.

OBJECTIVE

We set out to quantify the differences in biomarker levels present in inferior turbinate versus sphenoid sinus mucosa in paired healthy control patients. We hypothesize that statistically significant differences in cytokine/chemokine expression exist between these two distinct sites.

METHODS

A 38-plex commercially available cytokine/chemokine Luminex Assay was performed on 54 specimens encompassing paired inferior turbinate and sphenoid sinus mucosa samples from 27 patients undergoing endoscopic anterior skull base surgery. Patients with a history of CRS were excluded. Paired sample t-tests and Fisher's exact tests were performed.

RESULTS

Twenty-seven patients were included in the study, including 10 male and 17 female patients with an average age of 48 years. The following 8 biomarkers had statistically significant concentration differences between inferior turbinate mucosa and sphenoid mucosa sites: Flt-3L, Fractalkine, IL-12p40, IL-1Ra, IP-10, MCP-1, MIP-1β, and VEGF, with all P-values <0.01.

CONCLUSION

No consensus exists regarding the optimal choice of control specimen for CRS research. We present statistically significant quantitative differences in biomarker levels between paired inferior turbinate and sphenoid mucosa samples. This confirms the presence of heterogeneity between different subsites of sinonasal mucosa and highlights the need for standardization in future CRS research.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

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

METHODS

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

RESULTS

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

CONCLUSION

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

The incidence of prostate cancer is increased in patients with obstructive sleep apnea: Results from the national insurance claim data 2007-2014

ABSTRACT

Some studies have demonstrated an increased risk of prostate cancer in patients with obstructive sleep apnea (OSA). However, the relationship is unclear and the results are conflicting. This study aims to investigate associations between OSA and prostate cancer using the Korea National Health Insurance Service database.A total of 152,801 men (≥ 20 years of age) newly diagnosed with OSA between 2007 and 2014 were included. A control group of 764,005 subjects was selected using propensity score matching by age and sex. The mean follow-up time was 4.6 years (range 2.3-6.9). The primary endpoint was newly diagnosed prostate cancer. The prostate cancer hazard ratio (95% confidence interval) was calculated for patients with OSA and compared to the control group.The incidence of prostate cancer among patients with OSA was significantly higher than that in controls (1.34 [1.23-1.49]). In particular, the incidence of prostate cancer was highest in patients aged 40-65 years (1.51 [1.32-1.72]).This study provides additional evidence for a link between OSA and prostate cancer.

COX-2 Overexpression in Schneiderian Papillomas

Background

Schneiderian papillomas (SP) are aggressive sinonasal tumors that occasionally extend into areas that are surgically unresectable.

Objective

evaluate the signifcance of cyclo-oxygenase-2 (COX-2) expression in SP.

Methods

Immunohistochemistry for COX-2 was performed on SP samples and middle turbinates from chronic rhinosinusitis without nasal polyps controls obtained during surgical resection between 2009–2017. A positive stain was defined as having 10% or more cells exhibiting diffuse immunoreactivity. Comparisons were performed using Fisher Exact tests, t-tests, and ANOVA.

Results

The study included 67 tumor samples and 9 controls from two academic institutions. The mean age of the SP group was 55.4 years and 53.2 years in the control group (p = 0.71). Thirty-nine (58.2%) SP patients had previous surgery compared to 1 (11.1%) in the control group (p = 0.01). The most common tumor attachment sites were the maxillary (47.8%) and ethmoid (25.4%) sinuses. Fifteen (22.4%) SP samples stained strongly positive for COX-2 and 24 (35.8%) stained weakly positive compared to no positive stains in the control group (p < 0.01). When stratified by COX-2 intensity, there were no statistically significant differences in gender, smoking history, history of previous sinus surgery, site of attachment, papilloma subtype, or future recurrence between SP samples.

Conclusion

COX-2 was overexpressed in 58.2% of SP cases, and strongly positive in 22.4% of cases, compared to no positive staining among controls. No significant differences in COX-2 expression were observed between SP subtypes or recurrent tumors. Further studies are warranted to evaluate COX-2 as a possible therapeutic target in tumors that overexpress the enzyme.

Single Layer Biomaterial Repair of Frontal Sinus Encephalocele in a Pediatric Patient

INTRODUCTION

Reconstruction of skull base defects are determined by size, location, and complexity of the defect.

METHODS

Case report.

CASE DISCUSSION

An 11-year old girl presented with a right frontoethmoidal encephalocele after an episode of meningitis. An endoscopic approach was performed with a Draf III to provide exposure. The skull base defect extended superolateral over the orbit, which limited the choice of reconstructive options. The defect was successfully repaired with a single layer onlay graft of bovine collagen matrix.

CONCLUSIONS

Single layer repairs using commercial biomaterials should be considered where multilayer closure or vascularized flaps may not be possible. Laryngoscope, 131:E1750-E1752, 2021.

National Analysis of 30-Day Readmission Following Inpatient Sinus Surgery for Chronic Rhinosinusitis

OBJECTIVES

To characterize the incidence, causes, risk factors, and costs of 30-day readmission after inpatient functional endoscopic sinus surgery (FESS) for patients with chronic rhinosinusitis.

STUDY DESIGN

Retrospective cohort study.

METHODS

The Nationwide Readmissions Database was used to characterize readmission after inpatient sinus surgery for chronic rhinosinusitis from 2015 to 2017. International Classification of Disease codes were used to identify the patient population, which included 5,644 patients. Incidence, causes, costs, and predictors of readmission were analyzed and determined.

RESULTS

Among 6,386 patients who underwent inpatient FESS, 742 (11.6%) were readmitted within 30 days of discharge. On univariate analysis, patients who were readmitted were more commonly older than 70 years (23.3% vs. 16.2%); had a higher burden of comorbidities including chronic kidney disease (15.0% vs. 7.8%), diabetes (25.6% vs. 20.4%), and hypertension (13.5% vs. 8.5%); had a greater rate of postoperative complications (20.7% vs. 12.2%); and had a longer length of stay (12.4 vs. 6.9 days) compared to patients who were not readmitted. Readmissions cost an additional $27,141 per patient. On multivariable analysis, age greater than 70 years, Medicaid insurance, several comorbidities, prolonged length of stay, postoperative neurologic complications, and lower hospital volume were independent predictors of 30-day readmission. The most common cause for readmission was infection (36.3%).

CONCLUSION

Readmission following inpatient FESS is not uncommon. Identification and management of preoperative comorbidities, optimized patient selection for inpatient surgery, and thorough postoperative discharge care may improve patient outcomes and decrease healthcare expenditures.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E1422-E1428, 2021.

CSF Leaks due to Electric Scooter Injury

BACKGROUND

There has been a rapid increase in electric motorized scooter (e-scooter) usage after the introduction of dockless, shareable devices.

METHODS

Case series from three tertiary hospitals in Los Angeles between May-September 2019.

RESULTS

Five patients had skull base fractures and CSF leaks or pneumocephalus after e-scooter accident, none wore helmets. Two patients were treated with observation alone, two patients were treated with lumbar drain or external ventriculostomy placement, and one patient died of their injuries prior to definitive management.

CONCLUSION

Without appropriate safety policies in place, the number of such injuries may increase as the use of e-scooters increase. Laryngoscope, 131:E1035-E1037, 2021.

Expression of Iron-Regulatory Hormone Hepcidin and Iron Transporters Ferroportin and ZIP8 in Patients With and Without Chronic Rhinosinusitis

Airway epithelia express intrinsic antimicrobial and nutrient-sequestering factors, which contribute to the host defense of the respiratory tract. Hepcidin is an endogenous peptide hormone that serves as a key regulator of iron metabolism, and ferroportin and ZIP8 are iron transporters. All exhibit innate antimicrobial activity. The purpose of this pilot study is to determine if molecules involved in iron regulation are expressed within sinus epithelia and to compare levels of expression between patients with and without chronic rhinosinusitis (CRS). Sinus mucosa was obtained from patients with (n = 19) and without (n = 14) CRS. Real-time polymerase chain reaction following RNA extraction was used to quantify expression of hepcidin, ferroportin, and ZIP8 mRNA. Hepcidin, ferroportin, and ZIP8 were all detected in the sinus epithelia of patients with and without CRS. However, only ZIP8 was significantly changed in CRS, with a 2.5-fold mean increase in mRNA expression relative to controls ( P = .005). These findings suggest that ZIP8 may play a role in the innate epithelial defense of the paranasal sinuses.

Modified endoscopic Denker approach in management of inverted papilloma of the anterior maxillary sinus

BACKGROUND

Inverted papilloma (IP) is a benign epithelial tumor of the sinonasal cavity that is locally aggressive and has a propensity for recurrence. Tumors involving the anterior maxillary sinus can be challenging to reach endoscopically, and have historically been approached through a Caldwell-Luc or canine fossa trephination. We present a case series of 22 patients with maxillary IPs originating from the anterior wall, which were successfully resected using a modified endoscopic Denker (MED) procedure. This technique enables access to the entire maxillary sinus without the need for a separate transseptal or sublabial incision.

METHODS

A retrospective chart review was performed on patients who underwent the MED approach for management of maxillary IPs involving the anterior wall from 2012 to 2018. The demographic data, clinical presentation, radiographic findings, pathology, and surgical outcomes were reviewed.

RESULTS

Twenty-two patients were identified, including 13 males and 9 females. Eighteen of the 22 patients had prior surgery and all had Krouse stage 3 disease. After a mean follow-up of 24 (range, 4-63) months, only 1 patient (4.5%) developed a recurrence, which was treated successfully with endoscopic resection. Complications included 1 patient with preoperative epiphora who required dacryocystorhinostomy, epistaxis in another, and 1 patient with transient upper lip numbness. No patients developed alar notching or pyriform aperture stenosis.

CONCLUSION

The MED technique is highly effective for surgical resection of primary and recurrent maxillary IPs involving the anterior wall, providing complete access to the entire maxillary sinus. In many cases, the MED can obviate the need for an adjunctive sublabial or transseptal incision, while also providing excellent exposure for postoperative surveillance.

Retrospective Analysis of Patients With Acute Invasive Fungal Rhinosinusitis in a Single Tertiary Academic Medical Center: A 10-Year Experience

Background

Acute invasive fungal rhinosinusitis (AIFRS) is an aggressive, potentially fatal disease that can spread rapidly to the orbit and intracranial structures causing significant mortality and morbidity.

Objective

In this study, we present a 10-year experience from a tertiary academic medical center of patients presenting with AIFRS. Data on presentation, mortality rate, comorbidities, surgical, and medical management were analyzed.

Methods

A retrospective chart review was performed in a tertiary academic medical center of patients with AIFRS from January 2009 through February 2019. Data collected included demographics, presenting symptoms, comorbidities, immunosuppression status, endoscopic and imaging findings, orbital and intracranial complications, surgical and medical management, as well as outcomes and mortality.

Results

A total of 34 patients were identified. In our series, mortality was noted to be 61.8%, excluding patients who were lost to follow-up. The most common presenting symptoms included facial pain, ophthalmologic complaints, headaches, and proptosis. Only 4 of the 34 patients did not undergo surgical intervention, as they were not deemed surgical candidates; they all succumbed to their disease. Twenty-six of the 30 surgical patients (86.7%) underwent endoscopic sinus surgery, 8 underwent an open approach (26.7%), while 7 patients underwent orbital exenteration (23.3%). All patients had surgical pathology consistent with AIFRS. Fungal species isolated from culture included Aspergillus, Mucor/ Rhizopus, Candida, Cunninghamella Scedosporium boydii, Paecilomyces, and Scopulariopsis. Medical therapies included intravenous amphotericin B, caspofungin, posaconazole, voriconazole, isavuconazole, and micafungin.

Conclusion

AIFRS was associated with 61.8% mortality in our series of 34 patients over the past 10 years. Early diagnosis, as well as rapid and aggressive surgical and medical management, is necessary for optimal outcomes in this devastating disease.

A preliminary report on the effect of gabapentin pretreatment on periprocedural pain during in-office posterior nasal nerve cryoablation

BACKGROUND

Posterior nasal nerve (PNN) cryoablation is a novel surgical technique to address allergic and nonallergic rhinitis. Periprocedural pain has been reported after PNN cryoablation and there are no standardized protocols for optimal in-office local anesthesia. This study sought to evaluate the effect of gabapentin on patient discomfort following in-office PNN cryoablation.

METHODS

Multi-institutional prospective analysis of patients undergoing in-office PNN cryoablation for allergic or nonallergic rhinitis between March 2018 and April 2019. Patients received local anesthesia with or without 600 mg oral gabapentin 1 hour preprocedure. Rhinitis diagnosis, demographics, and baseline disease-specific quality of life (mini-Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ] and Total Nasal Symptom Score [TNSS]) were recorded. Patient discomfort was measured by the pain visual analogue scale (VAS) posttreatment and rated 0 to 10 on an ordinal scale. Fisher's exact and Wilcoxon 2-sample tests were used to evaluate differences between the 2 groups.

RESULTS

A total of 26 patients were enrolled (gabapentin n = 15, control = 11). Baseline TNSS scores in the gabapentin vs control group were median [25th percentile to 75th percentile]) 10 (7.5 to 11.0) and 9 (6.0 to 10.0) (p = 0.35). Baseline Mini-RQLQ scores in gabapentin vs control groups were 3.21 (2.0 to 4.0) and 2.92 (2.78 to 4.35) (p = 0.51). The median VAS pain scores at 5, 20, and 30 minutes in the gabapentin vs control group were 0.0 (0.0 to 2.0) vs 3.0 (1.0 to 4.0), 2.0 (0.0 to 3.0) vs 8.0 (6.0 to 10.0), and 1.0 (0.0 to 1.0) vs 5.0 (4.0 to 6.0) (p = 0.02, p = 0.0043, and p = 0.003, respectively).

CONCLUSION

Preprocedure gabapentin significantly reduces immediate and delayed postprocedural patient discomfort following PNN cryoablation.

Readmissions after endoscopic skull base surgery: associated risk factors and prevention

BACKGROUND

Unplanned readmissions within 30 days of discharge is a quality measure introduced by the Centers for Medicare Services. This measure has been used to rate hospital quality and also to penalize hospitals for excess readmissions. It has been hypothesized that shorter hospital stays and fewer readmissions are associated with endoscopic skull base procedures. In this study we analyze endoscopic skull base procedures performed at our institution over a 10-year period to identify rates and factors associated with readmissions after endoscopic skull base surgery.

METHODS

A retrospective chart review was performed at a tertiary care academic medical center identifying patients who underwent endoscopic skull base surgery over the past 10 years. Data on patient demographics and tumor variables, as well as patient variables such as body mass index (BMI), revision surgery, history of skull base radiation, medical comorbidities, intraoperative cerebrospinal fluid (CSF) leaks, and postoperative CSF leaks, were recorded.

RESULTS

Eight hundred thirty-three patients were included in our study. Sixty-one patients (7.3%) were readmitted a total of 66 times within 30 days. The most common reasons were as follows: hyponatremia (n = 18); CSF leak (n = 17); epistaxis (n = 3); diabetes insipidus (n = 3); rhinorrhea (n = 3); as well as other reasons. Statistical analysis revealed that the presence of intraoperative CSF leak was the only statistically significant variable associated with increased rate of readmissions within 30 days of discharge (p < 0.001).

CONCLUSION

Presence of intraoperative CSF leak was the only statistically significant variable associated with an increased risk for readmission after surgery. Other tumor and patient variables were not associated with an increased risk of readmission within 30 days.

Zoonotic Staphylococcus pseudintermedius sinonasal infections: risk factors and resistance patterns

BACKGROUND

Staphylococcus pseudintermedius is a Gram-positive bacteria that colonizes the skin and orifices of healthy canines and felines. It has recently been identified as a cause of sinonasal infections in humans.

METHODS

This study was a retrospective review of chronic rhinosinusitis (CRS) patients with S pseudintermedius-positive sinonasal cultures and comparison to a prospectively collected control sample of patients who underwent culture for acute exacerbation of CRS.

RESULTS

Thirty-three patients with CRS had nasal cultures positive for S pseudintermedius. Of the positive cultures, 82% demonstrated resistance to penicillin, 58% to clindamycin, 45% to trimethoprim-sulfamethoxazole, 33% to doxycycline, and 27% to oxacillin. Ninety-seven percent of patients with S pseudintermedius were dog owners. There was no significant difference in age, gender, recent endoscopic sinus surgery, or immunosuppression or deficiency between S pseudintermedius patients and patients undergoing culture for acute exacerbation of CRS, but S pseudintermedius infection was associated with dog ownership (p < 0.01). S pseudintermedius infection was not associated with behaviors such as a dog sleeping in the bedroom, routinely licking humans, or being diagnosed with a soft tissue infection.

CONCLUSION

Although a rare cause of infection in humans, S pseudintermedius should be considered in sinonasal infections refractory to standard medical management, especially if the patient has regular contact with dogs. S pseudintermedius is not readily identified with routine laboratory diagnostic testing and often demonstrates multidrug resistance, making it a pathogen that is commonly misdiagnosed and difficult to treat.

The Role of Staphylococcus aureus in Patients with Chronic Sinusitis and Nasal Polyposis

PURPOSE OF REVIEW

Staphylococcus aureus (S. aureus) is correlated with the development of persistent severe inflammatory disease of the upper airway including chronic rhinosinusitis with nasal polyps (CRSwNP). The presence of S. aureus is associated with atopic disease including allergic rhinitis and atopic dermatitis and is associated with poor outcomes.

RECENT FINDINGS

Several different strains of S. aureus generate different toxins and gene products that can account for organism pathogenicity. S. aureus bacteria and its antigens shape the bacterial and fungal microbiome and the mucosal niche which generates host responses that can account for inflammation. The multiple disease phenotypes and molecular endotypes seen in CRSwNP can be characterized by T-helper cell environment within the inflammatory milieu, the presence of epithelial barrier dysfunction, aberrant eicosanoid metabolism, poor wound healing, and dysfunctional host-bacteria interactions which lead to recalcitrant disease and worse surgical outcomes. Understanding the pathomechanisms that S. aureus utilizes to promote nasal polyp formation, prolonged tissue inflammation, and bacterial dysbiosis are essential in our efforts to identify new therapeutic approaches to resolve this chronic inflammatory process.