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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Integrative Approach to Rhinosinusitis: An Update

Rhinosinusitis is characterized by inflammation of the mucosa involving the paranasal sinuses and the nasal cavity and is one of the most common and significant health care problems, with significant impairment of quality of life. Current standard conventional management of rhinosinusitis commonly uses multiple therapeutic modalities to break the cycle of chronic disease. However, to date, there is no consensus as to the optimal treatment algorithm for patients with chronic rhinosinusitis. There is a growing interest in the use of complementary and integrative medicine for the treatment of rhinosinusitis. This article update focuses on an integrative approach to rhinosinusitis.

Acupuncture and the Otolaryngology-Head & Neck Surgery Patient

The use of acupuncture among US adults was estimated at nearly 40% in 2012. A study from the United Kingdom in 2010 found 60% of otolaryngologic patients had used a form of complementary or integrative medicine, with greater than a third in the last year alone. Acupuncture, a therapeutic modality of traditional Chinese medicine, has been used for millennia in Asian countries. Within otolaryngology, acupuncture has been used for a variety of conditions encompassing otology, laryngology, rhinology, and pediatrics. Herein, we review the current literature on the applications of acupuncture for a range of ENT disorders.

Integrative care of the patient with head and neck cancer

Objective

To review the literature on integrative care of the patient with head and neck cancer.

Methods

A review of the English language literature for articles relating to integrative care of patients with head and neck cancer, focusing on treatment of sequelae of surgery and chemoradiation.

Results

Many studies show a significant utilization of nontraditional (complementary/integrative) treatments by patients in dealing with head and neck cancer. Treatment of head and neck cancer entails potentially debilitating consequences of surgery and/or chemoradiation on cosmesis, speech, swallowing, breathing, and quality of life. While complementary/integrative treatments for head and neck cancer are not established as effective therapies, their use for relieving sequelae of treatment, improving quality of life, and providing potential chemoprevention is well documented.

Conclusion

Given the landscape of increasing use of nontraditional methodologies by patients with head and neck cancer and the complexity of care, the head and neck cancer surgeon should be aware of the uses and abuses of complementary/integrative medicine by patients as they navigate their care.

Level of Evidence

5

Acupuncture for treating polycystic ovary syndrome: guidance for future randomized controlled trials

OBJECTIVE

To provide guidance for future randomized controlled trials (RCTs) based on a review concerning acupuncture for treating polycystic ovary syndrome (PCOS).

METHODS

A comprehensive literature search was conducted in October 2015 using MEDLINE, EMBASE, SCISEARCH, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Menstrual Disorders and Subfertility Group trials register, Allied and Complementary Medicine (AMED), China National Knowledge Infrastructure (CNKI), and the Wanfang databases. RCTs comparing either acupuncture with no/sham/pharmacological intervention or a combination of acupuncture and conventional therapy with conventional therapy in the treatment of PCOS were included in this review. A quality evaluation was performed for each of the included studies.

RESULTS

Thirty-one RCTs were included in the review and were divided into four categories according to the type of intervention used in the comparator or control group. Menstrual frequency, hormones, anthropometrics, insulin sensitivity, blood lipids, and fertility were used as the main measurements to assess the effects of acupuncture on the patients with PCOS. Thirty trials, except for one, showed an improvement in at least one of the indicators of PCOS after acupuncture treatment. However, normalizing the methodological and reporting format remains an issue.

CONCLUSIONS

Based upon this review of current clinical trials concerning acupuncture for treating PCOS, we provide guidelines for better clinical trial design in the future.

Integrative medicine, or not integrative medicine: that is the question

On September 26-27, 2015, the 8th European Congress for Integrative Medicine convened the Global Summit on Integrative Medicine and Healthcare in Greater Copenhagen and Helsingør, Denmark at the Culture Yard just across from Kronborg Castle, which is home to William Shakespeare's Hamlet. This article is a summary of the author's presentation about integrative medicine within the Nordic region, driving factors that determine value in healthcare, key tenets of integrative medicine that lead to healthcare cost savings and the potential for a Nordic healthcare renaissance.

Clinical Practice Guideline

The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Tinnitus. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 13 recommendations developed address the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the impact of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers.

Clinical Practice Guideline

Objective

Tinnitus is the perception of sound without an external source. More than 50 million people in the United States have reported experiencing tinnitus, resulting in an estimated prevalence of 10% to 15% in adults. Despite the high prevalence of tinnitus and its potential significant effect on quality of life, there are no evidence-based, multidisciplinary clinical practice guidelines to assist clinicians with management. The focus of this guideline is on tinnitus that is both bothersome and persistent (lasting 6 months or longer), which often negatively affects the patient’s quality of life. The target audience for the guideline is any clinician, including nonphysicians, involved in managing patients with tinnitus. The target patient population is limited to adults (18 years and older) with primary tinnitus that is persistent and bothersome.

Purpose

The purpose of this guideline is to provide evidence-based recommendations for clinicians managing patients with tinnitus. This guideline provides clinicians with a logical framework to improve patient care and mitigate the personal and social effects of persistent, bothersome tinnitus. It will discuss the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the effect of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers.

Action Statements

The development group made a strong recommendation that clinicians distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus. The development group made a strong recommendation against obtaining imaging studies of the head and neck in patients with tinnitus, specifically to evaluate tinnitus that does not localize to 1 ear, is nonpulsatile, and is not associated with focal neurologic abnormalities or an asymmetric hearing loss. The panel made the following recommendations: Clinicians should (a) perform a targeted history and physical examination at the initial evaluation of a patient with presumed primary tinnitus to identify conditions that if promptly identified and managed may relieve tinnitus; (b) obtain a prompt, comprehensive audiologic examination in patients with tinnitus that is unilateral, persistent (≥ 6 months), or associated with hearing difficulties; (c) distinguish patients with bothersome tinnitus of recent onset from those with persistent symptoms (≥ 6 months) to prioritize intervention and facilitate discussions about natural history and follow-up care; (d) educate patients with persistent, bothersome tinnitus about management strategies; (e) recommend a hearing aid evaluation for patients who have persistent, bothersome tinnitus associated with documented hearing loss; and (f) recommend cognitive behavioral therapy to patients with persistent, bothersome tinnitus. The panel recommended against (a) antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for the routine treatment of patients with persistent, bothersome tinnitus; (b) Ginkgo biloba, melatonin, zinc, or other dietary supplements for treating patients with persistent, bothersome tinnitus; and (c) transcranial magnetic stimulation for the routine treatment of patients with persistent, bothersome tinnitus. The development group provided the following options: Clinicians may (a) obtain an initial comprehensive audiologic examination in patients who present with tinnitus (regardless of laterality, duration, or perceived hearing status); and (b) recommend sound therapy to patients with persistent, bothersome tinnitus. The development group provided no recommendation regarding the effect of acupuncture in patients with persistent, bothersome tinnitus.

Integrative Approach to Atypical Facial Pain and Headache

Program Description:

The otolaryngologist may frequently deal with patients who present with atypical facial pain and headache, with no obvious anatomic, infectious, or inflammatory etiology. Such patients are challenging and require a multidisciplinary approach for diagnosis and treatment. In this miniseminar, we will review the definition, differential diagnosis, workup, and treatment recommendations for patients with atypical facial pain and headache. An integrative approach to the management of atypical facial pain will be outlined, including role for surgery, pharmacotherapy, complementary/alternative methods, mind-body approaches, and lifestyle changes. Challenging cases will be presented to the panel of experts for discussion.

Educational Objectives:

1) Define atypical facial pain based on the International Headache Society’s classification. Other diagnoses, including cranial neuralgias, optic neuritis, and temporomandibular joint must be ruled out. 2) Recognize the etiology of rhinogenic headache and discuss the workup, controversies, and recommended treatment options. 3) Apply integrative approaches to treatment of atypical facial pain, including pharmacotherapy, role for surgery, complementary/alternative methods, mind-body approaches, and lifestyle changes.

Complementary and integrative treatments: rhinosinusitis

Rhinosinusitis is characterized by inflammation of the mucosa involving the paranasal sinuses and the nasal cavity and is one of the most common health care problems, with significant impairment of quality of life. There is a growing amount of interest in the use of complementary and integrative medicine for the treatment of rhinosinusitis. This article focuses on an integrative approach to rhinosinusitis.

Treatment of recalcitrant chronic rhinosinusitis with integrative East-West medicine: a pilot study

OBJECTIVE

To establish the feasibility of studying the impact of integrative East-West medicine (IEWM) on sinonasal symptoms and quality of life (QOL) for patients with chronic rhinosinusitis (CRS).

DESIGN

Prospective, nonrandomized trial.

SETTING

Academic hospital and ambulatory clinic.

PATIENTS

Patients with recalcitrant CRS offered treatment with IEWM in addition to standard medical treatment.

METHODS

Prior to study enrollment, study participants were given the Sino-Nasal Outcome Test (SNOT-20) and the 36-Item Short Form (SF-36) questionnaires.

INTERVENTIONS

Patients underwent 8 weeks of weekly acupuncture and counseling on dietary modification, lifestyle changes, and acupressure.

MAIN OUTCOME MEASURES

Patients completed posttreatment SNOT-20 and SF-36 surveys, which were compared for changes in sinonasal symptoms and QOL measures.

RESULTS

Eleven patients completed the protocol. No adverse events were observed. There were trends toward improvement in most elements of the SNOT-20, whereas "need to blow nose" (P = .002), "runny nose" (P = .04), "reduced ability to concentrate" (P = .005), and "feeling frustrated, restless, or irritable" (P = .046) were statistically significant. In the SF-36, role physical (P = .01), vitality (P = .04), and social functioning (P = .008) were significantly improved.

CONCLUSIONS

Preliminary data suggest that an integrated approach of traditional Western medicine with IEWM is safe and may improve symptoms and QOL for patients with recalcitrant CRS. Future randomized controlled trials are needed to validate the effects of IEWM and clarify its role in the treatment of CRS.

Combined revascularization and microvascular free tissue transfer for limb salvage: a six-year experience

Atherosclerotic vascular disease causing extensive tissue loss of the lower extremities often results in primary amputation. Combined revascularization and free tissue transfer has been described as a method of extending limb salvage to these patients. The durability of this combined procedure remains unknown, thus the objective of this report is to describe the immediate and long-term results in a series collected over 6 years. From 1992 to 1998, 15 patients with a mean age of 60 years underwent combined revascularization and free tissue transfer. Mean ulcer size measured 45 cm(2) for a mean duration of 7.4 months preoperatively and 12 patients had exposed bone or tendon. Vascular reconstruction included popliteal (3), tibial (6), and pedal (6) bypass with concomitant myocutaneous free flap, using mostly rectus abdominis or latissimus dorsi muscle. There were no perioperative deaths. One patient suffered a nonfatal myocardial infarction. Two patients had a postoperative wound hematoma and one required vascular graft revision. Patients were followed for 4 to 75 months (mean = 23 months). Four patients have required amputations (3 early, 1 late), three of whom had preoperative renal failure. The limb salvage rate has been 72% at 36 months,