Restarting Antithrombotic Therapies After Endoscopic Sinus Surgery: A Systematic Review

OBJECTIVES

Antithrombotic therapies, comprised of both anticoagulant and antiplatelet agents, are routinely paused prior to endoscopic sinus surgery (ESS) to reduce the risk of perioperative hemorrhage. At present, no clear guidelines exist to guide otolaryngologists on when to resume these agents after ESS. Our goal was to systematically review the existing literature related to this topic.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically queried the PubMed, Embase, Ovid, Web of Science, Cochrane, and CINAHL databases to identify publications reporting on antithrombotic and antiplatelet therapy in the context of ESS. The primary outcomes we sought were recommendations on the timing of antithrombotic therapy resumption after ESS.

RESULTS

Of the 104 unique articles identified, all were screened for relevance by 2 independent reviewers based on title and abstract, 20 underwent full-text review, and 6 met inclusion criteria for analysis. Of these, 3 were literature reviews, 2 were case-control studies, and 1 was a cohort study. All publications discussed when to pause antithrombotic therapy prior to surgery while only 3 articles discussed resumption of these agents. Recommendations were mixed.

CONCLUSION

A paucity of literature exists on the resumption of antithrombotic therapies after ESS. As a major determining factor in patient morbidity, guideline-based resumption of these therapies is needed.

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

3D printing for virtual surgical planning of nasoseptal flap skull-base reconstruction: A proof-of-concept study

KEY POINTS

3D printing for virtual surgical planning of nasoseptal flap skull base reconstruction is a viable approach. Results indicate improved mucosal preservation but further research is needed to define impact on quality of life.

Trends in clinical trials for olfactory dysfunction in the COVID-19 era

KEY POINTS

Nearly half of all olfactory dysfunction (OD) clinical trials since 2010 are COVID-19-related. COVID-19-related OD trials are published significantly faster than COVID-19-unrelated trials. High-quality clinical trials and publications are crucial to discovering effective treatments.

Endoscopic Medial Orbitotomy for Lateral Access to Anterior Cranial Base Pathology

This article showcases a technique to further expand the endoscopic endonasal approach to the skull base by traversing the orbit for further lateral exposure. Laryngoscope, 2023.

Profiles of Odorant Specific Performance in Olfactory Testing

BACKGROUND

Olfactory dysfunction (OD) can occur from a variety of etiologies. However, there are few reports examining whether varying etiologies have unique profiles of psychophysical testing that may provide insight into the pathophysiology of OD.

METHODS

Adults with chronic rhinosinusitis with and without nasal polyps (CRSwNP/CRSsNP) and healthy control adults with no sinus complaints underwent olfactory assessment with Sniffin' Sticks. Profiles of identification and discrimination were compared between CRS and non-CRS subjects across the spectrum of OD.

RESULTS

Normosmics with or without CRS identified apple, pineapple, and turpentine less frequently than expected (range 52%-68% correct). Hyposmics with CRS correctly identified orange more frequently than control hyposmics (83%-93% vs 68% for controls) with similar findings for rose. Hyposmics of all cohorts were unable to identify apple (26%). Discrimination profiles were similar across the spectrum of OD and between diagnostic groups.

CONCLUSIONS

Identification and discrimination rates of specific odorants may provide unique information regarding the etiology of OD, however psychophysical testing is a complex interplay of olfactory and trigeminal function, the strength of target odorant, distractor choices, and familiarity with odorants.

Cumulative comorbidity burden does not worsen outcomes in management of chronic rhinosinusitis

BACKGROUND

The impact of multiple coexisting medical comorbidities on treatment outcomes in chronic rhinosinusitis (CRS) is unknown. In this study we sought to evaluate the effect of comorbidities on sinonasal quality of life (QOL) and general health utility values by utilizing the Functional Comorbidity Index (FCI) in CRS patients.

METHODS

Patients with CRS were prospectively enrolled in a cross-sectional study of medical and surgical therapies. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Medical Outcomes Study Short-Form 6D (SF-6D) scores were recorded at enrollment and 6-month follow-up; Lund-Kennedy endoscopy and Lund-Mackay computed tomography scores were recorded at enrollment. The FCI was calculated using the electronic medical record. The impact of cumulative comorbidity burden on baseline and posttreatment outcomes was assessed using univariate and bivariate correlations.

RESULTS

A total of 428 participants with CRS were included. The average (mean standard ± deviation) FCI score was 3.03 ± 2.28 (range, 0-12). Significant linear correlations were identified between increasing FCI score and baseline SNOT-22 and SF-6D scores (R = 0.166, p = 0.001 and R = -0.245, p < 0.001, respectively). There was no correlation between FCI and change in SNOT-22 or SF-6D scores after CRS treatment (R = 0.066, p = 0.17 and R = -0.087, p = 0.074, respectively). Achievement of a minimally clinically important difference was also independent of FCI.

CONCLUSION

Although cumulative comorbidity burden, as measured by FCI, is associated with worse baseline SNOT-22 and SF-6D scores, it does not appear to limit posttreatment improvement in either outcome measure. On average, patients with high comorbidity burden report substantial improvement in both QOL and health utility after CRS treatment, similar to those with fewer comorbidities.

Postoperative Anatomic Position of Mandibular Free Flap Neocondyles Affects Patient Symptoms

Importance: Mandibular condyle reconstruction with vascularized free flaps can re-establish form and function after resection. However, no reports have been published regarding the postoperative anatomic seating of these reconstructions. Objective: To use postoperative axial imaging to determine whether condylar reconstructions migrate and correlate their ultimate location with postoperative symptoms. Design, Setting, and Participants: A prospectively maintained database of free flap cases performed between 2006 and 2019 at a single institution was queried. Twenty-one consecutive patients who underwent reconstructions that involved the mandibular condyle who also had postoperative axial imaging were selected for review. Distances were measured from the reconstructed condyle to the lateral, superior, and posterior aspect of the temporomandibular joint (TMJ), and correlated with postoperative symptoms and jaw function. Main Outcomes and Measures: Condyle displacement, postoperative diet, jaw pain, trismus, and malocclusion. Results: In total, 57% of patients had 1 cm or greater displacement of the condylar reconstruction from the TMJ in at least one vector. Anterior displacement of condyle by >1 cm was associated with jaw misalignment (42.8%) and clicking (14.3%) [odds ratio (OR) 37.3, 95% confidence interval (CI) 1.6-866.9, p = 0.024]. However, 83.3% of these patients were able to return to a normal diet and denied dysphagia. All edentulous patients had acceptable anteroposterior alignment, but 42.8% of dentulous patients had anterior displacement >1 cm (p = 0.12). Inferior displacement >1 cm was associated with dysphagia (OR 23, 95% CI 1.07-494.6, p = 0.04), but not pain or trismus. Eleven patients had multiple postoperative computed tomography scans, on average 21 months apart. The reconstructed location was stable in all 11 patients. Conclusions and Relevance: Patients undergoing free flap reconstruction of the mandibular condyle often return to normal diet, even when their reconstructions do not sit perfectly within the TMJ. Anterior displacement of the neocondyle may be more common in dentulous patients due to stress on the joint from chewing and produces some dysfunction and misalignment. Inferior displacement of the neocondyle may result in dysphagia. The reconstructed condyles are unlikely to migrate over time.

Endoscopic Nasopharyngectomy Combined with a Nerve-sparing Transpterygoid Approach

OBJECTIVES/HYPOTHESIS

Surgical management of nasopharyngeal tumors has evolved in the endoscopic era. Lateral exposure remains difficult especially near the petrous internal carotid artery and bony Eustachian tube (ET). Our study examines the need to sacrifice the vidian and greater palatine nerves in order to successfully perform en bloc endoscopic nasopharyngectomy.

METHODS

Four cadaveric specimens (eight sides) were dissected bilaterally using a binarial, extended, endoscopic endonasal approach (EEA). Nasopharyngectomy was completed including an extended transptyergoid approach for resection of the cartilaginous ET at its junction with the bony ET. Dissection was attempted without sacrifice of the vidian or palatine nerves.

RESULTS

Successful en bloc nasopharyngectomy combined with a nerve-sparing transpterygoid approach was achieved in all specimens with successful preservation of the palatine and vidian nerves. The approach provided exposure of foramen lacerum, the petrous carotid, foramen spinosum, and foramen ovale as well as all segments of the cartilaginous Eustachian tube, Meckel's cave and the parapharyngeal carotid. There was no inadvertent exposure or injury of the internal carotid artery.

CONCLUSION

Endoscopic nasopharyngectomy combined with a nerve-sparing transpterygoid approach allows for en bloc resection of the cartilaginous Eustachian tube and nasopharyngeal contents with broad skull base exposure and preservation of the internal carotid artery, vidian and palatine nerves.

LEVEL OF EVIDENCE

VI Laryngoscope, 130:2343-2348, 2020.

Brassica napus DNA markers linked to white rust resistance in Brassica juncea

White rust, caused by Albugo candida, is an economically important disease of Brassica juncea mustard. The most efficient and cost effective way of protecting mustard plants from white rust is through genetic resistance. The development of canola quality B. juncea through interspecific crosses of B. juncea with Brassica napus has lead to the introgression of white rust resistance from B. napus into B. juncea. The objective of this study was to identify DNA markers for white rust resistance, derived from the introgressed B. napus chromosome segment, in a BC(3)F(2) population of condiment B. juncea mustard. This segregating population was phenotyped for white rust reaction and used to screen for AFLP markers associated with white rust resistance using bulked segregant analysis. Segregation data indicated that a single dominant gene controlled resistance to white rust. Eight AFLP markers linked to white rust resistance were identified, all derived from B. napus. The B. napus chromosome segment, carrying the white rust resistance gene ( Ac2V(1)), appeared to have recombined with the B. juncea DNA since recombinant individuals were identified. Comparative mapping of the eight B. napus-derived AFLP markers in a typical B. napus mapping population was inconclusive; therefore, the size of the introgressed B. napus fragment could not be determined.

Is that absolutely true? Reflections on reality in general practice

Biomedical scientific knowledge appeared to me, as a medical student, to be carved in stone. After many years in general practice it seemed more like it was carved in the shifting sands of time. A feeling of insecurity in diagnosis and treatment followed. There was also a perceived superiority of scientific knowledge over knowledge gained by other means. This did not sit well with my experience in everyday general practice. This article explores a rational framework for change in medical science and a justification for giving equal importance to other forms of knowledge in general practice.

A multicentre comparison of piroxicam and indomethacin in acute soft tissue sports injuries

One hundred and five patients suffering from sport-associated soft tissue injuries were included in a randomized controlled trial comparing the efficacy and side-effects of piroxicam and indomethacin. Patients were treated for 7 days. Both groups showed a similar degree of improvement in joint tenderness, swelling and pain. Eighty-eight per cent of patients on piroxicam showed a marked or moderate improvement in their injury at the end of the trial and 79% of indomethacin-treated patients. Approximately 50% of patients in both groups resumed full activity within 7 days. One patient, in the indomethacin group, was withdrawn from treatment due to a side-effect.