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.

Radiological Assessment of High Anterior Septal Deviation and Its Impact on Sinus Access

OBJECTIVES/HYPOTHESIS

High anterior septal deviation (HASD) is an underreported anatomic variant that can affect the decision to perform septoplasty for access during sinus surgery and ease of postoperative debridement. This study aims to 1) describe an objective method of assessing HASD, and 2) explore its prevalence and implications for performing septoplasty.

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

Computed tomography scans from 2014 to 2020 were retrospectively reviewed. Two independent observers measured the following with respect to midline: distance to septum (SDD), distance to lateral nasal wall (LNW), and septal deviation angle (SDA).

RESULTS

A total of 147 patients were included, with excellent interrater reliability across 99 patients (0.8-0.9). Mean measurements across all patients were SDD (2.77 mm ± 1.34), SDD/LNW (0.26 ± 0.12), and SDA (8.9° ± 4.0). Of 102 patients who underwent sinus surgery, 47 received septoplasty. Compared to the non-septoplasty cohort, the septoplasty cohort had a greater mean SDD (3.61 mm ± 1.48 vs. 2.27 mm ± 0.95; d = 1.10 [95% CI 0.67-1.51]), SDD/LNW (0.34 ± 0.13 vs. 0.21 ± 0.09; d = 1.18 [95% CI 0.76-1.60]), and SDA (11.1° ± 4.3 vs. 7.3° ± 3.4; d = 1.00 [95% CI 0.58-1.40]). Receiver operating characteristic cutoffs were SDD ≥2.43 mm, SDD/LNW ≥0.25, and SDA ≥7.6°, corresponding to a 49%-58% prevalence of HASD.

CONCLUSION

HASD is relatively common and the methods described herein can reliably assess its dimensions. Measurements of SDD, SDD/LNW, and SDA exceeding cutoffs determined by this study may represent clinically significant deflections prompting consideration of septoplasty. These methods may aid in preoperative planning.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Evidence-Based Medicine in Otolaryngology, Part 8: Shared Decision Making—Impact, Incentives, and Instruments

In our previous installment, we introduced shared decision making (SDM) as a collaborative process in which patients, families, and clinicians develop a mutually optimized treatment plan when more than 1 reasonable treatment option exists. In this subsequent installment of our Evidence-Based Medicine in Otolaryngology Series, we expand on the topic of SDM, including the related current state of clinical decision making, the impact of SDM on health care utilization and patient satisfaction, the potential role of system and society changes, the experience with SDM as it relates to race and ethnicity, existing financial incentives, and the validated instruments that assess the extent to which SDM occurs.

Evidence-Based Medicine in Otolaryngology Part 7: Introduction to Shared Decision Making

Shared decision making (SDM) is a collaborative process in which patients, families, and clinicians develop a mutually agreed upon treatment plan when more than one reasonable treatment option exists. This cooperative engagement fosters improvements in patient satisfaction, disease management, and outcomes and also has the capacity to promote evidence-based care. Thus, this seventh installment of our Evidence-Based Medicine in Otolaryngology series focuses on SDM. We introduce SDM, including its potential to reduce decisional conflict and decisional regret, when it should be used, its potential benefits, barriers to implementation, and its role in the management of chronic disease and otolaryngological conditions.

Mucosal remodeling in chronic rhinosinusitis

BACKGROUND

Despite pathophysiologic similarities, mucosal remodeling is well described in asthma but not chronic rhinosinusitis (CRS).

OBJECTIVE

This study attempts to identify mucosal remodeling in CRS and correlate it with clinical information.

METHODS

Charts and histopathology from 53 CRS patients who underwent functional endoscopic sinus surgery were reviewed. Clinical data and basement membrane (BM) thickness were recorded. BM thickness was graded as 0 (no thickening), 1 (mild thickening), 2 (moderate thickening), or 3 (marked thickening). Control mucosae from ten patients without CRS were analyzed for comparison.

RESULTS

Duration of CRS symptoms positively correlated with BM thickness (p = 0.007). Also, patients with a markedly thickened BM (score of 3) had a significantly greater duration of CRS symptoms (120 months) compared to patients with a thinner BM (score < or =2) (33 months) (p = 0.010). Markedly thickened BM was associated with increased coincidence of asthma (p = 0.019) and aspirin sensitivity (p = 0.003). No correlation was found between BM thickness and preoperative Lund-MacKay score. There was no statistically significant difference between markedly thickened BM and thinner BM with respect to coincidence of polyps, course of preoperative systemic steroids, estimated blood loss at surgery, and number of prior surgeries.

CONCLUSION

Increased BM thickness is correlated with prolonged duration of symptoms and the coincidence of asthma. This may indicate paranasal sinus remodeling akin to that which occurs in the bronchioles of persistent asthmatic sufferers.

The assessment and treatment of nasal obstruction after rhinoplasty

Complaints of nasal obstruction after rhinoplasty and nasal surgery are disheartening for both the patient and the surgeon. When a patient presents with complaints of nasal obstruction after rhinoplasty and nasal surgery, the surgeon must reassess the history of symptoms and physical attributes contributing to nasal airway narrowing. The patient's expectations from surgery must also be discussed. The goal is total management of mucosal and anatomic contributors to nasal obstruction. This article describes various causes of nasal obstruction so as to provide rhinoplasty surgeons with the background needed to enhance their preoperative evaluations and avoid future surgical complications.

Gunshot wounds to the head and neck

Gunshot wounds to the head and neck contribute to substantial medical, economic, and social problems in the United States today. The treatment of these patients requires the contemporary head and neck surgeon to be precisely informed in anatomy, wound ballistics, resuscitation, and surgical decision making. Ninety recent cases at the University of Texas Health Science Center affiliated hospitals in Houston were reviewed and are reported. Data show substantial trends in patient demographics and corroborate other reports in the trauma literature. Controversies in patient management continue, but current evidence favors a protocol of selective surgical exploration.