Cost Analysis of High-Signal Approach in Otolaryngology-Head and Neck Surgery Residency

OBJECTIVE

The objective of this study is to analyze a high-signal approach for otolaryngology-head and neck surgery (OHNS) residency applicants and calculate cost savings for programs and applicants.

METHODS

Data from both the 2022-2024 Electronic Residency Application Service (ERAS) and a data model were used to demonstrate cost savings with a high-signal approach. Modeled data assumed that the number of applications per applicant would be equal to the number of signals allowed. Predicted and real-world cost savings across the five other specialties participating in a high-signal approach were calculated.

RESULTS

ERAS data cost savings for the entire OHNS applicant pool amounted to $365,950. In the modeled data, cost savings amounted to $825,921. When extrapolated to include all five high-signal specialties, total cost savings amounted to $2,570,464 (ERAS data) and $6,359,478 (modeled data). Otolaryngology programs were predicted to experience significant time savings, resulting in cost savings of $437,883 and $1,113,342 for ERAS data and modeled data, respectively.

CONCLUSIONS

The study highlights the advantages of a high-signal approach, including financial advantages or increased time for programs to engage in holistic review and diversify the pool of interview candidates. Cost savings in this study were shown to be significant when extrapolated across all specialties using a high-signal approach. Further research is needed to optimize the signaling system and confirm the favorable interview distribution and equity data from the low-signal OHNS experience with a high-signal approach.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:2684-2688, 2024.

Leadership Training Curriculum for Otolaryngology-Head and Neck Surgery Residents: A Scoping Review

OBJECTIVE

Otolaryngologists take on various leadership roles throughout their daily practice, but specific training focused on leadership development during otolaryngology-head and neck surgery (OHNS) residency is not well-defined. This project explores the current state of leadership curricula for OHNS residents.

DATA SOURCES

Google Scholar, Embase, PubMed, and MedEdPORTAL.

REVIEW METHODS

A scoping review was performed on English-language, full-text, peer-reviewed articles that describe leadership curricula for OHNS residents. Investigators reviewed curriculum settings, content, delivery methods, and assessment; curriculum effectiveness was evaluated using Kirkpatrick effectiveness scores and article quality was assessed using the Best Evidence in Medical Education (BEME) index.

CONCLUSION

Three thousand four hundred sixteen articles met search criteria, 198 articles were included for full-text review, and 4 articles met inclusion criteria. Curriculum content and delivery methods were diverse. Curriculum cadence ranged from 2-day immersion trainings to year-long longitudinal programs. Only one of the included studies utilized a needs assessment to inform curriculum development. Two articles achieved Kirkpatrick effectiveness scores of 2, indicating changes in the attitudes or perceptions among participants and a quality measure of 3, indicating clear conclusions drawn from the results.

IMPLICATIONS FOR PRACTICE

The current state of leadership training in OHNS residency is limited and nonuniform. These data align with descriptions of leadership training in other surgical residencies which are reported as heterogenous and lacking in effectiveness. This review highlights the need for standardized leadership training for OHNS residents. The high-quality leadership development initiatives within graduate medical education are reviewed to inform future directions for effective curriculum development and assessment.

Determinants of physician assessment of chronic rhinosinusitis disease control using EPOS 2020 criteria and the importance of incorporating patient perspectives of disease control

BACKGROUND

We identify chronic rhinosinusitis (CRS) manifestations associated with how rhinologists assess CRS control, with a focus on patient perspectives (patient-reported CRS control).

METHODS

Fifteen rhinologists were provided with real-world data from 200 CRS patients. Participating rhinologists first classified patients' CRS control as "controlled," "partly controlled," and "uncontrolled" using seven CRS manifestations reflecting European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) CRS control criteria (nasal obstruction, drainage, impaired smell, facial pain/pressure, sleep disturbance, use of systemic antibiotics/corticosteroids in past 6 months, and nasal endoscopy findings) and patient-reported CRS control. They then classified patients' CRS control without knowledge of patient-reported CRS control. Interrater reliability and agreement of rhinologist-assessed CRS control with patient-reported CRS control and EPOS guidelines were determined.

RESULTS

CRS control classification with and without knowledge of patient-reported CRS control was highly consistent across rhinologists (κw  = 0.758). Rhinologist-assessed CRS control agreed with patient-reported CRS control significantly better when rhinologists had knowledge of patient-reported CRS control (κw  = 0.736 vs. κw  = 0.554, p < 0.001). Patient-reported CRS control, nasal obstruction, drainage, and endoscopy findings were most strongly associated with rhinologists' assessment of CRS control. Rhinologists' CRS control assessments weakly agreed with EPOS CRS control guidelines with (κw  = 0.529) and without (κw  = 0.538) patient-reported CRS control. Rhinologists classified CRS as more controlled than EPOS guidelines in almost 50% of cases.

CONCLUSIONS

This study directly demonstrates the importance of patient-reported CRS control as a dominant influence on rhinologists' CRS control assessment. Knowledge of patient-reported CRS control may better align rhinologists' CRS control assessments and treatment decisions with patients' perspectives.

Effects of hunger on neuronal histone modifications slow aging in Drosophila

Hunger is an ancient drive, yet the molecular nature of pressures of this sort and how they modulate physiology are unknown. We find that hunger modulates aging in Drosophila. Limitation of branched-chain amino acids (BCAAs) or activation of hunger-promoting neurons induced a hunger state that extended life span despite increased feeding. Alteration of the neuronal histone acetylome was associated with BCAA limitation, and preventing these alterations abrogated the effect of BCAA limitation to increase feeding and extend life span. Hunger acutely increased feeding through usage of the histone variant H3.3, whereas prolonged hunger seemed to decrease a hunger set point, resulting in beneficial consequences for aging. Demonstration of the sufficiency of hunger to extend life span reveals that motivational states alone can be deterministic drivers of aging.

IL-13-associated epithelial remodeling correlates with clinical severity in nasal polyposis

BACKGROUND

Epithelial remodeling is a histopathologic feature of chronic inflammatory airway diseases including chronic rhinosinusitis (CRS). Cell-type shifts and their relationship to CRS endotypes and severity are incompletely described.

OBJECTIVE

We sought to understand the relationship of epithelial cell remodeling to inflammatory endotypes and disease outcomes in CRS.

METHODS

Using cell-type transcriptional signatures derived from epithelial single-cell sequencing, we analyzed bulk RNA-sequencing data from sinus epithelial brushings obtained from patients with CRS with and without nasal polyps in comparison to healthy controls.

RESULTS

The airway epithelium in nasal polyposis displayed increased tuft cell transcripts and decreased ciliated cell transcripts along with an IL-13 activation signature. In contrast, CRS without polyps showed an IL-17 activation signature. IL-13 activation scores were associated with increased tuft cell, goblet cell, and mast cell scores and decreased ciliated cell scores. Furthermore, the IL-13 score was strongly associated with a previously reported activated ("polyp") tuft cell score and a prostaglandin E2 activation signature. The Lund-Mackay score, a computed tomographic metric of sinus opacification, correlated positively with activated tuft cell, mast cell, prostaglandin E2, and IL-13 signatures and negatively with ciliated cell transcriptional signatures.

CONCLUSIONS

These results demonstrate that cell-type alterations and prostaglandin E2 stimulation are key components of IL-13-induced epithelial remodeling in nasal polyposis, whereas IL-17 signaling is more prominent in CRS without polyps, and that clinical severity correlates with the degree of IL-13-driven epithelial remodeling.

Impact of the Standardized Interview Offer Date Initiatives: A Survey of Otolaryngology Applicants and Programs

OBJECTIVE

To investigate residency applicant and program compliance with and attitudes toward a newly implemented standardized interview offer date program.

STUDY DESIGN

Cross-sectional survey.

SETTING

US Otolaryngology-Head and Neck Surgery training programs.

METHODS

An electronic survey was distributed to applicants during match week in March 2022, and to program directors and program managers shortly after. The surveys included questions assessing program compliance with the standardized interview offer date as well as both applicant and program attitudes toward this newly implemented initiative.

RESULTS

This study achieved a 47% (263/559) response rate from applicants and 57% (68/120) from programs. Both applicants and program directors reported high program compliance with this initiative. Ninety-six percent of program directors reported complying with releasing interview offers on 1 standardized day. Applicants endorsed a reduction in their anxiety surrounding the residency application process as well as an increased ability to engage in the fourth year of medical school as benefits of the initiative. Providing clarity surrounding the applicant's final application status and further standardization of the interview scheduling process were identified as areas for improvement.

CONCLUSION

Standardization of residency interview offer and acceptance practices is both feasible and impactful. Providing applicants with a final applicant status and further efforts to improve the interview scheduling process may continue to bolster this initiative in future years.

Two-Year Interview and Match Outcomes of Otolaryngology Preference Signaling

OBJECTIVE

To present the first year-over-year data comparison of preference signaling for residency interviews in the otolaryngology application marketplace.

STUDY DESIGN

Cross-sectional study conducted over 2 application cycles.

SETTING

Otolaryngology training programs in the United States.

METHODS

Otolaryngology residency applicants were invited to participate in preference signaling during the 2021 and 2022 application cycles. Submissions were collected using a web-based interface. The distribution of signals among programs was evaluated descriptively and in relationship to Doximity program reputation rankings. Surveys were sent to applicants to assess general attitudes and the number of interview invitations received from signaled and nonsignaled programs. Surveys were sent to programs to evaluate use of signals and the impact on match results.

RESULTS

Programs received a range of signals, from 0 to 66, with 50% of signals going to 24% of programs in 2022, which was similarly found in 2021. Programs of higher rank tended to receive more signals. Overall, >87% of surveyed applicants received an interview offer from at least 1 program that they signaled. In 2021 and 2022, applicants were 2.6 times more likely to get an interview from a signaled program than a comparator nonsignaled program. A greater positive impact on interview offer rate was seen for less competitive applicants. Signaling was viewed favorably by the majority of surveyed applicants and programs.

CONCLUSIONS

Preference signaling for otolaryngology residency interviews demonstrates a promising mechanism to improve applicant visibility to programs during the application cycle. This impact is consistent over 2 application cycles.

Interview Invitations for Otolaryngology Residency Positions Across Demographic Groups Following Implementation of Preference Signaling

IMPORTANCE

Preference signaling is a new initiative in the residency application process that has been adopted by 17 specialties that include more than 80% of applicants in the 2023 National Resident Matching cycle. The association of signals with interview selection rate across applicant demographics has not been fully examined.

OBJECTIVE

To assess the validity of survey-based data on the association of preference signals with interview offers and describe the variation across demographic groups.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study examined the interview selection outcomes across demographic groups for applications with and without signals in the 2021 Otolaryngology National Resident Matching cycle. Data were obtained from a post-hoc collaboration between the Association of American Medical Colleges and the Otolaryngology Program Directors Organization evaluating the first preference signaling program used in residency application. Participants included otolaryngology residency applicants in the 2021 application cycle. Data were analyzed from June to July 2022.

EXPOSURES

Applicants were provided the option of submitting 5 signals to otolaryngology residency programs to indicate specific interest. Signals were used by programs when selecting candidates to interview.

MAIN OUTCOMES AND MEASURES

The main outcome of interest was the association of signaling with interview selection. A series of logistic regression analyses were conducted at the individual program level. Each program within the 3 program cohorts (overall, gender, and URM status) was evaluated with 2 models.

RESULTS

Of 636 otolaryngology applicants, 548 (86%) participated in preference signaling, including 337 men (61%) and 85 applicants (16%) who identified as underrepresented in medicine, including American Indian or Alaska Native; Black or African American; Hispanic, Latino, or of Spanish origin; or Native Hawaiian or other Pacific Islander. The median interview selection rate for applications with a signal (48% [95% CI, 27%-68%]) was significantly higher than for applications without a signal (10% [95% CI, 7%-13%]). No difference was observed in median interview selection rates with or without signals when comparing male (46% [95% CI, 24%-71%] vs 7% [95% CI, 5%-12%]) and female (50% [95% CI, 20%-80%] vs 12% [95% CI, 8%-18%]) applicants or when comparing applicants who identified as URM (53% [95% CI, 16%-88%] vs 15% [95% CI, 8%-26%]) with those who did not identify as URM (49% [95% CI, 32%-68%] vs 8% [95% CI, 5%-12%]).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of otolaryngology residency applicants, preference signaling was associated with an increased likelihood of applicants being selected for interview by signaled programs. This correlation was robust and present across the demographic categories of gender and self-identification as URM. Future research should explore the associations of signaling across a broad range of specialties and the associations of signals with inclusion and position on rank order lists and match outcomes.

Impact of Preference Signaling on Residency Interview Distribution Among Otolaryngology-Head and Neck Surgery Applicants

OBJECTIVE

This study investigates interview offer distribution among applicants of varying levels of competitiveness in a residency application cycle with and without preference signaling.

DESIGN AND SETTING

Self-reported applicant survey data evaluating the 2021-2022 Otolaryngology-Head and Neck Surgery residency signal experience was used to investigate the current distribution of interview offers among applicants. These data then informed a model to assess the distribution of interview offers without signaling in place.

PARTICIPANTS

260 (47% response rate) Otolaryngology-Head and Neck Surgery residency applicants who responded to the survey.

RESULTS

Applicants were divided into four quartiles based on their overall interview offer rate (self-reported number of interviews/self-reported number of applications submitted). Applicants in the top quartile received fewer interview offers while applicants in all other quartiles received more interview offers when signaling was introduced.

CONCLUSIONS

Our data demonstrate that when signaling is introduced, interviews are more evenly distributed among applicants.

IL-13-programmed airway tuft cells produce PGE2, which promotes CFTR-dependent mucociliary function

Chronic type 2 (T2) inflammatory diseases of the respiratory tract are characterized by mucus overproduction and disordered mucociliary function, which are largely attributed to the effects of IL-13 on common epithelial cell types (mucus secretory and ciliated cells). The role of rare cells in airway T2 inflammation is less clear, though tuft cells have been shown to be critical in the initiation of T2 immunity in the intestine. Using bulk and single-cell RNA sequencing of airway epithelium and mouse modeling, we found that IL-13 expanded and programmed airway tuft cells toward eicosanoid metabolism and that tuft cell deficiency led to a reduction in airway prostaglandin E2 (PGE2) concentration. Allergic airway epithelia bore a signature of PGE2 activation, and PGE2 activation led to cystic fibrosis transmembrane receptor-dependent ion and fluid secretion and accelerated mucociliary transport. These data reveal a role for tuft cells in regulating epithelial mucociliary function in the allergic airway.

The Otolaryngology Residency Program Preference Signaling Experience

PROBLEM

In the 2021 residency application cycle, the average otolaryngology applicant applied to more than half of programs. Increasing application numbers make it difficult for applicants to stand out to programs of interest and for programs to identify applicants with sincere interest.

APPROACH

As part of the 2021 Match, otolaryngology applicants could participate in a preference signaling process, signaling up to 5 programs of particular interest at the time of application submission. Programs received a list of applicants who submitted signals to consider during interview offer deliberations. Applicants and program directors completed surveys to evaluate the signaling process and assess the impact of signals on interview offers.

OUTCOMES

All otolaryngology residency programs participated in the signaling process. In total, 611 students submitted applications for otolaryngology residency programs, 559 applicants submitted a Match list including an otolaryngology program, and 558 applicants participated in the signaling process. The survey response rate was 42% for applicants (n = 233) and 52% for program directors (n = 62). The rate of receiving an interview offer was significantly higher from signaled programs (58%) than from both nonsignaled programs (14%; P < .001) and the comparative nonsignal program (23%; P < .001) (i.e., the program an applicant would have signaled given a sixth signal). This impact was consistent across the spectrum of applicant competitiveness. Applicants (178, 77%) and program directors (53, 91%) strongly favored continuing the program.

NEXT STEPS

Many specialties face high residency application numbers. Programs have difficulty identifying applicants with sincere interest, and applicants face limited opportunities to identify programs of particular interest. Applicants to these specialties may benefit from a preference signaling process like that in otolaryngology. Additional evaluation is needed to determine the impact of signals across racial and demographic lines and to validate these early outcomes.

Factors affecting operative autonomy and performance during otolaryngology training: A multicenter trial

Objective

Surgical education is changing in an era of new regulations and evolving training cultures. We sought to understand the factors that affect operative experiences during otolaryngology residency.

Methods

From December 2019 to December 2020, five otolaryngology training programs used the SIMPL OR smartphone application to evaluate residents after each operation. Residents and attendings rated the trainee's autonomy on a 4‐level Zwisch scale, performance on a 5‐level scale, and case complexity on a 3‐level scale. We examined associations between ratings of autonomy and performance with variables including postgraduate year (PGY), case complexity, gender, week of the academic year (AY), and whether multiple procedures were logged.

Results

78 attendings and 92 residents logged 2984 evaluations. PGY level and week of the AY were positively associated with attending ratings of autonomy and performance (PGY3 vs. PGY2: B = 0.63, p < .001 for autonomy and B = 1.05, p < .001 for performance; week of the AY: B = 0.013, p = .002 for autonomy; B = 0.025, p < .001 for performance). Multiple procedures logged and increasing case complexity were negatively associated with attending ratings (multiple procedures: B = −0.19, p = .04 for autonomy and B = −0.48, p < .001 for performance; hardest vs. easiest 1/3 of cases: B = −1.01, p < .001 for autonomy and B = −0.59, p < .001 for performance). Attending and trainee genders were not associated with attending ratings of autonomy or performance.

Conclusion

Resident autonomy and performance were positively associated with PGY level and week of the academic year, and negatively associated with case complexity and multiple procedures. These findings highlight the need to align training level with case complexity to promote quality operative experiences.

Level of Evidence

2.

Multi-institutional Study of Otolaryngology Resident Intraoperative Experiences for Key Indicator Procedures

OBJECTIVE

There is concern that current otolaryngology residents may not receive adequate surgical training. We aimed to characterize residents' surgical experiences at 5 academic centers performing the 14 key indicator procedures (KIPs) outlined by the Accreditation Council for Graduate Medical Education.

STUDY DESIGN

Prospective study.

SETTING

Five otolaryngology training programs.

METHODS

Data were gathered from December 2019 to December 2020 with a smartphone application from the Society for Improving Medical Professional Learning. After each operation, residents and faculty rated trainee autonomy on a 4-level Zwisch scale and performance on a 5-level modified Dreyfus scale.

RESULTS

Residents and attendings (n = 92 and 78, respectively) logged 2984 evaluations. Attending ratings of resident autonomy and performance increased with training level (P < .001). Resident self-assessments of autonomy and performance were lower than paired attending assessments (P < .001). Among attending evaluations of KIPs performed by senior residents (postgraduate year 4 or 5), 55% of cases were performed with meaningful autonomy (passive help or supervision only). Similarly, attendings rated 55% of these cases as a practice-ready or exceptional performance. Senior residents had meaningful autonomy for ≥50% of cases for most KIPs, with the exception of flaps and grafts (40%), pediatric/adult airway (39%), and stapedectomy/ossiculoplasty (33%). Similarly, senior residents received practice-ready or exceptional performance ratings for ≥50% of cases across all KIPs other than pediatric/adult airway (42%) and stapedectomy/ossiculoplasty (33%).

CONCLUSION

In this multicenter study, resident surgical autonomy and performance varied across otolaryngology KIPs. The development of nationwide benchmarks will help programs and residents set educational goals.

LEVEL OF EVIDENCE

2.

Proposal for the Standardization of Otolaryngology Residency Interview Offer Dates

The process of receiving and scheduling residency interviews for otolaryngology-head and neck surgery positions is chaotic, inducing unnecessary anxiety for applicants and introducing inefficiencies for programs. With incomplete information, applicants often accept all invitations they receive, resulting in interview hoarding and late cancellations. Various specialties have attempted to improve the interview offer and scheduling process through standardization of interview offer dates. In this commentary, we propose that otolaryngology programs adopt a uniform interview offer and scheduling date. We also advise programs commit to limiting the number of interview invitations to the number of interview slots available, and we review best practices to optimize the interview offer and scheduling process for both applicants and programs.

Septum submucosal glands exhibit aberrant morphology and reduced mucin production in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is characterized by significant accumulation and thickening of mucus in the sinonasal cavities. One contributor of aberrant mucus production and impaired mucociliary clearance (MCC) is altered function of the sinonasal submucosal glands (SMGs), yet contributions of SMGs to upper airway disease initiation and progression remain unknown. The objective of this study was to characterize the morphology and secretory cell identities of the nasal septum SMGs in both healthy and CRS adults.

METHODS

Biopsies from adult participants with CRS without nasal polyps (CRSsNP, n = 4), CRS with nasal polyps (CRSwNP, n = 8), and non-CRS controls (n = 14) were collected from the posterior septum. Glandular morphology and mucus markers were investigated using histological techniques and high-resolution confocal microscopy.

RESULTS

Analysis revealed a significant decrease in gland density in the posterior septum of CRSsNP (28% ± 6.15%) and CRSwNP (23% ± 3.09%) compared to control participants (53% ± 1.59%, p < 0.0001). Further analysis of the CRS SMG secretory function revealed an overall decrease in Mucin 5B+ gland mucus being produced. Dilated and cystic ductal structures filled with inspissated mucus were also common to CRS glands.

CONCLUSION

Here, we describe a significant alteration in SMG structure and function in the adult CRS posterior septum suggesting reduced gland contribution to MCC. The SMGs of both the nose and sinuses may represent targets for future therapeutic approaches.

Patient Use of Low-cost Digital Videoscopes and Smartphones for Remote Ear and Oropharyngeal Examinations

Importance

During the novel coronavirus disease 2019 pandemic, telehealth has become a vital component of health care delivery. For otolaryngology evaluations, examination of the ear and oropharynx is important but difficult to achieve remotely.

Objective

To assess the feasibility of patient use of low-cost digital videoscopes and smartphones for examination of the ear and oropharynx.

Design, Setting, and Participants

A prospective quality improvement study was conducted in an academic adult otolaryngology clinic including 23 patients who presented for an in-person appointment and owned a smartphone device. The study was conducted from July 1 to 15, 2020.

Interventions

Participants were asked to capture pictures and videos of their ear canals and oropharynx with digital videoscopes and their smartphones under real-time guidance over a telehealth platform. They were then surveyed about their experience.

Main Outcomes and Measures

The primary outcomes were ratings by health care clinicians and a blinded otolaryngologist reviewer of image acceptability. Secondary outcomes included participant time to image acquisition and willingness to purchase digital videoscopes for telehealth use.

Results

Of the 23 participants included, 14 were women (61%); mean age was 50 years (range, 21 to 80 years). Of the images obtained using the digital otoscope ear examination, 95% were considered acceptable by the health care clinicians and 91% were considered acceptable by the blinded reviewer; 16 participants (70%) reported that the otoscope was easy to use. The mean time to acquire images for both ears was 114 seconds (95% CI, 84-145 seconds). Twenty-one participants (91%) were willing to pay for a digital otoscope for telehealth use. For the oropharyngeal examination, a greater proportion of smartphone video examinations were considered acceptable by clinicians (63% acceptability) and the blinded reviewer (55%) compared with the digital endoscope (clinicians, 40%; blinded reviewer, 14%). The mean time required for the oropharyngeal examination smartphone video capture was shorter at 35 seconds compared with both the digital endoscope (difference, -27 seconds; 95% CI, -7 to -47 seconds) and smartphone photo capture (difference, -53 seconds; 95% CI, -20 to -87 seconds).

Conclusions and Relevance

Digital otoscopes and smartphones apparently can facilitate remote head and neck physical examination in telehealth. Digital otoscopes were useful for ear examinations, and smartphone videos appeared to be the most useful for oropharyngeal examinations. Further studies are required to determine specific diagnostic capabilities in various telehealth practice settings.

Evolving Otolaryngology Resident Roles and Concerns at the Peak of the US COVID-19 Pandemic

BACKGROUND

The roles of US otolaryngology residents have changed in response to the coronavirus disease 2019 (COVID-19) pandemic. As the pandemic peaked in the United States, we characterized resident activities and concerns.

METHODS

A cross-sectional study of US otolaryngology residents between April 20, 2020 and May 2, 2020.

RESULTS

A total of 219 residents at 65/118 (55%) institutions responded. Thirty (14%) residents had been redeployed. Residents reported greatest concerns regarding education (P < .00001). Assuming adequate protective equipment, 55% desired active participation in high-risk procedures on COVID-19-positive patients. Redeployed residents had greater concern for burnout and reduced in-hospital well-being (P < .05). Resident satisfaction correlated with comfort communicating concerns to their department (odds ratio [OR] = 4.9, 95% confidence interval [CI] 1.4-17.3, P = .01) and inversely correlated with low perceived meaning in work (OR = 3.1, CI 1.1-9.1, P = .03).

CONCLUSION

Otolaryngology resident concerns have evolved as the pandemic progressed. Residency programs should prioritize resident education, well-being in redeployed residents, and open communication as they transition toward recovery.

Otolaryngology Residency Interviews in a Socially Distanced World: Strategies to Recruit and Assess Applicants

Due to concerns surrounding travel during the COVID-19 pandemic, the 2020-2021 otolaryngology residency application cycle will be conducted virtually for the first time. Residency programs should consider the logistics of video interviews, drawing on experiences of other programs that have successfully performed virtual interviews in the past. The lack of in-person interviews will create challenges in assessing applicants, and we recommend that programs develop structured and targeted questions and even consider having candidates answer standardized questions prior to the virtual interview day. From an applicant perspective, gauging the intangibles of individual residency programs, such as resident camaraderie, program culture, and program location, will be difficult. To address this, programs should consider hosting informal virtual gatherings, create videos that highlight the resident experience, and ensure that program websites are up-to-date. Ultimately, adaptability, resilience, and innovation will allow residency programs to achieve a successful 2021 otolaryngology match.

Development of clinical care guidelines for faculty and residents in the era of COVID-19

Background

The global COVID‐19 pandemic brings new challenges to otolaryngology resident education. Surgical volume and clinic visits are curtailed, personal protective equipment for operating room participation is restricted, and the risk of COVID‐19 disease transmission during heretofore routine patient care is the new norm.

Methods

We describe a small‐team “cohorting” protocol including guidelines for faculty and resident in common clinical scenarios with attention paid to the risk of common otolaryngologic procedures.

Results

A rotating small‐team approach was implemented at each clinical site, limiting interaction between department members but providing comprehensive coverage. Faculty were involved at the earliest phase of clinical interactions. Guidelines delineated faculty and resident roles based on risk stratification by patient COVID status and anticipated procedures. Special consideration was given to high‐risk procedures such as endoscopy and tracheotomy.

Conclusions

A small‐team‐based approach with guidelines for faculty/resident roles may mitigate risk while optimizing patient care and maximizing education.

Loss of Microbial Niche Specificity Between the Upper and Lower Airways in Patients With Cystic Fibrosis

OBJECTIVES/HYPOTHESIS

To determine the relationship between mucosal-associated sinus and bronchial microbiota in cystic fibrosis (CF) patients compared to non-CF patients with chronic rhinosinusitis (CRS).

STUDY DESIGN

Case series.

METHODS

We examined the microbial composition of 52 paired sinus and bronchial brushings from 26 patients with CRS. Paired airway samples from nine subjects with CF were compared with samples from 17 non-CF-CRS disease control patients. The Illumina MiSeq platform was used to sequence the V4 region of the 16S rRNA gene. Sequences were analyzed using QIIME 1.9.0.

RESULTS

CF patients demonstrate increased severity of sinus inflammation (Lund-Mackay score 16.3 vs. 12.4, P = .023) and diminished diversity of microbial communities in both the sinuses (Shannon diversity 0.98 vs. 3.3, P = .009) and lungs (Shannon diversity 2.2 vs. 4.0, P = .042) relative to non-CF-CRS. Non-CF-CRS sinus and lung microbiota were distinct and clustered by niche (sinus vs. lung, P = .004). However, CF airway microbiota demonstrated a loss of niche specificity (sinus vs. lung, P = .492). Two CF patients underwent lung transplantation at 4.5 and 9 months prior to sampling. Sinus and lung samples from these two patients demonstrated distinct microbial communities.

CONCLUSIONS

Patients with CF undergoing surgery for CRS exhibit substantial bacterial community collapse in the sinuses and a loss of niche specificity between the upper and lower airways compared to non-CF patients with CRS. These results extend previous studies elucidating the lower airway microbiome in cystic fibrosis and provide support for the concept of microbial translocation in the cystic fibrosis airways.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:544-550, 2019.

Heterogeneity of Microbiota Dysbiosis in Chronic Rhinosinusitis: Potential Clinical Implications and Microbial Community Mechanisms Contributing to Sinonasal Inflammation

Recent studies leveraging next-generation sequencing and functional approaches to understand the human microbiota have demonstrated the presence of diverse, niche-specific microbial communities at nearly every mucosal surface. These microbes contribute to the development and function of physiologic and immunological features that are key to host health status. Not surprisingly, several chronic inflammatory diseases have been attributed to dysbiosis of microbiota composition or function, including chronic rhinosinusitis (CRS). CRS is a heterogeneous disease characterized by inflammation of the sinonasal cavity and mucosal microbiota dysbiosis. Inflammatory phenotypes and bacterial community compositions vary considerably across individuals with CRS, complicating current studies that seek to address causality of a dysbiotic microbiome as a driver or initiator of persistent sinonasal inflammation. Murine models have provided some experimental evidence that alterations in local microbial communities and microbially-produced metabolites influence health status. In this perspective, we will discuss the clinical implications of distinct microbial compositions and community-level functions in CRS and how mucosal microbiota relate to the diverse inflammatory endotypes that are frequently observed. We will also describe specific microbial interactions that can deterministically shape the pattern of co-colonizers and the resulting metabolic products that drive or exacerbate host inflammation. These findings are discussed in the context of CRS-associated inflammation and in other chronic inflammatory diseases that share features observed in CRS. An improved understanding of CRS patient stratification offers the opportunity to personalize therapeutic regimens and to design novel treatments aimed at manipulation of the disease-associated microbiota to restore sinus health.

Silent sinus syndrome without opacification of ipsilateral maxillary sinus

Silent sinus syndrome (SSS) is a rare disease characterized by spontaneous enophthalmos and hypoglobus secondary to collapse of the orbital floor in patients with asymptomatic maxillary sinusitis. Radiographic findings include ipsilateral maxillary sinus opacification, lateralization of the uncinate and middle turbinate, and infundibular occlusion. We present a case series of three patients with clinical and radiographic evidence of SSS but without maxillary sinus opacification. Although uncommon, an aerated maxillary sinus in patients with unexplained enophthalmos, hypoglobus, and maxillary atelectasis should not exclude the diagnosis of SSS. Laryngoscope, 128:2004-2007, 2018.

Surgical treatment of chronic rhinosinusitis after sinus lift

BACKGROUND

The sinus lift (or sinus augmentation) is a common procedure to improve maxillary bone stock before dental implantation. Chronic rhinosinusitis (CRS) is a potential complication of this procedure and may be refractory to medical treatment. Functional endoscopic sinus surgery has previously been used to address CRS, however, results of previous studies indicated that implant removal is required. There are limited follow-up data available.

OBJECTIVE

The purpose of this study was to characterize the long-term outcomes and efficacy of endoscopic sinus surgery for refractory CRS after sinus lift, including the ability to salvage dental implants.

METHODS

This was a retrospective case series that described nine patients who, between June 2011 and September 2016, underwent endoscopic sinus surgery for CRS after a sinus lift procedure. The presenting symptoms of the patients, medical management, imaging results, operative procedures, and outcomes were reviewed.

RESULTS

The majority of patients developed symptoms (mucopurulent nasal drainage, facial pain and/or pressure, nasal congestion, and foul smell) within 3 months of implant placement and were treated with at least three courses of antibiotics before referral to an otolaryngologist. All the patients underwent wide endoscopic maxillary antrostomy, with no surgical complications or postoperative reports of infection. There was a statistically significant improvement in 22-item Sino-Nasal Outcome Test scores (t(8) = -2.908; p = 0.02) and discharge, inflammation, and polyps/edema endoscopic scores ([z = -2.539; p = 0.011) between pre- and postsurgical treatment. Four patients had their dental implants removed before presentation. Among the five patients who presented with intact dental implants, none required removal before or after functional endoscopic sinus surgery.

CONCLUSION

Functional endoscopic sinus surgery was a reasonable and efficacious treatment option for patients who presented with paranasal sinus disease after a sinus lift. Dental implant removal may not be a requirement for successful treatment of CRS associated with sinus lift procedures.

Use of Acupuncture in the Treatment of Sinus and Nasal Symptoms: Results of a Practitioner Survey

Background

The use of complementary medicine is increasingly popular in the United States. The use of acupuncture and its efficacy in treating chronic sinus and nasal symptoms is not well studied.

Methods

Regional licensed acupuncturists (1516) were mailed our acupuncture and chronic sinus and nasal symptoms survey.

Results

Three hundred thirty-one surveys (22%) were returned. Ninety-nine percent of those who returned surveys reported treating patients with chronic sinus and nasal symptoms. On a five-point scale the mean perceived efficacy for the overall treatment of chronic sinus and nasal symptoms was 4.2. The mean cost of an acupuncture treatment course for chronic sinus and nasal symptoms was calculated to be $730.00.

Conclusion

Complementary medicine practitioners frequently use acupuncture in the treatment of patients with chronic sinus and nasal symptoms. Although practitioners report good efficacy using acupuncture to treat such patients, quantitative data are certainly needed to substantiate these self-reports.

Fungal Microbiota in Chronic Airway Inflammatory Disease and Emerging Relationships with the Host Immune Response

The respiratory tract is a complex system that is inhabited by niche-specific communities of microbes including bacteria, fungi, and viruses. These complex microbial assemblages are in constant contact with the mucosal immune system and play a critical role in airway health and immune homeostasis. Changes in the composition and diversity of airway microbiota are frequently observed in patients with chronic inflammatory diseases including chronic rhinosinusitis (CRS), cystic fibrosis, allergy, and asthma. While the bacterial microbiome of the upper and lower airways has been the focus of many recent studies, the contribution of fungal microbiota to inflammation is an emerging research interest. Within the context of allergic airway disease, fungal products are important allergens and fungi are potent inducers of inflammation. In addition, murine models have provided experimental evidence that fungal microbiota in peripheral organs, notably the gastrointestinal (GI) tract, influence pulmonary health. In this review, we explore the role of the respiratory and GI microbial communities in chronic airway inflammatory disease development with a specific focus on fungal microbiome interactions with the airway immune system and fungal-bacterial interactions that likely contribute to inflammatory disease. These findings are discussed in the context of clinical and immunological features of fungal-mediated disease in CRS, allergy, and asthmatic patients. While this field is still nascent, emerging evidence suggests that dysbiotic fungal and bacterial microbiota interact to drive or exacerbate chronic airway inflammatory disease.

Biocompatibility and Pharmacokinetics of Fluticasone-Eluting Sinus Implant in a Rabbit Model

Background

A novel, bioabsorbable, fibrinogen-based implant has been developed as a mucosal dressing after endoscopic sinus surgery (ESS). This implant can be formulated with fluticasone propionate (TP) for local elution of corticosteroid to reduce postoperative inflammation and promote mucosal healing.

Objective

This study investigated the biocompatibility and pharmacokinetics of the implant in a rabbit model.

Methods

Implants with and without TP were placed on both intact and demucosalized maxillary sinuses of 33 New Zealand White rabbits. Sinuses with either intact or denuded bone without implants acted as controls. Histopathologic assessments were carried out at 5, 15, and 28 days. Concentrations of TP in the maxillary sinus mucosa, nasal cavity mucosa, and plasma were measured for up to 44 days.

Results

Implants placed on intact mucosa or denuded bone were grossly integrated within 15 days. Minimal foreign body reaction was seen with negligible differences for inflammation, fibrosis, or bone remodeling among controls, sinuses with the implant, or sinuses with the implant plus TP, at all time points. All samples also showed complete or near-complete percentage reepithelialization at 28 days, although the denuded bone controls demonstrated greater percentage reepithelialization at 5 days compared with denuded bone with the implant or implant plus TP (p <0.0001). The maxillary sinus mucosa demonstrated levels of TP of >140 ng/g up to 44 days. Plasma concentrations of TP were generally very low and were undetectable after day 7.

Conclusions

The implant and the implant plus TP seemed to be biocompatible in rabbits. The implant plus TP effectively eluted steroid locally over at least 44 days, with negligible plasma concentrations. Further studies are warranted regarding potential therapeutic applications in patients undergoing ESS for chronic rhinosinusitis.

Compositionally and functionally distinct sinus microbiota in chronic rhinosinusitis patients have immunological and clinically divergent consequences

BACKGROUND

Chronic rhinosinusitis (CRS) is a heterogeneous disease characterized by persistent sinonasal inflammation and sinus microbiome dysbiosis. The basis of this heterogeneity is poorly understood. We sought to address the hypothesis that a limited number of compositionally distinct pathogenic bacterial microbiota exist in CRS patients and invoke discrete immune responses and clinical phenotypes in CRS patients.

RESULTS

Sinus brushings from patients with CRS (n = 59) and healthy individuals (n = 10) collected during endoscopic sinus surgery were analyzed using 16S rRNA gene sequencing, predicted metagenomics, and RNA profiling of the mucosal immune response. We show that CRS patients cluster into distinct sub-groups (DSI-III), each defined by specific pattern of bacterial co-colonization (permutational multivariate analysis of variance (PERMANOVA); p = 0.001, r ² = 0.318). Each sub-group was typically dominated by a pathogenic family: Streptococcaceae (DSI), Pseudomonadaceae (DSII), Corynebacteriaceae [DSIII(a)], or Staphylococcaceae [DSIII(b)]. Each pathogenic microbiota was predicted to be functionally distinct (PERMANOVA; p = 0.005, r ² = 0.217) and encode uniquely enriched gene pathways including ansamycin biosynthesis (DSI), tryptophan metabolism (DSII), two-component response [DSIII(b)], and the PPAR-γ signaling pathway [DSIII(a)]. Each is also associated with significantly distinct host immune responses; DSI, II, and III(b) invoked a variety of pro-inflammatory, T_H1 responses, while DSIII(a), which exhibited significantly increased incidence of nasal polyps (Fisher's exact; p = 0.034, relative risk = 2.16), primarily induced IL-5 expression (Kruskal Wallis; q = 0.045).

CONCLUSIONS

A large proportion of CRS patient heterogeneity may be explained by the composition of their sinus bacterial microbiota and related host immune response-features which may inform strategies for tailored therapy in this patient population.

A chronic rhinosinusitis-derived isolate of Pseudomonas aeruginosa induces acute and pervasive effects on the murine upper airway microbiome and host immune response

BACKGROUND

Diverse microbial communities colonize healthy sinus mucosa and specific species within these communities are capable of protecting the host from pathogenic infection. However, little is known of the dynamics of upper airway infection and the role of the sinus mucosal microbiome in short- and longer-term outcomes using clinical isolates from patients with chronic rhinosinusitis.

METHODS

We examine microbiome and immune dynamics after murine sinus infection with Pseudomonas aeruginosa EC1, isolated previously from a chronic rhinosinusitis patient. Microbiota profiling (16S rRNA sequencing), histologic, and immunologic analyses [interferon-gamma (IFN-γ) and eotaxin-1 (CCL11) gene expression] were performed at 1, 7, and 10 days postinfection (D1PI, D7PI, and D10PI) in antimicrobial-treated and untreated animals.

RESULTS

At D1PI, P. aeruginosa EC1 dominated the upper airway microbiome and was associated with a significant increase in sinus mucosa goblet cell hyperplasia, mucin hypersecretion (p < 0.001), and IFN-γ expression in antibiotic-treated and untreated animals, although the magnitude of pathogen enrichment was lower in the latter group. Mucin hypersecretion and IFN-γ expression subsided by 7D7PI in both groups of mice, coincident with a depletion of the infectious strain. However, other members of the Pseudomonadaceae family remained significantly enriched (p < 0.05, q < 0.05) in the microbiome at D7PI and D10PI and this perturbation was associated with induction of eotaxin-1 at these later time-points.

CONCLUSION

Murine intranasal P. aeruginosa EC1 infection causes a pervasive shift in the sinus microbiome that persists despite histologic resolution and is associated with a reproducible immunologic shift from an initial IFN-γ response to a temporal induction of eotaxin-1.

Microdebrider eustachian tuboplasty: A preliminary report

Objective

To evaluate microdebrider eustachian tuboplasty for treatment of patients with eustachian tube dysfunction.

Study Design

A prospective study of 20 patients with eustachian tube dysfunction who underwent microdebrider eustachian tuboplasty (mETP) was performed at an academic medical center. Surgery involved use of a microdebrider to remove hypertrophied mucosa from the posterior eustachian tube cushion. All patients had concurrent sinonasal disease and underwent endoscopic sinus surgery at the time of mETP.

Results

There were no surgical complications. Following mETP, subjective symptoms of ear blockage improved in 14 of 20 patients (70%). Mean pure tone average improved by 6 dB (27 dB pre-op vs 21 dB post-op; P = 0.013). Abnormal tympanogram improved in 11 of 17 patients (65%). Failure of the procedure correlated with severity of mucosal disease as measured by both elevated tissue eosinophil count and advanced sinus CT stage ( P = 0.018 and P = 0.014, respectively). Mean follow-up was 13 months (range 3-34 months).

Conclusion

Microdebrider eustachian tuboplasty appears to be a safe procedure for the treatment of eustachian tube dysfunction.

An unusual presentation of a lingual dermoid cyst

Dermoid cysts are rare lesions of the head and neck that usually present in children as an asymptomatic, slowly growing mass. We report a case that demonstrates that dermoid cysts can present later in life as a recurrent acute infection. Our patient was a 48-year-old man with a 22-year history of recurrent abscesses of the tongue and floor of the mouth that had required a tracheotomy and multiple hospitalizations. Magnetic resonance imaging performed between acute episodes revealed the presence of a 1.8-cm lesion within the tongue musculature. The patient underwent resection, and pathology was consistent with a lingual dermoid cyst. At 2 years of follow-up, he experienced no recurrence of symptoms.

Risk factors for postoperative cerebrospinal fluid leak and meningitis after expanded endoscopic endonasal surgery

Postoperative cerebrospinal fluid (CSF) leak is a serious complication of transsphenoidal surgery, which can lead to meningitis and often requires reparative surgery. We sought to identify preoperative risk factors for CSF leaks and meningitis. We reviewed 98 consecutive expanded endoscopic endonasal surgeries performed from 2008-2012 and analyzed preoperative comorbidities, intraoperative techniques, and postoperative care. Univariate and multivariate analyses were performed. The most common pathologies addressed included pituitary adenoma, Rathke cyst, chordoma, esthesioneuroblastoma, meningioma, nasopharyngeal carcinoma, and squamous cell carcinoma. There were 11 CSF leaks (11%) and 10 central nervous system (CNS) infections (10%). Univariate and multivariate analysis of preoperative risk factors showed that patients with non-ideal body mass index (BMI) were associated with higher rate of postoperative CSF leak and meningitis (both p<0.01). Also, patients with increasing age were associated with increased CSF leak (p = 0.03) and the length of time a lumbar drain was used postoperatively was associated with infection in a univariate analysis. In addition, three of three endoscopic transsphenoidal surgeries combined with open cranial surgery had a postoperative CSF leak and CNS infection rate which was a considerably higher rate than for transsphenoidal surgeries alone or surgeries staged with open cases (p<0.01 and p=0.04, respectively) In this series of expanded endoscopic transsphenoidal surgeries, preoperative BMI remains the most important preoperative predictor for CSF leak and infection. Other risk factors include age, intraoperative CSF leak, lumbar drain duration, and cranial combined cases. Risks associated with complex surgical resections when combining open and endoscopic approaches could be minimized by staging these procedures.

Maxillary sinus posterior wall remodeling following surgery for silent sinus syndrome

Silent SINUS SYNDROME is a clinical syndrome defined by unilateral maxillary sinus opacification with atelectasis of the uncinate process. Clinically, this disorder is characterized by enophthalmos and hypoglobus. The current case report illustrates dramatic bony remodeling of the maxillary sinus following maxillary antrostomy. Although the remodeling is noted in the posterior wall of the maxillary sinus, this demonstrates the dynamic nature of bone remodeling in silent sinus syndrome, which may obviate the need for surgical correction of enophthalmos and hypoglobus. Following maxillary antrostomy, observation with staged orbital surgery, if required, is recommended.

Risk factors for cerebrospinal leak after endoscopic skull base reconstruction with nasoseptal flap

OBJECTIVE

The use of expanded endonasal surgery (EES) in the treatment of skull base neoplasms has increased significantly in recent years. Since 2006, the nasoseptal flap (NSF) has become the workhorse for the closure of skull base defects involving the anterior and central skull base. We hypothesized that defect site impacts the rate of cerebrospinal fluid (CSF) leak following EES.

STUDY DESIGN

Retrospective cohort study.

SETTING/SUBJECTS/METHODS

Patients who underwent skull base defect repair using a NSF at the University of California at San Francisco (UCSF) minimally invasive skull base center were retrospectively reviewed. Patient demographics, disease, and defect location and size were recorded along with the presence of a postoperative CSF leak. Data were analyzed using Fisher's exact test.

RESULTS

One hundred and twenty-one patients met inclusion criteria. Ten patients had a NSF failure with CSF leakage, 2 in the anterior skull base (frontal sinus, ethmoid, cribriform, planum), and 8 in the central skull base (sella, clivus) (P = .047). Dural defect size ≥2.0 cm(2) in the central skull base strongly correlated with the risk of flap failure (P = .034).

CONCLUSIONS

This study of endoscopic closure of skull base defects using a NSF demonstrates there is an association between both surgical site and dural defect size with NSF failure. Expanded defects of the sella and clivus have an increased risk of failure and may warrant augmented techniques.

Sinus microbiome diversity depletion and Corynebacterium tuberculostearicum enrichment mediates rhinosinusitis

Persistent mucosal inflammation and microbial infection are characteristics of chronic rhinosinusitis (CRS). Mucosal microbiota dysbiosis is found in other chronic inflammatory diseases; however, the relationship between sinus microbiota composition and CRS is unknown. Using comparative microbiome profiling of a cohort of CRS patients and healthy subjects, we demonstrate that the sinus microbiota of CRS patients exhibits significantly reduced bacterial diversity compared with that of healthy controls. In our cohort of CRS patients, multiple, phylogenetically distinct lactic acid bacteria were depleted concomitant with an increase in the relative abundance of a single species, Corynebacterium tuberculostearicum. We recapitulated the conditions observed in our human cohort in a murine model and confirmed the pathogenic potential of C. tuberculostearicum and the critical necessity for a replete mucosal microbiota to protect against this species. Moreover, Lactobacillus sakei, which was identified from our comparative microbiome analyses as a potentially protective species, defended against C. tuberculostearicum sinus infection, even in the context of a depleted sinus bacterial community. These studies demonstrate that sinus mucosal health is highly dependent on the composition of the resident microbiota as well as identify both a new sino-pathogen and a strong bacterial candidate for therapeutic intervention.

A novel sinonasal endoscopy scoring system: the discharge, inflammation, and polyps/edema (DIP) score

BACKGROUND

There is an increasing need for a validated grading system to assess sinusitis severity as observed on endoscopic examination. Existing endoscopy scales have limitations in complexity, validation, and/or applicability. We present a novel and straightforward endoscopic scoring system measuring discharge, inflammation, and polyps/edema (DIP). The aim of this study is to determine correlation of the DIP score with existing sinus endoscopy scoring systems, and to determine interrater and test-retest reliability.

METHODS

This retrospective cohort includes a total of 29 patients who underwent functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis. Sinus endoscopy videos were scored in a random and blinded fashion by 3 rhinologists (S.D.P., A.N.G., A.H.M.) using the Lund-Kennedy Endoscopic Score (LKES), the Perioperative Sinus Endoscopy (POSE) score, and the DIP score. Pearson correlation coefficients, interrater reliability and test-retest reliability were determined.

RESULTS

The results of this study show that the DIP score correlates well (p < 0.0001) with the existing LKES and POSE (Pearson correlation coefficients of 0.78 and 0.90, respectively). The interrater reliability intraclass correlation coefficient (ICC) is highest for the DIP score (0.87), followed by the POSE score (0.84) and the LKES (0.78). Test-retest reliability ICC is highest for the DIP score (0.78), followed by the POSE score (0.59) and the LKES (0.53).

CONCLUSION

The DIP score is a novel and straightforward endoscopic sinus scoring system that shows substantial test-retest and interrater reliability in the post-FESS population. It also demonstrates a high correlation with existing scoring parameters (LKES and POSE).

The propensity for consuming ethanol in Drosophila requires rutabaga adenylyl cyclase expression within mushroom body neurons

Alcohol activates reward systems through an unknown mechanism, in some cases leading to alcohol abuse and dependence. Herein, we utilized a two-choice Capillary Feeder assay to address the neural and molecular basis for ethanol self-administration in Drosophila melanogaster. Wild-type Drosophila shows a significant preference for food containing between 5% and 15% ethanol. Preferred ethanol self-administration does not appear to be due to caloric advantage, nor due to perceptual biases, suggesting a hedonic bias for ethanol exists in Drosophila. Interestingly, rutabaga adenylyl cyclase expression within intrinsic mushroom body neurons is necessary for robust ethanol self-administration. The expression of rutabaga in mushroom bodies is also required for both appetitive and aversive olfactory associative memories, suggesting that reinforced behavior has an important role in the ethanol self-administration in Drosophila. However, rutabaga expression is required more broadly within the mushroom bodies for the preference for ethanol-containing food than for olfactory memories reinforced by sugar reward. Together these data implicate cAMP signaling and behavioral reinforcement for preferred ethanol self-administration in D. melanogaster.

Sinus anatomy associated with inadvertent cerebrospinal fluid leak during functional endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

Anatomic variations in skull base anatomy may predispose the surgeon to inadvertent skull base injury with resultant cerebrospinal fluid (CSF) leak during functional endoscopic sinus surgery (ESS). Our objective was to compare preoperative sinus imaging of patients who underwent FESS with and without CSF leak to elucidate these variations.

STUDY DESIGN

In this retrospective case-control study, 18 patients with CSF leak following FESS for chronic rhinosinusitis (CRS) from 2000 to 2011 were compared to 18 randomly selected patients who underwent preoperative imaging for FESS for CRS.

METHODS

Measurements were obtained from preoperative computed tomography images with specific attention to anatomic differences in cribriform plate and ethmoid roof heights in the coronal plane, and the skull base angle in the sagittal plane. Mean values of measured variables were compared using a nonparametric Mann-Whitney test.

RESULTS

When compared to controls, patients with CSF leak demonstrated a greater angle of the skull base in the sagittal plane (P < .001) and a greater slope of the skull base in the coronal plane (P < .006). A lower cribriform height relative to ethmoid roof height was also noted in cases of CSF leak as compared to controls (P < .04).

CONCLUSIONS

A steep skull base angle in the sagittal plane, a greater slope of the skull base in the coronal plane, and a low cribriform height relative to the ethmoid roof predispose the patient to CSF leak during FESS. Preoperative review of imaging with specific attention paid to these anatomic variations may help to prevent iatrogenic CSF leak.

Some chronic rhinosinusitis patients have elevated populations of fungi in their sinuses

Objectives/Hypothesis:

To measure the populations of 36 fungi in the homes and sinuses of chronic rhinosinusitis (CRS) and non‐CRS patients.

Study Design:

Single‐blind cross‐sectional study.

Methods:

Populations of 36 fungi were measured in sinus samples and in the home vacuum cleaner dust of CRS (n = 73) and non‐CRS patients (n = 16) using quantitative polymerase chain reaction. Etest strips containing amphotericin B, anidulafungin, caspofungin, fluconazole, and voriconazole were used to test the susceptibility of seven potentially relevant fungi.

Results:

Seven fungi (Alternaria alternata, Cladosporium cladosporioides types 1 and 2, Cladosporium herbarum, Penicillium brevicompactum, Penicillium crustosum, and Penicillium chrysogenum type 2) were discovered at very high concentrations in some CRS patients. In vitro antifungal susceptibility testing of these seven fungi demonstrated species specific sensitivities. Four CRS patients with marked elevations of fungal populations in their sinus samples underwent endoscopic sinus surgery. After surgical treatment, the fungal populations were reduced by several orders of magnitude.

Conclusions:

Seven fungi were found in very high concentrations in the sinuses of some CRS patients. Not one of the five common antifungal agents could control all seven of these fungi based on in vitro tests.

Treatment of recurrent sinonasal polyposis with steroid-infused carboxymethylcellulose foam

BACKGROUND

Recurrence of sinonasal polyposis after endoscopic sinus surgery can be difficult to manage. Topical steroid sprays and irrigations may not provide adequate treatment and systemic steroid therapy is limited by side effects. This study was designed to evaluate the efficacy of steroid-infused carboxymethylcellulose (CMC) foam as a treatment for recurrence of chronic rhinosinusitis with nasal polyposis after endoscopic sinus surgery.

METHODS

A prospective cohort study was performed enrolling patients with recurrent sinonasal polyposis after endoscopic sinus surgery. All patients had development of symptomatic polyp disease despite aggressive postoperative topical steroid treatment. The study treatment entailed endoscopic placement of 4 mL of CMC foam hydrated with triamcinolone, 40 mg/mL (Kenalog 40; Bristol-Myers Squibb, New York, NY), into the ethmoid cavities bilaterally. Patients were evaluated using videoendoscopy and the Sino-Nasal Outcomes Test 20 (SNOT-20) at three time points: immediately before treatment, 7-14 days after treatment, and 28-35 days after treatment. The videoendoscopies were randomized and scored in a blinded fashion using a modification of the perioperative sinus endoscopy (POSE) scoring system.

RESULTS

Ten treatments were performed in eight patients; two patients underwent two treatments each. Mean SNOT-20 score improved at both 1 week and 1 month after treatment (2.44 versus 1.65, p < 0.05, and 2.44 versus 1.36, p < 0.01, respectively). Videoendoscopy also revealed improvement when evaluated with the modified POSE score at 1 week (11.8 versus 8.2, p < 0.001), and 1 month (11.8 versus 7.9, p < 0.001).

CONCLUSION

Endoscopic placement of steroid-infused CMC foam improves symptoms and endoscopic findings in patients with recurrent sinonasal polyposis after endoscopic sinus surgery.

Nucleic acid extraction efficiency and bacterial recovery from maxillary sinus mucosal samples obtained by brushing or biopsy

BACKGROUND

Chronic rhinosinusitis (CRS) is a common disease with a complex pathophysiology involving a microbial component. Culture-independent molecular analysis represents a promising new approach to clarify the microbiology of CRS, but standardized, optimized sampling methods still have not been defined. This study was designed to compare nucleic acid extraction rates and recovery of bacteria for two methods of sampling the maxillary sinus, mucosal biopsy, and brushing.

METHODS

Samples were obtained from 20 patients undergoing maxillary sinus surgery. Total extracted nucleic acid concentration and bacterial burden were compared between sample types.

RESULTS

Total nucleic acid concentration varied across patients. No statistically significant difference in mean total DNA concentration from mucosal biopsy specimens or brushings was observed. However, compared with biopsy specimens, brush samples possessed a significant (p < 0.035) increase in bacterial copy number.

CONCLUSION

Endoscopically directed mucosal brushings of the maxillary sinus provide equivalent concentrations of total DNA to mucosal biopsy specimens but possess greater concentrations of bacterial DNA, likely because of the greater surface area sampled by this method. Given the additional advantage of lower risk associated with obtaining brush samples, we suggest they represent the preferred sampling method for future genomic sinus studies.

Rheologic properties of sinonasal mucus in patients with chronic sinusitis

BACKGROUND

Mucociliary clearance is impaired in chronic rhinosinusitis (CRS). Clearance of sinonasal secretions is influenced by its rheological properties. The purpose of this study was to describe the rheological properties of sinonasal mucus in patients with CRS and correlate them with disease severity.

METHODS

Twenty-three adult subjects with CRS underwent collection of sinonasal secretions. Samples were analyzed using the AR2000 cone and plate rheometer (TA Instruments, New Castle, DE) to determine the dynamic viscosity and elasticity. These properties were used to calculate mucus clearance indices. All patients completed the Sinonasal Outcome Test (SNOT-20). Recent sinus computed tomography (CT) scans were electronically reviewed and scored according to the Lund-McKay staging system.

RESULTS

The mean dynamic elasticity and viscosity of sinus mucus at 1 Hz were 78.24 +/- 103.4 Pa and 22.09 +/- 29.62 Pa, respectively. The mean elasticity and viscosity values at 10 Hz were 118.9 +/- 155.5 Pa and 32.36 +/- 45.58 Pa, respectively. Three indices of disease severity (SNOT-20 score, Lund-McKay score, and nasal polyps) correlated with increased mucus viscoelasticity and/or worsened mucociliary clearance indices (MCIs).

CONCLUSION

This study establishes the range of rheological properties of sinonasal mucus in patients with CRS and suggests an association between disease severity and MCIs.

Postoperative packing after septoplasty: is it necessary?

The use of nasal packing following septoplasty has been proposed to serve multiple purposes. One of the most common reasons for use of packing is to prevent postoperative complications such as bleeding and formation of either synechiae or a septal hematoma. Stabilization of the remaining cartilage to prevent postoperative deviation is another reason that packing may be used. Although it appears intuitive that packing may prevent or decrease the incidence of these complications, evidence supporting this assertion is limited at best. Furthermore, certain types of nasal packing have been demonstrated to increase postoperative pain and have been implicated as a causative factor of catastrophic complications, such as toxic shock. With limited evidence to suggest a beneficial effect and a potential for deleterious side-effects, the routine use of postoperative packing following septoplasty should be questioned.

The frontal wishbone: anatomic and clinical implications

BACKGROUND

The interfrontal septal cell, which often takes the shape of a wishbone on axial CT scan, was first described by Van Alyea more than 50 years ago; however, its potential role in disease of the frontal sinus was only recently recognized. The purpose of this study was to correlate the incidence and dimensions of this "frontal wishbone" (FWB) with the presence of frontal sinus disease.

METHODS

The dimensions, drainage pathways, and disease state of the FWB were measured in 150 consecutive sinus CT scans performed at a tertiary care referral center. Statistical analysis was performed to correlate the FWB configuration to the presence of frontal sinus disease.

RESULTS

A FWB was present in 77.3% of patients. The wishbone drained through a discrete ostium into either the left (54.8%), the right (45.2%), or the bilateral (0.8%) frontal sinuses. In those scans with mucosal thickening or opacification of the frontal sinus (36%), concurrent FWB disease was found in 82%. Patients with a large (>1 cm) FWB in the anterior-posterior dimension were more likely to have a diseased frontal sinus (p = 0.02).

CONCLUSION

The term FWB is used to describe an air cell within the interfrontal septum, which may play a role in the pathogenesis of frontal sinus disease.