Publications by authors named "Brent A Senior"

103 Publications

International consensus statement on allergy and rhinology: rhinosinusitis 2021.

Int Forum Allergy Rhinol 2021 Mar;11(3):213-739

Capital Medical University, Beijing, China.

I.

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

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

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

Conclusion: This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
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http://dx.doi.org/10.1002/alr.22741DOI Listing
March 2021

Cystic fibrosis: On the cusp of cure?

Authors:
Brent A Senior

Int Forum Allergy Rhinol 2021 Apr 18;11(4):745-746. Epub 2020 Oct 18.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.

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http://dx.doi.org/10.1002/alr.22714DOI Listing
April 2021

Quantification of Aerosol Concentrations During Endonasal Instrumentation in the Clinic Setting.

Laryngoscope 2021 05 5;131(5):E1415-E1421. Epub 2020 Oct 5.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A.

Objective: Recent anecdotal reports and cadaveric simulations have described aerosol generation during endonasal instrumentation, highlighting a possible risk for transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) during endoscopic endonasal instrumentation. This study aims to provide a greater understanding of particle generation and exposure risk during endoscopic endonasal instrumentation.

Study Design: Prospective quantification of aerosol generation during office-based nasal endoscopy procedures.

Methods: Using an optical particle sizer, airborne particles concentrations 0.3 to 10 microns in diameter, were measured during 30 nasal endoscopies in the clinic setting. Measurements were taken at time points throughout diagnostic and debridement endoscopies and compared to preprocedure and empty room particle concentrations.

Results: No significant change in airborne particle concentrations was measured during diagnostic nasal endoscopies in patients without the need for debridement. However, significant increases in mean particle concentration compared to preprocedure levels were measured during cold instrumentation at 2,462 particles/foot (95% CI 837 to 4,088; P = .005) and during suction use at 2,973 particle/foot (95% CI 1,419 to 4,529; P = .001). In total, 99.2% of all measured particles were ≤1 μm in diameter.

Conclusion: When measured with an optical particle sizer, diagnostic nasal endoscopy with a rigid endoscope is not associated with increased particle aerosolization in patient for whom sinonasal debridement is not needed. In patients needing sinonasal debridement, endonasal cold and suction instrumentation were associated with increased particle aerosolization, with a trend observed during endoscope use prior to tissue manipulation. Endonasal debridement may potentially pose a higher risk for aerosolization and SARS-CoV-2 transmission. Appropriate personal protective equipment use and patient screening are recommended for all office-based endonasal procedures.

Level Of Evidence: 3 Laryngoscope, 131:E1415-E1421, 2021.
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http://dx.doi.org/10.1002/lary.29122DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675733PMC
May 2021

Quantification of Aerosol Particle Concentrations During Endoscopic Sinonasal Surgery in the Operating Room.

Am J Rhinol Allergy 2020 Oct 4:1945892420962335. Epub 2020 Oct 4.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Recent indirect evidence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmission during endoscopic endonasal procedures has highlighted the dearth of knowledge surrounding aerosol generation with these procedures. As we adapt to function in the era of Coronavirus Disease 2019 (COVID-19) a better understanding of how surgical techniques generate potentially infectious aerosolized particles will enhance the safety of operating room (OR) staff and learners.

Objective: To provide greater understanding of possible SARS-CoV-2 exposure risk during endonasal surgeries by quantifying increases in airborne particle concentrations during endoscopic sinonasal surgery.

Methods: Aerosol concentrations were measured during live-patient endoscopic endonasal surgeries in ORs with an optical particle sizer. Measurements were taken throughout the procedure at six time points: 1) before patient entered the OR, 2) before pre-incision timeout during OR setup, 3) during cold instrumentation with suction, 4) during microdebrider use, 5) during drill use and, 6) at the end of the case prior to extubation. Measurements were taken at three different OR position: surgeon, circulating nurse, and anesthesia provider.

Results: Significant increases in airborne particle concentration were measured at the surgeon position with both the microdebrider (p = 0.001) and drill (p = 0.001), but not for cold instrumentation with suction (p = 0.340). Particle concentration did not significantly increase at the anesthesia position or the circulator position with any form of instrumentation. Overall, the surgeon position had a mean increase in particle concentration of 2445 particles/ft3 (95% CI 881 to 3955; p = 0.001) during drill use and 1825 particles/ft3 (95% CI 641 to 3009; p = 0.001) during microdebrider use.

Conclusion: Drilling and microdebrider use during endonasal surgery in a standard operating room is associated with a significant increase in airborne particle concentrations. Fortunately, this increase in aerosol concentration is localized to the area of the operating surgeon, with no detectable increase in aerosol particles at other OR positions.
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http://dx.doi.org/10.1177/1945892420962335DOI Listing
October 2020

Efficacy of the exhalation delivery system with fluticasone in patients who remain symptomatic on standard nasal steroid sprays.

Int Forum Allergy Rhinol 2021 May 24;11(5):837-845. Epub 2020 Sep 24.

Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC.

Background: Standard nasal steroid sprays are often first-line treatment for chronic rhinosinusitis (CRS), but many patients remain symptomatic despite their use. The exhalation delivery system with fluticasone (EDS-FLU) has been shown to be efficacious in mixed populations of symptomatic patients, but the question remains whether benefits would be similar in those already on traditional steroid sprays. The goal of this study was to compare EDS-FLU treatment outcomes in patients who have previously failed nasal steroids.

Methods: Using pooled data from the NAVIGATE I and II trials, EDS-FLU efficacy was compared in the subgroup treated with a conventional nasal steroid at trial entry (mean duration, ≈3 years) to efficacy in the overall study population. Sensitivity analyses were performed for more restrictive definitions of the subgroup changing from prior standard nasal steroids.

Results: Of 482 total subjects, 218 (45.2%) reported using standard nasal steroid sprays at entry (mean duration, 1051 days). Across multiple outcome measures, improvements for "switchers" receiving EDS-FLU (least squares mean change from baseline vs EDS plus placebo) were comparable with improvements in the overall population. For EDS-FLU 372 μg, comparable improvements were observed in congestion (-0.73 vs -0.62), rhinorrhea (-0.71 vs -0.57), facial pain/pressure (-0.48 vs -0.41), and sense of smell (-0.35 vs -0.30) at week 4 and 22-item Sino-Nasal Outcome Test (-21.01 vs -20.52), Patient Global Impression of Change, and other outcomes at week 16. Results for EDS-FLU 186 μg were similar.

Conclusion: EDS-FLU comparably improves symptoms, irrespective of whether patients are symptomatic while using conventional nasal steroids before treatment.
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http://dx.doi.org/10.1002/alr.22693DOI Listing
May 2021

Radiologic Analysis of Balloon Sinuplasty in a Human Cadaver Model: Observed Effects on Sinonasal Anatomy.

Am J Rhinol Allergy 2021 Jan 7;35(1):107-113. Epub 2020 Jul 7.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina Chapel Hill, Chapel Hill, North Carolina.

Background: Balloon sinuplasty is increasingly used in the outpatient clinic for treatment of chronic rhinosinusitis, but radiologic analysis of its effects on sinonasal anatomy is largely uncharacterized in the known literature.

Objective: The purpose of this study is to examine the anatomic effects of balloon sinuplasty in a cadaveric model.

Methods: Five fresh cadaver heads underwent sequential endoscopic balloon dilation of maxillary ostia, frontal recess outflow tracts, and sphenoid ostia bilaterally by fellowship-trained rhinologists. Pre- and post-procedural CT imaging was obtained. CT scans were imported into Mimics™ software and sinonasal anatomy was analyzed systematically.

Results: Visual confirmation of balloon dilation was achieved in all 3 sites bilaterally in each cadaver. Radiologic analysis demonstrated that the frontal sinus outflow tract was appropriately dilated 60% (6/10 sites) of the time while the agger was inadvertently dilated 30% of the time (3/10). The sphenoid os was successfully dilated 70% (7/10 sites) of the time. In two cases, a posterior sphenoethmoid (Onodi) cell was dilated instead of the sphenoid. Successful dilation of maxillary os was noted 60% of the time (6/10 sites). No significant change in maxillary os was noted after balloon dilation. Normal middle turbinates were significantly medialized following balloon dilation 75% (6/8 sites) of the time.

Conclusions: While the goal of balloon sinuplasty is to improve natural sinonasal drainage by dilating existing outflow tracts, as evidenced by radiologic evaluation the procedure appears not to achieve this in all cases, while occasionally creating unintended changes in sinonasal anatomy as well. These unrecognized changes in anatomy may be responsible for the post-procedure change in symptomatology that some patients experience.
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http://dx.doi.org/10.1177/1945892420939430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874344PMC
January 2021

Numerical evaluation of spray position for improved nasal drug delivery.

Sci Rep 2020 06 29;10(1):10568. Epub 2020 Jun 29.

Department of Otolaryngology/Head and Neck Surgery, School of Medicine - University of North Carolina, Chapel Hill, NC, 27599, United States.

Topical intra-nasal sprays are amongst the most commonly prescribed therapeutic options for sinonasal diseases in humans. However, inconsistency and ambiguity in instructions show a lack of definitive knowledge on best spray use techniques. In this study, we have identified a new usage strategy for nasal sprays available over-the-counter, that registers an average 8-fold improvement in topical delivery of drugs at diseased sites, when compared to prevalent spray techniques. The protocol involves re-orienting the spray axis to harness inertial motion of particulates and has been developed using computational fluid dynamics simulations of respiratory airflow and droplet transport in medical imaging-based digital models. Simulated dose in representative models is validated through in vitro spray measurements in 3D-printed anatomic replicas using the gamma scintigraphy technique. This work breaks new ground in proposing an alternative user-friendly strategy that can significantly enhance topical delivery inside human nose. While these findings can eventually translate into personalized spray usage instructions and hence merit a change in nasal standard-of-care, this study also demonstrates how relatively simple engineering analysis tools can revolutionize everyday healthcare. Finally, with respiratory mucosa as the initial coronavirus infection site, our findings are relevant to intra-nasal vaccines that are in-development, to mitigate the COVID-19 pandemic.
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http://dx.doi.org/10.1038/s41598-020-66716-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7324389PMC
June 2020

Sinus Development and Pneumatization in a Primary Ciliary Dyskinesia Cohort.

Am J Rhinol Allergy 2021 Jan 19;35(1):72-76. Epub 2020 Jun 19.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Primary ciliary dyskinesia (PCD) is a genetically diverse disease which causes impaired mucociliary clearance, and results in pulmonary, otologic, and rhinologic disease in affected patients. Genetic mutations in multiple genes impair the ability of patients to clear mucous from the lungs, middle ear, and sinonasal cavity and lead to chronic pulmonary and sinonasal symptoms.

Methods: We identified 17 PCD patients who had available CT scans. Volumes for bilateral maxillary, sphenoid, and frontal sinuses were calculated. A control population of patients who had preoperative CT scans for endoscopic endonasal resection of skull base pathology without sinonasal cavity involvement was also identified.

Results: The mean age of PCD was 33 and ranged from 13 to 54 years. Patients were age- and gender-matched to a control group that underwent resection of anterior skull-base tumors and had a mean age of 35 that ranged between 17-53 years old. The volumes for all thee sinus cavities were significantly smaller (p < 0.007) compared to the control population. The average Lund-Mackay score was 10.6 in the PCD cohort (range 6-16) in comparison to an average of 0.7 in the control cohort (range 0-2).

Conclusions: Overall sinus volumes were smaller in patients with PCD compared to our control population. Future studies will be aimed at understanding defects in sinus development as a function of specific genetic mutations in PCD patients. Ultimately, a better understanding of the underlying pathophysiology of PCD will allow us to identify the optimal treatment practices for this unique patient group.
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http://dx.doi.org/10.1177/1945892420933175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7750665PMC
January 2021

Nasal Airflow Changes With Bioabsorbable Implant, Butterfly, and Spreader Grafts.

Laryngoscope 2020 12 4;130(12):E817-E823. Epub 2020 May 4.

Department of Otolaryngology, University of North Carolina, School of Medicine, Chapel Hill, North Carolina, U.S.A.

Objectives/hypothesis: Internal nasal valve compromise is a major cause of nasal obstruction, with a growing number of ways to treat this condition. In this study, we compared the effects of butterfly graft, spreader graft, and the bioabsorbable nasal implant on nasal airflow resistance.

Study Design: Cadaver study.

Methods: Computational fluid dynamics (CFD) simulations were completed from nine preoperative and postoperative cadaveric subjects. Each cadaveric head underwent placement of a bioabsorbable nasal implant (BNI) (Spirox Latera; Stryker ENT, Plymouth, MN), butterfly graft, or spreader graft. Pre- and postoperative computed tomography (CT) scans were used to generate three-dimensional models of the nasal airway used in steady-state CFD simulations of airflow and heat transfer during inspiration.

Results: Butterfly graft placement resulted in a mean improvement in nasal airway resistance of 24.9% (±7.3), whereas BNI placement resulted in a 6.7% (±1.2) improvement, and spreader graft placement also resulted in a consistent improvement of 2.6% (±13.5). Pressure within the main nasal cavity was consistently lower following butterfly graft placement versus a spreader graft or BNI. Butterfly and spreader graft placement also resulted in modest improvements in airflow allocation, whereas BNI demonstrated more variation (-1% to 12%). Heat flux was not significantly different; however, a small improvement in total heat flux was seen with all three interventions.

Conclusions: The results of this study demonstrate reduction in nasal airway resistance in all three surgical interventions, with the butterfly graft demonstrating superiority to the other two techniques. However, these data only reflect a static environment and not dynamic changes in airflow seen during respiration.

Level Of Evidence: NA Laryngoscope, 130:E817-E823, 2020.
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http://dx.doi.org/10.1002/lary.28691DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7609515PMC
December 2020

Extramedullary Hematopoiesis in the Sinonasal Cavity: A Case Report and Review of the Literature.

Allergy Rhinol (Providence) 2020 Jan-Dec;11:2152656720918874. Epub 2020 Apr 21.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina, Chapel Hill, North Carolina.

Background: Extramedullary hematopoiesis (EMH) occurs in patients with hematologic disorders, but rarely within the paranasal sinuses. We report a case of EMH in a 17-year-old male with sickle cell disease (SCD) who presented with occipital pain and sinusitis. A computed tomography (CT) scan demonstrated heterogeneous opacification of the right maxillary sinus concerning for allergic fungal sinusitis or a fungal ball with bony erosion. He was taken to the operating room for endoscopic biopsy and a limited endoscopic sinus surgery. Grossly, his maxillary sinus was filled with spiculated osseous tissue. Final pathology demonstrated active hematopoietic bone marrow filling the sinus.

Methods: We present a case report and literature review of sinonasal EMH.

Results: We identified 14 articles with 15 patients. EMH was typically associated with SCD or beta thalassemia. The average age of presentation was 30. There was a male sex predilection with a ratio of 11:15. The most common presenting symptom was a headache and nasal obstruction (33% for both). The most common finding on CT was a soft tissue expansile mass (73%). The most commonly affected location was the maxillary sinus (60%).

Conclusions: This case report serves as a reminder to consider EMH as an uncommon cause of sinus opacification, particularly in patients with SCD or beta thalassemia. The expansion of hematopoietic tissue may be identified as a sinus mass on CT. By recognizing the potential manifestations of chronic anemia, an accurate and timely diagnosis can be made.
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http://dx.doi.org/10.1177/2152656720918874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7177988PMC
April 2020

Understood? Evaluating the readability and understandability of intranasal corticosteroid delivery instructions.

Int Forum Allergy Rhinol 2020 06 13;10(6):773-778. Epub 2020 Apr 13.

Department of Otolaryngology/Head and Neck Surgery, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Background: Allergic rhinitis is a widespread disease that has significant quality-of-life ramifications. Symptoms include rhinorrhea, nasal obstruction, cough, and postnasal drip. Intranasal corticosteroids are a hallmark of treatment of allergic rhinitis. However, the benefits of treatment are dependent on correct nasal spray technique, of which many patients are not aware. Patient instructions are included with the purchase of these medications. The readability and understandability for these educational materials has been minimally assessed in the medical literature. The aim of this study was to evaluate the readability and understandability of commonly used intranasal steroids.

Methods: Three readability measures (Gunning Fog, Simple Measure of Gobbledygook [SMOG], and FORCAST) and an understandability assessment (Patient Education Materials Assessment Tool for Printable Materials [PEMAT-P]) were used to evaluate the instructions for use of commonly prescribed intranasal steroids. Instructions with 6th grade readability level or lower were considered to meet health literacy experts' recommendations. Higher understandability values correlate to easier understandability.

Results: Instructions for 10 intranasal corticosteroid brands were reviewed. Gunning Fog consistently estimated easiest readability, whereas FORCAST estimated most difficult readability. Twenty percent (20%) of analyzed instructions met National Institutes of Health and health literacy experts' recommended reading levels. Understandability of instructions ranged from 33% to 90%, with an average of 66%.

Conclusion: The benefit of intranasal corticosteroids is contingent on correct use by patients. However, the prepackaged instructions provided are most often above recommended reading levels and are difficult to understand. Future development of intranasal steroid instructions should meet recommended readability levels and be understandable to maximize their utility.
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http://dx.doi.org/10.1002/alr.22550DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7266716PMC
June 2020

Cystic Fibrosis Transmembrane Conductance Regulator Modulator Therapy: A Review for the Otolaryngologist.

Am J Rhinol Allergy 2020 Jul 13;34(4):573-580. Epub 2020 Mar 13.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Cystic fibrosis (CF) is a genetic disease that may result in multiple systemic disorders and potentially fatal severe respiratory compromise. However, the advent of CF transmembrane conductance regulator (CFTR) modulators has changed the management of CF for patients with select mutations. Although clinical trials have highlighted increased pulmonary function and decreased exacerbations as a result of these novel therapies, their effect on the sinuses has not been well-described.

Objective: Our objective is to review the CFTR modulators to provide otolaryngologists, physicians who frequently care for patients with CF, a basic understanding of these drugs and their effects on chronic rhinosinusitis (CRS) in patients with CF.

Methods: The clinically approved and available CFTR modulators and specific indications for their use are reviewed. Additionally, a systematic review of these therapies and effects on CRS in CF was performed.

Results: Four Food and Drug Administration approved CFTR modulators are available for patients with CF. Current drugs are approved for gating, residual function, or F508del mutations. Multiple reports describe CFTR modulators' increase in transepithelial ion transport in nasal epithelial cultures; however, clinical studies regarding effects of these modulators on sinonasal health are limited to 5 studies that present new data of the effects of CFTR modulators in CRS.

Conclusions: CFTR modulators have changed management of CF. Initial studies of these medications demonstrate promising results in CF; however, there is a paucity of literature describing the effect of CFTR modulators on CF-associated CRS, although initial results are encouraging.
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http://dx.doi.org/10.1177/1945892420912368DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7573678PMC
July 2020

Streamlining care in cystic fibrosis: survey of otolaryngologist, pulmonologist, and patient experiences.

Int Forum Allergy Rhinol 2020 05 17;10(5):591-603. Epub 2020 Jan 17.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Background: Care coordination for cystic fibrosis (CF) is essential. The objectives of this study were to: (1) compare otolaryngologists' and pulmonlogists' understanding of long-term chronic rhinosinusitis (CRS) management; and (2) query patient perceptions of otolaryngologic care and CRS.

Methods: A cross-sectional survey was administered by the Cystic Fibrosis Foundation in 2018 to patients with CF or their caregivers, otolaryngologists, and pulmonologists. Statistical analysis was performed comparing specialists. Descriptive statistics were computed for patient/caregiver-reported data.

Results: Respondents included 126 otolaryngologists, 115 pulmonologists, and 186 patients with CF or their caregivers. Pulmonologists had greater experience caring for CF patients compared with otolaryngologists (66.7% vs 43.2% with 13 years of experience, respectively), but more otolaryngologists cared for both adult and pediatric CF patients (39.2% vs 10.4%, respectively). Significantly more otolaryngologists advocated for establishing otolaryngologic care at time of CF diagnosis (64.8%) compared with pulmonologists (14.4%, p < 0.001), of whom 60.4% recommended otolaryngologist referral when sinonasal symptoms affect quality of life. More otolaryngologists perceived sinus surgery as beneficial for pulmonary function (74.5% vs 57.7%, p = 0.009); 60.8% of patients first sought otolaryngologic care in infancy or childhood (<13 years). Median number of sinus surgeries was 3 (interquartile range, 2-5). The most common perceived benefits of surgery according to patients/caregivers included improved breathing (31.2%) and improved sinonasal symptoms (23.7%). Top patients/caregiver otolaryngologic priorities included symptom/infection control (49.0%) and care coordination (15.0%).

Conclusion: Our results highlight variable patient/caregiver experiences, and suggest that otolaryngologist and pulmonologist perceptions of CF otolaryngologic care also differ in some respects requiring improved interspecialty coordination/education.
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http://dx.doi.org/10.1002/alr.22522DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7278084PMC
May 2020

Nasopharyngeal Hyalinizing Clear Cell Carcinoma: A Case Report and Review of the Literature.

Allergy Rhinol (Providence) 2019 Jan-Dec;10:2152656719889030. Epub 2019 Nov 20.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Hyalinizing clear cell carcinomas (HCCCs) are rare, low-grade, malignant tumors which most often arise from the minor salivary glands primarily in palate and tongue but can arise in any location with minor salivary glands including the nasopharynx.

Methods: A case report of primary nasopharyngeal HCCC is presented. Because of the rarity of this tumor and location, a literature search was conducted to determine the most common presenting symptoms, treatment strategies, and outcomes.

Results: A 48-year-old man underwent biopsy of a 4.5 cm mass of the right nasopharynx with pathology suggesting an intermediate grade mucoepidermoid carcinoma. After discussing management with the patient, an endoscopic resection was performed. Final pathology revealed an HCCC which was confirmed after negative Mastermind-like 2 (MAML2) and positive Ewing sarcoma breakpoint region 1 (ESWR1) gene rearrangements on fluorescence in situ hybridization (FISH) studies. Literature review of other nasopharyngeal HCCC cases shows diverse presentation and overall excellent prognosis through surgical and radiation therapy.

Conclusion: HCCCs are rare, low-grade malignant tumors of the minor salivary glands and can present as a nasopharyngeal mass. Presenting symptoms are diverse but frequently involve otologic and sinonasal disturbances. HCCC is an indolent tumor with an excellent prognostic outcome when treated appropriately with surgical resection and adjuvant radiotherapy.
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http://dx.doi.org/10.1177/2152656719889030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6883668PMC
November 2019

Mometasone absorption in cultured airway epithelium.

Int Forum Allergy Rhinol 2019 12 21;9(12):1451-1455. Epub 2019 Oct 21.

Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Background: Topical mometasone is frequently used as an intranasal spray, on drug-eluting stents, and compounded by specialty pharmacies as a sinus rinse. A typical sinus rinse contains 1.2 mg of mometasone dissolved in 240 mL of buffered saline and is flushed through the sinonasal cavity. The mometasone irrigation rapidly flows to the contralateral sinonasal cavity or the nasopharynx with a contact time on the order of 5 to 10 seconds. However, no information is available on the absorption rate of topical mometasone on the sinonasal surface.

Methods: To determine the absorption characteristics of mometasone, we harvested nasal epithelium from 2 healthy donors and differentiated them into a mature ciliated epithelium on Millicell membranes. We applied mometasone to the apical surface for various time intervals and then rinsed off non-absorbed mometasone with phosphate-buffered saline. Millicell membranes with the adherent epithelial cells were then harvested and stored in guanidine hydrochloride for quantification using high-performance liquid chromatography-mass spectrometry.

Results: Fifty percent of the maximal absorption occurred after an average of 38 minutes after application, and maximal absorption occurred after an average of 114 minutes.

Conclusion: Our data provide an estimate for rates of absorption of mometasone applied to the sinonasal cavity and suggest that the absorption rates poorly match contact time during saline lavage.
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http://dx.doi.org/10.1002/alr.22441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6927533PMC
December 2019

Readability of patient-reported outcome measures for chronic rhinosinusitis and skull base diseases.

Laryngoscope 2020 10 11;130(10):2305-2310. Epub 2019 Oct 11.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, U.S.A.

Objective: Outcome measures in healthcare that presume a higher level of patient health and overall literacy may inadequately estimate the disease experiences of less-educated patients and further disadvantage them. Patient-Reported Outcome Measures (PROMs) are widely used communication tools for clinical practice and are often used to evaluate and guide management for chronic rhinosinusitis (CRS) and skull base diseases. However, their readability and subsequent incomprehensibility for patients have not been assessed. The aim of this study is to evaluate the readability of commonly used PROMs for these conditions and whether they meet recommended readability levels.

Methods: Three readability measures, Gunning Fog, Simple Measure of Gobbledygook (SMOG), and FORCAST were used in the evaluation of commonly used PROMs for CRS and skull base disease. PROMs with sixth-grade readability level or lower were considered to meet health literacy experts' recommendations.

Results: A total of 11 PROMs were reviewed (8 CRS, 3 skull base). Gunning Fog consistently estimated the easiest readability, whereas FORCAST the most difficult. One hundred percent of CRS and 67% of skull base PROMs were above National Institutes of Health and health literacy experts' recommended reading levels. PROMs developed more recently had easier readability.

Conclusion: PROMs are important clinical tools in otolaryngology that help guide management of disease for improved patient-centered care. Like many other fields of medicine, those used in otolaryngology are beyond recommended reading levels. Development of PROMs in the future should meet recommended readability levels to fully assess the disease experience of our patients.

Level Of Evidence: 4 Laryngoscope, 130:2305-2310, 2020.
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http://dx.doi.org/10.1002/lary.28330DOI Listing
October 2020

Modeling Microdebrider-Mediated Ophthalmic Damage: A Word of Caution in Endoscopic Sinus Surgery.

Rhinol Online 2019 7;2:44-49. Epub 2019 Mar 7.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Background: The microdebrider has become nearly universal in the treatment of sinonasal pathology; however, recent case reports have demonstrated the potential for major ophthalmic complications. The goal of this study was twofold: 1) determine the anatomical proximity of ophthalmic structures to the paranasal sinuses, and 2) assess the timeframe at which ophthalmic injury may occur with the use of a microdebrider during FESS utilizing a cadaveric model.

Methodology/principal: Computed tomography scans from 50 patients were accessed retrospectively. The distances between the lamina papyracea (LP) and orbital structures were determined at varying depths. Seven cadavers (14 sides) were studied using three microdebrider systems operated by otolaryngology residents. Following removal of a window of LP, the time from activation of the microdebrider on the periorbita until transection of the medial rectus (MR), optic nerve (ON), and to aspiration of the globe were measured.

Results: The mean distance between the LP and MR at the level of the anterior aspect of the anterior ethmoid and basal lamella were 3.59 ±1.2mm and 1.5 ±0.8mm, respectively. The mean distance between the LP and ON at the level of the basal lamella was 8.1 ±2.1mm. Mean transection times for the MR and ON were 13.4 ± 7.3 seconds and 37.3 ± 9.2 seconds, respectively, with minimum times of 4 seconds and 26 seconds.

Conclusions: The proximity of orbital structures to the paranasal sinuses and the rapidity of ophthalmic damage following violation of the periorbita reaffirms the need for cautious use of the microdebrider during FESS.
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http://dx.doi.org/10.4193/RHINOL/19.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6748634PMC
March 2019

Effect of Zileuton Treatment on Sinonasal Quality of Life in Patients with Aspirin-Exacerbated Respiratory Disease.

Am J Rhinol Allergy 2019 Nov 4;33(6):791-795. Epub 2019 Sep 4.

Department of Otolaryngology/Head and Neck Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina.

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http://dx.doi.org/10.1177/1945892419873211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6843740PMC
November 2019

Optimizing international otolaryngology service trips: Perceptions from learners versus volunteers.

Laryngoscope 2020 05 30;130(5):E305-E310. Epub 2019 Jul 30.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A.

Objectives/hypothesis: Optimizing value of medical service trips (MSTs) requires alignment of the services provided with the needs and desires of hosts. Our aim was to understand which MST services Vietnamese otolaryngologists find most beneficial and contrast to those believed most important by volunteers.

Study Design: Cross-sectional survey.

Methods: Otolaryngologists from a tertiary care institution travel to Vietnam yearly. In March 2018, surveys were distributed to Vietnamese otolaryngology faculty, residents, and US otolaryngology volunteers. The value of 11 MST-provided services were graded on a five-point Likert scale. Services included observing US otolaryngology volunteers perform surgery, US otolaryngology volunteer lectures, paper/electronic lecture material, instrument donation, minifellowships in the United States, among others. Respondents also voted for the single most important service. Responses were analyzed via Kruskal-Wallis analysis of variance and Wilcoxon rank sum test.

Results: A total of 153 survey responses were recorded. There were 52% respondents who identified as male and 39% as female. The highest-valued services by Vietnamese otolaryngologists were didactic lectures given by US otolaryngology volunteers (4.6/5 ± 0.6), and reviewing cases with US otolaryngology volunteers in the clinic (4.4/5 ± 0.9). The least important services were instrument donation and seeing US otolaryngology volunteers assist with surgery (≤4.1/5). The highest-value services perceived by US otolaryngology volunteers were reviewing cases in the clinic and sponsoring minifellowships (4.9 ± 0.4). Vietnamese faculty perceived the single most important service to be US volunteer lectures (20/74 votes), whereas Vietnamese residents perceived minifellowships to be most important (13/34 votes) CONCLUSIONS: Vietnamese otolaryngologists desire an education-focused relationship with US otolaryngology volunteers, with didactic lectures and sponsored US fellowships having the highest value and performance of surgeries having less value.

Level Of Evidence: 4 Laryngoscope, 130:E305-E310, 2020.
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http://dx.doi.org/10.1002/lary.28218DOI Listing
May 2020

Comparative study of simulated nebulized and spray particle deposition in chronic rhinosinusitis patients.

Int Forum Allergy Rhinol 2019 07 1;9(7):746-758. Epub 2019 Mar 1.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Background: Topical intranasal drugs are widely prescribed for chronic rhinosinusitis (CRS), although delivery can vary with device type and droplet size. The study objective was to compare nebulized and sprayed droplet deposition in the paranasal sinuses and ostiomeatal complex (OMC) across multiple droplet sizes in CRS patients using computational fluid dynamics (CFD).

Methods: Three-dimensional models of sinonasal cavities were constructed from computed tomography (CT) scans of 3 subjects with CRS refractory to medical therapy using imaging software. Assuming steady-state inspiratory airflow at resting rate, CFD was used to simulate 1-µm to 120-µm sprayed droplet deposition in the left and right sinuses and OMC with spray nozzle positioning as in current nasal spray use instructions. Zero-velocity nebulization simulations were performed for 1-µm to 30-µm droplet sizes, maximal sinus and OMC deposition fractions (MSDF) were obtained, and sizes that achieved at least 50% of MSDF were identified. Nebulized MSDF was compared to sprayed droplet deposition. We also validated CFD framework through in vitro experiments.

Results: Among nebulized droplet sizes, 11-µm to 14-µm droplets achieved at least 50% of MSDF in all 6 sinonasal cavities. Four of 6 sinonasal cavities had greater sinus and OMC deposition with nebulized droplets than with sprayed droplets at optimal sizes.

Conclusion: Nebulized droplets may target the sinuses and OMC more effectively than sprayed particles at sizes achieving best deposition. Further studies are needed to confirm our preliminary findings. Several commercial nasal nebulizers have average particle sizes outside the optimal nebulized droplet size range found here, suggesting potential for product enhancement.
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http://dx.doi.org/10.1002/alr.22324DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457377PMC
July 2019

Image quality and dose reduction in sinus computed tomography using iterative reconstruction: a cadaver study.

Rhinol Online 2018 ;1:45-49

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, USA.

Background: Concerns about radiation dose in computed tomography (CT) imaging have renewed interest in iterative reconstruction (IR), a technique which has the potential to produce images with less noise at lower radiation doses than traditional filtered back projection (FBP). This study aimed to assess whether application of IR could provide comparable quality sinus CT images to FBP at lower kilovolt (kV) and milliamp (mA) settings, and to establish optimal scan settings for sinus imaging.

Methodology/principal: 30 sinus CT scans were performed on 5 cadaver heads at two kV setting and three mA settings. Each scan was reconstructed using FBP and 3 IR settings, yielding a total of 120 images series. Each image set was blinded and randomly reviewed by 3 rhinologists and 2 neuroradiologists. Using a 5-point Likert scale, 16 anatomical landmarks, were graded with respect to image quality. Data were assessed with respect to dose and IR settings using statistical analysis.

Results: Higher kV and mAs settings produced significantly higher quality images for structure identification across all 16 landmarks; however, the suitability for surgery did not increase in a linear fashion and plateaued by a total radiation dose of 0.1201 mSv. IR algorithm did not provide a benefit in the overall score of scans at a fixed kV and mAs.

Conclusions: Identification of structures in sinus CT imaging significantly correlate with the kV and mA and overall dose of radiation; however, IR did not provide additional benefit in the image quality.
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http://dx.doi.org/10.4193/RHINOL/18.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6292212PMC
January 2018

How Much Blood Could a JP Suck If a JP Could Suck Blood?

Laryngoscope 2019 08 13;129(8):1806-1809. Epub 2018 Dec 13.

Department of Otolaryngology Head and Neck Surgery at Chapel Hill, Chapel Hill, North Carolina, U.S.A.

Objective: Active surgical drains minimize fluid accumulation in the postoperative period. The Jackson-Pratt (JP) system consists of a silicone drain connected by flexible tubing to a bulb. When air in the bulb is evacuated, negative pressure is applied at the surgical site to aspirate fluid. The objective of this study was to determine if the evacuation method and volume of accumulated fluid affect the pressure generated by the bulb.

Methods: Bulbs were connected to a digital manometer under various experimental conditions. A random number generator determined the initial evacuation method for each bulb, either side-in or bottom-up. Subsequent evacuations were alternated until data was collected in triplicate for each method. Predetermined amounts of water were placed into the bulb; air was evacuated; and pressure was recorded. The digital manometer was allowed to equilibrate for 1 minute prior to data acquisition.

Results: The average amount of pressure after a side-in evacuation of a JP bulb was 87.4 cm H O compared to 17.7 cm H O for a bottom-up evacuation (P < 0.0001). When the drain contained 25 mL, 50 mL, 75 mL, and 100 mL of fluid, the pressure applied dropped to 72.6, 41.3, 37.0, and 35.6 cm H O, respectively.

Conclusions: JP drains generate negative pressure in order to reduce fluid accumulation at surgical sites. Although its function is frequently taken for granted, this study demonstrates that both the specific method for evacuating the bulb as well as the amount of fluid in the bulb significantly affect the performance of this device.

Level Of Evidence: NA Laryngoscope, 129:1806-1809, 2019.
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http://dx.doi.org/10.1002/lary.27710DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6565520PMC
August 2019

Sex bias: Is it pervasive in otolaryngology clinical research?

Laryngoscope 2019 04 15;129(4):858-864. Epub 2018 Nov 15.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A.

Objectives/hypothesis: Recent initiatives highlight substantial sex bias in biomedical research. The objective was to determine whether sex bias is present in otolaryngology and whether sex is appropriately analyzed as an independent variable in otolaryngology clinical research.

Study Design: Literature review.

Methods: We systematically reviewed all 2016 articles in three major otolaryngology journals: The Laryngoscope, JAMA Otolaryngology-Head and Neck Surgery, and Otolaryngology-Head and Neck Surgery. Extracted data included study origin, location, subspecialty, number/sex of subjects, ≥50% sex matching (SM ), and sex-based statistical analysis.

Results: Six hundred of 1,209 articles comprising original clinical research were reviewed including 8,997,345,495 subjects (males: 3,898,559,264 [43.3%]; females: 5,095,592,583 [56.6%]; and unknown: 3,193,648 [0.04%]). There were 533/600 (88.8%) studies that included both sexes, eight (1.3%) included females only, five (0.8%) included males only, and 56 (9.3%) did not document participant sex. Only 280 studies (46.7%) analyzed data by sex, and 330 studies (60.7%) had SM . Sex-based statistical analysis and SM were similar in domestic and international studies (48.7% vs. 42.8% and 60.9% vs. 62%, respectively). Database studies performed sex-based statistical analysis more frequently than single and multi-institutional studies (79.1% vs. 40.4% and 43.4%, P < .00001). Analysis by sex was more frequently performed in head and neck surgery (53.6%) and pediatric otolaryngology (51.3%), whereas SM was highest in pediatric otolaryngology (86.8%) and otology (82.4%).

Conclusions: Sex bias exists in the clinical otolaryngology literature, with less than half the studies analyzing sex. Acknowledging the intertwinement of sex with disease pathophysiology and outcomes is important. Eliminating sex bias in research and clinical care should become a major focus for otolaryngologists.

Level Of Evidence: NA Laryngoscope, 129:858-864, 2019.
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http://dx.doi.org/10.1002/lary.27497DOI Listing
April 2019

Sex bias in basic science and translational otolaryngology research.

Laryngoscope 2019 03 8;129(3):613-618. Epub 2018 Nov 8.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, U.S.A.

Objectives/hypothesis: Recent studies revealed sex bias in surgical research. Although many diseases exhibit sex-based clinically relevant differences, otolaryngology research has not been evaluated for sex reporting and sex-based analysis. We postulate that a similar bias is prevalent in otolaryngology literature.

Study Design: Literature review.

Methods: Articles published from 2016 to 2017 in The Laryngoscope, Otolaryngology-Head and Neck Surgery, and JAMA Otolaryngology-Head and Neck Surgery were reviewed. Articles with animal subjects, human subject cells, or commercial cell lines were included. Data collected included study type, cell/animal sex, and sex-based data analysis.

Results: One hundred forty-four basic/translational research articles were identified. Sixty-nine (47.9%) of those lacked sex reporting. Of 75 studies that reported sex, 22 (29.3%) included both sexes, and 11 (14.7%) analyzed data by sex. One hundred five (72.9%) used animal subjects, of which 54 (51.9%) lacked sex breakdown. Among animal studies, 48/105 included only one sex, and three articles analyzed data by sex. Fifty-four studies used commercial cell lines (N = 23) or human/animal subject cells (N = 31). Among cell groups, 28/54 (51.9%) were of unknown sex, and seven were single sex. Eight (14.8%) studies included data analysis by sex. Domestic studies exhibited a lower rate of sex reporting in both animal and cell studies, and a lower rate of sex-based analysis in cell studies.

Conclusions: Sex may influence outcomes significantly but is underreported and underanalyzed in basic/translational otolaryngology research. Because this research frequently lays the groundwork for clinical trials and standards of care, future research must address these sex-based discrepancies.

Level Of Evidence: NA Laryngoscope, 129:613-618, 2019.
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http://dx.doi.org/10.1002/lary.27498DOI Listing
March 2019

Faculty Attitudes Toward Rhinology Fellowship Training: A Survey of Rhinology Fellowship Programs.

Am J Rhinol Allergy 2019 Jan 3;33(1):8-16. Epub 2018 Oct 3.

1 Department of Otolaryngology - Head and Neck Surgery, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York.

Background: The number of rhinology fellowship programs has grown rapidly over the past decade. To date, no standardization or accreditation process exists, raising the potential for disparate programs. The attitudes of faculty regarding training are important to elucidate the educational experience of rhinology fellowship.

Methods: An anonymous, web-based survey of rhinology faculty assessed the subjective attitudes toward various domains of fellowship training including surgery, office-based procedures, research, and career development. A 5-point Likert-type scale assessing importance was used (1-not at all important, 5-extremely important).

Results: A total of 34 faculty (response rate 35.8%) completed the survey. The surgical procedures that received the highest mean importance scores were endoscopic surgery for advanced inflammatory disease (median = 5), cerebrospinal fluid leak closure (5), and extended endoscopic sinus surgery (5). The procedures with the lowest scores were nasal valve repair (2), inferior turbinate surgery (3), and open approaches to the sinuses (4). A wide range of responses was noted for the minimum target number of fellow cases for the surveyed procedures. Higher importance scores were noted for direct attending supervision (5) when compared to fellow autonomy (4, P < .001) or shadowing (3.5, P < .001) in the operating room. Higher scores were noted for career preparation in academic (4) versus private practice (3, P < .001) and providing opportunities for clinical (4) versus basic science research (2, P < .001). The majority of faculty felt that there were too many fellowship positions with respect to the market place for private practice (58.8%), academic jobs (85.3%), and overall societal need (61.8%).

Conclusion: A range of faculty attitudes with respect to fellowship training was noted in this study. Continued assessment and refinement of the educational experience in rhinology fellowships is necessary.
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http://dx.doi.org/10.1177/1945892418801403DOI Listing
January 2019

Evaluation of absorbable PLA nasal implants in an ovine model.

Laryngoscope Investig Otolaryngol 2018 Jun 25;3(3):156-161. Epub 2018 May 25.

Department of Otolaryngology-Head and Neck Surgery University of North Carolina at Chapel Hill Chapel Hill North Carolina U.S.A.

Objective: To examine biocompatibility and absorption profile of a poly (L-lactide-co-D,L-lactide) 70:30 nasal implant.

Methods: In an ovine model, 66 rod-shaped absorbable implants were placed in 11 nasal dorsa. The sheep were sacrificed at 1.5 (N = 3), 6 (N = 3), 12 (N = 3), 18 (N = 1), and 24 months (N = 1). The nasal dorsum was harvested from each animal. Gross and histopathological examinations were performed.

Results: There were no postoperative complications, signs of infection, or tissue rejection throughout follow-up time points. Upon sacrifice, no abnormalities were identified during gross pathological examinations. The histology of the implant sites at all time points showed the implants were fully encapsulated through 12 months. The inflammatory reaction to the implants was minimal to mild at 1.5, 6, and 12 months. At 18 months the implant material was in the mass loss phase, being actively absorbed. During this phase, the inflammatory reaction within the fibrous connective tissue capsule reached expected moderate levels. By 24 months, the inflammatory reaction had diminished in most implantation sites and complete absorption of the rod implants was noted at some sites with nodular bundles of mature collagenized fibrous tissue replacing the implant, devoid of an inflammatory infiltrate.

Conclusion: Biocompatibility of the poly (L-lactide-co-D,L-lactide) 70:30 material was demonstrated when used as a nasal implant in the nasal dorsum ovine model. Absorption of the implant occurred approximately 18 to 24 months postoperatively, and the implant site was replaced with collagenized fibrous tissue.

Level Of Evidence: NA.
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http://dx.doi.org/10.1002/lio2.166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6057223PMC
June 2018

Nasal airway obstruction: Prevalence and anatomic contributors.

Ear Nose Throat J 2018 Jun;97(6):173-176

Department of Otolaryngology-Head and Neck Surgery, Baylor Scott & White Health, and Texas A&M Health Science Center College of Medicine, Temple, TX, USA.

Surgical treatments for nasal airway obstruction (NAO) are commonly offered as part of otolaryngology practice. Anatomic causes include septal deviation, inferior turbinate hypertrophy, and nasal valve collapse (NVC). This study was performed to determine the prevalence of anatomic contributors to NAO. A total of 1,906 patients with sinonasal complaints were surveyed by 50 otolaryngologists in varying U.S. geographic regions. Patients were first evaluated using the Nasal Obstruction Symptom Evaluation (NOSE) instrument to assess the NAO symptoms and their severity. Physicians then examined patients for the presence of the three anatomic contributors. Presence of septal deviation and turbinate hypertrophy was assessed through an internal nasal exam with direct or endoscopic visualization based on the physician's standard methodology for diagnosis. Presence of NVC was determined by the modified Cottle maneuver. Among all patients surveyed, prevalence was 67% for NVC, 76% for septal deviation, and 72% for inferior turbinate hypertrophy. We found that 64% of the patients (n = 1,211) had severe/extreme NOSE scores (≥55), representing the most likely nasal obstruction candidates for intervention. In these patients, the prevalence of NVC, septal deviation, and inferior turbinate hypertrophy was 73, 80, and 77%, respectively. Eighty-two percent of the 236 patients with severe/extreme NOSE scores who reported prior septoplasty and/or inferior turbinate reduction had NVC. Our study revealed a comparable prevalence of all three anatomic contributors across all patients and the subset with severe/extreme NOSE scores, highlighting the importance of evaluating the lateral nasal wall as a component of NAO treatment strategy.
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http://dx.doi.org/10.1177/014556131809700615DOI Listing
June 2018

Sex bias in rhinology research.

Int Forum Allergy Rhinol 2018 12 20;8(12):1469-1475. Epub 2018 Jul 20.

Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Background: Analysis of general surgery literature has revealed noteworthy sex bias and underreporting. Our objective was to determine the prevalence of sex bias and underreporting in rhinology.

Methods: All articles in 2016 issues of Rhinology, the American Journal of Rhinology and Allergy (AJRA), and the International Forum of Allergy and Rhinology (IFAR) were reviewed. Of 369 articles, 248 met inclusion criteria. Excluded studies were cadaveric, meta-analysis/review, and editorial. Data collected included study type, demographics, and sex-based statistical analysis.

Results: There were 202 clinical and 46 basic science/translational studies. From 188 of 202 clinical studies with known sex, 1 included participants of a single sex. Sex matching >50% (SM ) was found in 81.9%, and 55.9% performed sex-based statistical analysis. Domestic clinical studies performed sex-based analysis more frequently than international (54.9% vs 44.4%) and exhibited a higher rate of SM (84.5% vs 80.3%), though these differences were not statistically significant. For basic/translational studies, 54.5% (24/44) provided sex breakdown. Among these, 29.2% included 1 sex, and 8.3% performed sex-based analysis. Of 10 using animals, 70.0% utilized 1 sex. The remaining 30.0% did not report sex. None of 4 cell line studies reported cell sex. Less than half (46.2%) of domestic and 56.3% of international studies reported sex breakdown; 7.7% of domestic and 3.0% of international studies performed sex-based analysis.

Conclusion: Although sex may impact outcomes, research without sex reporting and analysis is prevalent, particularly among basic science/translational studies. Future research must account for sex in demographics and analysis to best inform evidence-based clinical guidelines.
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http://dx.doi.org/10.1002/alr.22179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279575PMC
December 2018

Treatment Paradigm for Nasal Airway Obstruction.

Otolaryngol Clin North Am 2018 Oct 23;51(5):873-882. Epub 2018 Jun 23.

Division of Rhinology, Allergy, and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, 170 Manning Drive, CB #7070, Chapel Hill, NC 27599-7070, USA. Electronic address:

Nasal airway obstruction (NAO) is a common otolaryngic complaint with many potential causes, frequently structural or inflammatory in nature. Patients typically have multiple coexisting factors leading to symptoms. Good patient outcomes require careful preoperative evaluation, including nasal endoscopy, to accurately identify sources of obstruction and tailor intervention appropriately. Common structural causes of NAO include inferior turbinate hypertrophy, nasal septal deviation, and narrowing or collapse of the internal or external nasal valves. The internal nasal valve has the narrowest cross-sectional area within the nasal airway and is thus most sensitive to changes in dimension due to anatomic variation or surgical intervention.
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http://dx.doi.org/10.1016/j.otc.2018.05.003DOI Listing
October 2018

A Pilot Comparison between Caregiver's and Patient's Perceived Quality of Life in Chronic Rhinosinusitis.

Am J Rhinol Allergy 2018 May 12;32(3):153-159. Epub 2018 Apr 12.

1 Department of Otolaryngology-Head and Neck Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Introduction Chronic rhinosinusitis negatively impacts a patient's quality of life, but current studies only address the patient's perception of their disease. Caregivers living with the patient may have an alternative perception of the severity of the quality of life disturbance that patient's experience with chronic rhinosinusitis. Methods This was a prospective cohort study that enrolled patients with a confirmed chronic rhinosinusitis diagnosis who presented to clinic with a caregiver. At the initial visit, patients completed a Rhinosinusitis Disability Index. The caregiver completed a Rhinosinusitis Disability Index based on their perception of the patient's symptoms in addition to a Modified Caregiver Strain Index and a Short Form-36 to assess caregiving strain and overall health, respectively. Statistical analyses were performed with significance defined as P < 0.05 a priori. Results A total of 44 total subjects (22 patient and caregiver pairs) were enrolled. Patients reported a total Rhinosinusitis Disability Index of 36.8 (confidence interval: 26.9, 46.6), and caregivers reported a total Rhinosinusitis Disability Index of 50.4 [confidence interval: 38.8, 61.9] ( P = 0.02). The principal differences between patient and caregiver scores were noted in the emotional and physical domains ( P = 0.01 and P = 0.05, respectively). Only the functional domain was not statistically different ( P = 0.20). The patient's total Rhinosinusitis Disability Index is positively correlated with the caregiver's total Modified Caregiver Strain Index with a spearman coefficient of .60 (p ≤ 0.005). Conclusions Caregivers experience greater strain as the patient's quality of life declines. Caregivers perceive patients to have worse quality of life than patients report. Based on these data, caregivers may provide additional insight to the quality of life disturbance of chronic rhinosinusitis. In addition, the societal impact of chronic rhinosinusitis may be underestimated.
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http://dx.doi.org/10.1177/1945892418765001DOI Listing
May 2018