Publications by authors named "Daniel M Beswick"

44 Publications

Psychometric properties of the brief version of the questionnaire of olfactory disorders in patients with chronic rhinosinusitis.

Int Forum Allergy Rhinol 2021 Apr 17. Epub 2021 Apr 17.

Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.

Background: The Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS) is a 17-item instrument measuring olfactory-specific quality of life (QOL). However, in clinical research patients can be overwhelmed with multiple questionnaires. We recently developed the 7-item brief QOD-NS (B-QOD). Our objective was to evaluate the psychometric properties of the B-QOD in both the development (D) sample, and in a separate replication (R) sample.

Methods: Testing on D (n = 203) and R (n = 281) samples included initial exploratory factor analysis (EFA), followed by internal reliability, information loss, and confirmatory factor analysis (CFA). Finally, incremental predictive utility analysis (IPUA) was performed by correlating the B-QOD with the 22-item Sino-Nasal Outcome Test (SNOT-22) survey.

Results: EFAs of both D and R demonstrated an underlying single-factor structure (eigenvalue = 4.17 and 3.57, respectively) with comparable loading factors (R > 0.30 for both). B-QOD also had good internal reliability in both D and R (Cronbach's alpha = 0.88 and 0.83, respectively). Also, there is minimal information loss with B-QOD compared to QOD-NS in both D and R (R = 0.98 and 0.96, respectively). CFA indicates that the B-QOD single-factor model has good overall fit as measured by the Comparative Fit Index (CFI) and the Standardized Root Mean Squared Residuals (SRMSR) in the D and R samples (CFI = 0.99 and 0.97; SRMSR = 0.035 and 0.053). IPUA shows that the QOD-NS offers no additional predictive benefit of SNOT-22 scores when compared with B-QOD.

Conclusion: The 7-item B-QOD captures a structurally coherent and reliable single dimension, with minimal information loss and excellent external predictive utility when compared to the QOD-NS.
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http://dx.doi.org/10.1002/alr.22800DOI Listing
April 2021

CFTR-related disorder in an adult with refractory chronic rhinosinusitis: A missed diagnosis and novel mutation.

Int Forum Allergy Rhinol 2021 Apr 6. Epub 2021 Apr 6.

Department of Otolaryngology, University of Colorado, Aurora, Colorado, USA.

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http://dx.doi.org/10.1002/alr.22792DOI Listing
April 2021

Olfactory cleft mucus inflammatory proteins in CRS: a case-control study.

Int Forum Allergy Rhinol 2021 Feb 24. Epub 2021 Feb 24.

Division of Pulmonary, Critical Care & Sleep Medicine, University of Florida, Gainesville, FL.

Background: Multiple hypotheses are evolving that suggest several, potentially overlapping etiologies for olfactory dysfunction (OD) in chronic rhinosinusitis (CRS). Understanding inflammatory cytokine profiles of the olfactory cleft (OC) and their association with olfactory function is foundational for future clinical care and research.

Methods: This cross-sectional, case-control study evaluates associations among OC mucus inflammatory proteins, psychophysical olfactory testing, and computed tomography (CT) analysis of the OC and sinuses. Normative reference intervals were determined for each protein and odds ratios (ORs) were used to compare proportions of altered expression between CRS without nasal polyposis (CRSsNP) and CRS without nasal polyposis (CRSwNP).

Results: Case subjects with CRS (n = 151) and controls (n = 74) were evaluated. A majority of OC proteins tested were found within detectable ranges for cases and controls. The CRS cohort had significantly higher concentrations for 23 of 26 proteins. CRS cases with abnormal levels of C-C motif chemokine ligand 2 (CCL2), CCL3, interleukin 5 (IL5), IL10, and IL13 associated with greater olfactory deficits. The prevalence of elevated IL5 and IL13 in anosmic patients was 64.6% and 62.5%, respectively (p < 0.004). CRS cases with the highest odds of elevated expression in CRSwNP were IL5 (OR = 10.83) and IL13 (OR = 8.36). However, both IL5 and IL13 were still elevated in approximately 14% of CRSsNP patients. The highest magnitude of correlation between the total percent of OC opacification was found to be with IL5 (r = 0.543; p < 0.001), whereas other moderate correlations were noted with immunoglobulin E (IgE), IL10, and IL13.

Conclusion: This study confirmed that OC inflammatory proteins vary both by disease phenotype and in their association with OD. Type 2 inflammatory mediators are increased in CRS, especially within the CRSwNP group. However, a substantial proportion of CRSsNP also express type 2 inflammatory mediators. Further research is necessary to understand the complex roles OC mucous inflammatory proteins might play in defining endotype and in impacting CRS-related OD. ©2021 ARSAAOA, LLC.
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http://dx.doi.org/10.1002/alr.22770DOI Listing
February 2021

Stakeholder feedback informs investigations for chronic rhinosinusitis in cystic fibrosis.

Int Forum Allergy Rhinol 2021 Jan 29;11(1):79-80. Epub 2020 Sep 29.

Department of Medicine, National Jewish Health, Denver, CO.

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http://dx.doi.org/10.1002/alr.22705DOI Listing
January 2021

Olfactory Function After Surgical Treatment of CRS: A Comparison of CRS Patients to Healthy Controls.

Am J Rhinol Allergy 2021 May 20;35(3):391-398. Epub 2020 Sep 20.

Department of Otolaryngology, Head and Neck Surgery, University of Colorado-Anschutz Medical Campus, Aurora, Colorado.

Background: Many patients with chronic rhinosinusitis (CRS) have persistent olfactory dysfunction (OD) following endoscopic sinus surgery (ESS). Few studies compare outcomes to control subjects so it is unknown if residual OD is due to persistent CRS.

Objective: Compare postoperative measures of OD in case patients with CRS to healthy controls without sinonasal disease.

Methods: Prospective, observational, multicenter cohort study between October, 2016 and May, 2019. Case participants were selected from referred adult patients diagnosed with CRS, with or without nasal polyposis (NP), electing ESS as subsequent treatment modality. Controls voluntarily enrolled from a community-based sample without a history of CRS. Primary outcomes included measures of preoperative and postoperative OD using "Sniffin' Stick" pens which summarize odorant threshold (T), discrimination (D), and identification (I) scores. Secondary outcomes included the Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS) survey and olfactory cleft endoscopy scores (OCES).

Results: Outcomes were compared between 113 cases and 164 controls of similar average age and gender. Cases reported significantly worse baseline Sniffin' Sticks TDI total scores (-6.8[SE ± 1.0]; 95% CI: -4.9 to -8.7), QOD-NS (8.9[SE ± 1.1]; 95% CI: 6.8-10.9), and OCES (3.5[SE ± 0.4]; 95% CI: 2.9-4.2) on average. Cases reported significant postoperative improvement in TDI total score (3.7[SD ± 8.2]; 95% CI: 2.2-5.2), QOD-NS (-5.9[SD ± 8.7]; 95% CI: -7.6 to -4.3), and OCES (-1.7[SD ± 3.8]; 95% CI: -2.7 to -0.8) on average, while 63% of anosmics reported improved postoperative olfaction. Multivariate regression identified that NP (OR = 0.4; 95% CI: 0.2-1.0) and previous ESS (OR = 0.3; 95% CI: 0.1-0.8) decreased the odds of postoperative improvement equal to mean TDI scores of controls, while septoplasty increased those odds (OR = 4.5; 95% CI: 1.5-13.7).

Conclusion: ESS improved olfactory metrics and restored olfactory function in approximately 50% of patients with CRS to that of healthy controls. Concurrent septoplasty increased the likelihood of achieving normal olfaction, while NP and previous ESS decreased those odds.
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http://dx.doi.org/10.1177/1945892420960671DOI Listing
May 2021

Disease control after surgery for chronic rhinosinusitis: prospective, multi-institutional validation of the Sinus Control Test.

Int Forum Allergy Rhinol 2021 Feb 26;11(2):106-114. Epub 2020 Jul 26.

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

Background: The Sinus Control Test (SCT) is a 4-question, patient-reported questionnaire that assesses disease control in chronic rhinosinusitis (CRS). This prospective, multicenter study examines SCT outcomes following endoscopic sinus surgery (ESS), further validating its use as a control instrument for CRS.

Methods: Adults with CRS undergoing ESS were prospectively enrolled from 5 centers across North America. The SCT was administered at baseline and once 6 months after surgery. Quality of life and disease burden were evaluated using the 22-item Sino-Nasal Outcome Test (SNOT-22) and Lund-Kennedy endoscopy scores. Linear regression was used to determine whether specific demographic, comorbidity, or disease severity measures were independently associated with changes in SCT scores postoperatively.

Results: A total of 218 patients, 111 females (50.9%) and 107 males (49.1%), were enrolled, with mean ± standard deviation age of 50.1 ± 15.6 years. Mean SCT score improved from 8.9 ± 3.5 to 4.3 ± 3.7 postoperatively (p < 0.001). Preoperatively, 21.6% were uncontrolled, 71.5% partially controlled, and 6.9% controlled. Postoperatively, 6.0% were uncontrolled, 42.6% partially controlled, and 51.4% controlled (p < 0.001). Change in SCT score correlated independently with change in SNOT-22 (r = 0.500, p < 0.001) and endoscopy scores (r = 0.310, p < 0.001). Endoscopy scores did not correlate with control status among patients with CRS without nasal polyposis (CRSsNP) nor between uncontrolled and partially controlled patients. Demographics and comorbidities were not associated with changes in SCT.

Conclusion: Improvement in disease control following ESS as measured by the SCT correlated with improvements in SNOT-22 and endoscopy scores. The SCT is an easily administered instrument that provides information complementary to existing patient-reported and objective measures of disease severity.
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http://dx.doi.org/10.1002/alr.22659DOI Listing
February 2021

Allergic Fungal Sinusitis Imitating an Aggressive Skull Base Lesion in the Setting of Pembrolizumab Immunotherapy.

Ann Otol Rhinol Laryngol 2021 Jan 29;130(1):108-111. Epub 2020 Jun 29.

Department of Otolaryngology-Head & Neck Surgery, Oregon Health and Science University, Portland, OR, USA.

Objectives: We report a case of acutely worsening allergic fungal sinusitis in a patient receiving immunotherapy with pembrolizumab, a programmed cell death protein 1 (PD-1) inhibitor.

Methods: A 53-year-old man with a history of metastatic melanoma and recent initiation of pembrolizumab therapy presented with acutely worsening headaches, left abducens nerve palsy, and neuroimaging demonstrating an erosive skull base lesion with bilateral cavernous sinus involvement.

Results: Intraoperative findings were consistent with non-invasive allergic fungal sinus disease. Microbiology and histopathologic data ruled out malignancy and demonstrated Aspergillus fumigatus without concern for angioinvasion. After treatment with antifungal therapy, the patient's symptoms and abducens nerve palsy resolved. Symptoms were well-controlled 7 months after his initial presentation.

Conclusions: Inflammatory sinusitis in patients receiving anti-PD-1 therapy may be secondary to T-cell infiltration, a similar pathophysiology as immune-related adverse events, and warrants appreciation by otolaryngologists given our increasing exposure to immunotherapy and its head and neck manifestations.
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http://dx.doi.org/10.1177/0003489420937728DOI Listing
January 2021

Ethmoid-to-maxillary opacification ratio: a predictor of postoperative olfaction and outcomes in nasal polyposis?

Int Forum Allergy Rhinol 2021 Jan 18;11(1):48-57. Epub 2020 Jun 18.

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

Background: Inflammatory profiles for patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) vary between North American and Asian populations. An elevated ethmoid-to-maxillary (E/M) opacification ratio on preoperative imaging is associated with certain postoperative outcomes in Asian populations and populations that are non-type 2 dominant. In this study we explore this factor in North American/type 2-based populations.

Methods: Adult patients (n = 165) from a North American population with CRSwNP who underwent endoscopic sinus surgery (ESS) were prospectively enrolled into an observational, multi-institutional study. The 22-item Sino-Nasal Outcome Test (SNOT-22), Brief Smell Identification Test (BSIT), and Lund-Kennedy (LK) endoscopic scores were obtained pre- and postoperatively. Patients were stratified according to increasing E/M ratios based on Lund-Mackay (LM) scores.

Results: On average, significant within-subject postoperative improvement was found in all patients for SNOT-22 total and domain scores, and also BSIT results (p ≤ 0.019). Preoperatively, elevated E/M ratio correlated with worse BSIT scores (r = -0.343, p < 0.001). Postoperatively, elevated E/M ratio correlated with BSIT improvement (r = 0.284, p = 0.002), but did not correlate with SNOT-22 improvement or polyp recurrence. An elevated E/M ratio was associated with greater likelihood of reporting a minimal clinically important difference in BSIT scores (χ = 9.96, p = 0.041).

Conclusion: Elevated E/M ratios were found to associated with worse baseline olfaction and an increased likelihood of achieving a clinically meaningful postoperative improvement in olfaction in this North American population with CRSwNP. Elevated E/M ratios did not predict postoperative changes in SNOT-22 measures or polyp recurrence. This suggests that prognostic factors may vary according to geography and generalized inflammatory profiles (type 2 vs non-type 2) in patients with CRS.
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http://dx.doi.org/10.1002/alr.22625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7746627PMC
January 2021

Volumetric assessment of paranasal sinus opacification on computed tomography can be automated using a convolutional neural network.

Int Forum Allergy Rhinol 2020 Nov 15;10(11):1218-1225. Epub 2020 Jun 15.

Department of Radiology, National Jewish Health, Denver, CO.

Background: Computed tomography (CT) plays a key role in evaluation of paranasal sinus inflammation, but improved, and standardized, objective assessment is needed. Computerized volumetric analysis has benefits over visual scoring, but typically relies on manual image segmentation, which is difficult and time-consuming, limiting practical applicability. We hypothesized that a convolutional neural network (CNN) algorithm could perform automatic, volumetric segmentation of the paranasal sinuses on CT, enabling efficient, objective measurement of sinus opacification. In this study we performed initial clinical testing of a CNN for fully automatic quantitation of paranasal sinus opacification in the diagnostic workup of patients with chronic upper and lower airway disease.

Methods: Sinus CT scans were collected on 690 patients who underwent imaging as part of multidisciplinary clinical workup at a tertiary care respiratory hospital between April 2016 and November 2017. A CNN was trained to perform automatic segmentation using a subset of CTs (n = 180) that were segmented manually. A nonoverlapping set (n = 510) was used for testing. CNN opacification scores were compared with Lund-MacKay (LM) visual scores, pulmonary function test results, and other clinical variables using Spearman correlation and linear regression.

Results: CNN scores were correlated with LM scores (rho = 0.82, p < 0.001) and with forced expiratory volume in 1 second (FEV ) percent predicted (rho = -0.21, p < 0.001), FEV /forced vital capacity ratio (rho = -0.27, p < 0.001), immunoglobulin E (rho = 0.20, p < 0.001), eosinophil count (rho = 0.28, p < 0.001), and exhaled nitric oxide (rho = 0.40, p < 0.001).

Conclusion: Segmentation of the paranasal sinuses on CT can be automated using a CNN, providing truly objective, volumetric quantitation of sinonasal inflammation.
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http://dx.doi.org/10.1002/alr.22588DOI Listing
November 2020

Measuring Success in the Treatment of Patients with Chronic Rhinosinusitis.

Immunol Allergy Clin North Am 2020 05 22;40(2):265-279. Epub 2020 Jan 22.

Department of Otolaryngology/Head and Neck Surgery, University of Colorado, 12631 East 17th Avenue, MSB-205, Aurora, CO 80045, USA.

Chronic rhinosinusitis (CRS) has a substantial impact on patients' quality of life (QOL). Among the many metrics available for measuring treatment success in CRS, patient-reported outcome measures that quantify changes in QOL are the most widely used methods. In addition, objective data from imaging, endoscopy, and olfactory testing are useful adjunct measures to diagnose and prevent progression of disease, although these metrics have mixed correlations with symptoms and QOL. In the future, molecular biology, and multiomics techniques may change how successful CRS treatment is defined.
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http://dx.doi.org/10.1016/j.iac.2019.12.004DOI Listing
May 2020

The Utility of Image Guidance in Endoscopic Sinus Surgery: A Narrative Review.

JAMA Otolaryngol Head Neck Surg 2020 03;146(3):286-290

Department of Otolaryngology-Head and Neck Surgery, University of Colorado, Aurora.

Importance: More than a quarter-million cases of endoscopic sinus surgery (ESS) are performed annually in the United States. Most surgeons use image-guided systems as an adjunct during surgery in certain situations. Understanding the association of image-guided surgery (IGS) with surgical outcomes, complications, and surgeon factors is paramount.

Observations: Three systematic or evidenced-based review articles demonstrated no clear evidence that IGS improves surgical outcomes for chronic rhinosinusitis, including completeness of surgical dissection, patient-reported outcomes, or rates of revision surgery. Results from 2 systematic reviews suggest that major and total surgical complications may be decreased with use of IGS in certain cases, although bias may confound these findings. When complications were analyzed individually, there was no definitive evidence that IGS is associated with decreased rates of orbital, intracranial, or hemorrhagic complications. The rarity of complications in ESS, developing surgical experience, evolving training strategies, and selective use of IGS in more complex cases make future study on the association of IGS with complications challenging. Limited data on the influence of IGS on surgeon satisfaction and stress level suggests that more experienced surgeons might glean benefits in these realms, whereas junior surgeons may feel additional stress when using the technology.

Conclusions And Relevance: Level 2A evidence from systematic reviews suggests that in certain cases IGS may be associated with decreased major and total surgical complications, though the potential for bias and confounding exists in these conclusions. It is possible that, among more experienced surgeons, the use of IGS is associated with improvements in stress and satisfaction, although evidence in this realm is limited and there may be additional stresses associated with IGS for surgeons early in their career. The choice to use IGS in any endoscopic procedure remains best determined by the operating surgeon based on factors including case complexity and surgeon comfort.
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http://dx.doi.org/10.1001/jamaoto.2019.4161DOI Listing
March 2020

Factors driving olfactory loss in patients with chronic rhinosinusitis: a case control study.

Int Forum Allergy Rhinol 2020 01;10(1):7-14

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

Background: Olfactory dysfunction (OD) in chronic rhinosinusitis (CRS) is common. It is likely that numerous factors such as sex, race, age, allergies, asthma, smoking, and other comorbidities play a role in CRS-related OD. In order to determine which aspects of OD are due solely to CRS and which are associated with other confounders, control populations are needed to allow appropriate risk assessments.

Methods: Prospective, multi-institutional enrollment of patients with CRS and control subjects without CRS was performed. Demographic information, comorbidities, and olfactory testing (Sniffin' Sticks) of threshold (T), discrimination (D), and identification (I) scores (TDI) was collected.

Results: A total of 224 patients with CRS and 164 control subjects were enrolled. Olfaction was worse in CRS patients compared to controls (mean ± standard deviation (SD) TDI = 22.4 ± 9.5 vs 28.8 ± 7.0, respectively, p < 0.001). Only 27% of CRS patients were normosmic compared to 49% of controls (p < 0.001). When stratifying by nasal polyp (NP) status, CRSwNP patients had significant impairments in TDI, T, D, and I compared to controls with mean differences of 11.2, 3.3, 3.5, and 4.4 points, respectively (all p < 0.001). In contrast, CRSsNP patients only had impaired T when compared to controls with a mean difference of 2.2 points (p < 0.001). Multivariate modeling of TDI scoring showed that OD was driven by polyps, asthma, diabetes, and age. CRSsNP was not independently associated with worse TDI scores.

Conclusion: OD in CRS patients is multifactorial. Independent drivers appear to be polyp status, asthma, diabetes, and age. OD in patients with CRSsNP is similar to controls with the exception of impaired thresholds.
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http://dx.doi.org/10.1002/alr.22445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6948021PMC
January 2020

Correlation of mucus inflammatory proteins and olfaction in chronic rhinosinusitis.

Int Forum Allergy Rhinol 2020 03 19;10(3):343-355. Epub 2019 Dec 19.

Division of Rhinology and Sinus/Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Oregon Health Sciences University, Portland, OR.

Background: Chronic rhinosinusitis (CRS) is one of the most common causes of olfactory loss, but the pathophysiology underlying olfactory dysfunction in CRS has not been fully elucidated. Previous studies found correlations between olfactory cleft (OC) inflammatory cytokines/chemokines and olfaction in CRS. The purpose of this study was to evaluate the relationship between OC mucus inflammatory proteins and olfaction in a multi-institutional cohort.

Methods: Adults with CRS were prospectively recruited. Demographics, comorbidities, olfactory assessment (Sniffin' Sticks), computed tomography (CT), and OC mucus for protein analysis were collected. Statistical analysis was performed to determine associations between olfactory function, OC mucus protein concentrations, and CT opacification.

Results: Sixty-two patients were enrolled in the study, with an average age of 48.2 (standard deviation, 16.2) years, and 56.5% were female and 59.7% were classified as CRS with nasal polyps (CRSwNP). Ten of 26 OC mucus proteins were significantly correlated with threshold, discrimination, and identification (TDI) scores and OC opacification. Subgroup analysis by polyp status revealed that, within the CRSwNP group, C-C motif ligand 2 (CCL2), interleukin-5 (IL-5), IL-6, IL-13, IL-10, IL-9, tumor necrosis factor-α (TNF-α), CCL5, and CCL11 were significantly correlated with olfaction. For CRS without nasal polyps (CRSsNP), only C-X-C ligand 5 (CXCL5) showed a correlation. In CRSwNP, IL-6, IL-10, vascular endothelial growth factor-A, and immunoglobulin E (IgE) correlated with OC opacification, whereas, in CRSsNP, only CXCL5 showed a correlation. OC mucus proteins and Lund-Mackay score correlated only in the CRSsNP group (CXCL5, IL-5, IL-13, IgE).

Conclusion: Several OC mucus proteins have been found to correlate with olfactory function and OC opacification. The profile of OC mucus proteins differs between CRSsNP and CRSwNP subgroups, suggesting different mechanisms between groups, but further study is required.
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http://dx.doi.org/10.1002/alr.22499DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7145735PMC
March 2020

Acute Exacerbations in Recurrent Acute Rhinosinusitis: Differences in Quality of Life and Endoscopy.

Laryngoscope 2020 12 14;130(12):E736-E741. Epub 2019 Dec 14.

Division of Rhinology and Sinus/Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A.

Objectives/hypothesis: Research surrounding outcome differences for patients with recurrent acute rhinosinusitis (RARS) is scarce. This investigation explored quality of life (QOL) and sinonasal attributes in patients during acute episodes (AEs) and in-between AEs of RARS.

Study Design: Retrospective outcomes research.

Methods: Data from patients with RARS were collected from two academic institutions between 2009 and 2017 using prospective and retrospective methodology. During clinical presentation, subjects were classified as with or without an AEs using guideline definitions of acute bacterial rhinosinusitis (ABRS). Between-group differences in 22-item Sino-Nasal Outcome Test (SNOT-22) survey and Lund-Kennedy (LK) endoscopy scores were assessed.

Results: Four hundred twenty-three clinical visits from 202 patients were included. Visits during an AE (168/423, 40%) were associated with significantly worse SNOT-22 total scores compared to between AEs (255/423, 60%; median = 53.0 [interquartile range (IQR) = 24.0] vs. 34.0 [IQR = 29.5]) and all SNOT-22 subdomain scores (all P < .001). LK scores were available for 167 visits, with 56 (34%) completed during an AE. Compared to visits without an AE, endoscopy findings associated with an AE were less frequently normal (LK score = 0, 45% vs. 62%, P = .031) with worse median LK scores (2.0 [IQR = 4.0] vs. 0.0 [IQR = 2.0], P = .005).

Conclusions: AEs are associated with significantly worse QOL and mildly worse endoscopic findings. Almost half of visits during AEs had negative endoscopy, identifying a disparity between patient symptoms and objective findings and calling into question alternative or concomitant diagnoses. Diagnostic criteria for ABRS or AEs in RARS do not require objective confirmation of inflammation, presenting a conundrum for clinicians. The potential for overdiagnosis of ABRS and AEs should be considered when determining the risk/benefit ratio of treatments for RARS.

Level Of Evidence: 2c Laryngoscope, 2019.
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http://dx.doi.org/10.1002/lary.28460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7293548PMC
December 2020

Socioeconomic status impacts postoperative productivity loss and health utility changes in refractory chronic rhinosinusitis.

Int Forum Allergy Rhinol 2019 09 27;9(9):1000-1009. Epub 2019 Jun 27.

Division of Rhinology and Sinus/Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, OR.

Background: Social determinants of health can have a substantial impact on treatment outcomes. Prior study has shown that socioeconomic status influences the likelihood of improvement in quality-of-life (QOL) following endoscopic sinus surgery (ESS). However, the impact of socioeconomic factors on changes in productivity loss and health utility after ESS remains unknown.

Methods: Adult patients (≥18 years of age) with chronic rhinosinusitis (CRS) who underwent ESS were prospectively enrolled into a multi-institutional cohort study. Productivity losses were calculated using the human capital approach and monetized using U.S. government-estimated wage rates. Health utility values (HUVs) were derived from the Medical Outcomes Study Short-Form-12 survey using University of Sheffield algorithms. Independent socioeconomic factors of interest included: age, gender, ethnicity, insurance status, educational attainment, and household income categorized via the Thompson-Hickey model.

Results: A total of 229 patients met inclusion criteria, and 163 (71%) provided postoperative follow-up. All subjects reported significant, within-subject improvement in both mean monetized productivity loss (p < 0.001) and HUV postoperatively (p < 0.001). Using paired sample statistics, patients with lowest income (≤$25,000/year) and with Medicare insurance did not report significant improvement in productivity loss (p ≥ 0.112) or HUV (p ≥ 0.081), although sample size limitations may have contributed to this finding. Patients in higher income tiers ($25,001 to $100,000/year and $100,001+/year) and those with employer-provided/private health insurance reported significant postoperative improvements in productivity loss and HUV (all p ≤ 0.003).

Conclusion: Socioeconomic factors, including income and insurance provision, may impact improvements in productivity loss and HUV following ESS. Further research to validate these findings, ascertain mechanisms behind these results, and improve these outcomes is warranted.
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http://dx.doi.org/10.1002/alr.22374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6718304PMC
September 2019

Long-term outcomes of endoscopic sinus surgery in the management of adult chronic rhinosinusitis.

Int Forum Allergy Rhinol 2019 08 17;9(8):831-841. Epub 2019 Jun 17.

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

Background: There is a striking lack of long-term, prospective outcomes data for endoscopic sinus surgery (ESS) in chronic rhinosinusitis (CRS) using validated instruments. Our primary objective in this study was to report long-term outcomes (>10 years) after ESS for CRS obtained by prospective data collection.

Methods: An observational cohort (n = 59) of adult patients with CRS electing ESS was enrolled between 2004 and 2008. Long-term, disease-specific quality-of-life (QOL) outcomes, health utility values (HUV), revision surgery rate, development of asthma, and patient expectations/satisfaction with outcomes of ESS were examined using descriptive statistics and simple fixed-effects linear modeling.

Results: Fifty-nine adult patients were followed for 10.9 years (±13.8 months), on average. Mean QOL significantly improved between baseline and 6 months and remained durable to 10 years. HUV improved to normal. A 17% revision surgery rate within the 10-year follow-up period was observed with a 25% revision rate in CRS with polyposis. New-onset asthma after ESS occurred at a rate of 0.8%/year. Patient satisfaction with ESS outcomes was generally high.

Conclusions: Ten-year prospective outcomes of ESS for CRS demonstrate that the initial clinically significant improvements in QOL seen 6 months postoperatively are durable over the long term. Over 75% of patients reported clinically significant long-term QOL and HUV improvement. HUV returned to normal. Revision surgery rate was 17% and worse postoperative endoscopy scores within 18 months of initial ESS were associated with higher likelihood of revision surgery. Most patients would pursue ESS again and recommend the procedure to other patients considering this treatment option.
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http://dx.doi.org/10.1002/alr.22369DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6685750PMC
August 2019

Deadly amoeba infections from nasal and sinus irrigation: how should we discuss with our patients?

Int Forum Allergy Rhinol 2019 04 18;9(4):435-437. Epub 2019 Jan 18.

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

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http://dx.doi.org/10.1002/alr.22294DOI Listing
April 2019

Socioeconomic factors impact quality of life outcomes and olfactory measures in chronic rhinosinusitis.

Int Forum Allergy Rhinol 2019 03 10;9(3):231-239. Epub 2018 Dec 10.

Division of Rhinology and Sinus/Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR.

Background: Healthcare disparities related to socioeconomic factors may adversely impact disease states and treatment outcomes. Among patients with chronic rhinosinusitis (CRS), the impact of socioeconomic factors on outcomes following endoscopic sinus surgery (ESS) remains uncertain.

Methods: Adult patients with refractory CRS were prospectively enrolled into an observational, multi-institutional cohort study between March 2011 and June 2015. Socioeconomic factors analyzed included household income, insurance status, years of education completed, race, age, and ethnicity. Income was stratified according to the Thompson and Hickey model. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Brief Smell Identification Test (BSIT) were completed preoperatively and postoperatively.

Results: A total of 392 patients met inclusion criteria. Higher age and male gender were associated with better mean preoperative SNOT-22 scores (both p < 0.02), whereas Medicare insurance status and male gender were associated with worse preoperative mean BSIT scores (both p < 0.02). Postoperatively, higher household income ($100,001+/year) and lower age were associated with a greater likelihood of improving at least 1 minimal clinically important difference (MCID) on SNOT-22 scores (OR = 2.40 and 1.03, respectively, both p < 0.05), while no factors were associated with increased odds of achieving a MCID on BSIT scores.

Conclusions: Preoperative olfactory function and postoperative quality of life (QOL) improvement were associated with metrics of socioeconomic status in patients with CRS electing ESS. The odds of experiencing a clinically meaningful QOL improvement were more than twice as likely for patients with the highest household income level compared to other income tiers. Further investigation is warranted to identify barriers to postoperative improvement.
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http://dx.doi.org/10.1002/alr.22256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6397069PMC
March 2019

Appropriateness Criteria for Surgery in the Management of Adult Recurrent Acute Rhinosinusitis.

Laryngoscope 2019 01 3;129(1):37-44. Epub 2018 Oct 3.

The Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon.

Objectives/hypothesis: Endoscopic sinus surgery (ESS) is frequently performed for recurrent acute rhinosinusitis (RARS). Appropriate indications for surgery among patients with RARS have not yet been rigorously determined. The objective of this study was to define appropriateness criteria for ESS in the management of adult RARS.

Study Design: Application of RAND-UCLA appropriateness methodology.

Methods: A panel of nine multidisciplinary experts in RARS was formed to evaluate RARS scenarios generated from current evidence. The panel completed two rounds of a modified Delphi-ranking process and a teleconference.

Results: A total of 32 clinical scenarios were ranked in each round. For adult patients with RARS, ESS can appropriately be offered as a treatment option when patients experience ≥ four annual episodes, and there is confirmation of at least one episode via computed tomography or nasal endoscopy, and the patient and clinician jointly participate in shared decision making, and the patient has either failed a trial of topical nasal steroids or experienced RARS-related productivity loss.

Conclusions: This study has defined appropriateness criteria for ESS as a management option for adult patients with RARS. These criteria are intended to represent a minimum threshold for which ESS should be considered in the treatment of RARS and do not suggest that all patients who meet these criteria should undergo surgery. These criteria may serve as a baseline set of indications for ESS in patients with RARS.

Level Of Evidence: NA Laryngoscope, 129:37-44, 2019.
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http://dx.doi.org/10.1002/lary.27438DOI Listing
January 2019

Productivity changes following medical and surgical treatment of chronic rhinosinusitis by symptom domain.

Int Forum Allergy Rhinol 2018 12 28;8(12):1395-1405. Epub 2018 Jul 28.

Department of Otolaryngology-Head and Neck Surgery, Division of Rhinology, Oregon Health & Science University, Portland, OR.

Background: Chronic rhinosinusitis (CRS) is associated with substantial productivity losses. Prior cross-sectional study has identified risk factors and symptom subdomains contributing to baseline productivity loss. This study evaluates correlations between posttreatment changes in symptom subdomain and productivity loss.

Methods: A total of 202 adult patients with refractory CRS were prospectively enrolled into an observational, multi-institutional cohort study between August 2012 and June 2015. Respondents provided pretreatment and posttreatment 22-item Sino-Nasal Outcome Test (SNOT-22) scores. Productivity losses were monetized using measures of absenteeism, presenteeism, lost leisure time, and U.S. government-estimated wage and labor rates.

Results: A total of 39 (19%) participants elected continued appropriate medical therapy (CAMT) and 163 (81%) elected endoscopic sinus surgery (ESS). CAMT patients experienced improvement in SNOT-22 total and rhinologic subdomain scores (both p ≤ 0.039). ESS patients reported improvement in SNOT-22 total scores and all subdomains (all p < 0.001). Mean monetized productivity losses were nearly unchanged following CAMT (-$200, p = 0.887) but significantly reduced following ESS (-$5,015, p < 0.001). Mean productivity losses were reported in CAMT patients reporting worse mean posttreatment extra-rhinologic, psychological, and sleep symptom severity scores; however, no statistically significant linear correlations (r ≤ 0.249; p ≥ 0.126) were reported.

Conclusion: Treatment modalities associate with different posttreatment productivity changes. Patients electing ESS experienced postoperative improvement in productivity distributed across all SNOT-22 symptom domains, suggesting productivity improvement correlates with multiple symptom domains. Patients electing CAMT had better baseline productivity compared to patients electing ESS, and this productivity level was maintained through treatment. Greater productivity loss occurred in patients with worse SNOT-22 scores in the extra-rhinologic, psychological, and sleep subdomains.
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http://dx.doi.org/10.1002/alr.22191DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279579PMC
December 2018

Porcine small intestine submucosal grafts improve remucosalization and progenitor cell recruitment to sites of upper airway tissue remodeling.

Int Forum Allergy Rhinol 2018 10 1;8(10):1162-1168. Epub 2018 Jun 1.

Department of Otolaryngology-Head and Neck Surgery, University of Alabama Birmingham, Birmingham, AL.

Background: To better understand upper airway tissue regeneration, the exposed cartilage and bone at donor sites of tissue flaps may serve as in vivo "Petri dishes" for active wound healing. The pedicled nasoseptal flap (NSF) for skull-base reconstruction creates an exposed donor site within the nasal airway. The objective of this study is to evaluate whether grafting the donor site with a sinonasal repair cover graft is effective in promoting wound healing.

Methods: In this multicenter, prospective trial, subjects were randomized to intervention (graft) or control (no graft) intraoperatively after NSF elevation. Individuals were evaluated at 2, 6, and 12 weeks postintervention with endoscopic recordings. Videos were graded (Likert scale) by 3 otolaryngologists blinded to intervention on remucosalization, crusting, and edema. Scores were analyzed for interrater reliability and cohorts compared. Biopsy and immunohistochemistry at the leading edge of wound healing was performed in select cases.

Results: Twenty-one patients were randomized to intervention and 26 to control. Subjects receiving the graft had significantly greater overall remucosalization (p = 0.01) than controls over 12 weeks. Although crusting was less in the small intestine submucosa (SIS) group, this was not statistically significant (p = 0.08). There was no overall effect on nasal edema (p = 0.2). Immunohistochemistry demonstrated abundant upper airway basal cell progenitors in 2 intervention samples, suggesting that covering grafts may facilitate tissue proliferation via progenitor cell expansion.

Conclusion: This prospective, randomized, controlled trial indicates that a porcine SIS graft placed on exposed cartilage and bone within the upper airway confers improved remucosalization compared to current practice standards.
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http://dx.doi.org/10.1002/alr.22156DOI Listing
October 2018

Appropriateness criteria predict outcomes for sinus surgery and may aid in future patient selection.

Laryngoscope 2018 11 14;128(11):2448-2454. Epub 2018 May 14.

Department of Otolaryngology-Head and Neck Surgery, Division of Rhinology, Oregon Health & Science University, Portland, Oregon.

Objectives: Appropriateness criteria to determine surgical candidacy for chronic rhinosinusitis (CRS) have recently been described. This study stratified patients who underwent endoscopic sinus surgery (ESS) according to these new appropriateness criteria and evaluated postoperative improvements among appropriateness categories.

Methods: Adult patients with uncomplicated CRS electing ESS were prospectively enrolled in a multi-institutional cohort study between March 2011 and June 2015 to assess outcomes. Subsequently, appropriateness criteria that consider preoperative medical therapy, 22-item SinoNasal Outcome Test (SNOT-22) scores, and Lund-Mackay computed tomography scores were retrospectively applied.

Results: A total of 92.6% (436 of 471) were categorized as "appropriate" ESS candidates, 3.8% (18 of 471) as "uncertain," and 3.6% (17 of 471) as "inappropriate." Among uncertain patients, two-thirds (12 of 18) had identifiable reasons for undergoing ESS, most commonly oral corticosteroid intolerance (n = 6). Postoperative follow-up was available for 79% (n = 372). Clinically significant SNOT-22 improvements occurred in both appropriate and uncertain groups (all P < 0.050) but not among the inappropriate group. The inappropriate group reported less mean improvement in SNOT-22 total score compared to appropriate (P = 0.008) and uncertain (P = 0.006) groups.

Conclusion: The vast majority of patients (∼93%) who underwent ESS in a multi-institutional research program were identified as appropriate candidates for surgical intervention, as defined by current appropriateness criteria. Valid considerations frequently exist for offering ESS to patients categorized as uncertain. Appropriate and uncertain candidates report similar, clinically significant SNOT-22 improvements following surgery. Patients classified as inappropriate reported significantly less improvement following ESS. Surgical appropriateness criteria may assist in predicting outcomes of ESS.

Level Of Evidence: 2b. Laryngoscope, 2448-2454, 2018.
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http://dx.doi.org/10.1002/lary.27227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6235736PMC
November 2018

Risk Stratification for Postoperative Venous Thromboembolism after Endoscopic Sinus Surgery.

Otolaryngol Head Neck Surg 2018 04 20;158(4):767-773. Epub 2018 Feb 20.

1 Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA.

Objectives Venous thromboembolism (VTE) contributes to significant patient morbidity, yet the incidence of VTE following endoscopic sinus surgery (ESS) is unknown. Quality improvement criteria are prompting increased standardization of perioperative VTE prophylaxis. Risk stratification for VTE may better define best practice measures to balance limiting VTE development with avoiding unnecessary chemoprophylaxis. Study Design Retrospective cohort study. Setting Tertiary institution. Subjects and Methods Adult patients who underwent ESS without perioperative chemoprophylaxis from 2008 to 2016 were evaluated. Identification of VTE was performed via screening diagnosis and procedure codes and clinical records, with subsequent confirmation of true-positive VTE. Data for individual Caprini scores were abstracted from electronic medical records. The primary outcome was development of VTE within 30 days following ESS relative to the Caprini score. Results A total of 2369 ESS cases were evaluated. While initial screening identified multiple potential VTE events, in-depth medical record review confirmed only 4 true VTE (0.17%). The VTE rate among cases with a Caprini score of <8 (0.09%, 2/2278) was significantly less ( P = .008) than the rate with a score of ≥8 (2.2%, 2/91). Beyond overall score, specific risk factors associated with development of postoperative VTE included stroke, central venous access, sepsis, and inpatient status (all P < .025), while prior VTE and hypercoagulability were not associated with postoperative VTE (all P > .5). Conclusions In the absence of perioperative chemoprophylaxis, postoperative VTE following ESS is extremely rare, particularly for patients carrying low-to-moderate Caprini scores. Risk stratification based on these data can assist in the design of VTE prophylaxis guidelines for ESS patients.
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http://dx.doi.org/10.1177/0194599818755340DOI Listing
April 2018

Biomedical device innovation methodology: applications in biophotonics.

J Biomed Opt 2017 Dec;23(2):1-7

Stanford University, Department of Otolaryngology, Head and Neck Surgery, Stanford, California, United States.

The process of medical device innovation involves an iterative method that focuses on designing innovative, device-oriented solutions that address unmet clinical needs. This process has been applied to the field of biophotonics with many notable successes. Device innovation begins with identifying an unmet clinical need and evaluating this need through a variety of lenses, including currently existing solutions for the need, stakeholders who are interested in the need, and the market that will support an innovative solution. Only once the clinical need is understood in detail can the invention process begin. The ideation phase often involves multiple levels of brainstorming and prototyping with the aim of addressing technical and clinical questions early and in a cost-efficient manner. Once potential solutions are found, they are tested against a number of known translational factors, including intellectual property, regulatory, and reimbursement landscapes. Only when the solution matches the clinical need, the next phase of building a "to market" strategy should begin. Most aspects of the innovation process can be conducted relatively quickly and without significant capital expense. This white paper focuses on key points of the medical device innovation method and how the field of biophotonics has been applied within this framework to generate clinical and commercial success.
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http://dx.doi.org/10.1117/1.JBO.23.2.021102DOI Listing
December 2017

Epithelial separation theory for post-tonsillectomy secondary hemorrhage: evidence in a mouse model and potential heparin-binding epidermal growth factor-like growth factor therapy.

Eur Arch Otorhinolaryngol 2018 Feb 29;275(2):569-578. Epub 2017 Nov 29.

Department of Otolaryngology, Head and Neck Surgery, Stanford University, Palo Alto, CA, USA.

Objective: To provide histological evidence to investigate a theory for post-tonsillectomy secondary hemorrhage (PTH) in a mouse model and to evaluate the potential for heparin-binding epidermal growth factor-like growth factor (HB-EGF) treatment on wound healing in this model.

Methods: A prospective randomized single-blinded cohort study. A uniform tongue wound was created in 84 mice (day 0). Mice were randomized to HB-EGF (treatment, n = 42) or saline (control, n = 42). In treatment mice, HB-EGF 5 µg/ml was administered intramuscularly into the wound daily (days 0-14). In control mice, normal saline was administered daily. Three mice from each group were sacrificed daily through day 14 and the wounds evaluated histologically by blinded reviewers.

Results: Key stages of wound healing, including keratinocyte proliferation and migration, wound contraction, epithelial separation, and neoangiogenesis, are defined with implications for post-tonsillectomy wound healing. Epithelial separation (59 vs. 100%, p = 0.003) and wound reopening (8 vs. 48%, p < 0.001) were reduced with HB-EGF. Epithelial thickness (220 vs. 30 µm, p = 0.04) was greater with HB-EGF. Wound closure (days 4-5 vs. day 6, p = 0.01) occurred earlier with HB-EGF.

Conclusions: In healing of oral keratinocytes on muscle epithelial separation secondary to muscle, contraction occurs concurrently with neoangiogenesis in the base of the wound, increasing the risk of hemorrhage. This potentially explains why post-tonsillectomy secondary hemorrhage occurs and its timing. HB-EGF-treated wounds showed greater epithelial thickness, less frequent epithelial separation and wound reopening, and earlier wound closure prior to neovascularization, suggesting that HB-EGF may be a potential preventative therapy for PTH.

Level Of Evidence: NA-animal studies or basic research.
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http://dx.doi.org/10.1007/s00405-017-4810-6DOI Listing
February 2018

Comparison of surgical outcomes between patients with unilateral and bilateral chronic rhinosinusitis.

Int Forum Allergy Rhinol 2017 12 22;7(12):1162-1169. Epub 2017 Sep 22.

Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland, OR.

Background: Although the majority of patients with chronic rhinosinusitis without nasal polyposis (CRSsNP) suffer from bilateral disease, a subset suffer from unilateral disease. Currently, outcomes following endoscopic sinus surgery (ESS) for medically recalcitrant CRS are inferred from outcomes for patients with bilateral disease. This study compares outcomes of ESS between patients with unilateral and bilateral disease.

Methods: Patients with CRSsNP who failed appropriate medical therapy and elected ESS were enrolled between 2011 and 2015. Patients were dichotomized according to radiographic evidence of unilateral disease (Lund-Mackay [LM] score = 0 for 1 side) or bilateral disease (LM ≥ 1 for both sides). The primary outcome of interest was the 22-item Sino-Nasal Outcome Test (SNOT-22), with secondary outcomes including the Brief Smell Identification Test (BSIT) and the Lund-Kennedy (LK) endoscopy staging system.

Results: A total of 190 patients met inclusion criteria consisting of 19 with unilateral (10%) and 171 with bilateral CRSsNP (90%). Both groups were similar across all preoperative demographic factors, SNOT-22, and BSIT scores. Postoperatively, patients with bilateral disease reported greater improvement in mean SNOT-22 scores compared to unilateral disease, but this difference was not statistically or clinically significant (-24.3 ± 21.1 vs -21.5 ± 24.0, p = 0.582). Mean LK scores improved for patients with bilateral disease but not unilateral disease, without a difference between groups (-2.0 ± 3.5 vs -0.4 ± 2.4, p = 0.090).

Conclusion: Patients with unilateral CRSsNP experience improvement after ESS comparable to patients with bilateral disease on patient reported outcome measures.
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http://dx.doi.org/10.1002/alr.22020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5716933PMC
December 2017

Pharmacological Management of Chronic Rhinosinusitis: Current and Evolving Treatments.

Drugs 2017 Oct;77(16):1713-1721

Department of Otolaryngology, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.

Chronic rhinosinusitis (CRS) is an inflammatory sinonasal condition with multiple etiologic factors that is associated with a vast economic cost. Treatment is most frequently pharmacologic and has centered on agents that ameliorate inflammation, decrease bacterial or pathogen load, and facilitate egress of mucus or purulence from the sinonasal cavity. Nasal saline irrigations, topical nasal steroids, certain antibiotics, and systemic steroids have shown some efficacy in the management of CRS. Recently, biologic therapeutics that target specific inflammatory pathways associated with subsets of CRS have been developed and evaluated. Early data evaluating these biologic treatments suggest a potential role in treating a subset of CRS with refractory, poorly controlled disease. Additional studies are necessary to identify which patients would benefit most from biologic therapies and to assess the cost of these therapies compared with the benefit they provide. This review describes the pathophysiology of CRS and summarizes both established and novel biologic pharmacologic treatments.
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http://dx.doi.org/10.1007/s40265-017-0803-4DOI Listing
October 2017

Pediatric Chronic Rhinosinusitis Management in Rhinologists and Pediatric Otolaryngologists.

Ann Otol Rhinol Laryngol 2017 Sep 2;126(9):634-639. Epub 2017 Aug 2.

1 Stanford University School of Medicine, Department of Otolaryngology-Head and Neck Surgery, Stanford, California, USA.

Objective: To compare the management of pediatric chronic rhinosinusitis (PCRS) between members of the American Rhinologic Society (ARS) and the American Society of Pediatric Otolaryngology (ASPO).

Study Design: Comparison of surveys.

Methods: A web-based survey was distributed to ASPO membership twice in September-October 2016. Data were compared to previously published data from ARS membership in March-April 2016.

Results: ASPO survey completion rate was 22%. ARS members were more likely to employ oral steroids in initial ( P = .025) and maximal medical management ( P = .001). ASPO members more commonly performed adenoidectomy before computed tomography (CT) ( P < .001). Both groups commonly included adenoidectomy as part of initial surgical management (90% vs 94%, P = .316), while ASPO members more frequently performed adenoidectomy alone (70% vs 43%, P = .001). If initial surgical treatment failed, both groups commonly performed endoscopic sinus surgery (ESS; 81% vs 88%, P = .56) with a similar extent including frontal ( P ≥ .207) and sphenoid ( P ≥ .304) surgery.

Conclusions: Pediatric chronic rhinosinusitis management is similar between groups, yet there are differences including oral steroid use, relative order of CT versus adenoidectomy, and performing concomitant procedures with adenoidectomy. Both groups commonly perform ESS with similar surgical extent if prior surgical treatment fails. Management by both groups is largely in agreement with published consensus statements.
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http://dx.doi.org/10.1177/0003489417719717DOI Listing
September 2017

Practice patterns in pediatric chronic rhinosinusitis: A survey of the American Rhinologic Society.

Am J Rhinol Allergy 2016 Nov;30(6):418-423

Department of Otolaryngology, Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA.

Background: The management of pediatric chronic rhinosinusitis (PCRS) is evolving.

Objective: To assess current practice patterns of members of the American Rhinologic Society (ARS) in managing PCRS.

Methods: A 27-item Web-based survey on treatment of PCRS was electronically distributed to the ARS membership.

Results: The survey was completed by 67 members, 40% of whom had completed a rhinology fellowship. The most frequently used medical therapies as part of initial treatment for PCRS were nasal saline solution irrigation, (90%), topical nasal steroids (93%), oral antibiotics (52%), and oral steroids (20%). For initial surgical therapy, 90% performed adenoidectomy; in addition, 31% also performed sinus lavage, 17% performed balloon catheter dilation (BCD), and 17% performed endoscopic sinus surgery (ESS). Sixty percent performed adenoidectomy before obtaining computed tomography imaging. When initial surgical treatment failed, 85% performed traditional ESS. In patients with pansinusitis, 50% of the respondents performed frontal sinusotomy and 70% performed sphenoidotomy. BCD was not frequently used; overall, 66% never or rarely used it, 20% sometimes used it, 12% usually used it, and 3% always or almost always used BCD.

Conclusions: Most aspects of PCRS management among ARS members were aligned with published consensus statements. Adenoidectomy was almost always included as part of first-line surgical treatment but was also combined with adjunctive surgical procedures with moderate frequency. ESS was performed by a minority of rhinologists as a primary procedure for medically refractory PCRS but was favored when previous surgery failed. BCD was uncommonly used in PCRS.
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http://dx.doi.org/10.2500/ajra.2016.30.4373DOI Listing
November 2016