Publications by authors named "Fuad M Baroody"

95 Publications

Systemic Bevacizumab for Treatment of Respiratory Papillomatosis: International Consensus Statement.

Laryngoscope 2021 Jan 6. Epub 2021 Jan 6.

Department of Otolaryngology-Head and Neck Surgery, Eastern Virginia Medical School, Children's Hospital of the King's Daughters, Norfolk, Virginia, U.S.A.

Objectives/hypothesis: The purpose of this study is to develop consensus on key points that would support the use of systemic bevacizumab for the treatment of recurrent respiratory papillomatosis (RRP), and to provide preliminary guidance surrounding the use of this treatment modality.

Study Design: Delphi method-based survey series.

Methods: A multidisciplinary, multi-institutional panel of physicians with experience using systemic bevacizumab for the treatment of RRP was established. The Delphi method was used to identify and obtain consensus on characteristics associated with systemic bevacizumab use across five domains: 1) patient characteristics; 2) disease characteristics; 3) treating center characteristics; 4) prior treatment characteristics; and 5) prior work-up.

Results: The international panel was composed of 70 experts from 12 countries, representing pediatric and adult otolaryngology, hematology/oncology, infectious diseases, pediatric surgery, family medicine, and epidemiology. A total of 189 items were identified, of which consensus was achieved on Patient Characteristics (9), Disease Characteristics (10), Treatment Center Characteristics (22), and Prior Workup Characteristics (18).

Conclusion: This consensus statement provides a useful starting point for clinicians and centers hoping to offer systemic bevacizumab for RRP and may serve as a framework to assess the components of practices and centers currently using this therapy. We hope to provide a strategy to offer the treatment and also to provide a springboard for bevacizumab's use in combination with other RRP treatment protocols. Standardized delivery systems may facilitate research efforts and provide dosing regimens to help shape best-practice applications of systemic bevacizumab for patients with early-onset or less-severe disease phenotypes.

Level Of Evidence: 5. Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29343DOI Listing
January 2021

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

Rhinitis 2020: A practice parameter update.

J Allergy Clin Immunol 2020 10 22;146(4):721-767. Epub 2020 Jul 22.

Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY.

This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.
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http://dx.doi.org/10.1016/j.jaci.2020.07.007DOI Listing
October 2020

Pediatric Modification of the Medically Necessary, Time-Sensitive Scoring System for Operating Room Procedure Prioritization During the COVID-19 Pandemic.

J Am Coll Surg 2020 08 27;231(2):205-215. Epub 2020 May 27.

Sections of Pediatric Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL; Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL.

Background: The COVID-19 pandemic forced surgeons to reconsider concepts of "elective" operations. Perceptions about the time sensitivity and medical necessity of a procedure have taken on greater significance during the pandemic. The evolving ethical and clinical environment requires reappraisal of perioperative factors, such as personal protective equipment conservation; limiting the risk of exposure to COVID-19 for patients, families, and healthcare workers; preservation of hospital beds and ICU resources; and minimizing COVID-19-related perioperative risk to patients.

Study Design: A scaffold for the complex decision-making required for prioritization of medically necessary, time-sensitive (MeNTS) operations was developed for adult patients by colleagues at the University of Chicago. Although adult MeNTS scoring can be applied across adult surgical specialties, some variables were irrelevant in a pediatric population. Pediatric manifestations of chronic diseases and congenital anomalies were not accounted for. To account for the unique challenges children face, we modified the adult MeNTS system for use across pediatric subspecialties.

Results: This pediatric MeNTS scoring system was applied to 101 cases both performed and deferred between March 23 and April 19, 2020 at the University of Chicago Comer Children's Hospital. The pediatric MeNTS scores provide a safe, equitable, transparent, and ethical strategy to prioritize children's surgical procedures.

Conclusions: This process is adaptable to individual institutions and we project it will be useful during the acute phase of the pandemic (maximal limitations), as well as the anticipated recovery phase.
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http://dx.doi.org/10.1016/j.jamcollsurg.2020.05.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251404PMC
August 2020

A Surgical Safety Checklist for Performing Tracheotomy in Patients with Coronavirus Disease 19.

Otolaryngol Head Neck Surg 2020 07 28;163(1):42-46. Epub 2020 Apr 28.

Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, The University of Chicago Medicine, Chicago, Illinois, USA.

Performance of tracheotomy is a potential necessary step in the patient with coronavirus disease 19 (COVID-19) and prolonged mechanical ventilation. Due to viral aerosolization, tracheotomy carries a high risk of transmission of COVID-19 to the health care team performing the procedure. We share our institution's surgical safety checklist for performing tracheotomy in patients with COVID-19, including key modifications intended to mitigate risk to the surgical team.
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http://dx.doi.org/10.1177/0194599820922981DOI Listing
July 2020

A Pragmatic Approach Towards Sinonasal Diseases.

J Allergy Clin Immunol Pract 2020 05 17;8(5):1556-1558. Epub 2020 Feb 17.

Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Md. Electronic address:

Sinonasal disease in its multiple forms affects billions of people worldwide. Although physicians train to precisely diagnose a patient and then treat appropriately, the sheer number of people afflicted with sinonasal disease precludes this approach. We argue that patients should first be treated with an intranasal corticosteroid for 2 weeks. Based on their perceived response, they should be triaged. Those who respond well can be instructed on how to continue to manage their disease. Those who do not would be referred to allergists or otolaryngologists for diagnosis and treatment. We believe this pragmatic approach is safe, provided first-line physicians, physician assistants, and nurse practitioners recognize some warning symptoms and signs of serious, but infrequently occurring, sinonasal diseases that would not lend themselves to this proposed approach.
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http://dx.doi.org/10.1016/j.jaip.2020.02.003DOI Listing
May 2020

Airway Morphological Changes in Pierre Robin Sequence: A Retrospective Study.

Cleft Palate Craniofac J 2020 07 22;57(7):828-839. Epub 2020 Jan 22.

Bernard Sarnat Scholar of Craniofacial Research, Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, IL, USA.

Objective: To investigate airway morphology changes in patients with Pierre Robin sequence (PRS) pre-/post-mandibular distraction osteogenesis (MDO) and to compare morphologic changes to age-matched controls.

Design: Retrospective case-control study.

Setting: Urban, academic, tertiary medical center.

Patients, Participants: Fifteen patients with PRS after MDO to relieve upper airway obstruction (UAO) (2008-2018); age-matched controls for post-MDO patients.

Interventions: Mandibular distraction osteogenesis, curvilinear internal mandibular distractors.

Main Outcome Measures: (1) Physiologic improvement after MDO (apnea-hypopnea index; minimum oxygen saturation); (2) airway size (volume, surface area, length, mean/minimum cross-sectional area), shape (lateral:anterior-posterior ratio, cross-sectional area ratios, uniformity, sphericity), and changes with MDO; and (3) post-MDO airway size, shape versus age-matched controls.

Results: Airway size increased after MDO (volume, = .01; surface area, = .02; length, = .01), as did cross-sectional area (mean, = .02; minimum, = .02; minimum retropalatal, = .05, mid-retroglossal, = .02). Post-MDO PRS airways were larger than controls (volume, < .01; surface area, < .01; length, < .01, cross-sectional area, = .03). Airway shape remained nonuniform and flat post-MDO; control airways were round. Two syndromic patients required repeat MDO and had subphysiologic post-MDO airway cross-sectional area. Post-MDO PRS patients with supraphysiologic cross-sectional area along the entire airway had no UAO recurrence.

Conclusions: In this small, heterogenous patient sample, MDO increases airway size, may preferentially affect the retropalatal airway, and often results in supraphysiologic airway dimensions. These retropalatal changes may be important in relieving severe UAO in patients with PRS. Generalizability of our results is limited by small cohort size and patient heterogeneity.
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http://dx.doi.org/10.1177/1055665619900624DOI Listing
July 2020

The Generalizability of the Clinical Assessment Score-15 for Pediatric Sleep-Disordered Breathing.

Laryngoscope 2020 09 29;130(9):2256-2262. Epub 2019 Nov 29.

Research Division, State University of New York Downstate Medical Center, Brooklyn, New York.

Objective: The Clinical Assessment Score-15 (CAS-15) has been validated as an office-based assessment for pediatric sleep-disordered breathing in otherwise healthy children. Our objective was to determine the generalizability of the CAS-15 in a multi-institutional fashion.

Methods: Five hundred and thirty children from 13 sites with suspected sleep-disordered breathing were recruited, and the investigators completed the CAS-15. Based on decisions made in the course of clinical care, investigators recommended overnight polysomnography, observation, medical therapy, and/or surgery. Two hundred and forty-seven subjects had a follow-up CAS-15.

Results: Mean age was 5.1 (2.6) years; 54.2% were male; 39.1% were white; and 37.0% were African American. Initial mean (standard deviation [SD]) CAS-15 was 37.3 (12.7), n = 508. Spearman correlation between the initial CAS-15 and the initial apnea-hypopnea index (AHI) was 0.41 (95% confidence interval [CI], 0.29, 0.51), n = 212, P < .001. A receiver-operating characteristic curve predicting positive polysomnography (AHI > 2) had an area under the curve of 0.71 (95% CI, 0.63, 0.80). A score ≥ 32 had a sensitivity of 69.0% (95% CI, 61.7, 75.5), a specificity of 63.4% (95% CI, 47.9, 76.6), a positive predictive value of 88.7% (95% CI, 82.1, 93.1), and a negative predictive value of 32.9% (95% CI, 23.5, 44.0) in predicting positive polysomnography. Among children who underwent surgery, the mean change (SD) score was 30.5 (12.6), n = 201, t = 36.85, P < .001, effect size = 3.1.

Conclusion: This study establishes the generalizability of the CAS-15 as a useful office tool for the evaluation of pediatric sleep-disordered breathing.

Level Of Evidence: 2B Laryngoscope, 130:2256-2262, 2020.
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http://dx.doi.org/10.1002/lary.28428DOI Listing
September 2020

Uncharted Waters: Challenges in the Era of Biologic Therapies for Nasal Polyposis.

J Allergy Clin Immunol Pract 2019 01 11;7(1):68-70. Epub 2018 Sep 11.

Section of Otolaryngology-Head and Neck Surgery, The University of Chicago, Chicago, Ill. Electronic address:

Several new, promising, targeted therapies for nasal polyposis are being tested in large-scale clinical trials. These agents target pathways thought to be involved in the disease, including IgE, IL-5, IL-4/IL-13, and others. Designing these trials poses significant challenges: who and when to enroll is not completely clear, optimal dosing is not known, outcome measures are insufficiently robust, there are no validated biomarkers, trial regimens may not comport with how clinicians might use these drugs once approved, and cost-benefit ratios have not been assessed. Thus, there is a need to consider such questions, as trials of these novel treatments continue and these biologics become available. Despite these uncertainties about trial design, there remains a great deal of excitement in the field as we approach the dawn of a new era of therapeutic options for nasal polyposis. In this rostrum, we enumerate these issues and call for a conference that will allow stakeholders in the field to confront them as we enter this new era of opportunity to advance the treatment of nasal polyposis.
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http://dx.doi.org/10.1016/j.jaip.2018.07.017DOI Listing
January 2019

Heterotopic Gastrointestinal Cyst of the Oral Cavity Radiology-Pathology Correlation.

Head Neck Pathol 2019 Dec 25;13(4):668-670. Epub 2018 Jul 25.

Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, IL, USA.

Heterotopic gastrointestinal cyst of the oral cavity is a rare congenital lesion that may arise from ectopic undifferentiated endodermal cells. Imaging, particularly MRI, is useful for surgical planning. On MRI, the cysts typically demonstrate high signal on T2-weighted sequences and variable signal on T1-weighted sequences, which can resemble other conditions, such as dermoids. On histology, the appearance of these lesions can be variable, and may include stratified squamous, simple and ciliated columnar, as well as foveolar and intestinal-type epithelia, often surrounding by smooth muscle. Complete surgical excision is the treatment of choice.
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http://dx.doi.org/10.1007/s12105-018-0955-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854194PMC
December 2019

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis.

Int Forum Allergy Rhinol 2018 02;8(2):108-352

Otolaryngology, University of Michigan, USA.

Background: Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

Methods: Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

Results: The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

Conclusion: This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.
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http://dx.doi.org/10.1002/alr.22073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286723PMC
February 2018

Clinical Consensus Statement: Balloon Dilation of the Sinuses.

Otolaryngol Head Neck Surg 2018 02;158(2):203-214

14 American Academy of Otolaryngology-Head and Neck Surgery Founda-tion, Alexandria, Virginia, USA.

Objective To develop a clinical consensus statement on the use of sinus ostial dilation (SOD) of the paranasal sinuses. Methods An expert panel of otolaryngologists was assembled to represent general otolaryngology and relevant subspecialty societies. The target population is adults 18 years or older with chronic or recurrent rhinosinusitis (with or without nasal polyps, with or without prior sinus surgery) for whom SOD is being recommended, defined as endoscopic use of a balloon device to enlarge or open the outflow tracts of the maxillary, frontal, or sphenoid sinuses, as a standalone procedure or with endoscopic surgery. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus. Results After 3 iterative Delphi method surveys, 13 statements met the standardized definition of consensus while 45 statements did not. The clinical statements were grouped into 3 categories for presentation and discussion: (1) patient criteria, (2) perioperative considerations, and (3) outcomes. Strong consensus was obtained for not performing SOD in patients without sinonasal symptoms or positive findings on computed tomography (CT) in patients with symptoms only of headache or sleep apnea without criteria for sinusitis. In addition, strong consensus was met that CT scan of the sinuses was necessary before performing SOD and that surgeons need to understand and abide by regulations set forth by the US Food and Drug Administration if they choose to reuse/reprocess devices. Conclusion Expert panel consensus may provide helpful information for the otolaryngologist considering the use of SOD for the management of patients with a diagnosis of rhinosinusitis. This panel reached consensus on a number of statements that defined the use of SOD as inappropriate in the management of a variety of symptoms or diseases in the absence of underlying sinusitis. When patients meet the definition of chronic sinusitis as confirmed by CT scan, SOD of the sinuses can be indicated and/or effective in certain scenarios. Additional consensus statements regarding proper setting and safeguards for performing the procedure are described.
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http://dx.doi.org/10.1177/0194599817750086DOI Listing
February 2018

Airway Volume Simulation in Virtual Mandibular Distraction: A Cohort Study.

Plast Reconstr Surg 2018 04;141(4):1003-1009

Chicago, Ill.; and Fort Lauderdale, Fla.

Background: The authors investigated the accuracy of virtual surgical planning in predicting airway volume changes after mandibular distraction in patients with Pierre Robin sequence and associated tongue-based airway obstruction.

Methods: The authors completed a single-institution retrospective review of patients for whom virtual surgical planning was used during mandibular distraction osteogenesis for treatment of tongue-based airway obstruction. Preoperative airway volume, virtual surgical planning-predicted airway volume, and postoperative airway volume were calculated from three-dimensional computed tomographic scans using industry software. A blinded institutional radiologist also calculated pre- and post-operative airway volumes. Pre- and post-operative polysomnography was used to titrate the endpoint of mandibular lengthening.

Results: Eleven patients were included in the study. Mean apnea-hypopnea index (5.42 ± 4.53 versus 44.96 ± 20.57; p < 0.001) and mean nadir oxygen saturation (70.3 ± 9.72 percent versus 82.9 ± 9.62 percent; p = 0.003) improved with mandibular distraction. There was moderate correlation between predicted and actual mandibular distraction lengths (R = 0.65; p = 0.003). There was a strong correlation between predicted and industry-calculated actual post-distraction airway volume (R = 0.99; p < 0.001). There was no significant correlation between actual mandibular distraction length and industry-calculated actual post-distraction airway volume for the entire cohort (R = 0.05; p = 0.49), but correlation approached significance by institutional calculations. No significant correlation existed between industry and institutional-calculated percentage change in post-distraction airway volume (R = 0.06; p = 0.57).

Conclusions: Predictive airway volume calculation may be an effective adjunct to determine anatomic endpoint of mandibular distraction but small sample size, operator and software variability, and patient airway morphology may confound firm conclusions. Further studies are warranted.
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http://dx.doi.org/10.1097/PRS.0000000000004249DOI Listing
April 2018

Nasal Polyps and Biomarkers.

J Allergy Clin Immunol Pract 2017 Nov - Dec;5(6):1589-1590

Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Chicago, Chicago, Ill.

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http://dx.doi.org/10.1016/j.jaip.2017.05.007DOI Listing
May 2019

Three-dimensional image analysis for staging chronic rhinosinusitis.

Int Forum Allergy Rhinol 2017 11 22;7(11):1052-1057. Epub 2017 Sep 22.

Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Chicago, Chicago, IL.

Background: Traditional methods of staging chronic rhinosinusitis (CRS) through imaging do not differentiate between degrees of partial mucosal sinus inflammation, thus limiting their utility as imaging biomarkers. We hypothesized that software-aided, quantitative measurement of sinus inflammation would generate a metric of disease burden that would correlate with clinical parameters in patients with suspected sinus disease.

Methods: Adults with rhinologic complaints undergoing computed tomography imaging were recruited at an urban, academic, tertiary care center (n = 45 with Lund-Mackay [LM] scores ≥4). Three-dimensional (3D) volumetric image analysis was performed using a semiautomated method to obtain a "Chicago-modified Lund-Mackay" (Chicago MLM) score, which provides a continuous scale to quantify extent of opacification. Linear regression was used to test the association of the Chicago MLM score with concurrent symptoms (Total Nasal Symptom Score [TNSS]) and disease-specific quality of life, based on the Sinonasal Outcome Test-22 (SNOT-22).

Results: Chicago MLM scores were significantly associated with both symptoms (p = 0.037) and disease-specific quality of life (p = 0.007). Inflammation in the ethmoid and sphenoid sinuses appeared to influence these associations. These findings were even more robust when analysis was limited to patients with more severe disease (LM >6).

Conclusion: The quantitative measurement of sinus inflammation by computer-aided 3D analysis correlates modestly with both symptoms and disease-specific quality of life. Posterior sinuses appear to have the greatest impact on these findings, potentially providing an anatomic target for clinicians to base therapy. The Chicago MLM score is a promising imaging biomarker for clinical and research use.
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http://dx.doi.org/10.1002/alr.22014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965263PMC
November 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

Role of the Allergist-Immunologist and Upper Airway Allergy in Sleep-Disordered Breathing.

J Allergy Clin Immunol Pract 2017 May - Jun;5(3):628-639. Epub 2016 Dec 5.

SUNY Downstate Medical Center, Brooklyn, NY.

Background: Sleep-disordered breathing in general and obstructive sleep apnea in particular are commonly encountered conditions in allergy practice. Physiologically, nasal (or nasopharyngeal) obstruction from rhinitis, nasal polyposis, or adenotonsillar hypertrophy are credible contributors to snoring and nocturnal respiratory obstructive events. Nevertheless, existing practice parameters largely relegate the role of the allergist to adjunctive treatment in cases of continuous positive airway pressure intolerance.

Objectives: To survey active American Academy of Allergy, Asthma & Immunology members regarding their perceptions and practices concerning sleep-disordered breathing in adult and pediatric patients with rhinitis, and to review the medical literature concerning this connection to identify therapeutic implications and research gaps.

Methods: Members of the Work Group on Rhinitis and Sleep-disordered Breathing composed and distributed a Web-based clinically oriented survey to active American Academy of Allergy, Asthma & Immunology members in mid-2015. The group, in addition, conducted an English-language literature review using PubMed and other sources.

Results: Survey results were returned by 339 of 4881 active members (7%). More than two-third of respondents routinely asked about sleep problems, believed that sleep-disordered breathing was a problem for at least a "substantial minority" (10%-30%) of their adult patients, and believed that medical therapy for upper airway inflammatory conditions could potentially help ameliorate sleep-related complaints. Literature review supported the connection between high-grade nasal congestion/adenotonsillar hypertrophy and obstructive sleep apnea, and at least in the case of pediatric patients, supported the use of anti-inflammatory medication in the initial management of obstructive sleep apnea of mild-to-moderate severity.

Conclusions: Clinical allergy practice and the medical literature support a proactive role for allergists in the diagnosis and management of sleep-disordered breathing.
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http://dx.doi.org/10.1016/j.jaip.2016.10.007DOI Listing
February 2018

Allergy and asthma medication use in home-dwelling U.S. older adults.

Int Forum Allergy Rhinol 2017 02 3;7(2):192-198. Epub 2016 Oct 3.

Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, The University of Chicago, Chicago, IL.

Background: Little is known about the use of allergy and asthma medications in older adults. This study aimed to assess the prevalence of use of these medications in older adults and evaluate predictors of their use.

Methods: Cross-sectional study using data from the National Social Life, Health, and Aging Project (NSHAP), a nationally representative sample of community-dwelling, U.S. adults 57 to 85 years (n = 2976) collected in 2005-2006. We determined prevalence of medication use and used logistic regression to evaluate sociodemographic and health factors associated with their use.

Results: Overall prevalence of allergy medication usage was 8.4% (most commonly antihistamines), and prevalence of asthma medication usage was 8.0% (most commonly bronchodilators). Allergy medication use was significantly associated with history of asthma (odds ratio [OR] 2.37; 95% confidence interval [CI], 1.52 to 3.69), chronic obstructive pulmonary disease (COPD) (OR 2.35; 95% CI, 1.58 to 3.51), or nasal surgery (OR 1.97; 95% CI, 1.00 to 3.86). Older age was associated with decreased allergy medication use (per decade, OR 0.80; 95% CI, 0.66 to 0.98). Although increased education was associated with increased overall allergy medication use, it was associated with decreased use of allergy medications generally contraindicated in the elderly. In contrast, the only significant predictors of asthma medication use were history of asthma (OR 19.66; 95% CI, 3.18 to 121.70) or COPD (OR 4.25; 95% CI, 0.88 to 20.44).

Conclusion: Allergy and asthma medication use is prevalent among older adults and driven mostly by history of asthma or COPD. Additional sociodemographic factors predict allergy (but not asthma) medication use. Further studies are needed to evaluate efficacy of these drugs in the elderly.
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http://dx.doi.org/10.1002/alr.21856DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6057748PMC
February 2017

A clinical trial of a microcrystalline cellulose topical nasal spray on the acute response to allergen challenge.

Am J Rhinol Allergy 2016 Jul;30(4):269-73

Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.

Background: Allergic rhinitis is a common disorder that leads to a negative impact on quality of life. Multiple options are available for treatment of the symptoms, but preventing the reaction should be an effective strategy.

Objective: We tested a nasal spray that contained microcrystalline cellulose designed to limit airborne allergens from penetrating the nasal mucosa (nasal blocker) and, therefore, prevent the initiation of the allergic reaction.

Methods: We performed a randomized, double-blind, placebo-controlled, two-way crossover clinical trial with 20 subjects who had a history of seasonal grass and/or ragweed allergy symptoms. Each subject underwent two separate nasal challenges with antigen (provocations) after application of the investigational product or placebo to both nostrils. The allergen was delivered into one nostril at a time and was administered at 2-hour intervals (identified as challenge 1 and challenge 2). We assessed peak nasal inspiratory flow and total nasal symptoms as well as the number of sneezes recorded at both 15-minute and 1-hour intervals after challenge 1 and, later, challenge 2. After a washout period, the subjects returned to undergo the alternate therapy.

Results: There was a significant overall decrease in peak nasal inspiratory flow after both treatments (investigational product, p = 0.005; placebo, p = 0.001), but, when the average of the change from baseline in peak nasal inspiratory flow was compared with the baseline, the results showed no significant differences between the groups (p = 0.31). Similar results were obtained for total nasal symptoms.

Conclusion: The investigational product did not prove to be significantly better than placebo in treating seasonal allergic rhinitis symptoms.
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http://dx.doi.org/10.2500/ajra.2016.30.4314DOI Listing
July 2016

Other Phenotypes and Treatment of Chronic Rhinosinusitis.

J Allergy Clin Immunol Pract 2016 Jul-Aug;4(4):613-20

Department of Surgery, Section of Otolaryngology, Head and Neck Surgery, The University of Chicago Medicine and Biological Sciences, Chicago, Ill; Department of Pediatrics, The University of Chicago Medicine and Biological Sciences, Chicago, Ill.

Chronic rhinosinusitis (CRS) is difficult to define, partly because the disease recognized by clinicians is both heterogeneous and the endpoint of different pathophysiologic, genetic, and environmental interactions. For this article, we define CRS as symptoms lasting more than 3 months combined with an imaging study showing inflammation in the sinuses. This article comments on some factors that are believed to influence the expression of CRS. These factors include anatomic abnormalities, immotile cilia, age, allergic sensitization, immune deficiency, dental infections, gastrointestinal reflux, smoking, biofilm, and the microbiome. Other factors are discussed in other sections. The article concludes with an overview of treatment. In brief, nasal steroids and large volume nasal irrigations are the first line of treatment for this inflammatory disease. Antibiotics are used when infections are thought to contribute. Oral steroids are frequently used in severe disease. Endoscopy and sinus computed tomography scans are used when surgery is contemplated.
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http://dx.doi.org/10.1016/j.jaip.2016.03.016DOI Listing
October 2017

Nonallergic Rhinitis: Mechanism of Action.

Authors:
Fuad M Baroody

Immunol Allergy Clin North Am 2016 May 5;36(2):279-87. Epub 2016 Mar 5.

Section of Otolaryngology, Head and Neck Surgery, Departments of Surgery and Pediatrics, The University of Chicago Medicine and Biological Sciences, 5841 South Maryland Avenue, MC1035, Chicago, IL 60637, USA. Electronic address:

Nonallergic rhinitis is a common disease that affects many Americans. It is characterized by nasal symptoms of congestion and rhinorrhea without evidence of allergic sensitization. The pathophysiology of the disease has not been studied extensively. In the following article, the author concentrates on summarizing the available information related to cellular inflammation and neurogenic mechanisms in patients with nonallergic rhinitis. The author also explores nasal reactivity to various stimuli in these patients.
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http://dx.doi.org/10.1016/j.iac.2015.12.005DOI Listing
May 2016

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis.

Int Forum Allergy Rhinol 2016 Feb;6 Suppl 1:S22-209

University of Pennsylvania.

Background: The body of knowledge regarding rhinosinusitis(RS) continues to expand, with rapid growth in number of publications, yet substantial variability in the quality of those presentations. In an effort to both consolidate and critically appraise this information, rhinologic experts from around the world have produced the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS).

Methods: Evidence-based reviews with recommendations(EBRRs) were developed for scores of topics, using previously reported methodology. Where existing evidence was insufficient for an EBRR, an evidence-based review (EBR)was produced. The sections were then synthesized and the entire manuscript was then reviewed by all authors for consensus.

Results: The resulting ICAR:RS document addresses multiple topics in RS, including acute RS (ARS), chronic RS (CRS)with and without nasal polyps (CRSwNP and CRSsNP), recurrent acute RS (RARS), acute exacerbation of CRS (AECRS), and pediatric RS.

Conclusion: As a critical review of the RS literature, ICAR:RS provides a thorough review of pathophysiology and evidence-based recommendations for medical and surgical treatment. It also demonstrates the significant gaps in our understanding of the pathophysiology and optimal management of RS. Too often the foundation upon which these recommendations are based is comprised of lower level evidence. It is our hope that this summary of the evidence in RS will point out where additional research efforts may be directed.
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http://dx.doi.org/10.1002/alr.21695DOI Listing
February 2016

Predictive Soft Tissue Airway Volume Analysis in Mandibular Distraction: Pushing The Envelope in Surgical Planning for Obstructive Sleep Apnea.

J Craniofac Surg 2016 Jan;27(1):181-4

*Pritzker School of Medicine, University of Chicago, Chicago, IL †Stryker Medical Inc, Kalamazoo, MI ‡Department of Pediatrics, University of Chicago §Department of Surgery, Section of Otolaryngology ||Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Chicago, Chicago, IL.

Three-dimensional computed tomography has been used in both preoperative planning of mandibular distraction osteogenesis and in the evaluation of postoperative resolution of tongue-based airway obstruction. The authors present a case report using software to predict postdistraction airway volume during virtual surgical planning (VSP) of mandibular distraction osteogenesis in a 7 year old. The predicted increase in airway volume derived from VSP was 33.57% (1716 mm(3) preoperatively to 2292 mm(3) postvirtual distraction). Based on the three-dimensional computed tomography, the actual airway volume increased to 2211 mm(3) postoperatively, a 28.85% increase.The implications of this advancing technology are far-reaching. An illustrative case is presented herein to demonstrate the efficacy of the airway prediction and its limitations. The authors believe that, with continued investigation, this novel approach may be a standard feature of all VSP sessions for the treatment of tongue-based airway obstruction.
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http://dx.doi.org/10.1097/SCS.0000000000002342DOI Listing
January 2016

Pediatric tracheotomy decannulation: a protocol for success.

Curr Opin Otolaryngol Head Neck Surg 2015 Dec;23(6):485-90

aSection of Otolaryngology-Head and Neck Surgery, The University of Chicago Medicine and Biological Sciences bDepartment of Pediatrics, The University of Chicago Medicine Comer Children's Hospital, Chicago, Illinois, USA.

Purpose Of Review: Pediatric tracheotomy is a common procedure. Given the risk of morbidity and mortality associated with long-term placement, it is imperative that decannulation is considered once the indication for tracheotomy placement is corrected or resolved. In this article, we discuss the critical steps necessary for the assessment of readiness for decannulation, and we review the recent literature that supports several methods of evaluation that may be incorporated into a protocol for decannulation.

Recent Findings: Recent literature related to the topics of pediatric tracheotomy and decannulation is limited to case series and retrospective reviews, though relatively large patient populations are encompassed within individual studies. The data presented support the use of routine predecannulation endoscopic exam, as well as progressive daytime and overnight inpatient capping trials to ensure adequate airway patency, capped polysomnography for patients with underlying obstructive sleep apnea and/or dynamic airway disease, and 24-h inpatient observation after decannulation to determine tolerance and detect early failures requiring tracheotomy replacement.

Summary: Although the assessment of readiness for decannulation may be challenging, several evaluative steps are recommended to ensure safe and effective decannulation in pediatric patients. Apparent variation in decannulation outcomes by underlying cause may herald the development of indication-specific decannulation protocols in the future.
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http://dx.doi.org/10.1097/MOO.0000000000000204DOI Listing
December 2015

Diagnostic algorithm for unilateral sinus disease: a 15-year retrospective review.

Int Forum Allergy Rhinol 2015 Jul 16;5(7):590-6. Epub 2015 Apr 16.

Section of Otolaryngology-Head and Neck Surgery, The University of Chicago Medicine and Biological Sciences, Chicago, IL.

Background: Patients presenting with unilateral sinus symptoms or nasal polyps raise concerns about sinister pathology. Yet despite the relatively common occurrence of this presentation, and its potential severity, an organized diagnostic approach to unilateral sinus disease (USD) has never been defined. The purpose of this work was to propose a diagnostic algorithm for managing patients with USD based on prior experience.

Methods: We performed a retrospective review of the medical records of all patients with USD who underwent surgical intervention and had pathological specimens during a 15-year period at an urban academic center. Nasal endoscopy and computed tomography (CT) scan findings, demographic characteristics, presenting symptoms, medical histories, and previous treatments were analyzed.

Results: A total of 191 patients met the inclusion criteria, 153 of whom were initially diagnosed at our center. Among the latter group, 51 (33%) presented with a nasal mass or polyp observed by endoscopy. Inverted papilloma was present in 16% of those cases, and malignant tumors comprised 14%. In contrast, of patients without an obvious nasal polyp (n = 102), 2% had inverted papilloma and 3% had malignancies. Overall, chronic rhinosinusitis was the most common diagnosis both in patients with polyps (67%) and those without nasal polyps (69%).

Conclusion: Although USD is most likely to represent chronic inflammation, there exists a fair likelihood of finding malignant pathology, particularly in cases where patients have a unilateral polyp. Based on this review, we propose a strategy for the management of new presentations of USD.
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http://dx.doi.org/10.1002/alr.21526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4830336PMC
July 2015

Computer-assisted staging of chronic rhinosinusitis correlates with symptoms.

Int Forum Allergy Rhinol 2015 Jul 8;5(7):637-642. Epub 2015 Apr 8.

Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, The University of Chicago.

Background: The Lund-Mackay (LM) staging system for chronic rhinosinusitis (CRS) does not correlate with clinical parameters, likely due to its coarse scale. We developed a "Modified Lund Mackay" (MLM) system, which uses a three-dimensional (3D), computerized method to quantify the volume of mucosal inflammation in the sinuses, and sought to determine whether the MLM would correlate with symptoms and disease-specific quality of life.

Methods: We obtained Total Nasal Symptom Score (TNSS) and 22-item Sino-Nasal Outcome Test (SNOT-22) data from 55 adult subjects immediately prior to sinus imaging. The volume of each sinus occupied by mucosal inflammation was measured using MATLAB algorithms created using customized, image analysis software after manual outlining of each sinus. Linear regression was used to model the relationship between the MLM and the SNOT-22 and TNSS. Correlation between the LM and MLM was tested using Spearman's rank correlation coefficient.

Results: Adjusting for age, gender, and smoking, a higher symptom burden was associated with increased sinonasal inflammation as captured by the MLM (β = 0.453, p < 0.013). As expected due to the differences in scales, the LM and MLM scores were significantly different (p < 0.011). No association between MLM and SNOT-22 scores was found.

Conclusion: The MLM is one of the first imaging-based scoring systems that correlates with sinonasal symptoms. Further development of this custom software, including full automation and validation in larger samples, may yield a biomarker with great utility for both treatment of patients and outcomes assessment in clinical trials.
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http://dx.doi.org/10.1002/alr.21499DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4509627PMC
July 2015

Clinical practice guideline: allergic rhinitis executive summary.

Otolaryngol Head Neck Surg 2015 Feb;152(2):197-206

Department of Research and Quality, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Allergic Rhinitis. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed address the evaluation of patients with allergic rhinitis, including performing and interpretation of diagnostic testing and assessment and documentation of chronic conditions and comorbidities. It will then focus on the recommendations to guide the evaluation and treatment of patients with allergic rhinitis, to determine the most appropriate interventions to improve symptoms and quality of life for patients with allergic rhinitis.
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http://dx.doi.org/10.1177/0194599814562166DOI Listing
February 2015

Clinical practice guideline: Allergic rhinitis.

Otolaryngol Head Neck Surg 2015 Feb;152(1 Suppl):S1-43

Department of Research and Quality, American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA.

Objective: Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as $2 to $4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options.

Purpose: The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients.

Action Statements: The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.
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http://dx.doi.org/10.1177/0194599814561600DOI Listing
February 2015

Seasonal allergic rhinitis affects sinonasal microbiota.

Am J Rhinol Allergy 2014 Jul-Aug;28(4):281-6

Section of Otolaryngologty-Head and Neck Surgery, The University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.

Background: Microbes and allergens can stimulate the nasal mucosa, potentially leading to the development of acute bacterial rhinosinusitis (ABRS). This study was designed to determine if allergen exposure alters the sinonasal microbiome.

Methods: We performed a parallel observational study of healthy adults with seasonal allergic rhinitis (SAR; grass or tree, n = 20) or nonallergic subjects (n = 19). Microbiota specimens were obtained by endoscopy from the middle meatus and vestibule before and during the relevant season and were analyzed by terminal restriction fragment length polymorphism analysis. Differences in bacterial microbiota were assessed by standard ecological measures of bacterial diversity. Quality of life and symptom scores were recorded, and nasal lavages for eosinophils were performed.

Results: SAR subjects had increased nasal symptoms in season, impaired disease-specific quality of life, and increased nasal eosinophils, compared with no changes in nonallergic subjects. During the season, SAR subjects had a significantly greater variety of organisms in the middle meatus compared with nonallergic subjects (p < 0.036) and increased bacterial diversity (Shannon index, p < 0.013). We found a significant positive correlation between bacterial diversity in the middle meatus during the season and the nasal lavage eosinophil count of SAR subjects. There were no significant changes in the nasal vestibule (p > 0.05, all comparisons).

Conclusion: The interaction of allergy and microbiota may affect the sinonasal physiology, with broad implications for several airway diseases. Characterization of the specific organisms involved using next-generation sequencing may clarify the relationship between allergic inflammation and ABRS. This finding may help explain why allergic inflammation predisposes to ABRS.
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http://dx.doi.org/10.2500/ajra.2014.28.4050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4101129PMC
June 2015