Publications by authors named "John M Lee"

102 Publications

Readability and quality assessment of internet-based patient education materials related to nasal septoplasty.

J Otolaryngol Head Neck Surg 2021 Mar 17;50(1):16. Epub 2021 Mar 17.

Division of Rhinology, Department of Otolaryngology - Head & Neck Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.

Background: Given that nasal septoplasty is a common procedure in otolaryngology - head and neck surgery, the objective of this study was to evaluate the quality and readability of online patient education materials on septoplasty.

Methods: A Google search was performed using eight different search terms related to septoplasty. Six different tools were used to assess the readability of included patient education materials. These included the Flesch-Kincaid Grade Level, Flesch Reading Ease, Gunning-Fog Index, Simple Measure of Gobbledygook Index, Coleman-Liau Index, and Automated Readability Index. The DISCERN tool was used to assess quality and reliability.

Results: Eighty-five online patient education materials were included. The average Flesch-Reading Ease score for all patient education materials was 54.9 ± 11.5, indicating they were fairly difficult to read. The average reading grade level was 10.5 ± 2.0, which is higher than the recommended reading level for patient education materials. The mean DISCERN score was 42.9 ± 10.5 and 42% (36/85) of articles had DISCERN scores less than 39, corresponding to poor or very poor quality.

Conclusion: The majority of online patient education materials on septoplasty are written above the recommended reading levels and have significant deficiencies in terms of their quality and reliability. Clinicians and patients should be aware of the shortcomings of these resources and consider the impact they may have on patients' decision making.
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http://dx.doi.org/10.1186/s40463-021-00507-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970817PMC
March 2021

Comparative Study of Chemosensory Dysfunction in COVID-19 in 2 Geographically Distinct Regions.

Ear Nose Throat J 2021 Mar 17:1455613211000170. Epub 2021 Mar 17.

Department of Otolaryngology-Head & Neck Surgery, St. Michael's Hospital, Unity Health Toronto, 7938University of Toronto, Toronto, Ontario, Canada.

Objective: To directly compare the prevalence of chemosensory dysfunction (smell and taste) in geographically distinct regions with the same questionnaires.

Methods: A cross-sectional study was performed to evaluate the self-reported symptoms among adults (older than 18 years) who underwent COVID-19 testing at an ambulatory assessment center in Canada and at a hospital in Israel between March 16, 2020, and August 19, 2020. The primary outcome was the prevalence of self-reported chemosensory dysfunction (anosmia/hypomsia and dysgeusia/ageusia). Subgroup analysis was performed to evaluate the prevalence of chemosensory deficits among the outpatients.

Results: We identified a total of 350 COVID-19-positive patients (138 Canadians and 212 Israelis). The overall prevalence of chemosensory dysfunction was 47.1%. There was a higher proportion of chemosensory deficits among Canadians compared to Israelis (66.7% vs 34.4%, P < .01). A subgroup analysis for outpatients (never hospitalized) still identified a higher prevalence of chemosensory dysfunction among Canadians compared to Israelis (68.2% vs 36.1%, P < 0.01). A majority of patients recovered their sense of smell after 4 weeks of symptom onset.

Conclusion: Although the prevalence of chemosensory deficit in COVID-19 was found to be similar to previously published reports, the prevalence can vary significantly across different geographical regions. Therefore, it is important to obtain regionally specific data so that the symptom of anosmia/dysgeusia can be used as a guide for screening for the clinical diagnosis of COVID-19.
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http://dx.doi.org/10.1177/01455613211000170DOI Listing
March 2021

The effect of dietary supplementation with high- or low-dose omega-3 fatty acid on inflammatory pathology after traumatic brain injury in rats.

Transl Neurosci 2021 Jan 4;12(1):76-82. Epub 2021 Feb 4.

Department of Mechanical and Industrial Engineering, University of Illinois at Chicago, Room 2035 Engineering Research Facility, 842 W Taylor Street, Chicago, IL 60607, United States of America.

This study investigated dietary supplementation as a prophylactic for neuroinflammation following traumatic brain injury (TBI) in a preclinical model. Adult male Sprague-Dawley rats received 30 days of supplementation with either water or two dietary supplements. The first consisted of high-dose omega-3 fatty acid (O3FA) (supplement A) along with vitamin D3 and vitamin E. The second had the same ingredients at different doses with an addition of cannabidiol (supplement B). Rats were subjected to an impact TBI and then euthanized 7 days post-injury and neuroinflammation quantified by histological detection of glial fibrillary acidic protein (GFAP), a marker of astrocyte activation, and CD68, a marker of microglial activity. There was a trend toward increased GFAP staining in injured, unsupplemented animals as compared to sham, unsupplemented animals, consistent with increased activation of astrocytes in response to trauma which was reversed by supplement A but not by supplement B. The pattern of CD68 staining across groups was similar to that of GFAP staining. There was a trend toward an increase in the injured unsupplemented group, relative to sham which was reversed by supplement A but not by supplement B. CD68 staining in injured animals was concentrated in the perivascular domain. The consistency between trends across different measures of neuroinflammation showing benefits of high-dose O3FA supplementation following TBI suggests that the observed effects are real. These findings are preliminary, but they justify further study to determine the functional benefits associated with improvements in histological outcomes and understand associated dose-response curves.
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http://dx.doi.org/10.1515/tnsci-2021-0010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885303PMC
January 2021

Long-Term Follow-Up After Maxillary Sinus Balloon Sinuplasty and ESS.

Ear Nose Throat J 2021 Feb 19:145561320986030. Epub 2021 Feb 19.

Skin and Allergy Hospital, 159841Helsinki University Hospital and University of Helsinki, Helsinki, Finland.

Objectives: The aim of this controlled follow-up study was to compare the need for revision surgery, long-term efficacy, and satisfaction in chronic rhinosinusitis patients who had undergone maxillary sinus operation with either balloon sinuplasty or traditional endoscopic sinus surgery (ESS) technique.

Methods: Thirty-nine ESS patients and 36 balloon patients of our previously described cohort, who had been primarily operated in 2008 to 2010, were contacted by phone. Symptoms, satisfaction, and need for revision surgery were asked. In addition, we collected data of patients who had undergone primary maxillary sinus balloon sinuplasty in the Helsinki University Hospital during the years 2005 to 2019. As a control group, we collected data of patients who had undergone primary maxillary sinus ESS at 3 Finnish University Hospitals, and 1 Central Hospital in years 2005, 2008, and 2011.

Results: Altogether, 77 balloon patients and 82 ESS patients were included. The mean follow-up time was 5.3 years in balloon group and 9.8 years in ESS group. Revision surgery was performed on 17 balloon patients and 6 ESS patients. In the survival analysis, the balloon sinuplasty associated significantly with a higher risk of revision surgery compared to ESS. According to the phone interviews, 82% of ESS patients and 75% of balloon patients were very satisfied with the primary operation.

Conclusion: Although the patient groups expressed equal satisfaction and change in symptoms after the operations, the need for revision surgery was higher after balloon sinuplasty than after ESS. This should be emphasized when counselling patients regarding surgical options.
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http://dx.doi.org/10.1177/0145561320986030DOI Listing
February 2021

CSO (Canadian Society of Otolaryngology - Head & Neck Surgery) position paper on rhinologic and skull base surgery during the COVID-19 pandemic.

J Otolaryngol Head Neck Surg 2020 Dec 3;49(1):81. Epub 2020 Dec 3.

Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, ON, Canada.

Healthcare services in many countries have been partially or completely disrupted by the Coronavirus (COVID-19) pandemic since its onset in the end of 2019. Amongst the most impacted are the elective medical and surgical services in order to conserve resources to care for COVID-19 patients. As the number of infected patients decrease across Canada, elective surgeries are being restarted in a staged manner. Since Otolaryngologists - Head & Neck Surgeons manage surgical diseases of the upper aerodigestive tract where the highest viral load reside, it is imperative that these surgeries resume in a safe manner. The aim of this document is to compile the current best evidence available and provide expert consensus on the safe restart of rhinologic and skull base surgeries while discussing the pre-operative, intra-operative, and post-operative care and tips. Risk assessment, patient selection, case triage, and pre-operative COVID-19 testing will be analyzed and discussed. These guidelines will also consider the optimal use of personal protective equipment for specific cases, general and specific operative room precautions, and practical tips of intra-operative maneuvers to optimize patient and provider safety. Given that the literature surrounding COVID-19 is rapidly evolving, these recommendations will serve to start our specialty back into elective rhinologic surgeries over the next months and they may change as we learn more about this disease.
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http://dx.doi.org/10.1186/s40463-020-00476-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7714255PMC
December 2020

Sinonasal Chondrosarcoma Presenting With Isolated Severe Vision Loss.

J Neuroophthalmol 2020 Oct 27. Epub 2020 Oct 27.

Department of Ophthalmology and Vision Sciences (MTBN, JAM), University of Toronto, Toronto, Ontario, Canada; Faculty of Medicine (AF), University of Toronto, Toronto, Ontario, Canada; Department of Pathology and Laboratory Medicine (BCD), Mount Sinai Hospital; Department of Laboratory Medicine and Pathobiology (BCD), University of Toronto, Toronto, Ontario, Canada; Department of Otolaryngology-Head and Neck Surgery (JML), St. Michael's Hospital, Toronto, Ontario, Canada; Department of Otolaryngology-Head and Neck Surgery (JML), University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery (MDC), Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery (MDC), University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program (DST), Princess Margaret Cancer Centre, University Health Network; Department of Radiation Oncology (DST), University of Toronto, Toronto, Ontario, Canada; Division of Neurology (JAM), Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and Department of Ophthalmology (JAM), St. Michael's Hospital, Toronto, Ontario, Canada.

A 24-year-old man presented with a 2-month history of progressive, painless vision loss in the right eye, with no history of headache, nasal congestion, rhinorrhea, or epistaxis. His visual acuity was counting fingers at 1 ft in the right eye and 20 of 20 in the left eye with a right relative afferent pupillary defect and mild temporal optic disc pallor. MRI of the brain and orbits showed a mass involving bilateral ethmoid and sphenoid sinuses and right nasal cavity. He underwent urgent extended endoscopic endonasal transsphenoidal approach for resection of the sinonasal skull base tumor and photon radiation therapy. Pathology revealed a well-differentiated cartilaginous neoplasm with focal areas of entrapped native bone, consistent with a chondrosarcoma WHO grade I/III. At 6-month follow-up after surgery, he had a visual acuity of 20/40 in the right eye and 20/20 in the left eye. Malignant tumors from the sinonasal area should be kept in the differential diagnosis for compressive optic neuropathies and may present with vision loss even in the absence of nasal or sinus symptoms.
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http://dx.doi.org/10.1097/WNO.0000000000001130DOI Listing
October 2020

Evaluating YouTube as a Source of Patient Information for Functional Endoscopic Sinus Surgery.

Ear Nose Throat J 2020 Oct 6:145561320962867. Epub 2020 Oct 6.

Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, St. Michael's Hospital, Toronto, Ontario, Canada.

Objective: To evaluate the quality of information presented on YouTube regarding functional endoscopic sinus surgery (FESS) for patients.

Methods: YouTube was searched using FESS-specific keywords under the setting of "relevance." The first 50 videos from each keyword were reviewed and analyzed by 2 independent physician reviewers. Videos not related to FESS and duplicates were excluded. Outcome measures included the modified DISCERN score (range 0-5), the () benchmark criteria (range: 0-4), a novel scoring checklist for FESS assessing usefulness (range: 0-16), and the Video Power Index (VPI). Intraclass correlation coefficient (ICC) was calculated.

Results: Of the 200 videos identified, 95 videos were analyzed after exclusions. Videos had an average VPI of 40.8 and SD 133.2. Average scores from the 3 objective checklists among all videos were low: modified DISCERN: 1.91, SD: 1.15; benchmark: 1.91, SD: 0.76; and FESS score: 3.54, SD: 1.77. The ICC between the 2 independent reviewers was excellent for all 3 checklists. We noted significant positive Pearson correlation between all 3 checklist scores ( < .001). In between-group comparisons of mean scores, there was significantly higher DISCERN and scores for videos from university/professional organizations, as compared to videos from medical advertising/for-profit companies and independent users. There were no significant differences in FESS scores noted between the 3 groups.

Conclusion: There were overall low scores across the modified DISCERN, benchmark criteria, and FESS scoring checklists, reflecting the poor quality of YouTube videos as a source of patient information for FESS.
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http://dx.doi.org/10.1177/0145561320962867DOI Listing
October 2020

Pupil-Sparing Third Nerve Palsy and Papilledema Due to Granulomatosis With Polyangiitis.

J Neuroophthalmol 2020 Sep 11. Epub 2020 Sep 11.

Max Rady College of Medicine (AV), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Department of Laboratory Medicine (CJS), Unity Health Toronto, Toronto, Canada; Department of Laboratory Medicine and Pathobiology (CJS), University of Toronto, Toronto, Canada; Division of Rheumatology (SPY), Department of Medicine, University of Toronto, Toronto, Canada; Department of Otolaryngology-Head and Neck Surgery (JML), St. Michael's Hospital, University of Toronto, Toronto, Canada; Division of Neurology (JAM), Department of Medicine, University of Toronto, Toronto, Canada; and Department of Ophthalmology and Vision Sciences (JAM), University of Toronto, Toronto, Canada.

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http://dx.doi.org/10.1097/WNO.0000000000001086DOI Listing
September 2020

Medical and surgical treatment outcomes in patients with chronic rhinosinusitis and immunodeficiency: a systematic review.

Int Forum Allergy Rhinol 2021 Feb 15;11(2):162-173. Epub 2020 Jul 15.

Division of Rhinology, Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, ON, Canada.

Background: Immunodeficiency is a risk factor for recalcitrant chronic rhinosinusitis (CRS). Currently, there is no consensus on effective treatment modalities for immunodeficient CRS patients. This review aims to evaluate the existing evidence on the treatment outcomes and its limitations in patients with CRS and immunodeficiency.

Methods: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to April 2019 for studies reporting measurable medical or surgical treatment outcomes for adult patients with CRS and underlying primary or secondary immunodeficiency.

Results: Of the 2459 articles screened, 13 studies met the inclusion criteria: 2 prospective double-blind placebo-controlled trials, 2 prospective case-control studies, 2 prospective cohort studies, and 7 case series. The high degree of study heterogeneity precluded a meta-analysis. Antibiotic monotherapy was not linked with significant improvement in clinical, radiographic, or endoscopic outcomes. Immunoglobulin replacement therapy may potentially reduce the frequency of acute or chronic sinusitis in patients with primary immunodeficiency (PID) but may not improve their sinonasal symptoms. Outcomes from endoscopic sinus surgery (ESS) were reported in 8 studies, which found that surgery was linked with improvement in symptoms, disease-specific quality of life, endoscopy scores, and radiographic scores. The average reported ESS revision rate was 14%.

Conclusion: Patients with CRS and immunodeficiency likely benefit from ESS based on the available evidence. Data supporting medical therapy in this targeted population is limited overall, but there may be a potential role for immunoglobulin therapy in patients with PID and CRS.
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http://dx.doi.org/10.1002/alr.22647DOI Listing
February 2021

Otolaryngology needs among an adult homeless population: a prospective study.

J Otolaryngol Head Neck Surg 2020 Jul 9;49(1):47. Epub 2020 Jul 9.

Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, Canada.

Background: Homeless individuals frequently experience poor access to healthcare, delayed clinical presentation, and higher disease burden. Providing subspecialty otolaryngology care to this population can be challenging. We previously reported on the prevalence of hearing impairment in Toronto's homeless community. As a secondary objective of this study, we sought to define otolaryngology specific need for this population.

Methods: One hundred adult homeless individuals were recruited across ten homeless shelters in Toronto, Canada using a stratified random sampling technique. An audiometric evaluation and head and neck physical examination were performed by an audiologist and otolaryngology resident, respectively. Basic demographic and clinical information was captured through verbal administration of a survey. Descriptive statistics were used to estimate frequency of otolaryngology specific diseases for this population.

Results: Of the 132 individuals who were initially approached to participant, 100 (76%) agreed. There were 64 males, with median age of 46 years (IQR 37-58 years). The median life duration of homelessness was 24 months (IQR 6-72 months). Participants had a wide range of medical comorbidities, with the most common being current tobacco smoking (67%), depression (36%), alcohol abuse (32%), and other substance abuse (32%). There were 22 patients with otolaryngology needs as demonstrated by one or more abnormal findings on head and neck examination. The most common finding was nasal fracture with significant nasal obstruction (6%). Eleven patients required referral to a staff otolaryngologist based on concerning or suspicious findings, including two head and neck masses, 6 were later seen in follow-up.

Conclusion: There were substantial otolaryngology needs amongst a homeless population within a universal healthcare system. Future research should focus on further elucidating head and neck related issues in this population and expanding the role of the otolaryngologist in providing care to homeless individuals.
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http://dx.doi.org/10.1186/s40463-020-00445-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7346481PMC
July 2020

Should Oral Corticosteroids be Used in Medical Therapy for Chronic Rhinosinusitis? A Risk Analysis.

Laryngoscope 2021 03 7;131(3):473-481. Epub 2020 Jul 7.

Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada.

Objectives: Oral corticosteroid (OCS) as a part of appropriate medical therapy (AMT) (formerly maximal medical therapy) in chronic rhinosinusitis remains controversial. While the risks of OCS are well known, the benefit remains unclear due the absence of a standardized prescribing regimen. Consequently, it is difficult to characterize whether the risks of OCS and its ability to avert endoscopic sinus surgery (ESS) are helpful in AMT. When OCS is highly effective at averting surgery, the lesser risks of OCS would be justified because it can avoid the greater risks of ESS. When OCS is poorly effective at averting ESS, the risks of OCS would not be justified because many patients will be exposed to both risks. This study seeks to identify the threshold effectiveness of OCS at averting ESS that would minimize risk exposure to patients.

Methods: A probabilistic risks-based decision analysis was constructed from literature reported incidences and impacts of adverse events of OCS and ESS. Monte Carlo analysis was performed to identify the minimum effectiveness required to avoid further intervention (MERAFI) for chronic sinusitis without nasal polyp (CRSsNP) and chronic sinusitis with nasal polyp (CRSwNP).

Results: The analysis showed MERAFI results of 20.8% (95% CI 20.7-20.9%) for CRSsNP and 16.8% (95% CI 16.7-16.9%) for CRSwNP.

Conclusions: Given reported OCS effectiveness in the range of 34-71% in CRSsNP and 46-63% in CRSwNP, this analysis suggests that the inclusion of OCS in AMT may be the lower risk strategy.

Level Of Evidence: N/A Laryngoscope, 131:473-481, 2021.
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http://dx.doi.org/10.1002/lary.28843DOI Listing
March 2021

Surgical outcomes in aspirin-exacerbated respiratory disease without aspirin desensitization.

Int Forum Allergy Rhinol 2020 Oct 18;10(10):1149-1157. Epub 2020 Jun 18.

Division of Rhinology, Department of Otolaryngology-Head & Neck Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.

Background: Aspirin-exacerbated respiratory disease (AERD) represents a severe endotype of chronic rhinosinusitis with nasal polyposis. Although aspirin desensitization (AD) has emerged as an effective therapeutic option, the natural history of AERD without AD remains unclear.

Methods: A retrospective review was conducted of AERD patients who underwent endoscopic sinus surgery (ESS) without AD between 2010 and 2019. The primary outcomes were revision surgery rate and time to revision surgery. Secondary outcomes included changes in 22-item Sino-Nasal Outcome Test (SNOT-22) scores and Lund-Kennedy endoscopy scores (LKES). A subgroup analysis was performed for patients on monoclonal antibody therapy (MAT).

Results: Of 141 patients, 37 (26.2%) underwent revision ESS with a median time to revision of 3.3 (interquartile range [IQR], 2.2-4.9) years. The probability of remaining free of revision surgery at 1, 3, and 5 years was: 98.2% (95% confidence interval [CI], 95.7-100.0%), 78.8% (95% CI, 70.2-88.4%), and 44.8% (95% CI, 32.4-62.1%), respectively. SNOT-22 scores decreased by 34 (IQR, 18-52) points at 6 months and 27 (IQR, 20-46) points at 1 year postoperatively. In the revision cohort, the decrease in SNOT-22 score was not sustained at 1 year postoperatively. No difference was found in time to revision compared with those without MAT (p = 0.23).

Conclusion: A significant proportion of AERD patients benefit from ESS and medical therapy alone without AD. This study presents preliminary results on the impact of MAT on surgical outcomes as it is limited by the small sample size. Further research on the use of MAT in AERD is needed.
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http://dx.doi.org/10.1002/alr.22626DOI Listing
October 2020

In-Office KTP Laser for Treating Hereditary Hemorrhagic Telangiectasia-Associated Epistaxis.

Laryngoscope 2021 03 18;131(3):E689-E693. Epub 2020 Jun 18.

Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada.

Objective: To evaluated the efficacy and safety of in-office potassium titanyl phosphate (KTP) laser treatment for the management of epistaxis in hereditary hemorrhagic telangiectasia (HHT) patients.

Methods: A retrospective case series of all HHT patients over age of 18 who underwent in-office KTP laser treatment from July 1, 2017 to December 31, 2019 was performed. The primary outcome measure was the epistaxis severity score (ESS) pre- and post-procedure. Secondary outcome measures included patient reported pain (on a 10-point Likert-type scale), and procedural adverse events and complications.

Results: A total of 16 patients underwent KTP in-office laser treatment during the review period. There was both a clinically and statistically significant decrease in the ESS after in-office laser treatment, baseline ESS -7.24, SD 1.71, follow up ESS -4.92, SD 1.83 (mean difference 2.94, 95% confidence interval, 1.83-4.04, P < .0001). There were no reported adverse events or complications associated with the procedure. The mean pain score reported was 0.19, SD 0.75. The average blood loss was 10.8 mL, SD 37.3. The majority of patients (62.5%, 10/16) had no blood loss during the procedure.

Conclusion: Clinically and statistically significant decreases were noted in the ESS of HHT patients after in-office KTP laser photocoagulation. The procedure was well tolerated by patients, without any adverse events or complications.

Level Of Evidence: 4 Laryngoscope, 131:E689-E693, 2021.
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http://dx.doi.org/10.1002/lary.28824DOI Listing
March 2021

Self-reported anosmia and dysgeusia as key symptoms of coronavirus disease 2019.

CJEM 2020 09;22(5):595-602

Department of Otolaryngology - Head and Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, ON.

Objectives: To slow down the transmission of coronavirus disease 2019 (COVID-19), it is important to identify specific symptoms for effective screening. While anosmia/hyposmia and dysgeusia/ageusia have been identified as highly prevalent symptoms, there are wide geographic variations, necessitating the regional evaluation of the prevalence of the symptoms.

Methods: A cross-sectional study was performed to evaluate the self-reported symptoms among adults (over 18 years old) who underwent COVID-19 tests at an ambulatory assessment centre. We identified 1,345 patients (102 positive and 1,243 negative) who visited the assessment centre between March 16 and April 15, 2020. We randomly sampled negative patients in a 1:3 ratio. The primary outcome was the prevalence of self-reported anosmia/hyposmia and dysgeusia/ageusia. Logistic regression was performed to evaluate the association between COVID-19 positivity and loss of smell and taste.

Results: Fifty-six of 102 (50%) positive patients and 72 of 306 (23.5%) negative patients completed the survey. Anosmia/hyposmia and dysgeusia/ageusia were more prevalent among COVID-19 positive patients (41.1% v. 4.2%, p < 0.001 for smell and 46.4% v. 5.6%, p < 0.001 for taste). Anosmia/hyposmia and dysgeusia/ageusia were independently highly associated with COVID-19 positivity (adjusted odds ratios 14.4 and 11.4 for smell and taste, respectively).

Conclusion: In this Canadian study, smell and taste loss may be key symptoms of COVID-19. This evidence can be helpful in the clinical diagnosis of COVID-19, particularly settings of limited testing capacity.
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http://dx.doi.org/10.1017/cem.2020.420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7308595PMC
September 2020

Considerations for head and neck oncology practices during the coronavirus disease 2019 (COVID-19) pandemic: Wuhan and Toronto experience.

Head Neck 2020 06 27;42(6):1202-1208. Epub 2020 Apr 27.

Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.

The practices of head and neck surgical oncologists must evolve to meet the unprecedented needs placed on our health care system by the Coronavirus disease 2019 (COVID-19) pandemic. Guidelines are emerging to help guide the provision of head and neck cancer care, though in practice, it can be challenging to operationalize such recommendations. Head and neck surgeons at Wuhan University faced significant challenges in providing care for their patients. Similar challenges were faced by the University of Toronto during the severe acute respiratory syndrome (SARS) pandemic in 2003. Herein, we outline our combined experience and key practical considerations for maintaining an oncology service in the midst of a pandemic.
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http://dx.doi.org/10.1002/hed.26205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7267482PMC
June 2020

Nasal nitric oxide as a long-term monitoring and prognostic biomarker of mucosal health in chronic rhinosinusitis.

Int Forum Allergy Rhinol 2020 Aug 7;10(8):971-977. Epub 2020 Jun 7.

Division of Rhinology, Department of Otolaryngology-Head & Neck Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.

Background: Nasal nitric oxide (nNO) is a potential biomarker of chronic rhinosinusitis (CRS), and correlates well with endoscopic and radiologic severity of disease. However, the long-term profile of nNO as a biomarker is not established in the literature. The objectives of our study were to examine whether nNO can maintain this correlation in a 5-year follow-up after endoscopic sinus surgery (ESS) and to investigate whether nNO value can be used to prognosticate revision rates in patients with CRS.

Methods: We enrolled CRS patients 5 years after initial ESS at our institution. Patients underwent initial ESS at our institution between January 2013 and January 2015. Patients prospectively had the following measurements at baseline, 1 month, 6 months, and 5 years post-ESS: nNO levels, Lund-Kennedy Endoscopy Score (LKES), and 22-item Sino-Nasal Outcome Test-22 (SNOT-22) score. We also compared the nNO levels between patients who underwent revision ESS and those who did not.

Results: There were 32 patients included in the study with 8 patients undergoing revision ESS during the 5-year follow-up. nNO levels were elevated at 1 month, 6 months, and 5 years post-ESS compared to baseline. A significant negative correlation between nNO and LKES was found at 5 years post-ESS. nNO levels were significantly reduced at baseline and 6 months post-ESS in the revision cohort compared to the nonrevision cohort despite having comparable radiologic severity.

Conclusion: nNO may serve as a noninvasive long-term biomarker to monitor sinus disease severity and to prognosticate results in patients with CRS. This has implications for potential integration into clinical practice.
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http://dx.doi.org/10.1002/alr.22581DOI Listing
August 2020

Quality Indicators for the Diagnosis and Management of Acute Bacterial Rhinosinusitis.

Am J Rhinol Allergy 2020 Jul 24;34(4):519-531. Epub 2020 Mar 24.

Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.

Background: Acute bacterial rhinosinusitis (ABRS) is a highly prevalent disease that is treated by a variety of specialties, including but not limited to, family physicians, emergency physicians, otolaryngology-head and neck surgeons, infectious disease specialists, and allergy and immunologists. Unfortunately, despite high-quality guidelines, variable and substandard care continues to be demonstrated in the treatment of ABRS.

Objective: This study aimed to develop ABRS-specific quality indicators (QIs) to evaluate the diagnosis and management that reduces symptoms, improves quality of life, and prevents complications.

Methods: A guideline-based approach, proposed by Kötter et al., was used to develop QIs for ABRS. Candidate indicators (CIs) were extracted from 4 guiding documents and evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND/University of California at Los Angeles appropriateness methodology.

Results: Twenty-nine CIs were identified after literature review and evaluated by our panel. Of these, 5 CIs reached consensus as being appropriate QIs, with 1 requiring additional discussion. After a second round of evaluations, the panel selected 7 QIs as appropriate measures of high-quality care.

Conclusion: This study proposes 7 QIs for the diagnosis and management of patients with ABRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay for performance initiatives.
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http://dx.doi.org/10.1177/1945892420912158DOI Listing
July 2020

Hearing loss and hearing needs in an adult homeless population: a prospective cross-sectional study.

CMAJ Open 2020 Jan-Mar;8(1):E199-E204. Epub 2020 Mar 16.

Department of Otolaryngology - Head and Neck Surgery (Noel, Mok, Wu, Eskander, Yao, Zirkle, Lin), University of Toronto; Institute of Health Policy, Management and Evaluation (Noel), Dalla Lana School of Public Health, University of Toronto; Department of Otolaryngology - Head & Neck Surgery (Eskander, Syrett, Lin), Sunnybrook Health Sciences Centre; Li Ka Shing Knowledge Institute (Hwang, Lee); Division of General Internal Medicine (Hwang), Department of Medicine, University of Toronto; Departments of Ophthalmology (Lichter), Audiology (Reekie, Smith) and Otolaryngology - Head & Neck Surgery (Zirkle, Lee), St. Michael's Hospital, Toronto, Ont.

Background: Given that hearing loss is associated with increased social isolation, reduced earning potential and neurocognitive disease, findings of uncorrected hearing loss in the homeless population have important policy implications. We sought to estimate the prevalence of hearing impairment in an adult homeless population.

Methods: We recruited adult (age ≥ 18 yr) homeless people across 10 homeless shelters in Toronto between April and June 2018 using a 2-stage sampling technique. Participants were interviewed by 1 interviewer using a modified survey that had been used in previous studies looking at other health needs in homeless populations. A comprehensive head and neck examination and audiometric evaluation were performed in each participant by an otolaryngologist and an audiologist. Descriptive statistics were estimated. Audiometric data were standardized directly for age and sex to facilitate direct comparisons with the general Canadian population.

Results: Of the 132 people invited, 100 (75.8%) agreed to participate. The median age was 46 (interquartile range [IQR] 37-58) years. The median duration of homelessness was 24 (IQR 6-72) months. Although most participants (78) had some form of extended health care benefits through social assistance, only 22/78 (28%) were aware that hearing tests and hearing aids were covered through these programs. After direct standardization for age and sex, the proportions of participants with a speech-frequency and high-frequency hearing loss were 39.5% (95% confidence interval [CI] 30.4%-49.3%) and 51.9% (95% CI 42.2%-61.4%), respectively. Nineteen participants were hearing aid candidates, only 1 of whom owned functional hearing aids. Rates of speech-frequency hearing loss (39.5%, 95% CI 30.4%-49.3% v. 19.2%, 95% CI 16.9%-21.7%) and high-frequency hearing loss (51.9%, 95% CI 42.2%-61.4% v. 35.5%, 95% CI 33.1%-37.7%) were substantially higher than in the general Canadian population.

Interpretation: Our results suggest that homeless adults have a high prevalence of hearing impairment, even when living within a system of universal health insurance; awareness of health care benefits through social assistance programs was poor. Results from this study may prompt initiatives surrounding homeless outreach and health screening.
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http://dx.doi.org/10.9778/cmajo.20190220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082104PMC
February 2021

Complete versus Limited Endoscopic Sinus Surgery for Chronic Rhinosinusitis in Adults with Cystic Fibrosis.

Otolaryngol Head Neck Surg 2020 Apr 25;162(4):572-580. Epub 2020 Feb 25.

Department of Otolaryngology-Head and Neck Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.

Objective: To examine the effects of the extent of endoscopic sinus surgery (ESS) on pulmonary health, including the pulmonary exacerbations and lung function in patients with cystic fibrosis (CF).

Study Design: Retrospective cohort study.

Setting: Tertiary health care center.

Subjects And Methods: A retrospective review of patients with CF who underwent ESS at St. Michael's Hospital between 1999 and 2016 was performed. Two groups of patients were identified based on the surgical extent: (1) complete (maxillary antrostomy, complete ethmoidectomy, sphenoidotomy, and frontal sinusotomy) and (2) limited (any ESS that involved less than complete). Primary outcomes included the number of pulmonary exacerbations (the use of oral or intravenous [IV] antibiotics), number of hospital admissions and hospital days during a 2-year pre- and postoperative period, and pulmonary function outcomes during a 1-year pre- and postoperative period.

Results: There were 70 procedures (30 complete and 40 limited) among 57 patients. Baseline characteristics were similar between the groups. Complete ESS group had a significant reduction in the oral antibiotic use compared to the limited ESS group (median, -1.0 [interquartile range (IQR), -2 to 0] in complete vs 0 [IQR, -1 to 1] in limited, = .028). There was no difference in the use of IV antibiotics, number and duration of admissions, or rate of lung function change between the 2 groups.

Conclusion: Complete ESS may reduce mild forms of pulmonary exacerbations as shown in the decreased use of oral antibiotics. Overall, ESS does not significantly modify pulmonary outcomes in patients with CF.
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http://dx.doi.org/10.1177/0194599820904956DOI Listing
April 2020

Prospective pilot study of Floseal® for the treatment of anterior epistaxis in patients with hereditary hemorrhagic telangiectasia (HHT).

J Otolaryngol Head Neck Surg 2019 Oct 15;48(1):48. Epub 2019 Oct 15.

Department of Otolaryngology - Head and Neck Surgery, Ottawa Hospitals, University of Ottawa, Ottawa, Canada.

Background: Epistaxis is the most common symptom of hereditary hemorrhagic telangiectasia (HHT), affecting more than 98% of adults with HHT, with significant impact on quality of life. Floseal® has been shown to be effective for the management of anterior epistaxis, but has yet to be thoroughly evaluated in this population. Our goal was to evaluate the efficacy of Floseal® for managing acute anterior epistaxis in patients with HHT.

Methods: A pilot prospective clinical trial was conducted at two tertiary referral centres, St. Michael's Hospital, Toronto, Canada and The Ottawa Hospital, Ottawa, Canada. All patients with HHT presenting with acute anterior epistaxis to the two study centres, who enrolled in the study, received Floseal® treatment. The primary outcome measures were achievement of hemostasis and changes in the Epistaxis Severity Score (ESS) between baseline and one-month follow up. Secondary outcome measure included clinical assessment of the nasal cavity.

Results: Seven patients were included in the final analysis. All patients underwent treatment of anterior epistaxis with Floseal® and achieved control of epistaxis within 15-min post-application. Application of Floseal® was well tolerated, with patients reporting a pain score of 3 ± 3.13 out of 10. There was no statistically significant difference noted in ESS scores pre-treatment and one-month follow up, 6.27 ± 2.42 vs. 4.50 ± 2.44, p = 0.179. There was a significant improvement clinically on exam of the nasal cavity between baseline and at one-month follow up, indicated by a decrease in the clinical assessment score, 17.29 ± 7.70 vs. 9.57 ± 7.81 (p = 0.0088).

Conclusions: Patients with HHT presenting with acute epistaxis were able to achieve hemostasis with one application of Floseal®, with the procedure being very well tolerated with minimal pain. Although there was no significant change in ESS scores, clinical assessment of the nasal cavity revealed significant improvement at one-month follow up post treatment with Floseal®.

Trial Registration: This multi-centered prospective clinical trial was registered with ClinicalTrials.gov ( NCT02638012 ). Registered on December 22, 2015.
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http://dx.doi.org/10.1186/s40463-019-0379-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6794791PMC
October 2019

Quantitative Analysis of Surgical Working Space During Endoscopic Skull Base Surgery.

J Neurol Surg B Skull Base 2019 Oct 26;80(5):469-473. Epub 2018 Nov 26.

Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.

 Selective dissection of intranasal anatomy may improve visualization and maneuverability at the skull base. We aimed to quantify the dimensions of working space and angles achieved following sequential removal of intranasal structures using an endoscopic transphenoidal approach to the skull base.  Cone beam computed tomography scans of four cadaveric heads were obtained for registration of an optical tracking system. Each head was sequentially dissected: (1) sphenoidotomy and limited posterior septectomy, (2) unilateral partial middle turbinectomy, (3) bilateral partial middle turbinectomy, and (4) wide posterior septectomy. The maximal craniocaudal and mediolateral distance (mm) and angle (degrees) reached were calculated at the sphenoid face and sella. Data were analyzed using descriptive statistics and tests of statistical significance. The significance level was set at  ≤  0.05.  A significant improvement in both dimensions of working space was observed with each stage of dissection at the level of the sphenoid face. Maximal working space was achieved following bilateral middle turbinectomy and wide posterior septectomy with a 38 and 29% increase in working space in the mediolateral and craniocaudal dimensions, respectively. The largest stepwise increase in working space was observed with unilateral middle turbinectomy (mediolateral: 24 ± 3 mm and craniocaudal: 20 ± 3 mm). A trend toward improved degrees of visualization was observed with each stage of dissection but was not statistically significant.  Approaches to the skull base can be enhanced by selective unilateral/bilateral partial middle turbinectomy and posterior septectomy being performed to improve visualization and maximize surgical working freedom.
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http://dx.doi.org/10.1055/s-0038-1675591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6748850PMC
October 2019

Benefits and harms of aspirin desensitization for aspirin-exacerbated respiratory disease: a systematic review and meta-analysis.

Int Forum Allergy Rhinol 2019 12 13;9(12):1409-1419. Epub 2019 Sep 13.

Department of Otolaryngology-Head & Neck Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.

Background: Aspirin desensitization is increasingly recommended for the treatment of aspirin-exacerbated respiratory disease (AERD). The objective of this study is to systematically review the efficacy and safety of aspirin desensitization in patients with AERD.

Methods: We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and World Health Organization (WHO) International Clinical Trials Registry Platform from inception to January 5, 2019. We included randomized trials and comparative observational studies in any language. Data extraction and risk of bias assessment were performed in duplicate independently.

Results: Five randomized controlled trials (RCTs) enrolled 233 patients with AERD. Compared to placebo, aspirin desensitization (mean daily dose 800 mg) improved quality of life (risk ratio [RR] 2.00; 95% confidence interval [CI], 1.31 to 3.06; heterogeneity measure [I ] = 0%; risk difference [RD] +24%; 22-item Sino-Nasal Outcome Test [SNOT-22] scale [0 to 110, higher worse]; mean difference [MD] -10.27 [95% CI, -6.39 to -14.15]; moderate-certainty); and respiratory symptoms (RR 2.20 [95% CI, 1.55 to 2.73], I = 34%, RD +36%; American Academy of Otolaryngology (AAO) scale [0 to 20, higher worse]; MD -2.56 [95% CI,-1.12 to -3.92]; high-certainty). Aspirin desensitization increased adverse events severe enough to cause treatment discontinuation (major bleeding, gastritis, asthma exacerbation, or rash causing drug discontinuation, RR 4.39 [95% CI, 1.43 to 13.50], I = 0%, RD +11%, moderate-certainty), and gastritis (RR 3.84 [95% CI, 1.12 to 13.19], I = 0%, RD +9%, low-certainty). Findings were robust to sensitivity analyses. Two available observational studies were not informative because they lacked adjustment for confounders and/or contemporaneous controls.

Conclusion: In patients with AERD, moderate-certainty and high-certainty evidence shows that aspirin desensitization meaningfully reduces symptoms of rhinosinusitis and improves quality of life, but results in a significant increase in adverse events.
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http://dx.doi.org/10.1002/alr.22428DOI Listing
December 2019

Wait times for endoscopic sinus surgery influence patient-reported outcome measures in patients with chronic rhinosinusitis who fulfill appropriateness criteria.

Int Forum Allergy Rhinol 2019 04 10;9(4):396-401. Epub 2018 Dec 10.

Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.

Background: Previous studies on the impact of wait times for endoscopic sinus surgery (ESS) in medically recalcitrant chronic rhinosinusitis (rCRS) have not examined its influence on the 5 distinct symptoms domains of the 22-item Sino-Nasal Outcome Test (SNOT-22), and have not applied evidence-based surgical indications. Our primary study objective was to investigate the impact of ESS wait times on postoperative SNOT-22 global and symptom domain scores in patients with rCRS deemed "appropriate" surgical candidates.

Methods: This was a retrospective analysis of adult patients with rCRS undergoing ESS, categorized as "appropriate" surgical candidates. Primary outcome measure was change in SNOT-22 global/symptom domain score (preoperative - 6-month postoperative). Correlational analyses were performed between wait time and change in SNOT-22 global and symptom domain scores. For significant negative correlations, the threshold wait time to generate a worsening in health-related quality-of-life (HRQoL) equivalent to the mean clinically important difference (MCID) was calculated.

Results: A total of 104 patients with a mean ± standard deviation (SD) wait time of 310.8 ± 155.9 days were analyzed. Postoperative SNOT-22 global and symptom domain scores significantly improved postoperatively. Wait time for ESS was negatively correlated with change in SNOT-22 global, rhinologic, extranasal rhinologic, and ear/facial domain scores (p < 0.05), and a wait time threshold of 287, 452, 421, and 381 days corresponded to a decrease equivalent to the MCID, respectively.

Conclusion: We identified less improvement in HRQoL after ESS with increasing surgical wait time. Moreover, prolonged wait times may result in less improvement in disease-specific symptoms, but do not appear to worsen psychological or sleep dysfunction.
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http://dx.doi.org/10.1002/alr.22257DOI Listing
April 2019

Impact of Septal Deviation on Recurrent Chronic Rhinosinusitis after Primary Surgery: A Matched Case-Control Study.

Otolaryngol Head Neck Surg 2019 05 27;160(5):922-927. Epub 2018 Nov 27.

1 Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada.

Objective: To evaluate the impact of untreated deviated nasal septum (DNS) on recalcitrant chronic rhinosinusitis (CRS) among patients undergoing revision endoscopic sinus surgery (ESS).

Study Design: Case-control study.

Setting: Tertiary academic center.

Subjects And Methods: We performed a retrospective review of 489 patients undergoing revision ESS for CRS at a tertiary academic center. Patients undergoing septoplasty were matched to nonseptoplasty controls based on age and sex. Preoperative Lund-Mackay score (LMS) was compared between cohorts. Linear regression was used to identify predictors of LMS and ostiomeatal complex (OMC) obstruction.

Results: Thirty-six matched pairs (72 patients) were selected for analysis: 36 undergoing septoplasty and revision ESS and 36 undergoing revision ESS alone. Compared with nonseptoplasty controls, the septoplasty group had a significantly higher average LMS (17.8 vs 14.6, P = .02) and a greater rate of OMC obstruction (89% vs 61%, P < .01). The septoplasty group also had significantly higher opacification scores in the maxillary (1.5 vs 1.2, P = .03) and posterior ethmoid (1.8 vs 1.4, P = .02) sinuses. On multivariable analysis, DNS was an independent predictor of LMS ( P = .02) and OMC obstruction ( P < .01).

Conclusion: Untreated DNS is associated with radiographic markers of CRS severity among patients undergoing revision ESS and may contribute to the multifactorial pathogenesis of persistent CRS.
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http://dx.doi.org/10.1177/0194599818815106DOI Listing
May 2019

Quality indicators for the diagnosis and management of chronic rhinosinusitis.

Int Forum Allergy Rhinol 2018 12 12;8(12):1369-1379. Epub 2018 Jul 12.

Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada.

Background: Chronic rhinosinusitis (CRS) has been identified as a high-priority disease category for quality improvement. To this end, this study aimed to develop CRS-specific quality indicators (QIs) to evaluate diagnosis and management that relieves patient discomfort, improves quality of life, and prevents complications.

Methods: A guideline-based approach, proposed in 2012 by Kötter et al. was used to develop QIs for CRS. Candidate indicators (CIs) were extracted from 3 practice guidelines and 1 international consensus statement on the diagnosis and management of CRS. Guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND Corporation-University of California, Los Angeles (RAND/UCLA) appropriateness methodology.

Results: Thirty-nine CIs were identified after literature review and evaluated by our panel. Of these, 9 CIs reached consensus as being appropriate QIs, with 4 requiring additional discussion. After a second round of evaluations, the panel selected 9 QIs as appropriate measures of high-quality care.

Conclusion: This study proposes 9 QIs for the diagnosis and management of patients with CRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay-for-performance initiatives.
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http://dx.doi.org/10.1002/alr.22161DOI Listing
December 2018

Solitary Infiltrating Meningioma of the Trochlear Nerve: Case Report.

J Neurol Surg Rep 2018 Apr 25;79(2):e63-e64. Epub 2018 Jun 25.

Department of Pathology and Department of Neurosurgery, NorthShore University Health System, Evanston, Illinois, United States.

We report the case of a solitary meningioma infiltrating the trochlear nerve, the first in a patient without a neurocutaneous disorder or cavernous sinus involvement. The patient presented with diplopia was found to have a focal enhancing mass encompassing the trochlear nerve. Following surgical resection, pathological examination showed meningioma infiltrating the nerve itself, demonstrated on the included pathology images. A review of the literature and discussion of meningiomas infiltrating cranial nerves are included.
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http://dx.doi.org/10.1055/s-0038-1661005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6018071PMC
April 2018

Endoscopic management of maxillary sinus inverted papilloma attachment sites to minimize disease recurrence.

J Otolaryngol Head Neck Surg 2018 Apr 4;47(1):24. Epub 2018 Apr 4.

Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.

Background: Inverted papillomas (IPs) are benign neoplasms, most commonly arising from the mucosal lining of the maxillary sinus. IPs can have single or multifocal sites of attachment. Although pedicle location is an important factor to consider in surgical planning, it is less clear whether the location or number of IP attachment sites hold any prognostic value. Herein, we aimed to determine the prognostic significance of the number and location of attachment sites of IPs originating from the maxillary sinus when managed by a pure endoscopic approach.

Methods: This was a single-center, single-surgeon retrospective chart review. Patients with maxillary sinus IPs who were managed by endoscopic approaches only, from January 1, 2010 to June 30, 2016, were identified. Demographic data, operative technique, number and location of IP attachment sites, follow-up duration, recurrence, and presence of malignant transformation were captured.

Results: Twenty-eight maxillary IP patients (61% males) were included, with a mean age of 54.9 (standard deviation (SD): 16.5) years. Approximately 36% of patients were referred from other institutions for management of recurrent IPs after failing previous surgical treatment. All patients were managed with an endoscopic approach, and all required an endoscopic medial maxillectomy to facilitate access to the maxillary sinus. At a mean follow-up of 31.1 (SD: 22.6) months, there were no recurrences identified. IPs with single (46%) and multifocal (54%) attachments were predominately to the medial and lateral walls. Maxillary IPs with multifocal attachments most frequently involved 2-3 walls of the sinus. Osteitis (36%) was commonly seen.

Conclusion: IPs originating from the maxillary sinus frequently had multifocal attachments, but this did not impact disease recurrence. Despite the surgical challenges of accessing all of the maxillary sinus walls, IPs originating from the maxillary sinus can be effectively managed via a pure endoscopic approach.
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http://dx.doi.org/10.1186/s40463-018-0271-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885307PMC
April 2018

Combined Open and Endoscopic Endonasal Skull Base Resection of a Rare Endometrial Carcinoma Metastasis.

J Neurol Surg Rep 2018 Jan 22;79(1):e9-e13. Epub 2018 Feb 22.

Department of Neurosurgery, NorthShore University Health System, Evanston, Illinois, United States.

In the absence of significant extracranial disease, patients with solitary brain metastases have shown benefit with resection. Brain lesions due to endometrial cancer are uncommon, and the only described skull base involvement is limited to the pituitary gland. We report the case of a 60-year-old female with endometrial cancer who presented with weeks of right cheek pain and numbness that was accompanied by headaches. We describe the magnetic resonance imaging (MRI) findings and surgical resection of a solitary endometrial metastasis involving the infratemporal fossa, middle fossa, cavernous sinus, trigeminal nerve, and nasal sinuses. Due to extensive nasal and lateral involvement, a combined open and endoscopic approach was planned. The patient was discharged home without complication. She underwent adjuvant radiotherapy. Despite its suspected indolent course, intracranial endometrial adenocarcinoma metastases are gaining higher prevalence. This case report documents the first direct neural spread of an endometrial primary, and highlights the potential for extra-axial sites of metastasis.
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http://dx.doi.org/10.1055/s-0038-1635098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5823696PMC
January 2018

Extent of surgery in endoscopic transsphenoidal skull base approaches and the effects on sinonasal morbidity.

Am J Rhinol Allergy 2018 Jan;32(1):52-56

From the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.

Background: Endoscopic transsphenoidal skull base surgery (ETSS) is now considered the criterion standard approach for resection of pituitary adenomas and other midline anterior skull base lesions. Normal sinonasal structures are resected during ETSS, which raises concerns for nasal morbidity and patient-based outcome.

Objective: To perform a surgical outcome assessment by examining whether the extent of ETSS approaches affected patient-specific sinonasal quality of life as measured by the 22-item Sino-Nasal Outcome Test (SNOT-22).

Methods: A single-center prospective cohort study of patients operated on by the same skull base team between 2012 and 2016. Patients with completed pre- and postoperative SNOT-22 were included. The primary outcome was SNOT-22 scores at preoperative, 0-1 month, 2-4 months, >5 months follow-up. Age, sex, tumor pathology, surgical procedure, and intraoperative cerebral spinal fluid leak repair were also obtained.

Results: Of the 249 ETSS performed, 148 patients (59%) had at least one completed SNOT-22; 45 (18%) met the inclusion criteria. Sinonasal quality of life based on SNOT-22 at the 0-1-month follow-up was significantly worse than the presurgical levels (p < 0.05). However, there was a return of SNOT-22 scores to preoperative levels at 2-4 months (p > 0.05), which was sustained at >5 months (p > 0.05). Factors such as the extent of ETSS, a previous nasal surgery, repair of an intraoperative cerebral spinal fluid leak, and the tumor pathology did not affect SNOT-22 scores at any follow-up intervals (p > 0.05).

Conclusion: Sinonasal quality of life worsened after ETSS at 0-1 month follow-up but returned to preoperative levels at 2-4 months and remained at postoperative levels >5 months. Analysis of these data will allow us to educate our patients that the anticipated nasal morbidity after ETSS is usually only transient and should be expected to recover to preoperative levels.
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http://dx.doi.org/10.2500/ajra.2018.32.4499DOI Listing
January 2018

Paraneoplastic Optic Neuropathy and Pineal Germinoma With Collapsin Response-Mediating Protein Antibodies.

J Neuroophthalmol 2018 Jun;38(2):198-199

Departments of Ophthalmology and Visual Sciences (SYS), The University of Chicago, Chicago, Illinois; Department of Ophthalmology (SYS), Dean McGee Eye Institute, University of Oklahoma, Oklahoma City, Oklahoma; Department of Neurology (JHP), NorthShore University Health System, Glenview, Ilinois; Departments of Ophthalmology and Visual Sciences (SK), NorthShore University Health System, Glenview, Illinois; and Department of Pathology (JML), NorthShore University Health System, Evanston, Illinois.

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http://dx.doi.org/10.1097/WNO.0000000000000619DOI Listing
June 2018