Publications by authors named "Timothy L Smith"

279 Publications

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

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

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

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

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

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

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

Endotyping Chronic Rhinosinusitis Based on Olfactory Cleft Mucus Biomarkers.

J Allergy Clin Immunol 2021 Feb 4. Epub 2021 Feb 4.

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

Background: Although chronic rhinosinusitis (CRS) is considered the most treatable form of olfactory dysfunction (OD), there has been relatively little clinical attention focused on assessing endotypes as they pertain to olfactory loss.

Objective: The goal of this study was to explore inflammatory endotypes in CRS using an unsupervised cluster analysis of olfactory cleft (OC) biomarkers in a phenotype-free approach.

Methods: Patients with CRS were prospectively recruited and psychophysical olfactory testing, Questionnaire of Olfactory Dysfunction (QOD-NS), and bilateral OC endoscopy were obtained. Mucus was collected from the OC and evaluated for 26 biomarkers using principal component analysis (PCA). Cluster analysis was performed using only OC biomarkers and differences in olfactory measures were compared across clusters.

Results: 198 subjects (128 with CRS and 70 controls) were evaluated. Evaluation of OC biomarkers indicated 6 principal components, explaining 69.50% of the variance, with Type 2, mixed Type1/Th17, growth factor, and neutrophil chemo-attractant inflammatory signatures. A total of 10 clusters were identified which differed significantly in frequency of controls, CRSsNP, and CRSwNP across the clusters (LRT χ=178.64, p<0.001). Olfactory measures differed significantly across clusters, including olfactory testing, QOD-NS, and OC endoscopy (p<0.001 for all).

Conclusion: Clustering based solely on OC biomarkers can organize patients into clinically meaningful endotypes that discriminate between CRS and controls. Validation studies are necessary to confirm these findings and further refine olfactory endotypes.

Clinical Implications: Olfactory biomarkers can be utilized to organize chronic rhinosinusitis into endotypes that reflect underlying inflammation. These endotypes are likely to be the foundation of personalized treatment for CRS-related olfactory dysfunction.
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http://dx.doi.org/10.1016/j.jaci.2021.01.021DOI Listing
February 2021

Race in Rhinology Clinical Trials: A Decade of Disparity.

Laryngoscope 2021 Jan 25. Epub 2021 Jan 25.

Department of Otolaryngology Head and Neck Surgery, Columbia University Irving Medical Center, New York, New York, U.S.A.

Objective/hypothesis: The aim of this study is to assess the ethnic and racial demographics of patients enrolled in prospective chronic rhinosinusitis (CRS) studies relative to the corresponding geographic demographics of the United States (U.S.) census data.

Study Design: Systematic Review and Population analysis.

Methods: A systematic review was performed to identify CRS clinical trials, conducted in the U.S. and published between 2010 and 2020 in which patients were prospectively enrolled. Pooled racial and ethnicity data were compared to national and corresponding regional census data.

Results: Eighty-three studies were included, comprising 12,027 patients. 50.4% were male and the average age was 49.2 years. 8,810 patients underwent a surgical procedure. Of the 12,027 patients, 81.67% were identified as White, 5.35% as Black, 1.27% as Asian, 0.02% as Pacific Islander, 0.12% as American Indian, and 11.57% were classified as Other. The racial and ethnic composition of the pooled study population differs significantly from the national U.S. census data with the underrepresentation of each minority population (P ≤ .0002). Regional sub-analyses yield variable results. In the Northeast and West, there was an underrepresentation of all minority populations. In the South and Midwest, Black enrollment was similar to the U.S. census data, while all other minorities were underrepresented.

Conclusions: The racial and ethnic composition of patients enrolled in prospective CRS clinical trials differs significantly from the demographics of the U.S.

Population: The generalizability and external validity of findings derived from studies comprised of demographically mismatched populations has not been established. Future efforts to enroll more representative populations should be emphasized by the research community, funding bodies, and editorial boards.

Level Of Evidence: N/A Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29371DOI Listing
January 2021

Mucosal Eosinophilia and Neutrophilia Are Not Associated With QOL or Olfactory Function in Chronic Rhinosinusitis.

Am J Rhinol Allergy 2021 Jan 11:1945892420987439. Epub 2021 Jan 11.

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

Background: Chronic rhinosinusitis (CRS) is often differentiated by histopathologic phenotypes (eosinophilic versus neutrophilic), which may impact disease severity measures and outcomes. As such, it has been suggested that counts of cellular elements be included as part of a standard pathological report following endoscopic sinus surgery (ESS).

Objectives: This cross-sectional study evaluated associations of mucosal eosinophilia and neutrophilia with measures of quality-of-life (QoL) and olfactory function.

Methods: Patients with medically refractory CRS completed the SNOT-22 survey and Brief Smell Identification Test (BSIT) at enrollment. In addition, baseline Lund-Mackay computed tomography (CT) and Lund-Kennedy endoscopy scores were collected. Ethmoid mucosa was biopsied during ESS and reviewed using microscopy to quantify densest infiltrate of eosinophils or neutrophils per high-powered-field (HPF). Eosinophilic CRS (eCRS) and neutrophilic CRS (nCRS), both with and without nasal polyposis (NP), were compared across SNOT-22 and BSIT scores.

Results: 77/168 patients demonstrated mucosal eosinophilia (eCRS) while a total of 42/168 patients demonstrated mucosal neutrophilia (nCRS). After adjusting for polyp status, 35/168 had eCRSsNP, 42/168 eCRSwNP, 75/168 non-eCRSsNP, 16/168 non-eCRSwNP. Additionally, 22/161 were noted to have nCRSsNP, 20/161 nCRSwNP, 84/161 non-nCRSwNP, and 35/161 non-nCRSsNP. A small subset of patients demonstrated both eosinophilia and neutrophilia: 14 CRSwNP and 7 CRSsNP. When evaluating average Lund-Mackay Scores (LMS), significant differences existed between non-eCRSsNP and eCRSsNP (p = 0.006). However, after controlling for nasal polyps, eosinophilia did not significantly associate with differences in the Lund-Kennedy Score. Neutrophilia did not significantly associate with any changes in LMS or LKS after controlling for NP. Eosinophilic and neutrophilic histopathologic subtypes did not significantly associate with differences in baseline SNOT-22 or BSIT measures after controlling for NP.

Conclusion: Neither the presence of mucosal eosinophilia nor mucosal neutrophilia demonstrated significant associations with SNOT-22 quality-of-life or BSIT olfactory function scores when controlling for comorbid nasal polyposis.
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http://dx.doi.org/10.1177/1945892420987439DOI Listing
January 2021

Olfactory cleft mucus proteome in chronic rhinosinusitis: a case-control pilot study.

Int Forum Allergy Rhinol 2020 Dec 4. Epub 2020 Dec 4.

Department of Cell and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, SC.

Background: Mechanisms of smell loss in chronic rhinosinusitis (CRS) are still unclear and likely multifactorial. Little attention has been given to olfactory cleft (OC) mucus proteins involved in odorant binding and metabolizing enzymes and their potential role in smell loss.

Methods: Mucus from the OC was sampled from patients with CRS (n = 20) and controls (n = 10). Liquid chromatography and mass spectrometry were performed, followed by data processing so that protein groups could be identified, quantified, and compared. Hierarchical clustering and bioinformatic analysis were performed on significantly different proteins to explore for enrichment in known biologic pathways.

Results: A total of 2514 proteins were found in OC mucus from all 30 subjects. Significant differences in protein abundance were found between CRS and controls, including both CRSsNP (n = 351 proteins; log fold change range: -3.88 to 6.71) and CRSwNP (n = 298 proteins; log fold change range: -4.00 to -6.13). Significant differences were found between patients with normosmia and those with dysosmia (n = 183; log fold change range: -3.62 to -2.16) and across groups of interest for a number of odorant binding proteins and metabolizing enzymes.

Conclusion: OC mucous in CRS displays a rich and abundant array of proteins, many of which have been implicated in odorant transport and metabolization in animal studies. Significant differences in the olfactory mucus proteome were seen between CRS subtypes and controls, as well as between those with normal and abnormal olfaction. Further study should confirm these findings and explore the role individual proteins play in odorant transport and metabolization. ©2020 ARSAAOA, LLC.
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http://dx.doi.org/10.1002/alr.22743DOI Listing
December 2020

International Consensus Statement on Rhinology and Allergy: Rhinosinusitis.

Int Forum Allergy Rhinol 2020 Nov 24. Epub 2020 Nov 24.

Capital Medical University.

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. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1002/alr.22741DOI Listing
November 2020

Predictors of survival outcomes in sinonasal squamous cell carcinoma: an analysis of the National Cancer Database.

Int Forum Allergy Rhinol 2020 Nov 23. Epub 2020 Nov 23.

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

Background: Sinonasal squamous cell carcinoma (SNSCC) is a rare malignancy that poses management challenges. Although surgery and chemoradiation therapy (CRT) remain therapeutic mainstays, induction chemotherapy (IC) has emerged as a useful adjunct with locally advanced disease. This study used the National Cancer Data Base (NCDB) to examine treatment outcomes for patients diagnosed with SNSCC.

Methods: The NCDB (2004-2015) was queried for cases with SNSCC. Multivariate hazard regression modeling was used to identify significant predictors of 24-month and 60-month overall survival (OS) including treatment modality.

Results: A total of 3516 patients with SNSCC met inclusion criteria, including 1750 patients (49.8%) treated with surgery ± adjuvant therapy, 1352 (38.5%) treated with definitive radiotherapy (RT) or CRT, 300 (8.5%) who underwent IC followed by definitive CRT, and 114 (3.2%) who received IC followed by surgery and adjuvant therapy. Hazard modeling for confirmed treatment modality significantly associated (p < 0.001) with OS after adjustment. Patients who received surgical intervention ± adjuvant therapy had lower 24-month and 60-month mortality risk compared to definitive RT or CRT (hazard ratio [HR] ≥ 1.97; p < 0.001) or IC followed by definitive CRT (HR ≥ 1.73; p < 0.001). Compared to primary surgery ± adjuvant therapy, patients undergoing IC then surgery had similar 24-month and 60-month OS (p ≥ 0.672) after adjustment.

Conclusion: Multimodality therapy, including surgical intervention, associates with improved OS after multifactorial adjustments. IC followed by surgery associated with improved OS compared to IC, followed by CRT and CRT alone. Study results highlight the utility of surgery toward optimizing OS in patients with SNSCC and demonstrates the potential utility of IC when primary surgical management is not preferred.
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http://dx.doi.org/10.1002/alr.22737DOI Listing
November 2020

IFAR reviewers: best of 2020.

Authors:
Timothy L Smith

Int Forum Allergy Rhinol 2021 Jan 27;11(1):6-7. Epub 2020 Oct 27.

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http://dx.doi.org/10.1002/alr.22721DOI Listing
January 2021

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

Am J Rhinol Allergy 2020 Sep 20:1945892420960671. Epub 2020 Sep 20.

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

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

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

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

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

Conclusion: ESS improved olfactory metrics and restored olfactory function in approximately 50% of patients with CRS to that of healthy controls. Concurrent septoplasty increased the likelihood of achieving normal olfaction, while NP and previous ESS decreased those odds.
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http://dx.doi.org/10.1177/1945892420960671DOI Listing
September 2020

Patient-reported sleep outcomes lack association with mucosal eosinophilia or neutrophilia in patients with chronic rhinosinusitis undergoing functional endoscopic sinus surgery.

Int Forum Allergy Rhinol 2020 Aug 11. Epub 2020 Aug 11.

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

Background: Chronic rhinosinusitis (CRS) is associated with sleep dysfunction, but the underlying pathophysiology is poorly understood. The purpose of this study was to determine if mucosal eosinophilia or neutrophilia were associated with sleep dysfunction severity or altered the improvement in sleep dysfunction following functional endoscopic sinus surgery (FESS).

Methods: A total of 104 patients with medically refractory CRS with nasal polyposis (CRSwNP) and CRS without nasal polyposis (CRSsNP), completed the Pittsburgh Sleep Quality Index (PSQI) before and after FESS. Anterior ethmoid mucosa was collected during FESS and densest infiltrates of eosinophilia and neutrophilia per high-power field (HPF) were determined by microscopy. Eosinophilic (>10 eosinophils/HPF) and neutrophilic (>4 neutrophils/HPF) CRS were then compared to preoperative and postoperative PSQI measures.

Results: Of 104 study participants, 88 (85%) reported preoperative PSQI scores consistent with "poor sleep," (PSQI total > 5). The cohort overall demonstrated significant improvement in poor sleep (65%; χ = 12.03; p < 0.001) 16.8 ± 5.0 months after FESS. Regardless of nasal polyposis, neither eosinophilic nor neutrophilic CRS was associated with differences in mean postoperative PSQI improvement. However, in patients with neutrophilic CRSsNP, there was a significant relationship between severity of neutrophilia and improvement in sleep latency (R = -0.798, p = 0.003) and sleep efficacy (R = -0.777, p = 0.005).

Conclusion: Chronic inflammation has been hypothesized to play a pathophysiologic role in sleep dysfunction associated with CRS. This study suggests that in patients with medically refractory CRS, evidence of mucosal eosinophilia and neutrophilia lack strong associations with patient-reported sleep dysfunction or improvements in sleep quality after FESS, overall. However, neutrophilia may impact sleep latency and efficacy in patients with CRSsNP.
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http://dx.doi.org/10.1002/alr.22678DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7891455PMC
August 2020

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Guidance for contemporary use of biologics in management of chronic rhinosinusitis with nasal polyps: discussion from a National Institutes of Health-sponsored workshop.

Int Forum Allergy Rhinol 2020 Sep 3;10(9):1037-1042. Epub 2020 Jul 3.

Department of Otolaryngology, Head and Neck Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX.

Background: Biologic medications are emerging as options for treating chronic rhinosinusitis with nasal polyps (CRSwNP). Several questions remain regarding patient selection, indications, clinical efficacy, and cost effectiveness.

Methods: In November 2019, a group of physicians and scientists gathered to consider strategies for future studies regarding biologics. During the discussion, gaps in knowledge highlighted a need for a consensus on the present day use of biologics in polyp patients.

Results: The goal of this guideline is to propose recommendations for the current use of biologics in CRSwNP as new evidence continues to emerge and inform practice.

Conclusion: We suggest that physicians evaluate patients on an individual basis and closely monitor for improvement due to the high cost and unknown long-term effects of biologics.
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http://dx.doi.org/10.1002/alr.22633DOI Listing
September 2020

A new decade, a new Editor-in-Chief.

Authors:
Timothy L Smith

Int Forum Allergy Rhinol 2020 06;10(6):705

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http://dx.doi.org/10.1002/alr.22600DOI Listing
June 2020

Measuring Success in the Treatment of Patients with Chronic Rhinosinusitis.

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

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

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

Cost and operative time estimation itemized by component procedures of endoscopic sinus surgery.

Int Forum Allergy Rhinol 2020 06 26;10(6):755-761. Epub 2020 Mar 26.

Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT.

Background: Endoscopic sinus surgery (ESS) is a variable combination of individual procedures. Cost estimates for ESS as a single entity have wide variation, likely influenced by variation in procedures performed. We sought to identify operative time, supply costs, and total procedure cost specific to the component procedure combinations comprising ESS.

Methods: Bilateral ESS cases at 13 Intermountain Healthcare facilities (2008 to 2016) were identified from a database with corresponding cost and time data. Procedure details were obtained by chart review. Least-squares (LS) means of cost (in 2016 US dollars) and time for specific procedures were obtained by multivariable gamma regression models.

Results: Among 1477 bilateral ESS cases with 19 different procedure combinations, operative time ranged from 59.5 (95% confidence interval [CI], 48.6-73.0) minutes for total ethmoid to 147.1 (95% CI, 126.4-171.2) minutes for full ESS with maxillary and sphenoid tissue removal. Sphenoidotomy had lowest total and supply costs (in US dollars) of $2112 (95% CI, $1672-$2667) and $636 (95% CI, $389-$1040), respectively. Total cost was highest for full ESS with maxillary tissue removal at $4640 (95% CI, $4115-$5232). Supply cost was highest for full ESS with maxillary and sphenoid tissue removal at $2191 (95% CI, $1649-$2909).

Conclusion: Operative time and costs for ESS vary depending on the procedures performed, demonstrating the importance of procedure specificity in assessment of ESS time, cost, and, ultimately, value. These procedure-specific estimates of cost enable nonbinary valuation of ESS, appropriate for the multitude of procedure options intended to optimize individual outcomes.
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http://dx.doi.org/10.1002/alr.22554DOI Listing
June 2020

Clinical Research Needs for the Management of Chronic Rhinosinusitis with Nasal Polyps in the New Era of Biologics: A National Institute of Allergy and Infectious Diseases Workshop.

J Allergy Clin Immunol Pract 2020 05 4;8(5):1532-1549.e1. Epub 2020 Mar 4.

National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md. Electronic address:

The development of biologics targeting various aspects of type 2 inflammation for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) will provide clinicians with powerful tools to help treat these patients. However, other therapies are also available, and positioning of biologics in a management algorithm will require comparative trials. In November 2019, the National Institute of Allergy and Infectious Diseases convened a workshop to consider potential future trial designs. Workshop participants represented a wide spectrum of clinical specialties, including otolaryngology, allergy, and pulmonary medicine, as well as expertise in CRSwNP pathophysiology and in trial methodology and statistics. The workshop discussed the current state of knowledge in CRSwNP and considered the advantages and disadvantages of various clinical trial or observational study designs and various clinical outcomes. The output from this workshop, which is presented in this report, will hopefully provide investigators with adequate information and ideas to design future studies and answer critical clinical questions. It will also help clinicians understand the current state of the management of CRSwNP and its gaps and be more able to interpret the new information to come.
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http://dx.doi.org/10.1016/j.jaip.2020.02.023DOI Listing
May 2020

Concordance of self-reported practice patterns of American Rhinologic Society members with the International Consensus Statement of Allergy and Rhinology: Rhinosinusitis.

Int Forum Allergy Rhinol 2020 05 27;10(5):665-672. Epub 2020 Feb 27.

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

Background: The 2016 International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS) is a collaborative distillation of available research and consensus recommendations for the management for chronic rhinosinusitis (CRS). However, implementation of the ICAR:RS recommendations in the reality of clinical practice is not clearly defined.

Methods: An anonymous, web-based survey of the American Rhinologic Society membership was performed in October, 2018. Respondents were asked about the frequency that they recommended the various treatments reviewed in ICAR:RS in the context of medical management for CRS. A 7-point Likert-type scale assessed the frequency of treatment patterns.

Results: A total of 140 members completed the survey (response rate 11.9%). Seventy-two (51.4%) were in practice for 0 to 15 years, 61 (43.6%) completed a rhinology fellowship, and 73 (52.1%) worked in private practice. Disparate treatment patterns were reported for each of the therapies assessed for CRS, including those that were "recommended" or "recommended against" in ICAR:RS. Members with <15 years of experience were more likely to use nasal saline irrigation. Fellowship-trained respondents reported a greater likelihood of using nasal saline irrigation and aspirin desensitization (for patients with aspirin-exacerbated respiratory disease). Practitioners in academic medicine were more likely to utilize aspirin desensitization than those in private practice. Surgeons performing >100 sinus surgeries per year were more likely to use topical antibiotics.

Conclusion: The range of reported treatment patterns identified in this study despite the availability of the ICAR:RS recommendations may suggest the need for improved standardization of CRS management.
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http://dx.doi.org/10.1002/alr.22533DOI Listing
May 2020

Quality-of-life and olfaction changes observed with short-term medical management of chronic rhinosinusitis.

Int Forum Allergy Rhinol 2020 05 3;10(5):656-664. Epub 2020 Feb 3.

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

Background: Patients with chronic rhinosinusitis (CRS) commonly experience both reduced quality of life (QOL) and olfactory dysfunction (OD). Literature on the impacts of appropriate medical therapy (AMT) for CRS on QOL and OD is limited, and the focused design of these studies may limit their applicability to usual clinical practice.

Methods: Adults with symptomatic CRS were prospectively enrolled (November 2016 to October 2018) into an observational, multi-institutional study. Individualized AMT was initiated using standard practice according to evidence-based guidelines. Endoscopy examination (Lund-Kennedy), olfactory function (Sniffin' Sticks) testing, and QOL survey responses (22-item Sino-Nasal Outcome Test [SNOT-22], Questionnaire of Olfactory Disorders-Negative Statements [QOD-NS]) were obtained at enrollment and follow-up.

Results: Baseline measures demonstrated heterogeneity of QOL and OD. After an average of 7.8 weeks, within-subject median SNOT-22 total improved by 39.5% (n = 39, p < 0.001) relative to baseline, including 50% (p = 0.014) improvement for item #21, "Sense of smell/taste." QOD-NS improvement was also statistically significant (p = 0.044). Sniffin' Sticks score relative improvement of 10.9% (n = 33, p = 0.109) was not statistically significant and lacked correlation with SNOT-22 total scores (R = -0.247, p = 0.165) or QOD-NS total scores (R = -0.016, p = 0.930), but correlated moderately with endoscopy score (R = -0.436, p = 0.018).

Conclusions: Participants with varied impacts of CRS, treated with individualized short-term AMT, demonstrated significant improvements in CRS- and olfactory-specific QOL measures, without corresponding improvement in clinically measured olfactory function. Olfactory function changes moderately correlated with endoscopy score changes, but lacked an association with QOL measurements.
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http://dx.doi.org/10.1002/alr.22532DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7220819PMC
May 2020

The Ever-Expanding Balloon-Is Profit Shaping Practice?

Authors:
Timothy L Smith

JAMA Otolaryngol Head Neck Surg 2020 03;146(3):269

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

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http://dx.doi.org/10.1001/jamaoto.2019.4481DOI Listing
March 2020

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

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

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

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

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

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

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

Correlation of mucus inflammatory proteins and olfaction in chronic rhinosinusitis.

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

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

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

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

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

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

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

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

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

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

Study Design: Retrospective outcomes research.

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

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

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

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

Olfactory cleft and sinus opacification differentially impact olfaction in chronic rhinosinusitis.

Laryngoscope 2020 10 11;130(10):2311-2318. Epub 2019 Oct 11.

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

Objectives: Prior studies have indicated that olfactory cleft (OC) opacification correlates with olfaction in patients with chronic rhinosinusitis (CRS). However, the results have been unclear in patients without polyps. The purpose of this study was to further explore the relationship between OC opacification, sinus opacification, and olfactory function in patients with CRS.

Methods: One hundred and forty-eight patients with CRS were prospectively enrolled across five institutions. Olfactory function was evaluated using the Sniffin' Sticks tests (Burghardt, Wedel, Germany) and the 17-item Questionnaire of Olfactory Disorders (QOD-NS). Computed tomography (CT) scans for each patient were acquired and Lund-Mackay scores recorded. Opacification of the OC was determined using OsiriX MD (Pixmeo, Bernex, Switzerland) and correlated with olfaction scores.

Results: A total of 148 CRS patients, 73 CRS without nasal polyps (CRSsNP) and 75 CRS with nasal polyps (CRSwNP), as well as 30 control subjects were enrolled. Overall OC opacification averaged 63.7% in CRS patients and 47.1% in control subjects (P < 0.001). In the overall cohort, OC opacification significantly correlated with threshold, discrimination, and identification (TDI) (r = -0.520; P < 0.001) and QOD-NS scores (r = 0.374; P < 0.001). CRSwNP patients demonstrated a significant correlation between OC opacification and TDI scores (r = -0.464; P < 0.001) but not the CRSsNP group (r = -0.143; P = 0.229). Lund-Mackay score correlated with TDI in both the CRSsNP (r = -0.300; P = 0.010) and CRSwNP (r = -0.271; P = 0.019) groups.

Conclusion: CT opacification is associated with olfactory dysfunction differentially based on nasal polyp status. Smell loss in CRSwNP correlated with both OC opacification and Lund-Mackay score, whereas CRSsNP correlated only with Lund-Mackay score, indicating different relationships between olfactory function and local inflammatory processes in these disorders.

Level Of Evidence: 2 Laryngoscope, 130:2311-2318, 2020.
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http://dx.doi.org/10.1002/lary.28332DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7484975PMC
October 2020

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

Int Forum Allergy Rhinol 2019 10 20;9(10):1144-1150. Epub 2019 Aug 20.

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

Background: The Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS) is a valuable instrument in the measurement of olfactory-specific quality of life (QOL). In the clinical setting, patients can be overwhelmed with the time required to complete questionnaires. Our objective was to develop a brief version of the QOD-NS to streamline clinical care and research.

Methods: QOD-NS scores from 221 subjects were used to determine which subset of the 17 QOD-NS questions best correlated with total and subdomain QOD-NS scores. An initial pool of 11 questions was made by removing items with ρ < 0.80 to their respective subdomain scores. Next, 500 bootstrapped samples were taken. On each sampe, an all-subsets regression was performed with total QOD-NS scores and QOD-NS subdomain scores as the outcomes. From this, our "top" and "bottom" 10 subsets were identified based on mean r value, representation in bootstrap analysis, and number of items.

Results: All of our top subsets had excellent correlation with total and subdomain QOD-NS scores (mean r > 0.90). Our top choice has 7 total questions, is representative of all subdomains, has a mean r = 0.92, and was represented in 323 of our 500 bootstrapped samples. The worst-performing subset has 5 items, mean r = 0.81, and was represented in only 1 bootstrapped sample.

Conclusions: Using less than half of the questions in the QOD-NS, excellent correlations with both total and domain-specific scores are achieved. A brief version of the QOD-NS may prove useful in future clinical and research settings.
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http://dx.doi.org/10.1002/alr.22392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6773507PMC
October 2019

Frontal sinus "mega-trephination" in a tertiary rhinology practice.

Int Forum Allergy Rhinol 2019 10 12;9(10):1189-1195. Epub 2019 Aug 12.

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

Background: Frontal sinus trephination is traditionally performed through a small cutaneous incision and osteotomy, allowing irrigation of the frontal sinus. Utilizing the trephination osteotomy for endoscopic visualization and surgical manipulation requires a larger opening. This "mega-trephination" is thought to carry an increased risk of cosmetic deformity given the increased bony removal at the anterior table. The purpose of our study was to clarify the risks of frontal sinus mega-trephination and examine how this technique is incorporated into a modern, tertiary care rhinology practice.

Methods: Patients were identified through billing records and confirmed by retrospective chart review. All patients underwent frontal sinus mega-trephination, which is defined as an osteotomy large enough for insertion of a 4-mm endoscope and an operative instrument simultaneously. All patients had at least 2 years of follow-up. The primary outcome was complication rate, including cosmetic deformity.

Results: Sixty-four patients underwent frontal sinus mega-trephination from 2006 to 2016. The most common surgical indications were chronic sinusitis (34%), mucocele (19%), osteoma (17%), acute sinusitis (11%), and inverting papilloma (9%). Ten patients (16%) underwent mega-trephination alone, whereas the others had mega-trephination with endoscopic sinus surgery. Twenty-one patients (33%) had minor complications. The most common complications were self-limited paresthesia (11%), infection (8%), and epistaxis (3%). No patient complained of permanent cosmetic deformity or required revision surgery for cosmesis.

Conclusion: Frontal sinus mega-trephination is a useful tool to augment the rhinologist's armamentarium in complex frontal sinus anatomy and pathology. This procedure is well tolerated, safe, and not associated with long-term cosmetic deformity.
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http://dx.doi.org/10.1002/alr.22405DOI Listing
October 2019

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

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

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

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

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

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

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

Role of inferior turbinate reduction in the quality of life of patients undergoing endoscopic sinus surgery for chronic rhinosinusitis.

Int Forum Allergy Rhinol 2019 08 20;9(8):926-933. Epub 2019 Jun 20.

Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA.

Background: The impact on quality of life (QoL) of bilateral inferior turbinate reduction (BITR) performed in the setting of endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) has been a point of controversy. The aim of this study was to determine whether addition of BITR to ESS is associated with improved QoL when compared with ESS alone.

Methods: This study presented findings a multi-institutional, retrospective analysis of a prospective open cohort of patients electing ESS for failed medical management of CRS. QoL parameters were compared between patients who underwent ESS alone vs those who underwent ESS with BITR.

Results: A total of 571 patients with CRS who elected to undergo ESS were identified. Sixty-one of these patients also underwent concurrent BITR, whereas 510 patients underwent ESS without BITR. Mean length of follow-up was 15.1 months. Comparison between baseline and last postoperative QoL, olfaction, and endoscopic scores revealed significant improvement in both groups. Overall, BITR surgery was not significantly associated with clinically significant incremental improvement in QoL in either the polyp or non-polyp group. Nevertheless, statistically significant improvement was noted for the nasal congestion/blockage symptom in polyp patients (p = 0.006) and in primary surgery patients (p = 0.027) who underwent BITR.

Conclusion: BITR in the setting of ESS for CRS is not associated with significant incremental improvement in overall QoL vs ESS alone. However, BITR in polyp and primary surgery patients undergoing ESS appears to offer a significant incremental improvement in nasal congestion/blockage symptoms compared with ESS alone. Future studies are warranted to better corroborate these findings.
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http://dx.doi.org/10.1002/alr.22356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6687546PMC
August 2019