Validity of systemic antibiotics and systemic corticosteroid usage for chronic rhinosinusitis as metrics of disease burden.

BACKGROUND: The frequencies of systemic antibiotics and oral corticosteroids taken for chronic rhinosinusitis (CRS) indicate poor CRS disease control. We sought to determine the validity and responsiveness of these metrics as reflections of CRS disease burden. METHODOLOGY: One hundred and eighty-seven patients undergoing medical management for CRS were recruited. Participants were assessed at two time points: enrollment and a follow-up appointment three to nine months later. At each time point, CRS related antibiotic and oral corticosteroid usage in the previous three months was measured, while general and disease-specific quality of life (QOL) was measured using the visual analog scale of the 5-dimension EuroQol questionnaire (EQ-5D VAS) and the 22-item Sinonasal Outcome Test (SNOT-22), respectively. RESULTS: The frequency of CRS-related antibiotics and oral corticosteroids use was cross-sectionally correlated with EQ-5D VAS and SNOT-22 at the corresponding time points. For participants reporting usage of these medications at enrollment, there was a decrease of 1 course per 3 months for both CRS-related antibiotics and oral corticosteroids. Change in CRS-related antibiotics from enrollment to follow-up was correlated with change in both EQ-5D and SNOT-22 over the same timeframe. The change in CRSrelated oral corticosteroids was correlated with change in both EQ-5D VAS and SNOT-22). These correlations were stronger in the subset of patients who had a change in these metrics over the study period. CONCLUSIONS: The frequencies of CRS-related antibiotic use and oral corticosteroid use are valid and responsive measures of CRS disease burden.

Quality of life impairment due to chronic rhinosinusitis in asthmatics is mediated by asthma control.

BACKGROUND: Chronic rhinosinusitis (CRS) and asthma, when comorbid, may influence each other’s disease course and decrease quality of life (QOL). Our objective was to determine if poorer asthma control due to CRS symptoms could be a mechanism for decreased QOL in asthmatic CRS patients. METHODS: A total of 120 asthmatic CRS patients were recruited. CRS symptom burden was measured using the 22-item Sinonasal Outcome Test (SNOT-22) and patient-reported CRS symptom control, general health-related QOL was measured using the visual analog scale of the 5-dimensional EuroQol quality of life survey (EQ-5D VAS), and asthma control was measured using the Asthma Control Test (ACT). Association was sought between these outcome measures. A mediation model was created and validated to show that asthma control mediated the association between CRS symptom burden and decreased general health-related QOL. RESULTS: ACT score was associated with SNOT-22, EQ-5D VAS was associated with SNOT-22 score, and EQ-5D VAS was associated with ACT score. A statistically significant mediation effect for ACT score in the association between SNOT-22 and EQ-5D VAS), which represented 22.1% of the total effect of SNOT-22 on EQ-5D VAS, was identified. Similar findings were made for patientreported CRS symptom control instead of SNOT-22 score. CONCLUSIONS: In asthmatic CRS patients, a sizeable portion of CRS impact on QOL is indirectly mediated through the effect of CRS on poorer asthma control which may then drive decreased QOL.

Responsiveness and minimal clinically important difference for the EQ-5D in chronic rhinosinusitis.

BACKGROUND: The 5-dimensional EuroQol questionnaire (EQ-5D) is validated to measure general health-related quality of life (QOL). Our objective was to determine the responsiveness and minimal clinically important difference (MCID) of the EQ-5D health utility value (EQ-5D HUV) and visual analog scale (EQ-5D VAS) in chronic rhinosinusitis (CRS). METHODS: 203 adults undergoing medical management for CRS were prospectively recruited. General health-related QOL (using EQ-5D HUV and EQ-5D VAS) and CRS-specific QOL (using the 22-item Sinonasal Outcome Test [SNOT-22]) were measured at enrollment and a subsequent follow-up time point 2-12 months later. At follow-up, participants also rated change in general health as Much worse, A little worse, About the same, A little better or Much better compared to enrollment. The EQ-5D HUV and EQ-5D VAS MCIDs were calculated using distribution-based, anchor-based, and receiver operator characteristic (ROC) curve-based methods. RESULTS: Change in SNOT-22 score was correlated with EQ-5D HUV and EQ-5D VAS change. Using the different methods of calculating MCID, we find the EQ-5D HUV MCID to be 0.04 and EQ-5D VAS MCID to be 8.0. The calculated EQ-5D MCIDs had approximately a sensitivity of 40-50% and specificity of 80% in detecting patients experiencing noticeable improvement in general health. CONCLUSIONS: The EQ-5D responds well to changing CRS symptomatology. We propose MCIDs for EQ-5D HUV of 0.04 and EQ-5D VAS of 8 in CRS patients, which although specific, are not sensitive for detecting patients experiencing improvement in general health.

Chronic rhinosinusitis exacerbations are differentially associated with lost productivity based on asthma status.

BACKGROUND: The frequency of chronic rhinosinusitis (CRS) exacerbations is an independent predictor of quality of life. The objective of this study was to evaluate if increased CRS exacerbations predict decreased productivity. METHODS: Cross-sectional study of adult CRS patients. Number of patient-reported CRS-related antibiotic and oral corticosteroids courses and sinus infections in the past three months were used as metrics for acute exacerbations of CRS (AECRS). Productivity loss was measured by asking participants the number of lost days of work or school due to CRS in the past three months. Associations were sought between lost productivity and AECRS, controlling for clinical and demographic characteristics. RESULTS: 371 participants were recruited. 28.8% of study participants had comorbid asthma. The mean number of lost days of productivity due to CRS in the last three months was 1.5 for asthmatic participants and 2.4 for non-asthmatic participants. In asthmatics, CRS-related lost productivity was significantly associated with number of CRS-related antibiotics used (and oral corticosteroids used, with a trend for sinus infections. No AECRS metric was significantly associated with lost productivity in non-asthmatics. However, when focusing on non-asthmatics reporting missed days of work or school due to CRS, we found statistically significant associations between AECRS metrics and lost productivity. CONCLUSIONS: The frequency of AECRS is associated with CRS-related lost productivity in asthmatics and in the subset of non-asthmatics with moderate CRS-related productivity losses.

Symptom control in chronic rhinosinusitis is an independent predictor of productivity loss.

AIMS: Sinonasal symptoms cause significant productivity losses in patients with chronic rhinosinusitis (CRS). Patient-perceived CRS symptom control is a longitudinal measure of CRS symptomatology and is directly associated with general health-related quality of life (QOL) in patients with CRS. The aim of this study was to better understand the relationship between symptom control and productivity loss in CRS. MATERIALS AND METHODS: Prospective cross-sectional cohort study of 200 patients with CRS. Patients categorized their CRS symptom control as "Not at all", "A little", "Somewhat", "Very", and "Completely". Lost productivity was assessed by determining the number of work and/or school days missed in the last 3 months due to CRS symptoms. Sinonasal symptom severity was measured using the 22-item Sinonasal Outcomes Test (SNOT-22). Associations were sought between lost productivity and patient-perceived CRS symptom control. OBJECTIVE: To determine the association between patient-perceived longitudinal symptom control and productivity in patients with CRS. RESULTS: A total of 200 participants (48% male, 52% female), with a mean age of 52 years (Standard Deviation [SD]: 16) were enrolled. The mean SNOT-22 score of participants was 33.5 (SD: 22.4). Participants missed a mean of 3 days (SD: 10) of work or school due to CRS. CRS symptom control classified as "not at all" was associated with 11 days of lost productivity due to CRS on univariate analysis (ß=11.16, 95% CI: 5.39-16.94, P<0.001) and 8 days of lost productivity on multivariate analysis (ß=8.02, 95% CI: 1.92-14.13, P=0.011). None of the other categories of patient-reported CRS symptom control were associated with lost productivity due to CRS. CONCLUSIONS: Patient-perceived control of CRS symptoms, an important metric previously shown to be significantly associated with QOL in CRS patients, is independently associated with lost productivity. These results motivate longitudinal studies to determine if improvement of CRS symptom control may reduce losses in productivity.

Depressed mood is associated with loss of productivity in allergic rhinitis.

Allergic rhinitis (AR) is associated with significant decreases in quality of life and productivity losses. We hypothesized that symptoms of AR may differentially associate with lost productivity due to AR. We performed a cross-sectional cohort study of 105 prospectively recruited patients with persistent AR. AR control, severity of depressed mood, and sinonasal symptoms were assessed with the Rhinitis Control Assessment Test (RCAT), Patient Health Questionnaire (PHQ-2), and the 22-item Sinonasal Outcome Test (SNOT-22), respectively. Lost productivity was assessed by asking the number of days of work/school missed due to AR in the last 3 months. Patients missed a mean of 1.5 days (SD:2.9) of work or school. Lost productivity was associated with PHQ-2 (adjusted linear regression coefficient [ß] = .68, 95% CI: 0.20-1.15, P = .007) analysis but not SNOT-22 or RCAT scores. Productivity losses due to AR are associated with severity of depressed mood rather than classic nasal or extra-nasal symptoms of AR.

A contemporary analysis of clinical and demographic factors of chronic rhinosinusitis patients and their association with disease severity.

BACKGROUND: Chronic rhinosinusitis (CRS) is highly prevalent, significantly decreases quality of life and leads to tremendous health care costs every year. No recent study has characterised the prevalence of potentially CRS-modifying patient characteristics and simultaneously shown their impact on CRS severity. AIMS: We sought to determine the prevalence of potential clinical and demographic CRS-modifying characteristics and their associations with CRS symptom severity in a large contemporary cohort of CRS patients. METHODS: Retrospective review of CRS patients who visited our rhinology clinics between February 2016 and February 2017 was conducted. CRS symptom severity was measured using the 22-item Sinonasal Outcomes Test (SNOT-22) questionnaire, which all patients received. Association was sought between SNOT-22 score (as dependent variable) and patients' clinical and demographic characteristics using linear regression. RESULTS: Of the 572 included patients, the mean age was 51.1 years (SD = 15.8) and the mean SNOT-22 score was 34.3 (SD = 22.6). Prevalence of granulomatous diseases, immunodeficiency and cystic fibrosis were each approximately 5%. Prevalence of aeroallergen hypersensitivity was 42.3% and prevalence of asthma was 27.8%. More severe CRS symptomatology was associated with smoking tobacco (adjusted ß = 5.47, p = 0.034) and comorbid asthma (adjusted ß = 12.02, p < 0.001), whilst less severe symptomatology was associated with older age (adjusted ß = -0.23, p = 0.002) and diagnosis of cystic fibrosis (adjusted ß = -11.87, p = 0.009). CONCLUSIONS: In a contemporary cohort of CRS patients, prevalence of disease-modifying comorbidities ranged from approximately 5 to over 40%. Smoking tobacco and asthma were associated with more severe CRS symptomatology, whilst older age and diagnosis of cystic fibrosis were associated with less severe CRS symptomatology.

[The association between allergic rhinitis control and sleep quality]. / Assoziation zwischen Kontrolle der allergischen Rhinitis und Schlafqualität.

BACKGROUND: Allergic rhinitis (AR) is the most common form of atopic disease, comprising 50% of atopic diseases. Recently, this disease has increasingly been the focus of intensive research. Previous work has shown that AR has a significant impact on sleep quality. To date there are no published studies demonstrating a quantitative association between the extent of control of AR and the severity of compromised sleep quality. METHODS: Patients with AR were prospectively recruited into our cross-sectional study. Sleep quality was assessed using five of the sleep subdomain questions from the 22-item Sinonasal Outcome Test (SNOT-22). Control of AR was assessed using the Rhinitis Control Assessment Test (RCAT). Association was sought between the degree of allergic rhinitis control (RCAT) as independent variable and sleep quality as dependent variable using linear regression. RESULTS: A total of 104 patients (54.8% female and 45.2% male) with an average age of 41.4 years (SD: 15.9 years) were included in the study. There were statistically significant associations between the RCAT score and the score of each of the five SNOT-22 questions used to assess decreased sleep quality (p < 0.001). These associations remained significant (p < 0.001) even after controlling participants' clinical and demographic characteristics. CONCLUSION: This is the first study showing that level of control of AR correlates with the severity of subjectively perceived sleep quality detriment. These results indicate that an improvement in AR control could lead to improved subjective sleep quality but a prospective interventional study is needed to confirm these results.

Chronic rhinosinusitis severity is associated with need for asthma-related systemic corticosteroids.

BACKGROUND: Chronic rhinosinusitis (CRS) is highly prevalent in patients with asthma. However, no study has evaluated the effect of CRS severity on asthma-related oral corticosteroid use - a marker of poor asthma control and prognosis. We therefore sought to evaluate the association between CRS severity and asthma-related oral corticosteroid use. METHODOLOGY: Prospective cross-sectional study of 110 adult asthmatic CRS patients. CRS severity was measured using the 22-item Sinonasal Outcomes Test (SNOT-22) and Lund-Kennedy endoscopy score. Number of asthma-related courses of oral corticosteroids in the past year was queried at enrollment. Association was sought between metrics for CRS severity and asthma-related oral corticosteroids use in the last year. Receiver operating characteristic (ROC) curves defined whether SNOT-22 or endoscopy scores could be used for detecting asthma-related oral corticosteroid use. RESULTS: The mean SNOT-22 score was 44.9 (standard deviation [SD] : 23.3) and mean endoscopy score was 4.1 (SD: 3.0). The mean number of asthma-related oral corticosteroid courses taken in the last year was 1.1 (SD: 1.9). SNOT-22, but not endoscopy score, was associated with requiring at least one course of asthma-related oral corticosteroids in the last year (odds ratio = 1.03, 95%CI: 1.02 - 1.06, p=0.003), which translates to an odds ratio of 2.0 for a 21-point increase in SNOT-22. ROC analysis identified equally optimal SNOT-22 scores of greater than 32 (sensitivity: 88.1%, specificity: 41.2%) or greater than 65 (sensitivity: 38.1%, specificity: 91.2%) for detecting the need for at least one course of oral corticosteroids within the past year. CONCLUSIONS: CRS symptom severity is associated with past asthma-related oral corticosteroid use. SNOT-22 scores may be used as a versatile tool to screen for past asthma-related oral corticosteroid use in asthmatic CRS patients - i.e. those at greatest risk from their asthma - with either high sensitivity or high specificity.

Patient-reported control of chronic rhinosinusitis symptoms is positively associated with general health-related quality of life.

OBJECTIVE: In chronic rhinosinusitis (CRS), although patient-reported severity of sinonasal symptoms is significantly associated with diminishment of patients' general health-related quality of life (QOL), it remains unclear whether patient-perceived control of CRS symptomatology is associated with patients' QOL. In this study, we sought to determine the association between patient-perceived control of CRS symptomatology and QOL. DESIGN: Prospective cross-sectional study. SETTING: Academic, tertiary care centre. PARTICIPANTS: A cohort of 166 adults with CRS who were asked to categorise their level of CRS symptom control as "Not at all," "A little," "Somewhat," "Very" and "Completely." MAIN OUTCOME MEASURE: General health-related QOL, as reflected by the five-dimensional EuroQol quality of life survey-derived visual analogue scale (EQ5D-VAS) and health utility values (EQ5D-HUV). RESULTS: We found that higher EQ5D-VAS scores were associated with CRS patients who classified their symptom control as "Very" (adjusted ß=15.74, 95% CI: 5.44 to 26.04, P=.003) and "Completely" (adjusted ß=14.24, 95% CI: 2.98 to 25.52, P=.014) compared to patients who classified their symptom control as "Not at all." This was also true for higher EQ5D-HUV which was associated with patient-reported CRS symptom control of "A little" (adjusted ß=0.10, 95% CI: 0.01 to 0.18, P=.024), "Somewhat" (adjusted ß=0.08, 95% CI: 0.00 to 0.17, P=.049), "Very" (adjusted ß=0.13, 95% CI: 0.05 to 0.21, P=.002) and "Completely" (adjusted ß=0.18, 95% CI: 0.09 to 0.27, P<.001). CONCLUSIONS: Higher levels of patient-reported CRS symptom control are therefore associated with better QOL. These findings suggest that CRS symptom control should be targeted for improving patients' QOL.

Symptoms of chronic rhinosinusitis differentially impact general health-related quality of life.

BACKGROUND: The degree to which different sinonasal symptoms contribute to the overall quality of life (QOL) detriment in chronic rhinosinusitis (CRS) patients remains unknown. In this study we sought to characterize the effect of different CRS symptoms on the general health-related QOL in patients. METHODOLOGY: We performed a prospective cross-sectional study of 131 adult patients with CRS. Sinonasal symptoms were evaluated using the 22-item Sinonasal Outcomes Test (SNOT-22) and general health-related QOL was evaluated using the EuroQol 5-Dimensional general health-related QOL survey (EQ5D) and visual analog scale (EQ5D-VAS). Health utility values (HUV) were determined using responses to the EQ5D. SNOT-22 scores were broken down into subdomain scores for sleep, nasal, otologic/facial pain and emotional function symptoms. RESULTS: The otologic/facial pain subdomain score consistently had the largest impact on EQ5D-VAS and HUV. After otologic/facial pain, the sleep subdomain score had the second largest effect while the nasal subdomain score had the least impact on general health-related QOL. CONCLUSIONS: Different types of CRS symptoms - most prominently otologic/facial pain and sleep-related symptoms - and their underlying pathophysiologic mechanisms may differentially affect the general health-related QOL detriment associated with CRS. These findings raise the possibility that treatment of the various symptoms associated with CRS may lead to differential improvement in general-health related QOL.

Osteopathic manual therapy versus conventional conservative therapy in the treatment of temporomandibular disorders: a randomized controlled trial.

OBJECTIVE: Temporomandibular disorders (TMD) is a term reflecting chronic, painful, craniofacial conditions usually of unclear etiology with impaired jaw function. The effect of osteopathic manual therapy (OMT) in patients with TMD is largely unknown, and its use in such patients is controversial. Nevertheless, empiric evidence suggests that OMT might be effective in alleviating symptoms. A randomized controlled clinical trial of efficacy was performed to test this hypothesis. METHODS: We performed a randomized, controlled trial that involved adult patients who had TMD. Patients were randomly divided into two groups: an OMT group (25 patients, 12 males and 13 females, age 40.6+/-11.03) and a conventional conservative therapy (CCT) group (25 patients, 10 males and 15 females, age 38.4+/-15.33). At the first visit (T0), at the end of treatment (after six months, T1) and two months after the end of treatment (T2), all patients were subjected to clinical evaluation. Assessments were performed by subjective pain intensity (visual analogue pain scale, VAS), clinical evaluation (Temporomandibular index) and measurements of the range of maximal mouth opening and lateral movement of the head around its axis. RESULTS: Patients in both groups improved during the six months. The OMT group required significantly less medication (non-steroidal medication and muscle relaxants) (P<0.001). CONCLUSIONS: The two therapeutic modalities had similar clinical results in patients with TMD, even if the use of medication was greater in CCT group. Our findings suggest that OMT is a valid option for the treatment of TMD.

Anatomic location of the tongue base neurovascular bundle.

Knowledge of the location of the hypoglossal/lingual artery neurovascular bundle (HLNVB) is essential in performing tongue base resections for neoplasm and for obstructive sleep apnea. Transoral and transcervical resections of the tongue base may be performed with greater exposure and certainty when the relationship of the HLNVB to local landmarks is understood; knowledge of the HLNVB allows resection of a larger amount of contralateral tongue base during partial glossectomy without violating the contralateral remnant tongue's blood supply. Ten cadaver heads were dissected to determine the position of the HLNVB with respect to soft tissue and bony landmarks at the tongue base. Our results indicate the position of the tongue base HLNVB is significantly inferior and lateral, that is, 2.7 cm inferior and 1.6 cm lateral to the foramen cecum, 0.9 cm superior to the hyoid bone, and 2.2 cm medial to the mandible. This inferolateral location allows the potential for aggressive tongue base resection without neurovascular compromise.

Fixed mandibular implant after microvascular mandibular reconstruction.

OBJECTIVE: To evaluate the use of fixed mandibular implants to retain dental prostheses after microvascular mandibular reconstruction. DESIGN: Case series. SETTING: Tertiary referral center. PATIENTS: Eight patients with microvascular mandibular reconstruction after mandibular resection. OUTCOME MEASURES: Clinically noted functional results, serial radiographic evidence of fixed mandibular implant and mandibular integrity, and complications encountered. RESULTS: Eight of 8 fixed mandibular implants were successfully placed and remained stable. The follow-up period ranged from 10 to 21 months (mean, 14.3 months). CONCLUSION: The use of fixed mandibular implants to retain dental prostheses after microvascular mandibular reconstruction is a safe and effective treatment option.