Biologics for chronic rhinosinusitis with nasal polyps: Economics and ethics.

Biologics have recently been approved for use in chronic rhinosinusitis with nasal polyps patients. While effective in controlling disease on subjective and objective short-term outcome measures, limited data suggest that biologics have the potential to be used long term. The current wholesale acquisition costs for biologics are quite high. Widespread, prolonged use of these medications may create a large burden to our healthcare system. Cost-effectiveness analyses, particularly for specific patient cohorts, are needed to determine appropriate use of these medications. The ethics of patient preference of various treatment options, counseling regarding side effect profiles, and healthcare economics also need to be addressed.

Cross-reactivity in Skin Prick Test Results of Members Within Pooideae Subfamily.

OBJECTIVE: Molecular similarities of grass pollen antigens have led to the view that cross-reactivity exists within members of the Pooideae subfamily of grasses. This has resulted in testing for only the most antigenically representative member of Pooideae, Timothy grass (Phleum pratense), despite little literature to support the claim that Phleum is the most representative member or that in vitro cross-reactivity correlates with in vivo cross-reactivity. The aim of the study was to determine if patients with allergic rhinitis symptoms and positive skin prick test results to meadow fescue (Festuca pratensis) also have positive results to Timothy grass. STUDY DESIGN: Retrospective cross-sectional study. SETTING: Tertiary care center in middle Missouri. METHODS: A retrospective chart review identified patients ≥12 years old with a diagnosis of allergic rhinitis who underwent skin prick testing between March 2016 and July 2018, by using a search with CPT code 95004 (Current Procedural Terminology). Positive skin prick test results were based on wheal produced ≥3 mm than the negative control. RESULTS: After review of 2182 charts, 1587 patients met criteria to test for Phleum and Festuca. In total, 1239 patients had a positive result for Phleum or Festuca. Of these, 479 (38.6%) tested positive for Festuca alone, while 342 (27.6%) and 418 (33.7%) tested positive for Phleum alone and Phleum+Festuca, respectively. CONCLUSION: Clinical cross-reactivity among Pooideae members may not be as complete as traditionally thought. P pratense may not be the most antigenically representative subfamily member, and other grasses may need to be included in skin prick testing.

Targeted Molecular Therapies in Allergy and Rhinology.

Biologic agents, monoclonal antibodies that target highly-specific molecular pathways of inflammation, are becoming integrated into care pathways for multiple disorders that are relevant in otolaryngology and allergy. These conditions share common inflammatory mechanisms of so-called Type 2 inflammation with dysregulation of immunoglobulin E production and eosinophil and mast cell degranulation leading to tissue damage. Biologic agents are now available for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP), asthma, eosinophilic granulomatosis with polyangiitis (EGPA), atopic dermatitis (AD), and chronic spontaneous urticaria (CSU). This paper summarizes the diagnosis and management of these conditions and critically reviews the clinical trial data that has led to regulatory approval of biologic agents for these conditions.

The Role of Biologics in the Treatment of Nasal Polyps.

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heteromorphic disease with both medical and surgical aspects to its treatment. CRSwNP is a chronic inflammatory condition with exacerbations that can be controlled through surgical and/or medical interventions, including biological agents. The role of biological agents in the treatment of CRSwNP as well as the patient characteristics that make suitable candidates for biologics are discussed.

Advances in Food Allergy.

Food allergy has been increasing in prevalence for the last few decades, and numerous studies have evaluated ways of improving the allergy practitioner's ability to accurately diagnose patients who are truly food allergic, rather than sensitive but able to tolerate food. Once diagnosed, the current standard treatment is food elimination and avoidance, but other potential treatment options like oral immunotherapy, sublingual immunotherapy, and epicutaneous immunotherapy are becoming promising alternatives. Due the health care costs and potential for life-threatening adverse reactions, much attention has been given to the prevention of food allergies, resulting a shift in recent guideline recommendations.

Extremes in Otolaryngology Resident Surgical Case Numbers: An Update.

Objectives The purpose of this study is to examine the effect of minimum case numbers on otolaryngology resident case log data and understand differences in minimum, mean, and maximum among certain procedures as a follow-up to a prior study. Study Design Cross-sectional survey using a national database. Setting Academic otolaryngology residency programs. Subjects and Methods Review of otolaryngology resident national data reports from the Accreditation Council for Graduate Medical Education (ACGME) resident case log system performed from 2004 to 2015. Minimum, mean, standard deviation, and maximum values for total number of supervisor and resident surgeon cases and for specific surgical procedures were compared. Results The mean total number of resident surgeon cases for residents graduating from 2011 to 2015 ranged from 1833.3 ± 484 in 2011 to 2072.3 ± 548 in 2014. The minimum total number of cases ranged from 826 in 2014 to 1004 in 2015. The maximum total number of cases increased from 3545 in 2011 to 4580 in 2015. Multiple key indicator procedures had less than the required minimum reported in 2015. Conclusion Despite the ACGME instituting required minimum numbers for key indicator procedures, residents have graduated without meeting these minimums. Furthermore, there continues to be large variations in the minimum, mean, and maximum numbers for many procedures. Variation among resident case numbers is likely multifactorial. Ensuring proper instruction on coding and case role as well as emphasizing frequent logging by residents will ensure programs have the most accurate data to evaluate their case volume.

Interleukin-9 and interleukin-17C in chronic rhinosinusitis.

BACKGROUND: Interleukin (IL)-9 and IL-17C have been known to play a role in allergic inflammation, yet, their roles in chronic rhinosinusitis (CRS) are not well defined. IL-9 induces changes in epithelial cell gene expression leading to goblet cell metaplasia, whereas IL-17C is functionally distinct in that its expression can be induced by bacterial challenge and inflammatory stimuli. This study aimed to compare levels of IL-9 and IL-17C in CRS with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP) as well as atopy. METHODS: Nasal polyp or sinus mucosal specimens from CRSwNP (n = 36), CRSsNP (n = 9), and control (n = 9) groups were collected and processed. Patient atopy status was determined by history of skin-prick test and pulmonary function test. Immunohistochemistry was carried out using anti-human IL-9 and IL-17C antibodies. Positively-stained cells were enumerated under high-power (×400) magnification in 5 consecutive fields. RESULTS: The level of expression of IL-9 was higher in CRSwNP than CRSsNP and control. Similar findings were demonstrated in IL-17C with higher expression in CRSwNP than CRSsNP and control. Both the averages of positively-stained cells expressing IL-9 and IL-17C were higher in CRS with asthma and allergy compared to control. This suggested that IL-9 and IL-17C were both involved in the pathogenesis of CRS, allergy, and asthma. CONCLUSION: Inflammatory cell expression of IL-9 and IL-17C were increased in CRS, particularly with allergy and asthma. These interleukins may contribute to the pathogenesis of CRSwNP as well as atopy and may serve as therapeutic targets for disease management.

AAOA allergy primer: history and physical examination.

BACKGROUND: Allergic disease is very common in the general population and makes a significant impact on the quality of life of patients. Immunoglobulin E (IgE)-mediated allergic disease manifests throughout the body, but many signs and symptoms of inhalant allergy are centered in the head and neck region. METHODS: A thorough yet focused history of allergic symptoms and potential physical examination findings of inhalant allergy are described. RESULTS: History should include types and timing of symptoms, environmental and occupational exposures, family history, associated diseases, and prior treatment, if any. Physical examination should include the skin and structures of the head and neck region. Nasal endoscopy can be helpful in visualization of nasal polyps. CONCLUSION: Many times, history alone can serve to make the diagnosis, but physical examination also demonstrates specific findings that confirm the practitioner's presumptive diagnosis of allergic disease. However, should medical treatment fail or the diagnosis be in doubt, further diagnostic investigation with allergy testing should be pursued.

Extremes in otolaryngology resident surgical case numbers.

OBJECTIVE: Understand (1) significance between minimum, mean, and maximum case numbers for otolaryngology resident surgical procedures; (2) weaknesses of Accreditation Council for Graduate Medical Education (ACGME) resident case log system contributing to inaccurate data/case inflation; and (3) when excessive case load may transform education into service. STUDY DESIGN: Cross-sectional survey using a national database. SETTING: Academic otolaryngology residency programs. SUBJECTS/METHODS: Review of otolaryngology resident national data reports from ACGME resident case log system performed from 2004 to 2010. Minimum, mean, standard deviation, and maximum values for total number of resident surgeon cases and for specific surgical procedures were compared. Case unbundling, resident data entry habits, and tracked vs untracked Current Procedural Terminology (CPT) codes were reviewed. RESULTS: Mean total number of resident surgeon cases remained constant (1699.5 ± 424.2 to 1772.2 ± 517). Minimum total number of cases ranged from 730 to 811 (approaching 2 standard deviations below the mean). Zero was reported as the minimum case number for some procedures. Maximum for total number of cases increased (3559 to 4857) and surpassed the mean by 4 to 5 standard deviations. Some procedures have maximums greater than 11 standard deviations above the mean. The authors identified untracked CPT codes and variations in resident case log documentation habits. CONCLUSIONS: Large differences between the minimum, mean, and maximum resident surgeon case numbers exist. Establishing minimum case number requirements for otolaryngology residents should be considered. Educational benefit derived from excessive case load is unclear. Critical examination of the ACGME resident case log system and resident documentation habits is needed to improve accuracy of reporting.

The current status of allergy training in otolaryngology residency programs.

PURPOSE OF REVIEW: Allergy is an important part of the practice of otolaryngology. The American Board of Otolaryngology (ABO) and the Accreditation Council for Graduate Medical Education (ACGME) have increased specific requirements to include allergy as part of the didactic curriculum in training programs and in examinations of all levels. However, how much actual allergy training and education occurs in otolaryngology residency programs is unclear. RECENT FINDINGS: The current and upcoming changes in ABO and ACGME requirements are reviewed, which include and expand on required allergy education in residency programs and standardized testing, including intraining, written, and maintenance of certification examinations. There is a dearth of literature regarding resident training in otolaryngic allergy and evaluation of resident competency in this area. A recent resident survey indicates that almost half of residents feel undertrained in this area and desire more education. SUMMARY: Despite increasing requirements and specifications for allergy training from the ABO and ACGME, how much actual training and education in otolaryngology allergy occurs in residency programs is uncertain. Residents' survey responses indicate it is not enough and there is a void in the literature regarding this topic and resident competency assessment in this area. Further investigation is needed to help determine how residents are being trained and assessed.

The patient with allergies.

Allergic disease affects a sizeable percentage of the general population, has a significant impact on patient quality of life, and exerts a significant financial burden on society. Atopic symptoms from inhalant allergens are among the most frequent complaints in outpatient medical visits. Key history and physical examination findings help to distinguish allergic rhinitis from other forms of chronic rhinosinusitis. Diagnostic testing may not be necessary unless immunotherapy is contemplated.

Pilot study of an Objective Structured Clinical Examination ("the Six Pack") for evaluating clinical competencies.

OBJECTIVE: The purpose of this study was to evaluate an Objective Structured Clinical Examination (OSCE) designed to examine all six competencies and provide meaningful results to improve resident performance. STUDY DESIGN: A prospective, observational study. METHODS: The OSCE consists of 1 hour for examination of a simulated patient, documentation, and feedback, with 30 minutes for an evidence-based medicine (EBM) test. Eight otolaryngology residents participated. Digital recordings and written documentation were evaluated on all competencies except practice-based learning. An EBM test was scored to assess practice-based learning. RESULTS: Overall, senior residents scored better. Seniors scored better on performing a focused history, whereas juniors scored better for thoroughness. Seniors coded better than juniors, although seniors tended to undercode and juniors tended to overcode. Two cases of "insurance fraud" were also discovered. CONCLUSIONS: The "Six Pack" successfully evaluated all competencies while providing valuable information. A clinical practicum was added to improve history and physical examination skills. The discussion of coding and a billing seminar also resulted. Residents believed the OSCE was valuable. Faculty members were impressed with the useful information obtained.

The evolution of surgical training: perspectives on educational models from the past to the future.

Surgical education and training have progressed through the centuries, with the most commonly used model being the apprentice model. With advances in medical knowledge and practice, the apprentice model has evolved and competing models have arisen. However, the apprentice model remains the gold standard today, but for future use, further evolutionary changes will need to be made to the apprentice model if it is to continue to remain an effective education paradigm.

Adult outpatient tracheostomy care: practices and perspectives.

OBJECTIVES: To determine the attitudes, opinions, and current practice of adult outpatient tracheostomy care from the surgeon and primary care physician's perspective. STUDY DESIGN: Multidisciplinary physician survey. RESULTS: Found 53.4% (667 of 1250) and 28.9% (404 of 1400) of otolaryngologists and internists responded, respectively; 47% of otolaryngologists lack standardized tracheostomy discharge protocols. General ward nurses most commonly (33%) provide discharge education. A total of 64% of otolaryngologists felt primarily responsible for tracheostomy care and follow-up; 48% expect the primary physician to provide some or all tracheostomy care. Ninety-seven percent of internists received little or no residency training in tracheostomy care, which was significantly associated with decreased comfort (P<0.0001) and willingness (P<0.0001) to care for these patients. CONCLUSIONS: Tracheostomy care is a concerted effort between the patient, surgeon, primary physician, and interdisciplinary team. Otolaryngologists should strive to standardize tracheostomy discharge, education, and follow-up practices. SIGNIFICANCE: Disparities are highlighted between disciplines in their comfort, willingness, and knowledge of outpatient tracheostomy care.

Infantile myofibromatosis: unusual diagnosis in an older child.

This manuscript describes the unusual presentation of infantile myofibromatosis (IM) in an older child with its diagnosis and management. An 8-year-old girl presented with a painless, rapidly expanding malar mass. CT demonstrated an erosive soft tissue lesion and needle biopsy was nondiagnostic. Complete excision returned the pathologic diagnosis of IM. The patient had no complications and no evidence of recurrence at 1 year. Almost 90% of IM cases present by age two and IM in older children is highly unusual. The solitary form of IM is most common and its treatment is complete excision with an excellent prognosis.

Economic analysis of the use of limited coronal computed tomography scans in the management of sinusitis.

BACKGROUND: As medical costs increase, less expensive alternatives to standard diagnostic tests are sought to reduce the economic burden placed on society. One alternative is using limited, non-consecutive cut computed tomography (CT) scans for the evaluation of sinonasal disease. This study evaluates the cost-effectiveness of using limited CT scans instead of full sequence CT scans in the diagnosis and management of rhinosinusitis. METHODS: A Medline search was performed to obtain data for the sensitivity and specificity of limited CT scans, the prevalence of abnormal CT scans, and recommendations on using limited CT scans for operative management. A standard cost-effectiveness analysis, including a sensitivity analysis, was performed using a hypothetical population of patients with sinus complaints who failed prior appropriate medical therapy. RESULTS: At baseline, the limited CT scan was found to be less cost-effective than the full CT scan, costing $217.13 more per correct diagnosis. The sensitivity analysis demonstrated that changes in the prevalence of abnormal CT scans and the percentage of surgeons who would operate using a limited scan had the greatest impact on cost, whereas changes in the price of the full CT or limited CT scan had the least effect. CONCLUSIONS: This study finds the use of limited CT scans to be economically unsound as a method to reduce costs in the defined population. Published literature recommends obtaining a full CT scan before operative management. Basing intervention on limited CT scans increases the possibility of erroneous diagnoses leading to either excessive or inadequate treatment of patients.

Diagnosis and surgical management of nasopalatine duct cysts.

OBJECTIVES/HYPOTHESIS: Nasopalatine duct cysts are the most common cystic lesion of nonodontogenic origin of the maxilla. The purposes of the study were to review the epidemiology and clinical presentation, to describe the radiographic and pathological findings, and to discuss surgical management of this entity. STUDY DESIGN: Case presentations of two patients with nasopalatine duct cysts at a tertiary care institution with a review of the English medical literature from January 1960 to the present. METHODS: A 69-year-old man presented with an asymptomatic swelling of the premaxilla, and a 17-year-old woman presented with a painful swelling of the hard palate. A computed tomography scan, fine-needle aspiration, and preoperative workup were obtained in both cases. Literature was reviewed with respect to epidemiology, etiology, presentation, diagnostic studies, operative management, and recurrence rates. RESULTS: Computed tomography scan demonstrated midline ovoid cystic lesions in both cases. Fine-needle aspiration of both lesions revealed no evidence of malignancy. Surgical treatment consisted of enucleation in the first case and marsupialization in the second case. Both patients did well with no evidence of recurrence. Nasopalatine duct cyst presents in the fourth to sixth decades of life with a male predilection. Recurrence rates range from 0% to 11%. CONCLUSION: Nasopalatine duct cyst occurs in approximately 1% of the population. Presentation may be asymptomatic or include swelling, pain, and drainage from the hard palate. A well-circumscribed, round, ovoid, or heart-shaped radiolucency is seen on computed tomography. Pathological findings reveal squamous or respiratory cell types, or a combination of these, infiltrated by inflammatory cells. Enucleation is the preferred treatment with low recurrence rates.

Surgical management of amiodarone-induced thyrotoxicosis.

OBJECTIVE: Amiodarone can cause thyroid dysfunction in patients with or without previous thyroid disease. With increased use from its placement in advanced cardiac life support guidelines and cardiac transplant programs, the incidence of amiodarone-induced thyrotoxicosis (AIT) will likely increase. Medical management is complex and nonuniform and frequently fails. This study investigates the role of surgery in AIT and proposes indications for surgical management. STUDY DESIGN AND SETTING: Two AIT case reports at a tertiary care institution and 31 surgical AIT cases in the world literature are reviewed. METHODS: The 2 AIT cases involved patients with cardiomyopathy and resistant arrhythmias. Despite medical therapy, both patients' conditions failed to improve. Thirty-one surgical cases of AIT in the literature are evaluated with respect to symptoms and onset, medical therapy, AIT classification, pathology, perioperative management, and complications. RESULTS: Both patients underwent total thyroidectomy without difficulty or complication, one as an overnight stay and one as an inpatient with an intraaortic balloon pump. One patient received a successful cardiac transplant and the other remains a viable candidate. In the literature, the majority (80%) of surgical cases are AIT type II (less common type) with no underlying thyroid disease. Range and duration of symptoms varied, in addition to type and duration of medical management. Almost all patients underwent total thyroidectomy, and all were successful with no mortality and minimal morbidity. CONCLUSION: AIT can develop in any patient during or after amiodarone therapy. Medical management is extremely difficult due to the absence of a proven therapeutic armamentarium, and surgery offers a safe, viable option. Surgical management should play a larger role in treatment algorithms and should be strongly considered for patients whose conditions necessitate continuation of amiodarone, or with severe symptoms resistant to medical therapy.

Peritonsillar and parapharyngeal space abscess in the older adult.

OBJECTIVE: To review the presentation and management of peritonsillar (PTA) and parapharyngeal space (PPSA) abscesses in older adults and compare this with the usual presentation and management in the younger patient. STUDY DESIGN: An 18-year retrospective review at a tertiary care hospital. METHODS: The patient database was searched by using the diagnosis codes for PTA and PPSA. The search included inpatient and outpatient visits of patients 50 years of age and older from 1983 to 2001. The charts were reviewed, and data regarding presentation, management, and outcome were recorded. Comparisons to the current literature were made. RESULTS: Fourteen patients were identified, 8 with PTA and 6 with PPSA. The most common symptoms in both groups were sore throat and dysphagia. Only 1 patient in either group was febrile. All vital signs were within normal limits in all other patients. Only 1 patient in each group experienced trismus, and no patients showed drooling. Five of the PTA patients required inpatient care, and 2 were taken to the operating room. CONCLUSIONS: PTA and PPSA are uncommon infections in the older adult, with only 14 patients identified at a tertiary care hospital over an 18-year period. Complaints of new onset sore throat and dysphagia of several days duration in patients over 50 years old should alert the evaluating physician to these 2 clinical entities, even in afebrile, nontoxic patients. PTA in this group may be more likely to require inpatient care along with surgical treatment in the operating room.

Amiodarone-induced thyrotoxicosis: a case for surgical management.

OBJECTIVE: Amiodarone can cause the development of thyroid dysfunction in patients with or without previous thyroid disease. Although most cases of amiodarone-induced thyrotoxicosis (AIT) are mild, a significant number become life threatening. Because of its pharmacokinetics, simply discontinuing amiodarone provides no relief and can worsen the patient's condition. Medical management frequently fails, and many patients cannot discontinue amiodarone because of its effect against resistant arrhythmias. METHODS: This retrospective chart review of a case at a tertiary care institution presents the case of a fifty-five-year-old male with dilated cardiomyopathy and no previous thyroid disease. The patient was in normal sinus rhythm on amiodarone for control of atrial fibrillation. He experienced the acute onset of symptoms with return to atrial fibrillation resistant to cardioversion. Physical examination, laboratory tests, and imaging findings were all consistent with a diagnosis of AIT. An attempt to withdraw amiodarone resulted in severe ventricular tachyarrhythmias. RESULTS: Despite medical treatment, the patient's condition continued to deteriorate. Because amiodarone was the only effective drug, surgical treatment was elected. The patient underwent a total thyroidectomy and experienced no difficulties or complications. Postoperatively, the patient's condition improved, and he was successfully cardioverted. CONCLUSIONS: Although an uncommon clinical entity, life-threatening AIT has been reported. Thyrotoxicosis can develop in any patient during or after amiodarone therapy. Medical management of this entity is extremely difficult because of the lack of a proven, consistent therapeutic armamentarium. Surgical management should be considered for patients whose conditions necessitate the continuation of amiodarone or those with severe symptoms resistant to medical therapy.