Artificial Intelligence in Rhinology.

Rhinology, allergy, and skull base surgery are fields primed for the integration and implementation of artificial intelligence (AI). The heterogeneity of the disease processes within these fields highlights the opportunity for AI to augment clinical care and promote personalized medicine. Numerous research studies have been published demonstrating the development and clinical potential of AI models within the field. Most describe in silico evaluation models without direct clinical implementation. The major themes of existing studies include diagnostic or clinical decisions support, clustering patients into specific phenotypes or endotypes, predicting post-treatment outcomes, and surgical planning.

Implementation of a Streamlined Care Pathway to Reduce Cost and Length of Stay for Patients Undergoing Endoscopic Transsphenoidal Pituitary Surgery.

BACKGROUND: We implemented a streamlined care pathway for patients undergoing endoscopic transsphenoidal (TSA) pituitary surgery. Select patients are recovered in the postanesthesia care unit and transferred to a step-down unit for intermediate neurologic care (INCU), with clinicians trained to manage cerebrospinal fluid leak, diabetes insipidus (DI), and other complications. METHODS: We evaluated all TSA surgeries performed at 1 academic medical center from 7th January, 2017 to 30th March, 2020, collecting patient factors, tumor characteristics, cost variables, and outcomes. The INCU pathway was implemented on 7th January 2018. Pathway patients were compared with nonpathway patients across the study period. Outcomes were assessed using multivariate regression, adjusting for patient and surgical characteristics, including intraoperative cerebrospinal fluid leak, postoperative DI, and tumor dimensions. RESULTS: One hundred eighty-seven patients were identified. Seventy-nine were on the INCU pathway. Mean age was 53.5 years. Most patients were male (66%), privately insured (62%), and white (66%). Mean total cost of admission was $27,276. Mean length of stay (LOS) was 3.97 days. Use of the INCU pathway was associated with total cost reduction of $6376.33 (P < 0.001, 95% confidence interval [CI]: $3698.21-$9054.45) and LOS reduction by 1.27 days (P = 0.008, 95% CI: 0.33-2.20). In-hospital costs were reduced across all domains, including $1964.87 in variable direct labor costs (P < 0.001, 95% CI: $1142.08-$2787.64) and $1206.52 in variable direct supply costs (P < 0.001, 95% CI: $762.54-$1650.51). Pathway patients were discharged earlier despite a higher rate of postoperative DI (25% vs. 11%, P = 0.011), with fewer readmissions (0% vs. 6%, P = 0.021). CONCLUSIONS: A streamlined care pathway following TSA surgery can reduce in-hospital costs and LOS without compromising patient outcomes.

In-Hospital Cost Comparison for Open Versus Endoscopic Endonasal Approach for Meningioma Resection.

OBJECTIVE: To determine the in-hospital cost implications of an endoscopic expanded endonasal approach (EEEA) for meningioma resection relative to the open transcranial approach. METHODS: All anterior skull base meningioma surgeries performed over a period from January 1st, 2015 to October 31th, 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate analysis was performed using R software. All cost data were converted into August 2021-equivalent dollar amounts using the United States Bureau of Labor Statistics consumer price index. RESULTS: Thirty-five patients met study criteria, including 27 patients undergoing an open transcranial approach and 8 undergoing an EEEA. Average length of stay for patients undergoing an open approach was 9.3 days compared to 5.6 within the EEEA group (P = .126). The average total in-hospital cost of patient undergoing an EEEA was $35417.1 compared to $46406.9 among patients undergoing an open transcranial approach (P = .168). On univariate analysis, the cost of an open transcranial approach relative to the EEEA was $10989.8 (P = .411). CONCLUSIONS: The open transcranial approach remained the dominant surgical approach to anterior skull base meningiomas over our study time period. However, despite limited patient numbers the EEEA was associated with decreased total in-hospital costs.

In-Hospital Costs for Open versus Endoscopic Endonasal Approach for Craniopharyngioma Resection.

OBJECTIVE: To determine the in-hospital cost implications of an expanded endoscopic endonasal approach (EEEA) for craniopharyngioma resection relative to the traditional open transcranial approach. METHODS: All craniopharyngioma surgeries performed at a single institution over a period from January 1st 2001 to October 31th 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate regression analysis was performed using R software. RESULTS: Thirty-six patients met study criteria, including 22 undergoing an open approach and 14 undergoing an EEEA. There was a significantly longer average length of stay among patients undergoing open resection (21.5 vs. 10.6 days, p = 0.024). The average total in-hospital cost of a patient undergoing an EEEA was $58979.3 compared to $89142.3 for an open approach (p = 0.127). On univariate regression analysis, the total in-hospital cost for a patient undergoing an open approach relative to an EEEA was $30163.0 (p = 0.127). The open approach was exclusively performed from study onset until April 2010 (16 patients). From April 2010 to August 2013, 6 open approaches and 5 EEEA were performed. The EEEA has been exclusively performed from August 2013 until the conclusion of our study period (9 patients). CONCLUSIONS: There has been a shift toward surgical resection of craniopharyngioma via an EEEA approach for amenable tumors. Our study demonstrates that the EEEA has become the preferred surgical approach at our institution, and shows that the EEEA is associated with shorter postoperative length of stay and lower total in-hospital cost. Laryngoscope, 133:83-87, 2023.

Longitudinal Study of Analgesic Use and Risk of Incident Persistent Tinnitus.

BACKGROUND: Persistent tinnitus is common, disabling, and difficult to treat. High-dose aspirin may precipitate tinnitus, but longitudinal data on typical dose aspirin and other analgesics are scarce. OBJECTIVE: To investigate independent associations of aspirin, NSAIDs, and acetaminophen and risk of incident persistent tinnitus. DESIGN: Longitudinal cohort study. SETTING: Nurses' Health Study II (1995-2017). PARTICIPANTS: A total of 69,455 women, age 31-48 years, without tinnitus at baseline. MAIN MEASURES: Information on analgesic use and tinnitus obtained by biennial questionnaires. KEY RESULTS: After 1,120,936 person-years of follow-up, 10,452 cases of incident persistent tinnitus were reported. For low-dose aspirin, the risk of developing persistent tinnitus was not elevated among frequent low-dose aspirin users. For moderate dose aspirin, frequent use was associated with higher risk of tinnitus among women aged < 60 years, but not among older women (p-interactionage = 0.003). Compared with women aged < 60 using moderate-dose aspirin < 1 day/week, the multivariable-adjusted hazard ratio (MVHR, 95% CI) among women using moderate-dose aspirin 6-7 days per week was 1.16 (1.03, 1.32). Among all women, frequent non-aspirin non-steroidal anti-inflammatory drug (NSAID) or acetaminophen use was associated with higher risk. Compared with women using NSAIDs <1 day/week, the MVHR for use 4-5days/week was 1.17 (1.08, 1.28) and for 6-7days/week was 1.07 (1.00, 1.16) (p-trend=0.001). For acetaminophen, compared with use <1 day/week, the MVHR for use 6-7days/week was 1.18 (1.07, 1.29) (p-trend=0.002). LIMITATIONS: Information on tinnitus and analgesic use was self-reported. Information on indications for analgesic use was not available. Studies in non-White women and men are needed. CONCLUSION: The risk of developing persistent tinnitus was not elevated among frequent low-dose aspirin users. Among younger women, frequent moderate-dose aspirin use was associated with higher risk. Frequent NSAID use and frequent acetaminophen use were associated with higher risk of incident persistent tinnitus among all women, and the magnitude of the risks tended to be greater with increasing frequency of use. Our results suggest analgesic users are at higher risk for developing tinnitus and may provide insight into the precipitants of this challenging disorder, but additional investigation to determine whether there is a causal association is needed.

The Impact of COVID-19 on Otolaryngology Community Practice in Massachusetts.

OBJECTIVES: Coronavirus disease 2019 (COVID-19) significantly affected many health care specialties, including otolaryngology. In response to governmental policy changes, many hospitals and private practices in Massachusetts canceled or postponed nonurgent office visits and elective surgeries. The objective of this study was to quantify the impact of COVID-19 on the provision and practice trends of otolaryngology services for 10 private practices in Massachusetts. STUDY DESIGN: Retrospective review. SETTING: Multipractice study for community practices in Massachusetts. METHODS: Electronic billing records from 10 private otolaryngology practices in Massachusetts were obtained for the first 4 months of 2019 and 2020. Questionnaires from these otolaryngology practices were collected to assess financial and staffing impact of COVID-19. RESULTS: The local onset of the COVID-19 pandemic had a significant decrease of 63% of visits in comparison to equivalent weeks in 2019. Virtual visits overtook in-person visits over time. A greater decline in operating room (OR) procedures than for office procedures was recorded. Ninety percent of practices reduced working hours, and 80% furloughed personnel. Seventy percent of practices applied for the Paycheck Protection Program (PPP). CONCLUSION: COVID-19 has had a multifaceted impact on private otolaryngology practices in Massachusetts. A significant decline in provision of otolaryngology services aligned with the Massachusetts government's public health policy changes. The combination of limited personnel and personal protective equipment, as well as suspension of nonessential office visits and surgeries, led to decrease in total office visits and even higher decrease in OR procedures.

Drivers of In-Hospital Costs Following Endoscopic Transphenoidal Pituitary Surgery.

OBJECTIVE: To characterize the patient and clinical factors that determine variability in hospital costs following endoscopic transphenoidal pituitary surgery. METHODS: All endoscopic transphenoidal pituitary surgeries performed from January 1, 2015, to October 24, 2017, with complete data were evaluated in this retrospective single-institution study. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables during each hospital stay. Multivariate linear regression was performed using Stata software. RESULTS: The analysis included 190 patients and average length of stay was 4.71 days. Average total in-hospital cost was $28,624 (95% confidence interval $25,094-$32,155) with average total direct cost of $19,444 ($17,136-$21,752) and total indirect cost of $9181 ($7592-$10,409). On multivariate regression, post-operative cerebrospinal fluid (CSF) leak was associated with a significant increase in all cost variables, including a total cost increase of $40,981 ($15,474-$66,489, P = .002). Current smoking status was associated with an increased total cost of $20,189 ($6,638-$33,740, P = .004). Self-reported Caucasian ethnicity was associated with a significant decrease in total cost of $6646 (-$12,760 to -$532, P = .033). Post-operative DI was associated with increased costs across all variables that were not statistically significant. CONCLUSIONS: Post-operative CSF leak, current smoking status, and non-Caucasian ethnicity were associated with significantly increased costs. Understanding of cost drivers of endoscopic transphenoidal pituitary surgery is critical for future cost control and value creation initiatives. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:760-764, 2021.

The impact of expanded endonasal skull base surgery on midfacial growth in pediatric patients.

OBJECTIVE: Surgical resection of skull base tumors in children is increasingly accomplished through an expanded endonasal approach (EEA). We aim to evaluate the potential effect of the EEA on midfacial growth as a result of iatrogenic damage to nasal growth zones. METHODS: We performed a retrospective review of children undergoing craniopharyngioma resection via an open transcranial or EEA. Pre- and postoperative magnetic resonance imaging was evaluated for growth in four midfacial measurements based on established cephalometric landmarks: anterior midface height, posterior midface height, palatal length, and sella-nasion distance. Statistical analysis was conducted using a mixed-effects linear regression model. RESULTS: Twenty-two patients underwent an EEA (n = 12) or open transcranial approach (n = 10) for tumor resection with 3 years of imaging follow-up. There was no difference in midfacial growth between groups for each measurement. Compared to the open group, patients undergoing EEA demonstrated relative anterior midface height growth of -0.42 mm (P = 0.880), posterior midface height growth of -0.44 mm (P = 0.839), palatal length growth of 0.35 mm (P = 0.894), and sella-nasion distance growth of -2.16 (P = 0.365). CONCLUSION: We found no difference in midfacial growth measurements between patients undergoing craniopharyngioma resection via an EEA and the open transcranial route after 3 years of imaging follow-up. Preliminary results on midfacial growth demonstrate that the EEA is a safe alternative to traditional transcranial approaches for the pediatric population. Further investigation with larger sample size and longer duration of follow-up is warranted to more thoroughly investigate the long-term implications of the EEA to the skull base. LEVEL OF EVIDENCE: 3 Laryngoscope, 130:338-342, 2020.

Evaluating the impact of adenotonsillectomy for pediatric sleep-disordered breathing on parental sleep.

OBJECTIVES/HYPOTHESIS: To evaluate the impact of adenotonsillectomy for pediatric sleep-disordered breathing (SDB) on parental sleep quality, daytime sleepiness, and child quality of life. STUDY DESIGN: Prospective cohort study. METHODS: Pediatric patients aged 2 to 10 years with SDB and suspected obstructive sleep apnea (OSA) requiring adenotonsillectomy were identified at a single tertiary-care pediatric otolaryngology hospital. Parental daytime sleepiness and quality of sleep were evaluated pre- and postoperatively using the Epworth Sleepiness Scale (ESS) and Pittsburg Sleep Quality Index (PSQI), respectively. Child quality of life, in the context of suspected OSA, was evaluated by the Obstructive Sleep Apnea Quality of Life Survey (OSA-18), pre- and postoperatively. Paired-samples t tests were conducted to analyze data. RESULTS: Forty-seven patients with a mean (standard deviation [SD]) age of 4.9 (2.2) years, participated. Mean (SD) parental age was 35.5 (4.6) years. Statistically significant decreases of 2.1 points were observed between preoperative and postoperative parental mean global ESS (P = .007; 95% confidence interval [CI]: 0.6-3.6) and mean total PSQI (P = .001; 95% CI: 0.9-3.1) scores. A statistically significant improvement (41.6 points) was observed between preoperative and postoperative on mean OSA-18 scores (P < .0001; 95% CI: 35.7-47.6). CONCLUSIONS: Adenotonsillectomy performed in the pediatric population for SDB, with suspected OSA, can positively impact parental daytime sleepiness and sleep quality in addition to pediatric quality of life. LEVEL OF EVIDENCE: 2 Laryngoscope, 130:232-237, 2020.

Clinical and Radiographic Characteristics of Sinonasal Posttransplant Lymphoproliferative Disorder and Invasive Fungal Sinusitis.

BACKGROUND: Sinonasal posttransplant lymphoproliferative disorder (PTLD) is a serious but uncommon complication of solid organ and hematopoietic stem cell transplantation that can overlap in many features with invasive fungal sinusitis (IFS). OBJECTIVE: To identify clinical, laboratory, and radiographic features that may help to differentiate sinonasal IFS and PTLD in the posttransplant population. METHODS: We performed a retrospective chart review of patients with posttransplant sinonasal PTLD and IFS to evaluate for clinical, laboratory, and imaging characteristics. RESULTS: A total of 4 patients with sinonasal PTLD and 10 posttransplant IFS patients were evaluated. A total of 2 of 4 PTLD patients presented with a symptom duration of greater than 3 months compared to none in the IFS group (p = 0.07). Mean absolute neutrophil count (ANC) was 2,976 per mm3 (range 2,488-3,462) in the PTLD group compared to 773 per mm3 (range 0.0-2,744) in the IFS group (p = 0.01). Both PTLD lesions with available diffusion-weighted imaging demonstrated diffusion restriction on magnetic resonance im-aging (MRI) compared to zero of the IFS lesions (p = 0.10). No PTLD lesions demonstrated mucosal infarcts compared to three of seven IFS lesions (p = 0.23). CONCLUSION: IFS was associated with a significantly lower ANC at the time of diagnosis compared to PTLD. Additionally, three other measures trend towards association with their respective pathology. PTLD typically has a more chronic time course than IFS, diffusion restriction on MRI is predominantly associated with PTLD patients, and mucosal infarct on MRI is more suggestive of IFS. Additionally, all cases of sinonasal PTLD arose following solid organ transplantation. These factors may assist clinicians during diagnosis.

Nasopharyngeal Angiofibroma: A Forgotten Entity in Older Patients.

INTRODUCTION: Nasopharyngeal angiofibroma (NA) characteristically affects adolescent men. Although benign, these tumors can cause local destruction and surgical resection is warranted. OBJECTIVE: We present a case of a 62-year-old man with nasal congestion and epistaxis, found to be a right NA on pathology. We also present a review of the available NA staging systems. FINDINGS: In this case of NA, imaging revealed an aggressive, hypervascular mass in the nasal cavity with involvement of the middle cranial fossa and cavernous sinus. The patient underwent complete endoscopic surgical resection following vascular embolization. CONCLUSIONS: Although it is rare, NA should not be disregarded in the elderly population.

Accuracy of Self-reported Diagnosis of Chronic Rhinosinusitis.

Large cohort studies of chronic rhinosinusitis (CRS) prevalence often include patients who have been inappropriately diagnosed with the disease. In this investigation, new patients presenting to a tertiary rhinology practice completed a screening questionnaire that included questions about self-reported CRS status, demographic information, and symptomatology. Treating rhinologists evaluated patients according to clinical practice guideline criteria for CRS; 91 patients were ultimately diagnosed with CRS. The sensitivity of self-report for CRS was 84%; the specificity was 82%; and the estimated negative predictive value ranged from 97% to 99%. Prior sinus surgery or oral steroid use correlated with CRS self-report, and a concurrent self-report of nasal polyps or nasal steroid use improved the positive predictive value of CRS self-report. Self-report of CRS status may represent an effective and relatively inexpensive screening mechanism for CRS in large cohort studies, particularly when combined with other associated diagnostic features that improve performance parameters of self-report.

Alcohol-induced respiratory symptoms improve after aspirin desensitization in patients with aspirin-exacerbated respiratory disease.

BACKGROUND: Aspirin-exacerbated respiratory disease (AERD) is characterized by chronic eosinophilic rhinosinusitis, nasal polyps, asthma, and respiratory sensitivity to aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). In addition to sensitivity to aspirin and NSAIDs, the majority of patients with AERD have been reported to have respiratory intolerance associated with the consumption of alcohol. METHODS: A multicenter prospective cohort study was performed. Patients with AERD confirmed by aspirin challenge were eligible to participate. Those who described themselves as able to tolerate alcohol consumption were excluded. Patients underwent aspirin desensitization following endoscopic sinus surgery. A questionnaire was distributed to patients before and after desensitization to determine pre-desensitization and post-desensitization symptoms associated with alcohol ingestion. RESULTS: Forty-five patients were enrolled and 37 patients completed the study. The most common pre-desensitization symptoms were nasal congestion (95.6%), rhinorrhea (46.7%), and wheezing (40%). Improvement in the ability to tolerate alcohol was noted in 86.5% of participants (95% confidence interval [CI], 75.5% to 97.5%) and 70.3% of participants (95% CI, 55.5% to 85.0%) described desensitization to be "very helpful" or "extremely helpful" for their ability to tolerate alcohol. CONCLUSION: The majority of patients with AERD who experience respiratory symptoms with alcohol consumption describe improvement in this domain following aspirin desensitization.

Preoperative Lund-Mackay computed tomography score is associated with preoperative symptom severity and predicts quality-of-life outcome trajectories after sinus surgery.

BACKGROUND: Disagreement exists about the relationship between Lund-Mackay CT scores (LMCTS) and quality-of-life outcome (QoL) measures. We investigated whether preoperative LMCTS are associated with preoperative QoL, and whether LMCTS is predictive of postoperative QoL outcomes in chronic rhinosinusitis (CRS) patients. METHODS: Adult patients with medically recalcitrant CRS (n = 665) were enrolled in a prospective, observational cohort study. Preoperative LMCTS and pre- and postoperative self-reported QoL outcomes (22-item Sino-Nasal Outcomes Test [SNOT-22]) were collected and evaluated over 12 months. Five hundred sixty-eight patients met the inclusion criteria. Longitudinal linear mixed-effects modeling was used to investigate the effect of LMCTS on QoL after functional endoscopic sinus surgery (FESS). RESULTS: Preoperative LMCTS were significantly associated with preoperative SNOT-22 scores (p < 0.01) and postoperative SNOT-22 scores (p < 0.001), driven by Extranasal and Rhinologic subdomains of the QoL questionaire. Patients in the lowest preoperative LMCTS quartile had the lowest mean change in SNOT-22 scores at 12 months (16.8 points; 95% confidence interval [CI], 12.2-21.3). Patients in the second and third lowest preoperative LMCTS quartiles had mean changes at 12 months of 21.1 points (95% CI, 16.7-25.4) and 23.1 points (95% CI, 18.3-27.9). Patients in the highest preoperative LMCTS quartile had the greatest improvement in SNOT-22 scores after FESS (29.9 points; 95% CI, 24.9-34.8). The difference in QoL change at 12 months between the highest and lowest preoperative LMCTS quartiles was 13.1 points (95% CI, 6.0-20.2; p < 0.001). CONCLUSION: Our study demonstrates that preoperative LMCTS correlate with preoperative extranasal and rhinologic symptom severity and that the LMCTS is an indicator of postsurgical QoL outcomes for medically recalcitrant chronic rhinosinusitis patients in a large tertiary otolaryngology setting.

Sinonasal quality of life after endoscopic resection of malignant sinonasal and skull base tumors.

OBJECTIVES: Improvement in sinonasal quality of life (QoL) following sinus surgery has been well-documented across the literature. To our knowledge, only one series has evaluated long-term QoL in patients undergoing tumor resection, and that study demonstrated no improvement in rhinologic QoL following malignant tumor resection at 2-year follow-up. The objective of the present study was to evaluate QoL in the 2 years following endoscopic malignant tumor resection. METHODS: A prospective cohort study was performed, including patients with both malignant and benign sinonasal tumors in a tertiary academic medical center. Patients undergoing endoscopic tumor resection who had completed Sinonasal Outcome Test 22 (SNOT-22) questionnaires were included in the cohort. SNOT-22 questionnaires were administered preoperatively and over a 2-year follow-up period at clinic visits. Longitudinal linear mixed-effects regression was used to compare preoperative QoL to QoL over the 2 years following surgery. RESULTS: Among 145 patients included in this study, 64 had malignant tumors. There was a statistically significant improvement in SNOT-22 score from baseline to 2 years for patients with both malignant tumors (37.0, 95% confidence Interval [CI] 32.0-42.1 at baseline; 26.5 95% CI 20.8-32.2 at 2 years; P < 0.001) and benign tumors (26.5, 95% CI 21.4-30.4 at baseline; 12.9 95% CI 7.6-18.2 at 2 years; P < 0.001). CONCLUSION: In contrast to previously reported series, in this cohort endoscopic resection of sinonasal tumors appears to be followed by an improvement in QoL, which is sustained over a 2-year period. LEVEL OF EVIDENCE: 2b. Laryngoscope, 128:789-793, 2018.

Disparities in sinonasal squamous cell carcinoma short- and long-term outcomes: Analysis from the national cancer database.

OBJECTIVES/HYPOTHESIS: To examine sociodemographic, hospital-specific, and disease-related characteristics in relation to outcomes in sinonasal squamous cell carcinoma (SCC). STUDY DESIGN: The National Cancer Database was queried for location codes corresponding to the nasal cavity and paranasal sinuses and histology codes representing SCC malignancy. Multivariate analyses were performed against short- and long-term outcomes (overall survival, days to discharge, 30-day readmission, and 30- and 90-day mortality). RESULTS: The database included 5,584 sinonasal SCC patients with an overall median survival of 53.5 months (95% confidence interval [CI]: 49.7-57.8). On multivariate analysis, uninsured, Medicaid, and Medicare were independently associated with worse overall survival compared to private insurance (hazard ratio [HR]: 1.49, 95% CI: 1.22-1.82, P < .001; HR: 1.57, 95% CI: 1.34-1.85, P < .001; and HR: 1.14, 95% CI: 1.01-1.29, P = .03, respectively). Both Medicaid and Medicare were also associated with increased 30-day mortality (HR: 1.36, 95% CI: 1.76-143.29, P = .02; HR: 8.27, 95% CI: 1.66-70.88, P = .02, respectively), and Medicaid patients spent more time in the hospital following surgery (difference in days to discharge: HR: 2.09, 95% CI: 0.57-3.61, P < .01). Compared to white race, other race was associated with improved overall survival (HR: 0.79, 95% CI: 0.63-0.99, P = .04) but increased 30-day readmissions (HR: 3.85, 95% CI: 1.58-8.38, P < .01). Hispanic ethnicity was associated with increased 30-day readmissions (HR: 2.35, 95% CI: 1.08-4.75, P = .02]. The highest income bracket (≥$63,000) was associated with fewer hospital readmissions (HR: 0.33, 95% CI: 0.13-0.79, P = .01). CONCLUSIONS: Sociodemographic and economic differences in outcomes of patients with sinonasal SCC cancer exist. An understanding of these differences may help minimize disparities in oncologic treatment. LEVEL OF EVIDENCE: 2c. Laryngoscope, 128:560-567, 2018.

Outcomes after complete endoscopic sinus surgery and aspirin desensitization in aspirin-exacerbated respiratory disease.

BACKGROUND: In this study we assessed patient outcomes after complete endoscopic sinus surgery (ESS) and aspirin desensitization for patients with aspirin-exacerbated respiratory disease (AERD). METHODS: A retrospective chart review was conducted for patients with aspirin challenge-proven AERD who underwent complete ESS followed by aspirin desensitization. Outcomes assessed included need for revision surgery and quality-of-life measures using the 22-item Sino-Nasal Outcomes Test (SNOT-22). Data were collected preoperatively, postoperatively prior to desensitization, and then at intervals post-desensitization through 30 months after aspirin desensitization. A longitudinal linear mixed-effects model was used for data analysis. RESULTS: Thirty-four patients met the inclusion criteria for this study. Thirty-two patients successfully completed aspirin desensitization and were subsequently followed for 30 months after desensitization. Two patients were unable to complete desensitization. Five patients discontinued aspirin maintenance therapy due to gastrointestinal and respiratory side effects. Within the follow-up period, there were only 3 (9.4%) revision sinus surgeries. Notably, 1 of these revision cases occurred in a patient who had discontinued aspirin maintenance therapy. After surgical treatment and prior to desensitization patients had significant reductions in SNOT-22 scores. Our results demonstrate that total SNOT-22 scores remained statistically unchanged from immediate post-desensitization throughout the 30-month follow-up period. CONCLUSION: Complete sinus surgery followed by timely aspirin desensitization and maintenance therapy is an effective combination in the long-term management of sinus disease in patients with AERD.

18FDG PET/CT in Routine Surveillance of Asymptomatic Patients following Treatment of Sinonasal Neoplasms.

Objective Sinonasal neoplasms have a high rate of recurrence following treatment, and current guidelines support the use of a variety of surveillance techniques. Recent work demonstrates that performance parameters of surveillance modalities may differ with sinonasal tumors in particular when compared with head and neck tumors overall. This study aims to characterize the value of 18fluorodeoxyglucose (18FDG) positron emission tomography/computed tomography (PET/CT) as a screening tool in asymptomatic patients. Study Design Retrospective cohort study. Setting Hospital of the University of Pennsylvania and Pennsylvania hospital. Methods Records of asymptomatic patients without suspicious endoscopy or suspicious imaging other than PET during the first 3 years following definitive treatment for sinonasal malignancy were screened and analyzed for inclusion in the cohort. Disease recurrence was determined by biopsy following suspicious PET evaluation. Results PET/CT scans (n = 111) were performed for 45 disease-free asymptomatic patients with no evidence of disease on endoscopy, and 6.3% were suspicious and prompted biopsy during this period, revealing 3 cases of disease recurrence. Overall specificity for PET/CT alone was 96.3% (95% CI, 90.7%-99.0%), with a negative predictive value of 99% (95% CI, 94.8%-100%). All recurrences were detected between 7 and 12 months, and all patients with true recurrence diagnosed by PET/CT had extrasinonasal involvement of tumor at the time of surgery. Conclusion We examined performance parameters of 18FDG PET/CT in asymptomatic patients with no evidence of disease on endoscopy during the posttreatment period for sinonasal malignancy. The ability of PET/CT to detect recurrences that may be missed by structural imaging or endoscopy makes it a valuable tool for clinicians.

Accuracy of computer-assisted navigation: significant augmentation by facial recognition software.

BACKGROUND: Over the past 20 years, image guidance navigation has been used with increasing frequency as an adjunct during sinus and skull base surgery. These devices commonly utilize surface registration, where varying pressure of the registration probe and loss of contact with the face during the skin tracing process can lead to registration inaccuracies, and the number of registration points incorporated is necessarily limited. The aim of this study was to evaluate the use of novel facial recognition software for image guidance registration. METHODS: Consecutive adults undergoing endoscopic sinus surgery (ESS) were prospectively studied. Patients underwent image guidance registration via both conventional surface registration and facial recognition software. The accuracy of both registration processes were measured at the head of the middle turbinate (MTH), middle turbinate axilla (MTA), anterior wall of sphenoid sinus (SS), and nasal tip (NT). RESULTS: Forty-five patients were included in this investigation. Facial recognition was accurate to within a mean of 0.47 mm at the MTH, 0.33 mm at the MTA, 0.39 mm at the SS, and 0.36 mm at the NT. Facial recognition was more accurate than surface registration at the MTH by an average of 0.43 mm (p = 0.002), at the MTA by an average of 0.44 mm (p < 0.001), and at the SS by an average of 0.40 mm (p < 0.001). The integration of facial recognition software did not adversely affect registration time. CONCLUSION: In this prospective study, automated facial recognition software significantly improved the accuracy of image guidance registration when compared to conventional surface registration.

Primary care specialty career choice among Canadian medical students: Understanding the factors that influence their decisions.

OBJECTIVE: To identify which factors influence medical students' decision to choose a career in family medicine and pediatrics, and which factors influence their decision to choose careers in non-front-line specialties. DESIGN: Survey that was created based on a comprehensive literature review to determine which factors are considered important when choosing practice specialty. SETTING: Ontario medical school. PARTICIPANTS: An open cohort of medical students in the graduating classes of 2008 to 2011 (inclusive). MAIN OUTCOME MEASURES: The main factors that influenced participants' decision to choose a career in primary care or pediatrics, and the main factors that influenced participants' decision to choose a career in a non-front-line specialty. RESULTS: A total of 323 participants were included in this study. Factors that significantly influenced participants' career choice in family medicine or pediatrics involved work-life balance (acceptable hours of practice [P = .005], acceptable on-call demands [P = .012], and lifestyle flexibility [P = .006]); a robust physician-patient relationship (ability to promote individual health promotion [P = .014] and the opportunity to form long-term relationships [P < .001], provide comprehensive care [P = .001], and treat patients and their families [P = .006]); and duration of residency program (P = .001). The career-related factors that significantly influenced participants' decision to choose a non-front-line specialty were as follows: becoming an expert (P < .001), maintaining a focused scope of practice (P < .001), having a procedure-focused practice (P = .001), seeing immediate results from one's actions (P < .001), potentially earning a high income (P < .001), and having a perceived status among colleagues (P < .001). CONCLUSION: In this study, 8 factors were found to positively influence medical students' career choice in family medicine and pediatrics, and 6 factors influenced the decision to choose a career in a non-front-line specialty. Medical students can be encouraged to explore a career in family medicine or pediatrics by addressing misinformation, by encouraging realistic expectations of career outcomes in the various specialties, and by demonstrating the capacity of primary care fields to incorporate specific motivating factors.