Objective and subjective sinonasal and pulmonary outcomes in aspirin desensitization therapy: A prospective cohort study.

OBJECTIVE: Aspirin exacerbated respiratory disease (AERD) patients are challenging to manage with sinonasal and pulmonary symptoms refractory to maximal medical and surgical therapies. Our objective was to comprehensively examine objective and validated, disease-specific subjective sinonasal and pulmonary outcomes of aspirin (ASA) desensitization therapy in this patient population. METHODS: Prospective cohort study at an academic tertiary center. AERD patients with a history of chronic rhinosinusitis with nasal polyposis (CRSwNP), prior diagnosis of asthma, and a history of ASA sensitivity were eligible for inclusion. Patients underwent ASA desensitization using an established institutional protocol and continued on a 650mg twice daily maintenance dose. Baseline Sinonasal Outcome Test (SNOT-22) and Asthma Control Questionnaire (ACQ) responses, acoustic rhinometry, peak flow readings, and endoscopic scoring of nasal polyps were recorded prior to desensitization and after 6months of maintenance therapy. RESULTS: Twelve patients were recruited for participation and underwent desensitization. Eight patients continued maintenance therapy and follow up at 6months. Prior to desensitization, patients reported bothersome sinonasal symptoms with a median SNOT-22 score of 30.0±34.5 (interquartile range (IQR)). There was significant improvement after 6months of maintenance therapy to a median SNOT-22 score of 18.5±17.3 (p=0.025, Wilcoxon signed rank test). Acoustic rhinometry, endoscopic scores, ACQ and forced expiratory volume values remained stable at 6months. CONCLUSIONS: AERD patients may benefit from ASA desensitization with subjective sinonasal symptom improvement at 6months and stable asthma and objective sinonasal measures. Further discussion is needed in the otolaryngology community regarding ASA desensitization in AERD management.

Current perspectives on the role of tonsillectomy.

Tonsillectomy is one of the most common paediatric surgical procedures performed in Australasia. The aim of this paper is to provide an up-to-date review of the indications for the procedure (and the evidence base for each of these indications), as well as describe the surgical technique and perioperative management and risks for a non-surgical audience. The primary indications for tonsillectomy are obstructive sleep apnoea (OSA) (where it is most commonly performed in association with adenoidectomy) and recurrent pharyngotonsillitis. There is now high-quality evidence that tonsillectomy improves objective measures of OSA on sleep studies, as well as quality of life and child behaviour. The impact of surgery on cognitive function is less well delineated. For recurrent pharyngotonsillitis, tonsillectomy has a modest impact on recurrent sore throat symptoms - clinicians should ensure an appropriate pre-operative observation period and adequately discuss the potential benefits with parents prior to surgery. Traditional approaches to tonsillectomy involve surgically dissecting the entire tonsil from the underlying pharyngeal muscle. Subtotal tonsillectomy (intracapsular tonsillectomy or tonsillotomy) is described for OSA and may reduce perioperative morbidity. Children younger than 3 years and those with moderate to severe OSA or significant comorbidities should be admitted for overnight observation. Simple analgesia is adequate for most patients postoperatively. Codeine is contraindicated due to reports of postoperative death due to respiratory suppression. Overall, tonsillectomy is a well-tolerated procedure, with pain and postoperative haemorrhage (2-4%) being the most common complications. Haemorrhage can be life threatening; however, the mortality rate remains very small at approximately 1:30 000.

Objective sinonasal functional outcomes in endoscopic anterior skull-base surgery: an evidence-based review with recommendations.

BACKGROUND: The use of endoscopic endonasal approaches to the anterior skull base has dramatically expanded in recent years, with clinical endpoints and complication rates that compare favorably to traditional approaches. The impact of the endoscopic approach on sinonasal function has been less rigorously evaluated. The purpose of this study was to systematically analyze the literature evaluating objective sinonasal outcomes in endoscopic anterior skull-base surgery, and provide evidence-based recommendations. METHODS: A systematic review of the literature was performed based on a published guideline for developing an evidence-based review with recommendations. Objective sinonasal outcomes included were olfaction, mucociliary clearance, and nasal airflow. RESULTS: Ten articles were identified addressing objective olfactory outcomes: 2 randomized controlled trials; 6 cohort studies; and 2 retrospective case series. One cohort study investigating mucociliary clearance was identified. Six studies reporting postoperative endoscopic outcomes were identified. CONCLUSION: Based on the available evidence, nasoseptal flap (NSF) elevation with or without use in reconstruction likely leads to impairment in objective olfactory function. Endoscopic sellar and parasellar surgery without the elevation of an NSF may lead to a transient reduction in olfactory function. In the absence of a high a priori risk of cerebrospinal fluid (CSF) leak, it is an option to avoid routine NSF elevation in sellar and parasellar procedures, with preservation of at least 1 vascular pedicle during the approach. Monopolar electrocautery for mucosal incisions may increase the risk of olfactory impairment. If an NSF is used, donor site defect reconstruction may be considered.

Acinic cell carcinoma of the parotid gland: Auckland experience and literature review.

Acinic cell carcinoma is an uncommon malignancy of the salivary glands and as such it has been difficult to accurately delineate its natural history. The aim of this study is to assess the behaviour of acinic cell salivary cancer of the parotid gland presenting to a single head and neck surgical unit in Auckland. The study is a structured review of cases of acinic cell carcinoma of the parotid gland presenting from 2000 to 2006 to the Head and Neck Unit at Auckland Hospital, those identified from the pathology database and the Otobase head and neck database. Case records and pathology reports were reviewed. Fifteen patients were identified, 9 men and 6 women. The mean age was 67.2 years, with range 50-85 years. The mean follow up was 4.4 years and range 1.1-7 years. There was one case of local recurrence during study period and no deaths. Five of 15 patients received postoperative radiotherapy. Postoperative complications consisted of one wound haematoma and two cases of marginal mandibular weakness (one transient and one permanent). Current management strategies are obtaining appropriate rates of recurrence and postoperative complications within the Auckland population.