The argument against the use of dupilumab in patients with limited polyp burden in chronic rhinosinusitis with nasal polyposis (CRSwNP).

Dupilumab and other biologics have revolutionized the management of recalcitrant polyps in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP). Despite strong evidence for the efficacy of dupilumab in treating polyps, factors such as cost and uncertain efficacy over surgery have limited its use to patients who have failed the use of topical nasal steroids and initial surgical management. Likewise, the use of this drug is often directed towards patients with greater polyp burdens. Recent studies, however, have investigated the use of dupilumab and other biologics in expanded patient populations, including those with limited polyp burden. The overall trend in the literature suggests a future move towards the use of biologics as first-line therapy for all patients with CRSwNP. The arguments against widespread, routine use of dupilumab and biologics in all patients with CRSwNP are threefold. First, endoscopic sinus surgery has been found to provide similar symptomatic benefit to dupilumab in the treatment of these patient populations. The surgical improvement of patients' sinonasal anatomy offers a rapid elimination of sources of ongoing inflammation that contribute to long-term polyp formation and symptoms. Medical non-compliance in this specific patient population is known to be an issue, with surgery offering a much greater long-term prospect of symptomatic relief in non-compliant patients. The second concern revolves around the potential for side effects of dupilumab and other biologics. Initial studies have shown an acceptable safety profile, but trials assessing the use of dupilumab for a separate indication revealed a higher rate of conjunctivitis. Long-term safety data is limited for biologics, and we must be prepared for the possibility of severe, unanticipated adverse events in the future. Our third and most profound concern is the significant cost of dupilumab. This medication is enormously expensive, and all current literature suggests that treatment would need to be life-long to remain effective. Studies comparing endoscopic sinus surgery to various biologics, including dupilumab, have shown comparable overall quality of life metrics with biologics, all while delivering considerably higher anticipated lifetime costs. As our knowledge progresses regarding the efficacy of dupilumab and other biologics in a variety of clinic situations, it is important to understand the context in which these advances are being made. While dupilumab and other biologics offer undeniable efficacy in the treatment of chronic rhinosinusitis with nasal polyposis which has failed to respond to standard therapies, we argue that biologics remain only a component of effective management in this patient population. Endoscopic sinus surgery and topical nasal steroids offer equal efficacy and substantially lower costs than biologics, and these factors should be considered when selecting treatment options for patients.

The Effects of Double Gloving on Microsurgical Skills.

Objective To determine whether double gloving would negatively affect participants' ability to perform a simulated microsurgical task. Study Design Randomized single-blinded controlled crossover trial. Setting Temporal bone laboratory of an academic otolaryngology department. Subjects and Methods This study involved the simulated insertion of a stapes prosthesis into a model of the ossicular chain under microscopy. Forty-one participants were recruited from our medical and dental school and randomized into 2 groups. All groups began by performing the task without gloves, acting as their own control arm. The first group (A) then performed the task with a single pair of gloves while the second group (B) next performed the task with 2 pairs of gloves. The groups then switched gloving methods. The total time taken to perform the task was recorded for each participant and the results subjected to a series of statistical measures. Results This study found a statistically significant difference in the average time taken to complete the task between the "no-glove" arm of the study and both experimental groups but no difference between the 2 experimental groups. Likewise, no significant difference was found between the 2 experimental groups when comparing the rate at which they improved at performing the task. Conclusion These data suggest that wearing 2 pairs of surgical gloves does not negatively affect the speed at which a microsurgical procedure may be performed, lending support to the practice of double gloving, even in the setting of microsurgical fine motor tasks.

Severe necrosis of the palate and nasal septum resulting from intranasal abuse of acetaminophen.

Intranasal drug abuse frequently leads to sinonasal complications, particularly sinus, nasal, and palatal necrosis. Classically, this type of necrosis has been linked to cocaine use, but the intranasal abuse of prescription narcotics and other pain medications can also lead to severe damage to the sinonasal tract. We describe a case of palatal and nasal septal necrosis resulting from intranasal acetaminophen abuse. The patient was a 34-year-old man with a remote history of polysubstance abuse who presented to the emergency department with worsening dysphagia and a recent history of exclusive intranasal acetaminophen abuse. He had an existing palatal fistula that was found to have dramatically increased in size. Examination revealed complete destruction of the soft palate and nasal septum and partial destruction of the hard palate. The areas of necrosis were surgically debrided. We describe the general clinical presentation and surgical outcome of this case.