Features of Importance in Nasal Endoscopy: Deriving a Meaningful Framework.

OBJECTIVE: Critical components of the nasal endoscopic examination have not been definitively established for either the normal examination or for clinical disorders. This study aimed to identify concordance among rhinologists regarding the importance of examination findings for various nasal pathologies. STUDY DESIGN: A consortium of 19 expert rhinologists across the United States was asked to rank the importance of findings on nasal endoscopy for 5 different sinonasal symptom presentations. SETTING: An online questionnaire was distributed in July 2023. METHODS: The questionnaire utilized JotForm® software and featured 5 cases with a set of 4 identical questions per case, each covering a common indication for nasal endoscopy. Rankings were synthesized into Normalized Attention Scores (NASs) and Weighted Normalized Attention Scores (W-NASs) to represent the perceived importance of each feature, scaled from 0 to 1. RESULTS: General concordance was found for examination findings on nasal endoscopy within each case. The perceived features of importance differed between cases based on clinical presentation. For instance, in evaluating postnasal drip, the middle meatus was selected as the most important structure to examine (NAS, 0.73), with mucus selected as the most important abnormal finding (W-NAS, 0.66). The primary feature of interest for mucus was whether it was purulent or not (W-NAS, 0.67). Similar analyses were performed for features in each case. CONCLUSION: The implicit framework existing among rhinologists may help standardize examinations and improve diagnostic accuracy, augment the instruction of trainees, and inform the development of artificially intelligent algorithms to enhance clinical decision-making during nasal endoscopy.

Evaluation and treatment of rhinosinusitis with primary antibody deficiency in adults: Evidence-based review with recommendations.

BACKGROUND: There is clear evidence that the prevalence of primary antibody deficiency (PAD) is higher in patients with recurrent and chronic rhinosinusitis (CRS) than in the general population. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on rhinosinusitis with PAD, summarize the existing evidence, and provide recommendations on the evaluation and management of rhinosinusitis in patients with PAD. METHODS: The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through August 2022. Studies on the evaluation and management of rhinosinusitis in PAD patients were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on the evaluation and management principles for PAD were generated. RESULTS: A total of 42 studies were included in this evidence-based review. These studies were evaluated on incidence of PAD in rhinosinusitis patients, incidence of rhinosinusitis in PAD patients, and on the different treatment modalities used and their outcome. The aggregate quality of evidence was varied across reviewed domains. CONCLUSION: Based on the currently available evidence, PAD can occur in up to 50% of patients with recalcitrant CRS. Despite the presence of multiple studies addressing rhinosinusitis and PAD, the level of evidence supporting different treatment options continues to be lacking. Optimal management requires a multidisciplinary approach through collaboration with clinical immunology. There is need for higher-level studies that compare different treatments in patients with PAD and rhinosinusitis.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023.

BACKGROUND: In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document. METHODS: ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work. RESULTS: ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost. CONCLUSION: The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Systemic Steroids for Otolaryngology-Head and Neck Surgery Disorders: An Evidence-Based Primer for Clinicians.

OBJECTIVE: To offer pragmatic, evidence-informed guidance on the use of systemic corticosteroids (SCS) for common otolaryngologic disorders. DATA SOURCES: PubMed, Cochrane Library, and American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guidelines. REVIEW METHODS: A comprehensive search of published literature through November 2021 was conducted on the efficacy of SCS, alone or in combination with other treatments, for managing disorders in otolaryngology and the subdisciplines. Clinical practice guidelines, systematic reviews, and randomized controlled trials, when available, were preferentially retrieved. Interventions and outcomes of SCS use were compiled to generate summary tables and narrative synthesis of findings. CONCLUSIONS: Evidence on the effectiveness of SCS varies widely across otolaryngology disorders. High-level evidence supports SCS use for Bell's palsy, sinonasal polyposis, and lower airway disease. Conversely, evidence is weak or absent for upper respiratory tract infection, eustachian tube dysfunction, benign paroxysmal positional vertigo, adenotonsillar hypertrophy, or nonallergic rhinitis. Evidence is indeterminate for acute laryngitis, acute pharyngitis, acute sinusitis, angioedema, chronic rhinosinusitis without polyps, Ménière's disease, postviral olfactory loss, postoperative nerve paresis/paralysis, facial pain, and sudden sensorineural hearing loss. IMPLICATIONS FOR PRACTICE: Clinicians should bring an evidence-informed lens to SCS prescribing to best counsel patients regarding the risks, anticipated benefits, and limited data on long-term effects. Alternate routes of corticosteroid administration-such as sprays, drops, inhalers, and intralesional injections-may be preferable for many disorders, particularly those that are self-limited or require a prolonged duration of therapy. Prudent use of SCS reduces the risk of medication-related adverse effects. Clinicians who are conversant with high-level evidence can achieve optimal outcomes and stewardship when prescribing SCS.

Climate change, the environment, and rhinologic disease.

BACKGROUND: The escalating negative impact of climate change on our environment has the potential to result in significant morbidity of rhinologic diseases. METHODS: Evidence based review of examples of rhinologic diseases including allergic and nonallergic rhinitis, chronic rhinosinusitis, and allergic fungal rhinosinusitis was performed. RESULTS: The lower socioeconomic population, including historically oppressed groups, will be disproportionately affected. CONCLUSIONS: We need a systematic approach to improve healthcare database infrastructure and funding to promote diverse scientific collaboration to address these healthcare needs.

Radiological Assessment of High Anterior Septal Deviation and Its Impact on Sinus Access.

OBJECTIVES/HYPOTHESIS: High anterior septal deviation (HASD) is an underreported anatomic variant that can affect the decision to perform septoplasty for access during sinus surgery and ease of postoperative debridement. This study aims to 1) describe an objective method of assessing HASD, and 2) explore its prevalence and implications for performing septoplasty. STUDY DESIGN: Retrospective cross-sectional study. METHODS: Computed tomography scans from 2014 to 2020 were retrospectively reviewed. Two independent observers measured the following with respect to midline: distance to septum (SDD), distance to lateral nasal wall (LNW), and septal deviation angle (SDA). RESULTS: A total of 147 patients were included, with excellent interrater reliability across 99 patients (0.8-0.9). Mean measurements across all patients were SDD (2.77 mm ± 1.34), SDD/LNW (0.26 ± 0.12), and SDA (8.9° ± 4.0). Of 102 patients who underwent sinus surgery, 47 received septoplasty. Compared to the non-septoplasty cohort, the septoplasty cohort had a greater mean SDD (3.61 mm ± 1.48 vs. 2.27 mm ± 0.95; d = 1.10 [95% CI 0.67-1.51]), SDD/LNW (0.34 ± 0.13 vs. 0.21 ± 0.09; d = 1.18 [95% CI 0.76-1.60]), and SDA (11.1° ± 4.3 vs. 7.3° ± 3.4; d = 1.00 [95% CI 0.58-1.40]). Receiver operating characteristic cutoffs were SDD ≥2.43 mm, SDD/LNW ≥0.25, and SDA ≥7.6°, corresponding to a 49%-58% prevalence of HASD. CONCLUSION: HASD is relatively common and the methods described herein can reliably assess its dimensions. Measurements of SDD, SDD/LNW, and SDA exceeding cutoffs determined by this study may represent clinically significant deflections prompting consideration of septoplasty. These methods may aid in preoperative planning. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:1166-1171, 2022.

An Evaluation of YouTube Videos as a Surgical Instructional Tool for Endoscopic Endonasal Approaches in Otolaryngology.

OBJECTIVES: Online surgical videos are an increasingly popular resource for surgical trainees, especially in the context of the COVID-19 pandemic. Our objective was to assess the instructional quality of the YouTube videos of the transsphenoidal surgical approach (TSA), using LAParoscopic surgery Video Educational Guidelines (LAP-VEGaS). METHODS: YouTube TSA videos were searched using 5 keywords. Video characteristics were recorded. Two fellowship-trained rhinologists evaluated videos using LAP-VEGaS (scale 0 [worst] to 18 [best]). RESULTS: The searches produced 43 unique, unduplicated videos for analysis. Mean video length 7 minutes (standard deviation [SD] = 13), mean viewership was 16 017 views (SD = 29 415), and mean total LAP-VEGaS score was 9 (SD = 3). The LAP-VEGaS criteria with the lowest mean scores were presentation of the positioning of the patient/surgical team (mean = 0.2; SD = 0.6) and the procedure outcomes (mean = 0.4; SD = 0.6). There was substantial interrater agreement (κ = 0.71). CONCLUSIONS: LAP-VEGaS, initially developed for laparoscopic procedures, is useful for evaluating TSA instructional videos. There is an opportunity to improve the quality of these videos.

Evidence-Based Medicine in Otolaryngology, Part 8: Shared Decision Making-Impact, Incentives, and Instruments.

In our previous installment, we introduced shared decision making (SDM) as a collaborative process in which patients, families, and clinicians develop a mutually optimized treatment plan when more than 1 reasonable treatment option exists. In this subsequent installment of our Evidence-Based Medicine in Otolaryngology Series, we expand on the topic of SDM, including the related current state of clinical decision making, the impact of SDM on health care utilization and patient satisfaction, the potential role of system and society changes, the experience with SDM as it relates to race and ethnicity, existing financial incentives, and the validated instruments that assess the extent to which SDM occurs.

Evidence-Based Medicine in Otolaryngology Part 7: Introduction to Shared Decision Making.

Shared decision making (SDM) is a collaborative process in which patients, families, and clinicians develop a mutually agreed upon treatment plan when more than one reasonable treatment option exists. This cooperative engagement fosters improvements in patient satisfaction, disease management, and outcomes and also has the capacity to promote evidence-based care. Thus, this seventh installment of our Evidence-Based Medicine in Otolaryngology series focuses on SDM. We introduce SDM, including its potential to reduce decisional conflict and decisional regret, when it should be used, its potential benefits, barriers to implementation, and its role in the management of chronic disease and otolaryngological conditions.

An abscess causing a delayed optic neuropathy after decompression for thyroid eye disease.

A 63-year-old female with Graves' disease and chronic sinusitis presented with acute left orbital pain and proptosis five years after bilateral orbital decompression and sinus surgery. Imaging revealed bilateral frontal sinus opacification, frontoethmoidal mucoceles and left subperiosteal mass. Presence of an optic neuropathy drove emergent management with intravenous antibiotics and orbitotomy with exploration. Intra-operatively, a left orbital abscess and left frontal sinus purulence were drained. The patient regained her vision with relief of proptosis and pain.

Nonallergic rhinitis.

This article reviews a uniform way to describe nonallergic rhinitis in its various forms. The insights into its pathophysiology are briefly reviewed. A classification scheme for the different forms is provided. This is followed by descriptions of the diagnosis, evaluation, and management of nonallergic rhinitis.

Bilateral Inflammatory Aural Polyps: A Manifestation of Samter's Triad.

We report an unusual case of bilateral inflammatory aural polyps in a patient with Samter's triad. This 52-year-old patient had a history of chronic rhinosinusitis with sinonasal polyps, asthma, and aspirin sensitivity, with progressive right-sided hearing loss, otorrhea, and aural fullness. She was found to have bilateral aural polyps, with the larger obstructing lesion on the right. A computed tomography supported these findings and revealed bilateral opacification of the middle ear cleft and mastoid air cells. An initial right tympanomastoidectomy was performed with the specimen histologically resembling a typical sinonasal polyp. We speculate that this patient's middle ear polyposis is secondary to the inflammatory changes of Samter's triad. This has not been described previously in the literature.

A systematic review of the use of intranasal steroids in the treatment of chronic rhinosinusitis.

OBJECTIVE: To determine if intranasal steroids (INS) are useful in the management of chronic rhinosinusitis without polyps and chronic rhinosinusitis (CRS) with polyps. DATA SOURCES: Studies for inclusion were searched using Medline, EMBASE, Cochrane databases, and references of included studies. REVIEW METHODS: Initial screening of article titles and abstracts obtained from the literature search was performed independently by two reviewers (SAJ and RT) based on the research protocol criteria. These articles then underwent a second-stage review. Each article was read in detail and discussed by the two reviewers before inclusion in the study. RESULTS: The review yielded 13 studies regarding the treatment of sinonasal polyps with intranasal steroids. Six of these could be included in the meta-analysis. The outcome measure used for meta-analysis was change in polyp size from baseline compared between the treatment and control groups. Results from both conservative and optimistic selection of treatment effect are positive, providing significant improvement in polyp size in the treatment group as compared to controls. In the conservative estimate, the mean improvement in polyp size score between the treatment and placebo group is 0.43 with a 95% CI of [0.25, 0.61]. Of those treatment groups with the largest improvement, the mean improvement in polyp size score can go as high as 0.63 with a 95% CI of [0.43, 0.82]. CONCLUSION: Intranasal steroids are beneficial in the treatment of chronic rhinosinusitis with sinonasal polyps. Further studies looking at the use of INS in the treatment of CRS without polyps are warranted.

Chronic rhinosinusitis and asthma.

Based on considerations of the underlying epidemiology, pathophysiology, histopathology, clinical relationships and treatment outcomes, the links between rhinosinusitis and asthma become evident supporting the unified airway concept.

Executive summary: asthma and the unified airway.

Asthma is a common comorbid disorder that will be seen by otolaryngologists in their treatment of patients with rhinitis, rhinosinusitis, and otitis media. Among otolaryngologists, however, a diagnosis of asthma is infrequently considered in this patient population. Otolaryngologists, however, may be in an important position to recognize this potential diagnosis and provide treatment or appropriate referral. To further develop this relationship among upper and lower airway inflammation, and to provide important information to otolaryngologists regarding this relationship, a multidisciplinary workgroup was impaneled by the American Academy of Otolaryngologic Allergy in August 2006. The full report of this meeting is published separately as a Supplement to Otolaryngology-Head and Neck Surgery. This Executive Summary provides a brief synopsis of that document, with a focus on comorbid respiratory inflammation for otolaryngologists. In the treatment of their patients with allergic rhinitis and rhinosinusitis, otolaryngologists must be aware of the possible presence of asthma so that appropriate treatment and/or referral can be initiated. The impact of this practice will allow more comprehensive treatment of patients with upper and lower airway disease, and will improve patient symptoms, function, and quality of life.

Asthma and the unified airway.

Inflammatory processes of the upper and lower airway commonly co-exist. Patients with upper respiratory illnesses such as allergic rhinitis and acute and chronic rhinosinusitis often present to both otolaryngologists and primary care physicians for treatment of their symptoms of nasal and sinus disease. These patients often have concurrent lower respiratory illnesses such as asthma that may be contributing to their overall symptoms and quality of life. Unfortunately, asthma frequently remains undiagnosed in this population. It was the objective of this paper to examine the relationship between upper respiratory illnesses such as rhinitis and rhinosinusitis and lower respiratory illnesses such as asthma, and to provide a framework for primary care and specialty physicians to approach these illnesses as a spectrum of inflammatory disease. The present manuscript was developed by a multidisciplinary workgroup sponsored by the American Academy of Otolaryngic Allergy. Health care providers in various specialties contributed to the manuscript through preparation of written materials and through participation in a panel discussion held in August 2006. Each author was tasked with reviewing a specific content area and preparing a written summary for inclusion in this final document. Respiratory inflammation commonly affects both the upper and lower respiratory tracts, often concurrently. Physicians who are treating patients with symptoms of allergic rhinitis and rhinosinusitis must be vigilant to the presence of asthma among these patients. Appropriate diagnostic methods should be used to identify individuals with concurrent respiratory illnesses, and comprehensive treatment should be instituted to reduce symptoms and improve quality of life.

Amoxicillin-clavulanic acid-induced hepatitis.

OBJECTIVES: The aim of this study was to report a rare side effect of amoxicillin-clavulanic acid resulting in drug-induced hepatitis in the treatment of chronic rhinosinusitis. METHODS: This is a case report and literature review of amoxicillin-clavulanic acid-induced hepatitis in the treatment of chronic rhinosinusitis. A MEDLINE search of the published literature from 1966 to 2006 was performed using the term "amoxicillin-clavulanic acid + hepatitis." RESULTS: We report a case of a 53-year-old man who developed drug-induced hepatitis after the use of amoxicillin-clavulanic acid for the treatment of chronic rhinosinusitis. After a 4-week course of amoxicillin-clavulanic acid, the patient developed pruritus and jaundice. Liver function tests revealed elevated aminotransferase levels. Serologic examination result for hepatitis A, B, and C was negative. The amoxicillin-clavulanic acid was discontinued and the patient was treated conservatively. The pruritus and jaundice gradually resolved and the patient had no long-term complications. The literature review revealed this is the first reported case of amoxicillin-clavulanic acid-induced hepatitis for the treatment of chronic rhinosinusitis. CONCLUSIONS: Drug-induced hepatitis is a rare side effect of amoxicillin-clavulanic acid. Care must be taken in prescribing this drug to elderly patients and patients with liver disease. In general, the hepatitis is mild to moderate, rarely leads to liver failure, and can be managed conservatively.

Mucosal remodeling in chronic rhinosinusitis.

BACKGROUND: Despite pathophysiologic similarities, mucosal remodeling is well described in asthma but not chronic rhinosinusitis (CRS). OBJECTIVE: This study attempts to identify mucosal remodeling in CRS and correlate it with clinical information. METHODS: Charts and histopathology from 53 CRS patients who underwent functional endoscopic sinus surgery were reviewed. Clinical data and basement membrane (BM) thickness were recorded. BM thickness was graded as 0 (no thickening), 1 (mild thickening), 2 (moderate thickening), or 3 (marked thickening). Control mucosae from ten patients without CRS were analyzed for comparison. RESULTS: Duration of CRS symptoms positively correlated with BM thickness (p = 0.007). Also, patients with a markedly thickened BM (score of 3) had a significantly greater duration of CRS symptoms (120 months) compared to patients with a thinner BM (score < or =2) (33 months) (p = 0.010). Markedly thickened BM was associated with increased coincidence of asthma (p = 0.019) and aspirin sensitivity (p = 0.003). No correlation was found between BM thickness and preoperative Lund-MacKay score. There was no statistically significant difference between markedly thickened BM and thinner BM with respect to coincidence of polyps, course of preoperative systemic steroids, estimated blood loss at surgery, and number of prior surgeries. CONCLUSION: Increased BM thickness is correlated with prolonged duration of symptoms and the coincidence of asthma. This may indicate paranasal sinus remodeling akin to that which occurs in the bronchioles of persistent asthmatic sufferers.