The effect of endoscopic olfactory cleft polyp removal on olfaction.

BACKGROUND: The presence of olfactory cleft polyps in chronic rhinosinusitis with nasal polyposis is well documented, but the effect of endoscopic olfactory cleft polyp surgery on olfaction, versus observation, has not been well studied. This analysis assessed if microdebridement of olfactory cleft polyps yields significant objective smell improvements in those with anosmia or hyposmia. METHODS: A randomized prospective single-blinded study was performed on patients undergoing bilateral endoscopic sinus surgery with profound bilateral nasal polyposis, excluding those younger than 18 years or without olfactory polyps. A preoperative University of Pennsylvania Smell Identification Test (UPSIT), visual analog scale (VAS), and sinonasal outcomes 20 score (SNOT-20), and a follow-up at 6 months was performed. Two cohorts were created, including one with cleft polyp removal (group A) and one with cleft polyps left in place (group B). RESULTS: There were 10 patients in group A and 7 in group B. By using the Wilcoxon signed rank test, the two groups were individually analyzed for changes in the preoperative UPSIT, VAS, and SNOT-20 versus the 6-month test results. In group A, the improvement in the UPSIT, VAS, and SNOT-20 were statistically significant at p < 0.05. For group B only the improvement in the VAS was statistically significant, at p < 0.05. There was a statistically significant difference in clinical smell improvement between group A and B at 6 months (p = 0.00512). CONCLUSIONS: Evidence exists that olfactory cleft polyp surgery improves olfactory function outcomes. Long-term data beyond 6 months is needed to further validate these early promising outcomes.

Managing cerebrospinal fluid rhinorrhea after lateral skull base surgery via endoscopic endonasal eustachian tube closure.

BACKGROUND: A cerebrospinal fluid (CSF) leak, commonly presenting as rhinorrhea, is a well-recognized complication of lateral skull base surgery. Failure of conservative treatment measures in these cases necessitates surgical intervention. OBJECTIVE: Our aim is to demonstrate that endoscopic endonasal closure of the eustachian tube is a reasonable alternative to more traditional techniques for management of recalcitrant postoperative CSF rhinorrhea after removal of middle and posterior cranial fossa lesions. METHODS: A retrospective chart review was performed for patients who presented with CSF rhinorrhea after lateral skull base surgery at a tertiary medical center over a 17-year period, from 1997 to 2014. Nine patients managed with endoscopic endonasal closure of the eustachian tube were evaluated for preoperative hearing status, approach to lateral skull base surgery, pathology, size and location of the tumor, timing and presentation of CSF leak, methods of treatment, length of hospital stay, complications, and success of the procedure. RESULTS: Of the nine patients included in this review, seven were managed successfully with endoscopic endonasal eustachian tube closure. Of those seven, one required a revision procedure. Average length of postoperative stay was 5.8 days. There were no major complications. Follow up of greater than 100 months has been achieved since the first procedure. CONCLUSION: Endoscopic endonasal eustachian tube closure is a safe, minimally invasive and effective method for obliteration of the eustachian tube orifice. The algorithm for management of recalcitrant postoperative CSF rhinorrhea after lateral skull base surgery should include endoscopic endonasal closure of the eustachian tube.

Methicillin-resistant Staphylococcus aureus sinusitis in nonhospitalized patients: a systematic review of prevalence and treatment outcomes.

OBJECTIVES/HYPOTHESIS: Methicillin-resistant Staphylococcus aureus (MRSA) has been isolated from patients with acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS), although the exact prevalence is unknown. Similarly, the optimal treatment regimen for MRSA sinusitis has not been determined. The aim of this study was to summarize the existing data on prevalence and treatment outcomes for MRSA sinusitis in nonhospitalized patients. STUDY DESIGN: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. METHODS: MEDLINE, Embase, and Cochrane databases were queried for English-language studies published between 1942 and 2012. Studies were excluded that did not provide quantitative data on the prevalence or treatment of ARS or CRS with MRSA-positive cultures. An itemized assessment of the risk of bias was conducted for each included study. RESULTS: Of 409 studies identified during systematic review, 12 studies met the criteria for analysis. The level of evidence and freedom from bias of these studies were generally low. The prevalence of MRSA among all culture isolates ranged from 0% to 15.9% for ARS and 1.8% to 20.7% for CRS. Six studies reported quantitative treatment outcomes using variable measures, in which resolution of infection ranged from 58.3% to 100%. The treatment regimens were heterogeneous and included single- and multiple-agent therapy with oral, topical, and parental antibiotics. CONCLUSIONS: MRSA-positive cultures are found in a small but significant number of cases of ARS and CRS. Treatment of MRSA sinusitis may be effective, although treatment regimens and outcome measures are variable. Prospective studies utilizing standardized parameters are warranted.

Factors affecting time required to reach maintenance dose during subcutaneous immunotherapy.

BACKGROUND: Subcutaneous immunotherapy (SCIT) demands a significant time commitment on the part of the patient, especially during the escalation period when weekly visits are required. Many patients refuse or discontinue treatment in spite of the demonstrated clinical efficacy of SCIT. Understanding the factors that affect the length of the escalation phase would allow for counseling of patients, which may improve patient compliance. The aims of this study were to determine the mean time required to reach maintenance dose during conventional protocol SCIT and to identify factors that significantly affect the time required to reach maintenance dose. METHODS: We conducted a retrospective chart review of 55 patients (total of 79 treatment vials) who began SCIT between January 2007 and December 2010 and reached maintenance dose. The effect of demographic data, medical and social history, and SCIT allergen data on the time required to reach maintenance dose were examined using bivariate and multivariate analyses. RESULTS: The mean time to maintenance dose for the 79 treatment vials was 240.2 days (range, 76-720 days). Males (mean 294.7 days) took significantly longer than females (mean 205.1 days) to reach maintenance dose (p = 0.007). Asthmatics (mean 285.5 days) took significantly longer than nonasthmatics (mean 218.0 days) to reach maintenance dose (p = 0.008). Age also significantly affected the length of the escalation phase; each additional year of age was associated with an increase in 3.9 days needed to reach maintenance dose (p = 0.002). CONCLUSION: Gender, asthma, and age significantly impact the time required to reach maintenance dose during SCIT.

Endoscopic management of sinonasal hemangiopericytoma.

OBJECTIVE: Sinonasal hemangiopericytomas (SNHPCs) are rare perivascular tumors with low-grade malignant potential. Traditionally, these tumors have been treated with open approaches such as lateral rhinotomy, Caldwell-Luc, or transfacial approaches. Increased experience with endoscopic management of benign and malignant sinonasal tumors has led to a shift in management of SNHPC. The authors present their experience in the largest series of patients with SNHPC managed endoscopically. STUDY DESIGN AND SETTING: Case series at a tertiary care medical center. SUBJECTS AND METHOD: A retrospective chart review of all patients undergoing endoscopic management of SNHPC at the University of Miami between 1999 and 2008 was conducted. All endoscopic resections were performed with curative intent. RESULTS: Twelve patients with the diagnosis of SNHPC were treated endoscopically. Mean age was 62.5 years (range, 51-83 years). There were 6 men and 6 women. The mean follow-up was 41 months (range, 15-91 months). Seven (58.3%) presented with nasal obstruction, whereas 4 (41.6%) had epistaxis as their initial presenting symptom. Preoperative angiography or embolization was not performed in any case. Mean estimated blood loss was 630 mL (range, 100-1500 mL). Six patients underwent endonasal endoscopic anterior skull base resection; 4 had complete endoscopic resection all with negative margins. None underwent postoperative adjuvant treatment. No recurrence or metastatic disease was observed in this patient population. CONCLUSION: Endoscopic management of SNHPC is a feasible approach and did not compromise outcomes in this experience. In this series, familiarity with advance endoscopic sinus surgery was necessary to manage these patients. Postoperative adjuvant therapy was not necessary in this cohort.

Regional anesthesia for office-based procedures in otorhinolaryngology.

Local and topical anesthetic techniques have long been used for office-based procedures in otorhinolaryngology. There are numerous advantages to using local and topical anesthesia for office-based procedures, including a shorter recovery period, decreased health care cost, and the maintenance of a conscious patient who can communicate with the surgeon and maintain his or her own airway during the procedure. In this manuscript, we review the local and topical anesthetic techniques that can be used for otorhinolaryngic procedures including anesthesia of the external face, ear, nose, oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx.

Assessment of variation throughout the year in the incidence of idiopathic sudden sensorineural hearing loss.

OBJECTIVE: This study was conducted to determine whether the incidence of idiopathic sudden sensorineural hearing loss (ISSHL) varies throughout the year. STUDY DESIGN: This study is a retrospective case review. SETTING: This study was conducted at a tertiary referral center within a teaching hospital. PATIENTS: Inclusion criteria were a diagnosis of ISSHL confirmed by audiometric data. Exclusion criteria were intracranial neoplasms, a history of Ménière's disease, previous ear procedures, chemotherapy, or radiation therapy to the head or neck. There was no exclusion criterion based on age. Ninety-seven patients met these criteria. The median age was 52 years (range, 26-85 yr), and there were 53 (54.6%) women and 44 (45.4%) men. MAIN OUTCOME MEASURES: Monthly incidence counts were compiled across a 3-year period. Counts were analyzed for uneven incidence distributions and seasonal variation via standard statistical tests. RESULTS: Overall, no evidence was found for an uneven distribution or for a peak either by chi2 (p > 0.1), which assesses for any uneven distribution, or by the circular mean (p > 0.1), which assesses for a pattern of seasonal variation. In the subset of patients (24 of 97; 24.7%) who reported experiencing an upper respiratory infection before or concurrent with the onset of ISSHL, no evidence was found for an uneven distribution of hearing loss onset throughout the year either by chi2 (p > 0.1) or by the circular mean (p > 0.1). CONCLUSION: The results of this study suggest that ISSHL incidence does not display uneven distribution throughout the year.