Seeking an optimal dose of preoperative corticosteroids in chronic rhinosinusitis with nasal polyposis: A randomized controlled trial.

BACKGROUND: Preoperative corticosteroids have been shown to improve surgical visibility and intraoperative blood loss for chronic rhinosinusitis with nasal polyposis (CRSwNP) patients undergoing endoscopic sinus surgery (ESS). However, there is no consensus on the optimal dosing regimen. METHODS: A randomized, controlled trial was conducted to compare low, medium, and high dose corticosteroids prior to ESS. Patients with CRSwNP refractory to medical management were randomized to low (N = 8), medium (N = 10), or high (N = 5) dosing regimens of corticosteroids prior to ESS. Baseline disease severity was measured with the 22-item Sino-nasal Outcome Test and Lund-Mackay scores. Modified Lund-Kennedy endoscopic scores (MLKES) were measured at baseline and after corticosteroid treatment. Intraoperative parameters were measured including Boezaart surgical visibility score, intraoperative blood loss, and operative time. RESULTS: Medium dose corticosteroids demonstrated a superior surgical visibility score to low dose and comparable results to high dose, but these results were not significant (p = 0.33). No significant difference was observed between groups for total blood loss (p = 0.15), operative time (p = 0.87), or change in MLKES (p = 0.27). CONCLUSIONS: Current recommendations include the use of preoperative corticosteroids in patients with CRSwNP undergoing ESS, but there is no consensus on dose or duration. We did not find a statistically significant difference in surgical field visibility, intraoperative blood loss, or operative time between different dosing regimens. Further studies are needed to evaluate the efficacy of a low-dose preoperative regimen with the goal of reducing cumulative patient exposure to systemic corticosteroids.

Are nonsteroidal anti-inflammatory drugs effective enough for postoperative pain control after functional endoscopic sinus surgery and septoplasty? A randomized, controlled study.

BACKGROUND: Endoscopic sinus surgery (ESS) and septoplasty are commonly performed procedures without standardized postoperative pain regimens. There is reluctance to prescribe opioids for postoperative pain given their potential for abuse. Nonsteroidal anti-inflammatory drugs (NSAIDs) have been demonstrated to reduce or even obviate the need for opioid pain medications after otolaryngologic surgeries, but prospective validation is lacking. METHODS: A randomized, controlled study comparing the efficacy of diclofenac sodium to hydrocodone/acetaminophen (APAP) after ESS with or without septoplasty was performed. Participants were given a 100-mm visual analog pain scale (VAS) at postoperative days (PODs) 1, 2, 3, and 5 after ESS. Two-sample t tests were used to compare pain scores between groups. RESULTS: One hundred patients enrolled, and 74 patients provided pain scores to the survey. Pain was greatest for both groups on POD 1. Treatment with diclofenac sodium vs hydrocodone/APAP did not statistically impact pain scores at PODs 1, 2, 3, or 5. No cases of epistaxis requiring an emergency room visit or return to the operating room were noted during the study period. CONCLUSION: Diclofenac sodium may be non-inferior to hydrocodone/APAP in treating pain after ESS with or without septoplasty in opioid naive patients without pre-existing pain conditions. Further studies with larger samples are warranted to investigate the potential superiority of diclofenac to hydrocodone/APAP in certain patients after ESS and septoplasty.

PHQ-9 and SNOT-22: Elucidating the Prevalence of Depression in Chronic Rhinosinusitis.

OBJECTIVE: Chronic rhinosinusitis (CRS) has been associated with comorbid depression, yet the prevalence of depression among all patients with CRS is not well described. The Patient Health Questionnaire-9 (PHQ-9), a validated instrument for diagnosing depression, has been used to assess depression in a variety of clinical settings. PHQ-9 scores ≥10 are the threshold for a depression diagnosis. The purpose of this study was to assess the prevalence of depression in a rhinology practice and compare the PHQ-9 with the 22-item Sinonasal Outcome Test (SNOT-22). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary rhinology practice. SUBJECTS AND METHODS: During the 2-month period ending April 30, 2018, all rhinology patients were asked to complete the PHQ-9 and SNOT-22. RESULTS: Among 216 patients, 46 (21.3%) had a self-reported history of depression, and 39 (18.1%) had a PHQ-9 score ≥10. Of the 39 patients screening positive for depression, 18 (41.9%) had no history of depression. Comparison of PHQ-9 with overall SNOT-22 score had a Pearson's coefficient of 0.632 (P < .005). Logistic regression showed that the highest 2 quintiles of SNOT-22 scores had an odds ratio of 60.6 (95% CI, 9.7-378.3) for a positive depression screen (PHQ-9 score ≥10). CONCLUSION: Depression rates (estimated by PHQ-9 responses) among rhinology patients are similar to chronic disease populations; depression may be underdiagnosed in rhinology patients. Higher SNOT-22 scores were associated with higher PHQ-9 scores. Further studies are warranted to understand the impact of comorbid conditions of depression and CRS in patient quality of life.

The role of doxycycline in the management of chronic rhinosinusitis with nasal polyps.

INTRODUCTION: Many theories on the pathophysiology of chronic rhinosinusitis with nasal polyposis (CRSwNP) exist. The most effective management of CRSwNP has not been elucidated. Doxycycline, which has anti-inflammatory and anti-bacterial properties, has shown durable effects; however, its efficacy in combination with standard therapy has not been examined. We hypothesized that its addition to the standard anti-inflammatory regimen would improve patient outcomes. METHODS: We performed a double-blind, placebo-controlled trial at a tertiary level institution. Patients with moderate or severe CRSwNP were randomized into two groups, each receiving a 20-day course of oral corticosteroids and doxycycline or placebo. The 22-item Sinonasal Outcome Test (SNOT-22), nasal polyp scores, and visual analog scale (VAS) scores were recorded at the initial, 3-, 8- and 12-week visits. RESULTS: 49 patients were enrolled, 24 in the experimental and 25 in the placebo group with 3 moderate disease patients in each group. There were 12 dropouts in the treatment group and 14 in the placebo group. The most common reasons for dropout were severe CRS and asthma exacerbations. There was no significant difference in SNOT-22 scores, nasal polyp scores, and VAS scores between the two arms. CONCLUSIONS: Non-surgical management of patients with CRSwNP remains challenging. Our conclusions are limited given the high dropout rate and thus, limited sample size with inadequate power. This study is important, however, because a high dropout rate of mostly severe disease patients may illustrate that this patient population may not be optimally managed with medical therapy alone.

Office-Based Sinus Surgery.

Office-based rhinologic procedures have seen a dramatic rise in incidence over the last decade. It is crucial to select appropriate patients and understand which pathologies may be amenable to in-office procedures. It behooves the otolaryngologist to be familiar with the array of technologic advances that are expanding the limits of office-based rhinology and to have a solid understanding of the technical nuances of using these technologies in the clinic. This article highlights the issues associated with some of the more common office-based sinus procedures, and provides practical information on set-up and reimbursement.

Cutting-edge endonasal surgical approaches to thyroid ophthalmopathy.

OBJECTIVE: Thyroid orbitopathy is a poorly understood extrathyroidal manifestation of Graves' disease that can cause disfiguring proptosis and vision loss. Orbital decompression surgery for Graves' orbitopathy (GO) can address both cosmetic and visual sequelae of this autoimmune condition. Endonasal endoscopic orbital decompression provides unmatched visualization and access to inferomedial orbital wall and orbital apex. This review examines the state of the art approaches employed in endonasal endoscopic orbital decompression for GO. METHODS: Review of literature evaluating novel surgical maneuvers for GO. RESULTS: Studies examining the efficacy of endonasal endoscopic orbital decompression are heterogenous and retrospective in design; however, they reveal this approach to be a safe and effective technique in the management of GO. CONCLUSION: Subtle variations in endoscopic techniques significantly affect postsurgical outcomes and can be tailored to the specific clinical indication in GO making endonasal endoscopic decompression the most versatile approach available. LEVEL OF EVIDENCE: NA.

Use of pharyngeal packs in functional endoscopic sinus surgery: A randomized controlled trial.

OBJECTIVE: To determine if pharyngeal packs have an effect on postoperative pain and postoperative nausea and vomiting in functional endoscopic sinus surgery (FESS). STUDY DESIGN: Forty-six patients scheduled for routine endoscopic sinus surgery were recruited into this study. The patients were randomly allocated to have or to not have pharyngeal packing prior to surgery. METHODS: The placement of pharyngeal packs during FESS is controversial. Theoretically, pharyngeal packs may prevent postoperative nausea and vomiting by preventing ingestion of blood during sinus surgery. However, prior studies have not conclusively demonstrated this to be the case in FESS. Pharyngeal packs have been associated with complications including throat pain, aspiration, and death. The objective of this randomized control trial was to determine if pharyngeal packs have an effect on postoperative throat pain, nausea, and vomiting in order to determine their importance during FESS. Patients were blinded to intervention. Postoperatively, throat pain and nausea/vomiting scores were recorded. RESULTS: There was no significant difference in mean throat pain at 4 hours following surgery (P = 0.860). At 24 hours after surgery, patients without pharyngeal packing experienced more pain than those who had a throat pack placed (P = 0.002). There was no significant difference in the level of nausea at 4 hours after surgery (P = 0.315) or at 24 hours after surgery (P = 0.315). CONCLUSION: We recommend against the routine use of placing pharyngeal packs during FESS. LEVEL OF EVIDENCE: 1b. Laryngoscope, 127:2460-2465, 2017.

Evaluation and Decision Making in Frontal Sinus Surgery.

Management of frontal sinusitis can be challenging for even the most experienced otolaryngologists. A thorough understanding of the anatomy and pathophysiology of the frontal sinus is essential to properly manage disease affecting the frontal sinus. Being able to distinguish acute viral from acute bacterial and acute from chronic sinusitis is crucial because these distinctions guide appropriate management. Nasal endoscopy can confirm diagnosis, and radiologic imaging, including computed tomography and MRI, is often a necessary adjunct that aids in determining appropriate therapeutic decisions. One must be aware of the many procedures used in the surgical treatment of frontal sinusitis.

Sociodemographic disparities in choice of therapy and survival in advanced laryngeal cancer.

PURPOSE: To determine if sociodemographic factors are associated with treatment choice and survival in patients with advanced stage laryngeal cancer in the U.S. DESIGN/SETTING/SUBJECTS/METHODS: Population-based, non-concurrent cohort study of 5381 patients diagnosed with stage III or IV laryngeal squamous cell carcinoma from 1992-2009. Data was extracted from the Surveillance, Epidemiology, and End Results (SEER) database. MAIN OUTCOME(S) AND MEASURES: Choice of therapy (surgical vs. non-surgical) and disease-specific survival (DSS). RESULTS: Age ≥60 years (odds ratio [OR]=0.78; 95% CI, 0.70-0.88) and more recent year of diagnosis (OR=0.89; 95% CI, 0.87-0.90) decreased the odds of receiving surgical therapy, while residing in a county with low median household income (OR=1.36; 95% CI, 1.17-1.57) increased the odds of receiving surgical therapy. Age ≥60 years (hazard ratio [HR]=1.45; 95% CI, 1.33-1.59) and Black race (HR=1.14; 95% CI, 1.02-1.27) were negatively associated with DSS, while female sex (HR=0.81; 95% CI, 0.72-0.90) and married status (HR=0.69; 95% CI, 0.63-0.75) were positively associated with DSS. CONCLUSIONS AND RELEVANCE: For patients with advanced laryngeal cancer, younger age and residing in a low-income county increase the likelihood of receiving surgical therapy. Female sex and married status provide a survival benefit, while Black race appears to be a negative prognostic factor. This highlights the impact of sociodemographic factors on treatment strategies and outcomes and highlights areas for further research on health disparities.

Intraoral midline mandibulotomy improves laryngeal access for transoral resection of laryngeal cancer.

Intraoral midline mandibulotomy is a technique that can be used to increase exposure for transoral endoscopic laser microsurgery (TLS). We describe the case of a 51 year old male with persistent T1 glottic carcinoma. At initial diagnosis, he had been referred for curative radiotherapy as laryngeal access was not sufficient for TLS. For treatment of his recurrence, we describe the technique of performing a midline mandibular osteotomy to improve access to the larynx allowing for safe and effective transoral endoscopic laser microsurgery. Surgical access to the larynx was greatly improved, and we were able to perform TLS in a case that would have otherwise not been amenable to TLS. An intraoral midline mandibulotomy can improve access to the larynx and allow for successful transoral resection of laryngeal cancer in patients with otherwise inaccessible tumors.

Merkel cell carcinoma of the head and neck: pathogenesis, current and emerging treatment options.

Merkel cell carcinoma (MCC) is a relatively uncommon, neuroendocrine, cutaneous malignancy that often exhibits clinically aggressive features and is associated with a poor prognosis. It typically presents as a painless, rapidly enlarging, dome-shaped red or purplish nodule in a sun-exposed area of the head and neck or upper extremities. Our understanding of MCC has increased dramatically over the last several years and the pathogenesis continues to be an area of active research. The etiology is likely multifactorial with immunosuppression, UV-induced skin damage, and viral factors contributing to the development of MCC. The recent discovery of Merkel cell polyomavirus has allowed for at least one aspect of disease development to be much better understood. In most cases, treatment consists of wide local excision with adjuvant radiation therapy. The role of chemotherapeutics is still being defined. The recent advancement of knowledge regarding the pathogenesis of MCC has led to an explosion research into novel therapeutic agents and strategies. This review seeks to summarize the current body of literature regarding the pathogenesis of MCC and potential targets for future therapies.

Tonsillectomy on rivaroxaban.

OBJECTIVE: The objective of this case report is to increase awareness regarding a new category of drugs, new direct oral anticoagulants (specifically, rivaroxaban), which are increasingly being used instead of the more traditional vitamin K antagonists, to highlight the current recommendations for perioperative management of rivaroxaban, and to demonstrate a clinical scenario where a tonsillectomy was successfully performed in a patient requiring anticoagulation with rivaroxaban. METHODS: A literature review and a case report are presented. PubMed was reviewed for evidence based recommendations regarding the perioperative management of rivaroxaban and the recommendations for reversal in the event of a hemorrhagic complication. There is no evidence in the literature regarding the use of rivaroxaban in patients undergoing tonsillectomy. We present the case of a 38year old female on rivaroxaban for history of deep vein thrombosis and pulmonary embolism who successfully underwent tonsillectomy using the current recommendations for perioperative management of rivaroxaban. RESULTS: Our patient had no thrombotic or hemorrhagic complications during the postoperative period. This is the first report in the literature regarding the use of a new direct oral anticoagulant, rivaroxaban, in the setting of tonsillectomy. This case report suggests that tonsillectomy can be performed in patients anticoagulated with rivaroxaban. CONCLUSION: With the increasingly common use of new direct oral anticoagulants for short and long-term anticoagulation, further research is necessary to compare the efficacy and safety profile of the new direct oral anticoagulants to the more traditional vitamin K antagonists when performing tonsillectomy. Otolaryngologists should be familiar with the new oral anticoagulants and understand the proposed perioperative management as practitioners are increasingly likely to encounter patients using this new class of medication in clinical practice.