Levels of Evidence in Rhinology and Skull Base Surgery Research.

OBJECTIVE: The purpose of this study was to evaluate the quality of evidence of rhinology and rhinologic skull base surgery (RSBS) research and its evolution over the past decade. STUDY DESIGN: Review article. SETTING: We reviewed articles from 2007 to 2019 in 4 leading peer-reviewed otolaryngology journals and 3 rhinology-specific journals. METHODS: The articles were reviewed and levels of evidence were assigned using the Oxford Centre for Evidence-Based Medicine 2011 guidelines. High quality was defined as level of evidence 1 or 2. RESULTS: In total, 1835 articles were reviewed in this study spanning a 13-year period. Overall, the absolute number of RSBS publications increased significantly 22.6% per year, from 108 articles in 2007 to 481 in 2019 (P < .001; 95% CI, 7.9-37.2). In 2007, only 13 articles, or 15%, were high quality, and this grew to 146 articles, or 39%, in 2019. A 14.0% per year exponential increase in the number of high-quality publications was found to be statistically significant (P < .001; 95% CI, 7.2, 20.7). Overall, high-quality publications represented just 25.8% of RSBS articles overall. There was no significant difference in quality between rhinology-specific journals and general otolaryngology journals (χ2 = 3.1, P = .077). CONCLUSION: The number of overall publications and of high-quality RSBS publications has significantly increased over the past decade. However, the proportion of high-quality studies continues to represent a minority of total RSBS research.

Diseases of the nasal cavity.

Despite garnering minimal attention from the medical community overall, olfaction is indisputably critical in the manner in which we as humans interact with our surrounding environment. As the initial anatomical structure in the olfactory pathway, the nasal airway plays a crucial role in the transmission and perception of olfactory stimuli. The goal of this chapter is to provide a comprehensive overview of olfactory disturbances as it pertains to the sinonasal airway. This comprises an in-depth discussion of clinically relevant nasal olfactory anatomy and physiology, classification systems of olfactory disturbance, as well as the various etiologies and pathophysiologic mechanisms giving rise to this important disease entity. A systematic clinical approach to the diagnosis and clinical workup of olfactory disturbances is also provided in addition to an extensive review of the medical and surgical therapeutic modalities currently available.

Evolution of gender representation among Canadian OTL-HNS residents: a 27-year analysis.

BACKGROUND: The proportion of females enrolling into medical schools has been growing steadily. However, the representation of female residents among individual specialties has shown considerable variation. The purpose of this study was to compare the trends of gender representation in Otolaryngology - Head and Neck Surgery (OTL-HNS) residency programs with other specialty training programs in Canada. In order to contextualize these findings, a second phase of analysis examined the success rate of applicants of different genders to OTL-HNS residency programs. METHOD: Anonymized data were obtained from the Canadian Residency Matching Service (CaRMS) and from the Canadian Post-M.D. Education Registry (CAPER) from 1988 to 2014. The differences in gender growth rates were compared to other subspecialty programs of varying size. Descriptive analysis was used to examine gender representation among OTL-HNS residents across years, and to compare these trends with other specialties. Bayesian hierarchical models were fit to analyze the growth in program rates in OTL-HNS based on gender. RESULTS: CaRMS and CAPER data over a 27 year period demonstrated that OTL-HNS has doubled its female representation from 20% to 40% between 1990 and 1994 and 2010-2014. The difference in annual growth rate of female representation versus male representation in OTL-HNS over this time period was 2.7%, which was similar to other large specialty programs and surgical subspecialties. There was parity in success rates of female and male candidates ranking OTL-HNS as their first choice specialty for most years. CONCLUSIONS: Female representation in Canadian OTL-HNS residency programs is steadily increasing over the last 27 years. Large variation in female applicant acceptance rates was observed across Canadian universities, possibly attributable to differences in student body or applicant demographics. Factors influencing female medical student career selection to OTL-HNS require further study to mitigate disparities in gender representation and identify barriers to prospective female OTL-HNS applicants.

Medical management of chronic rhinosinusitis - a review of traditional and novel medical therapies.

INTRODUCTION: Chronic rhinosinusitis (CRS) is a commonly seen persistent inflammatory disease process affecting the paranasal sinuses with extensively reported economic implications. Despite an elusive pathophysiologic mechanism underlying this disease process, treatment outcomes are encouraging with the employment of an array of medical and surgical therapies. Areas covered: The goal of this paper is to provide a comprehensive, up to date analysis of the literature concerning the medical management of CRS by summarizing the evidence in support of traditional medical therapies for the management of CRS in addition to highlighting novel medical therapies currently under investigation. Expert opinion: The current staples of medical therapy for CRS based on the strength of available evidence include topical and oral corticosteroids, oral antibiotics and topical saline. The introduction of immunomodulatory therapies ('Biologics') for the treatment of CRS shows promise but have yet to be employed in a widespread fashion due to the need for additional research to better elucidate their role.

Bilateral silent sinus syndrome: A rare case and review of literature.

OBJECTIVE: In this report, we presented a rare case of bilateral silent sinus syndrome (SSS) in an otherwise healthy 57-year-old man treated with functional endoscopic sinus surgery (FESS). A systematic review of the literature regarding bilateral SSS was performed. CASE REPORT: A 57-year-old man with well-controlled allergic rhinitis in the absence of previous surgery or trauma presented with bilateral SSS, which was successfully managed with bilateral FESS. METHODS: A medical literature data base search of the terms "silent sinus syndrome" "maxillary atelectasis," "imploding antrum syndrome," and "bilateral silent sinus syndrome" was performed. The results were then narrowed to include only relevant articles. RESULTS: Relevant articles included three case reports and two articles that describe or mention bilateral SSS. Of the three case reports found, two patients presented with bilateral SSS, whereas the third patient presented metachronously, with the contralateral SSS manifesting 4 months after presentation of the initial ipsilateral SSS. CONCLUSION: The present literature regarding bilateral SSS is likely incomplete, and further investigation is required to provide greater insight into the prevalence of this disease. In this report, bilateral FESS was successful in resolving symptoms and preventing disease progression.

Quality-of-life improvement after endoscopic sinus surgery in patients with obstructive sleep apnea.

BACKGROUND: There is preliminary evidence that patients with chronic rhinosinusitis (CRS) and comorbid obstructive sleep apnea (OSA) have reduced quality-of-life (QOL) improvements after functional endoscopic sinus surgery (FESS) compared with patients without OSA. The effect of OSA severity on QOL improvement after FESS is unknown. OBJECTIVES: To better characterize the QOL improvement after FESS for patients with comorbid OSA and to assess whether QOL improvement is dependent on OSA severity. METHODS: This multi-institution, retrospective cohort study evaluated adult patients with CRS who underwent FESS between 2007 and 2015. Preoperative, 1-month, 3-month, 6-month, and 1-year postoperative 22-Item Sino-Nasal Outcome Test scores were used to evaluate QOL. We compared patients without OSA with patients with stratified OSA based on the preoperative apnea-hypopnea index. A multilevel, mixed-effects linear regression model was used for the analysis. RESULTS: Of 480 participants, 83 (17%) had OSA, and 47 of these patients had polysomnography results available for review. Both patients with OSA and patients without OSA reported significant QOL improvement after surgery (p < 0.0001) relative to baseline. In the unadjusted model, the subjects with OSA demonstrated a statistically worse outcome in 22-Item Sino-Nasal Outcome Test scores at each time point (2.4 points higher per time point, p = 0.006). When controlling for covariates, the adjusted model showed no difference in QOL outcome based on OSA status (p = 0.114). When stratified by OSA disease severity, the adjusted model showed no difference in the QOL outcome. CONCLUSIONS: Patients with CRS and comorbid OSA had worse QOL outcomes after FESS; however, when controlling for patient factors, there was no difference in QOL outcome. OSA disease severity did not seem to predict QOL improvement after FESS.

Intrasinus penetration of a silastic malar implant, which resulted in chronic sinusitis: A case report and literature review.

BACKGROUND: Malar augmentation is a common cosmetic procedure utilizing silastic materials. We describe an uncommon complication of a silastic implant eroding into the anterior maxillary sinus wall resulting in chronic rhinosinusitis (CRS). METHODS: A literature review is presented describing the presentation, surgical management and outcome of this uncommon adverse event. RESULTS: An 80 year old female with a history of bilateral cosmetic malar implants placed approximately 25 years ago presented to our office with a 4-5 month history of left-sided symptoms consistent with chronic sinusitis, and was found to have intrasinus penetration of her left malar implant. Only one other case series of 5 cases in 4 patients is reported in the literature. CONCLUSIONS: Intrasinus malar implant migration is a rare complication of malar augmentation. The present experience suggests that removal of the offending foreign body often results in successful symptom resolution.

The role of aspirin desensitization in the management of aspirin-exacerbated respiratory disease.

PURPOSE OF REVIEW: Aspirin-exacerbated respiratory disease (AERD) is a progressive inflammatory disease of the upper and lower airways characterized by marked eosinophilic nasal polyposis, asthma, and respiratory reactions to medications that inhibit the cyclooxygenase pathway. Aspirin desensitization has proven to be an effective tool in the management of this disease when used in a multidisciplinary setting. The purpose of this article is to review the current literature regarding AERD, aspirin desensitization, and share our opinion regarding the most optimal multidisciplinary approach to these complex patients. RECENT FINDINGS: Numerous studies, including randomized, double-blind, placebo-controlled trials, have demonstrated the therapeutic effectiveness of aspirin desensitization with significant improvement in number of sinus infections per year, olfactory scores, nasal symptom scores, asthma symptom scores, sinus operations, hospitalizations, emergency room visits, and oral steroid use. Furthermore, the role of surgery is becoming increasingly important for recalcitrant sinus disease with recent studies showing comprehensive surgery as more beneficial to disease management. SUMMARY: Aspirin desensitization is an effective therapeutic tool in the management of AERD. A multidisciplinary approach is critical between the otorhinolaryngologist and allergist to provide the most optimal care for this complex patient population.

Smell preservation following endoscopic unilateral resection of esthesioneuroblastoma: a multi-institutional experience.

BACKGROUND: The gold standard of treatment for esthesioneuroblastoma consists of en bloc craniofacial resection with postoperative therapy dictated by histology and tumor extent. Numerous studies have shown fully endoscopic approaches to provide comparable survival and recurrence rates with decreased patient morbidity. Here we report the first multi-institutional series assessing smell outcomes of patients who underwent unilateral endoscopic resection of esthesioneuroblastoma with preservation of the contralateral olfactory bulb. METHODS: A multi-institutional retrospective review was performed identifying patients who underwent endoscopic unilateral resection of esthesioneuroblastoma with preservation of 1 olfactory bulb between 2003 and 2015. After completion of postoperative radiation, patients were administered the University of Pennsylvania Smell Identification Test (UPSIT) to assess olfactory function. RESULTS: Fourteen patients (7 males, 7 females) were identified and tested for posttreatment olfactory function. All 14 patients received postoperative radiotherapy and 4 patients received additional chemotherapy. Mean follow-up time was 51.7 months. There was no disease recurrence. Six patients (43%) were found to have residual smell function with 2 patients (14%) having normal or mildly reduced smell function. CONCLUSION: Here we report the first multi-institutional series demonstrating smell preservation after unilateral endoscopic resection of esthesioneuroblastoma. In carefully selected patients, this approach can yield comparable survival with decreased patient morbidity.

Temporal patterns of 18 F-fluorodeoxyglucose positron emission tomography/computed tomography sinonasal uptake after treatment of sinonasal malignancy.

BACKGROUND: Current guidelines have identified 10 to 12 weeks posttreatment as the ideal time-point for improved diagnostic accuracy of positron emission tomography/computed tomography (PET/CT) for deep tissue sites of the head and neck. After treatment, the sinonasal skull base is predisposed to prolonged inflammation that may render this time-point inappropriate for initial posttreatment imaging surveillance for sinonasal malignancies. The purpose of this study is to evaluate temporal trends in 18 F-fluorodeoxyglucose (18 FDG) sinonasal uptake after treatment for sinonasal malignancies to better elucidate the optimal time-point for initial PET/CT posttreatment evaluation in this patient population. METHODS: A retrospective analysis of all successfully treated and non-locally recurrent sinonasal malignancies over a 15-year study period (2000 to 2015) was performed at our institution. Posttreatment 18 FDG PET/CT standardized uptake value data were collected and compared between various time-points (2 to 4 months, 5 to 12 months, 5 to 24 months, and 13 to 24 months) using an independent-samples t test. RESULTS: A statistically significant difference was noted between the posttreatment time windows 2 to 4 and 5 to 12 months (p = 0.048) as well as 2 to 4 and 5 to 24 months (p = 0.02). A trend toward significance was seen when comparing 2 to 4 and 13 to 24 months (p = 0.083). CONCLUSION: Our analysis of PET/CT in patients previously treated for sinonasal malignancy suggests that the posttreatment sinonasal skull base is characterized by a prolonged period of hypermetabolism that endures beyond the period previously described for deep tissue sites of the head and neck. These findings prompt a reevaluation of the previously described 10- to 12-week cutoff point for initial posttreatment PET/CT for head and neck squamous cell carcinoma as applied to sinonasal malignancies.

Medical management of chronic rhinosinusitis - an update.

Chronic rhinosinusitis (CRS) is an epidemiologically important, chronic inflammatory disease process affecting the paranasal sinuses with significant and extensively reported economic implications. Despite an elusive pathophysiologic mechanism underlying this disease process, treatment outcomes are encouraging with the employment of an array of medical and surgical therapies. The goal of this paper is to provide a comprehensive, up to date analysis of the literature concerning the medical management of CRS by highlighting the most recent evidence based recommendations addressing this ongoing field of research.

Understanding Biofilms in Chronic Sinusitis.

Chronic sinusitis is a burdensome disease that has substantial individual and societal impact. Although great advances in medical and surgical therapies have been made, some patients continue to have recalcitrant infections. Microbial biofilms have been implicated as a cause of recalcitrant chronic sinusitis, and recent studies have tried to better understand the pathogenesis of chronic sinusitis as it relates to microbial biofilms. Here, we provide an overview of biofilms in chronic sinusitis with emphasis on pathogenesis, treatment, and future directions. In addition, recent evidence is presented, elucidating the role of bitter taste receptors as a possible key factor leading to biofilm formation.

Topical probiotics as a therapeutic alternative for chronic rhinosinusitis: A preclinical proof of concept.

INTRODUCTION: Patients with chronic rhinosinusitis (CRS) have been shown to manifest a high inflammatory phenotype, with a sinus microbiome deficient in gram-positive bacteria. Gram-positive bacteria are capable of downregulating proinflammatory host responses via an interleukin (IL) 10 mediated response and may represent a potential therapeutic alternative for CRS. We wanted to (i) immunoprofile the IL-10 induction capacity of two gram-positive probiotic strains and (ii) verify the tolerance of these strains by the sinus epithelium. METHODS: A peripheral blood mononuclear cell (PBMC) challenge model was used to document probiotic induction of IL-10 and tumor necrosis factor (TNF) alpha responses at various bacterial dilutions. Epithelial cell tolerance was demonstrated by using a primary epithelial cell model derived from patient biopsy specimens (six patients total [three with CRS and three controls]). After an incubation period with either a live or a heat-killed probiotic strain, cell viability was assessed by using light microscopy. RESULTS: Both probiotic strains induced high IL-10 secretion in PBMCs, with differing profiles of TNF alpha production. Microscopic evaluation after probiotic incubation demonstrated intact cell viability for all cell cultures. CONCLUSION: We identified well-tolerated, nonpathogenic, "generally recognized as safe" status gram-positive probiotics with anti-inflammatory properties. Topical probiotics represented a potential novel topical therapeutic strategy for CRS relevant for further clinical evaluation.

Contemporary management of esthesioneuroblastoma.

PURPOSE OF REVIEW: This article provides a contemporary review of the management of esthesioneuroblastoma (ENB) within the context of recent surgical advancements, while highlighting the ongoing limitations and controversies surrounding this uncommon pathologic entity. RECENT FINDINGS: Surgical management of ENB is continuously evolving with contemporary endoscopic approaches complementing or in many cases replacing open approaches. SUMMARY: Complete surgical resection remains the mainstay definitive therapy for ENB. Aggressive, combined modality therapy appears to be justified in patients at greatest risk of developing recurrence based on advanced tumor stage and high pathologic grade. ENB requires prolonged surveillance following treatment given its tendency for late recurrence.

Modified endoscopic medial maxillectomy for zygomatic implant salvage.

OBJECTIVES: Odontogenic chronic rhinosinusitis (CRS) is an epidemiologically important disease process due, in part, to the increasingly commonplace use of dental restorative procedures such as zygomatic implantation. Traditional management of this clinical entity typically entails extraction of the infected hardware via an open or endoscopic approach. We describe a novel management strategy of odontogenic CRS following bilateral zygomatic implantation for oral rehabilitation that we surgically salvaged via a modified endoscopic medial maxillectomy. METHODS: We describe the presentation and management of a case of metachronous development of bilateral CRS subsequent to zygomatic implantation. RESULTS: The patient's postoperative course was characterized by marked endoscopic, radiologic, and symptomatic improvement as measured by the 22-item Sino-Nasal Outcome Test. CONCLUSION: We describe a novel treatment strategy for the management of odontogenic sinusitis resulting from erroneous zygomatic implant placement. Modified endoscopic medial maxillectomy in this clinical context facilitates mucosal normalization of the affected sinus, while permitting preservation of oral function through salvage of the displaced implant.

Nationwide study of publication misrepresentation in applicants to residency.

OBJECTIVES: This study was conducted to assess the prevalence of research publication misrepresentation amongst Canadian Resident Matching Service (CaRMS) applicants to a single surgical subspecialty residency as a potential means of assessing professional behaviour. METHODS: The authors reviewed CaRMS application forms to Canadian otolaryngology residency programmes over a 3-year period (2006-2008) for peer-reviewed publications reported as 'published', 'accepted' and 'in press'. Citations were verified by searching PubMed, Google Scholar and electronic journals. Misrepresentation was defined as any of: (i) falsely claimed authorship of an existing article; (ii) claimed authorship of a non-existing article, and (iii) improper ordering of authorship. Outcomes included descriptive statistics, as well as sub-analyses pertaining to age, gender, affiliated medical school and academic degree, and number of publications per applicant. RESULTS: A total of 427 peer-reviewed publications were reported by 124 of 182 applicants (68% of applicants reported at least one publication). Of the 385 verifiable publications, 47 (12% of articles) were misrepresented by 29 applicants (23% of applicants claiming publication) self-reporting at least one publication. Age, gender, location of medical training, prior academic degree and number of citations per applicant did not relate to likelihood of misrepresentation (p > 0.05). CONCLUSIONS: This study documents the nationwide prevalence of publication misrepresentation amongst applicants to Canadian otolaryngology residency programmes. The high rate of misrepresentation aligns with data reported in the literature and highlights the need to institute measures to dissuade graduates from this form of unprofessional behaviour.

The evolution of racial, ethnic, and gender diversity in US otolaryngology residency programs.

OBJECTIVE: To examine the evolution of racial, ethnic, and gender diversity in US otolaryngology-head and neck surgery residency programs and compare these figures with other residency programs. DESIGN: Retrospective database review. SETTING: US residency programs. METHODS: Information concerning minority and female representation in US residency programs was obtained from annually published graduate medical education reports by the Journal of the American Medical Association from 1975 to 2010. Minority representation among US population and university students was obtained from the US Census Bureau. The racial, ethnic, and gender diversity of otolaryngology residents was then compared with other medical fields (general surgery, family medicine, and internal medicine). RESULTS: Underrepresentation in otolaryngology-head and neck surgery is particularly disconcerting for African Americans (-2.3%/y, P = .09) and Native Americans (1.5%/y, P = .11) given their nonsignificant annual growth rates. Hispanic representation (17.3%/y, P < .0001) is growing in otolaryngology but is half the rate of growth of the Hispanic American population (32.8%/y, P < .0001). There is nonetheless promise for women (70.6%/y, P < .0001) and Asian Americans (63.0%/y, P < .0001), who demonstrated statistically significant growth trends. CONCLUSION: To our knowledge, this is the first study to describe the evolution of female and minority representation among US otolaryngology residents. Despite increasing gender, ethnic, and racial diversity among medical residents in general, female and certain minority group representation in US otolaryngology residency programs is lagging. These findings are in contrast to rising trends of diversity within other residency programs including general surgery.