Orbital Complications of Chronic Rhinosinusitis: Two Years' Experience in a Tertiary Referral Hospital.

PURPOSE: To investigate the different clinical manifestations in Egyptian patients with orbital complications of rhinosinusitis (RS) according to the pathology within the paranasal sinuses. METHODS: The medical records of patients presented with chronic RS between August 2018 and December 2020 were retrospectively reviewed. RESULTS: This study included 64 patients: 28 patients with subperiosteal abscess (SPA), 10 with allergic fungal RS, 6 with isolated fungal RS, 6 with invasive fungal RS, and 14 with mucocele. The most common manifestation was proptosis, limitation of ocular motility, periorbital swelling, and pain. A relative afferent pupillary defect was present in all cases of invasive fungal sinusitis. Surgical interventions were performed in 63 out of 64 cases. All the ophthalmological manifestations were reversible except for patients with invasive fungal rhinosinusitis. CONCLUSION: Orbital complications of RS may require early surgical intervention with multidisciplinary counseling between ophthalmologists, otorhinolaryngologists, radiologists, and neurologists.

A modified form of the St Thomas' Hospital (STH) classification to improve cochlear implantation outcomes.

OBJECTIVES: re-evaluation and modification of the St Thomas' Hospital (STH) classification to improve cochlear implantation outcomes. STUDY DEIGN: a prospective cohort study. PATIENTS: children (n = 20) between 2 to 8 years old who received a unilateral cochlear implant, all had difficult round window visibility and/or accessibility for electrode insertion. 10 had a round window insertion through the endoscopic assisted cochlear implantation and the remaining 10 had the same insertion using the retro-facial approach. THE SURGERY: two alternative techniques were used to overcome the difficult cases of round window electrode insertion: 1Endoscopic assisted cochlear implantation 2Transmastoid retro-facial approach RESULTS: both techniques proved to be effective and practical to overcome cases with difficult round window visibility and/or accessibility for electrode insertion. CONCLUSION: Round window insertion is associated with superior cochlear implantation outcomes, so we recommend a new modification to the STH classification to bypass the cochleostomy insertion.

Orbital Complications of Acute Invasive Fungal Rhinosinusitis: A New Challenge in the COVID-19 Convalescent Patients.

Purpose: Increased incidence of acute invasive fungal rhinosinusitis (AIFR) in the setting of COVID-19 is undeniable. This can be attributed to its effect on innate immunity and extensive use of corticosteroids. The goal of our study was to assess the orbital complications of AIFR and its management in the COVID-19 convalescent patients. Methods: Our longitudinal prospective study included 45 patients with orbital complications of AIFR in recently recovered COVID-19 patients. We performed otorhinolaryngological, ophthalmological, and neurological examinations to monitor the manifestations of the disease. Computed tomography and contrast enhanced magnetic resonance imaging were performed to detect the extent of infection. Antifungal medications, surgical intervention, and general condition management were all provided to all the patients. Results: We reported pre-septal cellulitis, orbital cellulitis, and orbital apex syndrome in 18, 13, and 10 patients, respectively. Four patients had cavernous sinus thrombosis. Mucormycosis and Aspergillus species were detected in 80% and 11.11% of our patients, respectively, while the mixed infection was found in 8.88% of our patients. Diabetes mellitus was the most common cause of immunocompromise (95.55% of our patients). Orbital pain and ophthalmoplegia were the most common ocular manifestations, followed by proptosis and relative afferent pupillary defect. All patients underwent surgical intervention, except for one patient who was unfit for surgery. One patient had orbital exenteration. The ophthalmological manifestations were reversible in cases of orbital and pre-septal cellulitis. The overall survival rate was 66.67%. Conclusion: Early diagnosis and treatment of AIFR can decrease the morbidity and mortality rate of affected patients.

Anterior part middle turbinoplasty in endoscopic sinus surgery: a randomized controlled study.

OBJECTIVE: Resection of middle turbinate in the setting of endoscopic sinus surgery is a controversial procedure. Our aim is to assess the impact of the anterior part middle turbinoplasty on the outcome of endoscopic sinus surgery, incidence of synechia between the middle turbinate and the lateral nasal wall, intra- and post-operative accessibility to the paranasal sinuses. METHODS: Single blinded randomized controlled study of 120 patients with chronic rhinosinusitis without polyps, they were allocated into two groups, we performed anterior part middle turbinoplasty in the group one "60 patients", and we preserved the middle turbinate in the group two "60 patients". We assessed the patients pre-operatively by Sino-nasal outcome Test (SNOT-22), intra-operatively by Likert scale score for the sinuses accessibility. At least 6 months post-operatively, we assessed the patients by SNOT-22, and Likert scale score for sinus accessibility. RESULTS: During and after surgery, the Likert scale score in the group one showed statistically significant better sinuses accessibility than in the group two. We noticed synechia between the MT and the lateral nasal wall in 9.2% and 18.2% of the operated sides in group one and group two, respectively. SNOT-22 and its smell item improved significantly in both groups with no statistically significant differences between them. No major complications were reported. CONCLUSION: Anterior part middle turbinoplasty is a safe and effective technique during endoscopic sinus surgery to improve the intra- and post-operative sinus accessibility, and decrease the incidence of post-operative synechia, with no adverse effect on olfaction or bleeding.

Long-term follow-up of repair of external nasal deformities in rhinoscleroma patients.

INTRODUCTION: Rhinoscleroma (RS) is a chronic, progressive, granulomatous infectious disease endemic in Egypt and the Middle East, affecting the nose in 95-100% of cases, and resulting in functional and esthetic sequelae. The aim of the study was to investigate the feasibility of performing reconstructive procedures to improve external deformities in RS patients, with long-term follow up. PATIENTS & METHODS: This prospective, controlled cohort study included 25 patients who were seeking rhinoplasty to improve their esthetic appearance, with evident clinical and histopathological history of RS. Another 25 patients seeking esthetic augmentation rhinoplasty in the same period formed the control group. All the participants were evaluated objectively by two independent rhinoplasty surgeons, and subjectively with ROE 2 years postoperatively. RESULTS: All the participants showed significant improvement in esthetic facial evaluation postoperatively, with a correlative rise in ROE score. There was an insignificant difference between the studied groups. Inconsequential complications were encountered throughout the follow-up period, but with insignificant incidence in both groups. CONCLUSION: Rhinoplasty for correction of RS external deformities is both safe and beneficial, with no risks of flaring up or increased complications. LEVEL OF EVIDENCE: Level 2b.

Validation and cross-cultural adaptation of the arabic version of the nasal obstruction symptom evaluation scale.

OBJECTIVES/HYPOTHESIS: Validation and cross-cultural adaptation of the Nasal Obstruction Symptom Evaluation (NOSE) scale into the Arabic language with studying of its psychometric properties. STUDY DESIGN: Prospective instrument-validation study. METHODS: Guidelines for the cross-cultural adaptation process from the original English language scale into the Arabic language version were followed. We assessed the psychometric properties of the Arabic version of the NOSE scale (A-NOSE) (feasibility, reproducibility, internal consistency, reliability, discriminatory validity, responsiveness to change) in 101 consecutive patients who underwent septal surgery (preoperatively and 3 months postoperatively) and 102 asymptomatic controls. RESULTS: The Mann-Whitney test showed a statistically significant difference for the mean score between the patients and the control group denoting good clinical validity. The Cronbach's α coefficient value for the A-NOSE scale for 101 cases was 0.995, demonstrating good internal consistency. The Wilcoxon signed rank test showed a marked improvement in the patients score 3 months postoperatively. Correlation and level of agreement of the mean score of the A-NOSE scale for each question were studied using Spearman's rank correlation for each question, and Pearson's correlation for the total score showed statistically significant results. CONCLUSIONS: The A-NOSE scale is a valid instrument for evaluating the subjective severity of nasal obstruction and is recommended to be used in rhinology research and daily practice. LEVEL OF EVIDENCE: 3b. Laryngoscope, 127:2455-2459, 2017.

Standardized letters of recommendation and successful match into otolaryngology.

OBJECTIVES/HYPOTHESIS: Historically, narrative letters of recommendation have been utilized in the selection of applicants for otolaryngology residency programs. In the last two application cycles, our specialty adopted a standardized letter of recommendation (SLOR). The intent was to decrease time burden for letter writers and to provide readers with an objective evaluation of applicants. The objective of this study was to determine attributes in the SLOR that correlate with matching into a residency program. STUDY DESIGN: We performed a retrospective study using SLOR, United States Medical Licensing Examination (USMLE) step 1 scores, and matched outcomes of applicants who applied to our institution for the 2013 and 2014 match cycle. METHODS: We included the following variables from the SLOR in the statistical analysis to determine which ones were associated with matching: patient care, medical knowledge, communication skills, procedural skills, research, initiative and drive, commitment to otolaryngology, commitment to academic medicine, match potential, and USMLE1 scores. RESULTS: We identified 532 applicants and 963 SLOR. In successful applicants, scores for patient care, medical knowledge, communication skills, initiative and drive, and match potential were statistically higher (P < 0.05). Scores for professionalism, procedural skills, research, commitment to otolaryngology, commitment to academic medicine, and USMLE step 1 scores were not higher among successfully matched applicants. CONCLUSION: Although SLOR can save time for letter writers and provide an objective description of applicants, the utility of individual domains within the SLOR is questionable. Additionally, it is concerning that applicants' professionalism and procedural skills are not correlated with matching in our specialty. LEVEL OF EVIDENCE: NA. Laryngoscope, 126:1071-1076, 2016.

Depression and anxiety in chronic rhinosinusitis.

BACKGROUND: Both depression and anxiety have been suspected to impact quality of life adversely in patients with chronic rhinosinusitis (CRS). The objective of this work was to assess for the presence of anxiety and/or depression in the setting of CRS and to assess their impact on disease-related quality of life by analyzing the correlation between the Rhinosinusitis Disability Index (RSDI) and the Hospital Anxiety and Depression score (HADS), as well as the Lund-Kennedy nasal endoscopic scores. METHODS: A total of 124 patients with CRS were prospectively evaluated in the outpatient setting using the RSDI and HADS questionnaires as well as the Lund-Kennedy nasal endoscopy scoring system. RESULTS: The total RSDI and its subscale scores had moderate to very strong correlation with the HADS total score and each of its subscale scores in comparison to their poor correlation with Lund-Kennedy endoscopic score. CRS patients with depression or anxiety scores 8 to 10 (possible case of clinically significant depression or anxiety) and 11 to 21 (probable case) reported worse total RSDI and subscale scores when compared with those with normal scores (0 to 7). There was no significant difference in the Lund-Kennedy endoscopic scores between the different groups of anxiety and depression scores. CONCLUSION: Depression and anxiety are prevalent in CRS. The total RSDI and its different subscale scores exhibit moderate to very strong correlation with depression/anxiety scores as determined by HADS, whereas poor correlation was seen with the Lund-Kennedy endoscopic score.

Endoscopic Management of Chronic Frontal Sinusitis: Prospective Quality of Life Analysis.

BACKGROUND: Previous studies of endoscopic frontal sinus surgery have been primarily retrospective and focused on symptom relief only. OBJECTIVES: To prospectively assess the impact of endoscopic frontal sinus surgery on frontal sinus ostium patency and disease-specific quality of life as measured by the Rhinosinusitis Disability Index (RSDI). STUDY DESIGN: A 60-patient cohort with chronic frontal sinusitis (100 diseased frontal sinuses) was prospectively evaluated using the RSDI, computed tomography (CT) imaging, and endoscopic examination. Image-guided endoscopic frontal sinusotomy (Draf 2a) was performed in each case. Patients were assessed with RSDI and endoscopic assessment at least 6 months postoperatively. RESULTS: At a mean follow-up of 10 months, endoscopic assessment revealed patent frontal recesses in 90 of 100 frontal sinuses (90%), with significant improvement in the total RSDI score (41.98 ± 26.48 preoperatively to 17.15 ± 15.66 postoperatively) as well as each of its physical, emotional, and functional subscales from 16.3 ± 9.03, 12.23 ± 10.55, 13.45 ± 9.59 preoperatively to 5.95 ± 5.71, 5.55 ± 5.66, 5.65 ± 5.72 postoperatively, respectively. Similar improvement was seen in patients with asthma, polyps, and those undergoing revision sinus surgeries. CONCLUSIONS: With frontal recess mucosal preservation and meticulous postoperative endoscopic surveillance, endoscopic frontal sinusotomy results in high rates of frontal sinus ostium patency with significant improvement in quality of life.

Use of a Foley catheter balloon as a tool during endoscopic frontal sinus surgery in a resource-poor environment.

OBJECTIVE: This study aimed to evaluate the non-Food and Drug Administration-approved off-label use of a 10F Foley catheter as a tool during endoscopic frontal sinus surgery. METHOD: A cohort of 40 patients with chronic frontal rhinosinusitis was prospectively evaluated using the Sino-Nasal Outcome Test (SNOT-22), computed tomography (CT) imaging, and endoscopic examination. Endoscopic sinus surgery (ESS) was performed in the usual fashion, however, when approaching the frontal sinus, a 10F Foley catheter was inserted and the balloon inflated in the frontal outflow. Patients were assessed postoperatively with SNOT-22, CT imaging, and endoscopic assessment at 6 months. RESULTS: Successful intraoperative dilation of the frontal recess was achieved in 62 of 69 frontal sinuses (90%). No cerebrospinal fluid leak or orbital entry occurred. Six months postoperative, SNOT-22 scores showed significant improvement, whereas endoscopic assessment revealed patent frontal recess in 55 of 62 (89%) frontal sinuses. Computed tomography imaging was completed in 25 patients comprising 41 operated frontal sinuses with no mucosal thickening seen in 37 of 41 (90%). CONCLUSION: The 10F Foley catheter is an effective tool to dilate the frontal recess by compression of edema during ESS. It may be a safe and cost-effective alternative to high-cost commercially available sinus balloons, especially in resource-poor environments.