Challenges in Medicine: The Odyssey of a Patient with Isolated IgG4-Related Eosinophilic Angiocentric Fibrosis Presenting as a Locally Destructive Sinonasal Mass.

Eosinophilic angiocentric fibrosis (EAF) is an exceeding rare clinical entity and is considered a part of the spectrum of IgG4-related disease (IgG4RD). We hereby present such an unusual case of a 60-year-old female who presented to us with recurrent sinonasal mass, after a decade long haul of multiple clinical evaluations, biopsies, and debulking surgery without a definitive diagnosis. Over this period, the mass eroded through the ethmoid cells along with nasal septal destruction leading to saddle nose deformity, extended superiorly through the cribriform plates to right frontal lobe, and compressed the optic nerve leading to visual loss. Although initial biopsy was negative, repeat biopsy was performed owing to high clinical suspicion due to all the classic histopathological findings compatible with the diagnosis of eosinophilic angiocentric fibrosis IgG4-related disease (EAF-IgG4RD). Steroids are the recommended first-line therapy; however, our case was resistant to steroids needing rituximab to halt the disease progression. Our case interestingly also had T-cell clonality and isolated isocitrate dehydrogenase 2 enzyme mutation on next-generation sequencing, suggesting a possible role of novel molecular-targeted therapies in this rare disease. This case highlights the clinical challenges physicians face towards diagnosing and treating EAF-IgG4RD, emphasizing the need for high clinical suspicion and the possible role of targeted therapies for this rare disease.

Management of Recurrent Acute Rhinosinusitis: A Systematic Review.

BACKGROUND OBJECTIVE STUDY DESIGN: RARS is a challenging clinical problem that impacts many patients. This article seeks to systematically review the literature on RARS management. METHODS: Cochrane, PubMed, EMBASE, and other databases were queried for articles related to RARS dating from 1990 to present, according to PRISMA guidelines. Inclusion criteria included articles specifically addressing RARS management; studies with 3 or more patients; and articles in English. RESULTS: A total of 1022 titles/abstracts potentially related to RARS were identified. Of these, sixty-nine full texts were selected for review, and 10 met inclusion criteria (five with level 4 evidence, four with level 3 evidence, one with level 2 evidence). The studies included a total of 890 patients (Age range 5.8 to 53.5 years), with follow up ranging from 1 to 19 months. Endpoints were primarily based on symptomatic improvement, although some articles also reported post-treatment endoscopic and radiographic findings. Management options included medical therapy (intranasal steroids, antibiotics, nasal saline irrigations, N-acetylcysteine, allergy treatment, and decongestants), balloon sinus dilation (BSD), and endoscopic sinus surgery (ESS). Surgical patients (BSD and ESS) had a trend towards greater symptom control than medically-treated patients, but meta-analysis was not possible. CONCLUSION: Despite increasing interest in the treatment of RARS, there remains a lack of consensus regarding optimal management. The literature thus far, largely based on expert opinion, suggests that surgical management, either through balloon sinus dilation or endoscopic sinus surgery, may be helpful in improving symptoms and quality of life in those who do not respond to initial trials of medical management.

Diagnostic Criteria of Recurrent Acute Rhinosinusitis: A Systematic Review.

BACKGROUND: RARS is a challenging clinical phenomenon that affects many patients, and diagnostic criteria for this condition are not fully characterized in the literature. OBJECTIVE: To examine diagnostic criteria for recurrent acute rhinosinusitis (RARS). STUDY DESIGN: Systematic review. METHODS: Cochrane, PubMed (MEDLINE), clinicaltrials.gov, EMBASE, Google Scholar, and Web of Science databases were queried for articles related to RARS dating from 1990 to present, according to PRISMA statement guidelines. Full text articles pertinent to the diagnostic criteria of RARS were included in this review. Inclusion criteria included articles specifically addressing RARS; studies with 3 or more patients; and articles in English. RESULTS: A total of 1022 titles/abstracts potentially related to RARS were identified. Of these, sixty-nine full texts were selected for review, and 22 of these ultimately met inclusion criteria. The level of evidence was generally low. Studies and guidelines have used many different definitions for RARS diagnosis over the years based on symptomatology, physical examination, nasal endoscopy, imaging, and laboratory domains. Clinically important RARS has been defined most commonly as 4 or more discrete episodes of ARS per year, but this frequency is typically based on expert opinion. Additionally, radiologic anatomic associations such as concha bullosa, accessory maxillary os, and narrowed infundibular distance may be associated with RARS. Endoscopic visualization and imaging are sometimes used to confirm the presence of sinus disease during exacerbations of RARS, but there is variability in this practice. CONCLUSION: The diagnostic definition for RARS has developed over time and is currently based on low level 4 and 5 evidence. Because of the migratory definition of RARS, comparing inter-study results of RARS management remains difficult, and future studies should aim to follow current expert guidelines on diagnostic criteria of RARS.

Otolaryngology Education in the Setting of COVID-19: Current and Future Implications.

The COVID-19 pandemic continues to garner extensive international attention. The pandemic has resulted in significant changes in clinical practice for otolaryngologists in the United States; many changes have been implemented to mitigate risks identified by otolaryngologists in other countries. COVID-19-induced limitations include social distancing and triaging of patient acuity. Additionally, a recent publication by Stanford University has drawn attention to the risks that otolaryngologists may face with regard to manipulation of the upper airway and mucosal disruption. As a result of COVID-19 recommendations, multiple institutions have overhauled resident clinical rotations and resident education. The result has been a rapid and significant change in resident education at most academic institutions. This commentary outlines the development of the otolaryngology resident education consortiums, with implications for future education within and outside of otolaryngology.

No-Show Rates in Employed Otolaryngology Practice.

OBJECTIVE: To report baseline no-show rates in the hospital-employed otolaryngology practice setting and to identify factors that may affect clinic show rates that are targets for potential improvement. STUDY DESIGN: Retrospective chart review. METHODS: Electronic medical records from October 2012 through July 2014 of a hospital-employed otolaryngology practice were reviewed. Patients were classified by insurance type: commercial, Medicare, Medicaid, and self-pay. Clinic visits were classified as new patient, follow-up, or postoperative. No-show rates were tabulated for each type of clinic visit and compared. Factors to improve no-show rates are discussed. RESULTS: There was an overall no-show rate of 8.3% for 5817 scheduled clinic visits. Among visit types, follow-up visits had the highest no-show rates. Among insurance types, Medicaid had the highest no-show rates. New patient Medicaid patients, follow-up Medicaid patients, and follow-up commercial insurance patients had the highest rate of no-shows among visit/insurance type combinations. Persistent reminders are a key factor in improving rate of clinic visit adherence. CONCLUSION: A previously unreported baseline no-show rate was established for hospital-employed otolaryngology clinics. The utilization of repeated, live-person reminders to mitigate the impact of clinic no-show rates needs to be further investigated.

Upper aerodigestive tract frostbite from inhalation of automotive nitrous oxide.

Nitrous oxide, a cryogenic gas, may be abused as an inhalant for its euphoric properties. If inhaled, nitrous oxide may cause frostbite to the oral cavity and upper aerodigestive tract, with possible airway compromise due to edema. In this article we describe what is, to the best of our knowledge, the first case of intentional inhalation of nitrous oxide from an automotive nitrous oxide canister and discuss the management and mechanism of the patient's injury.

Endoscopically assisted Crawford tube placement results in shorter general anesthesia times in pediatric patients.

BACKGROUND: Crawford tube placement is commonly used to achieve patency of nasolacrimal ducts for epiphora secondary to nasolacrimal duct obstruction. The nasal passages of pediatric patients are narrower than adults, and the result is a relatively higher risk of intranasal complications (e.g., synechiae, bleeding) with Crawford tube placement. There is evidence that general anesthesia may negatively affect the neurocognitive function and behavioral development of children, which prompts efforts to decrease operation times for potential health benefits and also potentially to reduce health care costs. Analysis of research reports supports the use of nasal endoscopy to reduce intranasal complications with Crawford tube placement; however, no publications currently address the effect of nasal endoscopy concurrent with Crawford tube placement on operative times on pediatric patients or the resulting effects on health care costs. OBJECTIVE: To determine the difference in procedure time and cost between Crawford tubes placed traditionally and those placed with endoscopic assistance in pediatric patients. METHODS: A chart review was performed from January 1, 2011 to December 31, 2016 for cases using CPT codes 68815 or 31231. Within this group of patients, the patient in whom nasal endoscopy was performed were placed in the "endoscopic" group and the patients without endoscopy were placed in the "traditional" group. Procedure times were noted, and the t-test was performed to examine for any statistically significant difference in operative times. Estimates of anesthesia cost savings were made. We identified 24 patients in the traditional group and 7 patients in the endoscopic group. RESULTS: The average operative time for the traditional group was 27.3 minutes compared with 14.0 minutes for the endoscopic group (p = 0.02). The cost comparison data revealed no significant difference with the traditional group averaging $9369 per procedure and the endoscopic group averaging $8891 (p = 0.51). CONCLUSION: An endoscopically assisted Crawford tube placement resulted in patients who had less time under general anesthesia compared with the traditional technique at no difference in cost.

Factors associated with patient no-show rates in an academic otolaryngology practice.

OBJECTIVES/HYPOTHESIS: Factors affecting access to healthcare is an expanding area of research. This study seeks to identify factors associated with no-show rates in an academic otolaryngology practice to improve clinical efficiency and patient access to care. STUDY DESIGN: Retrospective review. METHODS: A retrospective review of scheduled clinical appointments from February 1, 2015 to January 30, 2016 at a single academic otolaryngology department was performed. Statistical analysis was completed to examine the association of no-show rates with the following: otolaryngology subspecialty, clinic location (e.g., main campus vs. satellite), patient demographic factors, attending seniority, temporal factors, insurance types, rurality, and visit type. RESULTS: There was an overall no-show rate of 20% for 22,759 scheduled clinic visits. Satellite clinics had the highest no-show rates at 25% (P < .001). New patient visits had the highest no-show rate at 24% (P < .001). Among subspecialties, facial plastic surgery had the lowest no-show rate (12.6%), whereas Pediatrics had the highest (23%) (P < .001). No significant association between gender and no-show rates was observed (P = .29), but patients over 60 years old had the lowest no-show rate (12.7%, P < .0001). Patients with Medicaid (28%), Medicare (15.3%), and commercial insurance (12.9%) had significantly different overall no-show rates (P < .0001). CONCLUSIONS: Increased clinic no-show rates are associated with satellite clinics, new patient visits, younger age, and insurance type. No-show rates varied among subspecialties. Further investigation is warranted to assess barriers to appointment compliance and to develop interventions to improve access to care. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:626-631, 2018.

Audible sphenoid-sellar fistula: An unusual complication of transphenoidal surgery.

Eustachian tube problems are relatively common complaints to otolaryngologists' offices. However, clinicians should consider other possibilities when traditional therapies fail to improve symptoms. We present a previously not described case of sphenoid-sellar fistula after transphenoidal surgery causing objective and subjective clicking. Laryngoscope, 126:E314-E316, 2016.

Product comparison model in otolaryngology: Equivalency analysis of absorbable hemostatic agents after endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: Evidence-based medicine in otolaryngology literature continues to be lacking, especially with regard to new products brought to market. The marketing of products often includes statements of benefit that have limited objective support in research or literature. To address this, and to adequately determine product equivalency/superiority, careful evaluation must be made. In order to establish standards for this process in rhinology products, we directly compare three different absorbable hemostatic agents in patients with chronic rhinosinusitis (CRS) after undergoing endoscopic sinus surgery (ESS), using both objective and subjective outcomes. STUDY DESIGN: Double-blinded prospective (level 1) comparison and equivalency analysis of three plant-based absorbable hemostatic agents (carboxymethylcellulose [CMC] gel, mucopolysaccharide hemospheres (MPH), and potato starch wafer) in patients undergoing bilateral ESS. METHODS: Patients with medically refractory CRS who underwent bilateral ESS were recruited and prospectively followed. At the conclusion of ESS, one of three different hemostatic agents was applied to each nasal passage. Subjective patient data was obtained using rated symptoms compared between the two sides (nasal obstruction, bleeding, pain, and nasal discharge) at baseline and on postoperative days 1, 7, and 14. Objective data was obtained by blinded endoscopic scoring to rate mucosal edema, inflammation, granulation, crusting, infection, and synechiae formation on postoperative weeks 1, 3, and 6. RESULTS: Forty-eight patients who underwent ESS for CRS were included. There is no statistical difference in subjective scores for any of the variables measured, although (MPH) nearly reached statistical significance at postoperative day 7 for increased pain (P = 0.06) and obstruction (P = 0.22). Objective measures showed equivalency between all products, except the CMC gel approached significance at week 3 for increased crusting (P = 0.10), granulation (P = 0.24), and debridement (P = 0.07). At 6 weeks, increased debridement (P = 0.14) also approached significance. CONCLUSION: Careful and deliberate consideration should be taken when choosing products to assist our surgical endeavors. Subjectively, patients treated with MPH showed near-significant increases in pain and obstruction. In objective measures, CMC gel nearly reaches significance for more postoperative debridement, with increased crusting and inflammation. Product choice could consider these factors, although it remains at the discretion of the surgeon. This model of comparison allows careful product comparison and should be applied to other hemostatics, as well as other materials in use in otolaryngology. LEVEL OF EVIDENCE: 1b. Laryngoscope, 126:S5-S13, 2016.

Aspirin sensitivity does not compromise quality-of-life outcomes in patients with Samter's triad.

OBJECTIVES/HYPOTHESIS: To demonstrate that quality-of-life outcomes after endoscopic sinus surgery are not compromised in patients with Samter's triad (asthma, nasal polyps, aspirin sensitivity) when compared to patients with eosinophilic chronic rhinosinusitis with nasal polyposis (eCRSwP) who are not aspirin sensitive. STUDY DESIGN: Retrospective review of prospectively collected data. METHODS: Thirty-two patients with Samter's triad were identified from a prospectively collected patient database from 2003 to 2012. Preoperative and postoperative symptom and endoscopy scores were compared to those of 37 consecutive patients with eCRSwP who were not aspirin sensitive (control). Student t test and Fisher exact test were used to examine for differences between the two groups. Symptom scores were assessed using the 20-item Sino-Nasal Outcome Test (SNOT-20). Endoscopy findings were scored according to the Lund-Kennedy methodology. RESULTS: Samter's triad patients had significantly worse disease preoperatively when compared to the control group: SNOT-20 (31.1 vs. 22.1, P = .004), endoscopy score (10.9 vs. 7.6, P = .0005), and Lund-Mackay computed tomography score (18.9 vs. 13.9, P = .0001). Although postoperative endoscopy scores remained worse in the Samter's triad group, postoperative SNOT-20 scores were comparable to those of the control group at ≥ 3 years follow-up (22.8 vs. 17.3, P = .43). CONCLUSIONS: Although Samter's triad patients present with more severe disease and are more likely to undergo revision surgery, they have postoperative quality-of-life outcomes that are comparable to patients with eCRSwP who are not aspirin sensitive. This is the first study to utilize a disease-specific, validated outcomes instrument in comparing Samter's triad patients with aspirin-tolerant patients who have nasal polyposis and tissue eosinophilia.

Frontal sinus septations predict the presence of supraorbital ethmoid cells.

OBJECTIVES/HYPOTHESIS: This study is undertaken to determine if the presence or absence of multiseptated frontal sinuses is associated with the presence or absence of supraorbital ethmoid cells (SOECs). STUDY DESIGN: Analysis of prospectively collected data. METHODS: Sixty consecutive patients with chronic rhinosinusitis were identified from a prospectively collected database at a tertiary-referral institution as having full-sinus computed tomography (CT) scans. Preoperative or initial CT scans of the sinuses were reviewed, specifically identifying the presence or absence of supraorbital ethmoid air cells (SOECS) and frontal sinus multiseptated sections on coronal imaging. Statistical analysis was performed using the chi-squared test to evaluate any association between the two structural entities. RESULTS: Sixty total patients were identified, for a total of 120 sides. Of the 61 sides with frontal septations, 43 (70%) had SOECs present and 18 (30%) did not. Of the 59 sides without frontal sinus septations, 13 (22%) had SOECs present and 46 (78%) did not (chi squared = 28.3; P = 0.0000001). The difference in the presence of supraorbital ethmoid cells between whites and blacks is also statistically significant (chi squared = 4.23; P = 0.040). CONCLUSION: The presence of frontal sinus septations appears to be significantly associated with and predictive of the presence of supraorbital ethmoid cells. Thus, identifying frontal sinus septations on sinus CT is implicated with more complex anatomy of the frontal recess.

The association between supraorbital ethmoid air cells and orbital proptosis in patients with chronic rhinosinusitis.

BACKGROUND: Orbital proptosis is a known possible complication in patients with chronic rhinosinusitis (CRS). This study was undertaken to determine the association of sinus anatomy and anatomic variants with the predisposition for such a complication. METHODS: All adult patients (n = 16) with orbital proptosis were identified from a prospectively-collected database at a tertiary institution. These were compared with a series of randomly-selected patients (n = 50) diagnosed with chronic sinusitis and who had undergone sinus computed tomography. The presence or absence of supraorbital ethmoid air cells (SOECs) was noted and compared between the 2 groups. The primary sinus anatomy responsible for the proptosis was also identified. Statistical analysis was performed using the chi squared test. RESULTS: Sixteen patients with orbital proptosis were identified, of which all but 1 had SOECs present. Causal analysis showed that in all but 1 case the SOECs were the cause of proptosis. Of the 50 patients with CRS but without proptosis, only 13 had SOECs present and 37 patients did not (chi squared = 22.8, p = 0.000002). CONCLUSION: SOECs appear to be highly associated with and most often are responsible for orbital proptosis in patients with CRS.

Recognition and management of the spectrum of acute laryngeal trauma.

BACKGROUND: Blunt laryngeal trauma frequently takes place in the setting of more significant injuries. In the setting of multiple injuries or, more importantly, as an isolated event, missed injuries to the laryngotracheal complex can have devastating results. More importantly, underestimation of the severity of injury can result in an airway that becomes quite difficult to manage. However, early recognition and management of laryngotracheal injuries can result in minimal morbidity and the need for minimal long-term intervention. OBJECTIVES: Our goal is to heighten awareness of the severity of blunt laryngotracheal trauma and reduce both acute and long-term sequelae. CASE REPORT: We present a series of cases representing a spectrum of seemingly benign neck injuries requiring a diversity of interventions. The cases represent worsening gradations of laryngeal trauma, and the differing presentation, work-up, and management scenarios are discussed. CONCLUSIONS: Expedient evaluation, treatment, and management of blunt laryngeal trauma results in favorable outcomes. Awareness of the potential for significant injury in the presence of benign examination based on the history of injury and confirmed by radiographic or endoscopic evaluation is paramount. Although minimal findings on examination and stable patients in the setting of blunt trauma to the neck may be as innocuous as it seems, the severity of injury may "lie beneath."

Impact of endoscopic surgical techniques on efficiency in pituitary surgery.

OBJECTIVE: To assess the impact of the introduction of endoscopic surgical techniques into a neurosurgical practice for pituitary surgery on operative efficiency. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Patients undergoing transsphenoidal pituitary surgery over a 4-year period were identified. The approach over this period evolved from classic transseptal surgery to exclusively endoscopic techniques. Patients were classified as having transseptal surgery, endoscopic approach with microsurgical resection, aborted endoscopic resection with subsequent microsurgery, and exclusive endoscopic techniques. Patient and surgeon demographics, operative times, total operating room times, and room setup time were examined. Univariate analysis and multivariate regression modeling were used to assess outcome measures. RESULTS: One hundred seven patients were identified. The use of the endoscope for either sphenoid exposure alone (n = 41) or for the entire procedure (n = 35) resulted in a significant reduction in operative and room times compared to transseptal approaches (n = 25). Exclusively endoscopic techniques resulted in a significant reduction in operative and room times independent of all other clinical and surgical parameters (P < .001). Progressive use of endoscopic techniques resulted in statistically significant progressive reduction in setup time (P = .001), operative time (P = .04), and total room time (P = .03) over the study period. CONCLUSION: The transition from transseptal transsphenoidal pituitary surgery to endoscopic techniques implies a learning process for both neurosurgeon and otolaryngologist. Despite this, a noteworthy reduction in operative times, operating room times, and room setup times is observed. The impact of endoscopic techniques on efficiency in pituitary surgery is discussed.

Comparison of posttonsillectomy pain using the ultrasonic scalpel, coblator, and electrocautery.

OBJECTIVE: To compare postoperative tonsillectomy pain between 3 commonly used surgical devices: the Harmonic Ultrasonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH), the Coblator (ArthroCare Corp, Sunnyvale, CA), and electrocautery. STUDY DESIGN AND SETTING: A prospective, randomized trial. One hundred thirty-four patients were randomly assigned to receive a tonsillectomy with 1 of 3 surgical devices. All patients were asked to fill out a postoperative diary. RESULTS: Statistically significant differences in pain scores were revealed between the Coblator and electrocautery (P = 0.02) and between the Coblator and the Ultrasonic Scalpel (P = 0.003), with the Coblator having lower pain scores. Electrocautery and the Ultrasonic Scalpel did not differ significantly from each other. The Coblation method showed a strong trend toward quicker return to normal diet. CONCLUSION: Patients undergoing tonsillectomy with the Coblator device reported less pain over a 10-day period than patients undergoing tonsillectomy with electrocautery or the Ultrasonic Scalpel. Pain after tonsillectomy remains a major issue for our patients. The choice of surgical instrument appears to be one way to reduce this pain. EBM RATING: A-1b.