Patient knowledge and expectations in endoscopic sinus surgery.

BACKGROUND: The potential for patient misconceptions about endoscopic sinus surgery (ESS) has implications for the informed consent process. An understanding of patients' baseline knowledge and sources of information regarding ESS would improve surgeons' ability to counsel patients preoperatively and provide effective educational materials. METHODS: A prospective patient survey was performed at 2 independent tertiary care medical centers. Patients who were offered ESS as part of routine rhinology care were queried about expectations, knowledge, and sources of information regarding ESS before preoperative counseling. RESULTS: Of the 30 patients who completed the survey, 70% of patients reported doing research on ESS before the visit. The most common sources of information were friends and family (40%), YouTube (30.0%), and WebMD (26.7%). The most important factors researched included risks (95%), benefits (85%), and recovery related issues (70%). Patients in the younger group used healthcare and physician rating websites whereas none of the patients older than the median age of 44 years reported using them (33.3% vs 0%, p = 0.028). The older group more often relied upon healthcare providers than the younger group (71.5% vs 18.8%, p = 0.011). A range of responses were noted regarding early postoperative symptoms and recovery time. CONCLUSION: This study identified a varied understanding of ESS including significant misconceptions about risks, anesthesia, and need for ongoing therapy, among others. Patients obtain their information from a variety of sources including peers, other doctors, and the Internet. Awareness of the gaps in patient knowledge and the sources of information will improve preoperative counseling.

Pharyngeal Residue Severity Rating Scales Based on Fiberoptic Endoscopic Evaluation of Swallowing: A Systematic Review.

Identification of pharyngeal residue severity located in the valleculae and pyriform sinuses has always been a primary goal during fiberoptic endoscopic evaluation of swallowing (FEES). Pharyngeal residue is a clinical sign of potential prandial aspiration making an accurate description of its severity an important but difficult challenge. A reliable, validated, and generalizable pharyngeal residue severity rating scale for FEES would be beneficial. A systematic review of the published English language literature since 1995 was conducted to determine the quality of existing pharyngeal residue severity rating scales based on FEES. Databases were searched using controlled vocabulary words and synonymous free text words for topics of interest (deglutition disorders, pharyngeal residue, endoscopy, videofluoroscopy, fiberoptic technology, aspiration, etc.) and outcomes of interest (scores, scales, grades, tests, FEES, etc.). Search strategies were adjusted for syntax appropriate for each database/platform. Data sources included MEDLINE (OvidSP 1946-April Week 3 2015), Embase (OvidSP 1974-2015 April 20), Scopus (Elsevier), and the unindexed material in PubMed (NLM/NIH) were searched for relevant articles. Supplementary efforts to identify studies included checking reference lists of articles retrieved. Scales were compared using qualitative properties (sample size, severity definitions, number of raters, and raters' experience and training) and psychometric analyses (randomization, intra- and inter-rater reliability, and construct validity). Seven articles describing pharyngeal residue severity rating scales met inclusion criteria. Six of seven scales had insufficient data to support their use as evidenced by methodological weaknesses with both qualitative properties and psychometric analyses. There is a need for qualitative and psychometrically reliable, validated, and generalizable pharyngeal residue severity rating scales that are anatomically specific, image-based, and easily learned by both novice and experienced clinicians. Only the Yale Pharyngeal Residue Severity Rating Scale, an anatomically defined and image-based tool, met all qualitative and psychometric criteria necessary for a valid, reliable, and generalizable vallecula and pyriform sinus severity rating scale based on FEES.

Comparison of intranasal fluticasone spray, budesonide atomizer, and budesonide respules in patients with chronic rhinosinusitis with polyposis after endoscopic sinus surgery.

BACKGROUND: Nasal steroids are a critical part of the management of patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) after endoscopic sinus surgery (ESS). Increasingly, practitioners are using budesonide respules delivered to the sinonasal cavities, which is an off-label use, in lieu of traditional nasal steroids. There has been little research comparing budesonide with traditional nasal steroids and the most effective delivery method of budesonide. METHODS: A randomized controlled trial was performed on patients after ESS for CRSwNP in a tertiary care center. Patients were randomized into 1 of 3 groups: group A received fluticasone nasal spray twice daily; group B received budesonide respules via a mucosal atomization device (MAD) twice daily; and group C received budesonide respules instilled via the vertex-to-floor (VF) position twice daily. Primary endpoints were 22-item Sino-Nasal Outcome Test (SNOT-22) and Lund-Kennedy scores at 6 months. RESULTS: Thirty-two patients were enrolled in the study, 23 of whom completed the 6-month trial. There were no significant differences among groups A, B, and C with respect to age, gender, asthma, aspirin sensitivity, or previous ESS. Group B had a statistically significant greater reduction in SNOT-22 and Lund-Kennedy scores at the primary endpoint of 6 months compared to groups A and C. Group C had the next greatest reduction, which was statistically significant, followed by group A. CONCLUSION: Patients treated with budesonide after ESS for CRSwNP had greater improvement in SNOT-22 and Lund-Kennedy scores compared to fluticasone at 6 months. The data supports the use of budesonide respules, particularly with a MAD, over fluticasone for CRSwNP patients after ESS.

The Yale Pharyngeal Residue Severity Rating Scale: An Anatomically Defined and Image-Based Tool.

The Yale Pharyngeal Residue Severity Rating Scale was developed, standardized, and validated to provide reliable, anatomically defined, and image-based assessment of post-swallow pharyngeal residue severity as observed during fiberoptic endoscopic evaluation of swallowing (FEES). It is a five-point ordinal rating scale based on residue location (vallecula and pyriform sinus) and amount (none, trace, mild, moderate, and severe). Two expert judges reviewed a total of 261 FEES evaluations and selected a no residue exemplar and three exemplars each of trace, mild, moderate, and severe vallecula and pyriform sinus residue. Hard-copy color images of the no residue, 12 vallecula, and 12 pyriform sinus exemplars were randomized by residue location for hierarchical categorization by 20 raters with a mean of 8.3 years of experience (range 2-27 years) performing and interpreting FEES. Severity ratings for all images were performed by the same 20 raters, 2 weeks apart, and with the order of image presentations randomized. Intra-rater test-retest reliability, inter-rater reliability, and construct validity were determined by pooled multi-category multi-rater kappa statistics. Residue ratings were excellent for intra-rater reliability for vallecula (kappa = 0.957 ± 0.014) and pyriform sinus (kappa = 0.854 ± 0.021); very good to excellent for inter-rater reliability for vallecula (kappa = 0.868 ± 0.011) and pyriform sinus (kappa = 0.751 ± 0.011); and excellent for validity for vallecula (kappa = 0.951 ± 0.014) and pyriform sinus (kappa = 0.908 ± 0.017). Clinical uses include accurate classification of vallecula and pyriform sinus residue severity patterns as none, trace, mild, moderate, or severe for diagnostic purposes, determination of functional therapeutic change, and precise dissemination of shared information. Scientific uses include tracking outcome measures, demonstrating efficacy of interventions to reduce pharyngeal residue, investigating morbidity and mortality in relation to pharyngeal residue severity, and improving training and accuracy of FEES interpretation by students and clinicians. The Yale Pharyngeal Residue Severity Rating Scale is a reliable, validated, anatomically defined, and image-based tool to determine residue location and severity based on FEES.