Socioeconomic, comorbidity, lifestyle, and quality of life comparisons between chronic rhinosinusitis phenotypes.

BACKGROUND: Chronic rhinosinusitis (CRS) is a heterogeneous group of inflammatory sinonasal disorders with key defining symptoms, but traditionally separated into phenotypes by clinical/endoscopic findings. It is not known whether the two phenotypes have differing socioeconomic, comorbidity, and lifestyle differences. This analysis of the Chronic Rhinosinusitis Epidemiology Study (CRES) database sought to analyze any key differences in the socioeconomic variables between those with CRS with nasal polyps (CRSwNPs) and those without nasal polyps (CRSsNPs). We also sought to analyze differences in comorbidities, lifestyle, and quality of life. METHODS: Patients with a confirmed diagnosis of CRS in secondary and tertiary care outpatient settings in the UK were invited to participate in a questionnaire-based case-control study. Variables included demographics, socioeconomic factors, comorbidities, lifestyle factors, and health-related quality of life (HRQoL) (level 3 evidence). RESULTS: A total of 1204 patients' data were analyzed: 553 CRSsNP and 651 CRSwNP participants. The key socioeconomic variables did not demonstrate any notable differences, nor did lifestyle variables other than alcohol consumption being higher in those with CRSwNP (P = .032), but the latter was not significant after adjusting for age and sex. Aside from confirmation of asthma being more common in CRSwNP, it was notable that this group complained less of upper respiratory tract infections (URTIs), and CRSsNP participants showed evidence of worse HRQoL scores in respect of body pain (P = .001). CONCLUSIONS: Patients with CRSwNP experience higher rates of asthma and lower rates of URTIs; patients with CRSsNP have worse body pain scores. Otherwise, there are no demonstrable significant socioeconomic, comorbidity, lifestyle, or quality of life differences between the two phenotypes. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2179-2186, 2021.

Evaluation of Smoking as a Modifying Factor in Chronic Rhinosinusitis.

Importance: The negative association of smoking with the respiratory tract is well known; however, the association between smoking and chronic rhinosinusitis (CRS) has not been well characterized. Objective: To analyze whether active smoking was a risk factor for CRS development, smoking was associated with disease-specific quality of life, and smokers experience an increased symptom burden than nonsmokers. Design, Setting, and Participants: This subanalysis of the Chronic Rhinosinusitis Epidemiology Study (CRES), a prospective, questionnaire-based case-control study conducted between October 2007 and September 2013 was conducted across 30 UK tertiary/secondary care sites. Participants were identified at ear, nose, and throat outpatient clinics and classified into CRS phenotypes as per European Position Paper on Rhinosinusitis and Nasal Polyps 2012 criteria. The overall response rate of those identified to take part in the study was 66%. A total of 1535 questionnaires were returned, with 1470 considered eligible for inclusion. Data analysis was conducted in January 2020. Main Outcomes and Measures: The CRES was designed to distinguish differences in socioeconomic status, geography, medical comorbidities, lifestyle, and quality of life between patients with CRS and healthy controls. Results: A total of 1450 patients completed the smoking question, comprising 219 controls (15.1%; mean [SD] age, 47.3 [14.9] years; 143 women [68%]), 546 participants with CRS (37.7%; mean [SD] age, 51.8 [15.3] years; 259 women [53%]) without nasal polyps (CRSsNPs), and 685 participants (47.2%; mean [SD] age, 56.0 [14.5] years; 204 women [33%]) with CRS and nasal polyps/allergic fungal rhinosinusitis (CRSwNPs+). The mean age was similar, with a greater female preponderance in the control group and male in the CRSwNP group. The greatest number of active smokers was found among control participants (33 [15%]), with a lower rate of smokers in the patients with CRSwNPs+ (9.9%) and CRSsNPs (13.9%), respectively. We found a clinically significant difference in the mean difference in Sino-nasal Outcome Test (SNOT-22) scores between active smokers and nonsmokers for both CRS phenotypes (4.49, 12.25). In both CRS subgroups active smokers had significantly worse SNOT-22 scores than nonsmokers by a mean (SD) magnitude of 10 (18.99, 24.14) points. Nonsmokers also demonstrated a higher percentage of surgical procedures (1 or more), although this was not clinically or statistically different (0.34, 1.10). Conclusions and Relevance: This questionnaire-based case-control study demonstrated a clinically significant symptom burden associated with active cigarette smoking, with worse SNOT-22 scores in the smoking cohort by a mean magnitude of 10 points. We could find no demonstrable evidence that smoking increases the likelihood of need for revision sinus surgery. Clinicians should encourage smoking cessation alongside general CRS medical management.

The association of Leptospermum honey with cytokine expression in the sinonasal epithelium of chronic rhinosinusitis patients.

OBJECTIVE: To identify the differences in cytokine expression between sinonasal tissue from patients treated with Leptospermum (Manuka) honey (LH) irrigation versus normal saline irrigation twice-daily for twelve weeks following sinus surgery (FESS). METHODS: Forty-six CRS patients were recruited. Sinus tissue biopsies were collected during FESS and then at 5 and 12 weeks postoperatively during the course of treatment. A multi-plex cytokine assay quantified the abundance of 17 cytokines in biopsied tissue. Cytokine expression fold-change was analyzed between each time point using a robust linear regression model and compared between the two treatment groups. RESULTS: Compared to the saline irrigation group, five cytokines were differently expressed (CI = 95%) in sinonasal tissue obtained from subjects in the LH irrigation group during the 12-week treatment period. Cytokines IL-6 (P = 0.0400), IL-8 (P = 0.0398), MCP-1 (P = 0.0284), and MIP-1ß (P = 0.016) were significantly increased in the LH irrigation group compared to the saline irrigation group. IL-13 was significantly increased in the saline irrigation group compared to the LH group (P = 0.0086). CONCLUSION: LH may potentially act to modulate the expression of IL-6, IL-8, IL-13, MCP-1 and MIP-1ß in sinonasal tissue.

Prevalence of asthma, aspirin sensitivity and allergy in chronic rhinosinusitis: data from the UK National Chronic Rhinosinusitis Epidemiology Study.

BACKGROUND: Chronic rhinosinusitis (CRS) is a common disorder associated with other respiratory tract diseases such as asthma and inhalant allergy. However, the prevalence of these co-morbidities varies considerably in the existing medical literature and by phenotype of CRS studied. The study objective was to identify the prevalence of asthma, inhalant allergy and aspirin sensitivity in CRS patients referred to secondary care and establish any differences between CRS phenotypes. METHODS: All participants were diagnosed in secondary care according to international guidelines and invited to complete a questionnaire including details of co-morbidities and allergies. Data were analysed for differences between controls and CRS participants and between phenotypes using chi-squared tests. RESULTS: The final analysis included 1470 study participants: 221 controls, 553 CRS without nasal polyps (CRSsNPs), 651 CRS with nasal polyps (CRSwNPs) and 45 allergic fungal rhinosinusitis (AFRS). The prevalence of asthma was 9.95, 21.16, 46.9 and 73.3% respectively. The prevalence of self-reported confirmed inhalant allergy was 13.1, 20.3, 31.0 and 33.3% respectively; house dust mite allergy was significantly higher in CRSwNPs (16%) compared to CRSsNPs (9%, p < 0.001). The prevalence of self- reported aspirin sensitivity was 2.26, 3.25, 9.61 and 40% respectively. The odds ratio for aspirin sensitivity amongst those with AFRS was 28.8 (CIs 9.9, 83.8) p < 0.001. CONCLUSIONS: The prevalence of asthma and allergy in CRS varies by phenoytype, with CRSwNPs and AFRS having a stronger association with both. Aspirin sensitivity has a highly significant association with AFRS. All of these comorbidities are significantly more prevalent than in non-CRS controls and strengthen the need for a more individualised approach to the combined airway.

Randomized controlled trial: hybrid technique using balloon dilation of the frontal sinus drainage pathway.

BACKGROUND: The objectives of this study were as follows: (1) to evaluate frontal sinus ostial patency following balloon dilation with the Ventera Sinus Dilation System, compared with frontal sinusotomy (Draf 2a); and (2) to compare mean blood loss and mean surgical time for frontal sinusotomy using balloon dilation compared with traditional surgical methods. METHODS: A single blinded, randomized, controlled, prospective study was performed at St. Paul's Sinus Center, Vancouver, a tertiary referral rhinology center. Thirty patients undergoing functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis (CRS) were randomized to a hybrid approach with exposure of the frontal recess using standard instrumentation and then balloon dilation of 1 frontal sinus drainage pathway and traditional frontal sinusotomy for the opposite side. Blood loss and surgical time for opening the frontal sinus drainage pathway was recorded for each side. Patients acted as their own controls. Ostial patency and size were assessed 5 weeks and 3 months postoperatively using endoscopy. Ostial patency was also recorded at 1 year following surgery. RESULTS: All frontal sinus ostia in both groups (n = 30) were successfully opened and were patent with both techniques 3 months postoperatively. All frontal sinus ostia assessed at 1 year (73%) remained patent and none required revision frontal surgery. Balloon dilation showed a mean surgical time of 655 seconds compared to 898 seconds for traditional FESS (p = 0.03). Mean blood loss was less with balloon dilation (58 mL vs 91 mL; p = 0.008). CONCLUSION: A hybrid balloon technique successfully dilates the frontal sinus drainage pathway with reduced blood loss. Also, short-term patency appears to be comparable to traditional frontal sinusotomy.

Is cartilage interposition required for ossiculoplasty with titanium prostheses?

OBJECTIVE: To demonstrate that cartilage interposition between the head of a titanium prosthesis and the tympanic membrane is not necessary to prevent extrusion. STUDY DESIGN: Retrospective review. SETTING: District general hospital. PATIENTS: A retrospective review of 73 ears in patients aged between 5.9 and 64.5 years, which had an ossiculoplasty performed using a titanium prosthesis between the stapes footplate or stapes head and the tympanic membrane. INTERVENTIONS: Use of Spiggle and Theis two part, shortenable titanium PORP and TORP and Grace Alto titanium TORP and PORP. MAIN OUTCOME MEASURES: Number of extruded prostheses. Audiometric results. RESULTS: Five extrusions occurred in 4 patients, follow-up between 6 and 98 months. Extrusions were related to retraction of the tympanic membrane around the prosthesis. Audiometric results compared favorably with other ossiculoplasty techniques. CONCLUSION: The titanium head of the Spiggle and Theis and Grace Alto titanium prostheses interact well with the undersurface of the tympanic membrane in patients with favorable middle ear conditions. In our experience, cartilage interposition is not mandatory.

Blood transfusion requirements for endoscopic sinonasal inverted papilloma resections.

BACKGROUND: Endoscopic resection of sinonasal Inverted Papilloma (SNIP) tumors has been shown to reduce intra-operative blood loss and recovery time compared to open approaches. The purpose of this study is to investigate the incidence and requirements of blood transfusion for endoscopic SNIP surgeries. METHODS: An individual retrospective cohort study of endoscopic SNIP surgeries over a 10-year period was performed. Age, sex, pre-existing co-morbidity, use of anti-coagulants, tumor type and stage, time of surgery, estimated blood loss and the requirement for blood transfusion were recorded. RESULTS: 82 patients were included (57 males, 25 females). 4 (5%) Stage 1, 7 (8.5%) Stage 2, 62 (75.5%) Stage 3 and 9 (11%) Stage 4 SNIP tumors were identified according to the Krouse staging system. 3 (4%) patients required blood transfusion. 3 of the 9 (33%) Stage 4 tumors required blood transfusion. Stage 4 tumors were significantly associated with blood transfusion (p < 0.05). Higher staged tumors were associated with greater blood loss (p < 0.05) than lower staged cases. No other tumor stage required blood transfusion and no other pre-operative variable was associated with requirement for blood transfusion. CONCLUSION: Endoscopic SNIP resections rarely require blood transfusions. No pre-operative factor other than tumor stage is associated with the requirement for blood transfusion. We would therefore suggest that only Stage 4 SNIP tumors require pre-operative type and screen.

Validation of a grading system for the attachment of the superior turbinate to the sphenoid face.

BACKGROUND: The attachment of the superior turbinate to the sphenoid face may be an important factor in determining the approach for sphenoidotomy. We sought to validate a previously described 4-type grading system for superior turbinate attachment (Type: A, within its medial one-third; B, in its middle one-third; C, to its lateral one-third; and D, directly to the orbit) to the face of the sphenoid sinus and to make recommendations for its use in determining the method of sphenoidotomy (transethmoidal vs transsphenoethmoidal). METHODS: Single-slice images through both sphenoid sinus ostia were obtained from axial series of computed tomography (CT) scans. Eighteen (36 ostia) sets of scans were used. Attachment type (A-D) in each image was classified by 10 experienced sinus surgeons and compared against a "gold standard" grading performed by the senior author (A.J.), who was the developer of the grading system. RESULTS: Mean accuracy was 63% (95% confidence interval [CI], 54%-72%) for the 4-type grading system. When Types A+B and Types C+D were grouped together, mean accuracy was 91% (95% CI, 84%-97%). For the 2-group classification system, bootstrap analysis suggested that 97% of physicians attain an accuracy of at least 80%. CONCLUSION: Accuracy using the 4-type classification is too low to be practically useful. Accuracy using the 2-group system may be sufficiently high to be a useful aid in selecting a surgical approach. We recommend a transethmoid sphenoidotomy for Types A and B and a transsphenoethmoidal approach to the sphenoid for Types C and D.

Blood transfusion requirements for endoscopic sinonasal inverted papilloma resections.

BACKGROUND: Endoscopic resection of sinonasal inverted papilloma (SNIP) tumours has been shown to reduce intraoperative blood loss and recovery time compared to open approaches. OBJECTIVE: The purpose of this study was to investigate the incidence and requirements of blood transfusion for endoscopic SNIP surgeries. STUDY DESIGN: Individual retrospective cohort study. SETTING: St. Paul's Sinus Centre, a tertiary referral rhinology centre. METHODS: An individual retrospective cohort study of endoscopic SNIP surgeries over a 10-year period was performed. Age, sex, pre-existing comorbidity, use of anticoagulants, tumour type and stage, time of surgery, estimated blood loss, and requirement for blood transfusion were recorded. MAIN OUTCOME MEASURES: Incidence of blood transfusion, type and screen, and crossmatch requisitions. RESULTS: Eighty-two patients were included (57 males, 25 females). Four (5%) stage 1, 7 (8.5%) stage 2, 62 (75.5%) stage 3, and 9 (11%) stage 4 SNIP tumours were identified according to the Krouse staging system. Three (4%) patients required blood transfusion. Three of the nine (33%) stage 4 tumours required blood transfusion. Stage 4 tumours were significantly associated with blood transfusion (p < .05). Higher-staged tumours were associated with greater blood loss (p < .05) than lower-staged cases. No other tumour stage required blood transfusion, and no other preoperative variable was associated with the requirement for blood transfusion. CONCLUSION: Endoscopic SNIP resections rarely require blood transfusions. No preoperative factor other than tumour stage is associated with the requirement for blood transfusion. We therefore suggest that only stage 4 SNIP tumours require preoperative type and screen testing.

Topical anaesthetic or vasoconstrictor preparations for flexible fibre-optic nasal pharyngoscopy and laryngoscopy.

BACKGROUND: Nasal pharyngolaryngoscopy (NPL) is performed as an outpatient and inpatient procedure on a daily basis, for a variety of indications. It frequently causes some degree of discomfort to the patient. Various different topical agents, which are intended to reduce this discomfort, are in common use. This review aimed to assess the effectiveness of the various agents. OBJECTIVES: To assess the effectiveness of topical preparations used to reduce discomfort and facilitate NPL in adults. SEARCH STRATEGY: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 14 April 2010. SELECTION CRITERIA: Randomised controlled trials (RCTs) looking at the effect of topical anaesthetic or vasoconstrictor agents used reduce discomfort and facilitate NPL in adult patients. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, extracted data and assessed risk of bias. We contacted trial authors for further information where necessary. The primary outcome measured was pain/discomfort. Secondary outcomes that were looked at included side effects of the topical medications, ease of the procedure and the quality of the view from the operator's perspective. MAIN RESULTS: We included eight RCTs (746 participants) in the review. The risk of bias in the studies was generally low. Five studies did not demonstrate any advantage in using a topical treatment prior to endoscopy. One study suggested that a vasoconstrictor alone should be used to reduce the general level of unpleasantness. Two studies did not compare treatment against placebo or no treatment, so it was not possible to draw meaningful conclusions from them. There may be some unpleasant side effects from the use of topical preparations, such as unpleasant taste.There was variation in the format of the outcome data and a lack of complete data; none of the included studies reported their results in a way that would allow pooling and we could not therefore perform meta-analysis. AUTHORS' CONCLUSIONS: The included studies do not demonstrate any evidence to support the use of topical treatments prior to the use of a fibre-optic nasal endoscope. Some go as far as to suggest that these agents should not be used due to cost and unpleasant side effects. Five studies did not demonstrate any advantage in terms of reducing pain or discomfort when using a topical treatment prior to endoscopy. The absence of demonstrable effect may be due to relatively small patient groups. It is therefore possible that there is a small effect of using these sprays. Further research using standardised reporting methods is needed.