Smell Changes and Efficacy of Nasal Theophylline (SCENT) irrigation: A randomized controlled trial for treatment of post-viral olfactory dysfunction.

OBJECTIVE: To evaluate the efficacy and safety of intranasal theophylline saline irrigation on olfactory recovery in patients with post-viral olfactory dysfunction (PVOD). METHODS: Between May 2019 and April 2020, we conducted a double-blinded, placebo-controlled randomized clinical trial of adults with 6-36 months of PVOD. Patients were randomized to nasal theophylline saline irrigation or placebo saline irrigation twice a day for 6 weeks. The primary outcome was the Global Rating of Smell Change. Secondary outcomes were changes in the University of Pennsylvania Smell Identification Test (UPSIT) and Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS). RESULTS: Twenty-two patients (n = 12, theophylline; n = 10, placebo) completed the study. Slightly more patients in the theophylline group (33%) reported improved smell compared to the placebo group (30%, difference 3.3%, 95% CI -35.6% to 42.3%). The median differences in pre- and post-treatment UPSIT and QOD-NS change between the two groups were 1 (95% CI -3 to 5) and -10 (95% CI -15 to -4), respectively in favor of theophylline. Three patients receiving theophylline and 2 receiving placebo had clinically meaningful improvements on the UPSIT (difference 5%, 95% CI -30% to 40%). There were no adverse events, and serum theophylline levels were undetectable in 10/10 patients. CONCLUSIONS: While safe, there were no clinically meaningful differences in olfactory change between the two groups except for olfaction-related quality of life, which was better with theophylline. The imprecise estimates suggest future trials will need substantially larger sample sizes or treatment modifications, such as increasing the theophylline dose, to observe larger treatment effects.

Hazardous sound outputs of white noise devices intended for infants.

OBJECTIVES: To measure the sound intensity of popular infant white noise machines and Apple iPhone applications (apps) as they vary with volume setting and distance, and compare these output levels with current National Institute for Occupational Safety and Health (NIOSH) noise exposure threshold recommendations. METHODS: A total of eight infant white noise machines and six iPhone applications were included in the study based on product rating, number of ratings, and cost. The NIOSH Sound Level Meter application through the Apple App Store was used to measure output levels in A-weighted decibels (dBA). Each device was tested at its lowest and highest volume setting and at speaker-to-microphone distances simulating placement within a crib (10 cm), just outside of a crib rail (30 cm), and on a nightstand across the room (100 cm). RESULTS: At the minimum volume setting, no device exceeded the NIOSH recommended noise exposure threshold of 85 dBA at any distance tested. At maximum volume setting, nine out of fourteen (64.3%) devices exceeded output levels of 85 dBA at a speaker-to-microphone distance of 10 cm. No device exceeded the recommended threshold at its maximal volume when placed 30 cm or 100 cm away. CONCLUSION: Excessive white noise exposure has the potential to lead to noise-induced hearing loss and other adverse health effects in the neonatal and infant population. We recommend conservative use of white noise machines and apps by avoiding maximal volume setting and placing any device well outside of the crib or at least 30 cm away from the child. To promote safe use of white noise devices, future studies are needed to fully understand the association between early noise exposure and hearing loss in infants.

Association of Olfactory Training With Neural Connectivity in Adults With Postviral Olfactory Dysfunction.

Importance: Viral upper respiratory tract infections are a major cause of olfactory loss. Olfactory training (OT) is a promising intervention for smell restoration; however, a mechanistic understanding of the changes in neural plasticity induced by OT is absent. Objective: To evaluate functional brain connectivity in adults with postviral olfactory dysfunction (PVOD) before and after OT using resting-state functional magnetic resonance imaging. Design, Setting, and Participants: This prospective cohort study, conducted from September 1, 2017, to November 30, 2019, recruited adults with clinically diagnosed or self-reported PVOD of 3 months or longer. Baseline olfaction was measured using the University of Pennsylvania Smell Identification Test (UPSIT) and the Sniffin' Sticks test. Analysis was performed between December 1, 2020, and July 1, 2020. Interventions: Participants completed 12 weeks of OT using 4 essential oils: rose, eucalyptus, lemon, and clove. The resting-state functional magnetic resonance imaging measurements were obtained before and after intervention. Main Outcome and Measures: The primary outcome measure was the change in functional brain connectivity before and after OT. Secondary outcome measures included changes in UPSIT and Sniffin' Sticks test scores, as well as patient-reported changes in treatment response as measured by subjective changes in smell and quality-of-life measures. Results: A total of 16 participants with PVOD (11 female [69%] and 14 White [88%]; mean [SD] age, 60.0 [10.5] years; median duration of smell loss, 12 months [range, 3-240 months]) and 20 control participants (15 [75%] female; 17 [85%] White; mean [SD] age, 55.0 [9.2] years; median UPSIT score, 37 [range, 34-39]) completed the study. At baseline, participants had increased connectivity within the visual cortex when compared with normosmic control participants, a connection that subsequently decreased after OT. Furthermore, 4 other network connectivity values were observed to change after OT, including an increase in connectivity between the left parietal occipital junction, a region of interest associated with olfactory processing, and the cerebellum. Conclusions and Relevance: The use of OT is associated with connectivity changes within the visual cortex. This case-control cohort study suggests that there is a visual connection to smell that has not been previously explored with OT and that further studies examining the efficacy of a bimodal visual and OT program are needed.

Diagnostic dilemmas of mechanical restriction of the medial rectus: A case report.

BACKGROUND: Due to the proximity of the maxillary sinus and ethmoid sinuses to the orbit, inflammatory processes that originate in the sinonasal region have the potential to extend into the orbit. OBJECTIVE: We presented a case of ptosis and restrictive strabismus of the medial rectus muscle. METHODS: A case report with a literature review of possible diagnoses. RESULTS: Biopsy, imaging, and laboratory evaluation by otolaryngology, ophthalmology, and rheumatology services were unable to identify the cause of the fibrosis after 22 months of follow-up. A response to oral steroids indicated an inflammatory process. CONCLUSION: Unilateral mechanical restriction of the medial rectus muscle is a rare complication of nasal disease. Inflammatory processes and iatrogenic injury are known to cause fibrosis of surrounding tissue. We presented a unique case of medial rectus fibrosis that did not meet the diagnostic criteria of recognized etiologies.

Autoimmune-related nasal septum perforation: A case report and systematic review.

BACKGROUND: Inflammatory injury of nasal respiratory mucosa is a common feature of multisystem autoimmune disease. Certain autoimmune disorders are associated with nasal septum perforation (NSP). We performed a systematic review of the literature to better understand the association of NSP with specific autoimmune disorders. This is a case report of a 29-year-old woman with a history of arthralgia, autoreactive antibody titers, platelet dysfunction, and NSP. The constellation of symptoms and potential familial involvement indicated that the NSP in this patient was an early sign of an autoimmune disorder, an unknown autoimmune disorder, or a known disease with incomplete penetrance. METHODS: A systematic review of the literature was performed by two independent reviewers. Relevant articles were reviewed, and data that pertained to autoimmune-related NSP were extracted and analyzed. RESULTS: Overall, 140 cases of autoimmune-associated NSPs were reported. Granulomatosis with polyangiitis (48%), relapsing polychondritis (26%), and cocaine-induced midline lesions (15%) constituted 89.3% of the reported cases. CONCLUSION: NSP is a potential sign of systemic disease. The identification of an NSP, especially in the context of other unexplained symptoms or workup suggestive of an autoimmune disorder, should prompt clinical evaluation for multisystem autoimmune disease with consideration of granulomatosis with polyangiitis, relapsing polychondritis, or cocaine-induced midline lesions.

Nasopharyngeal acid reflux and Eustachian tube dysfunction in adults.

OBJECTIVE: This study aimed to evaluate the relationship between nasopharyngeal pH and Eustachian tube dysfunction (ETD) in adults. STUDY DESIGN: Unmatched case-control study. METHODS: Forty-one subjects, 20 adults with a diagnosis of ETD and 21 healthy adults as controls, were enrolled from an outpatient clinic. All subjects had a Dx-pH probe placed near the torus tubarius in the posterior nasopharynx for 24 hours. The pH values were recorded every 0.5 second. Decreases in pH were considered as reflux events if the pH dropped below 5.5. RESULTS: The average nasopharyngeal pH value was 6.90 (range, 5.33-7.73) in the subjects with ETD and 7.07 (range, 5.99-7.94) in the controls. The difference between the 2 groups was not statistically significant (P = .30). The ETD group, on average, had a higher number of nasopharyngeal reflux events (2.3 +/- 1.6 vs 0.8 +/- 1.2, respectively; P = .002) and higher reflux finding score (3.6 +/- 2.7 vs 0.4 +/- 1.4, respectively; P < .00 I) than the control group. CONCLUSION: By using a novel pH probe that allows detection of acidity in a nonliquid environment, a comparison of nasopharyngeal pH between control patients and those with ETD was performed. Eustachian tube dysfunction was more likely to be associated with a higher number of nasopharyngeal reflux events and higher reflux finding score. Nasopharyngeal reflux may have a role in the pathogenesis of ETD.

Detecting nasopharyngeal reflux: a novel pH probe technique.

OBJECTIVES: We sought to ascertain the normal pH values in the aerosolized environment of the nasopharynx in healthy subjects and utilize a novel pH probe that allows measuring acidity in a nonliquid environment. METHODS: Between November 2009 and February 2011, healthy volunteers without a history of reflux or eustachian tube dysfunction were enrolled in the prospective study. A total of 20 subjects had a Dx-pH Measurement System Probe (Respiratory Technology Corp) placed near the torus tubarius. The pH probe records the pH throughout the 24-hour study. A pH below 5.5 while the subject was upright or below 5.0 while the subject was supine was used as a criterion to determine a reflux event. Recording was stopped during meals. RESULTS: For normal individuals with no history of reflux or eustachian tube dysfunction, the pH values obtained from the nasopharynx ranged from 6.10 to 7.92. The average pH was 7.03 (SD, 0.67). Eight subjects (40%) had at least 1 reflux event during the 24-hour pH study. CONCLUSIONS: By utilizing a novel self-condensing pH probe, we were able to perform a 24-hour pH study in the nasopharynx of 20 healthy individuals. In our study, the average pH for individuals without symptomatic reflux or eustachian tube dysfunction was 7.03. Interestingly, 8 control subjects had at least 1 episode of pH below 5.5 while awake or below 5.0 while asleep, which was considered to be a reflux event in our study.

Impact of duty hour restrictions on otolaryngology training: divergent resident and faculty perspectives.

OBJECTIVES: In 2003, the Accreditation Council for Graduate Medical Education (ACGME) passed a controversial mandate limiting resident work hours. We sought to examine the impact of these restrictions on otolaryngology programs and to explore faculty and resident perspectives. METHODS: Faculty and residents of all 102 ACGME-accredited otolaryngology residency programs were invited to participate in an anonymous online survey. RESULTS: The study population consisted of 460 respondents: 275 residents and 185 faculty (including 41 program directors) representing 57 otolaryngology programs. Sixty-five percent of programs implemented at least one change specifically to comply with duty-hour restrictions. Strategies included tracking work hours electronically (35.7%), utilization of "home call" (33.1%), and hiring additional healthcare professionals (23.1%). When asked if the restrictions have had a negative effect on patient care, 61% of respondents said no, but a surprising 33% said yes. Sixty-nine percent of faculty felt that the restrictions have actually had a negative effect on resident training compared with only 31% of residents (P<.001). Thirty-nine percent of participants felt resident workload was excessive before the restrictions. Opinions on whether duty-hour limits had fostered improvements in resident education, research, or examination scores varied, but most agreed that resident mental health had improved (67%). CONCLUSIONS: Otolaryngology programs have successfully restricted resident duty hours through significant infrastructural changes. Of concern, the majority of residents surveyed appeared to be in favor of the ACGME restrictions, whereas most program directors and faculty were opposed. Further studies are needed to establish whether limited work hours will enhance or hinder the residency training experience.