High-risk human papillomavirus 16/18 associated with improved survival in sinonasal squamous cell carcinoma.

BACKGROUND: There has been conflicting evidence on the independent prognostic role of human papillomavirus (HPV) status in sinonasal cancer. The objective of this study was to assess whether the survival of patients with sinonasal cancer differs based on various HPV statuses, including HPV-negative, positive for the high-risk HPV-16 and HPV-18 (HPV16/18) subtypes, and positive for other high-risk and low-risk HPV subtypes. METHODS: In this retrospective cohort study, data from the National Cancer Database were extracted from the years 2010-2017 for patients who had primary sinonasal cancer (N = 12,009). The outcome of interest was overall survival based on HPV tumor status. RESULTS: Study included an analytic cohort of 1070 patients with sinonasal cancer who had confirmed HPV tumor status (732 [68.4%] HPV-negative; 280 [26.2%] HPV16/18-positive; 40 [3.7%] positive for other high-risk HPV; and 18 [1.7%] positive for low-risk HPV). HPV-negative patients had the lowest all-cause survival probability at 5 years postdiagnosis (0.50). After controlling for covariates, HPV16/18-positive patients had a 37% lower mortality hazard than HPV-negative patients (adjusted hazard ratio, 0.63; 95% confidence interval [CI], 0.48-0.82). Patients aged 64-72 years (crude prevalence ratio, 0.66; 95% CI, 0.51-0.86) and 73 years and older (crude prevalence ratio, 0.43; 95% CI, 0.31-0.59) presented with lower rates of HPV16/18-positive sinonasal cancer than those aged 40-54 years. In addition, Hispanic patients had a 2.36 times higher prevalence of non-HPV16/18 sinonasal cancer than non-Hispanic White patients. CONCLUSIONS: These data suggest that, for patients with sinonasal cancer, HPV16/18-positive disease may confer a significant survival advantage compared with HPV-negative disease. Other high-risk and low-risk HPV subtypes have survival rates similar to the rates for HPV-negative disease. HPV status might be an important independent prognostic factor in sinonasal cancer that could be used in patient selection and clinical decisions.

Comorbidity burden and nonclinical factors associated with sinonasal cancer all-cause mortality.

OBJECTIVE: To describe comorbidity burden and nonclinical factors associated with all-cause mortality of sinonasal cancer in the United States. METHODS: The National Cancer Database (2004-2013) was queried for adult cases of sinonasal cancer (n = 10,518). Outcome of interest was all-cause mortality. Independent variables included comorbidity score and nonclinical factors such as age, gender, race, facility type, distance to facility, insurance, and income. Survival analysis was conducted via multivariable extended Cox regression with Heaviside adjustments. RESULTS: Patients were mostly (79%), male (61%), and mean age of diagnosis was 63.5 years. Approximately one in five patients (18.7%) had a major comorbid condition (Charlson-Deyo score ≥ 1) at diagnosis. After adjusting for clinical factors, increasing comorbidity score was associated with a corresponding increase in hazard of mortality (aHR comorbidity score of 1 = 1.25; 95% CI, 1.16, 1.35), (aHR score of 2+ = 1.61; 95%, CI 1.41, 1.83). Hazard of mortality was also associated with being male (aHR = 1.11; 95% CI, 1.04, 1.17); black (aHR = 1.13, 95% CI, 1.03, 1.24); uninsured (aHR = 1.45; 95% CI, 1.25, 1.68) or on Medicaid (aHR = 1.50; 95% CI, 1.33, 1.69); residence in zip codes with lower median income quartile (aHR < $30,000 = 1.17; 95% CI, 1.06, 1.29); and treatment at community cancer programs (aHR = 1.14, 95% CI 1.01, 1.28). CONCLUSION: Comorbid disease is associated with all-cause sinonasal cancer mortality, and after accounting for known clinical factors, significant differences in mortality persist based on disparity-driven, nonclinical factors. LEVEL OF EVIDENCE: NA Laryngoscope, 130:1443-1449, 2020.

Evaluating Simulator-Based Teaching Methods for Endoscopic Sinus Surgery.

A multitude of simulator systems for endoscopic sinus surgery (ESS) are available as training tools for residents preparing to enter the operating room. These include human cadavers, virtual reality, realistic anatomic models, and low-fidelity gelatin molds. While these models have been validated and evaluated as independent tools for surgical trainees, no study has performed direct comparison of their outcomes. To address this deficiency, we aimed to evaluate the utility of high-fidelity and low-fidelity trainers as compared to a traditional control (no simulator exposure) for novice trainees acquiring basic ESS skills. Thirty-four first-year medical students were randomized to 3 groups and taught basic sinus anatomy and instrumentation. Two groups received training with either the high-fidelity or low-fidelity trainer, while 1 group served as control. These groups were then tested with cadaveric specimens. These sessions were recorded and graded by an expert. There was no statistical difference in performance between the 3 study groups with regard to identification of anatomy, endoscopic competency, or completion of basic tasks. When the high-fidelity and low-fidelity arms were grouped into a single "trained" cohort, they demonstrated significantly improved time to completion for basic anatomy (P = .043) and total time (P = .041). This is the first study to perform a direct comparison of performance between high-fidelity and low-fidelity ESS simulators and controls. Although we found no difference in performance of novice trainees with regard to basic anatomical identification or procedural tasks associated with ESS, the use of ESS simulators may improve time to completion.

Survival differences in nasopharyngeal carcinoma among racial and ethnic minority groups in the United States: A retrospective cohort study.

OBJECTIVE: The literature on nasopharyngeal carcinoma survival in the United States has focused mostly on Whites or Asians and not much is known about survivorship in other minority racial and ethnic groups. We aimed to determine the disease-specific survival rate and prognostic factors for nasopharyngeal carcinoma survival across the minority United States population. DESIGN: A retrospective cohort study. SETTING: The Surveillance, Epidemiology and End Results (SEER) 13 database from 1992 to 2014 was queried for adult cases of nasopharyngeal carcinoma (n = 2549). PARTICIPANTS: Eligible cases were Blacks, Hispanics, Asians/Pacific Islanders, American Indians/Alaska Natives; White patients were excluded. MAIN OUTCOMES MEASURE: A multivariable competing risk survival analysis yielded hazard ratios (HR) for competing mortality and was used to identify independent prognostic factors for survival. RESULTS: Non-Hispanic American Indians/Alaska Natives consistently had the worst cause-specific survival of any group and that non-Hispanic Asians/Pacific Islanders consistently had the best survival (P < 0.001). Even after adjusting for other poor prognostic factors in the study, including older age, keratinising histology, and lack of radiation treatment, non-Hispanic American Indians/Alaska Natives had more than double hazards of death from nasopharyngeal cancer compared with non-Hispanic Asians/Pacific Islanders (aHR = 2.63, 95% CI 1.67, 4.13). CONCLUSIONS: There are disparities in nasopharyngeal carcinoma survival among racial and ethnic minority groups in the United States, with American Indians/Alaskan Natives faring worst. It is critical that future research focuses on nasopharyngeal carcinoma among this population to improve survivorship and mitigate cancer-related health disparities.

40-year incidence trends for oropharyngeal squamous cell carcinoma in the United States.

OBJECTIVES: To determine differences in oropharyngeal squamous cell carcinoma (OPSCC) incidence between 1975 and 2014 stratified by race, sex, and age. MATERIALS AND METHODS: We obtained age-adjusted OPSCC incidence rates for race and sex groups from 1975 to 2014 using the Surveillance, Epidemiology, and End Results 9 database. We defined OPSCC as cancers of the base of tongue, lingual/palatine tonsil, oropharynx, soft palate, uvula, and Waldeyer's ring. We used Joinpoint analyses to determine incidence trends for race/sex/age groupings. RESULTS: There were 38,624 oropharyngeal primary tumors in the analyses. Males accounted for 74% of sample population, and whites accounted for 84% of tumors. Overall, there was a 57.3% increase in incidence of oropharyngeal between 1975 and 2014. For blacks and whites, average incidence was lower for females than males. Rates for black males aged ≥50years was highest for most of the follow-up time but decreased sharply around 1988 and were surpassed by the significant increase in incidence in white males aged 50-59 (1995-2014 APC=4.07, p<0.001) and ≥60years (2002-2014 APC=4.25, p<0.001). For males aged ≥60, whites had higher rates than blacks starting in 2010. OPSCC incidence in White males (10.99 per 100,000 person-years) surpassed rates in Blacks (10.14 per 100,000 person-years) beginning in 2008. CONCLUSION: OPSCC has significantly increased in the United States in the last 40 years. This overall increase in OPSCC can primarily be attributed to white males. OPSCC prevention and early detection efforts could target these demographic factors to decrease rising OPSCC incidence.

An update on endoscopic orbital decompression.

PURPOSE OF REVIEW: Endoscopic orbital decompression is an ever-evolving surgical procedure with modifications as well as new indications for the procedure. The purpose of this review is to update the reader on optimizing patient selection, surgical timing, highlight the latest modifications to surgical technique and to evaluate surgical outcomes that can be achieved. RECENT FINDINGS: Patient selection, disease pathology, and optimization of technology can lead to improved outcomes. Changes in technology continue to modify surgical techniques and surgical training, working towards decreased surgical complications with improved outcomes. Historically multiple approaches have been used for orbital decompression and this highlights that a balanced orbital decompression usually leads to the best outcome. SUMMARY: Orbital decompression has evolved significantly since its inception over 100 years ago. Identifying the right patient, the ideal timing, and the indication for the procedure with utilization of technology can lead to improved outcomes and decreased complications.

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.

Anatomic evaluation of endoscopic transnasal transorbital approach to the lateral orbital apex.

BACKGROUND: This anatomic study investigates the feasibility of an endoscopic transnasal transorbital approach to the lateral orbital apex. METHODS: Five cadavers with no prior history of sinus surgery were studied bilaterally. Standard techniques and instrumentation for functional endoscopic sinus surgery were used to perform dissections and delineate anatomy of sinuses and orbits. RESULTS: With resection of the inferior aspect of the lamina papyracea and the medial portion of the orbital floor, followed by incision of the periorbita along the inferomedial aspect of the orbit and removal of minimal orbital fat, a satisfactory view of the surgical field is achieved. The medial and inferior rectus muscles are dissected and retracted to allow visualization of the optic nerve. By dissecting inferior to the optic nerve and using 0 and 30° endoscopes, the lateral orbital apex could be accessed without damage to the optic nerve. CONCLUSION: In patients whose vision is irreparably damaged, one might consider an endoscopic approach to lesions of the lateral orbital apex. Approach in patients with intact vision should be handled with caution because of possible traction of the optic nerve.

Histopathological and clinical analysis of chronic rhinosinusitis by subtype.

BACKGROUND: Chronic rhinosinusitis (CRS) encompasses diverse phenotypic expression. Clinical and histological differences suggest 4 CRS subtypes: eosinophilic CRS with and without nasal polyps (eCRSwNP, eCRSsNP, respectively) and non-eosinophilic CRS with and without nasal polyps (neCRSwNP, neCRSsNP, respectively). The mucosal basement membrane (BM) and cilia are believed to play roles in CRS pathogenesis by impacting mucociliary clearance and immune barriers. This study aimed to identify clinical, surgical, and histopathological subtype differences to further elucidate disease mechanisms. METHODS: Ethmoid tissue from 33 adult CRS patients and 7 controls was obtained during endoscopic sinus or other sinonasal surgery (controls) and analyzed by light and transmission electron microscopy for BM thickness and presence of cilia. CRS patients were categorized into the 4 subtypes, and 22-item Sinonasal Outcome Test (SNOT-22) score, endoscopy, computed tomography (CT), and surgical data were compared and analyzed for association with histopathology measures. RESULTS: CRS subtypes could be distinguished by CT score and surgical data, with eCRSwNP patients exhibiting greatest disease severity. Whereas eosinophilia was associated with absence of cilia, nasal polyposis showed no association with surgical or histopathological measures. No significant difference in BM thickness was found between controls and CRS subtypes, but distinctions were found regarding cilia, which were less common in eosinophilic subgroups compared to controls and neCRSsNP patients. CONCLUSION: CRS subtypes exhibit some differentiating histopathological and surgical features. The absence of cilia appears to have an important role in the eosinophilic subgroups. Further histologic evaluation is warranted to evaluate for possible subtype-specific treatment targets or prognostic markers.

Management of sinonasal complications after endoscopic orbital decompression for Graves' orbitopathy.

OBJECTIVES/HYPOTHESIS: Endoscopic orbital decompression (EnOD) has proven to be safe and effective for the treatment of Graves' orbitopathy; however, complications do occur. Although the literature focuses on orbital complications, sinonasal complications including postobstructive sinusitis, hemorrhage, and cerebrospinal fluid (CSF) leak can also be challenging to manage. This study examines the incidence and management of sinonasal complications in these patients. STUDY DESIGN: Retrospective review. METHODS: Clinical data, surgical findings, and postoperative outcomes were reviewed of patients who underwent EnOD for Graves' disease between March 2004 and November 2010. The incidence and management of postoperative sinonasal complications requiring an intervention were examined. RESULTS: The study group consisted of 50 consecutive patients (86 decompression procedures): 11 males and 39 females with an average age of 48.6 years (SD = 12.9). Incidence of significant sinonasal complications was 3.5% (5/86): with one patient experiencing postoperative hemorrhage requiring operative management, three patients with postoperative obstructive sinusitis, and one patient with nasal obstruction secondary to nasal adhesions that required lysis. The maxillary sinus was the most commonly involved and was managed using the mega-antrostomy technique. In the case of frontal sinusitis, an endoscopic transaxillary approach was utilized to avoid injury to decompressed orbital contents. All complications were successfully managed without sequelae. CONCLUSION: Sinonasal complications following EnOD are uncommon. In the setting of a decompressed orbit, even routine types of postoperative issues can be challenging and require additional considerations. Successful management of postoperative sinusitis related to outflow obstruction may require more extensive approaches and novel techniques.

Sino-nasal outcome test tool assessment in patients with chronic rhinosinusitis and obstructive sleep apnea.

OBJECTIVE: The Sino-Nasal Outcome Test (SNOT-20) is a rhinosinusitis quality of life instrument. Nonrhinologic illnesses like obstructive sleep apnea (OSA) may elevate SNOT-20 scores. We compared SNOT-20 outcomes in patients with chronic rhinosinusitis (CRS) to those in patients with OSA. METHODS: We analyzed prospectively collected data of patients with CRS and OSA. Pretreatment SNOT-20 and Lund-Kennedy endoscopy scores were obtained. Scores and patterns of SNOT-20 symptom distribution were compared. RESULTS: Fifty-seven patients had CRS and 65 patients had OSA. Both groups had elevated mean total SNOT-20 scores (28 ± 12.2 and 29 ± 10.7, respectively). Higher scores were noticed for OSA patients on the wellness section of the SNOT-20 and for CRS patients on the sinonasal section of the SNOT-20 (p < 0.001). CONCLUSIONS: CRS and OSA patients present with elevated total SNOT-20 scores but differ in their symptom distribution pattern. This study demonstrates that other disorders can elevate SNOT-20 scores and confirms the need for additional objective data to confirm CRS diagnosis.

Microporous polysaccharide hemospheres do not increase synechiae after sinus surgery: randomized controlled study.

BACKGROUND: Many surgeons use absorbable packing materials after endoscopic sinus surgery (ESS). Despite their popularity, some of these agents have been shown to contribute to synechiae formation. Microporous polysaccharide hemospheres (MPH) is a plant-based hemostatic powder that does not interfere with regenerating sinus mucosa in the animal model. The goal of this study was to examine the impact of MPH on healing and synechiae formation after ESS in human subjects. METHODS: A prospective, randomized, controlled, double-blind study was performed. Forty consenting adult patients with chronic sinusitis requiring symmetric ESS were randomized to receive MPH unilaterally at the conclusion of surgery. The opposite side was untreated. Standard postoperative care was performed bilaterally. Outcomes measured included blinded observer ratings for synechiae formation, edema, and infection. Each side was examined endoscopically and scored at postoperative days 7, 14, and 30. RESULTS: Twenty men and 20 women with an average age of 48.2 years were included. There were no complications and all patients were discharged home the same day. There was no significant difference in synechiae formation at any point postoperatively. The rate of synechiae formation was determined to be 10% (4/40) on the MPH-treated side versus 7.5% (3/40) on the untreated side (p = 0.7639). In addition, there were no significant differences observed in edema (p = 0.7480) or infection (p = 0.5533). CONCLUSION: The use of MPH after sinus surgery does not increase synechiae formation and does not appear to deleteriously affect the healing of postoperative sinus cavities.

Epidemiologic factors affect surgical outcomes in allergic fungal sinusitis.

OBJECTIVES: To evaluate discrepancies in presentation and postoperative outcomes in a population of allergic fungal sinusitis (AFS) patients. STUDY DESIGN: Prospective cohort study. METHODS: Clinical and demographic records of 48 patients (26 males, 22 females) who underwent endoscopic sinus surgery (ESS) for treatment of AFS were collected from 2003 to 2008. All patients completed pre- and postoperative Sinonasal Outcome Test (SNOT)-20 questionnaires. Patients also underwent objective grading via the Lund-Kennedy nasal endoscopy and the Lund-Mackay computed tomography (CT) scan scoring systems. This data was interrogated by means of both univariate and multivariate analysis through the use of Mann-Whitney and chi-square tests to calculate statistical significance. RESULTS: Preoperatively African-Americans had significantly higher Lund-Mackay and mean endoscopy scores (P < .05) than Caucasians. However, there was no significant difference among SNOT-20 scores. Postoperative symptom and endoscopy scores improved in all patient groups with significantly greater improvement in women (both P < .05) versus men at 12 months. Improvement ratio of preoperative versus postoperative endoscopy scores trended toward significance at 6 months (P = .08), with African-Americans improving more than Caucasians. CONCLUSIONS: Epidemiologic factors may play an important role in the presentation and progression as well as in surgical outcomes of patients diagnosed with allergic fungal sinusitis.

Effect of microporous polysaccharide hemospheres (MPH) on bleeding after endoscopic sinus surgery: randomized controlled study.

OBJECTIVES: Absorbable hemostatic agents are commonly used after endoscopic sinus surgery (ESS). MPH (microporous polysaccharide hemospheres) is a novel hemostatic powder that is rapidly absorbed. The goal of this study was to examine the effects of MPH on bleeding after ESS. STUDY DESIGN: Randomized, controlled, single-blinded. SETTING: Tertiary university hospital. SUBJECTS AND METHODS: Patients undergoing bilateral (symmetric) ESS for CRS by the same surgeon were randomized to unilateral treatment with MPH at surgical conclusion. The untreated opposite side served as a control. All patients received standard postoperative management. Patients completed symptom diaries using visual analog scales (VAS, scored out of 100) at baseline and through postoperative day (POD) 30. Outcomes including bleeding, pain, obstruction, and nasal discharge were recorded separately for left and right sides. RESULTS: Forty patients (19 men, 21 women) with an average age of 48.3 years were included. There were no complications, and all patients were discharged home the same day. The mean bleeding score on POD one for MPH-treated sides was 22.5 vs 39.0 for untreated controls (mean reduction 16.5, P < 0.0001, 95% CI -23.2 to -9.7). The scores for bleeding at baseline and at all other post-treatment days were not significantly different (P > 0.05). There were no other significant differences between MPH-treated and control sides in any other variables measured. CONCLUSION: The use of MPH after ESS results in significantly less bleeding in the early postoperative period with no increase in pain, obstruction, or nasal discharge. Patients treated with MPH follow a normal postoperative recovery otherwise.

Symptom-specific outcomes of endoscopic sinus surgery: a systematic review.

BACKGROUND: Although multiple studies have demonstrated that symptoms of chronic rhinosinusitis (CRS) improve after endoscopic sinus surgery (ESS), a systematic large-scale evaluation of specific symptom response has not been performed. OBJECTIVE: To analyze the relative effectiveness of surgery in the improvement of individual CRS symptoms. STUDY DESIGN: A literature search of MEDLINE, EMBASE, Web of Science, Cochrane databases, and other Web-based sources from January 1, 1980 through June 1, 2008 was performed. Studies of 20 or more adult patients with CRS that used symptom severity scores to analyze at least 3 major CRS criteria (facial pressure, nasal obstruction, postnasal discharge, and hyposmia) or 2 major CRS criteria plus headache were included. SUBJECTS AND METHODS: Inclusion criteria were met by 21 of 289 ESS studies reviewed. Meta-analysis was conducted for each symptom separately with the standardized difference between the preoperative and postoperative severity scores as the effect size (ES). RESULTS: A total of 2070 patients with CRS were studied a mean of 13.9 months after ESS. All symptoms demonstrated improvement compared with their respective preoperative severity scores by an overall ES of 1.19 (95% confidence interval, 0.96 to 1.41; I(2) = 81.7%) using the random-effects model. Nasal obstruction (ES, 1.73) improved the most, with facial pain (ES, 1.13) and postnasal discharge (ES, 1.19) demonstrating moderate improvements. Hyposmia (ES, 0.97) and headache (ES, 0.98) improved the least. CONCLUSION: The relative improvements in major CRS symptoms and headache after surgery are similar, with the exception of nasal obstruction, which improves most.