Fine-tuned evaluation of olfactory function in patients operated for nasal polyposis.

Given the forced-choice procedure of the identification test, patients with profound anosmia are more likely to have higher identification scores by chance than patients with hyposmia or normosmia. This may be a confusing factor when assessing the sense of smell, which alters the appreciation of real olfaction improvement. The aim of this study was to fine-tune the results of the identification Sniffin' Sticks test before and 6 weeks after surgery using the real identification score. A total of 133 patients underwent the Identification (I) and Threshold (T) tests the day before and 6 weeks after nasalization surgery. The scores of the identification test, called I G (global identification), were ranked from 0 to 16. Patients had to specify if their forced-choice answers were given either surely or randomly, called I H (hazard identification). The real score of identification I R was obtained as follow: I R = I G - I H. Patients with an immeasurable threshold according to the T test were more prone to give randomly correct answers. On the basis of I G scores, 43.6% of patients remained hypo-anosmic after surgery compared to 72.9% before surgery. Using I R scores, only 3.8% of patients remained anosmic (I R = 0) at 6 weeks after surgery. Hence, patients with real anosmia (I R = 0) were less prone to improve their olfaction than patients with I R > 0. The analysis of random factor when using identification test allows differentiating a real anosmia from a hyposmia. An I G ≤ 4 could be considered as a profound/real anosmia or a severe hyposmia. This procedure cannot, however, replace the forced-choice method in odor identification testing.

Relationship between 18FDG-PET and different types of sinonasal malignancies.

CONCLUSION: The sensitivity and specificity of a 18FDG-PET scan may be different according to the histology. The SUVmax and SUV ratio may reflect the tumor's aggressive behavior. OBJECTIVES: To describe the characteristics of PET/CT scans, including the maximum standard uptake values (SUVmax), at initial diagnosis according to six main types of sinonasal malignancies: sinonasal adenocarcinoma (SNAC), sinonasal undifferentiated carcinoma (SNUC), adenoid cystic carcinoma (ACC), sinonasal malignant melanoma (SMM), olfactory neuroblastoma (ONB), and sinonasal neuroendocrine carcinoma (SNEC). METHODS: A chart review of 50 patients who were diagnosed and treated for six sinonasal malignancy types over a period of 6 years was conducted. Any 18F-FDG PET/CT scans for each patient were searched using the hospital's intranet. The SUVmax of the primary sinonasal site was recorded. The liver SUVs were utilized as reference SUVs. The SUV ratio was defined as the ratio of the SUVmax of the primary tumor and the SUVliver. RESULTS: The most common malignancy was SNAC (32%), followed by SNUC (24%), ONB (14%), ACC (10%), SMM (10%), and SNEC (10%). The SUVmax and SUV ratio values were significantly different between tumor types (p = 0.002 and 0.012, respectively). SNUC had the highest mean SUVmax (14.2), followed by SNAC (9.9). A similar mean SUVmax was observed for SMM, ONB, and ACC (∼ 7.0). SNEC up-takes the least 18FDG among these six tumor types (mean SUVmax = 4.7).

Evaluation of residual symptoms: A method to assess surgical outcomes for nasal polyposis.

BACKGROUND: The assessment of residual symptoms after endoscopic sinus surgery for nasal polyposis (NP) could be an accurate way to evaluate surgical outcomes. OBJECTIVE: To assess the residual symptoms and their severity at 6 weeks and 7 months after radical ethmoidectomy for NP. METHODS: Sixty-five patients who had surgery for NP were included in this prospective study. Six residual symptoms (nasal obstruction, anterior rhinorrhea, postnasal discharge, olfactory disturbances, facial pain, and cough) were assessed by using the validated Dysfonctionnement Nasal Chronique (French) or Chronic Nasal Dysfunction (English) questionnaire at 6 weeks and 7 months after surgery. Olfactory measurements were performed with the Sniffin' Stick test. A self-rating score of ≥1 was considered as "having a complaint." RESULTS: Radical ethmoidectomy for NP improved not only the number of symptoms but also the intensity of symptoms. Before surgery, 64 of 65 patients (98.46%) reported at least three of the six symptoms, whereas 26 patients (40%) reported six symptoms, 16 (24.62%) reported five symptoms, and 14 (21.54%) reported four symptoms. At 6 weeks and at 7 months after surgery, one-third of the patients had fewer than three symptoms. Olfactory disturbance remained the most mentioned postoperative disabling problem. Posterior discharge tended to become more pronounced at 7 months than at 6 weeks after surgery but remained considerably improved compared with the preoperative state. CONCLUSION: This information is useful to warn patients about the difficulty of getting rid of all symptoms and that there is a chance that some symptoms remain or even reappear after NP surgery.

Facial pain/headache before and after surgery in patients with nasal polyposis.

CONCLUSION: Endoscopic surgery improved facial pain/headache and physical-psychosocial impacts in patients with nasal polyposis. However, one fifth of patients still experienced residual pain after surgery, requiring neurologic counseling to look for the non-sinonasal cause of their symptoms. OBJECTIVE: Considering the limited amount of literature on facial pain/headache in patients with nasal polyposis, this prospective study assesses facial pain/headache and its impacts on the quality-of-life (QoL) before and after endoscopic surgery. METHODS: Facial pain/headache was assessed, using the DyNaChron questionnaire, in 107 patients with nasal polyposis 1 day prior to surgery and 6 weeks after surgery. All patients were operated on endoscopically on the bilateral ethmoidal labyrinths and olfactory clefts. RESULTS: Moderate or severe facial pain/headache was reported by 50% of the patients before surgery and by 20% after surgery. Post-operatively, 79.44% of patients reported no/very mild pain (vs 47.66% pre-operatively) and 20.56% moderate/severe pain (vs 52.33% pre-operatively). The pain was statistically reduced after surgery among patients with previous surgery (p = 0.0006). The scores of all analysed impacts of pain improved after surgery. However, patients with grade 1 polyps seemed to have less benefit from the surgery for facial pain/headache than those with more severe nasal polyposis.

Can surgeons predict the olfactory outcomes after endoscopic surgery for nasal polyposis?

OBJECTIVES/HYPOTHESIS: The aim of this study is to identify predictors for olfactory outcomes in patients with nasal polyposis (NP) after surgery on the ethmoidal labyrinths, either with or without resection of the polyps of the olfactory cleft (OC). STUDY DESIGN: Prospective study. METHODS: Ninety-six patients endoscopically operated on for NP were enrolled in this study. Olfactory measurements were performed 1 day prior to surgery and 6 weeks after surgery, using odor thresholds and identification tests of the Sniffin' Sticks kit and a 0- to 10-point visual analog scale. The multivariate logistic regression model was also used to assess independent predictors for olfactory outcomes after surgery. RESULTS: Twenty-seven patients with preoperative normosmia demonstrated normal olfactory function 6 weeks after surgery. Out of 69 patients with preoperative hypo-anosmia, 33 patients (47.83%) improved their olfactory function after surgery on the basis of the Sniffin' Sticks results. History of previous sinus surgery was reported by 77.78% of patients without olfactory improvement and by 51.52% with olfactory improvement (P = .022). By multivariate analysis, history of previous sinus surgery for NP remained a strong predictor of poor olfactory outcomes after surgery (adjusted odds ratio = 4.14, 95% confidence interval: 1.29-13.32, P = .017). Histopathological types of lesions inside the OC as well as the resection of moderate/big lesions in the OC were not predictors of olfactory outcomes. CONCLUSIONS: The more previous sinus surgeries, the smaller the chance for patients to recover their olfactory function after each surgical revision.

Assessment of quality-of-life outcomes after surgery for nasal polyposis with the DyNaChron questionnaire.

This prospective study assesses outcomes at 6 weeks and 7 months after radical ethmoid surgery in 65 patients with nasal polyposis using a new and detailed instrument, the DyNaChron questionnaire, which was filled in the day prior to surgery and at 6 weeks and 7 months after surgery at follow-up visits. Before surgery, the leading bothersome symptoms were olfactory disturbances (7.74 ± 2.81) and nasal obstruction (6.66 ± 2.28). After surgery (6th week and 7th month), there was a clear improvement of all symptoms including nasal obstruction, olfactory disturbances, anterior rhinorrhea, postnasal discharge, facial pain/headache and cough in comparison to baseline (p < 0.0001). Nasal obstruction was the most improved symptom (effect size of 2.24). At 7th post-operative month, the sense of smell continued to improve slightly. By contrast, the postnasal discharge score that was significantly improved at 6th post-operative week tended to worsen at 7 months (p = 0.0045). Before surgery, strong psychosocial impacts were observed in association with nasal obstruction and anterior rhinorrhea. The physical impacts of each symptom were proportionally correlated to the symptom score before and after surgery. The quality of life (QOL) related to each symptom was clearly better at 6 weeks and remained steady at 7 months after surgery. In conclusion, olfactory disorders and postnasal rhinorrhea were the main remaining symptoms after sinus surgery despite a global improvement of symptoms and quality of life. The earlier time point to stabilize QOL outcomes of endoscopic sinus surgery could be suggested at 6 weeks after surgery.

Respiratory epithelial adenomatoid hamartoma of the nose: an updated review.

BACKGROUND: This study was designed to update clinical and imaging features as well as treatment outcomes of the nasal respiratory epithelial adenomatoid hamartoma (REAH). Data sources included case reports, original articles, and reviews published in English or French in PubMed from 1995 to date. METHODS: Only published articles that met Wenig's histological criteria for the diagnosis of REAH were included. RESULTS: REAH is not rare and is probably underdiagnosed. It is usually observed in the fifth decade of life with a 3:2 male/female predilection. REAH can be represented in two forms: as an isolated lesion (less frequent) or in association with an inflammatory process (especially nasal polyposis). It was observed in 35-48% of patients undergoing endoscopic endonasal surgery for nasal polyposis. Its origin is found, in most cases, in the olfactory cleft, which is exhibited on computed tomography (CT) scans by widened opacified olfactory clefts without bone erosion. Resection of REAH from the olfactory clefts does not worsen, but instead, can improve the sense of smell after surgery. CONCLUSION: Looking for REAH on CT scans and during endoscopic examination can lead to its diagnosis and help avoid aggressive surgical procedures and their complications. Endoscopic resection is the treatment of choice. The removal of REAH constitutes a specific surgery on the olfactory clefts, which can improve nasal obstruction as well as sense of smell. Whether REAH can be defined as a hamartoma, an inflammatory reactive process, or a neoplastic lesion remains to be determined.

Predictors of respiratory epithelial adenomatoid hamartomas of the olfactory clefts in patients with nasal polyposis.

OBJECTIVES/HYPOTHESIS: To look for predictors of respiratory epithelial adenomatoid hamartomas (REAH) development in patients operated for nasal polyposis (NP) by adjusting on confounding factors. STUDY DESIGN: Prospective study. METHODS: One hundred and six patients with NP, endoscopically operated between September 2009 and March 2012 on the ethmoidal labyrinths and olfactory clefts, were enrolled in this study. Clinical data was collected 1 day prior to surgery by using a standard grid without knowledge of any histological features. Patients were then divided into two groups based on operative and pathological reports: with and without REAH in the olfactory cleft (REAH-OC). The multivariate logistic regression model was used to assess independent factors linked to the presence of REAH-OC in patients with NP. RESULTS: The mean duration of NP disease in patients with REAH-OC was about 13.95 ± 10.8 years versus 5.7 ± 5.6 years in patients without REAH-OC (P < 0.0001). Seventy-four percent of patients with REAH-OC had undergone one or more NP-related surgeries in their lifetime, in contrast with 49.21% of patients without REAH-OC (P = 0.009). According to the multivariate logistic regression analysis, those patients experiencing NP ≥ 10 years (OR 4.0, 95% CI 1.304-12.062, P = 0.015) and those with asthma (OR 2.5, 95% CI 1.004-6.29, P < 0.05) were at an increased risk of developing REAH-OC. CONCLUSION: The development of REAH in patients with NP appears as a specific disease of the mucosa of the OC, induced by a long-lasting and/or severe inflammation of the olfactory clefts. LEVEL OF EVIDENCE: 4.