Multi-institutional validation of an AI-based sinus CT analytic platform with olfactory assessments.

KEY POINTS: AI-based CT sinus analysis may have advantages over visual based systems, for example, Lund-Mackay score. Here, we show multi-institutional validation of an AI algorithm using novel OMC classification. Significant, robust correlations are seen between algorithm outputs and clinical outcomes.

An eosinophil peroxidase activity assay predicts acute exacerbations in post-operative chronic rhinosinusitis.

KEY POINTS: EPX activity has been correlated with eCRS diagnosis and baseline disease severity. Herein, EPX activity is shown to correlate with post-operative antibiotic and steroid use in CRS. EPX activity has potential to act as a prognostic biomarker of CRS disease severity and control.

Physician views of artificial intelligence in otolaryngology and rhinology: A mixed methods study.

Objective: The study aimed to investigate otolaryngologists' knowledge, trust, acceptance, and concerns with clinical applications of artificial intelligence (AI). Methods: This study used mixed methods with survey and semistructured interviews. Survey was e-mailed to American Rhinologic Society members, of which a volunteer sample of 86 members responded. Nineteen otolaryngologists were purposefully recruited and interviewed until thematic saturation was achieved. Results: Seventy-six respondents (10% response rate) completed the majority of the survey: 49% worked in academic settings and 43% completed residency 10 or fewer years ago. Of 19 interviewees, 58% worked in academic settings, and 47% completed residency 10 or fewer years ago. Familiarity: Only 8% of survey respondents reported having AI training in residency, although 72% had familiarity with general AI concepts; 0 interviewees had personal experience with AI in clinical settings. Expected uses: Of the surveyed otolaryngologists, 82% would use an AI-based clinical decision aid and 74% were comfortable with AI proposing treatment recommendations. However, only 44% of participants would trust AI to identify malignancy and 53% to interpret radiographic images. Interviewees trusted AI for simple tasks, such as labeling septal deviation, more than complex ones, such as identifying tumors. Factors influencing AI adoption: 89% of survey participants would use AI if it improved patient satisfaction, 78% would be willing to use AI if experts and studies validated the technologies, and 73% would only use AI if it increased efficiency. Sixty-one percent of survey respondents expected AI incorporation into clinical practice within 5 years. Interviewees emphasized that AI adoption depends on its similarity to their clinical judgment and to expert opinion. Concerns included nuanced or complex cases, poor design or accuracy, and the personal nature of physician-patient relationships. Conclusion: Few physicians have experience with AI technologies but expect rapid adoption in the clinic, highlighting the urgent need for clinical education and research. Otolaryngologists are most receptive to AI "augmenting" physician expertise and administrative capacity, with respect for physician autonomy and maintaining relationships with patients. Level of Evidence: Level VI, descriptive or qualitative study.

Cerebellar Compression by Giant Extracanalicular Osteoma with Central Cholesterol Granuloma.

Temporal bone osteomas comprise 0.1-1% of benign tumors involving the skull, the majority of which arise in the external auditory canal. More rarely, they can arise from the mastoid portion of the temporal bone. These generally present as a slow growing skull base lesion that can cause cosmetic deformity, headache, and/or hearing loss. Here, we report a case of extracanalicular mastoid osteoma uniquely presenting with posterior fossa and cerebellar compression with associated dizziness and imbalance.

Otolaryngologist perceptions of AI-based sinus CT interpretation.

BACKGROUND: Overcoming non-standardization, vagueness, and subjectivity in sinus CT radiology reports is an ongoing need, particularly in keeping with data-driven healthcare initiatives. Our aim was to explore otolaryngologists' perceptions of quantitative objective disease measures as enabled by AI-based analysis, and determine preferences for sinus CT interpretation. METHODS: A multi-methods design was used. We administered a survey to American Rhinologic Society members and conducted semi-structured interviews with a purposeful sample of otolaryngologists and rhinologists from varying backgrounds, practice settings and locations during 2020-2021. Interview topics included sinus CT reports, familiarity with AI-based analysis, and potential requisites for its future implementation. Interviews were then coded for content analysis. Differences in survey responses were calculated using Chi-squared test. RESULTS: 120 of 955 surveys were returned, and 19 otolaryngologists (8 rhinologists) were interviewed. Survey data revealed more trust in conventional radiologist reports, but that AI-based reports would be more systematic and comprehensive. Interviews expanded on these results. Interviewees believed that conventional sinus CT reports had limited utility due to inconsistent content. However, they described relying on them for reporting incidental extra-sinus findings. Reporting could be improved with standardization and more detailed anatomical analysis. Interviewees expressed interest in AI-derived analysis given potential for standardization, although they desired evidence of accuracy and reproducibility to gain trust in AI-based reports. CONCLUSIONS: Sinus CT interpretation has shortcomings in its current state. Standardization and objectivity could be aided with deep learning-enabled quantitative analysis, although clinicians desire thorough validation to gain trust in the technology prior to its implementation.

Examination of Sex Differences in a Chronic Rhinosinusitis Surgical Cohort.

OBJECTIVE: Sex discrepancies have been reported in chronic rhinosinusitis (CRS), but limited data exist exploring sex-specific biological processes and sinonasal quality of life. STUDY DESIGN: Prospective cohort. SETTING: Academic medical center. METHODS: Demographics, clinical data, and sinonasal mucus were collected from patients with CRS presenting for surgical consideration over a 5-year period. A random forest model and linear regression were used to assess predictor variables for the 22-item Sino-Nasal Outcome Test (SNOT-22) and subdomains. Enzyme-linked immunosorbent assays were used to measure substance P and tryptase in a subset of mucus samples to explore biological differences by sex. RESULTS: In total, 520 patients were studied (mean age 48.3 years, 50.9% female). Males were older (50.1 vs 46.6 years, P = .008), had more polyp disease (48.2% vs 35.5%, P = .004), and had higher mean Lund-Mackay CT score (11.3 vs 9.5, P = .004). Females had a higher overall mean SNOT-22 (40.9 vs 46.9, P = .001) and higher scores in ear/facial, psychological, and sleep domains (P < .01). Age, objective disease measures, and sex were top predictors for total SNOT-22. Neither mucus substance P or tryptase, alone or paired with sex, correlated with total SNOT-22. Analysis of mucus biomarkers by sex revealed correlation between mucus tryptase in females with the extranasal subdomain (P = .01). CONCLUSION: Sex differences exist in CRS disease manifestations and presentation for surgical consideration. Detection of mucus (substance P and tryptase) was reliable, but in this exploratory study, we were not able to establish neurogenic or allergic inflammatory processes as a large source of differential disease features between sexes.

Sample collection for laboratory-based study of the nasal airway and sinuses: a research compendium.

BACKGROUND: Collection of biologic samples from the nasal cavity and paranasal sinuses is of critical importance to the study of infectious or inflammatory conditions that affect both upper and lower airways. Numerous techniques for the study of ex-vivo samples exist, with specific applications, strengths, and weaknesses associated with each of them. In this compendium we summarize the available methods for collection of primary human samples and incorporate expert discussion of the pros, cons, and applications associated with each technique. METHODS: An expert panel containing members of the American Rhinologic Society's Research and Grants Committee compiled this educational reference. Rationale for use and the potential advantages and disadvantages are discussed. Research protocols and key references are enumerated. RESULTS: Sampling of the nasal cavity and paranasal sinuses can be achieved through a number of methods. Nonspecific sinonasal secretions may be collected via forced exhalation, nasal lavage, and nasal spray aspiration. Targeted collection of sinonasal secretions may be achieved via endoscopic placement of absorbent matrices. Nasal cytology or collection of superficial epithelium may be completed via brushing or scraping of endonasal structures. Collection of mucosal biopsies may be completed via sinonasal explant or full-thickness biopsy. CONCLUSION: Multiple sampling techniques are available to collect biologic samples from the sinonasal cavity. These techniques differ in their ease of application, reproducibility, sample yield, and utility for different sinonasal pathologies or research goals. An appreciation of the benefits and drawbacks of each approach will allow investigators to select the techniques most appropriate for achieving research objectives.

Persistent local demucosalization after endoscopic sinus surgery: A report of 3 cases.

Mucosal preservation is paramount to achieving successful outcomes after endoscopic sinus surgery (ESS). Despite best surgical practices and implementation of evidenced-based postoperative care, patients in rare cases might exhibit persistent demucosalization that is recalcitrant to conservative therapies. We retrospectively reviewed the records of 3 patients-a 63-year-old woman, a 67-year-old woman, and a 43-year-old man-who experienced clinically significant local demucosalization after uncomplicated ESS despite routine surgical and postoperative management. We collected data on the characteristics of presentation, wound management strategies, and postoperative care practices. Two patients achieved remucosalization with mechanical debridement, gelatin sponge placement, and intensive moisturization therapy. Our experience suggests that surgical debridement of these chronic, persistent demucosalized wounds may be an effective management strategy for patients who develop this unusual and rare postoperative complication. Biopsy and culture of the persistently demucosalized wound bed may be useful in recognizing the presence of worrisome disease processes and identifying any tenacious infectious agents so that more appropriate therapy can be initiated if necessary.

Advances in Absorbable Biomaterials and Nasal Packing.

Nasal biomaterials have been developed to improve postoperative outcomes after functional endoscopic sinus surgery (FESS). These products have been designed to overcome certain common complications in FESS, and to maximize patient comfort. This article evaluates the performance of nonabsorbable and absorbable packing with respect to these outcomes. The collected trials suggest superior performance of bioabsorbable packs compared with absorbable packs with respect to patient comfort. For hemostasis and wound healing, variation in performance metrics makes interstudy comparison difficult. Before further trials are conducted, consensus must be reached among rhinologists as to the proper method of evaluating these products.

Matrix- and plasma-derived peptides promote tissue-specific injury responses and wound healing in diabetic swine.

BACKGROUND: Non-healing wounds are a major global health concern and account for the majority of non-traumatic limb amputations worldwide. However, compared to standard care practices, few advanced therapeutics effectively resolve these injuries stemming from cardiovascular disease, aging, and diabetes-related vasculopathies. While matrix turnover is disrupted in these injuries, debriding enzymes may promote healing by releasing matrix fragments that induce cell migration, proliferation, and morphogenesis, and plasma products may also stimulate these processes. Thus, we created matrix- and plasma-derived peptides, Comb1 and UN3, which induce cellular injury responses in vitro, and accelerate healing in rodent models of non-healing wounds. However, the effects of these peptides in non-healing wounds in diabetes are not known. Here, we interrogated whether these peptides stimulate healing in a diabetic porcine model highly reminiscent of human healing impairments in type 1 and type 2-diabetes. METHODS: After 3-6 weeks of streptozotocin-induced diabetes, full-thickness wounds were surgically created on the backs of adult female Yorkshire swine under general anesthesia. Comb1 and UN3 peptides or sterile saline (negative control) were administered to wounds daily for 3-7 days. Following sacrifice, wound tissues were harvested, and quantitative histological and immunohistochemical analyses were performed for wound closure, angiogenesis and granulation tissue deposition, along with quantitative molecular analyses of factors critical for angiogenesis, epithelialization, and dermal matrix remodeling. RESULTS: Comb1 and UN3 significantly increase re-epithelialization and angiogenesis in diabetic porcine wounds, compared to saline-treated controls. Additionally, fluorescein-conjugated Comb1 labels keratinocytes, fibroblasts, and vascular endothelial cells in porcine wounds, and Far western blotting reveals these cell populations express multiple fluorescein-Comb1-interacting proteins in vitro. Further, peptide treatment increases mRNA expression of several pro-angiogenic, epithelializing, and matrix-remodeling factors, importantly including balanced inductions in matrix metalloproteinase-2, -9, and tissue inhibitor of metalloproteinases-1, lending further insight into their mechanisms. CONCLUSIONS: Comb1 and UN3 stimulate wound resolution in diabetic Yorkshire swine through upregulation of multiple reparative growth factors and cytokines, especially matrix metalloproteinases and inhibitors that may aid in reversing the proteolytic imbalance characteristic of chronically inflamed non-healing wounds. Together, these peptides should have great therapeutic potential for all patients in need of healing, regardless of injury etiology.

Biomaterials in Rhinology.

INTRODUCTION: Many different kinds of rhinologic biomaterials, both nonabsorbable and absorbable, have been developed over the years to improve outcomes following endoscopic sinus surgery (ESS) for patients with chronic rhinosinusitis. In particular, these products have been designed to prevent postoperative bleeding, optimize the wound healing process, and reduce inflammation. This review evaluates the most recent evidence on biomaterials used in rhinology, focusing on these outcomes after ESS. DATA SOURCES: MEDLINE, Scopus, Google Scholar, and Clinicaltrials.gov. REVIEW METHODS: A primary literature search based on the listed databases was performed with combinatorial search terms. Studies were considered for review if they met a set of inclusion and exclusion criteria. CONCLUSIONS: Some products have performed better than others in clinical trials, although significant heterogeneity among studies does not allow for selection of a clearly superior biomaterial. While nonabsorbable biomaterials are still effective in achieving certain outcomes, newer, absorbable substances may be just as effective and avoid the morbidity associated with nasal packing removal. Steroid-eluting biomaterials have shown promising early results in reducing inflammation and promoting wound healing. IMPLICATIONS FOR PRACTICE: Certain absorbable biomaterials, such as chitosan gel and fibrin glue, have performed well with respect to postoperative hemostasis and wound healing, although they do not address mucosal inflammation. Steroid delivery systems may play an increasingly important role in reducing disease recurrence after ESS, although more studies are needed to assess long-term outcomes.

Novel use of an ultrasonic bone aspirator for extended endoscopic frontal sinusotomy: A feasibility study.

INTRODUCTION: Extended endoscopic frontal sinusotomy is often required for surgical management of anterior skull base pathology. Such approaches are necessary for access to pathology and maintenance of postoperative frontal sinus outflow tract drainage. Cold steel instrumentation and endoscopic high-speed microdrills are typically used for bony removal during extended frontal sinus approaches but are associated with certain drawbacks, such as thermal injury and obscuration of the surgical field with bone dust. OBJECTIVE: We investigated the ultrasonic bone aspirator (UBA) as an adjunctive tool for extended endoscopic frontal sinusotomy in the setting of skull base surgery. METHODS: Medical records of patients who underwent either Draf IIB or Draf III sinusotomies from 2011 to 2014 were reviewed. The patients were split into two cohorts based on instrumentation: those who received sinusotomy primarily with the UBA, and those who had sinusotomy performed with conventional instrumentation only. The patients were followed up after surgery with routine endoscopic examinations and imaging when indicated. Patient demographics, surgical approach, operative complications, and postoperative outcomes were evaluated. RESULTS: A total of 18 patients underwent endoscopic extended frontal sinusotomy for a variety of skull base pathologies with the UBA and the conventional instrumentation cohorts, which contained nine patients each. Five of the nine patients in the UBA cohort received Draf III sinusotomies compared with three of nine in the conventional cohort. Three patients in the UBA cohort experienced postoperative transient pressure hyperemia of the lip; this was seen in a single patient in the conventional cohort. All patients with postoperative endoscopic examinations maintained frontal sinus ostial patency to varying degrees, irrespective of cohort. Lund-Mackay scores and the need for operative revision of the frontal sinus were similar for both groups and seemed to be related to the use of postoperative radiation. CONCLUSION: The UBA was a safe, effective tool for extended endoscopic frontal sinusotomy in endoscopic skull base surgery.