Assessing the safety and tolerability of rhinologic surgery under local anesthetic: an 8-year retrospective analysis.

PURPOSE: Office-based rhinologic procedures (OBRP) have become widely available in North America due to technological advances and appropriate patient selection. Nevertheless, the literature exploring the safety of these procedures remains limited. The objective of this study was to further evaluate the safety, tolerability and efficacy of these procedures with a more robust sample size to allow for capture of rare events. METHODS: A retrospective chart review of all patients who underwent OBRP from May 2015 to March 2023. Information regarding patient demographics, the indication for surgery, wait time, tolerability, intra- and postoperative complications, need for revisions, and type of revision (if applicable) was recorded. RESULTS: 1208 patients underwent OBRP during the study period. No patients were excluded. These included turbinoplasties (35%), endoscopic sinus surgeries (ESS) (26%), septoplasties (15%), nasal fracture reductions (7%), and a variety of other procedures. For ESS procedures, the anterior ethmoids and the maxillary sinuses were the most common sinuses treated. 1.1% of procedures were aborted prior to completion. The post-operative complication rate was 3.2%, with 2 major complications (significant bleeding and sepsis) encountered. The mean follow-up overall was 11 months and for ESS it was 15.8 months. CONCLUSION: Office-based rhinologic procedures are well tolerated and safe for the appropriate patient and associated with shorter wait-times as well as avoidance of general anesthesia. The complication rates are similar to or lower than previously reported rates for rhinologic surgeries done in the operating room. The low rates of revision surgery also demonstrate the efficacy of these procedures.

Clinical outcomes of expansion sphincter pharyngoplasty-a 17-year systematic review.

OBJECTIVES: To systematically review long-term (> 5 years) outcomes of ESP surgery for OSA treatment over 17 years. METHODS: Systemic review of MEDLINE, Google Scholar, Cochrane Library and Evidence Based Medicine Reviews to identify publications relevant to OSA and Expansion Pharyngoplasty and its variants. All relevant studies published between January 2007 and June 2023 were included. RESULTS: Twelve studies were included in this systematic review with a combined total of 1373 patients who had the ESP procedure were included. The clinical outcomes included encouraging long-term success rate, reductions in Epworth sleepiness scale, good mean disease alleviation, anatomical structural area and volume improvements, blood pressure reductions, biochemical improvements in acute phase reactants after ESP surgery, reductions in intra-ocular pressures, and post-operative reduction of sympathetic overdrive. CONCLUSIONS: Seventeen years on, the expansion sphincter pharyngoplasty has demonstrated not only increase in anatomical area and volume but significant desired improvements in polysomnographic, clinical and biochemical parameters post-surgery.

Reconsidering routine admission for children under age 3 undergoing partial tonsillectomy: a prospective study.

BACKGROUND: Partial Tonsillectomy (PT) is an alternative method to treat sleep disordered breathing (SDB) and/or obstructive sleep apnea (OSA). The current guidelines do not differentiate it from traditional tonsillectomy. Thus, children younger than 3 years old undergoing PT are admitted for surveillance similar to traditional tonsillectomy due to possible postoperative complications. The aim of this study is to assess the risks of PT in children 3 years old and younger, compared to older children. METHODS: Children underwent inpatient partial tonsillectomy and/or adenoidectomy, due to SDB/OSA, from 2018 to 2020. A special protocol was designed, including follow-up at 2-, 4-, 6-, 8- and 24-h after surgery. Variables analyzed included visual analogue pain score, oral intake, oxygen saturation, pulse rate, postoperative hemorrhage, urine output, temperature, analgesics and fluid administration. Furthermore, major interventions were recorded. Comparison of all variables between children younger than 3 years old with older children was performed. RESULTS: Ninety-two children were included; mean age of the whole cohort was 44.5 ± 21.9 months. Thirty-five (38%) children were 3-years old or younger and n = 57 (62%) were older than 3 years old, with no significant statistical difference in sex (p = 0.22). Mean age in the younger group was 25.7 ± 6.9 months, and 56.1 ± 20.1 months in the older group. In total we had 7 children with post-operative complications; 4 with fever, 3 with low intake. There were no major interventions recorded in either group. The complications were more common in the older group (n = 5) than the younger group (n = 2) without a statistical significance (p = 0.59). There were no differences in VAS, use of painkillers, oral intake, urine output, oxygen saturation and tachycardia among the two groups. CONCLUSION: This study supports that children undergoing ambulatory PT may be at low risk of complications, regardless of age.

Canadian multidisciplinary expert consensus on the use of biologics in upper airways: a Delphi study.

BACKGROUND: Chronic rhinosinusitis with nasal polyposis (CRSwNP) often coexists with lower airway disease. With the overlap between upper and lower airway disease, optimal management of the upper airways is undertaken in conjunction with that of the lower airways. Biologic therapy with targeted activity within the Type 2 inflammatory pathway can improve the clinical signs and symptoms of both upper and lower airway diseases. Knowledge gaps nevertheless exist in how best to approach patient care as a whole. There have been sixteen randomized, double-blind, placebo-controlled trails performed for CRSwNP targeted components of the Type 2 inflammatory pathway, notably interleukin (IL)-4, IL-5 and IL-13, IL- 5R, IL-33, and immunoglobulin (Ig)E. This white paper considers the perspectives of experts in various disciplines such as rhinology, allergy, and respirology across Canada, all of whom have unique and valuable insights to contribute on how to best approach patients with upper airway disease from a multidisciplinary perspective. METHODS: A Delphi Method process was utilized involving three rounds of questionnaires in which the first two were completed individually online and the third was discussed on a virtual platform with all the panelists. A national multidisciplinary expert panel of 34 certified specialists was created, composed of 16 rhinologists, 7 allergists, and 11 respirologists who evaluated the 20 original statements on a scale of 1-9 and provided comments. All ratings were quantitively reviewed by mean, median, mode, range, standard deviation and inter-rater reliability. Consensus was defined by relative interrater reliability measures-kappa coefficient ([Formula: see text]) value > 0.61. RESULTS: After three rounds, a total of 22 statements achieved consensus. This white paper only contains the final agreed upon statements and clear rationale and support for the statements regarding the use of biologics in patients with upper airway disease. CONCLUSION: This white paper provides guidance to Canadian physicians on the use of biologic therapy for the management of upper airway disease from a multidisciplinary perspective, but the medical and surgical regimen should ultimately be individualized to the patient. As more biologics become available and additional trials are published we will provide updated versions of this white paper every few years.

Expansion sphincter pharyngoplasty in OSA: a 15 year review.

OBJECTIVE: A 15 year review of the outcomes and success rates of the Expansion Sphincter Pharyngoplasty (ESP) in the treatment of patients with obstructive sleep apnea (OSA). METHODS: A systemic review with two independent searches of MEDLINE, Google Scholar, Cochrane Library and Evidence-Based Medicine Reviews to identify publications relevant to OSA and Expansion Pharyngoplasty. All relevant studies published before 31 December 2021 were included. RESULTS: Sixteen studies were included in this strict systematic review with a total of 747 patients who had the ESP procedure were included. The mean age was 41.3 years, mean BMI 28.2, the mean pre-op AHI was 32.3 and post-op AHI was 10.0 (p < 0.05), the mean pre-op ESS was 11.4, had reduced to post-op 5.3 (p < 0.05), and the mean pre-op snore VAS decreased from 8.7 to 2.9 (p < 0.05), with a mean follow-up time of 9.5 months. The overall pooled success rate for all the 747 patients was 80.0%. There were no significant reported complications noted in these studies. CONCLUSION: After 15 years of presence, the expansion sphincter pharyngoplasty has shown to be reliably effective in the management of patients with OSA.

Telemedicine as an environmental ally - The social, financial, and environmental impact of virtual care in the otolaryngology clinic.

PURPOSE: Synchronous virtual care rapidly expanded worldwide amid the COVID-19 pandemic to provide remote medical assessment, minimizing contact and disease transmission risk. Despite its benefits, such an abrupt expansion has shed light on the need to address patients' level of satisfaction with this service delivery. The purpose of this study was to investigate patients' satisfaction, travel cost, productivity loss, and CO2 emissions involved with synchronous virtual care and in-person assessments in rhinology and sleep apnea clinics. MATERIALS AND METHODS: This prospective comparative study included patients managed via virtual care, or in-person clinic visit at St. Joseph Hospital, London, Canada, from December/2020 to April/2021, with rhinology pathologies or sleep apnoea. Patient satisfaction questionnaire (PSQ-18) scores were assessed. The overall scores of respondents were recorded including cost implications. RESULTS: A total of 329 patients were invited, 28.5 % responded (n = 93). 33 virtual care (age 48 ± 6), and 60 in-person (age 51 ± 19). There was no statistical significance in PSQ-18 scores. However, under a diagnosis-based subgroup analysis, allergic rhinitis patients on virtual care presented a significantly lower PSQ-18 scores on the general satisfaction (3.28 vs. 4.25, p = 0.04). The time spent with the doctor was directly correlated with age for patients seen in-person (r = 0.27; p = 0.037). The estimated loss of productivity for the Virtual care group was CAD 12, patients assessed in-person presented an average loss of productivity about six times higher (CAD 74 ± 40). CONCLUSIONS: Overall patients' satisfaction did not depend on whether they were seen virtually or in-person. However, time spent with the doctor contributed to higher satisfaction levels, but only among older patients who were seen in person. Nonetheless, allergic rhinitis patients seemed less satisfied with the virtual care option. Virtual care demonstrates economic benefits.

How deep do you go? Clinical prediction of nasopharyngeal depth based on facial measurements.

Nasopharyngeal depth (ND) prediction is clinically relevant in performing medical procedures, and in enhancing technique accuracy and patient safety. Nonetheless, clinical predictive variables and normative data in adults remain limited. This study aimed to determine normative data on ND and its correlation to external facial measurements. A multicenter cross-sectional study obtained data from adults presenting to otolaryngology clinics at five sites in Canada, Italy, and Spain. Investigators compared endoscopically measured depth from the nasal sill (soft tissue between the nasal ala and columella) to nasopharynx along the nasal floor to the "curved distance from the alar-facial groove along the face to the tragus" and "distance from the tragus to a plane perpendicular to the philtrum." When sinus computed tomography images were available, the distance from the nasopharynx to the nasal sill was also collected. 371 patients participated in the study (41% women; 51 years old, SD 18). Average ND was 9.4 cm (SD 0.86) and 10.1 cm (SD 0.9) for women and men, respectively (p < 0.001; 95% CI 0.46-0.86). Perpendicular distance was strongly correlated to ND (r = 0.775; p < 0.001), with an average underestimation of 0.1 cm (SD 0.65; 95% CI 0.06-0.2). The equation: ND (cm) = perpendicular distance*0.773 + 2.344, generated from 271 randomly selected participants, and validated on 100 participants, resulted in a 0.03 cm prediction error (SD 0.61; 95% CI -0.08-0.16). Nasopharyngeal depth can be approximated by the distance from the tragus to a plane perpendicular to the philtrum.

Concurrent management of nasal bone expansion from nasal polyposis (Woakes' disease).

Background: Woakes' disease is the eponymous name for severe chronic rhinosinusitis with nasal polyposis (CRSwNP) leading to thinning and expansion of the nasal pyramid. The endoscopic treatment of the sinus disease, while extensive, is standard practice for the rhinologist. Management of their external nasal deformities, for many, is not. Simultaneous closed rhinoplasty in these patients is straightforward, easy to perform and achieves an excellent esthetic outcome. Methods: Three patients with CRSwNP and notable nasal pyramid expansion are reviewed. All patients had eosinophilic disease, with two having NSAID-exacerbated respiratory disease (N-ERD). All three patients underwent full house endoscopic sinus surgery from May 2018 to September 2019 along with simultaneous closed rhinoplasty. Two of these patients required only external digital pressure to fracture the nasal bones for gentle Boies elevator repositioning, while the third had osteotomies with minimal force to aid reduction. Results: Postoperatively, patients had excellent nasal airway symptom improvement, and the cosmetic results following rhinoplasty demonstrated normalization of symmetry, profile, and contour of the nose with high-patient satisfaction. Conclusion: Based on our experience, simultaneous rhinoplasty on the thinned nasal bones of Woakes' Disease patients is not only easy to perform, but provides excellent cosmetic and functional results by allowing bone to remodel in the appropriate position, and avoids a second-stage rhinoplasty.

Evaluation of septal perforation size using a novel measuring device.

BACKGROUND: Nasal septal perforations can be managed with a septal button prosthesis. While they do not restore the physiological function of the septal mucosa, they are able to improve laminar nasal airflow. With the development of septal buttons sized specifically to perforations, accurate measurement of perforations has become more important for patient satisfaction and comfort. This task can be difficult to accomplish in the clinical setting. In this study, 2 new instruments developed to measure septal perforations were evaluated for accuracy and ease of use. METHODS: Two types of measuring devices ("sizers") were created via 3D printing. One type included six serial, progressively sized instruments (serial sizers) and the other included two instruments with several size gradations (graded sizers). Septal perforations of varying sizes were surgically created in five fresh-frozen cadaver heads. Using a headlight and nasal speculum, 15 otolaryngology trainees and consultants were asked to measure the perforations (length × height) via four different methods: "eyeball" estimation, a ruler, the serial sizers, and the graded sizers. They were also asked to evaluate the methods themselves. An accurate measurement was defined as ± 1 mm of the true measurement. A combination of Chi-square analysis and ANOVA was used to assess the accuracy and ease of use of the four methods. RESULTS: Chi-square analysis showed that the sizers were more accurate than the two traditional methods (eyeball and ruler) for measuring perforation length (73% vs. 44%, p = 4.8 × 10-7) and height (71% vs. 50%, p = 0.0003). ANOVA showed that the eyeball method overestimated perforation length significantly more than the other three methods (p = 0.002), and was also significantly less accurate than the other three methods (p < 0.001). Chi-square analysis did not show any correlation between participant training experience and measurement accuracy for any of the three methods. Participant comments and scores demonstrated a clear preference for the two sizers over the traditional methods. CONCLUSIONS: The two novel sizers studied here were significantly more accurate and easier to use than traditional methods for measuring nasal septal perforations. With broader implementation and study of these devices, there is potential to improve patient care surrounding septal perforations.

Rapid visual field progression in a patient with glaucoma as the presenting manifestation of sarcoidosis.

PURPOSE: To report a case of accelerated visual field progression secondary to a new orbital apex lesion in a patient with a longstanding history of fatigue and cough. OBSERVATIONS: A 73-year-old myopic female with known open angle glaucoma presented with accelerated unilateral visual field progression. Maximally tolerated medical therapy was instituted over a period of 1-2 years with imminent discussions of surgical intervention. Around this time the patient reported worsening cough and fatigue, which were initially attributed to glaucoma medication side effects. Consideration of the patient's remote history of melanoma and the current asymmetry of the visual field progression triggered a computerized tomography (CT) scan of the orbits as part of the management. An orbital apex lesion was discovered, raising suspicion for metastatic melanoma, and restaging CT imaging uncovered renal, hepatic, and mediastinal masses. Unexpectedly, biopsies revealed non-necrotizing granulomatous inflammatory processes consistent with a diagnosis of sarcoidosis. It is perhaps noteworthy that the patient had received interferon therapy for management of her melanoma; previous reports have associated interferon exposure with subsequent sarcoid disease, regardless of duration of therapy or elapsed time since exposure. CONCLUSIONS AND IMPORTANCE: Although rare, sarcoidosis can occur virtually anywhere in the body, including the orbital apex. Its common early symptoms, fatigue and cough, are insidious and seen frequently in this patient's age group and medication side effect profile. It is important to maintain an appropriate index of suspicion when monitoring atypical visual field progression in a patient with glaucoma. In this case, imaging, subsequent biopsy, and a multi-specialty team were integral to this patient's diagnosis and management.