Reasons for rejection of rhinoplasty seeking patients: a multicentre observational study.

BACKGROUND: To date, research on preoperative patient selection has mainly focused on patient personality, with body dysmorphic disorder (BDD) being the most studied. Despite the many reasons for not planning a rhinoplasty, no data are available on the nature of these reasons. Our aim is to conduct a multicentre international observational study on the reasons for rejection of patients seeking rhinoplasty in 5 tertiary rhinoplasty care centres. METHODS: Surgeons documented the reasons for not scheduling a rhinoplasty in consecutive patients who consulted them between January 2021 and March 2022 using a predefined list of reasons for rejection. Surgeons were also asked to report on the patient attitudes after rejection, and about the advice given to patients in the event of refusal. RESULTS: 186 patients seeking rhinoplasty were included. Multiple reasons for rejection were present in 76% of patients, with a mean of 2.9 reasons for rejection per patient. Overall, patient-related factors were most frequently associated with rejection (64.3%), followed by nose-related factors (28.4%), surgeon-related factors (6.0 %) and surgery-related factors (1.3%). The presence of severe BDD symptoms was reported in only 11.3% of the rejected patients. Patients rejected for rhinoplasty were advised to reconsider the surgery (32.8 %) and/or were referred to another surgeon (32.8%). No further action was taken in 39.8% of the patients. Of the patients who were rejected, most had a neutral (39.2 %) or positive (37.1 %) attitude in relation to the lack of rhinoplasty planning. CONCLUSION: This study highlights the variety of reasons for which patients seeking rhinoplasty are not considered good candidates for a rhinoplasty, with patient-related factors being more prevalent than nose-related and other factors. Increasing awareness on the impact of adequate patient selection for rhinoplasty may contribute to better outcomes in rhinoplasty.

Consensus criteria for chronic rhinosinusitis disease control: an international Delphi Study.

BACKGROUND: Chronic rhinosinusitis (CRS) disease control is a global metric of disease status for CRS. While there is broad acceptance that it is an important treatment goal, there has been inconsistency in the criteria used to define CRS control. The objective of this study was to identify and develop consensus around essential criteria for assessment of CRS disease control. METHODS: Modified Delphi methodology consisting of three rounds to review a list of 24 possible CRS control criteria developed by a 12-person steering committee. The core authorship of the multidisciplinary EPOS 2020 guidelines was invited to participate. RESULTS: Thirty-two individuals accepted the invitation to participate and there was no dropout of participants throughout the entire study (3 rounds). Consensus essential criteria for assessment of CRS control were: overall symptom severity, need for CRS-related systemic corticosteroids in the prior 6 months, severity of nasal obstruction, and patient-reported CRS control. Near-consensus items were: nasal endoscopy findings, severity of smell loss, overall quality of life, impairment of normal activities and severity of nasal discharge. Participants’ comments provided insights into caveats of, and disagreements related to, near-consensus items. CONCLUSIONS: Overall symptom severity, use of CRS-related systemic corticosteroids, severity of nasal obstruction, and patient-reported CRS control are widely agreed upon essential criteria for assessment of CRS disease control. Consideration of near-consensus items to assess CRS control should be implemented with their intrinsic caveats in mind. These identified consensus CRS control criteria, together with evidence-based support, will provide a foundation upon which CRS control criteria with wide-spread acceptance can be developed.

The EUFOREA pocket guide for chronic rhinosinusitis.

Chronic rhinosinusitis (CRS) is known to affect around 5 % of the total population, with major impact on the quality of life of those severely affected (1). Despite a substantial burden on individuals, society and health economies, CRS often remains underdiagnosed, under-estimated and under-treated (2). International guidelines like the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) (3) and the International Consensus statement on Allergy and Rhinology: Rhinosinusitis 2021 (ICAR) (4) offer physicians insight into the recommended treatment options for CRS, with an overview of effective strategies and guidance of diagnosis and care throughout the disease journey of CRS.

Rhinology Future Debates 2018, a EUFOREA Report.

The third Rhinology Future Debates was organized by the European Forum for Research and Education in Allergy and Airways diseases (EUFOREA) in 2018 in Brussels. Experts from different specialties and countries, alongside patients, health policy makers and industry representatives discussed relevant topics in Rhinology, in an attempt to improve current clinical practices, through implementation of precision medicine, by empowering patients' participation and the use of eHealth tools. The debates which are available on-line (www.rhinology-future.com) dealt with 5 topics in Rhinology: the adoption of allergen-specific immunotherapy (AIT) by implementing change management strategies, the needs and obstacles in care delivery in respiratory diseases, 3D technology in nose and sinus surgery, ambulatory nasal surgery, and clinical evidence for efficacy of biologicals in CRSwNP and asthma. This report summarizes the outcomes of the brainstorming sessions highlighting novel approaches and unmet needs in the field of respiratory diseases by focusing on integrated care pathways.

European Position Paper on Rhinosinusitis and Nasal Polyps 2020.

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

EPOS2020: development strategy and goals for the latest European Position Paper on Rhinosinusitis.

BACKGROUND: The European Position Papers on Rhinosinusitis from 2005, 2007 and 2012 have had a measurable impact on the way this common condition with high impact on quality of life is managed around the world. EPOS2020 will be the latest iteration of the guideline, addressing new stakeholders and target users, presenting a summary of the latest literature and evolving treatment modalities, and formulating clear recommendations based on all available evidence. METHODOLOGY: Based on the AGREE II framework, this article demonstrates how the EPOS2020 steering group will address six key areas to ensure consistency in quality and presentation of information in the latest rhinosinusitis clinical practice guideline: scope and purpose; stakeholder involvement; rigour of development; clarity of presentation; recommendations and applicability; editorial independence. RESULTS: By analysing the guidance from AGREE II, we formulated a detailed development strategy for EPOS2020. We identify new stakeholders and target users and ratify the importance of patient involvement in the latest EPOS guideline. New and expanded areas of research to be addressed are highlighted. We confirm our intention to use mixed methodologies, combining evidence-based medicine with real life studies; when no evidence can be found, use Delphi rounds to achieve clear, inclusive recommendations. We also introduce new concepts for dissemination of the guideline, using Internet and social media to improve accessibility. CONCLUSION: This article is an introduction to the EPOS2020 project, and presents the key goals, core stakeholders, planned methodology and dissemination strategies for the latest version of this influential guideline.

Endoscopic management of paediatric meningoencephaloceles: a case series.

INTRODUCTION: Congenital meningoencephaloceles represent a rare clinical entity, with its frequency being around 1 out of 4000-5000 live births. They usually present as a midline mass and the differential diagnosis includes dermoids, encephaloceles, and gliomas. Although the standard coronal approach with frontal craniotomy and pericranial flap has been considered the preferred method for several years, it is associated with risks and prolonged hospitalization. The endoscopic procedure is gaining ground and we are aiming to present our experience from five cases that were treated endoscopically. MATERIALS AND METHODS: Five cases of paediatric meningoencephaloceles (age ranging from 2.5 to 10 years) were treated in our department between the years 2007-2017. Four children had a congenital and one child a post-traumatic meningoencephalocele. The presenting symptoms included nasal obstruction, meningitis and CSF leak. All patients had pre-operative imaging with CT and MRI scans and the preferred method of repair was multi-layered closure. RESULTS: All our patients had uneventful recovery, without any post-operative complications. The follow-up period ranges from 39 to 98 months. All five patients remain asymptomatic and recurrence-free. CONCLUSION: Endoscopic management of paediatric meningoencephaloceles is a reliable and safe approach and it is known to have no adverse effects on facial growth. It carries a satisfactory success rate, reduces the in-hospital stay with lower cost of treatment, better cosmesis and lower morbidity than external procedures. It requires multidisciplinary team setting in a tertiary centre with experienced endoscopic anterior skull base surgeons. Pre-operative assessment and post-operative care are of paramount importance and larger series need to be studied to reach safe conclusions and establish management guidelines.

Reconstruction of frontal defects with calvarial grafts.

BACKGROUND: There are many options for the reconstruction of frontal sinus wall defect resulting from injury, neoplastic lesions and aesthetic deformities. These mainly include autogenous grafts, allogenous grafts, and alloplastic materials. The aim of the present study is to report the advantages of using autogenous calvarial bone grafts over other reconstruction techniques, in the reconstruction of frontal defects. METHODS: We describe 16 consecutive cases of anterior frontal sinus defects between 2004 and 2015, in which calvarial bone grafts were used. Medical records were retrospectively analysed to evaluate graft survival. RESULTS: Bone defects were caused by injury (3), aesthetic deformities (2), external frontal sinus surgeries (2), tumours (6: three osteomas, two fibrous dysplasias, one squamous cell carcinoma), and osteomyelitis (3). There were no significant complications during harvesting, and morbidity was minimal. Furthermore, at one and five-year follow-up, no graft resorption or rejection was noted, and cosmetic results were satisfactory. CONCLUSIONS: Our results indicate that calvarial bone graft is an appropriate material to use in anterior frontal sinus reconstruction.

mySinusitisCoach: patient empowerment in chronic rhinosinusitis using mobile technology.

Mobile health technology is emerging to take a prominent position in the management of chronic diseases. These technologies aim at enhancing patient empowerment via education and self-management. To date, of all the different apps available for patients with sinus disease, none were developed by medical experts dealing with chronic rhinosinusitis (CRS). The European Forum for Research and Education in Allergy and Airway diseases (EUFOREA) has undertaken a multi-stakeholder approach for designing, developing and implementing a tool to support CRS patients in monitoring their symptoms and to provide patients with a digital support platform containing reliable medical information about their disease and treatment options. mySinusitisCoach has been developed by medical experts dealing with CRS in close collaboration with patients, primary care physicians and community pharmacists, meeting the needs of both patients and health care providers. From a research perspective, the generation of real life data will help to validate clinical studies, patient stratification and improve understanding of the socio-economic impact of CRS, thereby paving the way for better treatment strategies.

Long term effects of olfactory training in patients with post-infectious olfactory loss.

BACKGROUND: There is evidence of the effectiveness of repeated exposure to odours on short-term olfactory function. The aim of this study was to assess the long-term effects of olfactory training. METHODS: We conducted a prospective study of 111 patients with post-infectious olfactory dysfunction. Two groups of patients performed olfactory training for 16 and 56 weeks, respectively, and were compared with a control group. The training was performed twice daily using four odours (phenyl ethyl alcohol, eucalyptol, citronellal, eugenol). Olfactory testing was performed by means of the Sniffin Sticks test as a baseline assessment and then every 8 weeks for 56 weeks. Subjective ratings were performed using a visual analogue scale (0-100). RESULTS: Both training groups presented significantly higher scores than the controls. The long-term group had better results than the short-term group. Short-term training patients sustained their improvement within the follow-up period. Subsets analysis showed that training patients mainly increased identification and discrimination. Subjective ratings were in accordance with the olfactory test results. CONCLUSION: Long-term olfactory training seems to be associated with better results in patients with post-infectious olfactory loss than a short-term scheme. Short-term training provides sustainable results at 56 weeks follow-up assessment.

Long-term results of combined approach in parotid sialolithiasis.

Combined sialendoscopic and transcutaneous approach in parotid sialolithiasis is a surgical option for large and impacted stones. The aim of this study is to assess the long-term results regarding postoperative stenosis, recurrent swellings and gland function. Prospective study in a tertiary referral center of patients with parotid sialolithiasis requiring combined approach. A total of 12 patients have been treated within a period of 3 years. Intraductal stents were placed in 9 of 12 cases. Scintigraphic evaluation of salivary glands and follow-up sialendoscopy performed 1 year postoperatively. In total, fourteen stones (two stones in two cases) were successfully removed along with two coexisted inflammatory polyps. Postoperative endoscopic evaluation revealed mild stenosis in 7 out of 12 cases without clinical significance as no recurrent swellings were reported. Scintigraphy showed normal gland function in 11 cases and mild hypofunction in 1 case with long-standing history of sialolithiasis. All patients were free of symptoms within the follow-up period of time (median follow-up 15.5 months). Combined approach is a safe, gland preserving and efficacious procedure in long term. The stenosis in the area of ductal surgical opening when present does not seem to be of clinical value.

A novel technique for mitomycin-c application in frontal sinus surgery.

OBJECTIVE: Local application of mitomycin-c (MMC) seems to be effective in reducing adhesions and stenosis after FESS. However this is not clearly seen in frontal sinusotomy. This study assesses the effectiveness of local MMC in the frontal ostium using a foamy material (otowick) and compared with cottonoids. METHODS: Forty-seven patients with chronic rhinosinusitis without polyps enrolled in this study. Two subgroups were studied: one with MMC application in one nostril using cottonoids and a second with MMC injected in an otowick. In all patients MMC was applied twice, intraoperatively and 4 weeks later. In both groups normal saline was applied to the other nostril on the same material with the MMC side. Six months postoperatively all patients were assessed endoscopically by a clinician blinded to the MMC side. RESULTS: Overall, MMC application was more effective than normal saline in both groups. Otowick use presented favorable initial results especially in primary cases regarding ostium patency, and need for revision surgery. The use of MMC cottonoids did not show any benefit in primary cases. CONCLUSION: The described technique seems to be effective in maintaining frontal ostium patency as it provides a more precise and deeper drug delivery to this area.

Evaluation of the attributable fraction and burden of HPV-related oropharyngeal cancers in Greece-the ORPHEAS study.

BACKGROUND: Herein, we evaluated the attributable fraction (AF) of human papillomavirus (HPV)-mediated (HPV+) oropharyngeal carcinomas (OPCs) in Greece over a recent calendar period. PATIENTS AND METHODS: ORPHEAS, a retrospective, observational, multicenter, cross-sectional study with prospective recruitment, included adult patients with OPC in 2017-2022, each of them with a high-quality, treatment-naïve tumor specimen. The primary endpoint was the HPV-AF, defined as combined positivity for p16INK4a (p16) overexpression and HPV DNA presence by central laboratory testing, among included patients. Other endpoints evaluated the HPV+/HPV- patient/disease characteristics at OPC diagnosis and the HPV subtypes for HPV+ patients. RESULTS: 144/147 patients with available HPV status by central laboratory testing were analyzed [median age: 60.0 years; males: 111 (77.1%)]. The most common tumor anatomical sites were the tonsils (70/147, 48.6%) and the base of the tongue (51, 35.4%), and most patients were at the American Joint Committee on Cancer eighth edition TNM (tumor-node-metastasis) stages III (25, 22.7%) and IV (43, 39.1%). The HPV-AF was 52.1% (75/144; 95% confidence interval 43.6% to 60.5%). Most HPV+ patients were infected by an HPV type targeted by the 9-valent HPV vaccine (72/75, 96.0%), especially HPV16 (70/75, 93.3%). HPV+ compared with HPV- patients were younger (median age 58.0 versus 64.0 years; P = 0.003); more likely to have tumors in the tonsils (65.0% versus 30.4%; P < 0.001); less likely to have tumors in the base of the tongue (25.3% versus 46.4%; P = 0.008); and less frequently at TNM stage IV (20.4% versus 57.1%; overall P < 0.001). CONCLUSIONS: In Greece, we observed a high HPV-AF (52.1%) in OPC, approximating the AFs reported for some Northern European countries. HPV+ versus HPV- patients were younger, more frequently with tonsillar tumors, and less frequently at TNM stage IV. Since most patients were infected by ≥1 HPV type targeted by the 9-valent vaccine, the HPV+ OPC burden could be mitigated through a routine HPV gender-neutral vaccination program.

Endoscopic treatment of juvenile nasopharyngeal angiofibromas: our experience and review of the literature.

The endoscopic resection of juvenile nasopharyngeal angiofibroma (JNA) emerges as an alternative approach to open procedures due to reduced morbidity and comparable recurrence rates. The purpose of this study was to present our experience with the endoscopic management of JNA using retrospective chart review of ten male patients (mean age 15.7 years) with JNA who were treated endoscopically at our institution between the years 2003 and 2010. According to the Radkowski's system, one patient was at stage Ia, two at stage Ib, one at stage IIa, two at stage IIb, two at stage IIc (infratemporal fossa invasion) and two at stage IIIa (clivus erosion). Six patients underwent preoperative embolization. The endoscopic treatment involved total ethmoidectomy, middle meatal antrostomy, sphenoidotomy, clipping of the sphenopalatine artery and its branches and drilling of the pterygoid basis. All patients underwent magnetic resonance imaging 3 months postoperatively and then if indicated clinically. Mean follow-up was 23.7 months (range 3-70). All but one patient were free of macroscopic disease. A patient with stage IIb JNA developed a recurrence after 9 months. The residual tumor was resected endoscopically and the sphenopalatine foramen widened by drilling. The patient is free of disease 25 months postoperatively. The intra-operative blood loss was not excessive (200-800 ml, mean: 444 ml) and no patient required a blood transfusion. Patients were discharged after 4-8 days (mean 5 days). One patient developed postoperative infraorbital nerve hypoesthesia. Results showed that endoscopic treatment of stage I and IIa/b JNA is a valid alternative to external approaches. For select tumors with limited infratemporal fossa invasion and skull base erosion, the endoscopic approach may also be indicated. It is a safe and effective treatment modality due to the lack of external scars, minimal bone resection and blood loss and low recurrence rate.

The Rhinoconjunctivitis Quality of Life Questionnaire and its modified short version validation in adults and children with allergic rhinitis.

OBJECTIVE: This study aimed to develop the Greek versions of the Rhinoconjunctivitis Quality of Life Questionnaire and Mini-Rhinoconjunctivitis Quality of Life Questionnaire for adult and pediatric populations, discuss their differences and detect the impact of age and gender on quality of life questionnaire results. METHOD: Ninety-eight patients with allergic rhinitis participated. Quality of Life evaluation was made by two generic (Short Form-36 and Beck Depression Inventory) and two disease-specific questionnaires (Rhinoconjunctivitis Quality of Life Questionnaire and Mini-Rhinoconjunctivitis Quality of Life Questionnaire). Symptom evaluation was made by the Total 5 Symptoms Score assessment. RESULTS: Internal consistency and test-retest reliability of both questionnaires was high. Convergent validity showed statistically significant negative correlations of total Rhinoconjunctivitis Quality of Life Questionnaire and Mini-Rhinoconjunctivitis Quality of Life Questionnaire with overall Short Form-36 Health Survey score and positive correlations with Beck Depression Inventory and Total 5 Symptoms Score. Discriminative validity demonstrated statistically significant improvement for all instruments and all domains after treatment. Females presented highly significant increased scores. Patient age was positively correlated with total scores of Rhinoconjunctivitis Quality of Life Questionnaire and Mini-Rhinoconjunctivitis Quality of Life Questionnaire. The clinically significant improvement after treatment was higher among females than males, while it was independent of patient age. CONCLUSION: Rhinoconjunctivitis Quality of Life Questionnaire and Mini-Rhinoconjunctivitis Quality of Life Questionnaire proved to be valid and reliable methods of assessment of allergic rhinitis-related quality of life in children, adolescents and adults.

The value of bilateral simultaneous nasal spirometry in the assessment of patients undergoing septoplasty.

PROBLEM: There is no consensus regarding the best approach to select patients for septoplasty. Patient dissatisfaction after septoplasty implies that clinical examination alone is inadequate to detect a clinically relevant nasal septal deviation (NSD). Objective testing provides an in-depth analysis of nasal obstruction and its underlying anatomic causes but it is effort consuming, requires training and it is not widely available. AIM: We studied the role of bilateral simultaneous nasal spirometry (BSNS) in the preoperative selection of patients for septoplasty. PATIENTS, SUBJECTS AND METHODS: Thirty patients with nasal obstruction and NSD were assessed by subjective measures and BSNS before and after septoplasty. The decongested nasal partitioning ratio (NPR) was used as a measure of the degree of NSD. Thirty healthy controls were recruited for providing a normal range of NPR values. RESULTS: All patients were subjectively improved after septoplasty but only those with NPR out of the normal limits had a significant reduction of NPR. Patients with unilateral symptoms and NPR beyond normal limits were also able to identify the more obstructed side preoperatively. For this group of patients, physicians were able to identify the convex side of NSD preoperatively. No correlation between subjective measures of nasal obstruction or airflow asymmetry and NPR was observed. CONCLUSION: BSNS is a rapid, easily interpretable, noninvasive technique, which identifies patients with large NSDs who, irrespective of concomitant mucosal factors of nasal obstruction, warrant septoplasty. BSNS is not applicable in cases with a septal perforation or an S type septal deviation, it cannot detect an insufficient nasal valve and it does not substitute rhinomanometry or acoustic rhinometry.