Patient satisfaction with telemedicine in rhinology during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has forced the rapid integration of telemedicine services across several specialties, especially in Otolaryngology where risk of transmission is very high. Studies before and during the COVID-19 pandemic have shown that Otolaryngology is generally amenable to telemedicine. However, few studies have assessed patient satisfaction with telemedicine during the COVID-19 pandemic, and fewer have focused on patient satisfaction with telehealth in Rhinology. OBJECTIVES: To determine if patients believe the benefits of virtual live synchronous telemedicine visits out-weigh the drawbacks when compared to in-person clinical visits. METHODS: Single center retrospective case series and survey study of patients presenting to a tertiary care Rhinology practice between 3/15/2020 and 6/1/2020. All patients had previous in-person encounters with Rhinology (n = 45). RESULTS: Twenty-nine participants (64.4%) had audio-video visits while 16 (35.6%) had audio visits. 36 (80%) patients stated that their needs were met during their telemedicine visit while 32 (71.1%) patients felt that nothing was missed or not addressed during the virtual visit. The most commonly cited advantage to telemedicine visits was convenience (22.2%) and provider availability (20.0%). While most participants did not disclose a disadvantage to a virtual visit besides the lack of a physical exam (68.9%), the most commonly cited disadvantage to a virtual visit was technological difficulties (17.8%). CONCLUSIONS: Virtual telemedicine visits were shown to effectively meet the needs of established patients and address concerns in a convenient time efficient manner. However, patients indicated that limited technology and a less personalized feel hindered the telemedicine experience in Rhinology.

Effects of Quality Improvement Education in Diabetic Retinopathy on Routine Clinical Practice Patterns of Optometrists.

SIGNIFICANCE: Optometrists play a preventive role in diabetic care by detecting early signs of diabetic retinopathy (DR), a leading cause of blindness in adults. This study demonstrates that additional training can improve optometrists' ability to assess the presence and severity of DR in individuals with diabetes. PURPOSE: This study aimed to determine the impact of a quality improvement intervention involving education, assessment, and feedback on improving the evaluation and referral patterns of optometrists with regard to their patients with diabetes. METHODS: A pre-interventional and post-interventional analysis of optometrist practices was conducted through a retrospective chart review of diabetic patient encounters from July 2018 to March 2019. Dilated fundus examination (DFE) documentation, follow-up scheduling, referral practices, and usage of various imaging modalities were collected from patient records. Concordance of DR severity recordings between DFE findings, assessment and plan notes, and International Classification of Diseases codes was calculated. RESULTS: After intervention, the proportion of optometrists who conducted a DFE significantly increased from 79.5 (95% confidence interval [CI], 77.3 to 81.7%) to 84.4% (95% CI, 82.4 to 86.4%). In addition, the rate of improper follow-up instructions decreased from 13.8 (95% CI, 12.0 to 15.7%) to 10.8% (95% CI, 9.2 to 12.6%), and the decrease was significant (P = .02). Although overall referrals decreased from 19.8 (95% CI, 17.6 to 21.9%) to 14.6% (95% CI, 12.6 to 16.5%), optometrists were as likely to refer to retinal specialists. Finally, concordance between documented DFE findings, assessment and plan notes, and International Classification of Diseases codes significantly increased from 78.8 (95% CI, 76.5 to 81.0%) to 88.7% (95% CI, 86.9 to 90.4%). CONCLUSIONS: Providing optometrists education in screening and assessing DR is effective in improving diabetic patient care.

Mandibular Advancement vs Combined Airway and Positional Therapy for Snoring: A Randomized Clinical Trial.

Importance: Approximately 150 million individuals in the US snore in the absence of obstructive sleep apnea (primary snoring), but few studies have examined the efficacy of treatments for snoring or evaluated the effect of snoring in sleeping partners. Objective: To evaluate the efficacy of 2 treatments for primary snoring. Design, Setting, and Participants: This pilot randomized clinical trial that included a convenience sample of people who snore without sleep apnea and their sleeping partner who underwent 4 weeks of snoring treatment was conducted at an academic medical center between October 3, 2022, and July 3, 2023. Interventions: Fifty couples were randomized to either use a mandibular advancement device (MAD) or receive combined airway and positional therapy (CAPT; external nasal dilator, nasal saline lavage with mometasone, mouth taping, and lateral positional therapy). Main Outcome and Measure: Percentage of sleeping partners who reported that their partner's snoring was either very much improved or much improved (responder) on the Clinical Global Impression of Improvement scale. Results: A total of 42 dyads completed the study; 23 (55%) were randomized to MAD and 19 (45%) to CAPT. Among people who snore, 26 (62%) were female, and the mean (SD) age was 48 (14) years. Of 23 dyads randomized to MAD, 21 people who snore (91%) were rated by the sleeping partner as a responder, while 11 of the 19 dyads (58%) randomized to CAPT were rated by the sleeping partner as responder, resulting in a difference of 33 percentage points (95% CI, 8-58) and a number needed to treat of 3. Of the 10 participants who were withdrawn, 4 were withdrawn due to adverse effects of the treatment that were evenly distributed between the MAD (n = 2) and CAPT (n = 2) groups. Conclusion and Relevance: The results of this randomized clinical trial showed that the MAD may be more effective than CAPT for treating primary snoring, while both treatment options were found to reduce primary snoring. Physicians should have a patient-centered discussion to determine which treatment is best for individual patients with primary snoring, weighing convenience, adverse effects, and cost as factors. Trial Registration: ClinicalTrials.gov Identifier: NCT05756647.

Revision Rates and Symptom Trends Following Endoscopic Sinus Surgery: Impact of Race on Outcomes.

OBJECTIVE: The purpose of this study is to determine the impact of demographics and sinonasal comorbidities on the revision rate of functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis (CRS). BACKGROUND: Although endoscopic sinus surgery (ESS) is often successful in providing long-term relief for patients suffering from CRS, revision surgery can occur. There is conflicting literature on the impact of race on FESS outcomes. METHODS: A single-center retrospective cohort study of patients that underwent FESS for CRS between January 1, 2015 and June 1, 2021 at a single tertiary care academic center. RESULTS: A total of 682 patients between the ages of 18 and 89 underwent primary ESS between January 1, 2015 and June 1, 2021 and were included in this study. Of these patients, 388 (56.9%) were female, with an average age of 48.6 ± 16.7. Thirty-eight patients (5.6%) underwent revision sinus surgery during the study period. Patients that identified as White had significantly lower rates of revision sinus surgery (4.1%) than non-White patients (10.7%), including those identifying as Asian, Black, multiracial, or other. On multivariate analysis, non-White race (OR 4.933), polyposis (3.175), and high preoperative SNOT-22 scores (OR 1.029) were independently associated with revision sinus surgery. The mean preoperative SNOT-22 for all participants was 39.1 ± 22.0, whereas the mean postoperative SNOT-22 was 20.6 ± 17.5 (p < 0.001). CONCLUSION: Race plays an important role in outcomes following revision sinus surgery that is independent of location and insurance status. More studies are required to assess the reason race plays an important role in outcomes following revision sinus surgery. LEVEL OF EVIDENCE: Level 3 Laryngoscope, 133:2878-2884, 2023.

Depression, anxiety, and suicidal ideation in adults with COVID-induced parosmia.

KEY POINTS COVID-induced parosmia is associated with anxiety, depression, and suicidal ideation. Parosmic patients have low rates of treatment benefit and little hope for improvement. Hyposmia may mitigate the quality-of-life burden in patients with parosmia.

Efficacy of Gabapentin For Post-COVID-19 Olfactory Dysfunction: The GRACE Randomized Clinical Trial.

Importance: The COVID-19 pandemic affected millions of people and has become a dominant etiology of olfactory dysfunction (OD). No interventions with definitive clinical utility exist. Gabapentin represents a potential therapy for COVID-19-induced OD. Objective: To evaluate the efficacy of oral gabapentin on olfactory function and olfaction-related quality of life in patients with COVID-19-induced OD. Design, Setting, and Participants: This pilot double-blinded, placebo-controlled randomized clinical trial (RCT) was conducted at Washington University School of Medicine in St Louis from January 7, 2022, to February 3, 2023. Adults with at least 3 months of OD after COVID-19 infection were eligible for inclusion. Participants with a history of other causes of OD or contraindications to gabapentin were excluded. Intervention: Patients were randomized 1:1 to oral gabapentin or placebo. All patients underwent titration to a maximum tolerable dose, which was maintained during an 8-week fixed-dose (FD) phase then tapered off. Participants were monitored for 4 weeks following cessation of study medication. Main Outcomes and Measures: Outcomes were assessed following the 8-week FD phase and 4 weeks after taper completion. The primary outcome measure was the response rate determined by subjective improvement in OD on the Clinical Global Impression of Improvement (CGI-I) after the FD phase. Other subjective and objective measures of olfactory function were also assessed as secondary outcome measures. Results: Sixty-eight participants were enrolled (34 randomized to each arm), a total of 44 participants completed the FD period and 20 (45.4%) reported response to treatment with at least slight improvement in olfaction from baseline. Of those randomized, 51 (75%) were women and 56 were White (82%) with a mean (SD) age of 43 (13.5) years. Baseline demographic features including age, sex, and race and ethnicity were not significantly different between the groups. Of the 18 participants in the gabapentin group, 8 (44%) were responders and of the 26 participants in the placebo group, 12 (46%) reported response to treatment (percent difference, 1.7%; 95% CI, -31.6% to 28.2%). Mixed-model analysis of all secondary outcome measures demonstrated no clinically meaningful or statistically significant difference between the gabapentin and placebo groups throughout the trial. There were no serious adverse events. Conclusions and Relevance: In this randomized clinical trial, gabapentin was not associated with statistically significant or clinically meaningful benefit over placebo and likely is not an efficacious therapy for COVID-19-induced OD. Trial Registration: ClinicalTrials.gov Identifier: NCT05184192.

Most-Cited Patient-Reported Outcome Measures Within Otolaryngology-Revisiting the Minimal Clinically Important Difference: A Review.

Importance: Patient-reported outcome measures (PROMs) allow clinicians and researchers to assess health-related information from a patient's perspective. These measures have been used more frequently over the last several decades, but an associated minimal clinically important difference (MCID) is needed to optimize their utility. This narrative review identified the top 100 most-cited otolaryngology-related PROM development and validation publications and assessed the presence and characteristics of the PROMs' associated MCID. Observations: In this narrative review, a literature search in Scopus and Web of Science was conducted on June 29, 2022, using keywords related to PROM development and validation studies in otolaryngology and reference lists. Studies that met the definition of a PROM and assessed an otolaryngologic disorder or study population were included for full-text review. After full-text review of 188 articles, the top 100 most-cited PROM development and validation publications, resulting in 106 total PROMs, were chosen for review. A total of 39 (37%) of the identified PROMs had an associated MCID. Of those reporting an MCID, 14 (35.9%) used an anchor-based method, 12 (30.8%) used a distribution-based method, 10 (25.6%) used both, and 3 (7.7%) did not specify or used neither method. Rhinology had the greatest number of PROMs with an associated MCID (16 of 24, 66%), and pediatrics had the fewest (1 of 13, 7.7%). The median number of citations of PROMs with an MCID was higher than those without an MCID. Conclusions and Relevance: The majority of the most-cited PROMs in otolaryngology lack an associated MCID. These data indicated that there are a multitude of PROMs that have been cited hundreds of times and used for decades without the ability to identify whether a particular change in score on the instrument is clinically meaningful. There is a need to determine and validate MCIDs for commonly used PROMs to aid clinical research and trial interpretation.

Anterior and Lateral Skull Base Spontaneous CSF Leaks: Evaluation of Comorbidities and Treatment Outcomes.

OBJECTIVES: To evaluate clinical characteristics and outcomes of patients diagnosed with anterior (ASB) or lateral skull base (LSB) spontaneous cerebrospinal fluid (sCSF) leak. METHODS: Single center retrospective review of patients diagnosed with sCSF leaks of ASB or LSB between 1/1/2009 and 11/1/2019 (n = 69). Body mass index (BMI), gender, age at diagnosis, origin of CSF leak (ASB vs LSB), surgical approach, lumbar drain use, recurrence, pre-operative diagnosis of diabetes mellitus (DM), and obstructive sleep apnea (OSA) were collected. RESULTS: 69 patients included in this study met criteria for sCSF leak without a traumatic or iatrogenic cause (Female: 51 (74%); average BMI: 37.0 ± 7.9). Forty-eight (70.0%) presented with sCSF leaks of the lateral skull base. All ASB leaks were treated with an endoscopic transnasal approach. Eleven (22.9%) LSB leak patients were treated using transmastoid approaches and 35 (72.9%) patients with a middle cranial fossa approach. Eleven patients (15.9%) reported sCSF leak recurrence. Two patients (9.5%) with anterior skull base and 9 patients (18.8%) with lateral skull base leaks had recurrence. LSB sCSF leaks had a relative risk of 2.192 of recurrence compared to ASB leaks (95% CI: 0.431-11.157, P = .483). A 5.017 times increased risk (95% CI: 1.285-19.583, P = .020) was reported for patients with OSA, while the risks for DM and BMI were 1.351 (95% CI: 0.67-9.105, P = .177) and 1.026 (95% CI: 0.963-1.094, P = .426) respectively. Patients with sCSF leak recurrence had significantly lower lumbar drain use (33.3%) than those without recurrence (72.7%) (P = .049). CONCLUSION: Spontaneous CSF leak recurrence is complex and multifactorial, and while patients with both DM and OSA had the higher risk of recurrence, OSA is likely an independent clinical risk factor for sCSF leak recurrence in this patient population.

The Use of 0° and 70° Endoscopes in Maxillary Antrostomy.

BACKGROUND AND OBJECTIVES: Performing an effective maxillary antrostomy is critical to improving chronic maxillary sinusitis symptomatology. Incomplete dissection of the uncinate process and failure to incorporate the natural drainage pathway may lead to recirculation and need for revision surgery. The purpose of this study is to determine if 70° endoscopes provide added value in determining incomplete dissection or residual disease. METHODS: Prospective study of 35 sinuses from 18 patients undergoing FESS for Chronic Rhinosinusitis (CRS) between 11/1/2020 and 4/30/2021. Two fellowship trained Rhinologists initially performed maxillary antrostomies exclusively using a 0° endoscope, then transitioned to a 70° endoscope. Surgeons completed a survey to assess completion of the antrostomy prior to use of 70° endoscope, sino-nasal anatomy, and difficulty of the operation. Intraoperative photographs before and after using a 70° endoscope were evaluated by a third party. Pre-operative CT scans were used to evaluate the sphenoid keel-caudal septum-nasolacrimal duct (SK-CS-NL) angle. RESULTS: Of 35 sinuses from 18 patients all 35 sinuses had CRS with 48.5% having nasal polyposis and 42.9% having active infection. There was residual inflammatory tissue in the anterior maxillary sinus, including polypoid tissue and uncinate process prior to using the 70° endoscope in 82.9% of sinuses. The natural drainage pathway was not incorporated into the dissection in 28.6% of sinuses before converting to 70° endoscope. Incomplete dissection with 0° endoscope was not associated with nasal polyposis (P = .086) or uncinate position (0.741). Narrow SK-CS-NL angles were associated with incomplete dissection of the anterior maxillary sinus with 0° endoscope (16.0° ± 3.0° vs 20.6° ± 3.2°; P = .013). CONCLUSION: Use of 70° endoscope in maxillary antrostomy may be beneficial in identifying and resecting disease within the anterior maxillary sinus that may otherwise be difficult to find using a 0° endoscope. This is especially true in patients with narrow nasolacrimal duct positioning.

Age-related differences in presentation and outcomes of anti-VEGF treatment of retinal vein occlusion.

OBJECTIVE: To assess age-related differences at baseline and treatment outcomes in patients with retinal vein occlusion (RVO) and macular edema treated with anti-vascular endothelial growth factor (VEGF) therapy DESIGN: Single-centre retrospective chart review. PARTICIPANTS: 295 treatment-naïve RVO patients. METHODS: 295 RVO patients included were separated into age quartiles: group A (22-61 years), group B (62-70 years), group C (71-79 years), and group D (80-95 years). Outcomes including central subfield thickness (CST), cubic volume, cubic average thickness, and visual acuity (VA) were collected at baseline and at 6 and 12 months after treatment. The primary outcome of the study was the CST at 12 months after anti-VEGF therapy. RESULTS: Mean baseline CST for groups A, B, C, and D was 406.3 ± 161.2 µm, 463.4 ± 165.5 µm, 470.6 ± 187 µm, and 427.3 ± 187.2 µm, respectively. No significant differences in CST were observed between groups at baseline, 6 months, or 12 months (p ≥ 0.08). Mean baseline VA for groups A, B, C, and D was 55.8 ± 19.5, 54.4 ± 19.8, 54.7 ± 19, and 51.4 ± 20.4 Early Treatment Diabetic Retinopathy letters, respectively. VA did not differ significantly between age groups at baseline, 6 months, or 12 months (p ≥ 0.06). CONCLUSIONS: The presentation of RVO and the visual outcomes of anti-VEGF therapy do not vary based on age.

Management of Patients With DME With Good Visual Acuity in Routine Clinical Practice.

BACKGROUND AND OBJECTIVE: To determine outcomes of eyes with diabetic macular edema (DME) and best visual acuity (BVA) of 20/25 or better in routine clinical practice. PATIENTS AND METHODS: Retrospective study of 72 patients with DME and BVA of 20/25 or better. Patients were divided by anti-vascular endothelial growth factor (VEGF) treatment regimen: early (Group A), delayed (Group B), and none (Group C). RESULTS: Group A had higher baseline central subfield thickness (CST) (325 ± 62 µm) compared to Groups B (292 ± 24 µm) and C (296 ± 35 µm) (P = .033). All groups had similar 24-month CST (299 ± 62 µm, 280 ± 64 µm, 296 ± 65 µm; P = .61). There was no difference in baseline BVA among groups (81.9 ± 2.4, 83.2 ± 2.4, 82.4 ± 2.5 Early Treatment Diabetic Retinopathy Study [ETDRS] letters, respectively; P = .290), but at 6 months, Group A had lower BVA (76.6 ± 9.6 ETDRS letters) than groups B (81.9 ±3.3 ETDRS letters) and C (82.4 ± 5.0 ETDRS letters) (P = .008). There was no difference among groups in 24-month BVA (78.9 ± 6.6, 78.4 ± 12.3, and 80.6 ± 6.9 ETDRS letters, respectively; P = .448). CONCLUSION: Although observation may be indicated in eyes with stable BVA and CST less than 300 µm, anti-VEGF stabilizes BVA in eyes with CST greater than 300 µm and eyes with declining BVA. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:247-256.].