Comparison of sinus distribution between nasal irrigation and nasal spray using fluorescein-labelled in patients with chronic rhinosinusitis: A randomised clinical trial.

OBJECTIVE: This study aims to compare the potential sinus distribution between high-volume nasal irrigation and nasal spray in chronic rhinosinusitis (CRS) patients who have not undergone sinus surgery. DESIGN AND SETTING: A randomised clinical study was conducted at the Otolaryngology-Head & Neck Surgery Department, Ramathibodi Hospital, Faculty of Medicine, Mahidol University. PARTICIPANTS: Forty patients undergoing endoscopic sinus surgery (ESS) for CRS. Thirty-eight patients met the inclusion criteria and were randomly assigned to receive nasal irrigation or nasal spray mixed with fluorescein sodium preoperatively. MAIN OUTCOME MEASURES: The primary outcome was the mean difference in the staining score of fluorescein in all sinuses between the two groups. RESULTS: The total fluorescein staining score for all sinuses in the nasal irrigation group was significantly higher than the score from the nasal spray group, with a mean difference score of 2.90, 95% confidence interval: 1.22-4.58, p = .001. The most significantly affected sinuses were the maxillary and the anterior ethmoid sinuses, while the frontal and sphenoid sinuses had only minimal staining from both techniques. CONCLUSION: Nasal irrigation is a potential route to deliver drugs into the sinus in unoperated CRS patients. However, it is not considered a superior method to nasal spray in the most challenging anatomical areas, that is, the frontal and sphenoid sinuses.

Corticosteroid nasal irrigation as early treatment of olfactory dysfunction in COVID-19: A prospective randomised controlled trial.

OBJECTIVE: This study aimed to evaluate the efficacy of corticosteroid irrigation compared to saline to no nasal irrigation in COVID-19 patients with olfactory loss. DESIGN AND SETTING: A randomised controlled study was conducted at the Otolaryngology-Head & Neck Surgery Department, Ramathibodi Hospital, Faculty of Medicine, Mahidol University. PARTICIPANTS: Two hundred thirty-seven COVID-19 participants with a new-onset smell loss were recruited into the study. Two hundred twenty-two participants met the inclusion criteria and were randomised into three groups: corticosteroid irrigation, saline irrigation and no treatment. MAIN OUTCOME MEASURES: The primary outcome was the mean difference in the smell sensation score among the groups after treatment at 1, 2 and 6 weeks. The secondary outcomes measurements included (1) a self-rating quality of life (QOL)-related smell dysfunction score, (2) the change over time in smell sensation score and self-rating QOL-related smell dysfunction score and (3) the median time to complete recovery of smell loss. RESULTS: The mean differences in smell sensation scores among the three groups were not statistically significant at any follow-up period. The mean score of self-rating QOL-related smell dysfunction in the corticosteroid group was significantly better than the other groups at 1 week. The change of outcome scores showed significant improvement over time, regardless of the treatments. The median time to complete smell recovery was similar: 3 weeks. CONCLUSION: This study emphasised that corticosteroid nasal irrigation is not superior to saline or no nasal irrigation in restoring the sense of smell in COVID-19-associated olfactory loss.

Prevalence and Prognostic Factors Associated with Early Recovery of Olfactory Dysfunction in COVID-19 Patients.

BACKGROUND: The prevalence of smell dysfunction, along with its risk factors, has been evaluated in previous literature; however, little has been established regarding its relation to other factors such as disease severity, history of coronavirus disease-2019 (COVID-19) vaccinations, and medical treatment for COVID-19 infection. These factors may impact the overall recovery of olfaction in COVID-19 patients. OBJECTIVE: This study investigated the prevalence of early olfactory recovery from COVID-19 infection and its associated factors. METHODS: This study was a prospective cohort study on 348 COVID-19 patients with a new onset of anosmia or hyposmia. Smell sensation scores on the olfactory self-assessment test were collected at baseline and every week until 6 weeks of follow-up. The primary outcome was the prevalence of early olfactory recovery. The secondary outcomes were analyzing factors associated with early olfactory recovery and the median time to complete recovery of smell loss. RESULTS: The prevalence of early olfactory recovery was 63.1% (95% CI: 0.58-0.68), and significant associated factors in multivariate analysis included patients without allergic rhinitis (OR 2.22, 95% CI: 1.12-4.40, P = 0.023) and no alteration of taste perception (OR 1.62, 95% CI: 1.02-2.57, P = 0.042). The median time to complete recovery from smell loss was 2 weeks. CONCLUSION: The present study found that the prevalence of early olfactory recovery within 2 weeks was 63.1%. The median time to olfactory recovery was also 2 weeks. Patients without allergic rhinitis and taste alteration had a significantly better chance of early recovery of olfactory function.

Translation and Validation of the Thai Version of the Nasal Obstruction Symptom Evaluation (NOSE) Scale.

Objective: The Nasal Obstruction Symptom Evaluation (NOSE) was developed to evaluate subjective outcomes of patients with deviated nasal septum and symptomatic nasal obstruction. Considering the differences in individuals' cultural, cross-cultural translation, adaptation, and validation of the instrument are necessary. The current study aimed to translate and validate the Thai version of the NOSE Questionnaire for patients with nasal septum deviation. Study Design: A single-center prospective instrument validation study. Setting: Thai tertiary referral center. Methods: The study was conducted to translate and adapt the original English version of the NOSE to Thai. After translating, psychometric testing was conducted. The primary outcomes were validity (content, construct, and discriminant), reproducibility (test-retest procedure), and internal consistency (reliability). A total of 105 participants, of which 46 were patients with nasal airway obstruction and 59 were healthy asymptomatic volunteers, were enrolled in this study. Results: The Thai-NOSE was found to be adequate for all tested psychometric properties with high internal consistency (Cronbach's α = .942), and to discriminate accurately between patients and healthy controls. The interitem and item-total correlations indicated a related construct among all items. A high level of reproducibility of the questionnaire was obtained in the test-retest procedure for each item (γ = 0.898). The initial test and retest scores indicated adequate reproducibility. Conclusion: The Thai-NOSE questionnaire is a reliable instrument with appropriate psychometric properties for assessing the severity and impact of nasal airway obstruction in patients with nasal septum deviation.

Schwannoma Arising in Nasopharynx: A Case Report and Literature Review.

Schwannoma in paranasal sinus has been known as a rare tumor in this origin. This study reports on primary schwannoma arising in the nasopharynx, which is an uncommon location. A 36-year-old female presented with nasal obstruction for one month. Physical examination revealed a nasopharyngeal mass totally occluding bilateral posterior choanae and extended downward to the oropharynx. Magnetic resonance image showed heterogeneous enhancing mass at the nasopharynx extending inferiorly to the oropharynx. The tumor was excised via endoscopic combined trans-nasal/trans-oral approach under general anesthesia. The pathologic diagnosis was consistent with schwannoma. The tumor was successfully excised with en-block resection and the patient was discharged the next day after the operation, without any postoperative complications. There was no tumor recurrence at 12-months follow-up. Schwannoma primarily arising in the nasopharynx is uncommon. Minimally-invasive surgery via the endoscopic approach can be applied for tumor removal with fewer complications and reduced risk of morbidity.

The effect of topical epinephrine 1:1000 with and without infiltration of 1% lidocaine with epinephrine 1:100,000 on endoscopic surgical field visualization: a double-blind randomized controlled study.

BACKGROUND: The objective of this study is to determine whether the infiltration of 1% lidocaine with 1:100,000 epinephrine in addition to topical application of 1:1000 epinephrine significantly improves surgical field grading scale score over topical 1:1000 epinephrine alone. METHODS: A prospective, double-blind, randomized, controlled study was performed of 40 patients undergoing bilateral endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Patients were enrolled and randomly assigned to receive infiltration with 1% lidocaine with 1:100,000 epinephrine on 1 side of the nasal cavity vs plain saline on the other side in preparation for ESS. Both groups received topical application of 1:1000 epinephrine. Surgical videos were recorded and Wormald surgical field grading scale was assigned by 2 blinded reviewers. The number of extra 1:1000 epinephrine pledgets used during the surgery, estimated blood loss, and surgical duration were also recorded. RESULTS: There were no statistically significant differences in Wormald surgical field grading scale, number of extra pledgets used, or estimated blood loss between the nasal cavity side infiltrated with 1% lidocaine with 1:100,000 epinephrine in comparison to infiltration with saline. The side infiltrated with 1% lidocaine with 1:100,000 epinephrine had a reduced operative time compared to the side infiltrated with saline (p = 0.002). There were no differences in postoperative bleeding from questionnaire completed by patient at the first postoperative visit. CONCLUSION: Addition of infiltration of 1% lidocaine with epinephrine 1:100,000 to topical application of epinephrine 1:1000 for preparation of ESS does not significantly improve surgical field of view compared to topical epinephrine alone.

Inferior Meatus Augmentation Procedure (IMAP) to Treat Empty Nose Syndrome: A Pilot Study.

Our understanding of empty nose syndrome (ENS) continues to evolve. Prior studies evaluating airway augmentation to treat ENS did not use validated disease-specific questionnaires, making the true impact of these surgeries unclear. We present a case series of 10 patients with ENS (11 procedures) who underwent the inferior meatus augmentation procedure (IMAP) between September 2014 and May 2017. Subjective outcomes of IMAP included comparisons of preoperative and postoperative assessments (1 week, 1 month, 3 months, 6 months) using the Empty Nose Syndrome 6-item Questionnaire (ENS6Q), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder 7-item Scale (GAD-7), and Sino-Nasal Outcome Test-22 (SNOT-22). The decrement in ENS6Q scores observed maintained statistical significance at 6 months (P ≤ .001). Similar results were achieved with PHQ-9, GAD-7, and SNOT-22 (P ≤ .01, P ≤ .01, P ≤ .001, respectively). IMAP can dramatically improve the quality of life of ENS patients regarding both ENS-specific symptoms and psychological well-being.

The Horizon Sign and Frontal Bar: Two Topographic Landmarks to Confirm Endoscopic Frontal Sinusotomy.

Confirming a thorough dissection of the frontal sinus during endoscopic sinus surgery can be challenging, and some surgeons would benefit from reliable topographic landmark identification to ensure completion of this sinus dissection. We defined (1) the "horizon sign" as the curvilinear shadow of the posterior table cast superiorly upon the anterior table of the frontal sinus at the acute angle of their meeting point and (2) the "frontal bar" as a sagittal septation at the union of the anterior/posterior tables. A cadaveric study, followed by an intraoperative consecutive case series, was performed to evaluate these 2 landmarks as indicators of complete dissection. The horizon sign was extremely reliable, identified in 100% of cadaveric frontal sinuses and intraoperative frontal sinuses. The frontal bar was present in only 67% of frontal sinuses by computed tomography. In live patients, the sensitivity and specificity of the frontal bar were 62% and 95%, respectively.

The Upper Airway Nasal Complex: Structural Contribution to Persistent Nasal Obstruction.

OBJECTIVE: To determine the contribution of the nasal floor and hard palate morphology to nasal obstruction for nonresponders to prior intranasal surgery. STUDY DESIGN: Retrospective case-control study. SETTING: Tertiary academic center. METHODS: Institutional review board-approved, retrospective institutional database analysis was obtained of a cohort of 575 patients who presented with nasal obstruction over a 21-year period. Of the patients, 89 met inclusion criteria: 52 were placed into the experimental group, defined as having persistent nasal obstruction following endoscopic sinus surgery (ESS), septoplasty, nasal valve repair, and/or turbinoplasty using validated subjective questionnaires, and 37 were placed into the control group, defined as having resolution of subjective nasal obstruction. Computed tomography imaging was presented to 3 blinded experts, who measured numerous nasal airway and hard palate morphology parameters, including anterior nasal floor width, anterior maxillary angle, maxilla width, anterior nasal floor width, and palatal vault height. Standard demographic information, comorbidities, perioperative 22-item Sinonasal Outcome Test (SNOT-22), and follow-up time were also assessed. Wilcox rank sum analysis or t test was performed where appropriate. RESULTS: Follow-up ranged from 2 to 36 months following surgical intervention. Several skeletal characteristics within the upper airway were significantly associated with persistent nasal obstruction, including acute maxillary angle (P = .035), narrow maxillary width (P = .006), and high arched palate (P = .004). CONCLUSION: Persistent nasal obstruction may be seen in patients with narrow, high arched hard palate despite prior nasal surgical intervention and may benefit from additional skeletal remodeling procedures such as maxillary expansion.

Comparison of outcomes following culture-directed vs non-culture-directed antibiotics in treatment of acute exacerbations of chronic rhinosinusitis.

BACKGROUND: Acute exacerbations in patients with chronic rhinosinusitis (CRS) are often treated with courses of systemic antibiotics. Poor correlation between microbiologic culture results and the sinus microbiome in CRS has caused increased debate as to the relevance of culture-directed antibiotics. There is currently sparse data comparing outcomes of culture-directed antibiotics vs non-culture-directed antibiotics for treatment of CRS. METHODS: This work reports a retrospective review. A total of 946 CRS patients treated with antibiotics were examined; 122 CRS patients with acute exacerbations were treated with culture-directed (n = 61) vs empiric (n = 61) antibiotics. Lund-Kennedy (LK) and 22-item Sino-Nasal Outcome Test (SNOT-22) scores were compared pretreatment and posttreatment, with short-term (<1 month) and long-term (1-6 months) follow-up. Patient demographics, comorbidities, and prior surgical history were collected. RESULTS: Both groups had similar pretreatment SNOT-22 scores (p = 0.25) while the culture group had higher baseline LK endoscopy scores (p < 0.01). All data were adjusted for pertinent comorbidities, surgical history, co-therapeutics, and baseline scores. There was no difference in improvement in culture-directed and empirically treated groups in the short-term (p = 0.77) and long-term (p = 0.58) for minimal clinically important difference (MCID) of SNOT-22 and no difference in the short-term for LK scores (p = 0.11), but there was significantly more improvement in long-term LK scores in the culture-directed group (p = 0.01). CONCLUSION: Culture-directed therapy improves long-term endoscopy scores but does not yield an advantage in improving short-term endoscopy scores, nor in improving short-term and long-term quality of life scores in CRS patients. A prospective study is necessary to examine the relevance of routine microbiologic cultures in CRS patients.

The prevalence of Eustachian tube dysfunction symptoms in patients with chronic rhinosinusitis.

BACKGROUND: While Eustachian tube dysfunction (ETD) is a known comorbidity of chronic rhinosinusitis (CRS), the prevalence of ETD symptoms in the CRS population is poorly understood. We sought to determine the cross-sectional prevalence of ETD in patients with CRS using the validated Eustachian Tube Dysfunction Questionnaire (ETDQ-7) and to correlate ETDQ-7 scores with 22-item Sino-Nasal Outcome Test (SNOT-22) scores, endoscopy scores, and computed tomography (CT) scores. METHODS: A total of 101 patients with confirmed CRS completed the ETDQ-7 and SNOT-22 at their initial visit to our rhinology clinic. Lund-Mackay CT and Lund-Kennedy endoscopy scores were also obtained. Spearman's correlation coefficient (ρ) was calculated. RESULTS: Among the 101 patients, 49 patients (48.5%) had an ETDQ-7 score of ≥14.5, signifying clinically significant ETD. The mean ± standard deviation (SD) ETDQ-7 score of the entire cohort was 17.8 ± 10.1. There was a moderately strong correlation between ETDQ-7 and the SNOT-22 ear subdomain (ρ = 0.691, p < 0.001). The correlation coefficient between ETDQ-7 and total SNOT-22 scores was ρ = 0.491 (p < 0.001), indicating moderate correlation. ETDQ-7 scores were poorly correlated to objective measures of sinonasal disease, including Lund-Mackay CT score (ρ = -0.055, p = 0.594) and Lund-Kennedy endoscopy score (ρ = -0.099, p = 0.334). CONCLUSION: Symptoms of ETD are highly prevalent among patients with CRS as documented by patient-reported outcome measures. The correlation between ETDQ-7 scores and SNOT-22 ear subdomain scores is moderately strong, while the correlation between ETDQ-7 scores and SNOT-22 scores is moderate. ETD severity does not correlate with CT score or nasal endoscopy score.