Olfactory dysfunction management following unilateral cranial resection for olfactory neuroblastoma.

BACKGROUND: Despite advances in techniques for olfactory neuroblastoma (ONB), such as unilateral cranial resection, preserving the patient's sense of smell remains a challenge. This study aimed to examine the effectiveness of post-operative olfactory training in patients who underwent unilateral resection of ONB. METHODS: This retrospective cohort study assessed the effect of post-operative olfactory training on olfactory preservation in patients with ONB undergoing unilateral cranial resection. Patients were divided into training intervention (n = 5) and non-intervention (n = 6) groups. Olfactory tests were conducted pre-operatively and at multiple post-operative intervals. RESULTS: Partial olfactory function was preserved in all cases in the training intervention group, whereas only 17% of cases in the non-intervention group maintained partial olfactory function. Significant improvements in olfactory test scores were observed in the training intervention group compared with the non-intervention group. CONCLUSIONS: Our findings suggest that post-operative olfactory training could aid in olfactory preservation for patients with ONB after unilateral cranial resection. However, these results should be interpreted with caution, and further research with larger cohorts and extended follow-up periods is needed to confirm these observations.

Pre-asthma: a useful concept? A EUFOREA paper. Part 2-late onset eosinophilic asthma.

The concept of pre-diabetes has led to provision of measures to reduce disease progression through identification of subjects at risk of diabetes. We previously considered the idea of pre-asthma in relation to allergic asthma and considered that, in addition to the need to improve population health via multiple measures, including reduction of exposure to allergens and pollutants and avoidance of obesity, there are several possible specific means to reduce asthma development in those most at risk (pre- asthma). The most obvious is allergen immunotherapy (AIT), which when given for allergic rhinitis (AR) has reasonable evidence to support asthma prevention in children (2) but also needs further study as primary prevention. In this second paper we explore the possibilities for similar actions in late onset eosinophilic asthma.

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.

EPOS/EUFOREA update on indication and evaluation of Biologics in Chronic Rhinosinusitis with Nasal Polyps 2023.

Severe chronic rhinosinusitis with nasal polyps (CRSwNP) is a debilitating disease with a significant impact on the quality of life (QoL). It is typically characterized by a type 2 inflammatory reaction and by comorbidities such as asthma, allergies and NSAID-Exacerbated Respiratory Disease (N-ERD). Here, the European Forum for Research and Education in Allergy and Airway diseases discusses practical guidelines for patients on biologic treatment. Criteria for the selection of patients who would benefit from biologics were updated. Guidelines are proposed concerning the monitoring of the drug effects that provide recognition of responders to the therapy and, subsequently, the decision about continuation, switching or discontinuation of a biologic. Furthermore, gaps in the current knowledge and unmet needs were discussed.

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.

Pre-asthma: a useful concept for prevention and disease-modification? A EUFOREA paper. Part 1-allergic asthma.

Asthma, which affects some 300 million people worldwide and caused 455,000 deaths in 2019, is a significant burden to suffers and to society. It is the most common chronic disease in children and represents one of the major causes for years lived with disability. Significant efforts are made by organizations such as WHO in improving the diagnosis, treatment and monitoring of asthma. However asthma prevention has been less studied. Currently there is a concept of pre- diabetes which allows a reduction in full blown diabetes if diet and exercise are undertaken. Similar predictive states are found in Alzheimer's and Parkinson's diseases. In this paper we explore the possibilities for asthma prevention, both at population level and also investigate the possibility of defining a state of pre-asthma, in which intensive treatment could reduce progression to asthma. Since asthma is a heterogeneous condition, this paper is concerned with allergic asthma. A subsequent one will deal with late onset eosinophilic asthma.

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.

A computational fluid dynamics analysis of the effects of size and shape of anterior nasal septal perforations.

BACKGROUND: Nasal septal perforations (NSPs) often cause bleeding, crusting, obstruction, and/or whistling. The objective was to analyze the impact of anterior NSP size and shape on nasal physiology using computational fluid dynamics (CFD). METHODS: A 3-dimensional model of the nasal cavity was constructed from a radiologically normal CT scan using imaging software. Anterior NSPs (ovoid (ONSP): 0.5, 1, 2, and 3 cm long anterior-to-posteriorly and round (RNSP, 0.5 and 1 cm)) were virtually created in the model and divided into ventral, dorsal, anterior, and posterior regions. Steady-state inspiratory airflow, heat, and water vapor transport were simulated using Fluent CFD software. Air crossover through the perforation, wall shear, heat flux, water vapor flux, resistance, and humidification were analyzed. RESULTS: Air crossover and wall shear increased with perforation size. Regionally, wall shear and heat and water vapor flux were highest posteriorly and lowest anteriorly, generally increasing with size in those regions. RNSPs had greater heat and water vapor flux compared to corresponding size ONSPs. Resistance decreased by 10% or more from normal only in the 3 cm ONSP. Maximum water content was achieved more posteriorly in larger NSP nasal cavities. CONCLUSIONS: High wall shear and heat and water vapor flux in posterior perforation regions may explain the crusting most commonly noted on posterior NSP edges. This preliminary study suggests that larger NSPs have a greater effect on nasal resistance and water content. Decrease in resistance with larger NSP size may be implicated in reported symptomatic improvement following enlargement of NSPs for treatment.

Self-reported anxiety and depression unchanged after endoscopic sinus surgery for chronic rhinosinusitis.

BACKGROUND: Prior research has established that anxiety and depression, as measured by the Hospital Anxiety Depression Score (HADS), are strongly correlated with disease-specific quality of life (Rhinosinusitis Disability Index - RSDI) in chronic rhinosinusitis (CRS). We hypothesized that anxiety and depression would decrease after functional endoscopic sinus surgery (FESS), and furthermore that HADS would predict improvement in RSDI following surgery. METHODOLOGY: The study cohort from 2014 consisted of 99 CRS patients who underwent nasal endoscopy, RSDI, and HADS evaluation. The cohort was segregated by whether or not they underwent FESS and an updated HADS was administered. For 44 surgical patients, pre- and post-operative RSDI (n=38), Lund-Kennedy (LK) (n=34) and HADS (n=18) scores were compared. Delta RSDI was compared between patients with varying levels of anxiety and depression. RESULTS: Lund-Kennedy scores improved from 5.8 ± 4.1 to 3.2 ± 2.6 following surgery, as did total RSDI (39.3 ± 26.8 to 24.6 ± 29.2). Total HADS (9.8 ± 6.4 to 11.3 ± 7.4) and depression and anxiety subscores were unchanged. Linear regression did not reveal a correlation between HADS and change in RSDI following FESS. Delta RSDI was not significantly different between patients with varying levels of anxiety and depression. CONCLUSIONS: Despite improvements in objective evidence of sinonasal inflammation (LK) and disease-specific quality of life (RSDI), neither depression nor anxiety improved after FESS, nor did the magnitude of psychological comorbidity predict post-operative improvement in quality of life. Improvement in RSDI was not different among patients with varying levels of anxiety and depression. Levels of depression and anxiety may be hard-wired, and therefore not influenced by changes in objective or perceived sinonasal disease burden.

A computational study of functional endoscopic sinus surgery and maxillary sinus drug delivery.

BACKGROUND: Topical medication is increasingly used following functional endoscopic sinus surgery (FESS). Information on particle sizes that maximise maxillary sinus (MS) delivery is conflicting, and the effect of antrostomy size on delivery is unclear. The purpose of this study was to estimate antrostomy and particle size effects on topical MS drug delivery. METHODOLOGY: Sinonasal reconstructions were created from a pre- and a post-FESS CT scan in each of four chronic rhinosinusitis patients. Additional models were created from each post-FESS reconstruction representing four alternative antrostomy sizes. Airflow and particle deposition were simulated in each reconstruction using computational fluid dynamics for nebulised and sprayed delivery. RESULTS: MS ventilation and drug delivery increased following FESS, the largest virtual antrostomy led to greatest delivery, and MS delivery was sensitive to particle size. Particles within a 5-18 µm and 5-20 µm size range led to peak MS deposition for nebulised and sprayed particles, respectively. Post-FESS increases in drug delivery varied across individuals and within individuals by the type of antrostomy created. CONCLUSION: Our findings suggest that FESS, particularly with larger antrostomies, improves topical drug delivery, and that certain particle sizes improve this delivery. Further research is needed to contextualise these findings with other post-surgical effects.

Elevated levels of IgM and IgA antibodies to Proteus mirabilis and IgM antibodies to Escherichia coli are associated with early rheumatoid factor (RF)-positive rheumatoid arthritis.

OBJECTIVE: Antibodies to Proteus mirabilis were previously detected in patients with established rheumatoid arthritis (RA). We examined the prevalence of antibodies to P. mirabilis and their associations with RA in early synovitis patients. METHODS: Two hundred and forty-six patients with inflammatory arthritis for less than 1 yr were prospectively evaluated for 1 yr. Of these patients, 30% had rheumatoid factor (RF)-positive RA, 16% RF-negative RA, 17% a spondyloarthropathy and 37% undifferentiated arthritis. Serum antibodies to P. mirabilis, Escherichia coli and other potentially arthritogenic organisms (Chlamydia, Salmonella, Shigella, Campylobacter, Yersinia and parvovirus B19) and for antibodies specific for immunoglobulin (Ig) G damaged with advanced glycation end-products (anti-IgG-AGE) were measured. RESULTS: IgM and IgA anti-Proteus antibodies were significantly higher in patients with RF-positive RA compared with all other patient groups (P < 0.0005 and P < 0.005). Anti-P. mirabilis IgG, and IgG, IgA, and IgM antibodies to other potentially arthritogenic pathogens did not differ in the patient groups. IgM antibodies to E. coli were elevated in RF-positive RA patients. Anti-P. mirabilis IgM and IgA results were not explained by false-positive reactions, because after absorption of RF there was no decrease in antibodies to Proteus in 10 of 12 patients. Proteus and E. coli antibodies were highest in patients positive for both RF and anti-IgG-AGE antibodies (P<0.001). Patients with erosions tended to have higher IgA anti-Proteus titres, but no association with the shared HLA epitope or treatment was detected. CONCLUSION: Anti-P. mirabilis IgM and IgA and anti-E. coli IgM antibody elevations are associated with early seropositive RA and the presence of anti-IgG-AGE antibodies. The role that P. mirabilis or E. coli plays in early RF-positive RA requires further investigation.

Amino acid sequence requirements in the human IgA1 hinge for cleavage by streptococcal IgA1 proteases.

All the IgA1 proteases of the different pathogenic species of Streptococcus cleave the hinge of the alpha chain of human IgA1 only at one proline-threonine peptide bond. In order to study the importance of these amino acids for cleavage, several hinge mutant recombinant IgA1 antibodies were constructed. The mutations were found to be without major effect upon the structure or functional abilities of the antibodies. However, they had a major effect upon their sensitivity to cleavage by some of the IgA1 proteases.

Cleavage of the hormone human chorionic gonadotropin, by the Type 1 IgA1 protease of Neisseria gonorrhoeae, and its implications.

The hormone human chorionic gonadotropin (hCG) serves to maintain the fetus during early pregnancy and regulate the onset of labor in late pregnancy. hCG also prevents Neisseria gonorrhoeae from developing invasive characteristics. Part of the beta subunit of hCG has an amino acid sequence similar to that of the hinge of human IgA1, which is the site of action of IgA1 proteases. This study examined the sensitivity of hCG to gonococcal IgA1 proteases, by means of autoradiography, immunoblotting, and RIA. hCG was cleaved in the beta subunit by the type 1 but not the type 2 IgA1 proteases of N. gonorrhoeae. hCG cleavage by gonococcal IgA1 proteases in vivo may increase the invasiveness of the pathogen and destroy its natural biologic activity, with major consequences for the fetus and the pregnancy.

Benign lesions of the frontal sinus.

Benign tumors of the frontal sinus including fibro-osseous lesions and inverted papillomata present unique problems for the rhinologist. Because of the bony cavity surrounding the frontal sinus and relatively small portal into the nose, conventional techniques including the osteoplastic flap, frontal trephination, and lynch procedure have provided useful approaches to these tumors. The advent of endoscopic techniques in the management of chronic inflammatory disease of the paranasal and, specifically, frontal sinuses, has led to these traditional techniques being augmented successfully, and, in some cases, surpassed by newer endoscopic techniques. This article reviews the diagnosis and management of the two most common types of benign tumors of the frontal sinus, bony tumors and inverted papillomata, with emphasis on the usefulness of the endoscope in managing such lesions.

Use of the Rhinosinusitis Disability Index (RSDI) in rhinologic disease.

Chronic rhinosinusitis has been shown to have an adverse impact on the quality of life in those afflicted as determined by a number of standardized outcome tools. We have utilized a standardized, statistically validated, disease-specific tool, the Rhinosinusitis Disability Index (RSDI), to investigate the disability suffered by 292 consecutive patients with nine unique rhinologic diagnoses, including chronic rhinosinusitis. Physical, functional, and emotional domains were assessed. We have found that individuals with rhinologic disease in general have lower physical scores, followed by functional scores and emotional scores. Individuals with chronic rhinosinusitis and allergic rhinitis have the greatest level of disability, while those with aspirin triad are least affected.

Safety and efficacy of endoscopic repair of CSF leaks and encephaloceles: a survey of the members of the American Rhinologic Society.

The purpose of this article is to review the endoscopic management of cerebrospinal fluid (CSF) leaks and encephaloceles, with particular emphasis on safety and efficacy, by retrospective assessment utilizing the results of a mailed questionnaire. Surveys were mailed to members of the American Rhinologic Society with practices in both academic centers and/or private settings. Survey results were then assessed and tabulated. There were 635 mailings, with 197 responses (31%). Seventy-two (36% of respondents) indicated that they performed endoscopic management of CSF leaks and encephaloceles, while 125 (64% of respondents) did not. Respondents reported approximately 522 cases of CSF leaks and approximately 128 cases of encephaloceles managed by endoscopy. Success rates after a single procedure were estimated at 90% for CSF leaks and 93% for encephaloceles. Success rates after a secondary procedure were estimated at 86% and 97%, respectively; 29% of respondents have, at some point, made a referral to neurosurgery. A total of 13 complications related to endoscopic repairs were reported (2.5%). For CSF leak repair, complications included seizures, 0.2%; meningitis, 1.1%; and one reported case each of cavernous sinus thrombosis, temporary visual problems, sinusitis, and intracranial hypertension/bleed. There was only one reported death in the approximately 522 cases. Eleven complications following encephalocele repairs (8.5%) included seizures, 3.1%; meningitis, 2.3%; and one reported case each of brain abscess, sinusitis, false aneurysm of middle cerebral artery, and mild dizziness. No deaths following encephalocele repair were reported. The endoscopic management of CSF leaks and encephaloceles has become increasingly popular and has proven to have low morbidity and mortality with high success. Overall, our results confirm that in the hands of the skilled endoscopist, endoscopic management of CSF leaks and encephaloceles is highly efficacious and has a very low incidence of significant complication.

Gastroesophageal reflux and obstructive sleep apnea.

OBJECTIVE: To determine the extent to which gastroesophageal reflux (GER)-initiated laryngeal chemoreflexes contribute to obstructive sleep apnea (OSA). METHODS: Prospective, nonrandomized clinical trial of an antireflux treatment protocol as a means of reducing the severity of OSA. Population consisted of 10 males aged 20 to 64 years with confirmed OSA (by overnight polysomnography) and GER (by ambulatory pH probe monitoring). Patients were treated with omeprazole and standard antireflux protocol for 30 days and pre- and posttreatment polysomnography variables were compared. RESULTS: Mean apnea index declined 31% (45-31, P = .04); mean respiratory disturbance index declined 25% (62-46, P = .06). Three patients (30%) are "treatment responders" as defined by traditional OSA treatment definitions. CONCLUSIONS: These results suggest a potential relationship between OSA and GER, the treatment of which may be an effective adjunctive in those with both disorders. Treatment of GER may significantly impact OSA in select individuals.

Quantitative impact of pediatric sinus surgery on facial growth.

OBJECTIVE/HYPOTHESIS: To quantitatively evaluate the long-term impact of sinus surgery on paranasal sinus development in the pediatric patient. STUDY DESIGN: Longitudinal review of eight pediatric patients treated with unilateral sinus surgery for periorbital or orbital cellulitis with an average follow-up of 6.9 years. Control subjects consisted of two groups, 9 normal adult patients with no computed tomographic evidence of sinusitis and 10 adult patients with scans consistent with sinusitis and a history of sinus-related symptoms extending to childhood. METHODS: Application of computed tomography (CT) volumetrics, a technique allowing for precise calculation of volumes using thinly cut CT images, to the study and control groups. RESULTS: Paired Student t test analyses of side-to-side volume comparisons in the normal patients, patients with sinusitis, and patients who had surgery revealed no statistically significant differences. Comparisons between the orbital volumes of patients who did and did not have surgery revealed a statistically significant increase in orbital volume in patients who had surgery. CONCLUSIONS: Only minimal changes in facial volume measurements have been found, confirming clinical impressions that sinus surgery in children is safe and without significant cosmetic sequelae.

Efficacy of uvulopalatopharyngoplasty in unselected patients with mild obstructive sleep apnea.

OBJECTIVES: Uvulopalatopharyngoplasty (UPPP) is widely used as a first-step procedure for the surgical management of obstructive sleep apnea (OSA) syndrome but best manages obstruction occurring at the level of the oropharynx alone and not the hypopharynx. Previous publications have noted mediocre results with use of this procedure in unselected patients with OSA, but less clear is the effectiveness of this procedure in the unselected patient with mild OSA (respiratory event index [REI] 5-25). Using objective and subjective criteria, we retrospectively analyzed the results of UPPP in patients with mild OSA. METHODS: We examined 37 patients with mild OSA (REI 13.5 +/- 5.1, range 5.6-23.1) who had been operated on during 1996 with UPPP with or without tonsillectomy and/or septoplasty. Follow-up polysomnography was obtained in 25 (68%) an average of 40.5 weeks after surgery and compared with findings before surgery. Subjective assessment of sleepiness was performed with the Sleep-Wake Activity Inventory. RESULTS: Ten patients (40%) had a postoperative reduction in the REI of more than 50%, comparable with the improvements reported in those with more severe apnea. Those who did not have a reduction in REI after surgery actually saw an increase in average REI from 16.6 +/- 5 to 26.7 +/- 18.4. Similarly, subjective assessment of sleepiness with the Sleep-Wake Activity Inventory showed no statistically significant improvement after surgery. CONCLUSION: Overall, these results indicate that UPPP alone in the unselected patient provides little benefit in the management of mild OSA, similar to findings for more severe OSA. Surgeons must use great care in discerning the level of obstruction in the patient with mild OSA to tailor the appropriate retropalatal and/or retrolingual procedures and thereby achieve excellent surgical outcomes.