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

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

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

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

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

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

Expansion sphincter pharyngoplasty in OSA: a 15 year review.

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

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

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

Evaluation of septal perforation size using a novel measuring device.

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

Palate surgery for obstructive sleep apnea: a 17-year meta-analysis.

OBJECTIVES: Systematic review of palate surgery for the treatment of OSA. METHODS: Independent searches to identify publications relevant to OSA treatment and upper airway palate surgery. All relevant studies published between January 2001 and February 2018 were included. Inclusion criteria were adult patients, documented airway evaluation methods and absent hypopharyngeal collapse. Outcomes included success rates of treatment, AHI, Epworth scale, QOL and snoring VAS. RESULTS: Fifty-nine papers with a total of 2715 patients, UPPP accounted for 16.7% of all the procedures. Evident differentiation progressing from 2001 to 2018, from 2001 to 2010, the percentage of UPPP procedures were 25.67%, from 2011 to 2018, there were only 12.6% of UPPP procedures. The average follow up was 8.18 months. Meta-analysis on the AHI change for all procedures, showed the fixed effect AHI per follow-up (FU) month change was 1.45 (95% CI 1.33, 1.8), p < 0.001; while for ESS, the fixed effect AHI per FU month change was 0.61 (95% CI 0.56, 0.66), p < 0.001. The mean decrease in AHI was from 35.66 to 13.91 (p < 0.001). The mean decrease in ESS was from 11.65 to 5.08 (p < 0.001). The mean AHI change was 19.9 (p < 0.001). The mean ESS change was 5.8 (p < 0.001). The overall pooled success rate was 67.5%. Meta-analysis of the procedures, showed that the respective mean AHI reduction was 24.7 for the anterior palatoplasty (p = 0.015), 19.8 for the lateral/expansion pharyngoplasty (p = 0.046), and 17.2 for the uvulopalatopharyngoplasty (p = 0.360). CONCLUSIONS: Better understanding of the upper airway and objective airway evaluation diagnostic techniques and innovative palate surgeries have improved success rates of OSA surgery.

Fulminant bilateral papilloedema during low-dose steroid taper in a child with systemic idiopathic arthritis treated with tocilizumab.

Systemic juvenile idiopathic arthritis (SJIA) is one of the most severe forms of arthritis that affects children younger than 16 years of age at onset. SJIA often requires corticosteroids to control the inflammation. However, long-term corticosteroid use may have adverse effects, including intracranial hypertension (IH). Biologic therapies have been used as corticosteroid sparing agents. We report the first case of a child with steroid-dependent SJIA treated with tocilizumab, an IL-6 receptor monoclonal antibody, who developed fulminant IH, bilateral papilloedema and vision loss when oral prednisone was weaned from 2 to 1 mg per day. Despite repeated lumbar punctures and high dose acetazolamide, he required urgent unilateral optic nerve sheath fenestration (ONSF). This endoscopic surgical intervention released the pressure exerted by the cerebrospinal fluid on the optic nerve and stopped the progression of vision loss. Nine weeks after the diagnosis of bilateral papilloedema, his vision was completely restored in one eye and partially recovered in the contralateral one. Long-term treatment with corticosteroids even at very low dose and tocilizumab may predispose to severe IH, papilloedema and vision loss. The role that tocilizumab might have played in this case in unclear. Early recognition and prompt treatment of papilloedema is crucial in avoiding permanent vision loss. Fulminant papilloedema in an immunocompromised child carries additional significant challenges. Early ONSF is a safe and effective intervention in refractory papilloedema. Children with severe papilledema secondary to IH should be managed by a multidisciplinary team in tertiary centres.

Impact of nasal surgery on speech resonance.

OBJECTIVES: The nose and paranasal sinuses contribute to speech resonance and changes to these structures may alter speech nasality. This change may influence one's vocational and social functioning and quality of life. Our investigation explored objective and subjective changes in nasality following nasal surgery in a prospective and longitudinal fashion. METHODS: Recordings of sustained vowel and sentence stimuli and voice-related quality of life measurements were obtained preoperatively and at 2, 4, 8, and 24 weeks postoperatively from individuals undergoing nasal and/or sinus surgery. Objective measures of fundamental frequency, jitter, shimmer, and harmonic to noise ratio (HNR) were determined. Pre- and postoperative speech samples were assessed by 15 naïve listeners. RESULTS: In all, 15 subjects completed the study. Neither speakers nor listeners perceived a subjective change in nasality following surgery. No statistically significant change in microacoustic measures were identified. Although nasal sentences did not reveal differences for 3 microacoustic measures, a difference in HNR was identified. CONCLUSIONS: Patients undergoing nasal surgery did not exhibit subjective changes in resonance postoperatively. Aside from a difference in HNR for the nasal sentence, objective microacoustics remained unchanged. These results demonstrate the stability of oranasal resonance despite nasal surgery and provide valuable data for patient informed decision-making.

Postoperative nasal debridement after endoscopic sinus surgery: a randomized controlled trial.

OBJECTIVES: Postoperative debridement is a controversial subject in the rhinology literature. The objective of this randomized controlled trial was to determine the effect of regular debridement versus no debridement on disease-specific outcomes and patient inconvenience. METHODS: Patients with chronic rhinosinusitis with polyposis who were to undergo basic sinus surgery (antrostomy, ethmoidectomy, and polypectomy) were randomized to either debridement (at postoperative weeks 2 and 4) or no debridement, and their outcomes were assessed at 4 weeks and at 6 months with the Lund-Kennedy Endoscopic Score (LKES), the Sino-Nasal Outcome Test-21 (SNOT-21), a visual analog scale for postoperative pain, and a novel scoring system for postoperative inconvenience (Post-Operative Inconvenience Scale; POIS). All patients were instructed to use high-volume saline rinses twice daily. RESULTS: At 4 weeks after operation, there was no difference between the groups in regard to LKESs (control group, 2.1 of 20; debridement group, 2.4 of 20; p = 0.59) or SNOT scores (control group, 9.1; debridement group, 8.3; p = 0.47). The visual analog scale pain scores showed significance (control group, 19 mm; debridement group, 38 mm; p = 0.019), as did the POIS scores (control group, 18.3; debridement group, 6.1; p = 0.002). At 6 months after surgery, again no difference was seen between the groups on either LKESs or SNOT scores. CONCLUSIONS: In our patient population, debridement after surgery did not affect disease-specific outcomes.

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

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

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

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

Functional outcomes after lateral crural J-flap repair of external nasal valve collapse.

OBJECTIVES: We evaluated the lateral crural J-flap technique in the surgical repair of external nasal valve collapse with standardized and validated outcome measurements. METHODS: Prospective data were gathered on consecutive cases, performed by a single surgeon between 2007 and 2010, of adult patients who underwent a lateral crural approach to repair of external nasal valve collapse. Data were collected on diagnosis, surgical outcomes, and complications. Outcome measures included the Nasal Obstructive Symptom Evaluation and the Rhinoplasty Outcome Evaluation. RESULTS: Fifteen patients were included in the study. Their follow-ups ranged from 9 to 13 months. All patients had statistically significant improvements in Nasal Obstructive Symptom Evaluation scores. There was no significant change in perceived nasal appearance after surgery as measured by the Rhinoplasty Outcome Evaluation. There were no surgical complications. CONCLUSIONS: The lateral crural J-flap approach to repair of external nasal valve collapse is a technically straightforward and relatively safe procedure. The efficacy is excellent at the 1-year follow-up examination.

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

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

Comparison of purified plant polysaccharide (HemoStase) versus gelatin-thrombin matrix (FloSeal) in controlling bleeding during sinus surgery: a randomized controlled trial.

OBJECTIVES: Purified plant polysaccharide (HemoStase) is a plant-derived hemostatic agent that has not previously been used in sinus surgery. This study was conducted to evaluate the effectiveness of this novel agent in the control of nasal bleeding during endoscopic sinus surgery. The volume of bleeding during endoscopic sinus surgery was hypothesized to not be statistically significantly different between a control group (gelatin-thrombin matrix; FloSeal) and an experimental group (purified plant polysaccharide; HemoStase). METHODS: Eighteen patients with a history of chronic rhinosinusitis in whom maximal medical therapy failed who underwent endoscopic sinus surgery were randomized into one of two groups (control FloSeal group or experimental HemoStase group). In the control group, sites in the nose that were actively bleeding during the operation were controlled with FloSeal. In the experimental group, sites in the nose that were actively bleeding during the operation were controlled with HemoStase. The main outcome measure was total operative blood loss. Blood loss was the sum of blood removed by suction during the surgery (recorded in milliliters) and blood on surgical sponges (weighed and converted to milliliters). Statistical analysis was performed with the t-test and the Mann-Whitney U test. RESULTS: The amounts of blood loss (mean +/- SEM) were not significantly different between the FloSeal (262 +/- 15 mL) and HemoStase (265 +/- 33 mL) groups (p = 0.93). CONCLUSIONS: The results of this study demonstrate the use of a novel product for the control of intraoperative bleeding during endoscopic sinus surgery.

Revision rates after endoscopic sinus surgery: a recurrence analysis.

OBJECTIVES: Chronic rhinosinusitis with nasal polyposis is often refractory to medical and surgical management, especially in patients with asthma and aspirin intolerance. We used a contemporary database to investigate recurrence and revision surgery rates following endoscopic sinus surgery. METHODS: We performed a cohort study using a survival analysis technique. Records were reviewed of 549 patients with nasal polyposis who underwent endoscopic sinus surgery over a 10-year period. The main outcome measure was disease-free and surgery-free survival following endoscopic sinus surgery, investigated with Kaplan-Meier analyses. RESULTS: Patients with Samter's triad were significantly more likely to have a recurrence and undergo a second surgery following recurrence (risk-odds ratio, 2.7; 95% confidence interval, 1.5 to 3.2; p < 0.01) than were patients without asthma or with only asthma from the triad. The presence of initial frontal sinus disease also increased the likelihood of revision surgery (risk-odds ratio, 1.6; 95% confidence interval, 1.2 to 1.8; p < 0.05). CONCLUSIONS: This is the first study to use survival analysis to document revision surgery rates following endoscopic sinus surgery. Revision surgery occurs at a high rate, especially in patients with asthma, Samter's triad, or frontal sinus disease. Patients should routinely be informed during clinical consultations about the likelihood of recurrence. Early intervention for frontal sinus disease may be considered.