Surgical management of rhinosinusitis for the allergist-immunologist.

Chronic rhinosinusitis (CRS) is a common chronic inflammatory disease characterized by inflammation of the sinus, with or without nasal passage inflammation, occurring for more than 12 weeks at a time. CRS has historically been classified in 2 categories: CRS without nasal polyps or CRS with nasal polyps (25%-30% of cases). The mainstay of treatment for CRS with or without nasal polyps is medical management, and options may include a combination of saline irrigation, nasal steroids, allergy medications, antibiotics, oral steroids, and treatment with targeted monoclonal antibodies. Unfortunately, up to 60% of patents report symptoms refractory to maximal medical therapy. As such, a combined approach of surgery and medical therapy may be offered. Endoscopic sinus surgery for CRS is approached in a stepwise fashion, ranging from the simplest technique, such as polyp removal, to more expanded approaches that open the paranasal sinuses and allow gravity-dependent drainage. This review article provides a review and in-depth explanation of various surgical approaches for CRS, including the indications, techniques, and respective outcomes for each one.

Quality-of-life assessment in dementia: the use of DEMQOL and DEMQOL-Proxy total scores.

PURPOSE: There is a need to determine whether health-related quality-of-life (HRQL) assessments in dementia capture what is important, to form a coherent basis for guiding research and clinical and policy decisions. This study investigated structural validity of HRQL assessments made using the DEMQOL system, with particular interest in studying domains that might be central to HRQL, and the external validity of these HRQL measurements. METHODS: HRQL of people with dementia was evaluated by 868 self-reports (DEMQOL) and 909 proxy reports (DEMQOL-Proxy) at a community memory service. Exploratory and confirmatory factor analyses (EFA and CFA) were conducted using bifactor models to investigate domains that might be central to general HRQL. Reliability of the general and specific factors measured by the bifactor models was examined using omega (ω) and omega hierarchical (ω h) coefficients. Multiple-indicators multiple-causes models were used to explore the external validity of these HRQL measurements in terms of their associations with other clinical assessments. RESULTS: Bifactor models showed adequate goodness of fit, supporting HRQL in dementia as a general construct that underlies a diverse range of health indicators. At the same time, additional factors were necessary to explain residual covariation of items within specific health domains identified from the literature. Based on these models, DEMQOL and DEMQOL-Proxy overall total scores showed excellent reliability (ω h > 0.8). After accounting for common variance due to a general factor, subscale scores were less reliable (ω h < 0.7) for informing on individual differences in specific HRQL domains. Depression was more strongly associated with general HRQL based on DEMQOL than on DEMQOL-Proxy (-0.55 vs -0.22). Cognitive impairment had no reliable association with general HRQL based on DEMQOL or DEMQOL-Proxy. CONCLUSIONS: The tenability of a bifactor model of HRQL in dementia suggests that it is possible to retain theoretical focus on the assessment of a general phenomenon, while exploring variation in specific HRQL domains for insights on what may lie at the 'heart' of HRQL for people with dementia. These data suggest that DEMQOL and DEMQOL-Proxy total scores are likely to be accurate measures of individual differences in HRQL, but that subscale scores should not be used. No specific domain was solely responsible for general HRQL at dementia diagnosis. Better HRQL was moderately associated with less depressive symptoms, but this was less apparent based on informant reports. HRQL was not associated with severity of cognitive impairment.

Oral corticosteroid use and the risk of developing avascular necrosis: A large retrospective review.

INTRODUCTION: The risk of adverse events, specifically avascular necrosis (AVN), associated with corticosteroid use is not well reported. The aim of this study was to evaluate the prevalence of AVN among patients with prior oral corticosteroid administration. METHODS: An institutional database query recognized 113,734 adult patients with oral corticosteroid administration between January 2006 and May 2017. A temporal query performed on this cohort determined that 789 had a diagnosis of AVN following oral corticosteroids. A retrospective review was performed on this cohort. Data collected included demographics, comorbidities, date of initial oral corticosteroid exposure, and time to diagnosis of AVN. Records without radiographic confirmation of AVN were excluded from analysis. Patients with cumulative lifetime dosages greater than 10,000 mg prednisone were excluded from analysis. RESULTS: A total of 789 patients with oral corticosteroid use prior to diagnosis of AVN were identified. Five hundred and seventy-two patients were excluded due to insufficient documentation of oral corticosteroid dosage, no radiographic evidence supporting the diagnosis of AVN, insufficient data confirming the temporal relationship between oral corticosteroids and AVN, and/or a cumulative dosing of >10,000 mg prednisone. This left 217 patients included in the analysis. The mean duration of use prior to diagnosis of AVN was 219 (± 374) days, and mean cumulative dose was 3314 (± 2908) mg prednisone equivalents. Mean time between diagnosis of AVN and onset of pathologic fracture was 379 (± 1046) days. CONCLUSION: For patients receiving low cumulative doses of oral corticosteroids, corticosteroids pose a small risk of development of AVN. More studies are required to better characterize risk.

Objective sleep measures after endoscopic sinus surgery in patients with chronic rhinosinusitis.

BACKGROUND: Poor sleep quality is common in chronic rhinosinusitis (CRS). Prior studies have demonstrated improvements in patient-reported measures of sleep quality following endoscopic sinus surgery (ESS). The purpose of this study was to evaluate the effect of ESS on objective sleep parameters and identify any associations between specific objective measures and patient characteristics, comorbidities, and patient-reported outcome measures (PROMs). METHODS: Adults with CRS undergoing ESS were prospectively enrolled from 4 centers across North America. Any subject previously diagnosed with a known primary sleep disorder was excluded. Objective sleep indices were recorded using a portable sleep diagnostic device preoperatively and postoperatively. Patient-reported outcome instruments were completed including the Pittsburgh Sleep Quality Index (PSQI) and the 22-item Sino-Nasal Outcome Test (SNOT-22). RESULTS: Thirty-six patients (mean age 47 years, 56% male) completed baseline and postoperative sleep studies with mean ± standard deviation (SD) follow-up 9.6 ± 7.7 months. Mean PSQI and SNOT-22 before and after ESS was 10.2 ± 3.9 vs 7.8 ± 4.4 (p = 0.001); and 54.6 ± 14.6 vs 28.5 ± 15.3 (p < 0.001), respectively. Total sleep time, sleep latency, and awakenings after sleep onset did not change following ESS (all p > 0.5) despite improvements in PSQI and SNOT-22. Changes in PSQI did not correlate with comorbidities or objective sleep indices (all p > 0.1). CONCLUSION: In this multicenter prospective cohort, objective sleep indices were not improved following ESS for CRS despite significant improvements in patient-reported sleep quality and CRS-specific QOL.

Disease control after surgery for chronic rhinosinusitis: prospective, multi-institutional validation of the Sinus Control Test.

BACKGROUND: The Sinus Control Test (SCT) is a 4-question, patient-reported questionnaire that assesses disease control in chronic rhinosinusitis (CRS). This prospective, multicenter study examines SCT outcomes following endoscopic sinus surgery (ESS), further validating its use as a control instrument for CRS. METHODS: Adults with CRS undergoing ESS were prospectively enrolled from 5 centers across North America. The SCT was administered at baseline and once 6 months after surgery. Quality of life and disease burden were evaluated using the 22-item Sino-Nasal Outcome Test (SNOT-22) and Lund-Kennedy endoscopy scores. Linear regression was used to determine whether specific demographic, comorbidity, or disease severity measures were independently associated with changes in SCT scores postoperatively. RESULTS: A total of 218 patients, 111 females (50.9%) and 107 males (49.1%), were enrolled, with mean ± standard deviation age of 50.1 ± 15.6 years. Mean SCT score improved from 8.9 ± 3.5 to 4.3 ± 3.7 postoperatively (p < 0.001). Preoperatively, 21.6% were uncontrolled, 71.5% partially controlled, and 6.9% controlled. Postoperatively, 6.0% were uncontrolled, 42.6% partially controlled, and 51.4% controlled (p < 0.001). Change in SCT score correlated independently with change in SNOT-22 (r = 0.500, p < 0.001) and endoscopy scores (r = 0.310, p < 0.001). Endoscopy scores did not correlate with control status among patients with CRS without nasal polyposis (CRSsNP) nor between uncontrolled and partially controlled patients. Demographics and comorbidities were not associated with changes in SCT. CONCLUSION: Improvement in disease control following ESS as measured by the SCT correlated with improvements in SNOT-22 and endoscopy scores. The SCT is an easily administered instrument that provides information complementary to existing patient-reported and objective measures of disease severity.

Evaluating the Relationship Between Olfactory Function and Loneliness in Community-Dwelling Individuals: A Cross-sectional Study.

BACKGROUND: Olfactory dysfunction (OD) has been reported to impact social interactions. However, the relationship between OD and loneliness has received little attention. The purpose of this study was to determine the association between OD and loneliness, controlling for patient factors. METHODS: Subjects without otolaryngic complaints were enrolled and olfactory function was assessed using: Sniffin' Sticks test to measure threshold, discrimination and identification (TDI), Questionnaire of Olfactory Disorders Negative Statements (QOD-NS) and 9 - item Olfactory-Visual Analogue Scale (VAS). Loneliness was assessed using the De Jong Gierveld (DJG) and University of California Los Angeles (UCLA) loneliness scales. Bivariate analysis was performed followed by regression analysis, controlling for confounders. RESULTS: In total, 221 subjects were included with a mean age of 50.5 years (range 20 to 93), 133 (60.2%) females and 161 (72.9%) white. Mean TDI score was 29.3 (7.0) and 49.5% of the cohort was dysosmic. Using DJG, 36.4% of the cohort were classified as lonely, whereas 35.0% were lonely using UCLA. Olfactory measures were significantly associated with DJG, including TDI (ß = -0.03, p = 0.050), olfactory discrimination (ß = -0.111, p = 0.005), QOD-NS (ß = 0.058, p < 0.001) and olfactory-VAS (ß = 0.032, p < 0.001). UCLA scores were significantly associated with QOD-NS (PR 1.061 [CI 1.018-1.107], p = 0.005) and olfactory-VAS scores (PR 1.027, [CI 1.007-1.049], p = 0.009). After controlling for confounders, the association between DJG and olfactory discrimination, as well as DJG and olfactory-VAS remained significant. CONCLUSIONS: In this community-based sample of older adults, both OD and loneliness were common. Those subjects with worse olfactory function were more likely to report loneliness. Further research is necessary to establish causality, as well as explore the role of depression.

Utility of Second-Look Endoscopy with Debridement After Pediatric Functional Endoscopic Sinus Surgery in Patients with Cystic Fibrosis.

OBJECTIVES: To determine the utility of Second-look endoscopy with debridement (SLED) after functional endoscopic sinus surgery (ESS) in pediatric cystic fibrosis (CF) patients. To compare outcomes in pediatric CF patients undergoing sinus surgery for chronic sinusitis with or without SLED. To describe findings present at the time of SLED. METHODS: Retrospective chart review of 61 ESS procedures performed at a tertiary care pediatric center from 2013 to 2016. Data collected included demographics, SLED findings, and 6-month pre-/postoperative disease specific outcomes including incidence of sinonasal and pulmonary exacerbations and revisions. RESULTS: Sixty-one cases were reviewed. SLED was performed in 38 cases on average 22.4 days postoperatively. Average preoperative Lund-Mackay score was 14.9 and 14.8 among patients undergoing ESS with and without SLED, respectively. Pre-/postoperative intranasal steroid use and extent of surgery performed was similar among all patients. At the time of SLED, rates of synechiae, polyps and maxillary antrostomy obstruction were 26.3%, 23.7%, and 7.9%, respectively. The incidence and number of days to onset of postoperative sinonasal exacerbations requiring antibiotic therapy within 6 months of ESS were 1.0 (SD 1.0) and 85 days (SD 45.7); and 1.3 (SD 1.0) and 80.4 days (SD 40.5) for patients undergoing ESS with and without SLED, respectively (P value .33). The number of days to first pulmonary exacerbation was 113.9 (SD 45.5) and 47.4 (SD 34.1) among SLED and non-SLED patients, respectively (P value .01). No significant difference was observed in revision rates and time to revision ESS (30% and overall average 1.4 years, respectively). CONCLUSION: The utility of SLED among pediatric CF patients remains unclear. While debridement did not have a significant impact on sinonasal exacerbations or revision rates, pulmonary exacerbations for patients undergoing SLED were delayed. Further studies are needed to clarify the impact of SLED.

An approach to linking education, social care and electronic health records for children and young people in South London: a linkage study of child and adolescent mental health service data.

OBJECTIVES: Creation of linked mental health, social and education records for research to support evidence-based practice for regional mental health services. SETTING: The Clinical Record Interactive Search (CRIS) system was used to extract personal identifiers who accessed psychiatric services between September 2007 and August 2013. PARTICIPANTS: A clinical cohort of 35 509 children and young people (aged 4-17 years). DESIGN: Multiple government and ethical committees approved the link of clinical mental health service data to Department for Education (DfE) data on education and social care services. Under robust governance protocols, fuzzy and deterministic approaches were used by the DfE to match personal identifiers (names, date of birth and postcode) from National Pupil Database (NPD) and CRIS data sources. OUTCOME MEASURES: Risk factors for non-matching to NPD were identified, and the potential impact of non-match biases on International Statistical Classification of Diseases, 10th Revision (ICD-10) classifications of mental disorder, and persistent school absence (<80% attendance) were examined. Probability weighting and adjustment methods were explored as methods to mitigate the impact of non-match biases. RESULTS: Governance challenges included developing a research protocol for data linkage, which met the legislative requirements for both National Health Service and DfE. From CRIS, 29 278 (82.5%) were matched to NPD school attendance records. Presenting to services in late adolescence (adjusted OR (aOR) 0.67, 95% CI 0.59 to 0.75) or outside of school census timeframes (aOR 0.15, 95% CI 0.14 to 0.17) reduced likelihood of matching. After adjustments for linkage error, ICD-10 mental disorder remained significantly associated with persistent school absence (aOR 1.13, 95% CI 1.07 to 1.22). CONCLUSIONS: The work described sets a precedent for education data being used for medical benefit in England. Linkage between health and education records offers a powerful tool for evaluating the impact of mental health on school function, but biases due to linkage error may produce misleading results. Collaborative research with data providers is needed to develop linkage methods that minimise potential biases in analyses of linked data.

Odontogenic sinusitis: A review of the current literature.

OBJECTIVES: To present current literature on the topic of odontogenic sinusitis. DATA SOURCE: PubMed literature search for odontogenic sinusitis. RESULTS: Odontogenic sinusitis is an inflammatory condition of the paranasal sinuses that is the result of dental pathology, most often resulting from prior dentoalveolar procedures, infections of maxillary dentition, or maxillary dental trauma. Infections are often polymicrobial with an anaerobe-predominant microbiome requiring special considerations for antimicrobial therapy. Medical management and treatment of the underlying dental pathology remains a critical initial step in the treatment of odontogenic sinusitis, however recent literature suggests that a significant portion of patients may require endoscopic sinus surgery for successful disease resolution. CONCLUSIONS: This review describes the essential epidemiological and etiological factors, relevant clinical findings and diagnostic modalities, microbiologic and antimicrobial considerations, as well as the medical and surgical treatment approaches commonly utilized for the management of odontogenic sinusitis. LEVEL OF EVIDENCE: NA.

Pharyngoesophageal diverticuli: diagnosis, incidence and management.

PURPOSE OF REVIEW: Pharyngoesophageal diverticuli such as Zenker's diverticulum are relatively rare diseases that may have a significant impact on a patient's quality of life. Open surgical techniques have historically been the mainstay of treatment for Zenker's diverticuli and remain the preferred approach for many surgeons operating on Killian-Jamieson diverticuli (KJD) and pharyngoceles. However, advances in technology in recent decades have allowed for the development of successful endoscopic surgical techniques for the management of these conditions. RECENT FINDINGS: Endoscopic management of Zenker's diverticulum with carbon dioxide laser-assisted diverticulotomy or endoscopic stapler-assisted diverticulostomy has gained wide acceptance in recent years. This is based on studies showing high rates of successful outcomes, low rates of complications and shorter operative time with an associated impact on overall cost and patient recovery. Endoscopic management of KJD and pharyngoceles has recently been described, but remains controversial with many surgeons preferring open surgical approaches for the ability to identify and protect the recurrent laryngeal nerve. SUMMARY: Open and endoscopic techniques are accepted for the treatment of Zenker's diverticulum with open approaches remaining the traditional technique for management of non-Zenker's diverticulum. Further investigation of endoscopic approaches for management of KJD is necessary to assess safety and efficacy.

Cohort profile of the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register: current status and recent enhancement of an Electronic Mental Health Record-derived data resource.

PURPOSE: The South London and Maudsley National Health Service (NHS) Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register and its Clinical Record Interactive Search (CRIS) application were developed in 2008, generating a research repository of real-time, anonymised, structured and open-text data derived from the electronic health record system used by SLaM, a large mental healthcare provider in southeast London. In this paper, we update this register's descriptive data, and describe the substantial expansion and extension of the data resource since its original development. PARTICIPANTS: Descriptive data were generated from the SLaM BRC Case Register on 31 December 2014. Currently, there are over 250,000 patient records accessed through CRIS. FINDINGS TO DATE: Since 2008, the most significant developments in the SLaM BRC Case Register have been the introduction of natural language processing to extract structured data from open-text fields, linkages to external sources of data, and the addition of a parallel relational database (Structured Query Language) output. Natural language processing applications to date have brought in new and hitherto inaccessible data on cognitive function, education, social care receipt, smoking, diagnostic statements and pharmacotherapy. In addition, through external data linkages, large volumes of supplementary information have been accessed on mortality, hospital attendances and cancer registrations. FUTURE PLANS: Coupled with robust data security and governance structures, electronic health records provide potentially transformative information on mental disorders and outcomes in routine clinical care. The SLaM BRC Case Register continues to grow as a database, with approximately 20,000 new cases added each year, in addition to extension of follow-up for existing cases. Data linkages and natural language processing present important opportunities to enhance this type of research resource further, achieving both volume and depth of data. However, research projects still need to be carefully tailored, so that they take into account the nature and quality of the source information.

Local iontophoretic administration of cytotoxic therapies to solid tumors.

Parenteral and oral routes have been the traditional methods of administering cytotoxic agents to cancer patients. Unfortunately, the maximum potential effect of these cytotoxic agents has been limited because of systemic toxicity and poor tumor perfusion. In an attempt to improve the efficacy of cytotoxic agents while mitigating their side effects, we have developed modalities for the localized iontophoretic delivery of cytotoxic agents. These iontophoretic devices were designed to be implanted proximal to the tumor with external control of power and drug flow. Three distinct orthotopic mouse models of cancer and a canine model were evaluated for device efficacy and toxicity. Orthotopic patient-derived pancreatic cancer xenografts treated biweekly with gemcitabine via the device for 7 weeks experienced a mean log2 fold change in tumor volume of -0.8 compared to a mean log2 fold change in tumor volume of 1.1 for intravenous (IV) gemcitabine, 3.0 for IV saline, and 2.6 for device saline groups. The weekly coadministration of systemic cisplatin therapy and transdermal device cisplatin therapy significantly increased tumor growth inhibition and doubled the survival in two aggressive orthotopic models of breast cancer. The addition of radiotherapy to this treatment further extended survival. Device delivery of gemcitabine in dogs resulted in more than 7-fold difference in local drug concentrations and 25-fold lower systemic drug levels than the IV treatment. Overall, these devices have potential paradigm shifting implications for the treatment of pancreatic, breast, and other solid tumors.

Endoscopic endonasal transclival approaches: case series and outcomes for different clival regions.

Objective Transclival endoscopic endonasal approaches to the skull base are novel with few published cases. We report our institution's experience with this technique and discuss outcomes according to the clival region involved. Design Retrospective case series. Setting Tertiary care academic medical center Participants All patients who underwent endoscopic endonasal transclival approaches for skull base lesions from 2008 to 2012. Main Outcome Measures Pathologies encountered, mean intraoperative time, intraoperative complications, gross total resection, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, postoperative complications, and postoperative clinical course. Results A total of 49 patients underwent 55 endoscopic endonasal transclival approaches. Pathology included 43 benign and 12 malignant lesions. Mean follow-up was 15.4 months. Mean operative time was 167.9 minutes, with one patient experiencing an intraoperative internal carotid artery injury. Of the 15 cases with intraoperative cerebrospinal fluid (CSF) leaks, 1 developed postoperative CSF leak (6.7%). There were six other postoperative complications: four systemic complications, one case of meningitis, and one retropharyngeal abscess. Gross total resection was achieved for all malignancies approached with curative intent. Conclusions This study provides evidence that endoscopic endonasal transclival approaches are a safe and effective strategy for the surgical management of a variety of benign and malignant lesions. Level of Evidence 4.