Long-term role of zileuton in the treatment of chronic rhinosinusitis in aspirin exacerbated respiratory disease.

BACKGROUND: Chronic rhinosinusitis (CRS) in the setting of Aspirin Exacerbated Respiratory Disease (AERD) have high rate of treatment failure and disease recurrence. OBJECTIVE: Evaluate the long-term effect of zileuton on sinonasal outcomes in patients with AERD. METHODS: AERD patients were reviewed and divided into two cohorts, depending if they were treated with zileuton during their clinical course. Demographic data, 22-item sinonasal outcome test (SNOT-22), Lund-Kennedy (LK) endoscopy score, duration of treatment, and number of sinus surgeries performed were collected. RESULTS: 40 AERD patients were included, with follow-up duration up to 10 years (avg of 5.2 years). All patients were treated with topical saline and budesonide irrigations, intranasal steroid spray, and montelukast. 19 patients had uncontrolled sinus disease requiring multiple steroid tapers and were switched from montelukast to zileuton (cohort 1, 47.5%) at some point in their treatment. 21 patients (cohort 2, 52.5%) never needed zileuton. The average duration of treatment with zileuton was 6 years. Patients who required zileuton had a worse SNOT-22 (32.1 vs 19, p = 0.117), worse LK score (8.1 vs 7.5, p = 0.504), and higher average number of surgeries (1.9 vs 1.6, p = 0.343). The outcomes in the zileuton cohort trended toward improvement, however these did not reach statistical significance with an improved SNOT-22 from 32.1 to 27.4 (p = 0.617) and LK score from 7.9 to 6.2 (p = 0.092); The addition of zileuton significantly lowered the number of surgeries needed to an average of 0.5 (p < 0.0001). CONCLUSION: Zileuton may help decrease the number of sinus surgeries needed in AERD.

Disease involvement in the central compartment in eosinophilic chronic rhinosinusitis.

OBJECTIVE: To evaluate disease presence in the central compartment (CC) in patients with eosinophilic chronic rhinosinusitis (CRS). METHODS: Patients with eosinophilic CRS were divided into three endotypes: aspirin-exacerbated respiratory disease (AERD), allergic fungal rhinosinusitis (AFRS), and eosinophilic CRS with nasal polyps (eCRSwNP). CT scans were reviewed for CC involvement, defined as the area between the superior nasal septum (SNS) and middle turbinate (MT). CC involvement was measured based on the degree of opacification (0: no opacification, 1: up to 50% opacification, and 2: >50% opacification), and distance from SNS to MT (mm). Patients who had lateralized MTs from prior surgery as the cause of CC widening were excluded. Patients who underwent orbital decompression were included as a control group. RESULTS: Fifty patients in each group (AERD, AFRS, and eCRSwNP) and 50 control patients were included. Average number of surgeries was 2.5 in AERD (p = 0.05), 2 in AFRS (p = 0.4), and 1.7 in eCRSwNP. Preoperative CC distance was significantly higher in AERD versus control, AFRS, and eCRSwNP: 4.2 versus 2.8 mm (p < 0.0001), 4.2 versus 1.9 mm (p < 0.0001), and 4.2 versus 2.7 mm (p < 0.0001), respectively. Postoperatively, CC distance and degree of opacification were significantly higher in AERD versus control, AFRS, and eCRSwNP. Within the AERD group, CC distance was significantly higher postoperatively than preoperatively (6.5 vs. 4.2 mm, p = 0.002). CONCLUSION: CC involvement is more significant in AERD patients and if present, rhinologists should be suspicious of the diagnosis. This area could represent a source of inflammatory load in patients with AERD.

Symptoms and Clinical Findings in Primary Headache Syndrome Versus Chronic Rhinosinusitis.

BACKGROUND: Primary headache syndrome (PHS) patients frequently present to otolaryngologists with sinonasal complaints and diagnosis of chronic rhinosinusitis (CRS) due to symptomatic overlap. In this study, we compare demographic, subjective, and objective clinical findings of patients with PHS versus CRS. METHODS: We retrospectively reviewed a database of patients presenting to a single tertiary care Rhinology clinic from December 2011-July 2017. Sino-Nasal Outcome Test-22 (SNOT) scores and Lund-Kennedy endoscopy scores were obtained. Lund-MacKay CT scores were calculated, if available. Requirement of headache specialist management was compared between PHS and CRS groups. Patients with both CRS and PHS (CRScPHS) that required headache specialist management were compared to patients with CRS without PHS (CRSsPHS) and patients with PHS alone using Kruskal-Wallis analysis of variance. Receiver operating characteristic (ROC) analyses were carried out to determine significant diagnostic thresholds. RESULTS: One-hundred four PHS patients and 130 CRS patients were included. PHS patients (72.1%) were more likely than CRS patients to require headache specialist management (6.9%, p<0.0001). CRSsPHS patients had significantly higher Nasal domain scores compared to PHS patients (p = 0.042) but not compared to CRScPHS patients (p>0.99). CRScPHS (p = 0.0003) and PHS (p<0.0001) subgroups of patients had significantly higher Aural/Facial domain scores compared to CRSsPHS patients. PHS patients also had significantly higher Sleep domains scores compared to CRSsPHS patients (p<0.0001). Both CRScPHS and CRSsPHS subgroups had significantly higher nasal endoscopy scores (p<0.0001) and CT scores (p = 0.04 & p<0.0001, respectively) compared to the PHS group. Aural/Facial domain score of 4, nasal endoscopy score of 4, and CT score of 2 were found to be reliable diagnostic thresholds for absence of CRS. CONCLUSIONS: The SNOT-22 may be used to distinguish PHS from CRS based upon the Aural/Facial and Sleep domains. Patients with CRS have more severe Nasal domain scores and worse objective endoscopy and CT findings.

Subjective and Objective Measurements of Sinonasal Manifestations in Patients With Autoimmune Disorders.

OBJECTIVES/HYPOTHESIS: A number of autoimmune disorders (ADs) are associated with a spectrum of sinonasal manifestations comparable to chronic rhinosinusitis (CRS). Our objective was to study the subjective and objective measurements of sinonasal manifestations of ADs. STUDY DESIGN: Retrospective cohort study. METHODS: All patients with ADs referred to our tertiary care rhinology clinic from 2008 to 2019 with sinonasal symptoms were compared to randomly selected cohorts of noneosinophilic CRS without nasal polyps (neCRSsNP) and eosinophilic CRSsNP (eCRSsNP). Demographic data, along with the 22-item Sino-Nasal Outcome Test (SNOT-22), Lund-Kennedy (LK) endoscopy score, Lund-Mackay (LM) computed tomography (CT) score, nasal crusting, and epistaxis were reviewed at presentation. RESULTS: Fifty-three patients with an AD (26 with sarcoidosis, 14 with systemic lupus erythematosus, 10 with granulomatosis with polyangiitis [GPA], and three with pemphigoid vulgaris) were identified, and compared to 75 randomly selected neCRSsNP patients and 75 eCRSsNP patients. Patients with an AD had an average SNOT-22 score of 44.4 (confidence interval [CI]: 34.6-51.2) compared to 25 (CI: 24.4-25.1) and 29.7 (CI: 20.3-29.7) for neCRSsNP and eCRSsNP patients, respectively (P < .0001), and an average LK endoscopy score of 5.3 (CI: 4.3-6.3), compared to 3.4 (P = .005, CI: 2.7-4) in neCRSsNP and 4.4 in eCRSsNP (P = .2, CI: 3.7-5). There was no significant difference in the CT score compared to both groups. Patients with an AD also scored significantly worse on all four SNOT-33 subdomains, nasal obstruction, nasal crusting, and epistaxis. Additionally, patients with GPA had the worst symptomatic and endoscopy scores. CONCLUSIONS: Patients with ADs presenting with sinonasal symptoms have a more severe subjective and objective presentation than patients with CRS without nasal polyps. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:255-259, 2021.

Eosinophilic Mucin: A Predictor for Disease Severity in Chronic Rhinosinusitis.

OBJECTIVE: The presence of tissue eosinophilia is a determinate of disease severity in patients with chronic rhinosinusitis (CRS). The impact of eosinophilic mucin (EM) as an independent variable has not yet been elucidated. STUDY DESIGN: Retrospective review. SETTING: Tertiary academic clinic.Subjects Methods: CRS patients who failed medical therapy were classified by tissue eosinophilia, presence of polyps and EM. Tissue eosinophilia count per high power field (HPF) as well as the presence of EM were determined by pathologic examination of sinus tissue removed during surgery. Sinonasal Outcomes Test (SNOT-22), Lund-Mackay (LM), and Lund-Kennedy (LK) scores were compared between all groups preoperatively and postoperatively up to two and a half years (30 months). RESULTS: 192 patients with CRS were included in the study. 87 were diagnosed with eosinophilic CRS with polyps, 58 with eosinophilic CRS without polyps, 14 with noneosinophilic CRS with polyps, and 33 with noneosinophilic CRS without polyps. Only patients with eosinophilia had EM on pathology. Of eosinophilic CRS, 50% of patients with polyps and 12% of cases without polyps demonstrated EM, respectively. EM presence portended more severe disease in patients with eosinophilia on subjective and objective scores preoperatively (P < 0.005). Postoperatively, EM patients experienced a greater improvement of symptoms, but continued to have worse endoscopy scores until 1.5 years. A tissue eosinophil count of 30 or greater per HPF was identified as a potential marker for the development of EM. CONCLUSIONS: The presence of eosinophilic mucin predicts overall worse disease severity in patients with eosinophilic CRS.

How Does Age Impact Presentation and Outcomes in Chronic Rhinosinusitis?

OBJECTIVES/HYPOTHESIS: The presence of eosinophilia and nasal polyps are well-established prognostic indicators of chronic rhinosinusitis (CRS). The importance of demographic background, such as age, as independent variables has not been elucidated while taking these factors into account. STUDY DESIGN: Respective review. METHODS: CRS patients who underwent primary surgical treatment were subdivided based on age (young adults = age 18-39, adults = age 40-64, and elderly = age 65+). Groups were then subdivided based on tissue eosinophilia and nasal polyposis. Sinonasal Outcome Test (SNOT-22), Lund-Kennedy (LK) endoscopy scores, and Lund-McKay (LM) CT scores were compared preoperatively, and postoperatively during a 5-year period. RESULTS: A total of 431 CRS patients identified and then subsequently broken down into 63 young adults (YA), 209 adults (A), and 159 elderly (E). There was no statistical difference between tissue eosinophilia and presence of polyps between the groups. All three groups had similar short- and long-term SNOT-22 patterns postoperatively. At presentation, young adults had significantly higher SNOT-22 score (33.2 YA, 25.3 A, 23.5 E, P = .029) and significantly higher rhinologic scores (1.9 YA, 1.3 A, 1.3 E, P = .0012) than the adult and elderly patients. Objective disease severity using LK endoscopy scores were only significantly higher in young adults at 1-year time (P = .0026). There was no statistical difference between the groups in regards to preoperative LM CT scores. CONCLUSIONS: Young adults are more likely to present with overall higher subjective SNOT-22 scores over adults and elderly patients, despite similar objective findings in the groups. Short- and long-term postoperative improvement holds across all age groups. LEVEL OF EVIDENCE: 4.

Use of mucosal eosinophil count as a guide in the management of chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) is a local inflammatory process driven by eosinophils. Mucosal eosinophil count (MEC) has previously been demonstrated to be a reliable indicator of disease severity. We aim to evaluate use of MEC in guiding medical management of CRS after functional endoscopic sinus surgery (FESS). METHODS: We retrospectively reviewed patients with CRS who underwent FESS from 2004 to 2017. Tissue MEC per high-power field (HPF) was determined by pathologic examination. MECs were compared by polyp status, postoperative medication requirements, and revision surgery. Patients received normal saline (NS) nasal irrigations with additional treatment as needed for disease control: 1-drug therapy (1-DT) intranasal steroid spray (ISS), 2-drug therapy (2-DT) ISS plus budesonide nasal irrigations (BNI) or leukotriene receptor antagonist (LRA), or 3-drug therapy (3-DT) ISS plus BNI and LRA. Correlations between MEC and 22-item Sino-Nasal Outcome Test (SNOT-22), preoperative computed tomography (CT), and nasal endoscopy scores were evaluated. RESULTS: A total of 156 patients were included. Fifty-seven were managed with 1-DT, 35 with 2-DT, and 62 with 3-DT. Across all patients, mean postoperative 6-month and 1-year SNOT-22 (18.1 ± 17.0, 18.1 ± 20.2, respectively) and nasal endoscopy (3.6 ± 3.8, 3.6 ± 4.1, respectively) scores were significantly lower than preoperative scores (37.4 ± 22.8, 6.5 ± 4, respectively). With increasing MEC, odds of requiring 2-DT (odds ratio [OR] = 1.1, p = 0.0002), 3-DT (OR = 1.12, p < 0.0001), and revision surgery (OR = 1.11, p < 0.0001) were significantly increased. Preoperative endoscopy (ρ = 0.44, p < 0.0001) and CT scores (ρ = 0.51, p < 0.0001) and postoperative 6-month (ρ = 0.55, p < 0.0001) and 1-year (ρ = 0.4, p < 0.0001) endoscopy scores demonstrated good correlation with MEC. CONCLUSION: MEC correlates with objective clinical disease severity and may guide aggressiveness of management for the individual patient.

Endoscopic repair of cribriform plate cerebrospinal fluid leaks: An easy and reproducible technique sparing the middle turbinate.

OBJECTIVE: The purpose of this study was to evaluate the outcomes of patients with cribriform cerebrospinal fluid leaks undergoing endoscopic repair with an easy and reproducible middle turbinate-sparing technique. MATERIAL AND METHODS: Date was obtained by retrospective chart review and includes a description of the technique with technical pearls and contraindications to the approach. RESULTS: We report 17 patients who underwent repair of cribriform cerebrospinal fluid leaks with a middle turbinate-sparing technique with 100% success rate at a mean follow up of 38 months. One patient complained of hyposmia. There were no other complications. CONCLUSIONS: The endoscopic middle turbinate-sparing approach to repair cribriform cerebrospinal fluid leaks using a free mucosal graft is easy, effective, and reproducible.

Salivary Gland Cancers of the Nasopharynx: A Population-Based Analysis of 383 Cases.

OBJECTIVES/HYPOTHESIS: Salivary gland nasopharynx cancers (SGNPCs) are rare malignancies with few cases discussed in the literature. This study represents the largest cohort of SGNPC to date. STUDY DESIGN: Retrospective population-based analysis. METHODS: The Surveillance, Epidemiology, and End Results registry from 1973 to 2015 was utilized to extract 383 cases of SGNPC. Data were analyzed for demographic characteristics, incidence, clinicopathologic traits, and outcome prognosticators. RESULTS: White female patients aged >40 years were most commonly affected. The incidence was measured as 0.019 per 100,000 people. The majority of tumors presented at advanced stages (stage III/IV, 60.8%). Adenoid cystic carcinoma, adenocarcinoma, and mucoepidermoid carcinoma were the most commonly encountered histologies (43.1%, 31.6%, 13.3%, respectively). Cervical node involvement and distant metastasis were measured at 23% and 11.9%, respectively. Mucoepidermoid carcinomas presented with the best disease-specific survival at 5 and 10 years. Asian ethnicity, age <80 years, and earlier American Joint Committee on Cancer stages were positive prognostic factors. The inclusion of surgical therapy improved 5-year outcomes among the most common histologies, except for mucoepidermoid carcinoma. CONCLUSIONS: Salivary gland nasopharyngeal cancer represents a group of rare histologies with similar outcomes as squamous cell carcinomas. However, prognosis is primarily dependent on histologic subtype, race, age, and American Joint Committee on Cancer stage.

Conversion to Chronic Invasive Fungal Sinusitis From Allergic Fungal Sinusitis in Immunocompetence.

A review of the treatment of allergic and invasive fungal sinusitis, as well as a presentation of the first recorded case of a conversion from allergic fungal sinusitis (AFS) to chronic granulomatous invasive sinusitis and the fourth case of invasive fungal sinusitis associated with Curvularia. This immunocompetent patient suffering from chronic AFS converted after repeated high-dose steroid tapers and noncompliance. AFS may present atypically and should be suspected even in immunocompetent patients with sinus disease who report new onset pain and neurologic symptoms. Clinicians should consider the potential complications associated with repeated systemic steroid administration. Laryngoscope, 129:2447-2450, 2019.

Reliability of the supraorbital ethmoid cell vs Keros classification in predicting the course of the anterior ethmoid artery.

BACKGROUND: We previously showed that the supraorbital ethmoid cell (SOEC) is a reliable landmark for identifying the anterior ethmoid artery (AEA). Recent data have suggested that Keros classification is also a dependable predictor. We aim to characterize the location of the AEA and its relation to the skull base in patients with and without SOEC using the Keros classification. METHODS: Retrospective radiographic evaluation of computed tomography (CT) scans of 76 patients (40 with SOEC, 36 without) was conducted. Distance of AEA from skull base and prevalence of AEA outside of the skull base were measured on each side and compared between groups using the 2-sample t test and χ2 test, respectively. Subgroup analysis was carried out based on the Keros classification. RESULTS: Mean distance of AEA from the skull base was 1.32 ± 1.5 mm in patients with SOEC and 0.47 ± 1.08 mm in those without (p < 0.001). Prevalence of AEA outside of the skull base was 53.8% in those with SOEC and 18.1% in those without (p < 0.001). Comparing patients with SOEC to those without, AEA was found below the skull base in 30% vs 0% of cases with Keros type 1 (p = 0.45), 58% vs 14.5% with Keros type 2 (p < 0.001), and 60% vs 50% with Keros type 3 (p = 0.72). CONCLUSION: The presence of SOEC is associated with a higher prevalence of the AEA coursing below the level of the skull base in all Keros types, thus placing the artery at greater risk for injury. Careful surgical planning is needed to avoid potential orbital complications.

Basaloid nasopharyngeal carcinoma: A population-based analysis of a rare tumor.

OBJECTIVES: Basaloid nasopharyngeal carcinoma (BNPC) is an extremely rare malignancy with a paucity of cases reported in the literature. This analysis represents the largest cohort of BNPC to date. STUDY DESIGN: Retrospective population-based analysis. METHODS: The Surveillance, Epidemiology, and End Results registry from 2001 to 2015 was utilized to extract a total of 82 cases of BNPC. Data were analyzed for incidence trends, demographic, and tumor characteristics, as well as potential outcome prognosticators. RESULTS: White male patients between the ages of 40 to 79 years were most commonly affected. The incidence was measured at 0.06 per 100 thousand people. The majority of tumors were considered high grade (grade III/IV; 92.2%). At presentation, patients were most commonly advanced stage (American Joint Committee on Cancer [AJCC] stage IV) at 29.3%, followed by AJCC stages II and III (20.7%, respectively). T2 tumors were most common at 28.8%. Cervical node involvement and distant metastasis were measured at 53.7% and 10.4%, respectively. One-year, 5-year, and 10-year disease-specific survival was 87.7%, 60.7%, and 29.8%, respectively. No prognostic factors were identified in this study. CONCLUSION: Basaloid squamous cell carcinoma represents a histologic subtype of nasopharyngeal carcinoma with excellent short-term outcomes but poor survival at 10 years when compared to conventional squamous cell carcinomas. LEVEL OF EVIDENCE: NA Laryngoscope, 129:2727-2732, 2019.

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis.

BACKGROUND: The body of knowledge regarding rhinosinusitis(RS) continues to expand, with rapid growth in number of publications, yet substantial variability in the quality of those presentations. In an effort to both consolidate and critically appraise this information, rhinologic experts from around the world have produced the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS). METHODS: Evidence-based reviews with recommendations(EBRRs) were developed for scores of topics, using previously reported methodology. Where existing evidence was insufficient for an EBRR, an evidence-based review (EBR)was produced. The sections were then synthesized and the entire manuscript was then reviewed by all authors for consensus. RESULTS: The resulting ICAR:RS document addresses multiple topics in RS, including acute RS (ARS), chronic RS (CRS)with and without nasal polyps (CRSwNP and CRSsNP), recurrent acute RS (RARS), acute exacerbation of CRS (AECRS), and pediatric RS. CONCLUSION: As a critical review of the RS literature, ICAR:RS provides a thorough review of pathophysiology and evidence-based recommendations for medical and surgical treatment. It also demonstrates the significant gaps in our understanding of the pathophysiology and optimal management of RS. Too often the foundation upon which these recommendations are based is comprised of lower level evidence. It is our hope that this summary of the evidence in RS will point out where additional research efforts may be directed.

Effectiveness of leukotriene receptor antagonism in the postoperative management of chronic rhinosinusitis.

BACKGROUND: Montelukast is used in the treatment of allergic rhinitis and asthma. It has been used as adjuvant therapy in patients with chronic rhinosinusitis (CRS), but its effectiveness has not been evaluated. This study evaluates the efficacy of adjuvant leukotriene receptor antagonism in CRS and subtypes. METHODS: Retrospective review of collected data at a tertiary-referral institution. We identified all patients who were prescribed montelukast postoperatively and had a lapse in therapy for at least 1 month (n = 50), so that the patients themselves serve as their own control group. Twenty-item Sino-Nasal Outcomes Test (SNOT-20) scores and Lund-Kennedy endoscopy scores were obtained for each patient. Scores were compared with and without montelukast using Wilcoxon signed rank test. The analysis was controlled for changes in other medications. RESULTS: Fifty-two therapy lapses were identified in 50 patients. Twenty-seven patients had eosinophilic CRS with polyps (eCRSwNP), 8 had Samter's triad (ST), and 15 had allergic fungal sinusitis (AFS). Overall mean follow-up was 46.5 months. Overall, SNOT-20 scores and endoscopy scores were significantly lower with montelukast (p < 0.005 for both). On subgroup analysis, SNOT-20 scores were significantly improved for patients with eCRSwNP and AFS (p < 0.001 and p = 0.001, respectively). Endoscopy scores were significantly improved for patients with eCRSwNP (p = 0.044). Outcomes approached, but did not reach, significance for patients with ST (p = 0.123 for SNOT-20 and p = 0.146 for endoscopy). There was also significant improvements in patients with asthma. CONCLUSION: The addition of montelukast as postoperative therapy may be beneficial for patients with eCRSwNP and AFS.

Product comparison model in otolaryngology: Equivalency analysis of absorbable hemostatic agents after endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: Evidence-based medicine in otolaryngology literature continues to be lacking, especially with regard to new products brought to market. The marketing of products often includes statements of benefit that have limited objective support in research or literature. To address this, and to adequately determine product equivalency/superiority, careful evaluation must be made. In order to establish standards for this process in rhinology products, we directly compare three different absorbable hemostatic agents in patients with chronic rhinosinusitis (CRS) after undergoing endoscopic sinus surgery (ESS), using both objective and subjective outcomes. STUDY DESIGN: Double-blinded prospective (level 1) comparison and equivalency analysis of three plant-based absorbable hemostatic agents (carboxymethylcellulose [CMC] gel, mucopolysaccharide hemospheres (MPH), and potato starch wafer) in patients undergoing bilateral ESS. METHODS: Patients with medically refractory CRS who underwent bilateral ESS were recruited and prospectively followed. At the conclusion of ESS, one of three different hemostatic agents was applied to each nasal passage. Subjective patient data was obtained using rated symptoms compared between the two sides (nasal obstruction, bleeding, pain, and nasal discharge) at baseline and on postoperative days 1, 7, and 14. Objective data was obtained by blinded endoscopic scoring to rate mucosal edema, inflammation, granulation, crusting, infection, and synechiae formation on postoperative weeks 1, 3, and 6. RESULTS: Forty-eight patients who underwent ESS for CRS were included. There is no statistical difference in subjective scores for any of the variables measured, although (MPH) nearly reached statistical significance at postoperative day 7 for increased pain (P = 0.06) and obstruction (P = 0.22). Objective measures showed equivalency between all products, except the CMC gel approached significance at week 3 for increased crusting (P = 0.10), granulation (P = 0.24), and debridement (P = 0.07). At 6 weeks, increased debridement (P = 0.14) also approached significance. CONCLUSION: Careful and deliberate consideration should be taken when choosing products to assist our surgical endeavors. Subjectively, patients treated with MPH showed near-significant increases in pain and obstruction. In objective measures, CMC gel nearly reaches significance for more postoperative debridement, with increased crusting and inflammation. Product choice could consider these factors, although it remains at the discretion of the surgeon. This model of comparison allows careful product comparison and should be applied to other hemostatics, as well as other materials in use in otolaryngology. LEVEL OF EVIDENCE: 1b. Laryngoscope, 126:S5-S13, 2016.

Why sinonasal disease spares the inferior turbinate: An immunohistochemical analysis.

OBJECTIVES/HYPOTHESIS: Clinically, inflammatory polyps are found in the middle turbinate (MT) in patients with chronic rhinosinusitis (CRS) but not in the inferior turbinate (IT). The purpose of this study was to investigate differences in protein expression between IT and MT tissue in patients with CRS. STUDY DESIGN: Prospective cohort. METHODS: Pathologic specimens obtained from patients with CRS undergoing functional endoscopic sinus surgery with IT reduction were evaluated by immunohistochemical analysis of inflammatory markers cysteinyl leukotriene 1 receptor (CysLT1R), toll-like receptor 2 (TLR2), and vascular cell adhesion molecule 1 (VCAM1). Protein expression was quantified with nuance multispectral analysis and results compared between MT and IT tissue. RESULTS: The total expression of VCAM1 and CysLT1R was decreased in the IT compared to the MT. There was no difference in total TLR2 expression between the IT and MT. When comparing patients with eosinophilic CRS to noneosinophilic CRS (neCRS), there was decreased expression of VCAM1 in the IT of patients with neCRS. When comparing patients with nasal polyposis to those without polyps, there was decreased expression of VCAM1 in the IT of patients without polyps. CONCLUSIONS: There is a difference in protein receptor expression of VCAM1 and CysLT1R in MT compared to IT tissue. Although the leukotrienes are a well-known target for treatment of chronic sinusitis, this is the first study demonstrating an upregulation of VCAM1 expression in the MT and could be a potential future target for the treatment of CRS. LEVEL OF EVIDENCE: NA Laryngoscope, 126:E179-E183, 2016.

Comorbidities in patients with all-positive symptoms on sinonasal outcomes test quality-of-life instrument.

OBJECTIVES/HYPOTHESIS: The Sinonasal Outcomes Test-20 (SNOT-20) is a validated tool to assess treatment outcomes in patients with chronic rhinosinusitis (CRS). In the clinic, we observed that patients who responded with a positive score on all 20 items of the SNOT-20 questionnaire (pan-positive patients) often did not have evidence of CRS upon workup. Many of these patients had other underlying diseases contributing to their complaints. METHODS: Analysis of prospectively collected data was performed to identify SNOT-20 pan-positive patients and compare them to 100 consecutive non-pan-positive patients who served as the control group. The following parameters were compared between the two patient groups: presence or absence of chronic diseases such as obstructive sleep apnea, depression, anxiety, fibromyalgia, chronic pain, headaches, temporomandibular joint disease, and arthritis--in addition to sinus computed-tomography Lund-McKay scores and nasal endoscopy Lund-Kennedy scores. We also reviewed the medication list of each patient to look for the possible presence of mental illness. Statistical analysis was performed using the chi-squared and Student t test. RESULTS: One hundred twenty-two pan-positive patients were identified in our database collected from 2003 to 2011. Pan-positive patients had higher incidence of depression, fibromyalgia, anxiety, pain, headache, and use of depression medications--and they also had higher SNOT-20 and endoscopy scores when compared to controls (P < 0.05). Pan-positive patients were more likely female (P < 0.05), but age and race differences did not reach statistical significance. CONCLUSION: The SNOT-20 questionnaire assists clinicians to monitor outcomes in patients treated for CRS. However, clinicians should suspect other underlying chronic conditions in SNOT-20 pan-positive patients. LEVEL OF EVIDENCE: 3B.

The effect of smoking on quality of life following sinus surgery: 10-year follow-up.

OBJECTIVES: The purpose of this study is to investigate the 10-year postoperative quality of life outcomes in smokers and nonsmokers with chronic rhinosinusitis. STUDY DESIGN: This is a single-institution prospective cohort study. METHODS: 235 patients who have previously been enrolled in a 4-year follow-up study were identified and contacted for a telephone interview. Rates of revision surgery, smoking status and 20-item sinonasal outcomes test (SNOT-20) scores were obtained. Preoperative SNOT-20 scores were compared with those obtained at the 10-year follow-up. RESULTS: Of the patients enrolled in the initial 4-year study, 22.5% were available for a telephone interview, including 43 out of 185 nonsmokers (23.2%) and 9 out of 50 smokers (18%). Demographic data including age, sex and race were analyzed and found to be similar between the two groups. Preoperative SNOT-20 scores were similar between nonsmokers and smokers (28.9 vs. 25.8, p = 0.89). There was no significant difference in long-term SNOT-20 scores (10 years postoperatively) between nonsmokers and smokers (31.5 vs. 28.2, p = 0.629). CONCLUSIONS: While cigarette smoke may have long-term adverse effects on the sinonasal mucosa, we found no difference in quality of life outcomes between smokers and nonsmokers 10 years after functional endoscopic sinus surgery.

Supraorbital ethmoid cell: a consistent landmark for endoscopic identification of the anterior ethmoidal artery.

OBJECTIVE: To demonstrate that the supraorbital ethmoid cell (SOEC) is a consistent and reliable landmark in identification of the anterior ethmoidal artery (AEA). STUDY DESIGN: Retrospective radiographic study. SETTING: Tertiary care rhinology practice. SUBJECTS AND METHODS: The computed tomography (CT) scans for 78 consecutive patients were evaluated for the presence of SOECs, degree of pneumatization, and location of the AEA in relation to fixed anatomic structures. Forty-one patients with normal SOECs were identified and compared with a group of 15 patients with pathological expansion of the SOEC secondary to inflammatory disease. The CT findings were correlated with endoscopic findings. RESULTS: The incidence of SOECs was 53%. Compared to normal SOECs, expanded SOECs had significantly greater pneumatization laterally (9.3 vs 18.5 mm, respectively; P < .0001) and AEAs that were significantly farther from the skull base (1.3 vs 6.6 mm, respectively; P < .0001). The distance between the AEA and the nasal beak was similar between the 2 groups (P = .1). More importantly, 68 of 68 sides with normal SOECs (100%) demonstrated the AEA within or in continuity with the posterior border of the SOEC opening. In patients with pathological expansion, the AEA remained within the posterior border of the SOEC opening in 19 of 19 sides (100%), despite significant expansion of the cell superolaterally. CONCLUSION: This is the first study to demonstrate a consistent landmark to identify the AEA even in cases of distorted anatomy of the frontal recess. Identifying the SOEC is a practical and reliable technique for minimizing the risk of injury to the AEA during frontal recess surgery.