Enhancing paranasal sinus disease detection with AutoML: efficient AI development and evaluation via magnetic resonance imaging.

PURPOSE: Artificial intelligence (AI) in the form of automated machine learning (AutoML) offers a new potential breakthrough to overcome the barrier of entry for non-technically trained physicians. A Clinical Decision Support System (CDSS) for screening purposes using AutoML could be beneficial to ease the clinical burden in the radiological workflow for paranasal sinus diseases. METHODS: The main target of this work was the usage of automated evaluation of model performance and the feasibility of the Vertex AI image classification model on the Google Cloud AutoML platform to be trained to automatically classify the presence or absence of sinonasal disease. The dataset is a consensus labelled Open Access Series of Imaging Studies (OASIS-3) MRI head dataset by three specialised head and neck consultant radiologists. A total of 1313 unique non-TSE T2w MRI head sessions were used from the OASIS-3 repository. RESULTS: The best-performing image classification model achieved a precision of 0.928. Demonstrating the feasibility and high performance of the Vertex AI image classification model to automatically detect the presence or absence of sinonasal disease on MRI. CONCLUSION: AutoML allows for potential deployment to optimise diagnostic radiology workflows and lay the foundation for further AI research in radiology and otolaryngology. The usage of AutoML could serve as a formal requirement for a feasibility study.

Artificial intelligence chatbots as sources of patient education material for obstructive sleep apnoea: ChatGPT versus Google Bard.

PURPOSE: To perform the first head-to-head comparative evaluation of patient education material for obstructive sleep apnoea generated by two artificial intelligence chatbots, ChatGPT and its primary rival Google Bard. METHODS: Fifty frequently asked questions on obstructive sleep apnoea in English were extracted from the patient information webpages of four major sleep organizations and categorized as input prompts. ChatGPT and Google Bard responses were selected and independently rated using the Patient Education Materials Assessment Tool-Printable (PEMAT-P) Auto-Scoring Form by two otolaryngologists, with a Fellowship of the Royal College of Surgeons (FRCS) and a special interest in sleep medicine and surgery. Responses were subjectively screened for any incorrect or dangerous information as a secondary outcome. The Flesch-Kincaid Calculator was used to evaluate the readability of responses for both ChatGPT and Google Bard. RESULTS: A total of 46 questions were curated and categorized into three domains: condition (n = 14), investigation (n = 9) and treatment (n = 23). Understandability scores for ChatGPT versus Google Bard on the various domains were as follows: condition 90.86% vs.76.32% (p < 0.001); investigation 89.94% vs. 71.67% (p < 0.001); treatment 90.78% vs.73.74% (p < 0.001). Actionability scores for ChatGPT versus Google Bard on the various domains were as follows: condition 77.14% vs. 51.43% (p < 0.001); investigation 72.22% vs. 54.44% (p = 0.05); treatment 73.04% vs. 54.78% (p = 0.002). The mean Flesch-Kincaid Grade Level for ChatGPT was 9.0 and Google Bard was 5.9. No incorrect or dangerous information was identified in any of the generated responses from both ChatGPT and Google Bard. CONCLUSION: Evaluation of ChatGPT and Google Bard patient education material for OSA indicates the former to offer superior information across several domains.

Performance of artificial intelligence chatbots in sleep medicine certification board exams: ChatGPT versus Google Bard.

PURPOSE: To conduct a comparative performance evaluation of GPT-3.5, GPT-4 and Google Bard in self-assessment questions at the level of the American Sleep Medicine Certification Board Exam. METHODS: A total of 301 text-based single-best-answer multiple choice questions with four answer options each, across 10 categories, were included in the study and transcribed as inputs for GPT-3.5, GPT-4 and Google Bard. The first output responses generated were selected and matched for answer accuracy against the gold-standard answer provided by the American Academy of Sleep Medicine for each question. A global score of 80% and above is required by human sleep medicine specialists to pass each exam category. RESULTS: GPT-4 successfully achieved the pass mark of 80% or above in five of the 10 exam categories, including the Normal Sleep and Variants Self-Assessment Exam (2021), Circadian Rhythm Sleep-Wake Disorders Self-Assessment Exam (2021), Insomnia Self-Assessment Exam (2022), Parasomnias Self-Assessment Exam (2022) and the Sleep-Related Movements Self-Assessment Exam (2023). GPT-4 demonstrated superior performance in all exam categories and achieved a higher overall score of 68.1% when compared against both GPT-3.5 (46.8%) and Google Bard (45.5%), which was statistically significant (p value < 0.001). There was no significant difference in the overall score performance between GPT-3.5 and Google Bard. CONCLUSIONS: Otolaryngologists and sleep medicine physicians have a crucial role through agile and robust research to ensure the next generation AI chatbots are built safely and responsibly.

International Multicenter Study of Clinical Outcomes of Sinonasal Melanoma Shows Survival Benefit for Patients Treated with Immune Checkpoint Inhibitors and Potential Improvements to the Current TNM Staging System.

Objectives Sinonasal mucosal melanoma (SNMM) is an extremely rare and challenging sinonasal malignancy with a poor prognosis. Standard treatment involves complete surgical resection, but the role of adjuvant therapy remains unclear. Crucially, our understanding of its clinical presentation, course, and optimal treatment remains limited, and few advancements in improving its management have been made in the recent past. Methods We conducted an international multicenter retrospective analysis of 505 SNMM cases from 11 institutions across the United States, United Kingdom, Ireland, and continental Europe. Data on clinical presentation, diagnosis, treatment, and clinical outcomes were assessed. Results One-, three-, and five-year recurrence-free and overall survival were 61.4, 30.6, and 22.0%, and 77.6, 49.2, and 38.3%, respectively. Compared with disease confined to the nasal cavity, sinus involvement confers significantly worse survival; based on this, further stratifying the T3 stage was highly prognostic ( p < 0.001) with implications for a potential modification to the current TNM staging system. There was a statistically significant survival benefit for patients who received adjuvant radiotherapy, compared with those who underwent surgery alone (hazard ratio [HR] = 0.74, 95% confidence interval [CI]: 0.57-0.96, p = 0.021). Immune checkpoint blockade for the management of recurrent or persistent disease, with or without distant metastasis, conferred longer survival (HR = 0.50, 95% CI: 0.25-1.00, p = 0.036). Conclusions We present findings from the largest cohort of SNMM reported to date. We demonstrate the potential utility of further stratifying the T3 stage by sinus involvement and present promising data on the benefit of immune checkpoint inhibitors for recurrent, persistent, or metastatic disease with implications for future clinical trials in this field.

Clinical outcomes, Kadish-INSICA staging and therapeutic targeting of somatostatin receptor 2 in olfactory neuroblastoma.

INTRODUCTION: Olfactory neuroblastoma (ONB) is a rare cancer of the sinonasal region. We provide a comprehensive analysis of this malignancy with molecular and clinical trial data on a subset of our cohort to report on the potential efficacy of somatostatin receptor 2 (SSTR2)-targeting imaging and therapy. METHODS: We conducted a retrospective analysis of 404 primary, locally recurrent, and metastatic olfactory neuroblastoma (ONB) patients from 12 institutions in the United States of America, United Kingdom and Europe. Clinicopathological characteristics and treatment approach were evaluated. SSTR2 expression, SSTR2-targeted imaging and the efficacy of peptide receptor radionuclide therapy [PRRT](177Lu-DOTATATE) were reported in a subset of our cohort (LUTHREE trial; NCT03454763). RESULTS: Dural infiltration at presentation was a significant predictor of overall survival (OS) and disease-free survival (DFS) in primary cases (n = 278). Kadish-Morita staging and Dulguerov T-stage both had limitations regarding their prognostic value. Multivariable survival analysis demonstrated improved outcomes with lower stage and receipt of adjuvant radiotherapy. Prophylactic neck irradiation significantly reduces the rate of nodal recurrence. 82.4% of the cohort were positive for SSTR2; treatment of three metastatic cases with SSTR2-targeted peptide-radionuclide receptor therapy (PRRT) in the LUTHREE trial was well-tolerated and resulted in stable disease (SD). CONCLUSIONS: This study presents pertinent clinical data from the largest dataset, to date, on ONB. We identify key prognostic markers and integrate these into an updated staging system, highlight the importance of adjuvant radiotherapy across all disease stages, the utility of prophylactic neck irradiation and the potential efficacy of targeting SSTR2 to manage disease.

Comparison of MRI and CT in the Evaluation of Unilateral Maxillary Sinus Opacification.

OBJECTIVES: To evaluate the diagnostic performance of MRI compared with CT in differentiating neoplastic from infectious/inflammatory causes of complete unilateral maxillary sinus opacification (UMSO). Although MRI is increasingly used, no studies validate its utility compared to CT or nasal endoscopy in this context. METHODS: A retrospective analysis of 49 patients presenting with complete UMSO to a tertiary referral centre was performed, investigated with both CT and MRI. Two head and neck radiologists independently reviewed each imaging modality and recorded both a final diagnosis and Likert-scale diagnostic certainty score. A consensus radiological diagnosis was determined, stratified into potentially neoplastic or infectious/inflammatory aetiology, and compared with nasal endoscopy and final diagnosis. Diagnostic performance and interoperator agreement for predicting neoplasia were calculated. RESULTS: Both CT and MRI demonstrated high sensitivity and negative predictive value for neoplasm, although MRI was more specific (79%; 95% CI: 60-92%) than CT (14%; 95% CI: 4-32%), with a higher positive predictive value. MRI was more accurate (88%; 95% CI: 75-95%) than CT (49%; 95% CI: 34-64%) in diagnosing neoplasia. MRI had significantly higher diagnostic certainty Likert scores than CT (p < 0.0001 for both observers). Interobserver agreement was fair for CT (kappa coefficient = 0.327) and excellent for MRI (kappa coefficient = 0.918). CONCLUSIONS: MRI is more specific than CT in characterising UMSO, with greater diagnostic certainty and reproducibility. The additive diagnostic value of MRI complements CT, potentially reducing diagnostic delays in some cases and the need for diagnostic endoscopic sinus surgery in others. We recommend MRI incorporation into the diagnostic pathway for patients with UMSO.

Olfactory dysfunction in antineutrophil cytoplasmic antibody-associated vasculitides: A review of the literature.

Olfactory dysfunction (OD) has been described in patients with antineutrophil cytoplasmic antibody-associated vasculitides (AAV), but the underlying mechanisms are not completely understood. The causes of altered smell function can generally be divided into conductive, sensorineural or others. To date no specific treatment is available for AAV-related OD and the efficacy of currently available options has not been explored. The aim of this review is to provide an overview of the causes that may lead to OD in patients with AAV. Current available treatments for OD and possible options in patients with AAV presenting with smell impairment are also mentioned.

The Evidence Base for the Benefits of Functional Septorhinoplasty and its Future Post COVID-19.

Ever since the introduction of the concept of Procedures of Limited Clinical Value (PoLCV), procedures such as functional septorhinoplasty have been subject to additional funding restrictions within the British National Health Service. Recent publications have suggested that 10% of Clinical Commissioning Groups in the United Kingdom no longer fund septorhinoplasty surgery irrespective of the indications, including congenital malformations or post-trauma, and despite the strong evidence available in the literature in treating a range of health conditions. Thus, inequity exists across the country. At present functional septorhinoplasty surgery is frequently but incorrectly grouped together with aesthetic rhinoplasty, both of which are deemed to be cosmetic interventions. Moreover, as we exit the peak of the current coronavirus disease 2019 (COVID-19) pandemic, procedures deemed to be of lower clinical priority will potentially be at risk throughout Europe. The purpose of this review is twofold; the first is to put forward the evidence to commissioners in favor of functional septorhinoplasty surgery on patient well-being and mental health; the second is to demonstrate why functional septorhinoplasty surgery is a distinct procedure from aesthetic rhinoplasty and why it ought not to be classified as a procedure of limited clinical value.

Restoring Balance and Symmetry to the Aging Nose.

Accurate assessment of facial symmetry is a key component of successful rhinoplasty surgery but is often overlooked by both surgeon and patient. Up to three-quarters of patients with a significantly crooked nose have been found to have concurrent marked facial asymmetry. Whilst not a contraindication to rhinoplasty, provided that facial asymmetry is identified in advance and expectations realistic, the correction of nasal deformities can improve perceived facial asymmetry. In the aging face, aside from soft tissue and bony resorption that can amplify facial asymmetry, there are specific surgical challenges to the aging nose; the normal tip support mechanisms deteriorate with age giving rise to distinctive changes to the aging nose-typically tip ptosis and a hanging columella; bone quality becomes more brittle and skin overlying this area becomes thinner. There is also weakening of the external nasal valve thus causing functional impairment too. As a result, rhinoplasty techniques used in younger patients may not be suitable in the aging nose. In this article, the authors describe their experience and outline the evidence on the management of the aging patient with facial and nasal asymmetry.

The role of surgery in antineutrophil cytoplasmic antibody-associated vasculitides affecting the nose and sinuses: A systematic review.

BACKGROUND: The ear, nose and throat region has been reported to be one of the commonest sites involved in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis diseases and often precedes the diagnosis of ANCA-associated vasculitis by many months. Although treatment for ANCA-associated vasculitis primarily requires systemic immunosuppressive therapy, there are specific indications for sinonasal surgery during the course of the disease process. The three major roles for surgery in sinonasal vasculitis are to aid diagnosis through biopsy, enable symptom relief and nasal reconstructive surgery consideration when in remission. PURPOSE: The aim of this systematic review is to provide an overview of the surgical procedures which can be performed in patients with ANCA-associated vasculitis presenting with sinonasal involvement. MATERIALS AND METHODS: A systematic literature search was performed for scientific articles on MEDLINE (PubMed Advanced MEDLINE Search) and EMBASE. The search included all articles up to April 2020. CONCLUSION: Surgical intervention during the active phase of ANCA-associated vasculitis disease can improve the patient's symptoms and enable histological diagnosis. The surgical decision to manage the nose requires a multidisciplinary approach involving the vasculitis specialist and the ear, nose and throat surgeon. Nasal reconstruction can be performed to restore form and function but only when the disease is in remission so as to maximise success and minimise complications.

Nasal reconstructive surgery for vasculitis affecting the nose: our two-centre international experience.

PURPOSE: To recommend an international multidisciplinary medical and surgical algorithm of treatment in nasal vasculitis, which will create a more streamlined approach. METHODS: A two-centre, international retrospective analysis of granulomatosis with polyangiitis (GPA) and levamisole-associated vasculitis (LAV) cases presenting between 2005 and 2019 was carried out. Demographic data, and surgical and medical treatment were recorded. Patients' signs and symptoms were analysed, and recommended treatment strategies outlined with key surgical procedures described. RESULTS: Forty-one GPA patients and 11 LAV patients were included in the study with a mean age of 38.6 and 38.8 years, respectively. A stepwise surgical management approach with reconstructive options is described and includes: (1) examination under general anaesthesia, biopsy, and insertion of silastic nasal splints; (2) septal perforation repair (with caution); (3) mild-to-moderate saddle nose reconstruction with costal cartilage; (4) severe saddle nose reconstruction with osseocartilaginous rib grafts; (5) soft-tissue reconstruction techniques. CONCLUSIONS: The management of nasal vasculitis is a particular challenge in facial plastic surgery. It requires a close collaborative approach with a physician skilled in the medical management of vasculitis. Surgery must be planned judiciously, with realistic patient expectations and only after a sustained period of remission. For more severe saddle deformities, the modified osseocartilaginous Andrews technique gives excellent long-term results.

Recovery of Elective Facial Plastic Surgery in the Post-Coronavirus Disease 2019 Era: Recommendations from the European Academy of Facial Plastic Surgery Task Force.

The impact of the COVID-19 pandemic has resulted in widespread disruption to routine surgical services across the globe. As the peak of the initial pandemic passes, surgeons will increasingly resume elective work to address the backlog. Whilst urgent cases such as cancer work will be prioritized, the safe resumption of facial plastic surgery will remain an ongoing challenge; particularly if there are secondary waves of infection. Rhinoplasty and nasal reconstructive surgery in particular poses a unique challenge to address due to the due to the potential for aerosolizing the virus. A task force of facial plastic surgeons from the European Academy of Facial Plastic Surgery has collaborated to create this document detailing recommendations for resuming a safe facial plastic surgery practice. These include the need to embrace telemedicine, advice on surgical prioritization, planning of clinical area flow plans, advice on pre-/peri- and postoperative care as well as recommendations on training for residents and well-being for surgeons. The recommendations have been made in line with the best available evidence in the literature and are applicable to facial plastic surgery colleagues from around the world in order to resume a safe practice.

A Unilateral Mucoperichondrial/Mucoperiosteal Flap Including Inferior Turbinate with Contralateral Underlay Xenograft for a Large Nasal Septal Perforation Repair.

Findings: We describe a septal perforation repair technique aimed for moderate to large perforations, which involves a unilateral transpositional/rotational flap utilizing lateral nasal wall and inferior turbinate (IT) mucosa and a contralateral underlay porcine small intestinal submucosa mesh. Meaning: The addition of IT mucosa as part of the unilateral lateral nasal wall mucoperichondrium/periosteal flap combined with a contralateral acellular matrix underlay optimizes the repair of larger perforations. The underlay acellular matrix acts as a scaffold for the regeneration of healthy mucoperichondrium akin to a tympanoplasty repair and reduces donor site morbidity.

A national survey of functional septorhinoplasty surgery performed in the United Kingdom: a clinician end-user questionnaire to assess current practice and help inform future practice.

PURPOSE: The aim of this national survey is to assess the current practice of functional septorhinoplasty (SRP) surgery in the UK and better inform future practice. METHODS: An ENT-UK approved questionnaire was sent out to all 135 consultant members of the British Society of Facial Plastic Surgery (BSFPS). Data was collected on numbers of functional SRPs performed on the NHS, use of outcome measures, psychology and photography support, antibiotic use, referral base and consenting practice. RESULTS: The response rate was 38.5%, with 52 out of 135 completed. The median number of annual SRP cases per surgeon was 40. Most surgeons (95%) used clinical photography as an outcome measure. However, 27% of the respondents use a subjective outcome measurement and 3% of them use an objective outcome measurement. Only 34% had access to psychology support and 60% receive their referrals from primary care. All surgeons counsel patients for aesthetic change, 15% mention CSF leak and 38% mention olfactory disturbance. The key comment from our respondents was to relabel the rhinoplasty procedure as a functional SRP procedure with the aim to remove it from the Procedures of Limited Clinical Value (PoLCV) list. CONCLUSION: The majority of our respondents perform a large proportion of the SRP surgeries in the UK with each of the respondents performing an average of 40 SRP surgeries per year. There is a need to recatergorise functional septorhinoplasty as a functional operation and recommend functional SRP surgery to be removed from the PoLCV list.

A pilot study to determine the effects of nasal co-phenylcaine on drug-induced sleep endoscopy.

PURPOSE: The use of nasal decongestant and nasal anaesthesia is currently not recommended during drug-induced sleep endoscopy (DISE) according to the European position paper. The evaluation of the effects of nasal decongestant/anaesthesia on DISE has not been performed before and our aim is to perform a pilot study to determine whether nasal decongestants/anaesthesia affects DISE outcomes. METHODS: 27 patients undergoing DISE for OSA or for simple snoring were included. On each patient, DISE was performed twice, before and approximately 10 min after the administration of two puffs of co-phenylcaine nasal spray (lidocaine hydrochloride 5%, phenylephrine 0.5%, and benzalkonium chloride 0.01%) into each nostril. A nasal peak inspiratory flow was used for the objective assessment of nasal airway obstruction. During the first and the second DISE the loudness of the snoring was also recorded. RESULTS: Change in DISE total grading after nasal spray administration was not statistically significant. For the same grading, changes in percentage of contribution to collapse were not statistically significant. Sex, AHI, BMI, tonsils grade, presence of rhinitis, turbinate hypertrophy, nasal septal deviation, or nasal peak inspiratory flow limitation had no influence on the effect of nasal spray. Co-phenylcaine did not significantly influence the loudness of snoring. CONCLUSIONS: Our pilot study supports the use of co-phenylcaine nasal spray during DISE and the positive effects of the nasal spray do not influence the grading outcome. Importantly, the decongestant enhances the nasal assessment during DISE and potentially aids in the diagnosis of nasal obstruction while the nasal anaesthetic component may be beneficial by reducing nasal discomfort during DISE and thereby helping to reduce the total dose of intravenous anaesthetic administered. However, further studies on a larger population are needed to confirm our results.

Postoperative Care in Aesthetic Rhinoplasty Patients.

After rhinoplasty, during the first 24 hours, the patients should be closely monitored for pain and discomfort, nausea and vomiting, and cool compresses must be applied regularly to decrease edema and ecchymosis. In the early postoperative period of the first month, the sutures, cast, and splints are usually removed during the first week. Then the patient is followed-up at 1, 3, 6, and 12-month intervals routinely to observe healing. In the meantime, any kind of intranasal and extranasal complications should be noted. The outcome measures such as ROE, NOSE, or SCHNOS should be used 3 to 6 months after surgery. If the patient is closely followed-up, then any unwanted complication or dissatisfaction can be solved after 6 to 12 months.

Paediatric aneurysmal bone cyst: not as easy as ABC.

Aneurysmal bone cysts (ABCs) are expansile cystic lesions that can affect any bone of the body. Whilst these lesions are histologically benign, the lesions are locally aggressive and can affect the integrity of the affected bone as well as surrounding structures. ABCs arising in the head and neck region, particularly the paranasal sinuses are rare and they are limited to case reports in the literature. Due to the proximity of critical anatomical structures and the visual apparatus, the potential complications can be devastating. The present article discusses both the clinical and radiological findings of an ABC arising from the ethmoid sinuses in a 6-year-old child and the potentially challenging diagnosis with its complex ensuing surgical management. The identification of an ABC arising in the paranasal sinuses is both a diagnostic and surgical challenge and ideally requires complex management in a joint paediatric ENT and craniofacial unit.