International consensus statement on allergy and rhinology: Olfaction.

BACKGROUND: The literature regarding clinical olfaction, olfactory loss, and olfactory dysfunction has expanded rapidly over the past two decades, with an exponential rise in the past year. There is substantial variability in the quality of this literature and a need to consolidate and critically review the evidence. It is with that aim that we have gathered experts from around the world to produce this International Consensus on Allergy and Rhinology: Olfaction (ICAR:O). METHODS: Using previously described methodology, specific topics were developed relating to olfaction. Each topic was assigned a literature review, evidence-based review, or evidence-based review with recommendations format as dictated by available evidence and scope within the ICAR:O document. Following iterative reviews of each topic, the ICAR:O document was integrated and reviewed by all authors for final consensus. RESULTS: The ICAR:O document reviews nearly 100 separate topics within the realm of olfaction, including diagnosis, epidemiology, disease burden, diagnosis, testing, etiology, treatment, and associated pathologies. CONCLUSION: This critical review of the existing clinical olfaction literature provides much needed insight and clarity into the evaluation, diagnosis, and treatment of patients with olfactory dysfunction, while also clearly delineating gaps in our knowledge and evidence base that we should investigate further.

Should Oral Corticosteroids be Used in Medical Therapy for Chronic Rhinosinusitis? A Risk Analysis.

OBJECTIVES: Oral corticosteroid (OCS) as a part of appropriate medical therapy (AMT) (formerly maximal medical therapy) in chronic rhinosinusitis remains controversial. While the risks of OCS are well known, the benefit remains unclear due the absence of a standardized prescribing regimen. Consequently, it is difficult to characterize whether the risks of OCS and its ability to avert endoscopic sinus surgery (ESS) are helpful in AMT. When OCS is highly effective at averting surgery, the lesser risks of OCS would be justified because it can avoid the greater risks of ESS. When OCS is poorly effective at averting ESS, the risks of OCS would not be justified because many patients will be exposed to both risks. This study seeks to identify the threshold effectiveness of OCS at averting ESS that would minimize risk exposure to patients. METHODS: A probabilistic risks-based decision analysis was constructed from literature reported incidences and impacts of adverse events of OCS and ESS. Monte Carlo analysis was performed to identify the minimum effectiveness required to avoid further intervention (MERAFI) for chronic sinusitis without nasal polyp (CRSsNP) and chronic sinusitis with nasal polyp (CRSwNP). RESULTS: The analysis showed MERAFI results of 20.8% (95% CI 20.7-20.9%) for CRSsNP and 16.8% (95% CI 16.7-16.9%) for CRSwNP. CONCLUSIONS: Given reported OCS effectiveness in the range of 34-71% in CRSsNP and 46-63% in CRSwNP, this analysis suggests that the inclusion of OCS in AMT may be the lower risk strategy. LEVEL OF EVIDENCE: N/A Laryngoscope, 131:473-481, 2021.

Analysis of Sinus Balloon Catheter Dilation Providers Based on Medicare Provider Utilization and Payment Data.

BACKGROUND: The use of balloon catheter dilation (BCD) to treat chronic rhinosinusitis has increased dramatically since its conception, necessitating further characterization of BCD providers and trends in its usage. Medicare data on BCD providers have made it possible to study recent demographic patterns. There has also been an increase in mid-level providers' scope of otolaryngologic practice that is not well defined. OBJECTIVE: To better understand BCD adoption by studying volume of BCD procedures as well as training, geography, and practice socioeconomic characteristics of BCD providers for Medicare beneficiaries. METHODS: We reviewed Medicare Provider Utilization and Payment Data Public Use Files for 2014 and 2015 for providers with claims for BCD of the sinuses. We extracted provider zip code, state, gender, and number of services per BCD code. We obtained median household income by zip code and geographic region based on US Census Bureau data. Providers were classified using an Internet search to determine practice setting and type of specialty training/certification. RESULTS: In 2014 and 2015, 428 providers performed 42 494 BCDs billed to Medicare beneficiaries. Among BCD providers, 5.1% were female, 98.1% had Doctor of Medicine/Doctor of Osteopathic Medicine credentials, and 1.9% had nurse practitioner/physician assistant credentials. Over the 2-year period, the median number of BCDs was 63 for physicians and 37 for mid-level providers. Fellowship-trained rhinologists performed a median of 38 BCDs over 2 years. The most common subspecialty certification/training was in facial plastics and reconstructive surgery. The majority of providers (63.8%) performed 1 to 99 BCDs over the 2 years. In the South, there were 21.9 BCD procedures performed per 100 000 people compared to 7.3 in the Northeast, 9.3 in the Midwest, and 8.5 in the West. CONCLUSION: There is a large range in total BCD procedures performed by individual providers, and this varies by certain provider characteristics. Mid-level providers have emerged as a significant population performing BCD.

Workplace Indirect Cost Impacts of Nasal and Sinus Symptoms and Related Conditions.

OBJECTIVE: Evaluate associations of nasal and sinus and related symptoms, as well as selected health conditions which produce those symptoms, with total lost productive time (LPT) at work in the past 2 weeks. METHODS: We used a cross-sectional analysis of 2402 currently working subjects. Self-reported physician diagnoses, condition statuses measured with standardized instruments, and symptom-based factor scores from an exploratory factor analysis were used in survey weighted log-binomial regression. RESULTS: Pain and pressure, nasal blockage and discharge, and asthma and constitutional symptom factor scores as well as self-reported allergic rhinitis were associated with higher total LPT. Individuals who met operationalized criteria for multiple health conditions, especially chronic rhinosinusitis, had the greatest total LPT. CONCLUSIONS: Better management of these symptoms, and awareness of how they impact an individual's ability to perform job-functions in the workplace, could improve overall productivity.

Open versus endoscopic medial orbital decompression: Utilization, cost, and operating room time.

BACKGROUND: The advent of endoscopic sinus surgery has created an exciting interface between rhinology and ophthalmology in the area of orbital and optic nerve decompression Objectives: (1) To study the utilization of open versus endoscopic medial orbital decompression based on geography and indication, (2) to describe the demographics of the patient populations who underwent these different techniques, and (3) to compare outcomes, including mean charges and operating room (OR) times Methods: Cases identified by Current Procedural and Terminology codes were extracted from the California, Florida, Maryland, and New York State Ambulatory Surgery Databases from 2009 to 2011. Patient demographics, diagnoses, mean charge, and OR time were compared. RESULTS: A total of 1009 patients underwent orbital decompression; 93.0% of cases involved the medial wall only; 22.9% of medial decompressions were performed endoscopically, 74.5% were open, and 2.6% were via combined approach. Eighty percent of patients had thyroid eye disease. Analyses adjusted for sex, age, race, state, and diagnosis found that surgeries for infection (N = 47) were more likely to be performed endoscopically compared with procedures for other diagnoses (N = 962) (odds ratio 5.27 [2.67-10.40], p < 0.001). Patients in Florida were more likely to undergo endoscopic decompression compared with patients in California (odds ratio 2.35 [1.42-3.62]). The difference in median charge for endoscopic ($13,119) versus open ($11,291; p = 0.085) procedures was not significant on bivariate analysis but was significant on multivariate analysis (p = 0.04). The median OR time for open procedures was, on average, 33 minutes shorter (endoscopic, 132 minutes; open, 98 minutes; p ≤ 0.001) on bivariate analysis but was not significantly different when controlling for covariables (p = 0.08). CONCLUSION: In the study sample, endoscopic orbital decompression was performed in 22.9% of patients, with significant variation in surgical technique based on geography and indication. Procedures that used endoscopic compared with open decompression techniques had no significant difference in charge on bivariate analysis. The OR time for open procedures was shorter on bivariate but not on multivariate analysis. Further research is required regarding the relative effectiveness of open versus endoscopic surgical techniques for various indications.

National Institutes of Health Funding for Obstructive Sleep Apnea: An Opportunity for Otolaryngologists.

OBJECTIVE: To describe current levels and trends of funding for the National Institutes of Health (NIH) in obstructive sleep apnea (OSA) and to recognize the current status of otolaryngologists in OSA research. STUDY DESIGN: Scientometric analysis. METHODS: The NIH RePORTER database was queried for the search term "obstructive sleep apnea" for all available years. Sex, degree, academic department, NIH funding source, geography, funding totals and years, and h-index of principal investigators (PIs) were collected and summarized. RESULTS: A total of 397 projects spanning 1242 total funding years were funded. Of the 273 individual PIs, 33.3% (91/273) were female. Regarding credentials, 52.4% of PIs (143/273) were MD or MD/PhD, and 41.0% (112/273) were PhD alone. Academic departments of PIs were most often medicine (34.1%), pediatrics (12.1%), cell biology/physiology (10.6%), and psychiatry (7.7%). Seven otolaryngology faculty members had received NIH funding for OSA research (2.6% of total PIs) since 2000. They accounted for 8 grants (0.25% of total grants) and $7,235,729 (1.5% of total dollars) of research funding. CONCLUSION: Despite studies showing increasing levels of OSA surgery being performed and major areas of research and clinical opportunity, otolaryngologists represent a small minority of OSA research funding. This information may help direct our specialty when setting priorities regarding research funding, as research into the basic science and clinical management of OSA represents a broad and interdisciplinary pursuit.

Primary care and upfront computed tomography scanning in the diagnosis of chronic rhinosinusitis: a cost-based decision analysis.

OBJECTIVES/HYPOTHESIS: To diagnose chronic rhinosinusitis (CRS), current guidelines require either endoscopic or computed tomography (CT) findings of sinus disease. To a primary care physician, this means a referral to an otolaryngologist or obtaining a CT scan. Unfortunately, the sensitivity of endoscopy for detecting CRS is low, and examination by the Otolaryngologist may not yield a definitive diagnosis. This leaves CT scanning. However, this is contradicted by recommendations to limit CT scanning for only preoperative planning purposes due to cost concerns. This study aims to provide an evidence-based cost-efficient recommendation for primary care practice. STUDY DESIGN: Health care economics-based decision analysis model. METHODS: A cost-based decision analysis based on literature-reported probabilities and Medicare costs was constructed for two scenarios: 1) primary care physicians who are comfortable initiating first-line treatment for chronic rhinosinusitis, rhinitis, and atypical facial pain; and 2) primary care physicians who are less comfortable with medical management of these conditions. RESULTS: Under both scenarios and the extremes of sensitivity analysis, upfront CT scanning provides cost-efficient diagnosis over presuming a diagnosis of chronic rhinosinusitis. Primary care physicians who attempt first-line treatment can expect $503 (range = $296-$761) saved per patient. Meanwhile, primary care physicians who prefer to refer may expect $326 (range = $299-$353) saved per patient. CONCLUSIONS: In all scenarios, confirming diagnosis with CT scanning prior to treatment or referral is more cost-efficient than presuming a diagnosis of CRS based on symptoms alone.

Effect of symptom-based risk stratification on the costs of managing patients with chronic rhinosinusitis symptoms.

BACKGROUND: Current symptom criteria poorly predict a diagnosis of chronic rhinosinusitis (CRS) resulting in excessive treatment of patients with presumed CRS. The objective of this study was analyze the positive predictive value of individual symptoms, or symptoms in combination, in patients with CRS symptoms and examine the costs of the subsequent diagnostic algorithm using a decision tree-based cost analysis. METHODS: We analyzed previously collected patient-reported symptoms from a cross-sectional study of patients who had received a computed tomography (CT) scan of their sinuses at a tertiary care otolaryngology clinic for evaluation of CRS symptoms to calculate the positive predictive value of individual symptoms. Classification and regression tree (CART) analysis then optimized combinations of symptoms and thresholds to identify CRS patients. The calculated positive predictive values were applied to a previously developed decision tree that compared an upfront CT (uCT) algorithm against an empiric medical therapy (EMT) algorithm with further analysis that considered the availability of point of care (POC) imaging. RESULTS: The positive predictive value of individual symptoms ranged from 0.21 for patients reporting forehead pain and to 0.69 for patients reporting hyposmia. The CART model constructed a dichotomous model based on forehead pain, maxillary pain, hyposmia, nasal discharge, and facial pain (C-statistic 0.83). If POC CT were available, median costs ($64-$415) favored using the upfront CT for all individual symptoms. If POC CT was unavailable, median costs favored uCT for most symptoms except intercanthal pain (-$15), hyposmia (-$100), and discolored nasal discharge (-$24), although these symptoms became equivocal on cost sensitivity analysis. The three-tiered CART model could subcategorize patients into tiers where uCT was always favorable (median costs: $332-$504) and others for which EMT was always favorable (median costs -$121 to -$275). The uCT algorithm was always more costly if the nasal endoscopy was positive. CONCLUSION: Among patients with classic CRS symptoms, the frequency of individual symptoms varied the likelihood of a CRS diagnosis marginally. Only hyposmia, the absence of facial pain, and discolored discharge sufficiently increased the likelihood of diagnosis to potentially make EMT less costly. The development of an evidence-based, multisymptom-based risk stratification model could substantially affect the management costs of the subsequent diagnostic algorithm.

Cost effectiveness of magnetic resonance imaging in the workup of the dysosmia patient.

BACKGROUND: Intracranial causes of dysosmia are uncommon. Nonetheless, a missed intracranial disorder or neoplasm is worrisome. Magnetic resonance imaging (MRI) may be used in diagnosis; however, the cost effectiveness of this practice is unclear. We hypothesize that MRI scans for idiopathic dysosmia will demonstrate sufficient significant findings to be a cost-effective screening tool. METHODS: Tertiary-care otolaryngology clinic records were queried for smell and taste disturbance. The patients underwent anosmia-protocol MRI of the brain for idiopathic dysosmia in 122 cases. Each MRI report was reviewed for dysosmia findings, intracranial neoplasms, and incidental findings. RESULTS: MRI was normal in 44.3%, there were dysosmia-related findings in 25.4%, and incidental findings in 40.2%. The most common related diagnosis was occult frontoethmoid sinusitis (18.8%). The most common incidental diagnosis was small vessel disease (21.1%). Intracranial neoplasms were observed in 6 patients (4.9%). Nine patients had intracranial causes of dysosmia including olfactory meningiomas, infarct, trauma, and atrophy. MRI cost per dysosmia etiology diagnosis was $9445. Costs increased to $32,355 and $48,880 per intracranial cause or neoplasm, respectively. Cost to diagnose 1 causal intracranial neoplasm was $146,400. From 1997 to 2003, median medical malpractice settlements ranged from $625,616 for misdiagnosis to $682,500 for delay in treatment to $1,750,000 for brain injury. The median jury award was $975,000 for misdiagnosis, $1,550,000 for delayed treatment, and $6,000,000 for brain injury. CONCLUSION: MRI in idiopathic dysosmia yielded information regarding the diagnosis in one-quarter of cases. The implications of missing an intracranial neoplasm alone justify the cost of screening MRI for idiopathic dysosmia.

Establishing a threshold for surgery in recurrent acute rhinosinusitis: a productivity-based analysis.

OBJECTIVE: Treatment of recurrent acute rhinosinusitis (RARS) has 2 effective modalities: medical therapy with exacerbations or surgery to reduce the frequency and severity of infections. However, it is unclear when one therapy should be recommended over the other. This study seeks to identify a threshold number of infections where the morbidity of surgery is offset by the morbidity of RARS. STUDY DESIGN: Health economic breakeven threshold analysis. SETTING: Clinical otolaryngology practice. SUBJECTS: None. METHODS: A model of productivity was constructed to simulate the first 1 to 3 years after surgery using literature reported rates of medical and surgical response rates, quality of life, and productivity. RESULTS: Based on lost productivity, the lost time for the postoperative period balances out when patients suffer from 4 episodes per year (range, 1.8-12.8). CONCLUSION: Because of possible confusion with upper respiratory tract infections (URTIs), the authors have adopted an approach similar to that adopted by the Rhinosinusitis Task Force (RTF). Given the average number of URTIs suffered by adults annually is 1.4 to 2.3, they suggest adding 2 to the threshold number of episodes similar to the RTF guideline for RARS. From a productivity perspective, surgical intervention may be a viable consideration if patients have suffered from 6 episodes per year. However, the effects of surgery are expected to last longer than the 19 months observed in the literature, implying that the breakeven threshold is likely lower than projected. Discussion with the patient must include a rational consideration of the burden of disease, overall patient quality of life, and risks of surgery.

A randomized trial examining the effect of pretreatment point-of-care computed tomography imaging on the management of patients with chronic rhinosinusitis symptoms.

BACKGROUND: Recent consensus statements on the diagnosis of chronic rhinosinusitis (CRS) now require endoscopic or radiographic evidence of paranasal sinus inflammation. The timing of point-of-care (POC) computed tomography (CT) scan in the workup of these patients remains to be elucidated, particularly when endoscopy is negative. The objective of this research was to prospectively evaluate 2 algorithms for the initial management of patients with symptoms of CRS who manifest a normal nasal endoscopic examination. METHODS: A total of 40 such patients were randomized to 1 of 2 pathways: POC-CT at the initial visit followed by medical therapy based upon CT results (pre-CT group; n = 20), or empiric medical therapy (EMT) followed by POC posttreatment CT if symptoms persisted (EMT group; n = 20). RESULTS: The 2 groups were demographically and symptomatically similar with regard to 2003 Task Force major criteria. Otolaryngology follow-up was recommended in 11 of 20 pre-CT patients, all of whom (100%) returned. In contrast, only 10 of 20 EMT patients (50%) followed up as instructed (p < 0.05). Radiographic confirmation of CRS was found in 8 of 20 pre-CT patients, and only 2 of 9 patients after EMT (p = 0.61). EMT patients received more antibiotic prescriptions (relative ratio [RR], 2.50; 95% CI, 1.46-4.27), while pre-CT patients received more CT scans (RR, 2.22; 95% CI, 1.37-3.61). Overall prescriptions costs were similar to the EMT group ($253 vs $218; p = 0.37) and the overall number of otolaryngology visits was similar. CONCLUSION: In patients with symptoms of CRS but negative endoscopy, POC at initial presentation results in substantially less unnecessary antibiotic prescriptions and significantly greater compliance with otolaryngology care but does result in a higher utilization of radiographic imaging.

Evaluating the supportive care costs of severe radiochemotherapy-induced mucositis and pharyngitis : results from a Northwestern University Costs of Cancer Program pilot study with head and neck and nonsmall cell lung cancer patients who received care at a county hospital, a Veterans Administration hospital, or a comprehensive cancer care center.

BACKGROUND: Few studies have examined the costs of supportive care for radiochemotherapy-induced mucosits/pharyngitis among patients with head and neck cancer (HNC) or lung cancers despite the documented negative clinical impact of these complications. METHODS: The authors identified a retrospective cohort of patients with HNC or nonsmall lung cancer (NSCLC) who had received radiochemotherapy at 1 of 3 Chicago hospitals (a Veterans Administration hospital, a county hospital, or a tertiary care hospital). Charts were reviewed for the presence/absence of severe mucositis/pharyngitis and the medical resources that were used. Resource estimates were converted into cost units obtained from standard sources (hospital bills, Medicare physician fee schedule, Red Book). Estimates of resources used and direct medical costs were compared for patients who did and patients who did not develop severe mucositis/pharyngitis. RESULTS: Severe mucositis/pharyngitis occurred in 70.1% of 99 patients with HNC and in 37.5% of 40 patients with NSCLC during radiochemotherapy. The total median medical costs per patient were USD 39,313 for patients with mucositis/pharyngitis and USD 20,798 for patients without mucositis/pharyngitis (P = .007). Extended inpatient hospitalization accounted for USD 12,600 of the increased medical costs (median 14 days [USD 19,600] with severe mucositis/pharyngitis vs 5 days [USD 7,000] without; P = .017). For patients who had HNC with mucositis/pharyngitis, incremental inpatient hospitalization costs were USD 14,000, and total medical costs were USD 17,244. For patients who had NSCLC with mucositis/pharyngitis, these costs were USD 11,200 and USD 25,000, respectively. CONCLUSIONS: In the current study, the medical costs among the patients with HNC and NSCLC who received radiochemotherapy were greater for those who developed severe mucositis/pharyngitis than for those who did not.