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.

Topical Vitamin D May Modulate Human Sinonasal Mucosal Responses to House Dust Mite Antigen.

BACKGROUND: Respiratory epithelium is a key defense against inhaled pathogens. Vitamin D3 (VD) has been suggested to modulate airway inflammation; however, its effect on innate airway defenses, the physical barrier, mucociliary apparatus, and cytokine release remains unclear. OBJECTIVE: To investigate the outcomes of VD application prior to challenge in an in vitro model of human sinonasal epithelium, through assessment of epithelial transepithelial resistance (TER), cilia beat frequency (CBF), and interleukin (IL)-6 release, and secondarily to determine whether topical VD is beneficial to patients with inflammatory sinonasal pathology. METHODS: Primary human sinonasal epithelial cells from patients with eosinophilic chronic rhinosinusitis (eCRS) and healthy controls were cultured in air-liquid interface (ALI). Well-differentiated cultures from each patient were pretreated for 24 hours with 4 different VD doses. Toxicity was quantified at 24 hours in unchallenged ALI by lactate dehydrogenase (LDH) assay. Innate responses were assessed by measuring TER and CBF before and up to 24 hours after house dust mite Dermatophagoides pteronyssinus challenge. IL-6 release was evaluated 24-hour postchallenge. RESULTS: Fifteen patients (53 ± 13.5 years, 60% females, 53% eCRS) representing 120 ALI wells were assessed. VD (0, 25, 50, 150 IU/mL) released less LDH than vehicle, indicating noncytotoxicity (0.15 ± 0.02; 0.15 ± 0.00; 0.14 ± 0.02; 0.11 ± 0.01 vs 0.17 ± 0.03, P = .004). VD increased TER for eCRS wells at 5 minutes (50 IU/mL: Δ6.76 ± 3.93 vs Δ3.87 ± 2.46, P = .04) and 24 hours (50 IU/mL: Δ0.88 ± 0.49 vs Δ0.40 ± 0.42, P = .02; 150 IU/mL: Δ1.06 ± 0.58 vs Δ0.47 ± 0.46, P = .01). CBF increased at 1 hour for eCRS wells (50 IU/mL: Δ0.62 ± 0.14 vs Δ0.41 ± 0.13, P = .001; 150 IU/ml: Δ0.60 ± 0.13 vs Δ0.38 ± 0.11, P < .001). IL-6 release was similar between normal and eCRS wells. CONCLUSION: Topical VD supplementation in eCRS patients may be beneficial for innate epithelial defenses. VD is noncytotoxic and does not adversely affect the physical barrier, mucociliary apparatus, or IL-6 release. Further studies should clarify its potential as a therapeutic agent.

Hypertonic Saline Versus Isotonic Saline Nasal Irrigation: Systematic Review and Meta-analysis.

Background Saline nasal lavage is one of the treatments of sinonasal diseases. Evidence from basic research favors hypertonic saline (HS) over isotonic saline (IS) for mucociliary clearance, but evidence from clinical studies is controversial. Conversely, HS may carry greater side effects. Objective To compare the effects of HS and IS nasal irrigation in treating sinonasal diseases. Methods Systematic search with Ovid MEDLINE, Scopus, PubMed, Google Scholar, and Manual additional sources was conducted. Randomized controlled trials comparing HS with IS nasal irrigation in treating any sinonasal diseases, including rhinitis and rhinosinusitis, were included. Data were pooled for meta-analyses. Outcomes were symptom scores, sinonasal outcome test (SNOT), and adverse events. Heterogeneity was explored by subgroup analyses. Results Nine studies (740 patients) were included. HS nasal irrigation brought greater benefits over IS in symptom reduction (standardized mean difference (SMD) -0.58; 95% confidence interval [CI]: -0.76, -0.40); however, no difference was shown in SNOT-20 improvement (mean difference 1.81; 95% CI: -0.68, 4.30). In subgroup analyses, effects favoring HS on symptoms were larger in 4 subgroups. These were (1) patients with rhinitis (SMD -1.09; 95% CI: -1.42, -0.76) compared with rhinosinusitis (SMD -0.37; 95% CI: -0.58, -0.15), P < .01; (2) patients under the age of 18 years (SMD -1.22; 95% CI: -1.53, -0.91) compared with patients over the age of 18 years (SMD -0.26; 95% CI: -0.49, -0.04), P < .01; (3) saline irrigation using high volume (SMD -0.89; 95% CI: -1.18, -0.60) compared with low volume (SMD -0.39; 95% CI: -0.62, -0.16), P < .01; and (4) saline irrigation with hypertonicity of <3% (SMD -1.09; 95% CI: -1.42, -0.76) and hypertonicity of 3%-5% (SMD -1.20; 95% CI: -1.61, -0.78) compared with hypertonicity of >5% (SMD 0.20; 95% CI: -0.15, 0.55), P < .01. Buffered saline and operative status did not have impact. HS brought greater minor adverse effects. No major adverse effects were reported. Conclusion HS improves symptoms over IS nasal irrigation in treating sinonasal diseases. There is no difference in disease-specific quality of life. However, HS brings greater minor side effects than IS.

Nasal nitric oxide in unilateral sinus disease.

Unilateral sinus disease (USD) can sometimes be difficult to accurately diagnose before surgery. The application of nasal nitric oxide (nNO) for USD diagnosis and its surgical outcome in USD has not been reported in the literature. We prospectively enrolled sixty-six USD patients who underwent endoscopic sinus surgery for fungal rhinosinusitis (n = 19), chronic rhinosinusitis (CRS) without nasal polyps (n = 13), CRS with nasal polyps (n = 12) and sinonasal mass lesions (n = 22). nNO levels were measured preoperatively and at three and six months postoperatively. Correlations between nNO levels and potential clinical parameters, type of disease, disease severity, and disease-related quality of life (QOL) were assessed. Unlike bilateral CRS, in USD, nNO levels did not correlate with disease severity or postoperative QOL improvements. Except for fungus group, there were no differences in nNO levels between lesion and non-lesion sides in all the other groups. nNO levels on both sides were significantly elevated six months postoperatively in all groups. Fungal rhinosinusitis patients had the lowest preoperative nNO levels, and a cutoff of 239.3 ppb had the best sensitivity (79.0%) and specificity (87.2%) for preoperative diagnosis. While preoperative nNO levels cannot serve as an alternative marker for disease severity of USD, they were lower in fungal rhinosinusitis patients than in other USD patients and may be useful for more accurate diagnosis prior to surgery.

Chronic rhinosinusitis: the rationale for current treatments.

INTRODUCTION: Chronic rhinosinusitis (CRS) is a broad clinical syndrome linked by mucosal inflammation. Primary treatment modalities are corticosteroids and antibiotics with surgery an option for failures, but the level of supporting evidence is generally low. The primary reason is that CRS is a symptom complex and not a specific disease. Areas covered: The primary treatment modalities for CRS are corticosteroids, antibiotics and surgery. Corticosteroids, which have very broad anti-inflammatory properties, also have the strongest evidence for efficacy. Antibiotics are likely effective in a subpopulation of patients but the various phenotypes and endotypes that make up CRS have thus far been poorly defined. Early surgery as well as biologics may also be more efficacious and cost effective in some phenotypes as well. Expert commentary: A better understanding of the inflammatory pathways that drive CRS will permit investigators to separate patient groups. This will allow for clinical trials that target specific subpopulations and more personalized therapy for CRS patients in the future.

Is there a relationship between sinusitis and psychological disorders?

Chronic rhinosinusitis refers to inflammation of the nasal and sinuses mucosa and the main criteria for diagnosis of this disease related to the nasal cavity or the facial area. According to several reports based on the relationship of this disease with mental disorders, psychological issues are missing in the criteria of chronic rhinosinusitis diagnosis. In this study the etiology and clinical symptoms of the disease were studied by searching scientific databases and authentic Iranian Medicine books such as Avicenna's book The Canon of Medicine (Al-Qanun fi't-Tibb) that now taught in medicine schools of the Traditional East Asian; the results of this study showed that rhinosinusitis accompaniment with psychological symptoms are listed in abundance not only in old books but also in scientific literature before 1928 but after the discovery of antibiotics and extreme attention in the context of physiopathological assignment of diseases to pathogens, this relationship has been weakened. Given the positive results of recent studies on rhinosinusitis accompaniment with psychological disorders it is suggested that more studies are needed to explore the relationship between chronic rhinosinusitis and psychological diseases and, if necessary, to be included in the diagnostic criteria as a diagnostic standard.

Intranasal T-LysYal® as adjunctive therapy for patients after functional endoscopic sinus surgery.

Functional Endoscopic Sinus Surgery (FESS) is a common day surgery technique for upper airway disorders. Hyaluronic acid (HA) is a fundamental component of the human connective tissue. HA may exert reparative, anti-inflammatory and immune-modulating activities. Recently, a new intranasal HA formulation has been proposed: a supramolecular system containing lysine hyaluronate, thymine and sodium chloride (T-LysYal®). This randomized study investigated whether intranasal T-LysYal® (RinoLysYal®, Farmigea, Italy) was able to reduce symptom severity, endoscopic features, and nasal cytology in 83 patients (49 males and 34 females mean age 45.4±6.2 years) treated with FESS. All patients were treated with isotonic saline solution for 4 weeks, and a sub-group (active group) was also treated with intranasal T-LysYal®. Patients were visited at baseline, after treatment, and after 4-week follow-up. Intranasal T-LysYal® treatment significantly reduced the quote of patients with symptoms, endoscopic features, and inflammatory cells in comparison to isotonic solution. In conclusion, the present study demonstrates that intranasal T-LysYal® is able to significantly improve patients after FESS and its effect is long lasting.

Histamine type 2 receptor expression on peripheral blood regulatory lymphocytes in patients with allergic rhinitis treated with specific immunotherapy.

BACKGROUND: Both histamine H1- and H2-receptors (H2R) were found on regulatory T (Treg) cells; however, there is a paucity of information regarding the role of H2R in Treg function. This study aimed to investigate the effects of natural allergen stimulation and specific immunotherapy (SIT) on H2R expression in Treg cells in patients with allergic rhinitis (AR). METHODS: In this prospective, double-blind, placebo-controlled study 41 patients with AR were screened for 1 year and treated with SIT (n = 21) or placebo (n = 20) for the next 2 years. Fifteen healthy subjects were included as a control. Subsets of Treg cells that expressed H2R were assessed annually in the blood by flow cytometry: before, at the height of the pollen season, and after, at the end of the pollen season. In addition, total nasal symptom score, the use of rescue medication, and nasal eosinophilia were evaluated. RESULTS: Treg cells of AR patients slightly up-regulate H2R out of the pollen season. Natural allergen stimulation results in prompt up-regulation of H2R within these cells. SIT significantly decreased the number of Treg cells with increased expression of H2R in the blood exclusively at the height of pollen season, which, however, had no impact on the expression of H2R in Treg cells. SIT improved significantly the symptom score, rescue medication use, and decreased nasal eosinophilia. CONCLUSION: Natural pollen exposure results in up-regulation of H2R in Treg cells. Immunotherapy might transiently decrease the number of Treg-H2R(+) cells in the blood, which may be associated with their migration to the peripheral tissues. This study was part of the clinical trial registered in www.clinicaltrials.gov.

The microbiology and the efficacy of antibiotic-based medical treatment of chronic rhinosinusitis in Singapore.

BACKGROUND: Medical therapy including appropriate antibiotic treatment is advocated for the management of chronic rhinosinusitis (CRS), with sinus surgery reserved for treatment failures. This study investigates the microbiology of CRS and their response to culture-directed antibiotic treatment. METHODS: Sinus aspirates of mucopus from 172 consecutive CRS patients, with (n=89) and without (n=83) previous antibiotic treatment, were obtained for bacterial culture at their first visit. Medical treatment which included initial empirical and subsequent culture-directed antibiotics was instituted. Endoscopic sinus surgery (FESS) was performed for patients with persistent CRS and/or complications of CRS. A follow-up of 12 months was scheduled for all patients. RESULTS: One hundred and twenty (69.8%) patients were treated successfully by with antibiotic-based medical therapy. Thirty-eight patients (22.1%) did not respond to medical treatment and eventually underwent FESS. The incidence of CRS with nasal polyps (CRSwNP) was higher in FESS group (n=13, 34.2%) than patients with medical treatment only (n=9, 6.7%). Staphylococcus aureus was the most common pathogen (n=43, 25%) and amongst patients with no prior antibiotic treatment, the incidence was higher in patients with CRSwNP (n=8, 53 %) than CRS without NP (CRSwoNP) (n=20, 27%). The rate of sensitivity of the cultured microbes to amoxicillin with clavulanate and cephalosporins was 78% and 70%, respectively. CONCLUSION: The microbiology of CRS in Singapore is described. Staphylococcus aureus appears to be the most common bacterial isolates in both CRS with and without nasal polyps. Medical treatment with CRS using culture-directed antibiotics is effective in the majority of patients, especially in patients without nasal polyps.

A successful combined endovascular and surgical treatment of a cranial base mucormycosis with an associated internal carotid artery pseudoaneurysm.

OBJECTIVE: We report a rare case of internal carotid artery pseudoaneurysm owing to rhinocerebral mucormycosis and review 40 reported cases from 1980 to present. CLINICAL PRESENTATION: A 38-year-old Caucasian man presented with a 3-day history of headache, diplopia, and numbness in the distribution of the left ophthalmic and maxillary branches of the trigeminal nerve. A complete left cavernous syndrome was discovered upon neurological examination. Magnetic resonance imaging scans revealed an inflammatory process involving the paranasal sinuses with extension into the left cavernous sinus, temporal fossa, and petrous bone. INTERVENTION: The patient was immediately treated with amphotericin B, atorvastatin, and daily hyperbaric oxygen sessions before surgical intervention. The patient underwent endovascular treatment of the associated mycotic pseudoaneurysm after carotid test occlusion in addition to a radical bilateral debridement of the paranasal sinuses and infratemporal and temporal fossa. CONCLUSION: Aggressive multimodal therapy is imperative for late-stage rhinocerebral mucormycosis. Extensive resection of infected tissue combined with amphotericin B, atorvastatin, and hyperbaric oxygen seems to be the best course of management. If the internal carotid artery is involved, endovascular intervention is clearly an option to attain this goal. Further research and longer follow-up periods are required to better understand the long-term implications of endovascular coiling and hyperbaric oxygen therapy for rhinocerebral mucormycosis.

Gamma-tocopherol prevents airway eosinophilia and mucous cell hyperplasia in experimentally induced allergic rhinitis and asthma.

BACKGROUND: Traditional therapies for asthma and allergic rhinitis (AR) such as corticosteroids and antihistamines are not without limitations and side effects. The use of complementary and alternative approaches to treat allergic airways disease, including the use of herbal and dietary supplements, is increasing but their efficacy and safety are relatively understudied. Previously, we have demonstrated that gamma-tocopherol (gammaT), the primary form of dietary vitamin E, is more effective than alpha-tocopherol, the primary form found in supplements and tissue, in reducing systemic inflammation induced by non-immunogenic stimuli. OBJECTIVE: We used allergic Brown Norway rats to test the hypothesis that a dietary supplement with gammaT would protect from adverse nasal and pulmonary responses to airway allergen provocation. METHODS: Ovalbumin (OVA)-sensitized Brown Norway rats were treated orally with gammaT before intranasal provocation with OVA. Twenty-four hours after two challenges, histopathological changes in the nose, sinus and pulmonary airways were compared with gene expression and cytokine production in bronchoalveolar lavage fluid and plasma. RESULTS: We found that acute dosing for 4 days with gammaT was sufficient to provide broad protection from inflammatory cell recruitment and epithelial cell alterations induced by allergen challenge. Eosinophil infiltration into airspaces and tissues of the lung, nose, sinus and nasolacrimal duct was blocked in allergic rats treated with gammaT. Pulmonary production of soluble mediators PGE(2), LTB(4) and cysteinyl leukotrienes, and nasal expression of IL-4, -5, -13 and IFN-gamma were also inhibited by gammaT. Mucous cell metaplasia, the increase in the number of goblet cells and amounts of intraepithelial mucus storage, was induced by allergen in both pulmonary and nasal airways and decreased by treatment with gammaT. CONCLUSIONS: Acute treatment with gammaT inhibits important inflammatory pathways that underlie the pathogenesis of both AR and asthma. Supplementation with gammaT may be a novel complementary therapy for allergic airways disease.

Celulitis orbitaria en la edad pediátrica. Revisión / Orbital cellulitis in childhood. Review

La celulitis orbitaria comprende dos patologías bien diferenciadas desde un punto de vista anatomoclínico: la forma preseptal y la postseptal. Constituye una enfermedad infecciosa relativamente frecuente en la edad pediátrica que, normalmente, es secundaria a sinusitis. Presentamos una revisión de esta patología haciendo especial hincapié en el cambio etiológico acontecido en la última década tras la vacunación sistemática contra Haemophilus influenzae tipo B. (AU)

Diagnostic techniques in chronic sinusitis: endoscopy, sinusomanometry.

The first endoscope was conceived as early as 1806. Since then successive technical advances led endoscopy of the nose and paranasal sinuses to a routine procedure. From the rediscovery of the rigid telescopes by Hopkins in the fifties, progress has stemmed essentially from the quality of the more powerful cold lights and the improvement in the light output of the fiber optics. Exam procedures of the nose and sinuses are conducted under general as well as local anesthesia, and are commonly combined with concomitant diagnostic procedures: measure of the mucociliary clearance with indicators, biopsies, smear sampling for bacterial and fungal examinations, and sinusomanometry which can help to estimate the patency of the maxillary ostium and of the nasofrontal duct. Sinus endoscopy has been widely used to correlate efficiency of other diagnostic techniques such as plain X-rays, CT scanners, A and B mode ultrasonography. A similar work should be done for MRI. Endoscopic exploration is the key to the management of chronic pathology as it brings precise information on the quality of the naso-sinus mucosa, the presence of secretions and, combined with sinusomanometry, the functional state of the ostia or ducts.

Invasive rhinosino-orbital aspergillosis with precipitous visual loss.

OBJECTIVE: To describe the clinicopathological and radiologic features in five cases of primary and secondary orbital aspergillosis. DESIGN: Case series. SETTING: Ophthalmology department of a university hospital. PATIENTS: Five patients over 65 years of age with invasive rhinosino-orbital aspergillosis. RESULTS: Presenting features were abrupt onset of proptosis, ophthalmoplegia and blepharoptosis with precipitous visual loss. All had debilitating periorbital pain or headache, but none had orbital inflammatory signs or appeared "toxic." Predisposing causes included alcoholism, low-dose prednisone therapy and insulin-dependent diabetes mellitus. One patient, suspected of having mucormycosis based on tissue biopsy and results of potassium hydroxide preparations, harboured Aspergillus fumigatus, which grew on culture. Secondary bacterial infections developed in three patients. Three patients died from their disease despite aggressive surgical treatment, including exenteration and sinus extirpation. The one patient with primary orbital aspergillosis survived after exenteration. CONCLUSIONS: Sinonasal aspergillosis with orbital extension and primary orbital aspergillosis have a precipitous clinical course that mimics that of mucormycosis and may be fatal despite early exenteration. Computed tomography and magnetic resonance imaging of the sinuses, orbit and head provide complementary diagnostic signs. While results of potassium hydroxide preparations and tissue biopsy guide treatment of fungal infection, definitive diagnosis requires fungal culture. Relatively good vision may be associated with massive orbital and secondary intracranial extension.