Incorporating Asthma Evaluation into the Otolaryngic Allergy Practice: Presentation and Diagnosis.

Asthma occurs frequently as a comorbid condition in many patients presenting with common otolaryngology conditions, such as allergic rhinitis and chronic sinusitis with nasal polyps. The classic presentation of asthma includes symptoms of wheezing, shortness of breath, and chest tightness but can include other symptoms such as cough. The diagnosis is made mainly through history, although pulmonary function testing, spirometry, fractional exhaled nitric oxide, and impulse oscillometry may also prove helpful.

Allergic Fungal Rhinosinusitis in a 12-Year-Old Male Resulting in the Remodeling of Cribriform Plate With Protrusion Into the Anterior Cranial Fossa: A Case Report.

Allergic fungal rhinosinusitis (AFRS) in the pediatric population is a rare pathologic entity, and it is characterized by a type I hypersensitivity reaction to sinus fungi promoting the development of eosinophilic inflammation and thickened mucin. In the United States, a higher prevalence of AFRS is found among younger populations, African Americans, in counties characterized by elevated poverty rates, and patients without insurance or those reliant on Medicaid. Early clinical suspicion is essential for the timely diagnosis of this condition and to prevent the dissemination of the disease, thereby achieving a favorable prognosis. We report a case of a 12-year-old African American male who presented with the gradual onset of asymptomatic proptosis and seasonal allergy symptoms resulting in unilateral relative afferent pupillary defect and was ultimately diagnosed with AFRS.

Determinants of physician assessment of chronic rhinosinusitis disease control using EPOS 2020 criteria and the importance of incorporating patient perspectives of disease control.

BACKGROUND: We identify chronic rhinosinusitis (CRS) manifestations associated with how rhinologists assess CRS control, with a focus on patient perspectives (patient-reported CRS control). METHODS: Fifteen rhinologists were provided with real-world data from 200 CRS patients. Participating rhinologists first classified patients' CRS control as "controlled," "partly controlled," and "uncontrolled" using seven CRS manifestations reflecting European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) CRS control criteria (nasal obstruction, drainage, impaired smell, facial pain/pressure, sleep disturbance, use of systemic antibiotics/corticosteroids in past 6 months, and nasal endoscopy findings) and patient-reported CRS control. They then classified patients' CRS control without knowledge of patient-reported CRS control. Interrater reliability and agreement of rhinologist-assessed CRS control with patient-reported CRS control and EPOS guidelines were determined. RESULTS: CRS control classification with and without knowledge of patient-reported CRS control was highly consistent across rhinologists (κw  = 0.758). Rhinologist-assessed CRS control agreed with patient-reported CRS control significantly better when rhinologists had knowledge of patient-reported CRS control (κw  = 0.736 vs. κw  = 0.554, p < 0.001). Patient-reported CRS control, nasal obstruction, drainage, and endoscopy findings were most strongly associated with rhinologists' assessment of CRS control. Rhinologists' CRS control assessments weakly agreed with EPOS CRS control guidelines with (κw  = 0.529) and without (κw  = 0.538) patient-reported CRS control. Rhinologists classified CRS as more controlled than EPOS guidelines in almost 50% of cases. CONCLUSIONS: This study directly demonstrates the importance of patient-reported CRS control as a dominant influence on rhinologists' CRS control assessment. Knowledge of patient-reported CRS control may better align rhinologists' CRS control assessments and treatment decisions with patients' perspectives.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023.

BACKGROUND: In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document. METHODS: ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work. RESULTS: ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost. CONCLUSION: The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Defining the Efficacy of Omalizumab in Nasal Polyposis: A POLYP 1 and POLYP 2 Subgroup Analysis.

BACKGROUND: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous disease with variable underlying pathophysiologies. Numerous patient factors have been linked to differences in disease severity, control, and response to treatment, including asthma status, aspirin sensitivity, previous sinonasal surgery, and blood eosinophil levels. OBJECTIVE: The present study examines the efficacy of the anti-immunoglobulin E therapy, omalizumab, versus placebo in patients with CRSwNP from the replicate POLYP 1 (NCT03280550) and POLYP 2 (NCT03280537) trials, grouped by inherent patient characteristics to determine the response to therapy. METHODS: Patients in prespecified subgroups from POLYP 1 and POLYP 2 (studies pooled for analysis) were examined. Subgroups included blood eosinophil count at baseline (>300 or ≤300 cells/µL), previous sinonasal surgery (yes or no), asthma status (yes or no), and aspirin sensitivity status (yes or no). Subgroups were examined for subgroup-specific adjusted mean difference (95% confidence interval [CI]) (omalizumab-placebo) in change from baseline at week 24 in Nasal Congestion Score (NCS), Nasal Polyp Score (NPS), Sino-Nasal Outcome Test-22 (SNOT-22), Total Nasal Symptom Score (TNSS), and University of Pennsylvania Smell Identification Test (UPSIT). RESULTS: Adjusted mean difference (95% CI) (omalizumab-placebo) in NCS, NPS, SNOT-22, TNSS, and UPSIT change from baseline at week 24 consistently favored omalizumab treatment over placebo in patients with blood eosinophil count >300 and ≤300 cells/µL, with or without previous sinonasal surgery, asthma, and aspirin sensitivity. CONCLUSION: Together, these data suggest broad efficacy of omalizumab across clinical and patient-reported outcomes in patients with CRSwNP, independent of the underlying patient factors examined, including those with high eosinophil levels and those who have undergone previous surgery, which are associated with high recurrence. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifiers: POLYP 1: ClinicalTrials.gov identifier NCT03280550 (https://clinicaltrials.gov/ct2/show/NCT03280550); POLYP 2: ClinicalTrials.gov identifier NCT03280537 (https://clinicaltrials.gov/ct2/show/NCT03280537).

Mechanisms and Practical Use of Biologic Therapies for Allergy and Asthma Indications.

This article presents a concise overview of the important aspects of the immunologic mechanisms targeted by T-helper 2-directed monoclonal antibodies, as well as their practical applications in the treatment of allergic disorders (specifically allergic rhinitis) and asthma. Several of these novel agents treat multiple diseases, so understanding their targets and the underlying disease process can aid patient selection. In addition, the particular targets of the therapeutics seem to be shifting to include not only agents that intervene against inflammatory cytokines or their receptors but also specific molecular epitopes and cellular surface proteins.

Cost-effective Analysis of Subcutaneous vs Sublingual Immunotherapy From the Payor's Perspective.

OBJECTIVE: Compare the cost-effectiveness of subcutaneous immunotherapy (SCIT) and aqueous sublingual immunotherapy (SLIT) as treatment modalities for adult patients with allergic rhinitis and conjunctivitis who undergo testing and qualify for allergen immunotherapy (AIT). METHODS: A systematic review was performed to identify key statistics for analysis, including the compliance and efficacy rates for each treatment. The body of literature on this topic is highly heterogeneous, so ranges were obtained and assumptions stated clearly where they were made. Charges were derived from average commercial payor charges from a single hospital institution. A hypothetical 100 patients are examined for the study. RESULTS: A cost-effectiveness sensitivity analysis was then performed using a decision tree model to compare the modalities. A sensitivity and threshold analysis was then performed to assess the strength of recommendations after identifying results at baseline. DISCUSSION: Assuming an 80% compliance rate with allergen immunotherapy and an estimated efficacy (assumed to be clinically significant improvement in symptoms) of 70% for SLIT and 80% for SCIT, at the 12-month mark, the baseline total cost to the payor of SLIT per successful treatment outcome is $1196 while the charge of SCIT per successful treatment outcome is $2691. Our analysis favors SLIT as the more cost-effective modality per successful outcome. IMPLICATIONS FOR PRACTICE: When compared to SCIT, SLIT is economically favorable and should be considered the financially conscious option for patients with >40% adherence to therapy.

Cross-reactivity in Skin Prick Test Results of Members Within Pooideae Subfamily.

OBJECTIVE: Molecular similarities of grass pollen antigens have led to the view that cross-reactivity exists within members of the Pooideae subfamily of grasses. This has resulted in testing for only the most antigenically representative member of Pooideae, Timothy grass (Phleum pratense), despite little literature to support the claim that Phleum is the most representative member or that in vitro cross-reactivity correlates with in vivo cross-reactivity. The aim of the study was to determine if patients with allergic rhinitis symptoms and positive skin prick test results to meadow fescue (Festuca pratensis) also have positive results to Timothy grass. STUDY DESIGN: Retrospective cross-sectional study. SETTING: Tertiary care center in middle Missouri. METHODS: A retrospective chart review identified patients ≥12 years old with a diagnosis of allergic rhinitis who underwent skin prick testing between March 2016 and July 2018, by using a search with CPT code 95004 (Current Procedural Terminology). Positive skin prick test results were based on wheal produced ≥3 mm than the negative control. RESULTS: After review of 2182 charts, 1587 patients met criteria to test for Phleum and Festuca. In total, 1239 patients had a positive result for Phleum or Festuca. Of these, 479 (38.6%) tested positive for Festuca alone, while 342 (27.6%) and 418 (33.7%) tested positive for Phleum alone and Phleum+Festuca, respectively. CONCLUSION: Clinical cross-reactivity among Pooideae members may not be as complete as traditionally thought. P pratense may not be the most antigenically representative subfamily member, and other grasses may need to be included in skin prick testing.

Biologics for chronic rhinosinusitis with nasal polyps: Economics and ethics.

Biologics have recently been approved for use in chronic rhinosinusitis with nasal polyps patients. While effective in controlling disease on subjective and objective short-term outcome measures, limited data suggest that biologics have the potential to be used long term. The current wholesale acquisition costs for biologics are quite high. Widespread, prolonged use of these medications may create a large burden to our healthcare system. Cost-effectiveness analyses, particularly for specific patient cohorts, are needed to determine appropriate use of these medications. The ethics of patient preference of various treatment options, counseling regarding side effect profiles, and healthcare economics also need to be addressed.

Targeted Molecular Therapies in Allergy and Rhinology.

Biologic agents, monoclonal antibodies that target highly-specific molecular pathways of inflammation, are becoming integrated into care pathways for multiple disorders that are relevant in otolaryngology and allergy. These conditions share common inflammatory mechanisms of so-called Type 2 inflammation with dysregulation of immunoglobulin E production and eosinophil and mast cell degranulation leading to tissue damage. Biologic agents are now available for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP), asthma, eosinophilic granulomatosis with polyangiitis (EGPA), atopic dermatitis (AD), and chronic spontaneous urticaria (CSU). This paper summarizes the diagnosis and management of these conditions and critically reviews the clinical trial data that has led to regulatory approval of biologic agents for these conditions.

The Role of Biologics in the Treatment of Nasal Polyps.

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heteromorphic disease with both medical and surgical aspects to its treatment. CRSwNP is a chronic inflammatory condition with exacerbations that can be controlled through surgical and/or medical interventions, including biological agents. The role of biological agents in the treatment of CRSwNP as well as the patient characteristics that make suitable candidates for biologics are discussed.

The state of diversity based on race, ethnicity, and sex in otolaryngology in 2016.

OBJECTIVE: To compare the representation of women and racial minorities among otolaryngology residents and faculty to other surgical specialties. METHODS: Information from 2016 regarding female and minority representation among medical school graduates, otolaryngology applicants, otolaryngology residents, otolaryngology faculty and residents, and faculty in other surgical specialties was obtained from the publicly available registries from the American Medical Association and the American Association of Medical Colleges. The data obtained was used to explore the differences between the various stages of training in otolaryngology and to compare the female and minority diversity of otolaryngology residents with residents in other surgical specialties. RESULTS: Women and African Americans were underrepresented at the resident level compared with their level of representation as medical school graduates. Women were underrepresented in otolaryngology resident applicants (P < .001), but equally represented between otolaryngology residency applicants and residents (P = .582). African Americans were equally represented between medical school graduates and otolaryngology resident applicants (P = .871), but underrepresented in otolaryngology residents (P < .001). Asian Americans and Hispanics were underrepresented among otolaryngology faculty compared with their representation in otolaryngology residency programs (P < .001, P < .001, respectively). Otolaryngology has the lowest percentage of African-American residents and faculty compared to other surgical specialties. The representation of women in otolaryngology residencies is higher than most surgical specialties but worse than general surgery, integrated plastics, and medical school graduates. CONCLUSION: Otolaryngology lags behind other surgical specialties in representation of minorities and women. Continued efforts should be made to increase diversity in the field of otolaryngology, especially in regard to underrepresented minorities. LEVEL OF EVIDENCE: 3 Laryngoscope, 2019.

Pilot study of an Objective Structured Clinical Examination ("the Six Pack") for evaluating clinical competencies.

OBJECTIVE: The purpose of this study was to evaluate an Objective Structured Clinical Examination (OSCE) designed to examine all six competencies and provide meaningful results to improve resident performance. STUDY DESIGN: A prospective, observational study. METHODS: The OSCE consists of 1 hour for examination of a simulated patient, documentation, and feedback, with 30 minutes for an evidence-based medicine (EBM) test. Eight otolaryngology residents participated. Digital recordings and written documentation were evaluated on all competencies except practice-based learning. An EBM test was scored to assess practice-based learning. RESULTS: Overall, senior residents scored better. Seniors scored better on performing a focused history, whereas juniors scored better for thoroughness. Seniors coded better than juniors, although seniors tended to undercode and juniors tended to overcode. Two cases of "insurance fraud" were also discovered. CONCLUSIONS: The "Six Pack" successfully evaluated all competencies while providing valuable information. A clinical practicum was added to improve history and physical examination skills. The discussion of coding and a billing seminar also resulted. Residents believed the OSCE was valuable. Faculty members were impressed with the useful information obtained.

Congenital midline cervical cleft: a report of two cases.

Congenital midline cervical cleft is an uncommon malformation of the anterior neck. We report the cases of two patients with such an anomaly who had been born within 10 days of each other at a regional hospital in upstate New York. Fewer than 100 cases of congenital midline cervical cleft have been reported in the literature, and to the best of our knowledge, none of the other reported cases occurred so close to each other in terms of time and location. Diagnoses in both cases were established by clinical observation soon after birth. No likely epidemiologic commonalities between the two patients were found. Head and neck surgeons should be familiar with these malformations because early surgical excision is critical. Both of our patients were surgically treated at an early age, one with a Z-plasty and one with a straight closure. In both cases, the patients exhibited good functional and cosmetic results at 5 years of age.

The Gestational Diabetes Group Program.

The purpose of the Gestational Diabetes Group Program (GDGP) was to provide patients with diabetes self-management education that occurs in a supportive, prenatal group care setting. The Centering Pregnancy Interdisciplinary Model of Empowerment and the Chronic Care Model guided the program. The pilot project took place at an urban clinic that cares for a diverse, underserved population. The GDGP, a series of four prenatal group sessions after the diagnosis of gestational diabetes and one postpartum group, used an interprofessional/interdisciplinary approach to care with the groups cofacilitated by certified nurse-midwives, certified diabetes nurse-educators, and other community partners. The program was able to show statistically significant changes in knowledge and empowerment, optimal pregnancy outcomes, and high patient satisfaction.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis.

BACKGROUND: Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR). METHODS: Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus. RESULTS: The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR. CONCLUSION: This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

When to cut? Using an objective structured clinical examination to evaluate surgical decision-making.

OBJECTIVES: To create an objective structured clinical examination (OSCE) tailored to surgical residents that uses surgical case scenarios appropriate for the experience level of the resident to evaluate whether residents understand the indications for a specific surgery, identify when indications are met, and make the appropriate decision to proceed with an operation. METHODS: The surgical OSCE consisted of two case scenarios: a junior case created for postgraduate year (PGY) 2 to 3 level residents and a senior case created for PGY 4 to 5 level residents. Four senior residents and four junior residents in the otolaryngology department participated. Residents were instructed to proceed as if they had all the capabilities of the otolaryngology clinic. Recordings were made of each encounter and were reviewed by two separate faculty member with expertise in each case. Faculty evaluated whether surgical indications were elicited by history, whether certain physical examination or radiographic findings were recognized, whether residents made the correct diagnosis, and whether residents not only made the decision to proceed with surgery but also indicated the correct surgery. RESULTS: Seniors (100%) were better at obtaining needed surgical information and indications than juniors (25%). Seniors were more willing to make the decision to proceed with surgery (100%), whereas no juniors actually scheduled surgery. The reasons for this ranged from failure to elicit surgical indications to lack of surety in proceeding with surgery. All seniors recommended the appropriate surgery, but only 75% correctly identified the need for emergent intervention. Results of evaluations were reviewed with each resident individually. CONCLUSIONS: The surgical OSCE was successful in evaluating resident surgical decision-making. Juniors were not as capable as seniors in eliciting surgical indications and in "making the jump" to proceed with surgery. These results were used by our faculty to work with juniors on surgical history-taking and decision-making. These results were also useful in identifying seniors who could recognize an emergency situation.

Adult outpatient tracheostomy care: practices and perspectives.

OBJECTIVES: To determine the attitudes, opinions, and current practice of adult outpatient tracheostomy care from the surgeon and primary care physician's perspective. STUDY DESIGN: Multidisciplinary physician survey. RESULTS: Found 53.4% (667 of 1250) and 28.9% (404 of 1400) of otolaryngologists and internists responded, respectively; 47% of otolaryngologists lack standardized tracheostomy discharge protocols. General ward nurses most commonly (33%) provide discharge education. A total of 64% of otolaryngologists felt primarily responsible for tracheostomy care and follow-up; 48% expect the primary physician to provide some or all tracheostomy care. Ninety-seven percent of internists received little or no residency training in tracheostomy care, which was significantly associated with decreased comfort (P<0.0001) and willingness (P<0.0001) to care for these patients. CONCLUSIONS: Tracheostomy care is a concerted effort between the patient, surgeon, primary physician, and interdisciplinary team. Otolaryngologists should strive to standardize tracheostomy discharge, education, and follow-up practices. SIGNIFICANCE: Disparities are highlighted between disciplines in their comfort, willingness, and knowledge of outpatient tracheostomy care.

The evolution of surgical training: perspectives on educational models from the past to the future.

Surgical education and training have progressed through the centuries, with the most commonly used model being the apprentice model. With advances in medical knowledge and practice, the apprentice model has evolved and competing models have arisen. However, the apprentice model remains the gold standard today, but for future use, further evolutionary changes will need to be made to the apprentice model if it is to continue to remain an effective education paradigm.

Advances in Food Allergy.

Food allergy has been increasing in prevalence for the last few decades, and numerous studies have evaluated ways of improving the allergy practitioner's ability to accurately diagnose patients who are truly food allergic, rather than sensitive but able to tolerate food. Once diagnosed, the current standard treatment is food elimination and avoidance, but other potential treatment options like oral immunotherapy, sublingual immunotherapy, and epicutaneous immunotherapy are becoming promising alternatives. Due the health care costs and potential for life-threatening adverse reactions, much attention has been given to the prevention of food allergies, resulting a shift in recent guideline recommendations.