Investigation of gender-based needs in academic otolaryngology.

Objective: Gaps in gender-based equity persist in academic otolaryngology. Here we present a needs-based assessment of otolaryngology faculty and trainees regarding facilitators and barriers to professional satisfaction and career development in academic medicine. Methods: A qualitative study of otolaryngology faculty, trainees, and administrators who identify as women at an academic tertiary care center was performed from 2020 to 2021 using focus groups and semi-structured interviews. Five confidential, virtual focus group sessions moderated by a third-party executive coach were audio-taped, transcribed, and reviewed for thematic content. Results: Of 48 women invited, 77% participated (18 faculty/administrative leaders, 10 residents/fellows, 4 audiologists). Participants noted direct patient care, support from colleagues who identify as women, and the transition to virtual meetings as facilitators of current professional satisfaction. Five themes emerged as barriers to workplace satisfaction and career development including (1) limited professional schedule flexibility, (2) competing commitments such as childcare exacerbated by pandemic, (3) lack of visible departmental leadership who identify as women, (4) perceived lack of organic sponsorship within subspecialty divisions, and (5) frequent identity-associated microaggressions from patients and staff outside the department. Strategies identified for improving gender-based equity included (1) promoting department-wide awareness of workplace gender-based differences, (2) implicit bias training within established programming such as grand rounds conferences, and (3) novel faculty programming such as leadership development training and formal junior faculty mentorship. Conclusion: Confidential needs-based assessment of otolaryngology faculty and trainees identified both persistent gaps and strategies to enhance recruitment, support career development, and grow professional satisfaction of women within academic otolaryngology. Level of Evidence: 3.

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.

Phosphaturic Mesenchymal Tumors of the Sinonasal Area and Skull Base: Experience at a Single Institution.

OBJECTIVES: Phosphaturic mesenchymal tumor (PMT) is a rare, polymorphous neoplasm with a highly variable presentation and natural history and unpredictable clinical course. The primary objective was to describe our clinical experience with and management of 4 markedly different cases of sinonasal and skull base PMT. METHODS: A retrospective case series with chart review, and relevant literature review, was performed at a tertiary academic medical center between 1998 and 2020. Adult patients treated for PMTs of the sinonasal area and skull base were included. Our main outcome measures included postoperative laboratory findings and radiological evidence of disease remission. RESULTS: Four patients (2 Males, 2 Females; Mean Age: 63.5 years) with PMTs of the skull base have been managed at our institution since 1998. Patient presentations varied, ranging from severe phosphorus wasting and osteoporosis to symptoms secondary to mass effect, including nasal obstruction and rhinorrhea. All 4 patients were eventually found to have elevated levels of fibroblast growth factor 23. Tumors were located in the sinonasal area (right frontal sinus, right ethmoid sinus, and right nasal cavity, respectively) in 3 patients and in the lateral skull base (right jugular foramen) in 1 patient. All 4 patients underwent complete surgical resection of their tumors. PMT tissue pathology was confirmed in all cases. Gross total resection was achieved in all patients. There was no chemical or radiological evidence of disease recurrence in any patients at follow-up. CONCLUSIONS: The presentation of skull base PMT is variable, and it may mimic other mass pathologies of the head and neck. Complete surgical resection with negative margins is potentially curative.

Probiotics as adjunctive treatment for chronic rhinosinusitis: a randomized controlled trial.

OBJECTIVE: To determine if oral probiotics as adjunctive treatment are more effective than placebo in improving quality of life in patients with chronic inflammatory rhinosinusitis. DESIGN: Prospective, randomized, double-blind, placebo-controlled trial. METHODS: A total of 77 patients with chronic inflammatory rhinosinusitis were randomly assigned to receive oral probiotic Lactobacillus rhamnosus R0011 strain (500 million active cells/tablet twice daily) (n = 39) or oral placebo treatment (n = 38) for 4 weeks. RESULTS: In the probiotic group, the mean change from baseline in the SNOT-20 scores was significant at 4 weeks (P = 0.002) but not at 8 weeks (P = 0.37). Rhinological domain improved by 9.3 percent (P = 0.004) in probiotics group but returned to baseline level at 8 weeks. No significant differences were found between the probiotic and placebo groups in mean changes from baseline to 4 weeks (P = 0.79) or from baseline to 8 weeks (P = 0.23). No changes in symptom frequency were noted, either within each group or between treatment groups at 4 and 8 weeks. There was no difference in medication use or side effects between the two study groups. CONCLUSION: Oral use of the probiotic strain L rhamnosus R0011 did not improve sinonasal quality-of-life scores in patients with chronic inflammatory rhinosinusitis compared with placebo.

In-Office Balloon Dilation of the Eustachian Tube under Local Anesthesia.

Balloon dilation of the Eustachian tube (BDET) is an effective treatment of Eustachian tube dysfunction. This procedure can be performed under local anesthesia in the office. This article outlines the evolution of BDET under local anesthesia, describes the techniques of in-office BDET and provides an algorithm to identify suitable patients for this procedure.

Reprocessing Flexible Endoscopes in the Otolaryngology Clinic.

Reprocessing a flexible endoscope is a complex multistep process. Attention to detail is essential for patient safety. Physicians need to empower their staff to function as guardians and advocates for best practices in endoscope reprocessing. Current best practice standards and guidelines for flexible endoscope reprocessing in the United States have been led by the Society of Gastroenterology Nurses and Associates, the Association for the Advancement of Medical Instrumentation, the Association of periOperative Registered Nurses, American Society for Gastrointestinal Endoscopy, and Multisociety Guideline. This article focuses on important aspects and current best practices for flexible endoscope cleaning and high-level disinfection.

The current practice of open neck mass biopsy in the diagnosis of head and neck cancer: A retrospective cohort study.

OBJECTIVE: To characterize current use of open neck mass biopsy for diagnosis of squamous cell carcinoma in patients presenting with a neck mass. METHODS: Using the University of Michigan Specialized Program of Research Excellence in Head and Neck Cancer patient database (2008-2014), we reviewed patients' referral documentation to identify those who received open neck mass biopsies as part of their squamous cell carcinoma diagnosis. We compared subsequent treatment between patients who did and did not receive an open neck mass biopsy. RESULTS: Of 940 patients, 50 patients had received open neck mass biopsy leading to squamous cell carcinoma diagnosis. Only 19 of 50 patients (38%) had undergone fine-needle aspiration prior to open neck mass biopsy. There were no statistically significant differences in treatment or outcomes between patients who did and those who did not receive open neck mass biopsy. CONCLUSION: Optimal care for patients who present with a neck mass is fine-needle aspiration. Unfortunately, these data show that many patients undergo open neck mass biopsy for diagnosis, often without prior fine-needle aspirate. Compared to fine-needle aspiration, open biopsy incurs additional risks of general anesthesia and greater surgical risks. While our data did not find statistically significant differences between treatment offered and outcomes, this small study was not expected to demonstrate a difference in outcomes. Further work is needed to promote the utility of fine-needle aspiration for diagnosis of neck mass and to discourage use of open neck mass biopsy as a primary diagnostic intervention. LEVEL OF EVIDENCE: 2c (Outcomes Research).

Is There a Difference in Staging and Treatment of Head and Neck Squamous Cell Tumors Between Tertiary Care and Community-Based Institutions?

OBJECTIVE: To characterize the differences in the staging and treatment of patients with head and neck squamous cell carcinoma between a tertiary care center and community-based practices. METHODS: This study is a retrospective chart review of 943 adult patients with head and neck squamous cell cancer presenting to a tertiary care center between 2008 and 2014 as part of the University of Michigan Head and Neck Cancer Specialized Program of Research Excellence (UM HN-SPORE) database. Demographic information, diagnostic testing, staging information, and treatment recommendations were recorded. RESULTS: Of 943 patients reviewed, 159 had documentation of tumor stage that was assigned by the community-based practice. Of these, 53% had a tumor staging change made at the tertiary care center, with 43% of patients upstaged and 10% of patients downstaged. Fifty-one percent received different treatment than had previously been offered at the community-based practice, although only 31% of these patients had a change in tumor staging. CONCLUSION: Over half of patients with head and neck squamous cell carcinoma who are evaluated at a tertiary care center after the initial evaluation at a community-based practice have their tumors staged differently, with the majority upstaged. A significant number of these patients also received different treatment than was initially offered at the referring practice. Future studies are required to determine whether these differences have an effect on tumor recurrence and patient survival rates. LEVEL OF EVIDENCE: 2c (Outcomes Research).

Idiopathic Sudden Sensorineural Hearing Loss Is Not a Sentinel Event for Acute Myocardial Infarction.

OBJECTIVE: Given ongoing debate about the suggested association, the primary objective was to determine if idiopathic sudden sensorineural hearing loss (ISSNHL) was a sentinel event for acute myocardial infarction (AMI) in adults. STUDY DESIGN: Case-control study. SETTING: United States MarketScan administrative health claims database. PATIENTS: Aged 18 years or older, had a diagnosis of ISSNHL on or after January 1st, 2011 and had sufficient follow-up data available to assess for AMI occurrence. INTERVENTION: N/A. MAIN OUTCOME MEASURES: Incidence rates (per 1,000 patient years) of AMI for cases and controls were computed. Adjusted and unadjusted Cox proportional hazards models were created to explore possible associations between ISSNHL and initial AMI. RESULTS: A total of 10,749 ISSNHL cases and 10,749 matched controls were included. There were no significant differences in the incidence rate of AMI between ISSNHL cases (8.29 events/1,000 person-years) and controls (9.25 events/1,000 person-years), nor were there differences within age groups, sex, or comorbidity status (overall incidence rate ratio 0.90; 95% confidence interval [CI] 0.70-1.15 p = 0.39). The unadjusted and adjusted Cox proportional hazards models did not demonstrate an association between ISSNHL and initial AMI (hazard ratio [HR]: 0.90, 95% CI: 0.70-1.15; HR: 0.86, 95% CI: 0.67-1.10, respectively). CONCLUSIONS: ISSNHL is not a predictor of an initial AMI in adult patients from the United States. Considerable inconsistencies in associations between cardiovascular risk factors and ISSNHL exist in the literature. Further work is needed to confirm or refute direct associations between cardiovascular disease risk factors and ISSNHL before definitive mechanistic conclusions can be made.

Nasal saline for chronic sinonasal symptoms: a randomized controlled trial.

OBJECTIVE: To determine if isotonic sodium chloride (hereinafter "saline") nasal irrigations performed with large volume and delivered with low positive pressure are more effective than saline sprays at improving quality of life and decreasing medication use. DESIGN: A prospective, randomized controlled trial. SETTING: Community. PARTICIPANTS: A total of 127 adults with chronic nasal and sinus symptoms. INTERVENTIONS: Patients were randomly assigned to irrigation performed with large volume and delivered with low positive pressure (n = 64) or spray (n = 63) for 8 weeks. MAIN OUTCOME MEASURES: Change in symptom severity measured by mean 20-Item Sino-Nasal Outcome Test (SNOT-20) score; change in symptom frequency measured with a global question; and change in medication use. RESULTS: A total of 121 patients were evaluable. The irrigation group achieved lower SNOT-20 scores than the spray group at all 3 time points: 4.4 points lower at 2 weeks (P = .02); 8.2 points lower at 4 weeks (P < .001); and 6.4 points lower at 8 weeks (P = .002). When symptom frequency was analyzed, 40% of subjects in the irrigation group reported symptoms "often or always" at 8 weeks compared with 61% in the spray group (absolute risk reduction, 0.2; 95% confidence interval, 0.02-0.38 (P = .01). No significant differences in sinus medication use were seen between groups. CONCLUSION: Nasal irrigations performed with large volume and delivered with low positive pressure are more effective than saline sprays for treatment of chronic nasal and sinus symptoms in a community-based population.

Plain Language Summary: Evaluation of the Neck Mass in Adults.

This plain language summary serves as an overview in explaining the evaluation of the neck mass in adults. The summary applies to patients aged ≥18 years and is based on the 2017 "Clinical Practice Guideline: Evaluation of the Neck Mass in Adults." The evidence-based guideline includes research to support more effective evaluation and diagnosis of the neck mass in adults. The guideline was developed as a quality improvement opportunity for evaluation of the neck mass by creating clear recommendations to use in medical practice.

Preoperative ß-blockade and hypertension in the first hour of functional endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: Local anesthetic with epinephrine is commonly injected into the nasal mucosa during functional endoscopic sinus surgery (FESS). Systemic absorption of epinephrine following local injection may occur, resulting in a mild sympathetic response. This study seeks to determine whether an exaggerated sympathetic response to epinephrine is demonstrated in patients undergoing FESS treated preoperatively with established pharmacologic beta (ß) adrenoceptor blockade. STUDY DESIGN: A retrospective analysis of adult patients undergoing FESS at a tertiary care university hospital. METHODS: The primary outcome was the occurrence of an exaggerated hypertensive response within the first hour of surgical time defined by a relative increase (>20%) in the first measured intraoperative systolic blood pressure (SBP) prior to induction of anesthesia, or a single SBP value above 200 mm Hg. A mixed effects logistic regression model was developed to identify independent predictors of an exaggerated hypertensive response and describe the variance in the outcome attributable to the surgeon and anesthesiologist. RESULTS: There were 2,051 patients identified. Independent predictors of an exaggerated intraoperative hypertensive event included: preoperative ß-blocker use (adjusted odds ratio [AOR]: 3.33), female gender (AOR: 1.92), body mass index (AOR: 1.03), lower baseline SBP (AOR: 0.93), and advanced age (AOR: 1.03). The C statistic for the model was 0.8881. CONCLUSIONS: Preoperative ß-blocker use is an independent predictor of an exaggerated hypertensive response within the first hour of operative time. An exaggerated hypertensive effect should be anticipated in patients presenting for FESS with established pharmacologic ß-blockade, and caution should be applied to use of epinephrine-containing solutions. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1496-1505, 2017.

CHEER National Study of Chronic Rhinosinusitis Practice Patterns: Disease Comorbidities and Factors Associated with Surgery.

Objectives (1) Describe national patterns of chronic rhinosinusitis (CRS) care across academic and community practices. (2) Determine the prevalence of comorbid disorders in CRS patients, including nasal polyposis, allergic rhinitis, asthma, and cystic fibrosis. (3) Identify demographic, clinical, and practice type factors associated with endoscopic sinus surgery (ESS). Study Design Multisite cross-sectional study. Setting Otolaryngology's national research network CHEER (Creating Healthcare Excellence through Education and Research). Subjects and Methods A total of 17,828 adult patients with CRS were identified, of which 10,434 were seen at community practices (59%, n = 8 sites) and 7394 at academic practices (41%, n = 10 sites). Multivariate logistic regression was used to evaluate the association between demographic, practice type, and clinical factors and the odds of a patient undergoing ESS. Results The average age was 50.4 years; 59.5% of patients were female; and 88.3% were Caucasian. The prevalence of comorbid diseases was as follows: allergic rhinitis (35.1%), nasal polyposis (13.3%), asthma (4.4%), and cystic fibrosis (0.2%). In addition, 24.8% of patients at academic centers underwent ESS, as compared with 12.3% at community sites. In multivariate analyses, nasal polyposis (odds ratio [OR], 4.28), cystic fibrosis (OR, 2.42), and academic site type (OR, 1.86) were associated with ESS ( P < .001), while adjusting for other factors. Conclusions We describe practice patterns of CRS care, as well as demographic and clinical factors associated with ESS. This is the first study of practice patterns in CRS utilizing the CHEER network and may be used to guide future research.

Clinical Practice Guideline: Evaluation of the Neck Mass in Adults.

Objective Neck masses are common in adults, but often the underlying etiology is not easily identifiable. While infections cause most of the neck masses in children, most persistent neck masses in adults are neoplasms. Malignant neoplasms far exceed any other etiology of adult neck mass. Importantly, an asymptomatic neck mass may be the initial or only clinically apparent manifestation of head and neck cancer, such as squamous cell carcinoma (HNSCC), lymphoma, thyroid, or salivary gland cancer. Evidence suggests that a neck mass in the adult patient should be considered malignant until proven otherwise. Timely diagnosis of a neck mass due to metastatic HNSCC is paramount because delayed diagnosis directly affects tumor stage and worsens prognosis. Unfortunately, despite substantial advances in testing modalities over the last few decades, diagnostic delays are common. Currently, there is only 1 evidence-based clinical practice guideline to assist clinicians in evaluating an adult with a neck mass. Additionally, much of the available information is fragmented, disorganized, or focused on specific etiologies. In addition, although there is literature related to the diagnostic accuracy of individual tests, there is little guidance about rational sequencing of tests in the course of clinical care. This guideline strives to bring a coherent, evidence-based, multidisciplinary perspective to the evaluation of the neck mass with the intention to facilitate prompt diagnosis and enhance patient outcomes. Purpose The primary purpose of this guideline is to promote the efficient, effective, and accurate diagnostic workup of neck masses to ensure that adults with potentially malignant disease receive prompt diagnosis and intervention to optimize outcomes. Specific goals include reducing delays in diagnosis of HNSCC; promoting appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies; reducing inappropriate testing; and promoting appropriate physical examination when cancer is suspected. The target patient for this guideline is anyone ≥18 years old with a neck mass. The target clinician for this guideline is anyone who may be the first clinician whom a patient with a neck mass encounters. This includes clinicians in primary care, dentistry, and emergency medicine, as well as pathologists and radiologists who have a role in diagnosing neck masses. This guideline does not apply to children. This guideline addresses the initial broad differential diagnosis of a neck mass in an adult. However, the intention is only to assist the clinician with a basic understanding of the broad array of possible entities. The intention is not to direct management of a neck mass known to originate from thyroid, salivary gland, mandibular, or dental pathology as management recommendations for these etiologies already exist. This guideline also does not address the subsequent management of specific pathologic entities, as treatment recommendations for benign and malignant neck masses can be found elsewhere. Instead, this guideline is restricted to addressing the appropriate work-up of an adult patient with a neck mass that may be malignant in order to expedite diagnosis and referral to a head and neck cancer specialist. The Guideline Development Group sought to craft a set of actionable statements relevant to diagnostic decisions made by a clinician in the workup of an adult patient with a neck mass. Furthermore, where possible, the Guideline Development Group incorporated evidence to promote high-quality and cost-effective care. Action Statements The development group made a strong recommendation that clinicians should order a neck computed tomography (or magnetic resonance imaging) with contrast for patients with a neck mass deemed at increased risk for malignancy. The development group made the following recommendations: (1) Clinicians should identify patients with a neck mass who are at increased risk for malignancy because the patient lacks a history of infectious etiology and the mass has been present for ≥2 weeks without significant fluctuation or the mass is of uncertain duration. (2) Clinicians should identify patients with a neck mass who are at increased risk for malignancy based on ≥1 of these physical examination characteristics: fixation to adjacent tissues, firm consistency, size >1.5 cm, or ulceration of overlying skin. (3) Clinicians should conduct an initial history and physical examination for patients with a neck mass to identify those with other suspicious findings that represent an increased risk for malignancy. (4) For patients with a neck mass who are not at increased risk for malignancy, clinicians or their designees should advise patients of criteria that would trigger the need for additional evaluation. Clinicians or their designees should also document a plan for follow-up to assess resolution or final diagnosis. (5) For patients with a neck mass who are deemed at increased risk for malignancy, clinicians or their designees should explain to the patient the significance of being at increased risk and explain any recommended diagnostic tests. (6) Clinicians should perform, or refer the patient to a clinician who can perform, a targeted physical examination (including visualizing the mucosa of the larynx, base of tongue, and pharynx) for patients with a neck mass deemed at increased risk for malignancy. (7) Clinicians should perform fine-needle aspiration (FNA) instead of open biopsy, or refer the patient to someone who can perform FNA, for patients with a neck mass deemed at increased risk for malignancy when the diagnosis of the neck mass remains uncertain. (8) For patients with a neck mass deemed at increased risk for malignancy, clinicians should continue evaluation of patients with a cystic neck mass, as determined by FNA or imaging studies, until a diagnosis is obtained and should not assume that the mass is benign. (9) Clinicians should obtain additional ancillary tests based on the patient's history and physical examination when a patient with a neck mass is deemed at increased risk for malignancy who does not have a diagnosis after FNA and imaging. (10) Clinicians should recommend evaluation of the upper aerodigestive tract under anesthesia, before open biopsy, for patients with a neck mass deemed at increased risk for malignancy and without a diagnosis or primary site identified with FNA, imaging, and/or ancillary tests. The development group recommended against clinicians routinely prescribing antibiotic therapy for patients with a neck mass unless there are signs and symptoms of bacterial infection.

Clinical Practice Guideline: Evaluation of the Neck Mass in Adults Executive Summary.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published a supplement to this issue of Otolaryngology-Head and Neck Surgery featuring the "Clinical Practice Guideline: Evaluation of the Neck Mass in Adults." To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 12 recommendations developed emphasize reducing delays in diagnosis of head and neck squamous cell carcinoma; promoting appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies; reducing inappropriate testing; and promoting appropriate physical examination when cancer is suspected.

Conditions that masquerade as chronic rhinosinusitis: a medical record review.

OBJECTIVE: To identify conditions that are commonly mistaken for chronic rhinosinusitis (CRS). The hypothesis was that many patients referred to a rhinology clinic with a presumptive diagnosis of CRS do not have CRS. DESIGN: Retrospective, observational design study of adult patients referred for evaluation of CRS-like symptoms. The expert opinion of the rhinologist was the diagnostic standard. SETTING: Tertiary care rhinology clinic. PATIENTS: A consecutive sample of 186 patients referred to the University of Michigan Health Systems' Department of Otolaryngology-Head and Neck Surgery between April 1998 and June 2000 for evaluation of CRS-like symptoms. MAIN OUTCOME MEASURES: For each patient, a history was obtained and a physical examination was performed, including nasal endoscopy and, when indicated, computed tomographic evaluation of the sinuses. Each patient's diagnosis at referral, CRS, was compared with the final diagnosis made by the rhinologist. The final diagnoses were collected and analyzed using descriptive statistics. RESULTS: Of 186 patients, 112 (60%) had CRS and 74 (40%) did not. The most common diagnoses among the patients who did not have CRS were allergic rhinitis (n = 37), laryngitis associated with reflux (n = 21), head or facial pain (n = 18), and nonallergic rhinitis (n = 23). Many patients had more than 1 diagnosis. CONCLUSIONS: Among a tertiary care population, common medical disorders, including rhinitis, laryngitis associated with reflux, and headache disorders, may simulate CRS. Heightened awareness of these conditions may improve diagnostic accuracy in patients with CRS-like symptoms.

National Practice Patterns of Antireflux Medication for Chronic Rhinosinusitis.

IMPORTANCE: Antireflux medication has been endorsed as a useful adjunctive therapy for chronic rhinosinusitis, but its use remains controversial. OBJECTIVES: To determine whether chronic rhinosinusitis is associated with administration of proton pump inhibitors, histamine2-receptor antagonists, antacids, or prokinetic agents; whether practice patterns vary according to visit setting; and whether those patterns vary according to the presence or absence of potentially confounding conditions. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional analysis was performed of data from January 1, 2005, to December 31, 2010, from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, which included 590 772 observations representing 7 191 711 480 ambulatory care visits. Univariate, multivariate, and stratified analyses were performed from January 1, 2005, to December 31, 2010. EXPOSURES: Chronic rhinosinusitis. MAIN OUTCOMES AND MEASURES: The probability of receiving antireflux medications was the main measured outcome. RESULTS: Of 7 191 711 480 ambulatory care visits, those for chronic rhinosinusitis were not more likely to result in the administration of proton pump inhibitors (odds ratio, 1.00; 95% CI, 0.62-1.63; P = .99) or antacids and prokinetic agents (odds ratio, 1.24; 95% CI, 0.30-5.10; P = .77). In addition, patients with chronic rhinosinusitis were less likely to receive histamine2-receptor antagonists than were those without chronic rhinosinusitis, even when adjusted for age, sex, race/ethnicity, visit setting, other antireflux agents, and presence or absence of gastroesophageal reflux, laryngopharyngeal reflux, or allergy diagnoses (odds ratio, 0.25; 95% CI, 0.12-0.57; P = .001). CONCLUSIONS AND RELEVANCE: National practice patterns observed thus far have not favored the use of proton pump inhibitors, histamine2-receptor antagonists, antacids, or prokinetic agents for chronic rhinosinusitis.

Academic institution pilot study shows far fewer diagnoses of sinusitis than reported nationally.

OBJECTIVE: To compare the prevalence of acute sinusitis (AS) and chronic sinusitis (CS) diagnosed by primary care and emergency medicine physicians in our academic institution to national data. STUDY DESIGN: Cross-sectional pilot study of institutional census data and a population-based national sample. The setting was primary care and emergency departments at an academic healthcare institution and community healthcare practices nationally. MATERIALS AND METHODS: We determined the proportion of adults visits at our institution for AS and CS from January 1, 2005, to December 31, 2010. We used the same parameters with the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. As a control comparison, we determined the proportion of visits for epistaxis. RESULTS: The sinusitis prevalence was considerably lower at our academic institution: all sinusitis (AS and CS combined) ranged from 0.8% to 1.0% at our institution compared to 3.1% to 3.7% nationally. There were very small differences between AS rates at the academic institution (0.7%-0.8%) and nationally (0.8%-1.4%, P < 0.001) but very large differences between CS rates at the academic institution (0.1%) and national data (1.7%-2.9%, P < 0.001). Epistaxis rates were nearly identical in both datasets (0.1%-0.2%, P = 0.98-0.99). CONCLUSION: The prevalence of CS is much lower at our academic institution, but the prevalence of AS and epistaxis are similar to national data. This suggests CS is over-diagnosed by primary care and emergency medicine providers and that CS diagnosed outside of an academic institution or a specialty clinic may not hold up to diagnostic scrutiny. For this reason, diagnostic and treatment protocols for CS that have been developed in academic specialty clinics should not be extrapolated to patients diagnosed with CS in the community setting. The most appropriate intervention for the majority of patients diagnosed with CS in primary care and emergency medicine may be education of providers and patients about conditions that may be misdiagnosed as CS.

Obstructive Sleep Apnea and Gastroesophageal Reflux: A Multivariate Population-Level Analysis.

OBJECTIVES: Previous studies investigating the relationship between gastroesophageal reflux (GER) and obstructive sleep apnea (OSA) demonstrate mixed results and have had limited capacity to control for concurrent confounders. Our objectives were to (1) determine if GER is significantly associated with OSA when simultaneously adjusting for the presence of other potentially confounding conditions and (2) quantify the magnitude of any such association that exists. STUDY DESIGN: Cross-sectional analysis of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 2005-2010. SETTING: Ambulatory visits in the United States. SUBJECTS AND METHODS: Adults with a diagnosis of OSA or GER and potentially confounding conditions were identified. Univariate and multivariate logistic regression analyses were performed, as well as sensitivity analyses based on increasingly narrow diagnostic definitions. RESULTS: A significant positive association between GER and OSA was observed, which persisted after adjustment for age, sex, race/ethnicity, sinonasal obstructive and inflammatory disorders, laryngopharyngeal obstructive and inflammatory disorders, obesity, asthma, and lung disorders. This positive association remained significant regardless of diagnostic criteria, whether broad (odds ratio: 1.94, 95% confidence interval: 1.07-3.54, P = .030) or narrow (odds ratio: 2.13, 95% confidence interval: 1.17-3.88, P = .014). CONCLUSION: In this analysis of a national database defining the 3 most prioritized diagnoses, GER is independently associated with OSA, with double the odds of concurrent occurrence, even while controlling for potentially related conditions.

A diagnostic dilemma: chronic sinusitis diagnosed by non-otolaryngologists.

BACKGROUND: Ambulatory care visits for chronic sinusitis outnumber visits for acute sinusitis. The majority of these visits are with non-otolaryngologists. In order to better understand patients diagnosed with chronic sinusitis by non-otolaryngologists, we sought to determine if incident cases of chronic sinusitis diagnosed by primary care (PC) or emergency medicine (EM) providers meet diagnostic criteria. METHODS: This was a retrospective cohort study. Patients were identified using administrative data from 2005 to 2006. The dataset was then clinically annotated based on chart review. We excluded prevalent cases. RESULTS: We identified 114 patients with newly diagnosed chronic sinusitis in EM (75) or PC settings (39). Rhinorrhea (EM 61%, PC 59%) and nasal obstruction (EM 67%, PC 64%) were common in both settings but facial fullness (EM 80%, PC 39%) and pain (EM 40%, PC 18%) were more common in the EM setting. Few patients reported symptoms of 90 days or longer (EM 6.0%, PC 24%) and no patient had evidence of inflammation on physical examination. A minority of patients received a sinus computed tomography (CT) scan (22.8%) or nasal endoscopy (1.8%). In total, only 1 patient diagnosed with chronic sinusitis met the diagnostic criteria. CONCLUSION: Most patients diagnosed with chronic sinusitis by non-otolaryngologists do not have the condition. Caution should be used in studying chronic sinusitis using administrative data from non-otolaryngology providers because a large proportion of the patients may not actually have the disease.