Evaluation of the reproducibility of responses to nasal allergen challenge and effects of inhaled nasal corticosteroids.

BACKGROUND: Similar immune responses in the nasal and bronchial mucosa implies that nasal allergen challenge (NAC) is a suitable early phase experimental model for drug development targeting allergic rhinitis (AR) and asthma. We assessed NAC reproducibility and the effects of intranasal corticosteroids (INCS) on symptoms, physiology, and inflammatory mediators. METHODS: 20 participants with mild atopic asthma and AR underwent three single blinded nasal challenges each separated by three weeks (NCT03431961). Cohort A (n = 10) underwent a control saline challenge, followed by two allergen challenges. Cohort B (n = 10) underwent a NAC with no treatment intervention, followed by NAC with 14 days pre-treatment with saline nasal spray (placebo), then NAC with 14 days pre-treatment with INCS (220 µg triamcinolone acetonide twice daily). Nasosorption, nasal lavage, blood samples, forced expiratory volume 1 (FEV1), total nasal symptom score (TNSS), peak nasal inspiratory flow (PNIF) were collected up to 24 h after NAC. Total and active tryptase were measured as early-phase allergy biomarkers (≤30 min) and IL-13 and eosinophil cell counts as late-phase allergy biomarkers (3-7 h) in serum and nasal samples. Period-period reproducibility was assessed by intraclass correlation coefficients (ICC), and sample size estimates were performed using effect sizes measured after INCS. RESULTS: NAC significantly induced acute increases in nasosorption tryptase and TNSS and reduced PNIF, and induced late increases in nasosorption IL-13 with sustained reductions in PNIF. Reproducibility across NACs varied for symptoms and biomarkers, with total tryptase 5 min post NAC having the highest reproducibility (ICC = 0.91). Treatment with INCS inhibited NAC-induced IL-13 while blunting changes in TNSS and PNIF. For a similar crossover study, 7 participants per treatment arm are needed to detect treatment effects comparable to INCS for TNSS. CONCLUSION: NAC-induced biomarkers and symptoms are reproducible and responsive to INCS. NAC is suitable for assessing pharmacodynamic activity and proof of mechanism for drugs targeting allergic inflammation.

Operating Room Noise and Team Communication during Facial Plastic and Reconstructive Surgery: A Multicenter Study.

Operating room (OR) noise contributes to team miscommunication. In facial plastic and reconstructive surgery (FPRS), many cases are completed under sedation. This creates a unique environment wherein patients are aware of OR noise. The objectives of this study were to quantify noise and evaluate team members' perspectives on communication inside of FPRS ORs. This study was completed across three surgical institutions. Objective noise measurements were recorded with SoundMeter X. A communication questionnaire was delivered to OR team members following each case. Four hundred and twenty-three noise measurements were recorded during facelift/neck, eye/brow, rhinoplasty, and fat transfer/lip surgeries. The mean and maximum noise levels were 66.1 dB (dB) and 87.6 dB, respectively. Measurements during cases with general anesthetic (221/423, 52.2%) had higher noise measurements (70.3 dB) compared with those with sedation (202/423, 47.8%) (69.7 dB) (p = 0.04). The OR was louder with suction on (72.3 dB) versus off (69.3 dB) (p <0.00). Suction (34.5%) and music (22.4%) were the largest noise contributors according to questionnaire replies. Intraoperative noise, awake patients, and suctions/music may negatively impact FPRS OR communication. Innovation to improve FPRS intraoperative communication should be considered for effective patient care.

Effect of intranasal corticosteroid treatment on allergen-induced changes in group 2 innate lymphoid cells in allergic rhinitis with mild asthma.

BACKGROUND: Allergic rhinitis is characterized by rhinorrhea, nasal congestion, sneezing and nasal pruritus. Group 2 innate lymphoid cells (ILC2s), CD4+ T cells and eosinophils in nasal mucosa are increased significantly after nasal allergen challenge (NAC). Effects of intranasal corticosteroids (INCS) on ILC2s remain to be investigated. METHODS: Subjects (n = 10) with allergic rhinitis and mild asthma were enrolled in a single-blind, placebo-controlled, sequential treatment study and treated twice daily with intranasal triamcinolone acetonide (220 µg) or placebo for 14 days, separated by a 7-day washout period. Following treatment, subjects underwent NAC and upper airway function was assessed. Cells from the nasal mucosa and blood, sampled 24 h post-NAC, underwent flow cytometric enumeration for ILC2s, CD4+ T and eosinophil progenitor (EoPs) levels. Cell differentials and cytokine levels were assessed in nasal lavage. RESULTS: Treatment with INCS significantly attenuated ILC2s, IL-5+ /IL-13+ ILC2s, HLA-DR+ ILC2s and CD4+ T cells in the nasal mucosa, 24 h post-NAC. EoP in nasal mucosa was significantly increased, while mature eosinophils were significantly decreased, 24 h post-NAC in INCS versus placebo treatment arm. Following INCS treatment, IL-2, IL-4, IL-5 and IL-13 were significantly attenuated 24 h post-NAC accompanied by significant improvement in upper airway function. CONCLUSION: Pre-treatment with INCS attenuates allergen-induced increases in ILC2s, CD4+ T cells and terminal differentiation of EoPs in the nasal mucosa of allergic rhinitis patients with mild asthma, with little systemic effect. Attenuation of HLA-DR expression by ILC2s may be an additional mechanism by which steroids modulate adaptive immune responses in the upper airways.

A thymic stromal lymphopoietin polymorphism may provide protection from asthma by altering gene expression.

BACKGROUND: Genome-wide association studies have identified associations of the single nucleotide polymorphism rs1837253 in the thymic stromal lymphopoietin (TSLP) gene with asthma, allergic disease and eosinophilia. The TSLP gene encodes two isoforms, long and short, and previous studies have indicated functional differences between these two isoforms. OBJECTIVE: We investigated the expression of these TSLP isoforms in response to a pro-inflammatory signal, and the role of the rs1837253 genotype in gene isoform regulation. METHODS: We cultured nasal epithelial cells of asthmatic and non-asthmatic subjects and evaluated poly(I:C)-induced TSLP protein secretion using multiplex protein assays and gene expression profiles of the TSLP isoforms, and related genes using real-time qPCR. We correlated these profiles with rs1837253 genotype. RESULTS: Asthmatic nasal epithelial cells exhibited increased TSLP protein secretion compared with nasal epithelial cells from healthy controls. The long TSLP isoform was more responsive to poly(I:C) stimulation. Additionally, the minor T allele of rs1837253 was less inducible than the major C allele, suggesting differential regulation; this may explain the "protective" effects of the T allele in asthma. CONCLUSION: Our results provide important insights into the differential regulation and function of TSLP isoforms, including the role of TSLP rs1837253 polymorphisms in allergic inflammatory processes. CLINICAL RELEVANCE: The key finding on the influence of TSLP genetic variation on disease expression/endotype could provide basis for investigation into targeted biologics for anti-TSLP therapies.

The expanded endoscopic endonasal approach for suprasellar meningiomas: long-term outcomes in a single-center series of 27 patients.

BACKGROUND: The endoscopic endonasal approach (EEA) has become increasingly employed in the treatment of suprasellar meningiomas. These tumors often cause visual symptoms due to compression of the anterior visual pathway. We aimed to examine long-term visual outcomes after EEA for optic nerve decompression and resection of suprasellar meningioma at our center, and to identify preoperative factors predictive of postoperative visual improvement. METHODS: We performed a retrospective cohort study on 27 patients who underwent the EEA for resection of meningiomas extending into the suprasellar cistern and decompression of anterior visual pathway between January 1, 2005, and March 1, 2019. RESULTS: We treated 8 male and 19 female patients, with a mean follow-up of 7.6 years. The mean age of our patients at initial presentation was 60.1 years. Eighteen patients (66.7%) presented with visual acuity deficits, and 12 (44.4%) patients presented with visual field deficits. Postoperatively, 11 patients had improved visual acuity, 6 had stable visual acuity, and 1 patient had slow and progressive decline of visual acuity; 5 patients had improved visual field, 6 had stable visual field, and 1 patient had slow and progressive decline in visual field. Patients less likely to have postoperative improvement of visual acuity were those with longer than 6-month duration of visual symptoms (P = 0.024*) as well as patients with the presence of a relative afferent pupillary defect (RAPD) (P = 0.023*). CONCLUSION: The EEA can achieve good visual outcomes in patients harboring suprasellar meningiomas. Symptom duration of less than 6 months and lack of a RAPD were positive predictors of postoperative visual acuity.

Comorbidities associated with eosinophilic chronic rhinosinusitis: A systematic review and meta-analysis.

OBJECTIVE: Eosinophilic chronic rhinosinusitis (ECRS) is a histological subtype of CRS that is generally recognised as being more difficult to manage. Patients with ECRS tend to have greater disease severity and poorer treatment outcomes after sinus surgery when compared with non-ECRS patients. The histopathology and biomarker assessments of ECRS are often unavailable prior to surgery and may be impractical and costly to analyse. Thus, the primary objective of this study was to understand clinical comorbidities associated with ECRS. DESIGN/SETTING: We searched three independent databases for articles that reported clinical CRS comorbidities associated with tissue eosinophilia. Data from studies with the same reported comorbidities were pooled, and a forest plot analysis was used to assess potential associations with four different conditions including allergic rhinitis, ASA sensitivity, asthma and atopy. The association between the phenotype of nasal polyps and ECRS was also quantified as a secondary objective. ECRS cut-off levels were as defined by papers included. MAIN OUTCOME/RESULTS: Eighteen articles were identified. The presence of nasal polyps (the first numbers in brackets represent odds ratios) (5.85, 95% CI [3.61, 9.49], P < .00001), ASA sensitivity (5.63, 95% CI [3.43, 9.23], P < .00001), allergic rhinitis (1.84, 95% CI [1.27, 2.67], P = .001) and asthma (3.15, 95% CI [2.61, 3.82], P < .00001) were found to be significantly associated with tissue eosinophilia. Atopy, however, was not significantly associated with tissue eosinophilia (1.71, 95% CI [0.59, 4.95], P = .32). CONCLUSION: Certain clinical disease characteristics such as ASA sensitivity, allergic rhinitis and asthma are more associated with CRS patients with eosinophilia when compared to those without eosinophilia. The phenotype of nasal polyps was also associated with ECRS. It is important for surgeons to recognise these comorbidities to ensure correct diagnoses, management and follow-up are implemented.

Endotypes of Chronic Rhinosinusitis Across Ancestry and Geographic Regions.

PURPOSE OF REVIEW: Preliminary studies have suggested differences in endotypes of chronic rhinosinusitis (CRS) across ancestry/ethnic groups. Eosinophilic CRS (ECRS) is the predominant subtype for Western/European ancestry CRS patients and non-eosinophilic CRS (nECRS) for Asian patients. This review aims to re-analyze CRS endotypes across ancestry populations using one consistent criteria to existing data. RECENT FINDINGS: Although tissue eosinophilia is the most commonly used criterion for ECRS, various cut-off points are suggested. Surrogate markers have been extensively studied. Sixty-six cohorts with study criteria were included with a total of 8557 patients. Raw data from 11 studies 544 patients were re-analyzed using number of tissue eosinophils. At lower cut-off values of ≥ 5 and ≥ 10 cells/HPF, most patients of Asian and Western/European ancestry were classified as ECRS without difference. In contrast, at cut-off points of ≥ 70 and ≥ 120 cells/HPF, the majority of both groups became reclassified as nECRS. After applying one consistent criteria to existing data, differences across ancestry and geographic populations in endotypes of CRS were no longer evident.

Amelanotic melanocytoma of the sella mimicking pituitary adenoma.

We describe a 50-year-old man with a well-demarcated intra- and extrasellar lesion and clinical signs of a non-functioning pituitary adenoma. Neuropathological examination revealed tumor composed of non-pigmented spindle cells arranged in tightly packed nests separated by delicate vascular septae. There was no significant cellular atypia or mitotic activity, and Ki67-positive nuclei were present in less than 1% of cells. The neoplastic cells were positive for S-100 and vimentin, and negative for numerous cellular markers including HMB45, anti-melanoma cocktail antibodies, and Masson melanin stain. Electron microscopy revealed scattered cells with small numbers of premelanosomes, aiding in the correct diagnosis of an amelanotic melanocytoma. This is the first case report of entirely amelanotic melanocytoma of meninges, and in a very unique location. BRAF was negative supporting the diagnosis of intracranial origin of the tumor. Approximately 2 years after subtotal resection and stereotactic radiosurgery the patient is alive and well with a non-progressive residual tumor.
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Traumatic penetrating head injury by crossbow projectiles: A case report and literature review.

Background: Low-energy penetrating head injuries caused by arrows are relatively uncommon. The objective of this report is to describe a case presentation and management of self-inflicted intracranial injury using a crossbow and to provide a relevant literature review. Case Report: A 31-year-old man with a previous psychiatric history sustained a self-inflicted injury using a crossbow that he bought from a department store. The patient arrived neurologically intact at the hospital, fully awake and oriented. He was not able to verbalize due to immobilization of the jaw as well as fixation of his tongue to his hard palate secondary to the position of the arrow. The trajectory of the object showed an entry point at the floor of the oral cavity and an exit through the calvarium just off the midline. The oral and nasal cavity, along with the palate and, the skull base of the anterior cranial fossa, and the left frontal lobe, were all breached. No vascular injury was identified clinically or in imaging. The arrow was surgically removed in the operating room after establishing an elective surgical airway. The floor of the mouth, tongue, and palate was repaired next. A planned delayed cerebrospinal fluid leak repair was performed. The patient made a substantial recovery and was discharged home in good functional status. A systematic literature search was done using Medline for cases with intracranial injuries related to crossbows to review and appraise the available literature. Conclusion: A thorough assessment in a multidisciplinary trauma center and the availability of a subspecialty care team, including neurosurgery and otolaryngology, are paramount in such cases. The vascular imaging should be done before and after any planned surgical intervention. Emergent and elective surgical airway management should be considered and made available throughout the stabilization and care of the acute injury. Surgical management should be planned to remove the object with adequate exposure to facilitate visualization, removal, and the possible need for further intervention, including anticipating aerodigestive and vascular injuries on removal. Finally, access to weapons and the relation to psychiatric illness should not be overlooked, as many reported cases are self-harming in nature.

Tracheostomy in Critically Ill COVID-19 Patients on Extracorporeal Membrane Oxygenation: A Single-Center Experience.

OBJECTIVES: Novel coronavirus-19 (COVID-19) has led to over 6 million fatalities globally. An estimated 75% of COVID-19 patients who require critical care admission develop acute respiratory distress syndrome (ARDS) needing invasive mechanical ventilation (IMV) and/or extracorporeal membrane oxygenation (ECMO). Due to prolonged ventilation requirements, these patients often also require tracheostomy. We performed a review of clinical outcomes in COVID-19 patients on ECMO at a high-volume tertiary care center in Hamilton, Ontario, Canada. METHODOLOGY: We performed a retrospective case series, including 24 adult patients diagnosed with COVID-19 who required IMV, veno-venous (ECMO), and tracheostomy. All patients were included from April to December 2021. We extracted demographic and clinical variables pertaining to the tracheostomy procedure and ECMO therapy. We performed descriptive statistical analyses. This study was approved by the Hamilton Integrated Research Ethics Board (14217-C). RESULTS: We included 24 consecutive patients with COVID-19 who required tracheostomy while undergoing ECMO therapy. The mean age was 49.4 years [standard deviation (SD): 7.33], the majority of patients were male (75%), with mean body mass index of 32 (SD: 8.81). Overall mortality rate was 33.3%. Percutaneous tracheostomy was performed most frequently (83.3%) and, similar to open tracheostomy, was associated with a low rate of perioperative bleeding complications. Within surviving patients, the mean time to IMV weaning and decannulation was 60.2 (SD: 24.6) and 49.4 days (SD: 21.8), respectively. CONCLUSION: Percutaneous tracheostomy appears to be safe in COVID-19 patients on ECMO and holding anticoagulation 24 hours prior to and after tracheostomy may limit bleeding events in these patients.

Quantifying surgical completeness in patients with aspirin exacerbated respiratory disease.

BACKGROUND: Aspirin exacerbated respiratory disease (AERD) in patients who have had sinus surgery remains a management challenge. Aspirin desensitization and biologics are additional treatment options. It remains unclear if patients require a more comprehensive surgery prior to implementing such additional therapies. The purpose of this study was to quantify prior surgery completeness in AERD patients at a tertiary rhinology practice. METHODS: Paranasal sinus CT scans were reviewed by four academic rhinologists to assess surgery completeness. Using a published CT grading system, each sinus was graded on the completeness of surgery and middle turbinate reduction. A score out of 14 was calculated for each patient (7 per side). RESULTS: Sixty-one patients with AERD out of 141 available were included. Mean inter-rater agreement across all sinuses was moderate (k = 0.42). The mean completeness score was 6.7/14. The following procedures were rated as complete (means): uncinectomy (L: 84%, R: 82%, k = 0.44), maxillary (L: 83%, R: 77%, k = 0.32), middle turbinate reduction (L: 45%, R: 46%, k = 0.31), anterior ethmoid (L: 35%, R: 39%, k = 0.51), sphenoid (L: 36%, R: 35%, k = 0.4), posterior ethmoid (L: 30%, R: 30%, k = 0.48), frontal (L: 22%, R: 21%, k = 0.46). CONCLUSION: Prior surgery in AERD patients were mostly deemed incomplete. Uncinectomy and maxillary antrostomy are the most common procedures previously performed. It remains toe seen whether this would be considered 'adequate' surgery or more 'complete' surgery is required to achieve greater disease control.

Tranexamic acid in endoscopic sinus and skull base surgery: A systematic review and meta-analysis.

OBJECTIVE: Endoscopic sinus surgery (ESS) and endoscopic skull base surgery (ESBS) approaches have revolutionized the management of sinonasal and intracranial pathology. Maintaining surgical hemostasis is essential as bleeding can obscure the visibility of the surgical field, thus increasing surgical duration, risk of complications, and procedural failure. Tranexamic acid (TXA) acts to reduce bleeding by inhibiting fibrin degradation. This review aims to assess whether TXA improves surgical field quality and reduces intraoperative blood loss compared with control. METHODS: We searched PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library from inception until September 1, 2022. Two reviewers independently screened citations, extracted data, and assessed methodological quality using the Cochrane risk-of-bias tool for randomized trials. Data were pooled using a random-effect model, with continuous data presented as mean differences and dichotomous data presented as odds ratios. RESULTS: Seventeen ESS randomized controlled trials (n = 1377) and one ESBS randomized controlled trial (n = 50) were reviewed. Significant improvement in surgical field quality was achieved with both systemic TXA (six studies, p < 0.00001) and topical TXA (six studies, p = 0.01) compared with the control. Systemic TXA (eight studies) and topical TXA (three studies) both achieved a significant reduction in intraoperative blood loss compared with the control (p < 0.00001). There were significant differences in operative times (p < 0.001) but no significant difference in perioperative outcomes (p = 0.30). CONCLUSION: This meta-analysis demonstrated that the administration of TXA in ESS can improve surgical field quality and reduce intraoperative blood loss. TXA use did not result in increased perioperative complications including thrombotic events.

Canadian multidisciplinary expert consensus on the use of biologics in upper airways: a Delphi study.

BACKGROUND: Chronic rhinosinusitis with nasal polyposis (CRSwNP) often coexists with lower airway disease. With the overlap between upper and lower airway disease, optimal management of the upper airways is undertaken in conjunction with that of the lower airways. Biologic therapy with targeted activity within the Type 2 inflammatory pathway can improve the clinical signs and symptoms of both upper and lower airway diseases. Knowledge gaps nevertheless exist in how best to approach patient care as a whole. There have been sixteen randomized, double-blind, placebo-controlled trails performed for CRSwNP targeted components of the Type 2 inflammatory pathway, notably interleukin (IL)-4, IL-5 and IL-13, IL- 5R, IL-33, and immunoglobulin (Ig)E. This white paper considers the perspectives of experts in various disciplines such as rhinology, allergy, and respirology across Canada, all of whom have unique and valuable insights to contribute on how to best approach patients with upper airway disease from a multidisciplinary perspective. METHODS: A Delphi Method process was utilized involving three rounds of questionnaires in which the first two were completed individually online and the third was discussed on a virtual platform with all the panelists. A national multidisciplinary expert panel of 34 certified specialists was created, composed of 16 rhinologists, 7 allergists, and 11 respirologists who evaluated the 20 original statements on a scale of 1-9 and provided comments. All ratings were quantitively reviewed by mean, median, mode, range, standard deviation and inter-rater reliability. Consensus was defined by relative interrater reliability measures-kappa coefficient ([Formula: see text]) value > 0.61. RESULTS: After three rounds, a total of 22 statements achieved consensus. This white paper only contains the final agreed upon statements and clear rationale and support for the statements regarding the use of biologics in patients with upper airway disease. CONCLUSION: This white paper provides guidance to Canadian physicians on the use of biologic therapy for the management of upper airway disease from a multidisciplinary perspective, but the medical and surgical regimen should ultimately be individualized to the patient. As more biologics become available and additional trials are published we will provide updated versions of this white paper every few years.

Diagnosis and Localization of Cerebrospinal Fluid Rhinorrhea: A Systematic Review.

BACKGROUND: Cerebrospinal fluid (CSF) rhinorrhea results from abnormal communications between the subarachnoid and sinonasal spaces. Accurate preoperative diagnosis and localization are vital for positive clinical outcomes. However, the diagnosis and localization of CSF rhinorrhea remain suboptimal due to a lack of accurate understanding of test characteristics. OBJECTIVE: This systematic review aims to assess the diagnostic accuracy of various tests and imaging modalities for diagnosing and localizing CSF rhinorrhea. METHODS: A systematic review of the MEDLINE and EMBASE databases was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Our search identified 4039 articles-53 cohort studies and 24 case series describing 1622 patients were included. The studies were heterogeneous and had a wide range of sensitivities and specificities. Many specificities were incalculable due to a lack of true negative and false positive results, thus precluding a meta-analysis. Median sensitivities and specificities were calculated for cohort studies of the following investigations: high-resolution computed tomography (HRCT) 0.93/0.50 (sensitivity/specificity), magnetic resonance cisternography (MRC) 0.94/0.77, computed tomography cisternography (CTC) 0.95/1.00, radionuclide cisternography (RNC) 0.90/0.50, and contrast-enhanced magnetic resonance cisternography (CEMRC) 0.99/1.00, endoscopy 0.58/1.00, topical intranasal fluorescein (TIF) 1.00/incalculable, intrathecal fluorescein (ITF) 0.96/1.00. Case series were reviewed separately. Etiology and site-specific data were also analyzed. CONCLUSION: MR cisternography is more accurate than high-resolution CT at diagnosing and localizing CSF rhinorrhea. CT cisternography, contrast-enhanced MR cisternography, and radionuclide cisternography have good diagnostic characteristics but are invasive. Intrathecal fluorescein shows promising data but has not been widely adopted for purely diagnostic use. Office endoscopy has limited data but does not sufficiently diagnose CSF rhinorrhea independently. These findings confirm with current guidelines and evidence.

Self-reported olfactory and gustatory dysfunction and psychophysical testing in screening for COVID-19: A systematic review and meta-analysis.

BACKGROUND: A substantial proportion of coronavirus disease-2019 (COVID-19) patients demonstrate olfactory and gustatory dysfunction (OGD). Self-reporting for OGD is widely used as a predictor of COVID-19. Although psychophysical assessment is currently under investigation in this role, the sensitivity of these screening tests for COVID-19 remains unclear. In this systematic review we assess the sensitivity of self-reporting and psychophysical tests for OGD. METHODS: A systematic search was performed on PubMed, EMBASE, and ClinicalTrials.gov from inception until February 16, 2021. Studies of suspected COVID-19 patients with reported smell or taste alterations were included. Data were pooled for meta-analysis. Sensitivity, specificity, and diagnostic odds ratio (DOR) were reported in the outcomes. RESULTS: In the 50 included studies (42,902 patients), self-reported olfactory dysfunction showed a sensitivity of 43.9% (95% confidence interval [CI], 37.8%-50.2%), a specificity of 91.8% (95% CI, 89.0%-93.9%), and a DOR of 8.74 (95% CI, 6.67-11.46) for predicting COVID-19 infection. Self-reported gustatory dysfunction yielded a sensitivity of 44.9% (95% CI, 36.4%-53.8%), a specificity of 91.5% (95% CI, 87.7%-94.3%), and a DOR of 8.83 (95% CI, 6.48-12.01). Olfactory psychophysical tests analysis revealed a sensitivity of 52.8% (95% CI, 25.5%-78.6%), a specificity of 88.0% (95% CI, 53.7%-97.9%), and a DOR of 8.18 (95% CI, 3.65-18.36). One study used an identification test for gustatory sensations assessment. CONCLUSION: Although demonstrating high specificity and DOR values, neither self-reported OGD nor unvalidated and limited psychophysical tests were sufficiently sensitive in screening for COVID-19. They were not suitable adjuncts in ruling out the disease.

Sudden Sensorineural Hearing Loss and Metabolic Syndrome: A Systematic Review and Meta-analysis.

OBJECTIVE: The objective of this systematic review and meta-analysis is to examine the association between sudden sensorineural hearing loss (SSNHL) and risk of metabolic syndrome (MetS), and the association between MetS and prognosis of SSNHL. DATABASES REVIEWED: We systematically searched MEDLINE, Embase, and Cochrane Central Register electronic databases from their dates of conception to February 4, 2020. METHODS: We included observational studies analyzing 1) the prevalence of MetS among SSNHL patients, or 2) the prognosis of SSNHL patients in MetS patients. A standardized form was completed in duplicate extracting data on study characteristics, participant demographics, and SSNHL outcome or recovery measures. Random-effects meta-analyses were performed pooling odds ratios using the generic inverse method. Risk of bias was assessed using the Newcastle Ottawa Scale. RESULTS: Three studies examining the prevalence of MetS among patients with SSNHL (11,890 total participants; 3,034 SSNHL participants) yielded a significantly increased risk of MetS among SSNHL, with a pooled odds ratio of 1.88 (95% CI, 1.01-3.50). Three studies examining the association of SSNHL prognosis in patients with MetS (608 SSNHL participants, 234 concomitant SSNHL, and MetS participants) demonstrated that SSNHL patients with MetS were significantly more likely to have poorer recovery compared to SSNHL patients without MetS (pooled odds ratio 2.77; 95% CI, 2.33-3.28). CONCLUSION: Our findings suggest an association between prevalence of MetS and SSNHL, as well as poorer prognosis of SSNHL in patients with concomitant MetS.

Association of Tracheostomy With Outcomes in Patients With COVID-19 and SARS-CoV-2 Transmission Among Health Care Professionals: A Systematic Review and Meta-analysis.

Importance: Approximately 5% to 15% of patients with COVID-19 require invasive mechanical ventilation (IMV) and, at times, tracheostomy. Details regarding the safety and use of tracheostomy in treating COVID-19 continue to evolve. Objective: To evaluate the association of tracheostomy with COVID-19 patient outcomes and the risk of SARS-CoV-2 transmission among health care professionals (HCPs). Data Sources: EMBASE (Ovid), Medline (Ovid), and Web of Science from January 1, 2020, to March 4, 2021. Study Selection: English-language studies investigating patients with COVID-19 who were receiving IMV and undergoing tracheostomy. Observational and randomized clinical trials were eligible (no randomized clinical trials were found in the search). All screening was performed by 2 reviewers (P.S. and M.L.). Overall, 156 studies underwent full-text review. Data Extraction and Synthesis: We performed data extraction in accordance with Meta-analysis of Observational Studies in Epidemiology guidelines. We used a random-effects model, and ROBINS-I was used for the risk-of-bias analysis. Main Outcomes and Measures: SARS-CoV-2 transmission between HCPs and levels of personal protective equipment, in addition to complications, time to decannulation, ventilation weaning, and intensive care unit (ICU) discharge in patients with COVID-19 who underwent tracheostomy. Results: Of the 156 studies that underwent full-text review, only 69 were included in the qualitative synthesis, and 14 of these 69 studies (20.3%) were included in the meta-analysis. A total of 4669 patients were included in the 69 studies, and the mean (range) patient age across studies was 60.7 (49.1-68.8) years (43 studies [62.3%] with 1856 patients). We found that in all studies, 1854 patients (73.8%) were men and 658 (26.2%) were women. We found that 28 studies (40.6%) investigated either surgical tracheostomy or percutaneous dilatational tracheostomy. Overall, 3 of 58 studies (5.17%) identified a small subset of HCPs who developed COVID-19 that was associated with tracheostomy. Studies did not consistently report the number of HCPs involved in tracheostomy. Among the patients, early tracheostomy was associated with faster ICU discharge (mean difference, 6.17 days; 95% CI, -11.30 to -1.30), but no change in IMV weaning (mean difference, -2.99 days; 95% CI, -8.32 to 2.33) or decannulation (mean difference, -3.12 days; 95% CI, -7.35 to 1.12). There was no association between mortality or perioperative complications and type of tracheostomy. A risk-of-bias evaluation that used ROBINS-I demonstrated notable bias in the confounder and patient selection domains because of a lack of randomization and cohort matching. There was notable heterogeneity in study reporting. Conclusions and Relevance: The findings of this systematic review and meta-analysis indicate that enhanced personal protective equipment is associated with low rates of SARS-CoV-2 transmission during tracheostomy. Early tracheostomy in patients with COVID-19 may reduce ICU stay, but this finding is limited by the observational nature of the included studies.