Consensus criteria for chronic rhinosinusitis disease control: an international Delphi Study.

BACKGROUND: Chronic rhinosinusitis (CRS) disease control is a global metric of disease status for CRS. While there is broad acceptance that it is an important treatment goal, there has been inconsistency in the criteria used to define CRS control. The objective of this study was to identify and develop consensus around essential criteria for assessment of CRS disease control. METHODS: Modified Delphi methodology consisting of three rounds to review a list of 24 possible CRS control criteria developed by a 12-person steering committee. The core authorship of the multidisciplinary EPOS 2020 guidelines was invited to participate. RESULTS: Thirty-two individuals accepted the invitation to participate and there was no dropout of participants throughout the entire study (3 rounds). Consensus essential criteria for assessment of CRS control were: overall symptom severity, need for CRS-related systemic corticosteroids in the prior 6 months, severity of nasal obstruction, and patient-reported CRS control. Near-consensus items were: nasal endoscopy findings, severity of smell loss, overall quality of life, impairment of normal activities and severity of nasal discharge. Participants’ comments provided insights into caveats of, and disagreements related to, near-consensus items. CONCLUSIONS: Overall symptom severity, use of CRS-related systemic corticosteroids, severity of nasal obstruction, and patient-reported CRS control are widely agreed upon essential criteria for assessment of CRS disease control. Consideration of near-consensus items to assess CRS control should be implemented with their intrinsic caveats in mind. These identified consensus CRS control criteria, together with evidence-based support, will provide a foundation upon which CRS control criteria with wide-spread acceptance can be developed.

The EUFOREA pocket guide for chronic rhinosinusitis.

Chronic rhinosinusitis (CRS) is known to affect around 5 % of the total population, with major impact on the quality of life of those severely affected (1). Despite a substantial burden on individuals, society and health economies, CRS often remains underdiagnosed, under-estimated and under-treated (2). International guidelines like the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) (3) and the International Consensus statement on Allergy and Rhinology: Rhinosinusitis 2021 (ICAR) (4) offer physicians insight into the recommended treatment options for CRS, with an overview of effective strategies and guidance of diagnosis and care throughout the disease journey of CRS.

Outer retinal transduction by AAV2-7m8 following intravitreal injection in a sheep model of CNGA3 achromatopsia.

Sheep carrying a mutated CNGA3 gene exhibit diminished cone function and provide a naturally occurring large animal model of achromatopsia. Subretinal injection of a vector carrying the CNGA3 transgene resulted in long-term recovery of cone function and photopic vision in these sheep. Research is underway to develop efficacious vectors that would enable safer transgene delivery, while avoiding potential drawbacks of subretinal injections. The current study evaluated two modified vectors, adeno-associated virus 2-7m8 (AAV2-7m8) and AAV9-7m8. Intravitreal injection of AAV2-7m8 carrying enhanced green fluorescent protein under a cone-specific promoter resulted in moderate photoreceptor transduction in wild-type sheep, whereas peripheral subretinal delivery of AAV9-7m8 resulted in the radial spread of the vector beyond the point of deposition. Intravitreal injection of AAV2-7m8 carrying human CNGA3 in mutant sheep resulted in mild photoreceptor transduction, but did not lead to the clinical rescue of photopic vision, while day-blind sheep treated with a subretinal injection exhibited functional recovery of photopic vision. Transgene messenger RNA levels in retinas of intravitreally treated eyes amounted to 4-23% of the endogenous CNGA3 levels, indicating that expression levels >23% are needed to achieve clinical rescue. Overall, our results indicate intravitreal injections of AAV2.7m8 transduce ovine photoreceptors, but not with sufficient efficacy to achieve clinical rescue in CNGA3 mutant sheep.

An introduction to the sources, fate, occurrence and effects of endocrine disrupting chemicals released into the environment.

Many classes of compounds are known or suspected to disrupt the endocrine system of vertebrate and invertebrate organisms. This review of the sources and fate of selected endocrine disrupting chemicals (EDCs) in the environment includes classes of compounds that are "legacy" contaminants, as well as contaminants of emerging concern. EDCs included for discussion are organochlorine compounds, halogenated aromatic hydrocarbons, brominated flame retardants, per- and polyfluoroalkyl substances, alkylphenols, phthalates, bisphenol A and analogues, pharmaceuticals, drugs of abuse and steroid hormones, personal care products, and organotins. An exhaustive survey of the fate of these contaminants in all environmental media (e.g., air, water, soil, biota, foods and beverages) is beyond the scope of this review, so the priority is to highlight the fate of EDCs in environmental media for which there is a clear link between exposure and endocrine effects in humans or in biota from other taxa. Where appropriate, linkages are also made between the fate of EDCs and regulatory limits such as environmental quality guidelines for water and sediments and total daily intake values for humans.

Methods for the analysis of endocrine disrupting chemicals in selected environmental matrixes.

Endocrine disrupting chemicals (EDCs) are heterogenous in structure, chemical and physical properties, and their capacity to partition into various environmental matrixes. In many cases, these chemicals can disrupt the endocrine systems of vertebrate and invertebrate organisms when present at very low concentrations. Therefore, sensitive and varied analytical methods are required to detect these compounds in the environment. This review summarizes the analytical methods and instruments that are most used to monitor for EDCs in selected environmental matrixes. Only those matrixes for which there is a clear link between exposures and endocrine effects are included in this review. Also discussed are emerging methods for sample preparation and advanced analytical instruments that provide greater selectivity and sensitivity.

Dupilumab reduces systemic corticosteroid use and sinonasal surgery rate in CRSwNP.

BACKGROUND: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a type 2 inflammatory disease with a high symptom burden and poor quality of life. Treatment options include recurrent surgeries and/or frequent systemic corticosteroids (SCS). Dupilumab, a fully human monoclonal antibody, blocks the shared receptor component for interleukin-4 and interleukin-13, key drivers of type 2-mediated inflammation. We report results of pooled analyses from 2 randomised, double-blind, placebo-controlled phase 3 studies (SINUS 24 [NCT02912468]; SINUS-52 [NCT02898454]) to evaluate dupilumab effect versus placebo in adults with CRSwNP with/without SCS use and sinonasal surgery. METHODOLOGY: SINUS-24 patients were randomised 1:1 to subcutaneous dupilumab 300 mg (n=143) or placebo (n=133) every 2 weeks (q2w) for 24 weeks. SINUS-52 patients were randomised 1:1:1 to 52 weeks of subcutaneous dupilumab 300 mg q2w (n=150), 24 weeks q2w followed by 28 weeks of dupilumab 300 mg every 4 weeks (n=145) or 52 weeks of placebo q2w (n=153). RESULTS: Dupilumab reduced the number of patients undergoing sinonasal surgery (82.6%), the need for in-study SCS use (73.9%), and SCS courses (75.3%). Significant improvements were observed with dupilumab vs placebo regardless of prior sinonasal surgery or SCS use in nasal polyp, nasal congestion, Lund-MacKay, and Sinonasal Outcome Test (22-items) scores, and the University of Pennsylvania Smell Identification Test. CONCLUSIONS: Dupilumab demonstrated significant improvements in disease signs and symptoms and reduced the need for sino-nasal surgery and SCS use versus placebo in patients with severe CRSwNP, regardless of SCS use in the previous 2 years, or prior sinonasal surgery.

European Position Paper on Rhinosinusitis and Nasal Polyps 2020.

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

It is not just artemisinin: Artemisia sp. for treating diseases including malaria and schistosomiasis.

Artemisia sp., especially A. annua and A. afra, have been used for centuries to treat many ailments. While artemisinin is the main therapeutically active component, emerging evidence demonstrates that the other phytochemicals in this genus are also therapeutically active. Those compounds include flavonoids, other terpenes, coumarins, and phenolic acids. Artemisia sp. phytochemicals also improve bioavailability of artemisinin and synergistically improve artemisinin therapeutic efficacy, especially when delivered as dried leaf Artemisia as a tea infusion or as powdered dry leaves in a capsule or compressed into a tablet. Here results from in vitro, and in vivo animal and human studies are summarized and critically discussed for mainly malaria, but also other diseases susceptible to artemisinin and Artemisia sp. including schistosomiasis, leishmaniasis, and trypanosomiasis.

EPOS2020: development strategy and goals for the latest European Position Paper on Rhinosinusitis.

BACKGROUND: The European Position Papers on Rhinosinusitis from 2005, 2007 and 2012 have had a measurable impact on the way this common condition with high impact on quality of life is managed around the world. EPOS2020 will be the latest iteration of the guideline, addressing new stakeholders and target users, presenting a summary of the latest literature and evolving treatment modalities, and formulating clear recommendations based on all available evidence. METHODOLOGY: Based on the AGREE II framework, this article demonstrates how the EPOS2020 steering group will address six key areas to ensure consistency in quality and presentation of information in the latest rhinosinusitis clinical practice guideline: scope and purpose; stakeholder involvement; rigour of development; clarity of presentation; recommendations and applicability; editorial independence. RESULTS: By analysing the guidance from AGREE II, we formulated a detailed development strategy for EPOS2020. We identify new stakeholders and target users and ratify the importance of patient involvement in the latest EPOS guideline. New and expanded areas of research to be addressed are highlighted. We confirm our intention to use mixed methodologies, combining evidence-based medicine with real life studies; when no evidence can be found, use Delphi rounds to achieve clear, inclusive recommendations. We also introduce new concepts for dissemination of the guideline, using Internet and social media to improve accessibility. CONCLUSION: This article is an introduction to the EPOS2020 project, and presents the key goals, core stakeholders, planned methodology and dissemination strategies for the latest version of this influential guideline.

Case-control study of endoscopic polypectomy in clinic (EPIC) versus endoscopic sinus surgery for chronic rhinosinusitis with polyps.

INTRODUCTION: Endoscopic Polypectomy In Clinic (EPIC) is a recently described deescalated form of endoscopic sinus surgery (ESS) performed in the outpatient clinic for patients with chronic rhinosinusitis with polyps (CRSwNP). The quality of life benefit of EPIC in comparison to ESS is not known. The purpose of this study was to determine if the disease specific quality of life measured with the SNOT-22 attained with EPIC is similar to that attained with ESS for patients with CRSwNP. METHODS: A multi-institutional observational case-control study was performed to evaluate quality of life improvement in patients treated with ESS and EPIC for CRSwNP with a 3 month follow-up. Predicted probability of undergoing EPIC was calculated by fitting a logistic regression model using clinically relevant variables. EPIC patients were matched to ESS patients in a 1:1 fashion. RESULTS: 24 pairs were analyzed after matching. There was no statistical difference in the post-treatment SNOT-22 scores or proportion of patients achieving a minimal clinically important difference. CONCLUSIONS: In appropriate CRSwNP patients, the EPIC procedure may provide disease specific quality of life improvement similar to that seen with patients who undergo traditional ESS.

Eustachian tube symptoms are frequent in chronic rhinosinusitis and respond well to endoscopic sinus surgery.

BACKGROUND: Symptoms of Eustachian tube (ET) dysfunction are seldom assessed in patients with chronic rhinosinusitis (CRS). The Sino-Nasal Outcome Test (SNOT-22) quality-of-life tool includes two questions that specifically screen for symptoms of ET dysfunction (Ear Fullness; Ear Pain). OBJECTIVE: The purpose of this study was to determine the extent to which these ET symptoms were present in patients with CRS, and whether these symptoms respond to endoscopic sinus surgery (ESS). METHODOLOGY: SNOT-22 data collected prospectively at time of recruitment into IRB-approved clinical trials or case-control studies in CRS was pooled to provide a cross section of the frequency and severity of ET dysfunction. When applicable to the trials, the SNOT-22 was repeated at least 3 months following ESS. RESULTS: Five trials rendering 131 patients were available for assessment. The control group comprised of 251 participants from two case-control studies. Ear Fullness of equal/greather than 1 was reported in 80/131 CRS patients compared to 45/251 control patients. Ear Pain of equal/greather than 1 was reported in 39/131 CRS patients compared to 33/251 control patients. Following ESS, mean Ear Fullness and Ear Pain scores decreased to 1.17 and 0.73, respectively. CONCLUSION: Symptoms suggestive of ET dysfunction are frequent in CRS, and for most patients the symptoms will decrease post-ESS to a level comparable with a non-CRS population. Patients whose ET symptoms do not respond to ESS may represent a target population for emerging therapeutic options for ET dysfunction.

Bacterial immune evasion via an IL-10 mediated host response, a novel pathophysiologic mechanism for chronic rhinosinusitis.

BACKGROUND: Staphylococcus aureus is a frequently implicated pathogen in chronic rhinosinusitis (CRS). S. aureus may promote commensalism by downregulating pro-inflammatory T cell host responses via an IL-10 mediated pathway. This finding, coupled with the observation that S. aureus and CD8+ T cell numbers are inversely correlated in CRS mucosa, suggests that S. aureus may evade immune destruction via IL-10 induction. To support this hypothesis, we evaluated i) whether IL-10 levels differ in CRS compared to controls (CTL) using microarray and immunohistochemistry and ii) whether IL-10 levels correlate with S. aureus and CD8+ T cell levels. METHODOLOGY: Sinus epithelial brush samples from 12 patients undergoing ESS for CRS and 10 CTLs underwent microarray analysis of IL-10 gene expression. Microarray results were verified on simultaneously obtained surgical biopsy samples by immunohistochemistry staining for IL-10. Potential mechanisms were assessed by immunohistochemistry for CD8+ T cells and S. aureus. RESULTS: IL-10 gene expression was significantly higher in CRS vs CTL subjects at the time of surgery. Immunohistochemistry confirmed increased levels of intraepithelial IL-10. A strong inverse correlation was observed between intraepithelial IL-10 and CD8+ T cell levels as was intraepithelial IL-10 and S. aureus. CONCLUSION: Elevated IL-10 levels in sinus mucosa may be a potential pathophysiologic feature of CRS in association with a significant downregulation of host CD8+ T cell levels. While S. aureus is believed to play a role in IL-10 induction, a comparatively weaker relationship between S. aureus and IL-10 levels suggests other bacterial species may also induce IL-10 production as a common survival strategy in CRS.

The Management of Chronic Rhinosinusitis With Nasal Polyps (CRSwNP) With Biologics.

Chronic rhinosinusitis with nasal polyps affects a significant portion of the worldwide population. This illness is associated with several chronic conditions and has an important impact on patient quality of life, leading to a great societal economic burden. In recent years, biologic medications have been developed and found to be effective in the treatment of chronic rhinosinusitis with nasal polyps. This review focuses on these treatment options and their ability to improve patient outcomes, including quality of life. It also reviews available evidence with regards to patient selection, monitoring of patients after treatment initiation, and comparison of different biologics and with other treatment options such as sinus surgery.

A Comparison of Harwell & FWT Alanine Temperature Coefficients from 25 °C to 80 °C.

The dosimeters used to monitor industrial irradiation processing commonly experience significant temperature rises that must be considered in the dose analysis stage. The irradiation-temperature coefficient for a dosimetry system is derived from the dosimeter's radiation response to the absorbed dose and the irradiation temperature. This temperature coefficient is typically expressed in percent change per degree. The temperature rise in dosimeters irradiated with high-intensity ionizing radiation sources can be appreciable. This is especially true for electron-beam processing in which dosimeter temperatures can approach 80 °C. A recent National Institute of Standards and Technology (NIST) study revealed modest (0.5 % to 1.0 %) deviations from the predicted value at temperatures above 70 °C for absorbed doses of 1 kGy and 20 kGy. However, these data were inconsistent with a concurrent manuscript published by National Physical Laboratory (NPL) researchers that found a significant dose-dependent non-linear alanine response but used dosimeters from a different manufacturer and a different experimental design. The current work was undertaken to reconcile the two studies. Alanine dosimeters from each manufacturer used by NIST and NPL were co-irradiated over a wide range of absorbed dose and irradiation temperature. It was found that though there was a slight variation in the temperature coefficient between the two alanine dosimeter sources both systems were linear with irradiation temperature up to 70 °C and the NPL observations of non-linearity were not reproduced. These data confirmed that there is no fundamental difference in the two commercial alanine dosimeter sources and that temperature corrections could be made on industrial irradiations at the extremes of irradiation temperature and absorbed dose.

Identifying barriers to care for complex airway disease and multidisciplinary solutions to optimize therapy in Canada.

BACKGROUND: Complex airway disease such as Chronic Rhinosinusitis with Asthma or Aspirin Exacerbated Respiratory Disease requires a multidisciplinary approach to management and treatment. Many centers in the USA have created collaborative multidisciplinary clinics to support the management of these patients; however, similar structures do not appear to exist in Canada. METHODS: This mixed methods study used a combination of structured interviews and a cross-sectional national survey. Interviewees included members of the Canadian Rhinology Working Group and survey participants were a combination of academic and community Rhinologists, Respirologists and Allergists. All participation was voluntary and selection criteria was based on their involvement in treating complex airway disease. Our objective was to identify the current state of diagnosis and treatment of complex airway patients in Canada between Rhinology, Respirology and Allergy and understand the barriers, challenges and propose solutions to establishing a multidisciplinary airway clinic in Canada. RESULTS: Four Rhinologists participated in qualitative interviews and a convenience sample of 42 specialists through our known network responded to our quantitative survey. From our survey, 54.8% believed multidisciplinary clinics were necessary in the management of complex airway disease, providing better outcomes and cost-savings (69%, 45.2%). Most specialties agreed that history, physical, pulmonary function and skin prick testing was important for diagnosis (92.9%, 92.9%, 88.1%). If clinicians were to participate in a multidisciplinary clinic, they would be willing to forego an average of 14.2% of their mean daily income for that clinic. The ideal clinic location was split between a neutral shared location vs. a Rhinology clinic space (38.1%, 45.2%). CONCLUSIONS: Complex airway diseases are currently managed in subspecialty silos resulting in fragmented care. Our study highlights gaps in management, areas for improvement and support for establishing multidisciplinary complex airway disease clinics in Canada to better treat this population.

Canadian Rhinology Working Group consensus statement: biologic therapies for chronic rhinosinusitis.

BACKGROUND: Recent evidence suggests that biologic therapy with targeted activity within the Type 2 inflammatory pathway can improve the clinical signs and symptoms of chronic rhinosinusitis with nasal polyposis (CRSwNP). There remains a population in CRSwNP that despite medical therapy and endoscopic sinus surgery have persistent signs and symptoms of disease. Therefore, biologics, monoclonal antibody agents, could be beneficial therapeutic treatments for these patients. There have been eight 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. However, there are no formal recommendations for the optimal use of biologics in managing Chronic Rhinosinusitis (CRS) within the Canadian health care environment. 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. 17 fellowship trained rhinologists across Canada evaluated the 28 original statements on a scale of 1-10 and provided comments. A rating within 1-3 indicated disagreement, 8-10 demonstrated agreement and 4-7 represented being neutral towards a statement. All ratings were quantitively reviewed by mean, median, mode, range and standard deviation. Consensus was defined by removing the highest and lowest of the scores and using the "3 point relaxed system". RESULTS: After three rounds, a total of 11 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 CRS. CONCLUSION: This white paper provides guidance to Canadian physicians on the use of biologic therapy for the management of patients with CRS, 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.

Polymorphisms in interleukin-1 receptor-associated kinase 4 are associated with total serum IgE.

BACKGROUND: Serum immunoglobulin E (IgE) level is recognized to be under strong genetic control, but the causal and susceptibility genes remain to be identified. We sought to investigate the association between single nucleotide polymorphisms (SNPs) in the Toll-like receptor (TLR) signaling pathway and total serum IgE level. METHODS: A population of 206 patients with severe chronic rhinosinusitis (CRS) was used. Precise phenotyping of patients was accomplished by means of a questionnaire and clinical examination. Blood was drawn for measurement of total serum IgE, as well as DNA extraction. A maximally informative set of SNPs in the TLR1, 2, 3, 4, 6, 9, 10, CD14, MD2, MyD88, IRAK4, and TRAF6 genes were selected and genotyped. Significant findings were replicated in a second independent population of 956 subjects from 227 families with asthma. RESULTS: A total of 97 out of 104 SNPs were successfully genotyped. Three SNPs in IRAK4--rs1461567, rs4251513, and rs4251559--were associated with total serum IgE levels (P < 0.004). In the replication sample, the same SNPs as well as the same orientation of the risk allele were associated with IgE levels (P < 0.031). CONCLUSIONS: These results demonstrate a clear association between polymorphisms in the IRAK4 gene and serum IgE levels in patients with CRS and asthma. IRAK4 may be important in the regulation of IgE levels in patients with inflammatory diseases of the airways.

An Absorbed-Dose/Dose-Rate Dependence for the Alanine-EPR Dosimetry System and Its Implications in High-Dose Ionizing Radiation Metrology.

NIST developed the alanine dosimetry system in the early 1990s to replace radiochromic dye film dosimeters. Later in the decade the alanine system was firmly established as a transfer service for high-dose radiation dosimetry and an integral part of the internal calibration scheme supporting these services. Over the course of the last decade, routine monitoring of the system revealed a small but significant observation that, after examination, led to the characterization of a previously unknown absorbed-dose-dependent, dose-rate effect for the alanine system. Though the potential impact of this effect is anticipated to be extremely limited for NIST's customer-based transfer dosimetry service, much greater implications may be realized for international measurement comparisons between National Measurement Institutes.

An absorbed dose map of bone tissue treated with a radiopharmaceutical in vivo.

A beagle humerus treated with Ho-chelate radiopharmaceutical in vivo was examined by electron paramagnetic resonance (EPR) dosimetry. The bone was sectioned and the absorbed dose to each bone fragment was determined by additive re-irradiation of the bone tissue with calibrated doses of gamma radiation. The measured doses ranged from 4.3 Gy to 62 Gy. The highest doses were recorded in the predominately trabecular bone tissue and the lowest doses in the predominately cortical bone tissue. The mean absorbed dose for the entire bone was 17 Gy. The data from 50 bone fragments were combined to create an absorbed dose map of the interior bone surface.

Securing an OTL-HNS residency: how competitive is it? Comparing medical student perceptions to actual Canadian statistics.

BACKGROUND: The residency match is an important event in an aspiring physician's career. Otolaryngology - Head and Neck Surgery (OTL-HNS) is a surgical specialty that has enjoyed high numbers of applicants to its residency programs. However, recent trends in Canada show a decline in first-choice applicants to several surgical fields. Factors thought to influence a medical student's choice include role models, career opportunities and work-life balance. The notion of perceived competitiveness is a factor that has not yet been explored. This study sought to compare competitiveness of OTL-HNS, as perceived by Canadian medical students to residency match statistics published yearly by CaRMS (Canadian Residency Matching Service), with the hope of informing future decisions of surgical residency programs. METHODS: An electronic survey was created and distributed to all medical students enrolled in the 17 Canadian medical schools. After gathering demographic information, students were asked to rank what they perceived to be the five most competitive disciplines offered by CaRMS. They were also asked to rank surgical specialties from most to least competitive. Publically available data from CaRMS was then collected and analyzed to determine actual competitiveness of admissions to Canadian OTL-HNS residency programs. RESULTS: 1194 students, from first to fourth year of medical school, completed the survey. CaRMS statistics over the period from 2008 to 2014 demonstrated that the five most competitive specialties were Plastic Surgery, Dermatology, Ophthalmology, Emergency Medicine and OTL-HNS. Among surgical disciplines, OTL-HNS was third most competitive, where on average 72% of students match to their first-choice discipline. When students were questioned, 35% ranked OTL-HNS amongst the top five most competitive. On the other hand 72%, 74% and 80% recognized Opthalmology, Dermatology and Plastic Surgery as being among the five most competitive, respectively. We found that fourth-year medical students were significantly more knowledgeable about the competitiveness of both OTL-HNS and Plastic Surgery compared to first-year students (p < 0.01). CONCLUSION: Overall, Canadian medical students may underestimate the competitiveness of OTL-HNS. Furthermore, competitiveness would appear to be a concept that resonates with medical students during the match process.