Comparison of sinus distribution between nasal irrigation and nasal spray using fluorescein-labelled in patients with chronic rhinosinusitis: A randomised clinical trial.

OBJECTIVE: This study aims to compare the potential sinus distribution between high-volume nasal irrigation and nasal spray in chronic rhinosinusitis (CRS) patients who have not undergone sinus surgery. DESIGN AND SETTING: A randomised clinical study was conducted at the Otolaryngology-Head & Neck Surgery Department, Ramathibodi Hospital, Faculty of Medicine, Mahidol University. PARTICIPANTS: Forty patients undergoing endoscopic sinus surgery (ESS) for CRS. Thirty-eight patients met the inclusion criteria and were randomly assigned to receive nasal irrigation or nasal spray mixed with fluorescein sodium preoperatively. MAIN OUTCOME MEASURES: The primary outcome was the mean difference in the staining score of fluorescein in all sinuses between the two groups. RESULTS: The total fluorescein staining score for all sinuses in the nasal irrigation group was significantly higher than the score from the nasal spray group, with a mean difference score of 2.90, 95% confidence interval: 1.22-4.58, p = .001. The most significantly affected sinuses were the maxillary and the anterior ethmoid sinuses, while the frontal and sphenoid sinuses had only minimal staining from both techniques. CONCLUSION: Nasal irrigation is a potential route to deliver drugs into the sinus in unoperated CRS patients. However, it is not considered a superior method to nasal spray in the most challenging anatomical areas, that is, the frontal and sphenoid sinuses.

Corticosteroid nasal irrigation as early treatment of olfactory dysfunction in COVID-19: A prospective randomised controlled trial.

OBJECTIVE: This study aimed to evaluate the efficacy of corticosteroid irrigation compared to saline to no nasal irrigation in COVID-19 patients with olfactory loss. DESIGN AND SETTING: A randomised controlled study was conducted at the Otolaryngology-Head & Neck Surgery Department, Ramathibodi Hospital, Faculty of Medicine, Mahidol University. PARTICIPANTS: Two hundred thirty-seven COVID-19 participants with a new-onset smell loss were recruited into the study. Two hundred twenty-two participants met the inclusion criteria and were randomised into three groups: corticosteroid irrigation, saline irrigation and no treatment. MAIN OUTCOME MEASURES: The primary outcome was the mean difference in the smell sensation score among the groups after treatment at 1, 2 and 6 weeks. The secondary outcomes measurements included (1) a self-rating quality of life (QOL)-related smell dysfunction score, (2) the change over time in smell sensation score and self-rating QOL-related smell dysfunction score and (3) the median time to complete recovery of smell loss. RESULTS: The mean differences in smell sensation scores among the three groups were not statistically significant at any follow-up period. The mean score of self-rating QOL-related smell dysfunction in the corticosteroid group was significantly better than the other groups at 1 week. The change of outcome scores showed significant improvement over time, regardless of the treatments. The median time to complete smell recovery was similar: 3 weeks. CONCLUSION: This study emphasised that corticosteroid nasal irrigation is not superior to saline or no nasal irrigation in restoring the sense of smell in COVID-19-associated olfactory loss.

Translation and Validation of the Thai Version of the Nasal Obstruction Symptom Evaluation (NOSE) Scale.

Objective: The Nasal Obstruction Symptom Evaluation (NOSE) was developed to evaluate subjective outcomes of patients with deviated nasal septum and symptomatic nasal obstruction. Considering the differences in individuals' cultural, cross-cultural translation, adaptation, and validation of the instrument are necessary. The current study aimed to translate and validate the Thai version of the NOSE Questionnaire for patients with nasal septum deviation. Study Design: A single-center prospective instrument validation study. Setting: Thai tertiary referral center. Methods: The study was conducted to translate and adapt the original English version of the NOSE to Thai. After translating, psychometric testing was conducted. The primary outcomes were validity (content, construct, and discriminant), reproducibility (test-retest procedure), and internal consistency (reliability). A total of 105 participants, of which 46 were patients with nasal airway obstruction and 59 were healthy asymptomatic volunteers, were enrolled in this study. Results: The Thai-NOSE was found to be adequate for all tested psychometric properties with high internal consistency (Cronbach's α = .942), and to discriminate accurately between patients and healthy controls. The interitem and item-total correlations indicated a related construct among all items. A high level of reproducibility of the questionnaire was obtained in the test-retest procedure for each item (γ = 0.898). The initial test and retest scores indicated adequate reproducibility. Conclusion: The Thai-NOSE questionnaire is a reliable instrument with appropriate psychometric properties for assessing the severity and impact of nasal airway obstruction in patients with nasal septum deviation.

Prevalence and Prognostic Factors Associated with Early Recovery of Olfactory Dysfunction in COVID-19 Patients.

BACKGROUND: The prevalence of smell dysfunction, along with its risk factors, has been evaluated in previous literature; however, little has been established regarding its relation to other factors such as disease severity, history of coronavirus disease-2019 (COVID-19) vaccinations, and medical treatment for COVID-19 infection. These factors may impact the overall recovery of olfaction in COVID-19 patients. OBJECTIVE: This study investigated the prevalence of early olfactory recovery from COVID-19 infection and its associated factors. METHODS: This study was a prospective cohort study on 348 COVID-19 patients with a new onset of anosmia or hyposmia. Smell sensation scores on the olfactory self-assessment test were collected at baseline and every week until 6 weeks of follow-up. The primary outcome was the prevalence of early olfactory recovery. The secondary outcomes were analyzing factors associated with early olfactory recovery and the median time to complete recovery of smell loss. RESULTS: The prevalence of early olfactory recovery was 63.1% (95% CI: 0.58-0.68), and significant associated factors in multivariate analysis included patients without allergic rhinitis (OR 2.22, 95% CI: 1.12-4.40, P = 0.023) and no alteration of taste perception (OR 1.62, 95% CI: 1.02-2.57, P = 0.042). The median time to complete recovery from smell loss was 2 weeks. CONCLUSION: The present study found that the prevalence of early olfactory recovery within 2 weeks was 63.1%. The median time to olfactory recovery was also 2 weeks. Patients without allergic rhinitis and taste alteration had a significantly better chance of early recovery of olfactory function.

Schwannoma Arising in Nasopharynx: A Case Report and Literature Review.

Schwannoma in paranasal sinus has been known as a rare tumor in this origin. This study reports on primary schwannoma arising in the nasopharynx, which is an uncommon location. A 36-year-old female presented with nasal obstruction for one month. Physical examination revealed a nasopharyngeal mass totally occluding bilateral posterior choanae and extended downward to the oropharynx. Magnetic resonance image showed heterogeneous enhancing mass at the nasopharynx extending inferiorly to the oropharynx. The tumor was excised via endoscopic combined trans-nasal/trans-oral approach under general anesthesia. The pathologic diagnosis was consistent with schwannoma. The tumor was successfully excised with en-block resection and the patient was discharged the next day after the operation, without any postoperative complications. There was no tumor recurrence at 12-months follow-up. Schwannoma primarily arising in the nasopharynx is uncommon. Minimally-invasive surgery via the endoscopic approach can be applied for tumor removal with fewer complications and reduced risk of morbidity.

Contributing factors for delayed postoperative cerebrospinal fluid leaks and suggested treatment algorithm.

BACKGROUND: Delayed postoperative cerebrospinal fluid (CSF) leaks are uncommon and largely unstudied complications. In this study we aim to identify their etiology and understand the efficacy of various reconstruction strategies. METHODS: A retrospective chart analysis of 1017 endonasal skull base surgeries performed by a single neurosurgeon was completed identifying delayed CSF leaks (occurring >1 week after surgery). RESULTS: Seventeen cases of early (1-2 weeks after surgery) or delayed (>2 weeks after surgery) postoperative CSF leak were identified. The most common reconstruction during the initial surgery consisted of an inlay or gasket seal collagen matrix (82.4% of patients) with an onlay pedicled flap (76.5% of patients). Presenting symptoms of delayed CSF leak included rhinorrhea (82.4%), headache (41.2%), and meningitis (23.5%). The most common causes included flap dehiscence (17.6%); provoking events such as emesis, sneezing, or fall (17.6%); flap necrosis (11.8%); flap displacement (11.8%); and inadequate apposition of the flap, that is, folded flap (11.8%). Reconstructive techniques of the delayed CSF leak included fortification of the initial reconstruction with free fat grafts (29.4% of patients), combined collagen matrix with a fat graft (23.5% of patients), repositioning of the previous flap (11.8% of patients), and repair with a new flap (11.8% of patients). CSF diversion (spinal/ventricular drain or shunt) was used in 17.6% of patients. CONCLUSION: This study identifies the most common etiologic factors leading to a delayed CSF leak and its initial symptoms. Furthermore, it serves as the foundation for a reconstructive algorithm based on reinforcement of the initial repair with free abdominal fat graft with or without collagen matrix.

Role of fungi in chronic rhinosinusitis through ITS sequencing.

OBJECTIVE: Next-generation sequencing increases the sensitivity of fungal identification and may improve our understanding of the role that fungi play in sinus health and disease, which remains incompletely understood. We sequenced the internal transcribed spacer (ITS) amplicon to explore the role of the mycobiome in chronic rhinosinusitis (CRS). METHODS: Swabs were collected intraoperatively from the middle meatus of 90 patients (63 with CRS; 27 controls). DNA was extracted, and ITS amplicon concentration was measured using fluorometry. Internal transcribed spacer amplicons were sequenced on the Illumina MiSeq (Illumina Inc San Diego CA). Sequencing data were analyzed using QIIME. RESULTS: Using conventional detection techniques of culture and histology, fungi only were identified in nine of 63 (14.3%) CRS patients (fungus-identified group); the remaining 54 CRS patients and all controls did not have fungus identified using the traditional techniques. This fungus-identified group had a significantly higher average ITS concentration and a significantly lower Shannon's diversity index compared to the other two groups. The most abundant organism sequenced was Aspergillus (35.22% of all sequences). Multivariate analysis showed that positive fungal detection using traditional techniques and computed tomography (CT) double densities were the most important clinical predictors of a high fungal biomass, whereas Lund-Mackay score, polyps, eosinophilia, and eosinophilic mucus were not significant in comparison. CONCLUSION: Fungal biomass estimated through ITS amplicon concentration correlated with traditional fungal detection techniques and CT double densities. Our results suggest that fungal dysbiosis only occurs in the sinuses of a selected subset of patients, and therefore could not be a universal determinant of sinus disease pathogenesis in all CRS patients. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:16-22, 2018.

Potential Surgical Exposure of the Parapharyngeal Internal Carotid Artery by Endonasal, Transoral, and Transcervical Approaches.

Objectives Endoscopic and endoscopic-assisted approaches to the parapharyngeal space have been reported; however, their potential for vascular exposure has not been previously assessed. This study aims to compare the potential exposure and control of the parapharyngeal internal carotid artery (ppICA) via various approaches. Design and Main Outcome Measures Ten cadaveric specimens were dissected bilaterally, exposing the ppICA via endonasal, transoral, and transcervical approaches. Length of the exposed vessel and potential control were assessed (feasibility and time required to place an encircling suture). Results Endoscopic transoral and transcervical-transmandibular approaches expose a significantly longer segment of the ppICA (6.89 and 7.09 cm) than the transoral and endonasal approaches. Vascular control was achieved via endoscopic-endonasal, endoscopic-transoral, and open techniques in 121.6, 64.8, and 5.2 seconds, respectively. Conclusion Histopathology, goals of surgery, and familiarity of the surgeon with each technique may ultimately determine the choice of approach; however, this study suggests that exposure of the ppICA by endoscopic-assisted transoral approach is comparable to that of a transcervical-transmandibular approach. Vascular control was feasible under elective circumstances. However, the difficulty varied widely, potentially reflecting the challenges of controlling an injured ppICA. However, one must note that active bleeding obscures the surgical field in ways that may impair ppICA control. Furthermore, the results may not reflect clinical scenarios where tumor distorts the surgical field. Nonetheless, the study suggests that, in properly selected patients, the endoscopic-assisted transoral approach avoids problems associated with unsightly scars, mandibular osteotomy, and facial nerve manipulation, whereas, the transcervical-transmandibular approach offers the swiftest vascular control.