Symptoms and Clinical Findings in Primary Headache Syndrome Versus Chronic Rhinosinusitis.

BACKGROUND: Primary headache syndrome (PHS) patients frequently present to otolaryngologists with sinonasal complaints and diagnosis of chronic rhinosinusitis (CRS) due to symptomatic overlap. In this study, we compare demographic, subjective, and objective clinical findings of patients with PHS versus CRS. METHODS: We retrospectively reviewed a database of patients presenting to a single tertiary care Rhinology clinic from December 2011-July 2017. Sino-Nasal Outcome Test-22 (SNOT) scores and Lund-Kennedy endoscopy scores were obtained. Lund-MacKay CT scores were calculated, if available. Requirement of headache specialist management was compared between PHS and CRS groups. Patients with both CRS and PHS (CRScPHS) that required headache specialist management were compared to patients with CRS without PHS (CRSsPHS) and patients with PHS alone using Kruskal-Wallis analysis of variance. Receiver operating characteristic (ROC) analyses were carried out to determine significant diagnostic thresholds. RESULTS: One-hundred four PHS patients and 130 CRS patients were included. PHS patients (72.1%) were more likely than CRS patients to require headache specialist management (6.9%, p<0.0001). CRSsPHS patients had significantly higher Nasal domain scores compared to PHS patients (p = 0.042) but not compared to CRScPHS patients (p>0.99). CRScPHS (p = 0.0003) and PHS (p<0.0001) subgroups of patients had significantly higher Aural/Facial domain scores compared to CRSsPHS patients. PHS patients also had significantly higher Sleep domains scores compared to CRSsPHS patients (p<0.0001). Both CRScPHS and CRSsPHS subgroups had significantly higher nasal endoscopy scores (p<0.0001) and CT scores (p = 0.04 & p<0.0001, respectively) compared to the PHS group. Aural/Facial domain score of 4, nasal endoscopy score of 4, and CT score of 2 were found to be reliable diagnostic thresholds for absence of CRS. CONCLUSIONS: The SNOT-22 may be used to distinguish PHS from CRS based upon the Aural/Facial and Sleep domains. Patients with CRS have more severe Nasal domain scores and worse objective endoscopy and CT findings.

The Sensitivity and Specificity of Touch Preparation for Rapid Diagnosis of Invasive Fungal Sinusitis: A Pilot Study.

Invasive fungal sinusitis is a morbid pathology that typically affects immunocompromised patients and may quickly progress to fulminant disease. The purpose of this study was to measure the sensitivity and specificity of touch preparation of nasal debridement specimens as a rapid diagnostic tool for invasive fungal sinusitis. A retrospective chart review was performed of 22 patients undergoing nasal debridement due to suspicion for invasive fungal sinusitis over a 10-year period. Thirteen patients had touch preparation of nasal specimens followed by routine histologic processing; two of these patients underwent 2, and 1 patient had 3 separate debridements, for a total of 17 touch preparations performed. The sensitivity and specificity of touch preparation were calculated by correlating the initial results with the presence of fungal invasion on final pathologic analysis. The sensitivity of touch preparation was 56% (95% confidence interval [CI]: 0.23-0.85), specificity was 100% (95% CI: 0.60-1.00), positive predictive value was 100% (95% CI: 0.46-1.00), and negative predictive value was 67% (95% CI: 0.35-0.89). This procedure may be a useful adjunct in situations requiring rapid diagnosis of invasive fungal sinusitis but should not be used as the sole criteria for determining the need for surgical intervention.

The sensitivity and specificity of touch preparation for rapid diagnosis of invasive fungal sinusitis: A pilot study.

Invasive fungal sinusitis is a morbid pathology that typically affects immunocompromised patients and may quickly progress to fulminant disease. The purpose of this study was to measure the sensitivity and specificity of touch preparation of nasal debridement specimens as a rapid diagnostic tool for invasive fungal sinusitis. A retrospective chart review was performed of 22 patients undergoing nasal debridement due to suspicion for invasive fungal sinusitis over a 10-year period. Thirteen patients had touch preparation of nasal specimens followed by routine histologic processing; 2 of these patients underwent two and 1 patient had three separate debridements, for a total of 17 touch preparations performed. The sensitivity and specificity of touch preparation were calculated by correlating the initial results with the presence of fungal invasion on final pathologic analysis. The sensitivity of touch preparation was 56% (95% confidence interval [CI]: 0.23 to 0.85), specificity was 100% (95% CI: 0.60 to 1.00), positive predictive value was 100% (95% CI: 0.46 to 1.00), and negative predictive value was 67% (95% CI: 0.35 to 0.89). This procedure may be a useful adjunct in situations requiring rapid diagnosis of invasive fungal sinusitis but should not be used as the sole criterion for determining the need for surgical intervention.

Effectiveness of leukotriene receptor antagonism in the postoperative management of chronic rhinosinusitis.

BACKGROUND: Montelukast is used in the treatment of allergic rhinitis and asthma. It has been used as adjuvant therapy in patients with chronic rhinosinusitis (CRS), but its effectiveness has not been evaluated. This study evaluates the efficacy of adjuvant leukotriene receptor antagonism in CRS and subtypes. METHODS: Retrospective review of collected data at a tertiary-referral institution. We identified all patients who were prescribed montelukast postoperatively and had a lapse in therapy for at least 1 month (n = 50), so that the patients themselves serve as their own control group. Twenty-item Sino-Nasal Outcomes Test (SNOT-20) scores and Lund-Kennedy endoscopy scores were obtained for each patient. Scores were compared with and without montelukast using Wilcoxon signed rank test. The analysis was controlled for changes in other medications. RESULTS: Fifty-two therapy lapses were identified in 50 patients. Twenty-seven patients had eosinophilic CRS with polyps (eCRSwNP), 8 had Samter's triad (ST), and 15 had allergic fungal sinusitis (AFS). Overall mean follow-up was 46.5 months. Overall, SNOT-20 scores and endoscopy scores were significantly lower with montelukast (p < 0.005 for both). On subgroup analysis, SNOT-20 scores were significantly improved for patients with eCRSwNP and AFS (p < 0.001 and p = 0.001, respectively). Endoscopy scores were significantly improved for patients with eCRSwNP (p = 0.044). Outcomes approached, but did not reach, significance for patients with ST (p = 0.123 for SNOT-20 and p = 0.146 for endoscopy). There was also significant improvements in patients with asthma. CONCLUSION: The addition of montelukast as postoperative therapy may be beneficial for patients with eCRSwNP and AFS.

Effectiveness of a standardized education process for tracheostomy care.

OBJECTIVES/HYPOTHESIS: Evaluate the effectiveness of an educational curriculum on general tracheostomy care principles and determine the effect of this educational curriculum on the level of provider comfort with tracheostomy care. STUDY DESIGN: Cross-sectional questionnaire in an academic medical center. MATERIALS AND METHODS: A 25-question multiple choice and true/false quiz was given to nonotolaryngology health care providers (nurses and physicians) who routinely provide tracheostomy care. This was followed by an education module, and the quiz was repeated. Participants were also asked to rate their level of comfort (0-100 point scale) managing a tracheostomy before and after the module. A 6-month follow-up assessment was also obtained. RESULTS: A total of 94 health care providers participated in the education module (50 physicians, 37 nurses, 7 fourth-year medical students). The average number of correct answers increased by 3.1 (P < 0.001). The level of confidence in tracheostomy care improved by 18.8 points (P < 0.001). At the 6-month assessment, there was still a significant improvement in the number of correct questions and level of confidence when compared to preeducation values (P < 0.02 for both). There was no significant change in the 6-month values when compared to the posteducation values. CONCLUSIONS: A standardized education module for tracheostomy care teaching resulted in significant increases in provider knowledge and confidence. Standardization of tracheostomy education and care is essential in academic hospital medical centers where multiple specialties may be performing tracheostomies and health care providers frequently change. LEVEL OF EVIDENCE: N/A.

Chronic rhinosinusitis in patients requiring surgical repair of a midface fracture.

Midface fractures commonly occur following trauma to the face and may cause changes in the normal sinus outflow system. To the best of our knowledge, no study has examined the incidence of rhinosinusitis following midface fractures. We report the incidence of chronic rhinosinusitis in patients who underwent surgical repair of a midface fracture. Our evaluation tool was the 20-item Sino-Nasal Outcome Test quality-of-life survey (SNOT-20). We mailed a demographic survey and the SNOT-20 questionnaire to 486 eligible patients who had undergone surgical repair of either a midface (n = 234) or mandible (n = 252) fracture; we had intended to use the latter cohort as a control group. Of the 234 midface patients, 34 (14.5%) returned a usable survey, but only 7 of the 252 mandibular patients (2.8%) did so, which was not a sufficient number for analysis; therefore we used normative data obtained from another study for comparison purposes. The mean SNOT-20 score in our cohort was 24.15, which was similar to the 28.7 mean score in the control cohort of patients with rhinosinusitis. The highest mean scores for the individual components of the SNOT-20 were for "Wake up at night," "Lack of a good night's sleep," "Wake up tired," and "Frustrated/restless/irritable." The components that the most patients found bothersome were "Facial pain/pressure," "Need to blow nose," "Runny nose," and "Lack of a good night's sleep." We conclude that patients who experience a midface fracture have a much higher risk of developing chronic rhinosinusitis that negatively affects their long-term quality of life. These patients should be monitored with long-term follow-up and treated appropriately.

The clinical and audiologic features of hearing loss due to mitochondrial mutations.

OBJECTIVES: To characterize mitochondrial sequence variants present in a nationwide hereditary deafness DNA repository of samples from deaf subjects and to define the clinical presentation and audiometric characteristics of individuals with a mitochondrial sequence variant. STUDY DESIGN: Retrospective review of results for select mitochondrial mutations performed on DNA samples from subjects compiled from 1997 to 2009. SETTING: National hereditary deafness DNA repository. SUBJECTS AND METHODS: Available samples from subjects in the repository were screened to identify those with mitochondrial sequence variants. Clinical data on the nature of mutation, type and severity of the hearing loss, and sex, age at diagnosis, family history of hearing loss, and ethnicity were analyzed. RESULTS: Eighty-six patients were identified with mitochondrial mutations or 3.5% of the subjects studied. Among those with mitochondrial mutations, 21 (24.4%) had the m.7445A>G substitution, 18 (20.9%) had the m.1555A>G substitution, 18 (20.9%) had the m.961T>G substitution, and 29 (33.7%) had a m.961delT+C(n) complex deletion. The majority of patients had bilateral severe to profound hearing loss. Fifty-three (62%) patients were female, and a family history of hearing loss was documented in 66 (76.7%) patients. The deafness was recognized prior to 3 years of age in 26 patients. CONCLUSION: Mitochondrial deafness in this sample was associated with a variety of genetic mutations and a wide spectrum of clinical presentations. Because of increased aminoglycoside susceptibility associated with some forms of mitochondrial deafness, matrilineal relatives may be at risk in those cases, highlighting the importance of making an accurate diagnosis prior to exposure.

Risk factors associated with unilateral hearing loss.

OBJECTIVE: To analyze the presence of Joint Committee on Infant Hearing (JCIH) risk factors and co-occurring birth defects (CBDs) in children with unilateral hearing loss (UHL). DESIGN: Retrospective review. SETTING: Statewide registry of universal newborn hearing screen data for all children born in Virginia from 2002 through 2008. PATIENTS: The study population comprised 371 children with confirmed UHL. MAIN OUTCOME MEASURES: Universal newborn hearing screen status, presence or absence of JCIH risk factors, and CBDs RESULTS: Of the 371 children with confirmed unilateral hearing loss, 362 (97.5%) were identified through a failed universal newborn hearing screen. Of these 362 children, 252 (69.6%) had no JCIH risk factors and 110 (30.3%) had 1 or more risk factor reported. Nine children (2.5%) with 1 or more risk factors passed the universal newborn hearing screen but had later-onset UHL. Craniofacial anomaly was the most commonly reported JCIH risk factor in 48 children (43.6%). A family history of permanent childhood hearing loss was present in 24 children (21.8%). Twenty children (18.2%) had stigmata associated with a syndrome including hearing loss. Of the 110 children with UHL and a JCIH risk factor, additional CBDs were identified in 83 (75.5%). An ear-specific anomaly was most prevalent in 37 infants (44.6%), followed by cardiovascular anomalies in 34 infants (41.0%). CONCLUSIONS: Thirty percent of children with confirmed UHL had a JCIH risk factor, most commonly craniofacial anomalies, family history of hearing loss, and stigmata of syndromes associated with hearing loss. However, the absence of JCIH risk factors does not preclude the development of UHL. Further studies assessing the etiology of UHL and risk factor associations are warranted.

Prevalence of previously unknown elevation of glycosylated hemoglobin in spine surgery patients and impact on length of stay and total cost.

BACKGROUND: Elevated levels of glycosylated hemoglobin (HbA1c) among spine surgery patients may have an impact on length of stay (LOS) and healthcare cost. MATERIALS AND METHODS: We retrospectively reviewed the charts of 556 spine surgery patients who underwent 1 of 3 types of surgery: lumbar microdiscectomy (LMD), anterior cervical decompression and fusion (ACDF), and lumbar decompression and fusion (LDF). Information was collected about their diabetes mellitus (DM) history and HbA1c levels. We used HbA1c 6.1% as the screening cutpoint. Percentages of nondiabetic patients, those with subclinical elevation of HbA1c and those with already known DM were calculated and statistical analysis was applied. RESULTS: After excluding the small group of well-controlled DM (n = 14), 72.4% of patients were nondiabetic, 14.3% were subclinical patients with previously unknown HbA1c elevation, and 13.3% were already known, confirmed DM patients. There were significant differences in the LDF group between the "No DM" and "Subclinical" groups (P < 0.05) in terms of cost and LOS (P < 0.05). Age and body mass index (BMI) were very significant predictors of total cost in spine surgery patients (P 0.05) in determining cost. CONCLUSIONS: There is a significant segment of spine surgery patients who were unaware of their elevated HbA1c status before their preoperative visit. These patients seem to utilize more healthcare resources, which is especially evident in the LDF group. We believe that HbA1c should be considered in the routine preoperative workup of spine surgery patients.

Functional outcomes following secondary free flap reconstruction of the head and neck.

OBJECTIVES/HYPOTHESIS: To evaluate head and neck patients undergoing secondary (delayed) free flap reconstructions. STUDY DESIGN: Retrospective chart review. METHODS: Of the 523 free flaps between October 2004 and May 2008, 70 patients underwent 71 secondary free flaps. Outcomes include: hospital stay, complications, flap operative time, enterogastric tube, and tracheostomy requirement. Variables assessed include donor site, indication, prior radiation, and extra-cervical vascular anastomosis. RESULTS: Radial forearm (40.8%) and fibula free flaps (29.6%) were most commonly used. Mean hospital stay was 7.9 days, follow-up 23.5 months, and operative time 323 minutes. Complications occurred in 39.4% in hospital (early) and 31.4% after discharge (late). Many required further surgery (33.8%), tracheostomy at discharge (26.8%), and prolonged enterogastric tube feeding (31%). In-hospital mortality was 1.4%, total flap failure 1.4%, and partial failure 5.6%. The radial forearm required the least operative time (P = .002), and had least tracheostomies at discharge (P = .040). Osteocutaneous fibula took longest (P = .0001), and had the highest tracheostomy rate (P = .047). Early complications were highest with anterolateral thigh flaps (P = .001). Osteoradionecrosis resulted in higher tracheostomy rates at discharge (P = .0001). Osteocutaneous flaps took 111 minutes longer (P = .001), and required more tracheostomies on discharge (P = .031), but with lower fistula rates (P = .046). Previous irradiation and extra-cervical vessels did not significantly impact outcomes. CONCLUSIONS: Secondary free flaps are technically feasible for head and neck reconstruction with low mortality and flap failure rates. The extra-cervical and external carotid vessels were equally effective. Patients considering semi-elective free flap reconstruction for osteoradionecrosis should be cautioned about complication rates and tracheostomy retention.