SinoNasal Microbiota Transfer to treat recalcitrant chronic rhinosinusitis: A case series.

KEY POINTS: SinoNasal Microbiota Transfer (SNMT) was safe with immediate benefit in all recipients, with sustained improvement in two of three recipients for up to 180 days. The addition of antimicrobial photodynamic therapy worsened chronic rhinosinusitis. These promising SNMT results warrant further study of safety and efficacy.

The Effects of Nasal Surgery on Pulmonary Function: A Systematic Review and Meta-Analysis.

OBJECTIVE: A deviated nasal septum (DNS) can result in an anatomical obstruction and impact lung function through prolonged suboptimal inspiration. Given the improvements in respiration reported by patients following septoplasty or septorhinoplasty (with or without inferior turbinate reduction), our study investigated the effect of these procedures on pulmonary function through a systematic review and meta-analysis. DATA SOURCES: Medline, Embase, Cochrane Databases, Web of Science, and Google Scholar. REVIEW METHODS: The review was registered with PROSPERO [CRD42022316309]. The study population was composed of adult patients (18-65) who were symptomatic with confirmed DNS. Extracted outcomes (pre-operative versus postoperative) included the six-minute walk test (6MWT) and pulmonary function tests (FEV1, FVC, FEV1/FVC, FEF25-75, PEF). Meta-analyses were performed using a random-effects model. RESULTS: Three studies included measures of the 6MWT in meters and all three found a statistically significant increase in the distance walked after surgery with a mean difference of 62.40 m (95% CI 24.79-100.00). Statistically significant improvements in PFT outcomes were observed with a standard mean difference of 0.72 for FEV1 (95% CI 0.31-1.13), 0.63 for FVC (95% CI 0.26-1.00), and 0.64 for PEF (95% CI 0.47-0.82). Of the twelve studies which measured PFT outcomes, six showed statistically significant improvements, three studies showed mixed results, and three studies found no difference in PFT outcomes between pre-and post-surgery testing. CONCLUSIONS: The present study suggests that pulmonary function does improve after nasal surgery for DNS, but the high heterogeneity observed in the meta-analyses indicates that the evidence supporting this conclusion is low. Laryngoscope, 133:2837-2845, 2023.

Multiple spontaneous cerebrospinal fluid leaks: a rare case report and review of literature.

While a spontaneous cerebrospinal fluid leak (sCSFL) is a rare phenomenon, patients who present with multiple cerebrospinal fluid leaks (mCSFLs) are an even rarer entity. There have been documented cases reported over the last decades, but many with only limited descriptions of each patient. We present a mCSFL patient as a case report and demonstrate the need for future prospective studies to improve further understanding and management of the condition. This is explored through summarizing the literature on mCSFLs to the present time. A 45-year-old obese female presented with a 5-week history of bilateral clear nasal discharge with no previous surgery or trauma. Initially misdiagnosed as allergic rhinitis, nasal discharge was later confirmed positive for beta-2-transferrin and a CT scan revealed multiple bony areas of skull base erosion. The patient underwent image guided endoscopic sinus surgery with multilayer skull base defect repair of three active CSFLs. Three months post-operatively the patient had no evidence of a recurrence. As mCSFL tend to be sporadic and asymptomatic in nature, it is likely they are underreported. Future prospective studies in the area of mCSFLs that take into consideration demographic and geographical information are needed for more accurate interpretation and better recruitment. Additionally, studies need to ensure longer follow-up time due to the underlying chronicity of increased intracranial pressure (ICP) and investigate whether or not a non-active leak site should be repaired or left alone.

International consensus statement on allergy and rhinology: rhinosinusitis 2021.

I. EXECUTIVE SUMMARY: BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. METHODS: ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS: ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. CONCLUSION: This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

The efficacy of diluted topical povidone-iodine rinses in the management of recalcitrant chronic rhinosinusitis: a prospective cohort study.

PURPOSE: Recalcitrant chronic rhinosinusitis is a persistent inflammatory condition of the sinonasal mucosa despite adequate medical therapy and sinus surgery. This study aimed to demonstrate the effectiveness and safety of dilute povidone-iodine (PVP-I) sinonasal rinses as an adjunctive therapy. METHODS: Prospective cohort study. Twenty-nine recalcitrant CRS patients with endoscopic evidence of ongoing inflammation and purulent discharge were prescribed 0.08% diluted PVP-I rinses. Changes to endoscopic modified Lund-Kennedy (MLK) scores at 7 weeks post-PVP-I rinsing served as the primary outcome measure. RESULTS: The median MLK-discharge score significantly decreased in all patients by 1.50 points post-PVP-I rinsing (p value < 0.01). The total MLK score significantly decreased in all patients by 1.50 points (p value = 0.01). Up to a 17% reduction in serum inflammatory markers was measured post-PVP-I rinsing. Sinonasal culture revealed a shift from moderate-heavy growth to lighter bacterial growth overall. Subjective SNOT-22 scores significantly improved overall by ≥ 1 minimal clinically important difference (MCID > 12; baseline median = 33; follow-up median = 20; p value < 0.01; n = 22). TSH levels increased non-significantly within normal ranges (baseline median = 1.59 mU/L; follow-up median = 1.92 mU/L; p = 0.10; n = 15). Mucociliary clearance time increased non-significantly within normal ranges (baseline median = 9 min; follow-up median = 10 min; p value = 0.53; n = 17). Olfactory Sniffin'16 scores non-significantly decreased within age-related normal ranges (baseline median = 14; follow-up median = 13; p value = 0.72; n = 18). CONCLUSION: A dilute 0.08% PVP-I sinonasal rinse as an ancillary therapy in recalcitrant CRS significantly reduces signs of infection alongside notable symptom improvement, without affecting thyroid function, mucociliary clearance or olfaction.

Evaluation of sheep sinonasal endoscopic anatomy as a model for rhinologic research.

OBJECTIVES: Despite many publications describing sheep models for functional endoscopic sinus surgery (FESS) procedures, accurate endoscopic anatomical studies are lacking. There are no publications correlating computed tomography (CT) and 3D models with endoscopic anatomical descriptions. This study evaluates and describes the endoscopic anatomy of a sheep model. METHODS: Ten live sheep (20-sides) were included. Two cadaveric specimens, imaged using thin slice CT for 3D reconstruction correlation were also included. Using endoscopy, anatomical structures were measured and described. Measurement of the same structures was carried out using the 3D imaging model. RESULTS: Three sets of turbinates were identified at 2.3, 5.1 and 8.5 cm from the anterior nasal sill. Frontal recess and uncinate process were identified at 12.7 cm. The septum has a bony and cartilaginous component and measures 10.5 cm. The sphenopalatine foramen was measured at 12.1 cm. All anatomical measurements were correlated with the measurements on the CT scan 3D volume-rendering model, thereby allowing for an accurate description of the sheep sinonasal anatomy. CONCLUSION: This study describes the endoscopic sinonasal anatomical measurements of the adult sheep. It is the first study to evaluate the sheep CT and endoscopic anatomy in order to determine its feasibility as an animal model for research in FESS.

Potential risk factors associated with the development of synechiae following functional endoscopic sinus surgery.

PURPOSE: Synechiae formation in the middle meatus is the most common complication of functional endoscopic sinus surgery (FESS). Our objectives were to determine the incidence of synechiae occurring in a cohort of patients that have undergone FESS and identify characteristics associated with the development of synechiae postoperatively. METHODS: A retrospective chart review was conducted of CRS patients, with or without nasal polyposis, that had undergone bilateral FESS in the past. All patients had received non-absorbable spacers intraoperatively that were left in situ for 6 days. Demographic and preoperative variables were analyzed to identify synechiae risk factors. A multivariable logistic regression model was constructed to estimate the probability of developing synechiae, given demographic and preoperative variables. RESULTS: Two hundred cases of bilateral FESS were retrospectively reviewed. Thirty-eight (19.0%, 95% CI 13.6-24.4%) patients developed synechiae. Individuals receiving primary FESS and nasal septal reconstruction (NSR) were strongly associated with the development of synechiae (OR 3.5, 95% CI 1.5-8.5; OR 3.0, 95% CI 1.3-6.9). A multivariable logistic regression model adjusting for NSR, recurrent FESS, concha bullosa, requirement of anterior and posterior ethmoidectomy, Lund-Mackay CT score and gender, identified the likelihood of developing synechiae with a sensitivity of 68%, specificity of 73%, positive predictive value of 38% and likelihood ratio of 2.5. CONCLUSION: Patients undergoing primary FESS and NSR are at greatest odds of developing postoperative synechiae. Methods of assessing risk factors and preventing synechiae formation in this population should be evaluated in future prospective investigations.

Comparing the efficacy of Silastic and gloved-Merocel middle meatal spacers for functional endoscopic sinus surgery: a randomized controlled trial.

BACKGROUND: Spacers are inserted into the middle meatal space (MMS) following functional endoscopic sinus surgery (FESS) to prevent lateralization of the middle turbinate, scarring, and synechiae. Our objective was to determine if the incidence of postoperative synechiae, facial pain/discomfort, pain during spacer removal, scarring, and discharge differed between nasal cavities receiving Silastic or gloved-Merocel (GM) spacers following FESS. METHODS: A double-blind, randomized controlled trial (RCT) was conducted in adults requiring bilateral FESS for chronic rhinosinusitis (CRS) ± nasal polyposis. Participants served as their own controls, with each subject receiving both a Silastic and GM spacer. Spacers were inserted into the MMS during FESS and left in situ for 6 days. Participants were reviewed at 6 days, 5 weeks, and 12 weeks postoperatively. The presence of synechiae and scarring were evaluated endoscopically. Inflammation, discharge, and pain during spacer removal were assessed using a visual analogue scale (VAS). RESULTS: Forty-eight participants (96 nasal cavities) were recruited. Preoperatively, Lund-Mackay computed tomography (CT) scores were similar between Silastic-treated and GM-treated cavities (6.38 ± 2.35 vs 6.18 ± 2.17). The incidence of synechiae and scarring did not differ significantly between spacers up to 12 weeks postoperatively. Pain during spacer removal was significantly greater for Silastic than GM spacers (2.13 ± 1.34 vs 1.51 ± 1.23, p = 0.020). Facial pain prior to removal and extent of discharge did not differ significantly between spacers. CONCLUSION: Following FESS, patients report less pain during removal of GM than Silastic spacers. However, the likelihood of synechiae and scarring did not differ between either of the spacers.

Quality-of-life outcomes after sinus surgery in allergic fungal rhinosinusitis versus nonfungal chronic rhinosinusitis.

BACKGROUND: Given the differences in pathophysiology between allergic fungal rhinosinusitis (AFRS) and other chronic rhinosinusitis (CRS) subgroups, it remains unclear about whether these patients respond differently to a combination of surgical and medical treatments. OBJECTIVE: To evaluate differences in quality-of-life (QoL) outcomes for a cohort of patients who underwent endoscopic sinus surgery (ESS) for CRS. METHODS: This retrospective review included patients with CRS who underwent ESS between 2010 and 2013. QoL was measured by using the 22-item Sino-Nasal Outcome Test (SNOT-22). Variables collected included baseline demographics, SNOT-22 scores before ESS and at 1, 3, 6, 9, and 12 months after ESS. Groups tested were CRS with nasal polyposis, CRS without nasal polyposis (CRSsNP), and patients with AFRS. A linear mixed- effects regression model was used to calculate the adjusted mean QoL differences. RESULTS: Among the 250 patients included, 61.6% had CRS with nasal polyposis (n = 154), 28.8% had CRSsNP (n = 72), and 9.6% had AFRS (n = 24). Significant differences were seen in SNOT-22 scores between pre- and postoperative visits and between the etiologic subgroups (p < 0.001). Multivariate analysis revealed significantly greater improvement in QoL for patients with AFRS in comparison with those with CRSsNP at the 9-month follow-up (change in SNOT-22 score, 22.6 [95% confidence interval, 1.2-44.1]; p < 0.0) and the 12-month follow-up (change in SNOT-22 score, 20.2 [95% confidence interval, 0.5-39.9]; p < 0.04). CONCLUSIONS: Patients with AFRS experienced a more-prolonged QoL benefit from surgical and targeted medical intervention compared with those with CRSsNP, which may reflect the severity of inflammation that they presented with compared with other CRS subtypes.

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis.

BACKGROUND: The body of knowledge regarding rhinosinusitis(RS) continues to expand, with rapid growth in number of publications, yet substantial variability in the quality of those presentations. In an effort to both consolidate and critically appraise this information, rhinologic experts from around the world have produced the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS). METHODS: Evidence-based reviews with recommendations(EBRRs) were developed for scores of topics, using previously reported methodology. Where existing evidence was insufficient for an EBRR, an evidence-based review (EBR)was produced. The sections were then synthesized and the entire manuscript was then reviewed by all authors for consensus. RESULTS: The resulting ICAR:RS document addresses multiple topics in RS, including acute RS (ARS), chronic RS (CRS)with and without nasal polyps (CRSwNP and CRSsNP), recurrent acute RS (RARS), acute exacerbation of CRS (AECRS), and pediatric RS. CONCLUSION: As a critical review of the RS literature, ICAR:RS provides a thorough review of pathophysiology and evidence-based recommendations for medical and surgical treatment. It also demonstrates the significant gaps in our understanding of the pathophysiology and optimal management of RS. Too often the foundation upon which these recommendations are based is comprised of lower level evidence. It is our hope that this summary of the evidence in RS will point out where additional research efforts may be directed.

A population-based study investigating chronic rhinosinusitis and the incidence of asthma.

OBJECTIVES/HYPOTHESIS: Chronic rhinosinusitis (CRS) is an inflammatory disease of the paranasal sinuses, associated with reduced health-related quality of life and increased utilization of healthcare services. Chronic upper and lower respiratory diseases often coexist, although the extent to which CRS is associated with developing asthma remains unclear. To investigate the effect of CRS on receiving a subsequent diagnosis of asthma, we used data from a previously conducted national, longitudinal survey. METHODS: Respondents from the Canadian National Population Health Survey from 1998/1999 to 2010/2011 were used. Data were analyzed from 11,555 (66.9%) subjects, ≥ 19 years of age and reporting no asthma at baseline. Respondents were reviewed for 12 years to determine the cumulative incidence of asthma. Logistic regression was used to estimate the effect of CRS on the development of asthma, adjusting for age, gender, body mass index, cigarette smoking, and food- or nonfood-related allergies. RESULTS: During the 12-year study period, 6.0% (95% confidence interval [CI] [95% CI]: 5.4%-6.7%) of respondents developed asthma. Baseline CRS (odds ratio [OR]: 2.7, 95% CI: 1.9-3.9), female gender (OR: 1.4, 95% CI: 1.1-1.8), and allergies (OR: 2.6, 95% CI: 2.1 - 3.3) were significantly associated with developing asthma. After adjustment, respondents with CRS were significantly more likely to develop asthma than non-CRS counterparts (OR: 2.0, 95% CI: 1.4-2.9). CONCLUSION: Results indicate that one in 13 individuals with CRS will be subsequently diagnosed with asthma. Given the economic burden and use of healthcare services associated with asthma, providers managing CRS may consider increased awareness and subsequent treatment for asthma. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1296-1302, 2016.

Anatomic findings in revision endoscopic sinus surgery: Case series and review of contributory factors.

BACKGROUND: It is recognized that patients who undergo endoscopic sinus surgery (ESS) do not always achieve control of their disease. The causes are multifactorial; variations in surgical practice have been identified as possible factors in refractory disease. OBJECTIVE: To reflect on the frequent anatomic findings of patients with chronic rhinosinusitis (CRS) who require revision ESS. METHODS: A retrospective review of patients who required revision ESS at a tertiary institution over a 3-year period. Patients for whom maximal medical therapy failed for CRS underwent computed tomography of the paranasal sinuses and image-guided surgery. Surgical records of anatomic findings were reviewed and analyzed. RESULTS: Over 3 years, a total of 75 patients underwent revision procedures, 28% of all ESS performed in the unit. The most frequent finding was a residual uncinate process in 64% of the patients (n = 48); other findings included a maxillary antrostomy not based on the natural ostium of the maxillary sinus in 47% (n = 35), an oversized antrostomy in 29% (n = 22), resected middle turbinates in 35% (n = 26), middle meatal stenosis in 15% (n = 11), synechiae in 29% (n = 22), and osteitic bone that required drilling in 13% (n = 10). CONCLUSION: Surgical technique can give rise to anatomic variations that may prevent adequate mucociliary clearance and medication delivery, which leads to failure in ESS in patients with CRS. This study demonstrated the surgical findings encountered in revision ESS that should be highlighted in the training of Ear, Nose and Throat surgeons to help prevent primary failure and reduce health care costs.

The Sino-Nasal Outcome Test-22 as a tool to identify chronic rhinosinusitis in adults with cystic fibrosis.

BACKGROUND: Chronic rhinosinusitis (CRS) is becoming increasingly prevalent in adults with cystic fibrosis (CF), as the median age of survival rises for these individuals. Delayed identification of CRS may contribute to worsening health-related quality of life and increased treatment burden. Our objective was to investigate the utility of the 22-item Sino-Nasal Outcome Test (SNOT-22) as a tool to identify CRS in adults with CF. METHODS: In this cross-sectional study, participants were sampled from an adult-specific CF clinic in Vancouver, Canada, between September 2013 and April 2014. CRS was determined by use of standardized diagnostic guidelines. Participants completed the SNOT-22 and medical charts were reviewed for additional predictor variables. Logistic regression was used to compare the SNOT-22 as a univariable predictor variable to a multivariable prediction model, in order to best differentiate CRS and non-CRS participants. RESULTS: Ninety-three of 101 adults provided written informed consent. The prevalence of CRS was 56.3% (95% confidence interval [CI], 45.9% to 66.3%). Individuals with CRS reported significantly higher SNOT-22 scores than non-CRS participants (mean difference: 13.9; 95% CI, 6.1 to 21.7). The optimal SNOT-22 score to differentiate CRS was 21 out of 110 (sensitivity: 76%, specificity: 61%, positive predictive value: 71%, likelihood ratio: 1.9). CONCLUSION: Compared to the current diagnostic gold standard, SNOT-22 scores greater than 21 sufficiently identified adults with CF presenting with concomitant CRS. The SNOT-22 is a simple instrument that can easily be implemented in adult CF clinics to assist care providers identify individuals requiring more detailed assessment or referral to a sinus clinic.

Omalizumab therapy for refractory allergic fungal rhinosinusitis patients with moderate or severe asthma.

PURPOSE: 1. To assess the efficacy of omalizumab therapy in improving sinonasal outcomes in refractory allergic fungal rhinosinusitis (AFRS) patients with moderate or severe asthma. 2. To determine if omalizumab therapy reduces the usage of corticosteroids or antifungal therapy in AFRS patients DESIGN: The clinical charts of patients with AFRS with moderate or severe asthma who received at least three subcutaneous injections of omalizumab therapy between 1st January 2012 and 1st May 2014 were retrospectively reviewed. These patients had undergone bilateral functional endoscopic sinus surgery (FESS) and failed adjunct medical treatments (oral or topical corticosteroids and/or antifungal therapy) prior to omalizumab therapy. RESULTS: Seven patients met the inclusion criteria and were included in this study. The mean age of the patients was 48.14. The average number of subcutaneous omalizumab injections was 7.57 (range 6-11) with a mean dosage of 287mg (range 225-375mg). The mean pre-omalizumab treatment Sino-Nasal Outcome Test-22 (SNOT-22) score was 52.14 while the mean post-omalizumab treatment SNOT-22 score was 35.86 (31% improvement). The mean pre-omalizumab therapy Phillpott-Javer endoscopic score (over the last one year before omalizumab therapy) was 36 while the mean post-omalizumab therapy endoscopic score (from the last clinic visit) was 14 (61% improvement). Omalizumab therapy reduced the dependence of AFRS patients on corticosteroid and antifungal treatments. CONCLUSION: Omalizumab therapy can be considered as a potential adjunct for the treatment for patients with refractory AFRS with moderate or severe asthma. However, larger prospective studies to confirm the findings of this study will be required.

Association between Chronic Rhinosinusitis and Health-Related Quality of Life in Adults with Cystic Fibrosis.

RATIONALE: Over the past four decades, the median age of survival has nearly doubled for individuals living with cystic fibrosis (CF). Chronic diseases such as chronic rhinosinusitis increase in prevalence with age. In the non-CF population, chronic rhinosinusitis is associated with reduced health-related quality of life. OBJECTIVES: Our objectives were to determine the prevalence of chronic rhinosinusitis among adults with CF and to evaluate the impact of chronic rhinosinusitis on health-related quality of life. METHODS: Individuals from a large academic teaching hospital in Vancouver, British Columbia, Canada, were eligible to participate in this cross-sectional study. Included subjects were at least 19 years of age, had a confirmed diagnosis of CF, and attended the CF clinic between September 2013 and April 2014. Participants completed a CF-specific health-related quality of life questionnaire (the Cystic Fibrosis Questionnaire-Revised for adolescents and adults over 14 years of age [CFQ-R 14+]) and underwent symptom and endoscopic assessment for diagnosis of chronic rhinosinusitis. Medical charts were reviewed for potential confounders, including sociodemographic (age, sex, and body mass index) and clinical (age at CF diagnosis, type of CF mutation, lung function, and chronic Pseudomonas aeruginosa infection) factors. Multivariable linear regression was used to model the relationship between chronic rhinosinusitis and CFQ-R 14+ domains, adjusted for potential confounders. MEASUREMENTS AND MAIN RESULTS: A total of 121 individuals were contacted in the clinic, of whom 113 (93.4%) consented to participate. The prevalence of chronic rhinosinusitis was found to be 59.2% (95% confidence interval [CI], 49.6-68.2%). Sociodemographic and clinical factors were similarly distributed between chronic rhinosinusitis-positive and chronic rhinosinusitis-negative groups. Lung function, as measured by FEV1 (% predicted value), did not significantly differ between participants with versus those without chronic rhinosinusitis (mean difference, 2.0%; 95% CI, -8.1% to 13.0%). Following adjustment for sex and lung function, individuals with chronic rhinosinusitis reported significantly worse scores on the respiratory symptoms domains compared with their counterparts without chronic rhinosinusitis (regression coefficient, -3.93; 95% CI, -8.02 to 0.15). CONCLUSIONS: The majority of adults with CF have evidence of concomitant chronic rhinosinusitis. Chronic rhinosinusitis is independently associated with worse respiratory symptom on the CFQ-R 14+. Chronic rhinosinusitis should be diagnosed and managed to optimize the health-related quality of life of adults with CF. Clinical trial registered with clinicaltrials.gov (NCT02003079).

A systematic review of factors associated with health-related quality of life in adolescents and adults with cystic fibrosis.

RATIONALE: As the life expectancy for individuals with cystic fibrosis (CF) continues to improve, an emphasis on optimizing health-related quality of life (HRQoL) has become increasingly important. The Cystic Fibrosis Questionnaire-Revised (CFQ-R 14+) is the most widely accepted method to quantify HRQoL in this patient population. OBJECTIVES: Our objective was to systematically review the literature to identify sociodemographic and clinical factors associated with HRQoL among adolescents and adults with CF. METHODS: Five major literature databases were searched (MEDLINE, EMBASE, CENTRAL, CINAHL, psychINFO) to identify studies published from January 1989 to April 2014 (n=1,921). We included all full-text studies that: (1) focused on individuals 14 years of age or older, and (2) examined the relationship between sociodemographic (age, sex, body-mass index [BMI], socioeconomic status, and employment) and clinical (FEV1 % predicted, pulmonary exacerbation, comorbidities) factors with the CFQ-R 14+. Effect estimates and levels of statistical significance in the association between sociodemographic and clinical factors with each of the 12 CFQ-R 14+ domains were analyzed, if examined in at least two studies. MEASUREMENTS AND MAIN RESULTS: Twenty-eight articles met our inclusion/exclusion criteria, but 5 studies were excluded at the data synthesis stage, leaving 23 articles for analysis. In relation to the CFQ-R 14+, 10 candidate factors were examined in at least two studies. The five most commonly studied factors were FEV1 % predicted (57.1% of 28 studies), sex (32.1%), BMI (28.6%), age (17.6%), and pulmonary exacerbations (13%). In studies incorporating multivariable methods, FEV1 % predicted was positively associated with all CFQ-R 14+ domains with the exception of Digestion, Social Functioning, and Emotional Functioning. Male subjects reported higher Physical Functioning and lower Body Image scores than female subjects, BMI was positively correlated with Body Image and Weight, and age was negatively correlated with Treatment Burden. Pulmonary exacerbations were negatively associated with multiple domains, including Respiratory Symptoms, Physical, and Role Functioning. CONCLUSIONS: Although several factors have been found to be associated with the CFQ-R in adolescents and adults with CF, FEV1 % predicted and pulmonary exacerbations have the broadest impact on HRQoL. Further research is required to investigate the impact of age-related comorbidities, psychosocial factors, and treatment-related factors on HRQoL in adolescents/adults with cystic fibrosis.

Randomized controlled trial: hybrid technique using balloon dilation of the frontal sinus drainage pathway.

BACKGROUND: The objectives of this study were as follows: (1) to evaluate frontal sinus ostial patency following balloon dilation with the Ventera Sinus Dilation System, compared with frontal sinusotomy (Draf 2a); and (2) to compare mean blood loss and mean surgical time for frontal sinusotomy using balloon dilation compared with traditional surgical methods. METHODS: A single blinded, randomized, controlled, prospective study was performed at St. Paul's Sinus Center, Vancouver, a tertiary referral rhinology center. Thirty patients undergoing functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis (CRS) were randomized to a hybrid approach with exposure of the frontal recess using standard instrumentation and then balloon dilation of 1 frontal sinus drainage pathway and traditional frontal sinusotomy for the opposite side. Blood loss and surgical time for opening the frontal sinus drainage pathway was recorded for each side. Patients acted as their own controls. Ostial patency and size were assessed 5 weeks and 3 months postoperatively using endoscopy. Ostial patency was also recorded at 1 year following surgery. RESULTS: All frontal sinus ostia in both groups (n = 30) were successfully opened and were patent with both techniques 3 months postoperatively. All frontal sinus ostia assessed at 1 year (73%) remained patent and none required revision frontal surgery. Balloon dilation showed a mean surgical time of 655 seconds compared to 898 seconds for traditional FESS (p = 0.03). Mean blood loss was less with balloon dilation (58 mL vs 91 mL; p = 0.008). CONCLUSION: A hybrid balloon technique successfully dilates the frontal sinus drainage pathway with reduced blood loss. Also, short-term patency appears to be comparable to traditional frontal sinusotomy.