Impact of allergic rhinitis on quality of life in patients with chronic rhinosinusitis.

OBJECTIVES: To evaluate the impact of allergic rhinitis (AR) on the quality of life (QoL) in patients with chronic rhinosinusitis (CRS). METHODS: Retrospective cross-sectional study of adult patients with CRS presenting to our clinic between August 2020 and February 2023 was performed. AR was diagnosed based on a positive skin or blood allergy test. Patients' characteristics, AR status, comorbidities, endoscopy scores, and SNOT-22 scores were collected. RESULTS: A total of 514 CRS patients were included, with 265 (51.6 %) patients with AR. CRS patients with AR were younger (p = 0.004), more likely to be female (p < 0.001), and more likely to have asthma (p < 0.001). Polyp status and endoscopy scores did not differ between patients with and without AR. Baseline SNOT-22 scores were slightly worse in the AR cohort (43.6 vs 38.7, p = 0.007), which was mainly secondary to rhinologic (p = 0.002), extrarhinologic (p = 0.007), and ear/facial (p = 0.007) subdomains. Worse rhinologic and extrarhinologic scores were associated with the presence of AR after adjusting for confounding variables (Coef = 1.55, p = 0.011; and Coef = 0.83, p = 0.021 respectively). CONCLUSION: The impact of allergic rhinitis on QoL is mainly on the nasal symptoms. Further studies should look at the role of AR on the QoL of different CRS endotypes; and at the role of AR-specific treatment, such as immunotherapy, on the QoL of patients with CRS.

Association of autoimmune and autoinflammatory disorders with chronic rhinosinusitis in children.

BACKGROUND: Increasing evidence suggests that autoimmune disorders and their immunomodulating medications may increase the risk of rhinosinusitis. The goal of this study is to determine if autoimmune and autoinflammatory diseases are associated with increased risk of chronic rhinosinusitis (CRS) in children. METHODS: A retrospective case-control study of pediatric patients (age 2-18 years) seen in the West Virginia University Hospitals System in the past 10 years was performed. Cases were children with autoimmune or autoinflammatory diseases. Controls were children without any autoimmune or autoinflammatory disorders. Query of our electronic medical record (Epic) was performed using ICD-10 codes. Univariate (unadjusted) and multivariate (adjusted) logistic regression were used to calculate the strength of association of autoimmune or autoinflammatory disorders with CRS and the other airway disorders while adjusting for age, sex, and race. RESULTS: 420582 pediatric patients were queried with mean age of 10.8 years (SD of 4.8, range of 2-18 years), and 47.9% being female. 1956 (0.5%) had autoimmune disorders and 293 (0.07%) had autoinflammatory disorders. Both autoimmune and autoinflammatory disorders increase the odds of having CRS in the unadjusted [OR = 3.36, p < 0.001 and 5.69, p < 0.001 for the respectively] and the adjusted [OR = 2.90, p < 0.001 and OR = 5.07, p < 0.001 respectively after adjusting for age, sex, and race] models. CONCLUSION: Autoimmune and autoinflammatory disorders increase the risk of CRS and chronic rhinitis in children.

Correlation of patient reported outcome measures with endoscopic findings in pediatric chronic adenoiditis and chronic rhinosinusitis.

BACKGROUND: Studies in adult chronic rhinosinusitis (CRS) showed poor correlation between patient reported outcome measures (PROMs) and objective findings. Our goal is to study the correlation between the sinus and nasal quality of life (SN-5) and the 22-items sinonasal outcome test (SNOT-22) surveys with endoscopy findings in children with chronic adenoiditis (CA) and CRS. METHODS: Cross-sectional study of all pediatric patients (age 2-18) presenting for CA or CRS was performed. Patients and caregivers were asked to fill the SN-5 and SNOT-22 questionnaires at initial and follow up visits. Demographics and comorbidities were collected. Objective findings included endoscopy Modified Lund-Kennedy (MLK) scores and adenoid tissue size. RESULTS: 124 children were included, with mean age of 9.9 years (SD = 4.8) and 46.8% female. 36.3% had allergic rhinitis, 23.4% had asthma, and 4% had obstructive sleep apnea. Moderate correlation was found between the rhinologic domain of SNOT-22 and MLK scores (r = 0.36, p = 0.001) and between SN5 scores and adenoid size in all patients (r = 0.39, p < 0.001). SNOT-22 scores showed moderate correlation with adenoid size (r = 0.42, p < 0.001) more specifically in CA patients (r = 0.54, p < 0.001). The correlation of SN5 and MLK scores were higher in children with allergic rhinitis or asthma. The correlation between SN5 and adenoid size was lower in children with allergic rhinitis or asthma. CONCLUSION: There is discrepancy between the subjective measures and the objective findings in children with CA or CRS. The physical exam findings may not reflect the effect of CRS on the quality of life of children.

Role of Sinonasal Anatomic Variants in Recurrent Acute Rhinosinusitis.

OBJECTIVES: Prior studies evaluating the role of sinonasal anatomic variants with recurrent acute rhinosinusitis (RARS) are limited by inconsistent results. The goal of this study is to evaluate the association between sinonasal anatomic variants and RARS. METHODS: A 1:2 retrospective case-control study was conducted using patients presenting to the rhinology clinic from August 2020 to January 2023. A total of 60 patients with RARS were compared to 120 control patients. RARS was diagnosed based on the International Consensus Statement on Allergy and Rhinology criteria of four or more independent episodes of acute rhinosinusitis per year with at least one episode documented by objective findings, with complete resolution of the infection in-between episodes. Sinonasal anatomic variants included nasal septal deviation (NSD), concha bullosa (CB), infraorbital (Haller) cells, nasal septal spur in the middle meatus, and frontal sinus cells (supra-agger, supra-agger frontal, and suprabullar frontal cells). RESULTS: Age was similar in RARS and control patients (47.4 ± 16.5 vs. 49.3 ± 14.5, p = 0.432). Both the RARS group and control group were more likely to be female (78.3% vs. 77.5%, p = 0.899). There was no significant association between NSD and RARS compared to the control group (OR = 0.97, p = 0.916), and no significant association between any of the anatomic variants and RARS [infraorbital cells (OR = 0.64, p = 0.167), CB (OR = 0.84, p = 0.596), spur in the middle meatus (OR = 1.28, p = 0.514), supra-agger (OR = 0.88, p = 0.708), supra-agger frontal cells (OR = 0.97, p = 0.939), or suprabullar frontal cells (OR = 1.13, p = 0.766)]. CONCLUSION: Our findings suggest no association between nasal septal deviation or any of the anatomic variants studied and RARS. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

Gender Differences in Adults With Chronic Rhinosinusitis: A Scoping Review.

OBJECTIVE: Gender differences in chronic rhinosinusitis (CRS) have been demonstrated in many studies over the last 15 years. The purpose of this scoping review is to investigate the current knowledge on gender differences in CRS and to analyze the gaps in the literature. DATA SOURCES: A systematic search of PubMed, Cochrane Library, and Embase databases was performed. REVIEW METHODS: This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Studies that evaluated gender differences in CRS were included in the review. RESULTS: Of the 523 abstracts reviewed, a total of 23 studies met the criteria for inclusion. Articles consisted of retrospective and prospective cohort studies. They were divided into 3 categories based on whether they evaluated gender differences in (1) presentation and baseline quality of life, (2) pathophysiology, and/or (3) outcomes of treatment. Eleven studies addressed differences in presentation, 5 addressed differences in pathophysiology, and 10 dealt with differences in outcomes after surgical or medical management. Most of the studies showed worse baseline QoL secondary to CRS in women, with outcome of treatment being similar in both genders. CONCLUSION: The experience of CRS appears to vary between genders, with women experiencing a greater subjective burden of disease than men, though with similar outcomes after treatment. Further research is indicated, particularly involving the pathophysiology of CRS, to fully understand the underlying causes of these discrepancies.

Role of Acute Rhinosinusitis in Periorbital Infections in Children.

OBJECTIVE: Periorbital cellulitis in children are commonly caused by acute rhinosinusitis (ARS). This study investigated the association of ARS and the severity of periorbital cellulitis in children. STUDY DESIGN: Retrospective case-control study of children with periorbital cellulitis with ARS versus periorbital cellulitis without ARS. SETTING: Patients were seen at West Virginia University Children's Hospitals between August 2011 to August 2022. METHODS: Patients were divided into cases and controls based on presence or absence of ARS. ARS was defined based on clinical symptoms with objective presence of disease on CT scan. Patients' characteristics, treatment, hospital length of stay, and readmission were collected. RESULTS: The sample consisted of 118 pediatric patients with orbital cellulitis. Patients with ARS were younger than patients without ARS (6.3 vs 8.5, p = 0.025), however there were no sex differences between two groups (p = 0.540). The ARS group had higher incidence of postseptal cellulitis (51.5% vs 9.6%, p < 0.001). As compared to patients without ARS, patients with ARS were more likely to be admitted (p < 0.001), have a longer length of stay (median of 3.5 days vs 0.5 days, p < 0.001), require IV antibiotics (95.3% vs 54.9%, p < 0.001), and require surgical intervention (23.1% vs 5.8%, p < 0.001). Readmission rate was similar between the two groups. CONCLUSION: Children presenting with acute periorbital cellulitis who have ARS tend to have more severe infection requiring higher level of care. ARS should be assessed and incorporated into the plan of care of pediatric patients with periorbital infections.

Gender Differences in Quality of Life of Adolescent Patients With Chronic Rhinosinusitis.

OBJECTIVES: To identify the differences in the impact of chronic rhinosinusitis (CRS) between female and male adolescent patients at presentation. STUDY DESIGN: Cross sectional study. METHODS: Adolescent patients, age 12 to 18 years old, presenting to our Otolaryngology clinic between August 2020 and April 2023 for CRS were asked to fill both the SNOT-22 and the SN5 forms. Female and male cohorts were compared regarding their demographics, comorbidities, subjective and objective disease measurements, and choice of treatment. RESULTS: Sixty-six patients were included, 30 female and 36 male patients. There were no differences in age, allergic rhinitis, asthma, obstructive sleep apnea, presence of nasal septal deviation, and objective disease severity (P > .05 for all). At presentation, mean overall SNOT-22, ear/facial, sleep, and psychological domains were all higher in female patients (43vs 30.9, P = .02; 9.1vs 6, P = .03; 11.8vs 8.3, P = .07; 14.1vs 8.8, P = .02 respectively). SN5 scores and overall QoL visual analog scale were similar in females and males. CONCLUSION: Female patients with CRS show higher subjective disease burden. Incorporating data on gender-specific differences may be important to personalize treatment decision making.

Risk Factors associated with Recurrent Acute Rhinosinusitis.

KEY POINTS: Few studies have evaluated the association of recurrent acute rhinosinusitis (RARS) with other comorbidities. Allergic rhinitis, asthma, primary antibody deficiency, and autoimmune disorders are associated with RARS. Evaluation for these comorbidities should be considered when treating patients with RARS.

Impact of recurrent acute rhinosinusitis on quality of life.

KEY POINTS: Quality of life (QoL) in patients with recurrent acute rhinosinusitis (RARS) is understudied. QoL for RARS patients is similar to chronic rhinosinusitis patients, although objective disease severity is lower. QoL of RARS patients is similarly affected during active and inactive infection.

Association of autoimmune disorders with chronic rhinosinusitis in adults.

INTRODUCTION: Increasing evidence suggests that autoimmune disorders and their immunomodulating medications may increase the risk of rhinosinusitis compared to rhinitis. GOAL: To investigate the association between autoimmune disorders and rhinosinusitis. METHODS: We performed a case-control study of patients referred to West Virginia University from August 2020 to October 2022 for rhinologic complaints. Rhinosinusitis patients were diagnosed with either chronic rhinosinusitis (CRS) or recurrent acute rhinosinusitis (RARS). These patients were compared to non-rhinosinusitis patients. Patients' characteristics, comorbidities, and type of treatment of autoimmune disorders were reviewed. RESULTS: The sample consisted of 527 rhinosinusitis [184 CRS without nasal polyps (CRSsNP), 263 CRS with nasal polyps (CRSwNP) and 80 RARS patients] patients and 564 non-rhinosinusitis patients. Patients with rhinosinusitis were more likely to be older, males, have asthma, and have current and past smoking history (all with p-value < 0.05). Autoimmune disorders, primary antibody deficiency, and immunomodulator agents were more common in rhinosinusitis patients (16.5 % vs 9.4 %, OR = 1.9, p < 0.001; 5.1 % vs 0.5 %, OR = 10.1, p < 0.001; and 3.8 % vs 1.1 %, OR = 3.7, p = 0.003 respectively). Multivariate logistic regression adjusting for confounders showed that autoimmune disorders were strongly associated with rhinosinusitis [OR = 1.6, 95 % CI = 1.10-2.48], whereas the immunomodulators did not reach statistical significance [OR = 2.4, 95 % CI = 0.87-6.47]. Subgroup analysis showed the autoimmune disorders did not significantly differ between CRS and RARS groups [OR = 1.0, 95 % CI = 0.5-2.1], or between the CRSsNP and CRSwNP groups [OR = 0.9, 95 % CI = 0.5-1.7]. CONCLUSION: Autoimmune disorders are associated with rhinosinusitis, both CRS and RARS, independently of other risk factors.

Evaluation and treatment of rhinosinusitis with primary antibody deficiency in adults: Evidence-based review with recommendations.

BACKGROUND: There is clear evidence that the prevalence of primary antibody deficiency (PAD) is higher in patients with recurrent and chronic rhinosinusitis (CRS) than in the general population. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on rhinosinusitis with PAD, summarize the existing evidence, and provide recommendations on the evaluation and management of rhinosinusitis in patients with PAD. METHODS: The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through August 2022. Studies on the evaluation and management of rhinosinusitis in PAD patients were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on the evaluation and management principles for PAD were generated. RESULTS: A total of 42 studies were included in this evidence-based review. These studies were evaluated on incidence of PAD in rhinosinusitis patients, incidence of rhinosinusitis in PAD patients, and on the different treatment modalities used and their outcome. The aggregate quality of evidence was varied across reviewed domains. CONCLUSION: Based on the currently available evidence, PAD can occur in up to 50% of patients with recalcitrant CRS. Despite the presence of multiple studies addressing rhinosinusitis and PAD, the level of evidence supporting different treatment options continues to be lacking. Optimal management requires a multidisciplinary approach through collaboration with clinical immunology. There is need for higher-level studies that compare different treatments in patients with PAD and rhinosinusitis.

Outcome of Endoscopic Repair of Nasal Septal Perforation.

INTRODUCTION: The anterior ethmoidal artery (AEA) flap has been demonstrated to be a reliable option for endoscopic repair of symptomatic nasal septal perforations. The purpose of this study is to study the outcome of this technique. METHODS: A retrospective case series of all consecutive patients who underwent repair of nasal septal perforation utilizing the AEA flap among 2 institutions from August 2020 to July of 2022 was conducted. Demographics and comorbidities were collected preoperatively and postoperatively. The main outcome of this study was to identify the risk factors for surgical failure. RESULTS: Forty-one patients were included. Mean perforation size was 2.2 cm (range 0.5-4.5 cm). Mean age was 42.5 years (range 14-65 years), 53.6% were female, 39% were active smokers, mean body-mass-index (BMI) was 31.9 (range 19.1-45.5), 20% with history of CRS and 31.7% had diabetes mellitus (DM). Etiologies of the perforation included idiopathic (n = 12), iatrogenic (n = 13), intranasal drug use (n = 7), trauma (n = 6), and secondary to tumor resection (n = 3). Overall success rate for complete closure was 73.2%. Active smoking, history of intranasal drug use, and DM were significantly associated with surgical failure (72.7%vs 26.7%, P = .007; 36.4%vs 10%, P = .047; and 63.6%vs 20%, P = .008 respectively). CONCLUSION: The endoscopic AEA flap is a reliable technique for closure of nasal septal perforation. It may not work when the etiology is intranasal drug use. Close attention to diabetes and smoking status is also needed.

Improvement in Quality of Life after Septoplasty in Children: a Systematic Review.

KEY POINTS: Septoplasty for nasal obstruction in the pediatric population shows positive outcomes in objective and subjective post-operative measurements. Septoplasty in children results in disease-related improvement in quality of life. Higher level studies are needed to confirm these results.

Rhinogenic Optic Neuropathy with No Light Perception Secondary to Onodi Cell Mucocele with Visual Recovery after Optic Nerve Decompression.

Rhinogenic optic neuropathy (RON) results from ethmoid or sphenoid sinus inflammation or infection causing optic nerve impairment.1 Treatment often requires endoscopic surgery and vision restoration occurs in select cases. There is no clear evidence for the benefit of optic nerve decompression (OND) in these situations. We present a unique case of RON caused by an Onodi cell mucocele for which isolated endoscopic mucocele drainage was not enough and further OND was needed to improve vision.

Using the sino-nasal outcome test (SNOT-22) to study outcome of treatment of nasal obstruction.

OBJECTIVE: To validate the sino-nasal outcome test (SNOT-22) as an outcome measure for nasal obstruction, and to determine if it correlates with the nasal obstruction and septoplasty effectiveness (NOSE) scale. STUDY DESIGN: Prospective cohort study. METHODS: All patients presenting to our otolaryngology clinic for nasal obstruction secondary to nasal septal deviation and/or inferior turbinate hypertrophy between August 2020 and June 2022 were asked to fill both the SNOT-22 and the NOSE questionnaires. Demographics and comorbidities were reviewed. Patients with chronic rhinosinusitis (CRS) were excluded. SNOT-22 total and subdomain scores were then compared to NOSE scores. RESULTS: 126 patients completed both surveys. Average age was 42.6 years (range 13.8-78.3 years), and 40.5 % were female. 35 patients had septoplasty and inferior turbinoplasty (IT), 34 had functional septorhinoplasty and IT, 6 patients had IT, 7 had nasal septal perforation repair and 44 patients had medical treatment. Overall, SNOT-22 and NOSE scores correlated well preoperatively and postoperatively (r = 0.54, p < 0.0001; r = 0.68, p < 0.0001 respectively). The rhinologic and sleep SNOT-22 subdomains scores had the strongest correlation to NOSE score (r = 0.56, p < 0.0001; r = 0.64, p < 0.0001 respectively). Both NOSE and SNOT-22 scores showed improvement postoperatively [NOSE: 67.4 vs 25.1 (p < 0.0001) at 3 months, 69.5 vs 34 (p < 0.0001) at 6 months; SNOT-22: 37.1 vs 25.2 (p = 0.002) at 3 months, 38.1 vs 22.6 (p = 0.002) at 6 months]. No significant improvement in NOSE or SNOT scores was seen in the medical treatment group. CONCLUSION: SNOT-22 instrument can be used to study the outcome of treatment for nasal obstruction secondary to nasal septal deviation and/or inferior turbinate hypertrophy.

Long-term Follow-up of Pediatric Chronic Rhinosinusitis After Surgical Treatment.

OBJECTIVE: To study the long-term outcomes of pediatric chronic rhinosinusitis (CRS) after surgical treatment. METHODS: Cross-sectional survey of patients who were treated surgically for CRS as children more than 10 years ago. Survey included SNOT-22 questionnaire, additional functional endoscopic sinus surgery (FESS) since last treatment, status of allergic rhinitis and asthma, and availability of any CT scan sinus/face for review. RESULTS: About 332 patients were contacted by phone or email. Seventy-three patients filled the survey (22.5% response rate). Current age was 26 years (±+/-4.7, 15.3-37.8 years). Age at initial treatment was 6.8 years (+/-3.1, 1.7-14.7 years). Fifty-two patients (71.2%) had FESS and adenoidectomy, and 21 patients (28.8%) had adenoidectomy only. Follow-up since surgical treatment was 19.3 years (+/-4.1). SNOT-22 score was 34.5 (+/-22.2). None of the patients had any additional FESS for the duration of the follow-up, and only 3 patients had septoplasty and inferior turbinoplasty as adults. Twenty-four patients had CT scan sinuses/face available for review. Scans were obtained at an average of 14 years after surgical intervention (+/-5.2). CT LM score was 0.9 (+/-1.9), compared to 9.3 at time of their surgery (+/-5.9) (P < .0001). Currently 45.8% and 36.9% of patients have asthma and AR, compared to 35.6% and 40.6% respectively as kids (P = .897 and P = .167). CONCLUSION: Children who had surgery for CRS do not seem to have CRS as adults. However, patients continue to have active allergic rhinitis that may affect their quality of life.

Complications and Outcomes of Endovascular Embolization for Intractable Epistaxis: A Systematic Review and Meta-analysis.

OBJECTIVES: Endovascular embolization has emerged as an effective treatment for intractable epistaxis. This systematic review and meta-analysis aimed to calculate the rates of success, rebleeds, and complications and to identify the etiologies and complications of patients who undergo endovascular embolization. METHODS: This systematic review and meta-analysis was conducted per the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles were extracted from Scopus, PubMed, Web of Science, and Cochrane Central and were filtered by a systematic review process using Rayyan software. A random-effects model was used to quantify the rates success, rebleeds, and complications. RESULTS: Forty-two studies were included, totaling 1660 patients. The pooled success rate was 89% (95% confidence interval [CI] 86%-92%) and the pooled rebleed rate was 19% (95% CI 16%-22%). The pooled minor complication rate was 18% (95% CI 11%-27%). The most common major complication was soft tissue necrosis followed by stroke. The most common minor complication was facial pain. No minor complications were reported to be permanent. Of the patients who failed initial embolization, 42% underwent repeat embolization and 34% underwent surgical arterial ligation. CONCLUSIONS: Endovascular embolization is an effective treatment for intractable epistaxis. The decision to perform embolization should be carefully weighed given the rare but significant major complications.

Immunoglobulin Deficiency and the Unified Airway.

Primary Ig deficiencies are a heterogeneous group of disorders with widespread implications for the unified airway. Manifestations can vary greatly, with some patients being asymptomatic, whereas others suffering from acute and chronic life-threatening pathologic conditions of the upper and lower airways. Although the diagnosis of PIDs can be complex, the onus of early diagnosis and initiation of treatment will often fall on the shoulders of the otolaryngologist.