The Effect of Corticosteroids on Sinus Microbiota in Chronic Rhinosinusitis Patients with Nasal Polyposis.

BACKGROUND: Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a multifactorial disease with no known single cause, but it is thought that bacteria play a role in the disease process. OBJECTIVE: This pilot study aims to assess the longitudinal effect of corticosteroid therapy on sinus microbiota in chronic rhinosinusitis patients with nasal polyposis (CRSwNP). METHODS: A longitudinal prospective case-control study was done on patients with CRSwNP and healthy controls. Patients with CRSwNP were randomly allocated to a corticosteroids and antibiotics treatment group (CRSwNP-SA) or a corticosteroid-only treatment group (CRSwNP-S). Data were collected at three-time points (before treatment, 1, and 3 months after treatment). Specimens were cultured and matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry (MS) was used as a bacterial detection method. RESULTS: Data from 29 patients with CRSwNP (16 CRSwNP-SA and 13 CRSwNP-S) was compared to 15 healthy subjects. Patients reported significant symptom improvement initially (1 month), but not in the long-term (3 months). This result was found in both treatment groups, whether or not antibiotics were used. After 3 months from treatment, the prevalence of Corynebacterium genera tended to increase in the CRSwNP-SA, while Staphylococcus and Gram-negative genera (Pseudomonas) tended to increase in the CRSwNP-S. Smoking, aspirin sensitivity, and previous endoscopic sinus surgery were found to be co-factors significantly associated with the response to systemic corticosteroid therapy. CONCLUSION: In this pilot study, both treatment options were effective to improve symptoms in the short-term but not in the long-term, and were not linked to any clear sinus microbiota response. As a result, this study supports the avoidance of systemic antibiotics without evidence of active infection.

A Case of Unilateral Proptosis Secondary to Prostatic Metastasis.

Prostate cancer metastases involving the orbit and/or paranasal sinuses represent a rare oncological presentation. Patients can have a myriad of symptoms such as proptosis, periorbital swelling, blurry vision, rhinorrhea, epistaxis, anosmia, or others depending on the structures involved. The differential diagnosis of paranasal sinus masses on imaging studies is broad and can include inflammatory, congenital, or neoplastic masses; leading to the requirement of biopsy for definitive diagnosis. Tissue sample is usually obtained via an endoscopic approach. The prognosis of such a presentation is not well described in the literature, but it is usually guarded due to the advanced stage of the disease and generally a poorly differentiated primary tumor. Treatments usually aim to reduce the burden of disease and debulk the tumor mass for palliative purposes. We present a case of a 71-year-old male presenting with unilateral proptosis and periorbital swelling secondary to prostatic metastasis.

Aerosolization in Endoscopic Sinus Surgery and Risk Mitigation in the COVID-19 Era: A Scoping Review.

Objective The continually evolving coronavirus disease 2019 (COVID-19) pandemic has created a dire need for rapid reorganization of health care delivery within surgical services. Ensuing initial reports of high infection rates following endoscopic sinus and skull base surgery, various expert and societal guidelines have emerged. We hereby provide a scoping review of the available literature on endoscopic sinus and skull base surgery, exploring both the risk of aerosolization and expert recommendations on surgical management during the pandemic. Methods A literature search of the PubMed database was performed up until May 9th, 2020. Additionally, websites and published statements from otolaryngology associations were searched for recommendations. This scoping review followed the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta Analyses Extension for Scoping Reviews. Results A total of 29 peer-reviewed publications and statements from expert recommendations or professional associations were included. Current expert guidance relies mainly on scarce, anecdotal evidence, and two cadaveric studies, which have demonstrated potential aerosolization during transnasal surgery. General consensus exists for delaying surgery when possible, ascertaining COVID-19 status preoperatively and donning of adequate personal protective equipment by all operating room staff (including at minimum an N95 mask). Cold, nonpowered surgical instruments are deemed the safest, while thermal instruments (electrocautery and laser) and high-speed drills should be minimized. Conflicting recommendations emerge for use of microdebriders. Conclusion Endoscopic sinus and skull base surgery impart a potential risk of aerosolization. Hence, surgical indications, protective measures for health care workers, and surgical instrumentation must be adapted accordingly in the COVID-19 context.

What is the optimal outcome after endoscopic sinus surgery in the treatment of chronic rhinosinusitis? A consultation of Canadian experts.

OBJECTIVES: Many experts feel that in the absence of well-defined goals for success, they have an easier time identifying failure. As success ought to not be defined only by absence of failure, we aimed to define optimal outcomes for endoscopic sinus surgery (ESS) in chronic rhinosinusitis (CRS) by obtaining expert surgeon perspectives. METHODS: A total of 12 surgeons participated in this targeted consultation. Face to face semi-structured interviews were performed with expert surgeons in the field of CRS and ESS. General impressions and personal definitions of acceptable operative success and optimal operative outcomes were compiled and summarized. RESULTS: According to an expert survey, patients' main objectives are an improvement in their chief complain, a general improvement in quality of life (QoL), and a better overall symptomatic control. The most important aspects of endoscopy for defining a successful intervention were an adequate mucus circulation, a healthy mucosa, minimal edema, and patency of all explored cavities or ostia. In the assessment of surgical outcomes, it was determined that both objective and patient reported data must be carefully examined, with more attention given to subjective outcomes. CONCLUSIONS: According to data gathered from a Canadian expert consultation, a definition of success must be based on both subjective data and nasal endoscopy. We propose to define an acceptable outcome as either a subjective improvement of at least the minimal clinically improvement difference of a validated patient reported outcome questionnaire, along with a satisfactory endoscopic result (1) or a complete subjective resolution with a sub-optimal endoscopy (2).

Development of a self-directed sinonasal surgical anatomy video curriculum: Phase 1 validation.

BACKGROUND: Sinusitis is a common outpatient diagnosis made by physicians and is a reason for referral to otolaryngologists. A foundation in basic sinonasal anatomy is critical in understanding sinus pathophysiology and avoiding complications. Our objective in this study was to develop and to validate a self-directed surgical anatomy video for medical students. METHODS: Two multimedia videos were developed highlighting sinonasal anatomy. In Video 1 we included audio narration and radiologic imaging. Video 2 incorporated highlighted images from a sinus surgery video. An assessment was developed to test sinonasal anatomy landmarks, spatial recognition of structures, and their clinical relevance. An expert panel of rhinologists scored face and content validity of the curriculum videos and assessment. Factor analysis was used to separate questions into face and content validity domains, and a one-sample t test was performed. RESULTS: The panel scored face validity (Videos 1 and 2: 4.4/5) and content validity (Video 1: 4.5/5, 0.83; Video 2: 4.3/5, 0.75) significantly higher than a neutral response. There were no statistical differences for face or content validity between videos. The assessment was rated suitable (29%) or very suitable (57%) for testing basic sinonasal surgical anatomy, and the majority (71%) of respondents agreed (14%) or strongly agreed (57%) that the assessment thoroughly covered the sinus anatomy content with which medical students should be familiar. CONCLUSION: We have developed two videos and an assessment that highlight and test sinonasal anatomy. Future studies will aim to identify whether the use of a self-directed video curriculum improves sinonasal anatomy awareness and whether incorporation of surgical endoscopic videos augments training.

Association of In-Ear Device Use With Communication Quality Among Individuals Wearing Personal Protective Equipment in a Simulated Operating Room.

Importance: The COVID-19 pandemic has brought forth new challenges for health care workers, such as the daily use of personal protective equipment, including reusable facial respirators. Poor communication while wearing respirators may have fatal complications for patients, and no solution has been proposed to date. Objective: To examine whether use of an in-ear communication device is associated with improved communication while wearing different personal protective equipment (N95 mask, half-face elastomeric respirator, and powered air-purifying respirator [PAPR]) in the operating room. Design, Setting, and Participants: This quality improvement study was conducted in June 2020. Surgical residents from the Department of Otolaryngology-Head and Neck Surgery at McGill University in Montreal, Quebec, Canada, were recruited. All participants had normal hearing, were fluent in English, and had access to the operating rooms at the Royal Victoria Hospital. Exposures: All participants performed the speech intelligibility tasks with and without an in-ear communication device. Main Outcomes and Measures: Speech intelligibility was measured using a word recognition task (Modified Rhyme Test) and a sentence recognition task (AzBio Sentence Test). A percentage correct score (0% to 100%) was obtained for each speech intelligibility test. Listening effort was assessed using the NASA Task Load Index. An overall workload score, ranging from 0 points (low workload) to 100 points (high workload), was obtained. Results: A total of 12 participants were included (mean [SD] age, 31.2 [1.9] years; 8 women [66.7%]). AzBio Sentence Test results revealed that, while wearing the N95 mask, the mean (SD) speech intelligibility was 98.8% (1.8%) without the in-ear device vs 94.3% (7.4%) with the device. While wearing the half-face elastomeric respirator, the mean speech intelligibility was 58.5% (12.4%) without the in-ear device vs 90.8% (8.9%) with the device. While wearing the PAPR, the mean speech intelligibility was 84.6% (9.8%) without the in-ear device vs 94.5% (5.5%) with the device. Use of the in-ear device was associated with a significant improvement in speech intelligibility while wearing the half-face elastomeric respirator (32.3%; 95% CI, 23.8%-40.7%; P < .001) and the PAPR (9.9%; 95% CI, 1.4%-18.3%; P = .01). Furthermore, use of the device was associated with decreased listening effort. The NASA Task Load Index results reveal that, while wearing the N95 mask, the mean (SD) overall workload score was 12.6 (10.6) points without the in-ear device vs 17.6 (9.2) points with the device. While wearing the half-face elastomeric respirator, the mean overall workload score was 67.7 (21.6) points without the in-ear device vs 29.3 (14.4) points with the in-ear device. While wearing the PAPR, the mean overall workload score was 42.2 (18.2) points without the in-ear device vs 23.8 (12.8) points with the in-ear device. Use of the in-ear device was associated with a significant decrease in overall workload score while wearing the half-face elastomeric respirator (38.4; 95% CI, 23.5-53.3; P < .001) and the PAPR (18.4; 95% CI, 0.4-36.4; P = .04). Conclusions and Relevance: This study found that among participants using facial respirators that impaired communication, a novel in-ear device was associated with improved communication and decreased listening effort. Such a device may be a feasible solution for protecting health care workers in the operating room while allowing them to communicate safely, especially during the COVID-19 pandemic.

Large pH oscillations promote host defense against human airways infection.

The airway mucosal microenvironment is crucial for host defense against inhaled pathogens but remains poorly understood. We report here that the airway surface normally undergoes surprisingly large excursions in pH during breathing that can reach pH 9.0 during inhalation, making it the most alkaline fluid in the body. Transient alkalinization requires luminal bicarbonate and membrane-bound carbonic anhydrase 12 (CA12) and is antimicrobial. Luminal bicarbonate concentration and CA12 expression are both reduced in cystic fibrosis (CF), and mucus accumulation both buffers the pH and obstructs airflow, further suppressing the oscillations and bacterial-killing efficacy. Defective pH oscillations may compromise airway host defense in other respiratory diseases and explain CF-like airway infections in people with CA12 mutations.

Levels of Evidence in Rhinology and Skull Base Surgery Research.

OBJECTIVE: The purpose of this study was to evaluate the quality of evidence of rhinology and rhinologic skull base surgery (RSBS) research and its evolution over the past decade. STUDY DESIGN: Review article. SETTING: We reviewed articles from 2007 to 2019 in 4 leading peer-reviewed otolaryngology journals and 3 rhinology-specific journals. METHODS: The articles were reviewed and levels of evidence were assigned using the Oxford Centre for Evidence-Based Medicine 2011 guidelines. High quality was defined as level of evidence 1 or 2. RESULTS: In total, 1835 articles were reviewed in this study spanning a 13-year period. Overall, the absolute number of RSBS publications increased significantly 22.6% per year, from 108 articles in 2007 to 481 in 2019 (P < .001; 95% CI, 7.9-37.2). In 2007, only 13 articles, or 15%, were high quality, and this grew to 146 articles, or 39%, in 2019. A 14.0% per year exponential increase in the number of high-quality publications was found to be statistically significant (P < .001; 95% CI, 7.2, 20.7). Overall, high-quality publications represented just 25.8% of RSBS articles overall. There was no significant difference in quality between rhinology-specific journals and general otolaryngology journals (χ2 = 3.1, P = .077). CONCLUSION: The number of overall publications and of high-quality RSBS publications has significantly increased over the past decade. However, the proportion of high-quality studies continues to represent a minority of total RSBS research.

CSO (Canadian Society of Otolaryngology - Head & Neck Surgery) position paper on rhinologic and skull base surgery during the COVID-19 pandemic.

Healthcare services in many countries have been partially or completely disrupted by the Coronavirus (COVID-19) pandemic since its onset in the end of 2019. Amongst the most impacted are the elective medical and surgical services in order to conserve resources to care for COVID-19 patients. As the number of infected patients decrease across Canada, elective surgeries are being restarted in a staged manner. Since Otolaryngologists - Head & Neck Surgeons manage surgical diseases of the upper aerodigestive tract where the highest viral load reside, it is imperative that these surgeries resume in a safe manner. The aim of this document is to compile the current best evidence available and provide expert consensus on the safe restart of rhinologic and skull base surgeries while discussing the pre-operative, intra-operative, and post-operative care and tips. Risk assessment, patient selection, case triage, and pre-operative COVID-19 testing will be analyzed and discussed. These guidelines will also consider the optimal use of personal protective equipment for specific cases, general and specific operative room precautions, and practical tips of intra-operative maneuvers to optimize patient and provider safety. Given that the literature surrounding COVID-19 is rapidly evolving, these recommendations will serve to start our specialty back into elective rhinologic surgeries over the next months and they may change as we learn more about this disease.

Microbiotyping the Sinonasal Microbiome.

This study offers a novel description of the sinonasal microbiome, through an unsupervised machine learning approach combining dimensionality reduction and clustering. We apply our method to the International Sinonasal Microbiome Study (ISMS) dataset of 410 sinus swab samples. We propose three main sinonasal "microbiotypes" or "states": the first is Corynebacterium-dominated, the second is Staphylococcus-dominated, and the third dominated by the other core genera of the sinonasal microbiome (Streptococcus, Haemophilus, Moraxella, and Pseudomonas). The prevalence of the three microbiotypes studied did not differ between healthy and diseased sinuses, but differences in their distribution were evident based on geography. We also describe a potential reciprocal relationship between Corynebacterium species and Staphylococcus aureus, suggesting that a certain microbial equilibrium between various players is reached in the sinuses. We validate our approach by applying it to a separate 16S rRNA gene sequence dataset of 97 sinus swabs from a different patient cohort. Sinonasal microbiotyping may prove useful in reducing the complexity of describing sinonasal microbiota. It may drive future studies aimed at modeling microbial interactions in the sinuses and in doing so may facilitate the development of a tailored patient-specific approach to the treatment of sinus disease in the future.

Quality Indicators for the Diagnosis and Management of Acute Bacterial Rhinosinusitis.

BACKGROUND: Acute bacterial rhinosinusitis (ABRS) is a highly prevalent disease that is treated by a variety of specialties, including but not limited to, family physicians, emergency physicians, otolaryngology-head and neck surgeons, infectious disease specialists, and allergy and immunologists. Unfortunately, despite high-quality guidelines, variable and substandard care continues to be demonstrated in the treatment of ABRS. OBJECTIVE: This study aimed to develop ABRS-specific quality indicators (QIs) to evaluate the diagnosis and management that reduces symptoms, improves quality of life, and prevents complications. METHODS: A guideline-based approach, proposed by Kötter et al., was used to develop QIs for ABRS. Candidate indicators (CIs) were extracted from 4 guiding documents and evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND/University of California at Los Angeles appropriateness methodology. RESULTS: Twenty-nine CIs were identified after literature review and evaluated by our panel. Of these, 5 CIs reached consensus as being appropriate QIs, with 1 requiring additional discussion. After a second round of evaluations, the panel selected 7 QIs as appropriate measures of high-quality care. CONCLUSION: This study proposes 7 QIs for the diagnosis and management of patients with ABRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay for performance initiatives.

The international sinonasal microbiome study: A multicentre, multinational characterization of sinonasal bacterial ecology.

The sinonasal microbiome remains poorly defined, with our current knowledge based on a few cohort studies whose findings are inconsistent. Furthermore, the variability of the sinus microbiome across geographical divides remains unexplored. We characterize the sinonasal microbiome and its geographical variations in both health and disease using 16S rRNA gene sequencing of 410 individuals from across the world. Although the sinus microbial ecology is highly variable between individuals, we identify a core microbiome comprised of Corynebacterium, Staphylococcus, Streptococcus, Haemophilus and Moraxella species in both healthy and chronic rhinosinusitis (CRS) cohorts. Corynebacterium (mean relative abundance = 44.02%) and Staphylococcus (mean relative abundance = 27.34%) appear particularly dominant in the majority of patients sampled. Amongst patients suffering from CRS with nasal polyps, a statistically significant reduction in relative abundance of Corynebacterium (40.29% vs 50.43%; P = .02) was identified. Despite some measured differences in microbiome composition and diversity between some of the participating centres in our cohort, these differences would not alter the general pattern of core organisms described. Nevertheless, atypical or unusual organisms reported in short-read amplicon sequencing studies and that are not part of the core microbiome should be interpreted with caution. The delineation of the sinonasal microbiome and standardized methodology described within our study will enable further characterization and translational application of the sinus microbiota.

Pendrin Mediates Bicarbonate Secretion and Enhances Cystic Fibrosis Transmembrane Conductance Regulator Function in Airway Surface Epithelia.

Bicarbonate facilitates mucin unpacking and bacterial killing; however, its transport mechanisms in the airways are not well understood. cAMP stimulates anion efflux through the cystic fibrosis (CF) transmembrane conductance regulator (CFTR; ABCC7) anion channel, and this is defective in CF. The anion exchanger pendrin (SLC26A4) also mediates HCO3- efflux and is upregulated by proinflammatory cytokines. Here, we examined pendrin and CFTR expression and their contributions to HCO3- secretion by human nasal and bronchial epithelia. In native tissue, both proteins were most abundant at the apical pole of ciliated surface cells with little expression in submucosal glands. In well-differentiated primary nasal and bronchial cell cultures, IL-4 dramatically increased pendrin mRNA levels and apical immunostaining. Exposure to low-Cl- apical solution caused intracellular alkalinization (ΔpHi) that was enhanced fourfold by IL-4 pretreatment. ΔpHi was unaffected by 4,4'-diisothiocyano-2,2'-stilbenedisulfonic acid (DIDS) or CFTR inhibitor CFTRinh-172, but was reduced by adenoviral shRNA targeting pendrin. Forskolin increased ΔpHi, and this stimulation was prevented by CFTRinh-172, implicating CFTR, yet forskolin only increased ΔpHi after pendrin expression had been induced by IL-4. The dependence of ΔpHi on pendrin suggests there is minimal electrical coupling between Cl- and HCO3- fluxes and that CFTR activation increases anion exchange-mediated HCO3- influx. Conversely, inducing pendrin expression increased forskolin-stimulated, CFTRinh-172-sensitive current by approximately twofold in epithelial and nonepithelial cells. We conclude that pendrin mediates most HCO3- secretion across airway surface epithelium during inflammation and enhances electrogenic Cl- secretion via CFTR, as described for other SLC26A transporters.

Teaching Residents Frontal Sinus Anatomy Using a Novel 3-Dimensional Conceptualization Planning Software-Based Module.

BACKGROUND: The Frontal Sinus Masterclass (FSMC) is an effective method for teaching frontal sinus anatomy. A third party developed new software using the same 3-dimensional building block concept. The authors sought to determine whether the use of the software for the educational module yielded similar results to the original FSMC, which used wooden blocks. METHODS: The study was performed at a sinus course for residents. A precourse test assessed the ability to decipher frontal sinus anatomy prior to the course. Computed tomography (CT) scans of the sinuses were evaluated in triplanar view, and participants attempted to reconstruct the anatomy using the new software. Subsequently, the course instructor explained the anatomy and showed a short corresponding surgical video of the frontal sinusotomy. Cases progressed in anatomical difficulty and inflammatory load. A postcourse test determined knowledge after the course. RESULTS: In sum, 50 residents completed the pre- and postcourse tests. Overall scores increased from 60.5% to 65.2% ( P = .004). Subanalysis also demonstrated improved ability to locate the frontal drainage pathway from 32.5% to 46% ( P = .011) and label the frontal recess cell structures from 64% to 67.6% ( P = .045). CONCLUSION: There is minimal literature on proven methods for teaching frontal sinus anatomy. Objectively, participants of the modified FSMC simulation training using new software improved their ability to recognize cells of the frontal recess on CT scans. They especially exhibited better localization of the frontal sinus drainage pathway. Subjectively, participants reported benefit from the course and felt they would be better surgeons.

Quality indicators for the diagnosis and management of chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) has been identified as a high-priority disease category for quality improvement. To this end, this study aimed to develop CRS-specific quality indicators (QIs) to evaluate diagnosis and management that relieves patient discomfort, improves quality of life, and prevents complications. METHODS: A guideline-based approach, proposed in 2012 by Kötter et al. was used to develop QIs for CRS. Candidate indicators (CIs) were extracted from 3 practice guidelines and 1 international consensus statement on the diagnosis and management of CRS. Guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND Corporation-University of California, Los Angeles (RAND/UCLA) appropriateness methodology. RESULTS: Thirty-nine CIs were identified after literature review and evaluated by our panel. Of these, 9 CIs reached consensus as being appropriate QIs, with 4 requiring additional discussion. After a second round of evaluations, the panel selected 9 QIs as appropriate measures of high-quality care. CONCLUSION: This study proposes 9 QIs for the diagnosis and management of patients with CRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay-for-performance initiatives.

Raman Spectroscopy for Inverted Papilloma: A Proof-of-Concept Study.

Inverted papillomas are tumors of the sinonasal tract with a propensity to recur. Raman spectroscopy can potentially identify inverted papillomas from other tissue based on biochemical signatures. A pilot study comparing Raman spectroscopy to histopathology for 3 types of sinonasal tissue was performed. Spectral data of biopsies from patients with normal sinonasal mucosa, chronic rhinosinusitis, and inverted papillomas are compared to histopathology using principal component analysis and linear discriminant analysis after data preprocessing. A total of 18 normal, 15 chronic rhinosinusitis, and 18 inverted papilloma specimens were evaluated. The model distinguished normal sinonasal mucosa, chronic rhinosinusitis, and inverted papilloma tissue with an overall accuracy of 90.2% (95% confidence interval, 0.86-0.94). In conclusion, Raman spectroscopy can distinguish inverted papilloma, normal sinonasal mucosa, and chronically rhinosinusitis tissue with acceptable accuracy.

Rhinosinusitis and Allergies in Elderly Patients.

The sinonasal tract plays important roles in respiration, olfaction, and defense against external pathogens. Like many organ systems, the nose and sinuses undergo several changes with advancing age that can play a role in the development of disease. This article discusses the physiology of the aging sinonasal tract and reviews the common diseases affecting older patients, such as rhinitis and rhinosinusitis.