Neurophysiologic Monitoring of Oculomotor Nerves During Transorbital Surgery: Proof of Concept and Anatomic Demonstration.

BACKGROUND AND OBJECTIVES: Transorbital neuroendoscopic surgery (TONES) is continuously evolving and gaining terrain in approaching different skull base pathologies. The objective of this study was to present our methodology for introducing recording electrodes, which includes a new transconjunctival pathway, to monitor the extraocular muscle function during TONES. METHODS: A translational observational study was performed from an anatomic demonstration focused on the transconjunctival electrode placement technique to a descriptive analysis in our series of 6 patients operated using TONES in association with intraoperative neurophysiologic monitoring of the oculomotor nerves from 2017 to 2023. The stepwise anatomic demonstration for the electrode placement and correct positioning in the target muscle was realized through cadaveric dissection. The descriptive analysis evaluated viability (obtention of the electromyography in each cranial nerve [CN] monitored), security (complications), and compatibility (interference with TONES). RESULTS: In our series of 6 patients, 16 CNs were correctly monitored: 6 (100%) CNs III, 5 (83.3%) CNs VI, and 5 (83.3%) CNs IV. Spontaneous electromyography was registered correctly, and compound muscle action potential using triggered electromyography was obtained for anatomic confirmation of structures (1 CN III and VI). No complications nor interference with the surgical procedure were detected. CONCLUSION: The methodology for introducing the recording electrodes was viable, secure, and compatible with TONES.

Disease phenotypes in adult patients with suspected undifferentiated autoinflammatory diseases and PFAPA syndrome: Clinical and therapeutic implications.

BACKGROUND: Undifferentiated autoinflammatory diseases are characterized by recurrent or persistent fever, usually combined with other inflammatory manifestations, and negative or inconclusive genetic studies for monogenic autoinflammatory disorders. AIMS: To define and characterize disease phenotypes in adult patients diagnosed in an adult reference center with undifferentiated autoinflammatory diseases, and to analyze the efficacy of the drugs used in order to provide practical diagnostic and therapeutic recommendations. METHODS: Retrospective study (2015-2022) of patients with undifferentiated autoinflammatory diseases among all patients visited in our reference center. Demographic, clinical, laboratory features and detailed therapeutic information was collected. RESULTS: Of the 334 patients with a suspected autoinflammatory disease, 134 (40%) patients (61% women) were initially diagnosed with undifferentiated autoinflammatory diseases. Mean age at disease onset and at diagnosis was 28.7 and 37.7 years, respectively. In 90 (67.2%) patients, symptoms started during adulthood. Forty-four (32.8%) patients met diagnostic/classification criteria for adult PFAPA syndrome. In the remaining patients, four additional phenotypes were differentiated according to the predominant manifestations: a) Predominantly fever phenotype (n = 18; 13.4%); b) Predominantly abdominal/pleuritic pain phenotype (n = 9; 6.7%); c) Predominantly pericarditis phenotype (n = 18; 13.4%), and d) Complex syndrome phenotype (n = 45; 33.6%). Prednisone (mainly on demand), colchicine and anakinra were the drugs commonly used. Overall, complete responses were achieved with prednisone in 41.3%, colchicine in 40.2%, and anakinra in 58.3% of patients in whom they were used. By phenotypes, prednisone on demand was more effective in adult PFAPA syndrome and colchicine in patients with the abdominal/pleuritic pain pattern and PFAPA syndrome. Patients with complex syndrome achieved complete responses with prednisone (21.9%), colchicine (25.7%) and anakinra (44.4%), and were the group more often requiring additional immunosuppressive drugs. CONCLUSIONS: The analysis of the largest single-center series of adult patients with undifferentiated autoinflammatory diseases identified and characterized different disease phenotypes and their therapeutic approaches. This study is expected to contribute to increase the awareness of physicians for an early identification of these conditions, and to provide the best known therapeutic options.

Endoscopic transorbital approach bone pillars: a comprehensive stepwise anatomical appraisal.

OBJECTIVE: The endoscopic superior eyelid transorbital approach has garnered significant consideration and gained popularity in recent years. Detailed anatomical knowledge along with clinical experience has allowed refinement of the technique as well as expansion of its indications. Using bone as a consistent reference, the authors identified five main bone pillars that offer access to the different intracranial targeted areas for different pathologies of the skull base, with the aim of enhancing the understanding of the intracranial areas accessible through this corridor. METHODS: The authors present a bone-oriented review of the anatomy of the transorbital approach in which they conducted a 3D analysis using Brainlab software and performed dry skull and subsequent cadaveric dissections. RESULTS: Five bone pillars of the transorbital approach were identified: the lesser sphenoid wing, the sagittal crest (medial aspect of the greater sphenoid wing), the anterior clinoid, the middle cranial fossa, and the petrous apex. The associations of these bone targets with their respective intracranial areas are reported in detail. CONCLUSIONS: Identification of consistent bone references after the skin incision has been made and the working space is determined allows a comprehensive understanding of the anatomy of the approach in order to safely and effectively perform transorbital endoscopic surgery in the skull base.

Type 2 and Non-type 2 Inflammation in the Upper Airways: Cellular and Molecular Alterations in Olfactory Neuroepithelium Cell Populations.

PURPOSE OF REVIEW: Neurogenesis occurring in the olfactory epithelium is critical to continuously replace olfactory neurons to maintain olfactory function, but is impaired during chronic type 2 and non-type 2 inflammation of the upper airways. In this review, we describe the neurobiology of olfaction and the olfactory alterations in chronic rhinosinusitis with nasal polyps (type 2 inflammation) and post-viral acute rhinosinusitis (non-type 2 inflammation), highlighting the role of immune response attenuating olfactory neurogenesis as a possibly mechanism for the loss of smell in these diseases. RECENT FINDINGS: Several studies have provided relevant insights into the role of basal stem cells as direct participants in the progression of chronic inflammation identifying a functional switch away from a neuro-regenerative phenotype to one contributing to immune defense, a process that induces a deficient replacement of olfactory neurons. The interaction between olfactory stem cells and immune system might critically underlie ongoing loss of smell in type 2 and non-type 2 inflammatory upper airway diseases. In this review, we describe the neurobiology of olfaction and the olfactory alterations in type 2 and non-type 2 inflammatory upper airway diseases, highlighting the role of immune response attenuating olfactory neurogenesis, as a possibly mechanism for the lack of loss of smell recovery.

"Boot-on-Donut" procedure for anterior and large septal perforation.

BACKGROUND: Surgical closure of large nasoseptal perforation (NSP) is challenging. The use of an extended anterior ethmoidal artery (eAEA) flap to reconstruct NSP may present with difficulties for NSPs which have their upper edge in a high position. METHOD: We propose adding a "donut-shape" flap from surrounding septal tissue to the eAEA flap. Thus, the inverted edges of this flap allow to cover the uppermost aspect of the NSP. A series of 18 patients with complete closure of NSPs was included. CONCLUSION: This novel "Boot-on-Donut" technique consisting of the eAEA flap (Boot) and inverted edges (Donut) is a feasible procedure that allows to reconstruct large NSP located superiorly.

Adaptation and validation of the Spanish version of NOSE-Perf questionnaire for septal perforations.

BACKGROUND AND OBJECTIVE: Septal perforation (SP) cause heterogeneous symptoms depending on the anatomical location, highlighting scabs, nasal obstruction and/or epistaxis. The use of questionnaires to determine the quality of life in different pathologies is increasing in sinonasal pathologies and in patients with SP the NOSE-Perf questionnaire was constructed, currently validated in English. The aim of this study is the translation, cross-cultural adaptation, and validation of the NOSE-Perf questionnaire into Spanish. MATERIAL AND METHODS: Prospective single-centre study of 81 patients (38 with SP and 43 controls), visited in the rhinology section of a tertiary hospital. Adaptation and translation NOSE-Perf into Spanish and validation using the NOSE and NOSE-Perf questionnaire in Spanish. RESULTS: Significant differences were found in the mean NOSE-Perf score and in the mean NOSE score (IC95% = 21.2-26.9; p < 0.001 and IC95% = 53.8-70.5; p < 0.001) between SP group and control group. Pearson's correlation between the two questionnaires NOSE-Perf and NOSE in the SP group was 0.74 (95% CI = 0.56-0.86; p < 0.001). In the control group it was r = 0.85 (95%CI = 0.73-0.91; p < 0.001). Cronbach's alpha coefficient of the NOSE-Perf was 0.95 (IC 95% = 0.93-0.96) for internal consistency. The reliability evaluation was carried out by test-retest, and a strong Pearson correlation was obtained between the questionnaires r = 0.94 (CI95% = 0.85-0.97; p < 0.001) and r = 0.89 (95%CI = 0.77-0.95; p < 0.001). CONCLUSIONS: The Spanish version of the NOSE-Perf is as reliable and valid as the English version, which makes it possible to assess the impact on quality of life that it causes in patients with perforations in the Spanish-speaking population.

Assessing the effect of absorbable steroid sinus implant: a state-of-the-art systematic review.

OBJECTIVES: Endoscopic sinus surgery is not a definitive treatment for chronic rhinosinusitis (CRS). The use of sinus stents after surgery to maintain sinus patency and deliver local steroids has gained popularity. The first steroid-eluting bioabsorbable implant (SEBI) approved for this indication, later Propel, was developed in 2011. This state-of-the-art review aims to summarize the available evidence, as well as to point out potential pitfalls and lack of specific analyses to guide future research on this new therapeutic option. DATA SOURCES: Pubmed (Medline), the Cochrane Library, EMBASE, SciELO. REVIEW METHODS: Nine research questions were defined: Are steroid-eluting Sinus implants useful for the control of CRS symptoms after surgery? Do they improve surgical field healing after CRS surgery? Do they decrease polyp regrowth after ESS? Do they decrease the need for ESS? Are they useful in symptom control as in-office procedure? Are they better than other steroid-impregnated resorbable materials? Do they have a positive impact on olfaction? Are they safe? Are they cost-effective? Retrieved articles were reviewed by two authors. RESULTS: Twenty nine studies were included: 3 metanalysis, 1 systematic review, 10 randomized clinical trials, 4 quasi-experimental studies, 1 retrospective cohort study, 4 cost studies, 3 case series and 2 expert consensus. The review encompassed a population of 3,012 patients treated with SEBI and 2826 controls. CONCLUSIONS: This is the first state-of-the-art review assessing steroid eluting bioabsorbable stent evidence. Despite the effort in recent years, still several questions remain unanswered. This review will hopefully guide future research efforts to better define the role of SEBI in the otolaryngology practice.

Significance of clinical-immunological patterns and diagnostic yield of biopsies in microscopic polyangiitis and granulomatosis with polyangiitis.

BACKGROUND: Microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) are the two major antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). OBJECTIVES: To characterize a homogenous AAV cohort and to assess the impact of clinicopathological profiles and ANCA serotypes on clinical presentation and prognosis. Clinical differences in GPA patients according to ANCA serotype and the diagnostic yield for vasculitis of biopsies in different territories were also investigated. RESULTS: This retrospective study (2000-2021) included 152 patients with AAV (77 MPA/75 GPA). MPA patients (96.1% myeloperoxidase [MPO]-ANCA and 2.6% proteinase 3 [PR3]-ANCA) presented more often with weight loss, myalgia, renal involvement, interstitial lung disease (ILD), cutaneous purpura, and peripheral nerve involvement. Patients with GPA (44% PR3-ANCA, 33.3% MPO, and 22.7% negative/atypical ANCA) presented more commonly with ear, nose, and throat and eye/orbital manifestations, more relapses, and higher survival than patients with MPA. GPA was the only independent risk factor for relapse. Poor survival predictors were older age at diagnosis and peripheral nerve involvement. ANCA serotypes differentiated clinical features in a lesser degree than clinical phenotypes. A mean of 1.5 biopsies were performed in 93.4% of patients in different territories. Overall, vasculitis was identified in 80.3% (97.3% in MPA and 61.8% in GPA) of patients. CONCLUSIONS: The identification of GPA presentations associated with MPO-ANCA and awareness of risk factors for relapse and mortality are important to guide proper therapeutic strategies in AAV patients. Biopsies of different affected territories should be pursued in difficult-to-diagnose patients based on their significant diagnostic yield.

Effect of turbinate surgery on mucociliary clearance. A systematic review and metanalysis / Efecto de la cirugía turbinal en el aclaramiento mucociliar. Revisión sistemática y metaanálisis

Despite the fact that turbinate surgery provides satisfactory results regarding nasal obstruction, most of these procedures are destructive, to some extent, for the respiratory epithelium. There are valid hypotheses suggesting either that turbinate surgery may improve mucociliary clearance (MCC) by improving rhinitis, as well hypotheses suggesting that these surgeries may impair it by damaging the nasal ciliated epithelia. This systematic review is designed with the objective of exploring the effect of turbinate surgery on MCC. Pubmed (Medline), the Cochrane Library, EMBASE, SciELO were analyzed. Four authors members of the YO-IFOS rhinology study group independently analyzed the articles. Extracted variables encompassed: sample size, age, indication for surgery, surgical technique, method used to measure mucociliary clearance, mucociliary transport time before and after surgery, and main outcome. 15 studies with a total population of 1936 participants (1618 patients excluding healthy controls) met the inclusion criteria. 9 studies could be combined in a metanalysis, wich revealed a non-statistically significant decrease of 3.86 min in MCTT after turbinate surgery (p = 0.06). The subgroup analysis of the 5 cohorts who underwent microdebrider turbinoplasty reached statistical significance under a random effect model, revealing a 7.02 min decrease in MCTT (p < 0.001). The laser turbinoplasty subgroup, composed of 4 cohorts, also reached significance, although the difference was lower than that for microdebrider turbinoplasty, 1.01 min (p < 0.001). This systematic review and meta-analysis suggests that turbinate surgery does not compromise mucociliary clearance. The available evidence also suggests that turbinate surgery with mucosa sparing techniques improves MCC, while with aggressive techniques it increases or remains the same. ... . (AU)

A pesar de que la cirugía turbinal tiene efectos positivos en la ventilación nasal, gran parte de estos procedimientos son agresivos con el epitelio respiratorio. Existen hipótesis que sugieren que la cirugía turbinal puede mejorar el aclaramiento mucociliar (AMC) al mejorar la rinitis, así como alterarlo al lesional el epitelio nasal. Esta revisión se diseña con el objetivo de explorar el efecto de la cirugía turbinal en el AMC. Se revisó Pubmed (Medline), the Cochrane Library, EMBASE, SciELO. 4 autores miembros de YO-IFOS grupo de estudio en rinología, analizaron de manera independiente los artículos. Las variables analizadas fueron tamaño muestral, edad, indicación quirúrgica, técnica quirúrgica, método de medición de AMC, AMC antes y después de la cirugía y resultado principal. Se incluyeron 15 estudios con 1936 participantes (1618 excluyendo controles sanos). 9 estudios fueron combinados en un metanálisis que demostró una diferencia no estadísticamente significativa de -3,86 minutos en AMC tras cirugía (p = 0,06). El análisis por subgrupos de las 5 cohortes sometidas a turbinoplastia con microdebridador si fueron estadísticamente significativas con una diferencia de -7,02 minutos (p < 0,001). El grupo sometido a laser (4 cohortes) también obtuvo diferencia estadística, aunque menor, -1,01 minutos (p < 0,001). Esta revision y metaanálisis sugiere que la cirugía turbinal no afecta al aclaramiento mucociliar. La evidencia disponible también sugiere que las técnicas menos agresivas con la mucosa mejoran el AMC, mientras que las agresivas podrían aumentarlo o no modificarlo. Este efecto beneficioso se observa desde el 1º al 3º mes postquirúrgico. Sin embargo, para poder obtener adecuadas conclusiones, debe existir un método estandarizado para medir el AMC, así como un método para describir adecuadamente la extensión quirúrgica. (AU)

Endonasal versus supraorbital approach for anterior skull base meningiomas: Results and quality of life assessment from a single-surgeon cohort.

OBJECTIVE: In this prospective non-randomized study we reported our experience related to planum sphenoidale (PS) and tuberculum sellae (TS) meningiomas in a similar cohort of patients operated via the endonasal or the supraorbital route. A comprehensive quality of life analysis has been performed. METHODS: Being comparable in general features, between November 2017 to January 2020, a total of 20 patients with anterior skull base meningioma were included. Hence, 10 patients were treated using the supraorbital keyhole procedure (SO) while 10 patients received an endoscopic endonasal approach (EEA). Both surgical techniques were analyzed and compared. Quality of life has been analyzed with the SF-36 questionnaire. RESULTS: Twenty patients were identified who underwent either EEA (n=10) or SO (n=10). The average extent of resection achieved was not significantly different between the 2 groups. Post-operatively, the EEA group demonstrated a longer hospital stay and bed days compared with SO patients as well as a longer surgical time. There was a significant rate of more CSF leakage after EEA then after SO (20% vs 0%, p=0,0491). The follow-up period resulted shorter in the SO group, with a slight increased recurrence rate. Overall, no differences in visual outcome were detected. There were no differences in terms of quality of life between the two groups in all the explored items. CONCLUSIONS: In this single-center single-surgeon study of similarly sized and located PS and TS meningiomas, EEA showed longer hospital stays with higher degree of CSF leak compared with the SO group. Supraorbital craniotomy via eyebrow incision reported a comparable quality of life results, even if with a slightly higher percentage of recurrence and less follow-up.

Endoscopic "Racket-on-Donut" Technique for Large Anterior Nasoseptal Perforations.

Endoscopic Racket-on-Donut technique is a combination of a modified greater palatine artery and inverted edges flaps. Endoscopic Racket-on-Donut technique is very useful for anterior NSP repair. Laryngoscope, 134:143-147, 2024.

Complications of the Superior Eyelid Endoscopic Transorbital Approach to the Skull Base: Preliminary Experience With Specific Focus on Orbital Outcome.

BACKGROUND: The endoscopic superior eyelid approach is a relatively novel mini-invasive technique that is currently investigating for skull base cancers. However, questions remain regarding specific approach-related complications when treating different skull base tumors. This study aims to analyze any surgical complications that occurred in our preliminary consecutive experience, with specific focus on orbital outcome. METHODS: A retrospective and consecutive cohort of patients treated via a superior eyelid endoscopic transorbital approach at the Division of Neurosurgery of the Hospital Clinic in Barcelona was analyzed. Patients features were described in detail. Complications were divided into 2 groups to analyze separately the approach-related complications, and those resulting from tumor removal. The ocular complications were subdivided into early ocular status (<3 weeks), late ocular status (3-8 weeks), and persistent ocular complications. The "Park questionnaire" was used to determine patient's satisfaction related to the transorbital approach. RESULTS: A total of 20 patients (5 spheno-orbital meningiomas, 1 intradiploic Meningioma, 2 intraconal lesions, 1 temporal pole lesion, 2 trigeminal schwannoma, 3 cavernous sinus lesions, and 6 petroclival lesions) were included in the period 2017-2022. Regarding early ocular status, upper eyelid edema was detected in all cases (100%) associated with diplopia in the lateral gaze in 30% of cases, and periorbital edema in 15% of cases. These aspects tend to resolve at late ocular follow-up (3-8 weeks) in most cases. Regarding persistent ocular complications, in one case of intraconal lesion, a limitation of eye abduction was detected (5%). In another patient with intraconal lesion, an ocular neuropathic pain was reported (5%). In 2 cases of petroclival menigioma, who were also treated with a ventriculo-peritoneal shunt, slight enophthalmus was observed as a persistent complication (10%). According to the Park questionnaire, no cosmetic complaints, no head pain, no palpable cranial irregularities, and no limited mouth opening were reported, and an average of 89% of general satisfaction was encountered. CONCLUSIONS: The superior eyelid endoscopic transorbital approach is a safe and satisfactory technique for a diversity of skull base tumors. At late follow-up, upper eyelid edema, diplopia, and periorbital edema tend to resolve. Persistent ocular complications are more frequent after treating intraconal lesions. Enophthalmus may occur in patients with associated ventriculo-peritoneal shunt. According to patient's satisfaction, fairly acceptable results are attained.

Effect of turbinate surgery on mucociliary clearance. A systematic review and metanalysis.

Despite the fact that turbinate surgery provides satisfactory results regarding nasal obstruction, most of these procedures are destructive, to some extent, for the respiratory epithelium. There are valid hypotheses suggesting either that turbinate surgery may improve mucociliary clearance (MCC) by improving rhinitis, as well hypotheses suggesting that these surgeries may impair it by damaging the nasal ciliated epithelia. This systematic review is designed with the objective of exploring the effect of turbinate surgery on MCC. Pubmed (Medline), the Cochrane Library, EMBASE, SciELO were analyzed. Four authors members of the YO-IFOS rhinology study group independently analyzed the articles. Extracted variables encompassed: sample size, age, indication for surgery, surgical technique, method used to measure mucociliary clearance, mucociliary transport time before and after surgery, and main outcome. 15 studies with a total population of 1936 participants (1618 patients excluding healthy controls) met the inclusion criteria. 9 studies could be combined in a metanalysis, wich revealed a non-statistically significant decrease of 3.86 min in MCTT after turbinate surgery (p = 0.06). The subgroup analysis of the 5 cohorts who underwent microdebrider turbinoplasty reached statistical significance under a random effect model, revealing a 7.02 min decrease in MCTT (p < 0.001). The laser turbinoplasty subgroup, composed of 4 cohorts, also reached significance, although the difference was lower than that for microdebrider turbinoplasty, 1.01 min (p < 0.001). This systematic review and meta-analysis suggests that turbinate surgery does not compromise mucociliary clearance. The available evidence also suggests that turbinate surgery with mucosa sparing techniques improves MCC, while with aggressive techniques it increases or remains the same. This beneficial effect is evident since the first to third month after surgery. However, for solid conclusions, a standard way to measure MCTT should be stablished, as well as a method to appropriately describe the extension of the surgery.

Management of patients with chronic rhinosinusitis with nasal polyps in Spain: learnings from a nationwide survey of otorhinolaryngologists.

PURPOSE: To describe the self-reported practices on the diagnosis, treatment, and follow-up of patients with chronic rhinosinusitis with nasal polyps (CRSwNP) by ear, nose, and throat (ENT) specialists in Spain to identify potential areas for management optimization. METHODS: A cross-sectional online survey with 16 questions was carried out. Recruitment was performed by emailing registered ENT specialists in the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC). RESULTS: In total, 127 ENT specialists completed the survey. Fifty-one percent of respondents combined clinical criteria and objective evidence of mucosal inflammation to diagnose CRSwNP. Patient interview and, to a lower degree, a visual analogue scale were the most employed diagnostic tools to quantify symptom severity. Less than half (45%) routinely used the 22-item sino-nasal outcomes test (SNOT-22) to assess the impact of CRSwNP disease in quality of life. The use of patient-reported outcomes and other clinical evaluation tools showed a larger uptake among ENT specialists that worked at an ENT department with an available rhinology unit. Almost all the specialists surveyed (95%) recommended biological treatment, particularly in patients with uncontrolled CRSwNP with respiratory comorbidities (76%), as well as in candidates for revision surgery (66%). CONCLUSION: Spanish otorhinolaryngologists showed a trend toward incorporating CRSwNP guideline recommendations in their clinical practice. The observed low uptake of patient-reported outcomes and objective clinical evaluation tools in routine clinical practise have been identified as areas for optimizing the management of patients with CRSwNP.

EUFOREA/EPOS2020 statement on the clinical considerations for chronic rhinosinusitis with nasal polyps care.

Following the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) treatment algorithm for chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP), patients suffering from severe uncontrolled CRSwNP are recommended to receive oral corticosteroids, (revision) sinus surgery, systemic biologicals and/or aspirin treatment after desensitization (ATAD). Given the major differences in indications, outcomes, practical considerations, risks and costs of these key pillars of treatment, there is a growing need to define criteria for each treatment option and list the clinically relevant and major considerations for them. This EUFOREA document therefore provides an expert panel overview of the expected outcomes, specific considerations and (contra)indications of the five major treatment arms of severe uncontrolled CRSwNP: oral corticosteroids, primary and revision sinus surgery, biological treatment and ATAD. This overview of treatment considerations is needed to allow physicians and patients to consider the different options in the context of providing optimal and personalized care for severe uncontrolled CRSwNP. In conclusion, the five major treatment options for severe uncontrolled CRSwNP have intrinsic advantages, specific indications and considerations that are of importance to the patient, the physician and the society. This EUFOREA statement supports the unmet need to define criteria for the indication of every treatment pillar of CRSwNP.

International clinical assessment of smell: An international, cross-sectional survey of current practice in the assessment of olfaction.

OBJECTIVES: Olfactory dysfunction (OD) is common and carries significant personal and societal burden. Accurate assessment is necessary for good clinical and research practice but is highly dependent on the assessment technique used. Current practice with regards to UK/international clinical assessment is unknown. We aimed to capture current clinical practice, with reference to contemporaneously available guidelines. We further aimed to compare UK to international practice. DESIGN: Anonymous online questionnaire with cross-sectional non-probability sampling. Subgroup analysis according to subspeciality training in rhinology ('rhinologists' and 'non-rhinologists') was performed, with geographical comparisons only made according to subgroup. PARTICIPANTS: ENT surgeons who assess olfaction. RESULTS: Responses were received from 465 clinicians (217 from UK and 17 countries total). Country-specific response rate varied, with the lowest rate being obtained from Japan (1.4%) and highest from Greece (72.5%). Most UK clinicians do not perform psychophysical smell testing during any of the presented clinical scenarios-though rhinologists did so more often than non-rhinologists. The most frequent barriers to testing related to service provision (e.g., time/funding limitations). Whilst there was variability in practice, in general, international respondents performed psychophysical testing more frequently than those from the UK. Approximately 3/4 of all respondents said they would like to receive training in psychophysical smell testing. Patient reported outcome measures were infrequently used in the UK/internationally. More UK respondents performed diagnostic MRI scanning than international respondents. CONCLUSIONS: To our knowledge, this is the most comprehensive UK-based, and only international survey of clinical practice in the assessment of OD. We present recommendations to improve practice, including increased education and funding for psychophysical smell testing. We hope this will promote accurate and reliable olfactory assessment, as is the accepted standard in other sensory systems.

Upregulation of Platelet-Activating Factor Receptor Expression and Lyso-Platelet-Activating Factor Isoforms in Human Nasal Polyp Tissues.

BACKGROUND: The Platelet-Activating Factor (PAF)/receptor (PAFR) system is involved in asthma and allergic rhinitis; however, its role in chronic rhinosinusitis (CRS) is still unclear. This study aimed to assess the expression of PAFR and the concentration of Lyso-PAF isoforms in the nasal polyps (NP) of patients suffering from CRS with/without comorbidities such as asthma and NSAID-exacerbated respiratory disease (N-ERD) compared to healthy nasal mucosa (NM) from control subjects. METHODS: NM (n = 8) and NP tissues were obtained from patients undergoing surgery for septal deviation/turbinate hypertrophy or endoscopic sinus surgery, respectively. Three phenotypes were studied: CRSwNP with no asthma (n = 6), CRSwNP with non-steroidal anti-inflammatory drug (NSAID)-tolerant asthma (n = 6), and CRSwNP with NSAID-exacerbated respiratory disease (n = 6). PAFR protein and mRNA were assessed via immunochemistry, immunofluorescence, Western blot, and real-time quantitative PCR. Lyso-PAF isoforms (C16, C18, and C18:1) were quantified via mass spectrometry. RESULTS: PAFR protein was expressed in the NM and NP, concretely in epithelial cells and submucosal glands. Compared to NM, PAFR mRNA expression was higher in all NP phenotypes (p < 0.05) while all Lyso-PAF isoform concentrations were higher in the NP from asthmatic patients (p < 0.05). Lyso-PAF C16 and C18 concentrations were higher in the NP from asthmatic patients than in the NP from patients without asthma. CONCLUSIONS: The PAF/PAFR system could play a pathophysiological role in CRSwNP pathogenesis.

Effects of Endoscopic Sinus Surgery on Olfactory Function.

PURPOSE OF REVIEW: To review the effects of endoscopic sinus surgery and endonasal approaches to the skull base on olfaction. RECENT FINDINGS: Advancements in endonasal endoscopic approaches to the sinuses and skull base allow for direct treatment of a variety of sinonasal and skull base diseases. However, these extended approaches will often require manipulation of normal anatomical structures and the olfactory neuroepithelium. Depending on the planned procedure and extent of disease, the prognosis of olfactory perception can vary significantly among patients. Endoscopic sinonasal surgical procedures may impact olfaction. Optimizing olfactory function requires proper surgical techniques, gentle handling of tissue, and perioperative care. Surgeons must discuss objectives and manage patient expectations. Routine olfactory assessment is crucial in surgical work-up and follow-up. Preserving anatomical structures while addressing the obstruction of the olfactory cleft helps to prevent decreased olfactory threshold. However, smell identification and discrimination do not always correlate with sinonasal anatomy.

Addressing the unmet needs in patients with type 2 inflammatory diseases: when quality of life can make a difference.

Background: Patients with asthma (AS), atopic dermatitis (AD), allergic rhinitis (AR), eosinophilic esophagitis (EoE), chronic rhinosinusitis with nasal polyps (CRSwNP), chronic urticaria (CU), non-steroidal anti-inflammatory drugs-exacerbated respiratory disease (N-ERD), and certain phenotypes of chronic obstructive pulmonary disease (COPD), among others, have a common underlying pathogenesis known as Type 2 inflammation (T2i). These diseases often coexist with other T2i conditions and have a substantial impact on the quality of life (QoL) of patients. However, limited data on patients' experiences, perspectives, and current management of T2i diseases have been published thus far. Aims: This survey, promoted by the patient-driven T2i Network Project, aimed at identifying the common drivers and challenges related to the QoL of patients with T2i diseases by putting the patient's perspective at the force and including it in the design of new care strategies. Methodology: An anonymous online survey was carried out through convenience sampling between May and June 2023. The survey was codesigned by members of different patient associations, healthcare professionals and healthcare quality experts, and implemented using EUSurvey and distributed through eight patient associations from Spain. The survey consisted of 29 questions related to the participant's sociodemographic features, a series of self-reported multiple choice or rating scale questions, including diagnosis, QoL measures, disease severity, healthcare resource utilization, and quality of care. Results: The survey included 404 participants, members from eight patient associations, the majority of whom had moderate-to-severe self-reported disease severity (93%) and one or more coexisting pathologies related to T2i (59%). Patients with more than one pathology had a significantly greater impact on QoL than those with only one pathology (p < .001). Participants with self-reported severe symptoms reported significantly worse QoL than those with mild-to-moderate severity (p < .001). More than half of the patients (56%) felt constantly bothered by the unpredictability of their illness caused by potential exposure to known or unknown disease triggers. The lack of coordination between specialists and primary care was also expressed as an area of dissatisfaction by participants, with 52% indicating a complete lack of coordination and 21% indicating an average coordination. Conclusion: This article reports the initial findings of a patient-led initiative, which highlights the common QoL challenges faced by individuals with type 2 inflammation-related diseases and emphasizes the importance of further clinical research to improve the management of this patient group. Considering the significant impact on QoL, a multidisciplinary approach integrated into new healthcare protocols has the potential to improve patient management and QoL, shorten the time to diagnosis and reduce healthcare resource utilization.

GEMA 5.3. Spanish Guideline on the Management of Asthma.

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

La Guía Española para el Manejo del Asma, mejor conocida por su acrónimo en español, GEMA, está a nuestra disposición desde hace más de veinte años. Veintiuna sociedades científicas o grupos relacionados, tanto de España como de otros países, han participado en la preparación y desarrollo de la edición actualizada de GEMA que, de hecho, se ha posicionado en la actualidad a nivel mundial como la guía de referencia sobre asma en lengua española.Su objetivo es prevenir y mejorar la situación clínica de las personas con asma, aumentando el conocimiento de los profesionales sanitarios involucrados en su cuidado. Su propósito es convertir la evidencia científica en recomendaciones prácticas sencillas y fáciles de seguir. Por lo tanto, no se trata de una monografía que reúna todo el conocimiento científico sobre la enfermedad, sino más bien de un documento conciso con lo esencial, diseñado para ser aplicado rápidamente en la práctica clínica de rutina. Las recomendaciones son necesariamente multidisciplinares, están desarrolladas para ser útiles y una herramienta indispensable para médicos de diferentes especialidades, así como para profesionales de enfermería y farmacia.Seguramente, los aspectos más destacados de la guía son las recomendaciones para: establecer el diagnóstico del asma utilizando un algoritmo secuencial basado en pruebas diagnósticas objetivas; el seguimiento de los pacientes, preferentemente basado en la estrategia de lograr y mantener el control de la enfermedad; el tratamiento según el nivel de gravedad del asma utilizando seis escalones, desde la menor hasta la mayor necesidad de medicamentos, y el algoritmo de tratamiento basado en fenotipos para la indicación de biológicos en pacientes con asma grave no controlada. A esto se suma ahora una novedad para su fácil uso y seguimiento a través de una aplicación informática basada en la inteligencia artificial conversacional de tipo chatbot (ia-GEMA).