SNOT-22 subdomain outcomes following treatment for sinonasal malignancy: A prospective, multicenter study.

BACKGROUND: Patients with sinonasal malignancy (SNM) present with significant sinonasal quality of life (QOL) impairment. Global sinonasal QOL as measured by the 22-item Sinonasal Outcomes Test (SNOT-22) has been shown to improve with treatment. This study aims to characterize SNOT-22 subdomain outcomes in SNM. METHODS: Patients diagnosed with SNM were prospectively enrolled in a multi-center patient registry. SNOT-22 scores were collected at the time of diagnosis and through the post-treatment period for up to 5 years. Multivariable regression analysis was used to identify drivers of variation in SNOT-22 subdomains. RESULTS: Note that 234 patients were reviewed, with a mean follow-up of 22 months (3 months-64 months). Rhinologic, psychological, and sleep subdomains significantly improved versus baseline (all p < 0.05). Subanalysis of 40 patients with follow-up at all timepoints showed statistically significant improvement in rhinologic, extra-nasal, psychological, and sleep subdomains, with minimal clinically important difference met between 2 and 5 years in sleep and psychological subdomains. Adjuvant chemoradiation was associated with worse outcomes in rhinologic (adjusted odds ratio (5.22 [1.69-8.66])), extra-nasal (2.21 [0.22-4.17]) and ear/facial (5.53 [2.10-8.91]) subdomains. Pterygopalatine fossa involvement was associated with worse outcomes in rhinologic (3.22 [0.54-5.93]) and ear/facial (2.97 [0.32-5.65]) subdomains. Positive margins (5.74 [2.17-9.29]) and surgical approach-combined versus endoscopic (3.41 [0.78-6.05])-were associated with worse psychological outcomes. Adjuvant radiation (2.28 [0.18-4.40]) was associated with worse sleep outcomes. CONCLUSIONS: Sinonasal QOL improvements associated with treatment of SNM are driven by rhinologic, extra-nasal, psychological, and sleep subdomains.

Predictive factors for decreased baseline quality of life in patients with sinonasal malignancies.

BACKGROUND: The impact of sinonasal malignancies (SNMs) on quality of life (QOL) at presentation is poorly understood. The Sinonasal Outcome Test (SNOT-22) and University of Washington Quality of Life (UWQOL) are validated QOL instruments with distinctive subdomains. This study aims to identify factors impacting pretreatment QOL in SNM patients to personalize multidisciplinary management and counseling. METHODS: Patients with previously untreated SNMs were prospectively enrolled (2015-2022) in a multicenter observational study. Baseline pretreatment QOL instruments (SNOT-22, UWQOL) were obtained along with demographics, comorbidities, histopathology/staging, tumor involvement, and symptoms. Multivariable regression models identified factors associated with reduced baseline QOL. RESULTS: Among 204 patients, presenting baseline QOL was significantly reduced. Multivariable regression showed worse total SNOT-22 QOL in patients with skull base erosion (p = 0.02). SNOT-rhinologic QOL was worse in women (p = 0.009), patients with epistaxis (p = 0.036), and industrial exposure (p = 0.005). SNOT extranasal QOL was worse in patients with industrial exposure (p = 0.016); worse SNOT ear/facial QOL if perineural invasion (PNI) (p = 0.027). Squamous cell carcinoma pathology (p = 0.037), palate involvement (p = 0.012), and pain (p = 0.017) were associated with worse SNOT sleep QOL scores. SNOT psychological subdomain scores were significantly worse in patients with palate lesions (p = 0.022), skull base erosion (p = 0.025), and T1 staging (p = 0.023). Low QOL was more likely in the presence of PNI on UW health (p = 0.019) and orbital erosion on UW overall (p = 0.03). UW social QOL was worse if palatal involvement (p = 0.023) or PNI (p = 0.005). CONCLUSIONS: Our findings demonstrate a negative impact on baseline QOL in patients with SNMs and suggest sex-specific and symptom-related lower QOL scores, with minimal histopathology association. Anatomical tumor involvement may be more reflective of QOL than T-staging, as orbital and skull base erosion, PNI, and palate lesions are significantly associated with reduced baseline QOL.

Long-term quality of life after treatment in sinonasal malignancy: A prospective, multicenter study.

BACKGROUND: Quality of life (QOL) for individuals with sinonasal malignancy (SNM) is significantly under-studied, yet it is critical for counseling and may impact treatment. In this study we evaluated how patient, treatment, and disease factors impact sinonasal-specific and generalized QOL using validated metrics in a large cohort over a 5-year posttreatment time frame. METHODS: Patients with SNM who underwent definitive treatment with curative intent were enrolled in a prospective, multisite, longitudinal observational study. QOL was assessed using the 22-item Sino-Nasal Outcome Test (SNOT-22) and University of Washington Quality of Life Questionnaire (UWQOL) instruments at pretreatment baseline and multiple follow-ups through 5 years posttreatment. Multivariable modeling was used to determine demographic, disease, and treatment factors associated with disease-specific and generalized physical and social/emotional function QOL. RESULTS: One hundred ninety-four patients with SNM were analyzed. All QOL indices were impaired at pretreatment baseline and improved after treatment. SNOT-22 scores improved 3 months and UWQOL scores improved 6 to 9 months posttreatment. Patients who underwent open compared with endoscopic tumor resection had worse generalized QOL (p < 0.001), adjusted for factors including T stage. Pterygopalatine fossa (PPF) involvement was associated with worse QOL (SNOT-22, p < 0.001; UWQOL Physical dimension, p = 0.02). Adjuvant radiation was associated with worse disease-specific QOL (p = 0.03). Neck dissection was associated with worse generalized physical function QOL (p = 0.01). Positive margins were associated with worse generalized social/emotional function QOL (p = 0.01). CONCLUSION: Disease-specific and generalized QOL is impaired at baseline in patients with SNM and improves after treatment. Endoscopic resection is associated with better QOL. PPF involvement, adjuvant radiation, neck dissection, and positive margins were associated with worse QOL posttreatment.

International consensus statement on allergy and rhinology: rhinosinusitis 2021.

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

Drug-eluting implants in chronic rhinosinusitis: an evidence-based review with recommendations.

BACKGROUND: Drug-eluting implants are becoming increasingly popular in the treatment of chronic rhinosinusitis (CRS). A previous attempt to make an evidence-based recommendation was hindered by limited evidence and experience with these implants. Since that time, the body of literature discussing drug-eluting implants has grown rapidly. The objective of this study was to review drug-eluting implants designed for use in the sinonasal cavity through an evidence-based review with recommendations. METHODS: A systematic review of the literature was performed using PubMed, EMBASE, Cochrane Review, and gray literature databases from January 1990 through February 2019 to examine drug-eluting implants used in CRS. Benefit-harm assessments, value judgments, and recommendations were made based on the available evidence. Study exclusion criteria included studies unavailable in English and non-endoscopic sinus surgeries. All authors agreed on recommendations through an iterative process. RESULTS: Thirty-one studies were included in the final analysis. Absorbable drug-eluting implants achieved a high aggregate grade of evidence (A), with a recommendation for their use to be considered in carefully selected patients. Nonabsorbable drug-eluting implants were recommended against due to minimal evidence supporting clinical efficacy. Antibiotic and alternative drug-eluting implants lack sufficient evidence for recommendations. CONCLUSION: Absorbable steroid-eluting implants are recommended for carefully selected patients with CRS. Additional research to define appropriate patient selection is needed.

Long-term outcomes after endoscopic dacryocystorhinostomy without mucosal flap preservation.

OBJECTIVE: A growing body of evidence demonstrates that endonasal endoscopic dacryocystorhinostomy (eDCR) techniques provide comparable results to conventional external techniques. The purpose of this study was to evaluate long-term outcomes after powered endoscopic DCR without preservation of mucosal flaps for the management of acquired nasolacrimal duct obstruction performed by a single surgical team. METHODS: A retrospective review was performed of patients with epiphora secondary to acquired nasolacrimal duct obstruction who underwent eDCR without mucosal flap preservation from May 2003 to April 2013 at a tertiary referral medical center. Main outcome measures were subjective improvement in epiphora and assessment of anatomic patency based on lacrimal irrigation and endoscopic evaluation. RESULTS: Eighty patients (69 primary and 11 revision) totaling 103 procedures (87 primary, 16 revision) were available for analysis at a mean follow-up of 28.7 (range 6-114) months. At the most recent follow-up, 92 of 103 (89.3%) procedures had complete resolution of epiphora, and 10 of 103 procedures achieved mild intermittent epiphora. Complete resolution of epiphora was noted in 93.1% (81 of 87) of primary procedures and 68.8% (11 of 16) of revision procedures. Objective anatomic patency was confirmed in 98% (101 of 103). A revision procedure was required in 5.8% (6 of 103). CONCLUSION: Outcomes of powered eDCR without the preservation of mucosal flaps compare favorably to previously reported results in the literature. These long-term results suggest that mucosal flap preservation is not required to achieve successful outcomes with eDCR. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:12-17, 2020.

Development of Chronic Sphenoid Sinusitis After Sellar Reconstruction with Medpor Porous Polyethylene Implant.

OBJECTIVE: The Medpor porous polyethylene implant is reported to be safe and effective for sellar reconstruction after transsphenoidal surgery (TSS). However, we have observed several cases of delayed chronic sphenoid sinusitis related to the implant. The purpose of this study is to describe the presentation and management of implant-related sphenoid sinusitis after sellar reconstruction. METHODS: This is a retrospective study of patients who underwent endonasal TSS with Medpor sellar reconstruction between December 2008 and January 2013 at a tertiary care institution. Patient demographics, initial surgical management, sinonasal symptoms, postoperative imaging, sinusitis management, and resulting outcomes were analyzed. RESULTS: From 2008-2013, 139 patients underwent sellar reconstruction using Medpor. Five patients (3.6%) presented between 8 and 60 months after surgery with chronic sphenoid sinusitis that required surgical management. All 5 patients presented as outpatients for management of headaches and nasal drainage, 4 patients experienced chronic nasal congestion, and 3 patients noted recurrent sinusitis. At the time of revision surgery, all 5 patients were found to have mucosal inflammation and edema surrounding the implant, and 4 of the 5 had an exposed or partially extruded implant that was removed. CONCLUSIONS: Reconstruction of the sellar floor may be performed after TSS to prevent postoperative complications. Although porous polyethylene implants have previously been described as safe and effective for this purpose, surgeons should be aware of the risk of subsequent implant extrusion and chronic sphenoid sinusitis that can occur in a delayed manner.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis.

BACKGROUND: Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR). METHODS: Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus. RESULTS: The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR. CONCLUSION: This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Expression of immunoglobulin D is increased in chronic rhinosinusitis.

BACKGROUND: Immunoglobulin (Ig) D is largely localized to the upper airway and reacts with colonizing respiratory pathogens. OBJECTIVE: To determine whether chronic rhinosinusitis (CRS) is associated with increased IgD expression. METHODS: We performed immunofluorescent staining for cytoplasmic IgD, IgA, IgM, and surface plasma cell marker CD138 (syndecan-1) in sinus tissue of patients with CRS with and without nasal polyps (CRSwNP and CRSsNP, respectively) and control subjects without CRS (n = 6 each). Sinonasal mucus antibody levels of patients with CRSwNP or CRSsNP and control subjects were measured by enzyme-linked immunosorbent assay (n = 13, 11, and 9 subjects, respectively). Cells per square millimeter and antibody levels were compared by analysis of variance. Histopathology was performed with sinus tissue from subjects in the 3 groups (n = 6, 8, and 13 subjects respectively). RESULTS: Cells expressing cytoplasmic IgD exceeded those with cytoplasmic IgA and IgM and represented most CD138+ plasma cells in the lamina propria. The frequencies of IgD+ plasma cells were significantly higher in patients with CRSsNP and CRSwNP compared with control subjects (P < .01). Only patients with CRSwNP showed increased frequencies of IgM and IgA plasma cells (P < .01). In contrast to high plasma cell frequencies in tissues, the levels of secreted IgD were lower than those of IgA, IgM, and IgG but were highest in the CRSwNP group compared with the other groups (P < .05). CONCLUSION: IgD plasma cells are prominent in sinus tissues and are increased in CRS. That IgD protein also shows the lowest concentration of antibodies in secretions suggests that its activity might be targeted to the tissue rather than secretions.

Endoscopic Management of Paranasal Sinus Mucoceles: Meta-analysis of Visual Outcomes.

Objective Paranasal sinus mucoceles are benign cystic lesions originating from sinus mucosa that can impinge on adjacent orbital structures, causing ophthalmic sequelae such as decreased visual acuity. Definitive treatment requires surgery. We present the first meta-analysis quantifying the effect of preoperative visual function and time to surgery on postoperative visual acuity outcomes. Data Sources PubMed, Ovid, Embase, Web of Science, and the Cochrane Library. Methods Two independent authors systematically reviewed articles describing outcomes after endoscopic sinus surgery for paranasal sinus mucoceles presenting with visual loss. Available data from case reports and series were combined to analyze the associations among preoperative visual acuity, time to surgery, and postoperative outcomes. Results Eighty-five studies were included that provided data on 207 patients. The average presenting visual acuity was 1.57 logMAR (logarithm of the minimum angle of resolution), and the average postoperative visual acuity was 0.21 logMAR, with visual improvement in 71.5% of cases. Preoperative visual acuity ≥1.52 logMAR correlated with postoperative improvement >1 logMAR ( R = 0.4887, P < .0001). A correlation was found between a time to surgery <6 days and postoperative improvement ( R = 0.297, P < .0001). Receiver operator curve analysis of these thresholds demonstrated a moderately accurate prognostic ability (area under the curve: 75.1 for preoperative visual acuity and 73.1 for time to surgery). Conclusion Visual loss resulting from paranasal sinus mucoceles is potentially reversible in most cases, even those presenting with poor vision. When possible, surgery should be performed promptly after diagnosis, but emergency surgery does not appear to be necessary for vision restoration.

Landmarks for rapid localization of the sphenopalatine foramen: A radiographic morphometric analysis.

BACKGROUND: Transnasal endoscopic sphenopalatine artery ligation is becoming the procedure of choice for surgical management of intractable posterior epistaxis. Landmarks for localization of the sphenopalatine foramen can assist in rapid surgical exposure of the sphenopalatine artery. OBJECTIVE: This study examined distances from easily identified endoscopic surgical landmarks to the sphenopalatine foramen. METHODS: By using computed tomography of the sinus to study radiologic anatomy in 50 adults, distances were measured between five simple endoscopic landmarks and the sphenopalatine foramen. The two-tailed t-test was used for statistical analysis. RESULTS: Right- and left-sided measurements were similar. The mean (standard deviation [SD]) anteroposterior distances to the sphenopalatine foramen were the following: from the maxillary line (36.7 ± 5.5 mm), anterior head of the middle turbinate (33.8 ± 6.7 mm), basal lamella (11.8 ± 1.9 mm), and choanal arch (-9.2 ± 1.4 mm). The mean (SD) distance in the vertical dimension from the nasal floor was 26.6 ± 2.6 mm. Female patients had statistically shorter distances to the sphenopalatine foramen from the maxillary line, anterior head of the middle turbinate, choanal arch, and nasal floor. CONCLUSION: Reliable endoscopic landmarks exist in relation to consistent anatomic structures and can be used to help quickly estimate the location of the sphenopalatine foramen at the onset of the procedure.

Selective expansion of human regulatory T cells in nasal polyps, and not adjacent tissue microenvironments, in individual patients exposed to steroids.

Severe forms of chronic rhinosinusitis (CRS), a common upper airway inflammatory disorder, are associated with nasal polyps (NPs). NP disease is ameliorated by glucocorticoid (GC) treatment, whose cellular effects are poorly understood. We therefore assessed the influence of GC therapy on NPs in CRS patients, focusing on regulatory T (Treg) cells. Treg cell populations were analyzed by flow cytometry in NPs and control tissues from GC-treated CRS patients and controls. After GC exposure, selective expansion of Treg cells was seen within NPs, and not blood or adjacent ethmoid tissues. To confirm direct GC effects, NPs from the same patients were biopsied prior to, and following, 1week of oral GC exposure. Direct expansion of Tregs into the same NP bed was detected in 4/4 CRS patients following GC exposure. Treg cell spikes into NPs were secondary to cellular recruitment given limited Ki67 expression within these regulatory cells. Chemokine gene expression profiling identified several chemokines, notably CCL4, induced within NPs upon GC treatment. Neutralization of chemokine receptor/ligand interactions using CCR4 small molecule antagonists reduced Treg migration towards GC-treated NPs in an ex vivo migration assay. Our findings suggest that the common use of GCs in the treatment of NP disease leads to recruitment of Treg cells from peripheral sites into NP tissues, which may be critical to the anti-inflammatory effect of GCs. Mechanistically Treg expansion appears to be conferred, in part, by chemokine receptor/ligand interactions induced following corticosteroid therapy.

Using fixed anatomical landmarks to avoid medial rectus injury: a radiographic analysis in patients with and without Graves' disease.

BACKGROUND: Injury to the medial rectus (MR) is a potentially devastating complication of orbital and sinus surgery. Precise knowledge of the MR relative to the lamina papyracea (LP) is important during endoscopic surgery for both Graves' ophthalmopathy and inflammatory disease. The objective of this study is to determine the location of the MR in relation to easily identified and frequently encountered intranasal landmarks in patients with and without Graves' disease. METHODS: High-resolution computed tomography scans were analyzed in 100 controls and 63 patients with Graves' disease. The MR position was recorded relative to the maxillary sinus ostium (MSO), anterior ethmoid artery (AEA), and posterior ethmoid artery (PEA)/horizontal basal lamella (BL). Clinically relevant variables recorded at each level included the Keros stage, AEA position, MR height, and distance of the MR to orbital floor, skull base, and LP. RESULTS: The mean distances between the MR and LP were statistically different for both groups. Controls at the MSO, AEA, and PEA/BL were 2.92, 1.69, and 1.06mm; for Graves' patients measurements at these sites were 2.12, 1.20, and 0.029mm. When comparing the two groups, each of these distances were statistically significant (p<0.02). There was no difference in ethmoid cavity width (p>0.05) between controls (9.66mm) and Graves' patients (9.70mm). Sex, age, and skull base depth were not statistically significant factors. CONCLUSION: This study illustrates the position of the MR from the perspective of an endoscopic surgeon utilizing fixed intranasal landmarks. Knowledge of the position of MR is critical to safely perform decompression surgery and when operating adjacent to the LP during endoscopic surgery.

Clinical Examination of Tissue Eosinophilia in Patients with Chronic Rhinosinusitis and Nasal Polyposis.

OBJECTIVE: (1) Describe clinical and histopathologic findings in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). (2) Determine if tissue and serum eosinophilia predicts disease severity in CRSwNP. STUDY DESIGN: Case series with chart review. SETTING: Academic hospital specializing in respiratory and allergic disease. SUBJECTS: Patients with CRSwNP treated from 2008 to 2010. METHODS: Clinical data were collected; sinus computed tomography (CT) scans were scored according to the Lund-Mackay system; and surgical specimens were evaluated for degree of tissue eosinophilia. Statistical analysis was performed to compare eosinophilia with indicators of disease severity. RESULTS: Seventy CRSwNP patients were included, with a mean Lund-Mackay score of 16.7; 62.1% of patients had severe asthma, and 62.9% were aspirin sensitive. Elevated tissue eosinophil level did not correlate with medication usage, olfactory symptoms, or Lund-Mackay scores, nor did it correlate with presence of asthma or aspirin-sensitivity (P = .09). Patients with mild asthma had significantly more tissue eosinophils versus patients with severe asthma, possibly because of the high amount of chronic corticosteroid use in severe asthmatics. There was no correlation between tissue and serum eosinophil counts (P = .97), but there was a significant positive correlation between CT score and peripheral eosinophil level (P < .05). CONCLUSIONS: Higher serum eosinophil levels may indicate more extensive mucosal disease as measured on CT scan. Neither serum nor tissue eosinophilia predicted disease severity in our retrospective analysis of CRSwNP patients, and serum eosinophil level did not serve as a marker of tissue eosinophilia.

Evaluation of bacterial transmission to the paranasal sinuses through sinus irrigation.

BACKGROUND: Saline nasal irrigation is effective in the treatment of sinonasal disorders, including chronic rhinosinusitis (CRS). Despite bacterial contamination in rinse bottles and reports of infections from contaminated irrigation water, tap water is still used by ∼50% of irrigation users, raising a potential public health concern. This study aimed to determine whether bacteria from the water supply used in sinus irrigations colonizes the paranasal sinuses. METHODS: Samples were taken from the: (1) water used for irrigation, (2) faucet or container the water originated from, (3) rinse bottle, and (4) postoperative ethmoid cavity from 13 subjects with CRS. Microbiota were characterized using quantitative polymerase chain reaction (qPCR) and 16S ribosomal RNA (rRNA) gene sequencing. The Morisita-Horn beta-diversity index (M-H) was used to assess similarity in microbiota between samples, and genomic analysis was performed to assess clonality of cultured bacteria. RESULTS: Of 13 subjects, 6 used distilled water, 6 used tap water, and 1 used well water in this institutional review board (IRB)-approved observational study. Well-water had markedly more bacteria than tap or distilled water. There was a trend toward tap having more bacteria than distilled water. The sinus samples were notably dissimilar to the bottle, faucet, and irrigant (M-H 0.15, 0.09, and 0.18, respectively). There was no difference in postoperative microbiotas between distilled and tap water users. CONCLUSION: The current study suggests that irrigation plays little role in establishing the sinus microbiome. Although rinsing with tap water may never be formally recommended, these data are useful to counsel patients who prefer to do so in non-endemic areas if the municipal water supply is appropriately treated.

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis.

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

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis Executive Summary.

BACKGROUND: The body of knowledge regarding rhinosinusitis (RS) continues to expand, with rapid growth in number of publications yet substantial variability in the quality of those presentations. In an effort to both consolidate and critically appraise this information, rhinologic experts from around the world have produced the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR:RS). This executive summary consolidates the findings of the ICAR:RS document. METHODS: ICAR:RS presents over 140 topics in the forms of evidence-based reviews with recommendations (EBRRs) and evidence-based reviews (EBR). The structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS: This summary compiles the EBRRs regarding medical and surgical management of acute RS (ARS) and chronic RS with and without nasal polyps (CRSwNP and CRSsNP). CONCLUSION: This ICAR:RS Executive Summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Investigation of bacterial repopulation after sinus surgery and perioperative antibiotics.

BACKGROUND: Endoscopic sinus surgery (ESS) enjoys high success rates, but repopulation with pathogenic bacteria is 1 of the hallmarks of poorer outcomes. There are many hypothesized sources of repopulating bacteria; however, this process remains largely unexplored. This study examined changes in the sinus microbiome after ESS and medical therapies to identify potential sources for postsurgical microbial repopulation. METHODS: Samples from the anterior nares, ethmoid sinus, and nasopharynx were taken at the time of surgery from 13 subjects undergoing ESS for chronic rhinosinusitis (CRS). Patients were treated postoperatively with 2 weeks of oral antibiotics and saline rinses. The ethmoid sinus was sampled at 2 and 6 weeks postoperatively; microbiota were characterized using quantitative polymerase chain reaction (qPCR) and 16S ribosomal RNA (rRNA) gene sequencing. The Morisita-Horn beta-diversity index (M-H) was used to compare similarity between samples. RESULTS: The bacterial burden of the ethmoid was higher 2 weeks postoperatively than 6 weeks postoperatively (p = 0.01). The 6-week samples most closely represented the anterior nares and ethmoid at surgery (M-H = 0.58 and 0.59, respectively), and were least similar to the nasopharynx (M-H = 0.28). Principal coordinates analysis (PCoA) plots illustrate that the ethmoid microbiota temporarily shifted after surgery and antibiotics but returned toward baseline in many subjects. CONCLUSION: Bacterial communities colonizing the ethmoid 6 weeks postoperatively were most similar to anterior nasal cavity and pretreatment sinus microbial profiles, indicating a high degree of resilience in the sinonasal microbiome of most subjects. Interestingly, surgery and postoperative antibiotic therapy does not appear to reduce bacterial burden, but rather, shifts the microbial consortia.

Does Image-Guided Surgery Reduce Complications?

Image-guided surgery (IGS) is progressively used in endoscopic sinus surgery (ESS), and surgeon comfort with the technology has increased. It remains a challenge to determine if the use of IGS in ESS leads to a reduction in surgical complications and improved outcomes. Current literature does not show a clear reduction in surgical complications. The routine use of IGS in ESS as a deterrent to medicolegal liability is not substantiated by recent reported data. There are particular situations in which IGS may be helpful, but its use is likely not required for routine ESS and seems best left to surgeon discretion.