Repeat Eustachian Tube Balloon Dilation Outcomes in Adults With Chronic Eustachian Tube Dysfunction.

OBJECTIVE: With increased focus on surgical management of the eustachian tube, clarifying management decisions benefits patients and surgeons. In this study, we examine the value of repeating the balloon dilation of the eustachian tube (BDET) procedure in patients who did not improve after the initial BDET. STUDY DESIGN: Level IV retrospective review of 145 BDETs performed on 86 patients between January 1, 2014, and May 1, 2019, identified 10 patients who underwent BDET more than once. SETTING: Managed care community otolaryngology practice. METHODS: Demographic and outcome data were collected on both single and repeat BDET cohorts. RESULTS: The Eustachian Tube Dysfunction Questionnaire 7 (ETDQ-7) was used as the primary outcome measure when comparing single vs repeat BDET cohorts. Generally, the 2 cohorts were similar in terms of sex and age distribution. Tobacco use and radioallergosorbent test-positive results were greater proportionally in the repeat BDET cohort. Preoperative ETDQ-7 scores were similar in both cohorts. Single BDET patients overall showed significant improvement in ETDQ-7 scores. ETDQ-7 scores for repeat BDET patients who did not improve after the first procedure similarly did not demonstrate improvement after the second procedure. CONCLUSIONS: Inevitably, some patients will not improve after an initial BDET procedure. The utility of a repeated BDET procedure should be considered in determining how to manage such failures. The results of this limited study suggest that patients who fail to improve meaningfully on ETDQ-7 scores after the initial procedure are unlikely to show substantial improvements after a repeated procedure.

Evaluation of In-Office Cryoablation of Posterior Nasal Nerves for the Treatment of Rhinitis.

BACKGROUND: Chronic rhinitis is a common condition generally treated with medical therapies. However, 10-22% of patients are refractory to medical therapies. A cryotherapy handheld device targeting the postganglionic nerve fibers of the posterior nasal nerve (PNN) now serves as an additional option for therapy. This study evaluates the efficacy of the cryosurgical ablation device of the PNN in the clinic setting. METHODS: This was a prospective single-arm trial of 24 adult patients at seven locations within a large health maintenance organization. Patients with chronic rhinitis that failed medical therapy were offered an in-office cryoablation of PNN. Patients completed the Total Nasal Symptom Score (TNSS) questionnaire consisting of 5 items reported based on the previous 12 hours and 2 weeks at the following time points: pre-treatment, 30 days, 90 days and 1 year post-treatment. RESULTS: Following cryoablation of the PNN, the TNSS 12-hour symptom score improved from 6.92 (±2.9) to 3.17 (±2.4, P < 0.001) at 30 days, 2.92 (±1.4, P < 0.001) at 90 days and 3.08 (±2.6, P < 0.001) at 1 year post treatment. Similar results were noted for the 2 weeks scores improving from 7.75 (±3.1) to 3.79 (±2.1, P < 0.001) at 30 days, 3.88 (±1.9, P < 0.001) at 90 days and 3.76 (±2.1, P < 0.001) at 1 year post-treatment. 64.7% of respondents stated the procedure decreased or eliminated nasal sprays. CONCLUSIONS: Our independent evaluation of cryoablation of the PNN shows improvement in nasal symptoms over a 1 year period and is consistent with other published data.

Unilateral versus bilateral sinonasal disease: Considerations in differential diagnosis and workup.

OBJECTIVE: Imaging findings play an important role in the workup and diagnosis of sinonasal disease. Unilateral versus bilateral involvement is a key finding that can differentiate between various diagnoses. Our objective is to characterize presenting symptoms, imaging findings, and most common diagnoses associated with unilateral versus bilateral sinonasal disease. METHODS: Patients who underwent surgical intervention for sinonasal disease at Emory University between May 2015 and December 2016 were included in the study. Information including demographic variables, comorbidities, presenting symptoms, imaging findings, and pathologic diagnosis was collected for each patient. Unilateral versus bilateral disease was determined by preoperative computer tomography and magnetic resonance imaging, and correlated to surgical and pathologic findings. Data was analyzed using quantitative methodologies and descriptive statistics. RESULTS: The study cohort consisted of 250 patients presenting for primary sinonasal surgery, including 110 patients with unilateral disease and 140 patients with bilateral disease. The most common diagnosis for patients with bilateral disease was chronic rhinosinusitis with nasal polyps (46%) followed by chronic rhinosinusitis without polyps (26%). For patients with unilateral disease the most common diagnoses were chronic rhinosinusitis without nasal polyps (21%), malignancy (19%), benign neoplasm (15%), and allergic fungal sinusitis (10%). There was a statistically significant association between unilateral sinonasal disease and the final diagnosis of benign neoplasm (OR = 7.8, P < .01) and malignancy (OR = 8, P < .01). CONCLUSION: Patients with unilateral sinus disease on initial imaging are less likely chronic rhinosinusitis compared to patients with bilateral disease. This should be taken into consideration in the workup and management of patients with unilateral sinus disease. LEVEL OF EVIDENCE: 3 Laryngoscope, 130:E116-E121, 2020.

Middle Turbinate Friendly Technique for Cribriform Cerebrospinal Fluid Leak Repair.

OBJECTIVE: To compare surgical outcomes between 2 techniques for cribriform cerebrospinal fluid leak (CSF) repair with middle turbinate preservation (MTP) vs middle turbinate resection (MTR). A secondary outcome is to examine the effectiveness of collagen dura matrix (CDM) as a grafting material for repair of isolated cribriform skull base defects. STUDY DESIGN: A retrospective chart review was performed of consecutive patients who underwent cribriform CSF repair at Emory University over the past 15 years. SETTING: Tertiary care rhinology practice. SUBJECTS: Adult patients with cribriform defects limited to the cribriform plate that did not extend lateral to the middle turbinate (MT) and were reconstructed with a free graft (mucosal or synthetic). METHODS: Patients were stratified into 2 primary groups by surgical technique: MTP vs MTR. A subset of patients underwent repair with CDM alone and was analyzed separately for CSF repair failure rate. RESULTS: Of 68 patients identified with cribriform defects, 42 underwent repair with MTP and 26 underwent repair with MTR. Average follow-up time was 495 days. Patients with idiopathic intracranial hypertension were also equally distributed (P = .20). Primary CSF leak repair success was 95.6%, with 100% of leaks ultimately repaired. A subset of 39 patients underwent repair with CDM alone, with a primary repair success rate of 94.9%. CONCLUSIONS: We present an effective method for repair of cribriform CSF leaks while preserving the MT. CDM can be successfully used as a free graft alone for repair of isolated cribriform CSF leaks.

Topical Drug Therapies for Chronic Rhinosinusitis.

Chronic rhinosinusitis is recognized as an inflammatory syndrome involving the nose and paranasal sinuses of multifactorial etiology. Research has demonstrated a complex interplay between host factors, microbiota, environmental exposures, and epigenetics resulting in chronic mucosal inflammation. The mainstay of medical therapy addresses this inflammation. In previously operated sinuses this includes topical saline and corticosteroids, reserving antibiotics for culture-directed acute exacerbations. Topical antiinflammatory therapies allow increased local concentration of drugs while minimizing side effects. Topical therapies have advanced the surgical field by improving and maintaining postoperative outcomes. The topical therapies include saline, corticosteroids, antibiotics, and antifungals.

Assessing asthma in the otolaryngologist's office.

PURPOSE OF REVIEW: To familiarize otolaryngologists and other practitioners with basic diagnosis and treatment of asthma in adults and children based on current literature. RECENT FINDINGS: Increased fractional excretion of nitrous oxide and sputum eosinophils have been identified in asthmatic patients being evaluated for chronic cough and appear to be more sensitive in diagnosis than traditional spirometry. Both sublingual and subcutaneous immunotherapy modalities are effective in decreasing symptoms and medication use in patients with allergic rhinitis and allergic asthma. SUMMARY: Undiagnosed comorbid asthma is prevalent among patients with chronic rhinosinusitis and allergic rhinitis and control of all diseases processes greatly improves quality of life. Office spirometry is a helpful tool in the evaluation and management of asthma. Otolaryngologists should be able to recognize undiagnosed or poorly controlled asthma, initiate and improve medical therapy, and treat rhinosinusitis to improve asthma control.

Implementation of a Pediatric Posttonsillectomy Pain Protocol in a Large Group Practice.

OBJECTIVE: In response to the increased risk of respiratory failure and death after tonsillectomy related to codeine use, Kaiser Permanente Northwest restricted use of opioids in patients <7 years old via electronic health record (EHR). However, opioids could be prescribed at physician discretion by overriding the EHR. This study aims to examine protocol compliance in a large group practice using EHR order sets and complication rates as compared with historical data. STUDY DESIGN: Case series with chart review. SETTING: Ambulatory care within a health maintenance organization. SUBJECTS AND METHODS: Procedural codes were used to identify children <7 years old who underwent tonsillectomy or adenotonsillectomy approximately 1.5 years before and after implementation of EHR protocol (n = 437). Primary outcome was opioid pain prescriptions received by patients. Secondary outcomes were emergency or urgent care utilization, postoperative bleeding, nausea, vomiting, dehydration, death, and reasons for prescribing opioid pain medication after EHR protocol implementation. Chi-square analysis and Fischer's exact testing were used to compare differences in event rates. RESULTS: Implementation of an age-based narcotic protocol significantly decreased physician narcotic prescribing from 82.2% to 15.4% (P < .0001). The most common reason for narcotic prescription after the intervention was the report of inadequate pain control by phone call (35%). There was no significant difference in rate of emergency or urgent care utilization between pre- and postimplementation groups (4% vs 6%, P = .29). CONCLUSIONS: Implementation of an age-based narcotic restriction for posttonsillectomy patients using an EHR order set is an effective and safe way to influence physician prescription practices.

Health utility outcomes in patients undergoing medical management for chronic rhinosinusitis: a prospective multiinstitutional study.

BACKGROUND: A health utility value represents an individual's preference for living in a specific health state and is used in cost-utility analyses. This study investigates the impact of continuing medical therapy on health utility outcomes in patients with chronic rhinosinusitis (CRS). METHODS: The Medical Outcomes Study Short Form-6D (SF-6D) questionnaire was administered to patients prospectively enrolled in a longitudinal study examining treatment outcomes for CRS. Patients were prescribed robust, initial medical therapy and then elected to continue with medical therapy (n = 40) or undergo endoscopic sinus surgery (ESS), followed by medical therapy (n = 152). Patients observed through treatment crossover to ESS were also evaluated (n = 20). Health utility values (SF-6D) were generated at baseline, 6-months, and 12-months follow-up for both cohorts and evaluated using repeated measures analysis of variance (ANOVA). RESULTS: Treatment crossover patients were found to have a significantly higher prevalence of previous sinus surgery compared to medical management (χ(2) = 6.91; p = 0.009) and surgical intervention (χ(2) = 8.11; p = 0.004) subgroups. Mean baseline utility value for the medical therapy cohort was significantly better compared to the ESS cohort (mean ± standard deviation; 0.76 ± 0.12 vs 0.70 ± 0.15; p = 0.023). Significant improvement in health utility was reported in the ESS cohort (F(2) = 37.69; p < 0.001), whereas values remained stable, without significant improvement, in both the medical therapy cohort (F(2) = 0.03; p = 0.967) and treatment crossover cohort (F(2) = 2.36; p = 0.115). CONCLUSION: Patients electing continued medical management report better baseline health utility compared to patients electing ESS. Patients electing ESS show significant improvement in health utility, whereas those electing continued medical management demonstrate stable health utility over 12 months.

Comparison of electrosurgical plasma coagulation and potassium-titanyl-phosphate laser photocoagulation for treatment of hereditary hemorrhagic telangiectasia-related epistaxis.

BACKGROUND: Potassium-titanyl-phosphate (KTP) laser photocoagulation is commonly used for treatment of hereditary hemorrhagic telangiectasia-related epistaxis (HHT-RE). Electrosurgical plasma coagulation (EPC), also known as coblation, has not been rigorously evaluated for HHT-RE. METHODS: Patients seeking treatment for HHT-RE between September 2010 and September 2012 were prospectively randomized (1:1) to KTP or EPC in a single blind prospective cohort study. Length of surgery and estimated blood loss (EBL) were recorded. Epistaxis severity scores (ESSs) and 10-cm visual analogue scale (VAS) scores for HHT-RE-related symptoms were administered at enrollment and at 3, 6, 12 months following surgery. Statistical analysis used Friedman's and Pearson's chi-square tests. RESULTS: Eleven HHT patients were prospectively enrolled and followed. Six patients underwent EPC treatment while 5 underwent KTP. Three patients in the KTP subgroup and 2 patients in the EPC subgroup requested additional surgical treatment within 12 months (p > 0.999). There were no significant differences in terms of EBL (p = 0.126) and length of surgery (p = 0.429) between treatment groups. Mean ESSs were not significantly different between groups at any follow-up point (KTP, p = 0.896; EPC, p = 0.159). Compared to KTP, mean ESSs were higher in the EPC subgroup at baseline and lower at all other time points. Mean nasal obstruction VAS scores were significantly lower in the EPC subgroup at all follow-up points. CONCLUSION: EPC is a viable alternative to KTP laser photocoagulation for epistaxis control in patients with HHT. Subjectively, patients experience less nasal obstruction following EPC as compared to KTP treatment. A multicentered, well-powered study is warranted to better determine treatment outcomes.

Integrity and regeneration of mechanotransduction machinery regulate aminoglycoside entry and sensory cell death.

Sound perception requires functional hair cell mechanotransduction (MET) machinery, including the MET channels and tip-link proteins. Prior work showed that uptake of ototoxic aminoglycosides (AG) into hair cells requires functional MET channels. In this study, we examined whether tip-link proteins, including Cadherin 23 (Cdh23), regulate AG entry into hair cells. Using time-lapse microscopy on cochlear explants, we found rapid uptake of gentamicin-conjugated Texas Red (GTTR) into hair cells from three-day-old Cdh23(+/+) and Cdh23(v2J/+) mice, but failed to detect GTTR uptake in Cdh23(v2J/v2J) hair cells. Pre-treatment of wildtype cochleae with the calcium chelator 1,2-bis(o-aminophenoxy) ethane-N,N,N',N'-tetraacetic acid (BAPTA) to disrupt tip-links also effectively reduced GTTR uptake into hair cells. Both Cdh23(v2J/v2J) and BAPTA-treated hair cells were protected from degeneration caused by gentamicin. Six hours after BAPTA treatment, GTTR uptake remained reduced in comparison to controls; by 24 hours, drug uptake was comparable between untreated and BAPTA-treated hair cells, which again became susceptible to cell death induced by gentamicin. Together, these results provide genetic and pharmacologic evidence that tip-links are required for AG uptake and toxicity in hair cells. Because tip-links can spontaneously regenerate, their temporary breakage offers a limited time window when hair cells are protected from AG toxicity.

Functional hair cell mechanotransducer channels are required for aminoglycoside ototoxicity.

Aminoglycosides (AG) are commonly prescribed antibiotics with potent bactericidal activities. One main side effect is permanent sensorineural hearing loss, induced by selective inner ear sensory hair cell death. Much work has focused on AG's initiating cell death processes, however, fewer studies exist defining mechanisms of AG uptake by hair cells. The current study investigated two proposed mechanisms of AG transport in mammalian hair cells: mechanotransducer (MET) channels and endocytosis. To study these two mechanisms, rat cochlear explants were cultured as whole organs in gentamicin-containing media. Two-photon imaging of Texas Red conjugated gentamicin (GTTR) uptake into live hair cells was rapid and selective. Hypocalcemia, which increases the open probability of MET channels, increased AG entry into hair cells. Three blockers of MET channels (curare, quinine, and amiloride) significantly reduced GTTR uptake, whereas the endocytosis inhibitor concanavalin A did not. Dynosore quenched the fluorescence of GTTR and could not be tested. Pharmacologic blockade of MET channels with curare or quinine, but not concanavalin A or dynosore, prevented hair cell loss when challenged with gentamicin for up to 96 hours. Taken together, data indicate that the patency of MET channels mediated AG entry into hair cells and its toxicity. Results suggest that limiting permeation of AGs through MET channel or preventing their entry into endolymph are potential therapeutic targets for preventing hair cell death and hearing loss.