When inflammation is not just inflammation-A review of systemic diseases of the nose and sinuses part 2: Granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis.

BACKGROUND: Chronic rhinosinusitis is a very common condition. Granulomatosis with polyangiitis (GPA) and eosinophilic granulomatosis with polyangiitis (eGPA) are systemic diseases which can contribute to the development of chronic rhinosinusitis in select patients. OBJECTIVE: Characterize the presenting features, diagnostic criteria, workup, and management of granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis as they are encountered in otolaryngology clinics. METHODS: Full length manuscripts published 2000 or later were reviewed. A separate search was conducted for each disease. Pertinent clinical features related to sinonasal manifestations of GPA and eGPA were collected and reported in this review. RESULTS: 467 references were discovered during literature review process. In total, 42 references for GPA and 35 references for eGPA were included in this review. CONCLUSION: GPA and eGPA are vasculitis syndromes which commonly present in the context of multisystem disease. For GPA, pulmonary and renal disease are common; for eGPA a history of asthma is nearly ubiquitous. Sinonasal disease is a very common feature for both disease processes and may precede the development of systemic symptoms in many patients. Clinical work up and diagnosis is complex and generally requires multidisciplinary care. Treatment primarily consists of immunosuppressive agents, and a number of steroids, steroid sparing agents, and biologics have been shown to be effective. The role of sinus surgery includes tissue biopsy for diagnosis, functional surgery for symptom management in select cases, and reconstruction of cosmetic and functional defects.

When inflammation is not just inflammation-A review of systemic diseases of the nose and sinuses part 1: IgG4-related disease and sarcoidosis.

BACKGROUND: Chronic rhinosinusitis is a very common condition. IgG4-related disease (IgG4-RD) and sarcoidosis are systemic diseases which can contribute to the development of chronic rhinosinusitis in select patients. OBJECTIVE: Characterize the presenting features, diagnostic criteria, workup, and management of sinonasal IgG4-RD and sarcoidosis as they are encountered in otolaryngology clinics. METHODS: Full length manuscripts published 2000 or later were reviewed. A separate search was conducted for each disease. Pertinent clinical features related to sinonasal manifestations of IgG4-RD and sarcoidosis were collected and reported in this review. RESULTS: 404 references were discovered during literature review process. In total, 42 references for IgG4-RD and 34 references for sarcoidosis were included in this review. CONCLUSION: IgG4-RD and sarcoidosis are autoimmune inflammatory conditions that can affect many systems of the body. For both disease entities, sinonasal disease is a less common presentation which can lead to delayed diagnosis. Sinonasal IgG4-RD commonly presents in the setting of multisystem disease. All with other clinical features, biopsy plays a key role in the diagnosis for both diseases. Treatment for IgG4-RD consists primarily of steroids and rituximab which can lead to excellent and durable remission. A variety of immunosuppressive agents are used in the management of sarcoidosis. Surgery for IgG4-RD is primarily utilized for tissue biopsy, although resection or debulking may be considered. For sarcoidosis, surgery can be used for tissue biopsy and functional sinus surgery can offer symptomatic relief in many patients.

Does gender affect experiences in the operating room for surgeons and anesthesiologists at a large academic center?

BACKGROUND: Although the number of women medical trainees has increased in recent years, they remain a minority of the academic workforce. Gender-based implicit biases may lead to deleterious effects on surgical workforce retention and productivity. METHODS: All 440 attending surgeons and anesthesiologists employed at our institution were invited to complete a survey regarding perceptions of the perioperative work environment and resources. Odds ratios for dichotomous variables were calculated using logistic regressions, and for trichotomous variables, polytomous regressions. RESULTS: 243 participants (55.2%) provided complete survey responses. Relative to men, women faculty reported a greater need to prove themselves to staff; less respect and fewer resources and opportunities; more frequent assumptions about their capabilities; and a greater need to adjust their demeanor to connect with their team (p â€‹< â€‹0.05). CONCLUSION: Perceived gender bias remains present in the perioperative environment. We need greater efforts to address barriers and create an equitable work environment.

An Updated Patient-Centered Sialadenitis Instrument: The Obstructive Salivary Problem Impact Test (SPIT).

OBJECTIVE: The Chronic Obstructive Sialadenitis Symptoms questionnaire (COSS) was created to assess chronic sialadenitis symptoms and treatment response, but its development lacked patient input and validation. We analyzed COSS responses and feedback from sialadenitis patients and physician experts to create the novel obstructive Salivary Problem Impact Test (SPIT), a new standardized measure of sialadenitis-associated symptoms. METHODS: We analyzed COSS responses via exploratory factor analysis (EFA) to identify essential symptom domains and reduce overlap in questions. Sialadenitis patients evaluated the significance of index symptoms identified from the literature review. Expert physicians rated symptom relevance in clinical assessment. An updated questionnaire (SPIT) was piloted with both patient and expert interviews to optimize structure and readability. The SPIT was assessed for internal consistency, construct validity, and test-retest stability. RESULTS: EFA of 310 COSS responses demonstrated 3 main symptom domains (functional impact, pain, swelling) that explained 58.4% of response variance. Results were not statistically different when collapsing from 11 to 5 question response options. Experts (n = 5) ranked gland swelling, mealtime pain, and foul taste as most clinically important, while patients (n = 12) ranked swelling, non-mealtime pain, and difficulty eating as most bothersome. Most patients experienced sialadenitis-related functional or psychosocial impairment. Following interviews for question refinement, a 25-question survey was finalized. SPIT responses from 50 sialadenitis patients demonstrated internal consistency (Cronbach's alpha = 0.96), 14-day stability (p < 0.001), and agreement with Oral Health Impact Profile-14 scores (p < 0.0001). CONCLUSIONS: We developed the SPIT instrument to improve usability and content validity in chronic sialadenitis evaluation. The psychometric assessment demonstrated high construct validity and test-retest reliability. Further work will assess longitudinal changes with treatment. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:539-546, 2023.

IgG4-Related Disease and the Salivary Glands: A Review of Pathophysiology, Diagnosis, and Management.

IgG4-related disease is a rare, immune-mediated, systemic disease that is characterized by soft tissue lymphocyte infiltration and resultant fibrosis. The salivary glands are among the most commonly affected organs. Patients present with subacute submandibular and/or parotid swelling and sialadenitis. Diagnosis incorporates clinical, serologic, radiologic, and pathologic findings. Most cases respond quickly to systemic glucocorticoids. IgG4-related disease mimics many infectious, inflammatory, and neoplastic diseases. Therefore, IgG4-related disease is frequently misdiagnosed. A knowledge of the pathophysiology, diagnosis, and management of IgG4-related disease is important for providers who treat salivary gland diseases.

Association of Olfactory Training With Neural Connectivity in Adults With Postviral Olfactory Dysfunction.

Importance: Viral upper respiratory tract infections are a major cause of olfactory loss. Olfactory training (OT) is a promising intervention for smell restoration; however, a mechanistic understanding of the changes in neural plasticity induced by OT is absent. Objective: To evaluate functional brain connectivity in adults with postviral olfactory dysfunction (PVOD) before and after OT using resting-state functional magnetic resonance imaging. Design, Setting, and Participants: This prospective cohort study, conducted from September 1, 2017, to November 30, 2019, recruited adults with clinically diagnosed or self-reported PVOD of 3 months or longer. Baseline olfaction was measured using the University of Pennsylvania Smell Identification Test (UPSIT) and the Sniffin' Sticks test. Analysis was performed between December 1, 2020, and July 1, 2020. Interventions: Participants completed 12 weeks of OT using 4 essential oils: rose, eucalyptus, lemon, and clove. The resting-state functional magnetic resonance imaging measurements were obtained before and after intervention. Main Outcome and Measures: The primary outcome measure was the change in functional brain connectivity before and after OT. Secondary outcome measures included changes in UPSIT and Sniffin' Sticks test scores, as well as patient-reported changes in treatment response as measured by subjective changes in smell and quality-of-life measures. Results: A total of 16 participants with PVOD (11 female [69%] and 14 White [88%]; mean [SD] age, 60.0 [10.5] years; median duration of smell loss, 12 months [range, 3-240 months]) and 20 control participants (15 [75%] female; 17 [85%] White; mean [SD] age, 55.0 [9.2] years; median UPSIT score, 37 [range, 34-39]) completed the study. At baseline, participants had increased connectivity within the visual cortex when compared with normosmic control participants, a connection that subsequently decreased after OT. Furthermore, 4 other network connectivity values were observed to change after OT, including an increase in connectivity between the left parietal occipital junction, a region of interest associated with olfactory processing, and the cerebellum. Conclusions and Relevance: The use of OT is associated with connectivity changes within the visual cortex. This case-control cohort study suggests that there is a visual connection to smell that has not been previously explored with OT and that further studies examining the efficacy of a bimodal visual and OT program are needed.

Evidence of a microbial etiology for sialoliths.

OBJECTIVES: Sialolithiasis is the primary etiology for parotid and submandibular swelling, potentially resulting in discomfort, bacterial infections, and hospitalization. The etiology of sialolith formation is unknown. Currently, the proposed etiologies range from inflammation, coalescence of organic molecules, sialomicrolith formation, pH changes, and biofilm formation. In this study, we performed a descriptive analysis of images obtained through electron microscopy of sialoliths. Based on our findings and descriptive analysis, we hypothesize that sialolith formation is likely multifactorial and begins with biofilm formation. Biofilm formation then triggers a host immune response, and it is the interaction of biofilm with host immune cells and calcium nanoparticles that forms the nidus and creates a favorable environment for calcium precipitation. METHODS: Sialoliths were extracted from patients and imaged under light and scanning electron microscopy. Specimens for light microscopy were prepared using a diamond saw. Specimens for electron microscopy were freeze-fractured, thus providing an undisturbed view of the core of the sialolith. RESULTS: We were able to identify clear evidence of biofilm caves at the core of each sialolith. These biofilm caves were complex with the presence of bacteria and dehydrated extrapolysaccharide matrix, host cells (immune cells, platelets and erythrocytes), and calcium nanoparticles. CONCLUSION: The etiology of sialolith formation is likely multifactorial. We propose that biofilm formation within a single salivary gland or duct leads to local ductal injury, which results in the influx of host immune cells that interact with the biofilm and calcium nanoparticles, creating a scaffold upon which further calcium deposition can occur. LEVEL OF EVIDENCE: NA Laryngoscope, 130:69-74, 2020.

Rates of sialoendoscopy and sialoadenectomy in 5,111 adults with private insurance.

OBJECTIVE: To determine frequencies and trends in sialoendoscopy and sialoadenectomy for the treatment of obstructive, nonneoplastic submandibular gland disease in the United States. METHODS: Epidemiologic study of insurance claims from 2006 to 2013 in a large, private insurance claims database. Rates were calculated for patients undergoing one or both index procedures. RESULTS: A total of 5,111 adults with sialadenitis who underwent sialoendoscopy or submandibular gland excision were included. Mean age was 47.6 years, and patients undergoing sialoendoscopy were less likely to be male (relative risk [RR] = 0.84; 95% confidence interval [CI], 0.78-0.89), more likely to have sialoadenitis without stones (RR = 1.60; 95% CI, 1.53-1.66), and had a similar number of comorbidities (RR = 1.00; 95% CI, 0.91-1.06) compared to patients undergoing sialoadenectomy. The most common complication after sialoadenectomy was surgical site infection (1.4%; 95% CI, 1.1-1.8%), and complications after sialoendoscopy were rare. From 2007 to 2013, use of sialoendoscopy increased from 0.13 (95% CI, 0.08-0.18) to 0.42 (95% CI, 0.40-0.45) per 100 thousand people, and sialoadenectomy decreased from 2.41 (95% CI, 2.39-2.42) to 1.43 (95% CI, 1.40-1.44) per 100 thousand. The highest mean rate of sialadenectomy was seen in the south (2.15 per 100,000; 95% CI, 2.13-2.16), the lowest was in the west (1.6 per 100,000; 95% CI, 1.57-1.62), and it decreased in all regions over time. CONCLUSION: Utilization of sialoendoscopy has increased over time, and the overall rate of sialoadenectomy is decreasing. Both procedures are safe for treatment of patients with sialadenitis and sialolithiasis. Future research should examine whether availability of sialoendoscopy leads to a decreased rate of sialoadenectomy in patients with salivary gland disease. LEVEL OF EVIDENCE: 2c Laryngoscope, 129:602-606, 2019.

Sialendoscopy-assisted transfacial removal of parotid sialoliths: A systematic review and meta-analysis.

OBJECTIVE: To review the literature and conduct a meta-analysis to determine the effectiveness and safety of the combined endoscopic-transfacial approach for parotid sialolith management. DATA SOURCES: PubMed 1946-, Embase 1947-, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Review Effects, Cochrane Central Register of Controlled Trials, clinicaltrials.gov, Proquest Dissertations and Theses, and FirstSearch Proceedings to March 2015. REVIEW METHODS: Published prospective or retrospective English-language studies with reported outcomes of more than one patient undergoing the combined endoscopic-transfacial procedure for parotid sialolithiasis were included. Two independent authors screened all eligible studies and reviewed and extracted data from relevant publications. Weighted pooled proportions for stone removal, symptom improvement, gland preservation, and complications were calculated. RESULTS: Ten studies, primarily retrospective single-institution studies, were included in the final analysis, with a total of 184 patients. Overall, the procedure was noted to be successful with low risk; the weighted pooled proportions were 0.99 (95% confidence interval [CI]: 0.97 to 1.00) for stone removal, 0.97 (95% CI: 0.93 to 0.99) for symptom improvement, 1 (95% CI: 0.99 to 1.00) for gland preservation, and 0.06 (95% CI: 0.01 to 0.15) for complications. CONCLUSIONS: Although our analysis is primarily based on retrospective data, the evidence shown here suggests that the combined endoscopic-transfacial technique is an effective treatment for parotid gland sialolithiasis not amenable to intraoral or purely endoscopic removal. This approach results in high rates of symptom improvement and gland preservation. The complication rates are low, further supporting the use of this technique. Laryngoscope, 127:2510-2516, 2017.

Interventional sialendoscopy after sialadenectomy.

OBJECTIVES/HYPOTHESIS: To evaluate the use of diagnostic and interventional sialendoscopy in patients with prior parotidectomy or submandibular gland excision and persistent sialadenitis and/or sialolithiasis. STUDY DESIGN: Retrospective case series. METHODS: Retrospective review of medical records, including demographic data, clinical presentation and exam, radiologic studies, and operative reports. RESULTS: Five patients, who had undergone prior sialadenectomy for sialadenitis and/or sialolithiasis, underwent sialendoscopy for persistent symptoms during the study period. Three patients were female and two were male, with ages ranging from 39 to 63 years (median, 47 years). Three patients had prior parotidectomy, and two had prior submandibular gland excision. The duration of time from sialadenectomy to sialendoscopy was 3.25 months to 6 years (median, 26 months). Four of the five patients had successful interventional sialendoscopy, with resolution of their symptoms. These four patients underwent extraction of stones, one of which was previously unrecognized. In one patient, duct cannulation and subsequent sialendoscopy could not be performed owing to scarring at the Stensen's papilla; the patient's symptoms initially persisted after the attempted procedure with gradual improvement. No complications occurred in any patients. Importantly, no sequelae resulted from endoscopic instrumentation and irrigation of salivary ducts that ended in blind pouches. CONCLUSIONS: Sialendoscopy is a safe and frequently effective intervention for persistent sialolithiasis and sialadenitis after salivary gland excision. LEVEL OF EVIDENCE: 4.

Predictors of future success in otolaryngology residency applicants.

OBJECTIVE: To evaluate the information available about otolaryngology residency applicants for factors that may predict future success as an otolaryngologist. DESIGN: Retrospective review of residency applications; survey of resident graduates and otolaryngology clinical faculty. SETTING: Otolaryngology residency program. PARTICIPANTS: Otolaryngology program graduates from 2001 to 2010 and current clinical faculty from Barnes-Jewish Hospital/Washington University School of Medicine. MAIN OUTCOME MEASURE: Overall ratings of the otolaryngology graduates by clinical faculty (on a 5-point scale) were compared with the resident application attributes that might predict success. The application factors studied are United States Medical Licensing Examination part 1 score, Alpha Omega Alpha Honor Medical Society election, medical school grades, letter of recommendation, rank of the medical school, extracurricular activities, residency interview, experience with acting intern, and extracurricular activities. RESULTS: Forty-six graduates were included in the study. The overall faculty rating of the residents showed good interrater reliability. The objective factors, letters of recommendation, experience as an acting intern, and musical excellence showed no correlation with higher faculty rating. Rank of the medical school and faculty interview weakly correlated with faculty rating. Having excelled in a team sport correlated with higher faculty rating. CONCLUSIONS: Many of the application factors typically used during otolaryngology residency candidate selection may not be predictive of future capabilities as a clinician. Prior excellence in a team sport may suggest continued success in the health care team.

Against the odds: idiopathic sudden sensorineural hearing loss-results from delayed treatment.

A 79-yr-old male was evaluated by the authors 4-6 wk following a rapid decline in perceived hearing in the right ear. Initial treatment with self-administered external ear canal irrigations and topical antibiotic prescribed by the patient's primary care physician resulted in no apparent improvement. The initial hearing evaluation revealed a mild-to-severe sloping sensorineural loss above 1000 Hz in the left ear and a moderately severe to severe sensorineural loss with a "flat" configuration in the right ear. There was normal word recognition in the left ear, with no measurable word recognition in the right ear. Initial treatment with oral steroids suggested some subjective improvement, and an intratympanic dexamethasone injection was performed. A repeat audiogram obtained approximately 1 mo postinjection showed significant improvement in pure tone thresholds and significant improvement in the word recognition score in the right ear. One week later a second intratympanic injection was completed, again, with follow-up in 1 mo. This case report reviews treatment options for idiopathic sudden sensorineural hearing loss (ISSNHL), including usual time lines for treatment and expected outcomes and the specific treatments and evaluation results for this patient for whom delayed treatment was unusually effective.