Air pollution, genetic factors, and chronic rhinosinusitis: A prospective study in the UK Biobank.

BACKGROUND: Chronic rhinosinusitis (CRS) is a prevalent upper respiratory condition that manifests in two primary subtypes: CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). While previous studies indicate a correlation between air pollution and CRS, the role of genetic predisposition in this relationship remains largely unexplored. We hypothesized that higher air pollution exposure would lead to the development of CRS, and that genetic susceptibility might modify this association. METHODS: This cohort study involving 367,298 adult participants from the UK Biobank, followed from March 2006 to October 2021. Air pollution metrics were estimated at residential locations using land-use regression models. Cox proportional hazard models were employed to explore the associations between air pollution exposure and CRS, CRSwNP, and CRSsNP. A polygenic risk score (PRS) was constructed to evaluate the joint effect of air pollution and genetic predisposition on the development of CRS. RESULTS: We found that the risk of CRS increased under long-term exposure to PM2.5 [the hazard ratios (HRs) with 95 % CIs: 1.59 (1.26-2.01)], PM10 [1.64 (1.26-2.12)], NO2 [1.11 (1.04-1.17)], and NOx [1.18 (1.12-1.25)], respectively. These effects were more pronounced among participants with CRSwNP, although the differences were not statistically significant. Additionally, we found that the risks for CRS and CRSwNP increased in a graded manner among participants with higher PRS or higher exposure to PM2.5, PM10, or NOx concentrations. However, no multiplicative or additive interactions were observed. CONCLUSIONS: Long-term exposure to air pollution increases the risk of CRS, particularly CRSwNP underscoring the need to prioritize clean air initiatives and environmental regulations.

Patient Questions Surrounding Posterior Nasal Nerve Ablation for Chronic Rhinitis.

Objective: In-office ablation of the posterior nasal nerve (PNN) has emerged as an effective treatment option for chronic rhinitis patients. This study explored questions patients commonly search online regarding this therapy and the quality of content available. Study Design: A retrospective analysis of online search criteria and sources was performed with subsequent analysis of results. Setting: Search and data acquisition was in September of 2023. Methods: Most common search terms related to cryotherapy and radiofrequency neurolysis of the PNN were identified with associated People Also Ask (PAA) questions. Questions were categorized and organized into subtopics and sources evaluated using readability and quality metrics. Results: A total of 255 unique PAA questions and 175 unique websites were identified. The most common subtopics were related to facts about chronic rhinitis (26.7%) and rhinitis treatment options (25.1%). Nearly a quarter (24.3%) of websites were from commercial sources. Quality metrics indicate difficult-to-read and low-quality materials. Conclusion: Existing online resources need improvement to provide patients material that is easier to read. Physicians counseling patients should be aware of these areas for adequate shared decision making.

A Case of Inverted Colonic Diverticulum.

Inverted colonic diverticulum (ICD) is an infrequent finding on colonoscopy, often misdiagnosed as colonic polyps. Further endoscopic intervention, such as polypectomy or biopsy, may lead to colonic perforation. For that reason, the endoscopist should be aware of the possibility of detecting these lesions when performing a colonoscopy. Diagnosing an ICD can be confirmed by inspection and gentle eversion using the probe. In this case report, we present a patient who was found to have inverted colonic diverticulum as we highlight the importance of distinguishing it from colonic polyps in order to prevent severe complications.

Cultural stress is toxic stress: An expanded cultural stress theory model for understanding mental health risk in Latinx immigrant youth.

OBJECTIVES: Latinx immigrant youth are at greater risk for mental health (MH) concerns than their nonimmigrant Latinx peers. Efforts to address mental health disparities have resulted in the much-needed development of theoretical frameworks explaining mental health disparities in marginalized populations. A theoretical framework that is particularly relevant to mental health disparities among Latinx immigrant youth is the Cultural Stress Theory (CST); however, an expansion of this model is necessary to thoroughly describe and explain mental health risk in this population. METHOD: This article integrates two frameworks-Toxic Stress Theory and the National Institute of Minority Health and Health Disparities research framework-with CST to better explain mental health risk in Latinx immigrant youth. In doing so, we propose an expanded model that seeks to build on the strengths of CST in two important ways-expanding the breadth of relevant ecological domains and emphasizing the continued focus on specific mechanisms and their associations across levels. RESULTS: The proposed expanded CST model acknowledges a range of influences from the broad systemic and sociopolitical level to the biological level to comprehensively guide research that can better explain mental health risk in Latinx immigrant youth. CONCLUSIONS: An expanded CST model that incorporates the two highlighted frameworks can elucidate additional mechanisms by which cultural stressors influence mental health risk in Latinx immigrant youth. Such mechanistic work holds the key to effectively reducing mental health disparities for Latinx immigrant youth. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Surgical Proposition of a Slow-Growing Calvarial Exostosis in a Female Patient With a Congenital Iris Cyst of the Anterior Chamber and Mandibular Tori.

We present an unusual case of a woman in her early 50s with a slow-growing calvarial exostosis. Exostoses are bony spurs or osteomas extending outward beyond a bone's surface and may be benign or malignant. Calvarial exostoses are a less common bone tumor that can occur in the population. We present a case of a rare, slow-growing calvarial exostosis with a combination of mandibular tori and a congenital iris cyst. We discuss differentials of this exostosis and different syndromes that may cause it such as hereditary multiple exostoses and Gardner syndrome. The current article aims to spread awareness of this atypical presentation of exostoses and present our institution's surgical proposition for removing a calvarial exostosis to obtain a further histological analysis of its composition. As these masses may commonly be benign, a definitive diagnosis cannot be made through imaging alone to rule out more threatening conditions. We have addressed radiological findings and diagnostic and treatment options offered to the patient. The patient decided not to move forward with removing the mass and would continue to monitor and return should she notice any unusual or acute changes.

Implementation of an Electronic Clinical Decision Support System for the Early Recognition and Management of Dysglycemia in an Inpatient Mental Health Setting Using CogStack: Protocol for a Pilot Hybrid Type 3 Effectiveness-Implementation Randomized Controlled Cluster Trial.

BACKGROUND: Severe mental illnesses (SMIs), including schizophrenia, bipolar affective disorder, and major depressive disorder, are associated with an increased risk of physical health comorbidities and premature mortality from conditions including cardiovascular disease and diabetes. Digital technologies such as electronic clinical decision support systems (eCDSSs) could play a crucial role in improving the clinician-led management of conditions such as dysglycemia (deranged blood sugar levels) and associated conditions such as diabetes in people with a diagnosis of SMI in mental health settings. OBJECTIVE: We have developed a real-time eCDSS using CogStack, an information retrieval and extraction platform, to automatically alert clinicians with National Health Service Trust-approved, guideline-based recommendations for dysglycemia monitoring and management in secondary mental health care. This novel system aims to improve the management of dysglycemia and associated conditions, such as diabetes, in SMI. This protocol describes a pilot study to explore the acceptability, feasibility, and evaluation of its implementation in a mental health inpatient setting. METHODS: This will be a pilot hybrid type 3 effectiveness-implementation randomized controlled cluster trial in inpatient mental health wards. A ward will be the unit of recruitment, where it will be randomly allocated to receive either access to the eCDSS plus usual care or usual care alone over a 4-month period. We will measure implementation outcomes, including the feasibility and acceptability of the eCDSS to clinicians, as primary outcomes, alongside secondary outcomes relating to the process of care measures such as dysglycemia screening rates. An evaluation of other implementation outcomes relating to the eCDSS will be conducted, identifying facilitators and barriers based on established implementation science frameworks. RESULTS: Enrollment of wards began in April 2022, after which clinical staff were recruited to take part in surveys and interviews. The intervention period of the trial began in February 2023, and subsequent data collection was completed in August 2023. Data are currently being analyzed, and results are expected to be available in June 2024. CONCLUSIONS: An eCDSS can have the potential to improve clinician-led management of dysglycemia in inpatient mental health settings. If found to be feasible and acceptable, then, in combination with the results of the implementation evaluation, the system can be refined and improved to support future successful implementation. A larger and more definitive effectiveness trial should then be conducted to assess its impact on clinical outcomes and to inform scalability and application to other conditions in wider mental health care settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT04792268; https://clinicaltrials.gov/study/NCT04792268. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/49548.

Posterior Nasal Nerve Ablation as a Viable Treatment Option for the Primary Symptom of Postnasal Drip.

BACKGROUND: Postnasal drip (PND) syndrome is a prevalent complaint encountered in otolaryngology practices. PND may be refractory to medical therapy, and surgical treatments are complicated by side effects. OBJECTIVE: While posterior nasal nerve (PNN) ablation has demonstrated efficacy for chronic rhinitis overall, we sought to examine the effect of PNN ablation for patients with PND as their primary complaint. METHODS: This is a retrospective case series study of 40 chronic rhinitis (CR) patients with a primary complaint of PND. Included patients had to have failed medical therapy such as anti-cholinergic nasal sprays, reflux treatments, and/or nasal steroids. Primary outcome measures included 22 item Sino-Nasal Outcome Test (SNOT-22) PND component and Total Nasal Symptom Score. Secondary outcome measure was subjective improvement, defined as a > 30% improvement in PND symptoms. RESULTS: Median follow-up was 138 days (interquartile range: 72-193). 72.5% (29/40) of patients reported at least a 30% improvement in PND symptoms. Mean PND SNOT-22 scores were 4.2/5 (SD = 0.8) pre-procedure versus 1.9/5 (SD = 1.3) post-procedure (P = .001). PNN ablation response did not correlate to ipratropium bromide nasal spray response, although younger and non-smoker patients had better response rates. CONCLUSION: This exploratory study of PNN ablation for the primary symptom of PND demonstrates efficacy as assessed by the PND component of SNOT-22 and subjective improvement. These results can be useful in guiding physician-patient discussions in determining treatment options for medically refractory PND.

Dimensions of caregiver strain may partially mediate the relationship between youth symptomology and counseling utilization among Latinxs.

Whether Latinx families use youth mental health services (MHS) depends on complex influences of barriers and facilitators within and outside of the home. This research sought to shed light on caregiver strain as part of the equation focused on parental identification and responses to youth mental health needs. We examined multiple dimensions of caregiver strain as potential mediators between youth mental health symptom severity and psychological counseling utilization. The present sample consisted of 598 Latinx caregivers to youths ages 6-18 who provided information on youth internalizing and externalizing problems, caregiver strain, and youth psychological counseling service utilization within the last year. Our findings suggest that youth symptom severity (internalizing and externalizing problems) was generally positively associated with dimensions of caregiver strain. Youth symptom severity through objective and subjective internalized strain pathways were associated with greater odds of youth MHS utilization. In contrast, youth symptom severity through subjective externalized strain reduced the odds that Latinx caregivers would report utilizing youth MHS. These models only partially mediated the relationship between youth problems and service use. Findings suggest that Latinx caregivers may navigate conflicting sources of strain related to their child's mental health problem severity in ways that may differentially impact the odds that they access youth MHS. Along with addressing structural and systemic barriers to care, utilization of psychological counseling services may also be improved through interventions that help Latinx caregivers view youth services as avenues for addressing caregiver strain and providing psychoeducation that frames externalized strain within a mental health lens.

Modified technique improves efficacy for in-office posterior nasal nerve ablation.

Objectives: Posterior nasal nerve (PNN) ablation is a minimally invasive treatment option for patients with chronic rhinitis. Recent evidence shows that parasympathetic innervation of the nasal cavity is more extensive and there are many fibers posterior to the lateral attachment of the middle turbinate. We describe a modified ablative technique that targets the extensive innervation of the posterior nasal nerves. Methods: Description of the technique and retrospective cohort analysis. In addition to the traditional radiofrequency and cryoablation targets, three additional treatment sites posterior to the middle turbinate were targeted using radiofrequency ablation, as well as one focused treatment posteroinferior to the middle turbinate attachment using cryotherapy ablation. The primary outcome collected was a 30% improvement in overall rhinitis symptoms. Results: Forty-five patients received treatment and completed 3-month follow-up using the modified technique for radiofrequency and cryotherapy PNN ablation. Previously, our institution documented a 64.5% responder rate at 3 months. After introducing the modified technique, the response rate at 3 months significantly improved (64.5% vs. 91.1%, p = .004). Conclusions: This report suggests improved efficacy with implementation of the modified technique for in-office PNN ablation. Given the extensive nature of the post-ganglionic parasympathetic fibers of the nasal cavity which often emerge posterior to the middle turbinate attachment, a modified technique to target these branches should be considered. Prospective randomized studies comparing this modified technique to the traditional technique are needed. Level of Evidence: III.

Multi-Institutional Analysis of Insurance Denial Patterns Within Rhinology.

BACKGROUND: Obtaining insurance approval is a necessary component of healthcare in the United States and denials of these claims have been estimated to result in a loss of 3% to 5% of revenue. OBJECTIVE: Examine the trends in insurance denials for rhinological procedures. METHODS: A retrospective review of deidentified financial data of patients who were treated by participating physicians across 3 institutions from January 1, 2021, to June 30, 2023. The data was queried for rhinological and non-rhinological procedures via CPT codes. Cumulative insurance denials were calculated and stratified by procedure and insurance type. Write-offs were dollar amounts associated with final denials. RESULTS: A sample of 102,984 procedures and visits revealed a final denial rate between 2.2% and 2.9% across institutions (p = .72). The top three rhinological procedures for final write-offs were: nasal endoscopy (16.24%, $111,836.87), nasal debridement or polypectomy (6.48%, $79,457.51), and destruction of intranasal lesion (2.11%, $56,932.20). The write-off percentage for each procedure was highest among commercial insurance payers as opposed to Medicare or Medicaid. CONCLUSION: Final denial rates of rhinology procedures ranged between 2% and 3%. Common procedures such as nasal endoscopy and nasal debridement are among the highest written-off procedures. Insurance denials can lead to notable revenue loss. Rhinology practices must continue to remain knowledgeable of the changes and effects of insurance reimbursement on their practice.

Factor structure, internal consistency, and construct validity of the Caregiver strain questionnaire in Latinx families.

Caregiver strain or stress directly related to caring for a youth with emotional and/or behavioral problems may be an important and understudied cultural factor associated with mental health disparities among Latinx families. Caregiver strain is a highly relevant construct for research questions focused on the identification of youth's mental health needs, family-level impacts of youth mental health problems, and utilization of youth mental health services. Unfortunately, there is a dearth of research on measures of caregiver strain and the psychometric properties of existing measures in Latinx samples. This study examined the structural and construct validity of the English version of the Caregiver Strain Questionnaire (CGSQ) with a sample of United States-based Latinx caregivers of youths ages 6-18 (N = 598). Confirmatory factor analysis showed that the original three-factor model of caregiver strain was evidenced in this sample. Internal consistency analyses and a poor factor loading led to the elimination of one item. The factor structure held after item removal. Significant associations between each dimension of caregiver strain with youth internalizing/externalizing symptom severity and utilization of youth mental health services provided evidence of construct validity (i.e., psychological counseling, telepsychology, parenting classes). Results provide important evidence of the psychometric properties of the English CGSQ in a Latinx sample and support its use in future research aimed at unpacking mental health disparities among Latinx youth and families. Researchers should translate and validate the CGSQ in Spanish to increase the utility of this measure for research with Latinx families.

Severe epistaxis after posterior nasal nerve ablation requiring surgical intervention: A multi-center case series.

KEY POINTS: Severe epistaxis occurs in 2% of PNN ablation cases, independent of method or device type. Major epistaxis requiring intervention after PNN ablation can occur on average 20 days post-procedure.

Temporal Orientation and the Association Between Adverse Life Events and Internalizing Symptoms in Vietnamese American and European American Adolescents.

Adverse life events are associated with greater internalizing symptoms. However, prior research has identified cross-cultural variation in whether and to what extent factors amplify or buffer the impact of these stressors. Broadly defined as the tendency to focus on past, present, or future events, temporal orientation is a dispositional factor that is culturally influenced and may explain variance in internalizing symptoms following adverse events. Cultural congruence, or the degree to which a factor is considered normative in an individual's culture, may be an important explanation of variation in levels of risk. The current study examines how culturally congruent temporal orientation differentially impacts the relation between adverse life events and internalizing symptoms in a longitudinal sample of 10th and 11th grade Vietnamese American (n = 372) and European American adolescents (n = 304). Results indicated that Vietnamese American adolescents endorsed significantly higher levels of past and present, but not future, temporal orientation compared to European American adolescents. Among both Vietnamese and European American adolescents, past temporal orientation was positively associated with internalizing symptoms and adverse life events. Findings also demonstrated that the influence of present temporal orientation on the relation between adverse life events and internalizing symptoms was further moderated by ethnicity, such that present temporal orientation buffered risk for negative outcomes among European Americans but not Vietnamese Americans. These data highlight the importance of measuring and testing specific dimensions of culturally relevant processes when considering responses to adverse life events.

New Medical Device and Therapeutic Approvals in Otolaryngology: State of the Art Review of 2022.

Objective: To review new drugs and devices relevant to otolaryngology approved by the Food and Drug Administration (FDA) in 2022. Data Sources: Publicly available FDA data on drugs and devices approved in 2022. Review Methods: A preliminary screen was conducted to identify drugs and devices relevant to otolaryngology. A secondary screen by members of the American Academy of Otolaryngology-Head and Neck Surgery's (AAO-HNS) Medical Devices and Drugs Committee differentiated between minor updates and new approvals. The final list of drugs and devices was sent to members of each subspecialty for review and analysis. Conclusion: A total of 1251 devices and 37 drugs were identified on preliminary screening. Of these, 329 devices and 5 drugs were sent to subspecialists for further review, from which 37 devices and 2 novel drugs were selected for further analysis. The newly approved devices spanned all subspecialties within otolaryngology. Many of the newly approved devices aimed to enhance patient experience, including over-the-counter hearing aids, sleep monitoring devices, and refined CPAP devices. Other advances aimed to improve surgical access, convenience, or comfort in the operating room and clinic. Implications for Practice: Many new devices and drugs are approved each year to improve patient care and care delivery. By staying up to date with these advances, otolaryngologists can leverage new innovations to improve the safety and quality of care. Given the recent approval of these devices, further studies are needed to assess long-term impact within the field of otolaryngology.

Multidisciplinary Management of Total Anterior Skull Base Osteoradionecrosis.

Cases of delayed osteoradionecrosis (ORN) of the anterior skull base have unique management considerations. A 59-year-old woman with a history of basaloid squamous cell carcinoma of the sinonasal cavity with intracranial extension through the anterior skull base developed delayed radiation sequelae of anterior skull base ORN. She underwent an initial endoscopic resection in 2011 with persistent disease that required an anterior craniofacial resection with left medial maxillectomy in 2012. She had a radiologic gross total resection with microscopic residual disease at the histologic margins prompting adjuvant chemoradiotherapy to target volume doses of 66 to 70 Gy with concurrent cisplatin chemotherapy. She subsequently developed an intracranial abscess in 2021 along the anterior skull base that required a craniotomy and endoscopic debridement. Despite aggressive surgical and medical therapy, she had persistent intracranial infections and evidence of skull base ORN. She ultimately underwent a combined open bifrontal craniotomy and endoscopic resection of the necrotic frontal bone and dura followed by an anterolateral thigh free flap reconstruction with titanium mesh cranioplasty. The patient recovered well from a microvascular free-tissue reconstruction without concern for cerebrospinal fluid leak. Anterior skull base reconstruction with free tissue transfer is a commonly utilized method for oncologic resections. Here, an anterolateral free flap was effectively used to treat an anterior skull base defect secondary to a rare indication of skull base ORN.

Postnasal drip and chronic cough in patients with chronic rhinitis treated with temperature-controlled radiofrequency neurolysis.

OBJECTIVE: To evaluate the contribution of postnasal drip (PND) and chronic cough (CC) to symptoms of patients with chronic rhinitis treated with temperature-controlled radiofrequency (TCRF) neurolysis of the posterior nasal nerve (PNN), and correlate PND and CC scores with components of the reflective total nasal symptom score (rTNSS). METHODS: Pooled data from three prospective studies: two single-arm studies and the index active treatment arm of a randomized controlled trial. Adult patients with baseline rTNSS ≥6 were treated with TCRF neurolysis at nonoverlapping regions of the PNN. PND and CC symptoms were evaluated on a 0 (none) to 3 (severe) scale. RESULTS: Data from 228 patients (57.9% women, 42.1% men) were included. The mean baseline rTNSS was 8.1 (95% confidence interval [CI], 7.8-8.3), which decreased to 3.2 (95% CI, 2.9-3.5) at 6 months. At baseline, 97.4% of patients had PND and 80.3% had CC. Median baseline PND and CC symptom scores were 3 (interquartile range [IQR], 2-3) and 2 (IQR, 1-2), respectively. At 6 months, this decreased to 1 (IQR, 0-2) and 0 (IQR, 0-1), respectively, showing significant improvement from baseline (both p < 0.001). Spearman correlation coefficients with components of rTNSS (rhinorrhea, congestion, itching, sneezing) were 0.16 to 0.22 for CC and 0.19 to 0.46 for PND, indicating only a weak to moderate correlation. CONCLUSION: PND and CC contribute to the symptomatology of chronic rhinitis and are significantly improved after TCRF neurolysis of the PNN. The inclusion of PND and CC symptoms in a chronic rhinitis assessment instrument could provide important additional information for the characterization of the disease state and outcomes after any therapeutic treatment.

Optimization of diagnostic and procedural codes to identify patients with acute invasive fungal sinusitis.

KEY POINTS: Acute invasive fungal sinusitis (IFS) is a rare disease with high mortality There is no designated International Classification of Diseases code for IFS We propose a novel method to identify IFS using optimized codes complemented by medications.

Air Quality, Allergic Rhinitis, and Asthma.

This review article highlights air pollution as a critical global health concern with emphasis on its effects and role in the development and exacerbation of upper airway and lower airway disease with a focus on allergic rhinitis and asthma. This review underscores the World Health Organization's recognition of air pollution as the biggest environmental threat to human health. It discusses the various components and categories of air pollutants and the evidence-based effects they have on asthma and allergic rhinitis, ranging from pathogenesis to exacerbation of these conditions across various age groups in different geographic locations.