Smell Changes and Efficacy of Nasal Theophylline (SCENT) irrigation: A randomized controlled trial for treatment of post-viral olfactory dysfunction.

OBJECTIVE: To evaluate the efficacy and safety of intranasal theophylline saline irrigation on olfactory recovery in patients with post-viral olfactory dysfunction (PVOD). METHODS: Between May 2019 and April 2020, we conducted a double-blinded, placebo-controlled randomized clinical trial of adults with 6-36 months of PVOD. Patients were randomized to nasal theophylline saline irrigation or placebo saline irrigation twice a day for 6 weeks. The primary outcome was the Global Rating of Smell Change. Secondary outcomes were changes in the University of Pennsylvania Smell Identification Test (UPSIT) and Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS). RESULTS: Twenty-two patients (n = 12, theophylline; n = 10, placebo) completed the study. Slightly more patients in the theophylline group (33%) reported improved smell compared to the placebo group (30%, difference 3.3%, 95% CI -35.6% to 42.3%). The median differences in pre- and post-treatment UPSIT and QOD-NS change between the two groups were 1 (95% CI -3 to 5) and -10 (95% CI -15 to -4), respectively in favor of theophylline. Three patients receiving theophylline and 2 receiving placebo had clinically meaningful improvements on the UPSIT (difference 5%, 95% CI -30% to 40%). There were no adverse events, and serum theophylline levels were undetectable in 10/10 patients. CONCLUSIONS: While safe, there were no clinically meaningful differences in olfactory change between the two groups except for olfaction-related quality of life, which was better with theophylline. The imprecise estimates suggest future trials will need substantially larger sample sizes or treatment modifications, such as increasing the theophylline dose, to observe larger treatment effects.

Hazardous sound outputs of white noise devices intended for infants.

OBJECTIVES: To measure the sound intensity of popular infant white noise machines and Apple iPhone applications (apps) as they vary with volume setting and distance, and compare these output levels with current National Institute for Occupational Safety and Health (NIOSH) noise exposure threshold recommendations. METHODS: A total of eight infant white noise machines and six iPhone applications were included in the study based on product rating, number of ratings, and cost. The NIOSH Sound Level Meter application through the Apple App Store was used to measure output levels in A-weighted decibels (dBA). Each device was tested at its lowest and highest volume setting and at speaker-to-microphone distances simulating placement within a crib (10 cm), just outside of a crib rail (30 cm), and on a nightstand across the room (100 cm). RESULTS: At the minimum volume setting, no device exceeded the NIOSH recommended noise exposure threshold of 85 dBA at any distance tested. At maximum volume setting, nine out of fourteen (64.3%) devices exceeded output levels of 85 dBA at a speaker-to-microphone distance of 10 cm. No device exceeded the recommended threshold at its maximal volume when placed 30 cm or 100 cm away. CONCLUSION: Excessive white noise exposure has the potential to lead to noise-induced hearing loss and other adverse health effects in the neonatal and infant population. We recommend conservative use of white noise machines and apps by avoiding maximal volume setting and placing any device well outside of the crib or at least 30 cm away from the child. To promote safe use of white noise devices, future studies are needed to fully understand the association between early noise exposure and hearing loss in infants.

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.

Diagnostic dilemmas of mechanical restriction of the medial rectus: A case report.

BACKGROUND: Due to the proximity of the maxillary sinus and ethmoid sinuses to the orbit, inflammatory processes that originate in the sinonasal region have the potential to extend into the orbit. OBJECTIVE: We presented a case of ptosis and restrictive strabismus of the medial rectus muscle. METHODS: A case report with a literature review of possible diagnoses. RESULTS: Biopsy, imaging, and laboratory evaluation by otolaryngology, ophthalmology, and rheumatology services were unable to identify the cause of the fibrosis after 22 months of follow-up. A response to oral steroids indicated an inflammatory process. CONCLUSION: Unilateral mechanical restriction of the medial rectus muscle is a rare complication of nasal disease. Inflammatory processes and iatrogenic injury are known to cause fibrosis of surrounding tissue. We presented a unique case of medial rectus fibrosis that did not meet the diagnostic criteria of recognized etiologies.

Autoimmune-related nasal septum perforation: A case report and systematic review.

BACKGROUND: Inflammatory injury of nasal respiratory mucosa is a common feature of multisystem autoimmune disease. Certain autoimmune disorders are associated with nasal septum perforation (NSP). We performed a systematic review of the literature to better understand the association of NSP with specific autoimmune disorders. This is a case report of a 29-year-old woman with a history of arthralgia, autoreactive antibody titers, platelet dysfunction, and NSP. The constellation of symptoms and potential familial involvement indicated that the NSP in this patient was an early sign of an autoimmune disorder, an unknown autoimmune disorder, or a known disease with incomplete penetrance. METHODS: A systematic review of the literature was performed by two independent reviewers. Relevant articles were reviewed, and data that pertained to autoimmune-related NSP were extracted and analyzed. RESULTS: Overall, 140 cases of autoimmune-associated NSPs were reported. Granulomatosis with polyangiitis (48%), relapsing polychondritis (26%), and cocaine-induced midline lesions (15%) constituted 89.3% of the reported cases. CONCLUSION: NSP is a potential sign of systemic disease. The identification of an NSP, especially in the context of other unexplained symptoms or workup suggestive of an autoimmune disorder, should prompt clinical evaluation for multisystem autoimmune disease with consideration of granulomatosis with polyangiitis, relapsing polychondritis, or cocaine-induced midline lesions.

Penetrating Ocular Trauma from a Bean Bag Gun: A Case Report and Review of Less-Lethal Force and Their Consequences.

Although bean bag guns are considered a "less-lethal" form of law enforcement, these blunt projectiles have risk. The purpose of this study was to perform a literature review of morbidity and mortality associated with less-lethal munitions and present a case report of a bean bag injury leading to a traumatic globe evisceration and skull base fracture. Patients presenting with bean bag gun associated injuries warrant a high clinical suspicion for injury to deeper structures.

Avascular necrosis after oral corticosteroids in otolaryngology: Case report and review of the literature.

OBJECTIVE: In this report, we present a rare case of avascular necrosis (AVN) in an otherwise healthy 42-year-old male patient treated with low dose oral corticosteroids for his bronchitis. A systematic review of the literature related to AVN and corticosteroids was performed. CASE REPORT: Forty-two-year-old male with no underlying conditions predisposing him to AVN who had been treated four years before for chronic bronchitis with two courses of oral prednisone therapy presented with bilateral AVN of the hips. METHODS: An OVID database search of the terms "low total dose," "corticosteroids," and "avascular necrosis" was performed. Two PubMed searches of various permutations of "low-dose," "corticosteroids," "avascular necrosis," and "osteonecrosis" were also performed. Results were then narrowed to relevant articles. RESULTS: Median total dose of oral corticosteroids in patients with AVN in reviewed articles was 981 mg, with lowest reported association at 105 mg. Median duration of therapy was 16 days with shortest course of six days. CONCLUSION: There is emerging data linking AVN with corticosteroid doses previously thought to be safe. After reviewing the relevant literature, it is our consensus to inform all patients regarding AVN before oral corticosteroid use.

Update on endoscopic endonasal resection of skull base meningiomas.

BACKGROUND: The objective of this work was to report success rates as well as potential obstacles in transnasal endoscopic resection of anterior skull base meningiomas. METHODS: The study design was a case series with chart review at tertiary referral centers in South Australia and New Zealand. The patients were 37 consecutive patients who underwent endoscopic resection of skull-base meningiomas between 2004 and 2013. Review of patient charts and operative details were performed. Outcomes including complications are reported. RESULTS: Eighty-four percent of patients were women. There were 28 primary and 9 revision cases. Tumor locations were as follows: 14 olfactory groove/subfrontal; 12 planum/jugum sphenoidale; 7 tuberculum sellae; 3 clinoidal; and 1 clival. Vision change was the most common presenting symptom. Mean tumor volume was 33.68 cm(3) , mean diameter was 2.78 cm. Average operating times decreased with an initial learning curve and then plateaued. Primary tumors larger than 60 cm(3) took an average of 10 hours to resect. Gross total removal was achieved in 29 patients. There were no perioperative deaths. Two deaths occurred within 1 year of surgery. Postoperative cerebrospinal fluid (CSF) leaks occurred in 13 patients. Seventy-five percent of patients presenting with visual loss reported visual improvement. Of the 29 patients considered to have had complete resection at surgery, one was found to have residual disease on a postoperative magnetic resonance imaging (MRI) and another one later developed radiological evidence of recurrence. CONCLUSION: Using a 2-team approach, meningiomas of the skull base were successfully removed via an intranasal endoscopic technique. Although complete resection is typically possible even with large tumors, the lengthy resection required time for tumors larger than 60 cm(3) (diameter ≥4 cm) may obviate some of the advantages of this approach. The rate of postoperative CSF leak decreases when a synthetic dural substitute is added but does not approach zero.

Nasopharyngeal acid reflux and Eustachian tube dysfunction in adults.

OBJECTIVE: This study aimed to evaluate the relationship between nasopharyngeal pH and Eustachian tube dysfunction (ETD) in adults. STUDY DESIGN: Unmatched case-control study. METHODS: Forty-one subjects, 20 adults with a diagnosis of ETD and 21 healthy adults as controls, were enrolled from an outpatient clinic. All subjects had a Dx-pH probe placed near the torus tubarius in the posterior nasopharynx for 24 hours. The pH values were recorded every 0.5 second. Decreases in pH were considered as reflux events if the pH dropped below 5.5. RESULTS: The average nasopharyngeal pH value was 6.90 (range, 5.33-7.73) in the subjects with ETD and 7.07 (range, 5.99-7.94) in the controls. The difference between the 2 groups was not statistically significant (P = .30). The ETD group, on average, had a higher number of nasopharyngeal reflux events (2.3 +/- 1.6 vs 0.8 +/- 1.2, respectively; P = .002) and higher reflux finding score (3.6 +/- 2.7 vs 0.4 +/- 1.4, respectively; P < .00 I) than the control group. CONCLUSION: By using a novel pH probe that allows detection of acidity in a nonliquid environment, a comparison of nasopharyngeal pH between control patients and those with ETD was performed. Eustachian tube dysfunction was more likely to be associated with a higher number of nasopharyngeal reflux events and higher reflux finding score. Nasopharyngeal reflux may have a role in the pathogenesis of ETD.

Inferior turbinate hypertrophy: review and graduated approach to surgical management.

BACKGROUND: Surgical techniques for managing inferior turbinate hypertrophy (ITH) vary widely and have evolved substantially in the past four decades as new technologies have emerged. METHODS: Literature review. RESULTS: Inferior turbinate (IT) procedures can be categorized as: simple turbinate outfracture; turbinoplasty techniques such as extramucosal destruction, and submucosal tissue removal; and extramural turbinate resection (partial or complete). Each of these approaches has advantages and drawbacks. Considerations for technique selection include clinical setting (in-office versus operating room), cost of the devices used, efficacy of the procedure to relieve nasal obstruction, and minimizing postoperative complications such as nuisance bleeding, adhesion formation, and crusting. CONCLUSION: There are a variety of contemporary surgical techniques used for IT reduction. This article highlights the available literature and gaps in current knowledge. A graduated approach to the management of ITH will be presented.

Sinonasal respiratory epithelial adenomatoid hamartomas: series of 51 cases and literature review.

BACKGROUND: Respiratory epithelial adenomatoid hamartomas (REAHs) are rare, benign glandular proliferations of the nasal cavity, paranasal sinuses, and nasopharynx. This study aimed to expand our understanding of this entity by presenting a series of REAHs combined with a review of the pertinent literature. METHODS: A retrospective review was performed on all patients with a diagnosis of REAH from 2002 to 2011. Data were collected with respect to age, gender, clinical presentation, imaging, histopathology, treatment, and outcome. Because olfactory cleft expansion by imaging evaluation has been reported to suggest REAH, maximum olfactory cleft (MOCs) widths were also measured. RESULTS: Fifty-one cases of REAH included 37 male (72.5%) and 14 female subjects (27.5%) with a mean age of 58.4 years. Headache, nasal obstruction, rhinorrhea, and hyposmia were the most common presenting symptoms. Although 35(68.6%) were associated with concurrent inflammatory pathology, 16 (31.4%) presented as isolated lesions of the nasal cavity. Enlargement of MOCs was evident on computed tomography, with mean MOCs of 8.64 and 9.4 mm, in the coronal/axial planes, respectively. There were no statistically significant differences between MOCs of isolated (7.96 mm) versus MOCs of associated (9.63 mm) lesions (p = 0.25). Forty-nine were treated with endoscopic resection without evidence of recurrence after a mean follow-up of 27.2 months. CONCLUSION: REAHs are rare sinonasal lesions that may appear as localized, isolated masses or more diffuse when in conjunction with other inflammatory processes. Irrespective of clinical presentation, endoscopic removal appears to be curative. Differentiation from more aggressive lesions is paramount to avoid unnecessarily radical surgery for an otherwise benign process.

Use of the Hadad-Bassagasteguy flap for repair of recurrent cerebrospinal fluid leak after prior transsphenoidal surgery.

The Hadad-Bassagasteguy vascularized nasoseptal pedicled flap (HBF) is an effective technique for reconstruction of skull base defects with low incidence of postoperative cerebrospinal fluid (CSF) leak. Advanced planning is required as posterior septectomy during transsphenoidal surgery can preclude its use due to destruction of the vascular pedicle. We present four cases in which the HBF was successfully used to repair recurrent CSF leaks despite prior posterior septectomy and transsphenoidal surgery. A retrospective chart review was performed on all patients who developed recurrent CSF leak after transsphenoidal surgery over a 7-year period (2006-2013). Data were collected regarding demographics, clinical presentation, intraoperative findings, and surgical outcomes. Four patients who developed recurrent CSF drainage after transsphenoidal surgery were managed with HBF reconstruction during the study period. Two were men and two were women with a mean age of 37 years (range, 24-48 years). All had previously undergone resection of a pituitary macroadenoma via a transsphenoidal approach, with intraoperative CSF leaks repaired using multilayered free grafts. Recurrent CSF rhinorrhea arose 0.37-12 months (mean, 2.98 months) after the initial pituitary surgery. Active CSF drainage could be visualized intraoperatively with posterior septal perforations present. The HBF was successfully used in all cases, with no evidence of recurrent CSF leak after a mean follow-up of 2.35 years. The HBF may be salvaged for repair of recurrent CSF leaks even in the context of prior posterior septectomy and transsphenoidal surgery. However, longer follow-up is necessary to determine the long-term efficacy of this procedure in such revision cases.

Intracranial mucocele formation in the context of longstanding chronic rhinosinusitis: A clinicopathologic series and literature review.

Chronic rhinosinusitis (CRS) can lead to serious long-term adverse sequelae, particularly if left untreated. The aim of this study was to describe a series of intracranial mucoceles (ICMs) that arose in the context of longstanding CRS combined with a review of the pertinent literature. A retrospective chart review was performed on all patients who developed ICMs in association with CRS between 2003 and 2012. The clinical presentation, radiographic features, surgical approach, intraoperative findings, and patient outcome were examined in the context of a literature review. Sixty-five cases of mucoceles were identified in patients with a history of CRS, of which seven (10.8%) were intracranial. Five patients were men and two were women with a mean age of 42.1 years. Headache, facial pressure, retro-orbital pain, and visual disturbances were the most common presenting symptoms. Five of the seven had previously undergone sinonasal surgery. Imaging studies showed ICMs involving the anterior cranial fossa, two of which were bilateral. Latency between onset of CRS and ICM detection ranged from 3 to 19 years (mean, 9.4 years). All patients underwent endoscopic transnasal drainage with three also requiring a concurrent, open neurosurgical procedure to access the intracranial component. There were no postoperative complications, and no recurrences were observed after a mean follow-up of 2.7 years. ICMs presenting as delayed complications of CRS are uncommon and constitute a surgical challenge. Open, external skull base approaches used in conjunction with transnasal endoscopic drainage procedures may be necessary to achieve successful management of this rare condition.

Accuracy of tinnitus pitch matching using a web-based protocol.

OBJECTIVES: We investigated the accuracy of a web-based protocol for tinnitus frequency matching compared to that of tinnitus pitch matching performed by an audiologist using an audiometer in an anechoic chamber. METHODS: Twenty subjects underwent tinnitus frequency-matching in a random order using an audiometer in an anechoic chamber and using web-based software with a multiple-choice protocol in octave or half-octave steps from 250 Hz to 12,000 Hz and a slider in 25-Hz steps from 20 to 20,000 Hz. Octave challenge testing was performed. The participants were asked to indicate which protocol resulted in the closest match to their tinnitus frequency. RESULTS: The median tinnitus frequency was 6,000 Hz (range, 2,000 to 12,000 Hz) with use of the audiometer and self-directed multiple-choice protocol. With the slider, the median frequency was 5,925 Hz (range, 1,850 to 16,000 Hz). The patients with a tinnitus frequency higher than 12,000 Hz experienced a greater level of satisfaction when using the computer-based slider system. Five patients experienced octave confusion with self-directed multiple-choice tinnitus matching that was corrected accurately after the octave challenge step. CONCLUSIONS: A web-based protocol for tinnitus frequency matching is as accurate as a standard audiometric protocol. An octave challenge test might be necessary for patient-directed tinnitus frequency matching.

Detecting nasopharyngeal reflux: a novel pH probe technique.

OBJECTIVES: We sought to ascertain the normal pH values in the aerosolized environment of the nasopharynx in healthy subjects and utilize a novel pH probe that allows measuring acidity in a nonliquid environment. METHODS: Between November 2009 and February 2011, healthy volunteers without a history of reflux or eustachian tube dysfunction were enrolled in the prospective study. A total of 20 subjects had a Dx-pH Measurement System Probe (Respiratory Technology Corp) placed near the torus tubarius. The pH probe records the pH throughout the 24-hour study. A pH below 5.5 while the subject was upright or below 5.0 while the subject was supine was used as a criterion to determine a reflux event. Recording was stopped during meals. RESULTS: For normal individuals with no history of reflux or eustachian tube dysfunction, the pH values obtained from the nasopharynx ranged from 6.10 to 7.92. The average pH was 7.03 (SD, 0.67). Eight subjects (40%) had at least 1 reflux event during the 24-hour pH study. CONCLUSIONS: By utilizing a novel self-condensing pH probe, we were able to perform a 24-hour pH study in the nasopharynx of 20 healthy individuals. In our study, the average pH for individuals without symptomatic reflux or eustachian tube dysfunction was 7.03. Interestingly, 8 control subjects had at least 1 episode of pH below 5.5 while awake or below 5.0 while asleep, which was considered to be a reflux event in our study.

Craniocervical necrotizing fasciitis resulting from dentoalveolar infection.

Craniocervical necrotizing fasciitis is a rare infectious process that can be life-threatening. It most commonly occurs as a result of a severe dentoalveolar infection. This article reviews the diagnosis, microbiology, anatomy, and pathophysiology behind this infectious process; the incidence; and the recommended treatments and therapies. It is hoped that this article provides the treating health care provider with an up-to-date review of this serious infectious process.

Head and neck manifestations and quality of life of patients with ectodermal dysplasia.

OBJECTIVES: Ectodermal dysplasias (EDs) are a group of genetic disorders characterized by deficient ectodermal and mesodermal development. Studies examining resultant otolaryngologic issues are few. The objectives of this study were to delineate the head and neck manifestations and quality of life in EDs. STUDY DESIGN AND SETTING: For 75 individuals, comprehensive histories were taken and otolaryngologic examinations were performed, and subjects rated their otolaryngologic symptom severity. A validated quality of life instrument (SF-8) was administered. RESULTS: The majority of subjects had a diagnosis of hypohidrotic ED (72%). Otolaryngologic conditions included otitis media (28%), cerumen impaction (48%), nasal obstruction/crusting (51%), heat intolerance (76%), and eczema (39%). Physical findings included peg teeth/hypodontia (76%), alopecia (41%), nasal crusting (41%), and saddle nose deformity (44%). Quality of life scores were generally high. Overall, health was rated "good to excellent" by 87 percent. CONCLUSION: Patients with ED frequently experience significant otolaryngologic symptoms, although most patients report a good quality of life. SIGNIFICANCE: A greater understanding of the otolaryngologic issues in ED should help facilitate diagnosis and improve management.

Rhinologic manifestations of ectodermal dysplasia.

BACKGROUND: The Ectodermal Dysplasias (ED) are a group of uncommon genetic disorders characterized by deficient development of tissues derived from ectoderm and mesoderm. Abnormalities of the respiratory epithelium prevent normal mucociliary function. We explored the prevalence and severity of sinonasal features in affected individuals. METHODS: Thirty-four subjects with ED were evaluated. A focused history and thorough nasal examination including flexible nasopharyngoscopy were performed. Patients and caregivers rated the severity of rhinologic symptoms with a standard scale. Standardized smell tests were also performed. RESULTS: The study included 21 males and 13 females whose mean age was 18.8 years (range, 4 months to 85 years). The majority (79%) had Hypohydrotic ED. Nearly half of the individuals evaluated reported moderate to severe nasal obstruction. Allergic symptoms were present in 44% of individuals whereas 41% had a history of sinusitis. Nasal concretions were significantly more troublesome in those aged 15 and under (p = 0.028). Eighteen percent had undergone sinonasal surgery. On examination, normal intranasal structures were identifiable in all patients. However, dry mucosae, prominent crusts, and concretions were found in most (79%). A deviated nasal septum was present in 23% of individuals and a saddle nose deformity in 18. Smell tests were normal for age in all subjects. CONCLUSION: Rhinologic issues are prevalent and problematic in individuals with ED. Management should focus on humidification, nasal debridement, and tailored therapy for allergic rhinitis and sinusitis. Increased awareness of the sinonasal concerns in ED will facilitate diagnosis and improve the care of these patients.