Pediatric Inferior Turbinate Hypertrophy: Diagnosis and Management. A YO-IFOS Consensus Statement.

OBJECTIVE: Pediatric inferior turbinate hypertrophy (PedTH) is a frequent and often overlooked cause or associated cause of nasal breathing difficulties. This clinical consensus statement (CCS) aims to provide a diagnosis and management framework covering the lack of specific guidelines for this condition and addressing the existing controversies. METHODS: A clinical consensus statement (CCS) was developed by a panel of 20 contributors from 7 different European and North American countries using the modified Delphi method. The aim of the CCS was to offer a multidisciplinary reference framework for the management of PedTH on the basis of shared clinical experience and analysis of the strongest evidence currently available. RESULTS: A systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria was performed. From the initial 96 items identified, 7 articles were selected based on higher-evidence items such as randomized-controlled trials, guidelines, and systematic reviews. A 34-statement survey was developed, and after three rounds of voting, 2 items reached strong consensus, 17 reached consensus or near consensus, and 15 had no consensus. CONCLUSIONS: Until further prospective data are available, our CCS should provide a useful reference for PedTH management. PedTH should be considered a nasal obstructive disease not necessarily related to an adult condition but frequently associated with other nasal or craniofacial disorders. Diagnosis requires clinical examination and endoscopy, whereas rhinomanometry, nasal cytology, and questionnaires have little clinical role. Treatment choice should consider the specific indications and features of the available options, with a preference for less invasive procedures. LEVEL OF EVIDENCE: 5 Laryngoscope, 134:1437-1444, 2024.

Clinical effectiveness of septoplasty versus medical management for nasal airways obstruction: multicentre, open label, randomised controlled trial.

OBJECTIVE: To assess the clinical effectiveness of septoplasty. DESIGN: Multicentre, randomised controlled trial. SETTING: 17 otolaryngology clinics in the UK's National Health Service. PARTICIPANTS: 378 adults (≥18 years, 67% men) newly referred with symptoms of nasal obstruction associated with septal deviation and at least moderate symptoms of nasal obstruction (score >30 on the Nasal Obstruction and Symptom Evaluation (NOSE) scale). INTERVENTIONS: Participants were randomised 1:1 to receive either septoplasty (n=188) or defined medical management (n=190, nasal steroid and saline spray for six months), stratified by baseline symptom severity and sex. MAIN OUTCOME MEASURES: The primary outcome measure was patient reported score on the Sino-Nasal Outcome Test-22 (SNOT-22) at six months, with 9 points defined as the minimal clinically important difference. Secondary outcomes included quality of life and objective nasal airflow measures. RESULTS: Mean SNOT-22 scores at six months were 19.9 (95% confidence interval 17.0 to 22.7) in the septoplasty arm (n=152, intention-to-treat population) and 39.5 (36.1 to 42.9) in the medical management arm (n=155); an estimated 20.0 points lower (better) for participants randomised to receive septoplasty (95% confidence interval 16.4 to 23.6, P<0.001, adjusted for baseline continuous SNOT-22 score and the stratification variables sex and baseline NOSE severity categories). Greater improvement in SNOT-22 scores was predicted by higher baseline symptom severity scores. Quality of life outcomes and nasal airflow measures (including peak nasal inspiratory flow and absolute inhalational nasal partitioning ratio) improved more in participants in the septoplasty group. Readmission to hospital with bleeding after septoplasty occurred in seven participants (4% of 174 who had septoplasty), and a further 20 participants (12%) required antibiotics for infections. CONCLUSIONS: Septoplasty is a more effective intervention than a defined medical management regimen with a nasal steroid and saline spray in adults with nasal obstruction associated with a deviated nasal septum. TRIAL REGISTRATION: ISRCTN Registry ISRCTN16168569.

One year into the COVID-19 pandemic: What do we know so far from studies assessing risk and mitigation of droplet aerosolisation during endonasal surgery? A systematic review.

OBJECTIVES: As we pass the anniversary of the declaration of a global pandemic by the World Health Organisation, it invites us to reflect upon the inescapable changes that coronavirus has wrought upon ENT and, in particular, rhinological practice. As it remains unclear when we will emerge from the shadow of COVID-19, a critical analysis of the evidence base on both the assessment and mitigation of risk is vital for ENT departments worldwide. This article presents a systematic review of the literature examining articles which consider either the quantification of risk or strategies to mitigate risk specifically in the setting of rhinological surgery. DESIGN: Systematic literature review. RESULTS: The literature search yielded a total of 3406 returns with 24 articles meeting eligibility criteria. A narrative synthesis stratified results into two broad themes: (1) those which made an assessment as to the aerosolisation of droplets during sinus surgery, further sub-divided into work which considered macroscopically visible droplets and that which considered smaller particles; (2) and those studies which examined the mitigation of this risk. CONCLUSION: Studies considering the aerosolisation of both droplets and smaller particles suggest endonasal surgery carries significant risk. While results both highlight a range of innovative adjunctive strategies and support suction as an important intervention to reduce aerosolisation, appropriate use of personal protective equipment (PPE) should be considered mandatory for all healthcare professionals involved in rhinological surgery. Studies have demonstrated that close adherence to PPE use is effective in preventing COVID-19 infection.

Analysis of Droplet Splatter Patterns During Coblation Tonsil Surgery in the Covid-19 Pandemic.

OBJECTIVES: To assess droplet splatter around the surgical field and surgeon during simulated Coblation tonsil surgery to better inform on mitigation strategies and evaluate choice of personal protective equipment. METHODS: This was an observational study performed using a life-size head model to simulate tonsil surgery and fluorescein-soaked strawberries to mimic tonsils. The Coblation wand was activated over the strawberries for 5 minutes. This was repeated 5 times with 2 surgeons (totalling 10 data sets). The presence of droplet around the surgical field and anatomical subsites on the surgeon was assessed in binary fashion: present or not present. The results were collated as frequency of droplet detection and illustrated as a heatmap; 0 = white, 1-2 = yellow, 3-4 = orange, and 5 = red. RESULTS: Fluorescein droplets were detected in all 4 quadrants of the surgical field. The frequency of splatter was greatest in the upper (nearest to surgeon) and lower quadrants. There were detectable splatter droplets on the surgeon; most frequently occurring on the hands followed by the forearm. Droplets were also detected on the visor, neck, and chest albeit less frequently. However, none were detected on the upper arms. CONCLUSION: Droplet splatter can be detected in the immediate surgical field as well as on the surgeon. Although wearing a face visor does not prevent splatter on the surgical mask or around the eyes, it should be considered when undertaking tonsil surgery as well as a properly fitted goggle. LEVEL OF EVIDENCE: 5.

Endoscopic balloon dilatation of the olfactory cleft - a feasibility study of a novel technique in cadavers.

OBJECTIVE: Smell dysfunctions are common with almost 20% percent of the population affected. There are no interventional solutions for these patients. The aim of this study is to investigate the feasibility and security of the balloon dilatation technique. METHODS: This paper describes interventional steps and determines the feasibility and safety of endoscopic olfactory cleft dilatation via balloon device. We included 10 nasal cavities in the study and dilated olfactory cleft areas via balloon device. RESULTS: We could smoothly perform the procedure and did not observe any fractures on the skull base or olfactory cleft of the cadavers after dilatation. CONCLUSIONS: A combination of this intervention with medical treatments can be promising for smell dysfunctions.

Droplet and bone dust contamination from high-speed drilling during mastoidectomy.

OBJECTIVES: The aim of this study was to examine contamination from otolaryngologic procedures involving high-speed drilling, specifically mastoid surgery, and to assess the adequacy of PPE in such procedures. DESIGN AND SETTING: Mastoid surgery was simulated in a dry laboratory using a plastic temporal bone, microscope and handheld drill with irrigation and suction. Comparisons of distance of droplet and bone dust contamination and surgeon contamination were made under differing conditions. Irrigation speed, use of microscope and drill burr size and type were compared. MAIN OUTCOME MEASURES: Measurement of the distance of field contamination while performing simulated mastoidectomy and location of surgeon contamination. RESULTS: There was a greater distance field contamination and surgeon contamination without the use of the microscope. Contamination was reduced by using a smaller drill burr and by using a diamond burr when compared to a cutting burr. The use of goggles and a face mask provided good protection for the surgeon. However, the microscope alone may provide sufficient protection to negate the need for goggles. CONCLUSIONS: While the risks of performing mastoid surgery during the coronavirus pandemic cannot be completely removed, they can be mitigated. Such factors include using the microscope for all drilling, using smaller size drill burrs and creating a safe zone around the operating table.

Reducing the risks of endoscopic sinonasal surgery in the Covid-19 era.

OBJECTIVES: Many routine sinonasal procedures utilising powered instruments are regarded as aerosol-generating. This study aimed to assess how different instrument settings affect detectable droplet spread and patterns of aerosolised droplet spread during simulated sinonasal surgery in order to identify mitigation strategies. DESIGN: Simulation series using three-dimensional (3-D) printed sinonasal model. Fluorescein droplet spread was assessed following microdebriding and drilling of fluorescein-soaked grapes and bones, respectively. SETTING: University dry lab. PARTICIPANTS: 3-D printed sinonasal model. MAIN OUTCOME MEASURES: Patterns of aerosolised droplet spread. RESULTS AND CONCLUSION: There were no observed fluorescein droplets or splatter in the measured surgical field after microdebridement of nasal polyps at aspecific irrigation rate and suction pressure. Activation of the microdebrider in the presence of excess fluid in the nasal cavity (reduced or blocked suction pressure, excessive irrigation fluid or bleeding) resulted in detectable droplet spread. Drilling with either coarse diamond or cutting burs resulted in detectable droplets and greater spread was observed when drilling within the anterior nasal cavity. High-speed drilling is a high-risk AGP but the addition of suction using a third hand technique reduces detectable droplet spread outside the nasal cavity. Using the instrument outside the nasal cavity inadvertently, or when unblocking, produces greater droplet spread and requires more caution.

A Comparison between Mygind and Kaiteki positions in administration of drops to the olfactory cleft.

OBJECTIVES: Topical nasal steroids are a common treatment intervention for olfactory dysfunction. Penetration of topical treatment to the olfactory cleft (OC), such as nasal drops, is greatly dependent on the position of the head when the treatment is administered. We aimed to examine the penetrance of nasal drops to the OC in two different head positions: the Mygind (lying head back) position and the Kaiteki position. DESIGN AND SETTING: The specimens were firstly positioned in Mygind, and thereafter in Kaiteki positions. Nasal drops mixed with blue food dye were administered into the nostrils in each of the head position. Endoscopic videos were recorded, and two blinded observers scored the extent of olfactory cleft penetration (OCP) using a 4-point scale (0 = none, 3 = heavy). PARTICIPANTS: Twelve fresh-frozen cadaver specimens. MAIN OUTCOME MEASURES: Penetration of the dye into the OC. RESULTS: The mean score of nasal drops penetrance to the OC in the Mygind position was 1.34 (standard deviation, SD = 0.92), as compared to 1.76 (SD = 0.65) in the Kaiteki position. The difference in the OCP score between the two groups was not statistically significant (P > .05). CONCLUSION: Both Mygind and Kaiteki head positions are reasonable options for patients considering topical nasal drops for olfaction impairment. The preference of one position over the other should be determined by patient's preference and comfort.

Quality-of-life changes following three-dimensional printing of prosthesis for large nasal septal perforations-Our experience of 13 patients.

Nasal septal perforations can be caused by a number of aetiology including intra-nasal drug abuse, trauma and iatrogenic causes.

Development and Validation of the Gene Expression Predictor of High-grade Serous Ovarian Carcinoma Molecular SubTYPE (PrOTYPE).

PURPOSE: Gene expression-based molecular subtypes of high-grade serous tubo-ovarian cancer (HGSOC), demonstrated across multiple studies, may provide improved stratification for molecularly targeted trials. However, evaluation of clinical utility has been hindered by nonstandardized methods, which are not applicable in a clinical setting. We sought to generate a clinical grade minimal gene set assay for classification of individual tumor specimens into HGSOC subtypes and confirm previously reported subtype-associated features. EXPERIMENTAL DESIGN: Adopting two independent approaches, we derived and internally validated algorithms for subtype prediction using published gene expression data from 1,650 tumors. We applied resulting models to NanoString data on 3,829 HGSOCs from the Ovarian Tumor Tissue Analysis consortium. We further developed, confirmed, and validated a reduced, minimal gene set predictor, with methods suitable for a single-patient setting. RESULTS: Gene expression data were used to derive the predictor of high-grade serous ovarian carcinoma molecular subtype (PrOTYPE) assay. We established a de facto standard as a consensus of two parallel approaches. PrOTYPE subtypes are significantly associated with age, stage, residual disease, tumor-infiltrating lymphocytes, and outcome. The locked-down clinical grade PrOTYPE test includes a model with 55 genes that predicted gene expression subtype with >95% accuracy that was maintained in all analytic and biological validations. CONCLUSIONS: We validated the PrOTYPE assay following the Institute of Medicine guidelines for the development of omics-based tests. This fully defined and locked-down clinical grade assay will enable trial design with molecular subtype stratification and allow for objective assessment of the predictive value of HGSOC molecular subtypes in precision medicine applications.See related commentary by McMullen et al., p. 5271.

Draf III frontal sinus surgery for the treatment of Pott's puffy tumour in adults: our case series and a review of frontal sinus anatomy risk factors.

PURPOSE: We present our case series of four adult patients with Pott's puffy tumour (PPT), successfully treated with Draf III over a mean period of 11 months. A critical review of the literature is also provided. METHODS: A retrospective review of patients undergoing Draf III for PPT from January 2018 to January 2019 was performed. RESULTS: Four consecutive male patients ranging from 26 to 62 years, with a mean age of 49.5 ± 16.3 years, undergoing Draf III for Pott's puffy tumour were included. Two patients had a Kuhn type IV frontal cell narrowing the frontonasal pathway and presented without previous sinus surgery, whereas the other two had previous sinus surgery. The success rate of the operation was 100% with an average length of follow-up of 11 months (range 5-18). CONCLUSION: In our experience, the Draf III procedure is a highly effective treatment of PPT. In particular, we have demonstrated it to be very effective in accessing highly positioned Kuhn type IV cells.

Adjunctive techniques to improve access of the endoscopic prelacrimal recess approach.

OBJECTIVES: To determine whether adjunctive surgical techniques could improve access of instruments provided by the endoscopic prelacrimal recess approach to the anatomical boundaries of the maxillary sinus, and pterygopalatine and infratemporal fossa. METHODS: Ten fresh-frozen adult cadaver heads were utilized. The anatomical areas of interest were fixed, bony boundaries of the maxillary sinus, infratemporal fossa, and pterygopalatine fossa: alveolar recess (AR), zygomatic recess (ZR), perpendicular plate of the palatine bone (PB), ascending ramus of mandible (RM), floor of the orbit medial and lateral to infraorbital nerve (M-ION and L-ION, respectively). Access to the areas were compared using standard sinus surgery instruments (straight and 45° forceps) introduced via the prelacrimal recess approach, trans-septal window and canine fossa puncture. RESULTS: The prelacrimal recess approach successfully provided access to the PB and M-ION in >90% of dissections when using both the straight and 45° forceps. With the straight forceps, the ability to successfully access to the AR and ZR was the lowest at 50% and 35% respectively, although improving to 75% and 60% respectively with the 45° forceps. Access to the AR, ZR, and L-ION improved significantly when the 45° forceps was introduced through the trans-septal window. Frequency of access to the RM when either instruments when introduced through the canine fossa puncture was no greater than 60% of the dissections. CONCLUSIONS: The addition of a small trans-septal window for instruments significantly improved access of the prelacrimal recess approach especially to the orbital floor, lateral margins of the maxillary sinus, and retromaxillary space. LEVEL OF EVIDENCE: 4 Laryngoscope, 130: 1857-1863, 2020.

Correlation of sinonasal symptoms with the size and position of nasal septal perforations.

OBJECTIVE: To assess the correlation of sinonasal symptoms and quality of life with size and position of nasal septal perforation (NSP). METHOD: This is a prospective observational study in a tertiary referral center involving adult patients presented with NSP. The Sino-Nasal Outcome Test-22 (SNOT-22) and its clinico-psychometric domains were analyzed, including additional NSP-specific symptoms (nasal crusting, epistaxis, and whistling noise during nasal breathing). The size of NSP was measured radiologically by calculating the area in cm2 and anteroposterior (AP) diameter. Position of perforation was determined clinically by distance from columella to the anterior edge of the perforation. RESULTS: Forty patients were included in this study (22 males). The most common etiology of NSP was iatrogenic. The mean SNOT-22 score was 50.8 (standard deviation 23.8), and mean NSP size was 3.0 cm2 . No statistical correlation was observed between the total SNOT-22 score with either position or size of NSP. As for NSP-specific symptoms, there was a statistically significant negative correlation with the size of perforation (A-P diameter) (r = -0.34, P = 0.03) and position of the perforation (r = -0.49, P = 0.0016), suggesting that these symptoms improved with posterior and larger perforations. CONCLUSION: Reported SNOT-22 scores were comparable to patients with recalcitrant chronic rhinosinusitis, although the scores did not correlate with size and position of NSP. Sinonasal symptoms typically observed in NSP improved with more posteriorly placed and larger sized perforations. This study provides an insight into the quality-of-life impact of NSP and affirms the clinical observation that anterior NSP are more symptomatic. LEVEL OF EVIDENCE: 4 Laryngoscope, 2019.

Innate and adaptive nasal mucosal immune responses following experimental human pneumococcal colonization.

Streptococcus pneumoniae (Spn) is a common cause of respiratory infection, but also frequently colonizes the nasopharynx in the absence of disease. We used mass cytometry to study immune cells from nasal biopsy samples collected following experimental human pneumococcal challenge in order to identify immunological mechanisms of control of Spn colonization. Using 37 markers, we characterized 293 nasal immune cell clusters, of which 7 were associated with Spn colonization. B cell and CD8+CD161+ T cell clusters were significantly lower in colonized than in non-colonized subjects. By following a second cohort before and after pneumococcal challenge we observed that B cells were depleted from the nasal mucosa upon Spn colonization. This associated with an expansion of Spn polysaccharide-specific and total plasmablasts in blood. Moreover, increased responses of blood mucosal associated invariant T (MAIT) cells against in vitro stimulation with pneumococcus prior to challenge associated with protection against establishment of Spn colonization and with increased mucosal MAIT cell populations. These results implicate MAIT cells in the protection against pneumococcal colonization and demonstrate that colonization affects mucosal and circulating B cell populations.

Innate and adaptive nasal mucosal immune responses following experimental human pneumococcal colonization

Streptococcus pneumoniae (Spn) is a common cause of respiratory infection, but also frequently colonizes the nasopharynx in the absence of disease. We used mass cytometry to study immune cells from nasal biopsy samples collected following experimental human pneumococcal challenge in order to identify immunological mechanisms of control of Spn colonization. Using 37 markers, we characterized 293 nasal immune cell clusters, of which 7 were associated with Spn colonization. B cell and CD161+CD8+ T cell clusters were significantly lower in colonized than in noncolonized subjects. By following a second cohort before and after pneumococcal challenge we observed that B cells were depleted from the nasal mucosa upon Spn colonization. This associated with an expansion of Spn polysaccharide–specific and total plasmablasts in blood. Moreover, increased responses of blood mucosa-associated invariant T (MAIT) cells against in vitro stimulation with pneumococcus prior to challenge associated with protection against establishment of Spn colonization and with increased mucosal MAIT cell populations. These results implicate MAIT cells in the protection against pneumococcal colonization and demonstrate that colonization affects mucosal and circulating B cell populations.

Innate and adaptive nasal mucosal immune responses following experimental human pneumococcal colonization

Streptococcus pneumoniae (Spn) is a common cause of respiratory infection, but also frequently colonizes the nasopharynx in the absence of disease. We used mass cytometry to study immune cells from nasal biopsy samples collected following experimental human pneumococcal challenge in order to identify immunological mechanisms of control of Spn colonization. Using 37 markers, we characterized 293 nasal immune cell clusters, of which 7 were associated with Spn colonization. B cell and CD161+CD8+ T cell clusters were significantly lower in colonized than in noncolonized subjects. By following a second cohort before and after pneumococcal challenge we observed that B cells were depleted from the nasal mucosa upon Spn colonization. This associated with an expansion of Spn polysaccharide–specific and total plasmablasts in blood. Moreover, increased responses of blood mucosa-associated invariant T (MAIT) cells against in vitro stimulation with pneumococcus prior to challenge associated with protection against establishment of Spn colonization and with increased mucosal MAIT cell populations. These results implicate MAIT cells in the protection against pneumococcal colonization and demonstrate that colonization affects mucosal and circulating B cell populations.

A meta-analysis of survival factors in rhino-orbital-cerebral mucormycosis-has anything changed in the past 20 years?

BACKGROUND: Rhino-orbital-cerebral mucormycosis (ROCM) is an uncommon yet potentially lethal fungal infection. Although most cases originate from developing countries, an ageing population and increased prevalence of chronic illness may mean some clinicians practicing in developed countries will encounter ROCM cases in their careers. Yohai et al published a systematic review of 145 case reports from 1970 to 1993 assessing prognostic factors for patients presenting with ROCM. We present an updated review of the literature and assess whether survival outcomes have changed in the two decades since that seminal paper. SEARCH STRATEGY: An extensive Medline literature search was performed for case reports published between 1994 and 2015. RESULTS: In total, 210 published cases were identified from the literature review, of which 175 patients from 140 papers were included in this review. Fifty-five were female, with an overall mean age of 43 years. Overall survival rate was 59.5%, which was not significantly better than the previous series reported (60%) reported by Yohai et al. Survival rates in patients with chronic renal disease had improved, from 19% to 52%, and in patients with leukaemia (from 13% to 50%). Facial necrosis and hemiplegia remained poor prognostic indicators (33% and 39% survival rates, respectively). Early commencement of medical treatment related to better survival outcomes (61% if commenced within first 12 days of presentation, compared to 33% if after 13 days). Timing of surgery had less of an effect on overall survival. However, in 28 cases that did not receive any surgical treatment, survival was only 21%. CONCLUSIONS: Although overall survival rates have not improved, survival in patients with renal disease were better, potentially due to the introduction of liposomal amphotericin B which is less nephrotoxic. Prompt recognition of ROCM, reversal of predisposing co-morbidities and aggressive medical treatment remain the cornerstone of managing this highly aggressive disease.

The impact of acoustic neuroma on long-term quality-of-life outcomes in the United Kingdom.

OBJECTIVE: To quantify the impact of acoustic neuroma on the quality-of-life (QOL) patients in the United Kingdom. STUDY DESIGN: Online questionnaire survey. PATIENTS: Members of the British Acoustic Neuroma Association received PANQOL questionnaires. RESULTS: Of the 880 BANA members contacted, 397 (45.1%) responded, although only 359 had complete datasets for analysis. Composite QOL scores were as follows: for microsurgery 58 (SD 35), for radiotherapy 56 (SD18), for combination of surgery and radiotherapy 49 (SD 14), and for the observation group 54 (SD 20). No statistical significance with ANOVA (p = 0.532). Mean (SD) composite QOL scores were as follows: for follow-up < 6 52 (SD 18), for follow-up 6-10 55 (SD 20) and follow-up > 10 years 65 (SD 45). Overall, these values were significantly different compared by ANOVA (p < 0.001). Patients with facial paralysis showed no statistical significant differences between the different treatment groups. CONCLUSIONS: Short- (< 6 years) and long-term (> 10 years) QOL outcomes show no significant differences between the different treatment groups.