Validation of a three-dimensionally printed simulator for training in endoscopic sinonasal surgery.

BACKGROUND: The ability to incorporate different materials in the construction of 3-D printed models has resulted in the ability to mimic a variety of anatomical structures such as cartilage, mucosa and bone. The aim of this study was to evaluate the face and content validities of a model as a training tool for endoscopic sinus surgery. METHODS: Twenty-six delegates and ten teaching faculty members were invited to complete a post-hoc questionnaire survey. The survey consisted of a 22-question 5-point Likert scale to assess the model's realism (face validity) and its effectiveness as a training tool (content validity). RESULTS: Over 80% of the delegates agreed or strongly agreed that the appearance of anatomical structures within the model was realistic and mimicked actual sinus anatomy. In addition, a similar proportion agreed or strongly agreed that the application of instruments on the composite materials of the model realistically mimicked bone. All faculty agreed that the model was useful to develop hand-eye coordination and was a useful training tool for endoscopic sinus surgery. Overall, the sinus model received high scores regarding its use for training surgeons, especially to develop camera and instrument handling skills. CONCLUSION: The results of this study suggest that otolaryngology doctors in their early or intermediate stage of training would benefit most from a clinical-based modular programme. The model requires further development in areas such as the realism of mucosa, incorporation of sinonasal pathology and having more complex anatomy to be useful for the training of more advanced surgeons.

Sino-Nasal Outcome Test-22 quality-of-life patterns in patients presenting with nasal septal perforation.

OBJECTIVES: To assess the impact of nasal septal perforation (NSP) on quality of life. DESIGN: Retrospective cohort study. SETTING: Rhinology clinics from two hospitals in Liverpool, United Kingdom. PARTICIPANTS: Patients diagnosed with NSP. MAIN OUTCOME MEASURES: Patients (n = 26) diagnosed with NSP completed the Sino-Nasal Outcome Test-22 (SNOT-22). The collated data were compared with SNOT-22 scores from a cohort of healthy volunteers (n = 34) and a cohort of patients (n = 30) diagnosed with chronic rhinosinusitis (CRS). RESULTS: The mean total SNOT-22 score of NSP and CRS cohorts was higher than that observed in healthy volunteers. The mean total SNOT-22 score in the CRS cohort (57.2, standard deviation SD 10.3) was the higher than NSP (50.2, SD 23.5), although this difference did not achieve statistical significance. The mean score for the rhinologic-specific domains (rhinologic symptoms, extranasal rhinologic symptoms), ear/facial symptoms and psychological dysfunction domain was higher in the CRS cohort compared to NSP, although statistical significance was only observed in the extranasal rhinologic symptoms domain (11.2, SD 2.4 vs 6.4, SD 4.1). Conversely, the mean sleep dysfunction domain score for NSP (12.7, SD 7.5) was higher than CRS (10.0, SD 4.9, respectively) although this was not statistically significant. CONCLUSIONS: This study has assessed the clinimetric and psychometric properties of patients suffering from symptomatic NSP. Future reports should consider inclusion of SNOT-22 data but with the addition of perforation-specific symptoms (nasal crusting, epistaxis, whistling noise).

Assessing the ideal microwave duration for disinfection of sinus irrigation bottles-A quantitative study.

OBJECTIVES: Saline irrigation of the nasal cavity and paranasal sinuses has a recognised role in the management of chronic rhinosinusitis. However, bacterial recontamination of irrigation bottles through backflow from the sinonasal cavity is a concern in recurrent sinus cavity infections. While patients are encouraged to clean the irrigation bottles regularly, there remains significant concern that the use of contaminated bottles may perpetuate chronic rhinosinusitis. This study assesses the optimal microwave duration to achieve decontamination for each irrigation bottle component part (reservoir, tube and nozzle) using a standard, commercially available microwave. In addition, the irrigation fluid was also tested for contamination after each microwave cycle. STUDY DESIGN: Laboratory-based experimental study. PARTICIPANTS: No patients were involved in this study. MAIN OUTCOME MEASURES: The percentage in vitro decontamination of the bottles' components was determined following 30, 60, 90, 120, 150 seconds of microwave cycles. RESULTS: Complete decontamination of the bottles was not achieved at any of the tested microwave cycles. Levels of decontamination differed for the different bottle components, and the greatest degree of decontamination for all bottle components occurred at 90 seconds. Although higher levels of decontamination were observed at microwave durations exceeding 90 seconds, this was at the expense of thermal degradation and deformation of the reservoir plastic component of the irrigation bottle. Similarly, lowest contamination of irrigation fluid was observed at 120 seconds. CONCLUSIONS: This study highlights the importance of establishing precise decontamination procedures and recommends a microwave cycle of 90 seconds for optimal decontamination.

What is the publication rate for presentations given at the British Academic Conference in Otolaryngology (BACO)?

OBJECTIVES: The publication rate of some large academic meetings such as the American Academy of Otolaryngology-Head and Neck Surgery has been reported as 32%. We aimed to compare the rate of publication at the British Academic Conference in Otolaryngology (BACO) to allow surveillance of research activity in the United Kingdom (UK). DESIGN AND SETTING: The abstract records of both BACO 2009 and 2012 were examined. The MEDLINE database was searched using PubMed (http://www.ncbi.nlm.nih.gov/pubmed) and an iterative approach. We recorded time to publication as well as the authors' region and journal. MAIN OUTCOME MEASURES: publication rate by conference, region and journal. RESULTS: Twice the number of presentations were made at BACO 2012 (n = 814) compared to BACO 2009 (n = 387). Absolute numbers of publications were 158 in 2012 and 92 in 2009. Overall, the publication rate dropped from 24% overall in 2009 to 19% in 2012. This difference in proportions was not significant (P = 0.08). The number of abstracts accepted for BACO 2012 doubled from BACO 2009 in nearly every subspecialty category, except the general/training category, which trebled. For both conferences, head and neck was the largest subspecialty abstract category, as well as the largest subspecialty publication category. CONCLUSIONS: This study showed that the majority of abstracts presented at BACO 2009 and 2012 did not progress to publication. The rate of publication was similar to that seen in other general ENT meetings but do not compare favourably to the 69% rate seen for presentations made at the Otorhinolaryngological Research Society (ORS). The large increase in accepted abstracts at BACO 2012 may reflect growing competition for entry to specialist training.

An analysis of the fate of 917 manuscripts rejected from Clinical Otolaryngology.

OBJECTIVES: The fate of all manuscripts rejected from the journal Clinical Otolaryngology (CO) over a three-year period was investigated. The aim was to review publication rate, delay and the impact factors of the journals that the papers went on to be published in. DESIGN: In total, 917 papers were rejected from CO between 2011 and 2013. The fate of these manuscripts was determined by searching for the corresponding author's surname, and if necessary keywords from the manuscript title, in both PubMed and Google Scholar. MAIN OUTCOME MEASURES: The main outcome measures recorded were as follows: the subsequent publication of the article, delay to publication and journal of publication. RESULTS: In all, 511 papers were subsequently published in journals, representing 55.7% of all rejected manuscripts. The average delay was 15.1 months (standard deviation [sd] = 8.8). The impact factor of CO was found to be higher than the average of the journals that accepted the rejected manuscripts in all 3 years. Only 41 (8%) papers were published in journals with a higher impact factor than CO. Of all subsequently accepted manuscripts, 60 (11.7%) were found only on Google Scholar (and not on PubMed). CONCLUSIONS: Rejection from CO certainly does not prevent subsequent publication, although the papers tend to be published after a lengthy delay and in journals with a lower impact factor than CO. When performing literature searches, it is important to search more than one database to ensure as many of the relevant articles are found as possible.

A re-appraisal of publication rates of scientific papers presented at the Otorhinolaryngology Research Society meetings.

OBJECTIVES: To review the rate of publication of papers in peer-reviewed journals after oral presentations at the Otorhinolaryngology Research Society meetings between 1996 and 2013 and to compare trends with the previous review (1979-1995). DESIGN: Literature review. SETTING: Merseyside ENT Research Collaborative. PARTICIPANTS: The abstracts of presentations at Otorhinolaryngology Research Society meetings are published in Clinical Otolaryngology. A structured search of PubMed was undertaken to identify published Otorhinolaryngology Research Society presentations. MAIN OUTCOME MEASURES: Publication rates. RESULTS: A total of 460 abstracts were identified. The interobserver reliability among reviewers was 98%. Of the total, 259 (56.3%) abstracts were published in peer-reviewed journals. The average time from Otorhinolaryngology Research Society presentation to publication was 27.7 months (median 23), which was not significantly different from the previous review. Publication by subspeciality was as follows: head and neck (45.6%), otology (30.5%), rhinology (22%) and others (1.9%). Most published Otorhinolaryngology Research Society presentations were published in Clinical Otolaryngology (22.4%), followed by the Journal of Laryngology and Otology (8.1%) and the Laryngoscope (7.3%). Clinical research was the most common category of abstracts being presented at Otorhinolaryngology Research Society meetings, followed by laboratory-based research. Over half (56.5%) of laboratory research presented were head and neck themed, while otology and rhinology predominated clinical research presentations. Over half (52.1%) of Otorhinolaryngology Research Society abstracts originated from units in the North of England. Bristol presented the most abstracts (30.1%), followed by Newcastle (25.1%). CONCLUSIONS: The publication rate of Otorhinolaryngology Research Society presentations remains high and many are subsequently published in high-impact factor otolaryngology journals. More Otorhinolaryngology Research Society presentations are now published in American and European journals.

Characterisation of patients with endoscopy-negative, computer tomography-negative midfacial segment pain using the sino-nasal outcome test.

BACKGROUND: The purpose of this study was to qualitatively characterise patients with midfacial segment pain (MSP) using the Sino-Nasal Outcome Test (SNOT). The data will provide a detailed overview of the physical and psychological impact on patients'well-being, and how it compares with the normal, healthy population. METHODS: Suitable patients were prospectively identified from the Multi-disciplinary Facial Pain Clinic at the Royal Liverpool University Hospital, based on the diagnostic criteria for MSP. The pre-treatment SNOT-22 of these patients were also compared to patients with chronic rhinosinusitis and normal healthy volunteers. RESULTS: Twenty-nine consecutive patients with a diagnosis of MSP were identified, and compared with 30 CRS patients and 34 healthy volunteers. The average SNOT-22 scores of MSP and CRS patients were higher than normal healthy volunteers. Patients with CRS had the highest rhinological subscale SNOT scores compared to normal healthy volunteers and MSP. Conversely, the reported ear and facial symptoms of MSP patients were most unfavourable. A similar trend was observed in reported sleep function where MSP patients recorded higher subscale scores than the other two cohorts. The subscale mean score for psychological function of MSP patients was not significant when compared to the mean score of patients diagnosed with CRS. CONCLUSION: MSP has an adverse impact on both physical and psychological well-being. The subtle differences in the SNOT subscores between MSP and CRS have provided greater insight into the character and disease impact of MSP. We propose that the SNOT may be suitably utilised in MSP to document disease severity and measure response to treatment.

Does endoscopic balloon dilatation improve intranasal drug delivery to the olfactory cleft? A pre-clinical cadaver feasibility study.

BACKGROUND: Although systemic steroids have been shown to improve olfactory function, topical steroids have not demonstrated the same efficacy. This could a result of limited drug delivery to the narrow, superiorly placed olfactory cleft. This study aimed to examine the penetration of intranasal drugs to the olfactory cleft following endonasal balloon dilatation. METHODS: Balloon dilatation was performed in 12 thawed, fresh-frozen cadaver specimens. In the Mygind position, nasal drops mixed with blue food dye were administered into the nostril before and after the dilatation procedure. Endoscopic videos were recorded to assess dye staining of the olfactory cleft and osteo-meatal complex using a 4-point Likert scale. RESULTS: Prior to balloon dilatation, the mean penetration of nasal drops into the olfactory cleft was 1.34, which improved significantly (p < 0.05) to 2.66 following the procedure. There was no change in dye penetration into the osteo-meatal complex after balloon dilatation. CONCLUSION: The results of this exploratory study suggest that balloon dilatation may improve the delivery of nasal drops to the olfactory cleft area. The clinical applicability and impact on olfactory function will require further assessment.

Spirulina in clinical practice: evidence-based human applications.

Spirulina or Arthrospira is a blue-green alga that became famous after it was successfully used by NASA as a dietary supplement for astronauts on space missions. It has the ability to modulate immune functions and exhibits anti-inflammatory properties by inhibiting the release of histamine by mast cells. Multiple studies investigating the efficacy and the potential clinical applications of Spirulina in treating several diseases have been performed and a few randomized controlled trials and systematic reviews suggest that this alga may improve several symptoms and may even have an anticancer, antiviral and antiallergic effects. Current and potential clinical applications, issues of safety, indications, side-effects and levels of evidence are addressed in this review. Areas of ongoing and future research are also discussed.

Rhinophototherapy: gimmick or an emerging treatment option for allergic rhinitis?

Photodynamic therapy has been used in treating immune-mediated dermatological conditions such as psoriasis and atopic dermatitis. There are emerging reports on the efficacy of intranasal phototherapy in allergic rhinitis. The aim of this review was to assess intranasal phototherapy in the treatment of allergic rhinitis, with particular emphasis on clinical efficacy, scientific basis and safety. A structured search of the U.S. National Library of Medicine (PubMed), the Cochrane Collaboration library, Google Scholar and ISI Web of Knowledge database was undertaken using MeSH terms `phototherapy` and `rhinitis.` Fourteen full-text articles were available for review. Three different phototherapy medical devices were assessed: (1) Bionase(TM), (2) Allergy Reliever SN206 and (3) Rhinolight(®). Light wavelength used in these devices ranged from red light to ultraviolet. Clinical use of intranasal phototherapy appears to be safe and well tolerated. Most studies demonstrated symptomatic improvement and quality of life scores. No improvement in objective measures of nasal airflow was demonstrated. Beneficial effects of phototherapy on inflammatory markers remain equivocal. Phototherapy treatment results in DNA damage but does not appear to predispose to carcinogenesis. However, long-term prospective studies are required to verify this. The quality of published studies was variable and thus the current strength of recommending intranasal phototherapy is currently weak.

The use of race as a demographic variable in clinical research.

BACKGROUND: Researchers continue to categorise demograpic variables according to racial lines despite the fact that the definition of race has no scientific or anthropological validity. PURPOSE: The aim of this article is to discuss the scientific rationale for using race as a demographic variable in clinical research and to explore other suitable alternatives such as ethnicity, genetics and the nasal index in rhinology research. RESULTS: There is consensus that research subjects should not be classified along racial lines. However, there is evidence that this practice remains prevalent. Ethnicity is not a good substitute for race. Whilst genomics is an objective measure of variation, it does not measure the impact of socioeconomic status, exposure to health risk factors and the availability of health- care on populations. CONCLUSIONS: It is important to define the population demographics in any study, but race appears to be a category without any scientific basis. Other parameters that may be important such as ethnicity and genetics are still not fully developed to be useful. At present there is no generally accepted way of describing and classifying the subjects. The nasal index may be a suitable discriminator of variation for studies in rhinology but more studies are required to define its clinical relevance.

Coblation® inferior turbinate reduction: a long-term follow-up with subjective and objective assessment.

This article presents long-term outcomes following Coblation® inferior turbinate reduction surgery (CITR) using both subjective and objective outcome measures in a cohort of patients with nasal obstruction secondary to enlarged inferior turbinate. Subjective assessment of the severity of nasal obstruction was assessed using a 100 mm visual analogue scale anchored by the descriptors 'nose completely clear' (0 mm) and 'nose completely blocked' (100 mm). Nasal conductance of airflow was measured by posterior rhinomanometry. Of the original cohort of 18 patients, 13 patients (76%) were available for follow-up at 32 months after surgery. The mean baseline nasal conductance was 248.6 cm3/s (range 2.5-614.8), which improved significantly (p=0.033) to 342.1 cm3/s (range 166.7-500) at 32 months post-operatively. Improvement in the subjective sensation of nasal obstruction was indicated by a lower VAS score compared to baseline. The mean pre-operative VAS was 72 mm (range 49-98), which improved to 53 mm (range 2-93) but this did not achieve statistical significance (10/13 patients scored improved airflow). This was a pilot study of the long-term outcomes of CITR. Despite the small study cohort, there appears to be sustained improvement in nasal conductance of air-flow up to 32 months follow-up. Although there was improvement in the subjective assessment of nasal obstruction, this did not achieve statistical significance.

A review of the implications of computational fluid dynamic studies on nasal airflow and physiology.

BACKGROUND: Computational fluid dynamics has been adapted to studying nasal aerodynamics. AIM: To review current literature on CFD studies, with an emphasis on normal nasal airflow, the impact of sinonasal pathology on airflow, and implications on nasal physiology. The objective is to provide the rhinologists with a greater understanding of nasal airflow and how symptomatology of sinonasal disease may be explained via CFD simulations. RESULTS: The nasal valve region redirects inspiratory airstreams over the inferior turbinate in a high turbulent kinetic energy, which is important in heat and moisture exchange. The bulk of airflow occurs in the common meatus with small streams traversing the olfactory groove, increasing during sniffing. Septal deviation and enlarged inferior turbinate causes redistribution of airflow, changes in intranasal pressure and increased turbulence. High velocity airflow and wall shear stress at the septal perforation causes desiccation and mucosal damage. The airflow within an atrophic nasal cavity is predominantly laminar with minimal contact with nasal mucosa. The inferior turbinate is an important organ for air conditioning and preservation during surgery is highlighted. CONCLUSIONS: Despite some limitations of CFD simulations, this technology has improved understanding of the complex nasal anatomy and the implications of disease and surgery on physiology.

Aerodynamic effects of inferior turbinate surgery on nasal airflow--a computational fluid dynamics model.

BACKGROUND: Turbinate reduction surgery may be indicated for inferior turbinate enlargement when conservative treatment fails. The aim of this study was to evaluate the effects of inferior turbinate surgery on nasal aerodynamics using computational fluid dynamics (CFD) simulations. METHODS: CFD simulations were performed for the normal nose, enlarged inferior turbinate and following three surgical procedures: (1) resection of the lower third free edge of the inferior turbinate, (2) excision of the head of the inferior turbinate and (3) radical inferior turbinate resection. The models were constructed from MRI scans of a healthy human subject and a turbulent flow model was used for the numerical simulation. The consequences of the three turbinate surgeries were compared with originally healthy nasal model as well as the one with severe nasal obstruction. RESULTS: In the normal nose, the bulk of streamlines traversed the common meatus adjacent to the inferior and middle turbinate in a relatively vortex free flow. When the inferior turbinate was enlarged, the streamlines were directed superiorly at higher velocity and increased wall shear stress in the nasopharynx. Of the three surgical techniques simulated, wall shear stress and intranasal pressures achieved near-normal levels after resection of the lower third. In addition, airflow streamlines and turbulence improved although it did not return to normal conditions. As expected, radical turbinate resection resulted in intra-nasal aerodynamics of atrophic rhinitis demonstrated in previous CFD studies. CONCLUSION: There is little evidence that inspired air is appropriately conditioned following radical turbinate surgery. Partial reduction of the hypertropic turbinate results in improved nasal aerodynamics, which was most evident following resection of the lower third. The results were based on a single individual and cannot be generalised without similar studies in other subjects.

Race and ethnicity in nasal plastic surgery: a need for science.

Race and ethnicity have no scientific or anthropologic validity, yet nasal plastic surgeons continue to categorize patient demographic variables according to racial and ethnic lines. The aim of this article is to discuss the problems of using race and ethnicity as demographic variables in nasal surgery. It is important to define the population demographics in any surgical study, but race and ethnicity are categories without any scientific basis. The nasal index or other anthropometric objective measures of the external nose may be used as discriminators of variation for studies in rhinology, but more studies are required to define their clinical relevance and usefulness in plastic surgery. The article critically examines the use of racial/ethnic categories and anthropometric measurements in nasal plastic surgery.

A systematic review of the nasal index and the significance of the shape and size of the nose in rhinology.

BACKGROUND: There was great interest in the 19th and early 20th century in classifying human races as Caucasian, Asian African etc. according to nasal shape and size, and the nasal index was the most commonly used measurement to differentiate races. OBJECTIVE OF REVIEW: To determine if there is any clinical relevance of the shape and size of the nose in relation to physiology, pathology and surgery. TYPE OF REVIEW: Systematic review. SEARCH STRATEGY: A structured search of PubMed was performed from 1966 to 2008 for each section of the review focusing on the ethnic variations in nasal index, the effect of climate of nasal shape, ethic variations of nasal physiology and racial predilection for sinonasal pathology. RESULTS: Nasal proportions do vary between ethnic groups but the size and shape of the nose does not define Caucasian, Asian and African races respectively. Anthropologists agree that the nasal variations are due to man's adaptation to the environment. However, this theory remains to be proven. Published data on nasal physiology have not shown significant differences between the ethnic groups despite obvious differences in nasal proportions. There is no evidence of ethnic specific predilection to disease due to anatomical variation, physiological vulnerability or genetic susceptibility. Rhinology research is often confounded by classifying populations according to race, as racial characteristics are not based on any scientific principles and the nasal index may be a more reliable discriminator. The only area in which the size and shape of the nose is of relevance is in aesthetic and reconstruction surgery. CONCLUSIONS: Nasal proportions are important aesthetically but appear to have little relevance to the rhinologist.