Relationship between pain-related comorbidities and quality of life in patients with symptoms of chronic rhinosinusitis.

INTRODUCTION: Facial pain is a common manifestation of sinonasal disease but may be due to a variety of other conditions. Misattribution of pain to chronic rhinosinusitis may result in worse quality of life in populations both with and without objective evidence of sinonasal disease. The purpose of this study was to determine if there is an association between pain-related comorbidities and worse chronic rhinosinusitis specific quality of life in patients with and without objective evidence of sinonasal inflammation. METHODS: Retrospective cohort study of 299 patients meeting diagnostic criteria for sinusitis evaluated at a tertiary academic medical center from 2017 to 2018. Objective evidence was measured using the Lund-Kennedy and Lund-MacKay scoring systems; for the purposes of this study a score >3 on either scale was considered indicative of disease. Quality of life was determined by the rhinosinusitis disability index. RESULTS: A total of 191 patients were included in the study, with an average age of 52.7. (SD=15.3). The average Lund-Kennedy and Lund-MacKay scores were 4.7 and 8.3, respectively. The average rhinosinusitis disability index was 32.1. When stratified by the presence of pain-related comorbidities, there was no significant difference in Lund-Kennedy (p = 0.203), Lund-MacKay (p = 0.101), or rhinosinusitis disability index (p = 0.421). CONCLUSION: Although prior studies have suggested a correlation between the presence of pain-related comorbidities and worse chronic rhinosinusitis specific quality of life, this relationship was not evident within the current cohort of patients. The relationship between pain and sinusitis specific quality of life is likely complex and requires further research to fully elucidate.

Correlations to Estimate the Key Anatomical Dimensions of Pediatric Nasal Airways using Minimally Invasive Measurements of Intranasal Pressure Gradient.

Background: Understanding the morphology of nasal airways is important in determining the nasal airway deposition of inhaled aerosol. Moreover, objective assessment of the anatomy of human nasal airways is useful to develop a database of reference or normal values as a resource to investigate anatomical abnormalities of airways. Current methods for the objective assessment of the nasal airways are either limited to very few dimensions or can only be performed by specialized researchers. Thus, the main objective of this study was to determine the correlations between the intranasal pressure gradient (Δp) and the key anatomical dimensions of the pediatric nasal airways, which could in turn allow the extrapolation of nasal airway morphology based on simple minimally invasive measurements of pressure. Methods: The anatomical data and Δp were obtained from in vitro studies with nasal airway models of 11 infants ages 3-18 months and 13 children ages 4-14 years old. Key anatomical dimensions were identified based on both rhinology and aerosol dosimetry literature. These anatomic data, including the volume, V, surface area, As, length, L, and the minimum cross-sectional area of the replicas, Amin, were then analyzed for correlation with Δp and flow parameters, using Bernoulli's principle and dimensional analysis. Results: Strong correlations were found between Δp and As/L for children, and between Δp and V/As for infants. Additional pressure gradient correlations were developed with Amin, V/As, V∕L, and L. Conclusions: The correlations identified between anatomic data and Δp have clinical implications in pediatric rhinology, suggesting that certain aspects of airway anatomy in infants and children can be predicted through the measurement of Δp. The airway dimensions, predicted using Δp measurement, may be used in tandem with aerosol nasal deposition correlations that account for nasal airway dimensions.

Pain Catastrophizing and Quality of Life in Adults With Chronic Rhinosinusitis.

OBJECTIVES/HYPOTHESIS: Psychological comorbidity is common in patients with chronic rhinosinusitis (CRS) and is correlated with decreased overall and disease-specific quality of life (QoL). Prior research reported that anxiety and depression, as measured by the hospital anxiety and depression scale (HADS), are associated with worse CRS-specific QoL, as assessed via the Rhinosinusitis Disability Index (RSDI). Furthermore, patients prone to anxiety/depression may display an exaggerated response to real or anticipated discomfort; the pain catastrophizing scale (PCS) is a validated instrument designed to measure this phenomenon. This study is intended to explore the role of pain catastrophizing in relation to anxiety, depression, and disease-specific QoL in patients with facial pain attributed to CRS. STUDY DESIGN: Prospective cohort study. METHODS: Diagnosis of presumed CRS was based upon current American Academy of Otolaryngology - Head & Neck Surgery (AAO-HNS) guidelines; all participants reported facial pain as a component of their CRS symptomatology. RSDI, HADS, and PCS questionnaires were administered upon presentation prior to intervention, and objective measurements of sinonasal inflammation were obtained via nasal endoscopy and computed tomography (CT). RESULTS: Seventy-five patients were enrolled in the study. Significant positive correlations were found between PCS and HADS, total RSDI, and RSDI emotional sub-scores (P < .05). The incidence of objective evidence of disease, as measured via nasal endoscopy and CT, was not significantly different in catastrophizing patients. CONCLUSIONS: Pain catastrophizing correlates with anxiety/depression and worse disease-specific QoL in patients meeting symptomatic criteria for CRS. Otolaryngologists should be aware that catastrophic thinking can intensify a patient's perception of sinonasal symptoms, and clinicians may consider management of psychological comorbidity to optimize rhinologic outcomes. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1939-1945, 2021.

The Sensitivity and Specificity of Touch Preparation for Rapid Diagnosis of Invasive Fungal Sinusitis: A Pilot Study.

Invasive fungal sinusitis is a morbid pathology that typically affects immunocompromised patients and may quickly progress to fulminant disease. The purpose of this study was to measure the sensitivity and specificity of touch preparation of nasal debridement specimens as a rapid diagnostic tool for invasive fungal sinusitis. A retrospective chart review was performed of 22 patients undergoing nasal debridement due to suspicion for invasive fungal sinusitis over a 10-year period. Thirteen patients had touch preparation of nasal specimens followed by routine histologic processing; two of these patients underwent 2, and 1 patient had 3 separate debridements, for a total of 17 touch preparations performed. The sensitivity and specificity of touch preparation were calculated by correlating the initial results with the presence of fungal invasion on final pathologic analysis. The sensitivity of touch preparation was 56% (95% confidence interval [CI]: 0.23-0.85), specificity was 100% (95% CI: 0.60-1.00), positive predictive value was 100% (95% CI: 0.46-1.00), and negative predictive value was 67% (95% CI: 0.35-0.89). This procedure may be a useful adjunct in situations requiring rapid diagnosis of invasive fungal sinusitis but should not be used as the sole criteria for determining the need for surgical intervention.

Use of anatomically-accurate 3-dimensional nasal airway models of adult human subjects in a novel methodology to identify and evaluate the internal nasal valve.

The optimal method for radiographic evaluation of the internal nasal valve (INV) has not been established. The objective of this study was to develop a method to assess the cross-sectional area and the angle of the INV using anatomically-accurate 3D digital nasal airway models. Axial CT images of the paranasal sinuses of twenty adult subjects with healthy nasal airways (50% female and 50% age ≥ 50) were used to create the models. Patients with significant radiographic evidence of sinonasal disease were excluded. A primary cutting plane that passed through the edge of the nasal bone, upper lateral cartilage, and the head of the inferior turbinate was defined in coronal view. This primary coronal cutting plane was then rotated in 5° increments anteriorly while ensuring the anatomic criteria for the INV were still met. The cutting plane resulting in the minimum INV area was identified as the optimal cutting plane and the total cross-sectional area of INV in this plane,198.79 ± 54.57 mm2, was significantly less than the areas obtained using the existing methods for radiographic evaluation of the INV. The angle between the optimal cutting plane and nasal dorsum was 75.00 ± 10.26°, and the corresponding INV angle was 10.77 ± 6.02°.

Long-term management and outcomes after repair of cerebrospinal fluid rhinorrhea related to idiopathic intracranial hypertension.

PURPOSE OF REVIEW: To identify long-term management strategies and outcomes for the treatment of spontaneous cerebrospinal fluid (CSF) rhinorrhea related to idiopathic intracranial hypertension (IIH). RECENT FINDINGS: Adjuvant treatments following surgical repair of spontaneous CSF leaks are aimed at normalizing intracranial pressure (ICP) to minimize the risk of recurrence. IIH is closely linked to obesity, and growing evidence suggests that weight loss, both through conservative and surgical approaches, is effective at addressing the root cause of this disorder. Recent data also support the use of acetazolamide and dural venous sinus stenting as adjuncts for reducing ICP. SUMMARY: Spontaneous CSF rhinorrhea associated with IIH represents a challenging clinical entity, with an increased risk of recurrence compared to CSF leaks because of other causes. Adjunct therapies intended to reduce ICP likely improve outcomes after surgical repair, but further research is necessary to better characterize the effects of these treatment modalities.

Treatment Paradigm for Nasal Airway Obstruction.

Nasal airway obstruction (NAO) is a common otolaryngic complaint with many potential causes, frequently structural or inflammatory in nature. Patients typically have multiple coexisting factors leading to symptoms. Good patient outcomes require careful preoperative evaluation, including nasal endoscopy, to accurately identify sources of obstruction and tailor intervention appropriately. Common structural causes of NAO include inferior turbinate hypertrophy, nasal septal deviation, and narrowing or collapse of the internal or external nasal valves. The internal nasal valve has the narrowest cross-sectional area within the nasal airway and is thus most sensitive to changes in dimension due to anatomic variation or surgical intervention.

Sinonasal epithelial-myoepithelial carcinoma: Report of a novel subsite and review of the literature.

BACKGROUND: Epithelial-myoepithelial carcinoma (EMC) is a rare tumor of the major and minor salivary glands. Sinonasal EMC is extremely uncommon and hitherto not described within the frontal or ethmoid sinuses. OBJECTIVE: To present a novel sinonasal subsite and review the literature regarding sinonasal EMC. METHODS: A case of frontoethmoidal EMC was presented. A medical literature data base was queried from January 1, 1950, to August 8, 2017, for all reports of sinonasal EMC. RESULTS: A 69-year-old man underwent combined open and endoscopic craniofacial resection of a right frontoethmoidal EMC, a previously undescribed primary location for this tumor. A comprehensive review of the literature revealed 13 additional cases of sinonasal EMC. CONCLUSION: EMC is an uncommon neoplasm typically found in the major salivary glands; occurrence in the nose or paranasal sinuses is extremely rare. EMC often follows an indolent clinical course, although, in a minority of cases, particularly in large tumors with nuclear atypia, more aggressive behavior may be observed.

The sensitivity and specificity of touch preparation for rapid diagnosis of invasive fungal sinusitis: A pilot study.

Invasive fungal sinusitis is a morbid pathology that typically affects immunocompromised patients and may quickly progress to fulminant disease. The purpose of this study was to measure the sensitivity and specificity of touch preparation of nasal debridement specimens as a rapid diagnostic tool for invasive fungal sinusitis. A retrospective chart review was performed of 22 patients undergoing nasal debridement due to suspicion for invasive fungal sinusitis over a 10-year period. Thirteen patients had touch preparation of nasal specimens followed by routine histologic processing; 2 of these patients underwent two and 1 patient had three separate debridements, for a total of 17 touch preparations performed. The sensitivity and specificity of touch preparation were calculated by correlating the initial results with the presence of fungal invasion on final pathologic analysis. The sensitivity of touch preparation was 56% (95% confidence interval [CI]: 0.23 to 0.85), specificity was 100% (95% CI: 0.60 to 1.00), positive predictive value was 100% (95% CI: 0.46 to 1.00), and negative predictive value was 67% (95% CI: 0.35 to 0.89). This procedure may be a useful adjunct in situations requiring rapid diagnosis of invasive fungal sinusitis but should not be used as the sole criterion for determining the need for surgical intervention.

Elimination of pain improves specificity of clinical diagnostic criteria for adult chronic rhinosinusitis.

OBJECTIVE: Determine whether the elimination of pain improves accuracy of clinical diagnostic criteria for adult chronic rhinosinusitis. STUDY DESIGN: Retrospective cohort study. METHODS: History, symptoms, nasal endoscopy, and computed tomography (CT) results were analyzed for 1,186 adults referred to an academic otolaryngology clinic with presumptive diagnosis of chronic rhinosinusitis. Clinical diagnosis was rendered using the 1997 Rhinosinusitis Taskforce (RSTF) Guidelines and a modified version eliminating facial pain, ear pain, dental pain, and headache. RESULTS: Four hundred seventy-nine subjects (40%) met inclusion criteria. Among subjects positive by RSTF guidelines, 45% lacked objective evidence of sinonasal inflammation by CT, 48% by endoscopy, and 34% by either modality. Applying modified RSTF diagnostic criteria, 39% lacked sinonasal inflammation by CT, 38% by endoscopy, and 24% by either modality. Using either abnormal CT or endoscopy as the reference standard, modified diagnostic criteria yielded a statistically significant increase in specificity from 37.1% to 65.1%, with a nonsignificant decrease in sensitivity from 79.2% to 70.3%. Analysis of comorbidities revealed temporomandibular joint disorder, chronic cervical pain, depression/anxiety, and psychiatric medication use to be negatively associated with objective inflammation on CT or endoscopy. CONCLUSION: Clinical diagnostic criteria overestimate the prevalence of chronic rhinosinusitis. Removing facial pain, ear pain, dental pain, and headache increased specificity without a concordant loss in sensitivity. Given the high prevalence of sinusitis, improved clinical diagnostic criteria may assist primary care providers in more accurately predicting the presence of inflammation, thereby reducing inappropriate antibiotic use or delayed referral for evaluation of primary headache syndromes. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1011-1016, 2017.

Effectiveness of a standardized education process for tracheostomy care.

OBJECTIVES/HYPOTHESIS: Evaluate the effectiveness of an educational curriculum on general tracheostomy care principles and determine the effect of this educational curriculum on the level of provider comfort with tracheostomy care. STUDY DESIGN: Cross-sectional questionnaire in an academic medical center. MATERIALS AND METHODS: A 25-question multiple choice and true/false quiz was given to nonotolaryngology health care providers (nurses and physicians) who routinely provide tracheostomy care. This was followed by an education module, and the quiz was repeated. Participants were also asked to rate their level of comfort (0-100 point scale) managing a tracheostomy before and after the module. A 6-month follow-up assessment was also obtained. RESULTS: A total of 94 health care providers participated in the education module (50 physicians, 37 nurses, 7 fourth-year medical students). The average number of correct answers increased by 3.1 (P < 0.001). The level of confidence in tracheostomy care improved by 18.8 points (P < 0.001). At the 6-month assessment, there was still a significant improvement in the number of correct questions and level of confidence when compared to preeducation values (P < 0.02 for both). There was no significant change in the 6-month values when compared to the posteducation values. CONCLUSIONS: A standardized education module for tracheostomy care teaching resulted in significant increases in provider knowledge and confidence. Standardization of tracheostomy education and care is essential in academic hospital medical centers where multiple specialties may be performing tracheostomies and health care providers frequently change. LEVEL OF EVIDENCE: N/A.

Staphylococcus aureus bound to complement receptor 1 on human erythrocytes by bispecific monoclonal antibodies is phagocytosed by acceptor macrophages.

Antibiotic resistant strains of Staphylococcus aureus pose a growing threat to public health, and immunotherapy offers potential modalities to combat antibiotic resistance. We prepared bispecific monoclonal antibody complexes (heteropolymers, HP), specific for the primate erythrocyte complement C3b receptor (CR1) and type 5 capsular polysaccharide of the T5 isolate of S. aureus. Fluorescence microscopy and flow cytometry revealed that HP promote binding of S. aureus to human erythrocytes. Incubation of erythrocyte-bound, HP-opsonized S. aureus with human monocyte/macrophages or mouse macrophage cell lines led to transfer, internalization and killing of bacteria by macrophages with little erythrocyte loss. This reaction is similar to the process in which C3b-opsonized substrates, bound to erythrocyte CR1 by immune adherence, are transferred to acceptor phagocytes. Our results provide the basis for development of an in vivo paradigm focused on immunotherapeutic approaches for treatment of infections due to antibiotic resistant bacteria.

Automatic Identification of Cochlear Implant Electrode Arrays for Post-Operative Assessment.

Cochlear implantation is a procedure performed to treat profound hearing loss. Accurately determining the postoperative position of the implant in vivo would permit studying the correlations between implant position and hearing restoration. To solve this problem, we present an approach based on parametric Gradient Vector Flow snakes to segment the electrode array in post-operative CT. By combining this with existing methods for localizing intra-cochlear anatomy, we have developed a system that permits accurate assessment of the implant position in vivo. The system is validated using a set of seven temporal bone specimens. The algorithms were run on pre- and post-operative CTs of the specimens, and the results were compared to histological images. It was found that the position of the arrays observed in the histological images is in excellent agreement with the position of their automatically generated 3D reconstructions in the CT scans.

Assessment of electrode placement and audiological outcomes in bilateral cochlear implantation.

OBJECTIVE: The goal of this study was to use highly accurate nonrigid algorithms to locate the position of cochlear implant (CI) electrodes and correlate this with audiological performance. PATIENTS: After obtaining institutional review board approval, adult patients who had bilateral CIs were identified, and those with preoperative temporal bone computed tomographic scans were asked to return for a postintervention computed tomography. Sixteen adult patients agreed. Demographics, cause of deafness, length of auditory deprivation, and audiological performance were recorded. INTERVENTION: Using a nonrigid model of the shape variations of intracochlear anatomy, the location of the basilar membrane was specified in relationship to the electrode array. The number of electrodes within each compartment of the cochlea was correlated with hearing in noise and consonant-noun-consonant scores for the known confounding variable: length of deafness. MAIN OUTCOMES: Mann-Whitney U tests of differences were used to compare the hearing performance resulting from implants completely in the scala tympani (ST) versus those not completely in the ST. RESULTS: Of all implants, 62.5% were fully inserted in the ST; 34.4% were partially inserted into the ST and 3.1% was fully inserted in the scala vestibuli. Controlling for the known contributing variable of length of auditory deprivation, our results show that the location of electrodes in relationship to the scala is not predictive of audiological performance. CONCLUSION: We have assessed electrode placement and correlated it with audiological outcome. The presence of the electrodes solely in the ST was not predictive of outcome. We estimate that it would take analyzing data of thousands of CI patients before any valid correlations can be made.

Concurrent nasal surgery and tympanoplasty in adults.

We conducted a retrospective chart review to determine if performing simultaneous nasal surgery and tympanoplasty jeopardizes tympanic membrane graft survival and the surgical outcome. Our study population consisted of 14 consecutively presenting adults with nasal septal deviation and otologic pathology who had undergone simultaneous nasal and otologic procedures at an academic tertiary care medical center. Surgical procedures included septoplasty and bilateral inferior turbinate submucous reduction with concurrent primary or revision tympanoplasty with or without mastoidectomy and ossicular chain reconstruction. Follow-up ranged from 1.8 to 29.8 months (mean: 12.8 ± 10.8). The primary outcomes measures were tympanic membrane graft survival and surgical success; the latter was defined as an absence of middle ear effusion and a lack of need for pressure-equalization tube placement in patients with intact grafts. We found that 13 of the 14 tympanic membrane grafts (92.9%) survived at the most recent follow-up and that 11 patients (78.6%) achieved an aerated middle ear without the need for a pressure-equalization tube. These rates compare favorably with those quoted in the literature for tympanoplasty performed without concomitant nasal surgery. We conclude that septoplasty can be safely and effectively performed at the same time as tympanoplasty with or without mastoidectomy with no increase in the risk of surgical failure.

Iatrogenic perinatal pharyngoesophageal injury: a disease of prematurity.

OBJECTIVE: Perinatal pharyngoesophageal instrumentation, including endotracheal intubation, oral suctioning, and feeding tube placement, is often necessary but risks tissue damage. Our objective was to estimate the incidence of iatrogenic perinatal pharyngoesophageal injury (IPPI) in preterm versus term infants in a children's hospital neonatal intensive care unit (NICU). A secondary goal was to explore the clinical characteristics and outcomes associated with these complications. METHODS: All NICU discharge summaries from 2004 to 2008 were searched for IPPI-related keywords. Highlighted records were reviewed and the incidence of complications calculated by gestational age and weight. RESULTS: Of 5910 total NICU discharges, 6 cases of IPPI were identified, for an overall incidence of 0.10%. All injuries occurred in infants less than 33 weeks gestational age and 1500g, with a trend towards higher incidence with increasing prematurity. The incidence of IPPI rose to 4/1321 (0.30%) at 27-32 weeks and 2/521 (0.38%) at less than 27 weeks gestation. Similarly, IPPI occurred in 3/675 (0.44%) babies born at 1000-1500g and 3/642 (0.47%) babies below 1000g. All affected infants survived with conservative management. CONCLUSIONS: IPPI is a rare but serious complication of perinatal airway instrumentation and is primarily a disease of prematurity. In this sizeable cohort, no complications occurred in term infants, and the incidence of injury increased with decreasing gestational age and weight. This increased propensity towards injury should prompt special care when performing even routine airway procedures on premature neonates.

Anatomic verification of a novel method for precise intrascalar localization of cochlear implant electrodes in adult temporal bones using clinically available computed tomography.

OBJECTIVES/HYPOTHESIS: We have previously described a novel, automated, nonrigid, model-based method for determining the intrascalar position of cochlear implant (CI) electrode arrays within human temporal bones using clinically available, flat-panel volume computed tomography (fpVCT). We sought to validate this method by correlating results with anatomic microdissection of CI arrays in cadaveric bones. STUDY DESIGN: Basic science. METHODS: Seven adult cadaveric temporal bones were imaged using fpVCT before and after electrode insertion. Using a statistical model of intracochlear anatomy, an active shape model optimization approach was employed to identify the scalae tympani and vestibuli on the preintervention fpVCT. The array position was estimated by identifying its midline on the postintervention scan and superimposing it onto the preintervention images using rigid registration. Specimens were then microdissected to demonstrate the actual array position. RESULTS: Using microdissection as the standard for ascertaining electrode position, automatic identification of the basilar membrane coupled with postintervention fpVCT for electrode position identification accurately depicted the array location in all seven bones. In four specimens, the array remained within the scala tympani; in three, the basilar membrane was breached. CONCLUSIONS: We have anatomically validated this automated method for predicting the intrascalar location of CI arrays using CT. Using this algorithm and pre- and postintervention CT, rapid feedback regarding implant location and expected audiologic outcomes could be obtained in clinical settings.