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Journal: American journal of rhinology & allergy

28

BACKGROUND: Transnasal cannulation of the natural ostium in patients with an intact uncinate process is complicated by the lack of direct visualizationof the ostium. Accuracy of transnasal dilation of the maxillary ostium was evaluated for a malleable-tipped balloon device that was bent to specific angles for avoiding the fontanelle during cannulation.METHODS: Transnasal cannulation and dilation of 42 cadaver maxillary sinus ostia was attempted by 6 surgeons including 3 with very limited clinicalexperience using the study device. All physicians received procedure training including the technique to shape the balloon device into the recommended 135 degree maxillary configuration. Tissue dissection was prohibited. Canine fossa trephination and transantral endoscopy were used to evaluate cannulation and dilation outcomes. Physician operators were blinded to transantral images and results were documented by two observers.RESULTS: Appropriate transnasal cannulation and dilation of natural maxillary sinus ostia occurred in 92.9% (39/42) of attempts. Two failures emanated from procedural deviations. In one deviation, the bend angle was changed to 90 degrees and the device tip did not cannulate the ostium. In the second, the device was passed through a preexisting hole in the uncinate and cannulated the natural ostium. A third failure occurred when the device was passed through the fontanelle creating a false lumen.CONCLUSION: Using recommended procedural techniques and a malleable-tipped balloon device, newly trained and experienced physicians alike can perform uncinate-preserving transnasal cannulation and dilation of the maxillary ostium with a high rate of success.

Concepts: Sinusitis, Physician, Failure, Angle, Maxillary sinus, Cadaver, Dissection, Uncinate process of ethmoid bone

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Background Saline nasal lavage is one of the treatments of sinonasal diseases. Evidence from basic research favors hypertonic saline (HS) over isotonic saline (IS) for mucociliary clearance, but evidence from clinical studies is controversial. Conversely, HS may carry greater side effects. Objective To compare the effects of HS and IS nasal irrigation in treating sinonasal diseases. Methods Systematic search with Ovid MEDLINE, Scopus, PubMed, Google Scholar, and Manual additional sources was conducted. Randomized controlled trials comparing HS with IS nasal irrigation in treating any sinonasal diseases, including rhinitis and rhinosinusitis, were included. Data were pooled for meta-analyses. Outcomes were symptom scores, sinonasal outcome test (SNOT), and adverse events. Heterogeneity was explored by subgroup analyses. Results Nine studies (740 patients) were included. HS nasal irrigation brought greater benefits over IS in symptom reduction (standardized mean difference (SMD) -0.58; 95% confidence interval [CI]: -0.76, -0.40); however, no difference was shown in SNOT-20 improvement (mean difference 1.81; 95% CI: -0.68, 4.30). In subgroup analyses, effects favoring HS on symptoms were larger in 4 subgroups. These were (1) patients with rhinitis (SMD -1.09; 95% CI: -1.42, -0.76) compared with rhinosinusitis (SMD -0.37; 95% CI: -0.58, -0.15), P < .01; (2) patients under the age of 18 years (SMD -1.22; 95% CI: -1.53, -0.91) compared with patients over the age of 18 years (SMD -0.26; 95% CI: -0.49, -0.04), P < .01; (3) saline irrigation using high volume (SMD -0.89; 95% CI: -1.18, -0.60) compared with low volume (SMD -0.39; 95% CI: -0.62, -0.16), P < .01; and (4) saline irrigation with hypertonicity of <3% (SMD -1.09; 95% CI: -1.42, -0.76) and hypertonicity of 3%-5% (SMD -1.20; 95% CI: -1.61, -0.78) compared with hypertonicity of >5% (SMD 0.20; 95% CI: -0.15, 0.55), P < .01. Buffered saline and operative status did not have impact. HS brought greater minor adverse effects. No major adverse effects were reported. Conclusion HS improves symptoms over IS nasal irrigation in treating sinonasal diseases. There is no difference in disease-specific quality of life. However, HS brings greater minor side effects than IS.

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Background Misuse and diversion of opioids have contributed to the U.S. opioid crisis, making an understanding of specialty-specific and procedure-specific trends essential. Objective The objective of this analysis was to evaluate nationwide trends in opioid prescribing patterns among sinus surgeons performing functional endoscopic sinus surgery and maxillary sinus balloon dilation, specifically examining factors associated with variations. Methods High-volume sinus surgeons were identified through the Centers for Medicare and Medicaid Services database and cross-referenced against prescriptions to Medicare Part D beneficiaries during 2013 through 2015. Number of opioid prescriptions, prescription lengths, and demographic information were obtained. Results This cohort of 570 surgeons wrote 21,042 opioid prescriptions (5.4 days per prescription) in 2015, with 80.3% and 54.7% writing >10 and >25 prescriptions, respectively. Surgeons writing a greater amount of prescriptions wrote lengthier courses throughout all 3 years ( P = .01, P = .002, P = .003). Female otolaryngologists wrote lengthier prescriptions (6.2 vs 5.3 days, P = .01). Early career otolaryngologists (≤10 years) offered fewer prescriptions compared to those who had greater experience (31.1 vs 39.3, P = .02). Moreover, 73.6% of fellowship-trained otolaryngologists offered >10 prescriptions versus 82.7% of nonfellowship-trained otolaryngologists ( P = .02). Practitioners in the South on average prescribed the greatest amount of opioids ( P < .05). Conclusion A majority of sinus surgeons prescribe ≥25 opioid prescriptions annually, with otolaryngologists who write a greater amount of prescriptions writing lengthier courses. As the mean opioid prescription length is 5.4 days, recent legislation limiting opioid prescriptions to 5 days may only have a modest impact for preventing the diversion of perioperative opioid prescriptions. These data suggest further standardized guidelines may be beneficial in elucidating the appropriate indications for the prescription of opioids among sinus surgeons.

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Background Chronic rhinosinusitis (CRS) is a devastating disease affecting nearly 30 million people in the United States. An interim analysis of data from the present study suggested that, in patients who had previously failed medical therapy, balloon sinus dilation (BSD) plus medical management (MM) provides a significant improvement in the quality of life (QOL) at 24 weeks postprocedure compared to MM alone. Objective The primary objective of this final analysis was to evaluate the durability of treatment effects through the 52-week follow-up. Methods Adults aged 19 and older with CRS who had failed MM elected either BSD plus MM or continued MM. Patients were evaluated at 2 (BSD arm only), 12, 24, and 52 weeks posttreatment. Balloon dilations were performed either as an office-based procedure under local anesthesia or in the operating room per physicians' and patients' discretion. The primary end point was change in patient-reported QOL as measured by Chronic Sinusitis Survey (CSS) total score from baseline to the 24-week follow-up. Secondary outcomes including changes in CSS, Rhinosinusitis Disability Index (RSDI), and Sino-Nasal Outcome Test (SNOT) total and subscores, sinus medication usage, missed days of work/school, number of medical care visits, and sinus infections from baseline to the 52-week follow-up are reported here within. Results BSD led to sustained greater improvements in self-reported QOL using the CSS and RSDI total scores with a trend toward improvement in the SNOT-20 total score from baseline to the 52-week follow-up compared to continued MM. There were no changes in medication usage apart from nasal steroid usage for which the MM cohort had an increase in usage. There were no device-related serious adverse events. Conclusion The current analysis highlights the safety, effectiveness, and durability of BSD in CRS patients aged 19 and older who had previously failed MM.

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Background Rhinitis is a highly prevalent yet often misdiagnosed condition. Patients who have local allergic rhinitis are regularly mislabeled as having a nonallergic etiology. Thus, a highly accurate, reproducible, and noninvasive assessment, which can be performed quickly and with minimal discomfort to the patient, is required. Objective The aim of this research was to identify the efficiency of various nasal brushes as tools for harvest and collection of epithelial proteins and its suitability for identification of rhinitis. Methods Nasal epithelial mucosa samples were taken from patients undergoing turbinate surgery using a cytology brush, a dental brush, and a nasal curette in random order. After washing in phosphate-buffered saline, the suspended cells were sonicated. Total protein content was assessed for all samples by bicinchoninic acid assay measured using a Nanodrop machine. Identification of nasal-specific immunoglobulin E (spIgE) was then assessed using immunoassay and compared to the patient’s allergic status from epicutaneous and serum testing. The lower threshold limit for the spIgE in nasal brushings was determined using the results of serum spIgE tests as the reference. The diagnostic accuracy of this new established cutoff value was determined. Results The cytology brush was found to be the optimal tool for maximal nasal mucosa protein collection followed by dental brush and nasal curette (0.75 ± 0.45 mg/mL vs 0.43 ± 0.24 mg/mL vs 0.071 ± 0.55 mg/mL, respectively; P < .01). The optimal cutoff value of nasal spIgE from the cytology nasal brushings was 0.14 kUA/L to predict allergic status from serum testing. This gave a sensitivity of 75%, specificity of 86%, positive predictive value of 74%, likelihood ration positive of 5.40, and diagnostic odds ratio of 18.62. Conclusion The cytology brush is the optimal tool for protein collection. This is an easy and direct method to sample the nasal mucosa for assessment of nasal allergy or future biomarkers.

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The most common tests for allergen sensitization in patients with allergic rhinitis are the skin-prick test (SPT) and an in vitro test to detect serum specific immunoglobulin E (sIgE). However, in vitro allergen test results were interpreted dichotomically as positive or negative at a threshold of 0.35 kU/L of sIgE, regardless of the patient characteristics or antigen types.

Concepts: Immune system, Antibody, Asthma, Patient, Immunology, Allergy, Antigen, House dust mite

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Radionecrosis is a complication of nasopharyngeal carcinoma (NPC) that is difficult to treat. Endoscopic debridement is the first-line treatment for radionecrosis. After debridement, however, either bone or the internal carotid artery is exposed and requires mucosal coverage.

Concepts: Internal carotid artery, Common carotid artery, External carotid artery, Carotid sinus, Internal jugular vein, Nasopharyngeal carcinoma, Nasopharynx

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Secondary cerebrospinal leaks (CSF) are leaks that recur after an initial endoscopic repair of CSF leaks. Identification of characteristics that could predict secondary leaks may allow surgeons to plan repairs with the knowledge that these defects are more likely to fail.

Concepts: Scientific method, Futurology, Taxonomy, Cerebrospinal fluid, Spontaneous cerebrospinal fluid leak

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Allergic rhinitis (AR) and chronic rhinosinusitis with nasal polyps (CRSwNP) are inflammatory diseases of the upper airway, with a similar immunologic profile, characterized by aberrant and persistent type 2 inflammation. One cell population that has been identified as altered in both disease types is regulatory T cell (Treg). Tregs have the capacity to modulate T-effector function and suppress inflammatory cytokine production in a broad range of cell types. Given the ability of Tregs to control inflammation, the role of Tregs in respiratory diseases has attracted much attention. As discussed in this article, alterations in the Treg numbers and function, or both, have been identified in AR and CRSwNP, although much of the data is conflicting. Here, we explored what is known and, in many cases, unknown about the mechanisms by which Tregs differentiate and function, and how these functions can be controlled in the mucosal microenvironment. By gaining a greater understanding of these processes, it may be possible to harness the natural immunosuppressive activity of Tregs to ameliorate the chronic inflammation associated with AR and CRSwNP.

Concepts: Immune system, Inflammation, Asthma, Sinusitis, Allergy, T cells, Autoimmunity, Regulatory T cell

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CD8+ T cells and natural killer (NK) cells are cytotoxic cells that use granzyme B (GrB) and perforin. Defective cytotoxic function is known to play a role in dysregulated immune response as seen in chronic sinusitis, also referred to as chronic rhinosinusitis (CRS). However, to our knowledge, in the United States, neither GrB or perforin expression has been reported in patients with CRS.

Concepts: Immune system, United States, Sinusitis, Natural killer cell, Allergy, T cell, Cytotoxic T cell, Granzyme