The price of pain in chronic rhinosinusitis

Background

Chronic rhinosinusitis (CRS) is associated with productivity losses exceeding US$13 billion annually. Although pain is well known to significantly affect patient productivity in other diseases, its economic impact on CRS‐related lost productivity has not been examined. The objective of this study was to determine whether CRS‐related facial pain correlates with lost productivity in patients with CRS.

Methods

Seventy patients with CRS were enrolled in a cross‐sectional investigation. Patients with a history of systemic inflammatory disease, ciliary dysfunction, chronic pain syndromes, migraines, and fibromyalgia were excluded. Pain was measured using the Brief Pain Inventory Short Form (BPI‐SF) and the Short‐Form McGill Pain Questionnaire (SF‐MPQ). Presenteeism, absenteeism and lost work, and household and overall productivity were assessed. Regression analysis was performed to assess potential confounders, including depression.

Results

Pain as measured with BPI‐SF and SF‐MPQ total scores correlated with all domains of productivity losses. Overall, lost productivity was significantly correlated with pain (R range, 0.354‐0.485; p < 0.001). Presenteeism (reduced work efficiency) had the highest correlation with all of the overall pain scores (R range, ?0.366 to ?0.515; p < 0.001). Lost household productivity time was the least affected by pain (R range, 0.267‐0.389; p < 0.05). These correlations remained statistically significant after regression analysis, which accounted for depression (p < 0.05).

Conclusion

A significant correlation exists between CRS‐related facial pain and productivity losses in patients with CRS that is independent of depression. Facial pain has the strongest correlation with presenteeism, which is the main driver of productivity losses and indirect costs associated with CRS.

     

Olfactory loss in chronic rhinosinusitis is associated with neuronal activation of c‐Jun N‐terminal kinase

Background

Olfactory inflammation in chronic rhinosinusitis (CRS) is associated with cytokines that may result in the death of olfactory sensory neurons. The principal signaling molecules involved in the apoptotic pathway are c‐Jun N‐terminal kinases (JNK). Although the JNK pathway has emerged as a key player in programmed cell death in neuroinflammation, its specific role in CRS‐associated olfactory loss has not been thoroughly investigated.

Methods

JNK activation was studied in human tissue samples from 9 control and 11 CRS patients by immunohistochemical staining for phosphorylated c‐Jun. A mouse model of inducible olfactory cytokine expression was used to experimentally control inflammation and assess JNK activation over time.

Results

In patients with CRS, activation of c‐Jun is significantly increased relative to non‐CRS control subjects, and there is an associated loss of sensory neurons. In the olfactory inflammation mouse model, prolonged induction of inflammation results in elevation of c‐Jun expression and neuronal apoptosis.

Conclusion

Activation of neuronal JNK is a feature of chronic olfactory inflammation that is associated with neuronal apoptosis. Given that inhibition of JNK activity is neuroprotective in other settings, antagonism of this pathway may have therapeutic potential in the management of inflammatory olfactory loss or other disorders linked to olfactory neuronal apoptosis.

     

Taste impairment in chronic rhinosinusitis

Background

Though many patients with chronic rhinosinusitis (CRS) describe disturbances in smell and taste, there have been no studies specifically assessing taste impairment in CRS. This study sought to objectively assess taste dysfunction in CRS patients and determine whether taste impairment correlates with olfactory dysfunction. Additionally, this investigation sought to determine the impact of taste dysfunction on quality of life (QOL) in CRS and identify the clinical factors that influence taste.

Methods

Sixty‐eight CRS patients were prospectively enrolled and completed several QOL surveys in relation to taste, smell, overall sinus‐specific QOL, and depression. Validated taste strips were used to determine gustatory dysfunction pertaining to sweet, sour, salty, and bitter. Olfactory testing was assessed using the Sniffin’ Sticks Test while both Lund‐Kennedy and Olfactory Cleft Endoscopy Scoring (OCES) systems were used for endoscopic evaluation.

Results

The overall prevalence of dysgeusia was 28%, with scores significantly lower for sour compared to other subgroups. No correlation was observed between taste scores and objective olfactory metrics including olfaction tests and OCES. Taste scores were better in younger patients (r = 0.28, p = 0.02), female patients (p = 0.004), and never smokers compared to former smokers (p = 0.01). Taste scores did not correlate with patient‐reported outcome measures or CRS disease severity metrics.

Conclusion

Taste dysfunction is a common complaint in CRS. This cohort shows prevalence of gustatory loss to be about 28% using ideal normative values. This dysfunction correlated with male gender, smoking history, and older age. Taste dysfunction did not correlate with measured olfactory outcomes.

     

Bacteriophage effectively kills multidrug resistant Staphylococcus aureus clinical isolates from chronic rhinosinusitis patients

Background

Bacteriophage (phage) therapy has been proposed as an alternative to antibiotics. Phages have been shown to kill antibiotic resistant Staphylococcus aureus strains; however, it is unknown whether stress‐induced antibiotic tolerance affects S. aureus susceptibility to phages. Our objective was to determine the effectiveness of 2 phages currently in clinical development, against antibiotic‐resistant and induced antibiotic‐tolerant clinical S. aureus isolates.

Methods

Antibiotic tolerant S. aureus strains were induced by incubation with increasing concentrations of gentamicin, mupirocin, and ciprofloxacin over time and their susceptibility to 2 clinically relevant phages (Sa83 and Sa87) was assessed. In addition, phage susceptibility was tested in relation to the antibiotic sensitivity of 65 clinical S. aureus isolates, harvested from the sinonasal cavities of chronic rhinosinusitis (CRS) patients. Phage sensitivity was assessed using a plaque spot assay and by measuring optical density values to observe planktonic S. aureus growth in the presence of the phage. Alamar Blue assays were used to assess biofilm viability after phage treatment.

Results

Frequency of antibiotic resistance amongst clinical S. aureus isolates was 90.7% (59/65) with 13 of 65 (20.0%) identified as multidrug‐resistant. Tolerance to gentamicin, mupirocin, and ciprofloxacin was rapidly induced by incubation with increasing concentrations of respective antibiotics. There was no significant difference in phage sensitivity between antibiotic‐sensitive and resistant/tolerant S. aureus clinical isolates in planktonic and biofilm form.

Conclusion

Clinical S. aureus isolates from CRS patients have a high (20%) incidence of multidrug resistance. Antibiotic resistance or tolerance did not affect phage susceptibility of those isolates.

     

Submucosal gland mucus strand velocity is decreased in chronic rhinosinusitis

Background

Chronic rhinosinusitis (CRS) may be initiated by innately impaired host defense mechanisms that predispose the upper airways to infection. Recent evidence suggests tethering of submucosal gland mucus strands represents an inciting event within cystic fibrosis (CF) airways, occurring prior to onset of chronic infection. Submucosal gland hypertrophy and defective mucociliary clearance (MCC) are present in actively inflamed sinuses, but mucus strand velocity may also be affected as a secondary event, further contributing to chronic disease. The objective of this study is to assess whether mucus strand velocity is decreased in patients with CRS.

Methods

Mucosal explants from patients with and without CRS were submerged in Ringer's solution mixed with fluorescent nanospheres. Methacholine was then added, and videos demonstrating strand growth and detachment were generated from a time‐lapse of Z‐stack images using a multiphoton confocal microscope. Dynamic mucus strands were identified and individual velocities quantified with the MTrackJ plug‐in of ImageJ.

Results

Fifteen patients met criteria for ex vivo analysis of mucus strand velocities (CRS, n = 9 vs controls, n = 6). Mucus strands were recorded (pixels/second) streaming from the submucosal gland openings. Average mucus strand velocities were significantly decreased in patients with CRS (1.53 ± 0.67 vs controls, 4.86 ± 1.68 pixels/second; p < 0.001).

Conclusion

This study is the first to report evidence of abnormal mucus strand velocity from submucosal glands in diseased sinonasal mucosa. Future pharmacologic studies targeting this critical component of MCC are warranted.

     

Asthma onset pattern and patient outcomes in a chronic rhinosinusitis population

Background

Chronic rhinosinusitis (CRS) is strongly associated with comorbid asthma. This study compares early‐onset and late‐onset asthma in a CRS population using patient‐reported and clinical characteristics.

Methods

At enrollment into a clinical registry, CRS patients completed the 22‐item Sino‐Nasal Outcome Test (SNOT‐22), Asthma Control Test (ACT), mini‐Asthma Quality of Life Questionnaire (miniAQLQ), the 29‐item Patient‐Reported Outcomes Measurement Information System (PROMIS‐29), and medication use questionnaires. Patients also reported comorbid asthma and age at first asthma diagnosis. Early‐onset (<18 years) and late‐onset (>18 years) asthma groups were defined. Analysis of variance (ANOVA), chi‐square, and Kruskal‐Wallis tests were used to compare patient responses.

Results

A total of 199 non‐asthmatic (56.1%), 71 early‐onset asthmatic (20.0%), and 85 late‐onset asthmatic (23.9%) CRS patients completed the survey. Body mass index (BMI) was significantly higher in late‐onset asthmatic (p = 0.046) while age, gender, race, and smoking history did not differ with time of asthma onset. SNOT‐22, ACT, and miniAQLQ were not different between asthma groups, but late‐onset asthmatics had significantly lower physical function than non‐asthmatics (p = 0.008). Compared to non‐asthmatics, late‐onset asthmatics showed increased rates of nasal polyps (p < 0.001), higher Lund‐Mackay scores (p = 0.005), and had received more oral steroid courses (p < 0.001) and endoscopic surgeries (p = 0.008) for CRS management. Late‐onset asthmatics compared to early‐onset asthmatics showed increased nasal polyposis (p = 0.011) and oral steroid courses for CRS (p = 0.003).

Conclusion

While CRS‐specific and asthma‐specific patient‐reported outcome measures (PROMs) were not significantly different among groups, CRS patients with late‐onset asthma had poorer physical function, more frequent nasal polyposis, and required increased treatment for CRS. Late‐onset asthma may predict more severe disease in CRS.

     

Shortcomings in the diagnosis of chronic rhinosinusitis: evaluating diagnosis by otolaryngologists and primary care physicians

Background

Chronic rhinosinusitis (CRS) is a prevalent illness in the United States that accounts for 18–22 million physician visits annually. The American Academy of Otolaryngology–Head and Neck Surgery (AAO‐HNS) has defined diagnostic criteria, but a recent study demonstrated that nearly all patients diagnosed by nonspecialists did not meet these criteria. In this study we aimed to evaluate the diagnostic rate of CRS by primary care physicians and otolaryngologists.

Methods

We retrospectively reviewed a random sample of adult patients diagnosed with CRS in 2016, based on ICD‐10 codes from primary care and otolaryngology departments. Patients with previous CRS diagnosis, previous sinus surgery, and related comorbidities were excluded.

Results

A total of 502 patients with a new CRS diagnosis were analyzed (308 from primary care, 194 from otolaryngology). The percentage of diagnoses meeting the criteria was significantly higher from otolaryngology (28.9% vs 0.97%, p < 0.0001), but was low in both cohorts. Symptom duration <12 weeks was higher in primary care (81.6% vs 53.6%, p < 0.0001), as was lack of evidence of inflammation (97.4% vs 50.0%, p < 0.0001). Having <2 of the required symptoms was significantly higher in otolaryngology (63.8% vs 50.8%, p = 0.013). The most commonly unevaluated symptom was decreased sense of smell (97.7% in primary care, 69.1% in otolaryngology encounters).

Conclusion

CRS diagnoses commonly do not meet the diagnostic criteria outlined by the AAO‐HNS in both primary care and otolaryngology. As a specialty, we should aim to improve our adherence to the guidelines and educate our primary care colleagues to better identify patients with CRS and initiate appropriate treatment.

     

Glucocorticoid receptor isoform expression in peripheral blood mononuclear leukocytes of patients with chronic rhinosinusitis

Background

In several inflammatory disorders, altered peripheral blood mononuclear leukocyte (PBML) glucocorticoid (GC) receptor isoform expression has been associated with GC resistance and disease severity. However, it is unclear if PBML GC receptor isoforms are expressed differentially and are associated with worsened disease severity in chronic rhinosinusitis (CRS).

Methods

PBMLs were isolated from control (n = 8), CRS without nasal polyps (CRSsNP) (n = 8), atopic CRS with nasal polyps (CRSwNP) (n = 8), non‐atopic CRSwNP (n = 8), and allergic fungal rhinosinusitis (AFRS) (n = 8) patients. Demographics, atopic status, asthmatic status, 22‐item Sino‐Nasal Outcome Test (SNOT‐22) scores, Lund‐Kennedy nasal endoscopy scores, Lund‐Mackay sinus computed tomography (CT) scores, Kennedy Osteitis scores, and GC utilization 6 months postoperatively were collected. Intracellular immunostaining was then performed for functional GC receptor α (GCRα) and nonfunctional GC receptor β (GCRβ), followed by flow cytometry analysis of geometric mean fluorescent intensity (MFI) and the percentage of cells expressing each GC receptor isoform.

Results

Compared to controls, each CRS subtype had decreased PBML GCRα and GCRα:GCRβ MFI expression, but no difference in GCRβ expression. Decreasing PBML GCRα in AFRS was associated with increasing Lund‐Mackay sinus CT scores (r = ?0.880, p =0.004). No significant associations were found between GC receptor isoform expression and other clinical measures.

Conclusion

CRS patients have reduced functional PBML GCRα expression and decreased GCRα:GCRβ compared to controls. Reductions in GCRα in AFRS are associated with worsening Lund‐Mackay sinus CT scores. The clinical implications of decreased functional GC receptor expression merits further investigation.

     

Monitoring olfactory function in chronic rhinosinusitis and the effect of disease duration on outcome

Background

Our primary aim in this study was to determine which of the “Sniffin’ Sticks” subtest components (threshold, discrimination, or identification) best reflect overall change in olfactory function during treatment for chronic rhinosinusitis (CRS). Our secondary aim was to determine whether duration of CRS affects olfactory outcomes after treatment.

Methods

A retrospective cohort study was performed. Sniffin’ Sticks test scores from patients medically treated for CRS at our center from 1999 to 2016 were analyzed. Only patients with 2 test scores available were included.

Results

Results from 408 patients were included (mean age, 56 years; male:female ratio, 217:191). There was a statistically significant improvement in threshold (T), discrimination (D), and identification (I) scores as well as the composite “TDI” score between the two testing sessions. Controlling for age, there was a significantly greater improvement in composite TDI score in patients with CRS of ≤24 months duration. As expected, we found statistically significant correlations between change in overall composite TDI score and change in threshhold, discrimination, and identification, between sessions. Of the individual subcomponents, change in discrimination correlated best with change in composite TDI score (r = 0.82, p < 0.0001). This relationship was maintained irrespective of duration of CRS.

Conclusions

In patients with CRS, odor discrimination appears to best reflect overall changes in olfactory function, as determined using the composite TDI score. Furthermore, olfactory outcomes are better when treatment is started sooner.

     

The prevalence of Eustachian tube dysfunction symptoms in patients with chronic rhinosinusitis

Background

While Eustachian tube dysfunction (ETD) is a known comorbidity of chronic rhinosinusitis (CRS), the prevalence of ETD symptoms in the CRS population is poorly understood. We sought to determine the cross‐sectional prevalence of ETD in patients with CRS using the validated Eustachian Tube Dysfunction Questionnaire (ETDQ‐7) and to correlate ETDQ‐7 scores with 22‐item Sino‐Nasal Outcome Test (SNOT‐22) scores, endoscopy scores, and computed tomography (CT) scores.

Methods

A total of 101 patients with confirmed CRS completed the ETDQ‐7 and SNOT‐22 at their initial visit to our rhinology clinic. Lund‐Mackay CT and Lund‐Kennedy endoscopy scores were also obtained. Spearman's correlation coefficient (ρ) was calculated.

Results

Among the 101 patients, 49 patients (48.5%) had an ETDQ‐7 score of ≥14.5, signifying clinically significant ETD. The mean ± standard deviation (SD) ETDQ‐7 score of the entire cohort was 17.8 ± 10.1. There was a moderately strong correlation between ETDQ‐7 and the SNOT‐22 ear subdomain (ρ = 0.691, p < 0.001). The correlation coefficient between ETDQ‐7 and total SNOT‐22 scores was ρ = 0.491 (p < 0.001), indicating moderate correlation. ETDQ‐7 scores were poorly correlated to objective measures of sinonasal disease, including Lund‐Mackay CT score (ρ = ?0.055, p = 0.594) and Lund‐Kennedy endoscopy score (ρ = ?0.099, p = 0.334).

Conclusion

Symptoms of ETD are highly prevalent among patients with CRS as documented by patient‐reported outcome measures. The correlation between ETDQ‐7 scores and SNOT‐22 ear subdomain scores is moderately strong, while the correlation between ETDQ‐7 scores and SNOT‐22 scores is moderate. ETD severity does not correlate with CT score or nasal endoscopy score.

     

EXHANCE‐12: 1‐year study of the exhalation delivery system with fluticasone (EDS‐FLU) in chronic rhinosinusitis

Background

Inadequate efficacy of current intranasal steroids in chronic rhinosinusitis (CRS) is attributable to ineffective and/or inconsistent drug delivery to target anatomic sites. A new exhalation delivery system with fluticasone (EDS‐FLU) may improve outcomes by significantly increasing superior/posterior corticosteroid delivery. A study was conducted to assess the long‐term efficacy and safety outcomes of EDS‐FLU in individuals with CRS.

Methods

This was a 12‐month, multicenter, single‐arm study evaluating the safety and efficacy of EDS‐FLU 372 μg twice daily in CRS patients (with [n = 34] or without [n = 189] nasal polyps [NP]). Efficacy assessments by serial nasal endoscopy and patient report included: 22‐item Sino‐Nasal Outcome Test (SNOT‐22), NP grade, standardized surgical indicator assessment, Lund‐Kennedy score, and Patient Global Impression of Change. Adverse event (AE) evaluations included nasal endoscopy. Additional safety and efficacy outcomes were assessed.

Results

Of 223 patients who received EDS‐FLU, 96% reported prior corticosteroid use and 29% prior sinus surgery. The EDS‐FLU AE profile was similar to conventional intranasal steroids studied in similar populations. Most patients (87%) reported symptom improvement. Through 12 months, mean SNOT‐22 scores improved by ?21.5 and ?21.1 for CRS with and without NP, respectively. Among patients with NP, 54.2% had polyp elimination in at least 1 nostril and 83.3% had ≥1‐point improvement in polyp grade.

Conclusion

Over 1 year of treatment in CRS with and without NP, EDS‐FLU 372 μg twice daily was well tolerated and produced improvements across a broad range of objective and subjective measures. EDS‐FLU may be a desirable new option for patients with this condition.

     

Role of Toll‐like receptor 9 signaling on activation of nasal polyp–derived fibroblasts and its association with nasal polypogenesis

Background

Nasal polyposis is characterized by persistent inflammation and remodeling in sinonasal mucosa. Toll‐like receptor 9 (TLR9) is a DNA receptor of the innate immune system that plays a pivotal role in fibrosis and inflammatory responses. The aim of this study is to explore the expression, activity, and potential pathogenic role of TLR9 signaling in tissue remodeling in nasal polyp–derived fibroblasts (NPDFs).

Methods

Fibrotic and inflammatory responses elicited by type A CpG oligonucleotides were examined in the NPDFs by a combination of real‐time quantitative polymerase chain reaction, Western blot analysis, enzyme‐linked immunosorbent assay, and immunofluorescence staining. For these experiments, the NPDFs were stimulated with different TLR9 agonists (CpG A and B) and blocked with inhibitors (MyD88 inhibitor and chloroquine).

Results

TLR9 expression was significantly higher in nasal polyposis (NP) tissues compared to control or chronic rhinosinusitis (CRS) mucosa. In the NPDFs, TLR9 showed intracellular localization and expression of TLR9 was increased after treatment with CpG A. CpG A increased production of α‐smooth muscle actin (α‐SMA), fibronectin, and matrix metalloproteinases (MMPs) (MMP1, MMP2, and MMP9) in the NPDFs, while MyD88 inhibitor and chloroquine, which are known to block the TLR9 signaling pathway, inhibited their production. CpG A also produced type I interferons (IFN‐α and IFN‐β), which were inhibited by MyD88 inhibitor.

Conclusion

Our data indicates that CpG A–induced fibroblast activation and cytokine production were mediated via TLR9 stimulation in NPDFs. Disrupting this process with an inhibitor targeting TLR9 or its downstream signaling pathways could represent a novel approach to CRS with NP (CRSwNP) therapy.

     

The sinonasal microbiota,neural signaling,and depression in chronic rhinosinusitis

Background

The complex relationships between the human microbiota, the immune system, and the brain play important roles in both health and disease, and have been of increasing interest in the study of chronic inflammatory mucosal conditions. We hypothesized that the sinonasal microbiota may act as a modifier of interkingdom neural signaling and, subsequently, mental health, in the upper respiratory inflammatory condition chronic rhinosinusitis (CRS). In this study we investigated associations between the sinonasal microbiota; local concentrations of the neurotransmitters serotonin, dopamine, and γ‐aminobutyric acid (GABA); and depression severity in a cohort of 14 CRS patients and 12 healthy controls.

Methods

Subject demographics, clinical severity scores, depression index scores, and sinonasal swab and mucus samples were collected at the time of surgery. Bacterial communities were characterized from swabs by 16S rRNA gene‐targeted sequencing and quantified by quantitative polymerase chain reaction. Mucus concentrations of the neurotransmitters serotonin, dopamine, and GABA were quantified by enzyme‐linked immunosorbent assay.

Results

Several commonly “health‐associated” sinonasal bacterial taxa were positively associated with higher neurotransmitter concentrations and negatively associated with depression severity. In contrast, several taxa commonly associated with an imbalanced sinonasal microbiota negatively associated with neurotransmitters and positively with depression severity. Few significant differences were identified when comparing between control and CRS subject groups, including neurotransmitter concentrations, depression scores, or sinonasal microbiota composition or abundance.

Conclusion

The findings obtained lend support to the potential for downstream effects of the sinonasal microbiota on neural signaling and, subsequently, brain function and behavior.

     

Mucus T helper 2 biomarkers predict chronic rhinosinusitis disease severity and prior surgical intervention

Background

Chronic rhinosinusitis (CRS) is a diverse clinical syndrome with a heterogeneous pathophysiology. Early attempts to identify CRS endotypes and biomarkers have largely relied on analysis of surgically obtained tissue, thus limiting their practical utility. This study examined the ability of mucus T helper 2 (Th2) biomarkers to predict CRS disease severity and clinical characteristics.

Methods

CRS (n = 90) and healthy control subjects (n = 17) were prospectively enrolled prior to surgical intervention and mucus levels of interleukin (IL)‐4, IL‐5, and IL‐13 were determined using a multiplex cytometric bead assay. Data for relevant cytokines was then scaled, normalized, and later combined to develop standardized metrics indicative of Th2‐associated inflammation. Th2‐high and Th2‐low subgroups were consequently identified and validated against factors associated with disease severity and clinical outcomes.

Results

Mucus levels of IL‐5 and IL‐13 were elevated in CRS subjects compared to controls, while no significant difference was noted for IL‐4. IL‐5 and IL‐13 high CRS were associated with worse objective measures of disease severity and greater rates of revision surgery. Similar relationships were noted for both cytokines when CRS with nasal polyps (CRSwNP) patients were analyzed separately. Th2‐high CRS and Th2‐low CRS were then categorized using a scaled IL‐5/IL‐13 metric. Th2‐high CRS was characterized by an increased number of subjects with nasal polyps and comorbid asthma, and worse symptom and computed tomography (CT) scores.

Conclusion

The Th2‐associated cytokines, IL‐5 and IL‐13, are detectable in sinonasal mucus and their levels can be used to define Th2‐high and Th2‐low CRS. Identification of Th2‐high and Th2‐low endotypes using mucus‐based biomarkers could facilitate stratification of CRS subgroups and guide personalized therapies.

     

Total intravenous anesthesia vs inhaled anesthetic for intraoperative visualization during endoscopic sinus surgery: a double blind randomized controlled trial

Background

Bleeding during endoscopic sinus surgery (ESS) can impair visualization and delay surgical progress. The role that anesthetic technique may have on the quality of surgical field during ESS has been previously studied. However, meta‐analyses have deemed the current literature inconclusive and lacking methodological consistency. This study was designed with these critiques in mind to assess the effect of total intravenous anesthesia (TIVA) vs inhaled anesthetic on the quality of the surgical field during ESS.

Methods

This study was a double‐blind, randomized, controlled trial of 30 patients of American Society of Anesthesiologists (ASA) class 1 or 2 undergoing bilateral ESS for the primary diagnosis of chronic rhinosinusitis. In addition to standard techniques to minimize blood loss, study patients were randomized to maintenance anesthesia with intravenous propofol or inhaled desflurane. Anesthetic depth was standardized using bispectral index (BIS). The primary outcome measured was the Wormald grading scale to assess the endoscopic surgical field.

Results

The use of TIVA was associated with a statistically significant reduction in mean Wormald score compared to desflurane (4.21 vs 5.53, p = 0.024). Mean Boezaart score was also lower in the TIVA arm (2.18 vs 2.76, p = 0.034). Experimental groups were homogeneous in all compared baseline characteristics. Secondary outcomes including surgical duration, time to extubation, and estimated blood loss were not found to be statistically significant between experimental groups.

Conclusion

Even with all other factors implemented to optimize the surgical field, utilization of TIVA vs inhaled anesthetic still resulted in a statistically significant improvement in surgical field during ESS.

     

Partial resection of the middle turbinate during endoscopic sinus surgery for chronic rhinosinusitis does not lead to an increased risk of empty nose syndrome: a cohort study of a tertiary practice

Background

The treatment of the middle turbinate (MT) during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) remains a contentious issue with arguments both for and against its resection. The purpose of this study was to examine the clinical impact of partial MT resection (PMTR) during ESS, paying particular attention to the risk of developing empty nose syndrome (ENS) and alteration to olfaction.

Methods

This cohort study was performed on prospectively collected data. A total of 177 patients underwent ESS for CRS; 93 had PMTR and 84 MT preservation (MTP). Preoperative data collection included subjective symptom scores as per the Adelaide Disease Severity Score (ADSS), Lund‐Mackay scores, and nasal polyp status. The Empty Nose Syndrome 6‐Item Questionnaire (ENS6Q) was administered by telephone consultation and analyzed alongside postoperative symptom scores.

Results

There was no difference in ENS6Q scores in patients who underwent PMTR vs those who had MTP. Patients who underwent PMTR had a higher baseline disease on Lund‐Mackay scoring, and were more likely to be nasal polyp patients and be undergoing revision surgery. ADSS scores demonstrated significant improvements in all rhinologic symptoms, with no difference between the cohorts.

Conclusion

PMTR is an adjunctive procedure to ESS. This study has established that PMTR as performed by the senior author carries no additional risk of developing ENS symptoms as defined by the ENS6Q, and that it carries no additional risk to olfaction or other rhinologic symptoms. PMTR can be safely considered at time of ESS, especially in patients at risk of lateralization of the MT.

     

Corticosteroid nasal irrigations are more effective than simple sprays in a randomized double‐blinded placebo‐controlled trial for chronic rhinosinusitis after sinus surgery

Background

Persistent mucosal inflammation in patients with chronic rhinosinusitis (CRS) often results in ongoing symptoms, recurrence of polypoid mucosa, infective exacerbations, and further systemic medication despite surgical intervention. Debate exists as to the most effective topical therapy in CRS.

Methods

The objective was to determine if corticosteroid delivered via a nasal irrigation or via a simple nasal spray would be more effective in controlling the symptoms and signs of CRS. A double‐blind placebo‐controlled randomized trial over 12 months was performed between 3 tertiary rhinologic clinics. After sinus surgery, all patients performed a nasal irrigation followed by a nasal spray once a day for 12 months. Groups were defined by corticosteroid (2 mg mometasone) delivered by either spray or irrigation. The primary outcomes were patient‐reported symptoms: visual analogue score (VAS) and 22‐item Sino‐Nasal Outcome Test (SNOT‐22), a global rating of sinonasal function. Secondary outcomes were also recorded from radiology (Lund‐Mackay score [LMS]) and endoscopic (Modified Lund‐Kennedy score [mLKS]) assessments.

Results

A total of 44 patients were randomized (age 50.3 ± 13.0 years; 40.9% female). Overall, patients improved significantly from either intervention. However, the corticosteroid nasal irrigation group had greater improvement in nasal blockage (?69.91 ± 29.37 vs ?36.12 ± 42.94; p = 0.029), a greater improvement on LMS (?12.07 ± 4.43 vs ?7.39 ± 6.94; p = 0.031) and less inflammation on mLKS at 12 months (7.33 ± 11.55 vs 21.78 ± 23.37; p = 0.018). One‐year posttreatment blockage, drainage, fever, and total VAS scores were all lower in the corticosteroid irrigation group.

Conclusion

In the setting of diffuse or patchy CRS disease, the use of corticosteroid delivered by nasal irrigation is superior to simple nasal spray in postsurgical patients.

     

Comparison of outcomes following culture‐directed vs non–culture‐directed antibiotics in treatment of acute exacerbations of chronic rhinosinusitis

Background

Acute exacerbations in patients with chronic rhinosinusitis (CRS) are often treated with courses of systemic antibiotics. Poor correlation between microbiologic culture results and the sinus microbiome in CRS has caused increased debate as to the relevance of culture‐directed antibiotics. There is currently sparse data comparing outcomes of culture‐directed antibiotics vs non‐culture‐directed antibiotics for treatment of CRS.

Methods

This work reports a retrospective review. A total of 946 CRS patients treated with antibiotics were examined; 122 CRS patients with acute exacerbations were treated with culture‐directed (n = 61) vs empiric (n = 61) antibiotics. Lund‐Kennedy (LK) and 22‐item Sino‐Nasal Outcome Test (SNOT‐22) scores were compared pretreatment and posttreatment, with short‐term (<1 month) and long‐term (1‐6 months) follow‐up. Patient demographics, comorbidities, and prior surgical history were collected.

Results

Both groups had similar pretreatment SNOT‐22 scores (p = 0.25) while the culture group had higher baseline LK endoscopy scores (p < 0.01). All data were adjusted for pertinent comorbidities, surgical history, co‐therapeutics, and baseline scores. There was no difference in improvement in culture‐directed and empirically treated groups in the short‐term (p = 0.77) and long‐term (p = 0.58) for minimal clinically important difference (MCID) of SNOT‐22 and no difference in the short‐term for LK scores (p = 0.11), but there was significantly more improvement in long‐term LK scores in the culture‐directed group (p = 0.01).

Conclusion

Culture‐directed therapy improves long‐term endoscopy scores but does not yield an advantage in improving short‐term endoscopy scores, nor in improving short‐term and long‐term quality of life scores in CRS patients. A prospective study is necessary to examine the relevance of routine microbiologic cultures in CRS patients.

     

Comparing the efficacy of Silastic and gloved‐Merocel middle meatal spacers for functional endoscopic sinus surgery: a randomized controlled trial

Background

Spacers are inserted into the middle meatal space (MMS) following functional endoscopic sinus surgery (FESS) to prevent lateralization of the middle turbinate, scarring, and synechiae. Our objective was to determine if the incidence of postoperative synechiae, facial pain/discomfort, pain during spacer removal, scarring, and discharge differed between nasal cavities receiving Silastic or gloved‐Merocel (GM) spacers following FESS.

Methods

A double‐blind, randomized controlled trial (RCT) was conducted in adults requiring bilateral FESS for chronic rhinosinusitis (CRS) ± nasal polyposis. Participants served as their own controls, with each subject receiving both a Silastic and GM spacer. Spacers were inserted into the MMS during FESS and left in situ for 6 days. Participants were reviewed at 6 days, 5 weeks, and 12 weeks postoperatively. The presence of synechiae and scarring were evaluated endoscopically. Inflammation, discharge, and pain during spacer removal were assessed using a visual analogue scale (VAS).

Results

Forty‐eight participants (96 nasal cavities) were recruited. Preoperatively, Lund‐Mackay computed tomography (CT) scores were similar between Silastic‐treated and GM‐treated cavities (6.38 ± 2.35 vs 6.18 ± 2.17). The incidence of synechiae and scarring did not differ significantly between spacers up to 12 weeks postoperatively. Pain during spacer removal was significantly greater for Silastic than GM spacers (2.13 ± 1.34 vs 1.51 ± 1.23, p = 0.020). Facial pain prior to removal and extent of discharge did not differ significantly between spacers.

Conclusion

Following FESS, patients report less pain during removal of GM than Silastic spacers. However, the likelihood of synechiae and scarring did not differ between either of the spacers.

     

Are multiple sinus cultures necessary during sinus surgery for chronic rhinosinusitis?

Background

Multiple cultures are commonly obtained from different sinuses where purulence is encountered during endoscopic sinus surgery (ESS). This brings into question the utility and necessity of obtaining multiple cultures. The purpose of this study was to evaluate if multiple cultures obtained during a single case is informative in finding additional pathogens or if it is a redundant, cost‐increasing practice. We hypothesized that multiple sinus cultures are necessary to identify the pathogens responsible for an individual's sinus disease. We seek to add information on the utility of performing multiple sinus cultures from a patient care and a health economics standpoint.

Methods

This study was a retrospective review of a single rhinologist's surgical database from 2008 to 2016. Patients that underwent ESS for chronic rhinosinusitis (CRS) and had multiple cultures obtained during surgery were included. Culture difference was recorded as a discrepancy of an infectious pathogen between cultures.

Results

We identified 231 patients with multiple sinus cultures. Of those, 39.4% had a difference of pathogens noted on culture between different sinuses. Only 5% of the cohort received clinically relevant benefit from the second culture obtained in regard to a change in antibiotics.

Conclusion

In this retrospective review we showed that, for the practitioner who obtains sinus cultures intraoperatively, limiting this practice to a single culture rather than multiple is cost‐effective and sufficient for identifying the pathogen to be treated. This study, and the resultant change in practice, has the potential to reduce healthcare costs associated with the surgical care of the patient with CRS.