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PurposeMethodsResultsConclusionsThis study aimed to quantify the proportion of patients with bilateral epiphora and suspected nasolacrimal obstruction who self-reported improved epiphora bilaterally following unilateral dacryocystorhinostomy and investigate predictive factors.A retrospective cohort study of patients from an Australian lacrimal clinic was performed. Eligible patients were at least 18 years of age, complained of bilateral epiphora, underwent unilateral dacryocystorhinostomy between 2012 and 2022 and followed-up. Outcome groups were created by grouping self-reported epiphora improvement levels for each eye. Two-sided confidence intervals were calculated for the proportion of participants in each outcome group. Ordinal elastic net regression identified clinical features associated with outcome groups and estimated their effect sizes.Of 243 patients, the median post-operative follow-up duration was 3 months. Fifty-eight percent (95% CI 52–64%, n = 141) reported significant improvement (≥50% ipsilateral and any contralateral improvement), 5% (95% CI 3–9%, n = 13) reported small improvement (<50% ipsilateral and any contralateral improvement) and 26% (95% CI 20–31%, n = 62) reported ipsilateral improvement only. Eleven percent had functional or anatomical failure. Older age (OR 1.01), contralateral nasolacrimal duct narrowing (OR 1.37), contralateral nasolacrimal duct obstruction (OR 0.93) and longer follow-up time (OR 0.85) predicted outcome groups.After unilateral DCR, many patients with bilateral epiphora and suspected nasolacrimal obstruction report an improvement of their symptoms bilaterally in the early postoperative period. Contralateral nasolacrimal system diagnosis, patient age and follow-up duration were associated with outcomes. Further study using validated epiphora assessment tools may quantify this observation, and we suggest a potential underlying mechanism of contralateral effects after unilateral treatment. [ABSTRACT FROM AUTHOR]

Objectives: A 2-surgeon technique has been proposed that allows resection of juvenile nasopharyngeal angiofibroma (JNA) with extension into the infratemporal fossa by utilizing a septal incision for passage of a retracting instrument from the opposite nostril. This technique, however, does not overcome the problem of limited space within the nasal cavity for the tumor to be retracted. Therefore, the tumor has to be divided lo allow for its removal. We are proposing a different 2-surgeon technique as an alternative operative technique for the resection of JNA. Methods: A new technique of endoscopic resection of JNA involves a transseptal posterior perforation. This perforation allows retraction of the tumor into the opposite nasal cavity by the second surgeon. The retraction of the tumor creates space for its resection. Results: Nineteen patients (all male) underwent this 2-surgeon technique for resection of JNA. The follow-up period ranged up to 9 years, and no recurrence was recorded. Conclusions: Longer-term follow-up is needed to assess recurrence rate and morbidity with this technique. However, in our small series, the 2-surgeon technique via posterior septal perforation was associated with low morbidity and recurrence rates. [ABSTRACT FROM AUTHOR]

Objective: Nasal airway surgery is often applied when treatment fails to relieve nasal obstruction. However, surgery that improves airflow does not always alleviate the symptoms of nasal obstruction. The perception of nasal breathing is likely more related to changes in mucosal temperature than the mechanical sensation of flow or pressure. This study aims to measure intranasal mucosal temperature pre-and post-surgery using endonasal thermal imaging, exploring its correlation with subjective nasal breathing and objective airflow measurements. Methods: A prospective study of adult patients with nasal obstruction managed with nasal airway surgery was performed. Intranasal mucosal temperatures were determined using the thermal endonasal image of the nasal passage produced by the infrared radiometric thermal camera (FILR VS290). A comparison was made between the mean values of mid-expiration (ExT) and mid-inspiration (InT) temperature data (internal nasal valve, nasal cavity, inferior turbinate, and overall airway [mean value]) and visual analog scale (VAS), Nasal Obstruction Symptom Evaluation (NOSE) scale and nasal airway resistance (NAR) before and after surgery. Results: Seven patients (35.14 ± 16.45 years, 57.14% female) were included. All NOSE, VAS, and NAR improved after surgery (59.29 ± 10.89 vs 17.14 ± 14.64; P <.001, 64.50 ± 26.79 vs 18.57 ± 19.99; P <.001, 0.82 ± 0.48 vs 0.34 ± 0.11 Pa/cm3/s; P =.002, respectively). ExT, InT, and the difference between ExT and InT of three areas and overall airway were similar between pre-and post-surgery. No statistically significant correlations were found between intranasal mucosal temperature, VAS, NOSE, and NAR at pre-and post-surgery except for the difference between ExT and InT of overall airway and NOSE pre-operative (Pearson r = 0.57; 95% CI 0.06-1.09; P =.03). Conclusion: Endonasal thermal imaging can assess the intranasal mucosal temperature of a patient. However, more precise imaging of the nasal passages and data acquisition are required to establish mucosal temperature as an objective measure of nasal obstruction before and after nasal airway surgery in a clinical setting. [ABSTRACT FROM AUTHOR]

Background: Sinonasal epithelial malignancies are uncommon tumours but represent a challenge to treatment given their close proximity to the orbit, brain and cranial nerves. Traditional external surgical approaches have potential for significant functional and cosmetic morbidity. An endoscopic approach provides the surgeon with good access for tumour removal and enables surveillance postoperatively. This study aimed to assess outcomes of an endoscopic approach to sinonasal epithelial malignancy and evaluate factors that may influence its utility. Methods: A case series was performed involving consecutive patients treated with endoscopic or endoscopic‐assisted surgery for epithelial sinonasal malignancy. Stratification included TNM staging, histopathology, surgical approach, margin status, perineural involvement and adjuvant or neoadjuvant therapy. At follow‐up, complications, local control, nodal status and evidence of distant metastases were recorded. Statistical analyses to identify risk factors for developing recurrence and survival differences were performed. Results: Thirty‐five patients were assessed in this study (59.2 ± 11.4 years, 42.9% female). T stage at presentation was T1 in 11.4%, T2 in 17.1%, T3 in 22.9% and T4 in 48.6%. The 3 and 5 year disease specific survival were 91.3% (SE 5) and 71.1% (SE 10). The only factors to influence survival outcomes were perineural invasion of tumour and positive margins at the time of initial surgery. Large tumours did not limit the utility of an endoscopic approach. Conclusion: Endoscopic approach is a safe and oncologically equitable treatment approach to external approaches in the management of epithelial sinonasal malignancy. As with external approaches, perineural invasion of malignance is a poor prognostic factor. [ABSTRACT FROM AUTHOR]

Objectives Sellar pathologies are frequently found on imaging performed to investigate headache. However, both headache and incidental sellar lesions are common. Hence, this study prospectively examined headache prevalence, phenotype, and severity in patients with sellar pathologies and the impact of transsphenoidal surgery on headache. Methods Patients undergoing transsphenoidal resection of sellar lesions were consecutively recruited. At baseline, participants were defined as having headache or not and headache phenotype was characterized using validated questionnaires. Headache severity was assessed at baseline and 6 months postoperatively using the Headache Impact Test-6 (HIT-6) and Migraine Disability Assessment Score (MIDAS). Tumor characteristics were defined using radiological, histological, and endocrine factors. Primary outcomes included baseline headache prevalence and severity and headache severity change at 6 months postoperatively. Correlation between headache and radiological, histological, and endocrine characteristics was also of interest. Results Sixty participants (62% female, 47.1 ± 18.6 years) were recruited. Sixty-three percent possessed baseline headache. HIT-6 scores were higher in patients with primary headache risk factors, including younger age (R 2 = −0.417, p = 0.010), smoking history (63.31 ± 7.93 vs 54.44 ± 9.21, p = 0.0060), and family headache history (68.13 ± 7.01 vs 54.94 ± 9.11, p = 0.0030). Headaches were more common in patients with dural invasion (55.70 ± 12.14 vs 47.18 ± 10.15, p = 0.027) and sphenoid sinus invasion (58.87 ± 8.97 vs 51.29 ± 10.97, p = 0.007). Postoperative severity scores improved more with higher baseline headache severity (HIT-6: R 2 = −0.682, p < 0.001, MIDAS: R 2 = −0.880, p < 0.0010) and dural invasion (MIDAS: −53.00 ± 18.68 vs 12.00 ± 17.54, p = 0.0030). Conclusion Headaches in sellar disease are likely primary disorders triggered or exacerbated by sellar pathology. These may respond to surgery, particularly in patients with severe headache and dural invasion. [ABSTRACT FROM AUTHOR]

Background: Biologic therapy targeting type 2 chronic rhinosinusitiswith nasal polyps (CRSwNP) has greatly improved disease control but nonresponders exist in a proportion of patients in phase 3 trials and clinical practice. This study explores the serum and histologic changes in biologic treated CRSwNP that predict disease control. Methods: A cross-sectional study was performed of patients with CRSwNP on biologics for their asthma, who underwent endoscopic sinus surgery while on biologic therapy. At the 6-month postoperative assessment, patients with poorly controlled CRSwNP while on biologic therapy were compared to patients who were controlled. Blood and mucosal samples taken at the time of surgery 6 months prior were assessed to predict disease control. Results:Atotal of 37 patientswere included (age 47.8±12.4 years, 43.2% female). Those with poorly controlled disease had reduced tissue eosinophils (% >100 cells/high-powered field: 8.3% vs. 50.0%, p < 0.001) and increased serum neutrophils (5.2 ± 2.7 vs. 3.7 ± 1.1 × 109 cells/L, p = 0.02). Logistic regression analysis demonstrated that reduced tissue eosinophil was predictive for poorly controlled disease (OR = 0.21, 95% CI [0.05, 0.83], p = 0.03). Receiver-operating characteristic analysis showed that need for rescue systemic corticosteroid was predicted at a serum neutrophil cut-off level of 5.75 × 109 cells/L (sensitivity = 80.0%, specificity = 96.9%, AUC = 0.938, p = 0.002). Conclusion: Low tissue eosinophils and increased serum neutrophils while on biologics predict for poor response in the biological treatment of with CRSwNP. A serum neutrophil level of =5.75 × 109 cells/L predicts for poor response to current biologic therapy. [ABSTRACT FROM AUTHOR]

Chronic rhinosinusitis (CRS) is common and often requires surgical intervention. Surgical failure may lead to persistent symptoms and recalcitrant disease, often secondary to synechiae between the middle turbinate (MT) and lateral nasal wall. Synechiae prevention techniques have been extensively investigated, however evidence for the effect of synechiae on sinonasal physiology is lacking. We aimed to model the effects of MT synechiae on a post-functional endoscopic sinus surgery (FESS) sinonasal cavity using computational fluid dynamics (CFD). DICOM data from a CT-sinus of a healthy 25-year-old female was segmented to create a three-dimensional model. Virtual surgery was performed to simulate a "full-house" FESS procedure. Multiple models were created, each with a single unilateral virtual MT synechia of varying extent. CFD analysis was performed on each model and compared with a post-FESS control model without synechiae. Airflow velocity, humidity and mucosal surface and air temperature values were calculated. All synechiae models demonstrated aberrant downstream sinonasal airflow. There was reduced ventilation of the ipsilateral frontal, ethmoid and sphenoid sinuses, with a concentrated central "jet" in the middle meatus region. Effects were proportionate to the size of synechiae. The impact on bulk inspired airflow was negligible. Post-FESS synechiae between the MT and lateral nasal wall significantly disrupt local downstream sinus ventilation and nasal airflow. These findings may explain the persistent symptoms seen in post-FESS CRS patients with MT synechiae, reinforcing the importance of prevention and adhesiolysis. Larger cohort studies with multiple models of actual post-FESS patients with synechiae are required to validate these findings. [ABSTRACT FROM AUTHOR]

Key Points: Culturable bacterial colonization is similar between type 2 CRS phenotypesStaphylococcus aureus coinfection is similar between eosinophilic CRS and CCADPatients with CCAD were younger, consistent with current knowledge of the disease [ABSTRACT FROM AUTHOR]

BACKGROUND: Petrous temporal bone cone-beam computed tomography scans help aid diagnosis and accurate identification of key operative landmarks in temporal bone and mastoid surgery. Our primary objective was to determine the accuracy of using a deep learning convolutional neural network algorithm to augment identification of structures on petrous temporal bone cone-beam computed tomography. Our secondary objective was to compare the accuracy of convolutional neural network structure identification when trained by a senior versus junior clinician. METHODS: A total of 129 petrous temporal bone cone-beam computed tomography scans were obtained from an Australian public tertiary hospital. Key intraoperative landmarks were labeled in 68 scans using bounding boxes on axial and coronal slices at the level of the malleoincudal joint by an otolaryngology registrar and board-certified otolaryngologist. Automated structure identification was performed on axial and coronal slices of the remaining 61 scans using a convolutional neural network (Microsoft Custom Vision) trained using the labeled dataset. Convolutional neural network structure identification accuracy was manually verified by an otolaryngologist, and accuracy when trained by the registrar and otolaryngologist labeled datasets respectively was compared. RESULTS: The convolutional neural network was able to perform automated structure identification in petrous temporal bone cone-beam computed tomography scans with a high degree of accuracy in both axial (0.958) and coronal (0.924) slices (P < .001). Convolutional neural network accuracy was proportionate to the seniority of the training clinician in structures with features more difficult to distinguish on single slices such as the cochlea, vestibule, and carotid canal. CONCLUSION: Convolutional neural networks can perform automated structure identification in petrous temporal bone cone-beam computed tomography scans with a high degree of accuracy, with the performance being proportionate to the seniority of the training clinician. Training of the convolutional neural network by the most senior clinician is desirable to maximize the accuracy of the results. [ABSTRACT FROM AUTHOR]

Radiologically undifferentiated lesions of the cavernous sinus can pose a diagnostic challenge. Although radiotherapy is the mainstay for treatment of cavernous sinus lesions, histologic diagnosis allows access to a wide variety of alternative treatment modalities. The region is considered a high-risk area for open transcranial surgical access, and the endoscopic endonasal approach presents an alternative technique for biopsy. A retrospective case series was performed of all patients undergoing endoscopic endonasal biopsy of isolated cavernous sinus lesions at 2 tertiary institutions. The primary outcomes were the percentage of patients in whom a histologic diagnosis was achieved and the proportion of patients in whom therapy differed from radiotherapy alone. Secondary outcomes included preoperative and postoperative 22-item Sino-Nasal Outcome Test symptom scores, as well as perioperative adverse outcomes. Eleven patients underwent endoscopic endonasal biopsy, with a diagnosis achieved in 10 patients. The most common diagnosis was perineural spread of squamous cell carcinoma, followed by perineuroma and single cases of metastatic melanoma, metastatic adenoid cystic carcinoma, mycobacterium lepri infection, neurofibroma, and lymphoma. Six patients had treatments other than radiotherapy, including immunotherapy, antibiotics, corticosteroids, chemotherapy, and observation alone. There was no significant difference in prebiopsy and postbiopsy 22-item Sino-Nasal Outcome Test scores. There was 1 case of epistaxis requiring return to theater for cautery of the sphenopalatine artery and there were no mortalities. In a limited case series, endoscopic endonasal biopsy was safe and effective in obtaining diagnosis for cavernous sinus lesions and had a significant impact on therapeutic decision making. [ABSTRACT FROM AUTHOR]

BACKGROUND: Pneumatization of the mastoid process is variable and of significance to the operative surgeon. Surgical approaches to the temporal bone require an understanding of pneumatization and its implications for surgical access. This study aims to determine the feasibility of using deep learning convolutional neural network algorithms to classify pneumatization of the mastoid process. METHODS: De-identified petrous temporal bone images were acquired from a tertiary hospital radiology picture archiving and communication system. A binary classification mode in the pretrained convolutional neural network was used to investigate the utility of convolutional neural networks in temporal bone imaging. False positive and negative images were reanalyzed by the investigators and qualitatively assessed to consider reasons for inaccuracy. RESULTS: The overall accuracy of the model was 0.954. At a probability threshold of 65%, the sensitivity of the model was 0.860 (95% CI 0.783-0.934) and the specificity was 0.989 (95% CI 0.960-0.999). The positive predictive value was 0.973 (95% CI 0.904-0.993) and the negative predictive value was 0.935 (95% CI 0.901-0.965). The false positive rate was 0.006. The F1 number was 0.926 demonstrating a high accuracy for the model. CONCLUSION: The temporal bone is a complex anatomical region of interest to otolaryngologists. Surgical planning requires high-resolution computed tomography scans, the interpretation of which can be augmented with machine learning. This initial study demonstrates the feasibility of utilizing machine learning algorithms to discriminate anatomical variation with a high degree of accuracy. It is hoped this will lead to further investigation regarding more complex anatomical structures in the temporal bone. [ABSTRACT FROM AUTHOR]

To evaluate the generalizability of artificial intelligence (AI) algorithms that use deep learning methods to identify middle ear disease from otoscopic images, between internal to external performance. 1842 otoscopic images were collected from three independent sources: (a) Van, Turkey, (b) Santiago, Chile, and (c) Ohio, USA. Diagnostic categories consisted of (i) normal or (ii) abnormal. Deep learning methods were used to develop models to evaluate internal and external performance, using area under the curve (AUC) estimates. A pooled assessment was performed by combining all cohorts together with fivefold cross validation. AI-otoscopy algorithms achieved high internal performance (mean AUC: 0.95, 95%CI: 0.80–1.00). However, performance was reduced when tested on external otoscopic images not used for training (mean AUC: 0.76, 95%CI: 0.61–0.91). Overall, external performance was significantly lower than internal performance (mean difference in AUC: −0.19, p ≤ 0.04). Combining cohorts achieved a substantial pooled performance (AUC: 0.96, standard error: 0.01). Internally applied algorithms for otoscopy performed well to identify middle ear disease from otoscopy images. However, external performance was reduced when applied to new test cohorts. Further efforts are required to explore data augmentation and pre-processing techniques that might improve external performance and develop a robust, generalizable algorithm for real-world clinical applications. [ABSTRACT FROM AUTHOR]

Introduction: Convolutional neural networks (CNNs) represent a state-of-the-art methodological technique in AI and deep learning, and were specifically created for image classification and computer vision tasks. CNNs have been applied in radiology in a number of different disciplines, mostly outside otolaryngology, potentially due to a lack of familiarity with this technology within the otolaryngology community. CNNs have the potential to revolutionize clinical practice by reducing the time required to perform manual tasks. This literature search aims to present a comprehensive systematic review of the published literature with regard to CNNs and their utility to date in ENT radiology. Methods: Data were extracted from a variety of databases including PubMED, Proquest, MEDLINE Open Knowledge Maps, and Gale OneFile Computer Science. Medical subject headings (MeSH) terms and keywords were used to extract related literature from each databases inception to October 2020. Inclusion criteria were studies where CNNs were used as the main intervention and CNNs focusing on radiology relevant to ENT. Titles and abstracts were reviewed followed by the contents. Once the final list of articles was obtained, their reference lists were also searched to identify further articles. Results: Thirty articles were identified for inclusion in this study. Studies utilizing CNNs in most ENT subspecialties were identified. Studies utilized CNNs for a number of tasks including identification of structures, presence of pathology, and segmentation of tumors for radiotherapy planning. All studies reported a high degree of accuracy of CNNs in performing the chosen task. Conclusion: This study provides a better understanding of CNN methodology used in ENT radiology demonstrating a myriad of potential uses for this exciting technology including nodule and tumor identification, identification of anatomical variation, and segmentation of tumors. It is anticipated that this field will continue to evolve and these technologies and methodologies will become more entrenched in our everyday practice. [ABSTRACT FROM AUTHOR]

Background: Eosinophilic chronic rhinosinusitis is an often treatment‐resistant inflammatory disease mediated by type‐2 cytokines, including interleukin (IL)‐5. Mepolizumab, a monoclonal antibody drug targeting IL‐5, has demonstrated efficacy and safety in inflammatory airway disease, but there is negligible evidence on direct tissue response. The study's aim was to determine the local effect of mepolizumab on inflammatory biomarkers in sinonasal tissue of eosinophilic chronic rhinosinusitis patients. Methods: Adult patients with eosinophilic chronic rhinosinusitis received 100mg mepolizumab subcutaneously at four‐weekly intervals for 24 weeks in this prospective phase 2 clinical trial. Tissue eosinophil counts, eosinophil degranulation (assessed as submucosal eosinophil peroxidase deposition by immunohistochemistry) and cytokine levels (measured in homogenates by immunoassay) were evaluated in ethmoid sinus tissue biopsies collected at baseline and at weeks 4, 8, 16 and 24. Results: Twenty patients (47.7 ± 11.7 years, 50% female) were included. Sinonasal tissue eosinophil counts decreased after 24 weeks of treatment with mepolizumab (101.64 ± 93.80 vs 41.74 ± 53.76 cells per 0.1 mm2; p =.035), eosinophil degranulation remained unchanged (5.79 ± 2.08 vs 6.07 ± 1.20, p =.662), and type‐2 cytokine levels increased in sinonasal tissue for IL‐5 (10.84 ± 18.65 vs 63.98 ± 50.66, p =.001), IL‐4 (4.48 ± 3.77 vs 9.38 ± 7.56, p =.004), IL‐13 (4.02 ± 2.57 vs 6.46 ± 3.99, p =.024) and GM‐CSF (1.51 ± 1.74 vs 4.50 ± 2.97, p =.001). Conclusion: Mepolizumab reduced eosinophils in sinonasal tissue, demonstrating that antagonism of IL‐5 suppresses eosinophil trafficking. With reduced tissue eosinophils, a local type‐2 inflammatory feedback loop may occur. The study exposes mechanistic factors which may explain incomplete treatment response. [ABSTRACT FROM AUTHOR]

Background Inadvertent injury to the internal carotid artery (ICA), if poorly managed, not only presents a risk of exsanguination but can also result in significant long-term morbidity. Through the implementation of a novel animal model of endoscopic carotid artery injury (CAI), effective techniques to manage this scenario have been developed. The Vascular Injuries Workshop has trained over 110 surgeons in these techniques. This study reviews events of major arterial hemorrhage managed by surgeons who completed this vascular injury workshop training. Methods We report a retrospective multicenter case series of patients who required endoscopic management of intranasal major arterial hemorrhage. Delegates who had attended the course were contacted by e-mail and surveyed with regard to instances of major arterial bleeding and the management undertaken. Patient demographics, tumor type, factors influencing injury, management technique, and outcomes were reviewed. Results The cases reported herein are characterized as follows: 9 cases are reported in total, 3 male, 6 female; age range 37 to 82 years; 1 basilar artery, and 8 ICA injuries. Each case was successfully managed endoscopically with intraoperative muscle patch application. There were no deaths, 1 case of pseudoaneurysm with successful endovascular treatment, 2 cases of impaired carotid flow, and 1 carotid dissection was conservatively managed. There were no permanent neurological sequelae or other permanent morbidity. Conclusion The Vascular Injuries Workshop arms surgeons with a structured approach to managing the surgical field and provides effective hemostatic techniques in the face of impending catastrophe. In comparison to the existing literature on ICA rupture, our results show trained surgeons are well equipped to achieve safe outcomes for their patients. [ABSTRACT FROM AUTHOR]

The right maxillary and right sinus is fluid-filled suggesting secondary obstruction. gl Incisional biopsy was discussed with the patient, but due to the high risk of bleeding, he instead elected to undergo endoscopic sinus surgery with stereotactic image guidance for surgical excision of the tumour. (b) A T2-weighted MRI scan of the paranasal sinuses demonstrated an enhancing solid mass centred in the right-side ethmoid cells with central cystic change/necrosis. A 56-year-old male with a history of right nephrectomy for clear cell renal carcinoma diagnosed in 2014 presented with longstanding right nasal obstruction (related to an incidental septal deformity) and new localized right nasal pain. [Extracted from the article]

Objectives: To summarise the accuracy of artificial intelligence (AI) computer vision algorithms to classify ear disease from otoscopy. Design: Systematic review and meta‐analysis. Methods: Using the PRISMA guidelines, nine online databases were searched for articles that used AI computer vision algorithms developed from various methods (convolutional neural networks, artificial neural networks, support vector machines, decision trees and k‐nearest neighbours) to classify otoscopic images. Diagnostic classes of interest: normal tympanic membrane, acute otitis media (AOM), otitis media with effusion (OME), chronic otitis media (COM) with or without perforation, cholesteatoma and canal obstruction. Main outcome measures: Accuracy to correctly classify otoscopic images compared to otolaryngologists (ground truth). The Quality Assessment of Diagnostic Accuracy Studies Version 2 tool was used to assess the quality of methodology and risk of bias. Results: Thirty‐nine articles were included. Algorithms achieved 90.7% (95%CI: 90.1–91.3%) accuracy to difference between normal or abnormal otoscopy images in 14 studies. The most common multiclassification algorithm (3 or more diagnostic classes) achieved 97.6% (95%CI: 97.3–97.9%) accuracy to differentiate between normal, AOM and OME in three studies. AI algorithms outperformed human assessors to classify otoscopy images achieving 93.4% (95%CI: 90.5–96.4%) versus 73.2% (95%CI: 67.9–78.5%) accuracy in three studies. Convolutional neural networks achieved the highest accuracy compared to other classification methods. Conclusion: AI can classify ear disease from otoscopy. A concerted effort is required to establish a comprehensive and reliable otoscopy database for algorithm training. An AI‐supported otoscopy system may assist health care workers, trainees and primary care practitioners with less otology experience identify ear disease. [ABSTRACT FROM AUTHOR]

Background Osteitis is a feature of chronic rhinosinusitis (CRS) and often associated with recalcitrant disease. Radiological characteristics of osteitic sinus changes are commonly reported in practice but the clinical and pathologic significance is poorly defined. The objective of this study was to correlate the Kennedy Osteitis Score (KOS) to clinico-histologic features of CRS. Methods A cross-sectional study of CRS patients undergoing sinus surgery was conducted. Osteitis was scored radiologically using the KOS. Associations between osteitis and histopathology, symptoms, 22-item Sino-Nasal Outcomes Test (SNOT-22), endoscopy, computed tomography (CT) mucosal score, and seromarkers were assessed. Interobserver correlation coefficient was performed. Additionally, the KOS was correlated to an alternate Global Osteitis Score. Results A total of 88 patients were assessed (45.5% female, age 50.3 ± 13.6 years); 45 (51.1%) patients had osteitis. Patients with KOS >0, had greater endoscopy score (6.1 ± 2.9 vs 4.4 ± 3.6, p = 0.03) and CT score (14.0 ± 6.0 vs 10.1 ± 5.7, p < 0.01) than those without osteitis. There was no difference in symptom score (2.4 ± 1.3 vs 2.4 ± 1.1, p = 0.89) and SNOT-22 (2.0 ± 1.0 vs 1.9 ± 1.1, p = 0.56) in patients with and without osteitis. KOS was higher in patients with tissue eosinophilia >10/high-power field (HPF) (median 3.0 [IQR, 1.0-5.3] vs 0.0 [0.0-4.0], p = 0.03) and serum eosinophilia >0.3 × 109/L (4.0 [2.0-7.0] vs 1.0 [0.0-4.0], p < 0.01). Importantly, this was also true for those without prior surgery. The interobserver correlation coefficient was good ( R = 0.86, p < 0.001). There was a significant correlation between the KOS and the Global Osteitis Score ( R = 0.93, p < 0.001). Conclusion The KOS is a simple, easy, and reproducible scale in assessing osteitic bones in patients with CRS and can predict measures of severity in eosinophilic rhinosinusitis. [ABSTRACT FROM AUTHOR]

Background: Tissue eosinophilia in chronic rhinosinusitis (CRS) is a marker of inflammatory disorders recalcitrant to surgical intervention. Eosinophilic chronic rhinosinusitis (ECRS) is traditionally associated with asthma, polyps, aspirin sensitivity, high serum eosinophilia, and elevated immunoglobulin E (IgE). However, patients with ECRS may not present with these associations and there is a need to establish other surrogate markers. The objective of the study was to determine the associations between the histopathology, serology, and clinical characteristics in CRS patients. Methods: A cross-sectional study was undertaken of CRS patients undergoing surgery. Tissue eosinophilia and other pathological features were compared to traditional surrogate features of ECRS, as well as to symptoms, and to radiologic and endoscopic scores. Results: A total of 51 patients were assessed (47% female, mean age 46.6 ± 4.1 years). High tissue eosinophilia (>10 per high-power field [HPF]) was more prominent in polyps (84%) (χ2 = 25.76; p < 0.01) but was also seen in nonpolyp patients (19%). Asthma was not associated with high tissue eosinophilia ( p = 0.60), with 43% of nonasthmatics demonstrating high tissue eosinophilia. Serum eosinophilia predicted high tissue eosinophilia at >0.30 × 109/L or 4.4% of leukocytes (sensitivity 52%, specificity 87%, receiver operating characteristic [ROC] p = 0.001), with low negative predictive value. Serum IgE was nonpredictive ( p = 0.08). Conclusion: The diagnosis of ECRS has unique prognostic implications. Traditional features of the ECRS phenotype are not necessarily reliable markers for the presence of tissue eosinophilia. Serum eosinophilia may be a good surrogate marker of tissue eosinophilia but of limited use. The routine use of structured histopathology reporting in CRS is suggested, to allow for the diagnosis of ECRS and to identify other prognostic markers. © 2012 ARS-AAOA, LLC. [ABSTRACT FROM AUTHOR]

For tonsillectomy, the ultrasonic harmonic scalpel has been purported to cause less tissue injury and postoperative morbidity while providing adequate levels of hemostasis. We undertook a prospective study to compare outcomes in 162 patients who had undergone harmonic scalpel tonsillectomy and 40 patients who had undergone monopolar diathermy tonsillectomy over a 33-month period. We found that patients in the harmonic scalpel group experienced significantly less intraoperative bleeding (5.0 vs. 16.5 ml; p < 0.0001). There was no clinically significant difference between the groups with respect to (1) the amount of operating time, (2) the incidence of postoperative nausea and vomiting, dysphonia, and primary or secondary bleeding, and (3) the amount of time patients needed to resume normal diet and activities. [ABSTRACT FROM AUTHOR]

Colloquially, many patients simply refer to any form of sinonasal symptoms as "sinus" or "sinusitis", but often patients simply have a rhinitis reaction. PATIENTS AND METHODS Study design A cross-sectional study was performed of patients presenting with sinonasal symptoms to an otolaryngologist. Only those with a final diagnosis of either rhinitis or CRS were included and all patients underwent nasal endoscopy and CT. [Extracted from the article]

Background: Monoclonal antibody therapies have a growing role in treating refractory airway disease. Objective: The review aimed to summarize the response of respiratory mucosa to monoclonal antibody treatments in inflammatory airway conditions. Design: We conducted a systematic review including risk of bias assessment. Data sources: MEDLINE, EMBASE and PubMed from 1 January 2000 to 16 November 2019 were searched. Eligibility criteria: Eligible studies assessed the immunological and histological response of airway mucosa to monoclonal antibody therapy compared with baseline or a comparison group in patients with respiratory diseases (asthma, chronic rhinosinusitis and allergic rhinitis). Any prospective interventional studies, including randomized controlled trials (RCTs) and single‐arm trials, were eligible. Results: There were 4195 articles screened, and full‐text analysis produced n = 11 studies with extractable data. Nine were RCTs, and two were single‐arm trials. These studies focused on asthma (n = 9 articles), chronic rhinosinusitis (n = 1) and allergic rhinitis (n = 1). Five monoclonal antibody drugs were assessed (omalizumab, mepolizumab, dupilumab, benralizumab and tralokinumab). Risk of bias was low (n = 6) or unclear (n = 3) in the RCTs and moderate in the single‐arm trials. Omalizumab reduced the mucosal concentration of its target, IgE. Dupilumab reduced the concentration of one of its targets, IL‐13, but not IL‐4. Omalizumab, mepolizumab and benralizumab reduced tissue eosinophil cell density. Dupilumab decreased mucosal eosinophil granule proteins. Tralokinumab did not affect airway mucosa. Conclusions: Knowledge of the expected biological response of monoclonal antibody therapy on biomarkers in disease tissue provides an important supplement to data about clinical outcomes. An understanding of the biological effect is essential to identify likely responders, reasons for treatment failure and necessary adjustments to monoclonal antibody treatment. Further investigation into the effect of monoclonal antibody therapy on disease mucosa and more precise endotyping are required to move closer to achieving personalized medicine. [ABSTRACT FROM AUTHOR]

Background: Nasal irrigation is an important component of medical management in chronic rhinosinusitis. Nasal irrigations facilitate topical medication of therapies and lavage of mucin. In this study we aim to compare the influence of increasing surgical sphenoid openings on the distribution, force, and clearance of nasal irrigations. Methods: A study was performed on fresh‐frozen adult cadaver heads. The surgical ostium was modified on one side via a simple sphenoidotomy, a sphenoid sinusectomy (type 1), and sphenoid sinusectomy (type 3a). The nasal cavity was irrigated using a 240‐mL squeeze bottle with 0.1% fluoroscein. An endoscope passed through the contralateral side through the sphenoid septum recorded the irrigation. Videos were recorded and blindly assessed. The distribution was defined as either no irrigation, less than one third of the sinus, less than or equal to two thirds of the sinus, or the complete sinus. The force was defined as minimal, minor, or major. The clearance was defined as no residual, less than one third of volume, less than or equal to two thirds of volume, and more than two thirds volume. Ordinal correlation scores were assessed using the Kendall tau‐B test. Results: Nine specimens (sphenoid sinuses) were assessed (44.4% female; age, 75.0 ± 12.7 years). The use of a sphenoid sinusectomy or larger produced better distribution (percent specimens with more than one third: 100% vs 59%, p < 0.01), more force (percent major: 83% vs 29%, p < 0.01), and better clearance (percent with one third or less remaining: 56% vs 18%, p < 0.01). Conclusion: Increasing sphenoid ostial size improves nasal irrigation penetration. We propose that greater sphenoid sinusectomy size allows for improved lavage and irrigation penetration. Complete removal of the anterior face appears to mitigate pooling of irrigation. [ABSTRACT FROM AUTHOR]

Background: Orbital cavernous hemangiomas (OCH) are the most common adult orbital tumor and represent an ideal index lesion for endonasal orbital tumor surgery. In order to standardize outcomes reporting, an anatomic‐based staging system was developed. Methods: An international, multidisciplinary panel of 23 experts in orbital tumor surgery was formed. A modified Delphi method was used to develop the cavernous hemangioma exclusively endonasal resection (CHEER) staging system with a total of 2 rounds being completed. Results: Tumors medial to a plane along the long axis of the optic nerve may be considered amenable for an exclusively endonasal resection. In select cases, tumors may extend inferolaterally if the tumor remains below a plane from the contralateral naris through the long axis of the optic nerve (ie, plane of resectability [POR]). This definition reached consensus with 91.3% of panelists in agreement. Five stages were designed based on increasing technical resection difficulty and potential for morbidity. Stages were based on the relationship of the tumor to the extraocular muscles, the inferomedial muscular trunk of the ophthalmic artery (IMT), and orbital foramina. Staging by anatomic location also reached consensus with 87.0% of panelists in agreement. Size was not included in the staging system due to the lack of agreement on the contribution of size to resection difficulty. Conclusion: Endoscopic orbital tumor surgery is a nascent field with a growing, yet heterogeneous, body of literature. The CHEER staging system is designed to facilitate international, high‐quality, standardized studies establishing the safety, efficacy, and outcomes of endonasal resection of OCH. [ABSTRACT FROM AUTHOR]

Introduction Identifying the internal carotid artery (ICA) when managing petroclival and infratemporal fossa pathology is essential for the skull base surgeon. The vidian nerve and eustachian tube (ET) cartilage come together at the foramen lacerum, the vidian--eustachian junction (VEJ). The ICA position, relative to the VEJ is described. Methods Endoscopic dissection of adult fresh-frozen cadaver ICAs and a case series of patients with petroclival pathology were performed. The relationship of the VEJ to the ICA horizontal segment, vertical segment, and second genu was assessed. The distance of the ICA second genu to VEJ was determined in coronal, axial, and sagittal planes. The length of the vidian nerve and ET was measured from the pterygopalatine fossa (PPF) and nasopharyngeal orifice to the VEJ. Results In this study, 10 cadaver dissections (82.3 ± 6.7 years, 40% female) were performed. The horizontal petrous ICA was at or behind VEJ in 100%, above VEJ in 100%, and lateral to VEJ in80%. The vertical paraclival segment was ator behindVEJ in 100%, above in 100%, and medial in 100%. The second genu was at or behind VEJ in 100% (3.3 ± 2.4 mm), at or above in 100%(2.5 ± 1.6mm), andmedial in100%(3.4 ± 2.0mm). The VEJwas successfully used to locate the ICA in nine consecutive patients (53.3 ± 13.6 years, 55.6% female) where pathology was also present. The VEJ was 15.0 ± 6.0 mm from the ET and 17.4 ± 4.1 mm from the PPF. Conclusion The VEJ is an excellent landmark as it defines both superior and posterior limits when isolating the ICA in skull base surgery. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background The diagnosis of allergic rhinitis (AR) is based on cutaneous and serological assessment to determine immunoglobulin E (IgE)-mediated disease. However, discrepancies between these tests and nasal provocation exist. Patients diagnosed as non-allergic rhinitis (NAR) but with positive nasal allergen provocation test (NAPT) may represent a local allergic condition or entopy, still suitable to allergy interventions. The objective of this study was to determine the frequency of nasal reactivity toward allergens among AR and NAR patients, and to describe the diagnostic characteristics of NAPT methodologies. Methods EMBASE (1947-) and Medline (1946-) were searched until December 8, 2015. A search strategy was used to identify studies on AR or NAR patients subjected to diagnostic local nasal provocation. All studies providing original NAPT data among the AR or NAR population were included. Meta-analysis of proportion data was presented as a weighted probability % (95% confidence interval [CI]). Results The search yielded 4504 studies and 46 were included. The probability of nasal allergen reactivity for the AR population was 86.3% (95% CI, 84.4 to 88.1) and in NAR was 24.7% (95% CI, 22.3 to 27.2). Reactivity was high with pollen for both AR 97.1% (95% CI, 94.2 to 99.2) and NAR 47.5% (95% CI, 34.8 to 60.4), and lowest with dust for both AR 79.1% (95% CI, 76.4 to 81.6) and NAR 12.2% (95% CI, 9.9 to 14.7). NAPT yielded high positivity when defined by subjective end-points: AR 91.0% (95% CI, 86.6 to 94.8) and NAR 30.2% (95% CI, 22.9 to 37.9); and lower with objective end-points: AR 80.8% (95% CI, 76.8 to 84.5) and NAR 14.1% (95% CI, 11.2 to 17.2). Conclusion Local allergen reactivity is demonstrated in 26.5% of patients previously considered non-allergic. Similarly, AR, when defined by skin-prick test (SPT) or serum specific IgE (sIgE), may lead to 13.7% of patients with inaccurate allergen sensitization or non-allergic etiologies. [ABSTRACT FROM AUTHOR]

Background Episodic or recurrent sinonasal symptoms are often suspected as 'sinus' in origin. With normal sinus radiology between events, the diagnosis of recurrent acute rhinosinusitis (RecARS) is made. However, other conditions can produce episodic symptoms. In this study we analyze acutely performed computed tomography (CT) in a population with suspected or self-diagnosed 'sinus' disease. Methods Patients referred to a tertiary clinic for suspected RecARS were assessed. Sinus changes were defined by CT (initial assessment) and during the acute event, by a semiurgent CT performed during the symptomatic episode. Mucosal thickening, ostiomeatal compromise, and severe septal deformity were recorded. Symptom profile was assessed during both time-points with the 22-item Sino-Nasal Outcome Test (SNOT-22). Results Forty-eight patients (49.5 ± 14.7 years of age, 70.8% female) were assessed. At presentation, 75% were resolute in a diagnosis of 'sinus.' Baseline Lund-Mackay scores were <6 (median 0 [interquartile range 1]). Ostiomeatal compromise was 6.8% left and 4.5% right at baseline. Of the patients who returned for acute CT (n = 27), SNOT-22 and subdomains were similar to baseline. Septal deviation was similar (13.6% vs 15.3%). Acutely, ostiomeatal compromise was 0% left and 7.4% right (n = 2). Of these 2 patients with ostiomeatal compromise, 1 was diagnosed with RecARS (4%) and the other with triptan-responsive migraine, with incidental sinus changes. Final diagnosis was rhinitis (47%), headache/migraine (37%), and facial pain otherwise undefined (12.5%). Conclusion Patients with a history of "recurrent acute sinusitis" and normal CT scans between episodes rarely have abnormal CT findings during acute exacerbations of symptoms. Antibiotics and surgical intervention are often inappropriate in this population. [ABSTRACT FROM AUTHOR]

Background Vitamin D deficiency is associated with many inflammatory respiratory disease states. However, serum vitamin D concentrations may not reflect tissue-specific availability. In this study we sought to assess the local expression of genes essential in vitamin D regulation in chronic rhinosinusitis (CRS). Methods A cross-sectional study of adult patients undergoing endoscopic sinus surgery was performed. Patients were defined as having CRS with polyps (CRSwNP) or without polyps (CRSsNP), or normal sinus mucosa. Sinus mucosal biopsies were assessed using quantitative polymerase chain reaction to determine expression of genes encoding the vitamin D receptor ( VDR), 25-hydroxylase ( CYP2R1), 1α-hydroxylase ( CYP27B1), and 24-hydroxylase ( CYP24A1). Expression levels correlated with serum 25(OH)D [sum 25(OH)D2 and 25(OH)D3], the 22-item Sinonasal Outcome Test (SNOT-22), and Nasal Symptom Score (NSS). Separate analyses were performed for patients grouped by tissue eosinophilia. Results Thirty-one patients were assessed (age 49.47 ± 18.14 years, 48.4% female), including 8 CRSsNP, 10 CRSwNP, and 13 controls. CRSsNP and CRSwNP mucosa exhibited decreased CYP27B1 compared with controls (0.0437 [Interquartile range (IQR) 0.0999] vs 0.3260 [IQR 2.9384] vs 0.6557 [IQR 1.1005], p = 0.039), whereas CYP24A1 was upregulated (0.8522 [IQR 1.3170] vs 1.2239 [IQR 4.4197] vs 0.1076 [IQR 0.1791], p = 0.025). CYP24A1 was upregulated in both non-eosinophilic CRS and eosinophilic CRS (1.1337 [IQR 2.3790] vs 0.9555 [IQR 3.2811] vs 0.1076 [IQR 0.1791], p = 0.033). Significant correlations were observed between NSS and CYP2R1 ( r = −0.432, p = 0.022), CYP24A1 ( r = 0.420, P = 0.026), and VDR ( r = 0.425, p = 0.024), although no correlations with serum 25(OH)D were observed. Conclusions The local regulation of vitamin D in sinonasal tissue during CRS may be independent of serum 25(OH)D levels. Vitamin D may be dysregulated at multiple levels, with decreased transcription of the metabolic gene CYP27B1 and increased transcription of the catabolic gene CYP24A1 observed. [ABSTRACT FROM AUTHOR]

Telehealth programs are important to deliver otolaryngology services for Aboriginal and Torres Strait Islander children living in rural and remote areas, where distance and access to specialists is a critical factor. To evaluate the inter-rater agreement and value of increasing levels of clinical data (otoscopy with or without audiometry and in-field nurse impressions) to diagnose otitis media using a telehealth approach. Blinded, inter-rater reliability study. Ear health and hearing assessments collected from a statewide telehealth program for Indigenous children living in rural and remote areas of Queensland, Australia. Thirteen board-certified otolaryngologists independently reviewed 80 telehealth assessments from 65 Indigenous children (mean age 5.7 ± 3.1 years, 33.8% female). Raters were provided increasing tiers of clinical data to assess concordance to the reference standard diagnosis: Tier A) otoscopic images alone, Tier B) otoscopic images plus tympanometry and category of hearing loss, and Tier C) as B plus static compliance, canal volume, pure-tone audiometry, and nurse impressions (otoscopic findings and presumed diagnosis). For each tier, raters were asked to determine which of the four diagnostic categories applied: normal aerated ear, acute otitis media (AOM), otitis media with effusion (OME), and chronic otitis media (COM). Proportion of agreement to the reference standard, prevalence-and-bias adjusted κ coefficients, mean difference in accuracy estimates between each tier of clinical data. Accuracy between raters and the reference standard increased with increased provision of clinical data (Tier A: 65% (95%CI: 63–68%), κ = 0.53 (95%CI: 0.48–0.57); Tier B: 77% (95%CI: 74–79%), 0.68 (95%CI: 0.65–0.72); C: 85% (95%CI: 82–87%), 0.79 (95%CI: 0.76–0.82)). Classification accuracy significantly improved between Tier A to B (mean difference:12%, p < 0.001) and between Tier B to C (mean difference: 8%, p < 0.001). The largest improvement in classification accuracy was observed between Tier A and C (mean difference: 20%, p < 0.001). Inter-rater agreement similarly improved with increasing provision of clinical data. There is substantial agreement between otolaryngologists to diagnose ear disease using electronically stored clinical data collected from telehealth assessments. The addition of audiometry, tympanometry and nurse impressions significantly improved expert accuracy and inter-rater agreement, compared to reviewing otoscopic images alone. [ABSTRACT FROM AUTHOR]

Background Middle turbinate edema could be a characteristic feature of aeroallergen sensitization. In this study we sought to determine the diagnostic characteristics of middle turbinate edema as a marker of inhalant allergy. Methods A cross-sectional diagnostic study was performed on patients who had undergone nasal endoscopy and allergy testing. Allergy status was determined by positive serology or epicutaneous testing. Endoscopy was reviewed by blinded assessors for middle turbinate head edema. Appearance was graded as either normal, focal, multifocal, diffuse, or polypoid edema. Receiver-operator (ROC) analysis, likelihood ratio (LR), sensitivity, specificity, and positive predictive value (PPV) were determined. Results One hundred eighty-seven patients representing 304 nasal cavities were assessed (42% female, age 39.74 ± 14.7 years, 57% allergic). Diffuse edema (PPV 91.7%/LR = 8) and polypoid edema (PPV 88.9%/LR = 6.2) demonstrated the strongest association with inhalant allergy. Multifocal edema was used as a cut-off to represent inhalant allergy from ROC analysis, which demonstrated 94.7% specificity and 23.4% sensitivity. The PPV for multifocal was 85.1% and LR = 4.4. Conclusion Middle turbinate edema is a useful nasal endoscopic feature to predict presence of inhalant allergy and, although not sensitive, has excellent PPV. [ABSTRACT FROM AUTHOR]

Background Prognostic implications of mucosal remodeling in chronic rhinosinusitis (CRS) remain unclear. Remodeling of respiratory mucosa in asthma is associated with greater medication use and decreased function. This study investigates the implications of mucosal remodeling on long-term clinical outcomes in patients with CRS. Methods A case-control study of adult patients with CRS undergoing endoscopic sinus surgery (ESS) was performed. Mucosal remodeling was defined by squamous metaplasia, subepithelial fibrosis, and/or basement membrane thickening. The presence of remodeling changes were assessed relative to clinical and treatment outcomes at a minimum of 12 months postoperatively. Clinical outcomes were assessed at baseline and 12 months using a Nasal Symptom Score (NSS) and 22-item Sino-Nasal Outcome Test (SNOT-22). Treatment outcomes were assessed by oral corticosteroid usage (burst/continuous), topical corticosteroid irrigation frequency, and further surgical intervention. Results A total of 110 patients (48.73 ± 14.75 years, 48.2% female) were assessed. Significant improvements where seen for the entire population, in both NSS (2.64 ± 1.06 to 1.34 ± 1.08, p < 0.001) and SNOT-22 (2.05 ± 0.96 to 1.06 ± 0.79, p < 0.001). Patients with remodeling (n = 88) were younger (47.2 ± 14.8 vs 54.7 ± 13.5 years, p = 0.03), but had similar symptom scores. Remodeling was seen in CRS with nasal polyposis (CRSwNP) (54.5%) and eosinophilic chronic rhinosinusitis (eCRS) (59.8%). Symptom improvement at 12 months was similar between remodeled and non-remodeled groups (NSS: Δ1.34 ± 1.20 vs Δ1.12 ± 1.31, p = 0.395; SNOT-22: Δ1.05 ± 0.91 vs Δ0.73 ± 0.95, p = 0.124); however, patients with remodeling had greater corticosteroid irrigation frequency (64.0% vs 31.6% daily use, Kendall's tau-b p = 0.004). Conclusion Established mucosal remodeling predicts a greater reliance on topical therapies to reach similar clinical endpoints as those without remodeling. [ABSTRACT FROM AUTHOR]

Background Effective mucus lavage and delivery of topical pharmaceuticals are central to successful management of chronic rhinosinusitis (CRS). The frontal sinus remains difficult to penetrate with topical therapies. This study evaluates the benefit of Draf III frontal dissection compared to traditional Draf IIa for distribution of topical therapies. Methods Fresh human cadaver heads were dissected sequentially with Draf IIa frontal sinusotomy and then Draf III procedures. Each cavity was irrigated with pediatric (120 mL) and adult (240 mL) irrigation bottles with 1/1000 10% fluorescein-labeled free water in 2 fixed positions (vertex and Frankfort horizontal). An endoscope at a fixed position within the frontal sinus recorded frontal sinus and frontal recess penetration. The images then underwent blinded evaluation of fluid distribution scored as 0 to 4 (nasal cavity only, frontal recess, medial one-half, lateral one-half, and lavage). Ordinal distribution score was analyzed with Kendall's tau-b. Results Eight specimens (age 76 ± 11.2 years; 50% female) were assessed. Draf III was superior to Draf IIa in ability to achieve frontal sinus distribution of irrigation (90.6% vs 50.1%, p < 0.001). Vertex head position improved distribution (90.6% vs 50.1%, p < 0.001), was synergistic with Draf III (100% with 87.5% lavage, p < 0.001), but was unable to overcome Draf IIa (81.2% with 25% lavage, p < 0.001). Irrigation volume trended toward improved distribution with larger volume irrigations. Conclusion Successful treatment of sinonasal disease may require postoperative delivery of topical therapies. Draf III frontal sinusotomy achieves superior topical access, and access to the frontal sinus with Draf IIa appears limited, despite large volumes and positioning. [ABSTRACT FROM AUTHOR]

Background Techniques for inferior turbinate reduction vary from complete turbinectomy to limited cauterization. Surgical methods differ on the degree of tissue reduction and reliance on surgical tissue removal vs tissue ablation. The outcome and morbidity from 3 different turbinate techniques are compared. Methods A randomized double-blinded study was performed. Patient nasal cavities were randomized to different interventions on each side within the same patient. One group had a combination of submucosal powered turbinate reduction (designated 'submucosal') and submucosal electrocautery (designated 'electrocautery'); and the second group had a combination of submucosal powered turbinate reduction (designated 'submucosal') and medial flap turbinoplasty (designated 'turbinoplasty'). Patient-scored nasal obstruction and rhinorrhoea (1 to 5) along with blindly assessed nasal airway patency ratings (1 to 4) was done at 12 and 60 months postoperatively. Pain requiring additional analgesia, crusting, bleeding (needing review), and revision were documented. Results A total of 100 patients were recruited (age 32.79 ± 13.58 years; 39% female). This represented 200 nasal airway surgeries with 100 submucosal procedures, 50 electrocautery and 50 medial flap turbinoplasties. No patients complained of worsening of their obstruction. At 60 months patients in the turbinoplasty group had greater outcomes, with 90.2% having occasional or no decongestant use (Kendall's tau B p < 0.001) compared to electrocautery (15.8%) and submucosal (37.8%). Fewer turbinoplasty patients had a revision procedure (12%, χ2 = 20.08, p < 0.001) compared to electrocautery (54%) and submucosal (40%). Crusting was more common in the electrocautery group (58% vs submucosal 2% and turbinoplasty 0%; χ2 = 92.04; p < 0.001). Conclusion The medial flap turbinoplasty provided consistent, robust results. Long-term relief of obstructive symptoms without additional risk of complication was observed in the turbinoplasty group. [ABSTRACT FROM AUTHOR]

Background Although remodeling changes of the lower airway are well described, similar changes in the upper airway are less well known. Remodeling changes of the upper airway in chronic rhinosinusitis (CRS) relevant to different phenotypes and endotypes and their clinical characteristics are investigated. Methods A cross-sectional study of adult patients with CRS was performed. Mucosal samples were taken during endoscopic sinus surgery (ESS). Histopathological analysis included eosinophil count, eosinophil activation (eosinophilic mucin), and remodeling changes. Mucosal damage was defined as ulceration, edema, and hypertrophic changes. Patient-reported outcomes (PROMs) were assessed using a Nasal Symptom Score (NSS) and Sino-Nasal Outcome Test (SNOT-22). Patients were subgrouped by presence of polyps (CRSwNP/CRSsNP) or tissue eosinophilia (>10/high power field). Subgroup analysis was performed when both eosinophilic chronic rhinosinusitis (eCRS) and eosinophil activation (eCRSwEA) were coexistent. Analysis between subgroups, pathology, and PROMs was also performed. Results A total of 259 patients (age 48.5 ± 15.6 years, 45% female) were recruited; 53% CRSwNP, 51% eCRS. Remodeling changes were present in 85%, higher in both CRSwNP (90%, p = 0.006) and eCRS (91%, p = 0.004). Mucosal damage changes were common in eCRS (ulceration 18%, p = 0.003; edema 98%, p < 0.001; hypertrophic changes 25%, p = 0.007). NSS was worse in CRSwNP compared to CRSsNP (2.84 ± 1.1 vs 2.29 ± 1.1, p < 0.001) and eCRSwEA (2.95 ± 0.16 vs 2.51 ± 0.11, p = 0.04). 'Loss of sense of smell or taste' was worse in patients with evidence of mucosal damage ( p = 0.006). Conclusion Remodeling features are present in CRS. Tissue eosinophilia and evidence of eosinophil activation is closely associated with remodeling features of CRS, associated mucosal damage and clinical symptoms. [ABSTRACT FROM AUTHOR]

Background Nasal polyposis is a common development in chronic rhinosinusitis (CRS), and sinus mucosa and polyp tissue have been used interchangeably in studies investigating CRS. However, potential differences may exist between these 2 tissue types, which have not been entirely characterized. Methods A cross-sectional study of CRS with nasal polyposis (CRSwNP) patients undergoing endoscopic sinus surgery was conducted. Sinus mucosal biopsies and corresponding polyp tissue were obtained from the same sinus cavity via flow cytometry, single-cell suspensions identified type 2 innate lymphoid cells (ILC2s), CD4 and CD8 T cells, activated CD4 and CD8 T cells, plasma cells, plasmacytoid dendritic cells (pDCs), regulatory T cells, T follicular helper cells, B cells, and immunoglobulin A (IgA)+ and IgG+ B cells. Cells were measured as a percentage of CD45+ cells. Paired nonparametric comparisons between sinus and polyp tissue were performed. Results Ten patients (50% female; age 48 ± 16 years) were recruited. Significantly elevated ILC2 levels were found in polyp tissue compared to sinus mucosa (0.12 [0.07 to 0.23] vs 0.07 [0.04 to 0.16], p = 0.02), as well as plasma cells (2.25 [0.84 to 3.68] vs 1.18 [0.74 to 2.41], p = 0.01); pDCs (0.15 [0.12 to 0.50[ vs 0.04 [0.02 to 0.17], p = 0.03); activated CD8 T cells (29.22 [17.60 to 41.43] vs 16.32 [10.07 to 36.16], p = 0.04) and IgG+ B cells (6.96 [0.06 to 11.82] vs 1.51 [0.38 to 5.13], p = 0.04). Other cell populations showed no significant differences. Conclusion Polyps have a similar cellular composition to that of mucosa. Higher levels of ILC2s, plasma cells, pDCs, activated CD8 T cells, and IgG+ B cells in polyp tissue may be reflective of cell populations driving nasal polyp development. The cellular machinery of CRS is present in polyps and representative of the disease process. This pilot study strongly suggests that a larger study would provide significant insights into the relationship of sinus mucosa to pathogenesis of nasal polyps. [ABSTRACT FROM AUTHOR]

Background Many chronic rhinosinusitis (CRS) treatment regimes revolve around 'one-off' maximal medical therapy (MMT) protocols, and although many patients initially respond, long-term control is unpredictable. The value of imaging, endoscopy, and patient progress after MMT for CRS is assessed. Methods Symptomatic CRS patients with computed tomography (CT)-confirmed disease were recruited at a tertiary rhinology clinic. All patients received at least a 3-week oral prednisone course as part of their MMT. Pretreatment and posttreatment nasal symptoms scores (NSS), quality of life (22-item SinoNasal Outcomes Test [SNOT-22]), and CT (Lund-Mackay [LM]) scores were recorded along with post-MMT endoscopy status. Results A total of 86 patients (38% female, age 46 ± 13 years) met inclusion criteria. Pre-MMT and post-MMT LM scores were 10.9 ± 5.3 and 8.3 ± 5.5 (change 2.6 ± 3.8, p < 0.001). Median follow-up after their initial post-MMT assessment was 6.3 (interquartile range [IQR] 17) months. At initial post-MMT review, 43 (50%) were symptomatic with persistent radiologic disease ('symptomatic CRS'), 12 (14%) were asymptomatic with no radiologic disease ('resolved CRS'), 21 (24%) were asymptomatic with persistent radiologic disease ('asymptomatic CRS'), and 10 (12%) were symptomatic with no radiologic disease ('alternate diagnosis'). Pre-MMT NSS and SNOT-22 were similar among groups. The 'asymptomatic CRS' group had the highest age (52 ± 11 years, p = 0.07). The 'alternate diagnosis' group had the lowest initial LM scores (5.2 ± 2.9, p = 0.001). Of the 'asymptomatic CRS' patients, 43% relapsed between 3 and 23 months (median 6; IQR 4.4 months) post-MMT and 29% eventually underwent surgery. Conclusion Although MMT for CRS achieved symptomatic relief in 38% patients, objective evidence of disease was associated with clinical relapse. The concepts of 'response' to medical therapy and the need to 'control' long-term inflammatory burden need to be balanced. [ABSTRACT FROM AUTHOR]

Background The histological features of osteitis in chronic rhinosinusitis (CRS) in animal studies induced by bacterial inoculation into maxillary sinuses revealed inflammatory involvement of the underlying bone matrix and/or the Haversian system; however, human studies do not mention these findings. The objective of this study was to investigate the inflammatory characterization of osteitis in CRS. Method A prospective study of primary CRS patients undergoing sinus surgery was conducted (August 2012 to April 2013). Bone-mucosa samples were taken from a predetermined site that correlated to a computed tomography location. Radiological bone thickness was measured. A blinded histopathological assessment included inflammatory infiltrate of bone, periosteal reaction, presence of osteoblasts or osteoclasts, fibrosis, and the percentage of new woven bone to total bone thickness, together with an overall opinion of whether neo-osteogenesis was present. Results Twenty-two primary CRS patients (age 45.8 ± 15.6 years; 59.1% female) were recruited. CRS with polyps accounted for 59.1% of patients. The bony thickness measured radiologically was a median 1.72 (interquartile range [IQR], 2.38; range, 0.3-12.14) mm. No samples (0%) had evidence of inflammatory infiltrate of bone; 90.9% had both osteoblasts present and new woven bone formation. Woven bone was greater with periosteal reaction (80.83% ± 9.25% vs. 47.50% ± 29.37%; p = 0.006), greater with osteoclasts present (80.00% ± 12.58% vs 59.00% ± 28.52%; p = 0.03), and greater when fibrosis was present (69.75% ± 24.14% vs 25.00% ± 7.07%; p = 0.003). Conclusion Most primary CRS patients demonstrated evidence of new woven bone formation. True 'osteitis' with inflammatory infiltrate of the bone was not observed. 'Osteitis' is likely a process of neo-osteogenesis and bone remodeling, rather than bone inflammation in primary CRS. [ABSTRACT FROM AUTHOR]

Background The influence of the microbial community on inflammatory subtype in chronic rhinosinusitis (CRS) has been proposed. Superantigen mechanisms potentially create a T helper 2 (Th-2)/eosinophilic dominated inflammation as a product of local flora rather than an intrinsic mucosal process. The associations between culturable bacteria and the histopathology and clinical features of CRS patients are described. Methods A cross-sectional study involving patients with CRS undergoing surgery was undertaken. Middle meatal swabs were performed at surgery for microbiological evaluation. Mucosal biopsies were taken and a blinded histopathological profile was performed. Disease specific quality of life and nasal symptom scores were recorded. The presence of culturable organisms and particular pathogens were compared with histopathology and clinical outcomes. Results A total of 95 patients were assessed (48.4% female, mean age 45.6 ± 14.0 years), of which 47.3% had a culturable organism. Tissue eosinophilia (>10/high-power field [HPF]) was found in 46.1% of these patients and 30.3% had neutrophilic infiltrate, with the presence of neither Gram-positive organisms, Gram-negative organisms, nor species correlating to pathology subtype. A culturable pathogen was a predictor of subepithelial fibrosis (χ2 = 6.36, p = 0.04) and Gram-negative bacteria had the strongest association (χ2 = 18.82, p < 0.01). There were no other significant associations with other clinical outcomes. Conclusion The culturable bacterial community has little impact on histopathology in CRS. While more sensitive tests may detect bacteria in the sinuses, the impact of the simple 'culturable' bacteria on the underlying pathologic process is limited. Changes, such as subepithelial fibrosis, suggest colonization may lead to undesirable local mucosal damage and remodeling. [ABSTRACT FROM AUTHOR]

Background Osteitic bone is a feature of chronic rhinosinusitis (CRS), potentially playing a role in pathogenesis. Although seen after previous endoscopic sinus surgery (ESS), it is also a de novo feature in patients without prior interventions. In these patients, osteitis is associated with high tissue and serum eosinophilia. However, the impact of osteitis on prognosis is unclear. This study investigates the clinical and endoscopic outcomes between patients with and without osteitis after primary ESS. Methods A prospective study of a cohort of previously unoperated patients with CRS undergoing ESS was performed. The sinuses were scored radiologically for osteitis using the Global Osteitis Score (GOS) and Kennedy Osteitis Score (KOS) preoperatively and were also scored dichotomously for the presence or absence of osteitis. Disease-specific quality of life (22-item Sino-Nasal Outcomes Test [SNOT-22]), nasal symptom score (NSS), endoscopic score (Lund-Kennedy), and clinical outcomes-including oral steroid use, frequency of nasal steroid irrigation, and infective exacerbations-were collected at baseline and 1 year postsurgery. The presence and extent of osteitis was assessed relative to clinical outcome. Results Fifty-three patients were included (41.5% female, age 47.4 ± 13.8 years), 42.9% of which had radiologic osteitis. There was no significant association between the presence or severity of osteitis at the time of surgery and SNOT-22, NSS, or endoscopy scores at 12 months postsurgery. However, the presence of osteitis was associated with the need for a course of oral steroid postsurgery (odds ratio [OR]=4.17; p = 0.026). High tissue eosinophilia could not predict this alone ( p = 0.55). There was no significant relationship between osteitis and the frequency of steroid irrigations or infective exacerbations. Conclusion Osteitis in CRS is associated with the degree of eosinophilia and as a independent process it was associated with the need for a course of systemic corticosteroid over a 12-month period, but did it not affect overall disease control. [ABSTRACT FROM AUTHOR]

Background Chronic rhinosinusitis (CRS) is a heterogeneous disease defined by epithelial inflammation. The link between measures of traditional disease severity and markers of epithelial inflammation is poorly understood as prior research has focused on presence of polyps or degree of eosinophilia. The expression of 3 epithelial derived cytokines implicated in initiation of T-helper 2 (Th2) inflammation and an eosinophil chemoattractant were compared with clinical measures used in CRS. Methods Sinus mucosal samples from CRS patients undergoing sinus surgery were analyzed for interleukin-25 (IL-25), IL-33, thymic stromal lymphopoietin (TSLP), and eotaxin-3 messenger RNA (mRNA) expression by quantitative polymerase chain reaction (PCR). Tumor patients undergoing surgery transnasally with normal sinus mucosa were controls. Gene expression was compared with symptom, radiology, and endoscopy scores, serological markers, presence of reactive airways disease (RAD), and atopy. Results Thirty-seven patients (38% female, mean age 48 ± 15 years), 12 CRS with nasal polyps (CRSwNP), 18 CRS without nasal polyps (CRSsNP), and 7 controls were recruited. CRSwNP phenotype predicted elevated IL-25, IL-33, and eotaxin-3 levels. Increased eotaxin-3 correlated with poorer computed tomography (CT) ( p = 0.004) and endoscopic scores ( p = 0.049). Increased IL-25 correlated with poorer CT scores ( p = 0.012) and raised serum eosinophils ( p = 0.006). No associations with RAD, atopy, and symptom measures were found. No associations for IL-33 and TSLP were found. Conclusion Inflammatory mediators of the epithelium in CRS has some correlation with traditional measures of disease burden. Certain epithelial profiles may predict highly dysfunctional epithelial barriers and prospective evaluation of the clinical outcomes from interventions is required. Future endotyping of the epithelium in CRS may be able to provide prognostic information. [ABSTRACT FROM AUTHOR]

Background: Inflammatory dysfunction is considered an important part of chronic rhinosinusitis (CRS). Corticosteroid therapy has been widely used in CRS. Effective topical delivery has been previously problematic. The post-endoscopic sinus surgery (ESS) corridor is essential for adequate topical drug access. Devices delivering large volume with positive pressure allow better distribution to sinus mucosa. The objective of this study is to evaluate the efficacy of postoperative topical sinonasal steroid irrigations for CRS. Methods: Patients with CRS undergoing ESS after failing previous medical therapy were recruited. Structured histopathology including markers of eosinophilia was performed. After surgery, patients received either budesonide 1 mg or betamethasone 1 mg delivered in a 240-mL squeeze bottle daily. Outcomes of the symptom score, Sino-Nasal Outcome Test 22 (SNOT-22) score, and endoscopy score were recorded. Results: A total of 111 patients (mean 50.1 ± 13.5 standard deviation [SD] years, 40.5% female) were included. Mean follow-up was 55.5 ± 33.9 weeks. Baseline and posttreatment symptom scores (2.6 ± 1.1 vs 1.2 ± 1.0), SNOT-22 scores (2.2 ± 1.1 vs 1.0 ± 0.8), and endoscopy scores (6.7 ± 3.0 vs 2.5 ± 2.0) revealed significant improvement (all, p < 0.001). Contrary to previous publications, patients with high tissue eosinophilia (>10/high power field [HPF]) had significantly more improvement on symptom score (1.9 ± 1.4 vs 1.1 ± 1.0, p = 0.04), SNOT-22 score (1.6 ± 1.3 vs 1.0 ± 0.8, p = 0.03), and endoscopy score (5.12 ± 3.4 vs 3.06 ± 3.0, p = 0.01) than those without. Conclusion: The philosophical approach to ESS in CRS is evolving. Topical therapies, when used appropriately, are highly effective for the most challenging eosinophilic patients. Although corticosteroid is a nonspecific therapy, it is effective when appropriately delivered. ©2012 ARSAAOA, LLC. [ABSTRACT FROM AUTHOR]