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Background: Dupilumab, an anti-IL4 receptor-α monoclonal antibody, was the first biologic to be approved in Canada for the treatment of Chronic Rhinosinusitis with Nasal Polyps (CRSwNP). In phase III clinical trials, it has demonstrated to be effective in reducing nasal polyp size and the severity of symptoms, improve disease-specific quality of life, and to have an acceptable safety profile. This study aims to present long-term follow-up data on disease-specific sinonasal outcomes of patients with CRSwNP who have been treated with dupilumab for up to 3 years in a real-world setting. Methods: Retrospective review of electronic medical records of a single Canadian rhinology center evaluating disease-specific sinonasal outcomes that are routinely collected for clinical care. This study included all patients who received dupilumab for the treatment of CRSwNP and who had completed at least one follow-up visit. The Sino-Nasal Outcome Test (SNOT)-22 was used to evaluate treatment symptom improvement. Results: Ninety-nine patients started dupilumab therapy during the study period. The mean SNOT-22 at the start of therapy was 61.1 (±22.91) At the time of the review, 65 patients had completed 1 year of therapy, 40 had completed 2 years of therapy, and 18 had completed 3 years of therapy. The mean SNOT-22 score at these timepoints was 16.75 (±13.86), 15.02 (±14.40), and 10.22 (±11.56), respectively. Conclusion: This real-world study shows that in patients with CRSwNP treated with dupilumab, improvement in disease-specific quality of life seen after 1 year continues and can be maintained at 3 years of treatment. [ABSTRACT FROM AUTHOR]

Chronic rhinosinusitis is a complex multifactorial inflammatory disease that affects up to 12% of the adult population globally. Chronic rhinosinusitis is associated with significant morbidity and represents a large healthcare burden. Despite medical and surgical treatment, a subset of “difficult-to-treat” patients have poor symptom control due to substantial inflammatory disease persistence. These patients represent ideal candidates for biologic therapeutics, which specifically modulate key inflammatory processes implicated in chronic rhinosinusitis pathophysiology. Chronic rhinosinusitis is often dichotomized phenotypically between those presenting with and without nasal polyps. Chronic rhinosinusitis with nasal polyps often represents the more severe disease phenotype and is classically associated with type 2 inflammation mediated by type 2 helper T cells, innate lymphoid cells, immunoglobulin E B cells, basophils, mast cells, and eosinophils. Biologic agents targeting known key mediators of type 2 inflammation have been shown to reduce disease burden. Phase 3 clinical trials studying the effects of anti-immunoglobulin E, anti- inter leuki n-5/a nti-i nterl eukin -5Rα, and anti- inter leuki n-4/i nterl eukin -13 humanized monoclonal antibodies have shown that these biologics can reduce both polyp size and the need for revision surgeries, improve symptoms, and downregulate inflammatory markers while maintaining an acceptable safety profile. Currently, biologics should be reserved for patients with chronic rhinosinusitis nasal polyps with moderate-to-severe disease who have failed maximal medical and surgical therapy, with sufficient surgery having been previously undertaken. Further studies are needed to better endotype patients to optimize biologic use and compare the relative effectiveness of biologics in difficult-to-treat patients. [ABSTRACT FROM AUTHOR]

Background  Pituitary apoplexy (PA) is a rare complication of pituitary tumors that can present with a myriad of symptoms, including sudden onset cranial nerve deficits. After patient stabilization and hormone replacement, surgical decompression is often recommended. The timing of surgical decompression remains controversial. In this case series, we describe our institutional experience pertaining to the cranial nerve recovery in patients who underwent endoscopic endonasal transsphenoidal (EETS) surgery for PA while evaluating outcome based on tumor stage using the suprasellar infrasellar parasellar anterior posterior (SIPAP) classification. Design  Present study is a single-institution retrospective cohort. Methods  A retrospective review of all EETS cases for pituitary tumor resection between November 2009 and August 2018. Queries of the hospital database were completed by trained personnel to identify cases of PA treated using the EETS approach. Baseline characteristics, tumor type, endocrine data, and SIPAP classification based on preoperative magnetic resonance imaging (MRI) and operation characteristics were extracted from medical records. Postoperative results were extracted for the duration of the follow-up period available for each patient. Results  Fifteen cases of PA were identified. Patient follow-up period was a mean of 30 months. The cranial nerve deficits present at admission were visual deficit (33%); unilateral third nerve palsy (47%) and unilateral sixth nerve palsy (27%). No fourth nerve palsies were observed. Following EETS, 60% of patients with preoperative visual deficit had normal visual fields. For those with third and sixth nerve palsies preoperatively, 43 and 75%, respectively, had return to normal function postoperatively. SIPAP tumor characteristics were not related to postoperative cranial nerve recovery. Conclusion  In this series of surgically treated patients with pituitary apoplexy, all cranial nerve deficits normalized or improved following surgery. The tumor SIPAP classification was not associated with patient outcome. Though in a small series, the presented results suggest surgical treatment is beneficial for these patients. [ABSTRACT FROM AUTHOR]

Background: Aspirin-exacerbated respiratory disease is characterized by asthma, chronic rhinosinusitis with nasal polyps, and sensitivity to aspirin and other cyclooxygenase-1 inhibitors. The use of medical identification by patients with aspirin-exacerbated respiratory disease can provide essential information to prevent accidental exposure to cyclooxygenase-1 inhibitor medications. There is no available literature on medical identification use in the aspirinexacerbated respiratory disease patient population. Methods: A cross-sectional survey study was designed to measure the perception of the need for a medical identification and its use by the patients diagnosed with aspirin-exacerbated respiratory disease at The Ottawa Hospital. Results: Six hundred eighty patients were identified in our registry with a documented sensitivity to nonsteroidal antiinflammatory drugs or aspirin; 12 additional patients were identified during a clinical visit. A total of 68 patients with aspirin-exacerbated respiratory disease met the inclusion criteria. Twenty-one patients were successfully enrolled. The majority (81%, n = 17) of the patients were not using any medical identification. The most common reason reported by patients for not using the medical identification was a lack of knowledge and awareness regarding its significance. Conclusion: In this survey of patients with aspirin-exacerbated respiratory disease, patients were found to have little knowledge regarding the benefits of medical identification use. Subsequently, medical identification use was very limited, supporting a clear need for further patient education and awareness. [ABSTRACT FROM AUTHOR]

Olfactory loss has been identified as one of the common symptoms related to COVID-19 infection. Although olfactory loss is recognized, our understanding of both the extent of loss and time to olfactory recovery following infection is less well known. Similarly, knowledge of potential impactful patient factors and therapies that influence olfactory recovery is desirable but is not overtly clear in the literature. Our systematic review sought to fill this knowledge gap. We included studies that: involved either an observational or an interventional design that reported data on patients with olfactory dysfunction due to Reverse Transcription Polymerase Chain Reaction (RT-PCR) diagnosed COVID-19 infection; and reported data regarding olfactory recovery measured by an objective olfactory test, Likert scale and/or visual analog scale (VAS). The study methods were determined a priori and registered in PROSPERO (Registration Number CRD42020204354). An information specialist searched Medline, Embase, LitCovid and the Cochrane Register of Controlled Trials up to March 2021, and two reviewers were involved in all aspects of study selection and data collection. After screening 2788 citations, a total of 44 studies of assorted observational designs were included. Patients had undergone objective COVID-19 testing, and most were adult patients with mild to moderate COVID-19. Olfactory recovery was found to occur as early as 7 days, with most patients recovering olfaction within 30 days. Few studies included prolonged follow-up to 6 months or longer duration. Poor olfaction at initial presentation was associated with poor recovery rates. Only a small number of studies assessed olfactory retraining and steroid therapy. Additional trials are underway. [ABSTRACT FROM AUTHOR]

Objective: To compare costs and quality‐adjusted life years of patients receiving endoscopic polypectomy in the clinic those receiving endoscopic sinus surgery from the perspective of Canada's health system. Method: We developed a Markov model to simulate costs and quality‐adjusted life years among a cohort of patients with chronic rhinosinusitis with polyps who received endoscopic polypectomy in clinic or endoscopic sinus surgery, over a patient's lifetime. Our study focused on patients with chronic rhinosinusitis with polyps who have the predominant symptom of bilateral nasal obstruction. Cost data were obtained from Canadian sources. Health utility values were derived from Sino‐nasal Outcome Test (SNOT‐22) scores reported in the published literature. A cycle length of six months was used. Both costs and quality‐adjusted life years were discounted using an annual rate of 1.5%. We conducted one‐way and probabilistic sensitivity analyses to assess the robustness of the study findings. Results: Endoscopic polypectomy in clinic was a cost‐saving option as it had a lower cost (C$736 vs. C$6,728) and produced more quality‐adjusted life years (13.85 vs 13.06) compared to endoscopic sinus surgery. Our findings were, however, highly sensitive to health utility values. Results from probabilistic sensitivity analysis showed that endoscopic polypectomy in clinic had a lower cost and was more effective compared to endoscopic sinus surgery in 99.86% of iterations. Conclusion: From the perspective of the publicly funded healthcare system, endoscopic polypectomy in clinic was economically attractive compared to endoscopic sinus surgery for chronic rhinosinusitis with polyps patients who have a primary symptom of bilateral nasal obstruction. The cost‐effectiveness results are, however, highly dependent on the relative impact of endoscopic polypectomy in the clinic and endoscopic sinus surgery on post‐surgery health utility values. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: To evaluate the cost-effectiveness of Floseal, a topically applied hemostatic agent, and nasal packing for the management of epistaxis in Canada.Study Design: Outcomes research, a cost-utility analysis.Methods: We developed a Markov model to compare the costs and health outcomes of Floseal with nasal packing over a lifetime horizon from the perspective of a publicly funded healthcare system. A cycle length of 1 year was used. Efficacy of Floseal and packing was sought from the published literature. Unit costs were gathered from a hospital case costing system, whereas physician fees were extracted from the Ontario Schedule of Benefits for Physician Services. Results were expressed as an incremental cost per quality-adjusted life year (QALY) gained. A series of one-way sensitivity and probabilistic sensitivity analyses were performed.Results: From the perspective of a publicly funded health are system, the Floseal treatment strategy was associated with higher costs ($2,067) and greater QALYs (0.27) than nasal packing. Our findings were highly sensitive to discount rates, the cost of Floseal, and the cost of nasal packing. The probabilistic sensitivity analysis suggested that the probability that Floseal treatment is cost-effective reached 99% if the willingness-to-pay threshold was greater than $120,000 per QALY gained.Conclusions: Prior studies have demonstrated Floseal to be an effective treatment for anterior epistaxis. In the Canadian healthcare system, Floseal treatment appears to be a cost-effective treatment option compared to nasal packing for anterior epistaxis.Level Of Evidence: 2c Laryngoscope, 1778-1782, 2018. [ABSTRACT FROM AUTHOR]

Background  Pituitary apoplexy (PA) is a rare complication of pituitary tumors that can present with a myriad of symptoms, including sudden onset cranial nerve deficits. After patient stabilization and hormone replacement, surgical decompression is often recommended. The timing of surgical decompression remains controversial. In this case series, we describe our institutional experience pertaining to the cranial nerve recovery in patients who underwent endoscopic endonasal transsphenoidal (EETS) surgery for PA while evaluating outcome based on tumor stage using the suprasellar infrasellar parasellar anterior posterior (SIPAP) classification. Design  Present study is a single-institution retrospective cohort. Methods  A retrospective review of all EETS cases for pituitary tumor resection between November 2009 and August 2018. Queries of the hospital database were completed by trained personnel to identify cases of PA treated using the EETS approach. Baseline characteristics, tumor type, endocrine data, and SIPAP classification based on preoperative magnetic resonance imaging (MRI) and operation characteristics were extracted from medical records. Postoperative results were extracted for the duration of the follow-up period available for each patient. Results  Fifteen cases of PA were identified. Patient follow-up period was a mean of 30 months. The cranial nerve deficits present at admission were visual deficit (33%); unilateral third nerve palsy (47%) and unilateral sixth nerve palsy (27%). No fourth nerve palsies were observed. Following EETS, 60% of patients with preoperative visual deficit had normal visual fields. For those with third and sixth nerve palsies preoperatively, 43 and 75%, respectively, had return to normal function postoperatively. SIPAP tumor characteristics were not related to postoperative cranial nerve recovery. Conclusion  In this series of surgically treated patients with pituitary apoplexy, all cranial nerve deficits normalized or improved following surgery. The tumor SIPAP classification was not associated with patient outcome. Though in a small series, the presented results suggest surgical treatment is beneficial for these patients., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Introduction: Chronic rhinosinusitis (CRS) is common, with a Canadian prevalence of 5%, and associated with significant morbidity. Understandably, CRS impairs workplace productivity but that productivity substantially increases following surgical treatment. CRS with nasal polyps (CRSwNP), the most common type of CRS, is usually treated with a combination of medications and endoscopic sinus surgery (ESS). Historically, surgical treatment has only been performed in the operating room at a cost of about $C3500. However, recent studies have shown that a de-escalated procedure, endoscopic polypectomy performed in clinic (EPIC), can provide an improvement in patient symptoms to levels equal to those for ESS. Moreover, EPIC has additional proposed advantages including shorter recovery time, significantly lower cost to the healthcare system and shorter wait time for the patient. There is currently insufficient evidence to draw conclusions about the superiority of polypectomy or ESS for the management of CRSwNP., Methods and Analysis: We designed a multicentre, open-label, randomised controlled trial to evaluate whether EPIC was non-inferior to the current clinical standard, ESS for the treatment of CRSwNP. The primary outcome is the Sinonasal Outcome Test-22 score measured at baseline and at 3 months after surgery. Other outcomes include peak nasal inspiratory flow, quality of life measured by the EuroQoL 5 Dimensions 5 Levels questionnaire and work impairment using the Work Productivity and Activity Impairment Questionnaire.We aim to recruit 140 patients from sites across Canada. Participants will be randomly assigned to EPIC or ESS and followed up for 3 months in clinic after the procedure. Additionally, participants will enter a 5-year long-term follow-up period., Ethics and Dissemination: This study was approved by the Ottawa Health Sciences Network Research Ethics Board for all sites in Ontario, Canada (study number CTO0801). Sites located outside of Ontario obtained approval from their local/institutional research ethics board., Trial Registration Number: NCT02975310., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Little was known about the role of socioeconomic status as a risk factor for epistaxis in adult population. The objective of this study was to determine whether socioeconomic status influences the presentation to emergency department for anterior epistaxis in an adult population., Methods: Retrospective review of emergency department visits from January 2012 to May 2014. The setting is in an emergency department of a Canadian tertiary care centre. Adult patients with primary diagnosis of anterior epistaxis in the emergency department were included in this study. The main outcome was emergency department visits for anterior epistaxis visits., Results: A total of 351 cases of anterior epistaxis were included. The mean age was 70 years and 51% of patients were male. The patients were stratified into two groups based on whether their age was equal to and above, or below 75 years. Our analysis indicated that those 75 years or older in higher income quintiles have an increased risk of anterior epistaxis compared to the subjects in the lower income quintiles ( P  < 0.05). This association did not hold true for those younger than 75 years or for all age groups combined., Conclusion: There is an association between higher socioeconomic status and the presentation to the emergency department with anterior epistaxis in the population older than 75 years but not in younger patients.